Dizziness

Previous surveys on the psychological impacts of SARS and influenza outbreaks were reviewed [18 (link),21 (link),24 ]. Authors included additional questions related to the COVID-19 outbreak. The structured questionnaire consisted of questions that covered several areas: (1) demographic data; (2) physical symptoms in the past 14 days; (3) contact history with COVID-19 in the past 14 days; (4) knowledge and concerns about COVID-19; (5) precautionary measures against COVID-19 in the past 14 days; (6) additional information required with respect to COVID-19; (7) the psychological impact of the COVID-19 outbreak; and (8) mental health status.
Sociodemographic data were collected on gender, age, education, residential location in the past 14 days, marital status, employment status, monthly income, parental status, and household size. Physical symptom variables in the past 14 days included fever, chills, headache, myalgia, cough, difficulty in breathing, dizziness, coryza, sore throat, and persistent fever, as well as persistent fever and cough or difficulty breathing. Respondents were asked to rate their physical health status and state any history of chronic medical illness. Health service utilization variables in the past 14 days included consultation with a doctor in the clinic, admission to the hospital, being quarantined by a health authority, and being tested for COVID-19. Contact history variables included close contact with an individual with confirmed COVID-19, indirect contact with an individual with confirmed COVID-19, and contact with an individual with suspected COVID-19 or infected materials.
Knowledge about COVID-19 variables included knowledge about the routes of transmission, level of confidence in diagnosis, level of satisfaction of health information about COVID-19, the trend of new cases and death, and potential treatment for COVID-19 infection. Respondents were asked to indicate their source of information. The actual number of confirmed cases of COVID-19 and deaths in the city on the day of the survey were collected. Concern about COVID-19 variables included self and other family members contracting COVID-19 and the chance of surviving if infected.
Precautionary measures against COVID-19 variables included avoidance of sharing of utensils (e.g., chopsticks) during meals, covering mouth when coughing and sneezing, washing hands with soap, washing hands immediately after coughing, sneezing, or rubbing the nose, washing hands after touching contaminated objects, and wearing a mask regardless of the presence or absence of symptoms. The respondents were asked the average number of hours staying at home per day to avoid COVID-19. Respondents were also asked whether they felt too much -unnecessary worry had been made about the COVID-19 epidemic. Additional health information about COVID-19 needed by respondents included more information about symptoms after contraction of COVID-19, routes of transmission, treatment, prevention of the spread of COVID-19, local outbreaks, travel advice, and other measures imposed by other countries.
The psychological impact of COVID-19 was measured using the Impact of Event Scale-Revised (IES-R). The IES-R is a self-administered questionnaire that has been well-validated in the Chinese population for determining the extent of psychological impact after exposure to a public health crisis within one week of exposure [25 (link)]. This 22-item questionnaire is composed of three subscales and aims to measure the mean avoidance, intrusion, and hyperarousal [26 (link)]. The total IES-R score was divided into 0–23 (normal), 24–32 (mild psychological impact), 33–36 (moderate psychological impact), and >37 (severe psychological impact) [27 (link)].
Mental health status was measured using the Depression, Anxiety and Stress Scale (DASS-21) and calculations of scores were based on the previous study [28 (link)]. Questions 3, 5, 10, 13, 16, 17 and 21formed the depression subscale. The total depression subscale score was divided into normal (0–9), mild depression (10–12), moderate depression (13–20), severe depression (21–27), and extremely severe depression (28–42). Questions 2, 4, 7, 9, 15, 19, and 20 formed the anxiety subscale. The total anxiety subscale score was divided into normal (0–6), mild anxiety (7–9), moderate anxiety (10–14), severe anxiety (15–19), and extremely severe anxiety (20–42). Questions 1, 6, 8, 11, 12, 14, and 18 formed the stress subscale. The total stress subscale score was divided into normal (0–10), mild stress (11–18), moderate stress (19–26), severe stress (27–34), and extremely severe stress (35–42). The DASS has been demonstrated to be a reliable and valid measure in assessing mental health in the Chinese population [29 (link),30 (link)]. The DASS was previously used in research related to SARS [31 (link)].

We have used a list of various possibly stress, anxiety or somatoform-related symptoms such as irritability, fatigue, hostility, feeling of tension, inability to concentrate, musculoskeletal symptoms (neck or upper back pain or discomfort), gastrointestinal symptoms (abdominal pain or discomfort, nausea, alterations in bowel habits), headaches, sleep disturbances, tachycardia, increased blood pressure, palpitations, chest discomfort, dizziness and substance abuse [27 ]. This checklist is not intended as a psychometric tool. It consists of nonspecific symptoms described as related to stress. Stress symptoms, in general, claim more sensitivity than specificity, as such, we were particularly interested on the number of cardinal stress manifestations and not on the evaluation of a situation or psychological state. Participants were asked about the frequency of experiencing these symptoms during the last year and each symptom was binary categorized as frequent or not. Some of these symptoms may not well be expressed as binary variables and suffered low specificity but our interest was to evaluate the coexistence of these stress-related symptoms with high PSS scores. The total number of frequent symptoms was calculated and each participant was categorized in five groups (symptoms less or equal to three, four, five, six and more than six).

Blood pressure is a modifiable risk factor for adverse cardiovascular events such as coronary heart disease and stroke. Hypertension is recognised as one of the most preventable causes of premature morbidity and mortality. The prevalence of both diabetes and hypertension increases sharply with age but can only be dealt with properly at a population level if we know how many go undiagnosed with these conditions. Evidence suggests that many older adults are unaware that they have hypertension. In the UK, 1 in 3 adults suffer from hypertension(a reading of 140/90 mm Hg or higher; [25 ] rising to at least 1 in 2 in those aged 65 years and over [26 ]. In addition, as a person ages, the tendency for postural hypotension (BP drop on standing) increases. This can result in dizziness, light headedness and increases the risk of falls. Systolic (SBP) and diastolic blood pressure (DBP) was measured using the OMRON TM digital automatic blood pressure monitor (Model M10-IT). Blood pressure and heart rate was measured three times (one minute apart) on either arm. The one-minute gap between blood pressure measurements was based on the 2005 AHA position statement [27 (link)] which recommended at that time, that at least two blood pressure readings should be taken at intervals of at least one minute and an average calculated. Given the pragmatic approach used in the design of the health assessment, a one-minute gap was also deemed more logistically feasible, in order to keep each assessment as short as possible for the participant. Two of the measurements were taken with the participant seated, while the third was recorded immediately upon standing (postural blood pressure). Hypertension was defined as SBP ≥ 140 mmHg or DBP ≥ 90 mmHg or current blood pressure-lowering treatment [25 ].

We prospectively and consecutively recruited patients with an acute attack or a history of TM who visited a tertiary referral center (Asan Medical Center, Seoul, South Korea) between July 2018 and April 2020. TM attacks were determined when the following criteria were fulfilled^{1 (link)}: (1) presence of signs or symptoms of sensory, motor, or autonomic dysfunction attributable to the spinal cord; (2) documentation of T2 high signal intensity on spinal MRI. Patients who had experienced clinical attacks within the last two months were regarded as being in an acute attack phase, while all others were regarded as being in the remission phase. For acute attack phase, we only included patients whose last attack was exclusively TM.
A diagnosis of ITM was made based on the previously suggested criteria^{30 (link)}. All patients underwent a detailed diagnostic workup including brain MRI, spinal MRI, cell-based assaying for anti-aquaporin-4 antibody (AQP4-Ab) and anti-myelin oligodendrocyte glycoprotein antibody (MOG-Ab)^{13 (link)}, anti-nuclear antibody (ANA), anti-SS-A/SS-B antibody, anti-neutrophil cytoplasmic (ANCA), screening test for HIV and syphilis and routine laboratory test. Patients with evidence of active infections, active malignancy, a history of systemic autoimmune diseases or signs of other various conditions mimicking ITM, such as mechanical compression, spinal cord infarction or spinal arteriovenous fistula were not diagnosed as ITM.
Among the patients with confirmed etiologies, we included AQP4 + NMOSD and RRMS patients for comparison. The diagnoses of AQP4 + NMOSD and RRMS were based on the 2015 International Panel for NMO diagnostic criteria for NMOSD^{31 (link)} and the 2017 revised McDonald criteria^{32 (link)}, respectively. We did not include patients with other etiologies due to small sample sizes. Additionally, healthy controls (HCs), defined as those who complained of mild neurologic symptoms such as headache or dizziness but had normal brain MRI findings, were recruited for further comparison.
All participants were over 18 years of age. Patients were sampled for blood and evaluated for the EDSS score on the day of enrollment.