Cognitive impairments in multiple sclerosis: a review

Barriers and strategies to medication adherence amongst people with multiple sclerosis and cognitive problems

BACKGROUND

Adherence to disease-modifying treatment (DMT) amongst people with multiple sclerosis (MS) varies greatly. Although research often identifies 'forgetting' as a reason for poor adherence, few studies have considered how cognitive problems impact adherence.

OBJECTIVES

To investigate prevalence of and barriers to adherence, including for people with MS-related cognitive problems, and to identify adherence-related strategies.

METHODS

Recruited via the UK MS Register and MS Society groups, participants completed a Medication Adherence Questionnaire and the Perceived Deficits Questionnaire. A subset were interviewed.

RESULTS

Of 257 participants, 94 % reported being adherent, although 59 % missed ≥1 dose, and 25 % reported cognitive problems. Adherence was lower amongst those with cognitive problems, who experienced more barriers: memory problems; negative feelings about taking medication; and not wanting medication to interfere with activities. Such barriers, along with mood, cognition, and method of DMT administration, explained 17 % of variance in adherence, with intravenous treatment a significant predictor. Cognitive problems explained a unique proportion of variance; however, was non-significant when anxiety was factored in. Interviews highlighted how anxiety about side-effects and injections, and difficulties accepting the diagnosis, hindered use of reminders.

CONCLUSION

Interventions for cognition and mood problems, minimising treatment burden and supporting adjustment to diagnosis, may improve adherence.

Attention-Deficit Hyperactivity Disorder Symptoms in Adults Diagnosed with Multiple Sclerosis: Prevalence and Correlates

Background: The relationship between adult ADHD symptoms in People with Multiple Sclerosis (PwMS) is understudied. This study aimed to answer two questions: are PwMS more likely to experience higher ADHD symptoms versus healthy subjects? And what are the correlates of severe ADHD symptoms in PwMS? Methods: This study followed a cross-sectional design with predefined inclusion criteria. The Adult ADHD Self-Report Scale-V1.1 (ASRS) was used to assess the ADHD symptoms severity. Results: Data were analyzed from 171 PwMS and 200 controls. Regression analysis revealed that PwMS were at a significantly (B = 3.05, t = 2.24, 95% CI = 0.37-5.73, p = 0.02) higher risk to report higher ADHD scores versus controls. In addition, PwMS with relapses in the last 6 months and PwMS reporting smartphone addiction were at a significantly higher risk for severe ADHD (B = 7.19, t = 269, 95% CI = 1.91-12.48, p = 0.008) and (B = 9.18, t = 3.47, 95% CI = 3.97-14.41, p = 0.001), respectively. In conclusion, diagnosis with MS in our study was identified as a risk for higher ADHD symptoms. Conclusions: Further research is required to establish this relationship, and holistic medical and psychological interventions are required to improve the cognitive status of PwMS.

Time perception impairment in multiple sclerosis patients: a survey on internal clock model

Time perception is known as a mental ability to discern time. Although relative nature of time leaves its numerous aspects undefined, several models have been developed to describe temporal information processing in the brain as well as several areas of the brain have shown to be involved. Time perception alteration has been reported in several neurological conditions; however, the effect of multiple sclerosis (MS) on time perception has yet to be explained. In this study, we aimed to investigate the domains of temporal processing involved in patients with MS and the probable factors affecting it, such as the location of brain demyelinating plaques and gender. Two groups of participants (MS: n = 27 (8 men, 19 women), mean age = 33.85; control: n = 30 (10 men, 20 women), mean age = 28.46) were asked to perform quadruplet time perception tasks (prospective time estimation, duration discrimination, temporal reproduction, and paced motor timing) designed with a software program. Patients with MS had significantly higher scores in time estimation (p < 0.01) and duration discrimination (p < 0.001, in 100-ms interval; p < 0.05, in 1000-ms interval), indicating that MS patients overestimate the time. Since a slower internal clock for MS patients was expected as a result of axonal demyelination, these results suggest the time overestimation in patients with MS which is in contrast with the internal clock model. It means that a slow internal clock causes underestimating and perceiving the time slower.

Two Ecological Tools for Testing Slowness of Information Processing in Italian Patients with Moderate-to-Severe Traumatic Brain Injury

Slowness of Information Processing (SIP) is frequently experienced after traumatic brain injury (TBI); however, the impact of SIP on everyday functioning may be underestimated by standard neuropsychological tests.

OBJECTIVE

we aimed to adapt two ecological instruments assessing SIP in Italian patients with moderate-to-severe TBI, as formerly proposed by Winkens and colleagues for persons with stroke, testing also its possible relation with other neuropsychological processes and functional outcomes.

METHOD

we performed an observational study on 37 patients with moderate-to-severe TBI and 35 demographically matched healthy controls, who underwent the Mental Slowness Observation Test (MSOT) and the Mental Slowness Questionnaire (MSQ), which had been adapted through a pilot study on independent sample of participants; extensive neuropsychological and functional evaluations were performed as well.

RESULTS

We found good clinical and psychometric properties of the Italian adaptation of the MSOT and MSQ; also, performance on MSOT significantly correlated with executive functions. Moreover, patients with TBI are significantly slower and less accurate than healthy controls on the MSOT, in particular in tasks with time limits. Even if the subjective feeling of SIP does not differ between patients and controls, we found a significant correlation between MSQ and MSOT. Finally, the performances on the MSOT correlated with measures of functional outcome and community integration.

CONCLUSIONS

the results support the use of the MSOT and the MSQ to measure SIP in an ecological fashion in patients with TBI, so that specific treatments for persons with acquired brain injury can be prescribed.

Predicting Neuropsychological Impairment in Relapsing Remitting Multiple Sclerosis: The Role of Clinical Measures, Treatment, and Neuropsychiatry Symptoms

OBJECTIVE

This retrospective observational study aimed to define neuropsychological impairment (NI) profiles and determine the influence of clinical, demographic, and neuropsychiatric measures in specific cognitive domains in a cohort of relapsing-remitting multiple sclerosis (RRMS) patients.

METHODS

Ninety-one RRMS patients underwent a neurological examination and a brief neuropsychological assessment. Patients were classified according to the disease-modifying therapies (DMTs) received (platform or high-efficacy). Differences between groups and multiple regression analyses were performed to determine the predictive value of the assessed measures in cognitive performance.

RESULTS

More than two-thirds of the patients showed NI. Specifically, mild to moderate NI was presented in approximately half of the participants. Paced Auditory Serial Addition Test (PASAT-3) and Symbol Digit Modalities Test (SDMT) were the most frequently impaired cognitive tests (45.3% and 41.3%, respectively) followed by phonemic verbal fluency (PVF) (27.8%). Expanded Disability Status Scale (EDSS), age, depressive symptoms, and disease duration were the best predictors of SDMT (R2 = .34; p < .01), whereas disease duration, EDSS, and anxiety-state levels predicted PASAT-3 (R2 = .33, p < .01). Educational level, age, EDSS, and depressive symptoms demonstrated the strongest association with PVF (R2 = .31, p < .01).

CONCLUSIONS

Our results indicated a significant prevalence of NI in RRMS patients that was not dependent on the DMT type. In addition to the meaningful working memory (PASAT-3) and information processing speed (SDMT) impairments found, PVF deficits may also be an important marker of cognitive impairment in RRMS patients. This study supports the relevance of standard clinical measures and reinforces the importance of quantifying clinical and neuropsychiatric symptoms to predict subsequent cognitive performance on a similar multiple sclerosis phenotype and disease stage.

Antidepressants on Multiple Sclerosis: A Review of In Vitro and In Vivo Models

Background

Increased prevalence of depression has been observed among patients with multiple sclerosis (MS) and correlated with the elevated levels of proinflammatory cytokines and the overall deregulation of monoaminergic neurotransmitters that these patients exhibit. Antidepressants have proved effective not only in treating depression comorbid to MS, but also in alleviating numerous MS symptoms and even minimizing stress-related relapses. Therefore, these agents could prospectively prove beneficial as a complementary MS therapy.

Objective

This review aims at illustrating the underlying mechanisms involved in the beneficial clinical effects of antidepressants observed in MS patients.

Methods

Through a literature search we screened and comparatively assessed papers on the effects of antidepressant use both in vitro and in vivo MS models, taking into account a number of inclusion and exclusion criteria.

Results

In vitro studies indicated that antidepressants promote neural and glial cell viability and differentiation, reduce proinflammatory cytokines and exert neuroprotective activity by eliminating axonal loss. In vivo studies confirmed that antidepressants delayed disease onset and alleviated symptoms in Experimental Autoimmune Encephalomyelitis (EAE), the most prevalent animal model of MS. Further, antidepressant agents suppressed inflammation and restrained demyelination by decreasing immune cell infiltration of the CNS.

Conclusion

Antidepressants were efficient in tackling numerous aspects of disease pathophysiology both in vitro and in vivo models. Given that several antidepressants have already proved effective in clinical trials on MS patients, the inclusion of such agents in the therapeutic arsenal of MS should be seriously considered, following an individualized approach to minimize the adverse events of antidepressants in MS patients.

Comparative study of arsenic toxicosis and ocular pathology in wild muskrats (Ondatra zibethicus) and red squirrels (Tamiasciurus hudsonicus) breeding in arsenic contaminated areas of Yellowknife, Northwest Territories (Canada)

The Giant Mine is an abandoned gold mine in Yellowknife, Northwest Territories, Canada. Throughout its operation from 1948 to 2004, the Giant Mine released heavy amounts of arsenic trioxide into the environment, thus contaminating the soil and surface water within and around the vicinity of the mine site. Chronic arsenic (As) poisoning negatively impacts wildlife health and can induce multi-organ damages including neurodegeneration and visual dysfunction depending on concentration and duration of exposure. The aim of the current study was to comparatively assess retina layer changes and prevalence of ocular lesions in wild rodent populations (i.e. muskrats and red squirrels) breeding in arsenic endemic areas of Yellowknife, near the vicinity of the abandoned Giant mine site (∼2 km radius), at an intermediate location (approximately 20 km from the mine area) as well as a reference location (spanning 52-105 km from the city of Yellowknife, Canada). Eye globes were removed from euthanized muskrats and squirrels from the three sampling locations with increasing distance from the Giant mine area. Optical Coherence Tomography (OCT) was used to attempt a pan-retinal layer assessment, and histologic examination was utilized for assessment and confirmation of ocular lesions. The retinal layers were measured and statistically compared between the groups based on sampling locations to enhance the scope of histologic evaluations. The preliminary results revealed that thicknesses of ganglion cell layer (GCL), retina nerve fibre layer (NFL), and inner retina layer (IR) were statistically reduced in the muskrats from arsenic endemic area, particularly near the vicinity of the Giant mine compared to the control group. Generalized ocular pathology was histologically confirmed in all the muskrats from the arsenic endemic areas with the manifestation of moderate to severe lymphocytic plasmacytic uveitis (LPU), keratitis and subcapsular cataracts. Inner retinal degeneration was also observed in all the muskrats from the arsenic endemic areas, while muskrats from the control group were predominantly normal. Three muskrats from the control group were noted to have a mild LPU and keratitis. Significant histopathologic changes were not detected in the squirrel eyes from the three groups except for incidental mild cornea scars from all the locations. In general, these preliminary findings confirm the presence of ocular lesions and retina abnormalities in wild muskrats in the Yellowknife area and provide the first evidence of visual dysfunction and impairment in wildlife inhabiting arsenic endemic areas of Canada.

A factor analytic investigation of the Mercy Evaluation of Multiple Sclerosis

OBJECTIVE

Neurocognitive deficits commonly are an accompanying feature of Multiple Sclerosis (MS). A brief, yet comprehensive neuropsychological battery is desirable for assessing the extent of these deficits. Therefore, the present study examined the validity of the Mercy Evaluation of Multiple Sclerosis (MEMS) for use with the MS population.

METHODS

Archival data from individuals diagnosed with MS (N = 378) by independent neurologists was examined. Cognitive domains assessed included processing speed and attention, learning, and memory, visuospatial, language, and executive functioning. A mean battery index was calculated to provide a general indicator of cognitive impairment within the current sample.

RESULTS

Overall performance across participants was found to be in the lower limits of the average range. Results of factor analytic statistical procedures yielded a four-factor solution, accounting for 67% of total variance within the MEMS. Four neurocognitive measures exhibited the highest sensitivity in detecting cognitive impairment, constituting a psychometrically established brief cognitive screening battery, which accounted for 83% of total variance within the mean battery index score.

CONCLUSION

Overall, the results of the current study suggest appropriate construct validity of the MEMS for use with individuals with MS, as well as provide support for previously established cognitive batteries.

Different types of exercise in Multiple Sclerosis: Aerobic exercise or Pilates, a single-blind clinical study

BACKROUND

The aim of our study is to examine effects of aerobic and Pilates exercises on disability, cognition, physical performance, balance, depression and fatigue in relapsing-remitting Multiple Sclerosis (MS) patients as compared to healthy controls.

METHODS

The subjects were divided as aerobic exercise (n = 26), Pilates (n = 9), and the healthy control group (n = 21). We used MSFC, physical performance, Berg balance scale, Beck depression scale, fatigue impact scale. All evaluations were performed before and after exercise training.

RESULTS

There are statistically meaningful differences between Nine hole testing, PASAT 3, physical performance and fatique impact scale before and after aerobic exercise. Also we found significant difference for physical performance in the Pilates group. There are no significant differences in measures of fatique impact scale and depression between aerobic exercise group and the healthy controls after exercise. We found significant differences between Pilates and control group's after measurements except depression. There were significant differences between the Pilates and aerobic group for cognitive tests in favor of the Pilates group.

CONCLUSION

Aerobic exercise and clinical Pilates exercises revealed moderate changes in levels of cognitive, physical performance, balance, depression, fatigue in MS patients.

Treating depression in multiple sclerosis with antidepressants: A brief review of clinical trials and exploration of clinical symptoms to guide treatment decisions

Depression is a common comorbidity in patients with multiple sclerosis (MS). Those with MS and concurrent depression have poorer quality of life and are also less likely to be compliant with disease-modifying treatment, which may ultimately affect their MS disease course. Treating depression in MS with pharmacological agents can improve not only depression, but may also impact the MS disease course. However, no guidelines exist around treating depression in MS. Few randomized-controlled trials using antidepressants in MS exist. Here, we briefly review trials using antidepressant medications to treat depression in MS. We also propose individualizing treatment of depression in MS, as the depressive symptoms and MS symptoms and disease course differ significantly between patients. We explore the heterogeneity in presentation of depression through different comorbid symptoms in MS, and discuss which antidepressant options would be appropriate in each situation. We propose that future clinical trials should incorporate differences in issues between those with depression (e.g. sexual dysfunction, urinary incontinence) into analysis. As MS is incredibly heterogeneous, treating concurrent depression on a case-by-case basis may enable for improving quality of life and the MS disease course.

Neuropsychological Assessment in Multiple Sclerosis

Abstract. Neuropsychological deficits in multiple sclerosis (MS) are common. Over the past decades, many different procedures have been employed in diagnosing these deficits. Even though certain aspects of cognitive performance such as information processing speed and working memory may be affected more frequently than other cognitive functions, no specific deficit profile has been established in MS. This article provides an overview of the neuropsychological diagnostic procedures in MS and allows the reader to reach an informed decision on the applicability of specific procedures and the availability of study data in the context of MS. Additionally, it makes recommendations on the compilation of both screening procedures and extensive test batteries.

Prospective memory impairment in multiple sclerosis: a review

OBJECTIVE

Multiple sclerosis (MS) is a progressive disease of the central nervous system affecting information processing speed, episodic memory, attention, and executive functions. MS patients also often report prospective memory (PM) failures that directly impact their functional autonomy, including professional and social life. The purpose of this paper was to review the literature concerning the assessment and remediation of PM deficits in MS.

METHOD

The literature pertaining to PM impairment in MS was carefully reviewed using PubMed, PsyINFO, and Google Scholar, as well as cross-references from the articles published on this topic. Since PM rehabilitation in MS patients is still in its infancy, this review mainly focuses on studies that have directly assessed PM through various measures including questionnaires, standardized clinical tests, and experimental procedures.

CONCLUSION

This literature review confirms the presence of PM deficits in MS patients, even in the early stages of the disease. A further need for controlled studies on PM assessment and PM interventions in patients with MS is stressed.

Medical decision-making capacity and its cognitive predictors in progressive MS: Preliminary evidence

BACKGROUND

Medical decision-making capacity (MDC) refers to the ability to make informed decisions about treatment and declines in cognition are associated with declines in MDC across multiple disease entities. However, although it is well known that cognitive impairment is prevalent in multiple sclerosis (MS), little is known about MDC in the disease.

METHODS

Data from 22 persons with progressive MS and 18 healthy controls were analyzed. All diagnoses were made by a board-certified neurologist with experience in MS. All study participants were administered a vignette-based measure of MDC and also a neuropsychological battery.

RESULTS

Performance on three MDC consent standards (i.e., Appreciation, Reasoning, Understanding) was significantly lower for people with progressive MS as compared to healthy controls. In the progressive MS group, verbal fluency was the primary cognitive predictor for both Reasoning and Understanding consent standards. Verbal learning and memory was the primary cognitive predictor for Appreciation. MS severity was not significantly correlated with any MDC variable.

CONCLUSION

MDC is a complex and cognitively mediated functional ability that is impaired in many people with progressive MS. Verbal measures of fluency and memory are strongly associated with MDC performances in the current sample of people with MS and could potentially be utilized to quickly screen for MDC impairment in MS.

Rapid cognitive screening in multiple sclerosis accomplished by the Free Recall and Recognition Test

This study sought to investigate the feasibility of the Free Recall and Recognition Test (FRRT) as a practical screening tool for cognitive impairment in multiple sclerosis (MS). Persons with MS (n =227) were consecutively recruited and assessed with four cognitive tests; FRRT, Symbol Digit Modalities Test (SDMT), Paced Auditory Serial Addition Test (PASAT), and the Mini-Mental State Examination (MMSE). Disease severity was assessed by the Expanded Disability Status Scale (EDSS). The FRRT, which was completed by 99% of the cohort in approximately 5 minutes per assessment, correlated significantly with the other cognitive tests, as well as with the disease severity rating. A cut-off of 4 for the FRRT recall rendered 90% sensitivity and 25% specificity, and a cut-off of 4.2 for the FRRT recognition resulted in 70% sensitivity and 51% specificity. We conclude that the FRRT proved feasible as a practical screening tool for cognitive impairment in MS within a clinical setting. Multiple Sclerosis 2007; 13: 272–274. http://msj.sagepub.com

Nursing home residents with multiple sclerosis and dementia compared to other multiple sclerosis residents

Cognitive impairment may be a significant symptom in multiple sclerosis (MS), affecting about one half of MS patients in study samples similar to the general MS population. An interesting question is what role dementia, of any aetiology, plays in the cognitive ability of people with MS. The objective of this research is to learn more about nursing home residents with MS and dementia, identifying how they differ from other residents with MS. We developed profiles of MS residents with dementia using the Minimum Data Set and compared these profiles to other residents with MS. Nursing home residents with MS and dementia are admitted to nursing facilities at an older age and seem less likely to have physical impairments but more mood and behaviour problems than other MS residents at admission. A cortical variant of MS may be more prevalent than previously suspected and may be a factor responsible leading to nursing home admission in this subgroup of patients. Further clinical analysis of this subgroup would be necessary to support this contention.

Impact of the Cognitive Status on the Memory Complaints in MS Patients

Objective:

Despite the evidence of cognitive deficits in Multiple Sclerosis (MS) patients, evaluation of their cognitive integrity is often limited to the use of clinical interviews and questionnaires. However, the consensus in the literature is that these patients under- or overestimate their deficits and repercussions. The objective of this study was to clarify why some patients overestimate while others underestimate their memory deficits.

Method:

Fifty-four participants (30 MS, 24 controls) completed the Prospective and Retrospective Memory Questionnaire (PRMQ) and were tested on a battery of neuropsychological tests. Based on the test results, MS patients were categorized as having either mild or moderate/severe cognitive deficits.

Results:

The moderate/severe MS group differed from the two other groups on the Rey Auditory Verbal Learning Test (RAVLT) but did not differ from the control group on the PRMQ. Conversely, the mild MS group did not differ from the control group on the RAVLT but did report significantly more problems than this group on the PRMQ. There was no difference between the two clinical groups on the Depression Index (Beck) but there was a significant correlation (r=.409) between the depression scores and the overestimation of prospective memory problems (PRMQ).

Conclusion:

The results explain the contradiction in the literature. It is the mild group who overestimates, maybe because they are overly concerned by their deficits, whereas the cognitive impairments of the moderate/severe group lead them to underestimate and may make their self-assessment unreliable. Formal testing or information from a significant other would be advisable.

Ocular motor measures of cognitive dysfunction in multiple sclerosis II: working memory

Our companion paper documents pervasive inhibitory deficits in multiple sclerosis (MS) using ocular motor (OM) measures. Here we investigated the utility of an OM working memory (WMem) task in characterising WMem deficits in these patients as a function of disease status and disease duration. 22 patients with CIS, 22 early clinically definite MS patients (CDMS: <7 years of diagnosis), 22 late CDMS patients (>7 years from diagnosis), and 22 healthy controls participated. All participants completed the ocular motor WMem task, the paced auditory serial addition test (PASAT), and the symbol digit modalities test (SDMT). Clinical disability was characterised in CDMS patients using the Expanded Disability Severity Scale (EDSS). WMem performance was measured as proportion of errors (WMem errors), saccade latency, and relative sensitivity to WMem loading (WMem effect), an indicator of WMem capacity. All patient groups performed more WMem errors than controls with proportion of WMem errors, and degree of WMem effect increasing with increasing disease duration. A larger WMem effect, reflecting poorer WMem capacity, corresponded to poorer performance on neuropsychological measures, and a higher disability score for CDMS patients with the longest disease duration; an observation that suggests wider implication of WMem executive processes with advancing disease. Conspicuously, performance decrements on standard neuropsychological testing did not similarly increase commensurate with disease duration. The ocular motor WMem task appears to meaningfully dissociate WMem deficit from healthy individuals as well as a function of increasing disease duration. Potentially, this task represents a highly informative and objective method by which to ascertain progressive WMem changes from the earliest inception of MS.

Prospective memory and chronic heart failure

Background

Patients with chronic heart failure (CHF) experience a number of debilitating symptoms, which impact on activities of daily living and result in poor quality of life. Prospective memory, which is defined as memory to carry out future intentions, has not been investigated in this group. However, emerging evidence suggests CHF patients have difficulties with cognitive processes related to prospective memory. Self-care, which partly relies on prospective memory, is essential in symptom management and preventing acute clinical deterioration. This study aims to measure prospective memory in CHF patients, and examine the relationship between prospective memory and CHF self-care.

Methods/Design

A comprehensive neuropsychological assessment will be conducted to assess a range of cognitive functions and psychopathology. The primary focus will be an assessment of prospective memory using a well-established behavioral measure; Virtual Week. Thirty CHF patients attending a nurse-led management program will be recruited from three hospital sites in Melbourne, Australia and their self-care behaviors will be assessed using the Self-care Chronic Heart Failure Index (SCHFI), a validated self-report tool. An additional 30 healthy controls, matched on age, gender, and IQ will be recruited from the general community.

Discussion

This is a group comparison study that will provide an evaluation of the prospective memory abilities of CHF patients. The findings of this research will provide insight into whether prospective memory may be hindering patients’ ability to perform adequate self-care.

Neuropsychiatric manifestations of multiple sclerosis

Multiple sclerosis is one of the most frequently observed neurological causes of progressive disability in early to middle adulthood. The disease is variable in its presentation and course, affects roughly 100 to 300 per 100,000 persons within the US alone and is slightly more common among females than males. Multiple sclerosis places substantial burdens on patients, families and caregivers. Its presentation includes disturbances in cognitive abilities and psychiatric functioning, as well as motor difficulties. This article reviews the current literature on the neuropsychiatric manifestations of multiple sclerosis. Cognitive domains discussed include general cognitive functioning, learning and memory ability, attention, processing speed, executive functioning, visual perceptual ability and language functioning. Attention is also given to alterations in neuropsychiatric functioning associated with disease progression and across various disease subtypes. In addition, reports are also reviewed regarding various psychiatric disturbances, affective changes, quality of life issues and fatigue and pain in individuals with multiple sclerosis. Finally, factors pertaining to pediatric populations in multiple sclerosis are addressed.

Prospective memory, emotional valence, and multiple sclerosis

Cognitive impairments in multiple sclerosis (MS) extend to tasks demanding prospective memory (PM): remembering to perform an intended act during ongoing activity. This study investigated whether emotional content influenced the effects of MS on PM, following evidence that emotional valence can influence other aspects of memory. Thirty participants with MS were compared to 30 controls on a PM task, Virtual Week, in which emotion was manipulated. People with MS showed a consistent deficit in PM performance across manipulations of task and valence. Results indicated that emotionally positive tasks improved the PM performance of MS participants, with implications for rehabilitation.

Exercise in multiple sclerosis -- an integral component of disease management

Multiple sclerosis (MS) is the most common chronic inflammatory disorder of the central nervous system (CNS) in young adults. The disease causes a wide range of symptoms depending on the localization and characteristics of the CNS pathology. In addition to drug-based immunomodulatory treatment, both drug-based and non-drug approaches are established as complementary strategies to alleviate existing symptoms and to prevent secondary diseases. In particular, physical therapy like exercise and physiotherapy can be customized to the individual patient's needs and has the potential to improve the individual outcome. However, high quality systematic data on physical therapy in MS are rare. This article summarizes the current knowledge on the influence of physical activity and exercise on disease-related symptoms and physical restrictions in MS patients. Other treatment strategies such as drug treatments or cognitive training were deliberately excluded for the purposes of this article.

Cognitive and neurobehavioral features in multiple sclerosis

Multiple sclerosis (MS) is the most common nontraumatic neurological condition of early and middle adulthood. Cognitive and neurobehavioral problems associated with this disorder are common. Approximately 50% of MS patients experience lifetime clinical depression, and at least 50% will experience significant cognitive difficulties. Fatigue is also extremely common and disabling in MS and appears to be associated with sleep problems and primary neurological features, in addition to secondary factors, including depression and pain. Quality of life is affected in MS by all of these factors and is an especially salient issue given that patients often live for many years following diagnosis. In this article, we explore the literature on cognitive and neurobehavioral features in MS, provide a commentary on the state of the literature and make suggestions for research directions over the next 5 years that would move the field forward significantly.

Fatigue and cognition in patients with relapsing multiple sclerosis treated with interferon β

INTRODUCTION

Fatigue and cognitive deficits are common symptoms affecting patients with multiple sclerosis.

METHODS

The effects of interferon beta on fatigue and cognitive deficits were assessed in 50 patients with relapsing multiple sclerosis (recruited at a single center). The pre-treatment assessments were performed on visits 1 and 2 (Months 0 and 3). Patients started treatment with subcutaneous interferon beta-1a or beta-1b, or intramuscular interferon beta-1a at Month 3, with reassessment at visits 3 and 4 (6 and 12 months, respectively). Co-primary endpoints were change in fatigue (Modified Fatigue Impact Scale) and change in cognition (Brief Repeatable Battery of Neuropsychological Tests) from pre-treatment to visits 3 and 4. Follow-up data were obtained for 40 patients.

RESULTS

The pre-treatment demographic and disease characteristics did not differ between groups. Improvements in fatigue levels were reported for patients receiving subcutaneous interferon beta-1a versus patients in the intramuscular interferon beta-1a group (p = .04) and in the interferon beta-1b group (p = .09). Improvements were also reported in five out of 17 cognitive indices for all the treatment groups.

CONCLUSION

The data suggest that interferon beta may reduce fatigue and cognitive deficits in patients with relapsing multiple sclerosis. Larger, randomized, and controlled studies are required to confirm our findings.

Quality and quantity of diffuse and focal white matter disease and cognitive disability of patients with multiple sclerosis

BACKGROUND AND PURPOSE

Using high-field magnetic resonance imaging (MRI), we investigated the relationships between white matter (WM) lesion volume (LV), normal-appearing WM (NAWM) normalized volume, WM-lesion and NAWM magnetization transfer ratios (MTRs), brain parenchyma fraction (BPF), and cognitive impairment (CI) in multiple sclerosis (MS).

METHODS

Twenty-four patients and 24 healthy volunteers (age, sex, and years of education-matched) underwent a 3.0 Tesla (3T) scan and evaluation of depression, fatigue, and CI using the Minimal Assessment of Cognitive Function in MS (MACFIMS) battery.

RESULTS

In this clinically relatively well-preserved cohort of patients (median score on the Expanded Disability Status Scale=1.5), CI was detected on Symbol Digit Modalities Test (SDMT), California Verbal Learning Test-II (CVLT-II), and Controlled Oral Word Association Test. MT data were available in 19 pairs on whom correlation analyses were performed. Associations were seen between SDMT and normalized NAWM volume (P=.034, r=.502), CVLT-II long delay and normalized NAWM volume (P=.012, r=.563), WM-LV (P=.024, r=.514), and BPF (P=.002, r=.666).

CONCLUSIONS

The use of 3T MRI in a sample of clinically stable MS patients shows the importance of WM disease in hampering processing speed and word retrieval.

Symptomatic therapy in multiple sclerosis: a review for a multimodal approach in clinical practice

As more investigations into factors affecting the quality of life of patients with multiple sclerosis (MS) are undertaken, it is becoming increasingly apparent that certain comorbidities and associated symptoms commonly found in these patients differ in incidence, pathophysiology and other factors compared with the general population. Many of these MS-related symptoms are frequently ignored in assessments of disease status and are often not considered to be associated with the disease. Research into how such comorbidities and symptoms can be diagnosed and treated within the MS population is lacking. This information gap adds further complexity to disease management and represents an unmet need in MS, particularly as early recognition and treatment of these conditions can improve patient outcomes. In this manuscript, we sought to review the literature on the comorbidities and symptoms of MS and to summarize the evidence for treatments that have been or may be used to alleviate them.

The impact of fatigue on cognitive functioning in patients with multiple sclerosis

Objective: To study the impact of physical and mental fatigue on cognitive complaints and cognitive performance in patients with multiple sclerosis.

Design: Cross-sectional study.

Setting: An outpatient neurology clinic.

Subjects: Eighty patients diagnosed with clinically definite multiple sclerosis.

Measures: The subscales physical and mental fatigue of the Multidimensional Fatigue Inventory; the Hospital Anxiety and Depression Scale and the Cognitive Failure Questionnaire. Cognitive performance was assessed by an extensive neuropsychological test battery, including several tasks requiring effortful information processing.

Results: Both anxiety and depression and mental fatigue significantly contributed to cognitive complaints, explaining respectively about 9% and 39% of the total variance. The contribution of physical fatigue to cognitive complaints was not significant. Both physical and mental fatigue did not significantly contribute to cognitive performance in terms of mental speed, attention, memory and executive functioning.

Conclusions: To refine interventions for those patients with cognitive complaints, we advise adding measurements of anxiety, depression and fatigue to their neuropsychological assessment. Fatigue permits extensive neuropsychological assessment, which is needed to detect cognitive impairment in multiple sclerosis.

Performance of activities of daily living in multiple sclerosis

PURPOSE

To assess the performance of activities of daily living (ADL) in individuals with moderate to severe multiple sclerosis (MS).

METHOD

A total of 12 men and 32 women with MS (Expanded Disability Status Scale, EDSS, 6.0-8.5) were studied. The performance of personal ADL (P-ADL) and instrumental ADL (I-ADL) was assessed with the Functional Independence Measure (FIM) and the Assessment of Motor and Process Skills (AMPS).

RESULTS

Twenty-four of the 44 individuals were rated dependent in P-ADL by the FIM motor score, mainly due to limitations in some areas of self-care and in transfers and locomotion. Only three individuals were rated dependent by the FIM cognitive score, indicating no or little cognitive disability. Two thirds of the individuals who were rated independent/modified independent in P-ADL by the FIM were rated dependent in I-ADL by the AMPS. Only the FIM motor score was significantly related to the EDSS score, indicating that ADL performance and disease severity is weakly related.

CONCLUSIONS

Moderate to severe MS reduces the ability to perform both P-ADL and I-ADL. An individual with MS can be independent in P-ADL but still unable to perform I-ADL satisfactorily. Assessments of both P-ADL and I-ADL are advocated to evaluate ADL performance in order to implement appropriate management strategies for individuals with MS.

Cognitive dysfunction in primary progressive multiple sclerosis: a neuropsychological and MRI study

Although cognitive dysfunction is known to occur in multiple sclerosis (MS), only few studies have reported cognitive performance in patients with primary progressive MS (PPMS). To find out the pattern of cognitive performance in PPMS, 28 PPMS patients underwent an extensive battery of neuropsychological tests. The results were compared to those of healthy controls ( n = 20) and patients with secondary progressive MS (SPMS, n = 28). Furthermore, the results of neuropsychological tests in PPMS were correlated to magnetic resonance imaging findings. Our study showed that the PPMS patients have deficits in several cognitive domains when compared to age-matched and education-matched controls, but the cognitive impairment in the PPMS and SPMS patients appeared to be similar. Cognitive deficits in PPMS patients correlated with diffuse brain lesion, T1- and T2-lesion load, but no correlations were found with atrophy.

Predicting accidental falls in people with multiple sclerosis -- a longitudinal study

OBJECTIVE

To investigate accidental falls and near fall incidents in people with multiple sclerosis with respect to clinical variables and the predictive values of four tests.

DESIGN

A longitudinal, multi-centred cohort study with prospectively collected falls.

PROCEDURES

Self-reported incidents during the three months following a standardized test procedure.

SUBJECTS

Seventy-six people with multiple sclerosis and an Expanded Disability Status Scale score between 3.5 and 6.0.

MAIN OUTCOME MEASURES

Berg Balance Scale, Timed Up and Go cognitive, Four Square Step Test (FSST) and 12-item Multiple Sclerosis Walking Scale.

RESULTS

Forty-eight people (63%) registered 270 falls. Most falls occurred indoors during activities of daily life. We found a correlation of r(s)=0.57 between near falls and falls, and of r(s) = 0.82 between registered and retrospectively recalled falls. Fallers and non-fallers differed significantly regarding Expanded Disability Status Score (odds ratio (OR) 1.99, 95% confidence interval (CI) 1.22; 3.40), spasticity (OR 1.14, CI 1.02; 1.31), proprioception (OR 2.50, CI 1.36; 5.12) and use of walking aids (OR 2.27, CI 1.23; 4.37). Reported use of walking aids both indoors and outdoors increased the odds of falling fivefold while disturbed proprioception increased the odds 2.5-15.6 times depending on severity. The odds of falling were doubled for each degree of increased Expanded Disability Status Score and more than doubled for each degree of increased spasticity. The Berg Balance Scale, use of walking aids and Timed Up and Go cognitive best identified fallers (73-94%) and proprioception, Expanded Disability Status Score, 12-item Multiple Sclerosis Walking Scale and Four Square Step Test best identified non-fallers (75-93%).

CONCLUSIONS

In clinical practice, looking at the use of walking aids, investigating proprioception and spasticity, rating Expanded Disability Status Score and using Berg Balance Scale or Timed Up and Go cognitive all contribute when identifying fallers.

Multiple sclerosis and reproductive risks in women

During the previous decades, women with Multiple Sclerosis (MS) were discouraged from having children, as pregnancy was deemed dangerous for pregnancy outcome and a contributing factor for exacerbation of MS. Current knowledge shows that women with MS are no more likely to have pregnancy or delivery complications compared to healthy women. Immunomodulatory therapies should be avoided during pregnancy and while breastfeeding. However, despite that it is still not recommended during pregnancy, Glatiramer acetate has fewer risks than the other MS drugs with respect to pregnancy outcome. IVIg treatment appears to be safe in unblinded studies and may be used after the first trimester to prevent the exacerbation of postpartum relapses. Gestation is a period of decreased risk for a relapse, whereas relapses are more common in the first six months after childbirth, compared to the pre-pregnancy period. Breastfeeding and epidural anaesthesia are not associated with increased incidence of post-partum relapses.

A review of disease-modifying therapies for MS: maximizing adherence and minimizing adverse events

BACKGROUND

In a chronic disabling disorder such as multiple sclerosis (MS), adherence to treatment is of critical importance in maximizing benefits of therapy over the long term. Adverse events (AEs) are often cited by patients who discontinue therapy.

METHODS

Databases including Medline, CINAHL, and International Pharmaceutical Abstracts were searched for literature pertaining to adherence and AEs in MS published between January 1970 and August 2008. Clinical studies and case reports of AEs were included, as were papers that outlined factors that influence adherence. An advisory board with extensive experience in managing patients with MS developed guidelines to assist healthcare providers in maximizing adherence to disease-modifying therapy.

DISCUSSION

Internally based factors such as self-image, and externally based factors such as AEs, may influence patients' willingness and ability to adhere to therapy. Management of AEs associated with disease-modifying therapies and other therapies is reviewed, including intramuscular and subcutaneous interferon beta (IFNbeta)-1a, IFNbeta-1b, glatiramer acetate, natalizumab, methylprednisolone, mitoxantrone, cyclophosphamide, methotrexate, azathioprine, and intravenous immunoglobulin.

CONCLUSIONS

Effective management of MS is an ongoing, dynamic process that can enhance patients' adherence to therapy. Healthcare practitioners may address factors influencing adherence among patients with MS by managing treatment expectations, maintaining good communication with the patient, and managing AEs of treatment. Although the guidelines proposed herein originate from a single advisory board, it seems clear that by addressing patient concerns, healthcare practitioners can work with patients to enhance their ability to continue to adhere to their therapies and thereby gain the benefits of their treatment over the long term.

The psychology of fatigue in patients with multiple sclerosis: a review

Fatigue is a frequent and disabling symptom in patients with multiple sclerosis (MS), but it is difficult to define and measure. Today, MS-related fatigue is not fully understood, and evidence related to explanatory pathophysiological factors are conflicting. Here, we evaluate the contribution of psychological factors to MS-related fatigue. Insight into the possible underlying psychological mechanisms might help us to develop adequate psychological interventions and to improve the overall management of fatigue. Conceptual issues and the relationships between MS-related fatigue and mood, anxiety, cognition, personality, and cognitive-behavioral factors are discussed, and the implications for clinical practice and research are presented.

Relationship of cognitive impairment to psychiatric symptoms in multiple sclerosis

Psychiatric and cognitive changes are common in patients with multiple sclerosis (MS), but their relationship has not received much attention. We studied the relationship between psychiatric symptoms and verbal memory, working memory, and mental speed in 78 patients with MS and 40 healthy control subjects using linear regression analyses. The MS group exhibited impaired performance on all cognitive tests. Apathy was associated with intrusions and depression with impaired memory and mental speed. The association between apathy and intrusions supports the hypothesis that lesions in frontal areas or frontal connections contribute to a specific neuropsychiatric syndrome in patients with MS.

Influences on cognition by immunosuppression and immunomodulation in multiple sclerosis

Cognitive impairment is common also in early stages of MS, but only little is known about its relationship to standard immunotherapeutic drugs. Present data suggest that both immunosuppressive as well as immunomodulatory therapy prevent or delay the onset and severity of cognitive impairment although reversible cognitive deficits can occur.

Internet-based cognitive testing in multiple sclerosis

Cognitive impairment in multiple sclerosis is difficult to study because of the heterogeneity and variability of this disease. The gold standard for measurement of cognitive function in multiple sclerosis is a full battery of neurocognitive tests, which is time consuming and expensive. Some cognitive tests like the PASAT, a measure of working verbal memory and processing speed, have been proposed for screening and follow-up of cognitive function in clinical trials. We studied whether we could measure cognitive function in multiple sclerosis over the Internet. For this we used the Cognitive Stability Index (CSI)™, developed for persons with known or suspected primary central nervous system illness. The CSI was compared with formal neurocognitive testing (NPsych) and the PASAT in a cross-sectional study of 40 consecutive multiple sclerosis patients with subjective cognitive complaints. NPsych revealed that only 18 of the 40 patients (46%) were cognitively impaired. Although both the CSI and the PASAT were equalivalent in their specificity (86%), the CSI was significantly more sensitive than the PASAT (83% versus 28%). We conclude that the CSI, because of its availability over the Internet, has great potential as a tool for screening and follow up of cognitive function in multiple sclerosis. Multiple Sclerosis 2007; 13: 1011—1019. http://msj.sagepub.com

Prospective memory in multiple sclerosis

There is considerable evidence that multiple sclerosis (MS) is associated with impaired retrospective memory. However, although preliminary evidence suggests that prospective memory is also affected by the disorder, the degree and nature of the impairment remains to be clarified. Twenty participants with MS were compared with 20 matched controls on Virtual Week, a measure of prospective memory that closely represents the types of prospective memory tasks that actually occur in everyday life, and provides an opportunity to investigate the different sorts of prospective memory failures that occur. The results indicated that irrespective of the specific prospective memory task demands, MS participants' performance was significantly impaired relative to controls. MS deficits could not be attributed to problems with retrospective memory because MS participants in the present study did not differ significantly from controls on measures of long- and short-term memory, and significant impairment was observed on a prospective memory task, which imposed only minimal demands on retrospective memory. These results therefore suggest that individuals with MS may experience general difficulties with prospective memory. The practical and theoretical implications of these findings are discussed.

Activity of attention related structures in multiple sclerosis patients

AIMS

It was investigated whether the cortical activity during tasks requiring focused or divided attention is reduced in multiple sclerosis patients with prominent deficits (MS(+D)) and increased in patients without impairment (MS(-D)) in these specific attention functions.

METHODS

Six MS(+D) patients with attention deficits, six unimpaired MS(-D) patients, and age-, gender-, and education-matched healthy control subjects were examined with functional magnetic resonance imaging (fMRI). The experimental paradigm consisted of visual tasks requiring focused or divided attention.

RESULTS

Performance accuracy and reaction times were impaired in MS(+D) patients. This subgroup showed reduced activation within superior and inferior frontal gyrus during focused attention. Under conditions of divided attention decreased activity was found within middle and inferior frontal gyrus, inferior parietal structures, and occipital areas. No compensatory activity was observed. MS(-D) patients did neither differ in behavioral data nor in cortical activity in attention related structures from control subjects.

CONCLUSIONS

The study found evidence for the neural correlate of attentional deficits in MS patients. In patients with specific attention deficits, reduced cortical activity in prefrontal and parietal areas, which are associated with attention and executive control, reflects the patients' reduced performance on a behavioral level. Our findings also suggest impaired top-down attentional control on sensory structures in these patients. In patients without verifiable attention deficits a normal functioning of structures relevant for executive attention was observed. Compensatory activity in these structures as a marker of reorganization in less pronounced stages of the disease was not found.

Cyclosporine A inhibits acetylcholinesterase activity in rats experimentally demyelinated with ethidium bromide

Cyclosporine A is the major immunosuppressive agent used for organ transplantation and for the treatment of a variety of autoimmune disorders such as multiple sclerosis. In this work, we investigated the effect of the cyclosporine A on the acetylcholinesterase activity in the cerebral cortex, striatum, hippocampus, hypothalamus, cerebellum and pons of the rats experimentally demyelinated by ethidium bromide. Rats were divided into four groups: I control (injected with saline), II (treated with cyclosporine A), III (injected with 0.1% ethidium bromide) and IV (injected with 0.1% the ethidium bromide and treated with cyclosporine A). The results showed a significant inhibition (p<0.05) of acetylcholinesterase activity in the groups II, III and IV in all brain structures analyzed. In the striatum, hippocampus, hypothalamus and pons the inhibition was greater (p<0.005) when ethidium bromide was associated with cyclosporine A. In conclusion, the present investigation demonstrated that cyclosporine A is an inhibitor of acetylcholinesterase activity and this effect is increased after an event of toxic demyelination of the central nervous system.

Psychometric evaluation of the Ways of Coping Questionnaire as applied to clinical and nonclinical groups

OBJECTIVE

The purpose of this study is to describe coping and evaluate the psychometric properties and the factor structure of the Ways of Coping Questionnaire (WCQ) applied to clinical and nonclinical groups.

METHOD

The responses of 510 subjects (chronically disabled patients, their next of kin, and students) who completed the Swedish version of the WCQ were the basis for confirmatory factor analyses of the original eight-factor model as well as of the model consistency across samples.

RESULTS

The coping patterns that emerged in the case of the patients were very similar to those of the next of kin. The exceptions were greater use of Distancing by patients and of Positive Reappraisal by next of kin. The results showed support for the original eight-factor model, but deviation from the equality of factor structures among the subsamples indicated a limited use of the WCQ in between-sample comparisons.

CONCLUSION

Modifications to the eight-factor model adequately described the subsamples, supporting the use of the WCQ in within-sample settings. This was particularly evident from the evaluation of alternative factor structures based on previously described models derived from clinical samples.

[Effects of high-dose cortisone therapy on cognition]

Treatment with high-dose corticosteroids over 3-5 days reduces the duration and severity of relapses in patients with multiple sclerosis. Since the benefit of this treatment appears to be dose-dependent, application of ultrahigh steroid doses becomes important. On the other hand, data from basic research and clinical studies indicate potential side effects on mnestic functions. Three recently published studies show that treatment with pulsed corticosteroids induces reversible impaired memory. The effects were independent of the dose administered.

Memory interference in multiple sclerosis

To explore verbal memory impairments associated with multiple sclerosis (MS), we compared proactive and retroactive interference effects on the California Verbal Learning Test (CVLT; Delis et al., 1987) in a sample of 83 community-residing individuals with MS and 80 healthy participants. Individuals with MS demonstrated normal accumulation of proactive interference (PI), but attenuated release from PI relative to healthy individuals. Furthermore, accumulation of retroactive interference (RI) at short-delay free recall (SDFR) was intensified for those with MS as compared to healthy participants. Interestingly, accumulation of RI predicted long-term memory (LTM) only for participants with MS. These findings suggest that individuals with MS may experience particular difficulty when required to use semantic properties of information flexibly to facilitate verbal LTM.

Young onset dementia

Young onset dementia is a challenging clinical problem with potentially devastating medical and social consequences. The differential diagnosis is wide, and includes a number of rare sporadic and hereditary diseases. However, accurate diagnosis is often possible, and all patients should be thoroughly investigated to identify treatable processes. This review presents an approach to the diagnosis, investigation, and management of patients with young onset dementia, with particular reference to common and treatable causes.

Effect of pioglitazone treatment in a patient with secondary multiple sclerosis

BACKGROUND: Ligands of the peroxisome proliferator-activated receptor-gamma (PPARgamma) induce apoptosis in activated T-lymphocytes and exert anti-inflammatory effects in glial cells. Preclinical studies have shown that the thiazolidinedione pioglitazone, an FDA-approved PPARgamma agonist used to treat type 2 diabetes, delays the onset and reduces the severity of clinical symptoms in experimental autoimmune encephalomyelitis, an animal model of multiple sclerosis (MS). We therefore tested the safety and therapeutic potential of oral pioglitazone in a patient with secondary MS. CASE PRESENTATION: The rationale and risks of taking pioglitazone were carefully explained to the patient, consent was obtained, and treatment was initiated at 15 mg per day p.o. and then increased by 15 mg biweekly to 45 mg per day p.o. for the duration of the treatment. Safety was assessed by measurements of metabolic profiles, blood pressure, and edema; effects on clinical symptoms were assessed by measurement of cognition, motor function and strength, and MRI. Within 4 weeks the patient exhibited increased appetite, cognition and attention span. After 12 months treatment, body weight increased from 27.3 to 35.9 kg (32%) and maintained throughout the duration of the study. Upper extremity strength and coordination improved, and increased fine coordination was noted unilaterally after 8 months and bilaterally after 15 months. After 8 months therapy, the patient demonstrated improvement in orientation, short-term memory, and attention span. MRIs carried out after 10 and 18 months of treatment showed no perceptible change in overall brain atrophy, extent of demyelination, or in Gd-enhancement. After 3.0 years on pioglitazone, the patient continues to be clinically stable, with no adverse events. CONCLUSIONS: In a patient with secondary progressive MS, daily treatment with 45 mg p.o. pioglitazone for 3 years induced apparent clinical improvement without adverse events. Pioglitazone should therefore be considered for further testing of therapeutic potential in MS patients.

Working memory deficits in multiple sclerosis: a controlled study with auditory P600 correlates

BACKGROUND

Recently, the P600 component of event related potentials, a waveform that is conceived to be generated and/or modulated by basal ganglia and cingulate area has been considered an index of the completion of any synchronised operation after target detection, having much in common with working memory operation. Moreover, dysfunction of these brain structures as well as working memory deficits have been implicated in the pathophysiology of multiple sclerosis. The aim of this study was to investigate the patterns of P600 elicited during a working memory test in multiple sclerosis patients compared with healthy controls.

METHODS

Twenty two definite, chronic progressive multiple sclerosis patients, with recent exacerbation of their illness, and 20 normal subjects matched for age, sex, and educational level, were studied with a computerised version of the digit span test of Wechsler batteries. Auditory P600 were measured during the anticipatory period of this test.

RESULTS

The patient group, as compared with healthy controls, showed significantly reduced latencies of P600 at left frontal areas and reduced P600 amplitudes at left temporoparietal region. Moreover, memory performance of patients was significantly more impaired when compared with healthy controls.

CONCLUSIONS

These findings may indicate that multiple sclerosis is associated with abnormal features of the completion of synchronised operation after target detection, as they are reflected by P600 amplitudes and latencies. Dysfunction of this mechanism may contribute to the identification of basic cognitive processes that could account for the cognitive deficits in multiple sclerosis.