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Intensive Care Unit-Acquired Weakness: Not just Another Muscle Atrophying Condition. Int J Mol Sci 2020; 21:ijms21217840. [PMID: 33105809 PMCID: PMC7660068 DOI: 10.3390/ijms21217840] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
Intensive care unit-acquired weakness (ICUAW) occurs in critically ill patients stemming from the critical illness itself, and results in sustained disability long after the ICU stay. Weakness can be attributed to muscle wasting, impaired contractility, neuropathy, and major pathways associated with muscle protein degradation such as the ubiquitin proteasome system and dysregulated autophagy. Furthermore, it is characterized by the preferential loss of myosin, a distinct feature of the condition. While many risk factors for ICUAW have been identified, effective interventions to offset these changes remain elusive. In addition, our understanding of the mechanisms underlying the long-term, sustained weakness observed in a subset of patients after discharge is minimal. Herein, we discuss the various proposed pathways involved in the pathophysiology of ICUAW, with a focus on the mechanisms underpinning skeletal muscle wasting and impaired contractility, and the animal models used to study them. Furthermore, we will explore the contributions of inflammation, steroid use, and paralysis to the development of ICUAW and how it pertains to those with the corona virus disease of 2019 (COVID-19). We then elaborate on interventions tested as a means to offset these decrements in muscle function that occur as a result of critical illness, and we propose new strategies to explore the molecular mechanisms of ICUAW, including serum-related biomarkers and 3D human skeletal muscle culture models.
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52
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McClafferty B, Umer I, Fye G, Kepko D, Kalayanamitra R, Shahid Z, Ramgobin D, Cai A, Groff A, Bhandari A, Aggarwal CS, Patel R, Bhatt D, Polimera H, Sahu N, Vunnam R, Golamari R, Kumar A, Jain R. Approach to critical illness myopathy and polyneuropathy in the older SARS-CoV-2 patients. J Clin Neurosci 2020; 79:241-245. [PMID: 33070904 PMCID: PMC7380205 DOI: 10.1016/j.jocn.2020.07.058] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/08/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
One of the major concerns of the health care community and the public surrounding the SARS-CoV-2 pandemic is the availability and use of ventilators. Unprecedented surges of patients presented to intensive care units across the country, with older adults making up a large proportion of the patient population. This paper illustrates contemporary approaches to critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuromyopathy (CIPNM) in older patients, including incidence, risk factors, mechanisms for pathology, diagnosis, contemporary treatment approaches, and outcomes. We hope that the following analysis may help educate clinicians and ultimately decrease the duration of the mechanical ventilation required by these patients, resulting in improved clinical outcomes and an increase in ventilator availability for other patients in need.
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Affiliation(s)
| | - Ibrahim Umer
- Lake Erie College of Osteopathic Medicine, United States
| | - Gary Fye
- Lake Erie College of Osteopathic Medicine, United States
| | - Douglas Kepko
- Lake Erie College of Osteopathic Medicine, United States
| | | | - Zainab Shahid
- Lake Erie College of Osteopathic Medicine, United States
| | | | - Alice Cai
- Penn State College of Medicine, United States
| | | | - Abani Bhandari
- Department of Internal Medicine, KISTMC, Tribhuvan University, Nepal, India
| | | | - Ravi Patel
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Dhirisha Bhatt
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Hyma Polimera
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Nitasa Sahu
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Ramarao Vunnam
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Reshma Golamari
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
| | - Ashutosh Kumar
- Department of Pediatrics and Neurology, Penn State Milton S. Hershey Medical Center, United States
| | - Rohit Jain
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, United States
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53
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Hydrocortisone mitigates ICU-AW by fine-tuning of muscle atrophic and hypertrophic signaling pathways in a sepsis model with limb immobilization. Life Sci 2020; 261:118366. [PMID: 32871182 DOI: 10.1016/j.lfs.2020.118366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/14/2020] [Accepted: 08/27/2020] [Indexed: 12/29/2022]
Abstract
AIMS Intensive care unit-acquired weakness (ICU-AW) is a complex spectrum of disability that delays recovery of critically ill-immobilized patients with sepsis. Much discrepancy remain on the use of corticosteroids and their impact on muscle regeneration in critical illness management. Therefore, the aim of this study is to investigate whether hydrocortisone (HCT) modulates muscle mass turnover in ICU-AW induced by sepsis with limb immobilization (SI). MAIN METHODS Sepsis by cecal ligation puncture (CLP) with forelimb-immobilization were performed in rats. The study consisted of four groups: Sham (left forelimb-immobilization), Sham HCT (left forelimb-immobilization + HCT), SI (CLP + left forelimb-immobilization) and SI HCT (CLP + left forelimb-immobilization + HCT). Motor force, blood and muscle sampling were assessed. KEY FINDINGS HCT prevented body weight loss associated with SI and attenuated systemic and muscular inflammation. Besides, myosin was restituted in SI HCT group in conjunction to muscle mass and strength restoration. Pro-hypertrophic calcineurin (PP2B-Aβ) and nuclear factor of activated T-cells C3 (NFATc3) but not protein kinase B (Akt) were re-activated by HCT. Finally, pro-atrophic extracellular signal-regulated kinases (ERK1/2) and p38 mitogen-activated protein kinases (p38) but not nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) were inhibited in SI HCT group. SIGNIFICANCE This study unravels new molecular events thought to control muscle protein synthesis in ICU-AW induced by sepsis and limb immobilization. HCT has a potential to fine-tune muscle-signaling pathways and to reduce the negative outcomes of ICU-AW.
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Hammond NE, Finfer SR, Li Q, Taylor C, Cohen J, Arabi Y, Bellomo R, Billot L, Harward M, Joyce C, McArthur C, Myburgh J, Perner A, Rajbhandari D, Rhodes A, Thompson K, Webb S, Venkatesh B. Health-related quality of life in survivors of septic shock: 6-month follow-up from the ADRENAL trial. Intensive Care Med 2020; 46:1696-1706. [PMID: 32676679 DOI: 10.1007/s00134-020-06169-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/30/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To investigate the impact of hydrocortisone treatment and illness severity on health-related quality of life (HRQoL) at 6 months in septic shock survivors from the ADRENAL trial. METHODS Using the EuroQol questionnaire (EQ-5D-5L) at 6 months after randomization we assessed HRQoL in patient subgroups defined by hydrocortisone or placebo treatment, gender, illness severity (APACHE II < or ≥ 25), and severity of shock (baseline peak catecholamine doses < or ≥ 15 mcg/min). Additionally, in subgroups defined by post-randomisation variables; time to shock reversal (days), treatment with renal replacement therapy (RRT), and presence of bacteremia. RESULTS At 6 months, there were 2521 survivors. Of these 2151 patients (85.3%-1080 hydrocortisone and 1071 placebo) completed 6-month follow-up. Overall, at 6 months the mean EQ-5D-5L visual analogue scale (VAS) was 70.8, mean utility score 59.4. Between 15% and 30% of patients reported moderate to severe problems in any given HRQoL domain. There were no differences in any EQ-5D-5L domain in patients who received hydrocortisone vs. placebo, nor in the mean VAS (p = 0.6161), or mean utility score (p = 0.7611). In all patients combined, males experienced lower pain levels compared to females [p = 0.0002). Neither higher severity of illness or shock impacted reported HRQoL. In post-randomisation subgroups, longer time to shock reversal was associated with increased problems with mobility (p = < 0.0001]; self-care (p = 0.0.0142), usual activities (p = <0.0001] and pain (p = 0.0384). Amongst those treated with RRT, more patients reported increased problems with mobility (p = 0.0307) and usual activities (p = 0.0048) compared to those not treated. Bacteraemia was not associated with worse HRQoL in any domains of the EQ-5D-5L. CONCLUSIONS Approximately one fifth of septic shock survivors report moderate to extreme problems in HRQoL domains at 6 months. Hydrocortisone treatment for septic shock was not associated with improved HRQoL at 6 months. Female gender was associated with worse pain at 6 months.
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Affiliation(s)
- Naomi E Hammond
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia. .,Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia.
| | - Simon R Finfer
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia.,Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Qiang Li
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia
| | - Colman Taylor
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia
| | - Jeremy Cohen
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Yaseen Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Rinaldo Bellomo
- Austin and Repatriation Medical Center, Melbourne, Australia
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia
| | - Meg Harward
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia.,Princess Alexandra Hospital, Brisbane, Australia
| | - Christopher Joyce
- Princess Alexandra Hospital, Brisbane, Australia.,The Wesley Hospital, Brisbane, Australia
| | - Colin McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - John Myburgh
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia.,St. George Hospital, Sydney, Australia
| | | | - Dorrilyn Rajbhandari
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia
| | | | - Kelly Thompson
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia
| | - Steve Webb
- Royal Perth Hospital, Perth, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Balasubramanian Venkatesh
- Statistics Division, The George Institute for Global Health, UNSW Sydney, Newtown, Australia.,Princess Alexandra Hospital, Brisbane, Australia.,The University of Queensland, Brisbane, Australia.,The Wesley Hospital, Brisbane, Australia
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55
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Vanhorebeek I, Latronico N, Van den Berghe G. ICU-acquired weakness. Intensive Care Med 2020; 46:637-653. [PMID: 32076765 PMCID: PMC7224132 DOI: 10.1007/s00134-020-05944-4] [Citation(s) in RCA: 284] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/16/2020] [Indexed: 01/04/2023]
Abstract
Critically ill patients often acquire neuropathy and/or myopathy labeled ICU-acquired weakness. The current insights into incidence, pathophysiology, diagnostic tools, risk factors, short- and long-term consequences and management of ICU-acquired weakness are narratively reviewed. PubMed was searched for combinations of “neuropathy”, “myopathy”, “neuromyopathy”, or “weakness” with “critical illness”, “critically ill”, “ICU”, “PICU”, “sepsis” or “burn”. ICU-acquired weakness affects limb and respiratory muscles with a widely varying prevalence depending on the study population. Pathophysiology remains incompletely understood but comprises complex structural/functional alterations within myofibers and neurons. Clinical and electrophysiological tools are used for diagnosis, each with advantages and limitations. Risk factors include age, weight, comorbidities, illness severity, organ failure, exposure to drugs negatively affecting myofibers and neurons, immobility and other intensive care-related factors. ICU-acquired weakness increases risk of in-ICU, in-hospital and long-term mortality, duration of mechanical ventilation and of hospitalization and augments healthcare-related costs, increases likelihood of prolonged care in rehabilitation centers and reduces physical function and quality of life in the long term. RCTs have shown preventive impact of avoiding hyperglycemia, of omitting early parenteral nutrition use and of minimizing sedation. Results of studies investigating the impact of early mobilization, neuromuscular electrical stimulation and of pharmacological interventions were inconsistent, with recent systematic reviews/meta-analyses revealing no or only low-quality evidence for benefit. ICU-acquired weakness predisposes to adverse short- and long-term outcomes. Only a few preventive, but no therapeutic, strategies exist. Further mechanistic research is needed to identify new targets for interventions to be tested in adequately powered RCTs.
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Affiliation(s)
- Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123, Brescia, Italy.,Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123, Brescia, Italy
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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56
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Hlophe ST, Masekela R. Life after paediatric intensive care unit. Afr J Thorac Crit Care Med 2019; 25:10.7196/AJTCCM.2019.v25i4.027. [PMID: 34286263 PMCID: PMC8278848 DOI: 10.7196/ajtccm.2019.v25i4.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2019] [Indexed: 11/23/2022] Open
Abstract
Advances in critical care medicine have led to reduced mortality but increased morbidity. Post-intensive care unit syndrome (PICS) develops after critical illness and presents as cognitive, physical and/or psychosocial impairments. PICS is prevalent in 10 - 36% of patients after discharge from paediatric intensive care unit. Multiple risk factors are associated with PICS, but there is no single causal factor. Factors range from clinical illnesses to intensive care intervention. The care plan should be aimed at prevention, early identification and post-ICU management of PICS by a multidisciplinary team.
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Affiliation(s)
- S T Hlophe
- Department of Paediatrics and Child Health, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R Masekela
- Department of Paediatrics and Child Health, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y, Pirracchio R, Rochwerg B. Corticosteroids for treating sepsis in children and adults. Cochrane Database Syst Rev 2019; 12:CD002243. [PMID: 31808551 PMCID: PMC6953403 DOI: 10.1002/14651858.cd002243.pub4] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. The original review was published in 2004 and was updated in 2010 and 2015 prior to this update. OBJECTIVES To examine the effects of corticosteroids on death in children and adults with sepsis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN, and the WHO Clinical Trials Search Portal, on 25 July 2019. In addition, we conducted reference checking and citation searching, and contacted study authors, to identify additional studies as needed. SELECTION CRITERIA We included randomized controlled trials (RCTs) of corticosteroids versus placebo or usual care (antimicrobials, fluid replacement, and vasopressor therapy as needed) in children and adults with sepsis. We also included RCTs of continuous infusion versus intermittent bolus of corticosteroids. DATA COLLECTION AND ANALYSIS All review authors screened and selected studies for inclusion. One review author extracted data, which was checked by the others, and by the lead author of the primary study when possible. We obtained unpublished data from the authors of some trials. We assessed the methodological quality of trials and applied GRADE to assess the certainty of evidence. Review authors did not contribute to assessment of eligibility and risk of bias, nor to data extraction, for trials they had participated in. MAIN RESULTS We included 61 trials (12,192 participants), of which six included only children, two included children and adults, and the remaining trials included only adults. Nine studies are ongoing and will be considered in future versions of this review. We judged 19 trials as being at low risk of bias. Corticosteroids versus placebo or usual care Compared to placebo or usual care, corticosteroids probably slightly reduce 28-day mortality (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.84 to 0.99; 11,233 participants; 50 studies; moderate-certainty evidence). Corticosteroids may result in little to no difference in long-term mortality (RR 0.97, 95% CI 0.91 to 1.03; 6236 participants; 7 studies; low-certainty evidence) and probably slightly reduce hospital mortality (RR 0.90, 95% CI 0.82 to 0.99; 8183 participants; 26 trials; moderate-certainty evidence). Corticosteroids reduced length of intensive care unit (ICU) stay for all participants (mean difference (MD) -1.07 days, 95% CI -1.95 to -0.19; 7612 participants; 21 studies; high-certainty evidence) and resulted in a large reduction in length of hospital stay for all participants (MD -1.63 days, 95% CI -2.93 to -0.33; 8795 participants; 22 studies; high-certainty evidence). Corticosteroids increase the risk of muscle weakness (RR 1.21, 95% CI 1.01 to 1.44; 6145 participants; 6 studies; high-certainty evidence). Corticosteroids probably do not increase the risk of superinfection (RR 1.06, 95% CI 0.95 to 1.19; 5356 participants; 25 studies; moderate-certainty evidence). Corticosteroids increase the risk of hypernatraemia (high-certainty evidence) and probably increase the risk of hyperglycaemia (moderate-certainty evidence). Moderate-certainty evidence shows that there is probably little or no difference in gastroduodenal bleeding, stroke, or cardiac events, and low-certainty evidence suggests that corticosteroids may result in little to no difference in neuropsychiatric events. Continuous infusion of corticosteroids versus intermittent bolus We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration. Three studies reported data for this comparison, and the certainty of evidence for all outcomes was very low. AUTHORS' CONCLUSIONS Moderate-certainty evidence indicates that corticosteroids probably reduce 28-day and hospital mortality among patients with sepsis. Corticosteroids result in large reductions in ICU and hospital length of stay (high-certainty evidence). There may be little or no difference in the risk of major complications; however, corticosteroids increase the risk of muscle weakness and hypernatraemia, and probably increase the risk of hyperglycaemia. The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain.
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Affiliation(s)
- Djillali Annane
- Center for Neuromuscular Diseases; Raymond Poincaré Hospital (AP‐HP)Department of Critical Care, Hyperbaric Medicine and Home Respiratory UnitFaculty of Health Sciences Simone Veil, University of Versailles SQY‐ University of Paris Saclay104 Boulevard Raymond PoincaréGarchesFrance92380
| | - Eric Bellissant
- Hôpital PontchaillouCentre d'Investigation Clinique INSERM 0203RennesFrance35033
| | | | - Josef Briegel
- Klinikum der UniversitätKlinik fur AnästhesiologieMünchenGermany81377
| | - Didier Keh
- Charité‐Campus Virchow Clinic, Charité Universitätsmedizin BerlinUniversity Clinic of Anesthesiology and Intensive Care Medicine CCM/CVKAugustenburger Platz 1BerlinGermany13353
| | - Yizhak Kupfer
- Maimonides Medical CenterDivision of Pulmonary and Critical Care Medicine4802 Tenth AvenueBrooklynNew YorkUSA11219
| | - Romain Pirracchio
- Zuckerberg San Francisco General Hospital and Trauma Center, University of CaliforniaDepartment of Anesthesia and Perioperative MedicineSan FranciscoCaliforniaUSA
| | - Bram Rochwerg
- McMaster UniversityDivision of Critical Care, Department of MedicineBox 211, Juravinski Hospital711 Concession StHamiltonOntarioCanada
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Batt J, Herridge MS, Dos Santos CC. From skeletal muscle weakness to functional outcomes following critical illness: a translational biology perspective. Thorax 2019; 74:1091-1098. [PMID: 31431489 DOI: 10.1136/thoraxjnl-2016-208312] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 12/23/2022]
Abstract
Intensive care unit acquired weakness (ICUAW) is now a well-known entity complicating critical illness. It increases mortality and in the critical illness survivor it is associated with physical disability, substantially increased health resource utilisation and healthcare costs. Skeletal muscle wasting is a key driver of ICUAW and physical functional outcomes in both the short and long term. To date, there is no intervention that can universally and consistently prevent muscle loss during critical illness, or enhance its recovery following intensive care unit discharge, to improve physical function. Clinical trials of early mobilisation or exercise training, or enhanced nutritional support have generated inconsistent results and we have no effective pharmacological interventions. This review will delineate our current understanding of the mechanisms underpinning the development and persistence of skeletal muscle loss and dysfunction in the critically ill individual, highlighting recent discoveries and clinical observations, and utilisation of this knowledge in the development of novel therapeutics.
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Affiliation(s)
- Jane Batt
- Keenan Research Center for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada .,Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Claudia C Dos Santos
- Keenan Research Center for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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59
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A unifying hypothesis for delirium and hospital-acquired weakness as synaptic dysfunctions. Med Hypotheses 2019; 124:105-109. [DOI: 10.1016/j.mehy.2019.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/20/2018] [Accepted: 02/03/2019] [Indexed: 12/23/2022]
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60
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Z’Graggen WJ, Schefold JC. Critical illness myopathy: Glucocorticoids revisited? Acta Physiol (Oxf) 2019; 225:e13205. [PMID: 30338655 DOI: 10.1111/apha.13205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/12/2018] [Indexed: 01/29/2023]
Affiliation(s)
- Werner J. Z’Graggen
- Departments of Neurosurgery and Neurology; Inselspital, Bern University Hospital; University of Bern; Bern Switzerland
| | - Joerg C. Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital; University of Bern; Bern Switzerland
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