How do Parkinson's disease patients manage Ramadan fasting? An observational study.

Twenty-four Parkinson's disease (PD) patients who had planned to fast during the 2016 Ramadan were included in this observational study. Twenty patients fasted during the whole Ramadan. Six were able to abstain from drug intakes from dawn to dusk; the others needed 1 or 2 intakes of L-DOPA during the day. There were no serious side effects reported during the Ramadan period. Compared to before Ramadan, there were no significant changes after the fasting period in quality of life (PDQ 39), non-motor symptom scale or clinical impression of severity index scores.

Non-Motor Symptoms Assessed by Non-Motor Symptoms Questionnaire and Non-Motor Symptoms Scale in Parkinson's Disease in Selected Asian Populations.

BACKGROUND: Ethnic variations have been described in medical conditions, such as hypertension, diabetes, and multiple sclerosis. Whether ethnicity plays a role in Parkinson's disease (PD), particularly with regard to non-motor symptoms (NMS), remains unclear. Existing literature is diverse, controversial, and inadequately documented. This review aims to analyse and report the currently available literature on NMS, specifically in Asian PD patients. SUMMARY: We conducted a literature review using PubMed, searching for articles and currently available publications that reference and assess NMS in PD patients living in Asia using the validated NMS Questionnaire (NMS Quest) and NMS Scale (NMSS). In total, 24 articles were included: 12 using the NMS Quest and 12 using the NMSS. Symptoms of constipation, memory impairment, and nocturia were the most frequently self-reported symptoms (NMS Quest) in selected Asian populations, while symptoms within the domains sleep/fatigue, attention/memory, and mood/apathy were most prevalent when applying the health-professional completed NMSS. Key Messages: NMS are generally prevalent and highly burdensome within selected Asian PD populations living in countries included in this review. Our review suggests that NMS-driven phenotypic heterogeneity is present in Asian patients, and compared to Western PD populations there might be variations in assessed NMS.

Clinical predictors of disease progression in multiple sclerosis patients with relapsing onset in a nation-wide cohort.

BACKGROUND: Predicting disease progression over time is challenging despite the available literature data. AIM: To assess whether baseline clinical variables of MS patients would predict the conversion to progressive phase of the disease. MATERIALS & METHODS: Utilizing the national MS registry, patients who had relapsing onsets and had confirmed EDSS score at baseline and follow-up visits were included. Primary progressive MS and CIS patients were excluded. Clinical variables (gender, age at onset, disease duration, number of relapses, EDSS score) were collected. The end point was conversion to secondary progressive MS. Chi Square and multivariable logistic regression were used to determine the influence of clinical variables on disease progression. RESULTS: Data of 803 MS patients with relapsing onset were analyzed. Eighty five (10.6%) patients reached the end point. The risk of disease progression was significantly higher in men (p=0.015), in patients who developed MS≥40 years of age (p=0.041) and who had ≥3 relapses during their disease course (p<0.001). Spinal cord presentation at onset was predictive of progression (aOR=2.01; p=0.06) while optic neuritis at onset was associated with lower risk of progression (aOR=0.30; p=0.03). EDSS score at first visit did not influence disease progression when tested at 2 different cutoffs (EDSS<4 vs. ≥4 and EDSS<6 vs. ≥6) using multivariable logistic regression analysis (p=0.960 and p=0.866), respectively. CONCLUSION: Men and patients who presented at age 40 yeas or beyond had increased risk of MS progression. Spinal cord symptoms at onset and 3 or more relapses were predictive of progression.

Increasing prevalence and incidence rates of multiple sclerosis in Kuwait.

BACKGROUND: Kuwait was considered as low to intermediate risk area for MS. OBJECTIVES: To determine the prevalence and incidence rates of MS among Kuwaiti nationals based on 2011 population census. METHODS: This cross-sectional study was conducted between October 2010 and April 2013 using the newly developed national MS registry in Kuwait. Patients with a diagnosis of MS according to 2010 revised McDonald criteria were identified. The crude, age- and sex-specific prevalence and incidence rates among Kuwaiti patients were calculated. RESULTS: 1176 MS patients were identified of which 927 (78.8%) were Kuwaitis and 249 (21.2%) were expatriates. Among Kuwaiti patients, female to male ratio was 1.8:1 with a mean age of 35.40 ± 10.99 years. The prevalence rate of MS was 85.05 per 100,000 persons (95% CI: 82.80 - 87.04). There was a peak in prevalence among patients aged 30-39 years. The incidence of MS was 6.88 per 100,000 persons (95% CI 5.52-8.55). Between 2003 and 2011, the incidence increased 3.22 and 2.54 times in women and men respectively. CONCLUSION: Kuwait is considered a high-risk area for MS. The significant increase in prevalence and incidence rates may represent a true increase despite the improvement in case ascertainment and case definition.

Demographics and clinical characteristics of multiple sclerosis in Kuwait.

Using the MS registries in two MS clinics in Kuwait, we studied the demographics and clinical characteristics of multiple sclerosis (MS). Data of 736 patients (77.7% with relapsing remitting course) were analyzed. The mean age at onset and mean duration were 26.87 and 7.71 years, respectively. About 47.9% of patients had a disease duration ≤5 years. Cerebellar/brainstem and spinal manifestations were the presenting symptoms in 29.5 and 27.4%, of patients, respectively. The EDSS score was ≤3 in 72.8% of patients. We concluded that in Kuwait, the clinical characteristics of MS have important differences in terms of presentations at onset and disease progression as compared to regional cohorts.

Use of natalizumab in patients with active relapsing-remitting multiple sclerosis in Kuwait.

OBJECTIVE: To evaluate the outcomes of patients with multiple sclerosis (MS) who were treated with natalizumab in Kuwait. MATERIALS AND METHODS: A retrospective study using the MS registry to identify patients who were treated with natalizumab was conducted. Patients' demographics, clinical characteristics and treatment parameters were collected at baseline and last follow-up visit. Primary outcome was the proportion of relapse-free patients at the last follow-up while secondary outcomes were the change in the mean annual relapse rate, Expanded Disability Status Scale (EDSS) and the proportion of patients with magnetic resonance imaging (MRI) activity at the last follow-up visit. Forty-four patients were included in the study. RESULTS: Of the 44 patients, 27 (61.4%) were females and the remaining 17 (38.6%) males. Mean age of patients and mean disease duration were 29.05 ± 7.25 and 5.71 ± 3.37 years, respectively. The mean number of natalizumab infusions was 18.14. The proportion of relapse-free patients significantly increased from 11.36 to 90.91% (p < 0.0001). The EDSS significantly improved from 4.76 to 3.15 (p < 0.0001) over the observational period. There was no significant difference between patients with EDSS <3 compared to those with EDSS ≥ 3 (p < 0.67). The proportion of patients with MRI activity was significantly reduced from 95.5 to 18.2% (p < 0.0001) at their last visit. Six patients discontinued the drug, 5 due to positive JC virus and 1 due to pregnancy. CONCLUSIONS: Natalizumab induced a suppression of disease activity and was responsible for a significant improvement in disability status in highly active MS patients.

Postoperative supplementary motor area syndrome: clinical evolution and prognosis in nine patients after left hemispheric tumor resection.

BACKGROUND: The postoperative supplementary motor area (SMA) syndrome may complicate unilateral surgery involving the SMA cortex and manifests as contralateral or global akinesia, mutism, or speech deficit, with complete or major recovery in weeks to months. CASE SERIES: We observed retrospectively nine patients (median age 47 years, range 27-60, five female) who underwent surgery for left premotor area tumors (six intra-axial and three extra-axial). Volumetric microsurgical resection was performed with neuro-navigational assistance (Vector Vision-BrainLab™ or SonoWand Invite™). We achieved gross or near gross total resection in all cases. The patients were followed clinically for one year, with control computed tomography scan within 24-48 hours from the operation and control magnetic resonance imaging three months and one year postoperatively. Five patients had only akinesia of the contralateral limbs, two had akinesia and mutism, and the remaining two had mutism only. All recovered within three months. The severity and duration were related to the location of resection rather than the volume removed. Cortical excision closer to the premotor area was related to more prominent SMA syndrome, while the cingular gyrus' involvement related to mutism. CONCLUSION: Prevention of SMA syndrome is not always possible in resective surgery. Given its favorable prognosis, it should be well known to the health professionals of different specialties engaged in such patients' postoperative care. The possibility of SMA should be preoperatively discussed with the patients and caregivers. HIPPOKRATIA 2020, 24(1): 38-42.

The prevalence of multiple sclerosis continues to increase in Kuwait.

BACKGROUND: The national MS registry was established in 2010 to assess the change in epidemiological status. The last reported data of the prevalence and incidence in Kuwait was in 2013. OBJECTIVES: To update the prevalence and incidence rates of MS among Kuwaiti nationals. METHODS: Using the national MS registry, a cross sectional study was conducted to estimate the number of all patients diagnosed with MS and clinically isolated syndrome suggestive of MS. The diagnosis was based on the revised 2017 McDonald criteria. The population census was acquired from the Public Authority of Civil Information. RESULTS: On 30th June 2018, 1454 Kuwaiti MS patients fulfilled the diagnostic criteria. Women represented 66.8% of the analyzed cohort with female to male ratio of 2.01:1. The crude prevalence of MS was 104.88 (95% CI: 89.5-121.9) per 100,000 persons, which increased 1.6 times since 2013. Age-adjusted prevalence peaked in the 30-39 and 40-49 year age groups in both females and male, with a decreasing tendency beyond 50 years of age. The incidence of MS was 5.39 (95% CI: 4.3-6.8) per 100,000 persons. The 5-year incidence was 6.4 per 100,000, which has been stable since the last reported rate. CONCLUSION: The prevalence of MS in Kuwaiti nationals continued to increase reflecting a better case ascertainment and improved awareness and referrals across the country. However, the incidence has stabilized in the last 5 years which was mostly driven by a slight decline in newly diagnosed cases in women compared to men despite the increase in the overall female to male ratio.

Alternative diagnoses in patients referred to specialized centers for suspected MS.

OBJECTIVES: The aim of this study is to explore the frequency, type, and predictors of alternative diagnoses among patients referred with a recent diagnosis of multiple sclerosis (MS) to two specialized MS centers in the Middle East. METHODS: This is a retrospective review of a prospectively followed cohort of MS patients at 2 University specialized MS centers. All patients referred for MS were included. The final diagnosis was recorded and demographic, clinical, laboratory, electrophysiological and radiological variables were collected. RESULTS: A total of 554 patients were included in this study of which 431 were referred for diagnostic confirmation. The final diagnosis of MS was confirmed in 300 (70%), while 114 (26%) turned out to have an alternative diagnosis and 15 (3.5%) fulfilled criteria for radiologically isolated syndrome (RIS). The most common alternative diagnoses were psychogenic (16.3%), non-specific MRI white matter lesions (14.7%), NMO (9.5%), migraine (8.6%) and systemic autoimmune disorders (8.6%). The strongest predictors of a final diagnosis of MS were: younger age, presence of oligoclonal bands in the CSF, periventricular, corpus callosum, spinal (P<0.0001), or enhancing lesions (P<0.005) on MRI. CONCLUSIONS: Our study shows that 30% of patients referred for a suspicion of MS end up with a different diagnosis. The most common alternative diagnoses of MS in the Middle East are not different from what has been described in Western countries. Age, MRI and CSF findings can help with the differential diagnosis.

Botulinum toxin A for palmar hyperhidrosis: assessment with sympathetic skin responses evoked by train of stimuli.

Objective assessment of the effect of botulinum toxin A (BT) treatment in primary palmar hyperhidrosis (PH) is attempted by different methods. We decided to use for this purpose sympathetic skin responses evoked by train of stimuli (TSSR). Twenty patients with severe PH (five female, median age 24, range 18-36) were examined regularly over 3 months after receiving 50 UI BT in each palm. TSSR were recorded from the palms after sensory stimulation by a train of three supramaximal electric pulses 3 millisecond apart. Results were compared to longitudinally studied TSSR of 20 healthy sex- and age-matched control subjects. All hyperhidrosis patients reported excellent improvement. TSSR amplitudes decreased at week 1 (mean 54% range 48%-67%) and over the following months in a clinically significant trend (slope R=-.82, P<.0001). TSSR in controls changed insignificantly (±13% from the baseline). The difference between patients and controls was highly significant at any time point (P<.001). This study suggests that TSSR may help in assessment of treatments in PH. It confirms objectively the efficacy of BT in PH.

Consensus recommendations for the diagnosis and treatment of multiple sclerosis in Kuwait.

OBJECTIVES: We aim to develop consensus recommendations to guide neurologists in the community for the diagnosis and treatment of Multiple Sclerosis (MS). METHODS: After reviewing the available literature, a group of neurologists with expertise in MS met to discuss the evidence and develop consensus recommendations for the diagnosis and treatment of MS. RESULTS: The revised 2010 McDonald criteria is the established diagnostic criteria for MS and has wide international acceptance among international MS experts. Several red flags in the history and examination, along with certain laboratory tests were pointed out to exclude MS mimickers in the diagnostic phase. The available approved disease modifying therapies (DMTs) were listed in an algorithmic fashion based on initial assessment of disease severity and subsequent disease breakthrough while on DMTs. Risk stratification based on the benefit versus risk ratio was used to help choosing the appropriate therapy to MS patients using an "individualized therapy" approach. The requirements for initiation and monitoring of treated MS patients were highlighted with emphasis on early identification of disease breakthrough, adverse events, and safety concerns. The role of multi-disciplinary MS clinics was discussed and a guide for referral to specialized MS clinics was developed. CONCLUSIONS: Consensus recommendations have been developed to guide local neurologists on the diagnosis and treatment of patients with MS. Implementation of the revised 2010 McDonald diagnostic criteria was advised while a personalized treatment approach was recommended using a treatment algorithm based on risk stratification and patient-centered outcomes.

Incidence and prevalence of pediatric onset multiple sclerosis in Kuwait: 1994-2013.

OBJECTIVES: This study aimed to assess the incidence and prevalence of pediatric-onset multiple sclerosis (POMS) along with temporal and gender differentials in these estimates in Kuwait. METHODS: We identified MS patients with pediatric (age <18 years) onset between 1994 and 2013 from national MS registry. Year and gender-specific incidence rate and prevalence estimates were computed. Multivariable Poisson regression analyses of time-series cross-sectional panel data were conducted to evaluate temporal and gender related variations in yearly POMS incidence rate and prevalence. RESULTS: 122 POMS patients were identified; of which 90 (73.8%) were females. During 2013, POMS incidence rate and prevalence (per 100,000) were 2.1 and 6.0 respectively. Multivariable Poisson regression model revealed statistically significant 5% increase in POMS incidence rate (p=0.002) and 6% increase in prevalence (p<0.001) from 1994 to 2013. Furthermore, during the study period, female children were more likely to have higher POMS incidence rate (relative rate=2.9; p<0.001) and prevalence (prevalence ratio=2.8; p<0.001). CONCLUSIONS: The temporal increase and gender disparity in POMS incidence and prevalence corroborate the findings of earlier studies conducted elsewhere. Knowledge of increasing POMS burden may help in optimal planning for better management of patients in the region.

Use of fingolimod in patients with relapsing remitting multiple sclerosis in Kuwait.

BACKGROUND: Post-marketing studies are important to confirm what was established in clinical trials, and to assess the intermediate and long-term efficacy and safety. OBJECTIVE: To assess efficacy and safety of fingolimod in multiple sclerosis (MS) in Kuwait. METHODS: We retrospectively evaluated MS patients using the MS registries in 3 MS clinics. Relapsing remitting MS patients according to revised 2010 McDonald criteria who had been treated with fingolimod for at least 12 months were included. Primary endpoint was proportion of relapse-free patients at last follow-up. Secondary endpoints were mean change in EDSS and proportion of patients with MRI activity (gadolinium-enhancing or new/enlarging T2 lesions). RESULTS: 76 patients met the inclusion criteria. Mean age and mean disease duration were 34.43 and 7.82 years respectively. Mean duration of exposure to fingolimod was 18.50 months. Proportion of relapse-free patients was 77.6% at last follow-up. Mean EDSS score significantly improved (2.93 versus 1.95; p<0.0001) while 17.1% of patients continued to have MRI activity versus 77.6% at baseline (p<0.0001). Four patients stopped fingolimod due to disease breakthrough (n=3) and lymphadenitis (n=1). CONCLUSION: Fingolimod is safe and effective in reducing clinical and radiological disease activity in relapsing remitting MS patients. Our results are comparable to reported results of phase III studies.

Predictors of Conversion to Multiple Sclerosis in Patients with Clinical Isolated Syndrome Using the 2010 Revised McDonald Criteria.

Background. Clinically isolated syndrome (CIS) is the first neurologic episode of multiple sclerosis (MS). Magnetic resonance imaging (MRI) and clinical features are used to predict risk of conversion to MS. Objectives. The aim of this prospective study is to evaluate predictors of conversion of CIS to McDonald MS. Method. 97 patients with CIS have been followed for 2 years. Age of onset, gender, initial clinical presentation, and MRI brain and spine were assessed. The 2010 revised McDonald criteria were applied. Results. Fifty-nine patients (60.8%) with CIS converted to McDonald MS after 10.1 + 4.2 months. Thirty-seven (38.1%) of the convertors satisfied the diagnostic criteria based on the radiological parameters, while 21.7% sustained their second clinical events. A multivariate regression analysis revealed that high number of lesions in MRI (P = 0.001) and earlier age of onset (P = 0.043) predicted the conversion of CIS to McDonald MS. Gender (P = 0.5) and initial clinical presentation (optic pathway (P = 0.4), supratentorial (P = 0.91), brain stem/ cerebellum (P = 0.97), and spinal (P = 0.76)) were not statistically significant. Conclusion. Age of onset and MRI parameters can be used as predictors of CIS conversion to McDonald MS. Application of the 2010 revised McDonald criteria allows an earlier MS diagnosis.