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End-Stage

Multiple Sclerosis (MS)

Please watch this 2:28 minute video explaining Multiple Sclerosis. 

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What is Multiple Sclerosis?

 

 

 

 

 

 

Overview

Multiple sclerosisOpen pop-up dialog box

Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system).

In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.

Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected. Some people with severe MS may lose the ability to walk independently or at all, while others may experience long periods of remission without any new symptoms.

There's no cure for multiple sclerosis. However, treatments can help speed recovery from attacks, modify the course of the disease and manage symptoms.

Symptoms

Myelin damage and the nervous system.

Multiple sclerosis signs and symptoms may differ greatly from person to person and over the course of the disease depending on the location of affected nerve fibers. Symptoms often affect movement, such as:

  • Numbness or weakness in one or more limbs that typically occurs on one side of your body at a time, or your legs and trunk

  • Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign)

  • Tremor, lack of coordination or unsteady gait

Vision problems are also common, including:

  • Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement

  • Prolonged double vision

  • Blurry vision

Multiple sclerosis symptoms may also include:

  • Slurred speech

  • Fatigue

  • Dizziness

  • Tingling or pain in parts of your body

  • Problems with bowel and bladder function

When to see a doctor

See a doctor if you experience any of the above symptoms for unknown reasons.

Disease course

Most people with MS have a relapsing-remitting disease course. They experience periods of new symptoms or relapses that develop over days or weeks and usually improve partially or completely. These relapses are followed by quiet periods of disease remission that can last months or even years.

Small increases in body temperature can temporarily worsen signs and symptoms of MS, but these aren't considered true disease relapses.

At least 50% of those with relapsing-remitting MS eventually develop a steady progression of symptoms, with or without periods of remission, within 10 to 20 years from disease onset. This is known as secondary-progressive MS.

The worsening of symptoms usually includes problems with mobility and gait. The rate of disease progression varies greatly among people with secondary-progressive MS.

Some people with MS experience a gradual onset and steady progression of signs and symptoms without any relapses, known as primary-progressive MS.

Causes

The cause of multiple sclerosis is unknown. It's considered an autoimmune disease in which the body's immune system attacks its own tissues. In the case of MS, this immune system malfunction destroys the fatty substance that coats and protects nerve fibers in the brain and spinal cord (myelin).

Myelin can be compared to the insulation coating on electrical wires. When the protective myelin is damaged and the nerve fiber is exposed, the messages that travel along that nerve fiber may be slowed or blocked.

It isn't clear why MS develops in some people and not others. A combination of genetics and environmental factors appears to be responsible.

Risk factors

These factors may increase your risk of developing multiple sclerosis:

  • Age. MS can occur at any age, but onset usually occurs around 20 and 40 years of age. However, younger and older people can be affected.

  • Sex. Women are more than two to three times as likely as men are to have relapsing-remitting MS.

  • Family history. If one of your parents or siblings has had MS, you are at higher risk of developing the disease.

  • Certain infections. A variety of viruses have been linked to MS, including Epstein-Barr, the virus that causes infectious mononucleosis.

  • Race. White people, particularly those of Northern European descent, are at highest risk of developing MS. People of Asian, African or Native American descent have the lowest risk.

  • Climate. MS is far more common in countries with temperate climates, including Canada, the northern United States, New Zealand, southeastern Australia and Europe

  • Vitamin D. Having low levels of vitamin D and low exposure to sunlight is associated with a greater risk of MS.

  • Certain autoimmune diseases. You have a slightly higher risk of developing MS if you have other autoimmune disorders such as thyroid disease, pernicious anemia, psoriasis, type 1 diabetes or inflammatory bowel disease.

  • Smoking. Smokers who experience an initial event of symptoms that may signal MS are more likely than nonsmokers to develop a second event that confirms relapsing-remitting MS.

Complications

People with multiple sclerosis may also develop:

  • Muscle stiffness or spasms

  • Paralysis, typically in the legs

  • Problems with bladder, bowel or sexual function

  • Mental changes, such as forgetfulness or mood swings

  • Depression

  • Epilepsy

Diagnosis

Neurological exam

There are no specific tests for MS. Instead, a diagnosis of multiple sclerosis often relies on ruling out other conditions that might produce similar signs and symptoms, known as a differential diagnosis.

Your doctor is likely to start with a thorough medical history and examination.

Spinal tap (lumbar puncture)

MRI multiple sclerosis lesions

Your doctor may then recommend:

  • Blood tests, to help rule out other diseases with symptoms similar to MS. Tests to check for specific biomarkers associated with MS are currently under development and may also aid in diagnosing the disease.

  • Spinal tap (lumbar puncture), in which a small sample of cerebrospinal fluid is removed from your spinal canal for laboratory analysis. This sample can show abnormalities in antibodies that are associated with MS. A spinal tap can also help rule out infections and other

       conditions with symptoms similar to MS.

  • MRI, which can reveal areas of MS (lesions) on your brain and spinal cord. You may receive an intravenous injection of a contrast material to highlight lesions that indicate your disease is in an active phase.

  • Evoked potential tests, which record the electrical signals produced by your nervous system in response to stimuli. An evoked potential test may use visual stimuli or electrical stimuli. In these tests, you watch a moving visual pattern, or short electrical impulses are applied to nerves in your legs or arms. Electrodes measure how quickly the information travels down your nerve pathways.

In most people with relapsing-remitting MS, the diagnosis is fairly straightforward and based on a pattern of symptoms consistent with the disease and confirmed by brain imaging scans, such as MRI.

Diagnosing MS can be more difficult in people with unusual symptoms or progressive disease. In these cases, further testing with spinal fluid analysis, evoked potentials and additional imaging may be needed.

Treatments for MS attacks

  • Corticosteroids, such as oral prednisone and intravenous methylprednisolone, are prescribed to reduce nerve inflammation. Side effects may include insomnia, increased blood pressure, increased blood glucose levels, mood swings and fluid retention.

  • Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then mixed with a protein solution (albumin) and put back into your body. Plasma exchange may be used if your symptoms are new, severe and haven't responded to steroids.

Treatments to modify progression

For primary-progressive MS, ocrelizumab (Ocrevus) is the only FDA-approved disease-modifying therapy (DMT). Those who receive this treatment are slightly less likely to progress than those who are untreated.

For relapsing-remitting MS, several disease-modifying therapies are available.

Much of the immune response associated with MS occurs in the early stages of the disease. Aggressive treatment with these medications as early as possible can lower the relapse rate, slow the formation of new lesions, and potentially reduce risk of brain atrophy and disability accumulation.

Many of the disease-modifying therapies used to treat MS carry significant health risks. Selecting the right therapy for you will depend on careful consideration of many factors, including duration and severity of disease, effectiveness of previous MS treatments, other health issues, cost, and child-bearing status.

Treatment options for relapsing-remitting MS include injectable and oral medications.

(www.mayoclinic.org)

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What Is Prostate Cancer?

The Facts:

Prostate cancer represents the second most common cancer in men worldwide and the fifth most common cause of cancer death in men; in the United States, it is the most common cancer in men and the second most common cause of cancer deaths in men. Acinar adenocarcinoma of the prostate comprises 90-95% of prostate cancers diagnosed.

Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the body can become cancer cells, and can then spread to other areas of the body. 

Prostate cancer begins when cells in the prostate gland start to grow out of control. The prostate is a gland found only in males. It makes some of the fluid that is part of semen.

The prostate is below the bladder (the hollow organ where urine is stored) and in front of the rectum (the last part of the intestines). Just behind the prostate are glands called seminal vesicles that make most of the fluid for semen. The urethra, which is the tube that carries urine and semen out of the body through the penis, goes through the center of the prostate.

 

 

The size of the prostate can change as a man ages. In younger men, it is about the size of a walnut, but it can be much larger in older men.

Types of prostate cancer

Almost all prostate cancers are adenocarcinomas. These cancers develop from the gland cells (the cells that make the prostate fluid that is added to the semen).

Other types of cancer that can start in the prostate include:

  • Small cell carcinomas

  • Neuroendocrine tumors (other than small cell carcinomas)

  • Transitional cell carcinomas

  • Sarcomas

 

These other types of prostate cancer are rare. If you are told you have prostate cancer, it is almost certain to be an adenocarcinoma.

Some prostate cancers grow and spread quickly, but most grow slowly. In fact, autopsy studies show that many older men (and even some younger men) who died of other causes also had prostate cancer that never affected them during their lives. In many cases, neither they nor their doctors even knew they had it.

Possible pre-cancerous conditions of the prostate

Some research suggests that prostate cancer starts out as a pre-cancerous condition, although this is not yet known for sure. These conditions are sometimes found when a man has a prostate biopsy (removal of small pieces of the prostate to look for cancer).

Prostatic intraepithelial neoplasia (PIN)

In PIN, there are changes in how the prostate gland cells look when seen with a microscope, but the abnormal cells don’t look like they are growing into other parts of the prostate (like cancer cells would). Based on how abnormal the patterns of cells look, they are classified as:

  • Low-grade PIN: The patterns of prostate cells appear almost normal.

  • High-grade PIN: The patterns of cells look more abnormal.

 

Low-grade PIN is not thought to be related to a man’s risk of prostate cancer. On the other hand, high-grade PIN is thought to be a possible precursor to prostate cancer. If you have a prostate biopsy and high-grade PIN is found, there is a greater chance that you might develop prostate cancer over time.

PIN begins to appear in the prostates of some men as early as in their 20s. But many men with PIN will never develop prostate cancer.

Proliferative inflammatory atrophy (PIA)

In PIA, the prostate cells look smaller than normal, and there are signs of inflammation in the area. PIA is not cancer, but researchers believe that PIA may sometimes lead to high-grade PIN, or perhaps directly to prostate cancer.

Prostate Cancer Risk Factors

A risk factor is anything that raises your risk of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person’s age or family history, can’t be changed.

But having a risk factor, or even several, does not mean that you will get the disease. Many people with one or more risk factors never get cancer, while others who get cancer may have had few or no known risk factors.

Researchers have found several factors that might affect a man’s risk of getting prostate cancer.

 

Age

Prostate cancer is rare in men younger than 40, but the chance of having prostate cancer rises rapidly after age 50. About 6 in 10 cases of prostate cancer are found in men older than 65.

Race/ethnicity

Prostate cancer develops more often in African-American men and in Caribbean men of African ancestry than in men of other races. And when it does develop in these men, they tend to be younger. Prostate cancer occurs less often in Asian-American and Hispanic/Latino men than in non-Hispanic whites. The reasons for these racial and ethnic differences are not clear.

Geography

Prostate cancer is most common in North America, northwestern Europe, Australia, and on Caribbean islands. It is less common in Asia, Africa, Central America, and South America.

The reasons for this are not clear. More intensive screening for prostate cancer in some developed countries probably accounts for at least part of this difference, but other factors such as lifestyle differences (diet, etc.) are likely to be important as well. For example, Asian Americans have a lower risk of prostate cancer than white Americans, but their risk is higher than that of men of similar ethnic backgrounds living in Asia.

Family history

Prostate cancer seems to run in some families, which suggests that in some cases there may be an inherited or genetic factor. Still, most prostate cancers occur in men without a family history of it.

Having a father or brother with prostate cancer more than doubles a man’s risk of developing this disease. (The risk is higher for men who have a brother with the disease than for those who have a father with it.) The risk is much higher for men with several affected relatives, particularly if their relatives were young when the cancer was found.

Gene changes

Several inherited gene changes (mutations) seem to raise prostate cancer risk, but they probably account for only a small percentage of cases overall. For example:

  • Inherited mutations of the BRCA1 or BRCA2 genes, which are linked to an increased risk of breast and ovarian cancers in some families, can also increase prostate cancer risk in men (especially mutations in BRCA2).

  • Men with Lynch syndrome (also known as hereditary non-polyposis colorectal cancer, or HNPCC), a condition caused by inherited gene changes, have an increased risk for a number of cancers, including prostate cancer.

 

Other inherited gene changes can also raise a man’s risk of prostate cancer. 

Factors with less clear effects on prostate cancer risk:

Diet

The exact role of diet in prostate cancer is not clear, but several factors have been studied.

Men who eat a lot of dairy products appear to have a slightly higher chance of getting prostate cancer.

Some studies have suggested that men who consume a lot of calcium (through food or supplements) may have a higher risk of developing prostate cancer. But most studies have not found such a link with the levels of calcium found in the average diet, and it’s important to note that calcium is known to have other important health benefits.

Obesity

Being obese (very overweight) does not seem to increase the overall risk of getting prostate cancer.

Some studies have found that obese men have a lower risk of getting a low-grade (slower growing) form of the disease, but a higher risk of getting more aggressive (faster growing) prostate cancer. The reasons for this are not clear.

Some studies have also found that obese men may be at greater risk for having more advanced prostate cancer and of dying from prostate cancer, but not all studies have found this.

Smoking

Most studies have not found a link between smoking and getting prostate cancer. Some research has linked smoking to a possible small increased risk of dying from prostate cancer, but this finding needs to be confirmed by other studies.

Chemical exposures

There is some evidence that firefighters can be exposed to chemicals that may increase their risk of prostate cancer.

A few studies have suggested a possible link between exposure to Agent Orange, a chemical used widely during the Vietnam War, and the risk of prostate cancer, although not all studies have found such a link. The National Academy of Medicine considers there to be “limited/suggestive evidence” of a link between Agent Orange exposure and prostate cancer. 

Inflammation of the prostate

Some studies have suggested that prostatitis (inflammation of the prostate gland) may be linked to an increased risk of prostate cancer, but other studies have not found such a link. Inflammation is often seen in samples of prostate tissue that also contain cancer. The link between the two is not yet clear, and this is an active area of research.

Sexually transmitted infections

Researchers have looked to see if sexually transmitted infections (like gonorrhea or chlamydia) might increase the risk of prostate cancer, because they can lead to inflammation of the prostate. So far, studies have not agreed, and no firm conclusions have been reached.

Vasectomy

Some studies have suggested that men who have had a vasectomy (minor surgery to make men infertile) have a slightly increased risk for prostate cancer, but other studies have not found this. Research on this possible link is still under way.

Can Prostate Cancer Be Found Early?

Screening is testing to find cancer in people before they have symptoms. For some types of cancer, screening can help find cancers at an early stage, when they are likely to be easier to treat.

Prostate cancer can often be found early by testing for prostate-specific antigen (PSA) levels in a man’s blood. Another way to find prostate cancer is the digital rectal exam (DRE). For a DRE, the doctor puts a gloved, lubricated finger into the rectum to feel the prostate gland.

Concerns about prostate cancer screening

If prostate cancer is found as a result of screening, it will probably be at an earlier, more treatable stage than if no screening were done. While this might make it seem like prostate cancer screening would always be a good thing, there are still issues surrounding screening that make it unclear if the benefits outweigh the risks for most men.

Possible inaccurate or unclear test results

As an example, neither the PSA test nor the DRE is 100% accurate. These tests can sometimes have abnormal results even when a man does not have cancer (known as a false-positive result), or normal results even when a man does have cancer (known as a false-negative result). Unclear test results can cause confusion and anxiety. False-positive results can lead some men to get prostate biopsies (with small risks of pain, infection, and bleeding) when they don’t have cancer. And false-negative results can give some men a false sense of security even though they might actually have cancer.

Over-diagnosis and over-treatment

Another important issue is that even if screening detects prostate cancer, doctors sometimes can’t tell if the cancer is truly dangerous (and therefore needs to be treated). Finding and treating all prostate cancers early might seem to make sense, but some prostate cancers grow so slowly that they would never cause a man problems during his lifetime. 

Because of screening, some men may be diagnosed with a prostate cancer that they would have never known about otherwise. It would never have led to their death, or even caused any symptoms. Finding a ‘disease’ like this that would never cause problems is known as over-diagnosis.

A problem with over-diagnosis in prostate cancer is that many of these men might still be treated with either surgery or radiation, either because the doctor can’t be sure how quickly the cancer might grow and spread, or because the man is uncomfortable knowing he has cancer and is not getting any treatment. Treatment of a cancer that would never have caused any problems is known as over-treatment. The major downside with this is that even if they weren’t needed, treatments like surgery and radiation can still have urinary, bowel, and/or sexual side effects that can seriously affect a man’s quality of life.

Men and their doctors may end up struggling to decide if treatment is needed or if the cancer can just be closely watched without being treated right away (an approach called, "watchful waiting or active surveillance"). Even when men are not treated right away, they still need regular blood PSA tests and prostate biopsies to determine their need for treatment in the future. These tests are linked with risks of anxiety, pain, infection, and bleeding.

Benefits of screening in studies have not been clear

Doctors are still studying if screening tests will lower the risk of death from prostate cancer. The most recent results from 2 large studies were conflicting, and didn’t offer clear answers.

  • Early results from a large study done in the United States found that annual screening with PSA and DRE did detect more prostate cancers than in men not screened, but this screening did not lower the death rate from prostate cancer. However, questions have been raised about this study, because some men in the non-screening group actually were screened during the study, which might have affected the results. 

  • A European study did find a lower risk of death from prostate cancer with PSA screening (done about once every 4 years), but the researchers estimated that about 781 men would need to be screened (and 27 cancers detected) to prevent one death from prostate cancer.

  • Neither of these studies has shown that PSA screening helps men live longer overall (that is, that it lowers the overall death rate).

 

Prostate cancer is often slow-growing, so the effects of screening in these studies might become clearer in the coming years. Both of these studies are being continued to see if longer follow-up will give clearer results. Prostate cancer screening is being studied in several other large studies, as well.

For now, the American Cancer Society recommends that men thinking about getting tested for prostate cancer learn as much as they can so they can make informed decisions based on available information, discussions with their doctor, and their own views on the possible benefits, risks, and limits of prostate cancer screening.

(www.cancer.org)

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Incidence & Mortality of Patients

with Prostate Cancer Worldwide