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In summary, while MMT is feasible and reliable on an outpatient basis [10, 23, 24] and in some patients with critical diseases without central nervous system dysfunction [6], neither group is at risk for acute brain failure affecting most patients during critical diseases [25] and does not exclude early participation in will tests. For the subgroup of patients with critical diseases that can be assessed by MMT, the agreement among observers on the diagnosis of ICUAW is good, especially when performed after discharge to intensive care. However, as clinicians and critical care researchers, we cannot simply limit our assessment of patients with neuromuscular dysfunction to those who may participate in the examination. Since neuromuscular dysfunction acquired in intensive care (including polyneuropathy and critical disease myopathy) is likely related to disease severity [4] and may even share the same pathogenesis as septic encephalopathy and acute brain failure [26, 27], patients who cannot be assessed are most affected. Latronico N, Bertolini G, Guarneri B, Botteri M, Peli E, Andreoletti S, Bera P, Luciani D, Nardella A, Vittorielli E, Simini B, Candiani A: Simplified electrophysiological evaluation of periphral nerves in critically ill patients: the Italian multi-centre CRIMYNE study. Crit Care 2007, 11: R11. 10.1186/cc5671 In a recent study in intensive care patients who received mechanical ventilation for 5 days or more, Ali et al. [7] received 174 patients and only 38 patients (22%) were unable to perform MMT. However, 94 patients were excluded because “they were unlikely to wake up” and another 40 patients were excluded for inability to communicate. Therefore, 50% of potential patients were not included because they were not able to cooperate with voluntary testing.

At the time of the first evaluation, the authors did not present data on the location of patients in intensive care relative to hospital. They indicated that most patients were assessed for the first time on or after stopping mechanical ventilation (NA Ali, personal communication, April 2009). The study by Ali et al. [7] included an assessment of compliance with the interobserver between two observers who examined 12 patients. They reported a perfect match regarding the diagnosis of ICUAW, but did not present the time or place of these 12 assessments. The objective of the study was to assess the concordance between 4 intensive physicians in the diagnosis of myocardial infarction (MI) in patients with critical diseases, based on screening electrocardiograms (ECG) and kardial troponin (cTn). Each observer identified six patients with ICUAW (total MRC <48) with an incidence of 17% (95% CI, 3% to 31%). For all patients, interobserver compliance was 93% (Cohens Kappa = 0.76; 95% CI 0.44 to 1.0). . .