Immediate stenting after thrombolysis leads to a significant reduction of cardiac events compared with a more conservative approach including delayed stenting after two weeks.

The Brugada syndrome is characterized by a distinct ECG pattern consisting of ST segment elevation in the right precordial leads and right bundle branch block, a propensity for life-threatening arrhythmias, and an apparently structurally normal heart. The authors describe the case of a patient with an aborted sudden cardiac death and the typical ECG signs of Brugada syndrome. Nevertheless, magnetic resonance imaging displayed signal enhancement in the left ventricular myocardium. Additionally, histologic examination, in-situ hybridization, and PCR revealed evidence of a locally restricted inflammation due to parvovirus B19. Brugada syndrome is regarded as a primary electrical disease due to dysfunction of distinctive ion channels, but focal myocarditis may serve as a trigger for ventricular arrhythmias in this patient. Further morphologic studies will be helpful to establish the possible role of structural changes in the pathophysiology of this syndrome.

The life threatening hypersensitivity syndrome with fever, eosinophilia, hepatitis, renal failure and skin eruptions as severe as epidermal necrolysis is the most dangerous complication of therapy with allopurinol. The trigger seems to be oxipurinol, the main metabolite of allopurinol, which particularly accumulates in patients with renal failure and concomitant therapy with thiazides. There is no specific treatment of the disease. The use of allopurinol in patients with asymptomatic hyperuricaemia is not indicated in most cases. Dose adjustment according to the clearance of creatinine is mandatory.

Postprocedural hypotension following endovascular stent placement of carotid artery disease (CAS) predicts increased in-hospital complications and long-term risk of death. Intra-aortic balloon counterpulsation (IABP) both increases mean arterial pressure and cerebral blood flow and therefore possibly reduces complications due to hemodynamic instability during and after CAS. In this study, we describe the use of IABP in a patient with severe depression of left ventricular function due to diffuse coronary artery disease undergoing CAS. Controlled studies are necessary to demonstrate a potentially protective role of IABP in high-risk CAS patients.

Multiple sclerosis (MS) care and research face multiple challenges in the Middle East region. The rapidly rising prevalence of the disease in this region, is putting a strain on medical and financial resources. Lack of awareness in the medical community leading to delayed or wrong diagnosis, is still a major drawback. There is an urgent need to improve such awareness by local educational symposia as well as educational grants to train MS specialists in major European and North American medical centers. MS therapies are quite expensive and are nearly always reimbursed by governmental agencies in Middle Eastern countries. Unfortunately, with the recent political and economic instability in the region, the governments have been less inclined to cover such expensive medications especially the most recent ones. The worsening economic and security situation in many Middle Eastern countries, is also affecting the overall healthcare quality provided to MS patients including availability of MS specialists, radiological facilities, physical therapy centers and other supporting services. Legislations regarding handicapped persons including public facilities, jobs, and discrimination are still lagging behind in our region as compared to the West. Public awareness of the disease, although significantly improved over the last decade, is still a major challenge in our region, leading to delayed medical referral, use of unproven or unconventional therapies, and poor adherence to treatment.Research in the field of MS is one of the major challenges we are currently facing in the Middle East. Short of few exceptions, well structured large patient registries, which are the basis of good clinical research, are lacking in the Middle East. MENACTRIMS launched earlier this year the MENACTRIMS Registry Project which aims at establishing and unifying registries all over the Middle East and North Africa region. This project will for the first time provide a large data base from the region and will help define the clinical and epidemiological characteristics of MS in the region. The research infrastructure, including human resources, laboratories, equipment and funding is also lacking in the Middle East, and is another major challenge that need to be addressed in the near future.