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Davis GE, Davis MJ, Lowell WE. Triggering multiple sclerosis at conception and early gestation: The variation in ultraviolet radiation is as important as its intensity. Heliyon 2023; 9:e16954. [PMID: 37346332 PMCID: PMC10279836 DOI: 10.1016/j.heliyon.2023.e16954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 04/17/2023] [Accepted: 06/01/2023] [Indexed: 06/23/2023] Open
Abstract
Background and objectives Medical science needs to further elucidate the role of ultraviolet radiation (UVR), geographic latitude, and the role of vitamin D in the autoimmune disease multiple sclerosis (MS). We separated several papers into categories out of the thousands published and used their conclusions to explore the relationship between UVR and MS. Relevance MS is increasing in incidence, particularly in women where MS is two to three times that in men and particularly severe in African Americans. Methods We collected UVR data at our observatory in Central Maine and calculated the average coefficient of variation (CVUVR) for each month for 15 years (2007-2021, inclusive). Results The month of conception (MOC) is more important than the month of birth (MOB) in explaining how UVR triggers the variable genetic predisposition to MS. We hypothesize that the rapidly increasing CVUVR is important in preventing an increase in the activity of the vitamin D receptor (VDR) from August to December, which then requires a higher intensity of UVR later in life to suppress the immune system, therefore predisposing to more MS. Limitations One observatory at about 44° latitude. Conclusions While variation in UVR is important at the MOC if UVR exceeds a threshold (e.g., if the sunspot number equals or is greater than 90, usually at a solar cycle MAX, or at elevations above approximately 3,000 feet above sea level), the MS mitigating vitamin D-VDR mechanism is overwhelmed and the genotoxic effects of higher-intensity UVR promote MS in those with a genetic predisposition. What is new in this research This paper offers a new concept in MS research.
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Affiliation(s)
- George E. Davis
- Riverview Psychiatric Center, 250 Arsenal Street, State House Station #11, Augusta, ME, 04333-0011, USA
| | - Matthew J. Davis
- Riverview Psychiatric Center, 250 Arsenal Street, State House Station #11, Augusta, ME, 04333-0011, USA
| | - Walter E. Lowell
- Riverview Psychiatric Center, 250 Arsenal Street, State House Station #11, Augusta, ME, 04333-0011, USA
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Mnassri B, Echtioui A, Kallel F, Ben Hamida A, Dammak M, Mhiri C, Ben Mahfoudh K. New Contrast Enhancement Method for Multiple Sclerosis Lesion Detection. J Digit Imaging 2023; 36:468-485. [PMID: 36478312 PMCID: PMC10039218 DOI: 10.1007/s10278-022-00729-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 08/19/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022] Open
Abstract
Multiple sclerosis (MS) is one of the most serious neurological diseases. It is the most frequent reason of non-traumatic disability among young adults. MS is an autoimmune disease wherein the central nervous system wrongly destructs the myelin sheath surrounding and protecting axons of nerve cells of the brain and the spinal cord which results in presence of lesions called plaques. The damage of myelin sheath alters the normal transmission of nerve flow at the plaques level, consequently, a loss of communication between the brain and other organs. The consequence of this poor transmission of nerve impulses is the occurrence of various neurological symptoms. MS lesions cause mobility, vision, cognitive, and memory disorders. Indeed, early detection of lesions provides an accurate MS diagnosis. Consequently, and with the adequate treatment, clinicians will be able to deal effectively with the disease and reduce the number of relapses. Therefore, the use of magnetic resonance imaging (MRI) is primordial which is proven as the relevant imaging tool for early diagnosis of MS patients. But, low contrast MRI images can hide important objects in the image such lesions. In this paper, we propose a new automated contrast enhancement (CE) method to ameliorate the low contrast of MRI images for a better enhancement of MS lesions. This step is very important as it helps radiologists in confirming their diagnosis. The developed algorithm called BDS is based on Brightness Preserving Dynamic Fuzzy Histogram Equalization (BPDFHE) and Singular Value Decomposition with Discrete Wavelet Transform (SVD-DWT) techniques. BDS is dedicated to improve the low quality of MRI images with preservation of the brightness level and the edge details from degradation and without added artifacts or noise. These features are essential in CE approaches for a better lesion recognition. A modified version of BDS called MBDS is also implemented in the second part of this paper wherein we have proposed a new method for computing the correction factor. Indeed, with the use of the new correction factor, the entropy has been increased and the contrast is greatly enhanced. MBDS is specially dedicated for very low contrast MRI images. The experimental results proved the effectiveness of developed methods in improving low contrast of MRI images with preservation of brightness level and edge information. Moreover, performances of both proposed BDS and MBDS algorithms exceeded conventional CE methods.
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Affiliation(s)
- Besma Mnassri
- Advanced Technologies for Medicine and Signals Laboratory 'ATMS', National Engineering School of Sfax, Sfax University, Sfax, Tunisia.
| | - Amira Echtioui
- Advanced Technologies for Medicine and Signals Laboratory 'ATMS', National Engineering School of Sfax, Sfax University, Sfax, Tunisia
| | - Fathi Kallel
- Advanced Technologies for Medicine and Signals Laboratory 'ATMS', National Engineering School of Sfax, Sfax University, Sfax, Tunisia
- National School of Electronics and Communications, Sfax University, Sfax, Tunisia
| | - Ahmed Ben Hamida
- Department IS, College of Computer Science, King Khalid University 'KKU', Abha, Saudi Arabia
| | - Mariem Dammak
- Department of Neurology, CHU Habib Bourguiba, Sfax, Tunisia
| | - Chokri Mhiri
- Department of Neurology, CHU Habib Bourguiba, Sfax, Tunisia
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Kesselring J, Boyko A, Laroni A, Bharadia T, van Galen P, Alexandri N. Caregiver Involvement in MS: Duty or Disruption? Neurol Ther 2022; 11:9-20. [PMID: 34792783 PMCID: PMC8857341 DOI: 10.1007/s40120-021-00299-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 11/01/2021] [Indexed: 11/06/2022] Open
Abstract
Multiple sclerosis (MS) is a complex condition with numerous physical, cognitive and emotional symptoms. These may necessitate significant, permanent lifestyle changes for people with multiple sclerosis (PwMS) and their caregivers and families, meaning it is important in contemporary neurological practice to consider including families and/or caregivers in the management of MS. However, existing evidence suggests that family involvement is not always beneficial; for example, it can exert either a strong positive or negative influence on the ability of PwMS to achieve optimal outcomes from their treatment and disease management. This paper, based on a live debate between neurologists and PwMS, examines the current perceptions on constructive involvement of families and caregivers in consultations for and management of MS, and reveals several areas where additional studies are warranted. Shared decision-making in MS has historically been a collaboration solely between healthcare professionals (HCPs) and PwMS, but PwMS are now more frequently being accompanied to appointments by a support person. This paper encourages HCPs to understand the dynamics between PwMS and their support person, and to individualize consultations and information accordingly. Family and caregiver involvement in the provision of care for PwMS needs to be for the benefit of, and at the discretion of, the PwMS. Support for families of PwMS, although important, may be more effectively and appropriately delivered through other channels outside of the clinical setting. Educating HCPs on the current patient experience to enable them to provide improved personalized care will ensure a mutualistic, patient-centred relationship with PwMS, which will help to optimize outcomes. Communication tools may also facilitate these interactions.
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Affiliation(s)
- Jürg Kesselring
- Department of Neurology and Neurorehabilitation, Kliniken Valens, Valens, Switzerland.
| | - Alexey Boyko
- Institute of Clinical Neurology and Department of Neuroimmunology of the Federal Centre of Brain Research and Neurotechnologies, Pirogov's Russian National Research Scientific Medical University, Moscow, Russia
| | - Alice Laroni
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Trishna Bharadia
- Patient Author, Member of the MS in the 21st Century Steering Group, Buckinghamshire, UK
| | - Pieter van Galen
- Patient Author, Member of the MS in the 21st Century Steering Group, Overijse, Belgium
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Cheniaux E. The bipolarity of Alberto Santos-Dumont: flights and falls of the “Father of Aviation”. JORNAL BRASILEIRO DE PSIQUIATRIA 2022. [DOI: 10.1590/0047-2085000000364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
ABSTRACT Objective: Discussing the psychiatric diagnosis of Alberto Santos-Dumont, considered in Brazil to be the inventor of the airplane, who was admitted to psychiatric institutions several times and committed suicide. Methods: A narrative review was carried out on the psychopathological manifestations he presented, based on some of the most important biographies about the aviator. No scientific article on the topic was found. Results: Depressive episodes were well characterized. Behavioral changes that suggest manic episodes have also been reported. Conclusion: He probably suffered from bipolar disorder.
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Charfi N, Omri S, Smaoui N, Feki R, Zouari L, Ben Thabet J, Maâlej Bouali M, Maâlej M. [The handling of psychotropics in diseases of central nervous system]. Encephale 2021; 47:461-469. [PMID: 33832715 DOI: 10.1016/j.encep.2020.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/10/2020] [Accepted: 11/17/2020] [Indexed: 11/29/2022]
Abstract
Psychiatric signs and symptoms occur frequently in individuals with central nervous system diseases. Inadequately treated, these comorbid conditions affect patient rehabilitation, compliance with treatment and quality of life. Their management poses a major challenge given the variable efficacy and safety profiles of available psychotropic drugs and increased risk of drug interaction. This review aims to summarize the existing literature on the prescription of psychotropic drugs for management of psychiatric disorders among persons with central nervous system's diseases.
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Affiliation(s)
- N Charfi
- Service de psychiatrie C, CHU Hédi Chaker, faculté de médecine de Sfax, Université de Sfax, Sfax, Tunisie
| | - S Omri
- Service de psychiatrie C, CHU Hédi Chaker, faculté de médecine de Sfax, Université de Sfax, Sfax, Tunisie.
| | - N Smaoui
- Service de psychiatrie C, CHU Hédi Chaker, faculté de médecine de Sfax, Université de Sfax, Sfax, Tunisie
| | - R Feki
- Service de psychiatrie C, CHU Hédi Chaker, faculté de médecine de Sfax, Université de Sfax, Sfax, Tunisie
| | - L Zouari
- Service de psychiatrie C, CHU Hédi Chaker, faculté de médecine de Sfax, Université de Sfax, Sfax, Tunisie
| | - J Ben Thabet
- Service de psychiatrie C, CHU Hédi Chaker, faculté de médecine de Sfax, Université de Sfax, Sfax, Tunisie
| | - M Maâlej Bouali
- Service de psychiatrie C, CHU Hédi Chaker, faculté de médecine de Sfax, Université de Sfax, Sfax, Tunisie
| | - M Maâlej
- Service de psychiatrie C, CHU Hédi Chaker, faculté de médecine de Sfax, Université de Sfax, Sfax, Tunisie
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León Ruiz M, Mitchell A, Benito-León J. Delirio de parasitosis en la esclerosis múltiple: una expresión enigmática de una enfermedad pleomórfica. Neurologia 2020; 35:445-448. [DOI: 10.1016/j.nrl.2018.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 03/29/2018] [Indexed: 11/27/2022] Open
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León Ruiz M, Mitchell A, Benito-León J. Delusional parasitosis in multiple sclerosis: an enigmatic manifestation of a multifaceted disease. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2018.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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8
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The Main Determinants for Suicidal Ideation in a Romanian Cohort of Multiple Sclerosis Patients. Behav Neurol 2020; 2020:2594702. [PMID: 32399081 PMCID: PMC7201511 DOI: 10.1155/2020/2594702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/26/2019] [Accepted: 12/06/2019] [Indexed: 11/18/2022] Open
Abstract
Objective To determine the prevalence of suicidal concerns (SC) in a large multiple sclerosis (MS) patient group and to assess the major determinants that are implicated in their occurrence. Methods A total of 349 patients were included in the study. They completed a survey about their demographic characteristics, psycho-socio-economic data, and disease-related information. Their disability level was assessed using the Expanded Disability Status Scale (EDSS) based on the neurological examination performed by the same doctor for every patient and the SC were documented with the Beck Depression Inventory-II questionnaire. Results The study included 112 men and 237 women, with a mean age around 42 years old. Suicidal thoughts were more frequent in men, while suicidal intentions in women. Positive correlations were found between SC and depression, EDSS, total number of relapses, disease duration, and level of education. From the EDSS functional scores, only the pyramidal score and the cerebellar score presented a significant correlation with SC. None of the patients with clinically isolated syndrome had SC. The type of disease-modifying therapy, marital and occupational status, and the presence of children did not influence the presence of SC. Conclusions The prevalence of SC is higher in patients with MS compared to the general population. Their occurrence is mostly influenced by the disease itself (duration, relapses, acquired disability) and also by depression and lack of education.
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Kocovski P, Jiang X, D'Souza CS, Li Z, Dang PT, Wang X, Chen W, Peter K, Hale MW, Orian JM. Platelet Depletion is Effective in Ameliorating Anxiety-Like Behavior and Reducing the Pro-Inflammatory Environment in the Hippocampus in Murine Experimental Autoimmune Encephalomyelitis. J Clin Med 2019; 8:jcm8020162. [PMID: 30717130 PMCID: PMC6406682 DOI: 10.3390/jcm8020162] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 01/21/2019] [Accepted: 01/27/2019] [Indexed: 01/16/2023] Open
Abstract
The neuropsychiatric symptoms of multiple sclerosis (MS), such as anxiety and depression, can result from disease activity itself as well as psychological reaction to an unfavorable diagnosis. Accordingly, the literature reports evidence of increased anxiety-like behavior in experimental autoimmune encephalomyelitis (EAE), an accepted MS model. Due to the recently described critical role of platelets in inflammation and autoimmune disease, we examined the relationship between platelets, inflammation, and anxiety-like behavior in EAE. In the elevated plus maze, EAE-induced C57BL/6J mice showed decreased time spent in the open arms relative to vehicle-only controls, demonstrating an increase in anxiety-like behavior. This effect occurred in the presence of platelet–neuron association, but absence of lymphocytic infiltration, in the hippocampal parenchyma. Platelet depletion at the pre-clinical disease stage, using antibody-mediated lysis prevented the EAE-induced increase in anxiety-like behavior, while no significant difference in distance moved was recorded. Furthermore, platelet depletion was also associated with reduction of the pro-inflammatory environment to control levels in the hippocampus and prevention of EAE disease symptomology. These studies demonstrate the high efficacy of a platelet-targeting approach in preventing anxiety-like symptoms and clinical manifestations of EAE and have implications for the treatment of neuropsychiatric symptoms in MS.
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Affiliation(s)
- Pece Kocovski
- Department of Psychology and Counselling, School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3086, Australia.
| | - Xiangrui Jiang
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science (LIMS), La Trobe University, Bundoora, VIC 3086, Australia.
| | - Claretta S D'Souza
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science (LIMS), La Trobe University, Bundoora, VIC 3086, Australia.
| | - Zhenjiang Li
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science (LIMS), La Trobe University, Bundoora, VIC 3086, Australia.
| | - Phuc T Dang
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science (LIMS), La Trobe University, Bundoora, VIC 3086, Australia.
| | - Xiaowei Wang
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia.
- Department of Medicine, Monash University, Melbourne, VIC 3800, Australia.
| | - Weisan Chen
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science (LIMS), La Trobe University, Bundoora, VIC 3086, Australia.
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia.
- Department of Medicine, Monash University, Melbourne, VIC 3800, Australia.
| | - Matthew W Hale
- Department of Psychology and Counselling, School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3086, Australia.
| | - Jacqueline M Orian
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science (LIMS), La Trobe University, Bundoora, VIC 3086, Australia.
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Aadil M, Munir A, Anwar MJ, Arshad H, Anjum I, Faraz A. Psychiatric Symptoms as the First Clinical Presentation of Multiple Sclerosis: A Case Report. Cureus 2017; 9:e1474. [PMID: 28944113 PMCID: PMC5602275 DOI: 10.7759/cureus.1474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune condition which affects the axon myelination in the brain. There can be multiple ways it can present initially, but physical signs and symptoms are the most common ones. We are reporting a case of MS from Pakistan which presented with neuropsychiatric features and was offered psychiatric care, but the patient declined treatment because of stigma related to psychiatric care. Four months later when her condition worsened, further investigation showed it to be a case of MS. The purpose of this case report is that psychiatric features should be considered for differentials of MS.
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Affiliation(s)
| | - Aitzaz Munir
- Department of Psychiatry, Howard University Hospital
| | | | - Hasnain Arshad
- Department of Internal Medicine, Howard University Hospital
| | - Ibrar Anjum
- Internal medicine, University of health science Lahore
| | - Aniqa Faraz
- Department of Internal Medicine, King Edward Medical University Lahore, Pakistan
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A Comparison of Neuroimaging Abnormalities in Multiple Sclerosis, Major Depression and Chronic Fatigue Syndrome (Myalgic Encephalomyelitis): is There a Common Cause? Mol Neurobiol 2017; 55:3592-3609. [PMID: 28516431 PMCID: PMC5842501 DOI: 10.1007/s12035-017-0598-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/03/2017] [Indexed: 01/23/2023]
Abstract
There is copious evidence of abnormalities in resting-state functional network connectivity states, grey and white matter pathology and impaired cerebral perfusion in patients afforded a diagnosis of multiple sclerosis, major depression or chronic fatigue syndrome (CFS) (myalgic encephalomyelitis). Systemic inflammation may well be a major element explaining such findings. Inter-patient and inter-illness variations in neuroimaging findings may arise at least in part from regional genetic, epigenetic and environmental variations in the functions of microglia and astrocytes. Regional differences in neuronal resistance to oxidative and inflammatory insults and in the performance of antioxidant defences in the central nervous system may also play a role. Importantly, replicated experimental findings suggest that the use of high-resolution SPECT imaging may have the capacity to differentiate patients afforded a diagnosis of CFS from those with a diagnosis of depression. Further research involving this form of neuroimaging appears warranted in an attempt to overcome the problem of aetiologically heterogeneous cohorts which probably explain conflicting findings produced by investigative teams active in this field. However, the ionising radiation and relative lack of sensitivity involved probably preclude its use as a routine diagnostic tool.
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Neuropathology of mood disorders: do we see the stigmata of inflammation? Transl Psychiatry 2016; 6:e946. [PMID: 27824355 PMCID: PMC5314124 DOI: 10.1038/tp.2016.212] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/08/2016] [Accepted: 08/30/2016] [Indexed: 12/15/2022] Open
Abstract
A proportion of cases with mood disorders have elevated inflammatory markers in the blood that conceivably may result from stress, infection and/or autoimmunity. However, it is not yet clear whether depression is a neuroinflammatory disease. Multiple histopathological and molecular abnormalities have been found postmortem but the etiology of these abnormalities is unknown. Here, we take an immunological perspective of this literature. Increases in activated microglia or perivascular macrophages in suicide victims have been reported in the parenchyma. In contrast, astrocytic markers generally are downregulated in mood disorders. Impairment of astrocytic function likely compromises the reuptake of glutamate potentially leading to excitotoxicity. Inflammatory cytokines and microglia/macrophage-derived quinolinic acid (QA) downregulate the excitatory amino acid transporters responsible for this reuptake, while QA has the additional effect of inhibiting astroglial glutamine synthetase, which converts glutamate to glutamine. Given that oligodendroglia are particularly vulnerable to inflammation, it is noteworthy that reductions in numbers or density of oligodendrocyte cells are one of the most prominent findings in depression. Structural and/or functional changes to GABAergic interneurons also are salient in postmortem brain samples, and may conceivably be related to early inflammatory insults. Although the postmortem data are consistent with a neuroimmune etiology in a subgroup of depressed individuals, we do not argue that all depression-associated abnormalities are reflective of a neuroinflammatory process or even that all immunological activity in the brain is deleterious. Rather, we highlight the pervasive role of immune signaling pathways in brain function and provide an alternative perspective on the current postmortem literature.
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Fiest K, Walker J, Bernstein C, Graff L, Zarychanski R, Abou-Setta A, Patten S, Sareen J, Bolton J, Marriott J, Fisk J, Singer A, Marrie R. Systematic review and meta-analysis of interventions for depression and anxiety in persons with multiple sclerosis. Mult Scler Relat Disord 2016; 5:12-26. [DOI: 10.1016/j.msard.2015.10.004] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 10/09/2015] [Accepted: 10/16/2015] [Indexed: 11/24/2022]
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Some neuropsychiatric and MRI manifestations in patients with multiple sclerosis. MIDDLE EAST CURRENT PSYCHIATRY 2015. [DOI: 10.1097/01.xme.0000458885.02819.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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