Complementary and alternative medicine use among ischemic stroke survivors in Jeddah,Saudi Arabia

Objectives:To determine the prevalence and pattern of complementary and alternative medicine (CAM) use and the CAM types used by stroke patients in Jeddah, Kingdom of Saudi Arabia.Methods:This cross-sectional study included 152 ischemic stroke survivors who visited King Fahad Hospital, Jeddah, Kingdom of Saudi Arabia, between January 2018 and December 2019. Phone-based and face-to-face surveys were conducted. Data on the patients’ demographic characteristics, their use of CAM, and their pattern of CAM use were gatheredResults:Ninety (59.2%) stroke patients used CAM, mainly cauterization (29.61%) and Quran recitation by a religious sheik (28.95%). Most of the patients (72.22%) used CAM post-hospitalization and within less than one month from stroke onset (62.22%). A minority (6.67%) of the patients stopped their medication while on CAM. Some patients (25.56% to 31.11%) discussed with their physician their use of CAM. The CAM users reported a subjective improvement in their physical weakness (45.6%) and psychological wellbeing (62.2%). The patients learned about CAM mainly from their relatives and friends (96.7%), and the most common reason for their CAM use was their belief in this intervention (42.22%).Conclusion:The CAM use was prevalent among our cohort of Saudi ischemic stroke patients, and cauterization and Quran recitation were the most commonly used CAM interventions. An effective communication was lacking between the medical professionals and the stroke patients as regards CAM use despite the interest of the patients in this intervention.

Over the past 2 decades, the burden of stroke has increased globally.1 Stroke is the second leading cause of morbidity and mortality; the annual incidence of stroke is approximately 15 million, and over 5.5 million stroke-related deaths occur annually.2–4 Also, the prevalence of the modifiable risk factors of stroke is increasing, and the burden of stroke increases with the aging of the population.5 Adults aged >25 years have an estimated lifetime stroke risk of 24.9%.6 Despite the advancements in acute stroke care, highly effective treatments for the later phases of stroke are lacking. This shortcoming in the stroke care leads patients and their relatives to seek other treatment options, such as complementary and alternative medicine (CAM).7 The CAM is defined by the United State of America National Institutes of Health as “a group of diverse medical and health care systems, practices, and products that are not generally considered conventional medicine.”8 The CAM has been used for a long time now,9 and people widely practice CAM for various health conditions, such as cancer, epilepsy, multiple sclerosis, infertility, surgical procedure, dermatological conditions, hypertension, pain, and other types of illnesses.1,9–11 The prevalence of CAM use varies by country. For example, the prevalence of CAM use is 82% in the United States,12 61% in Australia,13 51% in Malaysia,14 and 61% in Turkey.15 Religion, cultures, and values influence the types and patterns of its use.16 People in Western countries practice herbal medicine, reflexology, aromatherapy, massage, osteopathy, meditation, and spiritual healing;10,17–19 by contrast, those in Asian countries such as China, India, and Taiwan commonly use therapies such as traditional Chinese medicine, Ayurvedic medicine, physical exercises, acupuncture, Tai Chi, yoga, and homeopathy.20–23 In Saudi Arabia, different types of CAM are used including the Quran recitation therapy, honey consumption, plant-based traditional medicine (e.g., Murrah and black seed consumption), cupping (“Hojamah”), and cauterization (“skin ironing”)9,24–27Research highlighted that aside from their potential benefits, some types of CAM have many side effects and potential toxicities, and patients are commonly unaware of these possible dangers.28 One study reported 2 cases wherein the cauterization led to severe complications, such as skin burn.29 Another study that investigated the components of herbal medicines in Saudi Arabia indicated that 15.7% of the tested samples contain toxic amounts of heavy metals, including arsenic and mercury.30 Despite the potential risk of many CAM interventions, it has been noted that many patients do not inform their physicians about their practice of CAM.31Stroke patients in many countries, including the United States (30.6%–46%)32,33 and South Korea (54%), use CAM.34 In Riyadh, Saudi Arabia, 67% of patients with neurological problems use CAM,9 and most of them use cupping (Hojamah) (45.4%), herbal medicine (42.3%), cauterization (33.7%), and Quran recitation (20.4%).9 However, no available study has analyzed the use of CAM particularly by stroke patients in Saudi Arabia. Thus, this study aimed to determine the prevalence and pattern of CAM use and the types of CAM being practiced by ischemic stroke patients relation to their demographic data.     

Awareness of Saudi community toward multiple sclerosis in Qassim Region,Saudi Arabia

Objectives:To evaluate the awareness of Saudis in Qassim region, Saudi Arabia on multiple sclerosis (MS).Methods:A cross-sectional study was conducted on 350 Saudis in Qassim, Saudi Arabia between January 2019 and June 2019 using a pre-designed questionnaire including socio-demographic data and questions evaluating knowledge about MS.Results:The majority of studied participants were adult females (74%), between 20-30 year-old (45.1%) and with high education level or above (80.6%). Nearly one third of the studied group had good knowledge regarding MS (31.7%). Half of the studied group knew that central nervous system (CNS) is the system affected by MS, 52% reported that vitamin D deficiency, family history of MS, personal history of autoimmune disease, viruses, and obesity are the factors which increase the risk of developing MS. Approximately, 62.9% knew that blurred and double vision, numbness, paralysis or weakness and difficulty in concentration and memorizing are symptoms of MS. Female participants and those knowing someone having MS had a significant good knowledge level regarding MS than others. Getting knowledge from combined sources from internet or social media; family, friends or neighbors and health workers was significantly more prevalent among those with good knowledge.Conclusion:Most of the study participants had limited knowledge regarding MS. Planning health education programs for the public is essential.

Multiple sclerosis (MS) is an inflammatory neurodegenerative disease affecting the central nervous system (CNS).1,2 Among middle-aged adults (between 20 and 40 years), MS is considered as one of the main life-long disability chronic neurological causes which causes expressive health care and economic loads. Women are at 3 to 4 folds increased risk to be affected by MS than men.3,4 Neurologically, the common manifestations are loss of coordination and balance, visual impairment, weakness, fatigue, numbness, pain, bladder dysfunction, mood changes, and cognitive dysfunction.5,6 Multiple sclerosis has a complex pathophysiology. It is widely recommended as an autoimmune disease, and is mediated by autoreactive lymphocytes that cross the blood-brain barrier (BBB) and enter the CNS, causing local inflammation; producing demyelination, gliotic scarring, and axonal loss.7 Pathophysiological concepts revealed that exposure to some infectious agents during childhood as well as genetics involvement played a role.8,9 Data reported that females were more affected by MS than males due to genetic predisposition.3 Increased risk of MS was related to some environmental factors like obesity, smoking, and low level of vitamin D.10 It was reported that breastfeeding for more than 4 months is associated with lower risk for multiple sclerosis.11 The etiology of the disease might be related to consanguinity and some local factors.12Recent epidemiological data indicated higher prevalence of MS in Arabian Gulf region, with increasing incidence in Kingdom of Saudi Arabia (KSA).12 In the Gulf area, environmental conditions on one side and modulated lifestyle practices in the other side were palmed as associated factors for increasing MS prevalence.12,13 The objectives of the first MS multicenter registration in KSA which was carried out between 2015 and 2018 were studying the epidemiology of MS, and its pattern besides studying its clinical findings in the whole country. The result of this registration was alarming and warranted prompt community health actions as it indicated an increasing prevalence of the disease in the whole Kingdom.15 Among Saudi nationality the prevalence was 61.95/100,000; whereas between the whole population it was 40.40/100,00016.According to the available literature, community awareness of MS is generally unacceptable. This affects a person’s perception of the disease, delaying the opportunity for early diagnosis and management. Furthermore, it is essential to increase community awareness of MS, as better public understanding of the facts of the disease will engage patients more in the community, and create social activity, education, and employment opportunities. The aim of this study is to evaluate the awareness and level of knowledge regarding MS among the residents of Qassim Region.     

Patterns and prognosis of Ventriculoperitoneal shunt malfunction among pediatrics in Saudi Arabia

Objectives:To examine the predictors of pediatric ventriculoperitoneal (VP) shunt malfunction in a university hospital.Methods:A retrospective cohort was conducted. Patients under 18 years old who underwent VP shunt revision at least once between 2016 and 2019 were included. Data were stratified based on age, gender, diagnosis, type of valve, valve position, cause of revision, and part revised.Results:A total of 45 patients (64% males and 36% females) were included in this study. Eighty-two revision surgeries were identified. The most common revised part was the entire shunt system. The most common type of valve which required revision was the low-pressure valve (15.5%). Since a p-value of less than 0.05 was considered significant, no significant differences among the 4 groups for different points.Conclusions:Younger age at initial VP shunt insertion is associated with a higher rate of shunt malfunction. Valve mechanical failures followed by infections are the most common causes for the first 3 revisions. A prospective multi-center study to confirm the current findings is recommended.

Ventriculoperitoneal (VP) shunt insertion is one of the most common procedures in pediatric neurosurgery for treating hydrocephalus.1 Among pediatric age group hydrocephalus is considered a common, surgically correctable condition in which there is an increase in the volume cerebrospinal fluid (CSF), leading to cerebral ventricles dilatation, thinning of the cerebral mantle, and elevation of intracranial pressure.2 Patients with VP shunts represent more than 30,000 hospital admissions per year.2 Although VP shunting has decreased the morbidity and mortality of hydrocephalus, it is still associated with multiple complications, many of which require surgical revision.1–4 Recent studies have reported the rate of complications following VP shunting to be between 30% and 50%.3–6 Shunt malfunctions causes can be categorized into infectious, mechanical, or functional.2–4 Shunt failure definition is revision or replacement of the original shunt between 30-days and 1-year.2 Mechanical failure can happen at the proximal end, valve, or distal end, and it includes obstruction, disconnection, fracture, distal end migration, or inflammation. Functional failure happens when there is overdrainage or underdrainage of cerebrospinal fluid while the whole shunt system is properly functioning. Infection happens when the patients demonstrate clinical findings and positive fluid sampling results.3 The most common complication necessitating revision are obstruction, infection, and displacement.2,3,6,7 Shunt failure is most common within the first 2 years postoperatively.3 Many important predictors of VP shunt failure have been reported in the literature, including etiologies of the hydrocephalus, prematurity, and age at the initial placement of the shunt.1,8,9 Clinical factors that may increase the risk of shunt revision include time from the first surgery, surgical procedure duration, prior treatments, number of surgeons, surgical expertise, surgical technique, anatomic site of the shunt, and diagnosis.1,7–10 Proximal catheter tip location is another predictor, as tip positions in the Foramen of Monro, lateral ventricles, or the third ventricle all were associated with lower rates of surgical revision.11 Other predictors of shunt failure were reported to be poor catheter placement and use of a non-programmable valve.12Previous studies have emphasized the need to identify children at risk, and for prospective cohorts to to investigate the relationship of risk factors and incidence of shunt revisions.1,9,10 Risk factors for VP shunt complications vary across institutions and populations, and a very limited number of studies addressing VP shunt malfunction have been conducted in Saudi Arabia, and only one in the last 10 years was published.13The goal of this study was to determine patterns and predictors of pediatric VP shunt malfunction, causes of the hydrocephalus and VP shunt revision and type of valve malfunction and define the best preventive measures. This knowledge will contribute to lowering the incidence of shunt malfunction, decreasing the number of surgeries, and increasing complication-free intervals between surgeries in hydrocephalic pediatric patients.     

Association between craniovertebral junction abnormalities and syringomyelia in patients with chiari malformation type-1

Objectives:To assess the correlation between craniovertebral junction (CVJ) abnormalities and syringomyelia in patients with Chiari malformation type-1 (CM1).Methods:This was a retrospective study including patients with CM1. Identification of cases was done by searching a radiology database at a university hospital from 2012 to 2017. Patients were divided into 2 groups based on whether CVJ abnormalities were present (CVJ+) or absent (CVJ-). The patients’ demographic and clinical data were reviewed. All magnetic resonance imaging studies were examined by a certified neuroradiologist.Results:Sixty-four consecutive patients with CM1 were included. The mean age was 24±17 years; 59% were females. The CVJ+ group had more female patients (p = 0.012). The most frequent CVJ abnormality was platybasia (71%), followed by short clivus (44%) and cervical kyphosis (33%). The CVJ abnormalities were more in Syringomyelia cases (p = 0.045). However, the results were not significant when hydrocephalus cases were excluded.Conclusion:Among CM1 patients, CVJ abnormalities were found more in patients with syringomyelia. Future studies with larger sample size are required to further study the correlation between CVJ abnormalities and both syringomyelia and hydrocephalus in CM1 patients.

Chiari malformation type-1 (CM1) was first described in 1891 by Austrian pathologist Hans Chiari.1,2 The CM1 is defined as caudal displacement of the cerebellar tonsils below the foramen magnum by 5 mm or more.3,4 This definition is merely a radiological definition. In the literature, the degree of cerebellar tonsil displacement varies from 3 mm to 5 mm.4 CM1 affects approximately 1% of the population and may involve a spectrum of neurologic involvement.2 Syringomyelia is reported in 25% of CM1 cases and may cause irreversible damage to the spinal cord with subsequent neurological deficits.5The pathophysiology of syringomyelia development in patients with CM1 has been extensively studied.6-9 Majority of publications indicated a block to the cerebrospinal fluid (CSF) circulation at the level of the craniovertebral junction (CVJ).8,9 Subsequently, the cerebrospinal fluid (CSF) accumulates and forms syringomyelia.8,9 The source of the CSF forming the syringomyelia can be from the fourth ventricle, the subarachnoid space (SAS), or from an extracellular source.8,9 From the 1950s to the 1970s, syringomyelia was believed to result from a difference in CSF pressure between the fourth ventricle and the central canal of the spinal canal.7 Theories to explain this mechanism include James Gardner’s water-hammer theory, Bernard Williams’ cranio-spinal pressure dissociation theory, and Ball and Dayan’s theory of tonsillar obstruction to the CSF pathway.10-12 In the 1990s, Oldfield believed that the mechanism of the development of syringomyelia involved abnormal CSF flow at the level of the foramen magnum.6,7 The descent of the cerebellar tonsils with each cardiac cycle produces a pressure wave in the spinal SAS, and thereby compresses the spinal cord from the outside and propagates a syrinx.7,9Several intradural and extradural factors have been implicated in the pathophysiology of CM1. Among the intradural factors identified during surgery for CM1, the presence of an arachnoid membrane obstructing the foramen of Magendie (i.e., an arachnoid veil) was significantly more frequent in patients with an associated syringomyelia.6 Other studies have examined whether the degree of tonsillar descent below foramen magnum in the CM1 patients is a contributing factor to the development of syringomyelia; however, the impact of tonsillar descent is controversial.6,9,13 Some studies have reported that the rate of syringomyelia increases as the degree of tonsillar herniation increases.6,9 As a possible explanation for syringomyelia development, other studies14,15 have addressed crowding of the SAS at the foramen magnum caused by tonsillar decent. In a study by Doruk et al15, the measured cervicomedullary compression ratio, defined as the ratio of the area occupied by the cerebellar tonsils to the area of the foramen magnum, was significantly correlated with the development of syringomyelia. This ratio could reflect the severity of blockage of the SAS at the CVJ and further supports the previously described mechanisms of syringomyelia development.9Extradural abnormalities at the CVJ are associated with CM1.15 Such pathologies include a small posterior cranial fossa, platybasia, basilar invagination, and short clivus.3,6,8,9 Several studies have examined the presence of CVJ abnormities in CM1 patients with and without syringomyelia.13,16-21 However, the presence of associated syringomyelia within the context of CM1 with and without CVJ abnormalities was inadequately highlighted. For instance, in one study,13 syringomyelia existed in 64% of CM1 patients with a short clivus, compared to 36% of CM1 patients without a short clivus. In order to further understand the relationship between the presence of one or more CVJ abnormalities and syringomyelia in CM1, the current study was conducted. Such knowledge will likely enhance the understanding of CVJ relationship with CM1 and may aid in the management of syringomyelia in such patients.     

Risk factors of multiple sclerosis in Aseer region,Kingdom of Saudi Arabia A case-control study

Objectives:To investigate socio-demographic and environmental risk factors of multiple sclerosis (MS) in Aseer region, Kingdom of Saudi Arabia (KSA).Methods:This was a retrospective, record, and interview based matched case control study completed in the neurology clinics at tertiary hospitals in Aseer, KSA. It included 82 MS cases and 82 controls. The study used a structured questionnaire to collect information on key socio-demographic and environmental exposures. The main outcome measure was a statistically significant relationship of key socio-demographic and environmental risk factors with MS.Results:A total of 82 registered patients, 50 were females, resulting in a female to male ratio of 1.56:1. Various risk factors were found to have a statistically significant association with MS which included female (OR=3.01, 95% CI [1.59:5.69]; p<0.001), family history of MS (OR=2.1, 95%CI [2.4:1.7] p=0.04), low exposure to sunlight (OR=2.02, 95%CI [2.53: 9.9] p<0.001), only fed breast milk in childhood (OR=0.46, 95%CI [0.55:0.39]; p<0.001), parental consanguinity (OR=2.17 95%CI [4.11:1.14] p=0.017), history of chickenpox (OR=15.59 95% CI [68.7:3.55]; p<0.01). On using multiple logistic regression, chicken pox infection (AOR=0.045, 95%CI [0.015-0.135]; p=0.001)and low sun-exposure (AOR=.271, 95%CI [.121-.609]; p<0.05) were deduced as the predictors of MS in this region.Conclusion:This study offers unique insights into the risk factors of MS. Low sun exposure and childhood chickenpox are significantly related to the development of MS in the Aseer region.

Multiple sclerosis (MS) is disease affecting the central nervous system, that mainly occurs in young people and often incapacitates them for life. Autoimmunity along with several environmental risk factors plays an important role in its etiology, however the precise pathogenic mechanisms that bring on the development of MS have yet to be clearly identified.1-4 Multiple sclerosis, like other autoimmune diseases, is hypothesized to result from complex interactions between genetic susceptibility and environmental factors.5Environmental factors with established risk of developing MS include low sunlight exposure, vitamin D insufficiency, and smoking.3,6 Environmental effects on the development of MS are strongly suggested by its geographic distribution. The prevalence rates of MS are highest in regions at high latitudes and low in regions near the equator.1 The effect of latitude acts largely through exposure to sunlight and vitamin D synthesis in the body. Evidence of changes in MS risk after migration supports the influence of environmental factors on disease susceptibility.7Both active and passive cigarette smoking and MS risk have demonstrated a dose-dependent relationship. Increased MS risk is associated with cumulative smoking, which is reflected by serum nicotine levels. This risk typically subsides after a decade of smoking cessation.8 Case control studies have shown an estimated 40-80% increased risk of developing MS associated with smoking.9 Another risk factor that can induce or promote autoimmunity is microbial infection,10,11 which accelerate the autoimmune processes. Chicken pox or varicella zoster virus (VZV), which is a neurotropic virus that remains in the nervous system for decades, has been hypothesized to be a potential microbial agent in the pathogenesis of MS.12 A recent review supports the hypothesis and mentions several previous studies that have reported VZV DNA in the blood lymphocytes and cerebrospinal fluid (CSF) of MS patients during acute relapses, disappearing during phases of remission.13 Though these findings support the direct participation of VZV in the etiology of MS, however, conclusive evidence needs to be established. The association between breastfeeding and MS has also been investigated in a few studies, in which prolonged breastfeeding has shown a protective effect.14,15The incidence of MS has amplified quickly worldwide.16,17 In particular, this increase has affected the countries of the Arabian Gulf.18,19 Observing this quick rise in prevalence of MS suggests that environmental factors have played a more important role in this change than genetic factors. Unlike genetic risk factors, environmental and lifestyle factors are modifiable, and most regions around the globe, especially the Gulf countries, have shown remarkable socioeconomic and lifestyle changes in the past few decades.17 Most epidemiological studies focusing on the impact of environmental exposures on MS have occurred in the West.20 Given the reported increase in the incidence of MS both globally and in the Middle East, there is an urgent need to understand the role of modifiable factors traditionally implicated in the causation of MS. Information regarding these factors, which could play a role in disease causation as well as protection, could be incorporated into patient care and preventive programs, particularly for individuals with positive family histories of MS and therefore increased risk of developing the disease. The present paper presents data from a study of the distribution of disease characteristics and risk factors of MS in Southwest Saudi Arabia.     

Incidence,risk factors,clinical presentation,and outcomes of hemorrhagic transformation in patients with ischemic stroke admitted to a tertiary hospital in Kingdom of Saudi Arabia

Objectives:To describe the incidence rate, clinical presentation, relevant risk factors, and outcome of hemorrhagic transformation (HT) among ischemic stroke patients.Methods:This retrospective study analyzed HT in patients with ischemic stroke admitted to King Abdullah Medical City from August 2011 to April 2019. Data were analyzed using SPSS. Patients characteristics, procedures, treatments, and outcomes were reported.Results:There were 504 ischemic stroke patients. The HT was detected in 38 patients (8%). The median age was 66.5 (54.3 -77.5) years, and 24 (63%) were males. HT was classified as hemorrhagic infarction (HI) in 22 patients (58%) while 16 patients (42%) were parenchymal hematoma (PH). The most common risk factors noted were: hypertension (74%), diabetes mellitus (DM) (66%), hyperlipidemia (63%) and ischemic heart disease (IHD) (61%). Nine patients (23.6%) developed HT after receiving thrombolytic therapy. Only one patient (3%) died of HT patients.Conclusion:HT accounted for (8%) of all ischemic stroke patients. Old age, DM, hypertension, and hyperlipidemia are frequently encountered with stroke patients who developed HT. Follow up CT brain could be of value and could identify HT early to get better outcomes.

Hemorrhagic transformation (HT) which is a spectrum of hemorrhage related to brain ischemia.1 The HT is a primary complications of acute ischemic stroke (AIS).2 Ischemia makes the cerebral vasculature fragile and more reliable to cause HT after AIS.3–5 HT increases both morbidity and mortality rate in the ischemic stroke patients.2 The HT affects the outcomes with potential severe short- and long-term effects.6 The incidence of HT is between 10–40% and depends on many factors.1,7,8 Most of HT occurs within 2 weeks of an ischemic stroke.5 Previous studies considered old age, hypertension (HTN), diabetes mellitus (DM), large infarct (>2 cm), reperfusion time, lower platelet count and treatment with thrombotic- or anticoagulant-therapies as risk factors.9–12 The most effective treatment for AIS according to previous studies is recombinant tissue plasminogen activator (r-tPA),13 however, it appears to increase the risk of symptomatic or asymptomatic HT.1 Previous studies also suggest that the outcome of HT patients be strongly associated with HT type hemorrhagic infarction (HI) (Petechiae) or parenchymal hematoma (PH) (a space-occupying lesion), PH was a significant predictor of both mortality and neurological deterioration.14 Thus, it is critical to understand HT and its characteristics especially in our population. This retrospective study was designed to describe the incidence rate, clinical presentation, and relevant risk factors of HT among ischemic stroke patients. Identifying such knowledge could improve the outcome and decrease the risk of HT in AIS patients.     

The role of ketogenic diet in controlling epileptic seizures

Objectives:To study the role of the ketogenic diet (KD) in controlling seizures in children with medically resistant epilepsy in Saudi Arabia.Methods:This retrospective study was conducted in the Pediatric Neurology Clinic at a tertiary care epilepsy center. Thirty-one patients with medically resistant epilepsy were enrolled from 2013 to 2018. The seizure reduction variables were evaluated at 6, 12, 18 and 24 months after enrollment.Results:Of the 31 patients, 14 (45.2%) were males and 17 (54.8%) were females. The most common types of seizures were myoclonic seizures and mixed seizures, both of which occurred in 9 (29%) of the participants. Of the participants, 15 (48.4%) had seizures one to 5 times per day. Six months after starting a KD, 2 (6.45%) of participants were seizure-free; 6 (19.35%) were seizure-free after 12 months of treatment.Conclusion:The present study highlighted the effectiveness of KD in medically resistant epilepsy children to local population. A larger cohort is warrant to confirm these findings.

Epilepsy is a common neurological disorder. It is characterized by seizures and affects approximately 65–70 million people worldwide.1 Children and the elderly are most commonly affected by seizures; the condition is rarer in adults.2 Epilepsy remains a challenging neurological disorder despite effective pharmacological therapies.3 More than 30% of epileptic patients do not achieve complete control of seizures with available anti-epileptic drugs (AEDs).1,4 Around 20-40% of patients with epilepsy have refractory epilepsy “failure of, adequate trials of 2 tolerated, appropriately chosen and used AED schedules (whether as monotherapies or in combination) to achieve the sustained seizure freedom” and who are not candidates for surgery, non-pharmacological interventions should be considered for ketogenic diet (KD) treatment.5,6The KD has been proposed for first time in 1920s as a non-pharmacologic treatment to control refractory childhood epilepsy.1 The KD is a high-fat, low-protein, low-carbohydrate diet, with ketogenic ratio of 4:1 or 3:1 in grams which is the most commonly administered ratio.7,8 The KD increases the production of ketone bodies, which brain uses these ketone bodies as an energy source instead of glucose.2 Some hypotheses have been proposed regarding the KD’s anti-seizure effects, suggesting that changes in the nature and degree of energy metabolism in the brain, changes in neurotransmitter function, changes in synaptic transmission, and changes in neuronal cellular properties may explain the diet’s effectiveness.9 Higher ketone levels correlate with better seizure control.9 Ten to 15% of children with epilepsy become completely seizure free on a KD.3 Furthermore, the KD has a prolonged beneficial effect even after it is discontinued.9The International Ketogenic Diet Study Group strongly recommends that the KD be considered as a treatment for children with epilepsy who fail to respond to two or three anticonvulsant medications, regardless of age or gender.9 Our objective was to study the efficacy of the KD in children with medically resistant epilepsy in Saudi Arabia.     

Multiple Sclerosis Patients Knowledge in Saudi Arabia

Objectives:To assess Multiple Sclerosis (MS) patients’ knowledge in Saudi Arabia (SA) and in which aspect of the disease do patient need more awareness.Methods:A cross-sectional web-based survey has been conducted between June and August 2017. It consisted of 2 parts: sociodemographic and 23 multiple choice questions chosen from the previously validated MS Knowledge Questionnaire (MSKQ). The survey has been sent to 500 MS patients.Results:A total of 218 MS patients filled the questionnaire where only 200 included in the study. Female MS patient represents 66% of all the participants. More than half of the patients had achieved their bachelor degree. The total mean of the correct answer for both male and female found to be 58.98%(±SD 15.06%). Most patients were aware that MS is a disease of central nervous system (93%), autoimmune disease (79%), not contagious (90.5%), or inherited (64.5%). However, few patients were aware that there is no single test to diagnose MS (28.5%), and intravenous injection of contrast during MRI reveals new lesions (18.5%). Only (37%) knew what is “Relapsing–remitting”MS. The MS knowledge is positively correlated with the educational level.Conclusion:Patients with MS in SA have less knowledge in the disease’s types, workups, and treatment efficacy. While in contrast, they have more awareness of the disease’s pathophysiology. Patient’s awareness programs should aid more knowledge among MS patients in SA.

Multiple sclerosis (MS) is an autoimmune, chronic, inflammatory disease of the central nervous system; its behavior is highly varied and unpredictable, and the cause, until now, is not known.1 Nevertheless, it appears to be multifactorial; it involves a combination of genetic and environmental factors.1-3 Moreover, it is a common autoimmune disease of the central nervous system.4,5The prevalence of MS in the Middle East is low to medium.6 Incidences of MS in the Gulf countries including Saudi Arabia, in particular, suggest an indication of its increase.7 The Prevalence of the disease in Saudi Arabia has not been studied yet. Not to mention that MS awareness and knowledge is sub-optimal in the country.4Patients’ knowledge of pathophysiology, types, diagnostic modalities and medication effectiveness is critical to facilitate decision-making, achieving emotional stability, and help the patient cope with the disease. Because of the lack of published research in this area, as the literature review of this study indicates, the aim of this study is to measure patient’s knowledge of MS.     

Guillain–Barre syndrome: demographics,clinical features,and outcome in a single tertiary care hospital,Oman

Objectives:Guillain–Barre syndrome (GBS) is an acute autoimmune-mediated peripheral nervous system disease. Different studies from various geographical regions have reported considerable variability regarding its epidemiology, clinical features, and outcome. Our study aimed to document demographics, clinical features, and outcomes among GBS patients admitted to a single tertiary care hospital in Muscat, Oman.Methods:A retrospective data analysis of 44 GBS patients, who were admitted during a two-year period from January 2016 to December 2018 at Khoula hospital, was carried out. Demographics, antecedent illness, duration of symptoms, muscle power graded by the Medical Research Council scale (MRCs), sensory & autonomic involvements, nerve conduction study results, CSF study, need for ventilation, condition at discharge and subsequent follow-up status were obtained.Results:Ninety-one percent of the patients were Omanis, with male predominant 63.6% and the average age was 42.69 years. Quadriparesis was the predominant presenting complaint (61.3%) and AIDP was the commonest variant (52%). All patients received a single cycle of IVIg and (13.6%) patients admitted to the ICU for mechanical ventilation. The study showed good outcome and recovery in 18 months follow up.Conclusion:The clinical presentation of GBS in the majority of patients in Oman is similar to those reported in previous studies, and most patients had favorable prognoses. Our results can be used as baseline data for understanding the characteristics of GBS in Oman and, consequently, for better management.

Guillain–Barre syndrome (GBS), also known as Landry’s paralysis, is an acute immune-mediated polyradiculoneuropathy;1,2,3 with males are about 1.5 times more affected than females, and an overall incidence rate of 1–2 per 100,000 population per year worldwide.4,5 The syndrome is characterized by an acute or subacute progressive generalized muscle weakness of upper and lower limbs with relative or complete areflexia, and limb paraesthesia.1 The typical pattern starts with typically ascending flaccid paralysis, which progresses over a few days to a few weeks. Patients may also develop cranial nerves involvement, usually as a facial or pharyngeal weakness. In addition, autonomic dysfunction is common in the disease, which manifests as postural hypotension, loss of vasomotor control (causing wide fluctuation in blood pressure), and a variety of cardiac arrhythmias. Ventilator assistance is required when respiratory failure and oropharyngeal weakness develop in the course of the disease, which has been reported to be required in approximately one-third of hospitalized patients; these data indicate that early management is vitally important for GBS.1,3Proceeding infections (such as infections with Campylobacter jejuni, Cytomegalovirus, Epstein–Barr virus, Mycoplasma pneumonia, and HIV)2,4,5,6,7 may activate the immune response, owing to molecular mimicry, to cross-react with the peripheral nerve’s components (the myelin and/or the axon) resulting in the endoneural inflammation of spinal nerve roots, nerve’s distal segments, and at potential nerve entrapments sites.2 Some triggering factors (e.g., immunization, trauma, bone marrow transplantation, and surgery) may also affect the pathogenesis of GBS .6–8Seasonal variability is reported for GBS, which can reflect seasonal changes in the peaks of the predisposing factors, such as infections, although GBS may occur during any season.9,10 Seasonal occurrence has been reported to peak during the summer season in Asian countries.11,12The GBS is believed to include a variety of acute neuropathies with underlying immune-mediated pathogenic mechanisms rather than a single disease; therefore, GBS recognized variants are considered as syndromes [including acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor-sensory axonal neuropathy (AMSAN), and Miller–Fisher syndrome]. The most prevalent form of GBS reported is AIDP which is responsible for 70–90% of cases.5,6 In addition to history and clinical examination, confirming the diagnosis of GBS may include cerebrospinal fluid (CSF) analysis and electroneurodiagnostic testing, both of which can be normal in the early phase of the disease.3,4Therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIg) are used effectively for adult and pediatric patients with GBS; and if these treatments are administered during the first few weeks of the disease along with a efficient supportive care, they can minimize mortality and improve the outcome of the disease.13,14 Physical therapy is considered as an essential part of the supportive management for decreasing complications’ incidence, such as respiratory complications and deep venous thrombosis (DVT), as well as for pain management and to enhance early mobilization.15The understanding of clinical presentation and epidemiology of GBS in each population can help us better understand the pathogenesis of the disease, its risk factors, and prognosis.16 Moreover, the evaluation of GBS outcome may be effective for planning an appropriate therapeutic strategy and for determining disease-related morbidity and mortality. The results of different studies from various geographical regions have reported considerable variability regarding the epidemiology, clinical features, and outcomes of GBS.17,18 Therefore, our study aims to assess the presentation, clinical findings, demographics, seasonal variations, and outcomes among patients with GBS in a tertiary care institute in Muscat, Oman.     

Examination of the effects of coordination and balance problems on gait in ataxic multiple sclerosis patients

Objectives:To investigate the effects of coordination and balance problems on gait and plantar pressure distribution in multiple sclerosis patients.Methods:This was an observational, cross-sectional study. It was conducted at Necmettin Erbakan University between March and December 2017. Twenty-four individuals with coordination problems, 36 individuals with balance problems and 32 healthy individuals were included in the study. The EDSS, Functional Reach Test, Dynamic Gait Index, baropodometry and stabilometry evaluations were performed.Results:There were significant differences between the groups (velocity p = 0.000, cadence p = 0.000, step width p = 0.018, step length p = 0.000, foot angle p = 0.000). Multiple comparisons demonstrated that the velocities and cadences of the coordination group were lower, while their step widths were found to be higher, compared to the balance group (p = 0.012, p = 0.004, p = 0.017, respectively). In static plantar pressure distribution, lateral forefoot pressure, lateral hindfoot pressure and medial hindfoot pressure were significantly different between the groups (p = 0.002, p = 0.000, respectively) Multiple comparisons showed that the pressure on the lateral part of the hindfoot in the coordination group was found to be significantly higher compared to the balance group (p = 0.002). According to the dynamic plantar pressure distribution, lateral forefoot, medial forefoot, lateral hindfoot and medial hindfoot pressures were significantly different between the groups (p < 0.05).Conclusion:Coordination and balance problems affect gait and plantar pressure distribution. The identification of these changes will help physiotherapists determine specific therapeutic targets.

Multiple sclerosis (MS) is an infectious disease of the central nervous system of unknown etiology. Typically, patients initially experience a relapse and remission course (RRMS). In many cases, secondary progressive MS (SPMS) is observed, causing the slow and insidious development of disability.1 One of the common symptoms of MS is ataxia. Ataxia, which is characterised by postural control, balance and coordination impairment that causes limitation in MS, is one of the most important causes of disability. Coordination problems are common due to problems in the cerebellum and its connections. Cerebellar pathology causes nystagmus, dysarthria and tremor with limb, trunk and gait ataxia depending on the lesion area. In about 80% of MS patients, different types of ataxia emerge as significant symptoms.2Ataxia is one of the most critical factors affecting gait. Gait ataxia emerges with balance and coordination problems or a combination of these. While previous studies have clearly displayed the effect of balance on gait, the effects of coordination problems on gait are not apparent.3-5 In a limited number of studies, the effect of coordination on gait was investigated, and conflicting results were found. Limb coordination,3 standing and balance control4,5 and locomotion6-8 were the subjects that the researchers emphasised frequently. Morton and Bastian reported that balance in patients with cerebellar ataxia caused an impairment in the spatiotemporal parameters of gait, but coordination did not affect the spatiotemporal parameters of gait.9,10 Winfried et al11 reported that coordination problems affect gait. This study aimed to investigate the effect of balance and coordination problems on gait and plantar pressure in MS patients and to compare its effects with balance problems.     

The potential role of nutritional components in improving brain function among patients with Alzheimer’s disease: a meta-analysis of RCT studies

Objectives:To find out the potential role of nutritional components in improving brain function among patients with Alzheimer’s disease (AD).Methods:The correlation between nutrition and cerebral function in cases of AD has been the focus of 19 prospective randomised controlled trials (RCTs) with a combined research sample of 2297 patients. These RCTs are subject to systematic review and meta-analysis in the current paper.Results:Findings showed that chain-free secondary saturated fatty acids (SFA) and trans fatty acids (TFA) occurred in higher concentrations in AD patients’ brains than in controls. Furthermore, neuroinflammation was caused by remodelling of the lipid membrane and AD patients’ cognitive function was impacted by alterations in tyrosine, tryptophan, purine, and tocopherol pathway metabolomics. Moreover, in cases of mild-to-moderate AD, reduction in functionality was induced by administration of alpha-tocopherol for more than 12 months. Consumption of Souvenaid helps in synaptic synthesis, which enhances functional connectivity. Furthermore, consumption of the B vitamins folate, cobalamin and pyridoxine at dosages of 0.8 mg, 0.5 mg and 20 mg per day, respectively, over a period of one year resulted in lower plasma tHcy levels and brain atrophy.Conclusion:Chain-free SFA and TFA occur in greater amounts in the brains of individuals with AD than in those without AD.

Life expectancy has recently increased enormously throughout the world, owing to development in medical sciences. As a result, the ageing population has expanded quickly, causing a phenomenal rise in the prevalence of late-life cognitive diseases like AD and vascular dementia (VaD).1-3 Besides impacting cognition in ageing individuals, causing the brain to become atrophied and disrupting learning, cognitive, reasoning and communication capabilities, such conditions are also a significant burden from a social and economic perspective.4 Dementia occurs in 5-8% of people older than 65, 15-20% of those older than 75 and 25-50% of those older than 85 years of age.5 Age, gender, head trauma and CVD risk factors (e. g. cardiac disease, diabetes, high blood pressure, depression, high cholesterol, sedentarism, smoking, alcohol drinking) are among the known sporadic AD risk factors that are not of genetic origin.6-8The creation of medication capable of deferring AD onset by disrupting and mitigating Aβ synthesis has been the aim of a number of clinical research trials and empirical work and has attracted ample annual investment from pharmaceutical companies. Even though such medication is yet to be formulated, drugs for symptom management do exist.9 Thus, the approach toward drug development for AD, as well as the therapeutic role of nutrition in preventing AD, need to be reconsidered.Evidence has been produced that AD risk and progression are diminished by diet-related components like antioxidants,10,11 vitamins,12-14 polyphenols,15,16 and omega-3 fatty acids.17,18 By contrast, saturated fatty acids19 and simple carbohydrates20 are considered to increase likelihood of AD development.21 The RCTs carried out in the period 2010-2018 were reviewed in this paper to investigate whether AD patients’ cognitive function can be enhanced based on nutritional constituents. To this end, a meta-analysis was conducted to establish the extent to which cerebral function in AD cases was influenced by nutrition-based treatments. Furthermore, subgroup meta-analyses were also carried out to determine conformance to nutrition plans, proportion of deaths due to general causes and AD, respectively, body weight (BW), lean body mass (LBW), life expectancy, quality of life (QoL), and development of additional neurodegenerative diseases.     

Knowledge of and attitudes toward epilepsy surgery among neurologists in Saudi Arabia

Objectives:To investigate the levels of knowledge and attitudes toward epilepsy surgery among neurologists in Saudi Arabia and evaluate the factors that affect the physicians’ knowledge and attitudes.Methods:A quantitative observational cross-sectional study conducted at King Saud University Medical City, Riyadh. The data were collected using a newly developed, self-administered online questionnaire. The questionnaire contained 3 sections: demographic information, knowledge, and attitudes which then sent to neurologist in Saudi Arabia from December 2016 to March 2017.Results:A total of 106 neurologists met our inclusion criteria. Eighty percent of the participants had at least one epilepsy center in their city, and 78% indicated that they had access to adequate expertise and resources to enable the appropriate selection of epilepsy surgical candidates. Only 57.5% of the neurologists had a sufficient level of knowledge regarding epilepsy surgery. Neurologists with higher level of knowledge referred more patients to EMU and discussed epilepsy surgery more often with their patients. Overall, more than half of the neurologists (52.8%) had a positive attitude toward epilepsy surgery. There was a significantly positive correlation between the scores of knowledge and attitude (p<0.001).Conclusion:Neurologists in Saudi Arabia appear to have moderate knowledge of and positive attitudes toward epilepsy surgery. The place of the last neurology certificate, type of practicing hospital, and access to expertise and resources, affected their knowledge. Adequate knowledge was positively correlated with attitude.

Epilepsy is one of the most common neurological disorders in Saudi Arabia, with an estimated prevalence of 6.54 per 1000 individuals.1 It is estimated that 20-40% of newly diagnosed patients are expected to fail seizure control with medical treatment.2 Refractory epilepsy is commonly defined as the failure to achieve freedom from seizures despite two or more antiepileptic drugs (AEDs).3 Patients with drug-resistant epilepsy (DRE) have a lower quality of life and face more social difficulties than patients with controlled epilepsy.4-6 More than half of the economic burden of epilepsy is accounted for by patients with refractory epilepsy.7 Epilepsy surgery is the best evidence-based treatment option for these patients with drug resistant focal epilepsy.8,9 The current guidelines for patient referral to epilepsy surgery were published in 2003 by the American Academy of Neurology.9 The benefits of epilepsy surgery may not only reduce the frequency of seizures but might also lower mortality and improve the quality of life.10 Despite its proven efficacy and favorable outcome, the average referral delay of an epilepsy surgery candidate is more than 20 years.11 This delay is predominately attributed to non-adherence to referral guidelines, which results from a lack of awareness and familiarity with them.12 Another factor that contributes to the delay is patients’ misbeliefs regarding the surgery’s risks and benefits, which are highly influenced by physicians’ lack of knowledge.13 Epilepsy surgery was introduced to Saudi Arabia in 1998.14 Several epilepsy surgery centers have subsequently been established across the country. A survey in 2013 showed that 56% of health-care professionals in Saudi Arabia were not aware that surgery was a treatment option for patients with epilepsy.15 Our aims in this study were to investigate the levels of knowledge and attitudes toward epilepsy surgery among neurologists in Saudi Arabia and evaluate the factors that affect the physicians’ knowledge and attitudes.     

The role of the family in early intervention of preterm infants with abnormal general movements

Objectives:To determine the effect of family-based intervention on motor function in preterm infants.Methods:This study was designed as a randomized controlled trial between August 2015 and September 2016. Forty-two preterm infants were randomized and split equally between the family-based intervention group, composed of a physiotherapeutic and a familial component (8 males, 8 females; mean age 91±3.09 days), and the traditional early intervention group (8 females, 8 males, mean age: 91.06±2.4 days). Both groups received a treatment program based on a neurodevelopmental approach during 3- to 12-months-old. The groups were evaluated at corrected ages of the third, sixth, ninth, twelfth, and 24th months using the Bayley Scale of Infant and Toddler Development, Third Edition (Bayley-III).Results:Within-group changes over time were statistically significant using multivariate tests of fine motor (Multivariate analysis of variance (MANOVA); F=1515.27, p<0.001) and gross motor (MANOVA; F=1950.59, p=0.001) development. However, there was no interaction between groups in fine (MANOVA; F=0.027, p=0.872) and gross motor development (MANOVA; F=0.022, p=0.883).Conclusion:The early intervention approaches might support fine and gross motor function development in preterm infants in the first year of life.

There is growing evidence that the first year of life is critical for brain development.1,2 The neuronal differentiation process, including the formation of dendrites and axons, as well as the production of neurotransmitters and synapses, is especially active during the prenatal period and continues to be active postnatally.2,3 Myelination starts in the second trimester of pregnancy and progresses rapidly in the first year of life.1,4 Recent studies suggest that interventions during infancy, when high plasticity is observed in the brain, might be more effective than interventions during childhood.5,6 Early diagnosis of infants at high-risk for major developmental disorders, such as cerebral palsy (CP) or minor motor and neurological dysfunction,7,8 is therefore important in providing appropriate interventions.9 Even if early interventions cannot change the physical outcome for infants with neurodevelopmental disorders, intervening with these high-risk infants helps to decrease secondary musculoskeletal system disorders and increase their functional abilities.10 However, it is still unclear which interventions are the most successful. The literature shows that early interventions effectively support cognitive development, but do not or only slightly affect motor development.5,11 With the increase in the survival of preterm infants, comprehensive follow-up programs have been developed to determine appropriate interventions to support them1. One of these, entitled Coping with and Caring for Infants with Special Needs (COPCA), was developed by Dierks et al.12 As a new family-based approach aimed to provide active involvement of the family in the intervention. This program’s approaches are based on both family education and neural group selection theory for infants. In a randomized controlled study, Hielkema et al13 demonstrated no difference in outcomes between Traditional Infant Physical Therapy (TIP) and the COPCA program for infants with an abnormal General Movements Assessment (GMA). A recent review by Hielkema et al14 demonstrated a medium level of evidence on early interventions and family education and called for high-quality studies on these subjects. Dirks and Hadders-Algra et al15 indicated that the importance of the role of the family in early intervention for infants with special needs has increased, and high-quality studies are now required to investigate the effect of family-based care.In addition to them, the quality of mother-infant interaction is one of the most important aspects of normal development.16 In comparison with mothers of full-term infants, mothers of preterm infants have a higher risk of postpartum depression after infants’ discharge.17 This might be caused the effect of premature birth and maternal separation (with prolonged stay in the Neonatal Intensive Care Unit) on hormones in both the mother and infant, which are crucial for managing the adaptive maternal behavior and emotional changes.18 In a randomized controlled trial, Hane et al16 investigated the impact of Family Nurture Intervention (FNI) to improve the developmental trajectories via increasing emotional connection between mothers and their premature infants. These authors proved that infants in FNI had increased cognitive and language scores on the Bayley-III at 18-months-old and decreased risk of attention problems, autism spectrum disorders, and postpartum depression of mother.16 In the other valuable study, Myer et al19 showed an improvement in the frontal cortical brain region (which is responsible for attention, behavior adaptation and cognitive development) in preterm infants that received FNI. Also, Welch et al20 demonstrated greater developmental changes and increased brain activity between brain regions in the FNI group. These studies promote the importance of the mother-infant relationship for normal neurodevelopmental processes. Based on these results, integrating the mothers in early intervention programs is essential for physiotherapy approaches.In the literature, many studies investigated the effect of the early intervention approaches by comparing the traditional infant physiotherapy on infants’ motor development.21-23 However, these studies could not prove any significant effects on motor development after early intervention. The possible explanation of the absence of the differences in motor development between the experimental and control group might be the heterogeneity of interventions, less specificity of the assessment tools to present the changes in development, and the impact of the normal growth process of infants.6,13 It is, therefore, difficult to compare interventions based on randomized controlled trials.13 There is a need for high-quality research that investigates the effects of physiotherapy interventions on gross and fine motor development of the high-risk infants to determine more useful, inexpensive, and accessible interventions for mothers, infants, and clinicians. The present study aimed to determine the effects of a family-based COPCA intervention program on fine and gross motor function in preterm infants.     

Predicting future handedness and hemispheric dominance during infancy by analyzing sleep spindles

Objectives:To investigate whether sleep spindles asynchrony (SSA) using scalp sleep electroencephalogram (EEG) among children below 2 years of age can predict future handedness.Methods:This is a retrospective study conducted from October 2016 until June 2017 at the King Fahad Medical City (KFMC), Riyadh, Kingdom of Saudi Arabia. We retrospectively reviewed 300 EEGs recorded at our neurophysiology laboratory.We included EEGs performed during sleep for infants aged 2 months to 2 years who have already attained their handedness or those aged above 2 years. We excluded records of children younger than 2 months or above 2 years of age (at the time of the EEG) or those aged below 2 years (at the time of the interview), and severely abnormal tracings and those without sleep or enough SSA .Results:The lateralization of Sleep Spindles (SS) was mostly right-hemispheric (52%) compared to left-hemispheric (36.4%). The overall SS laterality did not correlate with handedness (p=0.81). In the majority of right-handed (64%) and left-handed (60%) children, the SSA was contralateral to the side of hand preference; however, it did not correlate statistically (p=0.377).Conclusion:We were unable to prove a statistically significant correlation between SSA and future hand preference. Further research involving larger cohorts is still needed.

Sleep architecture is an essential part of evaluating any electroencephalogram (EEG). Despite being recognized and described as early as the discovery of EEG, sleep features remain understudied. In most children, Sleep Spindles (SS) do not synchronize over the 2 hemispheres until the child develops Handedness, usually at 2 years of age. This coincidence of the establishment of Handedness and synchrony of SS makes the connection between the 2 maturational developments important. We planned to investigate the possibility of anticipating future hemispheric dominance and future Handedness using the concept of Sleep Spindles Asynchrony (SSA). The SS consist of bilaterally symmetric low to medium voltage bicentral synchronous rhythmic spindle-like waves, with frequency ranging from 12 to 16 Hz, which often appear along K-complexes lasting approximately 2-3 seconds.1 The identification of SS is easy in any sleep EEG due to their abundance in infants and children. Their typical location in adults is a synchronous burst of waves around the vertex; in children, it varies according to age.2–7 It is thought that the origin of sleep spindles is the thalamocortical network. However, there is no functional meaning definitively established for this mechanism so far, which makes our study relevant to this area.3 The SS are not seen in the first 2 months of life and start to appear afterward.8 The absence of sleep spindles during mid-infancy is considered a significant abnormality. However, their independent occurrence (asynchrony) below 2 years of age is common and a normal finding.9–12 These sleep milestones are consistent between subjects, and therefore they are an essential indication of functional maturation.13 Chatburn et al14 found that sleep spindle activity was associated with various aspects of maturation and is an integral part of brain development. It is suggested that sleep EEG may be a marker for intellectual ability.15 Specifically, SS are associated with the intelligence quotient (IQ).16 The SS are also found to be involved in procedural memory.17 There are a few speculations about how Handedness is created in individuals. Although antenatal mechanisms might be essential, analysis considering in utero development verified that Handedness was an extremely accurate indicator of hemispheric dominance after birth.18 Early hand preference does not develop before one-year of age, and the usual age at which Handedness appears is 2 years, coinciding electrographically with SS synchrony, making a causal relationship or mechanism between the 2 markers highly likely.19–20 There is no previously published research to date to have studied this area.21     

Is non-traditional therapy for multiple sclerosis overwhelming in Saudi Arabia

Objectives:To describe the prevalence, knowledge and attitudes about complementary and alternative medicine (CAM) use and the proportion that seek advice from their physician about CAM use.Methods:This cross-sectional observational study was performed in multiple sclerosis (MS) clinic of King Fahd Hospital of Universityin Alkhobar, Kingdom of Saudi Arabia from January-June 2017. A total of 133 patients have completed the survey.Results:The mean age of patients was 32.3±7.6 years and 84 (63.2 %) were female. Approximately 83.5% of the patients reported the use of CAM. Among all the reported forms of CAM, vitamins were the most prevalent form, followed by cupping, special prayers and meditation. The majority of patients (62%) obtained knowledge of CAM through social media. A significant number of patients (75.6%) did not disclose the use of CAM to their physician. There was a trend for using CAM more in highly educated, older age, and female patients. The most commonly reported rationale to use CAM was overall improvement in health status.Conclusion:The use of CAM among Saudi patients with MS is highly prevalent, without disclosure of its use to physicians. These factors should be taken into account in the doctor-patient consultation to avoid adverse events.

Multiple sclerosis (MS) is a chronic neurological disorder, typified by a relapsing and progressive course of symptoms, resulting in long-term severe disability. Multiple sclerosis was thought to be uncommon in Kingdom of Saudi Arabia, but the prevalence of MS is increasing in the Gulf region, particularly in Kingdom of Saudi Arabia, and the latest prevalence estimates are 40/100,000 in 2008.1,2 These increasing numbers of MS patients represent a challenge to provide treatment, health promotion, employment, and rehabilitation for severely disabled patients.3 The etiology of MS is still unknown. Multiple sclerosis patients face many challenges in their daily routine life, like other patients suffering from chronic diseases. Treatment for MS is not curative, though many disease modifying drugs (DMDs) are available with United States of America’s Food and Drug Administration (FDA) approval; the available treatment options for MS often have several adverse side effects and a very high cost. Therefore, MS patients turn to CAM with the hope to cure their MS, minimizing the relapses and treating their symptoms, even though the efficacy may not be established. Complementary and alternative medicine is defined as “a group of diverse medical and health-care systems, practices and products that are not presently considered to be part of conventional modern medicine”.1There is a worldwide interest in CAM. Its use ranges from 9-70% of the total population, despite insufficient scientific evidence for its use.4 Complementary and alternative medicine is popular among patients as well as healthy individuals.4 There are variations in CAM practices between countries, which depend on their traditions and the prevalence of diseases. Also, the methods that are used in different studies differ.4,5Patients suffering from MS are significant users of CAM.6 The prevalence of CAM use among MS patients has been reported in several studies, with a wide range of prevalence between 33-70%.6 Knowledge about CAM practices and the prevalence in MS patients in Arab countries is limited. To document the influence of psychosocial, religious and cultural factors on health beliefs and behaviors in Kingdom of Saudi Arabia, having a religious background, studying CAM is of utmost importance.4,7 Health care facilities are free for the nationals in Kingdom of Saudi Arabia and provided by The Ministry of Health, but the ministry does not cover CAM. However, a center for CAM was established by a ministerial decree (No. 236) on 10/8/1429 H (12/8/2008 G). This center, being a reference center for CAM and related issues, has the objectives to monitor the CAM practices among different health care services and to regulate them using evidence-based support.8 In a 2015 publication, Kingdom of Saudi Arabia was ranked very high in scientific research related to CAM among all Arab countries.9 This highlights the importance of CAM-related research in Kingdom of Saudi Arabia to document how their different psychosocial, cultural and religious background can influence the use of CAM and to see the effects on their health beliefs and attitudes.10We aimed to determine the prevalence of CAM use among MS patients in Kingdom of Saudi Arabia, as well as to document their knowledge and behaviors concerning CAM, the used types and the reasons behind them and the frequency of the patients disclosing the use of CAM to their physician. We also wanted to determine any association of demographic characteristics, health behaviors and health status with CAM use and disclosure.     

Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit

Objectives:To evaluate the effectiveness of an early mobility protocol for stroke patients in the intensive care unit.Methods:Participants were patients with first or recurrent stroke (n=60, age=49.02±6.36 years, body mass index=32.95±5.67 kg/m²) admitted to the intensive care stroke unit in general hospitals, Riyadh during October and December 2016. Single group pretest-posttest design involving an early mobility protocol was started within first 24 hours admission. Pre and post measurements of muscle strength, pulmonary function and quality of life were carried out.Results:There were significant improvements in muscle strength of upper and lower extremities´ muscles after treatment (p<0.05), pulmonary functions including Forced Vital Capacity, Forced Expiratory Volume 1 (p<0.05) and quality of life, namely, Barthel Index and modified Rankin Scale (p<0.01).Conclusion:This study demonstrates that initiating an early mobility protocol is safe and effective for intensive care unit stroke patients and supports introducing the current protocol as a standard protocol in neurogenic Intensive Care Units.

Stroke is a life-threatening condition caused by interruption of the blood supply to any part of the brain. Stroke causes acute neurological disorders and long-term disabilities and imposes economic, social and health impacts on individuals and their families.1 Survivors of stroke are left with mental and physical disabilities that cause social and economic burdens and impair quality of life (QOL). In Saudi Arabia stroke is becoming a rapidly increasing problem and a primary cause of morbidity and mortality.2 Worldwide the incidence of first-time stroke was 17 million during 1990-2000.3 Cerebrovascular diseases including stroke is a leading cause of mortality,4 and stroke is the fifth leading cause of death, but it remains the first cause of disability in the USA.5 By 2030 there will be almost 12 million stroke deaths and 70 million stroke survivors globally.6 Stroke has an adverse influence on the QOL of patients. The onset of stroke is sudden, and unlike other disabling conditions, it leaves patients and their family’s ill prepared for its sequelae.7 Stroke may create unique conditions that affect the patients’ QOL, involving dysfunctions in physical, emotional, memory, thinking, and social interactions.8Stroke is an urgent health care issue. It is a common cause of the hospital admissions. Immediate admission to the neuro-intensive care unit can facilitate early stroke treatment strategies.9 Stroke patients in the intensive care unit (ICU) experience a decrease in physical activity that represents a significant stress on the body and leads to a considerable decrease in functional status, increases morbidity, mortality rate, and duration of hospital stay and cost of care.10 In addition to comorbid diseases, patients on mechanical ventilation have many barriers to mobility because they are surrounded by tubes, catheters, life support and monitoring equipment. Additionally, other factors besides weakness, such as sleep loss, lack of social communication, nutritional status, sedation, and an ICU culture that encourages bed rest further contribute to functional deterioration.11 There is considerable loss of the muscle mass during the initial weeks of immobility in the ICU, therefore its management is inherently related to QOL after discharge.12 Considerable published evidence indicates that patients in ICUs have high morbidity and mortality, high costs of care and a marked decline in functional status.13,14Early and progressive mobilization program has been described as a key component for patients in the ICU. It may decrease post stroke complications such as infections, deep venous thrombosis, pneumonia, pressure ulcers, falls and de-conditioning with bed rest.15 It has been recognized that mobilization of post stroke patients is essential to prevent hospital-associated complications, functional decline and facilitate recovery.16 Moreover, the benefits of early mobilization include decreased ICU-acquired weakness, improved functional recovery within hospital,17 Effective stroke intervention begins the day the patient has a stroke.18 It has a positive effect on patient functional ability, promotes positive psychological effects and improves walking at hospital discharge and reduces hospital length of stay.19 While on the other hand, long term inactivity may affect the patients’ physical, social, emotional, behavioral, and psychological pattern.20 In addition, secondary changes associated with stroke-related inactivity include muscle atrophy, a shift in muscle fiber type to a greater predominance of fast-fatigable, insulin-resistant fibers, loss of cardiovascular fitness, and increased intramuscular fat.21 Therefore, early mobilization program which is a complex intervention that needs crucial patient assessment and management, as well as interdisciplinary team collaboration and training.22,23 The early mobilization may improve patient outcomes and recovery.24 Few studies have investigated the role of increased mobility in ICU patients. Therefore, this prospective intervention trial evaluated the effectiveness of an early mobility program administered by physical therapists and nursing personnel for stroke patients admitted in ICU.     

The comorbidity of headaches in pediatric epilepsy patients: How common and what types?

Objectives:To estimate the prevalence and characteristics of headache in pediatric epileptic patients.Methods:This cross-sectional study was performed over 6 months period from January 2018 to June 2018 at King Abdullah Specialist Children Hospital, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia using a structured questionnaire in pediatric patients with epilepsy.Results:There were 142 patients enrolled (males, 57.7%; average age, 10.7±3.1 years) with idiopathic epilepsy (n=115, 81%) or symptomatic epilepsy (n=27, 19%). Additionally, patients had focal epilepsy (n=102, 72%) or generalized epilepsy (n=40, 28%), and among them, 11 had absence epilepsy. Overall, 65 (45.7%) patients had headaches compared with 3/153 (2%) in the control group (p < 0.0001). Among the 65 patients with headaches, 29 (44.6%) had migraine-type, 12 (18.4%) had tension-type, and 24 (36.9%) had unclassified headache. There was no significant difference in age, gender, type of epilepsy syndrome, and antiepileptic used except in patients with or without headache. For migraine patients, there was a lower headache prevalence in the subgroup treated with valproic acid compared with other treatments.Conclusion:Headache, predominantly migraine, is a common problem in pediatric epileptic patients and choosing valproic acid when possible can be important in preventing migraine in these patients.

Epilepsy and headache are chronic paroxysmal disorders that affect adult and pediatric patients1 with episodic manifestations. Headache or (cephalalgia) is defined as a feeling of pain in the region of the head or neck. Primary headaches include migraines, tension-type headache, and cluster headache. Epileptic seizure is a brief episode of signs or symptoms caused by abnormal excessive synchronized neuronal activity.2 Epilepsy is defined as a condition where the patient has an enduring tendency to have recurrent unprovoked seizures.2 These two disorders coexist in some patients.3 There are few studies on the comorbidity of headaches in children with epilepsy.4-6 Other studies reported a significant association between migraine and epilepsy.1,7-9 Additionally, the genetic predisposition for both entities was reported in some forms of channelopathy,10 and others found more prevalence of migraine headache in specific diseases in pediatric like benign epilepsy with centrotemporal spikes and juvenile myoclonic epilepsy.11 Seizure-associated headache is common, with an incidence of 42–51% in adult epileptic patients.12 However, for pediatric patients, it is often neglected by parents and physicians because of other neurological manifestations of the seizure such as loss of consciousness and motor components,13 and approximately 36% of the parents were reported to be unaware that their children experienced headache.14 It is our experience that headache is a common problem in up to 50% of epilepsy patients but we do not know exactly the prevalence, in addition to what type of headache is most commonly found in epileptic pediatric patients. Because of few reports on this topic have conflicting results, the objective of this study was to evaluate the prevalence and characteristics of headache in children with epilepsy who were seen at one center in Saudi Arabia.     

Angiocentric glioma of brainstem

Angiocentric glioma is a rare brain tumor commonly found in frontal or temporal lobes. It has a benign course, and surgical resection can be curative. Brainstem location is extremely rare, with only six cases reported so far in the literature. In the present study, the seventh case of brainstem angiocentric glioma has been reported, and its course in comparison with supratentorial location and the role of molecular diagnosis has been discussed.

Angiocentric glioma is a rare brain tumor, which was initially reported in 2005.1 It is classified as a grade I distinct clinicopathological entity by WHO CNS-2016 classification.2 Less than 100 cases have been reported in literature, with common locations being in the cerebral cortex of frontal or temporal/ lobe or hippocampus.1 In these series, patients are typically presented with seizures at 14-17 years of age. Brainstem location is extremely rare, with only six cases ever reported in the literature studies.3–6 Here, we are reporting a rare case of brainstem angiocentric glioma with myxoid features with 7 years follow up.