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.     

Preparation and characterization of co-processed starch/MCC/chitin hydrophilic polymers onto magnesium silicate

It was aimed to investigate the compressibility, compactibility, powder flow and tablet disintegration of a new excipient comprising magnesium (Mg) silicate co-processed (5%–85% w/w) onto chitin, microcrystalline cellulose (MCC) and starch as the hydrophilic polymers of interest. Initially, the mechanism of tablet disintegration was studied by measuring water infiltration rate, moisture sorption, swelling capacity and hydration ability. Moreover, the powders compression behavior was carried out by applying Kawakita model of compression analysis in addition to porosity and radial tensile strength measurements. In vitro drug release of compacts made of 400?mg ibuprofen and 300?mg of the hydrophilic polymers containing 30% w/w Mg silicate co-precipitate was investigated in phosphate buffer (pH 7.8). This work demonstrated that the incorporation of Mg silicate to the hydrophilic polymers lead to the improvement of powder flowability, compactibility, stability (with regard to storage conditions), compacts crushing strength, and disintegration time in addition to faster drug release. The overall findings are practically advantageous in the context of finding a low cost and multifunctional co-processed excipient of natural origins.     

Assessment of Serum CoQ10 Levels and other Antioxidant Markers in Breast Cancer

Background: The balance of the oxidative state in the body is fundamental for the maintenance of homeostasis. It has been implicated in the onset and progression of several diseases including breast cancer. The way in which the Reactive Oxygen Species (ROS) / antioxidants balance leads to or responds to disease is still controversial. In this study, TAC is used as a reference for the total antioxidant power of the body and Coenzyme Q10 (CoQ10) for its vital importance in cellular antioxidant action and being the only lipid soluble antioxidant synthesized endogenously. Copper and zinc were measured as trace elements reflecting the antioxidant micronutrient profile of the body. Methods: After approval of the ethical committee, 60 recently diagnosed non-intervened breast cancer patients were recruited from the Medical Research Institute hospital, Alexandria University along with 20 apparently healthy volunteers as control group. Full patient history was taken including breastfeeding history, parity, hormone replacement therapy use, body mass index, pathological examination, metastatic work up results, past medical history and drug use. CA 15-3 and laboratory investigations evaluating blood glucose, kidney and liver functions were performed. Q10 levels were measured by HPLC using a kit from Recipe®. TAC was assayed spectrophotometrically (Biodiagnostics®). Copper and Zinc levels were determined by inductively coupled plasma-optical emission spectrometry. Results: There was a statistically significant increase in the CoQ10, TAC and copper levels in the breast cancer group when compared to the control group. Zinc showed no statistically significant difference between the studied groups. Conclusion: Inspite of the fact that a high antioxidant level is usually considered as a favourable state, TAC, CoQ10 and copper levels showed significantly higher levels in the breast cancer group when compared to the control group. It is worth mentioning that the cancer group were all recently diagnosed, non-intervened and showed no signs of metastasis. It is still unclear whether the increased antioxidant levels offer a selective growth advantage to tumor cells over their surrounding normal cells or serve as a protective measure by the body in an attempt to correct the assault triggered by the ROS.     

Immediate dental implant placement with a horizontal gap more than two millimetres: a randomized clinical trial

The purpose of this study was to evaluate the horizontal dimensional changes in buccal alveolar bone immediately after dental implant placement in the upper premolar area with horizontal gaps >2 mm. A total of 48 patients were enrolled in this randomized clinical trial and were randomly assigned to one of three groups. Group I (flap with graft; n = 16) patients received an immediate implant with bone graft, membrane, and primary flap closure. Group II (flap without graft; n = 16) patients received an immediate implant with primary flap closure only. Group III (flapless without graft; n = 16) patients received an immediate implant without graft, membrane, or primary closure. Cone beam computed tomography (CBCT) scans were obtained preoperatively, immediately after implant placement, and at 6 months postoperative to evaluate horizontal dimensional changes in the buccal alveolar bone. Pain intensity was measured using a numerical rating scale. CBCT examinations revealed that bone had filled the horizontal gap in all three groups. Group II showed the greatest horizontal dimensional changes in the buccal alveolar bone, followed by group I. The least amount of change was recorded for group III. Furthermore, significantly less postoperative pain was recorded in group III when compared to the other groups. Short-term results suggest that the ‘flapless without graft’ technique shows similar results to the ‘flap with graft technique’ for immediate implant placement in the maxillary premolar extraction site with a horizontal gap >2 mm, when the bone plate is intact.     

Expanded access to investigational drugs: balancing patient safety with potential therapeutic benefits

Introduction: Expanded access is the use of an investigational product by patients with serious medical conditions without participation in a clinical trial. It is a complicated process involving the collaboration of many parties and pharmaceutical companies. Ongoing efforts focus on accelerating expanded access procedures in the best interest of patients with cancer.

Areas covered: We review the regulatory and ethical challenges encountered in efforts to optimize expanded access.

Expert opinion: In the era of personalized medicine, patients may benefit from novel therapeutic agents that demonstrate encouraging results in early studies. However, drug approval is a lengthy and cumbersome procedure that might exceed the time frame of a life-threatening disease. Expanded access provides options to patients with unmet needs. It may provide informative safety and efficacy data to the manufacturers and the scientific and regulatory organizations.

Ongoing efforts are being made by global governmental and scientific committees, regulatory agencies, and patient organizations to address the ethical and regulatory issues and to optimize the expanded access process. Their goal is to expand access to promising novel drugs for individual patients and to accelerate the necessary procedures while preserving patient safety.     

Mobilizing political support proved critical to a successful switch from tOPV to bOPV in Kano,Nigeria 2016

Background

Kano is one of the high-risk states for polio transmission in Northern Nigeria. The state reported more cases of wild polioviruses (WPVs) than any other state in the country. The Nigeria Demographic and Health Survey of 2013 indicated that OPV3 coverage in the routine immunization (RI) programmewas 57.9%. Additionally, serial polio seroprevalence studies conducted from 2011 to 2015 in the eightmetropolitan LGAs indicated low immunity levels against all three polio serotypes in children below one year. Areas with sub-optimal RI coverage such as Kanothat fail to remove all tOPV during the tOPV-bOPV switchwill be at increased risk of VDPV2 circulation.

Methods

We assessed the impact of political leadership engagement in mobilizing other stakeholders on the outcomes of the bOPV-tOPV switch in Kano State from February to May 2016 using nationally-selected planning and outcome indicators.

Results

A total of 670 health facilities that provide RI services were assessed during the pre-switch activities. Health workers were aware of the switch exercise in 520 (95.1%) of the public health facilities assessed. It was found that health workers knew what to do should tOPV be found in any of the 521 (95.2%)public health facilities assessed. However, there was a wide disparity between the public and private health practitioners’ knowledge on basic concepts of the switch.There was 100% withdrawal of tOPV from the state and the seven zonal cold stores. Unmarked tOPVwas found in the cold chain system in 2 (4.5%) LGAs. Only one health facility (0.8%) had tOPV in the cold chain. No tOPVwas identified outside the cold chain without the “Do not use” sticker in any of the health facilities.

Conclusion

The engagement of the political leadership to mobilize other key stakeholders facilitated successful implementation of the tOPV-bOPVswitch exercise and provided opportunity to strengthen partnerships with the private health sector in Kano State.