Routine CSF parameters as predictors of disease course in multiple sclerosis: an MSBase cohort study.

BACKGROUND: It remains unclear whether routine cerebrospinal fluid (CSF) parameters can serve as predictors of multiple sclerosis (MS) disease course. METHODS: This large-scale cohort study included persons with MS with CSF data documented in the MSBase registry. CSF parameters to predict time to reach confirmed Expanded Disability Status Scale (EDSS) scores 4, 6 and 7 and annualised relapse rate in the first 2 years after diagnosis (ARR2) were assessed using (cox) regression analysis. RESULTS: In total, 11 245 participants were included of which 93.7% (n=10 533) were persons with relapsing-remitting MS (RRMS). In RRMS, the presence of CSF oligoclonal bands (OCBs) was associated with shorter time to disability milestones EDSS 4 (adjusted HR=1.272 (95% CI, 1.089 to 1.485), p=0.002), EDSS 6 (HR=1.314 (95% CI, 1.062 to 1.626), p=0.012) and EDSS 7 (HR=1.686 (95% CI, 1.111 to 2.558), p=0.014). On the other hand, the presence of CSF pleocytosis (≥5 cells/µL) increased time to moderate disability (EDSS 4) in RRMS (HR=0.774 (95% CI, 0.632 to 0.948), p=0.013). None of the CSF variables were associated with time to disability milestones in persons with primary progressive MS (PPMS). The presence of CSF pleocytosis increased ARR2 in RRMS (adjusted R2=0.036, p=0.015). CONCLUSIONS: In RRMS, the presence of CSF OCBs predicts shorter time to disability milestones, whereas CSF pleocytosis could be protective. This could however not be found in PPMS. CSF pleocytosis is associated with short-term inflammatory disease activity in RRMS. CSF analysis provides prognostic information which could aid in clinical and therapeutic decision-making.

Association between Non-Steroidal Anti-Inflammatory Drug Use and Major Cardiovascular Outcomes in Patients with Acute Coronary Syndrome in the Arabian Gulf.

Objectives: Studies on the association between non-steroidal anti-inflammatory drugs (NSAIDs) and major adverse cardiovascular events (MACE) in the Arabian Gulf are scarce. The aim of this study was to evaluate the association between NSAIDs use and MACE in acute coronary syndrome (ACS) patients in the Arabian Gulf region. Methods: Data were analyzed from 3007 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013, as well as being on prior NSAIDs use during the index admission. The MACE included stroke/transient ischemic attacks (TIAs), myocardial infarction (MI), all-cause mortality and readmissions for cardiac reasons. Results: The overall mean age of the cohort was 62 ± 12 years, and 9.6% (n = 290) of the patients were on prior NSAID use during the index admission. At 12-months follow-up, after adjusting for confounding factors, patients on NSAIDs were significantly more likely to have had MACE (adjusted OR (aOR), 1.89; 95% confidence interval (CI): 1.44-2.48; p < 0.001). Specifically, the higher event rates observed were stroke/TIA (aOR, 2.50; 95% CI: 1.51-4.14; p < 0.001) and readmissions for cardiac reasons (aOR, 2.09; 95% CI: 1.59-2.74; p < 0.001), but not MI (aOR, 1.26; 95% CI: 0.80-1.99; p = 0.320) and all-cause mortality (aOR, 0.79; 95% CI: 0.46-1.34; p = 0.383). Conclusions: NSAIDs use was associated with significant stroke/TIA events as well as readmissions for cardiac reasons. However, NSAIDs were not associated with increased MIs or all-cause mortality rates in patients with ACS in the Arabian Gulf.

Medical malpractice in Oman: A 12-year retrospective record review.

BACKGROUND: There is a paucity of studies documenting medical malpractice litigation in countries of the Arabian Gulf, such as Oman. OBJECTIVES: To describe the characteristics of malpractice claims, the outcomes decided by the medical liability committee, and predictors of medical errors. METHODS: This is a retrospective observational study that reviewed medical malpractice cases registered in Oman over a 12-year period (2010-2021) with the medical liability committee, known as the Higher Medical Committee (HMC). Descriptive and inferential statistical techniques, including multiple logistic regression techniques, were used for data analysis. RESULTS: Between 2010 and 2021, the HMC registered 1284 medical malpractice cases, out of which 1048 were fully investigated. The number of registered cases increased during this period. These cases included those raised by Omani nationals and expatriates, with a majority (86%) raised by Omani complainants. Two-thirds (67%) of the cases involved adult complainants aged 18-60 years. About 43% of the cases were from the urban Muscat region, and 68% were related to public hospitals. The most common specialties involved were obstetrics and gynecology (20.1%), internal medicine (19.7%), surgery (17.6%) and orthopedics (13.8%). Half (51%) of the appeals or grievances were dismissed because they were not preceded by medical negligence or malpractice. The average waiting time to initiate the investigation was 10 months. Errors were more common among non-Omani complainants and cases related to private hospitals. Significant predictors of errors included nationality (i.e. Omani vs. non-Omani), the referring institution, the medical specialty and the type of health institution involved, and the waiting time to initiate the investigation. CONCLUSION: To date, the number of cases of medical malpractice in Oman is lower compared to international trends, although there has been an upsurge in recent years. More research using a more robust methodology is warranted to contextualise the factors that contribute to this upward trend, as well as the preponderance in urban settings and among certain demographic populations.

The Relationship Between Epilepsy Control and the Duration of Nighttime Sleep and Afternoon Siesta.

CONTEXT: The association between epilepsy control and the duration of sleep among people with epilepsy (PWE) is not well studied in Middle Eastern countries such as Oman. AIMS: To describe the sleep habits of PWE in Oman and explore the association of their sleep habits at night and afternoon siesta with the level of seizure control achieved and antiseizure medications (ASMs) consumed. METHODS: The subjects of this cross-sectional study were adult epilepsy patients attending a neurology clinic. Their sleep parameters were measured for one week using actigraphy. Home sleep apnea testing for one night was conducted to rule out obstructive sleep apnea (OSA). RESULTS: A total of 129 PWE completed the study. Their mean age was 29.8 ±â€¯9.2  years, and their mean body mass index (BMI) was 27.1 kg/m2. There was no significant difference between the people with controlled and uncontrolled epilepsy as regards the duration of night sleep or afternoon siesta (p = 0.24 and 0.37, respectively). There was also no significant correlation between their nighttime sleep duration, afternoon siesta, and the number of ASMs they consumed (p = 0.402 and 0.717, respectively). CONCLUSION: The study revealed that the sleep habits of PWE with uncontrolled epilepsy who consumed more ASMs were not significantly different from those with controlled epilepsy who consumed fewer ASMs.

A plain language summary on the effectiveness of cladribine tablets compared with other oral treatments for multiple sclerosis: results from the MSBase registry.

WHAT IS THIS SUMMARY ABOUT?: Patient registries contain anonymous data from people who share the same medical condition. The MSBase registry contains information from over 80,000 people living with multiple sclerosis (MS) across 41 countries. Using information from the MSBase registry, the GLIMPSE (Generating Learnings In MultiPle SclErosis) study looked at real-life outcomes in 3475 people living with MS who were treated with cladribine tablets (Mavenclad®) compared with other oral treatments. WHAT WERE THE RESULTS?: Results showed that people treated with cladribine tablets stayed on treatment for longer than other treatments given by mouth. They also had fewer relapses (also called flare ups of symptoms) than people who received a different oral treatment for their MS. WHAT DO THE RESULTS MEAN?: The results provide evidence that, compared with other oral treatments for MS, cladribine tablets are an effective medicine for people living with MS.

A global survey on the attitudes of neurologists and psychiatrists about functional/psychogenic/dissociative/nonepileptic-seizures/attacks, in the search of its name.

PURPOSE: We conducted an observational study to investigate the opinions of neurologists and psychiatrists all around the world who are taking care of patients with seizures [epilepsy and functional seizures (FS)]. METHODS: Practicing neurologists and psychiatrists from around the world were invited to participate in an online survey. On 29th September 2022, an e-mail including a questionnaire was sent to the members of the International Research in Epilepsy (IR-Epil) Consortium. The study was closed on 1st March 2023. The survey, conducted in English, included questions about physicians' opinions about FS and anonymously collected data. RESULTS: In total, 1003 physicians from different regions of the world participated in the study. Both neurologists and psychiatrists identified "seizures" as their preferred term. Overall, the most preferred modifiers for "seizures" were "psychogenic" followed by "functional" by both groups. Most participants (57.9%) considered FS more difficult to treat compared to epilepsy. Both psychological and biological problems were considered as the underlying cause of FS by 61% of the respondents. Psychotherapy was considered the first treatment option for patients with FS (79.9%). CONCLUSION: Our study represents the first large-scale attempt of investigating physicians attitudes and opinions about a condition that is both frequent and clinically important. It shows that there is a broad spectrum of terms used by physicians to refer to FS. It also suggests that the biopsychosocial model has gained its status as a widely used framework to interpret and inform clinical practice on the management of patients.

Initial clinical and radiological features of patients with multiple sclerosis in Oman.

BACKGROUND AND OBJECTIVE: Multiple sclerosis (MS) is a lifelong demyelinating disorder with a varying disease course, resulting in different degrees of physical disability for affected patients. This study aimed to present the initial clinicoradiological features of Omani MS patients presenting to a tertiary care center in Oman. METHODS: In this retrospective study, all Omani patients diagnosed with MS from January 2006 to December 2020, whose treatment and followup were conducted in our center, were included. Data was retrieved from the patients' medical records. Disability status was assessed according to the Expanded Disability Status Scale. RESULTS: A total of N = 155 Omani patients were diagnosed with MS of whom 68.4% were female. The mean age at diagnosis was 28.6 ± 8 years. The mean duration from symptoms to diagnosis was 1.9 years. Relapsing-remitting MS was diagnosed in 97.4% patients. Most common presenting symptoms were unifocal (84.5%), supratentorial (34.2%) and optic pathway (33.5%). At first assessment, 94.8% patients had no to mild disabilities and 3.2% had severe disabilities. During the mean follow up period of 61.2 months, the frequency of severe disabilities increased to 12.9%. Out of 155 patients, 98 (63.2%) had their initial brain magnetic resonance (MRI) report available for review, 62/98 (63%) of whom showed ≥ 20 T2-weighted (T2W) lesions. Of these lesions, 75/98 (76.5%) were periventricular, 66 (67.3%) juxtacortical, and 56 (57.1%) infratentorial. The most common initially prescribed disease modifying therapies (DMT) were interferons (104/155; 67%), followed by fingolimod (16; 10.3%), natalizumab (14; 9%) and dimethyl fumarate (4; 2.6%). CONCLUSIONS: The results of this study indicate that the demographic and clinicoradiological features of MS patients in Oman are similar to those reported elsewhere in the Arabian Gulf region.

Spinal Cord Infarct Due to Fibrocartilaginous Embolism in an Adolescent Boy: A Case Report and Literature Review.

Fibrocartilaginous embolism (FCE) is one of the rare causes of acute spinal cord infarction. We report the case of a previously healthy 14-year-old boy with this condition. A few hours after lifting heavy objects, he developed sudden quadriparesis. On examination, he had asymmetric hypotonic quadriparesis and normal dorsal column function but absent spinothalamic function in all limbs with sensory level to shoulder. Magnetic resonance imaging (MRI) of the spine confirmed the diagnosis of spinal infarction secondary to FCE. The patient initially received methylprednisolone and plasma exchange. A follow-up visit after neurorehabilitation showed improvement but with residual neurological deficit. Although FCE is rare, it should be kept as one of the differential diagnoses of an acute neurological deficit of the spinal cord.

Comparative effectiveness of cladribine tablets versus other oral disease-modifying treatments for multiple sclerosis: Results from MSBase registry.

BACKGROUND: Effectiveness of cladribine tablets, an oral disease-modifying treatment (DMT) for multiple sclerosis (MS), was established in clinical trials and confirmed with real-world experience. OBJECTIVES: Use real-world data to compare treatment patterns and clinical outcomes in people with MS (pwMS) treated with cladribine tablets versus other oral DMTs. METHODS: Retrospective treatment comparisons were based on data from the international MSBase registry. Eligible pwMS started treatment with cladribine, fingolimod, dimethyl fumarate, or teriflunomide tablets from 2018 to mid-2021 and were censored at treatment discontinuation/switch, death, loss to follow-up, pregnancy, or study period end. Treatment persistence was evaluated as time to discontinuation/switch; relapse outcomes included time to first relapse and annualized relapse rate (ARR). RESULTS: Cohorts included 633 pwMS receiving cladribine tablets, 1195 receiving fingolimod, 912 receiving dimethyl fumarate, and 735 receiving teriflunomide. Individuals treated with fingolimod, dimethyl fumarate, or teriflunomide switched treatment significantly more quickly than matched cladribine tablet cohorts (adjusted hazard ratio (95% confidence interval): 4.00 (2.54-6.32), 7.04 (4.16-11.93), and 6.52 (3.79-11.22), respectively). Cladribine tablet cohorts had significantly longer time-to-treatment discontinuation, time to first relapse, and lower ARR, compared with other oral DMT cohorts. CONCLUSION: Cladribine tablets were associated with a significantly greater real-world treatment persistence and more favorable relapse outcomes than all oral DMT comparators.

Developmental Venous Anomaly Presenting as an Acute Stroke Mimic.

Several mimics of acute ischemic stroke may complicate the decision to administer intravenous thrombolysis. Developmental venous anomalies (DVA) are fairly common variants of normal cerebral vasculature and may occasionally present with acute focal neurologic symptoms. We report a case of DVA presenting with the acute onset of focal neurologic deficits and focal hypodensities on the CT of the brain, resulting in a dilemma regarding whether to administer intravenous tissue-type plasminogen activator (IV tPA) for stroke thrombolysis. Recognition of subtle brain changes on the CT that were inconsistent with an acute ischemic stroke led to further imaging and a definitive diagnosis. Developmental venous anomalies should be considered in the differential diagnosis of acute ischemic stroke.

The diagnostic yield, candidate genes, and pitfalls for a genetic study of intellectual disability in 118 middle eastern families.

Global Developmental Delay/Intellectual disability (ID) is the term used to describe various disorders caused by abnormal brain development and characterized by impairments in cognition, communication, behavior, or motor skills. In the past few years, whole-exome sequencing (WES) has been proven to be a powerful, robust, and scalable approach for candidate gene discoveries in consanguineous populations. In this study, we recruited 215 patients affected with ID from 118 Middle Eastern families. Whole-exome sequencing was completed for 188 individuals. The average age at which WES was completed was 8.5 years. Pathogenic or likely pathogenic variants were detected in 32/118 families (27%). Variants of uncertain significance were seen in 33/118 families (28%). The candidate genes with a possible association with ID were detected in 32/118 (27%) with a total number of 64 affected individuals. These genes are novel, were previously reported in a single family, or cause strikingly different phenotypes with a different mode of inheritance. These genes included: AATK, AP1G2, CAMSAP1, CCDC9B, CNTROB, DNAH14, DNAJB4, DRG1, DTNBP1, EDRF1, EEF1D, EXOC8, EXOSC4, FARSB, FBXO22, FILIP1, INPP4A, P2RX7, PRDM13, PTRHD1, SCN10A, SCYL2, SMG8, SUPV3L1, TACC2, THUMPD1, XPR1, ZFYVE28. During the 5 years of the study and through gene matching databases, several of these genes have now been confirmed as causative of ID. In conclusion, understanding the causes of ID will help understand biological mechanisms, provide precise counseling for affected families, and aid in primary prevention.

Physicians' beliefs about brain surgery for drug-resistant epilepsy: A global survey.

PURPOSE: To investigate the opinions of physicians about brain surgery for drug-resistant epilepsy worldwide. METHODS: Practicing neurologists, psychiatrists, and neurosurgeons from around the world were invited to participate in an online survey. The survey anonymously collected data about demographics, years in clinical practice, discipline, nation, work setting, and answers to the questions about beliefs and attitudes about brain surgery for drug-resistant epilepsy. RESULTS: In total, 1410 physicians from 20 countries and different world regions participated. The propensity to discuss brain surgery with patients, who have drug-resistant seizures, was higher among men (versus women) [Odds Ratio (OR) 1.67, 95% CI 1.20-2.31; p = 0.002]. In comparison to neurologists, psychiatrists were less likely (OR 0.28, 95% CI 0.17-0.47; p < 0.001) and neurosurgeons were more likely (OR 2.00, 95% CI 1.08-3.72; p = 0.028) to discuss about it. Survey participants working in Africa, Asia, the Middle East, and the Former Union of Soviet Socialist Republics showed a lower propensity to discuss epilepsy surgery with patients. CONCLUSION: This study showed that on an international level, there is still a knowledge gap concerning epilepsy surgery and much needs to be done to identify and overcome barriers to epilepsy surgery for patients with drug-resistant seizures worldwide.

Post-COVID-19 Guillain-Barré Syndrome: A case report from Oman.

Guillain-Barré syndrome (GBS) has been reported as one of the neurological manifestations linked to COVID-19, a severe acute respiratory syndrome caused by coronavirus 2. We present the case of a 72-year-old male patient attending a tertiary care hospital in Muscat, Oman, in 2020 with a history of progressive bilateral limb weakness and numbness. The current diagnosis was in line with a rare complication of COVID-19. After exclusion of other possible causes, a diagnosis of GBS induced by COVID-19 was made. The patient received 0.4g/kg of intravenous immunoglobulin (IVIG) per day for five days. This case report highlights the characteristics and course of GBS following COVID-19 infection. Further studies are needed to characterize the manifestations and course of various neuromuscular disorders in relation to COVID-19 infection.

A Multidisciplinary Perspective Addressing the Diagnostic Challenges of Late-Onset Pompe Disease in the Arabian Peninsula Region Developed From an Expert Group Meeting.

Pompe disease is a rare, metabolic, autosomal recessive disorder. Early diagnosis is critical for progressive Pompe disease as delays can significantly alter the clinical course of the disease. Diagnostic modalities, including dried blood spot testing and genetic testing, are available and are effective for diagnosing patients with late-onset Pompe disease (LOPD). However, clinicians face numerous clinical challenges related to the diagnosis of the disease. Two expert group committee meetings, involving 11 experts from the United Arab Emirates, Kuwait, the Kingdom of Saudi Arabia, and Oman, were convened in October 2019 and November 2020 respectively to develop a uniform diagnostic algorithm for the diagnosis of pediatric and adult LOPD in the Arabian Peninsula region. During the first meeting, the specialty-specific clinical presentation of LOPD was defined. During the second meeting, a diagnostic algorithm was developed after a thorough validation of clinical presentation or symptoms, which was performed with the aid of existing literature and expert judgement. A consensus was reached on the diagnostic algorithm for field specialists, such as neurologists, rheumatologists, general practitioners/internal medicine specialists, orthopedic specialists, and pulmonologists. This specialty-specific diagnostic referral algorithm for pediatric and adult LOPD will guide clinicians in the differential diagnosis of LOPD.

Counseling about sudden unexpected death in epilepsy (SUDEP): A global survey of neurologists' opinions.

OBJECTIVE: To investigate the opinions and attitudes of neurologists on the counseling about sudden unexpected death in epilepsy (SUDEP) worldwide. METHODS: Practicing neurologists from around the world were invited to participate in an online survey. On February 18th, 2021, we emailed an invitation including a questionnaire (using Google-forms) to the lead neurologists from 50 countries. The survey anonymously collected the demographic data of the participants and answers to the questions about their opinions and attitudes toward counseling about SUDEP. RESULTS: In total, 1123 neurologists from 27 countries participated; 41.5% of the respondents reported they discuss the risk of SUDEP with patients and their care-givers only rarely. Specific subgroups of patients who should especially be told about this condition were considered to be those with poor antiseizure medication (ASM) adherence, frequent tonic-clonic seizures, or with drug-resistant epilepsy. The propensity to tell all patients with epilepsy (PWE) about SUDEP was higher among those with epilepsy fellowship. Having an epilepsy fellowship and working in an academic setting were factors associated with a comfortable discussion about SUDEP. There were significant differences between the world regions. CONCLUSION: Neurologists often do not discuss SUDEP with patients and their care-givers. While the results of this study may not be representative of practitioners in each country, it seems that there is a severe dissociation between the clinical significance of SUDEP and the amount of attention that is devoted to this matter in daily practice by many neurologists around the world.

Risk Factors for Ischaemic Stroke in an Omani Community: A case-control study.

OBJECTIVES: Stroke is recognised as the third most common cause of mortality and it has an increasing incidence in developing countries. Recognition and control of risk factors are of prime importance in the prevention of stroke. This study aimed to examine the characteristics of ischaemic stroke (IS) patients in Oman and quantify its various risk factors using a case-control model. METHODS: This case-control study was conducted from January 2012 to March 2013 at Sultan Qaboos University Hospital and Royal Hospital, Muscat. Adult Omani patients with IS who were admitted to either hospital were compared to age- and gender-matched controls. Demographic factors and frequency of various conventional risk factors were documented. Univariate and stepwise multivariate logistic regression analyses were performed to evaluate the risk factors associated with IS. RESULTS: A total of 255 patients and age-and gender-matched controls were included in this study. The mean age was 62.2 ± 13.2 years and 63.14% were male. Most cases (89.02%) were above 45 years of age. Cardio-embolism (31.76%) was the commonest mechanism of IS. Stepwise multiple logistic regression model revealed that family history of stroke was the strongest independent risk factor, followed by hypertension and high-density lipoprotein levels (odds ratio: 10.10, 5.17 and 3.34, respectively; P <0.01 each). CONCLUSION: Cardio-embolism was the predominant mechanism of IS in this study. Family history of stroke, hypertension and reduced high-density lipoprotein were the leading independent risk factors. Strong emphasis on screening for risk factors, control of hypertension and lifestyle modification for those with a family history of stroke would be expected to emerge as the major stroke-preventive measures in Oman.

Health-related Quality of Life of People with Multiple Sclerosis in Oman.

OBJECTIVES: Multiple sclerosis (MS) is a disabling neurological disorder with significant adverse effects on patients' quality of life (QoL). Despite the increased prevalence of MS in Arabian Gulf countries in recent years, no study has assessed the impact of MS on the health-related QoL (HRQoL) of Omani patients. Therefore, the objective of this study was to determine the impact of MS on HRQoL of Omani patients using the validated disease-specific self-administered MS International QoL (MusiQoL) instrument. METHODS: We conducted a descriptive cross-sectional survey between April and December 2019 on 177 Omani patients with MS attending Sultan Qaboos University Hospital and Khoula Hospital in Oman using the MusiQoL instrument. RESULTS: The majority (51.4%) of patients had poor HRQoL, and 48.6% had moderate HRQoL. We found that being > 30 years, female, married, separated, widowed, or divorced, and having visual and sleep problems resulted in poorer HRQoL scores. Among the different HRQoL components, relationships with the healthcare system and relationships with family and friends were the most affected by the disease process. Our results also showed that psychological wellbeing and coping domains of MusiQoL questionnaires are significantly reduced in females compared to males. CONCLUSIONS: Understanding the HRQoL of Omanis with MS provides valuable knowledge that could help optimize the management of this disease.

Epidemiology of multiple sclerosis in the Sultanate of Oman: A hospital based study.

BACKGROUND: The prevalence of multiple sclerosis (MS) has been changing not only globally but also in individual countries. We aim to estimate the prevalence of MS in the Omani population over the period from 2006-2019 as well as the incidence between 2015-2018. METHODS: This is a retrospective observational hospital-based study. All MS patients diagnosed, as per the revised McDonald criteria, over the period from June 2006 and until May 2019, had their information reviewed for age at disease onset, gender and year of diagnosis. We obtained the population of Oman from the national census data. RESULTS: A total of 422 patients were diagnosed with MS during the study period and the population of Oman as per the 2019 census data was 2,652,199. The estimated crude prevalence was 15.9 (95% confidence interval: 14.4 - 17.5) per 100,000 and the female to male ratio was 2.17:1. The mean age at disease onset was 27.3 ± 7.7 (range: 9 - 59) years in which 83% of the patients had the first clinical manifestation at the age of 19 - 40 years, while only 9% had a disease onset at <19 years. The annual incidence increased from 1.00 case per 100,000 in 2015 to 1.38 cases per 100,000 in 2018. CONCLUSION: The prevalence of MS in the Omani population is 15.9 per 100,000 placing Oman as a medium risk zone.

Expert Consensus and Narrative Review on the Management of Multiple Sclerosis in the Arabian Gulf in the COVID-19 Era: Focus on Disease-Modifying Therapies and Vaccination Against COVID-19.

This article describes consensus recommendations from an expert group of neurologists from the Arabian Gulf region on the management of relapsing multiple sclerosis (RMS) in the COVID-19 era. MS appears not to be a risk factor for severe adverse COVID-19 outcomes (though patients with advanced disability or a progressive phenotype are at higher risk). Disease-modifying therapy (DMT)-based care appears generally safe for patients with MS who develop COVID-19 (although there may be an increased risk of adverse outcomes with anti-CD20 therapy). Interferon-ß, teriflunomide, dimethyl fumarate, glatiramer acetate, natalizumab and cladribine tablets are unlikely to increase the risk of infection; fingolimod, anti-CD20 agents and alemtuzumab may confer an intermediate risk. Existing DMT therapy should be continued at this time. For patients requiring initiation of a DMT, all currently available DMTs except alemtuzumab can be started safely at this time; initiate alemtuzumab subject to careful individual risk-benefit considerations. Patients should receive vaccination against COVID-19 where possible, with no interruption of existing DMT-based care. There is no need to alter the administration of interferon-ß, teriflunomide, dimethyl fumarate, glatiramer acetate, natalizumab, fingolimod or cladribine tablets for vaccination; new starts on other DMTs should be delayed for up to 6 weeks after completion of vaccination to allow the immune response to develop. Doses of the Oxford University/AstraZeneca vaccine may be scheduled around doses of anti-CD20 or alemtuzumab. Where white cell counts are suppressed by treatment, these should be allowed to recover before vaccination.

Expert Consensus and Narrative Review on the Management of Multiple Sclerosis in the Arabian Gulf in the COVID-19 Era: Focus on Disease-Modifying Therapies and Vaccination Against COVID-19.

This article describes consensus recommendations from an expert group of neurologists from the Arabian Gulf region on the management of relapsing multiple sclerosis (RMS) in the COVID-19 era. MS appears not to be a risk factor for severe adverse COVID-19 outcomes (though patients with advanced disability or a progressive phenotype are at higher risk). Disease-modifying therapy (DMT)-based care appears generally safe for patients with MS who develop COVID-19 (although there may be an increased risk of adverse outcomes with anti-CD20 therapy). Interferon-ß, teriflunomide, dimethyl fumarate, glatiramer acetate, natalizumab and cladribine tablets are unlikely to increase the risk of infection; fingolimod, anti-CD20 agents and alemtuzumab may confer an intermediate risk. Existing DMT therapy should be continued at this time. For patients requiring initiation of a DMT, all currently available DMTs except alemtuzumab can be started safely at this time; initiate alemtuzumab subject to careful individual risk-benefit considerations. Patients should receive vaccination against COVID-19 where possible, with no interruption of existing DMT-based care. There is no need to alter the administration of interferon-ß, teriflunomide, dimethyl fumarate, glatiramer acetate, natalizumab, fingolimod or cladribine tablets for vaccination; new starts on other DMTs should be delayed for up to 6 weeks after completion of vaccination to allow the immune response to develop. Doses of the Oxford University/AstraZeneca vaccine may be scheduled around doses of anti-CD20 or alemtuzumab. Where white cell counts are suppressed by treatment, these should be allowed to recover before vaccination.