Bassem Yamout

Bone marrow mesenchymal stem cell transplantation in patients with multiple sclerosis: A pilot study☆

We explore the safety, and therapeutic benefit of intrathecal injection of ex-vivo expanded autologous bone marrow derived mesenchymal stem cells (BM-MSCs) in 10 patients with advanced multiple sclerosis (MS). Patients were assessed at 3, 6 and 12 months. Assessment at 3-6 months revealed Expanded Disability Scale Score (EDSS) improvement in 5/7, stabilization in 1/7, and worsening in 1/7 patients. MRI at 3 months revealed new or enlarging lesions in 5/7 and Gadolinium (Gd+) enhancing lesions in 3/7 patients. Vision and low contrast sensitivity testing at 3 months showed improvement in 5/6 and worsening in 1/6 patients. Early results show hints of clinical but not radiological efficacy and evidence of safety with no serious adverse events.

Predictors of bone density in ambulatory patients on antiepileptic drugs

BACKGROUND AND AIM Antiepileptic drugs are associated with bone loss and fractures. Data in children is scarce and the impact of new therapies and of low vitamin D is not clear. This study assessed predictors of bone mineral density (BMD) in 225 ambulatory patients with epilepsy. METHODS BMD and detailed clinical information were obtained from 137 adults mean age of 31 years, on therapy for a mean of 11.7 years, and 88 children mean age of 13 years, on therapy for an average of 4.7 years. RESULTS Hypovitaminosis D was common in epileptic patients. BMD was reduced in adults but not children with epilepsy, by 0.3-0.6 SD depending on the skeletal site measured, compared to controls. Duration of treatment, but not vitamin D levels, was negatively correlated with BMD at the hip in adults. Bone density was reduced with the use of both enzyme and non-enzyme-inducing drugs, with both mono- and polytherapy, and was most severely reduced at the spine and hip with the use of enzyme-inducing drugs. In the multivariate analyses, polytherapy in children and duration of therapy and enzyme-inducing drugs in adults were independent predictors of BMD. CONCLUSION Antiepileptic drug therapy is associated with low bone density at clinically relevant skeletal sites, projecting into a possible doubling of fracture risk. Age, therapy duration, polypharmacy and the use of enzyme-inducing drugs were risk factors. Newer drugs may be associated with deleterious effects on bone. Skeletal monitoring with varying intervals, depending on the individual risk profile, is indicated.

Extracranial venous stenosis is an unlikely cause of multiple sclerosis.

Background: Extracranial venous stenosis (EVS) has recently been implicated as the primary cause of multiple sclerosis (MS). Objective: The aim of this study was to determine the presence of EVS in MS patients. Methods: We performed selective extracranial venography on 42 patients with early MS (EMS): clinically isolated syndrome (CIS) or relapsing—remitting MS (RRMS) of less than 5 years duration, and late MS (LMS): RRMS of more than 10 years duration. Magnetic resonance imaging (MRI) and clinical relapse data were reviewed for all patients with EVS. Results: EVS was present in 7/29 patients with EMS and 12/13 patients with LMS, a highly significant statistical difference (p< 0.001). Only 3/42 patients (all in the LMS group) had two vessel stenoses, while the rest had only one vessel involved. EVS was seen in 1/11 patients with CIS compared with 6/18 RRMS patients of less than 5 years duration. Disease duration was greater in patients with EVS overall (p < 0.005). LMS remained an independent predictor of EVS following multivariate adjustment for gender, age at disease onset and Expanded Disability Status Scale (EDSS) (Adjusted Odds Ratio = 29 (3—298); p = 0.005]. Within the EMS group, patients with (n = 7) and without (n = 22) EVS had similar EDSS and disease duration, suggesting similar disease severity. No clear correlation could be found between site of EVS and anatomic localization of either clinical relapses or MRI gadolinium-enhancing lesions. Conclusions: We conclude that EVS is an unlikely cause of MS since it is not present in most patients early in the disease and rarely involves more than one extracranial vein. It is likely to be a late secondary phenomenon.

Prolactin Secretion is Increased in Patients with Multiple Sclerosis

Before the onset and during experimental allergic encephalomyelitis (EAE), the animal counterpart of multiple sclerosis (MS), prolactin levels were found to be elevated and bromocriptine was found to attenuate the attacks. This study was designed to determine whether patients with MS show evidence of hyperprolactinemia. Twelve patients with MS and twelve healthy controls were studied at baseline and with TRH stimulation, a provocative test for prolactin secretion. Compared to matched controls, patients with MS had slightly but significantly higher prolactin levels at baseline (10.2+/-1.6 vs 6.4 4+/-0.57 ng/ml, P=0.042), however, values were within the normal range. The prolactin levels post TRH were significantly higher in patients with MS: peak prolactin level was higher in patients than controls (57.08+/-6.144 vs 32.94+/-4.92 ng/ml, P=0.006). The area under the curve of prolactin was also higher in patients than in controls (3421.87+/-394.53 vs 2317.62+/-257.22 ng/ml, P=0.030). These findings are compatible with data from studies of experimental animals with MS and suggest that prolactin may play a role in the immunology of MS.

Clinical characteristics of multiple sclerosis in Lebanon

The epidemiologic, clinical, radiological and laboratory characterization of multiple sclerosis (MS) is very well documented in Caucasian and Japanese populations, but very little is known about MS in the Arab world. Such knowledge is becoming of paramount importance, with the recent advances in therapies, MRI techniques and other diagnostic procedures. We report a cohort of Lebanese MS patients, including details of their clinical and laboratory characteristics. The medical records of 202 patients fulfilling the Mc Donalds diagnostic criteria, and followed in our tertiary care center were reviewed. This cohort is highly representative of the disease in Lebanon where the number of MS patients is estimated to be between 1200 and 1700. The peak age of onset of MS in our cohort was in the third decade with 62.4% of patients developing their first symptoms between 20 and 39 years. The female/male ratio was 1.8/1.0. A positive family history for MS was present in 5% of patients. The most frequent presenting symptoms were brainstem-cerebellar (46.2%) followed by sensory (42.5%), motor (33.9%) and visual (29.6%). Of the total number of patients, 85.1% had relapsing remitting MS at onset, and 7.9% primary progressive MS. Benign MS defined as EDSS<=2.0 after 10 years from onset was present in 20% of patients. The mean time from onset to secondary progressive MS was around 9 years. Visual, brainstem, and somatosensory evoked potentials were abnormal in 65.6%, 27.8%, and 50.7% of patients tested respectively. Cerebrospinal fluid showed pleocytosis in 32.6%, increased IgG synthesis in 45.2%, positive oligoclonal bands in 40%, and elevated protein in 34% of patients tested. Although some of the clinical characteristics of our MS population were different compared to western series, the natural history of the disease was similar.

The effect of war stress on multiple sclerosis exacerbations and radiological disease activity

OBJECTIVE The relationship between stressful life events and multiple sclerosis (MS) exacerbations or radiological disease activity is at best controversial. The aim of this study is to examine the relationship between exposure to war-related events incurred during the July 2006 Israeli-Lebanese war and clinical relapses and MRI disease activity among Lebanese MS patients. METHODS We studied a group of 216 patients with clinically definite relapsing remitting MS (RRMS), on whom clinical data was available for the war period and for the preceding and following year(s). The number of relapses was determined during the war period and during similar periods over a 3-year span. All patients with brain MRI during the war period had their scans reviewed for evidence of disease activity as defined by the presence of gadolinium enhancing (Gd+) lesions. A group of patients with brain MRI performed outside the war period was used for comparison. RESULTS The total number of relapses during the war period (n=23) was significantly higher than during non-war periods (mean=8.4, SD=0.86) (p=0.006). Of the 18 patients with brain MRI during the war, 5/7 with relapses and 1/11 without relapses had Gd+ lesions (p=0.013). More patients had Gd+ lesions during the war period (33%) compared to controls (13%) (p=0.075). INTERPRETATION Our study shows that exposure to war-related events is likely to lead to an increase in both clinical relapses and MRI disease activity in patients with MS.

Meralgia paresthetica as a complication of laparoscopic cholecystectomy.

Many complications have been reported to occur secondary to laparoscopic cholecystectomy. We report here the first case of meralgia paresthetica during laparoscopic abdominal surgery.

MR imaging findings in autosomal recessive hereditary spastic paraplegia.

BACKGROUND AND PURPOSE: Hereditary spastic paraplegia (HSP) is a disorder characterized by degeneration of the corticospinal tracts and posterior column of the spinal cord. Previously described radiologic findings included nonspecific brain abnormalities such as brain atrophy and white matter lesions, as well as atrophy of the spinal cord. In our study, we aimed to better characterize brain and spine MR imaging findings in a series of patients with HSP. MATERIALS AND METHODS: Nine patients from 4 different Lebanese families with the autosomal recessive form of HSP were included in the study. All patients underwent brain and whole-spine MR imaging. We assessed the presence of white matter abnormalities mainly along the corticospinal tracts, brain atrophy, thinning of the corpus callosum, and the presence of spinal cord atrophy or abnormal signal intensity. RESULTS: Imaging revealed mild brain atrophy (44%), atrophy of the corpus callosum (55%), white matter lesions (67%), abnormal T2 high signal intensity in the posterior limb of the internal capsule (55%), and mild spinal cord atrophy (33%). CONCLUSIONS: The MR imaging findings of HSP are nonspecific and variable; however, the most prominent features include atrophy of the corpus callosum, T2 signal intensity in the posterior limb of the internal capsule, and spinal cord atrophy.

Prognostic Factors of Multiple Sclerosis in Lebanon

ABSTRACT Background: Multiple sclerosis (MS) has a variable disease course. Identifying early predictive prognostic factors is of paramount importance. Most of the data on these factors however comes from studies performed in western countries. Such data is lacking in the Arab World. The objective of this study is to identify early predictors of disability among MS patients in Lebanon. Methods: 75 relapsing-remitting MS patients with 5 year follow-up from disease onset were selected from Project MS Lebanon database. The following parameters were studied as potential causes of early disability as defined by an EDSS ≥3, after five years from disease onset: age at onset of MS, gender, interval between first and second attack, residual deficit after first attack, initial symptoms, treatment for at least 1 year in the first 5 years, and the number of relapses in the first 2 and 5 years. Results: Patients with incomplete recovery from the first relapse were 11.66 times more likely to have a higher EDSS after 5 years (CI = 2.02–67.31, p = .001). Furthermore, the number of relapses during the first 5 years was also an independent predictor of EDSS ≥ 3 at 5 years (p = .024). Other factors were not shown to predict a worse outcome. Conclusion: Overall, early predictors of disability in MS among the Lebanese population were not very different from similar predictors in western countries.

Consensus guidelines for the diagnosis and treatment of multiple sclerosis

Abstract The diagnosis of multiple sclerosis (MS) is dependent on the presence of clinical and paraclinical evidence demonstrating dissemination of central nervous system lesions in both space and time, as well as the exclusion of other disorders. Diagnostic criteria were originally promulgated in 1965 by the Schumacher committee and modified subsequently by the Poser committee to include paraclinical evidence. The most recent criteria are the 2010 modifications of the 2001 McDonald criteria, which are focused on making an earlier diagnosis of MS. This article provides guidelines, derived from clinical experience as well as evidence-based medicine, for the diagnosis and management of MS with special emphasis on practices in the Middle East.