Parenchymal Neuro-Behçet's disease or Comorbid Behçet's disease with multiple sclerosis: A discriminative analysis of a complex clinical entity

BACKGROUND

Patients with Behçet's disease (BD) may rarely manifest with cerebral white matter lesions resembling multiple sclerosis (MS). This may result in misdiagnosis due to diagnostic difficulties between parenchymal neuro-BD (pNBD) and MS. This study aims to elucidate the distinguishing features of patients with comorbid BD and MS (BD+MS) in comparison to those with pNBD and MS alone by focusing on clinical and laboratory features. We also aimed to identify the distinctive characteristics of BD+MS patients by comparing them to patients with pNBD and MS.

METHODS

The methodology of this study involved a retrospective analysis of patient records followed in the Department of Neurology at the Istanbul Faculty of Medicine, Istanbul University. The study population included patients diagnosed with pNBD, MS, and a comorbid condition of BD and MS (BD+MS). We assessed clinical, radiological, and laboratory data, including disease onset, annual relapse rates, Expanded Disability Status Scale (EDSS) progression, and cerebrospinal fluid examination. Several parameters were examined between the pNBD, MS, and BD+MS patient groups to find similarities and differences between subgroups.

RESULTS

Our study included 1,764 patients: 172 with pNBD, 1,574 with MS, and 18 with BD+MS. A predominance of females was noted in the BD+MS (72%, p < 0.001) and MS (69 %, p < 0.001) groups compared to pNBD (30 %). The median age at the onset of neurological symptoms was 35.5 (IQR: 16.8) years for BD+MS, 34.6 (13.6) years for pNBD, and 27.6 (13.3) years for MS (BD+MS vs. MS; p = 0.3, pNBD vs. MS, p = 0.7). Additionally, the number of attacks was notably different, with BD+MS patients experiencing a median of 3.5 (2.0) attacks compared to 3.0 (3.0) for MS patients and only 1.0 (1.0) for pNBD patients, suggesting a more active disease course in the MS and BD+MS groups compared to pNBD (p < 0.001). The median annualized relapse rate for BD+MS was 0.3 (0.2), which was lower than the rate of 0.4 (0.4) in MS (p = 0.048) and equivalent to the rate of 0.2 (0.3) in pNBD (p = 0.2). The time to the first relapse was similar to those with BD+MS and MS, but considerably shorter than in individuals with pNBD (p < 0.0001). The cerebrospinal fluid (CSF) analysis showed no significant differences in neutrophil and lymphocyte counts between BD+MS and MS patients but elevated levels in pNBD patients (p < 0.05). CSF protein levels were consistent across all groups (p = 0.1 and p = 0.7). Oligoclonal bands were detected in all patients with BD+MS, in the majority of MS patients (83.6 %), and a small percentage of pNBD patients (19.7 %), showing a notable distinction between the BD+MS and pNBD groups (p < 0.001).

CONCLUSION

Our study underscores the need for a skeptical approach in diagnosing and treating patients with BD who exhibit symptomatic MS-like MRI lesions. Our findings suggest that BD+MS is a distinct clinical entity, warranting specific diagnostic and treatment approaches. Our findings highlight that BD patients with MS-like lesions meeting MS diagnostic criteria should be managed as patients with comorbid MS and BD rather than pNBD.

Prevalence and incidence of multiple sclerosis in Turkey: A nationwide epidemiologic study

BACKGROUND

Many studies on multiple sclerosis (MS) reveal different prevalence and epidemiologic results.

OBJECTIVES

In this study, we aimed to determine the epidemiologic profile of MS using official health records in Turkey.

METHODS

Patients diagnosed with MS from the official health data of the Ministry of Health, representing the entire population of Turkey, were included in the study. Prevalence and incidence calculations were performed using the data on gender, age, year of birth, city of residence, and year of diagnosis.

RESULTS

As a result of the study, the number of patients with the ICD code G35 was determined as 201,061 and the number of patients with this code entered at least three times was determined as 82,225. The prevalence of MS in Turkey was calculated as 96.4 per 100,000 and the female/male ratio as 2.1/1. The incidence of MS in 2022 was 6.2 per 100,000 and the mean patient age was 43.1 ± 13.3 years (female: 43.0 ± 13.1 vs male: 43.2 ± 13.7) while the mean age at first diagnosis was 34.0 ± 13.0 (female: 33.6 ± 12.6 vs male: 34.9 ± 13.7).

CONCLUSION

The research was conducted via Official Database of Turkey, which includes population of 85 million and provides valuable insights into the prevalence and incidence rates of this chronic disease.

[Cerebellar antibodies in post-stroke sera of acute ischemic stroke patients]

Background and purpose

Although serum anti-neuronal antibodies are found in acute ischemic stroke (AIS) patients, it is not completely clear whether they are already present before the cerebrovascular event or emerge thereafter. 

.

Methods

Sera of 21 consecutive first-ever AIS patients were collected within the first day of AIS (baseline), as well as 1 and 6 months after AIS. Well-characterized and novel anti-neuronal antibodies were investigated by cell-based assays, immunoblotting and indirect immunohistochemistry.

.

Results

None of the AIS sera collected at different time points showed well-characterized antibodies. In 7 patients, 1- and 6-month sera (but not baseline sera) showed IgG mostly reacting with soma and dendrites of cerebellar Purkinje cells. Antibody-positive patients did not differ in terms of clinical and etiological features.

.

Conclusion

Our results provide evidence for the antibody-triggering action of AIS. Although anti-cerebellar antibodies are not associated with the severity of stroke, they may potentially contribute to chronic post-stroke complications and disability.

.

Chloride intracellular channel protein-1 (CLIC1) antibody in multiple sclerosis patients with predominant optic nerve and spinal cord involvement

INTRODUCTION

Antibodies to cell surface proteins of astrocytes have been described in chronic inflammatory demyelinating disorders (CIDD) of the central nervous system including multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). Our aim was to identify novel anti-astrocyte autoantibodies in relapsing remitting MS (RRMS) patients presenting predominantly with spinal cord and optic nerve attacks (MS-SCON).

METHODS

Sera of 29 MS-SCON patients and 36 healthy controls were screened with indirect immunofluorescence to identify IgG reacting with human astrocyte cultures. Putative target autoantigens were investigated with immunoprecipitation (IP) and liquid chromatography-mass/mass spectrometry (LC-MS/MS) studies using cultured human astrocytes. Validation of LC-MS/MS results was carried out by IP and ELISA.

RESULTS

Antibodies to astrocytic cell surface antigens were detected in 5 MS-SCON patients by immunocytochemistry. LC-MS/MS analysis identified chloride intracellular channel protein-1 (CLIC1) as the single common membrane antigen in 2 patients with MS-SCON. IP experiments performed with the commercial CLIC1 antibody confirmed CLIC1-antibody. Home made ELISA using recombinant CLIC1 protein as the target antigen identified CLIC1 antibodies in 9/29 MS-SCON and 3/15 relapsing inflammatory optic neuritis (RION) patients but in none of the 30 NMOSD patients, 36 RRMS patients with only one or no myelitis/optic neuritis attacks and 36 healthy controls. Patients with CLIC1-antibodies showed trends towards exhibiting reduced disability scores.

CONCLUSION

CLIC1-antibody was identified for the first time in MS and RION patients, confirming once again anti-astrocytic autoimmunity in CIDD. CLIC1-antibody may potentially be utilized as a diagnostic biomarker for differentiation of MS from NMOSD.

Concomitant Crohn's Disease and Anti-Glutamic Acid Decarboxylase (GAD)-Associated Autoimmune Encephalitis: A Case Report

Crohn's disease is an inflammatory, autoimmune disorder that predominantly affects the intestines but can also affect extraintestinal organs. Certain neurological conditions, such as autoimmune encephalitis, can develop along with this disease. In this case report, we present a case of anti-glutamic acid decarboxylase (GAD) antibody-associated autoimmune encephalitis that occurred shortly after the diagnosis of Crohn's disease and was unrelated to the treatment and nutritional deficiencies. After a significant weight loss (24 kg) and persistent diarrhea, the patient was diagnosed with Crohn's disease by colonoscopy and biopsy. Within two weeks after the diagnosis, he experienced altered consciousness and memory impairment, followed by a rapid deterioration in consciousness and respiratory distress, leading to intubation and admission to the intensive care unit. His brain MRI revealed asymmetrical diffuse cortical diffusion restrictions, hyperintense signals on fluid-attenuated inversion recovery (FLAIR) sequences, and diffuse pachymeningeal contrast enhancement involving both cingulate gyri, bilateral insular cortices, amygdalae, hippocampi, and the right precuneus. Analysis of cerebrospinal fluid (CSF) revealed a slight elevation of CSF proteins, and the patient tested positive for serum anti-GAD antibodies. The patient responded favorably to a seven-day course of intravenous methylprednisolone, five days of intravenous immunoglobulin (IVIG), and oral corticosteroids. Subsequent treatment consisted of monthly IVIG, azathioprine, and vedolizumab, resulting in no neurologic sequelae except mild amnesia. A follow-up MRI at three months showed a nearly complete disappearance of the lesions. This is the first reported case of anti-GAD-associated encephalitis occurring in the presence of Crohn's disease.

The Effect of Smoking on Inactivated and mRNA Vaccine Responses Applied to Prevent COVİD-19 in Multiple Sclerosis

Introduction

Coronavirus disease 2019 (COVID-19) is the biggest health challenge of recent times. Studies so far reveal that vaccination is the only way to prevent this pandemic. There may be factors that decrease or increase vaccine effectiveness. In multiple sclerosis (MS), some of these factors may cause changes in the effectiveness of the vaccine, depending on the nature of the disease and disease-modifying treatments (DMT). In this study, we aimed to investigate the relationship between antibody titer and smoking in non-treated and DMT-treated MS patients who received inactivated vaccine (Sinovac) and messenger RNA BNT162b2 (BioNTech) mRNA vaccines.

Method

Vaccine antibody responses were measured between 4-12 weeks after two doses of inactivated vaccine and mRNA vaccines. Patients were separated into 6 groups as: patients with MS without treatment PwMS w/o T, ocrelizumab, fingolimod, interferons (interferon beta-1a and interferon beta-1b), dimethyl fumarate, and teriflunomide. Antibody titers of smokers and non-smokers were compared for both vaccines and for each group.

Results

The study included 798 patients. In the mRNA vaccine group, smokers (n=148; 2982±326 AU/mL) had lower antibody titers compared to the non-smokers (n=244; 5903±545 AU/mL) in total (p=0.020). In the inactivated vaccine group, no significant difference was detected between smokers (n=136; 383±51 AU/mL) and non-smokers (n=270; 388±49 AU/mL) in total (p=0.149). In both vaccine groups, patients receiving ocrelizumab and fingolimod had lower antibody titers than those receiving other DMTs or PwMS w/o T. In untreated MS patients, antibody levels in smokers were lower than in non-smokers in the mRNA vaccine group. No difference was found between antibody levels of smokers and non-smokers in any of the inactivated vaccine groups.

Conclusion

Ocrelizumab and fingolimod have lower antibody levels than PwMS w/o T or other DMTs in both mRNA and inactivated vaccine groups. Smoking decreases antibody levels in the mRNA vaccine group, while it has no effect in the inactivated vaccine group.

mRNA versus inactivated virus COVID-19 vaccines in multiple sclerosis: Humoral responses and protectivity-Does it matter?

BACKGROUND

COVID-19 vaccines are recommended for people with multiple sclerosis (pwMS). Adequate humoral responses are obtained in pwMS receiving disease-modifying therapies (DMTs) after vaccination, with the exception of those receiving B-cell-depleting therapies and non-selective S1P modulators. However, most of the reported studies on the immunity of COVID-19 vaccinations have included mRNA vaccines, and information on inactivated virus vaccine responses, long-term protectivity, and comparative studies with mRNA vaccines are very limited. Here, we aimed to investigate the association between humoral vaccine responses and COVID-19 infection outcomes following mRNA and inactivated virus vaccines in a large national cohort of pwMS receiving DMTs.

METHODS

This is a cross-sectional and prospective multicenter study on COVID-19-vaccinated pwMS. Blood samples of pwMS with or without DMTs and healthy controls were collected after two doses of inactivated virus (Sinovac) or mRNA (Pfizer-BioNTech) vaccines. PwMS were sub-grouped according to the mode of action of the DMTs that they were receiving. SARS-CoV-2 IgG titers were evaluated by chemiluminescent microparticle immunoassay. A representative sample of this study cohort was followed up for a year. COVID-19 infection status and clinical outcomes were compared between the mRNA and inactivated virus groups as well as among pwMS subgroups.

RESULTS

A total of 1484 pwMS (1387 treated, 97 untreated) and 185 healthy controls were included in the analyses (male/female: 544/1125). Of those, 852 (51.05%) received BioNTech, and 817 (48.95%) received Sinovac. mRNA and inactivated virus vaccines result in similar seropositivity; however, the BioNTech vaccination group had significantly higher antibody titers (7.175±10.074) compared with the Sinovac vaccination group (823±1.774) (p<0.001). PwMS under ocrelizumab, fingolimod, and cladribine treatments had lower humoral responses compared with the healthy controls in both vaccine types. After a mean of 327±16 days, 246/704 (34.9%) of pwMS who were contacted had COVID-19 infection, among whom 83% had asymptomatic or mild disease. There was no significant difference in infection rates of COVID-19 between participants vaccinated with BioNTech or Sinovac vaccines. Furthermore, regression analyses show that no association was found regarding age, sex, Expanded Disability Status Scale score (EDSS), the number of vaccination, DMT type, or humoral antibody responses with COVID-19 infection rate and disease severity, except BMI Body mass index (BMI).

CONCLUSION

mRNA and inactivated virus vaccines had similar seropositivity; however, mRNA vaccines appeared to be more effective in producing SARS-CoV-2 IgG antibodies. B-cell-depleting therapies fingolimod and cladribine were associated with attenuated antibody titer. mRNA and inactive virus vaccines had equal long-term protectivity against COVID-19 infection regardless of the antibody status.

Serum IgG of patients with relapsing inflammatory optic neuropathy immunoreacts with Sox2-positive glial cells of the optic nerve

BACKGROUND

Given the significance of glial cells in maintenance of neurons, antibodies directed against glial cells of the optic nerve might reasonably be expected to have a pathogenic impact in relapsing inflammatory optic neuropathy (RION).

METHODS

We investigated IgG immunoreactive with the optic nerve tissue by indirect immunohistochemistry using sera of 20 RION patients. Commercial Sox2-antibody was used for double immunolabeling.

RESULTS

Serum IgG of 5 RION patients reacted with cells aligned in the interfascicular regions of the optic nerve. IgG binding sites significantly co-localized with the Sox2-antibody.

CONCLUSION

Our results suggest that a subset of RION patients may harbor anti-glial antibodies.

Retrospective analysis of effectiveness of fingolimod in real life setting in Turkey (REFINE)

BACKGROUND

During multiple sclerosis (MS) treatment different modes of action such as lateral (interferon beta to glatiramer acetate or glatiramer acetate to interferon beta) or vertical (interferon beta/glatiramer acetate to fingolimod) drug switch can be performed. This study aims to investigate the clinical effectiveness of switching from the first-line injectable disease modifying treatments (iDMTs) to fingolimod (FNG) compared to switching between first-line iDMTs.

METHODS

This is a multicenter, observational and retrospective study of patients with relapsing-remitting MS who had lateral and vertical switch. The observation period included three key assessment time points (before the switch, at switch, and after the switch). Data were collected from the MS patients' database by neurologists between January 2018 and June 2019. The longest follow-up period of the patients was determined as 24 months after the switch.

RESULTS

In 462 MS patients that were included in the study, both treatments significantly decreased the number of relapses during the postswitch 12 months versus preswitch one year while patients in the FNG group experienced significantly fewer relapses compared to iDMT cohort in the postswitch 12 months period. FNG cohort experienced fewer relapses than in the iDMT cohort within the postswitch 2 year. The mean time to first relapse after the switch was significantly longer in the FNG group.

DISCUSSION

The present study revealed superior effectiveness of vertical switch over lateral switch regarding the improvement in relapse outcomes. Patients in the FNG cohort experienced sustainably fewer relapses during the follow-up period after the switch compared the iDMT cohort. Importantly, switching to FNG was more effective in delaying time to first relapse when compared with iDMTs.

Lesion probability map in cerebral vein thrombosis due to Behçet's disease

AIM

Behçet's disease (BD) is a multisystemic inflammatory disease. Cerebral venous sinus thrombosis (CVST) is the second most common form of neuro-BD after parenchymal central nervous system involvement. The purpose of this study was to construct flow-void probability maps of patients with CVST with and without BD to visually illustrate the impacted cerebral venous sinuses, to compare the subgroups of patients, and investigate the effect of thrombus localization on clinical findings.

METHODS

Seventeen patients with a diagnosis of BD-related CVST (CVST-BD) and 23 patients with a diagnosis of CVST related to other etiologies (CVST-O) were included. We collected data including gender, age at onset of BD and CVST, presenting symptoms, neurological findings, and the etiology. High-resolution magnetic resonance venographies obtained during CVST were used to mark and digitalize thrombosed areas. Thrombus probability and subtraction maps were created to reveal the differences between the subgroups.

RESULTS

Remarkably, all patients with CVST-BD had thrombosis in the transverse sinus (TS). However, TS was affected in 73.9% of the CVST-O patients (17/17 in CVST-BD vs 17/23 in CVST-O, P = .03). Thrombosis developed mostly in the superior sagittal sinus (SSS) and TS in the CVST-O group (11/23, 47.8% and 17/23, 73.9%, respectively). The frequency of SSS thrombosis tended to be higher in the CVST-O (47.8% vs 23.5%, P = .19).

CONCLUSION

Venous infarction and hemorrhage were less common in patients with CVST-BD. The only clinical symptom in most of the CSVT patients with BD was headache due to elevated intracranial pressure. TS thrombosis was more common in patients with BD.

Serum 3-phenyllactic acid level is reduced in benign multiple sclerosis and is associated with effector B cell ratios

BACKGROUND

3-phenyllactic acid (PLA) is produced by both intestinal bacteria and the human host. PLA exists in its D- and L- chiral forms. It modulates human immune functions, thereby acting as a mediator of bacterial-host interactions. We aim to determine the amount and potential influence of PLA on clinical and immunological features of MS.

METHODS

We measured D- and L-PLA levels in bacterial supernatants and in sera of 60 MS patients and 25 healthy controls. We investigated potential associations between PLA levels, clinical features of MS, serum cytokine levels and ratios of peripheral blood lymphocyte subsets.

RESULTS

Multiple gut commensal bacteria possessed the capacity to generate D- and L-PLA. MS patients with benign phenotype showed markedly lower PLA levels than healthy controls or other MS patients. Fingolimod resistant patients had higher PLA levels at baseline. Furthermore, MS patients with higher PLA levels tended to display increased memory B and plasma cell ratios, elevated IL-4 levels and increased ratios of IL-4 and IL-10 producing T cell subsets.

CONCLUSION

Collectively, our work indicates that reduced serum levels of PLA could be associated with a favorable clinical course in MS and possibly be used as a biomarker.

Coexistence of restless legs syndrome and multiple sclerosis aggravates anxiety and depression

BACKGROUND

Among the comorbidities that accompany multiple sclerosis (MS), restless legs syndrome (RLS) is one of the most common. Anxiety and depression are common psychological comorbidities that impact the quality of life of patients with MS (PwMS), as well as patients with RLS.

OBJECTIVE

To investigate the psychiatric burden of MS and RLS coexistence, we conducted a nationwide, multicenter and cross-sectional survey.

METHODS

Participants were assessed by using demographic and clinical parameters along with the Hamilton Anxiety and Hamilton Depression Scales (HAM-A and HAM-D).

RESULTS

Out of the 1,068 participants, 173 (16.2%) were found to have RLS [RLS(+)] and 895 (83.8%) did not [RLS(-)]. The mean scores for HAM-A and HAM-D were significantly higher among RLS(+) subjects than among RLS(-) subjects (p<0.001 for all variables).

CONCLUSIONS

According to our data, the presence of RLS in PwMS may increase the occurrence of both anxiety and depression symptoms. Awareness and treatment of RLS in PwMS could possibly reduce the symptoms of psychiatric comorbidities originating from RLS.

Lesion distribution pattern of parenchymal Neuro-Behçet's disease using probability mapping

BACKGROUND AND PURPOSE

Behçet's disease (BD) is an inflammatory disorder with multisystemic involvement. The most disabling aspect of BD is Neuro-Behçet's disease (NBD). In NBD, parenchymal lesions tend to occur in the mesodiencephalic region and brainstem, as reported in large series of NBD. Our study aimed to generate probability maps of parenchymal lesions to compare patient subgroups with different clinical and laboratory features.

METHOD

We included 66 non-standardized acute relapse MRIs of 55 patients with parenchymal NBD (p-NBD). We used T2-weighted axial images to digitalize the lesions using the CAD software. Boundaries of lesions were determined as polygons and converted into high-definition raster datasets. Then, digitalized lesion maps were transferred into the ICBM-152 brain template to perform spatial analyses. Finally, we created subtraction maps to compare the patient subgroups.

RESULTS

We used a total of 66 MRIs of 55 patients to generate the probability maps. The most frequently affected parenchymal structures were the rostral pons, mesencephalon, and diencephalic region. Interestingly, the brainstem was more commonly affected in females than males (p<0.01). In the late-onset disease, lesions were localized in the corticospinal tracts and caudal brainstem (p<0.01). Progressive disease and severe disability at the end of the follow-up period were associated with corticospinal tract lesions during relapses (p<0.01). Patients with positive pathergy tests were more likely to present right hemisphere involvement (p<0.01). Additionally, cyclosporine-induced lesions tend to be in atypical locations such as hemispheric white matter.

CONCLUSIONS

In the published studies, lesions in NBD were localized according to coarse anatomical regions. Our study uses visual maps to offer accurate lesion localizations using non-standardized brain MRIs, allowing comparisons across different NBD subgroups. By using this technique, we investigated the relationship of the clinical and laboratory features with the lesion locations. We found that the late age of onset was associated with a poor prognosis. Additionally, corticospinal lesions may predict severe and progressive disease course, requiring aggressive treatment. Interestingly, females had more brainstem lesions and lesion lateralization might be influenced by the pathergy test status.

Detailed Evaluation of Macular Ganglion Cell Complex in Patients with Multiple Sclerosis

Introduction:

Retinal nerve fiber layer thickness has been used for monitoring of disease activity in patients with multiple sclerosis (MS). Macular ganglion cell complex (GCC) layer of retina also can be measured by OCT and has been suggested as a potential biomarker in MS. In this study we investigated the macular GCC and its role as a potential biomarker in patients with Multiple Sclerosis (MS).

Methods:

A prospective cohort-study, subjects consisted of Relapsing-Remitting MS patients (n=62) and healthy controls (n=60). Eyes of MS patients were divided into two subgroups according to the history of the optic neuritis (ON). Standard peripapillary-RNFL and macular scan protocol, and retinal auto-segmentation of spectral-domain OCT were performed. Macular RNFL (mRNFL), ganglion cell layer (GCL), and inner plexiform layer (IPL), and GCC (the sum of these former three layers) were recorded. The macula was divided into nine sectors using the ETDRS grid (4×9=36 variables).

Results:

In total, 50 eyes of 36 patients had previous ON attacks. 35/36 GCC parameters were thinner in MS patients and subgroups compared to the control group (p<0.05). When the eyes with and without a history of optic neuritis were compared, 25 of 36 parameters were thinner in those with ON. There were strong correlations between visual acuity-GCC parameters and EDSS scores in patients with a history of optic neuritis. However, no such relationship was found in those without an ON story.

Conclusion:

Ganglion cell complex gets thinner in patients with MS with a decreasing order of GCL, IPL, and mRNFL. The examination of GCC in detail could be a beneficial biomarker for MS.

Anti-GAD associated post-infectious cerebellitis after COVID-19 infection

The coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), continues to spread rapidly all over the world. Besides severe pneumonia, it causes multisystemic disease, including neurological findings. Here, we present a patient with anti–glutamic acid decarboxylase (anti-GAD) antibody-associated cerebellitis developed after COVID-19 infection. The patient responded well to the immune treatments. Our knowledge about SARS-CoV-2 infection–related neurological disorders is limited. New data are needed to recognize the clinical spectrum of autoimmune neurological disorders that emerges after SARS-CoV-2 infection.

The efficacy of rituximab in patients with neuromyelitis optica spectrum disorder: A real-world study from Turkey

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) are a group of antibody-mediated chronic inflammatory diseases of the central nervous system. Rituximab is a monoclonal antibody that leads to a reduction in disease activity.

OBJECTIVE

To evaluate the efficacy of rituximab as monotherapy in NMOSD and to determine whether the efficacy varies depending on the presence of antibodies in this cohort.

METHOD

This multicentre national retrospective study included patients with NMOSD treated with rituximab at least for 12 months from Turkey. The primary outcomes were the change in the annualised relapse rate, the Expanded Disability Status Scale (EDSS), the number of relapse and radiological activity-free patients.

RESULTS

A total of 85 patients with NMOSD were included in the study. Of 85 patients, 58 (68.2%) were seropositive for anti-Aquaporin4-IgG (antI-AQP4-IgG). All patients were Anti-Myelin Oligodendrocyte Glycoprotein IgG (anti-MOG-IgG) negative. The median follow-up for rituximab treatment was 21 months (Q1 16-Q3 34.5). During rituximab treatment, the mean annualised relapse rate (ARR) significantly decreased from 1.45 ± 1.53 to 0.15 ± 0.34 (P < .001). In subgroup analyses, the mean ARR decreased from 1.61 ± 1.65 to 0.20 ± 0.39 in the seropositive group and 1.10 ± 1.19 to 0.05 ± 0.13 in the seronegative group. The mean EDSS improved from 3.98 ± 2.04 (prior to treatment onset) to 2.71 ± 1.59 (at follow-up) (P < .001). In the seropositive group, mean EDSS decreased from 3.94 ± 1.98 to 2.67 ± 1.54, and in the seronegative group, mean EDSS decreased from 4.07 ± 2.21 to 2.79 ± 1.73. There was no significant difference between anti-AQP4-IgG (+) and (-) groups in terms of ARR and EDSS. Sixty-four patients (75.2%) were relapse-free after the initiation of treatment. Seventy patients (82.3%) were radiological activity-free in the optic nerve, area postrema and brainstem. Additionally, 78 patients (91.7%) showed no spinal cord involvement after the treatment.

CONCLUSION

Rituximab therapy is efficacious in the treatment of Turkish NMOSD patients independent of the presence of the anti-AQP4-IgG antibody.

Serum anti-ganglioside antibodies in patients with autoimmune limbic encephalitis

BACKGROUND/AIM

Ganglioside antibodies are identified not only in patients with inflammatory neuropathies but also several central nervous system disorders and paraneoplastic neuropathies. Our aim was to investigate whether ganglioside antibodies are found in autoimmune encephalitis patients and may function as a diagnostic and prognostic biomarker.

MATERIALS AND METHODS

Sera and cerebrospinal fluid (CSF) samples of 33 patients fulfilling the criteria for probable autoimmune encephalitis were collected within the first week of clinical manifestation. None of the patients had evident symptoms and findings of peripheral polyneuropathy. Well-characterized anti-neuronal and paraneoplastic antibodies were investigated in sera and CSF and anti-ganglioside (anti-GM1, GM2, GM3, GD1a, GD1b, GT1b and GQ1b) IgG and IgM antibodies were measured in sera using commercial immunoblots.

RESULTS

Twenty-eight of 33 autoimmune encephalitis patients displayed antibodies against neuronal surface or onco-neural antigens with N-methyl-D-aspartate receptor (NMDAR), glutamic acid decarboxylase (GAD) and Hu antibodies being the most prevalent. While no anti-ganglioside IgG antibodies were found, 4 patients (2 anti-NMDAR+, 1 anti-GAD+ and 1 antibody negative) with autoimmune limbic encephalitis displayed anti-GM1, anti-GM2, anti-GM3 or anti-GQ1b IgM antibodies. There was no apparent association between anti-ganglioside positivity and clinical and demographic features.

CONCLUSION

Serum ganglioside IgM antibodies may infrequently emerge during the clinical course of autoimmune limbic encephalitis without evident polyneuropathy. Absence of the IgG response suggests that these antibodies might have developed as a hyperacute immune response to neuro-axonal destruction. Nevertheless, potential impact of ganglioside antibodies on axonal degeneration and neuronal loss in limbic encephalitis pends to be further investigated.

Evaluating the effects of transcutaneous tibial nerve stimulation or pelvic floor muscle training on sexual dysfunction in female multiple sclerosis patients reporting overactive bladder

AIMS

Sexual dysfunction (SD) is common in female patients with multiple sclerosis (MS) reporting overactive bladder (OAB) symptoms. The aim of the study was to evaluate the effects of transcutaneous tibial nerve stimulation (TTNS) and pelvic floor muscle training (PFMT) with biofeedback on SD in female patients with MS reporting OAB symptoms.

METHODS

Patients with overactive bladder and SD were allocated to receive TTNS or PFMT daily. Overactive bladder symptoms, sexual functions, and sexual quality of life were assessed at baseline and 6^th weeks. Female Sexual Function Index (FSFI), Overactive Bladder Questionnaire (OABv-8), and Sexual Quality of Life-Female (SQoL-F) questionnaires were used.

RESULTS

Thirty patients (TTNS = 10, PFMT = 20) were included in the study. Compared to baseline, total FSFIOABv-8, and SQoL-F scores improved in both TTNS (p = 0.005, p = 0.011, p = 0.444, respectively) and PFMT (p = 0.002, p = 0.001, p = 0.001, respectively) groups. Between-group comparisons did not show any significant differences.

CONCLUSION

This study demonstrates the efficacy of both TTNS and PFMT for improving sexual function in female MS patients with OAB symptoms, but did not show superiority of any particular method. Further studies are required to investigate the differences between these two non-invasive methods.

Bruch's membrane opening-minimum rim width: An alternative OCT biomarker study for multiple sclerosis

PURPOSE

Bruch's membrane opening-minimum rim width (BMO-MRW) and RNFL measured using anatomic positioning system (APS-RNFL) are novel OCT methods and remained unexplored in MS patients.To investigate the novel parameters of spectral-domain OCT as an alternative biomarker in patients with multiple sclerosis (MS).

METHODS

Retrospective cohort study; participants consisted of relapsing-remitting MS (RRMS) patients and healthy controls (HC). Eyes were classified according to the presence of MS and previous optic neuritis (ON). Measurements of standard peripapillary RNFL (S-RNFL), BMO-MRW, and APS-RNFL were performed.

RESULT

A total of 244 eyes of 122 participants (MS-patients: 63, HC: 59) were included in the study. Fifty-one eyes had a history of previous ON. In almost all measured parameters, neuroretinal rim thicknesses were observed the thinnest in eyes with ON history between all subgroups. S-RNFL and APS-RNFL techniques showed the difference in neuroretinal rim thickness in all three subjects (ON+, ON-, and HC). However, BMO-MRW, on the other hand, could not distinguish between ON(-) patients and HC. The relationship between OCT parameters and EDSS were observed only in eyes with an ON history in all three techniques. A meaningful model with 78% accuracy was obtained by using only the OCT parameters as risk factors. In the ROC analysis, no parameters were found to have acceptable high sensitivity and specificity. BMO-MRW was statistically weaker in every aspect than other RNFL techniques.

CONCLUSION

The novel APS-RNFL technique appears to be a bit more reliable alternative to S-RNFL technique to support therapeutic decision-making in MS. BMO-MRW has not been found as a successful alternative to S-RNFL.

Impact of Autoimmune Demyelinating Brain Disease Sera on Pericyte Survival

Introduction

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) characterized by demyelination and brain pericyte dysfunction might be involved in MS pathogenesis Our aim was to evaluate whether the factors in serum affect pericyte survival.

Method

C57BL/6 female mice were immunized with myelin oligodendrocyte glycoprotein (MOG) to induce experimental autoimmune encephalomyelitis (EAE). To confirm the animal model, the sera level of anti-MOG antibody in mice and platelet-derived growth factor-BB (PDGF-BB) in patients was measured by ELISA. Human brain vascular pericytes (HBVP) cell lines were incubated with sera of EAE mice and primer progressive MS (PPMS), seconder progressive MS (SPMS) and relapsing-remitting MS (RRMS) patients. The viability of HBVP is measured with Annexin V-FITC/propidium iodide staining with flow cytometry.

Results

Annexin V-FITC/propidium iodide staining with flow cytometry showed increased ratios of early apoptosis and decreased survival following incubation with sera of EAE and progressive MS. Levels of platelet-derived growth factor-BB were identical in serum and cerebrospinal fluids of patients with different forms of MS.

Conclusion

Our results suggest that serum factors might contribute to progressive MS pathogenesis via pericyte dysfunction.

A Case of HaNDL with Low Cerebrospinal Fluid Level of Neurofilament Light Chain

Diagnosis of the syndrome of headache and neurological deficits with cerebrospinal fluid (CSF) lymphocytosis (HaNDL) is based on clinical features, and no diagnostic biomarkers are available. We present a case presenting with characteristic features of HaNDL and an MRI lesion in the splenium of corpus callosum. CSF neurofilament light chain (NFL) levels were assessed in this patient together with 7 additional HaNDL patients, 18 multiple sclerosis (MS) patients, and 15 primary headache patients. Both HaNDL and primary headache patients showed significantly lower NFL levels than MS patients. Our results suggest that increased CSF levels of NFL and neuroaxonal loss are not characteristic features of HaNDL. Neurological disorders mimicking HaNDL often present with increased levels of NFL, and thus CSF measurement of NFL might be useful in differential diagnosis of HaNDL.

A case report with tuberculous meningitis during fingolimod treatment

OBJECTIVE

We aimed to describe a case study of tuberculous meningitis in a patient with multiple sclerosis (MS) receiving fingolimod.

CASE REPORT

A-Thirty-five-year-old woman with MS started interferon beta-1b treatment in 2016. Due to frequent relapses and disability accumulation, her treatment was switched to fingolimod in 2018. The patient presented with subacute headache, fever, confusion, nausea, and vomiting after one year of treatment with fingolimod. Her cerebrospinal fluid (CSF) examination yielded a lymphocytic pleocytosis, elevated protein level, and decreased glucose levels. Her brain magnetic-resonance-images (MRI) showed contrast enhancement of meninges without any new demyelinating lesions. Mycobacterium tuberculosis was isolated in her CSF culture. After using anti-tuberculosis treatment for nine months, the patient's infection resolved entirely without any disability related to meningitis. Then, the fingolimod therapy was switched to glatiramer acetate.

CONCLUSION

Herein, we report the first case with fingolimod-associated meningitis during Mycobacterium tuberculosis in a patient with MS. Clinicians should keep in mind that fingolimod treatment may reactivate latent tuberculosis, especially in endemic regions.

Effectiveness of the transcutaneous tibial nerve stimulation and pelvic floor muscle training with biofeedback in women with multiple sclerosis for the management of overactive bladder

Background:

Overactive bladder (OAB) is common in patients with multiple sclerosis (MS) with a limited number of treatment options.

Objective:

To investigate the effect of transcutaneous tibial nerve stimulation (TTNS) and pelvic floor muscle training (PFMT) with biofeedback on OAB symptoms in female MS patients.

Methods:

This study was conducted at the outpatient MS clinic in Istanbul. At baseline bladder diary, post-voiding residue (PVR), OAB, and Qualiveen Scales (QoL: Quality of Life; Siup: Specific Impact of Urinary Problems on QoL) were assessed. Patients were allocated to receive TTNS or PFMT daily for 6 weeks and reevaluated using the same tests.

Results:

Fifty-five patients (TTNS = 28, PFMT = 27) were included. Compared with baseline, both TTNS and PFMT groups improved in terms of OAB ( p = 0.0001, p = 0.0001), Qualiveen-siup ( p = 0.0001, p = 0.0001), Qualiveen-QoL ( p = 0.002, p = 0.006), PVR ( p = 0.0001, p = 0.21), frequency ( p = 0.0001, p = 0.69), nocturia ( p = 0.0001, p = 0.19), urgency ( p = 0.0001, p = 0.0001), and urge incontinence ( p = 0.0001, p = 0.0001). Between-group comparisons showed significant differences in 24-hour frequency ( p = 0.002) in favor of TTNS.

Conclusion:

Our study demonstrates the efficacy of both TTNS and PFMT for managing OAB symptoms in MS, associated with a significant impact on QoL, but did not show superiority of the methods. Further studies are needed to explore differences between these two non-invasive treatments.

'Is RLS a harbinger and consequence of MS?: Striking results of the 'RELOMS-T' study'

BACKGROUND

Although studies report a high prevalence rate of restless legs syndrome (RLS) among patients with multiple sclerosis (PwMS) ranging from 13.3 to 65.1%, little is known about the causes of this relationship.

METHODS

To ascertain the prevalence, features and impact of RLS among PwMS a nation-wide, multicenter, prospective and a cross-sectional survey, designed to reflect all of the PwMS throughout Turkey, was conducted in 13 centers. Exploring the relationship of the two conditions could possibly contribute to the understanding of the causes of the high and wide-ranging prevalence rates and the pathophysiology of both diseases.

RESULTS

Of the 1068 participants 173 (16,2%) found to have RLS [RLS(+)] and 895 (83,8%) did not [RLS(-)]. Among the RLS(+) 173, all but 8 patients (4,6%) were underdiagnosed in terms of RLS. More than half of the patients with RLS had 'severe' or 'very severe' RLS. The onset of RLS was before or synchronous with the onset of MS in about a half of our patients.

CONCLUSION

We conclude that RLS should be meticulously investigated in PwMS and MS can be a direct cause of RLS at least in part of PwMS. Our data about the timing of the onset of MS and RLS, along with the high prevalence of RLS in PwMS suggest that the pathologic changes in the initial phases of MS can possibly trigger RLS symptoms.

Microbiota stratification identifies disease-specific alterations in neuro-Behçet's disease and multiple sclerosis

OBJECTIVES

Altered gut microbiota community dynamics are implicated in diverse human diseases including inflammatory disorders such as neuro-Behçet's disease (NBD) and multiple sclerosis (MS). Traditionally, microbiota communities are analysed uniformly across control and disease groups, but recent reports of subsample clustering indicate a potential need for analytical stratification. The objectives of this study are to analyse and compare faecal microbiota community signatures of ethno-geographical, age and gender matched adult healthy controls (HC), MS and NBD individuals.

METHODS

Faecal microbiota community compositions in adult HC (n=14), NBD patients (n=13) and MS (n=13) were analysed by 16S rRNA gene sequencing and standard bioinformatics pipelines. Bipartite networks were then used to identify and re-analyse dominant compositional clusters in respective groups.

RESULTS

We identified Prevotella and Bacteroides dominated subsample clusters in HC, MS, and NBD cohorts. Our study confirmed previous reports that Prevotella is a major dysbiotic target in these diseases. We demonstrate that subsample stratification is required to identify significant disease-associated microbiota community shifts with increased Clostridiales evident in Prevotella-stratified NBD and Bacteroides-stratified MS patients.

CONCLUSIONS

Patient cohort stratification may be needed to facilitate identification of common microbiota community shifts for causation testing in disease.

Validation of the Turkish version of the eight-item actionable bladder symptom screening tool in multiple sclerosis

AIMS

This study aimed to translate the eight-item Actionable Bladder Symptom Screening Tool (ABSST) and determine its psychometric properties in Turkish speaking subjects.

METHODS

The study was conducted at the multiple sclerosis (MS) outpatient clinic of the Istanbul Faculty of Medicine, Istanbul University. First, the ABSST was translated into Turkish by an expert panel. We employed the back translation method for linguistic validation. Cronbach's α and test-retest analysis were performed for reliability analysis. The overactive bladder-v8 (OAB-v8) questionnaire was also administered for concurrent validation, and expanded disability status scale (EDSS) and multiple sclerosis quality of life scale-54 (MSQL-54) were used to evaluate construct validity.

RESULTS

One hundred and five patients (84 females; mean age, 39.5 ± 11.6 years; mean EDSS score, 3.2 ± 1.8) participated in the study. Mean duration of MS was 9.7 ± 8.3 years, and most (n = 96; 91.5%) had relapsing-remitting MS. The mean ABSST score was 9.7 ± 5.8 (range, 0-21). Highest scores were obtained from urgency and frequency, and the lowest from psychosocial effects of lower urinary tract (LUT) symptoms. The Cronbach's α coefficient was 0.856, and item-total score correlations ranged between 0.485 and 0.845. Correlations of ABSST scores with OAB-v8, EDSS, and MSQL-54 scales were significant (P < .001). According to the questionnaire, 38.1% (n = 40) of the patients needed a referral to a urologist or gynecologist for their LUT symptoms.

CONCLUSIONS

The Turkish version of the ABSST is a valid and reliable screening tool that can be used to identify LUT symptoms in an MS clinic.

Impact of fingolimod on CD4+ T cell subset and cytokine profile of relapsing remitting multiple sclerosis patients

Fingolimod inhibits the egress of lymphocytes from lymphatic tissues and also directly affects their functions by modulation of the sphingosine-1-phosphate receptor 1 (S1P1). Our aim was to evaluate the impact of fingolimod on diverse CD4+ T cell subsets, and cytokines. Sixty-six relapsing remitting multiple sclerosis (RRMS) patients were treated with oral fingolimod (0.5 mg) for 6 months, and blood samples were collected at baseline, 3 months, and 6 months. Serum levels of seven cytokines and five chemokines were measured by multiplex immunoassay, and frequencies of peripheral blood mononuclear cell subsets were assessed by flow cytometry, and compared with those of 60 healthy controls. CCL2 (p = 0.039), and CCL5 (p = 0.001) levels were significantly higher in fingolimod-treated patients than healthy controls, whereas end-of-study serum levels of IL-6, IL-8, IL-17A, IL-22, IL-23, TNF-α, CXCL10, and CXCL13 were comparable to the baseline levels. Six months of fingolimod treatment reduced CD3+ T cell (mean ± standard deviation, 72.9% ± 5.5 vs. 60.1% ± 11.1, p < 0.001), CD4+ T cell (62.2% ± 8.5 vs. 24.6% ± 12.9, p < 0.001), CD4+CD25hi regulatory T cell (Treg) (3.4% ± 1.3 vs. 2.0% ± 1.4, p < 0.01), and CD19+ B cell (13.2% ± 5.8 vs. 5.3% ± 2.7, p < 0.001) frequencies, while CD8+ T cells (31.8% ± 7.8 vs. 57.8% ± 13.2, p < 0.001) were increased, and NK and NKT cells remained unchanged. The proportions of intracytoplasmic IL-4, IL-10, IFN-γ, and TNF-α-producing T cells were increased, whereas IL-17-producing cells remained relatively constant as measured by flow cytometry. Fingolimod appears to primarily diminish lymphocyte subsets involved in antigen presentation (CD19+ B and CD4+ T cells) rather than immune cells (CD8+ T, NK, and NKT cells) in charge of host defense against pathogens. In contrast, a relative increase is observed in pro- and anti-inflammatory cytokine-producing T helper subsets (IFN-γ, TNF-α, IL-4, and IL-10-producing CD4+ T cells), suggesting that effector T cells are suppressed to a lesser degree by S1P1 modulation.

Clinical Features of the Patients with Neuromyelitis Optica Spectrum Disorder

Introduction

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory, demyelinating syndrome of the central nervous system (CNS) that predominantly affects the spinal cord and optic nerves. Since it was first described, new information about the pathophysiology gained momentum with the discovery of an antibody against Aquaporin-4, a water channel protein that is predominantly found in the astrocytes. In our study, we evaluated the clinical features of NMOSD and clinically related CNS disorders.

Method

In our study, we recruited patients that were followed by Clinic for Multiple Sclerosis and Myelin Disorders at Istanbul University between 1979 and 2016.

Results

Thirty-five NMOSD, fifteen relapsing inflammatory optic neuropathy (RION) and ten opticospinal multiple sclerosis (OSMS) patients were recruited in our study. Forty-eight patients (%80) were female and twelve (%20) were male. Age, sex, follow-up period, annualized relapse rate, relapses in the first two years and progression index were similar between the groups. Cerebrospinal fluid (CSF) protein levels were higher in the NMOSD group. Concomitant autoimmune disorders were observed in six NMOSD patients and two OSMS patients. One patient with RION had nonspecific white matter lesions without gadolinium enhancement in the brain MRI.

Conclusion

Laboratory and imaging findings suggests that NMOSD is a distinct disorder than RION and OSMS. Further studies are needed to say specific comments about the existence of OSMS.

Prognostic Factors in Anti-Neuronal Antibody Positive Patients

INTRODUCTION

Anti-neuronal antibodies (ANA) are found in paraneoplastic neurological syndrome and autoimmune encephalitis patients. Our aim was to analyze prognostic factors related with ANA seropositivity.

METHODS

Twenty-seven consecutive ANA seropositive patients were included in the study. ANA were detected by immunofluorescent staining, immunoblot and cell-based assay methods. All patients were followed with a standard treatment protocol. Clinical syndromes, tumor types, modified Rankin scores, cranial MRI and oligoclonal band (OCB) findings were recorded. Cases were divided into subgroups due to clinical-laboratory features and ANA types. Prevalence of good prognosis, response to treatment and survival were compared among these subgroups.

RESULTS

Patients showed antibodies to N-methyl-D-aspartate receptor (NMDAR) (6 cases), Hu (6 cases), Ma2 (5 cases), glutamic acid decarboxylase (GAD) (3 cases), Yo (3 cases), amphiphysin (1 case), gamma-amino butyric acid B receptor (GABABR) (1 case), Ri (1 case) and Zic4 (1 case). Associated neurological syndromes were limbic encephalitis (8 cases), subacute cerebellar degeneration (7 cases), brainstem encephalitis (5 cases), subacute sensory neuronopathy (4 cases), stiff-person syndrome (2 cases) and opsoclonus-myoclonus (1 case). A tumor (ductal breast, small cell lung cancer) was detected in six cases at first admission. Six patients died in an average follow-up time of 1.0±1.5 years. Detection of antibodies to extracellular or synaptic target antigens, but not presence of tumor, cranial MRI lesions or OCB, was associated with good prognosis and response to treatment.

CONCLUSION

NMDAR, Hu and Ma2-antibodies were the most prevalent ANA in this first antibody screening study in a Turkish cohort. Antibody type was determined to be the foremost prognostic factor in ANA seropositive cases.

Glial and neuronal antibodies in patients with idiopathic intracranial hypertension

Headache and visual disturbances are the main presenting symptoms of idiopathic intracranial hypertension (IIH) characterized by increased intracranial pressure (ICP) with an unknown cause. We aimed to investigate the antibodies against optic neuritis-associated glial antigens, aquaporin-4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) and uncharacterized neuronal membrane antigens in IIH patients. Consecutive patients diagnosed according to Friedman revised diagnostic criteria and control subjects were included after their consent. All serum samples were analyzed for antibodies against AQP4 and MOG using cell-based immunofluorescent assays and for uncharacterized neuronal membrane antigens by indirect immunocytochemistry utilizing live neurons. Sera of 34 patients with IIH and 40 control subjects were investigated but none of the patients showed AQP4 and MOG antibodies. However, serum IgG of five IIH patients showed reactivity against membrane antigens of rat hippocampal and cortical neurons. Interestingly, three out of these five patients had nonspecific white matter lesions on MRI, whereas only four of all other patients had these lesions (p = 0.048). AQP4 and MOG antibodies do not seem to have a role in the pathophysiology of IIH. However, association of immunocytochemistry findings with the presence of white matter lesions may suggest that immunological factors contribute to the pathogenesis of IIH in at least some of the patients.

Validity and Reliability of the Turkish Version of the Monitoring My Multiple Sclerosis Scale

INTRODUCTION

This research was conducted to adapt the Monitoring My Multiple Sclerosis (MMMS) scale, which is a scale used for self-evaluation by multiple sclerosis (MS) patients of their own health and quality of life, to Turkish and to determine the psychometric properties of the scale.

METHODS

The methodological research was conducted in the outpatient MS clinic of a university hospital between January and September 2013. The sample in this study consisted of 140 patients aged above 18 who had a diagnosis of definite MS. Patients who experienced attacks in the previous month or had any serious medical problems other than MS were not included in the group. The linguistic validity of MMMS was tested by a backward-forward translation method and an expert panel. Reliability analysis was performed using test-retest correlations, item-total correlations, and internal consistency analysis. Confirmatory factor analysis and concurrent validity were used to determine the construct validity. The Multiple Sclerosis Quality of Life-54 instrument was used to determine concurrent validity and the Expanded Disability Status Scale, Hospital Anxiety and Depression Scale, and Mini Mental State Examination were used for further determination of the construct validity.

RESULTS

We determined that the scale consisted of four factors with loadings ranging from 0.49 to 0.79. The correlation coefficients of the scale were determined to be between 0.47 and 0.76 for item-total score and between 0.60 and 0.81 for items and subscale scores. Cronbach's alpha coefficient was determined to be 0.94 for the entire scale and between 0.64 and 0.89 for the subscales. Test-retest correlations were significant. Correlations between MMMS and other scales were also found to be significant.

CONCLUSION

The Turkish MMMS provides adequate validity and reliability for assessing the impact of MS on quality of life and health status in patients.

Differences Between General Neurologists and Multiple Sclerosis Specialists in the Management of Multiple Sclerosis Patients: A National Survey

Introduction

The management of multiple sclerosis (MS) has become more complicated after the introduction of new diagnostic and treatment options. Despite the abundance of guidelines, the experience of physicians still plays a major role in the management of patients. This study aimed to define differences in behavior patterns between general neurologists (GNs) and MS specialists (MSSs).

Methods

We conducted a survey of 36 questions to 318 neurologists, including 33 MSSs. The survey covered topics including laboratory investigations, pregnancy, and treatment.

Results

Our study found many differences between GNs and MSSs in terms of management, the most important being treatment initiation and switching. GNs had a tendency to initiate treatment later than MSSs however, they tended to switch treatment faster. Our study also showed that GNs ordered magnetic resonance imaging (MRI) more frequently than MSSs, even if patients were clinically stable. Moreover, although GNs more frequently relied on MRI, they did not consider brain atrophy as an important measure in the follow-up of their patients. Furthermore, GNs considered replacement therapy less often than MSSs, even in patients with vitamin D deficiency.

Discussion

Our study revealed important discrepancies between the management patterns of GNs and MSSs in MS patients. These findings suggest the need for a national education program for GNs on MSSs.

Peripheral nerve hyperexcitability syndromes

Peripheral nerve hyperexcitability (PNH) syndromes can be subclassified as primary and secondary. The main primary PNH syndromes are neuromyotonia, cramp-fasciculation syndrome (CFS), and Morvan's syndrome, which cause widespread symptoms and signs without the association of an evident peripheral nerve disease. Their major symptoms are muscle twitching and stiffness, which differ only in severity between neuromyotonia and CFS. Cramps, pseudomyotonia, hyperhidrosis, and some other autonomic abnormalities, as well as mild positive sensory phenomena, can be seen in several patients. Symptoms reflecting the involvement of the central nervous system occur in Morvan's syndrome. Secondary PNH syndromes are generally seen in patients with focal or diffuse diseases affecting the peripheral nervous system. The PNH-related symptoms and signs are generally found incidentally during clinical or electrodiagnostic examinations. The electrophysiological findings that are very useful in the diagnosis of PNH are myokymic and neuromyotonic discharges in needle electromyography along with some additional indicators of increased nerve fiber excitability. Based on clinicopathological and etiological associations, PNH syndromes can also be classified as immune mediated, genetic, and those caused by other miscellaneous factors. There has been an increasing awareness on the role of voltage-gated potassium channel complex autoimmunity in primary PNH pathogenesis. Then again, a long list of toxic compounds and genetic factors has also been implicated in development of PNH. The management of primary PNH syndromes comprises symptomatic treatment with anticonvulsant drugs, immune modulation if necessary, and treatment of possible associated dysimmune and/or malignant conditions.