Trajectory and empowerment theory applied to care of patients with multiple sclerosis

Two theoretical frameworks were examined for their applicability to nursing care of multiple sclerosis (MS) patients. The Corbin and Strauss Trajectory Framework assumes that the course of chronic illness (eg, MS) varies over time and can be reconfigured by treatment and management. Miller's theory of chronically ill patient's empowerment to promote successful coping is derived by combining previously developed concepts of coping and empowerment to maintain control and enhance the quality of life. These theoretical frameworks offer great potential for guiding the nursing care of MS patients who require extensive repertoires of coping skills to deal with the stress of this chronic illness. However, further research is required to establish their validity.     

Pressor response to isometric exercise in patients with multiple sclerosis

The purpose of this study was to determine whether patients with multiple sclerosis (MS) would show attenuated heart rate and/or pressor responses to isometric handgrip exercise. Patients with MS (30 males, 74 females, aged 23-61 yr) and control subjects (9 males, 16 females, aged 25-47 yr) performed isometric handgrip exercise at 30% of maximal voluntary contraction (MVC) to fatigue. Systolic, diastolic, and mean arterial pressure (MAP) increased linearly in both groups, but were significantly lower (P < 0.05) in patients with MS at 20%, 40%, 60%, 80%, and 100% of exercise duration. Mean change in MAP at fatigue was +47.9 mm Hg for controls and +28.2 mm Hg for patients with MS, with 18 patients with MS between -6 mm Hg and +15 mm Hg. Heart rate increased normally in patients with MS. To predict change in MAP at fatigue in patients with MS, stepwise regression analysis using six variables yielded an R2 of 0.26. These data suggest that in some patients MS lesions exist in areas of autonomic cardiovascular control that result in attenuated pressor responses to exercise. In 17% of patients tested, attenuation was profound. Data also suggest an abnormal dissociation between the heart rate and pressor response to static work in patients with MS.     

Lipid peroxidation in patients with multiple sclerosis

Questions of lipid metabolism in patients with multiple sclerosis are considered in the light of biomembrane (myelin) pathology. The results of of the study of the lipids fatty acids spectrum in the blood plasma and the secondary product of their spontaneous and NADPhH-dependent peroxidation, malonic dialdehyde, are stated. The dependence of changes in saturation of fatty acids spectrum and dialdehyde concentrations on the stage and heaviness of the multiple sclerosis is shown. Certain dynamics of lipid metabolism indices as a result of treatment was found. The authors also give some recommendations as to the use of drugs at various stages of the disease.     

Influenza vaccination in patients with multiple sclerosis

Vaccination was well tolerated by 93 patients with multiple sclerosis who received a total of 209 doses of influenza vaccine. In one patient, evidence of a new lesion developed after vaccination; the relapse rate was less than would be expected in the natural course of the illness. Toxic and allergic reactions appeared with 7% and 0.5% of the vaccinations, respectively--a rate no higher than that observed in the general population.     

Introduction of integrated care pathways for patients with multiple sclerosis in an inpatient neurorehabilitation setting

Rehabilitation of progressive neurological disorders such as multiple sclerosis poses particular problems, and clear setting of goals and clinical audit are essential for effective management. Integrated care pathways (ICPs) offer a unique opportunity to document and audit the rehabilitation process. This preliminary study has shown that ICPs are useful in both assessing process and auditing goals. Their introduction has led to the identification of the key worker role within the neurorehabilitation unit (NRU), and has provided an opportunity to increase the participation of patients and carers in the rehabilitation process. Continuing refinement of the pathway is necessary, and its application to other neurological disorders such as cerebrovascular accident may be appropriate.     

Contraception and multiple sclerosis (author's transl)

This survey about the contraceptive behavior of women with multiple sclerosis (MS) established that they take less oral contraceptive (OC) agents than the general population; they were more frequently sterilized, or indicated that no sex relations were practiced. Young women in the group of MS patients and in the general population preferred OCs; while the number of sterilized women increased only for the general population with increasing age. Remarkably many 20-29 year old MS patients were already sterilized (16%). In half of the patients, who before their illness used OCs, MS began coincident with this use. However, only 14% of the women with MS deteriorated when they chose OCs. Considering that OCs were taken for many years, and that this time is also the susceptible age for MS, it may be presumed, that this is only a temporal coincidence. The calculation of the prognosis from the parameters "disablement" and "illness duration" does not distinguish between women with or without OCs. Accordingly, patients with MS can be advised in the taking of OCs insofar as no other contraindications exist.     

Brainstem lesions and click lateralization in patients with multiple sclerosis

The ability to lateralize dichotic clicks with either interaural time delays (ITD) or interaural level differences (ILD) was tested in seven multiple sclerosis (MS) subjects who had normal audiograms. Along with the psychoacoustical tests, magnetic resonance images (MRI) of the subjects' brainstem were obtained. After matching each MRI section with the corresponding section of a computerized atlas of the brainstem, the parts of the auditory pathway affected by each MS lesion were determined. Of the seven subjects two performed normally with both types of interaural asymmetry and had no brainstem lesions involving the auditory pathway. Two subjects performed normally only with level differences, but perceived all the dichotic clicks with different ITDs in the center of the head; both had lesions involving the trapezoid body. Three subjects could not perform normally with either task, perceiving the clicks to the sides and never in the center for both ITDs and ILDs; all three had unilateral lesions of the lateral lemniscus. A multi-level decision making model is proposed to account for these results.     

The metabolic characteristics of patients with multiple sclerosis

A comprehensive clinical and biochemical evaluation has been carried out in patients with multiple sclerosis (MS). Measured in the patients' blood were levels of cholesterol, triglycerides, malonic dialdehyde, and superoxidedysmutase activity. The interrelationship revealed between the above measures provides a deeper insight into the mechanisms of pathometabolism in MS.     

Influenza virus vaccination of patients with multiple sclerosis

Our previous data showed that at least five PKC isoforms (alpha, delta, zeta, lambda and tau) were present in the decidualization. In this study, we then localized the PKC alpha and zeta by immunohistochemistry in the decidualized uterine tissues. The decidualized uterine tissues were induced by trauma-stimulation and fixed in formalin. The immunofluorescence were photographed by confocal microscope. The data revealed that the fluorescence of PKC alpha was present in the deciduomata and myometrium. In the deciduomata, PKC alpha was mainly located in the surrounding nuclear. This phenomenon of localization was especially performed on day 2 and 3 of the decidualization, just on the time of higher frequence of cell mitosis. Since the myometrium with hypertrophy did not display the phenomenon of perinuclear localization, these suggested that the expression and localization of PKC alpha may be associated with the cell proliferation. On the other hand, the PKC zeta was also present and distributed broadly in the deciduomata and myometrium. This expression was increased and similar to the previous Western blot studies. Thus, the data confirmed that the various expression and localization of PKC isoforms may be correlated with the development of deciduomata.     

Epilepsy in patients with multiple sclerosis: radiological-clinical correlations

This study was performed to determine whether the stimulatory effect of plasma angiotensin II (ANG II) on arginine vasopressin (AVP) and oxytocin (OT) secretion in humans is mediated by AT1 subtype receptors. For this purpose, the effects of the AT1 receptor antagonist losartan (50 mg orally) or a placebo on the AVP and OT responses to ANG II (intravenous infusion for 60 minutes of successively increasing doses of 4, 8, and 16 ng/kg min; each dose for 20 minutes) administration were evaluated in seven normal men. In additional experiments, the same subjects were tested with losartan (50 mg orally) alone or placebo alone. Neither losartan nor placebo given alone modified the basal levels of AVP and OT. ANG II infusion induced significant increments in both serum AVP and OT levels (mean peaks were 1.55 and 1.41 times higher than baseline, respectively). Both hormonal responses to ANG II were completely abolished by pretreatment with losartan. These data provide evidence of AT1 receptor involvement in mediation of the ANG II-stimulating effect on AVP and OT secretion.     

Bladder cancer in patients with multiple sclerosis treated with cyclophosphamide

PURPOSE: We define the risk of bladder cancer in multiple sclerosis related to the use of indwelling catheters and cyclophosphamide administered as an immunomodulating agent. MATERIALS AND METHODS: We retrospectively reviewed the records of 2,351 patients with multiple sclerosis referred to the National Center for Multiple Sclerosis. RESULTS: Of the 2,351 patients 2 women and 5 men (0.29%) had bladder cancer. Of the 850 chronically catheterized patients the incidence was 0.7%. One patient with cancer performed intermittent catheterization for a rate of 0.23% in this group. In a subgroup of 70 patients treated with cyclophosphamide 5 chronically catheterized patients (5.7%) had bladder cancer. Hematuria was the most common presenting symptom. These data were compared with those in the literature on bladder cancer in spinal cord injury. CONCLUSIONS: These data suggest a possible synergistic role of cyclophosphamide and chronic catheterization in the induction of secondary bladder cancer. Regular cystoscopy is warranted in these patients to allow early detection of bladder tumors. Nitric oxide metabolism may be an important factor in the carcinogenesis of this type of bladder cancer.     

Micturitional disorders in multiple sclerosis (author's transl)

Micturitional disorders in multiple sclerosis have often an insidious onset; they aggravate during acute attacks of the nervous disease and are strongly influenced by the general condition of the patient, the evolution of his muscular spasms and the therapeutical measures. This changing behaviour of the bladder makes it necessary to perform repeated cystometries, uroflowmetries and electromyographies of the striated sphincter in order to adapt vesical therapy to the evolutive stadia of the disease. Although good results are frequently obtained by drugs (sympathicomimetics, sympathicolytics, muscle relaxants, parasympathicomimetics, parasympathicolytics), by transurethral resections of internal and/or external sphincters and by phenolisation, we feel that urinary derivations remain indicated for some patients, especially in order to facilitate social integration.     

T cell response to two immunodominant proteolipid protein (PLP) peptides in multiple sclerosis patients and healthy controls

Despite the fact that the neuroleptic drugs have been widely used for more than 40 years, one of their most common side-effects, akathisia, has been relatively neglected. There are still no universally agreed diagnostic criteria for akathisia, particularly chronic akathisia, and in this review article, we discuss the controversies surrounding the voluntary nature of its motor features and the importance of the dysphoric component. We also review the published epidemiological studies to show the great variation in frequency of occurrence. Finally, we discuss the possible neurotransmitters involved in the pathophysiology and treatment of this condition.     

Clinical characterization of patients with multiple sclerosis defined in Cuba

INTRODUCTION: Since 1975 no studies have been done in Cuba defining the clinical characteristics of patients with multiple sclerosis (MS). OBJECTIVE: To describe the characteristics of a group of Cuban patients with definite clinical MS. MATERIAL AND METHODS: Fifty eight patients with definite clinical MS were studied (Poser et al) with normal motor (VCM) and sensory (VCS) conduction velocities. Tests were done on them: clinical scale (Scripps), incapacity (EDSS) and quality of life (Steps), together with various complementary tests. Each patient was classified according to the way in which the disease evolved. Also the two commonest clinical types were compared and we applied the difference test between percentages of non-paired samples with an alfa level of 0.05. RESULTS: Onset of the illness in most cases was before the age of 40 (86.1%), 75.9% were women and 82.8% were white. In 15.3% there was a family history of MS. In 25.9% there were psychiatric disorders and trigger factors (43.1%. The most frequent initial symptoms were pyramidal (48.3%) sensorial (41.4%) and cerebellar (39.7%). Scripps scale scores were < 80 in 60.2%, in EDSS < 5 (61.9%) and in the Clinical Steps < 3 in 65.4%). Motor potentials (81.9%) somatosensory potential (PESS) (72.3%) and magnetic resonance imaging (MR) (76.4%) were the most abnormal results. Exacerbation-remission (ER) was the most frequent type of evolution (53.4%) generally affecting patients aged under 40 years old (p = 0.02), EDSS < 5 (64.4%), Scripps > 80 (61.2%), Steps < 3 (95.6%), pyramidal system involvement (58.5%), cerebellar (29.2%) and MRI abnormality (80%). The progressive primary form (PP) was the second most frequent (29.3%); 29.4% were under 40 years of age, had more marked changes in all functional system (100%), degree of incapacity and quality of life (100%). PESS (92.5%); the urodynamic tests 58.85%) were less positive on MRI (54.5%) as compared with the ER form. CONCLUSIONS: The differences found between the clinical forms ER and II indicate that there is greater deterioration in the PP form, probably due to age and more cerebellar and spinal cord involvement.     

Diagnostic studies of cerebrospinal fluid in patients with multiple sclerosis

The diagnostic criteria postulated by Poser necessitate clinical and laboratory CSF analysis for establishment of the diagnosis of definitive multiple sclerosis. The present paper reports methods for CSF examinations relating to multiple sclerosis with regard to the examinations suggested by the Charcot Foundation. In the course of CSF analysis, it is important to discriminate between the immunoglobulins present in normal amounts, those synthesized locally in pathological quantities and those penetrating across the damaged blood-CSF barrier. Normally, a parallel assay of CSF and serum specimens is carried out in the course of quantitative and qualitative protein analysis. In 37 patients with clinical multiple sclerosis, we determined the albumin and the immunoglobulin classes IgG, IgA and IgM, using laser nephelometry. An elevated IgG index was found in 76% of the cases, which points to local IgG snythesis and might be proof of the humoral immune response. The albumin quotient, which is suitable for examination of the integrity of the blood-CSF barrier, was within the reference range. Qualitative protein analysis was performed by means of electrophoresis on agarose-gel and isoelectric focusing. Agarose-gel electrophoresis revealed oligoclonal gammopathy in 68%, in contrast with the 91% demonstrated by isoelectric focusing. Comparison of the two kids of qualitative protein analyses indicated that isoelectric focusing was more sensitive for the detection of oligoclonal bands, in support of the literature finding.     

MR outcome parameters in multiple sclerosis: comparison of surface-based thresholding segmentation and magnetization transfer ratio histographic analysis in relation to disability (a preliminary note)

BACKGROUND AND PURPOSES: MR imaging is now widely used to monitor disease progression in patients with multiple sclerosis (MS). The purpose of this study was to explore the relationship between disability status and existing and new MR parameters in MS patients. METHODS: Forty-one patients with clinically definitive MS were studied. MR imaging included T2- and T1-weighted imaging as well as gradient-echo imaging with and without magnetization transfer contrast. We used surface-based thresholding segmentation techniques to obtain T2 and T1 lesion load, T1/T2 ratio, and several magnetization transfer ratio (MTR) lesion load parameters. MTR histographic analysis included measurements of absolute peak height (aHp), relative peak height (rHp), MTR of the peak (MTRp), mean MTR (MTRm), and MTR25, MTR50, and MTR75, relating to the integrals of the histogram at 25%, 50%, and 75%, respectively, of the total area under the curve. All MR parameters were correlated with Expanded Disability Status Scale (EDSS) score, disease duration, and patient's age. RESULTS: Using surface-based thresholding segmentation techniques, we found relatively low correlations with EDSS. T1 lesion load and T1/T2 ratios correlated most strongly. Regarding MTR histographic parameters, EDSS correlated best with rHp but only weakly with others. Similar correlations were found with disease duration, but not with age. CONCLUSION: The best MR correlations with disability were several MTR histographic parameters. Our findings may favor the use of these MR parameters over T2 lesion load to monitor disease progression in patients with MS, findings that should be explored further in longitudinal studies.     

Are physical activity and symptoms correlates of functional limitations and disability in multiple sclerosis?

Objective: This study examined physical activity and symptoms as correlates of functional limitations and disability among individuals with multiple sclerosis (MS). The authors hypothesized that physical activity and symptoms would be interrelated and that physical activity would be indirectly associated with disability through a pathway that involved functional limitations, whereas symptoms would be directly associated with both functional limitations and disability. Methods: Individuals with MS (N=133) who were recruited through a community organization wore an accelerometer for a 7-day period and completed a paper-and-pencil survey containing the Godin Leisure-Time Exercise Questionnaire (G. Godin & R. J. Shephard, 1985), Symptom Inventory (C. E. Schwartz, T. Vollmer, & H. Lee, 1999), MS-Related Symptom Checklist (E. E. Gulick, 1989), and abbreviated Late-Life Function and Disability Inventory (E. McAuley, J. F. Konopack, R. W. Motl, K. Rosengren, & K. S. Morris, 2005). The data were analyzed using structural equation modeling in AMOS 6.0. Results: The standardized coefficients indicated that (a) physical activity and symptoms were negatively correlated (Φ=-.59); (b) those who were more physically active had better function (γ=.40); (c) those with fewer symptoms had better function (γ=-.46) and less disability (γ=-.29); and (d) those with better function had less disability (β=.63). Conclusion: Findings indicate that physical activity is associated with reduced disability through a pathway that is consistent with S. Z. Nagi's disablement model in individuals with MS. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Doctors and patients don't agree: cross sectional study of patients' and doctors' perceptions and assessments of disability in multiple sclerosis

OBJECTIVES: To compare the judgments of clinicians on which domains of health in the short form questionnaire (SF-36) would be most important to patients with multiple sclerosis with the opinions of patients themselves; to compare assessment of physical disability in multiple sclerosis by a clinician using Kurtzke's expanded disability status scale and a non-clinically qualified assistant using the Office of Population Census and Surveys' (OPCS) disability scale with self assessment of disability and other domains of health related quality of life by patients using the SF-36 and the EuroQol questionnaire; and to compare the scores of patients for each domain of the SF-36 with control data matched for age and sex. DESIGN: Cross sectional study. SETTING: Clinical department of neurology, Edinburgh. SUBJECTS: 42 consecutive patients with multiple sclerosis attending a neurology outpatient clinic for review or a neurology ward for rehabilitation. MAIN OUTCOME MEASURES: Scores on the SF-36; EuroQol; Kurtzke's expanded disability status scale; the OPCS disability scale. RESULTS: Patients and clinicians disagreed on which domains of health status were most important (chi 2 = 21, df = 7, P = 0.003). Patients' assessment of their physical disability using the physical functioning domain of the SF-36 was highly correlated with the clinicians' assessment (r = -0.87, P < 0.001) and the non-clinical assessment (r = -0.90, P < 0.001). However, none of the measures of physical disability correlated with overall health related quality of life measured with EuroQol, Quality of life correlated with vitality, general health, and mental health in the SF-36, each of which patients rated as more important than clinicians and for each of which patients scored lower than the controls. CONCLUSIONS: Patients with multiple sclerosis and possibly those with other chronic diseases are less concerned than their clinicians about physical disability in their illness. Clinical trials in multiple sclerosis should assess the effect of treatment on the other elements of health status that patients consider important, which are also affected by the disease process, are more closely related to overall health related quality of life, and may well be adversely affected by side effects of treatment.