Part 2 — Story 1: House Freedom Caucus Is Right: First Complete Clean Repeal and Then Replace Obamacare — No Three Phases/Prongs Bull — Change Your Rules or American People Will Replace You — Restore Free Market Competition In Health Insurance Sector So That Companies and Consumers Are Free of Government Mandates and Dictates Thereby Lowering Premiums and Deductibles — Freedom Works — Repeal and Replace Obamacare Now! — Videos
What Is Budget Reconciliation?
Led by President Donald Trump, Republicans have promised to repeal the Affordable Care Act. They have control of both houses of Congress and the White House, but they still have one big obstacle in that effort.
In the Senate, opponents could stage a filibuster — the right of the minority to try to talk a bill to death and keep senators from voting. It takes 60 votes to stop a filibuster. Republicans have a majority but only 52 seats. And Democrats say they won’t help take apart the health law they voted to pass seven years ago.
Instead, Republicans are vowing to use a budget procedure called “reconciliation.” It comes from a 1974 law called the Congressional Budget and Impoundment Control Act. Lots of major health laws have been passed using reconciliation, including those guaranteeing the right to emergency room care, creating the Children’s Health Insurance Plan, and allowing private plans as an alternative to traditional Medicare coverage.
Here’s how reconciliation would work. First, Congress has to pass a budget resolution.
That budget document has to be agreed on by the House and Senate, but it doesn’t go to the president for his signature.
The budget resolution does two main things. First, it sets spending targets for federal programs Congress funds every year. Those are known as appropriations.
But there are also programs funded by the federal government that don’t need annual approvals from Congress. These include tax cuts or increases and so-called entitlement programs like Medicare and Medicaid.
So the budget resolution also instructs the congressional committees in charge of those programs to propose changes in the law that would “reconcile” how much those programs cost with the targets set by the budget. This is what Republicans would use to order changes to the Affordable Care Act.
When the committees report back their proposed changes, they are assembled into a budget reconciliation bill.
In the Senate, budget reconciliation has its own special rules that make it easier to pass. Debate is strictly limited, and the bill only needs a simple majority to pass.
But there are limits, too. Budget reconciliation bills can only change things that directly impact the federal budget — either adding to or reducing federal spending.
For the Affordable Care Act, that means Congress could use budget reconciliation to eliminate spending, like the help people get to pay their premiums or funding to states to expand the Medicaid program for the poor. It can also repeal the taxes that help pay for those benefits, including the tax penalties for individuals who fail to have insurance.
But Congress can’t use reconciliation to change parts of the health law like provisions requiring insurance companies to provide certain benefits or sell coverage to people with preexisting conditions. Those don’t directly affect federal spending.
That has led insurance companies to complain that they will go broke if they still have to sell to sick people, but healthy people won’t have any incentive to get covered. In that case, they say, only sick people will buy insurance, and premiums will skyrocket.
And the new Republican Congress seems set on using the technique to take apart the health law. Whether that’s a good idea may depend on whether you favor or oppose the Affordable Care Act.
Sen. Mitch McConnell: ‘If’ The House Passes Repeal/Replace Bill, ‘I’ll Bring It Up’
Rand Paul Doesn’t Want the GOP to Fail at Obamacare Replacement Plan
Paul Ryan’s Obamacare Lite Plan with Skyrocket Prices | Rand Paul
Let’s Stop Kissing the Boots of Insurance Companies | Rand Paul
How Trump is trying to sell Republicans on the health care bill
FreedomWorks Day of Action Obamacare Repeal Rally
Watch House Freedom Caucus members speak out on health care bill
Reps. Gohmert, Meadows detail the new ObamaCare proposal
Trump makes final push for health care bill
Paul Ryan: President Trump ‘Knocked The Ball Out Of The Park’ With Capitol Visit | NBC News
Speaker Ryan on President Trump’s Visit: “We Are All-In To End This Obamacare Nightmare”
FNN: Paul Ryan’s FULL PowerPoint Presentation on American Health Care Act (Obamacare Replacement)
AWESOME!! PRESIDENT TRUMP KEEPING HIS PROMISE ON OBAMACARE REPEAL AND REPLACE
House Freedom Caucus Throws Support Behind Paul Health Care Plan
Rand Paul Unveils His Brilliant Replacement Plan for Obamacare
CSPAN | Rand Paul Answers Tough Questions on His Healthcare Plan
Rand Paul and Mark Sanford Unveil Obamacare / Affordable Care Act Replacement Bill
Rand Paul on Why He Walked Out of Obamacare Meeting
Reconciliation in Congress
Exclusive — Rand Paul: ‘Easily 35 No Votes’ Against Paul Ryan’s Obamacare 2.0, ‘I Would Predict They Pull Bill, Start Over’
by MATTHEW BOYLE
21 Mar 2017Washington, D.C.2,723
Sen. Rand Paul (R-KY) told Breitbart News exclusively on Tuesday afternoon that he expects House Speaker Paul Ryan will be forced to pull the American Health Care Act (AHCA) before a scheduled Thursday vote because Ryan will not get the votes to pass the legislation.
The AHCA has been dubbed “Obamacare Lite” by Paul — a leading conservative critic of the plan — and by other conservatives as “RyanCare,” “RINO-Care,” and “Obamacare 2.0,” since the bill does not actually fully repeal Obamacare and keeps many of the main structures that the now-former President Barack Obama installed in the healthcare system. It has come under intense scrutiny from both sides of the Republican Party — moderates and conservatives are lining up against the bill — and Ryan, despite publicly projecting confidence, cannot find the necessary 216 votes to pass the legislation.
Paul, one of the leading senators out of more than a dozen Republicans in the upper chamber criticizing the bill there, told Breitbart News in this exclusive interview he believes there are at least 35 House Republicans ready to vote against the bill in its current form. And he predicted that, unless some major changes come to the legislation between now and the scheduled vote on Thursday, Ryan will need to withdraw the bill and Republicans will have to start from scratch with a new bill and a new strategy on Obamacare.
Paul said in the in-person interview at his U.S. Senate office in the Russell Senate Office Building:
I think there’s easily 35 no votes right now so unless something happens in the next 24 hours, I would predict they pull the bill and start over. I think if conservatives stick together, they will have earned a seat at the table where real negotiation to make this bill an acceptable bill will happen. But it’s interesting what conservatives are doing to change the debate. We went from keeping the Obamacare taxes for a year—hundreds of billions of dollars—but they’re coming towards us because we’re standing firm. So we have to stick together, and if we do stick together there will be a real negotiation on this. The main goal I have is not to pass something that does not fix the situation. If a year from now, insurance rates and premiums are still going through the roof and it’s now a Republican plan it will be a disservice to the president and all of us if we pass something that doesn’t work.
There is plenty of reason to believe that Paul is correct in predicting Ryan does not have the votes to pass this legislation and will need to pull the bill to start over. Despite overtures from President Donald Trump, the House Freedom Caucus members — and particularly its chairman Rep. Mark Meadows (R-NC) — remain steadfastly opposed to the bill.
NBC News has confirmed at least 26 Republicans who are opposed:
But Breitbart News can confirm several more than that are definitely opposed to the legislation. To kill the bill, Republicans need just 21 Republicans opposed—and some are talking about holding a press conference on Wednesday or Thursday with the necessary number of House Republicans to crush RyanCare, appearing arm-in-arm in public opposition before a vote.
House GOP leadership made some last minute changes, too, which Paul — in his interview with Breitbart News — flatly said “no,” were not enough to get the bill passed. Regarding those changed, Paul said:
If you keep all the insurance mandates, and you keep subsidizing insurance, basically it’s Obamacare Lite. So I think it’s still Obamacare Lite. The modifications, some are going in the right direction, but they actually expanded some of the subsidies. So one of the new things about it is it’s actually $75 billion more in subsidies. So, I think they’re stuck trying to split the baby. They’re trying to give conservatives a few token changes. And they’re trying to give the moderates more subsidies.
Paul added that Ryan would not have dragged President Trump into this awful position if he had been more open and inclusive in the process from the beginning. In effect, Paul argued as he has done before, that Ryan is hurting President Trump by doing this the way he is doing it. Paul said:
I’m still unclear as to why they completely ignored conservatives early on in the process and then they had the audacity to look at conservatives and say ‘this is what you all campaigned on.’ That just, frankly, was never true. I was elected in 2010 in the big Tea Party wave that was for repealing Obamacare root and branch, rip the whole thing out. We were for repealing it. I still think that our grassroots conservative supporters are for repealing it. But somewhere along the line, Paul Ryan decided that it wasn’t so much about repealing it but about replacing it with Obamacare Lite. And I think that was a tactical error on their part to think ‘oh, we’ll just be for this and everybody will be for this’ when in reality no conservatives are really for the Ryan plan.
Paul would not say if Ryan will lose the confidence necessary to run the House of Representatives if this bill fails, as some have suggested. When asked if Ryan can still run the House if the bill goes down, Paul told Breitbart News that instead he thinks the bill going down would lead to real negotiations on healthcare reform. He said:
I think what it will be is the real negotiations will begin the moment his bill fails, and when his bill fails conservatives will have a seat at the table. As long as conservatives stay unified and don’t start negotiating one person at a time — what’s a really bad part of negotiations is if everybody starts saying individually ‘oh if you give me this, give me this, give me this’ because then you won’t really fix the main thrust of the bill and the main outcome is that insurance premiums continue to rise and we continue to bail out insurance companies that’s not repeal of Obamacare—that’s Obamacare Lite.
More from Sen. Rand Paul’s latest exclusive interview with Breitbart News is forthcoming.
Many members are also part of the Republican Study Committee, another conservative House group. The caucus is sympathetic to the Tea Party movement. According to its mission statement, it “gives a voice to countless Americans who feel that Washington does not represent them. We support open, accountable and limited government, the Constitution and the rule of law, and policies that promote the liberty, safety and prosperity of all Americans.”
The origins of the caucus lie at the mid-January 2015 Republican congressional retreat in Hershey, Pennsylvania. Nine conservative active Republican members of the House began planning a new Congressional caucus separate from the Republican Study Committee and apart from the House Republican Conference. The group ultimately became the nine founding members and the first board of directors for the new caucus consisting of Republican Representatives Scott Garrett of New Jersey, Jim Jordan of Ohio, John Fleming of Louisiana, Matt Salmon of Arizona, Justin Amash of Michigan, Raúl Labrador of Idaho, Mick Mulvaney of South Carolina, Ron DeSantis of Florida and Mark Meadows of North Carolina. The group debated over a name for their new caucus eventually settling on “House Freedom Caucus” (HFC) because, according to founding member Mick Mulvaney, “it was so generic and universally awful that we had no reason to be against it.” The group of nine founding members in Hershey set as a criterion for new members that they had to be willing to vote against Speaker of the United States House of RepresentativesJohn Boehner on legislation that the group opposed.
During the crisis over the funding of the Department of Homeland Security in early 2015, the Caucus offered four plans for resolution, but all were rejected by the Republican leadership. One of the caucus leaders, Labrador of Idaho, said the Caucus will offer an alternative that the most conservative Republican members could support.[needs update]
The House Freedom Caucus was involved in the resignation of Boehner on September 25, 2015, and the ensuing leadership battle for the new Speaker. Members of the Caucus who had voted against Boehner for Speaker felt unfairly punished, accusing him of cutting them off from positions in the Republican Study Committee and depriving them of key committee assignments.[not in citation given] Boehner found it increasingly difficult to manage House Republicans with the fierce opposition of the Freedom Caucus, and he sparred with House Republican members (who later created and became members of the Freedom Caucus when it was created in 2015) in 2013 over their willingness to shut down the government in order to accomplish goals such as repealing the Affordable Care Act.[not in citation given]
Initially, Kevin McCarthy, the House Majority Leader, was the lead contender, but the Freedom Caucus withheld its support. However, McCarthy withdrew from the race on September 28, 2015. On the same day as McCarthy’s withdrawal, Reid Ribble resigned from the Freedom Caucus saying he had joined to promote certain policies and could not support the role that it was playing in the leadership race.
On October 20, 2015, Paul Ryan announced that his bid for the Speaker of the United States House of Representatives was contingent on an official endorsement by the Freedom Caucus. While the group could not reach the 80% approval that was needed to give an official endorsement, on October 21, 2015, it announced that it had reached a supermajority support for Ryan. On October 29, 2015, Ryan succeeded John Boehner as the Speaker of the House.
The group has faced backlash from the Republican Party establishment during the 2016 election cycle. One of its members, Congressman Tim Huelskamp, a Tea Party Republican representing Kansas’s First District, was defeated during a primary election on August 2, 2016, by Roger Marshall. GOP Establishment PACs, many of whom also opposed Donald Trump, spent nearly $2 million to defeat Huelskamp.
Congressional District map for Freedom Caucus membership of the 114th Congress. Former members in light color.
Members of the House Freedom Caucus as of March 2017 include:
It’s Rand Paul vs Paul Ryan in the battle over Obamacare — and the future of the GOP
Brandon Morse Mar 17, 2017 8:52 am
A protester wears a Repeal Obamacare button on his jacket during a Freedom Works rally Wednesday against the proposed GOP health care plan across from the U.S. Capitol in Washington, D.C. (Justin Sullivan/Getty Images)
The in-house Republican battle over the repeal of Obamacare is about to boil over as Kentucky Sen. Rand Paul and Speaker of the House Paul Ryan (R-Wis.) are engaged in an increasingly sharp war over words over their disagreements on how to proceed forward with the promised repeal and replace of former President Obama’s signature legislation.
Paul has been waging a war against the House GOP Obamacare repeal and replace plan since before it was given to the public. Calling it “Obamacare Lite,” Paul has lambasted not only the bill, but his fellow Republicans for their less-than-diligent attempts at getting rid of the unpopular health care law. This time, he turned his attention toward Ryan, who has been the bill’s primary spokesman.
“I think that Paul Ryan’s selling [Donald Trump] a bill of goods that he didn’t explain to the president, and the grassroots doesn’t want what Paul Ryan is selling,” Paul told CNN.
Paul Ryan, during an segment on CNN’s “The Lead with Jake Tapper,” fired back at the Kentucky senator, claiming that his remarks were a jab at President Donald Trump.
“Frankly, I think that’s kind of an insulting remark to the president — as if he doesn’t know what he’s doing,” Ryan said.
“We think this is a smarter way to go,” Ryan said to Tapper. “The alternative is the status quo, and the status quo is in the middle of a collapse.”
Ryan has made the case that this version of the Obamacare repeal bill is the “closest we will ever get” to repealing it.
Paul, however, believes that Trump is open to changing his mind on the health care bill, despite his prior statements of broad approval, and that it’s Republican leadership who have “dug in their heels.”
“They are not going to compromise. So the only way that we are going to get to a compromise where they listen to the grassroots that wants complete repeal, the only way we got to that compromise is that we have to demonstrate to the House leadership that we have the votes to stop them.”
As the battle continues between the conservatives and GOP leadership, the faith of the voters hangs in the balance, according to the conservatives. Paul believes that should the GOP pass “Obamacare Lite,” Republicans will pay for it come election time. Duncan wrote in the Daily Signal that should the bill pass, voters “will feel betrayed.”
If that is true, then winner of the struggle between Paul and Ryan may determine the GOP’s future momentum.
Rand Paul Unveils His Brilliant Obamacare Replacement Plan
WASHINGTON (AP) — Time for talk running out, President Donald Trump on Tuesday warned wavering House Republicans that their jobs were on the line in next year’s elections if they failed to back a GOP bill that would overhaul Barack Obama’s Affordable Care Act.
The countdown quickened toward an expected vote Thursday on legislation undoing much of the law that provided health coverage to some 20 million Americans. Trump huddled behind closed doors with rank-and-file Republicans just hours after GOP leaders unveiled changes intended to pick up votes by doling out concessions to centrists and hardliners alike.
“If we fail to get it done, fail to (meet) the promises made by all of us, including the president, then it could have a very detrimental effect to Republicans in ’18 who are running for re-election,” said Rep. Mike Conaway, R-Texas. “If it fails, then there will be a lot of people looking for work in 2018.”
Trump’s message to Republicans: “If you don’t pass the bill there could be political costs,” said Rep. Walter Jones, R-N.C.
The outlook for House passage remains dicey even with the revisions.
The GOP bill would scale back the role of government in the private health insurance market, and limit future federal financing for Medicaid. It would also repeal tax cuts on the wealthy that Democrats used to pay for Obama’s coverage expansion. Fines enforcing the Obama-era requirement that virtually all Americans have coverage would be eliminated.
The nonpartisan Congressional Budget Office estimates that 24 million fewer people will have health insurance in 2026 under the GOP bill.
Trump warned House Republicans they’d seal their political doom if they waver, with the party potentially losing majority control of the House. Still, several conservatives were steadfast in their opposition even after the session with Trump and the leadership’s changes.
“The president wouldn’t have been here this morning if they have the votes,” said Rep. Rod Blum, R-Iowa, a member of the Freedom Caucus who complained that the GOP bill leaves too much government regulation in place.
Rep. Don Bacon, R-Neb., said he was convinced to back the bill in part by Trump’s urging and the changes.
“I think a vote ‘no’ is a vote for Obamacare,” Bacon said. “We can vote for this, and continue to make it better. I intend to vote ‘yes’ Thursday.”
Speaker Paul Ryan, R-Wis., told reporters that if Republicans pass the legislation, “people will reward us. If we don’t keep our promise, it will be very hard to manage this.”
If the bill advances, prospects are uncertain in the Senate, where Republicans hold a slim majority. Six GOP senators have expressed deep misgivings including Tom Cotton of Arkansas, who said Tuesday he cannot support the House bill.
In an Associated Press interview, Senate Majority Leader Mitch McConnell, R-Ky., signaled he’d use Trump’s clout to pressure unhappy Republicans in his chamber. McConnell said he’s optimistic that in the end no Republican senator will want to be held responsible for “Obamacare’s” survival.
“I would hate to be a Republican whose vote prevented us from keeping the commitment we’ve made to the American people for almost 10 years now,” McConnell said.
The House GOP bill would dismantle Obama’s requirements that most people buy policies and that larger companies cover workers. Federal subsidies based on peoples’ incomes and the cost of insurance would end, and a Medicaid expansion to 11 million more low-income people would disappear.
Instead, the bill would provide tax credits based chiefly on age to help people pay premiums. Open-ended federal payments to help states cover Medicaid costs would be cut. Insurers could charge older consumers five times the premiums they charge younger people instead of Obama’s 3-1 limit, and would boost premiums 30 percent for those who let coverage lapse.
The latest changes to the bill by GOP leaders were largely aimed at addressing dissent that the measure would leave many older people with higher costs.
Included was an unusual approach: language paving the way for the Senate, if it chooses, to make the bill’s tax credit more generous for people age 50-64. Republicans said the plan sets aside $85 billion over 10 years for that purpose. The income tax threshold for deducting medical expenses would be lowered to 5.8 percent, from the current 10 percent.
The leaders’ proposals would accelerate the repeal of tax increases Obama imposed on higher earners, the medical industry and others.
On Medicaid, the changes would provide higher federal payments to help states care for older and disabled beneficiaries. States would be able to impose work requirements for able-bodied adults. But the bill would still limit future federal financing for Medicaid, seen by many state officials as a cost shift. Obama’s Medicaid expansion would be repealed.
In a bid to cement support from upstate New Yorkers, the revisions would also stop that state from passing on over $2 billion a year in Medicaid costs to upstate counties, though it exempts Democratic-run New York City from that protection. Local officials have complained the practice overburdens their budgets.
Democrats remain solidly opposed to the GOP repeal effort.
Rep. Chris Collins, R-N.Y., said Trump told Republicans he would campaign for them if they backed the bill.
Associated Press reporters Matthew Daly, Kevin Freking, Richard Lardner, Stephen Ohlemacher in Washington and Thomas Beaumont in Iowa contributed to this report.
Benson: Dem Operatives ‘Got Fired Awfully Quickly’ for Veritas Tape to be Edited
Rigging the Election – Video III: Creamer Confirms Hillary Clinton Was PERSONALLY Involved
Published on Oct 24, 2016
Part III of the undercover Project Veritas Action investigation dives further into the back room dealings of Democratic politics. It exposes prohibited communications between Hillary Clinton’s campaign, the DNC and the non-profit organization Americans United for Change. And, it’s all disguised as a duck. In this video, several Project Veritas Action undercover journalists catch Democracy Partners founder directly implicating Hillary Clinton in FEC violations. “In the end, it was the candidate, Hillary Clinton, the future president of the United States, who wanted ducks on the ground,” says Creamer in one of several exchanges. “So, by God, we would get ducks on the ground.” It is made clear that high-level DNC operative Creamer realized that this direct coordination between Democracy Partners and the campaign would be damning when he said: “Don’t repeat that to anybody.” The first video explained the dark secrets and the hidden connections and organizations the Clinton campaign uses to incite violence at Trump rallies. The second video exposed a diabolical step-by-step voter fraud strategy discussed by top Democratic operatives and showed one key operative admitting that the Democrats have been rigging elections for fifty years. This latest video takes this investigation even further.
Are you kidding me! Hillary Clinton hires Donald Duck to erupt Donald Trump press conference!
Part III of the undercover Project Veritas Action investigation dives further into the back room dealings of Democratic politics. It exposes prohibited communications between Hillary Clinton’s campaign, the DNC and the non-profit organization Americans United for Change. And, it’s all disguised as a duck. In this video, several Project Veritas Action undercover journalists catch Democracy Partners founder directly implicating Hillary Clinton in FEC violations. “In the end, it was the candidate, Hillary Clinton, the future president of the United States, who wanted ducks on the ground,” says Creamer in one of several exchanges. “So, by God, we would get ducks on the ground.” It is made clear that high-level DNC operative Creamer realized that this direct coordination between Democracy Partners and the campaign would be damning when he said: “Don’t repeat that to anybody.” The first video explained the dark secrets and the hidden connections and organizations the Clinton campaign uses to incite violence at Trump rallies. The second video exposed a diabolical step-by-step voter fraud strategy discussed by top Democratic operatives and showed one key operative admitting that the Democrats have been rigging elections for fifty years. This latest video takes this investigation even further.
Project Veritas Action Founder James O’Keefe brings you more Hillary shockers.
Impact of Project Veritas videos on the 2016 election
Top Clinton Strategist Discusses Project Veritas Action Videos With George Stephanopoulos
George Stephanopoulos and Eric Trump Discuss Project Veritas Action Videos
Anderson Cooper Calls Project Veritas Action Videos “Damning”
Bob Woodward on the Clinton Foundation: ‘It’s Corrupt’
BREAKING: HILLARY IS DISQUALIFIED! NEW UNDERCOVER VERITAS VIDEO CONVICTS HER OF GROSS FEDERAL CRIMES
BREAKING: HILLARY IS GOING DOWN!
O’KEEFE JUST FILED SUIT AGAINST CLINTON AND THE DNC
WIKILEAKS JUST ASSASSINATED HILLARY: TREASON REVEALED AFTER ONE NATION DONATED HUGE TO THE CLINTONS
WikiLeaks Reveals How Hillary Clinton’s Campaign Coordinates With Super PACs
Wikileaks emails prove illegal coordination between Clinton and her Super PACs
More Truth About The Hillary Clinton Wikileaks Scandal
Trey Gowdy On Hillary’s Treason Email Scandal ‘be in jail’
White House Responds to Project Veritas Action Videos
Judge Jeanine Pirro Goes Off on Project Veritas Video Democrats Inciting Violence at Trump Rally
Donald Trump Mentions Project Veritas Action Videos at Third Presidential Debate
Rigging the Election – Video I: Clinton Campaign and DNC Incite Violence at Trump Rallies
Rigging the Election – Video II: Mass Voter Fraud
Wikileaks: Hillary Plans To Implode US Economy
New Wikileaks Confirm Media Rigging Polls For Hillary
Trump Is Leading Hillary In New Polls And New Wikileaks – The Kelly File (FULL SHOW 10/21/2016)
HILLARY WIKILEAKS: Top 10 You Must Know
NEW WIKILEAKS Revelations DEADLY For Hillary Clinton – Hannity (FULL SHOW 10/14/2016)
O’KEEFE COMPLAINT TO FEC CITES DEMS’ ‘CRIMINAL CONSPIRACY’
Vote fraud, Trump-rally anarchy linked to Clinton campaign
Citing a Democratic operative’s confirmation of a chain of command that runs directly from Hillary Clinton’s campaign to agents who “execute … on the ground,” the activists at Project Veritas are asking the Federal Election Commission to investigate a “criminal conspiracy.’
The filing of the complaint with the federal agency follows the release earlier this week of two videos in which Democrats explain how they can attempt to change the outcome of the election through apparently fraudulent means, such as having people travel across state lines to vote illegally.
Also now out of work is Bob Creamer, founder and partner of Democracy Partners, and husband of Rep. Jan Schakowsky, D-Ill.
Foval credited Creamer with coming up with a number of ideas and strategies to enhance Democrats’ standing among voters.
The new complaint from O’Keefe’s organization explained his journalists “have uncovered a criminal conspiracy where, in the words of Scott Foval, ‘The way that works is: The [Clinton] campaign pays DNC, DNC pays Democracy Partners, Democracy Partners pays The Foval Group, The Foval group goes and executes … on the ground.’
The complaint states: “This has been done in a manner to evade federal election laws and violating coordinated expenditure rules.”
It is supplemented with pages of evidence.
“The criminal conspiracy involves the knowing and willful creation of coordinated expenditures from prohibited corporate sources. As is detailed numerous times in the Veritas transcript, attached as EXHIBIT A, the supposedly independent speech and actions of third-party groups were directed, controlled, or puppeteered by HFA or the DNC.
“Indeed, the record establishes not just simple violations of the FECA’s coordination provisions, but ongoing knowing and willful evasion of federal election law requirements through a complicated scheme. Because this conspiracy involves large numbers of employees, heightened travel, production, and distribution costs and because of the nationwide scale of the operation, upon information and belief, this triggers criminal penalties.”
One result of the six-month undercover investigation is that “the supposedly spontaneous and independent protests occurring at Donald Trump events nationwide were controlled and directed by Democratic Party operatives.”
“The commission should find reason to believe that Hillary for America and other named respondents have violated 52 U.S.C. [paragraph] 30101, et seq, and conduct an immediate investigation,” the complaint explains. “Because of the weighty public interest at stake here, it should do so within 120 days of the filing of this complaint … the complainants request that the FEC impose sanctions appropriate to these violations and take further action as may be appropriate, including referring the matter to the Department of Justice for a criminal investigation.”
Foval explains the subterfuge.
“We can hire any demo that we want. We use the same mechanism to recruit them that we do to make focus groups. … We have to be really careful. Um, because, what we don’t need is for it to show up on CNN that the DNC paid ‘x’ people to … that’s not gonna happen. We need to keep it, you know, I hate to use the Beyonce term, ‘partition,’ but we need to keep the partition. That’s as gay as I’ll get.”
“Where is the FBI, why is the FBI not investigating this?” the former House speaker asked during an appearance on Fox News on Tuesday, BizPacReview reported. “You have a deliberate willful effort to foment violence, to break up a presidential campaign [and] to intimidate voters.”
The PILF complaint, directed to the office of the general counsel for the FEC in Washington, names Hillary for America, the DNC, Democracy Partners, Americans United for Change and others.
“This complaint is based on information and belief that respondents have engaged in public communications, campaign activity, targeted voter registration drives, and other targeted GOTV activity … at the request, direction, and approval of the Hillary for America campaign committee and the Democratic National committee in violation of 11 C.F.R. 109.20 and 11 C.F.R. 114.4(d)(2) and (3).”
The activities, the complaint says, “potentially registered persons who were not citizens.” They also illegally coordinated political maneuvers between a candidate’s committee and groups that are supposed to be operating independently, the complaint charges.
That puts them in violation of Federal Election Campaign Act of 1971, the complaint contends.
Sen. Ted Cruz, R-Texas, said on Twitter, according to the Washington Examiner, that multiple visits to the White House by a “voter fraud operative” merits “a serious criminal investigation.”
Talk-radio icon Rush Limbaugh said the evidence is worrisome.
“Every Trump rally would feature none of this [violence] unless the Democrats were paying for it. I think it’s a big deal, folks. The media is complicit. They know who these people are. … They’re in on it. They’re part of the game. … None of it’s organic. None of it’s natural. None of it’s real. Every bit of it is bought and paid for.
“[Democrats] can’t leave elections to chance because they know that, despite the way it may look, the majority of Americans would not support them if they knew who they are.”
Foval said he works backward in his thinking. He first speculates how a charge of voter fraud could be proven, and then he manipulates circumstances and events to avoid those tactics.
He talked about bringing voters from one state to another to vote illegally.
Hiring a bus could be used as evidence of conspiracy, he noted, so people would need to drive their own cars, or better yet, rentals.
There also was a discussion about using local addresses for illegal voters.
He said what needs to happen is to “implement the plan on a much bigger scale.”
“You implement a massive change in state legislatures and in Congress. So you aim higher for your goals, and you implement it across every Republican-held state.”
Project Veritas says the actions are “behind-the-scenes shady practices with consequences most Americans have seen on national television at Donald Trump campaign rallies across the country.”
“What the media hasn’t reported is that the Clinton campaign and Democratic National Committee has been directing these activities with, at very best, a very thin veil of plausible deniability.”
Commented Foval at one point, “I’m saying we have mentally ill people, that we pay to do s—, make no mistake. Over the last 20 years, I’ve paid off a few homeless guys to do some crazy stuff, and I’ve also taken them for dinner, and I’ve also made sure they had a hotel, and a shower. And I put them in a program. Like I’ve done that. But the reality is, a lot of people especially our union guys. A lot of our union guys … they’ll do whatever you want. They’re rock and roll. When I need to get something done in Arkansas, the first guy I call is the head of the AFL-CIO down there, because he will say, ‘What do you need?’ And I will say, ‘I need a guy who will do this, this and this.’ And they find that guy. And that guy will be like, ‘Hell yeah, let’s do it.’”
Last week, O’Keefe reported his Twitter account was shut down as he was releasing reports on voter fraud.
In one video he released last week, a Clinton staffer confessed that ripping up voter registration forms – if they are for Republicans – is “fine.”
The video also revealed a sexist atmosphere inside the Clinton campaign in which another staffer boasts he would probably have to “grab a–” twice before he’d even be reprimanded. It underscores the double standard by Democrats who have been critical of the 11-year-old recording of Donald Trump making lewd remarks about women.
In the video, both Wylie Mao, a field organizer for the Clinton campaign and the Democratic Party of Florida in West Palm Beach, and Trevor Lafauci, a Clinton campaign staffer, agree that ripping up registration forms from Republicans should be “fine.”
“If I rip up completed VR forms, like 20 of them, I think I’ll just get reprimanded. I don’t think I would get fired,” Mao said.
Lafauci, after being told that someone else ripped up Republican registration forms, said, “Yeah, that should be fine.”
When Project Veritas journalists confronted both Mao and Lafauci about the comments they made on camera, they “refused to answer and walked away,” the organization said.
O’Keefe previously released an undercover video of Alan Schulkin, the New York Democratic commissioner of the Board of Elections, confirming there is widespread fraud.
In the video, he is heard disclosing that organizers use buses to haul people from poll to poll to vote.
Sweden has died. Do not allow your country to be next….
Immigrant rape statistics in Sweden
Hungary – Defending Europe’s Borders
Visegrad Alliance – Central Europe Rises
Tribute to the Visegrad Four countries: Poland, Hungary, Czech Republic and Slovakia. Often in the West we hear of “Europeans values”, “Western values”. Those values that are touted as “European” and “Western” by Leftist are anything but. The value of self-hate is a value of the far-left imposed on Europe over the last half-century. Those aren’t our real European values nor representative of our ancient cultures. It is manipulation and deceit to say they are.
Hungarian PM: Mass Migration a Plot to Destroy Christian West
The New Urban Agenda
Agenda 21 – Replacement Migration – United Nations
How the World Will Know if the New Urban Agenda Is Successful
George Soros Owns Hillary Clinton: Why We Need Trump (FULL SHOW)
Hillary Clinton embraces George Soros’ ‘radical’ vision of open-border world
By Rowan Scarborough – The Washington Times
Hillary Clinton has aligned herself closely with a vision for America laid out by her benefactor — left-wing financier George Soros, who talks of “international governance,” more open borders, increased Muslim immigration and diminished U.S. global power.
The phrase “American exceptionalism” is not part of his agenda. He wrote in 1998: “The sovereignty of states must be subordinated to international law and international institutions.”
“We need some global system of political decision-making. In short, we need a global society to support our global economy,” Mr. Soros wrote.
After the Sept. 11, 2001, al Qaeda attacks on New York City and the Pentagon, he said, “Military power is of limited use in dealing with asymmetric threats such as terrorism.”
The Clinton-Soros symbiosis came into clearer focus this month with WikiLeaks’ release of thousands of hacked emails from John Podesta, Mrs. Clinton’s campaign chairman. Mr. Soros‘ name comes up nearly 60 times.
The financial and ideological alliance is so complete that after Mr. Soros dined with Mrs. Clinton in 2014 and asked her to attend a liberal group’s fundraiser, her campaign manager, Robby Mook, wrote in an email, “I would only do this for political reasons (ie to make Soros happy).”
Just as America was tossed — or did we eagerly jump — into the sexual political gutter with Bill and Hillary and Donald, there was other news breaking.At least I thought it was news. But I must warn you: Sex and sexual politics has nothing to do with it.
It’s Hillary Clinton‘s dream of an America without borders, as expressed to investors of a Brazilian bank, in comments leaked by WikiLeaks.
An America without borders, Hillary? How positively George Soros of you, Madam Secretary.
“My dream is a hemispheric common market, with open trade and open borders, sometime in the future with energy that’s as green and sustainable as we can get it, powering growth and opportunity for every person in the hemisphere,” Clinton reportedly said to investors in a paid speech she gave to Brazilian Banco Itau in 2013.
Here’s the thing about borders. If you don’t have borders, you don’t have a country. Americans are beginning to understand this. Europeans understand it now, quite clearly.
Clinton’s dream also includes a Western Hemispheric common market, like the European common market that is dissolving in chaos, fear and debt.
If that is indeed her dream, then she dreams the internationalist dream that would end America. But Americans aren’t talking about this, perhaps because there is no video involving sex and Hollywood and Trump.
I would love to hear Clinton’s explanation. Perhaps she could put it in some proper context.
Or perhaps she was merely telling the Brazilians something they wanted to hear, because they were paying her a good chunk of cash.
And if there is a way for America to maintain sovereignty without borders, Hillary might be just the one to tell us. But the Clinton campaign isn’t commenting. And reporters aren’t really pressing, preoccupied as they are by that vulgar video of a boorish Trump.
Clinton campaign spokesman Robby Mook was on one of the talk shows saying Clinton’s dreams of American open borders didn’t really mean open borders.
Mook said she meant open borders in the context of green energy for all.
Cool. But then what about her dreams of the hemispheric common market and all the people traveling to and fro across the Western Hemisphere?
So I’d like to hear Hillary Clinton tell it.
The way to deal with this would be for Clinton to release the transcripts of all her well-paid speeches, the ones to Wall Street and the one about border dreams to Banco Itau. That’s what Bernie Sanders wanted.
But that’s not happening, just like Donald Trump isn’t releasing his tax returns.
So the Clintonistas are blaming the Russians for the hacking.
It might also be true that if a hacker could hack into Clinton campaign emails, then a hacker might also have hacked into top secret emails she kept on her home brew server in violation of federal law when she was secretary of state.
But I won’t say anything, lest I be denounced as a Russian spy.
That WikiLeaks information was available just before the last Clinton-Trump debate. The moderators could have asked a question about it, but they chose not to.
They did ask about another drop from WikiLeaks, that of Clinton’s belief in holding one public position on policy for the public and another for private consideration by insiders.
Kind of like when she was secretary of state and telling America that the four dead Americans in Benghazi were killed by protesters angry about some video. And then telling her daughter and others, in private emails, that the four were killed in a terrorist attack.
In the debate, Clinton was asked if an official holding a private and a public position could be considered “two-faced.”
She said Abraham Lincoln did it. In a movie.
And now, rather than worry about divisive issues such as borders, we’re consumed by that vulgar Trump video.
Yet back when the Clintons held the White House, back when Bill used the cigar on that intern in the Oval Office, the political left protected him. And they defended Hillary for defending Bill, who had a habit of putting his hands on women when he held office.
Sex was a private matter then. It’s quite a public matter now. But then it was all a private matter, remember?
And so, after a brief bout of impeachment interruptus, the American political establishment welcomed Bill and Hillary back into the establishment fold, where wealth and near absolute power awaited them.
What’s laughable about all this is the Clintonista argument that to cleanse America of the stain of Trump, we must re-install Hillary and Bill back into the same White House that they soiled years ago.
I get all that.
Trump is a boor and Bill Clinton is a boor and Hillary is Hillary — either a loyal spouse or a cunning enabler. And politics is politics, so you’ll hate the one or forgive the other based on your preferences, or shout a pox upon them all.
But having an America with or without borders is also rather important, no?
And someone running for president might want to explain it all, in the proper context of course.
An America without borders? That’s not a dream, that’s a nightmare.
Hillary an enthusiastic supporter of globalist plan for U.S. cities
The United Nations has cooked up a “New Urban Agenda” coming soon to a city near you.
It was unveiled this week in Quito, Ecuador, at the so-called Habitat III conference.
And part of the plan, enthusiastically embraced by Hillary Clinton, calls for unlimited migration across open borders. Migrants displaced by war, failing economies or other hardships will be seen as having “rights” in nations other than their own. Cities are seen as the key battlegrounds and the U.N. conference in Quito had a lot to say about how your city will be expected to embrace migrants of all types, from all regions of the world.
By now most Americans who follow world events are familiar with the U.N’s plan for global governance as envisioned by its “2030 Agenda for Sustainable Development,” approved by some 190 world leaders including President Obama and Pope Francis in September 2015.
This agenda includes 17 goals aimed at ending hunger, wiping out poverty and stamping out global income inequality by “transforming our world” through sweeping changes ostensibly aimed at freeing cross-border “labor mobility,” among other things.
Hillary Clinton, anointed by Obama as his successor, said in a speech to Wall Street bankers she envisions the U.S. as part of a single “hemispheric common market with free trade and open borders,” according to WikiLeaks data dumps.
In another bombshell revealed by WikiLeaks, Mrs. Clinton told Goldman Sachs bankers that Americans who want to limit immigration are “fundamentally un-American.” She has also called for a 550-percent increase in the resettlement of Syrian refugees in America – that’s 550 percent more than Obama’s vastly increased level of more than 12,000 resettled in one year.
In short, Hillary’s agenda for cities sounds an awful lot like the U.N.’s agenda for cities as laid out in the New Urban Agenda document approved this week by world leaders in Quito.
Clinton earlier this year announced her $135 billion “breaking every barrier” program to transform America’s cities.
In this plan, she makes 37 pledges promising everything from removal of blight to construction of affordable housing in areas that are currently out of the price range of refugees, immigrants, the chronically unemployed and under-employed. She intends to build on the “successes” of her husband and the Obama administration in using public-private partnerships to transform cities. Obama’s contribution in this area included his Affirmatively Furthering Fair Housing rule, which forces grant-receiving cities to infuse their low-crime suburban areas, deemed “too white,” with subsidized housing marketed to low-income renters.
This fits right in with the U.N.’s 2030 Agenda.
“She’s making a pre-announcement here that she’s going to follow the U.N. agenda,” Wood said. “She’s signaling to her fellow globalists that she’s 100 percent on board with their agenda.”
The problem that keeps globalists like Obama and Clinton up at night is how to implement the sweeping changes laid out in the U.N. 2030 Agenda last September at the global sustainability summit in New York.
That’s where Habitat III comes into play. It’s called the U.N. Conference on Housing and Sustainable Development or “Habitat III” for short. Its focus is on the world’s cities.
Largest U.N. conference ever
Habitat III was attended by a staggering 50,000 people including more than 200 mayors and another 140 city delegations
The sole purpose of this conference is to approve a 24-page document called the New Urban Agenda.
“The only purpose of the conference is to rubber stamp this document and elevate it and lift it up to the world,” said Wood. “And right now it looks like they are. Everybody. All the nations.”
In this document lies the globalists’ plans for cities. All cities. Big, small, even tiny cities. Every American who lives in a city will at some point see the fruits of the plan the U.N. has in store for the world, says Wood, an expert on global governance and the technocracy movement.
The Habitat conference convenes only once every 20 years but when it does, it leaves a trail of anti-capitalist, anti-liberty “global standards” in its wake, says Wood. These are the standards by which the U.N. wants each and every city in the world to be operated. They come packaged as “non-binding” and Congress never approves them.
Yet, somehow, the global standards coming out of the major U.N. conferences always seem to filter down to even the smallest American hamlet. How? Through federal grants. Any city that accepts federal grants will at some point be required to implement the practices that the U.N. has declared “sustainable.”
‘Inclusive’ by design, coercive by default
The buzzword in the New Urban Agenda is “inclusive” or “inclusivity.” This concept has a long history with global elites and technocrats.
The definition of “technocracy” as used by the original technocrats back 1938 was “the science of social engineering, the scientific operation of the entire social mechanism, to produce and distribute goods and services to the entire population.” That’s according to The Technocrat magazine.
“They use the word ‘entire’ twice in that definition so I’m really not surprised we see it showing up in these conferences today,” Wood said. “Their intent is to create a net that will catch 100 percent of the people.”
The word “inclusive” or “inclusivity” appear in the New Urban Agenda document no fewer than 36 times.
“There is no exclusion,” Wood says. “If you read the document, you’ll find for instance under item 6a, ‘transformative commitments,’ the statement starts out ‘leave no one behind.’”
That same phrase, leave no one behind, is in the U.N.’s 2030 Agenda.
“In fact just about everywhere you go now at the U.N. you’ll find this concept,” Wood said. “It’s a little disturbing.”
Wood says the U.N. is resurrecting an old concept that fizzled in the early days of the technocracy movement. Its time hadn’t arrived yet, back in the 1930s, but now things are different. The world is run by big data and the world is eager to embraced a set of globalized, one-world standards for everything, whether it be Common Core education standards, globalized police standards that Attorney General Loretta Lynch announced at the U.N. last fall in the form of the Strong Cities Network, or global standards for healthcare, ala Obamacare. You name it, the United Nations wants to standardize it.
The next big hurdle in the race to standardize the world is the issue of immigration.
Point 42 on page 7 of the New Urban Agenda talks about cities providing opportunities for dialogue, “paying particular attention to the potential contributions” of women and children, the elderly and disabled, “refugees and internally displaced persons and migrants, regardless of migration status, and without discrimination based on race, religion, ethnicity, or socio-economic status.”
Everyone is welcome
Wood notes that, in America, that would mean exactly what John Podesta, Clinton’s campaign manager, has already said — that anyone with a driver’s license should be allowed to vote.
“This is the way I read it,” he said. “It doesn’t matter if they’re legal or illegal, wanted or unwanted, jihadists or non-jihadists, sick or healthy. If they show up in your country, they must participate in the affairs of that country immediately, whatever country they find themselves in.”
The preamble to the New Urban Agenda says cities are the “key to tackling global challenges.”
“So these people are viewing cities as the key ingredient right now to implementing sustainable development, and they say this battle for sustainability will be won or lost in the cities.”
And the U.N. document goes on to state that this agenda is “the first step for operationalizing sustainable development in an integrated and coordinated way at the global, national, subnational, and local levels.”
In essence, it’s a roadmap to global governance where American cities will no longer get their direction from elected officials representing them on the city council, or even the state legislature, but the United Nations itself. The local councils will likely not even know that the rules they are following in order to qualify for federal grants are tied to United Nations’ standards for sustainability.
Cities committing to ‘a paradigm shift’
The document talks about cities committing to “a paradigm shift” in the way they “plan, develop and manage urban development.”
“It’s top to bottom,” Wood said. “They’re saying it’s going to be a top-down implementation. But for all the gains that sustainable development have made since 1992, there’s been a complaint that it hasn’t gone fast enough or far enough, and that it’s not inclusive enough, that some pockets have been left out. So, what they’re saying here is that this New Urban Agenda document is really, in their minds, the first step for operationalizing it. First step to making sustainable development completely operational. That’s huge.”
Wallace Henley, a journalist and former aide in the Nixon White House who went on to become a Christian pastor and who has written extensively on globalism, said the U.N. is making a full-on assault against the American system of government, which requires federalism, states’ rights and separation of powers.
“The U.N. is a glaring example of the inevitable course of bureaucracies. Like kudzu in Alabama, a tiny seed will inevitably spread until it controls the whole of a hillside,” Henley, author of “God and Churchhill,” told WND in an email.
And he, like Wood, sees Hillary Clinton in the thick of the battle, fighting on the side of the globalists, not America first.
“The leftist-progressive philosophy is the fertilizer. Agencies sprout and grow, and bring forth policy confabs like Habitat III. The conferences then produce white papers that ultimately become the source of policies,” he said. “It is a leftist-progressivist dream.”
“Sustainability” is a code word for regulatory authority, Henley said, and that is the suffocating vine that chokes out everything else.
“This meshes perfectly with the New Globalism and its dream of a world without borders. Anything can be done in the name of a ‘sustainable’ future, including the ‘humanitarian’ invasion of a sovereign state – but only if its leaders embrace the same left-progressive philosophy as the bureaucracies headquartered in New York. This makes a Hillary Clinton presidency even more foreboding,” he said.
And these “progressives” include many in the Republican Party who are now shilling for Clinton, such as House Speaker Paul Ryan and Arizona Sen. John McCain. Ryan, according to an article by Breitbart’s Julia Hahn, has been working hand in hand with the Clinton campaign for months.
“The true conservative seeks preservation of liberty-nurturing principles, and the sustenance of values that resist the control of the bureaucrats and guarantee freedom from a globalist hegemon in the form of the U.N.,” Henley said
Eric Voegelin’s 1975 book, “From Enlightenment to Revolution,” describes with amazing prescience the “line of progress” according to the revolutionaries who drive what Henley calls the New Globalism, from the local to the global, from the individual to the mass of humanity, from nation-states to a concentrated global power.
“This is the big picture of which Habitat III and its New Urban Agenda is a part.”
The future is urban and nowhere is that more true than in Bangladesh. If current rates of urbanisation continue, the country’s urban population will double by 2035. Around the Bay of Bengal, a mega city would join Dhaka to Chittagong, creating one of the world’s largest conglomerations. Whether that process produces a congested toxic unlivable mess of concrete and steel, or whether it becomes a thriving, connected, wonderful city to live in, is almost entirely down to the political and policy choices we make.
This week a critical meeting in Quito, Ecuador, will look at those critical political and policy choices. The Habitat III conference to adopt a “New Urban Agenda” builds on the Habitat Agenda of Istanbul in 1996 (Habitat II).The new agenda is intended to reinvigorate the global commitment to sustainable urbanisation. The conference is expected to result in a concise, focused, forward-looking and action-oriented outcome document on making cities and human settlements equitable, prosperous, sustainable, just, equal and safe until 2030. By the middle of the century, a majority of the world’s citizens —four out of five people — could be living in towns or cities. Indeed, in the time since the Habitat Agenda was adopted, the world has become majority urban, lending extra urgency to the New Urban Agenda.
Habitat III is one of the first major global conferences to be held after the adoption of two key agreements, last year. Agenda 2030, a new development plan for the world; and a new Climate Change agreement adopted in Paris. It offers a unique opportunity to discuss the important challenge of how cities, towns and villages are planned and managed in a sustainable manner, to meet the new global agenda and climate change goals.
The New Urban Agenda, agreed upon at Habitat III in Quito, will guide the efforts around urbanisation of a wide range of actors — nation states, city and regional leaders, international development funders, UN programmes and civil society — for the next 20 years. Inevitably, this agenda will also lay the groundwork for policies and approaches that will have long lasting impact.
HABITAT I and II
Forty years later, after both Habitat I and II, there is wide consensus that towns’ and cities’ structure, form, and functionality need to change as societies change. Especially, slums and related informal settlements that have become a spontaneous form of urbanisation, consisting of a series of survival strategies by the urban poor, most borne out of poverty and exclusion.
Habitat III represents an opportunity to make concrete the ideals of Habitat II in designing policies, planning urban spaces for all, and providing affordable urban services and utilities through adopting a ‘New Urban Agenda’ this October.
Towards the New Urban Agenda
The core issues of the Habitat II Agenda — adequate housing and sustainable human settlements — remain on the table, as the number of people worldwide living in urban slums continues to grow. There is also an increasing recognition that cities have morphed into mega-regions, urban corridors and city-regions whose economic, social and political geographies defy traditional conceptions of the “city”.
Impact of the agenda
The Agenda will seek to create a mutually reinforcing relationship between urbanisation and development. Several core ideas form the ideological underpinnings of the New Urban Agenda. Democratic development and respect for human rights feature prominently in the draft agreements, as does the relationship between the environment and urbanisation.
The new agenda also places importance on establishing a global monitoring mechanism to track progress on meeting commitments. As an “agenda”, it will provide guidance to nation states, city and regional authorities, civil society, foundations, NGOs, academic researchers and UN agencies. However, this guidance is not binding. This arrangement is different from, for example, the December 2015 climate negotiations in Paris, which resulted in a legally binding agreement.
Let’s take a practical example. The new urban agenda calls for mass transit systems and to cut back our dependence on vehicles. In recent years in Dhaka, our response to traffic congestion has been to build flyovers. This has been compared to an overweight person addressing the need to lose weight by loosening their belt. You feel better at first, but it doesn’t last. The underlying issues are not addressed. The government recently broke ground on metro rail link between Uttara and the airport. With policy choices like this, we can move Dhaka to the fore of the New Urban Agenda.
The New Urban Agenda and Bangladesh
A broad range of actors in Bangladesh were involved in contributing to developing the New Urban Agenda. The Government of Bangladesh, through the Ministry of Housing and Public Works, is engaged in both the Habitat III conference and related academic discussions through various national and international forums.
It is estimated that 60 percent of Bangladesh’s GDP is produced in urban areas. Having laid out an urban vision in the 7th Five-year Plan as “compact, networked, resilient, competitive, and inclusive and smart,” Bangladesh still has considerable work ahead to meet international goals set by the New Urban Agenda. Certainly, in Bangladesh the stakes are high, since it is the third most urbanised nation in South Asia.
The ‘new urban agenda’ will clearly influence policymakers as they consider cities, urbanisation and sustainable development, and set priorities at the national levels. With the global perspectives on managing urbanisation for making cities and human settlements equitable, prosperous, sustainable, just, equal and safe, Bangladesh can finalise the long awaited national urban sector policy. And it can begin drafting a ‘New Urban Agenda’ to tackle the country’s rapid urbanisation in order to maximise the benefits of urbanisation for the people of Bangladesh.
The writers are Acting Country Director of UNDP Bangladesh and Urban Programme Specialist of UNDP Bangladesh.
This article is part of the United Nations University’s Habitat III series featuring research and commentary related to the UN Conference on Housing and Sustainable Urban Development, 17–20 October 2016 in Quito, Ecuador.
For the first time in history, a majority of the global population lives in cities. The trend toward urbanisation is continuing, and by mid-century city dwellers are expected to account for two-thirds of the world’s people. Migration accounts for a significant, yet often controversial, part of this urban development. Twenty years ago at the Habitat II conference in Istanbul, urban migration was framed as a problem to be tackled. The focus at the time was on addressing the root causes of rural-to-urban migration and finding ways to minimise population movement to cities. As such, Habitat II did not go far enough to emphasise the positive contributions migrants make to urban life.
The legacy of this framing of urban migration has had lasting impacts that have reinforced the socio-economic and spatial marginalisation of migrants (and subsequent generations) in a number of cities, from Paris to Delhi. In the preparations for Habitat III, to be held in Quito from 17–20 October 2016, an issue paper on migrants and refugees points out that “the generic urbanisation model” over the past decades has “fostered segregation over integration”.
The adoption of the New Urban Agenda in Quito will bring in a new narrative on urban migration that centres on promoting migrants’ inclusion in cities and upholding their rights. States, local authorities, intergovernmental and civil society organisations can use this opportunity to collectively develop urban policies that reflect this narrative. More than half of the world’s population now lives in urban areas, and continuing migration is central to urbanisation processes — both in terms of internal migration (movement within the same country) and of international migration (be it voluntary or forced, bearing in mind that the line between the two is increasingly blurred).
“Migration is clearly an urban phenomenon, and especially so in this time of unprecedented global displacement.”
As the above issue paper notes, some 60% of the world’s refugees (and 80% of internally displaced persons) now live in urban areas rather than in camps. Cities, large and small, are where migrants seek to build their livelihoods, futures, and networks, pursue opportunities, and realise their aspirations.
Migration is thus very clearly an urban phenomenon, and especially so in this time of unprecedented global displacement. Even as states reinforce their borders, with security, fences, and walls, cities are opening themselves up to new arrivals. This is why the New Urban Agenda is so relevant to the global debates that are taking place about migration.
Where states are failing to honour the rights and dignity of migrants and refugees, cities in many parts of the world are acting in concrete ways to receive them, provide them with basic services, and find ways to include them in the everyday fabric of the city (including those without documents). This effort offers potential to transform the discourse and politics of migration by recognising the rich social, cultural, and economic contributions of migrants to urban life, while allowing us to imagine the possibilities for migrants to feel a sense of belonging at an urban level.
In New York City, for example, all migrants — regardless of their status — are eligible for an IDNYC (identification card) giving them access to many services in the city. The municipality of Sao Paulo, meanwhile, has created a municipal migration policy developed in accordance with the principles of human rights and non-discrimination, and drawing upon the voices of migrants through participative consultations. And cities in Germany are making novel uses of urban space and infrastructure to house recent arrivals of migrants and refugees, while volunteer-led projects among urban citizenshave emerged over the past year to foster a culture of welcome that, if cultivated in the long term, can lead to sustained forms of inclusion.
“We must also be aware that not all cities are powerful actors with the freedom to make and implement decisions.”
But lest we romanticise this ideal of welcoming cities, it is important to acknowledge that significant challenges remain for migrants in a number of cities: precarious work; language barriers; difficulties in accessing health, education, and justice; poor environmental health conditions and insecure housing; and discrimination.
We must also be aware that not all cities are powerful actors with the freedom to make and implement decisions. Some municipal governments remain poorly resourced and depend upon restrictive state-level policy directives — the experiences of urban refugees in Bangkok who live in a state of limbo and invisibility is a case in point. This is a reminder of the importance of multi-level governance that connects the grassroots and local levels to the national, regional, and global levels. If migration is well-managed throughout all levels, migrants are more likely to have the resources to sustain their livelihoods and the opportunities to make valuable, enduring, and creative contributions.
The New Urban Agenda is grounded in the Universal Declaration of Human Rights, and the need to take a human rights-based approach to migration has thus been recognised, far more than in the past. The draft Agenda includes commitments to support refugees, internally displaced persons, and migrants regardless of their migration status. Yet if the New Urban Agenda is based on a vision of “cities for all”, we need further clarity as to how these lofty statements will translate into practical and implementable projects and policies for social and spatial inclusion that take migration and displacement into consideration.
On this point, the New Urban Agenda remains vague. The points raised during the urban dialogues and thematic consultations in the run-up to Habitat III, which are intended to gather input from diverse stakeholders and citizens in the shaping of the Agenda, call on local and national authorities to include migration as a transversal feature of urban planning, and to promote the civic participation of migrants across urban spaces and institutions.
Indeed, we should see Habitat III as the starting point for developing and implementing inclusive policies and the sharing of good practices on these issues. In this particular moment of time — when the world’s attention is fixed on migration — it is vital that we shape our cities to be inclusive, convivial, and progressive places that embrace cultural pluralism and diversity as a hallmark of sustainable urban development.
Story 1: Name That Malady — Parkinson’s Disease? Multiple sclerosis (MS)? A.L.S. ( Amyotrophic Lateral Sclerosis) or sometimes called Lou Gehrig’s disease? Power Palpitations? — Clue: Blue Sung Glasses! — Videos
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.