Increasing prevalence and incidence of multiple sclerosis in South East Wales

Algorithmic approach to finding people with multiple sclerosis using routine healthcare data in Wales

BACKGROUND

Identification of multiple sclerosis (MS) cases in routine healthcare data repositories remains challenging. MS can have a protracted diagnostic process and is rarely identified as a primary reason for admission to the hospital. Difficulties in identification are compounded in systems that do not include insurance or payer information concerning drug treatments or non-notifiable disease.

AIM

To develop an algorithm to reliably identify MS cases within a national health data bank.

METHOD

Retrospective analysis of the Secure Anonymised Information Linkage (SAIL) databank was used to identify MS cases using a novel algorithm. Sensitivity and specificity were tested using two existing independent MS datasets, one clinically validated and population-based and a second from a self-registered MS national registry.

RESULTS

From 4 757 428 records, the algorithm identified 6194 living cases of MS within Wales on 31 December 2020 (prevalence 221.65 (95% CI 216.17 to 227.24) per 100 000). Case-finding sensitivity and specificity were 96.8% and 99.9% for the clinically validated population-based cohort and sensitivity was 96.7% for the self-declared registry population.

DISCUSSION

The algorithm successfully identified MS cases within the SAIL databank with high sensitivity and specificity, verified by two independent populations and has important utility in large-scale epidemiological studies of MS.

Could Mathematics be the Key to Unlocking the Mysteries of Multiple Sclerosis?

Multiple sclerosis (MS) is an autoimmune, neurodegenerative disease that is driven by immune system-mediated demyelination of nerve axons. While diseases such as cancer, HIV, malaria and even COVID have realised notable benefits from the attention of the mathematical community, MS has received significantly less attention despite the increasing disease incidence rates, lack of curative treatment, and long-term impact on patient well-being. In this review, we highlight existing, MS-specific mathematical research and discuss the outstanding challenges and open problems that remain for mathematicians. We focus on how both non-spatial and spatial deterministic models have been used to successfully further our understanding of T cell responses and treatment in MS. We also review how agent-based models and other stochastic modelling techniques have begun to shed light on the highly stochastic and oscillatory nature of this disease. Reviewing the current mathematical work in MS, alongside the biology specific to MS immunology, it is clear that mathematical research dedicated to understanding immunotherapies in cancer or the immune responses to viral infections could be readily translatable to MS and might hold the key to unlocking some of its mysteries.

Life expectancy in multiple sclerosis by EDSS score

The median survival time of newly-diagnosed MS patients without severe disabilities is approximately 30-35 years. The prognosis after the onset of severe disability has not been reported. Based on Harding et al.'s 2018 study of the Southeast Wales MS registry, we calculated life expectancies according to the Expanded Disability Status Scale (EDSS). Upon loss of independent ambulation (EDSS 6-6.5; mean age 51.2) life expectancy was 13.3 additional years. At EDSS 9-9.5 (mean age 70.8) life expectancy was 1.1 additional years. These figures provide an empirical basis for discussions of advanced MS care planning.

Multiple sclerosis and COVID-19: Assessing risk perception, patient behaviors and access to disease-modifying therapies

BACKGROUND

Following the outbreak of COVID-19, global healthcare systems have had to rapidly adapt. People with multiple sclerosis (pwMS) were required to make decisions about their individual risk and consequent work and social behaviors. This study aimed to evaluate risk perception and patterns of shielding behavior amongst pwMS at the onset of the COVID-19 pandemic and the subsequent impact on patients' employment and access to disease modifying therapies (DMTs).

METHODS

Postal surveys were sent to 1690 people within a UK population-based MS cohort during the first wave of the COVID-19 pandemic. Patients were surveyed on: (i) perceived vulnerability to COVID-19; (ii) isolation behavior; (iii) interruption to DMT; (iv) employment status; (v) level of satisfaction with their current working arrangement.

RESULTS

Responses were received from 1000 pwMS. Two thirds of patients reported isolating at home during the first wave of the pandemic. This behavior was associated with increased age (p<0.0001), higher disability (p<0.0001) and use of high-efficacy DMTs (p = 0.02). The majority of patients reported feeling vulnerable (82%) with perceived vulnerability associated with higher EDSS (p<0.0001) and receiving a high-efficacy DMT (p = 0.04). Clinician-defined risk was associated with shielding behavior, with those at high-risk more likely to self-isolate/shield (p<0.0001). Patients on high-efficacy DMTs were more likely to have an interruption to their treatment (50%) during the first wave of the pandemic. Most pwMS experienced a change to their working environment, and most were satisfied with the adjustments.

CONCLUSION

This study highlights the risk perception, social behavioral practices and changes to treatment experienced by pwMS during the first wave of the COVID-19 pandemic in a large, well-described UK cohort. The results may help inform management of pwMS during future pandemic waves.

The role of sex and pregnancy in multiple sclerosis: what do we know and what should we do?

INTRODUCTION

Multiple sclerosis (MS) is more prevalent in women than in men. The sex of the patient, and pregnancy, are reported to be associated with the clinical features of MS. The mechanism of this is unclear.

AREAS COVERED

This review summarizes data about sex differences in MS and the role of pregnancy. Possible mechanisms for the effects of sex and pregnancy are summarized, and practical suggestions for addressing these issues are provided.

EXPERT OPINION

There is considerable interdependence of the variables that are associated with MS. Men have a worse outcome of MS, and this could be due to the same factors that lead to greater incidence of neurodegenerative disease in men. The possible role of parity on the long-term outcome of MS is of interest. Future studies that look at the mechanisms of the effects of the sex of the patient on the outcome of MS are required. However, there are some actions that can be taken without further research. We can concentrate on public health measures that address the modifiable risk factors for MS and ensure that disease is controlled in women who intend to become pregnant and use appropriate disease modifying agents during pregnancy.

Apparent changes in the epidemiology and severity of multiple sclerosis

Multiple sclerosis (MS) is an immunological disease that causes acute inflammatory lesions and chronic inflammation in the CNS, leading to tissue damage and disability. As awareness of MS has increased and options for therapy have come into use, a large amount of epidemiological data have been collected, enabling studies of changes in incidence and disease course over time. Overall, these data seem to indicate that the incidence of MS has increased, but the course of the disease has become milder, particularly in the 25 years since the first disease-modifying therapies (DMTs) became available. A clear understanding of these trends and the reasons for them is important for understanding the factors that influence the development and progression of MS, and for clinical management with respect to prevention and treatment decisions. In this Review, we consider the evidence for changes in the epidemiology of MS, focusing on trends in the incidence of the disease over time and trends in the disease severity. In addition, we discuss the factors influencing these trends, including refinement of diagnostic criteria and improvements in health-care systems that have increased diagnosis in people with mild disease, and the introduction and improvement of DMT.

Effects of tactile stimulation on the sensory, motor and cognitive function in people with multiple sclerosis

OBJECTIVE

Multiple sclerosis (MS) is a chronic inflammatory neurodegenerative disease that causes demyelination in the brain and spinal cord. Repetitive sensory stimulation (RSS) can enhance sensory perception and motor function, improve inappropriate synaptic connections and adaptable malformations, and increase cognitive function. The purpose of this study was to specify the effect of RSS on the sensory, motor, and cognitive function in people with MS.

METHODS

RSS was applied to 50 people with MS. In this study, the following tests were used: two-point discrimination, 9-Hole Peg Test (9-HPT), Box and Block Test (BBT), hand mental rotation (HMR), Paced Auditory Serial Addition Test (PASAT), and Symbol Digit Modalities Test (SDMT). The tests were performed before and after the intervention.

RESULTS

The results of this study showed significant difference before and after the stimulation in intervention and control groups two-point discrimination threshold (both groups= 0.001), BBT score (both groups: P < 0.001) and 9-HPT score (both groups: P < 0.001), HMR ability (reaction time: both groups: P = 0.003; accuracy rate: intervention: P = 0.004, control: P < 0.001), PASAT score (intervention: P < 0.001, control: P = 0.012) and SDMT score (intervention: P = 0.008, control: P < 0.001), but there was no statistical difference observed between the two groups before and after the intervention in terms of the mentioned variables (P > 0.05).

CONCLUSION

The application of 30 min of RSS in the right index finger of people with MS could not improve the two-point discrimination threshold and the manual dexterity. In addition, this intervention did not improve cognitive function.

Occupational Therapy Interventions in Adults with Multiple Sclerosis or Amyotrophic Lateral Sclerosis: A Scoping Review

This scoping review aims to describe occupational therapy interventions carried out with multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS) patients in occupational therapy. A peer review of the literature was conducted in different databases: Pubmed, Scopus, Web of Science and Embase, and in some occupational therapy journals. A search of the literature published was carried out before December 2019. The inclusion criteria were as follows: (1) articles evaluating the intervention of occupational therapy in MS or ALS including experimental, randomized, nonrandomized and exploratory studies; (2) written in English or Spanish; (3) adult population (over 18 years old). The initial search identified 836 articles of which we included 32 divided into four areas of intervention: fatigue-targeted interventions, cognitive interventions, physical interventions and others. Only 16 studies were carried out exclusively by occupational therapists. Most occupational therapy interventions are aimed at fatigue and physical rehabilitation. The majority of the studies in our review included MS patients, with little representation from the ALS population. These interventions have shown an improvement in perceived fatigue, manual dexterity, falls prevention and improvement in cognitive aspects such as memory, communication, depression and quality of life in the MS and ALS populations.

Work Productivity Outcomes Associated with Ocrelizumab Compared with Other Disease-Modifying Therapies for Multiple Sclerosis

Objective

This study evaluated work and activity impairment in patients with multiple sclerosis (MS) treated with ocrelizumab (OCR) versus other disease-modifying therapies (DMTs).

Methods

Data were obtained from the Adelphi Real World Disease Specific Programme for Multiple Sclerosis. Patients with relapsing–remitting or secondary progressive MS who completed surveys in 2018 and 2019 and received ≥ 6 months of an eligible therapy, including OCR, injectable therapy, and oral therapy, were included. Outcomes were assessed using the patient-reported Work Productivity and Activity Impairment questionnaire. Doubly robust estimation, which combined propensity score weighting and regression modeling, was used to compare treatments, controlling for baseline clinical and demographic characteristics.

Results

This study included 630 patients (OCR, n = 90; injectable DMT, n = 224; oral DMT, n = 316) with a mean (standard deviation) age of 42 (11) years. A greater proportion of OCR-treated patients had an Expanded Disability Status Scale score of ≥ 3 at treatment initiation compared with those receiving oral and injectable DMTs (51 vs. 15% and 15%, respectively), and a smaller proportion of OCR-treated patients received treatment for ≥ 1 year (43 vs. 90% and 92%, respectively). OCR-treated patients had higher odds of employment [odds ratio (95% confidence interval) 3.4 (1.5–7.7) vs. oral DMT, 5.6 (2.6–12.0) vs. injectable DMT], lower overall work productivity loss [difference (95% confidence interval) − 10.0% (− 6.1 to − 15.0%) vs. oral DMT, − 13.0% (− 8.5 to − 17.0%) vs. injectable DMT] and lower activity impairment [difference (95% confidence interval) − 11% (− 7.1 to − 16.0%) vs. oral DMT, − 9.7% (− 5.0 to − 14.0%) vs. injectable DMT].

Conclusion

This real-world evidence suggests that patients with MS treated with OCR experience lower work and activity impairment than patients treated with other DMTs.

Electronic supplementary material

The online version of this article (10.1007/s40120-020-00224-1) contains supplementary material, which is available to authorized users.

Multiple sclerosis (MS) is the most common progressive neurological disease in young adults. It typically starts between the ages of 20 and 40 years—arguably some of the most productive years of an individual’s life—and it has a large impact on many aspects of everyday life for the rest of a person’s life. The reduction in the ability to do routine activities, including working, results in a large economic burden. Disease-modifying treatments (DMTs) available for MS, particularly high-efficacy DMTs, have been shown to improve work productivity. This study looked at work and activity impairment using the Work Productivity and Activity Impairment Questionnaire in patients with MS who were treated with ocrelizumab (OCR) or other DMTs for ≥ 6 months. A total of 630 patients with relapsing–remitting MS (RRMS) or secondary progressive MS (SPMS) from the Adelphi Real World Disease Specific Programme for Multiple Sclerosis were included in the study, including 90, 316 and 224 patients who completed ≥ 6 months of treatment with OCR, oral or injectable therapy. Compared with patients receiving oral or injectable DMTs, those receiving OCR had higher odds of employment [odds ratio (OR) vs. oral DMT 3.4; OR vs. injectable DMT 5.6], lower overall work productivity impairment (difference vs. oral DMT − 10%; difference vs. injectable DMT − 13%) and lower activity impairment (difference vs. oral DMT − 11%; difference vs. injectable DMT − 9.7%). These findings in patients with RRMS or SPMS being treated in the real world suggest that OCR may reduce the impact of MS disease on work productivity more than other DMTs.

Joinpoint Regression Analysis of Trends in Multiple Sclerosis Incidence in Kuwait: 1980-2019

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory demyelinating and neurodegenerative disease of the central nervous system with unknown precise etiology. Temporally, a tendency for increasing MS incidence has been recorded worldwide. This cross-sectional cohort study sought to quantify trends in the age-standardized incidence rates (ASIRs) (per million person-years) of MS in Kuwait from 1980 to 2019, overall and by subcohorts defined by age at MS onset, sex, and nationality.

METHODS

MS incidence data from 1980 to 2019 were obtained from the Kuwait National MS Registry (KNMSR). Using midyear relevant Kuwait population as denominator and the World Standard Population as a reference, MS ASIRs overall and by subcohorts defined by age at onset (0-19, 20-39, and 40+ years), sex (male and female), and nationality (Kuwaiti and non-Kuwaiti) were computed. Joinpoint regression analysis was conducted to estimate average annual percent change (AAPC) and its 95% confidence interval (CI) overall and by subcohorts.

RESULTS

During 1980-2019, a total of 1,764 MS incident cases of 95.6 million person-years at-risk were diagnosed and registered in KNMSR. The overall MS ASIR (per million person-years) during the study period was 34.1 (95% CI: 16.1, 52.1). Between 1980 and 2010, in the total cohort, ASIRs of MS significantly increased by 13% (AAPC = 13.0; 95% CI: 10.8, 15.3; p < 0.001), followed by statistically nonsignificant declining trend during the ensuing period (AAPC = -3.8; 95% CI: -14.8, 8.8; p = 0.522). Joinpoint regression analysis revealed that 2 subcohorts of Kuwaiti females each with one joinpoint had significant increasing trends in MS ASIRs (0- to 19-year-old Kuwaiti females, AAPC: 1980-2009, 81.0; 95% CI: 58.2, 107.0; p = 0.001; 20- to 39-year-old Kuwaiti females, AAPC: 1980-1999, 131.7; 95% CI: 26.9, 322.8; p = 0.021). Additionally, of remaining 10, 6 subcohorts had significantly (p < 0.05) increasing trends in MS ASIRs from 1980 to 2019.

CONCLUSIONS

From 1980 to 2010, Kuwait has an overall significantly increasing trend in MS ASIRs followed by a nonsignificant declining drift in the ensuing period. The increasing trend in MS risk appeared to be driven by increased risk among Kuwaiti females younger than 40 years. The underlying factors modulating MS risk in Kuwait need further studies.

Incidence and prevalence of multiple sclerosis in Hungary based on record linkage of nationwide multiple healthcare administrative data

Objectives

As there were only regional studies in Hungary about the prevalence of multiple sclerosis (MS), we aimed to estimate its epidemiological features using data of Hungary’s single-payer health insurance system.

Methods

Pseudonymized database of claims reported by hospitals and outpatient services between 2004–2016 was analyzed and linked with an independent database of outpatient pharmacy refills between 2010–2016. We established an administrative case definition of MS and validated it on medical records of 309 consecutive patients. A subject was defined as MS-patient if received MS diagnosis (International Classification of Diseases, 10th edition, code G35) on three or more occasions at least in 2 calendar years and at least once documented by a neurologist. Patients were counted as incident cases in the year of the first submitted claim for MS. We allowed a 6-year-long run-in period, so only data between 2010–2015 are discussed.

Results

Sensitivity of the administrative case definition turned out to be 99%, while specificity was >99%. Crude prevalence of MS has increased from 109.3/100,000 in 2010 to 130.8/100,000 in 2015 (p-value = 0.000003). Crude incidence declined from 7.1/100,000 (2010) to 5.4/100,000 (2015) (p-value = 0.018). Direct standardization − based on European standard population and results of nationwide Hungarian census of 2011 − revealed that age standardized prevalence was 105.2/100,000 (2010), which has grown to 127.2/100,000 (2015) (p-value = 0.000001). Age standardized incidence rate declined from 6.7/100,000 (2010) to 5.1/100,000 (2015) (p-value = 0.016). The ratio of MS-patients receiving ≥1 prescription for disease modifying treatment increased from 0.19 (2010) to 0.29 (2015) (p-value = 0.0051). The female/male ratio of prevalent cases remained 2.6.

Discussion

The prevalence of MS in Hungary is higher than previously reported, the incidence rate is moderate. The prevalence is rising, the incidence rate shows decline. The proportion of patients receiving disease modifying treatment grows but was still around 30% in 2015.

Age and sex-adjusted incidence and yearly prevalence of multiple sclerosis (MS) in Mazandaran province, Iran: An 11-years study

INTRODUCTION

The incidence rate of MS is a valuable indicator of the recent changes in the risk of this disease, and it is widely implicated for health planning purposes.

OBJECTIVES

This study aims to determine the MS incidence over the past eleven years in Mazandaran province and to compare it with the other parts of Iran and the world.

MATERIALS AND METHODS

This retrospective study is conducted in Mazandaran province by using registered data in the files of the patients with their consent. The yearly crude incidence rates, age, and sex-specific incidence rates and directly standardized incidence rates of this population are calculated, and the temporal changes in the incidence rates are analyzed.

RESULTS

662 (26%) male patients with the mean (SD) age of 32.6 (9.48) and 1884 (74%) female patients with the mean (SD) age of 31.9 (9.15) are studied. The direct standardized incidence rate of MS was 3.28 in 100.000 in 2008 and reached 4.17 in 100.000 in 2018, and this increase was significant (p<0.05). Also, the yearly prevalence of MS increased from 24.4 to 72.5 in this period.

CONCLUSIONS

The MS incidence has increased in Mazandaran. The potential role of some genetic or environmental factors needs further investigation.

Clinical Outcomes of Escalation vs Early Intensive Disease-Modifying Therapy in Patients With Multiple Sclerosis

Importance

Uncertainty remains about how aggressively to treat early multiple sclerosis. High-efficacy disease-modifying therapies (DMTs) are often reserved for individuals expressing poor prognostic features at baseline.

Objective

To analyze long-term outcomes in a population-based cohort according to initial treatment strategy.

Design, Setting and Participants

In this cohort study, data were derived from January 1998 to December 2016, and analysis was performed in January 2017. From a total of 720 patients prescribed a DMT, 592 (82%) were included in analysis. Reasons for exclusion were first treated elsewhere or privately (n = 39), clinical trial participant (n = 25), and insufficient clinical data (n = 45).

Exposures

Patients were classified according to first-line treatment strategy: high-efficacy (early intensive treatment [EIT]) or moderate-efficacy DMT (escalation [ESC]).

Main Outcomes and Measures

Primary outcome was 5-year change in Expanded Disability Status Scale score. Secondary outcome was time to sustained accumulation of disability (SAD). Models were adjusted for sex, age at treatment, year of starting DMT, and escalation to high-efficacy treatment in the ESC group.

Results

Mean (SD) age of 592 patients at symptom onset was 27.0 (9.4) years. Mean (SD) 5-year change in Expanded Disability Status Scale score was lower in the EIT group than the ESC group (0.3 [1.5] vs 1.2 [1.5]); this remained significant after adjustment for relevant covariates (β = -0.85; 95% CI, -1.38 to -0.32; P = .002). Median (95% CI) time to SAD was 6.0 (3.17-9.16) years for EIT and 3.14 (2.77-4.00) years for ESC (P = .05). For those within the ESC group who escalated to high-efficacy DMT as second-line treatment, median (95% CI) time to SAD was 3.3 years (1.8-5.6; compared with EIT group log-rank test P = .08). After adjustment for relevant covariates, there was no difference in hazard of SAD between the groups. However, 60% of those who escalated to high-efficacy DMTs were observed to develop SAD while still receiving initial moderate-efficacy treatment before escalation.

Conclusions and Relevance

In a real-life setting, long-term outcomes were more favorable following early intensive therapy vs first-line moderate-efficacy DMT. Contemporary surveillance strategies and escalation protocols may be insufficiently responsive. This finding is particularly relevant as patients in real-world practice are typically selected for an EIT approach to therapy on the basis of clinical and radiological features predictive of a poor outcome. These data support the need for a prospective randomized clinical trial.

Prevalence of multiple sclerosis in Cuenca, Ecuador

Background

Methods

Results

Conclusions

How common is truly benign MS in a UK population?

OBJECTIVES

The prevalence and definition of benign multiple sclerosis (BMS) remain controversial. Most definitions are based on the Expanded Disability Status Scale (EDSS), not encompassing the wider impact of disease. The explanation for favourable outcomes remains unclear. We aim to provide a detailed characterisation of patients with low EDSS scores at long disease durations.

METHODS

We screened a population-based registry containing 3062 people with MS to identify individuals with unlimited walking ability at disease durations >15 years. A representative cohort underwent detailed clinical assessment and classified as having BMS according to EDSS score <3, no significant fatigue, mood disturbance, cognitive impairment or disrupted employment, and had not received a disease-modifying therapy. We determined patient-reported perceptions of MS status and made comparisons with EDSS-based definitions.

RESULTS

Of 1049 patients with disease duration of >15 years, 200 (19.1%) had most recent EDSS score <4.0. Detailed contemporary clinical assessment of a representative sample of 60 of these patients revealed 48 (80%) had an EDSS score of <4.0, 35 (58%) <3.0 and 16 (27%) <2.0. Only nine (15%) fulfilled our criteria for BMS; impaired cognition (57%) and effects on employment (52%) the most common causes for exclusion. Meanwhile, 33/60 (69%) patients considered their disease benign. Population frequency for BMS was estimated at 2.9% (95% CI 2.0 to 4.1).

CONCLUSIONS

Comprehensive assessment reveals a small minority of people with MS who appear genuinely benign after 15 years. Study of such individuals may uncover insights about disease pathogenesis. However, discrepancy between patient perception and clinician perception of BMS undermines use of the term 'benign' in clinical settings.

Perceived fatigue and cognitive performance change in multiple sclerosis: Uncovering predictors beyond baseline fatigue

BACKGROUND

Fatigue is a common and disabling symptom in multiple sclerosis (MS) with a variety of direct and indirect influences, but remains poorly understood. Perceived fatigue and cognitive performance fatigability may only be weakly correlated and may have independent predictors. We adopted a multifactorial approach, utilising a measure of concurrent cognitive performance change in order to examine the clinical, psychological, and cognitive factors influencing perceived and cognitive performance fatigability in MS.

METHODS

Individuals with adult-onset MS were identified from a regional patient database and invited to complete an assessment battery during a home visit. Baseline perceived fatigue was measured using the Modified Fatigue Impact Scale, Fatigue Assessment Instrument, and a Visual Analogue Scale (VAS). The Conners Continuous Performance Test 3 (CCPT3) and VAS were administered before and after our intervention of roughly 2.5 hours of assessment, which represented a period of cognitive effort. The differences in scores formed measures of cognitive performance fatigability and perceived fatigue change, respectively. We examined differences across baseline fatigue, fatigue change and performance change classifications, using regression analysis to uncover predictors of perceived fatigue and performance change.

RESULTS

The sample comprised 61 participants who were recruited from an existing cohort of MS patients. Positive relationships with depression and emotion-focused coping, and a negative one with sleep, each predicted baseline perceived fatigue with the model explaining 53.5% of variance. Increased perceived fatigue change was not associated with baseline fatigue, cognitive impairment, disease variables or levels of disability, but was linked with higher anxiety, lower self-efficacy and gender. Most CCPT3 performance change variables did not show significant correlations with baseline clinical, psychological, or fatigue variables. However, two variables were predicted by positive relationships with estimated intelligence, whilst a negative relationship with self-efficacy and a positive one with post-intervention fatigue predicted one each.

CONCLUSION

Fatigue in MS is a multifactorial construct, with perceived fatigue and cognitive performance fatigability largely influenced by indirect psychological and cognitive factors. Future studies need to take these influences into account when developing fatigue assessment tools. Further, targeting influential fatigue drivers such as psychological variables may improve the burden of fatigue and quality of life of people with MS.

Socioeconomic status and disability progression in multiple sclerosis: A multinational study

OBJECTIVE

To examine the association between socioeconomic status (SES) and disability outcomes and progression in multiple sclerosis (MS).

METHODS

Health administrative and MS clinical data were linked for 2 cohorts of patients with MS in British Columbia (Canada) and South East Wales (UK). SES was measured at MS symptom onset (±3 years) based on neighborhood-level average income. The association between SES at MS onset and sustained and confirmed Expanded Disability Status Scale (EDSS) 6.0 and 4.0 and onset of secondary progression of MS (SPMS) were assessed using Cox proportional hazards models. EDSS scores were also examined via linear regression, using generalized estimating equations (GEE) with an exchangeable working correlation. Models were adjusted for onset age, sex, initial disease course, and disease-modifying drug exposure. Random effect models (meta-analysis) were used to combine results from the 2 cohorts.

RESULTS

A total of 3,113 patients with MS were included (2,069 from Canada; 1,044 from Wales). A higher SES was associated with a lower hazard of reaching EDSS 6.0 (adjusted hazard ratio [aHR] 0.90, 95% confidence interval [CI] 0.89-0.91), EDSS 4.0 (aHR 0.93, 0.88-0.98), and SPMS (aHR 0.94, 0.88-0.99). The direction of findings was similar when all EDSS scores were included (GEE: β = -0.13, -0.18 to -0.08).

CONCLUSIONS

Lower neighborhood-level SES was associated with a higher risk of disability progression. Reasons for this association are likely to be complex but could include factors amenable to modification, such as lifestyle or comorbidity. Our findings are relevant for planning and development of MS services.

Prevalence of multiple sclerosis in an urban population of Sivas province in Turkey

Background/aim

Multiple sclerosis (MS) is a common neurological disorder that can be a leading cause of nontraumatic disability in several countries. Recent reports have indicated a moderate to high risk of MS in European countries. In this study, we examined the prevalence of MS in a well-defined urban population of provincial center in Sivas Province in Turkey.

Materials and methods

This study sampled all registered residents of urban areas of provincial center in Sivas Province in April 2017 and 2018 January. All the included patients met the McDonald 2010 criteria. Medical records were reviewed, including all available previously acquired magnetic resonance imaging data. All patients were subsequently subjected to neurologic examination to confirm the MS diagnosis.

Results

We identified 21 possible MS patients, with MS diagnosis confirmed in 19. The prevalence of MS was 288 per 100,000 inhabitants.

Conclusion

For future studies, these high ratio results can be used in regional and national comparisons to determine cofactors contributing to the high prevalence of MS in our region and can help health-decision makers to better plan healthcare policies to improve neurological services and awareness about multifaceted clinical presentations of MS.

A contemporary study of mortality in the multiple sclerosis population of south east Wales

BACKGROUND

Mortality studies in multiple sclerosis (MS) are valuable to identify changing disease patterns and inform clinical management. This study examines mortality in a British MS cohort.

METHODS

Patients were selected from the southeast Wales MS registry. Hazard of death was analysed using Cox proportional hazards regression, adjusted for onset age, annualised relapse rate, initial disease course, time to EDSS 4.0, sex, socioeconomic status, and onset year. Age- and sex-stratified standardised mortality ratios (SMRs) were calculated by EDSS scores.

RESULTS

Median time from MS diagnosis to death was 35.5 years and median age 73.9. Older onset age (hazard ratio [HR] 1.05, 95% confidence interval 1.03-1.06) was associated with increased hazard of death. Primary progressive course was associated with increased hazard of death in women (HR 2.04, 1.15-3.63) but not men (HR 1.23, 0.61-2.47). Slow time to EDSS 4.0 (HR 0.41, 0.28-0.60) and high socioeconomic status (HR 0.54, 0.37-0.79) were associated with reduced hazard of death. SMR increased from EDSS 6.0 (3.86, 2.63-5.47) but more substantially at EDSS 8.0 (22.17, 18.20-26.75).

CONCLUSIONS

Risk of death in MS varies substantially with degree of disability. This has important implications for clinical management and health economic modelling.

Sex: A Significant Risk Factor for Neurodevelopmental and Neurodegenerative Disorders

Males and females sometimes significantly differ in their propensity to develop neurological disorders. Females suffer more from mood disorders such as depression and anxiety, whereas males are more susceptible to deficits in the dopamine system including Parkinson's disease (PD), attention-deficit hyperactivity disorder (ADHD) and autism. Despite this, biological sex is rarely considered when making treatment decisions in neurological disorders. A better understanding of the molecular mechanism(s) underlying sex differences in the healthy and diseased brain will help to devise diagnostic and therapeutic strategies optimal for each sex. Thus, the aim of this review is to discuss the available evidence on sex differences in neuropsychiatric and neurodegenerative disorders regarding prevalence, progression, symptoms and response to therapy. We also discuss the sex-related factors such as gonadal sex hormones and sex chromosome genes and how these might help to explain some of the clinically observed sex differences in these disorders. In particular, we highlight the emerging role of the Y-chromosome gene, SRY, in the male brain and its potential role as a male-specific risk factor for disorders such as PD, autism, and ADHD in many individuals.

Epidemiology of Multiple Sclerosis in Torbat-e Heydarieh (Northeast of Iran) during 1982-2016

It was believed that the risk of multiple sclerosis (MS) is associated with latitude gradient. Due to the increasing prevalence of MS in some areas around the equator such as Iran, this theory has been criticized in recent years. Since the distribution of MS in Iran is not uniform, this study was designed to describe the prevalence and incidence of MS in the northeastern area of Iran. The patients were registered in the MS center of Torbat-e Heydarieh County and all of them were living in this county during the study period (during 1 January 1982 to 31 December 2016). Data of the patients were extracted from their files in the MS center. Because of the long-term span of this study, we used different diagnosis criteria according to the files of the patients to proven case missing. In addition, population data were obtained from the website of Statistical Centre of Iran. The total number of the MS patients during the study period was 110 cases. The prevalence of the disease at the beginning and end of the research period was 0.33 (95% CI, 0.008-1.85) and 30.48 (95% CI, 25.25-37.03) patients per 100,000 persons, respectively. The incidence of the disease in this 36-year period was 1.41 (95%CI, 1.15-1.69) patients per 100,000 persons. The average age of the patients was 35.01 (95% CI, 33.37-36.65) years and the female to male ratio was 2.8:1. The prevalence of MS has been increased in the 36-year period in Torbat-e Heydarieh, especially for women. More epidemiological studies are needed to determine the factors affecting this increasing trend.

Predictors for Employment Status in People With Multiple Sclerosis: A 10-Year Longitudinal Observational Study

OBJECTIVE

To identify predictors for employment status after 10 years in a cohort of people with multiple sclerosis (MS), with the aim to increase knowledge concerning factors present at an early stage that are important for working life and work-life balance.

DESIGN

A 10-year longitudinal observational cohort study.

SETTING

University hospital.

PARTICIPANTS

A consecutive sample of people with MS (N=154) of working age were included at baseline, of which a total of 116 people participated in the 10-year follow-up; 27 people declined participation and 11 were deceased.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Baseline data on personal factors and functioning were used as independent variables. Employment status 10 years after baseline, categorized as full-time work, part-time work, and no work, was used as the dependent variable. A generalized ordinal logistic regression was used to analyze the predictive value of the independent variables.

RESULTS

Predictors for full- or part-time work after 10 years were young age (P=.002), low perceived physical impact of MS (P=.02), fatigue (P=.03), full-time work (P=.001), and high frequency of social/lifestyle activities (P=.001) at baseline. Low perceived physical impact of MS (P=.02) at baseline also predicted full-time work after 10 years.

CONCLUSIONS

This study underlines the complexity of working life for people with MS, and indicates that it may be valuable to give more attention to the balance between working and private life, both in clinical practice and future research, to achieve a sustainable working life over time.

Central nervous system neuroinflammatory disorders in Asian/Pacific regions

PURPOSE OF REVIEW

The discovery of aquaporin-4 (AQP4) antibodies with high specificity for neuromyelitis optica spectrum disorder (NMOSD) has induced tremendous changes in the approach and management of central nervous system (CNS) neuroinflammatory disorders. Owing to the increasing availability of the AQP4 antibody assay and evolution of diagnostic criteria for multiple sclerosis and NMOSD, recent studies have reevaluated CNS neuroinflammatory disorders. This review describes recent advances in the understanding of CNS neuroinflammatory disorders in Asian/Pacific regions.

RECENT FINDINGS

Although multiple sclerosis prevalence is lower in Asian countries than in Western countries, the overall clinical features of multiple sclerosis are comparable between these countries. Hospital-based studies have reported that the frequency of NMOSD is higher in Asian populations (22-42%) than in white populations (2-26%). Despite improvements in the AQP4 antibody assay, AQP4 antibodies are not detected in certain patients with NMOSD. Recently, myelin oligodendrocyte glycoprotein (MOG) antibodies have been identified in AQP4 antibody-negative patients with the NMOSD phenotype, and the clinical features differ slightly between MOG antibody-positive patients and AQP4 antibody-positive patients.

SUMMARY

The understanding of CNS neuroinflammatory disorders in Asian/Pacific regions continues to evolve owing to the discovery of new biological markers and recognition of broader clinical phenotypes.

Multiple sclerosis epidemiology in Latin America: An updated survey

Novel epidemiological data have appeared in recent years in Latin America (LATAM). The objective of this study was to perform an updated systematic review of the epidemiology of the disease reported in LATAM.

Diagnosis of multiple sclerosis: progress and challenges

The diagnosis of multiple sclerosis is based on neurological symptoms and signs, alongside evidence of dissemination of CNS lesions in space and time. MRI is often sufficient to confirm the diagnosis when characteristic lesions accompany a typical clinical syndrome, but in some patients, further supportive information is obtained from cerebrospinal fluid examination and neurophysiological testing. Differentiation is important from other diseases in which demyelination is a feature (eg, neuromyelitis optica spectrum disorder and acute disseminated encephalomyelitis) and from non-demyelinating disorders such as chronic small vessel disease and other inflammatory, granulomatous, infective, metabolic, and genetic causes that can mimic multiple sclerosis. Advances in MRI and serological and genetic testing have greatly increased accuracy in distinguishing multiple sclerosis from these disorders, but misdiagnosis can occur. In this Series paper we explore the progress and challenges in the diagnosis of multiple sclerosis with reference to diagnostic criteria, important differential diagnoses, controversies and uncertainties, and future prospects.

Ethnicity and prevalence of multiple sclerosis in east London

Background:

Incidence and prevalence rates of multiple sclerosis (MS) are generally higher in White populations than in other ethnic groups. Relevant studies in the United Kingdom were conducted over 30 years ago.

Objectives:

To provide updated ethnicity-specific MS prevalence rates in the United Kingdom.

Methods:

Electronic records from general practices (GPs) in four east London boroughs were queried for the number of people diagnosed with MS, grouped by ethnicity, into 5-year age bands. Compared against total registered GP patients in the area (c. 900,000), the age-standardised MS prevalence was calculated by ethnic group.

Results:

The overall age-standardised prevalence of MS was 111 per 100,000 (152 for women and 70 for men), and 180, 74 and 29 for the White, Black and South Asian populations, respectively. The sex ratios (female:male) were 2.2:1, 2.1:1 and 2.8:1, respectively.

Conclusion:

MS prevalence was considerably lower among Black and South Asian populations, compared to the White population, by 59% and 84%, respectively. However, compared to available data in Africa and South Asia, MS is several times more prevalent among Black people and South Asians living in the United Kingdom than their territorial ancestry.

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 Association Between C424c/A Polymorphism Within the IL-25 Gene and Multiple Sclerosis

BACKGROUND

Multiple Sclerosis (MS) is a common autoimmune system disease which affects the central nervous system. It has been documented that interleukin-25 (IL-25) plays key roles in suppressing Th1 responses, which is increased during MS.

OBJECTIVES

The aim of this study was to investigate the c424C/A polymorphism within the IL-25 gene in MS patients in comparison to healthy controls.

PATIENTS AND METHODS

In this case-control study, 74 patients with MS and 75 healthy controls were selected. Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP) was used in order to determine c424C/A polymorphism within the IL-25 gene.

RESULTS

The results showed that there was no statistical significant difference in distribution of genotype (AA, AC and CC) and allele (A and C) frequencies between MS patients and healthy controls (P = 0.901 and P = 0.728, respectively).

CONCLUSIONS

In conclusion, it appears that the c424C/A polymorphism within the IL-25 gene has no significant relationship with MS, and this polymorphism is probably not associated with MS complications, its onset and gender distribution.

Prevalence of multiple sclerosis in the Lazio region, Italy: use of an algorithm based on health information systems

Compared with other areas of the country, very limited data are available on multiple sclerosis (MS) prevalence in Central Italy. We aimed to estimate MS prevalence in the Lazio region and its geographical distribution using regional health information systems (HIS). To identify MS cases we used data from drug prescription, hospital discharge and ticket exemption registries. Crude, age- and gender-specific prevalence estimates on December 31, 2011 were calculated. To compare MS prevalence between different areas within the region, we calculated age- and gender-adjusted prevalence and prevalence ratios using a multivariate Poisson regression model. Crude prevalence rate was 130.5/100,000 (95 % CI 127.5–133.5): 89.7/100,000 for males and 167.9/100,000 for females. The overall prevalence rate standardized to the European Standard Population was 119.6/100,000 (95 % CI 116.8–122.4). We observed significant differences in MS prevalence within the region, with estimates ranging from 96.3 (95 % CI 86.4–107.3) for Latina to 169.6 (95 % CI 147.6–194.9) for Rieti. Most districts close to the coast showed lower prevalence estimates compared to those situated in the eastern mountainous area of the region. In conclusion, this study produced a MS prevalence estimate at regional level using population-based health administrative databases. Our results showed the Lazio region is a high-risk area for MS, although with an uneven geographical distribution. While some limitations must be considered including possible prevalence underestimation, HIS represent a valuable source of information to measure the burden of SM, useful for epidemiological surveillance and healthcare planning.

A 60-year follow-up of the incidence and prevalence of multiple sclerosis in Hordaland County, Western Norway

OBJECTIVE

Investigate the incidence of multiple sclerosis during 1953-2013 and estimate the prevalence rate of MS on 1 January 2003 and 2013 in Hordaland County, Western Norway.

METHODS

All patients with onset of disease in Hordaland 1953-2013 were identified in files from previous studies until 2003 and from patient records at the departments of Neurology, Haukeland University Hospital and Haugesund Hospital during 2003-2013. 1558 patients were assessed and 1402 of these were included, of whom 1035 were alive and living in Hordaland at prevalence day 1 January 2013. Annual incidence rates were calculated for 1953-2013.

RESULTS

On 1 January 2003, the crude prevalence rate was 191/100 000 population and on 1 January 2013, the crude prevalence rate was 211.4 (95% CI 198.3 to 224.2) per 100 000; 270.9 (95% CI 250.6 to 292.3) for women and 151.8 (95% CI 136.8 to 167.9) for men. Prevalence peaked at ages 55-59 years for women and 60-64 years for men. The annual incidence rate increased from 1.9 (95% CI 1.2 to 2.6) per 100 000 during 1953-1957 to 7.2 (95% CI 6.0 to 8.5) during 1978-1982 and to 8.5 (95% CI 7.3 to 9.7) during 2003-2007, thus indicating a stabilising incidence over the past 35 years. The female/male ratio ranged from 1.2:1 to 1.8:1 (p=0.381) during the period.

CONCLUSIONS

Stabilising rather than increasing incidence combined with the stable female/male ratio are indicative of non-fluctuating environmental factors in a geographical area otherwise characterised by lack of vitamin D effective sun exposure. The rising prevalence of MS could result from improved survival and follow-up methodology.

Increasing prevalence of multiple sclerosis in Västerbotten County of Sweden

OBJECTIVES

To update the incidence and prevalence of multiple sclerosis (MS) in Västerbotten County, Sweden, and to compare this to previous investigations in the same area.

BACKGROUND

Northern Sweden is a high-risk area for developing MS. Västerbotten County has previously been surveyed in detail regarding the occurrence of MS. In several countries, increases in MS prevalence and incidence as well as a change in the sex ratio have been reported.

MATERIALS AND METHODS

Multiple sources were used to identify MS cases in Västerbotten that either had their onset of the disease from 1998 to 2010 and/or lived in Västerbotten, the two dates chosen for prevalence calculation: the 31st of December 2005 and 2010.

RESULTS

The mean yearly incidence of MS in Västerbotten during the entire period 1998-2010 was 6.0/100,000. The female to male ratio was 2.1. The prevalence of MS in Västerbotten was 188/100,000 on 31st of December 2005 and 215/100,000 on 31st of December 2010. The MS prevalence increased over time from 1990 to 2010.

CONCLUSIONS

The prevalence of MS in Västerbotten County has increased between 1990 and 2010, while no statistically significant increase in incidence was seen.

Does the changing sex ratio of multiple sclerosis give opportunities for intervention?

In several international studies, an increasing women-to-men (w/m) ratio in patients with multiple sclerosis (MS) has been reported. Such sex ratios have been analysed by year of onset or by year of birth. In a Swedish study, data from the Swedish MS register (SMSreg) were used to analyse the w/m ratio in Sweden. The sex ratio was analysed both by year of birth (8834 patients) and by year of onset (9098 patients). No increased w/m ratio was seen in this study. The age-specific sex ratio did not demonstrate any significant changes. However, a new investigation of the sex ratio in Sweden, based on data from all available data sources (19,510 patients), showed a significantly increased w/m ratio of MS in Sweden from 1.70 to 2.67. Environmental factors such as cigarette smoking, hormonal factors and nutrition are of interest in this context, but the cause of the increasing w/m ratio in MS is yet not possible to explain.

Benign Multiple Sclerosis is Associated with Reduced Thinning of the Retinal Nerve Fiber and Ganglion Cell Layers in Non-Optic-Neuritis Eyes

Background and Purpose

It is exceedingly difficult to differentiate benign multiple sclerosis (BMS) from relapsing-remitting multiple sclerosis (RRMS) based on clinical characteristics, neuroimaging, and cerebrospinal fluid tests. Optical coherence tomography (OCT) allows quantification of retinal structures, such as the retinal nerve fiber layer (RNFL) thickness, at the optic disc and the ganglion cell layer (GCL) at the macula, on a micrometer scale. It can also be used to trace minor alterations and the progression of neurodegeneration, help predict BMS, and influence the choice of therapy. To utilize OCT to detect the extent of changes of the optic disk and macular microstructure in patients with BMS and RRMS compared to healthy controls (HCs), with special focus on changes related to the presence/absence of optic neuritis (ON).

Methods

Spectral-domain OCT was applied to examine eyes from 36 patients with multiple sclerosis (MS), comprising 11 with BMS and 25 with RRMS, and 34 HCs.

Results

The RNFL and GCL were significantly thinner in eyes previously affected by ON, irrespective of the type of MS (i.e., BMS or RRMS), than in HCs. Significant thinning of the GCL was also observed in non-ON RRMS (and not non-ON BMS) compared to HCs. Correspondingly, a significant association between disease duration and thinning rates of the RNFL and GCL was observed only in non-ON RRMS (-0.54±0.24 and -0.43±0.21 µm/year, mean±SE; p<0.05 for both), and not in non-ON BMS (-0.11±0.27 and -0.24±0.24 µm/year).

Conclusions

The RNFL and GCL were thinner in both ON- and non-ON MS, but the change was more pronounced in ON MS, irrespective of the MS subtype studied herein. GCL thinning and the thinning rate of both the GCL and RNFL were less pronounced in non-ON BMS than in non-ON RRMS. These findings may help to predict the course of BMS.

A longitudinal model for disease progression was developed and applied to multiple sclerosis

Objectives

To develop a model of disease progression using multiple sclerosis (MS) as an exemplar.

Study Design and Settings

Two observational cohorts, the University of Wales MS (UoWMS), UK (1976), and British Columbia MS (BCMS) database, Canada (1980), with longitudinal disability data [the Expanded Disability Status Scale (EDSS)] were used; individuals potentially eligible for MS disease-modifying drugs treatments, but who were unexposed, were selected. Multilevel modeling was used to estimate the EDSS trajectory over time in one data set and validated in the other; challenges addressed included the choice and function of time axis, complex observation-level variation, adjustments for MS relapses, and autocorrelation.

Results

The best-fitting model for the UoWMS cohort (404 individuals, and 2,290 EDSS observations) included a nonlinear function of time since onset. Measurement error decreased over time and ad hoc methods reduced autocorrelation and the effect of relapse. Replication within the BCMS cohort (978 individuals and 7,335 EDSS observations) led to a model with similar time (years) coefficients, time [0.22 (95% confidence interval {CI}: 0.19, 0.26), 0.16 (95% CI: 0.10, 0.22)] and log time [−0.13 (95% CI: −0.39, 0.14), −0.15 (95% CI: −0.70, 0.40)] for BCMS and UoWMS, respectively.

Conclusion

It is possible to develop robust models of disability progression for chronic disease. However, explicit validation is important given the complex methodological challenges faced.

MRI in Leber's hereditary optic neuropathy: the relationship to multiple sclerosis

BACKGROUND

Leber's hereditary optic neuropathy (LHON) and a multiple sclerosis (MS)-like illness appear to coexist 50 times more frequently than would be expected by chance. This association of LHON and MS (LMS) raises an important question about whether there could be a common pathophysiological mechanism involving mitochondrial dysfunction.

OBJECTIVE

The primary aim was to define MRI features of LMS and LHON, and to assess the proportions of individuals displaying features typical of MS. Secondarily, we investigated the effect of gender on the risk of developing white matter lesions in the context of LHON.

METHODS

A blinded standardised review of conventional brain MRIs of 30 patients with MS, 31 patients with LHON and 11 patients with LMS was conducted by three independent experts in the field. MS-like MRI features were assessed.

RESULTS

All patients with LMS and 26% of patients with LHON had white matter lesions. Of these, all patients with LMS and 25% with LHON were found to have an MRI appearance typical of MS. Female patients with LHON had a significantly greater risk of having white matter lesions consistent with MS compared with male patients (relative risk 8.3).

CONCLUSIONS

A blinded review of conventional brain MRIs shows that patients with LMS have a scan appearance indistinguishable from MS. Mitochondrial dysfunction could be a common pathophysiological pathway in the formation of white matter lesions. There appears to be a strong female influence on the radiological appearance as well as clinical development of MS in patients with LHON.

The changing face of multiple sclerosis: Prevalence and incidence in an aging population

Objective:

To assess multiple sclerosis (MS) incidence from 1998 to 2007, and MS prevalence on 31 December 2007, in the province of Genoa, Italy.

Methods:

We identified MS cases diagnosed before 31 December 2007 by analyzing archives of hospitals with neurological or rehabilitation wards, the local Italian MS society, family doctor records and requests for oligoclonal band analysis on cerebrospinal fluid (CSF).

Results:

A total of 1312 MS patients were residing in the province of Genoa on the prevalence day; 431 (32.85%) were men and 881 (67.15%) were women; mean age was 50.6 (± 13.9). The overall crude MS prevalence rate was 148.5/100,000; 103.1/100,000 in men and 189.1/100,000 in women. The crude mean annual MS incidence rate was 6.6 cases/100,000 (4.4/100,000 men; 8.6/100,000 women). Mean age at diagnosis was 39.5 ± 12.3 (men: 39.9 ± 13.0; women: 39.3 ± 11.9). A mean annual incidence of 4 MS patients ≥ 60 was observed.

Conclusions:

We observed an increased MS prevalence in the province of Genoa, compared to 1997. The mean age at diagnosis was relatively high (39 years old), 18% of our MS patients were over 65, and a notable incidence increase was seen in patients over 60. This has important implications, in terms of the need to organize the health system to better serve elderly MS patients, especially considering comorbidities and different medical needs of elderly MS patients; and to increase awareness within the medical community about the increasing risk of newly-presenting MS in the older population.

Modelling the natural history of primary progressive multiple sclerosis

BACKGROUND

A minority of patients with multiple sclerosis (MS) have primary progressive disease (PPMS). Treatment options are currently limited, but as prospects for interventional studies become more realistic, understanding contemporary outcome data will be key to successful trial design.

METHODS

234 PPMS patients were identified from a population-based cohort of 2131 (11.0%) and mean follow-up of 13.1 years. Time to established disability endpoints was compared with patients with relapsing-onset MS (ROMS) using survival analysis, and Cox regression employed to explore factors contributing to disability accumulation. Results were used to create predictive power models for clinical trials in PPMS.

RESULTS

Time to fixed disability milestones was shorter than in ROMS (Expanded Disability Status Scale (EDSS) 4.0:8.1 vs. 17.1 years, p<0.001; EDSS 6.0: 9.6 vs. 22.1 years, p<0.001; EDSS 8.0: 20.7 vs. 39.7 years, p<0.001), but there were no differences in age-related disability. Age and cerebellar symptoms at onset affected rate of progression. Modelling of these data indicated that trials employing EDSS change of 1.0 as the primary outcome measure would be powered to detect a 20% difference in progression using 600 patients with initial EDSS of 4.0 per trial arm, or 400 patients with initial EDSS of 5.0 per arm. However, trials including patients with fixed EDSS of ≥6.0 will be underpowered even with large numbers or prolonged duration.

CONCLUSIONS

Disability progression in PPMS is variable and influenced by age at onset. Although progression is more rapid, age-related disability milestones are identical to relapsing-onset disease. These data offer a contemporary paradigm for clinical trial design in progressive MS.

Prevalence and risk factors for depression in women with multiple sclerosis: a study from Iran

BACKGROUND

Multiple sclerosis is increasingly becoming a major health problem among women worldwide. The aim of the present study was to estimate prevalence of depression in women with multiple sclerosis and also to identify risk factors contributing to its development.

METHODS

This was a cross-sectional study of depression in a sample of 226 women with multiple sclerosis. The sample was recruited from an outpatient clinic in Tehran, Iran. Depression was assessed using the Beck Depression Inventory-II (BDI-II). Univariate and multiple logistic regression analyses were performed to examine the association between depression and independent variables.

RESULTS

Overall, 91 women (40.2 %) had moderate to severe depression. The mean age of participants was 35.7 years (SD = 8.07). The results obtained from multiple logistic regression analysis showed that the disease course (OR for relapsing-remitting MS = 2.36, % 95 CI = 1.14-5.53, P = 0.46), the expanded disability status scale (OR for score of 5-8 = 4.88, % 95 CI = 2.51-11.06, P < 0.001) and employment status (OR for housewife = 4.75, % 95 CI = 1.55-14.58, P = 0.006) were significant contributing factors to depression in patients with multiple sclerosis.

CONCLUSIONS

The findings suggest that depression in patients with multiple sclerosis is multi-factorial and very much dependent to physical and social conditions of patients. The recognition of such conditions might help clinicians to manage patients more effectively.

Multiple sclerosis in the far north--incidence and prevalence in Nordland County, Norway, 1970-2010

Background

The risk of multiple sclerosis (MS) increases with increasing latitude. Taking into consideration that Norway has a large latitude range, a south-to-north gradient would be expected. However, previous studies have reported an uneven distribution of the disease in Norway, with a relatively low prevalence in the most northern parts of the country.

We describe the incidence and prevalence of MS in a county in the north of Norway over a period of 40 years.

Methods

All patients with MS living in Nordland County in the period 1970–2010 were identified by reviewing hospital charts. The patients were included if they met the criteria of definitive or probable MS according to Poser [Ann Neurol 13:227-231, 1983] or MS according to McDonalds [Ann Neurol 50:121-127, 2001]. Point prevalence at the beginning of the decades was calculated. The average annual incidence was calculated for 5-year periods.

Results

The total crude prevalence on January 1, 2010 was 182.4 per 100 000. The annual incidence continuously increased from 0.7 per 100 000 in 1970 – 1974 to 10.1 per 100,000 in 2005 – 2009. The time delay from the first symptom to diagnosis was stable from 1975 to 2010. The proportion of primary progressive MS in the prevalence numbers was 38.2% in 1980, and decreases continuously, to 18.6% in 2010. The female to male prevalence ratio has been stable since 1990 at 2.2 to 1.

Conclusion

The prevalence and the incidence of MS have steadily increased over a 40 year period. Nordland County is a high-risk area for MS.

Assessment of Outcome Predictors after First Attack of Optic Neuritis

Background:

Optic Neuritis (ON) is one of the most common clinically isolated syndromes which develops into clinically diagnosed Multiple Sclerosis (CDMS) over time.

Objective:

To assess the conversion rate of Iranian patients presenting with idiopathic ON to CDMS as well as monitoring potential demographic and clinical risk factors.

Methods:

Atotal of 219 patients' medical records of idiopathic ON from March 2001 to May 2009 were reviewed. Demographic findings, ophthalmologic characteristics on admission and discharge, diagnostic approaches, type and dosage of therapy were retrospectively reviewed. A structured telephone interview was then conducted to identify patients who had subsequently been diagnosed with MS. Survival analysis was used to evaluate the cumulative probability of MS conversion and contributory risk factors.

Results:

From the 219 ON patients, 109 [age 11-51, female: 81%] were followed up. Among the male gender the mean age of patients developing MS was significantly lower (P=0.01). In cox regression model, female sex (p=0.07), bilateral ON (p=0.003), MRI abnormalities (p <0.001) and high dose (5g) corticosteroid therapy (p<0.001) were identified as risk factors for the development of MS. The two and five year cumulative probability of developing MS were 27% and 45%, respectively.

Conclusions:

Idiopathic ON in Iranian patients carries higher risk of progression to MS compared to other Asian countries. MRI lesions are the strongest independent risk factor of developing CDMS. Bilateral ON, female gender and high dose corticosteroid therapy are also important factors in predicting CDMS development.

Gender-related protection from or vulnerability to severe CNS diseases: gonado-structural and/or gonado-activational? A meta-analysis of relevant epidemiological studies

BACKGROUND

A vast scientific literature has dealt with gender-specific risk for brain disorder. That field is evolving toward a consensus to the effect that the estrogen hormone family is outstandingly and uniquely neuroprotective. However, the epidemiology relevant to this general outlook remains piecemeal.

METHOD

The present investigation strategically formats the relevant epidemiological findings around the world in order to quantitatively meta-analyze gender ratio of risk for a variety of relevant severe central nervous system (CNS) diseases at all three gonadal stages of the life cycle, pre pubertal, post adolescent/pre menopausal, and post menopausal.

RESULTS

The data quantitatively establish that (1) no single epidemiological study should be cited as evidence of gender-specific neuroprotection against the most common severe CNS diseases because the gender-specific risk ratios are contradictory from one study to the other; (2) risk for severe CNS disease is indeed significantly gender-specific, but either gender can be protected: it depends on the disease, not at all on the age bracket.

CONCLUSION

Our assay of gender-specific risk for severe brain disease around the world has not been able to support the idea according to which any one gender-prevalent gonadal steroid hormone dominates as a neuroprotective agent at natural concentrations.

Russell W Brain and the aetiology of multiple sclerosis--a historical perspective

The contribution of British neurologist Russell Walter Brain (1895-1966) to the field of neurology is difficult to overestimate and his seminal work continues to influence modern neurological education and practice. In a landmark review published in the Quarterly Review of Medicine in 1930, he gives a critically important account summarising ideas of the time thought to underlie the then called 'disseminated sclerosis', a disease he notes to be, 'after syphilis, the most frequent disease of the nervous system' in the UK. Across a century and a half, vast progress has been made in attempting to elucidate the as yet unknown cause of MS, which is unravelling to be multifactorial, highly complex and likely dependent on both genetic and environmental risk factors. Brain's observations highlight the changing epidemiology of MS over the last century which are likely to provide the platform in striving towards elucidating MS causation, notably a seemingly reduced latitudinal gradient of MS incidence, an increasing female-to-male sex ratio and an increasing disease rate in dark-skinned compared to light-skinned individuals. In this report we aim to evaluate the relevance today of what we believe to have been an important review demonstrating a perspective on MS far ahead that of its time, with a focus on Brain's ideas on the aetiology of MS; many of which have stood the test of time.