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.

Comparing infusion-related reactions of the first full dose (600 mg) biosimilar ocrelizumab administration with the standard divided protocol in multiple sclerosis patients: a randomized controlled trial study

BACKGROUND

Ocrelizumab is a humanized antiCD20, thought to be a highly effective disease-modifying therapy (DMT). Its most frequent adverse effects are infusion-related reactions (IRRs). To reduce these reactions, the first dose of ocrelizumab is administered as two 300 mg infusions separated by two weeks. However, in the phase II trial of ocrelizumab, severe IRRs were not significantly different between two doses of 600 mg dose (two separate 300 mg doses) and 2000 mg dose (two separate 1000 mg doses). We compared the IRRs in undivided full (one 600 mg) and divided (two 300 mg) doses of ocrelizumab which is the standard protocol.

METHODS

MS patients (relapsing or primary progressive MS) who are selected to receive ocrelizumab by neurologist or MS fellowship were enrolled in an open-label randomized controlled trial. Iranian biosimilar of the drug (Xacrel® by Cinnagen, approved by the Iranian Food and Drug Administration in 2021) was used. The participants received the first dose of ocrelizumab as either one 600 mg dose in one session or two 300 mg doses in two weeks apart. IRRs during or in the first 24 h after infusion were recorded.

RESULTS

Of 332 participants, 150 received two 300 mg doses, and 182 received one 600 mg dose (by random selection). Life-threatening adverse effects were not observed in both groups. Overnight admission or permanent drug discontinuation was not needed. Temporary drug discontinuation was significantly higher in the one 600 mg dose group (p-value < 0.001). During the infusions, malaise (p-value: 0.003), skin reactions (p-value: 0.04), throat swelling (p-value: 0.03), and dyspnea (p-value: 0.01) were significantly increased in the intervention group. However, in the first 24 h, there was no significant difference between two different treatment protocols (one 600 mg dose or two 300 mg doses) in the onset of IRRS (p-value: 0.12).

CONCLUSION

These findings suggest one 600 mg dose of ocrelizumab administration for the first dose is relatively safe. With some protocol modifications, it could lead to fewer patient referrals, saving time and cost and improvement the access for patients.

Effects of tele-exercise training on physical and mental health and quality of life in multiple sclerosis: Do the effects differ by modality and clinical disease course?

INTRODUCTION

Tele-exercise training has improved mental and physical health and quality of life (QOL) in people with multiple sclerosis (PwMS), but there is little known about the comparability of effects across modalities and clinical disease courses.

OBJECTIVE

To evaluate the effect of tele-Pilates and tele-yoga training on physical and mental factors and QOL in PwMS, with a focus on two phenotype classifications - relapsing-remitting MS (RRMS) and secondary progressive MS (SPMS).

METHODS

Eighty-two persons with RRMS (n = 48) and SPMS (n = 34) were randomly assigned into tele-Pilates (n = 29), tele-yoga (n = 26), or control (n = 27). The tele-exercis training was conducted three times per week for eight weeks.

RESULTS

Significant time × group interactions were observed for QoL (p = 0.01), physical activity levels (p < 0.001), mental health (p = 0.05), and a decline in depression (p = 0.002) following tele-Pilates and tele-yoga. The corresponding subfactors, including pain, energy, emotional well-being, and role limitation due to emotional and physical problems, have shown significant improvements after interventions compared with control (all p < 0.05). The effects of exercise over control did not depend on MS phenotype (all p > 0.05).

DISCUSSION

Tele-yoga and tele-Pilates exercises improved QoL and mental and physical health in PwMS, and the benefits were similar across both MS phenotypes. These findings highlight the potential of implementing tele-yoga and tele-Pilates as non-pharmacological mind-body symptomatic treatments for individuals with both RRMS and SPMS.

The effects of ginger supplementation on common gastrointestinal symptoms in patients with relapsing-remitting multiple sclerosis: a double-blind randomized placebo-controlled trial

BACKGROUND

Gastrointestinal (GI) symptoms affect more than 80% of individuals with relapsing-remitting multiple sclerosis (RRMS). Ginger is widely known for its GI relieving properties. Therefore, we investigated the effect of ginger supplementation on common GI symptoms in RRMS patients.

METHODS

This study was a 12-week double-blind parallel randomized controlled trial with a 3-week run-in period. The intervention (n = 26) and control (n = 26) groups received 500 mg ginger and placebo (as corn) supplements 3 times a day along with main meals, respectively. At the beginning and end of the trial, the frequency and severity of constipation, dysphagia, abdominal pain, diarrhea, bloating, belching, flatulence, heartburn, anorexia, and nausea were assessed using the visual analogue scale ranging from 0 to 100 mm. Totally, 49 participants completed the study. However, data analysis was performed on all 52 participants based on the intention-to-treat principle.

RESULTS

In comparison with placebo, ginger supplementation resulted in significant or near-significant reductions in the frequency (-23.63 ± 5.36 vs. 14.81 ± 2.78, P < 0.001) and severity (-24.15 ± 5.10 vs. 11.39 ± 3.23, P < 0.001) of constipation, the frequency (-12.41 ± 3.75 vs. 3.75 ± 1.82, P < 0.001) and severity (-13.43 ± 4.91 vs. 6.88 ± 2.69, P = 0.001) of nausea, the frequency (-9.31 ± 4.44 vs. 1.56 ± 4.05, P = 0.098) and severity (-11.57 ± 5.09 vs. 3.97 ± 3.99, P = 0.047) of bloating, and the severity of abdominal pain (-5.69 ± 3.66 vs. 3.43 ± 3.26, P = 0.069).

CONCLUSION

Ginger consumption can improve constipation, nausea, bloating, and abdominal pain in patients with RRMS.

TRIAL REGISTRATION

This trial was prospectively registered at the Iranian Registry of Clinical Trials ( www.irct.ir ) under the registration number IRCT20180818040827N3 on 06/10/2021.

The hospitalization rate and clinical characteristics of mucormycosis prior and during COVID-19 pandemic: A single-center study

INTRODUCTION

There have been some reports of the association between SARS-CoV-2 infection and mucormycosis. This study aims to compare the hospitalization rates and clinical characteristics of mucormycosis before and during the COVID-19 pandemic.

METHODOLOGY

In this retrospective study, we compared the hospitalization rate of mucormycosis patients in Namazi hospital in Southern Iran for two periods of 40 months. We defined July 1st, 2018 to February 17th, 2020, as the pre-COVID-19 period and February 18th, 2020, to September 30th, 2021, as the COVID-19 period. In addition, a quadrupled group of hospitalized patients with age and sex-matched SARS-COV-2 infection without any sign of mucormycosis was selected as the control group for COVID-associated mucormycosis.

RESULT

In the total of 72 mucormycosis patients in the COVID period, 54 patients had a clinical history and a positive RT-PCR, which confirms the diagnosis of SARS-COV2 infection. The hospitalization rate of mucormycosis showed an increase of + 306% (95% CI: + 259%, + 353%) from a monthly average value of 0.26 (95% confidence interval (CI): 0.14, 0.38) in the pre-COVID period to 1.06 in the COVID period. The use of corticosteroids prior to the initiation of hospitalization (p ≤ 0.01), diabetes (DM) (p = 0.04), brain involvement (p = 0.03), orbit involvement (p = 0.04), and sphenoid sinus invasion (p ≤ 0.01) were more common in patients with mucormycosis during the COVID period.

CONCLUSIONS

In high-risk patients, especially diabetics, special care to avoid the development of mucormycosis must be taken into account in patients with SARS-COV-2 infection considered for treatment with corticosteroids.

The effect of ginger (Zingiber officinale) supplementation on clinical, biochemical, and anthropometric parameters in patients with multiple sclerosis: a double-blind randomized controlled trial

Introduction: different lines of evidence have shown that ginger administration may be beneficial for patients with multiple sclerosis (MS). Therefore, we aimed to investigate the effect of ginger supplementation on disability, physical and psychological quality of life (QoL), body mass index (BMI), neurofilament light chain (NfL), interlukin-17 (IL-17), matrix metalloproteinase-9 (MMP-9), and neutrophil to lymphocyte ratio (NLR) in patients with relapsing-remitting MS. Methods: this was a 12 week double-blind parallel randomized placebo-controlled trial with a 3 week run-in period. The treatment (n = 26) and control (n = 26) groups received 500 mg ginger and placebo (corn) supplements 3 times daily, respectively. Disability was evaluated using the Expanded Disability Status Scale (EDSS). QoL was rated using the Multiple Sclerosis Impact Scale (MSIS-29). BMI was calculated by dividing weight by height squared. Serum levels of NfL, IL-17, and MMP-9 were measured using the enzyme-linked immunosorbent assay. NLR was determined using a Sysmex XP-300™ automated hematology analyzer. All outcomes were assessed before and after the intervention and analyzed using the intention-to-treat principle. Results: in comparison with placebo, ginger supplementation caused a significant reduction in the EDSS (-0.54 ± 0.58 vs. 0.08 ± 0.23, P < 0.001), the MSIS-29 physical scale (-8.15 ± 15.75 vs. 4.23 ± 8.46, P = 0.001), the MSIS-29 psychological scale (-15.71 ± 19.59 vs. 6.68 ± 10.41, P < 0.001), NfL (-0.14 ± 0.97 vs. 0.38 ± 1.06 ng mL-1, P = 0.049), IL-17 (-3.34 ± 4.06 vs. 1.77 ± 6.51 ng L-1, P = 0.003), and NLR (-0.09 ± 0.53 vs. 0.53 ± 1.90, P = 0.038). Nevertheless, the differences in BMI and MMP-9 were not significant between the groups. Conclusion: ginger supplementation may be an effective adjuvant therapy for patients with relapsing-remitting MS.

Assessing the psychometric properties of persian version of Zarit Burden interview among family caregivers of patients with multiple sclerosis

BACKGROUND

Caring for patients with multiple sclerosis (MS) imposes a great burden on caregivers and affects their lives in various aspects. This study aimed to evaluate the psychometric properties of Persian version of 22-item Zarit Burden Interview (ZBI-22) among family caregivers of patients with MS.

METHODS

This methodological study was conducted in Fars province, southern of Iran. For this purpose, 120 family caregivers were recruited to participate in the study from January to March 2022. Zarit Burden Interview (ZBI) was translated into Persian through forward-backward method. Face and content validity were assessed. Construct validity was assessed using exploratory factor analyses (EFA), and its reliability was assessed by measuring internal consistency and testretest stability.

RESULTS

According to face validity, the impact scores of all items were more than 1.5. Content validity ratio and content validity index values of all 22 items were 0.64-1 and 0.82-1, respectively. The scalelevel CVI/Ave was 0.97. Based on the results of factor analysis, five factors with eigenvalues more than 1 were extracted, which altogether explained 62.62% of the total variance of ZBI score. Among 22 items, one item was deleted during EFA validity assessment. Factor loading values ranged from 0.40 to 0.88. The reliability of the scale was confirmed (total Cronbach's alpha of the ZBI = 0.88). Moreover, testretest stability assessment revealed no significant difference between test and retest scores (P > 0.05). The intraclass correlation (ICC) for the ZBI and ICCs among its factors were 0.88 and 0.6-0.86, respectively.

CONCLUSION

The Persian version of five-factor structure ZBI can be a valid and reliable scale, and it can be used to assess caregiver burden among family caregivers of patients with MS in Iran.

Iranian specialists' approach to surgery in patients with multiple sclerosis

Background: Data on perioperative risk stratification in patients with multiple sclerosis (MS) are limited. In this regard, the present study was conducted to investigate Iranian specialists' approach to surgical counseling for patients with MS (PwMS). Methods: 21 MS specialists were asked about 11 case scenarios with different MS disease statuses, disease-modifying therapies (DMTs), and urgency of the operation. The reasons for refusing surgery or factors that have to be considered before surgery were studied. Results: Overall, Fleiss Kappa was estimated to be 0.091 [95% confidence interval (CI): 0.090-0.093, P < 0.001] indicating a very poor level of agreement among responders. Conclusion: PwMS face surgery for various reasons. Risk assessment of surgery, the effect of various drugs such as anesthetics and DMT on patients, as well as many other aspects of MS are issues challenging the practitioners. Clarifying the various dimensions of these issues requires further research.

Transverse Myelitis as a Rare Neurological Complication of Coronavirus Disease 2019: A Case Report and Literature Review

The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is primarily a respiratory virus. However, an increasing number of neurologic complications associated with this virus have been reported, e.g., transverse myelitis (TM). We report a case of a 39-year-old man admitted to Namazi Hospital affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. In December 2020, the patient was infected with Coronavirus Disease 2019 (COVID-19). During hospitalization, the patient suffered from sudden onset of paraplegia, and urinary retention, and had a T6-T7 sensory level. TM was diagnosed and an extensive workup was performed to rule out other etiologies. Eventually, para-infectious TM associated with COVID-19 was concluded. The patient received pulse methylprednisolone therapy of 1 g/day for 10 consecutive days followed by seven sessions of plasma exchange without a favorable response. The patient then underwent regular physical rehabilitation and tapering oral administration of prednisolone 1 mg/Kg. As a result, weakness in the lower extremities improved slightly after six months. Overall, we suspect a correlation between COVID-19 and TM, however, further studies are required to substantiate the association.

Late-onset multiple sclerosis in Iran: A report on demographic and disease characteristics

BACKGROUND

Today, it is estimated that around 5% of multiple sclerosis (MS) patients are in the late-onset category (age at disease onset ≥ 50). Diagnosis and treatment in this group could be challenging. Here, we report the latest update on the characteristics of Iranian patients with late-onset MS (LOMS).

METHODS

This cross-sectional study used the information provided by the nationwide MS registry of Iran (NMSRI). The registrars from 14 provinces entered data of patients with a confirmed diagnosis of MS by neurologists. Patients with disease onset at or later than 50 years of age were considered LOMS.

RESULTS

Of 20,036 records, the late-onset category included 321 patients (1.6%). The age-standardized LOMS prevalence was around 75 per 100,000 people. 215 patients (67%) were female. Median Expanded Disability Status Scale (EDSS) was 3 (interquartile range: 1.5-5). The majority of the cases (56%) suffered from relapsing-remitting (RR) course while 20% were diagnosed with primary progressive (PP) MS. Significantly higher proportion of male sex, PPMS, and higher EDSS were seen in the late-onset group compared with early-onset and adult-onset cases (p-value < 0.05). Seventy-five (23%) patients did not receive any disease-modifying treatment.

DISCUSSION

The more prominent degenerative pathology of LOMS may be the underlying mechanism of the observed differences in comparison to non-LOMS.

CONCLUSION

There are substantial differences and knowledge gaps regarding LOMS which could be the subject of further research.

Iranian specialists' approach to treatment escalation in multiple sclerosis patients with cognitive impairment

Background: People with multiple sclerosis ‎(MS) and their physicians recognize cognitive retention as an important desired outcome of disease-modifying therapies (DMTs). In this study, we attempted to gather the opinions of Iranian MS experts regarding the treatment approach toward clinical cases with different physical and cognitive conditions. Methods: Opinions of 20 MS specialists regarding the best approach to 6 case scenarios (with different clinical, cognitive, and imaging characteristics) were gathered via a form. Results: The estimated kappa of 0.16 [95% confidence interval (CI): 0.159-0.163; P < 0.001] suggested a poor degree of agreement on the treatment choice among the professionals. Conclusion: Although most specialists agreed with treatment escalation in cases with cognitive impairment, there was no general agreement. Furthermore, there was not enough clinical evidence in the literature to develop consensus guidelines on the matter.

The efficacy and safety of ginger supplementation in patients with multiple sclerosis: A rationale and study protocol for a double-blind randomized controlled trial

Background and Aims

Multiple sclerosis (MS) is a chronic disease characterized by axonal damage, demyelination, inflammation, oxidative stress, and immune cell infiltration. This disease is the first cause of nontraumatic disability in young adults leading to a decline in patients' quality of life. Patients with MS may also suffer from gastrointestinal symptoms due to the disease or prescription drugs. Unfortunately, no treatment for MS has been discovered yet, and prescribed drugs can only help control its clinical course. Interestingly, recent animal studies have shown positive effects of ginger administration in the MS model. Therefore, we aim to determine the effect of ginger supplementation on neurofilament light chain, matrix metalloproteinase-9, interleukin-17, nitric oxide, complete and differential blood counts, disability status, quality of life, gastrointestinal symptoms, and body mass index (BMI) in MS patients.

Methods

This study is a double-blind randomized controlled trial. Fifty-two patients with relapsing-remitting MS will be assigned to intervention and control groups using stratified permuted block randomization. The intervention and control groups will take 1500 mg/day ginger and placebo (as corn) supplements for 12 weeks, respectively. All outcomes will be assessed before and after the trial. Serum concentrations of neurofilament light chain, matrix metalloproteinase-9, and interleukin-17 will be measured by enzyme-linked immunosorbent assay. Nitric oxide serum levels will be detected using colorimetry. Complete and differential blood counts will be assessed by an automated hematology analyzer. Disability status, quality of life, and gastrointestinal symptoms will be evaluated by the Expanded Disability Status Scale, MS Impact Scale, and Visual Analog Scale, respectively. BMI will be calculated by dividing weight in kilograms by height in meters squared. Potential side effects of ginger supplementation will also be closely monitored during the study.

Trial Registration

This protocol was registered at the Iranian Registry of Clinical Trials (www.irct.ir) under the registration number IRCT20180818040827N3.

Early and mid-term outcomes of carotid angioplasty and stent placement in 579 patients

BACKGROUND AND PURPOSE

Carotid angioplasty and stenting (CAS) could be considered for preventing stroke in patients with carotid artery stenosis. This study aimed to determine the incidence and the risk factors of the early and mid-term complications associated with CAS.

METHODS

This is a retrospective cohort study conducted at Shiraz University of Medical Sciences from March 2011 to March 2019. Patients at high risk and standard risk for carotid endarterectomy were included. The primary composite outcome was defined as stroke, myocardial infarction (MI), and death in the first 30 days after CAS. All-cause mortality, vascular mortality, and stroke were investigated during mid-term follow-up.

RESULTS

A total of 579 patients (618 CAS) were recruited (mean age: 71.52 years). Overall, 394 (68.40%), 211 (36.63%), 179 (31.07%), and 96 (16.72%) patients had hypertension, dyslipidemia, diabetes mellitus, or were cigarette smokers, respectively. Primary composite outcomes were observed in 2.59% of patients (1.55% stroke, 0.69% MI, and 1.72% death). Atrial fibrillation was a predictor of primary composite outcome in multivariate logistic regression (p = .048). The presence of total occlusion in the contralateral carotid artery was significantly associated with the risk of stroke in univariate logistic regression (p = .041). The patients were followed for a period ranging from 1 to 83 months. The overall survival rate for all-cause mortality was 93.48% at 1 year, 77.24% at 5 years, and 52.92% at 8 years. All-cause mortality was significantly higher among patients with symptomatic carotid stenosis (p = .014).

CONCLUSION

CAS provides acceptable short-term and mid-term outcomes in a unique population of high- and standard-surgical-risk, symptomatic and asymptomatic, octogenarian, and nonoctogenarian patients.

Association of self-reported adherence to the Mediterranean diet with anthropometric indices, comorbidities, and degree of disability in patients with multiple sclerosis

BACKGROUND

One of the important challenges in the treatment of patients with multiple sclerosis (MS) is determining the effective factors in the treatment of MS, including dietary adherence. The aim of this study was to investigate the relationship between adherence to the Mediterranean diet with anthropometric indices and the expanded disability status scale (EDSS) scores in patients with MS.

MATERIAL AND METHODS

The present multicenter and cross-sectional study was conducted on patients with clinically definite MS (according to the 2017 revised McDonald criteria) who were referred to the MS clinics at medical centers affiliated to Shiraz and Tehran Universities of Medical Sciences during 2019. Disease phenotype, EDSS, waist circumference (WC), body mass index (BMI), and comorbidities were assessed. Adherence to the Mediterranean diet was measured with a 14-item modified Mediterranean Diet Adherence Questionnaire. In this questionnaire, a score of 0-5 indicates low adherence, a score of 6-9 shows moderate adherence, and a score of 10 and above demonstrates high adherence (healthy eating pattern).

RESULTS

This study was performed on 478 patients with a mean age of 37.99 ± 9.60 years, out of which 352 patients (73.6%) were female. The percentage of low, medium, and high adherence to the Mediterranean diet in patients with MS was 26.4%, 64%, and 9.6%, respectively. The difference in the level of education between the groups based on adherence to the Mediterranean diet was statistically significant. Low adherence to the Mediterranean diet in underweight, normal, and overweight patients was, respectively, 1.31, 1.32, and 2.29 times higher than in obese patients. This increased risk was only significant in overweight patients (P = 0.019). The results revealed that the score of adherence to the Mediterranean diet had no significant relationship with mild (2.86 ± 2.18), moderate (2.76 ± 2.16), and severe (2.70 ± 2.02) levels of disability.

CONCLUSION

The level of adherence to the Mediterranean diet in Iranian patients with MS was moderate. This level was associated with BMI, such that low adherence to the Mediterranean diet was higher in overweight patients than obese patients.

Multiple Sclerosis Diagnosed in a Woman With Von-Willebrand Disease: A Case Report

Background: Von-Willebrand Disease (VWD) is the most common inherited bleeding disorder with an autosomal inheritance pattern. Multiple Sclerosis (MS) is a neurological disease, causing neurodegeneration and demyelination of the central nervous system through autoimmune mechanisms, and is a major cause of non-traumatic disabilities in youths. Some studies have shown the higher plasma activity of Von-Willebrand Factor in the active phase of MS. However, we could not find any study reporting co-occurrence of VWD and MS. Case Presentation and Intervention: In this case report, we present a woman with VWD who had optic neuritis 8 years ago and a new onset right-side hemiparesis. She was finally diagnosed as a new case of MS. Conclusion: There is a case of both VWD and MS; however, further investigation is needed regarding the association of VWD and MS

Acute disseminated encephalomyelitis (ADEM) after SARS- CoV-2 vaccination: A case report

Acute disseminated encephalomyelitis (ADEM) is an acute demyelinating disorder of the central nervous system that is ordinarily monophasic. ADEM can develop following infection or vaccination. Here, we present a 37 y/o male patient with progressive muscle weakness in all limbs along with dysphagia following COVID-19 vaccination. Brain magnetic resonance imaging (MRI) revealed typical imaging findings which presented as multifocal T2-FLAIR signal changes in the corticospinal tract, pons, and temporal lobe with diffusion restriction. Magnetic resonance spectroscopy (MRS) further confirmed the diagnosis by the typical elevation of the Choline and Myoinositol peaks. Neurologic impairments have been reported as the potential side effects of COVID-19 vaccines. Appropriate imaging modalities together with a thorough clinical examination are essential for making a correct diagnosis.

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.

Epidemiology of familial multiple sclerosis in Iran: a national registry-based study

Background

Admittedly, little is known about the epidemiological signatures of familial multiple sclerosis (FMS) in different geographical regions of Iran.

Objective

To determine the epidemiology and the risk of FMS incidence in several provinces of Iran with a different ethnic population including, Fars, Tehran, Isfahan (Persians), and Mazandaran (Mazanis), Kermanshah (Kurds), and Chaharmahal and Bakhtiari (Lors).

Methods

This cross-sectional registry-based study was performed on nationwide MS registry of Iran (NMSRI) data collected from 2018 to 2021. This system, registers baseline characteristics, clinical presentations and symptoms, diagnostic and treatments at regional and national levels.

Results

A total of 9200 patients including, 7003 (76.1%) female and 2197 (23.9%) male, were participated. About 19% of patients reported a family history of MS; the order from highest to lowest FMS prevalence was as follows: Fars (26.5%), Chaharmahal and Bakhtiari (21.1%), Tehran (20.5%), Isfahan (20.3%), Mazandaran (18.0%), and Kermanshah (12.5%). Of all FMS cases, 74.7% (1308 cases) were female and 25.3% (442 cases) were male. FMS occurrence was much more common in females than males (P-value = 0.001). Further, the mean age at onset was 30 years among FMS cases. A substantially higher probability of relapsing-remitting MS and secondary-progressive MS was found among FMS cases than sporadic MS (SMS) (P_value = 0.001). There was no significant difference in Expanded Disability Status Scale (EDSS) scores between FMS and SMS. The majority of FMS cases were observed among first-degree relatives, with the highest rate in siblings. There was a significant association between MS risk and positive familial history in both maternal and paternal aunt/uncle (P_value = 0.043 and P_value = 0.019, respectively). Multiple sclerosis occurrence among offspring of females was higher than males (P_value = 0.027).

Conclusions

In summary, our findings imply a noteworthy upward trend of FMS in Iran, even more than the global prevalence, which suggests a unique Atlas of FMS prevalence in this multi-ethnic population. Despite the highest rate of FMS within Persian and Lor ethnicities, no statistically significant difference was observed among the provinces.

Cost-effectiveness analysis of rituximab versus natalizumab in patients with relapsing remitting multiple sclerosis

Introduction

Multiple sclerosis (MS) is an inflammatory disease in which the myelin sheaths of the nerve cells in the brain and spinal cord, which are responsible for communication, are destroyed and cause physical signs and symptoms. According to studies, anti-CD20 monoclonal antibodies have significant results in the treatment of this disease. Thus, the aim of the present study was to determine the cost-effectiveness of rituximab against natalizumab in the patients with RRMS in southern Iran in 2020.

Methods

This is an economic evaluation including cost-effectiveness analysis in which the Markov model with a lifetime horizon was used. The study sample consisted of 120 patients randomly selected from among those referred to the MS Association and the Special Diseases Unit of Shiraz University of Medical Sciences. In this study, the costs were collected from a societal perspective, and the outcomes were obtained in the form of Quality Adjusted Life Years (QALY) and the mean relapse rate. The TreeAge pro 2020 and Excel 2016 software were used for data analysis.

Results

The comparative study of rituximab and natalizumab showed that the patients receiving rituximab had lower costs ($ 58,307.93 vs. $ 354,174.85) and more QALYs (7.77 vs. 7.65). In addition, the incidence of relapse by rituximab was lower compared to natalizumab (1.15 vs. 2.57). The probabilistic one-way sensitivity analysis showed the robustness of the results. The scatter plots also showed that rituximab was more cost-effective for the patients in 100% of the simulations for the threshold of < $ 37,641.

Discussion and conclusion

According to the results of this study, rituximab had higher cost-effectiveness than natalizumab. Therefore, it could be a priority for RRMS patients compared to natalizumab because it reduced treatment costs and increased effectiveness.

Characteristics of COVID-19 in patients with multiple sclerosis

Background

Regarding the high prevalence of multiple sclerosis (MS) and COVID-19 in Iran, a multicenter study of COVID-19 in Iranian MS patients with is carried out to address the concerns of this population.

Methods

Data on MS patients with COVID-19 from nine provinces of Iran were entered in a web-based registry system, between July 2020 and March 2021. Among the COVID-19 symptoms, dyspnea, altered mental status, or those resulting in hospital admission were considered severe.

Results

A total of 397 eligible patients were identified. In addition, 310 (78%) were female. The mean age was 36.5 ± 9.5. 294 (74%) patients had relapsing- remitting form. Also, four patients (1%) expired due to COVID-19 infection. The mean duration of admission in hospitalized patients was 9 (± 5.3) days. MRI was performed on 111 (28%) patients after developing COVID-19. MRI changes were observed in 27 (24%) of these cases. MS drug was changed in 26 (6%) patients. Steroid use in the past three months (OR: 2.43, 95% CI: 1.003–5.88) (p value: 0.049) and antiCD20s (OR: 4.03, 95% CI: 2.41–6.68) (p value < 0.001) showed significant association with severe COVID-19 symptoms.

Conclusion

The death rate of COVID-19 among MS patients (1%) is lower than the overall death rate of the pandemic in Iran (3%). Those who received steroid in the past three months may be at increased risk of more severe forms of COVID-19. There are still doubts about the effect of anti CD20s on COVID-19 severity.

Simultaneous Encephalitis and Neuroretinitis After COVID-19 in a Young Adult: A Case Report

Coronavirus disease 2019 (COVID-19) pandemic greatly impacted many aspects of life in the world. Both neurological and ophthalmologic presentations after COVID-19 have been reported. Herein, we present a case of both neuroretinitis and encephalitis after COVID-19 in a young adult. Both presentations are among the rare presentations of COVID-19. Similar manifestations were not reported previously. The 18-year-old previously healthy girl initially presented with low-grade fever, nausea, vomiting, body pain, and headache. The patient tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcriptase-polymerase chain reaction (PCR) by using a nasal swab. Two days after the onset of COVID-19 symptoms, she reported blurred vision in both eyes, progressing to only light perception in 3 days. Based on the ophthalmological evaluation, she was diagnosed with neuroretinitis. A few days later, she gradually became drowsy, so she was referred for neurological evaluation. Brain magnetic resonance imaging (MRI) showed bilateral medial temporal T2 and fluid-attenuated inversion recovery (FLAIR) hyper-signal lesions suggestive of encephalitis. A low-dose steroid was started to treat the neuroretinitis. After about 2 weeks, significant improvement in visual acuity and resolution of retinitis patches were observed. Our case is rare in respect of both neurological and ophthalmic involvement.

An Intelligent Rule-based System for Status Epilepticus Prognostication

Background:

Status epilepticus is one of the most common emergency neurological conditions with high morbidity and mortality.

Objective:

The aim of this study is to propose an intelligent approach to determine prognosis and the most common causes and outcomes based on clinical symptoms.

Material and Methods:

In this descriptive-analytic study, a perceptron artificial neural network was used to predict the outcome of patients with status epilepticus on discharge. But this method, which is understandable, is known as black boxes. Therefore, some rules were extracted from it in this study. The case study of this paper is data of Nemazee hospital patients.

Results:

The proposed model was prognosticated with 70% accuracy, while Bayesian network and Random Forest approaches have 51% and 46% accuracy. According to the results, recovery and mortality groups had often used phenytoin and anesthetic drugs as seizure controlling drug, respectively. Moreover, drug withdrawal and cerebral infarction were known as the most common etiology for recovery and mortality groups, respectively and there was a relationship between age and outcome, like in previous studies.

Conclusion:

To identify some factors affecting the outcome such as withdrawal, their effects either can be avoided or can use sensitive treatment for patients with poor prognosis.

Concurrence of multiple sclerosis and primary biliary cholangitis: Report of 3 cases

Background:

Multiple sclerosis (MS) is an autoimmune disorder of the central nervous system which damages the myelin and axon. Primary biliary cholangitis (PBC) is a slow progressive liver disease with autoimmune feature in which non-purulent destructive cholangitis and interlobular bile duct destruction occur. Involvement of each of PBC and MS is thought to be related to environmental exposure in genetically susceptible persons.

Case Presentation:

Here, we aim to report 3 women 52, 27 and 51 years old with MS and PBC.

Conclusion:

Although MS seems to have an association with some autoimmune gastrointestinal disorders such as ulcerative colitis, the concurrence of MS and PBC has been rarely reported.

Epidermal neural crest stem cell transplantation as a promising therapeutic strategy for ischemic stroke

Introduction

Cell‐based therapy is considered as promising strategy to cure stroke. However, employing appropriate type of stem cell to fulfill many therapeutic needs of cerebral ischemia is still challenging. In this regard, the current study was designed to elucidate therapeutic potential of epidermal neural crest stem cells (EPI‐NCSCs) compared to bone marrow mesenchymal stem cells (BM‐MSCs) in rat model of ischemic stroke.

Methods

Ischemic stroke was induced by middle cerebral artery occlusion (MCAO) for 45 minutes. Immediately after reperfusion, EPI‐NCSCs or BM‐MSCs were transplanted via intra‐arterial or intravenous route. A test for neurological function was performed before ischemia and 1, 3, and 7 days after MCAO. Also, infarct volume ratio and relative expression of 15 selected target genes were evaluated 7 days after transplantation.

Results

EPI‐NCSCs transplantation (both intra‐arterial and intravenous) and BM‐MSCs transplantation (only intra‐arterial) tended to result in a better functional outcome, compared to the MCAO group; however, this difference was not statistically significant. The infarct volume ratio significantly decreased in NCSC‐intra‐arterial, NCSC‐intravenous and MSC‐intra‐arterial groups compared to the control. EPI‐NCSCs interventions led to higher expression levels of Bdnf, nestin, Sox10, doublecortin, β‐III tubulin, Gfap, and interleukin‐6, whereas neurotrophin‐3 and interleukin‐10 were decreased. On the other hand, BM‐MSCs therapy resulted in upregulation of Gdnf, β‐III tubulin, and Gfap and down‐regulation of neurotrophin‐3, interleukin‐1, and interleukin‐10.

Conclusion

These findings highlight the therapeutic effects of EPI‐NCSCs transplantation, probably through simultaneous induction of neuronal and glial formation, as well as Bdnf over‐expression in a rat model of ischemic stroke.

Necrotizing fungal osteomyelitis and fingolimod, 4 years after treatment with fingolimod

Fingolimod has been the first approved oral medication in MS for its relapsing remitting type. It is a non-selective sphingosine1-phosphate (S1P) receptor modulator on lymphocytes. Engagement of this receptor blocks the T cells and B cells migration from the lymph nodes into the inflamed central nervous system (CNS) via bloodstream. In spite of this known immunomodulatory mechanism, there are some reports about serious infection following the initiation of fingolimod therapy like herpes types or infections associated to the immunosuppressed situation (cryptococcal meningitis, primary cutaneous cryptococcosis and visceral leishmaniasis). To the best of our knowledge, in contrary to many reports about opportunistic or serious infections with fingolimod, there has been no report on fungal osteomyelitis associated to fingolimod until now. Here, we aimed to describe a woman who developed necrotizing fungal osteomyelitis four years after starting fingolimod, as a disease modifying drug for MS.

Predictors and Conversion Rate of Clinically Isolated Syndrome to Clinically Definite Multiple Sclerosis: A Follow-up Study in Patients Living in the Southern Part of Iran

Background: Clinical course of Clinically Isolated Syndrome (CIS) is variable, and identifying patients who will eventually develop Multiple Sclerosis (MS) is essential. Objectives: To assess the conversion rate of CIS to Clinically Definite Multiple Sclerosis (CDMS) and its predictors in southern Iran. Materials & Methods: A total of 143 CIS patients registered to Fars Multiple Sclerosis Society (FMSS) were enrolled in the study from 2006 until 2012, and all of them were followed for 5 years. Also, their demographic and MRI data were recorded. The obtained data were analyzed by univariate and multivariable Cox regression models in SPSS v. 17. P<0.05 was considered statistically significant. Results: About 26.6% of patients progressed to MS after a mean duration of 3.4±1.1 years. The conversion rate was 27.6% in patients presented with optic neuritis, and 25.6% in patients presented with spinal cord problems. Although it was not statistically significant (P=0.23), the mean age of the patients who converted to MS was lower at the onset of the presentation (27.6 vs. 29.4 years). In patients who had 3 or more MRI lesions, the conversion rate was 49.2%; however, it was only 9.8% in subjects who had fewer than 3 lesions (OR=8.95, 95% CI=3.69–21.7, P <0.001). Women had higher conversion rate though it was not statistically significant (OR=2.09, 95% CI=0.57–7.64, P=0.26). Conclusion: Our results supported this supposition that the number of MRI lesions at baseline can be used as a predictor of CIS conversion to MS.

Simultaneous Presence of Acetylcholine Receptor and Muscle Specific Tyrosine Kinase Antibodies in Myasthenia Gravis

Myasthenia gravis (MG) is known as an autoimmune disorder which affects transmission in neuromuscular junction. The serologic tests used for diagnosis include acetylcholine receptor and muscle specific receptor tyrosine kinase antibodies. Studies often have reported that patients with formal antibody are negative for the latter one. However, very limited studies have reported positive anti-muscle specific receptor tyrosine kinase antibody in a small percentage of patients with acetylcholine receptor antibody. Here, we reported a young woman who was diagnosed with MG and had a rapid and progressive course of the disease. She was seropositive for both acetylcholine receptor and muscle-specific receptor tyrosine kinase antibodies simultaneously. However, she discharged from the hospital with good condition after treatment.

Is There Any Correlation between Migraine Attacks and Iron Deficiency Anemia? ACase-Control Study

Background: Migraine headache is an episodic abnormality which usually presents with a severe headache, accompanied by nausea, photo and sound sensitivity, and autonomic symptoms. Iron accumulation in brain, especially peri-aqueductal grey is associated with duration of the disease, and apparently there is an association between body iron storage status and the incidence of migraine; hence, the present study was conducted to investigate the plausible association between iron-deficiency anemia and migraine in a case-control design. Materials and Methods: After signing the written informed consent, the blood samples were collected by a well-trained technician from the patients proved to have migraine, those having migraine clinical criteria and those having migraine attack frequency as high as that prophylaxis was required, and non-migraine healthy individuals, those having not migraine and anemia except iron-deficiency anemia. Based on the sample size, each group composed of samples with at least 100 individuals. Results: There were statistically significant differences between female cases and controls regarding hemoglobin, serum ferritin levels and iron-deficiency anemia (P-value: .0004; .006; .001), but no differences were observed among males (P-value: .606; .38; .303). Furthermore, the case-control comparisons revealed a significant difference in iron-deficiency anemia (P-value: .032), but no significant difference was seen in hemoglobin and serum ferritin levels (P-value: .161; .178). Conclusion: The present study suggests an association between iron-deficiency anemia, hemoglobin and serum ferritin levels and the incidence of migraine in females. As a result, there might be an association between body iron storage status and the incidence of migraine, especially among females, reflecting the fact that iron supplements might be an effective treatment or prophylaxis in patients with migraine associated with iron-deficiency anemia. However, further studies are required to provide a conclusive answer to the issues remained controversial.

Contrast Induced Nephropathy After Brain and Cervical CT Angiography in Stroke Patients: A Prospective Study

Background: Contrast-induced nephropathy (CIN) is a major side effect of intravenous iodinated contrast and causes both short- and long-term adverse effects. While diagnostic and interventional procedures of brain ischemia are recently advanced, it is necessary to be cautious about its major side effect. Objectives: To evaluate CIN and its risk factors in neurology patients after brain and cervical CT angiography. Materials & Methods: This prospective cross-sectional study was conducted on all patients who were admitted in stroke department of Nemazee hospital, affiliated to Shiraz University of Medical Sciences, Fars, Iran, and had undergone brain and cervical CT angiography from September 2014 to September 2016. Blood urea nitrogen (BUN) and creatinine (Cr) before contrast (BUN1, Cr1), 3 days after contrast (BUN2, Cr2), and 30 days after contrast (BUN3, Cr3) were recorded. t-test, paired t-test, Chi-squared test, repeated measurement-test and also SPSS V. 21 are used for statistical analysis. Results: 5(2.7%) patients developed CIN after receiving contrast. However, repeated measurement of glomerular filtration rate (GFR) and Cr at the end of one month showed no significant changes between Cr3 and GFR3 in 2 groups of non-CIN and CIN patients, and all patients showed normal renal function at that time. Multiivariate logistic regression analysis demonstrated that hemoglobin (Hb) level is related to CIN (OR:0.5, CI: 0.28-0.90). Conclusion: Our data showed that the rate of CIN in neurovascular evaluation was insignificant, but it is related to Hb level.

A Large Cerebellar Infarction Case Who Presented with Transient Nonspecific Symptoms

Background: The cerebellum is the most important portion of the brain, which audits our acts and establishes balance. Symptoms from a cerebellar stroke happen suddenly. In addition to specific cerebellar signs and symptoms, other common symptoms of a cerebral stroke include dizziness, headache, nausea, vomiting, double vision, tremor, and vertigo. These symptoms can be confused with other situations because they are nonspecific. In many cases, these symptoms are ignored. Clinical Presentation and Intervention: Here, we report a case of an apparent healthy middle-aged man with a large hemispheric cerebellar infarction presented just with a new onset headache and transient mild and nonspecific symptoms including mild left side ptosis and relatively impaired tandem gait which resolved rapidly without obvious and permanent neurological problems. Conclusion: Nonspecific symptoms should alert physicians to examine unusual manifestations of cerebellar infarction, which might be missed if they do not suspect it and do not examine accurately.

Thymolipoma-associated Myasthenia Gravis with High Titer of Anti-MuSKAb: A Case Report

Myasthenia gravis (MG) is a neuromuscular junction disorder caused by pathogenic autoantibodies to some parts of the post-synaptic muscle endplates. About 85% of generalized MG patients have autoantibodies against post-synaptic acetyl-choline receptors (AChR). From the 10-15% of the remaining patients, 45-50% are positive for Muscle Specific Tyrosine Kinase-Antibody (MuSK-Ab). It is believed that the thymus has a critical role in the pathogenesis of the disease with AChR-Ab, specially in patients with thymic abnormalities. In contrast, the role of thymus gland in MG with anti-MuSK-Ab is not clearly obvious. Patients with this antibody virtually have normal or only minimal follicular hyperplastic thymus. The presence of anti-MuSK Ab in a thymolipomatous (an uncommon tumor of thymus) MG is an atypical and new finding of MG because of not only thymolipoma but the presence of anti-MuSK antibodies which makes this case different from the previous reports of the antibodies-associated MG. Here, we present a young woman with thymolipoma and MG (a very uncommon kind of tumor-associated MG) and high level of anti-MuSK-Ab.

Prevalence and Incidence of Multiple Sclerosis in Fars Province, Southern Iran

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory and demyelinating disease of the central nervous system, which is accompanied by significant disabilities. Although there are some published data regarding the epidemiological features of MS in other parts of Iran, scarce data are available about the prevalence and demographic characteristics of MS in Fars province. The current study aimed to address the prevalence and incidence rate of MS as well as the temporal trend of the disease in Fars province, southern Iran.

METHODS

This historical retrospective cohort study was carried out in Fars Multiple Sclerosis Society affiliated with Shiraz University of Medical Sciences. All the consecutive patients who fulfilled 2010 McDonald criteria for definite MS were included in the study. The patients' gender, age at time of diagnosis, education, and clinical course were recorded. The prevalence and incidence rates were also calculated.

RESULTS

This study was conducted on 3,354 patients. Among the patients, 2,689 (80.2%) were female and 665 (19.8%) were male. The female/male ratio was 4.04. The point prevalence rate of the disease was 72.1/100,000 persons in October 2013. This index was 116.5 per 100,000 persons in females (95% CI: 113.4-119.6) and 28.3 per 100,000 persons in males (95% CI: 26.8-29.9). The mean annual incidence rate was 5.2/100,000 from 2002 until 2012.

CONCLUSION

Considering Kurtzke classification, Fars is a high-risk area for MS and women are affected more compared with men. Moreover, the incidence rate sharply increased in the last decade.

A case of chronic inflammatory demyelinating polyneuropathy presented with unilateral ptosis

Chronic Inflammatory Demyelinating Polyneuropathy is an autoimmune disease with progressive and relapsing courses. The main clinical presentations are diffuse deep tendon hyporeflexia or areflexia and symmetric proximal-distal muscles weakness. Myasthenia gravis is also an immune mediated disease with fluctuating ocular and bulbar symptoms and sometimes weakness. Although both myasthenia gravis and chronic inflammatory demyelinating polyneuropathy are immune mediated disorders, clinical presentations are obviously different in the two diseases. Herein, we will report a case of chronic inflammatory demyelinating polyneuropathy who presented with isolated unilateral ptosis. Initially, the patient was managed as ocular type of myasthenia gravis, but after progression to general limb weakness and areflexia, the diagnosis of chronic inflammatory demyelinating polyneuropathy was made. Although unilateral ptosis is a typical feature of myasthenia gravis, it may be seen as the first presentation of chronic inflammatory demyelinating polyneuropathy as well which mimics myasthenia gravis disease.

Cerebral venous-sinus thrombosis: a case series analysis

BACKGROUND

Cerebral venous-sinus thrombosis is an uncommon form but important cause of stroke, especially in young-aged women.

METHODS

We performed a retrospective descriptive-analytical study in which 124 patients with cerebral venous-sinus thrombosis, who referred to Nemazee Hospital, Shiraz University of Medical Sciences from January 2000 to March 2008, were included, and their demographic, etiologic, radiological and prognostic characteristics were evaluated.

RESULTS

The patients' mean age was 34.01±10.25. Eighty seven (70.16%) were women and 37 (29.83%) were men. The most frequent clinical manifestations were headache, papilledema and seizures. Fifty seven (65.51%) women took oral contraceptive pills. Twenty of 57 women (35.08%) took the pill longer than one month to be able to fast in Ramadan or perform the Hajj ceremonies. In the mean time they developed cerebral venous-sinus thrombosis. Superior sagital sinus, with or without lateral sinuses, was the most involved area (70.96%). High mortality and morbidity rates (14.51% and 35.48%, respectively) were found in patients. Poor prognostic factors at the time of admission were stupor and coma (P=0.001) and evidence of hemorrhage in primary CT scan (P=0.005).

CONCLUSION

Taking oral contraceptive pills was a main factor associated with cerebral venous-sinus thrombosis. Clinical manifestations, prognostic factors, common involved sinuses and image findings of this study were similar to those of other studies. Health care policy makers should design a plan to warn susceptible women of the risk of cerebral venous-sinus thrombosis, and to educate them the ways to prevent it.