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Ovchinnikova LA, Dzhelad SS, Simaniv TO, Zakharova MN, Gabibov AG, Lomakin YA. The Level of Anti-Viral Antigen-Specific Antibodies to EBNA-1 in the Serum of MS Patients Does not Depend on the Severity of the Disease. DOKL BIOCHEM BIOPHYS 2024; 515:48-51. [PMID: 38472667 PMCID: PMC11021220 DOI: 10.1134/s1607672924700753] [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: 11/10/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 03/14/2024]
Abstract
Multiple sclerosis (MS) is an autoimmune neurodegenerative disease leading to inevitable disability and primarily affecting the young and middle-aged population. Recent studies have shown a direct correlation between the risk of MS development and Epstein-Barr virus (EBV) infection. Analysis of the titer of EBV-specific antibodies among patients with MS and healthy donors among Russian population confirmed that MS is characterized by an increased level of serum IgG binding EBNA-1 (EBV nuclear antigen 1). The number of patients with elevated levels of EBNA-1-specific antibodies does not differ statistically significantly between two groups with diametrically opposite courses of MS: benign MS or highly active MS. It can be assumed that the primary link between EBV and the development of MS is restricted to the initiation of the disease and does not impact its severity.
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Affiliation(s)
- L A Ovchinnikova
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Moscow, Russia
| | - S S Dzhelad
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Moscow, Russia
| | - T O Simaniv
- Research Center of Neurology, Moscow, Russia
| | | | - A G Gabibov
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Moscow, Russia.
- Moscow State University, Moscow, Russia.
| | - Y A Lomakin
- Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Moscow, Russia.
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2
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Rhodes JS, Aumon A, Morin S, Girard M, Larochelle C, Brunet-Ratnasingham E, Pagliuzza A, Marchitto L, Zhang W, Cutler A, Grand'Maison F, Zhou A, Finzi A, Chomont N, Kaufmann DE, Zandee S, Prat A, Wolf G, Moon KR. Gaining Biological Insights through Supervised Data Visualization. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.11.22.568384. [PMID: 38293135 PMCID: PMC10827133 DOI: 10.1101/2023.11.22.568384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Dimensionality reduction-based data visualization is pivotal in comprehending complex biological data. The most common methods, such as PHATE, t-SNE, and UMAP, are unsupervised and therefore reflect the dominant structure in the data, which may be independent of expert-provided labels. Here we introduce a supervised data visualization method called RF-PHATE, which integrates expert knowledge for further exploration of the data. RF-PHATE leverages random forests to capture intricate featurelabel relationships. Extracting information from the forest, RF-PHATE generates low-dimensional visualizations that highlight relevant data relationships while disregarding extraneous features. This approach scales to large datasets and applies to classification and regression. We illustrate RF-PHATE's prowess through three case studies. In a multiple sclerosis study using longitudinal clinical and imaging data, RF-PHATE unveils a sub-group of patients with non-benign relapsingremitting Multiple Sclerosis, demonstrating its aptitude for time-series data. In the context of Raman spectral data, RF-PHATE effectively showcases the impact of antioxidants on diesel exhaust-exposed lung cells, highlighting its proficiency in noisy environments. Furthermore, RF-PHATE aligns established geometric structures with COVID-19 patient outcomes, enriching interpretability in a hierarchical manner. RF-PHATE bridges expert insights and visualizations, promising knowledge generation. Its adaptability, scalability, and noise tolerance underscore its potential for widespread adoption.
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3
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Reeve K, On BI, Havla J, Burns J, Gosteli-Peter MA, Alabsawi A, Alayash Z, Götschi A, Seibold H, Mansmann U, Held U. Prognostic models for predicting clinical disease progression, worsening and activity in people with multiple sclerosis. Cochrane Database Syst Rev 2023; 9:CD013606. [PMID: 37681561 PMCID: PMC10486189 DOI: 10.1002/14651858.cd013606.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system that affects millions of people worldwide. The disease course varies greatly across individuals and many disease-modifying treatments with different safety and efficacy profiles have been developed recently. Prognostic models evaluated and shown to be valid in different settings have the potential to support people with MS and their physicians during the decision-making process for treatment or disease/life management, allow stratified and more precise interpretation of interventional trials, and provide insights into disease mechanisms. Many researchers have turned to prognostic models to help predict clinical outcomes in people with MS; however, to our knowledge, no widely accepted prognostic model for MS is being used in clinical practice yet. OBJECTIVES To identify and summarise multivariable prognostic models, and their validation studies for quantifying the risk of clinical disease progression, worsening, and activity in adults with MS. SEARCH METHODS We searched MEDLINE, Embase, and the Cochrane Database of Systematic Reviews from January 1996 until July 2021. We also screened the reference lists of included studies and relevant reviews, and references citing the included studies. SELECTION CRITERIA We included all statistically developed multivariable prognostic models aiming to predict clinical disease progression, worsening, and activity, as measured by disability, relapse, conversion to definite MS, conversion to progressive MS, or a composite of these in adult individuals with MS. We also included any studies evaluating the performance of (i.e. validating) these models. There were no restrictions based on language, data source, timing of prognostication, or timing of outcome. DATA COLLECTION AND ANALYSIS Pairs of review authors independently screened titles/abstracts and full texts, extracted data using a piloted form based on the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS), assessed risk of bias using the Prediction Model Risk Of Bias Assessment Tool (PROBAST), and assessed reporting deficiencies based on the checklist items in Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD). The characteristics of the included models and their validations are described narratively. We planned to meta-analyse the discrimination and calibration of models with at least three external validations outside the model development study but no model met this criterion. We summarised between-study heterogeneity narratively but again could not perform the planned meta-regression. MAIN RESULTS We included 57 studies, from which we identified 75 model developments, 15 external validations corresponding to only 12 (16%) of the models, and six author-reported validations. Only two models were externally validated multiple times. None of the identified external validations were performed by researchers independent of those that developed the model. The outcome was related to disease progression in 39 (41%), relapses in 8 (8%), conversion to definite MS in 17 (18%), and conversion to progressive MS in 27 (28%) of the 96 models or validations. The disease and treatment-related characteristics of included participants, and definitions of considered predictors and outcome, were highly heterogeneous amongst the studies. Based on the publication year, we observed an increase in the percent of participants on treatment, diversification of the diagnostic criteria used, an increase in consideration of biomarkers or treatment as predictors, and increased use of machine learning methods over time. Usability and reproducibility All identified models contained at least one predictor requiring the skills of a medical specialist for measurement or assessment. Most of the models (44; 59%) contained predictors that require specialist equipment likely to be absent from primary care or standard hospital settings. Over half (52%) of the developed models were not accompanied by model coefficients, tools, or instructions, which hinders their application, independent validation or reproduction. The data used in model developments were made publicly available or reported to be available on request only in a few studies (two and six, respectively). Risk of bias We rated all but one of the model developments or validations as having high overall risk of bias. The main reason for this was the statistical methods used for the development or evaluation of prognostic models; we rated all but two of the included model developments or validations as having high risk of bias in the analysis domain. None of the model developments that were externally validated or these models' external validations had low risk of bias. There were concerns related to applicability of the models to our research question in over one-third (38%) of the models or their validations. Reporting deficiencies Reporting was poor overall and there was no observable increase in the quality of reporting over time. The items that were unclearly reported or not reported at all for most of the included models or validations were related to sample size justification, blinding of outcome assessors, details of the full model or how to obtain predictions from it, amount of missing data, and treatments received by the participants. Reporting of preferred model performance measures of discrimination and calibration was suboptimal. AUTHORS' CONCLUSIONS The current evidence is not sufficient for recommending the use of any of the published prognostic prediction models for people with MS in clinical routine today due to lack of independent external validations. The MS prognostic research community should adhere to the current reporting and methodological guidelines and conduct many more state-of-the-art external validation studies for the existing or newly developed models.
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Affiliation(s)
- Kelly Reeve
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zurich, Switzerland
| | - Begum Irmak On
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Joachim Havla
- lnstitute of Clinical Neuroimmunology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jacob Burns
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | | | - Albraa Alabsawi
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Zoheir Alayash
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
- Institute of Health Services Research in Dentistry, University of Münster, Muenster, Germany
| | - Andrea Götschi
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zurich, Switzerland
| | | | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Ulrike Held
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zurich, Switzerland
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Lana-Peixoto MA, Talim NC, Callegaro D, Marques VD, Damasceno A, Becker J, Gonçalves MVM, Sato H. Neuromyelitis optica spectrum disorders with a benign course. Analysis of 544 patients. Mult Scler Relat Disord 2023; 75:104730. [PMID: 37156036 DOI: 10.1016/j.msard.2023.104730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/16/2023] [Accepted: 04/23/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Neuromyelitis optica spectrum disorders (NMOSD) most commonly cause severe disability which is related to disease attacks. However, some patients retain good neurological function for a long time after disease onset. OBJECTIVES To determine the frequency, demographic and the clinical features of good outcome NMOSD, and analyze their predictive factors. METHODS We selected patients who met the 2015 International Panel for NMOSD diagnostic criteria from seven MS Centers. Assessed data included age at disease onset, sex, race, number of attacks within the first and three years from onset, annualized relapsing rate (ARR), total number of attacks, aquaporin-IgG serum status, presence of cerebrospinal fluid (CSF)-specific oligoclonal bands (OCB) and the Expanded Disability Status Scale (EDSS) score at the last follow-up visit. NMOSD was classified as non-benign if patients developed sustained EDSS score >3.0 during the disease course, or benign if patients had EDSS score ≤3.0 after ≥15 years from disease onset. Patients with EDSS <3.0 and disease duration shorter than 15 years were not qualified for classification. We compared the demographic and clinical characteristics of benign and non-benign NMOSD. Logistic regression analysis identified predictive factors of outcome. RESULTS There were 16 patients with benign NMOSD (3% of the entire cohort; 4.2% of those qualified for classification; and 4.1% of those who tested positive for aquaporin 4-IgG), and 362 (67.7%) with non-benign NMOSD, whereas 157 (29.3%) did not qualify for classification. All patients with benign NMOSD were female, 75% were Caucasian, 75% tested positive for AQP4-IgG, and 28.6% had CSF-specific OCB. Regression analysis showed that female sex, pediatric onset, and optic neuritis, area postrema syndrome, and brainstem symptoms at disease onset, as well as fewer relapses in the first year and three years from onset, and CSF-specific OCB were more commonly found in benign NMOSD, but the difference did not reach statistical significance. Conversely, non-Caucasian race (OR: 0.29, 95% CI: 0.07-0.99; p = 0.038), myelitis at disease presentation (OR: 0.07, 95% CI: 0.01-0.52; p <0.001), and high ARR (OR: 0.07, 95% CI: 0.01-0.67; p = 0.011) were negative risk factors for benign NMOSD. CONCLUSION Benign NMOSD is very rare and occurs more frequently in Caucasians, patients with low ARR, and those who do not have myelitis at disease onset.
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Affiliation(s)
| | - Natália C Talim
- Federal University of Minas Gerais Medical School, Belo Horizonte, MG, Brazil
| | | | | | | | - Jefferson Becker
- Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Henry Sato
- Neurological Institute of Curitiba, Curitiba, PR, Brazil
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5
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Al-Hawasi A, Lagali N, Fagerholm P, Huang-Link Y. Longitudinal Optical Coherence Tomography Measurement of Retinal Ganglion Cell and Nerve Fiber Layer to Assess Benign Course in Multiple Sclerosis. J Clin Med 2023; 12:jcm12062240. [PMID: 36983241 PMCID: PMC10054631 DOI: 10.3390/jcm12062240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
A benign form of multiple sclerosis (BMS) is not easily diagnosed, but changes of the retinal ganglion cell layer-inner plexiform layer (GCL-IPL) and retinal nerve fiber layer (RNFL) may be sensitive to the disease. The aim of this study was to use optical coherence tomography (OCT) to investigate longitudinal changes of GCL-IPL and RNFL in BMS. Eighteen patients with BMS and 22 healthy control (HC) subjects were included, with a mean follow-up period of 32.1 months in BMS and 34.3 months in HC. Mean disease duration in BMS was 23.3 years, with 14 patients left untreated. Unilateral optic neuritis (ON) was found in eight patients. Non-ON eyes showed thinner GCL-IPL layer in the BMS group relative to HC (p < 0.001). The thinning rate of GCL-IPL in non-ON BMS, however, was −0.19 ± 0.15 µm/year vs. 0 ± 0.11 µm/year for HC (p = 0.573, age-adjusted). Thinning rate of RNFL in non-ON BMS was −0.2 ± 0.27 µm/year vs. −0.05 ± 0.3 µm/year for HC (p = 0.454, age adjusted). Conclusions: Thinning rate of the GCL-IPL and RNFL in BMS is similar to the healthy population but differs from the thinning rate in relapsing-remitting MS, presenting a non-invasive OCT-based criterion for assessing a benign course in multiple sclerosis.
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Affiliation(s)
- Abbas Al-Hawasi
- Division of Ophthalmology, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 581 83 Linköping, Sweden
- Correspondence:
| | - Neil Lagali
- Division of Ophthalmology, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 581 83 Linköping, Sweden
| | - Per Fagerholm
- Division of Ophthalmology, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 581 83 Linköping, Sweden
| | - Yumin Huang-Link
- Division of Neurology, Department of Biomedical and Clinical Sciences, Linköping University, 581 85 Linköping, Sweden
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6
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Vaughn CB, Kavak KS, Jakimovski D, Qutab N, Avila R, Vignos M, Weinstock-Guttman B. Patient-reported outcomes are the strongest predictors of disease disability in intramuscular interferon beta-1a users. Neurodegener Dis Manag 2023. [PMID: 36779318 DOI: 10.2217/nmt-2022-0008] [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: 02/14/2023] Open
Abstract
Introduction: Patient-reported outcomes (PROs) are valuable measures for routine clinical care of people with multiple sclerosis (pwMS). Materials: 646 pwMS treated with interferon-β-1a (IFN-β-1a) were retrospectively included from the New York State Multiple Sclerosis Consortium. Clinical and PRO data at enrollment and 3 year follow-up were collected. PwMS with stable disease and disability worsening were matched (1:1) based on age, Expanded Disability Status Scale (EDSS) scores and disease duration. Disability worsening was determined based on trial criteria. Results: PwMS with future EDSS worsening had higher baseline and follow-up timed-25-foot walk (6.6 vs 5.5 s; 9.1 vs 5.5 s; p < .001) when compared with stable pwMS. Worsening pwMS reported higher baseline difficulties in getting up (odds ratio [OR] = 2.4; p = 0.009), climbing stairs (OR = 1.6; p = 0.024) and standing (OR = 2.2; p < 0.001). Worsening pwMS reported greater lower limb limitations (OR = 2.3; p = 0.004) and fatigue (OR = 1.8; p = 0.002). Conclusion: Higher fatigue and lower limb functional limitations are significant predictors of future disability worsening in pwMS.
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Affiliation(s)
- Caila B Vaughn
- Jacobs Comprehensive MS Treatment & Research Center, Department of Neurology, Jacobs School of Medicine & Biomedical Sciences University at Buffalo, Buffalo, NY 14202, USA
| | - Katelyn S Kavak
- Jacobs Comprehensive MS Treatment & Research Center, Department of Neurology, Jacobs School of Medicine & Biomedical Sciences University at Buffalo, Buffalo, NY 14202, USA
| | - Dejan Jakimovski
- Jacobs Comprehensive MS Treatment & Research Center, Department of Neurology, Jacobs School of Medicine & Biomedical Sciences University at Buffalo, Buffalo, NY 14202, USA.,Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14203, USA
| | - Natasha Qutab
- Jacobs Comprehensive MS Treatment & Research Center, Department of Neurology, Jacobs School of Medicine & Biomedical Sciences University at Buffalo, Buffalo, NY 14202, USA
| | - Robin Avila
- Biogen, 133 Boston Post Rd, Weston, MA 20493, USA
| | - Megan Vignos
- Biogen, 133 Boston Post Rd, Weston, MA 20493, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment & Research Center, Department of Neurology, Jacobs School of Medicine & Biomedical Sciences University at Buffalo, Buffalo, NY 14202, USA
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7
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Niiranen M, Koikkalainen J, Lötjönen J, Selander T, Cajanus A, Hartikainen P, Simula S, Vanninen R, Remes AM. Grey matter atrophy in patients with benign multiple sclerosis. Brain Behav 2022; 12:e2679. [PMID: 35765699 PMCID: PMC9304852 DOI: 10.1002/brb3.2679] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/22/2022] [Accepted: 06/03/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Brain atrophy appears during the progression of multiple sclerosis (MS) and is associated with the disability caused by the disease. METHODS We investigated global and regional grey matter (GM) and white matter (WM) volumes, WM lesion load, and corpus callosum index (CCI), in benign relapsing-remitting MS (BRRMS, n = 35) with and without any treatment and compared those to aggressive relapsing-remitting MS (ARRMS, n = 46). Structures were analyzed by using an automated MRI quantification tool (cNeuro®). RESULTS The total brain and cerebral WM volumes were larger in BRRMS than in ARRMS (p = .014, p = .017 respectively). In BRRMS, total brain volumes, regional GM volumes, and CCI were found similar whether or not disease-modifying treatment (DMT) was used. The total (p = .033), as well as subcortical (p = .046) and deep WM (p = .041) lesion load volumes were larger in BRRMS patients without DMT. Cortical GM volumes did not differ between BRRMS and ARRMS, but the volumes of total brain tissue (p = .014) and thalami (p = .003) were larger in patients with BRRMS compared to ARRMS. A positive correlation was found between CCI and whole-brain volume in both BRRMS (r = .73, p < .001) and ARRMS (r = .80, p < .01). CONCLUSIONS Thalamic volume is the most prominent measure to differentiate BRRMS and ARRMS. Validation of automated quantification of CCI provides an additional applicable MRI biomarker to detect brain atrophy in MS.
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Affiliation(s)
- Marja Niiranen
- Neuro Center, Neurology, Kuopio University Hospital, Kuopio, Finland
| | | | | | - Tuomas Selander
- Science Service Center, Kuopio University Hospital, Kuopio, Finland
| | - Antti Cajanus
- Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | - Päivi Hartikainen
- Neuro Center, Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Sakari Simula
- Department of Neurology, Mikkeli Central Hospital, Mikkeli, Finland
| | - Ritva Vanninen
- Institute of Clinical Medicine - Radiology, University of Eastern Finland, Kuopio, Finland.,Department of Radiology, Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Anne M Remes
- Unit of Clinical Neuroscience, Neurology, University of Oulu, Oulu, Finland.,Medical Research Center, Oulu University Hospital, Oulu, Finland
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8
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Niiranen M, Kontkanen A, Jääskeläinen O, Tertsunen HM, Selander T, Hartikainen P, Huber N, Solje E, Haapasalo A, Kokkola T, Lohioja T, Herukka SK, Simula S, Remes AM. Serum GFAP and NfL levels in benign relapsing-remitting multiple sclerosis. Mult Scler Relat Disord 2021; 56:103280. [PMID: 34627002 DOI: 10.1016/j.msard.2021.103280] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/13/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed to investigate serum glial fibrillary acidic protein (GFAP) and serum neurofilament light chain (NfL) levels as potential discriminative biomarkers between benign relapsing-remitting multiple sclerosis (BRRMS) and aggressive relapsing-remitting MS (ARRMS). METHODS Serum GFAP and NfL levels were analyzed in patients with BRRMS (n = 34), ARRMS (n = 29), and healthy controls (n = 14) by using Single Molecule Array (Simoa). Patients with ARRMS had been treated with highly effective disease-modifying treatments (DMT) (fingolimod or natalizumab). RESULTS Serum GFAP levels in both BRRMS (median 210.19 pg/ml, IQR 163.69-287.19) and in ARRMS (median 188.60 pg/ml, IQR39.23-244.93) were significantly higher (p = 0.035 and p = 0.034, respectively) compared to healthy controls (median 117.93 pg/ml, IQR 60.28-183.83). Serum GFAP levels did not differ between BRRMS and ARRMS. There were no statistical differences in NfL levels between BRRMS, ARRMS and healthy controls. GFAP level was significantly higher (p = 0.04) in BRRMS without DMT (median 216.04 pg/ml, IQR 188.60-274.79) than in those BRRMS patients who had used DMT (median 196.26 pg/ml, IQR 133.33-325.54). CONCLUSIONS We found elevated levels of serum GFAP in both BRRMS and ARRMS compared to healthy controls, reflecting astrocytic activation. Serum NfL did not differ between BRRMS and ARRMS, probably due to the stable inflammatory phase of the disease and effective DMT use in ARRMS. Single serum NfL and GFAP measurements cannot separate a patient with BRRMS from effectively treated ARRMS after a long history of the disease, thus consecutive samples are needed in the follow-up.
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Affiliation(s)
- Marja Niiranen
- Neuro Center, Neurology Outpatient Clinic, Kuopio University Hospital, P.O. BOX 100, Kuopio FI-70029, Finland.
| | - Aleksi Kontkanen
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - Olli Jääskeläinen
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - Hanna-Mari Tertsunen
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - Tuomas Selander
- Science Service Center, Kuopio University Hospital, Kuopio, Finland
| | - Päivi Hartikainen
- Neuro Center, Neurology Outpatient Clinic, Kuopio University Hospital, P.O. BOX 100, Kuopio FI-70029, Finland
| | - Nadine Huber
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Eino Solje
- Neuro Center, Neurology Outpatient Clinic, Kuopio University Hospital, P.O. BOX 100, Kuopio FI-70029, Finland; Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - Annakaisa Haapasalo
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Tarja Kokkola
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - Tarja Lohioja
- Neuro Center, Neurology Outpatient Clinic, Kuopio University Hospital, P.O. BOX 100, Kuopio FI-70029, Finland
| | - Sanna-Kaisa Herukka
- Neuro Center, Neurology Outpatient Clinic, Kuopio University Hospital, P.O. BOX 100, Kuopio FI-70029, Finland; Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - Sakari Simula
- Department of Neurology, Mikkeli Central Hospital, Mikkeli, Finland
| | - Anne M Remes
- Unit of Clinical Neuroscience, Neurology, University of Oulu, Oulu, Finland; Medical Research Center, Oulu University Hospital, Oulu, Finland
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9
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Doskas T, Vavougios GD, Karampetsou P, Kormas C, Synadinakis E, Stavrogianni K, Sionidou P, Serdari A, Vorvolakos T, Iliopoulos I, Vadikolias Κ. Neurocognitive impairment and social cognition in multiple sclerosis. Int J Neurosci 2021; 132:1229-1244. [PMID: 33527857 DOI: 10.1080/00207454.2021.1879066] [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: 10/22/2022]
Abstract
PURPOSE/AIM OF THE STUDY The impairment of neurocognitive functions occurs in all subtypes of multiple sclerosis, even from the earliest stages of the disease. Commonly reported manifestations of cognitive impairment include deficits in attention, conceptual reasoning, processing efficiency, information processing speed, memory (episodic and working), verbal fluency (language), and executive functions. Multiple sclerosis patients also suffer from social cognition impairment, which affects their social functioning. The objective of the current paper is to assess the effect of neurocognitive impairment and its potential correlation with social cognition performance and impairment in multiple sclerosis patients. MATERIALS AND METHODS An overview of the available-to-date literature on neurocognitive impairment and social cognition performance in multiple sclerosis patients by disease subtype was performed. RESULTS It is not clear if social cognition impairment occurs independently or secondarily to neurocognitive impairment. There are associations of variable strengths between neurocognitive and social cognition deficits and their neural basis is increasingly investigated. CONCLUSIONS The prompt detection of neurocognitive predictors of social cognition impairment that may be applicable to all multiple sclerosis subtypes and intervention are crucial to prevent further neural and social cognition decline in multiple sclerosis patients.
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Affiliation(s)
- Triantafyllos Doskas
- Department of Neurology, Athens Naval Hospital, Athens, Greece.,Department of Neurology, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | | | | | | | | | | | - Aspasia Serdari
- Department of Psychiatry, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Theofanis Vorvolakos
- Department of Psychiatry, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Ioannis Iliopoulos
- Department of Neurology, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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10
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On Seker BI, Reeve K, Havla J, Burns J, Gosteli MA, Lutterotti A, Schippling S, Mansmann U, Held U. Prognostic models for predicting clinical disease progression, worsening and activity in people with multiple sclerosis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Begum Irmak On Seker
- Institute for Medical Information Processing, Biometry and Epidemiology; Ludwig-Maximilians-Universität München; Munich Germany
| | - Kelly Reeve
- Epidemiology, Biostatistics and Prevention Institute; University of Zürich; Zurich Switzerland
| | - Joachim Havla
- lnstitute of Clinical Neuroimmunology; Ludwig-Maximilians-Universität München; Munich Germany
| | - Jacob Burns
- Institute for Medical Information Processing, Biometry and Epidemiology; Ludwig-Maximilians-Universität München; Munich Germany
- Pettenkofer School of Public Health; Munich Germany
| | | | | | - Sven Schippling
- Clinic for Neurology; University Hospital Zurich; Zurich Switzerland
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry and Epidemiology; Ludwig-Maximilians-Universität München; Munich Germany
| | - Ulrike Held
- Epidemiology, Biostatistics and Prevention Institute; University of Zürich; Zurich Switzerland
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11
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Hegedüs K, Kárpáti J, Iljicsov A, Simó M. Neuropsychological characteristics of benign multiple sclerosis patients: A two-year matched cohort study. Mult Scler Relat Disord 2019; 35:150-155. [PMID: 31376686 DOI: 10.1016/j.msard.2019.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/19/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The definition of benign multiple sclerosis (BMS) is still debated. It is mainly based on physical status, however, there is an attempt to involve cognitive functioning or paraclinical factors in order to avoid unnecessary long-term treatment with disease-modifying therapies and to identify these subjects in the early stages of the disease. Therefore the aim of our two-year follow-up study was to investigate the pattern of cognitive functioning and depression in patients with BMS compared to treated relapsing-remitting MS (RRMS) patients and healthy controls. METHODS A group of 22 BMS patients was tested against matched RRMS patients and healthy controls. All individuals underwent neuropsychological evaluation exploring mood and the cognitive domains most frequently impaired in MS. MS patients were retested at two-year follow-up. RESULTS In terms of cognitive functions there were no differences between BMS and RRMS patients either at baseline or at two-year follow-up. Compared to healthy controls BMS patients showed poorer performance in long-term visuo-spatial memory and information processing speed, whereas, complex attention, working memory, long-term verbal memory - despite slower verbal learning - and executive function were found to be intact. RRMS patients showed significant difference in complex attention, long-term visual memory and information processing speed. Cognitive impairment differed in the patient groups in terms of severity. Both patient groups were depressed compared to controls, but significant differences were found only between BMS and healthy individuals. CONCLUSION The results of our study confirm that cognitive functions and mood can be affected in MS independent of disease course and disease modifying treatment. The "benign" label should be treated as only a reference to physical status and non-motor symptoms should be routinely monitored. Without receiving therapy it is an existing entity with longstanding minimal disability.
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Affiliation(s)
- Katalin Hegedüs
- Department of Neurology, Semmelweis University, Balassa J. u. 6., 1083 Budapest, Hungary.
| | - Judit Kárpáti
- Department of Neurology, Semmelweis University, Balassa J. u. 6., 1083 Budapest, Hungary
| | - Anna Iljicsov
- Department of Neurology, Semmelweis University, Balassa J. u. 6., 1083 Budapest, Hungary
| | - Magdolna Simó
- Department of Neurology, Semmelweis University, Balassa J. u. 6., 1083 Budapest, Hungary
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12
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Crielaard L, Kavaliunas A, Ramanujam R, Olsson T, Hillert J, Stridh P, Kockum I, Manouchehrinia A. Factors associated with and long-term outcome of benign multiple sclerosis: a nationwide cohort study. J Neurol Neurosurg Psychiatry 2019; 90:761-767. [PMID: 30824631 DOI: 10.1136/jnnp-2018-319913] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/31/2019] [Accepted: 02/02/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Benign multiple sclerosis (BMS) is often defined by the Expanded Disability Status Scale (EDSS) score of ≤3.0 after ≥15 years of disease duration. This classification's clinical relevance remains unclear as benign patients may suffer other impairments and advance towards a progressive course, prompting our objective to holistically investigate factors associated with BMS and its long-term prognosis. METHODS Benign cases were identified in the Swedish Multiple Sclerosis registry. Baseline clinical data, demographic features and influence of multiple sclerosis (MS) major risk alleles on likelihood of benign course were investigated. Physical disability (EDSS), cognitive function (Symbol Digit Modalities Test; SDMT) and self-reported and socioeconomic differences between benign and non-benign patients were evaluated using generalised estimation equations models. RESULTS 11222 patients (2420 benign/8802 non-benign) were included. Benign patients were more likely to be female and younger at MS onset, have fewer relapses within the first two and 5 years from onset and fully recover from the first relapse (p<0.001). No association between human leucocyte antigen (HLA) DRB1*15:01 carriership (OR: 0.97, 95% CI: 0.86 to 1.09) or HLA-A*02:01 lacking (OR: 0.99, 95% CI: 0.87 to 1.11) and benign/non-benign was found. Non-benign patients accumulated an extra 0.04 (95% CI 0.03 to 0.04, p<0.001) EDSS score/year, lost an extra 0.3 (95% CI - 0.39 to - 0.18, p<0.001) SDMT score/year and deteriorated faster in self-reported impact and socioeconomic measures (p<0.001). CONCLUSION Patients with BMS have a better disease course as they progress more slowly at the group level in all respects. Lack of an association with major genetic risk factors indicates that MS course is most likely influenced by either environmental factor(s) or genetic factors outside the HLA region.
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Affiliation(s)
- Loes Crielaard
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Andrius Kavaliunas
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Ryan Ramanujam
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Tomas Olsson
- The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Centre for Molecular Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Pernilla Stridh
- The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Centre for Molecular Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Kockum
- The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Centre for Molecular Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ali Manouchehrinia
- The Karolinska Neuroimmunology & Multiple Sclerosis Centre, Centre for Molecular Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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13
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Cerqueira Pinto SC, Ferreira Vasconcelos CC, Aurenção JCK, Alvarenga MP, das Graças Gomes Camargo SM, Santos Thuler LC, Alvarenga RP. Pediatric Multiple Sclerosis in Rio de Janeiro: Secondary Progression and Disability. Pediatr Neurol 2019; 94:48-54. [PMID: 30850228 DOI: 10.1016/j.pediatrneurol.2018.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 12/21/2018] [Accepted: 12/23/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The onset of multiple sclerosis (MS) in 2% to 10% of cases occurs prior to 18 years of age. Early age onset appears to affect some aspects of multiple sclerosis. The objective of our study was to evaluate the prevalence, the clinical and demographic characteristics, and the disease progression in a sample of pediatric multiple sclerosis patients from a mixed population. METHODS In a cross-sectional design, the prevalence, demographic characteristics, and initial clinical forms were compared between 75 cases of pediatric multiple sclerosis (PMS) and 689 adults with MS. Sixty-five PMS patients with complete data and 260 randomly selected adults with relapsing-remitting multiple sclerosis were compared. A Kaplan-Meier analysis was conducted to compare the age at and time to Expanded Disability Status Scale (EDSS) 3, EDSS 6, and secondary progressive multiple sclerosis (SPMS). RESULTS A total of 9.8% of all MS cases with available data were PMS. All cases of PMS consisted of relapsing-remitting multiple sclerosis. Brazilians of African descent comprised 34.6% of the sample, and the female-to-male ratio was 2.4:1. At the first attack, motor alterations were more common. Benign forms were more common in PMS (84.6% versus 62.2%). Fewer PMS patients reached EDSS 6 (11.6% versus 25.4%) (P = 0.0017) and SPMS (11.1% versus 28.1%) (P = 0.005). PMS patients took longer to reach EDSS 3 (P = 0.017), EDSS 6 (P = 0.001), and SPMS (P < 0.001); however, they reached EDSS 3 earlier (P < 0.001). CONCLUSIONS In this mixed cohort, the prevalence of PMS was similar to that reported in other studies, and the pediatric patients had a more benign course than adults with MS.
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14
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Schaefer LM, Poettgen J, Fischer A, Gold S, Stellmann JP, Heesen C. Impairment and restrictions in possibly benign multiple sclerosis. Brain Behav 2019; 9:e01259. [PMID: 30884218 PMCID: PMC6456783 DOI: 10.1002/brb3.1259] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 12/08/2018] [Accepted: 02/10/2019] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The aim was to describe a broad range of health dimensions in possibly benign multiple sclerosis (MS) hypothesizing that despite some limitations there is a high adaptation to the disease. METHODS All patients from an outpatient university clinic data registry with an Expanded Disability Status Scale (EDSS) ≤3.5 and disease duration ≥15 years were addressed in a cross-sectional study. Physical impairment, neuropsychological functioning but also influence on activities and patient reported outcome measures including coping were studied. RESULTS One hundred and twenty-five patients could be included (mean EDSS: 2.8; mean disease duration: 24 years). Cognitive impairment was minor (8%) but fatigue (73%) and depression (46%) were prevalent. Nevertheless, QOL and daily activities seemed to be less affected. Patients showed high social support, coping abilities, and sense of coherence, which was predictive for their perceived benignity of the disease. Based on the EDSS alone, we estimated the rate of benign MS after 15 years of MS as high as 23% decreasing to 16% if cognition was included in the definition. However, cognitive performance was not relevantly associated with other outcomes. CONCLUSION Common benign MS definitions seem to simplify a complex disease picture where different impairments and personal resources lead to more or less impact on people's lives.
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Affiliation(s)
- Laura Melanie Schaefer
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jana Poettgen
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Fischer
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,University of Central Lancashire, Preston, UK
| | - Stefan Gold
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Klinik für Psychiatrie und Psychotherapie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan-Patrick Stellmann
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Heesen
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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15
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Marques VD, Passos GRD, Mendes MF, Callegaro D, Lana-Peixoto MA, Comini-Frota ER, Vasconcelos CCF, Sato DK, Ferreira MLB, Parolin MKF, Damasceno A, Grzesiuk AK, Muniz A, Matta APDC, Oliveira BESD, Tauil CB, Maciel DRK, Diniz DS, Corrêa EC, Coronetti F, Jorge FMH, Sato HK, Gonçalves MVM, Sousa NADC, Nascimento OJM, Gama PDD, Domingues R, Simm RF, Thomaz RB, Morales RDR, Dias RM, Apóstolos-Pereira SD, Machado SCN, Junqueira TDF, Becker J. Brazilian Consensus for the Treatment of Multiple Sclerosis: Brazilian Academy of Neurology and Brazilian Committee on Treatment and Research in Multiple Sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 76:539-554. [PMID: 30231128 DOI: 10.1590/0004-282x20180078] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 05/16/2018] [Indexed: 12/21/2022]
Abstract
The expanding therapeutic arsenal in multiple sclerosis (MS) has allowed for more effective and personalized treatment, but the choice and management of disease-modifying therapies (DMTs) is becoming increasingly complex. In this context, experts from the Brazilian Committee on Treatment and Research in Multiple Sclerosis and the Neuroimmunology Scientific Department of the Brazilian Academy of Neurology have convened to establish this Brazilian Consensus for the Treatment of MS, based on their understanding that neurologists should be able to prescribe MS DMTs according to what is better for each patient, based on up-to-date evidence and practice. We herein propose practical recommendations for the treatment of MS, with the main focus on the choice and management of DMTs, as well as present a review of the scientific rationale supporting therapeutic strategies in MS.
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Affiliation(s)
- Vanessa Daccach Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas de Ribeirão Preto, Ribeirão Preto SP, Brasil
| | | | - Maria Fernanda Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | - Dagoberto Callegaro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | - Marco Aurélio Lana-Peixoto
- Universidade Federal de Minas Gerais, Centro de Investigação em Esclerose Múltipla de Minas Gerais, Belo Horizonte MG, Brasil
| | | | | | | | | | | | | | | | | | | | | | - Carlos Bernardo Tauil
- Universidade de Brasília, Brasília DF, Brasil.,Universidade Católica de Brasília, Brasília DF, Brasil
| | | | | | | | | | - Frederico M H Jorge
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | | | | | | | | | | | - Renan Domingues
- Senne Líquor Diagnóstico, São Paulo SP, Brasil.,Hospital Cruz Azul, São Paulo SP, Brasil.,Faculdade São Leopoldo Mandic, Campinas SP, Brasil
| | - Renata Faria Simm
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | | | | | | | | | | | | | - Jefferson Becker
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre RS, Brasil.,Universidade Federal Fluminense, Niterói RJ, Brasil
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16
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Fabis-Pedrini MJ, James I, Seewann A, Yau WY, van de Bovenkamp AA, Sanders FRK, Qiu W, Burton J, Mastaglia FL, Carroll WM, Kermode AG. Natural history of benign multiple sclerosis: Clinical and HLA correlates in a Western Australian cohort. J Neurol Sci 2018; 388:12-18. [PMID: 29627005 DOI: 10.1016/j.jns.2018.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/20/2018] [Accepted: 02/21/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Benign multiple sclerosis (BMS) is a controversial term that has been used for MS patients with minimal disability decades after disease onset. Herein, we evaluated disease status after 20 years in a Western Australian cohort defined as BMS based on an Expanded Disability Status Scale (EDSS) score ≤ 3.0 at 10 years from onset. METHODS MS patients with an EDSS score ≤ 3.0 at 10 years from onset and minimum of 20 years follow up were included in the study. The 20-year EDSS score was considered the primary outcome. Associations with demographic and clinical characteristics and HLA-DRB1 genotype were investigated. RESULTS Among 120 patients with a benign course at 10 years, 78 (65%) remained benign at the 20-year follow up, but patients with an EDSS ≥ 2.5 were more likely to go on to develop more severe disability in the next decade. When considering factors associated with an increase in EDSS score ≤ 1 from 10 to 20 years, indicating limited progression, apart from the EDSS score at 10 years, poly-symptomatic presentation (p = 0.004) and cerebellar/brainstem mono-symptomatic presentation (p = 0.016) were independently associated with more rapid progression compared with other mono-symptomatic presentations. Carriage of the high risk HLA-DRB1*1501 allele was marginally associated with slower progression. CONCLUSIONS In this geographically isolated MS cohort of predominantly Anglo-Celtic origin clinical progression in the benign MS group was similar to that in other published series from Western countries. These results are in keeping with the view that patients labeled as benign MS are part of a heterogeneous continuum of disease progression and do not possess unique clinical characteristics. Possible genetic determinants of a benign course warrant further investigation.
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Affiliation(s)
- Marzena J Fabis-Pedrini
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, UWA, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Ian James
- Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
| | - Alexandra Seewann
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, UWA, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Wai Y Yau
- Sir Charles Gairdner Hospital, Neurology Department, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Arnold A van de Bovenkamp
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, UWA, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Fay R K Sanders
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, UWA, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Wei Qiu
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, UWA, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Jason Burton
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, UWA, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia; Sir Charles Gairdner Hospital, Neurology Department, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Frank L Mastaglia
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, UWA, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - William M Carroll
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, UWA, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia; Sir Charles Gairdner Hospital, Neurology Department, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Allan G Kermode
- Centre for Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, UWA, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia; Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia; Sir Charles Gairdner Hospital, Neurology Department, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia.
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17
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Repetitive Transcranial Magnetic Stimulation, Cognition, and Multiple Sclerosis: An Overview. Behav Neurol 2018; 2018:8584653. [PMID: 29568339 PMCID: PMC5822759 DOI: 10.1155/2018/8584653] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 12/07/2017] [Indexed: 11/30/2022] Open
Abstract
Multiple sclerosis (MS) affects cognition in the majority of patients. A major aspect of the disease is brain volume loss (BVL), present in all phases and types (relapsing and progressive) of the disease and linked to both motor and cognitive disabilities. Due to the lack of effective pharmacological treatments for cognition, cognitive rehabilitation and other nonpharmacological interventions such as repetitive transcranial magnetic stimulation (rTMS) have recently emerged and their potential role in functional connectivity is studied. With recently developed advanced neuroimaging and neurophysiological techniques, changes related to alterations of the brain's functional connectivity can be detected. In this overview, we focus on the brain's functional reorganization in MS, theoretical and practical aspects of rTMS utilization in humans, and its potential therapeutic role in treating cognitively impaired MS patients.
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18
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Ton AMM, Vasconcelos CCF, Alvarenga RMP. Benign multiple sclerosis: aspects of cognition and neuroimaging. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:394-401. [PMID: 28658410 DOI: 10.1590/0004-282x20170043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 03/20/2017] [Indexed: 11/22/2022]
Abstract
The existence of a benign multiple sclerosis (BMS) form is a controversial subject. Recent studies of these patients reveal different levels of cognitive impairment, despite the apparent preservation of motor function. The objective of this study was to review and analyze a number of publications that discuss the general aspects of this disease form, such as the definition criteria, prevalence, and clinical and neuroimaging markers. A systematic review of published data on BMS up to October 2015 was performed. Thirty-one published articles were analyzed. The estimated frequency of BMS varied between 6% and 73%. Cognitive impairment was recognized as affecting 17% to 47% of the subjects and presented significant correlation with neuroimaging, such as brain atrophy, increased lesion volume in T2 magnetic resonance assay, and regional grey matter atrophy. The current criteria overestimated the frequency of BMS and, for that reason, this highlights the importance of validating the diagnostic methods practiced.
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19
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Gouider R. Can we discontinue disease-modifying treatments in multiple sclerosis patients? Comments. Rev Neurol (Paris) 2016; 173:44-46. [PMID: 27919465 DOI: 10.1016/j.neurol.2016.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 10/12/2016] [Accepted: 10/13/2016] [Indexed: 11/26/2022]
Affiliation(s)
- R Gouider
- Service de neurologie, unité de recherche neurophysiologie clinique et électrodiagnostic 03/UR/08-09, hôpital Razi, rue des orangers, La Manouba, 2010 Tunis, Tunisie.
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20
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Zivadinov R, Cookfair DL, Krupp L, Miller AE, Lava N, Coyle PK, Goodman AD, Jubelt B, Lenihan M, Herbert J, Gottesman M, Snyder DH, Apatoff BR, Teter BE, Perel AB, Munschauer F, Weinstock-Guttman B. Factors associated with benign multiple sclerosis in the New York State MS Consortium (NYSMSC). BMC Neurol 2016; 16:102. [PMID: 27416843 PMCID: PMC4946222 DOI: 10.1186/s12883-016-0623-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 06/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This retrospective analysis explored prognostic factors associated with a benign multiple sclerosis (BMS) disease course at baseline and over the 4-year follow-up. METHODS Patients from the centralized New York State Multiple Sclerosis Consortium registry were classified as having BMS according to 3 different criteria centered on disease duration and disability. Additional analyses explored prognostic factors associated with BMS using the most conservative disability criteria (Expanded Disability Status Scale ≤2 and disease duration ≥10 years). RESULTS Among 6258 patients who fulfilled eligibility criteria, 19.8 % to 33.3 % were characterized as having BMS, at baseline depending on classification criteria used. Positive prognostic factors for BMS at baseline included female sex (p < 0.0001) and younger age at onset (p < 0.0001); negative prognostic factors included progressive-onset type of MS and African-American race. Of the 1237 BMS patients (per most conservative criteria), 742 were followed for a median of 4 years to explore effect of disease-modifying treatment (DMT) on benign status. DMT (p = 0.009) and longer disease duration (p = 0.007) were the only significant positive predictors of maintaining BMS at follow-up. The protective effect was stronger for patients taking DMT at both enrollment and follow-up (OR = 0.71; p = 0.006). CONCLUSIONS There is a need for development of more reliable prognostic indicators of BMS. Use of DMT was significantly associated with maintaining a benign disease state.
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Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA. .,Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA.
| | - Diane L Cookfair
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | - Lauren Krupp
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Aaron E Miller
- The Corinne Goldsmith Dickinson Center of Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA
| | - Neil Lava
- Department of Neurology, Albany Medical School, Multiple Sclerosis Center, Albany, NY, USA
| | - Patricia K Coyle
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Andrew D Goodman
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Burk Jubelt
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Joseph Herbert
- Department of Neurology, NYU School of Medicine, New York, NY, USA
| | - Malcolm Gottesman
- Department of Neuroscience, Winthrop University Hospital, Mineola, NY, USA
| | - David H Snyder
- Department of Neurology, Weill Medical College of Cornell University, New York, NY, USA.,Department of Neurology, Albert Einstein College of Medicine, New York, NY, USA
| | | | - Barbara E Teter
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | | | - Frederick Munschauer
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
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21
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Hatipoglu H, Canbaz Kabay S, Gungor Hatipoglu M, Ozden H. Expanded Disability Status Scale-Based Disability and Dental-Periodontal Conditions in Patients with Multiple Sclerosis. Med Princ Pract 2016; 25:49-55. [PMID: 26473494 PMCID: PMC5588297 DOI: 10.1159/000440980] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 09/09/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the association between different disability states in patients with multiple sclerosis (MS) as determined by the expanded disability status scale (EDSS) and dental-periodontal measures. SUBJECTS AND METHODS Eighty patients with MS (64 females and 16 males) were included in this study. Data on MS types, attack frequency, disease duration, EDSS scores and orofacial complaints prior to an MS attack were obtained from medical records. The plaque index (PI), probing depth (PD), clinical attachment level (CAL), gingival index (GI), decayed-missing-filled teeth (DMFT) index and number of present teeth were measured during one dental examination for each subject. The MS patients were divided into the following 2 groups based on their EDSS scores: low physical disability (L-DS) and high physical disability (H-DS). Differences in dental parameters between groups of low and high disability were investigated. p < 0.05 was considered statistically significant. RESULTS The mean age of the participants was 38.06 ± 10.11 years. Age and disease duration were higher in the H-DS MS group than in the L-DS MS group (p < 0.05). The PI, PD and GI were higher and the number of filled teeth was lower in the H-DS MS group than in the L-DS MS group (p < 0.05). The EDSS scores of the H-DS MS group presented a significant correlation with the number of decayed teeth (r = -0.548, p = 0.005). Orofacial complaints prior to an MS attack were reported by 18 (22.5%) patients. CONCLUSION Oral measurements revealed various differences between groups of low and high disability in MS patients. In addition, some maxillofacial-oral complaints prior to an MS attack were observed.
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Affiliation(s)
- Hasan Hatipoglu
- Department of Periodontology, Faculty of Dentistry, Eskisehir, Turkey
| | - Sibel Canbaz Kabay
- Department of Neurology, Faculty of Medicine, Dumlupinar University, Kutahya, Eskisehir, Turkey
| | - Mujgan Gungor Hatipoglu
- Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Eskisehir, Turkey
- *Dr. Mujgan Gungor Hatipoglu, Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Central Campus, Dumlupinar University, Tavsanlý, Yolu 10.km, TR–43100 Kutahya (Turkey) E-Mail
| | - Hilmi Ozden
- Department of Department of Anatomy, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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Radomski AD, Power C, Purdon SE, Emery DJ, Blevins G, Warren KG, Fujiwara E. Decision-making under explicit risk is impaired in multiple sclerosis: relationships with ventricular width and disease disability. BMC Neurol 2015; 15:61. [PMID: 25899600 PMCID: PMC4428249 DOI: 10.1186/s12883-015-0318-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 04/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decision-making is an essential function of everyday life. Decision-making under explicit risk requires developing advantageous decision strategies based on fixed outcomes (e.g., probabilities of winning or losing a bet). Decision-making and its neural substrates have been rarely studied in MS. We expected performance in decision-making under risk to be lowered in MS patients, and negatively correlated with disease-related disability, cognition, and ventricular width. METHODS Three groups were included: 32 MS patients and 20 healthy controls were examined with conventional neuropsychological tests and the Game-of-Dice Task (GDT) assessing decision-making under explicit risk. Linear 2-D ventricular width was assessed on MS patients' clinical MRIs and compared to a third group, 20 non-MS neurological control patients. RESULTS Compared to healthy controls, MS patients showed impaired GDT and neuropsychological performance, depending on the MS-subtype (relapsing-remitting (RR), n = 22; secondary progressive, n = 10) and disability severity among RR-MS patients. In MS patients, GDT performance correlated with processing speed, intercaudate ratio, and third ventricle ratio (p's < 0.05). Mediation analysis showed that the link between GDT performance and processing speed was fully explained by ventricular size. CONCLUSION Decision-making under explicit risk was reduced in MS patients, but only those with more pronounced disability. Independent of processing speed, decision-making under explicit risk correlates inversely with central atrophy in MS.
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Affiliation(s)
- Ashley D Radomski
- Department of Psychiatry, University of Alberta, 1E1.01 WCM Health Sciences Centre, Edmonton, Alberta, T6G 2R7, Canada.
| | - Christopher Power
- Department of Psychiatry, University of Alberta, 1E1.01 WCM Health Sciences Centre, Edmonton, Alberta, T6G 2R7, Canada.
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada.
| | - Scot E Purdon
- Department of Psychiatry, University of Alberta, 1E1.01 WCM Health Sciences Centre, Edmonton, Alberta, T6G 2R7, Canada.
- Neuropsychology Service, Alberta Hospital Edmonton, Edmonton, Canada.
| | - Derek J Emery
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada.
| | - Gregg Blevins
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada.
| | - Kenneth G Warren
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada.
| | - Esther Fujiwara
- Department of Psychiatry, University of Alberta, 1E1.01 WCM Health Sciences Centre, Edmonton, Alberta, T6G 2R7, Canada.
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Abstract
Multiple sclerosis (MS) has been thought to be a complex and indecipherable disease, and poorly understood with regards to aetiology. Here, we suggest an emphatically positive view of progress over several decades in the understanding and treatment of MS, particularly focusing on advances made within the past 20 years. As with virtually all complex disorders, MS is caused by the interaction of genetic and environmental factors. In recent years, formidable biochemical, bioinformatic, epidemiological and neuroimaging tools have been brought to bear on research into the causes of MS. While susceptibility to the disease is now relatively well accounted for, disease course is not and remains a salient challenge. In the therapeutic realm, numerous agents have become available, reflecting the fact that the disease can be attacked successfully at many levels and using varied strategies. Tailoring therapies to individuals, risk mitigation and selection of first-line as compared with second-line medications remain to be completed. In our view, the MS landscape has been comprehensively and irreversibly transformed by this progress. Here we focus on MS therapeutics-the most meaningful outcome of research efforts.
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Affiliation(s)
| | - David A Hafler
- Departments of Neurology and Immunobiology, Yale School of Medicine, 15 York Street, New Haven, CT 06520, USA
| | - Claudia F Lucchinetti
- Department of Neurology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Dang PT, Bui Q, D'Souza CS, Orian JM. Modelling MS: Chronic-Relapsing EAE in the NOD/Lt Mouse Strain. Curr Top Behav Neurosci 2015; 26:143-177. [PMID: 26126592 DOI: 10.1007/7854_2015_378] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Modelling complex disorders presents considerable challenges, and multiple sclerosis (MS) is no exception to this rule. The aetiology of MS is unknown, and its pathophysiology is poorly understood. Moreover, the last two decades have witnessed a dramatic revision of the long-held view of MS as an inflammatory demyelinating white matter disease. Instead, it is now regarded as a global central nervous system (CNS) disorder with a neurodegenerative component. Currently, there is no animal model recapitulating MS immunopathogenesis. Available models are based on autoimmune-mediated demyelination, denoted experimental autoimmune encephalomyelitis (EAE) or virally or chemically induced demyelination. Of these, the EAE model has been the most commonly used. It has been extensively improved since its first description and now exists as a number of variants, including genetically modified and humanized versions. Nonetheless, EAE is a distinct disease, and each variant models only certain facets of MS. Whilst the search for more refined MS models must continue, it is important to further explore where mechanisms underlying EAE provide proof-of-principle for those driving MS pathogenesis. EAE variants generated with the myelin component myelin oligodendrocyte glycoprotein (MOG) have emerged as the preferred ones, because in this particular variant disease is associated with both T- and B-cell effector mechanisms, together with demyelination. MOG-induced EAE in the non-obese diabetic (NOD) mouse strain exhibits a chronic-relapsing EAE clinical profile and high disease incidence. We describe the generation of this variant, its contribution to the understanding of MS immune and pathogenetic mechanisms and potential for evaluation of candidate therapies.
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Affiliation(s)
- Phuc T Dang
- Department of Biochemistry and La Trobe Institute for Molecular Science, La Trobe University, Bundoora, VIC, 3086, Australia
| | - Quyen Bui
- Department of Biochemistry and La Trobe Institute for Molecular Science, La Trobe University, Bundoora, VIC, 3086, Australia
| | - Claretta S D'Souza
- Department of Biochemistry and La Trobe Institute for Molecular Science, La Trobe University, Bundoora, VIC, 3086, Australia
| | - Jacqueline M Orian
- Department of Biochemistry and La Trobe Institute for Molecular Science, La Trobe University, Bundoora, VIC, 3086, Australia.
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25
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Fragoso YD. Glatiramer acetate to treat multiple sclerosis during pregnancy and lactation: a safety evaluation. Expert Opin Drug Saf 2014; 13:1743-8. [PMID: 25176273 DOI: 10.1517/14740338.2014.955849] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a disease that mainly affects young adults who are of reproductive age. MS can lead to severe disability and is associated with worse prognosis in untreated patients. Although MS is not negatively affected by pregnancy itself, it may be a high-risk decision to leave a woman without treatment because she may get pregnant. AREAS COVERED This paper reviews the literature on pregnancies where the mother was exposed to glatiramer acetate . Few data are available on paternal exposure, but this does not seem to pose a problem due to the pharmacological characteristics of the drug. Only a limited amount of data from individual groups in the world is available in the literature. EXPERT OPINION TEVA Pharmaceuticals would need to open the database on pregnancy exposure to glatiramer acetate to allow for proper conclusions. Glatiramer acetate is a drug of low risk in pregnancy (category B in the FDA classification) and may be a safe option for the treatment of women of fertile age with MS.
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Affiliation(s)
- Yara Dadalti Fragoso
- Universidade Metropolitana de Santos, Department of Neurology, Medical Faculty UNIMES , Rua da Constituicao 374, CEP 11015-470, Santos SP , Brazil +55 13 32263400 ;
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26
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Balk LJ, Tewarie P, Killestein J, Polman CH, Uitdehaag BMJ, Petzold A. Disease course heterogeneity and OCT in multiple sclerosis. Mult Scler 2014; 20:1198-206. [DOI: 10.1177/1352458513518626] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/08/2013] [Indexed: 11/16/2022]
Abstract
Background: The heterogeneity of the disease course in multiple sclerosis (MS) remains a challenge for patient management and clinical trials. Objective: The objective of this paper is to investigate the relationship between disease course heterogeneity and retinal layer thicknesses in MS. Methods: A total of 230 MS patients and 63 healthy control subjects were included. Spectral-domain OCT scanning of the peripapillary and macular regions was performed, followed by automated eight-layer segmentation. Generalised estimation equations were used for comparisons. Receiver operating characteristic (ROC) curves were calculated for distinguishing a benign from a typical disease course. Results: Primary progressive patients showed relative preservation of inner retinal layers, compared to the relapsing onset MS types. Only in MS eyes without optic neuritis did patients with typical MS show more severe thinning of the inner retinal layers (RNFL to INL) compared to patients with a benign disease course, even after an average disease course of 20 years. Conclusion: The thicknesses, particularly of the innermost retinal layers (RNFL, GCC), were significantly related to the heterogeneous disease course in MS. The relative preservation of these layers in primary progressive and benign MS suggests rather limited susceptibility of the retina to neurodegeneration, which may be relevant for future neurodegenerative treatment trials employing OCT as a secondary outcome measure in primary progressive MS.
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Affiliation(s)
- LJ Balk
- Department of Neurology, VU University Medical Centre, the Netherlands
| | - P Tewarie
- Department of Neurology, VU University Medical Centre, the Netherlands
| | - J Killestein
- Department of Neurology, VU University Medical Centre, the Netherlands
| | - CH Polman
- Department of Neurology, VU University Medical Centre, the Netherlands
| | - BMJ Uitdehaag
- Department of Neurology, VU University Medical Centre, the Netherlands
| | - A Petzold
- Department of Neurology, VU University Medical Centre, the Netherlands
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