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Barter K, Sharayah S, Mange U, Gaudioso CM, Schanzer N, Keuchel C, Zolno R, Mar S. The Multiple Sclerosis Prodrome in a Retrospective Pediatric Cohort. Pediatr Neurol 2024; 161:144-148. [PMID: 39383588 DOI: 10.1016/j.pediatrneurol.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 07/13/2024] [Accepted: 09/04/2024] [Indexed: 10/11/2024]
Abstract
BACKGROUND Evidence suggests a prodromal phase in multiple sclerosis (MS), with increased health care use preceding the first demyelinating event (FDE). Although prior studies have explored this in adults, limited data exist for pediatric cases. We aimed to analyze health care utilization and prodromal symptoms in the two years before FDE in patients with pediatric-onset MS (POMS). METHODS From 122 patients at the Pediatric Multiple Sclerosis & Demyelinating Diseases Center at Washington University School of Medicine from 2011 to 2021, 37 POMS cases were identified. Of these, 21 with at least two years of records preceding FDE were included. Retrospective analysis covered symptoms and health care utilization in the two-year period before FDE, including ambulatory visits, hospital admissions, and office calls. RESULTS Patients showed increased health care utilization in the year preceding FDE (period B; 96 interactions) compared with the prior year (period A; 77 interactions) and an increase in the percentage of neurology-related encounters (P < 0.001). There was an increase in all office calls from period A to period B (P = 0.01). Neurological complaints included headaches (28.6%), visual (19.0%), sensory (14.3%), and balance (14.3%) in the two years before FDE, and 28.6% of patients presented for psychiatric complaints. Common non-neurological complaints included infection, dermatologic, and musculoskeletal issues and injury. CONCLUSIONS Our POMS cohort showed increased health care use before FDE, consistent with population-based data. This study emphasizes diverse symptoms in prodromal POMS, with headaches being the most common neurological symptom in the two-year period before FDE.
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Affiliation(s)
- Kelsey Barter
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Siefaddeen Sharayah
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Urmi Mange
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Cristina M Gaudioso
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Natalie Schanzer
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Connor Keuchel
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Rachel Zolno
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Soe Mar
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri.
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Puthenparampil M, Gaggiola M, Ponzano M, Zanotelli G, Miscioscia A, Nosadini M, Di Paola A, Sartori S, Perini P, Rinaldi F, Bovis F, Gallo P. High NEDA and No PIRA in Natalizumab-Treated Patients With Pediatric-Onset Multiple Sclerosis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200303. [PMID: 39141876 PMCID: PMC11379434 DOI: 10.1212/nxi.0000000000200303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
BACKGROUND AND OBJECTIVES Although pediatric-onset multiple sclerosis (POMS) is characterized by a more rapid accumulation of CNS inflammation than adult-onset MS (AOMS), the therapeutic algorithms applied in POMS are usually based on AOMS therapeutic outcomes. To define a high-efficacy treatment (HET)-based strategy to treat POMS, we designed an observational retrospective study aimed at evaluating the efficacy and safety of natalizumab (NTZ) in naïve POMS and AOMS. METHODS Starting from 160 patients, we applied a 2:1 (adult:pediatric) matching on propensity scores and obtained 32 patients with NTZ-treated POMS and 64 with AOMS, estimated from a multivariable logistic regression model. All patients were clinically and radiologically followed up every 6 months for a mean period of 46.0 ± 26.9 months. RESULTS Following re-baseline at month 6, no difference (log-rank test: p = 0.924) in new and enlarging T2 white matter lesions, postcontrast T1 lesions, and relapse rate were observed between POMS and AOMS throughout the study. Progression independent of relapse activity (PIRA) was never observed in POMS, while 9 of 64 patients with AOMS (12.5%) had PIRA events during the follow-up (40.0 ± 25.9 months; log-rank p value 0.0156). JCV seroconversion rate during NTZ infusion did not differ between POMS and AOMS (log-rank test p = 0.3231). Finally, no serious adverse event was observed in both POMS and AOMS. DISCUSSION The favorable outcomes observed on clinical, especially in PIRA, and radiologic parameters strongly support the use of NTZ as a first-choice HET in POMS.
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Affiliation(s)
- Marco Puthenparampil
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Marta Gaggiola
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Marta Ponzano
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Giovanni Zanotelli
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Alessandro Miscioscia
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Margherita Nosadini
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Alessandro Di Paola
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Stefano Sartori
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Paola Perini
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Francesca Rinaldi
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Francesca Bovis
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
| | - Paolo Gallo
- From the Department of Neurosciences (M. Puthenparampil, M.G., G.Z., A.M., P.G.), University of Padua; Multiple Sclerosis Centre (M. Puthenparampil, M.G., G.Z., P.P., F.R., P.G.), and Day Hospital and Centre for Advanced Neurological Therapies Unit, University Hospital of Padua; Department of Health Sciences (M. Ponzano, F.B.), Section of Biostatistics, University of Genova; Padua Neuroscience Centre (A.M.), University of Padua; Paediatric Neurology and Neurophysiology Unit (M.N., S.S.), Department of Women's and Children's Health, University Hospital of Padua; Neuroimmunology Group (M.N., S.S.), Paediatric Research Institute "Città della Speranza", Padua; and Neuroradiology Unit (A.D.P.), University Hospital of Padua, Italy
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Nasr Z, Casper TC, Waltz M, Virupakshaiah A, Lotze T, Shukla N, Chitnis T, Gorman M, Benson LA, Rodriguez M, Tillema JM, Krupp L, Schreiner T, Mar S, Rensel M, Rose J, Liu C, Guye S, Manlius C, Waubant E. Clinical and magnetic resonance imaging outcomes in pediatric-onset MS patients on fingolimod and ocrelizumab. Mult Scler Relat Disord 2024; 87:105647. [PMID: 38838422 DOI: 10.1016/j.msard.2024.105647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 03/25/2024] [Accepted: 04/25/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Observational studies looking at clinical a++nd MRI outcomes of treatments in pediatric MS, could assess current treatment algorithms, and provide insights for designing future clinical trials. OBJECTIVE To describe baseline characteristics and clinical and MRI outcomes in MS patients initiating ocrelizumab and fingolimod under 18 years of age. METHODS MS patients seen at 12 centers of US Network of Pediatric MS were included in this study if they had clinical and MRI follow-up and started treatment with either ocrelizumab or fingolimod prior to the age of 18. RESULTS Eighty-seven patients initiating fingolimod and 52 initiating ocrelizumab met the inclusion criteria. Before starting fingolimod, mean annualized relapse rate was 0.43 (95 % CI: 0.29 - 0.65) and 78 % developed new T2 lesions while during treatment it was 0.12 (95 % CI: 0.08 - 1.9) and 47 % developed new T2 lesions. In the ocrelizumab group, the mean annualized relapse rate prior to initiation of treatment was 0.64 (95 % CI: 0.38-1.09) and a total of 83 % of patients developed new T2 lesions while during treatment it was 0.09 (95 % CI: 0.04-0.21) and none developed new T2 lesions. CONCLUSION This study highlights the importance of evaluating current treatment methods and provides insights about the agents in the ongoing phase III trial comparing fingolimod and ocrelizumab.
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Affiliation(s)
- Zahra Nasr
- UCSF, Weill Institute for Neurosciences, San Francisco, United States.
| | - T Charles Casper
- University of Utah, Department of Pediatrics, Salt Lake City, United States
| | - Michael Waltz
- University of Utah, Department of Pediatrics, Salt Lake City, United States
| | | | - Tim Lotze
- Baylor College of Medicine/Texas Children's Hospital, Neurology and Developmental Neuroscience, Houston, United States
| | - Nikita Shukla
- Baylor College of Medicine/Texas Children's Hospital, Neurology and Developmental Neuroscience, Houston, United States
| | - Tanuja Chitnis
- Massachusetts General Hospital for Children, Mass General Brigham Pediatric MS Center, Boston, United States
| | - Mark Gorman
- Boston Children's Hospital, Pediatric Multiple Sclerosis and Related Disorders Program, Boston, United States
| | - Leslie A Benson
- Boston Children's Hospital, Pediatric Multiple Sclerosis and Related Disorders Program, Boston, United States
| | | | - Jan M Tillema
- Mayo Clinic, Pediatric MS Center, Rochester, United States
| | - Lauren Krupp
- New York University Langone Medical Center, Pediatric Multiple Sclerosis Center, New York, United States
| | - Teri Schreiner
- University of Colorado, Rocky Mountain MS Center, Aurora, United States
| | - Soe Mar
- Washington University, Pediatric MS and other Demyelinating Disease Center, St. Louis, United States
| | - Mary Rensel
- Cleveland Clinic, Mellen Center for Multiple Sclerosis, Cleveland, United States
| | - John Rose
- University of Utah, Department of Neurology, Salt Lake City, United States
| | - Chuang Liu
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
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Saucier L, Healy BC, Saxena S, Sanon E, Chitnis T. Glial fibrillary acidic protein and neurofilament light chain as biomarkers in pediatric multiple sclerosis. Mult Scler J Exp Transl Clin 2024; 10:20552173241274567. [PMID: 39193071 PMCID: PMC11348348 DOI: 10.1177/20552173241274567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 07/25/2024] [Indexed: 08/29/2024] Open
Abstract
Background Serum neurofilament light chain (sNfL) is a marker of neuroaxonal injury, and serum glial fibrillary acidic protein (sGFAP) reflects reactive astrogliosis. In adult multiple sclerosis (MS), sNfL correlates with relapsing disease activity while sGFAP correlates with progressive disease. Objectives We evaluate sNfL and sGFAP as biomarkers in pediatric-onset MS (POMS) compared to pediatric healthy controls (PHC), and correlations with the disease course. Methods In this single-center observational cross-sectional study, we extracted data from a longitudinal database and measured NfL and GFAP from bio-banked serum using single-molecule array technology. Results The analysis included 61 POMS patients and 45 PHC. Controlling for age and BMI, sNfL was 414% higher and sGFAP was 42.3% higher in POMS. Disability (EDSS) is associated with higher sNfL (β = 0.32, p = 0.002) and higher sGFAP (β = 0.11, p = 0.03). sNfL is associated with MRI lesion burden, recent disease activity (β =0.95, p < 0.001), and untreated status (β = 0.5, p = 0.006). Conclusion sNfL and sGFAP are elevated in POMS compared to PHC. Both biomarkers are associated with clinical disability. Elevated sGFAP may reflect early neurodegeneration in POMS, while sNfL reflects disease activity and DMT response. Elevated sNfL among some clinically and radiographically stable POMS patients suggests ongoing neuroaxonal injury with a potential role for sNfL monitoring disease stability.
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Affiliation(s)
- Laura Saucier
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
- Mass General Brigham Pediatric MS Center, Massachusetts General Hospital, Boston, MA, USA; Brigham MS Center, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Brian C Healy
- Brigham MS Center, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA; Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Shrishti Saxena
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Brigham MS Center, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Eunnindy Sanon
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Brigham MS Center, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Tanuja Chitnis
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Mass General Brigham Pediatric MS Center, Massachusetts General Hospital, Boston, MA, USA; Brigham MS Center, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Jafarpour S, Pinto S, Vu MH, Khoshnood MM, Ahsan N, Saucier LE, Santoro JD. Delayed initiation of disease modifying therapy increases relapse frequency and motor disability in pediatric onset multiple sclerosis. Mult Scler Relat Disord 2024; 87:105669. [PMID: 38749351 DOI: 10.1016/j.msard.2024.105669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/15/2024] [Accepted: 05/05/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE To evaluate association between time to initiation of disease modifying treatment (DMT) and outcomes in pediatric-onset Multiple Sclerosis (POMS). METHODS A retrospective analysis of children with POMS from two tertiary referral pediatric Neuroimmunology clinics. Outcome measures comprised annualized relapse rate (ARR), MRI lesion burden (T1, T2-FLAIR, and post-GAD contrast sequences), EDSS, and 25-ft walk duration at the latest follow-up visit. Univariate and multivariate analysis using linear and logistic regression models were used to assess associations between patient characteristics and outcomes. RESULTS In total, 68 patients were reviewed. More than half of patients were female (62 %) and 32 (47 %) were Hispanic/LatinX. Median age at diagnosis was 14.2 years (IQR: 11.0-16.5), and median duration from diagnosis to the latest follow-up was 2.5 years (IQR: 1.6-4.6). Sensory (29.4 %), brainstem (23.5 %), and pyramidal (19.1 %) symptoms were most common. Interferon beta (32.4 %), dimethyl fumarate (27.9 %) and rituximab (26.5 %) were the most frequently used first-line DMT. Patients had a median ARR of 0.5 (IQR: 0.08-0.84), and EDSS score of 1.0 (IQR: 0.0-2.0) at the most recent follow-up. Delayed DMT initiation correlated with higher ARR (R = 0.38, p = 0.0016) and longer 25-ft walk duration (R = 0.34, p = 0.0077). In multivariate analysis, delayed DMT remained a significant predictor of higher ARR (p = 0.002) and longer 25-ft walk duration (p = 0.047). Delayed DMT initiation and use of low/moderate efficacy DMT predicted GAD enhancing lesions at the latest follow-up (p = 0.004 and 0.019 respectively). CONCLUSION Delayed DMT initiation in POMS is linked to unfavorable outcomes, including higher ARR and longer 25-ft walk duration.
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Affiliation(s)
- Saba Jafarpour
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, USA; Department of Neurology, Keck School of Medicine of the University of Southern California, USA
| | - Soniya Pinto
- Department of Diagnostic Imaging, St. Jude's Children's Research Hospital, USA
| | - My H Vu
- Biostatistics and Data Management Core, The Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Nusrat Ahsan
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, USA; Department of Neurology, Keck School of Medicine of the University of Southern California, USA
| | - Laura E Saucier
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, USA; Department of Neurology, Keck School of Medicine of the University of Southern California, USA; Department of Neurology, Stanford University School of Medicine, USA
| | - Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, USA; Department of Neurology, Keck School of Medicine of the University of Southern California, USA.
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6
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Makhani N, Lebrun-Frenay C, Siva A, Shabanova V, Wassmer E, Santoro JD, Narula S, Brenton JN, Mar S, Durand-Dubief F, Zephir H, Mathey G, Rojas JI, de Seze J, Tenembaum S, Stone RT, Casez O, Carra-Dallière C, Neuteboom RF, Ahsan N, Arroyo HA, Cabre P, Gombolay G, Inglese M, Louapre C, Margoni M, Palavra F, Pohl D, Reich DS, Ruet A, Thouvenot E, Timby N, Tintore M, Uygunoglu U, Vargas W, Venkateswaran S, Verhelst H, Wickstrom R, Azevedo CJ, Kantarci O, Shapiro ED, Okuda DT, Pelletier D. The diagnostic workup of children with the radiologically isolated syndrome differs by age and by sex. J Neurol 2024; 271:4019-4027. [PMID: 38564056 PMCID: PMC11323224 DOI: 10.1007/s00415-024-12289-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/19/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) and spinal MRIs are often obtained in children with the radiologically isolated syndrome (RIS) for diagnosis and prognosis. Factors affecting the frequency and timing of these tests are unknown. OBJECTIVE To determine whether age or sex were associated with (1) having CSF or spinal MRI obtained or (2) the timing of these tests. METHODS We analyzed children (≤ 18 y) with RIS enrolled in an international longitudinal study. Index scans met 2010/2017 multiple sclerosis (MS) MRI criteria for dissemination in space (DIS). We used Fisher's exact test and multivariable logistic regression (covariates = age, sex, MRI date, MRI indication, 2005 MRI DIS criteria met, and race). RESULTS We included 103 children with RIS (67% girls, median age = 14.9 y). Children ≥ 12 y were more likely than children < 12 y to have CSF obtained (58% vs. 21%, adjusted odds ratio [AOR] = 4.9, p = 0.03). Pre-2017, girls were more likely than boys to have CSF obtained (n = 70, 79% vs. 52%, AOR = 4.6, p = 0.01), but not more recently (n = 30, 75% vs. 80%, AOR = 0.2, p = 0.1; p = 0.004 for interaction). Spinal MRIs were obtained sooner in children ≥ 12 y (median 11d vs. 159d, p = 0.03). CONCLUSIONS Younger children with RIS may be at continued risk for misdiagnosis and misclassification of MS risk. Consensus guidelines are needed.
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Affiliation(s)
- Naila Makhani
- Department of Pediatrics, Yale University, LMP 3088, 333 Cedar Street, New Haven, CT, 06520, USA.
- Department of Neurology, Yale University, New Haven, CT, USA.
| | - Christine Lebrun-Frenay
- CRCSEP Neurologie Pasteur 2, CHU de Nice, Université Cote d'Azur, UMR2CA (URRIS), Nice, France
| | - Aksel Siva
- Neuroimmunology Unit, Neurology Department, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Veronika Shabanova
- Department of Pediatrics, Yale University, LMP 3088, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Evangeline Wassmer
- Neurology Department, Birmingham Children's Hospital, Aston University, Birmingham, UK
| | - Jonathan D Santoro
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, USA
- Division of Neurology, Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, USA
| | - Sona Narula
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, USA
| | | | - Soe Mar
- Department of Neurology, Washington University School of Medicine, St. Louis, USA
| | - Francoise Durand-Dubief
- Service de sclérose en plaques, Pathologies de la myéline et Neuro-Inflammation, Hôpital Neurologique, Groupement Hospitalier Est, 59 Bd Pinel, 69677, BRON Cedex, France
| | - Helene Zephir
- Inserm UMR-S 1172 LilNcog, Lille University Hospital FHU Precise, Lille University, Lille, France
| | - Guillaume Mathey
- Department of Neurology, Nancy University Hospital, 54035, Nancy, France
| | - Juan I Rojas
- Hospital Universitario de CEMIC, Buenos Aires, Argentina
| | - Jerome de Seze
- Department of Neurology, Hospital Hautepierre, CHU de Strasbourg and Clinical Investigation Center (CIC) INSERM 1434, Strasbourg, France
| | - Silvia Tenembaum
- Department of Neurology, National Pediatric Hospital Dr. Juan P Garrahan, Buenos Aires, Argentina
| | | | - Olivier Casez
- Neurology MS Clinic Grenoble, Grenoble Alpes University Hospital, Grenoble, France
- T-RAIG, TIMC-IMAG, Grenoble Alpes University, Grenoble, France
| | - Clarisse Carra-Dallière
- Neurology MS Clinic, Montpellier University Hospital, 34295, Montpellier, France
- University of Montpellier (MUSE), 34295, Montpellier, France
| | - Rinze F Neuteboom
- Department of Neurology, Erasmus MC Rotterdam, Sophia's Children's Hospital, Rotterdam, The Netherlands
| | - Nusrat Ahsan
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, USA
- Division of Neurology, Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, USA
| | - Hugo A Arroyo
- Department of Neurology, Hospital de Pediatría SAMIC. Prof. Dr. J.P. Garrahan, Buenos Aires, Argentina
| | - Philippe Cabre
- Centre Hospitalo Universitaire, Fort-de-France, Martinique
| | - Grace Gombolay
- Division of Neurology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health Department of Neuroscience (DINOGMI), University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Celine Louapre
- Assistance Publique Hôpitaux de Paris, Inserm, CNRS, Hôpital de la Pitié Salpêtrière, CIC Neurosciences, Sorbonne Université, Paris Brain Institute - ICM, Paris, France
| | - Monica Margoni
- Department of Neurosciences, Multiple Sclerosis Center of the Veneto Region, University Hospital-School of Medicine, Padua, Italy
| | - Filipe Palavra
- Center for Child Development - Neuropaediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Daniela Pohl
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, USA
| | - Aurélie Ruet
- Department of Neurology, CHU Bordeaux, Bordeaux, France
- INSERM, Neurocentre Magendie, University of Bordeaux, U1215, Bordeaux, France
| | - Eric Thouvenot
- Department of Neurology, Nîmes University Hospital, Nîmes, France
- IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Niklas Timby
- Department of Clinical Sciences/Pediatrics, Umeå University, Umeå, Sweden
| | - Mar Tintore
- Neurology Department, MS Center of Catalunya Cemcat, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona (UAB), UVIC-Universitat Central de Catalunya, Barcelona, Spain
| | - Ugur Uygunoglu
- Neuroimmunology Unit, Neurology Department, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Wendy Vargas
- Department of Neurology, Columbia University Medical Center, New York, USA
| | | | - Helene Verhelst
- Division of Pediatric Neurology, Department of Pediatrics, University Hospital Ghent, Ghent, Belgium
| | - Ronny Wickstrom
- Neuropaediatric Unit, Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Christina J Azevedo
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Orhun Kantarci
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Eugene D Shapiro
- Department of Pediatrics, Yale University, LMP 3088, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Darin T Okuda
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Daniel Pelletier
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, USA
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7
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Hiramatsu K, Maeda H. Adult and pediatric relapsing multiple sclerosis phase II and phase III trial design and their primary end points: A systematic review. Clin Transl Sci 2024; 17:e13794. [PMID: 38708586 PMCID: PMC11070945 DOI: 10.1111/cts.13794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/22/2024] [Accepted: 04/01/2024] [Indexed: 05/07/2024] Open
Abstract
No systematic review of trial designs in patients with relapsing multiple sclerosis (RMS) was reported. This systematic review was conducted on the trial designs and primary end points (PEs) of phase II and III trials intended to modify the natural course of the disease in patients with RMS. The purpose of the study is to explore trends/topics and discussion points in clinical trial design and PE, comparing them to regulatory guidelines and expert recommendations. Three trial registration systems, ClinicalTrials.gov, the EU Clinical Trials Register, and the Japan Registry of Clinical Trials, were used and 60 trials were evaluated. The dominant clinical trial design was a randomized controlled parallel-arms trial and other details were as follows: in adult phase III confirmatory trials (n = 32), active-controlled double-blind trial (DBT) (53%) and active-controlled open-label assessor-masking trial (16%); in adult phase II dose-finding trials (n = 9), placebo- and active-controlled DBT (44%), placebo-controlled DBT (22%), and placebo-controlled add-on DBT (22%); and in pediatric phase III confirmatory trials (n = 8), active-controlled DBT (38%) and active-controlled open-label non-masking trial (25%). The most common PEs were as follows: in adult confirmatory trials, annual relapse rate (ARR) (56%) and no evidence of disease activity-3 (NEDA-3) (13%); in adult dose-finding trials, the cumulative number of T1 gadolinium-enhancing lesions (56%), combined unique active lesions (22%), and overall disability response score (22%); and in pediatric confirmatory trials, ARR (38%) and time to first relapse (25%). It was suggested that some parts of the regulatory guidelines and expert recommendations need to be revised.
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Affiliation(s)
- Katsutoshi Hiramatsu
- Department of Regulatory Science, Faculty of PharmacyMeiji Pharmaceutical UniversityTokyoJapan
| | - Hideki Maeda
- Department of Regulatory Science, Faculty of PharmacyMeiji Pharmaceutical UniversityTokyoJapan
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8
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Spelman T, Simoneau G, Hyde R, Kuhelj R, Alroughani R, Ozakbas S, Karabudak R, Yamout BI, Khoury SJ, Terzi M, Boz C, Horakova D, Kubala Havrdova E, Weinstock-Guttman B, Patti F, Altintas A, Mrabet S, Gouider R, Inshasi J, Shaygannejad V, Eichau S, Ward WL, Butzkueven H. Comparative Effectiveness of Natalizumab, Fingolimod, and Injectable Therapies in Pediatric-Onset Multiple Sclerosis: A Registry-Based Study. Neurology 2024; 102:e208114. [PMID: 38447093 PMCID: PMC11033984 DOI: 10.1212/wnl.0000000000208114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/19/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with pediatric-onset multiple sclerosis (POMS) typically experience higher levels of inflammation with more frequent relapses, and though patients with POMS usually recover from relapses better than adults, patients with POMS reach irreversible disability at a younger age than adult-onset patients. There have been few randomized, placebo-controlled clinical trials of multiple sclerosis (MS) disease-modifying therapies (DMTs) in patients with POMS, and most available data are based on observational studies of off-label use of DMTs approved for adults. We assessed the effectiveness of natalizumab compared with fingolimod using injectable platform therapies as a reference in pediatric patients in the global MSBase registry. METHODS This retrospective study included patients with POMS who initiated treatment with an injectable DMT, natalizumab, or fingolimod between January 1, 2006, and May 3, 2021. Patients were matched using inverse probability treatment weighting. The primary outcome was time to first relapse from index therapy initiation. Secondary study outcomes included annualized relapse rate; proportions of relapse-free patients at 1, 2, and 5 years; time to treatment discontinuation; and times to 24-week confirmed disability worsening and confirmed disability improvement. RESULTS A total of 1,218 patients with POMS were included in this analysis. Patients treated with fingolimod had a significantly lower risk of relapse than patients treated with injectable DMTs (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.29-0.83; p = 0.008). After adjustment for prior DMT experience in the unmatched sample, patients treated with natalizumab had a significantly lower risk of relapse than patients treated either with injectable DMTs (HR, 0.15; 95% CI 0.07-0.31; p < 0.001) or fingolimod (HR, 0.37; 95% CI 0.14-1.00; p = 0.049). The adjusted secondary study outcomes were generally consistent with the primary outcome or with previous observations. The findings in the inverse probability treatment weighting-adjusted patient populations were confirmed in multiple sensitivity analyses. DISCUSSION Our analyses of relapse risk suggest that natalizumab is more effective than fingolimod in the control of relapses in this population with high rates of new inflammatory activity, consistent with previous studies of natalizumab and fingolimod in adult-onset patients and POMS. In addition, both fingolimod and natalizumab were more effective than first-line injectable therapies. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that patients with POMS treated with natalizumab had a lower risk of relapse than those with fingolimod.
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Affiliation(s)
- Tim Spelman
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Gabrielle Simoneau
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Robert Hyde
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Robert Kuhelj
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Raed Alroughani
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Serkan Ozakbas
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Rana Karabudak
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Bassem I Yamout
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Samia J Khoury
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Murat Terzi
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Cavit Boz
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Dana Horakova
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Eva Kubala Havrdova
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Bianca Weinstock-Guttman
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Francesco Patti
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Ayse Altintas
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Saloua Mrabet
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Riadh Gouider
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Jihad Inshasi
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Vahid Shaygannejad
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Sara Eichau
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - W Luke Ward
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
| | - Helmut Butzkueven
- From the MSBase Foundation (T.S.), Melbourne, Australia; Department of Clinical Neuroscience (T.S.), Karolinska Institute, Stockholm, Sweden; Biogen (G.S.), Toronto, Ontario, Canada; Biogen (R.H., Robert Kuhelj), Baar, Switzerland; Division of Neurology (R.A.), Department of Medicine, Amiri Hospital, Sharq, Kuwait; Dokuz Eylul University (S.O.), Konak/Izmir; Hacettepe University (Rana Karabudak), Ankara, Turkey; Nehme and Therese Tohme Multiple Sclerosis Center (B.I.Y., S.J.K.), American University of Beirut Medical Center, Lebanon; 19 Mayis University (M.T.), Samsun; KTU Medical Faculty Farabi Hospital (C.B.), Trabzon, Turkey; Department of Neurology and Center of Clinical Neuroscience (D.H., E.K.H.), First Faculty of Medicine, Charles University in Prague and General University Hospital, Czech Republic; Department of Neurology (B.W.-G.), Buffalo General Medical Center, Buffalo, NY; Department of Medical and Surgical Sciences and Advanced Technologies (F.P.), GF Ingrassia, Catania, Italy; Department of Neurology (A.A.), School of Medicine and Koc University Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey; Department of Neurology and Clinical Investigation Center Neurosciences and Mental Health (S.M.), Razi University Hospital; Department of Neurology (R.G.), Razi University Hospital, Tunis, Tunisia; Rashid Hospital (J.I.), Dubai, United Arab Emirates; Isfahan University of Medical Sciences (V.S.), Iran; Department of Neurology (S.E.), Hospital Universitario Virgen Macarena, Sevilla, Spain; Ashfield MedComms (W.L.W.), Middletown, CT; Department of Neuroscience (H.B.), Central Clinical School, Monash University, Melbourne; and Department of Neurology (H.B.), Box Hill Hospital, Monash University, Box Hill, Victoria, Australia
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Poisson KE, Newsome SD, Graves J, Zamvil SS, Marcus LR. Teenager With Recurrent Ataxia, Ophthalmoplegia, and Encephalopathy Associated With Demyelination: From the National Multiple Sclerosis Society Case Conference Proceedings. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200193. [PMID: 38181318 PMCID: PMC11078149 DOI: 10.1212/nxi.0000000000200193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/27/2023] [Indexed: 01/07/2024]
Abstract
A 15-year-old adolescent boy developed subacute ataxia, encephalopathy, ophthalmoplegia, and dysarthria following a sore throat. An MRI examination revealed multifocal enhancing and nonenhancing supratentorial white matter and symmetric brainstem lesions. After 2 additional presentations with worsening symptoms and lesion accumulation, he was ultimately successfully treated with rituximab for his condition.
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Affiliation(s)
- Kelsey E Poisson
- From the Nationwide Children's Hospital (K.E.P.), Columbus, OH; Johns Hopkins University School of Medicine (S.D.N.), Baltimore, MD; University of California San Diego School of Medicine (J.G.); University of California, San Francisco (S.S.Z.); and Children's of Alabama (L.R.M.), Birmingham
| | - Scott D Newsome
- From the Nationwide Children's Hospital (K.E.P.), Columbus, OH; Johns Hopkins University School of Medicine (S.D.N.), Baltimore, MD; University of California San Diego School of Medicine (J.G.); University of California, San Francisco (S.S.Z.); and Children's of Alabama (L.R.M.), Birmingham
| | - Jennifer Graves
- From the Nationwide Children's Hospital (K.E.P.), Columbus, OH; Johns Hopkins University School of Medicine (S.D.N.), Baltimore, MD; University of California San Diego School of Medicine (J.G.); University of California, San Francisco (S.S.Z.); and Children's of Alabama (L.R.M.), Birmingham
| | - Scott S Zamvil
- From the Nationwide Children's Hospital (K.E.P.), Columbus, OH; Johns Hopkins University School of Medicine (S.D.N.), Baltimore, MD; University of California San Diego School of Medicine (J.G.); University of California, San Francisco (S.S.Z.); and Children's of Alabama (L.R.M.), Birmingham
| | - Lydia R Marcus
- From the Nationwide Children's Hospital (K.E.P.), Columbus, OH; Johns Hopkins University School of Medicine (S.D.N.), Baltimore, MD; University of California San Diego School of Medicine (J.G.); University of California, San Francisco (S.S.Z.); and Children's of Alabama (L.R.M.), Birmingham
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Huppke B, Reinert MC, Hummel-Abmeier H, Stark W, Gärtner J, Huppke P. Pretreatment Neurofilament Light Chain Serum Levels, Early Disease Severity, and Treatment Response in Pediatric Multiple Sclerosis. Neurology 2023; 101:e1873-e1883. [PMID: 37748882 PMCID: PMC10663003 DOI: 10.1212/wnl.0000000000207791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/12/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES High disease activity and frequent therapy failure in pediatric multiple sclerosis (MS) make prognostic biomarkers urgently needed. We investigated whether serum neurofilament light chain (sNfL) levels in treatment-naive pediatric patients with MS are associated with early disease severity and indicate treatment outcomes. METHODS A retrospective cohort study of patients seen in the Göttingen Center for MS in Childhood and Adolescence, Germany. Inclusion criteria were MS diagnosis according to the McDonald criteria, MS onset <18 years, and available pretreatment serum sample. sNfL levels were analyzed using a single-molecule array assay. Associations with clinical and MRI evidence of disease severity at sampling were evaluated using the Spearman correlations and nonparametric tests for group comparisons. Correlations between pretreatment sNfL and annualized relapse and new T2 lesion rate on first-line therapy, and odd ratios for switch to high-efficacy therapy were assessed. RESULTS A total of 178 patients (116 women [65%]) with a mean sampling age of 14.3 years were included in the study. Pretreatment sNfL levels were above the ≥90th percentile reported for healthy controls in 80% of patients (median 21.1 pg/mL) and correlated negatively with age, but no correlation was seen with sex, oligoclonal band status, or body mass index. High pretreatment sNfL levels correlated significantly with a high number of preceding relapses, a shorter first interattack interval, a high T2 lesion count, and recent gadolinium-enhancing lesions. Of interest, sNfL levels reflected more strongly MRI activity rather than clinical activity. Pretreatment sNfL levels also correlated significantly with the relapse rate and occurrence of new/enlarging T2 lesions while on first-line injectable therapy. Odds of future therapy escalation increased from 0.14 for sNfL below 7.5 pg/mL to 6.38 for sNfL above 15 pg/mL. In patients with a recent relapse, higher sNfL levels were associated with poorer recovery 3 months after attack. DISCUSSION The results of this study have 3 important implications: First, pretreatment sNfL levels are a valuable biomarker for underlying disease activity in pediatric patients with MS. Second, pretreatment sNfL levels in pediatric patients with MS have a predictive value for the response to first-line therapy and the necessity of future therapy escalation. Third, high sNfL levels during a relapse are associated with poor recovery in this age group.
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Affiliation(s)
- Brenda Huppke
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany.
| | - Marie-Christine Reinert
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany
| | - Hannah Hummel-Abmeier
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany
| | - Wiebke Stark
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany
| | - Jutta Gärtner
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany
| | - Peter Huppke
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany.
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11
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Alkolfat F, Said S, Mekky J, Eldeeb H. What an adult multiple sclerosis registry can tell us about pediatric onset multiple sclerosis? Mult Scler Relat Disord 2023; 79:104962. [PMID: 37714097 DOI: 10.1016/j.msard.2023.104962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/05/2023] [Accepted: 08/28/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Multiple Sclerosis (MS) is an immune-mediated, chronic disease of the central nervous system that affects mainly adults. However, it is increasingly recognized that MS may start in childhood resulting in a relentlessly progressive disability and cognitive impairment. Registries across the globe are reporting inconstant data about their Pediatric-Onset Multiple Sclerosis (POMS) patients. Moreover, newer lines of treatments are emerging and showing efficacy in controlling the MS disease regardless of the onset. Therefore, there is a requirement for more research into the clinical profile of POMS in different populations and ethnicities. METHODS This study was a cross-sectional study that included MS patients who visited the MS unit at Alexandria University from January 2019 to January 2021. We analyzed their epidemiological, clinical, radiological data, and cerebrospinal fluid (CSF) results from their updated records as well as follow-up interviews. RESULTS Annual Relapse Rate (ARR) was marginally less in POMS than AOMS (0.72 ± 0.57 vs 1.04 ± 0.78 relapse/year, P =.008). POMS patients had a bigger gap to their first relapse (40.0 ± 47.35 vs 22.71 ± 34.33 months, p= .066). The difference in relapse rate between the two groups was abolished after the exclusion of patients who had a gap of more than 5 years to their first relapse. AOMS patients were significantly more likely to start with a second-line disease-modifying treatment (DMT) than POMS patients (11.5% vs 31%, p= .04), whereas POMS patients were more likely to be escalated to the second line (34.6% vs 19.3%, p= .07). ARR had a positive and significant correlation with expanded disability status scale (EDSS) progression per year (rs(24)= .57 p=.003). A Mann-Whitney test indicated that POMS patients who had infratentorial involvement in the initial MRI brain had higher EDSS (3.08 ± 1.99) than POMS who did not (1.07 ± 0.79) U=24 P =.013. IgG index had a significant and positive correlation with annual EDSS progression rate rs (8) = 0.8 p=.001. CONCLUSION Early disease onset does not mean a higher relapse rate when including the full spectrum of POMS and longer follow-up duration. POMS patients relapsed more on the first-line DMT and escalation should be considered early. Infratentorial involvement in the initial magnetic resonance imaging (MRI) brain and high IgG index are potential predictors for aggressive disease course in POMS.
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Affiliation(s)
- Fatma Alkolfat
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Sameh Said
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Jaidaa Mekky
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hany Eldeeb
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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12
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Bose G, Healy BC, Barro C, Moreira Ferreira VF, Saxena S, Glanz BI, Lokhande HA, Polgar-Turcsanyi M, Bakshi R, Weiner HL, Chitnis T. Accuracy of serum neurofilament light to identify contrast-enhancing lesions in multiple sclerosis. Mult Scler 2023; 29:1418-1427. [PMID: 37712409 DOI: 10.1177/13524585231198751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND Contrast-enhancing magnetic resonance imaging (MRI) lesions (CELs) indicate acute multiple sclerosis inflammation. Serum biomarkers, neurofilament light (sNfL), and glial fibrillary acidic protein (sGFAP) may increase in the presence of CELs, and indicate a need to perform MRI. OBJECTIVE We assessed the accuracy of biomarkers to detect CELs. METHODS Patients with two gadolinium-enhanced MRIs and serum biomarkers tested within 3 months were included (N = 557, 66% female). Optimal cut-points from Bland-Altman analysis for spot biomarker level and Youden's index for delta-change from remission were evaluated. RESULTS A total of 116 patients (21%) had CELs. A spot sNfL measurement >23.0 pg/mL corresponded to 7.0 times higher odds of CEL presence (95% CI: 3.8, 12.8), with 25.9% sensitivity, 95.2% specificity, operating characteristic curve (AUC) 0.61; while sNfL delta-change >30.8% from remission corresponded to 5.0 times higher odds (95% CI: 3.2, 7.8), 52.6% sensitivity, 81.9% specificity, AUC 0.67. sGFAP had poor CEL detection. In patients > 50 years, neither cut-point remained significant. sNfL delta-change outperformed spot levels at identifying asymptomatic CELs (AUC 0.67 vs 0.59) and in patients without treatment escalation between samples (AUC 0.67 vs 0.57). CONCLUSION Spot sNfL >23.0 pg/mL or a 30.8% increase from remission provides modest prediction of CELs in patients <50 years; however, low sNfL does not obviate the need for MRI.
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Affiliation(s)
- Gauruv Bose
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA/Department of Medicine, The University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian C Healy
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Christian Barro
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Vanessa F Moreira Ferreira
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Shrishti Saxena
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Bonnie I Glanz
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Hrishikesh A Lokhande
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Mariann Polgar-Turcsanyi
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Rohit Bakshi
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Howard L Weiner
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA/Harvard Medical School, Boston, MA, USA
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Canavese C, Favole I, D'Alessandro R, Vercellino F, Papa A, Podestà B, Longaretti F, Brustia F, Rampone S, Benedini F, Giraudo M, Tocchet A. Acquired Demyelinating Syndromes of the Central Nervous System in Children: The Importance of Regular Follow-up in the First Year After Onset. J Child Neurol 2023; 38:537-549. [PMID: 37574786 DOI: 10.1177/08830738231193495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
AIM We reviewed the clinical features of a sample of pediatric acquired demyelinating syndromes with the purpose of determining the appropriate protocol for follow-up after the first episode. METHODS A multicenter retrospective observational study was conducted on a cohort of 40 children diagnosed with a first episode of acquired demyelinating syndrome over the period 2012-2021. Patients were evaluated with clinical and neuroradiologic assessment after 3, 6, and 12 months, with a median follow-up of 4.0 years. RESULTS At the first acquired demyelinating syndrome episode, 18 patients (45%) were diagnosed with acute disseminated encephalomyelitis, 18 (45%) with clinical isolated syndrome, and 4 (10%) with multiple sclerosis. By month 12, 12 patients (30%) had progressed from an initial diagnosis of acute disseminated encephalomyelitis (2) or clinical isolated syndrome (10) to multiple sclerosis. Of these, 6 had clinical relapse and 6 radiologic relapse only. The first relapse occurred after a median of 3 months. Among the patients who had evolved toward multiple sclerosis, there was a prevalence of females (P = .014), higher oligoclonal bands positivity (P = .009), and older median age (P < .001) as compared with those who had remained stable. INTERPRETATION Both clinical and radiologic follow-up of children with acquired demyelinating syndromes is crucial, especially during the first year after acute onset, for early identification of multiple sclerosis and prompt initiation of disease-modifying treatment to delay axonal damage and to limit disability.
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Affiliation(s)
- Carlotta Canavese
- Child and Adolescent Neuropsychiatry Unit, University of Torino, Regina Margherita Hospital, Torino, Italy
| | - Irene Favole
- Child and Adolescent Neuropsychiatry Unit, University of Torino, Regina Margherita Hospital, Torino, Italy
| | - Rossella D'Alessandro
- Child and Adolescent Neuropsychiatry Unit, University of Torino, Regina Margherita Hospital, Torino, Italy
| | - Fabiana Vercellino
- Child Neuropsychiatry Unit, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Amanda Papa
- Infantile Neuropsychiatric Unit, University Hospital Maggiore della Carità, Novara, Italy
| | - Barbara Podestà
- Child Neurology and Psychiatry Unit, S. Croce and Carle Hospital, Cuneo, Italy
| | | | - Francesca Brustia
- Infantile Neuropsychiatric Unit, University Hospital Maggiore della Carità, Novara, Italy
| | - Sara Rampone
- Child Neuropsychiatry Unit, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Francesca Benedini
- Child and Adolescent Neuropsychiatry Unit, University of Torino, Regina Margherita Hospital, Torino, Italy
| | - Mariachiara Giraudo
- Child and Adolescent Neuropsychiatry Unit, University of Torino, Regina Margherita Hospital, Torino, Italy
| | - Aba Tocchet
- Child and Adolescent Neuropsychiatry Unit, University of Torino, Regina Margherita Hospital, Torino, Italy
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14
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Brenton JN. The Evolving Spectrum of Inflammatory Demyelination of the Central Nervous System in Children. Semin Pediatr Neurol 2023; 46:101057. [PMID: 37451750 DOI: 10.1016/j.spen.2023.101057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- James Nicholas Brenton
- Division of Child Neurology, Deptartment of Neurology, University of Virginia, Charlottesville, VA.
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15
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Mandato C, Colucci A, Lanzillo R, Staiano A, Scarpato E, Schiavo L, Operto FF, Serra MR, Di Monaco C, Napoli JS, Massa G, Vajro P. Multiple Sclerosis-Related Dietary and Nutritional Issues: An Updated Scoping Review with a Focus on Pediatrics. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1022. [PMID: 37371254 PMCID: PMC10297186 DOI: 10.3390/children10061022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/03/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE Lifestyle/dietetic habits play an important role in the development and progression of multiple sclerosis (MS) disease. Here, we examine the basic pathomechanisms underlying intestinal and brain barrier modifications in MS and consider diets and dietary supplementations proposed over time to complement pharmacological therapies for improving disease outcome both in adults and in children. METHODS Scoping literature search about evidence-based findings in MS-related gut-brain axis (GBA) pathophysiology and nutritional issues at all ages. FINDINGS Data show that (1) no universal best diet exists, (2) healthy/balanced diets are, however, necessary to safeguard the adequate intake of all essential nutrients, (3) diets with high intakes of fruits, vegetables, whole grains, and lean proteins that limit processed foods, sugar, and saturated fat appear beneficial for their antioxidant and anti-inflammatory properties and their ability to shape a gut microbiota that respects the gut and brain barriers, (4) obesity may trigger MS onset and/or its less favorable course, especially in pediatric-onset MS. Vitamin D and polyunsaturated fatty acids are the most studied supplements for reducing MS-associated inflammation. CONCLUSIONS Pending results from other and/or newer approaches targeting the GBA (e.g., pre- and probiotics, engineered probiotics, fecal-microbiota transplantation), accurate counseling in choosing adequate diet and maintaining physical activity remains recommended for MS prevention and management both in adults and children.
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Affiliation(s)
- Claudia Mandato
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Pediatrics Section, University of Salerno, 84081 Baronissi, Salerno, Italy (P.V.)
| | - Angelo Colucci
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Pediatrics Section, University of Salerno, 84081 Baronissi, Salerno, Italy (P.V.)
| | - Roberta Lanzillo
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, 80138 Naples, Naples, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, 80138 Naples, Naples, Italy
| | - Elena Scarpato
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, 80138 Naples, Naples, Italy
| | - Luigi Schiavo
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Nutrition Section, University of Salerno, 84081 Baronissi, Salerno, Italy
| | - Francesca Felicia Operto
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Pediatric Psychiatry Section, University of Salerno, 84081 Baronissi, Salerno, Italy
| | - Maria Rosaria Serra
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, 80138 Naples, Naples, Italy
| | - Cristina Di Monaco
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, 80138 Naples, Naples, Italy
| | - Julia Sara Napoli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Pediatrics Section, University of Salerno, 84081 Baronissi, Salerno, Italy (P.V.)
| | - Grazia Massa
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Pediatrics Section, University of Salerno, 84081 Baronissi, Salerno, Italy (P.V.)
| | - Pietro Vajro
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Pediatrics Section, University of Salerno, 84081 Baronissi, Salerno, Italy (P.V.)
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Devlin L, Gombolay G. The Neutrophil-to-Lymphocyte Ratio and the Monocyte-to-Lymphocyte Ratio Predict Expanded Disability Status Scale Score at One Year in Pediatric Neuromyelitis Optica Spectrum Disorder but not in Multiple Sclerosis. Pediatr Neurol 2023; 143:84-88. [PMID: 37044044 PMCID: PMC10205676 DOI: 10.1016/j.pediatrneurol.2023.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 03/03/2023] [Accepted: 03/14/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND The neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) are inflammatory biomarkers that may predict disease course in neuroinflammatory diseases. We examine whether NLR or MLR at the time of the first attack predicts longitudinal disease outcomes in pediatric neuromyelitis optica spectrum disorder (NMOSD) and multiple sclerosis (MS). METHODS Clinical data were collected retrospectively at a single institution. NLR (ratio of percent neutrophils to percent lymphocytes) and MLR (ratio of percent monocytes to percent lymphocytes) were calculated in the complete blood cell count at the time of presentation before treatments. Expanded Disability Status Scale (EDSS) score and time to next relapse were used as the outcome assessments. RESULTS Twenty-eight patients with MS and eight patients with aquaporin-4-positive NMOSD were included. For NMOSD, NLR at presentation associated with EDSS at six months (P = 0.003) and one year (P = 0.032) even when adjusting for age at presentation. MLR associated with EDSS at six months (P = 0.0203) and EDSS at one year (P = 0.0079). However, NLR and MLR did not predict EDSS scores in MS. MLR and NLR did not predict time to next relapse or did not associate with magnetic resonance imaging activity in MS and NMOSD. Changes in MLR and NLR were observed with disease-modifying therapies but did not predict disease activity. CONCLUSIONS NLR and MLR associated with six-month and one-year EDSS in children with NMOSD but not in MS. Future studies should explore whether changes in NLR and MLR could predict disease activity or treatment efficacy.
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Affiliation(s)
- Lily Devlin
- Emory University School of Medicine, Atlanta, Georgia
| | - Grace Gombolay
- Division of Pediatric Neurology, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia.
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17
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Afanasjeva B, Afanasjevas D, Endzinienė M, Balnytė R. Characteristics of the Manifestation of Multiple Sclerosis in Children in Lithuania. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1055. [PMID: 37374259 DOI: 10.3390/medicina59061055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Multiple sclerosis (MS) starts quite rarely in childhood, comprising just 3-10% of all diagnosed cases of MS population. The age of onset of the disease may be related to the initial phenotype and the prognosis of MS. The aim of the study is to assess the characteristics of the manifestation of MS in children. Materials and Methods: Two groups of patients were analyzed: those diagnosed with MS in childhood (0 < 18 years of age) and who developed MS in 2005-2021, and those diagnosed in adulthood (≥18 years old). The data were collected from the database of the Lithuanian University of Health Sciences Kauno Klinikos. Results: For the analysis, 105 patients were selected: 35 children (group A) and 70 adults (group B). At the onset of the disease, 62.9% of children and 70.0% of adults experienced visual disturbances (p > 0.05). Isolated symptoms were more common in children (65.7%) as compared to adults (28.6%), p < 0.001. Sensory disorders were more common in adults than in children (p < 0.001). Optic nerve and cerebral hemispheres were the most affected in group A (p < 0.05). During the first year after diagnosis, the median number of relapses in group A was higher (3, range 1-5) as compared to group B (1, range 1-2) (p < 0.001). Recovery time after a relapse was shorter in children as compared to adults (p < 0.001). Oligoclonal bands were found in 85.7% of children and in 98.6% of adults. Oligoclonal bands were less common in the childhood-onset than in the adult-onset group (p = 0.007). Conclusions: The initial symptoms of multiple sclerosis in pediatric patients usually appeared around the age of 16, with a similar frequency in boys and girls, and in most of the childhood cases the initial symptoms were limited to the dysfunction of a single part of the nervous system children usually started with visual disorders, while sensory, coordination and motor disorders were less common. The course of the disease in juvenile patients with MS was more aggressive in the first year as there were more relapses, but the functional impairment recovered faster as compared to adults.
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Affiliation(s)
- Brigita Afanasjeva
- Department of Neurology, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, 50161 Kaunas, Lithuania
- Department of Neurology, Faculty of Medicine, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
| | - Dominykas Afanasjevas
- Department of Maxillofacial Surgery, Faculty of Medicine, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
| | - Milda Endzinienė
- Department of Neurology, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, 50161 Kaunas, Lithuania
- Department of Neurology, Faculty of Medicine, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
| | - Renata Balnytė
- Department of Neurology, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, 50161 Kaunas, Lithuania
- Department of Neurology, Faculty of Medicine, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
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18
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Zhang Y, Ren R, Yang L, Zhang H, Shi Y, Vitiello MV, Sanford LD, Tang X. Sleep in multiple sclerosis: a systematic review and meta-analysis of polysomnographic findings. J Clin Sleep Med 2023; 19:253-265. [PMID: 36117421 PMCID: PMC9892728 DOI: 10.5664/jcsm.10304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVES This study aims to explore the polysomnographically measured sleep differences between patients with multiple sclerosis (MS) and healthy control patients. METHODS An electronic literature search was conducted in EMBASE, MEDLINE, all EBM databases, CINAHL, and PsycINFO from inception to March 2022. A random-effects model was applied to explore the pooled effect sizes of polysomnographic differences between patients with MS and control patients. RESULTS Thirteen studies were identified for meta-analysis. The meta-analyses revealed significant reductions in stage N2 sleep and sleep efficiency and increases in wake time after sleep onset, the periodic limb movement index, and the periodic limb movement arousal index in patients with MS compared with control patients. Meta-regression analyses showed that some of the heterogeneity was explained by age and daytime sleepiness of patients with MS. CONCLUSIONS Our study showed that polysomnographic abnormalities are present in MS. Our findings also underscore the need for a comprehensive polysomnographic assessment of sleep changes in patients with MS. Furthermore, the effects of age and daytime sleepiness in patients with MS on sleep changes should also be carefully considered and closely monitored in the management of MS. CITATION Zhang Y, Ren R, Yang L, et al. Sleep in multiple sclerosis: a systematic review and meta-analysis of polysomnographic findings. J Clin Sleep Med. 2023;19(2):253-265.
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Affiliation(s)
- Ye Zhang
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Mental Health Center, Translational Neuroscience Center, and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Rong Ren
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Mental Health Center, Translational Neuroscience Center, and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Linghui Yang
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Mental Health Center, Translational Neuroscience Center, and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Haipeng Zhang
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Mental Health Center, Translational Neuroscience Center, and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan Shi
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Mental Health Center, Translational Neuroscience Center, and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Michael V. Vitiello
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Larry D. Sanford
- Sleep Research Laboratory, Center for Integrative Neuroscience and Inflammatory Diseases, Pathology and Anatomy, Eastern Virginia Medical School, Norfolk, Virginia
| | - Xiangdong Tang
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Mental Health Center, Translational Neuroscience Center, and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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19
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Gaudioso CM, Zolno R, Wagner A, Mar S. Clinical Reasoning: A 6-Year-Old Girl With Right-Sided Pain and Weakness. Neurology 2023; 100:97-102. [PMID: 36257712 DOI: 10.1212/wnl.0000000000201481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/13/2022] [Indexed: 02/05/2023] Open
Abstract
We outline the case of a 6-year-old girl presenting with a 2-week course of waxing and waning neurologic symptoms, including right-sided pain, weakness, dizziness, and difficulty walking. Her examination was notable for right-sided weakness, hyperreflexia, and dysmetria. Diagnostic evaluation was significant for MRI with numerous T2 hyperintense, T1 hypointense, and T1-enhancing lesions located in the juxtacortical and periventricular regions, corpus callosum, brainstem, and spinal cord; positive CSF oligoclonal bands; negative serum aquaporin-4 immunoglobulin G (IgG) and myelin oligodendrocyte glycoprotein IgG; and positive serum Epstein-Barr viral capsid antigen IgG.
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Affiliation(s)
- Cristina M Gaudioso
- From the Washington University Pediatric MS, Other Demyelinating Disease Center, St. Louis, MO.
| | - Rachel Zolno
- From the Washington University Pediatric MS, Other Demyelinating Disease Center, St. Louis, MO
| | - Anne Wagner
- From the Washington University Pediatric MS, Other Demyelinating Disease Center, St. Louis, MO
| | - Soe Mar
- From the Washington University Pediatric MS, Other Demyelinating Disease Center, St. Louis, MO
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Abolghasemi M, Ali Ashrafi S, Asadi M, Shanehbandi D, Sadigh Etehad S, Poursaei E, Nejadghaderi SA, Shaafi S. MicroRNAs expression in peripheral blood mononuclear cells of patients with multiple sclerosis propose. Mol Biol Rep 2023; 50:167-172. [PMID: 36319782 DOI: 10.1007/s11033-022-07905-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/09/2022] [Accepted: 08/31/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND MicroRNAs (miRs) are involved in the autoimmune and neurological diseases, including multiple sclerosis (MS), through modulating post-transcriptional gene regulation. Accumulating evidence indicates that miR-10, miR-24a, miR-124, and miR-21 play an imperative role in MS pathogenesis. Therefore, the current research aimed to analyze the expression of the selected miRNAs for MS in Iranian population. METHODS AND RESULTS Blood sample of 75 relapsing-remitting MS (RRMS) patients and 75 healthy individuals suffering no neurodegenerative illness was collected. Subsequently, the isolation of peripheral blood mononuclear cells (PBMCs) was performed by employing Ficoll-Hypaque density gradient method. Afterward, total RNA was extracted and subjected to qRT-PCR analysis. The obtained results evidenced that the relative expression of miR-10 (P = 0.0002), miR-21 (P = 0.0014), and miR-124 (P = 0.0091) significantly decreased in RRMS patients compared to healthy participants. On the contrary, no notable change was observed between the studies groups regarding miR-24a expression levels (P = 0.107). ROC curve analysis estimated an area under the curve (AUC) value equal to 0.75 with P = 0.0006 for miR-10, while it was decreased for miR-21 (AUC = 0.67 and P = 0.0054) and miR-124 (AUC = 0.66 and P = 0.012). CONCLUSION The change in miR-10, miR-124, and miR-21 expression patterns was implied to participate in MS development. Further large scale observational studies are recommended.
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Affiliation(s)
- Mahsa Abolghasemi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sepide Ali Ashrafi
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Milad Asadi
- Department of Basic Oncology, Health Institute of Ege University, Izmir, Turkey
| | - Dariush Shanehbandi
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeed Sadigh Etehad
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elham Poursaei
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Aria Nejadghaderi
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sheida Shaafi
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran.
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21
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Piri Cinar B, Konuskan B, Anlar B, Ozakbas S. Narrative review based on fingolimod therapy in pediatric MS. SAGE Open Med 2023; 11:20503121231171996. [PMID: 37181277 PMCID: PMC10170592 DOI: 10.1177/20503121231171996] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
The course of pediatric-onset multiple sclerosis and adult multiple sclerosis shows some clinical differences. The rate of having a second attack after the first clinical event is 80% in children and around 45% in adults but the time to the second event is similar in all age groups. The pediatric group usually has a more aggressive onset than adults. On the other hand, a higher rate of complete recovery is observed in pediatric-onset multiple sclerosis after the first clinical event compared to the adult group. Despite a highly active initial disease course, pediatric-onset multiple sclerosis patients show a slower increase in disability than patients with adult-onset disease. This is thought to be due to greater remyelination capacity and plasticity of the developing brain. The management of pediatric-onset multiple sclerosis includes safety issues as well as effective disease control. In the pediatric-onset multiple sclerosis group, similar to adult multiple sclerosis, injectable treatments have been used for many years with reasonable efficacy and safety. Since 2011, oral treatments and then infusion treatments have been approved and used effectively in adult multiple sclerosis and have gradually entered clinical use in the pediatric-onset multiple sclerosis group. However, clinical trials are fewer, smaller, and include shorter follow-up due to the much lower prevalence of pediatric-onset multiple sclerosis than adult multiple sclerosis. This is particularly important in the era of recent disease-modifying treatments. This review of the literature presents existing data on the safety and efficacy of fingolimod, pointing to a relatively favorable profile.
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Affiliation(s)
- Bilge Piri Cinar
- Samsun University, Samsun, Turkey
- Bilge Piri Cinar, Neurology Department, School of Medicine, Samsun University, Samsun, Turkey.
| | - Bahadır Konuskan
- University of Health Sciences Turkey, Etlik City Hospital, Ankara, Turkey
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22
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Shavit E, Menascu S, Achiron A, Gurevich M. Age-related blood transcriptional regulators affect disease progression in pediatric multiple sclerosis. Neurobiol Dis 2023; 176:105953. [PMID: 36493973 DOI: 10.1016/j.nbd.2022.105953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pediatric onset multiple sclerosis patients (POMS) are defined as multiple sclerosis with an onset before the age of 18 years. Compared to adult onset multiple sclerosis (AOMS), POMS has more severe disease activity at onset, but better recovery. Little is known about the molecular mechanism responsible for the differences in the clinical presentations. METHODS Peripheral Blood Mononuclear Cells samples were taken from 22 POMS patients (mean age 14.1 ± 2.4 years, 15 females, 7 male), and 16 AOMS patients, (mean age 30.8 ± 6.1 years,10 females, 6 males), and gene-expression were analyzed using Affymetrix Inc. HU-133-A2 microarrays. Differentially Expressed Genes (DEGs) that significantly distinguished between POMS and AOMS with pvalue <0.05 after false discovery rate correction were evaluated using Partek software. Twenty-one matched age and gender control was applied to clarify age-related changes. Clinical assessment was performed by analysis of expanded disability status scale (EDSS) and brain MRI lesion loads. Gene functional analysis was performed by Ingenuity Pathway Analysis software. RESULTS Compared to AOMS, POMS had higher EDSS (3.0 IQR 2.0-3.0 and 2.0 IQR 2.0-3.0, p = 0.005), volume of T1 (2.72 mm3, IQR 0.44-8.39 mm3 and 0.5 mm3 IQR 0-1.29 mm3 respectively, p = 0.04) and T2 (3.70 mm3, IQR 1.3-9.6 and 0.96 mm3, IQR 0.24-4.63 respectively, p = 0.02) brain MRI lesions. The POMS transcriptional profile was characterized by 551 DEGs, enriched by cell cycling, B lymphocyte signaling and senescent pathways (p < 0.02). Of these, 183 DEGs significantly correlated with T2 lesions volume. The POMS MRI correlated DEGs (n = 183) and their upstream regulators (n = 718) has overlapped with age related DEGs obtained from healthy subjects (n = 497). This evaluated common DEGs (n = 29) defined as POMS age-related regulators, suggesting to promote effect on disease severity. CONCLUSION Our finding of higher transcriptional levels of genes involved in cell cycle, cell migration and B cell proliferation that promoted by transcriptional level of age-associated genes and transcription factors allows better understanding of the more aggressive clinical course that defines the POMS.
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Affiliation(s)
- Eitan Shavit
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; St. George's Hospital Medical School, University of London, London, United Kingdom; Arrow project for medical research education, Sheba Medical Center, Ramat-Gan, Israel.
| | - Shay Menascu
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Anat Achiron
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Michael Gurevich
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
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23
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Brenton JN, Florenzo B, Koshiya H, Min S, Woolbright E, Coleman R, Chen S, Goldman M. Six-Minute Walk as a Measure of Walking Capacity and Endurance in Patients With Pediatric-Onset Multiple Sclerosis. Neurology 2022; 99:e2161-e2170. [PMID: 35985830 PMCID: PMC9651457 DOI: 10.1212/wnl.0000000000201098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite low levels of disability, youth with pediatric-onset multiple sclerosis (POMS) engage in less physical activity compared with peers. The contribution of walking capacity, endurance, behavior, and MS comorbidities remains relatively undefined and may provide valuable insights into the limitations toward physical activity in youth with MS. The primary objective of this study was to investigate differences in walking capacity, endurance, and real-world behaviors of daily activity between youth with POMS and controls. METHODS Youth diagnosed with MS prior to 18 years and aged 21 years or younger were recruited in addition to healthy controls. Participants completed questionnaires to quantify fatigue, depression, and physical activity levels and the timed 2- and 6-minute walk (6MW) as an assessment of walking capacity and endurance. Participants completed questionnaires to quantify fatigue, depression, and physical activity levels. Participants also completed the timed 2- and 6-minute walk (6MW) as an assessment of walking capacity and endurance and were sent home with a waist-worn accelerometer to assess real-world walking behavior. RESULTS Forty-five patients with POMS and 85 control participants were enrolled. The POMS cohort had a mean age of 16.9 ± 2.7 years, with a mean disease duration of 2.8 ± 2.6 years. A greater proportion of the POMS cohort was overweight/obese compared with controls (75% vs 33%). Participants with MS walked a significantly shorter distance in 6 minutes compared with controls (1,848 feet vs 2,134 feet, p < 0.0001) and, unlike controls, were unable to accelerate to their peak speed at the end of the 6MW. Body mass index category and MS disease significantly affected 6MW performance. Using continuous accelerometry, participants with MS spent less time in moderate-to-vigorous physical activity compared with controls (20.4 vs 35.4 min/d, p = 0.0003). The POMS cohort reported significantly higher levels of depression and fatigue but self-reported similar levels of daily physical activity as controls. DISCUSSION Youth with POMS exhibit slower 6MW performance and less daily engagement in moderate-to-vigorous physical activity, suggesting limitations in functional walking capacity, endurance, and daily activity behavior. Limitations in walking endurance and capacity are most prominent in those youth who are overweight/obese and living with MS. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that, compared with healthy controls, patients with POMS walk shorter distances on the 6MW test, are less able to accelerate to peak speed at the end of the test, and are less physically active.
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Affiliation(s)
- J Nicholas Brenton
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond.
| | - Brian Florenzo
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Hitoshi Koshiya
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Seulgi Min
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Emma Woolbright
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Rachael Coleman
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Shanshan Chen
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
| | - Myla Goldman
- From the Division of Pediatric Neurology (J.N.B., S.M., E.W., R.C.), Department of Neurology, and School of Medicine (B.F., H.K.), University of Virginia, Charlottesville; and Departments of Biostatistics (S.C.) and Neurology (M.G.), Virginia Commonwealth University, Richmond
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24
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Sharmin S, Malpas CB, Roos I, Diouf I, Alroughani R, Ozakbas S, Izquierdo G, Eichau S, Horakova D, Havrdova EK, Patti F, Terzi M, Boz C, Yamout B, Khoury SJ, Onofrj M, Lugaresi A, Altintas A, Prat A, Girard M, Duquette P, Sá MJ, La Spitaleri D, Sidhom Y, Gouider R, Mrabet S, Soysal A, Turkoglu R, Amato MP, Fragoso YD, Kalincik T. Early predictors of disability in paediatric multiple sclerosis: evidence from a multi-national registry. J Neurol Neurosurg Psychiatry 2022:jnnp-2022-329713. [PMID: 36180218 DOI: 10.1136/jnnp-2022-329713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/28/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Early recognition of markers of faster disability worsening in paediatric-onset multiple sclerosis (MS) is a key requisite of personalised therapy for children with MS at the earliest possible time. OBJECTIVE To identify early predictors of rapid disability accrual in patients with paediatric-onset MS. METHODS Using the global MSBase registry, we identified patients who were <18 years old at the onset of MS symptoms. The clinico-demographic characteristics examined as predictors of future MS Severity Score (MSSS) included sex, age at symptom onset, absence of disability at the initial assessment, maximum Expanded Disability Status Scale (EDSS) score, relapse frequency and presence of brainstem, pyramidal, visual or cerebellar symptoms in the first year. A Bayesian log-normal generalised linear mixed model adjusted for cumulative proportion of time on higher-efficacy disease-modifying therapies (DMTs) was used to analyse the data. RESULTS 672 patients (70% female) contributing 9357 visits were included. The median age at symptom onset was 16 (quartiles 15-17) years. Older age at symptom onset (exp(β)=1.10 (95% CI 1.04 to 1.17)), higher EDSS score (1.22 (1.12 to 1.34)) and pyramidal (1.31 (1.11 to 1.55)), visual (1.25 (1.10 to 1.44)) or cerebellar (1.18 (1.01 to 1.38)) symptoms in the first year were associated with higher MSSS. MSSS was reduced by 4% for every 24% increase in the proportion of time on higher-efficacy DMTs (0.96 (0.93 to 0.99)). CONCLUSIONS A relatively later onset of MS in childhood, higher disability and pyramidal, visual or cerebellar symptoms during the first year predicted significant worsening in disability in patients with paediatric-onset MS. Persistent treatment with higher-efficacy DMTs was associated with a reduced rate of disability worsening.
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Affiliation(s)
- Sifat Sharmin
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Charles B Malpas
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Izanne Roos
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ibrahima Diouf
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Serkan Ozakbas
- Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Guillermo Izquierdo
- Multiple Sclerosis Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Sara Eichau
- Multiple Sclerosis Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva K Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Murat Terzi
- Medical Faculty, 19 Mayis University, Samsun, Turkey
| | - Cavit Boz
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | - Bassem Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
- Neurology Department, American University of Beirut, Beirut, Lebanon
| | - Samia J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio, Chieti, Italy
| | - Alessandra Lugaresi
- UOSI Riabilitazione Sclerosi Multipla, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Alexandre Prat
- CHUM MS Center and Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Marc Girard
- CHUM MS Center and Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Pierre Duquette
- CHUM MS Center and Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Maria José Sá
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | | | - Youssef Sidhom
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Riadh Gouider
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Saloua Mrabet
- Clinical Investigation Center Neurosciences and Mental Health, Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - Aysun Soysal
- Department of Neurology, Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | - Recai Turkoglu
- Department of Neurology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy
| | - Yara D Fragoso
- Department of Neurology, Universidade Metropolitana de Santos, Santos, Brazil
| | - Tomas Kalincik
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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25
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Vermersch P, Scaramozza M, Levin S, Alroughani R, Deiva K, Pozzilli C, Lyons J, Mokliatchouk O, Pultz J, N’Dure F, Liu S, Badwan R, Branco F, Hood-Humphrey V, Franchimont N, Hanna J, Maghzi AH. Effect of Dimethyl Fumarate vs Interferon β-1a in Patients With Pediatric-Onset Multiple Sclerosis: The CONNECT Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2230439. [PMID: 36169959 PMCID: PMC9520348 DOI: 10.1001/jamanetworkopen.2022.30439] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE With few approved multiple sclerosis therapies in the pediatric population, there is a need for further approved treatment options. Limited data exist for dimethyl fumarate (DMF) treatment in pediatric-onset multiple sclerosis (POMS). OBJECTIVE To compare the efficacy, safety, and tolerability of DMF vs intramuscular interferon β-1a (IFNβ-1a) in POMS. DESIGN, SETTING, AND PARTICIPANTS The CONNECT study was an active-controlled, open-label, rater-blinded 96-week randomized clinical trial in patients with POMS aged 10 to less than 18 years treated between August 2014 and November 2020. Data were analyzed from January through October 2021. INTERVENTIONS Patients were randomized to DMF or IFNβ-1a. MAIN OUTCOMES AND MEASURES The primary end point was the proportion of patients free of new or newly enlarging (N or NE) T2 hyperintense lesions at week 96 among trial completers. Secondary end points included number of N or NE T2 lesions, proportion of patients free of relapse, annualized relapse rate (ARR), and safety. The estimated proportion of participants who were relapse free up to week 96 was calculated based on the Kaplan-Meier method. Adjusted ARR was obtained from a negative binomial regression adjusted for baseline relapse rate, baseline Expanded Disability Status Scale (EDSS) score, and age group. RESULTS Among 150 patients with POMS in the intention-to-treat (ITT) population (median [range] age, 15 [10-17] years; 101 [67.3%] female patients), 78 individuals received DMF and 72 individuals received IFNβ-1a. At week 96, the proportion of patients with no N or NE T2 hyperintense lesions among 103 trial completers was 16.1% (95% CI, 8.0%-27.7%) for DMF vs 4.9% (95% CI, 0.6%-16.5%) for IFNβ-1a, and in a sensitivity analysis among the ITT population, the proportions were 10 patients receiving DMF (12.8%) vs 2 patients receiving IFNβ-1a (2.8%). The estimated proportion of patients who remained relapse free at week 96 was 66.2% for DMF vs 52.3% for IFNβ-1a. Adjusted ARR (95% CI) at week 96 was 0.24 (95% CI, 0.15-0.39) for DMF vs 0.53 (95% CI, 0.33-0.84) for IFNβ-1a; the rate ratio for DMF vs IFNβ-1a was 0.46 (95% CI, 0.26-0.80; P = .006). The number of treatment-emergent adverse events (TEAEs; 74 patients [94.9%] vs 69 patients [95.8%]), serious TEAEs (18 patients [23.1%] vs 21 patients [29.2%]), and treatment discontinuations due to TEAEs (5 patients [6.4%] vs 8 patients [11.1%]) was similar for DMF vs IFNβ-1a. CONCLUSIONS AND RELEVANCE This study found that more pediatric patients with POMS treated with DMF were free of new or newly enlarging T2 lesions and that the adjusted ARR was lower among these patients compared with those treated with interferon β-1a. DMF was well tolerated. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02283853.
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Affiliation(s)
- Patrick Vermersch
- University Lille, Inserm, Centre Hospitalier Universitaire de Lille, Fédératif Hospitalo-Universitaire Precise, Lille, France
| | | | | | | | - Kumaran Deiva
- Assistance Publique-Hôpitaux de Paris, Pediatric Neurology Department, University Hospitals Paris Saclay, Bicêtre Hospital, Le Kremlin Bicêtre, France
- French Reference Network of Rare Inflammatory Brain and Spinal Diseases, Le Kremlin Bicêtre, France
| | - Carlo Pozzilli
- Sant’ Andrea Multiple Sclerosis Center, Sapienza University, Rome, Italy
| | | | | | - Joe Pultz
- Biogen, Cambridge, Massachusetts
- Now with CR Medicon, Orange, Connecticut
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26
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Machado-Rivas F, Jaimes C, Scherrer B, Benson LA, Gorman MP, Warfield SK, Afacan O. Evaluation of white matter microstructure in pediatric onset multiple sclerosis with diffusion compartment imaging. J Neuroimaging 2022; 32:1098-1108. [PMID: 36036739 DOI: 10.1111/jon.13038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/20/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Pediatric-onset multiple sclerosis (POMS) shows earlier axonal involvement and greater axonal loss than in adults. We aim to characterize the white matter (WM) microstructural changes in POMS using a diffusion compartment imaging (DCI) model and compare it to standard diffusion tensor imaging (DTI). METHODS Eleven patients (2 males, mean age 18.8 ± 3.9 years) with a diagnosis of relapsing and remitting POMS (mean age at disease onset 13.8 ± 2.9 years, mean duration 5.1 ± 1.9 years) and healthy controls (8 males, mean age 26.4 ± 6.5 years) were recruited and imaged at 3 T. A 90-gradient set Cube and Sphere acquisition and a novel DCI model known as DIstribution of Anisotropic MicrOstructural eNvironments with Diffusion-weighted imaging (DIAMOND) were used to calculate a single anisotropic compartment, an isotropic compartment, and a free diffusion compartment. Lesions and contralateral normal-appearing white matter (NAWM) in patients and whole brain WM for controls were labeled. RESULTS Eleven patients and 11 controls were recruited. When comparing lesions and contralateral NAWM in patients using DCI, compartmental axial diffusivity, radial diffusivity (cRD), and mean diffusivity (cMD) were higher in lesions. Conversely, compartmental fractional anisotropy (cFA) and heterogeneity index were lower in lesions. An analysis of DTI equivalents showed the same trends. In whole-brain NAWM of patients compared to controls, cRD and cMD were higher and cFA was lower in patients. CONCLUSION Lesions in POMS can be accurately characterized by a DCI model. Incipient changes in NAWM seen in DCI may not be readily observable by DTI.
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Affiliation(s)
- Fedel Machado-Rivas
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Camilo Jaimes
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benoit Scherrer
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Onur Afacan
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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27
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Bose G, Healy BC, Barro C, Glanz BI, Lokhande HA, Polgar-Turcsanyi M, Guttmann CR, Bakshi R, Weiner HL, Chitnis T. Younger age at multiple sclerosis onset is associated with worse outcomes at age 50. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329353. [PMID: 35953266 DOI: 10.1136/jnnp-2022-329353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/26/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Older age at multiple sclerosis (MS) onset has been associated with worse 10-year outcomes. However, disease duration often exceeds 10 years and age-related comorbidities may also contribute to disability. We investigated patients with>10 years disease duration to determine how age at MS onset is associated with clinical, MRI and occupational outcomes at age 50. METHODS We included patients enrolled in the Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham and Women's Hospital with disease duration>10 years. Outcomes at age 50 included the Expanded Disability Status Scale (EDSS), development of secondary-progressive multiple sclerosis (SPMS), brain T2-lesion volume (T2LV) and brain parenchymal fraction (BPF), and occupational status. We assessed how onset age was independently associated with each outcome when adjusting for the date of visit closest to age 50, sex, time to first treatment, number of treatments by age 50 and exposure to high-efficacy treatments by age 50. RESULTS We included 661 patients with median onset at 31.4 years. The outcomes at age 50 were worse the younger first symptoms developed: for every 5 years earlier, the EDSS was 0.22 points worse (95% CI: 0.04 to 0.40; p=0.015), odds of SPMS 1.33 times higher (95% CI: 1.08 to 1.64; p=0.008), T2LV 1.86 mL higher (95% CI: 1.02 to 2.70; p<0.001), BPF 0.97% worse (95% CI: 0.52 to 1.42; p<0.001) and odds of unemployment from MS 1.24 times higher (95% CI: 1.01 to 1.53; p=0.037). CONCLUSIONS All outcomes at age 50 were worse in patients with younger age at onset. Decisions to provide high-efficacy treatments should consider younger age at onset, equating to a longer expected disease duration, as a poor prognostic factor.
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Affiliation(s)
- Gauruv Bose
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Brian C Healy
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Christian Barro
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Bonnie I Glanz
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Mariann Polgar-Turcsanyi
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Rohit Bakshi
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Howard L Weiner
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Tanuja Chitnis
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW This article reviews the clinical presentation, diagnostic evaluation, treatment, and prognosis of the most common monophasic and relapsing acquired demyelinating disorders presenting in childhood. RECENT FINDINGS Our understanding of neuroimmune disorders of the central nervous system is rapidly expanding. Several clinical and paraclinical factors help to inform the diagnosis and ultimately the suspicion for a monophasic versus relapsing course, including the age of the patient (prepubertal versus postpubertal), presence or absence of clinical encephalopathy, identification of serum autoantibodies (eg, myelin oligodendrocyte glycoprotein [MOG] and aquaporin-4), presence of intrathecally unique oligoclonal bands, and location/extent of radiologic abnormalities. Collaborative international research efforts have facilitated understanding of the safety and efficacy of currently available immunotherapies in children with acquired demyelinating disorders, particularly multiple sclerosis. SUMMARY Although many of the demyelinating disorders presented in this article can affect children and adults across the age spectrum, the clinical and radiologic phenotypes, treatment considerations, and long-term prognoses are often distinct in children.
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Sattarnezhad N, Healy BC, Baharnoori M, Diaz-Cruz C, Stankiewicz J, Weiner HL, Chitnis T. Comparison of dimethyl fumarate and interferon outcomes in an MS cohort. BMC Neurol 2022; 22:252. [PMID: 35820822 PMCID: PMC9277810 DOI: 10.1186/s12883-022-02761-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background To compare the effectiveness of dimethyl fumarate (DMF) with subcutaneous interferon beta-1a (IFNβ-1a) in controlling disease activity in patients with relapsing–remitting Multiple Sclerosis (MS). Methods Clinical and imaging data from patients treated with either IFNβ-1a or DMF for at least one year were reviewed. The proportion of patients with at least one clinical relapse within 3–15 months after treatment onset, the proportion of patients with new T2 or gadolinium-enhancing lesions, and the proportion of subjects who achieved no evidence of disease activity (NEDA) status were assessed. Results Three hundred sixteen (98 on IFNβ-1a, 218 on DMF) subjects were included. Baseline demographics were comparable between groups except for age, disease duration, and the number of previous treatments being higher and relapse rate in the prior year being lower in the DMF-treated group. The proportion of patients having a clinical relapse (24.5% vs. 9.6%; OR = 3.04; P < 0.001) or a new MRI lesion (28.6% vs. 8.7%; OR = 4.19, P < 0.001) at 15 months were higher on IFNβ-1a. 79.9% of the patients achieved NEDA status at 15 months on DMF (vs. 51.1% for IFNβ-1a; OR = 0.26, P < 0.001). Further adjustment for demographics, disease characteristics, treatment and relapse history, and subgroup analyses confirmed these findings. Conclusion DMF was associated with less clinical and radiological disease activity compared to IFNβ-1a. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02761-8.
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Affiliation(s)
- Neda Sattarnezhad
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Brian C Healy
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Moogeh Baharnoori
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Camilo Diaz-Cruz
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - James Stankiewicz
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Howard L Weiner
- Harvard Medical School, Boston, Massachusetts, 02115, USA.,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
| | - Tanuja Chitnis
- Harvard Medical School, Boston, Massachusetts, 02115, USA. .,Brigham Multiple Sclerosis Center, Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA.
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Baroncini D, Ghezzi A, Guaschino C, Moiola L, Filippi M, Ianniello A, Pozzilli C, Lanzillo R, Brescia-Morra V, Margoni M, Gallo P, Callari G, Grimaldi L, Lus G, Calabrese M, Simone M, Marfia GA, Rasia S, Cargnelutti D, Comi G, Zaffaroni M, Trojano M, Centonze D, Capra R, Capobianco M, Laroni A, Uccelli A, Gallo A, Patti F, Danni MC, Gasperini C, Coniglio G. Long-term follow-up (up to 11 years) of an Italian pediatric MS cohort treated with Natalizumab: a multicenter, observational study. Neurol Sci 2022; 43:6415-6423. [PMID: 35781765 DOI: 10.1007/s10072-022-06211-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/12/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Natalizumab (NAT) has a strong impact on disease activity of aggressive pediatric multiple sclerosis (MS), with no difference in safety profile compared to adult MS. However, available data are limited by short follow-up. Our aim was to report long-term follow-up data (up to 11 years) of a large Italian pediatric MS cohort treated with NAT. MATERIALS AND METHODS We retrospectively collected data of pediatric MS patients treated with NAT included in a previous study and prospectively followed in Italian MS centers. We compared disease activity pre, during, and post-NAT and we performed survival analyses of time to evidence of disease activity (EDA) during NAT, time to reach EDA post-NAT, and time to NAT discontinuation. RESULTS Ninety-two patients were included from 19 MS centers in Italy. At NAT initiation, cohort's characteristics were as follows: 55 females; 14.7 ± 2.4 (mean ± SD) years of age; 34 naïve to disease modifying therapies; 1-year pre-NAT annualized relapse rate (ARR): 2.2 ± 1.2; EDSS (median [IQR]): 2.5 [2.0-3.0]; gadolinium-enhancing lesions: 2 [1-5]; 41 JCV positives. During NAT treatment (61.9 ± 35.2 mean infusions), ARR lowered to 0.08 ± 0.23 (p < 0.001), EDSS score to 1.5 [1.0-2.5] at last infusion (p < 0.001), and 51% patients had EDA (21% after 6 months of rebaseline). No serious adverse events were reported. Forty-nine patients discontinued NAT, mainly due to PML concern; the majority (29/49) had disease reactivation in the subsequent 12 months, of which three with a clinical rebound. CONCLUSION NAT treatment maintains its high efficacy for a long time in pediatric MS patients, with no new safety issues.
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Solmaz I, Acar Ozen P, Parlak S, Tuncer A, Anlar B. Newer disease modifying treatments in pediatric onset multiple sclerosis: Experience from a single center. Eur J Paediatr Neurol 2022; 39:110-115. [PMID: 35777190 DOI: 10.1016/j.ejpn.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/18/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Disease modifying treatments (DMTs) for multiple sclerosis include injectable drugs (iDMTs) like interferons (IFNs) or glatiramer acetate (GA), and newer agents (nDMTs) in oral and intravenous forms. nDMTs are usually applied in escalation and less frequently as initial treatment in pediatric-onset (POMS). OBJECTIVE We intended to evaluate the effect of nDMTs in comparison with iDMTs by retrospective examination of our patients with POMS. METHOD Clinical records of POMS cases who received nDMTs either as escalation or initial treatment and who had at least 12 months' follow-up in our clinic were examined in two groups: patients who were started on iDMTs and later switched to nDMTs (Group A), and those who received nDMTs from the beginning (Group B). Presenting symptoms, annualized relapsing rate (ARR), recent Expanded Disability Status Scale (EDSS), lesion load and presence of contrast enhancing (CE) lesions on magnetic resonance imaging (MRI) were compared. RESULTS Total 43 patients were included: 33 in Group A and 10 in Group B. Age at onset, female/male ratio, duration since disease onset and duration under nDMT were similar in both groups. Initial involvement was predominantly brainstem and cerebellar in Group A and sensorial, brainstem/cerebellar, and optic nerve in Group B. The most frequently used nDMT was fingolimod in Group A (n = 17, 51.5%) and teriflunomide (n = 6, 60%) in Group B. Median ARR before any treatment was 2 in Group A and 1.5 in Group B (p > 0.05); it decreased to median 1 under iDMTs in Group A and to 0 under nDMTs. Mean follow-up was 6.7 ± 5 years (1-19, median 6 years) in Group A and 3.9 ± 3.7 years (range 1-12, median 2 years) in Group B. At the latest follow-up median EDSS scores were 1 in Group A and 0 in Group B. ARR had increased and lesion load on MRI went up progressively in both groups during follow-up. However, the rate of patients with CE lesions diminished in Group B. CONCLUSION This single-center study of POMS shows the ARR decreases under any treatment, more markedly under nDMTs, and nDMTs reduce the rate of patients with CE lesions on MRI without a clear effect on lesion load. The ARR tends to increase after the first 2 years of both iDMT and nDMT, suggesting a re-evaluation at that time. The ARR decreases shorty after treatment is changed from an iDMT to a nDMT.
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Affiliation(s)
- Ismail Solmaz
- Hacettepe University, Faculty of Medicine, Department of Pediatric Neurology, Ankara, Turkey.
| | - Pınar Acar Ozen
- Hacettepe University, Faculty of Medicine, Department of Neurology, Ankara, Turkey
| | - Safak Parlak
- Hacettepe University, Faculty of Medicine, Department of Radiology, Ankara, Turkey
| | - Aslı Tuncer
- Hacettepe University, Faculty of Medicine, Department of Neurology, Ankara, Turkey
| | - Banu Anlar
- Hacettepe University, Faculty of Medicine, Department of Pediatric Neurology, Ankara, Turkey
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Vališ M, Pavelek Z, Novotný M, Klímová B, Šarláková J, Halúsková S, Peterka M, Štětkárová I, Štourač P, Mareš J, Hradílek P, Ampapa R, Vachová M, Recmanová E, Meluzínová E. Analysis of the Group of Pediatric Patients With Relapsing-Remitting Multiple Sclerosis: Data From the Czech National Registry. Front Neurol 2022; 13:851426. [PMID: 35518208 PMCID: PMC9062179 DOI: 10.3389/fneur.2022.851426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/11/2022] [Indexed: 11/20/2022] Open
Abstract
Importance Multiple sclerosis can also affect children. Approximately 3–10% of patients develop multiple sclerosis before the age of 16. Objective The aim of this analysis is to describe the characteristics of pediatric patients with multiple sclerosis who started their treatment with disease-modifying drugs in 2013–2020, with data obtained from the Czech National Registry of patients with multiple sclerosis. Design and Setting A method of retrospective analysis conducted with 134 pediatric patients with multiple sclerosis was used. Results The findings reveal that the mean age at the date of the introduction of the first disease-modifying drugs treatment is 15.89 years, and gender does not play any role. In addition, moderate (51.6%) and mild (45.2%) relapses are predominant in these young patients. Seventy five percent of patients will not experience a confirmed progression of the expanded disability status scale within 54.7 months from starting the treatment. Furthermore, the results confirm that the first-choice treatment is interferon beta-a and glatiramer acetate, which is common for adult patients. However, some factors, such as a low efficacy or a lack of tolerance may impact on treatment discontinuation in children. Conclusion More research should be performed on novel disease-modifying drugs for this target group.
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Affiliation(s)
- Martin Vališ
- Department of Neurology, University Hospital Hradec Kralove, Hradec Kralove, Czechia
| | - Zbyšek Pavelek
- Department of Neurology, University Hospital Hradec Kralove, Hradec Kralove, Czechia
| | - Michal Novotný
- Department of Neurology, University Hospital Hradec Kralove, Hradec Kralove, Czechia
| | - Blanka Klímová
- Department of Neurology, University Hospital Hradec Kralove, Hradec Kralove, Czechia
| | - Jana Šarláková
- Department of Neurology, University Hospital Hradec Kralove, Hradec Kralove, Czechia
| | - Simona Halúsková
- Department of Neurology, University Hospital Hradec Kralove, Hradec Kralove, Czechia
| | - Marek Peterka
- Department of Neurology, Faculty of Medicine, University Hospital Plzen, Charles University, Plzen, Czechia
| | - Ivana Štětkárová
- Third Faculty of Medicine, Charles University and Hospital Kralovské Vinohrady, Charles University, Prague, Czechia
| | - Pavel Štourač
- Department of Neurology, University Hospital, Masaryk University, Brno, Czechia
| | - Jan Mareš
- Department of Neurology, Faculty of Medicine, Palacky University and University Hospital Olomouc, Olomouc, Czechia
| | - Pavel Hradílek
- Clinic of Neurology, University Hospital Ostrava, Ostrava, Czechia
| | - Radek Ampapa
- Department of Neurology, Hospital of Jihlava, Jihlava, Czechia
| | - Marta Vachová
- Department of Neurology, KZ a.s., Hospital Teplice, Teplice, Czechia
| | - Eva Recmanová
- Department of Neurology, Tomas Bata Regional Hospital, Zlín, Czechia
| | - Eva Meluzínová
- Department of Neurology, Second Faculty of Medicine, Charles University, Prague, Czechia
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Krupp L, Banwell B, Chitnis T, Deiva K, Gaertner J, Ghezzi A, Huppke P, Waubant E, DeLasHeras V, Azmon A, Karan R. Effect of fingolimod on health-related quality of life in paediatric patients with multiple sclerosis: results from the phase 3 PARADIG MS Study. BMJ Neurol Open 2022; 4:e000215. [PMID: 35308898 PMCID: PMC8883212 DOI: 10.1136/bmjno-2021-000215] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 01/11/2022] [Indexed: 11/20/2022] Open
Abstract
Background In the PARADIGMS Study, fingolimod demonstrated superior efficacy versus interferon (IFN) β-1a and comparable overall incidence of adverse events but slightly higher rate of serious adverse events in patients with paediatric-onset multiple sclerosis (PoMS). Here, we report the health-related quality of life (HRQoL) outcomes from PARADIGMS. Methods Patients with PoMS (N=215; aged 10-<18 years) were randomised to once-daily oral fingolimod (N=107) or once-weekly intramuscular IFN β-1a (N=108). HRQoL outcomes were assessed using the 23-item Pediatric Quality of Life (PedsQL) scale that comprises Physical and Psychosocial Health Summary Scores (including Emotional, Social and School Functioning). A post hoc inferential analysis evaluated changes in self-reported or parent-reported PedsQL scores from baseline up to 2 years between treatment groups using an analysis of covariance model. Results Treatment with fingolimod showed improvements versus IFN β-1a on the PedsQL scale in both the self-reported and parent-reported Total Scale Scores (4.66 vs -1.16, p≤0.001 and 2.71 vs -1.02, p≤0.05, respectively). The proportion of patients achieving a clinically meaningful improvement in the PedsQL Total Scale Score was two times higher with fingolimod versus IFN β-1a per the self-reported scores (47.5% vs 24.2%, p=0.001), and fingolimod was favoured versus IFN β-1a per the parent-reported scores (37.8% vs 24.7%, p=non-significant). Group differences in self-reported Total Scale Scores in favour of fingolimod were most pronounced among patients who had ≥2 relapses in the year prior to study entry or who showed improving or stable Expanded Disability Status Scale scores during the study. Conclusion Fingolimod improved HRQoL compared with IFN β-1a in patients with PoMS as evidenced by the self-reported and parent-reported PedsQL scores.
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Affiliation(s)
- Lauren Krupp
- Pediatric MS Center, NYU Langone Health, New York, New York, USA
| | - Brenda Banwell
- The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tanuja Chitnis
- Pediatric Multiple Sclerosis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kumaran Deiva
- Department of Pediatric Neurology, French National Reference Center for Rare inflammatory and Auto-Immune Brain and Spinal Diseases, University Hospitals Paris Saclay, Bicêtre Hospital, Le Kremlin Bicêtre, Paris, France
| | - Jutta Gaertner
- Department of Pediatrics and Adolescent Medicine, German Centre for Multiple Sclerosis in Childhood and Adolescence University Medical Centre, Göttingen, Germany
| | - Angelo Ghezzi
- Centro Studi Sclerosi Multipla, Ospedale di Gallarate, Gallarate, Italy
| | - Peter Huppke
- Department of Pediatrics and Adolescent Medicine, German Centre for Multiple Sclerosis in Childhood and Adolescence University Medical Centre, Göttingen, Germany
- Department of Neuropediatrics, Jena University Hospital, Jena, Germany
| | - Emmanuelle Waubant
- Department of Neurology, University of California, San Francisco, California, USA
| | | | - Amin Azmon
- Biostatistics, Novartis Pharma AG, Basel, Switzerland
| | - Rajesh Karan
- Global Drug Delivery, Novartis Pharma AG, Basel, Switzerland
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De Meo E, Filippi M, Trojano M, Comi G, Patti F, Brescia Morra V, Salemi G, Onofrj M, Lus G, Cocco E, Fonderico M, Torri Clerici V, Maniscalco GT, Valentino P, Bertolotto A, Lugaresi A, Bergamaschi R, Rovaris M, Sola P, Tedeschi G, Pesci I, Aguglia U, Cavalla P, Maimone D, Granella F, Vianello M, Simone M, Portaccio E, Amato MP. Comparing natural history of early and late onset pediatric multiple sclerosis. Ann Neurol 2022; 91:483-495. [PMID: 35150168 DOI: 10.1002/ana.26322] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/05/2022] [Accepted: 02/08/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To describe and compare disease course and prognosis of early (i.e., disease onset before age 11 years) and late (i.e., disease onset after age 11 years) onset pediatric multiple sclerosis. METHODS Prospectively-collected clinical information from Italian Multiple Sclerosis Register of 1993 pediatric multiple sclerosis patients, of whom 172 with early onset, was analyzed. Cox models adjusted for sex, baseline Expanded Disability Status Scale score and disease-modifying treatments and stratified for diagnostic criteria adopted (Poser vs McDonald) were used to assess the risk of reaching irreversible Expanded Disability Status Scale scores of 3, 4, and 6, and conversion to secondary progressive phenotype in early vs late onset pediatric patients. Prognostic factors were also evaluated. RESULTS A greater proportion of males, isolated brainstem involvement, and longer time interval between first and second clinical episode was observed in early vs late onset pediatric patients. Compared to late onset, early onset pediatric patients took longer time from disease onset to convert to secondary progressive phenotype and to reach all disability milestones. Recovery from first demyelinating event, time to first relapse, annualized relapse rate during the first 3 years of disease and disease-modifying treatments exposure were independent predictors for long-term disability in early onset pediatric patients. In late onset pediatric patients, isolated optic neuritis, multifocal symptoms or progressive course at disease onset were additional predictors for long-term disability. INTERPRETATION These findings point towards the existence of a different natural history in early vs late onset pediatric multiple sclerosis patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ermelinda De Meo
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute.,Vita-Salute San Raffaele University, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro' Policlinico, Bari, Italy
| | | | - Francasco Patti
- Dipartimento di Scienze Mediche e Chirurgiche e Tecnologie Avanzate, GF Ingrassia, Sez. Neuroscienze, Centro Sclerosi Multipla, University of Catania, Catania
| | - Vincenzo Brescia Morra
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Federico II University, Napoli
| | - Giuseppe Salemi
- Dipartimento di Biomedicina Sperimentale e Neuroscienze, Palermo
| | | | - Giacomo Lus
- Università della Campania Luigi Vanvitelli, Naples
| | - Eleonora Cocco
- Centro Sclerosi Multipla, ASSL Cagliari; Dipartimento di Scienze Mediche e Sanità Pubblica, University of Cagliari, Cagliari
| | | | | | - Giorgia Teresa Maniscalco
- Multiple Sclerosis Center and Neurological Clinic/Stroke Unit "A. Cardarelli" Hospital, Naples, Italy
| | | | | | | | | | | | - Patrizia Sola
- Centro Malattie Demielinizzanti - Dipartimento di Neuroscienze, Azienda Ospedaliero-Universitaria/OCSAE, UO Neurologia, University of Modena and Reggio Emilia, Modena
| | | | - Ilaria Pesci
- Centro SM UO Neurologia, Ospedale Di Vaio, Fidenza
| | | | - Paola Cavalla
- Multiple Sclerosis Center and I Neurology Unit, Department of Neuroscience and Mental Health, City of Health and Science University Hospital of Torino, Turin, Italy
| | - Davide Maimone
- Centro Sclerosi Multipla, UOC Neurologia ARNAS Garibaldi, Catania
| | - Franco Granella
- Unit of Neurosciences, Department of Medicine and Surgery, University of Parma
| | - Marika Vianello
- Centro Sclerosi Multipla - Ospedale Regionale 'Ca' Foncello', Neurology Unit, Treviso
| | - Marta Simone
- Child Neuropsychiatric Unit-Department of Biomedical Science and Human Oncology-University of Bari Aldo Moro
| | | | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
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Ysrraelit MC, Correale J. Impact of Andropause on Multiple Sclerosis. Front Neurol 2021; 12:766308. [PMID: 34803897 PMCID: PMC8602357 DOI: 10.3389/fneur.2021.766308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 10/18/2021] [Indexed: 11/18/2022] Open
Abstract
Andropause results from the natural decrease in testosterone levels that occurs with age. In contrast to menopause, which is a universal, well-characterized process associated with absolute gonadal failure, andropause ensues after gradual decline of both hypothalamic-pituitary-gonadal axis activity, as well as of testicular function, a process which usually develops over a period of many years. Increasing evidence on greater risk of Multiple sclerosis (MS) associated with lower testosterone levels is being reported. Likewise, epidemiological studies have shown a later age of onset of MS in men, relative to women, which could perhaps respond to the decline in protective testosterone levels. In this review, we will discuss the role of androgens in the development and function of the innate and adaptive immune response, as well as in neuroprotective mechanisms relevant to MS. Testosterone effects observed in different animal models and in epidemiological studies in humans will be discussed, as well as their correlation with physical disability and cognitive function levels. Finally, published and ongoing clinical trials exploring the role of androgens, particularly at key stages of sexual maturation, will be reviewed.
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Affiliation(s)
- Maria C Ysrraelit
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
| | - Jorge Correale
- Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia (FLENI), Buenos Aires, Argentina
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Abstract
Teriflunomide (Aubagio®), which was developed by Sanofi, is an oral immunomodulatory agent targeting the mitochondrial enzyme dihydroorotate dehydrogenase and available to adults to treat relapsing-remitting multiple sclerosis (MS). On 18 June 2021, teriflunomide received its first approval in this indication in pediatric patients aged ≥ 10 years in the EU. This article summarizes the milestones in the development of teriflunomide leading to this first pediatric approval for relapsing-remitting MS.
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Affiliation(s)
- Julia Paik
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Dahlke F, Arnold DL, Aarden P, Ganjgahi H, Häring DA, Čuklina J, Nichols TE, Gardiner S, Bermel R, Wiendl H. Characterisation of MS phenotypes across the age span using a novel data set integrating 34 clinical trials (NO.MS cohort): Age is a key contributor to presentation. Mult Scler 2021; 27:2062-2076. [PMID: 33507835 PMCID: PMC8564259 DOI: 10.1177/1352458520988637] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Oxford Big Data Institute, multiple sclerosis (MS) physicians and Novartis aim to address unresolved questions in MS with a novel comprehensive clinical trial data set. OBJECTIVE The objective of this study is to describe the Novartis-Oxford MS (NO.MS) data set and to explore the relationships between age, disease activity and disease worsening across MS phenotypes. METHODS We report key characteristics of NO.MS. We modelled MS lesion formation, relapse frequency, brain volume change and disability worsening cross-sectionally, as a function of patients' baseline age, using phase III study data (≈8000 patients). RESULTS NO.MS contains data of ≈35,000 patients (>200,000 brain images from ≈10,000 patients), with >10 years follow-up. (1) Focal disease activity is highest in paediatric patients and decreases with age, (2) brain volume loss is similar across age and phenotypes and (3) the youngest patients have the lowest likelihood (<25%) of disability worsening over 2 years while risk is higher (25%-75%) in older, disabled or progressive MS patients. Young patients benefit most from treatment. CONCLUSION NO.MS will illuminate questions related to MS characterisation, progression and prognosis. Age modulates relapse frequency and, thus, the phenotypic presentation of MS. Disease worsening across all phenotypes is mediated by age and appears to some extent be independent from new focal inflammatory activity.
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Affiliation(s)
| | - Douglas L Arnold
- Brain Imaging Centre, Montreal Neurological
Institute and Hospital, McGill University, Montréal, QC, Canada
| | | | - Habib Ganjgahi
- Oxford Big Data Institute, Li Ka Shing Centre
for Health Information and Discovery, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
| | | | | | - Thomas E Nichols
- Oxford Big Data Institute, Li Ka Shing Centre
for Health Information and Discovery, Nuffield Department of Population
Health, University of Oxford, Oxford, UK
| | | | - Robert Bermel
- Department of Neurology, Mellen MS Center,
Cleveland Clinic, Cleveland, OH, USA
| | - Heinz Wiendl
- Department of Neurology, University Hospital
Münster, Münster, Germany
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38
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Gadde JA, Wolf DS, Keller S, Gombolay GY. Rate of Leptomeningeal Enhancement in Pediatric Myelin Oligodendrocyte Glycoprotein Antibody-Associated Encephalomyelitis. J Child Neurol 2021; 36:1042-1046. [PMID: 34547933 PMCID: PMC9054459 DOI: 10.1177/08830738211025867] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Myelin oligodendrocyte glycoprotein antibodies (MOG-abs) are associated with demyelinating diseases. Leptomeningeal enhancement occurs in 6% of adult MOG-abs patients but rates in pediatric MOG-abs patients are unknown. METHODS Retrospective review of pediatric MOG-abs patients was performed. RESULTS Twenty-one patients (7 boys, 14 girls) were included with an average age of 8.6 years (range 2-15 years). Seven of 21 (33%) pediatric MOG-abs patients had leptomeningeal enhancement. Two patients' relapses were manifested by leptomeningeal enhancement alone and another patient presented with seizures, encephalopathy, and aseptic meningitis without demyelinating lesions. Cerebrospinal fluid pleocytosis was seen in both leptomeningeal (4/7 patients) and nonleptomeningeal enhancement (10/14 patients). Interestingly, 3 patients with leptomeningeal enhancement had normal cerebrospinal fluid white blood cell count. Cortical edema was more likely in patients with leptomeningeal enhancement (P = .0263). CONCLUSION We expand the clinical spectrum of anti-MOG antibody-associated disorder. Patients with recurrent leptomeningeal enhancement without demyelinating lesions should be tested for MOG antibodies.
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Affiliation(s)
- Judith A. Gadde
- Department of Radiology and Imaging Sciences & Pediatrics, Emory University School of Medicine, GA, USA,Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Division of Pediatric Radiology and Neuroradiology, IL, USA
| | - David S. Wolf
- Division of Pediatric Neurology, Children’s Healthcare of Atlanta: Pediatrics Institute, Emory University, GA, USA
| | - Stephanie Keller
- Division of Pediatric Neurology, Children’s Healthcare of Atlanta: Pediatrics Institute, Emory University, GA, USA
| | - Grace Y. Gombolay
- Division of Pediatric Neurology, Children’s Healthcare of Atlanta: Pediatrics Institute, Emory University, GA, USA
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39
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Horton MK, McCauley K, Fadrosh D, Fujimura K, Graves J, Ness J, Wheeler Y, Gorman MP, Benson LA, Weinstock‐Guttman B, Waldman A, Rodriguez M, Tillema J, Krupp L, Belman A, Mar S, Rensel M, Chitnis T, Casper TC, Rose J, Hart J, Shao X, Tremlett H, Lynch SV, Barcellos LF, Waubant E. Gut microbiome is associated with multiple sclerosis activity in children. Ann Clin Transl Neurol 2021; 8:1867-1883. [PMID: 34409759 PMCID: PMC8419410 DOI: 10.1002/acn3.51441] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To identify features of the gut microbiome associated with multiple sclerosis activity over time. METHODS We used 16S ribosomal RNA sequencing from stool of 55 recently diagnosed pediatric-onset multiple sclerosis patients. Microbiome features included the abundance of individual microbes and networks identified from weighted genetic correlation network analyses. Prentice-Williams-Peterson Cox proportional hazards models estimated the associations between features and three disease activity outcomes: clinical relapses and both new/enlarging T2 lesions and new gadolinium-enhancing lesions on brain MRI. Analyses were adjusted for age, sex, and disease-modifying therapies. RESULTS Participants were followed, on average, 2.1 years. Five microbes were nominally associated with all three disease activity outcomes after multiple testing correction. These included butyrate producers Odoribacter (relapse hazard ratio = 0.46, 95% confidence interval: 0.24, 0.88) and Butyricicoccus (relapse hazard ratio = 0.49, 95% confidence interval: 0.28, 0.88). Two networks of co-occurring gut microbes were significantly associated with a higher hazard of both MRI outcomes (gadolinium-enhancing lesion hazard ratios (95% confidence intervals) for Modules 32 and 33 were 1.29 (1.08, 1.54) and 1.42 (1.18, 1.71), respectively; T2 lesion hazard ratios (95% confidence intervals) for Modules 32 and 33 were 1.34 (1.15, 1.56) and 1.41 (1.21, 1.64), respectively). Metagenomic predictions of these networks demonstrated enrichment for amino acid biosynthesis pathways. INTERPRETATION Both individual and networks of gut microbes were associated with longitudinal multiple sclerosis activity. Known functions and metagenomic predictions of these microbes suggest the important role of butyrate and amino acid biosynthesis pathways. This provides strong support for future development of personalized microbiome interventions to modify multiple sclerosis disease activity.
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Affiliation(s)
- Mary K. Horton
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Kathryn McCauley
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Douglas Fadrosh
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Kei Fujimura
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Jennifer Graves
- Department of NeurosciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Jayne Ness
- Division of Pediatric NeurologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Yolanda Wheeler
- Division of Pediatric NeurologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Mark P. Gorman
- Department of NeurologyBoston Children’s HospitalBostonMassachusettsUSA
| | - Leslie A. Benson
- Department of NeurologyBoston Children’s HospitalBostonMassachusettsUSA
| | | | - Amy Waldman
- Department of NeurologyChildren’s Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | | | | | - Lauren Krupp
- Pediatric Multiple Sclerosis CenterNew York University Langone Medical CenterNew YorkNew YorkUSA
| | - Anita Belman
- Pediatric Multiple Sclerosis CenterNew York University Langone Medical CenterNew YorkNew YorkUSA
| | - Soe Mar
- Department of NeurologyWashington University in St. LouisSt. LouisMissouriUSA
| | - Mary Rensel
- Department of NeurologyCleveland ClinicClevelandOhioUSA
| | - Tanuja Chitnis
- Division of Child NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | | | - John Rose
- School of MedicineUniversity of Utah SchoolSalt Lake CityUtahUSA
| | - Janace Hart
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Xiaorong Shao
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Helen Tremlett
- Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Susan V. Lynch
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Lisa F. Barcellos
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Emmanuelle Waubant
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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40
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Gaudioso C, Oo S, Mar S, Hendricks-Ferguson VL, Newland P, Varni JW. PedsQL Multiple Sclerosis Module Domain and Item Development: Qualitative Methods. J Child Neurol 2021; 36:901-910. [PMID: 34048290 DOI: 10.1177/08830738211015016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this qualitative methods study was to develop the domains and items to support the content validity for the Pediatric Quality of Life Inventory (PedsQL) Multiple Sclerosis Module for youth with pediatric-onset multiple sclerosis. METHODS A literature review of multiple sclerosis-specific questionnaires and clinical research was conducted to generate domains. An expert panel composed of 12 neurologists who were pediatric-onset multiple sclerosis specialists provided feedback on the conceptual framework. Focus interviews with 9 youth with pediatric-onset multiple sclerosis and 6 parents were conducted to develop the relevant domains and item content from the patient and parent perspective. In the cognitive interviews phase, 9 youth with pediatric-onset multiple sclerosis and 6 parents provided feedback on item content, relevance, importance, and understandability of the pediatric-onset multiple sclerosis-specific domains and items. The final interview phase with 5 youth with pediatric-onset multiple sclerosis and 5 parents comprised a pilot testing of the new PedsQL MS Module. RESULTS Eighteen domains were derived from the qualitative methods with item content saturation achieved at 100 items based on 40 interviews with 23 youth with pediatric-onset multiple sclerosis aged 10-21 years and 17 parents. The domains derived include general fatigue, sleep/rest fatigue, cognitive functioning, tingling sensations, numbness sensations, physical weakness, pain, speech, balance, fine motor, vision, urination, constipation, bowel incontinence, worry, communication, treatment, and medicines. CONCLUSIONS Qualitative methods involving 23 youth with pediatric-onset multiple sclerosis and 17 parents in the domain and item development process support the content validity for the new PedsQL MS Module. Future plans include a national field test of the PedsQL MS Module scales and items.
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Affiliation(s)
- Cristina Gaudioso
- Department of Neurology, Division of Pediatric Neurology, 12275Washington University School of Medicine, St Louis, MO, USA
| | - Samuel Oo
- Department of Neurology, Division of Pediatric Neurology, 12275Washington University School of Medicine, St Louis, MO, USA
| | - Soe Mar
- Department of Neurology, Division of Pediatric Neurology, 12275Washington University School of Medicine, St Louis, MO, USA
| | | | - Pamela Newland
- 499763Goldfarb School of Nursing, Barnes Jewish College, St Louis, MO, USA
| | - James W Varni
- Department of Pediatrics, College of Medicine, Department of Landscape Architecture and Urban Planning, College of Architecture, 14736Texas A&M University, College Station, TX, USA
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41
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de Chalus A, Taveira M, Deiva K. Pediatric onset multiple sclerosis: Future challenge for early diagnosis and treatment. Presse Med 2021; 50:104069. [PMID: 34265375 DOI: 10.1016/j.lpm.2021.104069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/04/2021] [Indexed: 11/19/2022] Open
Abstract
Multiple sclerosis is a major socio-economical burden as it represents the most common cause of non-traumatic neurological disability in young adults [1]. It affects also children with a lower prevalence and incidence but remains a major concern as disability may occur later during their adulthood. Therefore, there is an absolute need for earlier diagnosis and treatment. In this review, we would focus on how these objectives can be achieved.
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Affiliation(s)
- Aliénor de Chalus
- University Hospitals Paris Saclay, Bicêtre Hospital, Pediatric Neurology Department, France.
| | - Mélanie Taveira
- University Hospitals Paris Saclay, Bicêtre Hospital, Pediatric Neurology Department, France
| | - Kumaran Deiva
- University Hospitals Paris Saclay, Bicêtre Hospital, Pediatric Neurology Department, France
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42
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Fernandez-Carbonell C, Charvet LE, Krupp LB. Enhancing Mood, Cognition, and Quality of Life in Pediatric Multiple Sclerosis. Paediatr Drugs 2021; 23:317-329. [PMID: 33997945 PMCID: PMC8275506 DOI: 10.1007/s40272-021-00451-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 12/12/2022]
Abstract
Pediatric-onset multiple sclerosis (POMS), representing approximately 5% of all MS cases, affects the central nervous system during its ongoing development. POMS is most commonly diagnosed during adolescence but can occur in younger children as well. For pediatric patients with MS, it is critical to manage the full impact of the disease and monitor for any effects on school and social functioning. Disease management includes not only disease-modifying therapies but also strategies to optimize wellbeing. We review the interventions with the highest evidence of ability to improve the disease course and quality of life in POMS. High levels of vitamin D and a diet low in saturated fat are associated with lower relapse rates. Exercise ameliorates fatigue and sleep. Behavioral strategies for sleep hygiene and mood regulation can also improve fatigue and perceived health. POMS management should be addressed holistically, including assessing overall symptom burden as well as the psychological and functional impact of the disease.
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Affiliation(s)
| | - Leigh E Charvet
- NYU Langone Pediatric Multiple Sclerosis Center, New York, NY, USA
| | - Lauren B Krupp
- NYU Langone Pediatric Multiple Sclerosis Center, New York, NY, USA
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43
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Zaffaroni M. Fingolimod in pediatric-onset multiple sclerosis. Neurol Sci 2021; 42:1-4. [PMID: 33945033 DOI: 10.1007/s10072-021-05294-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Mauro Zaffaroni
- Multiple Sclerosis Centre, Hospital of Gallarate, ASST della Valle Olona, Via Pastori 4, 21013, Gallarate, Italy.
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44
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Zanetta C, Filippi M, Moiola L. Fingolimod as an effective therapeutic strategy for pediatric relapsing-remitting multiple sclerosis: two case reports. Neurol Sci 2021; 42:9-13. [PMID: 33904006 DOI: 10.1007/s10072-021-05270-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/16/2021] [Indexed: 11/26/2022]
Abstract
Approximately 3-10% of patients with multiple sclerosis (MS) have onset during childhood. Pediatric MS is characterized by a relapsing-remitting course and a high relapse rate. In 2010, fingolimod (Gilenya®) was approved in the USA for the treatment of relapsing-remitting MS in adults. In 2018, both the United States Food and Drug Administration and the European Medicines Agency expanded the approved indications of fingolimod to include its use in children with relapsing MS, and the drug was approved in Italy for this indication in September 2020. We describe two cases of children with relapsing-remitting MS who were treated with fingolimod at IRCCS Ospedale San Raffaele Multiple Sclerosis Center (Milan, Italy) for more than 2 years. Our real-world data confirm that fingolimod is an effective therapeutic strategy for children with relapsing MS, and its use could be considered in pediatric patients with active disease.
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Affiliation(s)
- Chiara Zanetta
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University , Milan, Italy.
| | - Lucia Moiola
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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45
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Long-term fingolimod treatment in two pediatric patients with multiple sclerosis. Neurol Sci 2021; 42:29-36. [PMID: 33751260 DOI: 10.1007/s10072-021-05116-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/03/2021] [Indexed: 10/21/2022]
Abstract
Data suggest that patients with pediatric-onset multiple sclerosis (POMS) should initiate treatment with a disease-modifying therapy early to slow progression. The PARADIGMS trial demonstrated that oral fingolimod reduced the annual rate of relapse by 82% compared with intramuscular interferon beta-1a in children with POMS. The PARADIGMS study had a follow-up of 2 years, but no data are available about the safety and efficacy of fingolimod for longer periods in children with POMS. Here we present two cases of children with POMS who achieved sustained clinical benefit from treatment with fingolimod for more than 2 years. The first patient, an 11-year-old male, who participate in the PARADIGMS study, was treatment naïve at the time of fingolimod initiation. His clinical condition remained stable over 5 years of treatment, with no relapses and no radiological lesion progression. The second patient was a female who initiated fingolimod at the age of 12 years, 2 years after her POMS diagnosis and after an 8-month trial of interferon beta-1a. The patient had experienced two relapses during interferon beta-1a but had no relapses in more than 2 years of treatment with fingolimod, and her MRI scans showed no new or active lesions. These data show that prolonged treatment with fingolimod can be safe and effective during long-term treatment as first- or second-line therapy in children with POMS.
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46
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Fingolimod as first-line treatment in pediatric-onset multiple sclerosis: a case report. Neurol Sci 2021; 42:25-28. [PMID: 33712907 DOI: 10.1007/s10072-020-05027-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/23/2020] [Indexed: 11/27/2022]
Abstract
Pediatric-onset multiple sclerosis (MS) has a highly active and aggressive course, which can have a devastating effect on the physical and cognitive functioning of a child if not treated appropriately with effective disease-modifying drugs. The optimal treatment strategy of pediatric MS is currently unknown and debate continues as to whether treatment escalation or initiation of a highly active therapy provides a better outcome. Here, we present the case of a 16-year-old female diagnosed with highly active relapsing-remitting MS (age at onset: 14 years) who received first-line treatment with fingolimod within 1 year of the first recorded symptom. Since starting fingolimod, the course of the disease has essentially been stable. No new or active lesions were observed in magnetic resonance imaging scans performed at 3 and 12 months after starting fingolimod, and treatment was well tolerated. These data suggest that, in this case, early treatment with first-line fingolimod was able to slow disease progression.
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47
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De Meo E, Bonacchi R, Moiola L, Colombo B, Sangalli F, Zanetta C, Amato MP, Martinelli V, Rocca MA, Filippi M. Early Predictors of 9-Year Disability in Pediatric Multiple Sclerosis. Ann Neurol 2021; 89:1011-1022. [PMID: 33598931 DOI: 10.1002/ana.26052] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to assess early predictors of 9-year disability in pediatric patients with multiple sclerosis. METHODS Clinical and magnetic resonance imaging (MRI) assessments of 123 pediatric patients with multiple sclerosis were obtained at disease onset and after 1 and 2 years. A 9-year clinical follow-up was also performed. Cox proportional hazard and multivariable regression models were used to assess independent predictors of time to first relapse and 9-year outcomes. RESULTS Time to first relapse was predicted by optic nerve lesions (hazard ratio [HR] = 2.10, p = 0.02) and high-efficacy treatment exposure (HR = 0.31, p = 0.005). Predictors of annualized relapse rate were: at baseline, presence of cerebellar (β = -0.15, p < 0.001), cervical cord lesions (β = 0.16, p = 0.003), and high-efficacy treatment exposure (β = -0.14, p = 0.01); considering also 1-year variables, number of relapses (β = 0.14, p = 0.002), and the previous baseline predictors; considering 2-year variables, time to first relapse (2-year: β = -0.12, p = 0.01) entered, whereas high-efficacy treatment exposure exited the model. Predictors of 9-year disability worsening were: at baseline, presence of optic nerve lesions (odds ratio [OR] = 6.45, p = 0.01); considering 1-year and 2-year variables, Expanded Disability Status Scale (EDSS) changes (1-year: OR = 26.05, p < 0.001; 2-year: OR = 16.38, p = 0.02), and ≥ 2 new T2-lesions in 2 years (2-year: OR = 4.91, p = 0.02). Predictors of higher 9-year EDSS score were: at baseline, EDSS score (β = 0.58, p < 0.001), presence of brainstem lesions (β = 0.31, p = 0.04), and number of cervical cord lesions (β = 0.22, p = 0.05); considering 1-year and 2-year variables, EDSS changes (1-year: β = 0.79, p < 0.001; 2-year: β = 0.55, p < 0.001), and ≥ 2 new T2-lesions (1-year: β = 0.28, p = 0.03; 2-year: β = 0.35, p = 0.01). INTERPRETATION A complete baseline MRI assessment and an accurate clinical and MRI monitoring during the first 2 years of disease contribute to predict 9-year prognosis in pediatric patients with multiple sclerosis. ANN NEUROL 2021;89:1011-1022.
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Affiliation(s)
- Ermelinda De Meo
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Raffaello Bonacchi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lucia Moiola
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Bruno Colombo
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Chiara Zanetta
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | | | - Maria Assunta Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
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48
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Palavra F, Figueiroa S, Correia AS, Tapadinhas F, Cerqueira J, Guerreiro RP, de Sá J, Sá MJ, Almeida S, Mota P, Sousa L. TyPed study: Natalizumab for the treatment of pediatric-onset multiple sclerosis in Portugal. Mult Scler Relat Disord 2021; 51:102865. [PMID: 33714125 DOI: 10.1016/j.msard.2021.102865] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/08/2021] [Accepted: 02/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND A significant proportion of pediatric-onset multiple sclerosis (POMS) patients do not respond to first-line disease-modifying therapies. Clinical trials showed that natalizumab is effective and safe in adults, but there are limited clinical trial data for children. Natalizumab is currently prescribed off-label for POMS. We aimed to characterize the effectiveness, safety and tolerability of natalizumab in all POMS cases treated in Portugal (from 2007 to 2018). METHODS Data from clinical records were retrospectively collected for all POMS cases treated with natalizumab in Portugal. RESULTS Twenty-one patients were included, 14 (67%) of which were female. The median age at POMS diagnosis was 13 years old. The median duration of treatment with natalizumab was 2 years and 3 months. Median Expanded Disability Status Scale score decreased from 1.5 to 1.0 after 24 months. The Annualized Relapse Rate decreased from 1.31 events/patient/year before treatment with natalizumab to 0 after 12 months of treatment and to 0.04 after 24 months. No gadolinium-enhancing lesions or new or enlarged T2 hyperintense lesions were observed in 8/8 patients (100%) after 12 months, and 4/5 (80%) after 24 months. There was one possible serious adverse event, which did not require dose adjustment. Five patients discontinued treatment due to positive anti-JCV (JC virus) antibody JC serostatus. CONCLUSION Natalizumab may be an effective and safe disease-modifying therapy for POMS. Our results are in line with data published for the adult population, as well as with similar observational studies in pediatric populations in other regions.
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Affiliation(s)
- Filipe Palavra
- Centre for Child Development - Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra; Laboratory of Pharmacology and Experimental Therapeutics, Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
| | - Sónia Figueiroa
- Neuropediatrics Unit, Centro Materno-Infantil do Norte, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Ana Sofia Correia
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental; CEDOC, Nova Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Fernando Tapadinhas
- Department of Pediatrics, Hospital de Faro, Centro Hospitalar e Universitário do Algarve, Faro, Portugal
| | - João Cerqueira
- Department of Neurology, Hospital de Braga; 2CA - Clinical Academic Centre Braga; School of Medicine, University of Minho, Braga, Portugal
| | - Rui Pedro Guerreiro
- Department of Neurology, Hospital de São Bernardo, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - João de Sá
- Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Maria José Sá
- Department of Neurology, Centro Hospitalar e Universitário de São João; Faculty of Health Sciences, University Fernando Pessoa, Porto, Portugal
| | | | | | - Lívia Sousa
- Department of Neurology, Centro Hospitalar e Universitário de Coimbra; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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49
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Chitnis T, Aaen G, Belman A, Benson L, Gorman M, Goyal MS, Graves JS, Harris Y, Krupp L, Lotze T, Mar S, Ness J, Rensel M, Schreiner T, Tillema JM, Waubant E, Weinstock-Guttman B, Roalstad S, Rose J, Weiner HL, Casper TC, Rodriguez M. Improved relapse recovery in paediatric compared to adult multiple sclerosis. Brain 2021; 143:2733-2741. [PMID: 32810215 DOI: 10.1093/brain/awaa199] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/01/2020] [Accepted: 04/29/2020] [Indexed: 11/14/2022] Open
Abstract
Incomplete relapse recovery contributes to disability accrual and earlier onset of secondary progressive multiple sclerosis. We sought to investigate the effect of age on relapse recovery. We identified patients with multiple sclerosis from two longitudinal prospective studies, with an Expanded Disability Status Scale (EDSS) score within 30 days after onset of an attack, and follow-up EDSS 6 months after attack. Adult patients with multiple sclerosis (n = 632) were identified from the Comprehensive Longitudinal Investigations in Multiple Sclerosis at Brigham study (CLIMB), and paediatric patients (n = 132) from the US Network of Paediatric Multiple Sclerosis Centers (NPMSC) registry. Change in EDSS was defined as the difference in EDSS between attack and follow-up. Change in EDSS at follow-up compared to baseline was significantly lower in children compared to adults (P = 0.001), as were several functional system scores. Stratification by decade at onset for change in EDSS versus age found for every 10 years of age, EDSS recovery is reduced by 0.15 points (P < 0.0001). A larger proportion of children versus adults demonstrated improvement in EDSS following an attack (P = 0.006). For every 10 years of age, odds of EDSS not improving increase by 1.33 times (P < 0.0001). Younger age is associated with improved recovery from relapses. Age-related mechanisms may provide novel therapeutic targets for disability accrual in multiple sclerosis.
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Affiliation(s)
- Tanuja Chitnis
- Partners Paediatric Multiple Sclerosis Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Greg Aaen
- Paediatric Multiple Sclerosis Center, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Anita Belman
- Paediatric MS Center at NYU Langone Health, New York, NY, USA
| | - Leslie Benson
- Paediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital, MA, USA
| | - Mark Gorman
- Paediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital, MA, USA
| | | | - Jennifer S Graves
- Paediatric Multiple Sclerosis Center, University of California San Diego, San Diego, CA, USA
| | - Yolanda Harris
- UAB Center for Paediatric-Onset Demyelinating Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lauren Krupp
- Paediatric MS Center at NYU Langone Health, New York, NY, USA
| | - Timothy Lotze
- The Blue Bird Circle Clinic for Multiple Sclerosis, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Soe Mar
- Washington University, St. Louis, MO, USA
| | - Jayne Ness
- UAB Center for Paediatric-Onset Demyelinating Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Teri Schreiner
- Rocky Mountain Multiple Sclerosis Center, Children's Hospital Colorado, University of Colorado at Denver, Aurora, CO, USA
| | - Jan-Mendelt Tillema
- Mayo Clinic Paediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MN, USA
| | - Emmanuelle Waubant
- Paediatric Multiple Sclerosis Center, University of California San Francisco, San Francisco, CA, USA
| | - Bianca Weinstock-Guttman
- Jacobs Paediatric Multiple Sclerosis Center, State University of New York at Buffalo, Buffalo, NY, USA
| | - Shelly Roalstad
- Data Coordinating and Analysis Center, University of Utah, Salt Lake City, UT, USA
| | - John Rose
- Data Coordinating and Analysis Center, University of Utah, Salt Lake City, UT, USA
| | - Howard L Weiner
- Harvard Medical School, Boston, MA, USA.,Partners MS Center, Brigham and Women's Hospital, Boston, MA, USA
| | - T Charles Casper
- Data Coordinating and Analysis Center, University of Utah, Salt Lake City, UT, USA
| | - Moses Rodriguez
- Mayo Clinic Paediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MN, USA
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50
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Rosso M, Healy BC, Saxena S, Paul A, Bjornevik K, Kuhle J, Benkert P, Leppert D, Guttmann C, Bakshi R, Weiner HL, Chitnis T. MRI Lesion State Modulates the Relationship Between Serum Neurofilament Light and Age in Multiple Sclerosis. J Neuroimaging 2021; 31:388-393. [DOI: 10.1111/jon.12826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 01/10/2023] Open
Affiliation(s)
- Mattia Rosso
- Brigham and Women's Hospital Harvard Medical School Boston MA
- Ann Romney Center for Neurologic Diseases Harvard Medical School Boston MA
| | - Brian C. Healy
- Brigham and Women's Hospital Harvard Medical School Boston MA
- Ann Romney Center for Neurologic Diseases Harvard Medical School Boston MA
- Biostatistics Center Massachusetts General Hospital Boston MA
| | - Shrishti Saxena
- Brigham and Women's Hospital Harvard Medical School Boston MA
- Ann Romney Center for Neurologic Diseases Harvard Medical School Boston MA
| | - Anu Paul
- Brigham and Women's Hospital Harvard Medical School Boston MA
- Ann Romney Center for Neurologic Diseases Harvard Medical School Boston MA
| | - Kjetil Bjornevik
- Harvard T.H. Chan School of Public Health Harvard University Boston MA
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research University Hospital Basel University of Basel Basel Switzerland
| | - Pascal Benkert
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel University of Basel Basel Switzerland
| | - David Leppert
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research University Hospital Basel University of Basel Basel Switzerland
| | - Charles Guttmann
- Brigham and Women's Hospital Harvard Medical School Boston MA
- Ann Romney Center for Neurologic Diseases Harvard Medical School Boston MA
| | - Rohit Bakshi
- Brigham and Women's Hospital Harvard Medical School Boston MA
- Ann Romney Center for Neurologic Diseases Harvard Medical School Boston MA
- Brigham Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Howard L. Weiner
- Brigham and Women's Hospital Harvard Medical School Boston MA
- Ann Romney Center for Neurologic Diseases Harvard Medical School Boston MA
- Brigham Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Tanuja Chitnis
- Brigham and Women's Hospital Harvard Medical School Boston MA
- Ann Romney Center for Neurologic Diseases Harvard Medical School Boston MA
- Brigham Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital Harvard Medical School Boston MA
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