The clinical and radiological features and prevalence of Neuro-Behçet's Disease: A retrospective cohort multicenter study in Saudi Arabia

BACKGROUND

Neuro-Behçet's disease (NBD) is defined as primary neurological involvement in patients with systemic symptoms of BD. The variety of clinical presentations seen in NBD and the long list of similar conditions make diagnosis challenging. This retrospective study aimed to estimate the prevalence and describe neurological involvement in patients with Behçet's disease who presented to King Abdulaziz Medical Cities in Jeddah and Riyadh, Saudi Arabia.

METHODS

This was a retrospective, cohort study which utilized a non-probability consecutive sampling technique to include all patients diagnosed with NBD patients. All patients with BD (215) were screened for neurological symptoms. Thirty-five patients were found to be diagnosed with NBD. Outcomes were estimated using the modified Rankin scale (mRS).

RESULTS

In our cohort, one in six patients with BD was diagnosed with NBD. A total of 35 patients were diagnosed with NBD (mean age 27.56 ± 10.36 years; [2.88:1; Male: Female]). The main clinical features of NBD were headaches, weakness, unsteadiness, and dysarthria. The most commonly involved sites on imaging were the brainstem, diencephalon, cerebellum and basal ganglia. Oligocolonal bands were negative in all patients. Maintenance therapy most commonly included oral corticosteroids, azathioprine, and/or infliximab. Most patients received pulse corticosteroids alone when presenting with acute relapse. Half of our cohort was asymptomatic and three in four had favorable outcomes.

CONCLUSION

NBD is common among patients with BD in our population with most patients having favorable outcomes. Patients might have a wide array of symptoms which might make the diagnosis challenging.

Plasmapheresis Versus Intravenous Immunoglobulin in Patients With Autoimmune Neuromuscular and Neuro-immunological Conditions

OBJECTIVES

Plasmapheresis (PLEX) and intravenous immunoglobulin (IVIg) are commonly used to treat autoimmune neuromuscular disorders, including myasthenia gravis, acute inflammatory demyelinating polyradiculoneuropathy, chronic inflammatory demyelinating polyradiculoneuropathy, and other autoimmune neurological disorders. The side effect profiles of these therapies vary, and concern has been raised regarding the safety of PLEX in the elderly population. In this study, we have examined the pattern of PLEX and IVIg use for autoimmune neurological disorders at a single facility and in a national database, focusing on the complications in elderly patients.

METHODS

We performed a retrospective chart review of adult patients at our institution receiving PLEX or IVIg for any autoimmune neuromuscular or neuro-immunological disease. Next, we analyzed the National Inpatient Sample database to confirm the trend in IVIg and PLEX use from 2012 to 2018 for a set of neuromuscular and neuro-immunological primary diagnoses.

RESULTS

IVIg was overall favored over PLEX. The adverse effects were similar among elderly patients (age ≥65 years) compared with younger patients (<65 years) in our institution, even after adequate matching of patients based on age, sex, and medical history. We examined the National Inpatient Sample dataset and noted increasingly higher frequency of IVIg use, consistent with the findings from our institution or facility.

CONCLUSIONS

Both PLEX and IVIg are safe therapeutic choices in adult patients with autoimmune neuromuscular disorders and other neuro-immunological diseases and can be safely administered in the appropriate clinical setting.

Severe ataxia uncovered Hodgkin's lymphoma: do not forget CT neck when looking for covert malignancy

A 53-year-old woman without medical problems presented with 5-month history of dizziness, difficulty speaking, severe ataxia, which worsened a day before admission to inability to stand unsupported. An extensive workup was initiated to find the cause of ataxia. The laboratory investigations and imaging of the brain and whole spine revealed no lesions. She was found to have autoimmune thyroiditis, positive coeliac disease antibodies without clinical features and vitamin D deficiency. No intravenous steroids or immunosuppressive therapy was given. Cerebrospinal fluid showed lymphocytic pleocytosis. The workup for the cause of severe ataxia revealed an oropharyngeal lesion with cervical lymph nodes, and the biopsy showed classical Hodgkin's lymphoma of mixed cellularity. She was treated with chemotherapy followed by radiation therapy and made a remarkable recovery, and currently, she is in remission without distant metastases, 5 years after the initial diagnosis. Her neurological status improved, and she remained with mild ataxia.

Managing multiple sclerosis in the Covid19 era: a review of the literature and consensus report from a panel of experts in Saudi Arabia

Disease-modifying therapies (DMT) for relapsing-remitting MS (RRMS) act on the immune system, suggesting a need for caution during the SARS-CoV2/Covid-19 pandemic. A group of experts in MS care from Saudi Arabia convened to consider the impact of Covid-19 on MS care in that country, and to develop consensus recommendations on the current application of DMT therapy. Covid-19 has led to disruption to the care of MS in Saudi Arabia as elsewhere. The Expert Panel considered a DMT's overall tolerability/safety profile to be the most important consideration on whether or not to prescribe at this time. Treatment can be started or continued with interferon beta, teriflunomide, dimethyl fumarate, or natalizumab, as these DMTs are not associated with increased risk of infection (there was no consensus on the initiation of other DMTs). A consensus also supported continuing treatment regimens with fingolimod (or siponimod) and cladribine tablets for a patient without active Covid-19. No DMT should be imitated in a patient with active Covid-19, and (only) interferon beta could be continued in the case of Covid-19 infection. Vaccination against Covid-19 is a therapeutic priority for people with MS. New treatment should be delayed for 2–4 weeks for vaccination. Where treatment is already ongoing, vaccination against Covid-19 should be administered immediately without disruption of treatment (first-line DMTs, natalizumab, fingolimod), when lymphocytes have recovered sufficiently (cladribine tablets, alemtuzumab) or 4 months after the last dose (ocrelizumab). These recommendations will need to be refined and updated as new clinical evidence in this area emerges.

Guillain-Barré Syndrome as a Complication of COVID-19

Coronavirus disease 2019 (COVID-19) is associated with multiple neurological complications including Guillain-Barre syndrome (GBS). While there are reports of COVID-19 -related GBS cases, much remain unknown. We report two cases of GBS-associated COVID-19, which started about eight weeks after the initial COVID-19 infection. Such a long duration between infection and symptom onset of GBS is unusual for post-infectious GBS. Moreover, severely ill patients with COVID-19 may have prolonged hospital stay leading to critical illness myoneuropathy. Diagnosing superimposed GBS can be challenging in such cases. Clinical suspicion, nerve conduction studies with electromyography, and cerebrospinal fluid analysis can help in making the correct diagnosis. Both presented cases responded to intravenous immunoglobulin therapy.

Transcriptomic and clonal characterization of T cells in the human central nervous system

T cells provide critical immune surveillance to the central nervous system (CNS), and the cerebrospinal fluid (CSF) is thought to be a main route for their entry. Further characterization of the state of T cells in the CSF in healthy individuals is important for understanding how T cells provide protective immune surveillance without damaging the delicate environment of the CNS and providing tissue-specific context for understanding immune dysfunction in neuroinflammatory disease. Here, we have profiled T cells in the CSF of healthy human donors and have identified signatures related to cytotoxic capacity and tissue adaptation that are further exemplified in clonally expanded CSF T cells. By comparing profiles of clonally expanded T cells obtained from the CSF of patients with multiple sclerosis (MS) and healthy donors, we report that clonally expanded T cells from the CSF of patients with MS have heightened expression of genes related to T cell activation and cytotoxicity.

Precision Medicine: Steps along the Road to Combat Human Cancer

The diagnosis and treatment of diseases such as cancer is becoming more accurate and specialized with the advent of precision medicine techniques, research and treatments. Reaching down to the cellular and even sub-cellular level, diagnostic tests can pinpoint specific, individual information from each patient, and guide providers to a more accurate plan of treatment. With this advanced knowledge, researchers and providers can better gauge the effectiveness of drugs, radiation, and other therapies, which is bound to lead to a more accurate, if not more positive, prognosis. As precision medicine becomes more established, new techniques, equipment, materials and testing methods will be required. Herein, we will examine the recent innovations in assays, devices and software, along with next generation sequencing in genomics diagnostics which are in use or are being developed for personalized medicine. So as to avoid duplication and produce the fullest possible benefit, all involved must be strongly encouraged to collaborate, across national borders, public and private sectors, science, medicine and academia alike. In this paper we will offer recommendations for tools, research and development, along with ideas for implementation. We plan to begin with discussion of the lessons learned to date, and the current research on pharmacogenomics. Given the steady stream of advances in imaging mass spectrometry and nanoLC-MS/MS, and use of genomic, proteomic and metabolomics biomarkers to distinguish healthy tissue from diseased cells, there is great potential to utilize pharmacogenomics to tailor a drug or drugs to a particular cohort of patients. Such efforts very well may bring increased hope for small groups of non-responders and those who have demonstrated adverse reactions to current treatments.

Multiple Sclerosis Patients Knowledge in Saudi Arabia

Objectives:

To assess Multiple Sclerosis (MS) patients’ knowledge in Saudi Arabia (SA) and in which aspect of the disease do patient need more awareness.

Methods:

A cross-sectional web-based survey has been conducted between June and August 2017. It consisted of 2 parts: sociodemographic and 23 multiple choice questions chosen from the previously validated MS Knowledge Questionnaire (MSKQ). The survey has been sent to 500 MS patients.

Results:

A total of 218 MS patients filled the questionnaire where only 200 included in the study. Female MS patient represents 66% of all the participants. More than half of the patients had achieved their bachelor degree. The total mean of the correct answer for both male and female found to be 58.98%(±SD 15.06%). Most patients were aware that MS is a disease of central nervous system (93%), autoimmune disease (79%), not contagious (90.5%), or inherited (64.5%). However, few patients were aware that there is no single test to diagnose MS (28.5%), and intravenous injection of contrast during MRI reveals new lesions (18.5%). Only (37%) knew what is “Relapsing–remitting”MS. The MS knowledge is positively correlated with the educational level.

Conclusion:

Patients with MS in SA have less knowledge in the disease’s types, workups, and treatment efficacy. While in contrast, they have more awareness of the disease’s pathophysiology. Patient’s awareness programs should aid more knowledge among MS patients in SA.

Changing opinions about research by Saudi medical students

OBJECTIVE

The objective of this study was to investigate and compare the opinions and attitudes of medical students toward medical research in five Saudi universities and examine the changes observed in these opinions and attitudes in one of these universities over a period of time.

METHODS

This is a cross-sectional study conducted among medical students in five Saudi universities. This study was based on a survey undertaken in 2015. The survey consisted of five questions inquiring about the opinions and attitudes of medical students toward medical research. The same survey was carried out 8 years earlier in one of these universities (King Abdulaziz University [KAU]), and the results obtained during the two periods (2007 and 2015) were compared.

RESULTS

A convenient sample of 924 students was selected from five Saudi universities. Ninety-five (10.3%) of the medical students were not aware of the usefulness and importance scientific research will have on their future careers. A total of 409 (44.3%) stated that they had no knowledge on how to conduct scientific research. On the other hand, a vast majority of medical students (98.1%) expressed a willingness and interest to participate in scientific research if provided with an opportunity. The percentage of students from KAU strongly agreeing to participate in research rose from 33.1% in 2007 to 81.5% in 2015 (P=0.001). Of all the students surveyed, 431 (46.6%) had participated in scientific research as undergraduates.

CONCLUSION

Most students in five Saudi universities expressed enthusiasm for participating in a research project, but only a few of them had sufficient knowledge on basic research. There was considerable improvement in students' perception of research in KAU when comparing their responses in 2007 to those in 2015.

Intravenous Versus Nonintravenous Benzodiazepines for the Cessation of Seizures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

The acquisition of intravenous (IV) access in the actively convulsing patient is difficult. This often delays the administration of the IV benzodiazepine (BDZ) necessary for seizure cessation. Delays in seizure cessation are associated with increased pharmacoresistance, increased risk of neuronal injury, worse patient outcomes, and increased morbidity.

OBJECTIVE

The objective was to assess whether the delay imposed by IV access acquisition is justified by improved outcomes. We compared IV versus non-IV BDZ efficacy in the real world with regard to failure rates (primary outcome), interval to seizure control, and observed complications (secondary outcomes).

METHODS

A systematic review was performed using Medline, Embase, and the Cochrane Library. All studies published or in press from the inception of the respective database to July 2016 were included. Only randomized and quasi-randomized controlled trials directly comparing IV to non-IV (buccal, rectal, intranasal, or intramuscular) BDZ were included.

RESULTS

Our search strategy retrieved 2,604 citations for review. A total of 11 studies were finally included in qualitative synthesis and 10 in quantitative analysis. Only one was of high quality. For treatment failure, non-IV BDZ was superior to IV BDZ (odd ratio [OR] = 0.72; 95% confidence interval [CI] = 0.56-0.92). However, no significant difference was found between the two treatments in the pediatric subgroup (OR = 1.16; 95% CI = 0.74-1.81). Non-IV BDZ was administered faster than IV BDZ and therefore controlled seizures faster (mean difference = 3.41 minutes; 95% CI = 1.69-5.13 minutes) despite a longer interval between drug administration and seizure cessation (mean difference = 0.74 minutes; 95% CI = 0.52-0.95 minutes). Respiratory complications requiring intervention were similar between non-IV BDZ and IV BDZ, regardless of administration route (risk difference = 0.00; 95% CI = -0.02 to 0.01).

CONCLUSION

Non-IV BDZ, compared to IV BDZ, terminate seizures faster and have a superior efficacy and side effect profile. Higher-quality studies and further evaluation in different age groups are warranted.

Hereditary neurometabolic causes of infantile spasms in 80 children presenting to a tertiary care center

BACKGROUND

Infantile spasms are a devastating infantile epileptic syndrome with multiple etiologies. Hereditary neurometabolic disorders are rarely recognized causes of infantile spasms. The aim of this study was to identify hereditary neurometabolic disorders when they were the cause of infantile spasms in patients presenting to a tertiary care center in Saudi Arabia.

METHODOLOGY

We conducted a retrospective review of children presenting to the Pediatric Department of King Abdulaziz Medical City in Riyadh, Saudi Arabia over a 15-year interval.

RESULTS

Eighty patients with infantile spasms were identified. A hereditary neurometabolic disorder was diagnosed in 10 patients (12.5%). Of these patients, two had a Leigh-like disorder and one patient had each of the following diagnoses: ethylmalonic aciduria, nonketotic hyperglycinemia, hyperinsulinemic hypoglycemia, leukodystrophy, short-chain acyl-coenzyme A dehydrogenase deficiency, molybdenum cofactor deficiency, primary carnitine deficiency, and neonatal hypoglycemia due to panhypopituitarism. This article is the first to report the association of the last three conditions with infantile spasms. Compared with the other etiologies, the hereditary neurometabolic disorder group had a strong history of similar disease in the same family (P = 0.002), and most of the patients were born of consanguineous parents (P = 0.021). In addition, a typical hypsarrhythmia pattern was more common in the hereditary neurometabolic disorder group (P = 0.003). Furthermore, this group had a poor response to therapy (P = 0.04). Otherwise, there were no significant differences regarding the type of spasms, neuroimaging or outcome; however, there was a trend toward poorer outcomes and death in the hereditary neurometabolic disorder group.

CONCLUSION

Hereditary neurometabolic disorders are relatively common causes of infantile spasms in this subpopulation of Saudi patients. An early diagnosis via proper metabolic and genetic testing has significant implications for applying specific treatments and for facilitating proper family counseling.

The impact of the Healthcom mass media campaign on timely initiation of breastfeeding in Jordan

Initiation of breastfeeding within several hours after a child's birth increases the likelihood of exclusive breastfeeding and longer duration of breastfeeding. However, common beliefs among mothers and health-care providers and routine hospital practices can constrain timely breastfeeding initiation. This article examines the impact of a mass media breastfeeding campaign in Jordan within the context of other activities occurring during and after the child's birth. The campaign had a positive impact on all mothers' knowledge, and on timely initiation of breastfeeding for home and public hospital deliveries, but not for those in private hospitals. The findings indicate that a communication campaign can bring about change in breastfeeding initiation behavior, but that providing mothers with information should be but one part of an integrated program to ensure that hospital and midwife policies and practices support timely initiation.

Severe mental retardation in Jordanian children. A retrospective study

The etiology of severe mental retardation has not previously been studied in Jordan. In a group of 203 mainly severely mentally retarded children born 1975-1985, we found the etiology to be related to two main factors: (1) sequele from high perinatal morbidity or meningitis in infancy leading to a combination of severe mental retardation and cerebral palsy; (2) a high degree of intermarriage and a high frequency of retarded siblings indicating that genetic causes of MR are common. The results underscore the importance of further development of antenatal and perinatal care, especially for poor people and the need of genetic counselling.

The duration for which exclusive breast-feeding is adequate. A study in Jordan

The object of this study was to determine the length of time for which exclusive breast-feeding supported adequate growth in a cohort of infants from families in and around Amman, Jordan. The infants were described as "faltering" if their incremental growth over 4 weeks fell below -2 standard deviations of the increments reported by Fomon in the USA. The infants were examined every 2 weeks until they faltered, or, without faltering, were started on supplementary foods. In general, up to the time of faltering, growth was satisfactory by international standards. The median time of faltering was 6 months. The results support the view that, at least in this relatively well-nourished community, exclusive breast-feeding is satisfactory for 4-6 months. However, further examination is needed of the risk factors that lead to early faltering in some breast-fed children.

Distribution of adult lactase phenotypes in Bedouins and in urban and agricultural populations of Jordan

Lactose tolerance tests with breath hydrogen determination identified 39 lactose malabsorbers among 162 Jordanian Bedouins (24%), and 111 lactose malabsorbers among 148 subjects from the urban/agricultural zone of western Jordan and Palestine (75%). This highly significant difference supports the hypothesis that milk dependence in nomadic desert populations resulted in selective pressures in favour of the lactase persistence gene. Within the urban/agricultural zone which extends from the desert border in Jordan to the Mediterranean shore, a significant increase in the frequency of lactose malabsorbers (and hypolactasia gene frequencies) from east to west was observed. The suggested genetic cline is problably due to migration from the desert populations to the agricultural zone.