Multiple Sclerosis.docx

Multiple Sclerosis Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system). In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause the nerves themselves to deteriorate or become permanently damaged. Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected. Some people with severe MS may lose the ability to walk independently or at all, while others may experience long periods of remission without any new symptoms. There's no cure for multiple sclerosis. However, treatments can help speed recovery from attacks, modify the course of the disease and manage symptoms.

Symptoms Multiple sclerosis signs and symptoms may differ greatly from person to person and over the course of the disease depending on the location of affected nerve fibers. They may include: 

Numbness or weakness in one or more limbs that typically occurs on one side of your body at a time, or the legs and trunk

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Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement

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Prolonged double vision

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Tingling or pain in parts of your body

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Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign)

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Tremor, lack of coordination or unsteady gait

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Slurred speech

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Fatigue

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Dizziness

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Problems with bowel and bladder function

Diagnosis 

Blood tests, to help rule out other diseases with symptoms similar to MS. Tests to check for specific biomarkers associated with MS are currently under development and may also aid in diagnosing the disease.

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Lumbar puncture (spinal tap), in which a small sample of fluid is removed from your spinal canal for laboratory analysis. This sample can show abnormalities in antibodies that are associated with MS. Spinal tap can also help rule out infections and other conditions with symptoms similar to MS.

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MRI, which can reveal areas of MS (lesions) on your brain and spinal cord. You may receive an intravenous injection of a contrast material to highlight lesions that indicate your disease is in an active phase.

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Evoked potential tests, which record the electrical signals produced by your nervous system in response to stimuli. An evoked potential test may use visual stimuli or electrical stimuli, in which you watch a moving visual pattern, or short electrical impulses are applied to nerves in your legs or arms. Electrodes measure how quickly the information travels down your nerve pathways.

In most people with relapsing-remitting MS, the diagnosis is fairly straightforward and based on a pattern of symptoms consistent with the disease and confirmed by brain imaging scans, such as MRI. Diagnosing MS can be more difficult in persons with unusual symptoms or progressive disease. In these cases, further testing with spinal fluid analysis, evoked potentials and additional imaging may be needed.

Treatment There is no cure for multiple sclerosis. Treatment typically focuses on speeding recovery from attacks, slowing the progression of the disease and managing MS symptoms. Some people have such mild symptoms that no treatment is necessary. Treatments for MS attacks

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Corticosteroids, such as oral prednisone and intravenous methylprednisolone, are prescribed to reduce nerve inflammation. Side effects may include insomnia, increased blood pressure, mood swings and fluid retention.

Indication: Corticosteroids (cortisone-like medicines) are used to provide relief for inflamed areas of the body. They lessen swelling, redness, itching, and allergic reactions. They are often used as part of the treatment for a number of different diseases, such as severe allergies or skin problems, asthma, or arthritis.

Nursing consideration: 

Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then mixed with a protein solution (albumin) and put back into your body. Plasma exchange may be used if your symptoms are new, severe and haven't responded to steroids.

Treatments to modify progression For primary-progressive MS, ocrelizumab (Ocrevus) is the only FDA-approved diseasemodifying therapy. It slows worsening of disability in people with this type of MS. For relapsing-remitting MS, several disease-modifying therapies are available. Much of the immune response associated with MS occurs in the early stages of the disease. Aggressive treatment with these medications as early as possible can lower the relapse rate and slow the formation of new lesions. Many of the disease-modifying therapies used to treat MS carry significant health risks. Selecting the right therapy for you will depend on careful consideration of many factors, including duration and severity of disease, effectiveness of previous MS treatments, other health issues, cost, and child-bearing status. Treatment options for relapsing-remitting MS include: 

Beta interferons. These medications are among the most commonly prescribed medications to treat MS. They are injected under the skin or into muscle and can reduce the frequency and severity of relapses.

Side effects of beta interferons may include flu-like symptoms and injection-site reactions. You'll need blood tests to monitor your liver enzymes because liver damage is a possible side effect of interferon use. People taking interferons may develop neutralizing antibodies that can reduce drug effectiveness. 

Ocrelizumab (Ocrevus). This humanized immunoglobulin antibody medication is the only DMT approved by the FDA to treat both the relapse-remitting and primary progressive forms of MS. Clinical trials showed it reduced relapse rate in relapsing disease and slowed worsening of disability in both forms of the disease. Ocrevus is given via an intravenous infusion by a medical professional. Side effects may infusion-related reactions including irritation at the injection site, low blood pressure, fever, and nausea among others. Ocrevus may also increase the risk of some types of cancer, particularly breast cancer.

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Glatiramer acetate (Copaxone). This medication may help block your immune system's attack on myelin and must be injected beneath the skin. Side effects may include skin irritation at the injection site.

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Dimethyl fumarate (Tecfidera). This twice-daily oral medication can reduce relapses. Side effects may include flushing, diarrhea, nausea and lowered white blood cell count.

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Fingolimod (Gilenya). This once-daily oral medication reduces relapse rate. You'll need to have your heart rate monitored for six hours after the first dose because your heartbeat may be slowed. Other side effects include headache, high blood pressure and blurred vision.

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Teriflunomide (Aubagio). This once-daily medication can reduce relapse rate. Teriflunomide can cause liver damage, hair loss and other side effects. It is harmful to a developing fetus and should not be used by women who may become pregnant and are not using appropriate contraception, or their male partner.

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Natalizumab (Tysabri). This medication is designed to block the movement of potentially damaging immune cells from your bloodstream to your brain and spinal cord. It may be considered a first line treatment for some people with severe MS or as a second line treatment in others. This medication increases the risk of a viral infection of the brain called progressive multifocal leukoencephalopathy in some people.

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Alemtuzumab (Lemtrada). This drug helps reduce relapses of MS by targeting a protein on the surface of immune cells and depleting white blood cells. This effect can limit potential nerve damage caused by the white blood cells, but it also increases the risk of infections and autoimmune disorders. Treatment with alemtuzumab involves five consecutive days of drug infusions followed by another three days of infusions a year later. Infusion reactions are common with alemtuzumab. The drug is only available from registered providers, and people treated with the drug must be registered in a special drug safety monitoring program.

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Mitoxantrone. This immunosuppressant drug can be harmful to the heart and is associated with development of blood cancers. As a result, its use in treating MS is extremely limited. Mitoxantrone is usually used only to treat severe, advanced MS.

Treatments for MS signs and symptoms 

Physical therapy. A physical or occupational therapist can teach you stretching and strengthening exercises and show you how to use devices to make it easier to perform daily tasks. Physical therapy along with the use of a mobility aid when necessary can also help manage leg weakness and other gait problems often associated with MS.

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Muscle relaxants. You may experience painful or uncontrollable muscle stiffness or spasms, particularly in your legs. Muscle relaxants such as baclofen (Lioresal) and tizanidine (Zanaflex) may help.

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Medications to reduce fatigue.

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Other medications. Medications also may be prescribed for depression, pain, sexual dysfunction, and bladder or bowel control problems that are associated with MS.

Myasthenia Gravis Myasthenia Gravis is characterized by weakness and rapid fatigue of any of the muscles under your voluntary control. Myasthenia gravis is caused by a breakdown in the normal communication between nerves and muscles.

There is no cure for myasthenia gravis, but treatment can help relieve signs and symptoms, such as weakness of arm or leg muscles, double vision, drooping eyelids, and difficulties with speech, chewing, swallowing and breathing. Though myasthenia gravis can affect people of any age, it's more common in women younger than 40 and in men older than 60.

Symptoms Muscle weakness caused by myasthenia gravis worsens as the affected muscle is used repeatedly. Because symptoms usually improve with rest, your muscle weakness may come and go. However, myasthenia gravis symptoms tend to progress over time, usually reaching their worst within a few years after the onset of the disease. Although myasthenia gravis can affect any of the muscles that you control voluntarily, certain muscle groups are more commonly affected than others. Eye muscles In more than half the people who develop myasthenia gravis, their first signs and symptoms involve eye problems, such as: Drooping of one or both eyelids (ptosis). Double vision (diplopia), which may be horizontal or vertical, and improves or resolves when one eye is closed. Face and throat muscles In about 15 percent of people with myasthenia gravis, the first symptoms involve face and throat muscles, which can cause: Altered speaking. Your speech may sound very soft or nasal, depending upon which muscles have been affected. Difficulty swallowing. You may choke very easily, which makes it difficult to eat, drink or take pills. In some cases, liquids you're trying to swallow may come out your nose. Problems chewing. The muscles used for chewing may wear out halfway through a meal, particularly if you've been eating something hard to chew, such as steak. Limited facial expressions. Your family members may comment that you've "lost your smile" if the muscles that control your facial expressions have been affected. Neck and limb muscles

Myasthenia gravis can cause weakness in your neck, arms and legs, but this usually happens along with muscle weakness in other parts of your body, such as your eyes, face or throat. The disorder usually affects arms more often than legs. However, if it affects your legs, you may waddle when you walk. If your neck is weak, it may be hard to hold up your head.

Diagnosis To diagnose your condition, your doctor will review your symptoms and your medical history and conduct a physical examination. Your doctor may conduct several tests, including: Neurological examination Your doctor may check your neurological health by testing your: 

Reflexes

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Muscle strength

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Muscle tone

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Senses of touch and sight

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Coordination

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Balance

The key sign that points to the possibility of myasthenia gravis is muscle weakness that improves with rest. Tests to help confirm the diagnosis may include: Edrophonium test Injection of the chemical edrophonium chloride (Tensilon) may result in a sudden, although temporary, improvement in your muscle strength. This is an indication that you may have myasthenia gravis.

Edrophonium chloride blocks an enzyme that breaks down acetylcholine, the chemical that transmits signals from your nerve endings to your muscle receptor sites. Ice pack test If you have a droopy eyelid, your doctor may conduct an ice pack test. In this test, a doctor places a bag filled with ice on your eyelid. After two minutes, your doctor removes the bag and analyzes your droopy eyelid for signs of improvement. Doctors may conduct this test instead of the edrophonium test. Blood analysis A blood test may reveal the presence of abnormal antibodies that disrupt the receptor sites where nerve impulses signal your muscles to move. Repetitive nerve stimulation In this nerve conduction study, doctors attach electrodes to your skin over the muscles to be tested. Doctors send small pulses of electricity through the electrodes to measure the nerve's ability to send a signal to your muscle. To diagnose myasthenia gravis, doctors will test the nerve many times to see if its ability to send signals worsens with fatigue. Single-fiber electromyography (EMG) Electromyography (EMG) measures the electrical activity traveling between your brain and your muscle. It involves inserting a fine wire electrode through your skin and into a muscle to test a single muscle fiber. Imaging scans Your doctor may order a CT scan or an MRI to check if there's a tumor or other abnormality in your thymus.

Pulmonary function tests Your doctor may perform pulmonary function tests to evaluate whether your condition is affecting your breathing.

Treatment Doctors use a variety of treatments, alone or in combination, to relieve symptoms of myasthenia gravis.

Medications 

Cholinesterase inhibitors. Medications such as pyridostigmine (Mestinon) enhance communication between nerves and muscles. These medications don't cure the underlying condition, but they may improve muscle contraction and muscle strength. Possible side effects may include gastrointestinal upset, nausea, and excessive salivation and sweating.

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Corticosteroids. Corticosteroids such as prednisone inhibit the immune system, limiting antibody production. Prolonged use of corticosteroids, however, can lead to serious side effects, such as bone thinning, weight gain, diabetes and increased risk of some infections.

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Immunosuppressants. Your doctor may also prescribe other medications that alter your immune system, such as azathioprine (Imuran), mycophenolate mofetil (CellCept), cyclosporine (Sandimmune, Neoral), methotrexate (Trexall) or tacrolimus (Prograf). Side effects of immunosuppressants can be serious and may include nausea, vomiting, gastrointestinal upset, increased risk of infection, liver damage and kidney damage.

Intravenous therapy 

Plasmapheresis (plaz-muh-fuh-REE-sis). This procedure uses a filtering process similar to dialysis. Your blood is routed through a machine that removes the antibodies that block transmission of signals from your nerve endings to your muscles' receptor sites. However, the beneficial effects usually last only a few weeks. After repeated treatments, it may be difficult for doctors to gain access to your vein. They may need to implant a long, flexible tube (catheter) into your chest to conduct the procedure.

Other risks associated with plasmapheresis include a drop in blood pressure, bleeding, heart rhythm problems or muscle cramps. Some people may also develop an allergic reaction to the solutions used to replace the plasma. 

Intravenous immunoglobulin (IVIg). This therapy provides your body with normal antibodies, which alters your immune system response. IVIg has a lower risk of side effects than do plasmapheresis and immune-suppressing therapy. However, it may take about a week to start working, and the benefits usually last no more than three to six weeks. Side effects, which usually are mild, may include chills, dizziness, headaches and fluid retention.

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Monoclonal antibody. Rituximab (Rituxan) is an intravenous medication that is used in some cases of myasthenia gravis. This drug depletes certain white blood cells, altering the immune system and improving myasthenia gravis. Rituximab is usually given in infusions at an infusion center or done in a hospital on an outpatient basis. Repeat infusions are often done over a few weeks. Occasionally the infusions are repeated months later.

Surgery About 15 percent of the people with myasthenia gravis have a tumor in their thymus gland, a gland under the breastbone that is involved with the immune system. If you have a tumor, called a thymoma, doctors will conduct surgery to remove your thymus gland (thymectomy). If you don't have a tumor in the thymus gland, surgery to remove the thymus gland may improve your myasthenia gravis symptoms. It may eliminate your symptoms, and you may be able to stop taking medications for your condition. However, you may not notice the benefits of a thymectomy for several years, if at all. A thymectomy may be performed as an open surgery or as a minimally invasive surgery. In an open surgery, your surgeon splits the central breast bone (sternum) to open your chest and remove your thymus gland. Surgeons may perform minimally invasive surgery to remove the thymus gland, which uses smaller incisions. Minimally invasive thymectomy may include:

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Video-assisted thymectomy. In one form of this surgery, surgeons make a small incision in your neck and use a long thin camera (video endoscope) and small instruments to visualize and remove the thymus gland through your neck. Alternatively, surgeons may make a few small incisions in the side of your chest. Doctors use a video scope and small instruments to conduct the procedure and remove the thymus gland through these incisions.

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Robot-assisted thymectomy. In a robot-assisted thymectomy, surgeons make several small incisions in the side of your chest. Surgeons conduct the procedure to remove the thymus gland using a robotic system, which includes a camera arm and mechanical arms.

Guillain-Barre syndrome Guillain-Barre is a rare disorder in which your body's immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms. These sensations can quickly spread, eventually paralyzing your whole body. In its most severe form Guillain-Barre syndrome is a medical emergency. Most people with the condition must be hospitalized to receive treatment. The exact cause of Guillain-Barre syndrome is unknown. But it is often preceded by an infectious illness such as a respiratory infection or the stomach flu. There's no known cure for Guillain-Barre syndrome, but several treatments can ease symptoms and reduce the duration of the illness. Most people recover from Guillain-Barre syndrome, though some may experience lingering effects from it, such as weakness, numbness or fatigue.

Symptoms Guillain-Barre syndrome often begins with tingling and weakness starting in your feet and legs and spreading to your upper body and arms. In about half of people with the disorder, symptoms begin in the arms or face. As Guillain-Barre syndrome progresses, muscle weakness can evolve into paralysis. Signs and symptoms of Guillain-Barre syndrome may include:

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Prickling, pins and needles sensations in your fingers, toes, ankles or wrists

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Weakness in your legs that spreads to your upper body

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Unsteady walking or inability to walk or climb stairs

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Difficulty with eye or facial movements, including speaking, chewing or swallowing

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Severe pain that may feel achy or cramplike and may be worse at night

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Difficulty with bladder control or bowel function

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Rapid heart rate

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Low or high blood pressure

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Difficulty breathing

People with Guillain-Barre syndrome usually experience their most significant weakness within two to four weeks after symptoms begin.

Types Once thought to be a single disorder, Guillain-Barre syndrome is now known to occur in several forms. The main types are: 

Acute inflammatory demyelinating polyradiculoneuropathy (AIDP), the most common form in the U.S. The most common sign of AIDP is muscle weakness that starts in the lower part of your body and spreads upward.

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Miller Fisher syndrome (MFS), in which paralysis starts in the eyes. MFS is also associated with unsteady gait. MFS occurs in about 5 percent of people with Guillain-Barre syndrome in the U.S. but is more common in Asia.

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Acute motor axonal neuropathy (AMAN) and acute motor-sensory axonal neuropathy (AMSAN) are less common in the U.S. But AMAN and AMSAN are more frequent in China, Japan and Mexico.

Diagnosis Guillain-Barre syndrome can be difficult to diagnose in its earliest stages. Its signs and symptoms are similar to those of other neurological disorders and may vary from person to person.

Your doctor is likely to start with a medical history and thorough physical examination. Your doctor may then recommend: 

Spinal tap (lumbar puncture). A small amount of fluid is withdrawn from the spinal canal in your lower back. The fluid is tested for a type of change that commonly occurs in people who have Guillain-Barre syndrome.

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Electromyography. Thin-needle electrodes are inserted into the muscles your doctor wants to study. The electrodes measure nerve activity in the muscles.

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Nerve conduction studies. Electrodes are taped to the skin above your nerves. A small shock is passed through the nerve to measure the speed of nerve signals.

Treatment There's no cure for Guillain-Barre syndrome. But two types of treatments can speed recovery and reduce the severity of the illness: 

Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then put back into your body, which manufactures more plasma to make up for what was removed. Plasmapheresis may work by ridding plasma of certain antibodies that contribute to the immune system's attack on the peripheral nerves.

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Immunoglobulin therapy. Immunoglobulin containing healthy antibodies from blood donors is given through a vein (intravenously). High doses of immunoglobulin can block the damaging antibodies that may contribute to Guillain-Barre syndrome.

These treatments are equally effective. Mixing them or administering one after the other is no more effective than using either method alone. You also are likely to be given medication to: 

Relieve pain, which can be severe

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Prevent blood clots, which can develop while you're immobile

People with Guillain-Barre syndrome need physical help and therapy before and during recovery. Your care may include:

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Movement of your arms and legs by caregivers before recovery, to help keep your muscles flexible and strong

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Physical therapy during recovery to help you cope with fatigue and regain strength and proper movement

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Training with adaptive devices, such as a wheelchair or braces, to give you mobility and self-care skills