Time interval between the onset of symptoms and diagnosis of multiple sclerosis and the influential factors: A national registry-based study.

OBJECTIVE: The time to diagnosis of multiple sclerosis (MS) is of great importance for early treatment, thereby reducing the disability and burden of the disease. The purpose of this study was to determine the time from the onset of clinical symptoms to the diagnosis of MS and to evaluate the factors associated with a late diagnosis in Iranian MS patients. METHODS: The present cross-sectional study was conducted on patients with MS who were registered in the National MS Registry System of Iran (NMSRI). RESULTS: Overall, 23291 MS patients registered in 18 provinces of Iran were included in this study. The mean (standard deviation) interval between the onset of the disease and diagnosis of MS was 13.42 (32.40) months, and the median was one month. The diagnostic interval of 41.6% of patients was less than one month, and 14.8% of them had a one-month time to diagnosis. Patients with an age of onset below 18 years and those diagnosed after the age of 50 years had a longer time to diagnosis (P<0.001). Patients with primary progressive MS (PPMS) had the longest time to diagnose and those with relapsing-remitting MS (RRMS) had the shortest time (P<0.001). The results of negative binominal regression showed that the average rate of delay in diagnosis in women was 12% less than that in men. The average delay in diagnosis in patients with a positive family history of MS was 23% more than that in others. The rate of delay in the diagnosis of patients with PPMS and secondary progressive MS was 2.22 and 1.66 times higher, respectively, compared with RRMS. CONCLUSION: The findings of the present study revealed that more than half of the MS patients were diagnosed within a one-month interval from the symptom onset, which is an acceptable period. More attention should be paid to patients' access to medical facilities and MS specialists.

Safety and Effectiveness of Cinnomer® on Disease Characteristics, Depression, and Quality of Life of Patients with Multiple Sclerosis: A Phase IV, Post-marketing, Prospective, Multicenter Study.

BACKGROUND: Every patient diagnosed with definite multiple sclerosis (MS) should begin disease modifying therapies. Cinnomer® contains 40 mg glatiramer acetate (GA) and is available in prefilled syringes and autoinjector devices. METHODS: A phase IV multicenter study was conducted to explore the safety and effectiveness of Cinnomer® in the treatment of MS. Study-related data were collected for 14 months. RESULTS: Totally, 368 Iranian relapsing-remitting MS patients in nine cities were enrolled. The patients were either treatment naïve (n=191) or switchers (n=177). Cinnomer® treatment was associated with a significant reduction in annual relapse rate (ARR) (RR: 0.65, 95% CI: 0.43, 0.98). Final mean Expanded Disability Status Scale (EDSS) scores showed improvement from baseline (difference: -0.21, 95% confidence interval (CI): -0.34, -0.08). There was a significant decrease in gad-enhancing lesions during treatment (difference: -0.38, 95% CI: -0.64, -0.12). The mean score for the depression measure (21-item BDI-II questionnaire) significantly improved (difference: -2.39, 95% CI: -3.74, -1.03). There was a significant change in the "psychological well-being" dimension (P=0.02) (in line with BDI-II scores) and "rejection" MusiQoL dimensions (P=0.04). The adverse events documented throughout the study were not unexpected for GA and were principally not serious. CONCLUSION: Safety measures were in line with the known profiles of GA. The results suggest that Cinnomer® is effective with respect to clinical outcomes and from the patient's perspective and in reducing MRI-measured MS activity.

Economic and Social Standing of Individuals in Iran Diagnosed with Multiple Sclerosis.

BACKGROUND: Multiple sclerosis (MS) may be affected by socioeconomic status (SES). This study aims to explore the determinants of SES among Iranian patients with MS and examine how these factors relate to disability and disease progression. METHODS: All patients with MS listed in the nationwide MS registry of Iran (NMSRI) until January 8, 2022, were included in this population-based study. RESULTS: Among the 5153 patients, most were female (74.5%), married (70.8%), and did not hold an academic degree (53.8%). Unemployment (OR: 3.75) and being unmarried (OR: 2.60) were significantly associated with Expanded Disability Status Scale (EDSS)≥6, and the time to progression was shorter in the unemployed group (P value: 0.03). There was also a significant negative correlation between the time to progression and the age at disease onset. CONCLUSION: The study suggests that providing financial and social support to MS patients and their families through investment could reduce both individual and societal burdens.

Epidemiology of familial multiple sclerosis and its comparison to sporadic form in Markazi Province, Iran.

BACKGROUND: Limited data have been published about the epidemiology of familial multiple sclerosis (FMS) and its comparison to the sporadic form. Additionally, the epidemiology of FMS varies significantly in numerous provinces of Iran. OBJECTIVES: The current study aimed to establish the epidemiology and clinical presentations of FMS and compare this form of the disease to sporadic multiple sclerosis (SMS) in Markazi province, Iran. METHODS: In this cross-sectional registry-based study, the data were collected by the Multiple Sclerosis (MS) Society of Markazi province within 2012-2021. The demographic and clinical characteristics, diagnosis, and treatment of the MS patients living in the province were registered in this system. RESULTS: A total of 924 MS cases who completed the data about the familial history of MS participated in this study. Based on the results, the female/male ratios were equal to 3.11 and 3.96 in FMS and SMS groups, respectively. Furthermore, 29.4% of the individuals had a history of the disease in their first- to third-degree relatives. The prevalence of primary-progressive multiple sclerosis was higher among the FMS patients (8.5%) than in the SMS patients (4.6%). Along with motor, sphincter, cognitive, and brain stem signs as the onset symptoms, the FMS group experienced a higher rate of polysymptomatic onset (P = 0.000). Moreover, significantly more autoimmune diseases and consanguineous marriages (P = 0.000) were observed in the FMS group than in the SMS group. The individuals with FMS reported a higher mean number of recurrences and higher Expanded Disability Status Scale (EDSS) scores (P = 0.000). CONCLUSION: The results showed a significant prevalence of FMS in Markazi province. The FMS and SMS patients were significantly different regarding first presentations, onset symptoms, MS clinical characteristics, and EDSS scores. Finally, consanguineous marriage was significantly more common in the FMS group than in the SMS group.

Prescription trends of disease-modifying treatments for multiple sclerosis in Iran over the past 30 years.

BACKGROUND: Iran, as a middle income country, is one of the places with high and rising prevalence of multiple sclerosis (MS). Regarding the substantial economic burden, reviewing the trend in prescribed disease modifying treatments (DMTs) could be of help. Here we studied the DMT information of nearly 14000 MS cases and its trends change for 30 years to improve health services to patients. METHODS: The population base of this descriptive-analytical (cross-sectional) study consisted of all MS patients in the nationwide MS registry of Iran (NMSRI), up to August 1, 2021. Registrars from 15 provinces, 24 cities, 13 hospitals,8 MS associations, 16 private offices, and 7 clinics had entered the data. RESULTS: Overall, 14316 cases were enrolled. The majority (76.1%) were female. The youngest and eldest patients were 5 and 78 years old, respectively. Diagnosis delay was under one year in most cases (median: 0, IQR: 0 - 1). Most (61.4%) had RRMS. Generally, platform injectables (IFN beta, glatiramer acetate) were the most used DMTs until 2010. It seems that introduction of newer agents (antiCD20s and oral DMTs) resulted in a decrease in the use of former drugs since around 2015. Some unusual practices are prominent such as using not approved DMTs for PPMS over the years, or administering high efficacy drugs like natalizumab for CIS. The results indicate the remaining popularity of first line injectable DMTs in female and pediatric patients. DISCUSSION: Mean age (SD) at onset in our study (29 ± 8.8) is near the statistics in Asia and Oceania (28 ± 0.7). Concerns about COVID-19 had a noticeable impact on administering high efficacy drugs like rituximab and fingolimod. However, in male patients this approach has not been the case. It may be related to more aggressive disease course in this group. The other possible explanation could be planning for pregnancy in female cases. The popularity of platform injectable drugs in pediatric MS may be related to its favorable safety profile over the years. Another point in this group, is the superiority of rituximab over other highly efficient medications.

Temporal Incidence and Prevalence Trends of Multiple Sclerosis in Markazi Province, Iran.

BACKGROUND: The epidemiology of multiple sclerosis (MS) exhibits significant variability all over the world. Additionally, the incidence and prevalence of the disease are geographically diverse in the different provinces of Iran. OBJECTIVES: Due to the lack of a research about the epidemiology of MS in the Markazi province of Iran, the present study aimed to estimate its prevalence and incidence in this province. METHODS: This cross-sectional register study was conducted according to the data related to the MS Society of Markazi province. The inclusion criteria were definite MS during 2010-2019, residence in Markazi province, and membership in the MS society of Markazi province. The annual incidence and prevalence of MS (per 100,000 person-years) were computed by sex and age groups. Further, age-standardized prevalence and incidence rates were calculated based on the Iranian population. A gamma regression model with log link was utilized for comparing the rates over time statistically. The prevalence and incidence rates were computed by using Excel, and R 4.0.5 was applied to fit the gamma model. RESULTS: In the study, the total number of MS cases was 1,391, among whom 1,098 (78.9%) and 293 (21.1%) were females and males, respectively. The onset of MS occurred at the mean (S.D) age of 31.76 (8.98) years with a female/male ratio of 3.75. During the study period (2010-2019), the incidence rate of the disease was on the decline, while the prevalence rate elevated, by indicating a rising trend in MS prevalence in both sexes. CONCLUSION: The results represented the decreasing and increasing trend of the incidence and prevalence of MS in Markazi province over the recent years. The province is one of the regions with a high prevalence and incidence rate of MS compared to the national and global statistical data.

The Serum Oxidative Stress Biomarkers and Selenium Levels in a Group of Migraine Patients Compared with Healthy Controls: a Case-Control Study.

Migraine is one of the most common neurological disorders associated with recurrent attacks of moderate to severe headache. Oxidative stress may play an important role in migraine pathogenesis. This study aimed to measure and compare the serum levels of Selenium, total antioxidant capacity (TAC), and malondialdehyde) MDA (in migraine patients and healthy individuals. This case-control study was performed on 31 migraine patients and 30 age and gender-matched healthy controls. The severity of headache was assessed with a standard questionnaire, and the serum levels of Selenium (Se), MDA, and TAC were measured via biochemical methods. The odds of migraine were calculated across quartile of Se and oxidative stress biomarkers via binary logistic regression. Migraine patients had a significant lower Se levels (81.06 ± 8.66 vs. 88.94 ± 10.23 µg/L, P = 0.002) and a significant higher MDA levels (3.04 ± 1.74 vs. 2.06 ± 0.59 nmol/ml, P = 0.005) compared to healthy participants. Although serum TAC levels (1.34 ± 0.34 vs.1.37 ± 0.33 mmol/L, P = 0.755) were not significantly different between migraine patients rather than healthy subjects. Individuals in the lowest quartile of Se levels were about eleven times more likely to have migraine than those in the highest quartile (OR: 11.2; 95%CI: 1.57 to 80.2; P-trend: 0.016). Besides, being in the highest quartile of the serum MDA level, the odds of having migraine increases 15.4 times compared to the lowest quartile (OR = 15.4, 95%CI: 1.1 to 221, P = 0.044). No significant association was found between TAC and migraine. The lower Se and MDA levels in migraine patients gives rise to the probability which oxidant status may play an underlying role in migraine pathophysiology.

Reduced regulatory T lymphocytes in migraine patients.

Objectives: Migraine is a primary headache disorder with unknown pathophysiology. Recently, many studies have suggested the role of immune dysfunction in the pathophysiology of this disorder. In this study, we investigated the percentage of regulatory T cells (Treg cells) in different migraine categories.Methods: Peripheral blood samples of 40 newly diagnosed cases of migraine and 33 healthy individuals were collected for Treg cell analysis by flow cytometry.Results: The percentage of Treg cells in migraine patients with all subgroups including patients with or without auras and patients with chronic or episodic migraine was significantly lower than that of the control group. Also, a significant increase in the CD25 means fluorescence intensity (MFI) was observed in migraine without aura and chronic migraine groups, compared to the normal group.Conclusions: In this study, the number of Treg cells significantly decreased in new cases of migraine, which suggests that migraine is a result of an impairment in the immunological system or an autoimmune disease. Also, the insignificant difference in the number of Treg cells between the two categories of migraine suggests that there is no link between the reduced number of Treg cells and the emergence of aura symptoms or duration of the disease.

Occupational performance of individuals with Multiple Sclerosis based on disability level in Iran.

Background: Multiple sclerosis (MS) is a common disease across the world as well as in Iran. Individuals with MS usually experience occupational performance problems that result in limitations in their daily life. This study aimed to determine the occupational performance of individuals with MS based on the disability level in Iran. Methods: In this cross-sectional study, 50 individuals with MS (20 to 50 years old) were recruited through a convenience sampling strategy from different clinics in Arak City, Iran, during 2016-2017. The Persian versions of Canadian Occupational Performance Measure (COPM) and Expanded Disability Status Scale (EDSS) were used to assess the status of occupational performance and level of disability. The data were analyzed using chi-square, Spearman's rank correlation, and Mann-Whitney U tests. Results: The total number of 248 occupations were identified as difficult to perform in the following areas: 125 (50.40%) in self-care, 58 (23.38%) in productivity, and 65 (26.20%) in leisure. In addition, the prioritized occupations (n = 149, median: 3, range: 1-4) had significant difference in the distribution of occupations compared with the non-prioritized occupations (P < 0.0001) and the ratings for performances and satisfactions were generally low. There were significant differences between the occupational performance and level of EDSS. Conclusion: The findings of current study suggest that individuals with MS suffer from widespread problems in the areas of occupational performance, particularly in self-care. The findings emphasize the need for identifying the problems of daily occupations in individuals with MS.

Combination therapy with interferon beta-1a and sesame oil in multiple sclerosis.

OBJECTIVES: Multiple sclerosis (MS) is an autoimmune disease of the central nervous system. Several effector mechanisms are involved in the immunopathology of MS and a variety of medications such as beta interferons are applied to treat the disease. This study was conducted to evaluate the anti-inflammatory and immunomodulatory effects of sesame oil in combination with interferon beta-1a in MS treatment. METHODS: Ninety-three MS patients were enrolled in the study. The patients were randomly divided into two groups. The control group (n = 39) received 30 µg/week of interferon beta-1a intra-muscularly. The sesame oil-treated group (n = 54) received interferon beta-1a the same as the control group with the addition of 0.5 ml/kg/day of oral sesame oil for 6 months. RESULTS: After the 6-month study period, the interleukin (IL)-10 concentration in the sesame oil-treated group was significantly greater than that of the control group (p = 0.04). The concentrations of interferon-γ (IFN-γ), nitric oxide (NO), and tumor necrosis factor-α (TNF-α) in the sesame oil group after treatment were significantly less than those of the control group (p = 0.029, p = 0.0001, and p = 0.01, respectively). Lymphocyte proliferation in the sesame oil-treated group was significantly lower at the end of the study than at the beginning (p = 0.001). CONCLUSION: Sesame oil, through a decrease in IFN-γ secretion and anti-inflammatory and anti-oxidant activities, may have beneficial effects for MS patients.

A Randomized Control Trial Study to Determine the Effect of Melatonin on Serum Levels of IL-1ß and TNF-α in Patients with Multiple Sclerosis.

Multiple sclerosis (MS) is the most common neurological disease that happens at a young age. MS is an inflammatory disease; associated with the demyelination of the central nervous system. Therefore, some inflammatory factors are effective in the mechanism and progression of the disease. Melatonin, as a multi-effect substance including anti-inflammatory effects, can reduce symptoms of MS in patients with a change in their inflammatory factors level. In this study, 50 MS patients who were referred to the MS Society of Markazi Province were randomly selected. All patients were treated with routine MS treatment (interferon) and were divided into control (25 placebo recipients) and treatment (25 recipients of 3 mg melatonin per day for 24 weeks) groups. Anthropometric data of patients including height, weight, and age were determined. Blood samples were collected after fasting in order to determine serum levels of interleukin 1 beta (IL-1ß) and tumor necrosis factor-alpha (TNF-α). Then, samples were immediately centrifuged for serum separation and sera were transferred to a freezer at -80°C and serum levels of these factors were determined; using ELISA kit. The results of this study showed that there was no significant difference between the control and treatment groups in terms of serum levels of TNF-α. However, the level of IL-1ß was significantly reduced in the treatment group compared to the control group, indicating that melatonin decreases this inflammatory substance. Our findings suggest a valuable strategy in the treatment of patients who suffer from MS.

Maxillary sinus floor augmentation and simultaneous dental implant placement in a patient with Guillain-Barre syndrome: A case report.

Dental implant placement in patients with Guillain-Barre syndrome could be accomplished, and it may turn into a successful treatment for edentulous sites and functionally stabilized for long life. However, a proper patient selection, accurate medical consultation with physician, atraumatic surgery, and other important cautions should be considered.

Use of melatonin versus valproic acid in prophylaxis of migraine patients: A double-blind randomized clinical trial.

BACKGROUND: Melatonin is known to be effective in curing migraine. OBJECTIVE: This study aimed to investigate the therapeutic effect of melatonin versus sodium valproate in the prophylaxis of chronic migraine. METHODS: This randomized, double-blind, placebo-controlled clinical trial included patients with chronic migraine who were divided into three equal sized groups, and baseline therapy with nortriptyline (10-25 mg) and propranolol (20-40 mg) was used. Patients in groups A, B, and C were adjunctively treated daily with 3 mg melatonin, 200 mg sodium valproate, and a placebo, respectively. The patients underwent treatment for 2 months and follow-up was done at baseline (baseline), first (I) and second month (II). Attack frequency (AF), attack duration, attack severity, Migraine Disability Assessment (MIDAS) score (within 3 months in two steps), analgesic intake, and drug side effects between the groups and during follow-up were compared. RESULTS: The mean of monthly AF (melatonin: baseline: 4.2, I: 3.1, II: 2.5, p = 0.018; valproate: baseline: 4.3, I: 3.1, II: 2.3, p = 0.001; placebo: baseline: 4.1, I: 3.8, II: 3.8 p = 0.211), attack duration (hr) (melatonin: baseline: 19.8, I: 10.1, II: 8.7, p < 0.001; valproate: baseline: 19.5, I: 10.2, II: 8.8, p < 0.001; placebo: baseline: 19.6, I: 15.4, II: 14.1, p = 0.271), attack severity (melatonin: baseline: 7.3, I: 5.4, II: 3.5, p < 0.001; valproate: baseline: 7.4, I: 5.3, II: 3.4, p = 0.000; placebo: baseline: 7.3, I: 6.4, II: 6, p = 0.321), and MIDAS score (melatonin: baseline: 15.2, II: 8.9, p = 0.005; valproate: baseline: 16.1, II: 8.3, p = 0.001; placebo: baseline: 16, II: 12.1, p = 0.44), were significantly reduced in the melatonin and sodium valproate groups, but not in the placebo groups. Adverse events were reported in 11 patients (10.47%): 2 (5.71%) during melatonin treatment, 8 (22.85%) during valproate, and 1 (2.85%) during placebo. CONCLUSION: The adjuvant treatment with melatonin was found to be superior to the placebo and had the same clinical efficacy as sodium valproate, but with higher tolerability. Melatonin may prove to be an efficient substitute for sodium valproate, as a chronic migraine prophylaxis.

Multiple sclerosis and environmental risk factors: a case-control study in Iran.

Studies have shown an increase in the incidence of MS in Iran. The aim of our study was to evaluate the relationship between environmental exposure and MS in Iran. This case-control study was conducted on 660 MS patients and 421 controls. Many environmental factors are compared between the two groups. Our findings demonstrated that prematurity ([OR = 4.99 (95% CI 1.34-18.68), P = 0.017]), history of measles and mumps ([OR = 1.60 (95% CI 1.05-2.45), P = 0.029; OR = 1.85 (95% CI 1.22-2.78), P = 0.003, respectively]), breast feeding [OR = 2.90 (95% CI 1.49-5.65), P = 0.002], head trauma in childhood ([OR = 8.21 (95% CI 1.56-43.06), P = 0.013]), vaccination in adulthood ([OR = 4.57 (95% CI 1.14-18.41), P = 0.032, respectively]), migraine ([OR = 3.50 (95% CI 1.61-7.59), P = 0.002]), family history of MS, IBD, migraine, and collagen vascular diseases ([OR = 2.73 (95% CI 1.56-4.78), P < 0.001], [OR = 3.14 (95% CI 1.460-6.78), P = 0.004; OR = 3.18 (95% CI 1.83-5.53), P < 0.001; OR = 1.81 (95% CI 1.03-3.20), P = 0.040, respectively]), stressful events ([OR = 32.57 (95% CI 17.21-61.64), P < 0.001]), and microwave exposure ([OR = 3.55 (95% CI 2.24-5.63), P ≤0.001]) were more in the MS group. Sun exposure ([OR = 0.09 (95% CI 0.02-0.38), P = 0.001]), dairy and calcium consumption ([OR = 0.44 (95% CI 0.27-0.71), P = 0.001]), diabetes mellitus ([OR = 0.11 (95% CI 0.01-00.99), P = 0.049], and complete vaccination during childhood appeared to decreased MS risk. Our results investigated many risk factors and protective factors in Iran.

Risk factors of Multiple sclerosis and their Relation with Disease Severity: A Cross-sectional Study from Iran.

BACKGROUND: Many risk factors have been investigated in multiple sclerosis (MS); however, few studies have focused on the association between risk factors and the disease severity. The aim of our study was to evaluate the association between some of these risk factors and MS severity in a population sample of Iranian patients. METHODS: This cross-sectional study was conducted on 660 patients with MS. In addition to demographic variables, many potential risk factors were recorded. To compare the severity, progression index (PI) was calculated. This index is created by current Expanded Disability Status Scale (EDSS) /disease duration. RESULTS: Univariate analysis revealed that active smoking status is related with MS severity. (P-value = 0.012). Furthermore, our findings demonstrated that age at the disease onset [P < 0.001; OR = 1.05 (95% CI: 1.03-1.07)], female gender [P = 0.002; OR = 1.86 (95% CI: 1.24-2.77)] and marital status [P = 0.002; OR = 1.71 (95% CI: 1.21-2.41)] correlated with the severity of MS in the adjusted model. MS severity was observed to be related with high school and academic studies ([P = 0.004; OR = 0.56 (95% CI: 0.38-0.83)], [P = 0.001; OR = 0.52 (95% CI: 0.35-0.78)]) (Primary/secondary school studies are used as reference). Moreover, there was an association between MS severity and occupation (white collar, pink collar) ([P = 0.006; OR = 0.32 (95% CI: 0.14-0.73)], [P = 0.007; OR = 0.47 (95% CI: 0.27-0.81)]) (Student is used as reference). Furthermore, the results showed a significant correlation between vision and motor symptoms as an initial symptom and PI (P = 0.001, P = 0.025). CONCLUSION: Due to high cost of MS care and its moderate to severe disability, identification of factors influencing the MS severity is important. Our results demonstrated that the major modifiable factors related with MS severity in Iranian population, some protective and some promotive, were smoking, education, marital status and occupation. Prospective studies on larger scale are needed for further proof of these results.

Interferon ß-1a and Atorvastatin in the Treatment of Multiple Sclerosis.

BACKGROUND: Statins, widely used cholesterol-lowering agents, have also been demonstrated to have anti-inflammatory and immunomdulatory effects. OBJECTIVE: To evaluate the effects of atorvastatin in combination with Interferon-ß in the treatment of multiple sclerosis (MS) in a randomized controlled clinical trial. METHODS: Multiple sclerosis patients were randomized independently, in a double blind design, into one of two treatment groups. Control group (n=45) received 30 µg/week interferon ß-1a via intra-muscular injection. Atorvastatin-treated group (n=50) received interferon ß-1a similar to control group in addition to atorvastatin (40 mg/day) for 18-months. All clinical and immunological variables were measured at the baseline and at the end of the study. RESULTS: There was no significant difference between the two groups in the expanded disability status scale scores and the number of gadolinium-enhancing lesions during the 18-month treatment period. After 18 months, the levels of interleukin (IL)-4, IL-10, transforming growth factor-ß and serum ferric reducing antioxidant power in the atorvastatin treatment group were significantly higher than the control group. Levels of IL-17, TNF-α and lymphocyte proliferation in the atorvastatin treatment group were significantly lower than the control group. CONCLUSION: Although combined atorvastatin and interferon-ß do not change the clinical course of MS, atorvastatin might have beneficial effects in MS treatment possibly through inducing anti-inflammatory responses.

Designing Iranian Pre-hospital Stroke Scale.

BACKGROUND: Various studies have shown that stroke morbidity and mortality could be decreased if patients receive early diagnosis and treatment. Iranian Pre-hospital Stroke Scale (IPSS) is designed based on other prehospital stroke scales available across the world as well as experiences of emergency medicine specialists and pre-hospital emergency technicians to improve the diagnostic accuracy of the stroke scale in Iran. METHODS: Using a mixed method, the study was carried out in two main phases. In the first phase, concept elicitation was conducted based on the review of the literature. Related stroke diagnosis and usual instruments in pre-hospital emergency stroke centers were documented. The IPSS was designed based on semi- structured interviews with 35 neurologists, emergency medicine practitioners and physicians working in hospitals and emergency technicians in the pre-hospital field. In the second phase, the face and content validity, and reliability were checked. RESULTS: According to results from the first phase of this study (items generation), three domains were introduced as the most important factors in detection of early signs and symptoms of stroke. In the second phase (items reduction), the face validity of the IPSS was checked based on the comments from participants (the experts and EMS technicians). The content validity was calculated based on Lawshe index. The IPSS scale content validity index (S-CVI/Ave) was calculated as 89%. To determine the criterion validity of the instrument, the IPSS scores were compared with the final diagnosis based on results from brain CT scan in hospital. CONCLUSION: During this study we developed IPSS to be used by emergency technicians in pre-hospital field with a dichotomous items and simple and easy administration. It is recommended for future studies to apply this tool to emergency dispatch units as well as triage procedures in hospitals.

Uncontrolled seizures resulting from cerebral venous sinus thrombosis complicating neurobrucellosis.

Cerebral venous sinus thrombosis is a rare form of stroke caused by thrombosis in venous sinuses of the brain. In this study, we reported on a patient with venous sinus thrombosis and brucellosis who presented with uncontrolled seizure despite being treated with anti-epileptic drugs at high doses. The case was a 33-year-old woman with a history of controlled complex partial seizure who presented with headache, asthenia, and uncontrolled seizure for one month. She was febrile and a brain CT scan indicated hemorrhagic focus in the left posterior parietal and the temporal lobe. Magnetic resonance imaging and magnetic resonance venography also proved venous sinus thrombosis in the left transverse sinus. Besides [In addition], a laboratory assessment confirmed brucellosis. Following the treatment with anti-coagulant, anti-brucellosis, and anti-epileptic agents, the patient was discharged in good condition with medical orders. Clinical suspicion and accurate evaluation of a patient's history is the most important clue in diagnosis and treatment of brucellosis and cerebral venous sinus thrombosis, especially in uncontrolled seizure in patients who had previously been under control.

Prognostic factors in acute stroke, regarding to stroke severity by Canadian Neurological Stroke Scale: A hospital-based study.

INTRODUCTION: Stroke is an acute vascular disease and the second leading cause of death in the world. We have assessed the patients on hospital admission with some other prognostic factors besides the preliminary neurological examinations in order to estimate their clinical status in the future. MATERIALS AND METHODS: The present study was performed on the patients admitted to Valiasr Hospital of Arak within 72 h of stroke onset from April to October 2011. Diagnosis of stroke in the suspected patients was done by a neurologist and verified by the findings of the computed tomography scans. For each patient, a specific questionnaire, which described its stroke severity according to canadian neurological scale of stroke (CNSS), was prepared in order to define the severity of the stroke. Systolic as well as diastolic blood pressure of the patients was measured at the admission and their level of blood sugar, cholesterol, and triglyceride was also determined. RESULTS: Out of 62 patients under study (mean age, 66.14 ± 10.9 years), 36 (58.1%) were males and 26 (41.9%) were females. Overall, 66.1% of the patients were diagnosed with the ischemic stroke, while 33.9% were diagnosed with the hemorrhagic stroke. Regression analysis showed that cholesterol and diastolic blood pressure were the most important prognostic factors of the severity of stroke (CNSS). CONCLUSION: Diastolic blood pressure and serum cholesterol level have the potential to be used for assessing the stroke outcome as well as to improve the stroke rehabilitation.