Deterioration in the health-related quality of life of persons with multiple sclerosis: the possible warning signs.

Baseline data from a population-based study examining the health-related quality of life (HRQL) of MS patients about to begin disease modifying therapy was used to determine the factors associated with the HRQL of Saskatchewan adults with relapsing-remitting MS. Participants completed a self-report questionnaire regarding demographic and socioeconomic status, fatigue, comorbid medical conditions, disability level (EDSS), number of attacks in past 6 months, illness intrusiveness (Illness Intrusiveness Ratings Scale), depression (Beck Depression Inventory), and HRQL (SF-36 Health Status Survey). Multiple linear regression models were used to identify the factors associated with the physical and mental health summary scores of the SF-36. We found poorer physical HRQL in those who are female; older; not working; have musculoskeletal or respiratory problems; greater fatigue, higher disability scores, and more MS attacks. High illness intrusiveness; digestive system problems; genitourinary problems; and headaches were associated with poorer mental HRQL. Interestingly, we found an interaction between sex and age in mental HRQL, with worse mental health in older men but better mental health in older women. These findings may assist health care providers in identifying patients who may be at risk for decline in their HRQL, permitting appropriate and timely interventions.

Intratumoral therapy with bleomycin for cystic craniopharyngiomas in children.

Surgical removal of cystic craniopharyngiomas in children is associated with significant operative morbidity and recurrence rates. The purpose of this study was to review our experience with a less invasive therapy, namely, intratumoral bleomycin, in the treatment of predominantly cystic craniopharyngiomas. All children with craniopharyngiomas treated at a tertiary care pediatric neurosurgical center since 1994, when bleomycin was first used, were reviewed retrospectively. Seven patients received intratumoral bleomycin therapy. Patients received 2-5 mg bleomycin per dose, 3 times per week, for 3-5 weeks as an initial course. Mean follow-up of these patients was 3 years. In 4 patients, treatment resulted in a significant decrease (>50%) in tumor size, which has remained stable. Two patients' tumors progressed and underwent resection, and 1 patient had surgical removal because of persistent headaches, although no growth of residual tumor had been noted. One patient developed peritumoral edema as a result of bleomycin therapy. Intratumoral bleomycin is a useful alternative therapy for cystic craniopharyngiomas, and may control tumor growth and delay potentially harmful resection and/or radiotherapy in young children.

The value of routine cultures of the cerebrospinal fluid in patients with external ventricular drains.

OBJECTIVE: The purpose of this study was to determine whether routine cerebrospinal fluid (CSF) bacteriological cultures in patients with external ventricular drains (EVDs) can identify infections early and prevent complications related to bacterial ventriculitis. METHODS: We retrospectively reviewed the microbiological reports and clinical data for all patients in whom an EVD was placed at a tertiary care pediatric neurosurgical center between 1984 and 1997. EVDs were inserted in the operating room or intensive care unit, and, in most patients whose EVD remained in place for more than 2 days, daily cultures of CSF were performed. RESULTS: One hundred fifty-seven patients in whom 160 EVDs had been placed were included in the study. Forty-eight positive cultures were identified, of which the majority were determined to be contaminants. Seven infections were identified on the basis of microbiological criteria (i.e., a gram-positive stain and positive culture) and a subsequent positive culture. In all patients in whom infections developed, routine daily cultures of CSF were performed, and, in each instance, these cultures failed to identify the infections before clinical changes occurred. All seven patients with infection had fever (>38.5 degrees C) and peripheral leukocytosis (>11 x 10(3)/mm3) on the day the infection was identified, and one had a change in CSF appearance. CONCLUSION: The results of this study suggest that routine culture of CSF in children with EVDs is not necessary, and that if CSF cultures are performed for new fever (>38.5 degrees C) or peripheral leukocytosis, neurological deterioration, or a change in CSF appearance, infections will be identified in a timely fashion. In situations in which these clinical indicators might be masked, routine cultures may be valuable.

Giant intraspinal pseudomeningoceles cause delayed neurological dysfunction after brachial plexus injury: report of three cases.

OBJECTIVE AND IMPORTANCE: Delayed neurological dysfunction after a brachial plexus injury is uncommon. We present the cases of three patients with a history of significant brachial plexus trauma and late neurological deterioration secondary to giant intraspinal extradural pseudomeningoceles. CLINICAL PRESENTATION: Three patients, each with a remote history of brachial plexus trauma, presented with slowly progressive upper-limb weakness. An examination revealed bilateral lower motor neuron weakness in the upper extremities in all patients and evidence of spastic paraparesis in one. Magnetic resonance imaging and postmyelogram computed tomographic scans demonstrated large anterior extradural cerebrospinal fluid collections extending from the upper cervical to lower thoracic and lumbar levels in each patient. Myelograms demonstrated a connection with the subarachnoid space in two patients. INTERVENTION: Direct obliteration of the connection between the cyst and the subarachnoid space was completed in two patients, and a cystoperitoneal shunt was placed in the third. Postoperative imaging demonstrated complete resolution of the extradural collections. Arrest of progression of upper-limb deterioration was observed in all patients, and dramatic improvement of long tract symptoms occurred in one. CONCLUSION: Giant intraspinal pseudomeningoceles are a rare complication of brachial plexus root injuries or avulsion, capable of causing significant morbidity. Early intervention can improve symptoms related to long tract involvement and prevent further deterioration of lower motor neuron disease. The pathophysiology of neurological dysfunction caused by these giant collections is unclear; however, vascular and mechanical factors thought to be important in the pathogenesis of cervical myelopathy also may have a role.

Intramedullary spinal teratoma and diastematomyelia. Case report and review of the literature.

The authors present a patient with diastematomyelia and a spinal intramedullary teratoma, remote from the split cord malformation. A split cord malformation at the L2-L3 level was initially discovered during investigations for thoracic congenital scoliosis, and this was treated surgically. The teratoma, which was at the level of the scoliosis, went undiagnosed until neurological deterioration occurred many years later. Surgical removal of the teratoma resulted in return to normal function. The potential for coexisting congenital anomalies at separate levels of the spinal cord must be considered in radiological investigations of a developmental spinal lesion.

The Mayo Clinic-Canadian Cooperative trial of sulfasalazine in active multiple sclerosis.

OBJECTIVE: To determine whether sulfasalazine is better than placebo in slowing disability progression in MS. METHODS: In this randomized, double-blind, placebo-controlled phase III trial, 199 patients with active relapsing-remitting (n = 151) or progressive (n = 48) MS were evaluated at 3-month intervals for a minimum of 3 years (94% completed 3 years of follow-up; mean follow-up, 3.7 years). MRI studies were performed at 6-month intervals on a subset of 89 patients. RESULTS: Sulfasalazine failed to slow or prevent disability progression as measured by the primary outcome (confirmed worsening of the Expanded Disability Status Scale [EDSS] score by at least 1.0 point on two consecutive 3-month visits). Sulfasalazine influenced favorably a number of secondary outcomes during the first 18 months of the trial (e.g., annualized relapse rate, proportion of relapse-free patients; progressive subgroup only: rate of EDSS progression at 1 and 2 years, median time to EDSS progression) but these positive findings were not sustained into the second half of the trial. CONCLUSIONS: Sulfasalazine does not prevent EDSS score progression in the subset of MS patients studied by this protocol. Treatments may improve relapse-related outcomes in MS, at least temporarily, without providing sustained slowing of EDSS progression. Phase III MS trials should be of sufficient length to determine a meaningful impact on disease course.

The occurrence of multiple sclerosis in the Hutterites of North America.

OBJECTIVE: To report the occurrence, clinical characteristics and genealogical analysis of multiple sclerosis in the Hutterites of North-Western United States and Western Canada. BACKGROUND: The incidence of multiple sclerosis is reported to be lower or rare in certain ethnic groups and genetic isolates and was previously observed to be absent in the Hutterite population. METHODS: After long-term surveillance, six patients were identified and clinical examinations and laboratory investigations including VER and MRI were completed. RESULTS: The six cases included two brothers, two first cousins, male and female, another male and female, all representing two of the three endogamous groups of Hutterites, are linked to two common ancestors through lines of descent dating to 1723. The individual pedigrees were analyzed from extensive genealogical records covering eight generations. CONCLUSION: The incidence of multiple sclerosis in Hutterites is low in a high risk area of North America. A specific mode of inheritance pattern has not been established and a common founder effect may play a role in the development of multiple sclerosis. The genetic contribution of the Hutterites seems greater than previously recognized.

A cluster-focus of multiple sclerosis at Henribourg, Saskatchewan.

This study presents the clinical characteristics of 8 victims of multiple sclerosis from the hamlet of Henribourg, Saskatchewan with a population of less than 75 people. A diligent victim of the disease had observed that six female classmates from the early 1940's had later developed multiple sclerosis. Two male military personnel who had also resided briefly in close proximity, during the same common exposure time, also later developed multiple sclerosis. The mean onset time of developing the disease after leaving the area was 20 years. This cluster-focus suggests a common exposure to an environmental factor or a common infective agent in the etiology of multiple sclerosis.

Geotoxicology of multiple sclerosis: the Henribourg, Saskatchewan, Cluster Focus. I. The water.

Some childhood-related, geographically-linked factor predisposes towards (or protects against) multiple sclerosis (MS). It is quite plausible that this factor could be one or more chemicals in the environment, and that chemical study of the environment or "focus" of an MS cluster might maximize the chances of detecting such an etiological link. The water chemistry of such a focus (Henribourg, Saskatchewan) was compared with North American norms, and with the chemistry of water from a nearby control area with a near-zero incidence of MS and of childhood homes of MS cases. Overall, the results suggest that an environment predisposing to MS may have a number of water chemistry characteristics such as: relative deficiency of selenium and sulfate, but relative abundance of barium, calcium, chloride, chromium, magnesium, manganese, molybdenum, nitrate plus nitrite, strontium and zinc. Possible explanations for the apparent link between the excess rate of MS and the water geochemistry findings at Henribourg are discussed.

Geotoxicology of multiple sclerosis: the Henribourg, Saskatchewan, cluster focus. II. The soil.

The childhood-related, geographically-linked factor which predisposes towards (or protects against) multiple sclerosis (MS) could be one or more chemicals in the environment. Chemical study of the environment or "focus" of an MS cluster may maximize the chances of detecting such an etiological link. The soil chemistry of an MS focus (Henribourg, Saskatchewan) was compared with North American norms, and with the chemistry of soil from a nearby control area with a near-zero incidence of MS and of childhood homes of MS cases. A combination of our present results with those reported in the literature suggests that an environment predisposing to MS may have a number of the following chemical characteristics: Calcareous; with soils (but not necessarily waters) generally low in copper, iron and vanadium; with excess lead, nickel and zinc in the upper soil layer; with waters relatively high in chloride, chromium, molybdenum, nitrate plus nitrite, and zinc; but low in selenium and sulfate. One possible causal pathway to explain the apparent link between the excess rate of MS and some of the curious geochemical findings at Henribourg is presented. Many other possible explanations could equally well be advanced, and methods for testing such alternative hypotheses are proposed.

Epidemiology of multiple sclerosis in London and Middlesex County, Ontario, Canada.

A case-controlled epidemiologic study of multiple sclerosis (MS) was carried out in London, Ontario, and its surrounding Middlesex County for the period 1974-1983. The prevalence rates for clinically definite/probable MS on January 1, 1984 were 94/100,000 for the city and 91/100,000 for the county. The estimated annual incidence rate for the decade 1974-83 was 3.4/100,000. The female-to-male sex ratio was 2.5:1. A familial history of MS was recorded in 14.4% of close relatives and a total of 17% when distant relatives are included. The MS group is predominantly of British (70%) and European (23%) origin. The urban-rural residence pattern analysis indicates no significant regional influence on the risk of developing MS.

The incidence of amyotrophic lateral sclerosis in southwestern Ontario, Canada.

The incidence, prevalence, and mortality rates of amyotrophic lateral sclerosis in southwestern Ontario, Canada, were determined for the years 1978 through 1982. The average annual incidence rate was 1.63 per 100,000 population. The prevalence rate was 4.9 per 100,000 on January 1, 1983. The average annual mortality rate was 1.52 per 100,000 population and increased with age, reaching a peak in the 70 to 79-year decade in both sexes. The male:female ratio was 1.2:1. The average age at diagnosis was 62.5 years, and the average duration from date of diagnosis was 2.5 years. The distribution of the disease was uneven in 12 counties, with the highest incidence in Perth (3.33) and Essex (2.43) counties. The city of Windsor, in an industrial region, had a high average annual incidence rate of 2.81.

The role of myo-inositol in multiple sclerosis.

Myo-inositol was given orally to nine multiple sclerosis patients and nine healthy control subjects. Pattern reversal evoked potential testing was used to assess its effect. The principal positive wave increased in amplitude, duration and area in a dose-dependent manner in the multiple sclerosis group compared with controls. Cerebrospinal fluid concentrations of myo-inositol in multiple sclerosis and controls were similar. The significance of these observations is discussed in relation to recent discoveries in inositol phospholipid function.

The concurrence of multiple sclerosis and amyotrophic lateral sclerosis.

We report the clinical and pathological findings of the unusual combination of two idiopathic central nervous system diseases, multiple sclerosis and amyotrophic lateral sclerosis in a 56 year old physician with a twenty-seven year history of a disease initially characterized by relapses and remissions, followed by an eight year quiescent period. During the last year of life there was rapid deterioration with development of generalized weakness, atrophy, weight loss and fasciculations of body and tongue, and associated difficulty with swallowing and sudden respiratory failure. The autopsy confirmed characteristic "burned out" plaques of multiple sclerosis and anterior horn cell and axonal degeneration of amyotrophic lateral sclerosis.

Adherent cells suppress measles and herpes simplex I virus-induced blastogenesis of multiple sclerosis lymphocytes.

Viral antigen-induced blastogenesis of lymphocytes from multiple sclerosis (MS) patients was investigated to determine if the responses were actively suppressed. We found that depletion of adherent cells increased measles and herpes simplex I virus antigen-induced transformation of MS lymphocytes. Addition of indomethacin to cultures of unfractionated MS lymphocytes also caused an increase in viral antigen-induced responses. These two facts, plus finding that the cell type mediating the immunosuppression did not rosette with 2-aminoethylisothiouronium bromide hydrobromide-treated sheep red blood cells, indicate that the suppressed T-cell responsiveness of MS patients is caused by macrophages rather than T-cells. These results have a major implication for the divergent published data on blastogenesis induced in MS patient lymphocytes by specific antigens, viral or otherwise. We feel the inconsistencies may simply have arisen from the different lymphocyte isolation and washing procedures used giving variable levels of macrophages and, hence, variable levels of immune suppression. This clearly suggests that induction of blastogenesis in MS patient lymphocytes by a wider array of infectious agent antigens and by various neural antigens should now be undertaken using adherent cell-depleted lymphocytes.

Multiple sclerosis: new techniques in earlier diagnosis.

Improved laboratory methods provide an objective means of evaluating the central nervous system, and give supporting evidence in the diagnosis of multiple sclerosis. Measurement of gamma globulins and identification of oligoclonal bands in the cerebrospinal fluid are reliable indicators. Visual, auditory, and sensory evoked responses reveal a high instance of abnormalities in MS, and may establish the existence of asymptomatic lesions, providing additional evidence in early cases. The enhanced CT scan detects cerebral lesions consistent with the diagnosis. The laboratory methods are incorporated in the new classification and diagnostic criteria of multiple sclerosis.

Prevalence of multiple sclerosis in Saskatoon.

In an epidemiologic survey based on a search of all available medical records for 1955 to 1980 at the city's three general hospitals the prevalence in Saskatoon of probable multiple sclerosis was found to be 111/100,000 and that of combined probable and possible multiple sclerosis 134/100,000 on Jan. 1, 1977. The average annual incidence over the three decades was 4.8/100,000. These prevalence and incidence rates were two to three time greater than those reported for other Canadian cities. Of the 150 individuals with probable multiple sclerosis 87 were living in Saskatoon at the time of onset of the disease; thus, the prevalence of the disease among residents was 64/100,000. The prevalence was 77/100,000 among Saskatchewan-born residents, including those born in Saskatoon, and 48/100,000 among immigrants from other provinces and outside Canada.

Sports as a prescription.

Movement in all its forms has become important in the treatment of clinical problems. The physical, physiological, psychological, and social benefits of therapeutic exercise are well recorded. The prescription of a sport, a dynamic exercise with additional skills and an element of competition, can achieve a clinical objective during different phases of patient care, just as drugs are prescribed and regulated as to dosage. The prescription should fulfill the patient's individual needs and interests, and the ingredients should be adjusted and regulated according to the response.