During the COVID-19 pandemic, healthcare professionals took various protective measures including personal protective equipment (PPE) such as masks, eyewear, and protective jumpsuits. These protective devices may pose certain health hazards, such as headaches. This study aims to find out the association between new-onset headaches (de novo) or exacerbation of preexisting headaches in military healthcare professionals using PPE. A total of 209 healthcare professionals participated in this cross-sectional observational study. Data were collected on headaches before and after using PPE through a self-administered questionnaire. Most participants were young with a mean age of 26.7 ± 5.6 years. The number of male participants was almost twice that of females (64.6%). de novo headache occurred in 88 participants (47.6%). Previous primary headaches were present in 24 patients, of whom 83.3% experienced exacerbation of primary headaches after using PPE. Doctors and nurses suffered from headaches significantly more than the other healthcare workers (P < 0.001). N95 mask usage was significantly associated with headaches (P < 0.001). In addition, the combination of masks, specifically surgical and N95 combination, was also associated with headaches (P = 0.019 and P < 0.001, respectively). Use of eye protection, irrespective of type was found to be associated with headaches (P < 0.05). Additional PPE, such as the protective jumpsuits, was also associated with headaches (P < 0.001). Our study did not find any significant association between headaches and the duration of hours of usage of masks or protective eyewear (P > 0.05). Masks, eye protective gear, and additional protective gown use are associated with new-onset headaches or exacerbation of previous headaches. These protective devices should be redesigned not compromising safety and to increase comfort and compliance.

Intraoperative neurophysiological monitoring (IONM) has the advantage of minimizing intraoperative neurological injury and limiting serious postoperative complications. No previous studies have evaluated the importance of IONM, especially in Gulf and Arab countries. We aimed to investigate the importance of IONM, as evaluated from a neurologist perspective in Saudi Arabia. This cross-sectional study was conducted in Saudi Arabia through face-to-face interviews. The inclusion criterion was adult neurology consultants in Saudi Arabia. The instrument used was a self-administered questionnaire consisting of 20 items to evaluate the perceptions on IONM. Data collection was from January 2022 to June 2022. A total of 72 neurology consultants from Saudi Arabia participated in this study. The years of experience of the participants were 10-20 years (43.1%), most of whom worked in a tertiary healthcare center (72.2%), 31.9% had a certified neurologist trained in IONM, and approximately two-thirds of the institutions did not have an IONM setup (59.7%). Most neurologists believed that IONM should be part of neurology training programs (59.7%). Approximately, half of the respondents believed that IONM was mandatory (52.8%). IONM is considered the standard of care in many complex intracranial, spinal, and vascular surgeries. In our study, the perception of neurologists regarding IONM was promising, and the readiness of secondary and tertiary care centers to implement IONM was encouraging. Education, training, implementation, and regulations regarding IONM should be mandatory to prevent operative complications.

Adherence to medication adherence plays a vital role in controlling the problems and complications of epilepsy. During the COVID - 19 pandemic and limitations of face-to-face education, the use of distance education can play an important role in providing education to patients. The aim of this study is the effect of model 5A self-management training on medication adherence in epileptic patients. In this single-blind randomized controlled trial, 56 epileptic patients referred to Shiraz Namazi Hospital were divided into intervention and control groups using random allocation. Thereafter, 5A self - management training sessions were virtually held in 5 sessions in WhatsApp application for intervention group. The data collection tool was MMAS-8 at two stages of before and two months after intervention. Data analysis was performed using SPSS 21 software. The results of Wilcoxon test showed that in intervention group, the mean drug adherence in patients after intervention significantly increased compared to before intervention (p = 0.005). But in control group, this was not significant (p = 0.909). According to results of Mann-Whitney test, there was no significant difference between intervention and control groups before intervention (p = 0.632). However, by passing two months from intervention, a significant difference was found between intervention and control groups (p = 0.041). Based on results, the implementation of model 5A can be effective on medication adherence in epileptic patients. This program can be considered as a suitable method in epileptic patients during COVID - 19 pandemic.

Abstract Originally thought to be incurable, huge therapeutic progress has been made in recent years in the field of inherited neuromuscular disorders. Approaches aiming to rescue the underlying pathophysiology, i.e. loss-of-function or gain-of-function mutations, have been developed via end-product replacement or gene delivery/modulation, with promising results. In the review, advanced treatment in some of the inherited neuromuscular disorders will be discussed. On the other hand, it has been found more than 1000 genes are responsible for the clinical diversities in this group of diseases, and finding a way which owns the therapeutic potential to various diseases is the optimal goal. The discovery of CRISPR-Cas9 system in the last decade offers such an opportunity and is under rigorous investigation. This important issue will also be discussed.

Abstract Background: Ischemic stroke has been a common cause of death and disability in Taiwan, particularly among the elderly. Social isolation is a significant issue in an aging society, which can be associated with delayed medical care and difficulties in diagnosis. Case: A 76-year-old man presented with altered mental status, left-sided weakness, and declining cognitive function over three months. He had limited social connections and an unknown medical history. Initial brain imaging showed communicating hydrocephalus. Cerebrospinal fluid analysis revealed increased lymphocytes and high protein levels. Further imaging revealed multiple hyperintense lesions in the brain’s white matter and acute ischemic stroke in specific areas. The patient was diagnosed with tuberculosis and HIV coinfection, leading to probable tuberculous meningitis, HIV encephalopathy, and pneumocystis jirovecii pneumonia. Treatment with antituberculous agents, antibiotics, and steroids improved the patient’s level of consciousness. Conclusion: Addressing social isolation and altered consciousness in elderly individuals requires a thoughtful approach. Reconsidering the differential diagnosis is crucial when it doesn’t match the clinical severity. Clinicians should consider rare co-occurrences like ischemic stroke, TBM, and HIV infection in atypical TBM cases. A biopsychosocial perspective helps gather a comprehensive medical history for holistic care. Early diagnosis and timely intervention are vital for better outcomes in severe infections.

Self-efficacy is one of the factors affecting on the quality of life and adjustment to the chronic diseases such as multiple sclerosis. Self-efficacy is the individual's belief that they have the ability to overcome challenges presented to them. The current study aimed to develop and validate of selfefficacy questionnaire in Iranian MS patients. This is a methodological study that was performed in three phases. In the first phase, the concept of self-efficacy was defined through qualitative content analysis approach. In the second phase, early items of questionnaire was generated according to findings of the first phase. In the final phase, validation of the developed questionnaire were evaluated using face, content and construct validity as well as reliability. In exploratory factor analysis, four subscales including: adherence to medication regimens (5 items), social performance control (4 items), symptom management (4 items) and maintain independence and activity (5 items) were extracted by Eigen value above one and factor load above 0.3. Internal consistency and stability of the developed questionnaire confirmed with 0.91 and 0.88 respectively that indicated acceptable reliability. The 18-item developed questionnaire is valid and reliable for measurement of self-efficacy of Iranian MS patients.

A 17-year-old male presented with a 20-day history of vomiting, abdominal pain, weight loss, headache and fever progressing to dysarthria, somnolence, urinary incontinence, slurred speech, weakness, and inability to walk. Neurological examination revealed diminished visual acuity and diplopia. A head computed tomography (CT) showed acute hydrocephalus (Figure 1). Cerebrospinal fluid (CSF) analysis revealed pleocytosis (lymphocyte predominant), hypoglycorrhachia (8 mg/dL), and hyperproteinorrachia (156 mg/dL). The brain magnetic resonance imaging (MRI) revealed leptomeningitis, basal ganglia infarcts and basal meningeal enhancement highly suggestive of tuberculous meningitis (TBM) (Figure 2). We calculated a positive Thwaites score (-5) for TBM. The patient responded well to antituberculous treatment and dexamethasone. At 2 year follow-up the patient remains symptom-free. Stroke is a frequent complication of TBM and might contribute to long-term disability. Brain imaging findings, such as basal meningeal enhancement and basal exudates, hydrocephalus, and infarctions (TBM triad) are useful tools to rapidly identify probable TBM(3,4). Brain infarcts in TBM are located mostly in the arterial territory of distal branching arterires(5). Other less frequent imaging findings are tuberculomas and vasospasm. Key message: Hydrocephalus, basal meningeal enhancement, and basal ganglia infarcts should raise suspicion of tuberculosis, especially in endemic regions.

Abstract Objective: Self-efficacy is one of the factors affecting on the quality of life and adjustment to the chronic diseases such as multiple sclerosis. Self-efficacy is the individual’s belief that they have the ability to overcome challenges presented to them. The current study aimed to develop and validate of self- efficacy questionnaire in Iranian MS patients. Materials and methods: This is a methodological study that was performed in three phases. In the first phase, the concept of self-efficacy was defined through qualitative content analysis approach. In the second phase, early items of questionnaire was generated according to findings of the first phase. In the final phase, validation of the developed questionnaire were evaluated using face, content and construct validity as well as reliability. Results: In exploratory factor analysis, four subscales including: adherence to medication regimens (5 items), social performance control (4 items), symptom management (4 items) and maintain independence and activity (5 items) were extracted by Eigen value above one and factor load above 0.3. Internal consistency and stability of the developed questionnaire confirmed with 0.91 and 0.88 respectively that indicated acceptable reliability. Conclusions: The 18-item developed questionnaire is valid and reliable for measurement of self-efficacy of Iranian MS patients.

An 80-year-old woman with a history of rheumatoid arthritis, hypertension, and hyperlipidemia, and no family history of hyperkinesis developed suddenly involuntary movement and visited our hospital two-day after onset. Neuro-examination revealed hemichorea-hemiballismus in the right side of the body, including the face (Suppl. video). Blood tests revealed neither hyperglycemia nor acanthocyte. Brain MRI showed acute microbleeding in the left subthalamic nucleus (Figure 1A-C). Although she was treated with haloperidol (max. 4.5 mg/day), hemichorea-hemiballismus did not subside. Repetitive transcranial magnetic stimulation (rTMS) with a low-frequency protocol (LFP) (1 Hz, 1200 pulses, with a stimulus intensity of 90% of the resting motor threshold, 3 days/week for 2-week) was applied to the left precentral knob (Figure 1D). Its effect was drastic, as the symptoms disappeared for half-hour after rTMS. Hemichorea-hemiballism then reappeared but was attenuated by repeated rTMS. The symptoms disappeared after one-month. Subthalamic nucleus lesions can develop hemichorea-hemiballism (1). According to a study on Huntington's disease and diabetic hemichorea-hemiballism, increased thalamocortical drive may increase the excitability of excitatory and inhibitory circuits of the frontal cortex as the etiologies of hyperkinesia (2-3). However, the target points of rTMS in treating hemichorea-hemiballism have not been consistent in literature. Moreover, rTMS with a LFP on the bilateral supplementary motor areas is effective in treating chorea in Huntington's disease (2). Additionally, rTMS on the ipsilateral precentral knob (primary motor cortex) with continuous θ burst stimulation (cTBS), which decreases the excitability and inhibitory cortical circuits, was effective in treating contralateral hemichorea caused by midbrain hemorrhage (3). Similar to cTBS, LFP can suppress cortical excitation (4); therefore, we applied rTMS with LFP on the primary motor cortex to treat hemichorea-hemiballism. Our results were drastic for both short- and long-term efficiency. This is the first report of the efficacy of rTMS with LFP in treating hemichorea-hemiballism caused by encephalorrhagia.

Objective: The purpose of this study was to investigate the effects of Crocin on brain neuroterophins, cognition, sensory and motor dysfunction and compare to fingolimod effects in toxic-induced demyelination with Ethidium Bromide (EB) in female Wistar rats. Methods: Animals were assigned in to 8 groups; Sham, Sham operated (ShOp), Experimental Autoimmune Encephalomyelitis (EAE), crocin treated (Cr5,10,20 mg/kg), Vehicle, Fingolompd (Fing) and fingolimod + crocin (Cr+Fing). Demyelination was induced by single dose injection of 10 μl of EB 0.1% into the fourth ventricle of the brain. Crocin and fingolimod were administered for 21 days, daily, oral gavage. BDNF, NGF1, tail flake latency, balance and behavioral variables were sampled and analyzed by paired t-test and ANOVA test with repeated post hoc measurements. Results: The results showed that crocin improves all studied factors, but remarkable improvements were observed in dosage of 10 mg/kg. Crocin (10mg/kg) and fingolimod (1mg/kg) significantly improved cognition variables in open field test, sensory and motor nerve conduction velocity, tail flick latency and clinical scores (p&lt;005). In addition, applying of crocin co-administered with fingolimod led to significant increases in all assessed factors, greater than crocin or fingolimod intervention alone (α≤0.001). Conclusion: Based on the current findings, crocin can improve the level of brain neurotrophins, exploratory behavior, balance and pain after toxin-demyelination as close as fingolimod results.