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Koch MW, Mostert J, Repovic P, Bowen JD, Wolinsky JS, Lublin FD, Strijbis E, Cutter G. Early first-line treatment response and subsequent disability worsening in relapsing-remitting multiple sclerosis. Eur J Neurol 2021; 29:1106-1116. [PMID: 34927308 DOI: 10.1111/ene.15220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Treatment success in relapsing-remitting multiple sclerosis (RRMS) is generally determined using relapse frequency and magnetic resonance imaging (MRI) activity in the first 6 or 12 months on treatment. The association of these definitions of short-term treatment success with disability worsening and disease activity in the longer term is unclear. In this study, we investigated risk factors associated with early first-line treatment failure in RRMS, and the association of early treatment failure with subsequent disability worsening or "no evidence of disease activity" (NEDA-3) status. METHODS We used data from CombiRx (clinicaltrials.gov identifier NCT00211887) to investigate risk factors associated with early treatment failure, and the association of early treatment failure at 6 and 12 months with subsequent disability worsening or NEDA-3 at 36 months. RESULTS CombiRx included 1008 treatment-naïve participants with RRMS, who were randomly assigned to treatment with glatiramer acetate, interferon beta, or the combination of both. Early treatment failure at 6 or 12 months by several definitions was associated with NEDA-3 failure at 36 months, but not with subsequent disability worsening at 36 months. Expanded Disability Status Scale (EDSS) was the only baseline characteristic associated with the risk of disability worsening at 36 months. Approximately 70% of NEDA-3 failures occurred due to MRI activity, and <10% occurred due to EDSS worsening. CONCLUSIONS Our investigation shows that current definitions of early treatment failure in RRMS are unrelated to patient-relevant disability worsening at 36 months of follow-up. Further research into useful definitions of treatment success and failure in RRMS is needed.
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Affiliation(s)
- Marcus W Koch
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jop Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Pavle Repovic
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - James D Bowen
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Jerry S Wolinsky
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Fred D Lublin
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eva Strijbis
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Hidalgo de la Cruz M, Valsasina P, Sangalli F, Esposito F, Rocca MA, Filippi M. Dynamic Functional Connectivity in the Main Clinical Phenotypes of Multiple Sclerosis. Brain Connect 2021; 11:678-690. [PMID: 33813839 DOI: 10.1089/brain.2020.0920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Dynamic functional connectivity (dFC) allows capturing recurring patterns (states) of interaction among functional networks. In this study, we investigated resting state (RS) dFC abnormalities across the different clinical phenotypes of multiple sclerosis (MS) and assessed their correlation with motor and cognitive performances. Methods: RS functional magnetic resonance imaging (fMRI) and 3D T1-weighted MRI data were acquired from 128 MS patients (69 relapsing-remitting [RR] MS, 34 secondary progressive [SP] MS, and 25 primary progressive [PP] MS) and 40 healthy controls (HC). RS fMRI data underwent independent component analysis and sliding-window correlations, to identify recurring dFC states and between-group dFC differences in the main networks. Results: dFC identified three recurring connectivity states: State 1 (frequency of appearance during fMRI acquisition = 57%, low dFC strength), State 2 (frequency = 19%, middle-high dFC strength), and State 3 (frequency = 24%, high sensorimotor and visual dFC strength). Compared to HC, MS (as a whole), RRMS, and PPMS patients exhibited lower State1/State 3 dFC (p = 0.0001, corrected) between sensorimotor, cerebellar, and cognitive networks, and some dFC increments (p = 0.001-0.05, uncorrected) in sensorimotor, visual, default-mode, and frontal/attention networks in States 2 and 3. Similar results were observed in SPMS versus RRMS patients. In MS, dFC decrease in sensorimotor, default-mode, and frontal/attention networks was correlated with worse motor and cognitive performances. Conclusions: MS patients exhibited overall lower dFC, and marginally higher dFC in sensorimotor/cognitive networks in the less-frequent middle/high-connected States. dFC abnormalities became more severe in progressive MS and correlated with motor and cognitive impairment, suggesting the presence of maladaptive mechanisms concomitant with accumulation of damage.
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Affiliation(s)
| | - Paola Valsasina
- Neuroimaging Research Unit, Division of Neuroscience, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | | | - Federica Esposito
- Neurology Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCSS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCSS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy.,Neurophysiology Service and IRCSS San Raffaele Scientific Institute, Milan, Italy.,Neurorehabilitation Unit, IRCSS San Raffaele Scientific Institute, Milan, Italy
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3
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Baharlooi H, Nouraei Z, Azimi M, Moghadasi AN, Tavassolifar MJ, Moradi B, Sahraian MA, Izad M. Umbilical cord mesenchymal stem cells as well as their released exosomes suppress proliferation of activated PBMCs in multiple sclerosis. Scand J Immunol 2020; 93:e13013. [PMID: 33338274 DOI: 10.1111/sji.13013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 11/28/2020] [Accepted: 12/12/2020] [Indexed: 12/16/2022]
Abstract
Multiple sclerosis (MS) is a central nervous system (CNS) degenerative disorder which is caused by a targeted autoimmune-mediated attack on myelin proteins. Previously, mesenchymal stem cells were considered as a novel and successful treatment of MS. One of the underlying mechanisms behind their immunomodulatory function is the release of extracellular vesicles, particularly exosomes. In this study, we aimed to evaluate the suppressive efficacy of MSCs and their exosomes on the proliferation of peripheral mononuclear blood cells (PBMC) in relapsing-remitting MS (RRMS) patients and healthy subjects. To do, mesenchymal stem cells were derived from human umbilical cord tissues and used for exosome isolation through ultracentrifugation. Suppressive function of MSCs and MSC-derived exosomes was examined in a coculture with CFSE-labelled PBMCs in vitro. PBMC proliferation of the patients and healthy individuals was measured using flow cytometry. We first demonstrated that proliferation of PBMCs decreased in the presence of MSCs and suppression was more efficient by MSC-derived exosomes, with a minimum alloreaction rate. However, suppression capacity of MSCs and their exosomes significantly decreased during extensive sub-culturing. The present study showed that MSC-derived exosomes as an effective cell-free therapy could prevent proliferation of PBMCs. However, further evaluations are need to move towards a functional approach that can be translated to the clinic.
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Affiliation(s)
- Hussein Baharlooi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Zeynab Nouraei
- Department of Obstetrics and Gynecology, School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Maryam Azimi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran.,Immunology Research Center, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Abdorreza Naser Moghadasi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | | | - Batool Moradi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Mohammad Ali Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Maryam Izad
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran.,Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences (TUMS), Tehran, Iran
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Patti F, Visconti A, Capacchione A, Roy S, Trojano M. Long-term effectiveness in patients previously treated with cladribine tablets: a real-world analysis of the Italian multiple sclerosis registry (CLARINET-MS). Ther Adv Neurol Disord 2020; 13:1756286420922685. [PMID: 32587633 PMCID: PMC7294475 DOI: 10.1177/1756286420922685] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background The CLARINET-MS study assessed the long-term effectiveness of cladribine tablets by following patients with multiple sclerosis (MS) in Italy, using data from the Italian MS Registry. Methods Real-world data (RWD) from Italian MS patients who participated in cladribine tablets randomised clinical trials (RCTs; CLARITY, CLARITY Extension, ONWARD or ORACLE-MS) across 17 MS centres were obtained from the Italian MS Registry. RWD were collected during a set observation period, spanning from the last dose of cladribine tablets during the RCT (defined as baseline) to the last visit date in the registry, treatment switch to other disease-modifying drugs, date of last Expanded Disability Status Scale recording or date of the last relapse (whichever occurred last). Time-to-event analysis was completed using the Kaplan-Meier (KM) method. Median duration and associated 95% confidence intervals (CI) were estimated from the model. Results Time span under observation in the Italian MS Registry was 1-137 (median 80.3) months. In the total Italian patient population (n = 80), the KM estimates for the probability of being relapse-free at 12, 36 and 60 months after the last dose of cladribine tablets were 84.8%, 66.2% and 57.2%, respectively. The corresponding probability of being progression-free at 60 months after the last dose was 63.7%. The KM estimate for the probability of not initiating another disease-modifying treatment at 60 months after the last dose of cladribine tablets was 28.1%, and the median time-to-treatment change was 32.1 (95% CI 15.5-39.5) months. Conclusion CLARINET-MS provides an indirect measure of the long-term effectiveness of cladribine tablets. Over half of MS patients analysed did not relapse or experience disability progression during 60 months of follow-up from the last dose, suggesting that cladribine tablets remain effective in years 3 and 4 after short courses at the beginning of years 1 and 2.
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Affiliation(s)
- Francesco Patti
- Azienda Ospedaliera-Universitaria, "Policlinico Vittorio Emanuele", Catania via Santa Sofia 78, Catania, 95123, Italy
| | - Andrea Visconti
- Merck Serono S.p.A., Rome, Italy, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Antonio Capacchione
- Merck Serono S.p.A., Rome, Italy, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Sanjeev Roy
- Merck, Aubonne, Switzerland, a division of Merck KGaA, Darmstadt, Germany
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Italy
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Mirmosayyeb O, Brand S, Barzegar M, Afshari-Safavi A, Nehzat N, Shaygannejad V, Sadeghi Bahmani D. Clinical Characteristics and Disability Progression of Early- and Late-Onset Multiple Sclerosis Compared to Adult-Onset Multiple Sclerosis. J Clin Med 2020; 9:jcm9051326. [PMID: 32370288 PMCID: PMC7290335 DOI: 10.3390/jcm9051326] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Compared to the adult onset of multiple sclerosis (AOMS), both early-onset (EOMS) and late-onset (LOMS) are much less frequent, but are often under- or misdiagnosed. The aims of the present study were: 1. To compare demographic and clinical features of individuals with EOMS, AOMS and LOMS, and 2. To identify predictors for disability progression from relapsing remitting MS (RRMS) to secondary progressive MS (SPMS). Method: Data were taken from the Isfahan Hakim MS database. Cases were classified as EOMS (MS onset ≤18 years), LOMS (MS onset >50 years) and AOMS (MS >18 and ≤50 years). Patients’ demographic and clinical (initial symptoms; course of disease; disease patterns from MRI; disease progress) information were gathered and assessed. Kaplan–Meier and Cox proportional hazard regressions were conducted to determine differences between the three groups in the time lapse in conversion from relapsing remitting MS to secondary progressive MS. Results: A total of 2627 MS cases were assessed; of these 127 were EOMS, 84 LOMS and 2416 AOMS. The mean age of those with EOMS was 14.5 years; key symptoms were visual impairments, brain stem dysfunction, sensory disturbances and motor dysfunctions. On average, 24.6 years after disease onset, 14.2% with relapsing remitting MS (RRMS) were diagnosed with secondary progressive MS (SPMS). The key predictor variable was a higher Expanded Disability Status Scale (EDSS) score at disease onset. Compared to individuals with AOMS and LOMS, those with EOMS more often had one or two relapses in the first two years, and more often gadolinium-enhancing brain lesions. For individuals with AOMS, mean age was 29.4 years; key symptoms were sensory disturbances, motor dysfunctions and visual impairments. On average, 20.5 years after disease onset, 15.6% with RRMS progressed to SPMS. The key predictors at disease onset were: a higher EDSS score, younger age, a shorter inter-attack interval and spinal lesions. Compared to individuals with EOMS and LOMS, individuals with AOMS more often had either no or three and more relapses in the first two years. For individuals with LOMS, mean age was 53.8 years; key symptoms were motor dysfunctions, sensory disturbances and visual impairments. On average, 14 years after disease onset, 25.3% with RRMS switched to an SPMS. The key predictors at disease onset were: occurrence of spinal lesions and spinal gadolinium-enhancement. Compared to individuals with EOMS and AOMS, individuals with LOMS more often had no relapses in the first two years, and higher EDSS scores at disease onset and at follow-up. Conclusion: Among a large sample of MS sufferers, cases with early onset and late onset are observable. Individuals with early, adult and late onset MS each display distinct features which should be taken in consideration in their treatment.
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Affiliation(s)
- Omid Mirmosayyeb
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran; (O.M.); (M.B.); (N.N.)
- Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran 14197-33151, Iran
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran
| | - Serge Brand
- Center of Depression, Stress and Sleep Disorders, Psychiatric Clinics (UPK), University of Basel, 4002 Basel, Switzerland; (S.B.); (D.S.B.)
- Division of Sport Science and Psychosocial Health, Department of Sport, Exercise, and Health, University of Basel, 4032 Basel, Switzerland
- Substance Abuse Prevention Research Center, Health Institute, Kermanshah University of Medical Sciences (KUMS), Kermanshah 6719851351, Iran
- Sleep Disorders Research Center, Health Institute, Kermanshah University of Medical Sciences (KUMS), Kermanshah 6719851351, Iran
- School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran 1416753955, Iran
| | - Mahdi Barzegar
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran; (O.M.); (M.B.); (N.N.)
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran
| | - Alireza Afshari-Safavi
- Department of Biostatistics and Epidemiology, Faculty of Health, North Khorasan University of Medical Sciences, Bojnurd 74877-94149, Iran;
| | - Nasim Nehzat
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran; (O.M.); (M.B.); (N.N.)
- Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran 14197-33151, Iran
- Faculty of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 6135715794, Iran
| | - Vahid Shaygannejad
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran; (O.M.); (M.B.); (N.N.)
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran
- Correspondence:
| | - Dena Sadeghi Bahmani
- Center of Depression, Stress and Sleep Disorders, Psychiatric Clinics (UPK), University of Basel, 4002 Basel, Switzerland; (S.B.); (D.S.B.)
- Substance Abuse Prevention Research Center, Health Institute, Kermanshah University of Medical Sciences (KUMS), Kermanshah 6719851351, Iran
- Departments of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL 35209, USA
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Abstract
Selective depletion of CD20+ B cells by anti-CD20 monoclonal antibodies as monotherapy in multiple sclerosis (MS) profoundly suppresses acute inflammatory disease activity and signifies an important advance in the treatment of relapsing-remitting MS. Ocrelizumab, a humanized anti-CD20 monoclonal antibody, is also the first proven therapy to lessen disability progression in primary progressive MS-a breakthrough for patients with a disease that had no proven therapy. Ocrelizumab is generally well tolerated, with the most common adverse events experienced being infusion reactions and infections. In ocrelizumab trials in MS a numerical imbalance in the risk of malignancies was observed. In this article, we review advances in anti-CD20 B-cell-depleting biological therapies for MS, including ocrelizumab, rituximab, and ofatumumab.
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Affiliation(s)
- Jeffrey M Gelfand
- Multiple Sclerosis Center, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Bruce A C Cree
- Multiple Sclerosis Center, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Stephen L Hauser
- Multiple Sclerosis Center, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.
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Bryukhov VV, Krotenkova IA, Morozova SN, Krotenkova MV. [A current view on the MRI diagnosis of multiple sclerosis: an update of 2016 revised MRI criteria]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:66-73. [PMID: 28617364 DOI: 10.17116/jnevro20171172266-73] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Magnetic resonance imaging (MRI) is the primary method for confirming the clinical diagnosis of multiple sclerosis (MS). The article presents the current data on using MRI of the brain and spinal cord for diagnosis in suspected MS. Special attention is paid to the MRI criteria of McDonald and MAGNIMS for relapsing-remitting MS (RRMS) and primary-progressive MS (PPMS) in the latest revisions of 2010 and 2016. The information provided can help radiologists and neurologists to optimize the use of MRI in clinical practice for diagnosis of MS.
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Pakdaman H, Amini Harandi A, Gharagozli K, Abbasi M, Tabassi A, Ashrafi F, Ghaffarpor M, Sharifi S, Delavar Kasmae H, Assarzadegan F, Arabahmadi M, Behnam B. Health-related quality of life in patients with relapsing-remitting multiple sclerosis treated with subcutaneous interferon β-1a in Iran. Int J Neurosci 2016; 127:501-507. [PMID: 27279451 DOI: 10.1080/00207454.2016.1198793] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Multiple sclerosis (MS) requires long-term therapy and can affect many aspects of a patient's life, including quality of life. MS patients score lower on health-related quality of life (HRQoL) measures. The efficacy of subcutaneous interferon (IFN) β-1a has been extensively evaluated by using objective measures but its impact on HRQoL is currently unclear. In this observational study, we evaluated HRQoL of Iranian patients with relapsing-remitting MS (RRMS) treated with IFN β-1a by using short-form 36 (SF-36) and multiple sclerosis international quality of life (MusiQoL) questionnaires. METHODS Four hundred recruited RRMS patients were treated with human serum album free IFN β-1a for 1 year. Patients were required to fill in SF-36 and MusiQoL questionnaires at the first visit and at each follow-up visit. Expanded disability status scale (EDSS) evaluation was performed at baseline and at each visit. Comparisons in HRQoL between visits were calculated using Cohen's d effect size. The relationship between change in EDSS score and the score of each questionnaire was calculated using Pearson correlation coefficients. RESULTS Three-hundred and eighty three completed the study. Two-hundred and thirty nine were female. Mean (SD) age was 28.75 (±5.49). After 1 year, overall MusiQoL Index score effect size was -0.16 and SF-36 physical component and mental component showed overall effect sizes of -0.28 and -0.53, respectively. Mean (range) EDSS change was 1 (1-4). Three-hundred and seventy four were clinically stable with mean (range) EDSS change of 0.1 (-2-0.5). Increase in EDSS was linked to a decrease in both MusiQoL and SF-36. CONCLUSION We found that, HRQoL did not change significantly over the first year of therapy. Furthermore, decreases in HRQoL were inversely correlated with increases in EDSS score.
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Affiliation(s)
- Hossein Pakdaman
- a Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Ali Amini Harandi
- a Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Koroush Gharagozli
- a Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Mehdi Abbasi
- a Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Abdolreza Tabassi
- b Department of Neurology , Tehran University of Medical Sciences , Tehran , Iran
| | - Farzad Ashrafi
- a Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Majid Ghaffarpor
- b Department of Neurology , Tehran University of Medical Sciences , Tehran , Iran
| | - Shahdak Sharifi
- c Merck Serono Middle East FZ LLC , Dubai , United Arab Emirates
| | - Hosein Delavar Kasmae
- a Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Farhad Assarzadegan
- a Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Mehran Arabahmadi
- a Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Behdad Behnam
- a Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
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