Outcome of Guillain-Barre syndrome patients with respiratory paralysis

Outcome of Guillain-Barré syndrome with bulbar palsy

BACKGROUND

Elective intubation is advocated in Guillain-Barré syndrome (GBS) with bulbar palsy to prevent aspiration pneumonia and lung collapse. We evaluate the outcome of GBS patients with bulbar palsy, and also compare the risks and benefits of intubation and MV in them.

METHODS

187 GBS patients with bulbar palsy from a cohort of 547 GBS registry were analyzed. Detailed clinical records and peak disability on a 0-6 GBS Disability Scale (GBSDS) were noted. The patients were intubated if arterial blood gas (ABG) analysis revealed hypoxia, hypercarbia or acidosis. The patients with normal ABG parameters were fed by nasogastric tube, and nursed in lateral position. Occurrence of pneumonia, in-hospital death and outcomes at 6-months were classified as complete (GBSDS <2), partial (GBSDS 2-3) and poor (GBSDS >3).

RESULTS

76/187(40.6%) patients required MV, and they had a shorter duration of illness (p = 0.007), higher peak disability (p < 0.001), autonomic dysfunction (p < 0.001) and more frequently received IVIg (p = 0.02). Pneumonia (63% vs 10.8%; p < 0.001) and in-hospital deaths (7.9% vs 1.8%; p = 0.06) were more frequent in MV group compared to nasogastric fed group. At 6-months,104 (55.6%) patients recovered completely. On multivariate analysis, the independent predictors of poor outcome were peak disability [Adjusted Odds Ratio (AOR) 9.84, 95% Confidence Interval (CI) 3.15-30.74, p < 0.0001], day of hospitalization from disease onset (AOR 1.09, 95% Cl 1.01-1.01; p=0.009) and requirement of MV (AOR 0.10; 95% 0.02-0.50; p = 0.005).

CONCLUSION

GBS patients with bulbar palsy may be managed by nasogastric feeding and nursing in lateral position without increasing the risk of pneumonia. Mechanical ventilation based on ABG does not worsen outcomes of GBS with bulbar palsy.

Prediction of mechanical ventilation in Guillain-Barré syndrome at admission: Construction of a nomogram and comparison with the EGRIS model

Background

Respiratory failure requiring mechanical ventilation (MV) is a common and severe complication of Guillain-Barré syndrome (GBS) with a reported incidence ranging from 20 % to 30 %. Thus, we aim to develop a nomogram to evaluate the risk of MV in patients with GBS at admission and tailor individualized care and treatment.

Methods

A total of 633 patients with GBS (434 in the training set, and 199 in the validation set) admitted to the First Hospital of Jilin University, Changchun, China from January 2010 to January 2021 were retrospectively enrolled. Subjects (n = 71) from the same institution from January 2021 to May 2022 were prospectively collected and allocated to the testing set. Multivariable logistic regression analysis was applied to build a predictive model incorporating the optimal features selected in the least absolute shrinkage and selection operator (LASSO) in the training set. The predictive model was validated using internal bootstrap resampling, an external validation set, and a prospective testing set, and the model's performance was assessed by using the concordance index (C-index), calibration curves, and decision curve analysis (DCA). Finally, we established a multivariable logistic model by using variables of the Erasmus GBS Respiratory Insufficiency Score (EGRIS) and did the same analysis to compare the performance of our predictive model with the EGRIS model.

Results

Variables in the final model selected by LASSO included time from onset to admission, facial and/or bulbar weakness, Medical Research Council sum score at admission, neutrophil-to-lymphocyte ratio, and platelet-lymphocyte ratio. The model presented as a nomogram displaying favorable discriminative ability with a C-index of 0.914 in the training set, 0.903 in the internal validation set, 0.953 in the external validation set, and 0.929 in the testing set. The model was well-calibrated and clinically useful as assessed by the calibration curve and DCA. As compared with the EGRIS model, our predictive model displayed satisfactory performance.

Conclusions

We constructed a nomogram for early prediction of the risk of MV in patients with GBS. This model had satisfactory performance and appeared more efficient than the EGRIS model in Chinese patients with GBS.

Enhancing Tone and Strength in a Patient With Autoimmune Encephalitis and Guillain-Barré Syndrome Using Rood's Facilitatory Techniques and Neuromuscular Electrical Stimulation: A Case Report

This case report documents the comprehensive management of a 21-year-old female resident of Gadchiroli presenting with a 10-day history of fever, altered consciousness, and neurological sequelae following a traumatic incident. The patient exhibited a Glasgow Coma Scale score of 6/15, hypotonia in both upper and lower limbs, diminished deep tendon reflexes, and respiratory complications. This case study describes a thorough physiotherapeutic strategy that focuses on tone facilitation and muscle weakness improvement. The intervention used Rood's facilitative approaches as well as neuromuscular electrical stimulation (NMES). Rood's treatments, which emphasized mobilizing touch and tactile stimulation, brushing, quick icing, quick stretching, tapping, massaging the skin, heavy joint compression, and rolling, were used deliberately to move the patient from flaccidity to better muscle tone. These techniques' repetitive and task-specific nature coincided with motor learning principles, enabling adaptive modifications in brain networks. Concurrently, NMES was used to improve muscle activation, create a controlled environment for neurorehabilitation, and promote strength increases. The successful integration of various modalities highlights the possibility of favorable neuronal adaptations and functional improvements in individuals suffering from complicated neuromuscular disorders. This case demonstrates the need for individualized and diversified physiotherapeutic techniques in improving rehabilitation outcomes.

Guidelines for Neuroprognostication in Adults with Guillain-Barré Syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) often carries a favorable prognosis. Of adult patients with GBS, 10-30% require mechanical ventilation during the acute phase of the disease. After the acute phase, the focus shifts to restoration of motor strength, ambulation, and neurological function, with variable speed and degree of recovery. The objective of these guidelines is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling adult patients with GBS and/or their surrogates.

METHODS

A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and presence of appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Time frame/Setting (PICOTS) question was framed as follows: "When counseling patients or surrogates of critically ill patients with Guillain-Barré syndrome, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of [outcome, with time frame of assessment]?" Additional full-text screening criteria were used to exclude small and lower quality studies. Following construction of an evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format.

RESULTS

Eight candidate clinical variables and six prediction models were selected. A total of 45 articles met our eligibility criteria to guide recommendations. We recommend bulbar weakness (the degree of motor weakness at disease nadir) and the Erasmus GBS Respiratory Insufficiency Score as moderately reliable for prediction of the need for mechanical ventilation. The Erasmus GBS Outcome Score (EGOS) and modified EGOS were identified as moderately reliable predictors of independent ambulation at 3 months and beyond. Good practice recommendations include consideration of both acute and recovery phases of the disease during prognostication, discussion of the possible need for mechanical ventilation and enteral nutrition during counseling, and consideration of the complete clinical condition as opposed to a single variable during prognostication.

CONCLUSIONS

These guidelines provide recommendations on the reliability of predictors of the need for mechanical ventilation, poor functional outcome, and independent ambulation following GBS in the context of counseling patients and/or surrogates and suggest broad principles of neuroprognostication. Few predictors were considered moderately reliable based on the available body of evidence, and higher quality data are needed.

Predictors of discharge to home/community following inpatient-rehabilitation in a US national sample of Guillain-Barre-Syndrome patients

BACKGROUND

Guillain-Barre-Syndrome (GBS), an autoimmune polyneuropathy causing acute flaccid paralysis, is a rare condition with1-2 cases per 100,000 annually (approximately 5000 cases/year) in the United States (US). There is a paucity of published data regarding patient outcomes in association with discharge destinations following inpatient-rehabilitation (IR) in this patient population, thus this study.

OBJECTIVES

To analyze IR efficacy, and possible predictors of discharge to home/community in a US-national-sample of GBS patients.

METHODS

Retrospective-observational-cohort study of 1304 GBS patients admitted to IR comparing discharge disposition destinations (community/home, skilled-nursing-facility [SNF], or return to acute-care) by demographic (age, gender) and clinical variables (length-of-stay [LOS], case-mix-index [CMI], and Functional-Independence-Measure [FIM] score changes). Multinomial-logistic-regression and discriminant-function-analysis were performed to determine model fit in predicting discharge destination.

RESULTS

81.8% were discharged to home/community- average LOS 19-days, total-FIM-gain 43.2; 9.8% discharged to SNFs- average LOS 27.5-days, total-FIM-gain 27.2; and 8.4% discharged to acute-care- average LOS 15.4-days and total-FIM-gain 16.5, (F = 176, p < .001). Stepwise-linear-regression for prediction of community discharge showed change in FIM-Bed/chair/wheelchair-Transfers was the most significant predictor (Wald = 42.2; p < .001), followed by CMI (Wald = 26.9; p < .001), change in FIM-walking/wheelchair (Wald = 14.9; p < .001), and age (Wald = 9.5; p < .002). Using discriminant-function-analysis to test model validity for predicting discharge disposition, FIM-change for Bed/chair/wheelchair Transfers, Walking, and Self-Care as predictors resulted in a classification rate of 78.1%, 92% of variance explained, and Eigenvalue of .53 (p < .001).

CONCLUSIONS

Total-FIM scores improved in all groups, and most patients were discharged to home/community suggesting IR efficacy. The ability to transfer bed/chair/wheelchair was the most important predictive factor associated with discharge destination.

Manual therapeutic plasma exchange for treatment of a dog with suspected acute canine polyradiculoneuritis

BACKGROUND

Acute canine polyradiculoneuritis is one of the most common polyneuropathies occurring in dogs. The disease is very similar to the Guillain-Barré syndrome in humans. In veterinary medicine, there is no established treatment for this disease, while in human medicine, therapeutic plasma exchange and intravenous immunoglobulin administration are two main immunotherapy treatments of this syndrome.

CASE PRESENTATION

A 12-year-old male Jack Russel Terrier was presented with a history of acute weakness of the pelvic limbs progressing to flaccid tetraplegia with respiratory compromise. Complete diagnostic workup was performed including blood work, diagnostic imaging (radiographs of the thorax as well as ultrasound of the abdomen) and echocardiography. Based on the clinical course, neurological localisation and the results of electrodiagnostic examination acute canine polyradiculoneuritis was suspected. During the hospitalization, the dog deteriorated and was admitted to the intensive care unit for respiratory support via tracheostomy tube. In addition to symptomatic treatment, immunotherapy via single treatment of manual therapeutic plasma exchange was administered. This procedure was safe, and the dog showed improvement of clinical signs 3 days after therapy was initiated, as well as improvement of neurological signs (from grade 4 tetraplegia to grade 3) within 5 days. However, the dog was euthanized 3 weeks later due to complications related to the tracheostomy.

CONCLUSIONS

This is the first case report of a manual therapeutic plasma exchange in a dog with suspected acute canine polyradiculoneuritis suggesting that this method is safe and well tolerated in dogs with this disease. It may be a reasonable adjunctive treatment to supportive therapy in severe cases.

Identification of factors affecting outcomes in patients with Guillain Barre syndrome

Background

Guillain Barre syndrome (GBS) is a rare autoimmune neurological disorder resulting in variable clinical course and outcome. Various factors such as age, symptoms and disease form that influence the outcome of GBS have been previously studied.

Aim

This study aimed at identifying factors affecting the outcomes in patients with GBS.

Methods

A retrospective observational study was conducted on GBS (ICD-G61.0) patients admitted to the hospital between 2014 and 2019. Patient information on demographics, medical and medication history, laboratory parameters, electrophysiological data, type of GBS and therapy received were retrieved from medical records. Univariate and multivariate analysis were conducted to identify factors associated with outcome (improved and not improved) and calculate odds ratio (OR).

Results

A total of 212 GBS patients were included in the study, of which 67% were males and the mean age was 39.9±20.1 years. 168 (79%) patients showed improvement whereas the remaining 44(21%) did not show improvement. Patients with hypertension (OR=4.512; CI=1.309-15.556, p=0.017), alcoholics (OR=5.148; CI=1.234-21.472, p=0.025), sepsis (OR= 9.139; CI=1.102-75.760, p=0.040) and cardiac arrest (OR=17.495; CI=1.249-245.027, p=0.034) were associated with risk of no improvement. Whereas those treated with IVIgG plus Physiotherapy/Occupational therapy (OR=0.062; CI=0.016-0.242, p=0.001) and Plasmapheresis plus Physiotherapy/Occupational therapy (OR=0.007; CI=0.000-0.147, p=0.001) were associated with improvement.

Conclusion

Understanding these factors help to further give a more directed and focused management to improve the condition in patients who are at risk of poor outcome. Further follow-up studies could be done to determine and manage the residual disabilities associated with GBS to improve patient's quality of life.

The outcome of Guillain-Barré syndrome following intravenous immunoglobulin compared to the natural course

BACKGROUND

Intravenous immunoglobulin (IVIg) is recommended in Guillain-Barré syndrome (GBS), but its efficacy may vary in different subtypes. We report the outcomes of patients with GBS following IVIg treatment compared to the natural course (NC). We also compare the effect of IVIg treatment in different subtypes of GBS.

METHODS

From a cohort of 528 GBS, we have extracted 189 patients who received IVIg and compared their outcomes with 199 age and peak disability matched patients who did not receive IVIg, plasmapheresis, or corticosteroid. Disability was assessed using the 0-6 GBS Disability Scale (GBSDS). Clinical and neurophysiological subtypes were recorded. The primary outcome was functional disability at 6-months and was categorized as complete (GBSDS ≤ 1), partial (GBSDS 2-3), and poor (GBSDS > 3). The secondary outcomes were in-hospital death, and duration of hospitalization, and mechanical ventilation (MV).

RESULTS

In-hospital death (2.6% vs 2%; p = 0.74) and 3-months poor recovery (20.7% vs 18%) were similar in the IVIg and NC group. At 6-months, however, a lesser proportion of patients in IVIg group had poor recovery (2.2% vs 8.3%; p = 0.026). The outcomes of IVIg and NC were compared in 72 AMAN and 256 AIDP patients. IVIg therapy did not alter the outcome in AMAN but resulted in a lesser proportion of poor recovery at 6-months in AIDP (0.8% vs. 6.6%; p = 0.03).

CONCLUSION

Intravenous immunoglobulin is beneficial in AIDP variants of GBS but not in the AMAN subtype. A customized treatment may be cost-effective till a randomized controlled trial is conducted in AMAN.

Supervised, individualised exercise reduces fatigue and improves strength and quality of life more than unsupervised home exercise in people with chronic Guillain-Barré syndrome: a randomised trial

QUESTION

In people in the chronic phase of Guillain-Barré syndrome (GBS), how much more does a supervised, individualised exercise program improve functional independence with activities of daily living than a home-based exercise program? How do the two exercise programs compare regarding their effects on muscle strength, fatigue, pain and quality of life?

DESIGN

Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinding of outcome assessors.

PARTICIPANTS

Sixteen adults with stable residual disability ≥ 6 months after the onset of GBS.

INTERVENTION

Participants in the experimental group were allocated to 60-minute sessions of physiotherapist-supervised strengthening, endurance and breathing exercises, gait training and pain management, two to three sessions/week for 12 weeks. The control group was prescribed a home program of 30-minute sessions of maintenance exercises and education in self-management, two to three sessions/week for 12 weeks.

OUTCOME MEASURES

Functional independence in activities of daily living on the 100-point Barthel Index (primary outcome), muscle strength on the 60-point Medical Research Council scale, fatigue on the 0-to-63 Fatigue Severity Scale, a visual analogue scale of pain severity, and quality of life, measured at baseline and months 6 and 12.

RESULTS

At month 6, the median between-group difference was 5 (95% CI 0 to 20) for functional independence, 8 (95% CI 4 to 18) for strength, -13 (95% CI -28 to -1) for fatigue, and 12 (95% CI 3 to 13) for the environment domain of quality of life. Estimated effects at month 12 had a similar magnitude, but most of the CIs had greater uncertainty.

CONCLUSION

Supervised, individualised exercise reduced fatigue and improved strength and quality of life more than unsupervised home exercise in people with chronic Guillain-Barré syndrome.

REGISTRATION

CTRI/2016/08/007150.

Risk Factors for Mechanical Ventilation in Patients with Guillain-Barré Syndrome

BACKGROUND

Respiratory support is required in 20-30% of patients with Guillain-Barré syndrome (GBS). We investigated clinical and biological risk factors for mechanical ventilation (MV) in northeast China through a retrospective GBS study. The Erasmus GBS Respiratory Insufficiency Score (EGRIS) is a prognostic model for MV in patients with GBS, and its usefulness has been validated in several countries but not in China. Therefore, we intended to validate the EGRIS model in our GBS cohort.

METHODS

A total of 252 patients with GBS were included in this study from January 2013 to October 2017. Risk factors for MV were identified via multivariate logistic regression analysis. The prognostic value of the EGRIS was validated via receiver operating characteristic curve analysis.

RESULTS

Thirty-one patients (12.3%) required MV (mean age 54.19 years), with a majority being male (77.4%). The risk factors for MV were male sex [odds ratio (OR) 3.720, 95% confidence interval (CI) 1.155-11.985, p < 0.05], shorter interval from onset to admission (OR 0.830, 95% CI 0.711-0.970, p < 0.05), lower Medical Research Council sum score at admission (OR 0.942, 95% CI 0.911-0.973, p < 0.001), neutrophil-to-lymphocyte ratio at admission (OR 1.174, 95% CI 1.049-1.315, p < 0.01), and cranial nerve deficit (OR 3.805, 95% CI 1.373-10.541, p < 0.05). The EGRIS had a good predictive ability for MV (area under the receiver operating curve 0.861) in patients with GBS, and a high EGRIS was a predictor for MV (OR 8.778, 95% CI 3.432-22.448, p < 0.001). However, there was no significant difference in ganglioside administration between ventilated and nonventilated patients.

CONCLUSIONS

An elevated neutrophil-to-lymphocyte ratio at admission and a high EGRIS could serve as predictors for MV in our GBS cohort.

Prediction models for mechanical ventilation and outcome in Guillain-Barré syndrome

Various prediction models have been formulated to predict the need for mechanical ventilation (MV). In this study, we compare the sensitivity and specificity of Erasmus GBS Respiratory Insufficiency Score (EGRIS) and Sharshar score with single breath count (SBC) at 2 Hz to assess their usefulness in predicting MV and functional outcome. The primary outcome was prediction of MV and relative usefulness of all three models based on sensitivity and specificity. The secondary outcome was functional recovery at 6 months using the cut off points for MV and functional outcome at 6months was assessed using Hughes scale and categorized as good (<2) and poor (≥2). The median age was 30 years, and 64 (69.6%) were males. The sensitivity and specificity of EGRIS score was 78.1% and 67.2%, Sharshar score was 75.0% and 64.1%, and SBC at 2 Hz was 78.1% and 75.0%. The area under the receiver operating curves was maximum for SBC at 2 Hz (0.86) compared to other models, although insignificant. EGRIS score < 5 had better functional recovery compared to those with score ≥ 5 (66% vs 34%, p = 0.001). Similarly, in Sharshar score, 23/59 (39%) with score ≥ 4 had good recovery compared to 36 (61%) with score < 4 (p = 0.01). All the three models have comparable predictive values for MV. Outcome prediction is the best with EGRIS.

Characteristics of Guillain-Barré syndrome in a Lebanese tertiary care center

Guillain-Barré Syndrome (GBS) is a group of acute inflammatory disorders that share a clinical presentation of progressive polyradiculo-neuropathy. Data on GBS in the Middle East and Lebanon are scarce; hence, we explored the characteristics of patients presenting with GBS to a tertiary care center in Beirut, Lebanon. This was a single-centered retrospective study over a 12-year period. We reviewed the charts of patients presenting with GBS to the American University of Beirut medical center and examined their presentation, management and outcome. 61 patients were included, with the majority being males. 59% of the patients reported an infection prior to admission. 77% had sensory and motor symptoms and 69% were diagnosed with acute inflammatory demyelinating polyneuropathy (AIDP). 57% of patients had initial symptoms in the lower extremities, 25% experienced cranial neuropathies, and 26% complained of pain. 77% were managed by intravenous immunoglobulin with a median hospital stay of 6.5 days. AIDP was noted to be the most prevalent GBS variant in Lebanon. More than 50% had an unfavorable outcome at discharge, which raises the need for better treatment and management approaches.

Intensive Care and Treatment of Severe Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is an acute polyneuropathy mostly characterized by acute flaccid paralysis with or without sensory/autonomous nerve dysfunction. Current immuno therapies including intravenous immunoglobulin (IVIg), plasma exchange (PE), and newly developed biological drugs benefit patients by alleviating hyperreactive immune responses. Up to 30% of patients develop respiratory failure during hospitalization and require mechanical ventilation and intensive care. Immunotherapies, mechanical ventilation, supportive care, and complication management during the intensive care unit (ICU) stay are equally emphasized. The most important aspect of intensive care and treatment of severe GBS, that is, mechanical ventilation, has been extensively reviewed elsewhere. In contrast to immunotherapies, care and treatment of GBS in the ICU setting are largely empirical. In this review, we intend to stress the importance of intensive care and treatment, other than mechanical ventilation in patients with severe GBS. We summarize the up-to-date knowledge of pharmacological therapies and ICU management of patients with severe GBS. We aim to answer some key clinical questions related to the management of severe GBS patients including but not limited to: Is IVIg better than PE or vice versa? Whether combinations of immune therapies benefit more? How about the emerging therapies promising for GBS? When to perform tracheal intubation or tracheostomy? How to provide multidisciplinary supportive care for severe cases? How to avert life-threatening complications in severe cases?

Guillain-Barré syndrome in low-income and middle-income countries: challenges and prospects

The epidemiology, clinical characteristics, management and outcome of Guillain-Barré syndrome (GBS) differ between low-income and middle-income countries (LMIC) and high-income countries (HIC). At present, limited data are available on GBS in LMIC and the true incidence of GBS in many LMIC remains unknown. Increased understanding of GBS in LMIC is needed because poor hygiene and high exposure to infections render populations in LMIC vulnerable to GBS outbreaks. Furthermore, insufficient diagnostic and health-care facilities in LMIC contribute to delayed diagnosis in patients with severe presentations of GBS. In addition, the lack of national clinical guidelines and absence of affordable, effective treatments contribute to worse outcomes and higher mortality in LMIC than HIC. Systematic population-based surveillance studies, cohort and case-control studies are required to understand the incidence and risk factors for GBS. Novel, targeted and cost-effective treatment strategies need to be developed in the context of health system challenges in LMIC. To ensure integrative rehabilitation services in LMIC, existing prognostic models must be validated, and responsive outcome measures that are cross-culturally applicable must be developed. Therefore, fundamental and applied research to improve the clinical management of GBS in LMIC should become a critical focus of future research programmes.

Mechanical ventilation in Guillain-Barré syndrome

Introduction: Up to 30% of patients with Guillain-Barré syndrome (GBS) develop respiratory failure requiring intensive care unit (ICU) admission and mechanical ventilation. Progressive weakness of the respiratory muscles is the leading cause of acute respiratory distress and respiratory failure with hypoxia and/or hypercarbia. Bulbar weakness may compromise airway patency and predispose patients to aspiration pneumonia. Areas covered: Clinical questions related to the use of mechanical ventilation include but are not limited to: When to start? Invasive or noninvasive? When to wean from mechanical ventilation? When to perform tracheostomy? How to manage complications of GBS in the ICU including nosocomial infection, ventilator-associated pneumonia, and ICU-acquired weakness? In this narrative review, the authors summarize the up-to-date knowledge of the incidence, pathophysiology, evaluation, and general management of respiratory failure in GBS. Expert opinion: Respiratory failure in GBS merits more attention from caregivers. Emergency intubation may lead to life-threatening complications. Appropriate methods and time point of intubation and weaning, an early tracheostomy, and predictive prophylaxis of complications benefit patients' long-term prognosis.

Inclusion of Mechanical Ventilation in Severity Staging of Tuberculous Meningitis Improves Outcome Prediction

Patients with tuberculous meningitis (TBM) in any stage of the British Medical Research Council (BMRC) scale, if requiring mechanical ventilation (MV), are likely to have a poor outcome. We report the usefulness of BMRC, BMRC-MV, and BMRC-hydrocephalus (BMRC-HC) staging, and Haydarpasa Meningitis Severity Index (HAMSI) scoring in predicting the outcome of TBM. One hundred ninety-seven TBM patients were analyzed from a prospectively maintained TBM registry. The severity of meningitis was categorized using BMRC (stages I-III), BMRC-MV (I-IV [MV patients were grouped as stage IV]), and BMRC-HC (I-IV [BMRC stage III patients with hydrocephalus were grouped as stage IV]). Haydarpasa Meningitis Severity Index scoring was categorized as < 6 and ≥ 6. The outcome was defined at 6 months using the modified Rankin Scale (mRS) as death, poor (mRS score > 2), or good (mRS score ≤ 2). Forty-nine (25%) patients died. BMRC-mechanical ventilation stage IV had the highest predictive value for defining death, with a sensitivity of 88% and a specificity of 86%. About 81.7% of surviving patients had a good outcome at 6 months. BMRC-mechanical ventilation stages I-III had the highest predictive value for defining good outcome, with a sensitivity of 93% and a specificity of 61%. In TBM, BMRC-MV staging has the best predictive value for defining death and disability.

Integrated Chinese and Western Medicine for Acute Guillain-barré Syndrome Treatment

Introduction

Guillain-Barré syndrome (GBS) is a worldwide demyelinating polyradiculopathy and polyneuropathy. Currently, there is no specific drug for GBS, and established treatment is generally based on immune-modulating treatment with plasma exchange or intravenous immunoglobulin in combination with supportive care. This study aimed to investigate the efficiency of integrated Chinese and Western medicine for acute GBS treatment.

Methods

We enrolled 73 subjects, and randomly divided them into two groups: 35 cases in the traditional Chinese medicine (TCM) group, and 28 in the Control group. The Control group was treated with the common Western medicine for one month; and the TCM group was administrated with one month of common treatment combined with TCM medication.

Results

Compared to the controls, TCM significantly enhanced the treatment efficiency in symptom expression, including the TCM syndrome score, the activity of daily living score, Hughes functional score and sensory dysfunction assessment. The total effective rate of the TCM group was 94.29%, significantly better than controls (78.59%). Moreover, TCM provide better improvement in motor nerve conduction functions (distal motor latency and motor conduction velocity) and sensory nerve conduction functions (sensory conduction velocity and sensory nerve action potential) in median nerve, ulnar nerve, and common fibular nerve.

Conclusion

When combined with TCM administration, the GBS treatment could acquire better outcomes.

Cardiovascular complications and its relationship with functional outcomes in Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) is a monophasic disease characterized by acute polyradiculoneuropathy.

AIM

This study investigated cardiovascular complications in patients with GBS and their relationship with outcomes.

DESIGN AND METHODS

We included 96 patients, who were diagnosed with GBS according to Brighton case definitions. All enrolled patients were evaluated according to a predetermined algorithm, which included nerve conduction studies, cerebrospinal fluid analysis, electrocardiography, 2D echo, cardiac markers and autonomic function testing.

RESULTS

We enrolled a total of 96 patients. The mean age of patients was 35.75 ± 17.66 years. Furthermore, 54.2% of patients developed cardiovascular complications, of which changes in electrocardiography (ECG) findings (50%), hypertension (28.12%), labile hypertension (12.5), tachycardia (26.04), bradycardia (13.54%) and a fluctuating heart rate (HR) (11.46) were common. Other cardiovascular complications seen in GBS patients were increased pro-BNP (26.04%), raised troponin T levels (3.12%), acute coronary syndrome (2.08%), heart failure (2.08%) and abnormal 2D echo findings (8.33%). The results of the univariate analysis revealed that a history of preceding infection, a Medical Research Council sum score, neck muscle weakness, facial nerve involvement, bulbar involvement, respiratory failure, cardiovascular complications, autonomic dysfunction, acute motor sensory axonal neuropathy subtype and baseline Hughes score were significantly (P < 0.005) associated with poor outcomes. However, none of these factors were found to be independently associated with poor outcomes in the multivariate analysis.

CONCLUSION

A considerable number of patients with GBS developed cardiovascular complications and it needs attention.

A Predictive Model for Respiratory Failure and Determining the Risk Factors of Prolonged Mechanical Ventilation in Children with Guillain-Barre Syndrome

OBJECTIVE

Determining the predictors of respiratory failure and duration of intubation in children with Guillain-Barre syndrome (GBS).

MATERIALS & METHODS

Children diagnosed with GBS at Tabriz Children's Hospital were studied. Factors associated with and influencing respiratory failure as well as the duration of intubation were determined using both univariate and multiple analyses.

RESULTS

Overall, 324 children were enrolled in the study, 54.0% of whom were males. Thirty-one (9.6%) patients underwent mechanical ventilation, the patients under 5 years old were more prone to the requirement of mechanical ventilation (11.3% vs. 6.9%). Cases hospitalized in winter were more likely to need ventilation compared to those hospitalized in spring (OR =7.00; 95% CI:1.51-32.53). Also, autonomic involvement (OR=8.88, 95% CI:4.03-19.58; p<0.001) and cranial nerves involvement (OR=9.88, 95% CI:3.68 - 26.52; p<0.001) emerged as risk factors for mechanical ventilation requirement. Overall, 16.1% of patients with axonal electrophysiologic pattern required mechanical ventilation compared to 7.4% of those with demyelinating type (OR:2.15, 95% CI: 1.01-4.69). In univariate analysis, the only variable that showed a correlation with the duration of intubation was axonal electrophysiologic pattern (p= 0.028).

CONCLUSION

Approximately, 10% of the patients required mechanical ventilation. Season, cranial nerve involvement, autonomic dysfunction and electrophysiologic pattern were the most important variables in predicting respiratory failure and duration of mechanical ventilation.

Influenza Vaccination and Guillain-Barré Syndrome: Reality or Fear

Guillain-Barré syndrome (GBS) is an inflammatory disorder and an acute immune-mediated demyelinating neuropathy that causes reduced signal transmissions, progressive muscle weakness, and paralysis. The etiology of the syndrome still remains controversial and uncertain. GBS can be initiated and triggered by respiratory tract infections such as influenza, and intestinal infections such as Campylobacter jejuni. In addition, there is considerable evidence suggesting links between influenza vaccination and GBS. As reported previously, the incidence of GBS in individuals receiving swine flu vaccine was about one to two cases per million. Despite the influenza vaccine efficacy, its association with an immune-mediated demyelinating process can be challenging as millions of people get vaccinated every year. In this review we will discuss the association between influenza infection and vaccination with GBS by focusing on the possible immunopathological mechanisms.

Role of IV Immunoglobulin in Indian Children With Guillain-Barré Syndrome

OBJECTIVES

To evaluate the outcome of Indian children with Guillain-Barré syndrome who received IV immunoglobulin compared with those who did not receive any specific therapy.

DESIGN

Single center, prospective cross-sectional study.

SETTING

Tertiary care neurology teaching hospital.

PATIENTS

Children (≤ 18 yr old) with Guillain-Barré syndrome were included from a prospectively maintained Guillain-Barré syndrome registry from January 2008 to April 2017. Children were classified into acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, acute motor-sensory axonal neuropathy, and inexcitable motor nerves based on nerve conduction study.

INTERVENTIONS

Out of 138 pediatric Guillain-Barré syndrome, 50 received IV immunoglobulin and another 50 age and peak disability matched controls (who did not receive IV immunoglobulin or plasmapheresis) were selected from the same registry for comparison.

MEASUREMENTS AND MAIN RESULTS

Outcome at 3 and 6 months was defined on the basis of a 0-10 Clinical Grading Scale into complete (Clinical Grading Scale < 3), partial (Clinical Grading Scale 3-5), and poor (Clinical Grading Scale > 5) recovery. The primary outcome was proportion of patients with complete recovery at 3 and 6 months in IV immunoglobulin and non-IV immunoglobulin groups. Secondary outcomes included in-hospital deaths, duration of mechanical ventilation, and hospital stay. Subgroup analysis was done in acute motor axonal neuropathy and acute inflammatory demyelinating polyradiculoneuropathy groups. The baseline characteristics were similar except for shorter duration of illness and higher proportion of facial palsy in IV immunoglobulin group. Hospital deaths, duration of mechanical ventilation, hospital stay, and outcome at 3 and 6 months were not different between the two groups. Children with acute motor axonal neuropathy had better recovery at 6 months on IV immunoglobulin (58.3% vs 11.1%; p = 0.03), but not those with acute inflammatory demyelinating polyradiculoneuropathy (58.3% vs 72.2%; p = 0.22). In nonambulatory Guillain-Barré syndrome children, complete recovery at 6 months was similar in IV immunoglobulin and non-IV immunoglobulin group (57.4% vs 57.1%; p = 0.98).

CONCLUSIONS

In Indian children with Guillain-Barré syndrome, the outcome at 6 months in IV immunoglobulin treated group was similar to non-IV immunoglobulin group. Children with acute motor axonal neuropathy responded better to IV immunoglobulin.

Clinical Profile, Functional Outcome, and Mortality of Guillain-Barre Syndrome: A Five-Year Tertiary Care Experience from Nepal

Introduction

Guillain-Barre syndrome is the most common cause of acute flaccid paralysis in the adult population. It occurs at the rate of 0.34 to 4 per 100000 individuals. This study was conducted to determine the clinicoepidemiological profile and outcome of the patients with Guillain-Barre syndrome.

Materials and Methods

We conducted a retrospective study of patients with Guillain-Barre syndrome, presented at B.P. Koirala Institute of Health Sciences, a tertiary care centre in eastern Nepal, from January 2013 to December 2017. All patients diagnosed with Guillain-Barre syndrome were included in this study. The handwritten case record files of the study population were retrieved from medical record section of the institute.

Results

Of 31 patients with Guillain-Barre syndrome, the mean age of patients was 17±12 years. The most common presenting symptom of study population was ascending paralysis (93.5%). Respiratory failure requiring mechanical ventilation occurred in 16.1%. The common variants are AIDP and AMAN. Respiratory tract infection (29%) was the most common antecedent event. The in-hospital mortality of Guillain-Barre syndrome was 6.45%.

Conclusion

Guillain-Barre syndrome is commonly seen in the young population. The most common symptom of Guillain-Barre syndrome was ascending paralysis. The in-hospital mortality rate of patients with GBS was 6.45%.

Predictors of respiratory failure in patients with Guillain-Barré syndrome: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature regarding the ability of clinical features to predict respiratory failure in patients with Guillain-Barré syndrome (GBS).

DATA SOURCES

We searched the PubMed and Ovid MEDLINE databases with the search terms "guillain barre syndrome" OR "acute inflammatory demyelinating polyneuropathy" OR "acute motor axonal neuropathy" OR "acute motor sensory axonal neuropathy" AND "respiratory failure" OR "mechanical ventilation". We excluded articles that did not report the results of original research (eg, review articles, letters), were case reports or series (ten or fewer patients), were not available in English, reported research in paediatric populations (16 years of age or younger), or were interventional studies. Article quality was assessed with the Newcastle-Ottawa quality assessment scale.

DATA SYNTHESIS

Thirty-four relevant studies were identified. Short time from symptom onset to hospital admission (less than 7 days), bulbar (odds ratio [OR], 9.0; 95% CI, 3.94-20.6; P < 0.001) or neck weakness (OR, 6.36; 95% CI, 2.32-17.5; P < 0.001), and severe muscle weakness at hospital admission were associated with increased risk of intubation. Facial weakness (OR, 3.74; 95% CI, 2.05-6.81; P < 0.001) and autonomic instability (OR, 6.40; 95% CI, 2.83-14.5; P < 0.001) were significantly more frequent in patients requiring intubation in our meta-analyses; however, the differences were not statistically significant in individual multivariable analysis studies. Four predictive models have been developed to assess the risk of respiratory failure for patients with GBS, each with good to excellent discriminative power (area under the receiver operating characteristic curve, 0.79-0.96).

CONCLUSIONS AND RELEVANCE

Early identification of GBS patients at risk of respiratory failure could reduce the rates of adverse outcomes associated with delayed intubation. Algorithms that predict a patient's risk of subsequent respiratory failure at hospital admission appear more reliable than individual clinical variables.

Spectrum and outcome of acute infectious encephalitis/encephalopathy in an intensive care unit from India

PURPOSE

To evaluate the spectrum of acute infectious encephalitis/encephalopathy syndrome (AIES) in intensive care unit (ICU) and the predictors of mechanical ventilation (MV) and outcome of these patients.

METHODS

AIES patients diagnosed on the basis of fever, altered sensorium, seizure and cerebrospinal fluid pleocytosis admitted to the neurology ICU were prospectively included. The demographic and clinical details, hematological, biochemical, MRI and etiological findings of the patients were noted. Need of MV, death in hospital and 3-month functional outcome were analyzed.

RESULTS

One hundred sixty-four out of 258 (64%) AIES patients needed ICU admission. Their median age was 35 (2-85) years and 71 (43%) were females. The etiology was viral in 44 (herpes and Japanese encephalitis in 12 each, dengue in 17, mumps, measles and varicella in 1 patient each), non-viral in 64 (scrub typhus in 48, falciparum malaria in 6, leptospira in 3 and bacterial in 7) and undetermined etiology in 56 (34%) patients. Sixty-nine (42%) patients needed MV. On multivariate analysis, Glasgow Coma Scale (GCS) score, Sequential Organ Failure Assessment (SOFA) score and raised intracranial pressure were independent predictors of MV. Forty-three (26%) patients died, and all were in the MV group. Higher SOFA score and untreatable etiology were independent predictors of mortality. At 3-month follow-up, 14% had poor and 86% had good outcome. Low GCS score, focal weakness and status epilepticus independently predicted poor outcome.

CONCLUSION

Twenty-six percent patients with AIES died in ICU, and 86% had good recovery at 3 months. Admission SOFA scores and untreatable etiology predicted mortality.

Successful surgical treatment of scoliosis secondary to Guillain-Barré syndrome: Case report

Guillain-Barré syndrome (GBS) is an acute autoimmune inflammatory demyelinating polyneuropathy that mostly affects the peripheral nervous system. Little is reported about spinal deformity associated with GBS. This study aims to present a case of scoliosis occurring in the setting of GBS.Case report and literature review.The patient was a 14-year-old male with scoliosis. His spinal plain radiographs showed that the Cobb angle of thoracic scoliosis was 114°. History review revealed that he developed profound lower extremity pain, weakness, and numbness after catching a cold 5 years ago. These symptoms progressed to unsteady gait and inability to stand up from squatting position. The diagnosis of GBS was confirmed based on these symptoms. He underwent a posterior correction at Thoracic 5-Lumbar 5 (T5-L12) levels using the (LEGACY, USA) spinal system. The Cobb angle was corrected from 114° to 45° (correction rate 60.5%). His follow-up was symptomatic, well balanced in the coronal planes, with solid fusion 12 months after the operation.Neuromuscular scoliosis could develop secondary to GBS. When evaluating patients with acute inflammatory polyneuropathy, clinical examination of the spine is essential to identify patients with rare neuromuscular scoliosis.