The socioeconomic consequences of multiple sclerosis: a controlled national study

Economic and societal burden of myasthenia gravis in Denmark, Finland, and Sweden: A population-based registry study

BACKGROUND AND PURPOSE

Health care resource utilization (HCRU) and the economic burden of myasthenia gravis (MG) are significant, but existing studies rarely include comprehensive nationwide data. We examined HCRU and direct and indirect costs associated with MG overall and by disease severity in Denmark, Finland, and Sweden.

METHODS

Data were collected retrospectively from nationwide health and social care registries. All individuals ≥18 years of age with ≥2 International Classification of Diseases diagnoses of MG between 2000 and 2020 were included. HCRU, direct (inpatient and outpatient contacts, medication) and indirect costs (early retirement, sick leave, death), and associated factors were calculated.

RESULTS

The full study cohort comprised 8622 people with MG (pwMG). Mean annual numbers of all-cause secondary health care contacts for pwMG were 3.4 (SD = 8.3), 7.0 (SD = 12.3), and 2.9 (SD = 3.9), with mean annual total costs of €12,185, €9036, and €5997 per person in Denmark, Finland, and Sweden, respectively. Inpatient periods, involving 77%-89% of study participants in the three countries, contributed most to direct costs, whereas the majority of indirect costs resulted from early retirement in Denmark and Finland, and sick leave periods in Sweden. Mean annual total costs were highest with very severe MG (€19,570-€33,495 per person across the three countries). Female sex and comorbidities, such as mental and behavioral disorders and severe infections, were also associated with higher total costs.

CONCLUSIONS

This population-based study shows a high level of HCRU and a significant direct and indirect economic burden of MG across three Nordic countries, especially for severe forms of MG.

Multiple sclerosis: emerging epidemiological trends and redefining the clinical course

Multiple sclerosis is a chronic, inflammatory, and neurodegenerative disease of the central nervous system and a major cause of neurological disability in young adults. Its prevalence and incidence are increasing, and it has been estimated at over 2.8 million cases worldwide, in addition to recent trends towards a shift in MS prevalence to older ages, with peak prevalence estimates in the sixth decade of life. Although historically the relapsing and progressive phases of the disease have been considered separate clinical entities, recent evidence of progression independent of relapse activity (PIRA) has led to a reconsideration of multiple sclerosis as a continuum, in which relapsing and progressive features variably coexist from the earliest stages of the disease, challenging the traditional view of the disease course. In this Series article, we provide an overview of how the traditional description of the clinical course of MS and epidemiological trends in Europe have evolved. For this purpose, we focus on the concept of PIRA, discussing its potential as the main mechanism by which patients acquire disability, how its definition varies between studies, and ongoing research in this field. We emphasise the importance of incorporating the assessment of hidden clinical manifestations into patient management to help uncover and quantify the PIRA phenomenon and the possible implications for future changes in the clinical classification of the disease. At the same time, we provide insights into overcoming the challenges of identifying and defining PIRA and adopting a new understanding of the clinical course of MS.

Age-related decline in cerebral oxygen consumption in multiple sclerosis

Cerebral oxygen metabolism is altered in relapsing-remitting multiple sclerosis (RRMS), possibly a result of disease related cerebral atrophy with subsequent decreased oxygen demand. However, MS inflammation can also inhibit brain metabolism. Therefore, we measured cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO2) using MRI phase contrast mapping and susceptibility-based oximetry in 44 patients with early RRMS and 36 healthy controls. Cerebral atrophy and white matter lesion load were assessed from high-resolution structural MRI. Expanded Disability Status Scale (EDSS) scores were collected from medical records. The CMRO2 was significantly lower in patients (-15%, p = 0.002) and decreased significantly with age in patients relative to the controls (-1.35 µmol/100 g/min/year, p = 0.036). The lower CMRO2 in RRMS was primarily driven by a higher venous oxygen saturation in the sagittal sinus (p = 0.007) and not a reduction in CBF (p = 0.69). There was no difference in cerebral atrophy between the groups, and no correlation between CMRO2 and MS lesion volume or EDSS score. Therefore, the progressive CMRO2 decline observed before the occurrence of significant cerebral atrophy and despite adequate CBF supports emerging evidence of dysfunctional cellular respiration as a potential pathogenic mechanism and therapeutic target in RRMS.

Performance of administrative databases for identifying individuals with multiple sclerosis

Administrative databases are an alternative to disease registries as a research tool to study multiple sclerosis. However, they are not initially designed to fulfill research purposes. Therefore, an evaluation of their performance is necessary. Our objective was to assess the performance of the French administrative database comprising hospital discharge records and national health insurance databases in identifying individuals with multiple sclerosis, in comparison with a registry that exhaustively compiles resident multiple sclerosis cases in Lorraine, northeastern France, as reference. We recorded all individuals residing in the Lorraine region who were identified by the administrative database or the registry as having multiple sclerosis from 2011 to 2016. We calculated the Matthews correlation coefficient and other concordance indicators. For identifying individuals with multiple sclerosis, the Matthews correlation coefficient by the administrative database was 0.79 (95% CI 0.78-0.80), reflecting moderate performance. The mean time to identification was 5.5 years earlier with the registry than the administrative database. Administrative databases, although useful to study multiple sclerosis, should be used with caution because results of studies based on them may be biased. Our study highlights the value of regional registries that allow for a more exhaustive and rapid identification of cases.

Gender differences in earnings among people with multiple sclerosis and associations with type of occupation and family composition: A population-based study with matched references

Gender differences in earnings exist worldwide. Gender segregation or familial status have been previously stated as possible explanations for these differences as well as health differences between women and men. Women are diagnosed with multiple sclerosis (MS) as twice much as men. Moreover, MS limitations may affect the work capacity of people with MS (PwMS) implying a reduction in their earnings. We aimed to explore gender differences in earnings among people with MS and without MS and between groups of those diagnosed while also considering types of occupation and family composition, and how these possible differences relate to sickness absence (SA) and disability pension (DP). We conducted a population-based cohort study in Sweden with microdata from several nationwide registers. PwMS aged 19-57 years (n = 5128) living in Sweden and 31,767 matched references from the population without MS. Outcome measures included earnings, number of SA and DP days combined (SA/DP). A four-way weighted least-squares analysis of covariance was performed to explore the associations of gender, MS, type of occupation, and family composition with earnings. Risk of SA and DP days was assessed with logistic regression. Overall, and across all occupations, women earned less than men, although less so among managers with MS. Annual gender differences in earnings were larger if living with children at home compared to not living with children. Nevertheless, these gender differences decreased after adjusting for SA/DP, both among PwMS and references. PwMS had considerably more SA/DP days than references. Women also had more SA/DP days than men. We observed that working women earned less than working men, and that gender differences in earnings were present in all occupations, although less evident among PwMS in managerial positions. The combination of gender, occupation, family composition, and MS, was associated with earnings, even when adjusting for the number of SA and DP days.

The socioeconomic impact of disability progression in multiple sclerosis: A retrospective cohort study of the German NeuroTransData (NTD) registry

Background

Multiple sclerosis (MS) is a progressively debilitating neurologic disease that poses significant costs to the healthcare system and workforce.

Objective

To evaluate the impact of MS disease progression on societal costs and quality of life (QoL) using data from the German NeuroTransData (NTD) MS registry.

Methods

Cross-sectional cohort study. The cost cohort included patients with MS disability assessed using Expanded Disability Status Scale (EDSS) in 2019 while the QoL cohort included patients assessed using EDSS and EuroQol-5 Dimension 5-Levels between 2009 and 2019. Direct and indirect medical, and non-medical resource use was quantified and costs derived from public sources.

Results

Within the QoL cohort (n = 9821), QoL worsened with increasing EDSS. Within the cost cohort (n = 7286), increasing resource use with increasing EDSS was observed. Societal costs per patient, excluding or including disease-modifying therapies, increased from €5694 or €19,315 at EDSS 0 to 3.5 to €25,419 or €36,499 at EDSS 4 to 6.5, and €52,883 or €58,576 at EDSS 7 to 9.5. In multivariate modeling, each 0.5-step increase in EDSS was significantly associated with increasing costs, and worsening QoL.

Conclusion

This study confirms the major socioeconomic burden associated with MS disability progression. From a socioeconomic perspective, delaying disability progression may benefit patients and society.

Socioeconomic status of the elderly MS population compared to the general population: a nationwide Danish matched cross-sectional study

Introduction/objectives

Multiple sclerosis (MS) leads to physical and cognitive disability, which in turn impacts the socioeconomic status of the individual. The altered socioeconomic trajectory combined with the critical role of aging in MS progression could potentially lead to pronounced differences between MS patients and the general population. Few nations have the ability to connect long-term clinical and socioeconomic data at the individual level, and Denmark's robust population-based registries offer unique insights. This study aimed to examine the socioeconomic aspects of elderly Danish MS patients in comparison to matched controls from the general population.

Methods

A nationwide population-based study in Denmark was conducted, comprising all living MS patients aged 50 years or older as of 1 January 2021. Patients were matched 1:10 based on sex, age, ethnicity, and residence with a 25% sample of the total Danish population. Demographic and clinical information was sourced from the Danish Multiple Sclerosis Registry, while socioeconomic data were derived from national population-based registries containing details on education, employment, social services, and household characteristics. Univariate comparisons between MS patients and matched controls were then carried out.

Results

The study included 8,215 MS patients and 82,150 matched individuals, with a mean age of 63.4 years (SD: 8.9) and a 2:1 female-to-male ratio. For those aged 50-64 years, MS patients demonstrated lower educational attainment (high education: 28.3 vs. 34.4%, P < 0.001) and fewer received income from employment (46.0 vs. 78.9%, P < 0.001), and working individuals had a lower annual income (48,500 vs. 53,500€, P < 0.001) in comparison to the controls. Additionally, MS patients within this age group were more likely to receive publicly funded practical assistance (14.3 vs. 1.6%, P < 0.001) and personal care (10.5 vs. 0.8%, P < 0.001). Across the entire population, MS patients were more likely to live alone (38.7 vs. 33.8%, P < 0.001) and less likely to have one or more children (84.2 vs. 87.0%, P < 0.001).

Conclusion

MS presents significant socioeconomic challenges among the elderly population, such as unemployment, reduced income, and increased dependence on social care. These findings underscore the pervasive impact of MS on an individual's life course, extending beyond the clinical symptoms of cognitive and physical impairment.

Cost-effectiveness Analysis of Ocrelizumab for the Treatment of Relapsing and Primary Progressive Multiple Sclerosis in Portugal

OBJECTIVES

Ocrelizumab demonstrated significant clinical benefit for the treatment of relapsing (RMS) and primary progressive (PPMS) multiple sclerosis (MS), an incurable disease characterized by disability progression. This study evaluated the clinical and economic impact of ocrelizumab relative to current clinical practice, including other disease-modifying therapies (DMT), available in Portugal.

METHODS

Markov models for MS were adapted to estimate the impact of ocrelizumab across three patient populations: treatment-naïve RMS, previously treated RMS, and PPMS. Health states were defined according to the Expanded Disability Status Scale. For RMS, the model further captured the occurrence of relapses and progression to secondary progressive multiple sclerosis (SPMS). A lifetime time-horizon and Portuguese societal perspective were adopted.

RESULTS

For RMS patients, ocrelizumab was estimated to maximize the expected time (years) without progression to SPMS (10.50) relative to natalizumab (10.10), dimethyl fumarate (8.64), teriflunomide (8.39), fingolimod (8.38), interferon β-1a (8.33) and glatiramer acetate (8.18). As the most effective option, with quality-adjusted life year (QALY) gains between 0.3 and 1.2, ocrelizumab was found to be cost-saving relative to natalizumab and fingolimod, and presented incremental cost-effectiveness ratios (ICER) below €16,720/QALY relative to the remaining DMT. For PPMS patients, the ICER of ocrelizumab versus best supportive care was estimated at €78,858/QALY.

CONCLUSIONS

Ocrelizumab provides important health benefits for RMS and PPMS patients, comparing favourably with other widely used therapies. In RMS, ocrelizumab was revealed to be either cost-saving or have costs-per-QALY likely below commonly accepted cost-effectiveness thresholds. In PPMS, ocrelizumab fills a clear clinical gap in the current clinical practice. Overall, ocrelizumab is expected to provide good value for money in addressing the need of MS patients.

Neuropathic pain, cognitive fusion, and alexithymia in patients with multiple sclerosis: Cross-sectional evidence for an explanatory model of anxiety symptoms

Multiple sclerosis (MS) presents a high prevalence, a marked increase worldwide, and a relevant impact on patients, public health, and society. Anxiety often cooccurs with MS and can contribute to the worsening of MS symptoms. However, knowledge about predictors of anxiety in Patients with MS (PwMS) is scarce.

OBJECTIVE

This preliminary study explored a novel model for anxiety symptoms in PwMS, including neuropathic pain (NeP), cognitive fusion (CF), experiential avoidance (EA), and alexithymia as explanatory factors.

METHOD

This cross-sectional study integrated two independent convenience samples: 107 PwMS recruited from the Portuguese Society for Multiple Sclerosis and 97 age- and gender-matched participants without the MS diagnosis (no-MS sample) recruited from the Portuguese general population. Self-report questionnaires that measured the constructs included in the model were administered to both groups.

RESULTS

PwMS showed significantly higher values regarding anxiety symptoms and their explanatory variables (NeP, CF, EA, alexithymia) in comparison to non-MS participants. In the MS sample, no correlations were found between anxiety symptoms and sociodemographic and clinical characteristics. NeP, CF, and alexithymia showed significant correlations with anxiety symptoms and significantly explained this symptomatology in simple linear regression models. Thus, these variables were retained in the multiple linear regression model and emerged as significant regressors that together explained 38% of the variance in anxious symptomatology in PwMS.

CONCLUSIONS

This preliminary study provides novel evidence on NeP and some maladaptive emotion regulation strategies related to EA/psychological inflexibility, as vulnerability to anxiety in PwMS can be considerably increased by CF and alexithymia. Clinical implications were discussed.

social determinants of health in multiple sclerosis

Social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are the non-medical factors that influence health outcomes. Evidence indicates that health behaviours, comorbidities and disease-modifying therapies all contribute to multiple sclerosis (MS) outcomes; however, our knowledge of the effects of social determinants — that is, the ‘risks of risks’ — on health has not yet changed our approach to MS. Assessing and addressing social determinants of health could fundamentally improve health and health care in MS; this approach has already been successful in improving outcomes in other chronic diseases. In this narrative Review, we identify and discuss the body of evidence supporting an effect of many social determinants of health, including racial background, employment and social support, on MS outcomes. It must be noted that many of the published studies were subject to bias, and screening tools and/or practical interventions that address these social determinants are, for the most part, lacking. The existing work does not fully explore the potential bidirectional and complex relationships between social determinants of health and MS, and the interpretation of findings is complicated by the interactions and intersections among many of the identified determinants. On the basis of the reviewed literature, we consider that, if effective interventions targeting social determinants of health were available, they could have substantial effects on MS outcomes. Therefore, funding for and focused design of studies to evaluate and address social determinants of health are urgently needed.

Here, the authors discuss the potential effects of social determinants of health on multiple sclerosis risk and outcomes. They suggest that addressing these determinants of health could substantially improve the lives of individuals with multiple sclerosis and call for more research.

Addressing an individual’s social determinants of health — that is, the conditions under which they are born, grow, live, work and age — could provide opportunities to reduce the burden of living with multiple sclerosis (MS).

Individual factors that may influence MS-related outcomes include sex, gender and sexuality, race and ethnicity, education and employment, socioeconomic status, and domestic abuse.

Societal infrastructures, including access to food, health care and social support, can also affect MS-related outcomes.

Awareness of the specific circumstances of a patient with MS might help neurologists deliver better care.

Social determinants of health are not static and can change according to wider sociopolitical contexts, as highlighted by the COVID-19 pandemic.

Rigorous studies of interventions to ameliorate the effects of poor social determinants on people with MS are urgently needed.

Spatial and temporal distribution of the prevalence of unemployment and early retirement in people with multiple sclerosis: A systematic review with meta-analysis

Background

We aimed to summarise the prevalence of unemployment and early retirement among people with MS and analyze data according to a spatio-temporal perspective.

Methods

We undertook a systematic search of PubMed/MEDLINE, Scopus, SciVerse ScienceDirect, and Web of Science. We included any peer-reviewed original article reporting the prevalence of unemployment and early retirement in the working-age population with MS. We excluded articles off-topic, with other study designs, whose study sample were unlikely to be representative of the MS population and in case of unavailability of the full text or essential information. A random-effects meta-analysis was used to measure overall prevalence estimates of unemployment and early retirement. We used meta-regression and subgroup analysis to evaluate potential moderators of prevalence estimates and the leave-one-out method for sensitivity analyses.

Results

Our research identified 153 studies across 29 countries encompassing 188436 subjects with MS. The pooled overall effect size for unemployment and early retirement was 35.6% (95% CI 32.8–38.4; I² = 99.31) and 17.2% (95% CI 14.6–20.2; I² = 99.13), respectively. The prevalence of unemployment varied according to the year of publication (p < 0.001) and there was a statistically significant decrease in the prevalence of unemployment over time (p = 0.042). Regarding early retirement, only seven (31.8%) estimates obtained from studies that were published before 2010 were below the overall effect size in comparison to 27 (60.0%) estimates extracted from data published between 2010 and 2021 (p = 0.039). There was a significant difference in prevalence according to countries (p < 0.001). Psychiatric illness was an important clinical feature responsible for patients leaving the workforce in regions with a high MS prevalence.

Conclusions

Unemployment and early retirement due to MS remain highly prevalent, despite a slight decline in the last decade. The prevalence of unemployment and early retirement varies globally.

Self-employment, sickness absence, and disability pension in multiple sclerosis

Objectives

Early withdrawal from work is common among people with multiple sclerosis (PwMS). However, little is known about how this is influenced by the type of employment. The aims were to explore the distributions of self‐employed and other types of employment (employed or no earnings from work) before and after MS diagnosis and its associations with sickness absence (SA) and disability pension (DP) among PwMS and matched references without MS.

Materials & Method

A 6‐year longitudinal cohort study of 2779 individuals diagnosed with MS in 2008–2012 when aged 20–59 and of 13,863 matched individuals without MS from Sweden's population was conducted. Hazard ratios (HR) of >180 SA and/or DP days/year were compared by employment status among PwMS and references using Cox proportional hazard models with 95% confidence intervals (CI).

Results

Most had no SA or DP. Nevertheless, PwMS had higher SA and DP levels compared with references. PwMS had a higher likelihood to reach >180 days of SA (HR = 4.89, 95% CI = 4.43–5.40) or days of DP (HR = 6.31, 95% CI = 5.46–7.30), irrespective of the employment status. Self‐employed references had less likelihood for >180 SA days than employed references. However, self‐employed and employed PwMS had a similar likelihood for >180 SA days. Transitions of employees to self‐employment were infrequent among PwMS (1.7%) and references (2.6%).

Conclusions

PwMS transit to SA and DP to a higher extent than references. In contrast to individuals without MS, self‐employed PwMS had similar SA levels to employed PwMS. Switching to self‐employment was not a predominant choice for people recently diagnosed with MS.

Occupational outcomes of people with multiple sclerosis: a scoping review

OBJECTIVES

To update the knowledge on the occupational outcomes associated with multiple sclerosis (MS), systematically examine the extent, scope and nature of the pre-existing literature and identify research gaps in the existing literature.

DESIGN

Scoping review.

DATA SOURCES

A comprehensive database search of PubMed/MEDLINE, Scopus, SciVerse ScienceDirect and Web of Science was performed. There were no time limits.

ELIGIBILITY CRITERIA

We included any peer-reviewed original article reporting the occupational outcomes of people with MS between the ages of 18 and 65 years. We excluded those off-topic and with insufficient information.

METHODS

This review was conducted following the Joanna Briggs Institute recommendations and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for scoping review checklist. Screening, reading of full-texts and data extraction was performed in a standardised way by expert reviewers from 14 July 2021 to 31 October 2021. We provided a narrative synthesis and an overview of findings.

RESULTS

The initial systematic search yielded 104 228 results. After removing duplicates and applying the exclusion criteria, 403 articles were included in the review. In total, the studies evaluated 492 062 subjects with MS. One hundred fifty-four (38.2%) articles were published in the last 5 years, mostly from Europe and North America (50.9% and 33.0%, respectively). Concerning the occupational outcomes, studies mostly addressed unemployment (311, 77.2%), early retirement (120, 29.8%), disability pension (117, 29.0%), sick leave (77, 19.1%), the indirect cost of MS (74, 18.4%) and work characteristics (57, 14.1%). The results were categorised into seven subtopics: 'Changes in work and occupational status due to MS', 'work-related socio-economic consequences of MS', 'risk factors for unfavourable occupational outcomes', 'reported barriers to employment', 'reported job accommodations and vocational rehabilitation strategies', 'job satisfaction, stigma, and disclosing the diagnosis in the workplace' and 'rating clinical scales'.

CONCLUSIONS

There are several issues that deserve further in-depth study by the scientific community in order to improve the occupational outcomes of people with MS.

Long-term trajectories of employment status, workhours and disability support pension status, after a first episode of CNS demyelination

BACKGROUND

People with multiple sclerosis face significant employment-related challenges, with little known of the drivers of these outcomes.

OBJECTIVE

We examined prospective trajectories of employment-related outcomes up to 11 years following a first episode of central nervous system (CNS) demyelination (FCD).

METHODS

Participants were aged 18-59 years, at FCD, with at least two observations and were employed at study entry or anytime during follow-up (n = 207). Outcomes were employment status (full-time, part-time and unemployed), average workhours per week and disability support pension (DSP; receiving/not receiving). We used group-based trajectory modelling to identify groups with common trajectories. Factors associated with trajectory membership were explored using log-multinomial regression.

RESULTS

Distinct trajectories were identified for employment (4), workhours (4) and DSP (2). Compared with stable full-time, female sex was strongly associated with being in the stable part-time trajectory (risk ratio (RR): 5.35; 95% confidence interval (CI) = 2.56-11.20; p < 0.001). A greater level of disability at 5-year review (RR: 1.35; 95% CI = 1.19-1.53) and having more than two comorbidities at baseline (RR: 2.77; 95% CI = 1.37-5.64) were associated with being in early and late deteriorated employment trajectories, respectively. Compared with the increased part-time trajectory, every additional relapse during the 5 years post-FCD was associated with a 10% increased risk of being in the reduced part-time trajectory (RR = 1.10; 95%CI = 1.00-1.22). For every additional EDSS point at 5-year review, the risk of being in the DSP trajectory increased (RR = 1.21; 95% CI = 1.05-1.41).

CONCLUSION

These trajectories indicate substantial heterogeneity and the complex impact of MS on employment from its earliest timepoints. Understanding these trends could enable better targeting of interventions to facilitate workforce retention, particularly for females, those with a higher number of comorbidities, more frequent relapses and greater rate of disability accrual.

Factors associated with requesting accommodations among people with multiple sclerosis

BACKGROUND

Almost one million individuals are living with multiple sclerosis (MS) in the United States with a majority being diagnosed when they are in their 20s or early stages of their careers. Employees with MS experience various job-related challenges such as high unemployment and underemployment. Accommodations assist individuals with MS to obtain and maintain employment, yet the current understanding of factors affecting decisions to request or withhold accommodations is limited.

OBJECTIVE

This study aimed to explore barriers and facilitators of workplace accommodation requests among individuals with MS through a qualitative approach.

METHODS

Eighty-six participants were recruited from agencies serving individuals with MS in the US. Content analysis was conducted to examine responses to one open-ended question related to their perception of barriers or facilitative strategies to request accommodations.

RESULTS

Ten overarching themes related to barriers and facilitators for requesting accommodations were identified. Among them were three facilitators (i.e., positive work environment, employer compliance and flexibility, and employee self-advocacy and proactivity) and seven barriers (i.e., employers' lack of knowledge of Americans with Disabilities Act and accommodations, employers' discrimination and resistance to accommodation requests, employees' fear/anxiety to request due to associated stigma, employees' lack of knowledge about accommodations/disability/resources as well as inaccessible workspace).

CONCLUSIONS

Rehabilitation professionals can educate and empower employees with MS to disclose disability and request needed accommodations. Rehabilitation professionals also can educate employers for individuals with MS about their obligations under the laws to provide accommodations and sensitize coworkers of individuals with MS regarding the disability.

Burden of illness the first year after diagnosed bladder dysfunction among people with spinal cord injury or multiple sclerosis - a Danish register study

BACKGROUND

People with spinal cord injury (SCI) or multiple sclerosis (MS) are often living with some degree of bladder and/or bowel dysfunction due to acquired neurogenic damage. The objective was to estimate the burden of illness of SCI and MS the first year after diagnosed bladder dysfunction.

METHODS

Data were extracted from registers covering all Danish citizens. People with SCI or MS were indexed at diagnosis of bladder dysfunction. Inclusion period was 2002-2015 and cases and matched controls were followed for one year.

RESULTS

A total of 2,132 subjects with SCI and 1,887 subjects with MS were identified. Healthcare utilization and societal costs per patient-year were significantly higher for cases compared to controls driven primarily by inpatient care. Cases with urinary tract infection had significantly higher inpatient costs per patient-year compared to controls (SCI: 544 EUR vs 23, p < 0.05; MS: 497 EUR vs 6, p< 0.05) and medication for constipation was significantly more costly per patient-year (SCI: 178 EUR vs 3, p < 0.05; MS: 78 vs 1, p < 0.05).

CONCLUSIONS

The study demonstrates heavy societal and personal costs in the first year after bladder dysfunction in people with SCI or MS. This emphasizes the need for medical and social interventions to reduce the burden of illness.

Aging With Multiple Sclerosis: Age-Related Factors and Socioeconomic Risks

Background

Studies have demonstrated an increasing mean age of the population with multiple sclerosis (MS). The association between increased age and socioeconomic outcomes has been investigated sparsely.

Objective

The purpose of this study is to describe the demographic and socioeconomic status of the current Danish population of patients with MS according to age and to assess the age-related risks of no income or losing all income from earnings or receiving disability pension.

Methods

The nationwide population-based Danish Multiple Sclerosis Registry provided data linked with the Danish Income Statistics Register and the Danish Rational Economic Agents Model (DREAM) database. The prevalence of socioeconomic milestones of the current MS population was compared with healthy controls and the risks of reaching socioeconomic milestones were assessed using cause-specific Cox models and cumulative incidence functions compared to healthy controls.

Results

The current Danish population of patients with MS of working age (18–65 years of age) consists of 11,287 patients, of which 29.3% was older than 55 years. In 2018, 38.0% of all patients and 18.9% of controls had no income from earnings, whereas 30.5% of all patients and 7.7% of controls received disability pension. The risk of losing all income from earnings was higher for patients with MS with a hazard ratio (HR) peaking at of 4.0 (95% CI, 3.8–4.2) for the ages of 45–54 years. The risk of receiving disability pension was much higher for patients with MS peaking at a HR of 22.6 (95% CI, 20.9–24.4) for the ages of 25–34 years. Likewise, the absolute risks of both outcomes were higher for the patients with MS at all ages.

Conclusion

Danish patients with MS are at a higher risk of losing all income from earnings and at a much higher risk of receiving disability pension compared with healthy controls.

Cost of illness in multiple sclerosis by disease characteristics - A review of reviews

Introduction: In light of the increasing number of economic burden studies and heterogeneity in methodology and reporting standards, there is a need for robust evidence synthesis on an umbrella review level.Areas covered: We performed the first review of reviews of cost-of-illness studies in multiple sclerosis. Focusing on disaggregated costs by disease characteristics (disability level, relapse, disease course), we also characterized the underlying methodological evidence base of individual (primary) studies.Expert Commentary: We identified 17 reviews encompassing 111 unique primary studies, and a high degree of overlap across reviews. Costs were substantial, rising with disability level, relapse episodes, and disease progression. Disability was the key cost driver. Compared to mild disability, total costs for moderate disability were 1.4-2.3-fold higher and 1.8-2.9-fold higher for severe disability. With escalating disability, the share of costs outside the health system (indirect costs, informal care) increasingly outweighed the share of direct medical costs. Of all 111 primary studies, 72% gathered resource use/loss data by patient self-report. Associated costs were mostly reported by disability level (75%), followed by relapse (48%) and disease course (21%). In conclusion, although heterogeneity can make in-depth comparisons of costs across studies impossible, important patterns are broadly apparent.

Effects of Vibration Training on Cognition and Quality of Life in People with Multiple Sclerosis

Background: Multiple sclerosis (MS) detrimentally affects cognition and quality of life (QOL). Interventions that can improve cognitive deficit and QOL in people with MS are desired. This pilot study investigated the possible effects of vibration training on improving cognition and QOL in people with MS.

Methods: Eighteen adults with MS were randomized into two groups: training and control. The training group underwent 6 weeks of vibration training, and the control group maintained their normal lifestyle throughout the study. In both groups, before and after the training course, the disability status was evaluated by the Patient-Determined Disease Steps scale and the Multiple Sclerosis Functional Composite (MSFC), cognitive function was assessed by the Behavior Rating Inventory of Executive Function (BRIEF) and the Selective Reminding Test (SRT), and QOL was gauged by the 36-item Short Form Health Survey (SF-36).

Results: The training was well accepted by the participants, and no major adverse event was reported. All participants finished the entire protocol. Compared with the control group, after the training the training group showed greater improvements in MSFC score, Metacognition Index score of the BRIEF, SRT score, and physical domain score of the SF-36.

Conclusions: These results suggest that vibration training could be an effective alternative training paradigm to enhance cognition and QOL in people with MS, and they provide an encouraging base to conduct a large-scale clinical trial.

Costs of schizotypal disorder: A matched-controlled nationwide register-based study of patients and spouses

OBJECTIVE

Information on societal cost of patients with schizotypal disorder is limited. The aim was to investigate the societal costs of schizotypal disorder before and after initial diagnosis including both patients and their spouses.

METHODS

A register-based cohort study of 762 patients with incident schizotypal disorder (ICD-10; F21) including their spouses and 3048 matched controls, during 2002 to 2016. Total healthcare costs, home care costs, and costs of lost productivity of patients and spouses were included in the analysis.

RESULTS

Total costs amounted €47,215 per year for patients with schizotypal disorder, which was fifteen times higher than the matched controls. Of these, 41% were healthcare and home care costs and 59% were costs of lost productivity. Healthcare costs and costs of lost productivity were increased during five years before initial diagnosis of schizotypal disorder. Total costs of spouses to patients were €21,384 compared with € 2519 among spouses of controls. 75% of the total costs of spouses to patients were related to lost productivity. The total costs were higher than the costs of borderline personality disorder, but on the same level as the costs of schizophrenia identified in earlier comparable studies.

CONCLUSIONS

The total societal costs of patients with schizotypal disorder drawn from national registers differed substantially from the controls representing the general population. As evidence-based recommendations for diagnoses and treatment of patients with schizotypal disorder do not exist, future research should focus on developing effective treatment for this group of patients to reduce cost of illness.

Cost-of-Illness Progression Before and After Diagnosis of Multiple Sclerosis: A Nationwide Register-Based Cohort Study in Sweden of People Newly Diagnosed with Multiple Sclerosis and a Population-Based Matched Reference Group

BACKGROUND

Multiple sclerosis (MS) is a chronic disease associated with increased healthcare utilisation and productivity losses.

OBJECTIVE

The objective of this study was to explore the progression of healthcare costs and productivity losses before and after diagnosis of MS in comparison to that of a population-based matched reference group.

METHODS

We conducted a nationwide, Swedish register-based cohort study of working-aged people with MS diagnosed in 2010-12 (n = 1988) and population-based matched references without MS (n = 7981). Nine years of observation spanned from 4 years prior (Y_-4) to 4 years (Y₊₄) after the year of diagnosis (Y₀). Differences in annual all-cause healthcare costs (inpatient and specialised outpatient healthcare as well as pharmacy-dispensed prescribed drugs) and costs of productivity loss (days with sickness absence and disability pension) were estimated between the people with MS and references using t tests with 95% confidence intervals. The average excess costs of MS were estimated using generalised estimating equation models.

RESULTS

People with multiple sclerosis had higher costs before the diagnosis of MS and also thereafter. The mean differences in healthcare costs and productivity losses between the people with MS and matched references in Y_-4 were 216 EUR (95% confidence interval 58-374) and 1540 EUR (95% confidence interval 848-2233), with larger cost excesses observed in later study years. Summarising the 9 study years, people with MS had fivefold higher excess healthcare costs than references, and more than twice as high productivity losses.

CONCLUSIONS

Excess healthcare costs and productivity losses occur already before the diagnosis of MS and increase with time. The excess costs findings before diagnosis could suggest that an earlier diagnosis might lead to reduced excess costs of MS over time.

Socioeconomic consequences of multiple sclerosis-A systematic literature review

Multiple sclerosis (MS) is a challenging and disabling condition, predominantly affecting individuals in their early life, and has an impact functionally, financially, and on quality of life. However, there is a lack of systematic approach towards assessing socioeconomic consequences of MS. Our objective was to systematically review observational analytical studies investigating the socioeconomic consequences of MS. We conducted a systematic review on socioeconomic consequences of MS with a focus on employment-, income-, work ability- and relationship-related outcomes between MS and the general population. Additionally, the educational characteristics were extracted. From 4958 studies identified, 187 were assessed for eligibility and a total of 27 studies from eight countries were included in this qualitative assessment; 32 different outcomes were identified. All studies indicated pronounced differences between MS patients and the general population, for example 15%-30% lower employment, lower earnings and higher social benefits, higher absenteeism and presenteeism proportions, higher work disability (eg, sick-leave days) among MS patients. Some studies also indicated differences in the family or relationship characteristics. There were no apparent differences with regard to educational level. In conclusion, socioeconomic data can serve as robust outcome measures to study various aspects of MS reflecting the broader consequences of the disease.

Socioeconomic status and access to multiple sclerosis treatment in Mexico

INTRODUCTION

Multiple sclerosis (MS) is a chronic neurological autoimmune condition and the leading non-traumatic cause of neurological disability worldwide. Disease-modifying therapies (DMT) directly impact on the long-term prognosis of patients with MS preventing relapses and the associated disability progression. Here, we analyzed the impact of socioeconomic status (SES) on DMT access in Mexican patients.

METHODS

We evaluated the association between SES and DMT access using the MS registry from the National Institute of Neurology and Neurosurgery in Mexico City. We included 974 patients with MS (McDonald 2010 criteria). We categorized SES according to the 2018 Mexican Association of Market Research Agencies (AMAI) SES classification. We analyzed DMT type, MS phenotype, educational level, symptomatic onset to diagnosis, EDSS at arrival, as well as the progression index. Chi-squared and Wilcoxon tests were used, and multivariable analysis performed for DMT access.

RESULTS

When comparing the lower versus higher levels of SES, a significant association was found on the percentage of patients with higher levels of disability (EDSS >6) at arrival, the proportion of patients not receiving any DMT and a higher proportion of secondary progressive MS (p=0.006, p<0.001and p=0.004, respectively). We also found that lower educational levels had a significance and inverse association with EDSS on first visit (p=0.019), symptomatic onset to diagnosis (p<0.001) and a higher disability status at arrival (EDSS >6, p=0.010).

CONCLUSIONS

Our study suggests that SES is an important factor determining not only prompt but overall access to highly effective DMT. Lower SES are associated with greater levels of disability at the first clinic visit and a higher proportion of patients not receiving DMT up to 12 months of follow-up.

m6A RNA Methylation in Systemic Autoimmune Diseases-A New Target for Epigenetic-Based Therapy?

The general background of autoimmune diseases is a combination of genetic, epigenetic and environmental factors, that lead to defective immune reactions. This erroneous immune cell activation results in an excessive production of autoantibodies and prolonged inflammation. During recent years epigenetic mechanisms have been extensively studied as potential culprits of autoreactivity. Alike DNA and proteins, also RNA molecules are subjected to an extensive repertoire of chemical modifications. N6-methyladenosine is the most prevalent form of internal mRNA modification in eukaryotic cells and attracts increasing attention due to its contribution to human health and disease. Even though m6A is confirmed as an essential player in immune response, little is known about its role in autoimmunity. Only few data have been published up to date in the field of RNA methylome. Moreover, only selected autoimmune diseases have been studied in respect of m6A role in their pathogenesis. In this review, I attempt to present all available research data regarding m6A alterations in autoimmune disorders and appraise its role as a potential target for epigenetic-based therapies.

The clinical correlates of participation levels in people with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) has a huge impact on patients and affects their ability to participate in meaningful activities.

OBJECTIVE

To identify motor and non-motor factors that are associated with the participation level in instrumental activities of daily living (IADL), leisure, social and religious activities in people with MS.

METHOD

This is a cross-sectional study conducted on 110 individuals with MS. The used outcome measures are: Arabic version of the Activity Card Sort, Berg Balance Scale, Modified Fatigue Impact Scale, Nine Hole Peg Test, 6-Minute Walk Test, Brief International Cognitive Assessment for Multiple Sclerosis, Stroop test and Hospital Anxiety and Depression Scale.

RESULTS

Hand function, balance, gender and cognitive status can predict the participation in IADL (R2 = 0.425, P < 0.0001); depression, age, and cognitive status can predict the participation in leisure activities (R2 = 0.372, P < 0.0001), and fatigue, balance and cognitive status can predict social activities participation (R2 = 0.492, P < 0.000).

CONCLUSION

Balance, cognition and fatigue affect the level of participation in instrumental activities of daily living, leisure, and religious and social activities.

The Prevalence and Association of Depression and Anxiety With Multiple Sclerosis in Riyadh, Saudi Arabia: A Cross-Sectional Study

Introduction Multiple sclerosis (MS) is often associated with depression and anxiety, with no clear prevalence, and the relationship between them is not fully understood. Methods In a cross-sectional study of 365 multiple sclerosis patients selected through a random sampling method from the MS society of Riyadh, Saudi Arabia, we collected data by self-administered questionnaires - the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) questionnaire - and analyzed by descriptive and analytical statistics. Results Approximately 51.1% of participants had moderate or severe anxiety and 64% of them had depression among community-based multiple sclerosis patients according to Generalized Anxiety Disorder (GAD-7) questionnaire, and according to the PHQ-9 Arabic version about 28.85% showed mild to moderate depression. The MS patients aged 53 to over 60 years showed higher levels of mild anxiety (76.32%) and higher levels of depression ranging from mild to moderate (53.61%) (P = 0.001). While the MS patients younger than 53 years showed moderate to severe anxiety (60.71%) and depression levels (62.32%). In different age group bad health status (37.6%) was associated with a higher prevalence of depression levels (P =< 0.001) and people who were widowed (22.38%), divorced (26%), and separated (37.82%) had significant depression levels (P = 0.017). In terms of anxiety, 54.58% of females had anxiety (P = 0.005), more older people showed anxiety (43.17%) (P = 0.026), and people with a bad general health state (26.38%) had anxiety (P = <0.001). Conclusion Among different types of MS patients, anxiety is more prevalent in the elder group (76%) of people and depression is more prevalent in young patients (62%).

Effects of mesenchymal stem cells transplantation on multiple sclerosis patients

Multiple Sclerosis (MS) is a demyelinating autoimmune disease of the central nervous system (CNS) with symptoms such as neuroinflammation and axonal degeneration. Existing drugs help reduce inflammatory conditions and protect CNS from demyelination and axonal damage; however, these drugs are unable to enhance axonal repair and remyelination. In this regard, cell therapy is considered as a promising regenerative approach to MS treatment. High immunomodulatory capacity, neuro-differentiation and neuroprotection properties have made Mesenchymal Stem Cells (MSCs) particularly useful for regenerative medicine. There are scant studies on the role of MSCs in patients suffering from MS. The low number of MS patients and the lack of control groups in these studies may explain the lack of beneficial effects of MSC transplantation in cell therapies. In this review, we evaluated the beneficial effects of MSC transplantation in clinical studies in terms of immunomodulatory, remyelinating and neuroprotecting properties of MSCs.

Social support in multiple sclerosis: Associations with quality of life, depression, and anxiety

OBJECTIVE

Social support plays a role in the well-being of persons with multiple sclerosis (PwMS). The aims of this study were to compare social support in PwMS with relapsing versus progressive disease, examine the relationships with patient reported outcomes (PROs), and investigate social support longitudinally.

METHODS

For this study, we have performed an analysis of data routinely collected from subjects enrolled in the CLIMB at the Partners MS Center. Subjects (n = 789) completed measures of social support, quality of life (QOL), depression, and anxiety. Relapsing and progressive PwMS were compared using a two sample t-test, and linear regression was used to adjust for other variables. Correlations between social support and PROs were assessed using partial Pearson's correlation coefficient. A random intercept and slope model with a linear trend with time estimated the change over time.

RESULTS

Subjects with relapsing MS reported higher overall social support than subjects with progressive disease (difference in means = -6.7; 95% CI: -10.3, -3.1) as well as higher levels of 3 of the 4 dimensions of social support measured. These differences remained after adjusting for age and gender only, but were attenuated adjusting for age, gender, and depression (adjusted difference in means = -1.2; 95% CI: -5.0, 2.6). Higher overall social support was associated with higher QOL (r = 0.16-0.27), lower depression (r = -0.36), and lower state (r = -0.27) and trait (r = -0.29) anxiety. Social support was mostly stable over time.

CONCLUSION

Social support was associated with QOL, depression, and anxiety in PwMS.

Effect of mood and anxiety disorders on health care utilization in multiple sclerosis

Background:

Little is known about the effects of changes in the presence or absence of psychiatric disorders on health care utilization in multiple sclerosis (MS).

Objective:

To evaluate the association between “active” mood and anxiety disorders (MAD) and health care utilization in MS.

Methods:

Using administrative data from Manitoba, Canada, we identified 4748 persons with MS and 24,154 persons without MS matched on sex, birth year, and region. Using multivariable general linear models, we evaluated the within-person and between-person effects of any “active” MAD on annual physician visits, hospital days, and number of drug classes dispensed in the following year.

Results:

Annually, the MS cohort had an additional two physician visits, two drug classes, and nearly two more hospital days versus the matched cohort. Individuals with any MAD had more physician visits, had hospital days, and used more drug classes than individuals without a MAD. Within individuals, having an “active” MAD was associated with more utilization for all outcomes than not having an “active” MAD, but the magnitude of this effect was much smaller for visits and drugs than the between-person effect.

Conclusion:

Within individuals with MS, changes in MAD activity are associated with changes in health services use.

Increased socioeconomic burden in patients with primary progressive multiple sclerosis: A Danish nationwide population-based study

BACKGROUND

Primary progressive multiple sclerosis (PPMS) is characterized by development of more chronic neurological manifestations from disease onset compared with relapsing remitting MS (RRMS) and secondary progressive MS (SPMS) but the following socioeconomic consequences have never been described in a nation-wide patient population.

OBJECTIVE

To determine if socioeconomic burden of PPMS is increased compared with RRMS and SPMS.

METHODS

We included patients from The Danish Multiple Sclerosis Registry diagnosed between 1998 and 2015. Yearly average health costs, public transfers and earned income was calculated from the index diagnosis date, and each year in a five-year period before and after index diagnosis date, for the three patient groups. A regression model estimating the odds ratio (OR) with PPMS as the comparator, was used to analyze the differences between PPMS vs. RRMS and PPMS vs. SPMS controlling for age and sex.

RESULTS

In total, 9563 MS patients were identified (1998-2015), with a characteristic distribution between different disease courses: 7012 patients with RRMS (73%), 1099 patients with PPMS (11%) and 1452 patients with SPMS (15%). Total health costs were lower in RRMS vs. PPMS (OR 0.76; 95% CI 0.74-0.78; p<0.0001) but not in SPMS vs. PPMS (OR 1.06; 95% CI 1.03-1.09; p<0.0001). Especially homecare costs were lower in RRMS vs. PPMS (OR 0.17; 95% CI 0.17-0.18; p<0.0001), less pronounced in SPMS vs. PPMS (OR 0.93; 95% CI 0.90-0.97; p = 0.0001). OR for health costs before and after diagnosis was significantly lower in RRMS vs. PPMS regarding most variables, less pronounced in SPMS vs. PPMS.

CONCLUSION

This nation-wide population-based study show that socioeconomic burden is significantly higher in PPMS relative to RRMS, but less pronounced compared with SPMS.

Importance of early treatment decisions on future income of multiple sclerosis patients

Background

Early initiation of disease-modifying treatment (DMT) is associated with better disability outcomes in multiple sclerosis (MS). However, little is known of how treatment decisions affect socio-economic outcomes.

Objective

To estimate the long-term impact of early initiation of DMT on the income of MS patients.

Methods

In total, 3610 MS patients were included in this register-based cohort study. We measured the association between the time to treatment and the outcome, defined as time from treatment initiation to a 95% decrease in annual earnings compared to each patient´s baseline level. Additionally, the association between time to treatment and increase of social benefits (sickness absence, disability pension) was investigated. A Cox model was adjusted for sex, onset age, education, family situation, country of birth, living area, and disability.

Results

MS patients initiating treatment later had a higher risk of reaching the outcome- those who started treatment after 2 years from MS onset lost 95% of their earnings sooner (HR, 1.19; 95% CI, 1.04–1.37). Furthermore, risk to receive an annual compensation of SEK 100,000 (≈EUR 10,500) was higher for the delayed treatment group.

Conclusion

Early treatment initiation in MS is associated with better socioeconomic outcome, adding to previous studies showing benefits regarding disability.

A Journey to the Conformational Analysis of T-Cell Epitope Peptides Involved in Multiple Sclerosis

Multiple sclerosis (MS) is a serious central nervous system (CNS) disease responsible for disability problems and deterioration of the quality of life. Several approaches have been applied to medications entering the market to treat this disease. However, no effective therapy currently exists, and the available drugs simply ameliorate the destructive disability effects of the disease. In this review article, we report on the efforts that have been conducted towards establishing the conformational properties of wild-type myelin basic protein (MBP), myelin proteolipid protein (PLP), myelin oligodendrocyte glycoprotein (MOG) epitopes or altered peptide ligands (ALPs). These efforts have led to the aim of discovering some non-peptide mimetics possessing considerable activity against the disease. These efforts have contributed also to unveiling the molecular basis of the molecular interactions implicated in the trimolecular complex, T-cell receptor (TCR)–peptide–major histocompatibility complex (MHC) or human leucocyte antigen (HLA).

Natural product piperine alleviates experimental allergic encephalomyelitis in mice by targeting dihydroorotate dehydrogenase

Multiple sclerosis (MS) is the most popular chronic and debilitating inflammatory disease of the central nervous system (CNS) that remains incurable. Dihydroorotate dehydrogenase (DHODH) is critical to the activity of T lymphocytes and represents a potential therapeutic target for MS. Here we identify piperine, a bioactive constituent of black pepper, as a potent inhibitor of DHODH with an IC₅₀ value of 0.88 μM. Isothermal titration calorimetry and thermofluor assay demonstrate the directly interaction between piperine and DHODH. The co-complex crystal structure of DHODH and piperine at 1.98 Å resolution further reveal that Tyr356 residue of DHODH is crucial for piperine binding. Importantly, we show that piperine can inhibit T cell overactivation in a DHODH-dependent manner in concanavalin A-triggered T-cell assay and mixed lymphocyte reaction assay. Finally, piperine exhibits strong preventive and therapeutic effect in the MOG-induced experimental allergic encephalomyelitis (EAE), a useful model for studying potential treatments for MS, by restricting inflammatory cells infiltration into the CNS and preventing myelin destruction and blood-brain barrier (BBB) disruption. Taken together, these findings highlight DHODH as a therapeutic target for autoimmune disease of the nervous system, and demonstrate a novel role for piperine in the treatment of MS.

Diagnosis-specific sickness absence and disability pension before and after multiple sclerosis diagnosis: An 8-year nationwide longitudinal cohort study with matched references

BACKGROUND

Multiple sclerosis (MS) typically onsets when of working age and may reduce work capacity. Previous studies have examined the risk of sickness absence (SA) and disability pension (DP) among MS patients, however, limited knowledge is available on whether MS patients have an excess risk for SA/DP when compared with the general population in Sweden. Moreover, no information exists on the actual diagnoses for SA and DP among MS patients and whether the patterns of SA/DP diagnoses differs to those without MS. We aimed to explore diagnosis-specific SA and DP among working-aged MS patients both before and after MS diagnosis, in comparison to the levels and distributions of SA and DP diagnoses of a matched reference group and analyze the risk of diagnosis-specific DP.

MATERIALS AND METHODS

Longitudinal Swedish register data of the 2567 MS patients diagnosed with MS in 2009-2012 when aged 25-59 and 10,268 population-based matched references (matched on sex, age, educational level, type of living area, and country of birth) were analysed regarding annual diagnosis-specific SA and DP in the four years before and four years after MS diagnosis. Annual differences in the mean numbers of SA and/or DP net days were calculated with 95% confidence intervals (CI). Hazard ratios (HR) with 95% CI from Cox proportional hazard models were used to compare risks for new all-cause and diagnosis-specific DP after MS diagnosis among the MS patients and references.

RESULTS

The mean SA/DP net days/year increased among MS patients over follow-up, due to both MS and other diagnoses. During follow-up, around 50% of MS patients had some SA/DP compared to 20% of references. The mean days of SA/DP among the MS patients compared to references increased from 10.3 more days (95% CI: 6.6-14.2) four years prior to MS diagnosis to 68.9 days (62.8-75.1) 4 years after MS diagnosis. Although most new DP among MS patients were due to MS, 15% were not. The adjusted HR for all-cause DP was 23.1 (18.1-29.5). MS patients also had higher risks of new DP due to all diagnoses except MS (HR 3.4; 2.4-4.8), musculoskeletal (HR 2.6; 1.1-6.0) and mental (HR 2.0; 1.1-3.6) diagnoses compared with references.

CONCLUSION

MS patients had higher levels of SA/DP days/year than the references, already 4 years before the MS diagnosis, and increasingly so thereafter. The excess of SA/DP prior to MS diagnosis could be related to MS onset. However, the excess of SA/DP days were not all due to MS diagnoses, even after being diagnosed with MS. MS patients had a higher risk of having a new DP after being diagnosed with MS in total, but also for diagnoses other than MS.

The GPR17 Receptor-A Promising Goal for Therapy and a Potential Marker of the Neurodegenerative Process in Multiple Sclerosis

One of the most important goals in the treatment of demyelinating diseases such as multiple sclerosis (MS) is, in addition to immunomodulation, reconstruction of the lost myelin sheath. The modulator of the central nervous system myelination is the metabotropic receptor coupled to the G-protein: GPR17. GPR17 receptors are considered to be sensors of local damage to the myelin sheath, and play a role in the reconstruction and repair of demyelinating plaques caused by ongoing inflammatory processes. GPR17 receptors are present on nerve cells and precursor oligodendrocyte cells. Under physiological conditions, they are responsible for the differentiation and subsequent maturation of oligodendrocytes, while under pathological conditions (during damage to nerve cells), their expression increases to become mediators in the demyelinating processes. Moreover, they are essential not only in both the processes of inducing damage and the death of neurons, but also in the local repair of the damaged myelin sheath. Therefore, GPR17 receptors may be recognized as the potential goal in creating innovative therapies for the treatment of the neurodegenerative process in MS, based on the acceleration of the remyelination processes. This review examines the role of GRP17 in pathomechanisms of MS development.

Predictors of Change in Employment Status and Associations with Quality of Life: A Prospective International Study of People with Multiple Sclerosis

Purpose This prospective international study aimed to assess the changes in employment, and predictors thereof, and associated change in mental health quality of life in people with multiple sclerosis (MS). Methods People with MS were recruited online through social media, forums and newsletters to complete an online English-language survey in 2012 and again in 2015, to assess changes in employment and clinical characteristics. Results 1276 people with MS of working age were included of whom 35.9% were employed full time, 25.6% part-time, 3.1% were unemployed and seeking employment, 19.7% were retired due to disability and 15.7% were not in the labour force. Part/full time employment decreased from 61.4 to 57.1% of the sample 2.5 years later, and 25.5% experienced some change in employment status. Lower level of education and higher level of disability at baseline predicted loss of employment at follow-up. 62.0% of the sample indicated that MS impacted on employment over their lifetime, associated with a lower level of education and progressive MS at time of diagnosis. Retiring due to disability was predictive of a decreased mental health related QOL score. Conclusion Employment status was negatively impacted by MS for most participants. We showed for the first time that employment loss was prospectively associated with poorer mental health related quality of life. Employment support including vocational services, reasonable flexibility in the workplace, and legal protection against discrimination should be widely available to assist people with MS, especially for those with progressive onset MS, higher disability and lower levels of education who are at higher risk of employment loss.

Aberrant DNA methylation profile exacerbates inflammation and neurodegeneration in multiple sclerosis patients

Multiple sclerosis (MS) is an autoimmune and demyelinating disease of the central nervous system characterised by incoordination, sensory loss, weakness, changes in bladder capacity and bowel function, fatigue and cognitive impairment, creating a significant socioeconomic burden. The pathogenesis of MS involves both genetic susceptibility and exposure to distinct environmental risk factors. The gene x environment interaction is regulated by epigenetic mechanisms. Epigenetics refers to a complex system that modifies gene expression without altering the DNA sequence. The most studied epigenetic mechanism is DNA methylation. This epigenetic mark participates in distinct MS pathophysiological processes, including blood-brain barrier breakdown, inflammatory response, demyelination, remyelination failure and neurodegeneration. In this study, we also accurately summarised a list of environmental factors involved in the MS pathogenesis and its clinical course. A literature search was conducted using MEDLINE through PubMED and Scopus. In conclusion, an exhaustive study of DNA methylation might contribute towards new pharmacological interventions in MS by use of epigenetic drugs.

Societal Costs of Schizophrenia in Denmark: A Nationwide Matched Controlled Study of Patients and Spouses Before and After Initial Diagnosis

BACKGROUND

Information on welfare cost of patients with schizophrenia and spouses is limited.

AIM

The main aim of this study to investigate factual societal mean annual costs per individual during 5 years before and after the initial diagnosis of schizophrenia.

METHOD

A register-based cohort study of 12 227 patients with incident schizophrenia (International Classification of Diseases, Tenth Revision F20-F20.99) with spouses and 48 907 matched controls in Denmark during 2002-2016.

RESULTS

The total annual costs of health care and lost productivity were Euro 43 561 higher for patients with schizophrenia and health care costs and costs of lost productivity were increased during 5 years before the initial diagnosis. The total annual direct health care and indirect costs of lost productivity were Euro 21 888 higher for spouses to patients with schizophrenia than spouses of individuals with no diagnosis of schizophrenia. Also before initial diagnosis, health care costs and lost productivity were increased among spouses of patients with schizophrenia.

CONCLUSION

Patients with schizophrenia differed from the general population with respect to all included costs. The study documented a significant burden on spouses. The excess health care costs of schizophrenia are further increased by psychiatric and somatic comorbidity, and the societal costs are 4-10 times higher than chronic neurological disorders such as epilepsy and multiple sclerosis. Early onset of schizophrenia implies that patients are affected before finishing school and before entrance to labor market. Cost savings could be achieved by investments in preventive interventions reaching young people's needs; in initiatives to reduce hospital admissions caused by medication side effects, substance misuse, and lifestyle factors; and in occupational training.

Clinically stable disease is associated with a lower risk of both income loss and disability pension for patients with multiple sclerosis

OBJECTIVE

To assess the risk of losing income from salaries and risk disability pension for multiple sclerosis patients with a clinically stable disease course 3 years after the start of disease-modifying therapy (DMT).

METHODS

Data from the Danish Multiple Sclerosis Registry were linked to other Danish nationwide population-based databases. We included patients who started treatment with a DMT between 2001 and 2014. Patients were categorised into a clinically stable group (No Evidence of Disease Activity (NEDA-2)) and a clinically active group (relapse activity or 6-month confirmed Expanded Disability Status Scale worsening). Outcomes were: (1) loss of regular income from salaries and (2) a transfer payment labelled as disability pension. We used a Cox proportional hazards model to estimate confounder-adjusted HRs, and absolute risks were plotted using cumulative incidence curves accounting for competing risks.

RESULTS

We included 2406 patients for the income analyses and 3123 patients for the disability pension analysis. Median follow-up from index date was ~5 years in both analyses. The NEDA-2 group had a 26% reduced rate of losing income (HR 0.74; 95% CI 0.60 to 0.92). HRs were calculated for 5-year intervals in the disability pension analysis: year 0-5: a 57% reduced rate of disability pension for the NEDA-2 group (HR 0.43; 95% CI 0.33 to 0.55) and year 5-10: a 36% reduced rate (HR 0.64; 95% CI 0.40 to 1.01).

CONCLUSION

Clinically stable disease course (NEDA-2) is associated with a reduced risk of losing income from salaries and a reduced risk of disability pension.

Effect of Atrial Septal Defect in Adults on Work Participation (from a Nation Wide Register-Based Follow-Up Study Regarding Work Participation and Use of Permanent Social Security Benefits)

Low work participation is well known in patients with chronic disease but has not been described in patients with atrial septal defect (ASD). In this nation-wide cohort study, we report the first long-term follow-up of use of permanent social security benefits and work participation in adults with ASD. All Danes born before 1994 and diagnosed with ASD from 1959 to 2013 (n = 2,277) were identified from the Danish medical registries. We used Cox proportional hazards regression to compare the risk of receiving permanent social security benefits in the ASD patients compared with an age- and gender-matched general population cohort. Using the DREAM database, we calculated work participation score and proportion of patients working or not working at the age of 30 years. Median follow-up from ASD diagnosis was 23.4 years (range 0.2 to 59.3). ASD patients had a higher risk of receiving permanent social security benefits (hazard ratio 2.3 [95% confidence interval 2.1 to 2.6]) compared with the comparison cohort with 24% of the ASD patients receiving permanent social security benefits at the end of follow-up compared with 12% of the comparison cohort. At the age of 30 years, the proportion not working was 28% in the ASD cohort and 18% in the comparison cohort. In patients with ASD, 23% of those without a job had a psychiatric diagnosis. In conclusion, the risk of receiving permanent social security benefits was twice as high in patients with ASD and the work participation score was reduced compared with the background population.

Societal costs of Borderline Personality Disorders: a matched-controlled nationwide study of patients and spouses

OBJECTIVE

Information on societal cost of patients with Borderline Personality Disorder (BPD) and spouses is limited. The aim was to investigate factual societal costs before and after initial BPD diagnosis.

METHOD

A register-based cohort study of 2756 patients with incident BPD (ICD F60.3) with spouses and 11 024 matched controls, during 2002-2016.

RESULTS

Total direct healthcare costs and lost productivity costs amounted €40 441 for patients with BPD, which was more than 16 times higher than the matched controls. Somatic and psychiatric health care costs and costs of lost productivity were increased during 5 years before initial diagnosis of BPD. Before and after initial diagnosis, health care costs and lost productivity were increased among spouses of patients with BPD.

CONCLUSION

Patients with BPD differed substantially from the general population with respect to all included costs. The study documented a significant burden on their spouses. Besides the early onset of BPD, which implies that patients are affected before they finish school and enter labor market, the neurocognitive impairment and fundamental symptoms of BPD, e.g. unstable, intense relationships, impulsivity, and lack of stable sense of self together with psychiatric and somatic comorbidity are part of explanation of the excess costs of BPD.

Earnings among people with multiple sclerosis compared to references, in total and by educational level and type of occupation: a population-based cohort study at different points in time

OBJECTIVES

To investigate earnings among people with multiple sclerosis (PwMS) before and after MS diagnosis compared with people without MS, and if identified differences were associated with educational levels and types of occupations. Furthermore, to assess the proportions on sickness absence (SA) and disability pension (DP) in both groups.

DESIGN

Population-based longitudinal cohort study, 10 years before until 5 years after MS diagnosis.

SETTING

Working-age population using microdata linked from nationwide Swedish registers.

PARTICIPANTS

Residents in Sweden in 2004 aged 30-54 years with MS diagnosed in 2003-2006 (n=2553), and references without MS (n=7584) randomly selected by stratified matching.

OUTCOME MEASURES

Quartiles of earnings were calculated for each study year prior to and following the MS diagnosis. Mean earnings, by educational level and type of occupation, before and after diagnosis were compared using t-tests. Tobit regressions investigated the associations of earnings with individual characteristics. The proportions on SA and/or DP, by educational level and type of occupation, for the diagnosis year and 5 years later were compared.

RESULTS

Differences in earnings between PwMS and references were observed beginning 1 year before diagnosis, and increased thereafter. PwMS had lower mean earnings for the diagnosis year (difference=SEK 28 000, p<0.05), and 5 years after diagnosis, this difference had more than doubled (p<0.05). These differences remained after including educational level and type of occupation. Overall, the earnings of PwMS with university education and/or more qualified occupations were most like their reference peers. The proportions on SA and DP were higher among PwMS than the references.

CONCLUSIONS

The results suggest that the PwMS' earnings are lower than the references' beginning shortly before MS diagnosis, with this gap increasing thereafter. Besides SA and DP, the results indicate that educational level and type of occupation are influential determinants of the large heterogeneity of PwMS' earnings.