LSN MS guidelines for the management of multiple sclerosis

OBJECTIVE

The prevalence of multiple sclerosis (MS) in Lebanon is unknown, as there are no available or reliable epidemiological studies to date. The circumstances of Middle East countries are different from those of Europe and North America in terms of differential diagnoses and disease management. The aim of the conference is to establish guidelines for diagnosis, treatment, follow-up and management of patients with MS in Lebanon. Another objective is to discuss and participate in research projects based on epidemiology, clinical trials and more fundamental aspects of the disease in the future.

METHODS

Under the authority of the Lebanese Society of Neurology (LSN), a group of neurologists took the initiative to participate in this LSN MS committee with the purpose of establishing a consensus for the management of patients with MS, and under the supervision of a Coordinator (A.T.) designed by the LSN board.

RESULTS

Diagnostic and therapeutic, follow-up and research recommendations were proposed with special emphasis on the specific needs and circumstances of Lebanon. The experts highlighted the importance of considering particular needs, the identification of patients at high risk of developing MS in order to maximize therapeutic opportunities, and cost-effective control of treatment efficacy, as well as global assessment of disability.

CONCLUSIONS

The experts established guidelines concerning diagnosis, treatment, and follow-up of patients with MS in Lebanon. Furthermore, they recommended some clinical and fundamental research projects.

[Stimulation probe, by involuntary transseptal ventricular trajectory]

The introduction in the left ventricle of a stimulation probe, by an involuntary ventricular transseptal trajectory can pass unobserved during the implantation and can be revealed later on occasion of complications. It is a rarely described possibility and can have some serious consequences. We discuss through our observation ways to avoid this trap of the definitive cardiac stimulation.

[Quantification of longitudinal myocardial velocities by Doppler tissue imaging during dobutamine echocardiography]

Doppler tissue imaging has been suggested to be a valuable method for the diagnosis of myocardial ischaemia during dobutamine echocardiography. The authors studied this mode of investigation in 49 consecutive patients (average age 60 +/- 12 years) referred for dobutamine stress echocardiography and who had undergone coronary angiography. The stress echo was carried out according to a standard protocol (5 to 40 m g/kg/min +/- atropine) with additional acquisition of 3 apical views (4, 2 and 3 chambers) with colour Doppler tissue imaging. Analysis of systolic and diastolic myocardial velocities was performed afterwards from digitised data. The different Doppler tissue parameters were measured in 12 left ventricular segments (excluding the apical segments) for each dosage of dobutamine: peak systolic velocity (S), Q-S duration, systolic velocity time integral (ITVS), peak early diastolic velocity (E), peak end diastolic velocity (A). These parameters were analysed throughout the stress for each segment without significant coronary stenosis to define normal values. ROC curves were constructed to determine threshold values of relative changes of velocity (between maximal dobutamine dosage and basal conditions) to improve detection of ischaemia in a segment with coronary stenosis (vessel diameter reduction > or = 70%). Similar diagnostic performances were observed with different systolic and diastolic parameters. The feasibility of measurement of diastolic velocities was, however, reduced (from 29% to 49%). The diagnostic accuracy of each parameter was the same for each vessel territory. A satisfactory concordance was observed between 2D echocardiography and Doppler tissue imaging for the detection of significant coronary stenosis in an analysis by vascular territory. The authors conclude that analysis of myocardial velocities during dobutamine stress echocardiography is feasible. It may be a useful complement for the detection of coronary stenosis during pharmacological stress echocardiography.

Difficult percutaneous mitral commissurotomy: failure of the Inoue balloon technique and successful double-balloon technique

From December 1994 to May 1999, 487 patients underwent percutaneous transvenous mitral commissurotomy according to the Inoue balloon technique for tight mitral stenosis. In three cases, the Inoue balloon technique was not possible because the catheter balloon could not enter the mitral orifice and the double-balloon technique was performed instead. In two cases, a flow-guided balloon catheter met the mitral orifice and the double-balloon technique was effective. In the third case, passing the valve with a flow balloon catheter was impossible, a 0.032" Terumo straight wire crossed the valve, which was dilated with a single balloon the first time and a double balloon the second time. The mitral valve area increased in the three cases from 0.8 to 1.8 cm2, from 0.7 to 1.6 cm2, and from 0.5 to 1.5 cm2, respectively. There were no complications.

[Coronary aneurysm in Behcet's disease. Report of a case]

Cardiac involvement is rare in Behçet's disease. The authors report the case of a young patient with Behçet's disease and multiple cardiac complications. The remarkable feature of this case was the presence of a coronary artery (first diagonal) aneurysm associated with multiple venous thromboses. Anticoagulant therapy was changed for a platelet aggregant. Surgery was not indicated because of the fragility of the vessels.

[Percutaneous transluminal valvuloplasty in congenital pulmonary stenosis in adults. Apropos of 34 cases]

Percutaneous pulmonary valvulotomy is the treatment of choice for isolated congenital pulmonary valvular stenosis in childhood. However, experience of this procedure in the adult is much more limited. Between January 1984 and December 1994, 34 patients with severe or moderate pulmonary valvular stenosis underwent percutaneous transluminal valvuloplasty. The age of the patients ranged from 20 to 47 years (mean 22 +/- 4 years). Cardiac catheterisation was performed using the femoral vein in 27 cases and the internal jugular vein in 7 cases. Success was obtained in 28 patients (81% of cases). Pulmonary artery-right ventricular pressure gradient decreased from 113 +/- 35 to 32 +/- 13 mmHg (p < 0.001) after valvuloplasty with one or two balloon catheters. The tolerance of transluminal valvuloplasty was generally good. The poor results were explained by cases of dysplasic valves or of infundibular reactions. There was one death which occurred 24 hours after the procedure. Clinical and echocardiographic follow-up was obtained in 20 patients, 3 to 36 months after valvuloplasty (average: 23 +/- 13 months). No cases of restenosis were observed. Percutaneous transluminal pulmonary valvuloplasty in the adult is feasible and gives good results which are maintained at medium-term; it has become the treatment of choice of valvular pulmonary stenosis and gives good results which are maintained at medium-term, thereby avoiding surgical valvulotomy.

[Cavernous sinus thrombosis. Late diagnosis and complications]

We report a case of cavernous sinus thrombosis in an 8-year-old boy, following a neglected and untreated nasal furuncle. This rare entity is manifested by hyperthermia, with headache, vomiting and involvement of the III-IV & VI cranial nerves. It is usually a complication of a facial infection. The diagnosis is established by CT-Scan or MRI. Without appropriate and early treatment, the prognosis is poor, with a fatal outcome or severe sequelae.

Mechanism of resistance to amikacin and kanamycin in Mycobacterium tuberculosis

An A1400G mutation of the rrs gene was identified in Mycobacterium tuberculosis (MTB) strain ATCC 35827 and in 13 MTB clinical isolates resistant to amikacin-kanamycin (MICs, >128 microg/ml). High-level cross-resistance may result from such a mutation since MTB has a single copy of the rrs gene. Another mechanism(s) may account for high-level amikacin-kanamycin resistance in two mutants and lower levels of resistance in four clinical isolates, all lacking the A1400G mutation.

[Tumor in the right cardiac chambers. Regression after antitubercular treatment. Apropos of a case]

The authors report the case of a young patient with a tumour of the right atrium and right ventricular outflow tract without visceral complications but with multiple muscular and skin localisations. The diagnosis of tuberculosis was made on biopsy of a suppurating skin lesion. The diagnosis of tuberculosis was made on biopsy of a suppurating skin lesion. Anti-tuberculosis treatment resulted in regression of these tumours, especially the cardiac lesions, confirmed by transoesophageal echocardiography.

[Ulcero-hemorrhagic rectocolitis: operative morbidity and mortality. Apropos of 100 cases]

We performed a retrospective analysis of morbidity and mortality in 100 cases of ulcerative colitis treated at the surgical care unit of the Ibn Sina hospital over a 10 year period from 1984 to 1994. One major complication, usually infection, was observed in 40% of the cases. Overall mortality was 22%, a rate higher than the larger published series. The main factor incriminated in our study ; besides surgical circumstances, was the delay in care, including in the intensive care unit. It must be concluded that medical and surgical management must be initiated as soon as a flare up is diagnosed.

[Early surgery in acute endocarditis complicated by cardiac insufficiency; the Moroccan experience]

The aim of this review of 20 cases was to identify the surgical indications in heart failure complicating the acute phase of left heart valve endocarditis, to determine the optimal timing of surgery and to evaluate the early and medium term postoperative prognosis. Between January 1985 and May 1990, 20 patients (14 men and 6 women with an average age of 29 +/- 7 years) with native left heart valve endocarditis underwent surgery in the acute phase complicated by heart failure. The were 9 aortic regurgitations and 2 mixed mitral and tricuspid regurgitations. The haemodynamic status of the patients was poor before surgery: 15 NYHA class IV and 5 class III. The average time from the onset of heart failure to surgery was 21 days. The surgical procedure was monovalvular replacement in 14 cases, double valve replacement in 4 cases and 2 isolated mitral valvuloplasties. Two patients died in the first postoperative month of irreducible low output syndrome. One patient was reoperated early for dehiscence of a mechanical valve prosthesis. Late complications included 2 cerebrovascular accidents and one reoperation for degeneration of a bioprosthesis. There were no late fatalities. Seventeen of the 18 survivors are regularly followed up with an average of 80 months follow-up: 12 NYHA class I and 5 class II. The most useful prognostic factor was the preoperative haemodynamic status.(ABSTRACT TRUNCATED AT 250 WORDS)

[Correlation between the persistence of ST elevation and left ventricular aneurysm in the post-infarction period]

The objective of this study was to verify whether the persistence of ST elevation on ECG after myocardial infarction was well correlated with the presence of left ventricular aneurysm. This study concerns 30 male patients with a mean age of 46 +/- 7.6 years, with ST elevation of more than 1 mm on ECG, at least 15 days after the presumed onset of myocardial infarction. All patients were investigated by echocardiography and cardiac catheterization. ST elevation was recorded in the ECG leads corresponding to the site of necrosis. 2D echocardiography identified 21 cases (70%) of left ventricular aneurysm and cardiac catheterization revealed 26 cases (86%). The electrical site of ST elevation was correlated with the site of the aneurysm. In conclusion, the persistence of ST elevation on the ECG more than 15 days after the onset of myocardial infarction has a good predictive value for the presence of left ventricular aneurysm, which can only be confirmed by cardiac catheterization.