[Access to orphan drugs for the treatment of spinal muscular atrophy in Spain]

INTRODUCTION

Spinal muscular atrophy (SMA) is a rare disease whose diagnosis and treatment are complex. In Spain, there are two orphan medicines that are currently financed by the state, nusinersen and onasemnogene abeparvovec and, a third in process, risdiplam. The objective was to detect possible causes of inequity in the diagnosis and treatment of SMA in Spain.

MATERIALS AND METHOD

Descriptive study realized in two phases: a first phase of bibliographic revision and a second phase of semi-structured interviews with clinical experts in SMA in Andalusia, Castilla-La Mancha, Catalonia and Murcia.

RESULTS

The number of centers, services or units of reference, the availability of regional autonomous plans for rare diseases and pilot programs of neonatal screenings can regulate access to treatments. The number of new patients diagnosed per year is estimated between one and six in the four autonomous communities (ACs) of Spain studied. Differences were not found in logistical resources. Two of the four ACs studied have regional autonomous plans for rare diseases, however, their utility has only had relevance in one of two of the ACs.

CONCLUSIONS

Important differences in access to nusinersen were not identified in the studied ACs The diagnosis of SMA requires clinical specialized experts and specialized centers for early intervention of disease-modifying therapies.

Outcomes After Direct Thrombectomy or Combined Intravenous and Endovascular Treatment Are Not Different

Background and Purpose—

Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients.

Methods—

Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel–Haenszel test statistic.

Results—

We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74–1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74–1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25–1.27).

Conclusions—

This observational study suggests that outcomes after direct EVT or combined intravenous thrombolysis+EVT are not different. If confirmed by a randomized controlled trial, it may have a significant impact on organization of stroke systems of care.

Idiopathic acute transverse myelitis: a clinical study and prognostic markers in 45 cases

Objective The Transverse Myelitis Consortium Working Group has proposed new diagnostic criteria for idiopathic acute transverse myelitis (ATM). We reviewed patients admitted to our center diagnosed with myelitis with two objectives: (i) to evaluate the usefulness of these criteria in distinguishing between myelitis as the first episode of multiple sclerosis (MS) and idiopathic ATM; and (ii) to analyse the clinical and laboratory variables that may be used as functional prognostic markers.

Methods We selected patients who met the criteria. We recorded clinical epidemiological data, patients treated with methylprednisolone, maximal disability reached and disability at final follow-up. We also recorded cerebrospinal fluid (CSF) data and the number of levels affected in the spinal magnetic resonance imaging (MRI).

Results Twenty-four patients fulfilled the criteria for definite ATM and 21 for possible ATM. Five patients converted to MS. Mean follow-up time was 3.5 years. There was an association between younger patients and female patients with conversion to MS. The highest Rankin score reached and increased CSF glucose levels were associated with a poor outcome. In multivariate analysis, only the admission Rankin score was associated with outcome.

Conclusions (i) About 10% of patients who met the criteria may convert to MS; and (ii) admission Rankin score was the only independent prognostic factor found.

Access to Endovascular Treatment in Remote Areas

Background and Purpose—

Since demonstration of the benefit of endovascular treatment (EVT) in acute ischemic stroke patients with proximal arterial occlusion, stroke care systems need to be reorganized to deliver EVT in a timely and equitable way. We analyzed differences in the access to EVT by geographical areas in Catalonia, a territory with a highly decentralized stroke model.

Methods—

We studied 965 patients treated with EVT from a prospective multicenter population-based registry of stroke patients treated with reperfusion therapies in Catalonia, Spain (SONIIA). Three different areas were defined: (A) health areas primarily covered by Comprehensive Stroke Centers, (B) areas primarily covered by local stroke centers located less than hour away from a Comprehensive Stroke Center, and (C) areas primarily covered by local stroke centers located more than hour away from a Comprehensive Stroke Center. We compared the number of EVT×100 000 inhabitants/year and time from stroke onset to groin puncture between groups.

Results—

Baseline characteristics were similar between groups. Throughout the study period, there were significant differences in the population rates of EVT across geographical areas. EVT rates by 100 000 in 2015 were 10.5 in A area, 3.7 in B, and 2.7 in C. Time from symptom onset to groin puncture was 82 minutes longer in group B (312 minutes [245–435]) and 120 minutes longer in group C (350 minutes [284–408]) compared with group A (230 minutes [160–407]; P <0.001).

Conclusions—

Accessibility to EVT from remote areas is hampered by lower rate and longer time to treatment compared with areas covered directly by Comprehensive Stroke Centers.

Regression to the mean in multiple sclerosis

In order to ensure sufficient disease activity, patients with relapsing remitting (RR) multiple sclerosis (MS) are often included in randomized placebo-controlled trials, only if they have a high baseline activity. These patients, whose evolution is unusual in the pre-study period, will tend to show a more usual behavior when followed up over a period of time. This phenomenon is known as regression to the mean. Regression to the mean should be taken into account in correctly interpreting long-term studies of cohorts treated without a placebo control group, which use the baseline period as control. The aim of this study was to evaluate the relevance of this phenomenon in a non-treated cohort of RRMS patients, selected with similar criteria to those used in randomized placebo-controlled clinical trials. Forty-four patients with definite RRMS, with two or more relapses in the previous two years, and a baseline EDSS < or = 5.5 were prospectively followed. The mean number of relapses spontaneously decreased from 1.72 (SD: 1.4) in the year prior to enrolment, to 1.0 (SD: 1.3) during the first year of follow-up (P < 0.05). Regression to the mean may explain as much as 40% of the reduction in the relapse rate from the baseline period to the period on-study.

Clinical benefits of interferon beta-1a in relapsing-remitting MS: a phase IV study

OBJECTIVE

To evaluate the efficacy and safety of IFNbeta-1a (Avonex, Biogen, Inc., Cambridge, MA, USA) in patients with relapsing-remitting multiple sclerosis (MS).

METHODS

In this multicenter, open-label, prospective clinical trial, 96 patients with relapsing-remitting MS received IFNbeta-1a 30 mcg intramuscularly once weekly for 2 years. Outcome variables included: change from baseline in mean number of exacerbations, proportion of exacerbation-free patients, and mean Expanded Disability Status Scale (EDSS) scores at Years 1 and 2.

RESULTS

IFNbeta-1a significantly (P < 0.0001) reduced exacerbation rate at Years 1 and 2 of treatment. The percentage of exacerbation-free patients was 53% during Year 1 and 33% during Year 2. Mean EDSS scores were 2.96 +/- 1.26 at baseline, 2.89 +/- 1.42 at Year 1, and 3.00 +/- 1.62 at Year 2 (P = 0.116). EDSS scores improved in 35.4%, remained stable in 28.1%, and worsened in 36.5% of patients. IFNbeta-1a treatment was well tolerated.

CONCLUSION

This study confirms and extends the beneficial clinical profile for IFNbeta-1a in relapsing MS.

[Impairment, disability and handicap scales in multiple sclerosis]

INTRODUCTION AND METHOD

In recent years the need to create scales for measuring the dysfunction or impairment suffered by patients with multiple sclerosis has increased. The aim of the scales that measure neurological impairment is two fold: to homogenise the data from different series so that studies into the prognosis and natural history of the disease can be compared, and to measure the changes in the progress of the disease when a therapy has been established. Over the past few years a large number of scales have appeared that attempt to redress the shortcomings of the EDSS (Expanded Disability Status Scale). The latest of these, the MSF Composite, manages to overcome the statistical problems of the EDSS and enables significant differences between two groups to be detected when studying the effect of a treatment.

CONCLUSIONS

In the coming years we will possibly witness a joint use of several of the scales described, and both the EDSS and the Composite will be employed together in the evaluation of patients in therapeutic protocols, perhaps together with a quality of life scale.

14-3-3 protein in the CSF as prognostic marker in early multiple sclerosis

Axonal damage probably occurs early in the evolution of MS. Five of 38 (13%) patients had a positive assay for the neuronal 14-3-3 protein in the CSF obtained at the first clinically isolated syndrome suggestive of MS. A positive 14-3-3 assay was the only independent predictor for a shorter time to conversion to clinical definite MS (risk ratio 4.1; 95% CI 1.1 to 15) and to reach an Expanded Disability Status Scale (EDSS) > or =2 at the end of follow-up (odds ratio 14.8; 95% CI 2.86 to 76.8). The detection of the 14-3-3 protein in the CSF at the first neurologic event suggestive of MS may be a useful predictor of short-term evolution.

[Axonal damage in multiple sclerosis]

The presence of axonal lesions in plaques of demyelination in patients with multiple sclerosis (MS) has been known for many years. Traditionally it was believed that axonal loss occurred in chronic lesions. However, demonstration of pathological degeneration in active plaques, use of new resonance techniques such as spectroscopy or the transfer of magnetization, showing axonal damage in white matter of apparently normal aspect, and the presence of axonal neurofilaments in the cerebrospinal fluid during the episode has made it necessary to reconsider the contribution made by axonal damage to the pathogenesis of MS. Besides, recent studies have shown that a factor present in the cerebrospinal fluid of patients with MS may contribute to the induction of neuronal apoptosis. These facts, apart from their pathogenic implications and consequent clinical repercussions, will affect investigation of alternative treatments for this disorder, and by means of clinico-immunoradiological correlation will help to define the prognosis of the course of the disorder in these patients.

[The involvement of the parenchyma of the central nervous system in Behçet disease]

INTRODUCTION

Behçet disease is a systemic form of vasculitis which presents with neurological symptoms with a frequency varying between 16 and 40%. Involvement of the parenchyma has been found to worsen the prognosis in patients with neuroBehçet (NB).

OBJECTIVE

To review the clinical features and course of patients with NB involving the parenchyma of the central nervous system (CNS).

CLINICAL CASES

Seven patients with Behçet disease and neurological localizing signs were seen in our hospital between 1989 and 1996. The initial diagnosis was of ischemic ictus in five of the seven patients. Both neuroimaging studies and investigation of the cerebrospinal fluid were always pathological in all cases. Vascular studies (arteriography and echo-Doppler of the supra-aortic trunks) were normal. One patient died. Four patients had serious sequelae following treatment.

CONCLUSION

NB should be included in the different diagnosis of ictus. Involvement of the parenchyma of the CNS was accompanied by lymphocytic meningitis, perhaps also leading to a worse functional prognosis.