Critical Illness Polyneuropathy And Myopathy Research Articles

Electrophysiological Screening to Assess Foot Drop Syndrome in Severe Acquired Brain Injury in Rehabilitative Settings.

Foot drop syndrome (FDS), characterized by severe weakness and atrophy of the dorsiflexion muscles of the feet, is commonly found in patients with severe acquired brain injury (ABI). If the syndrome is unilateral, the cause is often a peroneal neuropathy (PN), due to compression of the nervous trunk on the neck of the fibula at the knee level; less frequently, the cause is a previous or concomitant lumbar radiculopathy. Bilateral syndromes are caused by polyneuropathies and myopathies. Central causes, due to brain or spinal injury, mimic this syndrome but are usually accompanied by other symptoms, such as spasticity. Critical illness polyneuropathy (CIP) and myopathy (CIM), isolated or in combination (critical illness polyneuromyopathy, CIPNM), have been shown to constitute an important cause of FDS in patients with ABI. Assessing the causes of FDS in the intensive rehabilitation unit (IRU) has several limitations, which include the complexity of the electrophysiological tests, limited availability of neurophysiology consultants, and the severe disturbance in consciousness and lack of cooperation from patients. We sought to propose a simplified electrophysiological screening that identifies FDS causes, particularly PN and CIPNM, to help clinicians to recognize the significant clinical predictors of poor outcomes in severe ABI at admission to IRU. This prospective, single-center study included 20 severe ABI patients with FDS (11 females/9 males, mean age 55.10 + 16.26; CRS-R= 11.90 + 6.32; LCF: 3.30 + 1.30; DRS: 21.45 + 3.33), with prolonged rehabilitation treatment (≥2 months). We applied direct tibialis anterior muscle stimulation (DMS) associated with peroneal nerve motor conduction evaluation, across the fibular head (NCS), to identify CIP and/or CIM and to exclude demyelinating or compressive unilateral PN. At admission to IRU, simplified electrophysiological screening reported four unilateral PN, four CIP and six CIM with a CIPNM overall prevalence estimate of about 50%. After 2 months, the CIPNM group showed significantly poorer outcomes compared to other ABI patients without CIPNM, as demonstrated by the lower probability of achieving endotracheal-tube weaning (20% versus 90%) and lower CRS-R and DRS scores. Due to the subacute rehabilitation setting of our study, it was not possible to evaluate the motor results of recovery of the standing position, functional walking and balance, impaired by the presence of unilateral PN. The implementation of the proposed simplified electrophysiological screening may enable the early identification of unilateral PN or CIPNM in severe ABI patients, thereby contributing to better functional prognosis in rehabilitative settings.

Critical Illness Polyneuropathy and Functional Outcome in Subjects with Covid-19: Report on Four Patients and a Scoping Review of the Literature.

Patients with COVID-19 may develop a range of neurological disorders. We report here 4 COVID-19 subjects with intensive care unit-acquired weakness and their functional outcome. In addition, a scoping review of COVID-19 literature was performed to investigate this issue. Of the post-COVID-19 patients admitted to our Neuro-Rehabilitation Unit, 4 (3 males, 1 female; mean age 59.2 ± 8.62 years) had intensive care unit-acquired weakness, diagnosed with electromyography. Muscle strength and functional evaluation were performed on all patients with Medical Research Council, Disability Rating Scale and Functional Independence Measure, respectively, at admission, discharge and 6-month follow-up after discharge. Electromyography revealed that 3 subjects had critical illness polyneuropathy and 1 had critical illness polyneuropathy/critical illness myopathy. At follow-up, the 3 subjects with critical illness polyneuropathy reached full recovery. The patient with critical illness polyneuropathy/critical illness myopathy showed moderate disability requiring bilateral ankle foot-orthosis and support for ambulation. The scoping review retrieved 11 studies of COVID-19 patients with intensive care unit-acquired weakness, concerning a total of 80 patients: 23 with critical illness myopathy (7 probable), 21 with critical illness polyneuropathy (8 possible), 15 with critical illness polyneuropathy and myopathy (CIPNM) and 21 with intensive care unit-acquired weakness. Of 35 patients who survived, only 3 (8.5%) reached full recovery. All 3 had critical illness myopathy, but 2 of these had a diagnosis of probable critical illness myopathy. Intensive care unit-acquired weakness commonly occurred in subjects with COVID-19. Recovery was variable and a low percentage reached full recovery. However, the heterogeneity of studies did not allow definitive conclusions to be drawn. LAY ABSTRACTPatients with COVID-19 may develop a range of neurological disorders. We report here 4 cases of COVID-19 patients with intensive care unit-acquired weakness and their functional outcome. In addition, a scoping review of the COVID-19 literature was performed to investigate the occurrence of, and recovery from, intensive care unit-acquired weakness and sub-types (critical illness polyneuropathy, critical illness myopathy and critical illness polyneuropathy/critical illness myopathy) in subjects with COVID-19. Of these 4 patients, the 3 patients with critical illness polyneuropathy reached full recovery. The patient with critical illness polyneuropathy/critical illness myopathy showed moderate disability, requiring use of a bilateral device (ankle foot-orthosis). The scoping review of studies of COVID-19 patients with intensive care unit-acquired weakness retrieved a total of 80 patients: 21 with intensive care unit-acquired weakness, 23 with critical illness myopathy, 21 with critical illness polyneuropathy, and 15 with critical illness polyneuropathy/critical illness myopathy. Intensive care unit-acquired weakness commonly occurred in COVID-19 subjects, but the outcome was variable and a low percentage reached full recovery. COVID-19 subjects can develop long-term consequences and limitations, particularly those with intensive care unitacquired weakness, who need more rehabilitation. New rehabilitative strategies and well-designed studies investigating the benefit of rehabilitation are necessary.

Critical Illness Polyneuropathy and Myopathy and Clinical Detection of the Recovery of Consciousness in Severe Acquired Brain Injury Patients with Disorders of Consciousness after Rehabilitation.

Background: Disorders of consciousness (DoCs) include unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS). Critical illness polyneuropathy and myopathy (CIPNM) is frequent in severe acquired brain injuries and impacts functional outcomes at discharge from the intensive rehabilitation unit (IRU). We investigated the prevalence of CIPNM in DoCs and its relationship with the consciousness assessment. Methods: Patients with DoCs were retrospectively selected from the database including patients admitted to the IRU of the IRCCS Don Gnocchi Foundation, Florence, from August 2012 to May 2020. Electroneurography/electromyography was performed at admission. Consciousness was assessed using the Coma Recovery Scale-Revised (CRS-R) at admission and discharge. Patients transitioning from a lower consciousness state to a higher one were classified as improved responsiveness (IR). Results: A total of 177 patients were included (UWS: 81 (45.8%); MCS: 96 (54.2%); 78 (44.1%) women; 67 years (IQR: 20). At admission, 108 (61.0%) patients had CIPNM. At discharge, 117 (66.1%) patients presented an IR. In the multivariate analysis, CRS-R at admission (p = 0.006; OR: 1.462) and CIPNM (p = 0.039; OR: −1.252) remained significantly associated with IR only for the UWS patients. Conclusions: CIPNM is frequent in DoCs and needs to be considered during the clinical consciousness assessment, especially in patients with UWS.

Critical illness polyneuropathy, myopathy and neuronal biomarkers in COVID-19 patients: A prospective study

ObjectiveThe aim was to characterize the electrophysiological features and plasma biomarkers of critical illness polyneuropathy (CIN) and myopathy (CIM) in coronavirus disease 2019 (COVID-19) patients with intensive care unit acquired weakness (ICUAW). MethodsAn observational ICU cohort study including adult patients admitted to the ICU at Uppsala University Hospital, Uppsala, Sweden, from March 13th to June 8th 2020. We compared the clinical, electrophysiological and plasma biomarker data between COVID-19 patients who developed CIN/CIM and those who did not. Electrophysiological characteristics were also compared between COVID-19 and non-COVID-19 ICU patients. Results111 COVID-19 patients were included, 11 of whom developed CIN/CIM. Patients with CIN/CIM had more severe illness; longer ICU stay, more thromboembolic events and were more frequently treated with invasive ventilation for longer than 2 weeks. In particular CIN was more frequent among COVID-19 patients with ICUAW (50%) compared with a non-COVID-19 cohort (0%, p = 0.008). Neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAp) levels were higher in the CIN/CIM group compared with those that did not develop CIN/CIM (both p = 0.001) and correlated with nerve amplitudes. ConclusionsCIN/CIM was more prevalent among COVID-19 ICU patients with severe illness. SignificanceCOVID-19 patients who later developed CIN/CIM had significantly higher NfL and GFAp in the early phase of ICU care, suggesting their potential as predictive biomarkers for CIN/CIM.

EPIDEMIOLOGY OF CRITICAL ILLNESS MYOPATHY AND POLYNEUROPATHY IN MECHANICALLY VENTILATED PATIENTS

SESSION TITLE: Advances in the Care of Mechanically-Ventilated Patients SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Critical-illness myopathy and polyneuropathy (CIMP) is a condition causing significant morbidity and mortality amongst patients admitted to the critical care units. CIMP can either be a single factor, or may be associated with concomitant risk factors. It can lead to failed weaning trials and longer duration of Mechanical Ventilation (MV). We aimed to estimate the temporal trends and predictors of CIMP in hospitalized patients receiving MV using a nationally representative database for the last decade. METHODS: Study cohort is derived from the Nationwide Inpatient Sample (NIS) for the years 2008-2017. Adult hospitalizations with length of stay (LOS) ≥7 days and who received mechanical ventilation were identified using International Classification of Diseases (9th/10th Editions) Clinical Modification (ICD-9/10-CM) procedures codes. CIMP and other diagnosis of interests were identified by either ICD-9/10-CM diagnosis codes or Elixhauser comorbidity software. We then utilized the Cochran Armitage trend test and multivariate survey logistic regression models to analyze temporal incidence trends, predictors, and outcomes. RESULTS: Out of a total 5,846,573 hospitalizations who had LOS ≥7 days and received mechanical ventilation, 71684(1.23%) developed CIMP. Incidence of CIMP increased from 5/1000 in 2008 to 19/1000 in 2017 with 13% yearly increase (OR 1.13; 95%CI 1.1-1.5; p<0.001). Patients who developed CIMP had lower mean age (61 vs 63; p<0.001) and higher LOS (31d Vs. 19d, p<0.001). Furthermore, in multivariable regression analysis, predictors of CIMP are female sex (OR 1.1; 95%CI 1.1-1.2; p<0.0001) and caucasian race (OR 1.5; 95%CI 1.4-1.6;p<0.001), on-Teaching Hospital (OR 1.2; 95%CI 1.1-1.3; p<0.005), MV ≥ 96 hours (OR 2.3; CI 2.1-2.4; p<0.0001), ventilator associated pneumonia (OR 1.6; 95%CI 1.5-1.8; p<0.0001), Septicemia (OR 1.5; 95%CI 1.5-1.6; p<0.0001), weight loss (OR 1.5; 95%CI 1.5-1.6; p<0.0001) and electrolyte imbalance (OR 1.4; 95%CI 1.3- 1.4; p<0.0001). Amongst the patients who developed CIMP, 69.47% were discharged to long term facilities and 14.7% died during the hospitalization. CONCLUSIONS: In this nationally representative study, we observed that the incidence of CIMP has been increasing. We identified several risk factors strongly associated with development of CIMP, some of which may be potentially modifiable. CLINICAL IMPLICATIONS: Our study highlights the need for early diagnosis, better risk stratification and need for complex long-term care in these vulnerable patients. Further studies are warranted to consider factoring some of the modifiable factors into account and to ameliorate the incidence and outcomes of CIMP. DISCLOSURES: No relevant relationships by Mohammed Abdulqader, source=Web Response No relevant relationships by Sohiel Deshpande, source=Web Response no disclosure on file for Preetam Jolepalem; No relevant relationships by Varshitha Kondapaneni, source=Web Response No relevant relationships by Faizan Malik, source=Web Response No relevant relationships by Uvesh Mansuri, source=Web Response No relevant relationships by Achint Patel, source=Web Response No relevant relationships by Harshil Shah, source=Web Response No relevant relationships by Venus Sharma, source=Web Response

Critical illness polyneuromyopathy: Functional impact after severe acquired brain injuries.

Critical illness polyneuropathy and myopathy (CIPNM) frequently affects critical patients and can occur after severe acquired brain injuries (sABI) influencing the functional recovery. We aimed to assess how the concomitance between CIPNM and sABI might influence the rehabilitative outcomes in terms of functional autonomy, oral feeding recovery and endotracheal tube weaning. Adult patients with sABI admitted to an intensive rehabilitation unit and underwent an electromyography examination within seven days after admission were included. Assessed rehabilitative outcomes at discharge were decannulation success and its timing, functional autonomy measured by the Functional Independence Measure (FIM) and the Glasgow outcome scale expanded (GOS-E) and oral feeding recovery assessed by the Functional Oral Intake Scale (FOIS) score. Among the 224 included patients (81 (36%) females, age (median[IQR]): 68.73[21.66] years), 119 (53.1%) presented CIPNM at admission. Albeit the change of rehabilitative outcomes between admission and discharge was significant in all the sABI patients (P<.001 for ΔFOIS, ΔFIM and ΔGOS-E), those with a concomitant CIPNM achieved significantly lower scores as evaluated by Mann-Whitney tests (P<.001 for ΔFIM Δ and GOS-E; P<.005 for ΔFOIS). The CIPNM absence was associated with a higher probability to achieve functional autonomy (GOS-E>4) (OR:4.57 (1.49/14.06); P<.01) and oral feeding recovery (FOIS≥4) (OR:2.07 (1.07/3.99); P=.03) at discharge. CIPNM presence did not influence decannulation success but a longer time to cannula weaning was required (P<.01 in the log-rank test). CIPMN significantly affects the rehabilitative outcomes after a sABI and should be taken into account for better rehabilitative handling.

Implementation of a gait center training to improve walking ability and vital parameters in inpatient neurological rehabilitation- a cohort study

BackgroundMany studies showed that robot-assisted gait training might improve walking of patients after stroke. The question remains whether patients with other neurological diagnoses can improve their ability to walk by training in a gait center. Aim of the present study was therefore to investigate the effects of a gait center training in inpatient neurological rehabilitation on walking ability.MethodsWe implemented a gait center training in addition to individual inpatient rehabilitation. Our primary outcome was walking ability based on the Functional Ambulation Categories (FAC). Our secondary outcomes were vital capacity and blood pressure. We predefined subgroups of patients with ischemic and hemorrhagic stroke and critical illness myopathy (CIM) and polyneuropathy (CIP).ResultsWe included 780 patients from our inpatient rehabilitation center in our cohort study. We analyzed 329 patients with ischemic, 131 patients with hemorrhagic stroke and 74 patients with CIP/ CIM.A large number of patients were able to improve their ability to walk. At the end of rehabilitation, patients with ischemic stroke and FAC 3 = increased theirFAC scores by 5%, FAC 4 = 4% and FAC 5 = 7%. Patients with hemorrhagic stroke and FAC 3 = increased by 5%, FAC 4 = 11% and FAC 5 = 9% and patients with CIP/CIM increased by FAC 3 = 3%, FAC 4 = 22% and FAC 5 = 26%.The largest improvement in walking ability during rehabilitation had patients with a FAC = 1 at baseline who improved by a median of 1.4 FAC points (p < 0.001). After adjusting for the number of gait training sessions, the largest improvement in walking ability during rehabilitation had patients with a FAC = 0 at baseline who improved by 1.8 FAC points (p < 0.001).ConclusionsImplementation of an additional gait center training may significantly improve walking ability in neurological rehabilitation.

The role of neuromuscular electrical stimulation for rehabilitation in ICU acquired weakness

Objective: To provide an overview of the muscle weakness development in intensive care units (ICU), summarize clinical trials on the role of neuromuscular electrical stimulation for muscle weakness rehabilitation in ICU and highlight recent strategies that may prevent or minimize this condition.Methodology: Literature review. Results: Some recent studies have shown that an increasing number of survivors of critical illness develop significant functional impairment; one of the common impairments being ICU acquired muscle weakness. Prolonged immobilization and mechanical ventilation likely contribute to the development of ICU-acquired weakness. Several novel therapeutic strategies have been used to overcome the impairment, including neuromuscular electrical stimulation. This neuromuscular electrical stimulation, a kind of physical therapy, is known to stimulate the nerves and thus increase muscle contraction. Conclusion: Neuromuscular electrical stimulation for rehabilitation in ICU-related muscle weakness has shown some promise, but more efforts are needed to detect the development of ICU-acquired weakness as early as possible and rigorously evaluate novel rehabilitation interventions.Abbreviations: ICU (Intensive Care Unit); ICU-Acquired Weakness (ICU-AW); CIP (Critical Illness Polyneuropathy); CIM (Critical Illness Myopathy), CIPM (Critical Illness Polyneuropathy and Myopathy)Citation: Kusumawardani MK, Poerwandari D, Narasinta I, Hidayati HB, Subadi I. The role of neuromuscular electrical stimulation for rehabilitation in ICU acquired weakness. Anaesth Pain &amp; Intensive Care 2018;22 Suppl 1:S164-S169

Functional outcome of critical illness polyneuropathy in patients affected by severe brain injury.

Critical illness polyneuropathy and myopathy (CIPNM) frequently occur in intensive care unit (ICU) critically ill subjects; about 55-70% of subjects achieve full recovery. CIPNM can occur in ICU subjects with severe acquired brain injury (sABI), but no data have been reported regarding their outcome. The aim of the present study was to investigate the functional recovery in subjects suffering from both CIPNM and sABI and whether they had poorer outcome than those with sABI only. Prospective cohort study. Dedicated rehabilitation setting. Adult ICU subjects with sABI causing a disorder of consciousness graded 3-8 on the Glasgow Coma Scale admitted to a dedicated rehabilitative setting were enrolled from January 2015 to June 2016. The enrolled sample was divided in two groups: patients with CIPNM and coexistent sABI (CIPNM+sABI) and patients with sABI. Electromyography was performed in all subjects to ascertain CIPNM occurrence, at admission. Functional outcome was investigated using the Rancho Los Amigos Levels of Cognitive Functioning (LCF), Disability Rating Scale (DRS), Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS), at admission and discharge. Mortality and length of stay (LOS) were recorded. One-hundred and thirty-one patients (59 F, 72 M; mean age 54.7±15.8) were admitted to the rehabilitation setting, and 111 (47 F, 64 M; mean age: 53.6±18.4 years) were enrolled. Thirty-six (31.8%) had CIPNM+sABI, and 75 patients had isolated sABI. Significant functional outcomes in all assessment measures were observed after rehabilitation in all samples. The estimated mean scores (95% confidence interval) of LCF, DRS, GOS and mRS from a multivariate model adjusted for age, sex and time of ICU stay were: 2.85 (2.53-3.21) and 5.24 (4.81-5.71), 23.94 (22.37-25.62) and 16.04 (14.77-17.41), 2.86 (2.70-3.04) and 3.46 (3.28-3.65), and 4.91 (4.67-5.17) and 3.79 (3.58-4.02), at admission and at discharge, respectively. Despite functional improvement, CIPNM+sABI patients showed lesser improvement than those with sABI only. Furthermore, patients with both disorders had significantly higher median LOS than sABI subjects: 107 (q1-q3: 65-146), and 65 (q1-q3: 38-105) days (P=5.5x10-83), respectively. No statistically significant difference in mortality rates was found between groups. Subjects with CIPNM and coexistent sABI improved after rehabilitation, but had poorer recovery than those with solely sABI requiring a longer LOS. The rehabilitation process in subjects suffering from CINPM is challenging and no evidence support the use of specific rehabilitative approaches to improve function and activities of daily living.

Critical illness polyneuropathy and myopathy as neurological complications of sepsis

Intensive care unit acquired weakness (ICUAW) is a frequent and severe complication of intensive care management. Within ICUAW critical illness polyneuropathy (CIP) and myopathy (CIM) can be differentiated. The major symptom of ICUAW is progressive quadriparesis, which makes weaning from the respirator more difficult, can appear early after admission to an ICU and can often be detected several months after discharge from the ICU. The pathophysiology of ICUAW is multifactorial and complex. Potential therapeutic approaches are the early and sufficient therapy of mulitorgan dysfunction, optimal control of glucose levels as well as early and intensive physiotherapy. This review article discusses the data on incidence, pathophysiology, diagnostic approaches and prognosis of ICUAW.

Physical rehabilitation for critical illness myopathy and neuropathy.

Intensive care unit (ICU) acquired or generalised weakness due to critical illness myopathy (CIM) and polyneuropathy (CIP) are major causes of chronically impaired motor function that can affect activities of daily living and quality of life. Physical rehabilitation of those affected might help to improve activities of daily living. Our primary objective was to assess the effects of physical rehabilitation therapies and interventions for people with CIP and CIM in improving activities of daily living such as walking, bathing, dressing and eating. Secondary objectives were to assess effects on muscle strength and quality of life, and to assess adverse effects of physical rehabilitation. On 16 July 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register and on 14 July 2014 we searched CENTRAL, MEDLINE, EMBASE and CINAHL Plus. In July 2014, we searched the Physiotherapy Evidence Database (PEDro, http://www.pedro.org.au/) and three trials registries for ongoing trials and further data about included studies. There were no language restrictions. We also handsearched relevant conference proceedings and screened reference lists to identify further trials. We planned to include randomised controlled trials (RCTs), quasi-RCTs and randomised controlled cross-over trials of any rehabilitation intervention in people with acquired weakness syndrome due to CIP/CIM. We would have extracted data, assessed the risk of bias and classified the quality of evidence for outcomes in duplicate, according to the standard procedures of The Cochrane Collaboration. Outcome data collection would have been for activities of daily living (for example, mobility, walking, transfers and self care). Secondary outcomes included muscle strength, quality of life and adverse events. The search strategy retrieved 3587 references. After examination of titles and abstracts, we retrieved the full text of 24 potentially relevant studies. None of these studies met the inclusion criteria of our review. No data were suitable to be included in a meta-analysis. There are no published RCTs or quasi-RCTs that examine whether physical rehabilitation interventions improve activities of daily living for people with CIP and CIM. Large RCTs, which are feasible, need to be conducted to explore the role of physical rehabilitation interventions for people with CIP and CIM.

Concomitant acute transverse myelitis and sensory motor axonal polyneuropathy in two children: two case reports.

Acute transverse myelitis (ATM) is an upper motor neuron disease of the spinal cord, and concomitant association of peripheral polyneuropathy, particularly the axonal type, is rarely reported in children. Our cases presented with ATM complicated with axonal type polyneuropathy. Axonal type polyneuropathy may be caused by acute motor-sensory axonal neuropathy (AMSAN) or critical illness polyneuropathy and myopathy (CIPNM). These cases emphasize the need for nerve and muscle biopsies to make the differential diagnosis between AMSAN and CIPNM in patients with ATM complicated with axonal polyneuropathy.

Validation of the peroneal nerve test to diagnose critical illness polyneuropathy and myopathy in the intensive care unit: the multicentre Italian CRIMYNE-2 diagnostic accuracy study

Objectives: To evaluate the accuracy of the peroneal nerve test (PENT) in the diagnosis of critical illness polyneuropathy (CIP) and myopathy (CIM) in the intensive care unit (ICU). We hypothesised that abnormal reduction of peroneal compound muscle action potential (CMAP) amplitude predicts CIP/CIM diagnosed using a complete nerve conduction study and electromyography (NCS-EMG) as a reference diagnostic standard. Design: prospective observational study. Setting: Nine Italian ICUs. Patients: One-hundred and twenty-one adult (≥18 years) neurologic (106) and non-neurologic (15) critically ill patients with an ICU stay of at least 3 days. Interventions: None. Measurements and main results: Patients underwent PENT and NCS-EMG testing on the same day conducted by two independent clinicians who were blind to the results of the other test. Cases were considered as true negative if both NCS-EMG and PENT measurements were normal. Cases were considered as true positive if the PENT result was abnormal and NCS-EMG showed symmetric abnormal findings, independently from the specific diagnosis by NCS-EMG (CIP, CIM, or combined CIP and CIM). All data were centrally reviewed and diagnoses were evaluated for consistency with predefined electrophysiological diagnostic criteria for CIP/CIM.During the study period, 342 patients were evaluated, 124 (36.3%) were enrolled and 121 individuals with no protocol violation were studied. Sensitivity and specificity of PENT were 100% (95% CI 96.1-100.0) and 85.2% (95% CI 66.3-95.8). Of 23 patients with normal results, all presented normal values on both tests with no false negative results. Of 97 patients with abnormal results, 93 had abnormal values on both tests (true positive), whereas four with abnormal findings with PENT had only single peroneal nerve neuropathy at complete NCS-EMG (false positive). Conclusions: PENT has 100% sensitivity and high specificity, and can be used as a screening test to diagnose CIP/CIM in the ICU.

Validation of the peroneal nerve test to diagnose critical illness polyneuropathy and myopathy in the intensive care unit: the multicentre Italian CRIMYNE-2 diagnostic accuracy study.

To evaluate the accuracy of the peroneal nerve test (PENT) in the diagnosis of critical illness polyneuropathy (CIP) and myopathy (CIM) in the intensive care unit (ICU). We hypothesised that abnormal reduction of peroneal compound muscle action potential (CMAP) amplitude predicts CIP/CIM diagnosed using a complete nerve conduction study and electromyography (NCS-EMG) as a reference diagnostic standard. prospective observational study. Nine Italian ICUs. One-hundred and twenty-one adult (≥18 years) neurologic (106) and non-neurologic (15) critically ill patients with an ICU stay of at least 3 days. None. PATIENTS underwent PENT and NCS-EMG testing on the same day conducted by two independent clinicians who were blind to the results of the other test. Cases were considered as true negative if both NCS-EMG and PENT measurements were normal. Cases were considered as true positive if the PENT result was abnormal and NCS-EMG showed symmetric abnormal findings, independently from the specific diagnosis by NCS-EMG (CIP, CIM, or combined CIP and CIM). All data were centrally reviewed and diagnoses were evaluated for consistency with predefined electrophysiological diagnostic criteria for CIP/CIM. During the study period, 342 patients were evaluated, 124 (36.3%) were enrolled and 121 individuals with no protocol violation were studied. Sensitivity and specificity of PENT were 100% (95% CI 96.1-100.0) and 85.2% (95% CI 66.3-95.8). Of 23 patients with normal results, all presented normal values on both tests with no false negative results. Of 97 patients with abnormal results, 93 had abnormal values on both tests (true positive), whereas four with abnormal findings with PENT had only single peroneal nerve neuropathy at complete NCS-EMG (false positive). PENT has 100% sensitivity and high specificity, and can be used as a screening test to diagnose CIP/CIM in the ICU.

Validation of the peroneal nerve test to diagnose critical illness polyneuropathy and myopathy in the intensive care unit: the multicentre Italian CRIMYNE-2 diagnostic accuracy study

Objectives: To evaluate the accuracy of the peroneal nerve test (PENT) in the diagnosis of critical illness polyneuropathy (CIP) and myopathy (CIM) in the intensive care unit (ICU). We hypothesised that abnormal reduction of peroneal compound muscle action potential (CMAP) amplitude predicts CIP/CIM diagnosed using a complete nerve conduction study and electromyography (NCS-EMG) as a reference diagnostic standard.Design: prospective observational study.Setting: Nine Italian ICUs.Patients: One-hundred and twenty-one adult (≥18 years) neurologic (106) and non-neurologic (15) critically ill patients with an ICU stay of at least 3 days.Interventions: None.Measurements and main results: Patients underwent PENT and NCS-EMG testing on the same day conducted by two independent clinicians who were blind to the results of the other test. Cases were considered as true negative if both NCS-EMG and PENT measurements were normal. Cases were considered as true positive if the PENT result was abnormal and NCS-EMG showed symmetric abnormal findings, independently from the specific diagnosis by NCS-EMG (CIP, CIM, or combined CIP and CIM). All data were centrally reviewed and diagnoses were evaluated for consistency with predefined electrophysiological diagnostic criteria for CIP/CIM.During the study period, 342 patients were evaluated, 124 (36.3%) were enrolled and 121 individuals with no protocol violation were studied. Sensitivity and specificity of PENT were 100% (95% CI 96.1-100.0) and 85.2% (95% CI 66.3-95.8). Of 23 patients with normal results, all presented normal values on both tests with no false negative results. Of 97 patients with abnormal results, 93 had abnormal values on both tests (true positive), whereas four with abnormal findings with PENT had only single peroneal nerve neuropathy at complete NCS-EMG (false positive).Conclusions: PENT has 100% sensitivity and high specificity, and can be used to diagnose CIP/CIM in the ICU.

Validation of the peroneal nerve test to diagnose critical illness polyneuropathy and myopathy in the intensive care unit: the multicentre Italian CRIMYNE-2 diagnostic accuracy study

Objectives: To evaluate the accuracy of the peroneal nerve test (PENT) in the diagnosis of critical illness polyneuropathy (CIP) and myopathy (CIM) in the intensive care unit (ICU). We hypothesised that abnormal reduction of peroneal compound muscle action potential (CMAP) amplitude predicts CIP/CIM diagnosed using a complete nerve conduction study and electromyography (NCS-EMG) as a reference diagnostic standard. Design: prospective observational study. Setting: Nine Italian ICUs. Patients: One-hundred and twenty-one adult (≥18 years) neurologic (106) and non-neurologic (15) critically ill patients with an ICU stay of at least 3 days. Interventions: None. Measurements and main results: Patients underwent PENT and NCS-EMG testing on the same day conducted by two independent clinicians who were blind to the results of the other test. Cases were considered as true negative if both NCS-EMG and PENT measurements were normal. Cases were considered as true positive if the PENT result was abnormal and NCS-EMG showed symmetric abnormal findings, independently from the specific diagnosis by NCS-EMG (CIP, CIM, or combined CIP and CIM). All data were centrally reviewed and diagnoses were evaluated for consistency with predefined electrophysiological diagnostic criteria for CIP/CIM. During the study period, 342 patients were evaluated, 124 (36.3%) were enrolled and 121 individuals with no protocol violation were studied. Sensitivity and specificity of PENT were 100% (95% CI 96.1-100.0) and 85.2% (95% CI 66.3-95.8). Of 23 patients with normal results, all presented normal values on both tests with no false negative results. Of 97 patients with abnormal results, 93 had abnormal values on both tests (true positive), whereas four with abnormal findings with PENT had only single peroneal nerve neuropathy at complete NCS-EMG (false positive). Conclusions: PENT has 100% sensitivity and high specificity, and can be used to diagnose CIP/CIM in the ICU.

Guillain–Barré syndrome and ulceroglandular tularemia

Ylipalosaari and colleagues [1] reported an interesting case of Guillain–Barre syndrome (GBS) in a patient with ulceroglandular tularemia. Similar cases have been reported in the authors’ hospital [2] and another institution [3]. Clinically, GBS is characterized by the acute or subacute onset of varying degrees of weakness in limbs or cranial nerve-innervated muscles, associated with characteristic albuminocytologic dissociation in the cerebrospinal fluid (CSF). GBS is usually preceded by various infections. About two-thirds of cases are preceded by symptoms of upper respiratory tract infection or diarrhea [4]. In this case, however, the clinical course of weakness of limbs and respiratory muscles paralleled that of ulceroglandular tularemia too perfectly. This is concomitant with the ineffectiveness of intravenous immunoglobulin. Moreover, the characteristic albuminocytologic dissociation in the CSF was absent for this patient. As mentioned by the authors, there have been reports of tularemia meningitis and intracranial abscesses [5]. The elevated number of white blood cells in the CSF (we believe that the real number should be 47 9 10/L, instead of 47/L in the text) strongly suggests direct involvement of the nervous system by pathogens. Taken together, the atypical clinical manifestations of the patient prompt us to consider other differential diagnoses, including infectious polyneuritis, critical illness polyneuropathy (CIP) and myopathy (CIM), etc.

Muscle ultrasound for early assessment of critical illness neuromyopathy in severe sepsis

IntroductionMuscle ultrasound is emerging as a promising tool in the diagnosis of neuromuscular diseases. The current observational study evaluates the usefulness of muscle ultrasound in patients with severe sepsis for assessment of critical illness polyneuropathy and myopathy (CINM) in the intensive care unit.Methods28 patients with either septic shock or severe sepsis underwent clinical neurological examinations, muscle ultrasound, and nerve conduction studies on days 4 and 14 after onset of sepsis. 26 healthy controls of comparable age underwent clinical neurological evaluation and muscle ultrasound only.Results26 of the 28 patients exhibited classic electrophysiological characteristics of CINM, and all showed typical clinical signs. Ultrasonic echogenicity of muscles was graded semiquantitatively and fasciculations were evaluated in muscles of proximal and distal arms and legs. 75% of patients showed a mean echotexture greater than 1.5, which was the maximal value found in the control group. A significant difference in mean muscle echotexture between patients and controls was found at day 4 and day 14 (both p < 0.001). In addition, from day 4 to day 14, the mean grades of muscle echotexture increased in the patient group, although the values did not reach significance levels (p = 0.085). Controls revealed the lowest number of fasciculations. In the patients group, fasciculations were detected in more muscular regions (lower and upper arm and leg) in comparison to controls (p = 0.08 at day 4 and p = 0.002 at day 14).ConclusionsMuscle ultrasound represents an easily applicable, non-invasive diagnostic tool which adds to neurophysiological testing information regarding morphological changes of muscles early in the course of sepsis. Muscle ultrasound could be useful for screening purposes prior to subjecting patients to more invasive techniques such as electromyography and/or muscle biopsy.Trial registrationGerman Clinical Trials Register, DRKS-ID: DRKS00000642.

Therapeutic effect of insulin in reducing critical illness; polyneuropathy and myopathy in the pediatric intensive care unit.

Hyperglycemia may occur in the patients affected by any kind of critical illness. This complication makes an adverse effect on the clinical outcome of these patients by causing polyneuropathy and myopathy. It has been recently shown that treatment of hyperglycemia with insulin administration significantly reduces the prevalence of critical illness polyneuropathy and myopathy (CIPNM) and on the other hand reduces the demand for long-term mechanical ventilation in the patients admitted to the ICU for more than 1 week. The aim of this study was to determine the therapeutic effect of insulin in reducing the incidence of CIPNM in the pediatric intensive care unit (PICU). In this study, we recruited 30 patients admitted to the PICU of Tabriz Pediatric Hospital. The incidence of CIPNM following hyperglycemia was evaluated in these patients. The patients were categorized into two groups. In the case group, blood sugar was controlled in the range of 140-180mg/dl by administration of 0.05 unit per kilogram body weight of insulin as drip protocol in an hour and in the control group, placebo was used. Consequently, the incidence of CIPNM, duration of PICU and duration of mechanical ventilation were compared between the two groups. The incidence of CIPNM and duration of PICU stay and mechanical ventilation were significantly reduced in the patients treated with insulin compared to the control group. This study shows that blood sugar control decreases the incidence of CIPNM.

Rehabilitation of critical illness polyneuropathy and myopathy patients

Critical illness polyneuropathy and myopathy (CIPNM) frequently develops in patients hospitalized in intensive care units. The number of patients with CIPNM admitted to inpatient rehabilitation is increasing. The aim of this study was to comprehensively evaluate the outcome of their rehabilitation. Twenty-seven patients with CIPNM were included in the study. The diagnosis was established clinically and confirmed electrophysiologically. Manual muscle testing was used for the assessment of function. Activity was assessed using the functional independence measure and two walking tests. The patients were also assessed using an adapted International Classification of Functioning, Disability and Health (ICF) checklist. All assessments were performed at admission and discharge. Clinically important and statistically significant improvements were found in all observed measures. High and significant correlations were found between the measures, except between muscle strength and the results of walking tests. Improvement in body functions during rehabilitation decreased as the time from established diagnosis to the start of rehabilitation increased, but it was not related to rehabilitation duration. Improvements in terms of the ICF mainly corresponded to the gain in functional independence measure scores. Major improvement regarding body functions and activities/participation was achieved in patients with CIPNM with a relatively short rehabilitation. Rehabilitation of such patients should start as early as possible once the diagnosis has been established. Comprehensive assessment of such patients combining established scales, objective clinical tests, and the ICF is recommended.