Comorbidity increases the risk of relapse in multiple sclerosis: A prospective study

Diet and multiple sclerosis - development and mixed methods feasibility testing of a comprehensive nutritional information resource (NUTRIMS)

PURPOSE

Persons with multiple sclerosis (pwMS) are often confused by contradictory dietary advice. The purpose of this research was to explore the information needs and design a comprehensive, evidence-based nutritional information resource on diet and MS (NUTRIMS).

METHODS

A mixed-methods design with three sequential phases was adopted: (1) Needs assessment and development: Two focus groups with pwMS to explore experiences, information needs and preferred support around diet. Development of a draft NUTRIMS, (2) Feasibility Step 1: Feedback on the draft NUTRIMS from stakeholders and (3) Feasibility Step 2: Online survey among pwMS to explore content quality and acceptability.

RESULTS

Two focus groups with a total of 12 pwMS showed that MS-specific evidence on food groups/ingredients, nutrients and special diets were of most interest. The draft NUTRIMS was refined through feedback from 13 stakeholders. The pre-final NUTRIMS consisted of 81 pages including scientific references on each topic, 16 illustrations and a glossary of terms. 85 pwMS participated in the online survey and reported an intensive use and high satisfaction with the information resource, which was perceived as comprehensible, highly credible and useful for making decisions on dietary change.

CONCLUSIONS

A collaborative research approach led to a well-accepted nutrition information resource.

Effects of a Multimodal Lifestyle Intervention on Cardiometabolic Markers in People with Progressive Multiple Sclerosis: A Secondary Analysis of a Pilot Study

Background: Cardiometabolic comorbidities are common in multiple sclerosis (MS), and lifestyle interventions are effective in managing these conditions in the general population, though evidence in the MS patient population is limited. Objective: To evaluate the effect of a multimodal lifestyle intervention on serum apolipoproteins (Apo), creatine kinase (CK), glucose, and insulin in people with progressive MS (PwPMS). Methods: This study included n = 19 PwPMS who participated in a 12-month multimodal lifestyle intervention (including a modified Paleolithic diet, exercise, neuromuscular electrical stimulation, supplements, and stress reduction). Lipid profile (ApoA1, B, and E), CK, glucose, and insulin were obtained at baseline and after 12 months under fasting conditions. Results: At 12 months, there was a marginally significant decrease in ApoB (mean change: -7.17 mg/dL; 95% CI: -14.4, 0.12; p = 0.06), while no significant changes were observed for ApoA1 (mean change: -1.28 mg/dL; 95% CI: 12.33, 9.76; p = 0.80), ApoE (mean change: +0.12 mg/dL; 95% CI: -0.27, 0.52; p = 0.51), CK (mean change: +13.19 U/L; 95% CI: -32.72, 59.11; p = 0.55), Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) (mean change: -0.44; 95% CI: -1.11, 0.22; p = 0.17), and HOMA-β (mean change: +45.62; 95% CI: -95.6, 186.9; p = 0.50). A positive association was observed between changes in HOMA-IR and fatigue changes at 12 months (β = 0.81, p = 0.02), suggesting that an increase in HOMA-IR was linked to increased fatigue, which was no longer significant following the exclusion of outliers (β = 0.71, p = 0.16). Conclusions: A multimodal lifestyle intervention did not negatively impact glycemic and lipid profiles. While improvements were observed in serum biomarkers, these changes were not statistically significant, highlighting the need for stronger evidence from larger, controlled studies to confirm the cardiometabolic health benefits in PwPMS.

Vascular risk factors are associated with grey matter atrophy in secondary progressive multiple sclerosis

BACKGROUND

Comorbidities including vascular risk factors can be associated with whole and regional brain atrophy in multiple sclerosis (MS). This has been examined in mixed MS cohorts in prospective or observational studies; however, the association between vascular comorbidities (VCM) in secondary progressive MS (SPMS) and brain atrophy has been less well studied. The aim was to investigate the cross-sectional and longitudinal association between VCM, comorbidity burden and brain atrophy in SPMS.

METHODS

Post hoc analysis of 445 participants from the MS-Secondary Progressive multi-arm trial (MS-SMART)-a multi-arm multicentre phase-2b randomised placebo-controlled trial of three agents in SPMS (NCT01910259). VCM (hypertension, hyperlipidaemia) but also asthma, hypothyroidism and osteoporosis were recorded. Regional and whole brain volume (WBV), and percentage brain volume change were calculated using SIENAX and SIENA, respectively. Multiple linear regression was used to investigate the cross-sectional and longitudinal relationships between VCM, overall comorbidity count and whole brain, grey matter (GM) and white matter (WM) atrophy.

RESULTS

The cohort was predominantly female (67%), mean age 55 with median EDSS 6.0. In total, 13% and 9% had hypertension and hyperlipidaemia, respectively. In cross-sectional regression models, VCM was associated with decreased cortical GM volume [(hypertension β = -0.30, 95%CI -0.54 to -0.06, p = 0.01) (hyperlipidaemia β = -0.37, 95%CI -0.64 to -0.09, p = 0.008)]; but not WBV. Having ≥2 comorbidities was also associated with decreased cortical GM volume (β = -0.36, 95%CI -0.61 to -0.10, p = 0.007). No relationship was observed between VCM/comorbidity count and whole brain or GM atrophy rate over 96 weeks.

CONCLUSIONS

People with SPMS with VCM or increased overall comorbidity burden showed reduced whole brain and especially cortical grey matter volumes, but no significant impact on subsequent 2-year atrophy rate was detected.

The prevalence of obstructive sleep apnea-hypopnea syndrome in patients with multiple sclerosis: a systematic review and meta-analysis

Objective

Obstructive sleep apnea-hypopnea syndrome is the most common respiratory disorder in patients with multiple sclerosis. The purpose of this meta-analysis was to evaluate the prevalence of OSAHS in MS patients and to analyze their sleep monitoring indicators of patients.

Methods

Online databases such as PubMed, EMBASE, Web of Science, CNKI, and WanFang were used to review the Chinese and English literature about OSAHS in MS patients in detail. Two researchers analyzed the Quality of included studies based on the Quality Assessment of Diagnostic Accuracy Studies. The prevalence and sleep monitoring data were analyzed using STATA 11.0 software. Based on the I2 values, pooled analyses were performed using either random (I2 > 50%) or fixed-effect models (I2 ≤ 50%).

Results

Fourteen articles were selected for the final analysis. Our study shows that different diagnosis methods of OSAHS lead to different incidences. When the screening method was PSG, the incidence of OSAHS in MS patients was 36%; when the method was STOP-BANG, the incidence of OSAHS in MS patients was 26%; when the method was Berlin questionnaire, the incidence of OSAHS in MS patients was 30%. We performed subgroup analyses based on race, age, OSAHS severity, and BMI of patients with MS. The results suggested that the incidence of OSAHS was different in different subgroups of MS patients. In addition, we found that patients with MS generally had poorer sleep monitoring indicators.

Conclusion

The current literature shows that the incidence of OSAHS is higher in MS patients. MS may affect the progression of OSAHS.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=551500, CRD42024551500.

Comorbidities and their association with outcomes in the multiple sclerosis population: A rapid review

INTRODUCTION

Multiple sclerosis (MS) has a high comorbidity burden. Despite known associations with adverse outcomes, a comprehensive evaluation of the specific associations between individual comorbidities and disability, treatment initiation, and mortality remains underexplored. This study aimed to review and summarize existing evidence on the association between comorbidities and these three MS outcomes.

METHODS

A rapid review spanning the period from January 2002 to October 2023 was conducted following the Cochrane Rapid Review Methods Group recommendations. MEDLINE, Embase, and the grey literature were searched to identify studies examining the effects of comorbidities on disability, treatment initiation, and mortality among individuals with MS. Data extraction and risk of bias assessments were systematically performed, with the Newcastle-Ottawa scale and A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) criteria for observational studies and systematic reviews respectively.

RESULTS

The review included 100 primary studies, encompassing 88 different comorbidities. Most study populations were between 60-80% female, with an average age of 30-45 years at study start. The majority of included studies were conducted in Europe, North America, and Asia (specifically the Middle East). Over half (66%) of specific comorbidity-outcome relationships were examined within a single study only, and just two studies examined treatment initiation as an outcome. Methods used to assess comorbidities and outcomes varied widely and included self-report measures, medical records and diagnostic codes, and standardized clinical assessments. Depression was consistently associated with greater disability (adjusted hazard ratio (aHR): 1.50-3.59) and mortality (aHR: 1.62-3.55). Epilepsy was similarly associated with increased disability (aOR: 1.13-1.77) and increased mortality (aHR: 2.23-3.85). Diabetes was generally associated with increased mortality (aHR: 1.39-1.47), but results for disability were inconsistent. Most other conditions were examined in one or two studies only or findings varied across studies, unable to collectively indicate a clear association. Although the anxiety-disability relationship was assessed by 24 studies, the findings varied in terms of the presence, direction, and strength of a possible association, requiring nuanced interpretation.

CONCLUSIONS

This study identifies relationships between various comorbidities and three outcomes in MS, providing a foundation for future research and clinical guidelines. People with psychiatric, metabolic, and neurological conditions may be at a higher risk of MS disease progression and may therefore benefit from the targeted treatment of their comorbidities. Overall, comorbidities have varying associations with MS outcomes and individual associations require further exploration. However, there is evidence that some comorbidities indicate worse disability and higher mortality risk, and present barriers to initiating MS treatment, making the prevention and management of comorbidities an integral piece of MS patient care.

PROTOCOL

The protocol for this rapid review was registered on PROSPERO (ID: CRD42023475565) and published on Protocol Exchange (https://doi.org/10.21203/rs.3.pex-2438/v1).

Nutrition Knowledge and Food Literacy Among Persons with Multiple Sclerosis-Development and Validation of Patient-Reported Outcome Measures

BACKGROUND/OBJECTIVES

Persons with MS (pwMSs) are often confronted with contradictory dietary advice, which is not always based on sound scientific evidence. This may lead to poor MS-specific nutrition knowledge (MSNK) and food literacy (MSFL). To date, no studies have assessed MSNK and MSFL among pwMSs. Moreover, no validated tools to measure the effects of educational interventions are available. The aim of this study was to develop and validate MS-specific instruments to measure MSNK and MSFL among pwMSs.

METHODS

Based on a validated food literacy (FL) screener for the general population and prior research about the information needs of pwMSs, we developed 14 MSFL items and 11 MS-specific nutrition knowledge questions. Cognitive debriefing was conducted with 10 pwMSs and resulted in a 12-item MS food literacy questionnaire (MSFLQ) and an 11-item MS nutrition knowledge questionnaire (MSNKQ). After refinement, both questionnaires were pilot tested in an online survey to explore their comprehensibility. The MSNKQ was analyzed descriptively (mean and percentage of correctly answered questions). For MSFLQ item difficulty, the discriminatory power of the items, internal consistency and convergent/divergent validity were assessed.

RESULTS

In total, 148 pwMSs (age: 47.1 years (SD = 12.5); 102 women (69%)) completed the online survey. On average, participants answered 3.51/11 MSNK questions correctly (31.9%). The MSFLQ showed good internal consistency (Cronbach's alpha = 0.85), item difficulty was good and the discriminatory power of the items was satisfactory. Correlations between the MSFLQ and a general food literacy questionnaire was high (r = 0.626, p < 0.001), but only small with the MSNKQ (r = 0.180; p = 0.029), underlining the different constructs.

CONCLUSIONS

MSNK among pwMSs in Germany is low. The MSNKQ and MSFLQ appear to be suitable instruments to assess MSNK and MSFL and might serve as outcome measures for educational interventions.

Comorbidity and Disease Activity in Multiple Sclerosis

Importance

Multiple studies suggest that comorbidity worsens clinically relevant outcomes in multiple sclerosis (MS), including the severity of disability at diagnosis and rate of disability worsening after diagnosis. However, less is known regarding the association of comorbidity with measures of disease activity, such as relapse rate and magnetic resonance imaging lesion accrual, which are relevant to clinicians and clinical trialists.

Objective

To evaluate the association of comorbidities with disease activity in clinical trials of disease-modifying therapies (DMTs) in populations with MS.

Design, Setting, and Participants

A 2-stage meta-analytic approach was used in this cohort study of individual participant data from phase 3 clinical trials of MS DMTs that had 2 years of follow-up and were conducted from November 2001 to March 2018. Data were analyzed from February 2023 to June 2024.

Exposure

Comorbidity burden and individual comorbidities present at trial enrollment, including hypertension; hyperlipidemia; functional cardiovascular disease, ischemic heart, cerebrovascular, and peripheral vascular disease; diabetes; autoimmune thyroid and miscellaneous autoimmune conditions; migraine; lung and skin conditions; depression; anxiety; and other psychiatric disorders.

Main Outcomes and Measures

The main outcome was evidence of disease activity (EDA) over 2 years of follow-up, defined as confirmed relapse activity, disability worsening, or any new lesions on magnetic resonance imaging.

Results

A total of 16 794 participants with MS were included from 17 clinical trials (67.2% female). Over the 2-year follow-up, 61.0% (95% CI, 56.2%-66.3%; I2 = 97.9%) of the pooled trials had EDA. After adjusting for multiple factors, the presence of 3 or more comorbidities was associated with an increased hazard of EDA (adjusted hazard ratio [AHR], 1.14; 95% CI, 1.02-1.28) compared with no comorbidity. Presence of 2 or more cardiometabolic conditions was also associated with an increased hazard of EDA (AHR, 1.21; 95% CI, 1.08-1.37) compared with no cardiometabolic comorbidity. Presence of 1 psychiatric disorder was associated with an increased hazard of EDA (AHR, 1.07; 95% CI, 1.02-1.14).

Conclusions and Relevance

In this study, a higher burden of comorbidity was associated with worse clinical outcomes in people with MS, although comorbidity could potentially be a partial mediator of other negative prognostic factors. Our findings suggest a substantial adverse association of the comorbidities investigated with MS disease activity and that prevention and management of comorbidities should be a pressing concern in clinical practice.

Comorbid onset of cardiovascular diagnosis and long-term confirmed disability progression in multiple sclerosis: A 15-year follow-up study

BACKGROUND

People with multiple sclerosis (pwMS) have greater prevalence of comorbid cardiovascular diseases (CVD) when compared to the general population despite similar frequency of CV risk factors.

OBJECTIVE

Determine the impact of comorbid-onset of CVD diagnosis on long-term confirmed disability progression (CDP).

METHODS

276 pwMS (29 clinically isolated syndrome, 130 relapsing-remitting and 117 progressive) were clinically followed an average of 14.9 years, with a mean of 14.4 clinical visits. Retrospective electronic medical records (EMR) review determined CVD diagnoses (hypertension, hyperlipidemia, diabetes, and heart disease) at baseline and over the follow-up. CDP was determined with ≥1.0 point Expanded Disability Status Scale (EDSS) increase from EDSS <5.5, or ≥ 0.5-point increase from ≥5.5, and was sustained on next clinical visit.

RESULTS

A significantly shorter time to overall CDP was detected in 213 pwMS who had an existing (28 pwMS) or developed new onset (185 pwMS) of CVD, compared to 63 CVD-healthy pwMS over the follow-up (13.4 vs 15.9 years, Mantel-Cox p < 0.001), independent of baseline age and EDSS score. The CVD diagnosis preceded the CDP in 103 pwMS (55.7%), occurred after CDP in 71 pwMS (38.4%) and was concurrent in 11 pwMS (5.9%). Using mixed-effect models adjusted for significant age (F = 56.5, p < 0.001) and time effects (F = 67.8, p < 0.001), the CVD-onset diagnosis was associated with greater accrual of disability, as measured by longitudinal increase in EDSS score (F = 4.207, p = 0.04). Sex was not significant predictor of future disability in our cohort.

CONCLUSION

PwMS with an existing or new onset of comorbid CVD diagnosis showed accelerated disability worsening over long-term. There was no temporal relationship between the onset of CVD and CDP within the group that had CVD-onset diagnosis.

Subjective Well-Being, Positive Affect, Life Satisfaction, and Happiness With Multiple Sclerosis: A Scoping Review of the Literature

PURPOSE

People with multiple sclerosis (MS) may face challenges maintaining their subjective well-being, life satisfaction, happiness, and positive emotions. This scoping review's purpose was to summarize studies on these positive psychological constructs among people with MS.

METHODS

Observational and interventional studies that included measures of subjective well-being, life satisfaction, happiness, or positive affect were identified. Variables associated with these constructs were classified using the International Classification of Functioning, Disability and Health (ICF).

RESULTS

The review included 22 observational and 10 interventional studies. Variables were categorized into each of the ICF domains. Cognitive behavior therapy was the most common intervention, with content and dosing varying widely.

CLINICAL RELEVANCE

Subjective well-being, life satisfaction, happiness, and positive affect are crucial components of community and individual health. The findings of this scoping review highlight the complex interplay between function, personal factors, and environmental conditions in influencing positive psychological constructs. Given the limited evidence, rehabilitation nurses should leverage their skills in delivering holistic care and adopt data-driven approaches to integrate positive psychological strategies into care plans.

CONCLUSION

Further research is needed to measure and compare interventions aimed at improving these constructs and to examine the influence of personal and environmental factors among diverse MS populations.

Metabolic syndrome and the phenotype of multiple sclerosis

BACKGROUND

Comorbidities, particularly vascular comorbidities, have been shown to exacerbate the progression of disability in multiple sclerosis (MS). Metabolic syndrome (MetS) is a cluster of conditions including abdominal obesity, insulin resistance, atherogenic dyslipidemia, and vascular dysfunction, which contribute to vascular morbidity and chronic inflammation.

OBJECTIVE

To describe the characteristics of MetS in a cohort of MS patients and evaluate its relationship with the MS phenotype.

METHODS

A monocentric cohort study was conducted on MS patients, collecting demographic, clinical, radiological, and therapeutic data, as well as metabolic data including waist circumference, blood pressure, serum triglycerides, high-density lipoprotein cholesterol, and fasting blood glucose.

RESULTS

Among the 84 patients included in the study, 27% were diagnosed with MetS. MetS was found to be associated with secondary progressive MS (SPMS). Patients with SPMS had a higher prevalence of MetS compared to those with relapsing-remitting MS (RRMS), even after adjusting for disease duration. While MetS was associated with Expanded Disability Status Scale (EDSS) progression in the 3-year period according to univariate analysis, it did not show a significant association with disease activity.

CONCLUSION

This study provides evidence supporting the connection between MetS and the progression of disability in MS, independent of disease relapse activity.

Current understanding of cardiovascular autonomic dysfunction in multiple sclerosis

Autoimmune diseases, including multiple sclerosis (MS), are proven to increase the likelihood of developing cardiovascular disease (CVD) due to a robust systemic immune response and inflammation. MS can lead to cardiovascular abnormalities that are related to autonomic nervous system dysfunction by causing inflammatory lesions surrounding tracts of the autonomic nervous system in the brain and spinal cord. CVD in MS patients can affect an already damaged brain, thus worsening the disease course by causing brain atrophy and white matter disease. Currently, the true prevalence of cardiovascular dysfunction and associated death rates in patients with MS are mostly unknown and inconsistent. Treating vascular risk factors is recommended to improve the management of this disease. This review provides an updated summary of CVD prevalence in patients with MS, emphasizing the need for more preclinical studies using animal models to understand the pathogenesis of MS better. However, no distinct studies exist that explore the temporal effects and etiopathogenesis of immune/inflammatory cells on cardiac damage and dysfunction associated with MS, particularly in the cardiac myocardium. To this end, a thorough investigation into the clinical presentation and underlying mechanisms of CVD must be conducted in patients with MS and preclinical animal models. Additionally, clinicians should monitor for cardiovascular complications while prescribing medications to MS patients, as some MS drugs cause severe CVD.

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.

Dietary Modification Combined with Nutrition Education and Counseling for Metabolic Comorbidities in Multiple Sclerosis: Implications for Clinical Practice and Research

PURPOSE OF REVIEW

Metabolic comorbidities such as obesity, diabetes, hypertension, and dyslipidemia are common to multiple sclerosis (MS) and are associated with negative outcomes of the disease. Dietary intervention has the potential to improve MS co-morbidities; thus, it is a high priority for people living with MS to self-manage their disease. The present review aimed to summarize the recent evidence on the impacts of combining dietary modification with nutrition education and counseling on managing metabolic comorbidity markers in MS.

RECENT FINDINGS

Evidence suggests important roles for tailored dietary change strategies and nutrition education and counseling in managing metabolic comorbidities for MS. There is also indirect evidence suggesting a relationship between dietary fiber, the gut microbiome, and improved metabolic markers in MS, highlighting the need for more research in this area. For people living with MS, addressing both barriers and facilitators to dietary changes through behavior change techniques can help them achieve sustainable and tailored dietary behavior changes. This will support person-centered care, ultimately improving metabolic comorbidity outcomes. Metabolic comorbidities in MS are considered modifiable diseases that can be prevented and managed by changes in dietary behavior. However, the impact of targeted dietary interventions on mitigating MS-related metabolic comorbidities remains inadequately explored. Therefore, this review has provided insights into recommendations to inform future best practices in MS. Further well-designed studies based on tailored dietary strategies applying behavior change theories are needed to address the underlying determinants of dietary practice in this population.

Correlates and trajectories of relapses in relapsing-remitting multiple sclerosis

BACKGROUND AND AIMS

In people with relapsing-remitting multiple sclerosis (pwRRMS), data from studies on non-pharmacological factors which may influence relapse risk, other than age, are inconsistent. There is a reduced risk of relapses with increasing age, but little is known about other trajectories in real-world MS care.

METHODS

We studied longitudinal questionnaire data from 3885 pwRRMS, covering smoking, comorbidities, disease-modifying therapy (DMT), and patient-reported outcome measures, as well as relapses during the past year. We undertook Rasch analysis, group-based trajectory modelling, and multilevel negative binomial regression.

RESULTS

The regression cohort of 6285 data sets from pwRRMS over time showed that being a current smoker was associated with 43.9% greater relapse risk; having 3 or more comorbidities increased risk and increasing age reduced risk. Those diagnosed within the last 2 years showed two distinct trajectories, both reducing in relapse frequency but 25.8% started with a higher rate and took 4 years to reduce to the rate of the second group. In the cohort with at least three data points completed, there were three groups: 73.7% followed a low stable relapse rate, 21.6% started from a higher rate and decreased, and 4.7% had an increasing then decreasing pattern. These different trajectory groups showed significant differences in fatigue, neuropathic pain, disability, health status, quality of life, self-efficacy, and DMT use.

CONCLUSIONS

These results provide additional evidence for supporting pwRRMS to stop smoking and underline the importance of timely DMT decisions and treatment initiation soon after diagnosis with RRMS.

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.

The Impact of Aging on Multiple Sclerosis

PURPOSE OF REVIEW

Multiple sclerosis (MS) is a chronic, immune-mediated demyelinating disorder of the central nervous system. Age is one of the most important factors in determining MS phenotype. This review provides an overview of how age influences MS clinical characteristics, pathology, and treatment.

RECENT FINDINGS

New methods for measuring aging have improved our understanding of the aging process in MS. New studies have characterized the molecular and cellular composition of chronic active or smoldering plaques in MS. These lesions are important contributors to disability progression in MS. These studies highlight the important role of immunosenescence and the innate immune system in sustaining chronic inflammation. Given these changes in immune function, several studies have assessed optimal treatment strategies in aging individuals with MS. MS phenotype is intimately linked with chronologic age and immunosenescence. While there are many unanswered questions, there has been much progress in understanding this relationship which may lead to more effective treatments for progressive disease.

Health, Wellness, and the Effect of Comorbidities on the Multiple Sclerosis Disease Course: Tackling the Modifiable

Multiple sclerosis (MS) is a disease of the central nervous system characterized by inflammatory demyelination and neurodegeneration. Numerous disease-modifying therapies for MS exist but are only partially effective, making it essential to optimize all factors that may influence the course of the disease. This includes conscientious management of both mental and physical comorbidities, as well as a comprehensive strategy for promoting wellness in patients with MS. Thoughtful engagement of those living with MS through shared decision making and involvement of a multidisciplinary team that includes primary care, relevant specialists, psychology, and rehabilitation is likely to lead to better outcomes.

Perceived health- related quality of life in persons with multiple sclerosis with and without a vascular comorbidity

PURPOSE

Vascular comorbidities are prevalent and can contribute to adverse health outcomes in persons with multiple sclerosis (PwMS). Understanding the association between vascular comorbidities and health-related quality of life (HRQOL) among PwMS may be beneficial in improving outcomes and disease management. This cross-sectional study aimed to examine the relationship between vascular comorbidities and the different dimensions of HRQOL in PwMS.

METHODS

Participants (n = 185) were PwMS recruited from a community-based comprehensive MS care center. Demographics, comorbid conditions, and disability level were collected via a self-report REDCap survey, with the 29-item Multiple Sclerosis Quality of Life (MSQOL-29) as the outcome measure. Regression models were used to examine the association between vascular comorbidities and the MSQOL-29, controlling for age, gender, ethnicity, level of education, marital status, MS subtype, disease duration, and disability.

RESULTS

Approximately 35% reported at least one vascular comorbidity, with the most common being hypertension (27.0%), followed by hyperlipidemia (24.9%) and diabetes (8.1%). After factoring in for demographics and disability, having a vascular comorbidity was associated with lower physical HRQOL (β = - 10.05, 95% CI: - 28.24, 23.50), but not mental HRQOL (β = - 2.61, 95% CI: - 10.54, 5.32). Hypertension was negatively associated with several dimensions of HRQOL, including Physical Function, Change in Health, Health Perceptions, Energy, and Health Distress.

CONCLUSIONS

 Having at least one vascular comorbidity is associated with lower physical HRQOL, independent of demographics and level of physical disability. Focus should be directed to the physical burden and challenges vascular comorbidities may cause on the lives of PwMS.

Stroke risk in multiple sclerosis: a critical appraisal of the literature

Observational studies suggest that the occurrence of stroke on multiple sclerosis (MS) patients is higher compared to the general population. MS is a heterogeneous disease that involves an interplay of genetic, environmental and immune factors. The occurrence of stroke is subject to a wide range of both modifiable and non-modifiable, short- and long-term risk factors. Both MS and stroke share common risk factors. The immune mechanisms that underlie stroke are similar to neurodegenerative diseases and are attributed to neuroinflammation. The inflammation in autoimmune diseases may, therefore, predispose to an increased risk for stroke or potentiate the effect of conventional stroke risk factors. There are, however, additional determinants that contribute to a higher risk and incidence of stroke in MS. Due to the challenges that are associated with their differential diagnosis, the objective is to present an overview of the factors that may contribute to increased susceptibility or occurrence of stroke in MSpatients by performing a review of the available to date literature. As both MS and stroke can individually detrimentally affect the quality of life of afflicted patients, the identification of factors that contribute to an increased risk for stroke in MS is crucial for the prompt implementation of preventative therapeutic measures to limit the additive burden that stroke imposes.

The association between multiple sclerosis and migraine: A meta-analysis

BACKGROUND

Multiple sclerosis (MS) is a chronic progressive condition marked by the deterioration of myelin and impairment of neurological function. The global prevalence of MS is approximately 2.2 million. Migraines are common in MS patients, with inconclusive data on their relationship. Our systematic review aimed to assess the prevalence and odds of migraine in pwMS and investigate the potential factors that may influence these associations.

METHOD

Through an extensive search and meticulous study selection, we identified pertinent literature investigating the occurrence and odds of migraines among pwMS. Additionally, we explored the comparative risk of migraines in MS patients compared to healthy controls. Data were extracted, including publication details, diagnostic criteria, and migraine prevalence in MS patients.

RESULTS

A total of 35 studies were included, involving 279,620 pwMS and 279,603 healthy controls. The overall prevalence of migraine in pwMS was 0.24 (95% CI: 0.21-0.28). Subgroup analyses and meta-regression were conducted to investigate the potential impact of various factors on the relationship between migraine and MS. These factors included age, duration of MS, study design, and the Expanded Disability Status Scale (EDSS), migraine diagnosis method, study design, publication year of the study, country and continent of the study population. The results of these analyses revealed no significant influence of these factors on the relationship between migraine and MS. The meta-analysis indicated that pwMS had significantly increased odds of having migraine compared to healthy controls (OR = 1.96, 95% CI: 1.20-3.20). Sensitivity analyses supported the robustness of the findings.

CONCLUSIONS

Our study highlights that approximately 24% of pwMS experience migraine. The method of diagnosis significantly affects the reported prevalence, with questionnaires yielding higher rates. Furthermore, pwMS have a 1.96-fold increased odds of having migraine compared to healthy individuals. These findings emphasize the importance of further research and interventions to address the significant burden of migraine in the MS population.

The Importance of Managing Modifiable Comorbidities in People with Multiple Sclerosis: A Narrative Review

Multiple sclerosis (MS) is a chronic, inflammatory, degenerative demyelinating disease of the central nervous system (CNS) of unknown etiology that affects individuals in their early adulthood. In the last decade, life expectancy for people with MS (PwMS) has almost equaled that of the general population. This demographic shift necessitates a heightened awareness of comorbidities, especially the ones that can be prevented and modified, that can significantly impact disease progression and management. Vascular comorbidities are of particular interest as they are mostly modifiable health states, along with voluntary behaviors, such as smoking and alcohol consumption, commonly observed among individuals with MS. Vascular risk factors have also been implicated in the etiology of cerebral small vessel disease. Furthermore, differentiating between vascular and MS lesion load poses a significant challenge due to overlapping clinical and radiological features. This review describes the current evidence regarding the range of preventable and modifiable comorbidities and risk factors and their implications for PwMS.

Cardiovascular risk factors in secondary progressive multiple sclerosis: A cross-sectional analysis from the MS-STAT2 randomized controlled trial

BACKGROUND AND PURPOSE

There is increasing evidence that cardiovascular risk (CVR) contributes to disability progression in multiple sclerosis (MS). CVR is particularly prevalent in secondary progressive MS (SPMS) and can be quantified through validated composite CVR scores. The aim was to examine the cross-sectional relationships between excess modifiable CVR, whole and regional brain atrophy on magnetic resonance imaging, and disability in patients with SPMS.

METHODS

Participants had SPMS, and data were collected at enrolment into the MS-STAT2 trial. Composite CVR scores were calculated using the QRISK3 software. Prematurely achieved CVR due to modifiable risk factors was expressed as QRISK3 premature CVR, derived through reference to the normative QRISK3 dataset and expressed in years. Associations were determined with multiple linear regressions.

RESULTS

For the 218 participants, mean age was 54 years and median Expanded Disability Status Scale was 6.0. Each additional year of prematurely achieved CVR was associated with a 2.7 mL (beta coefficient; 95% confidence interval 0.8-4.7; p = 0.006) smaller normalized whole brain volume. The strongest relationship was seen for the cortical grey matter (beta coefficient 1.6 mL per year; 95% confidence interval 0.5-2.7; p = 0.003), and associations were also found with poorer verbal working memory performance. Body mass index demonstrated the strongest relationships with normalized brain volumes, whilst serum lipid ratios demonstrated strong relationships with verbal and visuospatial working memory performance.

CONCLUSIONS

Prematurely achieved CVR is associated with lower normalized brain volumes in SPMS. Future longitudinal analyses of this clinical trial dataset will be important to determine whether CVR predicts future disease worsening.

The Prevalence of Diabetes Mellitus Type II (DMII) in the Multiple Sclerosis Population: A Systematic Review and Meta-Analysis

Introduction: The interactions between Diabetes Mellitus type II (DMII) and Multiple Sclerosis (MS) lead to higher levels of fatigue, higher risk of physical disability, faster cognitive decline, and in general a lower quality of life and a higher frequency of depression compared to the general population. All of the above accelerate the disability progression of patients with MS, reduce the patients' functional capacity, and further increase their psychological and economic burden. Methods: This systematic review and meta-analysis aims to calculate the prevalence of DMII in the MS population. Following PRISMA guidelines, a thorough search of the Medline Pubmed, Cochrane Library, and Scopus databases was performed, focusing on the frequency of DMII in the MS population. Results: A total of 19 studies were included in the synthesis. The results of the main meta-analysis of random effects using R studio 3.3.0 for Windows and the Meta r package showed that the prevalence of DMII in the MS population is 5% (95% CI [0.03, 0.07], 19 studies, I2 = 95%, pQ < 0.001). Additional subgroup analysis based on region showed a difference of 4.4% (I2 = 95.2%, pQ < 0.001), psubgroupdifference = 0.003) between European and non-European participants, while demographic- and MS-specific characteristic (EDSS, Disease Duration) did not seem to affect the prevalence of DMII in the MS population (p = 0.30, p = 0.539, p = 0.19, p = 0.838). No publication bias was discovered (Egger's p test value: 0.896). Conclusions: Even though the prevalence of DMII in the MS population is lower than 10% (the reported prevalence of DMII in the general population) the interactions between the two conditions create significant challenges for MS patients, their caregivers, and physicians. DΜΙΙ should be systematically recorded in the case of MS patients to clearly delineate any potential relationship between the two conditions. Additionally, more structured studies investigating the interactions of MS and DMΙΙ as well as the direction of the causation between those two conditions are necessary in order to gain a deeper insight into the nature of the interaction between MS and DMII.

Etiology, effects and management of comorbidities in multiple sclerosis: recent advances

Comorbid conditions commonly affect people with multiple sclerosis (MS). Population-based studies indicate that people with MS have an increased incidence of ischemic heart disease, cerebrovascular disease, peripheral vascular disease, and psychiatric disorders as compared to people without MS. People with MS from underrepresented minority and immigrant groups have higher comorbidity burdens. Comorbidities exert effects throughout the disease course, from symptom onset through diagnosis to the end of life. At the individual level, comorbidity is associated with higher relapse rates, greater physical and cognitive impairments, lower health-related quality of life, and increased mortality. At the level of the health system and society, comorbidity is associated with increased health care utilization, costs and work impairment. A nascent literature suggests that MS affects outcomes from comorbidities. Comorbidity management needs to be integrated into MS care, and this would be facilitated by determining optimal models of care.

The impact of menopause on multiple sclerosis

Menopause, defined as the permanent cessation of ovarian function, represents a period of significant fluctuation in sex hormone concentrations. Sex hormones including oestrogen, progesterone, testosterone and anti-Mullerian hormone are thought have neuroinflammatory effects and are implicated in both neuroprotection and neurodegeneration. Sex hormones are thought to have a role in modifying clinical trajectory in multiple sclerosis (MS) throughout the lifespan. Multiple sclerosis predominantly effects women and is typically diagnosed early in a woman's reproductive life. Most women with MS will undergo menopause. Despite this, the effect of menopause on MS disease course remains unclear. This review examines the relationship between sex hormones and MS disease activity and clinical course, particularly around the time of menopause. It will consider the role of interventions such as exogenous hormone replacement therapy in modulating clinical outcomes in this period. Understanding the impact of menopause on multiple sclerosis is fundamental for delivering optimal care to women with MS as they age and will inform treatment decisions with the aim of minimising relapses, disease accrual and improving quality of life.

Women in the field of multiple sclerosis: How they contributed to paradigm shifts

History is full of women who made enormous contributions to science. While there is little to no imbalance at the early career stage, a decreasing proportion of women is found as seniority increases. In the multiple sclerosis (MS) field, 44% of first authors and only 35% of senior authors were female. So, in this review, we highlight ground-breaking research done by women in the field of MS, focusing mostly on their work as principal investigators. MS is an autoimmune disorder of the central nervous system (CNS), with evident paradigm shifts in the understating of its pathophysiology. It is known that the immune system becomes overactivated and attacks myelin sheath surrounding axons. The resulting demyelination disrupts the communication signals to and from the CNS, which causes unpredictable symptoms, depending on the neurons that are affected. Classically, MS was reported to cause mostly physical and motor disabilities. However, it is now recognized that cognitive impairment affects more than 50% of the MS patients. Another shifting paradigm was the involvement of gray matter in MS pathology, formerly considered to be a white matter disease. Additionally, the identification of different T cell immune subsets and the mechanisms underlying the involvement of B cells and peripheral macrophages provided a better understanding of the immunopathophysiological processes present in MS. Relevantly, the gut-brain axis, recognized as a bi-directional communication system between the CNS and the gut, was found to be crucial in MS. Indeed, gut microbiota influences not only different susceptibilities to MS pathology, but it can also be modulated in order to positively act in MS course. Also, after the identification of the first microRNA in 1993, the role of microRNAs has been investigated in MS, either as potential biomarkers or therapeutic agents. Finally, concerning MS therapeutical approaches, remyelination-based studies have arisen on the spotlight aiming to repair myelin loss/neuronal connectivity. Altogether, here we emphasize the new insights of remarkable women that have voiced the impact of cognitive impairment, white and gray matter pathology, immune response, and that of the CNS-peripheral interplay on MS diagnosis, progression, and/or therapy efficacy, leading to huge breakthroughs in the MS field.

Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systematic Review and Network Meta-analysis of Randomized Trials

BACKGROUND AND OBJECTIVE

Emerging evidence suggests a role for diet in multiple sclerosis (MS) care; however, owing to methodological issues and heterogeneity of dietary interventions in preliminary trials, the current state of evidence does not support dietary recommendations for MS. The objective of this study was to assess the efficacy of different dietary approaches on MS-related fatigue and quality of life (QoL) through a systematic review of the literature and network meta-analysis (NMA).

METHODS

Electronic database searches were performed in May 2021. Inclusion criteria were (1) randomized trial with a dietary intervention, (2) adults with definitive MS based on McDonald criteria, (3) patient-reported outcomes for fatigue and/or QoL, and (4) minimum intervention period of 4 weeks. For each outcome, standardized mean differences (SMDs) were calculated and included in random effects NMA to determine the pooled effect of each dietary intervention relative to each of the other dietary interventions. The protocol was registered at PROSPERO (CRD42021262648).

RESULTS

Twelve trials comparing 8 dietary interventions (low-fat, Mediterranean, ketogenic, anti-inflammatory, Paleolithic, fasting, calorie restriction, and control [usual diet]), enrolling 608 participants, were included in the primary analysis. The Paleolithic (SMD -1.27; 95% CI -1.81 to -0.74), low-fat (SMD -0.90; 95% CI -1.39 to -0.42), and Mediterranean (SMD -0.89; 95% CI -1.15 to -0.64) diets showed greater reductions in fatigue compared with control. The Paleolithic (SMD 1.01; 95% CI 0.40-1.63) and Mediterranean (SMD 0.47; 95% CI 0.08-0.86) diets showed greater improvements in physical QoL compared with control. For improving mental QoL, the Paleolithic (SMD 0.81; 95% CI 0.26-1.37) and Mediterranean (SMD 0.36; 95% CI 0.06-0.65) diets were more effective compared with control. However, the NutriGRADE credibility of evidence for all direct comparisons is very low because of most of the included trials having high or moderate risk of bias, small sample sizes, and the limited number of studies included in this NMA.

DISCUSSION

Several dietary interventions may reduce MS-related fatigue and improve physical and mental QoL; however, because of the limitations of this NMA, which are driven by the low quality of the included trials, these findings must be confirmed in high-quality, randomized, controlled trials.

Association between improved metabolic risk factors and perceived fatigue during dietary intervention trial in relapsing-remitting multiple sclerosis: A secondary analysis of the WAVES trial

Background

Preliminary dietary intervention trials with the low-saturated fat (Swank) and modified Paleolithic elimination (Wahls) diets have shown favorable effects on fatigue among people with multiple sclerosis (MS); however, their impact on metabolic health is unknown.

Objective

To evaluate the impact of the Swank and Wahls diets on markers of metabolic health and to determine the association and mediation effect between changes in metabolic health and perceived fatigue among people with relapsing-remitting MS (RRMS).

Methods

As part of a randomized parallel-arm trial, vital signs, blood metabolic biomarkers, and the fatigue scale for motor and cognitive functions (FSMC) were collected from participants with relapsing-remitting MS (n = 77) at four study visits spaced 12 weeks apart: (1) run-in, (2) baseline, (3) 12-weeks, and (4) 24-weeks. Participants followed their usual diet at run-in, then were randomized at baseline to either the Swank or Wahls diets and followed for 24 weeks.

Results

Both groups had significant reductions in weight, body mass index (BMI), total cholesterol, and low-density lipoprotein (LDL) at 12- and 24-weeks compared to respective baseline values (p ≤ 0.04 for all). The Swank group also had a significant reduction in high-density lipoprotein (HDL) at 12- and 24-weeks (p = 0.0001 and p = 0.02, respectively), while the Wahls group had significant reductions in diastolic blood pressure (DBP). In addition, both groups had significant reductions in FSMC total perceived fatigue and the motor and cognitive fatigue subscales at 12- and 24-weeks (p ≤ 0.01 for all); however, change in the cognitive subscale was not significant at 12-weeks in the Swank group (p = 0.06). Furthermore, the favorable effects, of both diets, on markers of metabolic health were not associated with and did not mediate the effect of the diets on perceived fatigue (p > 0.05 for all).

Conclusion

Both diets lead to significant reductions in perceived fatigue, weight, BMI, total cholesterol, and LDL, but the significant reductions in perceived fatigue were independent of changes in markers of metabolic health.

Internal comorbidities and complications of multiple sclerosis therapy - don't be caught off guard!

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system, mainly affecting young adults. Factors positively influencing its course include early antiinflammatory treatment and the influencing of other comorbidities. The most common comorbidities occurring in MS patients with a higher frequency than in the general population are neurological, psychiatric, cardiovascular, metabolic and autoimmune. Just as comorbidity compensation affects the course of MS, in some cases, MS decompensation is associated with a worse course of associated diseases. Due to common risk factors and partially shared immunopathogenesis, treatment covering multiple conditions can be used, especially for some autoimmune diseases. On the other hand, some drugs may potentiate the development of other autoimmunity or disorder. A special topic is the side effects and complications of treatment (especially infections and malignancies) of disease-modifying therapies used in patients with MS. However, the potential treatment discontinuation carries significant risks and should always be discussed with the MS specialist. Therefore, close interdisciplinary collaboration is crucial.

Non-immune system comorbidity in neuromyelitis optica spectrum disorders

Comorbidities may influence the clinical features, prognosis, and treatment outcomes of neuromyelitis optica spectrum disorders (NMOSD). The aim of this study was to determine the status of non-immune system comorbidities in patients with NMOSD and the effect on treatment response and prognosis. We retrospectively collected data from all patients who met the 2015 NMOSD diagnostic criteria from the NMOSD database established by our center. Patients were divided into positive and negative groups based on the presence of non-immune disease comorbidities. Patient data, clinical characteristics, treatment response, prognosis, and mortality were compared between the two groups. A total of 138 patients with NMOSD plus comorbidities were included, and 404 patients without comorbidities were selected as controls. The average age at onset was older (45 years vs 38 years, P < 0.001), the mean body mass index was higher (23.12 vs 22.04, P = 0.042) and more patients experienced relapse after immunotherapy (68.5 % vs 54.5 %, P = 0.020) in the comorbidity group than in the non-comorbidity group. Multifocal central nervous system lesions as an initial symptom was more common in the comorbidity group than in the non-comorbidity group (30.4 % vs 18.32 %, P = 0.003). Further, more patients experienced severe vision attacks (28.3 % vs 15.8 %, P = 0.003) and severe motor attacks (30.4 % vs 11.9 %, P < 0.001) in the comorbidity group than in the non-comorbidity group. In conclusion, patients with NMOSD with comorbidities tended to be older, less responsive to treatment, and at a higher risk of vision loss and paralysis.

Ageing and multiple sclerosis

The factor that is most relevant and strongly associated with the clinical course of multiple sclerosis is chronological age. Very young patients exclusively have relapsing remitting disease, whereas those with later onset disease face a more rapid development of permanent disability. For people with progressive multiple sclerosis, the poor response to current disease modifying therapies might be related to ageing in the immune system and CNS. Ageing is also associated with increased risks of side-effects caused by some multiple sclerosis therapies. Both somatic and reproductive ageing processes might contribute to development of progressive multiple sclerosis. Understanding the role of ageing in immune and neural cell function in patients with multiple sclerosis might be key to halting non-relapse-related progression. The growing literature on potential therapies that target senescent cells and ageing processes might provide effective strategies for remyelination and neuroprotection.

Patterns of Comorbidity and Multimorbidity Among Patients With Multiple Sclerosis in a Large US Commercially Insured and Medicare Advantage Population

Background: Comorbidities are common in patients with multiple sclerosis (MS), thus increasing the complexity of disease management and economic burden and worsening their prognosis and quality of life. Real-world evidence comparing comorbidities and multimorbidity patterns of commercially insured vs Medicare enrollees with MS is lacking. Objective: To evaluate the patterns of comorbidity and multimorbidity among patients with MS in a US commercially insured and Medicare Advantage population. Methods: This retrospective observational cohort study was conducted using Aetna health claims data from January 1, 2015, to October 31, 2019. Eligibility criteria were (1) at least 3 MS-related inpatient/outpatient (ICD-10-CM: G35), or disease-modifying therapy claims within 1 year (date of first claim = index date); (2) Aetna commercial health plan or Medicare Advantage medical and pharmacy benefits at least 12 months pre-/post-index; and (3) age 18 and older. Commercially insured patients, Medicare Advantage patients younger than 65 years of age, and Medicare Advantage patients 65 years and older were compared. Results: Among 5000 patients (mean [SD] age, 52.6 [12.9]; 75.2% female), 53% had commercial insurance and 47% had Medicare Advantage (59.2% disabled age <65). Medicare Advantage patients were older (age <65: 53.3 [7.9]; age ≥65: 70.8 [5.2]) vs commercial (age, 45.7 [10.2]), had greater comorbidity burden (Charlson Comorbidity Index; age <65: 1.17 [1.64], age ≥65: 1.65 [1.95]) vs commercial (0.53 [1.02]) (all P < .0001). Symptoms specific to MS (ie, malaise, fatigue, depression, spasms, fibromyalgia, convulsions) were more common among patients younger than 65 (all P < .0001). Age-related and other comorbidities (ie, hypertension, hyperlipidemia, dyspepsia, osteoarthritis, osteoporosis, glaucoma, diabetes, cerebrovascular, cancer) were more common among patients 65 years and older Medicare Advantage (all P < .0001). Multiple comorbidities were highly prevalent (median, 4 comorbidities), particularly among Medicare Advantage patients younger than 65 (median, 6) and Medicare Advantage patients 65 and older (median, 7). Conclusions: Comorbidities and multimorbidity patterns differed between patients with MS with commercial insurance and patients with Medicare Advantage. Multimorbidity was highly prevalent among patients with MS and should be considered in the context of clinical decision making to ensure comprehensive MS management and improve outcomes.

Sex and age differences in the Multiple Sclerosis prodrome

Background and objectives

Little is known of the potential sex and age differences in the MS prodrome. We investigated sex and age differences in healthcare utilization during the MS prodrome.

Methods

This was a population-based matched cohort study linking administrative and clinical data from British Columbia, Canada (population = 5 million). MS cases in the 5 years preceding a first demyelinating event ("administrative cohort;" n = 6,863) or MS symptom onset ("clinical cohort;" n = 966) were compared to age-, sex- and geographically-matched controls (n = 31,865/4,534). Negative binomial and modified Poisson models were used to compare the rates of physician visits and hospitalizations per international classification of diseases chapter, and prescriptions filled per drug class, between MS cases and controls across sex and age-groups (< 30, 30-49, ≥50 years).

Results

In the administrative cohort, males with MS had a higher relative rate for genitourinary-related visits (males: adjusted Rate Ratio (aRR) = 1.65, females: aRR = 1.19, likelihood ratio test P = 0.02) and antivertigo prescriptions (males: aRR = 4.72, females: aRR = 3.01 P < 0.01). Injury and infection-related hospitalizations were relatively more frequent for ≥50-year-olds (injuries < 30/30-49/≥50: aRR = 1.16/1.39/2.12, P < 0.01; infections 30-49/≥50: aRR = 1.43/2.72, P = 0.03), while sensory-related visits and cardiovascular prescriptions were relatively more common in younger persons (sensory 30-49/≥50: aRR = 1.67/1.45, P = 0.03; cardiovascular < 30/30-49/≥50: aRR = 1.56/1.39/1.18, P < 0.01). General practitioner visits were relatively more frequent in males (males: aRR = 1.63, females: aRR = 1.40, P < 0.01) and ≥50-year-olds (< 30/≥50: aRR = 1.32/1.55, P = 0.02), while differences in ophthalmologist visits were disproportionally larger among younger persons, < 50-years-old (< 30/30-49/≥50: aRR = 2.25/2.20/1.55, P < 0.01). None of the sex and age-related differences in the smaller clinical cohort reached significance (P ≥ 0.05).

Discussion

Sex and age-specific differences in healthcare use were observed in the 5 years before MS onset. Findings demonstrate fundamental heterogeneity in the MS prodromal presentation.

Prevalence of depression and anxiety in the different clinical forms of multiple sclerosis and associations with disability: A systematic review and meta-analysis

Multiple sclerosis (MS) is a chronic neurodegenerative and autoimmune disease. Motor, sensory and cognitive deficits in MS are commonly accompanied by psychiatric disorders. Depression and anxiety affect the quality of life of MS patients, and the treatment is still not well-established. Prevalence rates in MS patients for depression and anxiety vary widely between studies. However, the prevalence of these psychiatric disorders in the subgroups of MS patients and their association with a disability has not been studied yet. Therefore, this systematic review and meta-analysis proposes to estimate the prevalence of depression and anxiety in MS and to perform subgroup analyses (study type, Extended Disability Status Scale/EDSS, duration of MS, region, type of MS) on observational studies. The protocol was registered in PROSPERO (4202125033). A computerized search on PubMed, EMBASE and Scopus for studies on depression and anxiety in MS was performed from 2015 to 2021, and 12 articles were included. Most of the studies in the meta-analysis had a low risk of bias. The prevalence of depression was 27.01% (MS), 15.78% (relapsing-remitting multiple sclerosis/RRMS), and 19.13% (progressive multiple sclerosis/PMS). For anxiety the prevalence was 35.19% (MS), 21.40% (RRMS), and 24.07% (PMS). The prevalence of depression/anxiety for patients with EDSS <3 was 26.69/45.56% and for EDSS >3 was 22.96/26.70%. Using HADS-A (8) the prevalence was 38.5% and for depression was 22.4%. Then, our study brought together current data regarding psychiatric disorders in MS patients, which are comorbidities that affect the quality of life of these patients.

•

Prevalence of depression/anxiety for the MS patients was 27.01%/35.19%.

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Prevalence of depression was 15.78% (RRMS) and 19.13% (PMS).

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Prevalence of anxiety was 21.40% (RRMS) and 24.07% (PMS).

•

Prevalence of depression/anxiety for the patients with EDSS <3 was 26.69/45.56% and for EDSS >3 was 22.96/26.70%.

•

Prevalence of anxiety using HADS-A (8) was 38.5% and for depression was 22.4%.

Using personalized prognosis in the treatment of relapsing multiple sclerosis: A practical guide

The clinical course of multiple sclerosis (MS) is highly variable among patients, thus creating important challenges for the neurologist to appropriately treat and monitor patient progress. Despite some patients having apparently similar symptom severity at MS disease onset, their prognoses may differ greatly. To this end, we believe that a proactive disposition on the part of the neurologist to identify prognostic “red flags” early in the disease course can lead to much better long-term outcomes for the patient in terms of reduced disability and improved quality of life. Here, we present a prognosis tool in the form of a checklist of clinical, imaging and biomarker parameters which, based on consensus in the literature and on our own clinical experiences, we have established to be associated with poorer or improved clinical outcomes. The neurologist is encouraged to use this tool to identify the presence or absence of specific variables in individual patients at disease onset and thereby implement sufficiently effective treatment strategies that appropriately address the likely prognosis for each patient.

The comorbidity and cognition in multiple sclerosis (CCOMS) neuroimaging protocol: Study rationale, MRI acquisition, and minimal image processing pipelines

The Comorbidity and Cognition in Multiple Sclerosis (CCOMS) study represents a coordinated effort by a team of clinicians, neuropsychologists, and neuroimaging experts to investigate the neural basis of cognitive changes and their association with comorbidities among persons with multiple sclerosis (MS). The objectives are to determine the relationships among psychiatric (e.g., depression or anxiety) and vascular (e.g., diabetes, hypertension, etc.) comorbidities, cognitive performance, and MRI measures of brain structure and function, including changes over time. Because neuroimaging forms the basis for several investigations of specific neural correlates that will be reported in future publications, the goal of the current manuscript is to briefly review the CCOMS study design and baseline characteristics for participants enrolled in the three study cohorts (MS, psychiatric control, and healthy control), and provide a detailed description of the MRI hardware, neuroimaging acquisition parameters, and image processing pipelines for the volumetric, microstructural, functional, and perfusion MRI data.

Acute myocardial infarction risk in multiple sclerosis and neuromyelitis optica spectrum disorder: A nationwide cohort study in South Korea

BACKGROUND

The link between neuromyelitis optica spectrum disorder (NMOSD) and cardiovascular disease is currently unclear.

OBJECTIVE

To determine the acute myocardial infarction (MI) risk in patients with MS and NMOSD.

METHODS

This study analyzed the Korean National Health Insurance Service database between January 2010 and December 2017. The included patients comprised 1503/1675 adults with MS/NMOSD who had not experienced ischemic heart disease or ischemic stroke at the index date. Matched controls were selected based on age, sex, and the presence of hypertension, diabetes mellitus (DM), and dyslipidemia.

RESULTS

The risks of developing MI were 2.61 (hazard ratio (HR), 95% confidence interval (CI) 1.73-3.95) and 1.95 (95% CI = 1.18-3.22) times higher in MS and NMOSD compared with the control populations. Patients with NMOSD had a similar MI risk compared with patients with MS, after adjusting for age, sex, income, hypertension, DM, and dyslipidemia (HR = 0.59, 95% CI = 0.34-1.02, p = 0.059). Among each patient group, the MI risk did not differ significantly with age (20-39, 40-64 or ⩾65 years), sex, or the presence of hypertension, DM, or dyslipidemia.

CONCLUSION

The MI risk increased in MS and NMOSD and seemed to be comparable between NMOSD and MS.

Adverse Drug Reactions with Drugs Used in Multiple Sclerosis: An Analysis from the Italian Pharmacovigilance Database

Given the importance of inflammation at the onset of multiple sclerosis (MS), therapy is mainly based on the use of anti-inflammatory drugs including disease modifying therapies (DMTs). Considering the recent approval of some DMTs, pharmacovigilance becomes a fundamental tool for the acquisition of new safety data. The aim of the study was to analyze adverse drug reactions (ADRs) related to the use of drugs approved for MS. All national publicly-available aggregated ADR reports recorded from 2002 to 2020 into the Reports of Adverse Reactions of Medicines (RAM) system and all complete Sicilian data reported into the Italian spontaneous reporting system (SRS) database having as suspected drugs interferon β-1a (IFN β-1a), interferon β-1b (IFN β-1b), peginterferon β-1a (PEG-IFN β-1a), glatiramer acetate (GA), natalizumab (NTZ), fingolimod (FNG), teriflunomide (TRF), dimethyl fumarate (DMF), alemtuzumab (Alem), ocrelizumab (OCZ), or cladribine (Cladr), were collected. Descriptive analyses of national, publicly-available aggregated data and full-access regional data were performed to assess demographic characteristics and drug-related variables followed by a more in-depth analysis of all Sicilian ADRs with a case-by-case assessment and a disproportionality analysis of unexpected ADRs. A total of 13,880 national reports have been collected from 2002 to 2020: they were mainly not serious ADRs (67.9% vs. 26.1%) and related to females (71.7% vs. 26.3%) in the age group 18–65 years (76.5%). The most reported ADRs were general and administration site conditions (n = 6,565; 47.3%), followed by nervous (n = 3,090; 22.3%), skin (n = 2,763; 19.9%) and blood disorders (n = 2,180; 15.7%). Some unexpected Sicilian ADRs were shown, including dyslipidemia for FNG (n = 10; ROR 28.5, CI 14.3–59.6), NTZ (n = 5; 10.3, 4.1–25.8), and IFN β-1a (n = 4; 8.7, 3.1–24.1), abortion and alopecia for NTZ (n = 9; 208.1, 73.4–590.1; n = 3; 4.9, 1.5–15.7), and vitamin D deficiency for GA (n = 3; 121.2, 30.9–475.3). Moreover, breast cancer with DMF (n = 4, 62.8, 20.5–191.9) and hypothyroidism with Cladr (n = 3; 89.2, 25.9–307.5) were also unexpected. The reporting of drugs-related ADRs in MS were mostly reported in the literature, but some unknown ADRs were also found. However, further studies are necessary to increase the awareness about the safety profiles of new drugs on the market.

Socioeconomic disparity is associated with faster retinal neurodegeneration in multiple sclerosis

Disease course in multiple sclerosis is notably heterogenous, and few prognostic indicators have been consistently associated with multiple sclerosis severity. In the general population, socioeconomic disparity is associated with multimorbidity and may contribute to worse disease outcomes in multiple sclerosis. Herein, we assessed whether indicators of socioeconomic status (SES) are associated with disease progression in people with multiple sclerosis using highly sensitive imaging tools like optical coherence tomography (OCT) and determined if differential multiple sclerosis management or comorbidity mediate any observed SES-associated effects. We included 789 participants with longitudinal OCT and low contrast letter acuity (LCLA; at 1.25% and 2.5%) in whom neighborhood- (derived via 9-digit postal codes) and participant-level SES indicators were available ≤10 years of MS symptom onset. Sensitivity analyses included participants with SES indicators available ≤3years of symptom onset (n = 552). Neighborhood-level indicators included state and national area deprivation indices (ADI), median household income, and the Agency for Healthcare Research and Quality (AHRQ) SES Index. Participant-level indicators included education level. Bi-annual OCT scans were segmented to quantify thickness of the composite macular ganglion cell+inner plexiform layer (GCIPL). We assessed the association between SES indicators and GCIPL atrophy or LCLA loss using mixed models adjusting for demographic (including race and ethnicity) and disease-related characteristics. We also assessed SES indicators in relation to multiple sclerosis therapy changes and comorbidity risk using survival analysis. More disadvantaged neighborhood-level and patient-level SES indicators were associated with faster retinal atrophy. Differences in rate of GCIPL atrophy for individuals in the top quartile (most disadvantaged) relative to the bottom quartile (least) for state ADI were -0.12 µm/year faster (95%CI: -0.19, -0.04; p = 0.003), for national ADI were -0.08 µm/year faster (95%CI: -0.15, -0.005; p = 0.02), for household income were -0.11 µm/year faster (95%CI: -0.19, -0.03; p = 0.008), for AHRQ SES Index were -0.12 µm/year faster (95% CI: -0.19, -0.04) and for education level were -0.17 µm/year faster (95%CI: -0.26, -0.08; p = 0.0002). Similar associations were observed for SES indicators and LCLA loss. Lower SES was associated with higher risk of incident comorbidity during follow-up. Low SES individuals had faster rates of therapy escalation, suggesting the association between SES and GCIPL atrophy may not be explained by differential contemporaneous multiple sclerosis therapy management. In conclusion, socioeconomic disparity is associated with faster retinal neurodegeneration in multiple sclerosis. As low SES was associated with a higher risk of incident comorbidities that may adversely affect multiple sclerosis outcomes, comorbidity prevention may mitigate some of the unfavorable SES-associated consequences.

Vascular comorbidity is associated with lower brain volumes and lower neuroperformance in a large multiple sclerosis cohort

OBJECTIVE

The objective of this study is to assess the association between vascular comorbidity burden with clinical and imaging features of disease burden in a large population of people with multiple sclerosis (MS).

METHODS

We included participants from the MS Partners Advancing Technology Health Solutions (MS PATHS) cohort. We evaluated if vascular comorbidities (diabetes, hypertension, and dyslipidemia) or a composite sum of comorbidities was associated with MS characteristics, including objective neurologic function assessments and quantitative brain magnetic resonance imaging (MRI) measurements in propensity score-weighted models.

RESULTS

In total, 11,506 participants (6409 (55%) with brain MRI) were included. Individuals with 2+ vascular comorbidities had slower walking speed (standard deviation (SD) = -0.49; 95% confidence interval (CI) = -0.78, -0.19; p = 0.001), slower manual dexterity (SD = -0.41; 95% CI = -0.57, -0.26; p < 0.0001), and fewer correct scores on cognitive processing speed (SD = -0.11; 95% CI = -0.20, -0.02; p = 0.02) versus those with no comorbidities. Those with 2+ had lower brain parenchymal (-0.41%, 95% CI = -0.64, -0.17) and gray matter fractions (-0.30%, 95% CI = -0.49, -0.10), including reduced cortical (-10.10 mL, 95% CI = -15.42, -4.78) and deep (-0.44 mL, 95% CI = -0.84, -0.04) gray matter volumes versus those with no comorbidity.

CONCLUSION

Increased vascular comorbidity burden was associated with clinical and imaging markers of neurologic dysfunction and neurodegeneration in MS. Strategies to optimize comorbidity management in people with MS are warranted.

Headache in multiple sclerosis - pharmacological aspects

For decades, headache was not considered a typical symptom of multiple sclerosis (MS) and was construed as a "red flag" for important differential diagnoses such as cerebral vasculitis. Meanwhile, several studies have demonstrated an increased prevalence of headache in MS compared to the general population. This is due to the heterogeneity of headache genesis with frequent occurrence of both primary and secondary headaches in MS. On the one hand, MS and migraine are often comorbid. On the other hand, secondary headaches occur frequently, especially in the course of MS relapses. These are often migraine-like headaches caused by inflammation, which can improve as a result of MS-specific therapy. Headaches are particularly common in the early stages of chronic inflammatory CNS disease, where inflammatory activity is greatest. In addition, headache can also occur as a side effect of disease-modifying drugs (DMDs). Headache can occur with most DMDs and is most frequently described with interferon-beta therapy. The aim of this work is to present the prevalence of headache and describe the heterogeneity of possible causes of headache in MS. In addition, important therapeutic aspects in the treatment of MS patients in general will be presented as well as different approaches to the treatment of headache in MS depending on the etiological classification.

Comorbidity and persistence of disease-modifying therapy use in relapsing remitting multiple sclerosis

BACKGROUND

Comorbidity decreases the likelihood of initiating disease-modifying therapy (DMT) for multiple sclerosis (MS). Our objective was to characterize the relationship between comorbidity and initial DMT persistence along with reasons for DMT discontinuation.

METHODS

We identified individuals with relapsing remitting MS or clinically isolated syndrome starting a platform DMT (interferon-β, glatiramer acetate, dimethyl fumarate, teriflunomide) as initial therapy in the Canadian province of Nova Scotia from 2001 to 2016. Cases were identified using a clinic database for the only clinic providing specialty MS care in a province with universal publicly-funded health care. Comorbidity was determined by linkage of MS cases to provincial health administrative data using validated case definitions for mental health disorder, hypertension, hyperlipidemia, diabetes, chronic lung disease, ischemic heart disease, epilepsy, and inflammatory bowel disease. Cox proportional hazards models explored the relationship between comorbidity, as a count or individual comorbidities, and time to discontinuation of initial DMT. Logistic regression models explored reasons for DMT discontinuation.

RESULTS

Among 1464 individuals starting platform therapy as initial DMT, the median duration on first DMT was 4 years (95% CI 4 - 4). Comorbidity count (0, 1, ≥2) was not associated with time to discontinuation of initial DMT. However, the presence of a mental health disorder was associated with an increased hazard of discontinuing DMT (hazard ratio 1.22, 95% CI 1.03-1.44). Comorbidity count was not associated with discontinuation for lack of efficacy or lack of tolerability after adjusting for covariates.

CONCLUSION

Individuals with mental health comorbidity may have unique challenges that affect persistence on DMT after treatment initiation.

High prevalence of comorbidities at diagnosis in immigrants with multiple sclerosis

Background:

Multiple sclerosis (MS) has been associated with certain comorbidities in general population studies, but it is unknown how comorbidity may affect immigrants with MS.

Objective:

To compare prevalence of comorbidities in immigrants and long-term residents at MS diagnosis, and in matched control populations without MS.

Methods:

We identified incident MS cases using a validated definition applied to health administrative data in Ontario, Canada, from 1994 to 2017, and categorized them as immigrants or long-term residents. Immigrants and long-term residents without MS (controls) were matched to MS cases 3:1 on sex, age, and geography.

Results:

There were 1534 immigrants and 23,731 long-term residents with MS matched with 4585 and 71,193 controls, respectively. Chronic obstructive pulmonary disease (COPD), diabetes, hypertension, ischemic heart disease, migraine, epilepsy, mood/anxiety disorders, schizophrenia, inflammatory bowel disease (IBD), and rheumatoid arthritis were significantly more prevalent among immigrants with MS compared to their controls. Prevalence of these conditions was generally similar comparing immigrants to long-term residents with MS, although COPD, epilepsy, IBD, and mood/anxiety disorders were less prevalent in immigrants.

Conclusion:

Immigrants have a high prevalence of multiple comorbidities at MS diagnosis despite the “healthy immigrant effect.” Clinicians should pay close attention to identification and management of comorbidity in immigrants with MS.

Migraine in multiple sclerosis and other chronic inflammatory diseases

Migraine is a very prevalent disease worldwide and is a major cause of disability. As known for a long time, migraine is associated with neurogenic inflammation. Epidemiological studies have shown that migraine is comorbid with several chronic inflammatory diseases, including multiple sclerosis (MS), chronic inflammatory rheumatic diseases (CIRDs) and inflammatory bowel diseases (IBDs). This brief narrative review highlights some recent data supporting a link between migraine and these three chronic inflammatory diseases. Studies found that migraine prevalence is approximately two-fold higher in these diseases compared to the general population. The causal link between migraine and these chronic inflammatory diseases has not been identified yet. Here, we suggest that systemic mediators (such as cytokines) and gut microbiome make migraine worse or add significant risks. Systemic inflammation biomarkers and gut microbiome modification are certainly avenues worth exploring.