Fatigue in neuroimmunological diseases.

Fatigue is a widespread symptom in numerous neuroimmunological diseases like multiple sclerosis (MS), myasthenia gravis, morbus Behcet, neurosarcoidosis, neuroborreliosis or immune vasculitis. This phenomenon is best investigated in MS. The complex mechanisms underlying fatigue in MS are still poorly understood; alterations in immune system activation, central nervous system dysregulation, impaired nerve conduction, and neuroendocrine dysregulation have to be considered. These immune and neural mechanisms may cause the initial symptoms of fatigue; however, the fatigue symptom may be exacerbated by secondary overlapping factors (e. g. depressive mood, sleep disturbances, unhealthy life style) which are likely associated with the feeling of fatigue. Wessely conceptualised four components of fatigue: behaviour (effects of fatigue), feeling (subjective experience), mechanisms, and context (e. g. environment, attitudes). So far most examinations have dealt with the first or the second component of the multidimensional construct fatigue, either concentrating on the behavioural aspect in the physical or in the cognitive sphere or on the subjective aspect. The Rostock Fatigue Study investigated two of the components: objective performance and subjective fatigue estimation in the cognitive and in the physical sphere. MS patients showed a reversed relationship between below-average objective performance in the cognitive and in the physical sphere and high subjective feeling of tiredness when compared to healthy individuals. The clinical management of fatigue should include an assessment of the various factors that can cause fatigue as well as a step-wise treatment approach that encompasses nonpharmacological approaches and pharmacological interventions.

Diagnostics of cognitive dysfunctions in multiple sclerosis.

Cognitive dysfunctions are frequent symptoms in multiple sclerosis (MS). Up to 65% of MS patients suffer from cognitive dysfunctions. Especially memory, attention and executive functions are impaired. These problems strongly affect the patients' ability to work and their quality of life (QoL). A differentiating diagnostic effort is necessary to control fatigue and depression. Screening tools alone can not provide a detailed description of all cognitive domains. Therefore, an elaborated neuropsychological diagnostics is necessary. This report provides a description of cognitive functions and its diagnostic opportunities, especially in MS patients. After displaying aspects of differential diagnostics, a recommendation for a diagnostic work schedule is given.

Qualitative and quantitative assessment of fatigue in multiple sclerosis (MS).

It was the aim of the present study to develop a synoptic multidimensional test system for assessment of fatigue in multiple sclerosis (MS) patients objectifying physical and mental fatigue as well as the subjective and objective standpoint in these two fatigue forms. Seventy nine patients with relapsing remitting multiple sclerosis (RRMS) and 51 age-matched healthy controls (H) were analysed by means of the physical fatigue test (hand dynamometer) and an objective mental fatigue test (vigilance test from the computerised Test Battery for Attentional Performance). Furthermore, subjective tiredness caused by test procedures, subjective persisting tiredness (Modified Fatigue Impact Scale; MFIS: physical and cognitive scale) and mood (Beck Depression Inventory; BDI-18) were analysed.MS patients differed significantly from the controls in their objective physical and mental performance under fatigue, as well as in their subjective estimation of tiredness. MS patients showed an inverse relationship between below-average objective performance and high subjective feeling of tiredness when compared to controls. Subjectively severely tired MS patients achieved clearly poorer performances on the hand dynamometer test and slightly poorer performances on the vigilance test when compared to subjectively rarely tired MS patients. Depressed MS patients estimated their subjective tiredness in the MFIS significantly higher than non-depressed MS patients, but attained the same objective performance. This set of standardised tests enables meaningful comparisons between objective fatigue performance and subjective fatigue estimations in the physical and mental sphere and considers the influence of depression. Depression affects the subjective tiredness but not the objective fatigue performance.

Frequency of current utilisation of complementary and alternative medicine by patients with multiple sclerosis.

OBJECTIVE: The purpose of the study was to examine the frequency and characteristics of complementary and alternative medicine (CAM) use among patients with multiple sclerosis (MS). METHOD: In order to collect sociodemographic and disease related variables as well as aspects of CAM utilisation 254 MS patients were examined with an interview. The investigation was completed by data of the neurological examination. RESULTS: At the time of investigation 67.3% of the MS patients reported that they were currently using one or more CAMs. Overall, most of the overall utilized therapies (90.6%) were chosen as a complement and 9.4% as an alternative therapy. Users of complementary medicine were more severely affected by the MS than non-users and had a longer duration of illness. No sociodemographic differences were found between users and non-users. When evaluating the efficacy of CAM, patients reported improvement in 67.1%, no influence in 32.3% and worsening in 0.6% of the cases. 3.7% of the CAM therapies were accompanied by minor side effects. CONCLUSIONS: Since MS patients are frequently using CAM despite the absence of clinically proven efficacy and appraise it positively, further research on the motivation for utilisation and on objective effects of CAM are needed.

Sonographic discrimination of dementia with Lewy bodies and Parkinson's disease with dementia.

OBJECTIVE: To study the use of transcranial sonography (TCS) in discriminating between patients with dementia with Lewy bodies (DLB) and Parkinson's disease with dementia (PDD). METHODS: Fourteen patients with DLB, 31 with PDD and 73 with PD without dementia (PDnD) were studied with TCS. RESULTS: All assessable patients with DLB, 97% with PDD, and 94% with PDnD showed at least unilateral hyperechogenicity of substantia nigra (SN). However, bilateral marked SN hyperechogenicity was present in 80% of DLB patients but only in one third of PDD and PDnD patients, and was associated with younger age at disease onset in PD but not in DLB. An asymmetry index > or = 1.15 of bilateral SN echogenic sizes, estimated by division of larger size by smaller size, was found in 69% of PDD patients but only 20% of DLB patients. Combination of SN echogenic sizes, asymmetry indices and onset age discriminated PDD from DLB with a sensitivity of 96%, a specificity of 80% and a positive predictive value of 93%. TCS of brainstem raphe, thalami, lenticular nuclei, caudate nuclei and ventricle widths did not discriminate between DLB and PDD. Compared with PDnD patients, DLB and PDD patients exhibited significantly larger widths of third ventricle and of frontal horns. In PDD patients, scores on the Unified Parkinson's Disease Rating Scale correlated with widths of third ventricle and of frontal horns. CONCLUSIONS: SN hyperechogenicity is typical for PDD and DLB. However, size, asymmetry and relation of SN hyperechogenicity to age at disease onset discriminate PDD from DLB.

How frequently do patients with multiple sclerosis use complementary and alternative medicine?

OBJECTIVE: The purpose of the study was to examine the prevalence and characteristics of the utilisation of complementary and alternative medicine (CAM) by patients with multiple sclerosis (MS). DESIGN: Cross-sectional study using a semi-structured interview. SETTING: One hundred and fifty-four MS patients were examined by interview to collect sociodemographic and disease-related variables as well as aspects of their usage of CAM. The investigation was completed by data from neurological examination. MAIN OUTCOME MEASURES: Reported utilisation of CAM by MS patients. RESULTS: At the time of the investigation 61.7% (n = 95) of the MS patients reported that they were currently using CAM. Most of the therapies utilised (90.3%; n = 205) were complementary and only 9.7% (n = 22) were alternative choices. Users of complementary medicine were more severely affected by the disease than non-users, but no sociodemographic differences between users and non-users were found. Concerning the efficacy of CAM, 65.8% (n = 146) of MS patients reported improvement, 32.9% (n = 73) no influence, and 1.3% (n = 3) worsening of their condition. 4.5% (n = 10) of the CAM therapies were accompanied by slight side-effects. CONCLUSION: A large proportion of MS patients use unconventional treatments, yet clinical studies on the efficacy of CAM in these cases have not been undertaken. Therefore, further research on their motivation and on objective effects of CAM is required.

Evaluation of coated oxygenators in cardiopulmonary-bypass systems and their impact on neurocognitive function.

INTRODUCTION: Coronary artery bypass graft surgery (CABG) using cardiopulmonary bypass (CPB) is assumed to be associated with a decline of neurocognitive functions. This study was designed to analyse the neurocognitive function of patients with coronary heart disease before and after CABG and to determine possible protective effects of oxygenator surface coating on neurological outcome. METHODS: Forty patients scheduled for selective CABG were prospectively randomized into two groups of 20 patients each according to the type of hollow-fibre membrane oxygenator used. Non-coated oxygenators (Group A) were compared to phosphorylcholine (PC)coated oxygenators (Group B). A battery of six neurological tests was administered preoperatively, 7-10 days and 4-6 months after surgery. RESULTS: One patient of Group A suffered from a perioperative stroke and died on postoperative day 3, presumably because of sudden heart failure. Two patients of Group A (10%) developed a symptomatic transitory delirious psychotic syndrome (STPT) on postoperative days 3 and 5. None of the patients of Group B had perioperative complications. The test analysis revealed a trend of declined neurocognitive function early after CABG, but did not show any difference in neurocognitive outcome between the two groups. DISCUSSION: PC coating of the oxygenators did not show any significant benefit on neurocognitive function after CABG using CPB.