Multiple sclerosis: diagnosis, differential diagnosis, and clinical presentation

Comparison of different telerehabilitation protocols for urogenital symptoms in females with multiple sclerosis: a randomized controlled trial

Telerehabilitation has been suggested to be equally effective than in-person rehabilitation, and could be helpful to increase participation and reduce barriers. People with multiple sclerosis (MS) often present urogenital dysfunctions, impairing independence and quality of life (QoL). Since the different available telerehabilitation protocols, the present study aimed to compare a live video urogenital rehabilitation intervention protocol (REMOTE) with a home-based pre-recorded video protocol (SELF). A randomized-controlled trial was performed, with 14 females with MS being allocated in the REMOTE group (36 ± 9 y) and 14 females in the SELF group (37 ± 7 y). Both telerehabilitation protocols were identical in terms of contents (including pelvic floor training and relaxation exercises), frequency and duration, consisting of 10 sessions of 45 min each, every 5 days. Questionnaires were administered at the beginning and the end of the study: Short Form Health Survey 36 (SF-36), Beck Depression Inventory (BDI), Female Sexual Function Index (FSFI), International Consultation on Incontinence Questionnaire (ICIQ) symptoms and related QoL, the main outcome being ICIQ incontinence score. Despite most of the outcomes improved in both groups, REMOTE was found to be more effective than SELF in most of the SF-36 domains (from p < 0.001 pη2 0.555 to p = 0.044 pη2 0.147), FSFI (p = 0.001 pη2 0.373), ICIQ (p = 0.003 pη2 0.291). Despite the home-based pre-recorded videos could be effective in improving urogenital symptoms, live video urogenital rehabilitation results in larger improvements. Telerehabilitation should be encouraged for urogenital dysfunctions in females with MS, and pre-recorded videos could represent an alternative when live sessions are not available. Clinical trial registration This randomized controlled trial was registered on ClinicalTrials.gov with the number NCT05984095.

CSF Parvalbumin Levels at Multiple Sclerosis Diagnosis Predict Future Worse Cognition, Physical Disability, Fatigue, and Gray Matter Damage

BACKGROUND AND OBJECTIVES

Cognitive impairment (CI) in multiple sclerosis (MS) is frequent and determined by a complex interplay between inflammatory and neurodegenerative processes. We aimed to investigate whether CSF parvalbumin (PVALB), measured at the time of diagnosis, may have a prognostic role in patients with MS.

METHODS

In this cohort study, CSF analysis of PVALB and Nf-L levels was performed on all patients at diagnosis (T0) and combined with physical, cognitive, and MRI assessment after an average of 4 years of follow-up (T4) from diagnosis. Cognitive performance was evaluated with a comprehensive neuropsychologic battery: both global (cognitively normal, CN, mildly CI, mCI, and severely CI, sCI) and domain cognitive status (normal/impaired in memory, attention/information processing speed, and executive functions) were considered. Cortical thickness and gray matter volume data were acquired using 3T MRI scanner.

RESULTS

A total of 72 patients with MS were included. At diagnosis, PVALB levels were higher in those patients who showed a worsening physical disability after 4 years of follow-up (p = 0.011). CSF PVALB levels were higher in sCI patients than in CN (p = 0.033). Moreover, higher PVALB levels significantly correlated with worse global cognitive (p = 0.024) and memory functioning (p = 0.044). A preliminary clinical threshold for PVALB levels at diagnosis was proposed (2.57 ng/mL), which maximizes the risk of showing CI (in particular, sCI) at follow-up, with a sensitivity of 91% (specificity 30%). No significant results were found for these associations with Nf-L. In addition, patients with higher levels of PVALB at diagnosis showed higher cognitive (p = 0.024) and global fatigue (p = 0.043) at follow-up. Finally, higher PVALB levels also correlated significantly with more pronounced CTh/volume at T4 in the inferior frontal gyrus (p = 0.044), postcentral gyrus (p = 0.025), frontal pole (p = 0.042), transverse temporal gyrus (p = 0.008), and cerebellar cortex (p = 0.041) and higher atrophy (change T0-T4) in the right thalamus (p = 0.038), pericalcarine cortex (p = 0.009), lingual gyrus (p = 0.045), and medial frontal gyrus (p = 0.028).

DISCUSSION

The significant association found between parvalbumin levels in the CSF at diagnosis and cognitive, clinical, and neuroradiologic worsening after 4 years of follow-up support the idea that parvalbumin, in addition to Nf-L, might represent a new potential prognostic biomarker, reflecting MS neurodegenerative processes occurring since early disease stages.

An extensible and unifying approach to retrospective clinical data modeling: the BrainTeaser Ontology

Automatic disease progression prediction models require large amounts of training data, which are seldom available, especially when it comes to rare diseases. A possible solution is to integrate data from different medical centres. Nevertheless, various centres often follow diverse data collection procedures and assign different semantics to collected data. Ontologies, used as schemas for interoperable knowledge bases, represent a state-of-the-art solution to homologate the semantics and foster data integration from various sources. This work presents the BrainTeaser Ontology (BTO), an ontology that models the clinical data associated with two brain-related rare diseases (ALS and MS) in a comprehensive and modular manner. BTO assists in organizing and standardizing the data collected during patient follow-up. It was created by harmonizing schemas currently used by multiple medical centers into a common ontology, following a bottom-up approach. As a result, BTO effectively addresses the practical data collection needs of various real-world situations and promotes data portability and interoperability. BTO captures various clinical occurrences, such as disease onset, symptoms, diagnostic and therapeutic procedures, and relapses, using an event-based approach. Developed in collaboration with medical partners and domain experts, BTO offers a holistic view of ALS and MS for supporting the representation of retrospective and prospective data. Furthermore, BTO adheres to Open Science and FAIR (Findable, Accessible, Interoperable, and Reusable) principles, making it a reliable framework for developing predictive tools to aid in medical decision-making and patient care. Although BTO is designed for ALS and MS, its modular structure makes it easily extendable to other brain-related diseases, showcasing its potential for broader applicability.Database URL  https://zenodo.org/records/7886998 .

Human Endogenous Retroviruses in Neurodegenerative Diseases

Human endogenous retroviruses (HERVs) are DNA transposable elements that have integrated into the human genome via an ancestral germline infection. The potential importance of HERVs is underscored by the fact that they comprise approximately 8% of the human genome. HERVs have been implicated in the pathogenesis of neurodegenerative diseases, a group of CNS diseases characterized by a progressive loss of structure and function of neurons, resulting in cell death and multiple physiological dysfunctions. Much evidence indicates that HERVs are initiators or drivers of neurodegenerative processes in multiple sclerosis and amyotrophic lateral sclerosis, and clinical trials have been designed to target HERVs. In recent years, the role of HERVs has been explored in other major neurodegenerative diseases, including frontotemporal dementia, Alzheimer's disease and Parkinson's disease, with some interesting discoveries. This review summarizes and evaluates the past and current research on HERVs in neurodegenerative diseases. It discusses the potential role of HERVs in disease manifestation and neurodegeneration. It critically reviews antiretroviral strategies used in the therapeutic intervention of neurodegenerative diseases.

The Role of Gut-derived Short-Chain Fatty Acids in Multiple Sclerosis

Multiple sclerosis (MS) is a chronic condition affecting the central nervous system (CNS), where the interplay of genetic and environmental factors influences its pathophysiology, triggering immune responses and instigating inflammation. Contemporary research has been notably dedicated to investigating the contributions of gut microbiota and their metabolites in modulating inflammatory reactions within the CNS. Recent recognition of the gut microbiome and dietary patterns as environmental elements impacting MS development emphasizes the potential influence of small, ubiquitous molecules from microbiota, such as short-chain fatty acids (SCFAs). These molecules may serve as vital molecular signals or metabolic substances regulating host cellular metabolism in the intricate interplay between microbiota and the host. A current emphasis lies on optimizing the health-promoting attributes of colonic bacteria to mitigate urinary tract issues through dietary management. This review aims to spotlight recent investigations on the impact of SCFAs on immune cells pivotal in MS, the involvement of gut microbiota and SCFAs in MS development, and the considerable influence of probiotics on gastrointestinal disruptions in MS. Comprehending the gut-CNS connection holds promise for the development of innovative therapeutic approaches, particularly probiotic-based supplements, for managing MS.

Neuroprotective effects of gemfibrozil in neurological disorders: Focus on inflammation and molecular mechanisms

BACKGROUND

Gemfibrozil (Gem) is a drug that has been shown to activate PPAR-α, a nuclear receptor that plays a key role in regulating lipid metabolism. Gem is used to lower the levels of triglycerides and reduce the risk of coronary heart disease in patients. Experimental studies in vitro and in vivo have shown that Gem can prevent or slow the progression of neurological disorders (NDs), including cerebral ischemia (CI), Alzheimer's disease (AD), Parkinson's disease (PD), and multiple sclerosis (MS). Neuroinflammation is known to play a significant role in these disorders.

METHOD

The literature review for this study was conducted by searching Scopus, Science Direct, PubMed, and Google Scholar databases.

RESULT

The results of this study show that Gem has neuroprotective effects through several cellular and molecular mechanisms such as: (1) Gem has the ability to upregulate pro-survival factors (PGC-1α and TFAM), promoting the survival and function of mitochondria in the brain, (2) Gem strongly inhibits the activation of NF-κB, AP-1, and C/EBPβ in cytokine-stimulated astroglial cells, which are known to increase the expression of iNOS and the production of NO in response to proinflammatory cytokines, (3) Gem protects dopamine neurons in the MPTP mouse model of PD by increasing the expression of PPARα, which in turn stimulates the production of GDNF in astrocytes, (4) Gem reduces amyloid plaque pathology, reduces the activity of glial cells, and improves memory, (5) Gem increases myelin genes expression (MBP and CNPase) via PPAR-β, and (6) Gem increases hippocampal BDNF to counteract depression.

CONCLUSION

According to the study, Gem was investigated for its potential therapeutic effect in NDs. Further research is needed to fully understand the therapeutic potential of Gem in NDs.

A Closed-Loop Falls Monitoring and Prevention App for Multiple Sclerosis Clinical Practice: Human-Centered Design of the Multiple Sclerosis Falls InsightTrack

BACKGROUND

Falls are common in people with multiple sclerosis (MS), causing injuries, fear of falling, and loss of independence. Although targeted interventions (physical therapy) can help, patients underreport and clinicians undertreat this issue. Patient-generated data, combined with clinical data, can support the prediction of falls and lead to timely intervention (including referral to specialized physical therapy). To be actionable, such data must be efficiently delivered to clinicians, with care customized to the patient's specific context.

OBJECTIVE

This study aims to describe the iterative process of the design and development of Multiple Sclerosis Falls InsightTrack (MS-FIT), identifying the clinical and technological features of this closed-loop app designed to support streamlined falls reporting, timely falls evaluation, and comprehensive and sustained falls prevention efforts.

METHODS

Stakeholders were engaged in a double diamond process of human-centered design to ensure that technological features aligned with users' needs. Patient and clinician interviews were designed to elicit insight around ability blockers and boosters using the capability, opportunity, motivation, and behavior (COM-B) framework to facilitate subsequent mapping to the Behavior Change Wheel. To support generalizability, patients and experts from other clinical conditions associated with falls (geriatrics, orthopedics, and Parkinson disease) were also engaged. Designs were iterated based on each round of feedback, and final mock-ups were tested during routine clinical visits.

RESULTS

A sample of 30 patients and 14 clinicians provided at least 1 round of feedback. To support falls reporting, patients favored a simple biweekly survey built using REDCap (Research Electronic Data Capture; Vanderbilt University) to support bring-your-own-device accessibility-with optional additional context (the severity and location of falls). To support the evaluation and prevention of falls, clinicians favored a clinical dashboard featuring several key visualization widgets: a longitudinal falls display coded by the time of data capture, severity, and context; a comprehensive, multidisciplinary, and evidence-based checklist of actions intended to evaluate and prevent falls; and MS resources local to a patient's community. In-basket messaging alerts clinicians of severe falls. The tool scored highly for usability, likability, usefulness, and perceived effectiveness (based on the Health IT Usability Evaluation Model scoring).

CONCLUSIONS

To our knowledge, this is the first falls app designed using human-centered design to prioritize behavior change and, while being accessible at home for patients, to deliver actionable data to clinicians at the point of care. MS-FIT streamlines data delivery to clinicians via an electronic health record-embedded window, aligning with the 5 rights approach. Leveraging MS-FIT for data processing and algorithms minimizes clinician load while boosting care quality. Our innovation seamlessly integrates real-world patient-generated data as well as clinical and community-level factors, empowering self-care and addressing the impact of falls in people with MS. Preliminary findings indicate wider relevance, extending to other neurological conditions associated with falls and their consequences.

Adult inflammatory leukoencephalopathies

Inflammatory white matter disorders may commonly mimic genetic leukoencephalopathies. These include atypical presentations of common conditions, such as multiple sclerosis, together with rare inflammatory disorders. A structured approach to such cases is essential, together with judicious use of the many available diagnostic biomarkers. The potential for such conditions to respond to immunotherapy emphasizes the importance of an accurate and prompt diagnosis in improving patient outcomes.

Astrocyte Activation and Drug Target in Pathophysiology of Multiple Sclerosis

Multiple sclerosis (MS) is a neurodegenerative disease, which is also referred to as an autoimmune disorder with chronic inflammatory demyelination affecting the core system that is the central nervous system (CNS). Demyelination is a pathological manifestation of MS. It is the destruction of myelin sheath, which is wrapped around the axons, and it results in the loss of synaptic connections and conduction along the axon is also compromised. Various attempts are made to understand MS and demyelination using various experimental models out of them. The most popular model is experimental autoimmune encephalomyelitis (EAE), in which autoimmunity against CNS components is induced in experimental animals by immunization with self-antigens derived from basic myelin protein. Astrocytes serve as a dual-edged sword both in demyelination and remyelination. Various drug targets have also been discussed that can be further explored for the treatment of MS. An extensive literature research was done from various online scholarly and research articles available on PubMed, Google Scholar, and Elsevier. Keywords used for these articles were astrocyte, demyelination, astrogliosis, and reactive astrocytes. This includes articles being the most relevant information to the area compiled to compose a current review.

Pharmacological targeting of coagulation factor XI attenuates experimental autoimmune encephalomyelitis in mice

Multiple sclerosis (MS) is the most common causes of non-traumatic disability in young adults worldwide. MS pathophysiologies include the formation of inflammatory lesions, axonal damage and demyelination, and blood brain barrier (BBB) disruption. Coagulation proteins, including factor (F)XII, can serve as important mediators of the adaptive immune response during neuroinflammation. Indeed, plasma FXII levels are increased during relapse in relapsing-remitting MS patients, and previous studies showed that reducing FXII levels was protective in a murine model of MS, experimental autoimmune encephalomyelitis (EAE). Our objective was to determine if pharmacological targeting of FXI, a major substrate of activated FXII (FXIIa), improves neurological function and attenuates CNS damage in the setting of EAE. EAE was induced in male mice using murine myelin oligodendrocyte glycoprotein peptides combined with heat-inactivated Mycobacterium tuberculosis and pertussis toxin. Upon onset of symptoms, mice were treated every other day intravenously with anti-FXI antibody, 14E11, or saline. Disease scores were recorded daily until euthanasia for ex vivo analyses of inflammation. Compared to the vehicle control, 14E11 treatment reduced the clinical severity of EAE and total mononuclear cells, including CD11b+CD45high macrophage/microglia and CD4+ T cell numbers in brain. Following pharmacological targeting of FXI, BBB disruption was reduced, as measured by decreased axonal damage and fibrin(ogen) accumulation in the spinal cord. These data demonstrate that pharmacological inhibition of FXI reduces disease severity, immune cell migration, axonal damage, and BBB disruption in mice with EAE. Thus, therapeutic agents targeting FXI and FXII may provide a useful approach for treating autoimmune and neurologic disorders.

Self-management interventions for people with multiple sclerosis: A systematic review and meta-analysis protocol

Background and Aims

Educational self-management interventions (SMI) have an important role in improving symptom management, preventing relapse of multiple sclerosis (MS) and promoting quality of life (QoL) of these patients; since there is little knowledge about overall effectiveness of MS self-management programs and which types of SMI improves the outcomes, this research aims to assess the efficacy of structured SMI in improving health outcomes in people with MS (PwMS) by synthesizing and compare outcomes from related randomized controlled trials.

Methods

In the present systematic review protocol, the keywords related to self-management and MS will be searched in electronic databases including (PubMed, Web of Science, Scopus, EMBASE, Cochrane Central Register of Controlled Trials [CENTRAL]), gray literature resources and key journals from 2000 to July 2023. Research-related articles will be collected and after removing duplicate articles, will be included in the study. In the screening step, titles and abstracts of articles will be reviewed and after deleting irrelevant articles, the full text of related articles will be evaluated independently by two researchers and data will be extracted from final articles and the findings will be categorized in an extraction table. Risk of bias will be assessed by using the Cochrane collaboration's tool. If possible, the data will be analyzed using random effect models and the statistical analysis will be performed using STATA software (version 14.2) developed by StataCorp.

Discussion

Comparative effectiveness of SMI is currently unknown. We will analyze outcome measures used to assess effectiveness of self-management education in improving QoL, depression, self-efficacy, pain, and fatigue. These findings will help identify the most promising components of SMIs, guiding targeted interventions for specific subpopulations, and facilitating the design of better interventions.

Association between cognitive impairment and motor dysfunction among patients with multiple sclerosis: a cross-sectional study

BACKGROUND

Previous studies have shown that there is a relationship between cognitive impairment (CI) and motor dysfunction (MD) in neurological diseases, such as Alzheimer's and Parkinson's disease. However, there whether CI and MD are associated in patients with multiple sclerosis (MS) is unknown. Here we studied the association between CI and MD in patients with MS and examined if muscle weakness or incoordination, balance impairment, gait abnormalities, and/or increased fall risk are indicators of CI in patients with MS.

METHODS

Seventy patients with MS were included in this cross-sectional study. Cognitive impairment was assessed using the Montreal Cognitive Assessment Scale (MoCA), muscle strength using a hand-held dynamometer, and balance, gait, and fall risk assessment using the Tinetti scale. Motor coordination was assessed using the timed rapid alternating movement test for the upper extremity and the timed alternate heel-to-knee test for the lower extremity.

RESULTS

There was a significant association between CI and motor coordination, balance, gait, and risk of fall (p < 0.005) but not muscle strength. Stepwise multiple linear regression showed that 22.7% of the variance in the MoCA was predicted by the fall risk and incoordination of the upper extremities in the MS population.

CONCLUSIONS

CI is significantly associated with motor incoordination, balance impairment, gait abnormality, and increased fall risk. Furthermore, the risk of fall and upper extremity incoordination appeared to be best indicators of CI in patients with MS.

Risk Factors for Multiple Sclerosis Development After Optic Neuritis Diagnosis Using a Nationwide Health Records Database

Multiple sclerosis (MS) is an autoimmune demyelinating disease that often initially presents with optic neuritis (ON). Little is known about the demographic factors and familial histories that may be associated with the development of MS after a diagnosis of ON. We utilised a nationwide database to characterise specific potential drivers of MS following ON as well as analyse barriers to healthcare access and utilisation. The All of Us database was queried for all patients who were diagnosed with ON and for all patients diagnosed with MS after an initial diagnosis of ON. Demographic factors, family histories, and survey data were analysed. Multivariable logistic regression was performed to analyse the potential association between these variables of interest with the development of MS following a diagnosis of ON. Out of 369,297 self-enrolled patients, 1,152 were identified to have a diagnosis of ON, while 152 of these patients were diagnosed with MS after ON. ON patients with a family history of obesity were more likely to develop MS (obesity odd ratio: 2.46; p < .01). Over 60% of racial minority ON patients reported concern about affording healthcare compared with 45% of White ON patients (p < .01). We have identified a possible risk factor of developing MS after an initial diagnosis of ON as well as alarming discrepancies in healthcare access and utilisation for minority patients. These findings bring attention to clinical and socioeconomic risk factors for patients that could enable earlier diagnosis and treatment of MS to improve outcomes, particularly in racial minorities.

EVs vs. EVs: MSCs and Tregs as a source of invisible possibilities

Extracellular vesicles (EVs) are produced by various cells and exist in most biological fluids. They play an important role in cell-cell signaling, immune response, and tumor metastasis, and also have theranostic potential. They deliver many functional biomolecules, including DNA, microRNAs (miRNA), messenger RNA (mRNA), long non-coding RNA (lncRNA), lipids, and proteins, thus affecting different physiological processes in target cells. Decreased immunogenicity compared to liposomes or viral vectors and the ability to cross through physiological barriers such as the blood-brain barrier make them an attractive and innovative option as diagnostic biomarkers and therapeutic carriers. Here, we highlighted two types of cells that can produce functional EVs, namely, mesenchymal stem/stromal cells (MSCs) and regulatory T cells (Tregs), discussing MSC/Treg-derived EV-based therapies for some specific diseases including acute respiratory distress syndrome (ARDS), autoimmune diseases, and cancer.

To wait, or too late? Modeling the effects of delayed ofatumumab treatment in relapsing-remitting multiple sclerosis

BACKGROUND

Several disease-modifying treatments (DMTs) for relapsing-remitting multiple sclerosis (RRMS) reduce relapse rates and slow disease progression. RRMS DMTs have varying efficacy and administration routes; DMTs prescribed first may not be the most effective on relapses or disease progression. Here, we aimed to quantify the benefit of initiating ofatumumab, a high-efficacy DMT, earlier in the treatment pathway.

METHODS

Aggregate data from a real-world cohort of patients with RRMS, who were eligible for dimethyl fumarate (DMF) or ofatumumab treatment within the UK National Health Service (N = 615), were used to produce a simulated patient cohort. The cohort was tracked through a discrete event simulation (DES) model, based on the Expanded Disability Status Scale (EDSS), with a lifetime time horizon. Outcomes assessed were: mean number of relapses, time to wheelchair (EDSS ≥7), and time to death. Two modeling approaches were used. The first compared outcomes between two treatment sequences (base case: ofatumumab to natalizumab versus DMF to ofatumumab). The second incorporated a time-specific delay of 1-5 years for switching from DMF to ofatumumab; the difference in outcomes as a function of increasing delay to ofatumumab are reported.

RESULTS

Compared with delayed ofatumumab, fewer relapses and increased time to wheelchair were predicted for earlier ofatumumab in the treatment-sequence approach (mean relapses over the lifetime time horizon: 8.63 versus 9.00; time to wheelchair: 17.55 versus 16.60 years). Time to death was similar for both sequences. At Year 10, a numerically greater proportion of patients receiving earlier ofatumumab had mild disease (EDSS 0-3: 44.12% versus 40.06%). Greater differences, reflecting poorer outcomes, were predicted for relapses and time to wheelchair with increasing delays to ofatumumab treatment.

CONCLUSIONS

The DES model provided a means by which the magnitude of benefit associated with earlier ofatumumab initiation could be quantified; fewer relapses and a prolonged time to wheelchair were predicted.

Spinal cord motor disorders

Spinal cord diseases are frequently devastating due to the precipitous and often permanently debilitating nature of the deficits. Spastic or flaccid paraparesis accompanied by dermatomal and myotomal signatures complementary to the incurred deficits facilitates localization of the insult within the cord. However, laboratory studies often employing disease-specific serology, neuroradiology, neurophysiology, and cerebrospinal fluid analysis aid in the etiologic diagnosis. While many spinal cord diseases are reversible and treatable, especially when recognized early, more than ever, neuroscientists are being called to investigate endogenous mechanisms of neural plasticity. This chapter is a review of the embryology, neuroanatomy, clinical localization, evaluation, and management of adult and childhood spinal cord motor disorders.

Deciphering the Genetic Crosstalk between Microglia and Oligodendrocyte Precursor Cells during Demyelination and Remyelination Using Transcriptomic Data

Demyelinating disorders show impaired remyelination due to failure in the differentiation of oligodendrocyte progenitor cells (OPCs) into mature myelin-forming oligodendrocytes, a process driven by microglia-OPC crosstalk. Through conducting a transcriptomic analysis of microarray studies on the demyelination-remyelination cuprizone model and using human samples of multiple sclerosis (MS), we identified molecules involved in this crosstalk. Differentially expressed genes (DEGs) of specific regions/cell types were detected in GEO transcriptomic raw data after cuprizone treatment and in MS samples, followed by functional analysis with GO terms and WikiPathways. Additionally, microglia-OPC crosstalk between microglia ligands, OPC receptors and target genes was examined with the NicheNet model. We identified 108 and 166 DEGs in the demyelinated corpus callosum (CC) at 2 and 4 weeks of cuprizone treatment; 427 and 355 DEGs in the remyelinated (4 weeks of cuprizone treatment + 14 days of normal diet) compared to 2- and 4-week demyelinated CC; 252 DEGs in MS samples and 2730 and 12 DEGs in OPC and microglia of 4-week demyelinated CC. At this time point, we found 95 common DEGs in the CC and OPCs, and one common DEG in microglia and OPCs, mostly associated with myelin and lipid metabolism. Crosstalk analysis identified 47 microglia ligands, 43 OPC receptors and 115 OPC target genes, all differentially expressed in cuprizone-treated samples and associated with myelination. Our differential expression pipeline identified demyelination/remyelination transcriptomic biomarkers in studies using diverse platforms and cell types/tissues. Cellular crosstalk analysis yielded novel markers of microglia ligands, OPC receptors and target genes.

Probiotics and Commensal Gut Microbiota as the Effective Alternative Therapy for Multiple Sclerosis Patients Treatment

The gut-brain axis (GBA) refers to the multifactorial interactions between the intestine microflora and the nervous, immune, and endocrine systems, connecting brain activity and gut functions. Alterations of the GBA have been revealed in people with multiple sclerosis (MS), suggesting a potential role in disease pathogenesis and making it a promising therapeutic target. Whilst research in this field is still in its infancy, a number of studies revealed that MS patients are more likely to exhibit modified microbiota, altered levels of short-chain fatty acids, and enhanced intestinal permeability. Both clinical and preclinical trials in patients with MS and animal models revealed that the administration of probiotic bacteria might improve cognitive, motor, and mental behaviors by modulation of GBA molecular pathways. According to the newest data, supplementation with probiotics may be associated with slower disability progression, reduced depressive symptoms, and improvements in general health in patients with MS. Herein, we give an overview of how probiotics supplementation may have a beneficial effect on the course of MS and its animal model. Hence, interference with the composition of the MS patient's intestinal microbiota may, in the future, be a grip point for the development of diagnostic tools and personalized microbiota-based adjuvant therapy.

Effectiveness of Virtual Reality on Balance and Risk of Falls in People with Multiple Sclerosis: A Systematic Review and Meta-Analysis

The aim of this study was to systematically review the scientific evidence related to the physiotherapy interventions in neurorehabilitation that utilize virtual reality (VR) for balance training and risk of falls in people with multiple sclerosis (MS). A search was conducted in Medline (PubMed), PEDro, and Google Scholar to identify all the relevant studies. Clinical trials assessing the effects of VR in people with MS were included. Risk of bias was evaluated using the Cochrane Risk of Bias Tool and PEDro scale. Qualitative analysis was performed according to the GRADE. In total, 16 studies (n = 663) were included. The meta-analysis showed statistically significant differences for the VR intervention in comparison with conventional treatment for balance, with a moderate clinical effect in eight studies (SMD: 0.63; 95% CI 0.34-0.92; p < 0.05). In addition, the meta-analysis showed statistically significant differences for the VR intervention in comparison with conventional treatment for risk of falls, with a small clinical effect in six studies (SMD: -0.55; 95% CI -1.07-0.04; p < 0.05). VR-based treatments are more effective than non-intervention in improving balance and fall risk in people with MS, with a very low certainty of evidence. In addition, they also show to be more effective than conventional rehabilitation, with a very low certainty of evidence.

Longitudinal microstructural MRI markers of demyelination and neurodegeneration in early relapsing-remitting multiple sclerosis: Magnetisation transfer, water diffusion and g-ratio

INTRODUCTION

Quantitative microstructural MRI, such as myelin-sensitive magnetisation transfer ratio (MTR) or saturation (MTsat), axon-sensitive water diffusion Neurite Orientation Dispersion and Density Imaging (NODDI), and the aggregate g-ratio, may provide more specific markers of white matter integrity than conventional MRI for early patient stratification in relapsing-remitting multiple sclerosis (RRMS). The aim of this study was to determine the sensitivity of such markers to longitudinal pathological change within cerebral white matter lesions (WML) and normal-appearing white matter (NAWM) in recently diagnosed RRMS.

METHODS

Seventy-nine people with recently diagnosed RRMS, from the FutureMS longitudinal cohort, were recruited to an extended MRI protocol at baseline and one year later. Twelve healthy volunteers received the same MRI protocol, repeated within two weeks. Ethics approval and written informed consent were obtained. 3T MRI included magnetisation transfer, and multi-shell diffusion-weighted imaging. NAWM and whole brain were segmented from 3D T1-weighted MPRAGE, and WML from T2-weighted FLAIR. MTR, MTsat, NODDI isotropic (ISOVF) and intracellular (ICVF) volume fractions, and g-ratio (calculated from MTsat and NODDI data) were measured within WML and NAWM. Brain parenchymal fraction (BPF) was also calculated. Longitudinal change in BPF and microstructural metrics was assessed with paired t-tests (α = 0.05) and linear mixed models, adjusted for confounding factors with False Discovery Rate (FDR) correction for multiple comparisons. Longitudinal changes were compared with test-retest Bland-Altman limits of agreement from healthy control white matter. The influence of longitudinal change on g-ratio was explored through post-hoc analysis in silico by computing g-ratio with realistic simulated MTsat and NODDI values.

RESULTS

In NAWM, g-ratio and ICVF increased, and MTsat decreased over one year (adjusted mean difference = 0.007, 0.005, and -0.057 respectively, all FDR-corrected p < 0.05). There was no significant change in MTR, ISOVF, or BPF. In WML, MTsat, NODDI ICVF and ISOVF increased over time (adjusted mean difference = 0.083, 0.024 and 0.016, respectively, all FDR-corrected p < 0.05). Group-level longitudinal changes exceeded test-retest limits of agreement for NODDI ISOVF and ICVF in WML only. In silico analysis showed g-ratio may increase due to a decrease in MTsat or ISOVF, or an increase in ICVF.

DISCUSSION

G-ratio and MTsat changes in NAWM over one year may indicate subtle myelin loss in early RRMS, which were not apparent with BPF or NAWM MTR. Increases in NAWM and WML NODDI ICVF were not anticipated, and raise the possibility of axonal swelling or morphological change. Increases in WML MTsat may reflect myelin repair. Changes in NODDI ISOVF are more likely to reflect alterations in water content. Competing MTsat and ICVF changes may account for the absence of g-ratio change in WML. Longitudinal changes in microstructural measures are significant at a group level, however detection in individual patients in early RRMS is limited by technique reproducibility.

CONCLUSION

MTsat and g-ratio are more sensitive than MTR to early pathological changes in RRMS, but complex dependence of g-ratio on NODDI parameters limit the interpretation of aggregate measures in isolation. Improvements in technique reproducibility and validation of MRI biophysical models across a range of pathological tissue states are needed.

Satisfaction with alemtuzumab in relapsing multiple sclerosis patients: Results from the real-world PRO-ACT study

BACKGROUND

Patient-reported outcomes are increasingly used in the management of patients with multiple sclerosis to understand the patient's perspective of disease and treatment. These measures provide insights into important factors including treatment satisfaction, physical and psychological function, and quality of life.

OBJECTIVE

To present results from the real-world PRO-ACT study in patients with multiple sclerosis who switched to alemtuzumab from another disease-modifying therapy.

METHODS

This 24-month, prospective, multicenter, observational study had a primary endpoint of change in overall satisfaction, measured using the Treatment Satisfaction Questionnaire for Medication (TSQM) version 1.4. Secondary endpoints included the Multiple Sclerosis Impact Scale-29 (MSIS-29), Modified Fatigue Impact Scale-5 (MFIS-5), and the Patient-Determined Disease Steps (PDDS). Safety was monitored with adverse events (AEs).

RESULTS

Of 199 enrolled patients, improvements were observed in mean TSQM scores for overall satisfaction (baseline, 50.3; year 2, + 13.2; p < 0.0001), effectiveness (49.3 and + 12.2; p < 0.0001), and side effects (77.6 and + 4.5; p = 0.04). Improvements were also observed in MSIS-29 physical (52.4 and -6.0; p < 0.0001), MSIS-29 psychological (53.4 and -7.0; p = 0.0003), and MFIS-5 (12.8 and -1.7; p < 0.0001). Most (95.0%) patients experienced ≥ 1 AE (88.4% mild, 67.8% moderate).

CONCLUSIONS

The primary endpoint was met; the safety of alemtuzumab was consistent with pivotal studies.

Cognitive-motor interference in people with mild to moderate multiple sclerosis, in comparison with healthy controls

BACKGROUND

Reduced motor and cognitive dual-task capacity is found to be more common among people with multiple sclerosis (MS), than among healthy populations. However, studies in larger samples of MS conducted using a more stringent methodology, which includes comparisons to healthy controls, are needed. Thus, the primary aim of this study was to explore the effects on motor and cognitive dual-tasking in people with mild to moderate overall MS-disability, in comparison to healthy controls. A second aim was to explore the differences in dual-task performance on a cognitive task between two motor tasks in people with mild to moderate MS and healthy controls.

METHODS

This case-control study evaluated dual-task performance of the motor tasks standing with eyes closed (hereafter standing) and walking and a cognitive task assessing selective executive functions (auditory-Stroop test). Fifty-five people with MS (mild MS, n = 28; moderate MS, n = 27), and 30 healthy controls participated. Standing and walking were assessed using wireless inertial measurement unit sensors (APDM). Standing (three 30 s trials) was measured using sway area and root mean square sway, while walking (2 min) was measured using speed, stride length, and step time. Auditory-Stroop was measured using accuracy and response time. During dual-task assessments, each subject was instructed to pay equal attention to both tasks. Statistical significance was considered if p < .05.

RESULTS

Instanding no significant within-group differences in the standing measures were found between single-task and dual-task performance. However, dual-task performance differed significantly between all groups (moderate MS > mild MS > healthy controls), except between mild and moderate MS in sway area. Inwalking, all groups slowed down speed and shortened stride length during dual-task condition compared to single-task condition. Moderate MS performed significantly poorer than mild MS and healthy controls in dual-task walking, but mild MS did not differ from healthy controls. In thecognitivetask only mild MS increased significantly in auditory-Stroop response time during walking. In healthy controls, the performance of auditory-Stroop was not affected by dual-tasking. Moderate MS had significantly longer response time in dual-task auditory-Stroop compared to the other groups, but no differences were observed between mild MS and healthy controls. Only mild MS had significantly longer response time during walking than during standing.

CONCLUSION

This study showed that cognitive-motor interference in people with MS is present also in the early phases of the disease. This was shown during dual-tasking with slower walking and a longer response time in the cognitive task compared to healthy controls. Moderate MS performed poorer in almost every aspect of the motor and cognitive assessments in dual-task condition, compared to mild MS and healthy controls. Furthermore, during standing, people with MS performed poorer in standing measures compared to healthy controls. Additionally, healthy controls showed no cognitive interference during motor tasks. The results suggest that standardized regular assessment of dual-tasking in MS care might increase the individual's knowledge of dual-task capacity and contribute to understanding of possible related consequences. However, feasible assessment equipment and specific motor-cognitive dual-task training interventions for people with MS need to be developed.

Oral Health Status and Multiple Sclerosis: Classic and Non-Classic Manifestations—Case Report

Background: Multiple sclerosis is an autoimmune disease of the central nervous system with neurological and motor symptoms that affect the orofacial region. The aim of this work is to present a patient that lacks the three classic orofacial manifestations but has other less common clinical alterations. Case presentation: A 49-year-old female patient diagnosed with long-term relapsing–remitting multiple sclerosis visited the dentist complaining of mild but persistent orofacial pain including the temporomandibular joint and pain not specific to any tooth. She presented mucosal irritation, xerostomia, halitosis, and localized gingivitis. There was excessive wear of the upper and lower incisal edges and the occlusal faces of the upper canines and loss of six teeth due to caries. After a clinical oral examination, the diagnosis was temporomandibular joint disorder, gingivitis, dental hypersensitivity, bruxism, hyposalivation, xerostomia, and halitosis. Conclusions: Patients with multiple sclerosis present classic orofacial manifestations. Although these were not observed in this patient, she had others, such as gingivitis, tooth hypersensitivity, and bruxism. In addition, despite few studies associating a higher prevalence of caries with these patients, the number of carious and missing teeth in this patient highlight the evidence that multiple sclerosis has had a significant impact on the patient’s dental status over the years.

Brain functional connectivity analysis in patients with relapsing-remitting multiple sclerosis: A graph theory approach of EEG resting state

Multiple sclerosis (MS) is an autoimmune disease related to the central nervous system (CNS). This study aims to investigate the effects of MS on the brain's functional connectivity network using the electroencephalogram (EEG) resting-state signals and graph theory approach. Resting-state eyes-closed EEG signals were recorded from 20 patients with relapsing-remitting MS (RRMS) and 18 healthy cases. In this study, the prime objective is to calculate the connectivity between EEG channels to assess the differences in brain functional network global features. The results demonstrated lower cortical activity in the alpha frequency bands and higher activity for the gamma frequency bands in patients with RRMS compared to the healthy group. In this study, graph metric calculations revealed a significant difference in the diameter of the functional brain network based on the directed transfer function (DTF) measure between the two groups, indicating a higher diameter in RRMS cases for the alpha frequency band. A higher diameter for the functional brain network in MS cases can result from anatomical damage. In addition, considerable differences between the networks' global efficiency and transitivity based on the imaginary part of the coherence (iCoh) measure were observed, indicating higher global efficiency and transitivity in the delta, theta, and beta frequency bands for RRMS cases, which can be related to the compensatory functional reaction from the brain. This study indicated that in RRMS cases, some of the global characteristics of the brain's functional network, such as diameter and global efficiency, change and can be illustrated even in the resting-state condition when the brain is not under cognitive load.

Towards Effective Telerehabilitation: Assessing Effects of Applying Augmented Reality in Remote Rehabilitation of Patients Suffering from Multiple Sclerosis

Multiple Sclerosis (MS) is a chronic, incurable disease of the central nervous system that is also one of the most common causes of disability among young adults. Despite available pharmacological treatments, the patients often require ongoing, supervised rehabilitation. Thus, therapists are constantly searching for new, effective ways of improving functional performance and quality of life without frequently visiting medical centers. One of the most promising methods is remote telerehabilitation enhanced with an immersive augmented reality (AR) interface. Here, we investigated the effectiveness of using a commercially available AR system in MS patients’ treatment. To evaluate such an approach to rehabilitation, we conducted a medical study with 30 MS patients undergoing immunomodulatory treatment. In this study, we evaluated the influence on the patients’ upper limbs’ hand grip strength and efficiency of the patients’ upper limbs. In addition, we also analyzed the level of neurotrophins to assess the potential impact of the training on the brain plasticity process. Our results show that rehabilitation enhanced with AR significantly improves the strength and efficiency of the patients’ upper limbs. Furthermore, we further infer that AR-enhanced systems are a promising possibility of training without leaving home.

Brain Structural and Functional Alterations in Multiple Sclerosis-Related Fatigue: A Systematic Review

Fatigue is one of the most disabling symptoms of multiple sclerosis (MS); it influences patients’ quality of life. The etiology of fatigue is complex, and its pathogenesis is still unclear and debated. The objective of this review was to describe potential brain structural and functional dysfunctions underlying fatigue symptoms in patients with MS. To reach this purpose, a systematic review was conducted of published studies comparing functional brain activation and structural brain in MS patients with and without fatigue. Electronic databases were searched until 24 February 2021. The structural and functional outcomes were extracted from eligible studies and tabulated. Fifty studies were included: 32 reported structural brain differences between patients with and without fatigue; 14 studies described functional alterations in patients with fatigue compared to patients without it; and four studies showed structural and functional brain alterations in patients. The results revealed structural and functional abnormalities that could correlate to the symptom of fatigue in patients with MS. Several studies reported the differences between patients with fatigue and patients without fatigue in terms of conventional magnetic resonance imaging (MRI) outcomes and brain atrophy, specifically in the thalamus. Functional studies showed abnormal activation in the thalamus and in some regions of the sensorimotor network in patients with fatigue compared to patients without it. Patients with fatigue present more structural and functional alterations compared to patients without fatigue. Specifically, abnormal activation and atrophy of the thalamus and some regions of the sensorimotor network seem linked to fatigue.

Making Every Step Count: Minute-by-Minute Characterization of Step Counts Augments Remote Activity Monitoring in People With Multiple Sclerosis

Background

Ambulatory disability is common in people with multiple sclerosis (MS). Remote monitoring using average daily step count (STEPS) can assess physical activity (activity) and disability in MS. STEPS correlates with conventional metrics such as the expanded disability status scale (Expanded Disability Status Scale; EDSS), Timed-25 Foot walk (T25FW) and timed up and go (TUG). However, while STEPS as a summative measure characterizes the number of steps taken over a day, it does not reflect variability and intensity of activity.

Objectives

Novel analytical methods were developed to describe how individuals spends time in various activity levels (e.g., continuous low versus short bouts of high) and the proportion of time spent at each activity level.

Methods

94 people with MS spanning the range of ambulatory impairment (unaffected to requiring bilateral assistance) were recruited into FITriMS study and asked to wear a Fitbit continuously for 1-year. Parametric distributions were fit to minute-by-minute step data. Adjusted R² values for regressions between distributional fit parameters and STEPS with EDSS, TUG, T25FW and the patient-reported 12-item MS Walking scale (MSWS-12) were calculated over the first 4-weeks, adjusting for sex, age and disease duration.

Results

Distributional fits determined that the best statistically-valid model across all subjects was a 3-compartment Gaussian Mixture Model (GMM) that characterizes the step behavior within 3 levels of activity: high, moderate and low. The correlation of GMM parameters for baseline step count measures with clinical assessments was improved when compared with STEPS (adjusted R² values GMM vs. STEPS: TUG: 0.536 vs. 0.419, T25FW: 0.489 vs. 0.402, MSWS-12: 0.383 vs. 0.378, EDSS: 0.557 vs. 0.465). The GMM correlated more strongly (Kruskal-Wallis: p = 0.0001) than STEPS and gave further information not included in STEPS.

Conclusions

Individuals' step distributions follow a 3-compartment GMM that better correlates with clinic-based performance measures compared with STEPS. These data support the existence of high-moderate-low levels of activity. GMM provides an interpretable framework to better understand the association between different levels of activity and clinical metrics and allows further analysis of walking behavior that takes step distribution and proportion of time at three levels of intensity into account.

Isolated sixth nerve palsy: a rare first presentation in multiple sclerosis

True isolated sixth nerve palsy as the initial presentation of multiple sclerosis (MS) is rare. MS is a chronic inflammatory, immune-mediated disease of the central nervous system. This is the most common cause of neurological disability in young adults. Common symptoms include acute episodes of muscle weakness, altered sensation, balance and gait disturbances, visual loss and bladder dysfunction.Diagnosis of MS is supported with the incidence of symptomatic clinical episodes with subsequent cross-sectional imaging to confirm radiological lesions that are disseminated in space and time.In the following report, we discuss the case of a woman in her 30s who presented to ophthalmology with a sixth nerve palsy in the absence of ocular or systemic disease. This is the first presentation of MS, a rare clinical event.

Lower cerebral arterial blood flow is associated with greater serum neurofilament light chain levels in multiple sclerosis patients

BACKGROUND

Hypoperfusion, vascular pathology, and cardiovascular risk factors are associated with disease severity in multiple sclerosis (MS). We aimed to assess relationships between cerebral arterial blood flow (CABF) and serum neurofilament light chain (sNfL), as neuronal damage biomarker.

METHODS AND MATERIALS

Total CABF was measured in 137 patients (86 clinically isolated syndrome (CIS)/relapsing-remitting (RR) and 51 progressive MS (PMS)) and 48 healthy controls (HCs) using Doppler ultrasound. sNfL was quantitated using single molecule assay (Simoa). 3.0T MRI examination allowed quantification of T2 lesion and whole-brain volume (WBV). Multiple linear regression models determined the sNfL associated with CABF after correction for demographic and MRI-derived variables.

RESULTS

After adjustment for age, sex and BMI, total CABF remained statistically significant and model comparisons showed that CABF explained additional 2.6% of the sNfL variance (β=-0.167, p=0.044). CABF also remained significant in a step-wise regression model (β=0.18, p=0.034) upon the inclusion of T2 lesion burden and WBV effects. Patients in the lowest CABF quartile (CABF≤761mL/min) had significantly higher sNfL (34.6pg/mL versus 23.9pg/mL, adjusted-p=0.042) when compared to the highest quartile (CABF≥1130mL/min).

CONCLUSION

Lower CABF is associated with increased sNfL in MS patients, highlighting the relationship between cerebral hypoperfusion and axonal pathology.

Molecular Biomarkers and Their Implications for the Early Diagnosis of Selected Neurodegenerative Diseases

The degeneration and dysfunction of neurons are key features of neurodegenerative diseases (NDs). Currently, one of the main challenges facing researchers and clinicians is the ability to obtain reliable diagnostic tools that will allow for the diagnosis of NDs as early as possible and the detection of neuronal dysfunction, preferably in the presymptomatic stage. Additionally, better tools for assessing disease progression in this group of disorders are also being sought. The ideal biomarker must have high sensitivity and specificity, be easy to measure, give reproducible results, and reflect the disease progression. Molecular biomarkers include miRNAs and extracellular microvesicles known as exosomes. They may be measured in two extracellular fluids of the highest importance in NDs, i.e., cerebrospinal fluid (CSF) and blood. The aim of the current review is to summarize the pathophysiology of the four most frequent NDs—i.e., Alzheimer’s disease (AD), Parkinson’s disease (PD), amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS)—as well as current progress in the research into miRNAs as biomarkers in these major neurodegenerative diseases. In addition, we discuss the possibility of using miRNA-based therapies in the treatment of neurodegenerative diseases, and present the limitations of this type of therapy.

The central vein sign helps in differentiating multiple sclerosis from its mimickers: lessons from Fabry disease

OBJECTIVES

Although the use of specific MRI criteria has significantly increased the diagnostic accuracy of multiple sclerosis (MS), reaching a correct neuroradiological diagnosis remains a challenging task, and therefore the search for new imaging biomarkers is crucial. This study aims to evaluate the incidence of one of the emerging neuroradiological signs highly suggestive of MS, the central vein sign (CVS), using data from Fabry disease (FD) patients as an index of microvascular disorder that could mimic MS.

METHODS

In this retrospective study, after the application of inclusion and exclusion criteria, MRI scans of 36 FD patients and 73 relapsing-remitting (RR) MS patients were evaluated. Among the RRMS participants, 32 subjects with a disease duration inferior to 5 years (early MS) were also analyzed. For all subjects, a Fazekas score (FS) was recorded, excluding patients with FS = 0. Different neuroradiological signs, including CVS, were evaluated on FLAIR T2-weighted and spoiled gradient recalled echo sequences.

RESULTS

Among all the recorded neuroradiological signs, the most striking difference was found for the CVS, with a detectable prevalence of 78.1% (57/73) in RRMS and of 71.4% (25/32) in early MS patients, while this sign was absent in FD (0/36).

CONCLUSIONS

Our results confirm the high incidence of CVS in MS, also in the early phases of the disease, while it seems to be absent in conditions with a different etiology. These results corroborate the possible role of CVS as a useful neuroradiological sign highly suggestive of MS.

KEY POINTS

• The search for new imaging biomarkers is crucial to achieve a correct neuroradiological diagnosis of MS. • The CVS shows an incidence superior to 70% in MS patients, even in the early phases of the disease, while it appears to be absent in FD. • These findings further corroborate the possible future central role of CVS in distinguishing between MS and its mimickers.

Identifying falls remotely in people with multiple sclerosis

BACKGROUND

Falling is common in people with multiple sclerosis (MS) but tends to be under-ascertained and under-treated.

OBJECTIVE

To evaluate fall risk in people with MS.

METHODS

Ninety-four people with MS, able to walk > 2 min with or without an assistive device (Expanded Disability Status Scale (EDSS ≤ 6.5) were recruited. Clinic-based measures were recorded at baseline and 1 year. Patient-reported outcomes (PROs), including a fall survey and the MS Walking Scale (MSWS-12), were completed at baseline, 1.5, 3, 6, 9, and 12 months. Average daily step counts (STEPS) were recorded using a wrist-worn accelerometer.

RESULTS

50/94 participants (53.2%) reported falling at least once. Only 56% of participants who reported a fall on research questionnaires had medical-record documented falls. Fallers had greater disability [median EDSS 5.5 (IQR 4.0-6.0) versus 2.5 (IQR 1.5-4.0), p < 0.001], were more likely to have progressive MS (p = 0.003), and took fewer STEPS (mean difference - 1,979, p = 0.007) than Non-Fallers. Stepwise regression revealed MSWS-12 as a major predictor of future falls.

CONCLUSIONS

Falling is common in people with MS, under-reported, and under-ascertained by neurologists in clinic. Multimodal fall screening in clinic and remotely may help improve patient care by identifying those at greatest risk, allowing for timely intervention and referral to specialized physical rehabilitation.

Walk Your Talk: Real-World Adherence to Guidelines on the Use of MRI in Multiple Sclerosis

(1) Although guidelines about the use of MRI sequences for Multiple Sclerosis (MS) diagnosis and follow-up are available, variability in acquisition protocols is not uncommon in everyday clinical practice. The aim of this study was to evaluate the real-world application of MS imaging guidelines in different settings to clarify the level of adherence to these guidelines. (2) Via an on-line anonymous survey, neuroradiologists (NR) were asked about MRI protocols and parameters routinely acquired when MS patients are evaluated in their center, both at diagnosis and follow-up. Furthermore, data about report content and personal opinions about emerging neuroimaging markers were also retrieved. (3) A total of 46 participants were included, mostly working in a hospital or university hospital (80.4%) and with more than 10 years of experience (47.9%). We found a relatively good adherence to the suggested MRI protocols regarding the use of T2-weighted sequences, although almost 10% of the participants routinely acquired 2D sequences with a slice thickness superior to 3 mm. On the other hand, a wider degree of heterogeneity was found regarding gadolinium administration, almost routinely performed at follow-up examination (87.0% of cases) in contrast with the current guidelines, as well as a low use of a standardized reporting system (17.4% of cases). (4) Although the MS community is getting closer to a standardization of MRI protocols, there is still a relatively wide heterogeneity among NR, with particular reference to contrast administration, which must be overcome to guarantee an adequate quality of patients’ care in MS.

Genetic diseases mimicking multiple sclerosis

Multiple sclerosis (MS) is an inflammatory neurodegenerative disorder manifesting as gradual or progressive loss of neurological functions. Most patients present with relapsing-remitting disease courses. Extensive research over recent decades has expounded our insights into the presentations and diagnostic features of MS. Groups of genetic diseases, CADASIL and leukodystrophies, for example, have been frequently misdiagnosed with MS due to some overlapping clinical and radiological features. The delayed identification of these diseases in late adulthood can lead to severe neurological complications. Herein we discuss genetic diseases that have the potential to mimic multiple sclerosis, with highlights on clinical identification and practicing pearls that may aid physicians in recognizing MS-mimics with genetic background in clinical settings.

Is There a Place for Spinal Cord Stimulation in the Management of Patients with Multiple Sclerosis? A Systematic Review of the Literature

OBJECTIVE

Spinal cord stimulation (SCS) is a minimally invasive technique mainly used to treat neuropathic pain associated with failed back surgery syndrome. However, this therapy has been utilized to treat other chronic painful conditions, such as pain associated with multiple sclerosis (MS). Nonetheless, the efficacy of SCS in MS patients has not been fully established. In fact, in most of SCS series, MS patients represent only a subset of a bigger cohort which comprises different causes of pain, motor disorder, and other functional limitations. The aim of our study was to systematically review the literature to evaluate the effectiveness of SCS in MS patients.

METHODS

A literature search was performed through different databases (PubMed, Scopus, and Embase) using the following terms: "multiple sclerosis," "spinal cord stimulation," and "dorsal column stimulation," according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

A total of 452 articles were reviewed, and 7 studies were included in the present analysis. 373 MS patients were submitted to a stimulation trial, and 82 MS patients underwent a de novo implantation. 285/373 (76.4%) of cases submitted to the SCS trial were enrolled for permanent stimulation. We found a long-lasting improvement in 193/346 (55.8%) MS patients with motor disorders, in 90/134 (67.13%) MS patients with urinary dysfunction, and in 28/34 (82.35%) MS patients with neuropathic pain. The efficacy of SCS was higher for urinary dysfunction (p = 0.0144) and neuropathic pain (p = 0.0030) compared with motor disorders.

CONCLUSIONS

Our systematic review evidences that SCS is effective in MS patients. Urinary dysfunction and pain symptoms seem to be most responsive to SCS. Further studies are needed to improve the patient selection and clarify the best timing to perform SCS in these patients.

Cuprizone-Induced Neurotoxicity in Human Neural Cell Lines Is Mediated by a Reversible Mitochondrial Dysfunction: Relevance for Demyelination Models

Suitable in vivo and in vitro models are instrumental for the development of new drugs aimed at improving symptoms or progression of multiple sclerosis (MS). The cuprizone (CPZ)-induced murine model has gained momentum in recent decades, aiming to address the demyelination component of the disease. This work aims at assessing the differential cytotoxicity of CPZ in cells of different types and from different species: human oligodendroglial (HOG), human neuroblastoma (SH-SY5Y), human glioblastoma (T-98), and mouse microglial (N-9) cell lines. Moreover, the effect of CPZ was investigated in primary rat brain cells. Cell viability was assayed by oxygen rate consumption and by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide-based (MTT) method. Our results demonstrated that CPZ did not cause death in any of the assayed cell models but affected mitochondrial function and aerobic cell respiration, thus compromising cell metabolism in neural cells and neuron-glia co-cultures. In this sense, we found differential vulnerability between glial cells and neurons as is the case of the CPZ-induced mouse model of MS. In addition, our findings demonstrated that reduced viability was spontaneous reverted in a time-dependent manner by treatment discontinuation. This reversible cell-based model may help to further investigate the role of mitochondria in the disease, and study the molecular intricacies underlying the pathophysiology of the MS and other demyelinating diseases.

Evaluating Treatment Patterns, Relapses, Healthcare Resource Utilization, and Costs Associated with Disease-Modifying Treatments for Multiple Sclerosis in DMT-Naïve Patients

Purpose

Early diagnosis and treatment of multiple sclerosis (MS) with disease-modifying therapy (DMT) can reduce relapse number and severity, which has cost implications. We describe treatment patterns, healthcare utilization, and cost among MS patients newly initiating DMTs (index).

Patients and Methods

DMT-naïve adults with 12 months' continuous enrollment pre- and post-index and ≥2 MS claims (2009‒2018) were identified from the Optum Clinformatics Data Mart database. Treatment adherence and persistence were measured as time on index DMT. Relapses were identified using a validated claims-based algorithm. All-cause and MS-related healthcare expenditures and utilization were captured pre- and post-index. Outcomes were stratified by route of administration. Multivariate analyses assessed differences in outcomes and costs.

Results

The analysis included 5906 MS patients (mean age, 46.6 years). The majority initiated injectable (63.5%) followed by oral (28.8%) and infusion (7.7%) DMTs. Post-index, 45.3% of patients were nonadherent and 39.4% were nonpersistent. Relapse rates decreased from pre- to post-index (oral: 24.3%‒16.1%; injectable: 25.0%‒17.1%; infusion: 29.3%‒15.5%). Post-index mean (SD) all-cause total costs were lowest with oral ($70,970 [$36,681]) vs injectable ($82,521 [$58,569]) and infusion ($80,871 [$49,627]) DMTs. MS-related total costs were lowest with oral ($65,149 [$65,133]) vs injectable ($76,197 [$60,204]) and infusion ($72,703 [$47,287]) DMTs. Multivariate analysis showed no differences between oral and injectable DMTs in adherence, persistence, or relapse rate; however, oral DMTs had significantly lower all-cause and MS-related costs.

Conclusion

With similar outcomes across DMT administration routes, initiating the least costly DMT may be warranted for many patients. In newly treated MS patients, the need exists to improve adherence and persistence.

Neuroprotective Effect of Apolipoprotein D in Cuprizone-Induced Cell Line Models: A Potential Therapeutic Approach for Multiple Sclerosis and Demyelinating Diseases

Apolipoprotein D (Apo D) overexpression is a general finding across neurodegenerative conditions so the role of this apolipoprotein in various neuropathologies such as multiple sclerosis (MS) has aroused a great interest in last years. However, its mode of action, as a promising compound for the development of neuroprotective drugs, is unknown. The aim of this work was to address the potential of Apo D to prevent the action of cuprizone (CPZ), a toxin widely used for developing MS models, in oligodendroglial and neuroblastoma cell lines. On one hand, immunocytochemical quantifications and gene expression measures showed that CPZ compromised neural mitochondrial metabolism but did not induce the expression of Apo D, except in extremely high doses in neurons. On the other hand, assays of neuroprotection demonstrated that antipsychotic drug, clozapine, induced an increase in Apo D synthesis only in the presence of CPZ, at the same time that prevented the loss of viability caused by the toxin. The effect of the exogenous addition of human Apo D, once internalized, was also able to directly revert the loss of cell viability caused by treatment with CPZ by a reactive oxygen species (ROS)-independent mechanism of action. Taken together, our results suggest that increasing Apo D levels, in an endo- or exogenous way, moderately prevents the neurotoxic effect of CPZ in a cell model that seems to replicate some features of MS which would open new avenues in the development of interventions to afford MS-related neuroprotection.

Presenting Symptoms and Disease Severity in Multiple Sclerosis Patients

Introduction: The study aims to determine an association between presenting symptoms in multiple sclerosis and measures of disease severity, including the expanded disability status score (EDSS) and MRI based lesion volumes. Methods: Data was collected as part of a larger 3 year MS study, from 2014 to 2017, to compare Vitamin A levels and MS progression. All data was collected from a single clinical site. Demographic data as well as date of diagnosis and use of disease modifying therapies. Patients not able to obtain MRIs or lab tests and histories of vitamin abnormalities were excluded from the study. 29 patients met inclusion criteria. We chose presenting symptoms of vision, balance, sensory function, and motor function as these represented the most common manifestations of the disease and mirror the domains of the EDSS, which is the most commonly used scale for MS disease severity. We also included neuroimaging based lesion volume as another objective measure for comparison. Results: Although duration of disease was different between comparator groups, no significant difference was found between them when EDSS and lesion volumes were compared. There was a difference in lesion volumes when comparing those patients that had presenting symptoms of visual changes or balance symptoms with those presenting with sensory changes. Conclusions: This study supports the notion that presenting symptoms are not associated with EDSS independent disease duration. It also verifies that severity of disease is not associated with lesion volumes. However, sensory symptoms as a presenting symptom was associated with less lesion volumes in our study.

Underutilization of physical therapy for symptomatic women with MS during and following pregnancy

BACKGROUND

Many patients with MS continue to have symptoms of their disease even when inflammatory activity is reduced by DMTs. Although disease activity tends to be reduced during pregnancy - especially in the third trimester - women with MS can experience ongoing symptoms during pregnancy, or new ones in the immediate postpartum period, that degrade quality of life. While many MS-related and postpartum symptoms can be improved with physical therapy (PT), there are currently no guidelines on pregnancy-related rehabilitation in MS. In this analysis, we evaluated the prevalence of PT-amenable symptoms and patterns of PT referrals in a cohort of UCSF MS Clinic patients who became pregnant.

METHODS

We extracted electronic medical records (EMR) data for the year before conception, during pregnancy, and year postpartum for women with MS cared for at UCSF between 09-2005 and 08-2019. This included clinical visits, MS therapies and symptoms (as defined by the National MS Society). PT and pelvic floor PT orders and notes were also extracted.

RESULTS

We included 142 live birth pregnancies from 118 women. During the course of their pregnancy and within the year postpartum, 107 women (75.4%) reported at least one PT-amenable symptom. A total of 30 (28.0%) referrals were made to PT, with attendance confirmed for 10 (33.3% of referrals). Symptoms most commonly triggering a referral for PT evaluation were numbness and urinary incontinence. Falls were reported after 10 of the pregnancies; 4 resulted in a referral to PT. Forty-one women reported urinary incontinence: 11 (26.8%) were referred to PT, and 2 to pelvic floor PT. Nineteen women experienced a documented relapse during pregnancy and/or postpartum: 11 received a PT referral, and 4 attended PT.

CONCLUSIONS

While women with MS recorded at least 1 PT-amenable symptom during or following 75.4% of their pregnancies, only 28% of these were referred to PT - and only a third attended PT. Of significance was the 4.9% referral rate for pelvic floor PT in postpartum women with a record of urinary incontinence. Pelvic floor PT is a mainstay of general postpartum care in many European countries. These data illustrate critical gaps in rehabilitation referral, access and use at the intersection of neurological conditions and pregnancy in a large US-based MS clinic. They lend support for quality improvement efforts to improve care pathways and for telerehabilitation innovations to reduce barriers to access and improve synergistic care between PT, MD and urologic care.

ENT-MS-12 questionnaire: A novel tool to investigate otolaryngology symptoms in patients with relapsing-remitting multiple sclerosis. Results from a pilot study

BACKGROUND

Multiple sclerosis (MS) is associated with otolaryngology-related manifestations including vestibular or auditory symptoms; facial motor or sensory disorders; voice or swallowing impairment; and snoring/sleep apnea. Because these symptoms are nonspecific, their significance in MS is seldom recognized by patients with MS and their physicians; yet, presence of these symptoms may be a harbinger of impending relapse or disease progression. We developed and investigated a survey instrument, the ENT-MS-12, to standardize reporting of otolaryngology symptoms in patients with MS, correlating its scoring with disability and lesions.

METHODS

The ENT-MS-12 was administered to 40 patients with relapsing-remitting MS in different phases of their disease. We collected data using the Expanded Disability Status Scale (EDSS) and analyzed patient brain MRIs to evaluate the state (active or non-active) of brain lesions based on gadolinium enhancement. Odds ratios for diverse otolaryngology symptoms across the EDSS scores and brain lesions were calculated.

RESULTS

Higher EDSS scores were associated with auditory and vestibular symptoms (Odd Ratio (OR): 3.06; p: 0.0003); voice and swallowing symptoms (OR: 6.8; p=0.007); and snoring/sleep apnea (OR: 5.1; p=0.03). Presence of active brain lesions was also associated with auditory and vestibular symptoms (OR: 6.7); voice and swallowing symptoms (OR: 5.7); and snoring/sleep apnea (OR: 5).

CONCLUSIONS

The ENT-MS-12 survey instrument standardizes reporting of otolaryngology symptoms in patients with MS and documents association between symptoms and phase of disease in this series. Because ear, nose and throat (ENT)- related symptoms (i.e., sensory symptoms, such as numbness) are under-reported in MS, further investigation is warranted, as such data may improve clinical management of MS.

Multiple sclerosis clinical practice guidelines provide few complementary and alternative medicine recommendations: A systematic review

OBJECTIVE

Complementary and alternative medicine (CAM) use is prevalent among individuals with multiple sclerosis (MS), yet the quantity and quality of CAM recommendations in MS clinical practice guidelines (CPGs) has not been assessed. The objective of this study was to determine the mention of CAM in MS CPGs and assess the quality of CAM recommendations.

DESIGN/SETTING

A systematic review was conducted to identify MS CPGs. MEDLINE, EMBASE and CINAHL were searched from 2008 to 2018. The Guidelines International Network and the National Center for Complementary and Integrative Health (NCCIH) websites were also searched. Eligible CPGs containing CAM recommendations published by non-profit agencies on the treatment of MS for adults were assessed for quality and reporting using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument.

OUTCOME/RESULTS

From 204 unique search results, six CPGs mentioned CAM and four made CAM recommendations. Scaled domain percentages from highest to lowest were clarity of presentation (90.3 % Overall, 83.3 % CAM), scope and purpose (87.5 % Overall, 86.8 % CAM), rigour of development (80.0 % Overall, 61.7 % CAM), applicability (55.2 % Overall, 44.3 % CAM), editorial independence (49.0 % Overall, 47.9 % CAM), and stakeholder involvement (55.6 % Overall, 39.6 % CAM). Quality varied within and across CPGs. Three of the four CPGs were recommended by both appraisers; one was recommended as "No" or "Yes with modifications".

CONCLUSION

CAM recommendations were only present in one third of all eligible CPGs. CPGs that scored highly can be used by patients and healthcare professionals as the basis for discussion about the use of CAM therapies for MS treatment/management. Although many people living with MS (PwMS) seek CAM therapies, few CPGs are available to provide guidance for clinicians and patients.

Longitudinal cortical thinning progression differs across multiple sclerosis phenotypes and is clinically relevant: A multicentre study

Background:

Longitudinal evolution of cortical thickness (CTh) in different MS phenotypes has been rarely studied.

Aim:

To investigate the regional pattern and 1-year progression of cortical thinning in relapsing-remitting (RR) and progressive (P) MS.

Methods:

3T high-resolution T1-weighted magnetic resonance imaging (MRI) was obtained from 86 patients (75 RRMS, 11 PMS) and 34 healthy controls (HC) at three European sites at baseline and 1-year follow-up. Using FreeSurfer, baseline CTh between-group differences, longitudinal CTh changes and their correlations with clinical and MRI variables were assessed.

Results:

Baseline frontal, parietal and sensorimotor atrophy was found in MS versus HC. Such pattern was driven by RRMS, while PMS showed additional parietal, insular and sensorimotor cortical atrophy versus RRMS. At 1-year versus baseline, additional frontal and temporal cortical thinning was detected in RRMS patients, while a widespread CTh reduction was found in PMS patients (significant at time-by-group interaction vs RRMS). In MS, baseline fronto-parietal atrophy correlated with more severe disability and higher lesion volume. Baseline inferior parietal CTh decrease and 1-year temporal cortical thinning correlated with more severe disability.

Conclusion:

Parieto-temporal baseline CTh abnormalities and thinning pattern over time characterized the main MS clinical phenotypes and were associated with 1-year disability worsening.

Exosome Circuitry During (De)(Re)Myelination of the Central Nervous System

Reciprocal neuron-glia cell communication is fundamental for the proper function of the nervous system. Oligodendrocytes are the myelinating cells of the central nervous system (CNS) that insulate and provide trophic support to neurons. This effective interaction is crucial not only for myelination but also for long-term axonal survival and neural connectivity. In recent years, exosomes have been portrayed as key players in intercellular interaction in the context of the healthy and diseased CNS. They act as communicating vehicles, true attachés operating between neurons and glial cells. Despite the complex exosome circuitry within the nervous system, experimental evidence supports the role of exosomes in modulating myelination. Oligodendrocytes secrete exosomes in response to neuronal signals in an electric activity-dependent manner. These released exosomes are then internalized by neurons, contributing to their integrity and activity. In turn, neurons secrete exosomes to control the communication between them and with myelinating cells in order to regulate synaptic function in neuronal development, myelin maintenance, and neuroregeneration. In this review, we provide a critical view of the current understanding on how exosomes, either from CNS-resident cells or from the periphery, contribute to the formation and maintenance of myelin and, additionally, on how the differential content of exosomes in normal and pathological conditions foresees the use of these nanovesicles as putative diagnostic and/or therapeutical agents in white matter degeneration-associated diseases.

Personal Autonomy as Quality of Life Predictor for Multiple Sclerosis Patients

Multiple sclerosis (MS) is a chronic, severe disease, characterized by a progressive alteration in neuronal transmission, which decreases personal independence and quality of life (QoL). This study aimed to investigate the relationship between QoL and personal autonomy in patients with MS, as well as its correlation with age, educational level, and diseases severity. Twenty-six MS patients were followed-up for six months. All patients completed the 15D questionnaire two times: at T0, when they started a new treatment, and at T1 after six months of treatment. At the end point, all patients completed the Personal Autonomy Questionnaire. The average patient age was 43 years (SD = 10), and 89% of them were female. The mean severity and duration of MS were 3.5 (SD = 1.75) and 9.5 (SD = 5.1), respectively. The average QoL of MS patients at T0 was 0.66 (SD = 0.18), and that at T1 was 0.71 (SD = 0.16). The scores of patients with different types of MS, i.e., relapsing–remitting MS (RRMS) or secondary progressive MS (SPMS), were compared. SPMS patients were older than RRMS patients (mean age 47.5 vs. 39.7 years; p = 0.032), and more RRMS patients were working (0.014). SPMS patients described the same QoL and personal autonomy as RRMS patients. Results from bivariate correlation analyses showed a significant relationship between QoL and age, education, and severity of MS. Also, the analysis showed no significant correlation between QoL and personal autonomy.