Case 6 - Multiple Sclerosis

Question 1

1. Which section of the MCA 2005 refers to lasting powers of attorney?
2. What 2 decisions can a person confer authority on another for?
3. How old must a person be to confer an LPA?
4. What must a person have before they can confer a LPA?

Answer 1

1. Section 9
2. Financial matters, and their personal welfare
3. 18 years old
4. Capacity

Question 2

1. How old must a person be to make an advanced decision?
2. What must the patient do in order for an AD to be valid?
3. Does a withdrawal of an AD need to be in writing?
4. What can nullify an advanced decision?
5. What are the 3 things that can invalidate an AD?
6. What must an AD in relation to life sustaining treatment have? (2)
7. What are the barriers to advanced care planning? (5)

Answer 2

1. 18 yrs old
2. Must specify the treatment they are refusing
3. No
4. A lasting power of attorney
5. Treatment not being specified, Any specified circumstances are absent, or if there are reasonable grounds to believe patient didnt anticipate something
6. In writing and witnessed, patient must make clear that it is to apply in that situation
7. Lack of skills, difficult conversations, resources, logistics, inequality in terms of access

Question 3

1. What is an advanced statement?
2. What is its effect?
3. Is it legally binding?

Answer 3

1. Statement setting down preferences etc regarding future care
2. Provides guidance to those making decisions about the patient (Best interests)
3. No, only advisory

Question 4

1. Do patients with capacity have the right to refuse treatment?
2. Is there a right to demand treatment?
3. Which case demonstrates this?

Answer 4

1. Yes
2. No
3. R v Burke

Question 5

1. What does the double effect doctrine say?
2. What does s2 of the suicide act 1961 say?
3. What does s1 say?
4. What was the result of R v Purdy & Pretty v UK?

Answer 5

1. Doctors who administer medication to relieve a patients pain and suffering, but which could cause their death are legally protected
2. It is an offence to aid and abet the suicide of another person
3. Suicide is legal, no crime is committed
4. DPP set out factors which would lead to prosecution of a person aiding another to commit suicide. Doctors will very likely always be charged. There is no right to die in the UK

Question 6

1. What is the aim of end of life care?
2. What is palliative care?

Answer 6

1. To allow a person to live as well as possible and die with dignity
2. Making a patient as confortable as possible with psychological, social and spiritual support for them

Question 7

1. What are the 2 aspects of the health belief model?
2. What are the 2 key beliefs of threat perception?
3. What are the 2 key beleifs of behavioural evaluation?

Answer 7

1. Threat perception and behavioural evaluation
2. susceptibility to illness or health problems & anticipated severity of the illness
3. beliefs about the benefits of a recommended health behaviour & concerning the costs of or barriers to enacting that behaviour

Question 8

1. What is stress?
2. What is a stressor?
3. What are the physiological symptoms of stress? (4)
4. What is activated when a situation is deemed stressful?
5. What is the short term response by the body? what pathway?
6. What is the long term response? what pathway?

Answer 8

1. Physiological response when we encounter a threat we feel we dont have the resources to deal with
2. Stimulus that causes stress
3. Increased HR, BR, decrease in digestive activity, and liver releases glucose for energy
4. Hypothalamus
5. Fight or flight response - Sympathomedullary pathway
6. Hypothalamic pituitary adrenal pathway

Question 9

1. In the HPA axis what is activated first?
2. What does this then stimulate?
3. What hormone is secreted?
4. What is the purpose of it?
5. What does it also do which can be detrimental?

Answer 9

1. Hypothalamus
2. Pituitary gland
3. Adenocorticotropic hormone (ACTH)
4. Enables body to maintain steady supply of glucose to cope with the stressor
5. Suppresses the immune system

Question 10

1. In the SAM pathway, what is activated first?
2. What does it then activate?
3. What does this secrete?
4. What is the physiological response? (2)
5. What happens when the threat is over?

Answer 10

1. Hypothalamus
2. Adrenal medulla
3. Adrenaline
4. Leads to arousal of SNS and reduces activity of PNS (Decrease in digestion etc)
5. When threat is over, the PNS takes over and balances the body again

Question 11

1. What are the 2 types of coping responses?
2. What is emotion focused coping?
3. When is this useful?
4. Is it useful?
5. Who is more likely to use this method of coping? (Men or women)
6. What is problem focused coping?
7. Is it useful?

Answer 11

1. Emotion focused coping & Problem focused coping
2. Aim is to reduce negative emotional responses associated with stress
3. When the source of the stress is outside the persons control
4. No, Doesnt provide long term solution, just delays the persons problem
5. Women
6. Targets the cause of the stress, such as using social support or problem solving
7. Yes as it deals with the root cause of the stress, but only works if the stressor is within their control

Question 12

1. How are neurons classified?

Identify the different types of neurons:

• Unipolar
• Bipolar
• Multipolar
• Pseudo-unipolar

Answer 12

1. Based on the number of axons and dendrites that extend from the soma

Question 13

1. What are the other types of glial cells? (4)
2. What is the difference between an oligodendrocyte, and a Schwann cell?
3. What is the function of Astrocyctes?
4. What is the function of myelin sheaths?
5. What is the function of microglia?
6. What is the function of epedymal cells?

Answer 13

1. Astrocytes, Oligodendrocytes, Microglia, Ependymal cells
2. Oligodendrocytes - CNS and can myelinate more than 1 axon, Schwann cells - PNS
3. They influence the growth and retraction of neurons, and regulate the chemical content of the brain (BBB)
4. They insulate axons, speed up nerve impulses
5. Phagocytes which remove debris in the brain
6. Line the ventricles, direct cell migration during development

Question 14

1. What is the lipid that makes up the myelin sheath?
2. What are the 3 glycoproteins that make up the myelin sheath?

Answer 14

1. Galactocerebroside
2. MBP, MOG, and MAG

Question 15

1. What is Multiple sclerosis?
2. What are the 4 possible causes of MS?
3. What is the condition called when it is in the peripheral nervous system?
4. Which nerve is most often affected in MS? What is this called?

Answer 15

1. De-myelinating disease
2. Immune mediated destruction of myelin, Leukoencephalopathy (Infection), Inherited disorders which affect synthesis of myelin, and Leukodystrophies
3. Gullian Barre syndrome
4. CN II, Optic Neuritis

Question 16

1. What causes MS lesions?
2. What is the cause of the neurological deficits?

Answer 16

1. Auto-immune response directed against components of myelin sheath
2. Loss of saltatory conduction, slower conduction which can lead to inefficiency or conduction block

Question 17

1. Which nervous system cells initiate the response?
2. What do TH1 cells secrete? What does this do?
3. What do TH17 cells secrete? What does this do?
4. Which T cells are responsible for the damage?
5. What is believed to cause the cells to attack the myelin?
6. Which interleukins are thought to be involved?

Answer 17

1. TH1 & TH17
2. IFN Gamma - activation of macrophages
3. Recruitment of leukocytes
4. CD4 & CD8 T cells, and Macrophages
5. The homologous myelin proteins which look like foreign proteins, causing them to be attacked.
6. IL 2 & IL 7

Question 18

1. What determines the symptoms of MS for the patient?

Answer 18

1. Which area of the brain is affected

Question 19

1. Are the myelin sheaths formed during remylination the same?
2. What cells promote remyelination?
3. What sends the signal that remyelination is needed?
4. What molecule plays a key role in their differentiation?

Answer 19

1. No, they are thinner, but provide protection from further damage
2. Oligodendrocyte precursor cells
3. Microglia or astrocytes at the injured axon site
4. TNF alpha

Question 20

1. What is the BBB?
2. What happens in an active plaque?
3. What cells can be found there?
4. What is found in an inactive plaque?
5. Which cells are found?
6. What is a shadow plaque?

Answer 20

1. Capillary system which prevents foreign bodies, and immune cells from entering the brain
2. There is ongoing myelin breakdown with macrophages containing lipid rich PAS debris
3. Lymphocytes and monocytes and activated microglia containing myelin degredation products
4. Little or no myelin is found, and there is a reduction in the number of oligodendrocytes
5. Astrocytes proliferate in the area, and there is gliosis
6. In between inactive and normal, thinned out myelin but not gone.

Question 21

1. What is an MS relapse?
2. How long must the symptoms last for? What must not be present?
3. What is a remission in MS?

Answer 21

1. An attack which leads to the worsening of MS symptoms
2. At least 24hrs, and in absence of fever or infection
3. Improvement for the patient, no new signs of disease. When symptoms of an attack subside

Question 22

1. What is benign MS?
2. What is Relapsing remitting MS?
3. What is secondary progressive MS?
4. What is primary progressive MS?
5. What is progressive relapsing MS?
6. Which is most common?

Answer 22

1. Deficits resolve between attacks, disability in the long term
2. Unpredictable relapses (Attacks), may not leave permanent deficits with periods of improvement (Remission)
3. Initially there are relapses and remission, then progresses with more neurological deficits
4. Steady increase in disability with no remission. Decline is continous
5. Steady decline with relapses superimposed
6. Relapsing remitting MS is most common

Question 23

Which graph corresponds to which course:

• Relapsing remitting MS
• Secondary progressive MS
• Primary progressive MS
• Progressive relapsing MS

Answer 23

Question 24

1. What is the prevalence of MS in the UK?
2. Are men more affected than women?

Answer 24

1. Affects 1 in 500 people in the UK
2. No, women are more affected 3:1

Question 25

1. What is the link between vitamin D and MS? 2. How is it relevant?

Answer 25

1. People with high levels of vitamin D are less likely to develop MS 2. Due to its use in the regulation of the immune system

Question 26

1. What are the changes in the CSF of a person with MS? 2. How is the CSF obtained? 3. What proteins are present in the CSF of a MS sufferer?

Answer 26

1. Increased IgG levels 2. Lumbar puncture 3. Oligoclonal bands

Question 27

1. What are the Mcdonald criteria used for? 2. What is required in terms of lesions? 3. What is the time requirement?

Answer 27

1. Early diagnosis of MS 2. Lesions in 2 areas out of 4 (Periventricular, juxtacortical, infratentorial, or spinal cord) 3. Must have new lesion with reference to baseline scan (2 attacks at least)

Question 28

1. What are MRI scans used for? 2. What does it image? 3. Which molecule? 4. What is emitted by the protons? 5. What will be seen in non-myelinated areas?

Answer 28

1. Imaging the brain, spinal cord, etc. 2. Measuring water content in tissue 3. H+ or protons 4. Resonance signals, which are picked up 5. More water content - so bright spot or darkened area

Question 29

1. What is a T1 weighted scan? 2. What does it show? 3. Why is it useful?

Answer 29

1. MRI exhanced with Gadolinium 2. Shows areas of active inflammation 3. Shows areas where the BBB has broken down, shouldnt normally cross it

Question 30

1. What are the better prognostic factors? 2. Which are the poor prognostic factors?

Answer 30

1. Being female, caucasian, and low relapse rate 2. non-white, male, smokers, high relapse rate

Question 31

1. What are the 7 components of a neurological exam?

Answer 31

1. General appearance 2. Mini mental status exam 3. Cranial nerve examination 4. Motor system examination 5. Sensory system examination 6. Reflex exam 7. Coordination exam

Question 32

1. What is the visual evoked potential test? 2. What does it detect? 3. How is this relevant for MS? 4. What are the 3 other types of evoked potential?

Answer 32

1. Measures electrical activity of brain in response to stimulation 2. Detects slowing of electrical conduction 3. Can show demyelination as this would lead to slowed conduction 4. Visual evoked potential, brainstem auditory evoked potentials, sensory evoked potentials

Question 33

1. What are some of the symtpoms of Major Depressive disorder? 2. What must the patient have to be diagnosed under DSM IV? 3. Within what time period must they have these symptoms?

Answer 33

1. Low mood, self esteem, loss of libido, sleep disturbance 2. Little interest or pleasure in things nearly every day & Feeling down and depressed more than half of the days 3. 2 weeks

Question 34

1. What areas are thought to be involved? (3) 2. What are the 2 types of depressive syndrome? 3.

Answer 34

1. Amygdala, Hippocampus, Prefrontal cortex 2. Unipolar depression & Bipolar depression

Question 35

1. What is unipolar depression? 2. What is bipolar depression? 3. What happens when a person has more depressive episodes?

Answer 35

1. Non-familial, associated with stressful life events 2. Mix of depression & mania 3. They are more likely to have more depressive episodes

Question 36

1. What are the areas of ventral neural system? (5) 2. Is it overactive or underactive?

Answer 36

1. Ventral anterior cingulate, lateral orbitfrontal cortex, medial thalamus, ventral striatum, amygdala 2. Overactive - Amygdala, and Ventral anterior cingulate. Depressed mood

Question 37

1. What are the areas of the dorsal neural system? 2. Is it underactive or overactive?

Answer 37

1. Hippocampus, Dorsal anterior cingulate, DLPFC 2. Underactive - leads to apathy, deficits in attention

Question 38

1. What are the genetic vulnerabilities which lead to MDD? 2. What are the 3 variations of the gene? 3. Which has a higher likelihood of MDD? 4. What is the normal combination of the alleles?

Answer 38

1. 5-HT reuptake transporter gene 2. short/short (s/s), short/long (s/l), Long/Long (l/l) 3. s/s 4. s/l

Question 39

1. Which serotonin receptors are positive? 2. What type of receptors are they? 3. What does NA do to th 5HT receptor? 4. What does the a2 receptor do?

Answer 39

1. All except for 5HT1 and 5HT5 2. All are G protein except for 5HT3 3. Activates a1 receptor, Increases firing of the 5HT cell 4. Decrease firing, so switches off 5-HT release

Question 40

1. What is thought to be the cause of depression? 2. What hormone is increased in the brain? (2) 3. What does this affect? 4. What causes the decrease in hippocampal volume?

Answer 40

1. Deficit of NA and 5-HT transmitters 2. Corticotrophin releasing hormone (CRH) & Cortisol 3. Dysregulates the amygdala, and increases MAO so decreases NT's 4. Decrease in BDNF or malfunction of its receptor (TrkB)