This document summarizes key points from a presentation on accurately diagnosing relapses in multiple sclerosis (MS) patients. It discusses the clinical definition of an MS relapse according to textbooks and reality, and highlights factors like pre-morbid function and medication that can influence relapse diagnosis. Several clinical scenarios are then presented where attendees must determine if new symptoms represent a relapse or have alternative causes like infection, autoimmune conditions from MS treatments, musculoskeletal issues, or functional neurological symptoms. Accurately diagnosing relapses is important for treatment decisions and understanding the natural disease course.
Autoimmune Encephalitis is a particularly intimidating entity, as recognition of this disease can be delayed because diagnosis can involve ambiguous neurological symptoms, leading to detrimental long-term consequences. Auto-anti-bodies (NMDA,VGKC) can be found through serum lab tests, and magnetic resonance imaging can show inflammation, and spinal tap can reveal auto antibodies and other biomarkers in the cerebrospinal fluid that point to autoimmune encephalitis. Being that autoimmune encephalitis is a recently described diagnosis, there is still a tremendous amount of investigation to be done to discover the root causes of the disease, more anti-body essays need to be developed to discover all of the phenotypes, and the best most effective treatments need to be found to treat this mysterious disease.
Autoimmune Encephalitis is a particularly intimidating entity, as recognition of this disease can be delayed because diagnosis can involve ambiguous neurological symptoms, leading to detrimental long-term consequences. Auto-anti-bodies (NMDA,VGKC) can be found through serum lab tests, and magnetic resonance imaging can show inflammation, and spinal tap can reveal auto antibodies and other biomarkers in the cerebrospinal fluid that point to autoimmune encephalitis. Being that autoimmune encephalitis is a recently described diagnosis, there is still a tremendous amount of investigation to be done to discover the root causes of the disease, more anti-body essays need to be developed to discover all of the phenotypes, and the best most effective treatments need to be found to treat this mysterious disease.
In this presentation, we will discuss Chemotherapy Induced Peripheral Neuropathy with strict application of Evidence based medicine about the magnitude of the problem, how to diagnose, how to prevent and how to treat?
Clinico pathologic case conference 2019, NeurologyPramod Krishnan
This presentation was part of the annual Clinico pathologic case conference of the Bengaluru Neurological Society for the year 2019. The case was provided by the Department of Neurology and pathology, NIMHANS, Bengaluru and i was the discussant. The clinical, radiological and investigation aspects of the case are discussed in detail and the final diagnosis based on histopathology was revealed in the end.
Chemotherapy Induced Peripheral Neuropathy (CIPN): A Song of Ice and FireChristopher B. Ralph
Chemotherapy-induced peripheral neuropathy (CIPN) is a dose-limiting neurotoxic effect affecting many patients receiving chemotherapy, characterized by pain and loss of sensation in the hands and feet. It can interfere with cancer patients’ treatment and significantly reduce their quality of life. With better treatment options like new anti-emetics and hematopoietic colony stimulating factors for other serious side-effects, CIPN emerges more often as a dose limiting factor. In this session, we will discuss prevention, monitoring, pharmaceutical treatment options, as well as other modalities to consider. We will also explore future management options for this pervasive, debilitating adverse effect of cancer treatment.
Author: Twitter @ChrisRalphRx
Facial neuropathology Maxillofacial SurgeryLama K Banna
Lecture 4 facial neuropathology
Maxillofacial Surgery
Dental Students Fifth Year second semester
Al Azhar University Gaza Palestine
Dr. Lama El Banna
https://twitter.com/lama_k_banna
In this presentation, we will discuss Chemotherapy Induced Peripheral Neuropathy with strict application of Evidence based medicine about the magnitude of the problem, how to diagnose, how to prevent and how to treat?
Clinico pathologic case conference 2019, NeurologyPramod Krishnan
This presentation was part of the annual Clinico pathologic case conference of the Bengaluru Neurological Society for the year 2019. The case was provided by the Department of Neurology and pathology, NIMHANS, Bengaluru and i was the discussant. The clinical, radiological and investigation aspects of the case are discussed in detail and the final diagnosis based on histopathology was revealed in the end.
Chemotherapy Induced Peripheral Neuropathy (CIPN): A Song of Ice and FireChristopher B. Ralph
Chemotherapy-induced peripheral neuropathy (CIPN) is a dose-limiting neurotoxic effect affecting many patients receiving chemotherapy, characterized by pain and loss of sensation in the hands and feet. It can interfere with cancer patients’ treatment and significantly reduce their quality of life. With better treatment options like new anti-emetics and hematopoietic colony stimulating factors for other serious side-effects, CIPN emerges more often as a dose limiting factor. In this session, we will discuss prevention, monitoring, pharmaceutical treatment options, as well as other modalities to consider. We will also explore future management options for this pervasive, debilitating adverse effect of cancer treatment.
Author: Twitter @ChrisRalphRx
Facial neuropathology Maxillofacial SurgeryLama K Banna
Lecture 4 facial neuropathology
Maxillofacial Surgery
Dental Students Fifth Year second semester
Al Azhar University Gaza Palestine
Dr. Lama El Banna
https://twitter.com/lama_k_banna
Diagnosis of MS and related disorders in children - Cheryl HemingwayMS Trust
Aims:
Review the spectrum of ADS and the
IPMSSG criteria for diagnosis of MS
Through cases illustrate the key features
of ADS and the differential diagnoses
Discuss some of the current challenges
and new phenotypes
Understanding, Diagnosing, and Classifying MS Symptom Managementericss1234_msvn
Understanding, Diagnosing, and Classifying MS Symptom Management. Presented by Tricia Pagnotta, MSN, ARNP, CNRN, MSCN at the MS Views and News Education Seminar Maitland, Fl on April 2013
A case of Neuromyelitis optica as a presenting manifestation of Systemic Lupu...Apollo Hospitals
Neuromyelitis optica (NMO) is a well characterised, autoimmune, clinicopathological syndrome, which is uncommon and occurs as an isolated entity. Unlike multiple sclerosis, in NMO, the autoimmunity is humorally mediated and the recent availability of Antiaquaporin antibody testing has increased the positive diagnosis of this condition. NMO can also occur in patients with established Systemic Lupus Erythematosis (SLE) who have multiple autoantibodies. The presence of Antiaquaporin antibody is specific for NMO and is seen in patients with SLE who develop inflammatory CNS disease. However, Neuromyelitis optica occurring as a presenting manifestation of SLE is extremely rare and we report one such case.
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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.
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
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
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Top 10 Best Ayurvedic Kidney Stone Syrups in India
Differential diagnosis in a relapse clinic
1. MS Trust Conference
Differential diagnosis in a relapse clinic
Dr Emma Tallantyre
Post-doctoral Research Fellow
Rachel Wallbank
Occupational Therapist MS Team
University Hospital of Wales, Cardiff.
2. Learning objectives
• To appreciate the clinical definition of an MS relapse
• To understand the reasons for accurately classifying
relapse
• To recognise the common mimics of relapse and the
pitfalls of relapse diagnosis
• To use clinical examples to gain confidence in
accurately diagnosing and managing relapses
• To appreciate key issues in relapse management and
service design
3. Acute relapse: what the textbooks say
• Pathophysiology: Acute inflammation and
demyelination occurring within clinically eloquent
areas of the central nervous system.
4. Acute relapse: what the textbooks say
• Pathophysiology: Acute inflammation and
demyelination occurring within clinically eloquent
areas of the central nervous system.
• Clinical: “patient-reported or objectively observed
events typical of an acute inflammatory
demyelinating event in the CNS, current or historical,
with duration of at least 24 hours, in the absence of
fever or infection.”1
1. Polman CH et al. Diagnostic criteria for multiple sclerosis: 2010
revisions to the McDonald criteria. Annals of neurology 2011;69:292-302.
5. Acute relapse: what the textbooks say
• Pathophysiology: Acute inflammation and
demyelination occurring within clinically eloquent
areas of the central nervous system.
• Clinical: “patient-reported or objectively observed
events typical of an acute inflammatory
demyelinating event in the CNS, current or historical,
with duration of at least 24 hours, in the absence of
fever or infection.”1
1. Polman CH et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald
criteria. Annals of neurology 2011;69:292-302.
6. Acute relapse: the reality
Acute
symptoms
in MS
Pre-morbid
function
Medication
Heat
Psychosocial
factors
Spasticity/
spasms
Other
medical
conditions
Progressive
disability
8. Acute relapse: the reality
From : Tallantyre et al. Multiple Sclerosis Journal (2015) 21 (1): 67-75.
9. Why do we need to diagnose relapse?
• Establishing the clinical diagnosis
• Optimising short-term ability
• Guide longer-term treatment decisions
• Inform on the natural history of disease
• Support the patient and their family
www.multiplesclerosis.net
11. Scenario 1
32 year old lady with RRMS, three weeks post-
partum.
• Blurred vision left eye. Mild pain on eye
movements. Has seen optician and told she has
optic disc swelling.
• Visual acuity: left 6/24; right 6/6
Questions:
• Is this a relapse?
• Would you treat? If so, what with?
12. Scenario 1
Questions:
• Is this a relapse?
– YES: acute optic neuritis
• Would you treat? If so, what with?
13. 2. Sellebjerg F et al. Neurology. 1998; 51: 529-34.
3. Sellebjerg F et al. Neurology. 1999; 52: 1479-84. 4. Burton et al. Cochrane Database 2012.
5. Ramo-Tello et al. Mult Scler. 2014; 20: 717-25.
Acute relapse and steroids: who to treat, and how.
WHO?
• Optic Neuritis Treatment Trial (ONTT)1:
– 457 individuals with ON: IV methylpred vs oral pred vs placebo:
significant improvement in speed of recovery with IV
methylpred, no impact on long term vision.
• NICE guidance (2014): “Assess and offer treatment for relapses of
MS, that affect the person's ability to perform their usual tasks”
HOW?
• High dose oral steroids effective2,3
• Oral and IV steroids thought to have equivalent efficacy4
• One RCT showed non-inferiority of oral methylprednisolone5
• NICE: Oral methylprednisolone 500mg od for 5d
1. Beck et al, (1992) NEJM. 326 (9): 581-588.
14. Scenario 2
30 year old lady with RR MS
– One week history of difficulty walking.
– No symptoms of infection.
– Legs weak and stiff on examination.
– Urine dipstick:
• Leucocytes: +
• Nitrites: +
Questions:
• Is this a relapse?
• What, if any, treatment would you give?
• When would you follow her up?
15. Scenario 3
30 year old lady with RR MS
– One week history of difficulty walking.
– Dysuria and frequency to micturate.
– Temp 37.5C.
– Legs weak and stiff on examination.
– Urine dipstick:
• Leucocytes +
• Nitrites: trace
• Protein 1+
• Blood 1+
Questions:
• Is this a relapse?
• What, if any, treatment would you give?
• When would you follow her up?
16. Acute relapse and infection
Questions:
• Is this a relapse?
– “patient-reported or objectively observed events
typical of an acute inflammatory demyelinating event
in the CNS, current or historical, with duration of at
least 24 hours, in the absence of fever or infection.”
– Pseudo-relapse: Heat/ infection can cause transient
neurological deterioration.
– But infection can also trigger relapse.
• Relapses associated with infection: worse
outcome
17. Acute relapse and infection
• At risk period
• Relapse rate ↑ x 2
• More often prolonged and sustained
1. Sibley WA et al, Lancet 1985;1:1313-5. 2. Andersen O, et al. Journal of neurology 1993;240:417-22.
3. Edwards S, et al. JNNP 1998;64:736-41. 4. Panitch HS. Annals of neurology 1994;36 Suppl:S25-8.
5. Buljevac D, et al. Brain 2002;125:952-60. 6. Correale J, Fet alNeurology 2006;67:652-9.
Infection
Weeks
18. Scenario 2/3
• What, if any, treatment would you give?
• When would you follow her up?
19.
20. • What, if any, treatment would you give?
– Scenario 2: Antibiotics and steroids.
– Scenario 3: Antibiotics initially.
• When would you follow her up?
– Scenario 3: In 1 to 2 weeks to reassess neurology
and consider steroids.
21. Scenario 4
24 year old lady
• Resident in Saudi until 2/52 previously
• March 2014 : headaches, blurred vision, arm and leg
numbness
• August 2014: visual loss left eye
• Began with central blurring
• Progressed over 1-2/52
• At worst sliver of retained temporal field
• Pressure feeling in eye worse on eye movement
• Some improvement over last 1 week but still little useful
vision in left eye
• Right eye unaffected
25. Ophthalmology
• Corneal oedema
• Intra-ocular pressures 40 (Normal: 12-22)
• Deep cupped optic discs
• Marked optic atrophy
• Diagnosis: acute angle-closure glaucoma
• Cause of ON signal change ? Ischaemia
• VEPs?
• Rx Diamox
• Recovery unlikely
26. Scenario 4
Questions:
• Is this a relapse?
– No
• Would you treat with steroids?
– No
• What else would you do?
– Refer to ophthalmology
27. Acute relapse: ON mimics
Unusual clinical features:
• Persistent or absent pain
• Severe visual loss
• Visual disturbance continues to progress after one
month
• Bilaterality
• Steroid response, followed by a relapse when stopped
Differential diagnosis
• Uveitis
• Glaucoma
• Ischaemic optic neuropathy including vasculitis
• Neuroretinitis e.g. syphilis, TB, toxoplasma.
• Leber hereditary optic neuropathy.
• Other inflammatory optic neuropathy e.g. NMO,
sarcoid
28. Scenario 5
31y lady, known relapsing-remitting MS
• 2 week history:
– Headaches
– Palpitations
– Short of breath on exertion
• On examination:
– Pansystolic murmur
– Bilateral pitting oedema
Questions:
• Is this a relapse?
• Would you treat with steroids?
• What else would you do?
29. Scenario 5
Questions:
• Is this a relapse?
– No
• Would you treat with steroids?
– No
• What else would you do?
30. Scenario 5 - continued
• TFTs: FT4 37.3, TSH <0.02
• CTPA: no pulmonary
embolus
• Carbimazole
• Radio-iodine
Diagnosis: pulmonary hypertension due to autoimmune
thyrotoxicosis (related to alemtuzumab)
32. Alemtuzumab side-effects
• Prospective follow-up of 100 patients (mean 6y)
– Thyroid disease 35%
– Other autoimmunity 16%
Willis et al. (2015) Multiple Sclerosis Journal. In press
33. Natalizumab and possible relapse
Guidance for evaluation of new neurological symptoms in patients
receiving TYSABRI. Biogen Idec. 2015
34. Guidance for evaluation of new neurological symptoms in patients
receiving TYSABRI. Biogen Idec. 2015
35. Scenario 6
54 y man progressive MS
• 3 month history
– R leg numbness
– R sided lower back pain
• Weak left leg with brisk reflexes
• Loss of sensation dorsum right foot
Questions:
• Is this a relapse?
• Would you treat with steroids?
• What else would you do?
38. Musculoskeletal comorbidity in MS
• Greater trochanteric bursitis1
• Fibromyalgia2
• Arthritis
• Adverse neural tension
1. Sloan RL, Practical neurology 2009:9: 163-5.
2. Marrie, R. Multiple Sclerosis and Related Disorders. 2012: 1 :162.
39. Scenario 7
39 year old lady with RRMS
• Diagnosed with MS 2004
– Optic neuritis 2004
– Trigeminal neuralgia
– Earlier this year: giddy/ unsteady, partial
improvement with steroids
• New loss of vision left eye
40. Scenario 7 (examination)
“Her walking is a bit wobbly and she has to hang on to
somebody’s arm.
Examining her today her acuity is 1/60 left, counting fingers
right, but despite this apparent complete blindness she was
able to walk in heels reasonably well and her pupils had
really quite brisk reactions. Her discs were pale, she
seemed reluctant to check eye movements, she couldn’t or
wouldn’t close her eyes to test facial power.
Although she walked up and down the corridor 45 metres or
more, when she got on the bed she couldn’t move her legs.
She would only twitch her toes when I asked her to lift her
legs up and both plantars were definitely flexor. Her gait
was rather odd and shuffling.”
41. Scenario 7
Questions:
• Is this a relapse? If not, what would you call it?
• Would you treat with steroids?
• What else would you do?
42. Functional neurological symptoms
• AKA: non-organic, hysterical, psychogenic,
medically unexplained.
• How to recognise functional symptoms:
– Discrepancy with functional ability
– Discrepancy with neuroanatomy
– Objective tests (bedside or investigation)
1. Merwick, A. The International MS Journal 2008; 15: 47–51
43. Scenario 7 (examination)
“Her walking is a bit wobbly and she has to hang on to
somebody’s arm.
Examining her today her acuity is 1/60 left, counting fingers
right, but despite this apparent complete blindness she was
able to walk in heels reasonably well and her pupils had
really quite brisk reactions. Her discs were pale, she
seemed reluctant to check eye movements, she couldn’t or
wouldn’t close her eyes to test facial power.
Although she walked up and down the corridor 45 metres or
more, when she got on the bed she couldn’t move her legs.
She would only twitch her toes when I asked her to lift her
legs up and both plantars were definitely flexor. Her gait
was rather odd and shuffling.”
44. Scenario 7 (examination)
“Her walking is a bit wobbly and she has to hang on to
somebody’s arm.
Examining her today her acuity is 1/60 left, counting fingers
right, but despite this apparent complete blindness she was
able to walk in heels reasonably well and her pupils had
really quite brisk reactions. Her discs were pale, she
seemed reluctant to check eye movements, she couldn’t or
wouldn’t close her eyes to test facial power.
Although she walked up and down the corridor 45 metres or
more, when she got on the bed she couldn’t move her legs.
She would only twitch her toes when I asked her to lift her
legs up and both plantars were definitely flexor. Her gait
was rather odd and shuffling.”
45. Scenario 7 (examination)
“Her walking is a bit wobbly and she has to hang on to
somebody’s arm.
Examining her today her acuity is 1/60 left, counting fingers
right, but despite this apparent complete blindness she was
able to walk in heels reasonably well and her pupils had
really quite brisk reactions. Her discs were pale, she
seemed reluctant to check eye movements, she couldn’t or
wouldn’t close her eyes to test facial power.
Although she walked up and down the corridor 45 metres or
more, when she got on the bed she couldn’t move her legs.
She would only twitch her toes when I asked her to lift her
legs up and both plantars were definitely flexor. Her gait
was rather odd and shuffling.”
46. Scenario 7 (examination)
“Her walking is a bit wobbly and she has to hang on to
somebody’s arm.
Examining her today her acuity is 1/60 left, counting fingers
right, but despite this apparent complete blindness she was
able to walk in heels reasonably well and her pupils had
really quite brisk reactions. Her discs were pale, she
seemed reluctant to check eye movements, she couldn’t or
wouldn’t close her eyes to test facial power.
Although she walked up and down the corridor 45 metres or
more, when she got on the bed she couldn’t move her legs.
She would only twitch her toes when I asked her to lift her
legs up and both plantars were definitely flexor. Her gait
was rather odd and shuffling.”
47. Functional neurological symptoms
Wong SH, et al. Interpretation of
Visual Fields. Practical Neurology
2015; 1–8.
Stone J, et al. Hoover’s Sign.
Practical Neurology 2011; 50–53.
49. Functional neurological symptoms
• What else would you do?
– Explain the symptoms to the patient
• Demonstrate discrepancies
• Use it to reassure
– Recognise the impact of the symptoms
• “Although these symptoms are not caused by MS, they are still very real
and I can see how they are really impacting on life at the moment.”
• “We see these sort of symptoms quite a lot and often find that people can
feel quite confused by not being able to firmly identify the underlying
cause. So it’s important that you know that I agree these symptoms are
real; you are not imagining them or making them up.”
– Minimise investigations : positive diagnosis
– Practical solutions
• Physiotherapy
• Social support
• Functional goals e.g. engagement with groups/ activities
50. Scenario 8
29 year old man
• Three weeks of worsening mobility.
• Needing unilateral assistance (previous EDSS 3).
• Numbness in the fingers. Vertigo in the mornings.
• Two steroid courses so far this year.
Questions:
• Is this a relapse?
• Would you treat with steroids?
• What else would you do?
51. Steroids: how often is too often?
• Common side-effects:
– headache, mood disturbance, fatigue, insomnia,
metallic taste, weight gain and skin changes.
• Other considerations:
– Diabetes/ hypertension
– Gastrointestinal complications
• Rare unless co-adminsitered with NSAIDS1
• Give PPI if history of peptic ulcer disease
– Bone health
• Pulsed steroids not thought to ↑ risk osteoporosis2
• Osteonecrosis is a cumulative risk3
1. Piper et al. Annals of internal medicine. 1991; 114: 735-40.
2. Zorzon et al. European journal of neurology 2005; 12: 550-6.
3. Ce et al. European journal of neurology 2006; 13: 857-61.
52. Consideration for disease modifying
therapy
• Consideration for disease modifying therapy
– Active MS
• 2 relapses within 2 years
– Ongoing relapses on existing therapy
• In the clinic
– Provide written information
– Order relevant investigations
– Enquire about patient preference
– Explain process of consideration
53. Acute relapses: other mimics
• Failed recovery from a previous relapse
• Progressive disability
• Paroxysmal MS symptoms
• Ensuring the original diagnosis is secure
54. Why do we need a dedicated relapse
service?
• Research shows:
– shortens delay in accessing specialist care
/receiving treatment
– reduces inpatient admissions
– minimises the psychological impact of MS relapses
• National recommendations