This one-year clinical Multiple Sclerosis & Neuroimmunology Fellowship at the University of Florida provides advanced specialist training in the diagnosis, treatment and management of patients with multiple sclerosis and related immune-mediated disorders of the central nervous system (CNS). The overall goals for the fellowship are to:
- Develop competence in the care of persons with MS and related neuroimmunological disorders
- Become familiar with principles of interdisciplinary comprehensive patient-centered care of persons with MS
- Incorporate personalized therapy and risk management into clinical decision making in the care of persons with MS
- Recognize and address health disparities and inequities in MS
- Develop the ability to create new or advance existing MS centers in the Unites States
- Teach medical professionals and the MS community in MS-specific education to advance health literacy
- Develop an in-depth knowledge and competence in the relationship between epidemiological factors, including infections and their influence on clinical course of MS
Goals for the Fellows
Clinical evaluation of patients with neuroimmunological disorders:
- Recognize common and unusual presentations and manifestations of MS, NMO and other CNS immune-mediated disorders
- Generate a differential diagnosis of the broad spectrum of Multiple Sclerosis, its variants, and its mimics
- Describe the basic immunopathophysiology of MS and related neuroimmunological disorders
- Discuss sensitivities, specificities, and indications for paraclinical and emerging tests that are used to help establish (or rule out) a diagnosis of MS
- Manage primary and secondary symptoms of MS
- Describe treatment of MS with disease modifying agents
- Lead the health care team in the rehabilitative approach to caring for persons with MS
- Serve as an expert consultant for questions of complicated management issues in persons with MS
- Design innovative treatment approaches utilizing neurologic and rehabilitative strategies
- Recognize and address health disparities due to race, ethnicity and socioeconomic status
- Provide a critical review of current literature regarding research and clinical trials in MS
- Implement clinical or basic science research in an MS or MS related area
- Appreciate the vital role played in comprehensive clinical care of persons with MS played by subspecialties and other medical providers; including physiatrist and rehabilitative medicine, physical therapy, occupational therapy, speech pathology, neuropsychology, psychiatry, urology, neurosurgery and indications for device placement, and complementary and alternative therapies
Expertise in the definition and recognition of the following neurological signs and syndromes:
- Visual
- nystagmus and oscillopsia, INO, afferent pupillary defect, disc pallor, opsoclonus, smooth pursuit decomposition,
- Ophthalmoplegia, chiasmal and post chiasmal syndromes
- Motor
- hemiparesis, paraparesis, monoparesis, muscle spasms, spasticity
- Sensory/pain syndromes
- paresthesias, dysesthesias, L’hermitte’s Sign, anaesthesia, trigeminal neuralgia, anaesthesia dolorosa, allodynia, musculoskeletal pain, spasticity, secondary lumbosacral pain syndrome, piriformis Syndrome, other pain syndromes
- Genitourinary
- urinary urgency, frequency, hesitancy, nocturia, incontinence, failure to store bladder, failure to empty bladder, bladder dyssynergia, constipation, tenesmus, fecal incontinence, impotence, anorgasmy, decreased libido, dyspareunia
- Cerebellar
- tremor, incoordination, ocular dysmetria, scanning/telegraphic speech, ataxia
- Brainstem
- dysphagia, dysarthria, vertigo/dizziness
- Cognitive
- memory, neuropsychology profile of MS, judgment, word finding, attention and concentration, mood disturbances, fatigue, impairment of higher intellectual function/dementia, emotional lability, pseudobulbar palsy, depression, euphoria
- Spinal Cord
- transverse myelitis, brown-Sequard syndrome, sensory level, sweat level
- Other
- seizures, encephalitis, limbic encephalitis
Diagnosis, treatment, and scientific understanding of neurological disorders that are considered within the specialty of Neuroimmunology:
- Genetics & Epidemiology – current epidemiologic facts about MS, relationship between infections and risk of MS including EBV, incidence and prevalence including geographic north-south gradient, clusters, epidemics, incidence and prevalence, migration studies, racial/ethnic distribution, describe the genetics of MS from population studies to molecular mechanisms, HLA-associated loci, risk related to affected family member, twin studies, molecular sites of genetic contribution to susceptibility (TCR, MHC expression, immunoglobulin), emerging data on the proteomic profiles of MS lesions, gender bias in MS, sex ratio, differences in disease severity between sexes, effects of pregnancy, menses, menopause, breast feeding, hypovitaminosis D and smoking as risk factors / prognostic factors
- Neurophysiology – electrical transmission in normal nerves, architecture of normal myelinated nerves, generation of action potentials, saltatory conduction, disorders of conduction in demyelinated nerves, decreased conduction velocity, conduction block, temporal dispersion, ephaptic transmission, heat sensitivity and Uthoff’s phenomenon, ion channel distribution
- Neuroimmunology – normal mechanisms for immune reactivity and self-tolerance, possible mechanisms for loss of self-tolerance (autoimmunity), possible candidates for “MS antigen” (e.g., MBP, MOG), role of infections in etiology of MS, role of cytokines in MS, role of adhesion molecules in MS, T cell biology and subtypes, regulatory mechanisms, role B cells and microglia, mitochondrial dysfunction, antibody-mediated CNS syndromes, autoimmune encephalitides
- Clinical -be able to recognize the clinical presentation of the following syndromes:
- Multiple Sclerosis (MS)
- Neuromyelitis Optica (NMO)
- Myelin oligodendrocyte glycoprotein antibody disease
- Neurosarcoidosis
- Acute disseminated encephalomyelitis (ADEM)
- Schilder disease, Baló concentric sclerosis
- Sarcoidosis, Behcet’s disease
- Sjogren’s syndrome
- cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
- CNS infections
- Transverse myelitis
- Infarction of the spinal cord
- Vasculitis
- Radiation myelitis
- Arteriovenous fistula
- Progressive multifocal leukoencephalopathy (PML)
- Subacute combined degeneration of the spinal cord (vitamin B 12 deficiency)
- Small-vessel ischemic disease (affecting the brain primarily, and caused by diseases with vascular risk factors, such as diabetes, hypertension, hyperlipidemia, old age)
- Limbic encephalitis
- Hashimoto’s encephalitis
- Erdheim-Chester disease and other non-Langerhans histiocytosis
- Antibody-mediated encephalitis
- paraneoplastic neurological syndromes
- Stiff person syndrome,
- Cerebellitis
Treatment: pharmacological, surgical, and rehabilitative with special emphasis on:
- Acute vs. chronic interventions
- Induction vs escalation approaches
- Clinical and paraclinical outcomes
- Definition of No Evidence of Disease Activity (NEDA) and its application in the care of MS patients
- Complexities of polypharmacies
- Treatment associated adverse events
- Relapsing vs progressive onset MS
- Competency in special treatments including intrathecal baclofen pump
- Differential treatment of patient subgroups: early vs. middle vs. late disease
- Present results from clinical trials of FDA approved immunomodulatory drugs, off label medications and immunotherapies
- Emerging immunotherapies including BTKI
- Symptomatic management, acute exacerbations
- Steroid regimens
- IVIG, plasmapheresis
- Pseudoexacerbations
- Rehabilitative Therapy
- Assistive devices/Orthotics
- Functional electrical stimulation
- Exercise, diet and other life-style modifications