Treatment-related Fluctuations Research Articles

Differentiating recurrent Guillain-Barre syndrome and acute-onset chronic inflammatory polyneuropathy: literature review.

Guillain-Barre syndrome (GBS) is an acute-onset immune-mediated polyneuropathy characterized by ascending symmetrical muscle weakness, diminished reflexes, and sensory symptoms. While GBS typically follows a monophasic course, some patients experience treatment-related fluctuations or recurrences, posing diagnostic challenges in distinguishing GBS from acute-onset chronic inflammatory polyneuropathy (A-CIDP). A-CIDP, may present acutely, simulating GBS, with a nadir in less than 8weeks, subsequently evolving into a chronic or relapsing course. The distinction between recurrent GBS and A-CIDP is crucial, as A-CIDP necessitates long-term immunosuppression. A PubMed search was conducted using the search terms 'recurrent Guillain Barre syndrome' and 'acute onset CIDP' focusing on studies in theEnglish language, published between January 1, 2004 and April 30, 2023. Overlapping clinical features, particularly in the early stages, complicate differentiation between recurrent GBS and CIDP. Electrophysiological studies, ultrasonography, and immunological markers have been explored for discrimination; however, definitive criteria for differentiation remain elusive. Recent follow-up studies have further blurred the boundaries between recurrent GBS and A-CIDP, suggesting the persistence of underlying immune processes even in GBS patients without clinical deterioration. This emphasizes the necessity of reevaluating diagnostic criteria and treatment strategies. In conclusion, distinguishing recurrent GBS from A-CIDP remains an ongoing challenge. Existing evidence questions the categorization of recurrent GBS as a distinct entity, challenging its very existence. Continued research is necessary to refine diagnostic criteria and deepen our understanding of these conditions, ultimately advancing patient care. This review delves into the intricacies of recurrent GBS and A-CIDP differentiation and highlights the need for a reevaluation of therecurrent GBS concept.

Case of post-dengue AIDP with treatment-related fluctuations

Cases of dengue fever have been increasing globally and so are the encounters with its rare presentations. Although known to involve central nervous system, dengue-related Guillian Barre syndrome (GBS) is a rare manifestation that has been seldom documented. A clinical challenge with early diagnosis, specific and supportive management, and active prognostication as key pillars toward effective management. We present the case of a 54-year-old man with post-dengue GBS with treatment fluctuations successfully managed at our center.

Introducing electronic monitoring of disease activity in patients with chronic inflammatory demyelinating polyneuropathy (EMDA CIDP): trial protocol of a proof of concept study

IntroductionChronic inflammatory demyelinating polyneuropathy (CIDP) is one of the most common immune neuropathies leading to severe impairments in daily life. Current treatment options include intravenous immunoglobulins (IVIG), which are administered at intervals of 4–12 weeks. Determination of individual treatment intervals is challenging since existing clinical scores lack sensitivity to objectify small, partially fluctuating deficits in patients. End-of-dose phenomena described by patients, manifested by increased fatigue and worsening of (motor) symptoms, are currently difficult to detect. From a medical and socio-economic point of view, it is necessary to identify and validate new, more sensitive outcome measures for accurate mapping of disease progression and, thus, for interval finding. Digital health technologies such as wearables may be particularly useful for this purpose, as they record real-life data and consequently, in contrast to classic clinical 'snapshots’, can continuously depict the disease course.MethodsIn this prospective, observational, non-interventional, single-center, investigator-initiated study, CIDP patients treated with IVIG will be continuously monitored over a period of 6 months. Clinical scores and blood analyses will be assessed and collected during three visits (V1, V2, V3). Additionally, activity, sleep, and cardiac parameters will be recorded over the entire period using a wearable device. Further, patients' subjective disease development and quality of life will be recorded at various visits (read-outs). The usability of the smartwatch will be assessed at the end of the study.PerspectiveThe study aims to evaluate different digital measurements obtained with the smartwatch and blood-based analyses for monitoring disease activity and progress in CIDP patients. In conjunction, both means of monitoring might offer detailed insights into behavioral and biological patterns associated with treatment-related fluctuations such as end-of-dose phenomena.Trial registrationThe study protocol was registered at ClinicalTrials.gov. Identifier: NCT05723848. Initially, the protocol was submitted prospectively on January 10, 2023. The trial was publicly released after formal improvements on February 13, 2023, after first patients were included according to the original protocol.

Serum neurofilament light chain does not detect self-reported treatment-related fluctuations in chronic inflammatory demyelinating polyneuropathy.

Serum neurofilament light chain (sNfL) is a marker for axonal degeneration. Patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) often report a fluctuation of symptoms throughout one treatment cycle with intravenous immunoglobulins (IVIG). The aim of this study was to determine whether sNfL is suitable to quantify patient-reported symptom fluctuations. Twenty-nine patients with the diagnosis of CIDP or a CIDP-variant under treatment with IVIG were recruited in this study and underwent examination before IVIG infusion, in the middle of the treatment interval, and before their next IVIG infusion. Patients were surveyed regarding symptom fluctuations at the last visit and divided into two groups: those with and without fluctuations of symptoms. At the first visit, sociodemographic and disease-specific data were collected. Clinical scores were assessed at every examination. sNfL values were compared between both groups at the different time points after conversion into Z-scores-adjusted for age and body mass index. Patients with CIDP show elevated sNfL Z-scores (median at baseline: 2.14, IQR: 1.0). There was no significant change in sNfL Z-scores or questionnaire scores within the treatment cycle in either group. There was no significant difference in sNfL levels between the patients with and without symptom fluctuations. CIDP patients show elevated sNfL levels. However, sNfL is not suitable to reflect patient-reported fluctuations of symptoms. This indicates that symptom fluctuations during treatment with IVIG in patients with CIDP are not caused by a neuroaxonal injury. Furthermore, repeated sNfL measurements within one treatment cycle with IVIG seem to have no benefit for symptom monitoring.

Clinical features and maternal and fetal outcomes in women with Guillain-Barré syndrome in pregnancy.

Guillain-Barre syndrome (GBS) is an acute inflammatory polyradiculoneuropathy rarely observed during pregnancy. In this retrospective study, we analyzed the characteristics of pregnant women with GBS (pGBS) diagnosed in French University Hospitals in the 2002-2022 period and compared them with a reference group of same-age non-pregnant women with GBS (npGBS) identified in the same institutions & timeframe. We identified 16 pGBS cases. Median age was 31years (28-36), and GBS developed in the 1st, 2nd, and 3rd trimester in 31%, 31% and 38% of cases respectively. A previous infection was identified in six cases (37%), GBS was demyelinating in nine cases (56%), and four patients (25%) needed respiratory assistance. Fifteen patients (94%) were treated with intravenous immunoglobulins, and neurological recovery was complete in all cases (100%). Unscheduled caesarean section was needed in five cases (31%), and two fetuses (12.5%) died because of cytomegalovirus (CMV) infection (1 case) and HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome (1 case). In comparison with a reference group of 18 npGBS women with a median age of 30years (27-33), pGBS patients more frequently had CMV infection (31% vs 11%), had a prolonged delay between GBS onset and hospital admission (delay > 7days: 57% vs 12%), more often needed ICU admission (56% vs 33%) and respiratory assistance (25% vs 11%), and more often presented with treatment-related fluctuations (37% vs 0%). This study shows GBS during pregnancy is a severe maternal condition with significant fetal mortality.

Can neurophysiology and nerve ultrasound differentiate acute-onset CIDP from GBS with treatment-related fluctuations?

Distinguishing acute-onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) from Guillain- Barré syndrome (GBS) with treatment-related fluctuations (TRF) in the early phase of disease can be challenging. Although characteristic clinical features have been previously reported, there is limited data on neurophysiological features. We aim to identify the electrophysiological and ultrasonographic features that might help differentiate between these two conditions. Patients with GBS-TRF and A-CIDP were identified from an existing cohort of GBS patients presenting to University of Malaya Medical Centre, Kuala Lumpur, Malaysia from 2011 to 2020. The clinical, electrophysiological and nerve ultrasound data were recorded and analysed. Five GBS-TRF (mean age 42 ± 23 years) and five A-CIDP (mean age 66 ± 13 years) patients were included. The mean time to first neurological deterioration was longer in A-CIDP compared to GBS-TRF (11 ± 5 vs 5 ± 1 weeks, p=0.028). Based on two sets of nerve conduction studies (NCS), both GBS-TRF and A-CIDP patients fulfilled the electrodiagnostic criteria for demyelinating neuropathy. A-CIDP patients had more prolonged ulnar minimal F-wave latencies (40.8 ± 5.8 vs 28.6 ± 2.2 ms, p=0.020) and slower sural conduction velocities (26.3 ± 8.6 vs 41.4 ± 3.4 m/s, p=0.015) on NCS. Nerve ultrasound showed significantly larger cross- sectional area of ulnar nerve at the wrist (7 ± 2 vs 5 ± 1 mm2, p=0.037) and forearm (8 ± 1 vs 5 ± 1 mm2, p=0.025) in A-CIDP patients. The Ultrasound Pattern Sum Score-A was significantly higher in A-CIDP compared to GBS-TRF (10 ± 3 vs 5 ± 1, p=0.015). We found nerve electrophysiological and ultrasonographic features can be useful in differentiating between GBS-TRF and A-CIDP.

Serum C3 complement levels predict prognosis and monitor disease activity in Guillain-Barré syndrome

ObjectiveBiomarkers are needed to predict prognosis and disease activity in patients with Guillain-Barré syndrome (GBS). The complement system is a key player in the pathogenesis of GBS. This study aimed to assess the potential utility of serum complement proteins as novel biomarkers in GBS. MethodsWe reviewed the medical records of 76 GBS patients with C3 and C4 measurements during hospitalization between 2010 and 2021. Clinical outcomes were correlated with baseline serum C3, C4, and seven additional predictors: four existing biomarkers (GM1, albumin, immunoglobulin G, neutrophil-lymphocyte ratio) and three clinical factors from the modified Erasmus GBS outcome score model. Five complement activation products (C3a, C4a, C5a, soluble C5b-9, factor Bb) were measured in 35 patients and were compared with C3 and C4 levels. Longitudinal changes in C3 and C4 levels were compared with the disease course in 12 patients. ResultsHigher C3, but not C4, was associated with poorer outcomes: lower Medical Research Council sum scores (MRCSS), higher GBS disability score (GBSDS), longer hospitalization, and more frequent treatment-related fluctuations. Age, MRCSS at admission, and baseline serum C3 were significant independent indicators of 1- and 3-month GBSDS. We found that C3 was positively correlated with C3a (r = 0.32) and C5a (r = 0.37), which indicates an activated complement cascade with high C3. Longitudinal change of C3 coincided with clinical severity of the disease course. InterpretationThis study highlights the use of serum C3 as a novel mechanistic biomarker in GBS. Larger prospective studies are needed to validate our findings.

A Rare Case of Guillain–Barré Syndrome with Signs of Meningeal Irritation and Treatment-Related Fluctuations/Relapse

Abstract Guillain–Barré Syndrome is an acute inflammatory demyelinating polyradiculoneuropathy that can present at any age. The presentation of Guillain–Barré syndrome may be variable as the classic symptoms of areflexia and flaccid paralysis may or may not be present. Here we reported a case of a 15-year-old male patient who presented with complaints of weakness in bilateral lower limbs with inability to sit along with slurred speech and drooling of saliva with positive meningeal signs like neck stiffness and Kernig's sign. His symptoms improved with immunoglobulin therapy. Five days later, the child again had pain and increased weakness with increased work of breathing for which repeat dose and course of immunoglobulins were given. As patients with signs of meningeal irritation may suggest other diseases such as meningitis, it is important to consider atypical cases of Guillain–Barré syndrome along with treatment-related fluctuations as observed in our patient.

COVID-19 vaccine-related Guillain-Barré syndrome in the Liguria region of Italy: A multicenter case series

Background and purposeGuillain-Barré-Syndrome (GBS) can follow COVID-19 vaccination, with clinical and paraclinical features still to be precisely assessed. We describe a cohort of patients who developed GBS after vaccination with different types of COVID-19 vaccines. MethodsPatients with post-COVID-19 vaccination GBS, admitted to the six hospitals that cover the whole Liguria Region, Northwestern Italy, from February 1st to October 30th 2021, were included. Clinical, demographic, and paraclinical data were retrospectively collected. ResultsAmong the 13 patients with post-COVID-19 vaccination GBS (9 males; mean age, 64 year), 5 were vaccinated with Oxford-AstraZeneca, 7 with Pfizer-BioNTech, and one with Moderna. Mean time between vaccination and GBS onset was 11.5 days. Ten patients developed GBS after the first vaccination dose, 3 after the second dose. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) was the predominant GBS variant, mainly characterized by sensory involvement. Bilateral seventh cranial nerve involvement followed AstraZeneca vaccination in two cases. Three patients presented treatment-related fluctuations, and 4 mild symptoms that delayed treatments and negatively affected prognosis. Prognosis was poor (GBS-disability score, ≥3) in 5/13 patients, with a disability rate of 3/13. ConclusionsOur findings confirm that most post-COVID-19 vaccination GBS belong to the AIDP subtype, and occur after the first vaccine dose. Treatment-related fluctuations, and diagnosis-delaying, mild symptoms at onset are clinical features that affect prognosis and deserve particular consideration.

Closing the loop for patients with Parkinson disease: where are we?

Although levodopa remains the most efficacious symptomatic therapy for Parkinson disease (PD), management of levodopa treatment during the advanced stages of the disease is extremely challenging. This difficulty is a result of levodopa's short half-life, a progressive narrowing of the therapeutic window, and major inter-patient and intra-patient variations in the dose-response relationship. Therefore, a suitable alternative to repeated oral administration of levodopa is being sought. Recent research efforts have focused on the development of novel levodopa delivery strategies and wearable physical sensors that track symptoms and disease progression. However, the need for methods to monitor the levels of levodopa present in the body in real time has been overlooked. Advances in chemical sensor technology mean that the development of wearable and mobile biosensors for continuous or frequent levodopa measurements is now possible. Such levodopa monitoring could help to deliver personalized and timely medication dosing to alleviate treatment-related fluctuations in the symptoms of PD. Therefore, with the aim of optimizing therapeutic management of PD and improving the quality of life of patients, we share our vision of a future closed-loop autonomous wearable 'sense-and-act' system. This system consists of a network of physical and chemical sensors coupled with a levodopa delivery device and is guided by effective big data fusion algorithms and machine learning methods.

Acute-onset chronic inflammatory demyelinating polyneuropathy complicating SARS-CoV-2 infection and Ad26.COV2.S vaccination: report of two cases

BackgroundThe spectrum of reported neurological sequelae associated with SARS-CoV-2 is continuously expanding, immune mediated neuropathies like Guillain–Barre syndrome (GBS) and exacerbations of preexisting chronic inflammatory demyelinating polyneuropathy (CIDP) being among them. However, respective cases of acute onset CIDP (A-CIDP) are rare.Case presentationWe hereby report two cases of A-CIDP after COVID-19 infection and Ad26.COV2.S vaccination that presented with flaccid paraparesis and acroparesthesias (Case presentation 1; female, 52) and facial diplegia accompanied by acroparesthesias (Case presentation 2; male, 62), respectively. In both instances clinical, neurophysiological and CSF findings were indicative of acute inflammatory demyelinating polyneuropathy, thus both patients were initially treated with intravenous immunoglobulins resulting in clinical improvement. Nevertheless, the first patient relapsed 5 weeks after the initial episode, thus was diagnosed with GBS with treatment related fluctuations (GBS-TRF) and treated successfully with seven plasma exchange (PLEX) sessions. However, 11 weeks from symptom onset she relapsed again. Taking into account that the second relapse occurred more than 8 weeks after the first episode, the potential diagnosis of A-CIDP was reached and oral dexamethasone 40 mg/d for 4 consecutive days every 4 weeks was administered. With regards to the second patient, he relapsed > 8 weeks after the initial episode, thus was also diagnosed with A-CIDP and treated with 7 PLEX sessions followed by similar to the aforementioned corticosteroid therapy. On 2 month follow-up both patients exhibited remarkable clinical improvement.ConclusionsClose surveillance of patients presenting with immune neuropathies in the context of SARS-CoV-2 infection or immunization is crucial for timely implementation of appropriate treatment. Prompt A-CIDP distinction from GBS-TRF is of paramount importance as treatment approach and prognosis between these two entities differ.

Abnormal sweating and “skin flushing” as possible predictive factor for treatment related fluctuations in Guillain-Barré syndrome: a case series and a review of the literature

Treatment related fluctuations (TRFs) in Guillain-Barré Syndrome (GBS) are described as one or more episodes of deterioration manifesting within two months after disease onset and following an initial improvement or stabilisation after treatment. They may be encountered in 8% to 16% of patients, but currently predictive factors of TRF occurrence and severity are poorly known. To this end, we evaluated the frequency and clinical features of TRFs in a cohort of GBS patients admitted to the Neurological unit of Sant'Andrea Hospital (La Spezia, Italy) from January 1st, 2003 to December 31st, 2017.Among the 98 GBS collected patients, five (5.1%) developed a TRF during disease course. Consistently with the literature, the majority of our GBS patients who developed a TRF did not report a preceding diarrhoea, had a predominant proximal weakness and all of them had sensory disturbances at the clinical onset. Interestingly, 80% of our TRF patients manifested since GBS onset an autonomic dysfunction with abnormal sweating and a peculiar ‘skin flushing’ in face, neck and chest. Two patients developed respiratory insufficiency at the TRF time, and they both died.We would advise to pay attention to GBS patients with particular ‘skin flushing’ in face, neck and chest and abnormal sweating, because these findings could be a red flag for TRF.

O-NE004. Distinguishing GBS with treatment-related fluctuations from acute-onset CIDP: A neurophysiological and ultrasonographic perspective

Introduction . Distinguishing Guillain-Barré syndrome (GBS) with treatment-related fluctuations (TRF) from acute-onset chronic inflammatory demyelinating polyneuropathy (A- CIDP) in the early phase can be challenging. Distinguishing features in clinical aspect have been reported previously. We aim to identify the neurophysiological and ultrasonographic features that might differentiate between patients with GBS-TRF and A-CIDP. Methods . Patients with GBS-TRF and A-CIDP were identified from an existing cohort of GBS patients presenting to University Malaya Medical Centre, Kuala Lumpur, Malaysia from 2011 to 2019. The clinical, neurophysiological and nerve ultrasound data were recorded and analysed. Results . Five GBS-TRF (mean age 42 ± 23 years old) and five A-CIDP (mean age 66 ± 13 years old) patients were included. The mean time to first neurological deterioration was significantly longer in the A-CIDP patients compared to GBS-TRF (11 vs 5 weeks; p = 0.028). Based on two sets of nerve conduction studies (NCS), both GBS-TRF and A-CIDP patients fulfilled the electrodiagnostic criteria for demyelination. At first study, A-CIDP patients had significantly prolonged ulnar minimal F-wave latencies (40.7 vs 28.6 ms; p = 0.020) and slower tibial nerve motor conduction velocities (32.1 vs 38.0 m/s; p = 0.050) when compared to GBS-TRF. The sural nerve conduction velocities were slower in A-CIDP compared to GBS-TRF during the second study (26.3 vs 41.4 m/s; p = 0.015). The sural potentials were also more likely to be unrecordable in A-CIDP patients in the second study. On nerve ultrasound, A-CIDP patients had significantly larger cross-sectional area of the ulnar nerve at the wrist (7 vs 5 mm 2 ; p = 0.039), forearm (8 vs 5 mm 2 ; p = 0.025), below elbow (9 vs 6 mm 2 ; p = 0.031) and above elbow (9 vs 7 mm 2 ; p = 0.037) compared to GBS-TRF patients. Conclusion . Other than distinguishing clinical features, we found that there were neurophysiological and ultrasonographic features that can be useful in differentiating between GBS-TRF and A-CIDP.

Managing Advanced Parkinson Disease.

Advanced Parkinson disease (PD) is associated with treatment-related motor fluctuations and reduced ability to perform activities of daily living. Progression of non-motor symptoms and medication-induced adverse effects complicate focused approach to motor symptom management, frequently accelerating reduced quality of life. It is thus critical for clinicians to consider disease progression versus therapeutic contributions when balancing management decisions. Such an approach requires careful recognition of inflection points resulting from therapeutic decisions and should prompt consideration of reduced pharmacologic burden and increased reliance on non-pharmacologic strategies in advanced disease. The successful approach to advanced PD requires a multidisciplinary effort focused on improving the patient's and family's quality of life, sometimes requiring sacrifice of motor symptom benefit. Here, we emphasize management strategies in advanced PD, focusing on the need to balance the therapeutic approach across advancing motor symptoms, progressive non-motor features, and potential pharmacologic adverse effects.

Quantifying Treatment-Related Fluctuations in CIDP: Results of the GRIPPER Study.

The objective of this study was to explore the extent of IV immunoglobulin (IVIG) treatment-related fluctuations (TRFs) by using home collection of daily grip strength in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and to use that information to develop evidence-based treatment optimization strategies. This prospective observational study included 25 patients with well-defined CIDP. Participants recorded grip strength daily for 6 months. Disability and gait metrics were collected weekly. Serum immunoglobulin G levels were obtained at peak, trough, and midcycle IVIG intervals. Day-to-day grip strength changes <10% were considered random. To identify patients with TRFs, 3-day averaged grip strength was calculated on each consecutive day after an IVIG infusion. TRFs were defined as ≥10% 3-day averaged grip strength difference compared to the pre-IVIG baseline. Participants successfully recorded grip strength on all but 9% of recordable days. Twelve patients (48%) were classified as low/no fluctuaters and 13 (52%) as frequent fluctuaters. In the frequent fluctuating group, grip strength improved over 1 week and thereafter was relatively stable until the third week after infusion. Grip strength was significantly correlated with measures of disability. Grip strength collection by patients at home is reliable, valid, and feasible. A change in grip strength by ≥10% is a useful, practical, and evidence-based approach that may be used to identify clinically meaningful TRFs. From these data, we propose a treatment optimization strategy for patients with CIDP on chronic IVIG that may be applied to routine clinic care during both face-to-face and virtual video or telephone patient encounters. ClinicalTrials.gov Identifier: NCT02414490.

Guillain-Barré syndrome: clinical features, treatment choices and outcomes in an Australian cohort.

Guillain-Barré syndrome (GBS) causes acute neuromuscular weakness. Severe cases are life-threatening and many are left disabled. Intravenous immunoglobulin (IVIg) and plasma exchange (PE), along with supportive care, are the mainstays of treatment. Treatment choice is influenced by multiple factors. The clinico-epidemiological features of GBS in Australia have not been reviewed in 30 years and few studies have assessed contemporary treatment choices. To investigate the clinico-epidemiological features, choice of treatment, clinical course and outcomes of GBS patients in an Australian tertiary metropolitan hospital. A retrospective observational study was performed of GBS presentations to a tertiary hospital in Sydney, Australia, over 5 years. Clinico-epidemiological features, treatment choices, clinical course and outcomes were assessed. We reviewed 46 GBS patients (54% male), average age 55 years. Antecedent infection was identified in 61%. Twenty-eight per cent had preceding immunogenic events or conditions. Acute inflammatory demyelinating polyradiculoneuropathy was the most common subtype (78%). Cerebrospinal fluid albumino-cytologic dissociation was present in 43%. Electrodiagnostic testing most frequently demonstrated demyelination (64%). Ninety-eight per cent received immunotherapy, mostly IVIg (93%). Twenty-two per cent received further treatment due to treatment-related fluctuations or lack of improvement. Thirteen per cent required ICU admission and 46% needed rehabilitation. There were no deaths or need for mechanical ventilation. Seventy-one per cent of the follow-up cohort had residual disability at 6 months, but this was generally mild. The clinico-epidemiological features are consistent with previous cohorts. Our experience in a large Australian tertiary centre demonstrates a clear preference for IVIg over PE.

Are The ACSM Exercise Guidelines Safe And Achievable For Women Receiving Chemotherapy For Ovarian Cancer?

PURPOSE: ECHO is a phase III, randomised, controlled trial (ACTRN12614001311640) evaluating the effect of exercise during first-line chemotherapy for women with ovarian cancer on progression-free survival (target sample, n=500). We report here preliminary findings on exercise safety and dose undertaken for the consenting women randomised to the exercise intervention. METHODS: Exercise-related adverse events (EAEs) were classified as grades 1-5 according to CTC-AE, and were assessed for exercise causality (not related, unlikely, possible, likely, certain) and whether modification to exercise prescription was required. Weekly exercise dose undertaken was recorded as minutes, intensity, mode and frequency. Data were collected by an Exercise Physiologist during weekly contact with participants over the intervention duration (duration is based on length of neo- and/or adjuvant chemotherapy; ~18 weeks). Exercise was considered safe if there were no grade 3 or higher EAEs, and in line with the new ACSM guidelines, the intervention was considered feasible for a participant if they completed ≥150 minutes of weekly, mixed-mode exercise ≥75% of intervention weeks. RESULTS: To date, we have recruited 225 women, 113 of whom have been randomised to the exercise intervention. One or more EAEs was reported by 42% of participants in the exercise intervention. Typical grade 1 (85% of EAEs reported) and 2 EAEs included delayed onset muscle soreness or adverse fluctuations in treatment-related symptoms (e.g., pain at surgical site, fatigue) that may have been caused by exercise. While no grade 3 or higher EAEs were reported, 58% required exercise intervention modification (i.e., change in minutes, intensity, mode or frequency). The median weekly minutes of exercise reported was 186.5 (range: 0-610), yet only 34% of participants completed ≥150min/week of mixed-mode exercise for ≥75% of the intervention duration. CONCLUSION: Exercise is proving safe during chemotherapy for ovarian cancer. Further, while an average of 150 minutes of mixed-mode exercise each week is feasible, flexibility in prescription is needed to accommodate individual circumstances (such as EAEs or typical treatment-related fluctuations in side effects) that inevitably present throughout the course of chemotherapy for ovarian cancer.

Diagnosis of Guillain-Barré syndrome and validation of the Brighton criteria in Malaysia.

We aimed to evaluate the key diagnostic features of Guillain-Barré syndrome (GBS) in Malaysian patients and validate the Brighton criteria. This was a retrospective study of patients presenting with GBS and Miller Fisher syndrome (MFS) between 2010 and 2019. The sensitivity of the Brighton criteria was evaluated. A total of 128 patients (95 GBS, 33 MFS) were included. In the GBS cohort, 92 (97%) patients presented with symmetrical limb weakness. Reflexes were depressed or absent in 90 (95%) patients. Almost all patients (94, 99%) followed a monophasic disease course, with 5 (5%) patients experiencing treatment-related fluctuations. Cerebrospinal fluid (CSF) albuminocytological dissociation was seen in 62/84 (73%) patients. Nerve conduction study (NCS) revealed neuropathy in 90/94 (96%) patients. In GBS patients with complete dataset (84), 56 (67%) patients reached level 1 of the Brighton criteria, 21 (25%) reached level 2, 3 (4%) reached level 3, and 4 (5%) reached level 4. In MFS, the clinical triad was present in 25 (76%) patients. All patients had a monophasic course. CSF albuminocytological dissociation was present in 10/25 (40%) patients. NCS was normal or showed sensory neuropathy in 25/33 (76%) patients. In MFS patients with complete dataset (25), 5 (20%) patients reached level 1 of the Brighton criteria, 14 (56%) reached level 2, 2 (8%) reached level 3, and 4 (16%) reached level 4. Inclusion of antiganglioside antibodies improved the sensitivity of the Brighton criteria in both cohorts. In the Malaysian cohort, the Brighton criteria showed a moderate to high sensitivity in reaching the highest diagnostic certainty of GBS, but the sensitivity was lower in MFS.

Predictive factors of Treatment-related fluctuations in patients with Guillain-Barre syndrome (2373)

Predictive factors of Treatment-related fluctuations in patients with Guillain-Barre syndrome (2373)

Current treatment practice of Guillain-Barré syndrome.

To define the current treatment practice of Guillain-Barré syndrome (GBS). The study was based on prospective observational data from the first 1,300 patients included in the International GBS Outcome Study. We described the treatment practice of GBS in general, and for (1) severe forms (unable to walk independently), (2) no recovery after initial treatment, (3) treatment-related fluctuations, (4) mild forms (able to walk independently), and (5) variant forms including Miller Fisher syndrome, taking patient characteristics and hospital type into account. We excluded 88 (7%) patients because of missing data, protocol violation, or alternative diagnosis. Patients from Bangladesh (n = 189, 15%) were described separately because 83% were not treated. IV immunoglobulin (IVIg), plasma exchange (PE), or other immunotherapy was provided in 941 (92%) of the remaining 1,023 patients, including patients with severe GBS (724/743, 97%), mild GBS (126/168, 75%), Miller Fisher syndrome (53/70, 76%), and other variants (33/40, 83%). Of 235 (32%) patients who did not improve after their initial treatment, 82 (35%) received a second immune modulatory treatment. A treatment-related fluctuation was observed in 53 (5%) of 1,023 patients, of whom 36 (68%) were re-treated with IVIg or PE. In current practice, patients with mild and variant forms of GBS, or with treatment-related fluctuations and treatment failures, are frequently treated, even in absence of trial data to support this choice. The variability in treatment practice can be explained in part by the lack of evidence and guidelines for effective treatment in these situations.