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PONE-D-20-39539

Neurological manifestations in hospitalized patients with COVID-19 in Mexico City

PLOS ONE

Dear Dr. Chiquete,

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall, a very nice & timely cross-sectional study that provides important insight in to the neurologic manifestations of the COVID-19. The manuscript is well written and precise. It certainly deserves publication.

I see no need for major revisions.

I have 2 suggestions for minor revisions: (1) I would recommend a more explicit statement of the study design be included in the methods section. That the study is a cross-sectional analysis is mentioned in the introduction but should be explicitly stated in the methods. (2) Although the comparison groups are evident from the Tables, it is not clear from the text of the manuscript. The addition of text in the methodology ("The study aims to describe differences in demographics, clinical presentation, and disease severity in those patients who experienced neurologic events and those who did not. For these purposes, we define patients with neurologic events as those who suffered delirium, delayed recovery...") or something similar. This addition will lend more clarity to the text.

Also, note that on p.7 of the submission, "Data Collection" section, there is a missing comma between pulmonary and neurological. Neurologic (rather than neurological - meaning pertaining to the study of or discipline of neurology) would be the preferred usage.

Reviewer #2: The authors have done a nice job in describing the neurological manifestations of COVID19 in Mexico City. I have no critiques or suggestions. I'm not sure what the minimum character count is, but i'm pasting in the abstract to fulfill it.

Background The coronavirus disease 2019 (COVID-19) is a systemic entity that

frequently implies neurological features at presentation and complications during the

disease course. We aimed to describe the characteristics and predictors for developing

in-hospital neurological manifestations in a large cohort of hospitalized patients with

COVID-19 in Mexico City. Methods We analyzed records from consecutive adult

patients hospitalized from March 15 to June 30, 2020, with moderate to severe COVID-

19 confirmed by reverse transcription real-time polymerase chain reaction (rtRT-PCR)

for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Neurological

syndromes were actively searched by a standardized structured questionnaire and

physical examination, confirmed by neuroimaging, neurophysiology of laboratory

analyses, as applicable. Results We studied 1,072 cases (65% men, mean age

53.2±13 years), 71 patients had pre-existing neurological diseases (diabetic

neuropathy: 17, epilepsy: 15, history of ischemic stroke: eight, migraine: six, multiple

sclerosis: one, Parkinson disease: one), and 163 (15.2%) developed a new

neurological complication. Headache (41.7%), myalgia (38.5%), dysgeusia (8%), and

anosmia (7%) were the most common neurological symptoms at hospital presentation.

Delirium (13.1%), objective limb weakness (5.1%), and delayed recovery of mental

status after sedation withdrawal (2.5%), were the most common new neurological

syndromes. Age, headache at presentation, preexisting neurological disease, invasive

mechanical ventilation, and neutrophil/lymphocyte ratio ≥9 were independent

predictors of new in-hospital neurological complications. Conclusions Even after

excluding initial clinical features and pre-existing comorbidities, new neurological

complications in hospitalized patients with COVID-19 are frequent and can be

predicted from clinical information at hospital admission.

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Reviewer #1: No

Reviewer #2: No

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Neurological manifestations in hospitalized patients with COVID-19 in Mexico City

PONE-D-20-39539R1

Dear Dr. Chiquete,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Tai-Heng Chen, M.D.

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: (No Response)

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: (No Response)

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: (No Response)

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I have no further recommendations for revision. I am have no further explanation to provide regarding the questions above.

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No