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Objectives: The aim of this study was to determine the prevalence and patterns of complementary and alternative medicine (CAM) usage amongst multiple sclerosis (MS) patients in Iran and to evaluate the perceived effectiveness. Methods: This was a descriptive cross-sectional study. Data were collected from 194 patients with MS at the neurology clinics affiliated with Shiraz University of Medical Sciences by a semi-structured questionnaire. Results: The prevalence of CAM usage was 67.9%. Herbal medicine was the most common CAM used among the patients (64.2%). Cupping therapy, relaxation therapies, acupuncture, leech therapy were the other common CAM modalities used. Although less commonly used, yoga had the highest perceived effectiveness. Conclusions: Due to the high prevalence of CAM usage, physicians should inform their patients about the advantages and disadvantages of CAM so as to help the patients make an informed choice.

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.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.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).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.

Objectives: There are several reports of the association between SARS-CoV-2 infection (COVID-19) and cerebral venous sinus thrombosis (CVST). In this study, we aimed to compare the hospitalization rate of CVST before and during the COVID-19 pandemic (before vaccination program). Materials and methods: In this retrospective cohort study, the hospitalization rate of adult CVST patients in Namazi hospital, a tertiary referral center in the south of Iran, was compared in two periods of time. We defined March 2018 to March 2019 as the pre-COVID-19 period and March 2020 to March 2021 as the COVID-19 period. Results: 50 and 77 adult CVST patients were hospitalized in the pre-COVID-19 and COVID-19 periods, respectively. The crude CVST hospitalization rate increased from 14.33 in the pre-COVID-19 period to 21.7 per million in the COVID-19 era (P = 0.021). However, after age and sex adjustment, the incremental trend in hospitalization rate was not significant (95% CrI: -2.2, 5.14). Patients > 50-year-old were more often hospitalized in the COVID-19 period (P = 0.042). SARS-CoV-2 PCR test was done in 49.3% out of all COVID-19 period patients, which were positive in 6.5%. Modified Rankin Scale (mRS) score ≥3 at three-month follow-up was associated with age (P = 0.015) and malignancy (P = 0.014) in pre-COVID period; and was associated with age (P = 0.025), altered mental status on admission time (P

Background: Cognitive fusion is a substantial variable of acceptance and commitment therapy (ACT). Recently, various instruments have been developed to assess cognitive fusion, including a version relevant to medical illness referred to as the Cognitive Fusion Questionnaire-Chronic Illness (CFQ-CI). Objectives: This study aimed to assess the validity and reliability of the Persian version of CFQ-CI in multiple sclerosis (MS) patients. Methods: In a cross-sectional study, the Persian version of CFQ-CI and several other measures that assessed self-compassion, depression, and social anxiety symptoms were administered on 195 MS patients in Shiraz Emam Reza Clinic. Exploratory factor analysis (EFA), internal consistency, and convergent validity were used for data analysis. Results: EFA revealed a 1-factor model. The Cronbach α was 0.92. As to the convergent validity, CFQ-CI had positive associations with measures of depression and social anxiety and negative associations with self-compassion. Conclusions: Overall, this research supports the psychometric properties of the Persian version of CFQ-CI.

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.

Background Aneurysm formation of internal carotid arteries (ICA) in patients with mucormycosis is a scarce phenomenon. However, the prevalence of rhino-cerebral mucormycosis has been reported to increase after the coronavirus disease 2019 (COVID-19) pandemic. Methods Three patients with stroke and subarachnoid hemorrhage due to ICA aneurysm after the involvement of adjacent paranasal sinuses with mucormycosis were presented. All patients were recruited from Namazi and Khalili hospitals affiliated with Shiraz University of Medical Sciences in Iran from April 2021 to May 2021. Results They had a history of diabetes and corticosteroid use. Also, one of them was treated with imatinib. Two out of three patients were infected with SARS-CoV-2 infection before developing mucormycosis. Two patients had diagnostic angiography before endovascular intervention. One patient did not undergo any therapeutic intervention due to total artery occlusion, whereas the other patient experienced a successful parent artery occlusion by coiling, and only this patient survived. Although all patients received antifungal treatment and surgical debridement, two of them died. Conclusions In the patients with rhino-cerebral mucormycosis evolving of aneurysm should be promptly and meticulously investigated by magnetic resonance angiography (MRA) and computed tomography angiography (CTA). As this type of aneurysms was very fast-growing, as soon as the involvement of sphenoid sinus was detected, the possibility of ICA aneurysm formation should always be kept in mind. If the patient developed an aneurysm, prompt intensive antifungal therapy and therapeutic endovascular interventions such as stenting, coiling, or sacrificing should be considered as soon as possible to optimize outcomes.

Background Multiple Sclerosis (MS) remains to be a public health challenge, due to its unknown biological mechanisms and clinical impacts on young people. The prevalence of this disease in Iran is reported to be 5.30 to 74.28 per 100,000-person. Because of high prevalence of this disease in Fars province, the purpose of this study was to assess the spatial pattern of MS incidence rate by modeling both the associations s of spatial dependence between neighboring regions and risk factors in a Bayesian Poisson model, which can lead to the improvement of health resource allocation decisions. Method Data from 5468 patients diagnosed with MS were collected, according to the McDonald’s criteria. New cases of MS were reported by the MS Society of Fars province from 1991 until 2016. The association between the percentage of people with low vitamin D intake, smoking, abnormal BMI and alcohol consumption in addition to spatial structure in a Bayesian spatio-temporal hierarchical model were used to determine the relative risk and trend of MS incidence rate in 29 counties of Fars province. Results County-level crude incidence rates ranged from 0.22 to 11.31 cases per 100,000-person population. The highest relative risk was estimated at 1.80 in the county of Shiraz, the capital of Fars province, while the lowest relative risk was estimated at 0.11 in Zarindasht county in southern of Fars. The percentages of vitamin D supplementation intake and smoking were significantly associated with the incidence rate of MS. The results showed that 1% increase in vitamin D supplementation intake is associated with 2% decrease in the risk of MS and 1% increase in smoking is associated with 16% increase in the risk of MS. Conclusion Bayesian spatio-temporal analysis of MS incidence rate revealed that the trend in the south and south east of Fars province is less steep than the mean trend of this disease. The lower incidence rate was associated with a higher percentage of vitamin D supplementation intake and a lower percentage of smoking. Previous studies have also shown that smoking and low vitamin D, among all covariates or risk factors, might be associated with high incidence of MS.

Objective The aim of this study was to determine the prevalence and patterns of complementary and alternative medicine (CAM) usage amongst multiple sclerosis (MS) patients in Iran and to evaluate the perceived effectiveness and factors affecting these therapies. Methods This is a descriptive and cross-sectional study. Data were collected from 194 patients with MS at the neurology clinics affiliated with Shiraz University of Medical Sciences by a semi-structured questionnaire. Results The prevalence of CAM usage was 67.9%. Herbs were the most common among patients (64.2%). Cupping therapy, relaxation therapies, acupuncture, leech therapy were the other common CAM modalities. Yoga had the highest perceived effectiveness. Conclusions Due to high prevalence of CAM usage, physicians should inform their patients about the advantages and disadvantages of CAM in order to make them aware of their choices.

The role of dietary interventions in improving the symptoms of Multiple Sclerosis (MS) has always been considered, but few studies have been conducted in this area. This study aimed to investigate the effects of modified anti-inflammatory diet on fatigue, quality of life, and inflammatory markers among patients with Relapsing-Remitting Multiple Sclerosis (RRMS).This randomized clinical trial was conducted on 100 patients with RRMS. The patients were randomly divided into the diet group (anti-inflammatory diet) or the control group (healthy diet recommendations) for 12 weeks. Fatigue and quality of life were assessed by Modified Fatigue Impact Scale (MFIS) and Multiple Sclerosis Quality of Life (MSQoL-54), respectively. Anthropometric measures and inflammatory biomarkers, including Interleukin 17 (IL-17), Interleukin 4 (IL-4), and high sensitivity C-Reactive Protein (hs-CRP), were assessed at baseline and end of the study.The results showed a significant improvement in MFIS as well as in physical and mental components of MSQoL-54 (Modified anti-inflammatory diet could improve fatigue and quality of life and increase IL-4 level.

Background and aims Carpal tunnel syndrome (CTS) is a common debilitating condition. As the reliability of CTS-specific physical tests and its clinical grading remain a matter of debate, we determined the correlations between these assessments with nerve conduction study (NCS). Methods In this cross-sectional study, patients with uni or bilateral CTS, which was confirmed in electrodiagnosis, were enrolled. Clinical grading was based on the modified criteria of the Italian CTS Study Group. Numeric Pain Rating Scale (NPRS) and Boston Questionnaire (BQ) were used. Physical tests [Phalen’s, reverse Phalen’s, Tinel’s and manual carpal compression test (mCCT)] were performed by a single blinded neurologist. A p-value Results A total of 100 patients (age=47.48±11.44 years; 85% female) with 181 involved hands were studied. The majority of hands (59.7%) were classified as grade 2 of clinical grading. On NCS, hands with mild (64%), moderate (27%) and severe (9%) CTS were identified. Sensory (velocity, latency and amplitude) and motor parameters (latency and amplitude) were significantly correlated with clinical grades (p-valuep-value=0.009) and BQ (p-valuep-value>0.05). Conclusions We found that physical tests are not a reliable screening method for evaluation of CTS severity. However, the BQ and clinical grading can be more valuable due to their significant correlation with NCS. Implications Physicians might benefit from employing clinical grading and BQ in practice for better assessment of CTS severity.

Objectives: Neuro-critical Intensive Care Units (NICUs) have functioned to deliver intensive medical care services for patients with acute neurology problems. However, physicians and ICU staff do not have any feedback about their patients and their abilities after successful discharge. Various studies have documented short-term survival in ICUs, but the long-term outcome and quality of life (QOL) are less studied. Methods: This is a retrospective cohort study over a period of one year from February 2011 to February 2012 (Shiraz, South of Iran). Patients' charts were used to collect the data. Survival and QOL after one year following NICU admission were assessed for surviving patients by a telephone interview with patients or their family members using Karnofsky Performance Scale (KPS). Results: Out of 93 patients, 42(45.2%) were male, and 51(54.8%) were female. Malignant ischemic stroke (34%) was the most common cause followed by Guillain Barre Syndrome (21%). Among the living successfully discharged patients, 45% were able to perform normal activity and work without any special assistance. The patients who were unable to work were 28%, but they were able to live at home and care for their most personal needs. The patients who were unable to care for themselves were 3% and required institutional or hospital care. Over one year following discharge, 24% patients were passed away. Discussion: is lower in NICU survivors compared with general population; however, if patients' selection and out of hospital care are done appropriately and continuously, more patients can live independently or even come back to their work. Indeed, it is important to identify patients who benefit more from NICU during decision making for ICU admission. As a result, more efficient rehabilitation could be achieved in the future. However, our conclusions are only related to our ward and do not apply to the total population of critical neurology patients.

Background: There is evidence that supports the neuroprotective effects of dimethyl fumarate (DMF) in stroke. Nuclear factor erythroid 2-related factor 2 (Nrf2) has both anti-oxidant and anti-inflammatory mechanisms. We investigated the neuroprotective effects of DMF via Nrf2 activation in the cortex, striatum, and diencephalon in a middle cerebral artery occlusion (MCAO) model of stroke. Methods: 22 Sprague-Dawley male rats were randomized into 3 groups. In DMF-treated group (n = 8), rats received 15 mg/kg oral DMF twice daily by gavage from day 0 to 14 after a 60-minute MCAO. The vehicle group (n = 7) underwent MCAO and were given methocel/H2O, using the same method and schedule. In the sham group (n = 7), neck was opened, but neither middle cerebral artery (MCA) was occluded nor any drug was administered. After 14 days, the animals were sacrificed. The infarct volume were assessed by stereology method. Nrf2 expression was evaluated in the cortex, striatum, and diencephalon by immunohistochemistry method. Results: Ratio of infarct to total brain volume was significantly lower in the DMF-treated group (5.76%) in comparison with the vehicle group (22.39%) (P < 0.0001). Nrf2 expression was higher in DMF-treated group in comparison with both the vehicle and sham groups in cortex, striatum, diencephalon, and total brain (P < 0.0001). In the DMF-treated group, significant negative correlation between Nrf2 expression and infarct volume was observed in cortex, striatum, diencephalon, and total brain. Conclusion: DMF induces Nrf2 expression and its neuroprotective effects in different brain anatomical regions.

Background: There is evidence that supports the neuroprotective effects of dimethyl fumarate (DMF) in stroke. Nuclear factor erythroid 2-related factor 2 (Nrf2) has both anti-oxidant and anti-inflammatory mechanisms. We investigated the neuroprotective effects of DMF via Nrf2 activation in the cortex, striatum, and diencephalon in a middle cerebral artery occlusion (MCAO) model of stroke. Methods: 22 Sprague-Dawley male rats were randomized into 3 groups. In DMF-treated group (n = 8), rats received 15 mg/kg oral DMF twice daily by gavage from day 0 to 14 after a 60-minute MCAO. The vehicle group (n = 7) underwent MCAO and were given methocel/H2O, using the same method and schedule. In the sham group (n = 7), neck was opened, but neither middle cerebral artery (MCA) was occluded nor any drug was administered. After 14 days, the animals were sacrificed. The infarct volume were assessed by stereology method. Nrf2 expression was evaluated in the cortex, striatum, and diencephalon by immunohistochemistry method. Results: Ratio of infarct to total brain volume was significantly lower in the DMF-treated group (5.76%) in comparison with the vehicle group (22.39%) (P < 0.0001). Nrf2 expression was higher in DMFtreated group in comparison with both the vehicle and sham groups in cortex, striatum, diencephalon, and total brain (P < 0.0001). In the DMF-treated group, significant negative correlation between Nrf2 expression and infarct volume was observed in cortex, striatum, diencephalon, and total brain. Conclusion: DMF induces Nrf2 expression and its neuroprotective effects in different brain anatomical regions.

Multiple sclerosis (MS) is a chronic, autoimmune, and inflammatory disease. If the first-line medicines are not effective enough, specialists will prescribe second-line medicines, such as natalizumab and fingolimod. This study aimed to compare the cost-effectiveness and cost-utility of fingolimod with those of natalizumab in patients with relapsing-remitting multiple sclerosis (RRMS) in Iran, Fars province in 2016.This study was a cost-effectiveness and cost-utility study in which a Markov model was used. The study used the census method to evaluate 81 patients with MS in Iran, Fars province who were being treated with fingolimod and natalizumab. In this study, costs were collected from the societal perspective, and the outcomes were the mean of relapse avoided rate and QALY. The cost data collection form, Kurtzke Expanded Disability Status Scale, and EQ-5D-3L questionnaire were used to collect the required data.The results showed that, compared to natalizumab, patients who used fingolimod had decreased costs (58,087 vs 201,707), increased QALYs (8.09 vs 7.37), and a better relapse avoided rate (6.27 vs 5.83) per patient over the lifetime. The results of the sensitivity analysis showed that the results of the study were robust. Also, the results of the scatter plots showed that fingolimod was more cost-effective based on the QALY and relapse avoided rate in 62% and 56%, respectively, of the simulations for the thresholds below $15,657 for the studied patients.According to the results of this study, the cost-effectiveness and cost-utility of fingolimod were higher than those of natalizumab. Therefore, it is recommended that treatment with fingolimod be the first priority of second-line treatment for MS patients, and policy-makers and health managers are encouraged to make efforts in order to increase insurance coverage and reduce the out-of-pocket payments of these patients.

Objective Licorice root has been reported to contain several neuroprotective compounds. In the present study we investigated its benefit in the treatment of acute ischemic stroke for which, treatment modalities are limited. Design Randomized double-blind placebo controlled trial. Subjects 75 patients admitted to the neurology emergency department of Namazi hospital affiliated to Shiraz University of Medical Sciences, Iran, diagnosed with acute ischemic stroke. Intervention Patients were randomly prescribed oral 450 mg or 900 mg licorice extract or placebo capsules three times daily for 7 days. National institute of Health stroke scale (NIHSS) and Modified Rankin Scale (MRS) scores were assessed before initiation of therapy and 3 months after treatment. Improvement of these scores were compared between study and control groups. Results Mean NIHSS scores in 450 mg and 900 mg groups decreased from an initial score of 10.68 and 10.44 to 6.4 and 5.48 after 3 months respectively; while in the control group changed from 8.36 to 5.64. The decline in NIHSS scores were significantly greater in licorice treated groups than the control group. Similarly the decrease in MRS was greater in the licorice treated groups (4.2–2.9 in 450 mg licorice group, and 4.4–2.8 in 900 mg licorice group) versus the control group (3.9–2.8). None of the participants developed adverse reactions attributed to licorice overdose. Conclusions The results of this study support the beneficial effect of whole licorice extract in neurologic improvement of patients with acute ischemic stroke. Licorice may be useful as a medication for the treatment of the adverse effects caused by acute ischemic stroke.

Background: Multiple Sclerosis (MS) is a chronic and inflammatory disease that can affect the patients’ quality of life and impose many costs on them. Several types of medicine are used to change the course of the disease, treat disease - related attacks, and treat the symptoms of multiple sclerosis. Objectives: The aim of this study was to determine and compare the cost-effectiveness and cost - utility of CinnoVex versus ReciGen as the first line treatment in patients with relapsing-remitting multiple sclerosis in Iran, Fars province, in 2016. Methods: This study was a cost - effectiveness and cost - utility study, in which a Markov model was used. A sample of 178 patients with MS was randomly selected. The costs were summed up from the societal perspective, and the study outcomes were QALY and the mean of relapse was avoided. To collect the required data, the cost data collection form, Kurtzke Expanded Disability Status Scale, and EQ - 5D questionnaire were used. To analyze the data collected, the TreeAge Pro 2011 and Excel 2010 software were used as well. Results: The results showed that the mean cost for ReciGen and CinnoVex patients were 349.84 and 289.92 USD, respectively. In addition, the QALY means were 0.291 and 0.297 and the means of relapse avoided were 0.309 and 0.239 for ReciGen and CinnoVex patients, respectively. The one - way sensitivity analysis showed that the results of the model were sensitive to effectiveness and utility of both medicines, but had little sensitivity to other parameters. Conclusions: According to the results, ReciGen was more cost - effective in terms of relapse avoided and CinnoVex was more cost - effective in terms of QALY. Therefore, ReciGen and CinnoVex can be the preferred options for physicians and for health policymakers and managers, respectively.

Purpose To explore the feasibility, safety and efficacy of enterally administered topiramate (TPM) as an adjunctive treatment for adult patients with refractory generalized convulsive status epilepticus (RGCSE). Methods This prospective open-label non-randomized clinical trial was performed at Namazee hospital, Shiraz University of Medical Sciences, Shiraz, Iran from January 2013 through February 2014. Patients 18 years of age and older with RGCSE were enrolled. Topiramate was used, in case of failure of at least two standard anti-epileptic drugs in patients in whom the standard third or fourth line therapies were not available. Topiramate tablets were crushed and administered through the nasogastric tube; 400mg stat and then 200mg Bid. Status epilepticus response to TPM was categorized as successful (termination of SE within 24h following TPM introduction, without modification of concomitant AEDs), possible (SE termination associated with the introduction of TPM, concomitantly with other medications) or unsuccessful. Results Twenty patients were studied. Topiramate was successful in terminating SE in five (25%) patients; possibly successful in 11 (55%); and not successful in four (20%). No clinically significant adverse effects related to TPM administration were observed. Eleven (55%) patients returned to their baseline clinical condition at the time of discharge from the hospital, but two (10%) patients did not. Conclusion Treatment with enterally administered topiramate could potentially be efficacious in some patients and appeared to be tolerated well in patients with RGCSE. Low cost and feasibility makes TPM a potentially useful agent in treating patients with RGCSE, especially in resource limited settings.

Background: Multiple Sclerosis (MS) is the most common demyelinating and inflammatory disease of the central nevus system especially in young adults, but in a subgroup of patients the first clinical symptoms present after the age of 50. This clinical presentation is defined as Late-Onset Multiple Sclerosis (LOMS). The incidence and prevalence of MS including LOMS vary geographically. The aim of this study is to determine epidemiological characteristics of LOMS in Fars province, South of Iran.Materials and Methods: All patients aged over 50, known to have had definite MS according to MC Donald’s criteria, being members of Shiraz University Multiple Sclerosis Database (SUMSD), were evaluated in this study. The following data were recorded via a questionnaire indicating gender, age at the time of diagnosis, clinical course and details of disease- modifying therapies (Beta-Interferon).Results: Among a total of 1705 patients, 7.2% were identified as having LOMS and 3.1% identified as having very late-onset MS (VLOMS). Mean age of the patients with LOMS at the time of diagnosis was 58.81 ± 2.6 years (20.8% were male and 107 (79.2%) were female). 8.9 % had EDSS 6 and more. 89.1% of patients received Beta-Interferon as a disease-modifying treatment including Avonex (16.3 %), Cinovex (32.6%), Rebif (14.1%) and Betaferon (26.1 %). Conclusion: In our study, 7.2% of all MS patients were identified as LOMS. In LOMS subgroup, clinical history and para-clinical data should be thoroughly evaluated to exclude more common conditions like cerebrovascular disease. [GMJ. 2014;3(4):228-31]

Background: Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after carotid angioplasty and stenting.Methods and Material: This is a prospective study conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing carotid angioplasty and stenting were enrolled. Both standard risk and high risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. 30-day stroke, myocardial infarction, and/or death were considered as the composite primary outcome of the study.Results: two hundred and fifty one patients were recruited (mean age: 71.1+ 9.6 years, male: 65.3%). One hundred and seventy eight (70.9%) patients were symptomatic; 73 (29.1%), 129 (51.4%), 165 (65.7%) and 62 (24.7%) patients were diabetic, hyperlipidemic, hypertensive and smoker respectively. CAS performed for left ICA in 113 (45.4%) patients. 14 (5.6%) patients had Sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 +13.8 %. Embolic protection device was used in 203 (96.2%) patients. Predilation and post-dilation were performed in 39 (18.5%) and 182 (86.3%) patients respectively. Composite outcome was observed in 3.6% (3.2% stroke, 0% myocardial infarction and 1.2% death). Left sided lesions and presence of DM was significantly associated with poor short term outcome. (P value: 0.025 and 0.020, respectively)Conclusion: There was a higher risk of short term major complications in diabetic patients and left carotid artery intervention.

In this study, mechanical alloying (MA) of Fe -50 Al , Fe -49.5 Al -1 B , and Fe -47.5 Al -5 B (at.%) alloy powders and mechanical properties of sintered products of the as-milled powders were investigated. X-ray diffraction (XRD) results showed the addition of B caused more crystallite refinement compared to the B -free powders. To consider the sintering and ordering behaviors of the parts produced from cold compaction of the powders milled for 80 h, sintering was conducted at various temperatures. It was found that the sintering temperature has no meaningful effect on the long-range order parameter. The transformation of the disordered solid solution developed by MA to ordered Fe - Al - ( B ) intermetallics was a consequence of sintering. Also, the nano-scale structure of the samples was retained even after sintering. The microhardness of pore-free zones of the nanostructured specimens decreased by increasing the sintering temperature. Moreover, the sintering temperature has no effect on the compressive yield stress. However, the fracture strain increased by increasing the sintering temperature. The samples containing 1 at.% B showed more strain to fracture compared with the B -free and 5 at.% B samples.

In this work, FeAl intermetallic compounds were prepared by mechanical alloying and subsequent sintering processes. The powder milled for 80 h was found to be disordered Fe(Al) nanocrystals with 15 nm in size, which was sintered at 900 and 1000 °C for 1, 3 and 5 h. X-ray diffraction studies of the samples revealed a microstructural evolution and ordering during sintering. At both the sintering temperatures, the long-range order parameter first increased due to the promotion of ordered FeAl from the disordered Fe(Al) solid solution and then decreased by increasing the sintering time. This behavior was attributed to an increase in the concentration and clustering of thermal vacancies. It was also found that by increasing the sintering time, the crystallite size and lattice strain decreased, whereas the relative density and hardness increased.

Iron aluminides, despite having desirable properties like excellent corrosion resistance, present low room-temperature ductility and low strength at high temperatures. Mechanical alloying as a capable process to synthesize nanocrystalline materials is under consideration to modify these drawbacks. In this study, the microstructure of iron aluminide powders synthesized by mechanical alloying and subsequent annealing was investigated. Elemental Fe and Al powders with the same atomic percent were milled in a planetary ball mill for 15 min to 100 h. The powder milled for 80 h was annealed at temperatures of 300, 500 and 700 °C for 1 h. The alloyed powders were disordered Fe(Al) solid solutions which were transformed to FeAl intermetallic after annealing. The effect of the milling time and annealing treatment on structural parameters, such as crystallite size, lattice parameter and lattice strain was evaluated by X-ray diffraction. Typically, these values were 15 nm, 2.92 A and 3.1% for the disordered Fe(Al) solid solution milled for 80 h and were 38.5 nm, 2.896 A and 1.2% for the FeAl intermetallic annealed at 700 °C, respectively.

In this paper, mechanical alloying (MA) of Fe–50Al, Fe–49.5Al–1B, and Fe–47.5Al–5B (at.%) powders and their ordering behavior during annealing were investigated. The results showed that the alloying process was completed after 50 h of milling and disordered Fe–Al–(B) solid solutions were developed. In addition, by increasing the boron content, more considerable crystallite refinement occurred in the course of MA. The ordering behavior of the powders milled for 80 h was evaluated by annealing at various temperatures. The transformation of the disordered solid solutions to ordered Fe–Al–(B) intermetallics was a consequence of annealing. It was also found that the annealing temperature had no meaningful effect on the long-range order parameter. However, by increasing the boron content, the long-range order parameter decreased. It was also notable that the nanoscale structure of the powders was retained even after annealing, suggesting their thermal stability.

Background: Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after CAS. Materials and Methods: This is a prospective study that was conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing CAS were enrolled. Both standard- and high-risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. Thirty-day stroke, myocardial infarction, and/or death were considered as the composite primary outcomes of the study. Results: A total of 251 patients were recruited (mean age: 71.1 ± 9.6 years; male: 65.3%). Of these, 178 (70.9%) were symptomatic, 73 (29.1%) were diabetic, 129 (51.4%) were hyperlipidemic, 165 (65.7%) were hypertensive, and 62 (24.7%) patients were smokers. CAS was performed for left internal carotid artery (ICA) in 113 (45.4%) patients. Fourteen (5.6%) patients had sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 ± 13.8%. An embolic protection device was used in 203 (96.2%) patients. Pre- and postdilation were performed in 39 (18.5%) and 182 (86.3%) patients, respectively. Composite outcomes were observed in 3.6% of patients (3.2% stroke, 0% myocardial infarction, and 1.2% death). Left-sided lesions and the presence of diabetes mellitus were significantly associated with poor short-term outcome (p = 0.025 and p = 0.020, respectively). Conclusion: There was a higher risk of short-term major complications in diabetic patients and for left carotid artery intervention.

Background: Embolus is one of the causes of ischemic stroke that can be due to cardiac sources such as valvular heart diseases and atrial fibrillation and atheroma of the aorta. Transesophageal echocardiography (TEE) is superior in identifying potential cardiac sources of emboli. Due to insufficient data on TEE findings in ischemic stroke in Iran, the present study was done to evaluate TEE in detecting cardiac sources of emboli. The main aim of this study was to describe the cardiogenic sources of emboli using TEE in the ischemic stroke patients. Methods: This is a cross-sectional study conducted during a 13-month period from January 2012 to February 2013 in Shiraz Nemazee teaching hospital. Patients admitted with stroke diagnosis were included; but hemorrhagic stroke cases were excluded. 229 patients with ischemic stroke diagnosis were included and underwent TEE. Results: Causes of cardiac emboli were detected in 65 cases (40.7%) and categorized to high-risk (29.7%) and potential risk (11%). High risk cardiac sources included atrial fibrillation (8.7%), mitral valve disease (MS or MI) 11 cases (4.75%), aortic valve disease (AS or AI) 8 (3.5%), prosthetic valve 3 (1.35%), dilated cardiomyopathy 45 (19.65%) and congestive heart failure with ejection fraction < 30% in 8 cases (3.5%). Potential cardiac sources of emboli comprised 7 cases (3.05%) of septal aneurysm, 4 (1.75%) left ventricular hypokinesia, 13 (5.7%) mitral annular calcification and 9 cases (3.95%) complex atheroma in the ascending aorta or proximal arch. Conclusion: Our study showed that high risk cardiac sources of emboli can be detected using TEE in a considerable percentage of ischemic stroke patients. The most common high risk cardiac etiologies were dilated cardiomyopathy and valvular heart diseases.

Background: Multiple Sclerosis (MS) is a chronic demyelinating disease of the central nervous system and its epidemiology has changed in recent years. Previously, Iran was considered to have a low MS prevalence. In this study, we aimed to update the prevalence and incidence of MS in Iran. Patients and Methods: This study was conducted based on the data derived from the new report of Iran's Ministry Of Health and Medical Education (MOHME) regarding the patients who have registered to obtain support for treatment in Iran till the end of 2013. Results: Among the 42,200 registered patients, 32,477 were female and 9,723 were male (sex ratio: 3.34: 1), and 4,545 were diagnosed in 2013. This resulted in a prevalence of 54.51 and an incidence of 5.87 per 100,000. Conclusion: According to our study results, Iran has a medium-to-high prevalence rate of MS. According to the previous epidemiologic studies from Iran, it seems that the prevalence of MS significantly has increased during recent years. This rate is similar to what is seen in many western countries.

Introduction Multiple sclerosis (MS) is the most common chronic autoimmune demyelinating disease of the central nervous system. The purpose of this study is to determine the relationship between the site of the cervical discopathy and cervical spinal cord plaque in MS patients. Methods This retrospective study included all patients with a definite diagnosis of MS who were treated at an outpatient clinic between September 2004 and September 2011. All patients underwent cervical magnetic resonance imaging (MRI) for primary investigation of the disease. Cervical MRI scans were evaluated for detection of any evidence of cervical discopathy and cervical MS plaques. Any correlation between the site of the MS lesions and discopathy was recorded. Results From 536 patients who were involved in the study, 214 patients had both cervical discopathy and cervical cord plaques. In this group 148 (69.1% of patients) had cervical plaque at the same site of cervical discopathy. The number of patients with cervical cord plaque and discopathy at same site was significantly higher than those with plaque and discopathy at different sites (P Conclusion The study data suggests a possible correlation between cervical discopathy and cervical MS plaque.

Purpose We investigated the various possible reasons for uncontrolled seizures in patients 18 years of age and older to determine the impact of pseudointractability. We also tried to investigate the various forms of pseudointractability. Methods In this cross-sectional study, all patients 18 years of age and older with their first seizure occurring at least six months prior to the referral date, taking at least one antiepileptic drug (AED) and having at least one seizure in the past three months were studied. The presumed reason for uncontrolled seizures was arbitrarily considered to be one of these five categories: Poor compliance; Wrong medication (misclassification); Wrong dose of the correct medication; Diagnosis other than epilepsy; and finally, Medically-refractory epilepsy. Statistical analyses were performed using Chi-square and Fisher's Exact tests, and a P value less than 0.05 was considered significant. Results 350 patients were referred to us due to uncontrolled seizures. One hundred ninety-one (55%) were male and 159 (45%) were female. Twelve percent of the patients had diagnoses other than epilepsy, 40% had indeed medically-refractory epilepsy; 29% were taking the wrong AEDs (misclassified epilepsy); 18% were taking suboptimal doses of AEDs; and 1% had poor drug compliance. The most common reason for uncontrolled seizures among patients with idiopathic generalized epilepsy was taking the wrong AED. However, among patients with focal epilepsy, true medically-refractory epilepsy was the most common reason. Conclusion Uncontrolled seizures are a commonly encountered problem, especially at epilepsy clinics and one should consider all possible reasons for these uncontrolled seizures. The mainstay for making a correct diagnosis is a detailed clinical history.

Dear editor Multiple sclerosis (MS) is the most common inflammatory demyelinating disease of the central nervous system. MS is characterized by dissemination in time and place. Dissemination can be clinically (clinically definite multiple sclerosis) or radiologically by magnetic resonance imaging (MRI). Correct diagnosis of MS needs dissemination both in time and in place and also exclusion of all other neurological diseases that can mimic MS. Clinically, dissemination in time is defined as two episodes of neurological symptoms occurrence, separated at least one month apart, and dissemination in place is characterized as the presence of symptoms or signs in at least two different parts of central nervous system (CNS) (e.g. visual, sensory, motor, etc.). Radiologically dissemination in space (DIS) was defined as the presence of clinically silent lesions in T2-weighted MRI in two of four locations including juxtacortical, preventricular, infratentorial, and spinal cord and dissemination in time (DIT) as the presence of simultaneous gadolinium enhancing and non enhancing lesions in MRI [1,2]. There are some terminologies which are frequently used in patients with demyelinating disorders including clinically definite MS (CDMS), clinically isolated syndrome (CIS) and radiologically isolated syndrome (RIS) [1-3]. CDMS is defined as two attacks of neurological symptoms in two different neurological systems (e.g. optic neuritis and myelitis) separated and apart for at least one month [1]. Radiologically isolated syndrome (RIS) was used in persons with MRI findings suggestive of MS without typical symptoms and signs [3].CIS is defined as the first episode of neurological symptoms and signs suggestive of MS. The onset of MS in 85% of patients presents as CIS. This terminology is widely used in clinical practice. By definition, CIS is always clinically isolated in time. Around 50-70% of patients with CIS have white matter lesions in brain or spinal MRI. On the other hand, CIS usually represents a wide clinical spectrum of diseases of CNS and can be present in a multitude of clinical manifestation [1, 2].At present time, MRI is the most important tool for diagnosis of MS in patients with CIS and the application of MRI for diagnosis of MS has been increased during the past few years [4]. Today, the diagnosis of MS is possible very earlier than before due to the wide integration of MRI in McDonalds’ criteria (2010). MacDonald’s criteria mostly rely on MRI findings to facilitate the early diagnosis of MS [1, 4]. By using the new MacDonald’s criteria some patients who presented with CIS can be diagnosed as MS if MRI fulfills dissemination in time and space. For patients who fulfill the criteria of both DIT and DIS, the term of CDMS is used; but for patients who have had one attack of neurological symptoms and fulfill DIT and DIS radiologically (by MRI) there is no appropriate terminology and all of them are classified as CIS [2, 4]. We know that this terminology is somewhat ambiguous, because CIS may be the first presentation of many neurological diseases including demyelinating diseases, inflammatory diseases such as vasculitis or non-inflammatory non-demyelinating diseases like vascular lesions [2].We recommend the term of radiologically definite MS (RDMS) for patients who have had one attack of neurological symptoms and fulfill DIT and DIS radiologically by MRI. Because many neurologists are not completely familiar with the term CIS and some are confused about it, we need an appropriate terminology to use in every day’s clinical practice. Also, early diagnosis of MS in patients with CIS is very important. Because early treatment of patients with CIS by disease modifying drugs including Beta-Interferon can delay turning into CDMS and also decreases brain atrophy and new brain lesions. All current disease modifying drugs have been shown to be effective in treating CIS [5]. But it is clear that all patients with CIS do not require these treatments and only those patients who show dissemination in time and space by MRI should be treated by these agents [2, 6].In conclusion, radiologicaly definite MS (RDMS) is the recommended terminology for patients who have one attack of neurological symptoms and radiologically fulfill DIT and DIS criteria and these patients should be treated by disease modifying agents as well.