BackgroundSince the identification of the first case of infection with the Middle East respiratory syndrome corona virus (MERS-CoV) in Saudi Arabia in June 2012, the number of laboratory-confirmed cases has exceeded 941 cases globally, of which 347 died. The disease presents as severe respiratory infection often with shock, acute kidney injury, and coagulopathy. Recently, we observed three cases who presented with neurologic symptoms. These are so far the first reported cases of neurologic injury associated with MERS-CoV infection.MethodsData was retrospectively collected from three patients admitted with MERS-CoV infection to Intensive Care unit (ICU) at King Abdulaziz Medical City, Riyadh. They were managed separately in three different wards prior to their admission to ICU.FindingThe three patients presented with severe neurologic syndrome which included altered level of consciousness ranging from confusion to coma, ataxia, and focal motor deficit. Brain MRI revealed striking changes characterized by widespread, bilateral hyperintense lesions on T2-weighted imaging within the white matter and subcortical areas of the frontal, temporal, and parietal lobes, the basal ganglia, and corpus callosum. None of the lesions showed gadolinium enhancement.InterpretationCNS involvement should be considered in patients with MERS-CoV and progressive neurological disease, and further elucidation of the pathophysiology of this virus is needed.Electronic supplementary materialThe online version of this article (doi:10.1007/s15010-015-0720-y) contains supplementary material, which is available to authorized users.

Background Seasonal influenza virus is a common cause of acute lower respiratory infection (ALRI) in young children. In 2008, we estimated that 20 million influenza-virus-associated ALRI and 1 million influenza-virus-associated severe ALRI occurred in children under 5 years globally. Despite this substantial burden, only a few low-income and middleincome countries have adopted routine influenza vaccination policies for children and, where present, these have achieved only low or unknown levels of vaccine uptake. Moreover, the influenza burden might have changed due to the emergence and circulation of influenza A/H1N1pdm09. We aimed to incorporate new data to update estimates of the global number of cases, hospital admissions, and mortality from influenza-virus-associated respiratory infections in children under 5 years in 2018.Methods We estimated the regional and global burden of influenza-associated respiratory infections in children under 5 years from a systematic review of 100 studies published between Jan 1, 1995, and Dec 31, 2018, and a further 57 high-quality unpublished studies. We adapted the Newcastle-Ottawa Scale to assess the risk of bias. We estimated incidence and hospitalisation rates of influenza-virus-associated respiratory infections by severity, case ascertainment, region, and age. We estimated in-hospital deaths from influenza virus ALRI by combining hospital admissions and in-hospital case-fatality ratios of influenza virus ALRI. We estimated the upper bound of influenza virus-associated ALRI deaths based on the number of in-hospital deaths, US paediatric influenza-associated death data, and populationbased childhood all-cause pneumonia mortality data in six sites in low-income and lower-middle-income countries.Findings In 2018, among children under 5 years globally, there were an estimated 109•5 million influenza virus episodes (uncertainty range [UR] 63•1-190•6), 10•1 million influenza-virus-associated ALRI cases (6•8-15•1); 870 000 influenza-virus-associated ALRI hospital admissions (543 000-1 415 000), 15 300 in-hospital deaths (5800-43 800), and up to 34 800 (13 200-97 200) overall influenza-virus-associated ALRI deaths. Influenza virus accounted for 7% of ALRI cases, 5% of ALRI hospital admissions, and 4% of ALRI deaths in children under 5 years. About 23% of the hospital admissions and 36% of the in-hospital deaths were in infants under 6 months. About 82% of the in-hospital deaths occurred in low-income and lower-middle-income countries.Interpretation A large proportion of the influenza-associated burden occurs among young infants and in low-income and lower middle-income countries. Our findings provide new and important evidence for maternal and paediatric influenza immunisation, and should inform future immunisation policy particularly in low-income and middleincome countries.Funding WHO; Bill & Melinda Gates Foundation.

Effect of disturbance on root colonization and vertical distribution of arbuscular mycorrhizal fungi (AMF) and dark septate endophytes (DSE) was investigated at two adjacent sites of Lal Suhanra Biosphere Reserve, Pakistan. Disturbance clearly affected AMF and DSE colonization, vertical distribution of AMF and plant community structure. Mean colonization of AMF and DSE was slightly less at the disturbed site. Average spore densities, diversity and richness of AMF and DSE were higher at the undisturbed site. A study of the vertical distribution of AMF associated with the five plant species most common to each study site indicated that beside AMF and DSE colonization disturbance may affect AMF species composition. Correlation of AMF with DSE is also discussed.

Background Handoff in cardiac intensive care units has been associated with improved outcomes. We aimed to determine whether a standardized protocol for handover could be implemented using the “theory of change” model by education, introduction of a checklist, and developing feedback mechanisms, measured by better knowledge transfer and bedside care provider satisfaction. Methods A theory of change model was developed and implemented to introduce a teamwork-driven handover process. A standardized checklist was made available at every bedside. A preintervention assessment of patient handovers was obtained by direct observation using a standardized checklist. The same checklist was used for assessment after implementation. A survey was conducted to measure intensive care unit staff perception and satisfaction with the handover process. Results After implementation, the standardized handover process was employed in 53 of 60 patient transfers (88.3% compliance): 49 preintervention and 29 postintervention observations were performed. Postimplementation, critical knowledge omissions (total score of 25) decreased from a median of 10 (range 4–17) to 0 (range 0–4; p < 0.001). At 6 months, knowledge omission scores improved to a median of 0 (range 0–1; p < 0.001); and 96% (24/25) of staff reported improvement in the quality of information transfer, and 100% reported improvement in overall team work. Conclusion Implementation of a standardized patient handover process improved the quality of knowledge transfer and overall staff satisfaction. The theory of change model is a unique and highly effective tool to implement and sustain behavior change.

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