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Traboulsee A, Li DKB. Routine MR Imaging Protocol and Standardization in Central Nervous System Demyelinating Diseases. Neuroimaging Clin N Am 2024; 34:317-334. [PMID: 38942519 DOI: 10.1016/j.nic.2024.03.002] [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: 06/30/2024]
Abstract
Standardized MR imaging protocols are important for the diagnosis and monitoring of patients with multiple sclerosis (MS) and the appropriate use of MR imaging in routine clinical practice. Advances in using MR imaging to establish an earlier diagnosis of MS, safety concerns regarding intravenous gadolinium-based contrast agents, and the value of spinal cord MR imaging for diagnostic, prognostic, and monitoring purposes suggest a changing role of MR imaging for the management and care of MS patients. The MR imaging protocol emphasizes 3 dimensional acquisitions for optimal comparison over time.
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Affiliation(s)
- Anthony Traboulsee
- Department of Medicine (Neurology), University of British Columbia, University of British Columbia Hospital, 2211 Wesbrook Mall, Room S113, Vancouver, British Columbia V6T 2B5, Canada.
| | - David K B Li
- Department of Radiology, University of British Columbia, University of British Columbia Hospital, 2211 Wesbrook Mall, Vancouver, British Columbia V6T 2B5, Canada
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2
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Gonçalves R, De Decker S, Walmsley G, Maddox TW. Prognosis in meningoencephalitis of unknown origin in dogs: Risk factors associated with survival, clinical relapse, and long-term disability. J Vet Intern Med 2024; 38:1583-1590. [PMID: 38483069 PMCID: PMC11099754 DOI: 10.1111/jvim.17037] [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: 09/13/2023] [Accepted: 02/26/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Meningoencephalitis of unknown origin (MUO) comprises a group of noninfectious inflammatory diseases affecting the central nervous system of dogs. Previous studies have reported individual risk factors for survival but prognostication for MUO remains challenging. OBJECTIVES Identify clinical prognostic variables in dogs with MUO. ANIMALS A retrospective study of 447 dogs presented to 2 UK referral hospitals and diagnosed with MUO. METHODS Medical records of dogs diagnosed with MUO were retrospectively reviewed. Multivariable logistic regression was used for the identification of risk factors for survival and Cox proportional hazards analysis for the identification of risk factors for clinical relapse. RESULTS Eighty-two percent (366/447) of dogs with presumptive MUO survived to discharge and 63.5% (284/447) were alive at 6 months; 36% of the latter (103/284) had persistent neurological deficits. Breed (pugs; P = .03), epileptic seizures (P < .001), paresis (P < .001), and higher neurodisability scale (NDS) score (P < .001) at presentation were negatively associated with survival to 6 months. Dogs with persistent deficits had higher NDS scores on presentation (P = .001). Median follow-up time was 11 months (interquartile range [IQR], 1-24) and 50.6% (160/316) relapsed during treatment (median time to relapse, 7 months; IQR, 2-15). Incomplete resolution of the clinical signs during the 6 months after diagnosis (P < .001), higher NDS score (P < .001), and longer duration of the clinical signs (P < .001) were associated with relapse. CONCLUSIONS AND CLINICAL IMPORTANCE Knowledge of risk factors associated with survival, incomplete recovery and clinical relapse in MUO can help guide monitoring and treatment and improve owner communications regarding prognosis for this debilitating disease.
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Affiliation(s)
- Rita Gonçalves
- Department of Veterinary ScienceSmall Animal Teaching Hospital, University of LiverpoolNestonUK
- Department of Musculoskeletal and Ageing ScienceInstitute of Lifecourse and Medical Sciences, University of LiverpoolNestonUK
| | - Steven De Decker
- Department of Clinical Science and ServicesRoyal Veterinary College, University of LondonHatfieldUK
| | - Gemma Walmsley
- Department of Veterinary ScienceSmall Animal Teaching Hospital, University of LiverpoolNestonUK
- Department of Musculoskeletal and Ageing ScienceInstitute of Lifecourse and Medical Sciences, University of LiverpoolNestonUK
| | - Thomas W. Maddox
- Department of Veterinary ScienceSmall Animal Teaching Hospital, University of LiverpoolNestonUK
- Department of Musculoskeletal and Ageing ScienceInstitute of Lifecourse and Medical Sciences, University of LiverpoolNestonUK
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3
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Tortosa-Carreres J, Quiroga-Varela A, Castillo-Villalba J, Piqueras-Rodríguez M, Ramió-Torrenta L, Cubas-Núñez L, Gasqué-Rubio R, Quintanilla-Bordas C, Huertas-Pons JM, Miguela A, Casanova B, Laiz-Marro B, Pérez-Miralles FC. Improving the efficiency of free kappa light chains as diagnostic biomarker of Multiple Sclerosis by using a novel algorithm. Mult Scler Relat Disord 2023; 79:104997. [PMID: 37714099 DOI: 10.1016/j.msard.2023.104997] [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: 08/01/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Intrathecal immunoglobulin synthesis (ITS) plays a crucial role in the diagnosis of multiple sclerosis (MS). Traditionally, the gold standard method for detecting ITS has been through the analysis of oligoclonal bands (OCB). However, the paradigm has shifted with the introduction of the free kappa light chains (FKLC) method. In fact, a recent consensus recommends evaluating FKLC index (FKLCi) as the primary approach and reserving oligoclonal bands with borderline results. The objective of our study is to investigate the diagnostic efficiency of combining FKLC with other methods to predict ITS while minimizing the reliance on OCB. METHODS A total of 192 patients were included in the study, consisting of 145 individuals diagnosed with multiple sclerosis (pwMS) and 46 with other neurological diseases (controls). Among the MS cases, 100 patients were assigned to the Training Cohort (TC), while an external Validation Cohort (VC) comprised of 45 MS patients was established. Diagnostic efficiency was assessed for FKLCi, OCB, Link index, and the Reiber formula for IgG and FKLC. Optimal cutoff values for Link index and FKLCi were also determined. The last procedure was developed for diverse algorithms using the parameters mentioned above, which included the optimal cutoffs previously obtained. The calculations were conducted independently for both the TC and the VC, as well as for a composite cohort formed by combining data from all patients (OC) RESULTS: One algorithm, named KRO, was developed based on the determination of FKLCi and Reiber Formula as the primary diagnostic parameters. For cases where the FKLCi result was mildly increased, OCB was utilized as a supplementary test. The KRO algorithm demonstrated superior diagnostic accuracy in the OC (89%), resulting in a reduction of OCB consumption by 91%. DISCUSSION The KRO algorithm demonstrated superior sensitivity and accuracy although lower specificity and NPV compared to the use of FKLCi and OCB alone. The present research aligns with the new consensus recommendations regarding the diagnostic approach. Our findings indicate that employing a combined marker approach via KRO could prove to be a proficient screening tool for multiple sclerosis. This approach also holds the potential to address inherent limitations associated with each individual marker. However, to further validate and solidify the efficacy of our algorithm, additional studies involving larger cohorts are warranted.
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Affiliation(s)
- Jordi Tortosa-Carreres
- Laboratory Department, La Fe University and Polytechnic Hospital, Valencia 46026, Spain; Medicine Department, University of Valencia, Valencia 46010, Spain.
| | - Anna Quiroga-Varela
- Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Jessica Castillo-Villalba
- Grupo de investigación en Neuroinmunología, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, España; Medicine Department, University of Valencia, Valencia 46010, Spain
| | - Mónica Piqueras-Rodríguez
- Laboratory Department, La Fe University and Polytechnic Hospital, Valencia 46026, Spain; Medicine Department, University of Valencia, Valencia 46010, Spain
| | - Lluís Ramió-Torrenta
- Girona Neuroimmumology and Multiple Sclerosis Unit, Neurology Department, Dr. Josep Trueta University Hospital and Santa Caterina Hospital, Girona, Spain; Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain; Medical Sciences Department, University of Girona, Girona, Spain
| | - Laura Cubas-Núñez
- Grupo de investigación en Neuroinmunología, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, España
| | - Raquel Gasqué-Rubio
- Grupo de investigación en Neuroinmunología, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, España; Medicine Department, University of Valencia, Valencia 46010, Spain
| | - Carlos Quintanilla-Bordas
- Neurology Department, La Fe University and Polytechnic Hospital, Valencia 46026, Spain; Grupo de investigación en Neuroinmunología, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, España
| | - Joana María Huertas-Pons
- Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Albert Miguela
- Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Bonaventura Casanova
- Neurology Department, La Fe University and Polytechnic Hospital, Valencia 46026, Spain; Grupo de investigación en Neuroinmunología, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, España
| | - Begoña Laiz-Marro
- Laboratory Department, La Fe University and Polytechnic Hospital, Valencia 46026, Spain
| | - Francisco Carlos Pérez-Miralles
- Neurology Department, La Fe University and Polytechnic Hospital, Valencia 46026, Spain; Grupo de investigación en Neuroinmunología, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, España
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Abstract
The multiple sclerosis (MS) neurotherapeutic landscape is rapidly evolving. New disease-modifying therapies (DMTs) with improved efficacy and safety, in addition to an expanding pipeline of agents with novel mechanisms, provide more options for patients with MS. While treatment of MS neuroinflammation is well tailored in the existing DMT armamentarium, concerted efforts are currently underway for identifying neuropathological targets and drug discovery for progressive MS. There is also ongoing research to develop agents for remyelination and neuroprotection. Further insights are needed to guide DMT initiation and sequencing as well as to determine the role of autologous stem cell transplantation in relapsing and progressive MS. This review provides a summary of these updates.
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Affiliation(s)
- Moein Amin
- Cleveland Clinic, Department of Neurology, Cleveland, OH 44195, USA
| | - Carrie M Hersh
- Cleveland Clinic, Lou Ruvo Center for Brain Health, Las Vegas, NV 89106, USA
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Van Wijmeersch B, Hartung HP, Vermersch P, Pugliatti M, Pozzilli C, Grigoriadis N, Alkhawajah M, Airas L, Linker R, Oreja-Guevara C. Using personalized prognosis in the treatment of relapsing multiple sclerosis: A practical guide. Front Immunol 2022; 13:991291. [PMID: 36238285 PMCID: PMC9551305 DOI: 10.3389/fimmu.2022.991291] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
The clinical course of multiple sclerosis (MS) is highly variable among patients, thus creating important challenges for the neurologist to appropriately treat and monitor patient progress. Despite some patients having apparently similar symptom severity at MS disease onset, their prognoses may differ greatly. To this end, we believe that a proactive disposition on the part of the neurologist to identify prognostic “red flags” early in the disease course can lead to much better long-term outcomes for the patient in terms of reduced disability and improved quality of life. Here, we present a prognosis tool in the form of a checklist of clinical, imaging and biomarker parameters which, based on consensus in the literature and on our own clinical experiences, we have established to be associated with poorer or improved clinical outcomes. The neurologist is encouraged to use this tool to identify the presence or absence of specific variables in individual patients at disease onset and thereby implement sufficiently effective treatment strategies that appropriately address the likely prognosis for each patient.
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Affiliation(s)
- Bart Van Wijmeersch
- Universitair Multiple Sclerosis (MS) Centrum, Hasselt-Pelt, Belgium
- Noorderhart, Revalidatie & Multiple Sclerosis (MS), Pelt, Belgium
- REVAL & BIOMED, Hasselt University, Hasselt, Belgium
- *Correspondence: Bart Van Wijmeersch,
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Palacky University Olomouc, Olomouc, Czechia
| | - Patrick Vermersch
- University Lille, Inserm U1172 LilNCog, Centre Hospitalier Universitaire (CHU) Lille, Fédératif Hospitalo-Universitaire (FHU) Precise, Lille, France
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
- Unit of Clinical Neurology, San Anna University Hospital, Ferrara, Italy
| | - Carlo Pozzilli
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Nikolaos Grigoriadis
- B’ Department of Neurology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mona Alkhawajah
- Neuroscience Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Laura Airas
- Turku University Hospital and University of Turku, Turku, Finland
| | - Ralf Linker
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Cliínico San Carlos (IDISSC), Madrid, Spain
- Department of Medicine, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Effectiveness and Safety of Early High-Efficacy Versus Escalation Therapy in Relapsing-Remitting Multiple Sclerosis in Argentina. Clin Neuropharmacol 2022; 45:45-51. [DOI: 10.1097/wnf.0000000000000503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Bsteh G, Hegen H, Berek K, Altmann P, Auer M, Di Pauli F, Haider L, Leutmezer F, Rommer P, Walchhofer LM, Wurth S, Zinganell A, Deisenhammer F, Berger T. Olfactory threshold predicts treatment response in relapsing multiple sclerosis. Mult Scler 2022; 28:1541-1552. [PMID: 35282741 DOI: 10.1177/13524585221079744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Olfactory threshold (OT) is associated with short-term inflammatory activity in relapsing multiple sclerosis (RMS). Objective: We aimed to investigate OT for prediction of treatment response in RMS. Methods: In this 5-year prospective study on 123 RMS patients, OT was measured at disease-modifying treatment (DMT) initiation (M0), after 3 months (M3), and 12 months (M12) by Sniffin’ Sticks test. Primary endpoint was defined as an absence of relapse during the observation period, with Expanded Disability Status Scale (EDSS) progression and magnetic resonance imaging (MRI) activity being the secondary endpoints. Optimal cutoff values were determined by receiver operating characteristic analyses and their predictive value assessed by multivariable Cox regression models. Results: Higher OT scores at M0, M3, and M12 were independently associated with decreased relapse probability with the strongest risk reduction at M3 (hazard ratio (HR) = 0.44, p < 0.001). Improvement of OT scores from M0 to M3 (ΔOTM3) was also associated with reduced relapse risk (HR = 0.12, p < 0.001). OT score > 6.5 at M3 was the strongest predictor of relapse freedom (HR = 0.10, p < 0.001) with high diagnostic accuracy (positive predictive value (PPV) = 87%), closely followed by ΔOTM3 ⩾ 0.5 (HR = 0.12, p < 0.001, PPV = 86%). Conclusions: OT is an independent predictor of freedom of disease activity upon DMT initiation within 5 years and may be a useful biomarker of treatment response.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Haider
- Department of Neuroradiology, Medical University of Vienna, Vienna, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Sebastian Wurth
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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8
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Cristiano E, Abad P, Becker J, Carrá A, Correale J, Flores J, Fruns M, Garcea O, Garcia Bónitto J, Gracia F, Hamuy F, Navas C, Patrucco L, Rivera V, Velazquez M, Rojas JI. Multiple sclerosis care units in Latin America: Consensus recommendations about its objectives and functioning implementation. J Neurol Sci 2021; 429:118072. [PMID: 34509134 DOI: 10.1016/j.jns.2021.118072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/23/2021] [Accepted: 09/05/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Currently, there are several reasons to promote worldwide the concept of multiple sclerosis care units (MSCU) for a better management of affected patients. Ideally, the MSCU should have some human and technical resources that distinguish and improve the care of affected patients; however, local, and regional aspects should be considered when recommending how these units should operate. The objective of these consensus recommendations was to review how MSCU should work in Latin America to improve long-term outcomes in MS patients. METHODS A panel of neurology experts from Latin America dedicated to the diagnosis and care of MS patients gathered virtually during 2019 and 2020 to carry out a consensus recommendation about objectives and functioning implementation of MSCU in Latin America. To achieve consensus, the methodology of "formal consensus-RAND/UCLA method" was used. RESULTS Recommendations focused on the objectives, human and technical resources, and the general functioning that MSCU should have in Latin America. CONCLUSIONS The recommendations of these consensus guidelines attempt to optimize the health care and management of MS patients by setting how MSCU should work in our region.
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Affiliation(s)
- Edgardo Cristiano
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Patricio Abad
- Servicio Neurologia, Hospital Metropolitano de Quito, Ecuador, Profesor de Neurología PUCE, Ecuador
| | - Jefferson Becker
- Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Adriana Carrá
- MS Section Hospital Britanico Buenos Aires, Argentina; Neurociencias Fundación Favaloro/INECO, Buenos Aires, Argentina
| | | | - José Flores
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, Mexico; Centro Neurológico ABC Santa Fé, Ciudad de México, Mexico
| | | | - Orlando Garcea
- Clínica de Esclerosis Múltiple, Hospital Ramos Mejía, Buenos Aires, Argentina
| | | | - Fernando Gracia
- Clinica de Esclerosis Multiple, Servicio de Neurologia Hospital Santo Tomas, Panama. Universidad Interamericana de Panama, Panama
| | - Fernando Hamuy
- Departamento de Neurologia, Hospital IMT, Paraguay; Departamento de Neurologia de Diagnóstico Codas Thompson, Paraguay
| | - Cárlos Navas
- Clinica Enfermedad Desmielinizante Clinica Universitaria Colombia, Colombia
| | - Liliana Patrucco
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Argentina
| | | | | | - Juan Ignacio Rojas
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina; Servicio de Neurología, Hospital Universitario de CEMIC, Buenos Aires, Argentina.
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9
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Arslan B, Arslan GA, Tuncer A, Karabudak R, Dinçel AS. Evaluation of Thiol Homeostasis in Multiple Sclerosis and Neuromyelitis Optica Spectrum Disorders. Front Neurol 2021; 12:716195. [PMID: 34526962 PMCID: PMC8435830 DOI: 10.3389/fneur.2021.716195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/12/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives: The aim of this pilot study was to evaluate dynamic thiol-disulfide homeostasis as a novel oxidative stress parameter in multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) to better understand the role of thiol homeostasis in neuroimmunological diseases. Methods: A total of 85 participants were included in this study, consisting of 18 healthy controls, 52 patients diagnosed with MS, seven with NMOSD, and eight with MOGAD. We measured total thiol (–SH+-S–S–) and native thiol (–SH) levels in the serum of all the participants, and in a subset of patients (n = 11), these parameters were investigated in paired cerebrospinal fluid (CSF) and serum samples. Dynamic disulfide concentrations were calculated separately. Finally, we determined if there was any relationship between clinical features and dynamic thiol homeostasis. Results: There was a statistically significant difference between serum and CSF levels of biomarkers of thiol homeostasis. Serum total thiol (317.88 ± 66.04) and native thiol (211.61 ± 44.15) levels were significantly lower in relapsed patients compared to those in remission (368.84 ± 150.36 vs. 222.52 ± 70.59, respectively). Conclusions: Oxidative stress plays a crucial role in the physiopathology of neuroimmunological diseases. Thiol homeostasis may be useful for monitoring disease activity.
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Affiliation(s)
- Burak Arslan
- Department of Medical Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey.,Department of Medical Biochemistry, Erciş State Hospital, Van, Turkey
| | | | - Aslı Tuncer
- Department of Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Rana Karabudak
- Department of Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Aylin Sepici Dinçel
- Department of Medical Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey
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10
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Radandish M, Khalilian P, Esmaeil N. The Role of Distinct Subsets of Macrophages in the Pathogenesis of MS and the Impact of Different Therapeutic Agents on These Populations. Front Immunol 2021; 12:667705. [PMID: 34489926 PMCID: PMC8417824 DOI: 10.3389/fimmu.2021.667705] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 07/31/2021] [Indexed: 01/03/2023] Open
Abstract
Multiple sclerosis (MS) is a demyelinating inflammatory disorder of the central nervous system (CNS). Besides the vital role of T cells, other immune cells, including B cells, innate immune cells, and macrophages (MФs), also play a critical role in MS pathogenesis. Tissue-resident MФs in the brain’s parenchyma, known as microglia and monocyte-derived MФs, enter into the CNS following alterations in CNS homeostasis that induce inflammatory responses in MS. Although the neuroprotective and anti-inflammatory actions of monocyte-derived MФs and resident MФs are required to maintain CNS tolerance, they can release inflammatory cytokines and reactivate primed T cells during neuroinflammation. In the CNS of MS patients, elevated myeloid cells and activated MФs have been found and associated with demyelination and axonal loss. Thus, according to the role of MФs in neuroinflammation, they have attracted attention as a therapeutic target. Also, due to their different origin, location, and turnover, other strategies may require to target the various myeloid cell populations. Here we review the role of distinct subsets of MФs in the pathogenesis of MS and different therapeutic agents that target these cells.
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Affiliation(s)
- Maedeh Radandish
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parvin Khalilian
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nafiseh Esmaeil
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.,Environment Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
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11
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Bansback N, Chiu JA, Metcalfe R, Lapointe E, Schabas A, Lenzen M, Traboulsee A, Lynd LD, Carruthers R. Preliminary testing of a patient decision aid for patients with relapsing-remitting multiple sclerosis. Mult Scler J Exp Transl Clin 2021; 7:20552173211029966. [PMID: 34350027 PMCID: PMC8287362 DOI: 10.1177/20552173211029966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background Multiple first-line disease modifying therapies (DMTs) are available for
relapsing-remitting multiple sclerosis (RRMS), each with different
characteristics. We developed an interactive patient decision aid (PtDA) to
promote informed shared decision-making (SDM). Objective To test the preliminary effectiveness of the PtDA in participants with
RRMS. Methods Knowledge, and decisional conflict were measured pre- and post-
implementation of the PtDA, SDM after the consultation, and 6-month
treatment patterns were observed. Differences in scores were analyzed using
descriptive statistics and paired t-tests. Qualitative interviews with
patients and neurologists were analyzed using thematic analysis. Results 52 participants were recruited: most were female (81%), 40 years of age or
younger (62%), and had experienced MS for less than 5 years (56%). After
participants used the PtDA, there was a significant improvement in
decisional conflict (change = 1.00; p < 0.001) and
knowledge (change = 2.15, p < 0.001). Nearly all patients wanted SDM, and
25 (56%) reported this occurred in their consult. Qualitative results
suggested the PtDA supported both patients and neurologists in making
decisions. Conclusion This pilot study suggests that PtDA use helps RRMS patients and their
clinician select a DMT. Future studies will assess the feasibility of
implementation and the impact of the PtDA on timely DMT initiation and
longer-term adherence.
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Affiliation(s)
- Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Judy A Chiu
- Centre for Health Evaluation & Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
| | - Rebecca Metcalfe
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | | | - Alice Schabas
- Division of Neurology, University of British Columbia, Vancouver, Canada
| | | | - Anthony Traboulsee
- Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Larry D Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, Canada
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12
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Luetic GG, Menichini ML, Fernández Ó. Oral administration of methylprednisolone powder for intravenous injection dissolved in water to treat MS and NMOSD relapses during COVID-19 pandemic in a real-world setting. Mult Scler Relat Disord 2021; 54:103148. [PMID: 34280680 PMCID: PMC8276560 DOI: 10.1016/j.msard.2021.103148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/25/2021] [Accepted: 07/08/2021] [Indexed: 11/19/2022]
Abstract
Background Upon the COVID-19 pandemic emergence, safety concerns and logistic drawbacks stimulated the search for alternatives to pulse therapy at infusion centres to treat multiple sclerosis relapses. Objective To describe our experience treating multiple sclerosis relapses with a dilute injectable methylprednisolone powder orally administered, in a safe home-based environment and with totally virtual assessment and follow up via telemedicine. Methods Descriptive observational, retrospective, single-centre, open label, study in the real-world setting. Results Between August 2020 and March 2021, ten multiple sclerosis patients and one neuromyelitis optica spectrum disease patient, regularly assisted at our multiple sclerosis centre in Argentina, experienced twelve disease relapses (nine moderate/severe relapses and three mild relapses) and were treated with the oral dilute of injectable methylprednisolone powder pulses with good efficacy as well as adequate tolerance and safety profile. Conclusions The oral pulse therapy based on the methylprednisolone powder dilution we describe is simple and comfortable to administer and can be an option in countries like Argentina, where the oral methylprednisolone formulation is not marketed. In these pandemic times, a home based and virtually monitored pulse therapy could represent a safe and effective alternative to manage relapses while minimizing the patient's risk of exposure to SARS-CoV-2.
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Affiliation(s)
| | | | - Óscar Fernández
- Department of Pharmacology, Faculty of Medicine, University of Malaga. Instituto de Investigación Biomédica de Málaga (IBIMA), Regional University Hospital of Malaga, Malaga, Spain
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13
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Kohler M, Kohler E, Vrech C, Pappolla A, Miguez J, Patrucco L, Correale J, Marrodan M, Gaitán MI, Fiol M, Negrotto L, Ysrraelit MC, Cristiano E, Carrá A, Steinberg J, Martinez AD, Curbelo MC, Cohen L, Alonso R, Garcea O, Pita C, Silva B, Luetic G, Deri N, Balbuena ME, Tkachuk V, Carnero Contentti E, Lopez PA, Pettinicchi JP, Caride A, Burgos M, Leguizamon F, Knorre E, Piedrabuena R, Barboza A, Liwacki S, Nofal P, Volman G, Alvez Pinheiro A, Hryb J, Tavolini D, Blaya P, Recchia L, Mainella C, Silva E, Blanche J, Tizio S, Saladino ML, Caceres F, Fernandez Liguori N, Lazaro L, Zanga G, Parada Marcilla M, Fracaro ME, Pagani Cassara F, Vazquez G, Sinay V, Sgrilli G, Divi P, Jacobo M, Reich E, Cabrera LM, Menichini ML, Coppola M, Martos I, Viglione JP, Jose G, Bestoso S, Manzi R, Giunta D, Doldan ML, Alonso Serena M, Rojas JI. Aggressive multiple sclerosis in Argentina: Data from the nationwide registry RelevarEM. J Clin Neurosci 2021; 89:360-364. [PMID: 34088579 DOI: 10.1016/j.jocn.2021.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/09/2020] [Accepted: 05/23/2021] [Indexed: 11/16/2022]
Abstract
The objectives of the present study were to describe the frequency of aggressive multiple sclerosis (aMS) as well as to compare clinical and radiological characteristics in aMS and non-aMS patients included in RelevarEM (NCT03375177). METHODS The eligible study population and cohort selection included adult-onset patients (≥18 years) with definite MS. AMS were defined as those reaching confirmed EDSS ≥ 6 within 5 years from symptom onset. Confirmation was achieved when a subsequent EDSS ≥ 6 was recorded at least six months later but within 5 years of the first clinical presentation. AMS and non-aMS were compared using the χ2 test for categorical and the Mann-Whitney for continuous variables at MS onset and multivariable analysis was performed using forward stepwise logistic regression with baseline characteristics at disease onset. RESULTS A total of 2158 patients with MS were included: 74 aMS and 2084 non-aMS. The prevalence of aMS in our cohort was 3.4% (95%CI 2.7-4.2). AMS were more likely to be male (p = 0.003), older at MS onset (p < 0.001), have primary progressive MS (PPMS) phenotype (p = 0.03), multifocal presentation (p < 0.001), and spinal cord as well as infratentorial lesions at MRI during disease onset (p = 0.004 and p = 0.002, respectively). CONCLUSION 3.4% of our patient population could be considered aMS. Men, patients older at symptom onset, multifocal presentation, PPMS phenotype, and spinal cord as well as brainstem lesions on MRI at clinical presentation all had higher odds of having aMS.
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Affiliation(s)
| | | | - Carlos Vrech
- Departamento de Enfermedades desmielinizantes - Sanatorio Allende, Córdoba, Argentina
| | - Agustín Pappolla
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jimena Miguez
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Liliana Patrucco
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | | | - Marcela Fiol
- Departamento de Neurología - FLENI, CABA, Argentina
| | | | | | | | - Adriana Carrá
- Sección de Enfermedades Desmielinizantes - Hospital Británico, CABA, Argentina; Instituto de Neurociencias - Fundación Favaloro/INECO, CABA, Argentina
| | - Judith Steinberg
- Sección de Enfermedades Desmielinizantes - Hospital Británico, CABA, Argentina
| | | | - María C Curbelo
- Sección de Enfermedades Desmielinizantes - Hospital Británico, CABA, Argentina
| | - Leila Cohen
- Centro Universitario de Esclerosis Múltiple - Hospital Dr. J. M. Ramos Mejía. Facultad de Medicina - UBA, CABA, Argentina
| | - Ricardo Alonso
- Centro Universitario de Esclerosis Múltiple - Hospital Dr. J. M. Ramos Mejía. Facultad de Medicina - UBA, CABA, Argentina; Sanatorio Güemes, CABA, Argentina
| | - Orlando Garcea
- Centro Universitario de Esclerosis Múltiple - Hospital Dr. J. M. Ramos Mejía. Facultad de Medicina - UBA, CABA, Argentina
| | - Cecilia Pita
- Centro Universitario de Esclerosis Múltiple - Hospital Dr. J. M. Ramos Mejía. Facultad de Medicina - UBA, CABA, Argentina
| | - Berenice Silva
- Centro Universitario de Esclerosis Múltiple - Hospital Dr. J. M. Ramos Mejía. Facultad de Medicina - UBA, CABA, Argentina
| | | | - Norma Deri
- Centro de Investigaciones Diabaid, CABA, Argentina
| | - Maria E Balbuena
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología - Hospital de Clínicas José de San Martín, CABA, Argentina
| | - Verónica Tkachuk
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología - Hospital de Clínicas José de San Martín, CABA, Argentina
| | | | - Pablo A Lopez
- Neuroimmunology Unit, Department of Neuroscience, Hospital Aleman, Buenos Aires, Argentina
| | - Juan P Pettinicchi
- Neuroimmunology Unit, Department of Neuroscience, Hospital Aleman, Buenos Aires, Argentina
| | - Alejandro Caride
- Neuroimmunology Unit, Department of Neuroscience, Hospital Aleman, Buenos Aires, Argentina
| | - Marcos Burgos
- Servicio de Neurología - Hospital San Bernardo, Salta, Argentina
| | | | - Eduardo Knorre
- Hospital de Agudos, Dr. Teodoro Álvarez, CABA, Argentina
| | - Raúl Piedrabuena
- Clínica Universitaria Reina Fabiola, Córdoba, Argentina; Instituto Lennox, Córdoba, Argentina
| | | | - Susana Liwacki
- Clínica Universitaria Reina Fabiola, Córdoba, Argentina; Servicio de Neurología - Hospital Córdoba, Córdoba, Argentina
| | - Pedro Nofal
- Hospital de Clínicas Nuestra Señora del Carmen, San Miguel de Tucumán, Tucumán, Argentina
| | - Gabriel Volman
- Hospital Presidente Perón de Avellaneda, Buenos Aires, Argentina
| | | | - Javier Hryb
- Servicio de Neurología - Hospital Carlos G. Durand, CABA, Argentina
| | - Dario Tavolini
- INECO Neurociencias Oroño - Fundación INECO, Rosario, Santa Fe, Argentina
| | | | | | | | - Emanuel Silva
- Predigma - Centro de Medicina Preventiva, Posadas, Misiones, Argentina
| | - Jorge Blanche
- IRNEC (Instituto Regional de Neurociencias), San Miguel de Tucumán, Argentina
| | | | | | | | | | | | - Gisela Zanga
- Unidad asistencial César Milstein, CABA, Argentina
| | | | | | | | - Guido Vazquez
- Instituto de Neurociencias - Fundación Favaloro/INECO, CABA, Argentina
| | - Vladimiro Sinay
- Instituto de Neurociencias - Fundación Favaloro/INECO, CABA, Argentina
| | | | - Pablo Divi
- RIAPEM (Red Integral Asistencial al Paciente con Esclerosis Múltiple), Santiago del Estero, Argentina
| | - Miguel Jacobo
- RIAPEM (Red Integral Asistencial al Paciente con Esclerosis Múltiple), Santiago del Estero, Argentina
| | - Edgardo Reich
- Servicio de Neurologia, Hospital Municipal Dr. Julio Méndez, CABA, Argentina
| | - Lorena M Cabrera
- Servicio de Neurología - Hospital Militar Central, CABA, Argentina; Hospital Militar Campo de Mayo, CABA, Argentina
| | | | - Mariano Coppola
- Servicio de Neurología, Hospital Ramón Santamarina, Tandil, Buenos Aires, Argentina
| | - Ivan Martos
- Clinica San Jorge, Ushuaia, Tierra del fuego, Argentina
| | | | - Gustavo Jose
- Sección de enfermedades desmielinizantes, Servicio de Neurología, Hospital Padilla, Tucumán, Argentina
| | - Santiago Bestoso
- Servicio Neurología - Hospital Escuela José F. de San Martín Corrientes, Corrientes, Argentina
| | | | - Diego Giunta
- Servicio de clínica médica, Hospital Italiano de Buenos Aires, CABA, Argentina
| | - Maria L Doldan
- Centro de esclerosis múltiple de Buenos Aires, CABA, Argentina
| | | | - Juan I Rojas
- Centro de esclerosis múltiple de Buenos Aires, CABA, Argentina; Servicio de Neurología, Hospital Universitario de CEMIC, CABA, Argentina.
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Bsteh G, Hegen H, Altmann P, Auer M, Berek K, Di Pauli F, Leutmezer F, Rommer P, Wurth S, Zinganell A, Zrzavy T, Deisenhammer F, Berger T. Retinal layer thinning predicts treatment failure in relapsing multiple sclerosis. Eur J Neurol 2021; 28:2037-2045. [PMID: 33735479 PMCID: PMC8251588 DOI: 10.1111/ene.14829] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
Background and purpose Peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell plus inner plexiform layer (GCIPL) thinning are markers of neuroaxonal degeneration in multiple sclerosis (MS), which is reduced by disease‐modifying treatment (DMT). We aimed to investigate the potential of pRNFL and GCIPL thinning for prediction of DMT failure in relapsing MS (RMS). Methods In this 4‐year prospective observational study on 113 RMS patients, pRNFL and GCIPL were measured at DMT initiation and after 12 months (M12) and 24 months (M24). Treatment failure was defined as 6‐month confirmed Expanded Disability Status Scale (EDSS) progression and/or Symbol Digit Modalities Test (SDMT) worsening. Optimal cutoff values for predicting treatment failure were determined by receiver operating characteristic analyses and hazard ratios (HRs) by multivariable Cox regression adjusting for age, sex, disease duration, EDSS/SDMT, and DMT class. Results Thinning of GCIPL >0.5 μm/year at M24 showed superior value for treatment failure prediction (HR: 4.5, 95% confidence interval [CI]: 1.8–7.6, p < 0.001; specificity 91%, sensitivity 81%), followed by GCIPL >0.5 μm at M12 (odds ratio [OR]: 3.9, 95% CI: 1.4–6.9, p < 0.001; specificity 85%, sensitivity 78%), and pRNFL ≥2 μm/year at M24 (OR: 3.7, 95% CI: 1.1–6.5, p = 0.023; specificity 84%, sensitivity 69%), whereas pRNFL at M12 was not predictive. Conclusions GCIPL, and to a lesser degree pRNFL, thinning predicts disability progression after DMT initiation and may be a useful and accessible biomarker of treatment failure in RMS.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sebastian Wurth
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Zrzavy
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Khamis F, Al Naabi H, Al Lawati A, Ambusaidi Z, Al Sharji M, Al Barwani U, Pandak N, Al Balushi Z, Al Bahrani M, Al Salmi I, Al-Zakwani I. Randomized controlled open label trial on the use of favipiravir combined with inhaled interferon beta-1b in hospitalized patients with moderate to severe COVID-19 pneumonia. Int J Infect Dis 2021; 102:538-543. [PMID: 33181328 PMCID: PMC7833906 DOI: 10.1016/j.ijid.2020.11.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To evaluate the therapeutic effectiveness of favipiravir combined with inhaled interferon beta-1b in adult patients hospitalized with moderate to severe COVID-19 pneumonia. METHODS A randomized, open-label controlled trial of oral favipiravir in adults hospitalized with moderate to severe COVID-19 pneumonia from June 22nd 2020 to August 13th 2020 was conducted. Patients were randomly assigned to receive either a combination of favipiravir with interferon beta-1b by inhalation aerosol or hydroxychloroquine (HCQ). The outcome endpoints included improvement in inflammatory markers, lower length of hospital stay (LOS), discharges and lower overall 14-day mortality. RESULTS A total of 89 patients underwent randomization with 49% (n = 44) assigned to favipiravir and 51% (n = 45) assigned HCQ. The overall mean age was 55 ± 14 years and 58% (n = 52) were males. There were no significant differences in the inflammatory biomarkers at hospital discharge between the two groups; C-reactive protein (p = 0.413), ferritin (p = 0.968), lactate dehydrogenase (p = 0.259) and interleukin 6 (p = 0.410). There were also no significant differences between the two groups with regards to the overall LOS (7 vs 7 days; p = 0.948), transfers to the ICU (18.2% vs 17.8%; p = 0.960), discharges (65.9% vs 68.9%; p = 0.764) and overall mortality (11.4% vs 13.3%; p = 0.778). CONCLUSIONS No differences in clinical outcomes were found between favipiravir plus inhaled interferon beta-1b and hydroxychloroquine in adults hospitalized with moderate to severe COVID-19 pneumonia.
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Affiliation(s)
- Faryal Khamis
- Infection Diseases Unit, Department of Medicine, Royal Hospital, Muscat, Oman.
| | - Hanan Al Naabi
- Acute Medicine Unit, Department of Medicine, Royal Hospital, Muscat, Oman.
| | - Adil Al Lawati
- Acute Medicine Unit, Department of Medicine, Royal Hospital, Muscat, Oman.
| | - Zaiyana Ambusaidi
- Acute Medicine Unit, Department of Medicine, Royal Hospital, Muscat, Oman.
| | | | | | - Nenad Pandak
- Infection Diseases Unit, Department of Medicine, Royal Hospital, Muscat, Oman.
| | - Zakariya Al Balushi
- Infection Diseases Unit, Department of Medicine, Royal Hospital, Muscat, Oman.
| | - Maher Al Bahrani
- Department of Anesthesia and Critical Care, Royal Hospital, Muscat, Oman.
| | - Issa Al Salmi
- Department of Nephrology, Royal Hospital, Muscat, Oman.
| | - Ibrahim Al-Zakwani
- Department of Pharmacology & Clinical Pharmacy, College of Medicine & Clinical Pharmacy, Sultan Qaboos University, Muscat, Oman.
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Bazi A, Baghbanian SM, Ghazaeian M, Saeedi M, Hendoiee N. Efficacy and safety of oral prednisolone tapering following intravenous methyl prednisolone in patients with multiple sclerosis relapses: A randomized, double-blind, placebo-controlled trial. Mult Scler Relat Disord 2020; 47:102640. [PMID: 33310419 DOI: 10.1016/j.msard.2020.102640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/19/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Relapse is one of the main features of multiple sclerosis (MS). Corticosteroids are the first line of management during MS relapse. Since tapering or non-tapering prednisolone after corticosteroid pulse has been a controversial issue, this clinical trial is designed to evaluate the efficacy and safety of the tapering regimen. METHODS Having been treated by intravenous methylprednisolone (IVMP) pulse, sixty-six patients with MS-relapse were randomly assigned to receive oral prednisolone tapering (OPT) or placebo. The regimen was administered in line with the study protocol and the dose was tapered over 20 days. Demographics and symptoms, impact on activities of daily living (ADL), and management procedures were recorded according to Assessing Relapse in Multiple Sclerosis (ARMS) Questionnaire. The incidence of adverse events was assessed using the same questionnaire. Patients' disability improvement was assessed using the Extended Disability Scale (EDSS) during relapse, and over the first, third, sixth months following treatment. RESULTS As shown by the results of the questionnaire, 75% reported that their ADL was not or minimally affected by OPT and there was no significant difference in terms of ADL after treatment between the two groups (p=0.3). The effect of treatment on return to the previous state of health (RSH) showed that there were no differences between the two groups of the study (p=0.5). The improvement of disability in the two groups of oral prednisolone and placebo did not indicate a difference in terms of EDSS in the first and third and six months (p = 0.5, p = 0.9, p=0.3, respectively). Also, the occurrence of some side effects such as weight gain (p = 0.000) and increased appetite (p = 0.004) was higher in the OPT group. CONCLUSION The findings of this study revealed that the efficacy of an OPT after a corticosteroid pulse is non-superior to IVMP plus only in case the safety and tolerability profile are comparable.
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Affiliation(s)
- Aliyeh Bazi
- Department of Clinical Pharmacy, Faculty of pharmacy, Mazandaran University of Medical Sciences, Mazandaran, Iran
| | | | - Monireh Ghazaeian
- Department of Clinical Pharmacy, Faculty of pharmacy, Mazandaran University of Medical Sciences, Mazandaran, Iran.
| | - Majid Saeedi
- Department of Pharmaceutics, Faculty of pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Narjes Hendoiee
- Department of Clinical Pharmacy, Faculty of pharmacy, Mazandaran University of Medical Sciences, Mazandaran, Iran
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Ng JY, Kishimoto V. Multiple sclerosis clinical practice guidelines provide few complementary and alternative medicine recommendations: A systematic review. Complement Ther Med 2020; 56:102595. [PMID: 33197670 DOI: 10.1016/j.ctim.2020.102595] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/16/2020] [Accepted: 10/13/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Complementary and alternative medicine (CAM) use is prevalent among individuals with multiple sclerosis (MS), yet the quantity and quality of CAM recommendations in MS clinical practice guidelines (CPGs) has not been assessed. The objective of this study was to determine the mention of CAM in MS CPGs and assess the quality of CAM recommendations. DESIGN/SETTING A systematic review was conducted to identify MS CPGs. MEDLINE, EMBASE and CINAHL were searched from 2008 to 2018. The Guidelines International Network and the National Center for Complementary and Integrative Health (NCCIH) websites were also searched. Eligible CPGs containing CAM recommendations published by non-profit agencies on the treatment of MS for adults were assessed for quality and reporting using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument. OUTCOME/RESULTS From 204 unique search results, six CPGs mentioned CAM and four made CAM recommendations. Scaled domain percentages from highest to lowest were clarity of presentation (90.3 % Overall, 83.3 % CAM), scope and purpose (87.5 % Overall, 86.8 % CAM), rigour of development (80.0 % Overall, 61.7 % CAM), applicability (55.2 % Overall, 44.3 % CAM), editorial independence (49.0 % Overall, 47.9 % CAM), and stakeholder involvement (55.6 % Overall, 39.6 % CAM). Quality varied within and across CPGs. Three of the four CPGs were recommended by both appraisers; one was recommended as "No" or "Yes with modifications". CONCLUSION CAM recommendations were only present in one third of all eligible CPGs. CPGs that scored highly can be used by patients and healthcare professionals as the basis for discussion about the use of CAM therapies for MS treatment/management. Although many people living with MS (PwMS) seek CAM therapies, few CPGs are available to provide guidance for clinicians and patients.
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Affiliation(s)
- Jeremy Y Ng
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Michael G. DeGroote Centre for Learning and Discovery, Room 2112, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada.
| | - Vanessa Kishimoto
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Michael G. DeGroote Centre for Learning and Discovery, Room 2112, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada.
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18
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Alshamrani F, Berger W, Alnajashi H, Payne MWC, Morrow SA. Potential of Timed 25-Foot Walk Values in Predicting Maximum Walking Distance in Persons with Multiple Sclerosis. Int J MS Care 2020; 22:215-218. [PMID: 33177957 DOI: 10.7224/1537-2073.2019-052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Expanded Disability Status Scale (EDSS) scores of 4.0 or greater are determined primarily by maximum walking distance (MWD). Estimation of MWD by persons with multiple sclerosis (MS) is often used due to the impracticality of formally walking a person with MS in a clinic setting. Previous studies have demonstrated discrepancies between estimated and actual MWDs. Whether Timed 25-Foot Walk test (T25FW) values can be used to predict MWD is currently unknown. This study aimed to determine whether T25FW time is predictive of MWD in persons with MS. Methods This study is a post hoc analysis of a previously described prospective cohort study. Persons with MS with an EDSS score of 3.5 to 5.5 were included. The participant's T25FW values and MWD were measured. Results Of the 38 adult participants (mean age, 50.8 years; 27 women [71%]), 24 (63%) had relapsing-remitting MS. The median EDSS score was 4.5 (range, 3.5-5.5). The T25FW times were divided into seven categories (<5.0, 5.0-5.9, 6.0-6.9, 7.0-7.9, 8.0-8.9, 9.0-9.9, and ≥10.0 seconds). The MWDs were divided into corresponding EDSS score categories: ≥500, 300-499, 200-299, 100-199, and ≤99 m. Ordinal logistic regression, when controlled for age, found the T25FW categories to be predictive of EDSS score (χ2 = 17.630, df = 7, P = .014). Conclusions The T25FW value may be used as a surrogate estimate of MWD. Further studies are needed to confirm the reliability of the T25FW in predicting MWD.
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Hamdy SM, Abdel-Naseer M, Shehata HS, Shalaby NM, Hassan A, Elmazny A, Shaker E, Nada MAF, Ahmed SM, Hegazy MI, Mourad HS, Abdelalim A, Magdy R, Othman AS, Mekkawy DA, Kishk NA. Management Strategies of Patients with Neuromyelitis Optica Spectrum Disorder During the COVID-19 Pandemic Era. Ther Clin Risk Manag 2020; 16:759-767. [PMID: 32884277 PMCID: PMC7443007 DOI: 10.2147/tcrm.s261753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/03/2020] [Indexed: 12/29/2022] Open
Abstract
The ongoing coronavirus (COVID-19) pandemic is a global health emergency of international concern and has affected management plans of many autoimmune disorders. Immunosuppressive and immunomodulatory therapies are pivotal in the management of neuromyelitis optica spectrum disorder (NMOSD), potentially placing patients at an increased risk of contracting infections such as COVID-19. The optimal management strategy of NMOSD during the COVID-19 era remains unclear. Here, however, we examined the evidence of NMOSD disease-modifying therapies (DMTs) use during the present period and highlighted different scenarios including treatment of relapses as well as initiation and maintenance of DMTs in order to optimize care of NMOSD patients in the COVID-19 era.
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Affiliation(s)
- Sherif M Hamdy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maged Abdel-Naseer
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hatem S Shehata
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nevin M Shalaby
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hassan
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Elmazny
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ehab Shaker
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona A F Nada
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sandra M Ahmed
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed I Hegazy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Husam S Mourad
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Abdelalim
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rehab Magdy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alshimaa S Othman
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Doaa A Mekkawy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nirmeen A Kishk
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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Hamdy SM, Abdel-Naseer M, Shehata HS, Hassan A, Elmazny A, Shalaby NM, Abokrysha NT, Kishk NA, Nada MAF, Ahmed SM, Hegazy MI, Mekkawy D, Mourad HS, Abdelalim A, Berger T. Managing Disease-Modifying Therapies and Breakthrough Activity in Multiple Sclerosis Patients During the COVID-19 Pandemic: Toward an Optimized Approach. Ther Clin Risk Manag 2020; 16:651-662. [PMID: 32801722 PMCID: PMC7398889 DOI: 10.2147/tcrm.s257714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/21/2020] [Indexed: 12/12/2022] Open
Abstract
The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has become a major public health challenge of global concern since December 2019, when the virus was recognized in Wuhan, the capital city of Hubei province in China and epicenter of the COVID-19 epidemic. Given the novelty of COVID-19 and the lack of specific anti-virus therapies, the current management is essentially supportive. There is an absence of consensus on guidelines or treatment strategies for complex disorders such as multiple sclerosis (MS), in which the risk of infections is higher than in the general population. This is due to the overall impairment of the immune system typical of autoimmune diseases, in addition to accumulation of disabilities, and the iatrogenic effect generated by corticosteroids and the recommended disease-modifying therapies (DMTs). DMTs have different modes of action, but all modulate and interfere with the patient's immune response, thereby raising concerns about adverse effects, such as an increased susceptibility to infections. In this review, we analyze the evidence for use of DMTs during the current critical period and ratify an algorithmic approach for management to optimize care between keeping DMTs, with their infection hazards, or coming off them, with the risk of disease activation. We also provide an algorithmic approach to the management of breakthrough activity during the COVID-19 pandemic.
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Affiliation(s)
- Sherif M Hamdy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maged Abdel-Naseer
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hatem S Shehata
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hassan
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Elmazny
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nevin M Shalaby
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Noha T Abokrysha
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nirmeen A Kishk
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona A F Nada
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sandra M Ahmed
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed I Hegazy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Doaa Mekkawy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Husam S Mourad
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Abdelalim
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Thomas Berger
- Neurology Department, Medical University of Vienna, Vienna, Austria
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21
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Patti F, Chisari CG, D'Amico E, Annovazzi P, Banfi P, Bergamaschi R, Clerici R, Conti MZ, Cortese A, Fantozzi R, Fischetti M, Frigo M, Gatto M, Immovilli P, Leoni S, Malucchi S, Maniscalco G, Marfia GA, Paolicelli D, Perini P, Serrati C, Sola P, Totaro R, Turano G, Valentino P, Zaffaroni M, Zuliani C, Centonze D. Clinical and patient determinants of changing therapy in relapsing-remitting multiple sclerosis (SWITCH study). Mult Scler Relat Disord 2020; 42:102124. [DOI: 10.1016/j.msard.2020.102124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 03/14/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022]
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22
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Sørensen PS, Centonze D, Giovannoni G, Montalban X, Selchen D, Vermersch P, Wiendl H, Yamout B, Salloukh H, Rieckmann P. Expert opinion on the use of cladribine tablets in clinical practice. Ther Adv Neurol Disord 2020; 13:1756286420935019. [PMID: 32636933 PMCID: PMC7318823 DOI: 10.1177/1756286420935019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/12/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Gaps in current product labels and a lack of detailed clinical guidelines leaves clinicians' questions on the practical management of patients receiving cladribine tablets for the treatment of relapsing multiple sclerosis (MS) unanswered. We describe a consensus-based programme led by international MS experts with the aim of providing recommendations to support the use of cladribine tablets in clinical practice. METHODS A steering committee (SC) of nine international MS experts led the programme and developed 11 clinical questions concerning the practical use of cladribine tablets. Statements to address each question were drafted using available evidence, expert experiences and perspectives from the SC and an extended faculty of 33 MS experts, representing 19 countries. Consensus on recommendations was achieved when ⩾75% of respondents expressed an agreement score of 7-9, on a 9-point scale. RESULTS Consensus was achieved on 46 out of 47 recommendations. Expert-agreed practical recommendations are provided on topics including: the definition of highly active disease; patterns of treatment response and suboptimal response with cladribine tablets; management of pregnancy planning and malignancy risk, infection risk and immune function, and switching to and from cladribine tablets. CONCLUSION These expert recommendations provide up-to-date relevant guidance on the use of cladribine tablets in clinical practice.
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Affiliation(s)
- Per Soelberg Sørensen
- Department of Neurology, Danish Multiple Sclerosis Center, University of Copenhagen, 2082, Rigshospitalet, 9, Blegdamsvej, Copenhagen, 2100, Denmark
| | - Diego Centonze
- Unit of Neurology and Neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Xavier Montalban
- Department of Neurology, Neuroimmunology, Multiple Sclerosis Centre of Catalonia (Cemcat), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniel Selchen
- Division of Neurology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Heinz Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Bassem Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut, Beirut, Lebanon
| | - Hashem Salloukh
- Ares Trading S.A., and affiliate of Merck Serono S.A., Eysins, Switzerland
| | - Peter Rieckmann
- Department of Neurology, Center for Clinical Neuroplasticity, Medical Park Loipl, Bischofswiesen, University of Erlangen, Germany
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23
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Navigating the TOR of Multiple Sclerosis. Can J Neurol Sci 2020; 47:435-436. [PMID: 32326985 DOI: 10.1017/cjn.2020.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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24
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Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations. Can J Neurol Sci 2020; 47:437-455. [DOI: 10.1017/cjn.2020.66] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract:The Canadian Multiple Sclerosis Working Group has updated its treatment optimization recommendations (TORs) on the optimal use of disease-modifying therapies for patients with all forms of multiple sclerosis (MS). Recommendations provide guidance on initiating effective treatment early in the course of disease, monitoring response to therapy, and modifying or switching therapies to optimize disease control. The current TORs also address the treatment of pediatric MS, progressive MS and the identification and treatment of aggressive forms of the disease. Newer therapies offer improved efficacy, but also have potential safety concerns that must be adequately balanced, notably when treatment sequencing is considered. There are added discussions regarding the management of pregnancy, the future potential of biomarkers and consideration as to when it may be prudent to stop therapy. These TORs are meant to be used and interpreted by all neurologists with a special interest in the management of MS.
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Real-World Effectiveness and Safety of Fingolimod in Patients With Relapsing Remitting Multiple Sclerosis: A Prospective Analysis in Buenos Aires, Argentina. Clin Neuropharmacol 2020; 42:163-166. [PMID: 31348014 DOI: 10.1097/wnf.0000000000000358] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this prospective observational postmarketing study was to evaluate fingolimod effectiveness in a real-world setting in Buenos Aires, Argentina. METHODS Relapsing remitting multiple sclerosis patients who had been prescribed fingolimod owing to treatment failure and had at least greater than or equal to 24 months of follow-up were included during August 2013 and June 2018. Three-monthly clinical evaluations and 12-monthly magnetic resonance were performed. Demographic and clinical variables were described as well as the safety and the effectiveness outcomes that included the proportion of patients free from clinical relapses, from disability progression, from new or enlarging T2 or T1 gadolinium-enhancing lesions on annual magnetic resonance imaging, and from any disease activity during the follow-up. RESULTS A total of 97 patients were included (68% female [n = 66]; mean ± SD age, 30 ± 10.5 years; mean ± SD disease duration, 6.5 ± 3.1 years; mean ± SD Expanded Disability Status Scale, 3.5 ± 1; mean ± SD fingolimod use, 30 ± 13 months [range, 18-56 months]). One hundred percent (97) used previous disease-modifying therapy, mainly interferons (87%; n = 84). Fourteen patients (14.4%) discontinued/withdrew fingolimod (10 owing to disease activity and 4 owing to tolerance and personal decisions). Eighty-two percent were free from clinical relapses, and 85% were free from disability progression; 75% of patients remained free from new or newly enlarging T2 lesions, and 78% of patients were free from gadolinium enhancing lesions. The proportion of patients free from any disease activity was 54%. CONCLUSIONS The effectiveness of fingolimod in a newly real-world setting was consistent with information provided from phase III clinical trials.
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Alonso RN, Eizaguirre MB, Silva B, Pita MC, Yastremiz C, Vanotti S, Cáceres F, Garcea O. Brain Function Assessment of Patients with Multiple Sclerosis in the Expanded Disability Status Scale: A Proposal for Modification. Int J MS Care 2020; 22:31-35. [PMID: 32123526 DOI: 10.7224/1537-2073.2018-084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background There is no consensus regarding assessment of the brain function functional system (FS) of the Expanded Disability Status Scale (EDSS) in patients with multiple sclerosis (MS). We sought to describe brain function FS assessment criteria used by Argentinian neurologists and, based on the results, propose redefined brain function FS criteria. Methods A structured survey was conducted of 113 Argentinian neurologists. Considering the survey results, we decided to redefine the brain function FS scoring using the Brief International Cognitive Assessment for MS (BICAMS) battery. For 120 adult patients with MS we calculated the EDSS score without brain function FS (basal EDSS) and compared it with the EDSS score after adding the modified brain function FS (modified EDSS). Results Of the 93 neurologists analyzed, 14% reported that they did not assess brain function FS, 35% reported that they assessed it through a nonstructured interview, and the remainder used other tools. Significant differences were found in EDSS scores before and after the inclusion of BICAMS (P < .001). Redefining the brain function FS, 15% of patients modified their basal EDSS score, as did 20% of those with a score of 4.0 or less. Conclusions The survey results show the importance of unifying the brain function FS scoring criteria in calculating the EDSS score. While allowing more consistent brain function FS scoring, including the modified brain function FS led to a change in EDSS score in many patients, particularly in the lower range of EDSS scores. Considering the relevance of the EDSS for monitoring patients with MS and for decision making, it is imperative to further validate the modified brain function FS scoring.
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Knox KB, Saini A, Levin MC. The Dilemma of When to Stop Disease-Modifying Therapy in Multiple Sclerosis: A Narrative Review and Canadian Regional Reimbursement Policies. Int J MS Care 2020; 22:75-84. [PMID: 32410902 PMCID: PMC7204360 DOI: 10.7224/1537-2073.2018-107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Disease-modifying therapy (DMT) has changed the landscape of multiple sclerosis (MS) care. However, there is lack of consensus on the duration of treatment and the selection of individuals most likely to benefit from continued treatment. Current evidence, practice guidelines, health policy, and ethical considerations presented together may further inform challenging clinical decision making and future directions. The objectives of this study were to conduct a narrative review of original research and practice guideline recommendations on discontinuation of DMTs in MS; to collect information regarding Canadian regional reimbursement policies for DMT coverage in MS; and to present ethical considerations applicable to such decision making. METHODS A literature review was conducted of the MEDLINE/PubMed, OneFile (GALE), Scopus (Elsevier), and ProQuest Biological Science Collection databases. Data regarding Canadian regional reimbursement policies for DMT coverage in MS were collected from the ministry/government websites. Ethical considerations were reviewed in the context of the identified evidence, guidelines, and policies. RESULTS The literature lacks evidence from prospective randomized controlled trials that directly addresses the issue of discontinuation of DMTs in MS. Current practice guidelines advocate the vital role of patient choice in decision making. There are regional variations in Expanded Disability Status Scale criteria scores for continuing MS DMT coverage among Canadian provinces/territories. CONCLUSIONS In the absence of strong evidence on discontinuation of DMTs, shared decision making and consideration of the ethical complexities could help in the decision-making process.
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28
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Harirchian MH, Poursadeghfard M, Sadeghipour A, Kamali H, Sarraf P. Necrotizing fungal osteomyelitis and fingolimod, 4 years after treatment with fingolimod. Mult Scler Relat Disord 2020; 41:102021. [PMID: 32126512 DOI: 10.1016/j.msard.2020.102021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 01/20/2020] [Accepted: 02/21/2020] [Indexed: 10/24/2022]
Abstract
Fingolimod has been the first approved oral medication in MS for its relapsing remitting type. It is a non-selective sphingosine1-phosphate (S1P) receptor modulator on lymphocytes. Engagement of this receptor blocks the T cells and B cells migration from the lymph nodes into the inflamed central nervous system (CNS) via bloodstream. In spite of this known immunomodulatory mechanism, there are some reports about serious infection following the initiation of fingolimod therapy like herpes types or infections associated to the immunosuppressed situation (cryptococcal meningitis, primary cutaneous cryptococcosis and visceral leishmaniasis). To the best of our knowledge, in contrary to many reports about opportunistic or serious infections with fingolimod, there has been no report on fungal osteomyelitis associated to fingolimod until now. Here, we aimed to describe a woman who developed necrotizing fungal osteomyelitis four years after starting fingolimod, as a disease modifying drug for MS.
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Affiliation(s)
- Mohammad Hossein Harirchian
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Poursadeghfard
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Alireza Sadeghipour
- Department of Pathology, Oncopathology Research center, Iran University of Medical Sciences, Tehran, Iran
| | - Hoda Kamali
- Neurology research center, Kerman University of Medical Sciences, Kerman, Iran
| | - Payam Sarraf
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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29
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Harding K, Williams O, Willis M, Hrastelj J, Rimmer A, Joseph F, Tomassini V, Wardle M, Pickersgill T, Robertson N, Tallantyre E. Clinical Outcomes of Escalation vs Early Intensive Disease-Modifying Therapy in Patients With Multiple Sclerosis. JAMA Neurol 2020; 76:536-541. [PMID: 30776055 DOI: 10.1001/jamaneurol.2018.4905] [Citation(s) in RCA: 187] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Uncertainty remains about how aggressively to treat early multiple sclerosis. High-efficacy disease-modifying therapies (DMTs) are often reserved for individuals expressing poor prognostic features at baseline. Objective To analyze long-term outcomes in a population-based cohort according to initial treatment strategy. Design, Setting and Participants In this cohort study, data were derived from January 1998 to December 2016, and analysis was performed in January 2017. From a total of 720 patients prescribed a DMT, 592 (82%) were included in analysis. Reasons for exclusion were first treated elsewhere or privately (n = 39), clinical trial participant (n = 25), and insufficient clinical data (n = 45). Exposures Patients were classified according to first-line treatment strategy: high-efficacy (early intensive treatment [EIT]) or moderate-efficacy DMT (escalation [ESC]). Main Outcomes and Measures Primary outcome was 5-year change in Expanded Disability Status Scale score. Secondary outcome was time to sustained accumulation of disability (SAD). Models were adjusted for sex, age at treatment, year of starting DMT, and escalation to high-efficacy treatment in the ESC group. Results Mean (SD) age of 592 patients at symptom onset was 27.0 (9.4) years. Mean (SD) 5-year change in Expanded Disability Status Scale score was lower in the EIT group than the ESC group (0.3 [1.5] vs 1.2 [1.5]); this remained significant after adjustment for relevant covariates (β = -0.85; 95% CI, -1.38 to -0.32; P = .002). Median (95% CI) time to SAD was 6.0 (3.17-9.16) years for EIT and 3.14 (2.77-4.00) years for ESC (P = .05). For those within the ESC group who escalated to high-efficacy DMT as second-line treatment, median (95% CI) time to SAD was 3.3 years (1.8-5.6; compared with EIT group log-rank test P = .08). After adjustment for relevant covariates, there was no difference in hazard of SAD between the groups. However, 60% of those who escalated to high-efficacy DMTs were observed to develop SAD while still receiving initial moderate-efficacy treatment before escalation. Conclusions and Relevance In a real-life setting, long-term outcomes were more favorable following early intensive therapy vs first-line moderate-efficacy DMT. Contemporary surveillance strategies and escalation protocols may be insufficiently responsive. This finding is particularly relevant as patients in real-world practice are typically selected for an EIT approach to therapy on the basis of clinical and radiological features predictive of a poor outcome. These data support the need for a prospective randomized clinical trial.
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Affiliation(s)
- Katharine Harding
- Institute of Psychological Medicine and Clinical Neuroscience, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom.,Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Heath Park, Cardiff, United Kingdom.,Department of Neurology, Royal Gwent Hospital, Newport, United Kingdom
| | - Owain Williams
- Institute of Psychological Medicine and Clinical Neuroscience, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom.,Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Mark Willis
- Institute of Psychological Medicine and Clinical Neuroscience, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom.,Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - James Hrastelj
- Institute of Psychological Medicine and Clinical Neuroscience, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom.,Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Anthony Rimmer
- Department of Neurology, Royal Gwent Hospital, Newport, United Kingdom
| | - Fady Joseph
- Department of Neurology, Royal Gwent Hospital, Newport, United Kingdom
| | - Valentina Tomassini
- Institute of Psychological Medicine and Clinical Neuroscience, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom.,Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Mark Wardle
- Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Trevor Pickersgill
- Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Neil Robertson
- Institute of Psychological Medicine and Clinical Neuroscience, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom.,Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Emma Tallantyre
- Institute of Psychological Medicine and Clinical Neuroscience, School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom.,Helen Durham Centre for Neuroinflammatory Disease, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
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Yang T, Tian X, Chen CY, Ma LY, Zhou S, Li M, Wu Y, Zhou Y, Cui YM. The efficacy and safety of fingolimod in patients with relapsing multiple sclerosis: A meta-analysis. Br J Clin Pharmacol 2020; 86:637-645. [PMID: 31869429 DOI: 10.1111/bcp.14198] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 11/26/2022] Open
Abstract
AIMS The aim of the present meta-analysis was to evaluate the efficacy and safety of fingolimod in patients with relapsing multiple sclerosis (RMS). METHODS PubMed, Embase, the Cochrane Library and ClinicalTrials.gov were searched for relevant studies. Two authors independently selected the studies, assessed the risk of bias, and extracted the data. The meta-analysis was performed in RevMan 5.3 provided by the Cochrane Collaboration. RESULTS Ten studies met the inclusion criteria. In patients with RMS, fingolimod demonstrated a significantly lower annualized relapse rate (0.5 mg/d: mean difference [95% confidence interval] = -0.22 [-0.29 to -0.14]; 1.25 mg/d: -0.26 [-0.36 to -0.16]; 5 mg/d: -0.41 [-0.72 to -0.10]) than placebo. Fingolimod also exhibited a favorable performance on other magnetic resonance imaging outcomes and improved the quality of life in patients. No significant difference was noted in the prevalence of adverse events between the fingolimod treatment group and the placebo/disease-modifying therapy groups. CONCLUSIONS Fingolimod may offer benefits for RMS patients and presents an acceptable safety profile.
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Affiliation(s)
- Ting Yang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xin Tian
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Chao-Yang Chen
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Ling-Yun Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Min Li
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Ye Wu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Ying Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Yi-Min Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
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31
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Immunoglobulin G index as a biomarker of relapse response to corticosteroids during early stages of multiple sclerosis. Mult Scler Relat Disord 2020; 38:101495. [DOI: 10.1016/j.msard.2019.101495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/10/2019] [Accepted: 11/01/2019] [Indexed: 11/18/2022]
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32
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Cristiano E, Rojas JI, Alonso R, Alvez Pinheiro A, Bacile EA, Balbuena ME, Barboza AG, Bestoso S, Burgos M, Cáceres F, Carnero Contentti E, Curbelo MC, Deri N, Fernandez Liguori N, Gaitán MI, Garcea O, Giunta D, Halfon MJ, Hryb JP, Jacobo M, Kohler E, Luetic GG, Maglio I, Martínez AD, Míguez J, Nofal PG, Patrucco L, Piedrabuena R, Rotta Escalante R, Saladino ML, Silva BA, Sinay V, Tkachuk V, Villa A, Vrech C, Ysrraelit MC, Correale J. Consensus recommendations on the management of multiple sclerosis patients in Argentina. J Neurol Sci 2020; 409:116609. [DOI: 10.1016/j.jns.2019.116609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
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33
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Silveira F, Sánchez F, Miguez J, Contartese L, Gómez A, Patrucco L, Cristiano E, Rojas JI. New MRI lesions and topography at 6 months of treatment initiation and disease activity during follow up in relapsing remitting multiple sclerosis patients. Neurol Res 2020; 42:148-152. [PMID: 31959078 DOI: 10.1080/01616412.2019.1710415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: The objective of this study was to assess if the presence of new lesions and their topography on the reference MRI have a prognostic value regarding disease activity during the follow up in relapsing remitting multiple sclerosis (RRMS) patients.Methods: Retrospective cohort study that included patients with RRMS who had a reference MRI (performed at 6 months from the onset of a DMT) and radiological and clinical follow up for at least two years. We identified the number of new MRI lesions and their topography at reference MRI and during the follow up. Cox proportional hazards model analysis was used to evaluate the association between new lesions on reference MRI and the appearance of new lesions and/or clinical relapses at 24-month follow-up.Results: 56 patients were included, 13 (23.2%) showed new lesions in the reference MRI. The presence of new lesions at reference MRI predicted the occurrence of new lesions at month 24 (HR 3.1, CI 95% 2.5-5.8). The number of lesions and the infratentorial topography at reference MRI were associated with an increased risk of new radiological activity during follow up (HR 3.5, IC95% 3.1-6.1 and HR 2.4, IC95% 1.9-2.7 respectively).Conclusion: New lesions at the reference MRI in terms of number and topography increase the risk of radiological disease activity during the follow up.
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Affiliation(s)
- Facundo Silveira
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Francisco Sánchez
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Jimena Miguez
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Laura Contartese
- Servicio d Neurología, Hospital de Clínicas José de San Martin, Buenos Aires, Argentina
| | - Alejandra Gómez
- Servicio de Neurología, Hospital Ramos Mejía, Buenos Aires, Argentina
| | - Liliana Patrucco
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Edgardo Cristiano
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Juan Ignacio Rojas
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.,Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
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Salem M, Valverde S, Cabezas M, Pareto D, Oliver A, Salvi J, Rovira À, Lladó X. A fully convolutional neural network for new T2-w lesion detection in multiple sclerosis. NEUROIMAGE-CLINICAL 2019; 25:102149. [PMID: 31918065 PMCID: PMC7036701 DOI: 10.1016/j.nicl.2019.102149] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/23/2019] [Accepted: 12/26/2019] [Indexed: 11/17/2022]
Abstract
A deep learning model for new T2-w lesions detection in multiple sclerosis is presented. Combining a learning-based registration network with a segmentation one increases the performance. The proposed model decreases false-positives while increasing true-positives. Better performance compared to other supervised and unsupervised state-of-the-art approaches.
Introduction: Longitudinal magnetic resonance imaging (MRI) has an important role in multiple sclerosis (MS) diagnosis and follow-up. Specifically, the presence of new T2-w lesions on brain MR scans is considered a predictive biomarker for the disease. In this study, we propose a fully convolutional neural network (FCNN) to detect new T2-w lesions in longitudinal brain MR images. Methods: One year apart, multichannel brain MR scans (T1-w, T2-w, PD-w, and FLAIR) were obtained for 60 patients, 36 of them with new T2-w lesions. Modalities from both temporal points were preprocessed and linearly coregistered. Afterwards, an FCNN, whose inputs were from the baseline and follow-up images, was trained to detect new MS lesions. The first part of the network consisted of U-Net blocks that learned the deformation fields (DFs) and nonlinearly registered the baseline image to the follow-up image for each input modality. The learned DFs together with the baseline and follow-up images were then fed to the second part, another U-Net that performed the final detection and segmentation of new T2-w lesions. The model was trained end-to-end, simultaneously learning both the DFs and the new T2-w lesions, using a combined loss function. We evaluated the performance of the model following a leave-one-out cross-validation scheme. Results: In terms of the detection of new lesions, we obtained a mean Dice similarity coefficient of 0.83 with a true positive rate of 83.09% and a false positive detection rate of 9.36%. In terms of segmentation, we obtained a mean Dice similarity coefficient of 0.55. The performance of our model was significantly better compared to the state-of-the-art methods (p < 0.05). Conclusions: Our proposal shows the benefits of combining a learning-based registration network with a segmentation network. Compared to other methods, the proposed model decreases the number of false positives. During testing, the proposed model operates faster than the other two state-of-the-art methods based on the DF obtained by Demons.
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Affiliation(s)
- Mostafa Salem
- Research Institute of Computer Vision and Robotics, University of Girona, Spain; Computer Science Department, Faculty of Computers and Information, Assiut University, Egypt.
| | - Sergi Valverde
- Research Institute of Computer Vision and Robotics, University of Girona, Spain
| | - Mariano Cabezas
- Research Institute of Computer Vision and Robotics, University of Girona, Spain
| | - Deborah Pareto
- Magnetic Resonance Unit, Dept of Radiology, Vall d'Hebron University Hospital, Spain
| | - Arnau Oliver
- Research Institute of Computer Vision and Robotics, University of Girona, Spain
| | - Joaquim Salvi
- Research Institute of Computer Vision and Robotics, University of Girona, Spain
| | - Àlex Rovira
- Magnetic Resonance Unit, Dept of Radiology, Vall d'Hebron University Hospital, Spain
| | - Xavier Lladó
- Research Institute of Computer Vision and Robotics, University of Girona, Spain
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Gross RH, Corboy JR. Monitoring, Switching, and Stopping Multiple Sclerosis Disease-Modifying Therapies. Continuum (Minneap Minn) 2019; 25:715-735. [PMID: 31162313 DOI: 10.1212/con.0000000000000738] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW This article reviews appropriate monitoring of the various multiple sclerosis (MS) disease-modifying therapies, summarizes the reasons patients switch or stop treatment, and provides a framework for making these management decisions. RECENT FINDINGS With the increasing number of highly effective immunotherapies available for MS, the possibility of better control of the disease has increased, but with it, the potential for side effects has rendered treatment decisions more complicated. Starting treatment early with more effective and better-tolerated disease-modifying therapies reduces the likelihood of switching because of breakthrough disease or lack of compliance. Clinical and radiographic surveillance, and often blood and other paraclinical tests, should be performed periodically, depending on the disease-modifying therapy. Helping patients navigate the uncertainty around switching or stopping treatment, either temporarily or permanently, is one of the most important things we do as providers of MS care. SUMMARY Ongoing monitoring of drug therapy is a crucial component of long-term MS care. Switching treatments may be necessary for a variety of reasons. Permanent discontinuation of treatment may be appropriate for some patients with MS, although more study is needed in this area.
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Al-Sakran L, Marrie RA, Blackburn D, Knox K, Evans C. Association between disease-modifying therapies for multiple sclerosis and healthcare utilisation on a population level: a retrospective cohort study. BMJ Open 2019; 9:e033599. [PMID: 31772108 PMCID: PMC6887031 DOI: 10.1136/bmjopen-2019-033599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Disease-modifying therapy (DMT) use in multiple sclerosis (MS) has increased significantly. However, the impact of DMTs on healthcare use is limited and conflicting, and rarely examined at a population level. This study examined the association between DMTs and healthcare utilisation at the population level. DESIGN Retrospective cohort. SETTING Health administrative data from Saskatchewan, Canada (1997-2016). PARTICIPANTS To test for associations at the population level, we identified two cohorts. The general population cohort included all Saskatchewan residents ≥18 years who were drug plan beneficiaries. The MS cohort included individuals ≥18 years, identified using a validated definition (≥3 hospital, physician or drug claims for MS). MAIN OUTCOME MEASURES AND METHODS To test for an association between the total number of DMT dispensations per year and the total number of hospitalisations we used negative binomial regression fitted with generalised estimating equations (GEE); only hospitalisations that occurred after the date of MS diagnosis (date of first claim for MS or demyelinating disease) were extracted. To test for an association between the number of DMT dispensations and physician claims, negative binomial distributions with GEE were fit as above. Results were reported as rate ratios (RR), with 95% CIs, and calculated for every 1000 DMT dispensations. RESULTS The number of DMT dispensations was associated with a decreased risk for all-cause (RR=0.994; 95% CI 0.992 to 0.996) and MS-specific (RR=0.909; 95% CI 0.880 to 0.938) hospitalisations. The number of DMT dispensations was not associated with the number of all-cause (RR=1.006; 95% CI 0.990 to 1.022) or MS-specific (RR=0.962; 95% CI 0.910 to 1.016) physician claims. CONCLUSION Increased DMT use in Saskatchewan was associated with a reduction in hospitalisations, but did not impact the number of physician services used. Additional research on cost-benefit and differing treatment strategies would provide further insight into the true impact of DMTs on healthcare utilisation at a population level.
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Affiliation(s)
- Lina Al-Sakran
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ruth Ann Marrie
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Blackburn
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Katherine Knox
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Yamout B, Sahraian M, Bohlega S, Al-Jumah M, Goueider R, Dahdaleh M, Inshasi J, Hashem S, Alsharoqi I, Khoury S, Alkhawajah M, Koussa S, Al Khaburi J, Almahdawi A, Alsaadi T, Slassi E, Daodi S, Zakaria M, Alroughani R. Consensus recommendations for the diagnosis and treatment of multiple sclerosis: 2019 revisions to the MENACTRIMS guidelines. Mult Scler Relat Disord 2019; 37:101459. [PMID: 31670208 DOI: 10.1016/j.msard.2019.101459] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 12/19/2022]
Abstract
With evolving diagnostic criteria and the advent of new oral and parenteral therapies for MS, most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and in time, and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of multiple sclerosis (MS) therapies is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, and progressive MS. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.
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Affiliation(s)
- B Yamout
- Nehme and Therese Tohme MS Center, American University of Beirut Medical Center, Beirut, Lebanon.
| | - M Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - S Bohlega
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Al-Jumah
- King Fahad Medical Cit, MOH, Riyadh, Saudi Arabia
| | - R Goueider
- Service de Neurologie, Hôpital Razi, Manouba, Tunis
| | | | - J Inshasi
- Department of Neurology, Rashid Hospital and Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - S Hashem
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - I Alsharoqi
- Dept of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain
| | - S Khoury
- Nehme and Therese Tohme MS Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Alkhawajah
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - S Koussa
- MS Center- Geitaoui Lebanese University Hospital, Beirut, Lebanon
| | - J Al Khaburi
- Department of Neurology, The Royal Hospital, Sultanate of Oman
| | - A Almahdawi
- Consultant neurologist, neurology unit, Baghdad Teaching Hospital, Medical City Complex, Iraq
| | - T Alsaadi
- American Center for Psychiatry & Neurology- UAE
| | - E Slassi
- Hôpital Cheikh Khalifa Ibn Zaid, Casablanca- Morocco
| | - S Daodi
- Hospital Center Nedir Mohamed, Faculty of Medicine University Mouloud Mammeri Tizi-ouzou Algeria
| | | | - R Alroughani
- Amiri Hospital, Arabian Gulf Street, Sharq, Kuwait
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Amaral LLFD, Fragoso DC, Rocha AJD. Improving acute demyelinating lesion detection: which T1-weighted magnetic resonance acquisition is more sensitive to gadolinium enhancement? ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:485-492. [PMID: 31365640 DOI: 10.1590/0004-282x20190082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/14/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Because of the need for a standardized and accurate method for detecting multiple sclerosis (MS) inflammatory activity, different magnetic resonance (MR) acquisitions should be compared in order to choose the most sensitive sequence for clinical routine. To compare the sensitivity of a T1-weighted image to a single dose of gadolinium (Gd) administration both with and without magnetization transfer to detect contrast enhancement in active demyelinating focal lesions. METHODS A sample of relapsing-remitting MS patients were prospectively examined separately by two neuroradiologists using a 1.5 Tesla scanner. The outcome parameters were focused on Gd-enhancement detection attributed to acute demyelination. All MR examinations with at least one Gd-enhancing lesion were considered positive (MR+) and each lesion was analyzed according to its size and contrast ratio. RESULTS Thirty-six MR examinations were analyzed with a high inter-observer agreement for MR+ detection (k coefficient > 0.8), which was excellent for the number of Gd-enhancing lesions (0.91 T1 spin-echo (SE), 0.88 T1 magnetization transfer contrast (MTC) sequence and 0.99 magnetization-prepared rapid acquisition with gradient-echo (MPRAGE). Significantly more MR+ were reported on the T1 MTC scans, followed by the T1 SE, and MPRAGE scans. Confidently, the T1 MTC sequence demonstrated higher accuracy in the detection of Gd-enhancing lesions, followed by the T1 SE and MPRAGE sequences. Further comparisons showed that there was a statistically significant increase in the contrast ratio and area of Gd-enhancement on the T1 MTC images when compared with both the SE and MPRAGE images. CONCLUSION Single-dose Gd T1 MTC sequence was confirmed to be the most sensitive acquisition for predicting inflammatory active lesions using a 1.5 T magnet in this sample of MS patients.
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Affiliation(s)
- Lázaro Luiz Faria do Amaral
- Hospital Beneficência Portuguesa de São Paulo, BP Medicina Diagnóstica, Departamento de Neurorradiologia, São Paulo SP, Brasil.,Irmandade da Santa Casa de Misericórdia de São Paulo, Departamento de Radiologia, São Paulo SP, Brasil
| | - Diego Cardoso Fragoso
- Irmandade da Santa Casa de Misericórdia de São Paulo, Departamento de Radiologia, São Paulo SP, Brasil
| | - Antonio José da Rocha
- Irmandade da Santa Casa de Misericórdia de São Paulo, Departamento de Radiologia, São Paulo SP, Brasil
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Abstract
PURPOSE OF REVIEW Newly introduced disease-modifying therapies offer greater efficacy than previous therapies but also have serious side effects. This article reviews factors useful in identifying those at risk of developing aggressive relapsing multiple sclerosis (MS) and therapies available for treatment. RECENT FINDINGS Several factors predict aggressive MS, including demographic factors, relapses, symptom characteristics, MRI activity, and other biomarkers. These can be used to select patients for more aggressive therapies, including natalizumab, alemtuzumab, fingolimod, and ocrelizumab. Additional off-label treatments are available for patients with severe disease. The benefits and side effects of these treatments must be considered when making therapeutic decisions. SUMMARY Selecting patients who are most appropriate for aggressive therapy involves considering risk factors for poor outcomes, early recognition of treatment failure, balancing treatment efficacy and side effects, and sharing the decision with patients to assist them in making optimal treatment choices. Vigilance for signs of treatment failure and early switching to more aggressive therapy are important components in optimal care.
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Emotional expressions associated with therapeutic inertia in multiple sclerosis care. Mult Scler Relat Disord 2019; 34:17-28. [PMID: 31226545 DOI: 10.1016/j.msard.2019.05.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Emotions play a critical role in our daily decisions. However, it remains unclear how and what sort of emotional expressions are associated with therapeutic decisions in multiple sclerosis (MS) care. Our goal was to evaluate the relationship between emotions and affective states (as captured by muscle facial activity and emotional expressions) and TI amongst neurologists caring for MS patients when making therapeutic decisions. METHODS 38 neurologists with expertise in MS were invited to participate in a face-to-face study across Canada. Participants answered questions regarding their clinical practice, aversion to ambiguity, and the management of 10 simulated case-scenarios. TI was defined as lack of treatment initiation or escalation when there was clear evidence of clinical and radiological disease activity. We recorded facial muscle activations and their associated emotional expressions during the study, while participants made therapeutic choices. We used a validated machine learning algorithm of the AFFDEX software to code for facial muscle activations and a predefined mapping to emotional expressions (disgust, fear, surprise, etc.). Mixed effects models and mediation analyses were used to evaluate the relationship between ambiguity aversion, facial muscle activity/emotional expressions and TI measured as a binary variable and a continuous score. RESULTS 34 (89.4%) neurologists completed the study. The mean age [standard deviation (SD)] was 44.6 (11.5) years; 38.3% were female and 58.8% self-identified as MS specialists. Overall, 17 (50%) participants showed TI in at least one case-scenario and the mean (SD) TI score was 0.74 (0.90). Nineteen (55.9%) participants had aversion to ambiguity in the financial domain. The multivariate analysis adjusted for age, sex and MS expertise showed that aversion to ambiguity in the financial domain (OR 1.56, 95%CI 1.32-1.86) was associated with TI. Most common muscle activations included mouth open (23.4%), brow furrow (20.9%), brow raise (17.6%), and eye widening (13.1%). Most common emotional expressions included fear (5.1%), disgust (3.2%), sadness (2.9%), and surprise (2.8%). After adjustment for age, sex, and physicians' expertise, the multivariate analysis revealed that brow furrow (OR 1.04; 95%CI 1.003-1.09) and lip suck (OR 1.06; 95%CI 1.01-1.11) were associated with an increase in TI prevalence, whereas upper lip raise (OR 0.30; 95%CI 0.15-0.59), and chin raise (OR 0.90; 95%CI 0.83-0.98) were associated with lower likelihood of TI. Disgust and surprise were associated with a lower TI score (disgust: p < 0.001; surprise: p = 0.008) and lower prevalence of TI (ORdisgust: 0.14, 95%CI 0.03-0.65; ORsurprise: 0.66, 94%CI 0.47-0.92) after adjusting for covariates. The mediation analysis showed that brow furrow was a partial mediator explaining 21.2% (95%CI 14.9%-38.9%) of the association between aversion to ambiguity and TI score, followed by nose wrinkle 12.8% (95%CI 8.9%-23.4%). Similarly, disgust was the single emotional expression (partial mediator) that attenuated (-13.2%, 95%CI -9.2% to -24.3%) the effect of aversion to ambiguity on TI. CONCLUSIONS TI was observed in half of participants in at least one case-scenario. Our data suggest that facial metrics (e.g. brow furrow, nose wrinkle) and emotional expressions (e.g. disgust) are associated with physicians' choices and partially mediate the effect of aversion to ambiguity on TI.
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Hu XY, Rajendran L, Lapointe E, Tam R, Li D, Traboulsee A, Rauscher A. Three-dimensional MRI sequences in MS diagnosis and research. Mult Scler 2019; 25:1700-1709. [DOI: 10.1177/1352458519848100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The most recent guidelines for magnetic resonance imaging (MRI) in multiple sclerosis (MS) recommend three-dimensional (3D) MRI sequences over their two-dimensional (2D) counterparts. This development has been made possible by advances in MRI scanner hardware and software. In this article, we review the 3D versions of conventional sequences, including T1-weighted, T2-weighted and fluid-attenuated inversion recovery (FLAIR), as well as more advanced scans, including double inversion recovery (DIR), FLAIR2, FLAIR*, phase-sensitive inversion recovery, and susceptibility weighted imaging (SWI).
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Affiliation(s)
- Xun Yang Hu
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Luckshi Rajendran
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Emmanuelle Lapointe
- Department of Medicine, Division of Neurology, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Roger Tam
- Department of Radiology, School of Biomedical Engineering, The University of British Columbia, Vancouver, BC, Canada
| | - David Li
- Department of Radiology, UBC Hospital, Vancouver, BC, Canada
| | - Anthony Traboulsee
- Division of Neurology, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Alexander Rauscher
- Department of Radiology, The University of British Columbia, Vancouver, BC, Canada
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Freedman MS, Duquette P, Grand'Maison F, Lee L, Vorobeychik G, Lara N, Khurana V, Nakhaipour HR, Schecter R, Haddad P. The clinical and cost impact of switching to fingolimod versus other first line injectable disease-modifying therapies in patients with relapsing multiple sclerosis. Curr Med Res Opin 2019; 35:767-776. [PMID: 30614288 DOI: 10.1080/03007995.2019.1565818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND There is limited evidence on the effectiveness and healthcare costs of switching to fingolimod versus another first line injectable therapy (FLIT) in patients with relapsing multiple sclerosis (RMS) who have already been treated with FLIT. OBJECTIVE The objectives of the study were to assess the annualized relapse rate (ARR), socio-demographic and clinical characteristics, persistence and adherence rates, healthcare resource utilization and cost among patients with RMS who either switch to fingolimod or another FLIT in routine clinical practice. METHODS A multicenter, observational, retrospective chart review was conducted across eight clinics in Canada between 1 May 2011 and 30 June 2013. The data was collected from two cohorts: patients who switched to fingolimod and patients who switched to FLIT from a previous FLIT. RESULTS AND CONCLUSIONS A total of 124 patients were included in the study: 82 and 42 switched to fingolimod and FLIT, respectively. There were no significant differences in the patient characteristics at the date of switch except for number of previous disease-modifying therapies (DMTs) which was higher in the fingolimod cohort (fingolimod: 1.52; FLIT: 1.10, p < .001). The ARR during the first year of switching was numerically higher in the FLIT cohort compared to the fingolimod cohort (FLIT: 0.9 [95% CI 0.3-1.6]; fingolimod: 0.3 [95% CI 0.1-0.5]). The negative binomial model adjusted for the number of previous DMTs confirmed a statistically significant difference in ARR between the fingolimod and FLIT cohorts at 12 months of follow-up (p = .012). In the fingolimod cohort, 20.7% of patients experienced at least one relapse compared to 38.1% in the FLIT cohort. In both groups, a high proportion of patients (>90%) showed good treatment adherence (≥80% of prescribed doses).
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Affiliation(s)
- M S Freedman
- a University of Ottawa and The Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
| | - P Duquette
- b Notre Dame Hospital , Université de Montréal , Montreal , Quebec , Canada
| | - F Grand'Maison
- c Neuro-Rive Sud Clinic , Greenfield Park , Quebec , Canada
| | - L Lee
- d Sunnybrook Health Sciences Centre , University of Toronto , Toronto , Ontario , Canada
| | - G Vorobeychik
- e Fraser Health Multiple Sclerosis Clinic Burnaby Hospital , Burnaby , British Columbia , Canada
| | - N Lara
- f IQVIA , Barcelona , Spain
| | - V Khurana
- g Novartis Healthcare Private Limited , Hyderabad , India
| | - H R Nakhaipour
- h Novartis Pharmaceuticals Canada Inc ., Dorval , Quebec , Canada
| | - R Schecter
- h Novartis Pharmaceuticals Canada Inc ., Dorval , Quebec , Canada
| | - P Haddad
- h Novartis Pharmaceuticals Canada Inc ., Dorval , Quebec , Canada
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Cuascut FX, Hutton GJ. Stem Cell-Based Therapies for Multiple Sclerosis: Current Perspectives. Biomedicines 2019; 7:biomedicines7020026. [PMID: 30935074 PMCID: PMC6631931 DOI: 10.3390/biomedicines7020026] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/22/2019] [Accepted: 03/25/2019] [Indexed: 12/29/2022] Open
Abstract
Multiple sclerosis (MS) is an inflammatory and neurodegenerative autoimmune disease of the central nervous system (CNS). Disease-modifying therapies (DMT) targeting inflammation have been shown to reduce disease activity in patients with relapsing–remitting MS (RRMS). The current therapeutic challenge is to find an effective treatment to halt disease progression and reverse established neural damage. Stem cell-based therapies have emerged to address this dilemma. Several types of stem cells have been considered for clinical use, such as autologous hematopoietic (aHSC), mesenchymal (MSC), neuronal (NSC), human embryonic (hESC), and induced pluripotent (iPSC) stem cells. There is convincing evidence that immunoablation followed by hematopoietic therapy (aHSCT) has a high efficacy for suppressing inflammatory MS activity and improving neurological disability in patients with RRMS. In addition, MSC therapy may be a safe and tolerable treatment, but its clinical value is still under evaluation. Various studies have shown early promising results with other cellular therapies for CNS repair and decreasing inflammation. In this review, we discuss the current knowledge and limitations of different stem cell-based therapies for the treatment of patients with MS.
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Affiliation(s)
- Fernando X Cuascut
- Baylor College of Medicine, Maxine Mesigner Multiple Sclerosis Center, Houston, TX 77030, USA.
| | - George J Hutton
- Baylor College of Medicine, Maxine Mesigner Multiple Sclerosis Center, Houston, TX 77030, USA.
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Marques VD, Passos GRD, Mendes MF, Callegaro D, Lana-Peixoto MA, Comini-Frota ER, Vasconcelos CCF, Sato DK, Ferreira MLB, Parolin MKF, Damasceno A, Grzesiuk AK, Muniz A, Matta APDC, Oliveira BESD, Tauil CB, Maciel DRK, Diniz DS, Corrêa EC, Coronetti F, Jorge FMH, Sato HK, Gonçalves MVM, Sousa NADC, Nascimento OJM, Gama PDD, Domingues R, Simm RF, Thomaz RB, Morales RDR, Dias RM, Apóstolos-Pereira SD, Machado SCN, Junqueira TDF, Becker J. Brazilian Consensus for the Treatment of Multiple Sclerosis: Brazilian Academy of Neurology and Brazilian Committee on Treatment and Research in Multiple Sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 76:539-554. [PMID: 30231128 DOI: 10.1590/0004-282x20180078] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 05/16/2018] [Indexed: 12/21/2022]
Abstract
The expanding therapeutic arsenal in multiple sclerosis (MS) has allowed for more effective and personalized treatment, but the choice and management of disease-modifying therapies (DMTs) is becoming increasingly complex. In this context, experts from the Brazilian Committee on Treatment and Research in Multiple Sclerosis and the Neuroimmunology Scientific Department of the Brazilian Academy of Neurology have convened to establish this Brazilian Consensus for the Treatment of MS, based on their understanding that neurologists should be able to prescribe MS DMTs according to what is better for each patient, based on up-to-date evidence and practice. We herein propose practical recommendations for the treatment of MS, with the main focus on the choice and management of DMTs, as well as present a review of the scientific rationale supporting therapeutic strategies in MS.
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Affiliation(s)
- Vanessa Daccach Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas de Ribeirão Preto, Ribeirão Preto SP, Brasil
| | | | - Maria Fernanda Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | - Dagoberto Callegaro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | - Marco Aurélio Lana-Peixoto
- Universidade Federal de Minas Gerais, Centro de Investigação em Esclerose Múltipla de Minas Gerais, Belo Horizonte MG, Brasil
| | | | | | | | | | | | | | | | | | | | | | - Carlos Bernardo Tauil
- Universidade de Brasília, Brasília DF, Brasil.,Universidade Católica de Brasília, Brasília DF, Brasil
| | | | | | | | | | - Frederico M H Jorge
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | | | | | | | | | | | - Renan Domingues
- Senne Líquor Diagnóstico, São Paulo SP, Brasil.,Hospital Cruz Azul, São Paulo SP, Brasil.,Faculdade São Leopoldo Mandic, Campinas SP, Brasil
| | - Renata Faria Simm
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | | | | | | | | | | | | | - Jefferson Becker
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre RS, Brasil.,Universidade Federal Fluminense, Niterói RJ, Brasil
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Toward a Shared-Care Model of Relapsing-Remitting Multiple Sclerosis: Role of the Primary Care Practitioner. Can J Neurol Sci 2019; 45:304-312. [PMID: 29756588 DOI: 10.1017/cjn.2018.7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The objective of this study was to develop a shared-care model to enable primary-care physicians to participate more fully in meeting the complex, multidisciplinary healthcare needs of patients with multiple sclerosis (MS). DESIGN The design consisted of development of consensus recommendations and a shared-care algorithm. PARTICIPANTS A working group of 11 Canadian neurologists involved in the management of patients with MS were included in this study. MAIN MESSAGE The clinical management of patients with multiple sclerosis is increasing in complexity as new disease-modifying therapies (DMTs) become available, and ongoing safety monitoring is required. A shared-care model that includes primary care physicians is needed. Primary care physicians can assist in the early detection of MS of individuals presenting with neurological symptoms. Additional key roles for family physicians are health promotion, symptom management, and safety and relapse monitoring of DMT-treated patients. General principles of health promotion include counseling MS patients on maintaining a healthy lifestyle; performing standard screening measures; and identifying and treating comorbidities. Of particular importance are depression and anxiety, which occur in >20% of MS patients. Standard work-ups and treatments are needed for common MS-related symptoms, such as fatigue, pain, bladder dysfunction, sexual dysfunction, spasticity, and sleep disorders. Ongoing safety monitoring is required for patients receiving specific DMTs. Multiple sclerosis medications are generally contraindicated during pregnancy, and patients should be counseled to practice effective contraception. CONCLUSIONS Multiple sclerosis is a complex, disabling illness, which, similar to other chronic diseases, requires ongoing multidisciplinary care to meet the evolving needs of patients throughout the clinical course. Family physicians can play an invaluable role in maintaining general health, managing MS-related symptoms and comorbidities, monitoring for treatment-related adverse effects and MS relapses, and coordinating allied health services to ensure continuity of care to meet the complex and evolving needs of MS patients through the disease course. RÉSUMÉ: Élaborer un modèle de soins partagés dans les cas de sclérose en plaques récurrente-rémittente. Objectif: Élaborer un modèle de soins partagés afin de permettre aux médecins de première ligne de mieux répondre aux besoins complexes et multidisciplinaires de patients atteints de la sclérose en plaques (SP). Conception : Recommandations résultant d'un consensus et élaboration d'un algorithme en matière de soins partagés. PARTICIPANTS Un groupe de travail formé de onze neurologues canadiens impliqués dans la prise en charge de patients atteints de la SP. Message-clé : La prise en charge clinique de patients atteints de la SP est de plus en plus complexe dans la mesure où des médicaments modificateurs de l'évolution de la maladie (MMSP) deviennent accessibles et où un suivi permanent en matière de sécurité est nécessaire. Soulignons aussi qu'un modèle de soins partagés incluant les médecins de première ligne est nécessaire. Ces professionnels peuvent permettre un dépistage plus rapide de la SP chez des individus présentant des symptômes neurologiques. Ils peuvent aussi jouer un rôle de premier plan en matière de promotion de la santé, de soulagement des symptômes et de suivi de patients traités avec des MMSP en ce qui a trait à leur sécurité et à de possibles rechutes. Parmi les principes généraux de promotion de la santé, on peut inclure les suivants : offrir aux patients atteints de la SP des conseils leur permettant de maintenir de saines habitudes de vie ; adopter des mesures de dépistage standards ; identifier et traiter les comorbidités. À cet égard, l'anxiété et la dépression sont d'une importance particulière et sont fréquemment signalées (> 20 %) chez les patients atteints de SP. Des démarches d'investigation et des traitements standards sont nécessaires dans le cas des symptômes courants reliés à la SP, par exemple de la fatigue, des douleurs, une dysfonction vésicale, des dysfonctions sexuelles, de la spasticité et des troubles du sommeil. On l'a dit, un suivi permanent s'impose dans le cas de patients bénéficiant d'un traitement spécifique avec des MMSP. Les médicaments associés à la SP sont généralement contre-indiqués durant la grossesse de sorte qu'on devrait conseiller aux patients d'adopter des méthodes de contraception efficaces. CONCLUSIONS La SP est une maladie complexe et invalidante qui, à l'instar d'autres maladies chroniques, exige des soins multidisciplinaires continus afin de répondre, en lien avec un tableau clinique précis, aux besoins en constante évolution des patients. Les médecins de première ligne peuvent jouer un rôle irremplaçable à plusieurs égards : dans le maintien d'une bonne santé ; le suivi et le soulagement des symptômes et des comorbidités reliés à la SP ; le suivi des rechutes et des effets indésirables associés aux traitements. N'oublions pas non plus la coordination des services paramédicaux afin d'assurer, durant l'évolution de la SP, une continuité des soins répondant aux besoins complexes et en constante évolution des patients atteints de cette maladie.
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Lazo-Gomez R, Velázquez GDLLG, Mireles-Jacobo D, Sotomayor-Sobrino MA. Mechanisms of neurobehavioral abnormalities in multiple sclerosis: Contributions from neural and immune components. Clin Neurophysiol Pract 2019; 4:39-46. [PMID: 30911699 PMCID: PMC6416523 DOI: 10.1016/j.cnp.2019.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 12/21/2018] [Accepted: 01/10/2019] [Indexed: 12/14/2022] Open
Abstract
Multiple sclerosis-related neurobehavioral abnormalities are one of the main components of disability in this disease. The same pathological processes that explain demyelination periods and neurodegeneration also allow the comprehension of neurobehavioral abnormalities. Inflammation in the central nervous system caused by cells of the immune system, especially lymphocytes, and by resident cells, such as astrocytes and microglia, directly modulate neurotransmission and synaptic physiology, resulting in behavioral changes (such as sickness behavior) and amplifying the degenerative mechanisms that occur in multiple sclerosis. In addition, neuronal death caused by glutamate-mediated excitotoxicity, alterations in GABAergic, serotonergic, and dopaminergic neurotransmission, and the mechanisms of axon damage are of foremost importance to explain the reduction in brain volume and the associated cognitive decline. Neuroinflammation and neurodegeneration are not isolated phenomena and various instances of interaction between them have been described. This presents attractive targets for the development of therapeutic strategies for this neglected component of multiple sclerosis related disability.
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Affiliation(s)
- Rafael Lazo-Gomez
- Neuroscience franchise, Novartis Pharma México, Calzada de Tlalpan 1779, San Diego Churubusco, 04120 Coyoacán, CDMX, Mexico
| | | | - Diego Mireles-Jacobo
- Neuroscience franchise, Novartis Pharma México, Calzada de Tlalpan 1779, San Diego Churubusco, 04120 Coyoacán, CDMX, Mexico
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Demir S, Atmaca MM, Togrol RE. The First Cure Experience of A Clinic: Approach to The Patient to Start Ocrelizumab. ACTA ACUST UNITED AC 2019; 58:52-56. [PMID: 33795953 DOI: 10.29399/npa.23564] [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: 01/01/2019] [Accepted: 02/11/2019] [Indexed: 11/07/2022]
Abstract
Introduction Ocrelizumab is a newly introduced treatment in multiple sclerosis (MS). There is no data in the pivotal trials about in which extent liver function tests (LFTs) and lymphocyte count are affected before second-half dose of ocrelizumab and in which extent these results will prevent us giving the second-half dose. This study was designed for better understanding of the patient management and to support the data that showed no safety issues about ocrelizumab with real-life data. Methods The patients treated with ocrelizumab between May 20 and December 21, 2018 were retrospectively reviewed. Demographic and clinical data, side-effects due to ocrelizumab, laboratory results before and after the treatment were recorded. Results There were 30 (58.8%) females and 21 (41.2%) males. The mean age was 44.02±9.62 (24-65) years. Twenty-six (51%) of them were followed up with relapsing-remitting MS (RRMS), 18 (35.3%) with secondary progressive MS (SPMS) and 7 (13.7%) with primary progressive MS (PPMS). The mean lymphocyte value one day after the first half-dose was lower than the value before the treatment (p<0.001). The mean lymphocyte level one month after the second half-dose was higher than the value one day after the first half-dose (p=0.001), while it was still lower than the value before treatment (p=0.006). No changes were seen in LFTs. Mild infusion-related reactions were observed in 4 patients. Conclusion From our data, it is evident that ocrelizumab is safe in the short term. Long-term real-life studies are needed to assess the safety of ocrelizumab in the long term.
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Affiliation(s)
- Serkan Demir
- Sultan Abdulhamid Han Training and Research Hospital, Neurology Clinic, İstanbul, Turkey
| | - Murat Mert Atmaca
- Sultan Abdulhamid Han Training and Research Hospital, Neurology Clinic, İstanbul, Turkey
| | - Rıfat Erdem Togrol
- Sultan Abdulhamid Han Training and Research Hospital, Neurology Clinic, İstanbul, Turkey
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Brown JWL, Coles A, Horakova D, Havrdova E, Izquierdo G, Prat A, Girard M, Duquette P, Trojano M, Lugaresi A, Bergamaschi R, Grammond P, Alroughani R, Hupperts R, McCombe P, Van Pesch V, Sola P, Ferraro D, Grand'Maison F, Terzi M, Lechner-Scott J, Flechter S, Slee M, Shaygannejad V, Pucci E, Granella F, Jokubaitis V, Willis M, Rice C, Scolding N, Wilkins A, Pearson OR, Ziemssen T, Hutchinson M, Harding K, Jones J, McGuigan C, Butzkueven H, Kalincik T, Robertson N. Association of Initial Disease-Modifying Therapy With Later Conversion to Secondary Progressive Multiple Sclerosis. JAMA 2019; 321:175-187. [PMID: 30644981 PMCID: PMC6439772 DOI: 10.1001/jama.2018.20588] [Citation(s) in RCA: 303] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Within 2 decades of onset, 80% of untreated patients with relapsing-remitting multiple sclerosis (MS) convert to a phase of irreversible disability accrual termed secondary progressive MS. The association between disease-modifying treatments (DMTs), and this conversion has rarely been studied and never using a validated definition. OBJECTIVE To determine the association between the use, the type of, and the timing of DMTs with the risk of conversion to secondary progressive MS diagnosed with a validated definition. DESIGN, SETTING, AND PARTICIPANTS Cohort study with prospective data from 68 neurology centers in 21 countries examining patients with relapsing-remitting MS commencing DMTs (or clinical monitoring) between 1988-2012 with minimum 4 years' follow-up. EXPOSURES The use, type, and timing of the following DMTs: interferon beta, glatiramer acetate, fingolimod, natalizumab, or alemtuzumab. After propensity-score matching, 1555 patients were included (last follow-up, February 14, 2017). MAIN OUTCOME AND MEASURE Conversion to objectively defined secondary progressive MS. RESULTS Of the 1555 patients, 1123 were female (mean baseline age, 35 years [SD, 10]). Patients initially treated with glatiramer acetate or interferon beta had a lower hazard of conversion to secondary progressive MS than matched untreated patients (HR, 0.71; 95% CI, 0.61-0.81; P < .001; 5-year absolute risk, 12% [49 of 407] vs 27% [58 of 213]; median follow-up, 7.6 years [IQR, 5.8-9.6]), as did fingolimod (HR, 0.37; 95% CI, 0.22-0.62; P < .001; 5-year absolute risk, 7% [6 of 85] vs 32% [56 of 174]; median follow-up, 4.5 years [IQR, 4.3-5.1]); natalizumab (HR, 0.61; 95% CI, 0.43-0.86; P = .005; 5-year absolute risk, 19% [16 of 82] vs 38% [62 of 164]; median follow-up, 4.9 years [IQR, 4.4-5.8]); and alemtuzumab (HR, 0.52; 95% CI, 0.32-0.85; P = .009; 5-year absolute risk, 10% [4 of 44] vs 25% [23 of 92]; median follow-up, 7.4 years [IQR, 6.0-8.6]). Initial treatment with fingolimod, alemtuzumab, or natalizumab was associated with a lower risk of conversion than initial treatment with glatiramer acetate or interferon beta (HR, 0.66; 95% CI, 0.44-0.99; P = .046); 5-year absolute risk, 7% [16 of 235] vs 12% [46 of 380]; median follow-up, 5.8 years [IQR, 4.7-8.0]). The probability of conversion was lower when glatiramer acetate or interferon beta was started within 5 years of disease onset vs later (HR, 0.77; 95% CI, 0.61-0.98; P = .03; 5-year absolute risk, 3% [4 of 120] vs 6% [2 of 38]; median follow-up, 13.4 years [IQR, 11-18.1]). When glatiramer acetate or interferon beta were escalated to fingolimod, alemtuzumab, or natalizumab within 5 years vs later, the HR was 0.76 (95% CI, 0.66-0.88; P < .001; 5-year absolute risk, 8% [25 of 307] vs 14% [46 of 331], median follow-up, 5.3 years [IQR], 4.6-6.1). CONCLUSIONS AND RELEVANCE Among patients with relapsing-remitting MS, initial treatment with fingolimod, alemtuzumab, or natalizumab was associated with a lower risk of conversion to secondary progressive MS vs initial treatment with glatiramer acetate or interferon beta. These findings, considered along with these therapies' risks, may help inform decisions about DMT selection.
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Affiliation(s)
- J. William L. Brown
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- NMR Research Unit, Queen Square Multiple Sclerosis Centre, University College London, Institute of Neurology, London, United Kingdom
- Clinical Outcomes Research Unit, Melbourne Brain Centre, University of Melbourne, Melbourne, Australia
| | - Alasdair Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, General University Hospital, Prague, Czech Republic
- Charles University in Prague, Katerinska, Czech Republic
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, General University Hospital, Prague, Czech Republic
- Charles University in Prague, Katerinska, Czech Republic
| | | | - Alexandre Prat
- Hopital Notre Dame, Montreal, Canada
- CHUM and Universite de Montreal, Montreal, Canada
| | - Marc Girard
- Hopital Notre Dame, Montreal, Canada
- CHUM and Universite de Montreal, Montreal, Canada
| | - Pierre Duquette
- Hopital Notre Dame, Montreal, Canada
- CHUM and Universite de Montreal, Montreal, Canada
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Alessandra Lugaresi
- Department of Biomedical and Neuromotor Sciences, University of Bologna and IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Pierre Grammond
- CISSS Chaudi’re-Appalache, Centre-Hospitalier, Levis, Canada
| | | | | | - Pamela McCombe
- University of Queensland, Brisbane, Australia; Royal Brisbane and Women's Hospital
| | - Vincent Van Pesch
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Patrizia Sola
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Diana Ferraro
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
| | | | - Murat Terzi
- Medical Faculty, Ondokuz Mayis University, Kurupelit, Turkey
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, University Newcastle, Australia
- Department of Neurology, John Hunter Hospital, Hunter New England Health, Newcastle, Australia
| | | | - Mark Slee
- Flinders University, Adelaide, Australia
| | | | - Eugenio Pucci
- UOC Neurologia, Azienda Sanitaria Unica Regionale Marche, Macerata, Italy
| | | | - Vilija Jokubaitis
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Mark Willis
- Department of Neurology, Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Claire Rice
- Department of Neurology, Southmead Hospital, and Clinical Neurosciences, University of Bristol, Bristol, United Kingdom
| | - Neil Scolding
- Department of Neurology, Southmead Hospital, and Clinical Neurosciences, University of Bristol, Bristol, United Kingdom
| | - Alastair Wilkins
- Department of Neurology, Southmead Hospital, and Clinical Neurosciences, University of Bristol, Bristol, United Kingdom
| | - Owen R Pearson
- Abertawe Bro, Morgannwg University Local Health Board, Swansea, United Kingdom
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, MS Center Dresden, Dresden, Germany
| | - Michael Hutchinson
- School of Medicine and Medical Sciences, University College Dublin, St Vincent’s University, Hospital, Dublin, Ireland
| | - Katharine Harding
- Institute for Psychological Medicine and Clinical Neurosciences, Cardiff University, Wales
| | - Joanne Jones
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Christopher McGuigan
- School of Medicine and Medical Sciences, University College Dublin, St Vincent’s University, Hospital, Dublin, Ireland
| | - Helmut Butzkueven
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Neurology, Box Hill Hospital, Monash University, Melbourne, Australia
| | - Tomas Kalincik
- Clinical Outcomes Research Unit, Melbourne Brain Centre, University of Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Neil Robertson
- Institute for Psychological Medicine and Clinical Neurosciences, Cardiff University, Wales
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Gasperini C, Prosperini L, Tintoré M, Sormani MP, Filippi M, Rio J, Palace J, Rocca MA, Ciccarelli O, Barkhof F, Sastre-Garriga J, Vrenken H, Frederiksen JL, Yousry TA, Enzinger C, Rovira A, Kappos L, Pozzilli C, Montalban X, De Stefano N. Unraveling treatment response in multiple sclerosis: A clinical and MRI challenge. Neurology 2018; 92:180-192. [PMID: 30587516 DOI: 10.1212/wnl.0000000000006810] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 08/31/2018] [Indexed: 01/19/2023] Open
Abstract
Over the last few decades, the improved diagnostic criteria, the wide use of MRI, and the growing availability of effective pharmacologic treatments have led to substantial advances in the management of multiple sclerosis (MS). The importance of early diagnosis and treatment is now well-established, but there is still no consensus on how to define and monitor response to MS treatments. In particular, the clinical relevance of the detection of minimal MRI activity is controversial and recommendations on how to define and monitor treatment response are warranted. An expert panel of the Magnetic Resonance Imaging in MS Study Group analyzed and discussed published studies on treatment response in MS. The evolving concept of no evidence of disease activity and its effect on predicting long-term prognosis was examined, including the option of defining a more realistic target for daily clinical practice: minimal evidence of disease activity. Advantages and disadvantages associated with the use of MRI activity alone and quantitative scoring systems combining on-treatment clinical relapses and MRI active lesions to detect treatment response in the real-world setting were also discussed. While most published studies on this topic involved patients treated with interferon-β, special attention was given to more recent studies providing evidence based on treatment with other and more efficacious oral and injectable drugs. Finally, the panel identified future directions to pursue in this research field.
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Affiliation(s)
- Claudio Gasperini
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy.
| | - Luca Prosperini
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Mar Tintoré
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Maria Pia Sormani
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Massimo Filippi
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Jordi Rio
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Jacqueline Palace
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Maria A Rocca
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Olga Ciccarelli
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Frederik Barkhof
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Jaume Sastre-Garriga
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Hugo Vrenken
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Jette L Frederiksen
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Tarek A Yousry
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Christian Enzinger
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Alex Rovira
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Ludwig Kappos
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Carlo Pozzilli
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Xavier Montalban
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
| | - Nicola De Stefano
- From the Department of Neurosciences (C.G., L.P.), San Camillo-Forlanini Hospital, Rome, Italy; Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology (M.T., J.R., J.S.-G., X.M.), and Magnetic Resonance Unit, Department of Radiology (A.R.), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; Biostatistics Unit (M.P.S.), Department of Health Sciences, University of Genoa; Neuroimaging Research Unit (M.F., M.A.R.), Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Nuffield Department of Clinical Neurosciences (J.P.), West Wing, John Radcliffe Hospital, Oxford; Institutes of Neurology & Healthcare Engineering (O.C., F.B.), University College London (O.C.), UK; Amsterdam Neuroscience and Department of Radiology and Nuclear Medicine (F.B., H.V.), VU University Medical Center, Amsterdam, the Netherlands; Department of Neurology (J.L.F.), Rigshospitalet Glostrup and University of Copenhagen, Denmark; Neuroradiological Academic Unit (T.A.Y.), Institute of Neurology, London, UK; Department of Neurology (C.E.), Medical University of Graz, Austria; Neurologic Clinic and Policlinic, Department of Medicine (L.K.), Clinical Research, Biomedicine and Biomedical Engineering, University Hospital Basel, University of Basel, Switzerland; Department of Neurology and Psychiatry (C.P.), Sapienza University, Rome; and Neurology and Neurometabolic Unit, Department of Neurological and Behavioral Sciences (N.D.S.), University of Siena, Italy
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