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Williams MJ, Amezcua L, Cohan SL, Cohen JA, Delgado SR, Hua LH, Lucassen EB, Piccolo RS, Koulouris CR, Stankiewicz J. Efficacy of Ofatumumab and Teriflunomide in Patients With Relapsing MS From Racial/Ethnic Minority Groups: ASCLEPIOS I/II Subgroup Analyses. Neurology 2024; 103:e209610. [PMID: 39018512 PMCID: PMC11314949 DOI: 10.1212/wnl.0000000000209610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 05/09/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Race and ethnicity may influence the efficacy of disease-modifying therapies in patients with multiple sclerosis (MS). Incidence of MS in ethnically diverse groups may be higher; however, these populations are under-represented in MS trials. This post hoc analysis compared the proportion of patients achieving 3-parameter no evidence of disease activity (NEDA-3) with ofatumumab vs teriflunomide in participants with relapsing MS (RMS) enrolled in the ASCLEPIOS I/II trials by race/ethnicity subgroup. METHODS ASCLEPIOS I/II were identical, double-blind, double-dummy, active-controlled, multicenter, phase 3 trials. Participants were randomized (1:1) to receive ofatumumab 20 mg every 4 weeks or teriflunomide 14 mg once daily for up to 30 months. Pooled data were used to determine the efficacy/safety of ofatumumab vs teriflunomide in participants who self-identified as non-Hispanic Black, non-Hispanic Asian, Hispanic/Latino, or non-Hispanic White. Participants who did not self-identify into one of these groups were classified as other/unknown. RESULTS Of the 1,882 participants, 64 (3.4%) self-identified as non-Hispanic Black, 71 (3.8%) as non-Hispanic Asian, 145 (7.7%) as Hispanic/Latino, and 1,538 (81.7%) as non-Hispanic White. Baseline participant demographics/characteristics were largely balanced across subgroups, aside from minor variations in sex, disease duration, and MRI lesions. From months 0 to 24, the proportion of ofatumumab vs teriflunomide-treated patients achieving NEDA-3 (odds ratio [95% CI]) was as follows: non-Hispanic Black, 33.3% vs 3.4% (15.9 [1.67-151.71; p = 0.0162]); non-Hispanic Asian, 42.9% vs 21.9% (3.18 [0.95-10.59; p = 0.06]); Hispanic/Latino, 36.6% vs 18.6% (3.21 [1.32-7.79; p = 0.01]); and non-Hispanic White, 37.4% vs 16.6% (3.57 [2.73-4.67; p < 0.0001]). Rates of AEs were generally similar between treatment groups and across race/ethnicity subgroups; no new or unexpected safety signals were identified. DISCUSSION Ofatumumab was associated with greater proportions of NEDA-3 achievement than teriflunomide across race/ethnicity subgroups in the ASCLEPIOS trials. Within each treatment group, the proportion of patients achieving NEDA-3 from months 0 to 24 was similar across the subgroups and overall pooled population. Both ofatumumab and teriflunomide were well tolerated. Future MS trials should include ethnically diverse groups to better inform treatment decisions and improve real-world patient outcomes. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov: NCT02792218 (clinicaltrials.gov/ct2/show/NCT02792218), NCT02792231 (clinicaltrials.gov/ct2/show/NCT02792231). Submission date: June 2, 2016. First enrollment: August 26, 2016. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that among patients aged 18-55 years with RMS, the improvement in NEDA-3 with ofatumumab was comparably better than with teriflunomide among patients self-identified as non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, Hispanic/Latino, and other/unknown.
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Affiliation(s)
- Mitzi J Williams
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
| | - Lilyana Amezcua
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
| | - Stanley L Cohan
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
| | - Jeffrey A Cohen
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
| | - Silvia R Delgado
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
| | - Le H Hua
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
| | - Elisabeth B Lucassen
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
| | - Rebecca S Piccolo
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
| | - Chloe R Koulouris
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
| | - James Stankiewicz
- From the Joi Life Wellness MS Center (M.J.W.), Atlanta, GA; University of Southern California (L.A.), Los Angeles; Providence Multiple Sclerosis Center (S.L.C.), Providence Brain and Spine Institute, Portland, OR; Cleveland Clinic Mellen Center (J.A.C.) OH; Department of Neurology (S.R.D.), University of Miami Miller School of Medicine, FL; Cleveland Clinic Lou Ruvo Center for Brain Health (L.H.H.), Las Vegas, NV; Novartis Pharmaceuticals Corporation (E.B.L., R.S.P., J.S.), East Hanover, NJ; and Envision Pharma, Inc. (C.R.K.), Horsham, United Kingdom
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Abbatemarco JR, Aboseif A, Swetlik C, Widmar J, Harvey T, Kunchok A, O'Mahony J, Miller DM, Conway DS. Neighborhood disadvantage, race, and clinical outcomes in neuromyelitis optica spectrum disorder. Mult Scler 2024:13524585241267231. [PMID: 39105475 DOI: 10.1177/13524585241267231] [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: 08/07/2024]
Abstract
BACKGROUND Little is known about the relationship between neighborhood disadvantage and neuromyelitis optica spectrum disorder (NMOSD) outcomes. OBJECTIVE The objective is to determine the impact of neighborhood disadvantage on time from symptom onset to diagnosis and annualized relapse rate (ARR). METHODS Neighborhood disadvantage were captured with the Area Deprivation Index (ADI), a validated measure of neighborhood-level disadvantage. Negative binomial regression models assessed the impact of ADI on diagnostic delay (⩾3 months between symptom onset and diagnosis) and ARR. RESULTS A total of 158 NMOSD patients were identified, a majority of whom were White (56.3%) and female (89.9%) with a mean age of 46 years at diagnosis. The ADI did not significantly affect odds of diagnostic delay (odds ratio (OR) = 0.99, p = 0.26). In univariable models, the ADI was not significantly associated with ARR (OR = 1.004, p = 0.29), but non-White race (OR = 1.541, p = 0.02) and time on immunosuppressive therapies (ISTs; OR = 0.994, p = 0.03) were. White patients used IST for an average of 81% of the follow-up period, compared to an average of 65% for non-White patients (p < 0.01). CONCLUSION No significant relationship between neighborhood-level disadvantage and diagnostic delay or ARR in NMOSD patients was observed. Non-White patients had a higher ARR, which may be related to less IST use.
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Affiliation(s)
- J R Abbatemarco
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Aboseif
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, Cleveland, OH, USA
- Center for Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - C Swetlik
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - J Widmar
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - T Harvey
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Kunchok
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - J O'Mahony
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - D M Miller
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - D S Conway
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Foundation, Cleveland, OH, USA
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Shirozhan S, Rafiee-Vardanjani L, Motie M, Mohamadi S. Home-based telerehabilitation in multiple sclerosis: a scoping review. BMJ Support Palliat Care 2024:spcare-2024-004821. [PMID: 39084690 DOI: 10.1136/spcare-2024-004821] [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: 02/06/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Introducing home-based telerehabilitation (TR) approaches helps clinical experts to choose appropriate and effective interventions and researchers identify knowledge gaps to design clinical trial studies and systematic reviews. PURPOSE This study aimed to review the knowledge of home-based TR in multiple sclerosis. METHOD This scoping review study was conducted based on Arksey and O'Malley's five-step approach. The Embase, PubMed, Cochrane, Web of Sciences, Scopus and ProQuest databases were searched in 2017-2024 to find full-text English-language articles. FINDINGS In 25 studies reviewed, various and extensive home-based interventions have been used in physical and cognitive aspects. CONCLUSION Home-based rehabilitation is applicable, useful, safe and affordable, maintains the continuity of the rehabilitation process and increases patients' adherence to the rehabilitation programme. However, there are challenges such as patients' lack of familiarity with technology and limitations of outcome measurement tools that should be addressed in future studies.
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Affiliation(s)
- Shima Shirozhan
- Department of Nursing, Health in Emergency and Disaster Research Center, Social Health Research Institute, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Leila Rafiee-Vardanjani
- Student Research Committee, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
- School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Mahdieh Motie
- Student Research Committee, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Shamaneh Mohamadi
- Student Research Committee, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Ben-Zacharia AB, Smrtka J, Kalina JT, Vignos M, Smith S. Shared decision-making in underserved populations with multiple sclerosis: A systematic review. Mult Scler Relat Disord 2024; 90:105792. [PMID: 39121597 DOI: 10.1016/j.msard.2024.105792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 07/23/2024] [Accepted: 07/27/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND The concept of shared decision-making (SDM) is valuable to ensure patients receive individualized care. SDM occurs when healthcare providers engage patients in making personal healthcare decisions that could contribute to better long-term outcomes. With the ever-increasing landscape of treatment options available, SDM can be challenging but valuable for patients. Patients from underserved populations are potentially less likely to engage in SDM, impacting their long-term care. This systematic literature review aimed to explore SDM in these patient populations. METHODS Relevant articles were retrieved from PubMed using key search terms, without any restriction on publication date. All searches and data retrieval were conducted between May 25, 2022, and August 17, 2022, and abstracts were reviewed by two independent reviewers. A thematic analysis was used to present the data. RESULTS All search terms yielded 418 articles; 89 were included (33 involving patients with multiple sclerosis [MS]). Reported mean percentage of patients with MS (including from underserved populations) who preferred SDM was 52 % (range: 37.5-71.5; n = 4). Differences in racial/ethnic assimilation of information communicated by clinicians were reported, impacted by the lower literacy level and certain cultural health beliefs in groups of underserved populations. Primary care clinicians play a key role in providing information to patients in underserved populations. CONCLUSIONS There is a clear benefit for SDM for patients with MS, and without it, patients report dissatisfaction, decisional regret, and lack of confidence in the medical system. However, there are several challenges, including the need for further examination of social determinants of health, for underserved patient populations which still need to be addressed.
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Affiliation(s)
- Aliza Bitton Ben-Zacharia
- Hunter Bellevue School of Nursing and Mount Sinai Hospital; Hunter Bellevue School of Nursing, 425 E 25th St, New York, NY 10010, USA; Mount Sinai, 146 East 126 Street, New York, NY 10035, USA.
| | - Jen Smrtka
- Biogen, 225 Binney St, Cambridge, MA 02142, USA
| | | | | | - Stacyann Smith
- Judith Jaffe Multiple Sclerosis Center, Weill Cornell Medicine, 1300 York Ave, New York, NY 10065, USA
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Scalfari A, Traboulsee A, Oh J, Airas L, Bittner S, Calabrese M, Garcia Dominguez JM, Granziera C, Greenberg B, Hellwig K, Illes Z, Lycke J, Popescu V, Bagnato F, Giovannoni G. Smouldering-Associated Worsening in Multiple Sclerosis: An International Consensus Statement on Definition, Biology, Clinical Implications, and Future Directions. Ann Neurol 2024. [PMID: 39051525 DOI: 10.1002/ana.27034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/27/2024]
Abstract
Despite therapeutic suppression of relapses, multiple sclerosis (MS) patients often experience subtle deterioration, which extends beyond the definition of "progression independent of relapsing activity." We propose the concept of smouldering-associated-worsening (SAW), encompassing physical and cognitive symptoms, resulting from smouldering pathological processes, which remain unmet therapeutic targets. We provide a consensus-based framework of possible pathological substrates and manifestations of smouldering MS, and we discuss clinical, radiological, and serum/cerebrospinal fluid biomarkers for potentially monitoring SAW. Finally, we share considerations for optimizing disease surveillance and implications for clinical trials to promote the integration of smouldering MS into routine practice and future research efforts. ANN NEUROL 2024.
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Affiliation(s)
- Antonio Scalfari
- Center of Neuroscience, Department of Medicine, Charing Cross Hospital, Imperial College, London, UK
| | | | - Jiwon Oh
- Division of Neurology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Laura Airas
- University of Turku and Turku University Hospital, Turku, Finland
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN) and Immunotherapy (FZI), Rhine Main Neuroscience Network (Rmn2), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | | | - Cristina Granziera
- Translational Imaging in Neurology (THiNK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurology and MS Center, University Hospital Basel Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Basel, Switzerland
| | | | | | - Zsolt Illes
- Department of Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Jan Lycke
- Department of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Veronica Popescu
- University MS Centre Pelt-Hasselt, Noorderhart Hospital, Belgium Hasselt University, Pelt, Belgium
| | - Francesca Bagnato
- Neuroimaging Unit, Neuroimmunology Division, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurology, VA Hospital, TN Valley Healthcare System, Nashville, TN, USA
| | - Gavin Giovannoni
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
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Nikvarz N, Sedighi B, Ansari M, Shahdizade S, Shojaei R, Sharififar F. Medicinal plants used in multiple sclerosis patients, prevalence and associated factors: a descriptive cross-sectional study. BMC Complement Med Ther 2024; 24:278. [PMID: 39039480 PMCID: PMC11265095 DOI: 10.1186/s12906-024-04587-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 07/10/2024] [Indexed: 07/24/2024] Open
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronic and debilitating disease that not only leads to disability and associated condition but also impacts one's ability to maintain a professional life. People's acceptance and utilization of medicinal plants (MPs) play an important role in managing their treatment process. As a result, this study aims to investigate the use of medicinal herbs among patients with MS. METHODS A descriptive cross-sectional study was conducted on 150 MS patients who visited a private clinic and the MS Association in Kerman, Iran in 2021. A questionnaire comprising questions about sociodemographic information, disease variables, and aspects of MPs usage was utilized for data collection. Statistical analysis was performed using SPSS version 20 (SPSS Inc., Chicago, IL). The Chi-square test was employed to identify any association between demographic characteristics and MPs usage. To determine the prevalence of plant use in a specific area and the consensus among informants, the use value (UV) and Informant consensus factor (Fic) were calculated. RESULTS The study revealed a high prevalence of MPs usage among MS patients. Chamomile (66.6%) and golegavzaban (62.0%) were the most commonly used plants with the highest UV indices (0.88 and 0.82 respectively), while St. John's wort and licorice were rarely used (0.67% and 4% respectively). Participants cited pursuing a healthier lifestyle as the primary reason for using MPs (24%). St. John's wort, lavender, and chamomile were the most satisfying plants (100%, 100%, and 53.0% respectively). Chamomile had the highest Fic too. Most patients were motivated to get MPs from their relatives. CONCLUSIONS Given the widespread use of MPs among MS patients, neurologists should enhance their knowledge in this area to guide patients away from seeking advice from non-professionals. Providing standardized formulations can help prevent potential interactions between MPs and mainstream drugs, thereby improving patients safety and outcomes.
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Affiliation(s)
- Naemeh Nikvarz
- Herbal and Traditional Medicines Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Behnaz Sedighi
- Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Ansari
- Pharmaceutical Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Shirin Shahdizade
- Herbal and Traditional Medicines Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Reyhane Shojaei
- Herbal and Traditional Medicines Research Center, Kerman University of Medical Sciences, Kerman, Iran.
| | - Fariba Sharififar
- Herbal and Traditional Medicines Research Center, Kerman University of Medical Sciences, Kerman, Iran.
- Pharmaceutical Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran.
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Pouradeli S, Khadir E, Rezaeian M, Meimand HAE. Exploring suicidal ideation prevalence in multiple sclerosis patients during the COVID-19 pandemic: A study on the relationship between drug use and suicidal ideation. Mult Scler Relat Disord 2024; 87:105676. [PMID: 38776600 DOI: 10.1016/j.msard.2024.105676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 04/03/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The COVID-19 pandemic has exacerbated psychological challenges, leading to increased rates of clinically significant depression and suicidal ideation among MS patients. Despite advancements in MS treatments, there remains a need to investigate the impact of different drugs on the prevalence of suicidal ideation, particularly in the context of the pandemic. METHOD This cross-sectional study, conducted in 2021, received ethics approval from the Ethics Committee of Kerman University of Medical Science. The study involved 234 MS patients selected from the MS Association in Kerman Province. Questionnaires were prepared and distributed via Google Drive and WhatsApp, with participants providing informed consent. The collected data were analyzed using SPSS software. Inclusion criteria encompassed adults diagnosed with MS according to specific criteria and willing to complete the questionnaires, while exclusion criteria included unclear diagnostic criteria and lack of cooperation. The instruments included a demographic questionnaire, medication checklist, and the Beck Suicidal Thought Scale questionnaire, which has been validated in Iran. RESULTS 202 MS patients completed the questionnaires, most of whom were women and married. The prevalence of Suicidal Ideation was 46.5 %, with 8.9 % at high risk. Factors such as gender, marital status, education, occupation, and city did not show statistically significant differences in SI. Patients with SI had a longer duration of illness and were more likely to have seen a psychiatrist. The COVID-19 pandemic affected the necessary care for 44.6 % of patients and worsened symptoms in 28.7 %. Additionally, 30.2 % of patients had seen a psychiatrist, and the prevalence of SI was significantly higher in this group. The study also explored the prevalence of SI with comorbidities and types of drugs used, finding no statistically significant differences. CONCLUSION The study revealed a high prevalence of suicide ideation among MS patients, emphasizing the need for tailored comprehensive support. Factors contributing to SI included limited healthcare access, fear of COVID-19 complications, social isolation, and heightened anxiety. Recommendations for healthcare providers stress early diagnosis, personalized treatment plans, and collaborative efforts to enhance the well-being of individuals with MS in Iran post-COVID-19.
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Affiliation(s)
- Shiva Pouradeli
- Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Elham Khadir
- Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohsen Rezaeian
- Department of Epidemiology and Biostatistics, School of Health, Occupational Environment Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
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Sidhu NK, Proudfoot H, Adan HM, Fawson S, Moss-Morris R. Diversity and inclusion in behavioural intervention trials in multiple sclerosis: A commentary. Mult Scler 2024; 30:927-933. [PMID: 39054845 DOI: 10.1177/13524585241248279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Affiliation(s)
| | | | | | - Sophie Fawson
- Health Psychology Section, King's College London, London, UK
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DiMauro KA, Swetlik C, Cohen JA. Management of multiple sclerosis in older adults: review of current evidence and future perspectives. J Neurol 2024; 271:3794-3805. [PMID: 38689068 PMCID: PMC11233312 DOI: 10.1007/s00415-024-12384-3] [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: 12/20/2023] [Revised: 04/02/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
IMPORTANCE The prevalence of multiple sclerosis (MS) and aging MS patients is increasing worldwide. There is a need to better understand this MS sub-population, which historically is underrepresented in the literature. This narrative review examines the evolving demographics, disease course, and treatments for older adults with MS (OAMS) to address current knowledge gaps and highlight areas critical for future research. OBSERVATIONS OAMS populations require special consideration by clinicians. Older individuals have different care needs than individuals with adult onset MS who are mid-life or younger. Comorbidities, an aging immune system, increasing neurodegeneration, decreasing neurologic reserve, changing benefit/risk relationship for disease modifying therapies (DMTs), and wellness require special attention to provide holistic comprehensive care. Active areas of research include potential cessation of DMTs and novel disease targets. CONCLUSIONS AND RELEVANCE This review highlights both the current knowledge and information gaps in the literature that are critical to understanding and properly managing OAMS. The aims are to inform MS clinicians in their current practice, as well as inspire future studies which are critical to providing quality and evidence-based care for OAMS.
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Affiliation(s)
- Kimberly A DiMauro
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Carol Swetlik
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Jeffrey A Cohen
- Mellen Center for MS Treatment and Research, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA.
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Ponzano M, Signori A, Bellavia A, Carbone A, Bovis F, Schiavetti I, Montobbio N, Sormani MP. Race and ethnicity in multiple sclerosis phase 3 clinical trials: A systematic review. Mult Scler 2024; 30:934-967. [PMID: 38849992 DOI: 10.1177/13524585241254283] [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: 06/09/2024]
Abstract
BACKGROUND Distinctive differences in multiple sclerosis (MS) have been observed by race and ethnicity. We aim to (1) assess how often race and ethnicity were reported in clinical trials registered on ClinicalTrials.gov, (2) evaluate whether the population was diverse enough, and (3) compare with publications. METHODS We included phase 3 clinical trials registered with results on ClinicalTrials.gov between 2007 and 2023. When race and/or ethnicity were reported, we searched for the corresponding publications. RESULTS Out of the 99 included studies, 56% reported race and/or ethnicity, of which only 26% of those primarily completed before 2017. Studies reporting race or ethnicity contributed to a total of 33,891 participants, mainly enrolled in Eastern Europe. Most were White (93%), and the median percentage of White participants was 93% (interquartile range (IQR) = 86%-98%), compared to 3% for Black (IQR = 1%-12%) and 0.2% for Asian (IQR = 0%-1%). Four trials omitted race and ethnicity in publications and even when information was reported, some discrepancies in terminology were identified and categories with fewer participants were often collapsed. CONCLUSION More efforts should be done to improve transparency, accuracy, and representativeness, in publications and at a design phase, by addressing social determinants of health that historically limit the enrollment of underrepresented population.
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Affiliation(s)
- Marta Ponzano
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Alessio Signori
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Andrea Bellavia
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alessio Carbone
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Francesca Bovis
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Irene Schiavetti
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Noemi Montobbio
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy; Ospedale Policlinico San Martino IRCCS, Genoa, Italy
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11
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Jellinger KA. Depression and anxiety in multiple sclerosis. Review of a fatal combination. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02792-0. [PMID: 38869643 DOI: 10.1007/s00702-024-02792-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 06/01/2024] [Indexed: 06/14/2024]
Abstract
Depression and anxiety are the most frequent neuropsychiatric symptoms of multiple sclerosis (MS), an autoimmune-mediated demyelinating neurodegenerative disease. Their prevalence is 25-65% and 20-54%, respectively, often associated with chronic fatigue and cognitive impairment, but usually not correlated with motor and other deficits, suggesting different pathophysiological mechanisms. Both disorders often arise before MS diagnosis, lead to faster disability and impair the quality of life. Risk factors are (young) age, genetic and family history burden. While no specific neuropathological data for depression (and anxiety) in MS are available, modern neuroimaging studies showed bilateral fronto-temporal, subcortical and limbic atrophies, microstructural white matter lesions and disruption of frontoparietal, limbic and neuroendocrine networks. The pathogenesis of both depression and anxiety in MS is related to shared mechanisms including oxidative stress, mitochondrial dysfunction, neuroinflammation and neuroendocrine mechanisms inducing complex functional and structural brain lesions, but they are also influenced by social and other factors. Unfortunately, MS patients with anxiety, major depression or suicidal thoughts are often underassessed and undertreated. Current treatment, in addition to antidepressant therapy include transcranial magnetic stimulation, cognitive, relaxation, dietary and other healthcare measures that must be individualized. The present state-of- the-art review is based on systematic analysis of PubMed, Google Scholar and Cochrane Library until May 2024, with focus on the prevalence, clinical manifestation, neuroimaging data, immune mechanisms and treatment options. Depression and anxiety in MS, like in many other neuroimmune disorders, are related, among others, to multi-regional patterns of cerebral disturbances and complex pathogenic mechanisms that deserve further elucidation as a basis for early diagnosis and adequate management to improve the quality of life in this disabling disease.
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Affiliation(s)
- Kurt A Jellinger
- Institute of Clinical Neurobiology, Alberichgasse 5/13, Vienna, A-1150, Austria.
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12
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Robers MV, Amezcua L. Current opinion: Racial and ethnic health disparities in multiple sclerosis: considering the social determinants of health. Curr Opin Neurol 2024; 37:245-251. [PMID: 38506756 DOI: 10.1097/wco.0000000000001264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
PURPOSE OF REVIEW We discuss racial and ethnic disparities in multiple sclerosis (MS), outcomes, and social determinants of health (SDoH). We also provide essential considerations needed to bridge the gap in inequalities, including broader representation of racial and ethnic people in clinical trials and research in general and the inclusion of better measures of living conditions. RECENT FINDINGS The incidence and prevalence of MS have become more diverse in the USA. There is increased recognition that racial and ethnic health disparities and inequities exist due to adverse social conditions. Clinical trials have failed to be inclusive and diverse. Training in health disparity is an essential priority of funding sources, and designing clinical trials that consider the barriers these populations face can close significant gaps. SUMMARY The incidence, prevalence, and awareness of MS have seen an incline in diverse racial and ethnic populations. Health disparities exist in MS with Black, Hispanic, and indigenous populations appearing to have worse outcomes. SDoH play a significant role in causing these health disparities. Accessibility to clinical trials and treatment are barriers these populations face. Strategic and earnest interventions considering SDoH are critically needed to develop solutions that collectively improve health and MS care for all.
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Affiliation(s)
- Michael V Robers
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
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13
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Mahla RS. Lymphocytic infiltration in multiple sclerosis. Mult Scler Relat Disord 2024; 85:105533. [PMID: 38479047 DOI: 10.1016/j.msard.2024.105533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/26/2023] [Accepted: 02/29/2024] [Indexed: 05/07/2024]
Affiliation(s)
- Ranjeet Singh Mahla
- Kennedy Institute of Rheumatology, University of Oxford, Headington, Oxford, OX3 7FY, UK.
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14
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Rotstein DL, Freedman MS, Lee L, Marrie RA, Morrow SA, McCombe JA, Parks NE, Smyth P, Konig A, Vyas MV. Predicting time to serologic diagnosis of AQP4+ NMOSD based on clinical factors and social determinants of health. Mult Scler Relat Disord 2024; 83:105434. [PMID: 38242051 DOI: 10.1016/j.msard.2024.105434] [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: 09/03/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Early serologic diagnosis and initiation of targeted therapy are associated with better outcomes in aquaporin-4 IgG positive (AQP4+) neuromyelitis optica spectrum disorder (NMOSD). OBJECTIVE To determine predictors of time to serologic diagnosis of AQP4+ NMOSD. METHODS In CANOPTICS, a multi-centre, Canadian cohort study of NMOSD, we retrospectively evaluated time from the first clinical attack to first positive AQP4-IgG serology. We used a multivariable negative binomial regression model to evaluate possible predictors of time to diagnosis. RESULTS We identified 129 participants with AQP4+ NMOSD from 7 centres. Diagnostic delay of >1 month was observed in 82 (63.6 %). Asian compared to European (White) ethnicity (IRR:0.40, 95 % CI:0.21-0.78), female sex (IRR:0.56, 95 % CI:0.32-0.99), later calendar year (IRR:0.84, 95 % CI:0.81-0.86), and hospitalization for the first attack (IRR:0.35, 95 % CI:0.20-0.62) were associated with shorter times to serologic diagnosis. We did not observe any overall effect of Afro-Caribbean ethnicity, but in exploratory analyses, Afro-Caribbean individuals with low income had longer times to diagnosis. CONCLUSION More than 60 % of patients with NMOSD experienced delays to AQP4-IgG serologic diagnosis in this cohort. Given evidence of more adverse long-term outcomes in Afro-Caribbean individuals with NMOSD, intersectional effects of ethnicity and social determinants of health merit further study.
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Affiliation(s)
- Dalia L Rotstein
- St. Michael's Hospital, 30 Bond St., Toronto, Ontario M5B 1W8, Canada; Department of Medicine, University of Toronto, 6 Queen's Park Crescent West, 3rd floor, Toronto, Ontario M5S 3H2, Canada.
| | - Mark S Freedman
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Liesly Lee
- Department of Medicine, University of Toronto, 6 Queen's Park Crescent West, 3rd floor, Toronto, Ontario M5S 3H2, Canada; Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, Canada
| | - Ruth Ann Marrie
- Departments of Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sarah A Morrow
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada; University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Andrea Konig
- St. Michael's Hospital, 30 Bond St., Toronto, Ontario M5B 1W8, Canada
| | - Manav V Vyas
- St. Michael's Hospital, 30 Bond St., Toronto, Ontario M5B 1W8, Canada; Department of Medicine, University of Toronto, 6 Queen's Park Crescent West, 3rd floor, Toronto, Ontario M5S 3H2, Canada
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15
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Huynh TLT, Williams MJ, Motl RW. Walking and physical performance in black and white adults with multiple sclerosis controlling for social determinants of health. Mult Scler Relat Disord 2024; 83:105439. [PMID: 38219300 DOI: 10.1016/j.msard.2024.105439] [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: 11/03/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND There is evidence for reduced walking and physical performance in persons with multiple sclerosis (MS) compared with healthy controls (HCs). There is further evidence suggesting increased overall mobility disability in Black persons with MS compared with White counterparts, yet little is known about the interplay of social determinants of health (SDOH) when considering differences in walking and physical performance. PURPOSE This cross-sectional, comparative study examined differences in walking and physical performance in Black and White persons with MS and HCs (MS Status), statistically controlling for SDOH. METHODS The study sample consisted of 208 persons with MS (141 White participants and 67 Black participants) and 95 HCs (59 White participants and 36 Black participants). Walking and physical function were measured using timed 25-foot walk (T25FW), six-minute walk (6MW), timed-up-and-go (TUG), and short physical performance battery (SPPB). We examined the differences in the walking and physical functions as a function of MS Status (MS vs. HCs) and Race (Black vs. White) using Multivariate Analysis of Covariance, controlling for age, sex, marital status and SDOH (i.e., education, employment, income). RESULTS There were no significant interactions between MS Status and Race on the outcomes, and the main effects of MS Status and Race remained statistically significant, controlling for SDOH and covariates. The main effects indicated significant lower T25FW (F = 34.6, p < .001, Ƞp2 = 0.11), 6MW (F = 58.5, p < .001, Ƞp2 = 0.18), TUG (F = 22.1, p < .001, Ƞp2 = 0.08), and SPPB (F = 25.2, p < .001, Ƞp2 = 0.09) performance for MS than HCs, and lower T25FW (F = 15.5, p < .001, Ƞp2 = 0.05), 6MW (F = 11.6, p < .001, Ƞp2 = 0.04), and TUG (F = 4.1, p < .05, Ƞp2 = 0.02) performance in Black than White samples. CONCLUSIONS We conclude that MS Status and Race independently influence walking and physical performance even after accounting for SDOH, and Black persons with MS have compromised walking and physical performance, perhaps necessitating focal rehabilitation.
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Affiliation(s)
- Trinh L T Huynh
- Department of Kinesiology and Nutrition, School of Applied Health Sciences, University of Illinois Chicago, 1919 W Taylor Street, Chicago, IL, USA.
| | | | - Robert W Motl
- Department of Kinesiology and Nutrition, School of Applied Health Sciences, University of Illinois Chicago, 1919 W Taylor Street, Chicago, IL, USA
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16
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Radzik AM, Amezcua L, Anderson A, Gilmore S, Ahmad S, Brandstadter R, Fabian MT, Graham EL, Hodgkinson S, Horton L, Jacobs DA, Katz Sand IB, Kohli A, Levine L, McLemore M, Okai AF, Patel J, Poole S, Riley C, Satyanarayan S, Tardo L, Verter E, Villacorta V, Zimmerman V, Zuroff L, Williams MJ, Houtchens MK, Bove R. Disparities by Race in Pregnancy Care and Clinical Outcomes in Women With Multiple Sclerosis: A Diverse Multicenter Cohort. Neurology 2024; 102:e208100. [PMID: 38261988 PMCID: PMC10962915 DOI: 10.1212/wnl.0000000000208100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 11/15/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Racial disparities exist in both neurologic and obstetric populations, underscoring the importance of evaluating pregnancy outcomes in diverse women with multiple sclerosis (MS). The objective of this multicenter retrospective study was to compare pregnancy care and outcomes between Black and Hispanic (underrepresented) and White women with MS. METHODS Demographic and clinical data were extracted from medical records of 9 US MS centers for women with MS/clinically isolated syndrome who delivered live births between 2010 and 2021. Sites identified at last 15 consecutive Black/Hispanic women and a matching number of White women. Socioeconomic factors, pregnancy, and MS care/outcomes were compared between groups (underrepresented and White and then Black and Hispanic) using Wilcoxon rank sum (U statistic and effect size r reported), χ2, t tests and logistic regressions as appropriate to data type. Multiple imputation by chained equation was used to account for missing data. RESULTS Overall, 294 pregnancies resulting in live births were analyzed ( 81 Black, 67 Hispanic, and 146 White mothers). Relative to underrepresented women, White women lived in areas of higher median (interquartile range [IQR]) Child Opportunity Index (79 [45.8] vs 22 [45.8], U = 3,824, r = 0.56, p < 0.0001) and were more often employed (84.9% vs 75%, odds ratio [OR] 2.57, CI 1.46-4.50, p = 0.0008) and privately insured (93.8% vs 56.8%, OR 11.6, CI 5.5-24.5, p < 0.0001) and more received a 14-week ultrasound (98.6% vs 93.9%, OR 4.66, CI 0.99-21.96, p = 0.027). Mode of delivery was significantly different between the three groups (X2(10,294) = 20.38, p = 0.03); notably, Black women had the highest rates of emergency cesarean deliveries, and Hispanic women highest rates of uncomplicated vaginal deliveries. Babies born to underrepresented women had lower median (IQR) birthweights than babies born to White women (3,198 g [435.3 g] vs 3,275 g [412.5 g], U = 9,255, r = 0.12, p = 0.04) and shorter median (IQR) breastfeeding duration (4.5 [3.3] vs 6.0 [4.2] months, U = 8,184, r = 0.21, p = 0.003). While underrepresented women were younger than White women (mean [SD] 30.9 [4.8] vs 33.8 [4.0], t = 1.97, CI 1.96-3.98, p < 0.0001), their median (Q1-Q3, IQR) Expanded Disability Status Scale was higher (1.5 [1-2.5, 1.5] vs 1 [0-1.5, 1.5], U = 7,260, r = 0.29, p < 0.0001) before pregnancy. Finally, medical records were missing more key data for Black women (19.7% missing vs 8.9% missing, OR 2.54, CI 1.25-5.06, p = 0.008). DISCUSSION In this geographically diverse multicenter cohort, underrepresented women entered pregnancy with higher disability and fewer health care resources. Pregnancy represents a pivotal window where structural factors affect maternal and fetal health and neurologic trajectories; it is a critical period to optimize care and health outcomes.
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Affiliation(s)
- Anne Marie Radzik
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Lilyana Amezcua
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Annika Anderson
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Serena Gilmore
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Sophie Ahmad
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Rachel Brandstadter
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Michelle T Fabian
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Edith L Graham
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Sophia Hodgkinson
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Lindsay Horton
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Dina A Jacobs
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Ilana B Katz Sand
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Amit Kohli
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Libby Levine
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Monica McLemore
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Annette F Okai
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Jasmin Patel
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Shane Poole
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Claire Riley
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Sammita Satyanarayan
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Lauren Tardo
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Elizabeth Verter
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Veronica Villacorta
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Vanessa Zimmerman
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Leah Zuroff
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Mitzi J Williams
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Maria K Houtchens
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
| | - Riley Bove
- From the University of California San Francisco (A.M.R.); Department of Neurology (L.A.), University of Southern California, Los Angeles; Department of Neurology (A.A., S.P., R. Bove), UCSF Weill Institute for the Neurosciences, and Department of Neurology (S.G.), University of California San Francisco; Department of Neurology (S.A., E.L.G.), Northwestern University, Chicago, IL; Department of Neurology (R. Brandstadter, D.A.J., V.Z., L.Z.), Hospital of the University of Pennsylvania, Philadelphia; Corinne Goldsmith Dickinson Center for MS (M.T.F., I.B.K.S., A.K., J.P., S.S., E.V.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women's Hospital (S.H., M.K.H.), Boston, MA; University of Texas Southwestern Medical Center (L.H., L.T.), Dallas; Center for Translational and Computational Neuroimmunology and Multiple Sclerosis Center (L.L., C.R.), Department of Neurology, Columbia University Irving Medical Center, New York, NY; Family Health Care Nursing Department (M.M.), School of Nursing, University of California San Francisco; North Texas Institute of Neurology and Headache (A.F.O.), Frisco; University of Southern California (V.V.), Los Angeles; and Joi Life Wellness Group (M.J.W.), Multiple Sclerosis Center, Smyrna, GA
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Bridge F, Brotherton J, Stankovich J, Sanfilippo PG, Skibina OG, Buzzard K, Kalincik T, Nguyen AL, Guo K, Monif M, Wrede CD, Rath L, Taylor L, Butzkueven H, Jokubaitis VG, Van Der Walt A. Risk of Cervical Abnormalities for Women With Multiple Sclerosis Treated With Moderate-Efficacy and High-Efficacy Disease-Modifying Therapies. Neurology 2024; 102:e208059. [PMID: 38306594 DOI: 10.1212/wnl.0000000000208059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/27/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The impact of immunomodulatory therapies on the risk of cervical pre-cancer and invasive cancer development is important for the health and safety of women with multiple sclerosis (wwMS). We investigate the risk of cervical abnormalities in wwMS treated with disease-modifying therapies (DMTs). METHODS This is a multicenter cohort study with data collected from 1998 to 2019 in Victoria, Australia. Data linkage was performed using matching records from the MSBase Registry, the National Human Papillomavirus (HPV) Vaccination Program Register, and the Victorian Cervical Cytology Register. The primary outcome was the detection of any type of cervical abnormality as determined by cytology or histology. Survival methods were used to assess the time to cervical abnormality detection on cervical screening tests (CSTs). Crude and adjusted Cox proportional hazards models were used to determine time to and magnitude of association of DMTs with the risk of cervical abnormality. In a sensitivity analysis, we constructed standardized survival curves averaged over the same set of covariates to determine the commensurate population-average (marginal) causal effects. RESULTS We included 248 wwMS. The incidence of abnormal CSTs was lower (p < 0.001) for women not exposed to moderate-high-efficacy therapy (10.2 per 1,000 patient-years [95% confidence interval (CI) 5.5-14.9]), compared with those exposed (36.6 per 1,000 patient-years [95% CI 21.7-51.6]). Exposure to higher efficacy treatment was associated with a 3.79-fold increased hazard (95% CI 2.02-7.08, p < 0.001) of developing a cervical abnormality relative to those not exposed. When adjusted for vaccination status, smoking, hormonal contraceptive use, and socioeconomic status, the risk remained elevated at 3.79 (95% CI 1.99-7.21, p < 0.001). Marginal hazard ratios declined over time, ranging from 3.90 (95% CI 2.09-7.27) at 20 years of age to 2.06 (95% CI 1.14-3.73) at 70 years of age. DISCUSSION A greater than three-and-a-half-fold increased risk of cervical abnormalities was found after exposure to moderate-high-efficacy DMTs. This risk persisted despite adjusting for HPV vaccination status, hormonal contraception use, smoking, and socioeconomic status. If confirmed in future studies, we would advocate for wwMS exposed to moderate-high-efficacy DMTs to be treated in line with immune-deficient paradigm in cervical screening and HPV vaccination programs. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that highly active MS therapy compared with less active therapy increases the risk of developing cervical abnormalities among women with MS.
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Affiliation(s)
- Francesca Bridge
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Julia Brotherton
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Jim Stankovich
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Paul G Sanfilippo
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Olga G Skibina
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Katherine Buzzard
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Tomas Kalincik
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Ai-Lan Nguyen
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Kylie Guo
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Mastura Monif
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - C David Wrede
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Louise Rath
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Lisa Taylor
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Helmut Butzkueven
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Vilija G Jokubaitis
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
| | - Anneke Van Der Walt
- From the Department of Neuroscience (F.B., J.S., P.G.S., O.G.S., M.M., H.B., V.G.J., A.V.D.W.), Central Clinical School, Monash University; Department of Neurology (F.B., O.G.S., M.M., L.R., H.B., V.G.J., A.V.D.W.), Alfred Health, Melbourne; Australian Centre for the Prevention of Cervical Cancer (formerly Victorian Cytology Service) (J.B.), Carlton South; Centre for Epidemiology and Biostatistics (J.B.), Melbourne School of Population and Global Health, University of Melbourne; Department of Neurosciences (O.G.S., K.B.), Eastern Health; MS Centre (K.B., T.K., A.-L.N., K.G., M.M., L.T.), Department of Neurology, Royal Melbourne Hospital; Eastern Health Clinical School (K.B., A.-L.N.), Monash University, Box Hill; CORe (T.K., A.-L.N.), Department of Medicine, University of Melbourne; Oncology and Dysplasia Unit (C.D.W.), Royal Women's Hospital, Parkville; and Department of Obstetrics and Gynaecology (C.D.W.), University of Melbourne, Australia
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Giovannoni G, Ford HL, Schmierer K, Middleton R, Stennett AM, Pomeroy I, Fisniku L, Scalfari A, Bannon C, Stross R, Hughes S, Williams A, Josephs S, Peel C, Straukiene A. MS care: integrating advanced therapies and holistic management. Front Neurol 2024; 14:1286122. [PMID: 38351950 PMCID: PMC10862341 DOI: 10.3389/fneur.2023.1286122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/23/2023] [Indexed: 02/16/2024] Open
Abstract
Lifestyle and environmental factors are key determinants in disease causality and progression in neurological conditions, including multiple sclerosis (MS). Lack of exercise, poor diet, tobacco smoking, excessive alcohol intake, social determinants of health, concomitant medications, poor sleep and comorbidities can exacerbate MS pathological processes by impacting brain health and depleting neurological reserves, resulting in more rapid disease worsening. In addition to using disease-modifying therapies to alter the disease course, therapeutic strategies in MS should aim to preserve as much neurological reserve as possible by promoting the adoption of a "brain-healthy" and "metabolically-healthy" lifestyle. Here, we recommend self-regulated lifestyle modifications that have the potential to improve brain health, directly impact on disease progression and improve outcomes in people with MS. We emphasise the importance of self-management and adopting a multidisciplinary, collaborative and person-centred approach to care that encompasses the healthcare team, family members and community support groups.
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Affiliation(s)
- Gavin Giovannoni
- Centre for Neuroscience, Surgery and Trauma, Faculty of Medicine and Dentistry, The Blizard Institute, Queen Mary University of London, London, United Kingdom
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Helen L. Ford
- Leeds Teaching Hospitals, University of Leeds, Leeds, United Kingdom
| | - Klaus Schmierer
- Centre for Neuroscience, Surgery and Trauma, Faculty of Medicine and Dentistry, The Blizard Institute, Queen Mary University of London, London, United Kingdom
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Rod Middleton
- Disease Registers & Data Research in Health Data Science, Swansea University Medical School, Swansea, United Kingdom
| | - Andrea M. Stennett
- Centre for Neuroscience, Surgery and Trauma, Faculty of Medicine and Dentistry, The Blizard Institute, Queen Mary University of London, London, United Kingdom
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ian Pomeroy
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
- Department of Neurology, University of Liverpool, Liverpool, United Kingdom
| | - Leonora Fisniku
- Department of Neurosciences (Addenbrooke’s), Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Antonio Scalfari
- Centre of Neuroscience, Department of Medicine, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | | | - Ruth Stross
- Neurology Academy, Sheffield, United Kingdom
- Kingston Hospitals NHS Foundation Trust, Surrey, United Kingdom
| | - Sarah Hughes
- Torbay and South Devon NHS Foundation Trust, Torquay, United Kingdom
| | - Adam Williams
- Devon Partnership NHS Trust, Paignton, United Kingdom
| | | | | | - Agne Straukiene
- Torbay and South Devon NHS Foundation Trust, Torquay, United Kingdom
- University of Plymouth, Plymouth, United Kingdom
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19
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Polick CS, Rubenstein D, Shah S, Beckham JC, Calhoun PS, Noonan D. Addressing Smoking in Persons With Multiple Sclerosis: State of the Science and Need for a Targeted Intervention. Nicotine Tob Res 2024; 26:250-252. [PMID: 37625016 DOI: 10.1093/ntr/ntad159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Carri S Polick
- School of Nursing, Duke University, Durham, NC, USA
- Durham VA Health Care System, Durham, NC, USA
| | | | - Suma Shah
- Neurology Department, Duke University School of Medicine, Durham, NC, USA
- MS Center of Excellence, Durham VA Medical Center, Durham VA, USA
| | - Jean C Beckham
- Durham VA Health Care System, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham, NC, USA
| | - Patrick S Calhoun
- Durham VA Health Care System, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham, NC, USA
| | - Devon Noonan
- School of Nursing, Duke University, Durham, NC, USA
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20
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Stein M, Grittner U, Stegherr R, Gerischer L, Stascheit F, Hoffmann S, Herdick M, Legg D, Marbin D, Meisel A, Lehnerer S. The burden of myasthenia gravis - highlighting the impact on family planning and the role of social support. Front Neurol 2023; 14:1307627. [PMID: 38162439 PMCID: PMC10755901 DOI: 10.3389/fneur.2023.1307627] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Background Myasthenia gravis (MG) is a rare autoimmune disease and chronic condition that necessitates specialized care. Patients experience a significant burden of disease affecting various aspects of their lives. The aim of this study was to investigate the impact of MG on family planning, challenges associated with pregnancy, childcare responsibilities and the extent to which MG patients perceive and utilize social support. Methods This analysis used data from our main data of a large cross-sectional study built on a questionnaire-based survey encompassing 1,660 MG patients and members of the German Myasthenia Association (Deutsche Myasthenie Gesellschaft), and focused on sociodemographic, clinical and family planning relevant data points. Results Decisions regarding family planning were significantly impacted for individuals with MG when MG symptoms started either before or during their family planning (men: n = 19 and 29.7%; women: n = 156 and 58.4%). In this subgroup a substantial proportion opted against parenthood due to MG (men: n = 8 and 50.0%; women: n = 54 and 38.0% and/or another n = 12 and 8.4% of female participants encountered partner-related refusals). In the subgroup of female SP with MG starting before or during family planning who have reported ever been pregnant the self-reported miscarriage rate was 29.0% (n = 51). MG patients with medium incomes or moderate disease severity reported lower levels of perceived social support. 42.7% (n = 606) of participants needed assistance in negotiations with health insurers and 28.0% (n = 459) needed support for transportation to medical appointments. Conclusion This study shows a significant impact of MG on family planning decisions, affecting both women and men, and often resulting in life-altering decisions such as voluntary childlessness due to MG. The significance of social support becomes evident as a vital factor, especially when navigating through the healthcare system. Tailored healthcare approaches, organized guidance and comprehensive support is needed to enable informed decision-making and offer assistance for MG patients. Clinical trial registration https://clinicaltrials.gov/study/NCT03979521, Registered 7 June 2019 (retrospectively registered).
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Affiliation(s)
- Maike Stein
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Berlin, Germany
| | - Ulrike Grittner
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Regina Stegherr
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - Meret Herdick
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - David Legg
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Derin Marbin
- Department of Psychiatry of University Hospital Charité in St. Hedwig Hospital Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychiatry and Neurosciences, Berlin, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Berlin, Germany
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21
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Mateen FJ, Trápaga Hacker C. Perceptions of people with multiple sclerosis on social determinants of health: Mixed methods. Mult Scler Relat Disord 2023; 80:105089. [PMID: 37897932 DOI: 10.1016/j.msard.2023.105089] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/18/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE To explore the social determinants of health (SDOH) in people with multiple sclerosis (MS) with SDOH, elucidating the SDOH variables of highest salience in this geographical region. METHODS Focus groups and a structured survey of Massachusetts residents with SDOH and a diagnosis of MS were conducted by a neurologist and staff, December 2022-July 2023, via Zoom™. Twenty-one consecutively-recruited, convenience-sampled adults participated in four groups. A thematic inductive approach was taken. RESULTS Participants (average age 45 years old; average time since MS diagnosis 13.7 years; 14 cisgender female, 1 transgender female, 5 cisgender male, 1 non-binary; 33 % white, 57 % black, 5 % Asian, 5 % other; 18 % Hispanic/Latinx; modal response of 5 SDOH) identified the following key SDOH: (1) race and ethnicity, related to (a) diagnostic delays in MS, (b) limited familiarity with MS and its etiology, and (c) value of ongoing MS care; (2) gender, focused on limited published data in African American men and transgender people; (3) social and community contexts; and (4) financial burdens, related to (a) out-of-pocket costs of MS disease modifying therapies, (b) lost work time, and (c) transportation. Lower frequency SDOH variables were access to public toilets, lost job promotions, environmental exposures, and concern about discrimination. Unmet needs emphasized (1) public understanding of MS; (2) financial support for DMT costs, closer access to infusion centers, and culturally competent care; (3) support for research participation; (4) reliable transportation; and (5) patient awareness of extant services and support programs. CONCLUSIONS This in-depth assessment of people with MS who possess multiple SDOH identified the most salient and commonly experienced SDOH, common themes related to the SDOH in MS, unmet needs, and future opportunities.
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Affiliation(s)
- Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, United States; Harvard Medical School, United States.
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22
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Vitturi BK, Montecucco A, Rahmani A, Dini G, Durando P. Occupational risk factors for multiple sclerosis: a systematic review with meta-analysis. Front Public Health 2023; 11:1285103. [PMID: 38054069 PMCID: PMC10694508 DOI: 10.3389/fpubh.2023.1285103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/02/2023] [Indexed: 12/07/2023] Open
Abstract
Objective We decided to conduct the first systematic review with meta-analysis to provide the highest level of up-to-date evidence on the occupational risk factors for Multiple Sclerosis. Methods A systematic, comprehensive literature search was performed in four electronic academic databases. We included any case-control study that enrolled working-age subjects and compared the proportion of MS cases with controls who were not exposed to an occupational risk factor. The primary outcome was the occurrence of MS. The quality assessment was performed with the Critical Appraisal Checklist for Case Control Studies, developed, and validated by the Joanna Briggs Institute. All the selection process was also carried out by two independent and previously trained researchers. Results Overall, the total sample included 19,004 people with MS and 4,164,162 controls. Agricultural workers (OR = 1.44, 95% CI 1.13-1.83), offshore workers (OR = 3.56, 95% CI 2.74-4.61), and hairdressers (OR = 8.25, 95% CI 1.02-66.52) were associated with a higher probability of being diagnosed with MS. In parallel, workers exposed to toxic fumes from oil wells (OR = 16.80, 95% CI 8.33-33.90), low-frequency magnetic fields (OR = 1.71, 95% CI 1.03-2.72), and pesticides (OR = 3.17, 95% CI = 2.53-3.99) also had an increased likelihood of having MS. Conclusion Our study has the potential to influence more assertive public policies. Nevertheless, future studies on how the occupational setting may contribute to the incidence of MS are highly recommended. Systematic review registration The protocol was registered in the international prospective register of systematic reviews (PROSPERO- CRD42023443257).
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Affiliation(s)
| | - Alfredo Montecucco
- Department of Health Sciences, University of Genoa, Genoa, Italy
- Occupational Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alborz Rahmani
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Guglielmo Dini
- Department of Health Sciences, University of Genoa, Genoa, Italy
- Occupational Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Paolo Durando
- Department of Health Sciences, University of Genoa, Genoa, Italy
- Occupational Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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23
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Ciampi E, Soler B, Uribe-San-Martin R, Jürgensen L, Guzman I, Keller K, Reyes A, Bravo-Grau S, Cruz JP, Cárcamo C. Socioeconomic, health-care access and clinical determinants of disease severity in Multiple Sclerosis in Chile. Mult Scler Relat Disord 2023; 78:104918. [PMID: 37562199 DOI: 10.1016/j.msard.2023.104918] [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: 04/12/2023] [Revised: 07/07/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND MS severity may be affected by genetic, patient-related, disease-related and environmental factors. Socioeconomic status, including income and healthcare access, amongst others, may also have a role in affecting diagnostic delay or therapy prescription. In Chile, two main healthcare systems exist, public-healthcare and private-healthcare, nonetheless universal care laws (e.g., access to High Efficacy Therapy-HET), including both systems, have been recently enacted for people with MS. OBJECTIVE To assess the role of Socioeconomic Conditions (SEC), clinical variables and public health policies on the impact of disease severity of MS patients in Chile. METHODS Multicentric, observational, cross-sectional study including patients from two reference centres (1 national reference centre from the private-health system and 1 regional reference centre from the public-health system). SEC and clinical variables included healthcare insurance (private or public), subclassification of health insurance according to monthly income, sex, age at onset, diagnostic delay, disease duration, diagnosis before HET law (as a proxy of HET delay), and current HET treatment. Progression Index (PI), EDSS ≥6.0 and Progressive MS diagnosis were used as outcome measures. Multivariable binary logistic regression was performed. RESULTS We included 604 patients (460 private-health, 144 public-health), 67% women, 100% white/mestizo, 88% RRMS, mean age 42±12 years, mean age at onset 32±11 years, mean disease duration 10±6 years, median diagnostic delay 0 (0-34) years, 86% currently receiving any DMT, 55% currently receiving HET, median EDSS at last visit of 2.0 (0-10), and median PI 0.17 (0-4.5). Lower monthly income was associated with higher EDSS and higher PI. In the multivariable analysis, public-healthcare (OR 10.2), being diagnosed before HET-law (OR 4.89), longer diagnostic delay (OR 1.26), and older age at onset (OR 1.05) were associated with a higher risk of PI>0.2, while current HET (OR 0.39) was a protective factor. Diagnosis before HET-law (OR 7.59), public-healthcare (OR 6.49), male sex (OR 2.56), longer disease duration (OR 1.2) and older age at onset (OR 1.1) were associated with a higher risk of Progressive MS. Public-healthcare (OR 5.54), longer disease duration (OR 1.14) and older age at onset (OR 1.08) were associated with a higher risk of EDSS ≥6.0 while current treatment with HET had a trend as being a protective factor (OR 0.44, p = 0.05). CONCLUSION MS severity is impacted by non-modifiable factors such as sex and age at onset. Interventions focused on shortening diagnostic delay and encouraging early access to high-efficacy therapies, as well as initiatives that may reduce the disparities inherent to lower socioeconomic status, may improve outcomes in people with MS.
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Affiliation(s)
- E Ciampi
- Neurology Department, Pontificia Universidad Católica de Chile, Santiago, Chile; Neurology Service, Hospital Sótero del Río, Santiago, Chile.
| | - B Soler
- Neurology Department, Pontificia Universidad Católica de Chile, Santiago, Chile; Neurology Service, Hospital Sótero del Río, Santiago, Chile
| | - R Uribe-San-Martin
- Neurology Department, Pontificia Universidad Católica de Chile, Santiago, Chile; Neurology Service, Hospital Sótero del Río, Santiago, Chile
| | - L Jürgensen
- Neurology Department, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - I Guzman
- Neurology Department, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - K Keller
- Neurology Department, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - A Reyes
- Neurology Department, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - S Bravo-Grau
- Neurorradiology Department, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - J P Cruz
- Neurorradiology Department, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - C Cárcamo
- Neurology Department, Pontificia Universidad Católica de Chile, Santiago, Chile
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24
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Williams MJ, Amezcua L, Chinea A, Cohan S, Okai A, Okuda DT, Vargas W, Belviso N, Božin I, Jiang X, Lewin JB, Lyons J, Shen C, England SM, Grimes N. Real-World Safety and Effectiveness After 5 Years of Dimethyl Fumarate Treatment in Black and Hispanic Patients with Multiple Sclerosis in ESTEEM. Neurol Ther 2023; 12:1669-1682. [PMID: 37354276 PMCID: PMC10444730 DOI: 10.1007/s40120-023-00517-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/07/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION Multiple sclerosis (MS) clinical trials have included low numbers of patients from racial and ethnic minority populations; therefore, it is uncertain whether differences exist in response to disease-modifying therapies. We evaluated the real-world safety and effectiveness of dimethyl fumarate (DMF) treatment over 5 years in four patient cohorts: Black, non-Black, Hispanic, and non-Hispanic people with relapsing-remitting MS. METHODS ESTEEM is an ongoing, 5-year, multinational, prospective study evaluating the long-term safety and effectiveness of DMF in people with MS. The analysis included patients newly prescribed DMF in routine practice at 393 sites globally. RESULTS Overall, 5251 patients were analyzed (220 Black, 5031 non-Black; 105 Hispanic, 5146 non-Hispanic). Median (min-max) months of follow-up was 32 (0-72) for Black, 29 (1-77) for Hispanic, and 41 (0-85) for both the non-Black and non-Hispanic populations. In total, 39 (18%) Black and 29 (28%) Hispanic patients reported adverse events leading to treatment discontinuation versus 1126 (22%) non-Black and 1136 (22%) non-Hispanic patients; gastrointestinal disorders were the most common in all subgroups. Median lymphocyte counts decreased by 37% in Black, 40% in non-Black, 10% in Hispanic, and 39% in non-Hispanic patients in the first year, then remained stable and above the lower limit of normal in most patients. Annualized relapse rates (ARRs) (95% confidence intervals) up to 5 years were 0.054 (0.038-0.078) for Black, 0.077 (0.072-0.081) for non-Black, 0.069 (0.043-0.112) for Hispanic, and 0.076 (0.072-0.081) for non-Hispanic populations, representing reductions of 91-92% compared with ARR 12 months before study entry (all p < 0.0001). CONCLUSION The safety profile of DMF in these subgroups was consistent with the overall ESTEEM population. Relapse rates remained low in Black and Hispanic patients, and consistent with non-Black and non-Hispanic patients. These data demonstrate a comparable real-world treatment benefit of DMF in Black and Hispanic patients. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02047097.
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Affiliation(s)
| | - Lilyana Amezcua
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Stanley Cohan
- Providence Portland Medical Center, Portland, OR, USA
| | - Annette Okai
- North Texas Institute of Neurology and Headache, Plano, TX, USA
| | - Darin T Okuda
- Neuroinnovation Program, UT Southwestern Medical Center, Dallas, TX, USA
| | - Wendy Vargas
- Columbia University Medical Center, New York City, NY, USA
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25
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He A, Manouchehrinia A, Glaser A, Ciccarelli O, Butzkueven H, Hillert J, McKay KA. Premorbid Sociodemographic Status and Multiple Sclerosis Outcomes in a Universal Health Care Context. JAMA Netw Open 2023; 6:e2334675. [PMID: 37751208 PMCID: PMC10523174 DOI: 10.1001/jamanetworkopen.2023.34675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/11/2023] [Indexed: 09/27/2023] Open
Abstract
Importance Multiple sclerosis (MS) severity may be informed by premorbid sociodemographic factors. Objective To determine whether premorbid education, income, and marital status are associated with future MS disability and symptom severity, independent of treatment, in a universal health care context. Design, Setting, and Participants This nationwide observational cohort study examined data from the Swedish MS Registry linked to national population registries from 2000 to 2020. Participants included people with MS onset from 2005 to 2015 and of working age (aged 23 to 59 years) 1 year and 5 years preceding disease onset. Exposures Income quartile, educational attainment, and marital status measured at 1 and 5 years preceding disease onset. Main Outcome and Measures Repeated measures of Expanded Disability Status Scale (EDSS) scores and patient-reported Multiple Sclerosis Impact Scale (MSIS-29) scores. Models were adjusted for age, sex, relapses, disease duration, and treatment exposure. Secondary analyses further adjusted for comorbidity. All analyses were stratified by disease course (relapse onset and progressive onset). Results There were 4557 patients (mean [SD] age, 37.5 [9.3] years; 3136 [68.8%] female, 4195 [92.1%] relapse-onset MS) with sociodemographic data from 1-year preonset of MS. In relapse-onset MS, higher premorbid income and education correlated with lower disability (EDSS, -0.16 [95% CI, -0.12 to -0.20] points) per income quartile; EDSS, -0.47 [95% CI, -0.59 to -0.35] points if tertiary educated), physical symptoms (MSIS-29 physical subscore, -14% [95% CI, -11% to -18%] per income quartile; MSIS-29 physical subscore, -43% [95% CI, -35% to -50%] if tertiary educated), and psychological symptoms (MSIS-29 psychological subscore, -12% [95% CI, -9% to -16%] per income quartile; MSIS-29 psychological subscore, -25% [95% CI, -17% to -33%] if tertiary educated). Marital separation was associated with adverse outcomes (EDSS, 0.34 [95% CI, 0.18 to 0.51]; MSIS-29 physical subscore, 35% [95% CI, 12% to 62%]; MSIS-29 psychological subscore, 25% [95% CI, 8% to 46%]). In progressive-onset MS, higher income correlated with lower EDSS (-0.30 [95% CI, -0.48 to -0.11] points per income quartile) whereas education correlated with lower physical (-34% [95% CI, -53% to -7%]) and psychological symptoms (-33% [95% CI, -54% to -1%]). Estimates for 5-years preonset were comparable with 1-year preonset, as were the comorbidity-adjusted findings. Conclusions and relevance In this cohort study of working-age adults with MS, premorbid income, education, and marital status correlated with disability and symptom severity in relapse-onset and progressive-onset MS, independent of treatment. These findings suggest that socioeconomic status may reflect both structural and individual determinants of health in MS.
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Affiliation(s)
- Anna He
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Centre for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
- Queen Square MS Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, United Kingdom
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Ali Manouchehrinia
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Centre for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
| | - Anna Glaser
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Olga Ciccarelli
- Queen Square MS Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, United Kingdom
- National Institute for Health and Care Research University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Kyla A. McKay
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Centre for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
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Bergien SO, Siersma VD, Kristiansen M, Skovgaard L. Social relations and leisure activities as predictors of wellbeing among older adults with multiple sclerosis: A cross-sectional survey study in Denmark. Mult Scler Relat Disord 2023; 77:104878. [PMID: 37429098 DOI: 10.1016/j.msard.2023.104878] [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: 02/18/2023] [Revised: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Due to the growing number of people aging with multiple sclerosis (MS), there has been a call for rehabilitation specially targeted older adults with MS in order to support them in better wellbeing, despite physical and cognitive impairment. However, the existing research within the area of rehabilitation has primarily focused on the physical and psychological aspects of aging with MS, omitting the social element. OBJECTIVE This study aims to examine how social relations and engagement in leisure activities predict wellbeing among older adults with MS living in Denmark. Furthermore, the study aims to identify which sociodemographic and health-related factors are the most important in predicting whether older adults with MS face challenges in participating in leisure activities and experiencing different kinds of social relations. METHOD A cross-sectional survey was designed to measure social relations, wellbeing, and engagement in leisure activities among older adults with MS. Of the 4,329 people over 65 years diagnosed with MS in Denmark in 2022, 2,574 (59.46%) were invited to participated in the study, and 1,107 (43.03%) ended up answering the survey. Linear and logistic regression analyses and dominance analyses were conducted to examine the associations between wellbeing, leisure activities, social relations, sociodemographic and health-related factors. RESULTS The results of the study show that perceived emotional social support (mean difference 8.69, 95% CI 5.23; 12.14) and perceived instrumental social support (mean difference 4.15, 95% CI 0.95; 7.35), were associated with better wellbeing among older adults with MS. Perceived strained social relations (mean difference -7.95, 95% CI -10.66; -5.26) were on the contrary associated with lower levels of wellbeing. Strained social relations were the most important predictors of wellbeing accounting for 59% of the predicted variance. Experiencing social emotional support from friends, coworkers, or neighbors (39% of the predicted variance), experiencing instrumental social support from children or children in law (43% of the predicted variance), and experiencing strained social relations with partner (48% of the predicted variance) constituted he most important predictor of wellbeing. Engagement in five out of fourteen leisure activities were associated with better wellbeing among the participants. The leisure activities there was found to be the most important predictor of wellbeing represented both social (37% of the predicted variance), physical (18% of the predicted variance), and creative elements (13% of the predicted variance). Finally, cohabitation was found to be the most important predictor of having perceived emotional social support (59% of the predicted variance), instrumental social support (78.9% of the predicted variance) and strained social relations (18.8% of the predicted variance) and mobility was found to be the most important predictor of challenges in participating in leisure activities (81.8% of the predicted variance). CONCLUSION The findings of the study highlight that rehabilitation targeting older adults with MS should focus on both physical, psychological, and social elements of peoples' everyday life. Further, the results indicate that future rehabilitation focusing on social elements of aging with MS should take into account health and sociodemographic characteristics such as cohabitation, mobility, age, and sex, as these potentially relate to participation in leisure activities as well as social relations among older adults.
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Affiliation(s)
- Sofie Olsgaard Bergien
- The Danish Multiple Sclerosis Society, Valby, Denmark; Center for Healthy Aging, Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | - Volkert Dirk Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Maria Kristiansen
- Center for Healthy Aging, Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Vasileiou ES, Fitzgerald KC. Multiple Sclerosis Pathogenesis and Updates in Targeted Therapeutic Approaches. Curr Allergy Asthma Rep 2023; 23:481-496. [PMID: 37402064 DOI: 10.1007/s11882-023-01102-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 07/05/2023]
Abstract
PURPOSE OF REVIEW In this review, we provide a comprehensive update on current scientific advances and emerging therapeutic approaches in the field of multiple sclerosis. RECENT FINDINGS Multiple sclerosis (MS) is a common disorder characterized by inflammation and degeneration within the central nervous system (CNS). MS is the leading cause of non-traumatic disability in the young adult population. Through ongoing research, an improved understanding of the disease underlying mechanisms and contributing factors has been achieved. As a result, therapeutic advancements and interventions have been developed specifically targeting the inflammatory components that influence disease outcome. Recently, a new type of immunomodulatory treatment, known as Bruton tyrosine kinase (BTK) inhibitors, has surfaced as a promising tool to combat disease outcomes. Additionally, there is a renewed interested in Epstein-Barr virus (EBV) as a major potentiator of MS. Current research efforts are focused on addressing the gaps in our understanding of the pathogenesis of MS, particularly with respect to non-inflammatory drivers. Significant and compelling evidence suggests that the pathogenesis of MS is complex and requires a comprehensive, multilevel intervention strategy. This review aims to provide an overview of MS pathophysiology and highlights the most recent advances in disease-modifying therapies and other therapeutic interventions.
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Affiliation(s)
- Eleni S Vasileiou
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA.
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28
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Koch-Henriksen N. Worldwide Disparity in the Effectiveness of the Diagnostic Process in Multiple Sclerosis. Neurology 2023; 101:245-246. [PMID: 37399427 DOI: 10.1212/wnl.0000000000207530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 07/05/2023] Open
Affiliation(s)
- Nils Koch-Henriksen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
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29
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Finlayson M, Al-Mashita L, Sandhu R. Participant diversity in clinical trials of rehabilitation interventions for people with multiple sclerosis: A scoping review. Mult Scler 2023; 29:1149-1157. [PMID: 37555491 PMCID: PMC10413778 DOI: 10.1177/13524585231189670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/13/2023] [Accepted: 06/29/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The selection and description of participants in clinical trials enables health care providers to determine generalizability of findings to the populations they serve. Limited diversity of participants in trials restricts evidence-based decision-making. OBJECTIVES To determine the extent to which diverse participants are being included in clinical trials of rehabilitation interventions for people with multiple sclerosis (MS). METHODS We conducted a scoping review of MS rehabilitation trials published since January 2002 using MEDLINE, CINAHL, and Web of Science. Covidence was used to facilitate the review. Article selection required randomized control design, a rehabilitation intervention, and a functional status outcome. Data extracted included details of intervention(s), outcomes, and participant selection and description using a social determinants of health framework. RESULT A total of 243 studies were included. Exercise interventions and impairment-focused outcomes were most common. Most studies used only a MS Clinic for recruitment. Common exclusion criteria were physical or mental comorbidities, disability, age, and cognitive impairment. Participant age and sex were reported for almost all trials; reporting of other social determinants of health was atypical. CONCLUSION MS rehabilitation trials have used limited recruitment methods, restricted samples, and reported few participant descriptors. Changes are required to enhance participant diversity and the descriptions of participant characteristics.
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Affiliation(s)
- Marcia Finlayson
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Leyan Al-Mashita
- Health Sciences Program, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Rebekah Sandhu
- Aging and Health Program, School of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
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30
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Marrie RA, Chataway J, Bierer BE, Finlayson M, Martinez-Lapiscina EH, Panagoulias J, Sormani MP, Williams MJ, Amezcua L. Enhancing diversity of clinical trial populations in multiple sclerosis. Mult Scler 2023; 29:1174-1185. [PMID: 37555490 PMCID: PMC10413791 DOI: 10.1177/13524585231189677] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Demographic characteristics, social determinants of health (SDoH), health inequities, and health disparities substantially influence the general and disease-specific health outcomes of people with multiple sclerosis (MS). Participants in clinical trials do not represent all people with MS treated in practice. OBJECTIVE To provide recommendations for enhancing diversity and inclusion in clinical trials in MS. METHODS We held an international workshop under the Auspices of the International Advisory Committee on Clinical Trials in MS (the "Committee") to develop recommendations regarding diversity and inclusivity of participants of clinical trials in MS. Workshop attendees included members of the Committee as well as external participants. External participants were selected based on expertise in trials, SDoH, health equity and regulatory science, and diversity with respect to gender, race, ethnicity, and geography. RESULTS Recommendations include use of diversity plans, community engagement and education, cultural competency training, biologically justified rather than templated eligibility criteria, adaptive designs that allow broadening of eligibility criteria over the course of a trial, and logistical and practical adjustments to reduce study participant burden. Investigators should report demographic and SDoH characteristics of participants. CONCLUSION These recommendations provide sponsors and investigators with methods of improving diversity and inclusivity of clinical trial populations in MS.
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Affiliation(s)
- Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK/Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Barbara E Bierer
- The Multi-Regional Clinical Trials Center of Brigham and Women’s Hospital and Harvard, Cambridge, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Marcia Finlayson
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Elena H Martinez-Lapiscina
- Center of Neuroimmunology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clinic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain/Office of Therapies for Neurological and Psychiatric Disorders, Human Medicines Division, European Medicines Agency, Amsterdam, The Netherlands
| | | | | | | | - Lilyana Amezcua
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Nathoo N, Zeydan B, Neyal N, Chelf C, Okuda DT, Kantarci OH. Do magnetic resonance imaging features differ between persons with multiple sclerosis of various races and ethnicities? Front Neurol 2023; 14:1215774. [PMID: 37448745 PMCID: PMC10338060 DOI: 10.3389/fneur.2023.1215774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Those of African American or Latin American descent have been demonstrated to have more severe clinical presentations of multiple sclerosis (MS) than non-Latin American White people with MS. Concurrently, radiological burden of disease on magnetic resonance imaging (MRI) in African Americans with MS has also been described as being more aggressive. Here, we review MRI studies in diverse racial and ethnic groups (adult and pediatric) investigating lesion burden, inflammation, neurodegeneration, and imaging response to disease modifying therapy. We also discuss why such disparities may exist beyond biology, and how future studies may provide greater insights into underlying differences.
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Affiliation(s)
- Nabeela Nathoo
- Division of Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Burcu Zeydan
- Division of Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Nur Neyal
- Division of Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Cynthia Chelf
- Mayo Clinic College of Medicine and Science, Library-Public Services, Mayo Clinic, Rochester, MN, United States
| | - Darin T. Okuda
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Orhun H. Kantarci
- Division of Multiple Sclerosis and Autoimmune Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, United States
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Gouider R, Lorenz DH, Craven A, Grisold W, Dodick DW. Advocacy for patients with headache disorders. eNeurologicalSci 2023; 31:100466. [PMID: 37250108 PMCID: PMC10209324 DOI: 10.1016/j.ensci.2023.100466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/07/2023] [Accepted: 05/09/2023] [Indexed: 05/31/2023] Open
Abstract
Primary headache disorders are worldwide highly prevalent and burdensome and should be therefore considered as a global public health priority. However, too many patients with primary headache disorders still do not receive satisfying care. The most likely identified reasons for such a scenario - lack of public awareness, stigma, lack of trained professionals with inadequate healthcare systems and policies - are remediable. Despite the progresses that were made in headache advocacy, these efforts have not yielded substantial improvements in research funding or access to specialty care and even standards of care. The situation is more complex in Low and Middle Income Countries (LMICs) where headache advocacy is urgently needed given the magnitude of the difficulties that patients with primary headache disorders face in accessing care. The growing emergence of coordinated, collaborative, patient-centered advocacy efforts with improved patient-clinician partnership is an opportunity to enhance progress in advocacy for a satisfying life and optimal and equitable care for people with primary headache disorders. LMICs can benefit greatly from coordinating these efforts on a global scale. The recent organization of a training program on headache diagnosis and management for healthcare professionals in Africa is a concrete example.
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Affiliation(s)
- Riadh Gouider
- Neurology Department, LR18SP03, Razi Universitary Hospital, 1 rue des orangers Manouba, 2010 Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, 15, Rue Djebel Akhdhar, La Rabta, 1007, Tunis, Tunisia
- Clinical Investigation Center (CIC) "Neurosciences and Mental Health", Razi Universitary Hospital, 1 rue des orangers Manouba, 2010 Tunis, Tunisia
| | | | - Audrey Craven
- European Federation of Neurological Associations & European Headache & Migraine Alliance, Dublin, Ireland
| | - Wolfgang Grisold
- Ludwig Boltzmann Institute for Experimental und Clinical Traumatology, Donaueschingenstraße 13, A-1200, Vienna, Austria
| | - David W. Dodick
- Mayo Clinic Arizona, Chief Science Officer, Atria Academy of Science and Medicine, USA
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Lechner-Scott J, Agland S, Giovannoni G, Hawkes C, Levy M, Yeh EA. Inequality in accessing healthcare for people with MS. Mult Scler Relat Disord 2023; 72:104655. [PMID: 36990053 DOI: 10.1016/j.msard.2023.104655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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A Systematic Review and Meta-Analysis of the Brief Cognitive Assessment for Multiple Sclerosis (BICAMS) International Validations. J Clin Med 2023; 12:jcm12020703. [PMID: 36675637 PMCID: PMC9863826 DOI: 10.3390/jcm12020703] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/03/2023] [Accepted: 01/09/2023] [Indexed: 01/17/2023] Open
Abstract
Cognitive impairment is a prevalent and debilitating symptom of multiple sclerosis (MS) but is not routinely addressed in clinical care. The Brief Cognitive Assessment for Multiple Sclerosis (BICAMS) was developed in 2012 to screen and monitor MS patients’ cognition. This systematic review and meta-analysis aimed to identify, synthesise, and critically appraise current BICAMS’ international validations. The literature search was conducted using PubMed, PsycINFO and Web of Science electronic databases in August 2022. Quantitative, peer-reviewed adult studies, which followed the BICAMS international validation protocol and were published in English, were included. The search identified a total of 203 studies, of which 26 were eligible for inclusion. These reported a total of 2833 adults with MS and 2382 healthy controls (HC). The meta-analysis showed that BICAMS identified impaired cognitive functioning in adults with MS compared to HC for all three subtests: information processing speed (g = 0.854, 95% CI = 0.765, 0.944, p < 0.001), immediate verbal recall (g = 0.566, 95% CI = 0.459, 0.673, p < 0.001) and immediate visual recall (g = 0.566, 95% CI = 0.487, 0.645, p < 0.001). Recruitment sites and strategies limit the generalisability of results. BICAMS is a valid and feasible international MS cognitive assessment.
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Moccia M, Fontana L, Palladino R, Falco F, Finiello F, Fedele M, Lanzillo R, Reppuccia L, Triassi M, Brescia Morra V, Iavicoli I. Determinants of early working impairments in multiple sclerosis. Front Neurol 2022; 13:1062847. [PMID: 36570442 PMCID: PMC9784221 DOI: 10.3389/fneur.2022.1062847] [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: 10/06/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Unemployment can directly affect social status and identity. Assessing and adjusting determinants of early working impairments in a chronic disease can thus reduce its long-term burden. Hereby, we aim to evaluate differences in occupational history and early working impairments between people with multiple sclerosis (MS) and healthy workers. Methods This is a cross-sectional study comparing 71 workers with MS [age 41.7 ± 9.4 years; females 59.1%; EDSS 2.0 (1.0-6.0)] and 71 controls (age 42.6 ± 11.9 years; females 33.8%). All participants filled in Work Ability Index (WAI), Work Productivity and Activity Impairment (WPAI), European Questionnaire for Quality of Life (EuroQoL), Beck Depression Inventory II (BDI-II), and Pittsburgh Sleep Quality Index (PSQI). In MS, we further collected expanded disability status scale (EDSS), MS Questionnaire for Job difficulties (MSQ-Job), Fatigue severity scale (FSS), and the Brief International Cognitive Assessment for MS (BICAMS). Results Workers with MS were more working disabled (p < 0.01), less exposed to workplace risks (p < 0.01), and more limited in fitness to work (p = 0.01), compared with controls. On linear regression models adjusted by age, sex, education, and type of contract, people with MS had worse WAI (Coeff=-5.47; 95% CI = -7.41, -3.53; p < 0.01), EuroQoL (Coeff = -4.24; 95% CI = -17.85, -6.50; p < 0.01), BDI-II (Coeff = 3.99; 95% CI = 2.37, 7.01; p < 0.01), and PSQI (Coeff = 4.74; 95% CI = 3.13, 7.61; p < 0.01), compared with controls, but no differences in WPAI (p = 0.60). EuroQoL, BDI-II, and PSQI were equally associated with both WAI and WPAI in MS and controls (all p< 0.01). In MS, worse MSQJob was associated with higher EDSS (Coeff = 5.22; 95% CI = 2.24, 7.95; p < 0.01), progressive disease (Coeff = 14.62; 95% CI = 5.56, 23.69; p < 0.01), EuroQoL (Coeff = 4.63; 95% CI = 2.92, 6.35; p < 0.01), FSS (Coeff = 0.55; 95% CI = 0.38, 0.72; p < 0.01), and cognitive impairment (Coeff = 4.42; 95% CI = 0.67, 8.22; p = 0.02). Discussion Early factors associated with working difficulties in MS include disability, fatigue, depression, and cognitive dysfunction. Early identification of clinical features potentially causing working difficulties should be considered to enhance job retention, along with targeted prevention and protection measures.
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Affiliation(s)
- Marcello Moccia
- Department of Molecular Medicine and Medical Biotechnology, Federico II University of Naples, Naples, Italy,Multiple Sclerosis Clinical Unit, Federico II University Hospital, Naples, Italy,*Correspondence: Marcello Moccia
| | - Luca Fontana
- Occupational Health Unit, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Raffaele Palladino
- Department of Public Health, Federico II University of Naples, Naples, Italy,Department of Primary Care and Public Health, Imperial College, London, United Kingdom
| | - Fabrizia Falco
- Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University of Naples, Naples, Italy
| | - Ferdinando Finiello
- Occupational Health Unit, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Mauro Fedele
- Occupational Health Unit, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Roberta Lanzillo
- Multiple Sclerosis Clinical Unit, Federico II University Hospital, Naples, Italy,Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University of Naples, Naples, Italy
| | - Liberata Reppuccia
- Occupational Health Unit, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Maria Triassi
- Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Unit, Federico II University Hospital, Naples, Italy,Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University of Naples, Naples, Italy
| | - Ivo Iavicoli
- Occupational Health Unit, Department of Public Health, Federico II University of Naples, Naples, Italy
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