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      Incidence of first ever stroke during Hajj ceremony

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          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.


          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.


          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.


          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.

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          Most cited references 37

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          An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

          Despite the global impact and advances in understanding the pathophysiology of cerebrovascular diseases, the term "stroke" is not consistently defined in clinical practice, in clinical research, or in assessments of the public health. The classic definition is mainly clinical and does not account for advances in science and technology. The Stroke Council of the American Heart Association/American Stroke Association convened a writing group to develop an expert consensus document for an updated definition of stroke for the 21st century. Central nervous system infarction is defined as brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury. Central nervous system infarction occurs over a clinical spectrum: Ischemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, while silent infarction by definition causes no known symptoms. Stroke also broadly includes intracerebral hemorrhage and subarachnoid hemorrhage. The updated definition of stroke incorporates clinical and tissue criteria and can be incorporated into practice, research, and assessments of the public health.
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            Gender difference in neural response to psychological stress.

            Gender is an important biological determinant of vulnerability to psychosocial stress. We used perfusion based functional magnetic resonance imaging (fMRI) to measure cerebral blood flow (CBF) responses to mild to moderate stress in 32 healthy people (16 males and 16 females). Psychological stress was elicited using mental arithmetic tasks under varying pressure. Stress in men was associated with CBF increase in the right prefrontal cortex (RPFC) and CBF reduction in the left orbitofrontal cortex (LOrF), a robust response that persisted beyond the stress task period. In contrast, stress in women primarily activated the limbic system, including the ventral striatum, putamen, insula and cingulate cortex. The asymmetric prefrontal activity in males was associated with a physiological index of stress responses-salivary cortisol, whereas the female limbic activation showed a lower degree of correlations with cortisol. Conjunction analyses indicated only a small degree of overlap between the stress networks in men and women at the threshold level of P < 0.01. Increased overlap of stress networks between the two genders was revealed when the threshold for conjunction analyses was relaxed to P < 0.05. Further, machine classification was used to differentiate the central stress responses between the two genders with over 94% accuracy. Our study may represent an initial step in uncovering the neurobiological basis underlying the contrasting health consequences of psychosocial stress in men and women.
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              Excessive incidence of stroke in Iran: evidence from the Mashhad Stroke Incidence Study (MSIS), a population-based study of stroke in the Middle East.

              The epidemiology of stroke and its subtypes in the Middle East is unclear. Most previous studies have been performed in Western countries, and incidence rates are unlikely to apply in the Middle East. We aimed to determine the incidence of stroke in Mashhad, northeastern Iran. During a 12-month period (2006-2007), we prospectively ascertained all strokes occurring in a population of 450 229. Multiple overlapping sources were used to identify people with stroke. A large number of volunteers assisted in finding stroke patients not admitted to hospital. Potential cases were reviewed by a group of stroke experts before inclusion. A total of 624 first-ever strokes occurred during the study period, 98.4% undergoing imaging. Despite a relatively low crude annual incidence rate of first-ever stroke FES (139; 95% CI, 128 to 149) per 100 000 residents, rates adjusted to the European population aged 45 to 84 years were higher than in most other countries: 616 (95% CI, 567 to 664) for ischemic stroke, 94 (95% CI, 75 to 113) for intracerebral hemorrhage, and 12 (95% CI, 5 to 19) for subarachnoid hemorrhage. Age-specific stroke incidence was higher in younger patients than is typically seen in Western countries. Comparison of age-specific incidence rates between regions revealed that stroke in Mashhad occurs approximately 1 decade earlier than in Western countries. The results of this study provide evidence that the incidence of stroke in Iran is considerably greater than in most Western countries, with stroke occurring at younger ages. Ischemic stroke incidence was also considerably greater than reported in other regions.

                Author and article information

                [1 ]Department of Neurology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
                [2 ]Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
                [3 ]Department of Neurology, Golestan Hospital, Ahvaz University of Medical Sciences, Ahwaz, Iran
                [4 ]Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Ontario, Canada
                [5 ]Department of Neuropsychology, Ibn-e-Sina Hospital, Mashhad University of Medical Science, Mashhad, Iran
                [6 ]Department of Internal Medicine, Red Crescent Society, Tehran, Iran
                [7 ]Department of Medicine, Southern Clinical School, Monash University, Melbourne, and National Stroke Research Institute, Florey Neuroscience Institutes, Heidelberg Heights, Victoria, Australia
                [8 ]Health System Research Committee, Treatment Affairs of vice chancellery, Mashhad University of Medical Sciences, Mashhad, Iran
                [9 ]Discipline of Dental Public Health, Faculty of Dentistry, University of Toronto, Room 515-C, 124 Edward St, Toronto, ON M5G 1G6, Canada
                [10 ]Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, Canada
                BMC Neurol
                BMC Neurol
                BMC Neurology
                BioMed Central
                5 December 2013
                : 13
                : 193
                24308305 4234064 1471-2377-13-193 10.1186/1471-2377-13-193
                Copyright © 2013 Azarpazhooh et al.; licensee BioMed Central Ltd.

                This is an open access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Research Article


                hajj, incidence, acute stroke


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