Remote cognitive assessments for patients with multiple sclerosis: a feasibility study.

BACKGROUND: measuring cognitive function in patients with multiple sclerosis (MS) can be challenging given the obstacles faced when traveling to testing centers. OBJECTIVE: the purpose of this study was to evaluate the feasibility of remote cognitive assessment in patients with MS using the automated neuropsychological assessment metrics (ANAM-MS) and the symbol digit modalities test (SDMT). METHODS: patients meeting the McDonald criteria for MS (n = 24) were randomized to complete the live-in-office condition or a remote-in-office condition first, with all patients completing both sessions. Patients (n = 20) then completed a final remote-in-home testing session. Both remote sessions were proctored by a psychologist using a secure telehealth connection. RESULTS: scores on the live SDMT differed from scores in the two remote settings F(2, 38) = 4.46, p = 0.018. However, summary scores on the ANAM-MS were similar across the three settings, F(2, 36) = 2.21, p = 0.124. Satisfaction with telehealth testing was high on the part of the examiner and patients. Each telehealth testing session saved more than $144.00 in travel costs and lost wages. CONCLUSION: this study demonstrated that valid results can be obtained when evaluating patients remotely using ANAM-MS. Some differences were noted for the SDMT that suggest that either specific norms or a different implementation approach may be needed for telehealth.

Multiple sclerosis in gulf war era veterans. 2. Military deployment and risk of multiple sclerosis in the first gulf war.

BACKGROUND: Concern has been raised that US veterans of the 1990-1991 Gulf War (GW1) may be at increased risk to develop neurologic disease. METHODS: An incident cohort of multiple sclerosis (MS) and other demyelinating disease (ODD) was assembled from the US military comprising the Gulf War era (1990-2007). Cases of MS and ODD meeting standard diagnostic criteria were matched to a database of all active duty personnel from the Department of Defense. Relative risk (RR) estimates for MS and all demyelinating disease based on onset, deployment status, and exposures were calculated. RESULTS: For GW1, a total of 1,841 incident cases of definite MS and ODD were identified, with 387 among 696,118 deployed and 1,454 among 1,786,215 nondeployed personnel. The RR for MS alone among those deployed compared to those nondeployed was 0.69 (confidence interval, CI: 0.61-0.78), with 0.72 (CI: 0.62-0.83) in men and 0.96 (CI: 0.75-1.22) in women. Deployment was also nonsignificant or protective as an MS risk factor across racial groups, all age groups, and each military service. RRs for MS by service were: Air Force 0.71 (CI: 0.53-0.96), Army 0.80 (CI: 0.67-0.96), Marines 0.96 (CI: 0.63-1.47), and Navy 0.56 (CI: 0.43-0.74). CONCLUSION: Military deployment to GW1 was not a risk factor for developing MS.

The Gulf War era multiple sclerosis cohort: age and incidence rates by race, sex and service.

We characterize here a new nationwide incident cohort of multiple sclerosis from the US military-veteran population. This cohort provides an update to the only other US nationwide incidence study of multiple sclerosis performed during the 1970s. Medical records and data from the Department of Defense and Department of Veterans Affairs for cases of multiple sclerosis who served in the military between 1990, the start of the Gulf War era, and 2007 and who were service-connected for this disorder by the Department of Veterans Affairs from 1990 on, were reviewed. A total of 2691 patients were confirmed as having multiple sclerosis: 2288 definite, 190 possible, 207 clinically isolated syndrome and six neuromyelitis optica. Overall racial categories were White, Black and other, which included all Hispanics. There were 1278 White males and 556 females; 360 Black males and 296 females; and 200 others, 153 (77%) of whom were Hispanic. Mean age at onset of 30.7 years did not differ significantly by race or sex. Age at onset was 17-50 years in 99%, the same age range as 99% of the military. Average annual age specific (age 17-50 years) incidence rates per 100 000 for the entire series were 9.6 with 95% confidence interval of 9.3-10.0. Rates for Blacks were highest at 12.1 with confidence interval 11.2-13.1, Whites were 9.3 (interval 8.9-9.8) and others 6.9 (interval 6.0-7.9). For 83 Hispanics defined for 2000-07, the rate was 8.2 (interval 6.5-10.1). Much smaller numbers gave rates of 3.3 for Asian/Pacific Islanders and 3.1 for native Americans. Rates by sex for Whites were 7.3 and 25.8 male and female, respectively, for Blacks 8.4 and 26.3, and for Hispanics 6.6 and 17.0. Rates by service were high for Air Force (10.9) and Army (10.6), medium for Navy (9.1) and Coast Guard (7.9), and low for Marines (5.3). Relative risk of multiple sclerosis was 3.39 female:male and 1.27 Black:White. These new findings indicate that females of all races now have incidence rates for multiple sclerosis some three times those of their male counterparts and that among these groups, Blacks have the highest and others (probably including Hispanics) the lowest incidence rates regardless of sex or service. The low rate for Marines is unexplained. This Gulf War era multiple sclerosis cohort provides a unique resource for further study.

Ultrasound measures of muscle morphology in people with multiple sclerosis are associated with muscle performance and functional mobility.

BACKGROUND: Neurologically-based muscle weakness is a common symptom in people with multiple sclerosis MS (MS), who may also exhibit muscle morphology changes and intrinsic muscle dysfunction. Diagnostic ultrasound (sonography) is a non-invasive, inexpensive, and clinically feasible method to measure muscle morphology. The purpose of this study was to investigate possible asymmetries in lower limb muscle morphology and performance in people with MS, and to assess the relationships of muscle morphology measures with individual patient characteristics, muscle performance, and functional mobility. METHODS: This cross-sectional study was conducted at the Washington, DC Veterans Affairs Medical Center. The study participants were 29 Veterans with MS (52% female, 79% African-American, 48.6 ± 11.2 years old, Mean Expanded Disability Status Scale: 3.6 ± 1.4) who completed seated knee extension isokinetic strength and power tests, functional assessments (Timed 25-Foot Walk - T25FW, 5-Times Sit-to-Stand - 5STS), and quantitative B-mode ultrasound image acquisition of the rectus femoris muscle to derive morphology measures (thickness and echogenicity). The limb with weaker knee extension strength was identified as the more-involved limb. Differences between the more and less-involved limb were quantified using a t-test for all muscle morphology and muscle performance measures. Relationships between muscle morphology and patient characteristics, muscle performance, and functional mobility were evaluated using bivariate and multivariate analyses. RESULTS: The rectus femoris thickness from the more-involved limb was lower (p<0.001) than that of the less-involved limb, whereas echogenicity was not different between the two limbs (p=0.147). Rectus femoris thickness of the more-involved limb was directly related to age (r=-0.63, p<0.001), muscle strength (r=0.53, p=0.003) and power (r=0.53, p=0.003), and gait speed (r=0.42, p=0.024); whereas its echogenicity was positively associated only with muscle strength (r=-0.46, p=0.013) and power (r=-0.50, p=0.006). Together rectus femoris thickness and echogenicity of the more involved limb explained 44% and 48% of the variance in muscle strength and power, respectively (p<0.001). CONCLUSION: This study supports the ability of sonography to measure muscle morphology in people with MS, identify asymmetries, and quantify associations with important clinical correlates. Compared with more invasive and costly alternatives, sonography is a clinically feasible, relatively low-cost tool that can be used to assess muscle morphology in people with MS. Further research is warranted to determine the potential clinical utility of sonographic measures of muscle morphology in evaluating changes due to disease progression or therapeutic interventions in this population.

Telemedicine and Multiple Sclerosis: A Survey of Health Care Providers Before and During the COVID-19 Pandemic.

BACKGROUND: Telemedicine provides a gateway to specialty care that, otherwise, patients with multiple sclerosis (MS) could have difficulty accessing. Studies have shown that telemedicine provides a valid alternative to in-person visits. There are limited data on the strengths and limitations of telemedicine from the perspective of MS providers. METHODS: After reviewing the literature and pilot testing questions about telemedicine in provider focus groups, a 34-question survey was created on the Qualtrics web platform. A stratified sample of MS providers throughout the United States was recruited to participate. The survey initiated in November 2019 and closed in November 2020. RESULTS: Survey participants (N = 94) included neurologists (43.0%), advanced practice providers (28.0%), nurses (14.0%), mental health providers (7.0%), social workers (3.0%), rehabilitation providers (4.0%), and pharmacists (1.0%). Clinical video telemedicine (CVT) was the most commonly used platform, and 76.6% of respondents indicated that they used telemedicine to care for patients with MS. As a result of the COVID-19 pandemic, the rate of telemedicine use increased from 44.4% to 84.2%. Most health care providers (93.0%) were "very satisfied" or "somewhat satisfied" with their most recent telemedicine visit, and 94.4% of providers reported a desire to continue using telemedicine, although 84.6% found it difficult to perform a full examination. CONCLUSIONS: There was a large uptick in the use of telemedicine when the COVID-19 pandemic forced clinics to cease in-person visits. Providers predominantly used CVT; store-and-forward telemedicine and remote patient monitoring have fewer technical issues than CVT and seem to be underused.

A Qualitative, Multiperspective Inquiry of Multiple Sclerosis Telemedicine in the United States.

BACKGROUND: Telemedicine has expanded access to high-quality, appropriate, and affordable health care for people with multiple sclerosis (MS). This study explored how the expansion of MS telemedicine is perceived and experienced by people with MS, health care providers (HCPs), and payers and policy experts (PYs). METHODS: Forty-five semistructured interviews with 20 individuals with MS, 15 HCPs, and 10 PYs were conducted between September 2020 and January 2021. The interviews were recorded on a televideo platform, transcribed, and analyzed for themes using qualitative data software. RESULTS: Interviews revealed the following 4 themes. Technology: Telemedicine increases access and convenience. Technical challenges were the most cited downside to telemedicine. Clinical encounters: Confidence in MS care via telemedicine varies. Virtual "house calls" have clinical benefits. Financing and infrastructure: Reimbursement parity is critical to utilization and expansion of telemedicine. Stakeholders are hopeful and fearful as infrastructure and business models begin to shift. Shifting expectations: The familiar structure of the office visit is currently absent in telemedicine. Telemedicine visits need more intentionality from both providers and patients. CONCLUSIONS: Telemedicine is an efficient, convenient way to deliver and receive many aspects of MS care. To expand telemedicine care, many HCPs need more training and experience, people with MS need guidance to optimize their care, and PYs in the United States need to pass legislation and adjust business models to incorporate benefits and reimbursement for telemedicine health in insurance plans. The future is promising for the ongoing use of telemedicine to improve MS care, and stakeholders should work to preserve and expand the policy changes made during the COVID-19 pandemic.

Liver kinase B1 rs9282860 polymorphism and risk for multiple sclerosis in White and Black Americans.

BACKGROUND: We previously reported that the single nucleotide polymorphism (SNP) rs9282860 in serine threonine kinase 11 (STK11) gene which codes for liver kinase B1 (LKB1) has higher prevalence in White relapsing-remitting multiple sclerosis (RRMS) patients than controls. However it is not known if this SNP is a risk factor for MS in other populations. METHODS: We assessed the prevalence of the STK11 SNP in samples collected from African American (AA) persons with MS (PwMS) and controls at multiple Veterans Affairs (VA) Medical Centers and from a network of academic MS centers. Genotyping was carried out using a specific Taqman assay. Comparisons of SNP frequencies were made using Fisher's exact test to determine significance and odds ratios. Group means were compared by appropriate t-tests based on normality and variance using SPSS V27. RESULTS: There were no significant differences in average age at first symptom onset, age at diagnosis, disease duration, or disease severity between RRMS patients recruited from VAMCs versus non-VAMCs. The SNP was more prevalent in AA than White PwMS, however only in secondary progressive MS (SPMS) patients was that difference statistically significant. AA SPMS patients had higher STK11 SNP prevalence than controls; and in that cohort the SNP was associated with older age at symptom onset and at diagnosis. CONCLUSIONS: The results suggest that the STK11 SNP represents a risk factor for SPMS in AA patients, and can influence both early (onset) and later (conversion to SPMSS) events.

Acceptability and outcomes of an individualized exergaming telePT program for veterans with multiple sclerosis: a pilot study.

BACKGROUND: Physical rehabilitation services are an important component of treatment for persons with multiple sclerosis (PwMS) to improve and maintain physical mobility. However, PwMS often have significant barriers to outpatient physical therapy (PT) services including mobility deficits and lack of transportation. The integration of exercise gaming (exergaming) and telehealth into clinical PT practices may overcome these barriers. The overarching purpose of this pilot study was to evaluate the acceptability and effects of an individualized telePT intervention using exergaming. METHODS: Ten individuals with multiple sclerosis (MS) completed a 12-week exergaming (Jintronix®) telerehabilitation intervention. In order to measure the acceptability of the telerehabilitation intervention, adherence was measured through the tablet-based rehabilitation software and each participant completed a satisfaction questionnaire. Clinical outcome measures were assessed at baseline and post-intervention. To evaluate the efficacy of this intervention, the following measures of physical function and fatigue were included; the Short Physical Performance Battery (SPPB), 25-Foot Walk (25FW), Modified Fatigue Impact Scale (MFIS), Multiple Sclerosis Walking Scale-12 (MSWS), and the 2-Minute Walk Test (2MWT). Clinical outcomes were analyzed using the Sign test and Wilcoxon signed rank test. All other data were evaluated using descriptive statistics. RESULTS: After the intervention, participants demonstrated significant improvements in ambulation speed during the 25FW (p = 0.04) and ambulation distance during the 2MWT (p = 0.002). Statistically significant increases of SPPB total score (p = .04) and sub-scores were also found. Participants did not demonstrate significant changes in the MFIS (p = 0.31) or MSWS-12 (p = 0.06) after the intervention. Participants had a 58.3% adherence rate during the intervention and performed their exercise program an average of 2.5 times per week. All participants reported that they were either 'satisfied or 'very satisfied' with their telerehabilitation experience, would use telerehabilitation again, and would recommend telerehabilitation to others. CONCLUSION: This individualized telerehabilitation intervention which integrates exergaming and clinical video teleconferencing is acceptable to patients and may offer a viable alternative to traditional PT for PwMS. TRIAL REGISTRATION: NCT03655431, retrospectively registered on August 31st, 2018.

Telemedicine and multiple sclerosis: A comprehensive literature review.

INTRODUCTION: Patients with multiple sclerosis (pwMS) face barriers accessing specialty care for evaluation and treatment. Telemedicine, the practice of clinical care at a distance with the aid of technology, may be a potential bridge to close the access gap for pwMS separated by distance or disability. The objective of this review was to investigate the types of telemedicine being utilized and overall outcomes for pwMS and their providers. METHODS: A Boolean search of the medical literature was conducted between January 2000 and January 31, 2018. PubMed, EMBASE, PsycINFO and the Cochrane databases, were used to identify all relevant citations. Two reviewers independently appraised the articles for meeting study criteria and for study quality using the CASP system. Financial costs of the telemedicine applications were assessed. RESULTS: A total of 28 studies involving 3252 participants met criteria for inclusion. Telemedicine interventions were classified, and outcomes were assessed systematically by the following categories: general MS care; rehabilitation and exercise; and neuropsychology/mental health. Studies showed a range of outcomes with variable quality. Overall, remote clinical examinations, long-term telemedicine management interventions and telerehabilitation were shown to be beneficial, cost-effective and satisfactory for patients and providers. DISCUSSION: Telemedicine is a viable platform for delivering specialty MS care. Remote neurological assessments and several forms of therapy have been shown to be technically feasible. Optimal implementation and barriers to the use of telemedicine in the current healthcare system should be explored.

The Multiple Sclerosis Surveillance Registry: A Novel Interactive Database Within the Veterans Health Administration.

OBJECTIVE: To demonstrate the infrastructure and utility of an interactive health system database for multiple sclerosis (MS), we present the MS Surveillance Registry (MSSR) within the US Department of Veterans Affairs (VA). BACKGROUND: Disease specific databases can be helpful in the management of neurologic conditions but few are fully integrated into the electronic health record and linked to health system data. Creating a consistent information technology (IT) architecture and with ongoing support within disease specific registries has been a challenge. METHODS: Building the MSSR was initiated by an iterative process with an IT team and MS health care providers. A common registry platform shared by other VA disease specific registries (eg, traumatic brain injury and cancer) was used to develop the IT infrastructure. MS cases were entered online into the MS Assessment Tool at selected MS Centers of Excellence (MSCoE) clinics in the US. Other large VA databases linked to MSSR are reviewed. Patient demographic and clinical characteristics were compared and contrasted with the broader VA population and other US registry populations. RESULTS: We have enrolled 1,743 patients with MS in the MSSR through fiscal year 2019 from selected MS regional programs in the VA MSCoE network. The mean age of patients was 56.0 years, with a 2.7 male:female ratio. Among those with definite MS, the mean European Database for MS Disability Score was 4.7 and 75% had ever used an MS disease modifying therapy. A summary electronic dashboard was developed for health care providers to easily access demographic and clinical data for individuals and groups of patients. Data on comorbid conditions, pharmacy and prosthetics utilization, outpatient clinic visits, and inpatient admission were documented for each patient. CONCLUSIONS: The MSSR is a unique electronic database that has enhanced clinical management of MS and serves as a national source for clinical outcomes.

Monitoring medication adherence in multiple sclerosis using a novel web-based tool: A pilot study.

Monitoring medication adherence in multiple sclerosis (MS) can be time consuming and expensive; however, non-adherence is common and is very costly in terms of lost therapeutic benefit and unused medications. To address this problem, we employed a web-based system to monitor and potentially modify medication adherence. Participants (n = 30) were randomized either to routine care or to the MS Home Automated Telehealth (MS HAT) system. Weekly interferon beta-1a intramuscular (INFbeta-1a IM) injections and daily vitamin D adherence were tracked over a six-month period using multiple modalities: self-reported adherence, calendar diaries, pharmacy refill rates, blood serum levels, and MS HAT alerts. Weekly INFbeta-1a IM adherence was highly correlated across measures; however, vitamin D adherence was not as consistent. Healthcare providers were able to efficiently monitor adherence in a patient-centered way by using the MS HAT system to monitor adherence rather than employing chart reviews and phone calls. In addition, patients with more preserved cognitive function appeared to benefit more from use of the MS HAT system than those with cognitive impairment. While further research is needed to understand the differential effects of MS HAT on specific medications and for different individuals, it is a promising tool for monitoring medication adherence in patients with MS.

Presentation of multiple sclerosis with comorbid Huntington's disease.

We report a case of Huntington's disease (HD) in a 53-year-old male with multiple sclerosis (MS). The diagnosis of MS met the McDonald criteria and was based on clinical attacks separated in space and time, cerebrospinal fluid, and MRI. The diagnosis of HD was established by DNA testing, family history, and positron emission tomography. While a number of neurologic and autoimmune diseases have been reported with MS, this is the first co-occurrence of HD and MS. Salient features of both disorders are reviewed as well as the importance of obtaining a thorough family history.

Biomechanical analysis of spasticity treatment in patients with multiple sclerosis.

OBJECTIVES: New metrics for clinical spasticity are needed to assess motor performance, since scales such as the Ashworth and Tardieu are unreliable. Here, we assessed outcomes of baclofen treatment in patients with multiple sclerosis (MS) using biomechanical analysis of voluntary movements. METHODS: Patients with MS and symptomatic limb spasticity were recruited for a pre-post baclofen titration study, along with age-matched healthy controls. Oral baclofen was titrated to optimize spasticity symptoms in all MS cases over 4 weeks. Clinical assessments included the Modified Ashworth Scale (MAS), Tardieu Scale (TS); elbow kinematics were measured via the Transient Acceleration Measurement Interface (TAMI); performance was measured as the score at 4 weeks minus the baseline score in all measures. Movement proficiency within TAMI was quantified through a scale-free smoothness measure, according to the regional excursion deviation (RED) from a constant-velocity approximant. RESULTS: Twelve patients with MS [age: 47.8 ± 9.8 years; women: 4; disease duration: 20 ± 10 years; disease-modifying therapy use: 7; Expanded Disability Status Scale (EDSS): 6.8 ± 1.4] and eight age-matched healthy controls were evaluated concurrently (mean age: 49.5 ± 13.1 years; women = 3). In MS cases, no significant improvement in arm spasticity was observed with main effects: MAS: -41.6 ± 72.6 (p = 0.09); EDSS: -1.6 ± 10.4% (p = 0.49); and TS: -8.3 ± 2.1% (p = 0.32), -24.9 ± 63.6% (p = 0.42), and -30.7 ± 79.9% (p = 0.06), at slow, moderate, and fast speeds, respectively. However, voluntary motion smoothness, as measured by TAMI: RED, decreased significantly: 0.62 ± 0.08 versus 0.54 ± 0.09, p < 0.001, indicating significant increase in movement smoothness post treatment. CONCLUSION: A simple biomechanical analysis of voluntary movements revealed a significant reduction of spasticity after 30 days of baclofen therapy in patients with MS that was not detected by clinical assessments.

What does the nurse reinvestment act mean to you?

During 2002, the 107th Congress passed landmark legislation, the Nurse Reinvestment Act, P.L. 107-205. This article discusses the specific provisions of P.L. 107-205 within the context of the contemporary literature and the experience of the nursing shortage. The authors ask nurses to examine what the Nurse Reinvestment Act means for their career development. In laying out the anatomy of the Nurse Reinvestment Act, title by title, and section by section, the article presents the Congressional plan for addressing the two faces of the shortage: Nurse Recruitment, Title I, and Nurse Retention, Title II.

Multiple sclerosis: managing patients in primary care.

In this era of the Patient Centered Medical Home model of care, chronic diseases such as multiple sclerosis (MS) are managed in partnership with specialty care practices. For the patient and family living with MS, assuring that patients get proper care when and where they need it requires that nurse practitioners understand their role in assessing and managing complex chronic diseases.

Clinical management of multiple sclerosis through home telehealth monitoring: results of a pilot project.

This study examined the feasibility of using home telehealth monitoring to improve clinical care and promote symptom self-management among veterans with multiple sclerosis (MS). This was a longitudinal cohort study linking mailed survey data at baseline and 6-month follow-up with information from home telehealth monitors. The study was conducted in two large Department of Veterans Affairs (VA) MS clinics in Seattle, Washington, and Washington, DC, and involved 41 veterans with MS. The measures were demographic information and data from a standardized question set using a home telehealth monitor. Participants reported moderate levels of disability (median Expanded Disability Status Scale [EDSS] score, 6.5) and substantial distance from the nearest VA MS clinic (mean distance, 93.6 miles). Of the participants, 61.0% reported current use of MS disease-modifying treatments. A total of 85.4% of participants provided consistent data from home monitoring. Overall satisfaction with home telehealth monitoring was high, with 87.5% of participants rating their experience as good or better. The most frequently reported symptoms at month 1 were fatigue (95.1%), depression (78.0%), and pain (70.7%). All symptoms were reported less frequently by month 6, with the greatest reduction in depression (change of 23.2 percentage points), although these changes were not statistically significant. Home telehealth monitoring is a promising tool for the management of chronic disease, although substantial practical barriers to efficient implementation remain.