Clinical and Molecular Characteristics of Neuronal Ceroid Lipofuscinosis in Saudi Arabia.

BACKGROUND: Neuronal ceroid lipofuscinoses (NCLs) represent a heterogeneous group of inherited metabolic lysosomal disorders characterized by neurodegeneration. This study sought to describe the clinical and molecular characteristics of NCLs in Saudi Arabia and determine the most common types in that population. METHODS: A retrospective review of electronic medical records was conducted for 63 patients with NCL (55 families) from six tertiary and referral centers in Saudi Arabia between 2008 and 2022. Clinical, radiological, and neurophysiological data as well as genetic diagnoses were reviewed. RESULTS: CLN6 was the predominant type, accounting for 45% of cases in 25 families. The most common initial symptoms were speech delay (53%), cognitive decline (50%) and/or gait abnormalities (48%), and seizure (40%). Behavioral symptomatology was observed in 20%, whereas visual impairment was less frequently (9.3%) encountered. Diffuse cerebral and cerebellar atrophy was the predominant finding on brain magnetic resonance imaging. Electroencephalography generally revealed background slowing in all patients with generalized epileptiform discharges in 60%. The most common genotype detected was the p.Ser265del variant found in 36% (20 of 55 families). The most rapidly progressive subtypes were CLN2 and CLN6. Two patients with each died at age five years. The earliest age at which a patient was nonambulatory was two years in a patient with CLN14. CONCLUSIONS: This is the largest molecularly confirmed NCL cohort study from Saudi Arabia. Characterizing the natural history of specific NLC types can increase understanding of the underlying pathophysiology and distinctive genotype-phenotype characteristics, facilitating early diagnosis and treatment initiation as well as genetic counseling for families.

Diagnosis and management of infantile epileptic spasms syndrome (IESS) in Gulf Cooperation Council (GCC) countries: Expert consensus statement.

Despite the availability of international recommendations for the management of Infantile Epileptic Spasms Syndrome (IESS), there is a lack of recommendations adapted to the local context of clinical practice of pediatric neurology in the Gulf Cooperation Council (GCC) countries. By an initiative from the Saudi Pediatric Neurology Society (SPNS), a literature review was performed and an expert panel comprised of 13 pediatric neurologists from all GCC countries (Saudi Arabia, Kuwait, Bahrain, Oman, Qatar, and the United Arab Emirates) was subsequently convened to discuss all issues related to the management and diagnosis practices of IESS in the GCC. The overall aim of this consensus document was to develop practical recommendations to support the care of patients with IESS in the GCC and to reflect on how clinical management approaches compare with those adopted internationally.

Associations Among Knee Osteoarthritis Severity, Body Mass Index, and Physical Functions in Saudi Arabian Adults: A Multi-Center Cross-Sectional Study.

Background The purpose of this study was to investigate the associations among knee osteoarthritis severity, body mass index, and physical functions in Saudi Arabian adults. Methodology In this multi-center, cross-sectional study, we performed a secondary data analysis that included 189 adults aged 55 years or above with doctor-diagnosed knee osteoarthritis enrolled in five hospitals in Riyadh, Saudi Arabia, between March 2016 and March 2017. According to knee osteoarthritis severity, all of the individuals were divided into the following three groups: mild (n = 36), moderate (n = 75), and severe (n = 78). A high body mass index was defined as a body mass index score of >25 kg/m2. Physical function was evaluated using the 36-item physical functioning subscale. Results Severe knee osteoarthritis had a significantly 6.47-fold (95% confidence interval (CI) = 2.95-14.22, p < 0.0001) higher risk of physical function than those with mild knee osteoarthritis after adjusting for age, sex, educational status, occupational status, affected knee with osteoarthritis, knee pain, and body mass index. However, moderate knee osteoarthritis had a 1.22-fold higher risk of physical function, but the association was not statistically significant (95% CI = 0.60-2.49, p = 0.578). Conclusions Severe but not moderate knee osteoarthritis was more likely to have the worst physical function than mild knee osteoarthritis among adults with a high body mass index in Saudi Arabia.

The Relationship Between Knee Osteoarthritis-Related Pain Severity and Daily Activities Involving the Upper and Lower Limbs in Saudi Adults: A Cross-Sectional Study.

Introduction Earlier research has shown an association between pain intensity and everyday activities in adults. However, it is vital to examine the relationship within the context of Saudi people who have knee osteoarthritis. Therefore, this study aimed to explore the connection between pain intensity and daily activities involving the lower and upper limbs among patients with knee osteoarthritis in Saudi Arabia. Methods This study enrolled 209 individuals aged 55 years and above who were diagnosed with radiographic knee osteoarthritis by physicians from five hospitals in Riyadh, Saudi Arabia, between March 2016 and March 2017. Participants were divided into two groups based on their pain intensity, measured using the visual analog scale. The first group included 141 individuals with mild or moderate pain, while the second group comprised 68 individuals with severe pain. The study assessed the physical functioning of these individuals by evaluating their ability to perform daily activities involving the lower and upper limbs, using the Physical Functioning Subscale of the 36-item Short Form Health Survey, which includes 10 items. Results Adjusted logistic regression analysis revealed that individuals experiencing severe pain related to knee osteoarthritis were more likely to encounter difficulties in climbing several flights of stairs (odds ratio [OR] = 1.19, 95% confidence interval [CI] = 1.09-1.29), and one flight of stairs (OR = 1.19, 95% CI = 1.06-1.34), with challenges in bending, kneeling, or stooping (OR = 1.14, 95% CI = 1.05-1.23), walking more than one mile (OR = 1.15, 95% CI = 1.06-1.25), walking several blocks (OR = 1.17, 95% CI = 1.08-1.27), and walking one block (OR = 1.19, 95% CI = 1.06-1.34) than those with mild or moderate pain. Conclusion Our study results highlight the significant impact of severe pain on activities like climbing stairs, bending, kneeling, stooping, and walking longer distances among people with knee osteoarthritis in Saudi Arabia.

Developmental and/or epileptic encephalopathy with spike-and-wave activation in sleep in Saudi Arabia: Electroclinical, etiologic, genetic, and outcome multicenter study.

OBJECTIVES: To investigate the clinical features of developmental and/or epileptic encephalopathy with spike-and-wave activation in sleep (D/EE-SWAS), its electrographic characteristics, and etiology and to compare the effects of different treatment strategies on the outcomes using a Saudi Arabian database. METHODS: This multicenter study included children with D/EE-SWAS who were evaluated between 2010 and 2020 at 11 tertiary centers. Data were collected on their baseline clinical features, etiologies, and treatment modalities. Seizure reduction, spike-wave index, and cognitive state were examined as potential therapeutic outcomes. RESULTS: Ninety-one children were diagnosed with D/EE-SWAS, with a median age of 7 years (IQR: 3-5) and an almost equal sex distribution. The average age at which epilepsy was diagnosed was 3 years (IQR: 5-2). A genetic/metabolic etiology was found in 35.1% of the patients, and a structural etiology was found in 27.4%. Children with underlying genetic/metabolic diseases exhibited an earlier seizure onset (P = 0.001) than children with other etiologies. Benzodiazepines (76.6%) were the most common treatment, followed by steroids (51.9%). Sodium valproate (75%) was the most frequently used antiseizure medication, followed by levetiracetam (64.9%). Children with a later seizure onset were more likely to have better clinical responses (P = 0.046), EEG responses (P = 0.012), and cognitive outcomes (P = 0.006) than children with an earlier onset. Moreover, better seizure response and electrographic response were seen in patients with bilateral interictal discharges on the EEG than otherwise. Children had a higher likelihood of both clinical and electrographic improvement with combination therapy of benzodiazepines (P = 0.001) and steroids (P = 0.001) than with other therapies. SIGNIFICANCE: This study shows a higher prevalence of genetic/metabolic causes and suggests the superior efficacy of combination therapy with steroids and benzodiazepines in D/EE-SWAS. Prospective studies that strictly assess the treatment protocols and outcomes are needed.

Seizure-related injuries in people with epilepsy: A cohort study from Saudi Arabia.

OBJECTIVES: Patients with epilepsy have a high risk of accidents and injuries, resulting in minimized physical activity and social withdrawal. Therefore, we surveyed the prevalence and the types of injuries that patients with epilepsy may endure, and the factors that may increase the risk of injuries. METHODS: In this cohort study, adult and pediatric patients diagnosed with epilepsy (age ≥ 7 years) and a close family member (parents/guardian) attending the outpatient epilepsy clinics at King Fahd Medical City (Riyadh, Saudi Arabia) were interviewed by neurologists. They reviewed the patients' medical records and administered a structured questionnaire to identify and compare several variables, including injury frequency versus seizure type and seizure frequency, number of antiseizure medications used, medication compliance, and work and social limitations. RESULTS: Out of 200 patients, 86 (43%) sustained injuries during an attack of their habitual seizures. Almost half of this group showed a tendency for recurrent injuries. The most common traumas were soft tissue injury (36.5%), head injury (32%), dental injury (8.5%), burns (7%), dislocation (7%), fractures (6.5%), and submersion (2%). Two-thirds of the patients had their injury at home. 64% of patients who had seizures for more than 10 years sustained multiple injuries (P = .003). Injury frequency was higher among patients with daily or monthly seizures (P = .03). 76% of patients who suffered injuries more than twice had generalised tonic-clonic seizures, and genetic generalised epilepsy was encountered more in injured patients (P = .02). Also, patients on polytherapy were more likely than those on monotherapy to have an injury (P = .003). SIGNIFICANCE: Two-fifths of the patients reported seizure-related injuries. The most common were soft-tissue injuries and head traumas, while homes were the most frequent site. In addition, longer epilepsy duration, generalized tonic-clonic seizures, and polytherapy were associated with a higher prevalence of injuries. Therefore, injury prevention strategies should be developed for PWE, especially for those at higher risk.

Efficacy and safety of corpus callosotomy versus vagus nerve stimulation as long-term adjunctive therapies in children with Lennox-Gastaut syndrome: Experience of a tertiary care center.

OBJECTIVES: To compare the efficacy and safety of corpus callosotomy versus vagus nerve stimulation (VNS) as long-term adjunctive therapies in children with Lennox-Gastaut syndrome. METHODS: This retrospective study was conducted in King Fahad Medical City between 2010 and 2019. The authors identified and followed 9 patients with Lennox-Gastaut syndrome (LGS) who underwent corpus callosotomy or VNS implantation for at least 12 months; seizure frequency and major complications were monitored. Five patients with a mean age of 10.8±1.3 years had corpus callosotomy, and 4 patients with a mean age of 13.8±3.9 years were implanted with VNS stimulators. RESULTS: Reduction in seizure frequency was achieved in all 5 patients who underwent corpus callosotomy, with greater than 75% seizure reduction in more than 50% in one, and greater than 25% in 2 respectively. However, in those implanted with VNS, 2 (50%) patients achieved a reduction in seizure frequency of greater than 75% and 2 (50%) greater than 25%, respectively. No significant difference was observed between the 2 treatment groups. One patient who underwent corpus callosotomy suffered cerebrospinal fluid leakage, and swallowing difficulties in one patient who underwent VNS. CONCLUSION: Both corpus callosotomy and VNS are safe and effective as adjunctive treatments for LGS patients.

El-Hattab-Alkuraya syndrome caused by biallelic WDR45B pathogenic variants: Further delineation of the phenotype and genotype.

Homozygous pathogenic variants in WDR45B were first identified in six subjects from three unrelated families with global development delay, refractory seizures, spastic quadriplegia, and brain malformations. Since the initial report in 2018, no further cases have been described. In this report, we present 12 additional individuals from seven unrelated families and their clinical, radiological, and molecular findings. Six different variants in WDR45B were identified, five of which are novel. Microcephaly and global developmental delay were observed in all subjects, and seizures and spastic quadriplegia in most. Common findings on brain imaging include cerebral atrophy, ex vacuo ventricular dilatation, brainstem volume loss, and symmetric under-opercularization. El-Hattab-Alkuraya syndrome is associated with a consistent phenotype characterized by early onset cerebral atrophy resulting in microcephaly, developmental delay, spastic quadriplegia, and seizures. The phenotype appears to be more severe among individuals with loss-of-function variants whereas those with missense variants were less severely affected suggesting a potential genotype-phenotype correlation in this disorder. A brain imaging pattern emerges which is consistent among individuals with loss-of-function variants and could potentially alert the neuroradiologists or clinician to consider WDR45B-related El-Hattab-Alkuraya syndrome.

Uridine monophosphate (UMP)-responsive developmental and epileptic encephalopathy: A case report of two siblings and a review of literature.

Developmental and epileptic encephalopathy type 50 is an autosomal recessive disorder caused by pathogenic variants in CAD. This gene encodes a multifunctional enzyme involved in the initial steps of de novo pyrimidine synthesis. Uridine treatment has been shown to be effective in this disease. Here, we report two siblings with CAD pathogenic variants who presented with developmental regression and intractable epilepsy. Treatment with oral uridine monophosphate (UMP) resulted in remarkable and rapid clinical improvement in terms of developmental progress and seizure control. We also reviewed previous literature and summarized all reported patients to date.

Amelioration of Levetiracetam-Induced Behavioral Side Effects by Pyridoxine. A Randomized Double Blind Controlled Study.

BACKGROUND: Levetiracetam is a relatively new-generation antiseizure drug approved for the treatment of focal and generalized seizures. Despite its favorable side effect profile and minimal drug-drug interactions, neuropsychiatric side effects are reported in up to 13% of children. A few case series have suggested that supplementation of pyridoxine may mitigate these side effects, but controlled trials are lacking. To address this issue, a randomized interventional study was carried out in a pediatric tertiary hospital to qualify and quantify the potential beneficial effect of pyridoxine in attenuating the neuropsychiatric side effects of levetiracetam in children. METHODS: A total of 105 children with epilepsy who were taking levetiracetam (as a monotherapy or an adjunct) who showed behavioral symptoms coinciding with the start of levetiracetam, were included. Patients randomly and blindly received either a therapeutic (pyridoxine group, 46 of 105, 44%) or a homeopathic dose of pyridoxine (placebo, 59 of 105, 56%). A 30-item behavioral checklist was used to qualify and quantify the behavioral side effects at baseline and at different time points following initiation of treatment. RESULTS: Both placebo and pyridoxine groups experienced a statistical reduction in behavioral scores when compared with baseline. Our study indicated that although there was a placebo effect, the improvement in neuropsychiatric symptoms was more prominent in children who received therapeutic doses of pyridoxine. CONCLUSIONS: These data provide clinicians with pertinent evidence-based information that suggests that a trial of pyridoxine in patients who experience behavioral side effects due to the use of levetiracetam may avoid unnecessary change of antiseizure medications.

Cell-based analysis of CAD variants identifies individuals likely to benefit from uridine therapy.

PURPOSE: Pathogenic autosomal recessive variants in CAD, encoding the multienzymatic protein initiating pyrimidine de novo biosynthesis, cause a severe inborn metabolic disorder treatable with a dietary supplement of uridine. This condition is difficult to diagnose given the large size of CAD with over 1000 missense variants and the nonspecific clinical presentation. We aimed to develop a reliable and discerning assay to assess the pathogenicity of CAD variants and to select affected individuals that might benefit from uridine therapy. METHODS: Using CRISPR/Cas9, we generated a human CAD-knockout cell line that requires uridine supplements for survival. Transient transfection of the knockout cells with recombinant CAD restores growth in absence of uridine. This system determines missense variants that inactivate CAD and do not rescue the growth phenotype. RESULTS: We identified 25 individuals with biallelic variants in CAD and a phenotype consistent with a CAD deficit. We used the CAD-knockout complementation assay to test a total of 34 variants, identifying 16 as deleterious for CAD activity. Combination of these pathogenic variants confirmed 11 subjects with a CAD deficit, for whom we describe the clinical phenotype. CONCLUSIONS: We designed a cell-based assay to test the pathogenicity of CAD variants, identifying 11 CAD-deficient individuals who could benefit from uridine therapy.

Bi-allelic Variants in IQSEC1 Cause Intellectual Disability, Developmental Delay, and Short Stature.

We report two consanguineous families with probands that exhibit intellectual disability, developmental delay, short stature, aphasia, and hypotonia in which homozygous non-synonymous variants were identified in IQSEC1 (GenBank: NM_001134382.3). In a Pakistani family, the IQSEC1 segregating variant is c.1028C>T (p.Thr343Met), while in a Saudi Arabian family the variant is c.962G>A (p.Arg321Gln). IQSEC1-3 encode guanine nucleotide exchange factors for the small GTPase ARF6 and their loss affects a variety of actin-dependent cellular processes, including AMPA receptor trafficking at synapses. The ortholog of IQSECs in the fly is schizo and its loss affects growth cone guidance at the midline in the CNS, also an actin-dependent process. Overexpression of the reference IQSEC1 cDNA in wild-type flies is lethal, but overexpression of the two variant IQSEC1 cDNAs did not affect viability. Loss of schizo caused embryonic lethality that could be rescued to 2nd instar larvae by moderate expression of the human reference cDNA. However, the p.Arg321Gln and p.Thr343Met variants failed to rescue embryonic lethality. These data indicate that the variants behave as loss-of-function mutations. We also show that schizo in photoreceptors is required for phototransduction. Finally, mice with a conditional Iqsec1 deletion in cortical neurons exhibited an increased density of dendritic spines with an immature morphology. The phenotypic similarity of the affecteds and the functional experiments in flies and mice indicate that IQSEC1 variants are the cause of a recessive disease with intellectual disability, developmental delay, and short stature, and that axonal guidance and dendritic projection defects as well as dendritic spine dysgenesis may underlie disease pathogenesis.

Knee pain and health-related quality of life among older patients with different knee osteoarthritis severity in Saudi Arabia.

OBJECTIVE: There is a lack of knowledge about health-related quality of life (HRQoL) in Saudi patients with musculoskeletal impairment, particularly among older adult populations. Thus, the current research aimed to determine the association of knee osteoarthritis (OA) severity with knee pain (KP) and HRQoL among older patients in Riyadh, Saudi Arabia. METHODS: In a multicenter cross-sectional study, we recruited 209 consecutive males and females aged ≥55 years with radiographically diagnosed knee OA from five hospitals across Riyadh, Saudi Arabia. According to the Kellgren & Lawrence classification, patients were classified into two groups: mild/moderate knee OA (n = 126) and severe knee OA (n = 83). KP and HRQoL were assessed using the pain visual analogue scale (VAS) and the 36-Item Short Form Health Survey (SF-36), respectively. A higher score on the pain VAS and the SF-36 represented worse KP and better HRQoL, respectively. RESULTS: Severe knee OA was significantly associated with an increased score of 3.47 (p <.0001) points on the pain VAS compared with the score reported by patients with mild/moderate knee OA. Additionally, it was significantly associated with reduced scores of 6.83 and 5.82 (both: p <.0001) points on the physical and mental composite summary subscales of the SF-36, respectively, compared with the scores of patients with mild/moderate knee OA, even after adjusting for all covariates. CONCLUSION: Older patients with severe knee OA had significantly worse KP and reduced HRQoL compared to patients with mild/moderate knee conditions, even after controlling for confounders.

Intravenous ketamine for the treatment of refractory status epilepticus: a retrospective multicenter study.

PURPOSE: To examine patterns of use, efficacy, and safety of intravenous ketamine for the treatment of refractory status epilepticus (RSE). METHODS: Multicenter retrospective review of medical records and electroencephalography (EEG) reports in 10 academic medical centers in North America and Europe, including 58 subjects, representing 60 episodes of RSE that were identified between 1999 and 2012. Seven episodes occurred after anoxic brain injury. KEY FINDINGS: Permanent control of RSE was achieved in 57% (34 of 60) of episodes. Ketamine was felt to have contributed to permanent control ("possible" or "likely" responses) in 32% (19 of 60) including seven (12%) in which ketamine was the last drug added (likely responses). Four of the seven likely responses, but none of the 12 possible ones, occurred in patients with postanoxic brain injury. No likely responses were observed when infusion rates were lower than 0.9 mg/kg/h, when ketamine was introduced at least 8 days after SE onset, or after failure of seven or more drugs. Ketamine was discontinued due to possible adverse events in five patients. Complications were mostly attributed to concurrent drugs, especially other anesthetics. Mortality rate was 43% (26 of 60), but was lower when SE was controlled within 24 h of ketamine initiation (16% vs. 56%, p = 0.0047). SIGNIFICANCE: Ketamine appears to be a relatively effective and safe drug for the treatment of RSE. This retrospective series provides preliminary data on effective dose and appropriate time of intervention to aid in the design of a prospective trial to further define the role of ketamine in the treatment of RSE.