Multiple sclerosis: Introduction, Risk Factors, Diagnosis and TreatmentEnriqueAlvarez93
Introduction about Multiple Sclerosis.
Risk factors affect to Multiple Sclerosis.
When to Suspect Multiple Sclerosis.
Evaluation and Diagnosis of Multiple Sclerosis.
How to treatment of Multiple Sclerosis.
Treatment of Multiple Sclerosis with Monoclonal Antibody.
A brief description about Demyelination topics by Dr Sabu Augustine for MBBS Students in Medical school.
References from textbooks and other presentations.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Multiple sclerosis: Introduction, Risk Factors, Diagnosis and TreatmentEnriqueAlvarez93
Introduction about Multiple Sclerosis.
Risk factors affect to Multiple Sclerosis.
When to Suspect Multiple Sclerosis.
Evaluation and Diagnosis of Multiple Sclerosis.
How to treatment of Multiple Sclerosis.
Treatment of Multiple Sclerosis with Monoclonal Antibody.
A brief description about Demyelination topics by Dr Sabu Augustine for MBBS Students in Medical school.
References from textbooks and other presentations.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. Dr. Anzil Mani Singh Maharjan
Resident Phase- B
Department of Neurology
BSMMU
2. Myelin
Myelin forms a
layer, the myelin
sheath around
the axon of
a neuron
It is an outgrowth
of a type of glia
cell
3. Myelin composition
Cholesterol is an essential constituent of myelin
Myelinated axons appear white, hence the the
term "white matter" of the brain
Some of the proteins are myelin basic
protein, myelin oligodendrocyte glycoprotein,
and proteolipid protein
The intertwining hydrocarbon chains
of sphingomyelin serve to strengthen the myelin
sheath
4. Myelination
The production of the myelin sheath is called
myelination
In humans, myelination begins in the 14th week of
fetal development
During infancy, myelination occurs quickly and
continues through the adolescent stages of life
Schwann cells supply the myelin for peripheral
neurons
Oligodendrocytes myelinate the axons of the CNS
neurons
5. Myelin Function
Propagate nerve
impulses rapidly in a
saltatory fashion
Voltage-gated Na+
channels found at the
nodes of Ranvier
Na+ influx
Current cannot flow
outward in myelinated
internodal segments
• Provides insulation
6. Myelin Diseases
Demyelination is the
process of damage to the
myelin or oligodendroglial
cell
◦ Autoimmune- MS
◦ Infectious- PML
◦ Toxic and metabolic
◦ Vascular processes –
Binswanger
Dysmyelination - a primary
biochemical abnormality of
myelin formation exists
◦ Hereditary disorders-
Leukodystrophies
7. Classification of the Inflammatory
Demyelinative Diseases
I. Multiple sclerosis
Chronic relapsing encephalomyelopathic form
Acute multiple sclerosis (Marburg disease)
Primary and secondary progressive types
Diffuse cerebral sclerosis (Schilder disease
and concentric sclerosis of Balo
8. Classification of the Inflammatory
Demyelinative Diseases
IV. Acute and subacute necrotizing
hemorrhagic encephalitis
A. Acute encephalopathic form
B. Subacute encephalitis
III. Neuromyelitis optica (Devic disease)
II.Acute disseminated encephalomyelitis
A.Postinfectious: Following measles, chickenpox, smallpox,
mumps, rubella, influenza,Mycoplasma
B.Postvaccinal : Following rabies or smallpox
9.
10. Introduction
British as “disseminated sclerosis”
French as “sclérose en plaques”
MS is a chronic condition characterized clinically
by episodes of focal disorders of the:
◦ Optic nerves
◦ Spinal cord
◦ Brain
remit to a varying extent and recur over a period of
many years
12. Pathology
Hallmark of MS is the cerebral or spinal
plaque, which consists of a discrete region
of demyelination
Relative preservation of axons
Atrophy and ventricular dilatation
Disruption of BBB but vessel wall is
preserved
13. Pathology (Gross)
Active plaques appear whitish
yellow or pink with somewhat indistinct borders
Older plaques appear translucent with a blue-gray
discoloration and sharply demarcated margins
Plaques are small (1-2 cm) but may become confluent,
generating large plaques
Develop in a perivenular distribution
Most frequently in the periventricular white matter,
brainstem, and spinal cord
15. Histopathology
Active plaques reveals
perivascular infiltration of
lymphocytes
(predominantly T cells)
and macrophages, with
occasional plasma cells
In the plaque, myelin is
disrupted, resulting in
myelin debris found in
clumps or within lipid-
laden macrophages
Reactive astrocytes are
prominent in plaques
Venule
Demyelination
area
17. Epidemiology
Age of Onset
◦ Mean and median age of
onset in relapsing forms of
MS is age 29 to 32
◦ Primary progressive MS
(PPMS) has a mean age
of onset of 35 to 39
◦ Can occur as late as the
seventh decade
◦ 5% of cases of MS have
their onset before age 18
Sex Distribution
◦ F>M
◦ 2 : 1
18. Epidemiology
Geographical Distribution
MS is a location-related
illness with a latitude
gradient
High-frequency areas with
prevalence of 60 -100 per
100,000 or more, include
◦ All of Europe (including
Russia)
◦ Southern Canada
◦ Northern United States
◦ New Zealand
◦ SE portion of Australia
The highest reported rate of
300 per 100,000 occurring
in the Orkney Islands
19. Epidemiology
Race
Determinant of MS risk
White extraction, especially from Northern Europe are
the most susceptible
People of Asian, African, or Amerindian origin have the
lowest risk
Other groups are variably intermediate
Migration after puberty no increased risk
Migration before childhood increased risk
21. Pathogenesis
The cause of MS remains undetermined
Possible Etiologies include
◦ Infection
◦ Enviromental factors
◦ Autoimmunity
◦ Genetic Susceptibility
22. Pathogenesis
Infection
Little direct evidence supports the concept of a
role for viral infection
Human T-cell lymphotropic virus type 1 [HTLV1]
Human herpesvirus 6 (HHV6)
Epstein-Barr virus (EBV)
Chlamydia pneumoniae
Environmental Factors
Sunlight exposure during growth
Vitamin D
Epidemiological data supportive
23. Pathogenesis
Autoimmunity
Break down of tolerance (unresponsiveness of the
immune system)
By means of molecular mimicry between self-
antigens and foreign antigens
Myelin basic protein (MBP), the target for
autoimmune attack
T cells that respond to MBP are found in the
peripheral blood possibly at higher levels in MS
patients with active disease
24. Pathogenesis
Genetic susceptibility
The risk of familial recurrence in MS is 15%
Highest risk in first-degree relatives (age-adjusted risk):
4–5% for siblings and
2–3% for parents or offspring
Monozygotic twins have a concordance rate of 30%
The genes that predispose to MS are incompletely defined
Inheritance appears to be polygenic, with influences from
◦ Genes for human leucocyte antigen (HLA) typing
◦ Interleukin receptors
◦ CLEC16A (C-type lectin domain family 16 member A)
◦ CD226 genes
26. Clinical Manifestations
Multiple sclerosis is classically described as a relapsing
remitting disorder
MS may display marked clinical heterogeneity. This
variability includes
◦ age of onset
◦ mode of initial manifestation
◦ frequency
◦ severity
◦ sequelae of relapses
◦ extent of progression
◦ Cumulative deficit over time
High degree of variability and the difficulty in predicting
the course and severity make MS one of the most
puzzling CNS disease
28. Clinical Manifestations
Early Symptoms
Onset over hours or days
Motor or sensory system involvement in 50 % of
patients
Symptoms of tingling of the extremities and tight band-
like sensations around the trunk
Dragging or poor control of one or both legs to a spastic
or ataxic paraparesis
Early Signs
The tendon reflexes are retained and later become
hyperactive
Extensor plantar reflexes
Disappearance of the abdominal reflexes
Varying degrees of deep and superficial sensory loss
may be associated
29. Clinical Manifestations
The patient will complain of weakness,
incoordination, or numbness and tingling in one
lower limb
But the examination will reveal
◦ Bilateral Babinski signs
◦ Bilateral corticospinal tract signs
◦ Posterior column disease
30. Clinical Manifestations
Several syndromes typical of MS and may
be the initial manifestation :
(1) Optic neuritis
(2) Transverse myelitis
(3) Cerebellar ataxia - nystagmus and ataxia
(4) Various brainstem syndromes (vertigo, facial
pain or numbness, dysarthria, diplopia)
◦ These syndromes may pose a diagnostic
dilemma as these do occur in other diseases
too
31. Clinical Manifestations
Paresthesia or numbness of an entire arm or leg
Facial pain often simulating tic douloureux
Disorders of micturition
Cervical myelopathy- slowly progressive with
weakness and ataxia
32. Clinical Manifestations
Diplopia
◦ Medial longitudinal fasciculi
◦ Internuclear ophthalmoplegia
◦ Paresis of the medial rectus on attempted lateral
gaze, with a coarse nystagmus in the abducting
eye
◦ Usually bilateral
The presence of bilateral internuclear
ophthalmoplegia in a young adult is
virtually diagnostic of MS
33. Clinical Manifestations
Myokymia or paralysis of facial muscles
Deafness, tinnitus, unformed auditory hallucinations
(because of involvement of cochlear connections)
Vomiting (vestibular connections), and, rarely, stupor
and coma
Vertigo of central type
Dull, aching low back pain
Sharp, burning, poorly localized, or lancinating radicular
pain, localized to a limb or discrete part of the trunk
34. Clinical Manifestations
Lhermitte sign
Flexion of the neck may
induce a tingling, electric
shock like feeling down
the shoulders and back
Frequent occurrence of
this phenomenon in MS
Due to an increased
sensitivity of
demyelinated axons to
the stretch or pressure
on the spinal cord
induced by neck flexion
35. Clinical Manifestations
Uhthoff phenomenon
Transient worsening of function with
increased body temperature
Due to a drop below the safety threshold for
conduction because of physiological
changes involving the partially
demyelinated axon
36. Clinical Manifestations
Established Stage of the Disease
50 % will manifest a clinical picture of mixed or
generalized type with signs pointing to involvement of
the optic nerves, brainstem, cerebellum, and spinal cord
30 to 40 % will exhibit only varying degrees of spastic
ataxia and deep sensory changes in the extremities,
i.e., essentially a spinal form of the disease
5 % have a predominantly cerebellar or brainstem–
cerebellar form occurs
37. Clinical Manifestations
Cognitive impairment
Progressive decline, is present in perhaps one-
half of patients with long-standing MS
Reduced attention
Diminished processing speed and executive
skills
Memory decline
Language skills and other intellectual functions
are preserved
38. Clinical Manifestations
The most characteristic clinical course of MS
is the occurrence of relapses
Relapses can be defined as
◦ acute or subacute onset of clinical dysfunction
◦ that usually reaches its peak from days to
several weeks,
◦ followed by a remission during which the
symptoms and signs usually resolve partially or
completely
The minimum duration for a relapse has been
arbitrarily established at 24 hours
39. Clinical Manifestations (Course)
1. Relapsing-remitting (RRMS):
Clearly defined relapses with full recovery or with sequelae and
residual deficit on recovery
The periods between disease relapses are characterized by a
lack of disease progression
2. Secondary progressive (SPMS):
Initial relapsing remitting disease course followed by progression
with or without occasional relapses, minor remissions, and plateaus
3. Primary progressive (PPMS):
Disease progression from onset, with occasional plateaus and
temporary minor improvements allowed
4. Progressive relapsing (PRMS):
Progressive disease from onset, with clear acute relapses with or
without full recovery
The periods between relapses are characterized by continuing
progression
43. CSF ANALYSIS
Cytology
In 1/3 of with an acute onset or
an exacerbation, there may be a
slight to moderate mononuclear
pleocytosis (6 to 20 or less than
50 cells/mm3)
In rapidly severe demyelinating
disease of the brainstem, the
total cell count may reach or
exceed 100, and rarely 1,000,
cells/mm3
In the hyperacute cases, the
greater proportion of these may
be polymorphonuclear
leukocytes
44. CSF ANALYSIS
Protein
40 % of patients, the total protein content of the
CSF is increased slightly
Not more than 100 mg/dL
In two-thirds of patients, the proportion of gamma
globulin (mainly IgG) is increased (greater than
12 percent of the total protein)
IgG index obtained by measuring albumin and
gamma globulin in both the serum and CSF
45. CSF ANALYSIS
Oligoclonal bands
Gamma globulin proteins in the CSF of
patients with MS are synthesized in the
CNS
They migrate in agarose electrophoresis
as abnormal discrete populations, so-
called oligoclonal bands
The most widely used CSF test for the
confirmation of the diagnosis
Show several bands in the CSF in more
than 90 percent of cases of MS
But they are not always found with the
first attack or even in the later stages of
the disease
46. Magnetic Resonance Imaging
MRI is the most helpful ancillary examination
in the diagnosis of MS
Reveal asymptomatic plaques in the
cerebrum, brainstem, optic nerves, and spinal
cord
T2-weighted images show :
◦ Hyperintense well-demarcated lesions
◦ Multiple and asymmetrical
◦ Periventricular surface in location
48. Magnetic Resonance Imaging
The presence
lesions in the
corpus callosum is
diagnostically
useful
This structure is
spared in many
other disorders
Midsagittal FLAIR image
49. Magnetic Resonance Imaging
In sagittal images
extension of the lesion
outward from the
corpus callosum in a
fimbriated pattern and
have been termed
“Dawson fingers”
These areas may
extend into the
centrum semiovale
and may reach the
convolutional white
matter
Sagittal FLAIR image
51. Newer Imaging Tecniques
MAGNETIC RESONANCE SPECTROSCOPY
◦ a tool that derives MRI signal from
multiple metabolites
◦ A high choline (Cho) peak is indicative of
an increase in membrane turnover, as can
be seen in demyelination and
remyelination
DIFFUSION TENSOR IMAGING
HIGH-FIELD-STRENGTH MRI
52. Evoked Potentials
EPs are CNS electrical events
generated by peripheral stimulation of a
sensory organ
Are useful
◦ To determine abnormal function that may
be clinically unapparent
◦ When the clinical data point to only one
lesion in the CNS mainly in the early
stages of the disease or in the spinal form
Commonly used EPs are
1. Visual Evoked response (VEPs)
2. Somatosensory evoked potentials (SSEPs)
3. Brainstem auditory-evoked responses (BAER)
53. Comparison of Sensitivity of
Laboratory Testing
Investigations Sensitivity
VER 80%-85%
BAER 50%-65%
SSEP 65%-80%
OCB 85%-95%
MRI 90%-97%
56. Differential diagnosis
The differential diagnosis of MS in the setting
of a young adult with two or more clinically
distinct episodes of CNS dysfunction with at
least partial resolution is limited
Problems arise with
◦ Atypical presentations
◦ Monophasic episodes
◦ Progressive illness
◦ The unusual nature of some sensory symptoms
may result in a misdiagnosis of conversion
disorder
59. Treatment
Treatment of the MS patient should be directed toward these
basic goals:
Relief or modification of symptoms
Shortening the duration or limiting the residual effects of an
acute relapse
Reducing the frequency of relapses
Preventing disability progression or slowing its pace
Supporting family and patient, alleviating social and economic
effects, and advocating for the disabled or handicapped
60. Symptomatic Treatment
Spasticity
Baclofen a GABA agonist Daily divided doses of 20 to 120 mg and
occasionally .Intrathecal baclofen via an implanted pump
Tizanidine a centrally active α2-noradrenergic agonist, gradually
increased starting with 2 mg at bedtime
Benzodiazepines
Dantrolene sodium rarely
4-Aminopyridine and 3,4-diaminopyridine (3,4-DAP) block
potassium channels in the axolemma
Botulinum toxin type A (Botox) injections into spastic or
contracted muscles may also be effective in selective cases
61. Symptomatic Treatment
Tremor
Weighted wrist bracelets and specially adapted utensils are
nonpharmaceutical options
Most attempts at pharmacological amelioration of tremor fail
Isoniazid
Primidone
Carbamazepine
Gabapentin
Topiramate
Clonazepam
Propranolol
Ondansetron
62. Symptomatic Treatment
Fatigue
Amantadine 100 mg twice a day
Modafinil - a wakefulness promoting agent
Methylphenidate 10 to 60 mg/day in 2 to 3 divided dose
SSRIs
Fluoxetine 10 to 20 mg once twice daily
Bupropion
63. Symptomatic Treatment
Bladder Dysfunction
Initial steps in managing bladder dysfunction include
◦ fluid management,
◦ timed voiding
◦ use of a bedside commode
Hyperreflexic bladder without outlet obstruction
◦ Oxybutynin,Tolterodine,Trospium,Darifenacin,solifenacin,
Desmopressin
Imipramine for enuresis
Detrusor hyperreflexia with outlet obstruction may respond
Credé maneuvers terazosin hydrochloride
Intermittent catheterization
Chronic indwelling catheterization may be required
Surgical correction-augmentation of bladder capacity with an
exteriorized loop of bowel
64. Symptomatic Treatment
Depression
SSRIs are the medications of choice
Fluoxetine
Amitriptyline, 25 to 100 mg daily
Sexual Dysfunction
Sildenafil 25 to 100 mg 1 hour before sexual
intercourse for erectile dysfunction
65. Symptomatic Treatment
Cognitive Impairment
Interferon beta-1a SC
L-amphetamine
Modafinil
Donepezil
Cognitive-behavioral therapy
Family and individual counseling
Strategies to improve day-to-day function
Job modifications and accommodations
66. Treatment of Acute Attacks
Acute attacks are typically treated with corticosteroids
Indications for treatment of a relapse include
functionally disabling symptoms with objective evidence
of neurological impairment
Short courses of IV methylprednisolone – 500 to 1000
mg daily for 3 to 5 days
◦ With or without a short prednisone
S/Es include psychiatric changes, predilection for
infections,GI disturbances,anaphylactoid reactions,
Increased incidence of fracture
68. Disease-Modifying Treatments
Emerging Therapies
Laquinimod
Orally active synthetic immunoregulator
Oral fumarate/BG-12
Induces apotosis of activated T cells
Teriflunomide
Is a metabolite of leflunomide
Alemtuzumab
Humanized monoclonal anti-body against CD52 antigen expressed in all
lymphocytes
Rituximab
A chimeri murine-human monoclonal antibody directed against CD30
antigen on B lymphocytes
69. Treatment-Rehabilitation
Referral to
physical,occupational and
speech therapists
1.Physical therapy
Evaluate and train the patient
in appropriate exercise
programs to :
◦ decrease spasticity
◦ maintain range of motion
◦ strengthen muscles
◦ improve coordination
Mechanical aids, such as
ankle-foot orthoses, also can
be useful in spasticity
management.
72. Prognosis
Prognostic indicators:
MS appears to follow a more benign course in women than in men
Onset at an early age is a favorable factor, whereas onset at a later
age carries a less favorable prognosis
RRMS is more common in younger patients, and PPMS and SPMS
are more common in the older age group
Relapsing form of the disease is associated with a better prognosis
than progressive disease
Among initial symptoms, impairment of sensory pathways or ON has
a favorable prognostic feature
Pyramidal and particularly brainstem and cerebellar symptoms carry
a poor prognosis
Devic disease, Baló concentric sclerosis, and particularly Marburg
disease are more fulminant variants of MS, with early disability and
even death