Epilepsia partialis continua: A review

Epilepsia partialis continua (EPC) is a rare type of focal motor seizure characterized by continuous, involuntary muscle contractions in a specific part of the body. These contractions usually involve rhythmic, twitching movements and can last for several hours to days. The seizures are usually limited to one part of the body and can be clonic or dystonic. EPC can affect people of all ages but is more common in children and adolescents. The pathophysiology of EPC is complex and depends on the cause. There are several possible causes of EPC including structural brain abnormalities, infections, metabolic and genetic disorders, inflammatory conditions, traumatic brain injury, and vascular causes. The work-up of EPC includes electroencephalography (EEG), magnetic resonance imaging (MRI) of the brain, position emission tomography (PET) scan of the brain, autoimmune antibodies, infection work-up, and metabolic and genetic work-up. The management of EPC can be challenging. Antiseizure medications (ASDs) including benzodiazepines are an integral part of the management of EPC. Immunotherapy trials are recommended in resistant cases. Epilepsy surgery is one of the effective modalities in some surgically amenable cases. This article reviews the topic of EPC and summarizes diagnostic and .treatment recommendations.

Current Concepts in the Management of Sanfilippo Syndrome (MPS III): A Narrative Review

Sanfilippo syndrome is a childhood-onset (1-4 years) autosomal recessive lysosomal storage disease that presents as a neurodegenerative disease by targeting the brain and spinal cord. It is also known as mucopolysaccharidosis III. Mucopolysaccharidosis III is divided into four subtypes (A, B, C, or D). It can cause delayed speech, behavior problems, and features of autism spectrum disorder. Sanfilippo syndrome is of a higher prevalence within consanguineous families that carry its gene alteration. If both parents have a nonfunctional copy of a gene linked to this condition, their children will have a 25% (1 in 4) chance of developing the disease. In Saudi Arabia, the incidence rate is estimated at 2 per 100,000 live births. Recent research focused on promising treatment approaches, such as gene therapy, modified enzyme replacement therapy, and stem cells. These approaches work by exogenous administration of the proper version of the mutant enzyme (enzyme replacement therapy), cleaning the defective enzyme in individuals with glycolipid storage disorders (substrate reduction therapy), or using a pharmacological chaperone to target improperly folded proteins. However, there is currently no approved curative medication for Sanfilippo syndrome that can effectively halt or reverse the disorder.

Childhood-related neural genotype-phenotype in ATP1A3 mutations: comprehensive analysis

BACKGROUND

ATP1A3 is a gene that encodes the ATPase Na + /K + transporting subunit alpha-3 isoenzyme that is widely expressed in GABAergic neurons. It maintains metabolic balance and neurotransmitter movement. These pathways are essential for the proper functioning of the nervous system. A mutation in the ATP1A3 gene demonstrates remarkable genotype-phenotype heterogeneity.

OBJECTIVES

To provide insight into patients with ATP1A3 mutation.

MATERIAL AND METHODS

These cases were identified using next generation sequencing. The patients' clinical and genetic data were retrieved. Detailed revision of the literature was conducted to illustrate and compare findings. The clinical, genetical, neuroimaging, and electrophysiological data of all pediatric patients were extracted.

RESULTS

The study included 14 females and 12 males in addition to two novel females cases. Their mean current age is 6.3 ± 4.24 years. There were 11.54% preterm pregnancies with 5 cases reporting pregnancy complications. Mean age of seizure onset was 1.07 ± 1.06 years. Seizure semiology included generalized tonic-clonic, staring spells, tonic-clonic, and others. Levetiracetam was the most frequently used Anti-seizure medication. The three most frequently reported classical symptoms included alternating hemiplegia of childhood (50%), cerebellar ataxia (50%), and optic atrophy (23.08%). Non-classical symptoms included dystonia (73.08%), paroxysmal dyskinesias (34.62%), and encephalopathy (26.92%). Developmental delay was reported among 84.62% in cognitive, 92.31% in sensorimotor, 80.77% in speech, and 76.92% in socioemotional. EEG and MRI were non-specific.

CONCLUSION

Our study demonstrated high heterogeneity among patients with pathogenic variants in the ATP1A3 gene. Such variation is multifactorial and can be a predisposition of wide genetic and clinical variables. Many patients shared few similarities in their genetic map including repeatedly reported de novo, heterozygous, mutations in the gene. Clinically, higher females prevalence of atypical presentation was noted. These findings are validated with prior evidence and the comprehensive analysis in this study.

Identification of Child Abuse and Neglect Based on the Perception of Training Physicians in Jeddah, Saudi Arabia

Introduction Child abuse and neglect (CAN) affects many countries, including Saudi Arabia (SA). CAN in SA is more commonly detected in hospitals. Therefore, healthcare professionals must identify and report the cases. This study aims to assess knowledge and perceptions toward CAN among training physicians. Methodology A cross-sectional survey was conducted through a self-administrated structured questionnaire and involved 123 residents and fellows who deal with children in Jeddah, SA. The participants were recruited using convenient sampling methods. Descriptive statistics, t-test, and Chi-square test were used for statistical analysis. Results We found that approximately 78% would report their findings to the legal authority, document them, and assess their consistency with parents and the child's explanation. However, only 41.5% of the participants would report CAN to the proper authority. Most participants believed that CAN should be redefined according to Saudi culture and religious standards. In contrast, 68.9% of the participants believed that CAN cases are under-reported in SA. The main barrier to not reporting is the fear of consequences (63.4%). About 77% of the participants agreed to the need for further training. Identifying the CAN indicators was higher among those who handled a CAN case previously (median = 66.67, p = 0.023). Conclusions In conclusion, the study showed that appropriate undergraduate and postgraduate curriculum training should be developed to strengthen future healthcare practitioners in dealing with CAN cases to protect children's welfare.

Giant Axonal Neuropathy: A Case Report of Subclinical Childhood Manifestations

Giant axonal neuropathy (GAN) is a rare, inherited neurodegenerative disease that affects both the central and peripheral nervous systems. It is mostly characterized by a progressive loss of motor and sensory function, which can begin in early childhood. GAN is thought to be caused by a mutation in the GAN gene on chromosome 16q24.1. We report a seven-year-old Saudi male child with GAN who was diagnosed using whole-exome sequencing. The child presented with a history of progressive weakness and muscle wasting in the arms and legs as well as difficulty walking. The sequencing identified a mutation in the GAN gene (NM_022041.3: c.1456G>A). Electrodiagnostic studies showed evidence of diffuse axonal motor and sensory polyneuropathy involving cranial nerves. This case report adds to the growing evidence that whole-exome sequencing can be a useful tool for diagnosing rare inherited neuromuscular disorders. It also highlights the importance of early diagnosis and intervention for this condition.

The determining factors of medical students in considering a specialty as a future career path: A cross-sectional multinational study in the Middle East

Background and Aims

Throughout their years of study, undergraduate medical students are expected to gain broad comprehension of all medical specialties. After acquiring an undergraduate degree, the decision to choose a specialty is critical for every student's life as it determines the rest of their career path. This study aims to determine factors influencing medical students' choices between various specialties in different countries in the Middle East and North Africa.

Subjects and Methods

A cross-sectional study was conducted in March 2022 targeting medical students from the Middle East and North African countries. A questionnaire was used to collect data from the students, which consisted of four sections. Ethical approval was obtained from the Unit of Biomedical Ethics Research Committee at King Abdulaziz University. Participation was voluntary and anonymous. For statistical analysis, IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows (Version 21.0; IBM Corp., Armonk, NY, USA) was used. Categorical variables were presented using numbers, associated frequencies, and percentages (%). Categorical variables were correlated using the Chi-square test. One-way analysis of variance (ANOVA) test was used to compare the means of three or more independent groups. Logistic regression, odds ratio (OR), and 95% confidence interval (CI) were used to identify the factors associated with specialty selection. P < 0.05 was considered statistically significant.

Results

A total of 1109 students responded to the questionnaire. Participants' gender characteristics showed that there were 672 (60.6%) females and 437 (39.4%) males. Among them, 127 were in their second year, 180 in their third year, 362 in their fourth year, 85 in their fifth year, 37 in their sixth year, and 108 were interns. The median age of the participants was 22.0 years (mean = 22.09 ± 2.891). There were 473 (42.6%) students who were undecided about their future medical specialty. Income (759, 68.4%) and career prospects (723, 65.2%) were the most preferred factors in their decision to pursue a future medical specialization.

Conclusions

In conclusion, medical and surgical specialties have been identified as the preferred future career path. It was discovered that student's decision-making is influenced by income, career prospects, and the sense of competency needed to choose a future medical specialty. Future research would be more revealing.

Frontonasal Encephalocele Complicated With Pseudotumor Cerebri: A Case Report and Literature Review

Primary pseudotumor cerebri syndrome (PPTS) is a rare disorder of elevated intracranial pressure (ICP) in the absence of an identifiable underlying etiology. Afflicted patients are usually obese women in their reproductive age presenting with symptoms of elevated ICP. Seldom, patients can present with an encephalocele. We reported a case of a 31-year-old female who initially presented to our center with complaints of headaches, foreign body sensation in the nasal cavity, and decreased ability to smell. Brain computed tomography (CT) scan showed a large intranasal encephalocele and defect along the frontal skull base, through which brain tissue was herniating. The patient was successfully treated surgically by implantation of a lumboperitoneal shunt to manage the high ICP caused by her PPTS. In combination, reconstruction of the frontal skull base defect for the encephalocele was performed. Currently, the patient is doing well despite some on-and-off headaches.

Insight into Genetic Mutations of SZT2: Is It a Syndrome?

BACKGROUND

The seizure threshold 2 (SZT2) gene encodes a protein of unknown function, which is widely expressed, confers a low seizure threshold, and enhances epileptogenesis. It also comprises the KICSTOR protein complex, which inhibits the mTORC1 pathway. A pathogenic variant in the SZT2 gene could result in hyperactive mTORC1 signaling, which can lead to several neurological disorders.

AIM OF THE STUDY

To review every reported case and present two novel cases to expand the current knowledge and understanding of the mutation.

METHODS

Whole exome sequencing (WES) was used to identify the novel cases and present their clinical and radiological findings. A detailed revision of the literature was conducted to illustrate and compare findings. The clinical, genetical, neuroimaging, and electrophysiological data were extracted.

RESULTS

The study included 16 female patients and 13 male patients in addition to the 2 novel male cases. Eighteen patients had heterozygous mutations; others were homozygous. The majority presented with facial dysmorphism (n = 22). Seizures were noted as the predominant hallmark (n = 26). Developmental delay and hypotonia were reported in 27 and 15 patients, respectively. The majority of patients had multifocal epileptiform discharges on the electroencephalogram (EEG) and short and thick corpus callosum on the magnetic resonance imaging (MRI).

CONCLUSION

Several promising features are becoming strongly linked to patients with SZT2 mutations. High variability among the cases was observed. Developmental delay and facial dysmorphism can be investigated as potential hallmarks; aiding clinicians in diagnosing the condition and optimizing management plans.

Pediatric Neurology Workforce in Saudi Arabia: A 5-Year Update

BACKGROUND

The medical workforce plays a pivotal role in advancing human health, particularly within the healthcare system of Saudi Arabia. While government-employed healthcare providers form the central structure of the system and offer free healthcare services, the private healthcare sector is also witnessing significant growth. In parallel, the field of child neurology has experienced notable transformations in recent years, with continued expansion. This expansion brings forth a range of challenges for both current and future pediatric neurologists, necessitating careful consideration and proactive measures to address them.

AIM OF THE STUDY

To investigate and analyze the current characteristics of the workforce, with a specific focus on their employment status and related data.

METHODS

This is a cross-sectional analysis, using a survey to assess the distribution of pediatric neurologists in Saudi Arabia (SA). The final analytical sample included 82 subjects, working in 13 regions in SA. A descriptive analysis was used to address the study question.

RESULTS

The survey received responses from a total of 82 pediatric neurologists in Saudi Arabia (response rate 55%), with 38 (46%) being men and 44 (54%) being women. The mean age was 33 ± 1.225 years. The majority of participants practiced in major cities such as Riyadh and Jeddah. Nearly 50% of pediatric neurologists experienced some form of delay in obtaining their first job, ranging from 1 to 36 months.

CONCLUSION

The landscape of the pediatric neurology workforce is currently witnessing noteworthy demographic shifts. With the majority of practitioners concentrated in major cities, there is an ongoing demand for qualified professionals in peripheral areas. This study describes the real-life challenges faced by pediatric neurologists, particularly the delay in securing employment after graduation, and underscores the critical importance of addressing these persistent issues along the journey of pediatric neurology.

Clinical and Demographic Characteristics of Families Attending the Epilepsy, Neuromuscular, and Child Wellbeing Clinics

Background Neurological diseases entail a broad spectrum of disorders. Among such ailments are epilepsy and neuromuscular disorders which impose a substantial burden on children and their families. Ensuring adequate access to outpatient services is crucial for these children regardless of the subclinical specialty, and clinicians can better comprehend the caregivers' perspectives by being aware of their backgrounds which can be aided using epidemiological studies. Methods In June 2023, a cross-sectional study was carried out in pediatric neurology clinics at a tertiary care center. The study included all families with a child or more (14 years and younger) diagnosed with neurological disorders. The study adopted a three-section survey delivered to participants recruited using a non-probability sampling technique to achieve a 95% confidence interval with a 5% margin of error. Results A total of 821 families participated in this study. The mean age of respondents was 40.46±8.72 years. Of the affected children, there were 600 (73.08%) children following up with the general neurology and epilepsy clinics, 164 (19.98%) were following up with the neuromuscular disorders clinics, and 57 (6.94%) were following up with the neurogenetic clinics. Familial status had no association with the type of clinic the patient was following up with p=0.0054. Single respondents had a significantly higher prevalence of children with epilepsy (p<0.0001). Parents with a high school level of education or lower had a significantly greater prevalence of epilepsy clinic follow-ups (p=0.0048). Conclusion The findings of this study contribute to the assessment of prevalent neurological disorders in children and shed light on the family dynamics surrounding these conditions. Through statistical analysis, the study establishes connections between certain demographic and clinical traits and specific neurological disorders among pediatric patients and their families. The study emphasizes the importance of socio-economic and socio-clinical support in promoting child health in such cases. Similar research would offer a more accurate portrayal of the challenges faced by families in these circumstances.

The important role of family members in guiding medical professions to reach a diagnosis: Case report of under-noticed bilateral apraxia of eyelid closure

Apraxia of eyelid closure (AEC) is a rare disorder characterized by the inability to close the eyes on command with the preservation of the motor and sensory systems, coordination, comprehension, and cooperation. The prevalence of AEC is extremely small and the exact pathophysiological mechanisms underlying this condition remain unknown. It is, however, associated with extrapyramidal disorders. Very few cases of bilateral AEC have been reported. We report a case of an 81-year-old male patient having multiple comorbidities including neurological, respiratory, and abnormalities complicated by COVID-19 infection, who developed AEC that was noticed by the caregiver. We illustrate the clinical course leading to the diagnosis of bilateral AEC and highlight the important role of the caregiver in reporting subtle signs such as AEC.

Demographics and Clinical Presentations of Patients Visiting the Emergency Department During the Holy Month of Ramadan: A Three-Year Retrospective Study in a Muslim-Majority Country

Background and objective Ramadan is the Muslim's holiest month; it is a time when believers engage in special practices that include fasting from dawn till dusk and making cultural and dietary modifications in their everyday lives. The impact of Ramadan on human activity, sleeping patterns, and circadian rhythms of hormones have been addressed in the literature. Fasting, which constitutes the main pillar of practices during Ramadan and lasts from sunrise to sunset, can significantly affect common health conditions, leading many to seek medical care in the Emergency Department (ED). Hence, it is important to understand the pattern of ED visits and understand the impact caused by fasting during this holy month in a Muslim-majority country. In light of this, this study aimed to gather new insights into the pattern of ED visits during Ramadan at a busy tertiary care center in the period from 2019 to 2021. Methods This study was conducted by reviewing the hospital health information system to gather relevant information in May 2022. Data of patients who visited the ED during Ramadan were collected, as well as during a month prior to and after Ramadan for the purpose of comparison. Sociodemographic characteristics and clinical profiles were collected for analysis.  Results The total number of ED visits in the three months of Ramadan during the study period (three years) was 33,142, all of which were included in our analysis. Sociodemographic data were analyzed for patients who visited the ED during the month of Ramadan and the two lunar months that precede and succeed Ramadan (Shaban and Shawal). Fever was the most common complaint (16.5%), followed by abdominal pain (14%). When analyzing the findings based on patient age groups, fever was found to be the most prevalent complaint in both adults (15.6%) and pediatric patients (34.4%). Of the total ED patient visits, 7,527 patients were admitted for further care, and 197 patients deceased. Conclusion Our study findings illustrate the change in ED visit patterns during the month of Ramadan in a Muslim-majority country. Also, the type of complaints was affected significantly due to the ongoing coronavirus disease 2019 (COVID-19) pandemic during the study period. The outcomes in patients reflected substantial progress and outcomes in the ED. These findings highlight that analyzing ED data can help provide accurate information that can be used to help modify/adjust the quality of services provided in the ED. However, these modifications may affect all hospital facilities, not just the ED.

The Association of Sociodemographic Factors, Postictal Symptoms, and Medical History With Seizure Type in Patients With Epilepsy: A Cross-Sectional Study

Background Approximately 50 million people globally suffer from epilepsy. The prevalence of epilepsy in Saudi Arabia has been reported at 6.5 per 1,000 persons, affecting nearly 1% of the entire population. However, limited data is available in the country regarding the sociodemographic factors affecting epilepsy and its associated postictal symptoms, which may lead to stigmatization and negatively impact patients. Methods A cross-sectional study was conducted at King Abdulaziz University Hospital (KAUH) in a survey format. Ethical approval was obtained from the Research Ethics Committee of the Faculty of Medicine at King Abdulaziz University. The study population included patients with epilepsy who visited King Abdulaziz University Hospital's outpatient neurology clinics from October 2021 to March 2022. Results The study participants' average age at the time of the first seizure was 16.5 years, with patients experiencing seizures as early as within the first year of life and as late as 70 years of age. Patients who had had their first seizure during the first year of life did not have any schooling (p<0.0001) and had learning difficulties (p<0.00001). Focal onset impaired awareness seizures were significantly associated with motor weakness (p=0.023) and mood alterations (p=0.014), while postictal fear, anxiety or panic, and sleep disruption were statistically significant for focal onset aware seizures (p=0.015 and p=0.050). Conclusion This study highlights the sociodemographic differences between patients in Saudi Arabia and in other areas. It may also point to novel findings regarding the postictal symptoms associated with the various seizure types.

The Spectrum of MRI and Electrographic Findings in Pediatric Patients With Seizures: A Retrospective Tertiary Care Center Study

Background Seizures constitute a serious public health concern, especially in pediatric patients. They are among the most prevalent medical issues affecting children. Magnetic resonance imaging (MRI) is a widely used imaging modality to evaluate, assess, and follow up on brain abnormalities. Objectives The purpose of the study is to explore the clinical findings of pediatric patients with seizures and their associated findings on MRI examinations. Material and methods A retrospective cohort study was conducted between 2021 and 2022 at King Abdulaziz University Hospital (KAUH). A total of 171 pediatric patients (ages 1-14 years old) who had seizures and underwent brain MRI examinations were included in the study. The mean age of the group was two years. Results Focal seizures represented the majority of seizure types in 62 (60.2%) patients compared to 42 patients who presented with generalized seizures and 67 patients who presented with normal findings based on magnetic resonance imaging (MRI) analysis. The most common finding in imaging was the presence of developmental anomalies, which were found in 31 (18.5%) patients. This was followed by hypoxic-ischemic injury in 12 patients, vascular abnormalities in 10 patients, inherited metabolic disorders in nine patients, and infection-related findings in six patients. Conclusion MRI has an invaluable role in managing pediatric patients with seizures. Accurate diagnosis of patients is an essential step for delivering proper care to patients. MRI is considered the main imaging modality to establish a correct diagnosis and thereby improve prognosis, and electroencephalogram (EEG) should be taken into account during standard neurodiagnostic testing.

GAMT Deficiency Among Pediatric Population: Clinical and Molecular Characteristics and Management

Objective: Analyze the treatment modalities used in real practice by synthesizing available literature. Methods: We reviewed and evaluated 52 cases of GAMT deficiency including 4 novel cases from Saudi Arabia diagnosed using whole-exome sequencing. All data utilized graphical presentation in the form of line charts and illustrated graphs. Results: The mean current age of was 117 months (±29.03) (range 12-372 months). The mean age of disease onset was 28.32 months (±13.68) (range 8 days - 252 months). The most prevalent symptom was developmental delays, mainly speech and motor, seizures, and intellectual disability. The male-to-female ratio was 3:1. Multiple treatments were used, with 54 pharmacological interventions, valproic acid being the most common. Creatinine monohydrate was the prevalent dietary intervention, with 25 patients reporting an improvement. Conclusion: The study suggests that efficient treatment with appropriate dietary intervention can improve patients' health, stressing that personalized treatment programs are essential in managing this disorder.

Comparative Morphological and Morphometric Study between Medial and Lateral Menisci in Aged Male and Female Human Cadavers

Background

The meniscal cartilages are fibrous discs that are important for knee structures and have the ability to bear weight and stabilize joints. However, morphological and standard data for the meniscus are limited. Therefore, this work will compare anatomical and histological parameters of meniscal cartilages. The results will be important for the different measurements that are necessary for knee joint surgery.

Materials and Methods

A total of 24 aged cadavers (12 males and 12 females) were included. Knee joints were dissected and the menisci were excised and labeled as medial or lateral, right or left, male or female. Then, the menisci were kept in 10% formalin solution. Morphological variations of the meniscal shapes were macroscopically categorized. Different measurements, including the distance between anterior and posterior horns, outer and inner circumferences, width (breadth), and thickness, were done using a digital Vernier caliper and recorded manually.

Results

48 medial menisci (MMi) cartilages were studied, they were 54.6% crescent-shaped, 34.6% V-shaped, and 10.8% U-shaped. 48 lateral menisci (LMi) cartilages were studied, 41.6% were crescent-shaped, 56.4% were C-shaped, and 2% were disc-shaped articular cartilage. Findings included differences in their lengths and thickness.

Conclusion

The findings of this study were significant in providing new information on various morphological and morphometric parameters of the MMi and LMi in aged males and females, which are necessary to require more precise and comprehensive fundamental data that will be helpful for many specialists for better diagnostic and therapeutic approaches; aiming to restore normal joint conditions in senile people complaining of different meniscal pathologies.

Evaluation of Health Science Students' Health Fatalism and Perception Towards Patients With Epilepsy: A Cross-Sectional Global Study

Introduction The social acceptance of patients with epilepsy is largely determined by society's opinion of epilepsy; therefore, individuals with epilepsy could face prejudice and stigma as a result of negative impressions. Religious beliefs and mystical notions have been shown to influence attitudes toward epilepsy. Health fatalism could also be detrimental to society's and caregivers' approach toward such patients. In extreme settings, this could hinder them from obtaining an adequate treatment process. Methods A cross-sectional exploratory study was conducted from February 2022 to May 2022 in Saudi Arabia, Spain, Scotland, and Italy using an online questionnaire consisting of 33 questions concerning the Health Fatalism Scale (HFS), the Epilepsy Knowledge Scale (EKS), and the Epilepsy Attitude Scale (EAS). Results A total of 735 health science students (HSS) participated in the present study. The majority of participants were females (64.1%) while male participants represented 34.6% of the study. Health science students currently studying in Saudi Arabia represented the majority of participants with a percentage of 58.5%. Among the four countries, students in Saudi Arabia presented with the highest knowledge mean score. Students in Spain had the highest mean attitude score. Muslim students had the highest mean fatalism scores followed by Christian students. Conclusion In general, a high level of knowledge was observed among the participants, most notably, among Saudis who presented with the highest level of knowledge across the four countries. Regarding attitude, Spanish students presented the best attitude towards patients with epilepsy. Low fatalism scores were commonly observed across all countries regardless of their different demographic characteristics. Fatalism perception should be further detailed to ensure optimal services are delivered without prejudgment by future healthcare workers.