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Hillary Clinton’s medical history – and her tendency to keep personal and medical information far from view – is coming in for new scrutiny following revelations that the candidate got diagnosed with pneumonia Friday in advance of her stumble in New York.
Clinton’s stumble, caught on camera Sunday after she had to leave Sept. 11th anniversary memorial services after about an hour and a half, was the latest in a line of health spats that have made it into the news during her career.
‘Antibiotics can take care of pneumonia. What’s the cure for an unhealthy penchant for privacy that repeatedly creates unnecessary problems?’ asked President Obama’s former message guru David Axelrod in a tweet Monday – a message promptly retweeted by Trump‘s campaign manager Kellyanne Conway.
Below is a compilation of Clinton’s ailments and health incidents that have entered the public record:
Clinton’s medical history – and her tendency to keep personal and medical information far from view – is coming in for new scrutiny following revelations that the candidate got diagnosed with pneumonia Friday
Hillary’s dramatic collapse in New York on Sunday is prompting new examination of her health – as well as how her aides have closely guarded information
1998 Blood Clot
Clinton’s first known blood clot occurred in 1998, while she was still first lady.
Clinton experienced symptoms while attending a fundraiser for Sen. Charles Schumer of New York, who would soon become her Senate home-state colleague. Her right foot swelled up to the point where she couldn’t put on her shoe.
Clinton got quietly taken to the National Naval Medical Center in Bethesda for treatment at the time. She was found to have ‘a big clot’ blood clot behind her knee, Clinton wrote in her memoir, ‘Living History.’
She called it ‘the most significant health scare I’ve ever had,’ the Washington Post noted.
According to her physician, Mt. Kisco physician, Lisa Bardack, Clinton was advised at the time to take Lovenox, described as a short-acting blood thinner, when she took flights. The meds were discontinued when she went on Coumadin.
2009 Blood Clot
Clinton had a second blood clot incident in 2009. The episode was described by her doctor in a 2015 letter.
The doctor didn’t provide a detailed description of the event. Rather, she wrote that Clinton’s ‘past medical history is notable for a deep vein thrombosis in 1998, 2009 and a concussion in 2012.
Clinton takes a daily blood thinning medication for her deep vein thrombosis.
Clinton, a frequent flier whose staff catalogued her pursuit of the overall mileage record as secretary of state, may have exacerbated the problem through her extensive air travel.
Frequent jet travel can exacerbate blood clots, which is why some people make sure to walk around the cabin on long flights
2009 Elbow Fracture
Clinton had to work from home for a while after she fractured her elbow during a fall in 2009, CNN recounted. She fell at the State Department on the way to the White House, and went to George Washington University hospital for treatment.
She underwent a two-hour surgical procedure.
‘She is working from home. She is already taking some calls, and I’m sure starting to learn the limits of movement – how well you can text with one arm in a sling,’ quipped then spokesman P.J. Crowley at the time, in an early reference to Clinton’s communications habits.
Clinton was pictured wearing a sling emblazoned with the seal of the State Department when she returned to work. She also was photographed providing left-handed hand shake with a visiting Palestinian dignitary owing to her condition. She has showed no visible signs of lingering problems related to the injury.
HARD KNOCKS: Clinton got a fractured elbow in 2009, but still managed to negotiate with Hondouran leaders, and, according to her spokesman, text with one hand
2012 Blood Clot and Concussion
Clinton got a bad stomach bug and fainted at her home in Washington in 2012, an event that led her to get a concussion. Information about what exactly had happened emerged only slowly over time.
As her doctor put it, ‘In December 2012, Mrs. Clinton suffered a stomach virus after traveling, became dehydrated, fainted and sustained a concussion.’
The then-secretary of state wasn’t seen in public between Dec. 7th and when she left the hospital in New York January 2, 2013.
Clinton experienced ‘double vision for a period of time and benefited from wearing glasses with a Fresnel Prism,’ a special corrective lens, her doctor wrote in a letter voluntarily released to the media in 2015 as part of Clinton’s presidential campaign. Her concussion ‘resolved within two months,’ Bardack wrote.
In 2014, Bill Clinton revealed that the injury ‘required six months of very serious work to get over.’ The former president called it a ‘terrible concussion’
Clinton was diagnosed with a blood clot in the brain, transverse sinus venous thrombosis, and began anticoagulation therapy, her doctor wrote.
Clinton had to work from home and postpone planned testimony before a House Benghazi committee.
Clinton leaves New York Presbyterian Hospital with husband Bill and daughter Chelsea on January 2, 2013. The secretary of state, had not been seen in public since Dec. 7
Clinton also suffers from Hypothyroidismrefers to an under-active thyroid gland, resulting in a lack of important hormones.
Clinton’s doctor identified the condition in her 2015 letter, but did not state for how long Clinton has suffered from the condition. She takes a medication called Armour Thyroid.
Clinton suffers from ‘seasonal allergies,’ according to her physician. It isn’t known for how long she has suffered from allergies, although Clinton herself has cited her allergies when she has developed a cough – including on-stage during public events.
Her doctor states that Clinton is taking antihistamines, which treat the effects of allergies.
2016 Collapse and Pneumonia Diagnosis
Clinton had to leave a Sept. 11th service in New York early after spending 90 minutes at the ceremony. Her staff first cited heat and exhaustion, then ultimately revealed that Clinton had been diagnosed in pneumonia on Friday.
Clinton campaign spokesman Brian Fallon did not reveal what type of pneumonia Clinton has during a Monday interview on MSNBC, but said Clinton would be putting out more medical information.
‘She was put on antibiotics and advised to rest and modify her schedule,’ said Bardack in a statement released at the end of the day. While attending the event, ‘she became overheated and dehydrated. I have just examined her and she is now re-hydrated and recovering nicely.’
Hours after Clinton was taken away from the Sept. 11th ceremony, her office released a doctor’s statement. ‘Secretary Clinton has been experiencing a cough related to allergies. On Friday, during follow-up evaluation of her prolonged cough, she was diagnosed with pneumonia. She was put on antibiotics, and advised to rest and modify her schedule. While at this morning’s event, she became overheated and dehydrated. I have just examined her and she is now rehydrated and recovering nicely,’ Clinton’s doctor, Lisa Bardack, said in a written statement Sunday.’
‘There’s no other undisclosed condition. The pneumonia is the extent of it,’ Clinton campaign spokesman Brian Fallon told MSNBC.
Fallon also acknowledged: ‘I think in retrospect we could have handled it better in terms of providing more information more quickly.’
Campaign manager Robby Mook, speaking of the 90 minute delay before the press was told Clinton’s status after she left the New York event, said Monday: ‘We wish that that had been a lot shorter and that’s on us.’
Clinton herself tweeted Monday: ‘Thanks to everyone who’s reached out with well wishes! I’m feeling fine and getting better,’ signing the missive with the letter ‘H.’
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Clinton had to shake with her left hand following her 2009 injury. She is pictured here with Palestinian Authority Salam Fayyad
Clinton campaigned in New York in June along with aide Huma Abedin. She was diagnosed with pneumonia Friday, according to her office
Clinton is 68 and would be 69 when she assumed office, second to Ronald Reagan in age taking office. Donald Trump is 70, and has released few details about his medical background.
‘She participates in a healthy lifestyle and has had a full medical evaluation, which reveals no evidence of additional medical issues or cardiovascular disease. Her cancer screening evaluations are all negative. She is in excellent physical condition and fit to serve as President of the United States,’ her doctor wrote.
The letter released by Clinton’s physician details her 2012 concussion and double vision
Clinton was a ‘healthy-appearing female’ during her last examination, according to Dr. Lisa Bardack
The cause of Parkinson’s disease is generally unknown, but believed to involve both genetic and environmental factors. Those with a family member affected are more likely to get the disease themselves There is also an increased risk in people exposed to certain pesticides and among those who have had prior head injuries while there is a reduced risk in tobacco smokers and those who drink coffee or tea. The motor symptoms of the disease result from the death of cells in the substantia nigra, a region of the midbrain. This results in not enough dopamine in these areas. The reason for this cell death is poorly understood but involves the build-up ofproteins into Lewy bodies in the neurons. Diagnosis of typical cases is mainly based on symptoms, with tests such as neuroimaging being used to rule out other diseases.
There is no cure for Parkinson’s disease. Initial treatments is typically with the antiparkinson medicationlevodopa, with dopamine agonists being used once levodopa becomes less effective. As the disease progresses and neurons continue to be lost, these medications become less effective while at the same time they produce acomplication marked by involuntary writhing movements. Diet and some forms of rehabilitation have shown some effectiveness at improving symptoms.Surgery to place the microelectrodes for deep brain stimulation has been used to reduce motor symptoms in severe cases where drugs are ineffective. Evidence for treatments for the non-movement-related symptoms of PD, such as sleep disturbances and emotional problems, is less strong.
In 2013 PD was present in 53 million people and resulted in about 103,000 deaths globally. Parkinson’s disease typically occurs in people over the age of 60, of which about one percent are affected. Males are more often affected than females. When it is seen in people before the age of 40 or 50, it is called young onset PD. The average life expectancy following diagnosis is between 7 and 14 years. The disease is named after the English doctor James Parkinson, who published the first detailed description in An Essay on the Shaking Palsy, in 1817. Public awareness campaigns include World Parkinson’s Day (on the birthday of James Parkinson, 11 April) and the use of a red tulip as the symbol of the disease. People with parkinsonism who have increased the public’s awareness of the condition include actor Michael J. Fox, Olympic cyclist Davis Phinney, and late professional boxer Muhammad Ali.
The term parkinsonism is used for a motor syndrome whose main symptoms are tremor at rest, stiffness, slowing of movement and postural instability. Parkinsonian syndromes can be divided into four subtypes, according to their origin:
Parkinson’s disease is the most common form of parkinsonism and is usually defined as “primary” parkinsonism, meaning parkinsonism with no external identifiable cause. In recent years several genes that are directly related to some cases of Parkinson’s disease have been discovered. As much as this conflicts with the definition of Parkinson’s disease as an idiopathic illness, genetic parkinsonism disorders with a similar clinical course to PD are generally included under the Parkinson’s disease label. The terms “familial Parkinson’s disease” and “sporadic Parkinson’s disease” can be used to differentiate genetic from truly idiopathic forms of the disease.
Dementia with Lewy bodies (DLB) is another synucleinopathy that has similarities with PD, and especially with the subset of PD cases with dementia. However, the relationship between PD and DLB is complex and still has to be clarified. They may represent parts of a continuum or they may be separate diseases.
Signs and symptoms
A man with Parkinson’s disease displaying a flexed walking posture pictured in 1892.
Parkinson’s disease affects movement, producing motor symptoms. Non-motor symptoms, which include autonomic dysfunction, neuropsychiatric problems (mood, cognition, behavior or thought alterations), and sensory and sleep difficulties, are also common. Some of these non-motor symptoms are often present at the time of diagnosis and can precede motor symptoms.
Four motor symptoms are considered cardinal in PD: tremor, rigidity, slowness of movement, and postural instability.
Tremor is the most apparent and well-known symptom. It is the most common; though around 30% of individuals with PD do not have tremor at disease onset, most develop it as the disease progresses. It is usually a rest tremor: maximal when the limb is at rest and disappearing with voluntary movement and sleep. It affects to a greater extent the most distal part of the limb and at onset typically appears in only a single arm or leg, becoming bilateral later. Frequency of PD tremor is between 4 and 6 hertz (cycles per second). A feature of tremor is pill-rolling, the tendency of the index finger of the hand to get into contact with the thumb and perform together a circular movement.The term derives from the similarity between the movement of people with PD and the earlier pharmaceutical technique of manually making pills.
Hypokinesia (slowness of movement) is another characteristic feature of PD, and is associated with difficulties along the whole course of the movement process, from planning to initiation and finally execution of a movement. Performance of sequential and simultaneous movement is hindered. Bradykinesia is commonly a very disabling symptom in the early stages of the disease. Initial manifestations are problems when performing daily tasks which require fine motor control such as writing, sewing or getting dressed. Clinical evaluation is based on similar tasks such as alternating movements between both hands or both feet. Bradykinesia is not equal for all movements or times. It is modified by the activity or emotional state of the subject, to the point that some people are barely able to walk yet can still ride a bicycle. Generally people with PD have less difficulty when some sort of external cue is provided.
Rigidity is stiffness and resistance to limb movement caused by increased muscle tone, an excessive and continuous contraction of muscles. In parkinsonism the rigidity can be uniform (lead-pipe rigidity) or ratchety (cogwheel rigidity). The combination of tremor and increased tone is considered to be at the origin of cogwheel rigidity.Rigidity may be associated with joint pain; such pain being a frequent initial manifestation of the disease. In early stages of Parkinson’s disease, rigidity is often asymmetrical and it tends to affect the neck and shoulder muscles prior to the muscles of the face and extremities. With the progression of the disease, rigidity typically affects the whole body and reduces the ability to move.
Postural instability is typical in the late stages of the disease, leading to impaired balance and frequent falls, and secondarily to bone fractures. Instability is often absent in the initial stages, especially in younger people. Up to 40% may experience falls and around 10% may have falls weekly, with the number of falls being related to the severity of PD.
A person with PD has two to six times the risk of dementia compared to the general population. The prevalence of dementia increases with duration of the disease. Dementia is associated with a reducedquality of life in people with PD and their caregivers, increased mortality, and a higher probability of needing nursing home care.
In addition to cognitive and motor symptoms, PD can impair other body functions.
Sleep problems are a feature of the disease and can be worsened by medications. Symptoms can manifest as daytime drowsiness, disturbances in REM sleep, or insomnia. A systematic review shows that sleep attacks occur in 13.0% of patients with Parkinson’s disease on dopaminergic medications.
Parkinson’s disease in most people is idiopathic (having no specific known cause). However, a small proportion of cases can be attributed to known genetic factors. Other factors have been associated with the risk of developing PD, but no causal relationships have been proven.
A number of environmental factors have been associated with an increased risk of Parkinson’s including: pesticide exposure, head injuries, and living in the country or farming. Rural environments and the drinking of well water may be risks as they are indirect measures of exposure to pesticides.
PD traditionally has been considered a non-genetic disorder; however, around 15% of individuals with PD have a first-degree relative who has the disease. At least 5% of people are now known to have forms of the disease that occur because of a mutation of one of several specific genes.
Mutations in specific genes have been conclusively shown to cause PD. These genes code for alpha-synuclein (SNCA), parkin (PRKN), leucine-rich repeat kinase 2 (LRRK2 or dardarin), PTEN-induced putative kinase 1 (PINK1), DJ-1 and ATP13A2. In most cases, people with these mutations will develop PD. With the exception of LRRK2, however, they account for only a small minority of cases of PD. The most extensively studied PD-related genes are SNCA and LRRK2. Mutations in genes including SNCA, LRRK2 and glucocerebrosidase (GBA) have been found to be risk factors for sporadic PD. Mutations in GBA are known to cause Gaucher’s disease.Genome-wide association studies, which search for mutated alleles with low penetrance in sporadic cases, have now yielded many positive results.
The role of the SNCA gene is important in PD because the alpha-synuclein protein is the main component of Lewy bodies.Missense mutations of the gene (in which a singlenucleotide is changed), and duplications and triplications of the locus containing it have been found in different groups with familial PD. Missense mutations are rare. On the other hand, multiplications of the SNCA locus account for around 2% of familial cases. Multiplications have been found in asymptomatic carriers, which indicate that penetrance is incomplete or age-dependent.
The LRRK2 gene (PARK8) encodes a protein called dardarin. The name dardarin was taken from a Basque word for tremor, because this gene was first identified in families from England and the north of Spain.Mutations in LRRK2 are the most common known cause of familial and sporadic PD, accounting for approximately 5% of individuals with a family history of the disease and 3% of sporadic cases. There are many mutations described in LRRK2, however unequivocal proof of causation only exists for a few.
Several Parkinson-related genes are involved in the function of lysosomes, organelles that digest cellular waste products. It has been suggested that some forms of Parkinson may be caused by lysosome dysfunctions that reduce the ability of cells to break down alpha-synuclein.
Macroscopic alterations can be noticed on cut surfaces of the brainstem, where neuronal loss can be inferred from a reduction of neuromelanin pigmentation in the substantia nigra and locus coeruleus. The histopathology (microscopic anatomy) of the substantia nigra and several other brain regions shows neuronal loss and Lewy bodies in many of the remaining nerve cells. Neuronal loss is accompanied by death of astrocytes (star-shaped glial cells) and activation of the microglia (another type of glial cell). Lewy bodies are a key pathological feature of PD.
A. Schematic initial progression of Lewy body deposits in the first stages of Parkinson’s disease, as proposed by Braak and colleagues
B. Localization of the area of significant brain volume reduction in initial PD compared with a group of participants without the disease in a neuroimaging study, which concluded that brain stemdamage may be the first identifiable stage of PD neuropathology
There are five major pathways in the brain connecting other brain areas with the basal ganglia. These are known as the motor, oculo-motor, associative, limbic and orbitofrontalcircuits, with names indicating the main projection area of each circuit. All of them are affected in PD, and their disruption explains many of the symptoms of the disease since these circuits are involved in a wide variety of functions including movement, attention and learning. Scientifically, the motor circuit has been examined the most intensively.
A particular conceptual model of the motor circuit and its alteration with PD has been of great influence since 1980, although some limitations have been pointed out which have led to modifications. In this model, the basal ganglia normally exert a constant inhibitory influence on a wide range of motor systems, preventing them from becoming active at inappropriate times. When a decision is made to perform a particular action, inhibition is reduced for the required motor system, thereby releasing it for activation. Dopamine acts to facilitate this release of inhibition, so high levels of dopamine function tend to promote motor activity, while low levels of dopamine function, such as occur in PD, demand greater exertions of effort for any given movement. Thus, the net effect of dopamine depletion is to produce hypokinesia, an overall reduction in motor output. Drugs that are used to treat PD, conversely, may produce excessive dopamine activity, allowing motor systems to be activated at inappropriate times and thereby producing dyskinesias.
Brain cell death
There is speculation of several mechanisms by which the brain cells could be lost. One mechanism consists of an abnormal accumulation of the protein alpha-synucleinbound to ubiquitin in the damaged cells. This insoluble protein accumulates inside neurones forming inclusions called Lewy bodies. According to the Braak staging, a classification of the disease based on pathological findings, Lewy bodies first appear in the olfactory bulb, medulla oblongata and pontine tegmentum, with individuals at this stage being asymptomatic. As the disease progresses, Lewy bodies later develop in the substantia nigra, areas of the midbrain and basal forebrain, and in a last step theneocortex. These brain sites are the main places of neuronal degeneration in PD; however, Lewy bodies may not cause cell death and they may be protective. In people with dementia, a generalized presence of Lewy bodies is common in cortical areas. Neurofibrillary tangles and senile plaques, characteristic of Alzheimer’s disease, are not common unless the person is demented.
Fludeoxyglucose (18F) (FDG) PET scan of a healthy brain. Hotter areas reflect higher glucose uptake. A decreased activity in the basal ganglia can aid in diagnosing Parkinson’s disease.
A physician will diagnose Parkinson’s disease from the medical history and a neurological examination. There is no lab test that will clearly identify the disease, but brain scans are sometimes used to rule out disorders that could give rise to similar symptoms. People may be given levodopa and resulting relief of motor impairment tends to confirm the diagnosis. The finding of Lewy bodies in the midbrain on autopsy is usually considered proof that the person had Parkinson’s disease. The progress of the illness over time may reveal it is not Parkinson’s disease, and some authorities recommend that the diagnosis should be periodically reviewed.
Medical organizations have created diagnostic criteria to ease and standardize the diagnostic process, especially in the early stages of the disease. The most widely known criteria come from the UK Parkinson’s Disease Society Brain Bank and the U.S. National Institute of Neurological Disorders and Stroke. The PD Society Brain Bank criteria require slowness of movement (bradykinesia) plus either rigidity, resting tremor, or postural instability. Other possible causes of these symptoms need to be ruled out. Finally, three or more of the following features are required during onset or evolution: unilateral onset, tremor at rest, progression in time, asymmetry of motor symptoms, response to levodopa for at least five years, clinical course of at least ten years and appearance of dyskinesias induced by the intake of excessive levodopa.Accuracy of diagnostic criteria evaluated at autopsy is 75–90%, with specialists such as neurologists having the highest rates.
Exercise in middle age reduces the risk of Parkinson’s disease later in life.Caffeine also appears protective with a greater decrease in risk occurring with a larger intake of caffeinated beverages such as coffee.Although tobacco smoke causes adverse health effects, decreases life expectancy and quality of life, it may reduce the risk of PD by a third when compared to non-smokers. The basis for this effect is not known, but possibilities include an effect of nicotine as a dopamine stimulant. Tobacco smoke contains compounds that act as MAO inhibitors that also might contribute to this effect.
Antioxidants, such as vitamins C and D, have been proposed to protect against the disease but results of studies have been contradictory and no positive effect has been proven. The results regarding fat and fatty acids have been contradictory, with various studies reporting protective effects, risk-increasing effects or no effects. Also, there have been preliminary indications of a possible protective role of estrogens and anti-inflammatory drugs.
There is no cure for Parkinson’s disease, but medications, surgery, and multidisciplinary management can provide relief from the symptoms. The main families of drugs useful for treating motor symptoms are levodopa (usually combined with a dopa decarboxylase inhibitor or COMT inhibitor which does not cross the blood–brain barrier), dopamine agonists and MAO-B inhibitors. The stage of the disease determines which group is most useful. Two stages are usually distinguished: an initial stage in which the individual with PD has already developed some disability for which he needs pharmacological treatment, then a second stage in which an individual develops motor complications related to levodopa usage. Treatment in the initial stage aims for an optimal tradeoff between good symptom control and side-effects resulting from improvement of dopaminergic function. The start of levodopa (or L-DOPA) treatment may be delayed by using other medications such as MAO-B inhibitors and dopamine agonists, in the hope of delaying the onset of dyskinesias. In the second stage the aim is to reduce symptoms while controlling fluctuations of the response to medication. Sudden withdrawals from medication or overuse have to be managed. When medications are not enough to control symptoms, surgery, and deep brain stimulation can be of use. In the final stages of the disease, palliative care is provided to improve quality of life.
Levodopa has been the most widely used treatment for over 30 years. L-DOPA is converted into dopamine in the dopaminergic neurons by dopa decarboxylase. Since motor symptoms are produced by a lack of dopamine in the substantia nigra, the administration of L-DOPA temporarily diminishes the motor symptoms.
Tolcapone inhibits the COMT enzyme, which degrades dopamine, thereby prolonging the effects of levodopa. It has been used to complement levodopa; however, its usefulness is limited by possible side effects such as liver damage. A similarly effective drug, entacapone, has not been shown to cause significant alterations of liver function. Licensed preparations of entacapone contain entacapone alone or in combination with carbidopa and levodopa.
Levodopa preparations lead in the long term to the development of motor complications characterized by involuntary movements called dyskinesias and fluctuations in the response to medication. When this occurs a person with PD can change from phases with good response to medication and few symptoms (“on” state), to phases with no response to medication and significant motor symptoms (“off” state). For this reason, levodopa doses are kept as low as possible while maintaining functionality. Delaying the initiation of therapy with levodopa by using alternatives (dopamine agonists and MAO-B inhibitors) is common practice. A former strategy to reduce motor complications was to withdraw L-DOPA medication for some time. This is discouraged now since it can bring dangerous side effects such as neuroleptic malignant syndrome. Most people with PD will eventually need levodopa and later develop motor side effects.
Several dopamine agonists that bind to dopaminergic post-synaptic receptors in the brain have similar effects to levodopa. These were initially used for individuals experiencing on-off fluctuations and dyskinesias as a complementary therapy to levodopa; they are now mainly used on their own as an initial therapy for motor symptoms with the aim of delaying motor complications. When used in late PD they are useful at reducing the off periods. Dopamine agonists include bromocriptine, pergolide, pramipexole, ropinirole, piribedil, cabergoline, apomorphine and lisuride.
Dopamine agonists produce significant, although usually mild, side effects including drowsiness, hallucinations, insomnia, nausea, and constipation. Sometimes side effects appear even at a minimal clinically effective dose, leading the physician to search for a different drug. Compared with levodopa, dopamine agonists may delay motor complications of medication use but are less effective at controlling symptoms.Nevertheless, they are usually effective enough to manage symptoms in the initial years. They tend to be more expensive than levodopa. Dyskinesias due to dopamine agonists are rare in younger people who have PD, but along with other side effects, become more common with age at onset. Thus dopamine agonists are the preferred initial treatment for earlier onset, as opposed to levodopa in later onset. Agonists have been related to impulse control disorders (such as compulsive sexual activity and eating, and pathological gambling and shopping) even more strongly than levodopa.
Apomorphine, a non-orally administered dopamine agonist, may be used to reduce off periods and dyskinesia in late PD. It is administered by intermittent injections or continuous subcutaneous infusions. Since secondary effects such as confusion and hallucinations are common, individuals receiving apomorphine treatment should be closely monitored. Two dopamine agonists that are administered through skin patches (lisuride and rotigotine) and are useful for people in the initial stages and possibly to control off states in those in the advanced state.
MAO-B inhibitors (safinamide, selegiline and rasagiline) increase the level of dopamine in the basal ganglia by blocking its metabolism. They inhibit monoamine oxidase B (MAO-B) which breaks down dopamine secreted by the dopaminergic neurons. The reduction in MAO-B activity results in increased L-DOPA in the striatum. Like dopamine agonists, MAO-B inhibitors used as monotherapy improve motor symptoms and delay the need for levodopa in early disease, but produce more adverse effects and are less effective than levodopa. There are few studies of their effectiveness in the advanced stage, although results suggest that they are useful to reduce fluctuations between on and off periods. An initial study indicated that selegiline in combination with levodopa increased the risk of death, but this was later disproven.
Placement of an electrode into the brain. The head is stabilised in a frame forstereotactic surgery.
Treating motor symptoms with surgery was once a common practice, but since the discovery of levodopa, the number of operations declined. Studies in the past few decades have led to great improvements in surgical techniques, so that surgery is again being used in people with advanced PD for whom drug therapy is no longer sufficient. Surgery for PD can be divided in two main groups: lesional and deep brain stimulation (DBS). Target areas for DBS or lesions include the thalamus, the globus pallidus or the subthalamic nucleus.Deep brain stimulation (DBS) is the most commonly used surgical treatment, developed in the 1980s by Alim-Louis Benabid and others. It involves the implantation of a medical device called a neurostimulator which sends electrical impulses to specific parts of the brain. DBS is recommended for people who have PD with motor fluctuations and tremor inadequately controlled by medication, or to those who are intolerant to medication, as long as they do not have severe neuropsychiatric problems. Other, less common, surgical therapies involve intentional formation of lesions to suppress overactivity of specific subcortical areas. For example, pallidotomy involves surgical destruction of the globus pallidus to control dyskinesia.
Exercise programs are recommended in people with Parkinson’s disease. There is some evidence that speech or mobility problems can improve with rehabilitation, although studies are scarce and of low quality. Regular physical exercise with or without physiotherapy can be beneficial to maintain and improve mobility, flexibility, strength, gait speed, and quality of life. When an exercise program is performed under the supervision of a physiotherapist, there are more improvements in motor symptoms, mental and emotional functions, daily living activities, and quality of life compared to a self-supervised exercise program at home. In terms of improving flexibility and range of motion for people experiencing rigidity, generalized relaxation techniques such as gentle rocking have been found to decrease excessive muscle tension. Other effective techniques to promote relaxation include slow rotational movements of the extremities and trunk, rhythmic initiation, diaphragmatic breathing, and meditation techniques. As for gait and addressing the challenges associated with the disease such as hypokinesia (slowness of movement), shuffling and decreased arm swing; physiotherapists have a variety of strategies to improve functional mobility and safety. Areas of interest with respect to gait during rehabilitation programs focus on but are not limited to improving gait speed, the base of support, stride length, trunk and arm swing movement. Strategies include utilizing assistive equipment (pole walking and treadmill walking), verbal cueing (manual, visual and auditory), exercises (marching and PNF patterns) and altering environments (surfaces, inputs, open vs. closed). Strengthening exercises have shown improvements in strength and motor function for people with primary muscular weakness and weakness related to inactivity with mild to moderate Parkinson’s disease. However, reports show a significant interaction between strength and the time the medications was taken. Therefore, it is recommended that people with PD should perform exercises 45 minutes to one hour after medications when they are at their best. Also, due to the forward flexed posture, and respiratory dysfunctions in advanced Parkinson’s disease, deep diaphragmatic breathing exercises are beneficial in improving chest wall mobility and vital capacity. Exercise may improve constipation.
One of the most widely practiced treatments for speech disorders associated with Parkinson’s disease is the Lee Silverman voice treatment (LSVT). Speech therapy and specifically LSVT may improve speech.Occupational therapy (OT) aims to promote health and quality of life by helping people with the disease to participate in as many of their daily living activities as possible. There have been few studies on the effectiveness of OT and their quality is poor, although there is some indication that it may improve motor skills and quality of life for the duration of the therapy.
Palliative care is specialized medical care for people with serious illnesses, including Parkinson’s. The goal of this speciality is to improve quality of life for both the person suffering from Parkinson’s and the family by providing relief from the symptoms, pain, and stress of illnesses. As Parkinson’s is not a curable disease, all treatments are focused on slowing decline and improving quality of life, and are therefore palliative in nature.
Palliative care should be involved earlier, rather than later in the disease course. Palliative care specialists can help with physical symptoms, emotional factors such as loss of function and jobs, depression, fear, and existential concerns.
Along with offering emotional support to both the patient and family, palliative care serves an important role in addressing goals of care. People with Parkinson’s may have many difficult decisions to make as the disease progresses such as wishes for feeding tube, non-invasive ventilator, and tracheostomy; wishes for or against cardiopulmonary resuscitation; and when to use hospice care. Palliative care team members can help answer questions and guide people with Parkinson’s on these complex and emotional topics to help them make the best decision based on their own values.
Muscles and nerves that control the digestive process may be affected by PD, resulting in constipation and gastroparesis (food remaining in the stomach for a longer period than normal). A balanced diet, based on periodical nutritional assessments, is recommended and should be designed to avoid weight loss or gain and minimize consequences of gastrointestinal dysfunction. As the disease advances, swallowing difficulties (dysphagia) may appear. In such cases it may be helpful to use thickening agents for liquid intake and an upright posture when eating, both measures reducing the risk of choking. Gastrostomy to deliver food directly into the stomach is possible in severe cases.
Levodopa and proteins use the same transportation system in the intestine and the blood–brain barrier, thereby competing for access. When they are taken together, this results in a reduced effectiveness of the drug. Therefore, when levodopa is introduced, excessive protein consumption is discouraged and well balanced Mediterranean diet is recommended. In advanced stages, additional intake of low-protein products such as bread or pasta is recommended for similar reasons. To minimize interaction with proteins, levodopa should be taken 30 minutes before meals. At the same time, regimens for PD restrict proteins during breakfast and lunch, allowing protein intake in the evening.
PD invariably progresses with time. A severity rating method known as the Unified Parkinson’s Disease Rating Scale (UPDRS) is the most commonly used metric for clinical study. A modified version known as the MDS-UPDRS is also sometimes used. An older scaling method known as the Hoehn and Yahr scale (originally published in 1967), and a similar scale known as the Modified Hoehn and Yahr scale, have also been commonly used. The Hoehn and Yahr scale defines five basic stages of progression.
Motor symptoms, if not treated, advance aggressively in the early stages of the disease and more slowly later. Untreated, individuals are expected to lose independent ambulation after an average of eight years and be bedridden after ten years. However, it is uncommon to find untreated people nowadays. Medication has improved the prognosis of motor symptoms, while at the same time it is a new source of disability because of the undesired effects of levodopa after years of use. In people taking levodopa, the progression time of symptoms to a stage of high dependency from caregivers may be over 15 years. However, it is hard to predict what course the disease will take for a given individual. Age is the best predictor of disease progression. The rate of motor decline is greater in those with less impairment at the time of diagnosis, while cognitive impairment is more frequent in those who are over 70 years of age at symptom onset.
Since current therapies improve motor symptoms, disability at present is mainly related to non-motor features of the disease. Nevertheless, the relationship between disease progression and disability is not linear. Disability is initially related to motor symptoms. As the disease advances, disability is more related to motor symptoms that do not respond adequately to medication, such as swallowing/speech difficulties, and gait/balance problems; and also to motor complications, which appear in up to 50% of individuals after 5 years of levodopa usage. Finally, after ten years most people with the disease have autonomic disturbances, sleep problems, mood alterations and cognitive decline. All of these symptoms, especially cognitive decline, greatly increase disability.
The life expectancy of people with PD is reduced.Mortality ratios are around twice those of unaffected people. Cognitive decline and dementia, old age at onset, a more advanced disease state and presence of swallowing problems are all mortality risk factors. On the other hand, a disease pattern mainly characterized by tremor as opposed to rigidity predicts an improved survival. Death from aspiration pneumonia is twice as common in individuals with PD as in the healthy population.
In 2013 PD resulted in about 103,000 deaths globally, up from 44,000 deaths in 1990. The death rate increased from an average of 1.5 to 1.8 per 100,000 during that time.
Deaths from Parkinson disease per million persons in 2012
PD is the second most common neurodegenerative disorder after Alzheimer’s disease and affects approximately seven million people globally and one million people in the United States. The proportion in a population at a given time is about 0.3% in industrialized countries. PD is more common in the elderly and rates rises from 1% in those over 60 years of age to 4% of the population over 80. The mean age of onset is around 60 years, although 5–10% of cases, classified as young onset PD, begin between the ages of 20 and 50. PD may be less prevalent in those of African and Asian ancestry, although this finding is disputed. Some studies have proposed that it is more common in men than women, but others failed to detect any differences between the two sexes. The number of new cases per year of PD is between 8 and 18 per 100,000 person–years.
Many risk factors and protective factors have been proposed, sometimes in relation to theories concerning possible mechanisms of the disease, however, none have been conclusively related to PD by empirical evidence. When epidemiological studies have been carried out in order to test the relationship between a given factor and PD, they have often been flawed and their results have in some cases been contradictory. The most frequently replicated relationships are an increased risk of PD in those exposed to pesticides, and a reduced risk in smokers.
In 1817 an English doctor, James Parkinson, published his essay reporting six cases of paralysis agitans.An Essay on the Shaking Palsy described the characteristic resting tremor, abnormal posture and gait, paralysis and diminished muscle strength, and the way that the disease progresses over time. Early neurologists who made further additions to the knowledge of the disease include Trousseau, Gowers, Kinnier Wilson and Erb, and most notably Jean-Martin Charcot, whose studies between 1868 and 1881 were a landmark in the understanding of the disease. Among other advances, he made the distinction between rigidity, weakness and bradykinesia. He also championed the renaming of the disease in honor of James Parkinson.
“Parkinson’s awareness” logo with red tulip symbol.
The costs of PD to society are high, but precise calculations are difficult due to methodological issues in research and differences between countries. The annual cost in the UK is estimated to be between 449 million and 3.3 billion pounds, while the cost per patient per year in the U.S. is probably around $10,000 and the total burden around 23 billion dollars. The largest share of direct cost comes from inpatient care and nursing homes, while the share coming from medication is substantially lower. Indirect costs are high, due to reduced productivity and the burden on caregivers. In addition to economic costs, PD reduces quality of life of those with the disease and their caregivers.
Actor Michael J. Fox has PD and has greatly increased the public awareness of the disease. After diagnosis, Fox embraced his Parkinson’s in television roles, sometimes acting without medication, in order to further illustrate the effects of the condition. He has written two autobiographies in which his fight against the disease plays a major role, and appeared before the United States Congress without medication to illustrate the effects of the disease.The Michael J. Fox Foundation aims to develop a cure for Parkinson’s disease. Fox received an honorary doctorate in medicine from Karolinska Institutet for his contributions to research in Parkinson’s disease.
Professional cyclist and Olympic medalist Davis Phinney, who was diagnosed with young onset Parkinson’s at age 40, started the Davis Phinney Foundation in 2004 to support Parkinson’s research, focusing on quality of life for people with the disease.
PD is not known to occur naturally in any species other than humans, although animal models which show some features of the disease are used in research. The appearance of parkinsonian symptoms in a group of drug addicts in the early 1980s who consumed a contaminated batch of the synthetic opiateMPPP led to the discovery of the chemical MPTP as an agent that causes a parkinsonian syndrome in non-human primates as well as in humans. Other predominant toxin-based models employ the insecticide rotenone, the herbicideparaquat and the fungicide maneb. Models based on toxins are most commonly used in primates. Transgenic rodent models that replicate various aspects of PD have been developed. Using the neurotoxin 6-hydroxydopamine, also known as 6-OHDA, it creates a model of Parkinson’s disease in rats by targeting and destroying dopaminergic neurons in the nigrostriatal pathway when injected into the substantia nigra.
Gene therapy typically involves the use of a non-infectious virus (i.e., a viral vector such as the adeno-associated virus) to shuttle genetic material into a part of the brain. The gene used leads to the production of anenzyme that helps to manage PD symptoms or protects the brain from further damage. In 2010 there were four clinical trials using gene therapy in PD. There have not been important adverse effects in these trials although the clinical usefulness of gene therapy is still unknown. One of these reported positive results in 2011, but the company filed for bankruptcy in March 2012.
Several chemical compounds such as GDNF (chemical structure pictured) have been proposed as neuroprotectors in PD, but their effectiveness has not been proven.
Since early in the 1980s, fetal, porcine, carotid or retinal tissues have been used in cell transplants, in which dissociated cells are injected into the substantia nigra in the hope that they will incorporate themselves into the brain in a way that replaces the dopamine-producing cells that have been lost. Although there was initial evidence ofmesencephalic dopamine-producing cell transplants being beneficial, double-blind trials to date indicate that cell transplants produce no long-term benefit. An additional significant problem was the excess release of dopamine by the transplanted tissue, leading to dystonias.Stem cell transplants are a recent research target, because stem cells are easy to manipulate and stem cells transplanted into the brains of rodents and monkeys have been found to survive and reduce behavioral abnormalities.Nevertheless, use of fetal stem cells is controversial. It has been proposed that effective treatments may be developed in a less controversial way by use of induced pluripotent stem cells taken from adults.
Multiple sclerosis (MS) is a demyelinating disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged. This damage disrupts the ability of parts of the nervous system to communicate, resulting in a range of signs and symptoms, including physical, mental, and sometimes psychiatric problems. Specific symptoms can include double vision, blindness in one eye, muscle weakness, trouble with sensation, or trouble with coordination. MS takes several forms, with new symptoms either occurring in isolated attacks (relapsing forms) or building up over time (progressive forms). Between attacks, symptoms may disappear completely; however, permanent neurological problems often remain, especially as the disease advances.
While the cause is not clear, the underlying mechanism is thought to be either destruction by the immune system or failure of the myelin-producing cells. Proposed causes for this include genetics and environmental factors such as being triggered by a viral infection. MS is usually diagnosed based on the presenting signs and symptoms and the results of supporting medical tests.
There is no known cure for multiple sclerosis. Treatments attempt to improve function after an attack and prevent new attacks. Medications used to treat MS, while modestly effective, can have side effects and be poorly tolerated. Physical therapy can help with people’s ability to function. Many people pursue alternative treatments, despite a lack of evidence. The long-term outcome is difficult to predict, with good outcomes more often seen in women, those who develop the disease early in life, those with a relapsing course, and those who initially experienced few attacks.Life expectancy is on average 5 to 10 years lower than that of an unaffected population.
Multiple sclerosis is the most common autoimmune disorder affecting the central nervous system. In 2013, about 2.3 million people were affected globally with rates varying widely in different regions and among different populations. That year about 20,000 people died from MS, up from 12,000 in 1990. The disease usually begins between the ages of 20 and 50 and is twice as common in women as in men. MS was first described in 1868 by Jean-Martin Charcot. The name multiple sclerosis refers to the numerous scars (sclerae—better known as plaques or lesions) that develop on the white matter of the brain and spinal cord. A number of new treatments and diagnostic methods are under development.
The condition begins in 85% of cases as a clinically isolated syndrome (CIS) over a number of days with 45% having motor or sensory problems, 20% having optic neuritis, and 10% having symptoms related to brainstem dysfunction, while the remaining 25% have more than one of the previous difficulties. The course of symptoms occurs in two main patterns initially: either as episodes of sudden worsening that last a few days to months (called relapses, exacerbations, bouts, attacks, or flare-ups) followed by improvement (85% of cases) or as a gradual worsening over time without periods of recovery (10-15% of cases). A combination of these two patterns may also occur or people may start in a relapsing and remitting course that then becomes progressive later on. Relapses are usually not predictable, occurring without warning. Exacerbations rarely occur more frequently than twice per year. Some relapses, however, are preceded by common triggers and they occur more frequently during spring and summer. Similarly, viral infections such as the common cold, influenza, or gastroenteritis increase their risk.Stress may also trigger an attack. Women with MS who become pregnant experience fewer relapses; however, during the first months after delivery the risk increases. Overall, pregnancy does not seem to influence long-term disability. Many events have been found not to affect relapse rates including vaccination, breast feeding, physical trauma, and Uhthoff’s phenomenon.
The cause of MS is unknown; however, it is believed to occur as a result of some combination of genetic and environmental factors such as infectious agents.Theories try to combine the data into likely explanations, but none has proved definitive. While there are a number of environmental risk factors and although some are partly modifiable, further research is needed to determine whether their elimination can prevent MS.
MS is more common in regions with northern European populations and the geographic variation may simply reflect the global distribution of these high-risk populations. Decreased sunlight exposure resulting in decreased vitamin D production has also been put forward as an explanation. A relationship between season of birth and MS lends support to this idea, with fewer people born in the northern hemisphere in November as compared to May being affected later in life. Environmental factors may play a role during childhood, with several studies finding that people who move to a different region of the world before the age of 15 acquire the new region’s risk to MS. If migration takes place after age 15, however, the person retains the risk of his home country. There is some evidence that the effect of moving may still apply to people older than 15.
HLA region of Chromosome 6. Changes in this area increase the probability of getting MS.
MS is not considered a hereditary disease; however, a number of genetic variations have been shown to increase the risk. Some of these genes appear to have higher levels of expression in microglial cells than expected by chance. The probability of developing the disease is higher in relatives of an affected person, with a greater risk among those more closely related. In identical twins both are affected about 30% of the time, while around 5% for non-identical twins and 2.5% of siblings are affected with a lower percentage of half-siblings. If both parents are affected the risk in their children is 10 times that of the general population. MS is also more common in some ethnic groups than others.
Many microbes have been proposed as triggers of MS, but none have been confirmed. Moving at an early age from one location in the world to another alters a person’s subsequent risk of MS. An explanation for this could be that some kind of infection, produced by a widespread microbe rather than a rare one, is related to the disease.Proposed mechanisms include the hygiene hypothesis and the prevalence hypothesis. The hygiene hypothesis proposes that exposure to certain infectious agents early in life is protective, the disease being a response to a late encounter with such agents. The prevalence hypothesis proposes that the disease is due to an infectious agent more common in regions where MS is common and where in most individuals it causes an ongoing infection without symptoms. Only in a few cases and after many years does it cause demyelination. The hygiene hypothesis has received more support than the prevalence hypothesis.
Evidence for a virus as a cause include: the presence of oligoclonal bands in the brain and cerebrospinal fluid of most people with MS, the association of several viruses with human demyelination encephalomyelitis, and the occurrence of demyelination in animals caused by some viral infection.Human herpes viruses are a candidate group of viruses. Individuals having never been infected by the Epstein–Barr virus are at a reduced risk of getting MS, whereas those infected as young adults are at a greater risk than those having had it at a younger age. Although some consider that this goes against the hygiene hypothesis, since the non-infected have probably experienced a more hygienic upbringing, others believe that there is no contradiction, since it is a first encounter with the causative virus relatively late in life that is the trigger for the disease. Other diseases that may be related include measles, mumps and rubella.
Smoking has been shown to be an independent risk factor for MS.Stress may be a risk factor although the evidence to support this is weak. Association with occupational exposures and toxins—mainly solvents—has been evaluated, but no clear conclusions have been reached.Vaccinations were studied as causal factors; however, most studies show no association. Several other possible risk factors, such as diet andhormone intake, have been looked at; however, evidence on their relation with the disease is “sparse and unpersuasive”.Gout occurs less than would be expected and lower levels of uric acid have been found in people with MS. This has led to the theory that uric acid is protective, although its exact importance remains unknown.
The three main characteristics of MS are the formation of lesions in the central nervous system (also called plaques), inflammation, and the destruction of myelin sheaths of neurons. These features interact in a complex and not yet fully understood manner to produce the breakdown of nerve tissue and in turn the signs and symptoms of the disease. Additionally, MS is believed to be an immune-mediated disorder that develops from an interaction of the individual’s genetics and as yet unidentified environmental causes. Damage is believed to be caused, at least in part, by attack on the nervous system by a person’s own immune system.
Demyelination in MS. On Klüver-Barrera myelin staining, decoloration in the area of the lesion can be appreciated (Original scale 1:100)
To be specific, MS involves the loss of oligodendrocytes, the cells responsible for creating and maintaining a fatty layer—known as the myelin sheath—which helps the neurons carry electrical signals (action potentials). This results in a thinning or complete loss of myelin and, as the disease advances, the breakdown of the axons of neurons. When the myelin is lost, a neuron can no longer effectively conduct electrical signals. A repair process, called remyelination, takes place in early phases of the disease, but the oligodendrocytes are unable to completely rebuild the cell’s myelin sheath. Repeated attacks lead to successively less effective remyelinations, until a scar-like plaque is built up around the damaged axons. These scars are the origin of the symptoms and during an attack magnetic resonance imaging (MRI) often shows more than ten new plaques. This could indicate that there are a number of lesions below which the brain is capable of repairing itself without producing noticeable consequences. Another process involved in the creation of lesions is an abnormal increase in the number of astrocytes due to the destruction of nearby neurons. A number of lesion patterns have been described.
Apart from demyelination, the other sign of the disease is inflammation. Fitting with an immunological explanation, the inflammatory process is caused by T cells, a kind oflymphocyte that plays an important role in the body’s defenses. T cells gain entry into the brain via disruptions in the blood–brain barrier. The T cells recognize myelin as foreign and attack it, explaining why these cells are also called “autoreactive lymphocytes”.
The attack of myelin starts inflammatory processes, which triggers other immune cells and the release of soluble factors like cytokines and antibodies. Further breakdown of the blood–brain barrier in turn causes a number of other damaging effects such as swelling, activation of macrophages, and more activation of cytokines and other destructive proteins. Inflammation can potentially reduce transmission of information between neurons in at least three ways. The soluble factors released might stop neurotransmission by intact neurons. These factors could lead to or enhance the loss of myelin, or they may cause the axon to break down completely.
The blood–brain barrier is a part of the capillary system that prevents the entry of T cells into the central nervous system. It may become permeable to these types of cells secondary to an infection by a virus or bacteria. After it repairs itself, typically once the infection has cleared, T cells may remain trapped inside the brain.Gadolinium cannot cross a normal BBB and, therefore, Gadolinium-enhanced MRI is used to show BBB breakdowns.
Animation showing dissemination of brain lesions in time and space as demonstrated by monthly MRI studies along a year
Multiple sclerosis as seen on MRI
Multiple sclerosis is typically diagnosed based on the presenting signs and symptoms, in combination with supporting medical imaging and laboratory testing. It can be difficult to confirm, especially early on, since the signs and symptoms may be similar to those of other medical problems. The McDonald criteria, which focus on clinical, laboratory, and radiologic evidence of lesions at different times and in different areas, is the most commonly used method of diagnosis with the Schumacher and Poser criteria being of mostly historical significance. While the above criteria allow for a non-invasive diagnosis, some state that the only definitive proof is an autopsy or biopsy where lesions typical of MS are detected.
Several phenotypes (commonly named types), or patterns of progression, have been described. Phenotypes use the past course of the disease in an attempt to predict the future course. They are important not only for prognosis but also for treatment decisions. In 1996, the United States National Multiple Sclerosis Society described four clinical courses. This set of courses was later reviewed by an international panel in 2013, adding clinically isolated syndrome (CIS) and radiologically isolated syndrome (RIS) as phenotypes, but leaving the main structure untouched.
secondary progressive (SPMS)
primary progressive (PPMS)
progressive relapsing (PRMS). This entity was removed in the 2013 review.
The relapsing-remitting subtype is characterized by unpredictable relapses followed by periods of months to years of relative quiet (remission) with no new signs of disease activity. Deficits that occur during attacks may either resolve or leave problems, the latter in about 40% of attacks and being more common the longer a person has had the disease. This describes the initial course of 80% of individuals with MS. When deficits always resolve between attacks, this is sometimes referred to as benign MS,although people will still build up some degree of disability in the long term. On the other hand, the term malignant multiple sclerosis is used to describe people with MS having reached significant level of disability in a short period. The relapsing-remitting subtype usually begins with a clinically isolated syndrome (CIS). In CIS, a person has an attack suggestive of demyelination, but does not fulfill the criteria for multiple sclerosis. 30 to 70% of persons experiencing CIS later develop MS.
Nerve axon with myelin sheath
Secondary progressive MS occurs in around 65% of those with initial relapsing-remitting MS, who eventually have progressive neurologic decline between acute attacks without any definite periods of remission. Occasional relapses and minor remissions may appear. The most common length of time between disease onset and conversion from relapsing-remitting to secondary progressive MS is 19 years.
The primary progressive subtype occurs in approximately 10–20% of individuals, with no remission after the initial symptoms. It is characterized by progression of disability from onset, with no, or only occasional and minor, remissions and improvements. The usual age of onset for the primary progressive subtype is later than of the relapsing-remitting subtype. It is similar to the age that secondary progressive usually begins in relapsing-remitting MS, around 40 years of age.
Progressive relapsing MS describes those individuals who, from onset, have a steady neurologic decline but also have clear superimposed attacks. This is the least common of all subtypes.
Although there is no known cure for multiple sclerosis, several therapies have proven helpful. The primary aims of therapy are returning function after an attack, preventing new attacks, and preventing disability. As with any medical treatment, medications used in the management of MS have several adverse effects. Alternative treatments are pursued by some people, despite the shortage of supporting evidence.
During symptomatic attacks, administration of high doses of intravenouscorticosteroids, such as methylprednisolone, is the usual therapy, with oral corticosteroids seeming to have a similar efficacy and safety profile. Although, in general, effective in the short term for relieving symptoms, corticosteroid treatments do not appear to have a significant impact on long-term recovery. The consequences of severe attacks that do not respond to corticosteroids might be treatable by plasmapheresis.
In RRMS they are modestly effective at decreasing the number of attacks. The interferons and glatiramer acetate are first-line treatments and are roughly equivalent, reducing relapses by approximately 30%.Early-initiated long-term therapy is safe and improves outcomes. Natalizumab reduces the relapse rate more than first-line agents; however, due to issues of adverse effects is a second-line agent reserved for those who do not respond to other treatments or with severe disease. Mitoxantrone, whose use is limited by severe adverse effects, is a third-line option for those who do not respond to other medications.Treatment of clinically isolated syndrome (CIS) with interferons decreases the chance of progressing to clinical MS. Efficacy of interferons and glatiramer acetate in children has been estimated to be roughly equivalent to that of adults. The role of some newer agents such as fingolimod, teriflunomide, and dimethyl fumarate, as of 2011, is not yet entirely clear.
Progressive multiple sclerosis
No treatment has been shown to change the course of primary progressive MS and as of 2011 only one medication, mitoxantrone, has been approved for secondary progressive MS. In this population tentative evidence supports mitoxantrone moderately slowing the progression of the disease and decreasing rates of relapses over two years.
Irritation zone after injection of glatiramer acetate.
The disease-modifying treatments have several adverse effects. One of the most common is irritation at the injection site for glatiramer acetate and the interferons (up to 90% with subcutaneous injections and 33% with intramuscular injections). Over time, a visible dent at the injection site, due to the local destruction of fat tissue, known aslipoatrophy, may develop. Interferons may produce flu-like symptoms; some people taking glatiramer experience a post-injection reaction with flushing, chest tightness, heart palpitations, and anxiety, which usually lasts less than thirty minutes. More dangerous but much less common are liver damage from interferons,systolic dysfunction(12%), infertility, and acute myeloid leukemia (0.8%) from mitoxantrone, and progressive multifocal leukoencephalopathy occurring with natalizumab (occurring in 1 in 600 people treated).
Both medications and neurorehabilitation have been shown to improve some symptoms, though neither changes the course of the disease. Some symptoms have a good response to medication, such as an unstable bladder and spasticity, while others are little changed. For neurologic problems, a multidisciplinary approach is important for improving quality of life; however, it is difficult to specify a ‘core team’ as many health services may be needed at different points in time. Multidisciplinary rehabilitation programs increase activity and participation of people with MS but do not influence impairment level. There is limited evidence for the overall efficacy of individual therapeutic disciplines, though there is good evidence that specific approaches, such as exercise, and psychology therapies, in particular cognitive behavioral approaches are effective.
The expected future course of the disease depends on the subtype of the disease; the individual’s sex, age, and initial symptoms; and the degree of disability the person has. Female sex, relapsing-remitting subtype, optic neuritis or sensory symptoms at onset, few attacks in the initial years and especially early age at onset, are associated with a better course.
The average life expectancy is 30 years from the start of the disease, which is 5 to 10 years less than that of unaffected people. Almost 40% of people with MS reach the seventh decade of life. Nevertheless, two-thirds of the deaths are directly related to the consequences of the disease.Suicide is more common, while infections and other complications are especially dangerous for the more disabled. Although most people lose the ability to walk before death, 90% are capable of independent walking at 10 years from onset, and 75% at 15 years.[needs update?]
Deaths from multiple sclerosis per million persons in 2012
MS is the most common autoimmune disorder of the central nervous system. As of 2010, the number of people with MS was 2–2.5 million (approximately 30 per 100,000) globally, with rates varying widely in different regions. It is estimated to have resulted in 18,000 deaths that year. In Africa rates are less than 0.5 per 100,000, while they are 2.8 per 100,000 in South East Asia, 8.3 per 100,000 in the Americas, and 80 per 100,000 in Europe. Rates surpass 200 per 100,000 in certain populations of Northern European descent. The number of new cases that develop per year is about 2.5 per 100,000.
Rates of MS appear to be increasing; this, however, may be explained simply by better diagnosis. Studies on populational and geographical patterns have been common and have led to a number of theories about the cause.
MS usually appears in adults in their late twenties or early thirties but it can rarely start in childhood and after 50 years of age. The primary progressive subtype is more common in people in their fifties. Similar to many autoimmune disorders, the disease is more common in women, and the trend may be increasing. As of 2008, globally it is about two times more common in women than in men. In children, it is even more common in females than males, while in people over fifty, it affects males and females almost equally.
Robert Carswell (1793–1857), a British professor of pathology, and Jean Cruveilhier (1791–1873), a French professor of pathologic anatomy, described and illustrated many of the disease’s clinical details, but did not identify it as a separate disease. Specifically, Carswell described the injuries he found as “a remarkable lesion of the spinal cord accompanied with atrophy”. Under the microscope, Swiss pathologist Georg Eduard Rindfleisch (1836–1908) noted in 1863 that the inflammation-associated lesions were distributed around blood vessels.
The French neurologistJean-Martin Charcot (1825–1893) was the first person to recognize multiple sclerosis as a distinct disease in 1868. Summarizing previous reports and adding his own clinical and pathological observations, Charcot called the disease sclerose en plaques.
The first attempt to establish a set of diagnostic criteria was also due to Charcot in 1868. He published what now is known as the “Charcot Triad”, consisting in nystagmus,intention tremor, and telegraphic speech (scanning speech) Charcot also observed cognition changes, describing his patients as having a “marked enfeeblement of the memory” and “conceptions that formed slowly”.
Diagnosis was based in Charcot triad and clinical observation until Schumacher made the first attempt to standardize criteria in 1965 by introducing some fundamental requirements: Dissemination of the lesions in time (DIT) and space (DIS), and that “signs and symptoms cannot be explained better by another disease process”. Both requirements were later inherited by Poser criteria and McDonald criteria, whose 2010 version is currently in use.
During the 20th century theories about the cause and pathogenesis were developed and effective treatments began to appear in the 1990s.
Photographic study of locomotion of a MS female patient with walking difficulties created in 1887 byMuybridge
There are several historical accounts of people who probably had MS and lived before or shortly after the disease was described by Charcot.
A young woman called Halldora who lived in Iceland around 1200 suddenly lost her vision and mobility but, after praying to the saints, recovered them seven days after. Saint Lidwina of Schiedam (1380–1433), a Dutchnun, may be one of the first clearly identifiable people with MS. From the age of 16 until her death at 53, she had intermittent pain, weakness of the legs, and vision loss—symptoms typical of MS. Both cases have led to the proposal of a “Viking gene” hypothesis for the dissemination of the disease.
There is ongoing research looking for more effective, convenient, and tolerable treatments for relapsing-remitting MS; creation of therapies for the progressive subtypes;neuroprotection strategies; and effective symptomatic treatments.
During the 2000s and 2010s, there has been approval of several oral drugs that are expected to gain in popularity and frequency of use. Several more oral drugs are under investigation, including ozanimod and laquinimod. Laquinimod was announced in August 2012 and is in a third phase III trial after mixed results in the previous ones.Similarly, studies aimed to improve the efficacy and ease of use of already existing therapies are occurring. This includes the use of new preparations such as the PEGylatedversion of interferon-β-1a, which it is hoped may be given at less frequent doses with similar effects. Request for approval of peginterferon beta-1a is expected during 2013.
Monoclonal antibodies have also raised high levels of interest. Alemtuzumab, daclizumab, and CD20 monoclonal antibodies such as rituximab, ocrelizumab and ofatumumabhave all shown some benefit and are under study as potential treatments. Their use has also been accompanied by the appearance of potentially dangerous adverse effects, the most important of which being opportunistic infections. Related to these investigations is the development of a test for JC virus antibodies, which might help to determine who is at greater risk of developing progressive multifocal leukoencephalopathy when taking natalizumab. While monoclonal antibodies will probably have some role in the treatment of the disease in the future, it is believed that it will be small due to the risks associated with them.
Another research strategy is to evaluate the combined effectiveness of two or more drugs. The main rationale for using a number of medications in MS is that the involved treatments target different mechanisms and, therefore, their use is not necessarily exclusive.Synergies, in which one drug improves the effect of another are also possible, but there can also be drawbacks such as the blocking of the action of the other or worsened side-effects. There have been several trials of combined therapy, yet none have shown positive enough results to be considered as a useful treatment for MS.
Research on neuroprotection and regenerative treatments, such as stem cell therapy, while of high importance, are in the early stages. Likewise, there are not any effective treatments for the progressive variants of the disease. Many of the newest drugs as well as those under development are probably going to be evaluated as therapies for PPMS or SPMS.
MRI brain scan produced using aGradient-echo phase sequenceshowing an iron deposit in a white matter lesion (inside green box in the middle of the image; enhanced and marked by red arrow top-left corner)
While diagnostic criteria are not expected to change in the near future, work to develop biomarkers that help with diagnosis and prediction of disease progression is ongoing. New diagnostic methods that are being investigated include work with anti-myelin antibodies, and studies with serum and cerebrospinal fluid, but none of them has yielded reliably positive results.
Improvement in neuroimaging techniques such as positron emission tomography (PET) or magnetic resonance imaging (MRI) carry a promise for better diagnosis and prognosis predictions, although the effect of such improvements in daily medical practice may take several decades. Regarding MRI, there are several techniques that have already shown some usefulness in research settings and could be introduced into clinical practice, such as double-inversion recovery sequences, magnetization transfer, diffusion tensor, and functional magnetic resonance imaging. These techniques are more specific for the disease than existing ones, but still lack some standardization of acquisition protocols and the creation of normative values. There are other techniques under development that include contrast agents capable of measuring levels of peripheralmacrophages, inflammation, or neuronal dysfunction, and techniques that measure iron deposition that could serve to determine the role of this feature in MS, or that of cerebral perfusion. Similarly, new PET radiotracers might serve as markers of altered processes such as brain inflammation, cortical pathology, apoptosis, or remylienation. Antibiodies against the Kir4.1 potassium channel may be related to MS.
In 2008, vascular surgeon Paolo Zamboni suggested that MS involves narrowing of the veins draining the brain, which he referred to as chronic cerebrospinal venous insufficiency (CCSVI). He found CCSVI in all patients with MS in his study, performed a surgical procedure, later called in the media the “liberation procedure” to correct it, and claimed that 73% of participants improved. This theory received significant attention in the media and among those with MS, especially in Canada. Concerns have been raised with Zamboni’s research as it was neither blinded nor controlled, and its assumptions about the underlying cause of the disease are not backed by known data. Also, further studies have either not found a similar relationship or found one that is much less strong, raising serious objections to the hypothesis. The “liberation procedure” has been criticized for resulting in serious complications and deaths with unproven benefits. It is, thus, as of 2013 not recommended for the treatment of MS. Additional research investigating the CCSVI hypothesis are under way.
The cause is not known in 90% to 95% of cases. About 5–10% of cases are inherited from a person’s parents. About half of these genetic cases are due to one of two specific genes. The diagnosis is based on a person’s signs and symptoms with testing done to rule out other potential causes.
No cure for ALS is known. A medication called riluzole may extend life by about two to three months.Non-invasive ventilation may result in both improved quality and length of life. The disease usually starts around the age of 60 and in inherited cases around the age of 50. The average survival from onset to death is three to four years. About 10% survive longer than 10 years. Most die from respiratory failure. In much of the world, rates of ALS are unknown. In Europe and the United States the disease affects about two people per 100,000 per year.
Descriptions of the disease date back to at least 1824 by Charles Bell. In 1869, the connection between the symptoms and the underlying neurological problems was first described by Jean-Martin Charcot, who in 1874 began using the term amyotrophic lateral sclerosis. It became well known in the United States in the 20th century when in 1939 it affected the baseball player Lou Gehrig, and later worldwide when physicist Stephen Hawking, diagnosed in 1963 and expected to die within two years, became famous. In 2014 videos of the ice bucket challenge went viral on the Internet and increased public awareness.
Signs and symptoms
The disorder causes muscle weakness and atrophy throughout the body due to the degeneration of the upper and lower motor neurons. Individuals affected by the disorder may ultimately lose the ability to initiate and control all voluntary movement, although bladder and bowel function and the muscles responsible for eye movement are usually spared until the final stages of the disorder.
The start of ALS may be so subtle that the symptoms are overlooked. The earliest symptoms of ALS are muscle weakness and/or muscle atrophy. Other presenting symptoms include trouble swallowing or breathing, cramping, or stiffness of affected muscles; muscle weakness affecting an arm or a leg; and/or slurred and nasal speech. The parts of the body affected by early symptoms of ALS depend on which motor neurons in the body are damaged first.
About 75% of people contracting the disorder first experience weakness or atrophy in an arm or leg and this is known as “limb-onset” ALS. Awkwardness when walking or running or even tripping over or stumbling may be experienced and often this is marked by walking with a “dropped foot” which drags gently on the ground. Or if arm-onset, difficulty with tasks requiring manual dexterity such as buttoning a shirt, writing, or turning a key in a lock may be experienced. Occasionally, the symptoms remain confined to one limb for a long period of time or for the duration of the illness; this is known as monomelic amyotrophy.
About 25% of cases begin as progressive bulbar palsy termed “bulbar-onset” ALS. Initial symptoms will mainly be of difficulty speaking clearly or swallowing. Speech may become slurred, nasal in character, or quieter. There may be difficulty in swallowing and loss of tongue mobility. A smaller proportion of people experience “respiratory-onset” ALS, where the intercostal muscles that support breathing are affected first. A small proportion of people may also present with what appears to be frontotemporal dementia, but later progresses to include more typical ALS symptoms.
Over time, people experience increasing difficulty moving, swallowing (dysphagia), and speaking or forming words (dysarthria). Symptoms of upper motor neuron involvement include tight and stiff muscles (spasticity) and exaggerated reflexes (hyperreflexia) including an overactive gag reflex. An abnormal reflex commonly called Babinski’s sign also indicates upper motor neuron damage. Symptoms of lower motor neuron degeneration include muscle weakness and atrophy, muscle cramps, and fleeting twitches of muscles that can be seen under the skin (fasciculations) although twitching is not a diagnostic symptom and more of a side effect so twitching would either occur after or accompany weakness and atrophy. Around 15–45% of people experience pseudobulbar affect, a neurological disorder also known as “emotional lability”, which consists of uncontrollable laughter, crying, or smiling, attributable to degeneration of bulbar upper motor neurons, resulting in exaggeration of motor expressions of emotion. For ALS to be diagnosed, symptoms of both upper and lower motor neuron damage that cannot be attributed to other causes must be present.
Although the order and rate of symptoms varies from person to person, most people eventually are not able to walk or use their hands and arms. They also lose the ability to speak and swallow food, while most end up on a portable ventilator, called bilevel positive airway pressure. The rate of progression can be measured using an outcome measure called the “ALS Functional Rating Scale Revised (ALSFRS-R)”, a 12-item instrument administered as a clinical interview or patient-reported questionnaire that produces a score between 48 (normal function) and 0 (severe disability). Though the degree of variability is high and a small percentage of people have a much slower disorder, on average, patients lose about 0.9 FRS points per month. A survey-based study amongst clinicians showed that they rated a 20% change in the slope of the ALSFRS-R as being clinically meaningful. Regardless of the part of the body first affected by the disorder, muscle weakness and atrophy spread to other parts of the body as the disorder progresses. In limb-onset ALS, symptoms usually spread from the affected limb to the opposite limb before affecting a new body region, whereas in bulbar-onset ALS, symptoms typically spread to the arms before the legs.
Disorder progression tends to be slower in patients who are younger than 40 at onset, are mildly obese, have disorder restricted primarily to one limb, and those with primarily upper motor neuron symptoms. Conversely, progression is faster and prognosis poorer in people with bulbar-onset disorder, respiratory-onset disorder, and frontotemporal dementia.
The CX3CR1allelic variants have also been shown to have an effect on the disorder’s progression and life expectancy.
Although respiratory support can ease problems with breathing and prolong survival, it does not affect the progression of ALS. Most people with ALS die within three to five years from the onset of symptoms. In one study, the median survival time from onset to death was around 39 months, and only 4% survived longer than 10 years. Newer data point to around 10% of people surviving beyond 10 years. Guitarist Jason Becker has lived since 1989 with the disorder, while physicist Stephen Hawking has survived for more than 50 years, but they are considered unusual cases.
Difficulty in chewing and swallowing makes eating very difficult and increases the risk of choking or of aspirating food into the lungs. In later stages of the disorder, aspiration pneumonia can develop, and maintaining a healthy weight can become a significant problem that may require the insertion of a feeding tube. As the diaphragm and intercostal muscles of the rib cage that support breathing weaken, measures of lung functionsuch as vital capacity and inspiratory pressure diminish. In respiratory-onset ALS, this may occur before significant limb weakness is apparent. Most people with ALS die of respiratory failure or pneumonia.
In late stages, the oculomotor nerve that controls the movements of the eye can be affected as can the extraocular muscles (EOMs). The eye movements remain unaffected largely until the later stages due to differences in the extraocular muscles compared to the skeletal muscles that are initially and readily affected. In the disease’s final stages, a person’s condition may resemble locked-in syndrome.
About 5–10% of cases are directly inherited from a person’s parents. Overall, first-degree relatives of an individual with ALS have a 1% risk of developing ALS.
A defect on chromosome 21, which codes for superoxide dismutase, is associated with about 20% of familial cases of ALS, or about 2% of ALS cases overall. This mutation is believed to be transmitted in anautosomal dominant manner, and has over a hundred different forms of mutation. The most common ALS-causing mutation is a mutant SOD1 gene, seen in North America; this is characterized by an exceptionally rapid progression from onset to death. The most common mutation found in Scandinavian countries, D90A-SOD1, is more slowly progressive than typical ALS, and people with this form of the disorder survive for an average of 11 years.
In 2011, a genetic abnormality known as a hexanucleotide repeat was found in a region called C9orf72, which is associated with ALS combined with frontotemporal dementia ALS-FTD, and accounts for some 6% of cases of ALS among white Europeans.
The UBQLN2 gene encodes production of the protein ubiquilin 2 in the cell, which is a member of the ubiquilin family and controls the degradation of ubiquitinated proteins. Mutations in UBQLN2 interfere with protein degradation, leading to neurodegeneration and causing dominantly inherited, chromosome X-linked ALS and ALS/dementia.
To date, a number of genetic mutations have been associated with various types of ALS. The currently known associations are:
“Frontotemporal dementia and/or amyotrophic lateral sclerosis type 4”
In 1993, scientists discovered that mutations in the gene (SOD1) that produces the Cu–Znsuperoxide dismutase (SOD1) enzyme were associated with around 20% of familial ALS. This enzyme is a powerfulantioxidant that protects the body from damage caused by superoxide, a toxic free radical generated in the mitochondria. Free radicals are highly reactive molecules produced by cells during normal metabolism. Free radicals can accumulate and cause damage to DNA and proteins within cells. To date, over 110 different mutations in SOD1 have been linked with the disorder, some of which (such as H46R) have a very long clinical course, while others, such as A4V, are exceptionally aggressive. When the defenses against oxidative stress fail, programmed cell death (apoptosis) is upregulated.
A defect in SOD1 could be a loss or gain of function. A loss of SOD1 function could lead to an accumulation of free radicals. A gain of SOD1 function could be toxic in other ways.
Aggregate accumulation of mutant SOD1 is suspected to play a role in disrupting cellular functions by damaging mitochondria, proteasomes, protein folding chaperones, or other proteins. Any such disruption, if proven, would lend significant credibility to the theory that aggregates are involved in mutant SOD1 toxicity. Critics have noted that in humans, SOD1 mutations cause only 2% or so of overall cases and the etiological mechanisms may be distinct from those responsible for the sporadic form of the disease. To date, the ALS-SOD1 mice remain the best model of the disease for preclinical studies, but it is hoped that more useful models will be developed.
In 1994 the National Institute for Occupational Safety and Health (NIOSH) reported a nonsignificant increase in nervous system disorders due to four cases of ALS among NFL football players. It was unclear if this was due to chance or not. Another study from 2012 also found a possible increase in ALS in NFL football players. An older study did not find an increased risk among high school football players. A 2007 review found an increased risk among soccer players. ALS may also occur more often among the US military veterans however the reason is unknown. This may be due to head injury.
Where no family history of the disease is present – i.e., in around 90% of cases – no cause is known for ALS. Possible associations for which evidence is inconclusive include military service, frequent drug use, and participation in contact sports.[medical citation needed]
Studies also have focused on the role of glutamate in motor neuron degeneration. Glutamate is one of the neurotransmitters in the brain. Scientists have found, compared with healthy people, people with ALS have higher levels of glutamate in their serum and spinal fluid.Riluzole is currently the only FDA-approved drug for ALS and targets glutamate transporters. It only has a modest effect on survival, however, suggesting that excess glutamate is not the sole cause of the disease.
Certain studies suggested a link between sporadic ALS, specifically in athletes, and a diet enriched with branched-chain amino acids, a common dietary supplement among athletes, which cause cell hyperexcitability resembling that usually observed in people with ALS. The proposed underlying mechanism is that cell hyperexcitability results in increased calcium absorption by the cell, and thus brings about cell death of neuronal cells, which have particularly low calcium buffering capabilities.
Some evidence supports superoxide dismutase 1 (SOD1) protein misfolding propagates between molecules in a similar fashion to prions. Similarly, it has been proposed that incorporation of the cyanobacterial toxin β-methylamino-l-alanine (BMAA) leads to another prion-like protein misfolding propagation.
Another very common factor associated with ALS is a lesion to the motor system in areas such as the frontotemporal lobes. Lesions in these areas often show signs of early deficit, which can be used to predict the loss of motor function, and result in the spread of ALS. The mechanisms of ALS are present long before any signs or symptoms become apparent. Before any muscular atrophy becomes apparent during ALS, roughly one-third of the motor neurons must be destroyed.
The defining feature of ALS is the death of both upper and lower motor neurons in the motor cortex of the brain, the brain stem, and the spinal cord. Prior to their destruction, motor neurons develop protein-richinclusions in their cell bodies and axons. This may be partly due to defects in protein degradation. These inclusions often contain ubiquitin, and generally incorporate one of the ALS-associated proteins: SOD1,TAR DNA binding protein (TDP-43, or TARDBP), and/or FUS.
No test can provide a definite diagnosis of ALS, although the presence of upper and lower motor neuron signs in a single limb is strongly suggestive. Instead, the diagnosis of ALS is primarily based on the symptoms and signs the physician observes in the person and a series of tests to rule out other diseases. Physicians obtain the person’s fullmedical history and usually conduct a neurologic examination at regular intervals to assess whether symptoms such as muscle weakness, atrophy of muscles, hyperreflexia, and spasticity are worsening.
Because symptoms of ALS can be similar to those of a wide variety of other, more treatable diseases or disorders, appropriate tests must be conducted to exclude the possibility of other conditions. One of these tests is electromyography (EMG), a special recording technique that detects electrical activity in muscles. Certain EMG findings can support the diagnosis of ALS. Another common test measures nerve conduction velocity (NCV). Specific abnormalities in the NCV results may suggest, for example, that the patient has a form of peripheral neuropathy (damage to peripheral nerves) or myopathy (muscle disease) rather than ALS. While a magnetic resonance imaging (MRI) is often normal in people with early stage ALS, they can reveal evidence of other problems that may be causing the symptoms, such as a spinal cord tumor, multiple sclerosis, aherniated disk in the neck, syringomyelia, or cervical spondylosis.
Based on the person’s symptoms and findings from the examination and from these tests, the physician may order tests on blood and urine samples to eliminate the possibility of other diseases, as well as routine laboratory tests. In some cases, for example, if a physician suspects the person may have a myopathy rather than ALS, a muscle biopsy may be performed.
ALS must be differentiated from the “ALS mimic syndromes” which are unrelated disorders that may have a similar presentation and clinical features to ALS or its variants. Because of the prognosis carried by this diagnosis and the variety of diseases or disorders that can resemble ALS in the early stages of the disease, people should always obtain a specialist neurological opinion, so alternative diagnoses are clinically ruled out. Benign fasciculation syndrome is another condition that mimics many of the symptoms of ALS, but is accompanied by normal EMG readings and no major disablement.
However, most cases of ALS are readily diagnosed and the error rate of diagnosis in large ALS clinics is less than 10%. In one study, 190 patients who met the MND/ALS diagnostic criteria, complemented with laboratory research in compliance with both research protocols and regular monitoring. Thirty of these patients (16%) had their diagnosis completely changed during the clinical observation development period. In the same study, three patients had a false negative diagnosis, myasthenia gravis (MG), an autoimmune disease. MG can mimic ALS and other neurological disorders leading to a delay in diagnosis and treatment. MG is eminently treatable; ALS is not. Myasthenic syndrome, also known as Lambert-Eaton syndrome, can mimic ALS and its initial presentation can be similar to that of MG.
Management of ALS attempts to relieve symptoms and extend life expectancy. This supportive care is best provided by multidisciplinary teams of health care professionals working with the person and their caregivers to keep them as mobile and comfortable as possible.
Riluzole (Rilutek) has been found to modestly improve survival. It lengthens survival by several months, and may have a greater survival benefit for those with a bulbar onset. It also extends the time before a person needs ventilation support. People taking it must be monitored for liver damage (occurring in about 10% of people taking the drug). It is approved by Food and Drug Administration (US) and recommended by the National Institute for Clinical Excellence (UK). Riluzole does not reverse damage already done to motor neurons.
Other medications may be used to help reduce fatigue, ease muscle cramps, control spasticity, and reduce excess saliva and phlegm. Drugs also are available to help patients with pain, depression, sleep disturbances, dysphagia, and constipation. Baclofen and diazepam are often prescribed to control the spasticity caused by ALS, and trihexyphenidyl or amitriptyline may be prescribed when people with ALS begin having trouble swallowing their saliva.
When the muscles that assist in breathing weaken, use of ventilatory assistance (intermittent positive pressure ventilation, bilevel positive airway pressure (BiPAP), or biphasic cuirass ventilation (BCV) may be used to aid breathing. Such devices artificially inflate the person’s lungs from various external sources that are applied directly to the face or body. When muscles are no longer able to maintain oxygen and carbon dioxide levels, these devices may be used full-time. BCV has the added advantage of being able to assist in clearing secretions by using high-frequency oscillations followed by several positive expiratory breaths. People may eventually consider forms of mechanical ventilation (respirators) in which a machine inflates and deflates the lungs. To be effective, this may require a tube that passes from the nose or mouth to the windpipe (trachea) and for long-term use, an operation such as a tracheotomy, in which a plastic breathing tube is inserted directly in the person’s windpipe through an opening in the neck.
Persons and their families should consider several factors when deciding whether and when to use one of these options. Ventilation devices differ in their effect on the person’s quality of life and in cost. Although ventilation support can ease problems with breathing and prolong survival, it does not affect the progression of ALS. Patients need to be fully informed about these considerations and the long-term effects of life without movement before they make decisions about ventilation support and have deep discussions on quality of life. Some persons under long-term tracheotomy intermittent positive pressure ventilation with deflated cuffs or cuffless tracheotomy tubes (leak ventilation) are able to speak, provided their bulbar muscles are strong enough, though in all cases speech will be lost as the disease progresses. This technique preserves speech in some persons with long-term mechanical ventilation. Other persons may be able to use a speaking valve such as a Passey-Muir speaking valve with the assistance and guidance of a speech-language pathologist.
External ventilation machines that use the ventilation mode of BiPAP are frequently used to support breathing, initially at night, and later during the daytime, as well. The use of BPAP (more often referred to as noninvasive ventilation, NIV) is only a temporary remedy, however, and long before BPAP stops being effective, persons should decide whether to have a tracheotomy and long-term mechanical ventilation. At this point, some persons choose palliative hospice care.
Using low tech to communicate. A man with ALS communicates by pointing to letters and words using an head mounted laser pointer.
Physical therapy plays a large role in rehabilitation for individuals with ALS. Specifically, physical and occupational therapists can set goals and promote benefits for individuals with ALS by delaying loss of strength, maintaining endurance, limiting pain, preventing complications, and promoting functional independence.
Occupational therapy and special equipment such as assistive technology can also enhance patients’ independence and safety throughout the course of ALS. Gentle, low-impact aerobic exercise such as performing activities of daily living, walking, swimming, and stationary bicycling can strengthen unaffected muscles, improve cardiovascular health, and help patients fight fatigue and depression. Range of motion and stretching exercises can help prevent painful spasticity and shortening (contracture) of muscles. Physical and occupational therapists can recommend exercises that provide these benefits without overworking muscles. They can suggest devices such as ramps, braces, walkers, bathroom equipment (shower chairs, toilet risers, etc.), and wheelchairs that help patients remain mobile. Occupational therapists can provide or recommend equipment and adaptations to enable people to retain as much safety and independence in activities of daily living as possible.
People with ALS who have difficulty speaking may benefit from working with a speech-language pathologist. These health professionals can teach patients adaptive strategies such as techniques to help them speak louder and more clearly. As ALS progresses, speech-language pathologists can recommend the use of augmentative and alternative communication such as voice amplifiers, speech-generating devices (or voice output communication devices) and/or low tech communication techniques such as head mounted laser pointers, alphabet boards or yes/no signals.
Patients and caregivers can learn from dieticians how to plan and prepare numerous small meals throughout the day that provide enough calories, fiber and fluid, and how to avoid foods that are difficult to swallow. Patients may begin using suction devices to remove excess fluids or saliva and prevent choking. Occupational therapists can assist with recommendations for adaptive equipment to ease the physical task of self-feeding. Speech-language pathologists make food choice recommendations that are more conducive to their unique deficits and abilities. When patients can no longer get enough nourishment from eating, doctors may advise inserting a feeding tube into the stomach. The use of a feeding tube also reduces the risk of choking and pneumonia that can result from inhaling liquids into the lungs. The tube is not painful and does not prevent patients from eating food orally if they wish.
Researchers have stated, “ALS patients have a chronically deficient intake of energy and recommended augmentation of energy intake” and have a severe loss of appetite. Both animal and human research[unreliable medical source?][unreliable medical source?] suggest that ALS patients should be encouraged to consume as many calories as possible and not to restrict their caloric intake. As of 2012, “a lack of robust evidence for interventions” remained for the management of weight loss.
End of life care
Social workers and home care and hospice nurses help people with ALS, their families, and caregivers with the medical, emotional, and financial challenges of coping, particularly during the final stages of the disease. Social workers provide support such as assistance in obtaining financial aid, arranging durable power of attorney, preparing a living will, and finding support groups for patients and caregivers. Home nurses are available not only to provide medical care, but also to teach caregivers about tasks such as maintaining respirators, giving feedings, and moving patients to avoid painful skin problems and contractures. Home hospice nurses work in consultation with physicians to ensure proper medication, pain control, and other care affecting the quality of life of patients who wish to remain at home. The home hospice team can also counsel patients and caregivers about end-of-life issues.
In much of the world, rates of ALS are unknown. In Europe, the disease affects about 2.2 people per 100,000 per year. In the United States, more than 5,600 are diagnosed every year, and up to 30,000 Americans are currently affected. ALS is responsible for two deaths per 100,000 people per year.
ALS is classified as a rare disease, designated by the FDA as an “orphan” disease (affecting fewer than 200,000 people in the United States), but is the most common motor neuron disease. People of all races and ethnic backgrounds are affected. One or two of 100,000 people develop ALS each year. Amyotrophic lateral sclerosis affects around 30,000 Americans. ALS cases are estimated at 1.2–4.0 per 100,000 individuals in Caucasian populations with a lower rate in other ethnic populations.Filipinos are second to Caucasians in terms of ALS prevalence with 1.1-2.8 per 100,000 individuals.
Reports have been made of several “clusters” including three American football players from the San Francisco 49ers, more than 50 association football players in Italy, three association football-playing friends in the south of England, and conjugal (husband and wife) cases in the south of France. Although many authors consider ALS to be caused by a combination of genetic and environmental risk factors, so far the latter have not been firmly identified, other than a higher risk with increasing age.
English scientist Augustus Waller described the appearance of shriveled nerve fibers in 1850. In 1869, the connection between the symptoms and the underlying neurological problems were first described by Jean-Martin Charcot, who introduced the term amyotrophic lateral sclerosis in his 1874 paper. In 1881, the article was translated into English and published in a three-volume edition of Lectures on the Diseases of the Nervous System.
ALS became a cause célèbre in the United States in 1939 when baseball legend Lou Gehrig‘s career, and two years later, his life, were ended by the disease.
By 1991, researchers had linked chromosome 21 to familial ALS (FALS). In 1993, the SOD1 gene on chromosome 21 was found to play a role in some cases of FALS. In 1996, riluzole became the first FDA-approved drug for ALS.
In 1998, the El Escorial criteria were developed as the standard for classifying ALS patient in clinical research. The next year, the revised ALS Functional Rating Scale was published and soon becomes a gold standard for rating the declines in ALS patient in clinical research. Noncoding repeat expansions in C9ORF72 were found to be a major cause of ALS and frontotemporal dementia in 2011.
Amyotrophic comes from the Greek word amyotrophia: a- means “no”, myo refers to “muscle”, and trophia means “nourishment”; amyotrophia therefore means “no muscle nourishment,” which describes the characteristic atrophy of the sufferer’s disused muscle tissue. Lateral identifies the areas in a person’s spinal cord where affected portions of the nerve cells are located. Degeneration in this area leads to scarring or hardening (“sclerosis“).
In the United Kingdom, India, Australia and some other Commonwealth countries the term motor neurone disease (MND) is commonly used.
In August 2014, a challenge went viral online which was commonly known as the “ALS Ice Bucket Challenge“. Contestants fill a bucket full of ice and water, then state who nominated them to do the challenge, and nominate three other individuals of their choice to take part in it. The contestants then dump the buckets of ice and water onto themselves. However, it can be done in a different order. The contestants then donate at least US $10 (or a similar amount in their local currency) to ALS research at the ALS Association, or Motor Neurone Disease Association in the UK. Any contestants who refuse to have the ice and water dumped on them are expected to donate at least US$100 to ALS research. As of July 2015, the Ice Bucket Challenge had raised $115 million for the ALS Association. Many celebrities have taken part in the challenge. The Ice Bucket Challenge was credited with helping to raise funds that contributed to the discovery that the gene NEK1 may potentially contribute to the development for ALS.
After this 2012 report was released, some NFL players involved in the legal settlement with the NFL complained that the NFL, which initially agreed to pay $765 million, was not doing enough to help players. The judge in the case concurred, and the NFL then agreed to pay an unlimited amount of damages for players found to have ALS, Parkinson’s disease, Alzheimer’s disease and dementia.
Story 1: Islamic State: Come or Kill — Radical Islamic Terrorist Jihadi Targets and Kills 49 And Wounds 53 in Gay Club in Orlando, Florida — Laying Lunatic Left Blames Guns and American People — Home Grown Eugenics Racist Terrorist Organizations Planned Parenthood and Other Abortion Factories Will Kill About 3,000 Babies in The Womb Today — Guns Are Not The Problem — The Political Elitist Establishment Is The Problem — Importing Terrorists With Open Borders — Stand Up and Preserve, Protect and Defend The U.S. Constitution — Videos
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The president noted the man police have identified as the gunman, Omar S. Mateen, purchased a gun legally and was inspired by extremist information disseminated over the internet. Mr. Mateen pledged allegiance to Islamic State “at the last minute,” Mr. Obama said.
He added: “Countering this extremist ideology is increasingly going to be just as important as making sure that we are disrupting more extensive plots engineered from the outside.”
Meanwhile, investigators have found that Mr. Mateen previously visited Walt Disney Worldwhile searching for targets, according to two officials briefed on the probe. They added they don’t believe he examined the amusement park in the hours immediately before the nightclub shooting—and would not say which Disney World property was scouted.
In his Oval Office remarks, Mr. Obama also urged people considering how to respond to the attacks to avoid an “either/or” debate about terrorism or gun control and instead to consider addressing both.
Witness: Omar Mateen drank alone at Pulse before attack
By Gal Tziperman Lotan , Paul Brinkmann and Rene StutzmanContact Reporters Staff Writers
t least four regular customers at the Orlando gay nightclub where a gunman killed 49 people said Monday that they had seen Omar Mateen there before.
“Sometimes he would go over in the corner and sit and drink by himself, and other times he would get so drunk he was loud and belligerent,” Ty Smith said.
More details emerged Monday about the 29-year-old gunman and what he did in the days leading up to the massacre, the deadliest mass shooting in U.S. history.
He was at Walt Disney World in April, said a Disney manager who requested anonymity.
FBI Director James Comey said his agency was trying to nail down that report and the possibility that Mateen was scouting the amusement park as a potential target, the Associated Press reported.
Smith told the Orlando Sentinel that he saw Mateen inside at least a dozen times.
“We didn’t really talk to him a lot, but I remember him saying things about his dad at times,” Smith said. “He told us he had a wife and child.”
When asked about those sightings,Orlando Police Chief John Mina said he had no information.
Another Pulse regular, Kevin West, told the Los Angeles Times that Mateen messaged him on and off for a year using a gay chat app.
They had never met, West said, but he watched as Mateen entered the club about 1 a.m. Sunday, an hour before the shooting began.
Mateen was the security guard, born in New Hyde Park, NY., who walked into the club about 2 a.m. Sunday with a semiautomatic pistol and an assault rifle. While dance music blared, he opened fire, killing 49 people and injuring 53.
He died three hours later in a shootout with the Orlando Police Department SWAT team when it stormed the building.
During the standoff, Mateen proclaimed his allegiance to the Islamic State and his support for the Muslim brothers who set off two bombs at the 2013 Boston Marathon, police said.
Late Monday came word that Mateen’s wife, Noor Zahi Salman, was not cooperating with authorities, according to a law enforcement official who spoke on the condition of anonymity.
Investigators want to ask if she knew about his plans in advance or helped him scout out targets.
The official said they have talked extensively with Mateen’s ex-wife, Sitora Yusufiy, who told reporters Sunday that the gunman was bi-polar and sometimes violent.
Mateen bought the weapons he used — a 9-mm semiautomatic pistol and .223-caliber assault rifle — at St. Lucie Shooting Center a few days before the massacre. Owner Edward Henson on Monday said he “vaguely” remembered him.
“He’s a nobody,” said Henson. “He’s a customer. He came and purchased his guns, and he left.”
Although the FBI investigated Mateen for possible connections to Muslim terrorists in 2013 and 2014, they closed those cases, concluding he was not a threat, Comey said.
Nothing in Mateen’s background prohibited him from legally buying those guns, and the head of the state agency that oversees gun permits in Florida told reporters Monday that the system worked the way it was designed, The News Service of Florida reported.
Mateen applied for a state security guard license, the type that allows the holder to carry a firearm, and he got one, said Adam Putnam, state agriculture commissioner. Mateen was a U.S. citizen, had no criminal record and passed a psychological test.
He was eligible to buy as many guns as he liked because he was not a convicted felon, and was not facing a felony charge or a misdemeanor domestic violence charge. He was not a drug abuser, a fugitive, the subject of a domestic violence injunction, someone who was in the country illegally, someone who had been dishonorably discharged from the military or someone who had been found by a judge to be mentally incompetent.
“You cannot be deprived of rights because of an accusation,” said Eileen Rieg, a former gun shop owner in Orlando who now operates a security guard training company. She said she was troubled that the FBI had not earlier found enough evidence to make an arrest.
More details emerged Monday, too, about Maheen’s background, much of it related to law enforcement.
When he was 19, Mateen was injured when a St. Lucie County Sheriff’s deputy lost control of his cruiser while racing to the scene of an automobile crash, according to a report.
Mateen was a passenger in the patrol car, taking part in a citizen ride-along, according to Sheriff’s Office spokesman Bryan Beaty.
In 2006 he worked at a state prison — Martin Correctional Institution in Indiantown — for six months, according to Florida Department of Corrections.
That same year, he earned an associate’s degree in criminal justice from Indian River Community College, according to school spokesman Robert Lane. That’s a degree required to become a law enforcement officer in Florida.
In 2007, he was hired by G4S, a private security firm based in Jupiter. His assignment at the time of his death: working as a security guard at a gated retirement community in South Florida, the company reported.
Before that, G4S assigned him, for a time, to the St. Lucie County Courthouse in Fort Pierce, a gig that ended in 2013, according to court Administrator Thomas Genung.
Cord Cedeno and Chris Callen are other Pulse customers who told the Sentinel they had seen Mateen in the nightclub.
Callen said he had witnessed violent outbursts by Mateen.
“It was definitely him. He’d come in for years, and people knew him,” Cedeno said.
At about 5 a.m. on Sunday, Omar Mateen was in the bathroom of Pulse nightclub in Orlando holding several hostages, the city’s top cop said.He had been making phone calls and spoken with hostage negotiators, seeming all the while to be “cool and calm,” said Orlando Police chief John Mina at a press conference Monday giving updates on the Orlando mass shooting that left 49 people dead, in addition to Mateen.Mina said it was then that he made the decision to send in the SWAT team.”We believed further loss of life was imminent” based on what Mateen was telling people, Mina said.As the country holds vigils for the dozens of the victims, questions about the 29-year-old shooter and the police decision to storm the club known for tolerance for all people are only beginning to find answers.
Mina said at first the SWAT team attempted to breach a wall of the club with an explosive, but didn’t succeed in fully knocking it down. So they sent in an armored vehicle to finish the job, rescued dozens of hostages, and engaged in a ferocious shootuout with Mateen.
The Pulse nightclub – which describes itself as Orlando’s hottest gay bar — had been hosting a Latin night. Mateen called 911 during his nearly three-hour, well-armed standoff inside the club and pledged allegiance to the Islamic State of Iraq and Syria (ISIS.)
While ISIS took credit for the attack, investigators have so far uncovered no clear links between the shooter and its Syria-based terrorist administrators.
“So far, we see no indication that this was a plot directed from outside the United States and we see no indication that he was part of any kind of network,” Comey told reporters.
The intelligence community, Comey said, is “highly confident that this killer was radicalized at least in part through the Internet.”
Investigators have already seized electronics from the suspect’s residence, including a laptop computer, a Kindle and cell phones, a law enforcement source told CBS News senior investigative producer Pat Milton.
The electronic devices are being analyzed at the FBI lab in Quantico, Va., with the highest priority being what he was looking at on the Internet and who he was communicating with just prior to the attack. The source said that investigation indicates that the shooter heavily used the Internet and had a social media presence.
A law enforcement source said that the shooting suspect legally purchased recently the two weapons used in the attack at the shooting center in Port St. Lucie near his Fort Pierce home. He had a Glock 17 handgun purchased on June 5, a Sigsauer MCX assault rifle purchased on June 4 on his person during the shootout, and investigators later found a .38-caliber weapon in his vehicle.
The shooter had been contacted by U.S. law enforcement at least twice in recent years. He had traveled to Saudi Arabia at least twice – once in 2011 and again in 2012 – as part of a religious pilgrimage.
Mateen surfaced on the FBI’s radar in 2013, when coworkers said he’d made inflammatory remarks about terrorist ties.
“Mateen was interviewed twice,” said the FBI’s Ron Hopper, who is leading the investigation into the Orlando attack. “Ultimately we were unable to verify the substance of his comments and the investigation was closed.”
In 2014 he came to the FBI’s attention again, this time because of contact he had with Moner Abu-Salha, the first known American suicide bomber in Syria. But once again, Mateen was cleared of any wrongdoing
He was not on a current terror watchlist, a U.S. intelligence source tells CBS News’ Len Tepper. He was entered into a terrorist screening database during the time the FBI was questioning him, but he was removed when the FBI closed the investigation, Tepper reports.
Despite those two investigations, Mateen was not on any list that prevented him from purchasing a weapon.
Florida Governor Rick Scott many of the people who died in the Orlando gay bar were from Puerto Rico. So far, 48 of the 49 victims have been identified.
The Mexican Foreign Ministry said Monday that at least three of its country’s citizens were killed as well.
Josh McGill and friend Ashley Summers fled the club and lost track of one another. McGill found shelter behind a car.
“I was about to run for it, to the safe zone,” McGill said. “And I hear someone kind of like mumbling, ‘Help! Help!'”
A few feet away, 27-year-old Rodney Sumter Jr. lay wounded and bleeding, shot in each arm and once in the back.
“I only saw the one bullet at first, and I was like, ‘We need to stop the bleeding.’ And he’s like, ‘Okay.’ So I took my shirt off and I tied it around as tight as I could and then I saw his other arm had been shot. So I took his shirt off, tied it around that one,” McGill recounted.
The two hobbled their way to police at the scene.
“So the police officer turned to me and said, ‘Okay, this is what the deal is. You’re going to lay down in the back of that cop car and he’s going to lay on top of you, and I want you to bear hug him and try to keep all the pressure on him as you can.’ So I did,” McGill said. “And they were like ‘Also, like keep him conscious.'”
FBI: ORLANDO GUNMAN HAD STRONG INDICATIONS OF RADICALIZATION
BY ERIC TUCKER AND JACK GILLUM
The gunman at the Orlando gay nightclub had “strong indications of radicalization” and was likely inspired by foreign terrorist organizations, the FBI director said Monday.
James Comey also said the man, who has been identified as 29-year-old Omar Mateen, spoke with a 911 operator three times during the deadly event. At one point, Comey said, he pledged loyalty on the call to the head of the Islamic State group.
Comey’s remarks offered further detail on the shootings that left 49 victims dead and more than 50 hurt, making it the deadliest mass shooting in modern U.S. history. Mateen died in a gun battle with police.
President Barack Obama said Monday the killer was inspired by extremist information over the internet, calling it an apparent example of the “homegrown extremism” that U.S. officials have been worrying about for years.
Mateen had twice come to the FBI’s attention before Sunday’s shooting, the FBI said. It investigated him for 10 months, beginning in May 2013, because he had made “inflammatory and contradictory” statements about ties to terrorist groups that caught his coworkers’ attention.
Mateen was working at the time as a contract security guard at a local courthouse. He has held a Florida license to be an armed security officer since at least 2011, state records show.
The FBI director said that Mateen at the time claimed family connections to al-Qaida and said he was a member of Hezbollah, which Comey said “is a Shia terrorist organization that is a bitter enemy of the so-called Islamic State.”
Mateen had also told coworkers “he hoped that law enforcement would raid his apartment and assault his wife and child so that he could martyr himself,” Comey said.
The FBI’s Miami field office opened a preliminary investigation to determine whether Mateen was “possibly a terrorist.” The FBI began introducing him to confidential sources, following him, reviewing some details of his communications and running him through government databases looking for ties to terrorism.
Comey said Mateen admitted making the statements reported by his coworkers, but explained that he did it in anger because he thought they were discriminating against him and teasing him because he was Muslim, Comey said.
Agents closed the first investigation in early 2014, but Mateen’s name came up in a separate FBI investigation a few months later, in July 2014.
This time, the FBI was investigating Moner Mohammad Abusalha, a Florida man who blew himself up in a suicide attack in Syria on behalf of the al-Qaida affiliated Nusra Front.
The FBI found Mateen and the man had attended the same mosque and knew each other casually. “But the investigation turned up no ties of any consequence between the two of them,” Comey said.
Comey said that one witness interviewed during the investigation into Abusalha brought up Mateen’s name when asked if the witness knew of anyone “who might be radicalizing.”
The witness said he worried about Mateen because he mentioned videos of Anwar al-Alwaki, an al-Qaida leader killed in 2011 by a U.S. drone strike. But the witness said his concerns had diminished after Mateen got married, had a child and got a job as a security guard.
Comey said that FBI agents interviewed Mateen again during the investigation, but found no “significant contacts with the suicide bomber for Al-Nusra” and moved on.
Three handwritten copies of a five-page Arabic document were found by the FBI after the September 11 attack: one in a car used by the hijackers and left outside Dulles International Airport, one in a piece of Mohammad Atta’s luggage that, by accident, did not get on the plane from Logan Airport, one in the wreckage of the plane that crashed in Pennsylvania. Only a part of this document—pages two through five—is publicly available; it was posted on the FBI Web site on September 28, 2001.1 In view of the number of copies found, it is reasonable to assume that there were other copies in the luggage of the other hijackers. If so, it is unlikely that many of the hijackers did not know the suicidal nature of their mission, as some commentators have argued. Since one of the three copies was found in Mohammad Atta’s luggage, it also seems unlikely that the hijackers were trying, by leaving copies of the documents behind, to mislead the investigators who would retrace their steps after the event.2
We don’t know who wrote this document. From everything in it, the author seems to have been an organizer of the attacks. But the text contains a valuable record of the ideas that the hijackers would have been expected to accept. One of its underlying assumptions is that all its intended readers were going to die. It seems clearly intended for the eyes of the hijackers and no one else, and reads as if it were written to stiffen their resolve. One would expect each person to have studied his copy very carefully beforehand, reading it over many times before the mission.
The document is in effect an exacting guide for achieving the unity of body and spirit necessary for success. It is not a training manual of procedures, applicable to different situations; most of the sentences seem tailored to the particulars of the Septem- ber 11 operation. There are no technical instructions or operational instructions in the four pages, only a fairly obvious list of practical precautions:
[Check] the suitcase, the clothes, the knife, your tools, your ticket, …your passport, all your papers. Inspect your weapon before you leave…. Tighten your clothes well as you wear them. This is the way of the righteous predecessors, may God’s blessings be upon them. They tightened their clothes as they wore them prior to battle. And tighten your shoes well, and wear socks that hold in the shoes and do not come out of them.
In fact, it seems that an effort has been made to eliminate clues about the intended target should the document happen to fall into the wrong hands before the raid was carried out. No mention of the target is made throughout the document, and letters substitute for names or places. For example, “M” is used for matar, or airport, and “T” is used for ta’irah, or plane.
Page two begins abruptly, without the traditional basmallah, or invocation…
Religious Foundations of the Last Instructions of 9/11
Hans G. Kippenberg
The Writing and Its Authenticity
On September 28, 2001, the FBI distributed four pages of an Arabic document at a press conference and also published them on its website.1 The headline was spectacular: “Hijacking Letter Found at Three Locations.” Beneath the four pages of Arabic text, the website displayed three photos, surrounded by information about the hijackers, their flights, and the places where the documents were found. Mohamed Atta is connected with American Airlines #11 that crashed into the North Tower of the World Trade Center at 8:45 a.m.; underneath his photo appears: “Found in Atta’s suitcase.” The next photo shows Nawaf al-Hazmi; the text connects him with American Airlines #77, which crashed at 9:39 a.m. into the Pentagon, and the document is said to be “Found in Vehicle at Dulles International Airport.” Finally, a photo of the crash site of United Airlines #93 at Stony Creek Township is accompanied by the remark, “Found at Crime Scene.”
Figure 1. The Spiritual Manual as it was published by the FBI on its website on September 28, 2001.
Mohamed Atta, who navigated the first plane into the North Tower of the World Trade Center, originated his journey on September 11 in Portland, Maine, and changed planes in Boston. One piece of his luggage did not make it onto the plane from Logan Airport, whether by chance or not we do not know. When his suitcase was found, two documents were discovered. In a last will, written in English and laid down in 1996, Atta prescribed how his body should be handled after his death in order to prevent pollution. Much more spectacular is the handwritten Arabic text published by the FBI; English extracts were distributed during a FBI press conference on September 28. The text anticipates the stages of the attack and prescribes for each stage recitations of the Quran, prayers, and rituals. The British journal The Observerpublished an English translation of the four pages on September 30.2 An improved translation was later made by Hassan Mneimneh for The New York Review of Books.3
On September 28, The Washington Post published a leading article on the discovery, “In Hijacker’s Bags, a Call to Planning, Prayer and Death.” The article spoke about five pages instead of four, and later the same issue (p. A18) published two extracts in English:
In the name of God, the most merciful, the most compassionate … In the name of God, of myself and of my family … I pray to you God to forgive me from all my sins, to allow me to glorify you in every possible way.
Remember the battle of the prophet … against the infidels, as he went on building the Islamic state.
Since neither extract is found in the four pages previously published, the authenticity of both is disputed. The second quotation perfectly fits the manual, since it conceives of the attacks in terms of the Prophet Muhammad’sghazwa when the Islamic polity was established in Medina. But the first of the sentences elicited serious doubts about its authenticity. What pious Muslim would dare to say: “In the name of God, of myself and of my family”? Since the Arabic original of this text has never been published, a mistranslation cannot be ruled out. It may have its roots in “family” (usra), referring not to kinship but to a religious brotherhood, small section of the Muslim Brotherhood.
The writing found in Mohamed Atta’s bag was not the only one. A second copy was found in the car used by Nawaf al-Hazmi and left at Dulles International Airport. CBS News published an English translation of it on October 1, 2001.4 It likewise consists of four pages, and the translation accords widely with that of Mohamed Atta’s text. Yet all scans available on the Internet reproduce one original, not two. Perhaps the CBS journalist misunderstood the law enforcement agents when they distributed copies during the press conference. The remnants of a third copy have not been published.
The document and all information about it derive from U.S. Secret Service sources—a fact that has given rise to speculations about a forgery. It is worthwhile to note, therefore, that independent evidence exists about the manual. This evidence derives from Yosri Fouda, reporter for Al Jazeera, who under conspiratorial circumstances met Khalid Sheikh Muhammad and Ramzi bin al-Shibh (Binalshibh) in Karachi.5 Binal-Shibh was the intermediary between the Hamburg group and the chief of the military committee of al-Qaeda, Khalid Sheikh Muhammad. Fouda had an extensive interview with both men. He was told how the attacks were prepared. Bin al-Shibh showed him a suitcase with “souvenirs” from his stay in Hamburg, among them a booklet containing handwritten notes by Mohamed Atta in the margin. Since the handwriting differed from the document published by the FBI, bin al-Shibh explained to Fouda that “The Manual for a Raid” in Atta’s luggage had been written by Abdul Aziz al-Umari, who was highly respected in the group for his profound knowledge of Islam and his beautiful handwriting.6A video produced by the media outlet of al-Qaeda confirms this information. Osama bin Laden praised “Sheikh Abu al-‘Abbas, ‘Abd al-‘Aziz al-‘Umari al-Zahrani: an example for contemporary scholars and a vestige of the pious predecessors. The active scholar. He protected knowledge from the employ of the tyrants and prevented this knowledge from captivity to their salaries.”7
Though the find was spectacular, the manual had no major impact on the examination of the events and was widely ignored. What are the reasons for that? Immediately after its release, the well-known Middle East scholar Robert Fisk drew attention to statements in the document he found suspicious in the mouth of a Muslim. “What Muslim would write: ‘The time of fun and waste is gone’?” he asked in The Independent on September 29, 2001. As additional evidence he cited the expressions “100 per cent” and “optimistic,” too modern for Arabic theological language. Fisk, who at that time had seen only the English translation, drew a cautious conclusion about a possible Christian translator: “The translation, as it stands, suggests an almost Christian view of what the hijackers might have felt.”8
Fisk’s remark is ambiguous, since it refers to the translation. It gained additional weight in conjunction with conspiracy theories that started circulating soon after the events. Michael Barkun, who has studied the American culture of conspiracy for many years, pointed to certain American groups that did not attribute the attacks to Osama bin Laden and his organization but to the interests of the U.S. government in restricting the freedom of the citizens under the pretext of counterterrorism.9 Other conspiracy theories originated outside the United States. Rumors swept across the Muslim world that the attacks were perpetrated by the Secret Service of Israel and that four thousand Jews who normally worked in the WTC did not show up for work on September 11 because they had been tipped off by Mossad.10
Forgery is a common phenomenon in the history of religions. Well-known documents are ascribed to authorities who cannot have written them. Only after careful investigation and discussion can the suspicion of forgery become a plausible thesis. In the case of our document, no serious attempts have been made to prove it a forgery. It is an unfounded suggestion. Instead, despite all the doubts and uncertainties, qualified attempts have been made to take the document seriously. Hassan Mneimneh und Kanan Makiya published in January 2002, in The New York Review of Books, an examination of the “Manual for a ‘Raid,’” followed by the translation mentioned above.11 The authors explained the contents of the document in terms of Islamic literature, theology, theology, and history. In December 2002, the Martin Marty Center of the University of Chicago, a research institution for the study of religions, started on its website a debate about the document. Bruce Lincoln, following up on Mneimneh and Makiya, attempted to specify the worldview of the perpetrators by pointing to the Egyptian intellectual Sayyid Qutb, a spokesman for the militant wing of the Muslim Brotherhood in the 1960s. Sayyid Qutb denounced the westernization of Egypt’s culture and society as a new era of ignorance (jahiliyya). He called upon the faithful Muslim to do the same as the Prophet had once done: to fight to overthrow the power of paganism along with a few dedicated men. Sayyid Qutb paid for his subversive version of Islam with his life and was executed by the Egyptian government in 1966.12 Bruce Lawrence and Mark Juergensmeyer also joined the debate on the Chicago website and by and large supported Lincoln’s approach.13 In 2006 David Cook published an extensive investigation of the document in the light of Islamic apocalypticism and jihad and added at the end a new English translation of “The Last Night,” as he called the document.14 We owe a comprehensive analysis of the attack to Stephen Holmes, who put together all bits and pieces of evidence relating to the perpetrators and the organization of the attack.15 A critical edition, translation, and analysis of the Arabic text was published in 2006.16
The more the document has been studied, the more it has turned out to be representative of a specific current in contemporary Islamic activism and the suspicion of forgery has lost credibility. The most recent and extensive critical reconstruction of 9/11 by Anthony Summers and Robbyn Swan integrated the manual and its ritual instructions into the series of events preceding the attack. Yet, astonishingly, something else has become utterly incomprehensible.
Seventeen days after the attacks, the FBI released four pages of Arabic script that had also been found in Atta’s bag … Neither the 9/11 Commission Report nor a Commission staff document … even mentions the find … The omission is extraordinary, unconscionable, for the telltale pages were important evidence.17
The Commission Report reconstructs with extreme precision the chain of events preceding the attack but ignores the manual and even seems intentionally to contradict its relevance to the attacks. The manual required that during the last night, all fighters should perform rituals, recitations, and prayers. According to the Commission Report, however, Mohamed Atta and Abdul Aziz al-Umari that night pursued “ordinary activities: making ATM withdrawals, eating pizza, and shopping at a convenience store.”18 As we will see, this depiction was due to a political decision to portray the attackers as people devoid of any religious faith.
Muslims are the fastest-growing religious group in the world. The growth and regional migration of Muslims, combined with the ongoing impact of the Islamic State in Iraq and Syria (ISIS) and other extremist groups that commit acts of violence in the name of Islam, have brought Muslims and the Islamic faith to the forefront of the political debate in many countries. Yet many facts about Muslims are not well known in some of these places, and most Americans – who live in a country with a relatively small Muslim population – say they know little or nothing about Islam.
Here are answers to some key questions about Muslims, compiled from several Pew Research Center reports published in recent years:
Although many countries in the Middle East-North Africa region, where the religion originated in the seventh century, are heavily Muslim, the region is home to only about 20% of the world’s Muslims. A majority of the Muslims globally (62%) live in the Asia-Pacific region, including large populations in Indonesia, India, Pakistan, Bangladesh, Iran and Turkey.
Indonesia is currently the country with the world’s single largest Muslim population, but Pew Research Center projects that India will have that distinction by the year 2050 (while remaining a majority Hindu country), with more than 300 million Muslims.
According to our best estimate, Muslims make up just less than 1% of the U.S. adult population. Pew Research Center’s 2014 Religious Landscape Study (conducted in English and Spanish) found that 0.9% of U.S. adults identify as Muslims. A 2011 survey of Muslim Americans, which was conducted in English as well as Arabic, Farsi and Urdu, estimated that there were 1.8 million Muslim adults (and 2.75 million Muslims of all ages) in the country. That survey also found that a majority of U.S. Muslims (63%) are immigrants.
Our demographic projections estimate that Muslims will make up 2.1% of the U.S. population by the year 2050, surpassing people who identify as Jewish on the basis of religion as the second-largest faith group in the country (not including people who say they have no religion).
A recent Pew Research Center report estimated that the Muslim share of immigrants granted permanent residency status (green cards) increased from about 5% in 1992 to roughly 10% in 2012, representing about 100,000 immigrants in that year.
Why is the global Muslim population growing?
There are two major factors behind the rapid projected growth of Islam, and both involve simple demographics. For one, Muslims have more children than members of other religious groups. Around the world, each Muslim woman has an average of 3.1 children, compared with 2.3 for all other groups combined.
Muslims are also the youngest (median age of 23 years old in 2010) of all major religious groups, seven years younger than the median age of non-Muslims. As a result, a larger share of Muslims already are, or will soon be, at the point in their lives when they begin having children. This, combined with high fertility rates, will fuel Muslim population growth.
While it does not change the global population, migration is helping to increase the Muslim population in some regions, including North America and Europe.
What do Muslims around the world believe?
Like any religious group, the religious beliefs and practices of Muslims vary depending on many factors, including where in the world they live. But Muslims around the world arealmost universally united by a belief in one God and the Prophet Muhammad, and the practice of certain religious rituals, such asfasting during Ramadan, is widespread.
In other areas, however, there is less unity. For instance, a Pew Research Center survey of Muslims in 39 countries asked Muslims whether they want sharia law, a legal code based on the Quran and other Islamic scripture, to be the official law of the land in their country. Responses on this question vary widely. Nearly all Muslims in Afghanistan (99%) and most in Iraq (91%) and Pakistan (84%) support sharia law as official law. But in some other countries, especially in Eastern Europe and Central Asia – including Turkey (12%), Kazakhstan (10%) and Azerbaijan (8%) – relatively few favor the implementation of sharia law.
How do Muslims feel about groups like ISIS?
Recent surveys show that most people in several countries with significant Muslim populations have an unfavorable view of ISIS, including virtually all respondents in Lebanon and 94% in Jordan. Relatively small shares say they see ISIS favorably. In some countries, considerable portions of the population do not offer an opinion about ISIS, including a majority (62%) of Pakistanis.
Favorable views of ISIS are somewhat higher in Nigeria (14%) than most other nations. Among Nigerian Muslims, 20% say they see ISIS favorably (compared with 7% of Nigerian Christians). The Nigerian militant group Boko Haram, which has been conducting a terrorist campaign in the country for years, has sworn allegiance to ISIS.
More generally, Muslims mostly say that suicide bombings and other forms of violence against civilians in the name of Islam are rarely or never justified, including 92% in Indonesia and 91% in Iraq. In the United States, a 2011 survey found that 86% of Muslimssay that such tactics are rarely or never justified. An additional 7% say suicide bombings are sometimes justified and 1% say they are often justified in these circumstances.
In a few countries, a quarter or more of Muslims say that these acts of violence are at least sometimes justified, including 40% in the Palestinian territories, 39% in Afghanistan, 29% in Egypt and 26% in Bangladesh.
In many cases, people in countries with large Muslim populations are as concerned as Western nations about the threat of Islamic extremism, and have become increasingly concerned in recent years. About two-thirds of people in Nigeria (68%) and Lebanon (67%) said earlier this year they are very concerned about Islamic extremism in their country, both up significantly since 2013.
What do American Muslims believe?
Our 2011 survey of Muslim Americans found that roughly half of U.S. Muslims (48%) say their own religious leaders have not done enough to speak out against Islamic extremists.
Living in a religiously pluralistic society, Muslim Americans are more likely than Muslims in many other nations to have many non-Muslim friends. Only about half (48%) of U.S. Muslims say all or most of their close friends are also Muslims, compared with a global median of 95% in the 39 countries we surveyed.
Roughly seven-in-ten U.S. Muslims (69%) say religion is very important in their lives. Virtually all (96%) say they believe in God, nearly two-thirds (65%) report praying at least daily and nearly half (47%) say they attend religious services at least weekly. By all of these traditional measures, Muslims in the U.S. are roughly as religious as U.S. Christians, although they are less religious than Muslims in many other nations.
When it comes to political and social views, Muslims are far more likely to identify with or lean toward the Democratic Party (70%) than the Republican Party (11%) and to say they prefer a bigger government providing more services (68%) over a smaller government providing fewer services (21%). As of 2011, U.S. Muslims were somewhat split between those who said homosexuality should be accepted by society (39%) and those who said it should be discouraged (45%), although the group had grown considerably more accepting of homosexuality since a similar survey was conducted in 2007.
What is the difference between Shia Muslims and Sunni Muslims?
With the exception of a few countries, including Iran (which is majority Shia) as well as Iraq and Lebanon (which are split), most nations with a large number of Muslims have more Sunnis than Shias. In the U.S., 65% identify as Sunnis and 11% as Shias (with the rest identifying with neither group, including some who say they are “just a Muslim”).
How do Americans and Europeans perceive Muslims?
A Pew Research Center survey conducted in 2014 asked Americans to rate members of eight religious groups on a “feeling thermometer” from 0 to 100, where 0 reflects the coldest, most negative possible rating and 100 the warmest, most positive rating. Overall, Americans rated Muslims rather coolly – an average of 40, which was comparable to the average rating they gave atheists (41). Americans view the six other religious groups mentioned in the survey (Jews, Catholics, evangelical Christians, Buddhists, Hindus and Mormons) more warmly.
Republicans also are more likely than Democrats to say they are very concerned about the rise of Islamic extremism in the world (83% vs. 53%) and in the U.S. (65% vs. 38%), according to a December 2015 survey. That survey also found that Republicans are more likely than Democrats to say that Islam is more likely than other religions to encourage violence among its believers (68% vs. 30% of Democrats) and that Muslims should be subject to more scrutiny than people of other religions (49% vs. 20%). Overall, most Americans (61%) say Muslims should not be subject to additional scrutiny solely because of their religion, while U.S. adults are closely divided on the question of whether Islam is more likely than other religions to encourage violence. (Note: This paragraph was updated Dec. 17 to reflect a new survey.)
In spring 2015, we asked residents of some European countries a different question – whether they view Muslims favorably or unfavorably. Perceptions at that time varied across European nations, from a largely favorable view in France (76%) and the United Kingdom (72%) to a less favorable view in Italy (31%) and Poland (30%).
How do Muslims and Westerners perceive each other?
In a 2011 survey, majorities of respondents in a few Western European countries, including 62% in France and 61% in Germany, said that relations between Muslims and Westerners were bad, while about half of Americans (48%) agreed. Similarly, most Muslims in several Muslim-majority nations – including Turkey, Lebanon, Egypt and Jordan – agreed that relations were bad, although fewer Muslims in Pakistan (45%) and Indonesia (41%) had this view.
The same survey also asked aboutcharacteristics the two groups may associate with one another. Across the seven Muslim-majority countries and territories surveyed, a median of 68% of Muslims said they view Westerners as selfish. Considerable shares also called Westerners other negative adjectives, including violent (median of 66%), greedy (64%) and immoral (61%), while fewer attributed positive characteristics like “respectful of women” (44%), honest (33%) and tolerant (31%) to Westerners.
Westerners’ views of Muslims were more mixed. A median of 50% across four Western European countries, the U.S. and Russia called Muslims violent and a median of 58% called them “fanatical,” but fewer used negative words like greedy, immoral or selfish. A median of just 22% of Westerners said Muslims are respectful of women, but far more said Muslims are honest (median of 51%) and generous (41%).
Story 1: Trump Predicted To Win All 5 Primary States With 118 Delegates Plus and Cruz Eliminated From First Ballot Victory — Part 2: Decriminalize and Legalize/Regulate All Drugs To Stop The Deaths From Overdoses and Put All Drug Cartels Out of Business — Declare Victory on The War on Drugs — Trump Rockets To Nomination Pushing The Limits — Wow — Videos
2016 Delegate Count and Primary Results
By WILSON ANDREWS, KITTY BENNETT and ALICIA PARLAPIANOUPDATED APRIL 26, 2016
Candidates will seek to win delegates in each state’s contest to capture their party’s nomination for the presidency. Delegate totals are from The Associated Press. Read more to learn about how election results work. Latest ResultsRelated Article
Unpledged Democratic party leaders who are free to support any candidate. The majority of the 712 superdelegates have declared support for Mrs. Clinton, though they could switch candidates if she were to lose the lead in pledged delegates, which are awarded based on election results.
2016 Presidential Primaries, Caucuses, and Conventions
Republican Convention Presidential Nominating Process Debate – Fox – Cleveland, Ohio: Thursday 6 August 2015 Debate – CNN – Ronald Reagan Presidential Library, Simi Valley, California: Wednesday 16 September 2015 Debate – CNBC – Boulder, Colorado: Wednesday 28 October 2015 Debate – Fox Business News – Milwaukee, Wisconsin: Tuesday 10 November 2015 Debate – CNN – Las Vegas, Nevada: Tuesday 15 December 2015 Debate – Fox Business Channel, Charleston, South Carolina: Thursday 14 January 2016 Debate – Fox – Iowa: Thursday 28 January 2016 Debate – CBS – South Carolina: February 2016 (presumably) Debate – NBC/Telemundo – Texas: Friday 26 February 2016 Debate – CNN – TBD: March 2016 (presumably) Debate – Salt Lake City, Utah (announced 20 February 2016): Monday 21 March 2016 41st Republican National Convention: Monday 18 July – Thursday 21 July 2016
Delegate Selection: Proportional Primary,
Polling hours 7:00a EDT (1100 UTC) to 8:00p EDT (0000 UTC). Polls open 7a to as late as 12 noon by location for Presidential Primaries.
Voter Eligibility: Modified Primary
Voter Participation: Party members and Independents
Voter Affiliation: Party affiliation is changed19 total delegates – 10 base at-large / 6 re: 2 congressional districts / 3 party
Pennsylvania Republican Presidential Nominating Process Primary: Tuesday 26 April 2016 Summer Meeting: Saturday 21 May 2016
As we predicted on April 2nd…. As of today, April 26, 2016, Ted Cruz is mathematically eliminated from winning the Republican nomination outright.
On April 2nd we predicted that Donald Trump would have 953 delegates as of today (needing only 284 delegates for the nomination) and that Cruz would have 550 delegates as of today (needing 687 to win the nomination).
We also predicted that only 634 delegates would remain and therefore Cruz would need more delegates than would be available.
Ted Cruz is eliminated. It is clear that Cruz was eliminated tonight.
It is not clear yet on how devastating the final numbers will be for Ted Cruz.
After winning all five primaries tonight — Connecticut, Rhode Island, Delaware, Maryland and Pennsylvania — Donald Trump has 945 delegates so far.
Ted Cruz finished third in Connecticut, Maryland, Delaware and Rhode Island.
There are fewer delegates remaining than we originally projected because the delegates in Wyoming, Colorado and North Dakota were allocated in shady voter-less elections after April 2nd.
After tonight’s primaries Cruz has — 559 delegates – He did not win a single delegate tonight.
Cruz needs 678 delegates to reach 1,237 delegates.
There are only 651 available. It’s over.
The United States is home to the most obese population in the Americas, Asia and Europe, has the fattest kids by a wide margin and is tops in poor health for teenagers, according to the latest measure of well-being from the Organization for Economic Cooperation and Development.
In its “How’s Life 2015?” report released Tuesday, the United States is also among the nations with underperforming students and second in murders and assaults.
But the U.S. shines when it comes to personal wealth and even the number of rooms in our homes, said the organization that charts the personal and economic health of countries.
The report from the world organization is released every two years and this year it features a focus on child health and welfare in Europe, the Americas and much of Asia, including Japan and South Korea.
The report notes that all nations have room to improve quality of life for its citizens, though it doesn’t openly criticize the United States. However, in several graphics and charts, it is clear that the United States doesn’t match the world average in several areas besides child health.
For example, the U.S. is a nation of workaholics that doesn’t take as much time off as the rest of the world. It also is subpar on life expectancy, adult skills and suffers a higher rate of deaths due to assault than other nations in the report.
But it was the findings on obesity and child health that jumped out in the important report. The key page is shown below.
In the obesity chapter, the United States is put at No. 1, ahead of 33 other nations, despite years of work by the Obama administration, the first lady and the Agriculture Department, which has been pulling sugar and salt out of school lunches.
The report shows that obesity in America has jumped since 2000 and that 35 percent of the nation is overweight. For comparison, 4 percent of Japanese and 25 percent of Canadians are obese.
The U.S. also tops the list of teens report in poor health, at 22 percent.
Worse, the U.S. soars over every other country in the number of obese and overweight children, at a whopping 38 percent. The next worse country is Canada, with a combined obese and overweight child population at below 25 percent.
A new analysis of data on body mass index reveals we’re tipping the scales, and then some.
Staff Writer Liz Dwyer
There’s plenty to celebrate on the healthy eating front: Cereal brands and fast-food joints are dropping artificial colors and flavors, and trans fats have been banned. But while those kinds of changes will likely lead to more nutritious food offerings, given the latest data on America’s obesity problem, the adjustments seem like too little, too late.
At least, that’s how you might feel after reading some of the information culled from a study published Monday in the journal JAMA Internal Medicine. The data compiled by researchers at Washington University School of Medicine in St. Louis reveals just how jaw-dropping the nation’s weight problem has become.
The researchers pulled body mass index data collected by the Centers for Disease Control and Prevention from 2007 to 2012 on a representative sample size of more than 15,200 people ages 25 or older. From that they were able to estimate the BMI of more than 188 million Americans.
How out of control is our weight problem?
1. More Americans are obese than overweight.
Lifestyle magazines tend to be full of tips on how to drop five or 10 pounds. But plenty of Americans need to lose a whole lot more than that to have a healthy BMI (between 18.5 and 24.9). According to the researchers, 67.6 million Americans older than age 25 in 2012 had a BMI over 30, which is considered obese. That outpaces the 65.2 million citizens with BMIs between 25 and 29.9, who were considered overweight.
2. Overall, more men than women are too heavy.
Women are often fat shamed in the media and pressured to look like a Victoria’s Secret Angel. But when the researchers measured the number of folks who are either overweight or obese, they found that more guys are struggling with their waistline. The researchers found that nearly 75 percent of men are overweight or obese, compared with 67 percent of women. And thanks to the “dad bod” phenomenon, guys with bellies and love handles are being celebrated.
3. If they’re heavy, women are more likely to be obese than overweight.
Of the ladies who need to drop some pounds, 37 percent are classified as obese and 30 percent are considered overweight.
4. Black Americans are the most obese racial or ethnic group.
Black Lives Matter has become a rallying cry around gun violence and police brutality. But according to the data, it seems the phrase should also be applied to black Americans’ physical health. The researchers found that black Americans are the most obese of all racial and ethnic groups—an astounding 39 percent of black men and 57 percent of black women are obese. Even more sobering: Seventeen percent of black women and 7 percent of black men have a body mass index over 40, which puts them into the “extremely obese” category. This shouldn’t be such a surprise given the connection between poverty rates and obesity. And no wonder just over 13 percent of black folk are diabetic, the second-highest proportion after Native Americans.
5. Latino Americans are struggling with the scale too.
The nation’s Latino population is soaring—and many of those individuals are likely to be heavy, particularly if they are Mexican American. According to the researchers, 43 percent of Mexican American women and 38 percent of Mexican American men are obese. (Interestingly enough, residents of Mexico, which is home to one of the heaviest populations on the planet, are also the most confident about their bodies.)
So, Why Should You Care? With sky-high BMI rates such as these, America is well positioned to be the home of the free and the land of folks with type 2 diabetes, heart disease, high blood pressure, and cancer. Our health care costs have already played a role in recent presidential elections, and the expense of treating the obesity-related illnesses of millions of U.S. citizens could suck future state and federal budgets dry.
“There are many things we can do to interrupt this worrisome and costly trend, and the benefits go well beyond what’s obvious to the eye,” Graham A. Colditz, one of the study’s authors, said in a statement. “Some cancers, for example, can be prevented by eating a healthy diet, exercising and keeping weight in check. We need to do what we can to change behaviors of current and future generations to reverse this preventable societal burden.”
Perhaps these stats will be a wake-up call that eating less and moving more has to be a national priority.
More than a third of adults (34.9 percent) were obese as of 2011 to 2012.1 More than two-thirds of adults were overweight or obese (68.6 percent).2
Nearly 40 percent of middle-aged adults, ages 40 to 59, were obese (39.5 percent), which was more than younger adults, ages 20 to 39 (30.3 percent) or older adults, ages 60 and over (35.4 percent).3
More than 6 percent of adults were severely obese (body mass index (BMI) of 40 or higher).
More women than men, ages 20 and over, have higher rates of obesity and extreme obesity (36.1 percent and 8.3 percent versus 33.5 percent and 4.4 percent).4
Obesity rates were highest among Black (47.8 percent) adults, followed by Latino (42.5 percent) and White (32.6 percent) adults and lowest among Asian American (10.8 perfect) adults.5
Approximately 17 percent of children and teenagers (ages 2 to 19) were obese from 2011 to 2012, and 31.8 percent were either overweight or obese.6
More than one-in-12 children (8.4 percent) are obese in early childhood (2- to 5-year-olds).
By ages 12 to 19, 20.5 percent of children and adolescents were obese.
More than 2 percent of young children were severely obese, 5 percent of 6-to-11-year-olds were severely obese and 6.5 percent of 12- to 19-year olds were severely obese.7
Racial and ethnic inequities persist among children also; 22.5 percent of Latino children and 20.2 percent of Black children are obese, compared to 14.1 percent of non-Latino White and 6.8 percent of Asian-American children.
Stabilizing — At a High Rate
Over the past 35 years, obesity rates have more than doubled. From 2005 to 2006 to 2011 to 2012, rates remained the same.8 The average American is more than 24 pounds heavier today than in 1960.9
Childhood obesity rates have more than tripled since 1980.10 The overall rates have remained the same for the past 10 years.11
Some cohorts stable, some rising
While rates have remained stable among girls, regardless of race or ethnicity, rates have continued to increase among men and boys and Black and Mexican American women.12,13,14,15
Among obese adults (ages 20+), female obesity rates (36.5 percent) are higher than male obesity rates (33.1 perfect). This is also seen among adults that are severely and morbidly obese.16
Adults ages 40 to 59 (39.5 percent) have higher obesity than adults ages 20 to 39 (30.3 percent) and ages 60+ (35.4 percent). This is also true among those who are severely and morbidly obese, where those between ages 40 to 59 have higher rates than those between ages 20 to 39 and ages 60+.
Overall boys and girls ages 2 to 19 have similar obesity rates (16.7 percent versus 17.2 percent). However preschool (ages 2 to 5) boys have a higher obesity rate (9.5 percent) than preschool girls (7.2 percent). The reverse is true among ages 6 to 11 where girls’ obesity rates more than double to 17.9 percent and the rates among boys increase to 16.4 percent.17
Indian/Native Alaskan low-income preschool children (ages 2 to 4) have the highest obesity rates — at 21.1 percent. Overall rates among low-income preschoolers remain high at 14.7 percent, with Latinos at 18.7 percent, Whites at 12.7 percent, Blacks at 11.8 percent, and Asian/ Pacific Islanders at 11.6 percent.18
Among children between ages 6 to 11, Latino (26.1 percent) and Black (23.8 percent) obesity rates are higher than the White (13.1 percent) rate. These same increased rates are seen among Latino and non-Latino black teenagers ages 12 to 19 (2011 to 2012).19
1 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Obesity among Adults: United States, 2011-2012. NCHS Data Brief, 131, 2013.
2 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA, 311(8):806-814, 2014.
3 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Obesity among Adults: United States, 2011-2012. NCHS Data Brief, 131, 2013.
SSRI Stories is a collection of over 6,000 stories that have appeared in the media (newspapers, TV, scientific journals) in which prescription drugs were mentioned and in which the drugs may be linked to a variety of adverse outcomes including violence.
This updated site includes the stories from the previous site and new ones from 2011 to date. We have used a new “category” classification system on the new stories. We are working back through previously SSRI Stories to bring them into the new classification system. In the meantime use the search box in the upper right column to search through both the old and the new stories.
SSRI Stories focuses primarily on problems caused by selective serotonin reuptake inhibitors (SSRIs), of which Prozac (fluoxetine) was the first. For more see About SSRIs. Other medications prescribed as antidepressants that fit the “nightmares” theme of the collected stories are sometimes included.
Jefferson Airplane – White Rabbit (Grace Slick, Woodstock, aug 17 1969)
Jefferson Airplane – Somebody to love
Dylann Roof makes first South Carolina court appearance
Bond Hearing For Charleston Church Shooter Dylann Roof (Full Unedited): First Court Appearance
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Friend: Dyllan Storm Roof Took Gun from His Mom – She Didn’t Trust Him With It (VIDEO)
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Best 7 minutes on gun control I have ever seen!
In this segment of his Virtual State of the Union, the Virtual President talks about why politicians want to talk about gun control rather than crime control, and delivers the factual evidence and historical truths that make the case for the Second Amendment self-evident.
Dr Susan Gratia-Hupp – Survivor of the 1991 Kileen TX Lubys Shooting Massacre
Hupp and her parents were having lunch at the Luby’s Cafeteria in Killeen in 1991 when the Luby’s massacre commenced. The gunman shot 50 people and killed 23, including Hupp’s parents. Hupp later expressed regret about deciding to remove her gun from her purse and lock it in her car lest she risk possibly running afoul of the state’s concealed weapons laws; during the shootings, she reached for her weapon but then remembered that it was “a hundred feet away in my car.” Her father, Al Gratia, tried to rush the gunman and was shot in the chest. As the gunman reloaded, Hupp escaped through a broken window and believed that her mother, Ursula Gratia, was behind her. Actually however, her mother went to her mortally-wounded husband’s aid and was then shot in the head.
As a survivor of the Luby’s massacre, Hupp testified across the country in support of concealed-handgun laws. She said that if there had been a second chance to prevent the slaughter, she would have violated the Texas law and carried the handgun inside her purse into the restaurant. She testified across the country in support of concealed handgun laws, and was elected to the Texas House of Representatives in 1996. The law was signed by then-Governor George W. Bush.
The Animals – The House of the Rising Sun
“House Of The Rising Sun”
There is a house in New Orleans
They call the Rising Sun
And it’s been the ruin of many a poor boy
And God, I know I’m oneMy mother was a tailor
She sewed my new blue jeans
My father was a gamblin’ man
Down in New OrleansNow the only thing a gambler needs
Is a suitcase and trunk
And the only time he’s satisfied
Is when he’s on a drunk[Organ Solo]Oh mother, tell your children
Not to do what I have done
Spend your lives in sin and misery
In the House of the Rising SunWell, I got one foot on the platform
The other foot on the train
I’m goin’ back to New Orleans
To wear that ball and chainWell, there is a house in New Orleans
They call the Rising Sun
And it’s been the ruin of many a poor boy
And God, I know I’m one
The Moody Blues – Nights In White Satin
Charleston shooting: Dylann Roof’s stepmother defends ‘smart’ boy ‘drawn in by internet evil’
The stepmother of Dylann Roof, the 21-year-old charged with nine counts of murder for the shooting at a church in Charleston, has spoken out in his defence.
Paige Mann, who was married to Mr Roof’s father for 10 years and helped raise him, said that her stepson was so smart that he became bored in school and was a germophobe for some time.
“He went to catechism, he went to church,” Ms Mann said. “He was locked in his room looking up bad stuff on the computer.”
In an interview with the New York Daily News, she said: “Something on the computer drew him in – this is Internet evil. We just thought he was a lazy, this-generation kind of kid.”
Mr Roof’s manifesto, published online, shows how the 21-year-old’s views hardened after the shooting of Travyon Martin in Florida in 2012. Ms Paige claimed that it was only after her step-son began living with his mother over the past few years that he became a recluse.
Mr Roof sat with members of the Emanuel African Methodist Epsicopal Church for nearly an hour before he allegedly shot nine of them dead, including the pastor.
Divorce papers filed by Ms Paige in 2008 claim that Franklin Roof had hit her and that any hope Dylann had of a normal home left with her, it was reported by the Inquisitr.
According to the manifesto, which was updated just hours before the fatal attack, he believed that he had no choice but to carry out the attack on the church and “chose Charleston because it is the most historic city in my state”.
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Affidavits spell out chilling case against Dylann Roof
As a subdued Dylann Roof made his first official appearance Friday on charges of killing nine people at a historic black church, police affidavits offered grim details of the murder case, including an allegation that the gunman fired multiple shots into each victim and stood over them to issue “a racially inflammatory statement.”
The documents also said that Roof’s father and uncle contacted police to positively identify the 21-year-old as the suspect after authorities issued photos of the gunman within hours of the attack at the Emanuel AME Church in downtown Charleston Wednesday evening.
As those details trickled out, the suspect’s family issued a statement expressing sadness and offering condolences to the families of the victims:
Dylann Roof’s father, according to the court documents, told investigators that his son owned a .45-caliber handgun. The documents note that .45-caliber casings were found at the scene of the shootings.
The affidavits allege that Roof, wearing a fanny pack apparently to hide a weapon, spent an hour with the parishioners before opening fire on the group. Before leaving the scene of the carnage, he allegedly “uttered a racially inflammatory statement” over the bodies to a witness who was apparently allowed to survive to convey the message.
Roof was returned to South Carolina after waiving his extradition rights following his arrest Thursday near Shelby, N.C., about 245 miles northwest of Charleston.
He appeared at ease when he allegedly told investigators shortly after his capture that he had launched the attack that left nine dead, a federal law enforcement official said. The official, who is not authorized to comment publicly, said that the suspect expressed no remorse and appeared “comfortable” with what he had done.
Authorities have determined that Roof legally obtained a .45-caliber handgun earlier this year, using money likely provided as birthday gift from his family, the official said. The weapon was purchased at gun store near Columbia, S.C.
Statements made by some family members of victims were particularly powerful.
Charleston shooting: What is a ‘hate crime’?
Appearing by video link from jail, the 21-year-old Roof, who was handcuffed and wore a striped jail jumpsuit, often pursed his lips, closed his eyes, or stared at the floor as the relatives of five victims spoke to the court at the bond hearing.
“You took something really precious away from me, I will never talk to her again, never hold her again, but I forgive you,” said the daughter of one of the victims, Ethel Lance. “You hurt me, you hurt a lot of people but God forgive you and I forgive you.”
Roof appeared wan and subdued, his distinctive bowl hair, shown in surveillance photos outside the church on the night of the killings, stringy and unkempt. He stood with his hands cuffed behind his back. Two heavily armed guards stood behind him.
Bethanee Middleton-Brown, sister of another victim, DePayne Middleton-Doctor, addressed the hearing amid sniffles and sobs in the tiny courtroom.
She said her sister “taught me me that we are the family that love built, we have no room for hate, so we have to forgive. And I pray to God for your soul and I also thank God that And I also thank God I won’t be around when your judgment day comes with him.”
Although the court legally could not issue any bond in on the murder charges, Magistrate James Gosnell Jr. set Roof’s bond on a related weapons possession charge at $1 million.
Roof, who often swallowed hard as the judge asked questions, spoke only three times, answering “yes, sir” and “no, sir” to questions about his employment status. Roof is unemployed.
At the opening of the emotional, 13-minute hearing, Gosnell addressed the court, saying Charleston is a strong, loving community with “big hearts.”
“We are going to reach out to everyone, all the victims, and we will touch them,” he said. “We have victims — nine of them — but we also have victims on the other side.
“There are victims on this young man’s side of the family. No one would have ever thrown them into the whirlwind of events that they have been thrown into … We must find it in their heart to also help his family as well.”
In Washington, meanwhile, Justice Department spokeswoman Emily Pierce said the federal inquiry into the church shooting is ongoing.
What happens to mass killers: the data behind the crimes
Pierce said the investigation will not only consider possible hate crime violations, but prosecutors also will review the shooting as a possible “act of domestic terrorism.”
“This heartbreaking episode was undoubtedly designed to strike fear and terror into this community, and the department is looking at this crime from all angles,” Pierce said.
Charleston, South Carolina Mayor Joseph Riley said although he doesn’t condone the death penalty, he thinks prosecutors will seek it in the Emanuel AME church shooting. VPC
Gov. Nikki Haley, speaking on NBC’s Today show on Friday, said that “we will absolutely will want him to have the death penalty” for the fatal shooting of nine members of a Bible study group at the Emanuel AME Church on Wednesday evening.
Charleston Mayor Joseph P. Riley Jr., said at a news conference Friday that though he’s not a proponent of the death penalty, it’s the law in South Carolina and he expects it will be sought in the church shooting. “If you are going to have a death penalty, certainly this case would merit it,” Riley said.
Shelby police officials did not interview Roof formally, according to WBTV, a Charlotte TV station, which quotes an unidentified source as saying the suspect was videotaped during the entire time he was at the Shelby police department.
The source told WBTV that Roof spoke freely, told investigators he had been planning the attack for a period of time, had researched the Emanuel AME Church and targeted it because it was a historic African-American church.
According to WBTV’s source, Roof told investigators he had a Glock handgun hidden behind a pouch he was wearing around his waist. He also told investigators he thought he’d only shot a few people and when told he actually had killed nine people, he appeared to be somewhat remorseful, according to the source.
During the recorded conversation, Roof reportedly told investigators he actually thought he would be caught in Charleston before fleeing and was headed to Nashville when he was captured. When asked why he was going to Nashville, he reportedly told investigators “I’ve never been there before.”
Police alleged that Roof opened fire on worshipers after sitting with them for at least an hour. The victims included the pastor, Clementa Pinckney, 41, who was also a state senator.
The 21-year-old man accused of killing nine people as they worshiped at a Charleston, South Carolina church has a criminal past. Dylann Roof was arrested twice this year and images of him posted to social media seem to show a racist ideology. WCNC
Roof allegedly told police he “almost didn’t go through with (the shooting) because everyone was so nice to him,” other sources told NBC News’ Craig Melvin.
Police say they thought Roof was the lone gunman within hours of the bloody attack on the church, which was founded in 1816. Asked whether authorities believe Roof had acted alone, Mullen said: “We don’t have any reason to believe anyone else was involved.”
A one-time acquaintance of Roof’s told the Associated Press that he would rant that “blacks were taking over the world” as the pair got drunk on vodka.
Roof railed that “someone needed to do something about it for the white race,” said the former friend, Joseph Meek Jr., according to the AP.
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Secret Leaked Libya Tapes #4 – Dennis Kucinich
The intelligence community gathered no specific evidence of an Congressman Dennis Kucinich (D, OH) speaking with Saif al-Islam Gadhafi regarding the grounds for NATO intervention in Libya.
impending genocide in Libya in spring 2011, undercutting then-Secretary of State Hillary Clinton’s primary argument for using the U.S. military to remove Moammar Gadhafi from power, which cast his country into chaos.
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