Association between comorbidity and clinical characteristics of MS

Mortality in patients with multiple sclerosis

Mortality in patients with multiple sclerosis (MS) is significantly increased compared with the general population. Many questions concerning survival in MS are still unanswered due to the difficulty of comparing information collected at different times and in different geographic areas. The increasing incidence of MS, the improvement in care of the chronically disabled, and different methodologies may explain the lack of coherence among studies' results. Reported times to death from birth and from disease onset/diagnosis are highly variable. Patients older at onset or with primary progressive course have shorter survival; however, data on sex and mortality are contradictory. Changes in sex ratio in MS over time represent one possible explanation. MS is the main cause of death in ≥50% of patients and the incidence of deaths not due to MS varies among countries. Particularly, suicide is substantially increased in patients with MS, and, despite its varying incidence, mainly due to "cultural bias," it should be considered an MS-related cause of death. Recent results of the long-term follow-up study of interferon-β-1b demonstrated a significant reduction of mortality among treated patients. Notwithstanding its long latency, mortality is therefore an unambiguously valid long-term outcome in randomized controlled trials. It usefully combines the net impact of treatment efficacy on longevity and adverse events, which may reduce it.

Exercise in multiple sclerosis

Exercise is an intervention that may be used in the management of multiple sclerosis (MS). Certain exercise physiology characteristics are commonly seen among persons with MS, particularly in the more debilitated. Studies have shown that properly prescribed exercise programs can improve modifiable impairments in MS. Exercise is generally safe and well tolerated. General guidelines are available for exercise prescription for the MS population. There are several recommendations that may help improve the quality of future MS exercise trials.

Sexual disparities in the incidence and course of MS

Multiple sclerosis (MS) affects three times more women than men and this ratio appears to be increasing. However male patients experience increased disease progression, brain atrophy, and cognitive impairment. Gonadal hormones may modulate these sex differences. For example, female puberty heralds an increased risk of MS, and during pregnancy disease activity is milder, with an increased risk of postpartum relapses. Gonadal hormones likely have complex and inflammatory and neuroprotective effects, and may interact with other disease modulators, such as vitamin D. Sex differences in the heritability of disease susceptibility genes implicate a role for epigenetic modification. Many questions remain, including the impact of sex on treatment response and epigenetic changes, and the modulatory potential of hormonal treatments. This article summarizes what is known about sexual dimorphism in MS onset and course, as well as potential interactions between sex and other factors influencing MS pathogenesis, incidence and severity.

Evaluation of an online platform for multiple sclerosis research: patient description, validation of severity scale, and exploration of BMI effects on disease course

Objectives

To assess the potential of an online platform, PatientsLikeMe.com (PLM), for research in multiple sclerosis (MS). An investigation of the role of body mass index (BMI) on MS disease course was conducted to illustrate the utility of the platform.

Methods

First, we compared the demographic characteristics of subjects from PLM and from a regional MS center. Second, we validated PLM’s patient-reported outcome measure (MS Rating Scale, MSRS) against standard physician-rated tools. Finally, we analyzed the relation of BMI to the MSRS measure.

Results

Compared with 4,039 MS Center patients, the 10,255 PLM members were younger, more educated, and less often male and white. Disease course was more often relapsing remitting, with younger symptom onset and shorter disease duration. Differences were significant because of large sample sizes but small in absolute terms. MSRS scores for 121 MS Center patients revealed acceptable agreement between patient-derived and physician-derived composite scores (weighted kappa = 0.46). The Walking domain showed the highest weighted kappa (0.73) and correlation (rs = 0.86) between patient and physician scores. Additionally, there were good correlations between the patient-reported MSRS composite and walking scores and physician-derived measures: Expanded Disability Status Scale (composite rs = 0.61, walking rs = 0.74), Timed 25 Foot Walk (composite rs = 0.70, walking rs = 0.69), and Ambulation Index (composite rs = 0.81, walking rs = 0.84). Finally, using PLM data, we found a modest correlation between BMI and cross-sectional MSRS (rho = 0.17) and no association between BMI and disease course.

Conclusions

The PLM population is comparable to a clinic population, and its patient-reported MSRS is correlated with existing clinical instruments. Thus, this online platform may provide a venue for MS investigations with unique strengths (frequent data collection, large sample sizes). To illustrate its applicability, we assessed the role of BMI in MS disease course but did not find a clinically meaningful role for BMI in this setting.

The outliers become a stampede as immunometabolism reaches a tipping point

Obesity and Type 2 diabetes mellitus (T2D) are characterized by pro-inflammatory alterations in the immune system including shifts in leukocyte subset differentiation and in cytokine/chemokine balance. The chronic, low-grade inflammation resulting largely from changes in T-cell, B-cell, and myeloid compartments promotes and/or exacerbates insulin resistance (IR) that, together with pancreatic islet failure, defines T2D. Animal model studies show that interruption of immune cell-mediated inflammation by any one of several methods almost invariably results in the prevention or delay of obesity and/or IR. However, anti-inflammatory therapies have had a modest impact on established T2D in clinical trials. These seemingly contradictory results indicate that a more comprehensive understanding of human IR/T2D-associated immune cell function is needed to leverage animal studies into clinical treatments. Important outstanding analyses include identifying potential immunological checkpoints in disease etiology, detailing immune cell/adipose tissue cross-talk, and defining strengths/weaknesses of model organism studies to determine whether we can harness the promising new field of immunometabolism to curb the global obesity and T2D epidemics.

High rates of physician services utilization at least five years before multiple sclerosis diagnosis

BACKGROUND

Multiple sclerosis (MS) management has changed over time, but changes in health care utilization by MS patients remain understudied. We estimated physician services utilization in the five-year periods before and after MS diagnosis, and over the period 1984-2008.

METHODS

Using administrative data we identified 4092 persons with MS and a matched general population (GPOP) cohort of 21,446 persons. Using general linear models we compared physician visits between the MS and GPOPs for the period 1984-2008, the year of MS diagnosis, and for the five-year periods pre- and post-diagnosis.

RESULTS

From 1984 to 2008, 98% of the MS population averaged ≥1 physician visits/year versus 87% of the GPOP. In 2008, the MS population had 12.9 physician visits/person-year while the GPOP had 8.4 (rate ratio (RR) 1.53; 95% confidence interval (CI): 1.52-1.55). Five years pre-MS diagnosis, the MS population had more physician visits than the GPOP (RR 1.15; 95% CI; 1.10-1.21). The number of visits peaked the year of MS diagnosis (19.0), decreasing thereafter, but remaining elevated versus the pre-diagnosis period.

CONCLUSION

The MS population uses more physician services than the GPOP, starting at least five years pre-MS diagnosis. A better understanding of the reasons for these higher utilization rates may ultimately improve outcomes in MS.