Prone extension views in cervical MRI: A case-driven Novel approach.

The cervical spinal canal has a wide range of motion and specific biomechanics involved with different pathologies that may cause dynamic cord compressions. This study has introduced new protocol for acquiring an extension view of cervical MRI to assess dynamic cervical spinal canal compromise. We posit that dynamic MRI comprising extension view in prone position could be a practical option when deciding the best approach in treating challenging patients.

Adopting Clinical Practice Guidelines for Pharmacologic Management of Acute Spinal Cord Injury from a Developed World Context to a Developing Global Region.

BACKGROUND: Proper utilization of high-quality clinical practice guidelines (CPGs) eliminates the dependence of patients' outcomes on the ability and knowledge of "individual" health care providers and reduces unwarranted variation in care. The aim of this study was to adapt/adopt two CPGs for pharmacologic management of acute spinal cord injury (SCI) using guideline adaptation methods. METHODS: This study was conducted based on the ADAPTE process. Following establishment of an organizing committee and choosing the health topics, we appraised the quality of the CPGs using the Appraisal of Clinical Guidelines for Research & Evaluation II (AGREE II). Then, the authors extracted and categorized suggestions according to Population, Intervention, Professions, Outcomes and Health care setting (PIPOH). The decision-making process was based on systemic evaluation of each suggestion, utilizing a combination of AGREE II scores, the quality of supporting evidence for or against each suggestion and the triad of feasibility, acceptance and adoptability for the Iranian health-care context. RESULTS: Two guidelines were included in the adaptation process. Based on high-quality of these guidelines and the feasibility and adoptability evaluation of the organizing committee, we decided to adopt the suggestion of both guidelines. Overall, seven suggestions were extracted from the source guidelines. CONCLUSION: This work provides a framework to apply guidelines for acute SCI to the developing regions of the world. Attempts should be made to implement these suggestions in order to improve the health outcomes of Iranian SCI patients.

Interpretation of Hematological, Biochemical, and Immunological Findings of COVID-19 Disease: Biomarkers Associated with Severity and Mortality.

The severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) spread rapidly all over the world in late 2019 and caused critical illness and death in some infected patients. This study aimed at examining several laboratory factors, especially inflammatory and immunological mediators, to identify severity and mortality associated biomarkers. Ninety-three hospitalized patients with confirmed coronavirus disease 2019 (COVID-19) were classified based on disease severity. The levels of biochemical, hematological, immunological, and inflammatory mediators were assessed, and their association with severity and mortality were evaluated. Hospitalized patients were mostly men (77.4%) with an average (standard deviation) age of 59.14 (14.81) years. The mortality rate was significantly higher in critical patients (85.7%). Increased serum levels of blood sugar, urea, creatinine, uric acid, phosphorus, total bilirubin, serum glutamic-oxaloacetic transaminase, serum glutamic-oxaloacetic transaminase, lactic dehydrogenase, C-reactive protein, ferritin, and procalcitonin were significantly prevalent (p=0.002, p<0.001, p<0.001, p=0.014, p=0.047, p=0.003, p<0.001, p<0.001, p<0.001, p<0.001, P<0.001, and p<0.001, respectively) in COVID-19 patients. Decreased red blood cell, hemoglobin, and hematocrit were significantly prevalent among COVID-19 patients than healthy control subjects (p<0.001 for all). Troponin-I, interleukin-6, neutrophil/lymphocyte ratio (NLR), procalcitonin, and D-dimer showed a significant association with the mortality of patients with specificity and sensitivity more than 60%. Age, sex, underlying diseases, blood oxygen pressure, complete blood count along with C-reactive protein, lactic dehydrogenase, procalcitonin, D-dimer, and interleukin-6 evaluation help to predict the severity and required management for COVID-19 patients. Further investigations are highly recommended in a larger cohort study for validation of the present findings.

National Guidelines for Cognitive Assessment and Rehabilitation of Iranian Traumatic Brain Injury Patients.

BACKGROUND: Individuals with moderate to severe traumatic brain injury (TBI) often have prolonged cognitive impairments, resulting in long-term problems with their real-life activities. Given the urgent need for evidence-based recommendations for neuropsychological management of Iranian TBI patients, the current work aimed to adapt eligible international guidelines for cognitive assessment and rehabilitation of the TBI patients in Iran. METHODS: The project was led by an executive committee, under the supervision of the Iranian Ministry of Health and Medical Education (MOHME). Following a systematic literature search and selection process, four guidelines were included for adaptation. Clinical recommendations of the source guidelines were tabulated as possible clinical scenarios for 90 PICO clinical questions covering all relevant phases of care. After summing up the scenarios, our initial list of recommendations was drafted according to the Iranian patients' conditions. The final decision-making, with the contribution of a national interdisciplinary panel of 37 experts from across the country, was conducted in two rounds using online and offline survey forms (Round 1), and face-to-face and telephone meetings (Round 2). RESULTS: A total of 63 recommendations in six sections were included in the final list of recommendations, among which 24 were considered as key recommendations. In addition, some of the recommendations were identified as fundamental, meaning that proper implementation of the other recommendations is largely dependent on their implementation. CONCLUSION: Iranian health policy makers and rehabilitation program managers are recommended to address some fundamental issues to provide the necessary infrastructure to set up an efficient cognitive rehabilitation service system.

Different Pain States of Trigeminal Neuralgia Make Significant Changes in the Plasma Proteome and Some Biochemical Parameters: a Preliminary Cohort Study.

Trigeminal neuralgia (TN) with chronic and severe neuropathic pain leads to remarkable interference in daily living activities of patients. Unknown molecular mechanisms involved in TN pathophysiology are a challenge for complete treatment of the disease. The present study was conducted to investigate changes in the plasma proteome beside biochemical parameters, including calcitonin gene-related peptide (CGRP), nitric oxide (NO), amino acids, and vitamin D (Vit D) in different pain states in TN patients. Plasma samples were obtained from the control group (#13) and patients with purely paroxysmal type of classical TN (#13) before and after microvascular decompression (MVD). We analyzed plasma proteome using two-dimensional gel electrophoresis (2-DE) and identified altered proteins by applying MALDI-TOF/TOF mass spectrometry. The plasma levels of neurotransmitters (CGRP, NO, and amino acids) and Vit D were investigated by ELISA and liquid chromatography-tandem mass spectrometry (LC-MS/MS). The pain-rating index (PRI) was specified using a McGill pain questionnaire, which indicated a significant pain reduction after MVD. Plasma proteome analysis showed upregulated expression of transthyretin (TTR), retinol-binding protein 4 (RBP4), and alpha-1-acid glycoprotein 2 (AGP2) in TN patients compared to control group; whereas, TTR and RBP expression was downregulated after surgery. Moreover, the elevated NO and CGRP and decreased Vit D concentrations were observed in patients. After surgery, NO, Arg, Cit, and Gly levels were decreased along with pain relief. Our findings support the role of altered proteins in TN pathophysiology and suggest involvement of the evaluated neurotransmitters and Vit D in pain pathway sensitization during the disease.

Adaptation of Traumatic Brain Injury Guidelines in Iran.

CONTEXT: The National institute for health and care excellence (NICE) and scottish intercollegiate guidelines network (SIGN) are two well-known sources of clinical guideline development. In the past years, they have developed clinical guidelines for the management of head injury. In this report, we will highlight our modifications to these guidelines according to the domestic situation in a developing country. EVIDENCE ACQUISITION: The guidelines were appraised using the appraisal of guidelines for research and evaluation (AGREE) instrument. All key recommendations were reviewed by 14 prominent Iranian neurosurgeons; levels of evidence were evaluated and items with limited evidence were determined. Available evidence for selected items were reviewed and discussed. RESULTS: The following items were the most challenging when accounting for the domestic situation in Iran: age as a risk factor for referral, computed tomography scan, the impact of medical comorbidities, pregnancy, consultation, referral to a neurosurgical unit, and teleconsulting and observation before discharge. CONCLUSIONS: The evidence in the discussed topics was limited and controversial. This report is important because it exposes the current knowledge gap in head trauma studies in Iran.

Crocin improved locomotor function and mechanical behavior in the rat model of contused spinal cord injury through decreasing calcitonin gene related peptide (CGRP).

Various approaches have been offered to alleviate chronic pain resulting from spinal cord injuries (SCIs). Application of herbs and natural products, with potentially lower adverse effects, to cure diseases has been recommended in both traditional and modern medicines. Here, the effect of crocin on chronic pain induced by spinal cord contusion was investigated in an animal model. Female Wistar rats were randomly divided into five groups (5 rats in each); three groups were contused at the L1 level. One group was treated with crocin (150mg/kg) two weeks after spinal cord injury; the second group, control, was treated with vehicle only; and the third group was treated with ketoprofen. Two normal groups were also considered with or without crocin treatment. The mechanical behavioral test, the locomotor recovery test and the thermal behavioral test were applied weekly to evaluate the injury and recovery of rats. Significant improvements (p<0.05) in mechanical behavioral and locomotor recovery tests were seen in the rats treated with crocin. Thermal behavioral test did not show any significant changes due to crocin treatment. Plasma concentration of calcitonin-gene related peptide (CGRP) changed from 780.2±2.3 to 1140.3±4.5pg/ml due to SCI and reached 789.1±2.7pg/ml after crocin treatment. These changes were significant at the level of p<0.05. The present study shows the beneficial effects of crocin treatment on chronic pain induced by SCI, through decreasing CGRP as an important mediator of inflammation and pain.

Improvement of contusive spinal cord injury in rats by co-transplantation of gamma-aminobutyric acid-ergic cells and bone marrow stromal cells.

BACKGROUND AIMS: Cell therapy is considered a promising option for treatment of spinal cord injury (SCI). The purpose of this study is to use combined therapy of bone marrow stromal cells (BMSCs) and BMSC-derived gamma-aminobutyric acid (GABA)ergic inhibitory neurotransmitter cells (BDGCs) for the contusion model of SCI in rats. METHODS: BDGCs were prepared from BMSCs by pre-inducing them with ß-mercaptoethanol followed by retinoic acid and then inducing them by creatine. They were immunostained with BMSC, proneuronal, neural and GABA markers. The BDGCs were intraspinally transplanted into the contused rats, whereas the BMSCs were delivered intravenously. The animals were sacrificed after 12 weeks. RESULTS: The Basso, Beattie and Bresnahan test showed improvement in the animals with the combined therapy compared with the untreated animals, the animals treated with GABAergic cells only and the animals that received BMSCs. The immunohistochemistry analysis of the tissue sections prepared from the animals receiving the combined therapy showed that the transplanted cells were engrafted and integrated into the injured spinal cord; in addition, a significant reduction was seen in the cavitation. CONCLUSIONS: The study shows that the combination of GABAergic cells with BMSCs can improve SCI.

Induction of bone marrow stromal cells into GABAergic neuronal phenotype using creatine as inducer.

PURPOSE: Deficits involving GABAergic neurons have been reported in aging, central nervous trauma and neurodegenerative disorders; bone marrow stromal cells (BMSCs) have been proposed as a feasible source of donor cells in replacement cell therapy. In this study, the effects of creatine on transdifferentiating BMSCs into GABAergic-like neurons were evaluated in vitro. METHODS: The BMSCs were isolated from adult rats, preinduced by ß-mercaptoethanol (BME) and retinoic acid (RA), and then induced by creatine into GABAergic-like neurons. The cells were characterized using different differentiation markers. The functionality of the differentiated cells was evaluated using FM1-43. RESULTS: The isolated cells expressed Oct-4 and were immunoreactive to fibronectin and CD44. The highest percentages of cells immunoreactive to nestin and neurofilament-68 were found at the second day of preinduction. At the induction stage, there were increases in the number of cells immunoreactive to neurofilament-200, MAP-2, synapsin I, synaptophysin, and NeuN. The percentages of the immunoreactive cells to GABAergic neuron markers increased. The optimal induction dose was 5 mM. The dose of 10 mM showed a decline in the expression of most of these markers. The functionality test indicated that the synaptic vesicles were released upon stimulation. CONCLUSION: Creatine can induce the differentiation of BMSCs to the GABAergic neuronal phenotype within one week.

In vitro differentiation of bone marrow stromal cells into oligodendrocyte-like cells using triiodothyronine as inducer.

An in vitro technique was devised to induced autologous adult stem cells into oligodendrocyte-like cells. In this study, a protocol was developed for the induction of bone marrow stromal cells (BMSCs) into oligodendrocyte-like cells. BMSCs were incubated in one of these three pre-inducers: dimethyl sulfoxide (DMSO), ß-mercaptoethanol (ßME) or biotylated hydroxyanisol (BHA), each followed by retinoic acid (RA) treatment. The percentage of viable cells in BHA-RA preinduced cells was significantly lower than the others. The results showed that the preinduced cells were immunoreactive for nestin and NF-68; among the mentioned protocols, the immunoreactivity yielded by following the DMSO-RA protocol was significantly higher than the others. Moreover, no significant immunoreactivity was observed for preinduced cells to O4, O1, MBP (myelin basic protein), S100, and GFAP (glial fibrillary acidic protein). The cells were immunoreactive to oligo-2. Two phases of induction were done: the first was a combination of basic fibroblast growth factor (bFGF), platelet-derived growth factor (PDGF) and heregulin (HRG), followed by either triiodothyronine (T3) or Forskolin (FSK) as the second phase. The conclusion is that the trans-differentiation of BMSCs by DMSO followed by RA (preinduction stage) then bFGF-PDGF-HRG followed by T3 (10 ng/ml) (induction stage) can be a potential source for oligodendrocyte-like cells preparation.

In vitro differentiation of GABAergic cells from bone marrow stromal cells using potassium chloride as inducer.

Bone marrow stromal cells (BMSCs) are multipotent and can be induced to differentiate into different lineages including osteogenic, chondrogenic, myogenic and neuronal phenotypes. BMSCs were reported to be a suitable option for regenerative medical research. In this study, BMSCs were induced into GABAergic phenotypes using beta-mercaptoethanol (betaME) and retinoic acid (RA) as preinducers followed by potassium chloride as inducer, and were evaluated by fibronectin and Oct-4. The percentages of cells immunoreactive for nestin, neurofilaments (NF 68, NF 160, and NF 200), GABA and GABA synthesizing and packaging enzymes (GAD1, GAD2, VGAT) were used for evaluating GABAergic differentiation. RT-PCR was used for confirming the expression of these enzymes. The differentiated cells were loaded and unloaded with FM1-43 in order to assess the functionality of the cells. At the preinduction stage, the cells downregulated fibronectin and Oct-4, and expressed neuronal markers. At the induction stage, the preinduced cells transdifferentiated into GABAergic cells, as confirmed by immunohistochemistry and RT-PCR. The GABAergic cells were stained and destained with FM1-43. Therefore, the two-stage induction protocol resulted in transdifferentiation of BMSCs into GABAergic cells with synaptic release upon stimulation.

In vitro transdifferentiation of bone marrow stromal cells into GABAergic-like neurons.

BACKGROUND: Cell therapy of many neurodegenerative diseases using bone marrow stromal cells (BMSC) requires the differentiation of BMSC into neuronal subtype. However, the transdifferentiation of BMSC into GABAergic phenotype requires more investigation. METHODS: In this study, BMSC of adult female rats were pre-induced into neuroblast-like cells using 1 mM beta-mercaptoethanol (betaME) and 10 microM retinoic acid (RA), followed by 40 mM potassium chloride as inducer. The BMSC were evaluated by fibronectin as well as Oct-4. The percentage of nestin, neurofilaments (NF 68, NF 160, and NF 200) and GABA immuno-reactive cells was used to evaluate the GABAergic differentiation at the pre-induction and induction stages. The statistical analysis was carried out using unpaired student's t-test and ANOVA with Tukey's multiple comparison. RESULTS: The BMSC in the fourth passage expressed fibronectin up to 91.24 +/- 0.82%. The pre-induced cells after 2 days of RA exposure showed the expression of neuroblastic markers of nestin and NF68 (81.56 +/- 2.64% and 82.12 +/- 2.65%, respectively). The yield of GABAergic neurons with beta-ME for 1 h and RA as pre-inducer for 2 days followed by potassium chloride as inducer (40 mM for 3 days) was 60.64% +/- 1.97%. In addition, NF160 and NF200 were detected in the transdifferentiated cells. RT-PCR showed no expression of Oct-4 after the induction and pre-induction stages. CONCLUSION: GABAergic-like neurons obtained from BMSC can be potentially used in cell transplanting for some neurodegenerative disorders.

Induction of bone marrow stromal cells into cholinergic-like cells by nerve growth factor.

BACKGROUND: Bone marrow stromal cells (BMSC) are used as a source for cell therapy in different model for neurological disorder such as stroke and spinal cord injury. However, the transdifferentiation of BMSC into cholinergic phenotype requires more investigation. METHODS: BMSC were isolated from adult rats, pre-induced with beta-mercaptoethanol (BME) and followed by nerve growth factor (NGF) induction. Neurofilaments of 68 kDa, 160 kDa and 200 kDa (NF-200, NF-160 and NF-68, respectively) immuno-staining were used for evaluating the transdifferentiation of BMSC into neuronal phenotype. The percentage of neurofilaments immuno-reactive cells was applied in order to evaluate the results at the pre-induction and the induction stages. Also, NeuroD and Oct-4 expressions, using RT-PCR, were used in assessing the progression of BMSC into neuronal lineage. Choline acetyltransferase immuno-reactive cells were used for estimating the percentage of cholinergic neuronal phenotype. Immuno-staining with anti-microtubule-associated protein-2 (MAP-2) and anti-synapsin-I antibodies was done in order to evaluate cell tendency for synaptogenesis. RESULTS: The yield of cholinergic neurons with BME as pre-inducer and NGF as inducer was 80%. Also, NF-200, NF-160, NF-68, MAP-2 and synapsin-I were detected in the transdifferentiated cells. RT-PCR showed the expression of NeuroD, while Oct-4 was not detected. CONCLUSION: BME as pre-inducer and NGF as inducer for BMSC transdifferentiation into cholinergic phenotype are potential sources in traumatic injury therapy in the central nervous system.

Transdifferentiation of bone marrow stromal cells into cholinergic neuronal phenotype: a potential source for cell therapy in spinal cord injury.

BACKGROUND AIMS: Cholinergic neurons are very important cells in spinal cord injuries because of the deficits in motor, autonomic and sensory neurons. In this study, bone marrow stromal cells (BMSC) were evaluated as a source of cholinergic neurons in a rat model of contusive spinal cord injury. METHODS: BMSC were isolated from adult rats and transdifferentiated into cholinergic neuronal cells. The BMSC were pre-induced with beta-mercaptoethanol (BME), while the induction was done with nerve growth factor (NGF). Neurofilament (NF)-68, -160 and -200 immunostaining was used for evaluating the transdifferentiation of BMSC into a neuronal phenotype. NeuroD expression, a marker for neuroblast differentiation, and Oct-4 expression, a marker for stemness, were evaluated by reverse transcriptase (RT)-polymerase chain reaction (PCR). Choline acetyl transferase (ChAT) immunoreactivity was used for assessing the cholinergic neuronal phenotype. Anti-microtubule-associated protein-2 (MAP-2) and anti-synapsin I antibodies were used as markers for the tendency for synptogenesis. Finally, the induced cells were transplanted into the contused spinal cord and locomotion was evaluated with the Basso-Beattie-Bresnahan (BBB) test. RESULTS: At the induction stage, there was a decline in the expression of NF-68 associated with a sustained increase in the expression of NF-200, NF-160, ChAT and synapsin I, whereas MAP-2 expression was variable. Transplanted cells were detected 6 weeks after their injection intraspinally and were associated with functional recovery. CONCLUSIONS: The transdifferentiation of BMSC into a cholinergic phenotype is feasible for replacement therapy in spinal cord injury.

Improvement of chronic pain by treatment of erectile dysfunction.

INTRODUCTION: Pain specialists, who do not routinely examine patients regarding their sexual medicine problems, need to be aware that sexual problems can and do aggravate the patient's pain. Patients may refuse to admit suffering from erectile dysfunction (ED) but complain about continuous or progressive severe pain. These patients may be best managed by the combined team effort of a sexual medicine specialist and pain specialist. AIM: This report documents the management of three cases with long-term intractable pain after severe trauma. Treatment of occult ED led to significant improvement of their pain. MAIN OUTCOME MEASURES: The association of the treatment of uncovered ED and improvement of chronic severe pain. METHODS: Three case reports of patients with severe pain who attended a pain clinic in an academic medical center. RESULTS: Three men suffering from chronic pain due to severe trauma were observed for several years by different physicians as well as pain specialists. In spite of different treatments, including administration of several analgesics, psychotherapy, and physical therapy, pain was not alleviated. After finding ED problems, patients were referred to the family health clinic. Using different therapies such as psychosexual therapy, correction of sexual misconceptions, relaxation training, treatment of interpersonal difficulties, and pharmacological intervention ED was cured. Treatment of ED was accompanied by a significant reduction of chronic pain in all three patients. CONCLUSION: The present report indicates that uncovered ED in patients suffering from chronic pain may trigger their somatic pain or reduce its threshold. Significant improvement in sexual functioning may improve the pain and reduce its complications.