The association between multiple sclerosis-related fatigue and balance as a function of central sensory integration

BACKGROUND

Fatigue and impaired upright postural control (balance) are the two most common complaints in persons with multiple sclerosis (MS), with limited evidence on how they are related.

OBJECTIVE

To examine the relationship between symptomatic fatigue and balance as a function of central sensory integration in persons with multiple sclerosis.

MATERIALS AND METHODS

Seventeen persons with relapsing-remitting MS were enrolled in this cross-sectional study. Primary measurements included fatigue (modified fatigue impact scale - MFIS); balance (dynamic posturography, sensory organization testing - SOT); and walking capacity (six-minute walk test - 6MWT).

RESULTS

Fatigue scores were significantly associated with balance: MFIS total (r=-0.78; p<0.001), physical subscale (r=-0.77; p<0.001), cognitive subscale (r=-0.75; p=0.001) and psychosocial subscale (r=-0.53; p=0.030) scores. MFIS total score was a significant predictor of balance (p≤0.001), accounting for 62% of the variability in SOT composite scores. Significant differences in fatigue (d=1.75; p=0.005) and balance (d=1.74; p=0.005) were found for participants who had cerebellar and brainstem involvement compared to those without.

CONCLUSIONS

Symptomatic fatigue is significantly related to balance and is a significant predictor of balance as a function of central sensory integration in persons with MS. Fatigue and balance are associated with cerebellar and brainstem involvement. This study provides early evidence supporting the theory that for those persons with MS who struggle to maintain steady balance during tasks that stimulate the central sensory integration process, complaints of significant levels of fatigue are probable.

The differential diagnosis of Axis I psychopathology presenting to a university-based multiple sclerosis clinic

Patients carrying a presumptive diagnosis of multiple sclerosis (MS) sometimes present with non-specific clinical signs and symptoms that may be, at least in part, somatic manifestations of psychiatric conditions. This retrospective study was undertaken to identify psychiatric diagnoses among 63 patients whose initial clinical evaluations suggested a primary psychiatric, rather than a primary neurological, etiology for their symptoms. Some 92% of patients met Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) criteria for one or more primary psychiatric disorders, most often including somatoform, mood, and anxiety disorders. Accurate identification and diagnosis of psychiatric conditions producing pseudoneurological or non-specific somatic symptoms is necessary for both treatment and medico-economic reasons. Multiple Sclerosis 2007; 13: 749-753. http://msj.sagepub.com

Survey of training programs' means for promoting neurology and attracting trainees

OBJECTIVE

To determine neurology training opportunities available to medical students and to define factors that influence program choice.

METHODS

All neurology residency program directors and a random sample of residents were surveyed. Resident questions related to application, interview, and training experience. Directors' questions focused on ways their department generated interest in clinical neurosciences.

RESULTS

Medical schools introduce students to clinical neurology primarily through required clerkships. Contact time averages less than 4 weeks and emphasizes inpatient encounters. Preceptorships with neurology faculty do not exist at almost 40% of schools and only 14% have neuroscience tracks. Nearly all residency applicants matched their first or second choice. The majority declined at least one interview and 39% failed to rank at least one site they visited. When choosing where to apply, the programs' reputation and geographic considerations were paramount. When making a rank list, interactions with faculty and residents at interview were most important. Residents generally reported satisfaction with their programs and attribute morale to supportive relationships with faculty and residents.

CONCLUSIONS

Neurology programs may be able to enhance students' impression of neurology through changes in their clinical experience and development of venues for more meaningful relationships with faculty. Attention to the residents' personal needs may increase the likelihood of matching the best available candidates and ensuring their satisfaction.

The utility of MRI in suspected MS: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology

Advancements in imaging technologies and newly evolving treatments offer the promise of more effective management strategies for MS. Until recently, confirmation of the diagnosis of MS has generally required the demonstration of clinical activity that is disseminated in both time and space. Nevertheless, with the advent of MRI techniques, occult disease activity can be demonstrated in 50 to 80% of patients at the time of the first clinical presentation. Prospective studies have shown that the presence of such lesions predicts future conversion to clinically definite (CD) MS. Indeed, in a young to middle-aged adult with a clinically isolated syndrome (CIS), once alternative diagnoses are excluded at baseline, the finding of three or more white matter lesions on a T2-weighted MRI scan (especially if one of these lesions is located in the periventricular region) is a very sensitive predictor (>80%) of the subsequent development of CDMS within the next 7 to 10 years. Moreover, the presence of two or more gadolinium (Gd)-enhancing lesions at baseline and the appearance of either new T2 lesions or new Gd enhancement on follow-up scans are also highly predictive of the subsequent development of CDMS in the near term. By contrast, normal results on MRI at the time of clinical presentation makes the future development of CDMS considerably less likely.

HIV-1 LTR C/EBP binding site sequence configurations preferentially encountered in brain lead to enhanced C/EBP factor binding and increased LTR-specific activity

Recent studies have shown that two CAAT/enhancer binding protein (C/EBP) sites are critically important for efficient human immunodeficiency virus (HIV) type 1 (HIV-1) replication within cells of the monocyte/macrophage lineage, a primary cell type infected by HIV-1 and a potentially important vehicle for transport of virus to the central nervous system (CNS). Given the relevance of HIV-1 LTR sequence variation with respect to HIV-1 replication within monocyte populations and the important role that monocyte tropism likely plays in HIV-1 infection of the brain, C/EBP site sequence variation was examined within peripheral blood- and brain-derived LTR populations. Brain-derived LTRs commonly possessed a C/EBP site I configuration (6G, comprised of a thymidine to guanosine substitution with respect to the clade B consensus sequence at position 6 of C/EBP site I) that leads to enhanced binding of C/EBP proteins over that observed with the HIV-1 clade B consensus sequence at this site. In contrast, the 6GC/EBP site I configuration appeared infrequently within sequenced peripheral blood-derived LTRs. In addition, C/EBP site II was even more highly conserved in brain-derived HIV-1 LTR populations than site I. This was not the case with peripheral blood-derived LTR C/EBP site II sequences. The high degree of C/EBP site II conservation in brain-derived LTRs was likely important in LTR regulation since the clade B consensus sequence conserved at C/EBP site II recruited high amounts of C/EBP family members. Transient transfection analyses indicated that conservation of the strong C/EBP site II in brain-derived LTRs was likely due to important interactions with Tat. Overall, brain-derived HIV-1 LTRs preferentially contained two highly reactive C/EBP binding sites, which may suggest that these sites play important roles in LTR-directed transcription during invasion and maintenance of HIV-1 in the central nervous system.

Diffuse leptomeningeal gliomatosis associated with multifocal CNS infarcts

BACKGROUND

Widespread dissemination of astrocytoma throughout the cerebrospinal fluid is unusual, especially as the initial presentation in a patient, and association with cerebral infarcts is rare. CASE DESCRIPTION A 47-year-old man subacutely developed progressive headache and backache, vomiting, altered consciousness, and numbness in both arms. Brain computerized axial tomography showed calcification in the fourth ventricle and magnetic resonance imaging demonstrated diffuse meningeal enhancement, a lesion in the canal of Magendie, and T2-weighted hyperintense lesions in several locations. Angiography showed vasospasm/vasculopathy involving multiple cerebral vessels. Biopsy of the fourth ventricular mass revealed a subependymoma with an overlying leptomeningeal anaplastic astrocytoma with numerous Rosenthal fibers. The patient was treated with three doses of intrathecal methotrexate via lumbar puncture but suddenly became unresponsive and died 6 days later, 8 weeks after initial symptoms. Autopsy demonstrated the subependymoma and a widespread leptomeningeal anaplastic astrocytoma, which showed no clear-cut origin from the subependymoma, but microscopically infiltrated the left medial temporal lobe. Multiple subacute and acute infarcts of the brain, brain stem, and upper spinal cord were seen only in areas with leptomeningeal tumor. CONCLUSION Glioma cells surrounding and focally permeating central nervous system vessels without lumenal occlusion can lead to vasospasm and widespread infarcts.

Human herpesvirus 8 DNA in CNS lymphomas from patients with and without AIDS

BACKGROUND AND OBJECTIVE

Human herpesvirus 8 (HHV-8) has been found in association with Kaposi's sarcomas in human immunodeficiency virus (HIV)-positive and -negative patients, primary effusion lymphomas (PELs), multicentric Castleman's disease, and multiple myeloma. The PELs share several features with acquired immunodeficiency syndrome (AIDS)-associated primary central nervous system lymphomas (1 degree CNS-L), including B-cell phenotype, infection with Epstein-Barr virus, and lack of c-myc gene rearrangements. This prompted us to investigate the role of HHV-8 in 1 degree CNS-L and other brain lymphomas.

METHODS

To identify HHV-8, we performed nested and single polymerase chain reaction using DNA extracted from autopsy and biopsy brain lymphoma specimens of 36 patients with and without AIDS.

RESULTS

We detected HHV-8 DNA in 56% of all 1 degree CNS-L, with similar rates for patients with and without AIDS, but in just one of five metastatic B-cell lymphomas. Brain tissues histologically uninvolved by lymphoma were negative for HHV-8 in three patients in whom their 1 degree CNS-L was HHV-8 positive. In contrast, we easily demonstrated HHV-8 DNA in spleens and a KS lesion of patients with HHV-8-positive 1 degree CNS-L. All nonlymphoma brain controls were negative for HHV-8.

CONCLUSIONS

HHV-8 DNA is found in a significant percentage of 1 degree CNS-L, including patients with and without AIDS. Identification of HHV-8 in splenic tissue and absence of HHV-8 in control brain tissues suggests the possibility of a peripheral lymphocyte reservoir for HHV-8. Systemically infected lymphocytes may play a direct or indirect role in the pathogenesis of 1 degree CNS-L.

HIV-1 LTR DNA sequence variation in brain-derived isolates

Isolates of human immunodeficiency virus (HIV-1) derived from the central nervous system (CNS) display properties distinctive from blood-derived isolates, including a high incidence of macrophage tropism in CNS isolates. Macrophage tropism is a result, in part, of DNA sequence variation in the HIV-1 envelope glycoprotein gene, but evidence also exists suggesting differences in the long terminal repeat (LTR) may contribute to differential gene expression. To investigate the nature of HIV-1 LTR sequence variation in the brain, we have sequenced bases -374 to +43 of the LTR from the brains of four HIV-1-infected patients. A total of 56 clones were derived from either both gray and white matter (three brains) or white matter alone (one brain), and these sequences were compared to 17 published sequences derived from multiple sources. A total of five LTR quasispecies were found. Overall, there was a significant amount of sequence variation both within and between brains, comparable to that seen in quasispecies of the envelope glycoprotein derived from blood or brain. The vast majority of the variation was seen in regions upstream from the two NF-kappa B sites. Compared to the blood-derived, T cell-tropic IIIB LTR, a majority of clones from two or more of the brains shared 11 unique substitutions in transcription factor binding sites, of which eight were shared with the CNS-derived clones JR-CSF and JR-FL and altered the NF-AT and LEF-1 transcription factor binding sites. These findings correlate with published functional studies showing CNS-derived HIV-1 LTRs are distinct from the blood-derived IIIB LTR, and represent a starting point for future studies designed to determine which LTR sequence variations are associated with cell-specific differences in gene expression in the CNS.

Myelitis and toxic, inflammatory, and infectious disorders

Spinal epidural abscess is a rare infection that is usually treated with surgery and antibiotics. A small number of patients have been treated with medical therapy alone. We review several recent series of spinal epidural abscess and discuss the controversy surrounding the use of medical therapy alone. We also review recent clinical and pathogenetic data about human T-lymphotropic virus type 1 infection. The role of magnetic resonance imaging in the diagnosis of intramedullary spinal cord abscess, and methylprednisolone and cyclophosphamide treatment of transverse myelitis in systemic lupus erythematosus are also discussed briefly.

Expression directed from HIV long terminal repeats in the central nervous system of transgenic mice

Infection with the human immunodeficiency virus (HIV) is frequently accompanied by the AIDS (acquired immunodeficiency syndrome) dementia complex. The role of specific HIV genetic elements in the pathogenesis of central nervous system (CNS) disease is not clear. Transgenic mice were constructed that contained the long terminal repeats (LTRs) of two CNS-derived strains and a T cell tropic strain of HIV-1. Only mice generated with CNS-derived LTRs directed expression in the CNS, particularly in neurons. Thus, some strains of HIV-1 have a selective advantage for gene expression in the brain, and neurons can supply the cellular factors necessary for their transcription.

Familial cavernous angiomas manifesting with an acute chiasmal syndrome

We studied a family in which the proband had an acute chiasmal syndrome secondary to a cavernous angioma of the optic nerve and chiasm. A brain magnetic resonance imaging scan indicated additional asymptomatic intracerebral cavernous angioma, and several of the patient's relatives were found to have various central nervous system vascular malformations. Magnetic resonance imaging may distinguish, noninvasively, symptomatic and asymptomatic carriers of cavernous angiomas and further delineate their inheritance patterns. Asymptomatic cavernous angiomas of the central nervous system are best followed without intervention, whereas symptomatic patients should be treated on an individual basis, depending on the location of lesion and the risk of surgical removal.

Congestive cardiomyopathy in association with AIDS

During a 10-month period in 1985 and 1986, three cases of acquired immunodeficiency syndrome (AIDS) and a rapidly progressive fatal cardiomyopathy were encountered. All three patients originally presented with common opportunistic infections and later experienced marked congestive heart failure associated with echocardiographic and radiologic findings consistent with four-chamber cardiomyopathy. Diffuse cardiomyopathy was confirmed postmortem, but in each case a specific cause was not found.