Iraqi experts consensus on the management of relapsing remitting multiple sclerosis in adults.

OBJECTIVE: In Iraq, a lack of evidence-based management protocols for diagnosing, treating, and managing multiple sclerosis (MS) poses risks of suboptimal outcomes and clinical practice variability and potential harm to the patients. This study aimed to develop consensus recommendations regarding the diagnosis and management of MS in Iraq, specifically focusing on treatment-naïve patients, suboptimal responders, and women of childbearing age during preconception, pregnancy planning, and lactation.A survey was conducted to collect feedback from a panel of ten key opinion leaders (KOLs), who evaluated and discussed the statements to determine agreement levels. The mini-Delphi method was employed to establish a consensus on the management recommendations, and a meeting was held to analyze the responses and ensure that the recommendations were based on current evidence and followed a consensus-driven approach. RESULTS: The Revised McDonald Criteria is recommended for MS diagnosis, which includes evidence of dissemination of disease characteristics in space and time. Disease activity and progression can be monitored using relapses, MRI activity, and short-term disability progression. Experts suggest initiating treatment at diagnosis using higher efficacy medications, such as cladribine, ocrelizumab, natalizumab, or rituximab, for patients with high disease activity after careful risk stratification. Injectable interferon preparations have a tolerable risk profile but have drawbacks, such as the route and frequency of administration. Overall, disease-modifying therapies (DMTs) have shown efficacy in reducing relapse rates and short-term disability. CONCLUSION: This article presents expert panel recommendations for managing MS in Iraq, taking into account international guidelines, medication updates, and local resources. However, practical questions remain regarding the real-world use of disease-modifying therapies (DMTs). Personalizing treatment based on disease severity, prognosis, and individual risk factors while adhering to guidelines is crucial. A collaborative approach between healthcare providers and patients, considering individual preferences, is vital for achieving treatment goals.

Electrophysiological findings in patients with restless legs syndrome.

BACKGROUND: Restless legs syndrome (RLS) manifests as an urge to move the body to relieve the discomfortable sensations, primarily when resting, sitting, laying down, or sleeping. Diagnosis of RLS relies on clinical criteria, and the immobilization test was the only instrumental tool with equivocal results. OBJECTIVES: To assess different electrophysiological findings in patients with RLS, and compare the diagnostic values of these parameters in the diagnosis of RLS. METHODS: 30 patients with primary RLS and 30 controls who were matched for age and gender were studied. Participant's demographics, laboratory findings, and electrophysiological test, namely nerve conduction studies (NCS), cutaneous silent period (CSP), H reflex and sympathetic skin response (SSR), F-wave latency, amplitude, F-wave duration (FWD), and the ratio between FWD and duration of the corresponding compound muscle action potential (FWD/CMAPD) were analyzed. RESULTS: None of the patients showed altered NCS data. FWD of upper (12.37 ± 2.77 ms) and lower limb (21.71 ± 5.24 ms) were significantly longer in patients. Also, FWD/CMAP duration of the upper (1.03 ± 0.2) and lower limb (2.02 ± 0.55) was longer in patients. Likewise, they exhibited delayed CSP latency from TA (110.62 ± 13.73 ms) and APB (77.35 ± 12.16 ms) whereas the CSP duration from TA and APB was decreased (37.36 ± 11.59 ms; 42.55 ± 7.97 ms, respectively). The SSR latency was not different, and right-sided H reflex amplitude (5.07 ± 3.98 mV) and H/M ratio (0.65 ± 1.81) were significantly increased in the patient group. CONCLUSION: The data suggest that there may be a dysfunction of the inhibitory/excitatory circuits at a spinal level; and no pathology in the peripheral nerves. The unilateral difference of H reflex amplitude and H/M ratio may suggest asymmetrical central inhibitory dysfunction. Further prospective studies with larger cohorts are now needed to evaluate the pathophysiology of RLS with different neurophysiological assessment tools.

Association of ABCB1 gene polymorphism (C1236T and C3435T) with refractory epilepsy in Iraqi patients.

The mechanisms of refractory epilepsy (RE) are most likely multifactorial, involving environmental, genetic, as well as disease- and drug-related factors. We aimed to study is to investigate the possible association of two ABCB1 gene polymorphism (C3435T and C1236T) with the development of RE in Iraqi patients. One hundred patients with either generalized tonic-clonic seizures, myoclonic epilepsy, or absence epilepsy comprised of 60 patients responsive to AEDs and 40 patients who were refractory to treatment who used multi AEDs for at least one month were studied. Fifty family-unrelated age- and sex-matched healthy subjects represent the control group. ABCB1 gene fragments corresponding to two targeted polymorphisms were amplified with conventional polymerase chain reaction using specific sets of primers. Genotyping was performed by restriction fragment length polymorphism (RFLP) technique. Epileptic patients refractory to AEDs showed a significantly higher frequency of CC genotypes of C3435T polymorphism than controls. Allele C was significantly higher in patients than controls and far more frequent among patients with RE. C1235T polymorphism had no significant role neither in the incidence of epilepsy nor in the AEDs resistance. The CT haplotype was more frequent among patients refractory to AEDs. In contrast, the haplotype block TT was more frequent among responsive (41.3%) than refractory patients (28.7%) (p = 0.068). The CC genotype and C allele of the C3435T polymorphism can increase the risk of RE. The haplotype block CT of C3435T and C1236T can predispose for epilepsy as well as the drug resistance.

Epileptic Patients are at Risk of Cardiac Arrhythmias: A Novel Approach using QT-nomogram, Tachogram, and Cardiac Restitution Plots.

BACKGROUND: Sudden death is reported in patients who had a history of epilepsy and some authors believed that is due to cardiac arrhythmias. OBJECTIVES: This study aimed to predict that the epileptic patients are at risk of serious cardiac arrhythmias by QT-nomogram, tachogram (Lorenz), and cardiac restitution plots. METHODS: A total number of 71 healthy subjects (Group I) and 64 newly diagnosed epileptic patients (Group II) were recruited from Al-Yarmouk and Baghdad Teaching hospitals in Baghdad from March 2015 to July 2015 and included in this study. The diagnosis of epilepsy achieved clinically, electroencephalograph record and radio-images including computerized tomography and magnetic image resonance. At the time of entry into the study, an electrocardiography (ECG) was done, and the determinants of each ECG record were calculated. The QT-nomogram, tachogram, and cardiac restitution plots were used to identify the patients at risk of cardiac arrhythmias. RESULTS: Significant prolonged corrected QT corrected (QTc) and JT corrected intervals were observed in female compared with male at age ≥50 years while the TQ interval was significantly prolonged in males of Group II. Eight patients of Group II had a significant pathological prolonged QTc interval compared with undetectable finding in Group I. QT nomogram did not disclose significant findings while the plots of Lorenz and restitution steepness disclose that the patients of Group II were vulnerable to cardiac arrhythmias. Abnormal ECG findings were observed in the age extremities (≤18 years and ≥50 years) in Group II compared with Group I. CONCLUSION: Utilization of QT-nomogram, restitution steepness, and tachogram plots is useful tools for detection subclinical vulnerable epileptic patient with cardiac arrhythmias.

Results of a multinational study suggest the need for rapid diagnosis and early antiviral treatment at the onset of herpetic meningoencephalitis.

Data in the literature regarding the factors that predict unfavorable outcomes in adult herpetic meningoencephalitis (HME) cases are scarce. We conducted a multicenter study in order to provide insights into the predictors of HME outcomes, with special emphasis on the use and timing of antiviral treatment. Samples from 501 patients with molecular confirmation from cerebrospinal fluid were included from 35 referral centers in 10 countries. Four hundred thirty-eight patients were found to be eligible for the analysis. Overall, 232 (52.9%) patients experienced unfavorable outcomes, 44 died, and 188 survived, with sequelae. Age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02 to 1.05), Glasgow Coma Scale score (OR, 0.84; 95% CI, 0.77 to 0.93), and symptomatic periods of 2 to 7 days (OR, 1.80; 95% CI, 1.16 to 2.79) and >7 days (OR, 3.75; 95% CI, 1.72 to 8.15) until the commencement of treatment predicted unfavorable outcomes. The outcome in HME patients is related to a combination of therapeutic and host factors. This study suggests that rapid diagnosis and early administration of antiviral treatment in HME patients are keys to a favorable outcome.

Hamsi scoring in the prediction of unfavorable outcomes from tuberculous meningitis: results of Haydarpasa-II study.

Predicting unfavorable outcome is of paramount importance in clinical decision making. Accordingly, we designed this multinational study, which provided the largest case series of tuberculous meningitis (TBM). 43 centers from 14 countries (Albania, Croatia, Denmark, Egypt, France, Hungary, Iraq, Italy, Macedonia, Romania, Serbia, Slovenia, Syria, Turkey) submitted data of microbiologically confirmed TBM patients hospitalized between 2000 and 2012. Unfavorable outcome was defined as survival with significant sequela or death. In developing our index, binary logistic regression models were constructed via 200 replicates of database by bootstrap resampling methodology. The final model was built according to the selection frequencies of variables. The severity scale included variables with arbitrary scores proportional to predictive powers of terms in the final model. The final model was internally validated by bootstrap resampling. A total of 507 patients' data were submitted among which 165 had unfavorable outcome. Eighty-six patients died while 119 had different neurological sequelae in 79 (16%) patients. The full model included 13 variables. Age, nausea, vomiting, altered consciousness, hydrocephalus, vasculitis, immunosuppression, diabetes mellitus and neurological deficit remained in the final model. Scores 1-3 were assigned to the variables in the severity scale, which included scores of 1-6. The distribution of mortality for the scores 1-6 was 3.4, 8.2, 20.6, 31, 30 and 40.1%, respectively. Altered consciousness, diabetes mellitus, immunosuppression, neurological deficits, hydrocephalus, and vasculitis predicted the unfavorable outcome in the scoring and the cumulative score provided a linear estimation of prognosis.

Assessment of nitrosative oxidative stress in patients with middle cerebral artery occlusion.

OBJECTIVE: To assess serum levels of nitric oxide and peroxynitrite in patients presenting with cerebral infarction resulting from middle cerebral artery occlusion, at 48 hours from stroke onset. METHODS: We conducted the study in the Department of Pharmacology and in cooperation with Al-Yarmouk Teaching Hospital and the Department of Medicine, College of Medicine, Al-Mustansiriya University, Baghdad, Iraq from October 2003 to May 2004. Twenty patients presented with neurological deficits of middle cerebral artery occlusion, and we also enrolled 20 healthy individuals to serve as a control group. We obtained venous blood samples from each patient after 48 hours of stroke onset and each healthy individual. We determined the serum level of nitric oxide as well as peroxynitrite. RESULTS: Serum nitric oxide and peroxynitrite were significantly (p<0.001) higher in patients (103.9 +/- 40.2 umol and 2.7 +/- 0.6 umol) than in healthy individuals (53.3 +/- 20.7 umol and 2.3 +/- 0.2 umol). The formation of peroxynitrite directly correlated with nitric oxide in healthy individuals (r=0.84), and patients (r=0.514). CONCLUSION: Serum intermediate nitrogen species; nitric oxide and peroxynitrite were significantly increased after 48 hours of stroke onset in patients with middle cerebral artery occlusion. The rate of peroxynitrite formation from nitric oxide was slightly increased.

Transient ischemic attack and ischemic stroke, risk factors and preventive roles of the first contact physicians.

OBJECTIVE: This study had been designed to find the relative frequency of each of ischemic stroke`s risk factors and to evaluate the action of the first contact physician for transient ischemic attack (TIA) cases. METHODS: This study is a cross sectional study that enrolled 100 randomly selected patients with clinical and radiological diagnosis of ischemic stroke, who had attended Al-Yarmouk Teaching Hospital, Baghdad, Iraq during the period between the 1st of January 2002 and the 1st of July 2002. RESULTS: The patients` age range was 40-79 years old (mean 63.57 years, SD 8.31, coefficient of variation 0.31). Forty-four patients (44%) were smokers, 34 patients (34%) were hypertensive, and 28 patients (28%) were diabetics. Of those under the age of 55, 78.6% had 2 or more risk factors. Positive history of TIA was observed in 28 patients (28%), 64.3% of whom (18 patients) had consulted a physician for their TIA symptoms and 35.7% of them had ignored their symptoms. Only 25% of those with positive history of TIA had been managed properly by the first contact physician. Thirteen patients (46.4% of those with history of TIA) had been treated with antithrombotic drugs. CONCLUSION: Significant numbers of patients don`t worry about the symptoms of TIA and ignore it, another group are not subjected to full investigations to reach the cause and risk factors of TIA. Workshops are needed to increase education levels of the population about TIA and the modifiable risk factors of stroke.

Post-stroke seizure.

OBJECTIVE: This study was designed to estimate the incidence of seizures in patients with stroke and its relative frequency with each type of stroke, to find the frequency of early and late seizures, recurrent seizure, and the EEG findings. METHODS: This is a cross sectional study that enrolled 176 randomly selected patients with stroke admitted to Al-Yarmouk, Teaching Hospital, Baghdad, Iraq during the period between October 1998 and June 2001. Out of these, 42 patients with post-stroke seizure were chosen to undergo thorough clinical examination and investigations. RESULTS: Seizures had been observed in 42 patients with stroke (23.9% of the sample). Single seizure without recurrence had been observed in 83.3% of those with post-stroke seizures (35 patients). Electroencephalograph results showed abnormal findings in 66.6% of those with post-stroke seizure (28 patients). Twenty-five patients (59.5%) of those with post-stroke seizure had ischemic stroke according to brain CT scan. In addition, this study revealed that 69.1% of the seizures were primary generalized seizures and 38.1% were partial seizures. In this study, it was found that 50% of the patients (21 patients) had early onset seizure, namely, within the first week, while only 14.3% of them had seizure during the 3rd week after the stroke event. CONCLUSION: This study indicated that post-stroke seizures are quite a common problem in the management of patients with stroke but they are usually single without recurrence. Ischemic stroke is the most common cause of post-stroke seizure, and generalized seizure is the most common type. In addition, this study indicated that the initial 2 weeks after stroke carry the highest risk for stroke patients to have a seizure.

Autonomic dysfunction in multiple sclerosis.

OBJECTIVE: Multiple sclerosis (MS) is a demyelinating disorder of the central nervous system. Autonomic dysfunction in MS patients may cause significant morbidity. The aim of this controlled cross sectional study was to investigate the prevalence, pattern and severity of autonomic dysfunction in Iraqi MS patients and to correlate them with patient`s age, disease course, duration and severity. METHODS: Fifty-five patients with clinically definite MS according to Poser`s criteria attending Baghdad MS clinic at Baghdad Teaching Hospital were studied between July 2000 and August 2001. Each patient was assessed according to a detailed protocol paper. Expanded disability status scale was used to assess the severity of the disease. The severity of autonomic symptoms was classified according to autonomic nervous system disability scale (ANSDS). Five standardized autonomic cardiovascular (Ewing) tests were performed for every patient which included: heart rate responses to deep breathing, Valsalva maneuver and standing, and blood pressure responses to standing and sustained hand grip. Forty matched healthy subjects were studied as a control group who were assessed with the same protocol paper, ANSDS and Ewing tests. RESULTS: Autonomic symptoms were significantly more prevalent in MS patients than in the controls. Cardiovascular, urinary and gastrointestinal symptoms were highly prevalent. The severity of the different autonomic symptoms as assessed by ANSDS, were higher in the patients than the controls. All 5 Ewing tests in the patients showed highly significant abnormal results as compared to those of the control. Definite parasympathetic derangement was found in 45.5% of the patients while combined sympathetic and parasympathetic derangements were found in 34.5% of the patients. There were significant correlations between the finding of definite autonomic dysfunctions and the age of the patients at the time of assessment and the duration of the disease. CONCLUSION: Autonomic dysfunctions as assessed by a formal interview, ANSDS and by Ewing tests were common in Iraqi MS patients. Careful attention to autonomic disturbances should be considered in the routine evaluation of MS patients which might help in improving their quality of life.

Outcome of thymectomy in patients with Myasthenia Gravis.

OBJECTIVE: Myasthenia Gravis is a neuromuscular disorder characterized by weakness and fatigability of skeletal muscles. Thymectomy is now beneficial even for non-thymomatous patients. The aim of this paper is to evaluate the role of thymectomy as on the treatment options for myasthenia gravis. METHODS: Thirty patients underwent thymectomy in the period from April 1999 through to July 2000. They were collected from different teaching hospitals in Baghdad, Iraq. All these cases were studied conventionally including history, physical and neurological examination in addition to investigations with particular emphasis on connective tissue screen and thyroid function test. RESULTS: The age in this study ranged between 17-55 years. The preoperative duration ranged between 2-20 months and the postoperative follow up period ranged between 6 months-14 years. The most favorable results were obtained in patients without thymoma with short duration. CONCLUSION: Early thymectomy carries the best results in Myasthenia Gravis and every effort should be made to shorten the preoperative duration for both thymomatous and nonthymomatous patients. Patients with symptoms can be better controlled with anticholinesterase drugs than patients using steroid and cytotoxic drugs. Thymectomy is beneficial for most patients with Myasthenia Gravis and especially in those with benign folicular hyperplasia.

Clinical evaluation of optic atrophy in patients with neurological disorders.

OBJECTIVE: Optic atrophy is a pathological term applied to optic nerve shrinkage from any process that produces degeneration of axons in the anterior visual system (the retino-geniculate pathway). The pathologist can make the diagnosis of optic atrophy by direct observation of the histopathological changes in the optic nerve. The clinician is restricted to indirect evidence by observing the optic nerve as it enters the eye and through testing its function. METHODS: Fifty patients with bilateral or unilateral optic atrophy, were collected randomly from several teaching hospitals in Baghdad, Iraq, between August 1998 and June 1999. Those patients included in this study had ophthalmoscopic abnormalities of the optic disc in addition to defective visual function that could be localized to the optic nerve. RESULTS: The defects in visual function varied between patients according to the disease process and duration of illness. Eight-seven percent of patients had visual acuity impairment, 74.4% had visual field defect, 58.5% had impairment in color perception, 64% had defective pupillary response to light and 88.4% had prolonged visual evoked potential (VEP) responses. CONCLUSION: Patients who met the criteria for optic atrophy have different and unequal changes in optic nerve functions, ranging from 58.5% for color saturation test to 88.4% for VEP. Forty percent of patients with optic atrophy were discovered accidentally.

Outcome of thymectomy in patients with Myasthenia Gravis.

OBJECTIVE: Myasthenia Gravis is a neuromuscular disorder characterized by weakness and fatigability of skeletal muscles. Thymectomy is now beneficial even for non-thymomatous patients. The aim of this paper is to evaluate the role of thymectomy as on the treatment options for myasthenia gravis. METHODS: Thirty patients underwent thymectomy in the period from April 1999 through to July 2000. They were collected from different teaching hospitals in Baghdad, Iraq. All these cases were studied conventionally including history, physical and neurological examination in addition to investigations with particular emphasis on connective tissue screen and thyroid function test. RESULTS: The age in this study ranged between 17-55 years. The preoperative duration ranged between 2-20 months and the postoperative follow up period ranged between 6 months-14 years. The most favorable results were obtained in patients without thymoma with short duration. CONCLUSION: Early thymectomy carries the best results in Myasthenia Gravis and every effort should be made to shorten the preoperative duration for both thymomatous and nonthymomatous patients. Patients with symptoms can be better controlled with anticholinesterase drugs than patients using steroid and cytotoxic drugs. Thymectomy is beneficial for most patients with Myasthenia Gravis and especially in those with benign folicular hyperplasia.