Multiple sclerosis epidemiological trends in Italy highlight the environmental risk factors

Italy is definitely a high-risk country for multiple sclerosis (MS). Over the last 50 years, several epidemiological studies, including longitudinal surveys, have disclosed that MS incidence and prevalence in Italy mainland and Islands (Sardinia and Sicily) have progressively increased, picturing a semi-parabolic curve. Based on the comprehensive scrutiny of 58 papers, we conclude that the latitude risk gradient does not fit to the Italian map of MS. The genetic heterogeneity of the Italian ethnicities, that likely forms the basis of MS predisposition, does not account for the dramatic increase of MS incidence and prevalence observed in Italy over the last half century that, rather, seems better explained by the effect of environmental factors.

Exercise and Sports Science Australia (ESSA) position statement on exercise for people with mild to moderate multiple sclerosis

OBJECTIVES

Multiple sclerosis (MS), the most common chronic and progressive neurological condition of the central nervous system, affects 26,000 Australian adults. Exercise training has beneficial effects on MS-related impairments including reduced muscular strength, poor aerobic capacity and impaired mobility, and in consequence can improve quality of life. This Position Statement provides evidence-based recommendations for exercise prescription and delivery of exercise training for people with MS with mild to moderate disability.

DESIGN AND METHODS

Synthesis of published works within the field of exercise training in MS.

RESULTS

Exercise provides many benefits to people with MS. There is strong evidence that resistance and aerobic training, performed 2 to 3 times per week at a moderate intensity, are safe and can improve muscle strength, cardiorespiratory fitness, balance, fatigue, functional capacity, mobility and quality of life in people with MS with mild to moderate disability (Expanded Disease Severity Scale (EDSS) ≤ 6.5). However, the evidence for those with severe disability (EDSS >6.5) is less clear. The effects of exercise on MS pathogenesis, central nervous structures and other outcomes such as depression and cognitive impairment, have not been adequately investigated. Effective exercise interventions to improve balance, joint contractures and reduce falls in people with MS are also urgently needed as well as investigations of long-term (≥1 year) effects of exercise training.

CONCLUSIONS

Resistance and aerobic training exercises are effective to alleviate some characteristic signs and symptoms in MS and should be supplemented by balance exercise to prevent falls. Exercise training programs should be prescribed and delivered by qualified exercise professionals. It is important to recognise and accommodate exercise-associated complications such as fatigue and heat sensitivity.

Diversity of Reactive Astrogliosis in CNS Pathology: Heterogeneity or Plasticity?

Astrocytes are essential for the development and homeostatic maintenance of the central nervous system (CNS). They are also critical players in the CNS injury response during which they undergo a process referred to as "reactive astrogliosis." Diversity in astrocyte morphology and gene expression, as revealed by transcriptional analysis, is well-recognized and has been reported in several CNS pathologies, including ischemic stroke, CNS demyelination, and traumatic injury. This diversity appears unique to the specific pathology, with significant variance across temporal, topographical, age, and sex-specific variables. Despite this, there is limited functional data corroborating this diversity. Furthermore, as reactive astrocytes display significant environmental-dependent plasticity and fate-mapping data on astrocyte subsets in the adult CNS is limited, it remains unclear whether this diversity represents heterogeneity or plasticity. As astrocytes are important for neuronal survival and CNS function post-injury, establishing to what extent this diversity reflects distinct established heterogeneous astrocyte subpopulations vs. environmentally dependent plasticity within established astrocyte subsets will be critical for guiding therapeutic development. To that end, we review the current state of knowledge on astrocyte diversity in the context of three representative CNS pathologies: ischemic stroke, demyelination, and traumatic injury, with the goal of identifying key limitations in our current knowledge and suggesting future areas of research needed to address them. We suggest that the majority of identified astrocyte diversity in CNS pathologies to date represents plasticity in response to dynamically changing post-injury environments as opposed to heterogeneity, an important consideration for the understanding of disease pathogenesis and the development of therapeutic interventions.

Dietary conjugated linoleic acid links reduced intestinal inflammation to amelioration of CNS autoimmunity

A close interaction between gut immune responses and distant organ-specific autoimmunity including the CNS in multiple sclerosis has been established in recent years. This so-called gut–CNS axis can be shaped by dietary factors, either directly or via indirect modulation of the gut microbiome and its metabolites. Here, we report that dietary supplementation with conjugated linoleic acid, a mixture of linoleic acid isomers, ameliorates CNS autoimmunity in a spontaneous mouse model of multiple sclerosis, accompanied by an attenuation of intestinal barrier dysfunction and inflammation as well as an increase in intestinal myeloid-derived suppressor-like cells. Protective effects of dietary supplementation with conjugated linoleic acid were not abrogated upon microbiota eradication, indicating that the microbiome is dispensable for these conjugated linoleic acid-mediated effects. Instead, we observed a range of direct anti-inflammatory effects of conjugated linoleic acid on murine myeloid cells including an enhanced IL10 production and the capacity to suppress T-cell proliferation. Finally, in a human pilot study in patients with multiple sclerosis (n = 15, under first-line disease-modifying treatment), dietary conjugated linoleic acid-supplementation for 6 months significantly enhanced the anti-inflammatory profiles as well as functional signatures of circulating myeloid cells. Together, our results identify conjugated linoleic acid as a potent modulator of the gut–CNS axis by targeting myeloid cells in the intestine, which in turn control encephalitogenic T-cell responses.

Machine Learning Use for Prognostic Purposes in Multiple Sclerosis

The course of multiple sclerosis begins with a relapsing-remitting phase, which evolves into a secondarily progressive form over an extremely variable period, depending on many factors, each with a subtle influence. To date, no prognostic factors or risk score have been validated to predict disease course in single individuals. This is increasingly frustrating, since several treatments can prevent relapses and slow progression, even for a long time, although the possible adverse effects are relevant, in particular for the more effective drugs. An early prediction of disease course would allow differentiation of the treatment based on the expected aggressiveness of the disease, reserving high-impact therapies for patients at greater risk. To increase prognostic capacity, approaches based on machine learning (ML) algorithms are being attempted, given the failure of other approaches. Here we review recent studies that have used clinical data, alone or with other types of data, to derive prognostic models. Several algorithms that have been used and compared are described. Although no study has proposed a clinically usable model, knowledge is building up and in the future strong tools are likely to emerge.

Detecting and targeting neurodegenerative disorders using electrospun nanofibrous matrices: current status and applications

Neurodegeneration is defined as the progressive atrophy and loss of function of neurons; it is present in neurodegenerative disorders such as Multiple Sclerosis, Alzheimer's, Huntington's, and Parkinson's diseases. The detection of such disorders is performed by various imaging modalities while their therapeutic management is quite challenging. Besides, the pathogenesis of neurodegenerative disorders is still under ongoing research due to complex and multi-factorial mechanisms. Currently, targeting the specific proteins responsible for neurodegeneration is of great interest to many researchers. Furthermore, nanotechnology-based approaches for targeting the affected neurons became an emerging field of interest. Nanostructures of various forms have been developed aiming to act as therapeutics for neurodegeneration, in which electrospun nanofibers seem to play an important role as biomedical products for both detection and management of the diseases. Electrospinning is an intriguing method able to produce nanofibers with a wide range of sizes and morphological characteristics. Such nanofibrous matrices can be delivered through different administration routes to target various diseases. In this review, the most recent advancements in electrospun nanofibrous systems that target or detect multiple neurodegenerative diseases have been enlightened and an introduction to the general aspects of neurodegenerative diseases and the electrospinning process has been made. Finally, future perspectives of neurodegeneration targeting were also discussed.

The expression analyses of RMRP, DDX5, and RORC in RRMS patients treated with different drugs versus naïve patients and healthy controls

Although T helper 17 (Th17) lymphocytes protect mucosal barriers against infections, they have been implicated in the development of multiple sclerosis (MS). RORC and DDX5 can regulate Th17 differentiation and the development of MS. Since RMRP, as a long non-coding RNA (lncRNA), can mediate the RORC-DDX5 complex, this lncRNA can be involved in developing MS. This study investigated the expression levels of RORC, DDX5, and RMRP in treatment-naïve relapsing-remitting multiple sclerosis (RRMS) patients, healthy controls, and RRMS patients treated with IFNβ-1α or fingolimod, or dimethyl fumarate (DMF), or glatiramer acetate (GA). There was substantial up-regulation in the expression of RORC, DDX5, and RMRP in treatment-naïve RRMS patients compared to healthy controls. Among the comparisons of their expressions in the different groups of treated patients with treatment-naïve patients, only the down-regulation of the RMRP expression level was significant in IFNβ-1α-treated patients. Also, these changes were more pronounced in female patient groups. Our analyses have highlighted the high diagnostic value of RORC, DDX5, and RMRP in treatment-naïve RRMS patients. Furthermore, RMRP has demonstrated moderate positive correlations with the expression of DDX5 and RORC in treated RRMS patients.

Systematic review and meta-analysis of the association between Epstein-Barr virus, multiple sclerosis and other risk factors

BACKGROUND

Epstein-Barr virus (EBV) infection is thought to play a central role in the development of multiple sclerosis (MS). If causal, it represents a target for interventions to reduce MS risk.

OBJECTIVE

To examine the evidence for interaction between EBV and other risk factors, and explore mechanisms via which EBV infection may influence MS risk.

METHODS

Pubmed was searched using the terms 'multiple sclerosis' AND 'Epstein Barr virus', 'multiple sclerosis' AND EBV, 'clinically isolated syndrome' AND 'Epstein Barr virus' and 'clinically isolated syndrome' AND EBV. All abstracts were reviewed for possible inclusion.

RESULTS

A total of 262 full-text papers were reviewed. There was evidence of interaction on the additive scale between anti-EBV antibody titre and HLA genotype (attributable proportion due to interaction (AP) = 0.48, p < 1 × 10-4). Previous infectious mononucleosis (IM) was associated with increased odds ratio (OR) of MS in HLA-DRB1*1501 positive but not HLA-DRB1*1501 negative persons. Smoking was associated with a greater risk of MS in those with high anti-EBV antibodies (OR = 2.76) but not low anti-EBV antibodies (OR = 1.16). No interaction between EBV and risk factors was found on a multiplicative scale.

CONCLUSION

EBV appears to interact with at least some established MS risk factors. The mechanism via which EBV influences MS risk remains unknown.

Oral Colonization by Candida Species in Patients with Multiple Sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory demyelinating autoimmune disease that affects the central nervous system. Since immune system plays a key role in this disease, patients with MS can present higher risk of infections.

PURPOSE

This study aimed to investigate the prevalence of Candida spp. in the oral cavity of MS patients in relation to a control group METHODS: In total, 100 individuals were selected: 55 diagnosed with MS and 45 healthy individuals (control group). Saliva samples were collected and seeded in culture media selecting for Candida. Following an incubation period of 48 h, colony-forming units (CFU mL^-1) were counted and colonies were isolated for Candida species identification by multiplex PCR. The results were analysed by chi-squared and Mann-Whitney U statistical tests considering a significance level of 5%.

RESULTS

Candida spp. were confirmed in the oral cavity of 50.09% patients in the MS group and 35.55% individuals in the control group. In individuals positive for the growth of Candida spp., the median values of Candida colonies were 220 CFU mL^-1 for the MS group and 120 CFU mL^-1 for the control group. However, no statistically significant differences were observed between groups for both prevalence and CFU mL^-1 count. Of the Candida species identified, 73.91% were C. albicans, 21.73% C. glabrata, 2.17% C. tropicalis, and 2.17% C. krusei.

CONCLUSIONS

The colonization of Candida spp. in the oral cavity of individuals with multiple sclerosis was higher than in the control group; however these findings were not proven to be statistically significant.

Dietary fish intake and the risk of multiple sclerosis: a systematic review and meta-analysis of observational studies

Objectives: There is some inconclusive evidence for the role of fish consumption in susceptibility to multiple sclerosis (MS). The present study aimed to systematically review and determine the association between dietary fish intake and risk of MS.Methods: A systematic search with related keywords was carried out in PubMed-MEDLIN, Scopus-EMBASE, and OVID-MEDLINE from inception up to September 2019 to find observational studies that evaluated the association between dietary fish intake and the risk of MS. Random effect and subgroup analyses were performed to calculate pooled estimates at 95% CIs.Results: Six articles met the inclusion criteria for systematic review and meta-analysis. The results of this study indicated that the consumption of fish decreases the risk of MS [OR (95% CIs): 0.77 (0.64, 0.92); p-value = 0.004; I² = 54.7%] compared with controls.Discussion: Dietary intake of at least 0.5 servings of fish per week during adolescence and after might reduce the risk of MS; however, further studies are required to prove this preventive effect.

Influence of physical activity on serum vitamin D levels in people with multiple sclerosis

In most cases, multiple sclerosis (MS) patients reduce physical activity with disease progression and many patients are found to be vitamin D deficient. The aim of this study was to explore correlations between daily physical activity in everyday life and 25-hydroxyvitamin-D₃ (25(OH)D₃) serum levels in mildly disabled patients with an Expanded Disability Status Scale (EDSS) ≤ 4. We analyzed serum 25(OH)D₃ levels and recorded daily physical activity (activity duration, number of steps, distance, energy expenditure) using an activity tracker for 14-days in 25 women and 15 men. Participants recorded their daily sunlight exposure time by diary during the study period. We found a positive correlation between physical activity and 25(OH)D₃ levels in both, Pearson correlation (r = 0.221) and multivariate regression analysis (β = 0.236), which was stronger than correlation with sunlight exposure time (β = -0.081). EDSS and physical activity were weakly correlated (r = -0.228), but no correlation between EDSS and 25(OH)D₃ levels was found (r = -0.077). There were no relevant differences in physical activity (p = 0.803) and 25(OH)D₃ concentrations (p = 0.385) between the EDSS groups 0 – 1.5 and 2.0 – 4.0. In conclusion, physical activity has an effect on vitamin D levels independent of sunlight exposure time in people with MS (pwMS) with low-grade disability.

Vitamin D3 supplementation and neurofilament light chain in multiple sclerosis

OBJECTIVES

Low circulating vitamin D levels are associated with an increased risk of active MRI lesions and relapses in several cohorts with relapsing remitting multiple sclerosis (RRMS). Randomized controlled supplementation trials are, however, negative on their primary endpoints, while secondary MRI endpoints suggest anti-inflammatory effects. Circulating levels of neurofilament light chain (NfL) are a biomarker of disease activity in RRMS. We explored whether 48-week high-dose vitamin D₃ supplements were associated with lower circulating NfL levels.

MATERIALS & METHODS

Of N = 40 Dutch interferon beta-treated participants with RRMS of the SOLAR trial, plasma samples at baseline and 48-week follow-up were available. Of these participants, N = 24 were supplemented with 14 000 IU/d vitamin D₃ and N = 16 with placebo. Twenty-five hydroxyvitamin D₃ (25(OH)D₃ ) levels were measured with LC-MS/MS, and NfL levels were measured in duplicate with Simoa.

RESULTS

Serum 25(OH)D₃ levels at 48 weeks were increased in the vitamin D₃ when compared to placebo group (median level 281 [IQR 205-330] vs 72 [39-88] nmol/L; P < .01). NfL levels at 48 weeks did not differ between the treatment groups (median level 25.4 [IQR 19.6-32.2] vs 25.3 [17.9-30.1] pg/mL; P = .74). Higher week 48 NfL level showed a trend toward association with a higher risk of combined unique active lesions on the week 48 MRI scan (OR 2.39 [95% CI 0.93-6.12] for each 10 pg/mL increase; P = .07).

CONCLUSIONS

Supplementation of high-dose vitamin D₃ for 48 weeks was not associated with lower NfL levels. This study does not support an effect of vitamin D₃ on this biomarker of neuro-axonal injury.

Intake of dietary fibre, red and processed meat and risk of late-onset Chronic Inflammatory Diseases: A prospective Danish study on the "diet, cancer and health" cohort

Background: Human and animal studies support the involvement of diet in the development of CID -chronic inflammatory diseases such as inflammatory bowel disease, psoriasis, rheumatoid arthritis, psoriatic arthritis, and multiple sclerosis. Objective: This cohort study aimed to investigate the association between intake of fibre, red and processed meat, and occurrence of late-onset CID (50+ years of age) in the DCH: Danish Diet, Cancer and Health cohort. We hypothesised that risk of late-onset CID would be lower among those with high intake of fibre and/or low intake of meat compared to individuals with low fibre and/or high meat intake. Methods: The DCH recruited 56,468 individuals, aged 50-64 years, between 1993 and 1997. At recruitment, diet intake was registered using food frequency questionnaires as well as lifestyle factors in 56,075 persons. Exposure variables were generated as sex-adjusted tertiles of fibre and meat (g/day). Development of CIDs was identified in national registries. Hazard ratios (HR) of late-onset CIDs (adjusted for age, sex, energy intake, alcohol, smoking, education, comorbidity, and civil status) were estimated for all three exposure variables. Results: During follow-up of 1,123,754 years (median (Interquartile range) = 22.2 (20.1-23.1)), 1,758 (3.1%) participants developed at least one CID. The adjusted HRs for developing CID (low fibre 1.04 [0.89-1.22] and medium fibre 1.04 [0.91-1.18] (high fibre as reference), and medium meat 0.96 [0.86-1.09] and high meat 0.94 [0.82-1.07] (low meat as reference)) or the individual diseases were not statistically significant. Conclusion: This large study did not support that a high intake of fibre and/or a low intake of meat had a high impact on the risk of late-onset CID.

Considerations of psychotic symptomatology in anti-NMDA encephalitis: Similarity to cycloid psychosis

Most patients with anti-NMDA receptor (NMDAR) encephalitis present with acute psychosis which is difficult to differentiate from psychotic episodes related to a primarily psychiatric disease. A precise description of the psychiatric phenotype of this disease would greatly facilitate the early diagnosis of these patients. We provide here a detailed description of three of these patients and the similarity of the clinical features with cycloid psychosis. All three patients met Perris and Brockington's criteria for cycloid psychosis in the initial phase of the autoimmune process, including among other an acute and polysymptomatic onset, polymorphous psychotic symptomatology, mood swings, and changes in psychomotricity. In addition, none of the patients had experienced an extended psychiatric prodromal phase. External stress factors preceded symptom onset in the three patients, who also showed common base personality traits and intolerance to a range of antipsychotic treatments. Complementary studies disclosed that the three patients had ovarian teratoma as well as abnormal EEG, and CSF antibodies against NMDAR. Patients with anti-NMDAR encephalitis may present with clinical features that resemble cycloid psychosis. In addition, our patients did not have prodromal history of psychiatric symptoms and showed intolerance to antipsychotic medication, which all should raise concern for anti-NMDAR encephalitis, prompting CSF antibody testing.

An Update on Vitamin D and Disease Activity in Multiple Sclerosis

Vitamin D and its main active metabolite 1,25-dihydroxyvitamin D serve a crucial role in maintenance of a healthy calcium metabolism, yet have additional roles in immune and central nervous system cell homeostasis. Serum levels of 25-hydroxyvitamin D are a biomarker of future disease activity in patients with early relapsing-remitting multiple sclerosis (RRMS), and vitamin D supplementation in patients with low circulating 25-dihydroxyvitamin D levels has been anticipated as a potential efficacious treatment strategy. The results of the first large randomized clinical trials (RCTs), the SOLAR and CHOLINE studies, have now been published. The SOLAR study compared 14,000 IU of vitamin D3 (cholecalciferol) per day with placebo for 48 weeks in 232 randomized patients, whereas CHOLINE compared vitamin D3 100,000 IU every other week with placebo for 96 weeks in 129 randomized patients. All patients in both studies also used interferon-β-1a. None of the studies met their primary endpoints, which were no evidence of disease activity (NEDA-3) at 48 weeks in SOLAR and annualized relapse rate at 96 weeks in CHOLINE. Both studies did, however, suggest modest effects on secondary endpoints. Thus, vitamin D reduced the number of new or enlarging lesions and new T2 lesions in SOLAR, and the annualized relapse rate and number of new T1 lesions, volume of hypointense T1 lesions, and disability progression in the 90 patients who completed 96 weeks' follow-up in CHOLINE. We conclude that none of the RCTs on vitamin supplementation in MS have met their primary clinical endpoint in the intention to treat cohorts. This contrasts the observation studies, where each 25 nmol/l increase in 25-hydroxyvitamin D levels were associated with 14-34% reduced relapse risk and 15-50% reduced risk of new lesions on magnetic resonnance imaging. This discrepancy may have several explanations, including confounding and reverse causality in the observational studies. The power calculations of the RCTs have been based on the observational studies, and the RCTs may have been underpowered to detect less prominent yet important effects of vitamin D supplementation. Although the effect of vitamin D supplementation is uncertain and less pronounced than suggested by observational studies, current evidence still support that people with MS should avoid vitamin D insufficiency, and preferentially aim for vitamin D levels around 100 nmol/L or somewhat higher.

Cognitive impairment in multiple sclerosis: An exploratory analysis of environmental and lifestyle risk factors

BACKGROUND

Many potentially modifiable risk factors for MS are investigated. It is not known, however, if these factors also apply to MS-related cognitive impairment (CI), a frequent consequence of MS.

OBJECTIVE

The aim of our study was to assess risk factors for CI in MS patients, focusing on environmental exposures, lifestyle and comorbidities.

METHODS

We included MS patients referring to MS Centers in Florence and Barletta between 2014 and 2017. Neuropsychological performance was assessed through the Rao's battery and Stroop test, cognitive reserve (premorbid intelligence quotient-IQ) was evaluated using the National Adult Reading Test (NART). Potential risk factors were investigated through a semi-structured questionnaire.

RESULTS

150 patients were included. CI was detected in 45 (30%) subjects and was associated with older age (p<0.005), older age at MS onset (p = 0.016), higher EDSS score (p<0.005), progressive disease course (p = 0.048) and lower premorbid IQ score (p<0.005). As for risk factors, CI was related with lower physical activity in childhood-adolescence (p<0.005). In women, hormonal therapy resulted to be protective against CI (p = 0.041). However, in the multivariable analysis, the only significant predictors of CI were older age (p<0.05; OR 1.06, 95% CI 1.02-1.10) and lower premorbid IQ (p<0.05; OR 0.93, 95% CI: 0.88-0.98). Removing IQ from the model, CI was associated with higher EDSS (p = 0.030; OR 1.25, 95% CI 1.02-1.53) and, marginally, previous physical activity (p = 0.066; OR 0.49, 95% CI: 0.23-1.05).

CONCLUSIONS

Our findings suggest that physical activity in childhood-adolescence could be a contributor to cognitive reserve building, thus representing a potential protective factors for MS-related CI susceptible to preventive strategies.

The Gut Microbiota in Multiple Sclerosis: An Overview of Clinical Trials

Multiple sclerosis (MS) is a chronic, inflammatory, demyelinating, and degenerative disease that affects the central nervous system. A recent study showed that interaction between the immune system and the gut microbiota plays a crucial role in the development of MS. This review reports the clinical studies carried out in recent years that aimed to evaluate the composition of the microbiota in patients with relapsing–remitting MS (RR-MS). We also report what is available in the literature regarding the effectiveness of fecal microbiota transplantation and the role of the diet in restoring the intestinal bacterial population. Studies report that patients with RR-MS have a microbiota that, compared with healthy controls, has higher amounts of Pedobacteria, Flavobacterium, Pseudomonas, Mycoplana, Acinetobacter, Eggerthella, Dorea, Blautia, Streptococcus and Akkermansia. In contrast, MS patients have a microbiota with impoverished microbial populations of Prevotella, Bacteroides, Parabacteroides, Haemophilus, Sutterella, Adlercreutzia, Coprobacillus, Lactobacillus, Clostridium, Anaerostipes and Faecalibacterium. In conclusion, the restoration of the microbial population in patients with RR-MS appears to reduce inflammatory events and the reactivation of the immune system.

Environmental and genetic risk factors for MS: an integrated review

Recent findings have provided a molecular basis for the combined contributions of multifaceted risk factors for the onset of multiple sclerosis (MS). MS appears to start as a chronic dysregulation of immune homeostasis resulting from complex interactions between genetic predispositions, infectious exposures, and factors that lead to pro-inflammatory states, including smoking, obesity, and low sun exposure. This is supported by the discovery of gene-environment (GxE) interactions and epigenetic alterations triggered by environmental exposures in individuals with particular genetic make-ups. It is notable that several of these pro-inflammatory factors have not emerged as strong prognostic indicators. Biological processes at play during the relapsing phase of the disease may result from initial inflammatory-mediated injury, while risk factors for the later phase of MS, which is weighted toward neurodegeneration, are not yet well defined. This integrated review of current evidence guides recommendations for clinical practice and highlights research gaps.

The effects of probiotic Saccharomyces boulardii on the mental health, quality of life, fatigue, pain, and indices of inflammation and oxidative stress in patients with multiple sclerosis: study protocol for a double-blind randomized controlled clinical trial

BACKGROUND

The relationship between gut dysbiosis and inflammatory diseases including multiple sclerosis (MS) is presently recognized as an important health issue. It has been established that some bacterial probiotic strains are effective in treating MS. This study will investigate the effect of yeast probiotic Saccharomyces boulardii (SB) supplements on mental health, quality of life, fatigue, pain, and indices of inflammation and oxidative stress in MS patients.

METHODS/DESIGN

In this double-blind randomized controlled two-group parallel trial, 50 MS patients who meet the inclusion criteria will be recruited from outpatient settings. They will be randomly allocated to 4 months of daily placebo or the SB probiotic intervention. Blood samples will be taken from each participant at the baseline and after the intervention period to assess inflammation and oxidative stress. The primary endpoint will be the changes in their mental health evaluated by the 28-item General Health Questionnaire. The secondary endpoints include changes in: (1) quality of life, evaluated by the 36-item Short Form Questionnaire, (2) fatigue, evaluated by the Fatigue Severity Scale, (3) pain, evaluated by a visual analogue scale, and (4) serum levels of indices of inflammatory stress (high-sensitivity C-reactive protein) and oxidative stress (malondialdehyde and total antioxidant capacity). Moreover, any adverse events and side effects due to the intervention will be documented.

DISCUSSION

There is a need to discover safe and practical methods for managing the symptoms of MS. This trial will gather evidence on the effects of a probiotic.

TRIAL REGISTRATION

Iranian Clinical Trial Registry, IRCT20161022030424N1 . Registered on 9 April 2018.

Modifiable risk factors for poor health outcomes in multiple sclerosis: The urgent need for research to maximise smoking cessation success

Tobacco smoking is a well-established risk factor for multiple sclerosis (MS) onset, progression and poor health outcomes in people with MS. Despite smoking being a modifiable risk factor, no research has been undertaken to understand how, or who is best placed, to assess or understand smoking behaviour in people with MS, or how healthcare professionals can best assist people with MS to quit. People with MS may have unique motivators to continue smoking, or unique barriers to smoking cessation, that are not addressed by existing cessation tools. Research is urgently needed in this area if the aim is to maximise health outcomes for all people with MS.

Lifestyle-based modifiable risk factors in multiple sclerosis: review of experimental and clinical findings

Multiple sclerosis (MS) is a lifelong inflammatory and neurodegenerative disease influenced by multiple lifestyle-based factors. We provide a narrative review of the effects of modifiable risk factors that are identified as being associated with risk to develop MS and/or influencing the future clinical disease outcomes. The emerging data regarding the beneficial effects of diet modifications and exercise are further reviewed. In contrast, obesity and comorbid cardiovascular diseases are associated with increased MS susceptibility and worse disease progression. In addition, the potential influence of smoking, coffee and alcohol consumption on MS onset and disability development are discussed. Successful management of the modifiable risk factors may lead to better long-term outcomes and improve patients' quality of life. MS specialists should participate in educating and facilitating lifestyle-based modifications as part of their neurological consults.

Impact of red meat, processed meat and fibre intake on risk of late-onset chronic inflammatory diseases: prospective cohort study on lifestyle factors using the Danish 'Diet, Cancer and Health' cohort (PROCID-DCH): protocol

INTRODUCTION

Chronic inflammatory diseases (CIDs) (Crohn's disease, ulcerative colitis, psoriasis, psoriatic arthritis, rheumatoid arthritis and multiple sclerosis) are diseases of the immune system that have some shared genetic and environmental predisposing factors, but still few studies have investigated the effects of lifestyle on disease risk of several CIDs. The primary aim of this prospective cohort study is to investigate the impact of fibre, red meat and processed meat on risk of late-onset CID, with the perspective that results of this study can contribute in supporting future diet recommendations for effective personalised prevention.

METHODS AND ANALYSIS

The study will use data from 57 053 persons from the prospective Danish cohort study 'Diet, Cancer and Health' together with National Health Registry data. The follow-up period is from December 1993 to December 2018. Questionnaire data on diet and lifestyle were collected at entry to the Diet, Cancer and Health study. The outcome CID is defined as having a diagnosis of one of the CIDs registered in the National Patient Registry or, for multiple sclerosis, in the Danish Multiple Sclerosis Registry during follow-up and being treated with a drug used for the specific disease. The major outcome of the analyses will be to detect variability in risk of late onset of any CID and, if power allows, disease risk of late onset of each CID diagnosis between persons with different fibre and red meat, and processed meat intake. The outcome will be adjusted for age, sex, body mass index, physical activity, energy, alcohol, fermented dairy products, education, smoking status, hormone replacement therapy and comorbidity.

ETHICS AND DISSEMINATION

The study is approved by the Danish Data Protection Agency (2012-58-0018). The core study is an open register-based cohort study. The study does not need approval from the Ethics committee or Institutional Review Board by Danish law. Study findings will be disseminated through peer-reviewed journals, patient associations and presentations at international conferences.

TRIAL REGISTRATION NUMBER

NCT03456206; Post-results.

Identifying risk factors for cognitive issues in multiple sclerosis

INTRODUCTION

Cognitive impairment (CI) in Multiple Sclerosis (MS) has progressively regained clinical and research interest and is currently recognized as a debilitating and burdensome problem for these patients. Studying risk and protecting factors that may influence the development and course of CI is currently an area of increasing interest, due to the potential for preventive strategies. Areas covered: In this narrative review the authors briefly addressed the physiopathologic basis, assessment and management of CI in MS and then focused on identifying modifiable and not modifiable risk factors for CI in MS, providing an overview of the current knowledge in the field and indicating avenues for future research. Expert opinion: Improving our understanding of potentially modifiable environmental and lifestyle risk factors or protective factors for CI is important in order to prompt preventive strategies and orient patient counselling and clinical management. To this aim, we need to enhance the current level of evidence linking lifestyle factors to cognition and evaluate some factors that were only preliminary addressed in research. Moreover, we need to explore the role of each factor into the subject cognitive outcome, next to the possible interactions between different environmental factors as well as between environmental and genetic factors.

Short-chain fatty acids and gut microbiota in multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS) is a chronic immune-mediated neurological disease of the central nervous system with a complex and still not fully understood aetiology. In recent years, the gut microbiota and fermentative metabolites like short-chain fatty acids (SCFAs) have received increased attention in relation to the development and disease course of MS. This systematic review highlights and summarizes the existing literature within this field.

METHODS

A systematic search in PubMed was conducted on 12 October 2017, to find published original studies on SCFAs and their impact on MS and the animal model of MS experimental autoimmune encephalomyelitis (EAE). Furthermore, all studies analysing the gut microbiota in MS patients were included. A total of 14 studies were eligible for this review.

RESULTS

Short-chain fatty acids have been shown to ameliorate the disease course in EAE, but no studies specifically addressing the role of SCFAs in human MS patients were identified. However, some investigations have shown that the microbiota of MS patients is characterized by a reduction in SCFA-producing bacteria.

CONCLUSIONS

Studies of EAE in mice suggest that SCFAs may play a role in the development and progression of EAE, but so far this has not been confirmed in humans. An aberrant gut microbiota in MS patients has been reported to be differentially abundant compared with healthy controls, although with little consistency in the bacterial taxa. Further investigations are required to elucidate the involvement of the gut microbiota and its metabolites, including potential beneficial effects of SCFAs, in the development and course of MS.

Genome-wide DNA methylation changes in CD19+ B cells from relapsing-remitting multiple sclerosis patients

Multiple Sclerosis (MS) is an inflammatory and neurodegenerative disease of the central nervous system. The inflammatory process in MS is driven by both T and B cells and current therapies are targeted to each of these cell types. Epigenetic mechanisms may provide a valuable link between genes and environment. DNA methylation is the best studied epigenetic mechanism and is recognized as a potential contributor to MS risk. The objective of this study was to identify DNA methylation changes associated with MS in CD19+ B-cells. We performed an epigenome-wide association analysis of DNA methylation in the CD19+ B-cells from 24 patients with relapsing-remitting MS on various treatments and 24 healthy controls using Illumina 450 K arrays. A large differentially methylated region (DMR) was observed at the lymphotoxin alpha (LTA) locus. This region was hypermethylated and contains 19 differentially methylated positions (DMPs) spanning 860 bp, all of which are located within the transcriptional start site. We also observed smaller DMRs at 4 MS-associated genes: SLC44A2, LTBR, CARD11 and CXCR5. These preliminary findings suggest that B-cell specific DNA-methylation may be associated with MS risk or response to therapy, specifically at the LTA locus. Development of B-cell specific epigenetic therapies is an attractive new avenue of research in MS treatment. Further studies are now required to validate these findings and understand their functional significance.

Multiple sclerosis

Multiple sclerosis (MS) is the most common chronic inflammatory, demyelinating and neurodegenerative disease of the central nervous system in young adults. This disorder is a heterogeneous, multifactorial, immune-mediated disease that is influenced by both genetic and environmental factors. In most patients, reversible episodes of neurological dysfunction lasting several days or weeks characterize the initial stages of the disease (that is, clinically isolated syndrome and relapsing-remitting MS). Over time, irreversible clinical and cognitive deficits develop. A minority of patients have a progressive disease course from the onset. The pathological hallmark of MS is the formation of demyelinating lesions in the brain and spinal cord, which can be associated with neuro-axonal damage. Focal lesions are thought to be caused by the infiltration of immune cells, including T cells, B cells and myeloid cells, into the central nervous system parenchyma, with associated injury. MS is associated with a substantial burden on society owing to the high cost of the available treatments and poorer employment prospects and job retention for patients and their caregivers.

Understanding barriers, enablers, and long-term adherence to a health behavior intervention in people with multiple sclerosis

Background: The optimal management strategy for multiple sclerosis (MS), and many other chronic diseases, likely involves health behavior modification. Multimodal behavioral interventions may be most effective, but little is known about long-term adherence in people with MS.Methods: This qualitative study assessed barriers and enablers to long-term adherence by people with MS who self-selected for a 5-day health behavior intervention 3-5 years prior. Thirteen women and five men participated in semi-structured phone interviews, which were transcribed and thematically analyzed.Results: The experience was described as useful for information gathering, decision making, and practical strategies regarding health behaviors. The majority still followed supplementation and dietary recommendations most of the time, although consuming non-recommended food while eating out was common. Support at home, ability and enjoyment in food preparation, and ability to resist unhealthy foods were both barriers and enablers. Adherence to "time-consuming" exercise and meditation recommendations were less common and episodic. Many reported competing interests on time from work and family; and barriers including injuries and symptoms, weather, financial or geographical barriers, and lack of person-centred support and motivation. Increased fitness and mobility, weight loss, and a sense of accomplishment and control were advantages and motivators. Practical and attitudinal strategies employed included planning, tailoring activities to ability and preference, and self-monitoring.Conclusion: While most people attempted to engage with all components of the intervention initially, only some still engaged with all components, and none to the recommended levels. These data can inform future quantitative studies and health behavior interventions.Implications for rehabilitationA multimodal group lifestyle intervention may be useful to assist people with multiple sclerosis in information gathering, decision making, attitudinal changes, and practical strategies regarding health behaviors; as well as providing a sense of hope for the future and control over wellbeing.While participants are unlikely to engage with all components of a multimodal intervention to the recommended level, they are likely to make improvements to one or more health behaviors.Experiential learning, including going through recipes and ingredient lists, and practicing meditation and physical exercises, is helpful to instigate behavior change.The initiation and maintenance of behavior change was assisted by support from family, friends, and health practitioners; and practical strategies employed by participants, including planning, self-monitoring, and tailoring activities to ability and preference.

Changes in expression profiles of internal jugular vein wall and plasma protein levels in multiple sclerosis

Background

Multiple sclerosis (MS) is an inflammatory, demyelinating and degenerative disorder of the central nervous system (CNS). Several observations support interactions between vascular and neurodegenerative mechanisms in multiple sclerosis (MS). To investigate the contribution of the extracranial venous compartment, we analysed expression profiles of internal jugular vein (IJV), which drains blood from CNS, and related plasma protein levels.

Methods

We studied a group of MS patients (n = 19), screened by echo-color Doppler and magnetic resonance venography, who underwent surgical reconstruction of IJV for chronic cerebrospinal venous insufficiency (CCSVI). Microarray-based transcriptome analysis was conducted on specimens of IJV wall from MS patients and from subjects undergoing carotid endarterectomy, as controls. Protein levels were determined by multiplex assay in: i) jugular and peripheral plasma from 17 MS/CCSVI patients; ii) peripheral plasma from 60 progressive MS patients, after repeated sampling and iii) healthy individuals.

Results

Of the differentially expressed genes (≥ 2 fold-change, multiple testing correction, P < 0.05), the immune-related CD86 (8.5 fold-change, P = 0.002) emerged among the up regulated genes (N = 409). Several genes encoding HOX transcription factors and histones potentially regulated by blood flow, were overexpressed. Smooth muscle contraction and cell adhesion processes emerged among down regulated genes (N = 515), including the neuronal cell adhesion L1CAM as top scorer (5 fold-change, P = 5 × 10^− 4).

Repeated measurements in jugular/peripheral plasma and overtime in peripheral plasma showed conserved individual plasma patterns for immune-inflammatory (CCL13, CCL18) and adhesion (NCAM1, VAP1, SELL) proteins, despite significant variations overtime (SELL P < 0.0001). Both age and MS disease phenotypes were determinants of VAP1 plasma levels.

Data supported cerebral related-mechanisms regulating ANGPT1 levels, which were remarkably lower in jugular plasma and correlated in repeated assays but not between jugular/peripheral compartments.

Conclusions

This study provides for the first time expression patterns of the IJV wall, suggesting signatures of altered vascular mRNA profiles in MS disease also independently from CCSVI. The combined transcriptome-protein analysis provides intriguing links between IJV wall transcript alteration and plasma protein expression, thus highlighting proteins of interest for MS pathophysiology.

Electronic supplementary material

The online version of this article (10.1186/s10020-018-0043-4) contains supplementary material, which is available to authorized users.

Role of positive lifestyle activities on mood, cognition, well-being, and disease characteristics in multiple sclerosis

Multiple sclerosis (MS) is a neurological condition associated with a wide variety of physical, cognitive, and mood-related symptoms. While disease-modifying treatment has been shown to reduce the severity and frequency of MS symptom relapses, engagement in certain daily activities holds promise as an adjunctive treatment to better manage disease sequelae. The present study sought to determine whether healthy nutritional choices, exercise, and social/intellectual engagement impacts functioning in individuals with MS. Two hundred and forty-eight (248) MS participants completed a questionnaire assessing factors related to cognitive health (Cognitive Health Questionnaire; CHQ). They also endorsed measures assessing disease symptoms and management, mood, and well-being/quality of life. A measure of information processing speed was administered to a subset of participants. Findings indicated that a previously derived CHQ factor comprised of healthy nutritional habits and exercise items was associated with less fatigue, better sleep, reduced pain, and improved mood and disease management. A factor with items assessing social and intellectual engagement correlated with mood, disease management, and well-being. Endorsement of items in both CHQ factors was associated with better information processing speed. Subsequent regression analyses indicated that education and mood were most predictive of nutritional habits and exercise, while MS self-efficacy was particularly associated with engagement in social and intellectual activities. In sum, these findings suggest that self-reported engagement in healthy lifestyle habits has far-reaching effects on multiple aspects of daily living and disease management in MS.

Dietary responses to a multiple sclerosis diagnosis: a qualitative study

BACKGROUND/OBJECTIVES

Multiple sclerosis (MS) is an immune-mediated disease with no known cure and insufficient evidence to support a special therapeutic diet to alter symptom management or disease progression. Several studies have reported dietary changes made by people with MS, but there has been limited investigation into experiences surrounding diet in those recently diagnosed. This study explored responses to diet after a recent diagnosis of MS in people living in Western Australia.

SUBJECTS/METHODS

Eleven adults with MS (mean time since diagnosis 8 months) participated in semi-structured interviews focusing on responses to diet since MS diagnosis. Interviews were transcribed, coded and analysed using grounded theory principles.

RESULTS

Three theme responses emerged; (1) the perceived incompatibility of lack of/or generalised dietary advice with disease seriousness at the time of diagnosis; (2) extensive personal research and information seeking with difficulty judging credibility, and (3) self-experimentation with diet to either control MS symptoms or to cure MS.

CONCLUSIONS

Given the seriousness of the disease, there is a perceived gap in dietary information provided at the time of diagnosis. Healthcare professionals should address concerns with alternative therapeutic diets advertised to treat or cure MS, and clearly convey the reasoning for the general healthy dietary recommendations. This would better align advice with the perceptions about the role of diet in MS, assist people with MS in need of information and minimise dietary self-experimentation. Future research should explore the importance of diet for those who have had MS for a longer period of time.

Stress-Axis Regulation by Vitamin D3 in Multiple Sclerosis

Introduction

Multiple sclerosis (MS) has been associated with both a poor vitamin D status and hyperactivity of the hypothalamus–pituitary–adrenal (HPA) axis. Since nuclear receptor ligands may regulate each other, we explored the association of vitamin D₃ supplements with circadian cortisol levels in a double-blind and placebo-controlled supplementation study.

Methods

Female patients with relapsing-remitting MS received vitamin D₃ supplements (4,000 IU/day; n = 22) or placebo (n = 19) during 16 weeks. Salivary cortisol levels, repeatedly measured during the day, and serum 25(OH)D levels were assessed before (T0) and after (T1) this treatment period.

Results

Median 25(OH)D levels at T1 were 139.9 (interquartile range 123.5–161.2) and 74.5 nmol/L (58.6–88.1) in the vitamin D₃ and placebo group, respectively (p < 0.001). Comparisons within and between groups showed no differences in area under the curve (AUC) and slope of the cortisol day curve. Although the AUC of the cortisol awakening response (CAR, sampling each 15 min the first hour after awakening) showed a reduction over time in the vitamin D₃ group [39.16 nmol/L (27.41–42.07) at T0 to 33.37 nmol/L (26.75–38.08) at T1] compared to the placebo group [33.90 nmol/L (25.92–44.61) at T0 to 35.00 nmol/L (25.46–49.23) at T1; p = 0.044], there was no significant difference in AUC of CAR at T1 corrected for baseline AUC of CAR (p = 0.066).

Conclusion

Suppression of HPA-axis activity by vitamin D₃ supplements in non-depressed MS patients may be best reflected by CAR as primary outcome measure. Further studies should address this interaction and its potential implications for the disease course of MS.

Registration

This study was registered on ClinicalTrials.gov (NCT02096133) and EudraCT (2014-000728-97).

Reported Changes in Dietary Behavior Following a First Clinical Diagnosis of Central Nervous System Demyelination

Background/objectives

Although the current evidence is insufficient to recommend a special diet for people with multiple sclerosis (MS), dietary advice for people with MS is prolific online and in the media. This study aimed to describe dietary changes made in the year following a first clinical diagnosis of central nervous system demyelination (FCD), a common precursor to MS.

Subjects/methods

We used follow-up data from the Ausimmune Study, a multicentre matched case-control study examining the environmental risk factors for a FCD. A total of 244 cases (60 male, 184 female) completed a 1-year follow-up interview, which included a question about dietary changes. We described the number and proportion (%) of participants who reported making dietary changes and the type of change made. We investigated independent predictors of making a dietary change using a multivariable logistic regression model.

Results

A total of 38% (n = 92) of participants at the 1-year follow-up reported making at least one dietary change over the last year. There were no statistically significant independent associations between any participant characteristic and odds of making a dietary change. Of those who made at least one dietary change, the most common changes were increasing fruit and/or vegetable intake (27%, n = 25) and following a low-fat diet (25%, n = 23).

Conclusion

A considerable proportion of the study population reported making at least one dietary change in the year following a FCD, with the majority of changes being toward a healthier diet. Further research is warranted to investigate the reasons behind any dietary changes adopted by people with a FCD or with MS, and whether making a dietary change has benefits for the progression of demyelinating diseases, e.g., to a diagnosis of MS, as well as for general health and well-being.

Preservation of neuronal function as measured by clinical and MRI endpoints in relapsing-remitting multiple sclerosis: how effective are current treatment strategies?

INTRODUCTION

Approved medications for relapsing-remitting multiple sclerosis have shown to be effective in terms of their anti-inflammatory potential. However, it is also crucial to evaluate what long-term effects a patient can expect from current MS drugs in terms of preventing neurodegeneration. Here we aim to provide an overview of the current treatment strategies in MS with a specific focus on potential neuroprotective effects. Areas covered: Randomized, double-blind and placebo or referral-drug controlled phase 2a/b and phase 3 trials were examined; non-blinded phase 4 studies (extension studies) were included to provide long-term data, if not otherwise available. Endpoints considered were expanded disability status scale, various neuropsychological tests, percent brain volume change and T1-hypointense lesions as well as multiple sclerosis functional composite, confirmed disease progression, and no evidence of disease activity. Expert commentary: Overall, neuroprotective functions of classical MS therapeutics are not sufficiently investigated, but available data show limited effects. Thus, further research and development in neuroprotection are warranted. When counselling patients, potential long-term beneficial effects should be presented more conservatively.

Psychiatric and physical comorbidities and pain in patients with multiple sclerosis

Background

It has been observed that patients with multiple sclerosis (MS), who have psychiatric and physical comorbidities such as depression and COPD, have an increased risk of experiencing more pain. In this study, we have distinguished between pain intensity and pain affect, as the latter, particularly, requires treatment. Furthermore, while pain and comorbidities have been assessed using questionnaires, this is possibly a less reliable method for those who are cognitively vulnerable.

Objective

The aim of this study was to determine whether psychiatric and physical comorbidities can predict pain intensity and pain affect in MS patients, susceptible to cognitive impairment.

Methods

Ninety-four patients with MS and 80 control participants participated in this cross-sectional study. Besides depression and anxiety, 47 additional comorbidities were extracted from patients’ medical records. Depression and anxiety were assessed using the Beck Depression Inventory and the Symptom Check List-90. Pain was assessed using the Number of Words Chosen Affective, Coloured Analog Scale, and the Faces Pain Scale. Cognitive functions, for example, memory and executive functions, were assessed using several neuropsychological tests.

Results

The main findings indicate that psychiatric comorbidities (depression and anxiety) predict both pain intensity and pain affect and that total physical comorbidity predicts only pain affect in MS patients, susceptible to cognitive impairment.

Conclusion

Both psychiatric and physical comorbidities predict pain affect. All three clinical outcomes enhance MS patients’ suffering.

Why monkeys do not get multiple sclerosis (spontaneously): An evolutionary approach

The goal of this review is to apply an evolutionary lens to understanding the origins of multiple sclerosis (MS), integrating three broad observations. First, only humans are known to develop MS spontaneously. Second, humans have evolved large brains, with characteristically large amounts of metabolically costly myelin. This myelin is generated over long periods of neurologic development—and peak MS onset coincides with the end of myelination. Third, over the past century there has been a disproportionate increase in the rate of MS in young women of childbearing age, paralleling increasing westernization and urbanization, indicating sexually specific susceptibility in response to changing exposures. From these three observations about MS, a life history approach leads us to hypothesize that MS arises in humans from disruption of the normal homeostatic mechanisms of myelin production and maintenance, during our uniquely long myelination period. This review will highlight under-explored areas of homeostasis in brain development, that are likely to shed new light on the origins of MS and to raise further questions about the interactions between our ancestral genes and modern environments.

Diet, Gut Microbiota, and Vitamins D + A in Multiple Sclerosis

Central to the understanding of the relationships between diet, gut microbiota, and vitamins D and A in multiple sclerosis is low-grade inflammation, which is involved in all chronic inflammatory diseases and is influenced by each of the above effectors. We show that food components have either proinflammatory or anti-inflammatory effects and influence both the human metabolism (the "metabolome") and the composition of gut microbiota. Hypercaloric, high-animal-fat Western diets favor anabolism and change gut microbiota composition towards dysbiosis. Subsequent intestinal inflammation leads to leakage of the gut barrier, disruption of the blood-brain barrier, and neuroinflammation. Conversely, a vegetarian diet, rich in fiber, is coherent with gut eubiosis and a healthy condition. Vitamin D levels, mainly insufficient in a persistent low-grade inflammatory status, can be restored to optimal values only by administration of high amounts of cholecalciferol. At its optimal values (>30 ng/ml), vitamin D requires vitamin A for the binding to the vitamin D receptor and exert its anti-inflammatory action. Both vitamins must be supplied to the subjects lacking vitamin D. We conclude that nutrients, including the nondigestible dietary fibers, have a leading role in tackling the low-grade inflammation associated with chronic inflammatory diseases. Their action is mediated by gut microbiota and any microbial change induced by diet modifies host-microbe interactions in a consequent way, to improve the disease or worsen it.

The Genetics of Multiple Sclerosis: From 0 to 200 in 50 Years

Multiple sclerosis (MS) is a common autoimmune disease that targets myelin in the central nervous system (CNS). Multiple genome-wide association studies (GWAS) over the past 10 years have uncovered more than 200 loci that independently contribute to disease pathogenesis. As with many other complex diseases, risk of developing MS is driven by multiple common variants whose biological effects are not immediately clear. Here, we present a historical perspective on the progress made in MS genetics and discuss current work geared towards creating a more complete model that accurately represents the genetic landscape of MS susceptibility. Such a model necessarily includes a better understanding of the individual contributions of each common variant to the cellular phenotypes, and interactions with other genes and with the environment. Future genetic studies in MS will likely focus on the role of rare variants and endophenotypes.

Managing Epstein-Barr virus and other risk factors in MS-Future perspectives

Here, we discuss the rationale and feasibility of treatment directed against the modifiable risk factors in multiple sclerosis. The established environmental risk factors vitamin D insufficiency, cigarette smoke exposure, adolescence overweight, and Epstein-Barr virus infection are reviewed. Already available measures to target these risk factors are discussed.

Pain in People with Multiple Sclerosis: Associations with Modifiable Lifestyle Factors, Fatigue, Depression, Anxiety, and Mental Health Quality of Life

Background

People with multiple sclerosis (MS) often experience pain, which can interfere with mobility, employment, and quality of life (QOL).

Methods

This cross-sectional study explored associations between pain, demographic, disease, and modifiable lifestyle factors in an international sample of people with MS recruited online.

Results

Substantial pain, of moderate/severe intensity and interfering at least moderately with work/household or enjoyment of life in the past 4 weeks, was reported by 682/2,362 (28.9%). Substantial pain was associated with fatigue (odds ratio (OR): 6.7, 95% confidence interval (CI): 4.9,9.3), depression (OR:4.0, 95% CI:3.2,5.1), anxiety (OR:2.4, 95% CI:1.9,2.9), and lower mental health QOL (Mean Difference: −14.7, 95% CI:−16.6,−12.8). Regression analyses showed that smoking (OR: 2.0, 95% CI:1.35,2.87) and obesity (OR:2.1, 95% CI: 1.5,2.8), moderate alcohol use (OR: 0.7, 95% CI:0.5,0.9), moderate (OR 0.7, 95% CI: 0.55,0.98) or high (OR 0.6, 95% CI: 0.4,0.8) physical activity level, and healthy diet (OR 0.8, 95% CI: 0.75,0.95, per 10 points) were associated with substantial pain.

Conclusion

Our results show clear associations with modifiable lifestyle factors and substantial pain in MS. These factors are already considered in the prevention and management of pain in other populations but have not previously been considered in MS. Conversely, pain and associated common MS comorbidities, such as depression, anxiety, and fatigue, may hamper efforts to start or maintain healthy behaviors. Strategies to overcome these barriers need to be considered. Further research should clarify the direction of these associations.

Management of pregnancy-related issues in multiple sclerosis patients: the need for an interdisciplinary approach

Multiple sclerosis (MS) is a demyelinating and neurodegenerative disease of the central nervous system (CNS), most probably autoimmune in origin, usually occurring in young adults with a female/male prevalence of approximately 3:1. Women with MS in the reproductive age may face challenging issues in reconciling the desire for parenthood with their condition, owing to the possible influence both on the ongoing or planned treatment with the possible consequences on the disease course and on the potential negative effects of treatments on foetal and pregnancy outcomes. At MS diagnosis, timely counselling should promote informed parenthood, while disease evolution should be assessed before making therapeutic decisions. Current guidelines advise the discontinuation of any treatment during pregnancy, with possible exceptions for some treatments in patients with very active disease. Relapses decline during pregnancy but are more frequent during puerperium, when MS therapy should be promptly resumed in most of the cases. First-line immunomodulatory agents, such as interferon-β (IFN-β) and glatiramer acetate (GA), significantly reduce the post-partum risk of relapse. Due to substantial evidence of safety with the use of GA during pregnancy, a recent change in European marketing authorization removed the pregnancy contraindication for GA. This paper reports a consensus of Italian experts involved in MS management, including neurologists, gynaecologists and psychologists. This consensus, based on a review of the available scientific evidence, promoted an interdisciplinary approach to the management of pregnancy in MS women.

International Differences in Multiple Sclerosis Health Outcomes and Associated Factors in a Cross-sectional Survey

Multiple sclerosis (MS) is a major cause of disability and poor quality of life (QOL). Previous studies have shown differences in MS health outcomes between countries. This study aimed to examine the associations between international regions and health outcomes in people with MS. Self-reported data were taken from the Health Outcomes and Lifestyle In a Sample of people with Multiple Sclerosis online survey collected in 2012. The 2,401 participants from 37 countries were categorized into three regions: Australasia, Europe, and North America. Differences were observed between regions in disability, physical and mental health QOL, fatigue, and depression, but most of these disappeared after adjusting for sociodemographic, disease, and lifestyle factors in multivariable regression models. However, adjusted odds for disability were higher in Europe [odds ratio (OR): 2.17, 95% confidence interval (CI): 1.28 to 3.67] and North America (OR: 1.79, 95% CI: 1.28 to 2.51) compared to Australasia. There may be other unmeasured factors that vary between regions, including differences in access and quality of healthcare services, determining disability in MS. When assessing differences in MS health outcomes, lifestyle factors and medication use should be taken into consideration.