Venlafaxine can reduce the migraine attacks as well as amitriptyline: A noninferiority randomized trial.

OBJECTIVES: Migraine, as a primary headache, is among the leading causes of disability worldwide. The present study aimed at comparing the effects of venlafaxine (VLF) and amitriptyline (AMT) reducing the severity and the number of migraine attacks. METHODS: Patients with complaints of migraine attacks were randomly divided into two groups. The first group received amitriptyline at a dose of 25 mg every night, and the second group received venlafaxine at a dose of 37.5 mg daily. The duration of treatment was eight weeks. RESULTS: Eighty patients participated in the current study, out of which 57.5% were females. The mean age of the participants was 33 years, and the mean duration of disease was eight years. Both amitriptyline and venlafaxine significantly reduced the number of attacks per month (AMT: from 10.98 to 2.98, VLF: from 9.98 to 3.18), and six-item Headache Impact Test (HIT-6) score (AMT: from 67.78 to 49.73, VLF: from 66.65 to 48.88), and no significant difference was observed between the two drugs. The results demonstrated no significant relationship between age or disease duration with the score of the HIT-6. The decrease rate in the score of the HIT-6 in males was higher than that of females which shows the modifier role of the gender. Besides, it is noteworthy to mention that the adverse effects of amitriptyline exceeded the venlafaxine among the patients. CONCLUSION: The effectiveness of AMT and VLF in terms of their potential to reduce the intensity and duration of headaches was more noticeable in male patients than female patients. In terms of adverse drug reactions, patients in the amitriptyline group complained more about adverse drug reactions (ADR) than patients in the venlafaxine group. It seems that in similar conditions, venlafaxine could have priority over amitriptyline in migraine prophylaxis.

The prevalence of drug-resistant-epilepsy and its associated factors in patients with epilepsy.

BACKGROUND: Drug-resistant epilepsy (DRE) is a major challenge in patients with epilepsy. The majority of previous studies evaluating the risk factors of DRE have been conducted in children. Therefore, this study aimed to investigate the prevalence of DRE and its associated factors. METHODS: All patients aged over 12 years with an established diagnosis of epilepsy since at least one year before the admission who were admitted with seizure to the neurology ward of a tertiary care hospital were consecutively included from 20th March 2014-19th March 2020. Patients were classified into two groups of DRE and non-DRE groups. The archived files of the patients were retrospectively reviewed and the data were extracted and recorded in a pre-prepared checklist. RESULTS: A total of 410 patients were investigated. The most common causes of epilepsy were idiopathic (58.3%), vascular (23.9%), and cerebral palsy (CP)/developmental disorders (8.8%). There was no significant difference between DRE and non-DRE patients in terms of age, sex, seizure type (generalized/partial). Vascular causes were more prevalent in the non-DRE group, and idiopathic, post-traumatic/surgery, MS/degenerative, CP/developmental disorders, and space-occupying lesions were more prevalent in the DRE group. In multivariate regression analysis only the presence of CP/developmental disorders was independently associated with a higher probability of DRE (adjusted OR = 3.17, 95% CI = 1.21-5.12, p = 0.0415). CONCLUSION: The prevalence of DRE is still considerably high. Therefore, considering its serious consequences, more investigations should be carried out to determine proper strategies for reducing its incidence. We found the history of CP/developmental disorders to be independently associated with DRE. Therefore, perinatal care to reduce the incidence of CP/developmental disorders and encouraging these patients to use their medications accurately may be helpful.

Evaluation of the Relationship Between Celiac Disease and Refractory Epilepsy in Patients Referring to Imam Khomeini Hospital, Urmia.

Introduction: Celiac disease can be associated with other diseases, including neurological disorders. In this study, the relationship between celiac disease and refractory epilepsy was evaluated in patients who were referred to Imam Khomeini Hospital in Urmia. Methods: In this cross-sectional study, patients with refractory epilepsy who were referred to the neurology clinic of Imam Khomeini Hospital in Urmia, during the second half of 2019 and cases with controlled epilepsy were studied as a control group. The statistical population of the present study included 50 patients with refractory seizures and 50 patients with controlled seizures. The mean age of patients was 32.96±11.35 years. Five milliliters of blood samples were taken from the patients, and a serum anti-tTG test was performed using the ELISA kit. Then, in patients with positive anti-tTG, a duodenal biopsy sample was prepared using an endoscopy. Results: This study showed that the mean serum level of anti-tTG in patients with refractory epilepsy was higher than in patients with controlled epilepsy. Anti-tTG test results were positive in five out of 50 patients with refractory epilepsy, and it was positive in two out of 50 patients with controlled epilepsy. There was no significant difference between the two groups in terms of serum levels of anti-tTG (P=0.14). Also, there was no significant relationship between serum levels of anti-tTG, age, and genus (P>0.05). Biopsy results in three patients in the refractory epilepsy group and one patient in the controlled epilepsy group were in favor of a definitive diagnosis of celiac disease. Patients with confirmed celiac disease using endoscopy had higher anti-tTG levels (P=0.006). Conclusion: There was no significant difference between celiac disease in cases with refractory epilepsy and controlled epilepsy.

Sodium valproate compared to phenytoin in treatment of status epilepticus.

Background: Status epilepticus (SE) is a neurological emergency which can be life-threatening. Several medical regimens are used in order to control it. In this study, we intended to evaluate the clinical efficacy and tolerability of sodium valproate and intravenous phenytoin (IV PHT) in the control of SE. Methods: One hundred and ten consecutive patients suffering from benzodiazepine refractory SE who were referred to the emergency ward from March 2014 to March 2015 were randomly divided into two groups. The first group received intravenous sodium valproate, 30 mg/kg as loading dose and then 4-8 mg/kg every 8 hr as maintenance regimen. The second group received IV PHT 20 mg/kg as loading dose and then 1.5 mg/kg for 8 hr as maintenance therapy. All patients were monitored for vital signs every 2 hr up to 12 hr. The patients were also followed up for 7 days regarding drug response and adverse effects. Results: The administration of sodium valproate and phenytoin respectively resulted in seizure control in 43 (78.18%) and 39 (70.90%) of the patients within 7 days of drug administration (p = .428). Seven-day mortality rate was similar in both groups (12.73% vs. 12.73%; p = .612). There was no significant difference in adverse effects between two groups. Conclusion: Sodium valproate is preferred to IV PHT for treatment and control of SE due to its higher tolerability and lower hemodynamic instability.

Comparison of the effect of topiramate versus gabapentin on neuropathic pain in patients with polyneuropathy: A randomized clinical trial.

BACKGROUND: Neuropathic pain is one of the most common complaints of neurologic clinics. Neuropathic pain is common and important and has inappropriate complications, and despite their importance, there is no effective treatment for them. OBJECTIVE: Because of the importance of neuropathic pain and safe and effective treatment, in this study, we determined the effect of topiramate versus gabapentin in patients with neuropathic pain. METHODS: In this randomized clinical trial, 30 patients with pain attributed to neuropathy who had at least one month of neuropathic pain in one area, were randomized to receive either gabapentin, titrated from 300 mg/day to a maximum of 900 mg/day or topiramate, titrated from 50 mg/day to a maximum of 100 mg/day after a 4-week period in the neurology clinic of Imam Khomeini Hospital of Urmia city, Iran in 2015. Complication, drug tolerance rate and pain were investigated. The pain was measured on visual analog scale (VAS). The data were analyzed by SPSS version 18, and using descriptive statistics, t-test, and ANOVA. RESULTS: In patients treated by gabapentin, the primary pain score was 74.33±10.29, this score decreased to 49.46±11.41 and 29.93±11.92 in the second and fourth week after intervention with gabapentin. In topiramate treated patients, the primary score was 76.00±9.69. It decreased to 54.33±10.31 and 34.20±6.09 at the same time. There were no significant differences between both groups in terms of average reduction of pain intensity [gabapentin group (59.73%) compared with topiramate (55%) (p=0.48)]. In the present study, the only complication reported in patients treated by gabapentin was drowsiness, but other uncommon side effects were nausea and dizziness. CONCLUSION: This study showed that both gabapentin and topiramate reduce pain. Topiramate can also be a good alternative choice, if gabapentin has side effects for patients and it cannot be tolerated, topiramate can be a good replacement. TRIAL REGISTRATION: The trial was registered at the Thai Registry of Clinical Trials (http://www.clinicaltrials.in.th) with the TCTR ID: TCTR20170615001. FUNDING: This research has been financially supported by Research Council of Urmia University of Medical Sciences.

Clinical Outcomes of Myasthenia Gravis with Thymoma and Thymic Hyperplasia Undergoing Extended Transsternal Thymectomy: A Single-Center Experience.

BACKGROUND: Despite the widespread use of thymectomy in myasthenia gravis (MG) patients, it has remained controversial as to whether this procedure is of a similar efficacy and clinical outcome among MG patients with thymoma and thymic hyperplasia. AIM: We sought to determine the long-term clinical outcomes of MG patients who received extended transsternal thymectomy associated with pyridostigmine and prednisolone postoperatively. MATERIALS AND METHODS: In a retrospective study from January 1999 to December 2013, MG patients who underwent thymectomy were followed up. Out of 41 MG patients admitted in our center, 25 patients had undergone thymectomy adjunctive to pyridostigmine and prednisolone therapy postoperatively. The primary endpoints included improvement in individual diplopia, ptosis, dysphagia, dysarthria, dyspnea, and limb weakness. In addition, according to the MG Foundation of America (MGFA) criteria, response to therapy was defined as complete stable remission (CSR), pharmacologic remission (PR), and minimal manifestation (MM) as secondary endpoints. RESULTS: Majority of the patients were male (60%) and the mean age of the patients was 32.2 ± 13.9 years. Fifteen (60%) and 10 patients (40%) had thymoma and thymic hyperplasia, respectively. All the patients were followed up during a mean period of of 86.9 ± 50.3 months (minimum 10 months and maximum 168 months). The rates of CSR, PR, and MM were comparable between the thymoma and thymic hyperplasia groups (P = 0.584). Based on the Kaplan Meier analysis, the probabilities of CSR, PR, and MM were not significantly different between patients with thymoma and thymic hyperplasia. CONCLUSION: The extended transsternal thymectomy, along with the postoperative regimen of pyridostigmine and prednisolone was associated with a high rate of clinical improvement among MG patients with thymoma or thymic hyperplasia.

Application of Texture Analysis in Diagnosis of Multiple Sclerosis by Magnetic Resonance Imaging.

INTRODUCTION: Visual inspection by magnetic resonance (MR) images cannot detect microscopic tissue changes occurring in MS in normal appearing white matter (NAWM) and may be perceived by the human eye as having the same texture as normal white matter (NWM). The aim of the study was to evaluate computer aided diagnosis (CAD) system using texture analysis (TA) in MR images to improve accuracy in identification of subtle differences in brain tissue structure. MATERIAL & METHODS: The MR image database comprised 50 MS patients and 50 healthy subjects. Up to 270 statistical texture features extract as descriptors for each region of interest. The feature reduction methods used were the Fisher method, the lowest probability of classification error and average correlation coefficients (POE+ACC) method and the fusion Fisher plus the POE+ACC (FFPA) to select the best, most effective features to differentiate between MS lesions, NWM and NAWM. The features parameters were used for texture analysis with principle component analysis (PCA) and linear discriminant analysis (LDA). Then first nearest-neighbour (1-NN) classifier was used for features resulting from PCA and LDA. Receiver operating characteristic (ROC) curve analysis was used to examine the performance of TA methods. RESULTS: The highest performance for discrimination between MS lesions, NAWM and NWM was recorded for FFPA feature parameters using LDA; this method showed 100% sensitivity, specificity and accuracy and an area of Az=1 under the ROC curve. CONCLUSION: TA is a reliable method with the potential for effective use in MR imaging for the diagnosis and prediction of MS.

An open-label evaluator-blinded clinical study of minocycline neuroprotection in ischemic stroke: gender-dependent effect.

OBJECTIVES: Minocycline as an antibiotic has been found to have neuroprotective effect on neurodegenerative diseases. This study was aimed at determining the efficacy of minocycline adjunct to aspirin in improving neurological outcomes of ischemic stroke during 3-month follow-up. METHODS AND MATERIALS: In an open-label evaluator-blinded trial, 60 patients with ischemic stroke were allocated into two groups to receive either 200 mg of oral minocycline daily for 5 days during 6-24 h following onset of signs and symptoms, or not receiving any, as control; all patients also received 100 mg of aspirin daily. Clinical assessment at baseline and on days 30, 60, and 90 was performed using National Institutes of Health Stroke Scale (NIHSS) score. RESULTS: Fifty-three patients (88.3%) completed the study. Females in the treatment and control groups were 53.8% and 51.9%, respectively (P = 0.884). Among all patients, NIHSS score was significantly lower in the minocycline-treated compared with control on day 90 (minocycline median 4, interquartile range 4-7, control median 7, interquartile range 5-8, P = 0.031). Among males, NIHSS was lower in minocycline-treated compared with controls on days 30, 60, and 90 (P < 0.05); however, females showed no significant differences at the same times compared with controls. No adverse outcomes including myocardial infarction, recurrent stroke, and mortality were observed in the both groups. CONCLUSION: Patients with ischemic stroke who received oral minocycline daily for 5 days had significantly better neurological outcomes on day 90 than controls. However, females showed no significant clinical improvement compared to males.

Cerebrolysin effects on neurological outcomes and cerebral blood flow in acute ischemic stroke.

BACKGROUND: Cerebrolysin, a brain-derived neuropeptide, has been shown to improve the neurological outcomes of stroke, but no study has demonstrated its effect on cerebral blood flow. This study aimed to determine the cerebrolysin impact on the neurological outcomes and cerebral blood flow. METHODS: In a randomized, double-blinded, placebo-controlled trial, 46 patients who had acute focal ischemic stroke were randomly assigned into two groups to receive intravenously either 30 mL of cerebrolysin diluted in normal saline daily for 10 days (n=23) or normal saline alone (n=23) adjunct to 100 mg of aspirin daily. All patients were examined using the National Institutes of Health Stroke Scale and transcranial Doppler to measure the mean flow velocity and pulsatility index (PI) of their cerebral arteries at baseline as well as on days 30, 60, and 90. RESULTS: The patients' mean age was 60±9.7 years, and 51.2% of patients were male. The National Institutes of Health Stroke Scale was significantly lower in the cerebrolysin group compared with the placebo group on day 60 (median 10, interquartile range 9-11, P=0.008) and day 90 (median 11, interquartile range 10-13.5, P=0.001). The median of PI in the right middle cerebral artery was significantly lower in the cerebrolysin group compared with the placebo group on days 30, 60, and 90 (P<0.05). One patient in the cerebrolysin group and two patients in the placebo group died before day 30 (4.3% versus 8.7%). CONCLUSION: Cerebrolysin can be useful to improve the neurological outcomes and the PI of middle cerebral artery in patients with acute focal ischemic stroke.

Short fourth and fifth metacarpals in a case of idiopathic primary hypoparathyroidism.

Shortening of metacarpals is a useful diagnostic marker in patients with pseudohypoparathyroidism type Ia (PHP-Ia) with Albright's hereditary osteodystrophy (AHO) phenotype or pseudopseudohypoparathyroidism (PPHP). There are very rare reports of metacarpals shortening in idiopathic primary hypoparathyroidism (IPH) cases in the literature. Here we described a young woman with IPH who presented with hypocalcaemia and generalized tonic-clonic seizure. She had shortening of forth and fifth metacarpals which was prominent in her right hand. Based on our finding and other previous case reports we conclude that metarpals shortening is not a specific finding of PHP-Ia or PPHP and it may be found in IPH cases.