A case of recurrent Miller-Fisher syndrome with multiple anti-ganglioside antibodies / 中国综合临床

Guillain-Barré syndrome (GBS) defines a kind of Immune-mediated acute inflammatory peripheral neuropathy. Miller-Fisher Syndrome (MFS) is a special variant of GBS, with mostly one-way course and rare clinical recurrence. Only a few recurrent cases have been reported in China. Here we report a case of a young male patient with double vision and progressive aggravation of limb numbness, acute onset, with symptoms of upper respiratory tract infection before onset, accompanied by pupil abnormalities and autonomic nervous dysfunction, who was was admitted to our hospital for similar symptoms 3 years ago and was improved by immunotherapy. The patient had a triad of “ataxia, areflexia and ophthalmoplegia”. Cerebrospinal fluid showed protein-cell separation. Serum anti-Sulfatides antibody IgM, anti-GT1a antibody IgG, anti-GQ1b antibody IgG and anti-GM3 IgM were positive. Recurrent MFS was diagnosed and the symptoms improved after immunotherapy. This case suggests that MFS is clinically heterogeneous, a few patients can present with relapse and generally have a better prognosis with immunotherapy. Pre-existing infection and anti-GQ1b antibody production may be predisposing factors for MFS recurrence.

Research on the application of Miller's pyramid theory combined with Bahrain's team activities in standardized residency training of burn surgeons / 中华医学教育探索杂志

Objective:To explore the application of Miller's pyramid theory combined with Bahrain's team activities in the standardized residency training (SRT) of burn surgeons.Methods:Seventy-four residents who were on the SRT program in the Department of Burns & Wound Care in The Second Affiliated Hospital of Zhejiang University were enrolled in the study. The students were divided into control group and observation group according to the teaching methods. Thirty-seven students in the control group were provided with conventional teaching, and 37 students in the observation group were provided with training based on Miller' pyramid theory combined with Bahrain's team activities. The two groups were evaluated for teaching effectiveness and doctor-patient communication skills. SPSS22.0 was used for the chi-square test and t test. Results:The evaluation outcome of teaching effectiveness in the observation group was better than that in the control group ( t=3.01, 3.47, 3.49, 3.32, and 2.54; P=0.004, 0.001, 0.001, 0.001, and 0.013). After the training, the scores of Set Elicit Give Understand End scale in the two groups increased, with significantly higher scores achieved in the observation group than in the control group ( t=3.23, 2.99, 2.07, 3.62, 3.00, and 7.89; P=0.002, 0.004, 0.042, 0.001, 0.004, and <0.001). Conclusion:The application of Miller's pyramid theory and Bahrain's team activities in the SRT of burn surgeons can improve students' evaluation of teaching effectiveness and improve their doctor-patient communication skills.

Evaluation of pediatric patients presenting with acute-onset unilateral transient acquired blepharoptosis / Avaliação de pacientes pediátricos apresentando blefaroptose transitória unilateral de início agudo

ABSTRACT Purpose: To evaluate the clinical features of pediatric patients with acute-onset, unilateral transient acquired blepharoptosis. Methods: In this retrospective study, the clinical records of patients between April 2015 and June 2020 were reviewed for evaluation of demographic features, accompanying neurological and ophthalmologic manifestations, symptom duration, etiological cause, and imaging findings. Patients with congenital and acquired blepharoptosis with chronic etiologies were excluded. Results: Sixteen pediatric patients (10 boys and 6 girls) with acquired acute-onset unilateral transient blepharoptosis were included in this study. The patients' mean age was 6.93 ± 3.16 years. The most commonly identified etiological cause was trauma in 7 patients (43.75%) and infection (para-infection) in 5 patients (31.25%). In addition, Miller Fisher syndrome, Horner syndrome secondary to neuroblastoma, acquired Brown's syndrome, and pseudotumor cerebri were identified as etiological causes in one patient each. Additional ocular findings accompanied blepharoptosis in 7 patients (58.33%). Blepharoptosis spontaneously resolved, without treatment, in all the patients, except those with Miller Fisher syndrome, neuroblastoma, and pseudotumor cerebri. None of the patients required surgical treatment and had ocular morbidities such as amblyopia. Conclusion: This study demonstrated that acute-onset unilateral transient blepharoptosis, which is rare in childhood, may regress without the need for surgical treatment in the pediatric population. However, serious pathologies that require treatment may present with blepharoptosis.

RESUMO Objetivo: Avaliar as características clínicas de pacientes pediátricos com blefaroptose adquirida unilateral, transitória e de início agudo. Métodos: Neste estudo retrospectivo, foram revisados prontuários clínicos entre abril de 2015 e junho de 2020. Os pacientes foram avaliados em termos de características demográficas, manifestações neurológicas e oftalmológicas associadas, duração dos sintomas, etiologia e achados de imagem. Foram excluídos pacientes com blefaroptose congênita e com blefaroptose adquirida de etiologia crônica. Resultados: Foram incluídos neste estudo 16 pacientes pediátricos (10 masculinos e 6 femininos) com blefaroptose adquirida transitória unilateral de início agudo. A média de idade dos pacientes foi de 6,93 ± 3,16 anos. As causas etiológicas mais comumente identificadas foram trauma em 7 pacientes (43,75%) e infecção (casos parainfecciosos) em 5 pacientes (31,25%). Além disso, a síndrome de Miller-Fisher, a síndrome de Horner secundária a neuroblastoma, a síndrome de Brown adquirida e pseudotumor cerebral foram determinados como causas etiológicas em um paciente cada uma. Achados oculares adicionais estavam associados à blefaroptose em 7 pacientes (58,33%). Foi observada a resolução espontânea da blefaroptose, sem tratamento, em todos os pacientes, exceto nos pacientes com síndrome de Miller-Fisher, neuroblastoma e pseudotumor cerebral. Nenhum paciente precisou de tratamento cirúrgico. Morbidades oculares, como ambliopia, não foram encontradas em nenhum paciente. Conclusão: Este estudo demonstrou que a blefaroptose transitória unilateral de início agudo, rara na infância, pode regredir sem a necessidade de tratamento cirúrgico na população pediátrica. No entanto, também não deve ser esquecido que patologias graves que requerem tratamento podem se apresentar com blefaroptose.

Case-based practical examination as an introduction to formative assessment in pathology: Undergraduate student’s perception

Background: In pathology, students are assessed by both theory as well as practical examination, but we have more upper hand and regularity in conducting theory assessment over practical evaluation. We have put newer case-based practical examination (CBPE) module over traditional one to achieve better practical approach which consists of case scenario pertaining to hematology and urine exercise followed by its interpretation without performing procedure. Aim and Objectives: The objective of this study were to develop and implement this new method of CBPE as a formative assessment tool for undergraduate 2nd year medical students. Materials and Methods: We have included MBBS undergraduate students of 4th semester by dividing students into two groups. Each group consists of 25 students. Group 1 was exposed to CBPE of hematology and urine exercises, while Group 2 was exposed to conventional method of hematology and urine exercises. Evaluation form was given to each student at the end of session to know their perception and opinion regarding this newer form of practical examination. Results: Mean marks scored in Group 1(CBPE) were 28 and in Group 2 (conventional) were 20.32 out of 40 marks. We had used unpaired t-test to calculate significance with P value which was found to be 0.0012. Feedback was based on five-point Likert scale. Most of the faculty members and students gave positive opinion for case-based pattern. Conclusion: CBPE can be used as alternative to conventional practical examination for formative assessment with improvement in performance of students.

Síndrome de Miller-Fisher durante el embarazo

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Miller-Fisher syndrome is a rare, acute, autoimmune, demyelinating disorder which is considered a variant of Guillain-Barré syndrome. The pathologic mechanism is unclear, but acute demyelinating polyneuropathies may be triggered by bacterial or viral infections, major surgical interventions, or vaccination. Pregnancy may be a trigger of the immune response causing the onset of the syndrome. Miller-Fisher syndrome is characterized by acute onset, with predominant involvement of the facial and cranial nerves resulting in ophthalmoparesis, ataxia, and areflexia/hyporeflexia. Diagnosis is based on clinical suspicion together with the determination of specific ganglioside antibodies and other laboratory and imaging tests. Treatment consists of intravenous immunoglobulin and plasmapheresis, together with supportive measures. There are few reports of the syndrome occurring in pregnant women. A case of Miller-Fisher syndrome during pregnancy is presented.

INTRODUCTION Miller-Fisher syndrome (MFS) is a rare disorder that is characterized by acute onset of ophthalmoparesis, ataxia and hyporeflexia / areflexia(1). It was recognized 60 years ago as a variant of Guillain-Barré syndrome (GBS). The annual incidence is 0.09 per 100,000 persons and affects more males than females with a 2:1 ratio(2). GBS usually follows Campylobacter jenuni, cytomegalovirus, Epstein-Barr and influenza virus infections or secondary to major surgery, pregnancy, or vaccination(3,4). MFS accounts for 5%-10% of GBS cases and may have a major autoimmune component due to the presence of anti-ganglioside antibodies. During the acute phase of the disease, these antibodies have a diagnostic sensitivity and specificity of 92% and 97%, respectively(5). MFS during pregnancy is rare and there are only reports of 5 cases in pregnant women. A case of Miller-Fisher syndrome during pregnancy is presented. CLINICAL CASE The patient was 16 years old, primigravida of 20 weeks, who was referred for presenting nausea and incoercible vomiting of five days of evolution, accompanied by double vision, generalized weakness, ataxia,

Warren Miller y el Modelo TDI-B de toma de decisiones reproductivas: Una revisión teórica / Warren Miller and the T-D-I-B reproductive decision-making model: A theoretical review / Warren Miller e o Modelo T-D-I-B de tomada de decisões reprodutivas: Uma revisão teórica

El presente estudio teórico objetiva sistematizar los aspectos más importantes del modelo Trait-Desires-Intentions-Behaviors (T-D-I-B) de Warren Miller que explica las decisiones reproductivas. Organizamos la información en base a cuatro ejes temáticos: 1) Elementos biográficos de Warren Miller y sus primeras producciones científicas sobre el comportamiento reproductivo; 2) Descripción del modelo T-D-I-B; 3) Definición del modelo diádico donde las estructuras motivacionales de dos socios interactúan a medida que se desarrolla la secuencia de cuatro pasos de cada individuo y; 4) Exposición de la evidencia empírica del modelo T-D-I-B y estudios actuales realizados en Irán, Polonia, Brasil y Perú.

The present theoretical study aims to systematize the most important aspects of Warren Miller's Trait-Desires-Intentions-Behaviors (T-D-I-B) model that explains reproductive decisions. We organize the information based on four thematic axes: 1) Biographical elements of Warren Miller and his first scientific productions on reproductive behavior; 2) Description of the T-D-I-B model; 3) Definition of the dyadic model where the motivational structures of two partners interact as each individual's four-step sequence develops and 4) Exposure of the empirical evidence of the T-D-I-B model and current studies carried out in Iran, Poland, Brazil and Peru.

O presente estudo teórico visa sistematizar os aspectos mais importantes do modelo Traço-Desejo-Intenções-Comportamentos (T-D-I-B) de Warren Miller, que explica as decisões reprodutivas. Organizamos as informações com base em quatro eixos temáticos: 1) Elementos biográficos de Warren Miller e suas primeiras produções científicas sobre comportamento reprodutivo; 2) Descrição do modelo T-D-I-B; 3) Definição do modelo diádico em que as estruturas motivacionais de dois parceiros interagem conforme a sequência de quatro etapas de cada indivíduo se desenvolve; 4) Exposição da evidência empírica do modelo T-D-I-B e estudos atuais realizados no Irã, Polônia, Brasil e Peru.

Disfagia e Disfonia em um caso de Síndrome de Miller Fisher: Avaliação fonoaudiológica / Dysphagia and Dysphonia in a case of Miller Fisher Syndrome: Speech therapy evaluation

RESUMO Relato de caso de um paciente do sexo masculino internado no pronto socorro de um hospital com síndrome de Miller Fisher (SMF). A SMF é caracterizada pela presença de uma tríade de sinais: oftalmoparesia, arreflexia e ataxia, podendo apresentar outros sinais menos frequentes como alterações de fala e de deglutição. A partir da avaliação fonoaudiológica foi possível identificar disfagia orofaríngea de grau grave, hipernasalidade vocal e outras alterações fonoarticulatorias. O paciente apresentou boa evolução a partir de uma terapêutica multiprofissional integrada, incluído atendimento fonoaudiológico.

SUMMARY The case report of a male patient admitted to the emergency hospital with the diagnosis of Miller Fisher syndrome (MF), is presented. MFS is characterized by the presence of a triad of signs: ophthalmoparesis, areflexia and ataxia, and may present other less frequent signs such as speech and swallowing disorders. On the basis of findings during the speech therapy evaluation it was possible to identify severe oropharyngeal dysphagia, vocal hypernasality and other speech disorders. The patient presented a good evolution following an integrated multi-professional treatment program, including speech-language therapy.

Clinical application of the new classification criteria in children with Miller Fisher syndrome and clinical characteristics analysis of different types of Miller Fisher syndrome / 中华实用儿科临床杂志

Objective:To investigate the clinical application of the new classification criteria in children with Miller Fisher syndrome (MFS), and to analyze clinical characteristics of different types of MFS.Methods:Clinical data of MFS patients hospitalized in the Department of Neurology, Beijing Children′s Hospital, Capital Medical University from January 2015 to December 2019 were collected and analyzed retrospectively, including demographic characteristics, clinical symptoms, neurological examination findings, laboratory examination data, diagnosis and treatment, and prognosis.The counting data was described by percentage, and the measurement data was described by median.Results:A total of 23 patients were included in the research, including 14 males and 9 females, with a median age of 4 years and 8 months.There were 3 cases of pure MFS; 5 cases of incomplete MFS, including 1 case of acute ptosis and 4 cases of acute ataxia neuropathy; 15 cases of overlapping syndrome, including 13 cases of MFS/Guillain Barre syndrome (GBS), 1 case of MFS/pharyngocervical brachial variant GBS(PCB GBS)and 1 case of MFS/GBS/Bickertaff brainstem encephalitis (BBE). In addition to Ⅲ, Ⅳ and Ⅵ cranial nerve palsy, 11 cases had the involvement of other cra-nial nerves, including 2 cases in pure MFS, 8 cases in MFS/GBS and 1 case in MFS/GBS/BBE.Autonomic nervous dysfunction occurred in 6 cases.Respiratory muscle paralysis occurred in 6 cases, including 5 cases in MFS/GBS and 1 case in MFS/GBS/BBE.Graded by the Hughes scoring system (HG score), 3 cases with pure MFS were graded 4 points; 1 case with acute ptosis was graded 0; 3 cases with acute ataxia neuropathy were graded 2 points, and the other one was graded 3 points; 1 case with MFS/PCB GBS was graded 3 points; 10 cases with MFS/GBS were graded 4 points, 1 case was graded 3 points, and the other 2 cases were graded 2 points; 1 case with MFS/GBS/BBE was graded 4 points.Twenty-two patients were treated with intravenous immunoglobulin.The HG of all patients at discharge decreased at varying degree, which was graded 0 at 6 months of follow-up.Conclusions:The clinical application of the new diagnostic classification method is helpful to the accurate diagnosis of different types of MFS.More than half of MFS cases will develop into the overlapping syndrome.The overlapping of MFS and GBS or BBE is prone to the involvement of cranial nerves except for the external ophthalmic muscles, autonomic nerve dysfunction and respiratory muscle paralysis.The disease course of MFS varies, and its diagnosis should be comprehensively made.All cases of MFS in this study have a satisfactory prognosis.

Casos clínicos de los síndromes de Guillain-Barré y Miller-Fisher relacionados con la COVID-19 / Clinical cases of Guillain-Barré and Miller-Fisher syndromes linked to COVID-19

Introducción: la enfermedad por coronavirus del 2019 (COVID-19), causada por el nuevo coronavirus SARSCoV-2, se ha asociado con el desarrollo de enfermedades neurológicas como el síndrome de Guillain-Barré (SGB) y sus variantes. En el presente trabajo se reportan dos casos de síndromes desmielizantes asociados con la COVID-19. Casos clínicos: hombre de 53 años con SGB y mujer de 29 años con la variante del síndrome de Miller-Fisher (SMF), respectivamente. Ambos presentaron los signos y síntomas neurológicos clásicos de polineuropatía desmielinizante que caracterizan a estos síndromes. De las pruebas bioquímicas paraclínicas, el aumento de proteínas en líquido cefalorraquídeo fue distintiva. La positividad de la RT-qPCR para el SARS-CoV-2 indicó la asociación de los SGB y SMF con la COVID-19. Ambos pacientes se trataron con inmunoglobulina intravenosa y mostraron mejoría. La electromiografía realizada en semanas posteriores aún mostrabaafectación desmielinizante crónica. Conclusión: los casos de los SGB y SMF, junto con otros casos similares reportados en todo el mundo, proporcionan más evidencia para el SARS-CoV-2 como nueva posible etiología de estas raras enfermedades neurológicas.

Background: coronavirus disease 2019 (COVID-19), caused by the new coronavirus SARS CoV-2, has been associated with the development of neurological diseases such as Guillain-Barré syndrome (GBS) and its variants. In the present work, two cases of demyelinating syndromes associated with COVID-19 are reported. Clinical cases: 53-year-old male with GBS and and 29-yearold female with Miller-Fisher syndrome (MFS) variant, respectively. Both patients presented the classic neurological signs and symptoms of demyelinating polyneuropathy that characterizes the syndromes. From the paraclinical biochemical tests, the increase of proteins in cerebrospinal fluid was distinctive. The positivity of the RT-qPCR for SARSCoV-2 suggested the association of GBS and MFS with COVID-19. Both patients were treated with intravenous immunoglobulin showing improvement. Electromyography performed weeks ahead still showed chronic demyelinating involvement. Conclusion: The cases of GBS and MFS, along with other similar cases reported around the world, provide further evidence for SARS-CoV-2 as a new possible etiology of these rare neurological diseases.

Síndrome de Miller Fisher, un desafío diagnóstico de oftalmoplejía: reporte de un caso / Miller Fisher syndrome, a diagnostic challenge of ophthalmoplegia: a case report

El síndrome de Guillain-Barré (SGB), y sus derivados, entre ellos el síndrome de Miller Fisher (SMF); junto a otras patologías de origen neurológico como la Polineuropatía desmielinizante inflamatoria crónica (CIDP), las polineuropatías de causa metabólica, miastenia gravis, esclerosis lateral amiotrófica (ELA), síndrome de Lambert-Eaton, encefalopatía de Wernicke entre otras; presentan signos y síntomas neurológicos de presentación común. De este modo, la importancia del examen neurológico acabado; y los exámenes de apoyo diagnóstico como: laboratorio -destacando el líquido cefalorraquídeo (LCR)-, electromiografía, y toma de imágenes, son cruciales para esclarecer el diagnóstico. Así, es posible ofrecer un tratamiento de forma precoz, basado en la evidencia, y con el objetivo de disminuir la letalidad de la enfermedad. En el presente texto se plasma un subgrupo de patología de SGB, el SMF, el cual posee una incidencia significativamente baja, una clínica característica, y un pronóstico bastante ominoso sin un tratamiento adecuado. En el presente texto se plasma el reporte de un caso abordado en el Hospital San Pablo de Coquimbo, Chile.

Guillain-Barré syndrome (GBS) and its derivatives, including Miller Fisher syndrome (MFS), along others pathologies of neurological origin such as chronic inflammatory demyelinating polyneuropathy (CIDP), metabolic polyneuropathies, myasthenia gravis, amyotrophic lateral sclerosis (ALS), Lambert-Eaton syndrome, Wernicke's encephalopathy and well as others, have common neurological signs and symptoms. In this way, the importance of a thorough neurological examination, and supporting diagnostic tests such as: laboratory, -cerebrospinal fluid (CSF)-electromyography, and imaging, are crucial to clarify the diagnosis. Thus, it is possible to offer early, evidence-based treatment with an aim of reducing the disease's lethality. In the text below we present a subgroup of GBS pathology, MFS, which has a significantly low incidence, a characteristic clinical picture, and a rather ominous prognosis without adequate treatment. In the following text/paper is shown the report of a case approached in San Pablo Hospital, from Coquimbo, Chile.

Síndrome de Miller Fisher tratado con plasmaféresis durante el embarazo: reporte de un caso y revisión de la literatura / Miller Fisher syndrome treated with plasmapheresis during pregnancy: Case report and review of the literature

Resumen Objetivo: Reportar el caso de una paciente gestante con síndrome de Guillain-Barré (SGB) presentado en la variante denominada síndrome de Miller Fisher (SMF), y realizar una revisión en torno al diagnóstico, tratamiento y pronóstico de esta variedad de SGB durante la gestación. Materiales y métodos: Se presenta el caso de una gestante de 27 semanas con síndrome de Miller Fisher, quien fue tratada con plasmaféresis en un hospital militar de referencia, con evolución satisfactoria a los 15 días y continuación normal del embarazo, parto a las 38 semanas con recién nacido sano. Se realizó una búsqueda bibliográfica en bases de datos electrónicas: Medline vía PubMed, Lilacs, SciELO, ScienceDirect, Ovid, con los términos "Embarazo", "Síndrome de Miller Fisher", "Síndrome de Guillain-Barré". Se incluyeron cohortes, series y reportes de casos de mujeres gestantes con síndrome de Miller Fisher; se extrajo información sobre los métodos diagnósticos, el tratamiento utilizado y el pronóstico materno y perinatal. La búsqueda se hizo en junio de 2020, sin restricción por fecha, pero sí por tipo de idioma (español e inglés). Resultados: Se identificaron 423 títulos, tres estudios cumplieron los criterios de inclusión, los tres correspondieron a reportes de caso. Todos los casos mostraron seropositividad para antigangliósidos GQ1b positivos; en ningún caso hubo alteración imagenológica. Dos pacientes recibieron inmunoglobulina intravenosa y la tercera paciente se dejó en observación. Hasta el momento no se documentan complicaciones obstétricas. Conclusión: Existen pocos casos reportados de SMF durante la gestación, el diagnóstico se basa en el examen clínico; el tratamiento con inmunoglobulina IV representa la alternativa utilizada con mayor frecuencia. En el caso presentado se utilizó la plasmaféresis. Se desconoce el impacto de la variedad del síndrome de Miller Fisher sobre el curso normal de la gestación y sobre los resultados perinatales a largo plazo. Se requieren más estudios que aborden el diagnóstico, el tratamiento y el pronóstico de esta entidad.

Abstract Objective: To report the case of pregnant woman with Guillain-Barré syndrome (GBS) presenting as the Miller Fisher variant, and to review the literature on the diagnosis, treatment and prognosis of this GBS variant during gestation. Materials and Methods: Pregnant woman presenting at 27 weeks of gestation with Miller Fisher syndrome (MFS), treated in a military referral hospital with a satisfactory course after 15 days, continuation of normal pregnancy and delivery of a healthy neonate at 38 weeks. A search of the literature was conducted in the Medline via PubMed, Lilacs, SciELO, ScienceDirect and Ovid databases using the terms "Pregnancy," "Miller Fisher syndrome," "Guillain-Barré syndrome". Cohorts, case series and case reports of pregnant women with MFS were included. Data on diagnostic methods, treatment and maternal and perinatal prognosis were extracted. The search was made on June 2020, with no restriction by date, but restriction by language (Spanish and English). Results: Overall, 423 titles were identified, three studies met the inclusion criteria, the three of them corresponding to case reports. All cases were found to be seropositive for anti-GQ1b ganglioside antibodies. No imaging abnormalities were found in any of the cases. Two patients received IV immunoglobulin and the third patient was kept under observation. No obstetric complications have be documented so far. Conclusion: There are few cases of MFS reported during pregnancy. Intravenous immunoglobulin is the most frequently used treatment option. Plasmapheresis was used in the case presented here. The impact of the Miller Fisher variant on the normal course of gestation and on long-term perinatal outcomes is unknown. Further studies that look into the diagnosis, treatment and prognosis of this condition are required.

A study on the influence of situational simulation training combined with Miller pyramid teaching on emergency response ability and nursing skills of operating room nurses / 中华医学教育探索杂志

Objective:To explore the effect of situational simulation training combined with Miller pyramid teaching on emergency response ability and nursing skills of specialized nurses in operating room.Methods:A total of 56 disaster nursing trainees who received specialized nurse training in the operating room of Mianyang Central Hospital from June 2019 to June 2020 were selected in the study, and they were divided into control group and research group in average according to the order of training time. The control group adopted clinical one-to-one teaching, while the research group adopted situational simulation training combined with Miller pyramid teaching. After the training, the teaching effect of specialized nurse training was evaluated by their professional theoretical knowledge and nursing skill operation results, and self-designed assessment scale was used to evaluate the emergency response ability and satisfaction with the training effect of the nurses. SPSS 22.0 was used for t test and chi-square test. Results:The results of theoretical knowledge and nursing skills operation of specialize nurses in operating room in the research group were significantly higher than those in the control group, and the differences were statistically significant ( P<0.001). The scores of emergency capability assessment in the research group were significantly higher than those in the control group, with statistical significance ( P<0.001). The study group was better than the control group in 7 aspects of satisfaction, such as the improvement of the operation level of emergency ability, team cooperation ability, analysis and problem solving ability, clinical nursing decision-making ability, independent thinking ability and nurse-patient communication ability, with significant differences ( P<0.05). Conclusion:Situational simulation training combined with Miller pyramid teaching can significantly improve the emergency response ability, nursing skill operation and training satisfaction of operating room nurses, which is better than the traditional clinical teaching method, and is worthy of application and promotion in clinical nursing teaching.

Síndrome anti-GQ1b en un niño con síndrome de Miller-Fisher-Bickerstaff / Anti-GQ1b syndrome. A child with Miller-Fisher-Bickerstaff syndrome

El síndrome anti-GQ1b reúne el síndrome de Miller-Fisher y la encefalitis del tronco cerebral de Bickerstaff, entre otras entidades. Tienen etiopatogenia común, constituida por la presencia de anticuerpos anti-GQ1b que reaccionan contra los sitios GQ1b del sistema nervioso según sea su accesibilidad. La prevalencia anual del síndrome de Miller-Fisher es de 0,09 casos por 100 000 habitantes por año y no existen estudios epidemiológicos sobre la encefalitis del tronco cerebral de Bickerstaff, que sería menos frecuente. De evolución natural hacia la mejoría, se beneficia del tratamiento con gammaglobulina endovenosa.Se presenta a un paciente de 12 años con síndrome de Miller-Fisher­Bickerstaff tras un episodio de diarrea aguda por Campylobacter jejuni en el que los anticuerpos anti-GQ1b resultaron positivos. Es nuestro objetivo comunicar sobre un síndrome de presentación poco habitual en pediatría a fin de advertir acerca de la necesidad de su sospecha precoz y solicitud de estudios de laboratorio específico

Miller-Fisher syndrome and Bickerstaff brainstem encephalitis, among others, constitute the anti-GQ1b syndrome, with a common immune pathophysiologic pathway characterized by the presence of anti-GQ1b antibodies, which react against the different nervous system GQ1b sites according to their different accessibility. The Miller-Fisher syndrome has a prevalence of 0.09 cases per 100 000 people-year but there are not epidemiological studies about Bickerstaff brainstem encephalitis, that it seems to be less frequent. In spite of having a good natural outcome, the immunoglobulin administration has been established as efficacious at improving it. A twelve-year-old boy suffering from Miller-Fisher-Bickerstaff syndrome after an acute Campylobacter jejuni diarrhea with positive titers of anti-GQ1b and anti-QGT1a antibodies is presented. We communicate a very uncommon pediatric disease with the aim of warning about the importance of its early suspicion and the need of specific laboratory determination

Síndrome de Miller Fisher: relato de caso / Miller Fisher syndrome: case report

A síndrome de Miller Fisher é uma desmielinização dos nervos cranianos e periféricos, gerando graves consequências para o paciente, como, por exemplo, redução ou ausência dos reflexos, paralisia do III, IV e VI nervos cranianos e ataxia. Este relato descreveu o caso de uma mulher de 51 anos, natural e procedente de Penápolis (SP), admitida em um hospital de Araçatuba (SP) com quadro de arreflexia, ataxia e oftalmoplegia. No contexto clínico, foi suspeitada a hipótese de síndrome de Miller Fisher e, assim, começou o processo de investigação, com base nos critérios diagnósticos. O caso foi diagnosticado como síndrome de Miller Fisher, e o tratamento teve início.

Miller Fisher Syndrome is a demyelinating disease affecting cranial and peripheral nerves, leading to severe problems to the patient, such as reduced or absent reflexes, III, IV and VI cranial nerves palsy, and ataxia. This report describes the case of a 51-year-old woman from the city of Penápolis, in the state of São Paulo, who was admitted to the hospital in the city of Araçatuba, in the same state, with ataxia, areflexia and ophthalmoplegia. In the clinical context, the suspicion of Miller Fisher Syndrome was raised, and then investigation ensued for the disease, based on the diagnostic criteria. After evaluation, Miller Fisher Syndrome was confirmed and treatment was started.

Prevalencia e indicadores de riesgo de recesiones gingivales en adolescentes de Valdivia en el año 2018 / Prevalence and risk indicators of gingival recessions in school senior students in the city of Valdivia in 2018

OBJETIVO: Determinar la prevalencia de recesiones gingivales e identificar indicadores de riesgo, en estudiantes de cuarto medio de la ciudad de Valdivia en el año 2018. MATERIAL Y MÉTODOS: Estudio de corte transversal. Se midió la prevalencia, distribución y tipo de recesión gingival según clasificación de Miller en estudiantes de cuarto medio de establecimientos públicos y subvencionados de la ciudad de Valdivia, seleccionados mediante muestreo aleatorio estratificado. Dos examinadores calibrados realizaron un examen clínico utilizando una sonda periodontal carolina del norte y un cuestionario escrito individual a cada estudiante para evaluar indicadores de riesgo. Los datos fueron tabulados y el análisis estadístico se realizó usando el programa estadístico SPSS 18 (IBM® SPSS® software). RESULTADOS: Se examinaron 310 estudiantes. La prevalencia encontrada fue de 68,4%. La Clase I de Miller se presentó en un 97,7%. La arcada mandibular con un 64,8% presentó mayor prevalencia de recesiones gingivales y los premolares inferiores fueron los dientes más afectados con un 47,7%. CONCLUSIÓN: Existe una alta prevalencia de recesiones gingivales en la población estudiada. Los estudiantes de establecimientos públicos presentan significativamente mayor prevalencia de recesiones gingivales y menor frecuencia de cepillado.

AIM: To determine the prevalence of gingival recessions and identify risk indicators in school senior students in the city of Valdivia in 2018. MATERIAL AND METHODS: Descriptive observational study. Prevalence, distribution and type of gingival recession were measured according to Miller classification in school senior students of public and charter establishments in the city of Valdivia, selected by stratified random sampling. A clinical examination was performed by two calibrated examiners using a North Carolina periodontal probe and an individual written questionnaire for each student to assess risk indicators. A descriptive analysis was performed using the statistical program SPSS 18 (IMB® SPSS® software). RESULTS: 310 students were examined. The prevalence found of at least one gingival recession was 68.4%. Miller's Class I was present in 97.7%. The jaw presented a higher prevalence of gingival recessions with 64.8% and the lower premolars were the most affected teeth with 47.7%. CONCLUSION: There is a high prevalence of gingival recessions in the population studied. Students in public establishments have a higher prevalence of recessions and a lower frequency of tooth brushing.

Fresh leaves of ora-pro-nóbis in cakes prepared from commercial pre-mixture / Folhas frescas de ora-pro-nóbis em bolos preparados a partir de pré-mistura comercial

Establishing good eating habits in childhood is quite important for proper growth and development. Vegetables such as the ora-pro-nóbis (an unconventional vegetable, known in English speaking countries as Barbados Goosenberry, scientific name Pereskia aculeata Miller) have leaves that are rich in proteins, fibers and minerals, such as iron. These nutrients can contribute to improving child food products. In order to improve the nutritional value of commercial chocolate cake premixes, in natura ora-pro-nóbis leaves were added at ratios of 0 (standard), 10, 20, 30 and 40% leaf weight per batter weight, which were covered with chocolate icing. Moisture, ashes, lipids, proteins, crude fiber, carbohydrates and total caloric content (TCC) were analyzed in the elaborated formulations. The cakes with green leaves of ora-pro-nóbis are technologically viable up to 40% of leaf inclusion. The results showed a significant increase in water retention, crude fiber content and decrease in total caloric content (TCC) in cakes to which ora-pro-nóbis leaves were added. Lipid content was not affected by treatments.

O estabelecimento de uma boa alimentação na infância é de suma importância para o crescimento e desenvolvimento adequados. Vegetais como a ora-pro-nóbis (hortaliça não convencional) que possuem em suas folhas proteínas, fibras e minerais como o ferro, podem contribuir para melhorar a alimentação infantil. Com objetivo de melhorar o valor nutricional de pré-misturas comerciais de bolo, foram adicionadas folhas de ora-pro-nóbis in natura na proporção de 0 (padrão), 10, 20, 30 e 40% de folhas em relação a massa de sólidos pré-formulada para elaboração do bolo de sabor chocolate, com cobertura de chocolate tipo brigadeiro. Foram realizadas análises de umidade, cinzas, lipídeos, proteínas, fibra bruta e determinados os teores de carboidratos e valor calórico total (VCT) nas formulações elaboradas. Os bolos elaborados com folhas de ora-pro-nóbis in natura são viáveis do ponto de vista tecnológico, até 40% de inclusão de folhas. Os resultados revelaram um aumento significativo na retenção de água, no teor de fibra bruta e diminuição do valor calórico total (VCT) nos bolos adicionados de folhas de ora-pro-nóbis. Não houve influência dos tratamentos sobre o conteúdo de lipídeos.

Comparison of Glottic View and Haemodynamic Stress Response Associated with Laryngoscopy using the Macintosh, McCoy and Miller Blades in Adult Patients

Introduction: Laryngoscopy induces haemodynamic responsewhich has implications for patients with cardiovascularillnesses. We devised this study to compare the laryngoscopicview of the glottis obtained with the Macintosh, McCoy andMiller blades, and corresponding haemodynamic changes.Material and Methods: 105 ASA grade I and II patientsrandomly divided into three groups were intubated usingMacintosh, McCoy and Miller blade respectively. Cormackand Lehane grade of glottic view obtained, heart rate, systolicand diastolic blood pressure at baseline, immediately beforeinduction, following induction, and at 1, 3 and 10 minutesafter intubation were noted. Epi Info 7.2 was used forstatistical analysis. Chi square and ANOVA tests were appliedto compare haemodynamic parameters.Results: 18 patients (51.4%) were CL grade I and 17 (48.6%)were CL grade II in Macintosh, 24 (68.6%) were CL gradeI and 11 (31.4%) were CL II in McCoy and, 32 (91.4%)were CL I and 3 (8.6%) were CL II in Miller group. Risein heart rate following intubation was greatest with Millerblade, followed by Macintosh and least with McCoy, andwas statistically significant (P< 0.01). Rise in both, systolicand diastolic blood pressure following intubation was highestwith the Miller blade, followed by Macintosh and least withMcCoy, and the difference compared with baseline values wasstatistically significant (P<0.01).Conclusions: Miller blade provides best visualization of larynxbut McCoy blade produced least haemodynamic response,hence the latter is preferable when less haemodynamicresponse is desired.

Clinical features of 19 children with Bickerstaff brainstem encephalitis / 中华儿科杂志

Objective@#To summarize the clinical features of Bickerstaff brainstem encephalitis (BBE) in children.@*Methods@#In this retrospective study, data of 19 patients with BBE (11 males and 8 females) were collected from Department of Neurology, Beijing Children′s Hospital from October 2015 to January 2018. The clinical features, treatment and prognosis were analyzed.@*Results@#The onset age of BBE ranged from 1 year and 8 months to 12 years and 11 months. There were 18 cases with preceding infection. The most common infection was upper respiratory tract infection (9 cases), followed by simple fever (5 cases). The most common initial neurological symptoms were lethargy or disturbance of consciousness (8 cases), followed by limb weakness (5 cases). There were 6 cases of simple BBE and 13 cases of BBE overlapping Guillain-Barré syndrome (GBS). Besides the characteristic triad of altered mental status, ataxia, and ophthalmoplegia, there were other symptoms including convulsion (5 cases), diplopia (3 cases), nystagmus (7 cases), facial muscular weakness (7 cases),bulbar palsy (13 cases) and autonomic nerve symptoms (9 cases). Hypo or areflexia was seen in 16 cases. Positive Babinski′s signs were seen in 8 cases. Hyponatremia was present in 10 cases in whom 4 showed severe hyponatremia. Albumin-cytological dissociation of cerebrospinal fluid was seen in 10 cases. The autoimmune antibodies were examined in all 19 patients. Anti-ganglioside antibodies including anti-GM1 IgG antibody was positive in 2 patients and one of whom was also found with positive anti-GD1b IgG antibody. Anti-GQ1b IgG antibody was present in 2 patients. Electromyography was performed in 14 cases and 8 cases, who were all BBE overlapping GBS, showed neurological damage. A total of 16 cases were monitored by video electroencephalography and 8 cases showed slow waves of background. In addition to, interictal focal discharge was detected in 2 cases. T2 fluid-attenuated inversion recovery (FLAIR) sequence abnormal signals were detected in 3 of 18 cases performed brain magnetic resonance imaging (MRI), and lesions involved with brainstem, basal ganglia, thalamus, cerebellum, corpus callosum and cerebral cortex. Lesions involved cervical and thoracic spinal cord were found in 1 out of 11 cases for whom spinal cord MRI was performed. All of the 4 cases who underwent enhanced MRI of spinal had partial nerve roots enhancement. All of the 19 patients received 1 to 2 courses of intravenous immunoglobulin therapy, and 2 cases also received plasma exchange. Fifteen cases received steroid therapy. The following-up period ranged from 3 months to 2.5 years. Two cases were lost to follow-up. Twelve cases achieved a full recovery within 3 months. Three cases recovered within 6 months. One case still had slight limb weakness and ataxia after 1 year and 8 months of follow-up, and another case had left autonomic nerve symptoms in the follow-up of 2 years and 3 months. Both of them were BBE overlapping GBS.@*Conclusions@#Children′s BBE is similar to that in adults, and is frequently found overlapped with GBS. Furthermore, it is sometimes accompanied by central nervous system demyelination disease. The antiganglioside antibodies are not often detectable. Immunoglobulin therapy could usually achieve good response. The prognosis of simple BBE is good in most situations. For BBE overlapping GBS, the more severe the limb weakness during the peak of disease is, the slower the recovery would be.

Recent Concepts of Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is a representative form of post-infectious autoimmune neuropathy with heterogenous manifestations. It was originally considered as an ascending demyelinating polyneuropathy in Western countries. However, the discovery of anti-ganglioside antibodies on the basis of molecular mimicry theory could help us better understand various kinds of focal and regional variants as well as axonal type of GBS those were frequently found from Asian countries. Recent development of new techniques about anti-ganglioside complex antibodies is making more detailed descriptions for specific or unusual clinical manifestations. It has been regarded that GBS has good prognosis if treated properly as early as possible, but it still shows high mortality and morbidity rate with frequent long term neurologic and medical complications. Unfortunately, there are only two options for medical treatment, intravenous immunoglobulin and plasmapheresis, for the last 100 years. Several clinical studies on new immunotherapy targeting complement activating system with background of molecular mimicry using animal model are underway. We hope that these new treatments will be helpful for the future patients.

Pattern of Extraocular Muscle Involvements in Miller Fisher Syndrome

BACKGROUND AND PURPOSE: The most-common initial manifestation of Miller Fisher syndrome (MFS) is diplopia due to acute ophthalmoplegia. However, few studies have focused on ocular motility findings in MFS. This study aimed to determine the pattern of extraocular muscle (EOM) paresis in MFS patients. METHODS: We consecutively recruited MFS patients who presented with ophthalmoplegia between 2010 and 2015. The involved EOMs and the strabismus pattern in the primary position were analyzed. Antecedent infections, other involved cranial nerves, and laboratory findings were also reviewed. We compared the characteristics of the patients according to the severity of ophthalmoplegia between complete ophthalmoplegia (CO) and incomplete ophthalmoplegia (IO). RESULTS: Twenty-five patients (15 males and 10 females) with bilateral ophthalmoplegia were included in the study. The most-involved and last-to-recover EOM was the lateral rectus muscle. CO and IO were observed in 11 and 14 patients, respectively. The patients were aged 59.0±18.4 years (mean±SD) in the CO group and 24.9±7.4 years in the IO group (p<0.01), and comprised 63.6% and 21.4% females, respectively (p=0.049). Elevated cerebrospinal fluid protein was identified in 60.0% of patients with CO and 7.7% of patients with IO (p=0.019) for a mean follow-up time from the initial symptom onset of 3.7 days. CONCLUSIONS: The lateral rectus muscle is the most-involved and last-to-recover EOM in ophthalmoplegia. The CO patients were much older and were more likely to be female and have an elevation of cerebrospinal fluid protein than the IO patients.