Global uncertainty in the diagnosis of neurological complications of SARS-CoV-2 infection by both neurologists and non-neurologists: An international inter-observer variability study.

INTRODUCTION: Uniform case definitions are required to ensure harmonised reporting of neurological syndromes associated with SARS-CoV-2. Moreover, it is unclear how clinicians perceive the relative importance of SARS-CoV-2 in neurological syndromes, which risks under- or over-reporting. METHODS: We invited clinicians through global networks, including the World Federation of Neurology, to assess ten anonymised vignettes of SARS-CoV-2 neurological syndromes. Using standardised case definitions, clinicians assigned a diagnosis and ranked association with SARS-CoV-2. We compared diagnostic accuracy and assigned association ranks between different settings and specialties and calculated inter-rater agreement for case definitions as "poor" (κ ≤ 0.4), "moderate" or "good" (κ > 0.6). RESULTS: 1265 diagnoses were assigned by 146 participants from 45 countries on six continents. The highest correct proportion were cerebral venous sinus thrombosis (CVST, 95.8%), Guillain-Barré syndrome (GBS, 92.4%) and headache (91.6%) and the lowest encephalitis (72.8%), psychosis (53.8%) and encephalopathy (43.2%). Diagnostic accuracy was similar between neurologists and non-neurologists (median score 8 vs. 7/10, p = 0.1). Good inter-rater agreement was observed for five diagnoses: cranial neuropathy, headache, myelitis, CVST, and GBS and poor agreement for encephalopathy. In 13% of vignettes, clinicians incorrectly assigned lowest association ranks, regardless of setting and specialty. CONCLUSION: The case definitions can help with reporting of neurological complications of SARS-CoV-2, also in settings with few neurologists. However, encephalopathy, encephalitis, and psychosis were often misdiagnosed, and clinicians underestimated the association with SARS-CoV-2. Future work should refine the case definitions and provide training if global reporting of neurological syndromes associated with SARS-CoV-2 is to be robust.

NeuroCOVID protocol and pilot results: A multicentre case-control study of acute stroke and SARS-CoV-2 infection

Background and aims: Coronavirus disease (COVID-19) can predispose to vascular and neurological complications, through inflammatory and thrombogenic mechanisms. There is a high incidence of stroke and of COVID-19 in Brazil, making it important we better understand the association between stroke and SARS-CoV-2 infection. In view of this, we set up a NeuroCOVID study. Methods: This prospective case-control study is recruiting across 12 healthcare centres across all five Brazilian regions. We will enroll 1,000 stroke cases and 1,800 inpatients with other nonvascular acute diseases as controls with a 1:2 ratio. The main outcome is acute stroke (ischemic, haemorrhagic, venous thrombosis). The exposure is SARSCOV- 2 infection: previous (positive IgG), subacute (positive IgA) or acute (virus detected in nasopharynx). The Protect Code Stroke Protocol was translated into Portuguese to be validated in our population. All participants will respond to standardized questionnaires and have blood and nasopharyngeal swab samples collected at baseline, after signing the consent form (ethics approval no CAAE36538320.9.0000.5190). Results: Our pilot study ran at Hospital da Restauração (Northeast Brazil), from the 11th to 31st of December and included 20 cases (mean age 59 years;50% female) and 14 controls (mean age 52 years;36% female). Four patients had asymptomatic acute SARS-CoV-2 infection, all of them in the case group (20%). Conclusion: These preliminary results support our hypothesis of an association between SARS-CoV-2 and acute stroke in Brazil. The final report of the NeuroCOVID study will provide definitive evidence, along with similar studies worldwide.

Understanding the policy dynamics of COVID-19 in the UK: Early findings from interviews with policy makers and health care professionals.

The UK government response to COVID-19 has been heavily criticised. We report witnesses' perceptions of what has shaped UK policies and how these policies have been received by healthcare workers. Such studies are usually affected by hindsight. Here we deploy a novel prospective approach to capture real-time information. We are historians, social scientists and biomedical researchers who study how societies cope with infectious disease. In February 2020 we began regular semi-structured calls with prominent members of policy communities, and health care professionals, to elicit their roles in, and reactions to, the pandemic response. We report witnesses' perceptions that personal protective equipment (PPE) stocks were too small, early warnings have not led to sufficiently rapid policy decisions, and a lack of transparency is sapping public trust. Significant successes include research mobilisation. The early experiences and reactions of our witnesses suggest important issues for investigation, notably a perception of delay in decision making.