Subjective Rationalities of Nonadherence to Treatment and Vaccination in Healthcare Decision-Making

Objective

In this short report contributing to the literature on treatment and vaccination adherence, nonadherence was examined from the perspective of decision-making (DM) practice in healthcare. The objective of this study was to survey the rationalities given for treatment nonadherence and their association with DM practice.

Methods

The Ottawa decision Support Framework was used as a theoretical background for the study. Multiple choice and open-text responses indicating nonadherence were drawn from vignette survey data. The results have been analyzed and reported as descriptive statistics and findings of data-driven content analysis. The number of observatory units was 1032 in the within-subject study design.

Results

DM practice was predominantly associated with nonadherence to vaccination, whereas nonadherence to treatment was consistently associated with attitudinal reasons independent of DM practice. Nonadherence to vaccination was most often rationalized by prior negative experiences in simple DM scenarios. After other DM practices, nonadherence was rationalized by uncertainty and criticism about the benefits of the recommended vaccine. Mistrust toward healthcare providers stood out, first in treatment nonadherence generally and, second, in vaccination nonadherence after simple DM where the final decision was left to the patient.

Conclusion

In medical DM, adherence to treatment and vaccination may be achieved through a recognition of patients' previous healthcare encounters and potential trust-related concerns, which could pose a risk for nonadherence. To be able to observe these risks, patient engagement and mutual trust should be priorities in decision support in healthcare.

Problems Experienced by Health Care Professionals with Do not Attempt Resuscitation (DNAR) Orders - A Qualitative Study

A 'Do Not Attempt Resuscitation' (DNAR) order is one of the most important yet difficult medical decisions. Despite the recent European guidelines, health care professionals (HCPs) in general perceive challenges in making a DNAR order. We aimed to evaluate the types of problems related to DNAR order making. A link to a web-based multiple-choice questionnaire including open-ended questions was sent by e-mail to all physicians and nurses working in the Tampere University Hospital special responsibility area covering a catchment area of 900,000 Finns. The questionnaire covered issues on DNAR order making, its meaning and documentation. Here we report the analysis of the open-ended questions, examined based on the Ottawa Decision Support Framework with expanded individual decisional needs categories. Qualitative data describing respondents' opinions (N=648) regarding problems related to DNAR order decision making were analysed using Atlas.ti 23.12 software. In total, 599 statements (phrases) dealing with inadequate advice, information, emotional support, and instrumental help were identified. Our results show that HCPs experience lack of support in DNAR decision making on multiple levels. Digital decision-making support integrated into electronic patient records (EPR) to assure timely and clearly visible DNAR orders could be beneficial.

Neurologists' Experiences and Attitudes Towards Teleneurology - Has Covid-19 Pandemic Made a Difference?

Teleneurology is an adaption of telemedicine used in neurological practices. Due to the widespread availability of the Internet and the development of information and communication technology (ICT), the use of teleneurology has increased in healthcare systems. This study aimed to determine how the Covid-19 pandemic has affected neurologists' attitudes towards teleneurology as well as their experiences of remote health care before and after the pandemic. The study was conducted as a web-based questionnaire sent to all Finnish neurologists. Two identical surveys were sent via e-mail from the National Neurology Society. The first survey was conducted in spring 2021 and second in spring 2023. The results show that the pandemic moderately increased the use of teleneurology, which enhanced neurologists' technical skills. Neurologists estimated that the use of teleneurology will continue to increase in the future.

Real-world treatment outcomes and safety of natalizumab in Finnish multiple sclerosis patients

Objectives

The primary objective was to evaluate long-term treatment persistence and safety of natalizumab in Finnish multiple sclerosis patients. The secondary objectives were to assess patient characteristics, use of natalizumab-related safety protocol, and treatment persistence in patients with different anti-John Cunningham virus antibody statuses (John Cunningham virus status).

Materials & Methods

All adult multiple sclerosis patients in the Finnish multiple sclerosis register who started natalizumab between 1/2006 and 12/2018 were included in this study and followed retrospectively until treatment discontinuation or end of follow-up (12/2019).

Results

In total, 850 patients were included. Median duration of natalizumab treatment was 7.8 years in John Cunningham virus negative (n = 229) and 2.1 years in John Cunningham virus positive patients (n = 115; p < 0.001). The most common cause for treatment discontinuation was John Cunningham virus positivity. After natalizumab discontinuation, patients who had a washout duration of less than 6 weeks had fewer relapses during the first 6 months (p = 0.012) and 12 months (p = 0.005) compared with patients who had a washout duration of over 6 weeks. During the median follow-up of 3.6 years, 76% of patients remained stable or improved on their Expanded Disability Status Scale.

Conclusions

Treatment persistence was very high among John Cunningham virus negative patients. The study supports long-term effectiveness of natalizumab and a washout duration of less than 6 weeks after discontinuation.

Information Provision and Quality. A Pilot Study on Shared Decision-Making in Multiple Sclerosis

The patient as an active participant in decision-making has become an important resource in health care. Shared decision-making (SDM) relies on the patient's easy access to reliable and evidence-based health care information as well as the availability of patient-generated data, such as values and preferences for the health care professional (HCP). The aim of the present pilot study was to evaluate what type of information people with multiple sclerosis (pwMS) use in the SDM process, and what are the sources of that information. A semi-structured web-based survey of SDM was conducted through the MS-society in Finland. The results are presented against the Ottawa Decision Support Framework. A total of 27 pwMS participated. We found that all the participants wished to be involved in the decision-making process, but that they seldom found the information provided by HCP to be helpful. Instead, they searched the internet and visited various conversation platforms in social media, such as Facebook groups, for additional information.

Patient-generated data in epilepsy care decisions: a scoping review protocol

OBJECTIVE

This scoping review will explore the meaning and content of patient-generated data in epilepsy care decisions.

INTRODUCTION

Clinical decisions about management of long-term conditions such as epilepsy are based on multiple factors, including efficacy and safety of interventions, experiences of professionals as well as patient preferences and values. Patient-generated data integrates patient values and preferences into clinical decision-making. However, more information is needed about the meaning and content of patient-generated data when making clinical decisions in epilepsy care.

INCLUSION CRITERIA

This scoping review will consider studies focusing on patient-generated data and clinical decision-making in epilepsy management. Studies will be included if they concern adult patients with epilepsy, their family members/guardians, or health professionals who treat patients with epilepsy in any health care facility or eHealth services. All studies will be included regardless of methodology. Text and opinion papers will also be considered. Study protocols will be excluded.

METHODS

The databases to be searched include MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials. Sources of unpublished studies and gray literature will include websites of relevant epilepsy organizations and DART-Europe E-theses Portal. The data will be extracted by two independent reviewers using a tool created for the study purpose. Along with a narrative summary, the results will be presented in tabular or graphical format in a manner that aligns with the review objective and questions. There will be no time limit on the search. Studies published in English, Finnish, Swedish, and German will be included.

Lack of Human Resources Leads to Breaches in Information Management Processes

Effective information management promotes safe patient care. Lack of human resources can cause failures when managing patient information. The aim of this study was to analyse the nature of reported patient safety incidents and their location in Choo's information management process model phases when the contributing factor of the incidents was related to human resources and the consequence of the incident was related to harm to the organization's corporate image. Data consisted of the information management related patient safety incident reports (n = 475) from 49 health and social care organizations from 2007-2016 in Finland. Deductive analysis and descriptive statistics were used to analyse the data. The results of the study indicated that the shortage of human resources contributed to incomplete documentation, insufficient information sharing between professionals and documenting of information in the wrong place. The majority of the incidents occurred during the information organizing and storage and information distribution phases of the information management process model. Despite the use of electronic health records and electronic patient data, a lack of human resources can lead to breaches in information management processes and harm an organization's corporate image in health and social care contexts.

Healthcare Professionals' Perceptions and Opinions on "Do not Attempt Resuscitation" (DNAR) Order and Documentation

Insights on end-of-life care decisions, such as do not attempt resuscitation (DNAR), vary between institutions and individual health care professionals. At the era of electronic patient records (EPR), the information of DNAR order may still be recorded in multiple locations making it difficult to find and interpret. A link to a structured web-based questionnaire was sent to all physicians and nurses working in Tampere University Hospital special responsibility area covering a catchment area of 900 000 Finns. Perceptions on DNAR order and documentation was surveyed. In total 934 subjects responded, of which 727 (77%) were nurses and 219 (23%) physicians covering all specialties. We found substantial variation in DNAR order interpretation and documentation among all health care professionals possibly causing information breakdown and compromised end-of-life care.

Safety of alemtuzumab in a nationwide cohort of Finnish multiple sclerosis patients

Background

Alemtuzumab is an effective disease-modifying therapy (DMT) for highly active multiple sclerosis (MS). However, safety concerns limit its use in clinical practice.

Objectives

To evaluate the safety of alemtuzumab in a nationwide cohort of Finnish MS patients.

Methods

In this retrospective case series study, we analyzed the data of all but two MS patients who had received alemtuzumab in Finland until 2019. Data were systematically collected from patient files.

Results

Altogether 121 patients were identified, most of whom had received previous DMTs (82.6%). Median follow-up time after treatment initiation was 30.3 months and exceeded 24 months in 78 patients. Infusion-associated reactions (IARs) were observed in 84.3%, 57.3%, and 57.1% of patients during alemtuzumab courses 1–3, respectively. Serious adverse events (SAEs) were observed in 32.2% of patients, serious IARs in 12.4% of patients, and SAEs other than IARs in 23.1% of patients. Autoimmune adverse events were observed in 30.6% of patients. One patient died of hemophagocytic lymphohistiocytosis, and one patient died of pneumonia. A previously unreported case of thrombotic thrombocytopenic purpura was documented.

Conclusions

SAEs were more frequent in the present cohort than in previous studies. Even though alemtuzumab is a highly effective therapy for MS, vigorous monitoring with a long enough follow-up time is advised.

Initial treatment strategy and clinical outcomes in Finnish MS patients: a propensity-matched study

Background

The optimal treatment strategy with disease-modifying therapies (DMTs) in relapsing–remitting multiple sclerosis (RRMS) remains uncertain.

Objective

To compare outcomes of initial treatment with infusion therapies and starting therapy with medium efficacy therapy in a propensity-matched cohort of Finnish RRMS patients.

Methods

A total of 154 RRMS patients initiating natalizumab, alemtuzumab, ocrelizumab or rituximab as first DMT (high efficacy DMT, heDMT group) and 1771 patients initially treated with injectable therapies, teriflunomide or dimethylfumarate and escalated based on disease activity (moderate efficacy DMT, meDMT group) were identified from the Finnish MS registry. Nearest neighbor propensity matching (1:1, caliper 0.1) was performed for age, sex, baseline Expanded Disability Status Scale (EDSS), annual relapse rate (ARR) one year prior DMT and time since MS symptom onset. Primary outcome was time to 6-month confirmed EDSS progression and the secondary outcome time to first relapse.

Results

In the propensity-matched group comparisons, the probability of 6-month confirmed disability progression (CDP) at 5 years after DMT start was 28.4% (95% CI 15.7–39.3) in the heDMT group (n = 66) and 47.0% (95% CI 33.1–58.1) in meDMT group (n = 66), p = 0.013. Probability of relapse at 5 years was 34.6% (95% CI 24.1–43.6) for heDMT (n = 105) and 47.2% (95% CI 36.6–56.1) for meDMT (n = 105), p = 0.019.

Conclusions

Initiating MS-therapy with heDMT significantly reduced the risk of 5-year disability progression and relapse compared to using meDMT as first DMT choice in propensity-matched groups of Finnish MS-patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10673-9.

The Effect of Chronic Diseases on the Use of Health Technology and Digital Services in the Elderly Population in Finland

Digital services are growing in the health-care field. The population in Europe is aging, and digital services are on the rise. There are also plenty of new health-care devices on the market. The aim of this study was to survey how elderly people cope with digital services or devices, especially if they are chronically ill. This quantitative study focuses on the impact of chronic diseases on the use of health technology and digital services. The target group of this study is Finnish people aged 65 or over. Based on the results, a chronic disease or disability is not an obstacle to the use of digital services or health-care technology in the Finnish elderly population. The main obstacles to the use of health technology or digital services are complexity, obscure text, or small font size. According to this study, elderly people seem to trust the device or application. Devices, applications, and online services should be designed so that elderly people's diseases or ability to function are considered.

Health Professionals' Perceptions and Reactions to ICT-Related Patient Safety Incidents

Patient incident reporting is an important way to promote safer health care. The barriers for reporting can be organizational (leadership, culture, lack of feedback, etc.) or individual (time pressure, perceived competence, attitude, etc.). In this study, we examined what kinds of ICT-related incidents health professionals observe in Finland, how they react to them and the reasons for non-reporting. Our data was collected using a nationwide survey during the Spring of 2020. The theory of planned behaviour by Ajzen served as our framework for explaining non-reporting behaviour. While we found that attitudes, subjective norms and perceived behavioural control all explain non-reporting, our factor model based on our confirmatory factor analysis did not directly match Ajzen's theory.

Lipid Profile Alterations during Fingolimod Treatment in Multiple Sclerosis Patients

Fingolimod reduces inflammatory activity in multiple sclerosis (MS) by acting as a functional antagonist of sphingosine 1-phosphate (S1P) receptors. It has been suggested that S1P might also contribute to the antiatherogenic effect of high-density lipoprotein (HDL). We conducted a retrospective observational study using data of 72 MS patients from two Finnish hospital districts to find out whether lipid profiles change during treatment with fingolimod. A mixed-effects model with patient as a random effect was used to analyze lipid profile alterations. We found a statistically significant elevation in both total cholesterol (0.12 mmol/L per year) and HDL (0.04 mmol/L per year) during a median follow-up of 12 months, while low-density lipoprotein (LDL) and triglycerides remained unchanged. Since the mean elevation observed in both lipid values seems to be modest, we suggest that routine lipid profile monitoring is unnecessary during fingolimod treatment in MS patients without pre-existing cardiovascular comorbidities. Graphical abstract.

Patient Awareness of the Severity of Their Information and Medication Management-Related Adverse Events

Adverse events (AEs) in healthcare are commonly reported internationally. However, the structure of event reporting varies based on the healthcare service system, legislation, and the safety culture among service providers. Based on several studies, medication management-related errors have a long history of being reported. However, there is evidence that information management-related errors increase workload, costs, and patient suffering. This study focuses on AEs reported in the categories of medication and information management in a national reporting system. Our aim was to determine whether patients were informed about these errors and whether there were any relationships between the severity of these errors and the disclosure to patients. Based on the results, almost all errors in both categories without any harm to patients were disclosed to patients. Patients were not informed about 40% of information management-related AEs that caused severe harm.

The rate of neuropsychological assessments in multiple sclerosis has increased-A retrospective study in a Finnish Central Hospital

OBJECTIVE

To investigate possible changes in the rate of conducted neuropsychological assessments and rehabilitation process for patients with multiple sclerosis (pwMS) during the last two decades. The change in the rate of vocational rehabilitation process was also evaluated.

BACKGROUND

Cognitive deficits are frequent among pwMS and negatively affect patients' working ability and quality of life. Preliminary evidence suggests that neuropsychological rehabilitation positively affects cognitive symptoms. Vocational approaches are widely recommended for pwMS.

METHODS

A retrospective survey of all multiple sclerosis (MS) patients diagnosed and treated at the Department of Neurology in Kanta-Häme Central Hospital over the period 1988-2013 was conducted using hospital records. The rate of neuropsychological assessment and rehabilitation processes as well as vocational rehabilitation processes were evaluated.

RESULTS

A total of 417 pwMS were identified. A neuropsychological assessment was performed for 104 (24.9%) of these patients, of whom 21 (20.2%) were evaluated between 1988 and 1999 and 83 (79.8%) between 2000 and 2013. Of the 417 patients, eight (1.9%) received neuropsychological rehabilitation, each of these after the year 2000. Only 25 (6.0%) of the 417 pwMS received vocational rehabilitation. Fourteen (56.0%) of the 25 patients received vocational rehabilitation between 1988 and 1999 and 11 (44.0%) between 2000 and 2013.

CONCLUSIONS

Neuropsychological assessment has been a rarity in MS in Finland, but a marked increase in frequency has occurred since the year 2000. Although understanding of MS-related cognitive impairment and its impact on working ability has increased, the rate of neuropsychological and vocational rehabilitation has remained low.

Risk factors for reactivation of clinical disease activity in multiple sclerosis after natalizumab cessation

BACKGROUND

Natalizumab (NTZ) is widely used for highly active relapsing-remitting multiple sclerosis (MS). Inflammatory disease activity often returns after NTZ treatment discontinuation. We aimed to identify predictive factors for such reactivation in a real-life setting.

METHODS

We conducted a retrospective survey in four Finnish hospitals. A computer-based search was used to identify all patients who had received NTZ for multiple sclerosis. Patients were included if they had received at least six NTZ infusions, had discontinued treatment for at least three months, and follow-up data was available for at least 12 months after discontinuation. Altogether 89 patients were analyzed with Cox regression model to identify risk factors for reactivation, defined as having a corticosteroid-treated relapse.

RESULTS

At 6 and 12 months after discontinuation of NTZ, a relapse was documented in 27.0% and 35.6% of patients, whereas corticosteroid-treated relapses were documented in 20.2% and 30.3% of patients, respectively. A higher number of relapses during the year prior to the introduction of NTZ was associated with a significantly higher risk for reactivation at 6 months (Hazard Ratio [HR] 1.65, p < 0.001) and at 12 months (HR 1.53, p < 0.001). Expanded Disability Status Scale (EDSS) of 5.5 or higher before NTZ initiation was associated with a higher reactivation risk at 6 months (HR 3.70, p = 0.020). Subsequent disease-modifying drugs (DMDs) failed to prevent reactivation of MS in this cohort. However, when subsequent DMDs were used, a washout time longer than 3 months was associated with a higher reactivation risk at 6 months regardless of whether patients were switched to first-line (HR 7.69, p = 0.019) or second-line therapies (HR 3.94, p = 0.035). Gender, age, time since diagnosis, and the number of NTZ infusions were not associated with an increased risk for reactivation.

CONCLUSION

High disease activity and a high level of disability prior to NTZ treatment seem to predict disease reactivation after treatment cessation. When switching to subsequent DMDs, the washout time should not exceed 3 months. However, subsequent DMDs failed to prevent the reactivation of MS in this cohort.

Multiple sclerosis in Finland 2018-Data from the national register

OBJECTIVES

Finland is a high-risk multiple sclerosis (MS) region, but a national MS register has not existed until 2014. In this paper, we present the Finnish MS register variables and data collected by 31 December 2018.

MATERIALS AND METHODS

Numbers and data counts of MS patients in the register (ICD-10 code G35) are presented. The disease types and proportion of patients receiving disease-modifying treatments (DMTs) were analysed in five hospital districts with most complete data sets. MS prevalence in Finland was estimated using administrative hospital discharge data as an additional resource.

RESULTS

There were a total of 8722 MS patients in the Finnish MS register by 31 December 2018 (71.5% females). Mean age at MS diagnosis was 38.7 years and peak prevalence was at age 50-54 years. Disease course was relapsing remitting (RRMS) in 66.7%, secondary progressive (SPMS) in 13.5%, and primary progressive (PPMS) in 7.9% of the 5365 MS patients in the selected districts with most complete data. A total of 66.0% of RRMS patients, 19.6% of SPMS patients and 9.9% of PPMS patients were receiving DMTs. By combining MS register data with databases of those hospitals that had not joined the register, the nationwide prevalence estimate was between 10 and 11 thousand patients (corresponding to crude prevalence 180-200/100 000).

CONCLUSIONS

The Finnish MS register is currently used in 15/21 Finnish hospital districts. By register integration into the electronic patient files, the coverage of the register has increased to approximately 80% of the estimated Finnish MS population.

Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians

STUDY OBJECTIVE

Thrombolysis with tissue plasminogen activator should occur promptly after ischemic stroke onset. Various strategies have attempted to improve door-to-needle time. Our objective is to evaluate a strategy that uses an emergency physician-based protocol when no stroke neurologist is available.

METHODS

This was a retrospective before-after intervention analysis in an urban hospital. Reorganization of the acute ischemic stroke treatment process was carried out in 2013. We evaluated time delay, symptomatic intracerebral hemorrhage, and clinical recovery of patients before and after the reorganization. We used multivariable linear regression to estimate the change in door-to-needle time before and after the reorganization.

RESULTS

A total of 107 patients with comparable data were treated with tissue plasminogen activator in 2009 to 2012 (group 1) and 46 patients were treated during 12 months in 2013 to 2014 (group 2). Median door-to-needle time was 54 minutes before the reorganization and 20 minutes after it (statistical estimate of difference 32 minutes; 95% confidence interval 26 to 38 minutes). After adjusting for several potential cofounders in multivariable regression analysis, the only factor contributing to a significant reduction in delay was group (after reorganization versus before). Median onset-to-treatment times were 135 and 119 minutes, respectively (statistical estimate of difference 23 minutes; 95% confidence interval 6 to 39 minutes). The rates of symptomatic intracerebral hemorrhage were 4.7% (5/107) and 2.2% (1/46), respectively (difference 2.5%; 95% confidence interval -8.7% to 9.2%). Approximately 70% of treated patients were functionally independent (modified Rankin Scale score 0 to 2) when treated after the reorganization.

CONCLUSION

Implementation of a stroke protocol with emergency physician-directed acute care decreased both door-to-needle time and onset-to-treatment time without increasing the rate of symptomatic intracerebral hemorrhage.

Concomitant treatment with imipenem causes a rapid and extensive decrease in the plasma concentrations of valproic acid

Background. Valproic acid (VPA) is a wide-spectrum antiepileptic drug used both in children and in adults. We describe a clinically important interaction between VPA and imipenem, a carbapenem antimicrobial.

Case presentation. Our patient was a 19-year-old man with childhood onset of mental retardation and severe epilepsy. He was hospitalized due to pneumonia. His antiepileptic drugs, including VPA, were administered intravenously. Due to pneumonia, intravenously administered imipenem was started. After the start of imipenem treatment, a dramatic decrease in the plasma concentrations of VPA occurred within 24 hours. After the discontinuation of imipenem treatment, the concentration of VPA recovered within a few hours. The decrease in VPA levels was associated with increased seizure frequency.

Conclusions. The time course of the VPA-imipenem interaction suggests that mechanisms other than a change in the enzymatic elimination of VPA is the cause for this pharmacokinetic interaction. Concomitant use of VPA and imipenem should be avoided.

Stroke thrombolysis given by emergency physicians cuts in-hospital delays significantly immediately after implementing a new treatment protocol

Background

Tissue plasminogen activator (tPA) treatment for acute ischaemic stroke (AIS) should be given as soon as possible, preferably within 60 min after arrival at hospital. There is great variation in door-to-needle times (DNTs) internationally, nationally and even within the same hospital. Various strategies for improving treatment delays have been presented. The role of emergency physicians (EPs) in treating AIS has been under discussion in recent years. Emergency Medicine (EM) officially became a specialty in Finland in 2013. Practical education of EPs in Kanta-Häme Central Hospital began in October 2012, together with reorganization of the in-hospital treatment path for AIS patients. The main change was shifting the on-call duty regarding stroke patients from internists or neurologists to EPs after the third quarter of 2013.

Methods

This was a retrospective study. The data, concerning the characteristics of tPA-treated patients, DNTs and onset-to-treatment times (OTTs) was collected from electronic and paper records. The period studied was 1 year before and 1 year during reorganization, i.e. 2012 and 2013.

Results

During the study period a total of 64 tPA treatments were given, 31 before and 33 during reorganization. The median DNT was 54 min in 2012, while it was 28 min in 2013 (p < 0.001). The median OTTs were 139 and 101 min before and during the start of reorganization, respectively (p < 0.001).

Conclusions

Both total and in-hospital delays in the treatment of ischaemic stroke were shortened significantly during reorganization. Emergency physicians are able to treat AIS patients within international time guidelines. Success was based on scrutinized reorganization and good cooperation between neurologists, EPs and radiologists.

[Magnetic resonance imaging of the brain in the monitoring of immune therapy of multiple sclerosis]

Magnetic resonance imaging of the brain is currently the most sensitive method in detecting the lesions caused by multiple sclerosis. Assessment of the immunological treatment response used in the treatment of multiple sclerosis should be based on the clinical picture and brain MRI. T2-, flair- and T1-biased images, gadolinium enhancement and assessment of atrophy are required for MRI monitoring. In the first-line immune therapy MRI is taken at 6 to 12 months after starting the drug therapy, in fingolimod therapy after 6 to 12 months and 1 to 2 years, respectively, and in alemtuzumab and natalizumab therapy after one and two years.

Volumetric MRI assessment of brain and spinal cord in Finnish twins discordant for multiple sclerosis

BACKGROUND AND OBJECTIVE

Brain size, white matter hyperintensity, and the development of brain atrophy are known to be highly heritable. The decrease of brain volume starts from the very onset of multiple sclerosis and is 10-fold compared with normal aging. The aim of this study was to assess whether the brain and spinal cord volumes and the volume of white matter lesions differed between twins with multiple sclerosis and their asymptomatic co-twins.

MATERIAL AND METHODS

A co-twin control method was used to evaluate whether the brain and spinal cord volumes differ between twins with multiple sclerosis and their co-twins. Nineteen twin pairs were studied neurologically, and the volumes of T1, T2, FLAIR, and gadolinium-enhanced lesions and those of the brain and the spinal cord were obtained by magnetic resonance imaging.

RESULTS

Significant differences in the brain (P=0.064) or spinal cord (P=0.648) volumes were not detected. Four of the 7 monozygotic and 5 of the 12 dizygotic co-twins had focal brain white matter lesions, but none fulfilled the magnetic resonance imaging criteria of Barkhof. Spinal cord lesions were not seen in any of the co-twins.

CONCLUSIONS

The absence of a significant difference in the brain or spinal cord volume between the twins with multiple sclerosis and their co-twins supports the recent observation of brain size and the development of brain atrophy being highly heritable.

Hospital training program increases awareness of Good Clinical Practice (GCP)

OBJECTIVES

To develop an in-house training program of Good Clinical Practice (GCP) for the whole clinical team and to evaluate the effect of the program on the personnel's knowledge on GCP.

BACKGROUND

GCP is a set of ethical and scientific quality requirements to which clinical trials must adhere. Since it is included in the legislation of the member states of European Union, it represents a challenge for research, and therefore more GCP training is needed.

METHODS

At the Department of Neurology and Rehabilitation, Tampere University Hospital, Finland, we developed an in-house GCP training program for the whole department, including nurses. Before the training department staff was sent a questionnaire about their knowledge of and attitudes towards GCP as well as their perception of GCP compliance of studies being carried out at the Department. The subjects completed the questionnaire again after the training.

RESULTS

Almost all, 95%, of the nurses and 50% of the physicians participated in the entire program. The program was found to increase positive attitudes towards GCP.

CONCLUSION

A simple in-house training program is easy to implement and may help to improve GCP compliance.

Elevated cerebrospinal fluid adiponectin and adipsin levels in patients with multiple sclerosis: a Finnish co-twin study

BACKGROUND AND PURPOSE

The aim of this study was to investigate the levels of three adipocytokines: leptin, adiponectin and adipsin, in serum and cerebrospinal fluid (CSF) of twins discordant for multiple sclerosis (MS). Adipose tissue is an important component connecting immune system and several tissues and organs including CNS. Fat cells produce adipocytokines, which seem to have a role in various autoimmune disorders including MS.

METHODS

Plasma samples were collected from twelve twins and CSF samples from four twins discordant for MS. The concentrations of interleukine (IL)-6, adiponectin, adipsin and leptin in plasma and CSF samples were determined by enzyme immuno assay.

RESULTS

A significant difference was seen in the adipocytokine levels in CSF samples. Twins with MS had higher concentrations of adiponectin (P = 0.039) and adipsin (P = 0.039), than their asymptomatic co-twins.

CONCLUSION

As adiponectin and adipsin levels in CSF did not correlate with their levels in plasma, it seems that there could be a secondary intrathecal synthesis of these adipocytokines in MS.

Therapeutic activities of intravenous immunoglobulins in multiple sclerosis involve modulation of chemokine expression

The objective of this study was to identify genes that are differentially expressed in peripheral T cells of patients with MS exacerbation receiving treatment with IVIG. Using microarray analysis, we identified 360 genes that were at least two-fold up- or down-regulated. The expression of four representative genes (PTGER4, CXCL5, IL11 and CASP2) was confirmed by quantitative PCR. Four of the differentially expressed genes encode chemokines (CXCL3, CXCL5, CCL13 and XCL2) that are involved in directing leukocyte migration. We suggest that the modulation of chemokine expression in peripheral T cells contributes to the beneficial activity of IVIG in patients with MS exacerbation.

Apoptosis-related molecules in blood in multiple sclerosis

A failure in apoptosis of lymphocytes may lead to harmful immunoreactivity in MS. We analyzed apoptosis-related molecules including TRAIL, sFas, sFasL and MIF in the blood of 117 MS patients and controls to answer whether these molecules may be used in the evaluation of disease activity and immunomodulatory effect of IFN-beta. Increased levels of sTRAIL, sFasL and MIF were found in sera of untreated patients with MS relapse indicating their association with MS disease activity. IFN-beta treated patients in remission had increased TRAIL mRNA, sTRAIL, sFaL and MIF that most likely reflect bioactivity of IFN-beta.

Human herpes virus 6 and multiple sclerosis: a Finnish twin study

OBJECTIVE

To investigate the possible association of human herpes virus 6- (HHV6) infection and multiple sclerosis (MS).

BACKGROUND

Despite intensive investigations of genetic and environmental factors, the etiopathogenesis of MS remains unknown. HHV6 is a possible candidate in that it is neurotropic, able to induce demyelination and become latent and be reactivated. We had access to The Finnish National Twin Cohort, which provided a unique opportunity to study the association between HHV6 and MS in genetically homogenous patients.

METHODS

Thirty-four serum samples from 17 MS twin pairs and 12 cerebrospinal fluid (CSF) samples from six MS twin pairs were tested by PCR specific for HHV6. Immunoglobulin (Ig) G and M response against HHV6 in serum and CSF were analysed using ELISA method. The samples were collected during a remission of the disease.

RESULTS

No HHV6 DNA was found in any serum (n=34) or CSF (n=12) samples. Eighty-eight percent of the twins with MS and 86% of the healthy twin siblings were positive for IgG in serum. One twin with MS was also positive for IgM in serum, whereas none of the healthy twins was IgM positive. All CSF samples were negative for IgG and IgM in both groups.

CONCLUSIONS

During a clinical remission of MS the detection of antibodies against HHV6 in CSF and HHV6 DNA in serum, CSF supernatant or CSF leukocytes is unlikely. However, the results do not exclude a possibility of HHV6 reactivation during MS exacerbation or acute HHV6 infection being one of the triggering agents in development of MS long before its clinical manifestation.

Once-weekly 22microg subcutaneous IFN-beta-1a in secondary progressive MS: a 3-year follow-up study on brain MRI measurements and serum MMP-9 levels

OBJECTIVE

To study the effect of weekly injected subcutaneous interferon (IFN)-beta-1a 22 microg on the extent of brain lesions on magnetic resonance imaging (MRI) and the level of serum matrix metalloproteinase (MMP)-9 in patients with secondary progressive multiple sclerosis (SPMS).

SUBJECTS AND METHODS

All the 28 Finnish patients participating in the Nordic multicentre trial on the clinical efficacy of weekly IFN-beta-1a (Rebif) 22 microg in SPMS were studied neurologically and by volumetric MRI during a 3-year follow-up. The levels of MMP-9 in serum were measured over the 3-year study.

RESULTS

There was no obvious effect on the number of contrast medium-enhancing lesions, the volume of T1 or T2 lesions or level of serum MMP-9, nor was any effect detected on the relapse rate and the Expanded Disability Status Scale (EDSS). Brain atrophy progression was not affected by the treatment.

CONCLUSION

The lack of effect on MRI, clinical outcomes or the levels of MMP-9 indicates that subcutaneous administration of low-dose low-frequency IFN-beta-1a is insufficient in controlling either the inflammatory constitutes or the neurodegenerative changes of advanced SPMS.

NARP syndrome and adult-onset generalised seizures

The neurogenic muscle weakness, ataxia and retinitis pigmentosa (NARP) syndrome is a maternally inherited disorder attributable to a heteroplasmic mtDNA point mutation. Catastrophic epilepsy may accompany severe, early onset forms of NARP, but seizures seem to be rare in cases with adolescent and adult onset. We describe a patient who developed clumsiness and visual problems in her teens. She had no clinical seizures but an EEG showed generalized spike and wave discharges. At this time the patient remained without a specific diagnosis. At the age of 21, the patient developed progressive ataxia and she also experienced a tonic-clonic status epilepticus. Further examinations revealed NARP syndrome. EEG abnormalities may precede adult onset seizures in the NARP syndrome.

Effect of high-dose methylprednisolone treatment on CCR5 expression on blood cells in MS exacerbation

OBJECTIVES

Therapy of acute exacerbations of multiple sclerosis (MS) with high-dose intravenous methylprednisolone (IVMP) has shortened the recovery period after relapses, but the mechanisms responsible for the beneficial effects of IVMP in attacks have not been clearly established. Our purpose was to analyze the effect of IVMP on the expression of chemokine receptor 5 (CCR5) protein in blood in acute MS exacerbation.

MATERIALS AND METHODS

Blood samples were collected from 10 patients with an acute MS exacerbation and the levels of CCR5 on CD4(+) and CD8(+) T cells and CD14(+) monocytes were analyzed by using flow cytometry before IVMP, 24 h, 1 and 3 weeks after commencement of treatment.

RESULTS

During the 3-week period the percentages of CCR5-expressing CD4(+) T cells and CD8(+) T cells tended to decrease (P = 0.09 and 0.05, respectively), but the effect did not reach statistical significance. No marked changes were found in the percentage of CCR5-expressing CD14(+) cells.

CONCLUSIONS

A tendency to a reduction of CCR5-expressing CD4(+) and CD8(+) blood cells induced by IVMP suggests inhibition of their potential to transmigrate into the central nervous system, which is consistent with the short-term beneficial effect of IVMP in acute exacerbation of MS.

Gene expression profiles in Finnish twins with multiple sclerosis

Background

Since genetic alterations influencing susceptibility to multiple sclerosis (MS), the most common autoimmune demyelinating disease of the central nervous system (CNS), are as yet poorly understood, the purpose of this study was to identify genes responsible for MS by studying monozygotic (MZ) twin pairs discordant for MS.

Methods

In order to identify genes involved in MS development, the gene expression profiles in blood mononuclear cells obtained from eight MZ twin pairs discordant for MS were analyzed by cDNA microarray technology detecting the expression of 8 300 genes. The twins were collected from the Finnish Twin Cohort Study and both affected subjects and their healthy siblings underwent neurological evaluation and cerebral and spinal magnetic resonance imaging. Gene expressions were confirmed by relative quantitative reverse transcription PCR.

Results

It appeared that 25 genes were at least two-fold up-regulated and 15 genes down-regulated in 25% (2/8) of twins with MS when compared to their healthy siblings. Moreover, 6/25 genes were up-regulated in 40% of MS twins and one gene, interferon alpha-inducible protein (clone IFI-6-16) (G1P3), in 50% of them. The six most constantly expressed genes are (1) G1P3, (2) POU domain, class 3, transcription factor 1, (3) myxovirus resistance 2, (4) lysosomal-associated multispanning membrane protein-5, (5) hemoglobin alpha 2 and (6) hemoglobin beta.

Conclusion

Over two-fold up-regulation of these six genes in almost half of MZ twins with MS suggests their role in MS pathogenesis. Studies using MZ MS twins obtained from genetically homogeneous population offer a unique opportunity to explore the genetic nature of MS.

Increased disability and MRI lesions after discontinuation of IFN-beta-1a in secondary progressive MS

OBJECTIVE

To examine neurological and magnetic resonance imaging (MRI) changes following discontinuation of interferon (IFN)-beta-1a treatment in secondary progressive multiple sclerosis (SPMS).

METHODS

The study involved 21 SPMS patients who received subcutaneous (s.c.) IFN-beta-1a 44 microg three times weekly (t.i.w.) for 12 months and were thereafter followed up without treatment for a further 12 months. The number of relapses, disability on the Expanded Disability Status Scale (EDSS) and MRI were recorded at baseline, at 12 months of IFN-beta-1a 44 microg t.i.w. and 1 year after discontinuation of treatment.

RESULTS

During the 12-month treatment EDSS score and volumes of brain T2- and T1-weighted lesions remained without significant progression, but at 12 months after treatment discontinuation both EDSS score and the volumes of cerebral lesions increased significantly. Cerebrospinal fluid fraction increased significantly both during the treatment and during follow-up.

CONCLUSIONS

Discontinuation of IFN-beta-1a 44 microg t.i.w. in SPMS may be associated with an increase in neurological disability and brain lesions on MRI.

The efficacy of glatiramer acetate in beta-interferon-intolerant MS patients

OBJECTIVES

Glatiramer acetate (GA) is routinely used in multiple sclerosis (MS) patients who cannot tolerate or fail to respond to beta-interferon (IFN-beta). The aim of this study was to assess the efficacy and tolerability of GA in these patients.

METHODS

Fifteen relapsing-remitting MS patients who had discontinued IFN-beta therapy due to side effects were included in this open, 1-year prospective study. Neurologic examinations and laboratory assessments were performed every 3 months. The induction of MxA protein production was also evaluated.

RESULTS

Eleven of fifteen patients (73%) tolerated GA well whereas four patients (27%) discontinued treatment due to side effects. The relapse rate reduced from 1.86 per year to 0.91 per year. Neither laboratory abnormalities nor MxA protein induction was found.

CONCLUSION

GA can be considered as a good treatment alternative to IFN-beta-intolerant MS patients. However, some patients were not able to use available immunomodulative treatments, which emphasizes the need for new therapeutic options. The lack of MxA protein induction confirms the different mechanisms of action of GA and IFN-beta.

Enteroviruses and the risk of MS in the Finnish Twin Cohort

To investigate the possible association of enterovirus (EV) infection with the development of multiple sclerosis (MS). The role of various genetic and environmental factors has been intensively studied in the etiopathogenesis of MS but the cause of the disease has remained unknown. Enteroviruses are possible candidates because they are neurotropic and able to cause chronic infections. Serum and cerebrospinal fluid (CSF) were tested with reverse transcription-polymerase chain reaction specific for enteroviruses in 17 MS twin pairs. No enteroviral RNA was found in any serum (n = 34) or CSF (n = 12) sample. We found no evidence of enterovirus infection in twins with MS or their healthy siblings. To our knowledge this is a first study to assess the role of enterovirus infections in the risk of developing MS in twins.

Increase in CCR5 Delta32/Delta32 genotype in multiple sclerosis

Chemokines and their receptors participate in the development of multiple sclerosis (MS) by guiding immune cells into the brain tissue. A CCR5 Delta32 deletion mutation abolishes functional CCR5 on the cell surface and may reduce cell entry into the lesion sites. To analyse the significance of this mutation in MS, we compared the frequencies of CCR5 genotype in peripheral blood mononuclear cells from 89 MS patients and 119 healthy controls. The CCR5 genotype was further compared with the CCR5 RNA and surface protein expression in 48 MS patients and their controls. In all MS patients, the Delta32/32 genotype was found with 6.7% frequency, whereas it was present only in 0.8% of the controls (6/89 vs 1/119, P = 0.01). Specifically, the Delta32/Delta32 genotype was increased (11.5%, P = 0.05) among primary progressive MS patients, whereas it was present only in 4.8% in other MS subtypes and only in 0.8% of the controls. The amount of CCR5 protein on CD4(+) cells analysed in 48 MS patients (nine primary progressive MS, 18 secondary progressive MS, 21 relapsing-remitting MS) and 13 controls decreased with genotype, being 8.9% in wt/wt, 7.7% in wt/Delta32 and 4.3% in Delta32/Delta32. CCR5 surface expression analysed on these 48 MS patients and 13 controls was significantly decreased in Delta32/Delta32 MS patients as compared with that in wt/wt genotype individuals (P = 0.004). The significantly increased number of Delta32/Delta32 individuals among our MS patients suggests that this genotype could contribute as a general risk factor for MS. However, neither the levels of RNA or surface protein correlated with MS subtype, neurological disability as expressed by expanded disability status scale, or disease progression index. Our results suggest that the lack of CCR5 does not protect from MS, but rather it may predispose to the chronic course of the disease. This would further imply that in view of the redundancy in the chemokine system, CCR5 ligands must be assumed to function through other closely related chemokine receptors.