Risk factors for respiratory failure in Guillain-Barre syndrome in Bangladesh: a prospective study

Objective: We investigated clinical, biological, and electrophysiological risk factors for mechanical ventilation (MV) and patient outcomes in Bangladesh using one of the largest, prospective Guillain-Barre syndrome (GBS) cohorts in developing world. Methods: A total of 693 GBS patients were included in two GBS studies conducted between 2006 and 2016 in Dhaka, Bangladesh. Associations between baseline characteristics and MV were tested using Fisher’s exact test, v2 test, or Mann–Whitney U-test, as appropriate. Risk factors for MV were assessed using multivariate logistic regression. Survival analysis was performed using Kaplan–Meier method; comparisons between groups performed using logrank test. Results: Of 693 patients, 155 (23%) required MV (median age, 26 years; interquartile range [IQR] 17–40). Among the ventilated patients, males were predominant (68%) than females. The most significant risk factor for MV was bulbar involvement (adjusted odds ratio [AOR]:19.07; 95% CI = 89.00– 192.57, P = 0.012). Other independently associated factors included dysautonomia (AOR:4.88; 95% CI = 1.49–15.98, P = 0.009) and severe muscle weakness at study entry (AOR:6.12; 95% CI = 0.64–58.57, P = 0.048). At 6 months after disease onset, 20% of ventilated and 52% of non-ventilated patients (P < 0.001) had recovered completely or with minor symptoms. Mortality rate was significantly higher among ventilated patients than non-ventilated patients (41% vs. 7%, P < 0.001). Interpretation: Bulbar involvement, dysautonomia and severe muscle weakness were identified as the most important risk factors for MV among GBS patients from Bangladesh. The findings may help to develop predictive models for MV in GBS in developing countries to identify impending respiratory failure and proper clinical management of GBS patients

Use of low dose vaginal misoprostol in office hysteroscopy: a pre–post interventional study

A pre-post interventional study of patients undergoing office hysteroscopy alone and in combination with endometrial biopsy was performed during October 2015–March 2018 to evaluate the effect of low dose vaginal misoprostol on patient’s pain. Pain scores were assessed using the visual analog scale at the completion of the procedure. There were 646 patients included in the study. Of these, 462 had office hysteroscopy alone; 206 (44.6%) received 50 mcg of vaginal misoprostol the night prior to the procedure and the remaining 256 (55.4%) patients had no cervical ripening. The reported pain score following hysteroscopy was significantly lower among patients who received misoprostol [4(0–10) vs. 5(0–10); p=.001]. Most patients (78.2%) did not report any misoprostol related side effects. Of the 184 patients who underwent a combination of office hysteroscopy and endometrial biopsy, 97 (52.7%) received pre-procedure vaginal misoprostol while 87 (47.3%) did not. Post procedure pain was independent of pre-treatment with vaginal misoprostol (6.3 ± 2.7 vs. 6.6 ± 2.7; p = .54).Impact statement What is already known on this subject? Office hysteroscopy and endometrial biopsy is increasingly performed for evaluation of various gynaecologic conditions, however, patients’ perceived pain at the time of procedure may lead to incomplete procedures. Various doses of misoprostol have been tested to reduce patients’ pain, however none lower than 200 mcg vaginally, and at these doses, side effects are reported. What the results of this study add? To date, there is a scarcity of published data on the use of low dose misoprostol (50 mcg) in gynaecologic procedures. Our study found that the use of low dose vaginal misoprostol prior to office hysteroscopy is associated with lower reported pain and tenaculum utilisation during the procedure. However, vaginal misoprostol prior to successive office hysteroscopy and endometrial biopsy failed to decrease the reported pain, and the overall pain score was higher than hysteroscopy alone. What the implications are of these findings for clinical practice and/or further research? The use of low dose vaginal misoprostol (50 mcg) the evening prior to office hysteroscopy is associated with lower reported pain and tenaculum utilisation and is not associated with significant side effects. Therefore, 50 mcg of misoprostol could be used in clinical practice as a method to reduce patients’ reported pain during office hysteroscopy

Modified Erasmus GBS Respiratory Insufficiency Score: a simplified clinical tool to predict the risk of mechanical ventilation in Guillain-Barre syndrome

BackgroundThis study aimed to determine the clinical and diagnostic factors associated with mechanical ventilation (MV) in Guillain-Barre syndrome (GBS) and to simplify the existing Erasmus GBS Respiratory Insufficiency Score (EGRIS) for predicting the risk of MV. MethodsData from the first 1500 patients included in the prospective International GBS Outcome Study (IGOS) were used. Patients were included across five continents. Patients Results1133 (76%) patients met the study criteria. Independent predictors of MV were a shorter time from onset of weakness until admission, the presence of bulbar palsy and weakness of neck flexion and hip flexion. The modified EGRIS (mEGRIS) was based on these factors and accurately predicts the risk of MV with an area under the curve (AUC) of 0.84 (0.80-0.88). We internally validated the model within the full IGOS cohort and within separate regional subgroups, which showed AUC values of 0.83 (0.81-0.88) and 0.85 (0.72-0.98), respectively. ConclusionsThe mEGRIS is a simple and accurate tool for predicting the risk of MV in GBS. Compared with the original model, the mEGRIS requires less information for predictions with equal accuracy, can be used to predict MV at multiple time points and is also applicable in less severely affected patients and GBS variants. Model performance was consistent across different regions.Neurological Motor Disorder

Overexpression of Human Catalase Inhibits Proliferation and Promotes Apoptosis in Vascular Smooth Muscle Cells

Abstract —The role of reactive oxygen species, such as superoxide anions (O 2 · − ) and hydrogen peroxide (H 2 O 2 ), in modulating vascular smooth muscle cell proliferation and viability is controversial. To investigate the role of endogenously produced H 2 O 2 , rat aortic smooth muscle cells were infected with adenoviral vectors containing cDNA for human catalase (Ad Cat ) or a control gene, β-galactosidase (Ad LacZ ). Infection with Ad Cat resulted in dose-dependent increases in intracellular catalase protein, which was predominantly localized to peroxisomes. After infection with 100 multiplicity of infection (MOI) of Ad Cat , cellular catalase activity was increased by 50- to 100-fold, and intracellular H 2 O 2 concentration was reduced, as compared with control. Infection with Ad Cat reduced [ 3 H]thymidine uptake, an index of DNA synthesis, in cells maintained in medium supplemented with 2% serum (0.37±0.09 disintegrations per minute per cell [Ad LacZ ] versus 0.22±0.08 disintegrations per minute per cell [Ad Cat ], P &lt;0.05). Five days after infection with 100 MOI of Ad Cat , cell numbers were reduced as compared with noninfected or Ad LacZ -infected cells (157 780±8413 [Ad Cat ], P &lt;0.05 versus 233 700±3032 [noninfected] or 222 410±5332 [Ad LacZ ]). Furthermore, the number of apoptotic cells was increased 5-fold after infection with 100 MOI of Ad Cat as compared with control. Infection with Ad Cat resulted in induction of cyclooxygenase (COX)–2, and treatment with a COX-2 inhibitor overcame the Ad Cat -induced reduction in cell numbers. These findings indicate that overexpression of catalase inhibited smooth muscle proliferation while increasing the rate of apoptosis, possibly through a COX-2–dependent mechanism. Our results suggest that endogenously produced H 2 O 2 importantly modulates survival and proliferation of vascular smooth muscle cells. </jats:p

Zika virus and Guillain–Barré syndrome in Bangladesh

Objective: Previous studies have associated Guillain–Barré syndrome (GBS) with Zika virus (ZIKV) outbreaks in South America and Oceania. In Asia, ZIKV is known to circulate widely, but the association with Guillain–Barré syndrome is unclear. We investigated whether endemic ZIKV infection is associated with the development of GBS. Methods: A prospective study was conducted from 2011 to 2015 in Bangladesh. A total of 418 patients and 418 healthy family controls were included in the study. Patients were diagnosed with GBS prior to inclusion according to established criteria. Detailed information on the epidemiology, clinical presentation, electrophysiology, diagnosis, disease severity, and clinical course were obtained during a follow-up of 1 year using a predefined protocol. Results: ZIKV-neutralizing antibodies were detected in our study from 2013 onwards. The prevalence of ZIKV-neutralizing antibodies was not significantly higher in patients with GBS compared to healthy controls (OR 2.23, P = 0.14, 95% CI 0.77–6.53). Serological evidence for prior ZIKV infection in patients with GBS was associated with more frequent cranial, sensory, and autonomic nerve involvement compared to GBS patients with Campylobacter jejuni, the predominant preceding infection in GBS worldwide. Nerve-conduction studies revealed that ZIKV antibodies were associated with a demyelinating subtype of GBS, while C. jejuni infections were related to an axonal subtype. Interpretation: No significant association was found between ZIKV infection and GBS in Bangladesh, but GBS following ZIKV infection was characterized by a distinct clinical and electrophysiological subtype compared to C. jejuni infection. These findings indicate that ZIKV may precede a specific GBS subtype but the risk is low