Adherence to Antithrombotic Treatment and Ischemic Stroke Recurrence in Egypt and Germany: A Comparative Analysis.

BACKGROUND: The burden of stroke weighs heavily in developing countries where recurrence rates clearly exceed that of developed countries. The impact of nonadherence to antithrombotic treatment within this context has been poorly investigated. OBJECTIVE: The objective of this study was to evaluate patients with recurrent ischemic stroke in Egypt and Germany with focus on stroke subtype distribution and adherence to antithrombotic therapy. METHODS: We conducted a comparative cross-sectional retrospective cohort study enrolling consecutive patients hospitalized for recurrent ischemic stroke in 2017 in 2 academic centers. Data were collected on demographics, risk factors, stroke subtypes, and medication adherence. Nonadherence to antithrombotic agents was analyzed at the time point of index stroke (recurrent stroke). Predictors of nonadherence were analyzed using logistic regression. RESULTS: A total of 373 Egyptian and 468 German patients with ischemic stroke were included. The proportion of recurrent ischemic stroke among all patients was higher in the Egyptian cohort compared to the German cohort (33 vs. 10%, p < 0.05). Small-vessel occlusion stroke was the most frequent subtype in Egyptians, with a significantly greater proportion than in Germans (45 vs. 26%, p < 0.05). Nonadherence to antiplatelets at the time point of the recurrent stroke was higher in Egyptians than in Germans (82 vs. 19%, p < 0.001). Low educational attainment among Egyptians (OR 0.14, 95% CI [0.00-0.19], p < 0.01) and high comorbidity scores among Germans (OR 2.45, 95% CI [1.06-5.66], p < 0.05) were found to be predictors of nonadherence to antithrombotic treatment. CONCLUSIONS: The large stroke recurrence burden in Egypt may be partly explained by differing adherence to secondary preventative antithrombotic pharmacotherapy. Predictors of medication nonadherence have to be addressed to reduce stroke recurrence disparities.

Prevalence of Common Types of Compression Neuropathies in Qena Governorate/Egypt: A Population-Based Survey.

BACKGROUND: No epidemiological studies on the prevalence of compressive neuropathy have been undertaken in Arab countries. The aim of the study was to estimate the prevalence of the most common types of compressive neuropathies in Qena governorate/Egypt. METHODS: The study was part of a community-based survey carried out to assess the prevalence of neuromuscular disorders among the Qena population. A random sampling of 10 districts, 5,039 inhabitants aged ≥20. There were 3,050 urban residents (60.5%) and 1,989 (39.5%) from the rural community. Patients were diagnosed using a screening questionnaire for diagnosis of entrapment neuropathies. Positive cases were referred to the Qena University Hospital. They were given full clinical, electrophysiological and laboratory investigations. RESULTS: Compressive neuropathy was recorded in 165 cases giving a CPR = 3.3% of population at risk (≥20 years). Carpal tunnel syndrome (CTS) was diagnosed in 155 cases giving a CPR = 3.1% with a significantly higher prevalence among females than males (5.3 vs. 0.9%) and in rural compared with urban populations (4.6 vs. 2.1%). Ulnar neuropathy at the elbow was the second common type of entrapment with a CPR = 0.1% followed by radial nerve palsy, tarsal tunnel syndrome and common peroneal nerve palsy. CONCLUSION: The overall crude prevalence rate of CTS is comparable with that in other countries.

Prevalence of Diabetes and Diabetic Neuropathy in Qena Governorate: Population-Based Survey.

BACKGROUND: No previous study was done to estimate the prevalence of diabetic neuropathy (DN) in Arabic countries. The aim of this study was to estimate the prevalence of DN and its characteristics in Qena governorate. MATERIAL AND METHODS: This is a random sampling of 10 study areas, involving 9,303 inhabitants; 51.1% men and 48.9% women were recruited. There were 57.3% urban residents and 42.7% rural residents. Patients were diagnosed using a screening questionnaire for diabetes mellitus (DM) as well as for DN in addition to measuring blood sugar in suspected cases. All positive cases were referred to Qena University Hospital and were subjected to full clinical, electrophysiological and laboratory investigations. RESULTS: Out of 9,303 people screened, 837 were diabetic giving prevalence 8.99% of the population. Eight hundred eleven had type II DM and 26 cases had type I giving prevalence of 8.7 and 0.3%, respectively. One hundred fifty-five out of 837 (18.5%) diabetic patients had evidence of DN with prevalence rate being 1.7% of the total population. Diabetic polyneuropathy was the commonest type with prevalence 1.5%. The prevalence of DN was higher in women than in men. Rural residents had significantly higher prevalence of DN compared to urban residents (1.9 vs. 1.4) and illiterate population more than educated (5.8 vs. 1.2). CONCLUSION: The overall crude prevalence rate of DM and DN is nearly the same as in European countries and lower than that in other Arabic countries.

Prevalence of ischemic and hemorrhagic strokes in Qena Governorate, Egypt: community-based study.

BACKGROUND: Stroke is a major health problem in developing countries. In a previous survey, the prevalence rate of stroke in the Nile Valley governorate of Assiut was significantly higher than other Arabic countries. In view of this, we carried out a follow-up study in a second Nile Valley governorate (Qena). METHODS: A community-based, three-phase, door-to-door study with random sampling of 10 areas in Qena governorate (first phase), involving 8027 inhabitant with 4172 males (51.97%) and 3855 females (48.03%). There were 4427 urban residents (55.15%) and 3600 residents (44.85%) from the rural community. In the second phase, participants were screened using the questionnaire for stroke, whereas the third phase involved neurologic evaluation of all suspected cases, with diagnosis of stroke confirmed by evaluation of computed tomography (CT) scans. The Mini Mental State Examination and National Institute of Health Stroke Scale were evaluated for each patient. RESULTS: Of the 8027 participants, 74 were identified as positive cases with a crude prevalence rate 922 of 100,000, an age-adjusted local prevalence rate of 777 of 100,000 and an age-adjusted prevalence rate of Egyptian population 566.6 of 100,000. The highest age-specific prevalence rates were recorded among subjects 70 years of age or older (8,392 of 100,000). The crude prevalence rate of ischemic stroke was significantly higher than that of hemorrhagic stroke (797 vs 125 of 100,000). Illiterate participants had a significantly higher crude prevalence rate than those who were literate (3567 vs 704 of 100,000). There was no significant difference in the prevalence rate between rural and urban areas or between males and females. Fifty patients (67.57%) had 1 or more risk factors of stroke, with hypertension being the most common (62.16%), followed by diabetes mellitus (36.49%). CONCLUSIONS: The overall prevalence rate of stroke is nearly the same as in other Egyptian governorates and is higher than other Arabic countries.

Clinical and neurophysiological risk factors of learning disabilities in different types of idiopathic focal epilepsy.

Objectives: Academic difficulties are common in epileptic children. A learning disability (LD) is a reduction in the learning capacity of children or the intellectual ability of adults, which is different from mental retardation or dementia. Materials & Methods: The participants were 56 patients, of whom 35 were males (62.5%), and 21 were females (37.5%). The participants attended the Neurology Outpatient Clinic, the Sohag University Hospital, between December 2016 and May 2017. Children with chronological age between 7 and 16 years with idiopathic focal and normal mental and motor developmental history were enrolled in this cross-sectional study. The Revised Quick Neurological Screening Test was used to assess different types of LD. Results: LDs were present in 67.9% of our participants with a statistically significant association between LDs in one arm and younger age, earlier age of onset of epilepsy, frequent seizures, and seizure semiology, particularly of temporal lobe origin, in the other arm. In addition, left epileptic focus on EEG, prolonged treatment duration with antiepileptic drugs (AED), and polytherapy were significantly correlated with LDs. Conclusion: Many factors are significantly correlated with LDs in children with idiopathic focal epilepsy, like age of the patient, age of epilepsy onset, seizure semiology, prolonged AED treatment, and polytherapy.

Movement-related cortical stimulation can induce human motor plasticity.

Repeated paired associative stimulation combining peripheral nerve stimulation and transcranial magnetic stimulation (TMS) of the primary motor cortex (M1) can produce human motor plasticity. However, previous studies used paired artificial stimuli, so that it is not known whether repetitive natural M1 activity associated with TMS can induce plasticity or not. To test this hypothesis, we developed a movement-related cortical stimulation (MRCS) protocol, in which the left M1 was stimulated by TMS at specific timing with respect to the mean expected reaction time (RT) of voluntary movement during a simple reaction time task using the right abductor pollicis brevis (APB) muscle. Seventeen normal volunteers were subjected to repeated MRCS intervention (0.2 Hz, 240 pairs). Motor function was assessed before and after MRCS. When TMS was given 50 ms before the RT of movement [MRCS(-50)], motor-evoked potential (MEP) amplitude of the right APB, but not other muscles, increased for up to 15 min post-MRCS. The RT of the right APB was also shortened. However, spinal excitability measured by F-wave did not change. When TMS was given 100 ms after the RT [MRCS(+100)], MEP amplitude was decreased. These findings show that this new MRCS protocol can produce timing-dependent motor associative plasticity, which may be clinically useful.

Recovery of upper-limb function due to enhanced use-dependent plasticity in chronic stroke patients.

Patients with chronic stroke often show increased flexor hypertonia in their affected upper limbs. Although an intervention strategy targeting the extensors of the affected upper limb might thus be expected to have benefits for functional recovery, conventional repetitive motor training has limited clinical utility. Recent studies have shown that repetitive transcranial magnetic stimulation could induce motor recovery. The present study tested whether 5 Hz repetitive transcranial magnetic stimulation of the upper-limb area of the primary motor cortex, combined with extensor motor training, had a greater effect on motor recovery than either intervention alone in stroke hemiparesis. Nine patients with chronic subcortical stroke and nine age-matched healthy subjects completed the crossover study. In separate sessions, we examined the single intervention effect of repetitive wrist and finger extension exercises aided by neuromuscular stimulation, the single intervention effect of 5 Hz repetitive transcranial magnetic stimulation and the combined effect of the two interventions. The motor functions were evaluated behaviourally in patients (Experiment 1) and electrophysiologically in healthy subjects (Experiment 2), both before and after the intervention. In addition, we tested the long-term effect by repeating the combined interventions 12 times in patients (Experiment 3). The motor functions were measured again 2 weeks after the end of the repetitive intervention period. In Experiment 1, the combined intervention, but neither of the single interventions, resulted in an improvement of extensor movement (P < 0.0001) and grip power (P < 0.05), along with a reduction of flexor hypertonia (P < 0.01), in their paretic upper limbs. In Experiment 2, only the combined intervention resulted in selective plastic changes of cortico-spinal excitability (P < 0.01), motor threshold (P < 0.001) and silent period (P < 0.01) for the extensors. In Experiment 3, we also confirmed long-term beneficial effects of the combined intervention in patients. These findings indicate that combining motor training with repetitive transcranial magnetic stimulation can facilitate use-dependent plasticity and achieve functional recovery of motor impairments that cannot be attained by either intervention alone. This method could be a powerful rehabilitative approach for patients with hemiparetic stroke.

Prevalence of cervical and lumbosacral compressive radiculopathies in Qena governorate/Egypt: Population-based survey.

OBJECTIVES: The aim of the study was to estimate the crude prevalence rate (CPR) of compressive radiculopathies in Qena governorate/Egypt. PATIENTS AND METHODS: 10 areas in Qena governorate were selected by random sampling, involving 9303 inhabitants with 57.3% urban residents and 42.7% rural residence. Patients were diagnosed using a screening questionnaire for the diagnosis of cervical and lumbosacral radiculopathies. All positive cases were referred to Qena University Hospital where they underwent full neurological examination, neuro-imaging, and neurophysiological investigations. RESULTS: Out of 9303 inhabitants included in the study (1057 families), 49 cases were recruited positive on initial survey and 32 cases were confirmed after clinical examination, neuroimaging and neurophysiological examinations, giving a CPR of 10.1/1000 in those aged over 30 years. Compressive radiculopathy was more common in males than females (13 versus 6/1000) and in rural than urban populations (15 versus 7/1000). No cases were recruited below 30 years old. The highest age specific prevalence was at ≥60 years with a CPR of 26/1000. 11 cases had cervical radiculopathy while 21 cases had lumbosacral radiculopathy (CPR of 3.7 and 6.6/1000 respectively). The highest age specific CPR for males was earlier than females at 50-59 versus ≥60 years. CONCLUSION: The overall CPR of compressive radiculopathy in the general population in Qena governorate/Egypt is similar for cervical radiculopathy but higher for lumbosacral radiculopathy than a previous Egyptian study but mid-way compared to other countries.

K-variant BCHE and pesticide exposure: Gene-environment interactions in a case-control study of Parkinson's disease in Egypt.

Pesticide exposure is associated with increased risk of Parkinson's disease (PD). We investigated in Egypt whether common variants in genes involved in pesticide detoxification or transport might modify the risk of PD evoked by pesticide exposure. We recruited 416 PD patients and 445 controls. Information on environmental factors was collected by questionnaire-based structured interviews. Candidate single-nucleotide polymorphisms (SNPs) in 15 pesticide-related genes were genotyped. We analyzed the influence of environmental factors and SNPs as well as the interaction of pesticide exposure and SNPs on the risk of PD. The risk of PD was reduced by coffee consumption [OR = 0.63, 95% CI: 0.43-0.90, P = 0.013] and increased by pesticide exposure [OR = 7.09, 95% CI: 1.12-44.01, P = 0.036]. The SNP rs1126680 in the butyrylcholinesterase gene BCHE reduced the risk of PD irrespective of pesticide exposure [OR = 0.38, 95% CI: 0.20-0.70, P = 0.002]. The SNP rs1803274, defining K-variant BCHE, interacted significantly with pesticide exposure (P = 0.007) and increased the risk of PD only in pesticide-exposed individuals [OR = 2.49, 95% CI: 1.50-4.19, P = 0.0005]. The K-variant BCHE reduces serum activity of butyrylcholinesterase, a known bioscavenger for pesticides. Individuals with K-variant BCHE appear to have an increased risk for PD when exposed to pesticides.

Prevalence of Bell's palsy in Qena Governorate, Egypt.

BACKGROUND AND PURPOSE: There have been few studies to estimate the prevalence of Bell's palsy (BP) in Arab countries. A community-based study was conducted to estimate the prevalence, incidence rates, precipitating factors, and outcome of BP in Qena Governorate, Egypt. SUBJECTS AND METHODS: A door-to-door survey was carried out, with random sampling of 10 districts, involving 9303 inhabitants, 51.1% males and 48.9% females. Seventeen subjects were positive in screening questionnaire and referred to Qena University hospital and were subjected to a full clinical examination, House Brackmann's Facial grading system. RESULTS: In a total population of 9303 individuals, 15 cases were confirmed as having BP giving a prevalence rate (PR) 161/10(5) for all ages 95%CI (80-243). It was slightly but not significantly higher among women and the rural community. The incidence rate of BP was 107/10(5). The highest age-specific rate was 40-49 years age. The most frequent precipitating factors for an episode of BP were exposure to air draft in 40%, physical stress (13.3%), and upper respiratory tract infection (13.3%). Moreover, 46.7% had predisposing risk factors, DM and hypertension in 33.3%. Sixty percent of cases had complication and poor outcome. CONCLUSION: The overall prevalence and incidence rates of BP in Qena governorate were high. This could be related to the variation in day and night temperature in our community and the susceptibility to air draft exposure during the night. The high frequency of poor outcome among studied cases suggests that better local guidelines should be implemented to recognize and treat BP.

Prevalence of neuromuscular disorders in Qena governorate/Egypt: population-based survey.

BACKGROUND: Few epidemiological studies of the prevalence of neuromuscular disorders have been undertaken. The aim of the study was to estimate the prevalence of the most common types of neuromuscular disorders in Qena governorate/Egypt. METHODS: A random sample was taken from 11 districts, involving 9303 inhabitants with 57.3% urban residents and 42.7% rural residence. Patients were diagnosed using a screening questionnaire for the diagnosis of neuromuscular disorders. All positive cases were referred to Qena University hospital where they underwent full clinical, electrophysiological, and laboratory investigations. RESULTS: Out of 9303 participants 448 cases were identified positive during survey. Four hundred and twenty-six cases proved to have neuromuscular disorders giving a crude prevalence rate (CPR) of 4.57%; 408 cases had definite neuropathy and 18 cases had muscular disorders equivalent to CPR of 4.39% and 193/105 respectively. There was a higher prevalence in the rural than urban population. The CPR of focal compression neuropathies was 1.8%, with the majority of cases having carpal tunnel syndrome (CPR = 1.67%). CPR of diabetic neuropathy was 1.67%. The CPR of compressive radiculopathy was 0.34%. Traumatic nerve injury had a CPR 0.06%. The lifetime prevalence of Bell's palsy was 0.16%. Hereditary motor and sensory neuropathy had a CPR 0.08%. The CPR of idiopathic neuropathy was 0.09% and Infective Leprotic neuropathy was 0.04%. Five patients were diagnosed as having muscular dystrophy and another 5 patients had myotonia with CPR of 54/105 for each. Two cases of myasthenia gravis and another two cases with systemic myopathy were recorded giving a CPR of 21/105. CONCLUSION: The overall CPR of neuromuscular disorders in the general population in Qena governorate/Egypt was higher than reported in other countries.

Prevalence of Parkinsonism and Parkinson's disease in Qena governorate/Egypt: a cross-sectional community-based survey.

BACKGROUND AND PURPOSE: In a previous study we found a high crude prevalence rate (CPR) for Parkinson's disease (PD) in Assiut governorate/Egypt. We therefore surveyed a second Nile valley governorate (Qena) to provide confirmatory evidence for the high prevalence rate of PD in Egypt. SUBJECTS AND METHODS: 10 areas in Qena governorate were selected by random sampling to recruit 8027 inhabitants. Positive cases were identified using a modified screening questionnaire, the unified Parkinson disease rating scale (UPDRS), mini-mental state examination (MMSE) and the non-motor symptoms scale (NMSS) for PD. RESULTS: Forty-four patients were identified with Parkinsonism, giving a CPR of 548/10(5) inhabitants. Among them, 35 patients were diagnosed as PD with CPR of 436/10(5); three cases were diagnosed as drug-induced Parkinsonism with CPR 37/10(5); two cases had atherosclerotic Parkinsonism with CPR 25/10(5).Age-specific CPR of PD among population aged ≥ 50 years old was 2534/10(5).The highest age-specific CPR was recorded among subjects ≥ 75 years old. The CPR showed a tendency to be higher in males than females, urban than rural areas and industrial than non-industrial areas (503 vs 363/10(5), 474 vs 389/10(5) and 655 vs 312/10(5), respectively). There was a significantly higher CPR among illiterate than literate persons (1982 vs 299/10(5) with P = 0.00001). About one quarter of patients had cognitive impairment. All cases had positive symptoms in at least one or more NMS Domains. CONCLUSION: The overall prevalence of PD disease is high in Nile valley governorates of Upper Egypt compared to other Arabic countries.

Prevalence of mild cognitive impairment and dementia among the elderly population of Qena Governorate, Upper Egypt: a community-based study.

BACKGROUND: There are only a few reports which provide prevalence rates of mild cognitive impairment (MCI) and dementia specifically in Arabic countries. OBJECTIVE: This study is aimed at estimating the prevalence of MCI and dementia among subjects aged ≥60 years using door-to-door survey in Qena Governorate/Egypt. METHODS: We conducted a door-to-door survey with multistage probability random sampling. Screening of all subjects aged ≥60 years (n = 691) employed a simple questionnaire including changes in memory, behavior, and daily activity, Memory and Executive Screening test (MES)as well as the Mini-Mental State Examination. Suspected cases were referred to the hospital for full clinical examination, DSM-IV diagnostic criteria, Hachinski Ischemic Score, neuroimaging, and laboratory investigations if indicated. RESULTS: Of the 691 participants, 12 cases had MCI, giving a crude prevalence rate (CPR) of 1.74/100 and 35 were identified as positive for dementia with a CPR of 5.07/100. The highest age-specific prevalence rates were recorded among subjects ≥85 years old (100/100). The CPRs were significantly higher in urban than rural areas (7.1 versus 3.27/100, respectively; p = 0.03), in industrial areas than non-industrial areas (13.23 versus 1.99; p = 0.00001), and in illiterate than literate participants (10.12 versus 2.25/100; p = 0.00001). CONCLUSION: Overall, the prevalence rate of MCI and dementia were lower in Qena/Egypt than in other countries. Advanced age, illiteracy, and living in an industrial area were found to be associated with dementia.

Community-based epidemiological study of epilepsy in the Qena governorate in Upper Egypt, a door-to-door survey.

BACKGROUND: The aim of this study is to estimate the epidemiological features of epilepsy in a representative governorate of Upper Egypt. MATERIALS AND METHODS: A door-to-door community-based survey study was performed using a sample of 10 areas among various districts of the Qena governorate in Upper Egypt. Six were classified as rural areas, and the remaining four were classified as urban areas, with a total population of 8027 inhabitants. The population was screened using an epilepsy-screening questionnaire. Positive cases with suspected epilepsy were referred to Qena University Hospital to be further evaluated by a qualified neurologist and for further investigations, such as neuroimaging and electroencephalography. RESULTS: One hundred patients had a confirmed diagnosis of epilepsy, with a lifetime prevalence of 12.46/1000. The active prevalence rate of epilepsy was 2.12/1000, while the incidence rate was 123/100000. Seventy-six percent of the patients had idiopathic epilepsies, while 24% had symptomatic epilepsy. Generalized epilepsies were more common (70.1%) than partial epilepsy (26.3%), meanwhile epilepsies with mixed seizure types were 2.6%. The most common seizure type was generalized tonic clonic seizures (51.8%). The age-specific prevalence rate of epilepsy was much higher in infancy and early childhood (62.5 and 37.04/1000, respectively), which regressed steadily with age. Idiopathic epilepsies were significantly more common in urban areas than in rural areas (P=0.01), while symptomatic epilepsies were more common in rural areas than in urban areas (P<0.005). CONCLUSION: Upper Egypt is characterized by a relatively high incidence and prevalence of epilepsy and epilepsy-related medical service, and more cultural education should be directed to those areas in Egypt.

Momentary reward induce changes in excitability of primary motor cortex.

OBJECTIVE: To investigate the human primary motor cortex (M1) excitability changes induced by momentary reward. METHODS: To test the changes in excitatory and inhibitory functions of M1, motor-evoked potentials (MEPs), short-interval intracortical inhibition (SICI) and short-latency afferent inhibition (SAI) were tested in the abductor pollicis brevis (APB) muscle of non-dominant hand in 14 healthy volunteers by transcranial magnetic stimulation (TMS) during a behavioral task in which subjects were pseudorandomly received either reward target or non-target stimuli in response to a cue. To control sensorimotor and attention effects, a sensorimotor control task was done replacing the reward target with non-reward target. RESULTS: The SICI was increased, and the SAI was decreased significantly during the presentation of the reward target stimuli. Those changes were not evident during non-reward target stimuli in the sensorimotor control task, indicating that this change is specific to momentary reward. CONCLUSIONS: Momentary rewarding is associated with change in intracortical inhibitory circuits of M1. SIGNIFICANCE: TMS may be a useful probe to study the reward system in health and in many diseases in which its dysfunction is suspected.

Microbial risk factors of cardiovascular and cerebrovascular diseases: potential therapeutical options.

Infection and inflammation may have a crucial role in the pathogenesis of atherosclerosis. This hypothesis is supported by an increasing number of reports on the interaction between chronic infection, inflammation, and atherogenesis. Assessment of serological and inflammatory markers of infection may be useful adjuncts in identifying those patients who are at a higher risk of developing vascular events, and in whom more aggressive treatments might be warranted.