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do a thing. Hello, everyone. Welcome back to another mind to bleep weapon are from the urology team I'm out of school in I'm an F one doctor in Torbay Hospital. Got my colleague Terry is well, I another secretary call you or that's all right. Crackled. Sorry. Hi. Hello. On one of the neurology colleagues as well. And Terry's left one in the guilt foot area in Sorry, I think one or just Joe create. So the Southwest is limited at best, And so tonight was originally going to be on function urological disorders. But we have due to sort of unforeseen circumstances how the last minute change of speakers we've actually got next week session. I own peripheral. That's sort of that's been re rearranged it tonight. So sorry for any of you were expecting to come to a little from functional neurological disorders, but we will try to re arrange that for the future. As always, you convert you all of our webinars, including tonight by year, cheap as well as on metal. On a low slides from the previous talks are now available to download is pdf's well for those of you looking to revise a zoo Always. If you can provide feedback, fire the link that will upload in the chapped. And also, there'll be a QR codes a day. End of the presentation. Um, for tonight's you will get a stiff Get the news. Is your port failure COPD say I'm not going to be tonight. Speaker here is Dr James Talbert, who is on ST five. Neurology, registrar at the role, Devon and extra hospital. Currently, he's going to talk to our smart about peripheral nerve disorders. So Jemmy away you get okay. Brilliant. Thanks very much. So, yeah, I'm Jamie toe working extra at the moment on. I'm in ST five in urology. I'm gonna do this presentation on peripheral nerve disorders. Um, and I'm sorry if anyone wasn't collecting a presentation on functional disorders. Better peripheral nerve disorders is probably bit more the dry topic, but don't make it as interesting as possible. So I just outlined the the direction of travel, so to speak. Um, start by just talking about the anatomy and terminology associated with them peripheral nerve disorders, because it can get a bit confusing. Um, and then all of them try and then basically the aim of the presentations. Just Teo prepare you a bit to think about, um, presentations of peripheral nerve disorders on the way. You should really approach them when thinking diagnostically, um, ways and clues that you can pinpoint where the problem is and with reaching a diagnosis. Um, then I'll talk about some neuropathies not to be missed on. Then finally, I talked about peripheral neuropathy, just the the bread and butter of neurology. Really? Um, so peripheral nerve disorders could be a bit complicated on there's all this terminology if you ever get a nerve conduction. So the report. You'll see a lot of these terms thrown around things like demyelinating ganglion, opathy, neuropathy, and, um, and you can have symptoms feel a bit overwhelmed by what it'll means. And, um um, and I think we do to get into some extent because them, um, the neurophysiologist very much purveyors of the realm of brittle nerve problems. So So it takes a bit of getting used to and understanding the terminology in terms of the anatomy. You can think of the peripheral nervous system as, um, anything from the spinal cord. Um, well, where the nerve roots exit the spinal cord from from the anterior one really would probably be the first place to start from a a motor point of view. Um, from the motor fibers, leave the spinal cord vial eventual route whilst the sensory fibers. Um um, Levi, uh, the are the also columns on the smartest Lamictal act. Um, the motor five is the cell body is within the three anterior horn, whereas for sensory fibers, thie cell body of the Axiron is just outside is just next to the spinal cord. And then the toujeo, um, the two pathways converge into personal nerve. And then the nerve travels all the way down Teo Neuromuscular Junction, where there's a sign ups, um, in to the muscle. And it's important to know that, um, the nerve fibers contained within the grateful nerves a little slightly different. So it's the smallest of the fibers, which are unmyelinated. So the slow is conducting on may contain autonomic five is also sensory fibers, uh, containing pain on heat sensation. Um, and interestingly, these small fibers never really get tested when, with nerve conduction studies, they're just too small. So, um, whenever you're looking at results of nerve conduction studies, they're really looking at results from slightly larger axon. So motor five Isn't sensory fibers carrying more sort of vibration sense and things about, um, So, um um, so I'll talk a bit about nerve studies. Um, again, this is a subject which people get very tied up about, Um um, and it can be very confusing. Um, in reality, it's it's probably not as confusing as, well, that is a lot of terminology. And, um, it's very much a specialist area. But actually, when when it comes down to the principal's on really that confusing the nerve studies themselves a really test doing what they say. They're testing the nerve specifically. So So it's basically the way it works is that there's a stimulating electrode on a recording electrodes, um, and you're from you apply some electric shocks to stimulate the nerve, and you're just recording what happens on, and you can look at the sensory responses. We can look at the most responses in terms of the century responses, Um, given the shock, reading the action potential that you read, um, at the recording electrodes on D, you can usually clean two main things. You can look at the conducted the the latency. So how long it takes for the for it to arrive on? By that, you can work out the conduction velocity, which gives you an idea about the myelinating fibers and how quickly things are conducting on also the size of the action potentials. It gives you some idea about whether, um, whether there's a more ankle bone on your apathy rather than that's a demyelinating problem on this is anything with the motor responses again, You're looking at the house how quickly they conduct, um, on, um, on whether there's any accidental damage which would lower the so amplitude of the C map. There's some of the things that you can take it in the notes that he says these things called F waves, which is sometimes he referred to, um, essentially, they are, um, so you very sick after the main action potential. They're slightly like hump, which, which represents, and that those basically represent the, um, the nerve impulse, traveling backwards up the nerve all the way up to the to the nerve root around the end of the spinal cord, then coming back so there's a delay, but they're quite useful, especially fuel room wondering about more proximal lesion something closer to the spinal cord, like in the the nerve roots, which may just be a bit too upstream Teo to test when you're looking at the other. When when you're testing their studies in the conventional way. Um, so that nerve studies on then the e mg is definitely completely different. Basic with the mg, you're sticking a needle in the muscle. Um, and it gives you an idea, basically, about the nerves supplying that muscle and also the the muscle fibers themselves. Um, on there's a few things that they look up. Those was just the spontaneous activity. So that needle in the muscle and see and the muscles at rest and you record the pattern recorded there, then you can Diovan called Samir contraction where you just can't generally contract the muscle. And that gives you some idea about the individual sort of shapes of the birth of this off. Um, muscle units, AC action potentials. Um, and then you can ask patient does not maximum contraction of the muscle, which often referred to as an interference pattern where you basically get hold interconnected. Run off these, uh, muscle. You know acting action potentials all kind of joined up and again, it gives you some valuable information. We'll talk about these things in a second. There are some of the tests that you could do with them. No studies, for example, repetitive stimulation on but single 5 30 mg. Both of them are quite useful in particular, looking at my senior gravis, and they they basically with repetitive simulation, you're giving a Siris of shocks and then seeing if there's a decrease mental response difficult for my senior and the single fiber mg look for some called Jeter again. We should be suggestive off my senior. Um, so talk about the the mg. Um so this spontaneous activity, as I mentioned when you just put the muscle and see what I put the needle into the muscle and see what happens. Sometimes you can see these spontaneous depolarizations. There's different shapes spending what you see these that often refer to is positive sharp waves and fibrilation potentials. I mean, usually in a normal muscle, you should you should just be flattered that you can see the low. Um, but these when you see these spontaneous depolarizations, they're basically implying that there's a new repatha process, some damage to the nerve. There's a occurring, um, for example, motor neuron disease or any any process affecting the nerve. Um, so slight efforts again. You you start to see the the wave forms of the's motor units. Action potentials. That's on the left of the screening. You see a normal motion is action potential, which is often reverted by physical triphasic. So there's a couple of deflections off the of the spikes. Um, and when there's bean damage to the nerve, what you tend to see is that the motive, you know, cat action potential is quite long hinge aeration. It's quite high amplitude. Um and, um, you know, when you see quite a few defections, it's kind of polyphasic form to it. Um, whereas thie um, the Sure the myopathic motive interaction potential is, um is much shorter, and it's really low amplitude. So So you can kind of distinguish between these two processes. Um, and that's the interference pattern with the maximum effort. As I mentioned again, you can clearly see differences between a kind of neuropathic pattern of damage. Instead of getting a continuous stream of activity, you get a lot more punctuated activity we did with quite tool complexes. Where is them? In the my perfect mg. You just see that it's generally reduced, um, continuous stream. So that's basically nerve studies in the nut shell for us neurologists. We kind of read the reports, and you see it. You see, a lot of similar terminology referred to you, but, um, that's basically watered down version the Superbowl version of what about entails, um, So I was gonna go on a talk about just approach Teo nerve problems and, um, and how you should approach them and how you can think about what's going on. Um, there are a huge number of diseases and pathologies which can result in damage to the nerve. Um, and it gets extremely complicated sometimes. So there's a lot of different tests, so you can do so. It's good to have ah process in your mind just to think about things in the rational way and logically so. One way to think about purple nerve problems is just trying to localize the problem. Anatomically on by made this diagram, you can kind of think about which bits of the the the nervous system are affected. So? So if we start right in the beginning in the anterior horn, some processes and you know tourists for affecting the anterior whole. So motor neuron disease is one of them, especially the um, there's a press. It muscular atrophy once was a less, um, the there's some other pathology is which, Which kind of localized to the anterior whole spinal muscular atrophy earlier, Um, then spending out a bit more distally the nerve roots in the nerve plexus common things that can affect the nerve away in Plexuses trauma is a classic one. Often you get associative pain, you know, disc slips and causes a bit of compression with the nerve often with associated pain on, but it's often the location of diabetic. I'm not a thing, Um, in terms of sensory problems, the dorsal root ganglion is quite rare. Locations have ah problem. But when when you do see, um, patients with ganglion ganglion are perfect. So this is is quite needs term gangrene, not feel new or not pathy. They're basically the same thing that they both mean that they localized the dorsal root ganglion, which is the sensory ganglion. Um, and when you do see it probably often see, is them, Um, autonomic, It's, ah, failure of autonomic function and also kind of often get painful neuropathies on this. The processes that tend to affect that also root ganglion tend to be inflammatory. They often see in soccer with our show grins. Um, this a specific antibodies, um, out for three ganglionic antibody is very rare that I could have picked off the dorsal root ganglion. Um, Paraneoplastic syndrome cannot do that. Um, a low dose is a favorite sites. I mean, as you get right to the end of the nerve, you you get, um, love the problems which causes water Cool am length dependent. Examine on Europe with the or so of dying back in uropathy. And this is the the which is what is often synonymous with peripheral neuropathy. So it's the things like diabetes and hypothyroidism, which is, um, affects the longest nerves of the body most. So you have you have the longest nerves that usually nerves in the leg, um, which is most affected, and it affects the distal part of the nerve. So which is why you get up throughout glove and stocking distribution. Common causes for that things like diabetes and alcohol and also sort of toxic agents like the chemotherapy agents. Um, there's some processes which affect the length of the off the nerve. Um, on, Do you have a more sort of complete pattern of the distribution? Many on there, because they're probably lows of them. But, um, Classic one for that is, um, Guillain Barr A where you have, um, a whole of the nerve being affected. Use a bit patchy. Um, And then head, is it hereditary motor sensory neuropathy. I sharking marry tooth week, and then you also get the whole nerve, tend to be affected, and then you can get mononeuritis multiplex, which is usually, which is basically a problem in the distribution off. More than one refill nerves. They'll be radial nerve ulna, nerve or something together. Usually when you see that it's connective tissue disorder is a generic and usually quite nasty processes things like vasculitis and connective tissue disorders like rheumatoid arthritis. And that was Monday, and writers know multiple, um, again, on the theme of localization. Um, you can also think about things is being examinal demyelinating. So these things just demyelinating problems. So again, there's a kind of collection of disorders, which often tend to cause more of a demyelinating problem. So obviously the Guillain Barr A and CIDP a demyelinating problems, but you also see them with some infections, like HIV and diphtheria. Um, inflammatory causes. Apparently a plastic causes, uh, and then shortness the notes of RAM Day. So there's one particular disorder called most multi focal, most neuropathy where this if specifically as, um is antibodies targeting the nose of remove ear so you get a consult conduction block. So again, approaching neuropathy Z, Another good way to think about things is how quickly they come on, because that that's probably one of the most useful things to think about in terms of what the neuropathy represents. So something comes on overnight, you know, Fine. When I go to bed, do you wake up the next day? Um, the you know, things you got to think about is whether whether there's some injury, usually you will you know, you will have a story of them, you know, some some trauma. Or I am, uh, well, Saturday night palsy, where you saw drink too much and full in your hand, You got radial nerve palsy the next day, Um so often do. How about history? Or then It's not uncommon that you do, and there isn't an obvious injury process, and and even there isn't necessarily associated pain because you often get the nerve studies and see there's been some sort of them damage there. So injuries, a classic, um, and then inflammatory causes, especially involving the nerve things like Guillain Barre. There are other causes, well, rare things that you basically ever see. Things like family and toxicity and some genetic things into, um, acute Internet and porphyria. 18 ppd. Is over time there's the heard hereditary neuropathy with liability to pressure pauses. There's a genetic disease where you just your nerves are very sensitive, very susceptible and sensitive to compression, and so so it's kind of an injury. But on a background of a genetic problem, um, sub acute things tend to be inflammatory. So so CIDP. See, I speak to come since re variant of that again. The sub acute things usually coming on over days or weeks, thinks I vasculitis. Vasculitis is a common cause of nerve problems, although rare overall, it nerves are often effective, and vasculitis processes and can be quite nasty. I mean, you have three of the other systemic over to immune. Process is again things like, um, diabetic amyotrophy her infections hematological things can present in a sub acute way. Pretty critical illness polyneuropathy as well. That's something we commonly get asked Teo. Consult on in the intensive care patient. See them being in for a couple of weeks and being have add a stormy course and being intubated ventilated on. Then they're very weak. So that's something we see quite a lot of usually comes in, comes on over days or weeks and then thinking about things in the chronic chronic causes. So this is usually that kind of the peripheral neuropathy. The examinal length depend on your apathy is usually things like diabetes, chronic alcohol use, drugs in the past 12 deficiency, all those kind of things. And sometimes you see, hematological paraproteinemia is also having that sound kind of chronic chronic problem. And then, of course, genetic genetic diseases, things. I shock it, marry tooth, um, and some other diseases which is associated with nerve problems. You know, they're very slowly progressive neuropathies. I mean, that's usually the hallmark of genetic diseases. It's a very slow progression over over months or years, but well over years, Um, and then you can think about things in terms of what's what's affected eyes. It's century. Is that motor? Is it sensory motor is the autonomic predominant? Um uh, for the most case, most disorders effect. Sensory fibers are motor fibers recently equally, but there are some things which you know more sensory things, like the diabetes and B 12 deficiency, the ganglion not feasible to see also real problems and then some things that slightly more motor. So in particularly the a man, which is the motor variant of Guillain Barre that's that that could be a pure motor for Children, comes on quite quickly. It can often throw people off quite a lot because, um, barrier usually associate with kind of some numbness and tingling and things like that. But, um, you can get this pure motor form, you know. Similarly, Lucy of reflexes and stuff but often called, catches people off guard motor vehicle, motor neuropathy and then obviously processes which that, you know, like Motrin, urine disease and your muscular problems like my senior gravis offer. You know if it's purely motor. You really start to think, Think along those lines of being the Is it the neuromuscular junctions or muscle? There's that There's some autonomic predominant disease is these are things which usually affect the dorsal roots. So inflammatory problems and, um, a light a sister. So I'll, um, I thought the best way to talk about broached the nerve problems was to go through some cases on down from there, basically trying to discuss that I've said this up is a voting system. So I try and do that. I might have to duck out that presentation. We'll see how it goes in May. Uh, this is the first case, a 53 year old man with Type two diabetes developed over the course of several days, burning pain in the right hip and thigh, which slowly spread to the entire leg. A week after the pain began. He developed weakness in the leg, which progressed over a couple of months, requiring use of a stick to walk. You continue to suffer with severe pain, demanding opiate analgesia to manage the pain effectively. Examination revealed weakness throughout right leg with absent reflexes and mute plantar responses. Sensation was intact. You continue to experience weakness for 18 months before starting to experience. Um, slow improvement in symptoms. So? So if we, um, try and, uh, bring up the voting system. Okay. Um, so I think if you scan the QR code thing in there, um, and vote, um, we'll see how it goes. If it doesn't work, we'll just, you know, given a mess. So select the most likely diagnosis. Okay? I'll give it a month. See what people cannot give it 10, 20 more seconds. Okay. I think if we stop it now, show results yet. Perfect. Uh, that worked quite well, actually. S O is diabetic amyotrophy. Um, so if we think about it, So, um, this guy, he's got diabetes. Um, and he develops on one side in the leg. Um, a lot of pain on with associative learn motion. You're on signs. So this is basically sick of diabetic amyotrophy. And it's one of the neurological complications of diabetes. There's a few, but, um um it's, um, tenants tends to show you it. Um, okay. Diabetic number's a crew. Write it. Ridiculous. Excess neuropathy. So it's a monophasic. In Europe, the Esso typically put presents over weeks. Two months and you ate a symmetric is almost almost always asymmetric, and there's really significant pain with it on then. The weakness kind of developed alongside and know over time the muscles atrophy. Um, recently brand, Um, and it's mostly middle age patients with Type two diabetes and most men. Um, sometimes it is after they've seen them losing weight. Um, and interestingly, they ah, they tend to have better than average glycemia control. Interestingly, um, it's been It's a well, it's It's a weird phenomenon. Um, that, yeah, it often progresses over a number of a number of months and companies long as 18 months, and it really could be not very nasty, cause really severe pain. People have really struggled with it on it takes, you know, take years to him to recover properly. Often, even then, there's incomplete. Um, So, um so, yeah, that's that one. I'm sorry. So, next case, um, this may be a bit more difficult. We'll see. 50 roll man with no medical history presented with worsening postural hypertension with burning pain in his trunk and limbs, it lost a significant amount of weight and also complained of erectile dysfunction. his nerve studies were unremarkable, and CT tap did not reveal any malignancy. Soon the serum electrophoresis was negative for any paraproteinemia. However urinary Brent Bence Jones revealed a significant Lambda Light chain paraproteinemia. Okay, so if we go back to the the pump Okay, So, um, so you have almost a vote, so I'll give you a 10 more seconds. Nine. Okay. Okay. Uh, interesting. Um, so so you voted anti magnet or apathy as thie. Most likely then poems on systemic amyloidosis. I'm in diabetic neuropathy. Interesting. So Oh, bring up the presentation. So the answer is assistant Camelot basis. Um, Onda, um, as a tricky one, I put in them some random diagnosis to to fool you. Anti mag tends to be a very slow progressive, and it's usually a century in Europe. Face, it's, um you have a really profound sensory neuropathy, amyloidosis, but both both poems on D anti magarri. So seated with paraproteins. So they are both. You know, you would expect to see paraproteins, although that usually, um uh, gm related paraprotein use poems. IDG um, anti magazines. E i g m. Um, So it's a systemic amyloidosis on the reason for that is because of the prominent autonomic involvement. The other two poems on biologics is probably less likely to cause autonomic problems. Um, so we had a patient like this on the ward recently, and it took a book making exactly a Z. I describe this, um, chap, you felt very unwell, losing lots of weight, generally feeling quite terrible on he had really profound autonomic symptoms. So, you know, even standing up and feel really dizzy at these profound drops in his BP in this kind of neuropathic pain, Which is which is coming on length dependent anyway, affecting the trunk. So, um, Andi, he had a light chain paraproteinemia. So again low things are very profound. Autonomic symptoms suggest against it tenses Jesse a ganglion. Apathy, a neuropathy effect in the door. So regarding lien on, As I said earlier, there's a few things which there's. There's a limited range of conditions to to consider when when a patient present with lots of autonomic finding. So it's inflammatory stuff like shots, sugars and sarcoid's. Um, this Alpha three antique ganglionic cast or colon, apparently a plastic stuff. Previous chemotherapy. So, um, so if patients, if you do see patients who are presenting with a lot of autonomic dysfunction have those things in mind and on. But it's actually Sakowicz CT scanning looking for any lymphadenopathy. Send the electrophoresis on the light chains because often the light chains given away in the serum electrophoresis could be normal. So I always send the urine repentance. Jones and management of those symptoms could be very difficult indeed. So, um, attention. Both, um, find it with fluid, making sure that I am drink loads before getting up and doing anything lows of sold. You know they often have because of the body. Can't regulate the part of your BP. Patients typically have high BP at night. Low BP. They stand up, so you often have to give them anti hypertensive the night on. Then there's some pharmacological options, which usually kind of squeeze blood vessels. Big fluid in the body. Um, that's great, Right? Next. 1 19 year old woman attended the neurology clinic with a long history of leg symptoms and struggling in relation to her peers. She recalled symptoms since it least, the beginning of secondary school, including frequent tripping when walking to and from classes on poor sporting achievement, including fatty on carve pain during exercise examination revealed high stepping gait bilaterally with weakness of ankle dorsiflexion, reduced ankle reflexes and high arched feet with hammer toes. Nerve study showed slowing of motor nerve conduction velocities. And since reaction potentials in median and Cyril Nerve territories say we will go back to the voting. Okay, so give some time to select what you think the most likely diagnosis. Yeah. All right. Three to hum. Yeah. Um chocking. Varity. That's the clear winner. So shocking. Mary teeth, um also his head a tree. Hereditary motor sensory neuropathy. So So this is a genetic condition. Um on there's a lot of genes which can cause Charcot Marie teeth, um, seemingly and ever increasing number of jeans. It's four of them, which account for night for most of the cases, 90% of them. Um, I still got bit confusing that they found more genes. So they so this is the kind of system they have for a labeling. CMT you've got cm to you. 12345, implies one is demyelinating to is Aczone Or, uh, it does have other, um, qualifies as they go up, but it's, um, it gets a bit confusing after that, and some of them are obsolete on a B. C basically refers to the gene that's involved. There's a consistent of classification. Um and, um, the hallmark, um, clinical features to suggest this at the time. So it's a very slow progression. First of all, she's very young on she did before she she developed the symptoms when she's quite young and they slowly progressed from there. Um um and really, she's had these. The weakness is predominately in her her ankles. You've got weakness of dorsiflexion. She's got the characteristic high arched feet, eh? So So those were the kind of clues in there, and certainly the very slow progression. And that's kind of the pattern of distribution would be really suggestive of them. Chuck America T from her case. Um, So what do you Uh, no one here? A 40 roll man noticed increasing problems with right hand function over a period of nine months with some intermittent cramping sensations. He denied any sensory symptoms that's your motor on was otherwise well, physical examination revealed revealed some fasciculation in the first dorsal interosseous muscle of the right hand on weakness or finger risk extension and grip. Sensory examination was normal. No study showed. Belonged motor nerve licensees and slowed conduction velocities in the media and radial nerve territories of the right arm with a great and 50 cent reduction in the C map amplitude between proximal and distal nerve stimulation. Start sites indicative off conduction block. Okay, so, um, I will bring up next poem. Okay, Um, so I'll give you a bit of time just to vote on this one. Okay, Pray to one. Okay, that's very interesting. So the correct answer is actually multi focal motor neuropathy. For those of you that said, our military lateral raises already any any of them? Um, um, you wouldn't be wrong. To think that it'll now would certainly need to cross your mind is as am differential diagnosis, but I'll explain it. Why? It was multiple conditions. Motion your feet again. A lot of these cases there bit Easter, Terry. I think it's sometimes useful just to know some of these other calls and just have to think about things in the contemplating what that likely diagnoses are so so multiple motive uropathy. It's an auto auto immune process, which affects the nose of ramp yet, um, on gum. It tends to be quite young patients. To me in age 40 the often see patients in twenties and thirties. Having this, um, on the real give away from from the, um from the case that I presented was the nerve studies, which we showed this conduction block. Because conduction block is often it's space. It's anonymous, with demyelinating problems often pathognomonic of multi focal motor neuropathy. More patients tend to have is, um, very asymmetric, painless limb weakness. Sometimes there may be some cramps. Also, limb weakness, usually distal. It's usually in a couple of nerve territories and usually in the in the hands or in the distal part of the boy. Every beginning of slow progression on gets up your motor thing. So so again, the people who said motor neuron disease or a less would be right Teo have that in mind. Um, because, um um yeah, and there's one that you don't want to miss. Um, so Lewis, some some notes in the room I put in there as well as a differential. That's basically a sort of, um, asymmetric, full of CIDP, I guess the thing leading away from that would be the lack of any sensory findings. Often you would have sensory findings with that, so makes it less likely. Um, more frequent motor neuropathy. There's a good test you can do for that called anti ganglioside antibodies. And often patients have anti GM one antibodies. Um, and it's ah, it's a treatable condition. This s o it's young people, as I said. So I have the IgE tend to be that the treatment that they're works and patients don't respond to steroids or pound exchange, unlike patients with CIDP bit of a weird one. Um, so I think there's one more of these, but we're now in entering the next bit of the presentation, the neuropathy's neck. Not to be missed. Um, so an 18 year old man was brought to the emergency department by his parents after he collapsed at home. It's struggled in a football game three days ago from there, had experience worsening shooting pains in the arms and legs, became increasingly weak today, barely able to get out of bed in the emergency department. His pulse was high at 140 BPM on, he went into urinary retention, requiring catheterization. He displayed weakness of all four limbs. And now it's a grade three out of five bilaterally with associated patchy numbness. Reflexes were globally absent. Say well, but But it to the vote, um, is the last one. Um okay, so get voting. All right. Three to Well, fantastic. Um, yeah. You know, Barry, that's the right answer. Um, So, um, the so militant syndrome is a variant of Guillain Barre, but that tends to be a It tends to be a involving. Bulba functions patients typically all with cranial nerve symptoms. So patients typically have eye movement problems or a facial weakness or room swallowing problems. Speech problems. So So that's militias interest. It's more of a kind of in the head problem. Pretty clear on this. New York said That's usually associated with people being very unwell with other problems, although kind of present Quite cute. Least, uh, most of the crisis wouldn't be wouldn't be the one. Just because there's some patchy had some patchy numbness is well, so even though it can present with, um, you know, acute deterioration like that. So if it was deteriorated like that and very quickly in hand. Um, your motive, Um, you you would consider my senior. Um, so I talked about sick. Guillain Barr is Ah. You know, it's a common condition on it's one that's potentially very dangerous. So, um, was one that you will have to manage at some point in the medical assessment union. So I'll talk about the gold standard management What I would suggest for for this patient off the ABCDE approach to these things. Um, so this guy, he he is a bit of a concern, to be honest. Um, so he he's gone into urine retention, and his heart rate's really high. So So he's got some evidence of autonomic dysfunction. Um, any patient with GPS? You wanna There was anomic. Dysfunction is the thing that you're gonna worry about, and then you want to, um, keep an eye on, um, one of the things. So So all patients with GPS would really be hooked up to a heart monitor on. They also need hourly or, you know, several hours, FEC measurements. Um, I'm putting in an open baited to look for any sort of progressing respect you muscle weakness as important to just flag these patients up to the nurses to make sure that they know that they have absentia to two Syrian and that people are keeping an eye on them and to flag up any deterioration. So, with this patient, I would discuss this patient with people I would, um I give the neurology team a buzz if they if they're available in the hospital. Um, because GBS is treatable problem. You can give it. Just sort itself out spontaneously. Anywhere is usually, um, on a physical this But, um um, by giving my the ideal pap smear exchange, patients can you can recover quicker and, you know, hopefully not developed. They're horrible risperidone muscle weakness and things like that. So, um, so I discussed with neurology to think about starting out on my V. I, g, um, on The ideology tend to be given by the blood bank. So, um, dosed by weight, it's usually 2 g per kilogram over five days. That's about 50.4 kg. Put 0.4 grounds, pick it a grand per day, so there's nothing. The weight could be useful. What? What? Sometimes you just have to ask to me, um, with this guy's Well, I probably would it speak to? I see you. I mean, he's got this evidence of autonomic involvement, and these are the patients that really are gonna potentially do badly. Um, so I would be speaking to the I see you. Even if they don't want to take the patient is worth a patient being on their books. Just say, you know, um, I'm in some other some investigations could be quite useful. Lumbar puncture is useful. The typical number puncture finding is you see a high protein with normal cells or no cells in the fluid. Eso this kind of album in psychological association don't have to see it come. The protein can be normal. It doesn't rule anything out, but it helps on helps with the diagnosis you send the antigenic. You one b antibodies. They won't come back for several weeks, but it may give it to my dear on nerve studies again, we often use them, But, um, sometimes that changes don't become apparent for a couple of weeks, and they're not going to change things in the in the short term. And it's a clinical diagnosis. But, um, um, if you notice a test which can be helped. And it's important to remember that even though it looks just like Guillain Barre, there are masqueraders and Mimicker's. So, um, Lyme disease can mimic Guillain Barre. It can come out quite acutely. You get other infections like that. Fear and HIV. You have sort of vasculitis and things presenting in this in this manner, um, poisonings, eso it's worth keeping in mind differentials, and that's why lumbar puncture could be quite useful. That even though, um, it looks like it. And Barry, if you do a lumbar puncture and there's lots of cells in it, probably gonna start thinking is this. Lyme disease is something else that could be very useful for just thinking about alternative courses. Uh, GBS. Classically, it's symmetrical, becomes on acutely, and it's symmetrical. It's never a symmetrical, really, unless again, basically never in the acute GPS, Um, patients typically have ridiculous pain and says, um, know related pain on autonomic disturbance is quite common. Often it's not too severe. Um, the mortality associated with DBS tends to be the autonomic problems, so on the overall mortality it is low three temp sent, but is usually due to cardiac arrhythmias and BP, instability um, 20% of patients require mechanical ventilation. Um, on the outcomes, a usual. Quite good to 60 to 80% of patients are able to walk independently six months after these all set with all without treatment. So So people have a good outcome. Well, they're they also need to be of rehab and things like that afterwards. Um, and it's classically a monophasic illness. It would recur. It runs its course within a matter of sort of four weeks or so and then then improves. So, um, but you dearly around these relapses, sometimes we're very rapid on. There were these, um, subtypes Which a month, The motive. Arian. So So you don't get the century signs and things. I'm sounding it. I'm sure to be honest, very rare. Um, on then says, remember, if I did, this is a okay. We'll skip the way I can remember. If I did a vote for this pen, I'll talk through this case again, thinking on the lines of Europe of use. You don't want to miss. So some two year old women attended the neurology ambulatory clinic with a three week history of weakness and numbness in her hands. and feet with associated pain and swelling. She felt generally off thoughts on that experienced a night sweat. Her only past medical history was a high profile, which isn't on examination. She had significant weakness and numbness of the hands and feet in a glove and stocking distribution. Her bloods revealed an easy an affiliate and CRP of 250 p. Anca was positive with MPO antibodies. Um, diagnosis is vasculitic neuropathy. Um on do these could be very nasty indeed. When there you can, um, on be whilst that typical pinnacles in drum is mononeuritis multiplex. So, you know, in the single more than one purple know of territory patients doing in frequently present with the kind of glove and stalking kind of distal symmetric neuropathy. But you know what, a rapid onset I kind of days or weeks on the vasculitic in your apathy is basically within the urine. Your peer vasculitis donations contains is microscopic polyangiitis use anything granulomatosis with polyangiitis and granulomatosis with polyangiitis. Um, so, um, she's got his inner feels in the blood. So So the the this interferon granulomatosis. But they're very quite similar. Um, really necessary. Distinguish between them that Well, um, and obviously and get vasculitis in the context of other, more systemic problems. And connective tissue disorders like rheumatoid arthritis show grins, Lupus sarcoid on There also infections as well, Like B and C especially, um, with hep c get cryoglobulinemia, which cause quite similar pattern as well. And that's kind of a vasculitis in the same right, so important not to miss. Um, I copied this table just from a paper on suggested work up in sub acute neuro in vasculitis neuropathies. But, um would be a good one to have in mind just when you're when patients present with the kind of rapidly evolving neuropathy. So checking the hepatitis B and C serologies will be very, um, important crying populations. You know, you don't send them that often, but certainly if someone presenting with them, you know, in Europe rapidly progressive new rock that you probably would we'll send HIV and infections and things like that. And cerebral spinal fluid analysis is it's quite useful is Well, um, some of these I've never had So I don't know what soluble interleukin two receptor is. But, um, tell you what, don't worry about that. So, yes, I think the paper was for me to be out of date. You got this general immune screen. I've got my own sort of them. I mean, screen, which I send off of this stuff. So usually start Lupus, anticoagulant and anticardiolipin antibodies anchor you in a in a. So, um on on the complements is Well, um, so getting toward the end of the presentation, the last but I'll speak about is just peripheral neuropathy or the this still act own on neuropathy, which is basically the daily slog off uropathy. Um, so this is a typical example of that purple neuropathy 60 67 year old man presents to the neurology clinic with a sensation of walking on sponges for a couple of years. You know, this is some difficulty with balance when getting up in the night to go to the loo, but he's otherwise functioning well. He also describes unpleasant tingling pain in his toes on examination. Romberg's test is positive, and he's reduced sensation two modalities up to his mission. Lower limb reflexes, a reduced with absent ankle jerks and equivocal part of responses. That's a classic peripheral neuropathy presentation. The that Romberg's test is, um usually, although it does test a few things. It's the main purpose, despite testing for proprioceptor difficulty, which which is classically kind of eliminated in them Uh huh. In peripheral neuropathy. So patients often Romberg's positive, Um, on But yeah, at night as well. It's very dark. So you so you take out your vision, you can't see much and you're relying appropriate. Actually, patients often report this poor balance in the middle of the night. Um, and you'll hear lots of terms to refer to this distal accidental neuropathy on this dying back acts on the active not Please say, the fact that it kind of starts at the end of the accident that works its way back and York begin to come spread upwards. I represent 90% of her from Europe with the, um, and there's like the things that can cause it s I think I read some paper. There was over 100 different problems and diseases and medical things that can cause this kind of perform. You're up the so So there's a lot of there's a lot of things on. It's very common, so apparently crevice around one person to the general population rising to 7% in the elderly. I'm not sure exactly when the cutoff for being out, but it's quite prevalent. Um Onda A lot of times you just don't know The answer is idiopathic and 20 to 30% of cases. So despite checking all the, you know HBA one C something so you just don't find a cause. Um, and it could be quite frustrating when that's the case, but, uh, hopefully we may make some progress with it in the future. Um, the most common causes diabetes and alcohol, as you probably expect. So when you're taking history, asking about police is is essential. It's always worth asking about previous chemotherapy in cancers and things like that because they, they often lead to this kind of, um, chronic neuropathy is Well, B 12 deficiency is a classic one. Um, I find that you can sometimes detect this just, you know, you do Neurological exam has come for something completely different and, you know, the reflexes reduced and they'll have some reduced proprioception or something in the toes. And and you might just pick up a incidental low B 12. So So you do just pick these things off another common cause. Hypothyroidism sometimes see it in in general, sort of metabolic disturbance is, um and then these paraproteinemia associated ones. Sometimes it can be associated with just a monoclonal gammopathies of uncertain significance. Um, and you can also see association with them. You know, the sort of anti American thinks I'm not as well. So So, um, another systemic processes uremia, kidney failure, liver failure, things about you can see it in, um, my I mean, you could go. It's for it. He like investigating for these neuropathies. But for the most part, there's probably have quite limited number of tests which will kind of give you Yeah. And also and usually further investigation doesn't help a huge amount unless there's something atypical about it. So, um, I I suggest activity. Basic neuropathy screen CRP can give you a general idea If there's an inflammatory process. If it's very high, then you investigate further from there, um, diabetes screen, thyroid screen, B 12, and folate and serum electrophoresis. Been if Jones and some general blood, that's what I would recommend. Um, and pain could be quite disabling. So we, um the evidence, I think, still is that duloxetine tend to have the best evidence for treating a neuropathic pain in them. They sort disorders and performed a rock. A piece. Your oxygen is pretty good. One for going first line. But other options are, um, a trip, Cleon, gabapentin, pregabalin and probably a lot of other ones as well. So that's the presentation. Um, my conclusion, really, is that there are many neuropathies many different causes. Kind of a dizzying number, of course, is, and so thinking about things in a systematic way is probably the best way to approach them. And just to know that there are a lot of different causes and to, um, you know, by thinking logically about it, you can kind of hone the problem down something. The most important things are the three on set. How quickly came on the distribution. There's a kind of glove and stocking. Distribution is a multi ah mahn in your eighties multiplex. Um, again, is it purely motor? Is it sensory? Pure century is a mix of the two, um, again, is there pain or is it non painful? Painful things are often in nerve entrapment. Some things about it, diabetic amyotrophy. So they give a lot of helpful information, and you can start to refine things with a symmetrical or asymmetrical again. That's very important. Um, um a lot of New York things you won't necessarily get to the bottom with our get to the bottom of the acute and sub acute neuropathies always concerning, and they're often treat treatments for them. So, um, so if I'm coming with symptoms and side suggestive of neuropathy, insulin, Volver very quickly, I'd have a low threshold for speaking to a neurologist and investigating for lots of the inflammatory things and number punctures. It could be very helpful for for all kinds of things for him if thinks I'm asking lighted CIDP, um, Lyme disease demyelinating mainly demyelinating stuff better. Yeah, that could be very useful. Um, on by thought, it's just worth reminding you that even urologist find the peripheral nervous system very difficult to navigate. And I'm frequently on them, you know, Google searching which Myer Times a supplied by, you know, whichever reached to, um, you know, if I've seen a tricky case, So, um, so is tricky. The new if you're the oldest, probably the best people that have problems, but, uh, we do want best. So that's in the presentation. And I will. I don't have any ones. Got any questions, or, um, 11. I backed it. Chats. You can write them in a chat if you want. Or, uh, Ross. Yeah. Thanks so much, Jeremy. I'm standing like that because, well, we place it leg in the chat. There is slides. Well, I just thought that the mg Q arcade, the last people seem to walk this on that. So, um um yeah, it wasn't any questions. Please. Far away. If you want to watch it back, Um, well, it will be uploaded on the you treat with 48 hours of dollars. Hey, see Jamie feel happy to send across the slides. Yeah, be that would be fun to stick. Uh, we'll probably just wait a couple of minutes for questions. I don't think so. I'll try. And I know he's trying to come up with one myself. A disappoint. Um, I was wondering, with the, um, a lot of time with neurology, you tend to have to order sort of auto antibody stuff when you start getting towards the morning side of things. Um often those to take quite a long time to come back. Uh, I don't know if there's a way to extract or if there's any sort of broad spectrum of steroids you should start. You suspect something autoimmune, but just haven't quite got the answer yet. The and peripheral neuropathy or central water? I mean conditions, but yeah, eh, So usually when you're sending off these knee shandy bodies, there isn't any of inevitable weight, and, um and often it we're talking months. In some cases, I said, got some like those ganglionic acetylcholine receptor antibody is for, um, autonomic stuff sent some some of those. Often they dig two months to come back. So you can't really rely on them particularly too to guide your treatment, especially with your oxygen. And he's treating, um, I think probably the best way is just to find out which lab they get processed at them because sometimes you get results that have bean issued. And then there's just a delay in the results coming back. And it's just sitting there waiting so sometimes trying to find out which lab it's gone to. You come in, bring bring. You can usually find out by speaking to your local lab and they'll say, Oh, they've got to, you know, Poland down pulling down to the Lyme testing, for example. And yeah, that's yeah, it's useful today, actually. Helps know that she were some of the ocean or London where they will get processed on side. Yeah. So he's happy? Yeah. Yeah, usually, I mean, usually there's enough suspicion off the underlying process to, um, to help, you know, to go the treatment for things like vasculitis. It usually is, you know, becomes pretty obvious quickly. You know, you do have a yeah, high CRP, and you often do you take the anger and currents and quite quickly, um, Onda, so usually often you get so the thing that often causes a bit of delays is the nerve biopsies again, when there's a I mean, it's more waiting for nerve. Biopsy is rather antibody antibody results, which is, um, when you were wondering about what, what you're treating, whether you should be treating it so But again, we talked about turn around for several weeks or so there, and, um, you know, if they seem to progress, you know, aggressive process and which seemed to be inflammatory, you know, you'd often just give steroids or whatever cyclophosphamide, because, you know, the process itself, you know, it would seem to be relatively obvious. Will be there isn't inflammatory problem for foot, um, as the the one. If if I've got time The one patient the case study I used off the patient with systemic amyloidosis. You had a lot of autonomic findings. His case is very difficult Just trying to seal the diagnosis, cause amyloidosis is basically am diagnosis where you tend to make the diagnosis, you need tissues, a tissue diagnosis. Um, Onda. He was a Jehovah's Witness, so he couldn't have a kidney biopsy, which is usually the most sensitive, um, disk. And you had a bone marrow biopsy, which was negative. He had a A skin biopsy, which was negative. So well, with biopsy results came back negative. So even though we was heavily suspecting amyloidosis, it was very difficult to to get the diagnosis, you know, confirmed in a in a organ amount situation. We we went to be the the quit quit only central to the National Amyloid Center to help with the diagnosis. So if you're struggling, there's always hospitals, you know, quit only centers and things them higher up, which can provide support and advice and things like that. Yeah. Yeah. All right. It doesn't that that we've had any questions. So what? That's probably will stop broadcasting now. Thanks very much. Coming room. It looks like we're gonna have a break for a couple of weeks, just with the rearrangement obsessions and such s So I think the next session is gonna be the the reduced GCS session on the 28th of April. So hopefully, uh, we will see that, um, thanks very much for coming.