Liverpool, United Kingdom
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Solomon T.,University of Liverpool | Solomon T.,Walton Center Foundation Trust | Lewthwaite P.,University of Liverpool | Perera D.,University Malaysia Sarawak | And 4 more authors.
The Lancet Infectious Diseases | Year: 2010

First isolated in California, USA, in 1969, enterovirus 71 (EV71) is a major public health issue across the Asia-Pacific region and beyond. The virus, which is closely related to polioviruses, mostly affects children and causes hand, foot, and mouth disease with neurological and systemic complications. Specific receptors for this virus are found on white blood cells, cells in the respiratory and gastrointestinal tract, and dendritic cells. Being an RNA virus, EV71 lacks a proofreading mechanism and is evolving rapidly, with new outbreaks occurring across Asia in regular cycles, and virus gene subgroups seem to differ in clinical epidemiological properties. The pathogenesis of the severe cardiopulmonary manifestations and the relative contributions of neurogenic pulmonary oedema, cardiac dysfunction, increased vascular permeability, and cytokine storm are controversial. Public health interventions to control outbreaks involve social distancing measures, but their effectiveness has not been fully assessed. Vaccines being developed include inactivated whole-virus, live attenuated, subviral particle, and DNA vaccines. © 2010 Elsevier Ltd.


Elsone L.,Walton Center Foundation Trust | Panicker J.,Walton Center Foundation Trust | Mutch K.,Walton Center Foundation Trust | Boggild M.,Townsville Hospital | And 2 more authors.
Multiple Sclerosis Journal | Year: 2014

Prompt treatment of neuromyelitis optica (NMO) relapses with steroids or plasma exchange (PLEX) often prevents irreversible disability. The objective of this study is to report the use of intravenous immunoglobulins (IVIG) as treatment for acute relapses in NMO. A retrospective review of 10 patients treated with IVIG for acute relapses was conducted. IVIG was used in the majority of cases because of lack of response to steroids with/without PLEX. Improvement was noted in five of 11 (45.5%) events; the remaining had no further worsening. One patient, a 79-year-old woman, had a myocardial infarction seven days after IVIG. IVIG may have a role in treating acute NMO relapses. © The Author(s) 2013.


Srikandarajah N.,Walton Center Foundation Trust | Boissaud-Cooke M.A.,University of Warwick | Clark S.,Walton Center Foundation Trust | Wilby M.J.,Walton Center Foundation Trust
Spine | Year: 2015

Study Design. We analyzed retrospectively whether early surgery for cauda equina syndrome (CES) within 24, 48, or 72 hours of onset of autonomic symptoms made any difference to bladder function at initial outpatient follow-up. Objective. CES potentially causes loss of autonomic control including bladder dysfunction, resulting in significant disability. There is significant debate regarding appropriate timing of surgery. Summary of Background Data and Methods. We conducted a retrospective cohort study of 200 patients between 2000 and 2011 who underwent decompressive surgery for CES at a regional neurosurgical center. Data collected were from clinical admission and at initial follow-up. Presentation was categorized into CES with retention (CESR) and incomplete CES (CESI) and duration of autonomic symptoms before surgical intervention. Results. A total of 200 patients had complete clinical records; 61 cases with CESR and 139 cases with CESI. Average initial follow-up time was 96 days. For the 36 cases with CESI less than 24 hours, normal bladder function was seen at follow-up in all patients except 4 (11.1%), but with 103 cases with CESI more than 24 hours, 48 (46.6%) had bladder dysfunction (Pearson χ2P = 0.000). For the 64 cases with CESI less than 48 hours, normal bladder function was seen at follow-up in all except 10 (15.6%), but with 75 cases with CESI more than 48 hours, 42 (56%) had bladder dysfunction (Pearson χ2P = 0.000). For the 35 patients with CESR, operating within 24, 48, or 72 hours made no obvious difference to bladder outcome. Data were also reanalyzed changing the dataset groups to CESI less than 24 hours, 24 to 48 hours, and more than 48 hours to calculate odds ratios regarding normal bladder outcome. Conclusion. We identified that decompressive surgery within 24 hours of onset of autonomic symptoms in CESI reduces bladder dysfunction at initial follow-up, but no statistically significant difference in outcome was observed in CESR regarding timing of operation. © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.


Chibanda D.,University of Zimbabwe | Benjamin L.,University of Liverpool | Benjamin L.,University of Malawi | Benjamin L.,Walton Center Foundation Trust | And 3 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

Depression, alcohol use disorders (AUD), and neurocognitive disorders are the 3 most prevalent mental, neurological, and substance use disorders in people living with HIV infection in low-and middle-income countries (LMICs). Importantly, they have an impact on everyday functions and on HIV outcomes. Many LMICs have validated tools to screen for and diagnose depression and AUD in the general population that can be used among people living with HIV infection. Current screening and diagnostic methods for HIV-associated neurocognitive disorders in the era of antiretroviral therapy are suboptimal and require further research. In our view, 2 research priorities are most critical. One is the development of an integrated screening approach for depression, AUD, and neurocognitive disorders that can be used by nonspecialists in LMICs. Second, research is needed on interventions for depression and AUD that also target behavior change, as these could impact on adherence to antiretroviral therapy and improve mental symptoms. Mentorship and fellowship schemes at an individual and institutional level need to be further supported to build capacity and provide platforms for research on HIV and mental, neurological, and substance use disorders in LMICs. © 2014 by Lippincott Williams & Wilkins.


Sathasivam S.,Walton Center Foundation Trust
European Journal of Internal Medicine | Year: 2012

Statins are an effective treatment for the prevention of cardiovascular diseases and used extensively worldwide. However, myotoxicity induced by statins is a common adverse event and a major barrier to maximising cardiovascular risk reduction. The clinical spectrum of statin induced myotoxicity includes asymptomatic rise in creatine kinase concentration, myalgia, myositis and rhabdomyolysis. In certain cases, the cessation of statin therapy does not result in the resolution of muscular symptoms or the normalization of creatine kinase, raising the possibility of necrotizing autoimmune myopathy. There is increasing understanding and recognition of the pathophysiology and risk factors of statin induced myotoxicity. Careful history and physical examination in conjunction with selected investigations such as creatine kinase measurement, electromyography and muscle biopsy in appropriate clinical scenario help diagnose the condition. The management of statin induced myotoxicity involves statin cessation, the use of alternative lipid lowering agents or treatment regimes, and in the case of necrotizing autoimmune myopathy, immunosuppression. © 2012 European Federation of Internal Medicine.


Benjamin L.A.,University of Liverpool | Benjamin L.A.,Malawi Liverpool Wellcome Major Overseas Clinical Research Programme | Benjamin L.A.,Walton Center Foundation Trust | Bryer A.,University of Cape Town | And 8 more authors.
The Lancet Neurology | Year: 2012

HIV infection can result in stroke via several mechanisms, including opportunistic infection, vasculopathy, cardioembolism, and coagulopathy. However, the occurrence of stroke and HIV infection might often be coincidental. HIV-associated vasculopathy describes various cerebrovascular changes, including stenosis and aneurysm formation, vasculitis, and accelerated atherosclerosis, and might be caused directly or indirectly by HIV infection, although the mechanisms are controversial. HIV and associated infections contribute to chronic inflammation. Combination antiretroviral therapies (cART) are clearly beneficial, but can be atherogenic and could increase stroke risk. cART can prolong life, increasing the size of the ageing population at risk of stroke. Stroke management and prevention should include identification and treatment of the specific cause of stroke and stroke risk factors, and judicious adjustment of the cART regimen. Epidemiological, clinical, biological, and autopsy studies of risk, the pathogenesis of HIV-associated vasculopathy (particularly of arterial endothelial damage), the long-term effects of cART, and ideal stroke treatment in patients with HIV are needed, as are antiretrovirals that are without vascular risk. © 2012 Elsevier Ltd.


Nurmikko T.J.,Neuroscience Research Unit | Gupta S.,Walton Center Foundation Trust | Maclver K.,University of Liverpool
Current Pain and Headache Reports | Year: 2010

Central neuropathic pain is common in multiple sclerosis (MS), and its prevalence increases with physical disability. Sufficient evidence links dysesthetic pain, trigeminal neuralgia, Lhermitte's sign, and painful tonics spasms to plaque formation in the spinal cord and brain, whereas the association with headache and back pain remains unclear. Management varies according to the pain in question. For dysesthetic pain, drugs in use for neuropathic pain in general are recommended as first-line treatment, and emerging evidence suggests some benefit from cannabinoids and levetiracetam. Because of unique characteristics of MS-related trigeminal neuralgia, ganglion and root level neuroablative procedures are worth considering before microvascular decompression. Overall, the lack of controlled clinical trials, together with our limited understanding of the pathophysiological mechanisms involved, form a hindrance to a systematic and rational management of MS-related pain. © Springer Science+Business Media, LLC 2010.


Ruff L.M.,Walton Center Foundation Trust | Mendelow A.D.,Newcastle General Hospital | Lecky F.E.,Salford Royal Hospital
British Journal of Neurosurgery | Year: 2013

Introduction. Head injury is an important cause of death and disability in young people, with 1.4 million presentations each year in the UK. Extradural haematoma (EDH) is a potentially fatal head injury, which is easily remedied surgically. Several factors influence the mortality of EDH. The mortality of isolated EDH ranges from 1.2 to 33%.12,16,19,28 EDH outcome within the UK has not been recently described. Materials and methods. The Trauma Audit and Research Network (TARN) database was used to collate data on patients in England and Wales, with 'isolated' EDH between 1997 and 2003. Age, gender, GCS at 1st emergency department (ED), haematoma size, presence of a skull fracture, outcome (alive or dead) and injury-to-operation time were required. Where this time was unavailable, an estimation could be made using another time collected for the patient. Data co-ordinators at several hospitals were contacted in order to collect extra information missing from the database. The mortality for this group was then calculated and comparisons between this and previous series were made. Results. A total of four-hundred and eighty four (484) patients with isolated EDH were identified. One-hundred and ninety-seven (197) patients were operated on in England and Wales in this TARN dataset, between 1997 and 2003 for 'isolated' EDH. The mortality rate for this operative series was 2% (4 patients) (95% CI 0.1-4%). The non-operative mortality rate was 3% (95% CI 0.9-5.0%). Conclusion. This study has found a low EDH operative mortality rate of 2%. This is lower than that of previous studies on isolated EDH in the UK. This is likely to be valid as TARN is the largest European trauma registry, although we acknowledge that this first EDH sample derived from UK EDs may represent a selected series. © 2013 The Neurosurgical Foundation.


Wong S.H.,Walton Center Foundation Trust | White R.P.,Walton Center Foundation Trust
Journal of Neuro-Ophthalmology | Year: 2013

Background: The validity of the clinical dictum "the presence of spontaneous retinal venous pulsation (SVP) excludes raised intracranial pressure" has not been previously tested. We set out to determine the specificity and positive predictive value (PPV) of the presence of SVP to indicate normal intracranial pressure (ICP) in a routine clinical setting. Methods: We prospectively recruited patients undergoing lumbar puncture (LP), and 2 clinicians were blinded to the indications for LP and cerebrospinal fluid opening pressure (OP). Interobserver reliability was assessed. Results: There were 106 patients in our cohort with a median age of 44 years (range, 18-79 years) and median body mass index of 27.5 kg/m (range, 18-48 kg/m). SVP was present in 94 of 106 patients (88.7%). Thirteen of 106 (12.3%) patients had high OP (≥30 cmH2O), and SVP was present in 11 of 13 patients (86%) with high OP. The sensitivity (95% confidence interval) of the presence of SVP to exclude raised ICP was 0.89 (0.88-0.92), specificity of 0.15 (0.05-0.37), PPV of 0.88 (0.87-0.9), and negative predictive value of 0.17 (0.05-0.4). Interobserver agreement was moderate for SVP (kappa = 0.42). CONCLUSIONS:: Although the sensitivity and PPV of the presence of SVP to exclude raised ICP is high, it is not absolute. SVP can be seen in some patients with high ICP. Relying on the presence of SVP to exclude raised ICP may give a false sense of reassurance. © 2012 by North American Neuro-Ophthalmology Society.


Mutch K.,Walton Center Foundation Trust
British Journal of Nursing | Year: 2010

Background People are not expected to die from multiple sclerosis although, as the condition progresses over a period of time, some people become increasingly disabled and will require assistance with all activities of daily living. Their partners invariably carry out these tasks. Objective To gain a deeper understanding of the experiences of the partner living with and caring for a spouse disabled by multiple sclerosis. Methodology In a qualitative study, eight partners who live and care for a person with multiple sclerosis were interviewed using a semi-structured questionnaire to explore their experience of their role. Results The interview transcripts were analyzed using a thematic framework approach. Codes, themes and five categories were identified, which were worry, planning, frustrations, commitment to marriage and coping strategies. These categories were examined using quotes from the transcripts as evidence. Conclusion This qualitative study identified that these couples had been married for at least 20 years before disability of the spouse significantly affected their lifestyle. Partners felt obliged to continue in their caring role due to a sense of duty and commitment of marriage.Partners felt a sense of loss as they prioritized the health and needs of their spouse above their own and, finally, partners lost their identity as husband/wife as they were called 'the carer'. Partners felt out of control due to the unpredictable and progressive nature of MS and because it consumed their life 24 hours every day. Partners often felt guilty at not being satisfied with their life and wanting some independence.

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