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.

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.

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.

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.

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.

Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience.

BACKGROUND: Randomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications. OBJECTIVE: To study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD. METHODS: Prospectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up. RESULTS: A total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2-20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3-14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke. CONCLUSION: Our study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.

Cognitive Impairment, P300, and Transforming Growth Factor ß1 in Different Forms of Dementia.

BACKGROUND: There are currently few biomarkers to assist in early diagnosis of dementias. OBJECTIVE: To distinguish between different dementias: Alzheimer's disease (AD), vascular dementia (VaD), and Parkinson's disease dementia (PDD) using simple neurophysiologic (P300) and laboratory markers (transforming growth factor ß1 "TGF-ß1"). METHODS: The study included 15 patients for each type of dementia and 25 age- and sex-matched control subjects. Dementia patients were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition-revised (DSM-IV-R). Modified Mini-Mental State Examination (3MS), Memory Assessment Scale (MAS), P300, and TGF-ß1 were examined for each participant. RESULTS: There were no significant differences between groups as regard to age, sex, and education, social, and economic levels. Significant differences between groups were observed in registration and naming variables of the 3MS. Compared with the control group, P300 latency was prolonged in all groups, although to a greater extent in AD and PDD than in VaD. A serum level of TGF-ß1 was significantly elevated in all groups but was significantly higher in AD and VaD than in PDD. 3MS tended to correlate with P300 more than TGF-ß1, and to be stronger in AD than the other groups. CONCLUSION: Measurements of P300 latency and serum levels of TGF-ß1 can help distinguish AD, PDD, and VaD. P300 was more prolonged in AD and PDD than VaD whereas TGF-ß1 was significantly higher in AD and VaD than PDD. Thus P300 and TGF-ß1 may be useful biomarkers for detection and evaluation of the extent of cognitive dysfunction.

Prevalence of cervical and lumbosacral compressive radiculopathies in Qena governorate/Egypt: Population-based survey.

OBJECTIVES: The aim of the study was to estimate the crude prevalence rate (CPR) of compressive radiculopathies in Qena governorate/Egypt. PATIENTS AND METHODS: 10 areas in Qena governorate were selected by random sampling, involving 9303 inhabitants with 57.3% urban residents and 42.7% rural residence. Patients were diagnosed using a screening questionnaire for the diagnosis of cervical and lumbosacral radiculopathies. All positive cases were referred to Qena University Hospital where they underwent full neurological examination, neuro-imaging, and neurophysiological investigations. RESULTS: Out of 9303 inhabitants included in the study (1057 families), 49 cases were recruited positive on initial survey and 32 cases were confirmed after clinical examination, neuroimaging and neurophysiological examinations, giving a CPR of 10.1/1000 in those aged over 30 years. Compressive radiculopathy was more common in males than females (13 versus 6/1000) and in rural than urban populations (15 versus 7/1000). No cases were recruited below 30 years old. The highest age specific prevalence was at ≥60 years with a CPR of 26/1000. 11 cases had cervical radiculopathy while 21 cases had lumbosacral radiculopathy (CPR of 3.7 and 6.6/1000 respectively). The highest age specific CPR for males was earlier than females at 50-59 versus ≥60 years. CONCLUSION: The overall CPR of compressive radiculopathy in the general population in Qena governorate/Egypt is similar for cervical radiculopathy but higher for lumbosacral radiculopathy than a previous Egyptian study but mid-way compared to other countries.

Prognostic role of neurophysiological testing 3-7 days after onset of acute unilateral Bell's palsy.

OBJECTIVE: Recovery from acute Bell's palsy (BP) is variable and there are few predictors of response. We evaluated the usefulness of a range of neurophysiological parameters to predict outcome in BP. METHODS: Fifty-nine patients (age: 33.7±15.4 years) with acute unilateral BP were recruited within 3-7 days of onset. They were evaluated with electroneurography, facial nerve excitability, and the blink reflex. House-Brackmann (HB) clinical scores were obtained at the same time and three months later. All patients received prednisolone treatment and regular rehabilitation. RESULTS: At three months, 41 patients (69.5%) had good recovery, while 18 patients (30.5%) had poor recovery according to the HB scale. The facial nerve excitability threshold and threshold difference between sides were significantly lower in patients with good recovery than those with poor recovery (P values=0.022 and 0.006 respectively). Facial nerve degeneration rate (1 - affected/unaffected amplitude of CMAP of muscle ×100%) recorded in frontalis (P=0.002) and orbicularis oris (P=0.038) were also smaller in good recovery than poor recovery patients. There were no differences in latency and amplitude of CMAPs recorded from frontalis or orbicularis oris muscle, nor in latencies of the components of the blink reflex. ROC analysis showed that patients who had a threshold side difference <13mA (35 cases), had a higher chance of good recovery (85.7% versus 14.3% poor recovery). Patients who had a degeneration rate<50% (38 cases) also had a higher chance of good recovery (78.9%) versus 21.1% who had poor recovery, while patients with a degeneration rate>50% (21 cases) had a 47.8% chance of good recovery versus 52.2% poor recovery (P=0.004). Logistic regression analysis showed that the most significant predictive indicator of BP recovery was the facial nerve degeneration rate of frontalis muscle (P=0.011). CONCLUSION: Facial nerve degeneration rate of frontalis muscle provides the most sensitive prognostic indicator of recovery from acute BP and may provide useful management strategies.

Prevalence of neuromuscular disorders in Qena governorate/Egypt: population-based survey.

BACKGROUND: Few epidemiological studies of the prevalence of neuromuscular disorders have been undertaken. The aim of the study was to estimate the prevalence of the most common types of neuromuscular disorders in Qena governorate/Egypt. METHODS: A random sample was taken from 11 districts, involving 9303 inhabitants with 57.3% urban residents and 42.7% rural residence. Patients were diagnosed using a screening questionnaire for the diagnosis of neuromuscular disorders. All positive cases were referred to Qena University hospital where they underwent full clinical, electrophysiological, and laboratory investigations. RESULTS: Out of 9303 participants 448 cases were identified positive during survey. Four hundred and twenty-six cases proved to have neuromuscular disorders giving a crude prevalence rate (CPR) of 4.57%; 408 cases had definite neuropathy and 18 cases had muscular disorders equivalent to CPR of 4.39% and 193/105 respectively. There was a higher prevalence in the rural than urban population. The CPR of focal compression neuropathies was 1.8%, with the majority of cases having carpal tunnel syndrome (CPR = 1.67%). CPR of diabetic neuropathy was 1.67%. The CPR of compressive radiculopathy was 0.34%. Traumatic nerve injury had a CPR 0.06%. The lifetime prevalence of Bell's palsy was 0.16%. Hereditary motor and sensory neuropathy had a CPR 0.08%. The CPR of idiopathic neuropathy was 0.09% and Infective Leprotic neuropathy was 0.04%. Five patients were diagnosed as having muscular dystrophy and another 5 patients had myotonia with CPR of 54/105 for each. Two cases of myasthenia gravis and another two cases with systemic myopathy were recorded giving a CPR of 21/105. CONCLUSION: The overall CPR of neuromuscular disorders in the general population in Qena governorate/Egypt was higher than reported in other countries.

Prevalence of Bell's palsy in Qena Governorate, Egypt.

BACKGROUND AND PURPOSE: There have been few studies to estimate the prevalence of Bell's palsy (BP) in Arab countries. A community-based study was conducted to estimate the prevalence, incidence rates, precipitating factors, and outcome of BP in Qena Governorate, Egypt. SUBJECTS AND METHODS: A door-to-door survey was carried out, with random sampling of 10 districts, involving 9303 inhabitants, 51.1% males and 48.9% females. Seventeen subjects were positive in screening questionnaire and referred to Qena University hospital and were subjected to a full clinical examination, House Brackmann's Facial grading system. RESULTS: In a total population of 9303 individuals, 15 cases were confirmed as having BP giving a prevalence rate (PR) 161/10(5) for all ages 95%CI (80-243). It was slightly but not significantly higher among women and the rural community. The incidence rate of BP was 107/10(5). The highest age-specific rate was 40-49 years age. The most frequent precipitating factors for an episode of BP were exposure to air draft in 40%, physical stress (13.3%), and upper respiratory tract infection (13.3%). Moreover, 46.7% had predisposing risk factors, DM and hypertension in 33.3%. Sixty percent of cases had complication and poor outcome. CONCLUSION: The overall prevalence and incidence rates of BP in Qena governorate were high. This could be related to the variation in day and night temperature in our community and the susceptibility to air draft exposure during the night. The high frequency of poor outcome among studied cases suggests that better local guidelines should be implemented to recognize and treat BP.

Prevalence of Common Types of Compression Neuropathies in Qena Governorate/Egypt: A Population-Based Survey.

BACKGROUND: No epidemiological studies on the prevalence of compressive neuropathy have been undertaken in Arab countries. The aim of the study was to estimate the prevalence of the most common types of compressive neuropathies in Qena governorate/Egypt. METHODS: The study was part of a community-based survey carried out to assess the prevalence of neuromuscular disorders among the Qena population. A random sampling of 10 districts, 5,039 inhabitants aged ≥20. There were 3,050 urban residents (60.5%) and 1,989 (39.5%) from the rural community. Patients were diagnosed using a screening questionnaire for diagnosis of entrapment neuropathies. Positive cases were referred to the Qena University Hospital. They were given full clinical, electrophysiological and laboratory investigations. RESULTS: Compressive neuropathy was recorded in 165 cases giving a CPR = 3.3% of population at risk (≥20 years). Carpal tunnel syndrome (CTS) was diagnosed in 155 cases giving a CPR = 3.1% with a significantly higher prevalence among females than males (5.3 vs. 0.9%) and in rural compared with urban populations (4.6 vs. 2.1%). Ulnar neuropathy at the elbow was the second common type of entrapment with a CPR = 0.1% followed by radial nerve palsy, tarsal tunnel syndrome and common peroneal nerve palsy. CONCLUSION: The overall crude prevalence rate of CTS is comparable with that in other countries.

Prevalence of Diabetes and Diabetic Neuropathy in Qena Governorate: Population-Based Survey.

BACKGROUND: No previous study was done to estimate the prevalence of diabetic neuropathy (DN) in Arabic countries. The aim of this study was to estimate the prevalence of DN and its characteristics in Qena governorate. MATERIAL AND METHODS: This is a random sampling of 10 study areas, involving 9,303 inhabitants; 51.1% men and 48.9% women were recruited. There were 57.3% urban residents and 42.7% rural residents. Patients were diagnosed using a screening questionnaire for diabetes mellitus (DM) as well as for DN in addition to measuring blood sugar in suspected cases. All positive cases were referred to Qena University Hospital and were subjected to full clinical, electrophysiological and laboratory investigations. RESULTS: Out of 9,303 people screened, 837 were diabetic giving prevalence 8.99% of the population. Eight hundred eleven had type II DM and 26 cases had type I giving prevalence of 8.7 and 0.3%, respectively. One hundred fifty-five out of 837 (18.5%) diabetic patients had evidence of DN with prevalence rate being 1.7% of the total population. Diabetic polyneuropathy was the commonest type with prevalence 1.5%. The prevalence of DN was higher in women than in men. Rural residents had significantly higher prevalence of DN compared to urban residents (1.9 vs. 1.4) and illiterate population more than educated (5.8 vs. 1.2). CONCLUSION: The overall crude prevalence rate of DM and DN is nearly the same as in European countries and lower than that in other Arabic countries.