Samar Farouk Ahmed

Increasing prevalence and incidence rates of multiple sclerosis in Kuwait

Background: Kuwait was considered as low to intermediate risk area for MS. Objectives: To determine the prevalence and incidence rates of MS among Kuwaiti nationals based on 2011 population census. Methods: This cross-sectional study was conducted between October 2010 and April 2013 using the newly developed national MS registry in Kuwait. Patients with a diagnosis of MS according to 2010 revised McDonald criteria were identified. The crude, age- and sex-specific prevalence and incidence rates among Kuwaiti patients were calculated. Results: 1176 MS patients were identified of which 927 (78.8%) were Kuwaitis and 249 (21.2%) were expatriates. Among Kuwaiti patients, female to male ratio was 1.8:1 with a mean age of 35.40 ± 10.99 years. The prevalence rate of MS was 85.05 per 100,000 persons (95% CI: 82.80 – 87.04). There was a peak in prevalence among patients aged 30–39 years. The incidence of MS was 6.88 per 100,000 persons (95% CI 5.52–8.55). Between 2003 and 2011, the incidence increased 3.22 and 2.54 times in women and men respectively. Conclusion: Kuwait is considered a high-risk area for MS. The significant increase in prevalence and incidence rates may represent a true increase despite the improvement in case ascertainment and case definition.

Predictors of Conversion to Multiple Sclerosis in Patients with Clinical Isolated Syndrome Using the 2010 Revised McDonald Criteria

Background. Clinically isolated syndrome (CIS) is the first neurologic episode of multiple sclerosis (MS). Magnetic resonance imaging (MRI) and clinical features are used to predict risk of conversion to MS. Objectives. The aim of this prospective study is to evaluate predictors of conversion of CIS to McDonald MS. Method. 97 patients with CIS have been followed for 2 years. Age of onset, gender, initial clinical presentation, and MRI brain and spine were assessed. The 2010 revised McDonald criteria were applied. Results. Fifty-nine patients (60.8%) with CIS converted to McDonald MS after 10.1 + 4.2 months. Thirty-seven (38.1%) of the convertors satisfied the diagnostic criteria based on the radiological parameters, while 21.7% sustained their second clinical events. A multivariate regression analysis revealed that high number of lesions in MRI (P = 0.001) and earlier age of onset (P = 0.043) predicted the conversion of CIS to McDonald MS. Gender (P = 0.5) and initial clinical presentation (optic pathway (P = 0.4), supratentorial (P = 0.91), brain stem/ cerebellum (P = 0.97), and spinal (P = 0.76)) were not statistically significant. Conclusion. Age of onset and MRI parameters can be used as predictors of CIS conversion to McDonald MS. Application of the 2010 revised McDonald criteria allows an earlier MS diagnosis.

Early versus Late Surgical Treatment for Neurogenic Thoracic Outlet Syndrome

Objectives. To compare the outcome of early surgical intervention versus late surgical treatment in cases of neurogenic thoracic outlet syndrome (NTOS). Design. Prospective study. Settings. Secondary care (Al-Minia University Hospital, Egypt) from 2007 to 2010. Participants. Thirty-five patients of NTOS (25 women and 10 men, aged 20–52 years), were classified into 2 groups. First group (20 patients) was operated within 3 months of the onset and the second group (15 patients) was operated 6 months after physiotherapy. Interventions. All patients were operated via supraclavicular surgical approach. Outcomes Measures. Both groups were evaluated clinically and, neurophysiologically and answered the disabilities of the arm, shoulder, and hand (DASH) questionnaire preoperatively and 6 months after the surgery. Results. Paraesthesia, pain, and sensory nerve action potential (SNAP) of ulnar nerve were significantly improved in group one. Muscle weakness and denervation in electromyography EMG were less frequent in group one. The postoperative DASH score improved in both groups but it was less significant in group two (P < .001 in group 1 and P < .05 in group 2). Conclusions. Surgical treatment of NTOS improves functional disability and stop degeneration of the nerves. Early surgical treatment decreases the occurrence of muscle wasting and denervation of nerves compared to late surgery.

Incidence and prevalence of pediatric onset multiple sclerosis in Kuwait: 1994-2013.

OBJECTIVES This study aimed to assess the incidence and prevalence of pediatric-onset multiple sclerosis (POMS) along with temporal and gender differentials in these estimates in Kuwait. METHODS We identified MS patients with pediatric (age <18 years) onset between 1994 and 2013 from national MS registry. Year and gender-specific incidence rate and prevalence estimates were computed. Multivariable Poisson regression analyses of time-series cross-sectional panel data were conducted to evaluate temporal and gender related variations in yearly POMS incidence rate and prevalence. RESULTS 122 POMS patients were identified; of which 90 (73.8%) were females. During 2013, POMS incidence rate and prevalence (per 100,000) were 2.1 and 6.0 respectively. Multivariable Poisson regression model revealed statistically significant 5% increase in POMS incidence rate (p=0.002) and 6% increase in prevalence (p<0.001) from 1994 to 2013. Furthermore, during the study period, female children were more likely to have higher POMS incidence rate (relative rate=2.9; p<0.001) and prevalence (prevalence ratio=2.8; p<0.001). CONCLUSIONS The temporal increase and gender disparity in POMS incidence and prevalence corroborate the findings of earlier studies conducted elsewhere. Knowledge of increasing POMS burden may help in optimal planning for better management of patients in the region.

JC virus seroprevalence and seroconversion in multiple sclerosis cohort: A Middle-Eastern study

OBJECTIVES To estimate JCV seroprevalence and risk of seroconversion against JCV among MS patients in the Middle East. METHODS This multicenter study was conducted by implementing a cross-sectional design to assess JCV seroprevalence, and a longitudinal design to assess the risk of JCV seroconversion. Multivariable logistic and Poisson regression analyses were used to assess the relationship between clinical variables and JCV seropositivity and risk of seroconversion. RESULTS Of 581 MS patients, 64.9% patients were females. Mean age and mean disease duration were 33.9 and 8.4years respectively. JCV seroprevalence was 48.7%. Male gender (p=0.002), age at onset (p=0.001) and disease duration of 20 or more years (p=0.007) were significantly associated with JCV seropositivity. Among patients (n=125), followed longitudinally, the risk of JCV seroconversion was 17.6% (95% CI: 11.4%-25.4%) during a median follow-up of 18months. The proportion of seroreverted and pseudoconverted patients was 4% and 3.2% respectively. CONCLUSIONS JCV seroprevalence among MS patients in the Middle East was lower than international figures. Male gender, age at onset and disease duration were significantly associated with JCV seropositivity. Risk of JCV seroconversion was higher than previously reported figures. Observed JCV sero-reversion or pseudo-conversion entail watchful period before embarking on a clinical decision.

Status migrainosus as an initial presentation of multiple sclerosis

BackgroundDemyelinating plaques may induce headache through disruption of the pathways, which are implicated in the pathogeneses of migraine. We report a case of 25-year-old female patient, who presented with status migrainosus fulfilling the criteria of international classification of headache disorder. She was eventually diagnosed with multiple sclerosis (MS) after an extensive work-up and long-term clinical and radiological follow-up.FindingsAt the onset of status migrainosus, magnetic resonance imaging (MRI) revealed the presence of several demyelinating lesions fulfilling Swanton criteria. She was started on migraine prophylactic treatment but there was no subsequent response. One year later, she presented with recurrent status migrainosus and a follow-up MRI revealed multiple gadolinium-enhancing lesions in the brain. She was treated with abortive migraine medications. Within the following 2 year, she developed ascending parasthesia and weakness of both lower limbs indicative of incomplete transverse myelitis in association with recurrent status migrainosus. A diagnosis of MS was established based on a follow-up MRI that satisfied the revised 2010 McDonald criteria. Both the headache and neurological signs improved with IV methylprednisolone therapy. Her headache entered remission after initiation of a disease modifying therapy.ConclusionStatus migrainosus can be the initial presentation of MS. Unresponsiveness to migraine prophylactic therapy in the presence of active demyelinating plaque in MRI brain may pose a diagnostic challenge and a diagnosis of MS might be considered.

Clinical predictors of disease progression in multiple sclerosis patients with relapsing onset in a nation-wide cohort

Background: Predicting disease progression over time is challenging despite the available literature data. Aim: To assess whether baseline clinical variables of MS patients would predict the conversion to progressive phase of the disease. Materials & methods: Utilizing the national MS registry, patients who had relapsing onsets and had confirmed EDSS score at baseline and follow-up visits were included. Primary progressive MS and CIS patients were excluded. Clinical variables (gender, age at onset, disease duration, number of relapses, EDSS score) were collected. The end point was conversion to secondary progressive MS. Chi Square and multivariable logistic regression were used to determine the influence of clinical variables on disease progression. Results: Data of 803 MS patients with relapsing onset were analyzed. Eighty five (10.6%) patients reached the end point. The risk of disease progression was significantly higher in men (p = 0.015), in patients who developed MS ≥ 40 years of age (p = 0.041) and who had ≥ 3 relapses during their disease course (p < 0.001). Spinal cord presentation at onset was predictive of progression (aOR = 2.01; p = 0.06) while optic neuritis at onset was associated with lower risk of progression (aOR = 0.30; p = 0.03). EDSS score at first visit did not influence disease progression when tested at 2 different cutoffs (EDSS < 4 vs. ≥ 4 and EDSS < 6 vs. ≥ 6) using multivariable logistic regression analysis (p = 0.960 and p = 0.866), respectively. Conclusion: Men and patients who presented at age 40 yeas or beyond had increased risk of MS progression. Spinal cord symptoms at onset and 3 or more relapses were predictive of progression.

Relapse occurrence in women with multiple sclerosis during pregnancy in the new treatment era

Objective To determine the rate of relapse occurrence during pregnancy and postpartum. Methods In a cross-sectional study using the national multiple sclerosis (MS) registry, pregnant women with relapsing MS were identified. Data on demographics, clinical characteristics, and disease-modifying therapies (DMTs), including washout periods, were collected. Timings and durations of relapses were extracted. A multivariate logistic regression was used to assess the relationship between relapses and prior use of different DMTs. Results Completed data were available for 99 pregnancies (87 patients). Mean age and mean age at onset were 31.8 ± 5 and 24.4 ± 5.6 years, respectively, while the mean disease duration was 7.4 ± 4.6 years. Most pregnancies (89.9%) occurred in patients who were on DMTs in the year preceding pregnancy with a mean treatment duration of 63.4 ± 29 months. The rates of occurrence of relapses during pregnancy and postpartum were 17.2% and 13.7%, respectively. Most of the relapses occurred during the first (n = 6) and third (n = 7) trimesters. Rate of relapse was highest among patients receiving natalizumab and fingolimod before pregnancy. A longer washout period was significantly associated with relapse occurrence. Conclusion The relapse occurrence during pregnancy is higher than the previously published rates. The use of high-efficacy therapies with long washout periods before conception was associated with an increased risk of relapses during pregnancy. Postpartum relapse occurrence was similar to that in previous reports.

Use of fingolimod in patients with relapsing remitting multiple sclerosis in Kuwait

BACKGROUND Post-marketing studies are important to confirm what was established in clinical trials, and to assess the intermediate and long-term efficacy and safety. OBJECTIVE To assess efficacy and safety of fingolimod in multiple sclerosis (MS) in Kuwait. METHODS We retrospectively evaluated MS patients using the MS registries in 3 MS clinics. Relapsing remitting MS patients according to revised 2010 McDonald criteria who had been treated with fingolimod for at least 12 months were included. Primary endpoint was proportion of relapse-free patients at last follow-up. Secondary endpoints were mean change in EDSS and proportion of patients with MRI activity (gadolinium-enhancing or new/enlarging T2 lesions). RESULTS 76 patients met the inclusion criteria. Mean age and mean disease duration were 34.43 and 7.82 years respectively. Mean duration of exposure to fingolimod was 18.50 months. Proportion of relapse-free patients was 77.6% at last follow-up. Mean EDSS score significantly improved (2.93 versus 1.95; p<0.0001) while 17.1% of patients continued to have MRI activity versus 77.6% at baseline (p<0.0001). Four patients stopped fingolimod due to disease breakthrough (n=3) and lymphadenitis (n=1). CONCLUSION Fingolimod is safe and effective in reducing clinical and radiological disease activity in relapsing remitting MS patients. Our results are comparable to reported results of phase III studies.

Is Time to Reach EDSS 6.0 Faster in Patients with Late-Onset versus Young-Onset Multiple Sclerosis?

Background & Objectives Published natural history data on late-onset of multiple sclerosis are limited. We aimed to assess the risk of attaining EDSS 6.0 among patients with late-onset (> 40 years) MS (LOMS) and young-onset (18–40 years) MS (YOMS). Methods This cross-sectional cohort study was conducted to identify LOMS and YOMS patients’ with relapsing remitting course at MS diagnosis. Time (years) to reach sustained EDSS 6.0 was compared between LOMS and AOMS patients. Cox proportional hazards model was used to evaluate the demographic and clinical predictors of time to EDSS 6.0 in these cohorts. Results LOMS and YOMS cohorts comprised 99 (10.7%) and 804 (89.3%) patients respectively. Spinal cord presentation at MS onset was more common among LOMS patients (46.5% vs. 32.3%). The proportions of LOMS and YOMS patients reaching EDSS 6.0 during the follow-up period were 19.2% and 15.7% respectively. In multivariable Cox proportional hazards model, older age at MS onset (adjusted hazard ratio (aHR) = 3.96; 95% CI: 2.14–7.32; p < 0.001), male gender (aHR = 1.85; 95% CI: 1.22–2.81; p = 0.004) and spinal cord presentation at onset (aHR = 1.47; 95% CI: 0.98–2.21; p = 0.062) were significantly associated with shorter time to EDSS 6.0. Conclusions LOMS patients attained EDSS 6.0 in a significantly shorter period that was influenced by male gender and spinal cord presentation at MS onset.