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Avci AB, Feist E, Burmester GR. Targeting IL-6 or IL-6 Receptor in Rheumatoid Arthritis: What Have We Learned? BioDrugs 2024; 38:61-71. [PMID: 37989892 PMCID: PMC10789669 DOI: 10.1007/s40259-023-00634-1] [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] [Accepted: 10/18/2023] [Indexed: 11/23/2023]
Abstract
The use of different pathways in the treatment of rheumatoid arthritis has led to a significant decrease in the number of treatment-resistant patients. In this context, interleukin (IL)-6 inhibition has filled an important gap in rheumatoid arthritis treatment with its effectiveness and safety in both monotherapy and combinations. The process of IL-6 inhibition initiated with IL-6 receptor blockers has prompted questions regarding the potential impact and safety of different inhibitions of this pathway, such as the direct blockade of IL-6. Following the termination of the development of sirukumab because of mortality data in early studies, the investigation of olokizumab, which targets a different region of the IL-6 cytokine, has renewed the hope in this area and the safety concerns have been largely alleviated by the open-label extension data. In addition, the efficacy and safety of tocilizumab and sarilumab have led to a rapid investigation of biosimilars and new potent IL-6 receptor blockers. A comprehensive understanding of mechanisms of this pathway with further long-term clinical data and basic research may provide a decisive impact on selecting the appropriate mechanism as the first choice in personalized treatments.
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Affiliation(s)
- Ali Berkant Avci
- Department of Internal Medicine, Rheumatology, Medical Park Antalya Hospital, Antalya, Türkiye
| | - Eugen Feist
- Department of Rheumatology, Helios Fachklinik Vogelsang-Gommern, Cooperation Partner of the Otto-von-Guericke University Magdeburg, Gommern, Germany
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Medizinische Klinik für Rheumatologie und Klinische Immunologie, Charitéplatz 1, 10117, Berlin, Germany.
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2
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Farias-Jofre M, Romero R, Galaz J, Xu Y, Miller D, Garcia-Flores V, Arenas-Hernandez M, Winters AD, Berkowitz BA, Podolsky RH, Shen Y, Kanninen T, Panaitescu B, Glazier CR, Pique-Regi R, Theis KR, Gomez-Lopez N. Blockade of IL-6R prevents preterm birth and adverse neonatal outcomes. EBioMedicine 2023; 98:104865. [PMID: 37944273 PMCID: PMC10665693 DOI: 10.1016/j.ebiom.2023.104865] [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: 07/07/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Preterm birth preceded by spontaneous preterm labour often occurs in the clinical setting of sterile intra-amniotic inflammation (SIAI), a condition that currently lacks treatment. METHODS Proteomic and scRNA-seq human data were analysed to evaluate the role of IL-6 and IL-1α in SIAI. A C57BL/6 murine model of SIAI-induced preterm birth was developed by the ultrasound-guided intra-amniotic injection of IL-1α. The blockade of IL-6R by using an aIL-6R was tested as prenatal treatment for preterm birth and adverse neonatal outcomes. QUEST-MRI evaluated brain oxidative stress in utero. Targeted transcriptomic profiling assessed maternal, foetal, and neonatal inflammation. Neonatal biometrics and neurodevelopment were tested. The neonatal gut immune-microbiome was evaluated using metagenomic sequencing and immunophenotyping. FINDINGS IL-6 plays a critical role in the human intra-amniotic inflammatory response, which is associated with elevated concentrations of the alarmin IL-1α. Intra-amniotic injection of IL-1α resembles SIAI, inducing preterm birth (7% vs. 50%, p = 0.03, Fisher's exact test) and neonatal mortality (18% vs. 56%, p = 0.02, Mann-Whitney U-test). QUEST-MRI revealed no foetal brain oxidative stress upon in utero IL-1α exposure (p > 0.05, mixed linear model). Prenatal treatment with aIL-6R abrogated IL-1α-induced preterm birth (50% vs. 7%, p = 0.03, Fisher's exact test) by dampening inflammatory processes associated with the common pathway of labour. Importantly, aIL-6R reduces neonatal mortality (56% vs. 22%, p = 0.03, Mann-Whitney U-test) by crossing from the mother to the amniotic cavity, dampening foetal organ inflammation and improving growth. Beneficial effects of prenatal IL-6R blockade carried over to neonatal life, improving survival, growth, neurodevelopment, and gut immune homeostasis. INTERPRETATION IL-6R blockade can serve as a strategy to treat SIAI, preventing preterm birth and adverse neonatal outcomes. FUNDING NICHD/NIH/DHHS, Contract HHSN275201300006C. WSU Perinatal Initiative in Maternal, Perinatal and Child Health.
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Affiliation(s)
- Marcelo Farias-Jofre
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Division of Obstetrics and Gynecology, School of Medicine, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA.
| | - Jose Galaz
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Division of Obstetrics and Gynecology, School of Medicine, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Yi Xu
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Derek Miller
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Valeria Garcia-Flores
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Marcia Arenas-Hernandez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Andrew D Winters
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, MO, USA
| | - Bruce A Berkowitz
- Department of Ophthalmology, Visual and Anatomical Sciences, Wayne State University School of Medicine; Detroit, MI, USA
| | - Robert H Podolsky
- Division of Biostatistics and Design Methodology, Center for Translational Research, Children's National Hospital, Silver Spring, MD, USA
| | - Yimin Shen
- Department of Radiology, School of Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Tomi Kanninen
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bogdan Panaitescu
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Catherine R Glazier
- UCD School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - Roger Pique-Regi
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Kevin R Theis
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, MO, USA
| | - Nardhy Gomez-Lopez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA; Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, MO, USA; Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA.
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3
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Fa'ak F, Buni M, Falohun A, Lu H, Song J, Johnson DH, Zobniw CM, Trinh VA, Awiwi MO, Tahon NH, Elsayes KM, Ludford K, Montazari EJ, Chernis J, Dimitrova M, Sandigursky S, Sparks JA, Abu-Shawer O, Rahma O, Thanarajasingam U, Zeman AM, Talukder R, Singh N, Chung SH, Grivas P, Daher M, Abudayyeh A, Osman I, Weber J, Tayar JH, Suarez-Almazor ME, Abdel-Wahab N, Diab A. Selective immune suppression using interleukin-6 receptor inhibitors for management of immune-related adverse events. J Immunother Cancer 2023; 11:e006814. [PMID: 37328287 PMCID: PMC10277540 DOI: 10.1136/jitc-2023-006814] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 05/07/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Management of immune-related adverse events (irAEs) is important as they cause treatment interruption or discontinuation, more often seen with combination immune checkpoint inhibitor (ICI) therapy. Here, we retrospectively evaluated the safety and effectiveness of anti-interleukin-6 receptor (anti-IL-6R) as therapy for irAEs. METHODS We performed a retrospective multicenter study evaluating patients diagnosed with de novo irAEs or flare of pre-existing autoimmune disease following ICI and were treated with anti-IL-6R. Our objectives were to assess the improvement of irAEs as well as the overall tumor response rate (ORR) before and after anti-IL-6R treatment. RESULTS We identified a total of 92 patients who received therapeutic anti-IL-6R antibodies (tocilizumab or sarilumab). Median age was 61 years, 63% were men, 69% received anti-programmed cell death protein-1 (PD-1) antibodies alone, and 26% patients were treated with the combination of anti-cytotoxic T lymphocyte antigen-4 and anti-PD-1 antibodies. Cancer types were primarily melanoma (46%), genitourinary cancer (35%), and lung cancer (8%). Indications for using anti-IL-6R antibodies included inflammatory arthritis (73%), hepatitis/cholangitis (7%), myositis/myocarditis/myasthenia gravis (5%), polymyalgia rheumatica (4%), and one patient each with autoimmune scleroderma, nephritis, colitis, pneumonitis and central nervous system vasculitis. Notably, 88% of patients had received corticosteroids, and 36% received other disease-modifying antirheumatic drugs (DMARDs) as first-line therapies, but without adequate improvement. After initiation of anti-IL-6R (as first-line or post-corticosteroids and DMARDs), 73% of patients showed resolution or change to ≤grade 1 of irAEs after a median of 2.0 months from initiation of anti-IL-6R therapy. Six patients (7%) stopped anti-IL-6R due to adverse events. Of 70 evaluable patients by RECIST (Response Evaluation Criteria in Solid Tumors) V.1.1 criteria; the ORR was 66% prior versus 66% after anti-IL-6R (95% CI, 54% to 77%), with 8% higher complete response rate. Of 34 evaluable patients with melanoma, the ORR was 56% prior and increased to 68% after anti-IL-6R (p=0.04). CONCLUSION Targeting IL-6R could be an effective approach to treat several irAE types without hindering antitumor immunity. This study supports ongoing clinical trials evaluating the safety and efficacy of tocilizumab (anti-IL-6R antibody) in combination with ICIs (NCT04940299, NCT03999749).
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Affiliation(s)
- Faisal Fa'ak
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Maryam Buni
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adewunmi Falohun
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Huifang Lu
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juhee Song
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Van A Trinh
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Khaled M Elsayes
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kaysia Ludford
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Emma J Montazari
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julia Chernis
- University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA
| | - Maya Dimitrova
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Sabina Sandigursky
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Jeffrey A Sparks
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Osama Abu-Shawer
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Osama Rahma
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Rafee Talukder
- Fred Hutchinson Cancer Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Namrata Singh
- Fred Hutchinson Cancer Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sarah H Chung
- Fred Hutchinson Cancer Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Petros Grivas
- Fred Hutchinson Cancer Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - May Daher
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ala Abudayyeh
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Iman Osman
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Jeffrey Weber
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Jean H Tayar
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Noha Abdel-Wahab
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Assiut University Faculty of Medicine, Assiut University Hospitals, Assiut, Egypt
| | - Adi Diab
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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4
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Zhu J, Fu Q, Wang S, Ren L, Feng W, Wei S, Zhang Z, Xu Y, Ganz T, Liu S. Palladium Nanoplate-Based IL-6 Receptor Antagonists Ameliorate Cancer-Related Anemia and Simultaneously Inhibit Cancer Progression. Nano Lett 2022; 22:751-760. [PMID: 35030010 DOI: 10.1021/acs.nanolett.1c04260] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In recent years, targeted therapies and immunotherapeutics, along with conventional chemo- and radiotherapy, have greatly improved cancer treatments. Unfortunately, in cancer patients, anemia, either as a complication of cancer progression or as the result of cancer treatment, undermines the expected therapeutic efficacy. Here, we developed a smart nanosystem based on the palladium nanoplates (PdPLs) to deliver tocilizumab (TCZ, a widely used IL-6R antibody) to the liver for specific blockade of IL-6/IL-6R signaling to correct anemia. With chemical modifications, this nanosystem delivered a large mass of TCZ and enhanced liver delivery, inducing a marked suppression of hepcidin expression as a result of diminished IL-6 signaling. Through this mechanism, significant suppression of tumor progression was realized (at least in part) because of the corrected anemia after treatment.
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Affiliation(s)
- Jianqiang Zhu
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Qingfeng Fu
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Shunhao Wang
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Liting Ren
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
| | - Wenya Feng
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Shuting Wei
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhihong Zhang
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Yong Xu
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Tomas Ganz
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California 90095, United States
| | - Sijin Liu
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- University of Chinese Academy of Sciences, Beijing 100049, China
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5
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Ringelstein M, Ayzenberg I, Lindenblatt G, Fischer K, Gahlen A, Novi G, Hayward-Könnecke H, Schippling S, Rommer PS, Kornek B, Zrzavy T, Biotti D, Ciron J, Audoin B, Berthele A, Giglhuber K, Zephir H, Kümpfel T, Berger R, Röther J, Häußler V, Stellmann JP, Whittam D, Jacob A, Kraemer M, Gueguen A, Deschamps R, Bayas A, Hümmert MW, Trebst C, Haarmann A, Jarius S, Wildemann B, Grothe M, Siebert N, Ruprecht K, Paul F, Collongues N, Marignier R, Levy M, Karenfort M, Deppe M, Albrecht P, Hellwig K, Gold R, Hartung HP, Meuth SG, Kleiter I, Aktas O. Interleukin-6 Receptor Blockade in Treatment-Refractory MOG-IgG-Associated Disease and Neuromyelitis Optica Spectrum Disorders. Neurol Neuroimmunol Neuroinflamm 2022; 9:e1100. [PMID: 34785575 PMCID: PMC8596357 DOI: 10.1212/nxi.0000000000001100] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/25/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES To evaluate the long-term safety and efficacy of tocilizumab (TCZ), a humanized anti-interleukin-6 receptor antibody in myelin oligodendrocyte glycoprotein-IgG-associated disease (MOGAD) and neuromyelitis optica spectrum disorders (NMOSD). METHODS Annualized relapse rate (ARR), Expanded Disability Status Scale score, MRI, autoantibody titers, pain, and adverse events were retrospectively evaluated in 57 patients with MOGAD (n = 14), aquaporin-4 (AQP4)-IgG seropositive (n = 36), and seronegative NMOSD (n = 7; 12%), switched to TCZ from previous immunotherapies, particularly rituximab. RESULTS Patients received TCZ for 23.8 months (median; interquartile range 13.0-51.1 months), with an IV dose of 8.0 mg/kg (median; range 6-12 mg/kg) every 31.6 days (mean; range 26-44 days). For MOGAD, the median ARR decreased from 1.75 (range 0.5-5) to 0 (range 0-0.9; p = 0.0011) under TCZ. A similar effect was seen for AQP4-IgG+ (ARR reduction from 1.5 [range 0-5] to 0 [range 0-4.2]; p < 0.001) and for seronegative NMOSD (from 3.0 [range 1.0-3.0] to 0.2 [range 0-2.0]; p = 0.031). During TCZ, 60% of all patients were relapse free (79% for MOGAD, 56% for AQP4-IgG+, and 43% for seronegative NMOSD). Disability follow-up indicated stabilization. MRI inflammatory activity decreased in MOGAD (p = 0.04; for the brain) and in AQP4-IgG+ NMOSD (p < 0.001; for the spinal cord). Chronic pain was unchanged. Regarding only patients treated with TCZ for at least 12 months (n = 44), ARR reductions were confirmed, including the subgroups of MOGAD (n = 11) and AQP4-IgG+ patients (n = 28). Similarly, in the group of patients treated with TCZ for at least 12 months, 59% of them were relapse free, with 73% for MOGAD, 57% for AQP4-IgG+, and 40% for patients with seronegative NMOSD. No severe or unexpected safety signals were observed. Add-on therapy showed no advantage compared with TCZ monotherapy. DISCUSSION This study provides Class III evidence that long-term TCZ therapy is safe and reduces relapse probability in MOGAD and AQP4-IgG+ NMOSD.
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MESH Headings
- Adult
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/pharmacology
- Aquaporin 4/immunology
- Demyelinating Autoimmune Diseases, CNS/drug therapy
- Demyelinating Autoimmune Diseases, CNS/immunology
- Female
- Humans
- Male
- Middle Aged
- Myelin-Oligodendrocyte Glycoprotein/immunology
- Neuromyelitis Optica/drug therapy
- Neuromyelitis Optica/immunology
- Outcome Assessment, Health Care
- Receptors, Interleukin-6/antagonists & inhibitors
- Secondary Prevention
- Young Adult
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Affiliation(s)
| | | | - Gero Lindenblatt
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Katinka Fischer
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Anna Gahlen
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Giovanni Novi
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Helen Hayward-Könnecke
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Sven Schippling
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Paulus S. Rommer
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Barbara Kornek
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Tobias Zrzavy
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Damien Biotti
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Jonathan Ciron
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Bertrand Audoin
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Achim Berthele
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Katrin Giglhuber
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Helene Zephir
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Tania Kümpfel
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Robert Berger
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Joachim Röther
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Vivien Häußler
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Jan-Patrick Stellmann
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Daniel Whittam
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Anu Jacob
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Markus Kraemer
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Antoine Gueguen
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Romain Deschamps
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Antonios Bayas
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Martin W. Hümmert
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Corinna Trebst
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Axel Haarmann
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Sven Jarius
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Brigitte Wildemann
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Matthias Grothe
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Nadja Siebert
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Klemens Ruprecht
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Friedemann Paul
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Nicolas Collongues
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Romain Marignier
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Michael Levy
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Michael Karenfort
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Michael Deppe
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Philipp Albrecht
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Kerstin Hellwig
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Ralf Gold
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Hans-Peter Hartung
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Sven G. Meuth
- Department of Neurology (M.R., K.F., M.K.,P.A., H.P.H., S.G.M., O.A.), Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.R.), Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf; Department of Neurology (I.A., A.G., K.H., R.G., I.K.), St. Josef-Hospital, Ruhr University Bochum, Germany; Department of Neurology (I.A.), Sechenov First Moscow State Medical University, Russia; Department of Neurology (G.L.), Johanna Etienne Hospital, Neuss, Germany; Department of Neurology (G.N.), San Martino Hospital, Genova, Italy; Neuroimmunology and MS Research (H.H.K., S.S.), Department of Neurology, University Hospital Zürich, Switzerland; Department of Neurology (P.S.R., B.K., T.Z.), Medical University of Vienna, Austria; Department of Neurology (D.B., J.C.), B4 unit, CRC-SEP, Toulouse Purpan University Hospital, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) (D.B., J.C.) INSERM UMR1291-CNRS UMR5051 - Université Toulouse III, France; Aix Marseille University (B.A.), APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie, Marseille, France; Technical University of Munich (A.B., K.G.), School of Medicine, Department of Neurology, Klinikum rechts der Isar, Germany; University of Lille (H.Z.), Inserm, CRC-SEP, CHU Lille, France; Institute of Clinical Neuroimmunology (T.K.), Faculty of Medicine, Ludwig Maximilian University, Munich; Department of Neurology (R.B., J.R.), Asklepios Klinik Altona, Hamburg; Department of Neurology and Institute of Neuroimmunology and MS (INIMS) (V.H.), University Medical Center Hamburg-Eppendorf, Germany; APHM, Hôpital de la Timone (J.P.S.), CEMEREM; Aix Marseille Univ, CNRS, CRMBM (J.P.S), UMR 7339, Marseille, France; Department of Neurology (D.W., A.J.), The Walton Centre, Liverpool, United Kingdom; the Cleveland Clinic Abu Dhabi, (A.J.) UAE; Department of Neurology (M.K.), Alfried Krupp Hospital, Essen, Germany; Department of Neurology (A.G.,R.D.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France; Department of Neurology (A.B.), Universitätsklinikum Augsburg; Department of Neurology (M.W.H., C.T.), Hannover Medical School; Department of Neurology (A.H.), University of Würzburg; Molecular Neuroimmunology Group (S.J., B.W.), Department of Neurology, University of Heidelberg; Department of Neurology (M.G.), University hospital Greifswald; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (N.S., F.P), Max Delbrueck Center for Molecular Medicine and Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health; Department of Neurology (K.R.), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, and Berlin Institute of Health, Berlin; Department of Neurology (N.C.), University Hospital Strasbourg; Service de neurologie (R.M.), sclérose en plaques, pathologies de la myéline et neuro-inflammation – Hôpital Neurologique Pierre Wertheimer Hospices Civils de Lyon, France; Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of General Pediatrics (M.K.), Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University Düsseldorf; Department of Neurology (M.D.), University Hospital, Münster; and Marianne-Strauß-Klinik (I.K.), Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
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6
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Khuat LT, Vick LV, Dunai C, Collins CP, More SK, Le CT, Pai CCS, Stoffel KM, Maverakis E, Canter RJ, Monjazeb AM, Longo DL, Abedi M, Choi E, Blazar BR, Dave M, Murphy WJ. Increased efficacy of dual proinflammatory cytokine blockade on acute GVHD while maintaining GVT effects. Blood 2021; 138:2583-2588. [PMID: 34424962 PMCID: PMC8678998 DOI: 10.1182/blood.2021011216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 08/14/2021] [Indexed: 11/20/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains a potential curative option for treating a variety of hematologic diseases, but acute and chronic graft-versus-host disease (GVHD) remain major barriers limiting efficacy. Acute gut GVHD occurs with marked increases in proinflammatory cytokines (including TNF and IL-6), which we recently demonstrated was exacerbated in obesity resulting in severe gastrointestinal pathology. Given the pleiotropic and overlapping effects of these 2 cytokines, we assessed the impact of dual TNF and IL-6R blockade on GVHD as well as graft-versus tumor (GVT) effects in different mouse GVHD models. Early administration of combined blockade resulted in greater protection and survival from acute gut GVHD compared with single blockade regimens and even development of later chronic skin GVHD. Importantly, double cytokine blockade preserved GVT effects reinforcing that GVT and GVHD can be delineated and may result in greater efficacy in allo-HSCT.
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Affiliation(s)
| | | | | | | | - Shyam K More
- Division of Gastroenterology, Department of Internal Medicine
| | | | | | | | | | | | - Arta M Monjazeb
- Department of Radiation Oncology, School of Medicine, University of California, Davis, Sacramento, CA
| | - Dan L Longo
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Mehrdad Abedi
- Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, CA
| | - Eunju Choi
- Department of Pathology, Microbiology, and Immunology, University of California, Davis, Davis, CA; and
| | - Bruce R Blazar
- Masonic Cancer Center and Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Maneesh Dave
- Division of Gastroenterology, Department of Internal Medicine
| | - William J Murphy
- Department of Dermatology
- Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, CA
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7
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Lomakin NV, Bakirov BA, Protsenko DN, Mazurov VI, Musaev GH, Moiseeva OM, Pasechnik ES, Popov VV, Smolyarchuk EA, Gordeev IG, Gilyarov MY, Fomina DS, Seleznev AI, Linkova YN, Dokukina EA, Eremeeva AV, Pukhtinskaia PS, Morozova MA, Zinkina-Orikhan AV, Lutckii AA. The efficacy and safety of levilimab in severely ill COVID-19 patients not requiring mechanical ventilation: results of a multicenter randomized double-blind placebo-controlled phase III CORONA clinical study. Inflamm Res 2021; 70:1233-1246. [PMID: 34586459 PMCID: PMC8479713 DOI: 10.1007/s00011-021-01507-5] [Citation(s) in RCA: 9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE AND DESIGN The aim of this double-blind, placebo-controlled, phase III CORONA clinical trial was to evaluate the efficacy and safety of IL-6 receptor inhibitor levilimab (LVL) in subjects with severe COVID-19. SUBJECTS The study included 217 patients. The eligible were men and non-pregnant women aged 18 years or older, hospitalized for severe COVID-19 pneumonia. TREATMENT 206 subjects were randomized (1:1) to receive single subcutaneous administration of LVL 324 mg or placebo, both in combination with standard of care (SOC). 204 patients received allocated therapy. After the LVL/placebo administration in case of deterioration of symptoms, the investigator could perform a single open-label LVL 324 mg administration as the rescue therapy. METHODS The primary efficacy endpoint was the proportion of patients with sustained clinical improvement on the 7-category ordinal scale on Day 14. All efficacy data obtained after rescue therapy administration were considered missing. For primary efficacy analysis, all subjects with missing data were considered non-responders. RESULTS 63.1% and 42.7% of patients in the LVL and in the placebo groups, respectively, achieved sustained clinical improvement on Day 14 (P = .0017). The frequency of adverse drug reactions was comparable between the groups. CONCLUSION In patients with radiologically confirmed SARS-CoV-2 pneumonia, requiring or not oxygen therapy (but not ventilation) with no signs of other active infection administration of LVL + SOC results in an increase of sustained clinical improvement rate. TRAIL REGISTRATION The trial is registered at the US National Institutes of Health (ClinicalTrials.gov; NCT04397562).
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Affiliation(s)
- Nikita V Lomakin
- Federal State Budgetary Institution Central Clinical Hospital of the Management Affair of President Russian Federation (FSBI CCH), Moscow, Russian Federation
| | - Bulat A Bakirov
- Federal State Budgetary Educational Institution of Higher Education "Bashkir State Medical University of the Ministry of Healthcare of the Russian Federation" (FSBEI HE BSMU of the Ministry of Health of Russia), Ufa, Russian Federation
| | - Denis N Protsenko
- State Budgetary Healthcare Institution of the City of Moscow Municipal Clinical Hospital No. 40 of the Moscow Healthcare Department (SBHI MCH No. 40 MHD), Moscow, Russian Federation
| | - Vadim I Mazurov
- Federal State Budgetary Educational Institution of Higher Education "I.I. Mechnikov North-Western State Medical University", Ministry of Healthcare of the Russian Federation (FSBEI HE I.I. Mechnikov NWSMU, Ministry of Health of Russia), St. Petersburg, Russian Federation
| | - Gaziyavdibir H Musaev
- State Budgetary Institution of the Republic of Dagestan "Republican Clinical Hospital" (SBU RD RCH), Makhachkala, Russian Federation
| | - Olga M Moiseeva
- Federal State Budgetary Institution "Almazov National Medical Research Center", Ministry of Health of the Russian Federation (Almazov National Medical Research Center), St. Petersburg, Russian Federation
| | - Elena S Pasechnik
- State Budgetary Healthcare Institution «Kaluga Regional Clinical Hospital» (SBHI KR KRCH), Kaluga, Russian Federation
| | - Vladimir V Popov
- Private Healthcare Institution N.A. Semashko Clinical Hospital «RZD-Medicine» (PHI N.A. Semashko Railroad Clinical Hospital), (Formerly Known As Non-State Healthcare Institution N.A. Semashko Railroad Clinical Hospital at the Lyublino Station of the JSC Russian Railways), Institute of Continues Medical Education Moscow State University of Food Production, Moscow, Russian Federation
| | - Elena A Smolyarchuk
- Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), [FSAEI HE I.M. Sechenov First MSMU, Ministry of Health of Russia (Sechenov University)], Moscow, Russian Federation
| | - Ivan G Gordeev
- Moscow State Budgetary Healthcare Institution O.M. Filatov Municipal Clinical Hospital No. 15 of the Moscow Healthcare Department) (SBHI MCH No. 15 MHD) (formerly known as the State Healthcare Institution of Moscow O.M. Filatov Municipal Clinical Hospital No. 15 of the Moscow Healthcare Department), Moscow, Russian Federation
| | - Mikhail Yu Gilyarov
- State Budgetary Healthcare Institution of the City of Moscow N.I. Pirogov Municipal Clinical Hospital No. 1 of the Moscow Healthcare Department (N.I. Pirogov MCH No. 1), Moscow, Russian Federation
| | - Darya S Fomina
- State Budgetary Healthcare Institution of the City of Moscow Municipal Clinical Hospital No. 52 of the Moscow Healthcare Department (SBHI MCH No. 52 MHD), Moscow, Russian Federation
- Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University, FSAEI HE I.M. Sechenov First MSMU, Ministry of Health of Russia (Sechenov University), Moscow, Russian Federation
| | | | - Yulia N Linkova
- JSC BIOCAD, Ul. Italianskaya 17, St-Petersburg, Russia, 191186
| | | | - Anna V Eremeeva
- JSC BIOCAD, Ul. Italianskaya 17, St-Petersburg, Russia, 191186
| | | | | | | | - Anton A Lutckii
- JSC BIOCAD, Ul. Italianskaya 17, St-Petersburg, Russia, 191186
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Kharel S, Shrestha S, Ojha R, Guragain N, Ghimire R. Safety and efficacy of interleukin-6-receptor inhibitors in the treatment of neuromyelitis optica spectrum disorders: a meta-analysis. BMC Neurol 2021; 21:458. [PMID: 34814882 PMCID: PMC8609802 DOI: 10.1186/s12883-021-02488-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Interleukin-6-receptor inhibitors like Tocilizumab and Satralizumab are showing promising results in the treatment of Neuromyelitis Optica spectrum disorder (NMOSD). We aimed to investigate the efficacy and safety of various Interleukin-6-receptor inhibitors in the management of NMO/NMOSD. METHODS PubMed, Embase, and The Cochrane Library were systematically searched for suitable studies. Change in Annualized Relapse Ratio (ARR), Change in Extended Disability Status Scale (EDSS) s, the proportion of relapse-free patients and proportion of patients with adverse events, including serious adverse events and mortality were the parameters considered for the meta-analysis for Tocilizumab. Mean difference (MD) with 95% CI was used to quantify the change in ARR and change in EDSS before and after treatment. A forest plot was prepared to indicate the efficacy and adverse effects outcomes. The results were compared with those of Satralizumab included in two trials. RESULTS A total of nine studies with 202 patients were included in our study. Tocilizumab found a good proportion (76.95% CI: 0.61-0.91; p < 0.001) of relapse free patients at follow up. It also significantly reduced mean ARR (mean difference: -2.6, 95% CI: - 2.71 to - 1.68; p < 0.001) and but did not show significant difference in change in EDSS score (mean difference = - 0.79, 95% CI: - 1.89 to - 0.31; p = 0.16). Also, the toxicity profile of Tocilizumab was acceptable considering the proportions of patients with adverse events 56% (95% C.I.;0.27-0.85, I2 = 88.95%, p < 0.001), proportions of patients with serious adverse events 11% (95% C.I.; 0.05 to 0.17, I2 = 0%, p < 0.001) and zero treatment related deaths. SAkura studies for Satralizumab showed similar relapse free patients (70% to 80%) and reduction of ARR and EDSS from baseline. Some studies of Tocilizumab have shown to reduce pain and fatigue while trials of Satralizumab had non-significant findings. CONCLUSION Interleukin-6-receptor inhibitors therapy showed a promising result with good efficacy and acceptable adverse events profile for treatment of NMOSD.
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Affiliation(s)
- Sanjeev Kharel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, P.O. Box: 44600, Kathmandu, Nepal
| | - Suraj Shrestha
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, P.O. Box: 44600, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, 44600 Nepal
| | - Neha Guragain
- Department of Clinical Pharmacology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, 44600 Nepal
| | - Rakesh Ghimire
- Department of Clinical Pharmacology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, 44600 Nepal
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9
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Malgie J, Schoones JW, Zeegers MP, Pijls BG. Decreased mortality and increased side effects in COVID-19 patients treated with IL-6 receptor antagonists: systematic review and meta-analysis. Sci Rep 2021; 11:21522. [PMID: 34728658 PMCID: PMC8564515 DOI: 10.1038/s41598-021-00726-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 10/15/2021] [Indexed: 12/29/2022] Open
Abstract
There is controversy whether IL-6 (receptor) antagonists are beneficial in treating COVID-19 patients. We therefore update our systematic review to answer the following research questions: (1) Do patients hospitalized for COVID-19 treated with IL-6 (receptor) antagonists have lower mortality compared to standard of care? (2) Do patients hospitalized for COVID-19 treated with IL-6 (receptor) antagonists have more side effects compared to standard of care? The following databases were search up to December 1st 2020: PubMed, PMC PubMed Central, MEDLINE, WHO COVID-19 Database, Embase, Web-of-Science, COCHRANE LIBRARY, Emcare and Academic Search Premier. In order to pool the risk ratio (RR) and risk difference of individual studies we used random effects meta-analysis. The search strategy retrieved 2975 unique titles of which 71 studies (9 RCTs and 62 observational) studies comprising 29,495 patients were included. Mortality (RR 0.75) and mechanical ventilation (RR 0.78) were lower and the risk of neutropenia (RR 7.3), impaired liver function (RR 1.67) and secondary infections (RR 1.26) were higher for patients treated with IL-6 (receptor) antagonists compared to patients not treated with treated with IL-6 (receptor) antagonists. Our results showed that IL-6 (receptor) antagonists are effective in reducing mortality in COVID-19 patients, while the risk of side effects was higher. The baseline risk of mortality was an important effect modifier: IL-6 (receptor) antagonists were effective when the baseline mortality risk was high (e.g. ICU setting), while they could be harmful when the baseline mortality risk was low.
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Affiliation(s)
- Jishnu Malgie
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, Postzone J-11-S, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Jan W Schoones
- Directorate of Research Policy (Formerly: Walaeus Library), Leiden University Medical Centre, Leiden, The Netherlands
| | - Maurice P Zeegers
- Team Meta-Research, NUTRIM School of Translational Research in Metabolism, CAPHRI, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Bart G Pijls
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, Postzone J-11-S, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
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10
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Ma M, Sun Q, Li X, Deng G, Zhang Y, Yang Z, Han F, Huang Z, Fang Y, Liao T, Sun Q. Blockade of IL-6/IL-6R Signaling Attenuates Acute Antibody-Mediated Rejection in a Mouse Cardiac Transplantation Model. Front Immunol 2021; 12:778359. [PMID: 34777394 PMCID: PMC8581398 DOI: 10.3389/fimmu.2021.778359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Acute antibody-mediated rejection (AAMR) is an important cause of cardiac allograft dysfunction, and more effective strategies need to be explored to improve allograft prognosis. Interleukin (IL)-6/IL-6R signaling plays a key role in the activation of immune cells including B cells, T cells and macrophages, which participate in the progression of AAMR. In this study, we investigated the effect of IL-6/IL-6R signaling blockade on the prevention of AAMR in a mouse model. We established a mouse model of AAMR for cardiac transplantation via presensitization of skin grafts and addition of cyclosporin A, and sequentially analyzed its features. Tocilizumab, anti-IL-6R antibody, and recipient IL-6 knockout were used to block IL-6/IL-6R signaling. We demonstrated that blockade of IL-6/IL-6R signaling significantly attenuated allograft injury and improved survival. Further mechanistic research revealed that signaling blockade decreased B cells in circulation, spleens, and allografts, thus inhibiting donor-specific antibody production and complement activation. Moreover, macrophage, T cell, and pro-inflammatory cytokine infiltration in allografts was also reduced. Collectively, we provided a highly practical mouse model of AAMR and demonstrated that blockade of IL-6/IL-6R signaling markedly alleviated AAMR, which is expected to provide a superior option for the treatment of AAMR in clinic.
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Affiliation(s)
- Maolin Ma
- Organ Transplantation Research Institute, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Qipeng Sun
- Department of Kidney Transplantation, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Xiujie Li
- Department of Obstetrics and Gynecology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Gengguo Deng
- Organ Transplantation Research Institute, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yannan Zhang
- Department of Kidney Transplantation, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Zhe Yang
- Organ Transplantation Research Institute, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Fei Han
- Organ Transplantation Research Institute, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhengyu Huang
- Organ Transplantation Research Institute, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Youqiang Fang
- Department of Urology, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Tao Liao
- Department of Kidney Transplantation, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Qiquan Sun
- Department of Kidney Transplantation, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
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Amer M, Kamel AM, Bawazeer M, Maghrabi K, Butt A, Dahhan T, Kseibi E, Khurshid SM, Abujazar M, Alghunaim R, Rabee M, Abualkhair M, Al-Janoubi A, AlFirm AT, Gajic O, Walkey AJ, Mosier JM, Zabolotskikh IB, Gavidia OY, Teruel SY, Bernstein MA, Boman K, Kumar VK, Bansal V, Kashyap R. Clinical characteristics and outcomes of critically ill mechanically ventilated COVID-19 patients receiving interleukin-6 receptor antagonists and corticosteroid therapy: a preliminary report from a multinational registry. Eur J Med Res 2021; 26:117. [PMID: 34600589 PMCID: PMC8487342 DOI: 10.1186/s40001-021-00591-x] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/18/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Interleukin-6 receptor antagonists (IL-6RAs) and steroids are emerging immunomodulatory therapies for severe and critical coronavirus disease (COVID-19). In this preliminary report, we aim to describe the epidemiology, clinical characteristics, and outcomes of adult critically ill COVID-19 patients, requiring invasive mechanical ventilation (iMV), and receiving IL-6RA and steroids therapy over the last 11 months. MATERIALS AND METHODS International, multicenter, cohort study derived from Viral Infection and Respiratory Illness University Study registry and conducted through Discovery Network, Society of Critical Care Medicine. Data were collected between March 01, 2020, and January 10, 2021. RESULTS Of 860 patients who met eligibility criteria, 589 received steroids, 170 IL-6RAs, and 101 combinations. Patients who received IL-6RAs were younger (median age of 57.5 years vs. 61.1 and 61.8 years in the steroids and combination groups, respectively). The median C-reactive protein level was > 75 mg/L, indicating a hyperinflammatory phenotype. The median daily steroid dose was 7.5 mg dexamethasone or equivalent (interquartile range: 6-14 mg); 80.8% and 19.2% received low-dose and high-dose steroids, respectively. Of the patients who received IL-6RAs, the majority received one dose of tocilizumab and sarilumab (dose range of 600-800 mg for tocilizumab and 200-400 mg for sarilumab). Regarding the timing of administration, we observed that steroid and IL-6RA administration on day 0 of ICU admission was only 55.6% and 39.5%, respectively. By day 28, when compared with steroid use alone, IL-6RA use was associated with an adjusted incidence rate ratio (aIRR) of 1.12 (95% confidence interval [CI] 0.88, 1.4) for ventilator-free days, while combination therapy was associated with an aIRR of 0.83 (95% CI 0.6, 1.14). IL-6RA use was associated with an adjusted odds ratio (aOR) of 0.68 (95% CI 0.44, 1.07) for the 28-day mortality rate, while combination therapy was associated with an aOR of 1.07 (95% CI 0.67, 1.70). Liver dysfunction was higher in IL-6RA group (p = 0.04), while the bacteremia rate did not differ among groups. CONCLUSIONS Discordance was observed between the registry utilization patterns (i.e., timing of steroids and IL-6RA administration) and new evidence from the recent randomized controlled trials and guideline recommendations. These data will help us to identify areas of improvement in prescribing patterns and enhance our understanding of IL-6RA safety with different steroid regimens. Further studies are needed to evaluate the drivers of hospital-level variation and their impact on clinical outcomes. Trial registration ClinicalTrials.gov: NCT04486521. Registered on July 2020.
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Affiliation(s)
- Marwa Amer
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, (MBC # 11), PO Box 3354, Riyadh, 11211, Saudi Arabia.
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Ahmed M Kamel
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Giza, Egypt
| | - Mohammed Bawazeer
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Khalid Maghrabi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abid Butt
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Talal Dahhan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Eiad Kseibi
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Syed Moazzum Khurshid
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammed Abujazar
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Razan Alghunaim
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, (MBC # 11), PO Box 3354, Riyadh, 11211, Saudi Arabia
| | - Muath Rabee
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Maal Abualkhair
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ali Al-Janoubi
- Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abeer Turki AlFirm
- Biostatistics, Epidemiology & Scientific Computing Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | | | | | | | | | | | | | - Karen Boman
- Society of Critical Care Medicine, Mount Prospect, USA
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12
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Buryachkovskaya L, Lomakin N, Melkumyants A, Docenko J, Serebruany V. Tocilizumab, blood cells, and mild COVID-19: delayed vascular protection by interleukin blockade? Eur Heart J Cardiovasc Pharmacother 2021; 7:e81-e82. [PMID: 34185077 PMCID: PMC8344719 DOI: 10.1093/ehjcvp/pvab051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
| | - Nikita Lomakin
- Cardiology Division, Central Clinical Hospital of Presidential Administration, Moscow, Russia
| | - Arthur Melkumyants
- National Medical Research Center of Cardiology, Moscow, Russia
- Institute of Physics and Technology, Moscow, Russia
| | - Julia Docenko
- National Medical Research Center of Cardiology, Moscow, Russia
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13
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An EUA for tocilizumab (Actemra) for COVID-19. Med Lett Drugs Ther 2021; 63:113-4. [PMID: 34544106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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14
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Kang S, Kishimoto T. Interplay between interleukin-6 signaling and the vascular endothelium in cytokine storms. Exp Mol Med 2021; 53:1116-1123. [PMID: 34253862 PMCID: PMC8273570 DOI: 10.1038/s12276-021-00649-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 02/06/2023] Open
Abstract
Interleukin-6 (IL-6) plays a crucial role in host defense against infection and tissue injuries and is a bioindicator of multiple distinct types of cytokine storms. In this review, we present the current understanding of the diverse roles of IL-6, its receptors, and its signaling during acute severe systemic inflammation. IL-6 directly affects vascular endothelial cells, which produce several types of cytokines and chemokines and activate the coagulation cascade. Endothelial cell dysregulation, characterized by abnormal coagulation and vascular leakage, is a common complication in cytokine storms. Emerging evidence indicates that a humanized anti-IL-6 receptor antibody, tocilizumab, can effectively block IL-6 signaling and has beneficial effects in rheumatoid arthritis, juvenile systemic idiopathic arthritis, and Castleman's disease. Recent work has also demonstrated the beneficial effect of tocilizumab in chimeric antigen receptor T-cell therapy-induced cytokine storms as well as coronavirus disease 2019 (COVID-19). Here, we highlight the distinct contributions of IL-6 signaling to the pathogenesis of several types of cytokine storms and discuss potential therapeutic strategies for the management of cytokine storms, including those associated with sepsis and COVID-19.
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Affiliation(s)
- Sujin Kang
- Laborabory of Immune Regulation, Immunology Frontier Research Center, Osaka University, 3-1 Yamadaoka, Suita, Osaka, Japan.
| | - Tadamitsu Kishimoto
- Laborabory of Immune Regulation, Immunology Frontier Research Center, Osaka University, 3-1 Yamadaoka, Suita, Osaka, Japan.
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15
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Abstract
IL (interleukin)-6 is a pivotal cytokine of innate immunity, which enacts a broad set of physiological functions traditionally associated with host defense, immune cell regulation, proliferation, and differentiation. Following recognition of innate immune pathways leading from the NLRP3 (NOD-, LRR-, and pyrin domain-containing protein 3) inflammasome to IL-1 to IL-6 and on to the hepatically derived clinical biomarker CRP (C-reactive protein), an expanding literature has led to understanding of the proatherogenic role for IL-6 in cardiovascular disease and thus the potential for IL-6 inhibition as a novel method for vascular protection. In this review, we provide an overview of the mechanisms by which IL-6 signaling occurs and how that impacts upon pharmacological inhibition; describe murine models of IL-6 and atherogenesis; summarize human epidemiological data outlining the utility of IL-6 as a biomarker of vascular risk; outline genetic data suggesting a causal role for IL-6 in systemic atherothrombosis and aneurysm formation; and then detail the potential role of IL-6 inhibition in stable coronary disease, acute coronary syndromes, heart failure, and the atherothrombotic complications associated with chronic kidney disease and end-stage renal failure. Finally, we review anti-inflammatory and antithrombotic findings for ziltivekimab, a novel IL-6 ligand inhibitor being developed specifically for use in atherosclerotic disease and poised to be tested formally in a large-scale cardiovascular outcomes trial focused on individuals with chronic kidney disease and elevated levels of CRP, a population at high residual atherothrombotic risk, high residual inflammatory risk, and considerable unmet clinical need.
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MESH Headings
- Aneurysm/etiology
- Animals
- Antibodies, Monoclonal, Humanized/therapeutic use
- Atherosclerosis/etiology
- Atherosclerosis/metabolism
- C-Reactive Protein/metabolism
- Cardiovascular Diseases/metabolism
- Cardiovascular Diseases/therapy
- Cell Differentiation
- Cell Proliferation
- Disease Models, Animal
- Humans
- Immunity, Cellular
- Immunity, Innate
- Inflammasomes
- Inflammation/complications
- Interleukin-1beta/antagonists & inhibitors
- Interleukin-1beta/metabolism
- Interleukin-6/antagonists & inhibitors
- Interleukin-6/genetics
- Interleukin-6/immunology
- Interleukin-6/metabolism
- Mice
- Myocardial Ischemia/therapy
- NLR Family, Pyrin Domain-Containing 3 Protein
- Receptors, Interleukin-6/antagonists & inhibitors
- Receptors, Interleukin-6/metabolism
- Renal Dialysis
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/therapy
- Thrombosis/etiology
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Affiliation(s)
- Paul M Ridker
- Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Manas Rane
- Department of Medicine, Center for Cardiovascular Disease Prevention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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16
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Gordon AC, Mouncey PR, Al-Beidh F, Rowan KM, Nichol AD, Arabi YM, Annane D, Beane A, van Bentum-Puijk W, Berry LR, Bhimani Z, Bonten MJM, Bradbury CA, Brunkhorst FM, Buzgau A, Cheng AC, Detry MA, Duffy EJ, Estcourt LJ, Fitzgerald M, Goossens H, Haniffa R, Higgins AM, Hills TE, Horvat CM, Lamontagne F, Lawler PR, Leavis HL, Linstrum KM, Litton E, Lorenzi E, Marshall JC, Mayr FB, McAuley DF, McGlothlin A, McGuinness SP, McVerry BJ, Montgomery SK, Morpeth SC, Murthy S, Orr K, Parke RL, Parker JC, Patanwala AE, Pettilä V, Rademaker E, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Sligl WI, Turgeon AF, Turner AM, van de Veerdonk FL, Zarychanski R, Green C, Lewis RJ, Angus DC, McArthur CJ, Berry S, Webb SA, Derde LPG. Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19. N Engl J Med 2021; 384:1491-1502. [PMID: 33631065 PMCID: PMC7953461 DOI: 10.1056/nejmoa2100433] [Citation(s) in RCA: 1150] [Impact Index Per Article: 383.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The efficacy of interleukin-6 receptor antagonists in critically ill patients with coronavirus disease 2019 (Covid-19) is unclear. METHODS We evaluated tocilizumab and sarilumab in an ongoing international, multifactorial, adaptive platform trial. Adult patients with Covid-19, within 24 hours after starting organ support in the intensive care unit (ICU), were randomly assigned to receive tocilizumab (8 mg per kilogram of body weight), sarilumab (400 mg), or standard care (control). The primary outcome was respiratory and cardiovascular organ support-free days, on an ordinal scale combining in-hospital death (assigned a value of -1) and days free of organ support to day 21. The trial uses a Bayesian statistical model with predefined criteria for superiority, efficacy, equivalence, or futility. An odds ratio greater than 1 represented improved survival, more organ support-free days, or both. RESULTS Both tocilizumab and sarilumab met the predefined criteria for efficacy. At that time, 353 patients had been assigned to tocilizumab, 48 to sarilumab, and 402 to control. The median number of organ support-free days was 10 (interquartile range, -1 to 16) in the tocilizumab group, 11 (interquartile range, 0 to 16) in the sarilumab group, and 0 (interquartile range, -1 to 15) in the control group. The median adjusted cumulative odds ratios were 1.64 (95% credible interval, 1.25 to 2.14) for tocilizumab and 1.76 (95% credible interval, 1.17 to 2.91) for sarilumab as compared with control, yielding posterior probabilities of superiority to control of more than 99.9% and of 99.5%, respectively. An analysis of 90-day survival showed improved survival in the pooled interleukin-6 receptor antagonist groups, yielding a hazard ratio for the comparison with the control group of 1.61 (95% credible interval, 1.25 to 2.08) and a posterior probability of superiority of more than 99.9%. All secondary analyses supported efficacy of these interleukin-6 receptor antagonists. CONCLUSIONS In critically ill patients with Covid-19 receiving organ support in ICUs, treatment with the interleukin-6 receptor antagonists tocilizumab and sarilumab improved outcomes, including survival. (REMAP-CAP ClinicalTrials.gov number, NCT02735707.).
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Affiliation(s)
- Anthony C Gordon
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Paul R Mouncey
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Farah Al-Beidh
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Kathryn M Rowan
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Alistair D Nichol
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Yaseen M Arabi
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Djillali Annane
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Abi Beane
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Wilma van Bentum-Puijk
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Lindsay R Berry
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Zahra Bhimani
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Marc J M Bonten
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Charlotte A Bradbury
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Frank M Brunkhorst
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Adrian Buzgau
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Allen C Cheng
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Michelle A Detry
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Eamon J Duffy
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Lise J Estcourt
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Mark Fitzgerald
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Herman Goossens
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Rashan Haniffa
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Alisa M Higgins
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Thomas E Hills
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Christopher M Horvat
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Francois Lamontagne
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Patrick R Lawler
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Helen L Leavis
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Kelsey M Linstrum
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Edward Litton
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Elizabeth Lorenzi
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - John C Marshall
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Florian B Mayr
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Daniel F McAuley
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Anna McGlothlin
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Shay P McGuinness
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Bryan J McVerry
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Stephanie K Montgomery
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Susan C Morpeth
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Srinivas Murthy
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Katrina Orr
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Rachael L Parke
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Jane C Parker
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Asad E Patanwala
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Ville Pettilä
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Emma Rademaker
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Marlene S Santos
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Christina T Saunders
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Christopher W Seymour
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Manu Shankar-Hari
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Wendy I Sligl
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Alexis F Turgeon
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Anne M Turner
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Frank L van de Veerdonk
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Ryan Zarychanski
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Cameron Green
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Roger J Lewis
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Derek C Angus
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Colin J McArthur
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Scott Berry
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Steve A Webb
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
| | - Lennie P G Derde
- From Imperial College London (A.C.G., F.A.-B.), Imperial College Healthcare NHS Trust, St. Mary's Hospital (A.C.G.), Intensive Care National Audit and Research Centre (P.R.M., K.M.R.), University College London Hospital (R.H.), King's College London (M.S.-H.), and Guy's and St. Thomas' NHS Foundation Trust (M.S.-H.), London, University of Oxford (A. Beane) and NHS Blood and Transplant (L.J.E.), Oxford, and University of Bristol, Bristol (C.A.B.) - all in the United Kingdom; Monash University (A.D.N., A. Buzgau, A.C.C., A.M.H., S.P.M., J.C.P., C.G., S.A.W.) and Alfred Health (A.D.N., A.C.C.), Melbourne, VIC, Fiona Stanley Hospital (E. Litton, K.O.) and University of Western Australia (E. Litton), Perth, WA, University of Sydney and Royal Prince Alfred Hospital, Sydney (A.E.P.), and St. John of God Hospital, Subiaco, WA (S.A.W.) - all in Australia; University College Dublin, Dublin (A.D.N.); King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Y.M.A.); Hospital Raymond Poincaré (Assistance Publique-Hôpitaux de Paris) and Université Paris Saclay-Université de Versailles Saint-Quentin-en-Yvelines-INSERM, Garches, and Université de Versailles Saint-Quentin-en-Yvelines-Université Paris Saclay, Montigny-le-Bretonneux - all in France (D.A.); University Medical Center Utrecht, Utrecht (W.B.-P., M.J.M.B., H.L.L., E.R., L.P.G.D.), and Radboudumc, Nijmegen (F.L.V.) - both in the Netherlands; Berry Consultants, Austin, TX (L.R.B., M.A.D., M.F., E. Lorenzi, A.M., C.T.S., R.J.L., S.B.); St. Michael's Hospital Unity Health (Z.B., J.C.M., M.S.S.) and University Health Network and University of Toronto (P.R.L.), Toronto, Université de Sherbrooke, Sherbrooke, QC (F.L.), University of British Columbia, Vancouver (S.M.), University of Alberta, Edmonton (W.I.S.), Université Laval, Québec City (A.F.T.), and University of Manitoba, Winnipeg, MB (R.Z.) - all in Canada; Jena University Hospital, Jena, Germany (F.M.B.); Auckland City Hospital (E.J.D., T.E.H., S.P.M., R.L.P., C.J.M.), Middlemore Hospital (S.C.M.), and University of Auckland (R.L.P.), Auckland, and Medical Research Institute of New Zealand, Wellington (T.E.H., S.P.M., A.M.T.) - all in New Zealand; University of Antwerp, Wilrijk, Belgium (H.G.); University of Oxford, Bangkok, Thailand (R.H.); National Intensive Care Surveillance, Colombo, Sri Lanka (R.H.); UPMC Children's Hospital of Pittsburgh (C.M.H.) and University of Pittsburgh (K.M.L., F.B.M., B.J.M., S.K.M., C.W.S., D.C.A.), Pittsburgh; Queen's University Belfast and Royal Victoria Hospital, Belfast, Northern Ireland (D.F.M.); University of Helsinki and Helsinki University Hospital, Helsinki (V.P.); and Harbor-UCLA Medical Center, Torrance, CA (R.J.L.)
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Rosas IO, Bräu N, Waters M, Go RC, Hunter BD, Bhagani S, Skiest D, Aziz MS, Cooper N, Douglas IS, Savic S, Youngstein T, Del Sorbo L, Cubillo Gracian A, De La Zerda DJ, Ustianowski A, Bao M, Dimonaco S, Graham E, Matharu B, Spotswood H, Tsai L, Malhotra A. Tocilizumab in Hospitalized Patients with Severe Covid-19 Pneumonia. N Engl J Med 2021; 384:1503-1516. [PMID: 33631066 PMCID: PMC7953459 DOI: 10.1056/nejmoa2028700] [Citation(s) in RCA: 637] [Impact Index Per Article: 212.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (Covid-19) is associated with immune dysregulation and hyperinflammation, including elevated interleukin-6 levels. The use of tocilizumab, a monoclonal antibody against the interleukin-6 receptor, has resulted in better outcomes in patients with severe Covid-19 pneumonia in case reports and retrospective observational cohort studies. Data are needed from randomized, placebo-controlled trials. METHODS In this phase 3 trial, we randomly assigned patients who were hospitalized with severe Covid-19 pneumonia in a 2:1 ratio receive a single intravenous infusion of tocilizumab (at a dose of 8 mg per kilogram of body weight) or placebo. Approximately one quarter of the participants received a second dose of tocilizumab or placebo 8 to 24 hours after the first dose. The primary outcome was clinical status at day 28 on an ordinal scale ranging from 1 (discharged or ready for discharge) to 7 (death) in the modified intention-to-treat population, which included all the patients who had received at least one dose of tocilizumab or placebo. RESULTS Of the 452 patients who underwent randomization, 438 (294 in the tocilizumab group and 144 in the placebo group) were included in the primary and secondary analyses. The median value for clinical status on the ordinal scale at day 28 was 1.0 (95% confidence interval [CI], 1.0 to 1.0) in the tocilizumab group and 2.0 (non-ICU hospitalization without supplemental oxygen) (95% CI, 1.0 to 4.0) in the placebo group (between-group difference, -1.0; 95% CI, -2.5 to 0; P = 0.31 by the van Elteren test). In the safety population, serious adverse events occurred in 103 of 295 patients (34.9%) in the tocilizumab group and in 55 of 143 patients (38.5%) in the placebo group. Mortality at day 28 was 19.7% in the tocilizumab group and 19.4% in the placebo group (weighted difference, 0.3 percentage points; 95% CI, -7.6 to 8.2; nominal P = 0.94). CONCLUSIONS In this randomized trial involving hospitalized patients with severe Covid-19 pneumonia, the use of tocilizumab did not result in significantly better clinical status or lower mortality than placebo at 28 days. (Funded by F. Hoffmann-La Roche and the Department of Health and Human Services; COVACTA ClinicalTrials.gov number, NCT04320615.).
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Affiliation(s)
- Ivan O Rosas
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Norbert Bräu
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Michael Waters
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Ronaldo C Go
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Bradley D Hunter
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Sanjay Bhagani
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Daniel Skiest
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Mariam S Aziz
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Nichola Cooper
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Ivor S Douglas
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Sinisa Savic
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Taryn Youngstein
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Lorenzo Del Sorbo
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Antonio Cubillo Gracian
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - David J De La Zerda
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Andrew Ustianowski
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Min Bao
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Sophie Dimonaco
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Emily Graham
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Balpreet Matharu
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Helen Spotswood
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Larry Tsai
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Atul Malhotra
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
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Witting C, Quaggin-Smith J, Mylvaganam R, Peigh G, Angarone M, Flaherty JD. Invasive pulmonary aspergillosis after treatment with tocilizumab in a patient with COVID-19 ARDS: a case report. Diagn Microbiol Infect Dis 2021; 99:115272. [PMID: 33388572 PMCID: PMC7677089 DOI: 10.1016/j.diagmicrobio.2020.115272] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 11/09/2020] [Accepted: 11/14/2020] [Indexed: 12/16/2022]
Abstract
Tocilizumab, an interleukin-6 receptor antagonist, has been used to treat critically ill patients with coronavirus disease-2019. We present the case of a previously immunocompetent man with coronavirus disease-2019 who developed invasive pulmonary aspergillosis after treatment with tocilizumab, illustrating the importance of considering opportunistic infections when providing immune modulating therapy.
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Affiliation(s)
- Celeste Witting
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jessica Quaggin-Smith
- Department of Internal Medicine, McGaw Medical Center of Northwestern University, Chicago, IL, USA
| | - Ruben Mylvaganam
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, McGaw Medical Center of Northwestern University, Chicago, IL, USA
| | - Graham Peigh
- Department of Internal Medicine, McGaw Medical Center of Northwestern University, Chicago, IL, USA
| | - Michael Angarone
- Division of Infectious Disease, Department of Internal Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - James D Flaherty
- Division of Cardiology, Department of Internal Medicine, Northwestern Memorial Hospital, Chicago, IL, USA.
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Rubin EJ, Baden LR, Morrissey S. Audio Interview: A New SARS-CoV-2 Vaccine and a New Look at Treatment. N Engl J Med 2021; 384:e46. [PMID: 33657301 DOI: 10.1056/nejme2103680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Soin AS, Kumar K, Choudhary NS, Sharma P, Mehta Y, Kataria S, Govil D, Deswal V, Chaudhry D, Singh PK, Gupta A, Agarwal V, Kumar S, Sangle SA, Chawla R, Narreddy S, Pandit R, Mishra V, Goel M, Ramanan AV. Tocilizumab plus standard care versus standard care in patients in India with moderate to severe COVID-19-associated cytokine release syndrome (COVINTOC): an open-label, multicentre, randomised, controlled, phase 3 trial. Lancet Respir Med 2021; 9:511-521. [PMID: 33676589 PMCID: PMC8078880 DOI: 10.1016/s2213-2600(21)00081-3] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Global randomised controlled trials of the anti-IL-6 receptor antibody tocilizumab in patients admitted to hospital with COVID-19 have shown conflicting results but potential decreases in time to discharge and burden on intensive care. Tocilizumab reduced progression to mechanical ventilation and death in a trial population enriched for racial and ethnic minorities. We aimed to investigate whether tocilizumab treatment could prevent COVID-19 progression in the first multicentre randomised controlled trial of tocilizumab done entirely in a lower-middle-income country. METHODS COVINTOC is an open-label, multicentre, randomised, controlled, phase 3 trial done at 12 public and private hospitals across India. Adults (aged ≥18 years) admitted to hospital with moderate to severe COVID-19 (Indian Ministry of Health grading) confirmed by positive SARS-CoV-2 PCR result were randomly assigned (1:1 block randomisation) to receive tocilizumab 6 mg/kg plus standard care (the tocilizumab group) or standard care alone (the standard care group). The primary endpoint was progression of COVID-19 (from moderate to severe or from severe to death) up to day 14 in the modified intention-to-treat population of all participants who had at least one post-baseline assessment for the primary endpoint. Safety was assessed in all randomly assigned patients. The trial is completed and registered with the Clinical Trials Registry India (CTRI/2020/05/025369). FINDINGS 180 patients were recruited between May 30, 2020, and Aug 31, 2020, and randomly assigned to the tocilizumab group (n=90) or the standard care group (n=90). One patient randomly assigned to the standard care group inadvertently received tocilizumab at baseline and was included in the tocilizumab group for all analyses. One patient randomly assigned to the standard care group withdrew consent after the baseline visit and did not receive any study medication and was not included in the modified intention-to-treat population but was still included in safety analyses. 75 (82%) of 91 in the tocilizumab group and 68 (76%) of 89 in the standard care group completed 28 days of follow-up. Progression of COVID-19 up to day 14 occurred in eight (9%) of 91 patients in the tocilizumab group and 11 (13%) of 88 in the standard care group (difference -3·71 [95% CI -18·23 to 11·19]; p=0·42). 33 (36%) of 91 patients in the tocilizumab group and 22 (25%) of 89 patients in the standard care group had adverse events; 18 (20%) and 15 (17%) had serious adverse events. The most common adverse event was acute respiratory distress syndrome, reported in seven (8%) patients in each group. Grade 3 adverse events were reported in two (2%) patients in the tocilizumab group and five (6%) patients in the standard care group. There were no grade 4 adverse events. Serious adverse events were reported in 18 (20%) patients in the tocilizumab group and 15 (17%) in the standard care group; 13 (14%) and 15 (17%) patients died during the study. INTERPRETATION Routine use of tocilizumab in patients admitted to hospital with moderate to severe COVID-19 is not supported. However, post-hoc evidence from this study suggests tocilizumab might still be effective in patients with severe COVID-19 and so should be investigated further in future studies. FUNDING Medanta Institute of Education and Research, Roche India, Cipla India, and Action COVID-19 India.
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Affiliation(s)
- Arvinder S Soin
- Medanta Institute of Education and Research, Medanta-The Medicity Hospital, Gurugram, Haryana, India.
| | - Kuldeep Kumar
- Medanta Institute of Education and Research, Medanta-The Medicity Hospital, Gurugram, Haryana, India
| | - Narendra S Choudhary
- Medanta Institute of Education and Research, Medanta-The Medicity Hospital, Gurugram, Haryana, India
| | - Pooja Sharma
- Medanta Institute of Education and Research, Medanta-The Medicity Hospital, Gurugram, Haryana, India
| | - Yatin Mehta
- Medanta-The Medicity Hospital, Gurugram, Haryana, India
| | | | - Deepak Govil
- Medanta-The Medicity Hospital, Gurugram, Haryana, India
| | - Vikas Deswal
- Medanta-The Medicity Hospital, Gurugram, Haryana, India
| | - Dhruva Chaudhry
- Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | | | | | - Vikas Agarwal
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | | | | | | | | | | | | | - Manoj Goel
- Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust and Translational Health Sciences, Bristol Medical School, Bristol, UK
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21
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Strohbehn GW, Heiss BL, Rouhani SJ, Trujillo JA, Yu J, Kacew AJ, Higgs EF, Bloodworth JC, Cabanov A, Wright RC, Koziol AK, Weiss A, Danahey K, Karrison TG, Edens CC, Bauer Ventura I, Pettit NN, Patel BK, Pisano J, Strek ME, Gajewski TF, Ratain MJ, Reid PD. COVIDOSE: A Phase II Clinical Trial of Low-Dose Tocilizumab in the Treatment of Noncritical COVID-19 Pneumonia. Clin Pharmacol Ther 2021; 109:688-696. [PMID: 33210302 PMCID: PMC7753375 DOI: 10.1002/cpt.2117] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [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: 09/25/2020] [Accepted: 11/03/2020] [Indexed: 12/22/2022]
Abstract
Interleukin-6 (IL-6)-mediated hyperinflammation may contribute to the mortality of coronavirus disease 2019 (COVID-19). The IL-6 receptor-blocking monoclonal antibody tocilizumab has been repurposed for COVID-19, but prospective trials and dose-finding studies in COVID-19 have not yet fully reported. We conducted a single-arm phase II trial of low-dose tocilizumab in nonintubated hospitalized adult patients with COVID-19, radiographic pulmonary infiltrate, fever, and C-reactive protein (CRP) ≥ 40 mg/L. We hypothesized that doses significantly lower than the emerging standards of 400 mg or 8 mg/kg would resolve clinical and laboratory indicators of hyperinflammation. A dose range from 40 to 200 mg was evaluated, with allowance for one repeat dose at 24 to 48 hours. The primary objective was to assess the relationship of dose to fever resolution and CRP response. Thirty-two patients received low-dose tocilizumab, with the majority experiencing fever resolution (75%) and CRP decline consistent with IL-6 pathway abrogation (86%) in the 24-48 hours following drug administration. There was no evidence of a relationship between dose and fever resolution or CRP decline over the dose range of 40-200 mg. Within the 28-day follow-up, 5 (16%) patients died. For patients who recovered, median time to clinical recovery was 3 days (interquartile range, 2-5). Clinically presumed and/or cultured bacterial superinfections were reported in 5 (16%) patients. Low-dose tocilizumab was associated with rapid improvement in clinical and laboratory measures of hyperinflammation in hospitalized patients with COVID-19. Results of this trial provide rationale for a randomized, controlled trial of low-dose tocilizumab in COVID-19.
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MESH Headings
- Aged
- Anti-Inflammatory Agents/administration & dosage
- Anti-Inflammatory Agents/adverse effects
- Anti-Inflammatory Agents/pharmacology
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- C-Reactive Protein/analysis
- COVID-19/blood
- COVID-19/physiopathology
- Dose-Response Relationship, Drug
- Drug Monitoring/methods
- Female
- Fever/diagnosis
- Fever/drug therapy
- Humans
- Male
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/drug therapy
- Pneumonia, Viral/etiology
- Receptors, Interleukin-6/antagonists & inhibitors
- SARS-CoV-2/isolation & purification
- Severity of Illness Index
- Time Factors
- Treatment Outcome
- COVID-19 Drug Treatment
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Affiliation(s)
- Garth W. Strohbehn
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Brian L. Heiss
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Sherin J. Rouhani
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Jonathan A. Trujillo
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Jovian Yu
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Alec J. Kacew
- Pritzker School of MedicineThe University of ChicagoChicagoIllinoisUSA
| | - Emily F. Higgs
- Committee on ImmunologyThe University of ChicagoChicagoIllinoisUSA
| | - Jeffrey C. Bloodworth
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | | | - Rachel C. Wright
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Adriana K. Koziol
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Alexandra Weiss
- Department of MedicineSection of Pulmonary and Critical Care MedicineThe University of ChicagoChicagoIllinoisUSA
| | - Keith Danahey
- Center for Personalized TherapeuticsThe University of ChicagoChicagoIllinoisUSA
- Center for Research InformaticsThe University of ChicagoChicagoIllinoisUSA
| | | | - Cuoghi C. Edens
- Department of MedicineSection of RheumatologyThe University of ChicagoChicagoIllinoisUSA
- Department of PediatricsSection of RheumatologyThe University of ChicagoChicagoIllinoisUSA
| | - Iazsmin Bauer Ventura
- Department of MedicineSection of RheumatologyThe University of ChicagoChicagoIllinoisUSA
| | | | - Bhakti K. Patel
- Department of MedicineSection of Pulmonary and Critical Care MedicineThe University of ChicagoChicagoIllinoisUSA
| | - Jennifer Pisano
- Department of MedicineSection of Infectious Diseases and Global HealthThe University of ChicagoChicagoIllinoisUSA
| | - Mary E. Strek
- Department of MedicineSection of Pulmonary and Critical Care MedicineThe University of ChicagoChicagoIllinoisUSA
| | - Thomas F. Gajewski
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
| | - Mark J. Ratain
- Department of MedicineSection of Hematology/OncologyThe University of ChicagoChicagoIllinoisUSA
- Center for Personalized TherapeuticsThe University of ChicagoChicagoIllinoisUSA
| | - Pankti D. Reid
- Department of MedicineSection of RheumatologyThe University of ChicagoChicagoIllinoisUSA
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22
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Bovet M, Wadsack D, Kosely F, Zink W, Zahn R. [Fatal course of COVID-19 despite IL-6 receptor blockade in cytokine storm : Perimyocarditis and coagulopathy after administration of tocilizumab]. Anaesthesist 2021; 70:121-126. [PMID: 33064176 PMCID: PMC7563901 DOI: 10.1007/s00101-020-00871-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/27/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
A 59-year-old male patient was admitted to hospital diagnosed with moderate pneumonia associated with COVID-19. Upfront treatment with hydroxychloroquine and azithromycin was started. Due to a clinical deterioration (ARDS, circulatory shock) and greatly increased inflammation markers 6 days after admission, a cytokine storm was suspected and off-label treatment with the IL‑6 receptor antagonist tocilizumab was initiated. Subsequently there was a dramatic rise of D‑dimers indicating pulmonary intravascular coagulopathy and respiratory insufficiency worsened. After a second dose of tocilizumab was administered severe perimyocarditis with cardiac arrhythmia, hemodynamic instability and ST elevation occurred. Shortly afterwards the patient died due to multiorgan failure. From our experience, exacerbation of COVID-19 following treatment with tocilizumab cannot be ruled out. Randomized controlled studies are necessary to further investigate the efficacy, safety and patient selection criteria for tocilizumab treatment in COVID-19.
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Affiliation(s)
- M Bovet
- Klinik für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin (Medizinische Klinik B), Klinikum Ludwigshafen, Bremserstraße 79, 67073, Ludwigshafen, Deutschland.
| | - D Wadsack
- Klinik für Innere Medizin, Hämato-Onkologie, Nephrologie, Infektiologie und Rheumatologie (Medizinische Klinik A), Klinikum Ludwigshafen, Ludwigshafen, Deutschland
| | - F Kosely
- Klinik für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin (Medizinische Klinik B), Klinikum Ludwigshafen, Bremserstraße 79, 67073, Ludwigshafen, Deutschland
| | - W Zink
- Klinik für Anästhesiologie, Operative Intensivmedizin und Notfallmedizin, Klinikum Ludwigshafen, Ludwigshafen, Deutschland
| | - R Zahn
- Klinik für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin (Medizinische Klinik B), Klinikum Ludwigshafen, Bremserstraße 79, 67073, Ludwigshafen, Deutschland
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23
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Tleyjeh IM, Kashour Z, Damlaj M, Riaz M, Tlayjeh H, Altannir M, Altannir Y, Al-Tannir M, Tleyjeh R, Hassett L, Kashour T. Efficacy and safety of tocilizumab in COVID-19 patients: a living systematic review and meta-analysis. Clin Microbiol Infect 2021; 27:215-227. [PMID: 33161150 PMCID: PMC7644182 DOI: 10.1016/j.cmi.2020.10.036] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Cytokine release syndrome with elevated interleukin-6 (IL-6) levels is associated with multiorgan damage and death in severe coronavirus disease 2019 (COVID-19). Our objective was to perform a living systematic review of the literature concerning the efficacy and toxicity of the IL-6 receptor antagonist tocilizumab in COVID-19 patients. METHODS Data sources were Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus up, preprint servers and Google up to October 8, 2020. Study eligibility criteria were randomized controlled trials (RCTs) and observational studies at low or moderate risk of bias. Participants were hospitalized COVID-19 patients. Interventions included tocilizumab versus placebo or standard of care. We pooled crude risk ratios (RRs) of RCTs and adjusted RRs from cohorts, separately. We evaluated inconsistency between studies with I2. We assessed the certainty of evidence using the GRADE approach. RESULTS Of 1156 citations, 24 studies were eligible (five RCTs and 19 cohorts). Five RCTs at low risk of bias, with 1325 patients, examined the effect of tocilizumab on short-term mortality; pooled RR was 1.09 (95%CI 0.80-1.49, I2 = 0%). Four RCTs with 771 patients examined the effect of tocilizumab on risk of mechanical ventilation; pooled RR was 0.71 (95%CI 0.52-0.96, I2 = 0%), with a corresponding number needed to treat of 17 (95%CI 9-100). Among 18 cohorts at moderate risk of bias with 9850 patients, the pooled adjusted RR for mortality was 0.58 (95%CI 0.51-0.66, I2 = 2.5%). This association was observed over all degrees of COVID-19 severity. Data from the RCTs did not show a higher risk of infections or adverse events with tocilizumab: pooled RR 0.63 (95%CI 0.38-1.06, five RCTs) and 0.83 (95%CI 0.55-1.24, five RCTs), respectively. CONCLUSIONS Cumulative moderate-certainty evidence shows that tocilizumab reduces the risk of mechanical ventilation in hospitalized COVID-19 patients. While RCTs showed that tocilizumab did not reduce short-term mortality, low-certainty evidence from cohort studies suggests an association between tocilizumab and lower mortality. We did not observe a higher risk of infections or adverse events with tocilizumab use. This review will continuously evaluate the role of tocilizumab in COVID-19 treatment.
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Affiliation(s)
- Imad M Tleyjeh
- Infectious Diseases Section, Department of Medical Specialties King Fahad Medical City, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Zakariya Kashour
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Moussab Damlaj
- Division of Hematology and HSCT, Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Muhammad Riaz
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar
| | - Haytham Tlayjeh
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Department of Intensive Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | | | | | - Rana Tleyjeh
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | - Tarek Kashour
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University Medical City, Riyadh, Saudi Arabia
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24
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Xu C, Rafique A, Potocky T, Paccaly A, Nolain P, Lu Q, Iglesias-Rodriguez M, St John G, Nivens MC, Kanamaluru V, Fairhurst J, Ishii T, Maldonado R, Choy E, Emery P. Differential Binding of Sarilumab and Tocilizumab to IL-6Rα and Effects of Receptor Occupancy on Clinical Parameters. J Clin Pharmacol 2021; 61:714-724. [PMID: 33314148 DOI: 10.1002/jcph.1795] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 11/27/2020] [Indexed: 01/21/2023]
Abstract
We evaluated interleukin-6 (IL-6) receptor-α subunit (IL-6Rα) signaling inhibition with sarilumab and tocilizumab, the association between IL-6Rα receptor occupancy (RO) and C-reactive protein (CRP), and the potential clinical relevance of any differences. For this, we measured IL-6Rα binding and signaling inhibition with sarilumab and tocilizumab in vitro, simulated soluble IL-6Rα RO over time for approved sarilumab subcutaneous (SC) and tocilizumab intravenous (IV) and SC doses, and assessed associations between calculated RO and CRP reduction, 28-joint Disease Activity Score based on CRP, and 20%/50%/70% improvement in American College of Rheumatology responses from clinical data. Sarilumab binds IL-6Rα in vitro with 15- to 22-fold higher affinity than tocilizumab, and inhibits IL-6-mediated classical and trans signaling via membrane-bound and soluble IL-6Rα. Sarilumab 200 and 150 mg SC every 2 weeks achieved >90% RO after first and second doses, respectively, maintained throughout the treatment period. At steady-state trough, RO was greater with sarilumab 200 mg (98%) and 150 mg SC every 2 weeks (94%), and tocilizumab 162 mg SC weekly (>99%) and 8 mg/kg IV every 4 weeks (99%), vs tocilizumab 162 mg SC every 2 weeks (84%) and 4 mg/kg IV every 4 weeks (60%). Higher RO was associated with greater CRP reduction and 28-joint Disease Activity Score based on CRP reduction, and more sarilumab patients achieving 20%/50%/70% improvement in American College of Rheumatology responses. The greatest reduction in CRP levels was observed with sarilumab (both doses) and tocilizumab 8 mg/kg IV every 4 weeks (reductions proportionally smaller with 4 mg/kg IV every 4 weeks). Higher IL-6Rα binding affinity translated into higher RO with sarilumab vs tocilizumab 4 mg/kg every 4 weeks or 162 mg every 2 weeks; tocilizumab required the higher dose or increased frequency to maintain the same degree of RO and CRP reduction. Higher RO was associated with clinical parameter improvements.
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Affiliation(s)
- Christine Xu
- Translational Medicine and Early Development, Sanofi, Bridgewater, New Jersey, USA
| | - Ashique Rafique
- Therapeutic Proteins, Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Terra Potocky
- Bioassay Development, Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Anne Paccaly
- Immunology, Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Patrick Nolain
- Research and Development, Sanofi-Aventis, Montpellier, France
| | - Qiang Lu
- Modeling and Simulation, Pharmacokinetics, Dynamics, and Metabolism, Sanofi, Bridgewater, New Jersey, USA
| | | | - Gregory St John
- Immunology and Inflammation, Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Michael C Nivens
- Strategic Program Direction, Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Vanaja Kanamaluru
- Pharmacokinetics, Dynamics, and Metabolism, Sanofi, Bridgewater, New Jersey, USA
| | - Jeanette Fairhurst
- Therapeutic Proteins, Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Tomonori Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Rafael Maldonado
- Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Ernest Choy
- Department of Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Paul Emery
- Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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25
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Hermine O, Mariette X, Tharaux PL, Resche-Rigon M, Porcher R, Ravaud P. Effect of Tocilizumab vs Usual Care in Adults Hospitalized With COVID-19 and Moderate or Severe Pneumonia: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:32-40. [PMID: 33080017 PMCID: PMC7577198 DOI: 10.1001/jamainternmed.2020.6820] [Citation(s) in RCA: 523] [Impact Index Per Article: 174.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/01/2020] [Indexed: 01/08/2023]
Abstract
Importance Severe pneumonia with hyperinflammation and elevated interleukin-6 is a common presentation of coronavirus disease 2019 (COVID-19). Objective To determine whether tocilizumab (TCZ) improves outcomes of patients hospitalized with moderate-to-severe COVID-19 pneumonia. Design, Setting, and Particpants This cohort-embedded, investigator-initiated, multicenter, open-label, bayesian randomized clinical trial investigating patients with COVID-19 and moderate or severe pneumonia requiring at least 3 L/min of oxygen but without ventilation or admission to the intensive care unit was conducted between March 31, 2020, to April 18, 2020, with follow-up through 28 days. Patients were recruited from 9 university hospitals in France. Analyses were performed on an intention-to-treat basis with no correction for multiplicity for secondary outcomes. Interventions Patients were randomly assigned to receive TCZ, 8 mg/kg, intravenously plus usual care on day 1 and on day 3 if clinically indicated (TCZ group) or to receive usual care alone (UC group). Usual care included antibiotic agents, antiviral agents, corticosteroids, vasopressor support, and anticoagulants. Main Outcomes and Measures Primary outcomes were scores higher than 5 on the World Health Organization 10-point Clinical Progression Scale (WHO-CPS) on day 4 and survival without need of ventilation (including noninvasive ventilation) at day 14. Secondary outcomes were clinical status assessed with the WHO-CPS scores at day 7 and day 14, overall survival, time to discharge, time to oxygen supply independency, biological factors such as C-reactive protein level, and adverse events. Results Of 131 patients, 64 patients were randomly assigned to the TCZ group and 67 to UC group; 1 patient in the TCZ group withdrew consent and was not included in the analysis. Of the 130 patients, 42 were women (32%), and median (interquartile range) age was 64 (57.1-74.3) years. In the TCZ group, 12 patients had a WHO-CPS score greater than 5 at day 4 vs 19 in the UC group (median posterior absolute risk difference [ARD] -9.0%; 90% credible interval [CrI], -21.0 to 3.1), with a posterior probability of negative ARD of 89.0% not achieving the 95% predefined efficacy threshold. At day 14, 12% (95% CI -28% to 4%) fewer patients needed noninvasive ventilation (NIV) or mechanical ventilation (MV) or died in the TCZ group than in the UC group (24% vs 36%, median posterior hazard ratio [HR] 0.58; 90% CrI, 0.33-1.00), with a posterior probability of HR less than 1 of 95.0%, achieving the predefined efficacy threshold. The HR for MV or death was 0.58 (90% CrI, 0.30 to 1.09). At day 28, 7 patients had died in the TCZ group and 8 in the UC group (adjusted HR, 0.92; 95% CI 0.33-2.53). Serious adverse events occurred in 20 (32%) patients in the TCZ group and 29 (43%) in the UC group (P = .21). Conclusions and Relevance In this randomized clinical trial of patients with COVID-19 and pneumonia requiring oxygen support but not admitted to the intensive care unit, TCZ did not reduce WHO-CPS scores lower than 5 at day 4 but might have reduced the risk of NIV, MV, or death by day 14. No difference on day 28 mortality was found. Further studies are necessary for confirming these preliminary results. Trial Registration ClinicalTrials.gov Identifier: NCT04331808.
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Affiliation(s)
- Olivier Hermine
- Department of Hematology, Hôpital Necker, Assistance Publique - Hôpitaux de Paris, France
- Institut Imagine, Université de Paris, INSERM UMR1183, Paris France
| | - Xavier Mariette
- Department of Rheumatology, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, France
- Université Paris-Saclay, INSERM UMR1184, Le Kremlin Bicêtre, France
| | - Pierre-Louis Tharaux
- Paris Cardiovascular Center–PARCC, Université de Paris, INSERM, F-75015 Paris, France
| | - Matthieu Resche-Rigon
- Université de Paris, ECSTRRA Team-CRESS-UMR 1153, INSERM, 75010, Paris, France
- URC Saint-Louis, AP-HP, Hôpital Saint-Louis, 75010, France
| | - Raphaël Porcher
- Université de Paris, Centre of Research Epidemiology and Statistics (CRESS), INSERM U1153, Paris, France
| | - Philippe Ravaud
- Université de Paris, Centre of Research Epidemiology and Statistics (CRESS), INSERM U1153, Paris, France
- Centre d’Epidémiologie Clinique, AP-HP (Assistance Publique des Hôpitaux de Paris), Hôpital Hôtel Dieu, Paris, France
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26
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Di Nisio M, Potere N, Candeloro M, Spacone A, Pieramati L, Ferrandu G, Rizzo G, La Vella M, Di Carlo S, Cibelli D, Parruti G, Levi M, Porreca E. Interleukin-6 receptor blockade with subcutaneous tocilizumab improves coagulation activity in patients with COVID-19. Eur J Intern Med 2021; 83:34-38. [PMID: 33162299 PMCID: PMC7608031 DOI: 10.1016/j.ejim.2020.10.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/16/2020] [Accepted: 10/25/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Many COVID-19 patients develop a hyperinflammatory response which activates blood coagulation and may contribute to the occurrence of thromboembolic complications. Blockade of interleukin-6, a key cytokine in COVID-19 pathogenesis, may improve the hypercoagulable state induced by inflammation. The aim of this study was to evaluate the effects of subcutaneous tocilizumab, a recombinant humanized monoclonal antibody against the interleukin-6 receptor on coagulation parameters. METHODS Hospitalized adult patients with laboratory-confirmed moderate to critical COVID-19 pneumonia and hyperinflammation, who received a single 324 mg subcutaneous dose of tocilizumab on top of standard of care were enrolled in this analysis. Coagulation parameters were measured before tocilizumab and at day 1, 3, and 7 after treatment. All patients were followed-up for 35 days after admission or until death. RESULTS 70 patients (mean age 60 years, interquartile range 52-75) were included. Treatment with tocilizumab was associated with a reduction in D-dimer levels (-56%; 95% confidence interval [CI], -68% to -44%), fibrinogen (-48%; 95%CI, -60% to -35%), C-reactive protein (-93%; 95%CI, -99% to -87%), prothrombin time (-4%; 95%CI,-9% to 0.8%), and activated thromboplastin time (-4%; 95%CI,-8.7% to 0.8%), and an increase in platelet count (34%; 95%CI, 23% to 45%). These changes occurred already one day after treatment with sustained reductions throughout day 7. The improvement in coagulation was consistently observed in patients receiving prophylactic or therapeutic dose anticoagulants, and was paralleled by a rapid improvement in respiratory function. CONCLUSIONS Subcutaneous tocilizumab was associated with significant improvement of blood coagulation parameters independently of thromboprophylaxis dose.
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Affiliation(s)
- Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti-Pescara, Italy; Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.
| | - Nicola Potere
- Department of Internal Medicine, "G. D'Annunzio" University, Chieti, Italy
| | - Matteo Candeloro
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti-Pescara, Italy
| | | | - Leonardo Pieramati
- Department of Internal Medicine, "G. D'Annunzio" University, Chieti, Italy.
| | | | - Giulia Rizzo
- Department of Internal Medicine, "G. D'Annunzio" University, Chieti, Italy
| | - Matteo La Vella
- Department of Internal Medicine, "G. D'Annunzio" University, Chieti, Italy
| | - Silvio Di Carlo
- Geriatric Medicine Unit, Pescara General Hospital, Pescara, Italy.
| | | | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | - Marcel Levi
- Cardiometabolic Programme, National Institute for Health Research University College London Hospitals (UCLH) Biomedical Research Centre, Department of Medicine, UCLH National Health Service Foundation Trust, London NW1 2PG, UK.
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University, Chieti, Italy.
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27
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Vu CA, DeRonde KJ, Vega AD, Maxam M, Holt G, Natori Y, Zamora JG, Salazar V, Boatwright R, Morris SR, de Lima Corvino D, Betances AF, Colucci L, Keegan J, Lopez A, Rezk AH, Rodriguez Y, Moraru GM, Doblecki S, De La Zerda DJ, Abbo LM. Effects of Tocilizumab in COVID-19 patients: a cohort study. BMC Infect Dis 2020; 20:964. [PMID: 33353546 PMCID: PMC7755065 DOI: 10.1186/s12879-020-05701-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 12/09/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Due to the lack of proven therapies, we evaluated the effects of early administration of tocilizumab for COVID-19. By inhibition of the IL-6 receptor, tocilizumab may help to mitigate the hyperinflammatory response associated with progressive respiratory failure from SARS-CoV-2. METHODS A retrospective, observational study was conducted on hospitalized adults who received intravenous tocilizumab for COVID-19 between March 23, 2020 and April 10, 2020. RESULTS Most patients were male (66.7%), Hispanic (63.3%) or Black (23.3%), with a median age of 54 years. Tocilizumab was administered at a median of 8 days (range 1-21) after initial symptoms and 2 days (range 0-12) after hospital admission. Within 30 days from receiving tocilizumab, 36 patients (60.0%) demonstrated clinical improvement, 9 (15.0%) died, 33 (55.0%) were discharged alive, and 18 (30.0%) remained hospitalized. Successful extubation occurred in 13 out of 29 patients (44.8%). Infectious complications occurred in 16 patients (26.7%) at a median of 10.5 days. After tocilizumab was administered, there was a slight increase in PaO2/FiO2 and an initial reduction in CRP, but this effect was not sustained beyond day 10. CONCLUSIONS Majority of patients demonstrated clinical improvement and were successfully discharged alive from the hospital after receiving tocilizumab. We observed a rebound effect with CRP, which may suggest the need for higher or subsequent doses to adequately manage cytokine storm. Based on our findings, we believe that tocilizumab may have a role in the early treatment of COVID-19, however larger randomized controlled studies are needed to confirm this.
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Affiliation(s)
- Christine A Vu
- Department of Pharmacy, Jackson Health System, Miami, FL, USA.
- Jackson Memorial Hospital, Pharmacy Services, B069, 1611 NW 12th Ave, Miami, FL, 33136, USA.
| | | | - Ana D Vega
- Department of Pharmacy, Jackson Health System, Miami, FL, USA
| | - Meshell Maxam
- Department of Pharmacy, Jackson Health System, Miami, FL, USA
| | - Gregory Holt
- Division of Pulmonary Critical Care, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Yoichiro Natori
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jose Gonzales Zamora
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | - Stephen R Morris
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Daniela de Lima Corvino
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Anmary Fernandez Betances
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Leah Colucci
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - James Keegan
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Andy Lopez
- University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | - Gabriela M Moraru
- Department of Pediatrics, Jackson Health System/Holtz Children's Hospital, Miami, FL, USA
| | - Susanne Doblecki
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David J De La Zerda
- Division of Pulmonary Critical Care, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lilian M Abbo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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Stone JH, Frigault MJ, Serling-Boyd NJ, Fernandes AD, Harvey L, Foulkes AS, Horick NK, Healy BC, Shah R, Bensaci AM, Woolley AE, Nikiforow S, Lin N, Sagar M, Schrager H, Huckins DS, Axelrod M, Pincus MD, Fleisher J, Sacks CA, Dougan M, North CM, Halvorsen YD, Thurber TK, Dagher Z, Scherer A, Wallwork RS, Kim AY, Schoenfeld S, Sen P, Neilan TG, Perugino CA, Unizony SH, Collier DS, Matza MA, Yinh JM, Bowman KA, Meyerowitz E, Zafar A, Drobni ZD, Bolster MB, Kohler M, D'Silva KM, Dau J, Lockwood MM, Cubbison C, Weber BN, Mansour MK. Efficacy of Tocilizumab in Patients Hospitalized with Covid-19. N Engl J Med 2020; 383:2333-2344. [PMID: 33085857 PMCID: PMC7646626 DOI: 10.1056/nejmoa2028836] [Citation(s) in RCA: 928] [Impact Index Per Article: 232.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The efficacy of interleukin-6 receptor blockade in hospitalized patients with coronavirus disease 2019 (Covid-19) who are not receiving mechanical ventilation is unclear. METHODS We performed a randomized, double-blind, placebo-controlled trial involving patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, hyperinflammatory states, and at least two of the following signs: fever (body temperature >38°C), pulmonary infiltrates, or the need for supplemental oxygen in order to maintain an oxygen saturation greater than 92%. Patients were randomly assigned in a 2:1 ratio to receive standard care plus a single dose of either tocilizumab (8 mg per kilogram of body weight) or placebo. The primary outcome was intubation or death, assessed in a time-to-event analysis. The secondary efficacy outcomes were clinical worsening and discontinuation of supplemental oxygen among patients who had been receiving it at baseline, both assessed in time-to-event analyses. RESULTS We enrolled 243 patients; 141 (58%) were men, and 102 (42%) were women. The median age was 59.8 years (range, 21.7 to 85.4), and 45% of the patients were Hispanic or Latino. The hazard ratio for intubation or death in the tocilizumab group as compared with the placebo group was 0.83 (95% confidence interval [CI], 0.38 to 1.81; P = 0.64), and the hazard ratio for disease worsening was 1.11 (95% CI, 0.59 to 2.10; P = 0.73). At 14 days, 18.0% of the patients in the tocilizumab group and 14.9% of the patients in the placebo group had had worsening of disease. The median time to discontinuation of supplemental oxygen was 5.0 days (95% CI, 3.8 to 7.6) in the tocilizumab group and 4.9 days (95% CI, 3.8 to 7.8) in the placebo group (P = 0.69). At 14 days, 24.6% of the patients in the tocilizumab group and 21.2% of the patients in the placebo group were still receiving supplemental oxygen. Patients who received tocilizumab had fewer serious infections than patients who received placebo. CONCLUSIONS Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with Covid-19. Some benefit or harm cannot be ruled out, however, because the confidence intervals for efficacy comparisons were wide. (Funded by Genentech; ClinicalTrials.gov number, NCT04356937.).
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Affiliation(s)
- John H Stone
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Matthew J Frigault
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Naomi J Serling-Boyd
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Ana D Fernandes
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Liam Harvey
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Andrea S Foulkes
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Nora K Horick
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Brian C Healy
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Ruta Shah
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Ana Maria Bensaci
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Ann E Woolley
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Sarah Nikiforow
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Nina Lin
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Manish Sagar
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Harry Schrager
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - David S Huckins
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Matthew Axelrod
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Michael D Pincus
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Jorge Fleisher
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Chana A Sacks
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Michael Dougan
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Crystal M North
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Yuan-Di Halvorsen
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Tara K Thurber
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Zeina Dagher
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Allison Scherer
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Rachel S Wallwork
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Arthur Y Kim
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Sara Schoenfeld
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Pritha Sen
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Tomas G Neilan
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Cory A Perugino
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Sebastian H Unizony
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Deborah S Collier
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Mark A Matza
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Janeth M Yinh
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Kathryn A Bowman
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Eric Meyerowitz
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Amna Zafar
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Zsofia D Drobni
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Marcy B Bolster
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Minna Kohler
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Kristin M D'Silva
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Jonathan Dau
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Megan M Lockwood
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Caroline Cubbison
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Brittany N Weber
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
| | - Michael K Mansour
- From Massachusetts General Hospital (J.H.S., M.J.F., N.J.S.-B., A.D.F., L.H., A.S.F., N.K.H., B.C.H., C.A.S., M.D., C.M.N., Y.-D.H., T.K.T., Z.D., A.S., R.S.W., A.Y.K., S.S., P.S., T.G.N., C.A.P., S.H.U., D.S.C., M.A.M., J.M.Y., K.A.B., E.M., A.Z., Z.D.D., M.B.B., M.K., K.M.D., J.D., M.M.L., M.K.M.), Brigham and Women's Hospital (A.E.W., S.N., B.N.W.), and Boston Medical Center (N.L., M.S.), Boston, North Shore Medical Center, Salem (R.S., A.M.B., C.C.), Newton-Wellesley Hospital, Newton (H.S., D.S.H.), Beth Israel Lahey Health, Burlington (M.A., M.D.P.), and St. Elizabeth's Medical Center, Brighton (J.F.) - all in Massachusetts
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29
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Nouri B, Nair N, Barton A. Predicting treatment response to IL6R blockers in rheumatoid arthritis. Rheumatology (Oxford) 2020; 59:3603-3610. [PMID: 32864695 PMCID: PMC7733712 DOI: 10.1093/rheumatology/keaa529] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/23/2020] [Accepted: 07/13/2020] [Indexed: 12/30/2022] Open
Abstract
Patients with severe, active RA who have not responded to conventional therapy may receive biological disease modifying anti-rheumatic drugs (bDMARDs). However, 40% of cases do not achieve complete disease control, resulting in a negative impact on patient quality of life and representing a waste of healthcare resources. Ongoing research seeks to establish biomarkers, which can be used to predict treatment response to biologics in RA to enable more targeted approaches to treatment. However, much of the work has focused on one class of biologic drug, the TNF inhibitors (TNFi). Here, we will review the current state of research to identify biomarkers predictive of response to the class of bDMARDs targeting the IL6R. While success has been limited thus far, serum drug and low ICAM1 levels have shown promise, with associations reported in independent studies. The challenges faced by researchers and lessons learned from studies of TNFi will be discussed.
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Affiliation(s)
- Bako Nouri
- Centre of Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester
| | - Nisha Nair
- Centre of Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester
| | - Anne Barton
- Centre of Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester
- NIHR Manchester Musculoskeletal BRU, Central Manchester Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
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30
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Salvati L, Occhipinti M, Gori L, Ciani L, Mazzoni A, Maggi L, Capone M, Parronchi P, Liotta F, Miele V, Annunziato F, Lavorini F, Cosmi L. Pulmonary vascular improvement in severe COVID-19 patients treated with tocilizumab. Immunol Lett 2020; 228:122-128. [PMID: 33161002 PMCID: PMC7644186 DOI: 10.1016/j.imlet.2020.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/31/2020] [Indexed: 02/07/2023]
Abstract
As of October 2020 management of Coronavirus disease 2019 (COVID-19) is based on supportive care and off-label or compassionate-use therapies. On March 2020 tocilizumab - an anti-IL-6 receptor monoclonal antibody - was suggested as immunomodulatory treatment in severe COVID-19 because hyperinflammatory syndrome occurs in many patients similarly to the cytokine release syndrome that develops after CAR-T cell therapy. In our retrospective observational study, 20 severe COVID-19 patients requiring intensive care were treated with tocilizumab in addition to standard-of-care therapy (SOC) and compared with 13 COVID-19 patients receiving only SOC. Clinical respiratory status, inflammatory markers and vascular radiologic score improved after one week from tocilizumab administration. On the contrary, these parameters were stable or worsened in patients receiving only SOC. Despite major study limitations, improvement of alveolar-arterial oxygen gradient as well as vascular radiologic score after one week may account for improved pulmonary vascular perfusion and could explain the more rapid recovery of COVID-19 patients receiving tocilizumab compared to controls.
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Affiliation(s)
- Lorenzo Salvati
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Mariaelena Occhipinti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Leonardo Gori
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Luca Ciani
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessio Mazzoni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Laura Maggi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Manuela Capone
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paola Parronchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Immunology and Cell Therapy Unit, Careggi University Hospital, Florence, Italy
| | - Francesco Liotta
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Immunology and Cell Therapy Unit, Careggi University Hospital, Florence, Italy
| | - Vittorio Miele
- Department of Emergency Radiology, Careggi University Hospital, Florence, Italy
| | - Francesco Annunziato
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Flow Cytometry Diagnostic Center and Immunotherapy (CDCI), Careggi University Hospital, Florence, Italy
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Pneumology and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Lorenzo Cosmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Immunology and Cell Therapy Unit, Careggi University Hospital, Florence, Italy.
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31
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Scherger S, Henao-Martínez A, Franco-Paredes C, Shapiro L. Rethinking interleukin-6 blockade for treatment of COVID-19. Med Hypotheses 2020; 144:110053. [PMID: 32758889 PMCID: PMC7320867 DOI: 10.1016/j.mehy.2020.110053] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 12/21/2022]
Abstract
Interleukin-6 (IL-6) is a pleiotropic cytokine with effects in immune regulation, inflammation, and infection. The use of drugs that inhibit IL-6 biological activity has been proposed as a treatment for patients with Coronavirus Disease 2019 (COVID-19). The rationale for this approach includes commitment to the concept that inflammation is a cause of lung damage in COVID-19 and belief that IL-6 is a pro-inflammatory molecule. Observational data thought to support IL-6 inhibition include elevated circulating IL-6 levels in COVID-19 patients and association between elevated IL-6 and poor clinical outcomes. However, IL-6 has significant anti-inflammatory properties, which calls into question the rationale for employing IL-6 blockade to suppress inflammation-induced tissue injury. Also, studies suggesting a beneficial role for IL-6 in the host response to infection challenge the strategy of using IL-6 blockade to treat COVID-19. In studies of recombinant IL-6 injected into human volunteers, IL-6 levels exceeding those measured in COVID-19 patients have been observed with no pulmonary adverse events or other organ damage. These observations question the role of IL-6 as a contributing factor in COVID-19. Clinical experience with IL-6 receptor antagonists such as tocilizumab demonstrates increase in severe and opportunistic infections, raising concern about using tocilizumab and similar agents to treat COVID-19. Trials of drugs to inhibit IL-6 activity in COVID-19 are ongoing and will shed light on the role of IL-6 in COVID-19 pathogenesis. However, until more information is available, providers should exercise caution in prescribing these therapies given the potential for patient harm.
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Affiliation(s)
- S Scherger
- Division of Infectious Diseases, University of Colorado Denver Anschutz Medical Campus, 12700 E. 19th Avenue, Aurora CO 80045, United States.
| | - A Henao-Martínez
- Division of Infectious Diseases, University of Colorado Denver Anschutz Medical Campus, 12700 E. 19th Avenue, Aurora CO 80045, United States
| | - C Franco-Paredes
- Division of Infectious Diseases, University of Colorado Denver Anschutz Medical Campus, 12700 E. 19th Avenue, Aurora CO 80045, United States; Hospital Infantil de México, Federico Gómez, México City, México
| | - L Shapiro
- Division of Infectious Diseases, University of Colorado Denver Anschutz Medical Campus, 12700 E. 19th Avenue, Aurora CO 80045, United States; Division of Infectious Diseases, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling St, Aurora, CO 80045, United States; Supported by The Emily Foundation for Medical Research, One Beacon Street, 15th Floor, Boston MA 02108, United States
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32
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Vaidya G, Czer LSC, Kobashigawa J, Kittleson M, Patel J, Chang D, Kransdorf E, Shikhare A, Tran H, Vo A, Ammerman N, Huang E, Zabner R, Jordan S. Successful Treatment of Severe COVID-19 Pneumonia With Clazakizumab in a Heart Transplant Recipient: A Case Report. Transplant Proc 2020; 52:2711-2714. [PMID: 32563584 PMCID: PMC7275980 DOI: 10.1016/j.transproceed.2020.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is characterized by an overwhelming cytokine response. Various treatment strategies have been attempted. METHODS AND RESULTS A 61-year-old man with heart transplantation in 2017 presented with fever, cough, and dyspnea, and was confirmed positive for coronavirus disease 2019 (COVID-19). Laboratory tests showed significant elevations in C-reactive protein and interleukin-6 (IL-6). Echocardiogram showed left ventricular ejection fraction 58% (with ejection fraction 57% 6 months prior). Given the lack of clear management guidelines, the patient was initially managed symptomatically. However, the patient subsequently had a rapid respiratory deterioration with worsening inflammatory markers on day 5 of admission. Tocilizumab (anti-IL-6R) was in low supply in the hospital. The patient was offered clazakizumab (anti-IL-6) for compassionate use. Patient received 25 mg intravenously × 1 dose. Within 24 hours, he showed significant improvement in symptoms, oxygen requirements, radiological findings, and inflammatory markers. There was a transient leukopenia that improved in 4 days. He was discharged home on day 11, with negative nasopharyngeal SARS-CoV-2 PCR as an outpatient on day 35, development of positive serum COVID-19 IgG antibody, and he continued to do well on day 60, with no heart-related symptoms. CONCLUSION Clazakizumab is a monoclonal antibody against human IL-6, which may be helpful in inhibiting the cytokine response to SARS-CoV-2 in COVID-19. Although not yet FDA approved, it is being investigated for treatment of renal antibody-mediated rejection. Clinical trials of clazakizumab for treatment of COVID-19 are underway worldwide.
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Affiliation(s)
- Gaurang Vaidya
- Cedars-Sinai Smidt Heart Institute, Heart Transplant Program, Cedars Sinai Medical Center, Los Angeles, California
| | - Lawrence S C Czer
- Cedars-Sinai Smidt Heart Institute, Heart Transplant Program, Cedars Sinai Medical Center, Los Angeles, California.
| | - Jon Kobashigawa
- Cedars-Sinai Smidt Heart Institute, Heart Transplant Program, Cedars Sinai Medical Center, Los Angeles, California
| | - Michelle Kittleson
- Cedars-Sinai Smidt Heart Institute, Heart Transplant Program, Cedars Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Cedars-Sinai Smidt Heart Institute, Heart Transplant Program, Cedars Sinai Medical Center, Los Angeles, California
| | - David Chang
- Cedars-Sinai Smidt Heart Institute, Heart Transplant Program, Cedars Sinai Medical Center, Los Angeles, California
| | - Evan Kransdorf
- Cedars-Sinai Smidt Heart Institute, Heart Transplant Program, Cedars Sinai Medical Center, Los Angeles, California
| | - Anuja Shikhare
- Department of Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Hai Tran
- Department of Pharmacy Services, Cedars Sinai Medical Center, Los Angeles, California
| | - Ashley Vo
- Comprehensive Transplant Center, Transplant Immunotherapy Program, Cedars Sinai Medical Center, Los Angeles, California
| | - Noriko Ammerman
- Comprehensive Transplant Center, Transplant Immunotherapy Program, Cedars Sinai Medical Center, Los Angeles, California
| | - Edmund Huang
- Comprehensive Transplant Center, Transplant Immunotherapy Program, Cedars Sinai Medical Center, Los Angeles, California
| | - Rachel Zabner
- Division of Infectious Diseases, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Stanley Jordan
- Comprehensive Transplant Center, Transplant Immunotherapy Program, Cedars Sinai Medical Center, Los Angeles, California
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Piccirillo MC, Ascierto P, Atripaldi L, Cascella M, Costantini M, Dolci G, Facciolongo N, Fraganza F, Marata A, Massari M, Montesarchio V, Mussini C, Negri EA, Parrella R, Popoli P, Botti G, Arenare L, Chiodini P, Gallo C, Salvarani C, Perrone F. TOCIVID-19 - A multicenter study on the efficacy and tolerability of tocilizumab in the treatment of patients with COVID-19 pneumonia. Study protocol. Contemp Clin Trials 2020; 98:106165. [PMID: 33031955 PMCID: PMC7536129 DOI: 10.1016/j.cct.2020.106165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pneumonia is the most frequent complication of COVID-19, due to an aberrant host immune response that is associated with an acute respiratory distress syndrome, and, in most critical patients, with a "cytokine storm". IL-6 might play a key role in the cytokine storm and might be a potential target to treat severe and critical COVID-19. Tocilizumab is a recombinant humanized monoclonal antibody, directed against IL-6 receptor. METHODS This multicentre study project includes a single-arm phase 2 study and a further parallel cohort, enrolling hospitalized patients with COVID-19 pneumonia and oxygen saturation at rest in ambient air ≤93% or requiring respiratory support. Patients receive tocilizumab 8 mg/kg (up to 800 mg) as one intravenous administration. A second administration (same dose) after 12 h is optional. Two-week and one-month lethality rates are the co-primary endpoints. Sample size planned for the phase 2 study is 330 patients. The parallel cohort will include patients who cannot enter the phase 2 study because being intubated from more than 24 h, or having already received tocilizumab, or the phase 2 study has reached sample size. Primary analysis will include patients enrolled in the phase 2 study. Results of the primary analysis will be validated in the prospective cohort of patients consecutively registered after phase 2 closure from March 20 to March 24, who were potentially eligible for the phase 2 study. CONCLUSION This trial aims to verify the safety and efficacy of tocilizumab in the Italian population with COVID-19 pneumonia and respiratory impairment. EudraCT Number: 2020-001110-38; Clinicaltrials.gov ID NCT04317092.
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Affiliation(s)
| | - Paolo Ascierto
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Luigi Atripaldi
- AORN Ospedali dei Colli -Monaldi -Cotugno- CTO, Napoli, Italy
| | - Marco Cascella
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | | | - Giovanni Dolci
- Azienda USL-IRCCS di Reggio Emilia, Italy; Università degli Studi di Modena e Reggio Emilia, Italy
| | | | | | | | | | | | | | | | | | | | - Gerardo Botti
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Laura Arenare
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Paolo Chiodini
- Università degli Studi della Campania Luigi Vanvitelli, Italy
| | - Ciro Gallo
- Università degli Studi della Campania Luigi Vanvitelli, Italy
| | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia, Italy; Università degli Studi di Modena e Reggio Emilia, Italy
| | - Francesco Perrone
- Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy.
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34
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Guillén L, Padilla S, Fernández M, Agulló V, García JA, Telenti G, García-Abellán J, Botella Á, Gutiérrez F, Masiá M. Preemptive interleukin-6 blockade in patients with COVID-19. Sci Rep 2020; 10:16826. [PMID: 33033405 PMCID: PMC7545205 DOI: 10.1038/s41598-020-74001-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [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: 06/30/2020] [Accepted: 09/24/2020] [Indexed: 02/08/2023] Open
Abstract
Excessive interleukin-6 signaling is a key factor contributing to the cytokine release syndrome implicated in clinical manifestations of COVID-19. Preliminary results suggest that tocilizumab, a humanized monoclonal anti-interleukin-6 receptor antibody, may be beneficial in severely ill patients, but no data are available on earlier stages of disease. An anticipated blockade of interleukin-6 might hypothetically prevent the catastrophic consequences of the overt cytokine storm. We evaluated early-given tocilizumab in patients hospitalized with COVID-19, and identified outcome predictors. Consecutive patients with initial Sequential-Organ-Failure-Assessment (SOFA) score < 3 fulfilling pre-defined criteria were treated with tocilizumab. Serial plasma biomarkers and nasopharyngeal swabs were collected. Of 193 patients admitted with COVID-19, 64 met the inclusion criteria. After tocilizumab, 49 (76.6%) had an early favorable response. Adjusted predictors of response were gender, SOFA score, neutrophil/lymphocyte ratio, Charlson comorbidity index and systolic blood pressure. At week-4, 56.1% of responders and 30% of non-responders had cleared the SARS-CoV-2 from nasopharynx. Temporal profiles of interleukin-6, C-reactive protein, neutrophil/lymphocyte ratio, NT-ProBNP, D-dimer, and cardiac-troponin-I differed according to tocilizumab response and discriminated final in-hospital outcome. No deaths or disease recurrences were observed. Preemptive therapy with tocilizumab was safe and associated with favorable outcomes in most patients. Biological and clinical markers predicted outcomes.
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MESH Headings
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Betacoronavirus
- Biomarkers/blood
- C-Reactive Protein/analysis
- COVID-19
- Coronavirus Infections/drug therapy
- Coronavirus Infections/epidemiology
- Coronavirus Infections/virology
- Female
- Follow-Up Studies
- Humans
- Interleukin-6/blood
- Lymphocyte Count
- Lymphocytes
- Male
- Middle Aged
- Neutrophils
- Organ Dysfunction Scores
- Pandemics
- Pneumonia, Viral/drug therapy
- Pneumonia, Viral/epidemiology
- Pneumonia, Viral/virology
- Receptors, Interleukin-6/antagonists & inhibitors
- SARS-CoV-2
- Spain/epidemiology
- Treatment Outcome
- COVID-19 Drug Treatment
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Affiliation(s)
- Lucía Guillén
- Infectious Diseases Unit, Hospital General Universitario de Elche, Camí de la Almazara S/N, Elche, 03203, Alicante, Spain
| | - Sergio Padilla
- Infectious Diseases Unit, Hospital General Universitario de Elche, Camí de la Almazara S/N, Elche, 03203, Alicante, Spain
| | - Marta Fernández
- Infectious Diseases Unit, Hospital General Universitario de Elche, Camí de la Almazara S/N, Elche, 03203, Alicante, Spain
| | - Vanesa Agulló
- Infectious Diseases Unit, Hospital General Universitario de Elche, Camí de la Almazara S/N, Elche, 03203, Alicante, Spain
| | - José Alberto García
- Infectious Diseases Unit, Hospital General Universitario de Elche, Camí de la Almazara S/N, Elche, 03203, Alicante, Spain
| | - Guillermo Telenti
- Infectious Diseases Unit, Hospital General Universitario de Elche, Camí de la Almazara S/N, Elche, 03203, Alicante, Spain
| | - Javier García-Abellán
- Infectious Diseases Unit, Hospital General Universitario de Elche, Camí de la Almazara S/N, Elche, 03203, Alicante, Spain
| | - Ángela Botella
- Infectious Diseases Unit, Hospital General Universitario de Elche, Camí de la Almazara S/N, Elche, 03203, Alicante, Spain
| | - Félix Gutiérrez
- Clinical Medicine Department, Universidad Miguel Hernández, Ctra. de Valencia (N-322), Km 87, 03550, San Juan de Alicante, Spain.
- Universidad Miguel Hernández, Avda de la Universidad S/N, Elche, 03202, Alicante, Spain.
| | - Mar Masiá
- Clinical Medicine Department, Universidad Miguel Hernández, Ctra. de Valencia (N-322), Km 87, 03550, San Juan de Alicante, Spain.
- Universidad Miguel Hernández, Avda de la Universidad S/N, Elche, 03202, Alicante, Spain.
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35
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Leo A, Nesci V, Tallarico M, Amodio N, Gallo Cantafio EM, De Sarro G, Constanti A, Russo E, Citraro R. IL-6 Receptor Blockade by Tocilizumab Has Anti-absence and Anti-epileptogenic Effects in the WAG/Rij Rat Model of Absence Epilepsy. Neurotherapeutics 2020; 17:2004-2014. [PMID: 32681356 PMCID: PMC7851197 DOI: 10.1007/s13311-020-00893-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Indexed: 12/27/2022] Open
Abstract
Increased expression of interleukin-6 (IL-6) both in cerebrospinal fluid (CSF) and plasma is closely associated with convulsive epilepsy and symptom severity of depression. By comparison, at present, little is known about the role of this cytokine in childhood (non-convulsive) absence epilepsy. The aim of this work was to investigate the potential effects of acute and chronic treatment with tocilizumab (TCZ, 10 and 30 mg/kg/day), on absence seizures, their development, and related psychiatric comorbidity in WAG/Rij rats. It is known that lipopolysaccharide (LPS)-induced changes in inflammatory processes increase absence epileptic activity. In order to study the central effects of TCZ, we investigated whether administration of this anti-IL-6R antibody could modulate the lipopolysaccharide (LPS) or IL-6-evoked changes in absence epileptic activity in WAG/Rij rats. Our results demonstrate that TCZ, at both doses, significantly reduced the development of absence seizures in adult WAG/Rij rats at 6 months of age (1 month after treatment suspension) compared with untreated controls, thus showing disease-modifying effects. Decreased absence seizure development at 6 months of age was also accompanied by reduced comorbid depressive-like behavior, whereas no effects were observed on anxiety-related behavior. Acute treatment with TCZ, at 30 mg/kg, had anti-absence properties lasting ~25 h. The co-administration TCZ with i.c.v. LPS or IL-6 showed that TCZ inhibited the worsening of absence seizures induced by both proinflammatory agents in the WAG/Rij rats, supporting a central anti-inflammatory-like protective action. These results suggest the possible role of IL-6 and consequent neuroinflammation in the epileptogenic process underlying the development and maintenance of absence seizures in WAG/Rij rats. Accordingly, IL-6 signaling could be a promising pharmacological target in absence epilepsy and depressive-like comorbidity.
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MESH Headings
- Animals
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Epilepsy, Absence/drug therapy
- Epilepsy, Absence/genetics
- Epilepsy, Absence/metabolism
- Male
- Rats
- Rats, Transgenic
- Rats, Wistar
- Receptors, Interleukin-6/antagonists & inhibitors
- Receptors, Interleukin-6/metabolism
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Affiliation(s)
- Antonio Leo
- Science of Health Department, School of Medicine and Surgery, Magna Græcia University of Catanzaro, Viale Europa - Germaneto, 88100, Catanzaro, Italy
| | - Valentina Nesci
- Science of Health Department, School of Medicine and Surgery, Magna Græcia University of Catanzaro, Viale Europa - Germaneto, 88100, Catanzaro, Italy
| | - Martina Tallarico
- Science of Health Department, School of Medicine and Surgery, Magna Græcia University of Catanzaro, Viale Europa - Germaneto, 88100, Catanzaro, Italy
| | - Nicola Amodio
- Experimental and Clinical Medicine Department, School of Medicine and Surgery, Magna Græcia University, Catanzaro, Italy
| | - Eugenia M Gallo Cantafio
- Science of Health Department, School of Medicine and Surgery, Magna Græcia University of Catanzaro, Viale Europa - Germaneto, 88100, Catanzaro, Italy
| | - Giovambattista De Sarro
- Science of Health Department, School of Medicine and Surgery, Magna Græcia University of Catanzaro, Viale Europa - Germaneto, 88100, Catanzaro, Italy
| | | | - Emilio Russo
- Science of Health Department, School of Medicine and Surgery, Magna Græcia University of Catanzaro, Viale Europa - Germaneto, 88100, Catanzaro, Italy.
| | - Rita Citraro
- Science of Health Department, School of Medicine and Surgery, Magna Græcia University of Catanzaro, Viale Europa - Germaneto, 88100, Catanzaro, Italy
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Della-Torre E, Campochiaro C, Cavalli G, De Luca G, Napolitano A, La Marca S, Boffini N, Da Prat V, Di Terlizzi G, Lanzillotta M, Rovere Querini P, Ruggeri A, Landoni G, Tresoldi M, Ciceri F, Zangrillo AL, De Cobelli F, Dagna L. Interleukin-6 blockade with sarilumab in severe COVID-19 pneumonia with systemic hyperinflammation: an open-label cohort study. Ann Rheum Dis 2020; 79:1277-1285. [PMID: 32620597 PMCID: PMC7509526 DOI: 10.1136/annrheumdis-2020-218122] [Citation(s) in RCA: 178] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To assess the safety and efficacy of interleukin (IL)-6 blockade with sarilumab in patients with severe COVID-19 pneumonia and systemic hyperinflammation. METHODS We conducted an open-label study of sarilumab in severe COVID-19 pneumonia (PaO2/FiO2 <300 mm Hg) with hyperinflammation (elevated inflammatory markers and serum IL-6 levels). Sarilumab 400 mg was administered intravenously in addition to standard of care and results were compared with contemporary matched patients treated with standard of care alone. Clinical improvement, mortality, safety and predictors of response were assessed at 28 days. RESULTS Twenty-eight patients were treated with sarilumab and 28 contemporary patients receiving standard of care alone were used as controls. At day 28 of follow-up, 61% of patients treated with sarilumab experienced clinical improvement and 7% died. These findings were not significantly different from the comparison group (clinical improvement 64%, mortality 18%; p=NS). Baseline PaO2/FiO2 ratio >100 mm Hg and lung consolidation <17% at CT scan predicted clinical improvement in patients treated with sarilumab. Median time to clinical improvement in patients with lung consolidation <17% was shorter after sarilumab (10 days) than after standard treatment (24 days; p=0.01). The rate of infection and pulmonary thrombosis was similar between the two groups. CONCLUSIONS At day 28, overall clinical improvement and mortality in patients with severe COVID-19 were not significantly different between sarilumab and standard of care. Sarilumab was associated with faster recovery in a subset of patients showing minor lung consolidation at baseline.
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Affiliation(s)
- Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases, San Raffaele Hospital, Milano, Lombardia, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases, San Raffaele Hospital, Milano, Lombardia, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases, San Raffaele Hospital, Milano, Lombardia, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases, San Raffaele Hospital, Milano, Lombardia, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Angela Napolitano
- Università Vita-Salute San Raffaele, Milan, Italy
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, San Raffaele Hospital, Milan, Italy
| | - Salvatore La Marca
- Università Vita-Salute San Raffaele, Milan, Italy
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, San Raffaele Hospital, Milan, Italy
| | - Nicola Boffini
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases, San Raffaele Hospital, Milano, Lombardia, Italy
| | - Valentina Da Prat
- General Medicine and Advanced Care Unit, San Raffaele Hospital, Milan, Italy
| | - Gaetano Di Terlizzi
- General Medicine and Advanced Care Unit, San Raffaele Hospital, Milan, Italy
| | - Marco Lanzillotta
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases, San Raffaele Hospital, Milano, Lombardia, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Patrizia Rovere Querini
- Università Vita-Salute San Raffaele, Milan, Italy
- Internal Medicine, Diabetes & Endocrinology Unit, San Raffaele Hospital, Milan, Italy
| | - Annalisa Ruggeri
- Hematology and Bone Marrow Transplant Unit, San Raffaele Hospital, Milan, Italy
| | - Giovanni Landoni
- Università Vita-Salute San Raffaele, Milan, Italy
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Moreno Tresoldi
- General Medicine and Advanced Care Unit, San Raffaele Hospital, Milan, Italy
| | - Fabio Ciceri
- Università Vita-Salute San Raffaele, Milan, Italy
- Hematology and Bone Marrow Transplant Unit, San Raffaele Hospital, Milan, Italy
| | - ALberto Zangrillo
- Università Vita-Salute San Raffaele, Milan, Italy
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Francesco De Cobelli
- Università Vita-Salute San Raffaele, Milan, Italy
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, San Raffaele Hospital, Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases, San Raffaele Hospital, Milano, Lombardia, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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Melody M, Nelson J, Hastings J, Propst J, Smerina M, Mendez J, Guru P. Case report: use of lenzilumab and tocilizumab for the treatment of coronavirus disease 2019. Immunotherapy 2020; 12:1121-1126. [PMID: 32546029 PMCID: PMC7319491 DOI: 10.2217/imt-2020-0136] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/03/2020] [Indexed: 01/06/2023] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19) is a novel disease associated with a cytokine-mediated, severe, acute respiratory syndrome. Tocilizumab and lenzilumab are recombinant monoclonal antibodies against IL-6 and granulocyte macrophage colony-stimulating factor, respectively, and have been proposed as a potential treatment for acute, hypoxic respiratory failure associated with COVID-19. Results & methodology: We present the case of a 68-year-old man with COVID-19 who was initially treated with hydroxychloroquine and lenzilumab, but continued to develop hypoxemia, requiring an increase in respiratory support with an associated rise in serum inflammatory markers. He was subsequently treated with tocilizumab with marked clinical improvement and a decrease in acute phase reactants within 48 h. Discussion & conclusion: This case demonstrates the effective use of tocilizumab in the treatment of COVID-19 and suggests the superiority of tocilizumab over lenzilumab in the management of this cytokine-mediated syndrome.
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Affiliation(s)
- Megan Melody
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Jared Nelson
- Division of Infectious Disease, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Jacquelyn Hastings
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Joshua Propst
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Michael Smerina
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Julio Mendez
- Division of Infectious Disease, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Pramod Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
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Abrams-Downey A, Saabiye J, Vidaurrazaga M. Investigational Therapies for the Treatment of COVID-19: Updates from Ongoing Clinical Trials. Eur Urol Focus 2020; 6:1028-1031. [PMID: 32563675 PMCID: PMC7274606 DOI: 10.1016/j.euf.2020.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 01/18/2023]
Affiliation(s)
- Alexandra Abrams-Downey
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, New York, NY, USA.
| | - Joseph Saabiye
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, New York, NY, USA
| | - Monica Vidaurrazaga
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, New York, NY, USA
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39
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Castelli V, Cimini A, Ferri C. Cytokine Storm in COVID-19: "When You Come Out of the Storm, You Won't Be the Same Person Who Walked in". Front Immunol 2020; 11:2132. [PMID: 32983172 PMCID: PMC7492381 DOI: 10.3389/fimmu.2020.02132] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/06/2020] [Indexed: 01/08/2023] Open
Abstract
In December 2019, a novel coronavirus, COVID-19, was discovered to be the causal agent of a severe respiratory infection named SARS-CoV-2, and it has since been recognized worldwide as a pandemic. There are still numerous doubts concerning its pathogenesis and particularly the underlying causes of the various clinical courses, ranging from severe manifestations to asymptomatic forms, including acute respiratory distress syndrome. The major factor responsible for acute respiratory distress syndrome is the so-called "cytokine storm," which is an aberrant response from the host immune system that induces an exaggerated release of proinflammatory cytokines/chemokines. In this review, we will discuss the role of cytokine storm in COVID-19 and potential treatments with which counteract this aberrant response, which may be valuable in the clinical translation.
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Affiliation(s)
- Vanessa Castelli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | | | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
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40
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Abstract
The rapid spread of SARS-CoV-2 infection globally coupled with the relatively high case-fatality rate has led to immediate need for therapeutic intervention to prevent and treat COVID-19 disease. There is accumulating evidence that morbidity and mortality in COVID-19 may be exacerbated by a dysregulated host immune response resulting in significant hyperinflammation and cytokine release. The aim of this review is to describe the basis for the immune dysregulation caused by SARS-CoV-2 infection and to examine current investigations into immunomodulatory therapies aimed at targeting the excessive host immune response.
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Affiliation(s)
- Tamara Tanner
- Division of Pediatric Rheumatology, Children's Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY, 10467, United States.
| | - Dawn M Wahezi
- Division of Pediatric Rheumatology, Children's Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY, 10467, United States.
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Anada M, Tohyama M, Oda Y, Kamoshima Y, Amino I, Nakano F, Miyazaki Y, Akimoto S, Minami N, Kikuchi S, Terae S, Niino M. Progressive Multifocal Leukoencephalopathy during Tocilizumab Treatment for Rheumatoid Arthritis. Intern Med 2020; 59:2053-2059. [PMID: 32448834 PMCID: PMC7492111 DOI: 10.2169/internalmedicine.4431-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A 61-year-old woman was diagnosed with rheumatoid arthritis 12 years ago and received multiple treatment regimens before achieving symptomatic stability with methotrexate plus tocilizumab, a humanized monoclonal antibody against the IL-6 receptor, about 2 years prior to the current presentation. Sixteen months after tocilizumab initiation, she exhibited dysarthria and disorientation; five months later, she was hospitalized with movement difficulties. Her neurological symptoms deteriorated thereafter, accompanied by enlarged cerebral white matter lesions on magnetic resonance imaging. A biopsy of the right frontal lesion confirmed progressive multifocal leukoencephalopathy (PML). While several therapeutic monoclonal antibodies have been linked to PML, this is the first case associated with tocilizumab.
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Affiliation(s)
- Mamiko Anada
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | | | - Yoshitaka Oda
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Japan
| | - Yuuta Kamoshima
- Department of Neurosurgery, Sapporo Azabu Neurosurgical Hospital, Japan
| | - Itaru Amino
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Fumihito Nakano
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Yusei Miyazaki
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Sachiko Akimoto
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Seiji Kikuchi
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Satoshi Terae
- Department of Diagnostic Radiology, Sapporo City General Hospital, Japan
| | - Masaaki Niino
- Department of Clinical Research, National Hospital Organization Hokkaido Medical Center, Japan
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Montesarchio V, Parrela R, Iommelli C, Bianco A, Manzillo E, Fraganza F, Palumbo C, Rea G, Murino P, De Rosa R, Atripaldi L, D'Abbraccio M, Curvietto M, Mallardo D, Celentano E, Grimaldi AM, Palla M, Trojaniello C, Vitale MG, Million-Weaver SL, Ascierto PA. Outcomes and biomarker analyses among patients with COVID-19 treated with interleukin 6 (IL-6) receptor antagonist sarilumab at a single institution in Italy. J Immunother Cancer 2020; 8:e001089. [PMID: 32784217 PMCID: PMC7418768 DOI: 10.1136/jitc-2020-001089] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The inflammatory pathology observed in severe COVID-19 disease caused by the 2019 novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterized by elevated serum levels of C reactive protein (CRP) and cytokines, including interferon gamma, interleukin 8 (IL-8), and interleukin 6 (IL-6). Initial reports from the outbreak in Italy, China and the USA have provided anecdotal evidence of improved outcomes with the administration of anti-IL-6 agents, and large-scale trials evaluating these therapies are ongoing. STUDY DESCRIPTION In this retrospective case series, clinical outcomes and correlates of response to treatment with the IL-6 receptor antagonist sarilumab are described for 15 patients with COVID-19 from a single institution in Southern Italy. Among 10 patients whose symptoms improved after sarilumab treatment, rapid decreases in CRP levels corresponded with clinical improvement. Lower levels of IL-6 at baseline as well as lower neutrophil to lymphocyte ratio as compared with patients whose COVID-19 did not improve with treatment were associated with sarilumab-responsive disease. CONCLUSIONS This observation may reflect a possible clinical benefit regarding early intervention with IL-6-modulatory therapies for COVID-19 and that CRP could be a potential biomarker of response to treatment.
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Affiliation(s)
- Vincenzo Montesarchio
- Department of Medical Oncology, Azienda Ospedaliera dei Colli-Monaldi Hospital, Napoli, Italy
| | - Roberto Parrela
- Department of Infectious Diseases and Infectious Diseases Emergencies, Azienda Ospedaliera dei Colli-Cotugno Hospital, Napoli, Italy
| | - Chiara Iommelli
- Department of Medical Oncology, Azienda Ospedaliera dei Colli-Monaldi Hospital, Napoli, Italy
| | - Antonella Bianco
- Department of Medical Oncology, Azienda Ospedaliera dei Colli-Monaldi Hospital, Napoli, Italy
| | - Elio Manzillo
- Department of Infectious Diseases and Infectious Diseases Emergencies, Azienda Ospedaliera dei Colli-Cotugno Hospital, Napoli, Italy
| | - Fiorentino Fraganza
- Critical Area Department, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Cristiana Palumbo
- Department of Health Services, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Gaetano Rea
- Department of Health Services, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Patrizia Murino
- Critical Area Department, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Rosanna De Rosa
- Critical Area Department, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Luigi Atripaldi
- Department of Health Services, Azienda Ospedaliera dei Colli-Cotugno and Monaldi Hospital, Napoli, Italy
| | - Maurizio D'Abbraccio
- Department of Infectious Diseases and Infectious Diseases Emergencies, Azienda Ospedaliera dei Colli-Cotugno Hospital, Napoli, Italy
| | - Marcello Curvietto
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Domenico Mallardo
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Egidio Celentano
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Antonio Maria Grimaldi
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Marco Palla
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Claudia Trojaniello
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
| | - Maria Grazia Vitale
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Campania, Italy
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Rojas-Marte G, Khalid M, Mukhtar O, Hashmi AT, Waheed MA, Ehrlich S, Aslam A, Siddiqui S, Agarwal C, Malyshev Y, Henriquez-Felipe C, Sharma D, Sharma S, Chukwuka N, Rodriguez DC, Alliu S, Le J, Shani J. Outcomes in patients with severe COVID-19 disease treated with tocilizumab: a case-controlled study. QJM 2020; 113:546-550. [PMID: 32569363 PMCID: PMC7337835 DOI: 10.1093/qjmed/hcaa206] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/10/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND COVID-19 is an ongoing threat to society. Patients who develop the most severe forms of the disease have high mortality. The interleukin-6 inhibitor tocilizumab has the potential to improve outcomes in these patients by preventing the development of cytokine release storm. AIMS To evaluate the outcomes of patients with severe COVID-19 disease treated with the interleukin-6 inhibitor tocilizumab. METHODS We conducted a retrospective, case-control, single-center study in patients with severe to critical COVID-19 disease treated with tocilizumab. Disease severity was defined based on the amount of oxygen supplementation required. The primary endpoint was the overall mortality. Secondary endpoints were mortality in non-intubated patients and mortality in intubated patients. RESULTS A total of 193 patients were included in the study. Ninety-six patients received tocilizumab, while 97 served as the control group. The mean age was 60 years. Patients over 65 years represented 43% of the population. More patients in the tocilizumab group reported fever, cough and shortness of breath (83%, 80% and 96% vs. 73%, 69% and 71%, respectively). There was a non-statistically significant lower mortality in the treatment group (52% vs. 62.1%, P = 0.09). When excluding intubated patients, there was statistically significant lower mortality in patients treated with tocilizumab (6% vs. 27%, P = 0.024). Bacteremia was more common in the control group (24% vs. 13%, P = 0.43), while fungemia was similar for both (3% vs. 4%, P = 0.72). CONCLUSION Our study showed a non-statistically significant lower mortality in patients with severe to critical COVID-19 disease who received tocilizumab. When intubated patients were excluded, the use of tocilizumab was associated with lower mortality.
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Affiliation(s)
- G Rojas-Marte
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
- Department of Cardiology, Staten Island University Hospital-Northwell Health, 475 Seaview Avenue, Staten Island, NY 10305, USA
| | - M Khalid
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - O Mukhtar
- Department of Pulmonology, Interfaith Medical Center, 1545 Atlantic Avenue, Brooklyn, NY 11213, USA
| | - A T Hashmi
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - M A Waheed
- Department of Internal Medicine, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - S Ehrlich
- Department of Internal Medicine, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - A Aslam
- Department of Internal Medicine, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - S Siddiqui
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - C Agarwal
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - Y Malyshev
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - C Henriquez-Felipe
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - D Sharma
- Department of Internal Medicine, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - S Sharma
- Department of Internal Medicine, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - N Chukwuka
- Department of Internal Medicine, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - D C Rodriguez
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - S Alliu
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - J Le
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
| | - J Shani
- Department of Cardiology, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA
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Furutera N, Fukunaga N, Okita J, Suzuki T, Suenaga Y, Oyama Y, Aoki K, Fukuda A, Nakata T, Uesugi N, Daa T, Hisano S, Shibata H. Two cases of idiopathic multicentric Castleman disease with nephrotic syndrome treated with tocilizumab. CEN Case Rep 2020; 10:35-41. [PMID: 32715375 DOI: 10.1007/s13730-020-00511-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/14/2020] [Indexed: 01/11/2023] Open
Abstract
We report two cases of idiopathic multicentric Castleman disease (iMCD) with nephrotic syndrome (NS) treated with tocilizumab. Case 1 was a 58-year-old man diagnosed with iMCD prior to the onset of NS. Renal biopsy revealed membranous nephropathy, which was considered to be secondary membranous nephropathy associated with iMCD. Case 2 was a 49-year-old woman diagnosed with iMCD prior to NS. Renal biopsy revealed renal amyloidosis positive for Congo red staining and amyloid A protein immunostaining. In both the cases, the proteinuria improved after the initiation of glucocorticoid and tocilizumab therapy. Tocilizumab may be a good therapeutic choice for iMCD with NS.
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Affiliation(s)
- Norihiro Furutera
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Naoya Fukunaga
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan.
| | - Jun Okita
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Tomoko Suzuki
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Yuko Suenaga
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Yuzo Oyama
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Oita, Japan
| | - Kohei Aoki
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Akihiro Fukuda
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Takeshi Nakata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Noriko Uesugi
- Department of Pathology, Faculty of Medicine, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Tsutomu Daa
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Oita, Japan
| | - Satoshi Hisano
- Department of Pathology, Faculty of Medicine, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
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Moreno-Pérez O, Andres M, Leon-Ramirez JM, Sánchez-Payá J, Rodríguez JC, Sánchez R, García-Sevila R, Boix V, Gil J, Merino E. Experience with tocilizumab in severe COVID-19 pneumonia after 80 days of follow-up: A retrospective cohort study. J Autoimmun 2020; 114:102523. [PMID: 32690352 PMCID: PMC7365106 DOI: 10.1016/j.jaut.2020.102523] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To describe the clinical characteristics and predictors of major outcomes in patients treated with tocilizumab (TCZ) for severe COVID-19 pneumonia. PATIENTS AND METHODS Case series of all sequential patients with severe COVID-19 pneumonia treated with TCZ at an Academic Spanish hospital (March 12 - May 2, 2020). Clinical outcomes: death, length of hospital stay. An early clinical response to TCZ (48-72 h after the administration) was assessed by variations in respiratory function markers, Brescia COVID Respiratory Severity Scale (BCRSS), inflammatory parameters, and patients' and physicians' opinion. Associations were tested by multiple logistic regression. RESULTS From a cohort of 236 patients, 77 patients treated with TCZ were included (median age 62 years (IQR 53.0-72.0), 64.9% were males), 42.9% had Charlson index ≥3; hypertension (41.6%), obesity (34.7%), and diabetes (20.8%). Median follow-up was 83.0 days (78.0-86.5), no patient was readmitted. ICU admission was required for 42 (54.5%), invasive mechanical ventilation in 38 (49.4%) and 10 patients died (12.9% global, 23.8% at ICU admitted). After multivariate adjustment, TCZ response by BCRSS (OR 0.03 (0.01-0.68), p = 0.028), and Charlson index (OR 3.54 (1.20-10.44), p = 0.022) has been identified as independent factors associated with mortality. Median of hospital stay was 16.0 days (11.0-23.0); BCRSS, physician subjective and D-dimer response were associated with shorter hospitalization stay. CONCLUSIONS In a Mediterranean cohort, use of tocilizumab for severe COVID-19 show 12.9% of mortality. Early TCZ-response by BCRSS and low comorbidity were associated with increased survival. Early TCZ-response was related to shorter median hospital stay.
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MESH Headings
- Adult
- Aged
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antiviral Agents/administration & dosage
- Betacoronavirus/immunology
- Betacoronavirus/pathogenicity
- COVID-19
- Coronavirus Infections/diagnosis
- Coronavirus Infections/immunology
- Coronavirus Infections/mortality
- Coronavirus Infections/therapy
- Drug Therapy, Combination
- Female
- Fibrin Fibrinogen Degradation Products/analysis
- Follow-Up Studies
- Hospital Mortality
- Humans
- Infusions, Intravenous
- Interleukin-6/immunology
- Interleukin-6/metabolism
- Length of Stay/statistics & numerical data
- Male
- Middle Aged
- Pandemics
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/immunology
- Pneumonia, Viral/mortality
- Pneumonia, Viral/therapy
- Prognosis
- Receptors, Interleukin-6/antagonists & inhibitors
- Receptors, Interleukin-6/metabolism
- Respiration, Artificial/statistics & numerical data
- Respiratory Function Tests/statistics & numerical data
- Retrospective Studies
- SARS-CoV-2
- Severity of Illness Index
- Spain/epidemiology
- Survival Analysis
- Time Factors
- Time-to-Treatment
- Treatment Outcome
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Affiliation(s)
- Oscar Moreno-Pérez
- Endocrinology and Nutrition Department, Alicante General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain; Clinical Medicine Department, Miguel Hernández University, Elche, Spain.
| | - Mariano Andres
- Clinical Medicine Department, Miguel Hernández University, Elche, Spain; Rheumatology Department, Alicante General University Hospital Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain.
| | - Jose-Manuel Leon-Ramirez
- Pneumology Department, Alicante General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain.
| | - José Sánchez-Payá
- Preventive Department, Alicante General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain.
| | - Juan Carlos Rodríguez
- Microbiology Department, Alicante General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain; Miguel Hernández University, Elche, Spain.
| | - Rosario Sánchez
- Internal Medicine Department, Alicante General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain.
| | - Raquel García-Sevila
- Pneumology Department, Alicante General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain.
| | - Vicente Boix
- Clinical Medicine Department, Miguel Hernández University, Elche, Spain; Unit of Infectious Diseases, Alicante General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain.
| | - Joan Gil
- Pneumology Department, Alicante General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain.
| | - Esperanza Merino
- Unit of Infectious Diseases, Alicante General University Hospital - Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain.
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46
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Conrozier T, Lohse A, Balblanc JC, Dussert P, Royer PY, Bossert M, Bozgan AM, Gendrin V, Charpentier A, Toko L, Badie J, Mezher C, Roux MF, Kadiane-Oussou NJ, Contreras R, Kessler J, Mazurier I, Klopfenstein T, Zayet S. Biomarker variation in patients successfully treated with tocilizumab for severe coronavirus disease 2019 (COVID-19): results of a multidisciplinary collaboration. Clin Exp Rheumatol 2020; 38:742-747. [PMID: 32573419] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Acute respiratory distress syndrome (ARDS) related to SARS-CoV-2 is likely due to a cytokine storm characterised by a major release of pro-inflammatory cytokines, including interleukin-6 (IL-6). Blocking excessive IL-6 production might be the key to the COVID-19-ARDS treatment. Beneficial effects of IL-6 blockade using a humanised anti-IL-6 receptor antibody, tocilizumab (TCZ) were previously reported in patients with COVID-19 related ARDS. The aim of the study was to study the variation over time of several biomarkers, demonstrated to be predictors of poor prognostic, in subjects successfully treated with TCZ for severe COVID-19. METHODS Retrospective analysis of a case series of patients with COVID-19-ARDS, evidenced by RT-PCR and lung CT-scan. Patients with increasing O2 requirements, within the window of opportunity for TCZ treatment (Day 7 to Day 17 after onset of symptoms) were treated with TCZ (2 infusions of 8 mg/kg). Demographic, biological and clinical data were collected from the patients' files. Serum levels of CRP, ferritin, fibrinogen, lymphocytes, platelets, creatinine, D-dimer and liver enzymes were assayed at the time of the first TCZ administration, then every two days for 8 days. RESULTS 40 patients were treated with TCZ. Most of them had several comorbidities, and all had multiple biological abnormalities (lymphopenia, increased CRP, ferritin, fibrinogen, D-dimer, liver enzymes). 30 patients (75%) benefited from TCZ and 10 patients died. In the survivors, following TCZ administration CRP decreased dramatically as early as day 4 (-86.7%, p<0.0001) and returned to normal at day 6. Fibrinogen and lymphocyte count returned to normal values at day 6. Ferritin also decreased significantly. No significant change was observed for D-dimer (p=0.68) and other studied biomarkers (haemoglobin, leucocyte count, AST). CONCLUSIONS In patients with COVID-19 acute respiratory distress syndrome, treatment with TCZ resulted in favourable evolution in 75% of the cases. Biomarkers of inflammation (CRP, ferritin, fibrinogen) decreased dramatically as early as the 4th day after TCZ injection. Lymphopenia, a predictor of poor prognostic, was reversed 6 days after TCZ injection.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France.
| | - Anne Lohse
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | | | - Pascale Dussert
- Department of Biology, Nord Franche-Comté Hospital, Belfort, France
| | - Pierre-Yves Royer
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
| | - Marie Bossert
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Ana-Maria Bozgan
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Vincent Gendrin
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
| | - Aline Charpentier
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | - Lynda Toko
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
| | - Julio Badie
- Intensive Care Unit, Nord Franche-Comté Hospital, Belfort, France
| | - Chaouki Mezher
- Intensive Care Unit, Nord Franche-Comté Hospital, Belfort, France
| | | | | | | | - Julie Kessler
- Department of Rheumatology, Nord Franche-Comté Hospital, Belfort, France
| | | | | | - Souheil Zayet
- Department of Infectious Diseases, Nord Franche-Comté Hospital, Belfort, France
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47
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Iannaccone G, Scacciavillani R, Del Buono MG, Camilli M, Ronco C, Lavie CJ, Abbate A, Crea F, Massetti M, Aspromonte N. Weathering the Cytokine Storm in COVID-19: Therapeutic Implications. Cardiorenal Med 2020; 10:277-287. [PMID: 32599589 PMCID: PMC7360507 DOI: 10.1159/000509483] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/12/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) recently emerged in Wuhan, Hubei-China, as responsible for the coronavirus disease 2019 (COVID-19) and then spread rapidly worldwide. While most individuals remain asymptomatic or develop only mild symptoms, approximately 5% develop severe forms of COVID-19 characterized by acute respiratory distress syndrome (ARDS) and multiple-organ failure (MOF) that usually require intensive-care support and often yield a poor prognosis. SUMMARY The pathophysiology of COVID-19 is far from being completely understood, and the lack of effective treatments leads to a sense of urgency to develop new therapeutic strategies based on pathophysiological assumptions. The exaggerated cytokine release in response to viral infection, a condition known as cytokine release syndrome (CRS) or cytokine storm, is emerging as the mechanism leading to ARDS and MOF in COVID-19, thus endorsing the hypothesis that properly timed anti-inflammatory therapeutic strategies could improve patients' clinical outcomes and prognosis. Key Messages: The objective of this article is to explore and comment on the potential role of the promising immunomodulatory therapies using pharmacological and nonpharmacological approaches to overcome the dysregulated proinflammatory response in COVID-19.
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Affiliation(s)
- Giulia Iannaccone
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Roberto Scacciavillani
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Giuseppe Del Buono
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Massimiliano Camilli
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy
- Department of Nephrology, Dialysis and Kidney Transplant, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, USA
| | - Antonio Abbate
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Nadia Aspromonte
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,
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48
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Abstract
COVID-19 is a rapidly spreading global threat that has been declared as a pandemic by the WHO. COVID-19 is transmitted via droplets or direct contact and infects the respiratory tract resulting in pneumonia in most of the cases and acute respiratory distress syndrome (ARDS) in about 15 % of the cases. Mortality in COVID-19 patients has been linked to the presence of the so-called "cytokine storm" induced by the virus. Excessive production of proinflammatory cytokines leads to ARDS aggravation and widespread tissue damage resulting in multi-organ failure and death. Targeting cytokines during the management of COVID-19 patients could improve survival rates and reduce mortality.
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Affiliation(s)
- Dina Ragab
- Department of Clinical Pathology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Haitham Salah Eldin
- Department of Chest Diseases, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Taeimah
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rasha Khattab
- Department of Radiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ramy Salem
- Department of Clinical Pathology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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49
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Choi IA, Sagawa A, Lee EY, Lee EB, Song YW. Tocilizumab Increases Body Weight and Serum Adipokine Levels in Patients with Rheumatoid Arthritis Independently of Their Treatment Response: a Retrospective Cohort Study. J Korean Med Sci 2020; 35:e155. [PMID: 32508063 PMCID: PMC7279943 DOI: 10.3346/jkms.2020.35.e155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/27/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Causes of weight change after tocilizumab treatment are unclear. We aimed to investigate the effects of tocilizumab treatment on body weight and serum adipokine levels in patients with rheumatoid arthritis (RA). METHODS In this retrospective cohort study, we evaluated weight changes in patients with RA who received methotrexate (Cohort I) or tocilizumab with methotrexate (Cohorts II and III) for 24 weeks. Adipokine concentrations at baseline and 24 weeks were analyzed in Cohorts I and III. Cohorts I and II received tocilizumab therapy for an additional 48 weeks, during which weight changes were monitored (24-72 weeks). RESULTS No significant weight change occurred after 24 weeks of methotrexate treatment (mean difference, -0.2 kg; P = 0.630), but was observed after 24 weeks of tocilizumab treatment (mean difference, +0.9 kg; P = 0.010). Weight changed regardless of the treatment response in both treatment groups. The leptin-adiponectin ratio (P = 0.015) and levels of adiponectin (P < 0.001), leptin (P < 0.001), and resistin (P = 0.003) increased significantly after 24 weeks of tocilizumab, but not methotrexate treatment. After 24, 48 and 72 weeks of tocilizumab treatment in Cohort II, mean (95% confidence interval [CI]) weight changes from baseline were +0.7 (0.0-1.4), +1.2 (0.4-2.0) and +1.1 (0.2-2.0) kg, respectively, and mean (95% CI) percent weight changes from baseline were +1.3% (0.1%-2.6%), +2.2% (0.7%-3.6%), and +2.0% (0.4%-3.7%) at 24, 48, and 72 weeks, respectively. CONCLUSION Weight and the leptin-adiponectin ratio increased after tocilizumab treatment. Given that cardiovascular (CV) risk factors may deteriorate in patients with RA who receive tocilizumab, further studies are required to determine the effects of weight gain on CV outcomes in these patients.
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Affiliation(s)
- In Ah Choi
- Division of Rheumatology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Akira Sagawa
- Sagawa Akira Rheumatology Clinic, Sapporo, Japan
| | - Eun Young Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology and College of Medicine, Seoul National University, Seoul, Korea.
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50
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Campochiaro C, Della-Torre E, Cavalli G, De Luca G, Ripa M, Boffini N, Tomelleri A, Baldissera E, Rovere-Querini P, Ruggeri A, Monti G, De Cobelli F, Zangrillo A, Tresoldi M, Castagna A, Dagna L. Efficacy and safety of tocilizumab in severe COVID-19 patients: a single-centre retrospective cohort study. Eur J Intern Med 2020; 76:43-49. [PMID: 32482597 PMCID: PMC7242960 DOI: 10.1016/j.ejim.2020.05.021] [Citation(s) in RCA: 287] [Impact Index Per Article: 71.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tocilizumab (TCZ), a humanized monoclonal antibody targeting the interleukin-6 (IL-6) receptor, has been proposed for the treatment of COVID-19 patients; however, limited data are available on the safety and efficacy. METHODS We performed a retrospective study on severe COVID-19 patients with hyper-inflammatory features admitted outside intensive care units (ICUs). Patients treated with intravenous TCZ in addition to standard of care were compared to patients treated with standard of care alone. Safety and efficacy were assessed over a 28-day follow-up. RESULTS 65 patients were included. Among them, 32 were treated with TCZ. At baseline, all patients were on high-flow supplemental oxygen and most (78% of TCZ patients and 61% of standard treatment patients) were on non-invasive ventilation. During the 28-day follow-up, 69% of TCZ patients experienced a clinical improvement compared to 61% of standard treatment patients (p = 0.61). Mortality was 15% in the tocilizumab group and 33% in standard treatment group (p = 0.15). In TCZ group, at multivariate analysis, older age was a predictor of death, whereas higher baseline PaO2:FiO2 was a predictor of clinical improvement at day 28. The rate of infection and pulmonary thrombosis was similar between the two groups. CONCLUSIONS At day 28, clinical improvement and mortality were not statistically different between tocilizumab and standard treatment patients in our cohort. Bacterial or fungal infections were recorded in 13% of tocilizumab patients and in 12% of standard treatment patients. Confirmation of efficacy and safety will require ongoing controlled trials.
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MESH Headings
- Aged
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antiviral Agents/adverse effects
- Betacoronavirus/drug effects
- Betacoronavirus/isolation & purification
- COVID-19
- Coronavirus Infections/blood
- Coronavirus Infections/mortality
- Coronavirus Infections/physiopathology
- Coronavirus Infections/therapy
- Female
- Humans
- Italy/epidemiology
- Male
- Middle Aged
- Outcome and Process Assessment, Health Care
- Oxygen Inhalation Therapy/methods
- Pandemics
- Pneumonia, Viral/blood
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/drug therapy
- Pneumonia, Viral/etiology
- Pneumonia, Viral/mortality
- Pneumonia, Viral/physiopathology
- Pneumonia, Viral/therapy
- Receptors, Interleukin-6/antagonists & inhibitors
- Respiratory Insufficiency/etiology
- Respiratory Insufficiency/therapy
- Retrospective Studies
- SARS-CoV-2
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Affiliation(s)
- Corrado Campochiaro
- Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Emanuel Della-Torre
- Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Cavalli
- Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo De Luca
- Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Ripa
- Vita-Salute San Raffaele University, Milan, Italy; Department of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Boffini
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Tomelleri
- Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elena Baldissera
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizia Rovere-Querini
- Vita-Salute San Raffaele University, Milan, Italy; Internal Medicine, Diabetes & Endocrinology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Annalisa Ruggeri
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Monti
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco De Cobelli
- Vita-Salute San Raffaele University, Milan, Italy; Radiology Department, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Vita-Salute San Raffaele University, Milan, Italy; Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Moreno Tresoldi
- General Medicine and Advanced Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonella Castagna
- Vita-Salute San Raffaele University, Milan, Italy; Department of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy.
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