Patterns and outcomes of stroke thrombolysis in a large tertiary care hospital in Riyadh,Saudi Arabia

Objectives:To present the experience on stroke thrombolysis of a tertiary care center in Riyadh, KSA.Methods:Cross-sectional, observational study of patients thrombolyzed between January 2012 and December 2018.Results:Thrombolysis was performed in 148 patients (mean age: 58.2±14.5 years), 94 (63.5%) of them were men. The median onset-to-door time was 81 minutes, and 25% of the patients arrived within 1 hour. The median National Institute of Health Stroke Scale score upon admission was 13. Hypertension (68.9%), diabetes (56.1%), and dyslipidemia (40.5%) were the most common risk factors for stroke. The most common mechanism of stroke was cardioembolism (43.2%), which was associated with a more severe presentation (p=0.031). Intravenous thrombolysis alone was given to 98 patients (66.2%); the rest received intravenous tissue plasminogen activator plus endovascular therapy or endovascular therapy alone. The median door-to-needle (DTN) time was 70.5 min, with a significant improvement from 2012 (111.6 minutes) to 2018 (69.9 minutes) (p<0.001). Among the patients, 53 (35.8%) showed a good outcome (with a modified Rankin score of 0–2) whereas 14 (9.5%) died. Symptomatic intracranial hemorrhage (sICH) was seen in 8.1%. All vascular risk factors were more common in patients aged >60 years, except smoking, which was more common in the younger age group (p=0.007).Conclusion:In our cohort, the utilization of thrombolysis and the DTN time improved over time. One-thirds of the patients received endovascular treatment. Moreover, the frequency of the vascular risk factors was high. Compared with the published findings, our results showed that cardioembolic strokes were the most frequent and had severe presentation and were likely the cause of the slight increase in mortality and sICH.

Acute ischemic stroke remains a major cause of morbidity and mortality worldwide. Intravenous (IV) thrombolysis is the standard of care in eligible stroke patients since 1995 after the publication of the National Institute of Neurological Disorders and Stroke (NINDS) recombinant tissue plasminogen activator [alteplase] (rtPA) trial.¹ In appropriately selected patients with acute ischemic stroke and large vessel occlusion (LVO), mechanical thrombectomy (MT) significantly improved the patients’ functional independence without increasing the mortality rate or hemorrhagic complications.² Despite the proven efficacy and relative safety of IV thrombolysis and MT, they remain underutilized. In our center, thrombolysis was utilized in 8.6% of all ischemic strokes between February 2016 and July 2018 and in 29% of patients who arrived within the therapeutic window.³ Although acute stroke care has significantly improved in Saudi Arabia in the past decade, it remains far from being optimal. In a recent survey, nearly half of the Saudi emergency physicians considered the role of rtPA in stroke as controversial, whereas 37% presume that the efficacy of rtPA remains unproven.⁴ A recent survey showed that among the neurologists in Saudi Arabia, 21.3% had never used rtPA in acute stroke, 82.4% believed that the delayed presentation to a hospital was the most important barrier to the use of intravenous rtPA, and 50% considered that the unclear time of onset was the barrier to the use of thrombolysis.⁵ Another survey showed that among the neurology residents in Saudi Arabia, 79% reported lack of good knowledge about IV thrombolysis and 53.1% expressed lack of confidence in using IV thrombolysis.⁶ The use of IV thrombolysis and MT has gained momentum in Saudi Arabia, but the published literature on the patterns and outcomes of thrombolysis remains scant. Recently, results from the Safe Implementation of Treatment in Stroke (SITS)-Middle East and North African (MENA) registry for IV thrombolysis were published,⁷ and a report from Dubai described the use and outcomes of thrombolysis in 176 patients.⁸A stroke unit was formally established in our tertiary care center in 2012, although thrombolysis treatment was already offered prior to that. Here, we report our experience on thrombolysis in acute ischemic stroke from January 2012 to December 2018. We presume that this report is the first of its kind in Saudi Arabia.     

Differences in dual task paradigms and executive function ability for recreational athletes in United Arab Emirates

[Purpose] The purpose of this study to measure four components of executive function: (1) cognitive flexibility, (2) inhibition, (3) working memory and (4) processing speed, along with the ability to dual task in recreational athletes. [Participants and Methods] This was a cross-sectional study of (n=102) male and female participants, between the ages of 18–40 years of age across different levels and types of sport related physical activity. The International Physical Activity Questionnaire (IPAQ), short version, Dual Task Abilities (DTA) were measured utilizing a quantitative, dual task, gait test and Executive Function (EF) was measured through Stroop Color Word Test and Trail Making Test. [Results] Differences in EF and Dual Task-Interference (DTI) in recreational athletes did not show a significant difference between varying types of sport and level of sport related activity, with reported values high across all groups. Males reported better dual task interference abilities than females, though there were no significant differences in executive function between males and females. Executive function performance was the highest among the age group (18–24 years) population, but there were no significant differences between those in the higher age groups (25–34 years) and (35–40 years). [Conclusion] Overall, those participating in the study exhibited high prevalence of strong EF ability, regardless of sport activity type or level. This may suggest that type and level of sport activity may not be important when considering executive function performance maintenance for recreational athletes.Key words: Executive function, Dual task interference, Recreational athletes     

Antibacterial prophylaxis in pediatric patients with leukemia

Background

Bacterial infections in pediatric patients with leukemia are associated with increased risks for morbidity and mortality. Few Recommendations have been made on the use of antibacterial prophylaxis in pediatrics with acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML).

Quality of Life in Family Members of Vitiligo Patients: A Questionnaire Study in Saudi Arabia

Background

Many dermatologic disorders are known to adversely affect quality of life (QoL) in close relatives or partners of patients; however, it is unknown whether vitiligo impacts the QoL of family members.

Objective

The aim of this study was to identify the level and domains in which the QoL of partners/relatives of patients with vitiligo are affected by the disease.

Methods

A total of 141 patients with vitiligo, along with their family members, were recruited to complete validated QoL questionnaires, including the Dermatology Life Quality Index (DLQI) and the Family Dermatology Life Quality Index (FDLQI).

Results

Family member QoL was affected in 129 (91.5 %) of subjects. Mean FDLQI score was 10.3 ± 6.4 standard deviation. Higher FDLQI score (greater impairment in QoL) was significantly associated with male patients, a shorter duration of disease, and higher educational levels in family members. The most affected FDLQI items in order of decreasing incidence were emotional impact, burden of care, impact on the physical well-being of the family member, problems due to the reaction of others in response to the patient’s skin appearance and effect on social life. Overall FDLQI score and the number of items affected correlated with overall patient DLQI score (p < 0.001, r = 0.56 and p < 0.001, r = 0.53, respectively).

Conclusions

Vitiligo has a major impact on the QoL of family members of patients and often significantly impairs many aspects of their lives. Educational and supportive programs are recommended for family members of vitiligo patients who are at an increased risk for QoL impairments.     

Comparing musicians and non-musicians in signal-in-noise perception

Abstract

Objectives: The objective is to compare musicians and non-musicians in signal-in-noise perception.Design: Participants underwent the following tests: (1) High-frequency (HF) audiometry, (2) QuickSIN (a test for speech perception in noise), and (3) Binaural Masking Level Difference (BMLD) test (a test that examines the hearing threshold of a low-frequency tone from noise masking when the phase of the signal or noise in one ear is reversed with respect to the phase of the signal or noise in the other ear, i.e. the difference in the threshold for detection of the tone in noise under the S_πN_o and S_oN_o conditions).Study sample: Thirty-four healthy young normal-hearing listeners including 17 musicians (M) and 17 non-musicians (NM).Results: There were no study group difference in HF audiometry and QuickSIN. The M group had a significantly better performance under the S_oN_o but not under the S_πN_o condition. As a result, the BMLD value (S_oN_o–S_πN_o) was significantly smaller in the M group than in the NM group.Conclusions: There is a musicians’ advantage in binaural tone-in-noise detection in the BMLD task under the S_oN_o condition, suggesting that long-term music training positively shapes the auditory system.     

Pregnancy and ventriculoperitioneal shunt. Report of a case and literature review

Reported cases of pregnancy occurring in association with an extracranial shunt for hydrocephalus are very few. This report documents two uncomplicated pregnancies in a patient with ventriculoperitoneal shunt. Abdominal pain was the most frequent symptom in our patient.     

Hyperinsulinemic hypoglycemia in seven patients with de novo NSD1 mutations

Sotos syndrome is an overgrowth syndrome characterized by distinctive facial features and intellectual disability caused by haploinsufficiency of the NSD1 gene. Genotype–phenotype correlations have been observed, with major anomalies seen more frequently in patients with 5q35 deletions than those with point mutations in NSD1. Though endocrine features have rarely been described, transient hyperinsulinemic hypoglycemia (HI) of the neonatal period has been reported as an uncommon presentation of Sotos syndrome. Eight cases of 5q35 deletions and one patient with an intragenic NSD1 mutation with transient HI have been reported. Here, we describe seven individuals with HI caused by NSD1 gene mutations with three having persistent hyperinsulinemic hypoglycemia. These patients with persistent HI and Sotos syndrome caused by NSD1 mutations, further dispel the hypothesis that HI is due to the deletion of other genes in the deleted 5q35 region. These patients emphasize that NSD1 haploinsufficiency is sufficient to cause HI, and suggest that Sotos syndrome should be considered in patients presenting with neonatal HI. Lastly, these patients help extend the phenotypic spectrum of Sotos syndrome to include HI as a significant feature.     

Public awareness of central nervous system tumors in the Kingdom of Saudi Arabia

Objectives:To investigate individuals’ knowledge about central nervous system tumors (CNST) signs and symptoms and risk factors, as well as their readiness to seek medical advice. The signs and symptoms associated with CNSTs are often vague, and failure to recognize them could lead to delays in seeking help and possibly fatal results.Methods:This was a cross-sectional survey that utilized 2 delivery methods. A total of 1,500 personally delivered and 1,500 online self-administered questionnaires were completed in parallel between June 2015 and June 2016 for the occupants of the Kingdom of Saudi Arabia.Results:Significant differences were observed for the sociodemographic characteristics of participants recruited via the 2 methods. The most recognized symptom was “Headaches” (45.2%), and the most recognized risk factor was “Radioactive location/occupation” (84.1%). Overall knowledge scores were low, significantly predicted by employment and cancer contact (p<0.05), while the scores significantly higher for participants who were willing to see their doctors within a week (p<0.005). The most recognized barrier to seeking help was “Worry about what the doctor might find” (74.0%).Conclusion:The level of awareness of CNSTs was low. Using a questionnaire delivered in 2 different ways enabled the recruitment of sample pools with different sociodemographic characteristics.

For many health-related issues, awareness is considered an important factor associated with behavior.1 Several studies have linked high knowledge to the ability to address modifiable associated causes, for instance, improving diet and increasing exercise to prevent cancer, as well as taking appropriate actions in response to detecting associated symptoms.2 Assessing the level of public awareness of health-related issues is important for identifying deficient areas and increasing awareness in areas where needed.3 The occurrence of a central nervous system tumor (CNST) in any individual, with its associated consequences, is a devastating event.4 In 2012, the World Health Organization (WHO) Global Cancer report (GLOBOCAN) stated that more than 250,000 individuals worldwide were diagnosed with a CNST, and approximately 190,000 died, ranking CNSTs in the top 10 mortalities caused by cancer.5,6,7 More than 120 CNST entities have been classified by the World Health Organization (WHO) based on their clinicopathological characteristics and histological patterns.8 The signs and symptoms for CNSTs depend on the tumor location, and they are not exclusively indicative of the presence of these tumors.3,9,10 Causes associated with the development of CNSTs vary, and many are still under investigation.11-20 Many studies that assess health public awareness rely on random sampling through telephone directories, a system that is not necessarily available in many developing countries. Questionnaires provided online have frequently been used, including in marketing research and psychological studies. Due to their attractive ability to access larger cohorts and improve validation checks, and thus data quality, these Web-based questionnaires represent an important tool for many epidemiological studies on public health.21,22 Awareness of the symptoms and risk factors for CNSTs is especially critical, since the disease signs tend to be vague and easily overlooked, resulting in a delayed response to take appropriate action. Unfortunately, there is a lack of CNST awareness studies that assess the level of public understanding in many regions of the world. In this study, we aimed to investigate the knowledge concerning CNST signs and symptoms and risk factors, as well as readiness to seek medical advice, among citizens of the Kingdom of Saudi Arabia (KSA) using 2 questionnaire delivery methods.     

The impact of using pictorial aids in caregivers’ understanding of patient information leaflets of pediatric pain medications: A quasi-experimental study

IntroductionPatient information leaflets (PILs) are one of the main sources of information for over-the-counter medications (OTCs). This study aimed to assess caregivers'' understanding of instructions in PILs provided with paracetamol medications and the impact of pictograms use.MethodsA quasi-experimental study was conducted among caregivers of children aged < 13 years recruited in pediatric outpatient clinics at University Medical City in Riyadh. The calculated sample size was 128; at least 64 participants were needed in each group (the text-only group and the text-plus pictograms group). Caregivers'' health literacy was assessed using a validated Arabic version of the Newest Vital Sign scale. Participants’ understanding of PILs instructions was assessed using eight questions on the route of administration, minimal hours between doses, max daily dose, shake medication before use, storage, and reporting adverse events; and was rated based on the number of questions correctly understood. Characteristics of participants were compared by Pearson X² and t-test was used to assess the significance of mean score differences between groups.ResultsA total of 130 caregivers participated in the study; almost half of them were mothers (47%, [n = 61]) and 43% (n = 56) have “a possibility of limited health literacy”. The mean number of correct answers to questions assessing the understanding of PILs instructions was significantly higher among the text-plus pictograms group compared to the text-only group (5.25 ± 1.85 vs. 4.38 ± 1.27; p < 0.001). When results were controlled for age and gender, better health literacy was found to be associated with a better understanding of instructions (B = 0.39, 95 %CI 0.23–0.54).ConclusionLimited comprehension of medications instructions was observed; adding pictorial aids to PILs might enhance the comprehension. Differences in health literacy levels of caregivers should be considered when designing PILs.     

Outcomes of sinonasal mucosal melanomas with endoscopic and open resection: a retrospective cohort study

Journal of Neuro-Oncology - To compare the outcomes of Sinonasal Mucosal Melanomas (SNMM) treated with endoscopic and open resection. A retrospective case review of 20 patients with SNMM treated...