Characteristics of multiple sclerosis at onset and delay of diagnosis and treatment in Spain (the Novo Study)

Multiple Sclerosis diagnostic delay in a public reference center in Brazil: Related factors and functional impact

INTRODUCTION

Early and accurate MS diagnosis followed by prompt intervention is crucial in modifying the disease's natural history. This study aimed to assess the factors related to diagnostic delay in relapsing-remitting MS (RRMS) and its association with functional status.

METHODS

A cross-sectional study at a reference center in Bahia, Brazil, carried out from July/2021 to April/2024. Late MS diagnosis was defined as >3 months since the disease's clinical onset. EDSS assessed functional status.

RESULTS

A total of 265 patients were included. The median time from symptoms' onset until diagnosis was 7 (IQR, 2-29) months, and 159 patients (60 %) had a late diagnosis. Multivariate logistic regression showed that living outside the metropolitan region, comorbidities, prior misdiagnosis, and disease onset before the McDonald 2017 criteria update were associated with late diagnosis. Meanwhile, disease onset with visual symptoms was related to early diagnosis. Finally, late diagnosis was related to worse functional status in RRMS patients.

CONCLUSION

Diagnostic delays in our population are significant, driven by living in cities outside the metropolitan region, comorbidities, previous misdiagnosis, and the use of McDonald's diagnostic criteria before the 2017 update. Understanding this reality is crucial, as timely diagnosis and treatment are essential for a favorable prognosis in RRMS.

Diagnostic delay and misdiagnosis of symptoms reported by patients with multiple sclerosis participating in a research registry

Background

Research cohort data suggest diagnostic delay in multiple sclerosis (MS) has diminished in tandem with MS diagnostic criteria revisions, yet other studies have not replicated this finding. Recent data indicate misdiagnosis of initial symptoms of MS is a frequent contributor to diagnostic delay.

Objectives

This survey study assessed diagnostic delay and misdiagnosis in an MS patient registry.

Methods

Participants completed the survey study between November 12, 2021, through December 22, 2021.

Results

There were 428 participants. Diagnostic delay was a median of 2.0 months (mean of 22.8 months, range: 0-32.9 years); 173/428 (40.4%) reported misdiagnosis of symptoms later attributed to MS, and this was associated with longer diagnostic delay (p < 0.001). Diagnostic delay decreased over time proximal to revisions to MS diagnostic criteria. 217/428 (50.7%) reported earlier symptoms retrospectively recognized as referable to MS that were not clinically evaluated, resulting in a diagnostic delay median of 5.4 years (mean 8.9 years, range: 0-47.4 years).

Conclusions

Diagnostic delay was prevalent and associated with frequent misdiagnosis of initial symptoms of MS and earlier unevaluated symptoms later attributed to MS. Studies tracing the diagnostic journey of patients with MS are needed to understand and prevent causes of diagnostic delay.

Development and validation of a scoring system for predicting disease activity in treatment-naïve patients with relapsing-remitting multiple sclerosis

BACKGROUND

Relapsing-remitting MS (RRMS) exhibits significant heterogeneity and different treatment responses. Up to date, there is no international consensus on defining disease activity which foretells potential prognosis. This study aims to develop and validate a "Scoring System for Disease Activity Prognosis in Treatment-Naïve RRMS Patients" (DAPS-RRMS) to help guiding treatment decisions.

METHODS

A set of clinical and radiological factors predicting RRMS disease activity based on an extensive literature review were identified. Real-world data from 520 treatment-naïve RRMS patients were extracted from the Egyptian MS registry dataset by independent neurologists and were disseminated among a group of MS experts for evaluation of each case separately. To convert this clinical impression into a validated score, ordinal logistic regression was used to develop the scoring system and nomogram; validation was conducted using Receiver Operating Characteristic (ROC); interrater reliability was assessed using Kendall's coefficient of concordance and the Intraclass Correlation Coefficient (ICC).

RESULTS

According to cut off values based on the sum of scores of involved parameters, patients were classified into four categories predicting disease activity, "Active" (0-9), "Highly Active" (9.5-14), "Very Highly Active" (14.5-19), and "Aggressive" (>19). The scoring tool demonstrated excellent performance metrics with high inter-rater agreement (Kendall's W 0.764), and reliability including a high area under the curve (AUC) for discriminating between categories.

CONCLUSION

This validated scoring system provides a practical and reliable tool for predicting RRMS disease activity and guiding treatment decisions in treatment-naïve patients, particularly in resource-limited countries. The model is combined with a user-friendly nomogram.

High-Field-Blinded Assessment of Portable Ultra-Low-Field Brain MRI for Multiple Sclerosis

BACKGROUND AND PURPOSE

MRI is crucial for multiple sclerosis (MS), but the relative value of portable ultra-low field MRI (pULF-MRI), a technology that holds promise for extending access to MRI, is unknown. We assessed white matter lesion (WML) detection on pULF-MRI compared to high-field MRI (HF-MRI), focusing on blinded assessments, assessor self-training, and multiplanar acquisitions.

METHODS

Fifty-five adults with MS underwent pULF-MRI following their HF-MRI. Two neuroradiologists independently assessed pULF-MRI images in an evaluation process, including initial assessment blinded to HF-MRI, self-training with reference to HF-MRI and evaluation of 20 cases with additional T2-fluid-attenuated inversion recovery in an additional plane. A third rater conducted cross-referenced analysis with HF-MRI data to determine true-positive lesions, false-positive areas, and case-level sensitivity and positive predictive value.

RESULTS

The mean age of participants was 50 years (standard deviation: 11; 74% women). Initially, Rater 2 marked more false-positive areas than Rater 1 (p = 0.003). After self-training, both raters embraced a conservative approach, with Rater 2 marking fewer false-positive areas (p = 0.01). Both raters maintained 100% case-level sensitivity and positive predictive value for detecting at least one WML, particularly in periventricular areas. Multiplanar acquisitions reduced both false-positive areas and true-positive lesions. True-positive lesions and false-positive areas had similar contrast-to-noise ratios in the juxtacortical region (p = 0.73) but not in periventricular, deep parenchymal regions (p = 0.004, p = 0.01).

CONCLUSION

With adequate training, radiological interpretation of pULF-MRI has high sensitivity and positive predictive value for MS lesions but should be approached conservatively. These results suggest utility for patient triage, potentially reducing diagnostic delay, and screening high-risk individuals.

Time between the first symptom, diagnosis and treatment of multiple sclerosis in a Brazilian cohort. The impact of early diagnosis

INTRODUCTION

Multiple Sclerosis (MS) diagnosis can be challenging, especially in populations where the disease is rare. In Brazil, the average prevalence is 14/100,000 inhabitants, lower than the worldwide. Early treatment initiation can markedly reduce disease activity and accumulation of disability. Therefore, delayed diagnosis and access to disease modifying therapy (DMT) can have a negative impact on the course of MS.

OBJECTIVES

The aim of this study was to estimate the mean time between the first relapse, the diagnosis of MS and initiation of treatment in a cohort of Brazilian MS patients.

MATERIAL AND METHOD

We retrospectively analyzed the medical records of MS patients who met the 2017 McDonald diagnostic criteria followed in a MS reference center in Belo Horizonte, Minas Gerais. We assessed demographic and clinical data with focus on time to first symptom, time to diagnosis and treatment begging. The last Expanded Disability Status Scale (EDSS) was collected to access disability. The program GraphPad Prism 8.4.3. was used for the statistical analysis.

RESULTS

Data of 66 patients were analyzed, 77 % (51) were women. The mean age of the first symptom, diagnosis and DMT initiation was, respectively, 30,06 (± 12,43), 35,2 (± 13,59) and 36,10 (± 13,89) years. In 32 (46,38 %) patients the diagnosis was early (<1 year of disease), in 18 (26,09 %) between 1 and 5 years and in 19 (27,54 %) after to five years. Once the diagnosis was established, 65,5 % had access to DMT within 6 months and 79,71 % in the first year. Patients with diagnosis in the two first years had their first symptom at a younger age (p < 0.05). Comparing these two groups, patients with an earlier diagnosis presented less disability (EDSS: 3,5 vs 1,5; p < 0.05).

CONCLUSION

MS diagnosis can be challenging especially in low prevalence population of diseased and developing countries. Our study demonstrated the importance of early recognition of MS and its precocious intervention, impacting in reducing of disability a long term.

Misdiagnosis and underdiagnosis of multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Diagnostic errors in multiple sclerosis (MS) impact patients and healthcare systems.

OBJECTIVES

This study aimed to determine the prevalence of MS misdiagnosis and underdiagnosis, time delay in reaching a correct diagnosis and potential impact of sex.

METHODS

Systematic review and meta-analysis on MS diagnostic errors.

RESULTS

Out of 3910 studies, we included 62 for a qualitative synthesis and 24 for meta-analyses. Frequency of misdiagnosis (incorrect assignment of an MS diagnosis) ranged from 5% to 41%, with a pooled proportion based on six studies of 15% (95% CI: 9%-26%, n = 1621). The delay to rectify a misdiagnosis ranged from 0.3 to 15.9 years. Conversely, underdiagnosis (unrecognized diagnosis of MS) ranged from 3% to 58%, with a pooled proportion in four studies of 36% (95% CI: 20%-55%, n = 728). Pooling seven studies comprising 2851 individuals suggested a diagnostic delay to establish a correct MS diagnosis of 17.3 months (95% CI: 11.9-22.7) in patients underdiagnosed. In a meta-analysis of five studies, women were 2.1 times more likely to be misdiagnosed with MS compared to men (odds ratio, 95% CI: 1.53-2.86).

CONCLUSION

This study provides summary-level evidence for the high prevalence of MS misdiagnosis and underdiagnosis. Future studies are needed to understand the causes of these diagnostic challenges in MS care.

Albumin and multiple sclerosis: a prospective study from UK Biobank

Background

Multiple sclerosis (MS) is a chronic inflammatory disease affecting the central nervous system. While previous studies have indicated that albumin, the primary protein in human plasma, may exert influence on the inflammatory process and confer beneficial effects in neurodegenerative disorders, its role in the context of MS has been underexplored. Here, we aimed to explore the link between albumin and the risk of MS.

Methods

Employing data from the UK Biobank, we investigated the association between baseline levels of serum and urine albumin and the risk of MS using Cox proportional hazards regression analysis.

Results

A higher baseline level of serum albumin was associated with a lower risk of incident MS (HR=0.94, 95% CI: 0.91-0.98, P=7.66E-04). Subgroup analysis revealed a more pronounced effect in females, as well as participants with younger ages, less smoking and deficient levels of vitamin D. Conversely, no association was identified between baseline microalbuminuria level and risk of incident MS.

Conclusion

Higher serum albumin level at baseline is linked to a reduced risk of MS. These results contribute to an enhanced understanding of albumin's role in MS, propose the potential use of albumin as a biomarker for MS, and have implications for the design of therapeutic interventions targeting albumin in clinical trials.

Time interval between the onset of symptoms and diagnosis of multiple sclerosis and the influential factors: A national registry-based study

OBJECTIVE

The time to diagnosis of multiple sclerosis (MS) is of great importance for early treatment, thereby reducing the disability and burden of the disease. The purpose of this study was to determine the time from the onset of clinical symptoms to the diagnosis of MS and to evaluate the factors associated with a late diagnosis in Iranian MS patients.

METHODS

The present cross-sectional study was conducted on patients with MS who were registered in the National MS Registry System of Iran (NMSRI).

RESULTS

Overall, 23291 MS patients registered in 18 provinces of Iran were included in this study. The mean (standard deviation) interval between the onset of the disease and diagnosis of MS was 13.42 (32.40) months, and the median was one month. The diagnostic interval of 41.6% of patients was less than one month, and 14.8% of them had a one-month time to diagnosis. Patients with an age of onset below 18 years and those diagnosed after the age of 50 years had a longer time to diagnosis (P<0.001). Patients with primary progressive MS (PPMS) had the longest time to diagnose and those with relapsing-remitting MS (RRMS) had the shortest time (P<0.001). The results of negative binominal regression showed that the average rate of delay in diagnosis in women was 12% less than that in men. The average delay in diagnosis in patients with a positive family history of MS was 23% more than that in others. The rate of delay in the diagnosis of patients with PPMS and secondary progressive MS was 2.22 and 1.66 times higher, respectively, compared with RRMS.

CONCLUSION

The findings of the present study revealed that more than half of the MS patients were diagnosed within a one-month interval from the symptom onset, which is an acceptable period. More attention should be paid to patients' access to medical facilities and MS specialists.

Characteristics and long-term prognosis of Danish residents with a positive intrathecal antibody index test for herpes simplex virus or varicella-zoster virus compared with individuals with a positive cerebrospinal fluid PCR: a nationwide cohort study

OBJECTIVES

We compared characteristics and outcomes of individuals who in the cerebrospinal fluid (CSF) were positive for herpes simplex virus (HSV) or varicella-zoster virus (VZV)-intrathecal antibody index test ([AI]-positive) vs. individuals who were PCR-positive for HSV type 1 (HSV1), type 2 (HSV2), and for VZV.

METHODS

Nationwide cohort study of all Danish residents with positive CSF-AI or -PCR for HSV or VZV (1995-2021). We calculated short- and long-term risks as age-, sex-, and comorbidity-adjusted odds ratios (aOR), adjusted hazard ratios (aHR), and absolute risk differences with 95% CIs.

RESULTS

Compared with individuals with positive PCR for HSV1 (n = 321), HSV2 (n = 497), and VZV (n = 1054), individuals with a positive AI for HSV (n = 177) and VZV (n = 219) had CSF pleocytosis less frequently (leucocyte count >10/μL: HSV-AI: 39%, VZV-AI: 52%, HSV1-PCR: 81%, HSV2-PCR: 92%, VZV-PCR: 83%), and were less frequently diagnosed with central nervous system infection ([aOR {95%CI}]: HSV-AI vs. HSV1-PCR: [0.1 {0.1, 0.2}], HSV-AI vs. HSV2-PCR: [0.1 {0.0, 0.1}], VZV-AI vs. VZV-PCR: [0.2 {0.2, 0.3}]). Individuals with a positive HSV-AI or VZV-AI had increased risk of demyelinating disease ([aOR {95%CI}; aHR {95%CI}]: HSV-AI vs. HSV1-PCR: [4.6 {0.9, 24.5}; aHR not applicable], HSV-AI vs. HSV2-PCR: [10.4 {2.3, 45.9}; 12.4 {2.3, 66.0}], VZV-AI vs. VZV-PCR: [aOR not applicable; 10.3 {1.8, 58.8}]). Disability pension was less frequent among HSV-AI than HSV1-PCR cohort members (5-year risk difference: -23.6%, 95%CI: -35.2, -11.8), and more frequent among VZV-AI than VZV-PCR cohort members (5-year risk difference: 16.8%, 95%CI: 5.0, 28.7).

DISCUSSION

AI-positive individuals differ from PCR-positive individuals in several aspects. AI appears unspecific for current central nervous system infections.

Cerebrospinal fluid neurofilament light chains predicts early disease-activity in Multiple Sclerosis

BACKGROUND

Among biomarkers of axonal damage, neurofilament light chains (NFL) seem to play a major role, representing a promising and interesting tool in Multiple Sclerosis (MS). Our aim was to explore the predictive role of cerebrospinal fluid (CSF) NFL in patients with a recent diagnosis of MS, naïve to any MS therapy.

METHODS

We retrospectively collected data of patients diagnosed with MS, referred to the Neurology Clinic of the University-Hospital G. Rodolico of Catania between January 1st 2005 and December 31st 2015. All patients underwent CSF collection at the time of MS diagnosis and were followed-up for at least three years afterwards. NFL levels were measured in CSF samples with Simoa NFLight advantage kit at the CRESM (University Hospital San Luigi Gonzaga, Orbassano, Torino). NFL levels were expressed as LogNFL. Symbol Digit Modalities test (SDMT) was performed at baseline, at 1-year and at 3-year follow-up. Multivariate logistic regression analysis was performed to investigate LogNFL as a potential risk factor of different clinical outcomes.

RESULTS

244 MS patients (230 relapsing-remitting, RRMS; 94.3 %), with a mean age at diagnosis of 37.0 ± 11.1 years, were recruited. LogNFL did not correlate neither with EDSS score at diagnosis and at subsequent follow-up up to 12 years, nor with SDMT performed at diagnosis, at 1 year and at 3 years. LogNFL were an independent factor for the occurrence of at least one relapse during the first two years after MS diagnosis (OR = 2.75; 95 % CI 1.19-6.31; p = 0.02) and for the occurrence of gadolinium-enhanced (Gd+) lesions during the first 2 years from diagnosis at brain and spine MRI scans (OR = 3.45, 95 % CI 1.81-6.57; p < 0.001).

CONCLUSION

The detection of CSF NFL at the time of MS diagnosis can be a useful support to predict the two-year risk of clinical and radiological relapses, thus affecting therapeutic choices in the very early phases of the disease.

Diagnostic delay of multiple sclerosis: prevalence, determinants and consequences

BACKGROUND

Early diagnosis and treatment of patients with multiple sclerosis (MS) are associated with better outcomes; however, diagnostic delays remain a major problem.

OBJECTIVE

Describe the prevalence, determinants and consequences of delayed diagnoses.

METHODS

This single-centre ambispective study analysed 146 adult relapsing-remitting MS patients (2016-2021) for frequency and determinants of diagnostic delays and their associations with clinical, cognitive, imaging and biochemical measures.

RESULTS

Diagnostic delays were identified in 77 patients (52.7%), including 42 (28.7%) physician-dependent cases and 35 (24.0%) patient-dependent cases. Diagnosis was delayed in 22 (15.1%) patients because of misdiagnosis by a neurologist. A longer diagnostic delay was associated with trends towards greater Expanded Disability Status Scale (EDSS) scores (B = 0.03; p = 0.034) and greater z-score of the blood neurofilament light chain (B = 0.35; p = 0.031) at the time of diagnosis. Compared with patients diagnosed at their first clinical relapse, patients with a history of >1 relapse at diagnosis (n = 63; 43.2%) had a trend towards greater EDSS scores (B = 0.06; p = 0.006) and number of total (B = 0.13; p = 0.040) and periventricular (B = 0.06; p = 0.039) brain lesions.

CONCLUSION

Diagnostic delays in MS are common, often determined by early misdiagnosis and associated with greater disease burden.

Epidemiology of demyelinating diseases in Mexico: A registry-based study

BACKGROUND

Demyelinating diseases (DD) are a group of chronic neurological diseases associated with loss and injury of brain or spinal cord regions. These conditions could trigger impairment of neurological functions and disability from earlier stages of life. Epidemiological data on DD remains insufficient for decision-making in the Mexican healthcare system. This study aims to describe the epidemiology of DD based on data from Mexico's National Registry of Demyelinating Diseases.

METHODS

A cross-sectional, registry-based, observational study was performed. We analyzed 408 reports of multiple sclerosis (331, 81%), neuromyelitis optica spectrum disorder (67, 16%), chronic recurrent inflammatory optic neuropathy (5, 1%), clinically isolated syndrome (4, 0.9%), and autoimmune encephalitis (1, 0.2%) reported across 2021.

RESULTS

The time from first symptoms to diagnosis of any DD was about 3 years. A treatment failure history was detected in 40% of patients. It was estimated that NMOSD accounts for 20% of all disorders. There was evidence that the use of brand-name and generic IFN drug products lead to increased therapeutic failures.

CONCLUSION

Our research team suggests reinforcing educational programs and activities based on diagnosis and clinical management improvement to first-contact physicians and specialty doctors and promoting awareness in the whole population.

Multiple sclerosis diagnostic delay and its associated factors in Upper Egyptian patients

The earlier the diagnosis of multiple sclerosis (MS), the sooner disease-modifying treatments can be initiated. However, significant delays still occur in developing countries. We aimed to identify factors leading to delayed diagnosis of MS in Upper Egypt. One hundred forty-two patients with remitting relapsing MS (RRMS) were recruited from 3 MS units in Upper Egypt. Detailed demographic and clinical data were collected. Neurological examination and assessment of the Disability Status Scale (EDSS) were performed. The mean age was 33.52 ± 8.96 years with 72.5% of patients were females. The mean time from symptom onset to diagnosis was 18.63 ± 27.87 months and the median was 3 months. Seventy-two patients (50.7%) achieved diagnosis within three months after the first presenting symptom (early diagnosis), while seventy patients (49.3%) had more than three months delay in diagnosis (delayed diagnosis). Patients with a delayed diagnosis frequently presented in the period before 2019 and had a significantly higher rate of initial non-motor presentation, initial non-neurological consultations, prior misdiagnoses, and a higher relapse rate. Another possible factor was delayed MRI acquisition following the initial presentation in sixty-six (46.5%) patients. Multivariable logistic regression analysis demonstrated that earlier presentation, initial non-neurological consultation, and prior misdiagnosis were independent predictors of diagnostic delay. Despite advances in MS management in Egypt, initial non-neurological consultation and previous misdiagnoses are significant factors responsible for delayed diagnosis in Upper Egypt.

The impact of sociodemographic characteristics on diagnosis and access to disease-modifying treatment for patients with multiple sclerosis in Morocco

OBJECTIVE

This study aims to determine the link between sociodemographic factors, diagnosis, and access to disease-modifying treatment for patients with multiple sclerosis (MS) in Morocco.

METHODS

This study concerned a sample of 520 patients representing seven regions of Morocco. We obtained data from the patient record registers, the patient's files, and a questionnaire.

RESULTS

The results showed female dominance (69.4%) in patients with MS (69.4%). Besides, patients with this disease are generally young; their mean age is 35.36. The employment rate among the surveyed population was 24.9%. More than 74.6% have no health care coverage, and 70.4% of the patients investigated live without treatment. The results show a significant association between access to treatment and several sociodemographic factors, such as the patient's job, health care coverage, region, and marital status. There is also a link between these sociodemographic factors and access to diagnosis.

CONCLUSIONS

Diagnosis and access to treatment are associated with certain sociodemographic factors such as health insurance coverage, the patient's job, regional belonging, and marital status.

Immune aging in multiple sclerosis is characterized by abnormal CD4 T cell activation and increased frequencies of cytotoxic CD4 T cells with advancing age

BACKGROUND

Immunosenescence (ISC) describes age-related changes in immune-system composition and function. Multiple sclerosis (MS) is a lifelong inflammatory condition involving effector and regulatory T-cell imbalance, yet little is known about T-cell ISC in MS. We examined age-associated changes in circulating T cells in MS compared to normal controls (NC).

METHODS

Forty untreated MS (Mean Age 43·3, Range 18-72) and 49 NC (Mean Age 48·6, Range 20-84) without inflammatory conditions were included in cross-sectional design. T-cell subsets were phenotypically and functionally characterized using validated multiparametric flow cytometry. Their aging trajectories, and differences between MS and NC, were determined using linear mixed-effects models.

FINDINGS

MS patients demonstrated early and persistent redistribution of naïve and memory CD4 T-cell compartments. While most CD4 and CD8 T-cell aging trajectories were similar between groups, MS patients exhibited abnormal age-associated increases of activated (HLA-DR+CD38+; (P = 0·013) and cytotoxic CD4 T cells, particularly in patients >60 (EOMES: P < 0·001). Aging MS patients also failed to upregulate CTLA-4 expression on both CD4 (P = 0·014) and CD8 (P = 0·009) T cells, coupled with abnormal age-associated increases in frequencies of B cells expressing costimulatory molecules.

INTERPRETATION

While many aspects of T-cell aging in MS are conserved, the older MS patients harbour abnormally increased frequencies of CD4 T cells with activated and cytotoxic effector profiles. Age-related decreased expression of T-cell co-inhibitory receptor CTLA-4, and increased B-cell costimulatory molecule expression, may provide a mechanism that drives aberrant activation of effector CD4 T cells that have been implicated in progressive disease.

FUNDING

Stated in Acknowledgements section of manuscript.

Factors driving delayed time to multiple sclerosis diagnosis: Results from a population-based study

BACKGROUND

Multiple sclerosis (MS) is a highly complex chronic inflammatory disease, in which a diagnostic delay could reduce the available therapeutic options. Our aim was to identify factors contributing to diagnostic delay in a MS population living in the municipality of Biancavilla.

METHODS

This retrospective population-based study consecutively selected patients with MS diagnosed from 1992 to 2018 and resident in the city of Biancavilla. Socio-demographic and clinical data were collected through the iMed database. Date of final MS diagnosis was obtained and diagnostic delay was calculated.

RESULTS

A total of 70 patients (66.7% women) were found affected by MS according to the 2011 McDonald criteria in the municipality of Biancavilla in the period between 2005 and 2010. The mean diagnostic delay in the MS cohort of Biancavilla was 33.8 ± 56 months [median 19.5, range 1-315]. The multivariate logistic regression confirmed that age ≥ 40 years, lower educational level (1-5 years) and motor symptoms at onset were associated to longer diagnostic delay.

CONCLUSION

In this population-based study a mean delay of about 30 months occurred between initial symptoms and the MS diagnosis. Older age at onset, lower education level and motor symptoms at onset were associated to longer MS diagnostic delay.

A comprehensive assessment of patient experience and disease-related awareness in multiple sclerosis: A questionnaire-based nation-wide survey in Turkey

BACKGROUND

Comprehensive assessment of multiple sclerosis (MS) patients in terms of patient profile, clinical and disease-related factors has great epidemiological value. This study aimed to evaluate patient experience and disease-related awareness in MS patients through a nation-wide survey in Turkey Methods: A total of 1379 MS patients participated in this cross-sectional questionnaire survey conducted between November 2018 and December 2018. The online questionnaire form included items on sociodemographic, disease-related, first-admission, treatment and follow up characteristics as well as the disability status.

RESULTS

Patients were diagnosed at median 28.0 years of age, while the average time from admission to diagnosis and time from diagnosis to treatment were 1.2 years and 2.5 months, respectively. Neurology (45.4%) and ophthalmology (23.3%) were the most common clinics for the first admission, while numbness-weakness in lower and upper extremities (37.6%) and double vision-visual problems (30.6%) were the most common symptoms on initial admission. Treatment was initiated after the diagnosis in 1213(88.0%) patients, while 166 (12.0%) patients were treatment-naïve. Treatment discontinuation, treatment switch and use of alternative treatment methods were reported by 31.3%, 49.3% and 22.8% of patients, respectively. The ophthalmology admissions (with double vision or visual problems) were associated with the shortest time from presentation to diagnosis as compared with neurosurgery and internal medicine admissions (median 1.0 vs. 3.0 and 4.0 months, p<0.001). The neurology admissions (with numbness-weakness in extremities) were associated with more prompt (median 0.3 vs. 0.5 months, p=0.032) and more frequent onset of treatment after diagnosis (64.5% vs. 2.2% to 15.2%, p<0.001). Time from presentation to diagnosis was longer in patients aged >50 years (median 6.0 months vs. 2.0 months, p<0.001), in patients using alternative medicine (median 3.0 months vs. 1 month, p=0.001) and in patients admitted to a non-MS-center (median 3.0 months vs. 2.0 months, p=0.002). Median (min-max) age at diagnosis was significantly lower in patients with vs. without treatment discontinuation for any reason (26.0(10-56) vs. 29.0(3-60) years, p<0.001) and treatment switching (27.0(5-93) vs. 30.0(3-60) years, p<0.001).

CONCLUSIONS

In conclusion, our findings revealed higher likelihood of earlier diagnosis and earlier treatment in patients admitted to an MS-center and in those presenting with ocular problems and sensory-motor deficits, respectively. Our findings also emphasize the association of older patient age with higher likelihood of diagnostic delay, and increased likelihood of treatment discontinuation for any reason and/or treatment switching in case of older patient age, younger age at diagnosis and diagnostic delay. In this regard, our findings highlight the need for improved awareness among patients as well as clinicians on initial manifestations of MS to enable admission or referral to an MS-center and to prevent delay in diagnosis, particularly for onset symptoms other than ocular or sensory-motor characteristics.

Socioeconomic status and access to multiple sclerosis treatment in Mexico

INTRODUCTION

Multiple sclerosis (MS) is a chronic neurological autoimmune condition and the leading non-traumatic cause of neurological disability worldwide. Disease-modifying therapies (DMT) directly impact on the long-term prognosis of patients with MS preventing relapses and the associated disability progression. Here, we analyzed the impact of socioeconomic status (SES) on DMT access in Mexican patients.

METHODS

We evaluated the association between SES and DMT access using the MS registry from the National Institute of Neurology and Neurosurgery in Mexico City. We included 974 patients with MS (McDonald 2010 criteria). We categorized SES according to the 2018 Mexican Association of Market Research Agencies (AMAI) SES classification. We analyzed DMT type, MS phenotype, educational level, symptomatic onset to diagnosis, EDSS at arrival, as well as the progression index. Chi-squared and Wilcoxon tests were used, and multivariable analysis performed for DMT access.

RESULTS

When comparing the lower versus higher levels of SES, a significant association was found on the percentage of patients with higher levels of disability (EDSS >6) at arrival, the proportion of patients not receiving any DMT and a higher proportion of secondary progressive MS (p=0.006, p<0.001and p=0.004, respectively). We also found that lower educational levels had a significance and inverse association with EDSS on first visit (p=0.019), symptomatic onset to diagnosis (p<0.001) and a higher disability status at arrival (EDSS >6, p=0.010).

CONCLUSIONS

Our study suggests that SES is an important factor determining not only prompt but overall access to highly effective DMT. Lower SES are associated with greater levels of disability at the first clinic visit and a higher proportion of patients not receiving DMT up to 12 months of follow-up.

Status of Immunotherapy Acceptance in Chinese Patients With Multiple Sclerosis: Analysis of Multiple Sclerosis Patient Survival Report 2018

Objective: The prevalence of multiple sclerosis (MS) in China is low, although it has been increasing recently. Owing to the paucity of data on immunotherapy acceptance in the Chinese population, we conducted this study to analyze factors affecting the acceptance of immunotherapy and selection of disease-modifying therapies (DMTs) based on personal and clinical data of patients with MS. Methods: In this study, data were obtained from the Multiple Sclerosis Patient Survival Report 2018, which was the first national survey of patients with MS in China. There were 1,212 patients with MS from 31 provinces who were treated at 49 Chinese hospitals over a 4-month period from May 2018 to August 2018, and the patients were asked to complete online questionnaires to assess their understanding of the disease. Results: In general, highly educated patients with frequent relapses were more willing to receive treatment regardless of DMTs or other immunotherapy, and patients with more understanding of the disease opted to be treated. Younger patient population, patients with severe disease course, and those with more symptoms were likely to choose the treatment. Moreover, a higher proportion of women chose to be treated with DMTs than with other immunotherapies. Conclusions: Education status and patient awareness of the disease impact the treatment acceptance in Chinese patients with MS. Therefore, we call for improving the awareness of MS disease and social security to help patients to improve their quality of life.

A Deep Learning Approach to Diagnosing Multiple Sclerosis from Smartphone Data

Multiple sclerosis (MS) affects the central nervous system with a wide range of symptoms. MS can, for example, cause pain, changes in mood and fatigue, and may impair a person's movement, speech and visual functions. Diagnosis of MS typically involves a combination of complex clinical assessments and tests to rule out other diseases with similar symptoms. New technologies, such as smartphone monitoring in free-living conditions, could potentially aid in objectively assessing the symptoms of MS by quantifying symptom presence and intensity over long periods of time. Here, we present a deep-learning approach to diagnosing MS from smartphone-derived digital biomarkers that uses a novel combination of a multilayer perceptron with neural soft attention to improve learning of patterns in long-term smartphone monitoring data. Using data from a cohort of 774 participants, we demonstrate that our deep-learning models are able to distinguish between people with and without MS with an area under the receiver operating characteristic curve of 0.88 (95% CI: 0.70, 0.88). Our experimental results indicate that digital biomarkers derived from smartphone data could in the future be used as additional diagnostic criteria for MS.

Deep-Learning Generated Synthetic Double Inversion Recovery Images Improve Multiple Sclerosis Lesion Detection

OBJECTIVES

The aim of the study was to implement a deep-learning tool to produce synthetic double inversion recovery (synthDIR) images and compare their diagnostic performance to conventional sequences in patients with multiple sclerosis (MS).

MATERIALS AND METHODS

For this retrospective analysis, 100 MS patients (65 female, 37 [22-68] years) were randomly selected from a prospective observational cohort between 2014 and 2016. In a subset of 50 patients, an artificial neural network (DiamondGAN) was trained to generate a synthetic DIR (synthDIR) from standard acquisitions (T1, T2, and fluid-attenuated inversion recovery [FLAIR]). With the resulting network, synthDIR was generated for the remaining 50 subjects. These images as well as conventionally acquired DIR (trueDIR) and FLAIR images were assessed for MS lesions by 2 independent readers, blinded to the source of the DIR image. Lesion counts in the different modalities were compared using a Wilcoxon signed-rank test, and interrater analysis was performed. Contrast-to-noise ratios were compared for objective image quality.

RESULTS

Utilization of synthDIR allowed to detect significantly more lesions compared with the use of FLAIR images (31.4 ± 20.7 vs 22.8 ± 12.7, P < 0.001). This improvement was mainly attributable to an improved depiction of juxtacortical lesions (12.3 ± 10.8 vs 7.2 ± 5.6, P < 0.001). Interrater reliability was excellent in FLAIR 0.92 (95% confidence interval [CI], 0.85-0.95), synthDIR 0.93 (95% CI, 0.87-0.96), and trueDIR 0.95 (95% CI, 0.85-0.98).Contrast-to-noise ratio in synthDIR exceeded that of FLAIR (22.0 ± 6.4 vs 16.7 ± 3.6, P = 0.009); no significant difference was seen in comparison to trueDIR (22.0 ± 6.4 vs 22.4 ± 7.9, P = 0.87).

CONCLUSIONS

Computationally generated DIR images improve lesion depiction compared with the use of standard modalities. This method demonstrates how artificial intelligence can help improving imaging in specific pathologies.

Functional neurological disorder and multiple sclerosis: a systematic review of misdiagnosis and clinical overlap

Multiple sclerosis (MS) and functional neurological disorder (FND) are both diagnostically challenging conditions which can present with similar symptoms. We systematically reviewed the literature to identify patients with MS who were misdiagnosed with FND, patients with FND who were misdiagnosed with MS, and reports of patients with both conditions. In addition to FND, we included studies of patients with other functional and psychiatric disorders where these caused symptoms leading to investigation for or a diagnosis of MS, which in a different context would likely have been labeled as FND. Our review suggests that MS is one of the most common causes of misdiagnosis of FND and vice versa. We discuss the clinical errors that appear to result in misdiagnoses, such as over-reliance on psychiatric comorbidity when making a diagnosis of FND or over-reliance on neuroimaging for the diagnosis of MS, and practical ways to avoid them. Comorbidity between these two conditions is also likely common, has been poorly studied, and adds complexity to diagnosis and treatment in patients with both MS and FND. Misdiagnosis and comorbidity in a landscape of emerging evidence-based treatments for both MS and FND are issues not only of clinical importance to the care of these patients, but also to treatment trials, especially of MS, where FND could be a hidden confounder.

Assessment of delayed diagnosis and treatment in multiple sclerosis patients during 1990-2016

Multiple sclerosis (MS) is the most common inflammatory demyelinating disease in the central nervous system. It is one of the major causes of disability in young adults. Early diagnosis and treatment of this disease could decrease later disability and additional costs. In this cross-sectional analytical study, a total of 351 patients were selected from among the multiple sclerosis patients that went to MS clinic or neurologic clinic in 1990-2016. Data were collected and analysed by SPSS v16. This study was conducted on 82.6% females and 17.4% males. Family history of MS was positive in 12.8% of cases. Mean time of onset of symptoms till first medical visit was 3.25 months. Mean time from first medical visit to diagnosis was 14.98 months. Mean time from onset of symptoms till diagnosis was 18.01 months and the mean time from onset of symptoms till initiation of treatment was 18.73 months. Also, 29.3% of cases had delay in first medical visit and 42.2% of cases had delay in diagnosis of MS more than 6 weeks from first medical visit. Overall, delay in first medical visit and diagnosis of MS has decreased over the years. However, there is still delay in diagnosis of MS. Factors associated with delay are low education, male gender, living in rural areas, primary progressive MS, age at MS diagnosis and first clinical symptoms.

Delayed diagnosis of multiple sclerosis in a low prevalence country

Background: Early diagnosis and treatment of multiple sclerosis (MS) is crucial to avoid future disability. The factors that influence diagnostic delay in low prevalence settings have been poorly studied.Objectives: To evaluate the factors associated with a delayed diagnosis of MS after the symptomatic onset.Methods: Clinical records of confirmed MS patients were reviewed. Diagnostic delay was calculated by subtracting the date of onset from the date of diagnosis and categorized as early and delayed, when below and above than 1 year. Logistic regression was performed to evaluate the likelihood of a delayed diagnosis according to age at first symptom, gender, type of the first symptom, progressive vs relapsing onset, diagnostic criteria prevailing at the time of symptom onset, comorbidities, and family history of MS.Results: Data of 525 (95.6%) from a cohort of 549 patients were analyzed. About 69.1% were women. The mean age was 43.2 years. About 86.3% had relapsing-remitting MS. The mean overall diagnostic delay was 3.07 years. About 45.7% of the patients had a delayed diagnosis, and it was dependent on the symptom and the diagnostic criteria prevailing at the onset. Multivariate logistic regression showed onset during the Schumacher (OR = 10.03 [95%CI 1.30-77.1], p = 0.027) and Poser (OR = 4.26 [95%CI 1.25-15.15], p = 0.021) years were associated with delayed MS diagnosis.Conclusions: MS onset before the McDonald diagnostic criteria era is associated with delayed diagnosis.

Detecting Multiple Sclerosis via breath analysis using an eNose, a pilot study

OBJECTIVE

In the present study we investigated whether Multiple Sclerosis (MS) can be detected via exhaled breath analysis using an electronic nose. The AeonoseTM (an electronic nose, The eNose Company, Zutphen, The Netherlands) is a diagnostic test device to detect patterns of volatile organic compounds in exhaled breath. We evaluated whether the AeonoseTM can make a distinction between the breath patterns of patients with MS and healthy control subjects.

METHODS

In this mono-center, prospective, non-invasive study, 124 subjects with a confirmed diagnosis of MS and 129 control subjects each breathed into the AeonoseTM for 5 minutes. Exhaled breath data was used to train an artificial neural network (ANN) predictive model. To investigate the influence of medication intake we created a second predictive model with a subgroup of MS patients without medication prescribed for MS.

RESULTS

The ANN model based on the entire dataset was able to distinguish MS patients from healthy controls with a sensitivity of 0.75 [95% CI: 0.66-0.82] and specificity of 0.60 [0.51-0.69]. The model created with the subgroup of MS patients not using medication and the healthy control subjects had a sensitivity of 0.93 [0.82-0.98] and a specificity of 0.74 [0.65-0.81].

CONCLUSION

The study showed that the AeonoseTM is able to make a distinction between MS patients and healthy control subjects, and could potentially provide a quick screening test to assist in diagnosing MS. Further research is needed to determine whether the AeonoseTM is able to differentiate new MS patients from subjects who will not get the diagnosis.

Integration of the Extreme Gradient Boosting model with electronic health records to enable the early diagnosis of multiple sclerosis

BACKGROUND

Delayed multiple sclerosis (MS) diagnoses are not uncommon, an early diagnostic tool is urgently warranted. We aimed to develop an effective tool through electronic health records and machine learning techniques to early recognize MS patients from hospital visitors in China.

METHODS

Two case sets were collected from January 2016 to December 2018. The training set had 239 MS and 1142 controls, and the test set had 23 MS and 92 controls. The utility of Extreme Gradient Boosting (XGBoost), Random Forest (RF), Naive Bayes, K-nearest-neighbor (KNN) and Support Vector Machine (SVM) in early diagnosis of MS was evaluated by the area under curve of receiver operating characteristic, precision, recall, specificity, accuracy and F1 score.

RESULTS

The XGBoost performed the best and was used to generate the results. Thirty-four variables which were highly relevant to MS diagnosis were set for the XGBoost model, and their relative importance with MS were ranked. The training set recall was 0.632, with a precision of 0.576, and the test set recall was 0.609, with a precision of 0.609. Our study found that 61%, 51%, and 49% of the patients could be diagnosed with MS, 1, 2, and 3 years earlier than their real diagnostic time point, respectively.

CONCLUSIONS

A diagnostic tool for early MS recognition based on the XGBoost model and electronic health records were developed to help reduce diagnostic delays in MS.

Impact of communication on first treatment decisions in people with relapsing-remitting multiple sclerosis

OBJECTIVE

Disease-Modifying Treatments (DMTs) have contributed to a new clinical landscape for people with relapsing-remitting multiple sclerosis (pwRRMS). A challenge for services is how to support DMT decisions with changing clinical evidence, and differing treatment goals. This article investigates how pwRRMS weigh up the pros and cons of DMTs by examining how communication at the point of diagnosis is related to DMT decisions.

METHODS

30 semi-structured interviews with pwRRMS in England were conducted using a theoretical purposive sampling strategy and analysed using the thematic approach to answer: How does communication about RRMS during diagnosis influence decisions about when and which DMT to choose?

RESULTS

Three meta-themes were identified: a) communication context; b) delayed communication and hope for people with "non-active" RRMS at diagnosis; c) people with "active" RRMS at diagnosis: Conflated, generic, selective and simplified information CONCLUSION: At the time of diagnosis, patient-physician interactions are characterised by emotions and information complexity. Clinical, social and psychological DMT filtering mechanisms are activated during first decisions. Personalised evidence is needed to make informed decisions.

PRACTICE IMPLICATIONS

Patient decision aids should consider first and consecutive decisions and should not encourage a false sense of large choices that could add to decision anxiety.

Social value of a set of proposals for the ideal approach of multiple sclerosis within the Spanish National Health System: a social return on investment study

BACKGROUND

Multiple Sclerosis (MS) is a chronic inflammatory, demyelinating and neurodegenerative disease that in many cases produces disability, having a high impact in patients' lives, reducing significantly their quality of life. The aim of this study was to agree on a set of proposals to improve the current management of MS within the Spanish National Health System (SNHS) and apply the Social Return on Investment (SROI) method to measure the potential social impact these proposals would create.

METHODS

A Multidisciplinary Working Team of nine experts, with representation from the main stakeholders regarding MS, was set up to agree on a set of proposals to improve the management of MS. A forecast SROI analysis was carried out, with a one-year timeframe. Data sources included an expert consultation, a narrative literature review and a survey to 532 MS patients. We estimated the required investment of a hypothetical implementation, as well as the potential social value that it could create. We calculated outcomes in monetary units and we measured intangible outcomes through financial proxies.

RESULTS

The proposed ideal approach revealed that there are still unmet needs related to MS that can be addressed within the SNHS. Investment would amount to 148 million € and social return to 272 million €, so each euro invested could yield almost €2 of social return.

CONCLUSIONS

This study could guide health interventions, resulting in money savings for the SNHS and increases in patients' quality of life.

Illuminating an Invisible Epidemic: A Systemic Review of the Clinical and Economic Benefits of Early Diagnosis and Treatment in Inflammatory Disease and Related Syndromes

Healthcare expenditures in the United States are growing at an alarming level with the Centers for Medicare and Medicaid Services (CMS) projecting that they will reach $5.7 trillion per year by 2026. Inflammatory diseases and related syndromes are growing in prevalence among Western societies. This growing population that affects close to 60 million people in the U.S. places a significant burden on the healthcare system. Characterized by relatively slow development, these diseases and syndromes prove challenging to diagnose, leading to delayed treatment against the backdrop of inevitable disability progression. Patients require healthcare attention but are initially hidden from clinician's view by the seemingly generalized, non-specific symptoms. It is imperative to identify and manage these underlying conditions to slow disease progression and reduce the likelihood that costly comorbidities will develop. Enhanced diagnostic criteria coupled with additional technological innovation to identify inflammatory conditions earlier is necessary and in the best interest of all healthcare stakeholders. The current total cost to the U.S. healthcare system is at least $90B dollars annually. Through unique analysis of financial cost drivers, this review identifies opportunities to improve clinical outcomes and help control these disease-related costs by 20% or more.

A computer-aided diagnosis of multiple sclerosis based on mfVEP recordings

Introduction

The aim of this study is to develop a computer-aided diagnosis system to identify subjects at differing stages of development of multiple sclerosis (MS) using multifocal visual-evoked potentials (mfVEPs). Using an automatic classifier, diagnosis is performed first on the eyes and then on the subjects.

Patients

MfVEP signals were obtained from patients with Radiologically Isolated Syndrome (RIS) (n = 30 eyes), patients with Clinically Isolated Syndrome (CIS) (n = 62 eyes), patients with definite MS (n = 56 eyes) and 22 control subjects (n = 44 eyes). The CIS and MS groups were divided into two subgroups: those with eyes affected by optic neuritis (ON) and those without (non-ON).

Methods

For individual eye diagnosis, a feature vector was formed with information about the intensity, latency and singular values of the mfVEP signals. A flat multiclass classifier (FMC) and a hierarchical classifier (HC) were tested and both were implemented using the k-Nearest Neighbour (k-NN) algorithm. The output of the best eye classifier was used to classify the subjects. In the event of divergence, the eye with the best mfVEP recording was selected.

Results

In the eye classifier, the HC performed better than the FMC (accuracy = 0.74 and extended Matthew Correlation Coefficient (MCC) = 0.68). In the subject classification, accuracy = 0.95 and MCC = 0.93, confirming that it may be a promising tool for MS diagnosis.

Conclusion

In addition to amplitude (axonal loss) and latency (demyelination), it has shown that the singular values of the mfVEP signals provide discriminatory information that may be used to identify subjects with differing degrees of the disease.

How do patients enter the healthcare system after the first onset of multiple sclerosis symptoms? The influence of setting and physician specialty on speed of diagnosis

Background:

Diagnosing multiple sclerosis (MS) early is crucial to avoid future disability. However, potentially preventable delays in the diagnostic cascade from contact with a physician to definite diagnosis still occur and their causes are still unclear.

Objective:

To identify the possible causes of delays in the diagnostic process.

Methods:

We analyzed the data of the Swiss MS Registry. With logistic regression, we modeled the time from the first contact to the first consultation (contact-to-evaluation time, ⩽1 month/>1 month) and the evaluation-to-diagnosis time (⩽6 months/>6 months). Potential factors were health system characteristics, sociodemographic variables, first symptoms, and MS type.

Results:

We included 522 participants. Mostly, general practitioners (67%) were contacted first, without delaying the diagnosis. In contrast, first symptoms and MS type were the major contributors to delays: gait problems were associated with longer contact-to-evaluation times, depression as a concomitant symptom with longer evaluation-to-diagnosis times, and having primary progressive MS prolonged both phases. In addition, living in mountainous areas was associated with longer contact-to-evaluation times, whereas diagnosis after 2000 was associated with faster diagnoses.

Conclusion:

For a quicker diagnosis, awareness of MS as a differential diagnosis of gait disorders and the co-occurrence of depression at onset should be raised, and these symptoms should be attentively followed.

Enduring Clinical Value of Copaxone® (Glatiramer Acetate) in Multiple Sclerosis after 20 Years of Use

Multiple sclerosis (MS) is a chronic progressive neurodegenerative demyelinating disease affecting the central nervous system. Glatiramer acetate (GA; Copaxone®) was the first disease-modifying treatment (DMT) for MS successfully tested in humans (1977) and was approved by the US Food and Drug Administration in December 1996. Since then, there have been numerous developments in the MS field: advances in neuroimaging allowing more rapid and accurate diagnosis; the availability of a range of DMTs including immunosuppressant monoclonal antibodies and oral agents; a more holistic approach to treatment by multidisciplinary teams; and an improved awareness of the need to consider a patient's preferences and patient-reported outcomes such as quality of life. The use of GA has endured throughout these advances. The purpose of this article is to provide an overview of the important developments in the MS field during the 20 years since GA was approved and to review clinical data for GA in MS, with the aim of understanding the continued and widespread use of GA. Both drug-related (efficacy versus side-effect profile and monitoring requirements) and patient factors (preferences regarding mode of administration and possible pregnancy) will be explored.

Factors associated with time from first-symptoms to diagnosis and treatment initiation of Multiple Sclerosis in Switzerland

BACKGROUND

Recent studies emphasise the importance of timely diagnosis and early initiation of disease-modifying treatment in the long-term prognosis of multiple sclerosis.

OBJECTIVES

The objective of this study was to investigate factors associated with extended time to diagnosis and time to disease-modifying treatment initiation in the Swiss Multiple Sclerosis Registry.

METHODS

We used retrospective data (diagnoses 1996-2017) of the survey-based Swiss Multiple Sclerosis Registry and fitted logistic regression models (extended time to diagnosis ≥2 years from first symptoms, extended time to disease-modifying treatment initiation ≥1 year from diagnosis) with demographic and a priori defined variables.

RESULTS

Our study, based on 996 persons with multiple sclerosis, suggests that 40% had an extended time to diagnosis, and extended time to disease-modifying treatment initiation was seen in 23%. Factors associated with extended time to diagnosis were primary progressive multiple sclerosis (odds ratio (OR) 5.09 (3.12-8.49)), diagnosis setting outside of hospital (neurologist (private practice) OR 1.54 (1.16-2.05)) and more uncommon first symptoms (per additional symptom OR 1.17 (1.06-1.30)). Older age at onset (per additional 5 years OR 0.84 (0.78-0.90)) and gait problems (OR 0.65 (0.47-0.89)) or paresthesia (OR 0.72 (0.54-0.95)) as first symptoms were associated with shorter time to diagnosis. Extended time to disease-modifying treatment initiation was associated with older age at diagnosis (per additional 5 years OR 1.18 (1.09-1.29)). In more recent years, time to diagnosis and time to disease-modifying treatment initiation tended to be shorter.

CONCLUSIONS

Even in recent periods, substantial and partially systematic variation regarding time to diagnosis and time to disease-modifying treatment initiation remains. With the emerging paradigm of early treatment, the residual variation should be monitored carefully.

A nationwide epidemiological study on the prevalence of multiple sclerosis and neuromyelitis optica spectrum disorder with important multi-ethnic differences in Malaysia

OBJECTIVES

This study looked at observed crude prevalence/incidence of multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) in Malaysia and identified any inter-ethnic differences for MS/NMOSD.

METHODS

This was a nationwide tertiary hospital-based retrospective cross-sectional study using the capture-recapture method. It looked at the estimated crude prevalence of confirmed MS and NMOSD and annual incidence on 29 December 2017. Recapture of data was done between February and March 2018 on 1 March 2018. Public and referring private institutions were accessed.

RESULTS

The survey identified 767 MS and 545 NMOSD subjects, with crude prevalence rates of 2.73 per 100,000 (95% confidence interval (CI): 2.53; 2.92 per 100,000 population) and 1.94 per 100,000 (95% CI: 1.77; 2.10 per 100,000 population) with observed crude annual incidence of 0.55 (95% CI: 0.43; 0.58) for MS and 0.39 per 100,000 (95% CI: 0.35; 0.47) for NMOSD. The MS:NMOSD ratios were 1.4:1.0. The capture-recapture method revealed 913 MS (95% CI: 910; 915.9) and 580 (95% CI: 578.8; 581.2) NMOSD with prevalence per 100,000 of 3.26 (95% CI: 3.05; 3.47) and 2.07 (95% CI: 1.90; 2.24), respectively. In the MS group, 59.4% were Malay, 16.6% Chinese, 20.5% Indian, and 3.5% were from indigenous groups. In the NMOSD group, 47.3% were Malay, 46.9% Chinese, 3.5% Indian, and 2.3% were from other indigenous groups. The ratio of NMOSD to MS among the Chinese was 2:1, but the ratio of MS to NMOSD among the Malays was 1.8:1, and that in Indians was 8.3:1.

CONCLUSION

There is a modest increase in the prevalence of MS and NMOSD in Malaysia with inter-ethnic differences for MS/NMOSD.

Early recognition of multiple sclerosis using natural language processing of the electronic health record

BACKGROUND

Diagnostic accuracy might be improved by algorithms that searched patients' clinical notes in the electronic health record (EHR) for signs and symptoms of diseases such as multiple sclerosis (MS). The focus this study was to determine if patients with MS could be identified from their clinical notes prior to the initial recognition by their healthcare providers.

METHODS

An MS-enriched cohort of patients with well-established MS (n = 165) and controls (n = 545), was generated from the adult outpatient clinic. A random sample cohort was generated from randomly selected patients (n = 2289) from the same adult outpatient clinic, some of whom had MS (n = 16). Patients' notes were extracted from the data warehouse and signs and symptoms mapped to UMLS terms using MedLEE. Approximately 1000 MS-related terms occurred significantly more frequently in MS patients' notes than controls'. Synonymous terms were manually clustered into 50 buckets and used as classification features. Patients were classified as MS or not using Naïve Bayes classification.

RESULTS

Classification of patients known to have MS using notes of the MS-enriched cohort entered after the initial ICD9[MS] code yielded an ROC AUC, sensitivity, and specificity of 0.90 [0.87-0.93], 0.75[0.66-0.82], and 0.91 [0.87-0.93], respectively. Similar classification accuracy was achieved using the notes from the random sample cohort. Classification of patients not yet known to have MS using notes of the MS-enriched cohort entered before the initial ICD9[MS] documentation identified 40% [23-59%] as having MS. Manual review of the EHR of 45 patients of the random sample cohort classified as having MS but lacking an ICD9[MS] code identified four who might have unrecognized MS.

CONCLUSIONS

Diagnostic accuracy might be improved by mining patients' clinical notes for signs and symptoms of specific diseases using NLP. Using this approach, we identified patients with MS early in the course of their disease which could potentially shorten the time to diagnosis. This approach could also be applied to other diseases often missed by primary care providers such as cancer. Whether implementing computerized diagnostic support ultimately shortens the time from earliest symptoms to formal recognition of the disease remains to be seen.

Characteristics and predictors of progression in an Egyptian multiple sclerosis cohort: a multicenter registry study

BACKGROUND

Multiple sclerosis (MS) is a complex autoimmune disease with a heterogeneous presentation and diverse disease course. Recent studies indicate a rising prevalence of MS in the Middle East.

OBJECTIVE

To characterize the demographics and disease features of Egyptian patients attending four tertiary referral MS centers in Cairo.

MATERIALS AND METHODS

This was a retrospective, observational study on 1,581 patients between 2001 and 2015. Medical records were reviewed and data were identified and extracted in a standardized electronic registry.

RESULTS

The mean age of disease onset was 26.6±7.8 years, with the majority being female (2.11:1). Relapsing-remitting MS was the most common type (75.1%). The main presenting symptom was motor weakness (43.9%), which was also the most frequent symptom during the disease course. Family history of MS was found in 2.28%. Higher initial Expanded Disability Status Scale score, black holes, and infratentorial lesions on initial magnetic resonance imaging were independent factors for disease progression by univariate analysis (OR 3.87 [95% CI 1.84-6.51], 4.14 [95% CI 3.08-5.58], 4.07 [95% CI 3.21-4.99], respectively); however, in multivariate analysis, only infratentorial lesions were an independent risk for disease progression (OR 6, 95% CI 2.99-12.02; P=0.0005).

CONCLUSION

The results from this registry - the largest for MS in the Arab region to date - are comparable to other registries with slight differences.

The Prevalence of Bipolar Disorders and Association With Quality of Life in a Cohort of Patients With Multiple Sclerosis

Clinical observations of mood instability in multiple sclerosis (MS) have led to the hypothesis that bipolar disorder (BD) may be more prevalent in persons with MS than in the general population. This cross-sectional study assesses the prevalence of BD among patients with MS using standardized psychiatric diagnostic interviews and evaluates quality of life. This study demonstrates a higher prevalence of BD in patients with MS compared with the general population. It also reveals the negative impact of BD on quality of life, raises the concern that BD can occur before the onset of neurological symptoms in MS, and suggests that, in some cases, BD may delay diagnosis of MS.

Brain health: time matters in multiple sclerosis

INTRODUCTION

We present international consensus recommendations for improving diagnosis, management and treatment access in multiple sclerosis (MS). Our vision is that these will be used widely among those committed to creating a better future for people with MS and their families.

METHODS

Structured discussions and literature searches conducted in 2015 examined the personal and economic impact of MS, current practice in diagnosis, treatment and management, definitions of disease activity and barriers to accessing disease-modifying therapies (DMTs).

RESULTS

Delays often occur before a person with symptoms suggestive of MS sees a neurologist. Campaigns to raise awareness of MS are needed, as are initiatives to improve access to MS healthcare professionals and services. We recommend a clear treatment goal: to maximize neurological reserve, cognitive function and physical function by reducing disease activity. Treatment should start early, with DMT and lifestyle measures. All parameters that predict relapses and disability progression should be included in the definition of disease activity and monitored regularly when practical. On suboptimal control of disease activity, switching to a DMT with a different mechanism of action should be considered. A shared decision-making process that embodies dialogue and considers all appropriate DMTs should be implemented. Monitoring data should be recorded formally in registries to generate real-world evidence. In many jurisdictions, access to DMTs is limited. To improve treatment access the relevant bodies should consider all costs to all parties when conducting economic evaluations and encourage the continuing investigation, development and use of cost-effective therapeutic strategies and alternative financing models.

CONCLUSIONS

The consensus findings of an international author group recommend a therapeutic strategy based on proactive monitoring and shared decision-making in MS. Early diagnosis and improved treatment access are also key components.

The experiences of individuals with Multiple Sclerosis in the Western Cape, South Africa

Background: Multiple Sclerosis (MS) is a debilitating and degenerative lifelong neurological disease that seems to be growing increasingly more prevalent in South Africa.Objectives: The aim of this qualitative study was to explore the personal experiences of individuals with MS in the South African context. The focus of this study was on the challenges faced by individuals with MS, as well as the resources that help them to cope with this debilitating, neurological condition.Method: Thematic analysis was used to explore the semi-structured interviews that were conducted with ten individuals with MS.Results: Several themes emerged that related to the participants’ experiences of living with MS. These themes included several challenges faced by the participants on a daily basis, such as the process of being diagnosed, daily life, invisible illness and medical aid schemes. Numerous resources that help these individuals to cope with MS also emerged from the data analysis and consisted of social support, mobility aids, religion and knowledge about MS.Conclusion: It is evident from the findings of this study that although individuals living with MS, which is a debilitating neurological condition, face several challenges on a daily basis, they often have several resources that help them to cope effectively with this condition. The findings of this study regarding knowledge of the challenges faced and the resources utilised by individuals with MS will hopefully create awareness of the disease and contribute to and inform the design and implementation of interventions for such individuals. Agtergrond: Veelvuldige Sklerose (VS) is ‘n aftakelende en degerenatiewe lewenslange neurologiese toestand wat blyk of dit toenemend meer algemeen in Suid-Afrika voorkom.Objektief: Die doel van hierdie kwalitatiewe studie was om die persoonlike ervarings van individue met VS binne die Suid-Afrikaanse konteks te ondersoek.Die fokus van hierdie studie was op die uitdagings wat individue met VS in die gesig staar, sowel as die hulpbronne wat hulle help met die hantering van hierdie ernstige neurologiese toestand.Metode: Tematiese analise is gebruik om die semi-gestruktureerde onderhoude te ondersoek, wat gevoer is met tien individue met VS.Resultate: Verskeie temas wat verband hou met die deelnemers se ervarings van ‘n lewe met VS het na vore gekom. Hierdie temas het verskeie uitdagingsingesluit wat die deelnemers op ‘n daaglikse basis in die gesig staar, soos die proses om korrek gediagnoseer te word, daaglikse lewe, onsigbare siekte en mediese fonds skemas. ‘n Aantal hulpbronne wat hierdie individue help om VS te hanteer het ook na vore gekom en bestaan uit sosiale ondersteuning, mobiliteit hulpmiddels, geloof en kennis oor VS.Gevolgtrekking: Dit is duidelik uit die bevindinge dat alhoewel individue wat lewe met VS, wat ‘n ernstige neurologiese toestand is, verskeie uitdaging op ‘n daaglikse basis in die gesig staar, hulle beskik oor verskeie hulpbronne wat hulle help om hierdie toestand effektief te hanteer. Die bevindinge van hierdiestudie rakende kennis van die uitdagings wat hierdie individue in die gesig staar en die hulpbronne wat individue met VS gebruik sal hopelik ‘n bewustheid skep en bydra tot die ontwerp en implimentering van intervensies vir sulke individue.

Incidence of multiple sclerosis among European Economic Area populations, 1985-2009: the framework for monitoring

Background

A debate surrounding multiple sclerosis epidemiology has centred on time-related incidence increases and the need of monitoring. The purpose of this study is to reassess multiple sclerosis incidence in the European Economic Area.

Methods

We conducted a systematic review of literature from 1965 onwards and integrated elements of original research, including requested or completed data by surveys authors and specific analyses.

Results

The review of 5323 documents yielded ten studies for age- and sex-specific analyses, and 21 studies for time-trend analysis of single data sets. After 1985, the incidence of multiple sclerosis ranged from 1.12 to 6.96 per 100,000 population, was higher in females, tripled with latitude, and doubled with study midpoint year. The north registered increasing trends from the 1960s and 1970s, with a historic drop in the Faroe Islands, and fairly stable data in the period 1980-2000; incidence rose in Italian and French populations in the period 1970-2000, in Evros (Greece) in the 1980s, and in the French West Indies in around 2000.

Conclusions

We conclude that the increase in multiple sclerosis incidence is only apparent, and that it is not specific to women. Monitoring of multiple sclerosis incidence might be appropriate for the European Economic Area.

Multiple sclerosis, from referral to confirmed diagnosis: an audit of clinical practice

Background: The National Institute for Health and Clinical Excellence (NICE) guidelines recommend a timeline of 6 weeks from referral to neurology consultation and then 6 weeks to a diagnosis of multiple sclerosis (MS).

Objectives: We audited the clinical management of all new outpatient referrals diagnosed with MS between January 2007 and May 2010.

Methods: We analysed the timelines from referral to first clinic visit, to MRI studies and lumbar puncture (LP) (if performed) and the overall interval from first visit to the time the diagnosis was given to the patient.

Results: Of the 119 diagnoses of MS/Clinically Isolated Syndrome (CIS), 93 (78%) were seen within 6 weeks of referral. MRI was performed before first visit in 61% and within 6 weeks in a further 27%. A lumbar puncture (LP) was performed in 83% of all patients and was done within 6 weeks in 78%. In total, 63 (53%) patients received their final diagnosis within 6 weeks of their first clinic visit, with 57 (48%) patients having their diagnosis delayed. The main rate-limiting steps were the availability of imaging and LP, and administrative issues.

Conclusions: We conclude that, even with careful scheduling, it is difficult for a specialist service to obtain MRI scans and LP results so as to fulfil NICE guidelines within the optimal six-week period. An improved service would require MRI scans to be arranged before the first clinic visit in all patients with suspected MS.