Mortality in patients with multiple sclerosis

Clinical characteristics of middle-aged and older patients with MS treated with interferon beta-1b: post-hoc analysis of a 2-year, prospective, international, observational study

Background

Despite trends towards the increased age of patients living with multiple sclerosis (MS), little is known about the response of older adults with MS to disease-modifying therapies (DMTs). Thus, a post-hoc analysis was undertaken using data from a 2-year, international, non-interventional, prospective cohort study (NCT00787657; BEACON: BEtaferon prospective study on Adherence, COping and Nurse support) of patients above the age of 40 years with MS and starting interferon beta-1b (IFNB-1b) treatment within 6 months before study entry.

Methods

Middle-aged and older patients with MS were divided into two sub-groups: 41–50 years and > 50 years. Treatment with IFNB-1b started within 6 months before study entry. Patients were followed-up for a 2-year observation period. Assessments included disease history and course, annualised relapse rate (ARR), Expanded Disability Scale Score (EDSS), treatment adherence, Hospital Anxiety and Depression Scale (HADS), and adverse events (AE).

Results

At baseline, the intention-to-treat (ITT) population (n = 481) aged 41–50 years (n = 327) and > 50 years (n = 154), had mean (standard deviation [SD]) ages of 45.1 (2.8) and 56.2 (4.2) years, maximum age of 72 years, and duration of MS since onset of symptoms of 3.9 (5.2) and 5.9 (7.1) years, respectively. At baseline, the proportion of patients with relapsing–remitting MS (RRMS) was 96.3 and 94.9 %, and secondary progressive MS (SPMS) was 3.7 and 5.1 %, in the 41–50 and > 50 years sub-groups, respectively. The ARR in the 2 years before study start was 0.93 (0.48) and 0.86 (0.54) for the 41–50 and > 50 years groups, respectively, and decreased since study start to 0.20 (1.09) and 0.07 (0.37), respectively. The percentage of patients with anxiety and depression, as measured by HADS, were stable over the study period. Polypharmacy (five or more medications) was seen in 32.3 and 41.2 % of patients aged 41–50 and > 50 years. No unexpected AEs were reported.

Conclusions

This study provides observational data on patients between 40 and 72 years of age, suggesting that IFNB-1b can be an effective and well-tolerated treatment option in MS patients of advanced age.

Trial registration

ClinicalTrials.gov, NCT00787657.

Study protocol on advance care planning in multiple sclerosis (ConCure-SM): intervention construction and multicentre feasibility trial

INTRODUCTION

Multiple sclerosis (MS) is the most common cause of progressive neurological disability in young adults. The use of advance care planning (ACP) for people with progressive MS (pwPMS) remains limited. The ConCure-SM project aims to assess the effectiveness of a structured ACP intervention for pwPMS. The intervention consists of a training programme on ACP for healthcare professionals caring for pwPMS, and a booklet to be used during the ACP conversation. Herein, we describe the first two project phases.

METHODS

In phase 1 we translated and adapted, to the Italian legislation and MS context, the ACP booklet of the National ACP Programme for New Zealand. Acceptability, comprehensibility and usefulness of the booklet were assessed via 13 personal cognitive interviews with pwPMS and significant others (SOs), and one health professional focus group. Based on these findings, we will revise the booklet. In phase 2 we will conduct a single-arm pilot/feasibility trial with nested qualitative study. Participants will be 40 pwPMS, their SOs, health professionals from six MS and rehabilitation centres in Italy. In the 6 months following the ACP conversation, we will assess completion of an advance care plan document (primary outcome), as well as safety of the intervention. Secondary outcomes will be a range of measures to capture the full process of ACP; patient-carer congruence in treatment preferences; quality of patient-clinician communication and caregiver burden. A qualitative process evaluation will help understand the factors likely to influence future implementation and scalability of the intervention.

ETHICS AND DISSEMINATION

The project is coleaded by a neurologist and a bioethicist. Phase 1 has received ethical approvals from each participating centre, while phase 2 will be submitted to the centres in May 2021. Findings from both phases will be disseminated widely through peer-reviewed publications, conferences and workshops.

TRIAL REGISTRATION NUMBER

ISRCTN48527663; Pre-results.

Identification of immune-associated gene signature and immune cell infiltration related to overall survival in progressive multiple sclerosis

BACKGROUND

Delayed diagnosis and noneffective treatment contribute to the shorter life expectancy in patients with progressive multiple sclerosis (PMS). Studies demonstrate the key role of autoimmunity in PMS, but the prognostic value of immune-associated factors remains unknown. Thus, this study aimed to develop an immune-associated gene (IAG) signature related to overall survival (OS) and conduct an immune cell infiltration analysis using PMS data.

METHODS

The differentially expressed IAGs were identified based on gene expression profiles (from the Gene Expression Omnibus database) and IAGs (from the ImmPort database). Univariate and least absolute shrinkage and selection operator (LASSO)-penalized Cox regression analyses were used to develop the IAG signature related to OS. Kaplan-Meier analyses were conducted, and receiver operating characteristic (ROC) curves were generated to assess the performance. Additionally, the differential distribution of immune cells was identified by Wilcoxon rank-sum tests and correlations with IAGs were analyzed using Spearman correlation analyses. Moreover, univariate and multivariate Cox regression analyses were used to identify the independent prognostic factors to develop a prognostic nomogram.

RESULTS

The training group, consisting of 57 PMS lesions and 52 control tissues, was obtained through batch normalization to remove the inter-batch difference. A total of 206 differentially expressed IAGs were identified, and 38 of them were associated with OS. Thereafter, a 4-IAG signature was constructed to calculate the risk score and thus classify PMS patients into high- and low-risk groups according to mean risk score. Patients in the high-risk group had a lower survival time than those in the low-risk group. The Kaplan-Meier plots and ROC curves demonstrated a good performance in both the training and internal validation groups. Additionally, five differentially abundant immune cell types were identified and their relationships with IAGs were analyzed. Finally, risk score, cortical region, and naive B cells were identified as independent prognostic factors, and a nomogram incorporating these factors was developed to predict the OS in PMS.

CONCLUSION

The novel IAG signature may be a reliable tool for assisting neurologists in predicting the OS for PMS patients in clinical settings. These findings may facilitate personalized treatment and provide insights into the complex mechanism of PMS.

Death Anxiety and Attitudes towards Death in Patients with Multiple Sclerosis: An Exploratory Study

Background: Death and the anxiety of it becomes more apparent when confronted with a chronic disease. Even though multiple sclerosis (MS) is a treatable condition today, it is still accompanied by a multitude of impairments, which in turn may intensify of death anxiety. Objective: The aim of this study is to explore the relationship between depression, anxiety and death anxiety in individuals with MS. Methods: Fifty-six MS patients were recruited at the Department of Neurology of the University Clinic in Basel. Death anxiety was assessed using the Bochumer Questionnaire on attitude to death and death anxiety 2.0 (BOFRETTA 2.0). Results: Scores of death anxiety towards it in MS patients were low. Only disability (EDSS) was moderately correlated with death anxiety. Depression in MS was significantly correlated with fatigue and disability, but not with the BOFRETTA 2.0. Conclusion: Scores of death anxiety and the attitude towards death are low in this MS cohort. It was shown that both psychopathological and neurological deficits impact the subject of death with respect to multiple sclerosis.

Multiple sclerosis incidence and prevalence in Poland: Data from administrative health claims

BACKGROUND

The detailed data concerning multiple sclerosis (MS) epidemiology in Poland are based on studies from few and less populated provinces. Therefore, we evaluated MS incidence and prevalence in Poland using electronic administrative health claims (AHCs) from the National Health Fund.

METHODS

We retrospectively analyzed the AHC financial database collected from 2009 to 2019, encompassing all patients using public health resources. Three different algorithms for identification of MS cases were used: based on studies performed in German population (type 1), tested in the United States (type 2), and one created for the purpose of this study (type 3) that required at least 3 AHCs since 2009 with G35 ICD-10 diagnosis in outpatient specialist care, during hospitalization, and/or at rehabilitation service in any combination within maximally 3 years between the first and the last AHC, and provided that at least one AHC was either in neurological outpatient care or during hospitalization at a neurological ward or prescription of disease-modifying therapy. The American algorithm (type 2) required 3 AHCs within the analyzed year, while the German algorithm (type 1) required only one AHC in the analyzed year.

RESULTS

According to the type 3 algorithm, age-adjusted MS incidence and prevalence in 2019 was 6.6 and 131.2 / 100,000 inhabitants, respectively. From 2014 to 2019, the significant trend in increasing prevalence and decreasing incidence of MS was observed (p<0.001). Median age of prevalent MS patients was 50 years (interquartile range, IQR 39-61) whereas median age of incident MS cases was 37 years (IQR 28-48). Female-to-male ratio in MS patients was 2.4. According to the type 1 algorithm, age-adjusted MS incidence and prevalence in 2019 was 11.6 and 244.9 / 100,000 inhabitants, respectively. Use of the type 2 algorithm resulted in estimated age-adjusted MS incidence and prevalence values in 2019 of 6.2 and 120.1 / 100,000 inhabitants, respectively.

CONCLUSIONS

Multiple sclerosis incidence and prevalence in Poland are higher than previously reported and similar to the numbers shown for central European countries.

Exploring the Cost Effectiveness of Shared Decision Making for Choosing between Disease-Modifying Drugs for Relapsing-Remitting Multiple Sclerosis in the Netherlands: A State Transition Model

Background

Up to 31% of patients with relapsing-remitting multiple sclerosis (RRMS) discontinue treatment with disease-modifying drug (DMD) within the first year, and of the patients who do continue, about 40% are nonadherent. Shared decision making may decrease nonadherence and discontinuation rates, but evidence in the context of RRMS is limited. Shared decision making may, however, come at additional costs. This study aimed to explore the potential cost-effectiveness of shared decision making for RRMS in comparison with usual care, from a (limited) societal perspective over a lifetime.

Methods

An exploratory economic evaluation was conducted by adapting a previously developed state transition model that evaluates the cost-effectiveness of a range of DMDs for RRMS in comparison with the best supportive care. Three potential effects of shared decision making were explored: 1) a change in the initial DMD chosen, 2) a decrease in the patient’s discontinuation in using the DMD, and 3) an increase in adherence to the DMD. One-way and probabilistic sensitivity analyses of a scenario that combined the 3 effects were conducted.

Results

Each effect separately and the 3 effects combined resulted in higher quality-adjusted life years (QALYs) and costs due to the increased utilization of DMD. A decrease in discontinuation of DMDs influenced the incremental cost-effectiveness ratio (ICER) most. The combined scenario resulted in an ICER of €17,875 per QALY gained. The ICER was sensitive to changes in several parameters.

Conclusion

This study suggests that shared decision making for DMDs could potentially be cost-effective, especially if shared decision making would help to decrease treatment discontinuation. Our results, however, may depend on the assumed effects on treatment choice, persistence, and adherence, which are actually largely unknown.

A qualitative meta-synthesis of evidence (meta-ethnography) exploring the personal experiences of gastrostomy tube in neurodegenerative diseases: a case of motor neurone disease

PURPOSE

The lived experiences of a gastrostomy tube (GT) in adults with neurodegenerative diseases (NDDs) are not well understood. The aim of this qualitative meta-synthesis was to review and synthesise the available evidence to inform clinical practice and identify research gaps.

METHODS

Meta-ethnographic synthesis of qualitative studies was conducted with systematic searching of eight databases from inception to March 2021. Qualitative studies reporting personal experiences of GTs in adults with NDDs were identified. New theories were developed during translation of concepts from each study and combined as a "line-of-argument" synthesis. Patient and public involvement was incorporated as two of the authors are living with an NDD and a GT.

RESULTS AND CONCLUSIONS

Of 2863 unique records identified, only nine fulfilled the review criteria. All studies recruited participants with motor neurone disease (MND); no other NDDs were represented. Two main themes emerged: decision making and living with GT. Decision making was the predominant theme and data regarding living with GT were sparse. There is limited research on the lived experience of a GT in adults with NDDs. The lived experience of GT in MND is complex and individualised. Future research is indicated to inform clinical practice.Implications for rehabilitationEvidence related to the lived experiences of gastrostomy tube (GT) in neurodegenerative diseases (NDDs) is lacking especially in relation to the time after GT insertion.Decision making in relation to GT is a complex and individualised psychological process for some people, while others perceive no decisional conflict.Support from healthcare professionals is crucial during the decision-making time and should not cease after GT insertion.Support from healthcare professionals can help resolve any clinical complications and also incorporate GT into everyday routines.Healthcare professionals should be aware that their views on the benefits and problems related to GT may differ to those of individuals with a NDD.

Effects of Age and Disease Duration on Excess Mortality in Patients With Multiple Sclerosis From a French Nationwide Cohort

OBJECTIVE

To determine the effects of current age and disease duration on excess mortality in multiple sclerosis (MS), we describe the dynamics of excess death rates over these 2 time scales and study the effect of age at MS clinical onset on these dynamics, separately in each initial phenotype.

METHODS

We used data from 18 French MS expert centers participating in the Observatoire Français de la Sclérose en Plaques. Patients with MS living in metropolitan France and having a clinical onset between 1960 and 2014 were included. Vital status was updated on January 1, 2016. For each MS phenotype separately (relapsing onset [RMS] or primary progressive [PPMS]), we used an innovative statistical method to model the logarithm of excess death rates by a multidimensional penalized spline of age and disease duration.

RESULTS

Among 37,524 patients (71% women, mean age at MS onset ± SD 33.0 ± 10.6 years), 2,883 (7.7%) deaths were observed and 7.8% of patients were lost to follow-up. For patients with RMS, there was no excess mortality during the first 10 years after disease onset; afterwards, whatever the age at onset, excess death rates increased with current age. From current age 70, the excess death rate values converged and became identical whatever the age at disease onset, which means that disease duration had no more effect. Excess death rates were higher in men, with an excess hazard ratio of 1.46 (95% confidence interval 1.25-1.70). In contrast, in patients with PPMS, excess death rates rapidly increased from disease onset, and were associated with age at onset, but not with sex.

CONCLUSIONS

In RMS, current age has a stronger effect on MS mortality than disease duration, while their respective effects are not clear in PPMS.

Citicoline: A Candidate for Adjunct Treatment of Multiple Sclerosis

In remitting–relapsing multiple sclerosis (RR-MS), relapses are driven by autoreactive immune cells that enter the brain and spinal cord and damage myelin sheaths of axons in white and grey matter, whereas during remissions myelin is repaired by activated oligodendroglial cells. Disease-modifying therapies (DMTs) may either retard/attenuate myelin damage or promote/enhance/speed up myelin repair. Almost all currently approved DMTs inhibit myelin damage and are considerably toxic. Enhancement of myelin repair is considered an unmet medical need of MS patients. Citicoline, known for many years as a nootropic and neuroprotective drug and recently pronounced food supplement, has been found to be significantly efficacious in two complementary rodent models of MS, experimental autoimmune encephalomyelitis (EAE) and cuprizone-induced myelin toxicity. Moreover, citicoline treatment improves visual evoked potentials (VEPs) in glaucoma patients, which is relevant because VEP monitoring is frequently used as an indicator of remyelination in MS. Although over-the-counter availability of citicoline may impede its formal translation to the clinic of MS, evaluation of its efficacy for supporting remyelination in this disease is strongly indicated.

The nature of genetic and environmental susceptibility to multiple sclerosis

OBJECTIVE

To understand the nature of genetic and environmental susceptibility to multiple sclerosis (MS) and, by extension, susceptibility to other complex genetic diseases.

BACKGROUND

Certain basic epidemiological parameters of MS (e.g., population-prevalence of MS, recurrence-risks for MS in siblings and twins, proportion of women among MS patients, and the time-dependent changes in the sex-ratio) are well-established. In addition, more than 233 genetic-loci have now been identified as being unequivocally MS-associated, including 32 loci within the major histocompatibility complex (MHC), and one locus on the X chromosome. Despite this recent explosion in genetic associations, however, the association of MS with the HLA-DRB1*15:01~HLA-DQB1*06:02~a1 (H+) haplotype has been known for decades.

DESIGN/METHODS

We define the "genetically-susceptible" subset (G) to include everyone with any non-zero life-time chance of developing MS. Individuals who have no chance of developing MS, regardless of their environmental experiences, belong to the mutually exclusive "non-susceptible" subset (G-). Using these well-established epidemiological parameters, we analyze, mathematically, the implications that these observations have regarding the genetic-susceptibility to MS. In addition, we use the sex-ratio change (observed over a 35-year interval in Canada), to derive the relationship between MS-probability and an increasing likelihood of a sufficient environmental exposure.

RESULTS

We demonstrate that genetic-susceptibitly is confined to less than 7.3% of populations throughout Europe and North America. Consequently, more than 92.7% of individuals in these populations have no chance whatsoever of developing MS, regardless of their environmental experiences. Even among carriers of the HLA-DRB1*15:01~HLA-DQB1*06:02~a1 haplotype, far fewer than 32% can possibly be members the (G) subset. Also, despite the current preponderance of women among MS patients, women are less likely to be in the susceptible (G) subset and have a higher environmental threshold for developing MS compared to men. Nevertheless, the penetrance of MS in susceptible women is considerably greater than it is in men. Moreover, the response-curves for MS-probability in susceptible individuals increases with an increasing likelihood of a sufficient environmental exposure, especially among women. However, these environmental response-curves plateau at under 50% for women and at a significantly lower level for men.

CONCLUSIONS

The pathogenesis of MS requires both a genetic predisposition and a suitable environmental exposure. Nevertheless, genetic-susceptibility is rare in the population (< 7.3%) and requires specific combinations of non-additive genetic risk-factors. For example, only a minority of carriers of the HLA-DRB1*15:01~HLA-DQB1*06:02~a1 haplotype are even in the (G) subset and, thus, genetic-susceptibility to MS in these carriers must result from the combined effect this haplotype together with the effects of certain other (as yet, unidentified) genetic factors. By itself, this haplotype poses no MS-risk. By contrast, a sufficient environmental exposure (however many events are involved, whenever these events need to act, and whatever these events might be) is common, currently occurring in, at least, 76% of susceptible individuals. In addition, the fact that environmental response-curves plateau well below 50% (especially in men), indicates that disease pathogenesis is partly stochastic. By extension, other diseases, for which monozygotic-twin recurrence-risks greatly exceed the disease-prevalence (e.g., rheumatoid arthritis, diabetes, and celiac disease), must have a similar genetic basis.

A current understanding of multiple sclerosis

Multiple sclerosis (MS) is an autoimmune inflammatory disorder that affects more than 900,000 Americans. Patient presentations vary widely; therefore, symptom recognition and an understanding of diagnostic criteria are critical in providing timely patient referrals. This article describes recognition and diagnosis of MS using the updated 2017 criteria, and offers an overview of epidemiology, prognosis, and treatment strategies.

Living with severe multiple sclerosis: Cost-effectiveness of a palliative care intervention and cost of illness study

BACKGROUND

Little is known about the economic consequences of living with severe multiple sclerosis (SMS).

AIMS

To assess the cost-effectiveness of a home-based palliative approach (HPA) for people with SMS (pwSMS). To assess direct healthcare costs in this population.

METHODS

PwSMS from three Italian centers received (2:1 ratio) HPA or usual care over six months. Direct healthcare costs were collected on a monthly basis. Incremental cost-effectiveness was gauged from a national healthcare system (NHS) and a personal perspective, considering the Palliative Outcome Scale-Symptoms-MS (POS-S-MS) and the EuroQol five-dimension descriptive system quality-adjusted life years (EQ-5D-3L QALYs), both completed at baseline, after three and six months.

RESULTS

Of 78 randomized pwSMS, 76 (50 HPA, 26 usual care) were analyzed. Mean QALYs were close to zero, and the mean group difference was -0.006 (95% CI -0.057 to 0.044). The mean baseline-adjusted cost difference was € -394 (95% confidence interval, CI -3,532 to 2,743). POS-S-MS cost-effectiveness showed a slight mean reduction of symptom burden (-1.9; 95% CI -1.1 to 5.0) with unchanged costs. Mean direct costs due to MS were € 23,195/year, almost equally distributed between NHS (€ 13,108) and pwSMS (€ 10,087). Personal care, medications and home rehabilitation accounted for 80% of total expenditures. Most personal care costs were covered by pwSMS, and these costs were 3/4 of pwSMS out-of-pocket.

CONCLUSIONS

The slight reduction of symptom burden produced by the HPA was not associated with an increase in costs. NHS and pwSMS almost equally sustained these costs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN73082124.

Satisfaction of Patients With Severe Multiple Sclerosis and Their Family Members With Palliative Care: Interventional Study

BACKGROUND

Patients with MS should be provided palliative care, which could help them manage symptoms more efficiently and could solve some psychosocial problems. Evaluating the satisfaction with provided care may be one of the factors of the quality of care evaluation.

AIM

The aim of this controlled intervention study was to determine the factors affecting one's satisfaction with care in patients in advanced stages of MS and their caregivers. Furthermore, the aim was to study the difference in the satisfaction of patients and family members with the provided specialized palliative care, as opposed to the standard care.

METHODS

The sample consisted of 103 patients with MS who were randomized to either a palliative care intervention or the control group. Family members of each patient were invited in the study, and 97 caregivers agreed to participe. The patients in the intervention group were provided with neuropalliative care in the form of consultations with a multidisciplinary palliative team. A modified questionnaire, CANHELP Lite, was used to collect data. Patients and family members completed the questionnaire 3 months after the intervention.

RESULTS

The patients and caregivers in the intervention group expressed significantly greater satisfaction in all analyzed areas (p = 0.000-0.002). The provided intervention predicted the satisfaction in the domains of a relationship with the doctor, disease management, and decision-making/communication. Another important predictor of the satisfaction in all domains was the functional state of the patient.

CONCLUSION

Targeted consultations resulted in the greater satisfaction of patients with MS and their caregivers with the provided care.

Detection of Active Plaques in Multiple Sclerosis using 3 and 12 Directional Diffusion-weighted Imaging: Comparison with Gadolinium-enhanced MR Imaging

Background

Multiple Sclerosis (MS), distinguished by aggravating the function of central nervous system because of inflammatory demyelination. The most sensitive method for MS diagnosis is Magnetic resonance imaging (MRI). To distinguish inactive and active MS lesions, contrast-enhanced T1-weighted imaging (CE T1WI) is being used as a gold standard. There are some contraindications in gadolinium based contrast agents (GBCAs) usage. Moreover, diffusion-weighted imaging (DWI) can discover diffusion changes involved inflammatory lesions.

Objective

The current research aims at investigating if typical DWI (3 directional) and 12 directional DWI could be a substitute for CE T1WI in order to show active lesions of MS.

Material and Methods

In this cross-sectional study, 138 patients with CNS symptoms were examined. For all patients, along with CE T1WI, 3 & 12 directional DWI were performed. Intraclass correlation coefficient (ICC), receiver operating characteristic (ROC), the sensitivity versus specificity plot and the area under the curve (AUC) were calculated.

Results

There was a contrast enhancement in CE T1WI for 114 patients (82.6%); in addition, hyper-intense lesions on DWI 3 and DWI 12 were shown in 107 (77.5%) and 117 patients (84.7%) in order. Sensitivity, specificity and AUC were 94.7%, 62.5% and 84% for DWI 12. Moreover, the results were 86%, 62.5 and 79% for the sensitivity, specificity and AUC for DWI 3 respectively.

Conclusion

In spite of lower sensitivity of 12 directional DWI compared to CE T1WI, it could be used as a diagnostic sequence in differentiating enhanced lesions from non-enhanced ones when CE-MRI is a worry.

The Gut-Brain Axis: How Microbiota and Host Inflammasome Influence Brain Physiology and Pathology

The human microbiota has a fundamental role in host physiology and pathology. Gut microbial alteration, also known as dysbiosis, is a condition associated not only with gastrointestinal disorders but also with diseases affecting other distal organs. Recently it became evident that the intestinal bacteria can affect the central nervous system (CNS) physiology and inflammation. The nervous system and the gastrointestinal tract are communicating through a bidirectional network of signaling pathways called the gut-brain axis, which consists of multiple connections, including the vagus nerve, the immune system, and bacterial metabolites and products. During dysbiosis, these pathways are dysregulated and associated with altered permeability of the blood-brain barrier (BBB) and neuroinflammation. However, numerous mechanisms behind the impact of the gut microbiota in neuro-development and -pathogenesis remain poorly understood. There are several immune pathways involved in CNS homeostasis and inflammation. Among those, the inflammasome pathway has been linked to neuroinflammatory conditions such as multiple sclerosis, Alzheimer's and Parkinson's diseases, but also anxiety and depressive-like disorders. The inflammasome complex assembles upon cell activation due to exposure to microbes, danger signals, or stress and lead to the production of pro-inflammatory cytokines (interleukin-1β and interleukin-18) and to pyroptosis. Evidences suggest that there is a reciprocal influence of microbiota and inflammasome activation in the brain. However, how this influence is precisely working is yet to be discovered. Herein, we discuss the status of the knowledge and the open questions in the field focusing on the function of intestinal microbial metabolites or products on CNS cells during healthy and inflammatory conditions, such as multiple sclerosis, Alzheimer's and Parkinson's diseases, and also neuropsychiatric disorders. In particular, we focus on the innate inflammasome pathway as immune mechanism that can be involved in several of these conditions, upon exposure to certain microbes.

Early changes in IL-21, IL-22, CCL2, and CCL4 serum cytokines after outpatient autologous transplantation for multiple sclerosis: A proof of concept study

Changes in serum cytokines after autologous hematopoietic stem cell transplantation (AHSCT) in multiple sclerosis (MS) patients were documented. Thirty-six consecutive MS patients who had their Expanded Disability Status Scale (EDSS) scored before AHSCT were prospectively enrolled. Cyclophosphamide (Cy) was infused at 200 mg/kg in two administrations given 10 days apart: the first dose for mobilization, the second as the conditioning regimen. Patients were mobilized with 10 µg/kg/day subcutaneous G-CSF. Serum was collected 14 days before and 14 after AHSCT. IL-6, IL-9, IL-10, IL 17-A, IL-21, IL-22, IL-23, TNF-A, CCL2, CCL3, and CCL4 were measured by magnetic bead-based immunoassay. t Test and Wilcoxon test were used to compare cytokine levels before and after AHSCT. There were 28 women and 8 men with a median age of 46 (15-62) years, median duration of MS was 9.5 (1-32) years, and EDSS score was 5.7 (1.5-8.0). Patients had a decrement of pro-inflammatory IL-21 and IL-22 (p = .003 and p = .028) and an increment of anti-inflammatory CCL2 and CCL4 (p < .001 and p = .039) after AHSCT. Decrease of IL-21 and IL-22 coupled with an increment of CCL2 and CCL4 could reflect the immunomodulatory effect of auto-HSCT and be an early indicator of its efficacy.

Second-generation immunotherapeutics in multiple sclerosis: can we discard their precursors?

Options for disease-modifying therapies in multiple sclerosis have increased over the past two decades. Among these innovations are interferon-β, glatiramer acetate, fumaric acid and dihydroorotate dehydrogenase inhibitors, an antibody targeting the migration of immune cells, a compound that traps immune cells in lymphoid organs by sphingosine 1-phosphate receptor (S1PR) modulation and immune-reconstitution therapies. Second-generation drugs such as pegylated interferon-β, advanced CD20 depleting antibodies, more-specific S1PR modulators and new formulations have been developed to achieve higher efficacy while exhibiting fewer side effects. In this review, we address the shortcomings of the parent drugs, present the pros and cons of the second-generation therapies and summarize upcoming developments in the field of immunotherapy for multiple sclerosis.

Prevalence of Suicidal Ideation in Multiple Sclerosis Patients: Meta-Analysis of International Studies

The aim of this study is to estimate the worldwide prevalence of suicidal ideation in multiple sclerosis patients. Two researchers selected words such as "epidemiology" or "prevalence" or "incidence" and "suicidal ideation in multiple sclerosis" and searched them as relevant keywords in international databases such as PubMed, Web of Science CINAHL, Embase, Psyc INFO, and Scopus. A point prevalence with 95% confidence interval was estimated. The variances of each study were calculated using the binomial distribution formula. Heterogeneity among the studies was tested by a Q-Cochran test with a significance level less than 0.1. Index of changes attributed to heterogeneity (I²) was assessed. From among the 170 total articles found from 2011 to February 2019, we pooled and analyzed the data of eight final eligible studies, based on the inclusion criteria. The prevalence of suicidal ideation in multiple sclerosis patients was estimated as 13% (CI 95% = 0.09-0.17). A subgroup analysis was conducted based on the type of countries; it revealed that prevalence is higher in developed countries (15%; CI 95% = 0.1-0.2). Pooled worldwide prevalence of suicidal ideation in the MS population was calculated at 13% by random effect. It is recommended that training, counseling, and psychological support be used to help these patients.

Age-related decreases in relapses among adults with relapsing-onset multiple sclerosis

BACKGROUND

Relapsing-onset multiple sclerosis (MS) typically starts in early- to mid-adulthood, yet the trajectory of disease activity over the subsequent lifetime remains poorly defined. Previous studies have not quantified the age-specific portion of decreases in annualized relapse rates (ARR).

OBJECTIVE

The aim of this article is to determine, under a range of disease-related assumptions, the age-specific component of decreases in ARR over time among adults with relapsing-onset MS.

METHODS

We used a simulation modeling approach to examine a range of assumptions about changes in ARR due to age versus disability status. Scenarios included variations in initial ARR and rate of worsening on the Expanded Disability Status Scale. Model parameters were developed through analysis of MS patients in British Columbia, Canada, and literature review.

RESULTS

We found a substantial age-specific decrease in ARR in all simulated scenarios, independent of disability worsening. Under a range of clinically plausible assumptions, 88%-97% of the decrease was attributed to age and 3%-13% to disability. The age-specific decrease ranged from 22% to 37% per 5 years for a wide range of initial ARR (0.33-1.0).

CONCLUSION

Decreases in ARR were due mostly to age rather than disability status. To facilitate informed decision making in MS, it is important to quantify the dynamic relationship between relapses and age.

Nursing interventions in autologous stem cell transplantation for autoimmune diseases

AIMS

To identify clinical symptoms and nursing interventions for stem cell therapy in autoimmune diseases.

DESIGN

This is a retrospective, cross-sectional study.

METHODS

This study was undertaken with patients diagnosed with type 1 diabetes or multiple sclerosis, undergoing autologous haematopoietic stem cell transplantation from January 2004 - December 2018. Data were registered in a questionnaire, taken during the conditioning regimen comprising cyclophosphamide and rabbit anti-thymocyte globulin. Descriptive statistics and Fisher's exact test were used for data analysis.

RESULTS

There were 68 and 23 patients in the multiple sclerosis and type 1 diabetes groups respectively. Skin rash, nausea, vomiting and fever were more frequent and diverse in the type 1 diabetes group. Steroids were used as prophylaxis for anti-thymocyte globulin-associated allergic reactions in 97% of multiple sclerosis patients. Most of the identified symptoms and nursing interventions were more associated with one or other disease group (p < .05) and were more frequent in the type 1 diabetes group.

CONCLUSION

Patients with autoimmune diseases who underwent stem cell therapy present differences in their repertoire of adverse events and require disease-specific nursing actions.

IMPACT

Our results may enable nurses to establish transplant and disease-specific guidelines to improve prevention and management of adverse events and therefore optimize patient care and therapeutic success.

Immunosenescence: the role of age in multiple sclerosis

INTRODUCTION

The number of elderly people with multiple sclerosis (MS) has increased in line with population ageing. As the immune system presents profound changes over an individual's lifetime, it is important to understand the differences between these patients and younger patients.

DEVELOPMENT

Immunosenescence, defined as age-related alterations naturally occurring in the immune system, particularly influences tolerance, response, and adverse effects of disease-modifying treatments for MS. Thymic involution is the most noteworthy characteristic of this phenomenon. This process leads to a reduction in the number of virgin T cells. Other effects include an inverted CD4 + /CD8 + cell ratio, severe alterations in NK cell functioning, and reduced tissue repair capacity in the brain.

CONCLUSIONS

The number of older people with MS is increasing due to population ageing, advances in disease-modifying treatments, and improved health and social care of these patients. Ageing of the immune system increases the risk of infections, tumours, and autoimmune diseases in elderly individuals. Furthermore, neurodegeneration is accelerated in patients with MS due to the nervous system's loss of remyelination capacity. Understanding of the changes affecting the immune system in the elderly population is essential to improving the care provided to this ever-growing patient group.

Prognostic value of odor identification impairment in multiple sclerosis: 10-Years follow-up

BACKGROUND

Olfactory dysfunction has been linked to clinical severity variables in multiple MS populations. Though, its prognostic value is still unknown.

OBJECTIVE

The aim of this study was to explore the long-term outcome associated with Brief-Smell Identification Test (B-SIT) performance in a cohort of MS patients.

METHODS

A retrospective review of the clinical records was conducted in 149 patients who participated in a previous study, with a median follow-up of 121 months. Demographic and clinical data regarding the last clinical appointment with EDSS measurement were collected. Multiple Sclerosis Severity Scale (MSSS) and Age-Related Multiple Sclerosis Severity (ARMSS) scores were calculated. Date of the last clinical contact or death was recorded.

RESULTS

Among MS patients with progressive clinical course (n = 33), those with impaired B-SIT at baseline had greater change per month during follow-up (as measured by increases in MSSS and ARMSS scores) and a higher hazard of death. No significant associations were found among patients with relapsing and remitting MS (n = 116).

CONCLUSIONS

The study results demonstrate that odor identification impairment has prognostic value in progressive MS, suggesting that a brief odor identification measure can be a marker of neurodegeneration in progressive MS.

Epidemiology of multiple sclerosis in Santiago de Compostela (Spain)

OBJECTIVES

To analyze the frequency and demographic characteristics of multiple sclerosis (MS) in the Council of Santiago de Compostela (SPAIN).

MATERIAL AND METHODS

The patients diagnosed with MS according to the McDonald 2010 diagnostic criteria were identified within the population of the District of Santiago de Compostela. Several sources were used (records and databases from Hospital, General Practitioners, Private Clinics, and the MS Patients Association). Demographic and clinical data were obtained from the electronic files.

RESULTS

The incidence of MS between 2010 and 2015 was 8/100 000/year (95% CI: 6-10), and the prevalence on December 31, 2015, was 152/100 000 (95% CI: 127-176). The age-standardized prevalence (using the European Standard Population 2013) was 137 (95% CI: 114-159) and the incidence of 7 (95% CI: 2-12). The female:male ratio was 1.84, the mean age at the first symptom was 32.23 years, the diagnosis was delayed 3.12 years, and the mean EDSS was 2.82. 71.17% had relapsing-remitting MS, 16.55% secondary progressive MS, 7.59% primary progressive MS, and 0.69% progressive relapsing MS. A disease-modifying treatment was established in 62.76% of patients in a mean of 1.96 years after the diagnosis.

CONCLUSIONS

The northwest of Spain is a high-risk area for MS, with frequencies similar to other Atlantic regions and higher than the rest of the country.

The Microbiome as a Therapeutic Target for Multiple Sclerosis: Can Genetically Engineered Probiotics Treat the Disease?

There is an increasing interest in the intestinal microbiota as a critical regulator of the development and function of the immune, nervous, and endocrine systems. Experimental work in animal models has provided the foundation for clinical studies to investigate associations between microbiota composition and function and human disease, including multiple sclerosis (MS). Initial work done using an animal model of brain inflammation, experimental autoimmune encephalomyelitis (EAE), suggests the existence of a microbiota-gut-brain axis connection in the context of MS, and microbiome sequence analyses reveal increases and decreases of microbial taxa in MS intestines. In this review, we discuss the impact of the intestinal microbiota on the immune system and the role of the microbiome-gut-brain axis in the neuroinflammatory disease MS. We also discuss experimental evidence supporting the hypothesis that modulating the intestinal microbiota through genetically modified probiotics may provide immunomodulatory and protective effects as a novel therapeutic approach to treat this devastating disease.

Impact of sense of coherence on quality of life in patients with multiple sclerosis

AIM

Aiming at finding an effective way of empowering patients with multiple sclerosis (MS) to cope with their disease, the objective of the study was to explore the impact of sense of coherence (SOC) on their health-related quality of life (HRQoL).

METHODS

A total of 134/150 eligible MS patients followed-up at the Department of Neurology of the University Medical Centre Maribor, Slovenia, completed a multiple sclerosis quality of life 54 questionnaire (MSQoL-54) for assessment of HRQoL, and SOC-13-item questionnaire for assessment of SOC in 2013. Multiple linear regression was used to analyze the association between the SOC score and mental and physical subscores of MSQoL-54 adjusted to disease-related and sociodemographic characteristics as potential confounders.

RESULTS

In a univariate analysis SOC score proved to be the strongest predictor of mental subscore of MSQoL-54 (b = 0.834; p < 0.001) explaining 35.6% of its variance. When adjusted for confounders, it retained its position as the most important predictor (b = 0.758; p < 0.001). On the other hand, SOC score was a slightly less important predictor of physical subscore of MSQoL-54, being the fourth strongest factor (b = 0.582; p < 0.001) in univariate analysis explaining 19.1% of the variance; however, when adjusted for confounders, its importance slightly increased by becoming the third most important predictor (b = 0.508; p < 0.001).

CONCLUSION

Based on the results of the present study, we can propose SOC as an important and suitable intervention targeted outcome to consider in managing both aspects of MS difficulties.

Mortality trend for multiple sclerosis in Italy during the period 1980-2015

BACKGROUND

The epidemiology of Multiple Sclerosis (MS) is relevant for health-services planning. Most of MS prevalence and incidence studies in Italy referred to specific geographical areas and periods, whereas mortality data are routinely collected at the national level. The aim was to assess MS mortality trend and geographical differences in Italy from 1980 to 2015.

METHODS

Mortality data were provided by the Italian Institute of Statistics. Due to a low number of annual deaths, mortality data were analysed for both the entire period under study and for sub-periods. Temporal trends were first evaluated using age-adjusted mortality rates (AMRs) comparing each sub-period with the initial one. Then, the annual percent change in mortality was estimated through the joinpoint regression model. Spatial differences between 5 main geographical areas were evaluated using standardized mortality ratios (SMRs).

RESULTS

During the study period, 4,959 deaths for males and 7,434 for females were observed. The higher overall AMR was observed for females (F:0.71 vs. M: 0.56 per 100,000 persons per year). Analysing mortality by gender and geographical area, SMRs 〈 100 were observed in South Italy for both sexes, and in Central Italy for males only, whereas SMRs 〉 100 for Islands for both sexes, and in North-East and North-West for females only. The analysis of the mortality trend through AMRs calculated for sub-periods revealed no difference between the first and the last period for males, whereas a significant increase in mortality was observed for females. The joinpoint regression analysis showed a significant decrease in mortality up to 1995 for males (APC -3.23%) and up to 1999 for females, (APC -1.01%), followed by a significant increase for both sexes, but more marked for females (APC +1.9% M, +2.34% F).

CONCLUSION

The increasing trend of mortality for MS, especially for females, may reflect the increase in the prevalence of MS and the improvement in the quality of diagnosis or coding of the cause of death.

Informing Medication Discontinuation Decisions among Older Adults with Relapsing-Onset Multiple Sclerosis

BACKGROUND

For older adults with relapsing-onset multiple sclerosis (MS), limited information is available to inform if, or when, disease-modifying drugs (DMDs) may be safely discontinued.

OBJECTIVE

The aim of this study was to project the outcomes of DMD discontinuation among older adults with relapsing-onset MS.

METHODS

We projected the 10-year outcomes of discontinuation of a DMD (interferon-β, fingolimod, or natalizumab) among older adults (aged 55 or 70 years) who were relapse-free for 5 or more years and had not reached an Expanded Disability Status Scale (EDSS) score of 6. Outcomes included the percentage of people who had at least one relapse or reached EDSS 6, and quality-adjusted life-years (QALYs), which incorporated both relapses and disability. We used a simulation modeling approach. With increased age, relapses decreased and the effectiveness of DMDs for disability outcomes also decreased.

RESULTS

We found lower projected benefits for DMD continuation at 70 years of age than at 55 years of age. Compared with discontinuation, the projected benefit of DMD continuation ranged from 0.007 to 0.017 QALYs at 55 years of age and dropped to 0.002-0.006 at 70 years of age. The annual projected benefits of DMD continuation (0.1-3.0 quality-adjusted life-days) were very low compared with typical patient preferences regarding treatment burden.

CONCLUSION

The benefits of DMDs may not be substantial among older adults with relapsing-onset MS. Direct clinical evidence remains limited and the decision of whether to discontinue a DMD should also take into account patient preferences. It is important to gain a better understanding of how age-related changes in the trajectory of relapsing-onset MS affect treatment effectiveness among older adults.

Expenditure, Utilization, and Cost of Specialty Drugs for Multiple Sclerosis in the US Medicaid Population, 2008-2018

BACKGROUND

Multiple sclerosis (MS) is a rare, long-standing, and disabling disease that affects the central nervous system and causes several clinical manifestations. As a result, this disease is associated with a high societal economic burden.

OBJECTIVE

To analyze the trends in drug expenditure, utilization, and cost of specialty drugs for the treatment of patients with MS in the US Medicaid program.

METHODS

In this retrospective drug utilization research analysis, we obtained prescription data and reimbursement of disease-modifying therapies for MS from the Centers for Medicare & Medicaid Services Medicaid State Drug Utilization Data between January 2008 and December 2018. The specialty drugs considered in our analysis included dimethyl fumarate, fingolimod, teriflunomide, cladribine, siponimod, alemtuzumab, natalizumab, ocrelizumab, daclizumab, glatiramer acetate, peginterferon beta-1a, interferon beta-1a, and interferon beta-1b. The annual trends of the number of prescriptions, reimbursement expenditures, and costs were calculated. The average reimbursement per prescription was calculated as an estimate of the drug cost.

RESULTS

The annual MS drug utilization increased from 85,209 prescriptions in 2008 to 223,604 in 2016, and then decreased to 194,877 in 2018. The annual reimbursement surged by 633% in the 10-year study period between 2008 and 2018, from almost $172 million in 2008 to more than $1.4 billion in 2017, and then to approximately $1.26 billion in 2018. The cost per prescription increased over time for most MS brand-name drugs (eg, from $2033 in 2008 to $5114 in 2018 for natalizumab, and from $19,138 in 2016 to $23,588 in 2018 for alemtuzumab). In 2008, self-injectable drugs dominated the market. In recent years, a shift has occurred in the utilization and reimbursement of MS drugs, with oral medications becoming predominant.

CONCLUSION

The study findings indicate intermarket and interbrand competition among the MS specialty drugs. The growing utilization and spending trends for specialty MS medications are significant and sizable in the US Medicaid programs. Medicaid cost-containment strategy is warranted to control the economic burden of state budgets across the country.

Role of Vitamin D in Preventing and Treating Selected Extraskeletal Diseases-An Umbrella Review

Evidence is accumulating that vitamin D may have beneficial effects on respiratory tract, autoimmune, neuro-degenerative, and mental diseases. The present umbrella review of systematic reviews (SRs) of cohort studies and randomised controlled trials (RCTs), plus single Mendelian randomisation studies aims to update current knowledge on the potential role of vitamin D in preventing and treating these extraskeletal diseases. Altogether, 73 SRs were identified. Observational data on primary prevention suggest an inverse association between vitamin D status and the risk of acute respiratory tract infections (ARI), dementia and cognitive decline, and depression, whereas studies regarding asthma, multiple sclerosis (MS), and type 1 diabetes mellitus (T1DM) are scarce. SRs of RCTs support observational data only for the risk of ARI. No respective RCTs are available for the prevention of chronic obstructive pulmonary disease (COPD), MS, and T1DM. SRs of RCTs indicate beneficial therapeutic effects in vitamin D-deficient patients with asthma and COPD, while effects on major depression and T1DM need to be further elucidated. Mendelian randomisation studies do not consistently support the results of SRs. Since several limitations of the included SRs and existing RCTs do not permit definitive conclusions regarding vitamin D and the selected diseases, further high-quality RCTs are warranted.

Mortality among patients with idiopathic intracranial hypertension enrolled in the IH Registry

OBJECTIVE

To determine (1) if mortality among patients with idiopathic intracranial hypertension (IIH) enrolled in the Intracranial Hypertension Registry (IHR) is different from that of the general population of the United States and (2) what the leading underlying causes of death are among this cohort.

METHODS

Mortality and underlying causes of death were ascertained from the National Death Index. Indirect standardization using age- and sex-specific nationwide all-cause and cause-specific mortality data extracted from the Centers for Disease Control and Prevention Wonder Online Database allowed for calculation of standardized mortality ratios (SMR).

RESULTS

There were 47 deaths (96% female) among 1437 IHR participants that met inclusion criteria. The average age at death was 46 years (range, 20-95 years). Participants of the IHR experienced higher all-cause mortality than the general population (SMR, 1.5; 95% confidence interval [CI], 1.2-2.1). Suicide, accidents, and deaths from medical/surgical complications were the most common underlying causes, accounting for 43% of all deaths. When compared to the general population, the risk of suicide was over 6 times greater (SMR, 6.1; 95% CI, 2.9-12.7) and the risk of death from accidental overdose was over 3 times greater (SMR, 3.5; 95% CI, 1.6-7.7). The risk of suicide by overdose was over 15 times greater among the IHR cohort than in the general population (SMR, 15.3; 95% CI, 6.4-36.7).

CONCLUSIONS

Patients with IIH in the IHR possess significantly increased risks of death from suicide and accidental overdose compared to the general population. Complications of medical/surgical treatments were also major contributors to mortality. Depression and disability were common among decedents. These findings should be interpreted with caution as the IHR database is likely subject to selection bias.

Vitamin D Supplementation in Multiple Sclerosis: A Critical Analysis of Potentials and Threats

Multiple sclerosis (MS) is a chronic inflammatory demyelinating and neurodegenerative disease of the central nervous system (CNS). In recent years, vitamin D has gained attention, as low serum levels are suspected to increase the risk for MS. Cholecalciferol supplementation has been tested in several clinical trials, since hypovitaminosis D was linked to higher disease activity and may even play a role in long-term outcome. Here, we review the current understanding of the molecular effects of vitamin D beyond calcium homeostasis, the potential beneficial action in MS and hazards including complications of chronic and high-dose therapy. In clinical trials, doses of up to 40,000 IU/day were tested and appeared safe as add-on therapy for short-term periods. A recent meta-analysis of a randomized, double-blind, placebo-controlled clinical trial investigating vitamin D as add-on therapy in MS, however, suggested that vitamin D had no therapeutic effect on disability or relapse rate. We recognize a knowledge gap for chronic and high-dose therapy, which can lead to life-threatening complications related to vitamin D toxicity including renal failure, cardiac arrythmia and status epilepticus. Moreover, vitamin D toxicity may manifest as fatigue, muscle weakness or urinary dysfunction, which may mimic the natural course of progressive MS. Given these limitations, vitamin D supplementation in MS is a sensitive task which needs to be supervised by physicians. While there is strong evidence for vitamin D deficiency and the development of MS, the risk-benefit profile of dosage and duration of add-on supplementation needs to be further clarified.

Multiple sclerosis: effect of beta interferon treatment on survival

Worldwide, the beta interferons remain the most commonly prescribed disease-modifying drugs for multiple sclerosis. However, it is unclear if they alter survival. We investigated the association between beta interferon and mortality in the 'real-world' setting. This was a multi-centre population-based observational study of patients with relapsing-onset multiple sclerosis who were initially registered at a clinic in British Columbia, Canada (1980-2004) or Rennes, France (1976-2013). Data on this cohort were accessed from the clinical multiple sclerosis databases and from individually linked health administrative data; all data were collected prospectively. Participants were followed from the latter of their first multiple sclerosis clinic visit, 18th birthday or 1 January 1996; until death, emigration or 31 December 2013. Only those who were naïve to disease-modifying therapy and immunosuppressant treatment of multiple sclerosis at the start of their follow-up were included in the analysis. A nested case-control approach was used. Up to 20 controls, matched to cases (deaths) by country, sex, age ± 5 years, year and disability level at study entry, were randomly selected from the cohort by incidence density sampling. The associations between all-cause mortality and at least 6 months beta interferon exposure, and also cumulative exposure ('low', 6 months to 3 years; and 'high', >3 years), were estimated by conditional logistic regression adjusting for treatment with other disease-modifying therapies and age in years. Further analyses included separate analyses by sex and country, additional adjustment for comorbidity burden in the Canadian cohort, and estimation of the association between beta interferon and multiple sclerosis-related death in both countries. Among 5989 participants (75% female) with a mean age of 42 (standard deviation, SD 11) years at study entry, there were 742 deaths (70% female) and the mean age at death was 61 (SD 13) years. Of these cases, 649 were matched to between one and 20 controls. Results of the conditional logistic regression analyses are expressed as adjusted odds ratios with 95% confidence intervals. The odds of beta interferon exposure were 32% lower among cases than controls (0.68; 0.53-0.89). Increased survival was associated with >3 years beta interferon exposure (0.44; 0.30-0.66), but not between 6 months and 3 years exposure (1.00; 0.73-1.38). Findings were similar within sex and country, and for multiple sclerosis-related death. Beta interferon treatment was associated with a lower mortality risk among people with relapsing-onset multiple sclerosis. Findings were consistent between two geographically distinct regions in North America and Europe.

Epidemiology and treatment of multiple sclerosis in elderly populations

The prevalence of multiple sclerosis (MS) and the age of affected patients are increasing owing to increased longevity of the general population and the availability of effective disease-modifying therapies. However, ageing presents unique challenges in patients with MS largely as a result of their increased frequency of age-related and MS-related comorbidities as well as transition of the disease course from an inflammatory to a neurodegenerative phenotype. Immunosenescence (the weakening of the immune system associated with natural ageing) might be at least partly responsible for this transition, which further complicates disease management. Currently approved therapies for MS are effective in preventing relapse but are not as effective in preventing the accumulation of disability associated with ageing and disease progression. Thus, ageing patients with MS represent a uniquely challenging population that is currently underserved by existing therapeutic regimens. This Review focuses on the epidemiology of MS in ageing patients. Unique considerations relevant to this population are discussed, including the immunology and pathobiology of the complex relationship between ageing and MS, the safety and efficacy of disease-modifying therapies, when discontinuation of treatment might be appropriate and the important role of approaches to support wellness and cognition.

Cardiac Autonomic Dysfunction in Multiple Sclerosis: A Systematic Review of Current Knowledge and Impact of Immunotherapies

Cardiac autonomic dysfunction (CAD) has been reported in patients with multiple sclerosis (MS). This systematic review summarizes the evidence for the types and prevalence of CAD in MS patients, as well as its association with MS type, disease characteristics, fatigue and immunotherapies used to treat MS. The analysis revealed that CAD is correlated with pathophysiological processes of MS, can trigger serious cardiovascular complications that may reduce life expectancy, and may have implications for treatment with immunotherapies, especially fingolimod. Numerous mainly small case-control or cohort studies have reported various measures of CAD (particularly heart rate variation) in MS patients, showing higher rates of abnormality versus controls. A smaller number of studies have reported on cardiac autonomic symptoms in MS, including orthostatic intolerance/dizziness in around 50% of patients. CAD also appears to be associated with disease duration and to be more common in progressive than relapsing-remitting MS. However, although a substantial evidence base suggests that assessing CAD in people with MS may be important, standardised methods to evaluate CAD in these patients have not yet been established. In addition, no studies have yet looked at whether treating CAD can reduce the burden of MS symptoms, disease activity or the rate of progression.

Population size estimation with interval censored counts and external information: Prevalence of multiple sclerosis in Rome

We discuss Bayesian log-linear models for incomplete contingency tables with both missing and interval censored cells, with the aim of obtaining reliable population size estimates. We also discuss use of external information on the censoring probability, which may substantially reduce uncertainty. We show in simulation that information on lower bounds and external information can each improve the mean squared error of population size estimates, even when the external information is not completely accurate. We conclude with an original example on estimation of prevalence of multiple sclerosis in the metropolitan area of Rome, where five out of six lists have interval censored counts. External information comes from mortality rates of multiple sclerosis patients.

Predictors of Multiple Sclerosis Severity Score in Patients with Multiple Sclerosis

Background

Multiple sclerosis (MS) is a demyelinating autoimmune disorder. Several factors have been shown to associate with MS clinical severity. The influence of different lifestyle factors on MS clinical severity as assessed by the Multiple Sclerosis Severity Score (MSSS) was investigated.

Methods

A questionnaire was administered to 128 Kuwaiti MS patients to assess the association of smoking, nutritional supplement use, food allergy, physical activity (PA), and educational level with MSSS. A multiple linear regression model was used to test for associations. Regression model results were adjusted for sex, history of blood transfusion, age at MS onset, and marital status.

Results

Smoking status, passive smoking, and food allergy are not associated with MSSS. Patients with MS with a college education and graduate/professional degrees score, on average, 2.56 lower on the MSSS compared with those with less than a high school education (β= -2.22, P = .045; and β = -2.90, P = .048, respectively). Patients who perform PA score, on average, 2.32 lower on the MSSS compared with those with no PA (moderate exercise, P = .003; rigorous exercise, P = .001), and PA correlated significantly with MSSS outcomes (r² = 0.452, P < .001).

Conclusions

Educational level and PA are significantly associated with reduced MSSS, and both contribute to a less severe MS clinical course. Current MS management protocols should consider lifestyle changes to improve the quality of life of patients with MS.

Multiple cause of death analysis in multiple sclerosis: A population-based study

OBJECTIVE

To gain a better understanding of the complex patterns of causes that contribute to death due to multiple sclerosis (MS) by assessing the relationship between MS and other causes of death listed on death certificates.

METHODS

Multiple cause of death data for all adult deaths (aged ≥18 years) in British Columbia, Canada, between 1986 and 2013 were accessed. All causes, as listed on the death certificate, whether underlying or contributing, were considered "any mention" causes. The associations between mention of MS on the death certificate and mention of other causes of death were examined by logistic regression, adjusted for age, sex, and calendar year (Bonferroni-corrected α level = 0.002). Findings were also sex-stratified.

RESULTS

Among 771,288 deaths, MS was mentioned on 2,153 certificates. If MS was mentioned (versus not mentioned), there was a greater chance that specific conditions contributed to the death: respiratory infection (adjusted odds ratio [aOR], 3.03 [95% confidence interval (CI), 2.73-3.36]), aspiration pneumonia (aOR, 7.15 [95% CI, 6.23-8.22]), urinary tract infection (UTI) (aOR, 10.2 [95% CI, 8.7-12.0]), other infection including sepsis (aOR, 1.34 [95% CI, 1.15-1.56]), and skin disease (aOR, 5.06 [95% CI, 3.96-6.46]). Sex differences existed for urinary tract infection (men: aOR, 14.9 [95% CI, 11.5-19.3]; women: aOR, 8.00 [95% CI, 6.53-9.81]) and chronic respiratory disease (men = aOR, 1.36 [95% CI, 1.14-1.63]; women = aOR, 0.97 [95% CI, 0.84-1.13]).

CONCLUSIONS

Deaths attributed to MS were commonly caused by infection (especially respiratory and urinary tract-related); conditions associated with advanced disability and immobility, such as aspiration pneumonia; and chronic respiratory disease in men. All are potentially modifiable; interventions that reduce the frequency or severity of these complications could improve survival in MS.

Visualization of Myelin for the Diagnosis and Treatment Monitoring of Multiple Sclerosis

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system (CNS) affecting more than two million people worldwide. As the exact etiology of MS remains elusive, the diagnosis of MS is made by referring to the McDonald diagnostic criteria, which utilizes MRI as a tool to identify "demyelinated" MS lesions. In particular, hyperintense lesions on T2-weighted images (T2WI) or so-called "T2-lesions" are considered to represent demyelinated MS lesions. T2WI, however, lacks myelin specificity, and moreover, remyelination could not be depicted by the use of such modality. For the accurate diagnosis and treatment decision-making, or for the future development of remyelination therapeutics, imaging tools to visualize myelin-specific signals are mandatory. In this chapter, the current use and the limitation of imaging modalities in MS diagnosis and treatment will be reviewed, with the introduction of new imaging method, namely q-space Myelin Map (qMM), to be used for visualization of demyelination and remyelination in MS.

A 30-Year Clinical and Magnetic Resonance Imaging Observational Study of Multiple Sclerosis and Clinically Isolated Syndromes

Objective

Clinical outcomes in multiple sclerosis (MS) are highly variable. We aim to determine the long‐term clinical outcomes in MS, and to identify early prognostic features of these outcomes.

Methods

One hundred thirty‐two people presenting with a clinically isolated syndrome were prospectively recruited between 1984 and 1987, and followed up clinically and radiologically 1, 5, 10, 14, 20, and now 30 years later. All available notes and magnetic resonance imaging scans were reviewed, and MS was defined according to the 2010 McDonald criteria.

Results

Clinical outcome data were obtained in 120 participants at 30 years. Eighty were known to have developed MS by 30 years. Expanded Disability Status Scale (EDSS) scores were available in 107 participants, of whom 77 had MS; 32 (42%) remained fully ambulatory (EDSS scores ≤3.5), all of whom had relapsing–remitting MS (RRMS), 3 (4%) had RRMS and EDSS scores >3.5, 26 (34%) had secondary progressive MS (all had EDSS scores >3.5), and MS contributed to death in 16 (20%). Of those with MS, 11 received disease‐modifying therapy. The strongest early predictors (within 5 years of presentation) of secondary progressive MS at 30 years were presence of baseline infratentorial lesions and deep white matter lesions at 1 year.

Interpretation

Thirty years after onset, in a largely untreated cohort, there was a divergence of MS outcomes; some people accrued substantial disability early on, whereas others ran a more favorable long‐term course. These outcomes could, in part, be predicted by radiological findings from within 1 year of first presentation. ANN NEUROL 2020;87:63–74

Inflammation resolution and specialized pro-resolving lipid mediators in CNS diseases

Introduction: Inflammation resolution induced by specialized pro-resolving lipid mediators (SPMs) is a new concept. The application of SPMs is a promising therapeutic strategy that can potentially supersede anti-inflammatory drugs. Most CNS diseases are associated with hyperreactive inflammatory damage. CNS inflammation causes irreversible neuronal loss and permanent functional impairments. Given the high mortality and morbidity rates, the investigation of therapeutic strategies to ameliorate inflammatory damage is necessary.Areas covered: In this review, we explore inflammation resolution in CNS disorders. We discuss the underlying mechanisms and dynamic changes of SPMs and their precursors in neurological diseases and examine how this can potentially be incorporated into the clinic. References were selected from PubMed; most were published between 2010 and 2019.Expert opinion: Inflammation resolution is a natural process that emerges after acute or chronic inflammation. The evidence that SPMs can effectively ameliorate hyperreactive inflammation, shorten resolution time and accelerate tissue regeneration in CNS disorders. Adjuvants and nanotechnology offer opportunities for SPM drug design; however, more preclinical studies are necessary to investigate basic, critical issues such as safety.

Emotional outcomes in clinically isolated syndrome and early phase multiple sclerosis: a systematic review and meta-analysis

OBJECTIVE

To study depression, anxiety, suicide risk, and emotional health-related quality of life (HRQoL) in people with clinically isolated syndrome (CIS) and in early phase multiple sclerosis (MS).

METHODS

A systematic literature review was conducted with inclusion criteria of observational studies on outcomes of depression, anxiety, suicide risk, and emotional HRQoL in CIS and within five years since diagnosis of MS. Studies were screened using the Preferred Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, and study quality was determined for included studies. Meta-analysis and meta-regression were performed if applicable.

RESULTS

Fifty-one studies were included in the systematic review. In early phase MS, meta-analyses of the Hospital Anxiety Depression Scale (HADS) indicated prevalence levels of 17% (95% confidence interval (CI): 9 to 25%; p < .001) for depressive and 35% (95% CI: 28 to 41%; p < .001) for anxiety symptoms. Meta-regression analyses revealed an increase in mean HADS-D and HADS-A associated with larger sample size, and higher HADS-D mean with increased study quality. Similar depressive and anxiety symptoms were observed in CIS, and increased suicide risk and low emotional HRQoL was associated with depressive symptoms in early phase MS. The methodological quality of the studies was considered fair.

CONCLUSIONS

Findings suggest that mild-to-moderate symptoms of depression and anxiety might be prevalent in CIS and in early phase MS. Future research on both clinical populations are needed, especially longitudinal monitoring of emotional outcomes.

[Anxiety and depressive psychopathological characteristics of patients with multiple sclerosis at different stages of disease]

AIM

To study the development of anxiety and depressive disorders in patients with exacerbated multiple sclerosis (MS).

MATERIAL AND METHODS

Forty-three patients with MS were included in the study (women 74.4%, mean age 33.1 years old). SCL-90-R and MASQ questionnaire were used to evaluate psychopathological symptoms.

RESULTS AND CONCLUSION

There is the high prevalence of symptoms of anxiety and depression in patients with MS. Other symptoms, including interpersonal sensitivity, hostility and decrease of stress response, are observed as well.

Association between suicide and multiple sclerosis: An updated meta-analysis

BACKGROUND

Whether multiple sclerosis is associated with a higher rate of suicide remains controversial. Therefore, we aimed to evaluate the risk of suicide in multiple sclerosis patients based on meta-analysis of previously published data.

METHODS

We searched for studies that measured the suicide risk in multiple sclerosis patients compared with general population that were published up to 1 December 2018 in PubMed, EMBASE, and Web of Science databases. Sixteen studies fulfilled the eligibility criteria. We performed random-effects meta-analyses to calculate suicide rate ratio (SRR) and 95% confidence intervals (CIs) for patients with multiple sclerosis.

RESULTS

The association between suicide and multiple sclerosis was statistically significant with a pooled SRR 1.72 (95%CI 1.48-1.99, I-squared = 55.0%). Risk of suicide at diagnosis of multiple sclerosis (SRR 2.12, 95% CI 1.84-2.46; I-squared = 4.4%) was higher than the risk of suicide at symptom onset (SRR 1.69; 95% CI 1.43-2.00; I-squared = 0.0%). Gender may exert an influence on the impact of sex on the association between MS multiple sclerosis and suicide, but this requires is controversial and need more further studies to demonstrate.

CONCLUSION

Our meta-analysis shows a significant association between suicide and multiple sclerosis, although ethnic and geographical differences were not considered. These findings should be confirmed and extended in future large studies.

Psychiatric disorders in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is characterized by a large spectrum of symptoms, involving all functional systems. Psychiatric symptoms are common in people with MS (pwMS) having an important impact on quality of life and on some features of MS (fatigue, sleep, disability, adherence to disease-modifying drugs). The main psychiatric disturbances in MS are depressive, bipolar, anxiety, schizophrenic and obsessive-compulsive syndromes.

METHODS

Literature search for original articles and review in the databases, including PubMed and Scopus from 1959 to 2019.

RESULTS AND CONCLUSION

Studies answering the aim of this review were selected and reported. Epidemiological and clinical aspects of psychiatric syndromes (PS) in MS as well as self-report diagnostic scales and radiological correlates of PS in MS are described. Moreover, some radiological studies about primary psychiatric disorders (PD) are reported to underline how gray matter atrophy, white matter abnormalities and corpus callosum involvement in these diseases, as features in common with MS, may explain the more frequent occurrence of PD in MS than in the general population.

Early Clinical Features, Time to Secondary Progression, and Disability Milestones in Polish Multiple Sclerosis Patients

Background and Objectives: Determining the clinical course of multiple sclerosis (MS) and prediction of long-term disability can be a big challenge. To determine early clinical features of MS, their influence on long-term disability progression, and time to transition from relapsing-remitting MS (RRMS) to secondary progressive MS (SPMS), a cohort of Polish patients was studied. Materials and Methods: We retrospectively evaluated 375 Polish MS patients based on data from available medical records. We assessed early clinical MS features and the relationship between demographics and time from disease onset to attainment of 4 and 6 points on the Expanded Disability Status Scale (EDSS), as well as time to conversion from RRMS to SPMS. Results: The differences between initial MS variants were significantly associated with gender, age at disease onset, number and type of the first symptoms, and rate of the disability accrual. Mean times from disease onset to attainment of EDSS 4 and 6 were significantly influenced by the disease variant, age at onset, gender, degree of recovery from the initial symptoms, and first inter-bouts interval. The mean time to secondary progression was significantly influenced by the number and type of the first symptoms of RRMS. Conclusions: Early clinical features of MS are important in determining the disease variant, the time to transition from RRMS to SPMS, as well as predicting the disability accumulation of patients. Despite the small differences regarding the first MS symptoms, the disability outcomes in the cohort of Polish patients are similar to other regions of the world.

Global, regional, and national burden of multiple sclerosis 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Multiple sclerosis is the most common inflammatory neurological disease in young adults. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic method of quantifying various effects of a given condition by demographic variables and geography. In this systematic analysis, we quantified the global burden of multiple sclerosis and its relationship with country development level.

METHODS

We assessed the epidemiology of multiple sclerosis from 1990 to 2016. Epidemiological outcomes for multiple sclerosis were modelled with DisMod-MR version 2.1, a Bayesian meta-regression framework widely used in GBD epidemiological modelling. Assessment of multiple sclerosis as the cause of death was based on 13 110 site-years of vital registration data analysed in the GBD's cause of death ensemble modelling module, which is designed to choose the optimum combination of mathematical models and predictive covariates based on out-of-sample predictive validity testing. Data on prevalence and deaths are summarised in the indicator, disability-adjusted life-years (DALYs), which was calculated as the sum of years of life lost (YLLs) and years of life lived with a disability. We used the Socio-demographic Index, a composite indicator of income per person, years of education, and fertility, to assess relations with development level.

FINDINGS

In 2016, there were 2 221 188 prevalent cases of multiple sclerosis (95% uncertainty interval [UI] 2 033 866-2 436 858) globally, which corresponded to a 10·4% (9·1 to 11·8) increase in the age-standardised prevalence since 1990. The highest age-standardised multiple sclerosis prevalence estimates per 100 000 population were in high-income North America (164·6, 95% UI, 153·2 to 177·1), western Europe (127·0, 115·4 to 139·6), and Australasia (91·1, 81·5 to 101·7), and the lowest were in eastern sub-Saharan Africa (3·3, 2·9-3·8), central sub-Saharan African (2·8, 2·4 to 3·1), and Oceania (2·0, 1·71 to 2·29). There were 18 932 deaths due to multiple sclerosis (95% UI 16 577 to 21 033) and 1 151 478 DALYs (968 605 to 1 345 776) due to multiple sclerosis in 2016. Globally, age-standardised death rates decreased significantly (change -11·5%, 95% UI -35·4 to -4·7), whereas the change in age-standardised DALYs was not significant (-4·2%, -16·4 to 0·8). YLLs due to premature death were greatest in the sixth decade of life (22·05, 95% UI 19·08 to 25·34). Changes in age-standardised DALYs assessed with the Socio-demographic Index between 1990 and 2016 were variable.

INTERPRETATION

Multiple sclerosis is not common but is a potentially severe cause of neurological disability throughout adult life. Prevalence has increased substantially in many regions since 1990. These findings will be useful for resource allocation and planning in health services. Many regions worldwide have few or no epidemiological data on multiple sclerosis, and more studies are needed to make more accurate estimates.

FUNDING

Bill & Melinda Gates Foundation.

Modelling the impact of multiple sclerosis on life expectancy, quality-adjusted life years and total lifetime costs: Evidence from Australia

Objectives:

To quantify life expectancy (LE), quality-adjusted life years (QALYs) and total lifetime societal costs for a hypothetical cohort of Australians with multiple sclerosis (MS).

Methods:

A 4-state Markov model simulated progression from no/mild to moderate and severe disability and death for a cohort of 35-year-old women over a lifetime horizon. Death risks were calculated from Australian life tables, adjusted by disability severity. State-dependent relapse probabilities and associated disutilities were considered. Probabilities of MS progression and relapse were estimated from AusLong and TasMSL MS epidemiological databases. Annual societal (direct and indirect) costs (2017 Australian dollars) and health-state utilities for each state were derived from the Australian MS Longitudinal Study. Costs were discounted at 5% annually.

Results:

Mean (95% confidence interval (CI)) LE from age 35 years was 42.7 (41.6–43.8) years. This was 7.5 years less than the general Australian population. Undiscounted QALYs were 28.2 (26.3–30.0), a loss of 13.1 QALYs versus the Australian population. Discounted lifetime costs were $942,754 ($347,856–$2,820,219).

Conclusion:

We have developed a health economics model of the progression of MS, calculating the impact of MS on LE, QALYs and lifetime costs in Australia. It will form the basis for future cost-effectiveness analyses of interventions for MS.