Impact of Repetitive Transcranial Magnetic Stimulation on Cognitive and Psychiatric Dysfunction in Patients with Fibromyalgia: A Double-Blinded, Randomized Clinical Trial.

Few randomized controlled trials have reported that repetitive transcranial magnetic stimulation (rTMS) has controversial results for managing multiple domains of fibromyalgia-related symptoms. This work aimed to evaluate the effect of low-frequency rTMS over the right dorsolateral prefrontal area (DLPFC) on the Fibromyalgia Impact Questionnaire (FIQ) concerning psychiatric and cognitive disorders. Forty-two eligible patients with fibromyalgia (FM) were randomized to have 20 sessions of active or sham rTMS (1 Hz, 120% of resting motor threshold with a total of 1200 pules/session) over the right DLPFC. All participants were evaluated at baseline, post sessions, and 3 months after sessions with the FIQ, Hamilton depression, and anxiety rating scales (HDRS and HARS), Montreal Cognitive Assessment (MoCA), Rey Auditory Verbal Learning Test (RAVLT), Tower of London test (TOL), the Trail Making, and Digit Span Tests. Both groups showed improvement in most rating scales at 1 and 3 months follow-up, with greater improvement in the active group, with significant correlation between FIQ cognitive rating scales, including RAVLT and TOL. Twenty sessions of low-frequency rTMS over the right DLPFC can improve FIQ scores regarding the psychiatric and cognitive symptoms of medicated patients with FM to a greater extent than sham. Changes in RAVLT and TOL correlated with changes in FIQ results.

Treatment satisfaction with disease-modifying therapy is the only predictor of Adherence among multiple sclerosis patients from Upper Egypt.

Despite the proven efficacy of the disease-modifying therapy (DMT) for multiple sclerosis (MS), the rates of non-adherence are frequently high. We aimed to evaluate the rate of non-adherence to the first DMT in Upper Egypt and identify different contributing factors. Out of 310 patients, ninety-seven adult patients with RRMS were recruited from three MS units located in Upper Egypt and were subjected to the following: complete clinical history, expanded disability status score (EDSS), Eight-item Morisky Medication Adherence Scale (MMAS-8), abbreviated Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9), Hamilton depression scale, Fatigue Severity Scale (FSS) and the Pittsburgh Sleep Quality Index (PSQI). According to MMAS-8 scores, 63 (64.9%) of patients were non-adherent to their first DMT. Non-adherent patients are more likely to have longer disease duration (p = 0.002), longer duration on first DMT (p = 0.030), first DMT-start date before 2019 (p = 0.040), and lower treatment satisfaction scores (p = 0.016). However, there was no significant relation with physical disability, depression, fatigue, or sleep quality. On the regression analysis model, a lower treatment satisfaction score was the only predictor of DMT non-adherence (p = 0.012). Despite expanding DMT options, non-adherence among MS patients in Upper Egypt is high. Treatment satisfaction with DMT is the only predictor of adherence among MS patients of Upper Egypt. Adherence and satisfaction with the prescribed DMT should be assessed carefully to maximize DMT benefits.

A prospective study of the effect of COVID-19 on psychiatric symptoms and sleep problems from infection to 9-month follow-up.

Diverse psychological consequences of the COVID-19 pandemic have been reported for 6 months after infection. We conducted a prospective study to evaluate the psychological impact of COVID-19 infection in newly diagnosed cases that were followed up at 1, 6, and 9 months after infection. 137 people were recruited and divided into four groups based on the COVID-19 Treatment Guidelines. They were evaluated using the Pittsburgh Sleep Quality Index (PSQI), Post-traumatic stress disorder Checklist for DSM-5 (PCL-5), and Symptom Checklist 90 (SCL-90). We found that 9 months after infection, patients continued to report poor sleep (74.5%), PTSD (78.3%), somatization (17%), anxiety (17%), aggression (5.7%), phobic anxiety (4.7%), psychoticism (1.9%), paranoid (3.8%), and obsessive-compulsive (9.4%) symptoms, as well as depression and interpersonal sensitivity. The most significant risk factors for psychiatric complications were older age, level of education, smoking, hospitalization duration, hypertension, and critical severity. The negative mental health effects of COVID-19 persist after hospital discharge, and many patients continue to experience moderate-to-severe issues that may endure for 9 months. Notably, there was a progressive improvement in these symptoms over that time.

Predictors of long-term health-related quality of life in Guillain-Barré syndrome: A hospital-based study.

OBJECTIVE: This study aimed to determine the impact of patients' baseline clinical, neurophysiological data, and management plan of Guillain-Barré syndrome (GBS) on long-term quality of life (QoL) and to identify its potential predictors. METHODS: Seventy-nine GBS patients were recruited. On admission, participants were evaluated using the Medical Research Council (MRC) sumscore, GBS disability scale (GDS), and Erasmus GBS Respiratory Insufficiency Score (EGRIS). Neurophysiological data were collected, and a management plan was devised. MRC sumscore was repeated at nadir. MRC, GDS and Short Form Survey (SF-36) were assessed at first-year follow-up. RESULTS: The mean age was 37.84 ± 17.26 years, with 43 male patients (54.4%). QoL at one year correlated significantly with baseline clinical variables (age, number of days between weakness and admission, MRC sumscore at onset and nadir, high GDS, and EGRIS scores). Antecedent events, especially diarrhoea, neck muscle weakness, autonomic dysfunction, cranial nerve involvement, and mechanical ventilation (MV), associated with worse QoL. Axonal GBS patients had lower QoL than AIDP patients, and PE patients exhibited lower QoL than IVIG patients. Multiple regression analysis showed that older age, diarrhoea, number of days between weakness and admission, neck muscle weakness, cranial nerve involvement, autonomic dysfunction, early MV, and MRC at onset and nadir and high GDS could predict poor QoL. CONCLUSION: Older age, more days between weakness and admission, neck muscle weakness, cranial nerve involvement, autonomic dysfunction, early MV, diarrhoea, low MRC at onset and nadir, high GDS at onset, axonal type, and PE treatment were potential predictors of poor QoL in GBS.

Early electrophysiological study variants and their relationship with clinical presentation and outcomes of patients with Guillain-Barré syndrome.

This study compared the clinical outcomes of the two main neurophysiological types of Guillain-Barré Syndrome (GBS). Sixty-two GBS patients were examined clinically at onset using Medical Research Council (MRC), Hughes disability scales (HDS), and nerve conduction studies were evaluated in four limbs. The Modified Erasmus GBS outcome score (MEGOS) was assessed 2 weeks after onset. Outcomes were measured after 3 months using MRC and HDS scores. According to electrophysiological data two main groups identified acute inflammatory demyelinating polyneuropathy (AIDP = 31 cases) or acute axonal GBS including inexcitable forms (26 cases). The number of days between onset of weakness and admission was significantly shorter, and gastrointestinal symptoms were significantly higher among the axonal type than AIDP. MRC sum scores at onset and at nadir were significantly worse in the axonal type than in AIDP. Neck muscle weakness, impaired cough reflex, the need for mechanical ventilation, hypoalbuminemia, and hypernatremia were more common in the axonal type. At outcome, 74% of the AIDP were healthy/minor symptoms versus 38.46% of the axonal type. There was a high prevalence of the axonal variant (41.9%) compared with European and North American populations. The axonal type had a significantly worse outcome than AIDP type.

EDSS and infratentorial white matter lesion volume are considered predictors of fatigue severity in RRMS.

Fatigue is a common disabling symptom of relapsing remitting multiple sclerosis (RRMS). Many studies have linked grey matter atrophy to fatigue, but white matter lesion load (WM-LL) has received less attention. Here we assess the relation between fatigue and regional WM-LL volumetric measures. 63 patients with RRMS participated in this study; mean age was 31.9 ± 8.1 years. Each patient provided demographic details and was scored on the expanded disability status scale (EDSS) and fatigue severity scale (FSS). VolBrain, a fully automated, operator-independent tool was used to assess WM-LL and whole brain volume. The patients were classified into three groups: no fatigue (FSS < 4), low to moderate fatigue (FSS ≥ 4 ≤ 5) and high fatigue (FSS > 5). 33.3% of patients had no significant fatigue, 25.4% had mild-to-moderate fatigue, and 41.3% had significant fatigue. Age, disease duration, relapses, and EDSS were positively correlated to fatigue severity (P = 0.034, 0.002, 0.009 and 0.001 respectively). Whole brain volume, total and regional WM-LL (juxtacortical, periventricular, infratentorial) were also correlated with fatigue severity. Ordinal regression analysis for fatigue severity showed EDSS and infratentorial lesion volume were the best predictors. In conclusion, EDSS and infratentorial lesion volume (cerebellar and brainstem) are the best predictors of fatigue severity.

Cerebrovascular reactivity after functional activation of the Brain using Photic Stimulation in Migraine and Tension Type Headache: a transcranial doppler Ultrasonography Study.

BACKGROUND: Previous studies in headache patients measured the cerebrovascular reactivity (CVR) in response to photic stimulation but they have yielded contradictory results. The purpose of study was to measure CVR of both migraine and chronic tension headache (TTH) patients in response to photic stimulation. METHODS: The study included 37 migraineurs and 24 chronic TTH patients compared with 50 age- and sex-matched healthy volunteers. Peak systolic, end diastolic, mean flow velocities and CVR (PSV, EDV, MFV, and CVR) were measured using TCD ultrasonography of the middle, anterior, posterior cerebral and vertebral arteries (MCA, ACA, PCA, and VA) before and after 100 s of 14 Hz photic stimulation. RESULTS: A three-way repeated measures ANOVA interaction with main factors of Vessels (MCA, ACA, PCA, VA), Time (pre-post photic) and Groups (migraine, TTH, and control group) revealed significant 3-way interactions for measures of PSV (P = 0.012) and MFV (P = 0.043). In the migraine patients there was significantly higher PSV, EDV, and MFV in the MCA, ACA, and PCA after photic stimulation compared with baseline. The CVR of the MCA was also significantly higher in migraineurs than controls. In the TTH group, there was significantly higher PSV, EDV, and MFV (P = 0.003, 0.012, 0.002 respectively) in the VA after photic stimulation than at baseline. The CVR was significantly higher in the VA of TTH patients than controls. CONCLUSION: Compared with controls after photic stimulation, the higher CVR of the MCA in migraineurs and of the VA in TTH patients could be used as diagnostic tool to differentiate between the two types of headaches.

Myasthenia gravis with achalasia secondary to thymoma: a case report and literature review.

Background: Myasthenia gravis is an autoimmune neuromuscular junction disorder characterized by fatigable muscle weakness and autoantibodies. Frequent associations exist between myasthenia gravis and thymic abnormalities, including hyperplasia and thymoma. Several autoimmune illnesses have been identified to be associated with thymoma; however, a few case reports have linked thymoma and achalasia, and the underlying mechanism is unknown. Case report: A 43-year-old man with thymoma-associated myasthenia gravis presented with dysphagia that was refractory to conventional treatment of myasthenia gravis. This dysphagia was challenging to diagnose even after multiple gastroenterology consults and upper endoscopy. The diagnosis of achalasia type II was established after a comprehensive evaluation, including upper endoscopy, barium swallow, and high-resolution esophageal manometry. The patient underwent elective pneumatic balloon dilatation, which successfully alleviated his dysphagia. Conclusion: This case confirmed the association between myasthenia gravis secondary to thymoma and achalasia and showed how the diagnosis of achalasia was challenging. Awareness of this association is crucial for early diagnosis and treatment, improving affected patients' quality of life.

Multiple sclerosis diagnostic delay and its associated factors in Upper Egyptian patients.

The earlier the diagnosis of multiple sclerosis (MS), the sooner disease-modifying treatments can be initiated. However, significant delays still occur in developing countries. We aimed to identify factors leading to delayed diagnosis of MS in Upper Egypt. One hundred forty-two patients with remitting relapsing MS (RRMS) were recruited from 3 MS units in Upper Egypt. Detailed demographic and clinical data were collected. Neurological examination and assessment of the Disability Status Scale (EDSS) were performed. The mean age was 33.52 ± 8.96 years with 72.5% of patients were females. The mean time from symptom onset to diagnosis was 18.63 ± 27.87 months and the median was 3 months. Seventy-two patients (50.7%) achieved diagnosis within three months after the first presenting symptom (early diagnosis), while seventy patients (49.3%) had more than three months delay in diagnosis (delayed diagnosis). Patients with a delayed diagnosis frequently presented in the period before 2019 and had a significantly higher rate of initial non-motor presentation, initial non-neurological consultations, prior misdiagnoses, and a higher relapse rate. Another possible factor was delayed MRI acquisition following the initial presentation in sixty-six (46.5%) patients. Multivariable logistic regression analysis demonstrated that earlier presentation, initial non-neurological consultation, and prior misdiagnosis were independent predictors of diagnostic delay. Despite advances in MS management in Egypt, initial non-neurological consultation and previous misdiagnoses are significant factors responsible for delayed diagnosis in Upper Egypt.

Recombinant tissue plasminogen activator (rTPA) management for first onset acute ischemic stroke with covid -19 and non-covid -19 patients.

OBJECTIVES: Cerebrovascular stroke (CVS) is one of the well-known complications of coronavirus-2019 (Covid-19), but less is known about the outcome and safety of thrombolytic therapy in these patients. In this study we compare the efficacy and safety of Tissue plasminogen activator (rTPA) in acute ischemic stroke (AIS) patients with or without Covid-19 infection. MATERIALS AND METHODS: A comparative prospective study in which all patients who presented with AIS and eligible for rTPA were recruited from the emergency department and classified into 2 groups (AIS with Covid-19 infection and AIS without Covid-19 as controls). Demographic data, symptoms of Covid-19, clinical examination, neuroimaging, and laboratory investigations were obtained in each patient. National Institute of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (mRS) were assessed before, immediately after rTPA, and 3 months later. RESULTS: There were 22 patients in the COVID-19 group and 25 control patients. Those with COVID-19 were more likely to have a history of smoking and Diabetes Mellitus than controls. On admission, motor symptoms were more severe in patients with COVID-19. COVID-19 patients were more likely to have symptomatic intra-cerebral hemorrhage and radiological hemorrhagic transformation than controls. Onset to door time (ODT) and onset to successful reperfusion time were significantly longer in Covid-19 patients than controls. Clinical improvement and frequency of re-occlusion and recurrent ischemic stroke at 3 months follow-up did not differ between groups, although there was higher number of deaths (27.3%) in the Covid-19 group than controls (16%). CONCLUSIONS: Using rTPA is safe and effective in patients with AIS with or without COVID-19 infection despite the high frequency of hemorrhagic transformation and high number of deaths.

Constrained spherical deconvolution -based tractography of major language tracts reveals post-stroke bilateral white matter changes correlated to aphasia.

PURPOSE: Using constrained spherical deconvolution (CSD)-based tractography, we aimed to obtain conjoint analysis of diffusion measures of major language white matter (WM) tracts in post-stroke aphasic patients bilaterally, and to correlate the measures of each tract to the different language deficits. MATERIAL AND METHODS: 17 aphasic patients with left hemispheric stroke, at the subacute stage, and ten age- matched controls underwent diffusion MRI examination. CSD-based tractography was performed. Diffusion measures [fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), axial diffusivity (AD)] were extracted after dissection of major language tracts bilaterally. Aphasia was assessed using language subset of hemispheric stroke scale. Comparisons of diffusion measures, for all tracts, between the two groups were performed. Partial correlations between the diffusion measures and different language components were obtained. RESULTS: In the left hemisphere, significant lower FA and or higher MD with higher RD of patients' WM tracts compared to the control group. Significant differences of diffusion measures were also evident in the right hemisphere yet, less prominent. All changes reflected damage of the tracts' integrity. Significant correlations were found between comprehension and FA of the left arcuate fasciculus (AF) and left inferior longitudinal fasciculus. Additionally, a significant correlation was found between MD of the right AF and repetition. CONCLUSION: Conjoint analysis of diffusion measures, based on CSD tractography, can provide important markers for the underlying WM changes bilaterally. Moreover, our findings emphasize that language processing can be mediated by both ventral and dorsal streams and further highlight the contribution of the right AF in repetition.

Long-term outcomes of plasma exchange versus intravenous immunoglobulin for the treatment of Guillain-Barré Syndrome: A double-blind, randomized clinical trial.

Background: Most previous studies comparing the effectiveness of Plasma Exchange (PE) or intravenous immunoglobulin (IVIG) in treating Guillain-Barre syndrome (GBS) have focused on the short-term outcome at around 1 month. Objective: To compare the long-term efficacy of PE and IVIG at one year in adult patients with GBS. Methods: Eighty-one adult patients with acute GBS were randomized into two groups with a ratio of 2 : 1: PE (N = 54) and IVIG (N = 27). Patients were assessed with the Medical Research Council sum score (MRC sum score), GBS Disability Scale (GDS), and Functional assessment of acute inflammatory neuropathy (FAAIN) at baseline, ten days, one month, three months, and one year. Neurophysiological examinations were performed at baseline and three months following treatment. Results: There were no significant differences between groups in demographic, clinical, and laboratory data. Both treatments produced a significant improvement in all clinical rating scales in both groups that continued up to one year. There were significant differences in the time course of recovery in the MRC and FAAIN scales, with significantly more improvement in the IVIG group at 1 and 3 months, although there was no significant difference in outcome at one year. However the effect size showed measurable differences between the PE and IVIG groups across the different measures at one-year. Electrophysiological studies showed equal improvement in most measures in both groups at three months, with a slightly greater effect in the IVIG group. Conclusion: long term outcomes of IVIG and PE were equivalent. However the effect size showed measurable differences between the PE and IVIG groups across the different measures at one-year follow-up that indicate the superiorty of IVIG. There was also a tendency for improvement to be slightly faster in the IVIG group.

Efecto de la estimulación transcraneal mediante corriente continua sobre el dolor y el consumo de opioides después de la cirugía raquídea / Effects of transcranial direct current stimulation in pain and opioid consumption after spine surgery

Antecedentes: La estimulación transcraneal por corriente continua (ETCC o tDCS, por sus siglas en inglés) ha obtenido resultados prometedores para aliviar distintos tipos de dolor. El presente estudio compara la eficacia de tres sesiones de ETCC anódica aplicada sobre el área motora primaria (M1) o la corteza prefrontal dorsolateral (CPFDL) izquierda, o simulada, para reducir el dolor y el consumo total de opioides en pacientes en el postoperatorio de una cirugía de columna vertebral.Materiales: Sesenta y siete de 75 pacientes elegibles en el postoperatorio de una cirugía raquídea fueron asignados a uno de tres grupos experimentales. El grupo A recibió ETCC anódica sobre la corteza M1, el grupo B la recibió sobre la CPFDL izquierda (2 mA, 20 min) y el grupo C recibió una ETCC simulada, todos durante 3 días consecutivos del postoperatorio. Los pacientes se evaluaron mediante una escala analógica visual (EAV) y una escala analógica visual dinámica (EAVD) basalmente y en cada uno de los días de tratamiento. Se evaluó el consumo total de morfina durante los 3 días del postoperatorio.Resultados: El ANOVA de dos vías de medidas repetidas no mostró ninguna diferencia significativa en la EAV de reposo entre los tres grupos. Sin embargo, hubo una mejoría significativa del dolor (P < 0,001) en la EAVD en ambos grupos activos (grupos A y B) frente al grupo con simulación (grupo C) en el postoperatorio, sin diferencias significativas entre los grupos activos. El consumo de morfina se redujo significativamente en ambos grupos activos frente al grupo simulado, pero no hubo diferencias de consumo entre los grupos activos. Conclusión: Hubo una reducción significativa del consumo de morfina y de las puntuaciones de la EAVD en el postoperatorio después de las tres sesiones de ETCC real.Significación: La ETCC es una herramienta prometedora para aliviar el dolor en el campo de la cirugía raquídea durante el postoperatorio.(AU)

Background: Transcranial direct current stimulation (tDCS) has shown promising results in alleviating different types of pain. The present study compares the efficacy of three sessions of anodal tDCS applied over primary motor area (M1) or the left dorsolateral prefrontal cortex (DLPFC) or sham on reducing pain and the total opioid consumption in postoperative spine surgery patients.Materials: Sixty-seven out of 75 eligible patients for postoperative spine surgery were randomly allocated into one of the three experimental groups. Group A received anodal tDCS applied over M1 cortex, group B over left DLPF cortex (2 mA, 20 min) and group C received sham tDCS, all for 3 consecutive postoperative days. Patients were evaluated using a visual analogue scale (VAS) and adynamic visual analogue scale (DVAS) at baseline, and on each of the treatment days. The total morphine consumption over the 3 postoperative days was assessed.Results: Two-way repeated measures ANOVA showed no statistically significant difference in resting VAS between the three groups. However, there was significant pain improvement (P < 0.001) in DVAS in both active groups (group A and B) compared to the sham group (group C) in the postoperative period, with no significant difference between the active groups. Morphine consumption was significantly reduced in both active groups compared with the sham group,but there was no difference in consumption between the active groups.Conclusion: There was a significant postoperative reduction in morphine consumption and DVAS scores after three sessions of active tDCS.Significance: tDCS is a promising tool for alleviating pain in the field of postoperative spine surgery.(AU)

A double blind randomized clinical trial of the effectiveness of low frequency rTMS over right DLPFC or OFC for treatment of obsessive-compulsive disorder.

We compared the effectiveness of low frequency repetitive transcranial magnetic stimulation over right dorsolateral prefrontal cortex (DLPFC), right orbitofrontal cortex (OFC) and sham for treatment of obsessive-compulsive disorder (OCD) and sought to determine possible predictors of effective treatment. Sixty OCD patients participated and were randomly allocated to one of the 3 treatment groups. Treatment was administered daily for 10 days. Assessments were made at the beginning and end of therapy as well as three months later using the Yale-Brown obsessive compulsive scale (Y-BOCS), Hamilton Anxiety Rating Scale (HAM-A), Beck Depression Inventory (BDI), and Clinical Global Impression - Severity scale (CGI-S). There were no significant demographic or clinical differences between the groups at baseline. One-way repeated measures ANOVA showed that participants in all 3 groups improved their scores on all rating scales following treatment. A two-way repeated measures ANOVA revealed a significant time and group interaction due to the fact that both active treatment groups outperformed the sham group, although there was no significant difference between the two. Percent improvement had significant negative correlations with the following factors: duration of illness, baseline Y-BOCS, HAM-A, and BDI. We conclude that rTMS over either right DLPFC or OFC has a therapeutic effect on OCD symptoms. Patients with lower Y-BOCS and fewer comorbidities responded best to rTMS.

Comorbidities and outcomes among patients hospitalized with COVID-19 in Upper Egypt.

Background: The coronavirus disease 19 (COVID-19) pandemic has spread rapidly around the globe with considerable morbidity and mortality. Coexistence of comorbidities with COVID-19 had consistently been reported as risk factors for unfavorable outcome. We aimed to evaluate the impact of comorbidities in COVID-19 patients on the outcome and determine predictors of prolonged hospital stay, requisite for intensive care unit (ICU) admission. Four hundred and thirty-nine adult patients who are admitted through (June and July 2020) in our University Hospitals were included in the study. All participants were diagnosed with COVID-19 according to Egyptian Ministry of Health guidance as definite case or probable case. Results: Patients with comorbidities represented 61.7% of all cases. Constitutional symptoms especially myalgia and lower respiratory tract (LRT) symptoms such as dyspnea were significantly higher in patients with comorbidities (P < 0.05). Patients with comorbidities had significantly worse laboratory parameters. ICU admission was higher in patients with comorbidities (35.8%). Among different comorbidities 45.4% of cardiovascular diseases (CVD) cases were admitted in ICU followed by diabetes mellitus (DM) cases (40.8%). Also, patients with comorbidities needed invasive mechanical ventilation more than those without comorbidity (31 versus 10.7%, P < 0.001). Significant lower frequency of recovery was found in COVID-19 patients with comorbidities (59% versus 81%, P < 0.001) and death rate was significantly higher in cases with comorbidities (P < 0.001) . The survival rates in cases with pre-existing CVD and neurological diseases were lower than those without disease (P < 0.002 and 0.001, respectively). Conclusions: Association of cardiovascular comorbid conditions including hypertension or neurological diseases including old cerebrovascular strokes together with COVID-19 infections carries higher risks of mortality. However, other comorbidities such as diabetes mellitus, chronic pulmonary or kidney diseases may also contribute to increased COVID-19 severity.

Cerebrovascular function in tension-type headache and migraine with or without aura: Transcranial Doppler study.

The aim of the current study was to determine whether tension-type headache (TTH) and migraine with or without aura have altered anterior and posterior circulation compared with normal volunteers as assessed by Transcranial Doppler (TCD) ultrasonography. The study included 24 patients with chronic TTH and 37 patients with migraine (16 with aura and 21 without aura) classified according to the diagnostic criteria of the International Headache Society 2018. They were compared with a control group of 50 age- and sex-matched healthy volunteers. Each participant was examined with TCD ultrasonography of the middle, anterior and posterior cerebral and vertebral arteries (MCA, ACA, PCA, and VA) at rest. Patients in the TTH group had a significantly lower peak systolic velocity (PSV) and mean flow velocity (MFV) in the MCA compared with controls, whereas EDV and MFV in the ACA were significantly higher in the migraine without aura group than controls. Within the 3 groups of patients, the TTH group had significantly lower PSV in the MCA and PCA than the group of migraine with aura. In addition, the TTH group had significantly lower PSV and MFV in the MCA and a lower EDV in the VA than migraine patients without aura. In conclusion, the possibility of cerebrovascular changes is confirmed in the present study in both TTH and migraine without aura. The former has a low MFV in the MCA whereas the latter has a high MFV in the ACA.

Alteration of Gut Microbiota in Alzheimer's Disease and Their Relation to the Cognitive Impairment.

BACKGROUND: Dysbiosis of gut microbiota has been reported to be enrolled in the pathogenesis of Alzheimer's disease (AD). However, there is a lack of relevant studies on this topic in Egyptian patients with AD. OBJECTIVE: To investigate different species of gut microbiota in Egyptian patients with AD and correlate microbiota bacterial abundance with clinical data. METHODS: The study included 25 patients with AD and 25 healthy volunteers as age and sex-matched controls. Clinical data was taken for each patient, including medical history and examination; Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were assessed for each participant. Bacterial DNA was extracted from stool, and abundance quantified via qPCR using 16S rRNA group-specific primers. RESULTS: Akkermansia, Enterobacteria, Bacteroidetes, Bacillus cereus, Prevotella, and Clostridium cluster IV were more abundant in the AD group than in the control group, although there was significantly less abundance of Bifidobacterium spp., Firmicutes, and Actinobacteria in patients with AD than in controls, whereas no such significance was found for lactic acid bacteria between both groups. Lactic acid bacteria and Prevotella abundance was negatively correlated with cognitive impairment (p = 0.03 with MMSE, and p = 0.03 with MoCA). Prevotella abundance was positively correlated with age of onset and duration of illness and negatively correlated with smoking and coronary heart disease (p = 0.007, p = 0.03, p = 0.035, and p = 0.047, respectively). CONCLUSION: The current work highlighted a significant relationship between AD and gut microbiota dysbiosis. A higher abundance of Prevotella species and lactic acid bacteria was correlated with cognition.

Effects of transcranial direct current stimulation in pain and opioid consumption after spine surgery.

BACKGROUND: Transcranial direct current stimulation (tDCS) has shown promising results in alleviating different types of pain. The present study compares the efficacy of three sessions of anodal tDCS applied over primary motor area (M1) or the left dorsolateral prefrontal cortex (DLPFC) or sham on reducing pain and the total opioid consumption in postoperative spine surgery patients. MATERIALS: Sixty-seven out of 75 eligible patients for postoperative spine surgery were randomly allocated into one of the three experimental groups. Group A received anodal tDCS applied over M1 cortex, group B over left DLPF cortex (2 mA, 20 min) and group C received sham tDCS, all for 3 consecutive postoperative days. Patients were evaluated using a visual analogue scale (VAS) and adynamic visual analogue scale (DVAS) at baseline, and on each of the treatment days. The total morphine consumption over the 3 postoperative days was assessed. RESULTS: Two-way repeated measures ANOVA showed no statistically significant difference in resting VAS between the three groups. However, there was significant pain improvement (P < 0.001) in DVAS in both active groups (group A and B) compared to the sham group (group C) in the postoperative period, with no significant difference between the active groups. Morphine consumption was significantly reduced in both active groups compared with the sham group, but there was no difference in consumption between the active groups. CONCLUSION: There was a significant postoperative reduction in morphine consumption and DVAS scores after three sessions of active tDCS. SIGNIFICANCE: tDCS is a promising tool for alleviating pain in the field of postoperative spine surgery.

Fatigue and brain atrophy in Egyptian patients with relapsing remitting multiple sclerosis.

BACKGROUND: Fatigue is the most troublesome symptom in relapsing remitting multiple sclerosis (RRMS). It starts early in the disease course, escalates with disease progression and impacts the patients` quality of life. The aim of this work was to estimate the frequency of fatigue and to evaluate the relationship between severity of fatigue, clinical data, level of disability and volumetric brain atrophy in RRMS. METHODS: 43 RRMS patients with 40 age- and sex-matched normal volunteers were recruited. Demographic and clinical data were recorded. Each participant was assessed with the Expanded Disability Status Scale (EDSS), Fatigue Severity Scale (FSS), Brief Cognitive Assessment for Multiple Sclerosis (BICAMS) and a variety of brain volumetric measures. RESULTS: 31 (72.1%) of RRMS patients were found to have fatigue. There were no significant differences in demographic data between patients with or without fatigue according to FSS. However, patients with fatigue had a higher number of attacks, and higher scores in the EDSS and BICAMS than non-fatigued patients. There was a greater reduction in total brain volume, cerebral grey matter, and brain stem, thalamic and caudate volumes in fatigued compared with the non-fatigued patients and controls. FSS was significantly correlated with patients' age, duration of illness, total number of attacks, EDSS, and BICAMS. Total brain, cerebral grey matter and thalamic volumes all had negative correlations with fatigue severity. Regression analysis showed that EDSS accounted for 46% of the variance in fatigue scores while thalamic and brainstem atrophy accounted for 50.7%. CONCLUSION: Fatigue was fairly common in RRMS patients. Level of disability and atrophy of the thalamus and brain stem were the best predictors of fatigue.