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Background and Purpose: Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale. Methods: We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes. Results: Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were P =0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; P Conclusions: We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.

Mondello, Stefania/0000-0002-8587-3614; Alizada, Orkhan/0000-0003-0942-9906; Ghorbani, Mohammad/0000-0002-7709-3095; Abedi, Vida/0000-0001-7689-933X WOS:000575454600010 PubMed ID: 32818804 Background: There is an increased attention to stroke following SARS-CoV-2. The goal of this study was to better depict the short-term risk of stroke and its associated factors among SARS-CoV-2 hospitalized patients. Methods: This multicentre, multinational observational study includes hospitalized SARS-CoV-2 patients from North and South America (United States, Canada, and Brazil), Europe (Greece, Italy, Finland, and Turkey), Asia (Lebanon, Iran, and India), and Oceania (New Zealand). The outcome was the risk of subsequent stroke. Centres were included by non-probability sampling. The counts and clinical characteristics including laboratory findings and imaging of the patients with and without a subsequent stroke were recorded according to a predefined protocol. Quality, risk of bias, and heterogeneity assessments were conducted according to ROBINS-E and Cochrane Q-test. The risk of subsequent stroke was estimated through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines. Findings: We received data from 26,175 hospitalized SARS-CoV-2 patients from 99 tertiary centres in 65 regions of 11 countries until May 1st, 2020. A total of 17,799 patients were included in meta-analyses. Among them, 156(0.9%) patients had a stroke-123(79%) ischaemic stroke, 27(17%) intracerebral/subarachnoid hemorrhage, and 6(4%) cerebral sinus thrombosis. Subsequent stroke risks calculated with meta-analyses, under low to moderate heterogeneity, were 0.5% among all centres in all countries, and 0.7% among countries with higher health expenditures. The need for mechanical ventilation (OR: 1.9, 95% CI:1.1-3.5, p = 0.03) and the presence of ischaemic heart disease (OR: 2.5, 95% CI:1.4-4.7, p = 0.006) were predictive of stroke. Interpretation: The results of this multi-national study on hospitalized patients with SARS-CoV-2 infection indicated an overall stroke risk of 0.5%(pooled risk: 0.9%). The need for mechanical ventilation and the history of ischaemic heart disease are the independent predictors of stroke among SARS-CoV-2 patients. (C) 2020 The Authors. Published by Elsevier B.V.

Background: The Multiple Sclerosis Severity Score (MSSS) is a widely used measure of the disability progression rate. However, the global MSSS may not be the best basis for comparison between all patient groups. Objective: We evaluated sex-specific and onset phenotype–specific MSSS matrices to determine if they were more effective than the global MSSS as a basis for comparison within these subsets. Methods: Using a large international dataset of multiple sclerosis (MS) patient records and the original MSSS algorithm, we constructed global, sex-specific and onset phenotype–specific MSSS matrices. We compared matrices using permutation analysis. Results: Our final dataset included 30,203 MS cases, with 28.9% males and 6.5% progressive-onset cases. Our global MSSS matrix did not differ from previously published data ( p > 0.05). The progressive-onset-specific matrix differed significantly from the relapsing-onset-specific matrix ( p Conclusion: The differences in the disability accrual rate between progressive- and relapsing-onset MS have a significant effect on MSSS. An onset-specific MSSS should be used when comparing the rate of disability progression among progressive-onset cases and for mixed cohorts.

Background: There has been increasing attention on cerebrovascular events (CVEs) following SARS-CoV-2. The goal of this study was to better depict the short-term risk of CVEs and its associated factors among SARS-CoV-2 hospitalized patients. Methods: This multicenter, multinational observational study includes hospitalized SARS-CoV-2 patients from North and South America (United States, Canada, and Brazil), Europe (Greece, Italy, Finland, and Turkey), Asia (Lebanon, Iran, and India), and Oceania (New Zealand). The outcome was the risk of subsequent CVEs. The counts and clinical details of the patients with and without a CVE were received according to a predefined protocol. Quality, risk of bias, and heterogeneity assessments were conducted according to ROBINS-E and Cochrane Q-test. The risk of subsequent CVEs was estimated for individual states/districts, countries, continents, and within industrialized countries through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines. Findings: We received data from 26,133 hospitalized SARS-CoV-2 patients from 99 tertiary centers in 65 states/districts. A total of 17,774 patients were included in meta-analyses. Among them, 156 patients had a CVE complication—123(78·8%) ischemic stroke, 27(17·3%) intracerebral/subarachnoid hemorrhage, and 6(3·8%) cerebral sinus thrombosis. The meta-analyses indicated an overall 0·3%-1·2% risk of CVEs. Dependency on a ventilator and the presence of ischemic heart disease were predictive of CVEs. Interpretation: Although there is an increased risk of CVEs among SARS-CoV-2 patients, the risk is comparable to other viral infections and critical conditions. Funding: None Declaration of Interest: Neither I (Ramin Zand, corresponding author) nor any of the co-authors have a financial, commercial, legal, or professional relationship with other organizations, or with the people working with them, that could influence our presented research. Ethical Approval: The study receivedapproval bythe Institutional Review Board of Geisinger Health System and other participating institutions when it was required.

Background: Optic neuritis is an inflammation of the optic nerve. Because of importance of vision for human, management of optic neuritis is an important issue in neurology. Objectives: This study aimed at assessing the effect of oral steroid treatment after intravenous (IV) methylprednisolone therapy on demyelinating optic neuritis. Materials & Methods: 60 Patients with first episode of acute demyelinating optic neuritis who referred to a neurology clinic in an academic hospital in south-west of Iran in 2015-2016 included in this randomized double-blind clinical trial study (No: IRCT2015102724735N1). They were divided into two groups with (A) and without (B) tapering oral steroid treatment after IV methylprednisolone. Visual acuity and color vision were measured before treatment, before oral tapering, 1 and 3 months after treatment. Independent t-test in SPSS software version 20 was used to analyze the data. P0.05).Frequency of color vision abnormality in groups A and B were at baseline (53.3% vs. 56.6%) (P=0.796), before oral tapering (43.3% vs. 30%, P=0.284), 1 month after treatment (23.3% vs. 30%, P=0.559), 3 months after treatment (0% vs. 23%, P=0.011). Conclusion: Oral steroid treatment after IV methylprednisolone pulse therapy improves color vision after 3 months in patients with demyelinating optic neuritis but has no effect on visual acuity.

Objective To assess prognostic factors for a second clinical attack and a first disability-worsening event in pediatric clinically isolated syndrome (pCIS) suggestive of multiple sclerosis (MS) patients. Methods A cohort of 770 pCIS patients was followed up for at least 10 years. Cox proportional hazard models and Recursive Partitioning and Amalgamation (RECPAM) tree-regression were used to analyze data. Results In pCIS, female sex and a multifocal onset were risk factors for a second clinical attack (hazard ratio [HR], 95% confidence interval [CI] = 1.28, 1.06–1.55; 1.42, 1.10–1.84, respectively), whereas disease-modifying drug (DMD) exposure reduced this risk (HR, 95% CI = 0.75, 0.60–0.95). After pediatric onset MS (POMS) diagnosis, age at onset younger than 15 years and DMD exposure decreased the risk of a first Expanded Disability Status Scale (EDSS)-worsening event (HR, 95% CI = 0.59, 0.42–0.83; 0.75, 0.71–0.80, respectively), whereas the occurrence of relapse increased this risk (HR, 95% CI = 5.08, 3.46–7.46). An exploratory RECPAM analysis highlighted a significantly higher incidence of a first EDSS-worsening event in patients with multifocal or isolated spinal cord or optic neuritis involvement at onset in comparison to those with an isolated supratentorial or brainstem syndrome. A Cox regression model including RECPAM classes confirmed DMD exposure as the most protective factor against EDSS-worsening events and relapses as the most important risk factor for attaining EDSS worsening. Interpretation This work represents a step forward in identifying predictors of unfavorable course in pCIS and POMS and supports a protective effect of early DMD treatment in preventing MS development and disability accumulation in this population. Ann Neurol 2017;81:729–739

Background Boswellia Serrata (BS) has been shown to have anti-inflammatory effects and neuroprotective activity. Objective To determine whether BS improves cognitive performance among patients with multiple sclerosis (MS) related cognitive impairment (CI). Method This was a double-blind, randomized, placebo-controlled study, in which 60 patients who had subjective cognitive complaints (according to multiple sclerosis neuropsychological questionnaire) were selected and categorized in two groups (each with 30 persons). These groups were compared on the basis of the effect of 450 mg of BS or placebo capsules twice a day. A series of MACFIMS (minimum assessment of cognitive function in MS) tests were conducted on the patients at the beginning of the treatment process and after 2 months of the study. Results of the mentioned tests were analyzed and recorded. Results Considering changes in brief visuospatial memory test (BVMT) (p 0.05). Conclusion BS improved CVLT and BVMT in relapsing remitting (RR)MS patients without major depression who had subjective complaints of CI.

Signori, Alessio/0000-0001-6289-9144; Sajedi, Seyed Aidin/0000-0002-6704-9787; Jokubaitis, Vilija G./0000-0002-3942-4340; Shaygannejad, Vahid/0000-0002-6226-0161; Oreja-Guevara, Celia/0000-0002-9221-5716; amato, Maria Pia/0000-0003-3325-3760; Lugaresi, Alessandra/0000-0003-2902-5589; Majdinasab, Nastaran/0000-0001-5163-7210; Kalincik, Tomas/0000-0003-3778-1376; Butzkueven, Helmut/0000-0003-3940-8727; van Pesch, Vincent/0000-0003-2885-9004; pucci, eugenio/0000-0001-7606-7330; Petersen, Thor/0000-0001-5633-2600; Prat, Alexandre/0000-0001-6188-0580; Sanchez Menoyo, Jose Luis/0000-0003-2634-8294; Slee, Mark/0000-0003-4323-2453; SORMANI, MARIA PIA/0000-0001-6892-104X; Trojano, Maria/0000-0002-6329-8946 WOS: 000432098100013 PubMed: 28382837 Background: Several natural history studies on primary progressive multiple sclerosis (PPMS) patients detected a consistent heterogeneity in the rate of disability accumulation. Objectives: To identify subgroups of PPMS patients with similar longitudinal trajectories of Expanded Disability Status Scale (EDSS) over time. Methods: All PPMS patients collected within the MSBase registry, who had their first EDSS assessment within 5 years from onset, were included in the analysis. Longitudinal EDSS scores were modeled by a latent class mixed model (LCMM), using a nonlinear function of time from onset. LCMM is an advanced statistical approach that models heterogeneity between patients by classifying them into unobserved groups showing similar characteristics. Results: A total of 853 PPMS (51.7% females) from 24 countries with a mean age at onset of 42.4 years (standard deviation (SD): 10.8 years), a median baseline EDSS of 4 (interquartile range (IQR): 2.5-5.5), and 2.4 years of disease duration (SD: 1.5 years) were included. LCMM detected three different subgroups of patients with a mild (n = 143; 16.8%), moderate (n = 378; 44.3%), or severe (n = 332; 38.9%) disability trajectory. The probability of reaching EDSS 6 at 10 years was 0%, 46.4%, and 81.9% respectively. Conclusion: Applying an LCMM modeling approach to long-term EDSS data, it is possible to identify groups of PPMS patients with different prognosis. MSBase Foundation; Merck SeronoMerck SeronoMerck & Company; BiogenBiogen; Novartis Pharma; Bayer ScheringBayer AG; Sanofi-AventisSanofi-Aventis; BioCSL The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the MSBase Foundation. The MSBase Foundation is a not-for-profit organization that receives support from Merck Serono, Biogen, Novartis Pharma, Bayer Schering, Sanofi-Aventis and BioCSL. The study was conducted separately and apart from the guidance of the sponsors.

Objective Evidences from cultured cells and animal models of ischemia suggest that lithium has neuroprotective and neurotrophic effects and may play a desirable role in reducing infarct volume and even improving the brain insults from stroke. The aim of this study was to evaluate the efficacy of lithium in early motor recovery of patients after ischemic stroke. Methods Eighty patients with first ever stroke, allocated randomly in lithium, 300 mg twice daily, or placebo. Treatment was initiated 48 hours after stroke and continued for 30 days. Modified National Institute of Health Stroke Scale (mNIHSS) and hand subsection of Fugl-Meyer Assessment (hFMA) were used to evaluate impairment on the fifth and 30th day of treatment. Results Sixty-six subjects (32 subjects in the lithium group and 34 subjects in the placebo group) completed the study. There were no significant differences in the improvement in mNIHSS (P=0.40) and hFMA (P=0.07) after 30 days. However, a subgroup analysis showed that patients with cortical strokes in the lithium group had significantly better improvement in both mNIHSS and hFMA in comparison to the placebo group (P=0.003). Approximately 44% (n=14) of patients in the lithium group, mainly from the cortical stroke subgroup, regained more than 25% of full function based on hFMA, whereas this rate in the placebo group was 14.7% (n=5; P=0.009). Conclusion The observed discrete difference between the lithium group and the placebo group in the cortical stroke subgroup may suggest an enhanced motor recovery after stroke by using an early treatment with a low dose of lithium carbonate. However, a larger trial with more patients with cortical stroke is needed to investigate this effect better.

BACKGROUND AND PURPOSE Sickle cell disease (SCD) is strongly linked to stroke across all haplotypes in the pediatric population. Transcranial Doppler (TCD) ultrasound is known to identify the highest risk group in African-Americans who need to receive and stay on blood transfusions, but it is unclear if the same flow velocity cut-offs can be applied to the Iranian population. We aimed to evaluate baseline TCD findings in Iranian children with SCD and no prior strokes. METHODS Children with genetically confirmed SCD (Arabian haplotype, homozygote) and without SCD (controls) were prospectively recruited from pediatric outpatient clinic over a period of 9 months. We performed TCD in both groups to determine flow velocities in the middle cerebral (MCA) and terminal internal carotid arteries (TICA). RESULTS Of 74 screened children, 60 met the inclusion/exclusion criteria (62% female; mean age 10±4 years). Baseline characteristics did not differ between the cases and controls, except hemoglobin (Hb) which was significantly lower in the SCD group (P

Dr. Rathore et al. evaluated outcome after seizure recurrence during antiepileptic drug (AED) withdrawal following temporal lobectomy and found that despite initial seizure recurrence, 86% of patients become seizure-free and 18% become drug-free. Dr. Sethi commends the study's long postoperative follow-up of 12 years, but notes that every patient with temporal lobe epilepsy is unique and treatment decisions must be individualized. Drs. Rathore and Jeyaraj agree that medication management after temporal lobectomy should be personalized, but reiterate that withdrawal of AEDs is one of the goals of epilepsy surgery. They recommend use of the FND20 score described in their article to assist in determining which patients are ideal candidates for withdrawal of medications, but emphasize that this score does not provide absolute certainty about successful outcome following discontinuation of AEDs.

none 49 si studio multicentrico Background: Age at onset (AAO) in multiple sclerosis (MS) is an important marker of disease severity and may have prognostic significance. Understanding what factors can influence AAO may shed light on the aetiology of this complex disease, and have applications in the diagnostic process. Methods: The study cohort of 22 162 eligible patients from 21 countries was extracted from the MSBase registry. Only patients with MS aged ≥16 years were included. To reduce heterogeneity, only centres of largely European descent were included for analysis. AAO was defined as the year of the first symptom suggestive of inflammatory central nervous system demyelination. Predictors of AAO were evaluated by linear regression. Results: Compared with those living in lower latitudes (19.0-39.9°), onset of symptoms was 1.9 years earlier for those at higher latitudes (50.0-56.0°) (p=3.83×10-23). A reciprocal relationship was seen for ambient ultraviolet radiation (UVR), with a significantly increasing AAO for patients with MS per each quartile increment of ambient UVR (p=1.56×10-17). We found that the AAO of female patients was ∼5 months earlier than male patients (p=0.002). AAO of progressive-onset patients with MS were ∼9 years later than relapsing-onset patients (p=1.40×10-265). Conclusions: An earlier AAO in higher latitude regions was found in this worldwide European-descent cohort and correlated inversely with variation in latitudinal UVR. These results suggest that environmental factors which act at the population level may significantly influence disease severity characteristics in genetically susceptible populations. open Tao, Chunrong; Simpson, Steve; Van Der Mei, Ingrid; Blizzard, Leigh; Havrdova, Eva; Horakova, Dana; Shaygannejad, Vahid; Lugaresi, Alessandra; Izquierdo, Guillermo; Trojano, Maria; Duquette, Pierre; Girard, Marc; Grand'Maison, Franois; Grammond, Pierre; Alroughani, Raed; Terzi, Murat; Oreja-Guevara, Celia; Sajedi, Seyed Aidin; Iuliano, Gerardo; Sola, Patrizia; Lechner-Scott, Jeannette; Van Pesch, Vincent; Pucci, Eugenio; Bergamaschi, Roberto; Barnett, Michael; Ramo, Cristina; Singhal, Bhim; Spitaleri, Daniele L. A.; Slee, Mark; Verheul, Freek; Fernández Bolaños, Ricardo; Amato, Maria Pia; Cristiano, Edgardo; Granella, Franco; Hodgkinson, Suzanne; Fiol, Marcela; Gray, Orla; Mccombe, Pamela; Saladino, Maria Laura; Sánchez Menoyo, José Luis; Shuey, Neil; Vucic, Steve; Shaw, Cameron; Deri, Norma; Arruda, Walter Oleschko; Butzkueven, Helmut; Spelman, Tim; Taylor, Bruce V; MSBase Study Group Tao, Chunrong; Simpson, Steve; Van Der Mei, Ingrid; Blizzard, Leigh; Havrdova, Eva; Horakova, Dana; Shaygannejad, Vahid; Lugaresi, Alessandra; Izquierdo, Guillermo; Trojano, Maria; Duquette, Pierre; Girard, Marc; Grand'Maison, Franois; Grammond, Pierre; Alroughani, Raed; Terzi, Murat; Oreja-Guevara, Celia; Sajedi, Seyed Aidin; Iuliano, Gerardo; Sola, Patrizia; Lechner-Scott, Jeannette; Van Pesch, Vincent; Pucci, Eugenio; Bergamaschi, Roberto; Barnett, Michael; Ramo, Cristina; Singhal, Bhim; Spitaleri, Daniele L. A.; Slee, Mark; Verheul, Freek; Fernández Bolaños, Ricardo; Amato, Maria Pia; Cristiano, Edgardo; Granella, Franco; Hodgkinson, Suzanne; Fiol, Marcela; Gray, Orla; Mccombe, Pamela; Saladino, Maria Laura; Sánchez Menoyo, José Luis; Shuey, Neil; Vucic, Steve; Shaw, Cameron; Deri, Norma; Arruda, Walter Oleschko; Butzkueven, Helmut; Spelman, Tim; Taylor, Bruce V; MSBase Study Group

Stroke is the third common cause of mortality and the most common cause of morbidity in adults. MLC601 (NeuroAiD™) is a treatment indicated for post stroke recovery. An increase of impaired cerebral blood flow may be an important parameter for recovery processes. The aim of this study was to investigate the effect of MLC601 on cerebral blood flow velocity as an indirect evidence of cerebral blood flow increase in post stroke subjects.This is a double-blinded, placebo controlled, randomized study of 80 subjects included within a week of stroke onset. All subjects were given either MLC601 or placebo, 4 capsules, 3 times a day for 3 months. Cerebral blood flow within the middle cerebral artery, with blood flow velocity measured by transcranial Doppler (TCD), and Barthel index was assessed at baseline and at 3 months.The mean change in cerebral blood flow velocity in the MLC601 treatment group (15.9) was significantly increased (p=0.009) compared to the placebo group (9.6). Subjects in the treatment group also showed a significant difference in the mean rank of modified ranking scale (p0.001) and mean change of the Barthel Index: 36 vs. 29 in the placebo group (p0.001).This is the first study suggesting that treatment with MLC601 may increase cerebral blood flow in stroke subjects. This may be mediated by an effect on stimulating microcirculation, an important process contributing to neuroplasticity in the central nervous system. This effect on cerebral blood flow may be associated with improvement in measures of functional recovery.

Background We noticed that a hypothesis based on the effect of geomagnetic disturbances (GMD) has the ability to explain special features of multiple sclerosis (MS). Areas around geomagnetic 60 degree latitude (GM60L) experience the greatest amount of GMD. The easiest way to evaluate our hypothesis was to test the association of MS prevalence (MSP) with angular distance to geomagnetic 60 degree latitude (AMAG60) and compare it with the known association of MS with geographical latitude (GL). We did the same with angular distance to geographic 60 degree latitude (AGRAPH60) as a control. Methods English written papers with MSP keywords, done in Europe (EUR), North America (NA) or Australasia (AUS) were retrieved from the PubMed. Geomagnetic coordinates were determined for each location and AMAG60 was calculated as absolute value of numerical difference between its geomagnetic latitude from GM60L. By an ecological study with using meta-regression analyses, the relationship of MSP with GL, AMAG60 and AGRAPH60 were evaluated separately. MSP data were weighted by square root of number of prevalent cases. Models were compared by their adjusted R square (AR2) and standard error of estimate (SEE). Results 111 MSP data were entered in the study. In each continent, AMAG60 had the best correlation with MSP, the largest AR2 (0.47, 0.42 and 0.84 for EUR, NA and AUS, respectively) and the least SEE. Merging both hemispheres data, AMAG60 explained 56% of MSP variations with the least SEE (R = 0.75, AR2 = 0.56, SEE = 57), while GL explained 17% (R = 0.41, AR2 = 0.17, SEE = 78.5) and AGRAPH60 explained 12% of that variations with the highest SEE (R = 0.35, AR2 = 0.12, SEE = 80.5). Conclusions Our results confirmed that AMAG60 is the best describer of MSP variations and has the strongest association with MSP distribution. They clarified that the well-known latitudinal gradient of MSP may be actually a gradient related to GM60L. Moreover, the location of GM60L can elucidate why MSP has parabolic and linear gradient in the north and south hemisphere, respectively. This preliminary evaluation supported that GMD can be the mysterious environmental risk factor for MS. We believe that this hypothesis deserves to be considered for further validation studies.

Childhood hypertension has been extensively focused on in the past decades because of its increasing incidence, which is related to physicians' awareness and the increasing number of obese children. Age, gender, and body size are the main determinants of blood pressure in children. The revised childhood blood pressure tables of the National High Blood Pressure Education Program are a prerequisite for classification of childhood hypertension. Although these tables provide a reasonable basis, they are intricate and height percentile is needed for final diagnosis. Many attempts have been done to decrease such complexity. We present new formulas that are concise and memorable, and will help physicians to screen prehypertensive and hypertensive pediatric patients.

Multicystic dysplastic kidney is a noninherited congenital disease. Association of this disease with abnormalities of various organs is common. We, however, report a rare case of multicystic dysplastic kidney associated with congenital ichthyosiform erythroderma in an infant. Different developmental origins of the skin and the kidney can explain the scarcity of concurrent congenital skin and kidney abnormalities. Nonetheless, the development of both organs depends on mesenchyme-epithelial interactions for inductive signaling. It seems defects in the production of signaling molecules can explain such an association.

Background The Hajj Ceremony, the largest annual gathering in the world, is the most important life event for any Muslim. This study was designed to evaluate the incidence of stroke among Iranian pilgrims during the Hajj ceremony. Methods We ascertained all cases of stroke occurring in a population of 92,974 Iranian pilgrims between November 27, 2007 and January 12, 2008. Incidence and risk factors of the first ever stroke in Hajj pilgrims were compared, within the same time frame, to those of the Mashhad residents, the second largest city in Iran. Data for the latter group were extracted from the Mashhad Stroke Incidence Study (MSIS) database. Results During the study period, 17 first-ever strokes occurred in the Hajj pilgrims and 40 first-ever stroke strokes occurred in the MSIS group. Overall, the adjusted incidence rate of first ever stroke in the Hajj cohort was lower than that of the MSIS population (9 vs. 16 per 100,000). For age- and gender-specific subgroups, the Hajj stroke crude rates were in general similar to or lower than the general population of Mashhad, Iran, with the exception of women aged 35 to 44 years and aged >75 years who were at greater risk of having first-ever stroke than the non-pilgrims of the same age. Conclusion The first ever stroke rate among Iranian Hajj pilgrims was lower than that of the general population in Mashhad, Iran, except for females 35–44 or more than 75 years old. The number of events occurring during the Hajj suggests that Islamic countries should consider designing preventive and screening programs for pilgrims.