European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain–Barré syndrome

Guillain–Barré syndrome (GBS) is an acute polyradiculoneuropathy. Symptoms may vary greatly in presentation and severity. Besides weakness and sensory disturbances, patients may have cranial nerve involvement, respiratory insufficiency, autonomic dysfunction and pain. To develop an evidence-based guideline for the diagnosis and treatment of GBS, using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology a Task Force (TF) of the European Academy of Neurology (EAN) and the Peripheral Nerve Society (PNS) constructed 14 Population/Intervention/Comparison/Outcome questions (PICOs) covering diagnosis, treatment and prognosis of GBS, which guided the literature search. Data were extracted and summarised in GRADE Summaries of Findings (for treatment PICOs) or Evidence Tables (for diagnostic and prognostic PICOs). Statements were prepared according to GRADE Evidence-to-Decision (EtD) frameworks. For the six intervention PICOs, evidence-based recommendations are made. For other PICOs, good practice points (GPPs) are formulated. For diagnosis, the principal GPPs are: GBS is more likely if there is a history of recent diarrhoea or respiratory infection; CSF examination is valuable, particularly when the diagnosis is less certain; electrodiagnostic testing is advised to support the diagnosis; testing for anti-ganglioside antibodies is of limited clinical value in most patients with typical motor-sensory GBS, but anti-GQ1b antibody testing should be considered when Miller Fisher syndrome (MFS) is suspected; nodal–paranodal antibodies should be tested when autoimmune nodopathy is suspected; MRI or ultrasound imaging should be considered in atypical cases; and changing the diagnosis to acute-onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP) should be considered if progression continues after 8 weeks from onset, which occurs in around 5% of patients initially diagnosed with GBS. For treatment, the TF recommends intravenous immunoglobulin (IVIg) 0.4 g/kg for 5 days, in patients within 2 weeks (GPP also within 2–4 weeks) after onset of weakness if unable to walk unaided, or a course of plasma exchange (PE) 12–15 L in four to five exchanges over 1–2 weeks, in patients within 4 weeks after onset of weakness if unable to walk unaided. The TF recommends against a second IVIg course in GBS patients with a poor prognosis; recommends against using oral corticosteroids, and weakly recommends against using IV corticosteroids; does not recommend PE followed immediately by IVIg; weakly recommends gabapentinoids, tricyclic antidepressants or carbamazepine for treatment of pain; does not recommend a specific treatment for fatigue. To estimate the prognosis of individual patients, the TF advises using the modified Erasmus GBS outcome score (mEGOS) to assess outcome, and the modified Erasmus GBS Respiratory Insufficiency Score (mEGRIS) to assess the risk of requiring artificial ventilation. Based on the PICOs, available literature and additional discussions, we provide flow charts to assist making clinical decisions on diagnosis, treatment and the need for intensive care unit admission.     

Imaging of Group B Streptococcus infection in pyonephrosis: a case report

Introduction: Pyonephrosis is hydronephrosis accompanied by a bacterial infection in the kidney, causing suppurative destruction of the renal parenchyma; this condition is an emergency and usually associated with stones or chronic urinary tract infections. Urinalysis is typically inaccurate for establishing the diagnosis, as bacteriuria may not manifest due to ureteral obstruction. Case report: We reported a 55-year-old male patient with flanks pain and an account of stone expulsion. Based on history taking, physical examination, radiology examinations, and percutaneous nephrotomy, we concluded a diagnosis of pyonephrosis causing by Streptococcus agalactiae as known as Group B Streptococcus. Discussion: While both US and CT scan guided the early diagnosis, CT was more accurate as it is able to capture the renal function and the underlying cause of obstruction. Pyonephrosis was described as having a pus collection in the pelvicalyceal system, cortex thinning, and the appearance of stones. Conclusion: Pyonephrosis is a rare emergency, and many clinicians find it challenging to recognize since the presentations are frequently nonspecific. In order to prevent renal failure and the spread of bacteremia that entails life-threatening urosepsis, acquiring imaging knowledge (sonography and CT) and other findings are indispensable in determining this entity.     

Maternity care provider acceptance of a future Group B Streptococcus vaccine – A qualitative study in three countries

IntroductionThere are vaccines in clinical trials that target the bacterium Group B Streptococcus (GBS). When approved, GBS vaccines will be intended for administration to pregnant women to prevent infection in their infants. The success of any vaccine will depend on its’ uptake in the population. Experience with prior maternal vaccines, e.g. influenza, Tdap and COVID-19 vaccines, teaches us that acceptance of vaccines, especially if novel, is challenging for pregnant women, and that provider recommendation is a key driver of vaccine uptake.MethodsThis study investigated attitudes of maternity care providers towards the introduction of a GBS vaccine in three countries (the United States (US), Ireland, and the Dominican Republic (DR)) with different GBS prevalence and prevention practices. Semi-structured interviews with maternity care providers were transcribed and coded for themes. The constant comparative method, and inductive theory building were used to develop conclusions.ResultsThirty-eight obstetricians, 18 general practitioners and 14 midwives participated. There was variability in provider attitudes towards a hypothetical GBS vaccine. Responses ranged from enthusiasm to doubts over the need for a vaccine. Attitudes were influenced by perceived additional benefits of a vaccine over current strategy and confidence in the safety of vaccines during pregnancy. Knowledge, experience and approaches to GBS prevention differed geographically and according to provider type, and influenced how participants assessed the risks and benefits of a GBS vaccine.ConclusionMaternity care providers are engaged in the topic of GBS management and there is opportunity to leverage attitudes and beliefs that will support a strong recommendation for a GBS vaccine. However, knowledge of GBS, and of the limitations of current prevention strategies vary among providers in different regions, and between different provider types. Targeted educational efforts with antenatal providers should focus on highlighting safety data the potential benefits of vaccination over current strategies.     

B族链球菌孕妇感染血清炎症因子、Th1/Th2、β-hCG的变化及其对胎膜早破、妊娠结局的预测价值

目的 探讨B族链球菌孕妇感染血清炎症因子、Th1/Th2、β-绒毛膜促性腺激素（β-hCG）变化及对胎膜早破发生、妊娠结局的预测价值。方法 选取2016年3月—2019年1月攀枝花市妇幼保健院收治的168例B族链球菌感染孕妇（GBS感染组）及200例无B族链球菌感染孕妇（无GBS感染组）。根据是否发生胎膜早破将B族链球菌感染组孕妇分为无胎膜早破组147例、胎膜早破组21例，比较B族链球菌感染与未感染者、胎膜早破与无胎膜早破者血清炎症因子、Th1/Th2细胞因子［干扰素-γ（IFN-γ）、IL-2、IL-4、IL-10］、β-hCG水平、胎膜早破发生率、妊娠结局、新生儿Apgar评分。采用Logistic回归性分析影响胎膜早破发生的因素，采用受试者工作特征（ROC）曲线及ROC下面积（AUC）分析各指标预测胎膜早破发生的价值，采用Pearson法分析各指标与新生儿Apgar评分的相关性。结果 B族链球菌感染者IL-1、TNF-α、IFN-γ、IL-2、β-hCG水平及胎膜早破发生率、不良妊娠结局发生率较无B族链球菌感染者高，IL-4、IL-10水平较无B族链球菌感染者低（P <0.05）；胎膜早破组患者IL-1、TNF-α、IFN-γ、IL-2、β-hCG水平较无胎膜早破组患者高，IL-4、IL-10水平及新生儿Apgar评分较无胎膜早破组患者低（P <0.05）；高IL-1水平［O^R=3.161（95% CI：2.551，3.916）］、TNF-α水平［O^R=1.985（95% CI：1.367，2.883）］、IFN-γ水平［O^R=1.526（95% CI：1.269，1.834）］、IL-2水平［O^R=1.809（95% CI：1.112，2.943）］及β-hCG水平［O^R=2.944（95% CI：1.819，4.765）］是胎膜早破发生的危险因素（P <0.05），高IL-4水平［O^R=0.397（95% CI：0.204，0.771）］与IL-10水平［O^R=0.545（95% CI：0.531，0.559）］是胎膜早破的保护因素（P <0.05）；预测胎膜早破的AUC IFN-γ> IL-2 >β-hCG> IL-4 > IL-1 > TNF-α > IL-10，截断值依次为>12.99 ng/ml（敏感性为61.90%，特异性为82.31%）、> 10.6 ng/ml（敏感性为85.71%，特异性为55.10%）、>13 280.64 IU/L（敏感性为90.48%，特异性为46.26%）、< 2.12 ng/ml（敏感性为71.43%，特异性为62.59%）、>0.4 ng/ml（敏感性为66.67%，特异性为69.39%）、>435.56 pg/ml（敏感性为95.24%，特异性为31.97%）、<2.12 ng/ml（敏感性为47.62%，特异性为73.47%）；IL-1、TNF-α、IFN-γ、IL-2、β-hCG水平与新生儿Apgar评分呈负相关，IL-4、IL-10水平与新生儿Apgar评分呈正相关（P <0.05）。结论 B族链球菌感染孕妇血清IL-1、TNF-α炎症因子与β-hCG水平较高，Th1/Th2失衡，检测外周血各指标水平，可预测胎膜早破的发生及妊娠结局。