Behavioral Neurology of Multiple Sclerosis and Autoimmune Encephalopathies

REBISTART: Adherence of Patients with Multiple Sclerosis to Treatment with Subcutaneous Interferon Beta in the Context of a Patient Support Program

INTRODUCTION

Treatment adherence is a critical success factor in the disease-modifying therapy (DMT) of multiple sclerosis (MS). The REBISTART study prospectively evaluated adherence in patients using components of a patient support program (PSP).

METHODS

The 12-month non-interventional multicenter study examined the real-world adherence to subcutaneously (sc) injected interferon beta-1a (Rebif®). Patient-assessed adherence was measured by a visual analog scale (VAS) and the Morisky Medication Adherence Scale (MMAS). Objective adherence data were obtained by readouts from the RebiSmart® injection device.

RESULTS

Of 333 patients, 70.9% used the nursing service as the core component of the PSP. Self-assessed VAS-based adherence was stable over time at 94.0-96.3%. Similarly, MMAS score (maximum 4) was 3.8-3.9 at all visits, also reflecting high self-assessed adherence. In 269 patients using the RebiSmart® injection device, mean readout-based objective adherence was similarly high (93.0-98.4% throughout visits). At last available visit, VAS-based adherence was independent of participation in the PSP nursing service (93.1% with participation versus 91.7% without it). Adherence was also independent of injection method or disease-related measures, including fatigue, depression, cognition, and quality of life. The most frequent reason for the premature discontinuations (38.7% of patients) was "change of treatment" (10.0%).

DISCUSSION

We suggest that subgroups that may specifically benefit from PSP include patients who live alone, use multiple comedications, and are affected by cognitive impairment, depression, and/or fatigue. Further studies should investigate the potential usefulness of PSPs in these populations.

CONCLUSIONS

Very high adherence rates independent of the PSP nursing service over 1 year of treatment indicate that IFN beta-1a sc is an easy-to-use and well-tolerated disease-modifying drug.

TRIAL REGISTRATION NUMBER

Vfa.de: No. 892. https://www.vfa.de/de/arzneimittel-forschung/datenbanken-zu-arzneimitteln/nisdb/nis-details/_892 .

Serum lipids and cognitive outcomes in multiple sclerosis; a systematic review and meta-analysis

BACKGROUND

Cognitive impairment is highly prevalent in multiple sclerosis (MS) with poorly understood underlying mechanisms. Lipids are considered to be associated with MS progression through the inflammatory and oxidative stress pathways, brain atrophy, cellular signaling, and tissue physiology. In addition, serum lipids are proposed as a modifiable factor affecting the neuropsychiatric condition; therefore, this study aims to assess the association between serum lipid levels and cognitive outcomes in MS.

METHODS

This study was carried out following the PRISMA 2020 statement. A systematic search was conducted in PubMed, Scopus, Web of Science, and Embase in March 2023, and the Joanna Briggs Institute (JBI)'s critical appraisal tools were utilized for risk of bias (RoB) assessments in the included studies. The quantitative synthesis was performed with the comprehensive meta-analysis (CMA3) software.

RESULTS

Out of 508 screened records, 7 studies were eventually found to meet our inclusion criteria. In two studies, the course of MS in the sample of the study was only Relapsing-Remitting MS (RRMS), whereas the other five studies' sample was a combination of different phenotypes. Studies utilized different scales such as Minimal Assessment of Cognitive Function in MS (MACFIMS), Brief International Cognitive Assessment for MS (BICAMS), Montreal Cognitive Assessment (MoCA), Brief Repeatable Battery of Neuropsychological Tests (BRB-N) for cognitive evaluations. Dealing with possible confounders such as age, disease duration and level of disability was the most common possible source of bias in the included studies. One study revealed an inverse relationship between serum levels of apolipoproteins (including ApoA-I, ApoB, and ApoB/ApoA-I) and Symbol Digit Modalities Test (SDMT) scores. Also, a correlation between 24S-hydroxycholesterol (24OHC) serum concentrations and SDMT score was reported in one study. The association between serum total cholesterol (TC) and low-density lipoprotein cholesterol (LDL) and different aspects of cognitive function was reported in the studies; however, serum levels of high-density lipoprotein cholesterol (HDL) were not found to be associated. The quantitative synthesis revealed a significant correlation between TC and the MoCA scores (r =-0.238; 95 %CI: -0.366 to -0.100; p-value = 0.001); however, the correlation between TG levels and MoCA were not statistically significant (r:-0.070; 95 %CI: -0.209 to 0.072; p-value: 0.334). In addition, the mata-analyses were not associated with significant findings regarding the correlation between lipid profiles (including HDL, LDL, TG, and TC) and other cognitive assessment scales including SDMT, Brief Visuospatial Memory Test (BVMT), and California Verbal Learning Test (CVLT) (p-values>0.05).

DISCUSSION

Available evidence suggested a link between TC and LDL with cognitive outcomes of MS patients which was not evident in our quantitative synthesis. The limited number of studies, high RoB, different cognitive assessment scales and reporting methods, and the cross-sectional design of the included studies, were the main limitations that alleviate the clinical significance of the findings of this study and suggested further investigations on this topic.

FUNDING AND REGISTRATION

The research protocol was approved and supported by the Student Research Committee, Tabriz University of Medical Sciences (grant number: 71,909). This study is registered in the international prospective register of systematic reviews (PROSPERO ID: CRD42023441625).

A neuropsychologically based employment intervention for women with multiple sclerosis: A quasi-randomized controlled trial

OBJECTIVE

Job loss is common in multiple sclerosis (MS) and frequently associated with depression, fatigue, and cognitive dysfunction. Identifying these modifiable risk factors and providing "at-risk" women with a neuropsychologically-based intervention may improve employment outcomes. Our study seeks to investigate the utility of a neuropsychologically-based intervention with varying levels of treatment and follow-up, and evaluate treatment and employment outcomes among groups.

METHOD

In this longitudinal, quasi-randomized controlled trial, employed women with MS meeting criteria on screening measures were considered "at-risk" for job instability and randomized to one of two neuropsychological testing interventions (standard-care group received testing and phone feedback of results and recommendations; experimental group received testing and in-person feedback with subsequent care-coordinator calls from a nurse to help coordinate recommendation completion). Participants who did not meet criteria were considered "low-risk" and only followed over time.

RESULTS

56 women in the treatment groups (standard-care = 23; experimental = 33) and 63 women in the follow-only group were analyzed at 1 year. Rates of decreased employment were similar between standard-care (17.4%) and experimental (21.2%) groups (OR = .782, 95% CI .200-3.057). However, the experimental group completed significantly more treatment recommendations, t(53) = -3.237, p = .002. Rates of decreased employment were also similar between the "low-risk" (17.5%) and "at-risk" groups (19.6%), (OR = .721, 95% CI .285-1.826).

CONCLUSION

Employment outcomes were similar at 1 year between treatment groups receiving differing levels of a neuropsychologically-based intervention, however treatment adherence significantly improved in the experimental group. Treatment groups also had similar employment outcomes as compared to a "low-risk," no intervention group, suggesting that engaging in either neuropsychological intervention may have impacted job stability.

The Possible Direct Correlation between Cognitive Impairment and Fear of Catching COVID-19 among Patients with Multiple Sclerosis

Objective: The prevalence of cognitive impairment in multiple sclerosis (MS) is significant and it is estimated that 40% to 70% of patients with MS suffer from this impairment. COVID-19 is also a new infectious disease. The symptoms of this disease, which include fever, shortness of breath, and cough, can be mild to severe and can even lead to death. Due to the use of immunosuppressive drugs by Patients with MS, they might be at greater risk of catching COVID-19. Thus, patients with MS may be more afraid of catching the virus. One of the important factors is the relationship between cognitive deficit and the increase in patients' fear of COVID-19. The aim of this study was to assess the relationship between fear of catching COVID-19 and cognitive impairment in patients with MS.

Method: This cross-sectional study was conducted at the MS Clinic, Sina hospital, Tehran University of Medical Sciences, Tehran, Iran. Our participants in this project were Patients with MS who were over 18 years old and had no history of other neurological and psychiatric diseases. In addition to obtaining demographic and clinical information, we measured the fear of catching the COVID 2019 via Fear of COVID-19 Scale (FCV-19S), which is 7-item questionnaire. We also used Multiple Sclerosis Neuro Psychological Screening Questionnaire (MSNQ) to assess memory and information processing speed in Patients with MS.

Results: After adjustment for age, gender, disease duration, highest level of education, MS type, and EDSS in linear regression model, as well as the MSNQ total score and fear score of catching coronavirus, the results demonstrated a significant positive correlation with P value of 0.00 and β: 0.024.

Conclusion: The present study showed a direct relationship between cognitive disorder and level of fear regarding COVID-19. Patients with more cognitive disorders were more afraid of COVID-19.

The correlation between dyslipidemia and cognitive impairment in multiple sclerosis patients

BACKGROUND

A large number of multiple sclerosis [MS] patients suffer from cognitive dysfunction affecting their routine life in family and society. Investigating modifiable factors for cognition decline and controlling them, could improve the quality of life in MS patients. Therefore, the present study was aimed to evaluate the association between lipid profile components and cognition in MS patients.

METHODS

A cross-sectional study was conducted on 50 Relapsing-Remitting MS (RRMS) patients referred to Sina hospital, Tehran, Iran. The definite diagnosis of MS was done based on the revised McDonald criteria. Data on demographic and clinical data of patients were obtained. 5 cc blood samples were taken from all subjects after 10-hour night fasting, and lipid profile components including LDL, HDL, triglyceride, and total cholesterol were evaluated. The Persian version of the Minimal Assessment of Cognitive Functions in MS [MACFIMS] battery was administered to assess the cognitive function. Spearman and Pearson correlation tests were applied to investigate the correlation between lipid profile components and MACFIMS subtests or clinical features of MS patients.

RESULTS

The mean age of subjects was equal to 32.26 years old, and 85% of them were women. There was no significant correlation between MACFIMS subtests results with disease duration, patient's disability according to Expanded Disability Status Scale (EDSS), annual attack rate, and disease-modifying drug onset year (P value >0.05). A significant inverse correlation was found between greater serum total cholesterol and lower scores of Symbol Digit Modalities subtest [SDMT] (P value 0.02; r: -0.31), the Delis-Kaplan Executive Function System [DKEFS] sorting (P value 0.01; r: -0.34) and DKEFS-descriptive (P value 0.04; r: -0.28) subtests. This significant inverse correlation was also found in terms of the correlation between higher serum LDL and impairment in the case of DKEFS-sorting score (P value 0.05; r: -0.27), and DKEFS-descriptive score (P value 0.05; r: -0.27). No significant correlation was found in case of serum HDL or triglyceride and MACFIMS subtests (P value >0.05).

DISCUSSION

Our findings proposed a possible correlation between the increased serum LDL cholesterol, serum total cholesterol and cognitive dysfunction among MS patients.

Short Report: Adherence to Neuropsychological Recommendations in Patients with Multiple Sclerosis

Background

Adherence to nonmedication recommendations is typically low, as seen in various health populations. Because literature on adherence to treatment recommendations made after neuropsychological testing in multiple sclerosis (MS) is lacking, this study evaluated adherence and reasons for nonadherence. Relationships between adherence to recommendations and various other factors in patients with MS were also evaluated.

Methods

Of 66 adult patients seen for neuropsychological testing at an MS center, 55 were eligible for this study. Forty-five patients (mean age, 43.4 years; 75.6% women) were reached by phone, and all agreed to an interview involving questions regarding adherence to treatment recommendations. Other information was obtained through retrospective medical record review.

Results

Overall self-reported adherence to recommendations made from neuropsychological testing was 38%. Adherence rates varied by recommendation type: psychopharmacological management had the highest rate (80%), and referrals for cognitive rehabilitation had the lowest (6.5%). Reasons for nonadherence included needing more information and wanting to speak with one's physician regarding the recommendations. Adherence was associated with patients' ability to spontaneously recall at least some of their recommendations and with receiving both a written report and a phone call with test results.

Conclusions

Adherence to recommendations made after neuropsychological testing for patients with MS is low. Points of intervention may be to give directed feedback for each recommendation and to provide both a written report and a phone call with results and recommendations. Asking patients to repeat back the recommendations may be a simple and efficient way to increase understanding and improve adherence.

Sesquiterpenoids from the Root of Panax ginseng Attenuates Lipopolysaccharide-Induced Depressive-Like Behavior through the Brain-Derived Neurotrophic Factor/Tropomyosin-Related Kinase B and Sirtuin Type 1/Nuclear Factor-κB Signaling Pathways

The previous study indicated sesquiterpenoids from the root of Panax ginseng (SPG) exhibited a significant antidepressant-like effect, which might be mediated by the modification of the dopaminergic, GABAergic, and glutamatergic systems. This study was to investigate antidepressant effects and mechanisms on the lipopolysaccharide (LPS)-induced depression-like behavior of SPG. In the tail suspension test (TST) and forced swimming test (FST), SPG (0.25 and 1 mg/kg, i.g.) and fluoxetine (20 mg/kg, i.p.) effectively reduced the immobility time. SPG treatment significantly reduced serum levels of IL-6 and TNF-α and increased suppressed superoxide dismutase (SOD) activity in the hippocampus. In addition, SPG effectively upregulated the brain-derived neurotrophic factor (BDNF), tropomyosin-related kinase B (TrkB), and sirtuin type 1 (Sirt 1) expression in the hippocampus and downregulated the inhibitor of κB-α (IκB-α) and nuclear factor-κB (NF-κB) phosphorylation. These results suggested that SPG exhibited an antidepressant-like effect through the BDNF/TrkB and Sirt 1/NF-κB signaling pathways.

The influence of sodium on pathophysiology of multiple sclerosis

Multiple sclerosis (MS) is a chronic, inflammatory, autoimmune disease of the central nervous system, and is an important cause of disability in young adults. In genetically susceptible individuals, several environmental factors may play a partial role in the pathogenesis of MS. Some studies suggests that high-salt diet (>5 g/day) may contribute to the MS and other autoimmune disease development through the induction of pathogenic Th17 cells and pro-inflammatory cytokines in both humans and mice. However, the precise mechanisms of pro-inflammatory effect of sodium chloride intake are not yet explained. The purpose of this review was to discuss the present state of knowledge on the potential role of environmental and dietary factors, particularly sodium chloride on the development and course of MS.

Antidepressant-like effect of pramipexole in an inflammatory model of depression

Pramipexole (PPX), a dopamine D2/3 receptor preferring agonist, is currently in use for the treatment of Parkinson's disease symptoms and restless legs syndrome. Recently, anti-inflammatory properties of PPX have been shown in an autoimmune model of multiple sclerosis, and case reports indicate PPX ameliorates depressive symptoms. Since peripheral inflammation is known to induce depression-like behavior in rodents, we assessed the potential antidepressant effect of PPX in an inflammatory model of depression induced by LPS. Repeated (daily for 7days, 1mg/kg, i.p.), but not acute (1h before LPS) treatment with PPX abolished the depression-like behavior induced by LPS (0.1mg/kg, i.p.) in the forced swim test, and the anhedonic behavior in the splash test. Interestingly, PPX per se decreased interleukin 1β levels and reversed LPS-induced increase in its content in mice hippocampus⋅ Repeated PPX treatment also prevented the increase in hippocampal levels of the 3-nitrotyrosine protein adducts induced by LPS. Haloperidol (0.2mg/kg, i.p.) and sulpiride (50mg/kg, i.p.) were unable to prevent the antidepressant-like effect of PPX in LPS-treated mice. Altogether, these results suggest that the observed antidepressant-like effect of PPX in LPS-treated mice may be dependent on its anti-inflammatory properties and may not be related to dopamine D2 receptor activation.