Temporal trends in the incidence of multiple sclerosis: a systematic review

Environmental control of autoimmune inflammation in the central nervous system

Multiple sclerosis (MS) is a chronic autoimmune inflammatory demyelinating disorder of the central nervous system (CNS), which causes severe disability and requires extensive medical attention and treatment. While the infiltration of pathogenic immune cells into the CNS leads to the formation of inflammatory lesions in its initial relapsing-remitting stage, late stages of MS are characterized by progressive neuronal loss and demyelination even without continued interaction with the peripheral immune compartment. Several genetic and environmental factors modulate and influence these processes on multiple levels. Genetic variants confer a predisposition for the development of MS, but are not accessible to therapeutic intervention as of today. However, migration studies suggest that environmental factors influence disease development, activity and progression. This article reviews mechanisms of disease pathogenesis in MS and their modulation by environmental factors such as geographical localization, the gut microbiome and the diet.

Emerging pathogenic links between microbiota and the gut-lung axis

The microbiota is vital for the development of the immune system and homeostasis. Changes in microbial composition and function, termed dysbiosis, in the respiratory tract and the gut have recently been linked to alterations in immune responses and to disease development in the lungs. In this Opinion article, we review the microbial species that are usually found in healthy gastrointestinal and respiratory tracts, their dysbiosis in disease and interactions with the gut-lung axis. Although the gut-lung axis is only beginning to be understood, emerging evidence indicates that there is potential for manipulation of the gut microbiota in the treatment of lung diseases.

The absence of 25-hydroxyvitamin D3-1α-hydroxylase potentiates the suppression of EAE in mice by ultraviolet light

Ultraviolet B (UVB) light suppresses the development of multiple sclerosis (MS) in patients and experimental autoimmune encephalomyelitis (EAE) in mice. Although vitamin D3 is produced by ultraviolet light, the suppression of EAE by narrow band UVB (NBUVB) is independent of vitamin D3. However, it is possible that the NBUVB suppression of EAE can be further influenced by 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3). We used NBUVB lamps (10KJ/m(2)) to irradiate both wild type (WT) and 1α-hydroxylase knockout mice (CYP27B1 KO) that were then induced to develop EAE. There was a complete elimination of EAE development by NBUVB in the KO mice. On the other hand, the NBUVB treatment of WT mice reduced but did not eliminate the severity or incidence of EAE. This suggests that the presence of 1,25-dihydroxyvitamin D3 actually counteracts the suppressive effect of NBUVB. In support of this concept, cytokines (IFN-γ, IL-10) and chemokine (CCL-5) mRNA in spinal cord were reduced in wild type or eliminated in the KO mice by the NBUVB. Cytokine mRNA levels in the spinal cord correlated with clinical scores in both WT and KO mice.

Ongoing increase in incidence and prevalence of multiple sclerosis in Newcastle, Australia: A 50-year study

BACKGROUND

Since 1959, multiple sclerosis (MS) prevalence has been estimated for the east coast Australian city of Newcastle. Previous surveys, conducted in 1988 and 2003, have described an increase in the prevalence and incidence of MS.

OBJECTIVES

In this study, we evaluated whether these trends continue and provide 50 years of MS epidemiological follow-up for this southern hemisphere city.

METHODS

Expressed per 100,000 people, prevalence of MS in Newcastle was calculated for those with a confirmed diagnosis of MS on 9 August 2011 and incidence based on the number of cases with MS diagnosis made during the preceding decade. Data were age-standardised to the total Australian population. Statistical comparisons were undertaken using Poisson regression analysis.

RESULTS

In 2011, the estimate of MS prevalence was 124.2, with female-to-male ratio reaching 3.1, a 53% increase in female predominance since 1996. MS incidence increased to 6.7, with a significantly higher proportion of new female cases since the previous survey.

CONCLUSION

Prevalence of MS in Newcastle has risen linearly and is contributed to by a substantial increase in new cases over the preceding decade. Female predominance of MS cases continues to increase with a new diagnosis three times more likely in women.

Is Geo-Environmental Exposure a Risk Factor for Multiple Sclerosis? A Population-Based Cross-Sectional Study in South-Western Sardinia

Background

South-Western Sardinia (SWS) is a high risk area for Multiple Sclerosis (MS) with high prevalence and spatial clustering; its population is genetically representative of Sardinians and presents a peculiar environment. We evaluated the MS environmental risk of specific heavy metals (HM) and geographical factors such as solar UV exposure and urbanization by undertaking a population-based cross-sectional study in SWS.

Methods

Geochemical data on HM, UV exposure, urbanization and epidemiological MS data were available for all SWS municipalities. Principal Component Analysis (PCA) was applied to the geochemical data to reduce multicollinearity and confounding criticalities. Generalized Linear Mixed Models (GLMM) were applied to evaluate the causal effects of the potential risk factors, and a model selection was performed using Akaike Information Criterion.

Results

The PCA revealed that copper (Cu) does not cluster, while two component scores were extracted: 'basic rocks', including cobalt, chromium and nickel, and 'ore deposits', including lead and zinc. The selected multivariable GLMM highlighted Cu and sex as MS risk factors, adjusting for age and 'ore deposits'. When the Cu concentration increases by 50 ppm, the MS odds are 2.827 (95% CI: 1.645; 5.07) times higher; females have a MS odds 2.04 times (95% CI: 1.59; 2.60) higher than males.

Conclusions

The high frequency of MS in industrialized countries, where pollution by HM and CO poisoning is widespread, suggests a relationship between environmental exposure to metals and MS. Hence, we suggested a role of Cu homeostasis in MS. This is a preliminary study aimed at generating hypotheses that will need to be confirmed further.

Advancing drug delivery systems for the treatment of multiple sclerosis

Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease of the central nervous system. It is characterized by demyelination of neurons and loss of neuronal axons and oligodendrocytes. In MS, auto-reactive T cells and B cells cross the blood-brain barrier (BBB), causing perivenous demyelinating lesions that form multiple discrete inflammatory demyelinated plaques located primarily in the white matter. In chronic MS, cortical demyelination and progressive axonal transections develop. Treatment for MS can be stratified into disease-modifying therapies (DMTs) and symptomatic therapy. DMTs aim to decrease circulating immune cells or to prevent these cells from crossing the BBB and reduce the inflammatory response. There are currently 10 DMTs approved for the relapsing forms of MS; these vary with regard to their efficacy, route and frequency of administration, adverse effects, and toxicity profile. Better drug delivery systems are being developed in order to decrease adverse effects, increase drug efficacy, and increase patient compliance through the direct targeting of pathologic cells. Here, we address the uses and benefits of advanced drug delivery systems, including nanoparticles, microparticles, fusion antibodies, and liposomal formulations. By altering the properties of therapeutic particles and enhancing targeting, breakthrough drug delivery technologies potentially applicable to multiple disease treatments may rapidly emerge.

Diffusion tensor imaging of occult injury of optic radiation following optic neuritis in multiple sclerosis

Multiple sclerosis (MS) is easily detected by routine magnetic resonance imaging (MRI). However, it is not possible to detect early or occult lesions in MS by routine MRI, and this may explain the inconsistency between the severity of the lesions found by MRI and the degree of clinical disability of patients with MS. The present study included 10 patients with relapsing-remitting MS and 10 healthy volunteers. Each patient underwent routine 3.0 T MRI, diffusion tensor imaging (DTI), and diffusion tensor tractography (DTT). Optic nerve and optic radiation were analyzed by DTI and DTT. The fractional anisotropy (FA), mean diffusivity (MD), λ_//, and λ_┴ values were measured. In the 10 patients with MS, 7 optic nerves were affected, and 13 optic nerves were not affected. Cranial MRI showed that optic nerve thickening and hyperintensity occurred in 2 patients with MS. In the directionally encoded color maps, a hypointensive green signal in the optic nerve was observed in 3 patients with MS. The FA values were significantly lower and the MD, λ_//, and λ_┴ values were significantly higher in the affected and unaffected optic nerves and optic radiations in patients with MS in comparison with controls (P<0.05). There were no significant differences in these values between the affected and unaffected optic nerves and optic radiation in patients with MS (P>0.05). Diffusion tensor imaging is sensitive in the detection of occult injury of the optic nerve and optic radiation following optic neuritis. Diffusion tensor imaging may be a useful tool for the early diagnosis, treatment and management of MS.

Effect of interferon-β1α therapy on multiple sclerosis based on gadolinium-enhancing or active T2 magnetic resonance imaging outcomes: a meta-analysis

OBJECTIVES

Interferon-beta1alpha (IFN-β1α) is widely used to modify the course of relapsing-remitting multiple sclerosis. However, many patients have relapses. The purpose of this study was to evaluate magnetic resonance imaging (MRI) as a predictor of IFN-β1α treatment efficacy in patients with MS.

METHODS

PubMed, Embase, and the Cochrane Library were searched to identify eligible studies. Manual searches were also conducted. All eligible trials included MS patients who received IFN-β1α based on gadolinium-enhancing or active T2 MRI lesions for determination of relapse rates.

RESULTS

Of 499 identified studies, we included 10 trials reporting data on 6,037 MS patients. IFN-β1α therapy significantly reduced the risk of relapse (RR: 0.87; 95% confidence intervals (CI): 0.76-0.99; p = 0.032). Furthermore, baseline median T2 lesion volume was found to be related to IFN-β1α therapy and relapse (p = 0.018). Subgroup analysis suggested that IFN-β1α therapy was associated with reduced risk of relapse (RR: 0.82; 95%CI: 0.71-0.94; p = 0.005 versus placebo). However, there was no significant difference in the risk of relapse compared to treatment with low dose IFN-β1α (RR: 0.93; 95%CI: 0.80-1.08; p = 0.337) or glatiramer acetate (RR: 0.93; 95%CI: 0.77-1.14; p = 0.506). Finally, IFN-β1α therapy significantly increased the risk of injection-site disorders, influenza-like syndrome, and alanine transferase elevation.

DISCUSSION

Effects of IFN-β1α therapy are associated with a statistically significant impact on baseline median T2 lesion volume. However, the safety outcomes are significantly worse in patients who receive IFN-β1α therapy.

Barriers experienced by patients with multiple sclerosis in seeking care for lower urinary tract symptoms

AIM

The Actionable Bladder Symptom and Screening Tool (ABSST) is used to identify multiple sclerosis (MS) patients in possible need of evaluation for urinary symptoms. The primary objective of this study was to identify barriers experienced by MS patients in seeking evaluation for urinary symptoms. We also assessed the utility of ABSST tool in identifying patients that will follow up with urologic evaluation.

METHODS

This was a prospective observational study where 100 patients with MS were enrolled from an MS center. Patients completed demographic information, questions to assess barriers to care, a short form of the ABSST, and incontinence questionnaires. An ABSST score >3 met criteria for referral and evaluation. One year after enrollment, follow up calls assessed whether patients had seen a urinary specialist.

RESULTS

The most common barriers to seeking care included "Doctor never referred" (16%) and "Doctor never asked" (13%). Thirty-eight percent (n = 8/21) of men stated "Doctor never referred" compared to 10% (n = 8/79) of women (P = 0.002). Twenty-seven patients had an ABSST Score ≥3 and were more interested in seeing a specialist compared to those scoring <3 (88.9%, n = 24/27 vs. 26%, n = 19/73; P = <0.001). After 1 year, 70 patients were reached for follow up. A total of 57.9% (n = 11/19) patients who followed up for evaluation screened positive on the ABSST.

CONCLUSIONS

The ABSST is a valuable tool to identify MS patients with urinary symptoms who will likely follow up for genitourinary evaluation. However, other barriers beyond awareness exist and prevent patients from being evaluated.

Multiple sclerosis: Pregnancy and women's health issues

BACKGROUND

The course of multiple sclerosis (MS) is influenced by sex, pregnancy and hormonal factors.

AIMS

To analyse the influence of the above factors in order to clarify the aetiopathogenic mechanisms involved in the disease.

METHODS

We conducted a comprehensive review of scientific publications in the PubMed database using a keyword search for 'multiple sclerosis', 'MS', 'EAE', 'pregnancy', 'hormonal factors', 'treatment', and related terms. We reviewed the advances presented at the meeting held by the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) in March 2013 in London, as well as recommendations by international experts.

RESULTS AND CONCLUSIONS

We provide recommendations for counselling and treating women with MS prior to and during pregnancy and after delivery. Current findings on the effects of treatment on the mother, fetus, and newborn are also presented. We issue recommendations for future research in order to address knowledge gaps and clarify any inconsistencies in currently available data.

Prevalence and incidence of multiple sclerosis in central Poland, 2010-2014

Background

Comprehensive epidemiologic data for multiple sclerosis (MS) in Poland are limited. The aim of this cross-sectional population-based study was to determine the incidence and prevalence of MS in the Swietokrzyskie Region (central Poland).

Methods

This study identified MS cases every year between 1 January 2010 and 31 December 2014. The study area population on the prevalence day (December 31, 2014) was 1,263,176 (646,506 women and 616,670 men). A total of 1462 patients with a clinically definite diagnosis of MS according to McDonald’s criteria (2005), recorded in the Polish Multiple Sclerosis Registry, were considered for estimation of crude, age- and sex-specific prevalence, and incidence.

Results

The overall crude prevalence rate of confirmed MS patients was 115.7/100,000 (95 % confidence interval (CI), 111.2–121.4). A significantly higher prevalence was recorded in females (159.6/100,000; 95 % CI, 151.1–165.3) than in males (69.7/100,000; 95 % CI, 62.4–77.3) (P < 0.001). Age-adjusted rates for the Polish and European Standard Population were 109.8/100,000 (95 % CI, 105.4–114.8) and 106.6/100,000 (95 % CI, 101.1–111.2), respectively. The female/male ratio was 2.4. The mean annual incidence was 4.2/100,000 (95 % CI. 3.7–4.4).

Conclusion

The incidence and prevalence of MS in the Swietokrzyskie region confirm that central Poland is a high risk area for MS. Compared with previous epidemiologic studies from Poland, the prevalence of MS has increased during recent years.

Risk factors in multiple sclerosis: a population-based case-control study in Sicily. Background and methods

Incidence of multiple sclerosis (MS) has steeply increased over time during the last 30 years in the city of Catania. We carried out a population-based case-control study to evaluate the possible role of both environmental and genetic factors. From 1975 to 2004 in Catania, 367 MS patients diagnosed according to the Poser's criteria had the onset of disease. A sample of MS patients was randomly selected from this incident cohort. Three controls matched by age and sex were randomly selected from the rosters of 14 GPs. Controls were proportionally selected according to the distribution by municipality of the target population using a multistage sampling methods. All cases and controls underwent a face-to-face interview to record information concerning environmental factors and a blood sample was taken for serological and genetic analysis. 164 MS patients (64 % women; mean age of 46.4 ± 10.7) and 481 controls (69 % women; mean age of 47.7 ± 14.8) were enrolled in the study. The distribution of the whole population and the selected controls by municipalities was similar. A blood sample was taken from 150 MS cases and from 337 controls. At the end of the enrolment, we obtained a representative sample of the MS cases and population controls avoiding possible selection bias. Participation rate was very high also concerning the collection of biological specimens.

Estrogens, Neuroinflammation, and Neurodegeneration

Inflammatory activation of microglia is a hallmark of several disorders of the central nervous system. In addition to protecting the brain against inflammatory insults, microglia are neuroprotective and play a significant role in maintaining neuronal connectivity, but the prolongation of an inflammatory status may limit the beneficial functions of these immune cells. The finding that estrogen receptors are present in monocyte-derived cells and that estrogens prevent and control the inflammatory response raise the question of the role that this sex steroid plays in the manifestation and progression of pathologies that have a clear sex difference in prevalence, such as multiple sclerosis, Parkinson's disease, and Alzheimer's disease. The present review aims to provide a critical review of the current literature on the actions of estrogen in microglia and on the involvement of estrogen receptors in the manifestation of selected neurological disorders. This current understanding highlights a research area that should be expanded to identify appropriate replacement therapies to slow the progression of such diseases.

The efficacy and safety of teriflunomide based therapy in patients with relapsing multiple sclerosis: A meta-analysis of randomized controlled trials

The aim of this study was to evaluate the efficacy and safety of teriflunomide in reducing the frequency of relapses and progression of physical disability in patients with relapsing multiple sclerosis (RMS). Literatures were searched in Pubmed, Medline and Embase to screen citations from January 1990 to April 2015. Studies of parallel group design comparing teriflunomide and placebo for RMS were screened. After independent review of 234 citations by two authors, seven studies were identified as meeting the inclusion criteria. The results showed teriflunomide (7 and 14mg) could significantly reduce annualized relapse rate and teriflunomide at the higher dose could also decrease the disability progression (risk ratio (RR)=0.69, 95% confidence interval (CI): 0.55-0.87). And teriflunomide significantly reduce annualized rates of relapses with sequelae-EDSS/FS, relapses leading to hospitalization, and relapses requiring IV corticosteroids. Patients treated with teriflunomide 14mg have a lower annualized rate of relapses with sequelae-investigator (RR=0.37, 95% CI: 0.26-0.52). Teriflunomide 7mg has a higher incidence of diarrhea (RR=1.73, 95% CI: 1.32-2.26) and hair thinning (RR=1.99, 95% CI: 1.4-2.81), while teriflunomide 14mg has a higher incidence of diarrhea (RR=1.71, 95% CI: 1.34-2.18), hair thinning (RR=2.81, 95% CI: 2.02-3.91) and nausea (RR=1.65, 95% CI: 1.03-2.31) compared with placebo. The incidence of elevated alanine aminotransferase levels was also higher with teriflunomide than with placebo. However, the incidence of serious adverse events was similar across groups. In conclusion, teriflunomide significantly reduces annualized relapse rates and disability progression with a similar safety and tolerability profile to placebo.

Neurology of Pregnancy: A Case-Oriented Review

The anatomic and physiologic changes that occur during pregnancy are unique. A neurologist needs to be aware of normal pregnancy-induced physiologic changes in the cardiovascular, renal, hematologic, and autoimmune systems, and the local anatomic changes, which include alteration of body habitus and pelvic ligaments. These changes are clearly advantageous, but in certain circumstances may predispose to pathology. In addition, pregnancy effects treatment of chronic neurologic conditions as regards medication safety and metabolism. This case-oriented review discusses the important aspects of pregnancy physiology and an approach to treatment of common disorders encountered during pregnancy including stroke, multiple sclerosis, epilepsy, and compression neuropathies.

How global MS prevalence is changing: A retrospective chart review in the United Arab Emirates

BACKGROUND

Multiple Sclerosis (MS) is an autoimmune disorder leading to central nervous system inflammation. Traditionally, reported MS prevalence rates in the Middle East are low. Few studies include age/sex standardization giving an unreliable estimate of regional prevalence.

OBJECTIVE

to determine the prevalence, incidence and characteristics of MS in Abu Dhabi, United Arab Emirates.

METHODS

A retrospective chart review was conducted at the four largest hospitals in Abu Dhabi Emirate between 2010 and 2014. Data collected included MS type, age and symptoms at onset, expanded disability status scale, treatment, laboratory findings and family history.

RESULTS

510 patients were identified consisting of 318 (62.2%) Emiratis and 192 (37.6%) expatriates. Total crude prevalence rate was 18/100,000 (95% CI: 10-30/100,000). Crude prevalence rate in Emiratis was 57.09 (95% CI:50 to 63/100,000) but increased to 64.44 (95% CI: 57 to 72/100,000) when age standardized. Age-standardized incidence rate in Emiratis was 6.0 MS cases per 100,000 person-years (95% CI: 5.5 to 6.5 cases per 100,000 person-years).

CONCLUSION

At 64.44/100,000, the Abu Dhabi Emirati population has one of the highest, most reliable prevalence rate on the Arab peninsula. Age/sex standardized prevalence rates, uncommonly reported in the Middle East, should be standard for all prevalence studies.

Dietary Inflammatory Index and Risk of Multiple Sclerosis in a Case-Control Study from Iran

BACKGROUND

Diet and inflammation have been suggested to be important risk factors for multiple sclerosis (MS).

OBJECTIVES

In this study, we examined the ability of the dietary inflammatory index (DII) to predict MS in a case-control study conducted in Iran.

METHODS

This study included 68 MS cases and 140 controls hospitalized for acute non-neoplastic diseases. The DII was computed based on dietary intake assessed by a previously validated food frequency questionnaire. Logistic regression models were used to estimate ORs adjusted for age, energy, sex, body mass index, season of birth, rubella history, history of routine exercise before MS, smoking and history of consumption of cow's milk in the first 2 years of life.

RESULTS

Subjects with higher DII scores (i.e., with a more pro-inflammatory diet) had a higher risk of MS, with the DII being used both as a continuous variable (ORcontinuous 1.66; 95% CI 1.19-2.31; 1 unit increase corresponding to ≈15% of its range in the current study) and a categorical variable (ORDII (>1.43 vs.≤1.43) 2.68; 95% CI 1.15-6.26).

CONCLUSIONS

These results indicate that a pro-inflammatory diet is associated with increased risk of MS.

Sunshine, Sea, and Season of Birth: MS Incidence in Wales

Maternal sun exposure in gestation and throughout the lifetime is necessary for vitamin D synthesis, and living near the sea is a population level index of seafood consumption. The aim of this study was to estimate the incidence rate of multiple sclerosis (MS) in Wales and examine its association with sun exposure, coastal living, and latitude. The study used a database of MS hospital visits and admissions in Wales between 2002 and 2013. For the 1,909 lower layer super output areas (LSOAs) in Wales, coastal status, population, longitude/latitude, and average sunshine hours per day were obtained. Age-specific and age-standardised MS incidence were calculated and modelled using Poisson regression. The distribution of births by month was compared between MS cases and the combined England and Wales population. There were 3,557 new MS cases between 2002 and 2013, with an average annual incidence of 8.14 (95% CI: 7.69–8.59) among males and 12.97 (95% CI: 12.44–13.50) among females per 100,000 population. The female-to-male ratio was 1.86:1. For both sexes combined, the average annual incidence rate was 9.10 (95% CI: 8.80–9.40). All figures are age-standardized to the 1976 European standard population. Compared to the combined England and Wales population, more people with MS were born in April, observed-to-expected ratio: 1.21 (95% CI: 1.08–1.36). MS incidence varied directly with latitude and inversely with sunshine hours. Proximity to the coast was associated with lower MS incidence only in easterly areas. This study shows that MS incidence rate in Wales is comparable to the rate in Scotland and is associated with environmental factors that probably represent levels of vitamin D.

The Association Between Genetic Polymorphism rs703842 in CYP27B1 and Multiple Sclerosis: A Meta-Analysis

Multiple sclerosis (MS) is the most frequent nontraumatic disabling neurological disease among young adults. Previous studies have examined the association of rs703842 in CYP27B1 with MS susceptibility, with inconsistent results reported.The objective of this study is to conduct a systematic literature search and perform meta-analyses to examine whether rs703842 is associated with MS risk.We searched potential literature in PubMed, Cochrane Library, Embase, Google Scholar, Web of Science, and HuGE by using the following inclusion criteria: studies were on human subjects; the studies were case-control studies; studies included subjects who had MS and those who did not have MS; and the studies provided genotype data for rs703842 for subjects who had and did not have MS, or provided odds ratios (ORs) and the 95% confidence intervals (CIs) for assessing the association of rs703842 with MS, or provided sufficient data for the calculation of OR and the 95% CI. We used random-effects models to calculate the OR as a measure of association. We used I to assess between-study heterogeneity, and a funnel plot and Egger test to assess publication bias.Seven studies published since 2008 met the eligibility criteria and were included in the meta-analyses. We found that the C allele was significantly associated with reduced MS susceptibility (OR = 0.88, 95% CI: 0.80-0.89; P < 0.0001). We also found significant association of rs703842 with MS risk using a dominant and a recessive model (both P < 0.0002). Our results remain unchanged if our meta-analysis was limited to studies that included only Caucasian participants (OR = 0.85, 95% CI: 0.80-0.90; P < 0.0001).Our study has several limitations: The sample size is limited; We were unable to control for some important confounding factors as data for individual participant were not available; and Most of the included studies focus on MS risk in Caucasian. As a result, we could not perform meta-analysis for assessing the relationship in other ethnic groups.In summary, we found that the genetic variant rs703842 in CYP27B1 is associated with MS risk in Caucasians. More studies with larger sample size that control for important confounding factors are needed to validate the findings from this study.

VHA Multiple Sclerosis Surveillance Registry and its similarities to other contemporary multiple sclerosis cohorts

The Veterans Health Administration (VHA) has provided important contributions to our understanding of multiple sclerosis (MS); however, the characteristics of the modern VHA MS population have not been adequately characterized. Our objectives were to compare and contrast characteristics of the VHA MS population with other contemporary MS cohorts. A cross-sectional, mail-based survey of a stratified, random sample of 3,905 VHA users with MS was conducted. Detailed demographic and clinical data were collected as well as patient-reported outcomes assessing disability and quality of life. A total of 1,379 Veterans were enrolled into the MS Surveillance Registry (MSSR). Respondents did not differ from nonrespondents with regard to demographics or region. When compared to several other contemporary MS cohorts, some demographic differences were noted; however, the age of MS onset and diagnosis, subtype distribution, and most prevalent symptoms were very similar across MS cohorts. The MSSR appears to be representative of the general MS population. Combining the extensive VHA health services encounter data with the MSSR provides a rich and unique cohort for study.

Fingolimod for relapsing-remitting multiple sclerosis

BACKGROUND

Fingolimod was approved in 2010 for the treatment of patients with the relapsing-remitting (RR) form of multiple sclerosis (MS). It was designed to reduce the frequency of exacerbations and to delay disability worsening. Issues on its safety and efficacy, mainly as compared to other disease modifying drugs (DMDs), have been raised.

OBJECTIVES

To assess the safety and benefit of fingolimod versus placebo, or other disease-modifying drugs (DMDs), in reducing disease activity in people with relapsing-remitting multiple sclerosis (RRMS).

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System (CNS) Group's Specialised Trials Register and US Food and Drug Administration reports (15 February 2016).

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing the beneficial and harmful effects of fingolimod versus placebo or other approved DMDs in people with RRMS.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

Six RCTs met our selection criteria. The overall population included 5152 participants; 1621 controls and 3531 treated with fingolimod at different doses; 2061 with 0.5 mg, 1376 with 1.25 mg, and 94 with 5.0 mg daily. Among the controls, 923 participants were treated with placebo and 698 with others DMDs. The treatment duration was six months in three, 12 months in one, and 24 months in two trials. One study was at high risk of bias for blinding, three studies were at high risk of bias for incomplete outcome reporting, and four studies were at high risk of bias for other reasons (co-authors were affiliated with the pharmaceutical company). We retrieved 10 ongoing trials; four of them have been completed.Comparing fingolimod administered at the approved dose of 0.5 mg to placebo, we found that the drug at 24 months increased the probability of being relapse-free (risk ratio (RR) 1.44, 95% confidence interval (CI) (1.28 to 1.63); moderate quality of evidence), but it might lead to little or no difference in preventing disability progression (RR 1.07, 95% CI 1.02 to 1.11; primary clinical endpoints; low quality evidence). Benefit was observed for other measures of inflammatory disease activity including clinical (annualised relapse rate): rate ratio 0.50, 95% CI 0.40 to 0.62; moderate quality evidence; and magnetic resonance imaging (MRI) activity (gadolinium-enhancing lesions): RR of being free from (MRI) gadolinium-enhancing lesions: 1.36, 95% CI 1.27 to 1.45; low quality evidence.The mean change of MRI T2-weighted lesion load favoured fingolimod at 12 and 24 months.No significant increased risk of discontinuation due to adverse events was observed for fingolimod 0.5 mg compared to placebo at six and 24 months. The risk of fingolimod discontinuation was significantly higher compared to placebo for the dose 1.25 mg at 24 months (RR 1.93, 95% CI 1.48 to 2.52).No significant increased risk of discontinuation due to serious adverse events was observed for fingolimod 0.5 mg compared to placebo at six and 24 months. A significant increased risk of discontinuation due to serious adverse events was found for fingolimod 5.0 mg (RR 2.77, 95% CI 1.04 to 7.38) compared to placebo at six months.Comparing fingolimod 0.5 mg to intramuscular interferon beta-1a, we found moderate quality evidence that the drug at one year slightly increased the number of participants free from relapse (RR 1.18, 95% CI 1.09 to 1.27) or from gadolinium-enhancing lesions (RR 1.12, 95% CI 1.05 to 1.19), and decreased the relapse rate (rate ratio 0.48, 95% CI 0.34 to 0.70). We did not detect any advantage for preventing disability progression (RR 1.02, 95% CI 0.99 to 1.06; low quality evidence). We did not detect any significant difference for MRI T2-weighted lesion load change.We found a greater likelihood of participants discontinuing fingolimod, as compared to other DMDs, due to adverse events in the short-term (six months) (RR 3.21, 95% CI 1.16 to 8.86), but there was no significant difference versus interferon beta-1a at 12 months (RR 1.51, 95% CI 0.81 to 2.80; moderate quality evidence). A higher incidence of adverse events was suggestive of the lower tolerability rate of fingolimod compared to interferon-beta 1a.Quality of life was improved in participants after switching from a different DMD to fingolimod at six months, but this effect was not found compared to placebo at 24 months.All studies were sponsored by Novartis Pharma.

AUTHORS' CONCLUSIONS

Treatment with fingolimod compared to placebo in RRMS patients is effective in reducing inflammatory disease activity, but it may lead to little or no difference in preventing disability worsening. The risk of withdrawals due to adverse events requires careful monitoring of patients over time. The evidence on the risk/benefit profile of fingolimod compared with intramuscular interferon beta-1a was uncertain, based on a low number of head-to-head RCTs with short follow-up duration. The ongoing trial results will possibly satisfy these issues.

The role of adenosine and adenosine receptors in the immunopathogenesis of multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a heterogeneous neurological disorder with multifactorial etiologies characterized by demyelination, axonal degeneration, and oligodendroglial death. It is believed that both genetics and environmental risk factors such as infection are involved in disease etiology. Accumulating evidence indicates that alteration in purinergic system signaling is involved in immunity and inflammation. Adenosine, a key purine nucleoside, has been shown to be produced during metabolic stress, including ischemia, inflammatory condition, and tissue injury.

METHODS

Extracellular adenosine directly affects various physiological and pathological processes of MS by stimulating G protein-coupled adenosine receptors A1, A2A, A2B, and A3 on the surface of immune cells. It has been suggested that promotion of adenosinergic system may be an important factor in MS pathophysiology and considered as promising therapeutic target for this disease.

CONCLUSION

In this review, we will discuss about the immunopathologic effects of adenosine on MS and its animal model, experimental autoimmune encephalomyelitis.

Structural Brain Network Characteristics Can Differentiate CIS from Early RRMS

Focal demyelinated lesions, diffuse white matter (WM) damage, and gray matter (GM) atrophy influence directly the disease progression in patients with multiple sclerosis. The aim of this study was to identify specific characteristics of GM and WM structural networks in subjects with clinically isolated syndrome (CIS) in comparison to patients with early relapsing-remitting multiple sclerosis (RRMS). Twenty patients with CIS, 33 with RRMS, and 40 healthy subjects were investigated using 3 T-MRI. Diffusion tensor imaging was applied, together with probabilistic tractography and fractional anisotropy (FA) maps for WM and cortical thickness correlation analysis for GM, to determine the structural connectivity patterns. A network topology analysis with the aid of graph theoretical approaches was used to characterize the network at different community levels (modularity, clustering coefficient, global, and local efficiencies). Finally, we applied support vector machines (SVM) to automatically discriminate the two groups. In comparison to CIS subjects, patients with RRMS were found to have increased modular connectivity and higher local clustering, highlighting increased local processing in both GM and WM. Both groups presented increased modularity and clustering coefficients in comparison to healthy controls. SVM algorithms achieved 97% accuracy using the clustering coefficient as classifier derived from GM and 65% using WM from probabilistic tractography and 67% from modularity of FA maps to differentiate between CIS and RRMS patients. We demonstrate a clear increase of modular and local connectivity in patients with early RRMS in comparison to CIS and healthy subjects. Based only on a single anatomic scan and without a priori information, we developed an automated and investigator-independent paradigm that can accurately discriminate between patients with these clinically similar disease entities, and could thus complement the current dissemination-in-time criteria for clinical diagnosis.

The multiple sclerosis susceptibility genes TAGAP and IL2RA are regulated by vitamin D in CD4+ T cells

Multiple sclerosis (MS) is an inflammatory, demyelinating disorder of the central nervous system that develops in genetically susceptible individuals. The majority of the MS-associated gene variants are located in genetic regions with importance for T-cell differentiation. Vitamin D is a potent immunomodulator, and vitamin D deficiency has been suggested to be associated with increased MS disease susceptibility and activity. In CD4+ T cells, we have analyzed in vitro vitamin D responsiveness of genes that contain an MS-associated single-nucleotide polymorphism (SNP) and with one or more vitamin D response elements in their regulatory regions. We identify IL2RA and TAGAP as novel vitamin D target genes. The vitamin D response is observed in samples from both MS patients and controls, and is not dependent on the genotype of MS-associated SNPs in the respective genes.

Systematic Review of Correlates and Determinants of Physical Activity in Persons With Multiple Sclerosis

OBJECTIVE

To review the current evidence regarding correlates and determinants of physical activity (PA) in persons with multiple sclerosis (pwMS).

DATA SOURCES

PubMed and Scopus (1980 to January 2015) and reference lists of eligible studies.

STUDY SELECTION

Eligible studies include adults with multiple sclerosis; have a cross-sectional or prospective observational design; or examine the effect of a theory-based intervention trial on PA, including a mediation analysis. Eligible studies also apply a quantitative assessment of PA and correlates or proposed mediators and are published in English or German language.

DATA EXTRACTION

Two reviewers independently evaluated the risk of bias, extracted data, and categorized variables according to the International Classification of Functioning, Disability and Health.

DATA SYNTHESIS

Consistency and the direction of associations were evaluated with a semiquantitative approach. Fifty-six publications with data from observational studies and 2 interventional studies provided evidence for 86 different variables. Consistent correlates of PA were the disability level, walking limitations in particular, PA-related self-efficacy, self-regulation constructs, employment status, and educational level. One interventional study provided evidence for a causal relation between self-regulation and PA. However, 59 of the 86 investigated variables in observational studies are based on 1 or 2 study findings, and most results stem from cross-sectional designs.

CONCLUSIONS

Beside the importance of the general disability level and walking limitations, the results highlight the importance of personal factors (eg, PA-related self-efficacy, self-regulatory constructs, sociodemographic factors). Limitations and implications of the current review are discussed. Research that is more rigorous is needed to better understand what affects PA in pwMS.

The impact of persistence with therapy on inpatient admissions and emergency room visits in the US among patients with multiple sclerosis

OBJECTIVE

Disease-modifying therapy (DMT) for multiple sclerosis (MS) can reduce relapses and delay progression; however, poor adherence and persistence with DMT can result in sub-optimal outcomes. The associations between DMT adherence and persistence and inpatient admissions and emergency room (ER) visits were investigated.

METHODS

Patients with MS who initiated a DMT in a US administrative claims database were followed for 1 year. Persistence to initiated DMT was measured as the time from DMT initiation to discontinuation (a gap of >60 days without drug 'on hand') or end of 1-year follow-up. Adherence to initiated DMT was measured during the persistent period and was operationalized as the medication possession ratio (MPR). Patients with an MPR <0.80 were considered non-adherent. Claims during the 1-year follow-up period were evaluated for the presence of an all-cause inpatient admission or an ER visit. Adjusted odds ratios (AORs) for inpatient admission or ER visit comparing persistent vs non-persistent and adherent vs non-adherent patients were estimated using logistic regression models adjusted for patient characteristics.

RESULTS

The final sample included 16,218 patients. During the 1-year follow-up period, 35.3% of patients discontinued their initiated DMT and 13.9% were not adherent while on therapy. During that same period, 10.0% of patients had an inpatient admission and 24.9% had an ER visit. The likelihoods of inpatient admission and ER visit were significantly decreased in persistent patients (AOR [95% CI] = 0.50 [0.45, 0.56] and 0.65 [0.60, 0.69], respectively) and in adherent patients (AOR [95% CI] = 0.83 [0.71, 0.97] and 0.86 [0.77, 0.95], respectively).

CONCLUSIONS

Persistence and adherence with initiated DMT are associated with decreased likelihoods of inpatient admission or ER visit, which may translate to improved clinical outcomes.

Application of laser radiation and magnetostimulation in therapy of patients with multiple sclerosis

BACKGROUND

Multiple sclerosis is one of the most common neurological disorders. It is a chronic inflammatory demyelinating disease of the CNS, whose etiology is not fully understood. Application of new rehabilitation methods are essential to improve functional status.

OBJECTIVE

The material studied consisted of 120 patients of both sexes (82 women and 38 men) aged 21-81 years. The study involved patients with a diagnosis of multiple sclerosis. The aim of the study was to evaluate the effect of laser radiation and other therapies on the functional status of patients with multiple sclerosis.

METHODS

Patients were randomly divided into four treatment groups. The evaluation was performed three times - before the start of rehabilitation, immediately after rehabilitation (21 days of treatment) and subsequent control - 30 days after the patients leave the clinic. The following tests were performed for all patients to assess functional status: Expanded Disability Status Scale (EDSS) of Kurtzke and Barthel Index.

RESULTS

Results of all testing procedures show that the treatment methods are improving the functional status of patients with multiple sclerosis, with the significant advantage of the synergistic action of laser and magneto stimulation. The combination of laser and magneto stimulation significantly confirmed beneficial effect on quality of life. The results of these studies present new scientific value and are improved compared to program of rehabilitation of patients with multiple sclerosis by laser radiation which was previously used.

CONCLUSIONS

This study showed that synergic action of laser radiation and magneto stimulation has a beneficial effect on improving functional status, and thus improves the quality of life of patients with multiple sclerosis. The effects of all methods of rehabilitation are persisted after cessation of treatment applications, with a particular advantage of the synergistic action of laser radiation and magneto stimulation, which indicates the possibility to elicitation in these methods the phenomenon of the biological hysteresis.

Virus-Induced Demyelination: The Case for Virus(es) in Multiple Sclerosis

Multiple Sclerosis (MS) is the most common demyelinating disease of man with over 400,000 cases in the United States and over 2.5 million cases worldwide. There are over 64,000 citations in Pubmed dating back as far as 1887. Much has been learned over the past 129 years with a recent burst in therapeutic options (mostly anti-inflammatory) with newer medications in development that are neuroprotective and/or neuroreparative. However, with all these advancements the cause of MS remains elusive. There is a clear interplay of genetic, immunologic, and environmental factors that influences both the development and progression of this disorder. This chapter will give a brief overview of the history and pathogenesis of MS with attention to how host immune responses in genetically susceptible individuals contribute to the MS disease process. In addition, we will explore the role of infectious agents in MS as potential “triggers” of disease. Models of virus-induced demyelination will be discussed, with an emphasis on the recent interest in human herpesviruses and the role they may play in MS disease pathogenesis. Although we remain circumspect as to the role of any microbial pathogen in MS, we suggest that only through well-controlled serological, cellular immune, molecular, and animal studies we will be able to identify candidate agents. Ultimately, clinical interventional trials that either target a specific pathogen or class of pathogens will be required to make definitive links between the suspected agent and MS.

"Central vessel sign" on 3T FLAIR* MRI for the differentiation of multiple sclerosis from migraine

OBJECTIVE

The diagnosis of multiple sclerosis (MS) presently relies on radiographic assessments of imperfect specificity. Recent data using T2* methodology for the detection of the "central vessel sign" (CVS) in MS lesions suggests this novel MRI technique may distinguish MS from other disorders. Our aim was to determine if evaluation for CVS on 3T FLAIR* MRI differentiates MS from migraine.

METHODS

Patients with MS or migraine and a prior brain MRI demonstrating at least two hyperintense lesions ≥3 mm were recruited. Exclusion criteria included any additional comorbidity known to cause brain MRI abnormalities. 3T MRI was performed in each participant with administration of gadopentetate dimeglumine, and FLAIR* images were generated in postprocessing. The total number of discrete ovoid lesions ≥3 mm were counted on FLAIR, per participant, and subsequently evaluated for presence of CVS on FLAIR*. An exploratory method evaluating for CVS in a maximum of 12 lesions per subject was also completed.

RESULTS

Ten participants with MS and 10 with migraine completed the study. The median percentage (quartiles) of lesions in MS participants with CVS was 84 (79, 94) compared to 22 (15, 54) in migraine (P = 0.008). In a subanalysis by brain region, in the subcortical and deep white matter, the median percentage (quartiles) of lesions in MS participants with CVS was 88 (81, 100) compared to 19 (11, 54) in migraine (P = 0.004). This difference was not identified in juxtacortical, periventricular, or infratentorial regions.

INTERPRETATION

Identification of CVS using FLAIR* on 3T MRI helps differentiate MS from migraine, particularly in the subcortical and deep white matter.

Melatonin Lulling Th17 Cells to Sleep

In this issue, Farez et al. report that the circadian hormone melatonin, whose levels vary with seasonal changes in night length, shifts the immune response toward an anti-inflammatory state that may explain the seasonal variability of multiple sclerosis disease activity.

Genes and Environment in Multiple Sclerosis project: A platform to investigate multiple sclerosis risk

The Genes and Environment in Multiple Sclerosis project establishes a platform to investigate the events leading to multiple sclerosis (MS) in at-risk individuals. It has recruited 2,632 first-degree relatives from across the USA. Using an integrated genetic and environmental risk score, we identified subjects with twice the MS risk when compared to the average family member, and we report an initial incidence rate in these subjects that is 30 times greater than that of sporadic MS. We discuss the feasibility of large-scale studies of asymptomatic at-risk subjects that leverage modern tools of subject recruitment to execute collaborative projects.

Dimethyl fumarate in relapsing-remitting multiple sclerosis: rationale, mechanisms of action, pharmacokinetics, efficacy and safety

Dimethyl fumarate (DMF), a fumaric acid ester, is a new orally available disease-modifying agent that was recently approved by the US FDA and the EMA for the management of relapsing forms of multiple sclerosis (MS). Fumaric acid has been used for the management of psoriasis, for more than 50 years. Because of the known anti-inflammatory properties of fumaric acid ester, DMF was brought into clinical development in MS. More recently, neuroprotective and myelin-protective mechanism actions have been proposed, making it a possible candidate for MS treatment. Two Phase III clinical trials (DEFINE, CONFIRM) have evaluated the safety and efficacy of DMF in patients with relapsing-remitting MS. Being an orally available agent with a favorable safety profile, it has become one of the most commonly prescribed disease-modifying agents in the USA and Europe.

Multiple sclerosis increases the risk of venous thromboembolism: a nationwide cohort analysis

OBJECTIVES

The purpose of this study was to evaluate the effects of multiple sclerosis (MS) on the risk of venous thromboembolism (VTE) development.

METHODS

We identified patients diagnosed with MS in Taiwan between 1998 and 2010 using the National Health Insurance Research Database and the Catastrophic Illness Patient Database (RCIPD). Each MS patient was frequency matched to 4 controls according to age, sex and the year of MS registration to the RCIPD. Patients with a history of VTE and incomplete information of age and sex were excluded. All patients were followed up from the index year until VTE diagnosis, loss to follow-up or the end of 2010. We calculated the hazard ratios (HRs) and 95% confidence intervals (CIs) of VTE in the MS and comparison cohorts using Cox proportional hazards regression models.

RESULTS

We followed up 1238 MS patients and 4952 comparison patients for approximately 6437 and 27 595 person-years, respectively. After adjusting for age, sex and comorbidities, the MS patients exhibited a 6·87-fold increased risk of VTE compared with the control patients. Women with MS were associated with an 11·1-fold increased risk of VTE development compared with the non-MS women (95% CI: 2·70-45·5). The MS patients aged < 50 years exhibited a 14·8-fold increased risk of developing VTE compared with age-matched patients in the comparison cohort (95% CI: 2·99-73·4). The risk of VTE development increased with the duration of hospitalization stay.

CONCLUSION

MS patients are associated with significantly greater risk of developing VTE compared with non-MS patients.

Increasing prevalence of multiple sclerosis in Västerbotten County of Sweden

OBJECTIVES

To update the incidence and prevalence of multiple sclerosis (MS) in Västerbotten County, Sweden, and to compare this to previous investigations in the same area.

BACKGROUND

Northern Sweden is a high-risk area for developing MS. Västerbotten County has previously been surveyed in detail regarding the occurrence of MS. In several countries, increases in MS prevalence and incidence as well as a change in the sex ratio have been reported.

MATERIALS AND METHODS

Multiple sources were used to identify MS cases in Västerbotten that either had their onset of the disease from 1998 to 2010 and/or lived in Västerbotten, the two dates chosen for prevalence calculation: the 31st of December 2005 and 2010.

RESULTS

The mean yearly incidence of MS in Västerbotten during the entire period 1998-2010 was 6.0/100,000. The female to male ratio was 2.1. The prevalence of MS in Västerbotten was 188/100,000 on 31st of December 2005 and 215/100,000 on 31st of December 2010. The MS prevalence increased over time from 1990 to 2010.

CONCLUSIONS

The prevalence of MS in Västerbotten County has increased between 1990 and 2010, while no statistically significant increase in incidence was seen.

The epidemiology of multiple sclerosis in the Isle of Man: 2006-2011

BACKGROUND

We sought to determine the prevalence of MS on the Isle of Man in 2006 and 2011, and the incidence and mortality rates over this interval.

METHODS

Cases were identified by hospital medical record review, General Practitioners and the local MS Society. The significance of the change in prevalence over time and the significance of differences in frequencies by sex and place of birth were assessed by Poisson regression.

RESULTS

The 2006 prevalence was 153.64 per 100,000 persons and the 2011 prevalence was 179.89. The prevalence was higher among females and persons born in the Isle of Man at both time points. The 2006-2011 incidence rate was 6.86 per 100,000 person-years, much higher among females and persons born in the Isle of Man. The prevalence sex ratios in 2006 and 2011, 2.77 and 2.59, respectively, and the incidence sex ratio, 2.19, are similar to others found in the region. The mortality rate over the study period was 2.84 per 100,000 person-years, this solely among persons born overseas.

CONCLUSIONS

This is the first study of MS epidemiology in the Isle of Man, finding this area to be of high prevalence and to have one of the highest incidence rates in the UK region.

Sodium chloride promotes pro-inflammatory macrophage polarization thereby aggravating CNS autoimmunity

The increasing incidence in Multiple Sclerosis (MS) during the last decades in industrialized countries might be linked to a change in dietary habits. Nowadays, enhanced salt content is an important characteristic of Western diet and increased dietary salt (NaCl) intake promotes pathogenic T cell responses contributing to central nervous system (CNS) autoimmunity. Given the importance of macrophage responses for CNS disease propagation, we addressed the influence of salt consumption on macrophage responses in CNS autoimmunity. We observed that EAE-diseased mice receiving a NaCl-high diet showed strongly enhanced macrophage infiltration and activation within the CNS accompanied by disease aggravation during the effector phase of EAE. NaCl treatment of macrophages elicited a strong pro-inflammatory phenotype characterized by enhanced pro-inflammatory cytokine production, increased expression of immune-stimulatory molecules, and an antigen-independent boost of T cell proliferation. This NaCl-induced pro-inflammatory macrophage phenotype was accompanied by increased activation of NF-kB and MAPK signaling pathways. The pathogenic relevance of NaCl-conditioned macrophages is illustrated by the finding that transfer into EAE-diseased animals resulted in significant disease aggravation compared to untreated macrophages. Importantly, also in human monocytes, NaCl promoted a pro-inflammatory phenotype that enhanced human T cell proliferation. Taken together, high dietary salt intake promotes pro-inflammatory macrophages that aggravate CNS autoimmunity. Together with other studies, these results underline the need to further determine the relevance of increased dietary salt intake for MS disease severity.

Evidence for the Importance of Vitamin D Status in Neurologic Conditions

OPINION STATEMENT

Vitamin D status has been proposed as relevant to many neurological disorders. Data suggest that vitamin D may be important for the development of the nervous system, and it also plays a role in neuroimmunology and neuroprotection. Lower levels of circulating 25-hydroxyvitamin D have been linked with increased risk of multiple sclerosis (MS) and Alzheimer's disease (AD). While people with amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD), and stroke have lower vitamin D levels than those without the diseases, it is unclear if this is because hypovitaminosis D contributes to disease risk or is a consequence of immobility and other factors caused by the disease. Lower levels of vitamin D have been associated with worse prognosis in MS, PD, ALS, and stroke, while no longitudinal studies have been performed to evaluate such an association in AD. Small pilot trials have been performed to evaluate vitamin D supplementation for some of these diseases, but there have been no phase III studies to support vitamin D supplementation in these patient populations; further, ideal levels of 25-hydroxyvitamin D are not known. Thus, while some expert panels or individuals have suggested routine testing and supplementation for patients with these neurological conditions, it is our opinion that there are currently insufficient data to support high-dose vitamin D supplementation to specifically treat or prevent these conditions.

Sodium channel blockers for neuroprotection in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an autoimmune, inflammatory, demyelinating disease of the central nervous system (CNS), which can occur in many parts of the CNS and result in a wide range of symptoms including sensory impairment, fatigue, walking or balance problems, visual impairment, vertigo and cognitive disabilities. At present, the most commonly used MS treatments are immunomodulating agents, but they have little effect on the disability. Experimental studies show that sodium (Na(+)) accumulation leads to intracellular calcium (Ca(2+)) release, and the increased calcium levels can activate nitric oxide synthase and harmful proteases and lipases. These factors contribute to axonal injury in people with MS. If partial blockade of voltage-gated sodium channels could result in neuroprotection, this would be of benefit for preventing disability progression in these people. Neuroprotection is emerging as a potentially important strategy for preventing disability progression in people with MS.

OBJECTIVES

To assess the efficacy and safety of sodium channel blockers for neuroprotection in people with MS to prevent the occurrence of disability and alleviate the burden of the disease.

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register (27 August 2015) which, among other sources, contains references from the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2015, Issue (8), MEDLINE (1966 to August 2015), EMBASE (1974 to August 2015), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1981 to August 2015), Latin American and Caribbean Health Science Information Database (LILACS) (1982 to August 2015), ClinicalTrials.gov (http://clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Portal (ICTRP) search portal (http://apps.who.int/trialsearch). In addition, we searched four Chinese databases, ongoing trials registers and relevant reference lists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that examined sodium channel blockers used alone or as an add-on to any approved treatments for MS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality and extracted the data.

MAIN RESULTS

Only one study evaluating lamotrigine in secondary progressive MS was eligible. One hundred and twenty people were included, 61 randomly assigned to lamotrigine treatment and 59 to placebo treatment. The average age of participants in the two groups was 51.9 years and 50.1 years, respectively. The proportion of male participants was 27.5%. The period of follow-up was 2 years. No data were found on disability progression and people who experienced relapses. No significant differences were found for serious adverse events between the two groups. Treatment with lamotrigine was associated with more rashes (20% vs 5%, P value 0.03) and transient, dose-related deterioration of mobility (66% vs 34%, P value 0.001) than placebo. Furthermore, no significant difference between the two groups was found in the magnetic resonance imaging (MRI) measurements of cerebral atrophy, Expanded Disability Status Score changes, Multiple Sclerosis Functional Composite score changes. This study was judged to be at high risk of bias. This review will be updated when the three ongoing studies we identified are completed.

AUTHORS' CONCLUSIONS

The quality of evidence was judged to be very low due to the low number of available studies and included participants. There is a lack of evidence to address the review question on the efficacy of sodium channel blockers for people with MS. Assessment of the three ongoing trials might change this conclusion. Further high-quality large scale studies are needed.

Editorial note

No update planned, no new version forthcoming.

Prevalence and Incidence of Multiple Sclerosis in Fars Province, Southern Iran

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory and demyelinating disease of the central nervous system, which is accompanied by significant disabilities. Although there are some published data regarding the epidemiological features of MS in other parts of Iran, scarce data are available about the prevalence and demographic characteristics of MS in Fars province. The current study aimed to address the prevalence and incidence rate of MS as well as the temporal trend of the disease in Fars province, southern Iran.

METHODS

This historical retrospective cohort study was carried out in Fars Multiple Sclerosis Society affiliated with Shiraz University of Medical Sciences. All the consecutive patients who fulfilled 2010 McDonald criteria for definite MS were included in the study. The patients' gender, age at time of diagnosis, education, and clinical course were recorded. The prevalence and incidence rates were also calculated.

RESULTS

This study was conducted on 3,354 patients. Among the patients, 2,689 (80.2%) were female and 665 (19.8%) were male. The female/male ratio was 4.04. The point prevalence rate of the disease was 72.1/100,000 persons in October 2013. This index was 116.5 per 100,000 persons in females (95% CI: 113.4-119.6) and 28.3 per 100,000 persons in males (95% CI: 26.8-29.9). The mean annual incidence rate was 5.2/100,000 from 2002 until 2012.

CONCLUSION

Considering Kurtzke classification, Fars is a high-risk area for MS and women are affected more compared with men. Moreover, the incidence rate sharply increased in the last decade.

Long-term epidemiology of multiple sclerosis in the Northern Seville District

OBJECTIVES

Comprehensive epidemiologic data for multiple sclerosis (MS) in Spain are limited. The aim of this study was to collect epidemiologic data on MS in the Northern Seville District of Spain.

MATERIALS AND METHODS

This longitudinal study identified possible MS cases every year from nine centres between 1 January 1991 and 31 December 2011. Patients with a confirmed diagnosis of MS were included. MS data prior to enrolment were collected retrospectively from clinical records and prospectively during quarterly follow-up clinic visits. Variables included age at onset, age at diagnosis, treatment, follow-up duration, number of visits, number of relapses, change in the number of relapses over time and Expanded Disability Status Scale score. The incidence and prevalence of MS rate were calculated.

RESULTS

Overall, 156 patients with MS were identified (111 females; mean follow-up 7.5 years). Most patients had relapsing-remitting MS (73.7%); primary progressive disease was less frequent than secondary disease (10.9% vs 15.4%). The yearly incidence of MS was 4.6 per 100,000, and the prevalence at 31 December 2011 was 90.2 per 100,000.

CONCLUSIONS

The annual MS incidence rate in this southern region of Spain was higher than previously reported rates in Spanish studies.