Multiple sclerosis relapses are associated with increased fatigue and reduced health-related quality of life – A post hoc analysis of the TEMSO and TOWER studies

Comparative characteristics of fatigue in irritable bowel syndrome and inflammatory bowel disease: A systematic review and meta-analysis

OBJECTIVE

Fatigue is a common symptom in both irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC). This study aimed to distinguish fatigue characteristics in IBS and IBD, two functional and organic disorders.

METHODS

We systematically searched the PubMed and Cochrane Library databases from inception to June 30, 2023, and conducted a meta-analysis to generate precise estimates and 95% confidence intervals. The analyses were stratified by fatigue type, severity, sex, disease phase, and comorbidities, and study quality was assessed using Newcastle-Ottawa Scale (NOS).

RESULTS

Our analysis included 74 data (13 IBS, 31 CD, 30 UC) encompassing 16,689 participants (6484 males, 7402 females, and 2803 unknown). Overall, fatigue prevalence trended higher in IBS (54.5% [95%CI, 44.5-64.6]), followed by CD (49.8% [95%CI, 44.0-55.5]) and UC (43.6% [95%CI, 38.5-48.7]). This pattern persisted across sub-analyses, including general fatigue (63.4% vs. 51.3% vs. 45.3%) and moderate to severe fatigue (73.8% vs. 59.5% vs. 52.7%) for IBS, CD, and UC, respectively. Female predominance was observed in all three diseases (odds ratio: 1.5 in IBS and CD, 1.8 in UC). Fatigue prevalence significantly varied between disease phases (active vs. remission) in CD (61.3% vs. 36.3%) and UC (53.8% vs. 32.6%). Anemia, anxiety/depression, and/or IBS-like symptoms also contributed to fatigue in CD and UC.

CONCLUSIONS

This study is the first extensive comparison of fatigue prevalence and features in IBS, CD, and UC. The findings offer valuable insights for treatment and management, aiding our understanding of functional and organic diseases.

Impact of Disease Modifying Therapy on MS-Related Fatigue: A Narrative Review

Multiple sclerosis (MS) is a chronic autoimmune disease that affects the central nervous system by causing inflammation, demyelination and neurodegeneration. Fatigue is the most prevalent and one of the most disabling symptoms among people with MS (pwMS). Due to its complexity and subjective character, fatigue is still little understood despite its frequent occurrence and severe impact. The potential causes, effects, and treatments of fatigue associated with MS have been extensively studied in recent years. Though the benefits of such a variety of contributions are obvious, there have not been many attempts to evaluate the effect of disease modifying therapies (DMTs) on MS-related fatigue. In this review, we summarize clinical trials and research studies, and we discuss the effect of different DMTs on MS-related fatigue.

Estimating the disutility of relapse in relapsing-remitting and secondary progressive multiple sclerosis using the EQ-5D-5L, AQoL-8D, EQ-5D-5L-psychosocial, and SF-6D: implications for health economic evaluation models

BACKGROUND AND AIMS

Relapses are an important clinical feature of multiple sclerosis (MS) that result in temporary negative changes in quality of life (QoL), measured by health state utilities (HSUs) (disutilities). We aimed to quantify disutilities of relapse in relapsing remitting MS (RRMS), secondary progressive MS (SPMS), and relapse onset MS [ROMS (including both RRMS and SPMS)] and examine these values by disability severity using four multi-attribute utility instruments (MAUIs).

METHODS

We estimated (crude and adjusted and stratified by disability severity) disutilities (representing the mean difference in HSUs of 'relapse' and 'no relapse' groups as well as 'unsure' and 'no relapse' groups) in RRMS (n = 1056), SPMS (n = 239), and ROMS (n = 1295) cohorts from the Australian MS Longitudinal Study's 2020 QoL survey, using the EQ-5D-5L, AQoL-8D, EQ-5D-5L-Psychosocial, and SF-6D MAUIs.

RESULTS

Adjusted mean overall disutilities of relapse in RMSS/SPMS/ROMS were - 0.101/- 0.149/- 0.129 (EQ-5D-5L), - 0.092/- 0.167/- 0.113 (AQoL-8D), - 0.080/- 0.139/- 0.097 (EQ-5D-5L-Psychosocial), and - 0.116/- 0.161/- 0.130 (SF-6D), approximately 1.5 times higher in SPMS than in RRMS, in all MAUI. All estimates were statistically significant and/or clinically meaningful. Adjusted disutilities of RRMS and ROMS demonstrated a U-shaped relationship between relapse disutilities and disability severity. Relapse disutilities were higher in 'severe' disability than 'mild' and 'moderate' in the SPMS cohort.

CONCLUSION

MS-related relapses are associated with substantial utility decrements. As the type and severity of MS influence disutility of relapse, the use of disability severity and MS-type-specific disutility inputs is recommended in future health economic evaluations of MS. Our study supports relapse management and prevention as major mechanisms to improve QoL in people with MS.

Multiple sclerosis and mental health related quality of life: The role of defense mechanisms, defense styles and family environment

Background

Multiple sclerosis is a demyelinating chronic neurologic disease that can lead to disability and thus to deterioration of quality of life. Psychological parameters such as ego defense mechanisms, defense styles and family environment are important factors in the adaptation process, and as such they can play important roles in QoL. This study aims to assess the psychological factors as well as the clinical and demographic characteristics related to mental health quality of life (MHQoL).

Methods

This was an observational, cross-sectional study conducted in a sample of 90 people with MS in the years 2018-2020. All participants completed the following questionnaires: MSQoL-54, DSQ-88, LSI, FES-R, SOC, BDI-II, STAI. Disability was assessed using EDSS.

Results

In multiple linear regression, significant roles were played by depression (R2: 41.1%, p: 0.001) and, to a lesser extent, the event of a relapse (R2: 3.5%, p: 0.005), expressiveness (R2: 3.6%, p < 0.05) and image distortion style (R2: 4.5%, p: 0.032). After performing a hierarchical-stepwise analysis (excluding depression), the important factors were maladaptive defense style (R2: 23.7%, p: 0.002), the event of relapse (R2: 8.1%, p < 0.001), expressiveness (R2: 5.5%, p: 0.004) and self-sacrificing defense style (R2: 2.4%, p: 0.071).

Conclusion

Psychological factors play important roles in MHQoL of people with multiple sclerosis. Thus, neurologists should integrate in their practice an assessment by mental health specialists. Moreover, targeted psychotherapeutic interventions could be planned i to improve QoL.

Within-person fluctuations over three years in depression, anxiety, fatigue, and health-related quality of life in multiple sclerosis

BACKGROUND

Longitudinal studies of health-related quality of life (HRQoL) in multiple sclerosis (MS) are limited. Most have examined average changes within the population, rather than dynamic changes within individuals.

OBJECTIVE

To assess the between- and within-individual association between depression, anxiety, fatigue, cognition, physical functioning, and physical comorbidities and HRQoL.

METHODS

Adults with MS underwent physical and cognitive assessments and reported symptoms of fatigue (Daily Fatigue Impact Scale), depression and anxiety (Hospital Anxiety and Depression Scale (HADS)), and HRQoL (RAND-36) annually (n = 4 visits). We evaluated associations of elevated symptoms of anxiety (HADS-A) and depression (HADS-D), fatigue, physical function (timed-walk and nine-hole peg test), cognitive function and comorbidity count with physical (PCS-36) and mental (MCS-36) HRQoL using multivariable linear models-estimating between-person and within-person effects.

RESULTS

Of 255 participants with MS enrolled, 81.6% were women. After adjustment, within-person increases in depression and fatigue were associated with decreases in physical HRQoL. Increases in depression, anxiety, and comorbidity count were associated with decreases in mental HRQoL.

CONCLUSIONS

Within-person increases in symptoms of depression, anxiety and fatigue, and comorbidity count are associated with HRQoL decreases among adults with MS, highlighting the potential magnitude of individual benefit of intervention for these symptoms.

Real-World Clinical and Economic Outcomes Among Persons With Multiple Sclerosis Initiating First- Versus Second- or Later-Line Treatment With Ocrelizumab

INTRODUCTION

Prior research has demonstrated that early treatment with high-efficacy disease-modifying therapies (DMTs), including ocrelizumab (OCR), can reduce relapses and delay disease progression among persons with multiple sclerosis (pwMS) compared with escalation from low-/moderate-efficacy DMTs. However, there is a lack of research examining the impact of early use of OCR on real-world clinical and economic outcomes. This study aimed to evaluate differences in events often associated with a relapse (EOAR) as well as non-DMT healthcare resource use (HCRU) and costs among pwMS who received OCR as a first-line treatment compared with later-line treatment after diagnosis.

METHODS

Newly diagnosed adult pwMS were selected from deidentified Optum Market Clarity claims data (study period: January 1, 2015-June 30, 2021). All pwMS were required to have initiated OCR after diagnosis and have 12 months of continuous eligibility prior to diagnosis. The index date was the date of initiation of the first-line DMT after diagnosis. pwMS who initiated OCR as first-line (1L OCR cohort) or a second- or later-line treatment (2L + OCR cohort) were matched 1:1 based on length of continuous eligibility after the first-line DMT and weighted using stabilized inverse probability of treatment. In the follow-up period, differences in outcomes, including annualized EOAR, non-DMT HCRU and costs, were evaluated for pwMS in the 1L vs. 2L + OCR cohorts.

RESULTS

The sample included 748 pwMS. During the follow-up period, pwMS in the 1L OCR cohort had a significantly lower annual rate of EOAR compared with pwMS in the 2L + OCR cohort (0.37 vs. 0.56; difference: 0.20 [95% CI 0.08, 0.32]). pwMS in the 1L OCR cohort had a significantly lower probability of any hospitalization within 1 year, fewer non-DMT outpatient visits and lower all-cause and MS-related, non-DMT costs compared with pwMS in the 2L + OCR cohort.

CONCLUSIONS

First-line initiation OCR was associated with improvements in clinical and non-DMT economic outcomes compared with later-line initiation of OCR, suggesting that early initiation may benefit both patients and the healthcare system.

A retrospective claims analysis of fatigue in patients with multiple sclerosis on disease-modifying therapy

BACKGROUND

Fatigue, one of the most common symptoms in patients with multiple sclerosis (MS), severely impairs quality of life and the ability to work or perform activities of daily living. Real-world data on fatigue in MS can help inform healthcare decisions and identify care gaps. We identified fatigue in patients with MS, using existing codes for fatigue and proxies of fatigue in healthcare claims database records and characterized cohorts with and without markers of fatigue who had been prescribed disease-modifying therapies for MS (MS-DMTs).

METHODS

In this cohort study, we retrospectively analyzed Optum's de-identified Clinformatics® Data Mart database from 1 January 2015 to 31 December 2019. The index date was defined as the first prescription record date for any MS-DMT during the study identification period. Included patient records were from adults (≥18 years) with ≥2 MS diagnosis claims listed within 12 months prior to the index date. Patients had ≥1 claim for any MS-DMT during the identification period (1 January 2016-31 December 2018), continuous enrollment in a health plan with medical and pharmacy benefits for 12 months before the index date (assessment one), and 12 months following the index date or to end of data availability (assessment two). After exploratory analyses, we applied the following definition to sort patient records into two cohorts according to presence or absence of markers of fatigue: ≥1 diagnosis (International Classification of Diseases, Ninth/Tenth Revisions code) claim for fatigue or ≥2 claims for stimulant drugs or ≥2 procedure claims for a sleep study or ≥2 pharmacy claims for sleep aid drugs; we used the broadest definition of fatigue so meeting any of these criteria qualified patients with MS as having fatigue. To minimize assessment one differences in selected patient characteristics between cohorts, we applied 1:1 propensity score matching with age, sex, US geographic region, and Charlson Comorbidity Index score as covariates. We analyzed demographic data, markers of fatigue, comorbidities at assessment one, and physical disabilities and neurologic impairment at assessment two.

RESULTS

Of 4077 patient records that met the eligibility criteria, 1976 had markers of fatigue. The propensity score-matched cohorts included 1519 patients each with and without fatigue. Assessment one comorbidities including anxiety (25.3% vs 10.5%; P<0.0001), arthritis (17.6% vs 12.9%; P = 0.0003), depression (15.0% vs 3.5%; P<0.0001), and gastrointestinal disorders (20.3% vs 14.2%; P<0.0001) were significantly more prevalent in the cohort with markers of fatigue at assessment one compared with those without fatigue. At assessment two, the cohort with baseline fatigue upon initial assessment was more likely to have indication of physical impairments (spasticity [63.5% vs 35.8%; P<0.0001], bladder dysfunction [37.8% vs 24.0%; P<0.0001], cognitive/behavioral dysfunction [27.0% vs 18.6%; P<0.0001]), neurologic impairments (pain [59.1% vs 44.0%; P<0.0001], depression [29.2% vs 9.9%; P<0.0001], and sensory disturbances [54.2% vs 36.7%; P<0.0001]), compared with the cohort without markers of fatigue at assessment one.

CONCLUSIONS

In our analysis, patients with MS and fatigue were more likely to have comorbidities at assessment one and to develop physical disabilities and neurologic impairments at assessment two. Appropriate identification of patients with MS and fatigue may facilitate targeted care interventions to a group of patients at higher risk for disease progression and disability.

Fatigue and health-related quality of life depend on the disability status and clinical course in RRMS

BACKGROUND

Fatigue is a prominent and disabling symptom of multiple sclerosis (MS), impairing quality of life. The disease course of relapsing remitting MS (RRMS) is individual.

OBJECTIVES

We aimed to study the effects of demographic and clinical characteristics, as well as lifestyle risk factors on experienced fatigue and health-related quality of life (HRQoL) among RRMS patients, comparing benign and severe disease types.

METHODS

Altogether 198 Finnish RRMS patients were recruited for this real-life cross-sectional study. Self-reported questionnaires were used to evaluate fatigue and HRQoL by using Fatigue Scale for Motor and Cognitive Functions and 15D health-related quality of life questionnaires. Patients were categorized into subgroups based on the current disability status measured by the Expanded Disability Status Scale (EDSS) cut-off value of 4.5, and by retrospective clinical course divided into benign and aggressive RRMS.

RESULTS

All in all, 73% of the RRMS patients suffered from fatigue. Lower HRQoL had a strong correlation with more prominent fatigue (r = -0.719). Higher EDSS was associated with more prominent fatigue and lower HRQoL in the whole RRMS cohort. Older age at the disease onset was associated with more prominent fatigue and decreased HRQoL in the groups of aggressive RRMS and EDSS > 4.5. In the groups of EDSS ≤ 4.5 and benign RRMS, a higher number of used disease-modifying treatments (DMTs) was associated with more pronounced fatigue and reduced HRQoL. In addition, higher BMI was associated with lower HRQoL in patients with benign RRMS. Side effects (45 %) and lack of efficacy (26 %) were the most common reasons for discontinuing a DMT. Cessation due to side effects was the only reason that was significantly associated with more prominent fatigue and lower HRQoL. Use of nicotine products, gender, or disease duration were not associated with fatigue or HRQoL.

CONCLUSIONS

Individuals with severe RRMS and higher EDSS scores are more prone to experience fatigue and lower HRQoL. In addition, fatigue and lower HRQoL are more commonly observed among RRMS patients with older age at disease onset and in those with multiple DMT switches.

The socioeconomic impact of disability progression in multiple sclerosis: A retrospective cohort study of the German NeuroTransData (NTD) registry

Background

Multiple sclerosis (MS) is a progressively debilitating neurologic disease that poses significant costs to the healthcare system and workforce.

Objective

To evaluate the impact of MS disease progression on societal costs and quality of life (QoL) using data from the German NeuroTransData (NTD) MS registry.

Methods

Cross-sectional cohort study. The cost cohort included patients with MS disability assessed using Expanded Disability Status Scale (EDSS) in 2019 while the QoL cohort included patients assessed using EDSS and EuroQol-5 Dimension 5-Levels between 2009 and 2019. Direct and indirect medical, and non-medical resource use was quantified and costs derived from public sources.

Results

Within the QoL cohort (n = 9821), QoL worsened with increasing EDSS. Within the cost cohort (n = 7286), increasing resource use with increasing EDSS was observed. Societal costs per patient, excluding or including disease-modifying therapies, increased from €5694 or €19,315 at EDSS 0 to 3.5 to €25,419 or €36,499 at EDSS 4 to 6.5, and €52,883 or €58,576 at EDSS 7 to 9.5. In multivariate modeling, each 0.5-step increase in EDSS was significantly associated with increasing costs, and worsening QoL.

Conclusion

This study confirms the major socioeconomic burden associated with MS disability progression. From a socioeconomic perspective, delaying disability progression may benefit patients and society.

Biopsychosocial Correlates of Quality of Life in Multiple Sclerosis Patients

Multiple sclerosis (MS) is a demyelinating chronic disease that has had increasing prevalence over the last years. We have investigated whether the perceived quality of life is reduced in multiple sclerosis patients compared to control participants with a cross-sectional approach, and how it relates to sociodemographic, clinical, and psychosocial variables in MS with multiple regression. To that end, a group of MS patients (n = 50) and a control group (n = 50) that was matched for age and education level filled in the WHOQOL-BREF (perceived quality of life across four domains) and a sociodemographic questionnaire. The participants in the MS group also filled in a clinical questionnaire and three instruments measuring psychosocial variables (the DASS-21 for depression, anxiety, and stress, the Brief-COPE for coping skills, and the Meaning in Life Scale). The results showed that the perceived quality of life was lower in the MS group than in the control group. Multiple regression models incorporating the variables that showed significant correlations with the quality of life indicated that age, professional status, recovery from relapses, depression, active coping, and meaning in life predicted at least one domain of the quality of life. Meaning in life predicted the quality of life in all four of the domains. Although the quality of life in MS is linked to multiple biopsychosocial variables, meaning in life seems crucial.

Fatigue is a common symptom in myelin oligodendrocyte glycoprotein antibody disease

Background

Unlike multiple sclerosis and neuromyelitis optica, the burden of fatigue in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is unclear.

Objective

To compare fatigue levels between people with MOGAD and household controls (HC) and explore factors associated with fatigue severity.

Methods

In a cross-sectional survey, data were collected from people with MOGAD and HC by utilizing an online questionnaire. Data elements included demographics, sleep quality measures, comorbidities, MOGAD characteristics, and fatigue severity measured by the Modified Fatigue Impact Scale (MFIS). We compared fatigue severity between MOGAD participants and HC and assessed the associations between demographic and disease characteristics and fatigue severity.

Results

There were 180/283 MOGAD and 61/126 HC respondents. Compared to HC, people with MOGAD reported more severe fatigue, as measured by the MFIS total score (49.3 vs. 36.5; p < 0.001), and a larger proportion of MOGAD participants (75.6% vs. 44.3%; p < 0.001) were classified as fatigued. Among MOGAD participants, higher age ( p = 0.04), history of bilateral optic neuritis ( p = 0.02), and current use of acute treatment ( p = 0.04) were independently associated with higher fatigue.

Conclusions

Fatigue is common in people with MOGAD, and a history of bilateral optic neuritis, comorbid conditions, and ongoing disease activity appear to contribute to fatigue severity.

Fear of Relapse Scale: Spanish version and psychometric characteristics in a sample of patients with Relapsing-Remitting multiple sclerosis

INTRODUCTION

Relapses are a hallmark of multiple sclerosis, being a characteristic feature of relapsing-remitting multiple sclerosis (RRMS). The occurrence of a relapse constitutes a source of significant discomfort that impacts all domains of daily life of patients with multiple sclerosis (PwMS). In this study we first explored the psychometric properties of the Spanish version of the Fear of Relapse Scale (FoR) in a sample of patients with RRMS. Besides, we explored the relationship between the Fear of Relapse Scale with fatigue and cognitive perceived deficits in our PwMS sample.

METHODS

An online cross-sectional survey was conducted on 173 MS patients from 12 Spanish-speaking countries (Argentina, Mexico, Uruguay, Dominican Republic, Spain, Cuba, Colombia, Guatemala, Chile, Paraguay, Peru, and El Salvador). Confirmatory factor analysis (CFA) was performed to assess the factor structure of the scale. Multiple linear regression was used to evaluate the effects of health self-perception, fatigue, and perceived cognitive deficits over fear of relapse.

RESULTS

The three-factor model in the CFA yielded a good model fit (χ2/df = 2.25, P < .001, RMSEA = .078, CFI = .91). McDonalds' Omega of the FoR (Spanish version) was .91. There was a statistically significant inverse correlation between FoR and health self-perception, and a positive correlation between FoR, fatigue, and perceived cognitive deficits. Finally, level of fatigue was a predictor of fear of relapse.

CONCLUSIONS

The Spanish version of the Fear of Relapse Scale is a valid and reliable instrument to explore the experience of fear of relapse in patients with RRMS.

Current perspectives on the diagnosis and management of fatigue in multiple sclerosis

INTRODUCTION

Fatigue is a common and debilitating symptom among multiple sclerosis (MS) patients with a prevalence up to 81% and with a considerable impact on quality of life. However, its subjective nature makes it difficult to define and quantify in clinical practice. Research aimed at a more precise definition and knowledge of this construct is thus continuously growing.

AREAS COVERED

This review summarizes the most relevant updates available on PubMed up to July 1^st 2022 regarding: the assessment methods that aim to measure the concept of fatigue (as opposed to fatigability), the possible treatment pathways currently available to clinicians, interconnection with the pathophysiological substrates and with the common comorbidities of MS, such as depression and mood disorders.

EXPERT OPINION

The in-depth study of fatigue can help to better understand its actual impact on MS patients and can stimulate clinicians towards a more valid approach, through a targeted analysis of this symptom. Considering fatigue from a multidimensional perspective allows the use of patient-tailored methods for its identification and subsequent treatment by different professional figures. Better identification of methods and treatment pathways would reduce the extremely negative impact of fatigue on MS patients' quality of life.

Cross-cultural adaptation, reliability and validity of the Turkish version of the Fear of Relapse Scale (FoR) in individuals with multiple sclerosis

OBJECTIVE

The study aimed to translate and cross-culturally adapt the Fear of Relapse Scale (FoR) into Turkish and determine its psychometric properties.

METHODS

International guidelines were used for the translation and adaptation process. The patients were asked to fill the FoR, Intolerance of Uncertainty (IUS-12) and Depression Anxiety and Stress Scale (DASS-21). One week later, participants refilled the FoR. The test-retest reliability, internal consistency, and construct validity of the FoR were analyzed.

RESULTS

A total of 101 MS patients (37.6 ± 10.0 years, 81.2% women) were included in the research. The test-retest reliability of the FoR was excellent (ICC:0.883; CI:0.64-0.92). The reproducibility of the items of the FoR ranged from 0.2 to 0.8. The Cronbach's alpha coefficient of the FoR was 0.914. The internal consistency of the items was ranged between 0.90 and 0.91 The relationship between FoR with IUS-12, DASS-21 (depression), DASS-21 (anxiety), DASS-21 (stress) was 0.609, 0.641, 0.648 and 0.631, respectively. The correlation coefficients were greater than 0.50 (p < 0.01).

CONCLUSION

The Turkish version of the FoR is a reliable and valid tool to measure relapse fear in patients with MS.

Short quality of life scale: A cross-cultural validation in Iranian patients with multiple sclerosis

Health-related quality of life (HRQoL) is the prioritized measure in multiple sclerosis (MS) patients. The short quality of life scale (SQoL) developed by Devy et al. (2013) is an MS-specific and abbreviated scale with ten items suitable for routine medical care settings. The current study reported the cross-cultural validation of the scale in the Persian language. A total of 455 convenient MS patients with a mean age of 38.39 (9.28) ranged from 18 to 64 filled out the primary measure and the validating measures, including hospital anxiety and depression scale, visual analogue scale - quality of life, and a single index of the number of past-year MS relapse. The confirmatory factor analysis on original structure indicated an acceptable model fit. However, a modestly modified structure composing of physical-functional dimension (items #1-3), mental dimension (items #5-8), and pain & energy dimension (items 4 & 9,10) was also exposed with a sound fit and a meaningful structure. The overall internal consistency reliability was sound (0.88), and the concurrent validity was confirmed. The Persian short quality of life scale (P-SQoL) is the first translated and validated version of the scale, surfacing significant implications. Further cross-cultural investigations are recommended to re-examine current findings. The classic and recent suggestions concerning the close interplay between the immunity system and the psychological system and the implications based on Iran's context are discussed.

Inhalation of dimethyl fumarate-encapsulated solid lipid nanoparticles attenuate clinical signs of experimental autoimmune encephalomyelitis and pulmonary inflammatory dysfunction in mice

RATIONALE

The FDA-approved Dimethyl Fumarate (DMF) as an oral drug for Multiple Sclerosis (MS) treatment based on its immunomodulatory activities. However, it also caused severe adverse effects mainly related to the gastrointestinal system.

OBJECTIVE

Investigated the potential effects of solid lipid nanoparticles (SLNs) containing DMF, administered by inhalation on the clinical signs, central nervous system (CNS) inflammatory response, and lung function changes in mice with experimental autoimmune encephalomyelitis (EAE).

MATERIALS AND METHODS

EAE was induced using MOG35-55 peptide in female C57BL/6J mice and the mice were treated via inhalation with DMF-encapsulated SLN (CTRL/SLN/DMF and EAE/SLN/DMF), empty SLN (CTRL/SLN and EAE/SLN), or saline solution (CTRL/saline and EAE/saline), every 72 h during 21 days.

RESULTS

After 21 days post-induction, EAE mice treated with DMF-loaded SLN, when compared with EAE/saline and EAE/SLN, showed decreased clinical score and weight loss, reduction in brain and spinal cord injury and inflammation, also related to the increased influx of Foxp3+ cells into the spinal cord and lung tissues. Moreover, our data revealed that EAE mice showed signs of respiratory disease, marked by increased vascular permeability, leukocyte influx, production of TNF-α and IL-17, perivascular and peribronchial inflammation, with pulmonary mechanical dysfunction associated with loss of respiratory volumes and elasticity, which DMF-encapsulated reverted in SLN nebulization.

CONCLUSION

Our study suggests that inhalation of DMF-encapsulated SLN is an effective therapeutic protocol that reduces not only the CNS inflammatory process and disability progression, characteristic of EAE disease, but also protects mice from lung inflammation and pulmonary dysfunction.

Reduction in cognitive processing speed surrounding multiple sclerosis relapse

Objective

The purpose of this study was to explore the longitudinal relationship between multiple sclerosis (MS) relapses and information processing efficiency among persons with relapsing–remitting MS.

Methods

We conducted a Swedish nationwide cohort study of persons with incident relapsing–remitting MS (2001–2019). Relapse information and symbol digit modalities test (SDMT) scores were obtained from the Swedish MS Registry. Follow‐up was categorized into 2 periods based on relapse status: “relapse” (90 days pre‐relapse to 730 days post‐relapse, subdivided into 10 periods) and “remission.” Linear mixed models compared SDMT scores during the relapse periods to SDMT scores recorded during remission (reference) with results reported as β‐coefficients and 95% confidence intervals (CIs), adjusted for age, sex, SDMT type (written vs oral), time‐varying, disease‐modifying therapy exposure and sequence of SDMT.

Results

Over a mean (SD) follow‐up of 10.7 (4.3) years, 31,529 distinct SDMTs were recorded among 3,877 persons with MS. There was a significant decline in information processing efficiency that lasted from 30 days pre‐relapse up to 550 days post‐relapse, with the largest decline occurring 0 to 30 days post‐relapse (β‐coefficient: −4.00 (95% CI = −4.61 to −3.39), relative to the period of remission.

Interpretation

We found evidence of cognitive change up to 1 month prior to relapse onset. The reduction in SDMT lasted 1.5 years and was clinically significant up to 3 months post‐relapse. These results suggest that the effects of a relapse on cognition are longer than previously thought and highlight the importance of reducing relapse rates as a potential means of preserving cognitive function. ANN NEUROL 2022;91:417–423

Smartphone-derived keystroke dynamics are sensitive to relevant changes in multiple sclerosis

Background

To investigate smartphone keystroke dynamics (KD), derived from regular typing, on sensitivity to relevant change in disease activity, fatigue, and clinical disability in multiple sclerosis (MS).

Methods

Preplanned interim analysis of a cohort study with 102 MS patients assessed at baseline and 3‐month follow‐up for gadolinium‐enhancing lesions on magnetic resonance imaging, relapses, fatigue and clinical disability outcomes. Keyboard interactions were unobtrusively collected during typing using the Neurokeys App. From these interactions 15 keystroke features were derived and aggregated using 16 summary and time series statistics. Responsiveness of KD to clinical anchor‐based change was assessed by calculating the area under the receiver operating characteristic curve (AUC). The optimal cut‐point was used to determine the minimal clinically important difference (MCID) and compared to the smallest real change (SRC). Commonly used clinical measures were analyzed for comparison.

Results

A total of 94 patients completed the follow‐up. The five best performing keystroke features had AUC‐values in the range 0.72–0.78 for change in gadolinium‐enhancing lesions, 0.67–0.70 for the Checklist Individual Strength Fatigue subscale, 0.66–0.79 for the Expanded Disability Status Scale, 0.69–0.73 for the Ambulation Functional System, and 0.72–0.75 for Arm function in MS Questionnaire. The MCID of these features exceeded the SRC on group level. KD had higher AUC‐values than comparative clinical measures for the study outcomes, aside from ambulatory function.

Conclusions

Keystroke dynamics demonstrated good responsiveness to changes in disease activity, fatigue, and clinical disability in MS, and detected important change beyond measurement error on group level. Responsiveness of KD was better than commonly used clinical measures.

Fear of relapse in patients suffering from RRMS influence their quality of life

Multiple Sclerosis (MS) is a chronic, potentially debilitating disease that affects millions of patients worldwide. About 85% of patients experience a disease subtype characterised by relapses and remittance (RRMS). While many studies have investigated factors influencing patients'' health-related quality of life (HRQoL) in RRMS, none have taken patients' fear of relapses into account. In this study, we measured the patients' self-reported HRQoL, fear of relapse (FoR), health anxiety (HA), number of relapses, duration of disease, type of medication and perceived level of side effects. Treating neurologists provided an estimate of patients' disease severity. All covariates and demographic (personal and disease-related) characteristics were included in regression modelling of their association with HRQoL. The model showed that HRQoL was most strongly associated with disease severity estimated by neurologists, which was highly correlated with the number of relapses and disease duration. However, upon adjustment for FoR (in the presence of all covariates), this association between disease severity and HRQoL attenuated, and FoR remained the only covariate significantly associated with HRQoL. Notably, our modelling also revealed a significant association between HA and FoR in RRMS patients. This study's findings have important implications for the management of MS in RRMS patients and point to the critical roles of FoR and HA as drivers of HRQoL in RRMS. Given the importance of HRQoL to the patient experience and economically, we argue that a more nuanced understanding is needed of the subjective nature of quality of life and its determinants. Interventions aimed at reducing psychological distress and anxiety should be explored.

Analysis of frequency and severity of relapses in multiple sclerosis patients treated with cladribine tablets or placebo: The CLARITY and CLARITY Extension studies

Background:

In the CLARITY (CLAdRIbine Tablets treating multiple sclerosis orallY) study of patients with relapsing-remitting multiple sclerosis, treatment with cladribine tablets 3.5 mg/kg (CladT) significantly reduced the annualised relapse rate (ARR) versus placebo; this effect was sustained in CLARITY Extension, without further treatment.

Objective:

To assess the frequency and severity of relapses in patients treated with CladT versus placebo in CLARITY over 2 years and evaluate the durability of effect in patients who received no further treatment for 2 years in CLARITY Extension.

Methods:

In this post hoc analysis, ARRs were calculated for qualifying and all relapses, and qualifying and all severe relapses (i.e. requiring steroid treatment or leading to hospitalisation) in patients treated with CladT (n = 433) and placebo (n = 437) in CLARITY, and those from the CladT group who received placebo in CLARITY Extension (n = 98).

Results:

At Month 6, Year 1 and Year 2, patients receiving CladT had a significantly lower risk of qualifying or all relapses (all p < 0.0001), and qualifying or all severe relapses (all p < 0.005), compared with placebo. This effect was sustained in CLARITY Extension without further treatment.

Conclusion:

The results show durable efficacy of cladribine tablets 3.5 mg/kg for reducing frequency and severity of relapses in patients with relapsing-remitting multiple sclerosis.

CLARITY: NCT00213135; CLARITY Extension: NCT00641537

Safety and efficacy of amantadine, modafinil, and methylphenidate for fatigue in multiple sclerosis: a randomised, placebo-controlled, crossover, double-blind trial

BACKGROUND

Methylphenidate, modafinil, and amantadine are commonly prescribed medications for alleviating fatigue in multiple sclerosis; however, the evidence supporting their efficacy is sparse and conflicting. Our goal was to compare the efficacy of these three medications with each other and placebo in patients with multiple sclerosis fatigue.

METHODS

In this randomised, placebo-controlled, four-sequence, four-period, crossover, double-blind trial, patients with multiple sclerosis who reported fatigue and had a Modified Fatigue Impact Scale (MFIS) score of more than 33 were recruited at two academic multiple sclerosis centres in the USA. Participants received oral amantadine (up to 100 mg twice daily), modafinil (up to 100 mg twice daily), methylphenidate (up to 10 mg twice daily), or placebo, each given for up to 6 weeks. All patients were intended to receive all four study medications, in turn, in one of four different sequences with 2-week washout periods between medications. A biostatistician prepared a concealed allocation schedule, stratified by site, randomly assigning a sequence of medications in approximately a 1:1:1:1 ratio, in blocks of eight, to a consecutive series of numbers. The statistician and pharmacists had no role in assessing the participants or collecting data, and the participants, caregivers, and assessors were masked to allocation. The primary outcome measure was the MFIS measured while taking the highest tolerated dose at week 5 of each medication period, analysed by use of a linear mixed-effect regression model. This trial is registered with ClinicalTrials.gov, NCT03185065 and is closed.

FINDINGS

Between Oct 4, 2017, and Feb 27, 2019, of 169 patients screened, 141 patients were enrolled and randomly assigned to one of four medication administration sequences: 35 (25%) patients to the amantadine, placebo, modafinil, and methylphenidate sequence; 34 (24%) patients to the placebo, methylphenidate, amantadine, and modafinil sequence; 35 (25%) patients to the modafinil, amantadine, methylphenidate, and placebo sequence; and 37 (26%) patients to the methylphenidate, modafinil, placebo, and amantadine sequence. Data from 136 participants were available for the intention-to-treat analysis of the primary outcome. The estimated mean values of MFIS total scores at baseline and the maximal tolerated dose were as follows: 51·3 (95% CI 49·0-53·6) at baseline, 40·6 (38·2-43·1) with placebo, 41·3 (38·8-43·7) with amantadine, 39·0 (36·6-41·4) with modafinil, and 38·6 (36·2-41·0) with methylphenidate (p=0·20 for the overall medication effect in the linear mixed-effect regression model). As compared with placebo (38 [31%] of 124 patients), higher proportions of participants reported adverse events while taking amantadine (49 [39%] of 127 patients), modafinil (50 [40%] of 125 patients), and methylphenidate (51 [40%] of 129 patients). Three serious adverse events occurred during the study (pulmonary embolism and myocarditis while taking amantadine, and a multiple sclerosis exacerbation requiring hospital admission while taking modafinil).

INTERPRETATION

Amantadine, modafinil, and methylphenidate were not superior to placebo in improving multiple sclerosis fatigue and caused more frequent adverse events. The results of this study do not support an indiscriminate use of amantadine, modafinil, or methylphenidate for the treatment of fatigue in multiple sclerosis.

FUNDING

Patient-Centered Outcomes Research Institute.

Matching-adjusted comparisons demonstrate better clinical outcomes in patients with relapsing multiple sclerosis treated with peginterferon beta-1a than with teriflunomide

BACKGROUND

Peginterferon beta-1a and teriflunomide are both first-line disease-modifying therapies (DMTs) approved for the treatment of relapsing multiple sclerosis (RMS); however, no head-to-head trials have directly compared their clinical efficacy. We performed a matching-adjusted comparison of individual patient data from the peginterferon beta-1a pivotal phase 3 study, ADVANCE, and its extension study, ATTAIN, with pooled aggregated data from the teriflunomide pivotal phase 3 studies, TEMSO and TOWER.

METHODS

A total of 512 patients randomized to subcutaneous (SC) peginterferon beta-1a 125 mcg every 2 weeks in ADVANCE and 731 patients randomized to teriflunomide 14 mg daily (359 from TEMSO and 372 from TOWER) were matched on key baseline characteristics. After matching, weighted annualized relapse rate (ARR) and 24-week confirmed disability worsening (CDW) were calculated and compared for peginterferon beta-1a- and teriflunomide-treated patients. A subset analysis comparing weighted ARR in patients who were newly diagnosed with RMS (diagnosis ≤1 year before study enrollment and disease-modifying therapy naïve) was also performed.

RESULTS

After matching, the peginterferon beta-1a and teriflunomide treatment groups were identically matched across baseline characteristics. The proportion of patients in the overall study populations with 24-week CDW at 108 weeks was significantly lower in the peginterferon beta-1a group than the teriflunomide group both before matching (8.5% vs 12.6%; P = 0.0249) and after matching (8.4% vs 12.6%; P = 0.0323). ARR at 108 weeks was numerically lower with peginterferon beta-1a than with teriflunomide both before matching (0.278 vs 0.354; P = 0.1326) and after matching (0.257 vs 0.354; P = 0.0510). Newly diagnosed patients treated with peginterferon beta-1a had numerically lower ARR than patients treated with teriflunomide both at 108 weeks (before matching: 0.225 vs 0.270; P = 0.587; after matching: 0.201 vs 0.270; P = 0.384) and at 5 years (before matching: 0.150 vs 0.196; after matching: 0.142 vs 0.196).

CONCLUSIONS

In this matching-adjusted comparison of patients with RMS from three phase 3 trials, a significantly lower proportion of patients treated with SC peginterferon beta-1a 125 mcg every 2 weeks than with oral teriflunomide 14 mg once daily had 24-week CDW at 108 weeks. In addition, in both the overall population and newly diagnosed patient subgroups, ARR at 108 weeks was numerically lower with peginterferon beta-1a than with teriflunomide. The numerically lower ARR in newly diagnosed patients treated with peginterferon beta-1a compared with those treated with teriflunomide was sustained through up to 5 years of treatment.

Fatigue in Multiple Sclerosis is related to relapses, autonomic dysfunctions and introversion: A quasi-experimental study

BACKGROUND

Fatigue in Multiple Sclerosis (MS) might be partially due to inflammatory processes. If so, relapses should increase the fatigue level.

METHODS

Two groups of MS patients participated in this study. One suffered from a relapse and was treated by Methylprednisolone. The other group experienced a deterioration of their neurological condition but no relapse and received neurological rehabilitation. We assessed fatigue before admission, at admission and after discharge (t1, t2, t3). Furthermore, autonomic dysfunctions, depressive mood, apathy and extraversion were assessed at admission. Changes in fatigue were analysed with ANCOVAs and fatigue levels were analysed with regression analyses using clinical data and scores for depressive mood, apathy, extraversion and autonomic dysfunctions.

RESULTS

Only patients suffering from a relapse showed a significant increment in fatigue from t1 to t2. Regression analyses revealed that autonomic dysfunctions and introversion best explained the fatigue level.

CONCLUSIONS

This study shows that a relapse is accompanied by an increase in MS-related fatigue. Moreover, autonomic dysfunctions and introversion, more than depression and apathy, play a major role in the explanation of MS-related fatigue. This finding represents additional evidence for the relationship between inflammation, vagal afferent signaling, autonomic dysfunctions, introversion and the feeling of MS-related fatigue.

Evaluation of MS related central fatigue using MR neuroimaging methods: Scoping review

BACKGROUND

Fatigue is a common and debilitating symptom in multiple sclerosis (MS). Over the past decade, a growing body of research has focussed on the pathophysiological mechanisms underlying central (cognitive and physical) fatigue in MS. The precise mechanisms causing fatigue in MS patients are complex and poorly understood, and may differ between patients. Advanced quantitative magnetic resonance imaging (MRI) techniques allow for objective assessment of disease pathology and have been used to characterise the pathophysiology of central fatigue in MS.

OBJECTIVE

To systematically review the existing literature of MRI-based studies assessing the pathophysiological mechanisms of MS-related central fatigue.

METHODS

A systematic literature search of four major databases (PubMed, Medline, Embase, Scopus and Google Scholar) was conducted to identify MRI-based studies of MS-related fatigue published in the past 20 years. Studies using the following MRI-based methods were included: structural (lesion load/atrophy), T1 relaxation time/magnetisation transfer ratio (MTR), diffusion tensor imaging (DTI), functional MRI (fMRI) and magnetic resonance spectroscopy (MRS).

RESULTS

A total of 92 studies were identified as meeting the search criteria and included for review. Structurally, regional gray/white matter atrophy, cortical thinning, decreased T1 relaxation times and reduced fractional anisotropy were associated with central fatigue in MS. Functionally, hyperactivity and reduced functional connectivity in several regional areas of frontal, parietal, occipital, temporal and cerebellum were suggested as causes of central fatigue. Biochemically, a reduction in N-acetyl aspartate/creatine and increased (glutamine+glutamate)/creatine ratios were correlated with fatigue severity in MS.

CONCLUSION

Several advanced quantitative MRI methods have been employed in the study of central fatigue in MS. Central fatigue in MS is associated with macro/microstructural and functional changes within specific brain regions (frontal, parietal, temporal and deep gray matter) and specific pathways/networks (cortico-cortical and cortico-subcortical). Alternations in the cortico-striatal-thalamocortical (CSTC) loop are correlated with the development of fatigue in MS patients.

Benefit evaluation in multiple sclerosis relapse treatment from the patients' perspective - Development and validation of a new questionnaire

BACKGROUND

Little is known on how to measure patient-relevant benefit of relapse treatment in relapsing-remitting multiple sclerosis (MS). The objective of this study was to develop and validate a new method for monitoring recovery from MS relapses and patient-relevant treatment benefits.

METHODS

A 27-item questionnaire was developed using a multi-step approach comprising open item collection, multidisciplinary expert panel and cognitive debriefing. It was evaluated regarding psychometric properties and feasibility in a longitudinal validation study with 100 patients with MS undergoing relapse treatment. Construct validity was tested by correlations with patient and physician global impressions of change as well as disease-specific and generic health-related quality of life (HRQoL) measures.

RESULTS

Results of the feasibility survey indicated high patient acceptance. Reliability was high (Cronbach's α = 0.90). While the Expanded Disability Status Scale (EDSS) was not sensitive to change, Patient Benefit Index for Multiple Sclerosis (PBI-MS) showed a high correlation cross-sectionally with patient global impression of change (PaGIC) (r = 0.60, p < 0.001). Significant moderate to high correlations were found with change in generic HRQoL (r = 0.55-0.61, p < 0.001) and lower correlations with change in disease-specific HRQoL (r = -0.36, p < 0.01).

CONCLUSION

The PBI-MS is a reliable and valid instrument for ascertaining patient-relevant benefits of acute relapse treatment; it appears suited for use in routine care and in clinical or health care studies.

Multiple sclerosis relapse: Qualitative findings from clinician and patient interviews

BACKGROUND

In patients with relapsing forms of multiple sclerosis (MS), relapses are often unrecognized. These missed relapses have broad implications for the conduct of clinical trials as well as for the care and prognosis of people with multiple sclerosis (MS). With the ultimate goal of developing new methods to identify relapse, the purpose of this qualitative research with patients and clinicians was to examine the definition, symptoms, and impact of relapse.

METHODS

This qualitative study involved semi-structured interviews with clinicians specializing in MS and people with relapsing-remitting (RR) MS. A brief literature review was conducted to inform the development of interview guides. Qualitative data were gathered from 10 clinicians in a series of individual interviews and one focus group, followed by a series of interviews with 20 patients. Thematic analysis was conducted using ATLAS.ti to identify concepts emerging from the interviews.

RESULTS

Both clinicians and people with MS tend to describe classic neurologic symptoms that are confirmable on exam as indicative of relapses (e.g., sensory changes, vision issues, and walking difficulties), while also acknowledging that several less quantifiable symptoms are common (e.g., fatigue, pain, and cognitive issues). Patients described far-reaching impacts of relapse beyond just the quantifiable manifestations of the disease evaluated by commonly-used measures of MS severity and disability.

CONCLUSION

MS relapses, which have substantial impact on patient functioning, appear to include symptoms beyond those in typical definitions of relapse. Incorporating such constructs into new measures of relapse could lead to improved recognition of relapse episodes.

‘Normal’ and ‘failing’ mothers: Women’s constructions of maternal subjectivity while living with multiple sclerosis

Multiple sclerosis causes physical and cognitive impairment that can impact women’s experiences of motherhood. This study examined how women construct their maternal subjectivities, or sense of self as a mother, drawing on a framework of biographical disruption. A total of 20 mothers with a multiple sclerosis diagnosis took part in semi-structured interviews. Transcripts were analysed using thematic decomposition to identify subject positions that women adopted in relation to cultural discourses of gender, motherhood and illness. Three main subject positions were identified: ‘The Failing Mother’, ‘Fear of Judgement and Burdening Others’ and ‘The Normal Mother’. Women’s sense of self as the ‘Failing Mother’ was attributed to the impact of multiple sclerosis, contributing to biographical disruption and reinforced through ‘Fear of Judgement and Burdening Others’ within social interactions. In accounts of the ‘Normal Mother’, maternal subjectivity was renegotiated by adopting strategies to manage the limitations of multiple sclerosis on mothering practice. This allowed women to self-position as ‘good’ mothers. Health professionals can assist women by acknowledging the embodied impact of multiple sclerosis on maternal subjectivities, coping strategies that women employ to address potential biographical disruption, and the cultural context of mothering, which contributes to women’s experience of subjectivity and well-being when living with multiple sclerosis.

Teriflunomide for multiple sclerosis in real-world setting

OBJECTIVES

Teriflunomide 14 mg is a once-daily oral disease-modifying treatment for relapsing-remitting multiple sclerosis. We examined adverse event (AE) profile and efficacy in real life.

MATERIALS AND METHODS

In this observational cohort study, we retrospectively examined 1521 blood samples and data of 102 patients followed for up to 28 months.

RESULTS

The number of female patients starting teriflunomide peaked in the fifth decade, 10 years later compared to male patients (P<.001), reflecting pregnancy concerns. Seventy-six percentages of patients shifted to teriflunomide from treatment with interferon-beta. Expanded disability status scale improved in 11% of patients (18.2±3.6 months follow-up) and remained constant in 67.5% (15±5.3 months follow-up). Of ten relapses, three occurred within 6 months after starting treatment. Seventeen patients (16.5%) discontinued teriflunomide: 53% because of AEs and 29% because of relapse. Levels of alanine aminotransferase (ALT) remained normal in 95.3% of the blood samples and remained below 1.5 times the upper limit of normal in 91% of the 4.7% abnormal samples. One-third of the patients had abnormal ALT values at least once. Haematological abnormalities were found in <4% of the blood samples, but at least one abnormal value was observed in up to 21% of the patients.

CONCLUSIONS

Efficacy and safety of teriflunomide in real-life setting support data obtained by the pivotal trials. Laboratory abnormalities are rare among the large number of samples, but patients may commonly have a single mild, abnormal value if frequently tested.

Positive impact of cladribine on quality of life in people with relapsing multiple sclerosis

Background:

A number of elements of the pivotal ‘cladribine tablets treating multiple sclerosis orally’ (CLARITY) trial have remained unpublished.

Objective:

To report the impact of cladribine on health-related quality of life (QoL) in people with relapsing multiple sclerosis (pwRMS).

Methods:

QoL data from the phase III trial of two different doses (3.5 and 5.25 mg/kg) of oral cladribine in pwRMS were acquired from the European Medicines Agency through Freedom of Information. Spearman’s rank correlation was used to analyse the relationship between baseline QoL scores and baseline Expanded Disability Status Scale (EDSS) scores. Responses of the Euro Quality of Life 5 Dimensions (EQ-5D) and Multiple Sclerosis Quality of Life-54 (MSQOL-54) questionnaires were compared between treatment and control groups using univariate analyses of covariance.

Results:

In total, n = 5148 EQ-5D responses and n = 894 MSQOL-54 physical, mental health and dimension scores were extracted. Baseline EQ-5D indices correlated with EDSS scores. After 2 years, pwRMS taking 3.5 (p = .001) and 5.25 mg/kg (p = .022) reported significantly improved EQ-5D index scores compared with placebo. Positive, yet non-significant, differences were detected in MSQOL-54 scores between cladribine and placebo.

Conclusion:

Analysis of the CLARITY dataset suggests that, over and above its established clinical efficacy, cladribine leads to improved QoL over 96 weeks. ClinicalTrials.gov identifier: NCT00213135.

The impact of disease characteristics on multiple sclerosis patients' quality of life

OBJECTIVES

The aim of this study was to assess the quality of life (QoL) of patients with multiple sclerosis (MS), and to investigate the effects of characteristics of MS such as disease course, severity, and relapses on patients' QoL.

METHODS

This was a cross-sectional study, in which 171 patients were enrolled. Health-related QoL was assessed using the Persian version of the Multiple Sclerosis Quality of Life-54 questionnaire. To measure patients' disability status, we used the Expanded Disability Status Scale. Other variables included in the study were disease course and relapses of the disease.

RESULTS

The average scores for patients' physical and mental QoL were 60.9±22.3 and 59.5±21.4, respectively. In a bivariate analysis, disease course, severity of the disease, and relapses were significantly associated with the physical and mental health composite scores. In a hierarchal regression analysis, disease course, severity of the disease, and relapses were responsible for 38 and 16% of the variance in physical and mental QoL, respectively. It was also observed that relapses were a strong predictor of both physical and mental QoL.

CONCLUSIONS

Our results showed that disease characteristics significantly affected both dimensions of QoL. It is therefore suggested that health care providers should be aware of these characteristics of MS to more successfully improve MS patients' QoL.