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Sunder T. Intensive care unit-acquired weakness – preventive, and therapeutic aspects; future directions and special focus on lung transplantation. World J Clin Cases 2024; 12:3665-3670. [DOI: 10.12998/wjcc.v12.i19.3665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/24/2024] [Accepted: 05/11/2024] [Indexed: 06/29/2024] Open
Abstract
In this editorial, comments are made on an interesting article in the recent issue of the World Journal of Clinical Cases by Wang and Long. The authors describe the use of neural network model to identify risk factors for the development of intensive care unit (ICU)-acquired weakness. This condition has now become common with an increasing number of patients treated in ICUs and continues to be a source of morbidity and mortality. Despite identification of certain risk factors and corrective measures thereof, lacunae still exist in our understanding of this clinical entity. Numerous possible pathogenetic mechanisms at a molecular level have been described and these continue to be increasing. The amount of retrievable data for analysis from the ICU patients for study can be huge and enormous. Machine learning techniques to identify patterns in vast amounts of data are well known and may well provide pointers to bridge the knowledge gap in this condition. This editorial discusses the current knowledge of the condition including pathogenesis, diagnosis, risk factors, preventive measures, and therapy. Furthermore, it looks specifically at ICU acquired weakness in recipients of lung transplantation, because – unlike other solid organ transplants- muscular strength plays a vital role in the preservation and survival of the transplanted lung. Lungs differ from other solid organ transplants in that the proper function of the allograft is dependent on muscle function. Muscular weakness especially diaphragmatic weakness may lead to prolonged ventilation which has deleterious effects on the transplanted lung – ranging from ventilator associated pneumonia to bronchial anastomotic complications due to prolonged positive pressure on the anastomosis.
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Affiliation(s)
- Thirugnanasambandan Sunder
- Department of Heart Lung Transplantation and Mechanical Circulatory Support, Apollo Hospitals, Chennai 600086, Tamil Nadu, India
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Formenti P, Sabbatini G, Brenna G, Galimberti A, Mattei L, Umbrello M, Iezzi M, Uldedaj E, Pezzi A, Gotti M. Foot drop in critically ill patients: a narrative review of an elusive complication with intricate implications for recovery and rehabilitation. Minerva Anestesiol 2024; 90:539-549. [PMID: 38551615 DOI: 10.23736/s0375-9393.24.17912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Foot drop is a condition characterized by the inability to lift the foot upwards towards the shin bone. This condition may affect a proportion of critically ill patients, impacting on their recovery after the acute phase of the illness. The occurrence of foot drop in critical care patients may result from various underlying causes, including neurological injuries, muscular dysfunction, nerve compression, or vascular compromise. Understanding the etiology and assessing the severity of foot drop in these patients is essential for implementing appropriate management strategies and ensuring better patient outcomes. In this comprehensive review, we explore the complexities of foot drop in critically ill patients. We search for the potential risk factors that contribute to its development during critical illness, the impact it has on patients' functional abilities, and the various diagnostic techniques adopted to evaluate its severity. Additionally, we discuss current treatment approaches, rehabilitation strategies, and preventive measures to mitigate the adverse effects of foot drop in the critical care setting. Furthermore, we explore the roles of critical care physical therapists, neurologists, and other healthcare professionals in the comprehensive care of patients with foot drop syndrome and in such highlighting the importance of a multidisciplinary approach.
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Affiliation(s)
- Paolo Formenti
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy -
| | - Giovanni Sabbatini
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Giovanni Brenna
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Andrea Galimberti
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Luca Mattei
- Department of Neurosurgery, C. Besta IRCCS National Neurologic Institute Foundation, Milan, Italy
| | - Michele Umbrello
- Department of Intensive Care, New Hospital of Legnano, Legnano, Milan, Italy
| | - Massimiliano Iezzi
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Ersil Uldedaj
- Unit of Anesthesia, Resuscitation and Intensive Therapy, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
| | - Angelo Pezzi
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Miriam Gotti
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
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Volpe MS, dos Santos ACC, Gaspar S, de Melo JL, Harada G, Ferreira PRA, da Silva KRS, Souza NTS, Toufen C, Chiavegato LD, Amato MBP, Feltrim MIZ, de Carvalho CRR. A comprehensive physical functional assessment of survivors of critical care unit stay due to COVID-19. CRITICAL CARE SCIENCE 2024; 36:e20240284en. [PMID: 38716961 PMCID: PMC11098067 DOI: 10.62675/2965-2774.20240284-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/22/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE To examine the physical function and respiratory muscle strength of patients - who recovered from critical COVID-19 - after intensive care unit discharge to the ward on Days one (D1) and seven (D7), and to investigate variables associated with functional impairment. METHODS This was a prospective cohort study of adult patients with COVID-19 who needed invasive mechanical ventilation, non-invasive ventilation or high-flow nasal cannula and were discharged from the intensive care unit to the ward. Participants were submitted to Medical Research Council sum-score, handgrip strength, maximal inspiratory pressure, maximal expiratory pressure, and short physical performance battery tests. Participants were grouped into two groups according to their need for invasive ventilation: the Invasive Mechanical Ventilation Group (IMV Group) and the Non-Invasive Mechanical Ventilation Group (Non-IMV Group). RESULTS Patients in the IMV Group (n = 31) were younger and had higher Sequential Organ Failure Assessment scores than those in the Non-IMV Group (n = 33). The short physical performance battery scores (range 0 - 12) on D1 and D7 were 6.1 ± 4.3 and 7.3 ± 3.8, respectively for the Non-Invasive Mechanical Ventilation Group, and 1.3 ± 2.5 and 2.6 ± 3.7, respectively for the IMV Group. The prevalence of intensive care unit-acquired weakness on D7 was 13% for the Non-IMV Group and 72% for the IMV Group. The maximal inspiratory pressure, maximal expiratory pressure, and handgrip strength increased on D7 in both groups, but the maximal expiratory pressure and handgrip strength were still weak. Only maximal inspiratory pressure was recovered (i.e., > 80% of the predicted value) in the Non-IMV Group. Female sex, and the need and duration of invasive mechanical were independently and negatively associated with the short physical performance battery score and handgrip strength. CONCLUSION Patients who recovered from critical COVID-19 and who received invasive mechanical ventilation presented greater disability than those who were not invasively ventilated. However, they both showed marginal functional improvement during early recovery, regardless of the need for invasive mechanical ventilation. This might highlight the severity of disability caused by SARS-CoV-2.
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Affiliation(s)
- Marcia Souza Volpe
- Universidade Federal de São PauloDepartment of Human Movement SciencesSantosSPBrazilDepartment of Human Movement Sciences, Universidade Federal de São Paulo - Santos (SP), Brazil.
| | - Ana Carolina Cardoso dos Santos
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDivision of Pneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Sílvia Gaspar
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDepartment of Physiotherapy, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Jade Lara de Melo
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDivision of Pneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Gabriela Harada
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDepartment of Physiotherapy, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Patrícia Rocha Alves Ferreira
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDepartment of Physiotherapy, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Karina Ramiceli Soares da Silva
- Universidade Federal de São PauloDepartment of Human Movement SciencesSantosSPBrazilDepartment of Human Movement Sciences, Universidade Federal de São Paulo - Santos (SP), Brazil.
| | - Natália Tiemi Simokomaki Souza
- Universidade Federal de São PauloDiscipline of PneumologySão PauloSPBrazilDiscipline of Pneumology, Universidade Federal de São Paulo - São Paulo (SP), Brazil.
| | - Carlos Toufen
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDivision of Pneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Luciana Dias Chiavegato
- Universidade Federal de São PauloDiscipline of PneumologySão PauloSPBrazilDiscipline of Pneumology, Universidade Federal de São Paulo - São Paulo (SP), Brazil.
| | - Marcelo Britto Passos Amato
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDivision of Pneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Maria Ignez Zanetti Feltrim
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDepartment of Physiotherapy, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
| | - Carlos Roberto Ribeiro de Carvalho
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilDivision of Pneumology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil.
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Taylor J, Wilcox ME. Physical and Cognitive Impairment in Acute Respiratory Failure. Crit Care Clin 2024; 40:429-450. [PMID: 38432704 DOI: 10.1016/j.ccc.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.
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Affiliation(s)
- Jonathan Taylor
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029, USA
| | - Mary Elizabeth Wilcox
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
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Manuel SL, Sapone J, Lin F, Chalunkal M. Post-COVID-19 Neurological Sequelae of Polyneuropathy and Encephalitis: A Comprehensive Case Report. Cureus 2024; 16:e56645. [PMID: 38646272 PMCID: PMC11032167 DOI: 10.7759/cureus.56645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/23/2024] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, commonly known as COVID-19, has been associated with various neurological complications. However, the mechanisms underlying these neurological manifestations remain incompletely understood. We present a case of a 63-year-old male who was admitted to the intensive care unit with severe COVID-19 pneumonia. Following recovery from respiratory symptoms, he was found to have weakness in the limbs. Months later, he also developed altered mental status, hallucinations, and behavioral changes. Neurological examination revealed signs consistent with polyneuropathy and autoimmune encephalitis. Further investigations, including nerve conduction studies, cerebrospinal fluid analysis, and response to steroids, supported the diagnosis of COVID-19-related polyneuropathy and autoimmune encephalitis. This is a rare presentation of COVID-19 and has only been described in a few case reports. Further research is warranted to elucidate the pathophysiological mechanisms underlying neurological sequelae of COVID-19 and to develop targeted therapeutic strategies.
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Affiliation(s)
| | - Jenna Sapone
- Internal Medicine, St. Luke's University Health Network, Easton, USA
| | - Frank Lin
- Internal Medicine, St. Luke's University Health Network, Easton, USA
| | - Mathai Chalunkal
- Internal Medicine, St. Luke's University Health Network, Easton, USA
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de Gomes Figueiredo T, Frazão M, Werlang LA, Peltz M, Sobral Filho DC. Functional electrical stimulation cycling-based muscular evaluation method in mechanically ventilated patients. Artif Organs 2024; 48:254-262. [PMID: 37930042 DOI: 10.1111/aor.14677] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/22/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Intensive care acquired muscle weakness is a common feature in critically ill patients. Beyond the therapeutic uses, FES-cycling could represent a promising nonvolitional evaluation method for detecting acquired muscle weakness. OBJECTIVES To assess whether FES-cycling is able to identify muscle dysfunctions, and to evaluate the survival rate in patients with detected muscle dysfunction. METHODS A prospective observational study was carried out, with 29 critically ill patients and 20 healthy subjects. Maximum torque and power achieved were recorded, in addition to the stimulation cost, and patients were followed up for six months. RESULTS Torque (2.64 [1.53 to 4.81] vs 6.03 [4.56 to 6.73] Nm) and power (3.31 [2.33 to 6.37] vs 6.35 [5.22 to 10.70] watts) were lower and stimulation cost (22 915 [5069 to 37 750] vs 3411 [2080 to 4024] μC/W) was higher in patients compared to healthy people (p < 0.05). Surviving patients showed a nonsignificant difference in power and torque in relation to nonsurvivors (p > 0.05), but they had a lower stimulation cost (4462 [3598 to 11 788] vs 23 538 [10 164 to 39 836] μC/W) (p < 0.05). In total, 34% of all patients survived during the six months of follow-up. Furthermore, 62% of patients with a stimulation cost below 15 371 μC/W and 7% of patients with a stimulation cost above 15 371 μC/W survived. CONCLUSIONS FES-cycling has good sensitivity and specificity for detecting muscle disorders. Critical patients have low torque and power and a high stimulation cost. Stimulation cost is related to survival. A low stimulation cost was related to a 3 times greater chance of survival.
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Affiliation(s)
| | - Murillo Frazão
- Lauro Wanderley University Hospital, João Pessoa, Brazil
- CLINAR Exercise Physiology, João Pessoa, Brazil
| | | | - Maikel Peltz
- INBRAMED-Brazilian Medical Equipment Industry, Porto Alegre, Brazil
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Guillen-Grima F, Guillen-Aguinaga S, Guillen-Aguinaga L, Alas-Brun R, Onambele L, Ortega W, Montejo R, Aguinaga-Ontoso E, Barach P, Aguinaga-Ontoso I. Evaluating the Efficacy of ChatGPT in Navigating the Spanish Medical Residency Entrance Examination (MIR): Promising Horizons for AI in Clinical Medicine. Clin Pract 2023; 13:1460-1487. [PMID: 37987431 PMCID: PMC10660543 DOI: 10.3390/clinpract13060130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023] Open
Abstract
The rapid progress in artificial intelligence, machine learning, and natural language processing has led to increasingly sophisticated large language models (LLMs) for use in healthcare. This study assesses the performance of two LLMs, the GPT-3.5 and GPT-4 models, in passing the MIR medical examination for access to medical specialist training in Spain. Our objectives included gauging the model's overall performance, analyzing discrepancies across different medical specialties, discerning between theoretical and practical questions, estimating error proportions, and assessing the hypothetical severity of errors committed by a physician. MATERIAL AND METHODS We studied the 2022 Spanish MIR examination results after excluding those questions requiring image evaluations or having acknowledged errors. The remaining 182 questions were presented to the LLM GPT-4 and GPT-3.5 in Spanish and English. Logistic regression models analyzed the relationships between question length, sequence, and performance. We also analyzed the 23 questions with images, using GPT-4's new image analysis capability. RESULTS GPT-4 outperformed GPT-3.5, scoring 86.81% in Spanish (p < 0.001). English translations had a slightly enhanced performance. GPT-4 scored 26.1% of the questions with images in English. The results were worse when the questions were in Spanish, 13.0%, although the differences were not statistically significant (p = 0.250). Among medical specialties, GPT-4 achieved a 100% correct response rate in several areas, and the Pharmacology, Critical Care, and Infectious Diseases specialties showed lower performance. The error analysis revealed that while a 13.2% error rate existed, the gravest categories, such as "error requiring intervention to sustain life" and "error resulting in death", had a 0% rate. CONCLUSIONS GPT-4 performs robustly on the Spanish MIR examination, with varying capabilities to discriminate knowledge across specialties. While the model's high success rate is commendable, understanding the error severity is critical, especially when considering AI's potential role in real-world medical practice and its implications for patient safety.
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Affiliation(s)
- Francisco Guillen-Grima
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
- Healthcare Research Institute of Navarra (IdiSNA), 31008 Pamplona, Spain
- Department of Preventive Medicine, Clinica Universidad de Navarra, 31008 Pamplona, Spain
- CIBER in Epidemiology and Public Health (CIBERESP), Institute of Health Carlos III, 46980 Madrid, Spain
| | - Sara Guillen-Aguinaga
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
| | - Laura Guillen-Aguinaga
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
- Department of Nursing, Kystad Helse-og Velferdssenter, 7026 Trondheim, Norway
| | - Rosa Alas-Brun
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
| | - Luc Onambele
- School of Health Sciences, Catholic University of Central Africa, Yaoundé 1100, Cameroon;
| | - Wilfrido Ortega
- Department of Surgery, Medical and Social Sciences, University of Alcala de Henares, 28871 Alcalá de Henares, Spain;
| | - Rocio Montejo
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, University of Gothenburg, 413 46 Gothenburg, Sweden;
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, 413 46 Gothenburg, Sweden
| | | | - Paul Barach
- Jefferson College of Population Health, Philadelphia, PA 19107, USA;
- School of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Interdisciplinary Research Institute for Health Law and Science, Sigmund Freud University, 1020 Vienna, Austria
- Department of Surgery, Imperial College, London SW7 2AZ, UK
| | - Ines Aguinaga-Ontoso
- Department of Health Sciences, Public University of Navarra, 31008 Pamplona, Spain; (S.G.-A.); (L.G.-A.); (R.A.-B.)
- Healthcare Research Institute of Navarra (IdiSNA), 31008 Pamplona, Spain
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Morris NA, Sarwal A. Neurologic Complications of Critical Medical Illness. Continuum (Minneap Minn) 2023; 29:848-886. [PMID: 37341333 DOI: 10.1212/con.0000000000001278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article reviews the neurologic complications encountered in patients admitted to non-neurologic intensive care units, outlines various scenarios in which a neurologic consultation can add to the diagnosis or management of a critically ill patient, and provides advice on the best diagnostic approach in the evaluation of these patients. LATEST DEVELOPMENTS Increasing recognition of neurologic complications and their adverse impact on long-term outcomes has led to increased neurology involvement in non-neurologic intensive care units. The COVID-19 pandemic has highlighted the importance of having a structured clinical approach to neurologic complications of critical illness as well as the critical care management of patients with chronic neurologic disabilities. ESSENTIAL POINTS Critical illness is often accompanied by neurologic complications. Neurologists need to be aware of the unique needs of critically ill patients, especially the nuances of the neurologic examination, challenges in diagnostic testing, and neuropharmacologic aspects of commonly used medications.
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Tian R, Li R, Zhou X. Recent Progresses in Non-Dialysis Chronic Kidney Disease Patients with Hyperkalemia: Outcomes and Therapeutic Strategies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020353. [PMID: 36837554 PMCID: PMC9966910 DOI: 10.3390/medicina59020353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
Chronic kidney disease (CKD) affects about 10% of the world's population. Hyperkalemia is a life-threatening complication in patients with CKD, as it is associated with adverse cardiovascular and kidney outcomes. There are still many challenges and questions to address to improve the currently available therapeutic strategies to treat hyperkalemia, such as how to approach the emergency management of hyperkalemia. In recent years, in addition to novel oral potassium binders, great progress has been made in the application of novel kidney protective strategies, such as mineralocorticoid receptor antagonists and sodium-glucose cotransporter 2 inhibitors (SGLT2i) in hyperkalemia therapy. This review will discuss the recent advances from clinical trials in the effective management of hyperkalemia in non-dialysis CKD patients, enhancing the knowledge of physicians and internists concerning these newer agents and providing a helpful reference for clinical practice.
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Affiliation(s)
- Ruixue Tian
- The Fifth Clinical Medical College of Shanxi Medical University, Taiyuan 030012, China
| | - Rongshan Li
- Department of Nephrology, Shanxi Provincial People’s Hospital, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Kidney Disease Institute, 29 Shuang Ta East Street, Taiyuan 030012, China
- Correspondence: (R.L.); (X.Z.)
| | - Xiaoshuang Zhou
- Department of Nephrology, Shanxi Provincial People’s Hospital, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Kidney Disease Institute, 29 Shuang Ta East Street, Taiyuan 030012, China
- Correspondence: (R.L.); (X.Z.)
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10
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Stępień J, Pastuszak Ż. Electroneurological changes in peripheral nerves in patients post-COVID. J Neurophysiol 2023; 129:392-398. [PMID: 36515426 PMCID: PMC9902213 DOI: 10.1152/jn.00396.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Various neurological manifestations are observed in about 36.4% of patients infected with SARS-CoV-2 and post-COVID neuropathy is one of them. There is lack of studies describing neurophysiological abnormalities in peripheral nerves in case of patients who had SARS-CoV-2 infection. The aim of this study was to analyze the changes in peripheral nervous system in case of COVID-19 survivors. In the presented study, 45 COVID-19 survivors who had nerve conduction study (NCS) were involved. Results were compared with control group consisting of healthy patients who had nerve conduction study before the COVID-19 pandemic. In our study group, neurophysiological abnormalities were present in the case of both sensory and motor nerve fibers. The most significant reduction of NCS parameters was observed in the case of sensory action potential amplitude of sural nerve. Moreover, that correlation was the most significant in the case of amplitude and conduction velocity in sensory and motor neuron fibers both in arms and legs. Those abnormalities were observed even 6 mo after COVID-19. Further investigation needs to be done regarding the polyneuropathies associated with human coronaviruses, and we should answer the question whether the virus directly damages peripheral nerves or factors mediating inflammatory response are responsible for the neural damage.NEW & NOTEWORTHY Various neurological manifestations are observed in about 36.4% of patients infected with SARS-CoV-2 and post-COVID neuropathy is one of them. There is lack of studies describing neurophysiological abnormalities in peripheral nerves in case of patients who had SARS-CoV-2 infection. The aim of this study was to analyze changes in peripheral nervous system in case of COVID-19 survivors.
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Affiliation(s)
- Jakub Stępień
- 1Insula Clinical Trials Center, Warsaw, Poland,3Department of Neurosurgery, Bielanski Hospital, Warsaw, Poland
| | - Żanna Pastuszak
- 2Laboratory of Experimental and Clinical Neurosurgery, Mossakowski Medical Research Institute Polish Academy of Sciences, Warsaw, Poland,3Department of Neurosurgery, Bielanski Hospital, Warsaw, Poland
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11
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Neuromuscular Weakness in Intensive Care. Crit Care Clin 2023; 39:123-138. [DOI: 10.1016/j.ccc.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Sasano N, Yasuda M, Yamada G. Quadriplegia after
ECMO
therapy with sluggish recovery in a
COVID
‐19 patient: A case report with a 14‐month follow‐up. Clin Case Rep 2022; 10:e6735. [PMCID: PMC9748240 DOI: 10.1002/ccr3.6735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 11/05/2022] [Accepted: 11/26/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Nobuko Sasano
- Department of Intensive Care Medicine Nagoya City University West Medical Center Nagoya Japan
| | - Masami Yasuda
- Department of Rehabilitation Nagoya City University West Medical Center Nagoya Japan
| | - Gohei Yamada
- Department of Neurology Nagoya City University West Medical Center Nagoya Japan
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13
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Awad M, Al-hussaniy HA, Alburghaif AH, Tawfeeq KT. The role of COVID-19 in myopathy: incidence, causes, treatment, and prevention. J Med Life 2022; 15:1458-1463. [PMID: 36762328 PMCID: PMC9884359 DOI: 10.25122/jml-2022-0167] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/12/2022] [Indexed: 02/11/2023] Open
Abstract
Myopathy is a disease characterized by muscle dysfunction in general and may be associated with genetics, medication such as statins, or inflammation. In 2019, an epidemic viral infection (SARS-CoV-2 virus) that invaded most countries worldwide appeared and caused acute respiratory disease. Consequently, patients had to take a group of drugs for a relatively long treatment period. According to several studies, there was an increase in the cases of muscular disorders due to several factors. This study aimed to (1) investigate the relationship between COVID-19 and myopathy and (2) identify the causes and prevention methods. A systematic review was conducted, analyzing several articles from the following databases: ResearchGate, Medline, DOAJ (The Directory of Open-Access Journals), PubMed, and Google Scholar. After performing the search and filtering the results, we included 61 articles. There was a strong relationship between COVID-19 and myopathy, especially in patients admitted to the ICU department, due to medication or neurological dysregulation with multiorgan dysfunctions such as polyneuropathy, peripheral nerve involvement, dysautonomia, Guillain-Barré syndrome, and many others.
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Affiliation(s)
- Manal Awad
- Department of Family Physician (CCFP), Madigan Medical Centre, Calgary, Alberta, Canada
| | - Hany Akeel Al-hussaniy
- Department of Pharmacology, College of Medicine, University of Baghdad, Baghdad, Iraq,Dr. Hany Akeel Institute, Iraqi Medical Research Center, Baghdad, Iraq,Corresponding Author: Hany Akeel Al-hussaniy, Department of Pharmacology, College of Medicine, University of Baghdad, Baghdad, Iraq. E-mail:
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Crisafulli O, Baroscelli M, Grattarola L, Tansini G, Zampella C, D’Antona G. Case report: Personalized adapted motor activity in a COVID-19 patient complicated by critical illness polyneuropathy and myopathy. Front Physiol 2022; 13:1035255. [DOI: 10.3389/fphys.2022.1035255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
Background: COVID-19 may require hospitalization in an intensive care unit (ICU) and is often associated with the onset of critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). Due to the spread of the disease around the world, the identification of new rehabilitation strategies for patients facing this sequence of events is of increasing importance.Case presentation: We report the clinical presentation and the beneficial effects of a prolonged, supervised adapted motor activity (AMA) program in a highly deconditioned 61-year-old male COVID-19 patient discharged from the ICU and complicated by residual CIP and CIM. The program included aerobic, strength, gait, and balance training (1 h, 2 sessions per week).Measures: Pulmonary (spirometry), metabolic (indirect calorimetry and bioimpedance), and neuromuscular functions (electromyography) were evaluated at baseline and after 1 year of training.Results: Relative to baseline, an amelioration of several spirometric parameters such as vital capacity (VC, +40%), total lung capacity (TLC, +25%), and forced expiratory volume in 1 s (FEV1, +28%) was appreciable. Metabolic parameters such as body water (60%–46%), phase angle (3.6°–5.9°), and respiratory quotient (0.92–0.8) returned to the physiological range. Electromyographic parameters were substantially unchanged. The overall amelioration in clinical parameters resulted in a significant improvement of patient autonomy and the quality of life.Conclusion: Our results highlight the importance of AMA for counteracting respiratory, metabolic, and functional but not neuromuscular impairments in COVID-19 patients with residual CIM and CIP.
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Zhou J, Zhang C, Zhou JD, Zhang CK. Effect of early progressive mobilization on intensive care unit-acquired weakness in mechanically ventilated patients: An observational study. Medicine (Baltimore) 2022; 101:e31528. [PMID: 36343079 PMCID: PMC9646566 DOI: 10.1097/md.0000000000031528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Early progressive mobilization is usually considered as an effective method for intensive care unit-acquired weakness (ICU-AW), but the controversies on this topic remain debatable, especially in initiation time, safety profile, and other implementation details. So, more studies should be performed to solve these disputes. A set of critically ill patients underwent mechanical ventilation in intensive care unit (ICU) of our hospital from March 2018 to September 2020 were included as study object. Patients received early progressive mobilization were included into the intervention group (n = 160), and another patients matched with the intervention group by gender, age, and APACHE II score, and these patients received routine intervention were included into the control group (n = 160). Then, indexes involving muscle strength, Barthel index, functional independence, incidence rates of ICU-AW and other complications were comparatively analyzed between the 2 groups. The Medical Research Council score and Barthel index score in the intervention group were significantly higher than those in the control group (all P < .05). The percentages of patients who were able to complete taking a shower, wearing clothes, eating, grooming, moving from bed to chair and using the toilet by alone in the intervention group were significantly higher than those in the control group (69.38% vs 49.38%, 73.13% vs 51.88%, 81.25% vs 55.63%, 74.38% vs 48.75%, 82.50% vs 65.63%, 78.13% vs 63.13%, respectively, all P < .05). The incidence rate of ICU-AW and overall incidence rate of complications in the intervention group were significantly lower than those in the control group (6.88% vs 28.13% and 23.13% vs 48.13%, both P < .05). Early progressive mobilization can effectively increase muscle strength and daily basic motion ability, improve functional status, and decrease risk of ICU-AW in critically ill patients underwent mechanical ventilation, and it has an attractive application value in clinic.
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Affiliation(s)
- Jing Zhou
- Intensive Care Unit, The Fenghua People’s Hospital, Ningbo City, Zhejiang Province, China
| | - Chao Zhang
- Intensive Care Unit, The Fenghua People’s Hospital, Ningbo City, Zhejiang Province, China
| | - Ji-dong Zhou
- Intensive Care Unit, The Fenghua People’s Hospital, Ningbo City, Zhejiang Province, China
- * Correspondence: Ji-dong Zhou, the Fenghua People’s Hospital, Ningbo City 315500, Zhejiang Province, China (e-mail: )
| | - Cheng-kai Zhang
- Intensive Care Unit, The Fenghua People’s Hospital, Ningbo City, Zhejiang Province, China
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Grover KM, Sripathi N. Prevention of Adverse Outcomes and Treatment Side Effects in Patients with Neuromuscular Disorders. Semin Neurol 2022; 42:594-610. [PMID: 36400111 DOI: 10.1055/s-0042-1758779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this article, we review prevention of serious adverse clinical outcomes and treatment side effects in patients with neuromuscular disorders including myopathies and myasthenia gravis. While neither of these entities is preventable, their course can often be modified, and severe sequelae may be prevented, with the identification of risk factors and proactive attention toward treatment planning.
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Affiliation(s)
- Kavita M Grover
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
| | - Naganand Sripathi
- Department of Neurology, Henry Ford Medical Group, Wayne State University, Detroit, Michigan
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Zhou W, Yu L, Fan Y, Shi B, Wang X, Chen T, Yu H, Liu J, Wang X, Liu C, Zheng H. Effect of early mobilization combined with early nutrition on acquired weakness in critically ill patients (EMAS): A dual-center, randomized controlled trial. PLoS One 2022; 17:e0268599. [PMID: 35617287 PMCID: PMC9135241 DOI: 10.1371/journal.pone.0268599] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 04/18/2022] [Indexed: 01/17/2023] Open
Abstract
AIM The study aimed to investigate the effect of early mobilization combined with early nutrition (EMN) on intensive care unit-acquired weakness (ICU-AW) in intensive care unit (ICU) settings compared with early mobilization (EM) or routine care. METHODS A prospective, dual-center, randomized controlled trial was conducted. The control group underwent standard care without a pre-established routine for mobilization and nutrition. The EM group underwent early, individualized, progressive mobilization within 24 h of ICU admission. The EMN group underwent early mobilization, similar to the EM group plus guideline-based early nutrition (within 48 h of ICU admission). The primary outcome was the occurrence of ICU-AW at discharge from the ICU. Secondary outcomes included muscle strength, functional independence, organ failure, nutritional status, duration of mechanical ventilation (MV), length of ICU stay, and ICU mortality at ICU discharge. RESULTS A total of 150 patients were enrolled and equally distributed into the three groups. Patients undergoing routine care only were more susceptible to ICU-AW upon ICU discharge than those in the EM or EMN groups (16% vs. 2%; p = 0.014 for both), and had a lower Barthel Index than others (control vs. EM/EMN: 57.5 vs 70.0; p = 0.022). The EMN group had improved muscle strength (p = 0.028) and better nutritional status than the control group (p = 0.031). Both interventions were associated with a lower ICU-AW (EM vs. control: p = 0.027, OR [95% CI] = 0.066 [0.006-0.739]; EMN vs. control: p = 0.016, OR [95% CI] = 0.065 [0.007-0.607]). CONCLUSION EM and EMN had positive effects. There was little difference between the effects of EM and EMN, except for muscle strength improvement. Both EM and EMN may lead to a lower occurrence of ICU-AW and better functional independence than standard care. EMN might benefit nutritional status more than usual care and promote improvement in muscle strength.
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Affiliation(s)
- Wendie Zhou
- Clinical Nursing Teaching Department, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
- School of Nursing, Harbin Medical University, Harbin, Heilongjiang, China
| | - Lili Yu
- Clinical Nursing Teaching Department, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
- School of Nursing, Harbin Medical University, Harbin, Heilongjiang, China
- Nursing Department, Heilongjiang Academy of Traditional Chinese Medicine, Harbin, Heilongjiang, China
| | - Yuying Fan
- School of Nursing, Harbin Medical University, Harbin, Heilongjiang, China
- * E-mail:
| | - Baisheng Shi
- Department of Rehabilitation, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xiaohui Wang
- Department of Intensive Care Unit, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Tianling Chen
- Department of Intensive Care Unit, The First Hospital of Qiqihar, Qiqihar, Heilongjiang, China
| | - Haixia Yu
- Department of Intensive Care Unit, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Jie Liu
- Department of Intensive Care Unit, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xizhen Wang
- Department of Intensive Care Unit, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Caihong Liu
- Department of Intensive Care Unit, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Huijia Zheng
- Department of Intensive Care Unit, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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Yuan Z, Pan L, Wang Y, Wang W. Continuously protracted infusion of cisatracurium besilate in patients with ARDS. Ann Med Surg (Lond) 2022; 77:103718. [PMID: 35638041 PMCID: PMC9142704 DOI: 10.1016/j.amsu.2022.103718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/27/2022] [Accepted: 05/01/2022] [Indexed: 11/29/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is still associated with significant mortality, especially the elderly and those with comorbidities are at highest risk of death. Neuromuscular blocking agents (NMBAs) are used in a large but highly variable proportion of patients with ARDS. Case presentation We describe the case of one critically ill patient with serious ARDS, because of virus pneumonia. In spite of the reduced tidal volume to 4–6 mL/kg of predicted body weight (PBW) and prone position were applied timely, the irresistible progress of disease leaded to an amazing prolonged application of deep sedation and analgesia, as well as NMBA, for the purpose of lung-protective mechanical ventilation. Result The clinical and biochemical parameters guided us toward the recognition that cisatracurium, bolus of 0.1 mg/kg followed by a median infusion rate of 1.91 (1.43–9.52) μg/kg.min, combined with continuous infusion of midazolam 3.43 (2.06–6.17) mg/kg.d and remifentanil 3.79 (3.43–8.57) μg/kg.h is efficacious and suitable for continuous muscle paralysis. Conclusion The intensive care unit (ICU)-acquired weakness (ICU-AW) was inevitable. Besides, an increased demand on drug concentration with the extension of medication time was observed as well. The continuous infusion of cisatracurium is safety and efficacy. The drug concentration of cisatracurium is time-dependent. ICU-acquired weakness (ICU-AW) is inevitable for the critical illness.
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Rodriguez B, Larsson L, Z’Graggen WJ. Critical Illness Myopathy: Diagnostic Approach and Resulting Therapeutic Implications. Curr Treat Options Neurol 2022; 24:173-182. [PMID: 35370393 PMCID: PMC8958813 DOI: 10.1007/s11940-022-00714-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/26/2022]
Abstract
Abstract
Purpose of review
Critical illness myopathy (CIM) is a common neuro-muscular complication of intensive care treatment associated with increased morbidity and mortality. The current guidelines for diagnosis include clinical and electrophysiological criteria as well as a muscle biopsy, and allow diagnosis only at an advanced stage of the disease. To date, there is no treatment for CIM available, apart from symptomatic and rehabilitative interventions. In this review, we discuss different diagnostic approaches and describe new treatment possibilities for CIM.
Recent findings
Of the diagnostic approaches evaluated, a new electrophysiological technique for measuring muscle excitability has the greatest potential to allow earlier diagnosis of CIM than the current guidelines do and thereby may facilitate the conduction of future pathophysiological and therapeutic studies. Although clinical trials are still lacking, in animal models, BGP-15, vamorolone, and ruxolitinib have been shown to have anti-inflammatory effects, to reduce muscle wasting and to improve muscle function and survival.
Summary
In recent years, promising methods for early and confirmatory diagnosis of CIM have been developed, but still need validation. Experimental studies on novel pharmacological interventions show promising results in terms of preventive CIM treatments, but future clinical studies will be needed to study the effectiveness and safety of these drugs.
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Affiliation(s)
- Belén Rodriguez
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Lars Larsson
- Section of Clinical Neurophysiology, Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
- Viron Molecular Medicine Institute, Boston, MA 02108 USA
| | - Werner J. Z’Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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Physical Rehabilitation in the ICU: Is It Worth the Effort? Crit Care Med 2022; 50:504-507. [PMID: 35191870 DOI: 10.1097/ccm.0000000000005289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Florian IA, Lupan I, Sur L, Samasca G, Timiș TL. To be, or not to be… Guillain-Barré Syndrome. Autoimmun Rev 2021; 20:102983. [PMID: 34718164 DOI: 10.1016/j.autrev.2021.102983] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023]
Abstract
Guillain-Barré Syndrome (GBS) is currently the most frequent cause of acute flaccid paralysis on a global scale, being an autoimmune disorder wherein demyelination of the peripheral nerves occurs. Its main clinical features are a symmetrical ascending muscle weakness with reduced osteotendinous reflexes and variable sensory involvement. GBS most commonly occurs after an infection, especially viral (including COVID-19), but may also transpire after immunization with certain vaccines or in the development of specific malignancies. Immunoglobulins, plasmapheresis, and glucocorticoids represent the principal treatment modalities, however patients with severe disease progression may require supportive therapy in an intensive care unit. Due to its symptomology, which overlaps with numerous neurological and infectious illnesses, the diagnosis of GBS may often be misattributed to pathologies that are essentially different from this syndrome. Moreover, many of these require specific treatment methods distinct to those recommended for GBS, in lack of which the prognosis of the patient is drastically affected. Such diseases include exposure to toxins either environmental or foodborne, central nervous system infections, metabolic or serum ion alterations, demyelinating pathologies, or even conditions amenable to neurosurgical intervention. This extensive narrative review aims to systematically and comprehensively tackle the most notable and challenging differential diagnoses of GBS, emphasizing on the clinical discrepancies between the diseases, the appropriate paraclinical investigations, and suitable management indications.
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Affiliation(s)
- Ioan Alexandru Florian
- Department of Neurology, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania, Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Iulia Lupan
- Department of Molecular Biology, Babes Bolyai University, Cluj-Napoca, Romania.
| | - Lucia Sur
- Department of Pediatrics I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Gabriel Samasca
- Department of Immunology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Teodora Larisa Timiș
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
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