Clinical Features of Late-Onset Multiple Sclerosis: a Systematic Review and Meta-analysis

The janus face of astrocytes in multiple sclerosis: Balancing protection and pathology

Multiple sclerosis (MS) is a chronic autoimmune disorder characterized by demyelination and neurodegeneration in the central nervous system (CNS), predominantly affecting young adults with a notable female predominance. While the pathogenesis of MS involves complex interactions between peripheral immune cells and CNS glia, astrocytes-the most abundant glial cells-play a dual role in disease progression. Traditionally classified into pro-inflammatory A1 and neuroprotective A2 phenotypes, recent single-cell and spatial transcriptomics reveal that human astrocytes exhibit a continuum of states beyond this binary paradigm. In MS, reactive astrocytes contribute to neurotoxicity by disrupting the blood-brain barrier (BBB), promoting glutamate excitotoxicity, and presenting antigens to autoreactive T cells. Conversely, they also support repair through neurotrophic factor release (e.g., BDNF, CNTF) and remyelination. Emerging therapies like dimethyl fumarate (DMF) and fingolimod modulate astrocyte reactivity, targeting oxidative stress and sphingosine-1-phosphate receptors to mitigate neuroinflammation. However, challenges persist in translating murine A1/A2 concepts to human MS, as human astrocytes display heterogeneous, context-dependent responses influenced by regional microenvironments and disease stages. Advanced techniques, including spatial multi-omics, highlight astrocyte-microglia crosstalk and metabolic reprogramming as key drivers of MS pathology. This review synthesizes current evidence on astrocyte heterogeneity, their Janus-faced roles in MS, and the therapeutic potential of astrocyte-targeted strategies, advocating for precision approaches that account for human-specific astrocyte biology. Future research must priorities human-centric biomarkers and dynamic modelling to bridge the gap between experimental findings and clinical applications.

The path to prevention of multiple sclerosis: Considerations for Epstein-Barr virus vaccine-based prevention studies

Recent advancements in our understanding of the association between Epstein-Barr virus (EBV) and multiple sclerosis (MS), along with progress in EBV vaccine development, warrant serious considerations of future EBV vaccine-based MS-prevention studies. The clinical, financial, logistical, and technological considerations for designing and conducting retrospective and/or prospective prevention studies with the primary objective of evaluating the effectiveness of EBV vaccines in preventing MS and other EBV-associated sequelae are presented here. As implementation of these studies may require hundreds of thousands of participants, millions of dollars, and decades to observe if meaningful reductions in MS incidence occur, alternative approaches using pragmatic phase IV, post-licensure study designs focused on either the prevention of MS or infectious mononucleosis (IM), a common clinical manifestation of EBV infection that has been associated with increased risk of MS, are also explored. Current knowledge gaps in technology, funding, and research that must be addressed for a study protocol to be successfully designed and implemented are also discussed.

Multiple Sclerosis Disease-Modifying Treatment Algorithms: 2025 Positioning of the Portuguese Multiple Sclerosis Study Group

Multiple sclerosis (MS) is a chronic autoimmune-mediated neurodegenerative disease characterized by inflammation, demyelination, and axonal/neuronal damage in the central nervous system. In Portugal, the prevalence of MS is approximately 64.4 per 100 000 individuals. It is typically diagnosed in young adults aged 30 to 40, with a higher incidence in women, although it can also affect children/adolescents and the elderly. Recent advances in MS treatment include the development and approval of several new disease-modifying therapies (DMTs) such as ocrelizumab, cladribine, siponimod, and others, thus expanding options for relapsing-remitting MS (RRMS). However, the options for progressive forms of MS remain limited. In Portugal, MS management strategies, guided by the 2015 recommendations of the Directorate-General of Health and the Portuguese medicines agency, need updating to incorporate recent scientific evidence and clinical expertise. The aim of this manuscript is to highlight gaps in current Portuguese MS treatment algorithms and propose enhancements aligned with global standards, thus improving treatment selection and patient outcomes in the Portuguese healthcare system. Developed by nine Portuguese neurology experts from the Portuguese Multiple Sclerosis Study Group, this document not only provides evidence and clinical practice-based recommendations but also includes DMT algorithms tailored for various MS subtypes, including radiologically and clinically isolated syndromes, RRMS, progressive MS, and specific situations in MS treatment such as pediatric-onset MS, late-onset MS, pregnancy and breastfeeding. This document provides evidence- and clinical practice-based recommendations to optimize decision-making during MS management in Portuguese centers. The experts aim to prompt the urgent revision of national MS treatment frameworks, incorporating the latest advancements in MS research and international guidelines, to reduce the socio-economic burden on the national healthcare system and improve the long-term health outcomes of MS patients.

Environmental risk factors of late-onset multiple sclerosis: A population-based case-control study

INTRODUCTION

Late-onset multiple sclerosis (LOMS) was increasingly reported over the past two decades. Understanding the risk factors associated with LOMS can help improve early diagnosis, prevention strategies, and patients' quality of life. This study aimed to assess various environmental risk factors in the patients with late-onset disease.

METHODS

This study utilized a population-based case-control study design. Primary data on verified LOMS cases were received from Iran's national MS registry, with additional information gained via telephone interviews. The potential risk factors for LOMS were examined using a questionnaire modified from global case-control studies. Age and sex-matched healthy controls were selected using face-to-face interviews. The collected data were analyzed using matched logistic regression in Stata software version 14, reporting adjusted odds ratios (OR), and 95 % confidence intervals, with a significance level set at p < 0.05.

RESULTS

This study examined 82 LOMS cases and 207 matched controls. The mean age of cases and controls was 61 years. The findings revealed that moderate and high sunlight exposure during adolescence were related with 0.33 (95 % CI: 0.18-0.58) and 0.15 (95 % CI: 0.04-0.46) times decreased risks of developing LOMS, respectively. Similarly, compared to those with low sunlight exposure, participants with high and moderate sunlight exposure during adulthood had a lower chance of developing MS disease (OR = 0.35, 95 % CI: 0.18-0.69) and (OR = 0.40 95 % CI: 0.18-0.85) receptively. Moreover, age at first menstruation (p = 0.45), age at first delivery (p = 0.49), abortion history (p = 0.79), and oral contraceptive consumption (p = 0.18) did not significantly differ among the groups (all p > 0.05). The odds of developing LOMS were 2.47 (95 % CI: 1.05-5.81) times higher for 10 to 90 min of heavy physical activity per week and 2.39 (95 % CI: 1.08-5.27) times higher for over 90 min. Various emotional stress, including death of a loved one (OR = 2.19, 95 % CI: 1.07-4.48), family disruption (OR = 2.93 95 % CI: 1.62-1.02), homelessness (OR = 9.1 95 % CI: 1.4-57.5), employment dismissal (OR = 4.0, 95 % CI: 1.31-12.1), and unemployment (OR = 3.1, 95 % CI: 1.25-7.62), were significantly associated with an increased risk of developing LOMS. Depression (OR = 5.5, 95 % CI: 2.7-10.9), measles (OR = 2.63, 95 % CI: 1.4-4.8), and a family history of MS (OR = 4.7, 95 % CI: 1.4-15.6) were also associated with higher risk of LOMS development.

CONCLUSION

Sunlight exposure was shown to have a strong protective impact against LOMS. Furthermore, intensive physical activity, psychological stresses such as family upheavals, medical illnesses such as depression, and a positive family history of MS may all be associated with an increased risk of LOMS. These findings emphasized the importance of preventive measures for older individuals affected by the disease.

Multiple Sclerosis After the Age of 50 Years: A Comparative Analysis of Late Onset and Adult Onset

BACKGROUND AND PURPOSE

The incidence of multiple sclerosis (MS) among older patients is increasing. Some of these patients develop the disease after the age of 50 years, a condition known as late-onset MS (LOMS). This study aimed to characterize MS in older patients (50-75 years-old) by comparing LOMS with adult-onset MS (AOMS).

METHODS

We retrospectively analyzed data from 230 patients aged 50-75 years who attended a Portuguese tertiary referral center.

RESULTS

This study included 189 AOMS patients aged 58 [54-63] years (median [interquartile range]) and 41 LOMS patients aged 67 [61-70] years. Females predominated in both the LOMS (70.7%) and AOMS (75.1%) groups. Primary progressive MS was more common in LOMS than AOMS patients (19.5% vs. 8.0%, p=0.03) and these two groups had equivalent proportions of relapsing-remitting MS (53.7% vs. 59.0%, p=0.55). The Expanded Disability Status Scale (EDSS) score at the diagnosis was higher in the LOMS patients (2 [1-4], p=0.03), but the current EDSS score did not differ significantly between the LOMS and AOMS patients (3.5 [1.75-6] vs. 3 [1.5-6], p=0.86). After adjusting or matching for age and disease duration, the current EDSS scores were not significantly different in the two groups. The proportion of patients currently receiving disease-modifying therapies was higher in LOMS patients (97.6%, p=0.02). A higher proportion of patients with a later onset had infratentorial involvement at a 5-year follow-up (86.7%, p=0.01). The time to an EDSS score of 6.0 was shorter for LOMS patients.

CONCLUSIONS

The LOMS patients presented with higher EDSS scores at the diagnosis, reaching a level of disability not significantly different from AOMS patients of the same age group despite a shorter disease course.

Distinct clinical, imaging, and cerebrospinal fluid profiles in people with late-onset multiple sclerosis

INTRODUCTION

Late-onset multiple sclerosis (LOMS), defined as onset after age 50, poses unique diagnostic challenges due to clinical and radiological differences from early-onset multiple sclerosis (EOMS), which typically manifests in adults between 20 and 40 years of age. Limited research on these differences hampers accurate diagnosis of LOMS. This study aims to bridge this gap by comparing clinical presentation, imaging, and cerebrospinal fluid (CSF) findings in LOMS and EOMS patients.

METHODS

We retrospectively analyzed clinical, MRI, and CSF data from 148 LOMS patients treated in the neuroimmunology outpatient clinic of a Swiss tertiary referral center between 2013 and 2023. A control group of 148 EOMS patients, matched by year of diagnosis, was included for comparison.

RESULTS

LOMS patients, with a median onset age of 53 years (interquartile range (IQR) 51-58 years), more commonly presented with motor or multiple symptoms and a primary progressive multiple sclerosis subtype (p < 0.001). They were also more likely than EOMS patients (median onset age 28 years, IQR 24-33 years) to report cognitive impairment and fatigue at disease onset (p < 0.001). MRI analysis showed that LOMS patients had a significantly higher T2-lesion load (p = 0.026) but fewer Gadolinium-enhancing lesions at diagnosis (p < 0.001). The percentage of patients with CSF-specific oligoclonal bands was comparable between groups, whereas CSF pleocytosis was more common in EOMS patients (p < 0.001). Importantly, we noticed a significant delay in diagnosing multiple sclerosis in older adults likely due to misdiagnosis or difficulties in timely recognition.

DISCUSSION

LOMS represents a subgroup of multiple sclerosis with unique clinical and radiological characteristics compared to EOMS. The higher T2-lesion burden and fewer Gadolinium-enhancing lesions in LOMS can pose diagnostic challenges. Recognizing these differences may enhance diagnostic accuracy and guide more effective management strategies for LOMS.

Stratifying Multiple Sclerosis Susceptibility Risk: The Role of HLA-E*01 and Infectious Mononucleosis in a Population Cohort

BACKGROUND

Epstein-Barr Virus (EBV) and its clinical manifestation, infectious mononucleosis (IM), are strongly linked to MS risk. A recent in vitro study suggests that HLA-E*01:03, in contrast to HLA-E*01:01, may protect against MS through more effective immune responses against EBV-infected B cells. However, the role of HLA-E*01 in MS remains unclear.

METHODS

We investigated if HLA-E*01:01 was significantly associated with higher MS risk in individuals with a history of IM diagnosis, using 487,144 individuals from the UK Biobank's cohort. We estimated the interaction between HLA-E*01:01 and IM using Cox proportional hazard models, adjusting for demographics, smoking, childhood body size, older siblings, and MS-related HLA alleles (e.g., HLA-DRB1*15:01).

RESULTS

HLA-E*01:01 allele alone was not significantly associated with IM or MS (p > 0.05). However, a significant interaction between HLA-E*01:01 and IM history was observed in relation to MS risk (p < 0.001). Specifically, MS risk was significantly higher in both HLA-E*01:01 heterozygotes (HR = 1.74 [95% CI: 1.36, 1.97], p < 0.001) and homozygotes (HR = 3.01 [95% CI: 1.81, 3.88], p < 0.001) with IM history, compared to HLA-E*01:03 homozygotes. Conversely, these associations were non-significant in individuals without IM history (p > 0.05). The estimated proportion of the combined risk attributable to interaction effects was 40% in HLA-E*01:01 heterozygotes and 65% in HLA-E*01:01 homozygotes.

CONCLUSIONS

HLA-E*01:01 carriers diagnosed with IM are at significantly increased risk of MS, independently from other MS-related HLA alleles. This supports the hypothesis that HLA-E*01:01 may contribute to MS susceptibility due to weaker immune control over EBV infection. Incorporating HLA-E*01:01 into existing MHC-based MS risk models could then enhance personalized risk assessments in individuals with IM history.

Factors influencing adherence to Physical Exercise in patients with multiple sclerosis: a systematic review focusing on Exercise over General Physical Activity

BACKGROUND

While the barriers and facilitators of physical activity adherence are well-defined, there is a limited number of studies focusing specifically on exercise adherence, which is crucial to identify in patients with multiple sclerosis (MS) due to its known disease-modifying effect.

OBJECTIVE

To investigate the factors affecting adherence to physical exercise in MS patients.

METHODS

Literature search was conducted in PubMed, Cochrane, Web of Science, and Scopus electronic databases up to the current date. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS) for quantitative studies and the McMaster Critical Appraisal Tool for qualitative studies, with evidence synthesis conducted using the Modified Bakker Scale.

RESULTS

The systematic review incorporated thirteen studies, consisting of seven qualitative and six quantitative ones. These studies' methodological quality was high; 12 were high, and the other was medium (unclear). In all reviewed studies, the primary patient-related and environmental barriers with high levels of evidence regarding exercise adherence included fatigue (38%), false beliefs (18%), cost (18%), and lack of time (15%). Barriers identified in very few studies included cognitive problems (3%), bladder-bowel problems (3%), and family support and advice (3%), indicating a necessity for further research to reveal their impact on exercise adherence.

CONCLUSION

The scarcity of studies on exercise barriers in MS is partly due to the absence of reliable assessment methods for evaluating exercise adherence, along with the prevalent emphasis on physical activity. Future research should prioritize the development of adherence scales tailored to physical exercise and shifting focus towards less explored barriers.

Influence of Primary Neurologic Disease on Cardiovascular Health in Females

Neurocardiology is an interdisciplinary field that examines the complex interactions between the nervous and the cardiovascular systems, exploring how neurological processes, such as autonomic nervous system regulation and brain-heart communication impact heart function and contribute to cardiovascular health and disease. Although much of the focus on cardiovascular health has centered on traditional risk factors, the influence of the nervous system, especially in females, is increasingly recognized as a key determinant of cardiovascular outcomes. This article reviews existing literature on the neurological mechanisms that impact cardiovascular function in females. Specifically, we analyze how primary neurological disorders including cerebrovascular disease, headache disorders, and multiple sclerosis have specific downstream effects on cardiac function. By understanding the complex relationship between neurological and cardiovascular health, this review highlights the need for sex-specific approaches to prevention, diagnosis, and treatment of cardiovascular disease in females, ultimately encouraging the discovery of more effective care strategies and improving health outcomes.

Prevalence and incidence of multiple sclerosis in healthcare district IV of Asturias, Spain

BACKGROUND

Multiple sclerosis is an inflammatory demyelinating autoimmune disease of the central nervous system. Studies conducted in recent years point to an increase in its prevalence and a change in the age profile of patients. This study aims to analyse the prevalence and incidence of multiple sclerosis in healthcare district IV of the region of Asturias, in north-western Spain.

METHODS

We conducted a retrospective epidemiological study of the population of said healthcare district with a diagnosis of multiple sclerosis according to the 2017 McDonald criteria. The prevalence of the disease was calculated cross-sectionally (prevalence date: December 31, 2022), while the incidence was determined retrospectively over a six-year period, from 2017 to 2022. We gathered data from the registries and databases of the tertiary hospital in healthcare district IV, and from one private hospital. Relevant demographic and clinical data were gathered from electronic records.

RESULTS

The prevalence of multiple sclerosis in the population studied was 198 cases per 100 000 population. The incidence of multiple sclerosis during the study period (2017-2022) was 6.6 cases per 100 000 person-years. On the prevalence date, 66.5% of patients were women and 82.4% presented relapsing-remitting multiple sclerosis. Mean age was 33.98 years at symptom onset and 50.84 years on the prevalence date.

CONCLUSIONS

Asturias currently presents the highest multiple sclerosis prevalence rate in Spain; the estimated rate represents an increase with respect to those reported in studies conducted in the same region in the 1990s.

Pediatric, adult, and late onset multiple sclerosis: Cognitive phenotypes and gray matter atrophy

OBJECTIVES

We aim to investigate cognitive phenotype distribution and MRI correlates across pediatric-, elderly-, and adult-onset MS patients as a function of disease duration.

METHODS

In this cross-sectional study, we enrolled 1262 MS patients and 238 healthy controls, with neurological and cognitive assessments. A subset of 222 MS patients and 92 controls underwent 3T-MRI scan for brain atrophy and lesion analysis. Multinomial probabilistic models identified likelihood of belonging to cognitive phenotypes ("preserved-cognition," "mild verbal memory/semantic fluency," "mild multi-domain," "severe attention/executive," and "severe multi-domain") and experiencing MRI abnormalities based on disease duration and age at onset.

RESULTS

In all groups, the likelihood of "preserved-cognition" phenotype decreased, whereas "mild multi-domain" increased with longer disease duration. In pediatric- and adult-onset patients, the likelihood of "mild verbal memory/semantic fluency" phenotypes decreased with longer disease duration, and that of "severe multi-domain" increased with longer disease duration. Only in adult-onset patients, the likelihood of "severe executive/attention" phenotype increased with longer disease duration. All groups displayed escalating probabilities of cortical, thalamic, hippocampal, and deep gray matter atrophy over disease course. Compared to adult, pediatric-onset patients showed lower probability of experiencing thalamic atrophy with longer disease duration, while elderly-onset showed higher probability of experiencing cortical and hippocampal atrophy.

INTERPRETATION

Age at MS onset significantly influences the distribution of cognitive phenotypes and the patterns of regional gray matter atrophy throughout the disease course.

Acute respiratory failure caused by brainstem demyelinating lesions in an older patient with an atypical relapsing autoimmune disorder

An 84-year-old man presented with somnolence, dysphagia, and right hemiplegia, all occurring within a month, approximately one year after initial admission due to subacute, transient cognitive decline suggestive of acute disseminated encephalomyelitis involving the cerebral white matter. Serial magnetic resonance imaging (MRI) studies over that period revealed three high-intensity signal lesions on fluid-attenuated inversion recovery images, appearing in chronological order in the left upper and left lower medulla oblongata and left pontine base. Despite some clinical improvement following methylprednisolone pulse therapy, the patient died of respiratory failure. Autopsy revealed four fresh, well-defined lesions in the brainstem, three of which corresponded to the lesions detected radiologically. The remaining lesion was located in the dorsal medulla oblongata and involved the right solitary nucleus. This might have appeared at a later disease stage, eventually causing respiratory failure. Histologically, all four lesions showed loss of myelin, preservation of axons, and infiltration of lymphocytes, predominantly CD8-positive T cells, consistent with the histological features of autoimmune demyelinating diseases, particularly the confluent demyelination observed in the early and acute phases of multiple sclerosis (MS). In the cerebral white matter, autoimmune demyelination appeared superimposed on ischemic changes, consistent with the cerebrospinal fluid (CSF) and MRI findings on initial admission. No anti-AQP4 or MOG antibodies or those potentially causing autoimmune encephalitis/demyelination were detected in either the serum or CSF. Despite several similarities to MS, such as the relapsing-remitting disease course and lesion histology, the entire clinicopathological picture in the present patient, especially the advanced age at onset and development of brainstem lesions in close proximity within a short time frame, did not fit those of MS or other autoimmune diseases that are currently established. The present results suggest that exceptionally older individuals can be affected by an as yet unknown inflammatory demyelinating disease of the CNS.

Clinical Characteristics of Early-Onset and Late-Onset Multiple Sclerosis in Patients from Lithuania

Background and Objectives: Early-onset MS (EOMS) and late-onset MS (LOMS) differ in terms of symptom presentation, disease progression, and disability outcomes. This study aims to evaluate the clinical characteristics of patients with EOMS and LOMS in Lithuania. Materials and Methods: A retrospective analysis of patients' medical records was conducted at the Lithuanian University of Health Sciences, Kaunas Clinics Department of Neurology. This study included 97 patients with multiple sclerosis, of which 34 were diagnosed with EOMS and 63 with LOMS. Results: The female/male ratio did not differ significantly in the EOMS group (1.26:1), while in the LOMS group, the female-to-male ratio was 2:1. All EOMS patients were diagnosed with relapsing-remitting multiple sclerosis (RRMS), while in the LOMS group, RRMS was observed in 55.6%, secondary progressive multiple sclerosis (SPMS) was observed in 27%, and primary progressive multiple sclerosis (PPMS) was observed in 17.4% of patients (p < 0.001). The most common initial symptoms in the EOMS group were brainstem dysfunction (50%), and sensory (38.2%) and visual (26.5%) disorders, whereas LOMS patients predominantly experienced brainstem dysfunction (50.8%) and motor impairments (47.6%). The EOMS group experienced more clinical relapses in the first year after diagnosis, along with more frequent radiological signs of disease activity compared to LOMS (p < 0.001). Both groups demonstrated a significant increase in Expanded Disability Status Scale (EDSS) score at the last follow-up visit compared to the baseline, while the LOMS group had higher EDSS scores both at the baseline and at the last follow-up compared to the EOMS group (p < 0.001). Only LOMS patients had an increase in Multiple Sclerosis Severity Score (MSSS) at the last follow-up compared to the baseline (p = 0.028), and MSSS was higher than in EOMS patients both at the baseline (p = 0.004) and the last follow-up (p < 0.001). Conclusions: There was no significant gender difference in the EOMS group, whereas in the LOMS group, females were predominant. Both groups had RRMS as the most common disease course. At the onset of MS, brainstem dysfunction was the most common symptom in both patient groups. EOMS patients had a more active disease course, in contrast to LOMS patients, who exhibited higher levels of disability, suggesting a progressive disease.

Pediatric, adult, and late-onset multiple sclerosis patients: A unified analysis of clinical profiles and treatment responses

OBJECTIVE

This study aimed to conduct a unified analysis comparing the clinical characteristics, disease progression, and treatment responses of pediatric-onset multiple sclerosis (POMS), adult-onset multiple sclerosis (AOMS), and late-onset multiple sclerosis (LOMS) patients.

METHODS

Utilizing a retrospective cohort design, we analyzed the records of 269 patients from MS clinics and categorized them into the POMS (<18 years), AOMS (≥18 and <50 years), and LOMS (≥50 years) groups based on age at diagnosis. Data collection focused on demographics, clinical manifestations, disability scores, MRI findings, and treatment outcomes.

RESULTS

Our findings indicate that while there was a consistent female majority across all groups, distinct smoking habits and differences in disease onset and progression were observed. Disease onset showed substantial differences, with 38.5 % of LOMS patients having a progressive onset. Disability scores increased from the POMS to the LOMS, with a baseline mean EDSS score of 1.81, and the LOMS group had the highest current EDSS score of 3.33. The ARR was greater in the LOMS group. Brainstem and spinal cord lesions were more common in patients with POMS and LOMS, but the difference was not statistically significant. Among those tested, 89.6 % showed OCB positivity. There was a notable shift toward second-line therapies, especially among LOMS patients, with 49.1 % achieving disease control with their initial DMT. Disease control was achieved by 59.7 % of the POMS patients, 47 % of the AOMS patients, and 38.5 % of the LOMS patients. Progression independent of relapse activity (PIRA) was observed in 19.7 % of patients, with higher second-line treatment requirements and higher EDSS scores in the PIRA group.

CONCLUSION

Significant differences in clinical profiles and treatment responses among POMS, AOMS, and LOMS patients underscore the necessity for age-specific management strategies for MS, emphasizing the unique challenges faced by LOMS patients.

[Epidemiology of multiple sclerosis in the city of Novosibirsk]

OBJECTIVE

To study the dynamics of the epidemiological characteristics of multiple sclerosis (MS) from 01.01.2003 to 01.01.2024 in Novosibirsk in comparison with the previous 20-year study.

MATERIAL AND METHODS

The prevalence cohort included 2254 patients with MS living in Novosibirsk on 01.01.2024. The cohort of cases included 1998 patients with the onset of the disease from 01.01.2003 to 31.12.2023 inclusive. In order to level out the influence of heterogeneous sex and age composition of the population of Novosibirsk, the method of standardization of indicators was used in the study (standard European population, 13.07.2013). The results of our analysis were compared with the results of the previous epidemiological study in the city of Novosibirsk (Malkova N.A., 2005).

RESULTS

The prevalence of MS as of 01.01.2024 was calculated as 137.83 per 100 thousand population (standardized indicator - 123.43). The average age of the patients with MS was 46.146±0.479 years. The ratio of men to women was 1:2.1. The incidence of MS from 2003 to 2023 shows a trend toward an increase (5.12±0.0662 to 7.71±0.0246 per 100 thousand population/year (p<0.05), which is mainly due to a significant increase in the proportion of women (6.56±0.1118 to 11.01±0.091 per 100 thousand population/year, p<0.05), but not men (p>0.05). The average age of MS onset increased by 0.146 years annually during the study period and amounted to 30.479±0.329 years (rxy=0.08, p<0.001). An increase in the incidence of early-onset and late-onset MS was also noted (rxy=0.45, p=0.041 and rxy=0.622, p=0.003, respectively). A significant decrease in the «onset-diagnosis» interval was recorded (mean 5.28±6.41 years on 01.01.2003; mean 1.77±0.921 years on 01.01.2024).

CONCLUSIONS

In the era of controlled disease progression, our study showed an increase in the prevalence of MS from 2003 to 2023 (54.4 to 137.83 per 100 thousand population). The dynamics of the sex ratio of patients with MS in Novosibirsk does not demonstrate the global trend with a 3-4-fold increase in the proportion of women. An increase in the incidence of MS was noted from 2003 to 2023 (p<0.05), mainly due to women (p<0.05). The age of MS onset has increased significantly over the 20-year period (27.73±0.6 years in 2003; 30.479±0.329 years in 2023). A separate trend towards an increase in the incidence of early-onset and late-onset MS is shown (rxy=0.45, p=0.041 and rxy=0.622, p=0.003, respectively). In part, the increase in the epidemiological characteristics of MS is associated with a decrease in the «onset-diagnosis» interval (p<0.05), which is due to improved diagnostic criteria and health care services.

Fewer relapses and worse outcomes of patients with late-onset myelin oligodendrocyte glycoprotein antibody-associated disease

BACKGROUND

To delineate the clinical characteristics and outcomes of late-onset myelin oligodendrocyte glycoprotein antibody-associated disease (LO-MOGAD) and compare them with those of early-onset MOGAD (EO-MOGAD).

METHODS

This observational cohort study included 199 adult patients with MOGAD. We reviewed the patients' demographic and clinical data and performed comparative analyses between EO-MOGAD and LO-MOGAD (onset age 18-50 and ≥50 years, respectively).

RESULTS

Among the 199 patients, 42 had LO-MOGAD. Compared with patients with EO-MOGAD, those with LO-MOGAD patients exhibited a significantly higher incidence of optic neuritis both at the initial attack (66.67% vs 43.31%, p=0.007) and throughout all attacks (72.15% vs 52.51%, p=0.001). Over a similar disease duration, patients with LO-MOGAD exhibited significantly fewer relapsing courses (45.16% vs 70.97%), higher Expanded Disability Status Scale (EDSS) and visual functional system scores at the last visit (all p<0.05). Compared with patients with EO-MOGAD, those with LO-MOGAD had a significantly lower risk of relapse (HR 0.512, 95% CI 0.268 to 0.978, p=0.034), but higher risks of reaching EDSS ≥2 (HR 2.893, 95% CI 1.524 to 5.494, p<0.001) and visual acuity ≤0.6 (HR 3.097, 95% CI 1.073 to 8.937, p=0.022). Immunosuppressive therapies significantly reduced the annualised relapse rates of patients with LO-MOGAD, although adverse events leading to drug discontinuation and hospitalisation were observed.

CONCLUSIONS

Compared with patients with EO-MOGAD, patients with LO-MOGAD exhibited fewer relapsing courses but worse disability outcomes and should be actively treated.

The role of disease modifying therapies in late-onset multiple sclerosis: A Portuguese multicentric characterization study

INTRODUCTION

Knowledge about the effect of disease modifying treatment (DMT) in late-onset multiple sclerosis (LOMS, onset ≥50 years-old) is scarce. This study aims to evaluate the association between DMT use and multiple sclerosis (MS) evolution in a LOMS cohort.

METHODS

This multicentre, retrospective and observational study included LOMS patients with ≥2 years of follow-up. Data on demographics, clinical/paraclinical (baseline and follow-up), DMT and adverse events were collected. Primary outcomes were irreversible EDSS 4.0 and 6.0 achievement and first year ARR. Univariate and multivariate regression models were conducted, with treated and/or relapsing phenotypes (RMS) subgroups analyses.

RESULTS

We included 232 patients (53.4 % with RRMS phenotype; 84.9 % submitted to DMT; median follow-up time of 141.5 (IQR 92.7-193.1) months). Treatment versus non-treatment did not affect EDSS milestones in multivariate analysis (adjusted to phenotype, baseline EDSS, age, and ARR), but initially receiving monoclonal antibodies (MAbs) was associated with lower odds of EDSS 4.0 (OR 0.13). In treated patients, starting with high efficacy DMT (HE-DMT) was related to a lower chance of EDSS 4.0 (OR 0.05) and 6.0 (OR 0.26) compared with being exclusively treated with moderate efficacy DMT (ME-DMT), with similar results when analysing the subgroup of RMS treated patients. In multivariate models, initial treatment with MAbs (vs. non-treatment) and with HE-DMT (vs. ME-DMT) were related to a lower first year ARR; when considering only RMS patients, every DMT class analysed reduced first year ARR vs. non-treatment. During DMT, we documented a rate of 0.6 % serious infections, 0.07 % opportunistic infections and 0.7 % neoplasm diagnosis per patient year.

CONCLUSION

DMT type and therapeutic strategy influenced LOMS disability accumulation and relapses in our cohort. Our findings support the importance of investment in LOMS treatment optimization.

Incidence of late onset multiple sclerosis in Italy: a population-based study

Late onset multiple sclerosis (LOMS) represents between 0.6 and 12% of all MS patients. However, little is known on the incidence of LOMS in the general population. Therefore, we aimed to study the annual incidence of LOMS in a population-based cohort. The study was conducted in the province of Catania, Italy. Case ascertainment was conducted retrospectively including all patients aged ≥ 50 years at onset and with the onset between 2005 and 2020. Incidence rates (IR) have been calculated for all the study period, according to sex, age classes and for subperiods. Incidence rate ratios (IRR) have been computed to compare incidence rates. During the study period, 183 patients with LOMS were identified (113 women; 61.8%). The mean age at onset was 55.8 ± 5.4 years and the main phenotype was Relapsing Remitting MS (n = 123; 67.2%). The average annual crude IR was 2.87/100,000 person-years (95% Confidence Intervals, CI 2.31-3.13). IR increased from 2.54/100,000 in 2005-2010 to 3.32/100,000 in 2016-2020, especially in in the age group 60-69 (IRR 3.48; 95%CI 1.41-9.76; p-value 0.002). In conclusion, an increased IR over the time was observed in the age-group 60-69, possibly reflecting an increased age at onset of MS.

The ageing central nervous system in multiple sclerosis: the imaging perspective

The interaction between ageing and multiple sclerosis is complex and carries significant implications for patient care. Managing multiple sclerosis effectively requires an understanding of how ageing and multiple sclerosis impact brain structure and function. Ageing inherently induces brain changes, including reduced plasticity, diminished grey matter volume, and ischaemic lesion accumulation. When combined with multiple sclerosis pathology, these age-related alterations may worsen clinical disability. Ageing may also influence the response of multiple sclerosis patients to therapies and/or their side effects, highlighting the importance of adjusted treatment considerations. MRI is highly sensitive to age- and multiple sclerosis-related processes. Accordingly, MRI can provide insights into the relationship between ageing and multiple sclerosis, enabling a better understanding of their pathophysiological interplay and informing treatment selection. This review summarizes current knowledge on the immunopathological and MRI aspects of ageing in the CNS in the context of multiple sclerosis. Starting from immunosenescence, ageing-related pathological mechanisms and specific features like enlarged Virchow-Robin spaces, this review then explores clinical aspects, including late-onset multiple sclerosis, the influence of age on diagnostic criteria, and comorbidity effects on imaging features. The role of MRI in understanding neurodegeneration, iron dynamics and myelin changes influenced by ageing and how MRI can contribute to defining treatment effects in ageing multiple sclerosis patients, are also discussed.

Comprehensive analysis of multiple sclerosis hospitalization trends in Spain (1998-2022)

OBJECTIVE

To analyse the trends in MS hospitalization rates in Spain (1998-2022) considering age, period, and birth cohort (A-P-C) effects.

METHODS

This retrospective study used data on MS hospitalizations from the Spanish National Health System Minimum Basic Data Set (CMBD). Age-Standardized Hospitalization Rates (ASHRs) and Joinpoint analysis were used to assess trends. A-P-C analysis was performed to estimate age-specific rates, period and cohort effects.

RESULTS

From 1998 to 2022, MS hospital admissions in Spain declined annually by -2.1 %, with women showing a slightly greater decrease (-2.3 %) than men (-1.7 %). Joinpoint analysis revealed non-parallel trends, with three inflection points indicating distinct periods of stabilization and decline. ASHR showed an overall decrease, with -2.0 % for men and -2.2 % for women annually. Risk of hospitalization peaked in the 25-29-year age group for men and 30-34-year age group for women, declining with age. Women consistently had higher risk ratios across age groups. Cohort analysis showed periods of stabilization and decline in MS hospitalization risk, aligning with joinpoint analysis findings. Risk increased for cohorts born in the early 20th century, peaking around 1938, followed by a progressive decline in later cohorts.

CONCLUSIONS

Despite an aging population, MS hospitalization rates in Spain decreased. The risk of hospitalization for MS is affected by a person's age, the time period they were born in, the historical context of healthcare received, and potentially their sex.

The impact of different lifestyle factors on disability in multiple sclerosis at older ages: a monocentric retrospective study

Background

Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system affecting approximately 2.8 million people worldwide. In addition to genetic and environmental factors, various lifestyle factors contribute to disease development and progression.

Objectives

We performed a monocentric retrospective study and investigated the effect of lifestyle factors such as obesity, smoking, alcohol consumption, physical activity, and dietary habits on the degree of disability in a cohort of people with MS (pwMS) with an average onset of disease after the age of 55.

Design

This late-onset MS (LOMS) study group (n = 47) was characterized by a mean age of 60.9 years and a mean duration of disease of 5.0 years. The LOMS study group was compared with two control groups. The study participants in the "old control group" (Cold) were on average as old and in the "young control group" (Cyoung) as long suffering from MS as the pwMS in the LOMS group.

Methods

Data from medical documentation and a questionnaire were analyzed using descriptive frequency analyses and testing for correlation between different variables also by generalized estimating equations. The Expanded Disabilty Status Scale (EDSS) score and the progression index were used as a measure of disability.

Results

We found a significant association between smoking history and the current EDSS score in the Cyoung group, but not in the two older study groups. For physical activity, there was a significant negative correlation with EDSS score in the study group and the Cold group, alcoholic beverage consumption correlated with decreased EDSS in the Cold group. The intake of meat negatively correlated with the progression index in the LOMS group.

Conclusion

In summary, different life-style factors correlated with disability depending on patient age and disease duration. These life-style factors may be considered in the future counseling of pwMS at older ages.

Cognitive outcomes in late-onset versus adult-onset Multiple Sclerosis

INTRODUCTION

Recent studies show that cognitive impairment is more prevalent in older patients with Multiple Sclerosis (MS). However, whether this is the result of several years of a chronic disease or specific age-related changes is still unclear. Therefore, we aim to assess the outcomes in both classic and social cognition in late-onset MS (LOMS) and compare them to adult-onset MS (AOMS) when accounting for age and disease duration.

METHODS

In this cross-sectional study, a group of 27 LOMS patients (age of disease onset >50 years) was compared with patients with AOMS (age of disease onset between 18 and 50 years). Patients with AOMS were grouped based on age (AOAMS, n = 27) and on disease duration (AODMS, n = 27) in order that these variables are matched with LOMS. Their cognitive performance was evaluated using the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) and the Revised "Reading the Mind in the Eyes" Test (RMET). Clinical and demographic variables were collected and analysed.

RESULTS

In general, both classic and social cognitive performance was inferior in the LOMS group when accounting for age and disease duration. We found a statistically significant negative correlation between age of disease onset and performance in all cognitive domains except for verbal memory. The presence of at least one vascular risk factor (VRF) was associated with slower information-processing speed (SDMT) (p = 0.006) and poorer RMET performance (p = 0.020).

DISCUSSION

A later age of MS is associated with worse cognitive functioning possibly due to the loss of neuroplasticity in an already aged brain.

CONCLUSION

Patients with LOMS have worse cognitive outcomes than AOMS in both classic and social domains, especially when associated with the presence of VRF. Hence, health care providers and patients should not undervalue the importance of cognitive stimulating activities, management of VFR and socialization in this specific group of patients.

Comparative analysis of cognitive and physical characteristics in late-onset, adult-onset and early-onset multiple sclerosis patients

BACKGROUND

Late-onset multiple sclerosis (LOMS or L; MS) and early-onset MS (EOMS or E) are less common, and their prognosis can be different. To characterize the demographic and clinical features, and clinical outcomes of LOMS and EOMS patients, comparing them to adult-onset MS (AOMS or A) patients.

METHODS

The study was conducted as a secondary analysis of a prospective study. The participants were divided into three groups according to age of MS onset: early onset (<18 years of age), adult-onset (20-40 years of age), and late-onset (>55 years of age). Demographic variables, oligoclonal bands, IgG index, and Expanded Disability Status Scale (EDSS) score in admission, first year, second year and current EDSS were evaluated. The Timed 25-Foot Walk Test (T25FW), Timed Up and Go (TUG), Multiple Sclerosis Walking Scale-12, Single Leg Standing Test, Activity-Specific Balance Confidence Scale, Nine-Hole Peg Test, Epworth Sleepiness Scale and Restless Legs Syndrome Severity Scale were performed. Appropriate statistical analysis was made.

RESULTS

A total of 658 pwMS was included in the study and divided into three groups: EOMS (n = 117), AOMS (n = 499), and LOMS (n = 42). Statistically significant differences were determined between groups in terms of age [L (mean:59.86±5.45 years-y-)> A (36.87±9.12 y)> E(26.56±8.85 y), p < 0.001], education level, current EDSS score (L > E, p < 0.001), EDSS score in first admission, EDSS score in the first year, EDSS score in the second year (L > A > E, p < 0.001), reached an EDSS score 6 (E > L p = 0.001, E > A p = 0.015), disease duration (E > A, E > L, mean E = 11.66±9.7 y, A = 7.99±7.4 y, L = 6.31±4.67 y) time switching second-line treatment to the third line (E > L p < 0.001, A > L p = 0.002, mean E = 171.73±83.29 months-m-, A = 136.13±65.75 m, L = 65.85±45.96 m), number of relapses (A > E > L, median E = 4.0, A = 3.0, L = 2.0), distribution of MS type and oligoclonal band types. Significant differences were found in T25FW and TUG. Post-hoc analysis showed that participants in the LOMS group have longer T25FW (mean L = 7.8 ± 6.11, A = 6.25±5.09, E = 5.72±3.13, p = 0.011) and TUG (mean L = 11.01±5.53, A = 9.57±8.04, E = 8.38±5.51, p = 0.007) times than the AOMS and EOMS groups.

CONCLUSION

Our result revealed that individuals with LOMS face elevated disability levels and a heightened propensity to transition from first-line treatments to more advanced therapeutic interventions. LOMS have worse lower extremity functional status than AOMS and EOMS patient. Clinical evaluations and treatment choices require more attention in LOMS. However, according to the low number of LOMS in our cohort, these results were considered cautious, and more wide and multi-center studies must be designed.

Impact of multiple sclerosis on employment and income: Insights from a random sample representative of private sector employees in France using longitudinal administrative data

In France, few data sources are available to estimate the impact of multiple sclerosis (MS) on job retention and its consequences on the level of resources, especially in large representative samples. The aim of the present study was to measure impact of MS on employment rates, wages and income (including unemployment benefit, sickness benefit and disability pension) by comparing work trajectories of people living with MS with those of a matched control group. We used the HYGIE database, which is the result of the linkage of two administrative databases in the private sector for a random sample of over 900,000 people. In order to identify the causal effect of MS on employment after 1 to 20 years, the difference-in-differences method with matching (age, sex, career and health history) was used, overall and in subgroups. The year of entry in long-term disease status for MS was used to approximate the onset of MS. Overall, 946 people with MS were included. Their situation was fairly favorable before MS (88.1% in employment, resources higher than the median for the general population), but MS had strong and continuous negative effects. Indeed, at 10 years, the employment rate fell by 28.6 percentage points (pp) and the disability pension allowance increased by 50.5 pp; the wage percentile fell by 19.2 pp and the replacement income accounted for a growing share of total income (+ 39.7 pp). Although administrative data had several strengths, clinical information on the severity of the disease or on its therapeutic management was not available. In conclusion, this study shows that the effects of MS on the employed population in the private sector occur early in the disease course and are cumulative, and that replacement income helps to reduce the loss of resources thanks to the French health and social system.

Neuroticism as a Common Factor in Depression and Anxiety Associated with Multiple Sclerosis-A Systematic Review and Meta-Analysis

BACKGROUND

Left undiagnosed and untreated, the association between multiple sclerosis and mental health difficulties significantly increases the multimorbidity risk in these patients. Hence, the purpose of this systematic review and meta-analysis was to estimate the prevalence of neuroticism, depression, and anxiety in MS and to explore the cumulative impact of these psychological factors on the disease expression.

METHODS

A literature search was conducted on PubMed, Web of Science, Scopus, and Google Scholar databases, according to the PRISMA guidelines. Also, the potential risk of bias was assessed using the AXIS tool.

RESULT

After a rigorous full-text examination, among the 756 identified studies, 22 investigations were considered for the systematic review, and 10 studies were selected for the meta-analysis. The prevalence of neuroticism in the studied population was 24.06% (95% CI: 16.79-33.34), of depression 20.77% (95% CI: 7.67-33.88), while the presence of anxiety was found in 23.94% (95% CI: 6.21-40.36).

CONCLUSIONS

The main finding of this research confirms that psychiatric disorders often co-occur with MS, impacting the clinical symptoms and life quality of patients living with this illness. For a better understanding of the interaction between personality, depression, anxiety, and the disease symptoms, future research should consider conducting comparisons on more homogenous studies.

Differential Diagnosis of Suspected Multiple Sclerosis in Pediatric and Late-Onset Populations: A Review

IMPORTANCE

While the typical onset of multiple sclerosis (MS) occurs in early adulthood, 2% to 10% of cases initially present prior to age 18 years, and approximately 5% after age 50 years. Guidance on approaches to differential diagnosis in suspected MS specific to these 2 age groups is needed.

OBSERVATIONS

There are unique biological factors in children younger than 18 years and in adults older than age 50 years compared to typical adult-onset MS. These biological differences, particularly immunological and hormonal, may influence the clinical presentation of MS, resilience to neuronal injury, and differential diagnosis. While mimics of MS at the typical age at onset have been described, a comprehensive approach focused on the younger and older ends of the age spectrum has not been previously published.

CONCLUSIONS AND RELEVANCE

An international committee of MS experts in pediatric and adult MS was formed to provide consensus guidance on diagnostic approaches and key clinical and paraclinical red flags for non-MS diagnosis in children and older adults.

Current and future role of MRI in the diagnosis and prognosis of multiple sclerosis

In the majority of cases, multiple sclerosis (MS) is characterized by reversible episodes of neurological dysfunction, often followed by irreversible clinical disability. Accurate diagnostic criteria and prognostic markers are critical to enable early diagnosis and correctly identify patients with MS at increased risk of disease progression. The 2017 McDonald diagnostic criteria, which include magnetic resonance imaging (MRI) as a fundamental paraclinical tool, show high sensitivity and accuracy for the diagnosis of MS allowing early diagnosis and treatment. However, their inappropriate application, especially in the context of atypical clinical presentations, may increase the risk of misdiagnosis. To further improve the diagnostic process, novel imaging markers are emerging, but rigorous validation and standardization is still needed before they can be incorporated into clinical practice. This Series article discusses the current role of MRI in the diagnosis and prognosis of MS, while examining promising MRI markers, which could serve as reliable predictors of subsequent disease progression, helping to optimize the management of individual patients with MS. We also explore the potential of new technologies, such as artificial intelligence and automated quantification tools, to support clinicians in the management of patients. Yet, to ensure consistency and improvement in the use of MRI in MS diagnosis and patient follow-up, it is essential that standardized brain and spinal cord MRI protocols are applied, and that interpretation of results is performed by qualified (neuro)radiologists in all countries.

Sexual Health Education and Quality of Counseling in Pediatric-Onset Multiple Sclerosis

BACKGROUND

Disease-modifying therapies (DMTs) have revolutionized the management of multiple sclerosis (MS). Many DMTs have a risk of teratogenic outcomes, which is notable as MS disproportionally affects women of reproductive age and the rates of unplanned pregnancies among persons with MS (PwMS) are as high as 34%. Prior research suggests that patients' culture may influence their perspectives surrounding family planning. Given our institution's patient population, we compared the spectrum of knowledge in Hispanic and non-Hispanic patients with pediatric-onset MS (POMS) regarding DMTs and their associated risks during pregnancy and possible disparities in their treatment and counseling.

METHODS

A small cohort of patients with POMS (n = 22) were surveyed on their knowledge and beliefs surrounding family planning and sexual health counseling. Odds ratios and 95% confidence intervals were used to evaluate the association between survey question responses and ethnicity.

RESULTS

No significant differences in beliefs or knowledge regarding sexual health between Hispanic and non-Hispanic participants were identified, but many valuable themes emerged. Internet access and social relationships heavily influence participants' knowledge surrounding birth control and sexual health. Patients also desired continuous engagement in sexual health counseling.

CONCLUSIONS

In this small pilot cohort, cultural views did not significantly influence whether adolescent and young adult patients with POMS seek sexual health resources. Future studies should aim to identify effective interventions for providers to educate PwMS about sexual health and family planning to address the elevated unplanned pregnancy rate in this population and provide the education these patients have vocalized a desire to receive.

Management of multiple sclerosis in older adults: review of current evidence and future perspectives

IMPORTANCE

The prevalence of multiple sclerosis (MS) and aging MS patients is increasing worldwide. There is a need to better understand this MS sub-population, which historically is underrepresented in the literature. This narrative review examines the evolving demographics, disease course, and treatments for older adults with MS (OAMS) to address current knowledge gaps and highlight areas critical for future research.

OBSERVATIONS

OAMS populations require special consideration by clinicians. Older individuals have different care needs than individuals with adult onset MS who are mid-life or younger. Comorbidities, an aging immune system, increasing neurodegeneration, decreasing neurologic reserve, changing benefit/risk relationship for disease modifying therapies (DMTs), and wellness require special attention to provide holistic comprehensive care. Active areas of research include potential cessation of DMTs and novel disease targets.

CONCLUSIONS AND RELEVANCE

This review highlights both the current knowledge and information gaps in the literature that are critical to understanding and properly managing OAMS. The aims are to inform MS clinicians in their current practice, as well as inspire future studies which are critical to providing quality and evidence-based care for OAMS.

As time goes by: Treatment challenges in elderly people with multiple sclerosis

A demographic shift in multiple sclerosis (MS) is leading to an increased number of elderly people with MS (pwMS) and a rise in late-onset MS (LOMS) cases. This shift adds complexity to the treatment management of these patients, due to enhanced treatment-associated risks and the possible interplay between immunosenescence and disease-modifying therapies (DMTs). In the present paper, we performed a systematic review of the current evidence concerning the relationship between aging and treatment management in elderly pwMS. Our literature search identified 35 original studies relevant to this topic. The gathered evidence consistently indicates a diminished efficacy of DMTs in older pwMS, particularly in preventing disability accrual. Against this background, high-efficacy therapies (HETs) appear to show less benefit over moderate-low-efficacy DMTs in older patients. These data mainly derive from observational retrospective studies or meta-analyses conducted on randomized clinical trials (RCTs). RCTs, however, exclude pwMS older than 55 years, limiting our ability to acquire robust evidence regarding this patient group. Regarding treatment discontinuation in elderly pwMS with stable disease, the available data, which mainly focuses on older injectable DMTs, suggests that their suspension appears to be relatively safe in terms of disease activity. Nevertheless, the first RCT specifically targeting treatment discontinuation recently failed to demonstrate the non-inferiority of treatment discontinuation over continuation, in terms of MRI activity. On the other hand, the evidence on the impact of discontinuation on disease progression is more conflicting and less robust. Furthermore, there is an important lack of studies concerning sequestering DMTs and virtually no data on the discontinuation of anti-CD20 monoclonal antibodies. De-escalation strategy is gaining attention as a de-risking approach alternative to complete treatment discontinuation. It may be defined as the decision to shift from HETs to less potent DMTs in elderly pwMS who have a stable disease. This strategy could reduce treatment-related risks, while minimizing the risk of disease activity and progression potentially associated with treatment discontinuation. This approach, however, remains unexplored due to a lack of studies. Given these findings, the present scenario underlines the urgent need for more comprehensive and robust studies to develop optimized, data-driven treatment strategies for elderly pwMS and LOMS, addressing the unique challenges of MS treatment and aging.

The Role of Diet in Multiple Sclerosis Onset: A Prospective Study Using UK Biobank

Multiple sclerosis (MS) is a debilitating autoimmune condition primarily affecting young adults, and its rise is evident globally. Despite this, its precise etiology remains elusive. Both genetic and environmental factors contribute to MS susceptibility; however, the link between diet and MS lacks substantial evidence due to limited large-scale studies. We exploited the UK Biobank resources to explore the nexus between diet, lifestyle, and MS risk. The dietary and lifestyle habits of MS incident cases, derived from a general food frequency questionnaire (FFQ) completed by all participants at study enrollment, were compared to those of subjects who did not develop MS during the follow-up. Our findings suggest the protective role of moderate oily fish consumption and weekly alcohol intake. Furthermore, by analyzing food intake data obtained through 24 h recall, completed by a subset of participants, we found a protective, though non-significant, trend of an increased adherence to the Mediterranean diet (MD). These findings, derived from the analysis of the UK Biobank and representing an unprecedented approach for this inquiry, warrant further exploration and integration in future research.

Challenges in Diagnosis and Therapeutic Strategies in Late-Onset Multiple Sclerosis

Multiple sclerosis (MS) is a chronic inflammatory and degenerative demyelinating disease of the central nervous system of unknown etiology, which affects individuals in their early adulthood. However, nearly 5-10% of people with MS can be diagnosed at ages above 50 years old, referred to as late-onset multiple sclerosis (LOMS). Some studies have reported a distinctive presentation, clinical course, and prognosis for LOMS, implicating a different diagnostic and therapeutic approach for this population. Furthermore, similar manifestations between LOMS and other age-related conditions may lead to potential misdiagnosis and diagnostic delays, and a higher burden of multimorbidity associated with aging can further complicate the clinical picture. This review aims to explore the clinical characteristics, the disease course, and the differential diagnosis of LOMS and addresses therapeutic considerations for this population.

Increasing age of multiple sclerosis onset from 1920 to 2022: a population-based study

OBJECTIVE

To study the age at onset of relapsing-remitting multiple sclerosis (RRMS) during the past century.

METHODS

This is a population-based cohort study of persons diagnosed with RRMS in Hordaland, Møre, and Romsdal counties, Western Norway, from 1920 to 2022. Individual patient data were available and assessed from previously conducted prevalence and incidence studies in addition to hospital records up until October 31, 2022. Participants were categorized according to onset period and analyzed for temporal trends in age at onset, time from onset to diagnosis, and distribution of onset over time.

RESULTS

We identified 3364 persons with confirmed RRMS. The mean age at onset significantly increased (p < 0.001) throughout the study period, despite a decrease in time from symptom onset to diagnosis (p < 0.001). The proportion of persons with MS onset after 50 years of age increased from 2.6% before 1970 to 11.9% after 2010. We also found a trend toward a bimodal distribution of age at onset that peaked at around 30 years and 40-45 years of age in the latest period.

CONCLUSION

Age at onset of MS significantly increased throughout the study period. This was mainly due to an increasing number of persons with MS, predominantly female, experiencing onset after 40-45 years of age. This bimodal distribution could indicate different susceptibility periods of MS or changes in exposure to risk factors during the observation period.

Late-onset multiple sclerosis: disability trajectories in relapsing-remitting patients of the Italian MS Registry

BACKGROUND

Generally infrequent, multiple sclerosis (MS) with late onset (LOMS) is characterized by an onset over the age of 50 and a mainly progressive course, while relapsing-remitting (RR) forms are less frequently observed and explored. This study aimed to characterize a large cohort of MS patients with RRMS at onset to assess the baseline factors related to the worst disability trajectories and explore the role of LOMS.

METHODS

The data were extracted from the Italian MS Register (IMSR). Disability trajectories, defined using at least two and up to twenty expanded disability status scale (EDSS) assessments annually performed, were implemented using group-based trajectory models (GBTMs) to identify different groups with the same trajectories over time. MS profiles were explored using multinomial logistic regression.

RESULTS

A total of 16,159 RR patients [1012 (6.26%) presented with LOMS] were analyzed. The GBTM identified four disability trajectories. The group with the most severe EDSS trend included 12.3% of the patients with a mean EDSS score > 4, which increased over time and exceeded 6 score. The group with medium severity EDSS trend comprised 21.9% of the patients and showed a change in EDSS > 3 scores over time. The largest group with 50.8% of patients reported a constant EDSS of 2 score. Finally, the benign group comprised 14.9% of the patients with a low and constant EDSS of 1 score over time. The probability of being in the worst groups increased if the patient was male; had LOMS or experienced brainstem, spinal, or supratentorial symptoms.

CONCLUSIONS

Four MS severity profiles among RRMS patients in the IMSR have been reported, with LOMS being associated with a rapid worsening of EDSS scores. These findings have important implications for recognizing and managing how older age, aging, and age-related factors interact with MS and its evolution.

Clinical and demographic characteristics of late-onset multiple sclerosis: LOMS-TR study

OBJECTIVES

Multiple sclerosis (MS), which is known as a young-adult age disease, is called late-onset MS (LOMS) when it occurs at the age of 50 and older. In our study, we aimed to analyse the clinical and demographic characteristics, comorbidities, diagnostic and treatment challenges and prognosis of LOMS.

METHODS

In a retrospective analysis of 136 patients diagnosed with multiple sclerosis (MS) after the age of 50, based on the 2017 McDonald criteria, and who were under observation in eight distinct MS centers across Turkey; demographic information, clinical characteristics of the disease, oligoclonal band (OCB) status, initial and current Expanded Disability Status Scale (EDSS) values, administered treatments, and the existence of spinal lesions on magnetic resonance imaging (MRI) were investigated.

RESULTS

The mean age of the 136 patients was 60.96±6.42 years (51-79), the mean age at diagnosis was 54.94±4.30 years, and 89 (65.4 %) of the patients were female. Most of the cases, 61.1 % (83) had at least one comorbidity. In 97 patients who underwent lumbar puncture (LP), OCB positivity was observed in 63.6 %. In 114 patients (83.8 %), spinal lesions were detected on MRI. Eighty-seven patients had relapsing-remitting MS (RRMS) (64 %), 27 patients had secondary progressive MS (SPMS) (19.9 %), and 22 patients had primary progressive MS (PPMS) (16.2 %). The mean EDSS at the time of diagnosis was 2.44±1.46, and the mean current EDSS was 3.15±2.14.

CONCLUSIONS

In LOMS patients, the rates of delay in the diagnostic process, treatment disruption and progressive disease are higher than in the general MS population. The high rates of LP applying and OCB positivity of this study may indicate the habit of looking for clear evidences in advanged age in our country. This situation and comorbidities may cause a delay in diagnosis and eliminates the window of opportunity for early diagnosis. Although the high number of spinal lesions is a known marker for progressive disease, it is an issue that needs to be discussed whether the increased frequency of progressive course at older ages is due to the nature of the disease or immune aging itself.

Neuro-orthopaedic check-up and walking in people with multiple sclerosis: toward a more specific assessment to improve rehabilitation results

The rehabilitation process of people with multiple sclerosis (PwMS) is a challenge, and decision-making requires a thorough assessment to increase the chances of success in rehabilitation planning. The aim of this study was to investigate the importance of the neuroorthopaedic check-Up (NOChU) for gait prognosis. Participated in the study 105 PwMS with different levels of impairment. The NOChU includes measurements of passive range of motion (ROM), muscle strength, and spasticity. Additionally, was carried out the spatial-temporal analysis of the walking, Timed Up and Go test, and 6-min walk test. ROM remained relatively preserved to perform daily life activities except for ankle dorsiflexion. Muscle strength was also relatively preserved. Spasticity affected especially the ankle muscles, clearly the sural triceps. Among the NOChU measurements the catch seemed to have the most impact on walking on its different phases and on other activities. Accurate NOChU measurements play a crucial role in clinical settings, guiding informed decisions in rehabilitation planning. Future research endeavours could focus on exploring the correlations between NOChU deficiencies and the decline in walking capabilities among PwMS, with the goal of proposing personalized treatment strategies that address their specific requirements.

Multiple Sclerosis: An Emergency Medicine-Focused Narrative Review

BACKGROUND

Multiple sclerosis (MS) is a rare but serious condition associated with significant morbidity.

OBJECTIVE

This review provides a focused assessment of MS for emergency clinicians, including the presentation, evaluation, and emergency department (ED) management based on current evidence.

DISCUSSION

MS is an autoimmune disorder targeting the central nervous system (CNS), characterized by clinical relapses and radiological lesions disseminated in time and location. Patients with MS most commonly present with long tract signs (e.g., myelopathy, asymmetric spastic paraplegia, urinary dysfunction, Lhermitte's sign), optic neuritis, or brainstem syndromes (bilateral internuclear ophthalmoplegia). Cortical syndromes or multifocal presentations are less common. Radiologically isolated syndrome and clinically isolated syndrome (CIS) may or may not progress to chronic forms of MS, including relapsing remitting MS, primary progressive MS, and secondary progressive MS. The foundation of outpatient management involves disease-modifying therapy, which is typically initiated with the first signs of disease onset. Management of CIS and acute flares of MS in the ED includes corticosteroid therapy, ideally after diagnostic testing with imaging and lumbar puncture for cerebrospinal fluid analysis. Emergency clinicians should evaluate whether patients with MS are presenting with new-onset debilitating neurological symptoms to avoid unnecessary testing and admissions, but failure to appropriately diagnose CIS or MS flare is associated with increased morbidity.

CONCLUSIONS

An understanding of MS can assist emergency clinicians in better diagnosing and managing this neurologically devastating disease.

Clinical Characteristics and Long-Term Outcomes of Late-Onset Multiple Sclerosis: A Swedish Nationwide Study

BACKGROUND AND OBJECTIVES

Clinical onset of multiple sclerosis (MS) after the age of 50 years is uncommon and associated with a less favorable natural history. The differences in long-term outcomes in patients with late-onset MS (LOMS, onset 50 years or older) and adult-onset MS (AOMS, onset 18 years or older and younger than 50 years) during the disease-modifying therapy (DMT) era have been less studied. This study aimed to compare patient characteristics, DMT exposure, and disability progression in Swedish patients with LOMS and AOMS over 2 decades (2001-2022).

METHODS

The nationwide Swedish MS registry was searched for patients with an onset of MS between January 1, 2001, and December 31, 2018, with symptom onset at age 18 years or older and ≥2 recorded Expanded Disability Status Scale (EDSS) scores. Clinical and demographic parameters and exposure to DMT were compared between LOMS and AOMS. Time to disability milestones (EDSS 4 and 6) was assessed using Kaplan-Meier curves and Cox proportional hazards regression models adjusted for sex, disease course, calendar year at onset, and DMT exposure.

RESULTS

Among 8739 patients with MS who met inclusion criteria, 1,028 (11.8%) were LOMS. Primary progressive MS was more frequently diagnosed in LOMS compared with that in AOMS (25.2% vs 4.5%; p < 0.001). Most of the patients had been prescribed DMT, but more rarely in LOMS compared with AOMS (74.7% vs 95.6%; p < 0.001). Less than half of patients with LOMS had been exposed to a high-efficacy DMT (45.8%) compared with 73.5% of AOMS (p < 0.001). The risk of reaching disability milestones was greater for LOMS compared with that for AOMS (EDSS 4; adjusted hazard ratio [aHR] 2.71; 95% CI 2.22-3.30; p < 0.001, and EDSS 6; aHR 2.67; 95% CI 2.12-3.36; p < 0.001).

DISCUSSION

This study distinguishes LOMS as a particularly vulnerable group and clinically supports close vigilance of these patients. Further studies are needed to assess and clarify the benefit of DMT usage in older adults with MS.

Incidence of Multiple Sclerosis in Uruguay: A Prospective Population-Based Study

BACKGROUND

The worldwide incidence of multiple sclerosis (MS) is estimated at 0.5-10 cases per 100,000 person-years and is probably increasing. In 2014, a previous study estimated the incidence of multiple sclerosis in Uruguay at 1.2 cases per 100,000 person-years.

OBJECTIVES

We conducted an observational, prospective, population-based study to determine MS incidence from diagnosis in Uruguay.

METHODS

The population studied included people older than 18 years of age who were living in Uruguay between July 1, 2019, and June 30, 2021. The diagnosis was based on 2017 McDonald criteria. Multiple data sources were employed including neurologists, magnetic resonance imaging centers, laboratories performing oligoclonal band testing, neurophysiology laboratories, neurorehabilitation centers, the institution Fondo Nacional de Recursos, and the MS Patients' Association of Uruguay (EMUR). The capture-recapture method was used to estimate incidence.

RESULTS

155 new MS cases were confirmed after review. The median age was 35 (range 18-62). Thirteen patients (8.38%) were diagnosed with late-onset MS. The crude incidence rate was 2.89 cases per 100,000 person-years, 3.95 among females, and 1.72 among male patients. The incidence rate estimated using the capture-recapture method was 3.18 (95% CI: 3.02-3.34).

CONCLUSIONS

According to the Atlas of MS, Uruguay has a low incidence rate (2.0-3.99), even though it is one of the highest in Latin America. Our country aligns with the global trend of increasing incidence. Age and sex distribution were similar to other studies, with a high incidence of patients with late-onset multiple sclerosis. The capture-recapture method confirms the exhaustivity of our investigation.

A comparison of clinical, utilization, and cost outcomes between oral treatments for multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) affects nearly 1 million people in the United States and causes significant disability and economic loss. Among the first available oral MS treatment options, clinical outcome comparisons and associated health care resource utilization are not clearly defined.

OBJECTIVE

To compare MS outcomes, health care resource utilization, and relative costs across treatment with dimethyl fumarate (DMF), fingolimod (FG), or teriflunomide (TERI) among Medicare Advantage Prescription Drug (MAPD) plan and commercially insured beneficiaries.

METHODS

This retrospective cohort study used the Humana Research Database. Eligible study patients had their first MS medication claim for oral DMG, FG, or TERI between January 1, 2013, and December 31, 2018. Patients were followed for a minimum of 12 months (mean follow-up = 3.8 years), until the earliest of the following occurred: health plan disenrollment, the end of the study period, or death. Study cohorts were balanced with inverse probability of treatment weighting. All-cause and MS-related health care resource utilization, time on therapy, and time after therapy were compared using inverse probability of treatment-adjusted multivariate generalized linear models across treatment groups. Relative costs were compared using a generalized linear model with a gamma distribution and log link.

RESULTS

We identified 1,442 patients in 3 medication groups: DMF (n = 843), FG (n = 213), and TERI (n = 386). After weighting, there were no significant differences between the medication groups on demographic and clinical characteristics. Time on therapy (days) was significantly different across medication groups (P < 0.001). Time on therapy was longest for FG compared with the DM and TERI groups (644 vs 462 vs 521). The number discontinuing the index medication was significantly different for FG vs DMF vs TERI (74.7% vs 85.3% vs 80.7%; P < 0.001). FG had the lowest discontinuation rate. The mean (SD) annualized relapse rates (ARRs) were 0.47 (0.80), 0.42 (1.3), and 0.53 (1.3) (P = 0.037) for DMF, FG, and TERI, respectively. The percentage of those experiencing inpatient stays and the number of stays (mean [SD]) were significantly different among the FG group vs DMF vs TERI (29.9% vs 34.1% vs 40.9%; P < 0.001) and (0.57 [2.9] vs 0.74 [1.9] vs 0.91 [3.5]; P = 0.007), respectively. All-cause emergency department visits and the number of visits (mean [SD]) were significantly different for the FG cohort vs DMF vs TERI (46% vs 54.3% vs 61%; P < 0.001) and (1.84 [7.7] vs 2.38 [5.9] vs 2.87 [8.8]; P = 0.002), respectively. FG had the lowest impatient stays and emergency department visits of the 3 groups.

CONCLUSIONS

Patients with MS initiated on FG used fewer health care resources and experienced lower ARR compared with patients on DMF and TERI.

Clinical and Treatment Considerations for the Pediatric and Aging Patients with Multiple Sclerosis

Chronologic aging is associated with multiple pathologic and immunologic changes that impact the clinical course of multiple sclerosis (MS). Clinical phenotypes evolve across the lifespan, from a highly inflammatory course in the very young to a predominantly neurodegenerative phenotype in older patients. Thus, unique clinical considerations arise for the diagnosis and management of the two age extremes of pediatric and geriatric MS populations. This review covers epidemiology, diagnosis, and treatment strategies for these populations with nuanced discussions on therapeutic approaches to effectively care for patients living with MS at critical transition points during their lifespan.

The evolution of multiple sclerosis disease-modifying therapies: An update for pharmacists

PURPOSE

Multiple sclerosis (MS) and the evolution of disease-modifying therapies (DMTs) and their indications, mechanisms of action, efficacy, pregnancy class, and cost are discussed.

SUMMARY

MS is an immune-mediated, demyelinating, and progressive neurological disorder that can cause both motor and cognitive deficits. Onset of MS typically occurs between the ages of 20 and 40 years, and the disease can result in significant disability over time. Since the introduction of the first DMT for the treatment of MS in 1993, significant progress has been made in the development of new classes of DMTs with different mechanisms of action, higher efficacy, and simpler administration schedules, offering patients better alternatives. However, drawbacks with the use of DMTs include their increasing cost and formulary restrictions.

CONCLUSION

The treatment landscape of MS has significantly changed over the past 2 decades, and the introduction of newer classes of DMTs provides an opportunity for pharmacists to play an important role in the management of this patient population.

Horizontal Gaze Palsy and Ipsilateral Facial Nerve Palsy in Older Patient as Initial Manifestation of Very Late-Onset Multiple Sclerosis Successfully Treated with Oral Corticosteroids: A Case Report

Introduction

Multiple sclerosis (MS) is a demyelinating condition of the central nervous system (CNS) that primarily affects young adults. Very late-onset multiple sclerosis (VLOMS) is an uncommon form of MS, accounting for only 0.5 percent of all MS patients. Eye movement impairments such as internuclear ophthalmoplegia are common in MS, while horizontal gaze palsy is an uncommon occurrence.

Case Presentation

We report a case of a patient diagnosed with VLOMS who presented with left horizontal gaze palsy and ipsilateral facial nerve palsy. Brain magnetic resonance imaging showed Dawson's fingers in the left and right periventricular white matter; multiple small, round, hyperintense lesions in the left and right cortex and juxtacortical cerebellar hemisphere; and small hyperintense lesion in the left paramedian pontine reticular formation, suggesting the diagnosis of MS. Oral corticosteroids led to complete resolution of ocular movement and ipsilateral facial nerve palsy.

Conclusion

We propose that neuroimaging should be performed in ophthalmoplegia with a pattern representing CNS lesion and oral corticosteroids may be an effective alternative to high-cost intravenous corticosteroids.

Radiological features of late-onset multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Late-onset multiple sclerosis (LOMS) is most commonly defined as the onset of the disease's presentations at age 50 or older. There is still much to discover about the radiological features of LOMS. The current study aims to assess the imaging features of LOMS, as well as the correlation between these findings and the clinical characteristics of these patients.

METHOD

This study was conducted following the PRISMA statement. A systematic search was conducted through PubMed, Scopus, and EMBASE databases to identify the studies that have applied magnetic-resonance imaging (MRI) or other imaging methods to investigate the radiological findings, as well as the relationship between them and clinical findings of LOMS patients. The risk of bias was assessed using the Joanna Briggs Institute (JBI) checklists. Meta-analysis was conducted using the third version of the compressive meta-analysis software (CMA3).

RESULTS

Our search identified 753 unique titles. Among them, 15 studies, including seven case-control, five case-series, and three cross-sectional studies, met the eligibility criteria. According to the quantitative synthesis, brain lesions were detected among 72.2% of LOMS patients (4 studies; 95% CI: 67.0% - 93.1%). In the context of spinal lesions, overall spinal cord involvement was 64.0% (8 studies; 95% CI: 42.5% - 81.1%). Based on the available evidence, supratentorial involvement was found in 82.7% of cases (3 studies; 95% CI: 17.4% - 99.1%), juxtacortical involvement in 34.1% (3 studies; 95% CI: 26.4% - 42.7%), infratentorial involvement in 51.3% (4 studies; 95% CI: 32.1% - 70.1%), and cerebellar involvement in 18.5% (3 studies; 95% CI: 13.9% - 24.1%).

CONCLUSION

Based on the neuroimaging findings, we found that, given the heterogeneity of MS, LOMS patients have a high rate of spinal cord lesions and supratentorial involvement. The limited available evidence suggests that Barkhof criteria are the best compromise for the diagnosis of LOMS. There is still a need for future studies.

Assisted Reproductive Technology and Disease Management in Infertile Women with Multiple Sclerosis

Multiple sclerosis (MS) predominantly affects women of fertile age. Various aspects of MS could impact on fertility, such as sexual dysfunction, endocrine alterations, autoimmune imbalances, and disease-modifying therapies (DMTs). The proportion of women with MS (wMS) requesting infertility management and assisted reproductive technology (ART) is increasing over time. In this review, we report on data regarding ART in wMS and address safety issues. We also discuss the clinical aspects to consider when planning a course of treatment for infertility, and provide updated recommendations to guide neurologists in the management of wMS undergoing ART, with the goal of reducing the risk of disease activation after this procedure. According to most studies, there is an increase in relapse rate and magnetic resonance imaging activity after ART. Therefore, to reduce the risk of relapse, ART should be considered in wMS with stable disease. In wMS, especially those with high disease activity, fertility issues should be discussed early as the choice of DMT, and fertility preservation strategies might be proposed in selected cases to ensure both disease control and a safe pregnancy. For patients with stable disease taking DMTs compatible with pregnancy, treatment should not be interrupted before ART. If the ongoing therapy is contraindicated in pregnancy, then it should be switched to a compatible therapy. Prior to beginning fertility treatments in wMS, it would be reasonable to assess vitamin D serum levels, thyroid function and its antibody serum levels; start folic acid supplementation; and ensure smoking and alcohol cessation, adequate sleep, and food hygiene. Cervico-vaginal swabs for Ureaplasma urealyticum, Mycoplasma hominis, and Chlamydia trachomatis, as well as serology for viral hepatitis, HIV, syphilis, and cytomegalovirus, should be performed. Steroids could be administered under specific indications. Although the available data do not clearly show a definite raised relapse risk associated with a specific ART protocol, it seems reasonably safe to prefer the use of gonadotropin-releasing hormone (GnRH) antagonists for ovarian stimulation. Close clinical and radiological monitoring is reasonably recommended, particularly after hormonal stimulation and in case of pregnancy failure.

Epstein-Barr virus and genetic risk variants as determinants of T-bet+ B cell-driven autoimmune diseases

B cells expressing the transcription factor T-bet are found to have a protective role in viral infections, but are also considered major players in the onset of different types of autoimmune diseases. Currently, the exact mechanisms driving such 'atypical' memory B cells to contribute to protective immunity or autoimmunity are unclear. In addition to general autoimmune-related factors including sex and age, the ways T-bet+ B cells instigate autoimmune diseases may be determined by the close interplay between genetic risk variants and Epstein-Barr virus (EBV). The impact of EBV on T-bet+ B cells likely relies on the type of risk variants associated with each autoimmune disease, which may affect their differentiation, migratory routes and effector function. In this hypothesis-driven review, we discuss the lines of evidence pointing to such genetic and/or EBV-mediated influence on T-bet+ B cells in a range of autoimmune diseases, including systemic lupus erythematosus (SLE) and multiple sclerosis (MS). We provide examples of how genetic risk variants can be linked to certain signaling pathways and are differentially affected by EBV to shape T-bet+ B-cells. Finally, we propose options to improve current treatment of B cell-related autoimmune diseases by more selective targeting of pathways that are critical for pathogenic T-bet+ B-cell formation.

Relapse-associated worsening in a real-life multiple sclerosis cohort: the role of age and pyramidal phenotype

BACKGROUND AND PURPOSE

The overall disability in patients with relapsing-remitting multiple sclerosis is likely to be partly rather than entirely attributed to relapse.

MATERIALS AND METHODS

The aim was to investigate the determinants of recovery from first relapse and relapse-associated worsening (RAW) in relapsing-remitting multiple sclerosis patients from the Italian MS Registry during a 5-year epoch from the beginning of first-line disease-modifying therapy. To determine recovery, the functional system (FS) score was used to calculate the difference between the score on the date of maximum improvement and the score before the onset of relapse. Incomplete recovery was defined as a combination of partial (1 point in one FS) and poor recovery (2 points in one FS or 1 point in two FSs or any other higher combination). RAW was indicated by a confirmed disability accumulation measured by the Expanded Disability Status Scale score confirmed 6 months after the first relapse.

RESULTS

A total of 767 patients had at least one relapse within 5 years of therapy. Of these patients, 57.8% experienced incomplete recovery. Age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.04; p = 0.007) and pyramidal phenotype were associated with incomplete recovery (OR = 2.1, 95% CI 1.41-3.14; p < 0.001). RAW was recorded in 179 (23.3%) patients. Age (OR = 1.02, 95% CI 1.01-1.04; p = 0.029) and pyramidal phenotype (OR = 1.84, 95% CI 1.18-2.88; p = 0.007) were the strongest predictors in the multivariable model.

CONCLUSIONS

Age and pyramidal phenotype were the strongest determinants of RAW in early disease epochs.

Personality Traits and Fatigue in Multiple Sclerosis: A Narrative Review

(1) Background: Multiple sclerosis (MS) is a chronic neurodegenerative autoimmune disease. Fatigue is a prevalent and debilitating symptom that significantly impacts the quality of life of these patients. A relationship between personality traits and fatigue in MS has been hypothesized but not clearly defined. (2) Methods: A literature search was carried out from databases up to April 2023 for studies correlating personality traits and fatigue in patients suffering from MS. (3) Results: A total of ten articles was included; most of the studies depict a neuroticism-fatigue correlation; however, they were not consistent in terms of the fatigue, personality, and covariate assessments. (4) Conclusions: The clinical and methodological heterogeneity of the included studies prevented us from drawing any firm conclusion on the link between personality traits and fatigue in MS. Several models of personality and different fatigue assessments have been found. Despite this, a common pathway shows that the neuroticism trait or similar personality patterns has a role in fatigue diagnosis. This may be a useful target to improve the quality of life and enhance the modification of the disease treatment results. Further homogeneous and longitudinal studies are needed.

The Heterogeneous Multiple Sclerosis Lesion: How Can We Assess and Modify a Degenerating Lesion?

Multiple sclerosis (MS) is a heterogeneous disease of the central nervous system that is governed by neural tissue loss and dystrophy during its progressive phase, with complex reactive pathological cellular changes. The immune-mediated mechanisms that promulgate the demyelinating lesions during relapses of acute episodes are not characteristic of chronic lesions during progressive MS. This has limited our capacity to target the disease effectively as it evolves within the central nervous system white and gray matter, thereby leaving neurologists without effective options to manage individuals as they transition to a secondary progressive phase. The current review highlights the molecular and cellular sequelae that have been identified as cooperating with and/or contributing to neurodegeneration that characterizes individuals with progressive forms of MS. We emphasize the need for appropriate monitoring via known and novel molecular and imaging biomarkers that can accurately detect and predict progression for the purposes of newly designed clinical trials that can demonstrate the efficacy of neuroprotection and potentially neurorepair. To achieve neurorepair, we focus on the modifications required in the reactive cellular and extracellular milieu in order to enable endogenous cell growth as well as transplanted cells that can integrate and/or renew the degenerative MS plaque.