Faculty Bibliography

Objective: s To characterize a sample of patients with multiple sclerosis (MS) that would be recommended for evaluation by an expert in bladder dysfunction based on the Actionable Bladder Symptom and Screening Tool (ABSST), and to correlate the ABSST with several commonly used questionnaires including the Overactive Bladder Questionnaire (OABq), Patient Global Impression of Severity (PGI-S), International Consultation on Incontinence Questionnaire (ICIQ), and Medical Epidemiology and Social Aspects of Aging (MESA). Background: Although up to 80% of patients diagnosed with multiple sclerosis (MS) experience lower urinary tract symptoms, evaluation and treatments are significantly under accessed. The (ABSST) is a newly validated tool that can be used in patients with MS to screen for neurogenic overactive bladder symptoms (NDO). It is a simple 8-item questionnaire that aids in identifying patients that need a referral for evaluation. Methods: This was a prospective observational study. 100 patients diagnosed with MS, not currently seeing a bladder dysfunction specialist, were enrolled from an MS center. After obtaining consent, patients were asked to fill out a validated short form of the ABSST, the OABq short form, the PGI-S, the ICIQ and the MESA. An ABSST score >3 is considered a positive screening test and met criteria for referral to a specialist. OAB subscale scores grouped responses related to symptom bother and Quality of life (HRQL), which was further subdivided into HRQL-Coping, HRQL-Sleep, or HRQL-Emotions. A high score for the symptoms subscale indicated worse symptoms and a low score of the quality of life subscales indicated worse quality of life. The MESA scores grouped responses that characterized either urgency or stress incontinence. There were no subscales for PGIS or ICIQ. Mean questionnaire scores were compared between patients who screened positive or negative for the ABSST using one-way ANOVA and X2 tests. Results: Patient's mean age was 44.5 years and average time since diagnosis was 10.4 years. There were 79 women and 21 men. Ethnicities included 45% Caucasian, 21% African American, 21% Hispanic, 2% Asian, and 11% Other/Multiracial. 27 patients had an ABSST Score >3. When compared to patients with an ABSST<3, those with an ABSST>3 had a significant difference in level of education (p<0.05), level of mobility (p<0.05), and employment status (p=0.005). See figure 1. Patients with an ABSST>3 were more likely to have seen a doctor in the past for bladder problems (52% vs. 27%; p=0.019), more frequently for urinary incontinence (19%) and urinary tract infections (13%). They were also more likely to be using medications for bladder symptoms (23% vs. 4%; p=0.004) or to have used them in the past (42% vs. 15%; p=0.004). Patients with a positive ABSST had a significant difference in the mean scores of the following subscales: OABq Symptoms (57.4 vs. 15.0; p=0.000); OAB-Total HRQL (50.4 vs. 89.9;p=0.000); OABHRQL Cope (43.4 vs. 89.4;p=0.000); OAB-HRQL Sleep (42.5 vs. 84.2; p=0.000); OAB-HRQL Emotion (62.1 vs. 93.7; p=0.000); MESA-Urgency Incontinence (40.4 vs. 12.3; p=0.000); MESA-Stress Incontinence (33.8 vs.15.0; p=0.000); and ICIQ-SF (8.2 vs. 2.3; p=0.000). There was a significant correlation between PGIS Score and a positive ABSST (p=0.000). Conclusions: The differences observed in MS patients who score positive on the ABSST may represent the progressive nature of some cases of MS and its association with NDO. A positive screening response correlates and captures the severity of symptoms, impact on quality of life and classifications of both urinary incontinence across several overactive bladder and urinary incontinence questionnaires. These findings highlight the importance of continued screening in MS patients for NDO, even when patients have been evaluated or treated in the past. This need makes the ABSST a valuable simple tool for providers to efficiently identify and refer MS patients for further evaluation and treatment. (Figure presented)

BACKGROUND: Multiple sclerosis (MS) can affect virtually every neurological function which complicates the conceptualization and assessment of disability. Similar challenges are encountered in other medical fields including child cognitive development and psychiatry, for instance. In these disciplines progress in diagnosis and outcome measurement has been recently achieved by capitalizing on the concept of bifactor model. OBJECTIVE: To present in accessible terms an application of bifactor confirmatory factor analysis to study the clinical disability outcomes in MS. METHODS: Data included 480 assessments on 301 patients with relapsing-remitting MS who participated in the North American interferon beta-1a clinical trial (Avonex). Measures consisted of the Expanded Disability Status Scale (EDSS), the three components of the Multiple Sclerosis Functional Composite (MSFC), and five other clinical measures of neurological functions. We determined which of three confirmatory factor analysis models (unidimensional, multidimensional, and bifactor) best described the structure of the data. RESULTS: EDSS scores ranged from 0 to 8 (94% between 0 and 4). The final bifactor model fitted the data well, explained 59.4% of total variance, and provided the most useful representation of the data. In this model, the nine measures defined a scoring dimension of global neurological function (63.1% of total composite score variance) and two auxiliary dimensions of extra variability in leg and cognitive function (17.1% and 9% of total composite score variance). CONCLUSION: Bifactor modeling is a promising approach to further understanding of the structure of disability in MS and for refining composite measures of global disability.

Neuromyelitis Optica (NMO) is a potentially devastating, complex autoimmune disease of the central nervous system that differs clinically and pathologically from the more common Multiple Sclerosis (MS). In this paper, we briefly describe our clinical experience with NMO patients treated in an inner city hospital in central Brooklyn, New York, and offer a an up-to-date discussion of diagnosis, treatment, and prognosis of this rare condition

Objective. To compare periventricular lesions in multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOsd). Materials and Methods. Sagittal and axial fluid attenuated inversion recovery (FLAIR) sequences of 20 NMOsd and 40 group frequency-matched MS patients were evaluated by two neuroradiologists. On axial FLAIR, periventricular area was characterized as free of lesions/smooth-bordered ("type A") or jagged-bordered ("type B") pattern. On sagittal FLAIR, the images were evaluated for presence of "Dawson's fingers." Results. Type A pattern was observed in 80% of NMOsd patients by Reader 1 and 85% by Reader 2 but only in 5% MS patients by either Reader. Type B was seen in 15% NMOsd patients by Reader 1 and 20% by Reader 2 and in 95% MS patients by either Reader. Dawson's fingers were observed in no NMOsd patients by Reader 1 and 5% by Reader 2. In MS, Dawson's fingers were seen in 92.5% patients by Reader 1 and 77.5% by Reader 2. The differences in periventricular patterns and Dawson's finger detection between NMOsd and MS were highly significant (P < 0.001). Conclusions. Dawson's fingers and "jagged-bordered" periventricular hyperintensities are typical of MS and almost never seen in NMOsd, which suggests a practical method for differentiating the two diseases.