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Sharmin S, Roos I, Malpas CB, Iaffaldano P, Simone M, Filippi M, Kubala Havrdova E, Ozakbas S, Brescia Morra V, Alroughani R, Zaffaroni M, Patti F, Eichau S, Salemi G, Di Sapio A, Inglese M, Portaccio E, Trojano M, Amato MP, Kalincik T. Disease-modifying therapies in managing disability worsening in paediatric-onset multiple sclerosis: a longitudinal analysis of global and national registries. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:348-357. [PMID: 38547883 DOI: 10.1016/s2352-4642(24)00047-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND High-efficacy disease-modifying therapies have been proven to slow disability accrual in adults with relapsing-remitting multiple sclerosis. However, their impact on disability worsening in paediatric-onset multiple sclerosis, particularly during the early phases, is not well understood. We evaluated how high-efficacy therapies influence transitions across five disability states, ranging from minimal disability to gait impairment and secondary progressive multiple sclerosis, in people with paediatric-onset multiple sclerosis. METHODS Longitudinal data were obtained from the international MSBase registry, containing data from people with multiple sclerosis from 151 centres across 41 countries, and the Italian Multiple Sclerosis and Related Disorders Register, containing data from people with multiple sclerosis from 178 Italian multiple sclerosis centres. People younger than 18 years at the onset of multiple sclerosis symptoms were included, provided they had a confirmed diagnosis of relapsing-remitting multiple sclerosis and at least four Expanded Disability Status Scale (EDSS) scores recorded within 12-month intervals. The primary outcome was the time to change in disability state: minimal disability (EDSS scores 0, 1·0, and 1·5), mild disability (EDSS scores 2·0 and 2·5), moderate disability (EDSS scores 3·0 and 3·5), gait impairment (EDSS scores ≥4·0), and clinician diagnosed secondary progressive multiple sclerosis. A multi-state model was constructed to simulate the natural course of multiple sclerosis, modelling the probabilities of both disability worsening and improvement simultaneously. The impact of high-efficacy disease-modifying therapies (alemtuzumab, cladribine, daclizumab, fingolimod, mitoxantrone, natalizumab, ocrelizumab, rituximab, or autologous haematopoietic stem cell transplantation) and low-efficacy disease-modifying therapies (dimethyl fumarate, glatiramer acetate, interferon beta, or teriflunomide), compared with no treatment, on the course of disability was assessed. Apart from recruitment, individuals with lived experience of multiple sclerosis were not involved in the design and conduct of this study. FINDINGS A total of 5224 people (3686 [70·6%] female and 1538 [29·4%] male) with mean age at onset of multiple sclerosis 15·24 years (SD 2·52) were included. High-efficacy therapies reduced the hazard of disability worsening across the disability states. The largest reduction (hazard ratio 0·41 [95% CI 0·31-0·53]) was observed in participants who were treated with high-efficacy therapies while in the minimal disability state, compared with those remained untreated. The benefit of high-efficacy therapies declined with increasing disability. Young people with minimal disability who received low-efficacy therapy also experienced a reduced hazard (hazard ratio 0·65 [95% CI 0·54-0·77]) of transitioning to mild disability, in contrast to those who remained untreated. INTERPRETATION Treatment of paediatric-onset relapsing-remitting multiple sclerosis with high-efficacy therapy substantially reduces the risk of reaching key disability milestones. This reduction in risk is most pronounced among young people with minimal or mild disability when treatment began. Children with relapsing-remitting multiple sclerosis should be treated early with high-efficacy therapy, before developing significant neurological impairments, to better preserve their neurological capacity. FUNDING National Health and Medical Research Council, Australia; MSBase Foundation Fellowship; MS Australia Postdoctoral Fellowship.
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Affiliation(s)
- Sifat Sharmin
- CORe, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Izanne Roos
- CORe, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Charles B Malpas
- CORe, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Pietro Iaffaldano
- Centro SM Dipartimento di Scienze Mediche di Base, Neuroscienze ed Organi di Senso Universita' di Bari, Bari, Italy
| | - Marta Simone
- Pediatric MS Center, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Massimo Filippi
- Neurology Unit and MS Center, Neurorehabilitation Unit, Neurophysiology Service, and Neuroimaging Research Unit, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Serkan Ozakbas
- Izmir University of Economics, Medical Point Hospital, Izmir, Turkey
| | - Vincenzo Brescia Morra
- Unità Operativa Semplice Dipartimentale Sclerosi Multipla - AOU Policlinico Federico II, Naples, Italy
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Mauro Zaffaroni
- Centro Sclerosi Multipla, ASST Della Valle Olona, Ospedale Di Gallarate, Gallarate VA, Italy
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy; Multiple Sclerosis Centre, AOU Policlinico G Rodolico-San Marco, University of Catania, Catania, Italy
| | - Sara Eichau
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Giuseppe Salemi
- Centro Per La Diagnosi E Cura Della SM E Delle Malattie Demielinizzanti - Dipt Radiologia Diagnostica, Interventistica e Stroke, AOUP P Giaccone di Palermo, Palermo, Italy
| | - Alessia Di Sapio
- SCDO Neurologia, Centro Di Riferimento Regionale Sclerosi Multipla (CReSM)-AOU San Luigi, Turin, Italy
| | - Matilde Inglese
- Centro Per Lo Studio E La Cura Della Sclerosi Multipla E Malattie Demielinizzanti - Dipartimento Di Neuroscienze, Riabilitazione, Oftalmologia, Genetica E Scienze Materno, Infantili, Clinica Neurologica, Ospedale Policlinico San Martino (DiNOGMI), Genova, Italia
| | - Emilio Portaccio
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Maria Trojano
- School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Maria Pia Amato
- Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Tomas Kalincik
- CORe, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia.
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Wilson E, Howard D, Daniel D, Taylor L, Gorman MP, Benson LA. Disease modifying treatment for pediatric onset multiple sclerosis: Ethical considerations and strategies to navigate parental refusal. Mult Scler Relat Disord 2023; 79:104970. [PMID: 37690437 DOI: 10.1016/j.msard.2023.104970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Elizabeth Wilson
- Boston Children's Hospital, Department of Neurology 300 Longwood Avenue, Boston, MA 02115, United States; Massachusetts General Brigham Hospital, Department of Neurology 55 Fruit Street, Boston, MA 02114, United States.
| | - Danielle Howard
- Massachusetts General Brigham Hospital, Department of Neurology 55 Fruit Street, Boston, MA 02114, United States
| | - Dennis Daniel
- Boston Children's Hospital, Critical care medicine 300 Longwood Avenue, Boston, MA 02115, United States
| | - Lisa Taylor
- Boston Children's Hospital, Office of Ethics 300 Longwood Avenue, Boston, MA 02115, United States
| | - Mark P Gorman
- Boston Children's Hospital, Department of Neurology 300 Longwood Avenue, Boston, MA 02115, United States
| | - Leslie A Benson
- Boston Children's Hospital, Department of Neurology 300 Longwood Avenue, Boston, MA 02115, United States
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Alkolfat F, Said S, Mekky J, Eldeeb H. What an adult multiple sclerosis registry can tell us about pediatric onset multiple sclerosis? Mult Scler Relat Disord 2023; 79:104962. [PMID: 37714097 DOI: 10.1016/j.msard.2023.104962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/05/2023] [Accepted: 08/28/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Multiple Sclerosis (MS) is an immune-mediated, chronic disease of the central nervous system that affects mainly adults. However, it is increasingly recognized that MS may start in childhood resulting in a relentlessly progressive disability and cognitive impairment. Registries across the globe are reporting inconstant data about their Pediatric-Onset Multiple Sclerosis (POMS) patients. Moreover, newer lines of treatments are emerging and showing efficacy in controlling the MS disease regardless of the onset. Therefore, there is a requirement for more research into the clinical profile of POMS in different populations and ethnicities. METHODS This study was a cross-sectional study that included MS patients who visited the MS unit at Alexandria University from January 2019 to January 2021. We analyzed their epidemiological, clinical, radiological data, and cerebrospinal fluid (CSF) results from their updated records as well as follow-up interviews. RESULTS Annual Relapse Rate (ARR) was marginally less in POMS than AOMS (0.72 ± 0.57 vs 1.04 ± 0.78 relapse/year, P =.008). POMS patients had a bigger gap to their first relapse (40.0 ± 47.35 vs 22.71 ± 34.33 months, p= .066). The difference in relapse rate between the two groups was abolished after the exclusion of patients who had a gap of more than 5 years to their first relapse. AOMS patients were significantly more likely to start with a second-line disease-modifying treatment (DMT) than POMS patients (11.5% vs 31%, p= .04), whereas POMS patients were more likely to be escalated to the second line (34.6% vs 19.3%, p= .07). ARR had a positive and significant correlation with expanded disability status scale (EDSS) progression per year (rs(24)= .57 p=.003). A Mann-Whitney test indicated that POMS patients who had infratentorial involvement in the initial MRI brain had higher EDSS (3.08 ± 1.99) than POMS who did not (1.07 ± 0.79) U=24 P =.013. IgG index had a significant and positive correlation with annual EDSS progression rate rs (8) = 0.8 p=.001. CONCLUSION Early disease onset does not mean a higher relapse rate when including the full spectrum of POMS and longer follow-up duration. POMS patients relapsed more on the first-line DMT and escalation should be considered early. Infratentorial involvement in the initial magnetic resonance imaging (MRI) brain and high IgG index are potential predictors for aggressive disease course in POMS.
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Affiliation(s)
- Fatma Alkolfat
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Sameh Said
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Jaidaa Mekky
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hany Eldeeb
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Moreau A, Kolitsi I, Kremer L, Fleury M, Lanotte L, Sellal F, Gaultier C, Ahle G, Courtois S, Fickl A, Mostoufizadeh S, Dentel C, Collongues N, de Seze J, Bigaut K. Early use of high efficacy therapies in pediatric forms of relapsing-remitting multiple sclerosis: A real-life observational study. Mult Scler Relat Disord 2023; 79:104942. [PMID: 37633034 DOI: 10.1016/j.msard.2023.104942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/24/2023] [Accepted: 08/12/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Pediatric forms of multiple sclerosis are more active than those in adults. Yet, the effectiveness of different therapeutic approaches is not well studied in this population. Our objective was to compare the effectiveness of the early use of high efficacy therapies (HETs) with the effectiveness of moderate efficacy therapies (METs) in children with MS. METHODS This observational study included patients diagnosed with pediatric MS, at 4 hospital centers in France, during a 10-year period. METs included: interferon β-1a, glatiramer acetate, dimethyl fumarate, teriflunomide; HETs included: fingolimod, natalizumab, ocrelizumab, alemtuzumab. The primary endpoint was the occurrence of a new relapse, the secondary endpoint was EDSS worsening. RESULTS Sixty-four patients were included in the analysis (80% women; mean age 15.5 years, 81% treated with MET) with a median follow-up of 22.5 months. At baseline, 52 patients were on MET (interferon β-1a, glatiramer acetate, dimethyl fumarate, teriflunomide) and 12 patients were on HET (natalizumab, ocrelizumab). The cumulative probability of being relapse-free at 6.5 years was 23.3% on MET, vs 90.9% on HET (p = 0.013). The cumulative probability of no EDSS worsening did not differ between the 2 groups. CONCLUSION Patients starting with METs had much higher clinical disease activity than those starting early with HETs. Rapid initiation of more aggressive treatment may allow better disease control; however, the data on EDSS worsening are not conclusive.
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Affiliation(s)
- Augustin Moreau
- Department of Neurology, Strasbourg University Hospitals, 1 avenue Molière, Strasbourg 67200, France.
| | - Ioanna Kolitsi
- Department of Neurology, Strasbourg University Hospitals, 1 avenue Molière, Strasbourg 67200, France
| | - Laurent Kremer
- Department of Neurology, Strasbourg University Hospitals, 1 avenue Molière, Strasbourg 67200, France; Clinical Investigation Center INSERM CIC 1434, Strasbourg University Hospitals, Strasbourg, France; INSERM U1119, University of Strasbourg, Strasbourg, France
| | - Marie Fleury
- Department of Neurology, Strasbourg University Hospitals, 1 avenue Molière, Strasbourg 67200, France
| | - Livia Lanotte
- Department of Neurology, Strasbourg University Hospitals, 1 avenue Molière, Strasbourg 67200, France
| | - François Sellal
- Department of Neurology, Civilian Hospitals Colmar, Colmar, France
| | - Claude Gaultier
- Department of Neurology, Civilian Hospitals Colmar, Colmar, France
| | - Guido Ahle
- Department of Neurology, Civilian Hospitals Colmar, Colmar, France
| | - Sylvie Courtois
- Department of Neurology, Mulhouse and South Alsace Region Hospital Group, Mulhouse, France
| | - Andreas Fickl
- Department of Neurology, Mulhouse and South Alsace Region Hospital Group, Mulhouse, France
| | - Sohrab Mostoufizadeh
- Department of Neurology, Mulhouse and South Alsace Region Hospital Group, Mulhouse, France
| | - Christel Dentel
- Department of Neurology, Hospital Centre Haguenau, Haguenau, France
| | - Nicolas Collongues
- Department of Neurology, Strasbourg University Hospitals, 1 avenue Molière, Strasbourg 67200, France; Clinical Investigation Center INSERM CIC 1434, Strasbourg University Hospitals, Strasbourg, France; INSERM U1119, University of Strasbourg, Strasbourg, France
| | - Jérôme de Seze
- Department of Neurology, Strasbourg University Hospitals, 1 avenue Molière, Strasbourg 67200, France; Clinical Investigation Center INSERM CIC 1434, Strasbourg University Hospitals, Strasbourg, France; INSERM U1119, University of Strasbourg, Strasbourg, France
| | - Kévin Bigaut
- Department of Neurology, Strasbourg University Hospitals, 1 avenue Molière, Strasbourg 67200, France; Clinical Investigation Center INSERM CIC 1434, Strasbourg University Hospitals, Strasbourg, France; INSERM U1119, University of Strasbourg, Strasbourg, France
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5
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Palavra F, Silva D, Fernandes C, Faustino R, Vasconcelos M, Pereira C, Costa C, Ribeiro JA, Amaral J, Robalo C. Clinical predictors of NEDA-3 one year after diagnosis of pediatric multiple sclerosis: an exploratory single-center study. Front Neurosci 2023; 17:1259306. [PMID: 37781240 PMCID: PMC10536233 DOI: 10.3389/fnins.2023.1259306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Multiple sclerosis (MS) is an inflammatory and demyelinating disorder of central nervous system that can be diagnosed in pediatric age (<18 years) in 3-5% of the cases. This early onset is associated with higher relapse rates and earlier progression to neurological disability. By using NEDA-3 (No Evidence of Disease Activity-3) criteria, we aimed to identify clinical predictors associated with absence of disease activity and control of disease progression 12 months after the diagnosis, in a cohort of pediatric-onset MS (POMS) patients regularly followed-up in our center. Methods We analyzed demographic, clinical, laboratorial and imaging variables of patients with POMS identified in our center, between 2010 and 2021, in two moments: at the diagnosis and 12 months after it. Statistical tests were applied to compare the distribution of those variables between groups defined by NEDA-3 status and by each one of its three variable components. Results We included 27 patients in the study (18 female), with a mean age of 14.8 years (± 2.8), being all diagnosed with relapsing-remitting MS and with a median score of 1.5 at the Expanded Disability Status Scale (EDSS). The use of natalizumab (p = 0.017) and the negativity for anti-EBV IgG antibodies (p = 0.018) at diagnosis were associated with a higher achievement of NEDA-3 status 12 months after, in our cohort. Prescribed treatment was also associated with statistically significant differences in the "absence of MRI activity" component of NEDA-3 (p = 0.006): patients under treatment with natalizumab had a higher probability of achieving this status, and the opposite was observed in glatiramer acetate-treated children. Discussion and conclusion Our exploratory results underline the pivotal importance that an early and more effective therapeutical approach may have in the control of disease activity, in POMS. Additionally, they also seem to suggest that the presence of anti-EBV antibodies is not innocent, as it can be related to a less favorable evolution of the disease, even at a very early stage. Further studies are needed to confirm the applicability of these variables as prognostic and personalized tools in this clinical setting.
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Affiliation(s)
- Filipe Palavra
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Laboratory of Pharmacology and Experimental Therapeutics, Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra, Coimbra, Portugal
| | - Diogo Silva
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Catarina Fernandes
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ricardo Faustino
- Ribeiro Sanches Higher School of Health, Research Group in Health Sciences and Technologies–NICiTeS, Polytechnic Institute of Lusophony (IPLuso), Lisboa, Portugal
- Portuguese Red Cross Higher Health School (ESSCVP), Lisboa, Portugal
- Biomedical Research Group (BioRG), Faculty of Engineering and Faculty of Veterinary Medicine, Lusófona University, Lisboa, Portugal
| | - Mónica Vasconcelos
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Pereira
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carmen Costa
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Afonso Ribeiro
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Amaral
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Conceição Robalo
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Bhise V, Waltz M, Casper TC, Aaen G, Benson L, Chitnis T, Gorman M, Goyal MS, Wheeler Y, Lotze T, Mar S, Rensel M, Abrams A, Rodriguez M, Rose J, Schreiner T, Shukla N, Waubant E, Weinstock-Guttman B, Ness J, Krupp L, Mendelt-Tillema J. Silent findings: Examination of asymptomatic demyelination in a pediatric US cohort. Mult Scler Relat Disord 2023; 71:104573. [PMID: 36871372 DOI: 10.1016/j.msard.2023.104573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/29/2023] [Accepted: 02/12/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Limited data is available on children with evidence of silent central nervous system demyelination on MRI. We sought to characterize the population in a US cohort and identify predictors of clinical and radiologic outcomes. METHODS We identified 56 patients such patients who presented with incidental MRI findings suspect for demyelination, enrolled through our US Network of Pediatric Multiple Sclerosis Centers, and conducted a retrospective review of 38 patients with MR images, and examined risk factors for development of first clinical event or new MRI activity. MRI were rated based on published MS and radiologically isolated syndrome (RIS) imaging diagnostic criteria. RESULTS One-third had a clinical attack and ¾ developed new MRI activity over a mean follow-up time of 3.7 years. Individuals in our cohort shared similar demographics to those with clinically definite pediatric-onset MS. We show that sex, presence of infratentorial lesions, T1 hypointense lesions, juxtacortical lesion count, and callosal lesions were predictors of disease progression. Interestingly, the presence of T1 hypointense and infratentorial lesions typically associated with worse outcomes were instead predictive of delayed disease progression on imaging in subgroup analysis. Additionally, currently utilized diagnostic criteria (both McDonald 2017 and RIS criteria) did not provide statistically significant benefit in risk stratification. CONCLUSION Our findings underscore the need for further study to determine if criteria currently used for pediatric patients with purely radiographic evidence of demyelination are sufficient.
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Affiliation(s)
- Vikram Bhise
- Robert Wood Johnson Medical - Rutgers, Pediatrics & Neurology, 89 French Street, Suite 2300, New Brunswick, NJ 08901, USA.
| | | | | | | | - Leslie Benson
- Massachusetts General Hospital, Partners Pediatric Multiple Sclerosis Center, Neurology, USA
| | | | - Mark Gorman
- Massachusetts General Hospital, Partners Pediatric Multiple Sclerosis Center, USA
| | - Manu S Goyal
- Washington University in Saint Louis, Neurology, USA
| | - Yolanda Wheeler
- The University of Alabama at Birmingham School of Medicine Tuscaloosa, Neurology, USA
| | | | - Soe Mar
- Washington University St. Louis, Neurology, USA
| | | | - Aaron Abrams
- Cleveland Clinic Neurological Institute, Pediatric Neurology, USA
| | | | | | - Teri Schreiner
- University of Colorado School of Medicine, Neurology, USA
| | | | - Emmanuelle Waubant
- University of California San Francisco, Regional Pediatric Multiple Sclerosis Center, USA
| | | | - Jayne Ness
- University of Alabama at Birmingham, Pediatrics, USA
| | - Lauren Krupp
- New York University Medical Center, Neurology, USA
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7
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Rocca MA, Valsasina P, Meani A, Gobbi C, Zecca C, Barkhof F, Schoonheim MM, Strijbis EM, Vrenken H, Gallo A, Bisecco A, Ciccarelli O, Yiannakas M, Rovira A, Sastre-Garriga J, Palace J, Matthews L, Gass A, Eisele P, Lukas C, Bellenberg B, Margoni M, Preziosa P, Filippi M. Spinal cord lesions and brain grey matter atrophy independently predict clinical worsening in definite multiple sclerosis: a 5-year, multicentre study. J Neurol Neurosurg Psychiatry 2023; 94:10-18. [PMID: 36171105 DOI: 10.1136/jnnp-2022-329854] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/05/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the combined contribution of brain and cervical cord damage in predicting 5-year clinical worsening in a multicentre cohort of definite multiple sclerosis (MS) patients. METHODS Baseline 3.0T brain and cervical cord T2-weighted and three-dimensional T1-weighted MRI was acquired in 367 patients with MS (326 relapse-onset and 41 progressive-onset) and 179 healthy controls. Expanded Disability Status Scale (EDSS) score was obtained at baseline and after a median follow-up of 5.1 years (IQR=4.8-5.2). At follow-up, patients were classified as clinically stable/worsened according to EDSS changes. Generalised linear mixed models identified predictors of clinical worsening, evolution to secondary progressive (SP) MS and reaching EDSS=3.0, 4.0 and 6.0 milestones at 5 years. RESULTS At follow-up, 120/367 (33%) patients with MS worsened clinically; 36/256 (14%) patients with relapsing-remitting evolved to SPMS. Baseline predictors of EDSS worsening were progressive-onset versus relapse-onset MS (standardised beta (β)=0.97), higher EDSS (β=0.41), higher cord lesion number (β=0.41), lower normalised cortical volume (β=-0.15) and lower cord area (β=-0.28) (C-index=0.81). Older age (β=0.86), higher EDSS (β=1.40) and cord lesion number (β=0.87) independently predicted SPMS conversion (C-index=0.91). Predictors of reaching EDSS=3.0 after 5 years were higher baseline EDSS (β=1.49), cord lesion number (β=1.02) and lower normalised cortical volume (β=-0.56) (C-index=0.88). Baseline age (β=0.30), higher EDSS (β=2.03), higher cord lesion number (β=0.66) and lower cord area (β=-0.41) predicted EDSS=4.0 (C-index=0.92). Finally, higher baseline EDSS (β=1.87) and cord lesion number (β=0.54) predicted EDSS=6.0 (C-index=0.91). CONCLUSIONS Spinal cord damage and, to a lesser extent, cortical volume loss helped predicting worse 5-year clinical outcomes in MS.
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Affiliation(s)
- Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milano, Italy .,Neurology Unit, IRCCS Ospedale San Raffaele, Milano, Italy.,Vita-Salute San Raffaele University, Milano, Italy
| | - Paola Valsasina
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Alessandro Meani
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Claudio Gobbi
- Neurology Clinic, MS Center/Headache Center, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Chiara Zecca
- Neurology Clinic, MS Center/Headache Center, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Frederik Barkhof
- Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC - Locatie VUMC, Amsterdam, Netherlands.,Department of Neurology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC - Locatie VUMC, Amsterdam, Netherlands
| | - Menno M Schoonheim
- Department of Anatomy and Neurosciences, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC Locatie VUmc, Amsterdam, Netherlands
| | - Eva M Strijbis
- Department of Neurology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC - Locatie VUMC, Amsterdam, Netherlands
| | - Hugo Vrenken
- Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC - Locatie VUMC, Amsterdam, Netherlands.,Department of Neurology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC - Locatie VUMC, Amsterdam, Netherlands
| | - Antonio Gallo
- Department of Advanced Medical and Surgical Sciences, and 3T MRI-Center, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Alvino Bisecco
- Department of Advanced Medical and Surgical Sciences, and 3T MRI-Center, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Olga Ciccarelli
- NMR Research Unit, Queen Square MS Centre, Department of Neuroinflammation, UCL Institute of Neurology, London, UK
| | - Marios Yiannakas
- NMR Research Unit, Queen Square MS Centre, Department of Neuroinflammation, UCL Institute of Neurology, London, UK
| | - Alex Rovira
- Section of Neuroradiology, Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Department of Neurology/Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Lucy Matthews
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Achim Gass
- Department of Neurology, and Mannheim Center of Translational Neurosciences (MCTN), Ruprecht Karls University Heidelberg Faculty of Medicine Mannheim, Mannheim, Germany
| | - Philipp Eisele
- Department of Neurology, and Mannheim Center of Translational Neurosciences (MCTN), Ruprecht Karls University Heidelberg Faculty of Medicine Mannheim, Mannheim, Germany
| | - Carsten Lukas
- Institute of Neuroradiology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.,Department of Radiology and Nuclear Medicine, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Barbara Bellenberg
- Institute of Neuroradiology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Monica Margoni
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Paolo Preziosa
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milano, Italy.,Neurology Unit, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milano, Italy.,Neurology Unit, IRCCS Ospedale San Raffaele, Milano, Italy.,Vita-Salute San Raffaele University, Milano, Italy.,Neurorehabilitation Unit, IRCCS Ospedale San Raffaele, Milano, Italy.,Neurophysiology Service, IRCCS Ospedale San Raffaele, Milano, Italy
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8
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Alcalá Vicente C, Lacruz L, Gascón F, Carratalà S, Quintanilla-Bordás C, Sanz MT, Carcelén-Gadea M, Mallada J, Carreres J, Gabaldón Torres L, Dominguez JA, Cañizares E, Gil-Perotin S, Cubas L, Gasqué Rubio R, Castillo-Villalba J, Pérez-Miralles FC, Casanova B. Oligoclonal M bands and cervical spinal cord lesions predict early secondary progressive multiple sclerosis. Front Neurol 2022; 13:991596. [DOI: 10.3389/fneur.2022.991596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo determine baseline cerebrospinal fluid and magnetic resonance imaging (MRI) variables at the onset of a clinically isolated syndrome (CIS) suggestive of multiple sclerosis (MS) that predict evolution to secondary progressive MS (SPMS).Methods276 CIS patients with a minimum follow-up of 10 years were studied. Baseline presence of oligoclonal IgG and IgM bands (OCGB and OCMB respectively); number of brain T2 lesions (B-T2L), brain gadolinium enhancement lesions (brain-GEL), cervical spinal cord T2 lesions (cSC-T2L); and fulfillment of 2017 McDonald criteria among other variables were collected.Results14 patients ended up with a non-MS condition. 138/276 CIS patients fulfilled 2017 McDonald criteria. Mean age was 32.4 years, 185 female. 227 received treatment, 95 as CIS. After a mean follow-up of 12 years, 36 patients developed SPMS. Conversion to SPMS was associated with OCGB (p = 0.02), OCMB (p = 0.0001); ≥ 9 B-T2L (p = 0.03), brain-GEL (p = 0.03), and cSC-T2L (p = 0.03). However, after adjusting for sex, age, BT2L, brain-GEL, SC-T2, and OCMB status, only OCMB (HR 4.4, 1.9–10.6) and cSC-T2L (HR 2.2, 1.0–6.2) suggested an independent association with risk of conversion to SPMS. Patients with both risk factors had a HR of 6.12 (2.8–12.9).DiscussionOCMB and SC-T2 lesions are potential independent predictors of conversion to SPMS.
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9
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Sharmin S, Malpas CB, Roos I, Diouf I, Alroughani R, Ozakbas S, Izquierdo G, Eichau S, Horakova D, Havrdova EK, Patti F, Terzi M, Boz C, Yamout B, Khoury SJ, Onofrj M, Lugaresi A, Altintas A, Prat A, Girard M, Duquette P, Sá MJ, La Spitaleri D, Sidhom Y, Gouider R, Mrabet S, Soysal A, Turkoglu R, Amato MP, Fragoso YD, Kalincik T. Early predictors of disability in paediatric multiple sclerosis: evidence from a multi-national registry. J Neurol Neurosurg Psychiatry 2022:jnnp-2022-329713. [PMID: 36180218 DOI: 10.1136/jnnp-2022-329713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/28/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Early recognition of markers of faster disability worsening in paediatric-onset multiple sclerosis (MS) is a key requisite of personalised therapy for children with MS at the earliest possible time. OBJECTIVE To identify early predictors of rapid disability accrual in patients with paediatric-onset MS. METHODS Using the global MSBase registry, we identified patients who were <18 years old at the onset of MS symptoms. The clinico-demographic characteristics examined as predictors of future MS Severity Score (MSSS) included sex, age at symptom onset, absence of disability at the initial assessment, maximum Expanded Disability Status Scale (EDSS) score, relapse frequency and presence of brainstem, pyramidal, visual or cerebellar symptoms in the first year. A Bayesian log-normal generalised linear mixed model adjusted for cumulative proportion of time on higher-efficacy disease-modifying therapies (DMTs) was used to analyse the data. RESULTS 672 patients (70% female) contributing 9357 visits were included. The median age at symptom onset was 16 (quartiles 15-17) years. Older age at symptom onset (exp(β)=1.10 (95% CI 1.04 to 1.17)), higher EDSS score (1.22 (1.12 to 1.34)) and pyramidal (1.31 (1.11 to 1.55)), visual (1.25 (1.10 to 1.44)) or cerebellar (1.18 (1.01 to 1.38)) symptoms in the first year were associated with higher MSSS. MSSS was reduced by 4% for every 24% increase in the proportion of time on higher-efficacy DMTs (0.96 (0.93 to 0.99)). CONCLUSIONS A relatively later onset of MS in childhood, higher disability and pyramidal, visual or cerebellar symptoms during the first year predicted significant worsening in disability in patients with paediatric-onset MS. Persistent treatment with higher-efficacy DMTs was associated with a reduced rate of disability worsening.
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Affiliation(s)
- Sifat Sharmin
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Charles B Malpas
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Izanne Roos
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ibrahima Diouf
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Serkan Ozakbas
- Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Guillermo Izquierdo
- Multiple Sclerosis Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Sara Eichau
- Multiple Sclerosis Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva K Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Murat Terzi
- Medical Faculty, 19 Mayis University, Samsun, Turkey
| | - Cavit Boz
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | - Bassem Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
- Neurology Department, American University of Beirut, Beirut, Lebanon
| | - Samia J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio, Chieti, Italy
| | - Alessandra Lugaresi
- UOSI Riabilitazione Sclerosi Multipla, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Alexandre Prat
- CHUM MS Center and Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Marc Girard
- CHUM MS Center and Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Pierre Duquette
- CHUM MS Center and Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Maria José Sá
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | | | - Youssef Sidhom
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Riadh Gouider
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Saloua Mrabet
- Clinical Investigation Center Neurosciences and Mental Health, Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - Aysun Soysal
- Department of Neurology, Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | - Recai Turkoglu
- Department of Neurology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy
| | - Yara D Fragoso
- Department of Neurology, Universidade Metropolitana de Santos, Santos, Brazil
| | - Tomas Kalincik
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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10
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Yang Y, Wang M, Xu L, Zhong M, Wang Y, Luan M, Li X, Zheng X. Cerebellar and/or Brainstem Lesions Indicate Poor Prognosis in Multiple Sclerosis: A Systematic Review. Front Neurol 2022; 13:874388. [PMID: 35572921 PMCID: PMC9099189 DOI: 10.3389/fneur.2022.874388] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple sclerosis is a serious neurological disease that affects millions of people worldwide. Cerebellar and brainstem symptoms are common in the course of multiple sclerosis, but their prognostic value is unclear. This systematic review aimed to determine the relationship between the location of lesions in the cerebellum and/or brainstem and the prognosis in multiple sclerosis. In this systematic review, we searched and comprehensively read articles related to this research topic in Chinese and English electronic databases (PubMed, Embase, Cochrane Library, CNKI, and CBM) using search terms “multiple sclerosis,” “cerebellum,” “brainstem,” “prognosis,” and others. Cerebellar and brainstem clinically isolated syndromes and clinically definite multiple sclerosis were important predictors of transformation (hazard ratio, 2.58; 95% confidence interval, 1.58–4.22). Cerebellar and/or brainstem lesions indicate a poor overall prognosis in multiple sclerosis, but because of inconsistency, more clinical data are needed.
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Affiliation(s)
- Yuyuan Yang
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meng Wang
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lulu Xu
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meixiang Zhong
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yajuan Wang
- Department of Geriatric Medicine, The Qingdao Eighth People's Hospital, Qingdao, China
| | - Moxin Luan
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xingao Li
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xueping Zheng
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Xueping Zheng
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11
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Margoni M, Preziosa P, Rocca MA, Filippi M. Pediatric multiple sclerosis: developments in timely diagnosis and prognostication. Expert Rev Neurother 2022; 22:393-403. [PMID: 35400266 DOI: 10.1080/14737175.2022.2064743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Pediatric-onset (PO) multiple sclerosis (MS) accounts for about 2-10% of the total MS cases. Recently, a greater attention has been given to POMS, with substantial improvements in the understanding of its pathophysiology, in the diagnostic work-up and in the identification of reliable prognosticators associated with long-term disability in these patients. AREAS COVERED This review summarizes the most recent updates regarding the pathophysiology of POMS, the current diagnostic criteria and the clinical, neuroradiological and laboratoristic markers that have been associated with disease progression (i.e. occurrence of a second clinical attack at disease onset and accumulation of disability in definite MS). EXPERT OPINION The study of POMS, where the clinical onset is closer to the biological onset of MS, may contribute to better understand how the different pathological processes impact brain maturation and contribute to disease progression, but also how brain plasticity may counterbalance structural damage accumulation. Although rare, POMS is a severe disease, characterized by a prominent clinical and radiological activity at disease onset and by the accumulation of physical and cognitive disability at a younger age compared to the adult counterpart, with significant detrimental consequences at long-term. Early and accurate diagnosis, together with early treatment, is highly warranted.
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Affiliation(s)
- Monica Margoni
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Multiple Sclerosis Center of the Veneto Region, Department of Neurosciences, University Hospital - School of Medicine, Padua, Italy
| | - Paolo Preziosa
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy.,Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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12
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Jakimovski D, Awan S, Eckert SP, Farooq O, Weinstock-Guttman B. Multiple Sclerosis in Children: Differential Diagnosis, Prognosis, and Disease-Modifying Treatment. CNS Drugs 2022; 36:45-59. [PMID: 34940954 PMCID: PMC8697541 DOI: 10.1007/s40263-021-00887-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 12/19/2022]
Abstract
Pediatric-onset multiple sclerosis (POMS) is a rare neuroinflammatory and neurodegenerative disease that has a significant impact on long-term physical and cognitive patient outcomes. A small percentage of multiple sclerosis (MS) diagnoses occur before the age of 18 years. Before treatment initiation, a careful differential diagnosis and exclusion of other similar acquired demyelinating syndromes such as anti-aquaporin-4-associated neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody spectrum disorder (MOGSD) is warranted. The recent 2017 changes to the McDonald criteria can successfully predict up to 71% of MS diagnoses and have good specificity of 95% and sensitivity of 71%. Additional measures such as the presence of T1-weighted hypointense lesions and/or contrast-enhancing lesions significantly increase the accuracy of diagnosis. In adults, early use of disease-modifying therapies (DMTs) is instrumental to a better long-term prognosis, including lower rates of relapse and disability worsening, and numerous FDA-approved therapies for adult-onset MS are available. However, unlike their adult counterparts, the development, testing, and regulatory approval of POMS treatments have been significantly slower and hindered by logistic and/or ethical considerations. Currently, only two MS DMTs (fingolimod and teriflunomide) have been tested in large phase III trials and approved by regulatory agencies for use in POMS. First-line therapies not approved by the FDA for use in children (interferon-β and glatiramer acetate) are also commonly used and result in a significant reduction in inflammatory activity when compared with non-treated POMS patients. An increasing number of POMS patients are now treated with moderate efficacy therapies such as dimethyl fumarate and high-efficacy therapies such as natalizumab, anti-CD20 monoclonal antibodies, anti-CD52 monoclonal antibodies, and/or autologous hematopoietic stem cell transplantation. These high-efficacy DMTs generally provide additional reduction in inflammatory activity when compared with the first-line medications (up to 62% of relapse-rate reduction). Therefore, a number of phase II and III trials are currently investigating their efficacy and safety in POMS patients. In this review, we discuss potential changes in the regulatory approval process for POMS patients that are recommended for DMTs already approved for the adult MS population, including smaller sample size for pharmacokinetic/pharmacodynamic studies, MRI-centered primary outcomes, and/or inclusion of teenagers in the adult trials.
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Affiliation(s)
- Dejan Jakimovski
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA ,Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY USA
| | - Samreen Awan
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA
| | - Svetlana P. Eckert
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY 14202 USA
| | - Osman Farooq
- Division of Pediatric Neurology, Oishei Children’s Hospital of Buffalo, Buffalo, NY USA ,Department of Neurology, Jacobs School of Medicine, State University of New York at Buffalo, Buffalo, NY USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Comprehensive MS Treatment and Research Center, Jacobs School of Medicine and Biomedical Science, University of Buffalo, 1010 Main Street, Buffalo, NY, 14202, USA.
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