Case report: Rapid recovery after intrathecal rituximab administration in refractory anti-NMDA receptor encephalitis: report of two cases.

Background: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is one of the most prevalent etiologies of autoimmune encephalitis. Approximately 25% of anti-NMDAR encephalitis cases prove refractory to both first- and second-line treatments, posing a therapeutic dilemma due to the scarcity of evidence-based data for informed decision-making. Intravenous rituximab is commonly administered as a second-line agent; however, the efficacy of its intrathecal administration has rarely been reported. Case summary: We report two cases of severe anti-NMDAR encephalitis refractory to conventional therapies. These patients presented with acute-onset psychosis progressing to a fulminant picture of encephalitis manifesting with seizures, dyskinesia, and dysautonomia refractory to early initiation of first- and second-line therapeutic agents. Both patients received 25 mg of rituximab administered intrathecally, repeated weekly for a total of four doses, with no reported adverse effects. Improvement began 2-3 days after the first intrathecal administration, leading to a dramatic recovery in clinical status and functional performance. At the last follow-up of 6 months, both patients remain in remission without the need for maintenance immunosuppression. Conclusion: Our cases provide evidence supporting the intrathecal administration of rituximab as a therapeutic option for patients with refractory anti-NMDAR encephalitis. Considering the limited penetration of intravenous rituximab into the central nervous system, a plausible argument can be made favoring intrathecal administration as the preferred route or the simultaneous administration of intravenous and intrathecal rituximab. This proposition warrants thorough investigation in subsequent clinical trials.

Knowledge and attitudes towards E-cigarette use in Lebanon and their associated factors.

BACKGROUND: Despite the misconceptions regarding E-cigarettes (ECs), only a few studies have been conducted in the Middle East that focused on this topic. This study assesses the knowledge of and attitudes towards ECs in Lebanon, determines how these two measures are associated, and identifies the variables that explain each of these measures. METHODS: A cross sectional study was conducted on a convenience sample of Lebanese pedestrians aged between 18 and 64 inclusive. A structured self-administered questionnaire comprising of knowledge and attitude scales, and questions on demographical, health and smoking characteristics was used. RESULTS: Scores for attitudes and knowledge of ECs were summed and dichotomized using a 75% cutoff, above which the participant was considered to have a positive attitude and good knowledge. Among the 352 participants (56.6% males, 43.3% females, mean age 30.3, 46.2% smokers), 63.3% exhibited a lower level of EC knowledge. More than 50% erroneously thought that ECs are not associated with lung and bladder cancer or impair lung and heart function. 65% falsely thought that it is harmless and not addictive. As for attitude, 43.3, 53.9, and 44.3% thought that it is socially acceptable, helps in smoking cessation, and is a good replacement for cigarettes and an enjoyable recreational device respectively. Our results revealed an inverse correlation between attitude and knowledge scores (Spearman's correlation = -.30, p < .001). Predictors of knowledge included health-related occupation (p = .010), regular exercise (p = .016), healthy diet (p = .026), EC use (p = .026), perception that ECs are not harmful (p = .001), and help in smoking cessation (p = .017). Predictors of attitude included EC use (p = .008), sex (p = .010), and knowledge that most ECs are addictive (p = .006), harmful (p = .014), and impair heart and lung function (p = .047). CONCLUSIONS: Our study revealed a gap in EC knowledge, especially among participants who displayed a positive attitude towards ECs. Hence, measures should be undertaken to regulate its use by instituting more stringent laws and holding nationwide awareness campaigns.