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In vasculitic neuropathy (VN), a 50% side-to-side difference in the amplitude of compound muscle action potentials and sensory nerve action potentials is considered meaningful, but unequivocal evidence is lacking. The aim of this study is to characterize electrodiagnostic features that best distinguish VN from other axonal polyneuropathies.We conducted a case-control study between January 2000 and April 2021. We reviewed the records of patients with VN who had bilateral nerve conduction studies (NCS) and evaluated different electrodiagnostic models to help distinguish VN from non-inflammatory axonal polyneuropathies.We identified 82 cases, and 174 controls with non-inflammatory axonal neuropathies. The amplitude percent difference Z-score model showed the best discriminatory capability between cases and controls (area under the curve [AUC] 0.87; 95% confidence interval [CI] 0.82, 0.93), and the number of nerves tested did not significantly influence the model. Individually, the ulnar motor nerve (AUC 0.86; 95% CI 0.77, 0.94) and median motor nerve (AUC 0.85; 95% CI 0.77, 0.94) showed the best discriminatory capability. A 50% amplitude difference between at least two bilateral nerves, either in the upper (AUC 0.85; 95% CI 0.77, 0.93) or lower (AUC 0.79; 95% CI 0.71, 0.87) extremity showed good discriminatory threshold for detecting VN.The best electrodiagnostic criteria for VN utilizes z-scores of percent differences in nerve amplitudes, but this approach may be difficult to implement at the bedside. Alternately, a 50% amplitude difference in at least two nerves is a reasonable approximation.

A 59-year-old man presented with slowly progressive weakness. During childhood, he had difficulty climbing stairs. At age 30 years, he noted difficulty getting out of a chair or standing up from the floor without using his arms. At age 48 years, he started having 3–4 falls per year. He denied orthopnea and dyspnea. He had well-controlled hypothyroidism and hyperlipidemia. Medications included levothyroxine and niacin, and he denied the use of statins, fibrates, steroids, and alcohol intake. His parents (unrelated), sister, and 2 sons (aged 16 and 18 years) had no weakness. His maternal grandfather had leg weakness with difficulty climbing stairs around age 30 years and was using a wheelchair by age 60 years.

The prognostic value of cerebrospinal fluid (CSF) protein in Guillain Barré Syndrome (GBS) is unclear. We aimed to explore the potential association between CSF protein level and mechanical ventilation in GBS. We undertook a retrospective study of GBS patients from January 2000 to November 2019 at the University of Michigan. 94 patients were ultimately included for evaluation. After adjusting for the Erasmus GBS Respiratory Insufficiency Scale (EGRIS), we did not find a significant difference in CSF protein between ventilated and non-ventilated patients. Elevated CSF protein level does not appear to portend an increased likelihood of mechanical ventilation in GBS patients.

It is unknown how often patients with sensory neuronopathy (SNN) present with a distal symmetric polyneuropathy (DSP) phenotype. In these cases, electrodiagnostic testing may discriminate SNN with a DSP phenotype from DSP.We reviewed the records of patients who met SNN diagnostic criteria between January 2000 and February 2021 and identified patients with a DSP phenotype at the time of electrodiagnosis.Sixty-two patients fulfilled SNN diagnostic criteria. At symptom onset, 20 (32.2%) patients presented with distal symmetric sensory symptoms limited to the feet. However, most progressed rapidly over 6 months or developed asymmetric symptoms. At the time of electrodiagnosis, only seven (11.3%) patients had a DSP phenotype. Of these seven patients, four had cerebellar ataxia with neuropathy and vestibular areflexia syndrome, one had vitamin BPatients with SNN rarely present with a DSP phenotype at the time of electrodiagnosis. The finding that one third of cases resemble DSP at onset highlights the importance of clinical monitoring. In patients with a DSP phenotype, the presence of ataxia at onset or significant progression within 6 months may suggest the possibility of SNN and should prompt additional investigations, such as electrodiagnosis.

Introduction It is unknown how often patients with electrodiagnostic evidence of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), a potentially treatable condition, present with a distal symmetric polyneuropathy (DSP) phenotype. Methods We reviewed the records of patients who presented to our electrodiagnostic laboratory between January 1, 2011 to December 31, 2019 and fulfilled electrodiagnostic criteria for CIDP to identify those who presented with a sensory predominant DSP phenotype. Results One hundred sixty-two patients had a chronic acquired demyelinating neuropathy, of whom 138 met criteria for typical or atypical CIDP. Nine of these patients presented with a sensory predominant DSP phenotype, among whom 6 were eventually diagnosed with distal acquired demyelinating symmetric (DADS) neuropathy, 1 with Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin changes (POEMS) syndrome and 2 with idiopathic DSP. The prevalence of acquired chronic demyelinating neuropathies among all patients presenting with a DSP phenotype was estimated to be 0.34%. Discussion Patients who meet electrodiagnostic criteria for CIDP rarely present with a sensory predominant DSP phenotype, and electrodiagnostic testing rarely identifies treatable demyelinating neuropathies in patients who present with a DSP phenotype. This article is protected by copyright. All rights reserved.

OBJECTIVES: To determine the association between mean airway pressure and 90-day mortality in patients with acute respiratory failure requiring mechanical ventilation and to compare the predictive ability of mean airway pressure compared with inspiratory plateau pressure and driving pressure. DESIGN: Prospective observational cohort. SETTING: Five ICUs in Lima, Peru. SUBJECTS: Adults requiring invasive mechanical ventilation via endotracheal tube for acute respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of potentially eligible participants (n = 1,500), 65 (4%) were missing baseline mean airway pressure, while 352 (23.5%) were missing baseline plateau pressure and driving pressure. Ultimately, 1,429 participants were included in the analysis with an average age of 59 ± 19 years, 45% female, and a mean Pao(2)/Fio(2) ratio of 248 ± 147 mm Hg at baseline. Overall, 90-day mortality was 50.4%. Median baseline mean airway pressure was 13 cm H(2)O (interquartile range, 10–16 cm H(2)O) in participants who died compared to a median mean airway pressure of 12 cm H(2)O (interquartile range, 10–14 cm H(2)O) in participants who survived greater than 90 days (p < 0.001). Mean airway pressure was independently associated with 90-day mortality (odds ratio, 1.38 for difference comparing the 75th to the 25th percentile for mean airway pressure; 95% CI, 1.10–1.74) after adjusting for age, sex, baseline Acute Physiology and Chronic Health Evaluation III, baseline Pao(2)/Fio(2) (modeled with restricted cubic spline), baseline positive end-expiratory pressure, baseline tidal volume, and hospital site. In predicting 90-day mortality, baseline mean airway pressure demonstrated similar discriminative ability (adjusted area under the curve = 0.69) and calibration characteristics as baseline plateau pressure and driving pressure. CONCLUSIONS: In a multicenter prospective cohort, baseline mean airway pressure was independently associated with 90-day mortality in mechanically ventilated participants and predicts mortality similarly to plateau pressure and driving pressure. Because mean airway pressure is readily available on all mechanically ventilated patients and all ventilator modes, it is a potentially more useful predictor of mortality in acute respiratory failure.

The median cost of attending medical school is rising annually, and with it, student debt. Neurology residents have stepped up during the pandemic to answer the call of a health system at its breaking point. In this article, we outline how this escalating problem of student debt affects the neurology pipeline, the wellbeing and career decisions of current neurology trainees and practicing neurologists and through it, and the gap in healthcare. We describe currently available options for loan repayment and call for advocacy and legislation to address this mounting burden as a means to improve neurological care in the United States.

OBJECTIVES Weaning protocols establish readiness-to-wean criteria to determine the opportune moment to conduct a spontaneous breathing trial. Weaning protocols have not been widely adopted or evaluated in ICUs in low- and middle-income countries. We sought to compare clinical outcomes between participants whose weaning trials were retrospectively determined to have been premature, opportune, or delayed based on when they met readiness-to-wean criteria. DESIGN Prospective, multicenter observational study. SETTING Five medical ICUs in four public hospitals in Lima, Peru. SUBJECTS Adults with acute respiratory failure and at least 24 hours of invasive mechanical ventilation (n = 1,657). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We established six readiness-to-wean criteria and retrospectively categorized our sample into three weaning groups: 1) premature: if the weaning trial took place before fulfilling all criteria, 2) opportune: if the weaning trial took place within 24 hours after fulfilling the criteria, and 3) delayed: if the weaning trial took place over 24 hours after fulfilling criteria. We compared 90-day mortality, ventilator-free days, ICU-free days, and hospital-free days between premature, opportune, and delayed weaning groups. In our sample, 761 participants (60.8%) were classified as having a premature weaning trial, 196 underwent opportune weaning (15.7%), and 295 experienced delayed weaning (23.6%). There was no significant difference in 90-day mortality between the groups. Both the premature and delayed weaning groups had poorer clinical outcomes with fewer ventilator-free days (-2.18, p = 0.008) and (-3.49, p < 0.001), ICU-free days (-2.25, p = 0.001) and (-3.72, p < 0.001), and hospital-free days (-2.76, p = 0.044) and (-4.53, p = 0.004), respectively, compared with the opportune weaning group. CONCLUSIONS Better clinical outcomes occur with opportune weaning compared with premature and delayed weaning. If readiness-to-wean criteria can be applied in resource-limited settings, it may improve ICU outcomes associated with opportune weaning.

Objetivos. Describir las características clínicas, letalidad, susceptibilidad antibiótica y distribución de serotipos demeningitis neumocócica en pacientes pediátricos de Lima, Perú. Materiales y Métodos. Serie de casos de meningitis neumocócica en niños menores de 16 años. Los datos fueron obtenidos de dos estudios multicéntricos prospectivos, de vigilancia pasiva de enfermedad neumocócica invasiva realizados en Lima-Perú desde los años 2006 al 2008, y del 2009 al 2011. Resultados. Reportamos 44 episodios de meningitis neumocócica; 68,2% fueron en niños menores de 2 años. La tasa de letalidad fue 32,6; y 92,9% de los casos letales ocurrieron en niños menores de dos años (p

y tienen la ventajas que los estimados son altamente confiables y representativos a nivel nacional. Actualmente, en el Peru, se vienen realizando estudios poblacionales que usan disenos de muestras complejas con la finalidad de obtener informacion sobre entidades de interes nacional. Es posible trabajar con los datos de estos trabajos y profundizar en el estudio de un tema en especifico a traves del analisis secundario de datos. Sin embargo, es importante resaltar que el analisis de estos tipos de estudios requieren necesariamente la consideracion del tipo del diseno muestral en el analisis para poder obtener estimados confiables.

BACKGROUND: The interaction between physicians and the pharmaceutical industry influences physicians' attitudes and prescribing behavior. Although largely studied in the US, this topic has not been well studied in resource-poor settings, where a close relationship between physicians and industry still exists. OBJECTIVE: To describe physician interactions with and attitudes towards the pharmaceutical industry in a public general hospital in Lima, Peru. DESIGN: Descriptive, cross-sectional study through an anonymous, self-filled questionnaire distributed among faculty and trainee physicians of five different clinical departments working in a Peruvian public general hospital. A transcultural validation of an existing Spanish questionnaire was performed. Exposure to marketing activities, motivations to contact pharmaceutical representatives and attitudes towards industry were studied. Collected data was analyzed by degree of training, clinical department, gender and teaching status. Attitudes were measured on a four-point LIKERT scale. RESULTS: 155 physicians completed the survey, of which 148 were included in the study sample. 94.5% of attending physicians reported ongoing encounters with pharmaceutical representatives. The most common industry-related activities were receiving medical samples (91.2%), promotional material (87.8%) and attending meetings in restaurants (81.8%). Respondents considered medical samples and continuing medical education the most ethically acceptable benefits. We found significant differences between attendings and residents, and teaching and non-teaching attendings. An association between the amount of encounters with pharmaceutical representatives, and attitudes towards industry and acceptance of medical samples was found. CONCLUSIONS: A close physician-industry relationship exists in the population under study. The contact is established mainly through pharmaceutical representatives. Medical samples are the most received and ethically accepted benefit. The attitudes of physicians on the ethical standards of acceptance of medical samples and other benefits are closely related with their exposure to the pharmaceutical industry. Future studies could explore the motivations of physicians working in resource-poor settings to maintain a close relationship with industry.