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and acute&#44; motor and sensory&#44; axonal neuropathy &#40;AMSAN&#41; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> One third of these patients required ventilatory support&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> Most patients profited from immunoglobulins or plasmapheresis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> The study is appealing but raises concerns that require discussion&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We do not agree with the question mark at the end of the title&#46; There is ample evidence that not only the virus but also the vaccination can trigger GBS&#46; Arguments for a causal association between SARS-CoV-2 infections and GBS are that as per the end of June 2021 at least 300 cases with SARS-CoV-2 associated GBS have been reported &#91;Finsterer&#44; submitted for publication&#93;&#44; that there is a line-safe connex between the infection and the onset of GBS&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> that even the vaccination can trigger GBS&#44; and that the cytokine storm&#44; characteristic for the immune response against the virus&#44; can not only be documented in the serum but also in the cerebro-spinal fluid &#40;CSF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> We do not agree with the notion that the annual incidence of GBS needs to increase to serve as an argument for a causal relation between infection and GBS&#46; If the population to which the number of GBS cases is related is high&#44; an increase in the number of GBS cases may be hardly comprehensible&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">An indirect argument for a causal relation between the virus and GBS is that the prevalence of SARS-CoV-2 associated GBS is most likely underestimated&#46; This is because mild cases can go unrecognised&#44; work-up for suspected GBS is frequently not initiated because of limited resources or restrictions with the application of certain diagnostic tools to infected patients&#44; and because GBS may not be suspected in patients on the intensive care unit &#40;ICU&#41; undergoing mechanical ventilation&#46; Indications for GBS in ICU patients are if weaning from the respirator is not feasible despite absence of pneumonia&#44; if there is muscle weakness and missing tendon reflexes despite discontinuation of the sedation&#44; and if there are cranial nerve lesions in the absence of a central nervous system lesion&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We partially agree with the results of the index study&#46; In a recent review about the frequency of SARS-CoV-2 associated GBS between the beginning of January 2020 and the end of June 2020&#44; 33 patients&#44; aged 21&#8211;84 years&#44; with SARS-CoV-2 associated GBS were collected &#91;Finsterer&#44; submitted for publication&#93;&#46; The male to female ratio was 1&#46;8&#46; In two cases did GBS occur prior to clinical manifestations of the SARS-CoV-2 infection&#44; most likely due to initially subclinical infection with the virus&#46; The latency between onset of COVID-19 and the GBS ranged between &#8722;9 and 24 days&#46; Contrary to the index review four patients with acute motor&#44; axonal neuropathy &#40;AMAN&#41; and two with Miller&#8211;Fisher syndrome &#40;MFS&#41; were found in addition to 22 patients with AIDP and 2 with AMSAN&#46; Immunoglobulines were given to 27 patients and plasmapheresis was applied in six cases&#46; Nine patients required mechanical ventilation&#46; Complete recovery was achieved in nine patients and partial recovery in 19 cases&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Overall&#44; the review by Esteban Molina rather supports than questions the causal link between infection and GBS&#46; Intensive care doctors and neurologist should be encouraged to initiate work-up for GBS if there is the slightest suspicion as early treatment may shorten rehabilitation and can prevent fatal outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">No funding was received&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author contribution</span><p id="par0035" class="elsevierStylePara elsevierViewall">JF&#58; design&#44; literature search&#44; discussion&#44; first draft&#44; critical comments&#44; FS&#58; literature search&#44; discussion&#44; critical comments&#44; final approval&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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Letter to the Editor
Ample evidence suggests SARS-CoV-2 triggers polyradiculitis
Una amplia evidencia sugiere que el SARS-CoV-2 desencadena la polirradiculitis
J. Finsterer
Corresponding author
fifigs1@yahoo.de

Corresponding author.
, F.A. Scorza
Disciplina de Neurociência, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil
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      "titulo" => "The midline venous catheter in critically ill COVID-19 patients"
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            "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; The basilic vein of the arm is patent and with an optimal size for canulation &#40;6&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; v&#46; vein&#46; &#40;b&#41; The guidewire is in the vein lumen &#40;arrows&#41;&#59; v&#46; vein&#46; &#40;c&#41; The catheter tip lies in the axillary vein &#40;arrow&#41;&#59; v&#58; vein&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We eagerly read the review article by Esteban Molina et al&#46; about SARS-CoV-2 associated Guillain&#8211;Barre syndrome &#40;GBS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> The authors collected 39 patients with SARS-CoV-2 associated GBS reported from 14 countries all over the world between January 2020 and June 2020&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> Half of the patients were older than 60 years and almost 70&#37; were male&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> The most common GBS subtypes were acute&#44; inflammatory demyelinating polyneuropathy &#40;AIDP&#41; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>27&#41; and acute&#44; motor and sensory&#44; axonal neuropathy &#40;AMSAN&#41; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> One third of these patients required ventilatory support&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> Most patients profited from immunoglobulins or plasmapheresis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> The study is appealing but raises concerns that require discussion&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We do not agree with the question mark at the end of the title&#46; There is ample evidence that not only the virus but also the vaccination can trigger GBS&#46; Arguments for a causal association between SARS-CoV-2 infections and GBS are that as per the end of June 2021 at least 300 cases with SARS-CoV-2 associated GBS have been reported &#91;Finsterer&#44; submitted for publication&#93;&#44; that there is a line-safe connex between the infection and the onset of GBS&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> that even the vaccination can trigger GBS&#44; and that the cytokine storm&#44; characteristic for the immune response against the virus&#44; can not only be documented in the serum but also in the cerebro-spinal fluid &#40;CSF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> We do not agree with the notion that the annual incidence of GBS needs to increase to serve as an argument for a causal relation between infection and GBS&#46; If the population to which the number of GBS cases is related is high&#44; an increase in the number of GBS cases may be hardly comprehensible&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">An indirect argument for a causal relation between the virus and GBS is that the prevalence of SARS-CoV-2 associated GBS is most likely underestimated&#46; This is because mild cases can go unrecognised&#44; work-up for suspected GBS is frequently not initiated because of limited resources or restrictions with the application of certain diagnostic tools to infected patients&#44; and because GBS may not be suspected in patients on the intensive care unit &#40;ICU&#41; undergoing mechanical ventilation&#46; Indications for GBS in ICU patients are if weaning from the respirator is not feasible despite absence of pneumonia&#44; if there is muscle weakness and missing tendon reflexes despite discontinuation of the sedation&#44; and if there are cranial nerve lesions in the absence of a central nervous system lesion&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We partially agree with the results of the index study&#46; In a recent review about the frequency of SARS-CoV-2 associated GBS between the beginning of January 2020 and the end of June 2020&#44; 33 patients&#44; aged 21&#8211;84 years&#44; with SARS-CoV-2 associated GBS were collected &#91;Finsterer&#44; submitted for publication&#93;&#46; The male to female ratio was 1&#46;8&#46; In two cases did GBS occur prior to clinical manifestations of the SARS-CoV-2 infection&#44; most likely due to initially subclinical infection with the virus&#46; The latency between onset of COVID-19 and the GBS ranged between &#8722;9 and 24 days&#46; Contrary to the index review four patients with acute motor&#44; axonal neuropathy &#40;AMAN&#41; and two with Miller&#8211;Fisher syndrome &#40;MFS&#41; were found in addition to 22 patients with AIDP and 2 with AMSAN&#46; Immunoglobulines were given to 27 patients and plasmapheresis was applied in six cases&#46; Nine patients required mechanical ventilation&#46; Complete recovery was achieved in nine patients and partial recovery in 19 cases&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Overall&#44; the review by Esteban Molina rather supports than questions the causal link between infection and GBS&#46; Intensive care doctors and neurologist should be encouraged to initiate work-up for GBS if there is the slightest suspicion as early treatment may shorten rehabilitation and can prevent fatal outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">No funding was received&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author contribution</span><p id="par0035" class="elsevierStylePara elsevierViewall">JF&#58; design&#44; literature search&#44; discussion&#44; first draft&#44; critical comments&#44; FS&#58; literature search&#44; discussion&#44; critical comments&#44; final approval&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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Article information
ISSN: 21735727
Original language: English
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