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Case 6: Multiple Sclerosis By Armani Disclaimer Disclaimer: The teaching provided in this session is for revision purposes only and is based on UK medical guidelines. It is not endorsed by any medical school and does not replace the teaching provided your medical school curriculum and should not be used as a resource, guideline, or reference for clinical practice or decision making. Overview - Cellular composition of the CNS – Glia - Multiple sclerosis (MS): Overview - MS: Pathophysiology - MS: Disease patterns - MS: Diagnosis - MS: Treatment - Disease Modifying Therapy - Depression - Depression: Treatment - Mental Capacity Act 2005 - Coping: Approach vs Avoidance - Coping: Emotion - focused vs Problem- focused - Questions ILOs ● To apply their knowledge of the Mental Capacity Act and how it can be used to help support patients to prepare for their demise through Advanced Care Planning & Advanced Decisions. ● To demonstrate knowledge of neuronal structure and function including the propagation and conduction of action ● To demonstrate knowledge of problem and emotion focused coping ● To demonstrate knowledge of the basic clinical features of depressive disorder and its treatment by psychological and drug therapies ● To demonstrate knowledge of the brainstem (emphasising cranial nerves) ● To demonstrate knowledge of the cellular composition of the CNS ● To demonstrate knowledge of the epidemiology of multiple sclerosis ● To demonstrate knowledge of the pathological process involved in demyelination ● To demonstrate knowledge of the psychological concept of coping ● To demonstrate knowledge of the structural and functional organisation of sensory and motor pathways to and from the cerebral cortex ● To demonstrate knowledge of the structure and functional organisation of the midbrain, pons and cerebellum ● refusing treatment versus demanding treatment.both supporting and hindering choices, at the end of life eg patients ● To describe the importance of talking to patients about their death and discuss their views and feelings around this. ● To describe the ways in which a doctor must act in order to meet their legal obligations when supporting patients at the end of their lives. ● To understand the basic mechanisms of action of antidepressant drugs, including SSRIs, SNRIs, tricyclics and MAOIs Cellular composition of the CNS - Glia - Two main types of Cells – Glia and Neurons - Glial cells split into microglia and macroglia (Astrocytes, Oligodendrocyte and Schwann cell) - CNS - Blood-brain barrier - CNS Macrophages - CNS Myelin - PNS Myelin - First line of defense - Insulates axons and - Insulates axons and - Regulate - Phagocytosis faster conduction faster conduction neurotransmitters - Synchronizing axon activity Multiple Sclerosis - Chronic and progressive autoimmune condition - Demyelination and Inflammation in the CNS - Affects oligodendrocytes - Epidemiology: Under 50s and more common in women - Signs/symptoms: most common is optic neuritis - Also fatigue, numbness and tingling, loss of balance, stiffness or spasms, tremor, bladder urgency Multiple Sclerosis: Pathophysiology - Inflammation due to blood brain barrier being compromised causing infiltration of T- cells that attack the myelin sheaths of the CNS - Demyelination: - Relapse – T lymphocytes cannot distinguish between normal and foreign oligodendrocytes and thus attack the healthy cells - Remission – Oligodendrocytes cannot completely remyelinate or repair a destroyed myelin sheath so newly formed myelin is thinner - Plaques (lesions on MRI) can be active or inactive Multiple Sclerosis: Disease patterns - 4 patterns - Clinically isolated syndrome – may never develop MS - Relapsing – remitting - Active (new symptoms of lesions) or Worsening (is disability getting worse over time?) - Secondary progressive – progressive worsening of symptoms with incomplete remission - Primary progressive – worsening symptoms from diagnosis without relapse or remission Diagnosis - Neurological examination – changes in vision, limb strength, balance, coordination and reflexes - MRI scan – detect lesions - Evoked potentials test - detect slowing of electrical conduction - Lumbar puncture – detection of oligoclonal bands in CSF Treatment - No cure but medication to help control and ease symptoms - Vitamin D3 supplements and 5 day course of steroids ( methylprednisolone 500mg daily for 5 days after relapse) - Disease modifying therapy: - Initial therapy would be interferon beta and glatiramer acetate - Initial therapy in highly active or resistant MS would be natalizumab and fingolimod Disease Modifying therapy Drug MOA AIM Interferon Beta (injection) Inhibiting T cell activation, Reduce relapse and prevents new proliferation and migration lesions from forming Glatiramer acetate (injection) Immunomodulator. Not entirely Reduce frequency of relapse sure but thought to MHC class 2 molecules to prevent other antigens from binding Natalizumab (injection) Monoclonal antibody which inhibits Reduce relapse rate and slows migration of leucocytes into the down worsening of disability over CNS. Prevents binding of time lymphocytes to vascular endothelium via α4β1 ligands Fingolimod (tablet) sphingosine 1-phosphate receptor Reduce relapse rate and slows modulator. Binds to sphingosine 1- down worsening of disability over phosphate receptor 1 to reduce time lymphocyte migration to CNS Depression - Common mental disorder - Persistent feeling of sadness and loss of interest - Also sleep disturbances, lack of energy, reduced appetite, weight loss, trouble concentrating etc - Deficit in the concentration of the brain norepinephrine, dopamine, and/or serotonin resulting in depression - Antidepressant therapies focus on increasing the monoamine neurotransmitter levels within the synapses Depression: Treatment Drug Examples MOA When are they used? Selective- Serotonin fluoxetine, sertraline, Inhibit reuptake of First line – used for Reuptake Inhibitors paroxetine, fluvoxamine, serotonin by reversibly moderate to severe (SSRIs) escitalopram, citalopram blocking serotonin depression reuptake transporter Serotonin-Noradrenaline imipramine, venlafaxine Inhibit uptake of serotonin Used for moderate to Reuptake Inhibitors and noradrenaline by severe depression (SNRIs) blocking both reversibly reuptake transporters Tricyclic Antidepressants amitriptyline, Inhibit serotonin and Not as effective as SSRIs (TCAs) clomipramine noradrenaline reuptake and SNRIs and has more within the presynaptic side effects. Used if terminals so more SSRIs and SNRIs fail. available in synaptic cleft Monoamine-Oxidase Iproniazid, moclobemide inhibiting the activity Last line – due to too Inhibitors (MAOIs) of MA, thus preventing many interactions that the breakdown could be lethal of serotonin and noradrenaline Mental Capacity Act 2005 - Protect and empower people who lack to capacity to make decisions about their treatment - Based around 5 principles: - A presumption of capacity - The right for individuals to be supported to make their own decisions - right to make what might be seen as eccentric or unwise decisions - Best interests - Least restrictive intervention - Also deals with advance decisions Coping: Approach vs Avoidance - Leventhal’s self-regulatory model - Two types of coping – Approach and Avoidance Coping: Emotion- focused vs Problem – focused - “a person’s efforts to manage demands that are appraised as taxing or exceeding their resources” - Examples of emotion focused include letting out anger and frustration and emotional support seeking - Examples of problem-focused include planning and problem- solving - Problem – focused coping more effective Which cell type, found in the PNS, creates myelin? a. Astrocytes b. Schwann Cells c. Microglia d. Oligodendrocytes e. NeuronsWhich cell type forms the blood brain barrier in the CNS ? a. Astrocytes b. Schwann Cells c. Microglia d. Oligodendrocytes e. NeuronsWhich pattern of MS results in progressive worsening of symptoms with incomplete remission? a. Primary progressive b. Relapsing – remitting c. Secondary progressive d. Clinically isolated syndrome Which disease modifying therapy drug is an immunomodulator ? a. Interferon Beta b. Glatiramer acetate c. Natalizumab d. Fingolimod e. Methylprednisolone Which drugs are given via injection? a. Only Interferon Beta, Glatiramer acetate b. Only Interferon Beta, Glatiramer acetate and Natalizumab c. Only Fingolimod and Natalizumab d. Only Fingolimod e. Only interferon Beta Which enzyme breaks down serotonin and noradrenaline? a. Lipase b. Catechol-O-methyl transferase c. Monoamine- oxidase A d. Monoamine – oxidase BWhat is the first line treatment for moderate to severe depression? a. MAOIs b. SNRIs c. SSRIs d. TCAs