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NEUROIMMUNOLOGY & MS ELECTIVE



Purpose: The goal of this rotation is to learn principles necessary to evaluate, diagnose, and care for patients with neuro-inflammatory disorders of the nervous system.

LOGISTICS

Faculty Supervisors: Dr. David Benavides, Dr. Dan Harrison (Division Director), Dr. Sarah Fredrich

Responsibilities: Please contact Dr. Harrison ahead of starting the rotation (at least one week) to let him know you are on the rotation. Please also coordinate with Bernice Brown-Wiggins at least 1 week ahead of starting to ensure that she properly schedules you for clinics, as she works to properly distribute residents and students between attendings for outpatient clinic rotations.  During each week, work with each division attending in half-day session in the Frenkil clinic. At each session, perform a complete work up on 1-2 new and/or follow-up patients with a known or suspected diagnosis of MS. You will attempt to gain experience with the management of MS and learn to initiate at least one treatment-naïve patient per week on a MS disease-modifying therapy. You will learn to manage MS breakthrough disease and to assess the treatment of MS disease-associated symptoms. You will evaluate and manage up to 1 patient per week with a non-MS neuroimmunological disorder i.e., neuro-sarcoid, CNS manifestations of a systemic rheumatological disorder, CNS infectious disorder, autoimmune encephalitis.

SYLLABUS 

Goals/Objectives: At the end of the rotation, residents will be expected achieve the following competencies and milestones.

  1. Discuss key points related to the pathogenesis of MS

  2. Review the immunological and pathological features of the disease

  3. Discuss MS risk factors

    1. Genetic

    2. Environmental

  4. Discuss approaches to MS diagnosis

    1. The use of MRI in diagnosis

    2. The application of the McDonald Criteria

    3. Identify diseases that mimic MS and discuss approaches to ruling out these diagnoses

  5. Discuss the clinical features of MS

    1. The clinical features of the MS subtypes

    2. Identification and evaluation of a MS relapse

    3. Discuss MS disease variants

  6. Gain expertise in the treatment and management of MS

    1. Identify and discuss the MS platform disease-modifying therapies

    2. Identify MS treatment failure

    3. Gain experience in decision-making related to switching therapy

    4. Gain experience with MS symptom management

    5. Discuss evaluation of MS-related disability

    6. Discuss management of MS spasticity using a baclofen pump (experience in evaluation for and management using a baclofen pump is provided during the neurorehabilitation subspecialty rotation)

  7. Discuss differential diagnosis of demyelinating and other inflammatory CNS disorders

Key readings

AAN PRACTICE PARAMETERS

  1. Disease modifying therapies: https://www.aan.com/Guidelines/home/GuidelineDetail/898

  2. Rehabilitation in MS: https://www.aan.com/Guidelines/home/GuidelineDetail/720

  3. Assessment and management of psychiatric disorders in MS: https://www.aan.com/Guidelines/home/GuidelineDetail/628

  4. Complementary and Alternative Medicine: https://www.aan.com/Guidelines/home/GuidelineDetail/641

OTHERS

  1. Chapter on Multiple Sclerosis in Merritt’s textbook

  2. Thompson et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald Criteria. Lancet Neurol. 2018 Feb;17(2):162-173. [PMID]

  3. Hardy TA, Reddel SW, Barnett MH, Palace J, Lucchinetti CF, Weinshenker BG. Atypical inflammatory demyelinating syndromes of the CNS. Lancet Neurol. 2016;15:967-81. [PMID: 27478954].

  4. CONTINUUM: Multiple Sclerosis and Other Demyelinating Diseases. June 2016 - Volume 22 - Issue 3 (or most recent version if/when updated).

  5. Reich DS, et al. Multiple Sclerosis. NEJM. 2018 Jan 11;378(2):169-180. [PMID: 29320652]

  6. Myelitis and Other Autoimmune Myelopathies

MS ADVANCED READING

  1. Pathogenesis

    1. Yadav SK, Mindur JE, Ito K, Dhib-Jalbut S. Advances in the immunopathogenesis of multiple sclerosis. Curr Opin Neurol. 2015 Jun;28(3):206-19. [PMID: 25887768].

    2. Farez MF, Correale J. Immunizations and risk of multiple sclerosis: systematic review and meta- analysis. J Neurol. 2011;258:1197-206. [PMID: 21431896].

  2. Diagnosis

    1. Thompson et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald Criteria. Lancet Neurol. 2018 Feb;17(2):162-173. [PMID]

    2. Traboulsee A, Simon JH, Stone L, et al. Revised Recommendations of the Consortium of MS Centers Task Force for a Standardized MRI Protocol and Clinical Guidelines for the Diagnosis and Follow-Up of Multiple Sclerosis. AJNR Am J Neuroradiol. 2016;37(3):394-401. [PMID: 26564433].

    3. Tardieu M, Banwell B, Wolinsky JS, Pohl D, Krupp LB. Consensus definitions for pediatric MS and other demyelinating disorders in childhood. Neurology. 2016 Aug 30;87(9 Suppl 2):S8-S11. [PMID: 27572866].

    4. Miller DH, Weinshenker BG, Filippi M, Banwell BL, Cohen JA, Freedman MS, et al. Differential diagnosis of suspected multiple sclerosis: a consensus approach. Mult Scler. 2008 Nov;14(9):1157-74. [PMID: 18805839].

    5. Lublin FD, Reingold SC, Cohen JA, Cutter GR, et al. Defining the clinical course of multiple sclerosis: the 2013 revisions. Neurology. 2014 Jul 15;83(3):278-86. [PMID: 24871874]

    6. Hardy TA, Reddel SW, Barnett MH, Palace J, Lucchinetti CF, Weinshenker BG. Atypical inflammatory demyelinating syndromes of the CNS. Lancet Neurol. 2016;15:967-81. [PMID: 27478954].

  3. Treatment and management

    1. Any of the phase III, randomized clinical trials of the FDA-approved disease modifying drugs (search pubmed for generic drug name, “multiple sclerosis”, and “randomized”)

    2. Beck RW, Cleary PA, Anderson MM Jr, Keltner JL, Shults WT, Kaufman DI, et al. A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. The Optic Neuritis Study Group. N Engl J Med. 1992;326:581-8. [PMID: 1734247].

    3. Burton JM, O’Connor PW, Hohol M, Bevene J. Oral versus intravenous steroids for treatment of relapses in multiple sclerosis. Cochrane Database Syst Rev. 2012 Dec 12;12:CD006921. [PMID: 23235634].

    4. Tramacere I1, Del Giovane C, Salanti G, et al. Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev. 2015 Sep 18;(9):CD011381. [PMID: 26384035].

    5. Soilu-Hänninen M, Aivo J, Lindström BM, Elovaara I, Sumelahti ML, Färkkilä M, et al. A randomised, double blind, placebo controlled trial with vitamin D3 as an add on treatment to interferon β-1b in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry. 2012;83:565-71. [PMID: 22362918].

    6. Trebst C, Reising A, Kielstein JT, Hafer C, Stangel M. Plasma exchange therapy in steroid-unresponsive relapses in patients with multiple sclerosis. Blood Purif. 2009;28:108-15. [PMID: 19521072].

    7. Samkoff LM, Goodman AD. Symptomatic management in multiple sclerosis. Neurol Clin. 2011;29(2):449-63. [PMID: 21439453].

    8. Carruthers RL and Berger J. Progressive multifocal leukoencephalopathy and JC Virus-related disease in modern neurology practice. Mult Scler Relat Disord. 2014;3:419-30. [PMID: 25877052].

    9. Loebermann M, Winkelmann A, Hartung HP, Hengel H, Reisinger EC, Zettl UK. Vaccination against infection in patients with multiple sclerosis. Nat Rev Neurol. 2012;8(3):143-51. [PMID: 22270022].

    10. Merkel B, Butzkueven H, Traboulsee AL, Havrdova E, Kalincik T. Timing of high-efficacy therapy in relapsing-remitting multiple sclerosis: A systematic review. Autoimmun Rev. 2017 Jun;16(6):658-665. [PMID: 28428119]

  4. Other Neuroimmunology Topics

    1. Wingerchuk DM, Banwell B, Bennett JL, Cabre P, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology. 2015 Jul 14;85(2):177-89. [PMID: 26092914]

    2. Jarius S, Wildemann B, Paul F. Neuromyelitis optica: clinical features, immunopathogenesis and treatment. Clin Exp Immunol. 2014 May;176(2):149-64. [PMID: 24666204]

    3. Jarius S, Paul F, Aktas O, Asgari N, Dale RC, et al. MOG encephalomyelitis: international recommendations on diagnosis and antibody testing. J Neuroinflammation. 2018 May 3;15(1):134. [PMID: 29724224]

    4. Tavee JO, Stern BJ. Neurosarcoidosis. Continuum (Minneap Minn). 2014 Jun;20(3 Neurology of Systemic Disease):545-59. [PMID: 24893233]

    5. Dalmau J, Graus F. Antibody-Mediated Encephalitis. N Engl J Med. 2018 Mar 1;378(9):840-851. [PMID: 29490181]




Last Updated: September 8, 2022