Evolution of diagnostic criteria for multiple sclerosis

Multiple Sclerosis: An Emergency Medicine-Focused Narrative Review

BACKGROUND

Multiple sclerosis (MS) is a rare but serious condition associated with significant morbidity.

OBJECTIVE

This review provides a focused assessment of MS for emergency clinicians, including the presentation, evaluation, and emergency department (ED) management based on current evidence.

DISCUSSION

MS is an autoimmune disorder targeting the central nervous system (CNS), characterized by clinical relapses and radiological lesions disseminated in time and location. Patients with MS most commonly present with long tract signs (e.g., myelopathy, asymmetric spastic paraplegia, urinary dysfunction, Lhermitte's sign), optic neuritis, or brainstem syndromes (bilateral internuclear ophthalmoplegia). Cortical syndromes or multifocal presentations are less common. Radiologically isolated syndrome and clinically isolated syndrome (CIS) may or may not progress to chronic forms of MS, including relapsing remitting MS, primary progressive MS, and secondary progressive MS. The foundation of outpatient management involves disease-modifying therapy, which is typically initiated with the first signs of disease onset. Management of CIS and acute flares of MS in the ED includes corticosteroid therapy, ideally after diagnostic testing with imaging and lumbar puncture for cerebrospinal fluid analysis. Emergency clinicians should evaluate whether patients with MS are presenting with new-onset debilitating neurological symptoms to avoid unnecessary testing and admissions, but failure to appropriately diagnose CIS or MS flare is associated with increased morbidity.

CONCLUSIONS

An understanding of MS can assist emergency clinicians in better diagnosing and managing this neurologically devastating disease.

The disease-modifying therapy utilisation and cost trend for multiple sclerosis in Australia between 2013 and 2022

BACKGROUND

The MS disease-modifying therapies (DMTs) prescribing landscape in Australia have changed over time.

OBJECTIVES

This study evaluated the utilisation and cost trends of MS-related DMTs in Australia over 10 years and investigated differences between States/Territories.

METHODS

The prescription and costs of 16 DMTs were extracted from the Pharmaceutical Benefits Scheme for 2013-2022. Descriptive approaches analysed the total number of people prescribed DMTs and total DMT costs per 10,000 population, proportions of prescriptions/costs by DMT groups and the number of people prescribed each individual DMT and costs of each DMT over the 10-year period. All estimates were for Australia and each State/Territory individually.

RESULTS

The number of people prescribed DMT and costs per 10,000 population had substantial growth between 2013 and 2022: 125%/164% for Australia, and 94%-251%/129%-373% for individual States/Territories. Higher efficacy group accounted for 54% of total people prescribed DMTs in 2013 and 75% in 2022. Fingolimod was the most popular DMT until 2020, then was dominated by ocrelizumab. The trends of individual DMT prescriptions and costs differed between states particularly in Western Australia (WA), Tasmania and Northern Territory (NT).

CONCLUSION

DMT prescriptions and costs continuously increased over the last decade, particularly for higher efficacy DMTs, and their trends differed between States/Territories.

Acute optic neuritis: What do complementary tests add to diagnosis?

INTRODUCTION

Optic neuritis (ON) is the inflammation of the optic nerve due in many cases, to a pathological immune response. Since its symptoms can be subtle, diagnosis is sometimes challenging. The value of complementary tests for diagnosis and prognosis of ON was demonstrated in retrospective analysis, but their utility in the acute period of ON has been scarcely studied. The aim of this study is to determine the usefulness of clinical assessment, optical coherence tomography (OCT), visual evoked potentials (VEP) and orbit magnetic resonance imaging (MRI) for making diagnosis and prognosis of acute ON (AON).

MATERIALS AND METHODS

A cross-sectional study was conducted including patients with ON within 90 days of symptom onset. A complete neuro-ophthalmological evaluation, OCT, VEP and MRI were carried out, determining in each case its sensitivity, specificity and predictive values in the diagnosis of ON and the assessment of its severity.

RESULTS

75 eyes of 34 patients with ON were included. Regarding diagnosis, low contrast visual acuity (LCVA) displayed the highest sensitivity (100%), being superior than the sensitivity of all complementary tools, always below 80%. Orbit MRI abnormal findings has a Specificity of 100% to confirm diagnosis. Regarding severity assessment and prognosis, Ganglion cell +inner plexiform layer (GCIP) thickness, but not retinal nerve fibre layer (RNFL), correlates significantly with patients' visual acuity (VA) (p < 0.05). Furthermore, both P100latency and VEP's amplitude showed to be significantly associated with VA (p < 0.05) in the acute period. The combination of two predictors (measurement of RNFL and GCIP) are capable of explaining 60% of the variation of the patient's visual acuity, with statistical significance (p = 0.02) CONCLUSIONS: In depth neuro-ophthalmological assessment during the acute phase of ON, including contrast sensitivity measurement, proved to be superior to complementary tests for diagnosis, surpassing the performance of OCT and VEP. However, these tools can add to prognosis, as GCIP thickness and VEP's amplitude correlate with disease severity and its findings could encourage prompt aggressive treatments in AON.

Natural history of relapsing remitting multiple sclerosis in a long-lasting cohort from a tertiary MS centre in Portugal

BACKGROUND

Several disease-modifying therapies (DMTs) have emerged in the last two decades for the treatment of multiple sclerosis (MS). The increasing use of these therapies has enhanced the need to study its impact on long-term disease progression and on the natural history of MS. This study aimed to characterize a Portuguese MS patient cohort in what concerns the natural history of disease by exploring differences throughout 3 decades.

METHODS

Longitudinal, retrospective, non-interventional study. Patients aged ≥ 18 years old, with confirmed diagnosis of relapsing-remitting MS (RRMS), were included. Biodemographic and clinical characteristics (MS diagnosis, patient follow-up, relapses, treatment, and exams) were assessed and compared according to the first appointment date throughout 10-year spans (1987-1996; 1997-2006; 2007-2016).

RESULTS

548 patients were included in this analysis. Significant differences were observed between decades for evoked potential (EP) and cerebrospinal fluid (CSF) exams conducted at diagnosis, the first with less expression on the last decade; the median number of relapses per year (higher in the subgroup 07-16); EDSS at baseline and at last appointment (both higher in the subgroup 87-96); and the percentage of patients achieving EDSS 3.0 and EDSS 6.0 (increased in the subgroup 87-96). Additionally, time from diagnosis to first treatment was significantly lower in patients from the most recent decade, and a greater percentage of such patients, compared to the other two subgroups, was, at last appointment, under a second line DMT.

CONCLUSION

In general, our study reflects findings from longitudinal studies on MS progression already published in the literature. In recent years, the growing number of more effective DMTs, along with earlier disease detection, and improvements in access to healthcare appear to have had a positive impact on patients' access to treatment and, consequently, disease progression. Additional studies, with increased follow up time, are needed to further investigate the effect of treatment improvement in the natural history of MS.

Childhood pet ownership and multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Many studies have been conducted investigating a range of environmental factors which have been implicated in the pathogenesis of multiple sclerosis (MS). We collated available data about exposure to domestic animals before symptom onset in MS to perform a systematic review and meta-analysis.

METHODS

Medline, Embase and Cinahl were searched for relevant articles, based on pre-defined inclusion and exclusion criteria and reference lists were hand-searched. Data were extracted and critical analysis was conducted using the Newcastle-Ottawa criteria. Meta-analysis used random effects.

RESULTS

Study heterogeneity was high and study quality was variable. Random effects meta-analysis showed no associations with any pet ownership and development of MS.

CONCLUSION

It is not possible to draw definitive conclusions from this work. The studies included had a high level of heterogeneity. There are many variables involved in pet ownership and exposure and the nature of the way these have been studied makes the analysis challenging.

Is there a relationship between homes' radon gas of MS and non-MS individuals, and the patients' paraclinical magnetic resonance imaging and visually evoked potentials in Yazd-Iran?

Long-term inhalation of radon gas can cause harm to humans and lead to many diseases. One of these diseases is multiple sclerosis (MS), the most common chronic disease of the central nervous system, which alters the brain structure and impedes the rapid transmission of nerve signals throughout the neuron system. Therefore, this study aimed to investigate the relationship of the radon gas concentration in residential homes of MS and non-MS individuals with their results of paraclinical MRI and VEP in Yazd City, Iran. The radon gas concentration was measured in residential homes of 44 people with MS and 100 healthy people. To this end, the questionnaire of radon gas monitoring in residential buildings was administered, and the radon gas concentration was measured by CR-39 detectors. The mean radon concentrations in the homes of MS and non-MS people were 69.51 and 70.83, respectively. A significant positive relationship was found between radon concentration and building's age (P = 0.038). Furthermore, radon concentration had a significant inverse relationship with the building's ventilation (P = 0.053) and cooling systems (P = 0.021). No significant relationship was observed between total radon concentration and MS incidence (P = 0.88). Moreover, no significant correlation was found between radon concentration and location of the plaque in MRI test results of the patients. However, it showed an inverse non-significant correlation with the plaque's number (r = - 0.12, P = 0.42). Further studies in this area are recommended.

Cannabinoid Receptors and Ligands: Lessons from CNS Disorders and the Quest for Novel Treatment Venues

The potential use of cannabinoids for therapeutic purposes is at the forefront of cannabinoid research which aims to develop innovative strategies to prevent, manage and treat a broad spectrum of human diseases. This chapter briefly reviews the pivotal role of the endocannabinoid system in modulating the central nervous system and its roles on neurodegenerative diseases and brain disorders. Ligand-induced modulation of cannabinoid 1 and 2 receptors to modulate immune response, decrease neurodegeneration and pain are aspects that are also discussed.

Development of a Knowledge-based Clinical Decision Support System for Multiple Sclerosis Diagnosis

The diagnosis of multiple sclerosis (MS) is difficult considering its complexity, variety in signs and symptoms, and its similarity to the signs and symptoms of other neurological diseases. The purpose of this study is to design and develop a clinical decision support system (CDSS) to help physicians diagnose MS with a relapsing-remitting phenotype. The CDSS software was developed in four stages: requirement analysis, system design, system development, and system evaluation. The Rational Rose and SQL Server were used to design the object-oriented conceptual model and develop the database. The C sharp programming language and the Visual Studio programming environment were used to develop the software. To evaluate the efficiency and applicability of the software, the data of 130 medical records of patients aged 20 to 40 between 2017 and 2019 were used along with the Nilsson standard questionnaire. SPSS Statistics was also used to analyze the data. For MS diagnosis, CDSS had a sensitivity, specificity and accuracy of 1, 0.97 and 0.99, respectively, and the area under the ROC curve was 0.98. The agreement rate of kappa coefficient (κ) between software diagnosis and physician's diagnosis was 0.98. The average score of software users was 98.33%, 96.65%, and 96.9% regarding the ease of learning, memorability, and satisfaction, respectively. Therefore, the applicability of the CDSS for MS diagnosis was confirmed by the neurologists. The evaluation findings show that CDSS can help physicians in the accurate and timely diagnosis of MS by using the rule-based method.

Atypical adult-onset subacute sclerosing panencephalitis

Although subacute sclerosing panencephalitis is almost exclusively a childhood disease, it can occur in adults as well. We present an atypical case of adult-onset subacute sclerosing panencephalitis. The disease was characterized by prolonged insidious course followed by accelerated and aggressive phase, atypical EEG findings, and absence of myoclonic jerks. The diagnostic and treatment-related pitfalls are discussed.

Age at Menarche and Risk of Multiple Sclerosis: A Prospective Cohort Study Based on the Danish National Birth Cohort

Few studies have addressed the possible association between age at menarche and multiple sclerosis (MS), and results are conflicting. We studied this issue in a large prospective cohort study. The study cohort comprised 77,330 women included in the Danish National Birth Cohort (1996-2002). Information on menarcheal age was ascertained at the first interview, which took place in the 16th week of pregnancy. Women were followed for MS from the first interview to December 31, 2011. Associations between age at menarche and risk of MS were evaluated with hazard ratios and 95% confidence intervals using Cox proportional hazards regression models. Overall, 226 women developed MS during an average follow-up period of 11.7 years. Age at menarche among women with MS was generally lower than that among women without MS (Wilcoxon rank-sum test; P = 0.002). We observed an inverse association between age at menarche and MS risk. For each 1-year increase in age at menarche, risk of MS was reduced by 13% (hazard ratio = 0.87, 95% confidence interval: 0.79, 0.96). Early age at menarche appears to be associated with an increased risk of MS. The mechanisms behind this association remain to be established.

A challenging diagnosis of late-onset tumefactive multiple sclerosis associated to cervicodorsal syringomyelia: doubtful CT, MRI, and bioptic findings: Case report and literature review

BACKGROUND

Tumefactive multiple sclerosis (MS) is an unusual variant of demyelinating disease characterized by lesions with pseudotumoral appearance on radiological imaging mimicking other space-occupying lesions, such as neoplasms, infections, and infarction. Especially when the patient's medical history is incompatible with MS, the differential diagnosis between these lesions constitutes a diagnostic challenge often requiring histological investigation. An older age at onset makes distinguishing tumefactive demyelinating lesion (TDL) from tumors even more challenging.

METHODS

We report a case of brain TDL as the initial manifestation of late-onset MS associated with cervico-dorsal syringomyelia. A 66-year-old Caucasian woman with a 15-day history headache was referred to our hospital because of the acute onset of paraphasia. She suffered from noncommunicating syringomyelia associated to basilar impression and she reported a 10-year history of burning dysesthesia of the left side of the chest extended to the internipple line level.

RESULTS

Computed tomography (CT) and magnetic resonance imaging (MRI) examinations revealed a left frontal lesion with features suspicious for a tumor. Given the degree of overlap with other pathologic processes, CT and MRI findings failed to provide an unambiguous diagnosis; furthermore, because of the negative cerebrospinal fluid analysis for oligoclonal bands, the absence of other lesions, and the heightened suspicion of neoplasia, the clinicians opted to perform a stereotactic biopsy. Brain specimen analysis did not exclude the possibility of perilesional reactive gliosis and the patient, receiving anitiedemigen therapy, was monthly followed up. In the meanwhile, the second histological opinion of the brain specimen described the absence of pleomorphic glial cells indicating a tumor. These findings were interpreted as destructive inflammatory demyelinating disease and according to the evolution of MRI lesion burden, MS was diagnosed.

CONCLUSION

TDL still remains a problematic entity clinically, radiologically, and sometimes even pathologically. A staged follow-up is necessary, and in our case, it revealed to be the most important attitude to define the nature of the lesion, confirming the classic MS diagnostic criteria of disseminate lesions in time and space. We discuss our findings according to the recent literature.