Mean Medical Research Council Research Articles

Early shoulder-girdle MRI findings in severe COVID-19-related intensive care unit-acquired weakness: a prospective cohort study.

To describe clinical and early shoulder-girdle MR imaging findings in severe COVID-19-related intensive care unit-acquired weakness (ICU-AW) after ICU discharge. A single-center prospective cohort study of all consecutive patients with COVID-19-related ICU-AW from November 2020 to June 2021. All patients underwent similar clinical evaluations and shoulder-girdle MRI within the first month and then 3months (± 1month) after ICU discharge. We included 25 patients (14 males; mean [SD] age 62.4 [12.5]). Within the first month after ICU discharge, all patients showed severe proximal predominant bilateral muscular weakness (mean Medical Research Council total score = 46.5/60 [10.1]) associated with bilateral, peripheral muscular edema-like MRI signals of the shoulder girdle in 23/25 (92%) patients. At 3months, 21/25 (84%) patients showed complete or quasi-complete resolution of proximal muscular weakness (mean Medical Research Council total score > 48/60) and 23/25 (92%) complete resolution of MRI signals of the shoulder girdle, but 12/20 (60%) patients experienced shoulder pain and/or shoulder dysfunction. Early shoulder-girdle MRI findings in COVID-19-related ICU-AW included muscular edema-like peripheral signal intensities, without fatty muscle involution or muscle necrosis, with favorable evolution at 3months. Precocious MRI can help clinicians distinguish critical illness myopathy from alternative, more severe diagnoses and can be useful in the care of patients discharged from intensive care with ICU-AW. • We describe the clinical and shoulder-girdle MRI findings of COVID-19-related severe intensive care unit-acquired weakness. • This information can be used by clinicians to achieve a nearly specific diagnosis, distinguish alternative diagnoses, assess functional prognosis, and select the more appropriate health care rehabilitation and shoulder impairment treatment.

Covid Rehabilitation in two Malaysian Tertiary Hospitals

<h3>Research Objectives</h3> To investigate the severity of COVID-19 infections and complications experienced during inpatient admission. To study the patient outcomes after a 12 week outpatient rehabilitation program. <h3>Design</h3> A retrospective cohort study was conducted for a 12 month period from January 1st, 2021, to December 31st, 2021. COVID-19 patients who were referred to Rehabilitation Medicine team as inpatient or outpatient were included. Patient symptoms and outcome at 1 month and 3 month post initial contact were analysed. <h3>Setting</h3> Sultan Ahmad Shah Medical Centre@IIUM) and Penang General Hospital are both tertiary hospitals and referral centers. <h3>Participants</h3> 184 patients were selected for this study. By using IBM SPSS version 24, descriptive analysis was done to elaborate the demographic data and patient outcomes up to 3 months after the first contact with the Rehabilitation Medicine team. <h3>Interventions</h3> Pulmonary rehabilitation by telerehabilitation or face to face method. <h3>Main Outcome Measures</h3> Residual symptom report and Medical Research Council Dyspnea Scale. <h3>Results</h3> The mean age of patients in the study was 51.8 years (SD 16.0). Out of 184 patients, majority were male (58.7%), from Malay ethnicity (74.5%) and hypertensive (51.6%). 25.5% of patients received telerehabilitation review. Most patients were classified as category 4 and 5 COVID-19 infection (78.8 %). During inpatient admission, many patients received treatment with steroids (77.2%) and antibiotics (69.0%). 30.5% of patients received antiviral treatment. Three commonest COVID-19 complications were pulmonary complications (59.8%), pressure injury (28.8%), and nosocomial infections (23.4%). Dyspnea and fatigue were the main reported symptoms during initial rehabilitation contact and all outpatient follow ups. The mean Medical Research Council Dyspnea scale improved from 2.7 at baseline to 1.7 at 3 months follow up. 32.1% of patients were diagnosed with Long COVID syndrome. Default rates increased from 26.1% at 1 month to 36.4% at 3 month follow up. <h3>Conclusions</h3> COVID 19 patients who received inpatient rehabilitation input, followed by a 12 week outpatient follow up showed symptom improvement. Future studies need to establish long term outcomes of COVID-19 survivors in this region. <h3>Author(s) Disclosures</h3> All authors have no disclosures.

A systematic review of nerve grafting, end-to-end repair, and nerve transfer for obturator nerve injuries

ObjectiveObturator nerve injury can occur as a complication of gynecologic surgeries, occurring most frequently in patients with endometriosis and genitourinary malignancies. The resulting injury causes paresthesia and major weakness in...

Pain Relief Following Selective Tibial Neurotomy for Spastic Equinus Foot Secondary to Stroke and Traumatic Brain Injury

Selective tibial neurotomy (STN) has been indicated for spastic equinus foot (SEF); however, the impact of this procedure on quality of life and activities of daily living has not been evaluated in detail. This study aimed to evaluate the surgical outcomes of STN and its effect on SEF accompanied by pain. We evaluated 26 patients (mean age: 59.6±15.2years; 14 men and 12 women) who underwent STN for SEF, 10 of whom complained of spontaneous pain preoperatively. We used the following scales for clinical evaluation: the Modified Ashworth Scale, Medical Research Council (MRC), 10-m walking test, Functional Independence Measure, and numeric rating scale for pain. These scales were evaluated preoperatively and postoperatively. Differences in clinical characteristics were compared between the 10 patients with pain and the 16 patients without pain. Significant differences were observed in all evaluation scale scores except for the Functional Independence Measure, and no serious adverse events were reported. Pain intensity was significantly improved from 6.4±2.0 to 2.7±2.3 (P<0.05). An analysis showed that the preoperative mean Medical Research Council score of ankle movement was significantly lower in patients with pain but recovered to the same level postoperatively at the 6-month follow-up. Our study showed significant improvements in spasticity and its associated symptoms, and STN effectively addressed spastic pain and motor weakness. Among various treatment modalities, STN may be positively indicated for patients with spastic pain in the lower leg.

Guillain-Barre syndrome in Mexico: clinical features and validation of Brighton Collaboration Group criteria.

As SARS-CoV-2 vaccination is ongoing in Mexico and Guillain-Barre syndrome (GBS) cases have been reported, validation of Brighton criteria in Mexico is necessary. Moreover, epidemiology of GBS in Mexico differs from European and North American countries. To describe the clinical, cerebrospinal and electrodiagnostic features in Mexican patients diagnosed with GBS and classify them according to the Brighton Collaboration Group diagnostic criteria. Patrients and methods. An ambispective cohort study was conducted. We included patients that fulfilled the National Institute of Neurological Disorders and Stroke (NINDS) diagnostic criteria for Guillain-Barre syndrome. Patients in this study were classified according to Brighton collaboration group levels of certainty for Guillain-Barre syndrome. Sixty eight percent of patients were male. Of the 248 patients included, 58.4% had history of a precedent infection, mean time from symptom onset to admission was 5 (1-30) days. Mean Medical Research Council sum score 30.3 ± 15.5. Almost 98% of patients had a monophasic course. Level 1 of certainty according to Brighton collaboration group criteria was fulfilled by 54.6% of patients, level 2 by 45% and level 4 by 0.6%. Patients meeting level 2 of certainty were mostly because normal cerebrospinal fluid findings or findings in nerve conduction studies not consistent with any GBS variants. GBS is a frequent autoimmune neuropathy that has been associated with preceding infections and with vaccination campaigns. For SARS-CoV-2 vaccination campaign in Mexico, validation of Brighton Criteria is necessary. Although Mexico's GBS epidemiology has been changing throughout recent years, this study provides similar data compared to other countries.

Cardiovascular Autonomic Assessment in Guillain-Barré Syndrome: A Longitudinal Study.

Severe dysautonomia is typically seen during acute phase of Guillain-Barré syndrome (GBS). To investigate the relationship of cardiovascular autonomic dysfunction with motor recovery in GBS. Consecutive GBS patients presented to our hospital were recruited. Clinical assessment was evaluated with the Medical Research Council (MRC) sum score and GBS disability score (GDS). All patients had series of autonomic testing on admission and after treatment at 6 and 24 weeks. Both computation-dependent tests (heart rate variability [HRV] and baroreflex sensitivity [BRS]) and autonomic maneuvers were performed. Age- and gender-matched healthy controls (HC) were recruited. The data obtained at admission, 6 weeks and 24 weeks were compared within groups for statistical difference. Six patients (4 men; mean age 39.5 ± 14.3 years) were recruited over one year. Five had GBS and one Miller Fisher syndrome. The mean MRC sum score and GDS on admission were 52.3 ± 4.3 and 3.5 ± 0.8 respectively. During admission, time-domain average RR interval (AVNN) and BRS were significantly poorer among cases compared to HC. Active standing 30:15 ratio and cold pressor test at admission were also significantly abnormal when compared with HC. All the autonomic parameters had normalized by 6 weeks and these were significant for the high frequency-HRV, BRS, and active standing 30:15 ratio. For MRC and GDS, there were significant improvements in the scoring over a period of 24 weeks. Dysautonomia in GBS improved gradually and in keeping with motor and disability recovery.

Safe Discharge Home With Telemedicine of Patients Requiring Nasal Oxygen Therapy After COVID-19.

Introduction: The COVID-19 pandemic created challenges to healthcare systems worldwide. To allow overwhelmed hospitals to focus on the most fragile and severely ill patients, new types of management had to be set up. During the pandemic, patients with COVID-19 from greater Paris area were monitored at home using a web-based remote system called COVIDOM™, using self-administered questionnaires, which triggered alerts to a regional control center. To ease hospital discharge and to prevent hospital from being overwhelmed, patients still requiring low-flow oxygen therapy discharged home were also included in this telemedicine solution. We aim to evaluate the safety of this original management.Methods: We conducted a retrospective multicenter cohort of patients discharged home from hospital after COVID-19 and still requiring nasal oxygen therapy, who were monitored by questionnaire and trained physicians using COVIDOM. During late follow-up, the status of the patients using a Euro-Qol (EQ-5D-5L) questionnaire, and the Medical Research Council (MRC) Dyspnea scale was collected.Results: From March 21st to June 21st 2020, 73 COVID-19 patients still receiving nasal oxygen at hospital discharge were included. Median [Inter-Quartile Range (IQR)] age was 62.0 [52.5–69.0] years, 64.4% were male. Altogether, risk factors were observed in 49/73 (67%) patients, mainly hypertension (35.6%), diabetes mellitus (15.1%) and active neoplasia (11.0%). Among the cohort, 26% of patients were previously managed in ICU. Oxygen therapy was required for a median [IQR] of 20 [16–31] days. No death or urgent unplanned hospitalization were observed during the COVIDOM telemonitoring. During the late follow-up evaluation (6 months after inclusion), the mean EQ-5D-5L questionnaire score was 7.0 ± 1.6, and the mean MRC dyspnea scale was 0.8 ± 1.0, indicating absence of dyspnea. Five patients have died from non-COVID causes.Conclusions: In this preliminary study, early discharge home of patients with severe COVID-19 disease who still required low-oxygen therapy seems to be safe.

P-PN029. Clinical and electrophysiological profile of patients with Guillain-Barré Syndrome with conduction blocks

Introduction . Clinical data is limited in patients with Guillain Barre syndrome (GBS) who show conduction block (CB) on nerve conduction study (NCS). We aim to describe the clinical and electrophysiological profiles of GBS with CB. Methods . Between 2017 and 2020, 111 patients fulfilling the National Institute of Neurological Disorders and Stroke (NINDS) criteria for GBS and Brighton level of certainty one or two were seen in a single neurology unit. NCS of three motor (median, ulnar and common peroneal (CP)) and three sensory (median, ulnar and sural) nerves were performed. Definite and probable CBs were defined as proximal/distal latency of 20% of lower limit of normal (LLN). Results . Mean interval from symptom-onset to NCS was 9.4±6.5 days. Twenty patients had CB (one nerve: 15, two nerves: 4, three nerves: 1). This included probable CB in median (n=3), ulnar (n=2) and CP (n=4) nerves, and definite CB in median (n=5), ulnar (n=6) and CP (n=6) nerves. Electrophysiological subtypes included demyelinating (n=11), axonal (n=4) and equivocal (n=5). Demographic and clinical features included M:F of 3:1, mean age of 38.5±19.9 years, facial weakness (n=8), ophthalmoparesis (n=1), respiratory muscle weakness (n=2) and antecedent infection (n=12). At the time of peak neurological deficits, the mean Medical Research Council (MRC) sum score was 35.4±14.9 and Hughes disability score (HDS) was 3.5±0.8. The mean duration of hospital stay was 14.7±15.9 days. At the time of discharge, the mean MRC sum score was 39.8±15.2 and mean HDS was 3.1±0.7. Conclusion . We report CBs across non-entrapment sites in both demyelinating and axonal sub-types of GBS. Interruption of saltatory conduction due to distortion of paranodal myelin leads to reversible conduction failure and rapid recovery as noted in the present study.

Full-Endoscopic Lumbar Decompression with Minimal Nerve Root Retraction for Impending Neurologic Deficit in Degenerative Lumbar Spine Diseases.

The aim of this retrospective case study was to analyze the outcomes of minimal nerve root retraction in patients with impending neurologic deficit in degenerative lumbar spine disease using the full-endoscopic spine surgery. Thirty-seven consecutive patients with impending neurologic deficit underwent endoscopic spine surgery through either the transforaminal or the interlaminar approach. Their clinical outcomes were evaluated with visual analog scale (VAS) leg pain score, Oswestry Disability Index (ODI), and MacNab's criteria. The outcome of motor deficitis was evaluated with the Medical Research Council (MRC) grade. Completeness of decompression was documented with a postoperative magnetic resonance imaging (MRI) and computed tomography (CT) scan. A total of 40 lumbar levels of 37 patients were operated, VAS score of the leg improved from 7.7 ± 1 to 1.9 ± 0.6 (p < 0.0001). ODI score improved from 74.7 ± 6.5 to 25.4 ± 3.49 (p < 0.0001). Motor weakness improved significantly immediately after surgery. The mean MRC grade increased to 1.97, 3.65, 4.41, and 4.76 preoperatively, at 1 week, at 3 months, and at the final follow-up, respectively, and all the patients with foot drop and cauda equina syndrome symptom recovered completely. One patient with great toe drop recovered partially to MRC grade 3. Mean follow-up of the study was 13.3 ± 6.1 months. According to MacNab's criteria, 30 patients (80.1%) had good and 7 patients (18.9%) had excellent results. Three patients required revision surgery. Minimal nerve root retraction during full-endoscopic spine surgery is safe and effective for treatment of the impending neurologic deficit. We could achieve a thorough decompression of the affected nerve root with acceptable clinical outcome and minimal postoperative morbidity.

Guillain-Barre syndrome in North Indian children: Clinical and serial electrophysiological features.

Guillain-Barre syndrome (GBS) is a common acquired polyneuropathy in children. To describe the clinical and serial electrophysiological features along with short-term outcomes of children with GBS in north India. This was a prospective study conducted at a tertiary care pediatric hospital in north India. Consecutive children, aged 2 to 18 years, with GBS, presenting within 4-weeks of onset of weakness, diagnosed on clinical and/or electrophysiological grounds, were enrolled. The enrolled children underwent a detailed clinical-assessment followed by nerve conduction studies. Repeat nerve conduction studies were performed after 2-weeks of the first study to determine changes in the electrophysiological subtype. The patients were followed up for 3 months. Thirty-six children were studied. The mean age at presentation was 5.1 years [standard deviation (SD): 2.1]. The mean medical research council (MRC)-sum-score at admission was 24.1 (SD: 10.4). Thirty-three children (91%) had loss of ambulation, 24 (66%) had cranial nerve involvement, and 6 (16.6%) required ventilation. At presentation, 20 had acute motor axonal neuropathy (AMAN), 13 had acute inflammatory demyelinating polyneuropathy (AIDP), 2 had in-excitable nerves, and 1 had normal findings. Four children, initially diagnosed as AIDP, had AMAN with reversible conduction failure on the repeat study. The final classification was AMAN in 25 (69.4%; 95% confidence interval (CI), 51.9-83.7%) and AIDP in 9 children (25%; 95% CI, 12.1-42.2%). Only one patient was nonambulatory at a 3-month follow-up (n = 32). The Erasmus GBS outcome score was 2 in 2 (5.6%), 3 in 5 (13.9%), 4 in 26 (72.2%), and 5 in 3 (8.3%) patients. The serial electrophysiological studies were helpful in establishing the final correct diagnosis.

Arthroscopic treatment of iliopsoas impingement syndrome after hip arthroplasty.

Background and aim of the Work: Groin pain after hip arthroplasty (HA) ranges from 0.4% to 18.3%. Defining the cause of groin pain after HA can be difficult. Iliopsoas impingement (IPI) has been reported to be the underlying cause of groin pain in up to 4.4% of cases. The purpose of this study is to present arthroscopic surgical outcomes in the treatment of IPI after HA. Methods: Between September 2013 and March 2018, 13 patients, 11 total hip arthroplasty (THA), 1 hip endoprosthesis and 1 total hip resurfacing affected by groin pain due to unceasing iliopsoas tendinopathy for impingement after HA were treated arthroscopically. The patients underwent to physical examination, blood analysis, hip X-rays, bone scintigraphy and CT assessment. We performed the arthroscopic OUT-IN access to hip joint in all patients. VAS scale, Harris Hip Score (HHS) and Medical Research Council (MRC) scale were performed before surgery and during follow up at 1-3-6-12 months. Results: After 10 months of mean follow-up, average HHS and MRC scale improved significantly from preoperatively to postoperatively. No complications arose in our case series. Conclusions: Hip arthroscopy after hip arthroplasty is supported in the literature for a variety of indications. Hip arthroscopy is a viable and reproducible technique in treatment of IPI, being less invasive than the classic open technique. This simple arthroscopic release provides satisfactory results and preserves HA function. Moreover an arthroscopic OUT-IN access proves good clinical outcomes, few complications and iatrogenic lesions. (www.actabiomedica.it)

COPD patients prescribed inhaled corticosteroid in general practice: Based on disease characteristics according to guidelines?

In a primary care setting, our aim was to investigate characteristics of patients classified as having chronic obstructive pulmonary disease (COPD) and currently being prescribed inhaled corticosteroids (ICSs). The electronic patient record system in each participating general practice was searched for patients coded as COPD (ICPC, Second Edition code R95) and treated with ICS (ACT code R03AK and R03BA, that is, ICS in combination with a long-acting β2-agonist) or ICS as monotherapy. Data, if available, on demographics, smoking habits, spirometry, COPD medication, symptom score, blood eosinophils, co-morbidity and exacerbation history were retrieved from the medical records for all identified cases. Of all patients registered in the 138 participating general practices, 12.560 (3%) were coded as COPD, of whom 32% were prescribed ICS. The final study sample comprised 2.289 COPD patients currently prescribed ICS (98% also prescribed long-acting β2-agonist), with 24% being coded as both COPD and asthma. Post-bronchodilator spirometry was available in 79% (mean forced expiratory volume in 1 second 60% pred (standard deviation (SD) 23.3)), symptom severity score in 53% (mean Medical Research Council score 2.7 (SD 1.1)) and 56% of the COPD patients had had no exacerbation in the previous year (and 45% not within the 2 previous years). Blood eosinophils were measured in 67% of the patients. Information on severity of airflow limitation was missing in 15% of the patients, and the combined information on symptom severity and exacerbation history was missing in in 46%. Most of the patients (74%) were managed only by their general practitioner. Although only one-third of the COPD patients were prescribed ICSs, our findings from this study of a large cohort of patients prescribed ICSs for COPD in general practice suggest that more detailed assessment of diagnosis and disease characteristics is likely to improve the risk–benefit ratio of maintenance therapy with ICSs in COPD patients managed in primary care.

Clinical Outcomes of Nerve Transfers in Peroneal Nerve Palsy: A Systematic Review and Meta-Analysis.

Given the unsatisfactory outcomes with traditional treatments, there is growing interest in nerve transfers to reestablish ankle dorsiflexion in peroneal nerve palsy. The objective of this work was to perform a systematic review and meta-analysis of the primary literature to assess the effectiveness of nerve transfer surgery in restoring ankle dorsiflexion in patients with peroneal nerve palsy. Methodology was registered with PROSPERO, and PRISMA guidelines were followed. MEDLINE, EMBASE, and the Cochrane Library were systematically searched. English studies investigating outcomes of nerve transfers in peroneal nerve palsy were included. Two reviewers completed screening and extraction. Methodological quality was evaluated with Newcastle-Ottawa Scale. Literature search identified 108 unique articles. Following screening, 14 full-text articles were reviewed. Four retrospective case series met inclusion criteria for meta-analysis. Overall, 41 patients underwent nerve transfer for peroneal nerve palsy. The mean age of the patients was 36.1 years, mean time to surgery was 6.3 months, and the mean follow-up period was 19.0 months. Donor nerve was either tibial (n = 36) or superficial peroneal branches/fascicles (n = 5). Recipient nerve was either deep peroneal (n = 24) or tibialis anterior branch (n = 17). Postoperative ankle dorsiflexion strength demonstrated a bimodal distribution with a mean Medical Research Council of 2.1. There were no significant differences in dorsiflexion strength between injury sites (p = 0.491), injury mechanisms (p = 0.125), donor (p = 0.066), or recipient nerves (p = 0.496). There were no significant correlations between dorsiflexion strength and patient age (p = 0.094) or time to surgery (p = 0.493). There is variability in dorsiflexion strength following nerve transfer in peroneal nerve palsy, whereby there appear to be responders and non-responders. Further studies are needed to better define appropriate patient selection and the role of nerve transfers in the management of peroneal nerve palsy.

No association between systemic complement activation and intensive care unit-acquired weakness.

The main risk factors for intensive care unit-acquired weakness (ICU-AW) are sepsis, the systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction. These risk factors are associated with systemic complement activation. We hypothesized that critically ill patients who develop ICU-AW have increased systemic complement activation compared to critically ill patients who do not develop ICU-AW. Complement activation products C3b/c, C4b/c and C5a were measured in plasma of ICU patients with mechanical ventilation for ≥48 hours. Samples were collected at admission to the ICU and for 6 consecutive days. ICU-AW was defined by a mean Medical Research Council (MRC) score <4. We compared the level of complement activation products between patients who did and who did not develop ICU-AW. Muscle strength measurements and complement assays were available in 27 ICU patients, of whom 13 patients developed ICU-AW. Increased levels of C4b/c were seen in all patients. Neither admission levels, nor maximum, minimum and mean levels of complement activation products were different between patients who did and did not develop ICU-AW. Complement activation is seen in critically ill patients, but is not different between patients who did and who did not develop ICU-AW.

Drug therapy for chronic idiopathic axonal polyneuropathy.

Chronic idiopathic axonal polyneuropathy (CIAP) is an insidiously progressive sensory or sensorimotor polyneuropathy that affects elderly people. Although severe disability or handicap does not occur, CIAP reduces quality of life. CIAP is diagnosed in 10% to 25% of people referred for evaluation of polyneuropathy. There is a need to gather and review emerging evidence on treatments, as the number of people affected is likely to increase in ageing populations. This is an update of a review first published in 2004 and previously updated in 2006, 2008, 2011 and 2013. To assess the effects of drug therapy for chronic idiopathic axonal polyneuropathy for reducing disability and ameliorating neurological symptoms and associated impairments, and to assess any adverse effects of treatment. In July 2016, we searched Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews in the Cochrane Library, MEDLINE, Embase, and the Web of Science. We searched two trials registries for ongoing trials. We also handsearched the reference lists of relevant articles, reviews and textbooks identified electronically, and we would have contacted authors and other experts in the field to identify additional studies if this seemed useful. We sought all randomised or quasi-randomised (alternate or other systematic treatment allocation) trials that examined the effects of any drug therapy in people with CIAP at least one year after the onset of treatment. People with CIAP had to fulfil the following criteria: age 40 years or older, distal sensory or sensorimotor polyneuropathy, absence of systemic or other neurological disease, chronic clinical course not reaching a nadir in less than two months, exclusion of any recognised cause of the polyneuropathy by medical history taking, clinical or laboratory investigations, and electrophysiological studies in agreement with axonal polyneuropathy, without evidence of demyelinating features. The primary outcome was the proportion of participants with a significant improvement in disability. Secondary outcomes were change in the mean disability score, change in the proportion of participants who make use of walking aids, change in the mean Medical Research Council sum score, degree of pain relief and/or reduction of other positive sensory symptoms, change in the proportion of participants with pain or other positive sensory symptoms, and frequency of adverse effects. Two review authors independently reviewed the results of the literature search and extracted details of trial methodology and outcome data of all potentially relevant trials. We identified 39 studies and assessed them for possible inclusion in the review, but we excluded all of them because of insufficient quality or lack of relevance. We summarised evidence from non-randomised studies in the Discussion. Even though CIAP has been clearly described and delineated, no adequate randomised or quasi-randomised controlled clinical treatment trials have been performed. In their absence there is no proven efficacious drug therapy.

Diagnostic accuracy of quantitative neuromuscular ultrasound for the diagnosis of intensive care unit-acquired weakness: a cross-sectional observational study

BackgroundNeuromuscular ultrasound is a noninvasive investigation, which can be easily performed at the bedside on the ICU. A reduction in muscle thickness and increase in echo intensity over time have been described in ICU patients, but the relation to ICU-acquired weakness (ICU-AW) is unknown. We hypothesized that quantitative assessment of muscle and nerve parameters with ultrasound can differentiate between patients with and without ICU-AW. The aim of this cross-sectional study was to investigate the diagnostic accuracy of neuromuscular ultrasound for diagnosing ICU-AW.MethodsNewly admitted ICU patients, mechanically ventilated for at least 48 h, were included. As soon as patients were awake and attentive, an ultrasound was made of four muscles and two nerves (index test) and ICU-AW was evaluated using muscle strength testing (reference standard; ICU-AW defined as mean Medical Research Council score <4). Diagnostic accuracy of muscle thickness, echo intensity and homogeneity (echo intensity standard deviation) as well as nerve cross-sectional area, thickness and vascularization were evaluated with the area under the curve of the receiver operating characteristic curve (ROC–AUC). We also evaluated diagnostic accuracy of z-scores of muscle thickness, echo intensity and echo intensity standard deviation.ResultsSeventy-one patients were evaluated of whom 41 had ICU-AW. Ultrasound was done at a median of 7 days after admission in patients without ICU-AW and 9 days in patients with ICU-AW. Diagnostic accuracy of all muscle and nerve parameters was low. ROC–AUC ranged from 51.3 to 68.0% for muscle parameters and from 51.0 to 66.7% for nerve parameters.ConclusionNeuromuscular ultrasound does not discriminate between patients with and without ICU-AW at the time the patient awakens and is therefore not able to reliably diagnose ICU-AW in ICU patients relatively early in the disease course.

A study of acute muscle dysfunction with particular reference to dengue myopathy.

Background:Acute myopathy is a common cause of acute motor quadriparesis which has various etiologies with different courses of illness and prognosis depending on the cause. Understanding this diversity helps us in proper approach toward diagnosis, predicting the prognosis, and possible complications and in improving the treatments that are being provided. This study was planned to study the clinical, electrophysiological, and etiological profile of patients presenting with acute myopathy. We also studied how dengue-related acute myopathy differs from other causes and also difference between myopathy due to myositis and hypokalemia in cases of dengue.Materials and Methods:This was a prospective, observational study involving all clinically suspected cases of acute myopathy of not more than 4 weeks duration with raised serum creatine kinase (CK) level. They were subjected to detailed clinical evaluation along with hematological, biochemical, microbiological, and electrophysiological studies and followed-up for outcome at 1 and 3 months. Muscle biopsy and histopathological examination were done in selected patients after taking informed consent. Statistical analysis was performed by appropriate methods using SPSS version 16.0 (Chicago, IL, USA).Results:We evaluated thirty patients of acute myopathy with raised CK level. Seventeen patients had fever, 11 had myalgia, and 5 had skin lesions. All presented with symmetric weakness, 17 (56.7%) patients having predominantly proximal weakness, neck or truncal weakness in 6 (20%), hyporeflexia in 12 (40%), with mean Medical Research Council (MRC) sum score of 46.67 ± 6.0. Eight (mean modified Barthel index [MBI] at presentation - 15 ± 3.7) patients had poor functional status according to MBI and 15 according to modified Rankin scale (MRS) (mean MRS score - 2.5 ± 1.2). Etiology was dengue viral infection in 14 patients; hypokalemia due to various causes other than dengue in 8; pyomyositis in 3; dermatomyositis, polymyositis, thyrotoxicosis, systemic lupus erythematosus, and unknown etiology in one each. Only eight patients had abnormal electrophysiology and seven among nine biopsies done were abnormal. At 1 month, 24 (80.0%) and 23 (76.7%) patients had achieved normal MBI and MRS scores with 28 (93.3) and 27 (90%) patients, respectively, at 3 months. Dengue with hypokalemia had less myalgia, more of hyporeflexia, and lower serum CK compared to those without hypokalemia.Conclusion:Dengue infection and hypokalemia due to various causes are the most common causes of acute myopathy and are associated with rapid and complete recovery within 1 month. Shorter duration of illness, higher MRC sum score, better disability status at presentation, lower serum CK correlate with better outcome. Biopsy was decisive in <20% cases; hence, it is not primary investigation in acute myopathy.

A new treatment regimen with high-dose and fractioned immunoglobulin in a special subgroup of severe and dependent CIDP patients

ABSTRACTBackground: Chronic inflammatory demyelinating polyneuropathy (CIDP) is treated with intravenous immunoglobulins (IVIg), corticosteroids or plasma exchange (PE). IVIg dosage is not universal and markers for treatment management are needed. Methods: We report the response to high-dose and fractioned IVIg in a subgroup of definite CIDP patients, resistant to corticosteroids and PE, responders to IVIg but with an efficacy window <15 d. Results: Four patients were included with similar predominantly clinical motor form and conduction abnormalities. Treatment management consisted of fractioning IVIg and increasing the monthly cumulated dose (mean: 3 g/kg/month). Serum IgG concentration was measured and correlated to the clinical state. Monitoring of serum IgG helped to guide IVIg administration dosage and frequency. A mean of 10 months was required to improve symptoms; therapy was then switched to subcutaneous (SC) route (maintenance dose: 3.5 g/kg/month). The mean Overall Neuropathy Limitations Scale was improved from 11 to 3.2 and the mean Medical Research Council scale from 26 to 90. Conclusion: It is important to distinguish patients with short IVIg efficacy window from those with classical resistance since the former may benefit from fractioning and increasing the IVIg dose. The monitoring of serum IgG level and its correlation to the clinical response could be of help in monitoring each individual's dosage.

The Super Supinator! Reliably Restoring Active Hand Opening in C5/6 Tetraplegia Using the Supinator Nerve to Posterior Interosseous Nerve Transfer

Objective/Hypothesis: Achieving satisfactory hand opening as a part of surgical reanimation for the upper limb post cervical spinal cord injury (SCI) has been an elusive goal. This study presents outcomes in 11 consecutive patients (17 limbs) who underwent supinator nerve to posterior interosseous nerve (PIN) transfers for the restoration of finger and thumb extension. Materials and Methods: Eleven patients (17 limbs) with a mean age of 25.6 years and a C5 to C7 motor complete SCI underwent supinator nerve to PIN transfers between 5 and 52 months post injury at a single center. Prior to surgery, all patients had preserved biceps and supinator function, but absent digital extension. All patients received follow-up hand therapy and underwent a final evaluation at a mean age of 19.3 months (range, 14-26) post surgery. Clinical outcome measures included manual muscle testing and measurement of first web space opening. Canadian Occupation Performance Measure (COPM) and patient satisfaction scores were recorded. Results: All 17 transfers resulted in active, voluntary finger and thumb extension. The mean Medical Research Council Grade for power in extensor digitorum communis was 3.9 and for extensor pollicis longus was 3.7. The mean first web space opening was 99.7 mm. As a consequence, patients were able to open their hand to place it around or release an object and to extend their hand in greeting. Further benefits included counteracting spasticity in the finger flexors and reducing the radial deviation of the wrist through the reanimation of extensor carpi ulnaris. At final review, all patients had functional supination even with the elbow extended. Conclusions: The supinator to PIN transfer provides a promising option for restoring finger extension in people with C5/6/7 cervical SCI and has high rates of technical success along with high patient satisfaction rate. It can be performed in combination with other tendon or nerve transfers to maximize functional reconstruction of the upper limb in tetraplegia.

Sustained benefit from intravenous immunoglobulin therapy for gastrointestinal involvement in systemic sclerosis.

IVIG is known to confer significant benefit in rheumatologic conditions, including inflammatory myopathy. This study aimed to assess the efficacy of IVIG across different aspects of internal organ involvement in refractory active SSc, particularly the gastrointestinal (GI) system. SSc patients with overlap polymyositis who remained active and unresponsive to conventional disease-modifying agents and who subsequently received IVIG were identified. GI symptoms were assessed using validated questionnaires. The Medical Research Council Sum Score for muscle strength and modified Rodnan skin score (mRSS) were assessed. Serial measurements were undertaken at baseline prior to the first IVIG treatment and post-treatment in the most recent assessment. Fifteen SSc patients were consecutively recruited into this observational study. The mean duration of IVIG treatment was 2.3 years, with treatment frequency ranging from every 6 weeks to 4 months. Compared with baseline, there was a significant reduction in gastro-oesophageal reflux frequency and intensity mean scores (P = 0.006 and P = 0.013, respectively). Significant improvement in the Gastrointestinal Tract (GIT) 2.0 score from a baseline mean score of 1.07 (s.d. 0.67) to 0.60 (0.46) (P = 0.002) was observed. There was regression in the markers of muscle disease with a reduction in the mean (s.d.) Medical Research Council sum score and the median creatine kinase level (P = 0.001 and P = 0.025, respectively). Significant amelioration of the mean basal modified Rodnan skin score from 21.5 (s.d. 13.8) to 10 (10.6) (P = 0.005) was observed. IVIG may be a helpful adjunctive therapy in the amelioration of some key clinical aspects in refractory SSc. Sustained benefit from IVIG suggests a specific immunomodulatory effect on those with established SSc GI complications.