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Kvistad CE, Lehmann AK, Kvistad SAS, Holmøy T, Lorentzen ÅR, Trovik LH, Kristoffersen EK, Bø L, Torkildsen Ø. Autologous hematopoietic stem cell transplantation for multiple sclerosis: Long-term follow-up data from Norway. Mult Scler 2024; 30:751-754. [PMID: 38345003 PMCID: PMC11071593 DOI: 10.1177/13524585241231665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/22/2023] [Accepted: 01/23/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Autologous hematopoietic stem cell transplantation (HSCT) is a potent treatment option for patients with aggressive relapsing-remitting multiple sclerosis (RRMS). OBJECTIVE To evaluate long-term outcomes of HSCT in MS. METHODS National retrospective single-center observational study of patients with aggressive RRMS that underwent HSCT in Norway from January 2015 to January 2018. Criteria for receiving HSCT included at least two clinical relapses the last year while on disease modifying treatment (DMT). RESULTS In total, 29 patients, with a mean follow-up time of 70 months (standard deviation:14.3), were evaluated. Twenty patients (69%) had sustained no evidence of disease activity (NEDA-3) status, 24 (83%) were relapse-free, 23 (79%) free of magnetic resonance imaging (MRI) activity, and 26 (90%) free of progression. Number of patients working full-time increased from 1 (3%), before HSCT, to 10 (33%) after 2 years and 15 (52%) after 5 years. CONCLUSION HSCT offers long-term disease-free survival with successively increasing work participation in patients with aggressive MS resistant to DMTs.
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Affiliation(s)
| | - Anne Kristine Lehmann
- Haematology Section, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Linn Hereide Trovik
- Haematology Section, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Einar Klæboe Kristoffersen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Bø
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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2
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Gottschlich KN, Zolic-Karlsson Z, Aas E, Kvistad SAS, Bø L, Torkildsen Ø, Lehmann AK. Healthcare utilization and costs associated with autologous haematopoietic stem cell transplantation in Norwegian patients with relapsing remitting multiple sclerosis. Mult Scler Relat Disord 2024; 84:105507. [PMID: 38412758 DOI: 10.1016/j.msard.2024.105507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/24/2024] [Accepted: 02/15/2024] [Indexed: 02/29/2024]
Abstract
Multiple sclerosis (MS) patients experience long-term deterioration of neurological function, reduced quality of life, long-lasting treatment cycles, and an increased risk of early workability loss imposing an economic burden to society. Autologous haematopoietic stem cell transplantation (AHSCT) has shown promising treatment effects for relapsing remitting MS (RRMS). This study employs a micro-costing approach to estimate healthcare utilization and costs associated with AHSCT in Norwegian RRMS patients. Patient-level data were extracted from medical journals of 30 RRMS patients receiving AHSCT treatment at Haukeland University Hospital in the period from January 2015 to January 2018. The time horizon for the analysis was from the pretransplant screening until one year after AHSCT. A correlation was found between patient body weight and total healthcare cost. The average total healthcare cost of AHSCT for RRMS patients was estimated to EUR 66 304 (95% CI: EUR 63 598 - EUR 69 010) including costs associated with the pre-AHSCT period, AHSCT treatment phases and one-year follow-up. The majority of the costs, EUR 64 329, occurred during the treatment phase and within the first 100 days after AHSCT. The results indicate that long-term healthcare cost savings may be achieved using AHSCT in selected patients with aggressive RRMS. This is due to the high costs of most used disease modifying treatments. Further research including long-term clinical data is needed to determine the cost-effectiveness of this treatment.
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Affiliation(s)
- Katharina Natalie Gottschlich
- Centre for Alcohol and Drug Research (KORFOR), Stavanger University Hospital, PO Box 8100, Stavanger 4068, Norway; Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, PO Box 1089, Blindern, Oslo 0317, Norway; Haukeland University Hospital, Bergen 5021, Norway
| | - Zinajda Zolic-Karlsson
- The Norwegian Medical Products Agency, PO Box 240, Skøyen, Oslo 0213, Norway; Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Eline Aas
- Department of Health Management and Health Economics, Institute for Health and Society, University of Oslo, PO Box 1089, Blindern, Oslo 0317, Norway; Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Lars Bø
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Anne Kristine Lehmann
- Department of Medicine, Section of Haematology, Haukeland University Hospital, Bergen, Norway
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3
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Habbestad A, Willumsen JS, Aarseth JH, Grytten N, Midgard R, Wergeland S, Myhr KM, Torkildsen Ø. Increasing age of multiple sclerosis onset from 1920 to 2022: a population-based study. J Neurol 2024; 271:1610-1617. [PMID: 38097800 PMCID: PMC10973050 DOI: 10.1007/s00415-023-12047-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To study the age at onset of relapsing-remitting multiple sclerosis (RRMS) during the past century. METHODS This is a population-based cohort study of persons diagnosed with RRMS in Hordaland, Møre, and Romsdal counties, Western Norway, from 1920 to 2022. Individual patient data were available and assessed from previously conducted prevalence and incidence studies in addition to hospital records up until October 31, 2022. Participants were categorized according to onset period and analyzed for temporal trends in age at onset, time from onset to diagnosis, and distribution of onset over time. RESULTS We identified 3364 persons with confirmed RRMS. The mean age at onset significantly increased (p < 0.001) throughout the study period, despite a decrease in time from symptom onset to diagnosis (p < 0.001). The proportion of persons with MS onset after 50 years of age increased from 2.6% before 1970 to 11.9% after 2010. We also found a trend toward a bimodal distribution of age at onset that peaked at around 30 years and 40-45 years of age in the latest period. CONCLUSION Age at onset of MS significantly increased throughout the study period. This was mainly due to an increasing number of persons with MS, predominantly female, experiencing onset after 40-45 years of age. This bimodal distribution could indicate different susceptibility periods of MS or changes in exposure to risk factors during the observation period.
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Affiliation(s)
- A Habbestad
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - J S Willumsen
- Department of Neurology, Molde Hospital, Molde, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - J H Aarseth
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
- Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - N Grytten
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - R Midgard
- Department of Neurology, Molde Hospital, Molde, Norway
| | - S Wergeland
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - K M Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ø Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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Torkildsen Ø, Myhr KM, Brugger-Synnes P, Bjørnevik K. Antiviral therapy with tenofovir in MS. Mult Scler Relat Disord 2024; 83:105436. [PMID: 38217968 DOI: 10.1016/j.msard.2024.105436] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/20/2023] [Accepted: 01/06/2024] [Indexed: 01/15/2024]
Abstract
Infection by the Epstein-Barr virus (EBV) is implicated as the leading cause of multiple sclerosis (MS). We have previously published a case description of a person with MS (pwMS) who was also HIV positive and treated with a combination of antiretrovirals (ART) containing tenofovir, a potent inhibitor of EBV replication. In the years following this publication, the patient had no new relapses, even though she did not use any MS disease-modifying therapy for nearly five years. After switching to another ART with no known efficacy against EBV, her MS-disease activity gradually re-emerged. This finding further emphasizes that targeting EBV lytic reactivation should be explored further in clinical trials as a potential treatment option for MS.
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Affiliation(s)
- Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen N-5021, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen N-5021, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Kjetil Bjørnevik
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Eid K, Bjørk MH, Gilhus NE, Torkildsen Ø. Adverse Childhood Experiences and the Risk of Multiple Sclerosis Development: A Review of Potential Mechanisms. Int J Mol Sci 2024; 25:1520. [PMID: 38338799 PMCID: PMC10855716 DOI: 10.3390/ijms25031520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/16/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Adverse childhood experiences (ACEs), such as abuse, neglect, and household dysfunction, contribute to long-term systemic toxic stress and inflammation that may last well into adulthood. Such early-life stressors have been associated with increased susceptibility to multiple sclerosis (MS) in observational studies and with the development of experimental autoimmune encephalomyelitis in animal models. In this review, we summarize the evidence for an ACE-mediated increase in MS risk, as well as the potential mechanisms for this association. ACEs dysregulate neurodevelopment, stress responses, and immune reactivity; they also alter the interplay between the immune system and neural networks. All of this may be relevant for MS risk. We further discuss how ACEs induce epigenetic changes and how the toxic stress caused by ACEs may reactivate the Epstein-Barr Virus (EBV), a key risk factor for MS. We conclude by suggesting new initiatives to obtain further insights into this topic.
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Affiliation(s)
- Karine Eid
- Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, 5053 Bergen, Norway; (M.-H.B.); (N.E.G.)
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway;
| | - Marte-Helene Bjørk
- Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, 5053 Bergen, Norway; (M.-H.B.); (N.E.G.)
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway;
- NorHead, Norwegian Center for Headache Research, 5021 Bergen, Norway
| | - Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, 5053 Bergen, Norway; (M.-H.B.); (N.E.G.)
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway;
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway;
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021 Bergen, Norway
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Ueland GÅ, Ueland HO, Stokland AEM, Bhan A, Schønberg A, Sollid ST, Morgas DE, Holmøy T, Lima K, Methlie P, Løvås K, Torkildsen Ø, Husebye ES. Prevalence, Risk Factors, and Clinical and Biochemical Characteristics of Alemtuzumab-Induced Graves Disease. J Clin Endocrinol Metab 2024; 109:344-350. [PMID: 37708353 PMCID: PMC10795930 DOI: 10.1210/clinem/dgad540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Atypical Graves disease (GD) is a common complication in multiple sclerosis (MS) patients treated with alemtuzumab. We present epidemiological, clinical, and biochemical characteristics of alemtuzumab-induced GD. METHODS Retrospective follow-up study of MS patients treated with alemtuzumab from 2014 to 2020, including clinical course of GD, pregnancy outcome, and thyroid eye disease (TED). RESULTS We enrolled 183 of 203 patients (90%, 68% women) treated with alemtuzumab at 4 hospitals in Norway. Seventy-five (41%) developed thyroid dysfunction, of whom 58 (77%) had GD. Median time from the first dose of alemtuzumab to GD diagnosis was 25 months (range, 0-64). Twenty-four of 58 GD patients (41%) had alternating phases of hyper- and hypothyroidism. Thyrotropin receptor antibodies became undetectable in 23 of 58 (40%) and they could discontinue antithyroid drug treatment after a median of 22 (range, 2-58) months. Conversely, 26 (44%) had active disease during a median follow-up of 39 months (range, 11-72). Two patients (3%) received definitive treatment with radioiodine, 6 (10%) with thyroidectomy. Nine developed TED (16%), 7 had mild and 2 moderate to severe disease. Four patients completed pregnancy, all without maternal or fetal complications. Patients who developed GD had a lower frequency of new MS relapses and MRI lesions than those without. CONCLUSION GD is a very common complication of alemtuzumab treatment and is characterized by alternating hyper- and hypothyroidism. Both remission rates and the prevalence of TED were lower than those reported for conventional GD. Pregnancies were uncomplicated and GD was associated with a lower risk of subsequent MS activity.
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Affiliation(s)
| | - Hans Olav Ueland
- Department of Ophthalmology, Haukeland University Hospital, 5021 Bergen, Norway
| | | | - Alok Bhan
- Department of Neurology, Stavanger University Hospital, 4019 Stavanger, Norway
| | - Anne Schønberg
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
| | - Stina T Sollid
- Department of Medicine, Drammen Hospital, Vestre Viken Health Trust, 3004 Drammen, Norway
| | - Dina Edvarda Morgas
- Department of Ophthalmology, Drammen Hospital, Vestre Viken Health Trust, 3004 Drammen, Norway
| | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, 1478 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway
| | - Kari Lima
- Department of Medicine, Akershus University Hospital, 1478 Oslo, Norway
| | - Paal Methlie
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
- Department of Clinical Medicine, University of Bergen, 5009 Bergen, Norway
| | - Kristian Løvås
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, 5009 Bergen, Norway
- Department of Neurology, Neuro-SysMed, Haukeland University Hospital, 5021 Bergen, Norway
| | - Eystein S Husebye
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
- Department of Clinical Medicine, University of Bergen, 5009 Bergen, Norway
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Skripuletz T, Torkildsen Ø. Editorial: New cerebrospinal fluid research to uncover mechanisms driving neurological and psychiatric diseases, volume II. Front Neurol 2023; 14:1346377. [PMID: 38148983 PMCID: PMC10749915 DOI: 10.3389/fneur.2023.1346377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/04/2023] [Indexed: 12/28/2023] Open
Affiliation(s)
| | - Øivind Torkildsen
- Department of Neurology, Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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8
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Rød BE, Wergeland S, Bjørnevik K, Holmøy T, Ulvestad E, Njølstad G, Myhr KM, Torkildsen Ø. Humoral response to Epstein-Barr virus in patients with multiple sclerosis treated with B cell depletion therapy. Mult Scler Relat Disord 2023; 79:105037. [PMID: 37804765 DOI: 10.1016/j.msard.2023.105037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/25/2023] [Accepted: 09/24/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND B cell depletion therapy is highly effective in relapsing-remitting multiple sclerosis (RRMS). However, the precise underlying mechanisms of action for its biological effects in MS have still not been clarified. Epstein-Barr virus (EBV) is a known risk factor for MS and seems to be a prerequisite for disease development. EBV resides latently in the memory B cells, and may not only increase the risk of developing MS, but also contribute to disease activity and disability progression. Therefore, the effects of B cell depletion in MS could be associated with the depletion of EBV-infected cells and the altered immune response to the virus. In this study, we investigate the impact of B cell depletion on the humoral immune response specific to EBV in patients with MS. METHODS Newly diagnosed, treatment-naïve patients with RRMS were followed up to 18 months after initiation of B-cell depletion therapy in the Overlord-MS study, a phase III trial (NCT04578639). We analyzed serum sampled before treatment and after 3, 6, 12 and 18 months for immunoglobulin γ (IgG) against Epstein-Barr nuclear antigen 1 (EBNA1) and Epstein-Barr viral capsid antigen (VCA). We analyzed antibodies to cytomegalovirus (CMV) and total IgG in serum, as controls for viral and overall humoral immunity. The risk allele, HLA-DRB1*15:01, and the protective allele, HLA-A*02:01, were determined in all participants. In addition, polymerase chain reaction (PCR) for circulating EBV-DNA was performed in the first 156 samples drawn. The associations between time on B cell-depletion therapy and serum anti-EBV antibody levels were estimated using linear mixed-effects models. RESULTS A total of 290 serum samples from 99 patients were available for analysis. After 6, 12 and 18 months, the EBNA1 IgG levels decreased by 12.7 % (95 % CI -18.8 to -6.60, p < 0.001), 12.1 % (95 % CI -19.8 to -3.7, p = 0.006) and 14.6 % (95 % CI to -25.3 to -2.4, p = 0.02) respectively, compared to baseline level. Carriers of the HLA-DRB1*15:01 allele had higher EBNA1 IgG levels at baseline (p = 0.02). The VCA IgG levels significantly increased by 13.7 % (95 % CI 9.4 to 18.1, p < 0.001) after 3 months, compared to baseline, and persisted at this level throughout the follow-up. CMV IgG levels decreased, but to a lesser extent than the decrease of EBNA1 IgG, and total IgG levels decreased during therapy. Circulating EBV-DNA was found in only three of 156 samples from 64 patients. CONCLUSIONS EBNA1 IgG levels decreased, while VCA IgG levels increased, during B cell depletion therapy. This supports the hypothesis that the mechanism of action for B cell depletion therapy might be mediated by effects on EBV infection, which, in turn, mitigate immune cross-reactivity and disease perpetuation.
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Affiliation(s)
- Brit Ellen Rød
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Stig Wergeland
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway; The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Kjetil Bjørnevik
- Departments of Epidemiology and Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Elling Ulvestad
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Gro Njølstad
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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9
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Førde JL, Herfindal L, Myhr KM, Torkildsen Ø, Mollnes TE, Skrede S. Ocrelizumab and ofatumumab, but not rituximab, trigger complement induction in vitro. Int Immunopharmacol 2023; 124:111021. [PMID: 37816262 DOI: 10.1016/j.intimp.2023.111021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023]
Abstract
The clinical and adverse effects of the therapeutic monoclonal antibodies (mAb) ocrelizumab, ofatumumab and rituximab in multiple sclerosis (MS) are presently subject to extensive study. While the two former are approved for MS, the older and less costly rituximab is used off label, and adverse effect profiles are important in their evaluation. The three mAbs all induce B cell depletion, with complement-dependent cytotoxicity (CDC) as one of several mechanisms of action. Complement activation is also postulated to underlie adverse reactions related to infusion/injection. Such administration-related reactions are associated with all three mAbs, but comparisons have so far been indirect, resting on incidence reports from separate clinical trials. The objective of this study was to perform head-to-head comparison of complement activation by ofatumumab, ocrelizumab and rituximab. In vitro experiments were performed in whole blood from healthy donors. The complement-activating potential of the three mAbs was analyzed after 30 min of exposure to 0.3 mg/mL or 0.9 mg/mL of each drug, and compared with those of the well-known TNF inhibitory mAbs adalimumab and infliximab, the latter with recognized potential for infusion reactions. Ofatumumab, ocrelizumab, and infliximab, but not rituximab and adalimumab, triggered statistically significant complement activation measured as increased levels of terminal C5b-9 complement complex (TCC), a sensitive marker of such activation. While results demand careful interpretation, they provide an indication of distinct complement-inducing potential among anti-CD20 mAbs currently used to treat MS.
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Affiliation(s)
- Jan-Lukas Førde
- Centre for Pharmacy, Department of Clinical Science, Faculty of Medicine, University of Bergen, Jonas Lies vei 87, N-5021 Bergen, Norway; Department of Internal Medicine, Haukeland University Hospital, Haukelandsveien 22, N-5021 Bergen, Norway
| | - Lars Herfindal
- Centre for Pharmacy, Department of Clinical Science, Faculty of Medicine, University of Bergen, Jonas Lies vei 87, N-5021 Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Jonas Lies vei 87, N-5021 Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, N-5021 Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Jonas Lies vei 87, N-5021 Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, N-5021 Bergen, Norway
| | - Tom Eirik Mollnes
- Research Laboratory, Nordland Hospital Trust, Prinsensgate 164, N-8005 Bodø, Norway; Department of Immunology, Oslo University Hospital and University of Oslo, Sognsvannsveien 20, N-0327 Oslo, Norway
| | - Silje Skrede
- Section of Clinical Pharmacology, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Jonas Lies vei 87, N-5021 Bergen, Norway; Department of Clinical Science, University of Bergen, Jonas Lies vei 87, N-5021 Bergen, Norway.
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10
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Kalincik T, Sharmin S, Roos I, Freedman MS, Atkins H, Burman J, Massey J, Sutton I, Withers B, Macdonell R, Grigg A, Torkildsen Ø, Bo L, Lehmann AK, Havrdova EK, Krasulova E, Trněný M, Kozak T, van der Walt A, Butzkueven H, McCombe P, Skibina O, Lechner-Scott J, Willekens B, Cartechini E, Ozakbas S, Alroughani R, Kuhle J, Patti F, Duquette P, Lugaresi A, Khoury SJ, Slee M, Turkoglu R, Hodgkinson S, John N, Maimone D, Sa MJ, van Pesch V, Gerlach O, Laureys G, Van Hijfte L, Karabudak R, Spitaleri D, Csepany T, Gouider R, Castillo-Triviño T, Taylor B, Sharrack B, Snowden JA. Comparative Effectiveness of Autologous Hematopoietic Stem Cell Transplant vs Fingolimod, Natalizumab, and Ocrelizumab in Highly Active Relapsing-Remitting Multiple Sclerosis. JAMA Neurol 2023; 80:702-713. [PMID: 37437240 PMCID: PMC10186210 DOI: 10.1001/jamaneurol.2023.1184] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/12/2023] [Indexed: 07/14/2023]
Abstract
Importance Autologous hematopoietic stem cell transplant (AHSCT) is available for treatment of highly active multiple sclerosis (MS). Objective To compare the effectiveness of AHSCT vs fingolimod, natalizumab, and ocrelizumab in relapsing-remitting MS by emulating pairwise trials. Design, Setting, and Participants This comparative treatment effectiveness study included 6 specialist MS centers with AHSCT programs and international MSBase registry between 2006 and 2021. The study included patients with relapsing-remitting MS treated with AHSCT, fingolimod, natalizumab, or ocrelizumab with 2 or more years study follow-up including 2 or more disability assessments. Patients were matched on a propensity score derived from clinical and demographic characteristics. Exposure AHSCT vs fingolimod, natalizumab, or ocrelizumab. Main outcomes Pairwise-censored groups were compared on annualized relapse rates (ARR) and freedom from relapses and 6-month confirmed Expanded Disability Status Scale (EDSS) score worsening and improvement. Results Of 4915 individuals, 167 were treated with AHSCT; 2558, fingolimod; 1490, natalizumab; and 700, ocrelizumab. The prematch AHSCT cohort was younger and with greater disability than the fingolimod, natalizumab, and ocrelizumab cohorts; the matched groups were closely aligned. The proportion of women ranged from 65% to 70%, and the mean (SD) age ranged from 35.3 (9.4) to 37.1 (10.6) years. The mean (SD) disease duration ranged from 7.9 (5.6) to 8.7 (5.4) years, EDSS score ranged from 3.5 (1.6) to 3.9 (1.9), and frequency of relapses ranged from 0.77 (0.94) to 0.86 (0.89) in the preceding year. Compared with the fingolimod group (769 [30.0%]), AHSCT (144 [86.2%]) was associated with fewer relapses (ARR: mean [SD], 0.09 [0.30] vs 0.20 [0.44]), similar risk of disability worsening (hazard ratio [HR], 1.70; 95% CI, 0.91-3.17), and higher chance of disability improvement (HR, 2.70; 95% CI, 1.71-4.26) over 5 years. Compared with natalizumab (730 [49.0%]), AHSCT (146 [87.4%]) was associated with marginally lower ARR (mean [SD], 0.08 [0.31] vs 0.10 [0.34]), similar risk of disability worsening (HR, 1.06; 95% CI, 0.54-2.09), and higher chance of disability improvement (HR, 2.68; 95% CI, 1.72-4.18) over 5 years. AHSCT (110 [65.9%]) and ocrelizumab (343 [49.0%]) were associated with similar ARR (mean [SD], 0.09 [0.34] vs 0.06 [0.32]), disability worsening (HR, 1.77; 95% CI, 0.61-5.08), and disability improvement (HR, 1.37; 95% CI, 0.66-2.82) over 3 years. AHSCT-related mortality occurred in 1 of 159 patients (0.6%). Conclusion In this study, the association of AHSCT with preventing relapses and facilitating recovery from disability was considerably superior to fingolimod and marginally superior to natalizumab. This study did not find evidence for difference in the effectiveness of AHSCT and ocrelizumab over a shorter available follow-up time.
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Affiliation(s)
- Tomas Kalincik
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Sifat Sharmin
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Izanne Roos
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- CORe, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Mark S. Freedman
- University of Ottawa, Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Harold Atkins
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Joachim Burman
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Jennifer Massey
- Department of Neurology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ian Sutton
- Department of Neurology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Barbara Withers
- St Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Haematology, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Richard Macdonell
- Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Grigg
- University of Melbourne, Melbourne, Victoria, Australia
- Department of Haematology, Austin Health, Melbourne, Victoria, Australia
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bo
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva Krasulova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Marek Trněný
- Department of Haematology, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Tomas Kozak
- Department of Haematology, 3rd Faculty of Medicine, Charles University in Prague, and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Anneke van der Walt
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Helmut Butzkueven
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Pamela McCombe
- University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Olga Skibina
- Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Box Hill Hospital, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, University Newcastle, Newcastle, New South Wales, Australia
- Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Edegem, Belgium
- Translational Neurosciences Research Group, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | | | | | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy
- Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Pierre Duquette
- CHUM MS Center and Universite de Montreal, Montreal, Quebec, Canada
| | - Alessandra Lugaresi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Samia J. Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mark Slee
- Flinders University, Adelaide, South Australia, Australia
| | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | | | - Nevin John
- Monash Medical Centre, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Maria Jose Sa
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | - Vincent van Pesch
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium
| | - Oliver Gerlach
- Academic MS Center Zuyderland, Department of Neurology, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Guy Laureys
- Department of Neurology, University Hospital Ghent, Ghent, Belgium
| | | | - Rana Karabudak
- Department of Neurology, Hacettepe University Hospitals, Ankara, Turkey
| | - Daniele Spitaleri
- Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy
| | - Tunde Csepany
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Riadh Gouider
- Department of Neurology, Razi University Hospital, Manouba, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | | | - Bruce Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Basil Sharrack
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - John A. Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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11
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Riemer F, Skorve E, Pasternak O, Zaccagna F, Lundervold AJ, Torkildsen Ø, Myhr KM, Grüner R. Microstructural changes precede depression in patients with relapsing-remitting Multiple Sclerosis. Commun Med (Lond) 2023; 3:90. [PMID: 37349545 DOI: 10.1038/s43856-023-00319-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/06/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Multiple Sclerosis lesions in the brain and spinal cord can lead to different symptoms, including cognitive and mood changes. In this study we explore the temporal relationship between early microstructural changes in subcortical volumes and cognitive and emotional function in a longitudinal cohort study of patients with relapsing-remitting Multiple Sclerosis. METHODS In vivo imaging in forty-six patients with relapsing-remitting Multiple Sclerosis was performed annually over 3 years magnetic resonance imaging. Microstructural changes were estimated in subcortical structures using the free water fraction, a diffusion-based MRI metric. In parallel, patients were assessed with the Hospital Anxiety and Depression Scale amongst other tests. Predictive structural equation modeling was set up to further explore the relationship between imaging and the assessment scores. In a general linear model analysis, the cohort was split into patients with higher and lower depression scores. RESULTS Nearly all subcortical diffusion microstructure estimates at the baseline visit correlate with the depression score at the 2 years follow-up. The predictive nature of baseline free water estimates and depression subscores after 2 years are confirmed in the predictive structural equation modeling analysis with the thalamus showing the greatest effect size. The general linear model analysis shows patterns of MRI free water differences in the thalamus and amygdala/hippocampus area between participants with high and low depression score. CONCLUSIONS Our data suggests a relationship between higher levels of free-water in the subcortical structures in an early stage of Multiple Sclerosis and depression symptoms at a later stage of the disease.
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Affiliation(s)
- Frank Riemer
- Mohn Medical Imaging and Visualization Centre (MMIV), Department of Radiology, Haukeland University Hospital, 5021, Bergen, Norway.
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway.
| | - Ellen Skorve
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, 5020, Bergen, Norway
| | - Ofer Pasternak
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02215, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02215, USA
| | - Fulvio Zaccagna
- Department of Imaging, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, CB2 0QQ, Cambridge, United Kingdom
- Department of Radiology, University of Cambridge, CB2 0QQ, Cambridge, United Kingdom
- Investigative Medicine Division, Radcliffe Department of Medicine, University of Oxford, OX3 9DU, Oxford, United Kingdom
| | - Astri J Lundervold
- Department of Biological and Medical Psychology, University of Bergen, 5020, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, 5020, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, 5020, Bergen, Norway
| | - Renate Grüner
- Mohn Medical Imaging and Visualization Centre (MMIV), Department of Radiology, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Physics and Technology, University of Bergen, 5007, Bergen, Norway
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12
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Karlowicz JR, Klakegg M, Aarseth JH, Bø L, Myhr KM, Torgauten HM, Torkildsen Ø, Wergeland S. Predictors of hospitalization due to infection in rituximab-treated MS patients. Mult Scler Relat Disord 2023; 71:104556. [PMID: 36842313 DOI: 10.1016/j.msard.2023.104556] [Citation(s) in RCA: 1] [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] [Received: 09/09/2022] [Revised: 12/30/2022] [Accepted: 02/07/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Rituximab is extensively used off-label to treat multiple sclerosis (MS), and long-term vigilance for adverse events is needed. This study was conducted to determine frequencies and predictors of hematological adverse events, including hypogammaglobulinemia, severe lymphopenia, neutropenia, and infections leading to hospitalization. METHODS This retrospective cohort study included all patients with MS initiating rituximab treatment at Haukeland University Hospital between January 1st, 2017, and July 1st, 2021. Patients were followed by clinical monitoring and repeated blood sampling every six months. Clinical outcomes and laboratory results were retrieved from the Norwegian MS Registry and Biobank and the patient administrative system at Haukeland University Hospital. RESULTS Five hundred and fifty-six patients were included, 515 with relapsing-remitting MS (RRMS) and 41 with progressive MS. Overall, 33 patients (5.9%) experienced 56 episodes of infections requiring hospital admission. Sixty patients (10.8%) had confirmed hypogammaglobulinemia, 17 (3.1%) had confirmed severe lymphopenia, and 10 (1.8%) had confirmed severe neutropenia. Predictors of infection requiring hospital admission were progressive MS (adjusted OR (aOR): 4.81; 95%CI: 1.25-18.48), duration of treatment with rituximab (aOR: 1.52; 95%CI: 1.11-2.09) and confirmed severe lymphopenia (aOR: 13.58; 95%CI: 3.41-54.06) and neutropenia (aOR: 13.40; 95%CI: 2.93-61.25). Of the hematological abnormalities, only hypogammaglobulinemia was associated with treatment duration (aOR: 1.35; 95%CI: 1.09-1.69). CONCLUSION The risk of hospitalization due to infection is associated with time on rituximab treatment, in patients with lympho- or neutropenia, and in patients with primary progressive MS. We observed a time-dependent decline in IgG values, in contrast to neutrophil and lymphocyte count, suggesting a cumulative dose-dependent response. These predictors can assist clinicians in assessing and monitoring MS patients receiving rituximab.
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Affiliation(s)
| | - Mattias Klakegg
- Department of clinical medicine, University of Bergen, Norway
| | - Jan Harald Aarseth
- Norwegian MS-registry and biobank, Dept of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Hilde Marie Torgauten
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Department of clinical medicine, University of Bergen, Norway; Norwegian MS-registry and biobank, Dept of Neurology, Haukeland University Hospital, Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway.
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13
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König M, Lorentzen ÅR, Torgauten HM, Tran TT, Schikora-Rustad S, Vaage EB, Mygland Å, Wergeland S, Aarseth J, Aaberge IAS, Torkildsen Ø, Holmøy T, Berge T, Myhr KM, Harbo HF, Andersen JT, Munthe LA, Søraas A, Celius EG, Vaage JT, Lund-Johansen F, Nygaard GO. Humoral immunity to SARS-CoV-2 mRNA vaccination in multiple sclerosis: the relevance of time since last rituximab infusion and first experience from sporadic revaccinations. J Neurol Neurosurg Psychiatry 2023; 94:19-22. [PMID: 34670844 PMCID: PMC9763174 DOI: 10.1136/jnnp-2021-327612] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The effect of disease-modifying therapies (DMT) on vaccine responses is largely unknown. Understanding the development of protective immunity is of paramount importance to fight the COVID-19 pandemic. OBJECTIVE To characterise humoral immunity after mRNA-COVID-19 vaccination of people with multiple sclerosis (pwMS). METHODS All pwMS in Norway fully vaccinated against SARS-CoV-2 were invited to a national screening study. Humoral immunity was assessed by measuring anti-SARS-CoV-2 SPIKE RBD IgG response 3-12 weeks after full vaccination, and compared with healthy subjects. RESULTS 528 pwMS and 627 healthy subjects were included. Reduced humoral immunity (anti-SARS-CoV-2 IgG <70 arbitrary units) was present in 82% and 80% of all pwMS treated with fingolimod and rituximab, respectively, while patients treated with other DMT showed similar rates as healthy subjects and untreated pwMS. We found a significant correlation between time since the last rituximab dose and the development of humoral immunity. Revaccination in two seronegative patients induced a weak antibody response. CONCLUSIONS Patients treated with fingolimod or rituximab should be informed about the risk of reduced humoral immunity and vaccinations should be timed carefully in rituximab patients. Our results identify the need for studies regarding the durability of vaccine responses, the role of cellular immunity and revaccinations.
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Affiliation(s)
- Marton König
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Åslaug Rudjord Lorentzen
- Department of Neurology, Sørlandet Sykehus HF, Kristiansand, Norway.,The Norwegian National Advisory Unit on Tick-borne Diseases, Arendal, Norway
| | - Hilde Marie Torgauten
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - The Trung Tran
- Department of Immunology, Oslo University Hospital, Oslo, Norway
| | | | | | - Åse Mygland
- Department of Neurology, Sørlandet Sykehus HF, Kristiansand, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Stig Wergeland
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Norwegian MS Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Jan Aarseth
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Norwegian MS Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Ingeborg Aase S Aaberge
- Department of Infectious Disease Immunology, Norwegian Institute of Public Health, Oslo, Norway
| | - Øivind Torkildsen
- Institute of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lorenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tone Berge
- Department of Mechanical, Electronic and Chemical Engineering, Oslo Metropolitan University, Oslo, Norway.,Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hanne Flinstad Harbo
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jan Terje Andersen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Ludvig Andre Munthe
- Department of Immunology, Oslo University Hospital, Oslo, Norway.,K.G. Jebsen Centre for B cell malignancies, University of Oslo, Oslo, Norway
| | - Arne Søraas
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
| | - Elisabeth Gulowsen Celius
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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14
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Grytten N, Myhr KM, Celius EG, Benjaminsen E, Midgard R, Vatne A, Aarseth JH, Mannseth J, Torkildsen Ø. Cancer related mortality in multiple sclerosis. A population based cohort study. Mult Scler Relat Disord 2023; 69:104417. [PMID: 36423459 DOI: 10.1016/j.msard.2022.104417] [Citation(s) in RCA: 1] [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] [Received: 09/09/2022] [Revised: 10/27/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cancer is a major cause of death, but how cancer influences mortality risk in Multiple Sclerosis (MS) is unclear. OBJECTIVES Determine all-cause mortality and mortality following a cancer diagnosis among MS patients compared with matched population controls. METHODS Norwegian MS patients born 1930 - 1979 (n= 6950) followed-up 1953 - 2016, were matched with 37 922 controls. We compared incident cancer diagnosis from the Cancer Registry of Norway, date of death from the Cause of Death Registry, education from the National Education Database, by multivariate Cox proportional hazard regression. RESULTS Hazard ratio (HR) and 95% confidence interval (CI) for all-cause mortality among MS patients was 4.97 (4.64 - 5.33), and 2.61 (2.29 - 2.98) for mortality following a cancer diagnosis. Mortality in MS was highest following urinary- (2.53: 1.55 - 4.14), colorectal- (2.14: 1.47 - 3.11), hematological- (1.76: 1.08 - 2.88), ovarian - 2.30 (1.73-3.06) and breast cancer diagnosis (2.61: 1.85 - 3.68), compared to controls. High education was inversely associated with mortality among MS patients. CONCLUSIONS All-cause mortality was five- fold and mortality following a cancer diagnosis was two- fold increased among MS patients. Mortality following specific cancers raises the possibility of diagnostic neglect.
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Affiliation(s)
- Nina Grytten
- Norwegian Multiple Sclerosis Competence Centre, sDept. of Neurology, Haukeland University Hospital; Dept. of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Dept. of Neurology, Haukeland University Hospital, Bergen, Norway.
| | - Kjell-Morten Myhr
- Dept. of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Dept. of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Elisabeth G Celius
- Dept of Neurology, Oslo University Hospital Ullevål, Oslo, Norway; Institute of clinical medicine, University of Oslo, Oslo, Norway
| | | | - Rune Midgard
- Dept. of Neurology, Molde Hospital, Molde, Norway; Norwegian University of Science and Technology
| | - Anita Vatne
- Dept. of Rehabilitation, Southern Norway Hospital
| | - Jan H Aarseth
- The Norwegian Multiple Sclerosis Registry and Biobank, Dept. of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Janne Mannseth
- The Norwegian Multiple Sclerosis Registry and Biobank, Dept. of Neurology, Haukeland University Hospital, Bergen, Norway; Dept. of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Dept. of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Dept. of Neurology, Haukeland University Hospital, Bergen, Norway
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15
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Skorve E, Lundervold AJ, Torkildsen Ø, Riemer F, Grüner R, Myhr KM. Brief international cognitive assessment for MS (BICAMS) and global brain volumes in early stages of MS - A longitudinal correlation study. Mult Scler Relat Disord 2023; 69:104398. [PMID: 36462469 DOI: 10.1016/j.msard.2022.104398] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 12/27/2021] [Revised: 08/04/2022] [Accepted: 11/03/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cognitive impairment is common in patients with multiple sclerosis, even in the early stages of the disease. The Brief International Cognitive Assessment for multiple sclerosis (BICAMS) is a short screening tool developed to assess cognitive function in everyday clinical practice. OBJECTIVE To investigate associations between volumetric brain measures derived from a magnetic resonance imaging (MRI) examination and performance on BICAMS subtests in early stages of multiple sclerosis (MS). METHODS BICAMS was used to assess cognitive function in 49 MS patients at baseline and after one and two years. The patients were separated into two groups (with or without cognitive impairment) based on their performances on BICAMSs subtests. MRI data were analysed by a software tool (MSMetrix), yielding normalized measures of global brain volumes and lesion volumes. Associations between cognitive tests and brain MRI measures were analysed by running correlation analyses, and differences between subgroups and changes over time with independent and paired samples tests, respectively. RESULTS The strongest baseline correlations were found between the BICAMS subtests and normalized whole brain volume (NBV) and grey matter volume (NGV); processing speed r = 0.54/r = 0.48, verbal memory r = 0.49/ r = 0.42, visual memory r = 0.48 /r = 0.39. Only the verbal memory test had significant correlations with T2 and T1 lesion volumes (LV) at both time points; T2LV r = 0.39, T1LV r = 0.38. There were significant loss of grey matter and white matter volume overall (NGV p<0.001, NWV p = 0.003), as well as an increase in T1LV (p = 0.013). The longitudinally defined confirmed cognitively impaired (CCI) and preserved (CCP) patients showed significant group differences on all MRI volume measures at both time points, except for NWV. Only the CCI subgroup showed significant white matter atrophy (p = 0.006) and increase in T2LV (p = 0.029). CONCLUSIONS The present study found strong correlations between whole brain and grey matter volumes and performance on the BICAMS subtests as well as significant changes in global volumes from baseline to follow-up with clear differences between patients defined as cognitively impaired and preserved at both baseline and follow-up.
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Affiliation(s)
- Ellen Skorve
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Astri J Lundervold
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Frank Riemer
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Mohn Medical Imaging and Visualization Centre (MMIV), Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Renate Grüner
- Mohn Medical Imaging and Visualization Centre (MMIV), Department of Radiology, Haukeland University Hospital, Bergen, Norway; Department of Physics and Technology, University of Bergen, N-5007 Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Torkildsen Ø. Lessons to be learnt from the history of lobotomy. Tidsskr Nor Laegeforen 2022; 142:22-0505. [PMID: 36511739 DOI: 10.4045/tidsskr.22.0505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Torkildsen Ø, Rød BE, Bø L, Wergeland S, Holmøy T, Myhr KM. Breastfeeding and treatment for multiple sclerosis. Tidsskriftet 2022; 142:22-0529. [DOI: 10.4045/tidsskr.22.0529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Lie IA, Wesnes K, Kvistad SS, Brouwer I, Wergeland S, Holmøy T, Midgard R, Bru A, Edland A, Eikeland R, Gosal S, Harbo HF, Kleveland G, Sørenes YS, Øksendal N, Barkhof F, Vrenken H, Myhr KM, Bø L, Torkildsen Ø. The Effect of Smoking on Long-term Gray Matter Atrophy and Clinical Disability in Patients with Relapsing-Remitting Multiple Sclerosis. Neurol Neuroimmunol Neuroinflamm 2022; 9:9/5/e200008. [PMID: 35738901 PMCID: PMC9223432 DOI: 10.1212/nxi.0000000000200008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/06/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives The relationship between smoking, long-term brain atrophy, and clinical disability in patients with multiple sclerosis (MS) is unclear. Here, we assessed long-term effects of smoking by evaluating MRI and clinical outcome measures after 10 years in smoking and nonsmoking patients with relapsing-remitting MS (RRMS). Methods We included 85 treatment-naive patients with RRMS with recent inflammatory disease activity who participated in a 10-year follow-up visit after a multicenter clinical trial of 24 months. Smoking status was decided for each patient by 2 separate definitions: by serum cotinine levels measured regularly for the first 2 years of the follow-up (during the clinical trial) and by retrospective patient self-reporting. At the 10-year follow-up visit, clinical tests were repeated, and brain atrophy measures were obtained from MRI using FreeSurfer. Differences in clinical and MRI measurements at the 10-year follow-up between smokers and nonsmokers were investigated by 2-sample t tests or Mann-Whitney tests and linear mixed-effect regression models. All analyses were conducted separately for each definition of smoking status. Results After 10 years, smoking (defined by serum cotinine levels) was associated with lower total white matter volume (β = −21.74, p = 0.039) and higher logT2 lesion volume (β = 0.22, p = 0.011). When defining smoking status by patient self-reporting, the repeated analyses found an additional association with lower deep gray matter volume (β = −2.35, p = 0.049), and smoking was also associated with a higher score (higher walking impairment) on the log timed 25-foot walk test (β = 0.050, p = 0.039) after 10 years and a larger decrease in paced auditory serial addition test (attention) scores (β = −3.58, p = 0.029). Discussion Smoking was associated with brain atrophy and disability progression 10 years later in patients with RRMS. The findings imply that patients should be advised and offered aid in smoking cessation shortly after diagnosis, to prevent long-term disability progression.
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Affiliation(s)
- Ingrid Anne Lie
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway.
| | - Kristin Wesnes
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Silje S Kvistad
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Iman Brouwer
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Trygve Holmøy
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Rune Midgard
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Alla Bru
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Astrid Edland
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Randi Eikeland
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Sonia Gosal
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Hanne F Harbo
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Grethe Kleveland
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Yvonne S Sørenes
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Nina Øksendal
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Frederik Barkhof
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Hugo Vrenken
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- From the Department of Clinical Medicine (I.A.L., K.-M.M., L.B., Ø.T.), University of Bergen; Neuro-SysMed, Department of Neurology, Haukeland University Hospital (I.A.L., K.W., S.S.K., S.W., K.-M.M., Ø.T.), Bergen; St. Olav's University Hospital (K.W.), Trondheim; Department of Immunology and Transfusion Medicine (S.S.K.), Haukeland University Hospital, Bergen, Norway; Department of Radiology and Nuclear Medicine (I.B., F.B., H.V.), MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, The Netherlands; Norwegian Multiple Sclerosis Registry and Biobank (S.W.), Department of Neurology, Haukeland University Hospital, Bergen; Institute of Clinical Medicine (T.H., H.F.H.), University of Oslo; Department of Neurology, Akershus University Hospital (T.H.), Lørenskog; Department of Neurology (R.M.), Molde Hospital; Department of Neurology (A.B.), Stavanger University Hospital; Department of Neurology (A.E.), Vestre Viken Hospital Trust, Drammen; Department of Research and Education (R.E.), Sørlandet Hospital Trust, Kristiansand; Faculty of Health and Sport Science (R.E.), University of Agder, Grimstad; Department of Neurology (S.G.), Østfold Hospital Kalnes, Grålum; Department of Neurology (H.F.H.), Oslo University Hospital; Department of Neurology (G.K.), Innlandet Hospital Lillehammer; Department of Neurology (Y.S.S.), Haugesund Hospital; Department of Neurology (N.Ø.), Nordland Hospital Trust, Bodø, Norway; Institutes of Neurology and Healthcare Engineering (F.B.), University College London, Great Britain; and Norwegian Multiple Sclerosis Competence Centre (L.B.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Kvistad SAS, Burman J, Lehmann AK, Tolf A, Zjukovskaja C, Melve GK, Bø L, Torkildsen Ø. Impact of previous disease-modifying treatment on safety and efficacy in patients with MS treated with AHSCT. J Neurol Neurosurg Psychiatry 2022; 93:844-848. [PMID: 35508373 PMCID: PMC9304086 DOI: 10.1136/jnnp-2022-328797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/18/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Autologous haematopoietic stem cell transplantation (AHSCT) is a highly effective treatment for multiple sclerosis (MS). The impact of previous long-lasting disease-modifying treatments (DMT) for safety and efficacy of AHSCT is unknown. OBJECTIVE To explore whether previous DMTs with long-lasting effects on the immune system (anti-CD20 therapy, alemtuzumab and cladribine) affect treatment-related complications, long-term outcome and risk of new MS disease activity in patients treated with AHSCT. METHODS Retrospective observational study of 104 relapsing remitting patients with MS treated by AHSCT in Sweden and Norway from 2011 to 2021, grouped according to the last DMT used ≤6 months prior to AHSCT. The primary outcomes were early AHSCT-related complications (mortality, neutropenic fever and hospitalisation length), long-term complications (secondary autoimmunity) and proportion of patients with No Evidence of Disease Activity (NEDA-3 status): no new relapses, no MRI activity and no disease progression during the follow-up. RESULTS The mean follow-up time was 39.5 months (range 1-95). Neutropenic fever was a common AHSCT-related complication affecting 69 (66%) patients. There was no treatment-related mortality. During the follow-up period, 20 patients (19%) were diagnosed with autoimmunity. Occurrence of neutropenic fever, hospitalisation length or secondary autoimmunity did not vary dependent on the last DMT used prior to AHSCT. A total of 84 patients (81%) achieved NEDA-3 status, including all patients (100%) using rituximab, alemtuzumab or cladribine before AHSCT. CONCLUSION This study provides level 4 evidence that AHSCT in patients previously treated with alemtuzumab, cladribine or rituximab is safe and efficacious.
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Affiliation(s)
- Silje Agnethe Stokke Kvistad
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway .,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Joachim Burman
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden
| | - Anne Kristine Lehmann
- Department of Medicine, Section of Hematology, Haukeland University Hospital, Bergen, Norway
| | - Andreas Tolf
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden.,Department of Neurology, Akademiska sjukhuset, Uppsala, Sweden
| | | | - Guro Kristin Melve
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neurology, Norwegian Multiple Sclerosis Competence Centre, Bergen, Norway
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20
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Rød BE, Torkildsen Ø, Myhr KM, Bø L, Wergeland S. Safety of breast feeding during rituximab treatment in multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 94:jnnp-2022-329545. [PMID: 35879056 PMCID: PMC9763193 DOI: 10.1136/jnnp-2022-329545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND There are limited data on the safety of breast feeding during rituximab therapy. Our objective is to determine exposure from breast feeding and biological effects of rituximab in breastfed infants. METHODS In our case series of six mother-infant pairs, the nursing mothers with relapsing-remitting multiple sclerosis received rituximab during breast feeding. As part of clinical follow-up, six serial breast milk samples, and blood samples from both mothers and infants, were collected and analysed. RESULTS The median average rituximab concentration (Cavg) in breast milk was 0.04 µg/mL and the estimated relative infant dose (RID) was 0.07%. The highest measured concentration of rituximab in the breast milk samples was 0.25 µg/mL, giving an estimated RID of 0.26%.All infant serum rituximab concentrations were below 0.01 µg/mL. The CD19 +B cell count values were within the 10th- 90th percentiles of reported normal ranges in healthy infants. CONCLUSIONS We found minimal transfer of rituximab into breast milk and could not reliably detect levels of rituximab in infant serum. B cell counts in infants were unaffected.
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Affiliation(s)
- Brit Ellen Rød
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Bø
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Norwegian Multiple Sclerosis Competence Centre, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Norwegian MS-Registry and Biobank, Haukeland University Hospital, Bergen, Norway
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21
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Eid K, Torkildsen Ø, Aarseth J, Celius EG, Cortese M, Holmøy T, Kapali A, Myhr KM, Torkildsen CF, Wergeland S, Gilhus NE, Bjørk MH. Abuse and revictimization in adulthood in multiple sclerosis: a cross-sectional study during pregnancy. J Neurol 2022; 269:5901-5909. [PMID: 35780399 PMCID: PMC9553842 DOI: 10.1007/s00415-022-11249-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/28/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
Abstract
Background Knowledge concerning exposure to abuse in adulthood and in pregnancy in people with multiple sclerosis (MS) is sparse. Objective To determine the occurrence of adult abuse and abuse in relation to pregnancy in women with MS and their risk of revictimization (repeated abuse as adults after childhood abuse). Methods This cross-sectional study comprised pregnant women from the Norwegian Mother, Father and Child Cohort study. Information on abuse was acquired through self-completed questionnaires. We used logistic regression to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results We identified 106 women with MS at enrollment through linkage with national health registries. The reference group consisted of 77,278 women without MS. Twenty-seven women (26%) with MS reported any adult abuse compared to 15,491 women (20%) without MS, aOR 1.33 (0.85–2.09). Twenty-two (21%) women with MS reported systematic emotional abuse compared to 13% without MS, aOR 1.75 (1.08–2.83). Ten women (10%) with MS reported sexual abuse, compared to 6% without MS, aOR 1.72 (0.89–3.33). More women with MS reported rape as an adult, aOR 2.37 (1.02–5.49). Women with MS had higher risk of revictimization as adults, after childhood abuse, aOR 2.23 (1.22–4.10). The risk of abuse during pregnancy or 6 months preceding pregnancy was similar between the groups. Conclusions Women with MS had increased occurrence of systematic emotional abuse, rape, and revictimization as adults, compared to women without MS. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11249-x.
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Affiliation(s)
- Karine Eid
- Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, 5053, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Jan Aarseth
- Department of Neurology, Neuro-SysMed, Haukeland University Hospital, Bergen, Norway.,The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Elisabeth G Celius
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marianna Cortese
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Trygve Holmøy
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Akash Kapali
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Cecilie F Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | - Stig Wergeland
- Department of Neurology, Neuro-SysMed, Haukeland University Hospital, Bergen, Norway.,The Norwegian Multiple Sclerosis Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, 5053, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Marte-Helene Bjørk
- Department of Neurology, Haukeland University Hospital, Jonas Lies vei 71, 5053, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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22
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Eid K, Torkildsen Ø, Aarseth J, Aalstad M, Bhan A, Celius EG, Cortese M, Daltveit AK, Holmøy T, Myhr KM, Riise T, Schüler S, Torkildsen CF, Wergeland S, Gilhus NE, Bjørk MH. Association of adverse childhood experiences with the development of multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:645-650. [PMID: 35379699 PMCID: PMC9148981 DOI: 10.1136/jnnp-2021-328700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/22/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study whether exposure to childhood emotional, sexual or physical abuse is associated with subsequent multiple sclerosis (MS) development. METHODS A nationwide, prospective cohort study based on participants in the Norwegian Mother, Father and Child cohort study. Enrolment took place 1999-2008, with follow-up until 31 December 2018. Childhood abuse before age 18 years was obtained from self-completed questionnaires. We identified MS diagnoses through data-linkage with national health registries and hospital records. The Cox model was used to estimate HRs for MS with 95% CIs, adjusting for confounders and mediators. RESULTS In this prospective cohort study, 14 477 women were exposed to childhood abuse and 63 520 were unexposed. 300 women developed MS during the follow-up period. 71 of these (24%) reported a history of childhood abuse, compared with 14 406 of 77 697 (19%) women that did not develop MS. Sexual abuse (HR 1.65, 95% CI 1.13 to 2.39) and emotional abuse (HR 1.40, 95% CI 1.03 to 1.90) in childhood were both associated with an increased risk of developing MS. The HR of MS after exposure to physical abuse was 1.31 (95% CI 0.83 to 2.06). The risk of MS was further increased if exposed to two (HR 1.66, 95% CI 1.04 to 2.67) or all three abuse categories (HR 1.93, 95% CI 1.02 to 3.67). INTERPRETATION Childhood sexual and emotional abuse were associated with an increased risk of developing MS. The risk was higher when exposed to several abuse categories, indicating a dose-response relationship. Further studies are needed to identify underlying mechanisms.
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Affiliation(s)
- Karine Eid
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jan Aarseth
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- The Norwegian Multiple Sclerosis and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Mari Aalstad
- Department of Neurology, Innlandet Hospital Trust, Lillehammer, Norway
| | - Alok Bhan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Elisabeth G Celius
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marianna Cortese
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anne Kjersti Daltveit
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lorenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Trond Riise
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Stephan Schüler
- Department of Neurology, Nord-Trøndelag Hospital Trust, Namsos, Norway
| | - Cecilie F Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | - Stig Wergeland
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- The Norwegian Multiple Sclerosis and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Marte-Helene Bjørk
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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23
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Lie IA, Kaçar S, Wesnes K, Brouwer I, Kvistad SS, Wergeland S, Holmøy T, Midgard R, Bru A, Edland A, Eikeland R, Gosal S, Harbo HF, Kleveland G, Sørenes YS, Øksendal N, Varhaug KN, Vedeler CA, Barkhof F, Teunissen CE, Bø L, Torkildsen Ø, Myhr KM, Vrenken H. Serum neurofilament as a predictor of 10-year grey matter atrophy and clinical disability in multiple sclerosis: a longitudinal study. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-328568. [PMID: 35649699 PMCID: PMC9304101 DOI: 10.1136/jnnp-2021-328568] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/18/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The predictive value of serum neurofilament light chain (sNfL) on long-term prognosis in multiple sclerosis (MS) is still unclear. OBJECTIVE Investigate the relation between sNfL levels over a 2-year period in patients with relapsing-remitting MS, and clinical disability and grey matter (GM) atrophy after 10 years. METHODS 85 patients, originally enrolled in a multicentre, randomised trial of ω-3 fatty acids, participated in a 10-year follow-up visit. sNfL levels were measured by Simoa quarterly until month 12, and then at month 24. The appearance of new gadolinium-enhancing (Gd+) lesions was assessed monthly between baseline and month 9, and then at months 12 and 24. At the 10-year follow-up visit, brain atrophy measures were obtained using FreeSurfer. RESULTS Higher mean sNfL levels during early periods of active inflammation (Gd+ lesions present or recently present) predicted lower total (β=-0.399, p=0.040) and deep (β=-0.556, p=0.010) GM volume, lower mean cortical thickness (β=-0.581, p=0.010) and higher T2 lesion count (β=0.498, p=0.018). Of the clinical outcomes, higher inflammatory sNfL levels were associated with higher disability measured by the dominant hand Nine-Hole Peg Test (β=0.593, p=0.004). Mean sNfL levels during periods of remission (no Gd+ lesions present or recently present) did not predict GM atrophy or disability progression. CONCLUSION Higher sNfL levels during periods of active inflammation predicted more GM atrophy and specific aspects of clinical disability 10 years later. The findings suggest that subsequent long-term GM atrophy is mainly due to neuroaxonal degradation within new lesions.
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Affiliation(s)
- Ingrid Anne Lie
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Sezgi Kaçar
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Amsterdam, The Netherlands
| | - Kristin Wesnes
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Neurology, St. Olav's University Hospital, Trondheim, Norway
| | - Iman Brouwer
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Amsterdam, The Netherlands
| | - Silje S Kvistad
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Norwegian Multiple Sclerosis Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Trygve Holmøy
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Neurology, Akershus University Hospital, Lorenskog, Norway
| | - Rune Midgard
- Department of Neurology, Molde Hospital, Molde, Norway
| | - Alla Bru
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Astrid Edland
- Department of Neurology, Vestre Viken Hospital Trust, Drammen, Norway
| | - Randi Eikeland
- Department of Research and Education, Sørlandet Hospital Trust, Kristiansand, Norway
- Faculty of Health and Sport Science, University of Agder, Grimstad, Norway
| | - Sonia Gosal
- Department of Neurology, Østfold Hospital Kalnes, Grålum, Norway
| | - Hanne F Harbo
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Grethe Kleveland
- Department of Neurology, Innlandet Hospital Trust, Lillehammer, Norway
| | | | - Nina Øksendal
- Department of Neurology, Nordland Hospital Trust, Bodø, Norway
| | - Kristin N Varhaug
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Christian A Vedeler
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Amsterdam, The Netherlands
- Institutes of Neurology and Healthcare Engineering, UCL, London, UK
| | - Charlotte E Teunissen
- Neurochemistry Laboratory, Clinical Chemistry Department, Amsterdam Neuroscience, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Lars Bø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Hugo Vrenken
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Amsterdam, The Netherlands
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Hestvik ALK, Frederiksen JL, Nielsen HH, Torkildsen Ø, Eek C, Huang-Link Y, Haghighi S, Tsai JA, Kant M. Real-World Study of Relapsing-Remitting Multiple Sclerosis Patients Treated with Teriflunomide in Nordic Countries: Quality-Of-Life, Efficacy, Safety and Adherence Outcomes. Mult Scler Relat Disord 2022; 63:103892. [DOI: 10.1016/j.msard.2022.103892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/13/2022] [Accepted: 05/15/2022] [Indexed: 10/18/2022]
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25
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Nygaard GO, Torgauten H, Skattebøl L, Høgestøl EA, Sowa P, Myhr KM, Torkildsen Ø, Celius EG. Risk of fingolimod rebound after switching to cladribine or rituximab in multiple sclerosis. Mult Scler Relat Disord 2022; 62:103812. [DOI: 10.1016/j.msard.2022.103812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/12/2022] [Accepted: 04/16/2022] [Indexed: 11/29/2022]
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26
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Lie IA, Weeda MM, Mattiesing RM, Mol MAE, Pouwels PJW, Barkhof F, Torkildsen Ø, Bø L, Myhr KM, Vrenken H. Relationship Between White Matter Lesions and Gray Matter Atrophy in Multiple Sclerosis: A Systematic Review. Neurology 2022; 98:e1562-e1573. [PMID: 35173016 PMCID: PMC9038199 DOI: 10.1212/wnl.0000000000200006] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 01/03/2022] [Indexed: 11/20/2022] Open
Abstract
Background and Objectives There is currently no consensus about the extent of gray matter (GM) atrophy that can be attributed to secondary changes after white matter (WM) lesions or the temporal and spatial relationships between the 2 phenomena. Elucidating this interplay will broaden the understanding of the combined inflammatory and neurodegenerative pathophysiology of multiple sclerosis (MS), and separating atrophic changes due to primary and secondary neurodegenerative mechanisms will then be pivotal to properly evaluate treatment effects, especially if these treatments target the different processes individually. To untangle these complex pathologic mechanisms, this systematic review provides an essential first step: an objective and comprehensive overview of the existing in vivo knowledge of the relationship between brain WM lesions and GM atrophy in patients diagnosed with MS. The overall aim was to clarify the extent to which WM lesions are associated with both global and regional GM atrophy and how this may differ in the different disease subtypes. Methods We searched MEDLINE (through PubMed) and Embase for reports containing direct associations between brain GM and WM lesion measures obtained by conventional MRI sequences in patients with clinically isolated syndrome and MS. No restriction was applied for publication date. The quality and risk of bias in included studies were evaluated with the Quality Assessment Tool for observational cohort and cross-sectional studies (NIH, Bethesda, MA). Qualitative and descriptive analyses were performed. Results A total of 90 articles were included. WM lesion volumes were related mostly to global, cortical and deep GM volumes, and those significant associations were almost without exception negative, indicating that higher WM lesion volumes were associated with lower GM volumes or lower cortical thicknesses. The most consistent relationship between WM lesions and GM atrophy was seen in early (relapsing) disease and less so in progressive MS. Discussion The findings suggest that GM neurodegeneration is mostly secondary to damage in the WM during early disease stages while becoming more detached and dominated by other, possibly primary neurodegenerative disease mechanisms in progressive MS.
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Affiliation(s)
- Ingrid Anne Lie
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Merlin M Weeda
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Rozemarijn M Mattiesing
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Marijke A E Mol
- Medical Library, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Petra J W Pouwels
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Institutes of Neurology and Healthcare Engineering, UCL London, London, UK
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Hugo Vrenken
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
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Høglund RAA, Meyer HE, Stigum H, Torkildsen Ø, Grytten N, Holmøy T, Nakken O. Association of Body Mass Index in Adolescence and Young Adulthood and Long-term Risk of Multiple Sclerosis: A Population-Based Study. Neurology 2021; 97:e2253-e2261. [PMID: 34697245 DOI: 10.1212/wnl.0000000000012957] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/20/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To prospectively investigate the long-term relationship between body mass index (BMI) in adolescents and young adults and risk for multiple sclerosis (MS) at the population level. METHODS We used data from the population-based compulsory Norwegian tuberculosis screening program during 1963 to 1975, including objectively measured height and weight from ≈85% of all eligible citizens. This was combined with data from the Norwegian MS registry and biobank up to November 2020. BMI was standardized according to age and sex, and risk for MS was calculated with Cox proportional hazard models. RESULTS During 30,829,506 years of follow-up, we found 1,409 cases of MS among 648,734 participants in eligible age groups (14-34 years). Overall, obesity was associated with increased MS risk (hazard ratio [HR] 1.53 [95% confidence interval (CI) 1.25-1.88]), and the risk was similar in men (HR 1.4 [95% CI 0.95-2.06] and women (HR 1.59 [95% CI 1.25-2.02]). Risk was highest for the youngest age groups (age 14-16: HR 1.73 [95% CI 1.19-2.53]; 17-19: HR 1.61 [95% CI 1.08-2.39]; 20-24: HR 1.56 [95% CI 1.04-2.36]) and was no longer present for those >30 years of age. DISCUSSION High BMI in individuals 14 to 24 years of age was associated with increased MS risk later in life in both male and female individuals.
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Affiliation(s)
- Rune A Aa Høglund
- From the Department of Neurology (R.A.A.H., T.H., O.N.), Akershus University Hospital, Lørenskog; Norwegian Institute of Public Health (H.E.M., H.S.); Department of Community Medicine and Global Health (H.E.M., H.S.) and Institute of Clinical Medicine (T.H.), University of Oslo; Department of Clinical Medicine (O.T., N.G.), University of Bergen; Neuro-SysMed (O.T.), Department of Neurology, Haukeland University Hospital; and Norwegian Multiple Sclerosis Competence Centre (N.G.), Department of Neurology, Haukeland University Hospital, Bergen, Norway.
| | - Haakon E Meyer
- From the Department of Neurology (R.A.A.H., T.H., O.N.), Akershus University Hospital, Lørenskog; Norwegian Institute of Public Health (H.E.M., H.S.); Department of Community Medicine and Global Health (H.E.M., H.S.) and Institute of Clinical Medicine (T.H.), University of Oslo; Department of Clinical Medicine (O.T., N.G.), University of Bergen; Neuro-SysMed (O.T.), Department of Neurology, Haukeland University Hospital; and Norwegian Multiple Sclerosis Competence Centre (N.G.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Hein Stigum
- From the Department of Neurology (R.A.A.H., T.H., O.N.), Akershus University Hospital, Lørenskog; Norwegian Institute of Public Health (H.E.M., H.S.); Department of Community Medicine and Global Health (H.E.M., H.S.) and Institute of Clinical Medicine (T.H.), University of Oslo; Department of Clinical Medicine (O.T., N.G.), University of Bergen; Neuro-SysMed (O.T.), Department of Neurology, Haukeland University Hospital; and Norwegian Multiple Sclerosis Competence Centre (N.G.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- From the Department of Neurology (R.A.A.H., T.H., O.N.), Akershus University Hospital, Lørenskog; Norwegian Institute of Public Health (H.E.M., H.S.); Department of Community Medicine and Global Health (H.E.M., H.S.) and Institute of Clinical Medicine (T.H.), University of Oslo; Department of Clinical Medicine (O.T., N.G.), University of Bergen; Neuro-SysMed (O.T.), Department of Neurology, Haukeland University Hospital; and Norwegian Multiple Sclerosis Competence Centre (N.G.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Nina Grytten
- From the Department of Neurology (R.A.A.H., T.H., O.N.), Akershus University Hospital, Lørenskog; Norwegian Institute of Public Health (H.E.M., H.S.); Department of Community Medicine and Global Health (H.E.M., H.S.) and Institute of Clinical Medicine (T.H.), University of Oslo; Department of Clinical Medicine (O.T., N.G.), University of Bergen; Neuro-SysMed (O.T.), Department of Neurology, Haukeland University Hospital; and Norwegian Multiple Sclerosis Competence Centre (N.G.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Trygve Holmøy
- From the Department of Neurology (R.A.A.H., T.H., O.N.), Akershus University Hospital, Lørenskog; Norwegian Institute of Public Health (H.E.M., H.S.); Department of Community Medicine and Global Health (H.E.M., H.S.) and Institute of Clinical Medicine (T.H.), University of Oslo; Department of Clinical Medicine (O.T., N.G.), University of Bergen; Neuro-SysMed (O.T.), Department of Neurology, Haukeland University Hospital; and Norwegian Multiple Sclerosis Competence Centre (N.G.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Ola Nakken
- From the Department of Neurology (R.A.A.H., T.H., O.N.), Akershus University Hospital, Lørenskog; Norwegian Institute of Public Health (H.E.M., H.S.); Department of Community Medicine and Global Health (H.E.M., H.S.) and Institute of Clinical Medicine (T.H.), University of Oslo; Department of Clinical Medicine (O.T., N.G.), University of Bergen; Neuro-SysMed (O.T.), Department of Neurology, Haukeland University Hospital; and Norwegian Multiple Sclerosis Competence Centre (N.G.), Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Wergeland S, Parkar AP, Maric S, Torkildsen Ø. A young woman with persistent nausea, vomiting and hiccups. Tidsskr Nor Laegeforen 2021; 141:21-0071. [PMID: 34641651 DOI: 10.4045/tidsskr.21.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Neuromyelitis optica is an inflammatory syndrome of the central nervous system, associated with anti-aquaporin-4 IgG antibodies. It is associated with severe neurological symptoms and risk of permanent neurological disability. The diagnosis can be established on the basis of clinical core characteristics of neuromyelitis optica, together with serological testing for anti-aquaporin-4 IgG antibodies and magnetic resonance imaging of the central nervous system. CASE PRESENTATION We describe the case of a young woman presenting with obstipation, persistent nausea, vomiting and hiccups. The initial diagnostic workup confirmed obstipation, but did not find any underlying gastrointestinal pathology that could explain her persistent symptoms. Her condition deteriorated, she was unable to eat or drink without inducing vomiting, and eventually she received parenteral nutrition. Further diagnostic workup included magnetic resonance imaging of the brain, which revealed a T2-hyperintense lesion in the medulla oblongata, more specifically in the area postrema. Neurological and neuroradiological assessment led to a tentative clinical diagnosis of neuromyelitis optica spectrum disorder with a well-described, but rare, presentation: the area postrema syndrome. The diagnosis was confirmed by serological testing for anti-aquaporin-4 IgG antibodies. She was successfully treated with methylprednisolone with complete remission of symptoms. Patients with neuromyelitis optica spectrum disorders frequently experience relapses of the disease if untreated, and she was therefore treated with rituximab to prevent future relapses. INTERPRETATION This case is a reminder that common gastrointestinal symptoms may be caused by diseases of the central nervous system.
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29
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Grytten N, Myhr KM, Celius EG, Benjaminsen E, Kampman MT, Midgard R, Vatne A, Aarseth JH, Riise T, Torkildsen Ø. Incidence of cancer in multiple sclerosis before and after the treatment era- a registry- based cohort study. Mult Scler Relat Disord 2021; 55:103209. [PMID: 34419754 DOI: 10.1016/j.msard.2021.103209] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 04/07/2021] [Revised: 07/30/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Whether disease-modifying therapies (DMTs) influence cancer in multiple sclerosis (MS) is uncertain. OBJECTIVES Assess incidence of cancer diagnosis among Norwegian MS patients compared to the general population in 1953 to 1995 and 1996 to 2017-reflecting era before and after introduction of DMTs. METHODS We performed a nationwide cohort study comprising 6949 MS patients and 37,922 controls, matched on age, sex and county. The cohort was linked to Norwegian Cancer Registry, Cause of Death Registry and National Educational database. We used Poisson regression to calculate incidence rate ratio (IRR) of cancer. RESULTS During 1953-1995 MS patients had similar cancer frequency compared to controls (IRR: 1.11 (95% Confidence Intervals (CI): 0.90-1.37)), although MS patients had increased frequency of cancer in endocrine glands (IRR: 2.51 (1.27-4.93). During 1996-2017 we identified significant increased frequency of cancer among MS patients compared to controls (IRR: 1.38 (95% CI: 1.28-1.52): in brain (IRR: 1.97 (1.41-2.78)), meninges (IRR: 2.44 (1.54-3.77)), respiratory organs (IRR: 1.96 (1.49-2.63)). The excess cancer diagnosis was most frequent among MS patients ≥ 60 years of age (HR 1.30 (1.15-1.47)). CONCLUSION Incidence of cancer among MS patients compared to controls was higher in 1996 to 2017, corresponding in time to the introduction of DMT for MS. This was observed more frequently among MS patients older than 60 years of age.
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Affiliation(s)
- Nina Grytten
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Elisabeth G Celius
- Department of Neurology, Oslo University Hospital Ullevål, Oslo, Norway; Institute of clinical medicine, University of Oslo, Oslo, Norway
| | | | - Margitta T Kampman
- Department of Neurology, University Hospital of Northern Norway, Tromsø, Norway
| | - Rune Midgard
- Department of Neurology, Molde Hospital, Molde, Norway; Norwegian University of Science and Technology, Norway
| | - Anita Vatne
- Department of Rehabilitation, Southern Norway Hospital, Norway
| | - Jan H Aarseth
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Norwegian MS Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Trond Riise
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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30
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Torgauten HM, Myhr KM, Wergeland S, Bø L, Aarseth JH, Torkildsen Ø. Safety and efficacy of rituximab as first- and second line treatment in multiple sclerosis - A cohort study. Mult Scler J Exp Transl Clin 2021; 7:2055217320973049. [PMID: 33796328 PMCID: PMC7970692 DOI: 10.1177/2055217320973049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/11/2020] [Accepted: 10/17/2020] [Indexed: 12/04/2022] Open
Abstract
Background Rituximab is increasingly used as off-label therapy in multiple sclerosis (MS). More data are needed on safety and efficacy of rituximab, particularly in cohorts of de novo patients and patients in early therapy escalation. Objective To investigate the safety and efficacy of off-label treatment with rituximab in an MS-cohort of predominantly de novo patients or as therapy escalation. Methods We retrieved safety and efficacy data from the Norwegian MS-registry and biobank for all MS-patients treated with rituximab at Haukeland University Hospital, Bergen, Norway, during a four year period. Results In the 365 MS-patients (320 relapsing-remitting MS (RRMS), 23 secondary progressive MS (SPMS), and 22 primary progressive MS (PPMS)), the overall annualized relapse rate (ARR) was 0.03 and annualized drug discontinuation rate (ADDR) was 0.05. NEDA-3 was achived in 79% of patients with available data (n=351). Sixty-one patients experienced infusion-related adverse events of which two were serious (CTCAE grade 3–4). Eighteen patients experienced serious non-infusion related adverse events, of which 16 were infections. Infections (n = 34; 9.3%, CTCAE grade 2-5), hypogammaglobulinemia (n = 19, 5.2%) and neutropenia (n = 16; 4.4%) were the most common non-infusion-related adverse events. Conclusion Rituximab was a safe and highly efficient disease modifying therapy in this cohort of MS-patients; however, infections and neutropenia need to be monitored.
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Affiliation(s)
- Hilde Marie Torgauten
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Stig Wergeland
- Norwegian Multiple Sclerosis Registry, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Jan H Aarseth
- Norwegian Multiple Sclerosis Registry, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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31
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Wesnes K, Myhr KM, Riise T, Kvistad SS, Torkildsen Ø, Wergeland S, Holmøy T, Midgard R, Bru A, Edland A, Eikeland R, Gosal S, Harbo HF, Kleveland G, Sørenes YS, Øksendal N, Bjørnevik K. Low vitamin D, but not tobacco use or high BMI, is associated with long-term disability progression in multiple sclerosis. Mult Scler Relat Disord 2021; 50:102801. [PMID: 33636616 DOI: 10.1016/j.msard.2021.102801] [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] [Received: 12/18/2020] [Revised: 01/21/2021] [Accepted: 01/25/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Low vitamin D levels, tobacco use and high body mass index (BMI) have been linked to adverse disease outcomes in multiple sclerosis (MS), but their influence on long-term disability progression remains unclear. Therefore, we explored whether these modifiable lifestyle factors were associated with 10-year clinical disability progression in patients with MS. METHODS In this prospective study, a cohort of 88 patients with relapsing-remitting MS completed a randomized controlled study on ω-3 fatty acids between 2004 and 2008. During 24 months, serum 25-hydroxyvitamin D (25(OH)D), serum cotinine (nicotine metabolite), and BMI were repeatedly measured. In 2017, a follow-up study was conducted among 80 of the participants, including disability assessment by the Expanded Disability Status Scale (EDSS). Linear regression was used to explore associations between the lifestyle factors and the EDSS change over 10 years. RESULTS Higher seasonally adjusted 25(OH)D levels were associated with lower 10-year EDSS progression (change in EDSS per 1 SD increase in 25(OH)D in a model adjusted for sex, age and baseline EDSS: -0.45 point, 95% CI: -0.75 to -0.16, p=0.003). Further adjustments for potential confounders related to lifestyle and disease status gave similar results. The association was mainly driven by low 25(OH)D levels during spring, as well as seasonally adjusted levels below 80 nmol/L. No clear association was found for BMI and cotinine. CONCLUSION Lower 25(OH)D levels, but apparently not tobacco use or higher BMI, were significantly associated with worse long-term disability progression in MS.
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Affiliation(s)
- Kristin Wesnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Neurology, St. Olav's University Hospital, Trondheim, Norway.
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Trond Riise
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Silje Stokke Kvistad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Immunology and Transfusion medicine, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Norwegian Multiple Sclerosis Competence Center, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Trygve Holmøy
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Rune Midgard
- Department of Neurology, Molde Hospital, Molde, Norway
| | - Alla Bru
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Astrid Edland
- Department of Neurology, Vestre Viken Hospital Trust, Drammen, Norway
| | - Randi Eikeland
- Department of Neurology and Department of Paediatrics, Sørlandet Hospital Trust, Arendal, Norway
| | - Sonia Gosal
- Department of Neurology, Østfold Hospital Kalnes, Grålum, Norway
| | - Hanne F Harbo
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Neurology, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Grethe Kleveland
- Department of Neurology, Innlandet Hospital Lillehammer, Lillehammer, Norway
| | | | - Nina Øksendal
- Department of Neurology, Nordland hospital trust, Bodø, Norway
| | - Kjetil Bjørnevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Torkildsen Ø. Serum markers of multiple sclerosis - a new approach. EBioMedicine 2021; 64:103229. [PMID: 33516064 PMCID: PMC7847952 DOI: 10.1016/j.ebiom.2021.103229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen Norway.
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Skorve E, Lundervold AJ, Torkildsen Ø, Myhr KM. A two-year longitudinal follow-up of cognitive performance assessed by BICAMS in newly diagnosed patients with MS. Mult Scler Relat Disord 2020; 46:102577. [PMID: 33296975 DOI: 10.1016/j.msard.2020.102577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/09/2020] [Accepted: 10/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cognitive impairment is common in patients with multiple sclerosis (MS) and may occur at any stage and with any subtype of the disease. Screening and monitoring of cognitive function should therefore be implemented into everyday clinical neurology practice. The Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) was developed for this purpose. Although several cross-sectional studies have validated BICAMS, longitudinal studies evaluating its use as part of a clinical follow-up routine are still lacking. OBJECTIVE To investigate cognitive function and trajectories of change assessed by the BICAMS test battery in a cohort of newly diagnosed relapsing-remitting MS (RRMS) patients examined at baseline and after 12 and 24 months. METHODS BICAMS was used to assess cognitive function in 58 RRMS patients, who also filled in the Hospital Anxiety and Depression Scale (HADS) and the Fatigue Scale for Motor and Cognitive Functions (FSMC), and underwent standard neurological evaluations at baseline and at the two follow-ups. RESULTS A total of 27 patients (46.6%) were defined as cognitively impaired at baseline on at least one test, and 22 (37.9%) were defined as impaired at follow-up after 24 months. Throughout the study, 8 (13.8%) and 4 (6.9%) patients were consistently defined as impaired on two or three tests, respectively. The mean raw scores on two BICAMS subtests (SDMT and CVLT-II) improved significantly from baseline to the first follow-up, and then remained stable the next year, whereas the visual memory test (BVMT-R) were overall unchanged from baseline to the end of the study. The correlations between the scores on HADS, FSMC and the BICAMS subtests were non-significant at baseline, but weak to moderate negative correlations were found at the one- and two-year follow-ups. CONCLUSION The patients showed improved test results from baseline to the first follow-up examination, indicating that an effect of previous practise should be taken into account when interpreting the results. With results showing both trajectories of stability and change, our study supported the validity of including BICAMS as part of a clinical follow-up routine of RRMS patients. Anxiety, depression, fatigue and cognition should always be assessed at the same time to reveal interaction effects that are expected to affect the daily-life functioning of at least some of the RRMS patients.
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Affiliation(s)
- Ellen Skorve
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Astri J Lundervold
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Torkildsen Ø, Linker RA, Sesmero JM, Fantaccini S, Sanchez-de la Rosa R, Seze JD, Duddy M, Chan A. Living with secondary progressive multiple sclerosis in Europe: perspectives of multiple stakeholders. Neurodegener Dis Manag 2020; 11:9-19. [PMID: 33234006 DOI: 10.2217/nmt-2020-0054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The transition from relapsing-remitting multiple sclerosis to secondary progressive multiple sclerosis (SPMS) remains a clinical challenge owing to the heterogeneous course of the disease, indistinct disease progression and lack of availability of validated biomarkers and diagnostic tools. This article summarizes the outcomes from an international expert group meeting conducted to validate the preliminary research findings gathered through interviews with primary healthcare stakeholders and pharmaceutical representatives, and to understand the current and future patient journey of SPMS across seven European countries. We highlight the uncertainty in SPMS diagnosis and management and, consequently, the need for uniform assessment guidelines, enhanced awareness and a collaborative effort between the stakeholders associated with SPMS patient care and the pharmaceutical industry.
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Affiliation(s)
- Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, 5020, Bergen, Norway
| | - Ralf A Linker
- Department of Neurology, University Hospital, 93053, Regensburg, Germany
| | | | | | | | - Jerome de Seze
- University Hospital of Strasbourg, 67200, Strasbourg, France
| | - Martin Duddy
- Department of Neurology, The Newcastle upon Tyne Hospitals Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
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Torkildsen Ø, Myhr KM, Skogen V, Steffensen LH, Bjørnevik K. Tenofovir as a treatment option for multiple sclerosis. Mult Scler Relat Disord 2020; 46:102569. [DOI: 10.1016/j.msard.2020.102569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/14/2020] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
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Holmøy T, Høglund RA, Illes Z, Myhr KM, Torkildsen Ø. Recent progress in maintenance treatment of neuromyelitis optica spectrum disorder. J Neurol 2020; 268:4522-4536. [PMID: 33011853 PMCID: PMC8563615 DOI: 10.1007/s00415-020-10235-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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] [Received: 07/14/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
Background Treatment of neuromyelitis optica spectrum disorder (NMOSD) has so far been based on retrospective case series. The results of six randomized clinical trials including five different monoclonal antibodies targeting four molecules and three distinct pathophysiological pathways have recently been published. Methods Literature search on clinical trials and case studies in NMOSD up to July 10. 2020. Results We review mechanism of action, efficacy and side effects, and consequences for reproductive health from traditional immunosuppressants and monoclonal antibodies including rituximab, inebilizumab, eculizumab, tocilizumab and satralizumab. Conclusion In NMOSD patients with antibodies against aquaporin 4, monoclonal antibodies that deplete B cells (rituximab and inebilizumab) or interfere with interleukin 6 signaling (tocilizumab and satralizumab) or complement activation (eculizumab) have superior efficacy compared to placebo. Tocilizumab and rituximab were also superior to azathioprine in head-to-head studies. Rituximab, tocilizumab and to some extent eculizumab have well-known safety profiles for other inflammatory diseases, and rituximab and azathioprine may be safe during pregnancy.
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Affiliation(s)
- Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Rune Alexander Høglund
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Røsjø E, Lindstrøm JC, Holmøy T, Myhr KM, Varhaug KN, Torkildsen Ø. Natural Variation of Vitamin D and Neurofilament Light Chain in Relapsing-Remitting Multiple Sclerosis. Front Neurol 2020; 11:329. [PMID: 32425877 PMCID: PMC7205013 DOI: 10.3389/fneur.2020.00329] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/03/2020] [Indexed: 01/09/2023] Open
Abstract
Background: High serum levels of 25-hydroxyvitamin D (25(OH)D) have been found among patients with a favorable disease course in relapsing-remitting MS (RRMS), indicating that this may limit clinical deterioration. Clinical deterioration in RRMS correlates with increasing serum levels of neurofilament light chain (NfL). Objectives: To examine the association between physiological variations in serum 25(OH)D and NfL levels in RRMS patients before and during disease modifying therapy (DMT). Material and Methods: Serum 25(OH)D and NfL concentrations were measured in 85 newly diagnosed RRMS patients enrolled in a 24-month randomized double-blinded placebo-controlled trial of ω-3 fatty acid supplementation without vitamin D. Patients were without DMT until interferon β-1a (IFN-β) initiation at study month 6. Longitudinal serum measurements and brain magnetic resonance imaging (MRI) were obtained. Associations between 25(OH)D and NfL levels were analyzed with linear regression models for the whole study period and the periods before and during IFN-β treatment. Analyses with adjustment for inflammatory MRI disease activity were also performed. Results: No significant associations were found between variations in 25(OH)D and NfL levels during the whole study period (p = 0.95), or the periods without (p = 0.78) or with (p = 0.33) IFN-β therapy. Patients with inflammatory MRI disease activity had significantly higher serum NfL levels than patients without inflammatory MRI disease activity [mean (SD) difference 12.6 (2.0) pg/mL, p < 0.01]. Adjustment for this did not change the relationship between 25(OH)D and NfL concentrations. Conclusion: Natural variations in serum 25(OH)D values do not seem to be associated with alterations in serum NfL concentrations in RRMS patients.
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Affiliation(s)
| | - Jonas C Lindstrøm
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Trygve Holmøy
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kristin N Varhaug
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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38
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Holmøy T, Torkildsen Ø, Bø L. Behandling av multippel sklerose under covid-19-pandemien. Tidsskriftet 2020; 140:20-0333. [DOI: 10.4045/tidsskr.20.0333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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39
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Kvistad SAS, Lehmann AK, Trovik LH, Kristoffersen EK, Bø L, Myhr KM, Torkildsen Ø. Safety and efficacy of autologous hematopoietic stem cell transplantation for multiple sclerosis in Norway. Mult Scler 2019; 26:1889-1897. [DOI: 10.1177/1352458519893926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Hematopoietic stem cell treatment (HSCT) is a promising treatment option for multiple sclerosis (MS), but detailed safety and efficacy measures are still scarce. Objective: To evaluate the efficacy and safety of HSCT in MS. Methods: Retrospective single-center observational study of all MS patients that underwent HSCT in Norway during January 2015 to January 2018. The primary outcome was no evidence of disease activity (NEDA-3) status. Results: A total of 30 patients with a median follow-up time of 26 months (range: 11–48) were evaluated. In total, 25 (83%) achieved NEDA-3 status, and none received disease-modifying treatment after HSCT. For 13 (43%) of the patients, there were sustained improvement in Expanded Disability Status Scale (EDSS) score, and 10 (33%) were working full time after the treatment, compared to only 1 (3%) before treatment. There were no serious treatment-related complications and was no mortality. Five patients (17%) were diagnosed with an autoimmune thyroid disease after the procedure, and 10 (43%) of the women had amenorrhea lasting >12 months and symptoms of ovarian failure. Conclusion: HSCT in MS is an effective and relatively safe treatment option, with few serious complications and no mortality in Norway, so far. However, long-term adverse event with amenorrhea is a common problem.
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Affiliation(s)
- Silje Agnethe Stokke Kvistad
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway/Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | | | | | - Lars Bø
- Norwegian Multiple Sclerosis Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway/Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway/Norwegian Multiple Sclerosis Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway/Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Abstract
Vitamin D and its main active metabolite 1,25-dihydroxyvitamin D serve a crucial role in maintenance of a healthy calcium metabolism, yet have additional roles in immune and central nervous system cell homeostasis. Serum levels of 25-hydroxyvitamin D are a biomarker of future disease activity in patients with early relapsing-remitting multiple sclerosis (RRMS), and vitamin D supplementation in patients with low circulating 25-dihydroxyvitamin D levels has been anticipated as a potential efficacious treatment strategy. The results of the first large randomized clinical trials (RCTs), the SOLAR and CHOLINE studies, have now been published. The SOLAR study compared 14,000 IU of vitamin D3 (cholecalciferol) per day with placebo for 48 weeks in 232 randomized patients, whereas CHOLINE compared vitamin D3 100,000 IU every other week with placebo for 96 weeks in 129 randomized patients. All patients in both studies also used interferon-β-1a. None of the studies met their primary endpoints, which were no evidence of disease activity (NEDA-3) at 48 weeks in SOLAR and annualized relapse rate at 96 weeks in CHOLINE. Both studies did, however, suggest modest effects on secondary endpoints. Thus, vitamin D reduced the number of new or enlarging lesions and new T2 lesions in SOLAR, and the annualized relapse rate and number of new T1 lesions, volume of hypointense T1 lesions, and disability progression in the 90 patients who completed 96 weeks' follow-up in CHOLINE. We conclude that none of the RCTs on vitamin supplementation in MS have met their primary clinical endpoint in the intention to treat cohorts. This contrasts the observation studies, where each 25 nmol/l increase in 25-hydroxyvitamin D levels were associated with 14-34% reduced relapse risk and 15-50% reduced risk of new lesions on magnetic resonnance imaging. This discrepancy may have several explanations, including confounding and reverse causality in the observational studies. The power calculations of the RCTs have been based on the observational studies, and the RCTs may have been underpowered to detect less prominent yet important effects of vitamin D supplementation. Although the effect of vitamin D supplementation is uncertain and less pronounced than suggested by observational studies, current evidence still support that people with MS should avoid vitamin D insufficiency, and preferentially aim for vitamin D levels around 100 nmol/L or somewhat higher.
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Affiliation(s)
- Joost Smolders
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Neuroimmunology Research Group, Netherlands Institute for Neuroscience, Amsterdam, The Netherlands
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Institute for Clinical Medicine, University of Bergen, Bergen, Norway
| | - William Camu
- Centre de Référence SLA, CHU Gui de Chauliac et Univ Montpellier, Montpellier, France
| | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Box 1000, 1478, Lørenskog, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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Nystad AE, Lereim RR, Wergeland S, Oveland E, Myhr KM, Bø L, Torkildsen Ø. Fingolimod downregulates brain sphingosine-1-phosphate receptor 1 levels but does not promote remyelination or neuroprotection in the cuprizone model. J Neuroimmunol 2019; 339:577091. [PMID: 31739156 DOI: 10.1016/j.jneuroim.2019.577091] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 11/28/2022]
Abstract
Fingolimod is used to treat patients with relapsing-remitting multiple sclerosis; it crosses the blood-brain barrier and modulates sphingosine-1-phosphate receptors (S1PRs). Oligodendrocytes, astrocytes, microglia, and neuronal cells express S1PRs, and fingolimod could potentially improve remyelination and be neuroprotective. We used the cuprizone animal model, histo-, immunohistochemistry, and quantitative proteomics to study the effect of fingolimod on remyelination and axonal damage. Fingolimod was functionally active during remyelination by downregulating S1PR1 brain levels, and fingolimod-treated mice had more oligodendrocytes in the secondary motor cortex after three weeks of remyelination. However, there were no differences in remyelination or axonal damage compared to placebo. Thus, fingolimod does not seem to directly promote remyelination or protect against axonal injury or loss when given after cuprizone-induced demyelination.
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Affiliation(s)
- Agnes E Nystad
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Ragnhild Reehorst Lereim
- Proteomics Unit at University of Bergen (PROBE), Department of Biomedicine, University of Bergen, Norway; Computational Biology Unit (CBU), Department of Informatics, University of Bergen, Bergen, Norway
| | - Stig Wergeland
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Eystein Oveland
- Proteomics Unit at University of Bergen (PROBE), Department of Biomedicine, University of Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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42
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Affiliation(s)
- Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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43
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Grytten N, Myhr KM, Celius EG, Benjaminsen E, Kampman M, Midgard R, Vatne A, Aarseth JH, Riise T, Torkildsen Ø. Risk of cancer among multiple sclerosis patients, siblings, and population controls: A prospective cohort study. Mult Scler 2019; 26:1569-1580. [DOI: 10.1177/1352458519877244] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Risk of cancer in multiple sclerosis (MS) patients compared to their siblings is unknown. Objective: The objective was to prospectively investigate the risk of cancer among MS patients compared to siblings without MS and to population controls. Methods: We retrieved data on MS patients born between 1930 and 1979 from the Norwegian Multiple Sclerosis Registry and population studies and on cancer diagnosis from the Cancer Registry of Norway. We used adjusted Cox proportional hazard regression to estimate cancer risk among 6883 MS patients, 8918 siblings without MS, and 37,919 population controls. Results: During 65 years of follow-up, cancer risk among MS patients was higher than that among population controls (hazard ratio (HR) = 1.14, 95% confidence interval (CI): 1.05–1.23) in respiratory organs (HR = 1.66, 95% CI: 1.26–2.19), urinary organs (HR = 1.51, 95% CI: 1.12–2.04), and the central nervous system (HR = 1.52, 95% CI: 1.11–2. 09). Siblings had higher risk of hematological cancers compared with MS patients (HR = 1.82, 95% CI: 1.21–2.73) and population controls (HR = 1.72, 95% CI: 1.36–2.18). Conclusion: MS patients were associated with increased risk of cancer compared to population controls. Siblings had increased risk of hematological cancer. This indicates that MS and hematological cancer could share a common etiology.
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Affiliation(s)
- Nina Grytten
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway/Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Elisabeth G Celius
- Department of Neurology, Oslo University Hospital, Ullevål, Oslo, Norway/Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Margitta Kampman
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - Rune Midgard
- Department of Neurology, Molde Hospital, Molde, Norway/Norwegian University of Science and Technology, Trondheim, Norway
| | - Anita Vatne
- Department of Rehabilitation, Hospital of Southern Norway, Kristiansand, Norway
| | - Jan H Aarseth
- Norwegian MS Registry and Biobank, Haukeland University Hospital, Bergen, Norway
| | - Trond Riise
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway/Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway/Department of Clinical Medicine, University of Bergen, Bergen, Norway/Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Varhaug KN, Torkildsen Ø, Myhr KM, Vedeler CA. Neurofilament Light Chain as a Biomarker in Multiple Sclerosis. Front Neurol 2019; 10:338. [PMID: 31024432 PMCID: PMC6460359 DOI: 10.3389/fneur.2019.00338] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/19/2019] [Indexed: 12/12/2022] Open
Abstract
Due to the unpredictable course and heterogenous treatment response in multiple sclerosis (MS), there is a clear need for biomarkers that reflect disease activity in the clinical follow-up of these patients. Neurofilaments are neuron-specific components of the cytoskeleton that can be assayed in different body compartments. They have been explored as potential biomarkers for many years. Neurofilament light chain (NF-L) appears the most promising biomarker in MS patients, and there is now little doubt that NF-L should have a role in the follow-up of MS patients. Newer assays and techniques for NF-L detection available in serum samples confirms the usefulness of NF-L as a biomarker. Nevertheless, there is still a need for prospective studies, and studies to determine clinical useful cut-off values. This review evaluates the strengths and weaknesses of NF-L as a biomarker in patients with MS.
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Affiliation(s)
- Kristin N Varhaug
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway.,Neuro-SysMed - Centre of Excellence for Experimental Therapy in Neurology, Department of Neurology, Haukeland University Hospital, and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway.,Neuro-SysMed - Centre of Excellence for Experimental Therapy in Neurology, Department of Neurology, Haukeland University Hospital, and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway.,Neuro-SysMed - Centre of Excellence for Experimental Therapy in Neurology, Department of Neurology, Haukeland University Hospital, and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian A Vedeler
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway.,Neuro-SysMed - Centre of Excellence for Experimental Therapy in Neurology, Department of Neurology, Haukeland University Hospital, and Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. The latest development of B-cell depletion by anti-CD20 monoclonal antibodies has been a large step forward in the treatment of this devastating disease. AREAS COVERED In this manuscript, we review mechanisms of action, efficacy, safety, and tolerance of anti-CD20 therapies for MS, including rituximab, ocrelizumab, and ofatumumab. EXPERT OPINION B-cell depletion efficiently suppresses acute inflammatory disease activity in relapsing-remitting MS (RRMS), and may slowdown progression in primary progressive MS (PPMS). The treatment is generally well tolerated, with manageable adverse events related to infusion reactions and infections. Ocrelizumab, a humanized anti-CD20 monoclonal antibody, is the first therapy to be approved for the treatment of both RRMS and PPMS.
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Affiliation(s)
- Kjell-Morten Myhr
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Øivind Torkildsen
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Andreas Lossius
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,d Department of Immunology and Transfusion Medicine, Faculty of Medicine , University of Oslo and Oslo University Hospital Rikshospitalet , Oslo , Norway
| | - Lars Bø
- a Department of Clinical Medicine , University of Bergen , Bergen , Norway.,b Department of Neurology , Haukeland University Hospital , Bergen , Norway
| | - Trygve Holmøy
- c Department of Neurology , Akershus University Hospital , Lørenskog , Norway.,e Department of Clinical Medicine , University of Oslo , Oslo , Norway
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Hobart J, Bowen A, Pepper G, Crofts H, Eberhard L, Berger T, Boyko A, Boz C, Butzkueven H, Celius EG, Drulovic J, Flores J, Horáková D, Lebrun-Frénay C, Marrie RA, Overell J, Piehl F, Rasmussen PV, Sá MJ, Sîrbu CA, Skromne E, Torkildsen Ø, van Pesch V, Vollmer T, Zakaria M, Ziemssen T, Giovannoni G. International consensus on quality standards for brain health-focused care in multiple sclerosis. Mult Scler 2018; 25:1809-1818. [PMID: 30381987 PMCID: PMC6826858 DOI: 10.1177/1352458518809326] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [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: 11/15/2022]
Abstract
Background: Time matters in multiple sclerosis (MS). Irreversible neural damage and cell loss occur from disease onset. The MS community has endorsed a management strategy of prompt diagnosis, timely intervention and regular proactive monitoring of treatment effectiveness and disease activity to improve outcomes in people with MS. Objectives: We sought to develop internationally applicable quality standards for timely, brain health–focused MS care. Methods: A panel of MS specialist neurologists participated in an iterative, online, modified Delphi process to define ‘core’, ‘achievable’ and ‘aspirational’ time frames reflecting minimum, good and high care standards, respectively. A multidisciplinary Reviewing Group (MS nurses, people with MS, allied healthcare professionals) provided insights ensuring recommendations reflected perspectives from multiple stakeholders. Results: Twenty-one MS neurologists from 19 countries reached consensus on most core (25/27), achievable (25/27) and aspirational (22/27) time frames at the end of five rounds. Agreed standards cover six aspects of the care pathway: symptom onset, referral and diagnosis, treatment decisions, lifestyle, disease monitoring and managing new symptoms. Conclusion: These quality standards for core, achievable and aspirational care provide MS teams with a three-level framework for service evaluation, benchmarking and improvement. They have the potential to produce a profound change in the care of people with MS.
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Affiliation(s)
- Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Amy Bowen
- NHS RightCare, NHS England, London, UK
| | | | | | | | - Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexey Boyko
- Department of Neurology, Neurosurgery and Medical Genetics, Pirogov Russian National Research Medical University, Moscow, Russia/Demyelinating Diseases Center, Yusupov Hospital, Moscow, Russia
| | - Cavit Boz
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | - Helmut Butzkueven
- MS and Neuroimmunology Unit, Alfred Health and Eastern Health, Monash University, Melbourne, VIC, Australia
| | | | - Jelena Drulovic
- Department for Immune-Mediated Disorders of the Central Nervous System, Clinic of Neurology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - José Flores
- National Institute of Neurology and Neurosurgery, ABC Medical Center, Mexico City, Mexico
| | - Dana Horáková
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | | | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - James Overell
- Glasgow MS Clinical Research Centre, Queen Elizabeth University Hospital, Glasgow, UK
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Maria José Sá
- MS Clinic, Department of Neurology, Centro Hospitalar São João, Faculty of Health Sciences, University Fernando Pessoa, Porto, Portugal
| | - Carmen-Adella Sîrbu
- Clinic of Neurology, Central Military Emergency University Hospital, Bucharest, Romania
| | - Eli Skromne
- Instituto Mexicano de Neurociencias, Hospital Angeles Lomas, Mexico City, Mexico
| | - Øivind Torkildsen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Vincent van Pesch
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Timothy Vollmer
- Department of Neurology, University of Colorado, Denver, CO, USA
| | - Magd Zakaria
- Department of Neurology, Ain Shams University, Cairo, Egypt
| | - Tjalf Ziemssen
- Department of Neurology, MS Center Dresden, Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Gavin Giovannoni
- Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
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Wergeland S, Riise T, Torkildsen Ø. Response to 'Seasonal variation of vitamin D and Epstein-Barr virus antibody in multiple sclerosis patients', a comment letter regarding 'Vitamin D, HLA-DRB1 and Epstein-Barr virus antibody levels in a prospective cohort of multiple sclerosis patients'. Eur J Neurol 2018; 25:e104. [PMID: 30134049 DOI: 10.1111/ene.13719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 11/28/2022]
Affiliation(s)
- S Wergeland
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - T Riise
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ø Torkildsen
- Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Nystad AE, Torkildsen Ø, Wergeland S. Effects of vitamin D on axonal damage during de- and remyelination in the cuprizone model. J Neuroimmunol 2018; 321:61-65. [DOI: 10.1016/j.jneuroim.2018.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023]
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Kvistad SS, Myhr KM, Holmøy T, Benth JŠ, Wergeland S, Beiske AG, Bjerve KS, Hovdal H, Midgard R, Sagen JV, Torkildsen Ø. Serum levels of leptin and adiponectin are not associated with disease activity or treatment response in multiple sclerosis. J Neuroimmunol 2018; 323:73-77. [PMID: 30196837 DOI: 10.1016/j.jneuroim.2018.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 06/04/2018] [Revised: 06/29/2018] [Accepted: 07/23/2018] [Indexed: 01/07/2023]
Abstract
Adipokines secreted by fatty tissue have inflammatory properties and are suggested biomarkers of MS disease activity. To assess this, 88 MS patients were followed with nine repeated measurements of leptin and adiponectin and 12 magnetic resonance imaging (MRI) scans for two years; six months without any immunomodulatory treatment followed by 18 months during interferon-beta (IFNB) treatment. Serum levels of leptin dropped and adiponectin increased upon initiation of IFNB-therapy, but were not associated with clinical or MRI disease activity or with treatment response. Our findings indicate that leptin and adiponectin are not useful as biomarkers of MS disease activity.
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Affiliation(s)
- Silje Stokke Kvistad
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Norwegian Multiple Sclerosis Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Stig Wergeland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Norwegian Multiple Sclerosis Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Kristian S Bjerve
- Department of Medical Biochemistry, St. Olav's Hospital, Trondheim University Hospital, Norway; Clinic of Laboratory Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Harald Hovdal
- Department of Neurology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Rune Midgard
- Department of Neurology, Molde Hospital, Norway; Unit for Applied Clinical Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jørn V Sagen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Hormone Laboratory, Department of Laboratory Medicine and Pathology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
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50
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Bjornevik K, Myhr KM, Beiske A, Bjerve KS, Holmøy T, Hovdal H, Midgard R, Riise T, Wergeland S, Torkildsen Ø. α-Linolenic acid is associated with MRI activity in a prospective cohort of multiple sclerosis patients. Mult Scler 2018; 25:987-993. [PMID: 29862891 DOI: 10.1177/1352458518779925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 01/26/2023]
Abstract
BACKGROUND The plant-based ω-3 fatty acid α-linolenic acid (ALA) has been associated with lower MS risk. It is currently unknown whether ALA affects disease activity. OBJECTIVE To investigate the association between ALA levels and disease activity. METHODS We conducted a cohort study including 87 multiple sclerosis (MS)-patients who originally participated in a randomized trial of ω-3 fatty acids (the OFAMS study). We measured serum levels of ALA during follow-up and used random intercept logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CIs) for the association between ALA levels, new magnetic resonance imaging (MRI) lesions, Expanded Disability Status Scale (EDSS) progression and new relapses adjusting for age at inclusion, sex, and use of interferon beta-1a. RESULTS In continuous (per 1-SD increase) multivariable-adjusted analyses, higher ALA levels were significantly associated with lower odds of new T2-lesions (OR: 0.59, 95% CI: 0.37-0.95) during follow-up. The effect estimates were similar for new T1Gd + lesions (OR: 0.73, 95% CI: 0.48-1.11), EDSS-progression (OR: 0.62, 95% CI: 0.34-1.16) and new relapses (OR: 0.49, 95% CI: 0.22-1.10), but these estimates did not reach statistical significance. Further adjustment for vitamin D and tobacco use did not materially change the results. CONCLUSION We found that higher levels of ALA were associated with lower disease activity in MS-patients.
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Affiliation(s)
- Kjetil Bjornevik
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; The Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Norwegian MS Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Kristian S Bjerve
- Clinic of Laboratory Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Trygve Holmøy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Harald Hovdal
- Department of Neurology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Rune Midgard
- Department of Neurology, Molde Hospital, Molde, Norway
| | - Trond Riise
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; The Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Norwegian MS Registry and Biobank, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- The Norwegian Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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