Immune System Disorder

I am interested in interviewing someone with Multiple Sclerosis for this paper. 

Title of Assignment:

Module 2 assignment: Immune system disorders

Purpose of Assignment:

Apply knowledge and understanding of the pathophysiology of immune system disorders. Autoimmune disorders are generally considered the host attacking itself, which manifests in different types of disorders.

Course Competency(s):

· Determine the cellular functions required to regulate homeostasis.

Instructions:

Content:

Identify a person you know who has an immune system disorder or cancer. Review content in your text for potential types of disorders.

Interview the affected person and write a 3-5 page pager identifying your findings including:

· Identify the pathophysiology of the immune system disorder

· Discuss the treatment for the immune system disorder

· Summarize the findings of the interview.

· Use at least one scholarly sources to support your findings or identify therapies that may be new or different from what the affected person may be using. Examples of scholarly sources include academic journals, textbooks, reference texts, and CINAHL nursing guides. You can find useful reference materials for this assignment in the School of Nursing guide: https://guides.rasmussen.edu/nursing/referenceebooks

· Cite your sources in-text and on a References page using APA format. Have questions about APA? Visit the online APA guide: https://guides.rasmussen.edu/apa

Questions you may want to use to guide your interview:

1. Which immune system disorder do you have?

2. How long have you had this disorder?

3. How has this disorder changed your life (home and work)?

4. Are you able to carry out daily activities independently?

5. What therapies are you using to manage this disorder?

6. What, if any, side effects does the treatment have?

7. What therapies are you using to manage this disorder?

8. What, if any, side effects doe the treatment have?

9. Has this disorder changed your body?

10. Does this disorder have any emotional effects on you?

11. Have alternative therapies, such as Eastern medicine (acupuncture, herbal treatment, yoga) been tried or recommended?

Grading Rubric:

Levels of Achievement
CriteriaEmergingCompetenceProficiencyMastery
Pathophysiology(10 pts)Did not include discussion on the pathophysiology of one immune system disorder.Failure to provide pathophysiology will result in zero points for this criteria.Identify the pathophysiology of the one immune system disorder.Identified the pathophysiology of one immune system disorder and included one example of how the disorder impacts the patient.Identified the pathophysiology of one immune disorder and included multiple examples on how the disorder impacts the patient
Points: 6Points: 8Points: 9Points: 10
Treatment(20 pts)Did not present treatment for immune system disorder.Failure to provide treatment will result in zero points for this criteria.Provided treatment options for immune system disorder.Provided treatment options with expected outcomes for the immune system disorder.Provided detailed treatment options with expected outcomes for the immune system disorder.
Points: 12Points: 16Points: 18Points: 20
Interview(15 pts)Did not include interview discussion to show the client pathophysiology of the immune system disorder.Failure to provide interview information will result in zero points for this criteria.The interview discussion presents the pathophysiology of the immune system disorder.The interview discussion presents the pathophysiology of the immune system disorder and provides and one example.The interview discussion shows the relationship between the clients with the pathophysiology of the immune system disorder and provides more than one detailed example.
Points: 9Points: 12Points: 14Points: 15
APA/Spelling and Grammar(5 Pt)Six or more APA, spelling or grammar errors. Detracts from the readability of the submission.No more than five APA, spelling or grammar errors, minimally detracts from the readability of the submission.No more than three APA, spelling or grammar errors. Does not detract from the readability of the submission.No APA, spelling or grammar errors.
Points: 2Points: 3Points: 4Points: 5
Points: 29Points: 39Points: 45Points: 50

04/27/2020

Prevention

Twinning is a naturally occurring phenomenon and cannot be completely prevented. It occurs more often in older mothers. Multiple births due to ART are a concern because a multiple pregnancy represents a complication of pregnancy. Efforts within the ART community are being made to minimize the incidence of high-order multiples. Efforts to prevent or minimize maternal and fetal complications will result in closer monitoring. More frequent ultrasounds, biophysical profile, and/or nonstress tests may be ordered. Cervical length and change may be monitored as an indicator of preterm delivery. If both twins are vertex and vaginal delivery is attempted, both fetal heart rates will be monitored. Caesarean deliveries of twins are more common than for singletons; the rate of cesarean delivery for twins in the United States has increased by 22% since 1995, purely apart from the presentation positions of the twins at the time of birth. This increase is especially true for higher-order multiples. The overall cesarean delivery rate tends to be about 75% for multiple pregnancies as of 2012.

See also Fertility treatments; High-risk pregnancy.

Resources

BOOKS Hanretty, Kevin P. Obstetrics Illustrated, 7th ed. New York:

Churchill Livingstone, 2010.

Jauniaux, Eric, and Botros Rizk. Pregnncy after Assisted Reproductive Technology. New York: Cambridge Univer- sity Press, 2012.

Luke, Barbara, Tamara Eberlein, and Roger Newman. When You’re Expecting Twins, Triplets, or Quads: Proven Guidelines for a Healthy Multiple Pregnancy, 4th ed. New York: William Morrow, 2017.

PERIODICALS Breborowicz, G.H., et al. “Variable Outcome in Quintuplets

Pregnancy Based on Obstetric Care.” Twin Research and Human Genetics 14 (December 2011): 580–585.

Fisher, S.L., et al. “Sextuplet Heterotopic Pregnancy Presenting as Ovarian Hyperstimulation Syndrome and Hemoperito- neum. Fertility and Sterility 95 (June 2011): 2431: e1–e3.

Hasson, J., et al. “Reduction of Twin Pregnancy to Singleton: Does It Improve Pregnancy Outcome?” Journal of Mater- nal-Fetal and Neonatal Medicine 24 (November 2011): 1362–1366.

Klipstein, S. “Ethical Considerations Arising from the Use of Assisted Reproductive Technologies.” Seminars in Reproductive Medicine 30 (April 2012): 146–151.

Lee, H.C., et al. “Trends in Cesarean Delivery for Twin Births in the United States: 1995-2008.” Obstetrics and Gynecology 118 (November 2011): 1095–1101.

Memmo, A., et al. “Prediction of Selective Fetal Growth Restriction and Twin-to-twin Transfusion Syndrome in Monochorionic Twins.” BJOG 119 (March 2012): 417–421.

Moragianni, V.A., et al. “Biweekly Ultrasound Assessment of Cervical Shortening in Triplet Pregnancies and the Effect of Cerclage Placement.” Ultrasound in Obstetrics and Gynecology 37 (May 2011): 617–618.

Stock, S., and J. Norman. “Preterm and Term Labour in Multiple Pregnancies.” Seminars in Fetal and Neonatal Medicine 15 (December 2010): 336–341.

ORGANIZATIONS Association of Women’s Health, Obstetric and Neonatal Nurses ,

1800 M St. NW, Ste. 740 S, Washington, DC 20036, (202) 261-2400, (800) 673-8499, Fax: (202) 728-0575, customerservice@awhonn.org, http://www.awhonn.org.

American Congress of Obstetricians and Gynecologists, 409 12th St. SW, Washington, DC 20024, (202) 638-5577, (800) 673-8444, resources@acog.org, http://www.acog .org.

National Institute of Child Health and Human Development, PO Box 3006, Rockville, MD 20847, (800) 370-2943, Fax: (866) 760-5947, NICHDInformationResourceCenter@ mail.nih.gov, http://www.nichd.nih.gov.

Society for Maternal-Fetal Medicine, 409 12th St. SW, 6th Fl, Washington, DC 20024, (202) 863-2476, smfm@smfm .org, https://www.smfm.org.

American Society for Reproductive Medicine, 1209 Montgomery Hwy., Birmingham, AL 35216-2809, (205) 978-5000, Fax: (205) 978-5005, asrm@asrm.org, http://www.reproductivefacts.org.

Esther Csapo Rastegari, RN, BSN, EdM Revised by Rebecca J. Frey, PhD

Multiple sclerosis Definition

Multiple sclerosis (MS) is a chronic autoimmune disorder affecting movement, sensation, and bodily functions. It is caused by destruction of the myelin sheath (insulation) covering nerve fibers (neurons) in the central nervous system (brain and spinal cord).

Demographics

As of 2012, approximately 400,000 people in the United States had been diagnosed with MS, with 10,000 new cases being diagnosed each year. Worldwide, MS affects between 1.5 and 2.5 million people. Most people have their first symptoms between the ages of 20 and 40; symptoms rarely begin before age 15 or after age 60. The mean age range is 29–33 years. Women are almost twice as likely to get MS as men, especially in their early years. People of northern European ancestry are more likely to be affected than people of other racial backgrounds, and MS rates are higher in the United States, Canada, and Northern Europe than other parts of the world. The disorder is

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unknown among certain native peoples such as the Inuit (native people of the Arctic) and Maori (Native people of New Zealand).

Description

Multiple sclerosis is a slowly progressive disease of the central nervous system (CNS), which is comprised of the brain and spinal cord. In 1868, French physician Jean- Martin Charcot (1825–1893) provided the first detailed clinical description of the disease. Today researchers know that MS is an autoimmune disorder that causes the destruction of myelin, the insulating material that surrounds nerve fibers (neurons). Myelin helps electrical signals pass quickly and smoothly between the brain and the rest of the body. When the myelin layer is destroyed, nerve messages are sent more slowly and less efficiently. Patches of scar tissue, called plaques, form over the affected areas, further disrupting nerve communication. The symptoms of MS occur when the brain and spinal cord nerves no longer communicate properly with other parts of the body. MS causes a wide variety of symptoms and can affect vision, balance, strength, sensation, coordination, and bodily functions.

Risk factors

The risk of developing MS is slightly higher if another family member is affected, suggesting the influence of genetic factors. If one person in a family has MS, then that person’s close family relatives (parents, children, siblings) have about a 5% greater chance of developing MS than people who do not have family members with the disorder. In addition, the higher prevalence of MS among people of northern European background suggests some genetic susceptibility.

Causes and symptoms

Causes

Multiple sclerosis is an autoimmune disease, meaning its cause is due to an attack by the body’s own immune system. For unknown reasons immune cells attack and destroy the myelin sheath that insulates neurons in the brain and spinal cord. This myelin sheath, created by other brain cells called glia, speeds transmission and prevents electrical activity in one cell from short-circuiting to another cell. Disruption of communication between the brain and other parts of the body prevents normal passage of sensations and control messages, leading to the symptoms of MS. The demyelinated areas appear as plaques, small round areas of gray neurons without the white myelin covering. The progression of symptoms is correlated with development of new plaques in the portion of the brain or spinal cord controlling the affected areas.

Because there appears to be no pattern in the appearance of new plaques, the progression of MS is unpredictable.

Despite considerable research the trigger for this autoimmune destruction is still unknown. At various times evidence has pointed to genes, environmental factors, viruses, or a combination of these factors.

The fact that the risk of developing MS is slightly higher if another family member is affected suggests that there is a genetic susceptibility to the disease.

The role of an environmental factor is suggested by studies of the effect of migration on the risk of developing MS. Age plays an important role in determining this change in risk—young people in low-risk groups who move into countries with higher MS rates display the risk rates of their new surroundings, while older migrants retain the risk rate of their original home country. One interpretation of these studies is that an environmental factor, either protective or harmful, is acquired in early life; the risk of disorder later in life reflects the effects of the early environment.

These same data can be used to support the involvement of a slow-acting virus, one that is acquired early in life but begins its destructive effects much later. Slow viruses are known to cause other disorders, including Creutzfeldt-Jakob disease, bovine spongiform encephalopathy (“mad cow” disease), and AIDS. In addition, viruses have been implicated in other autoim- mune disorders. Many claims have been made for the role of viruses, slow or otherwise, as the trigger for MS, but as of 2012 no strong candidate had emerged.

How a virus could trigger the autoimmune reaction is also unclear. There are two main models of virally induced autoimmunity. The first suggests the immune system is actually attacking a virus (one too well hidden for detection in the laboratory), and the myelin damage is an unintentional consequence of fighting the infection. The second model suggests the immune system mistakes myelin for a viral protein encountered during a prior infection. Primed for the attack, the immune system destroys myelin because it resembles the previously recognized viral invader.

Either of these models allows a role for genetic factors, since certain genes can increase the likelihood of autoimmunity, and it seems likely that more than one gene is involved in a person’s susceptibility to MS. Environ- mental factors as well might change the sensitivity of the immune system or interact with myelin to provide the trigger for the secondary immune response. Possible environmental triggers that have been invoked in MS include viral infection, trauma, electrical injury, and chemical exposure, although controlled studies do not support a causative role.

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Symptoms

MS is a diverse disease. No two affected persons are the same and each will experience different combinations of symptoms with differing severity. The symptoms of MS may occur in one of three patterns:

• The most common pattern is the relapsing-remitting pattern, in which there are clearly defined symptomatic attacks lasting 24 hours or more, followed by complete or almost complete improvement. The period between attacks may be a year or more at the beginning of the disorder, but may shrink to several months later on. About three-quarters of all people diagnosed with MS have this version of the disorder. This pattern is especially common in younger people who develop MS.

• In the primary progressive pattern, the disorder pro- gresses without remission or with only occasional plateaus or slight improvements. This pattern is more common in older people. About 10% of people with the disorder have this pattern.

• In the secondary progressive pattern, the person with MS begins with relapses and remissions, followed by more steady progression of symptoms. In some people, what begins as a relapsing-remitting pattern develops into a secondary progressive pattern.

Between 10%–20% of people have a benign type of MS, meaning their symptoms progress very little over the course of their lives.

Because plaques may form in any part of the central nervous system, the symptoms of MS vary widely from person-to-person and from stage-to-stage of the disease. Initial symptoms often include:

• muscle weakness causing difficulty walking

• loss of coordination or balance

• numbness, “pins and needles,” or other abnormal sensations

• visual disturbances, including blurred or double vision

Later symptoms may include:

• fatigue

• muscle spasticity and stiffness

• tremors

• paralysis

• pain

• vertigo

• speech or swallowing difficulty

• loss of bowel and bladder control

• sexual dysfunction

• changes in cognitive ability

Weakness in one or both legs is common, and may be the first symptom noticed by a person with MS. Muscle spasticity, or excessive tightness, is also common and may be more disabling than weakness.

Double vision (diplopia) or eye tremor (nystagmus) may result from involvement of the nerve pathways controlling movement of the eye muscles. Visual disturbances result from involvement of the optic nerves (optic neuritis) and may include development of blind spots in one or both eyes, changes in color vision, or blindness. Optic neuritis usually involves only one eye at a time and is often associated with movement of the effected eye.

More than half of all people affected by MS have pain during the course of their disease. Many experience chronic pain, including pain from spasticity. Acute pain occurs in about 10% of cases. This pain may be a sharp, stabbing pain especially in the face, neck, or down the back. Facial numbness and weakness are also common.

Cognitive changes, including memory disturbances, depression, and personality changes, are found in people affected by MS, although it is not entirely clear whether these changes are due primarily to the disorder or to the psychological reaction to it. Depression may be severe enough to require treatment in up to 25% of those with MS. A smaller number of people experience disorder– related euphoria, or abnormally elevated mood, usually after a long disorder duration and in combination with other psychological changes.

Symptoms of MS may be worsened by heat or increased body temperature, including fever, intense physical activity, or exposure to sun, hot baths, or showers.

Diagnosis

There is no single test that confirms the diagnosis of multiple sclerosis and there are a number of other diseases with similar symptoms. While one person’s diagnosis may be immediately suggested by symptoms and history, another’s may not be confirmed without multiple tests and prolonged observation. The distribution of symptoms is important, as MS affects multiple areas of the body over time. The pattern of symptoms is also critical, especially evidence of the relapsing-remitting pattern. Thus, a detailed medical history is one of the most important parts of the diagnostic process. A thorough search to exclude other causes of a person’s symptoms is especially important if the following features are present: 1) family history of neurologic disease, 2) symptoms and findings attributable to a single anatomic location, 3) persistent back pain, 4) age of onset over 60 or under 15 years of age, or 5) progressively worsening disease.

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Tests

In addition to a medical history and a standard neurological exam, several lab tests are used to help confirm or rule out a diagnosis of MS:

• Magnetic resonance imaging (MRI) can reveal plaques on the brain and spinal cord. Gadolinium enhancement can distinguish between old and new plaques, allowing a correlation of new plaques with new symptoms. Plaques may be seen in several other diseases as well, including encephalomyelitis, neurosarcoidosis, and cerebral lupus. Plaques seen on an MRI may, however, be difficult to distinguish from damage caused by small strokes, areas of decreased blood flow, or changes seen with trauma or normal aging.

• A lumbar puncture, or spinal tap, is done to measure levels of immune proteins, which are usually elevated in the cerebrospinal fluid of a person with MS. This test may not be necessary if other diagnostic tests are positive.

• Evoked potential tests, electrical tests of conduction speed in the neurons, can reveal reduced speeds consistent with the damage caused by plaques. These tests may be done with small electrical charges applied to the skin (somatosensory evoked potential), with light patterns flashed on the eyes (visual evoked potential), or with sounds presented to the ears (auditory evoked potential).

The clinician making the diagnosis, usually a neurologist, may classify the disorder as “definite MS,” meaning the symptoms and test results all point toward MS as the cause. “Probable MS” and “possible MS” reflect less certainty and may require more time to pass to observe the progression of the disorder and the distribu- tion of symptoms.

Treatment

As of 2017, there was no known cure for MS. Nevertheless, several drugs may slow progression of the disorder and moderate some symptoms in many patients, especially if started early.

Multiple sclerosis causes a wide variety of symptoms, and the treatments for these are equally diverse. Most symptoms can be treated and complications avoided with good care and attention from medical professionals. Good health and nutrition remain important preventive mea- sures. Vaccination against influenza can prevent respira- tory complications. Preventing complications such as pneumonia, bedsores, injuries from falls, or urinary infection requires attention to the primary problems that may cause them. Shortened life spans with MS are almost always due to complications rather than primary symp- toms themselves.

Drugs

Drug treatment must be individualized. Not all drugs are appropriate for all patients. In the United States as of 2011, MS was most often treated with four drugs known as the ABCR drugs. These drugs are interferon beta-1a (Avonex), interferon beta-1b (Betaseron and Rebif), and glatiramer acetate (Copaxone). These drugs, on average, reduce relapses in the relapsing-remitting form of MS by about one-third. Different measurements from tests of each have demonstrated other benefits as well: Avonex may slow the progress of physical impairment, Betaseron and Rebif may reduce the severity of symptoms, and Copaxone may decrease disability. All four drugs are administered by injection, some into muscle (IM), and some under the skin (SC). Some controversy exists on the most effective dose and the frequency with which these drugs should be administered.

Although the ABCR drugs reduce relapses and may keep patients in relatively good health for the short- term, their long-term success has not been proven and they do not work well for patients who have reached a steadily progressive stage of MS. Individuals with progressive forms of MS may be treated with mitoxan- trone (Novantrone), cyclophosphamide (Cytoxan, Neo- sar), azathioprine (Imuran), or methotrexate (Rheuma- trex). All these drugs suppress the immune system. None are ideal, and all have potentially serious side effects. Corticosteroid drugs such as methylpredniso- lone (Medrol) also may be used to reduce inflammation. Long-term use of corticosteroids also causes serious side effects.

Two disease modifying agents, fingolimod (Gilenya) and natalizumab (Tysabri), are effective in keeping white blood cells in the lymph system, thus preventing these cells from crossing the blood-brain barrier into the central nervous system, which in turn reduces inflammation and damage to nerve cells.

Training in bowel and bladder care may be needed to prevent or compensate for incontinence. If the urge to urinate becomes great before the bladder is full, some drugs may be helpful, including propantheline bromide (Probanthine), oxybutynin chloride (Ditropan), or imipra- mine (Tofranil). Baclofen (Lioresal) may relax the sphincter muscle, allowing full emptying. Intermittent catheterization is effective in controlling bladder dysfunc- tion. In this technique, a catheter is used to periodically empty the bladder.

Spasticity can be treated with oral medications, including baclofen and diazepam (Valium), or by injection with botulinum toxin (Botox). Spasticity relief may also bring relief from chronic pain. More acute types of pain may respond to carbamazepine (Tegretol) or diphenylhydantoin (Dilantin). Low back pain is common

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from increased use of the back muscles to compensate for weakened legs. Physical therapy and over-the-counter pain relievers may help.

Fatigue may be partially avoidable with changes in the daily routine to allow more frequent rests. Amantadine (Symmetrel) and Modafinil (Provigil), although not specifically approved for use with MS, are often used to treat fatigue and improve alertness. Pemoline (Cylert), a drug formerly used to treat fatigue in MS patients, was withdrawn from sale in the United States in October 2005 because of potentially fatal liver complications. Visual disturbances often respond to corticosteroids. Other symptoms that may be treated with drugs include seizures, vertigo, and tremor.

Treatment for significant acute exacerbations include the use of steroids such as methyl-prednisolone (Medrol), administered in high doses for a number of days, then tapering to lower doses for a number of weeks.

Clinical trials of new drugs and drug combinations to treat MS are ongoing. Individuals with MS who wish to participate in the trial of an experimental therapy can find a list of clinical trials currently enrolling volunteers at http://clinicaltrials.gov. There is no cost to the patient to participate in a clinical trial.

Other drugs used for the treatment or management of symptoms associated with MS include:

Bladder dysfunction:

• tolterodine (Detrol)

• darifenacin (Enablex)

• tamsulosin (Flomax)

• terazosin (Hytrin)

• prazosin (Minipress)

• oxybutynin (Oxytrol)

• trospium chloride (Sanctura)

• solifenacin succinate (Vesicare)

Constipation:

• docusate (Colace)

• bisacodyl (Dulcolax)

• sodium phosphate (Fleet Enema)

• psyllium (Metamucil)

Depression and fatigue:

• venlafaxine (Effexor)

• paroxetine (Paxil)

• bupropion (Wellbutrin)

• sertraline (Zoloft)

• duloxetine hydrochloride (Cymbalta)

• fluoxetine (Prozac)

Dizziness:

• meclizine (Antivert)

Erectile dysfunction:

• tadalafil (Cialis)

• vardenafil (Levitra)

• alprostadil (Prostin VR)

• sildenafil (Viagra)

Itching:

• hydroxazyne (Atarax)

Pain:

• gabapentin (Neurontin)

• nortriptyline (Pamelor)

• amitriptyline (Elavil)

Spasticity:

• dantrolene (Dantrium)

• tizanidine (Zanaflex)

Urinary frequency:

• desmopressin (DDAVP)

Urinary tract infections:

• sulfamethoxazole (Bacrim, Septra)

• ciprofloxacin (Cipro)

• nitrofurantoin (Macrodantin)

• methenamine (Hiprex)

• vphenazopyridine (Pyridium)

Tremor:

• isoniazid (Laniazid, Nydrazid)

• clonazepam (Klonopin)

Walking:

• dalfampride (Ampyra)

Rehabilitative therapy

Physical therapy helps the person with MS to strengthen and retrain affected muscles, maintain range of motion, prevent muscle stiffening, learn to use assistive devices such as canes and walkers, and to learn safer and more energy- efficient ways of moving, sitting, and transferring. Exercise and stretching programs are usually designed by the physical therapist and taught to the patient and caregivers for use at home. Exercise is an important part of maintaining function for the person with MS. Swimming is often recommended, not only for its low-impact workout, but also because it allows strenuous activity without overheating.

Occupational therapy helps the person with MS adapt to her environment and adapt the environment to her. The

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occupational therapist suggests alternate strategies and assistive devices for activities of daily living, such as dressing, feeding, and washing, and evaluates the home and work environment for safety and efficiency improve- ments that may be made.

Alternative therapies

Bee venom has been suggested as a treatment for MS, but no studies or objective reports support this claim.

In several studies, marijuana has been shown to have variable effects on the symptoms of MS. Improvements have been documented for tremor, pain, and spasticity, and worsening for posture and balance. Side effects have included weakness, dizziness, relaxation, and incoordina- tion, as well as euphoria.

Some studies support the value of high doses of vitamins, minerals, and other dietary supplements for controlling disorder progression or improving symptoms. Alpha-linoleic and linoleic acids, as well as selenium and vitamin E, have shown effectiveness in the treatment of MS. Selenium and vitamin E act as antioxidants. In addition, a diet low in saturated fats, maintained over a long period, may retard the disorder process.

Studies have also shown that t’ai chi can be an effective therapy for MS because it works to improve balance and increase strength.

There are conflicting views about the herb Echinacea and its benefit to MS. Some alternative practitioners recommend Echinacea for people with MS. However, Echinacea appears to stimulate different parts of the immune system, particularly immune cells known as macrophages. In MS these cells are very active already and further stimulation could worsen the disorder.

Prognosis

It is difficult to predict how MS will progress in any one person. Most people with MS will be able to continue to walk and function at their work for many years after their diagnosis. The factors associated with the mildest course of MS are being female, having the relapsing- remitting form, having the first symptoms at a younger age, having longer periods of remission between relapses, and initial symptoms of decreased sensation or vision rather than of weakness or incoordination.

Fewer than 5% of people with MS have a severe progressive form, leading to death from complications within five years. At the other extreme, 10%–20% have a benign form, with a very slow or no progression of their symptoms. Studies have shown that about seven out of ten people with MS are still alive 25 years after their diagnosis, compared to about nine out of ten people of

similar age without disorder. On average, MS shortens the lives of affected women by about 6 years, and men by 11 years. Suicide is a significant cause of death in MS, especially in younger patients. Suicide is completed 7.5 times more often in patients with MS than in those without the disorder.

The degree of disability a person experiences five years after onset is, on average, about three-quarters of the expected disability at 10–15 years. A benign course for the first five years usually indicates the disorder will not cause marked disability.

Healthcare team roles

Physicians provide initial diagnoses. Neurologists may support diagnoses and monitor disease progression. Physi- cal and occupational therapists provide exercise and environmental support for relief from muscle strains and weakness. Radiologists are important in documenting disease progression. Psychiatrists, psychologists, and other therapists may be helpful in treating depression that may accompany MS. Nurses provide bedside care, education for the patient and caregiver, preparation for home manage- ment of the disease, and home safety assessment.

KEY TERMS

Clinical trial—All new drugs undergo clinical trials before approval. Clinical trials are carefully con- ducted tests in which effectiveness and side effects are studied, with the placebo effect eliminated.

Evoked potentials—Tests that measure the brain’s electrical response to stimulation of sensory organs (eyes or ears) or peripheral nerves (skin). These tests may help confirm the diagnosis of MS.

Myelin—A layer of insulation that surrounds the nerve fibers in the brain and spinal cord.

Plaque—Patches of scar tissue that form where the layer of myelin covering the nerve fibers is destroyed by the MS disorder process.

Primary progressive—A pattern of symptoms of MS in which the disorder progresses without remission, or with occasional plateaus or slight improvements.

Relapsing-remitting—A pattern of symptoms of MS in which symptomatic attacks occur that last 24 hours or more, followed by complete or almost complete improvement.

Secondary progressive—A pattern of symptoms of MS in which there are relapses and remissions, followed by more steady progression of symptoms.

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Prevention

There is no known way to prevent MS. Until the cause of the disorder is discovered, this is unlikely to change. Good nutrition; adequate rest; avoidance of stress, heat, and extreme physical exertion; and good bladder hygiene may improve quality of life and reduce symptoms.

Resources

BOOKS Aminoff, Michael, David Greenberg, and Roger Simon. Clinical

Neurology, 9th ed. New York: McGraw-Hill Professional/ Lange, 2015.

Bennett, Robin L. The Practical Guide to the Genetic Family History, 2nd ed. New York: Wiley-Blackwell, 2010.

Blackstone, Margaret. The First Year: Multiple Sclerosis: An Essential Guide for the Newly Diagnosed. New York: Marlowe, 2007.

Finlayson, Marcia, ed. Multiple Sclerosis Rehabilitation: From Impairment to Participation. Boca Raton, FL: CRC Press, 2012.

Ruggieri, Martino, Luigi Grimaldi, and Agata Polizzi, eds. Multiple Sclerosis in Childhood: And Other Immune– mediated Disorders of the Central Nervous System in Children. New York: Springer, 2012.

Schaaf, Christian, Johannes Zschocke, and Lorraine Potocki. Human Genetics: From Molecules to Medicine. New York: Wolters Kluwer, 2011.

Weiner, Howard L., and James M. Stankiewicz, eds.Multiple Sclerosis: Diagnosis and Therapy. Hoboken, NJ: Wiley- Blackwell, 2012.

PERIODICALS “9B Multiple sclerosis.” Nurse Practitioners’ Prescribing

Reference (Fall 2012): 169. Aschenbrenner, Diane S. “Multiple sclerosis drug fingolimod

receives new safety warnings related to cardiovascular risk.” American Journal of Nursing (September 2012): 23.

Chataway, Jeremy. “Treating multiple sclerosis with vitamin D.” Journal of Neurology, Neurosurgery and Psychiatry 83.5 (2012): 473.

Corthals, Angelique P. “Multiple sclerosis is not a disease of the immune system.” Quarterly Review of Biology 86.4 (2011): 287.

“Drugs in clinical development for multiple sclerosis: summary and table.” Pharmaceutical Medicine 26.2 (2012): 103.

Kuehn, Bridget M. “Scientists probe strategies to repair neuron damage in multiple sclerosis.” JAMA, The Journal of the American Medical Association 305.9 (2011): 871.

McLeod, James. “Overcoming multiple sclerosis.” The Medical Journal of Australia (7 February 2011): 145.

Pender, Michael P. “The Essential Role of Epstein-Barr Virus in the Pathogenesis of Multiple Sclerosis.” The Neuroscientist 17.4 (2011): 351–367.

“Tracking multiple sclerosis patients.” Canadian Nurse 107.5 (2011): 9.

Yeh, E. Ann. “Management of children with multiple sclerosis.” Pediatric Drugs 14.3 (2012): 165.

QUESTIONS TO ASK YOUR PROVIDER

• What are the indications that I may have multiple sclerosis?

• What symptom pattern for multiple sclerosis do I have?

• What diagnostic tests are needed for a thorough assessment?

• Can you estimate how rapidly my symptoms will progress?

• What treatment options do you recommend for me?

• What kind of changes can I expect to see with the medications you have prescribed for me?

• What are the side effects associated with the medications you have prescribed for me?

• Will medications for multiple sclerosis interact with my current medications?

• What kind of specialists should I contact?

• What tests or evaluation techniques will you perform to see if treatment has been beneficial for me?

• What changes in my health can I expect to see as my condition progresses?

• What physical or psychological limitations do you foresee?

• Will physical, occupational, or speech therapy benefit me?

• Does having multiple sclerosis put me at risk for other health conditions?

• How can my quality of life be improved?

• What research is being done to learn more about multiple sclerosis?

• What symptoms are important enough that I should seek immediate treatment?

• Can you recommend an organization that will provide me with additional information about multiple sclerosis?

• Can you refer me to a qualified person who can make an assessment of my home and recom- mend changes to make it safer and easier for me to get around?

• Can you recommend any support groups for me and my family?

2366 GALE ENCYCLOPEDIA OF NURSING AND ALLIED HEALTH, 4TH EDITION

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ORGANIZATIONS

American Academy of Physical Medicine and Rehabilitation, 9700 W. Bryn Mawr Ave., Ste. 200, Rosemont, IL 60018- 5701, (847) 737-6000, (877) 227-6799, info@aapmr.org, http://www.aapmr.org.

Multiple Sclerosis Foundation, 6350 N Andrews Ave., Fort Lauderdale, FL 33309, (954) 776-6805, (888) 673-6287, Fax: (954) 351-0630, support@msfocus.org, https:// msfocus.org.

National Institute of Neurological Disorders and Stroke, PO Box 5801, Bethesda, MD 20824, (301) 496-5751, (800) 352- 9424, http://www.ninds.nih.gov.

National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892, (301) 496-4000, NIHinfo@od.nih. gov, http://www.nih.gov.

National Multiple Sclerosis Society, 101A First Ave., Waltham, MA 02451, (800) 344-4867, Fax: (781) 890-2089, nationalmssocietyGNE@nmss.org, http://www.national mssociety.org.

U.S. National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894, (301) 594-5983, (888) 346-3656, http://www.nlm.nih.gov.

Tish Davidson, AM L. Fleming Fallon, Jr, MD, DrPH

Genevieve T. Slomski, PhD Revised by Laura Jean Cataldo, RN, EdD

Multiple-gated acquisition (MUGA) scan

Definition

The multiple-gated acquisition (MUGA) scan, also called a cardiac blood pool study, is a non-invasive nuclear medicine test that displays the distribution of a radioactive tracer in the heart. The images of the heart are obtained at intervals throughout the cardiac cycle and are used to calculate ejection fraction and evaluate regional myocardial wall motion.

Purpose

A MUGA scan may be done at rest and with stress. The resting study is primarily performed to obtain the ejection fraction of the right and left ventricles, to evaluate the left ventricular regional wall motion, to assess the effects of cardiotoxic drugs (i.e., chemotherapy), and to differentiate the cause of shortness of breath (pulmonary vs. cardiac). Ejection fraction and wall motion are also important measurements made during a stress study, but the stress study is performed primarily to detect coronary artery disease and to evaluate angina.

Precautions

The use of a radioactive material is required to perform this study, so pregnant women should not have this test unless absolutely necessary. Women who are breast feeding are asked to stop for a specified period of time, typically 24 hours. Patients who have had other recent nuclear medicine studies may need to wait until residual radioactivity in the body has cleared before having this test.

Description

The MUGA scan is a series of images that demonstrate the flow of blood through the heart, enabling clinicians to obtain information about heart muscle activity. Before images are taken, a radionuclide is injected into the bloodstream, a process that requires two injections in most institutions. The first contains a chemical that adheres to red blood cells, and the second contains a radioactive tracer (Tc99m) that attaches to that chemical. Alternatively, the two chemicals can be mixed together first and then injected, but the material then tends to accumulate in bone and may obscure the heart.

A gamma camera takes the pictures, which is driven by a computer program that times the pictures, processes the information, and performs the mathematical calcula- tions to provide ejection fraction and demonstrate wall motion. Images are obtained at various intervals during the cardiac cycle. Electrodes are placed on the patient so that a time frame can be established, for example, the time period between each “R” wave. The time frame is divided into several intervals, or “multiple gates.” The result is a series of pictures showing the left and right ventricles at end-diastole and end-systole, and a number of stages in between.

A MUGA scan is performed in a hospital nuclear medicine department or in an out-patient facility and takes approximately 30 minutes to one hour. The patient lies down on a bed alongside the gamma camera and receives the radionuclide injections, then multiple images are taken. If a stress study is indicated, the rest study is performed first. For stress, the patient usually lies on a special bed fitted with a bicycle apparatus. While an image is being recorded, the patient is asked to cycle for about two minutes, then the resistance of the wheels are increased. After another two minutes of exercise, another image is obtained and the resistance is increased again. Blood pressure and ECG are also monitored. After the stress portion is finished, one more resting, or recovery, study is obtained.

Preparation

Standard preparation an ECG for is required. In addition, special handling of nuclear materials may be required for the injections.

GALE ENCYCLOPEDIA OF NURSING AND ALLIED HEALTH, 4TH EDITION 2367

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COPYRIGHT 2018 Gale, Cengage Learning WCN 02-200-210

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