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

Background: Severe dysautonomia is typically seen during acute phase of Guillain-Barré syndrome (GBS). Objective: To investigate the relationship of cardiovascular autonomic dysfunction with motor recovery in GBS. Materials and Methods: 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. Results: 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. Conclusions: Dysautonomia in GBS improved gradually and in keeping with motor and disability recovery.

Prolonged Exercise Test in Patients With History of Thyrotoxicosis.

PURPOSE: Thyrotoxic periodic paralysis is characterized by recurrent episodes of reversible, severe proximal muscle weakness associated with hypokalemia and hyperthyroidism. Prolonged exercise test is an easy, noninvasive method of demonstrating abnormal muscle membrane excitability in periodic paralyses. Although abnormal in thyrotoxic periodic paralysis patients, the effects thyroid hormone levels in non-thyrotoxic periodic paralysis thyrotoxicosis patients have not been well studied. The study aims to evaluate thyrotoxicosis patients (regardless of thyrotoxic periodic paralysis history) with prolonged exercise test and correlate it with their thyroid status. METHODS: This is a prospective, cross-sectional study of consecutive thyrotoxicosis patients seen at the endocrine clinic of a tertiary medical center. Thyroid status was determined biochemically before prolonged exercise test. Compound muscle action potential (CMAP) amplitudes postexercise were compared against pre-exercise amplitudes and recorded as percentage of mean baseline CMAP amplitude. Comparisons of time-dependent postexercise CMAP amplitudes and mean CMAP amplitude decrement were made between hyperthyroid and nonhyperthyroid groups. RESULTS: Seventy-four patients were recruited, 23 (31%) men, 30 (41%) Chinese, and the mean age was 48.5 ± 16.8 years. Of 74 patients, 32 (43%) were hyperthyroid and 42 (57%) were nonhyperthyroid viz. euthyroid and hypothyroid. Time-dependent CMAP amplitudes from 10 to 45 minutes after exercise were significantly lower in hyperthyroid patients compared with nonhyperthyroid patients (P < 0.01). Mean CMAP amplitude decrement postexercise was significantly greater in hyperthyroid than nonhyperthyroid patients (23.4% ± 11.4% vs. 17.3% ± 10.5%; P = 0.02). CONCLUSIONS: Compound muscle action potential amplitude declines on prolonged exercise test were significantly greater in hyperthyroid patients compared with nonhyperthyroid patients. Muscle membrane excitability is highly influenced by thyroid hormone level. Thyrotoxic periodic paralysis occurs from increased levels of thyroid hormone activity in susceptible patients.

Comparison of indocyanine green dye fluorescent cholangiography with intra-operative cholangiography in laparoscopic cholecystectomy: a meta-analysis.

OBJECTIVE: To compare indocyanine green dye fluorescence cholangiography (ICG-FC) with intra-operative cholangiography (IOC) in minimal access cholecystectomy for visualization of the extrahepatic biliary tree. BACKGROUND: Although studies have shown that ICG-FC is safe, feasible, and comparable to IOC to visualize the extrahepatic biliary tree, there is no comparative review. METHODS: We searched The Embase, PubMed, Cochrane Library, and Web of Science databases up to 8 April 2020 for all studies comparing ICG-FC with IOC in patients undergoing minimal access cholecystectomy. The primary outcomes were percentage visualization of the cystic duct (CD), common bile duct (CBD), CD-CBD junction, and the common hepatic duct (CHD). We used RevMan v5.3 software to analyze the data. RESULTS: Seven studies including 481 patients were included. Five studies, comprising 275 patients reported higher CD (RR = 0.90, p = 0.12, 95% CI 0.79-1.03, I2 = 74%) and CBD visualization rates (RR = 0.82, p = 0.09, 95% CI 0.65-1.03, I2 = 87%) by ICG-FC. Four studies, comprising 223 patients, reported higher CD-CBD junction visualization rates using ICG-FC compared to IOC (RR = 0.68, p = 0.06, 95% CI = 0.45-1.02, I2 = 94%). Four studies, comprising 210 patients, reported higher CHD visualization rates using ICG-FC compared to IOC (RR = 0.58, p = 0.03, 95% CI 0.35-0.93, I2 = 91%). CONCLUSION: ICG-FC is safe, and it improves visualization of CHD.

Understanding patients' and caregivers' perspectives and educational needs in Parkinson's disease: a multi-ethnic Asian study.

INTRODUCTION: Little is known regarding the educational needs and perspectives of people living with Parkinson's disease (PD), particularly in Asia. OBJECTIVE: To assess knowledge and perceptions regarding PD in a large multiethnic urban Asian cohort of patients and caregivers. METHODS: We conducted a survey at a university hospital neurology clinic, using a novel Knowledge and Perception of Parkinson's Disease Questionnaire (KPPDQ). RESULTS: The KPPDQ had satisfactory psychometric properties among patients and caregivers. Five hundred subjects were recruited with a 97% response rate (211 patients, 273 caregivers). Non-motor symptoms such as urinary problems, visual hallucinations and pain were relatively poorly recognized. Many (≈ 50-80%) respondents incorrectly believed that all PD patients experience tremor, that PD is usually familial, and that there is a cure for PD. About one-half perceived PD to be caused by something the patient had done in the past, and that PD medications were likely to cause internal organ damage. Issues of stigma/shame were relevant to one-third of patients, and 70% of patients perceived themselves to be a burden to others. Two-thirds of participants felt that PD imposed a heavy financial toll. Participants were about equally divided as to whether they would consider treatment with deep brain stimulation, tube feeding or invasive ventilation. Over three-quarters of patients expressed a preference to die at home. CONCLUSIONS: Important knowledge gaps, misperceptions and perspectives on PD were identified, highlighting the need for further efforts to raise awareness and provide accurate information regarding PD, and to address patient's and caregivers' needs and preferences.