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A 28-year-old man presented with a 3-day history of left eye visual loss, coryza, headaches and painful eye movements. Examination showed a reduction in visual acuity, patchy visual field loss, relative afferent pupillary defect and optic disk swelling confined to the left eye.MR imaging showed an oedematous and hyperdense left optic nerve, and extensive sinus disease of the left paranasal sinuses. The affected sinuses did not have any clear communication with the intra- conal space.Diagnosis was made of a postinfectious/parainfectious optic neuritis in the setting of extensive sinusitis. He was commenced on high-dose intravenous steroids and oral antibiotics, and he improved rapidly. He completed a tapering regime of oral steroids, and testing at 6-week follow-up demonstrated normal visual acuities and visual fields.The treatment choice was made amidst considerable aetiological dilemma. The significance of paranasal sinusitis occurring concurrently with presentations of optic neuritis is controversial,1 2 with a paucity of high-grade research. Recommendations for surgical intervention are made in most available case studies.3-6 We present a case of optic neuritis in the setting of extensive paranasal sinusitis, that was successfully managed without surgical intervention. The available literature was reviewed to present this case in an instructional context.7 References DOI: 10.1159/000116409 DOI: 10.1001/archopht.1987.01060030065027 DOI: 10.1038/eye.1999.15 DOI: 10.1017/S0022215114003454 DOI: 10.1136/bjo.76.8.502 http://dx.doi.org/10.1136/ bjo.76.8.502 DOI: 10.1016/j.amjoto.2018.08.008

A 45-year-old woman presented with several months of right-sided headache, associated with vocal hoarseness, fever, night sweats and weight loss. Severe right-sided periorbital pain came in episodes lasting several hours, associated with ipsilateral partial ptosis, facial swelling and hyperaesthesia. Indomethacin and greater occipital nerve block were ineffectual; however, a transient symptomatic improvement had coincided with previous steroid treatment.She had a background of cocaine use. Longstanding sinus complaints were investigated with nasen- doscopy, revealing nasal septal crusting and a hole in the soft palate. Fluctuating lymphadenopathy on previous imaging was investigated with blood tests, showing persistently raised ESR and ANCA positivity. Normal eosinophil counts.Serial MRI head scans showed evidence of worsening inflammatory, sclerotic and bony erosive changes to the midfacial skull base. The nasal septum and turbinates were obliterated, and maxillary/ethmoid/sphenoid sinuses were persistently effused. Granulomatosis with polyangiitis was diagnosed, and treatment with high-dose steroids and mycophenolate mofetil was commenced. Headache symptoms convinc- ingly improved.We present a case of headache with atraumatic midline skull base destruction, in a patient satisfying diagnostic criteria for granulomatosis with polyangiitis [1-2]. However, chronic cocaine use can have over- lapping clinical, immunological and radiological features [3-6]. Recent literature is reviewed to evaluate this diagnostic challenge [8-10].

This article reviews our current understanding and modern treatment of multiple sclerosis (MS). MS is a disabling condition resulting in devastating social and economic impacts. As MS can affect any part of the central nervous system, the presentation is often diverse; however, there are key features that can be useful in the clinic. We comment on the diagnostic criteria and review the main subtypes of MS, including clinically isolated syndrome, relapsing remitting MS, secondary progressive MS and primary progressive MS. Although the underlying aetiology of MS is still not known, we summarise those with most evidence of association. Finally, we aim to present treatment strategies for managing the acute relapse, disease-modifying therapies and MS symptoms. This review highlights that progressive MS is an area where there is currently a paucity of available disease-modifying treatments and this will be a major focus for future development.

Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating central nervous system disorder that is more common in women, with onset often during reproductive years. The female:male sex ratio of MS rose in several regions over the last century, suggesting a possible sex by environmental interaction increasing MS risk in women. Since many with MS are in their childbearing years, family planning, including contraceptive and disease-modifying therapy (DMT) counselling, are important aspects of MS care in women. While some DMTs are likely harmful to the developing fetus, others can be used shortly before or until pregnancy is confirmed. Overall, pregnancy decreases risk of MS relapses, whereas relapse risk may increase postpartum, although pregnancy does not appear to be harmful for long-term prognosis of MS. However, ovarian aging may contribute to disability progression in women with MS. Here, we review sex effects across the lifespan in women with MS, including the effect of sex on MS susceptibility, effects of pregnancy on MS disease activity, and management strategies around pregnancy, including risks associated with DMT use before and during pregnancy, and while breastfeeding. We also review reproductive aging and sexual dysfunction in women with MS.

People with progressive multiple sclerosis (pwPMS), who typically have established lower limb dysfunction, experience greater disability from upper limb dysfunction (ULD). The 9-hole peg test (9HPT) is the primary clinical measure for ULD but does not fully capture the patient experience. The ABILHAND-23 is a well-validated patient-reported outcome measure (PROM) that evaluates bimanual ability in daily function. However, no large-scale studies have assessed if the 9HPT reflects the individual ULD experience in pwPMS. We sought to (van Munster et al. 2023) assess the associations between the ABILHAND-23 and 9HPT, and (Huertas-Hoyas et al. 2020) to assess the ability of the 9HPT and other relevant covariables to predict ABILHAND-23 scores, using baseline data from the MS-STAT2 trial, a phase 3 study on simvastatin for secondary progressive MS (SPMS). A cross-sectional analysis of baseline data from the UCLH cohort of the MS-STAT2 trial was performed using multiple linear regression to predict ABILHAND-23 logit scores by 9HPT. 225 participants were analyzed. ABILHAND-23 scores moderately correlated with the 9HPT (rho = 0.47). Regression analysis showed that better 9HPT performance modestly predicted ABILHAND-23 logits (β = -0.05, SE 0.008, p-value < 0.001). The 9HPT only modestly predicts the ABILHAND-23 but does not fully capture the individual's daily disability experience, underscoring the value of patient-reported outcome measures (PROMs) like the ABILHAND-23 in clinical trials.

Background Slower than planned recruitment is a major factor contributing to the delay or failure of randomised controlled trials to report on time. There is a limited evidence base regarding the optimisation of recruitment strategies. Here we performed an observational review of our experience in recruitment for two large randomised controlled trials for people with secondary progressive multiple sclerosis. We aimed to explicitly determine those factors which can facilitate trial recruitment in progressive neurodegenerative disease. Methods Recruitment data from the sequential MS-SMART [NCT01910259] and MS-STAT2 [NCT03387670] UK randomised controlled trials was reviewed from the largest recruiting site, University College London (UCL). The trial population was similar which allowed comparison over the two recruitment periods of 2015–2016 and 2018–2021. This included sources of referral, progress through stages of recruitment, reasons for participant ineligibility and the impact of publicity events upon recruitment. Results In MS-SMART, 18% of patients contacted were enrolled, compared to 27% for MS-STAT2. Online registration of interest portals provided the greatest number of referrals (76% in MS-SMART, and 51% in MS-STAT2), with publicity in national media outlets producing a demonstrable increase in the number of potential participants. The introduction of an online self-screening questionnaire for MS-STAT2 resulted in 67% of potential participants (3080 of 4605) automatically determining their own ineligibility . In both studies, however, around 60% of those directly telephoned to discuss the study were not eligible, with difficulties related to travel to trial visits, or excluded medication, being the most common issues. Eighty-four percent of those deemed potentially eligible following telephone calls were enrolled in the MS-STAT2 study, compared to only 55% for MS-SMART. Conclusions Through a detailed review of recruiting participants at the largest centre into two large randomised controlled trials with similar entry criteria, we have identified a number of approaches that may improve recruitment efficiency. We highlight here the importance of mandatory online self-screening questionnaires, a coordinated publicity campaign, and simple interventions such as eligibility checklists and appointment reminders. Recruitment approaches should be further assessed through a studies within a trial (SWAT) design. Trial registration MS-SMART: NCT01910259 ; registered July 2013 and MS-STAT2: NCT03387670 ; registered Jan 2018

This article reviews our current understanding and modern treatment of multiple sclerosis (MS). MS is a disabling condition resulting in devastating social and economic impacts. As MS can affect any part of the central nervous system, the presentation is often diverse; however, there are key features that can be useful in the clinic. We comment on the diagnostic criteria and review the main subtypes of MS, including clinically isolated syndrome, relapsing remitting MS, secondary progressive MS and primary progressive MS. Although the underlying aetiology of MS is still not known, we summarise those with most evidence of association. Finally, we aim to present treatment strategies for managing the acute relapse, disease-modifying therapies and MS symptoms. This review highlights that progressive MS is an area where there is currently a paucity of available disease-modifying treatments and this will be a major focus for future development.

A 68 year-old man presented with rapidly progressive deterioration in mobility, falls, change in speech and diplopia over several days. He had a background of small cell lung cancer diagnosed 8 months previously, treated with chemotherapy and recent adjuvant radiotherapy. Examination revealed severely ataxic gait, multidirectional nystagmus, broken saccades, dysarthria, limb incoordination with past-pointing and dysdiadochokinesis, normal power, reflexes, and sensation. Fundoscopy was unremarkable. He was vomiting profusely.CT and MRI brain were unremarkable with no evidence of metastases or meningeal enhancement. CT-body showed no signs of metastases and maintained partial response in the left upper lobe and mediastinal nodes. Extensive serum metabolic, infective and onconeuronal antibody screens were normal. Lumbar puncture revealed normal opening pressure with no evidence of infection, cytological dysfunction or occult inflammation. He responded well to high dose dexamethasone therapy and ondansetron and liaison with oncology confirmed radiation induced cerebellitis.We present an approach to the acute cerebellar syndrome; in particular using this vignette to highlight important signs, investigations, and management issues.

The aim was to assess whether renal investigations for grade 3 chronic kidney disease and referrals for specialist advice are being documented according to the 2006 Royal Colleges of Physicians and General Practitioners and Renal Association guidance 2 in the notes of those psychiatric in-patients currently prescribed lithium across the Trust. Of 18 in-patients prescribed lithium: (a) 3 (16.7%) patients had one-off abnormal results with other values recorded within the normal range; (b) 1 (5.6%) patient had one documented eGFR (54) that was abnormal. There was agreement that the current lithium documentation charts should be modified to include eGFR as a routine part of the lithium work up and ongoing monitoring process.