Predictors of severity and outcome of multiple sclerosis relapses.

BACKGROUND: Multiple Sclerosis (MS) is a demyelinating disease of the central nervous system (CNS). The most common type of MS is the relapsing-remitting MS (RRMS) where relapses are the main component of the disease course. However, the relationship between the characteristics of the relapses on one hand and their severity and outcome on the other hand has not been fully characterized. OBJECTIVES: To explore the characteristics of relapses among a cohort of Egyptian MS patients and their relation to the severity and outcome of the disease. SUBJECTS AND METHODS: We analyzed 300 attacks from 223 patients in a retrospective study to identify demographic, clinical and paraclinical (laboratory and radiological) factors affecting: 1- Severity of relapses (the difference between the EDSS at the day of maximum worsening and the EDSS before the onset of the attack). 2- Outcome of relapses (the difference between the EDSS at the day of maximum improvement and the EDSS before the onset of the relapse). RESULTS: Severe attacks were most likely to occur in patients who are males, single, presenting with poly-symptomatic presentation, slower tempo of evolution of attack symptoms, longer duration of the attack, absence of DMTs at the time of the attack. The risk of having a severe relapse is more than 3 times when the patient is single. Regarding attack outcome, poorly recovered attacks were more common in patients with older age at disease onset and at attack onset, male sex, higher number of relapses, longer duration of illness prior to the attack, severe relapses, polysymptomatic presentation, associated cognitive symptoms, slower tempo of symptom evolution, longer duration of the attack, patients on OCPs, smoking, and presence of black holes in brain MRI. The risk of having relapses with partial or no recovery is more than five times when the patient has black holes in brain MRI and more than 4 times when the patient is a smoker. CONCLUSION: Bearing in mind the demographic characteristics as well as the clinical and paraclinical characteristics of each attack and their relation to attack severity and outcome are a key to understanding the individual disease course of every patient and hence tailoring the best therapeutic plan suitable for his individual needs. In other words, prompt, rapid intervention in male patients, polysymptomatic attacks, slower tempo of evolution of attack symptoms and longer duration of the attack should be adopted since these factors are predictive of severe relapses as well as poor relapse outcome.

Impact of Ramadan fasting on disease activity in patients with multiple sclerosis: a multicenter study.

BACKGROUND: The safety of Ramadan fasting for Muslim patients suffering from multiple sclerosis (MS) is still a matter of debate. This work aimed to study the clinical course of MS during Ramadan fasting and to clarify the predictors of relapses and symptoms exacerbation. METHODS: This retrospective study included 153 Muslim patients with MS. Data related to the disease course before Ramadan were obtained from patients' files, whereas data related to the disease activity during Ramadan, were collected from patients over the two months following Ramadan. RESULTS: Patients with MS who experienced relapses, exacerbation of symptoms and development of new symptoms during Ramadan had a statistically significant longer disease duration compared to those who did not experience (P < 0.001, <0.001, 0.01 respectively). Also, patients who experienced relapses, exacerbation of symptoms and development of new symptoms during Ramadan had a statistically significant higher expanded disability status scale (EDSS) compared to those who did not experience (P <0.001, <0.001,0.01, respectively). The occurrence of relapses, exacerbation of symptoms and development of new symptoms during Ramadan, were significantly higher in patients who experienced relapses in the preceding year compared to those who did not (P= 0.002, 0.002, 0.01, respectively). Binary logistic regression revealed that each score elevation of EDSS increased the odds of relapse during Ramadan by 1.02 (P-value = 0.04). Also, each month's increase in disease duration increased the odds of relapse during Ramadan by 1.87 (P-value = 0.046). CONCLUSION: High EDSS and long disease duration are independent predictors of relapse during Ramadan.

Epilepsy and antiepileptic drugs: risk factors for atherosclerosis.

INTRODUCTION: Epilepsy is a chronic disease that affects metabolism either alone or through the antiepileptic drug (AED) treatment. A risk of atherosclerosis has been found in epileptic patients. AIM: Prove the potential role of epilepsy and/or its treatment as atherosclerotic risk factors. SUBJECT AND METHODS: Forty Egyptian patients with primary idiopathic epilepsy were compared to 20 healthy controls. B-mode ultrasound examination of the common carotid artery intima-media thickness (CCA IMT), measurement of serum lipid profile, fibrinogen and high sensitive C-reactive protein were performed to both groups. RESULTS: Patients had significantly increased right and left CCA IMT (p < 0.05); elevated levels of HDL (p < 0.01) and hs-CRP (p = 0.009) in comparison to control subjects. Positive correlation was found between IMT and hs-CRP (p < 0.05) as well as fibrinogen level (p < 0.05). Carbamazepine level was positively correlated to triglycerides (r = 0.748, p = 0.013) and Valproate level was positively correlated to hs-CRP serum level (r = 0.556, p = 0.032). CONCLUSION: Epilepsy and AED's are potential risk factors for atherosclerosis. Weak relation between epilepsy and/or AED's and lipid profile was found. Hs-CRP may be implicated in atherosclerosis in epileptic patients.

Multiple sclerosis patients' response to COVID-19 pandemic and vaccination in Egypt.

Background: On 11 March 2020, WHO declared COVID-19 has become a pandemic. This had an impact on everyday activity for every person. For special groups such as multiple sclerosis patients, the situation is a little bit confusing. In this study, COVID-19 infection impact on MS patients, willingness for vaccination, percentage of vaccinated patients and adverse effects of different vaccines were investigated. This cross-sectional descriptive study included 160 Egyptian MS patients. Demographic and clinical characteristics of all patients were extracted from their files MS unit archives. All these patients were contacted either by telephone and an oral informed consent was taken or in-person on their scheduled follow-up and informed written consent was taken to join this study. Patients were asked about: COVID-19 infection, severity of infection, and vaccination using a special questionnaire developed by the authors. Results: Only 39 (24.3%) patients have had COVID-19 infection with confirmed diagnosis. Most of infected patients (84.6%) were treated at home with no need for hospital admission. Five patients (12.8%) reported symptom suggestive of relapses after COVID-19 infection. Sixty-five patients (40.6%) were vaccinated against COVID-19. Out of these vaccinated patients, 22 patients (33%) developed adverse events from vaccine. These adverse events were self-limiting and related to local injection site and general manifestations. MS relapse after vaccination was reported in 7.7% of the vaccinated group. Conclusion: Prevalence of COVID-19 infection and severity of infection were equal to general population. Risk of relapse is low either with infection or vaccination. No severe adverse events were reported after vaccination.

Relation of post-stroke headachto cerebrovascular pathology and hemodynamics.

Despite high prevalence of cerebrovascular stroke, headache attributed to ischemic strokes is often undertreated and overlooked. The aim is to detect the relation of a post-stroke headache to cerebrovascular pathology and changes in hemodynamics through a high-resolution duplex ultrasound examination. The present study was a case-control study conducted among 239 patients, who presented with an acute ischemic stroke. Patients were sub-divided into two groups: group I included patients with headache attributed to ischemic stroke (cases) and group II included headache-free stroke patients (controls). History consisted of headache characteristics and risk factors. Clinical and radiological examination were preformed to detect the type of stroke. Ultrasound duplex examination of extra-cranial and intra-cranial cerebrovascular system was carried for both groups. Group I included 112 patients (mean age, 57.66 ±6.59 years), and group II included 127 patients (mean age 57.73 ±7.89 years). Post-stroke headache was more frequent in patients with posterior circulation infarction (58%). Post-stroke headache was reported within 7 days post-stroke in 61.6% of patients. Pre-stroke headache was an independent predictor for post-stroke headache occurrence (OR = 28.187, 95% CI: 6.612-120.158%, p < 0.001). Collateral opening and various degrees of intra-cranial vascular stenosis were strong predictors of headache occurrence (OR = 25.071, 95% CI: 6.498-96.722%, p < 0.001). In conclusion, post-stroke headache is a common phenomenon, especially in patients with pre-stroke headache, history of old stroke, posterior circulation infarction, and large artery disease. This headache was of moderate-intensity with clinical characteristics of tension-type. Intra-cranial cerebrovascular pathological changes including opening of collateral channels and variable degrees of stenosis of cerebrovascular systems were implicated in the production of that headache.

The burden of multiple sclerosis among postpartum women and self management's challenges: Pilot study of supportive program.

BACKGROUND: This study aims to determine the effect of multiple sclerosis supportive programs on mothers' self-management during postpartum. STUDY DESIGN: A quasi-experimental, nonequivalent group design was utilized. Primigravida pregnant women between 35-37 weeks of gestation and recently diagnosed with multiple sclerosis participated in two preparation sessions. While the first session during pregnancy was an open conversation about the delivery, the key topics of the second session were the nature of the postpartum cycle and the expected relapses. RESULTS: Seventy pregnant women with multiple sclerosis participated in this research. Results denoted a statistical difference between both groups regarding self-management in 6th and 12th weeks postpartum. The improvements were related to mothers' relationships with their health care providers and knowledge and information about multiple sclerosis during this transitional phase. On the other hand, there were no differences among both groups related to their levels of functional activities at 6th and 12th weeks postpartum. Although there was a slight deterioration in motor ability score among both groups at 12th week's postpartum, 54.3% of the intervention group vs. 49% of the non-intervention group reported 100% absolute independence. Moreover, the total relapses in the three-month postpartum ranged between 1-6, increasing the frequency of relapses during the three-month postpartum with no statistically significant differences between both groups. CONCLUSION: Conducting a multidisciplinary program to follow and counsel mothers with MS helps enhance self-management throughout the three-month postpartum period.

Neurological Manifestations in a Cohort of Egyptian Patients with COVID-19: A Prospective, Multicenter, Observational Study.

BACKGROUND: The COVID-19 pandemic has reached over 276 million people globally with 5.3 million deaths as of 22nd December 2021. COVID-19-associated acute and long-term neurological manifestations are well recognized. The exact profile and the timing of neurological events in relation to the onset of infection are worth exploring. The aim of the current body of work was to determine the frequency, pattern, and temporal profile of neurological manifestations in a cohort of Egyptian patients with confirmed COVID-19 infection. METHODS: This was a prospective study conducted on 582 hospitalized COVID-19 patients within the first two weeks of the diagnosis of COVID-19 to detect any specific or non-specific neurological events. RESULTS: The patients' mean (SD) age was 46.74 (17.26) years, and 340 (58.42%) patients were females. The most commonly encountered COVID-19 symptoms were fever (90.72%), cough (82.99%), and fatigue (76.98%). Neurological events (NE) detected in 283 patients (48.63%) and were significantly associated with a severe COVID-19 at the onset (OR: 3.13; 95% CI: 2.18-4.51; p < 0.0001) and with a higher mortality (OR: 2.56; 95% CI: 1.48-5.46; p = 0.019). The most frequently reported NEs were headaches (n = 167) and myalgias (n = 126). Neurological syndromes included stroke (n = 14), encephalitis (n = 12), encephalopathy (n = 11), transverse myelitis (n = 6) and Guillain-Barré syndrome (n = 4). CONCLUSIONS: Neurological involvement is common (48.63%) in COVID-19 patients within the first two weeks of the illness. This includes neurological symptoms such as anosmia, headaches, as well as a constellation of neurological syndromes such as stroke, encephalitis, transverse myelitis, and Guillain-Barré syndrome. Severity of acute COVID-19 illness and older age are the main risk factors.

The MuSC-19 study: The Egyptian cohort.

OBJECTIVE: This study aimed to report the severity of COVID-19 in a cohort of Egyptian patients with multiple sclerosis (MS) with particular attention on the impact of disease modifying drugs (DMDs). METHODS AND STUDY POPULATION: We included 119 MS patients recruited from two centers, Ain-Shams university and Cairo university with confirmed or suspected COVID-19 during the period from May to September 2020 as a part of the MuSC-19 project. Univariate logistic regression was fitted to assess risk factors for severe COVID-19 (at least one outcome among hospitalization, ICU admission and death). RESULTS: Females were 77%, mean age was 34 years, mean duration of MS was 5.28 years, median EDSS was 3, most of the patients (83%) had RRMS, while 15% and 2% had respectively SPMS and PPMS. Only eleven patients (9% of study population) had a severe outcome and 3 patients (3%) died. Headache was the only symptom significantly associated with the severity of COVID-19 (OR=10.85, P = 0.001). There was no association between any of the DMDs and severe COVID-19 outcome. CONCLUSION: This study showed an acceptable safety profile of DMDs in Egyptian MS patients who developed COVID-19, as 91% of the cohort had a favorable outcome. Headache as a symptom associated with severe outcome in Egyptian patients' needs further validation.

Neurological Complications in Recipients after Living Donor Liver Transplantation.

BACKGROUND AND AIM: Liver transplantation (LT) is the only curative treatment for patients with the end-stage liver disease. Amongst the complications post-LT, the neurological complications (NC) are particularly relevant. Our aim is to assess the incidence, risk factors and clinical presentation of NC in recipients after living donor liver transplantation. METHODS: Between November 2011 and December 2013, 149 patients were admitted to ICU in 3 different centres in Egypt after LDLT and were evaluated by full clinical examination, laboratory investigations, neuroimaging and the NC were observed over one month. This study was approved by the ethical committee of the National Research Center. RESULTS: 46 recipients (30.9%) developed neurological complications. The most common neurological complication was Encephalopathy (14.1%) while the least were both central pontine myelinolysis and meningoencephalitis (0.7%). In addition, 7 patients developed cerebrovascular events (either ischemic or hemorrhagic strokes). Patients were then classified into uncomplicated and complicated subgroups according to the highest percentage of neurological complication symptoms. These were encephalopathy, delirium with agitation, hallucinations, and delusions. CONCLUSION: A high incidence of neurological complications (30.9%) after LDLT was recorded, prolonging patient hospital stays. The most common complications were encephalopathy, delirium, hallucinations, delusions, and seizures some of which were drug related.

Managing Disease-Modifying Therapies and Breakthrough Activity in Multiple Sclerosis Patients During the COVID-19 Pandemic: Toward an Optimized Approach.

The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has become a major public health challenge of global concern since December 2019, when the virus was recognized in Wuhan, the capital city of Hubei province in China and epicenter of the COVID-19 epidemic. Given the novelty of COVID-19 and the lack of specific anti-virus therapies, the current management is essentially supportive. There is an absence of consensus on guidelines or treatment strategies for complex disorders such as multiple sclerosis (MS), in which the risk of infections is higher than in the general population. This is due to the overall impairment of the immune system typical of autoimmune diseases, in addition to accumulation of disabilities, and the iatrogenic effect generated by corticosteroids and the recommended disease-modifying therapies (DMTs). DMTs have different modes of action, but all modulate and interfere with the patient's immune response, thereby raising concerns about adverse effects, such as an increased susceptibility to infections. In this review, we analyze the evidence for use of DMTs during the current critical period and ratify an algorithmic approach for management to optimize care between keeping DMTs, with their infection hazards, or coming off them, with the risk of disease activation. We also provide an algorithmic approach to the management of breakthrough activity during the COVID-19 pandemic.

Interferon-Beta-Induced Headache in Patients with Multiple Sclerosis: Frequency and Characterization.

BACKGROUND: Studies have shown that interferon-beta (IFN-ß) treatment is associated with headaches in patients with multiple sclerosis (MS). Headaches can affect quality of life and overall function of patients with MS. We examined the frequency, relationships, patterns, and characteristics of headaches in response to IFN-ß in patients with relapsing-remitting multiple sclerosis (RRMS). PATIENTS AND METHODS: This study was a prospective, longitudinal analysis with 1-year follow-up. The study comprised 796 patients with RRMS treated with IFN-ß (mean age 30.84±8.98 years) at 5 tertiary referral center outpatient clinics in Egypt between January 2015 and December 2017. Headaches were diagnosed according to the International Classification of Headache Disorders ICHD-3 (beta version), and data were collected through an interviewer-administered Arabic-language-validated questionnaire with an addendum specifically designed to investigate the temporal relationship between commencement of interferon treatment, and headache onset and characteristics. RESULTS: Two hundred seventy-six patients had pre-existing headaches, and 356 experienced de novo headaches. Of 122 patients who experienced headaches before IFN-ß treatment, 55 reported headaches that worsened following onset of IFN-ß treatment. In patients with post-IFN-ß headaches, 329 had headaches that persisted for >3 months, 51 had chronic headaches, and 278 had episodic headaches, and 216 of these patients required preventive therapies. Univariate analysis showed a >6- and an approximately 5-fold increased risk of headache among those treated with intramuscular (IM) INF-ß-1a (OR 6.51; 95% CI: 3.73-10.01; P-value <0.0001) and 44 µg of SC INF-ß-1a (OR 5.44; 95% CI: 3.15-9.37; P-value <0.0001), respectively, compared with that in patients who received 22 µg of SC INF-ß-1a. CONCLUSION: Interferon-ß therapy aggravated pre-existing headaches and caused primary headaches in patients with MS. Headache risk was greater following treatment with IM INF-ß-1a and 44 µg SC INF-ß-1a.

Management Strategies of Patients with Neuromyelitis Optica Spectrum Disorder During the COVID-19 Pandemic Era.

The ongoing coronavirus (COVID-19) pandemic is a global health emergency of international concern and has affected management plans of many autoimmune disorders. Immunosuppressive and immunomodulatory therapies are pivotal in the management of neuromyelitis optica spectrum disorder (NMOSD), potentially placing patients at an increased risk of contracting infections such as COVID-19. The optimal management strategy of NMOSD during the COVID-19 era remains unclear. Here, however, we examined the evidence of NMOSD disease-modifying therapies (DMTs) use during the present period and highlighted different scenarios including treatment of relapses as well as initiation and maintenance of DMTs in order to optimize care of NMOSD patients in the COVID-19 era.

Quantitative evaluation of shoulder proprioception 6 months following stroke.

BACKGROUND: Chronic shoulder pain following cerebrovascular stroke (CVS) is a major problem that persists after maximum recovery of motor functions. Such pain has been attributed to altered shoulder joint kinematics causing soft tissue damage. AIM: Evaluation of shoulder proprioception in the ipsilateral paretic arm and contralateral unaffected side 6 months following cerebrovascular event. SUBJECT AND METHOD: Thirty adult patients (G1) with ischemic strokes ranging from 6 months to 1 year and 30 healthy control (G2) were assessed for shoulder proprioception. Angular displacement error was measured during active and passive repositioning of shoulder external and internal rotation in both patients' shoulders and in control's dominant upper limb. RESULTS: Statistically significant increase in angular displacement error was found in all tests in the affected shoulder compared to the unaffected contralateral shoulder and dominant arm of control subjects. The contralateral unaffected shoulder of patients showed within normal values and no differences with control values. Passive external and internal rotations showed statistically higher errors in patients with cortical lesions compared to those with subcortical lesions. CONCLUSION: Six months following the CVS, shoulder proprioception deficit in the affected hemiparetic side persists. Contralateral side shows no abnormalities. Cortical lesions might be associated with late shoulder proprioception recovery compared to subcortical lesions. The side of the lesion does not seem to affect the severity of proprioception deficit.

Development of a cobalt(II) phthalocyanine- MWCNT modified carbon paste electrode for the detection of polyunsaturated fatty acids.

In this work the development of an electrochemical sensor for the determination of polyunsaturated fatty acids (PUFAs), in particular linoleic acid, in commercially available safflower oil as complex matrix is described. The sensor consists of a carbon paste electrode with cobalt(II) phthalocyanine, Co(II)Pc, as mediator and multiwalled carbon-nanotubes (MWCNT) as nanomaterial. As carrier medium a sodium borate buffer (0.1 M, pH 9) was used. PUFAs were detected at a working voltage of 0.35-0.45 V (vs. Ag/AgCl). The sensor development was carried out in a batch system with differential pulse voltammetry (DPV) and cyclic voltammetry (CV). Sensor specification was tested by using various fatty acids (stearic acid, oleic acid, linoleic acid, linolenic acid and arachidonic acid) as well as esterified fatty acids, resulting in a specific applicability towards PUFAs, especially linoleic acid (LAH). The optimized sensor was applied in a flow injection analysis system (FIA) for the analysis of PUFAs in complex matrix. Linoleic acid was used as standard substrate to determine the analytical parameters. The linearity ranges between 7.5 and 200 µg mL-1 LAH, while the limit of detection was determined to be 2.5 µg mL-1 and the limit of quantification is approximately 7.5 µg mL-1 LAH. The LAH content was successfully detected in commercially available safflower oil via standard addition method and the results could be confirmed by a reference method. The PUFA content was calculated as LAH-equivalent.

Carpal Tunnel Syndrome Grading Using High-Resolution Ultrasonography.

PURPOSE: Carpal tunnel syndrome (CTS) is a common entrapment neuropathy of the wrist. The diagnosis of CTS has been a concern for physicians for a long time. The aim of this study is to evaluate the use of the median nerve (MN) cross-sectional area (CSA) in the wrist compared with the CSA in the forearm to grade the severity of CTS in Egyptian patients. METHODS: The CSAs of the MN in the wrist and forearm were measured in 72 wrists that were diagnosed with CTS via nerve conduction studies and 80 healthy wrists. The CTS group was subdivided into three subgroups (mild, moderate, and severe CTS). The ratio of the CSA of the MN in the wrist to that in the forearm was used to calculate cutoff values for CTS grading. RESULTS: There were positive correlations between the CSAs of the MN in the wrist and MN conduction latency. At a wrist-forearm ratio of 1.7, the high-resolution ultrasonography showed 96.1% accuracy in the detection of CTS. CONCLUSIONS: High-resolution ultrasonography can be used in CTS grading.

Ultrasound evaluation of internal jugular valve incompetence (IJVI) in Egyptian patients with idiopathic intracranial hypertension (IIH).

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a clinical syndrome with no identified causative factor. Internal jugular valve incompetence (IJVI) has been linked to many neurological disorders such as idiopathic intracranial hypertension (IIH), transient global amnesia and cough-induced headache. Intact valves prevent efficiently retrograde flow into the internal jugular vein. AIM: The aim of this study is to evaluate the competence of the jugular vein valves and its relationship to age, BMI, opening CSF pressure and MRV findings in IIH patients. SUBJECTS AND METHODS: Twenty-five Egyptian female patients diagnosed with IIH according to the modified Dandy criteria, and 24 female controls, matched for age and BMI, were included and examined using color-coded duplex for IJVI during the Valsalva maneuver. The patients underwent lumbar puncture to measure the opening pressure, MRV, ophthalmic examination and laboratory work-up. RESULTS: There was no statistically significant difference in the proportion of IJVI among the patients and controls (P=0.7). There was a statistically significant increase in the opening pressure and proportion of MRV abnormalities in the patients with IJVI compared to the patients without IJVI (P=0.03 and 0.007, respectively), but there were no statistically significant difference with regard to age, BMI, grade of papilledema and perimetry findings. CONCLUSION: This study showed that there is no relationship between IJVI and IIH; thus, IJVI would be a rather normal finding. Further studies are recommended to confirm or rule out a possible relationship.

Aerobic exercises enhance cognitive functions and brain derived neurotrophic factor in ischemic stroke patients.

BACKGROUND: Stroke is a leading cause of functional impairments. High percentage of these patients will experience some degree of cognitive affection, ranging from mild cognitive impairment to dementia. OBJECTIVE: Demonstrate the role of aerobic exercises enhancing cognitive functions and its effect on Brain Derived Neurotrophic factor (BDNF) in post-ischemic stroke patients in the territory of anterior circulation. SUBJECTS AND METHODS: We included thirty Egyptian ischemic stroke patients in the territory of anterior circulation. They were divided into 2 groups; group 1 (G1) were subjected to physiotherapy program without aerobic exercises and group 2 (G2) were subjected to the same previous program followed by aerobic exercises. Both groups were subjected to pre- and post-treatment Addenbrookes's Cognitive Examination- Revised (ACER) and serum level of BDNF. RESULTS: Our results showed a significant improvement in ACER score in G2 compared to G1 post-treatment (p = 0.017). BDNF serum level significantly increased in G2 post-treatment compared to pre-treatment (p = 0.001) and compared to G1 group (p = 0.0458). ACER improvement was positively correlated to increase in serum level of BDNF (r = 0.53, p = 0.044). CONCLUSION: Aerobic exercises improve cognitive functions of ischemic stroke patients. This improvement is related to the increase in serum level of BDNF.