Spectrum, risk factors and outcomes of neurological and psychiatric complications of COVID-19: a UK-wide cross-sectional surveillance study.

SARS-CoV-2 is associated with new-onset neurological and psychiatric conditions. Detailed clinical data, including factors associated with recovery, are lacking, hampering prediction modelling and targeted therapeutic interventions. In a UK-wide cross-sectional surveillance study of adult hospitalized patients during the first COVID-19 wave, with multi-professional input from general and sub-specialty neurologists, psychiatrists, stroke physicians, and intensivists, we captured detailed data on demographics, risk factors, pre-COVID-19 Rockwood frailty score, comorbidities, neurological presentation and outcome. A priori clinical case definitions were used, with cross-specialty independent adjudication for discrepant cases. Multivariable logistic regression was performed using demographic and clinical variables, to determine the factors associated with outcome. A total of 267 cases were included. Cerebrovascular events were most frequently reported (131, 49%), followed by other central disorders (95, 36%) including delirium (28, 11%), central inflammatory (25, 9%), psychiatric (25, 9%), and other encephalopathies (17, 7%), including a severe encephalopathy (n = 13) not meeting delirium criteria; and peripheral nerve disorders (41, 15%). Those with the severe encephalopathy, in comparison to delirium, were younger, had higher rates of admission to intensive care and a longer duration of ventilation. Compared to normative data during the equivalent time period prior to the pandemic, cases of stroke in association with COVID-19 were younger and had a greater number of conventional, modifiable cerebrovascular risk factors. Twenty-seven per cent of strokes occurred in patients <60 years. Relative to those >60 years old, the younger stroke patients presented with delayed onset from respiratory symptoms, higher rates of multi-vessel occlusion (31%) and systemic thrombotic events. Clinical outcomes varied between disease groups, with cerebrovascular disease conferring the worst prognosis, but this effect was less marked than the pre-morbid factors of older age and a higher pre-COVID-19 frailty score, and a high admission white cell count, which were independently associated with a poor outcome. In summary, this study describes the spectrum of neurological and psychiatric conditions associated with COVID-19. In addition, we identify a severe COVID-19 encephalopathy atypical for delirium, and a phenotype of COVID-19 associated stroke in younger adults with a tendency for multiple infarcts and systemic thromboses. These clinical data will be useful to inform mechanistic studies and stratification of patients in clinical trials.

COVID-19 Encephalitis with SARS-CoV-2 Detected in Cerebrospinal Fluid Presenting as a Stroke Mimic.

We report the case of a 35-year-old male with COVID-19 encephalitis presenting as a stroke mimic with sudden-onset expressive and receptive dysphasia, mild confusion and right arm incoordination. The patient received thrombolysis for a suspected ischaemic stroke, but later became febrile and SARS-CoV-2 was detected in cerebrospinal fluid. Electroencephalography demonstrated excess in slow waves, but neuroimaging was reported as normal. Respiratory symptoms were absent throughout and nasopharyngeal swab was negative for SARS-CoV-2. At the most recent follow-up, the patient had made a full neurological recovery. Clinicians should therefore consider testing for SARS-CoV-2 in CSF in patients who present with acute focal neurology, confusion and fever during the pandemic, even when there is no evidence of respiratory infection.

Baseline characteristics and outcomes of the main perpetrator programme within the Hampshire Domestic Abuse Prevention Partnership, UK: A mixed methods study.

Effective perpetrator programmes should be embedded within a community response, engage all types of perpetrators and involve an educational approach that integrates the survivor's voice. The Domestic Abuse Prevention Partnership (DAPP) is a transformative partnership based in the UK that aims to provide an integrated approach for perpetrators and survivors. This pragmatic mixed methods study was conducted to examine the baseline characteristics and individual outcomes of the main perpetrator programme within the DAPP. Applying a triangulation design, routine police re-offending aggregated data, pre- and post- perpetrator programme questionnaires, in-depth interviews with survivors, and focus-group discussions with perpetrators (clients) were integrated. Statistical analysis and thematic analysis were applied to quantitative and qualitative data, respectively. The majority of clients (47%) referred through the DAPP (n = 228) described wanting to make their relationship better as the main reason for engaging with the main perpetrators programme. Post-perpetrator programme questionnaires identified positive changes in both emotional behaviours and physical behaviours amongst clients, which were also supported by examples of improved relationships with their children described in survivor interviews. Three themes were described: first, making positive progress; second, impact of the children's module; and concerns around sustaining new behaviours. Over the monitoring period, 1 in 5 clients were either suspected or convicted of domestic abuse crimes following the programme. This suggests that further maintenance of positive behaviours and reinforcements are required for some clients. Given that clients felt children were a strong motivating factor for completing a programme, it seemed paradoxical that no specialist services were made available for them. Future reiterations of the DAPP model should at least address how best to work with children in families where domestic abuse occurs.

A Stab in the Dark: A Case Report of an Atypical Presentation of Giant Cell Arteritis (GCA).

Background: Giant cell arteritis/temporal arteritis (GCA) is an inflammatory condition that affects large to medium vessels such as the aorta and its primary branches. Patients classically present with fatigue, fever, headache, jaw claudication and in severe cases, may suffer either transient (amaurosis fugax) or permanent visual loss. The reference standard for diagnosis is the temporal artery biopsy (TAB) and the mainstay of treatment is with immunosuppression. Our patient JG, presented with a range of non-specific symptoms that mimicked generalised sepsis, but was ultimately diagnosed with GCA through effective, methodical multi-disciplinary team (MDT) work. Clinical case: JG, an 81 year old gentleman, presented acutely with a 3-4 weeks history of fatigue, lethargy, pyrexia and a marked inflammatory response suggestive of a sepsis but without a clear primary source or clinical features of vasculitis. His inflammatory markers were markedly raised although his erythrocyte sedimentation rate (ESR) was not elevated. He was initially treated for sepsis of unknown origin however, body imaging after admission suggested a possible infection around a previous aortic graft site. This was refuted in subsequent 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET/CT) scanning. Microbiological, parasitic, as well as autoimmune assays were unremarkable. He underwent a TAB which was diagnostic for GCA and as a result, was started on oral corticosteroids with immediate symptom relief. He was discharged and followed up on an outpatient basis. Conclusions: This case highlights how a vasculitis can present with a range of non-specific symptoms that may resemble a fever of unknown origin (FUO)/sepsis that can lead to a delay in making the correct diagnosis. It also highlights the importance of considering a diagnosis of vasculitis in patients who present with a FUO where there is no clear focus of infection. Delays in diagnosis and management of these conditions can potentially lead to significant irreversible morbidity.

A systematic review of the prevalence and odds of domestic abuse victimization among people with dementia.

Little is known about the prevalence of domestic abuse in later life or after the onset of dementia. Given the expanding population of dementia sufferers, it is imperative to identify the degree to which domestic abuse occurs within this population. The aim of this study was to establish the prevalence (lifetime and past year), odds, and trajectory of domestic abuse victimization among people with dementia. Systematic searches of 20 electronic databases were performed from inception to June 2016, using a pre-defined search strategy for English language articles containing data on the prevalence and/or odds of adult lifetime or past year domestic abuse among people with dementia. Six studies met the inclusion criteria. Among patients with dementia, the past year median prevalence of physical and psychological domestic abuse victimization is 11% and 19%, respectively. Findings from cross-sectional studies show an increased odds of domestic abuse among people with dementia vs those without. Trajectory information indicated that domestic abuse was more prevalent in relationships with a pre-morbid history of abuse. The lack of research into this area is highlighted by the small number of includable studies. There is a need for further research into the impact of dementia on domestic abuse.