Geographical variations in sex ratio trends over time in multiple sclerosis

Psychometric properties of the Polish version of the Multiple Sclerosis Self-Management Scale - Revised

PURPOSE

The main aim of this study was to analyse the psychometric properties of the Polish version of the Multiple Sclerosis Self-Management-Revised Scale.

METHODS

A total of 663 patients with multiple sclerosis were included in this study. The Polish version of the Multiple Sclerosis Self-Management-Revised Scale, The General Self-Efficacy Scale, Multiple Sclerosis Impact Scale-29, and Expanded Disability Status Scale were used. Cronbach's alpha and McDonald's omega coefficients were calculated to assess the Polish version of the scale's reliability. The reliability of the scale's test items was assessed using an information function with the multidimensional graded response model. Confirmatory factor and principal component analyses were conducted.

RESULTS

Cronbach's α and McDonald's ω were obtained (α = 0.896, ω = 0.909). Correlations between the scores of the Polish version of the Multiple Sclerosis Self-Management-Revised Scale and the General Self-Efficacy Scale (r = 0.34; p < 0.001) and the neurological assessment of patients by a physician (r = -0.23; p < 0.001) were significant. The original factor structure of the scale was not confirmed (Chi2(242) = 1480; p < .001; CFI = 0.829; TLI = .805; RMSEA = 0.088, 90% CI = [0.084-0.092]; SRMR = 0.079).

CONCLUSIONS

Using only the total score of the Multiple Sclerosis Self-Management-Revised Scale is recommended for Polish patients. The scale's factor structure requires further study.Implications for rehabilitationThe Polish version of the Multiple Sclerosis Self-Management-Revised Scale was reliable and valid when used in adult multiple sclerosis patients.At present, we recommend using only the total score of the Multiple Sclerosis Self-Management-Revised Scale. Further research is needed to distinguish the detailed subscales of the Polish version of the tool.The Polish version of the Multiple Sclerosis Self-Management-Revised Scale can be used in clinical practice and for research purposes to assess the general level of self-management in Polish-speaking multiple sclerosis patients in Poland.

Epidemiology of pediatric multiple sclerosis: A systematic literature review and meta-analysis

BACKGROUND

Multiple sclerosis (MS) is a debilitating immune disease leading to demyelination, neurodegeneration, and chronic inflammation of the central nervous system. Pediatric MS is a rare form of the disease and effects approximately 2-10% of individuals with MS. Diagnostic criteria and therapies are continuously evolving, thus it is imperative to further understand the epidemiology and subsequently global and regional disease burden of pediatric MS. Our objective was to conduct a systematic literature review and meta-analysis to assess the incidence and prevalence of pediatric MS globally. Subgroup analyses were also conducted by region and diagnostic criteria used to ascertain cases.

METHODS

A systematic literature review was conducted using searches run in EMBASE and MEDLINE. A hand search was also conducted, and the bibliographies of any relevant articles were reviewed for any studies potentially not captured by the databases. A random effects model was used to combine epidemiological estimates across studies. Subgroup analyses by region and diagnostic criteria were performed in instances when three or more studies were available for analyses.

RESULTS

A total of 2,965 publications were identified, of which 187 were eligible for full-text screening. A total of 21 full-text articles met the eligibility criteria and were included for data extraction, with 18 studies included for meta-analysis. Regional epidemiologic estimates were obtained for North America, Europe, Middle East, and Asia. Country specific data was available for Canada, United States, Germany, Iceland, Netherlands, Sardinia, Slovenia, UAE/Abu Dhabi, Iran, Israel, Jordan, Kuwait, Tunisia, Taiwan, and Japan. Thirteen studies representing 12 countries reported incidence of pediatric MS. Overall incidence ranged from 0.05 to 2.85 and pooled global incidence was calculated to be 0.87 (95% CI: 0.35-1.40) per 100,000 individuals annually. Ten studies representing 10 countries reported on the prevalence of pediatric MS. Overall prevalence ranged from 0.69 to 26.92 per 100,000 individuals and pooled global prevalence was calculated to be 8.11 (95% CI: 2.28-13.93) per 100,000 people.

CONCLUSION

To our knowledge, this is the first meta-analysis conducted to provide pooled estimates of incidence and prevalence estimates of pediatric MS globally. In general, incidence estimates were similar across regions; however, prevalence was found to be more variable. Noticeable gaps in evidence include a lack of pediatric MS estimates from other large regions of the world such as Africa, South America, Russia, and Australia. Moreover, there is a need for more population-based studies using the most up to date diagnostic criteria.

Incidence and prevalence of multiple sclerosis in Hungary based on record linkage of nationwide multiple healthcare administrative data

Objectives

As there were only regional studies in Hungary about the prevalence of multiple sclerosis (MS), we aimed to estimate its epidemiological features using data of Hungary’s single-payer health insurance system.

Methods

Pseudonymized database of claims reported by hospitals and outpatient services between 2004–2016 was analyzed and linked with an independent database of outpatient pharmacy refills between 2010–2016. We established an administrative case definition of MS and validated it on medical records of 309 consecutive patients. A subject was defined as MS-patient if received MS diagnosis (International Classification of Diseases, 10th edition, code G35) on three or more occasions at least in 2 calendar years and at least once documented by a neurologist. Patients were counted as incident cases in the year of the first submitted claim for MS. We allowed a 6-year-long run-in period, so only data between 2010–2015 are discussed.

Results

Sensitivity of the administrative case definition turned out to be 99%, while specificity was >99%. Crude prevalence of MS has increased from 109.3/100,000 in 2010 to 130.8/100,000 in 2015 (p-value = 0.000003). Crude incidence declined from 7.1/100,000 (2010) to 5.4/100,000 (2015) (p-value = 0.018). Direct standardization − based on European standard population and results of nationwide Hungarian census of 2011 − revealed that age standardized prevalence was 105.2/100,000 (2010), which has grown to 127.2/100,000 (2015) (p-value = 0.000001). Age standardized incidence rate declined from 6.7/100,000 (2010) to 5.1/100,000 (2015) (p-value = 0.016). The ratio of MS-patients receiving ≥1 prescription for disease modifying treatment increased from 0.19 (2010) to 0.29 (2015) (p-value = 0.0051). The female/male ratio of prevalent cases remained 2.6.

Discussion

The prevalence of MS in Hungary is higher than previously reported, the incidence rate is moderate. The prevalence is rising, the incidence rate shows decline. The proportion of patients receiving disease modifying treatment grows but was still around 30% in 2015.

Sex effects across the lifespan in women with multiple sclerosis

Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating central nervous system disorder that is more common in women, with onset often during reproductive years. The female:male sex ratio of MS rose in several regions over the last century, suggesting a possible sex by environmental interaction increasing MS risk in women. Since many with MS are in their childbearing years, family planning, including contraceptive and disease-modifying therapy (DMT) counselling, are important aspects of MS care in women. While some DMTs are likely harmful to the developing fetus, others can be used shortly before or until pregnancy is confirmed. Overall, pregnancy decreases risk of MS relapses, whereas relapse risk may increase postpartum, although pregnancy does not appear to be harmful for long-term prognosis of MS. However, ovarian aging may contribute to disability progression in women with MS. Here, we review sex effects across the lifespan in women with MS, including the effect of sex on MS susceptibility, effects of pregnancy on MS disease activity, and management strategies around pregnancy, including risks associated with DMT use before and during pregnancy, and while breastfeeding. We also review reproductive aging and sexual dysfunction in women with MS.

Mortality trend for multiple sclerosis in Italy during the period 1980-2015

BACKGROUND

The epidemiology of Multiple Sclerosis (MS) is relevant for health-services planning. Most of MS prevalence and incidence studies in Italy referred to specific geographical areas and periods, whereas mortality data are routinely collected at the national level. The aim was to assess MS mortality trend and geographical differences in Italy from 1980 to 2015.

METHODS

Mortality data were provided by the Italian Institute of Statistics. Due to a low number of annual deaths, mortality data were analysed for both the entire period under study and for sub-periods. Temporal trends were first evaluated using age-adjusted mortality rates (AMRs) comparing each sub-period with the initial one. Then, the annual percent change in mortality was estimated through the joinpoint regression model. Spatial differences between 5 main geographical areas were evaluated using standardized mortality ratios (SMRs).

RESULTS

During the study period, 4,959 deaths for males and 7,434 for females were observed. The higher overall AMR was observed for females (F:0.71 vs. M: 0.56 per 100,000 persons per year). Analysing mortality by gender and geographical area, SMRs 〈 100 were observed in South Italy for both sexes, and in Central Italy for males only, whereas SMRs 〉 100 for Islands for both sexes, and in North-East and North-West for females only. The analysis of the mortality trend through AMRs calculated for sub-periods revealed no difference between the first and the last period for males, whereas a significant increase in mortality was observed for females. The joinpoint regression analysis showed a significant decrease in mortality up to 1995 for males (APC -3.23%) and up to 1999 for females, (APC -1.01%), followed by a significant increase for both sexes, but more marked for females (APC +1.9% M, +2.34% F).

CONCLUSION

The increasing trend of mortality for MS, especially for females, may reflect the increase in the prevalence of MS and the improvement in the quality of diagnosis or coding of the cause of death.

Development and validation of the communication and language assessment questionnaire for persons with multiple sclerosis (CLAMS)

BACKGROUND

There is growing recognition that communication and language can be compromised in persons with multiple sclerosis (MS). However, patient-reported outcome measures (PROMs) designed to measure communication and language function in MS are currently lacking.

OBJECTIVES

This study aimed to develop and validate a novel PROM, the Communication and Language Assessment questionnaire for persons with Multiple Sclerosis (CLAMS).

METHODS

One-hundred and ninety-nine participants were recruited internationally through online channels. Participants completed an online questionnaire consisting of 41-items generated from the: (1) La Trobe Communication Questionnaire (LCQ), (2) Speech pathology-specific questionnaire for persons with Multiple Sclerosis (SMS), and (3) published research describing communication and language in MS. These items were then submitted to preliminary psychometric evaluation, including principal component analysis, internal consistency, test-retest reliability, criterion validity, and analyses of floor and ceiling effects. Criterion validity was assessed by comparing the CLAMS with the Communication Participation Item Bank (CPIB).

RESULTS

The final CLAMS contained 11-items. Internal consistency was high (α = 0.944) and test-retest reliability. All items produced an intra-class correlation coefficient ≥ 0.70. No floor or ceiling effects were present. A statistically significant strong correlation between the CLAMS and the CPIB was identified (r = -0.750, p = ≤ 0.001).

CONCLUSION

The CLAMS is a reliable and valid PROM that assesses self-perceived communication and language function in MS. This tool can be used for research and clinical purposes to measure intervention outcomes, monitor symptom evolution, evaluate service delivery, facilitate patient-centred care, and as an adjunct to clinical assessment.

Prevalence and Incidence of Multiple Sclerosis in Russian Federation: 30 Years of Studies

In the Russian Federation, multiple sclerosis prevalence rates vary from 10 to 80 cases per 100,000, depending on region and the nationality of the population. The main characteristics of multiple sclerosis epidemiology in the XX century in this big territory are: (1) steady increase in multiple sclerosis prevalence and incidence rates, maybe because of better diagnosis and treatment, but also changes in environmental/epigenetic risk profile and/or lifestyle factors; (2) increase of the female to male ratio, increase in multiple sclerosis incidence mainly in females; (3) appearance and increasing frequency of multiple sclerosis in ethnic groups, previously free of multiple sclerosis (Northern Tribes, Yakuts and others). The latest data show that in European Russia, the multiple sclerosis prevalence varies from 30 to 80 cases, in Siberia-from 20 to 70 cases, with steady increases, especially in women.

Sex-Specific Differences in Life Span Brain Volumes in Multiple Sclerosis

BACKGROUND AND PURPOSE

Numerous sex-specific differences in multiple sclerosis (MS) susceptibility, disease manifestation, disability progression, inflammation, and neurodegeneration have been previously reported. Previous magnetic resonance imaging (MRI) studies have shown structural differences between female and male MS brain volumes. To determine sex-specific global and tissue-specific brain volume throughout the MS life span in a real-world large MRI database.

METHODS

A total of 2,199 MS patients (female/male ratio of 1,651/548) underwent structural MRI imaging on either a 1.5-T or 3-T scanner. Global and tissue-specific volumes of whole brain (WBV), white matter, and gray matter (GMV) were determined by utilizing Structural Image Evaluation using Normalisation of Atrophy Cross-sectional (SIENAX). Lateral ventricular volume (LVV) was determined with the Neurological Software Tool for REliable Atrophy Measurement (NeuroSTREAM). General linear models investigated sex and age interactions, and post hoc comparative sex analyses were performed.

RESULTS

Despite being age-matched with female MS patents, a greater proportion of male MS patients were diagnosed with progressive MS and had lower normalized WBV (P < .001), GMV (P < .001), and greater LVV (P < .001). In addition to significant stand-alone main effects, an interaction between sex and age had an additional effect on the LVV (F-statistics = 4.53, P = .033) and GMV (F-statistics = 4.59, P = .032). The sex and age interaction was retained in both models of LVV (F-statistics = 3.31, P = .069) and GMV (F-statistics = 6.1, P = .003) when disease subtype and disease-modifying treatment (DMT) were also included. Although male MS patients presented with significantly greater LVV and lower GMV during the early and midlife period when compared to their female counterparts (P < .001 for LVV and P < .019 for GMV), these differences were nullified in 60+ years old patients. Similar findings were seen within a subanalysis of MS patients that were not on any DMT at the time of enrollment.

CONCLUSION

There are sex-specific differences in the LVV and GMV over the MS life span.

Evidence of an increased prevalence of multiple sclerosis: a population-based study of Tehran registry during 1999-2018

BACKGROUND

The epidemiological characteristics of multiple sclerosis (MS) have been investigated in various studies, which have revealed that the prevalence of MS varies across countries. The present study was conducted to investigate the longitudinal prevalence of MS in Tehran, Iran.

METHODS

The present population-based study was conducted in Tehran, the capital of Iran from 1999 to 2018 based on the annual report data provided by the Iranian MS Society (IMSS) registry system. The age-standardized and crude prevalence were estimated using population data presented by the Statistical Centre of Iran.

RESULTS

A total of 21,580 MS cases were registered and included in the analysis. Among the participant patients, 24.99% (5393) and 75.01% (16,187) of cases were male and female, respectively. The mean age of MS onset was 28.8 years (S.D: 8.7). The age-standardized prevalence (ASP) of MS increased from 73.7 (95%CI: 72.1-75.2) per 100,000 people in 2006 to 137.6 (95% CI: 135.7-139.5) per 100,000 people in 2018. The ASP of MS in 2018 was estimated to be 67.9 (95%CI: 66.0-69.8) and 207.3 (95%CI: 204.0-210.7) per 100,000 people among males and females, respectively. The age-standardized female-to-male ratio of MS ranged from 3.7 (in 2010) to 2.06 (in 2017).

CONCLUSION

The findings of this study suggested that the prevalence of MS in Tehran province is relatively high, and the occurrence of the disease is more common in the age groups under 40 years as compared with older-aged groups. In line with reports provided for various regions of the world, the prevalence of MS was higher among women. Similarly, the findings of this study revealed that the female-to-male ratio was 2.14 in 2018.

The Relationships between Physical Activity, Self-Efficacy, and Quality of Life in People with Multiple Sclerosis

Regular physical activity (PA) can enhance the physical and mental health of people with Multiple Sclerosis (MS) because of its impact on muscular strength, mobility, balance, walking, fatigue, pain and health-related quality of life (HRQoL). Previous studies have hypothesized that the relationship between PA and HRQoL is mediated by self-efficacy. The aim of this research is to evaluate whether self-efficacy in goal setting and self-efficacy in the management of symptoms, mediate the relationship between PA and HRQoL, in a similar way to exercise self-efficacy. A sample of 28 participants with MS (18 females) and different levels of physical activity have been recruited and completed the following measures: a) physical activity (GLTEQ); b) health-related quality of life (SF-12); c) self-efficacy in the management of Multiple Sclerosis (SEMS) and, d) exercise self-efficacy (EXSE). The statistical analysis highlighted that self-efficacy in goal setting mediated the relationship between PA and mental health better than exercise self-efficacy. Our findings suggest that self-efficacy in goal setting can contribute to the adoption and maintenance of regular physical activity for long-lasting times, supporting and increasing the mental quality of life of people suffering from MS.

Lost in translational biology: Understanding sex differences to inform studies of diseases of the nervous system

Female and male humans are different. As simple and obvious as that statement is, in biomedical research there has been an historical tendency to either not consider sex at all or to only use males in clinical and in preclinical model system studies. The result is a large volume of research that reflects the average biology and pathology of males even though we know that disease risk, presentation, and response to therapies can be different between females and males. This is true, albeit to differing degrees, for virtually all neurological and psychiatric diseases. However, the days of ignoring sex as a biological variable are over - both because of the realization that genetic sex impacts brain function, and because of the 2014 mandate by the U.S. National Institutes of Health that requires that "sex as a biological variable" be addressed in each grant application. This review is written for neuroscientists who may not have considered sex as a biological variable previously but who now are navigating the best way to adapt their research programs to consider this important biology. We first provide a brief overview of the evidence that male versus female differences in the brain are biologically and clinically meaningful. We then present some fundamental principles that have been forged by a dedicated but small group of ground-breaking researchers along with a description of tools and model systems for incorporating a sex differences component into a research project. Finally, we will highlight some key technologies that, in the coming years, are likely to provide critical information about sex differences in the human brain.

Redefining the Multiple Sclerosis Severity Score (MSSS): The effect of sex and onset phenotype

BACKGROUND

The Multiple Sclerosis Severity Score (MSSS) is a widely used measure of the disability progression rate. However, the global MSSS may not be the best basis for comparison between all patient groups.

OBJECTIVE

We evaluated sex-specific and onset phenotype-specific MSSS matrices to determine if they were more effective than the global MSSS as a basis for comparison within these subsets.

METHODS

Using a large international dataset of multiple sclerosis (MS) patient records and the original MSSS algorithm, we constructed global, sex-specific and onset phenotype-specific MSSS matrices. We compared matrices using permutation analysis.

RESULTS

Our final dataset included 30,203 MS cases, with 28.9% males and 6.5% progressive-onset cases. Our global MSSS matrix did not differ from previously published data (p > 0.05). The progressive-onset-specific matrix differed significantly from the relapsing-onset-specific matrix (p < 0.001), with lower MSSS attributed to cases with the same Expanded Disability Status Score (EDSS) and disease duration. When evaluated with a simulation, using an onset-specific MSSS improved statistical power in mixed cohorts. There were no significant differences by sex.

CONCLUSION

The differences in the disability accrual rate between progressive- and relapsing-onset MS have a significant effect on MSSS. An onset-specific MSSS should be used when comparing the rate of disability progression among progressive-onset cases and for mixed cohorts.

The Effect of Broad-Spectrum Dietary Supplementation on Quality of Life, Symptom Severity, and Functioning in Multiple Sclerosis

Multiple sclerosis (MS) is a progressive neurodegenerative disease that exerts a significant quality-of-life toll on patients. According to the literature, broad-spectrum dietary supplementation including a variety of nutrients, polysaccharides, and compounds may improve the quality of life, functionality, and symptom severity in people with MS. Individuals (n = 15) diagnosed with relapsing-remitting MS (RRMS) for an average of 12.4 years (SD = 7.4; R = 2, 25) were enrolled in a one-year open-label clinical trial in which they consumed a broad-spectrum dietary supplement regimen three times daily. Participants were assessed at baseline and at 3, 6, 9, and 12 months with the following: (1) Functional Assessment of MS (FAMS), (2) the EQ-5D-3L, (3) Beck Depression Inventory-II (BDI), (4) Health Conditions Discomfort Scale (HCDS), and (5) Self-Assessment of Severity of MS Symptoms Scale (SASMSSS). Participants included seven females and eight males (M age = 51.3 years; SD = 7.2; R = 38, 65). Few minor gastrointestinal effects were reported. At the end of the intervention, participants showed significant improvements in all outcome measures, particularly functionality on the FAMS, overall quality of life on the EQ-5D-3L, fewer depressive symptoms on the BDI, and improved severity of symptoms on the HCDS and the SASMSSS. Our results suggest that dietary supplementation containing a variety of nutrients can improve the quality of life, severity of disease symptoms, and functionality in MS patients. These findings are clinically promising for MS patients, given the lack of treatment options geared toward improving quality of life in this population.

Sex-dependent factors encoded in the immune compartment dictate relapsing or progressive phenotype in demyelinating disease

TCR1640 mice, which have a T cell receptor (TCR) directed against MOG92-106, spontaneously develop experimental autoimmune encephalomyelitis. Female mice mostly develop a relapsing-remitting (RR) course and have a higher incidence of disease, while males most frequently suffer from progressive disease, reflecting the unresolved clinical sex discrepancies seen in multiple sclerosis. Herein, we performed adoptive transfers of male and female TCR1640 immune cells into WT animals to investigate if disease course is dependent on the sex of the donor immune cells or on the sex of the recipient animal. We found that transfer of female TCR1640 immune cells led to a RR disease while transfer of male TCR1640 immune cells led to a progressive course, independent of the sex of the recipient. In addition, regulatory and pathogenic T cell infiltration after transfer was also immune cell sex intrinsic. We performed genetic profiling of the donor immune cells and found significant differences between the transcriptomic profiles of male and female TCR1640 immune cells, interestingly, within genes related to immune regulation of T lymphocytes. These results suggest that differences in gene expression profiles related to regulation of T cell immunity seen in male and female neuroinflammatory disease drive relapsing versus progressive disease course.

Autoimmune diseases: Role of steroid hormones

Autoimmune diseases (AIDs) are a heterogeneous group of disorders in terms of clinical manifestations, pathogenesis, and prevalence, and there is no agreement to date on a common classification. Adaptive immune responses are responsible for the existence of AIDs, although innate immunity is also involved in misguiding the immune response against self-antigens. Hormones, in general, and in particular steroid hormones, play a critical role in the physiology and pathology of the immune system, especially in adaptive immunity. Hormonal factors, alone or in relation to age, sex, and reproductive status, are involved in conditioning the onset of a number of AIDs. There is a well-defined sexual dimorphism for human AIDs. At the same time, the classic view has been that steroid hormones have well-defined effects, with one type, estrogens, being "pro-inflammatory" and the other two progestogens (progesterone and its synthetic analogs) and androgens being "anti-inflammatory." Although this view has been considered too simplistic and seems contradicted by numerous observations, it remains valid: progestogens and androgens are immunosuppressive and therefore protective against AIDs, whereas estrogens are immune-stimulatory and therefore pathogenic in AIDs.

The role of vitamin D and P2X7R in multiple sclerosis

Multiple sclerosis (MS) is characterized by neuroinflammatory infiltrates and central nervous system demyelination. In the neuroinflammatory foci of MS there is increased expression of a purinergic receptor, P2X7R. Although implicated in the neuroinflammation, the exact role of P2X7R in the context of MS is unclear and forms the basis of this review. In this review, we also introduce the immunopathologies and inflammatory processes in MS, with a focus on P2X7R and the possible immunomodulatory role of vitamin D deficiency in this setting.

Menarche, pregnancies, and breastfeeding do not modify long-term prognosis in multiple sclerosis

OBJECTIVE

To investigate the effect of menarche, pregnancies, and breastfeeding on the risk of developing multiple sclerosis (MS) and disability accrual using a multivariate approach based on a large prospective cohort of patients with clinically isolated syndrome (CIS).

METHODS

A cross-sectional survey of the reproductive information of female participants in a CIS cohort was performed. We examined the relationship of age at menarche with the risk of clinically definite MS (CDMS), McDonald 2010 MS, and Expanded Disability Status Scale (EDSS) 3.0 and 6.0. The effect of pregnancy (before and after CIS) and breastfeeding in the risk of CDMS, McDonald 2010 MS, and EDSS 3.0 was also examined. Univariate and multivariate analyses were performed and findings were confirmed using sensitivity analyses and a propensity score model.

RESULTS

The data of 501 female participants were collected. Age at menarche did not correlate with age at CIS and was not associated with the risk of CDMS or EDSS 3.0 or 6.0. Pregnancy before CIS was protective for CDMS in the univariate analysis, but the effect was lost in the multivariate model and did not modify the risk of EDSS 3.0. Pregnancy after CIS was protective for both outcomes in univariate and multivariate analyses when pregnancy was considered a baseline variable, but the protective effect disappeared when analyzed as a time-dependent event. Breastfeeding did not modify the risk for the 3 outcomes.

CONCLUSIONS

These results demonstrate that menarche, pregnancies, and breastfeeding did not substantially modify the risk of CDMS or disability accrual using a multivariable and time-dependent approach.

Short Report: Adherence to Neuropsychological Recommendations in Patients with Multiple Sclerosis

Background

Adherence to nonmedication recommendations is typically low, as seen in various health populations. Because literature on adherence to treatment recommendations made after neuropsychological testing in multiple sclerosis (MS) is lacking, this study evaluated adherence and reasons for nonadherence. Relationships between adherence to recommendations and various other factors in patients with MS were also evaluated.

Methods

Of 66 adult patients seen for neuropsychological testing at an MS center, 55 were eligible for this study. Forty-five patients (mean age, 43.4 years; 75.6% women) were reached by phone, and all agreed to an interview involving questions regarding adherence to treatment recommendations. Other information was obtained through retrospective medical record review.

Results

Overall self-reported adherence to recommendations made from neuropsychological testing was 38%. Adherence rates varied by recommendation type: psychopharmacological management had the highest rate (80%), and referrals for cognitive rehabilitation had the lowest (6.5%). Reasons for nonadherence included needing more information and wanting to speak with one's physician regarding the recommendations. Adherence was associated with patients' ability to spontaneously recall at least some of their recommendations and with receiving both a written report and a phone call with test results.

Conclusions

Adherence to recommendations made after neuropsychological testing for patients with MS is low. Points of intervention may be to give directed feedback for each recommendation and to provide both a written report and a phone call with results and recommendations. Asking patients to repeat back the recommendations may be a simple and efficient way to increase understanding and improve adherence.

Incidence and Prevalence of Chronic Inflammatory Demyelinating Polyradiculoneuropathy: A Systematic Review and Meta-Analysis

BACKGROUND

Prevalence and incidence rates of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are required to determine the impact of CIDP on society. We aimed to estimate the prevalence and incidence of CIDP worldwide and to determine the effect of diagnostic criteria on prevalence and incidence.

METHOD

A systematic review was conducted for all published incidence and prevalence studies on CIDP until May 18, 2017. Methodological quality was assessed using the Methodological Evaluation of Observational Research checklist. We performed a random effect meta-analysis to estimate pooled prevalence and incidence rates.

RESULTS

Of the 907 studies, 11 were included in the systematic review, 5 in the meta-analysis of incidence (818 cases; 220,513,514 person-years) and 9 in the meta-analysis of prevalence (3,160 cases; 160,765,325 population). These studies had a moderate quality. The pooled crude incidence rate was 0.33 per 100,000 person-years (95% CI 0.21-0.53; I2 = 95.7%) and the pooled prevalence rate was 2.81 per 100,000 (95% CI 1.58-4.39; I2 = 99.1%). Substantial heterogeneity in incidence and prevalence across studies seems to be partly explained by using different diagnostic criteria.

CONCLUSION

These findings provide a starting point to estimate the social burden of CIDP and demonstrate the need to reach consensus on diagnostic criteria for CIDP.

Geographic variations of multiple sclerosis in Iran: A population based study

BACKGROUND

The epidemiology of Multiple sclerosis (MS) has changed in recent decades. Considering that the incidence and geographical variations of MS is not well known in Iran. The present study was conducted to investigate the incidence of MS and its geographic variations in Iran.

METHODS

Data from a national registry, coordinated by the Ministry of Health (MOH), were collected for this study. In Iran, all MS patients are eligible to receive care and treatment services based on their records in this registry. Therefore, it seems that the related data are comprehensive with very high coverage, particularly in recent years. In this study, the annual incidence rates were calculated based on year of diagnosis of MS.

RESULTS

In this registry, 32,633 new cases were recorded between 2011 and 2016. After standardized for age, the mean annual incidence rate was 6.5 per 100,000 populations. It was 10.2 and 2.9 in women and men respectively. This incidence ranged from 1.7 to 12.8 in provincial level, with a higher intensity in the central part of the country.

CONCLUSION

It seems that the incidence rate of MS and its ratio in females and males are more or less comparable with the dominant patterns in developed countries, although its variation within the country is very considerable.

Incidence of pregnancy and disease-modifying therapy exposure trends in women with multiple sclerosis: A contemporary cohort study

BACKGROUND

Exposure to disease-modifying therapy (DMT) during early pregnancy in women with relapsing-remitting MS (RRMS) may be increasing.

OBJECTIVE

To retrospectively determine incidence of pregnancy, DMT exposure and pregnancy outcomes in women with RRMS.

METHODS

We identified all women with RRMS aged 15-45 years in the MSBase Registry between 2005-2016. Annualised pregnancy incidence rates were calculated using Poisson regression models. DMT exposures and pregnancy outcomes were assessed.

RESULTS

Of 9,098 women meeting inclusion criteria, 1,178 (13%) women recorded 1,521 pregnancies. The annualised incidence rate of pregnancy was 0.042 (95% CI 0.040, 0.045). A total of 635 (42%) reported pregnancies were conceived on DMT, increasing from 27% in 2006 to 62% in 2016. The median duration of DMT exposure during pregnancy was 30 days (IQR: 9, 50). There were a higher number of induced abortions on FDA pregnancy class C/D drugs compared with pregnancy class B and no DMT (p = 0.010); but no differences in spontaneous abortions, term or preterm births.

CONCLUSIONS

We report low pregnancy incidence rates, with increasing number of pregnancies conceived on DMT over the past 12-years. The median duration of DMT exposure in pregnancy was relatively short at one month.

Incidence rate and sex ratio in multiple sclerosis in Lithuania

OBJECTIVES

To determine the temporal changes in incidence rates of multiple sclerosis (MS) over the past 15 years in Lithuania with prediction up to 2020, and to estimate female-to-male sex ratio and its changes among MS patients.

MATERIALS AND METHODS

We conducted a descriptive incidence study. The crude incidence rates (CIR) were calculated using 15-year period, sex, age-groups, and the number of newly registered MS patients. Standardized incidence rates (SIR) were calculated using European standard in order to evaluate the influence of resident structure changes on incidence of MS during the last 15 years. The data were processed using Minitab set to estimate a linear trend model for the temporal changes of 16 parameters.

RESULTS

The data showed a substantial growth of the incidence rate of MS in Lithuania during the period of 2001-2015. In 2001, MS was diagnosed to 162 new individuals, whereas 343 new cases of MS were diagnosed in 2015. During 2001-2015, the incidence of MS was on average 6.5 (95% CI 5.70-7.30) cases per 100,000 residents, and 4.9 (95% CI 4.46-5.34) and 8.1 (5.86-9.34) for 100,000 male and female, respectively. Female-to-male sex ratio in MS in Lithuania had a tendency to increase over the period. Females were affected from 1.5 to 2 times more often than males.

CONCLUSIONS

In 2020, the incidence rate of MS is estimated to reach 13 cases per 100,000 persons and females are expected to be diagnosed with MS two times more often than males.

Impact of sex hormones on immune function and multiple sclerosis development

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) affecting young people and leading to demyelination and neurodegeneration. The disease is clearly more common in women, in whom incidence has been rising. Gender differences include: earlier disease onset and more frequent relapses in women; and faster progression and worse outcomes in men. Hormone-related physiological conditions in women such as puberty, pregnancy, puerperium, and menopause also exert significant influence both on disease prevalence as well as on outcomes. Hormonal and/or genetic factors are therefore believed to be involved in regulating the course of disease. In this review, we discuss clinical evidence for the impact of sex hormones (estrogens, progesterone, prolactin, and testosterone) on MS and attempt to elucidate the hormonal and immunological mechanisms potentially underlying these changes. We also review current knowledge on the relationship between sex hormones and resident CNS cells and provide new insights in the context of MS. Understanding these molecular mechanisms may contribute to the development of new and safer treatments for both men and women.

Cumulative influence of parity-related genomic changes in multiple sclerosis

Pregnancy reduces the frequency of relapses in Multiple Sclerosis (MS) and parity also has a beneficial long term effect on disease outcome. We aimed to uncover the biological mechanisms underlying the beneficial long-term effects of parity in MS. Genome-wide gene expression revealed 574 genes associated with parity; 38.3% showed significant DNA methylation changes (enrichment p = 0.029). These genes overlapped with previous MS genes in humans and a rat MS model and were overrepresented within axon guidance (P = 1.6e-05), developmental biology (P = 0.0094) and cell-cell communication (P = 0.019) pathways. This gene regulation could provide a basis for a protective effect of parity on the long-term outcome of MS.

Association Between Multiple Sclerosis and Risk of Female Sexual Dysfunction: A Systematic Review and Meta-Analysis

INTRODUCTION

It has been reported that multiple sclerosis (MS) would increase the susceptibility to female sexual dysfunction (FSD).

AIM

To assess whether MS was a risk factor for FSD through a comprehensive literature review and meta-analysis.

METHODS

MEDLINE (PubMed), Embase, Cochrane Library, and PsychINFO databases were systematically searched for all studies reporting sexual function in women with MS. The protocol for this meta-analysis is available from PROSPERO (CRD42018094392).

MAIN OUTCOME MEASURES

The association between MS and risk of FSD was summarized using relative risk or standard mean differences with 95% CI. Subgroup and sensitivity analyses were conducted to detect potential bias.

RESULTS

Overall, 1,485 women participants (the mean age ranged from 29.15 to 45.89 years) were included from 9 studies (4 cross-sectional and 5 case-control studies); 826 of them were patients with MS, with a mean disease duration from 2.7 to 16.51 years. Synthesis of results revealed that MS was significantly associated with an increased risk of FSD (relative risk 1.87, 95% CI 1.25-2.78, P = .002; heterogeneity: I² = 89.0%, P < .001). Women with MS had significantly lower values in total Female Sexual Function Index scores as compared with healthy controls (standard mean differences -2.41,95% CI -3.87 to -0.96, P = .017; heterogeneity: I² = 97.2%, P = .001). The grading of recommendations assessment, development, and evaluation-relevant outcomes revealed that the absolute effect of MS on FSD was 434 more per 1000 (from 125 more to 888 more); and the overall quality of the evidence was judged as low.

CLINICAL IMPLICATIONS

The present meta-analysis indicates that women patients with MS have a significant elevated risk of sexual dysfunction, which should raise awareness of the potential association between MS and FSD by both neurologists and urologists.

STRENGTHS & LIMITATIONS

This the first study to summarize all available evidence for combining the odds on the association between MS and the risk of developing FSD. However, all the included studies were observational design, which may downgrade this evidence.

CONCLUSION

Results of this meta-analysis revealed a potential hazardous effect of MS for developing FSD. High-quality stringently controlled studies with large sample size are still warranted to validate this relationship. Zhao S, Wang J, Liu Y, et al. Association Between Multiple Sclerosis and Risk of Female Sexual Dysfunction: A Systematic Review and Meta-analysis. J Sex Med;15:1716-1727.

A Systematic Assessment of Prevalence, Incidence and Regional Distribution of Multiple Sclerosis in Bavaria From 2006 to 2015

Introduction: Worldwide, incidence and prevalence of multiple sclerosis (MS) have increased over the last decades. We present a systematic epidemiological study with recent prevalence and incidence rates of MS in Bavaria. Methods: Incidence and prevalence of MS stratified by gender, age groups and region were analyzed by data records from 2006 to 2015 of more than 10 million people insured by the Bavarian Association of Statutory Health Insurance Physicians. Official statistics of the German Federal Ministry of Health provided the size of the general population. Future prevalence was estimated with a predictive model. Results: From 2006 to 2015 prevalence of MS in Bavaria increased from 171 per 100,000 to 277 per 100,000, while incidence rates remained relatively stable (range 16-18 per 100,000 inhabitants with a female to male ratio between 2.4:1 and 2:1). Incidence and prevalence were higher in urban than urbanized and rural areas. The prevalence is expected to increase to 374 per 100,000 in 2040 with the highest prevalence rates between 50 and 65 years. Conclusion: The prevalence of MS in Bavaria is among the highest worldwide and will further rise over the next two decades. This demonstrates a need to strengthen healthcare provision systems due to the increasing numbers of particularly older patients with MS in the future.

Sex differences in autoimmune disorders of the central nervous system

Stronger adaptive immune responses in females can be observed in different mammals, resulting in better control of infections compared to males. However, this presumably evolutionary difference likely also drives higher incidence of autoimmune diseases observed in humans. Here, we summarize sex differences in the most common autoimmune diseases of the central nervous system (CNS) and discuss recent advances in the understanding of possible underlying immunological and CNS intrinsic mechanisms. In multiple sclerosis (MS), the most common inflammatory disease of the CNS, but also in rarer conditions, such as neuromyelitis optica spectrum disorders (NMOSD) or neuronal autoantibody-mediated autoimmune encephalitis (AE), sex is one of the top risk factors, with women being more often affected than men. Immunological mechanisms driving the sex bias in autoimmune CNS diseases are complex and include hormonal as well as genetic and epigenetic effects, which could also be exerted indirectly via modulation of the microbiome. Furthermore, CNS intrinsic differences could underlie the sex bias in autoimmunity by differential responses to injury. The strong effects of sex on incidence and possibly also activity and progression of autoimmune CNS disorders suggest that treatments need to be tailored to each sex to optimize efficacy. To date, however, due to a lack of systematic studies on treatment responses in males versus females, evidence in this area is still sparse. We argue that studies taking sex differences into account could pave the way for sex-specific and therefore personalized treatment.

Hypothesis: Multiple sclerosis is caused by three-hits, strictly in order, in genetically susceptible persons

Multiple Sclerosis is a chronic, progressive and debilitating neurological disease which, despite extensive study for over 100 years, remains of enigmatic aetiology. Drawn from the epidemiological evidence, there exists a consensus that there are environmental (possibly infectious) factors that contribute to disease pathogenesis that have not yet been fully elucidated. Here we propose a three-tiered hypothesis: 1) a clinic-epidemiological model of multiple sclerosis as a rare late complication of two sequential infections (with the temporal sequence of infections being important); 2) a proposal that the first event is helminthic infection with Enterobius Vermicularis, and the second is Epstein Barr Virus infection; and 3) a proposal for a testable biological mechanism, involving T-Cell exhaustion for Epstein-Barr Virus protein LMP2A. We believe that this model satisfies some of the as-yet unexplained features of multiple sclerosis epidemiology, is consistent with the clinical and neuropathological features of the disease and is potentially testable by experiment. This model may be generalizable to other autoimmune diseases.

A case for gender-based approach to multiple sclerosis therapeutics

Despite established sex differences in multiple sclerosis (MS) risk and course, sex-specific efficacy and toxicity of existing MS therapies, and possible sex-specific therapeutic approaches, remain underexplored. We systematically reviewed published sex differences from Phase III pivotal trials for FDA or EMA-approved MS disease modifying therapies (DMTs), along with additional information from pharmaceutical companies, for pre-specified or post-hoc baseline characteristics, efficacy and safety outcomes by sex, and sex-specific concerns. Then, we reviewed trials testing hormonal therapies in MS. None of the Phase III clinical trials performed baseline sex-specific analyses or were powered to evaluated DMTs in menopausal/older populations. Some recent trials performed pre-specified or post-hoc stratification of outcomes by sex. Sex-specific hormonal intervention trials were limited. Adequately powered, pre-specified analyses accounting for baseline sex and age are required to maximize safety and efficacy in specific patient populations.

Incorporating machine learning approaches to assess putative environmental risk factors for multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) incidence has increased recently, particularly in women, suggesting a possible role of one or more environmental exposures in MS risk. The study objective was to determine if animal, dietary, recreational, or occupational exposures are associated with MS risk.

METHODS

Least absolute shrinkage and selection operator (LASSO) regression was used to identify a subset of exposures with potential relevance to disease in a large population-based (Kaiser Permanente Northern California [KPNC]) case-control study. Variables with non-zero coefficients were analyzed in matched conditional logistic regression analyses, adjusted for established environmental risk factors and socioeconomic status (if relevant in univariate screening),± genetic risk factors, in the KPNC cohort and, for purposes of replication, separately in the Swedish Epidemiological Investigation of MS cohort. These variables were also assessed in models stratified by HLA-DRB1*15:01 status since interactions between risk factors and that haplotype have been described.

RESULTS

There was a suggestive association of pesticide exposure with having MS among men, but only in those who were positive for HLA-DRB1*15:01 (OR pooled = 3.11, 95% CI 0.87, 11.16, p = 0.08).

CONCLUSIONS

While this finding requires confirmation, it is interesting given the association between pesticide exposure and other neurological diseases. The study also demonstrates the application of LASSO to identify environmental exposures with reduced multiple statistical testing penalty. Machine learning approaches may be useful for future investigations of concomitant MS risk or prognostic factors.

The Gut Microbiome and Multiple Sclerosis

The microbiome can be defined as the sum of the microbial and host's genome. Recent information regarding this complex organ suggests that in animal models of multiple sclerosis (MS), the composition of the gut microbiome can be altered, giving rise to both the effector and regulatory phases of central nervous system (CNS) demyelination. Experimental findings during the past decade in animal models of MS have provided clear evidence for the significant role of gut microbes in both the effector and regulatory phase of this condition. There is mounting evidence in preliminary human studies suggesting that a dysbiotic MS gut microbiome could affect disease progression. We propose considering the gut microbiome as a key organ for the regulation of tolerance mechanisms and speculate that the gut microbiome is the major environmental risk factor for CNS demyelinating disease. Accordingly, we hypothesize that intervention of the gut microbiome could result in safer novel therapeutic strategies to treat MS.

Caring for Women with Multiple Sclerosis Across the Lifespan

PURPOSE OF REVIEW

Caring for women with multiple sclerosis (MS), whose first symptoms typically begin during the childbearing years, requires a comprehensive approach to management across a range of reproductive exposures, and beyond through menopause.

RECENT FINDINGS

This article summarizes what is known about the disease course in women with MS, how it differs from men, and the current state of knowledge regarding effects of reproductive exposures (menarche, childbearing, menopause) on MS-related inflammation and neurodegeneration. Recent findings regarding pregnancy-associated relapses in the treatment era, protective effects of breastfeeding, and care for women during the menopausal transition are reviewed. Then, updated recommendations to guiding women during childbearing-including pre-conception counseling, discontinuation of MS therapies, and management of postpartum relapses-are provided. Whenever possible, areas of uncertainty and avenues for future research are highlighted. From childhood through the postreproductive life stages, gender and hormonal exposures appear to shape an individual's risk for MS, as well as the experience of living with MS.

Multiple Sclerosis Patients with Markedly Low Intrathecal Antibody Response in Sri Lanka

Multiple sclerosis (MS) is a heterogeneous disease which is poorly studied in Asia, where the disease is known to be rare with significant differences in clinical and radiological presentations and intrathecal antibody response. Therefore the objective of this study was to determine clinical presentation, radiological and neurophysiological characteristics, and oligoclonal band status in Sri Lankan MS patients, following careful exclusion of patients with neuromyelitis optica spectrum disorders and other conditions mimicking multiple sclerosis. Sixty-nine MS patients were recruited to the study adhering to McDonald 2010 criteria. Their clinical presentation, characteristics of central nervous system lesions in magnetic resonance imaging, visual evoked potential (VEP) results, oligoclonal bands (OCB), and AQP4 antibody status were studied. Of 69 MS patients, 54%, 6%, and 1% were relapsing remitting, secondary progressive, and primary progressive, respectively, and 39% were patients with clinically isolated syndrome. The commonest clinical presentations were cerebral motor followed by cerebral sensory and optic neuritis. Majority had typical periventricular and infratentorial lesions in MRI. Though not clinically apparent, bilateral delay of P100 wave latency was present in 52%. OCB positivity was 42% and AQP4 antibody was positive in only one patient. In conclusion, this group of Sri Lankan MS patients shares most of the clinical and radiological features of Caucasian MS patients. However, the OCB positivity is lower in this group, when compared to the Caucasian MS populations.

Sex ratio in multiple sclerosis mortality over 65 years; an age-period-cohort analysis in Norway

Increasing female: male ratio in multiple sclerosis (MS) has been assigned to cohort effects, with females in more recent birth cohorts possibly being more exposed or vulnerable to environmental risk factors than males. We collected MS mortality data in Norway from 1951 to 2015 from The Norwegian Cause of Death registry. Age-Period-Cohort analysis was conducted using log-linear Poisson models, including sex interaction terms. MS was registered as the underlying, contributing or direct cause in 6060 deaths. MS associated mortality remained stable with a slight preponderance among males until after 1980, and have since increased preferentially among females. Throughout the study period the mean annual increase was 1.25% for females and 0.3% for males (p < 0.0001). Age-period-cohort analysis revealed limited evidence of cohort effects for the gender differences; the best fitting model only included gender-age and gender-period interaction terms. The period effect evened out for males in the last three decades but increased for females, especially among the oldest age-groups. In conclusion, the increased female: male mortality ratio in MS associated mortality is driven mainly by increased mortality among females in the three last decades, particularly in the older age groups. It is best explained by disproportional period effects, providing evidence of time-varying external factors including improved access to diagnosis among females.

Exploring cued and non-cued motor imagery interventions in people with multiple sclerosis: a randomised feasibility trial and reliability study

Background

Motor imagery (MI) is increasingly used in neurorehabilitation to facilitate motor performance. Our previous study results demonstrated significantly improved walking after rhythmic-cued MI in people with multiple sclerosis (pwMS). The present feasibility study was aimed to obtain preliminary information of changes in walking, fatigue, quality of life (QoL) and MI ability following cued and non-cued MI in pwMS. The study further investigated the feasibility of a larger study and examined the reliability of a two-dimensional gait analysis system.

Methods

At the MS-Clinic, Department of Neurology, Medical University of Innsbruck, Austria, 15 adult pwMS (1.5–4.5 on the Expanded Disability Status Scale, 13 females) were randomised to one of three groups: 24 sessions of 17 min of MI with music and verbal cueing (MVMI), with music alone (MMI), or non-cued (MI). Descriptive statistics were reported for all outcomes. Primary outcomes were walking speed (Timed 25-Foot Walk) and walking distance (6-Minute Walk Test). Secondary outcomes were recruitment rate, retention, adherence, acceptability, adverse events, MI ability (Kinaesthetic and Visual Imagery Questionnaire, Time-Dependent MI test), fatigue (Modified Fatigue Impact Scale) and QoL (Multiple Sclerosis Impact Scale-29). The reliability of a gait analysis system used to assess gait synchronisation with music beat was tested.

Results

Participants showed adequate MI abilities. Post-intervention, improvements in walking speed, walking distance, fatigue, QoL and MI ability were observed in all groups. Success of the feasibility criteria was demonstrated by recruitment and retention rates of 8.6% (95% confidence interval, CI 5.2, 13.8%) and 100% (95% CI 76.4, 100%), which exceeded the target rates of 5.7% and 80%. Additionally, the 83% (95% CI 0.42, 0.99) adherence rate surpassed the 67% target rate. Intra-rater reliability analysis of the gait measurement instruments demonstrated excellent Intra-Class Correlation coefficients for step length of 0.978 (95% CI 0.973, 0.982) and step time of 0.880 (95% CI 0.855, 0.902).

Conclusion

Results from our study suggest that cued and non-cued MI are valuable interventions in pwMS who were able to imagine movements. A larger study appears feasible, however, substantial improvements to the methods are required such as stratified randomisation using a computer-generated sequence and blinding of the assessors.

Trial registration

ISRCTN ISRCTN92351899. Registered 10 December 2015.

Electronic supplementary material

The online version of this article (10.1186/s40945-018-0045-0) contains supplementary material, which is available to authorized users.

Management of multiple sclerosis patients in central European countries: current needs and potential solutions

Multiple sclerosis (MS) experts in Europe are facing rapidly rising demands of excellence due to the increasing complexity of MS therapy and management. A central European expert board of MS experts met to identify needs and obstacles with respect to raising quality of MS care in central and Eastern European countries. There are substantial variations across countries regarding delivery of care and its cost structure, as well as access to treatment. To date, Eastern European countries are often less able to afford reimbursement of immunomodulatory agents than Western countries. Overall, approximately 40% of working-age patients are not working due to MS. Costs rise steeply with increasing disability; indirect costs constitute the bulk of the financial burden in patients with severe MS. Magnetic resonance imaging (MRI) assessment is meanwhile obligatory as the diagnostic interface in the management of MS patients. Recommended measures directed at improving quality of care include the collection of patient data in registries, enhanced education of healthcare professionals, implementation of national strategies aiming at reducing regional variation, optimization of approval processes, and removal of administrative barriers. Local partnerships with authorities such as those that represent the interests of employees can contribute to leverage the importance of epidemiological data. The need for education extends to (neuro)radiologists who are responsible for reporting MRI findings in expert quality. Dissemination of the Magnetic Resonance Imaging in MS (MAGNIMS) protocol would be an important step in this context. Also, clinical freedom of choice is rated as essential. Physicians should have access to a range of treatment options due to the complexity of disease. Guidelines such as the upcoming EAN-ECTRIMS clinical practice guideline also aim at providing a basis for argumentation in negotiations with national health authorities.

Mapping of thalamic magnetic susceptibility in multiple sclerosis indicates decreasing iron with disease duration: A proposed mechanistic relationship between inflammation and oligodendrocyte vitality

Recent advances in susceptibility MRI have dramatically improved the visualization of deep gray matter brain regions and the quantification of their magnetic properties in vivo, providing a novel tool to study the poorly understood iron homeostasis in the human brain. In this study, we used an advanced combination of the recent quantitative susceptibility mapping technique with dedicated analysis methods to study intra-thalamic tissue alterations in patients with clinically isolated syndrome (CIS) and multiple sclerosis (MS). Thalamic pathology is one of the earliest hallmarks of MS and has been shown to correlate with cognitive dysfunction and fatigue, but the mechanisms underlying the thalamic pathology are poorly understood. We enrolled a total of 120 patients, 40 with CIS, 40 with Relapsing Remitting MS (RRMS), and 40 with Secondary Progressive MS (SPMS). For each of the three patient groups, we recruited 40 controls, group matched for age- and sex (120 total). We acquired quantitative susceptibility maps using a single-echo gradient echo MRI pulse sequence at 3 T. Group differences were studied by voxel-based analysis as well as with a custom thalamus atlas. We used threshold-free cluster enhancement (TFCE) and multiple regression analyses, respectively. We found significantly reduced magnetic susceptibility compared to controls in focal thalamic subregions of patients with RRMS (whole thalamus excluding the pulvinar nucleus) and SPMS (primarily pulvinar nucleus), but not in patients with CIS. Susceptibility reduction was significantly associated with disease duration in the pulvinar, the left lateral nuclear region, and the global thalamus. Susceptibility reduction indicates a decrease in tissue iron concentration suggesting an involvement of chronic microglia activation in the depletion of iron from oligodendrocytes in this central and integrative brain region. Not necessarily specific to MS, inflammation-mediated iron release may lead to a vicious circle that reduces the protection of axons and neuronal repair.

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.

Hormones and MS: Risk factors, biomarkers, and therapeutic targets

Sex differences in epidemiological, clinical, and pathological features of multiple sclerosis (MS) have been observed for decades, establishing a foundation for more recent progress in our understanding of their overall impact on the disease. In the ACTRIMS session on Hormones, Sex Chromosomes, and MS: Risk Factors, Biomarkers, and Therapeutic Targets, this progress was summarized in three presentations by pioneers in the field, revealing evidence that sex chromosomes, epigenetic factors, and sex hormones function as interactive determinants of disease risk and phenotype in a fashion dependent upon life stage, from prenatal development, childhood, and adolescence to adulthood and aging. Implications for the effects of puberty, pregnancy, menopause, and andropause on autoimmune and neurodegenerative mechanisms were discussed, along with potential applications of exogenous hormones. Although several limitations in current approaches and concepts were noted, current insights pave the way for future progress in our understanding of this enigmatic disease

Increasing Incidence and Prevalence of Multiple Sclerosis in Puerto Rico (2013-2016)

BACKGROUND

The incidence of multiple sclerosis (MS) has been increasing worldwide over the past decades. However, this upward trend has not been examined at the country level in Latin America and the Caribbean (LAC). The aims of this study are to examine trends of MS incidence over 4 years and to provide age- and gender-standardized incidence rate estimates for a Caribbean island.

METHODS

Data from the Puerto Rico (PR) MS Foundation's registry was used to identify all newly diagnosed MS cases between 2013 and 2016. MS patients were 18 years and older and met the 2010 revised McDonald criteria. Age- and gender-standardized incidence rates were estimated.

RESULTS

A total of 583 new MS cases were diagnosed in PR from 2013 to 2016. The age- and gender-standardized MS incidence rate for PR increased from 6.1/100,000 in 2013 to 6.7/100,000 in 2016. The annual age-standardized MS incidence rates for females rose from 8.4/100,000 in 2013 to 9.8/100,000 in 2016 and were higher than males, which remained around 3.7/100,000.

CONCLUSION

Incidence estimates for PR were higher than other LAC countries but consistent with MS increases in other world regions. Our findings tend to rule out several prior potential environmental explanations for high MS incidence rates.

Do gait patterns differ in men and women with multiple sclerosis?

BACKGROUND

Multiple Sclerosis (MS) affects men and women differently from several points of view: prevalence, severity of cognitive impairments and disability accumulation. However, it is unknown whether ambulatory dysfunctions are sex-related. This study investigated the existence of differences in spatio-temporal and kinematic parameters of gait in men and women with MS using 3D gait analysis.

METHODS

Gait patterns of 60 people with MS (pwMS, 32F, 28M) with low to moderate disability (average Expanded Disability Status Scale score 3, range 1-5.5) who underwent a gait analysis in the period 2014-2017 were retrospectively analyzed to calculate spatio-temporal parameters of gait and kinematics in the sagittal plane at hip, knee and ankle joints.

RESULTS

Significant differences between the groups were found in kinematics of gait. In particular, men exhibited reduced ankle plantar-flexion, increased knee flexion and hip flexion. In contrast, no differences were found in spatio-temporal parameters normalized by considering individuals' anthropometry.

CONCLUSIONS

The findings of the present study highlight the need to investigate gait dysfunctions in pwMS taking sex into consideration. Such an approach might be useful not only in better understanding the pathophysiology of gait disturbances originated by MS, but also in supporting a better orientation of rehabilitative treatments.