Defining secondary progressive multiple sclerosis

The Barcelona baseline risk score to predict long-term prognosis after a first demyelinating event: a prospective observational study

Background

In multiple sclerosis (MS), predicting at symptom onset who will develop early and severe disability is an unmet need with significant therapeutic implications. Here we propose the Barcelona-Baseline Risk Score (BRS) model to predict long-term disease outcomes in a flexible and generalisable manner.

Methods

Using prospectively acquired data from the Barcelona first-attack cohort, we created the Barcelona-BRS model as a set of six Weibull survival models of time to an Expanded Disability Status Scale score of 3.0, built with flexible combinations of predictors, including sex, age at first attack, and number and topography of T2 lesions, among others, adaptable to data availability. Data-driven risk groups were identified and compared in terms of long-term clinical and MRI outcomes, including relapse-associated worsening (RAW), progression independent of relapse activity (PIRA), conversion to secondary progressive MS (SPMS), lesional and brain volumetric data, and patient-reported/administered clinical scores, through Kaplan-Meier and mixed-effects models. Finally, we externally validated our model in a completely unseen cohort.

Findings

We included 1074 patients (737 [69%] female, mean age: 31.7 years) with a first demyelinating attack. Over a median follow-up of 11.9 years, 375 (35%), 298 (28%), and 94 (8.8%) developed RAW, PIRA, and SPMS, respectively. Weibull models included age at first attack, number of brain T2 lesions, and disability at first visit as main predictors. Four data-driven groups of increasing risk of unfavourable outcomes were created: Light-Green-BRS (N = 258), Dark-Green-BRS (N = 319), Orange-BRS (N = 321), and Red-BRS (N = 176), which, over time, behaved significantly differently across disability, quality of life, and MRI measures, being the Red-BRS the group with worst outcomes (p < 0.01). The results in the external validation cohort (N = 139, 100 female [72%], 34 years) mirrored those of the original one.

Interpretation

The robustness, flexibility, and generalisability of the Barcelona-BRS model support its consideration as a ready-to-use tool for clinical practice.

Funding

None.

Clinical risk stratification: Prague validation of the DAAE score, a clinical tool for estimating risk of disesase progression in multiple sclerosis

BACKGROUND

Secondary progressive MS is associated with a worse prognosis, warranting the need for early predictive tools. The DAAE score estimates the five-year risk of transition to clinical diagnosis of SPMS, showing a 38 % risk in high-risk patients in Amsterdam and Buffalo data. The DAAE score remains to be validated against objective disease progression criteria.

METHODS

External validation using data from the Prague MS cohort and MSBase-Lorscheider criteria.

RESULTS

Among 2022 patients from the Prague MS database, 14.3 % clinically progressed according to MSbase-Lorscheider criteria over five years. Risk increased with higher DAAE scores comparable to the Amsterdam and Buffalo data; secondary validation showed an AUROC of 0.742 with faster progression for higher risk groups (p < 0.05), therapy-adjusted.

CONCLUSION

The DAAE score performs similarly between centers and using objective criteria. These validation steps support its use in personalized MS management and treatment.

Association of Functional Gene Variants in DYSF-ZNF638, MTSS1 and Ferroptosis-Related Genes with Multiple Sclerosis Severity and Target Gene Expression

Multiple sclerosis (MS) is a chronic inflammatory, neurodegenerative disease with yet-unresolved mechanisms of progression. To address MS severity and neurological deficits, we analyzed seven potentially functional genetic variants and their haplotypes in 845 MS patients. Based on our previous results of targeted RNAseq on ferroptosis-related genes in distinctive MS phenotypes, we selected putative regulatory variants in the top three DEGs (CDKN1A, MAP1B and EGLN2) and investigated their association with gene expression, plasma/serum parameters and disease severity (EDSS, MSSS, gARMSS). The study included 604 patients with relapsing-remitting (RR) and 241 with progressive (P) MS. The variants CDKN1A rs3176326 and rs3176336, EGLN2 rs111833532, MAP1B rs62363242 and rs1217817 with the previously reported DYSF-ZNF638 locus rs10191329, and MTSS1 rs9643199 were genotyped using TaqMan®, and the HLA-DRB1*15:01 status was also determined. Significant association of the rare MAP1B rs62363242 allele with PMS in females, independent of HLA-DRB1*1501, was found. The A allele-containing genotypes were associated with molecular components of iron metabolism. CDKN1A haplotypes were significantly associated with CDKN1A mRNA levels in RRMS and SPMS patients. RAB4B-EGLN2 locus rs111833532 and DYSF-ZNF638 locus rs10191329 showed significant associations with EDSS, MSSS and gARMSS. We detected haplotypes associated with the expression of CDKN1A, a part of the p53-p21 axis known to affect T cell activation/proliferation. RAB4B-EGLN2, an oxygen sensor and critical regulator of the response to hypoxia, variant rs111833532, along with DYSF-ZNF638 locus rs10191329, was associated with clinical severity. The indicated, novel, sex-specific association of MAP1B rs62363242 with the course of MS remains to be validated in larger studies.

Progressive multiple sclerosis: Evaluating current therapies and exploring future treatment strategies

Progressive forms of multiple sclerosis (MS) include primary progressive MS (PPMS) and secondary progressive MS (SPMS). Unlike relapsing-remitting MS (RRMS), progressive MS is recognized by relentless progression with accumulating disability, rare to no relapses nor new activity on MRIs. Clinically, neurologic worsening in MS can occur in the relapsing-remitting (RRMS) phase of disease due to incomplete recovery from neuroinflammatory relapses. However, a progressive disease course is the dominant factor related to accumulating disability. There is persistent central nervous system (CNS) compartmentalized inflammation, mitochondrial dysfunction and altered immune responses. Unlike in RRMS, the efficacy of disease modifying agents (DMA) in progressive MS has been limited, highlighting the need for novel therapeutic approaches that address both inflammation and neurodegeneration. This article explores current management of progressive MS, and future directions in targeting the unique pathophysiology of this complex disease.

Explainable time-to-progression predictions in multiple sclerosis

BACKGROUND

Prognostic machine learning research in multiple sclerosis has been mainly focusing on black-box models predicting whether a patients' disability will progress in a fixed number of years. However, as this is a binary yes/no question, it cannot take individual disease severity into account. Therefore, in this work we propose to model the time to disease progression instead. Additionally, we use explainable machine learning techniques to make the model outputs more interpretable.

METHODS

A preprocessed subset of 29,201 patients of the international data registry MSBase was used. Disability was assessed in terms of the Expanded Disability Status Scale (EDSS). We predict the time to significant and confirmed disability progression using random survival forests, a machine learning model for survival analysis. Performance is evaluated on a time-dependent area under the receiver operating characteristic and the precision-recall curves. Importantly, predictions are then explained using SHAP and Bellatrex, two explainability toolboxes, and lead to both global (population-wide) as well as local (patient visit-specific) insights.

RESULTS

On the task of predicting progression in 2 years, the random survival forest achieves state-of-the-art performance, comparable to previous work employing a random forest. However, here the random survival forest has the added advantage of being able to predict progression over a longer time horizon, with AUROC >60% for the first 10 years after baseline. Explainability techniques further validated the model by extracting clinically valid insights from the predictions made by the model. For example, a clear decline in the per-visit probability of progression is observed in more recent years since 2012, likely reflecting globally increasing use of more effective MS therapies.

CONCLUSION

The binary classification models found in the literature can be extended to a time-to-event setting without loss of performance, thus allowing a more comprehensive prediction of patient prognosis. Furthermore, explainability techniques proved to be key to reach a better understanding of the model and increase validation of its behaviour.

Performance of a Modified Version of the Charlson Comorbidity Index in Predicting Multiple Sclerosis Disability Accrual

BACKGROUND

The natural history of multiple sclerosis (MS) is highly heterogeneous and almost unpredictable since several factors may affect the disease course including comorbidities. The aims of this study were to predict the risk of disability worsening and disease progression at the first patient's visit by using a modified version of the Charlson Comorbidity Index (mCCI).

METHODS

the mCCI was obtained by incorporating the grade of pyramidal functional system scores extracted by the Expanded Disability Status Scale (EDSS) into the original CCI version. The risk of reaching EDSS 4, EDSS 6, and secondary MS progression (SPMS) associated to mCCI classes was calculated by carrying out multivariable Cox-regression models and it was reported as hazard ratios (HRs) and 95% confidence intervals (95% CIs). The accuracy of mCCI for the recognition of individuals who reached the study milestones was estimated by building the receiving operator curves and the optimal cut-off values were estimated.

RESULTS

A total of n = 622 individuals were enrolled (72.7% women; median age 30.8 years [24-40]). Compared with patients with a mCCI equal to zero, the HRs for those with a mCCI comprised between 1 and 2 at the first visit were 1.53 (1.1-2.1), 2.17 (1.48-2.96), and 1.57 (1.16-2.1) for the reaching of EDSS 4, EDSS 6, and SPMS, respectively. Moreover, individuals with a mCCI equal or higher than 3 were at even higher risk of reaching EDSS 6 (HR = 2.34 [1.44-3.8]) and SPMS conversion (HR = 2.38 [1.29-4.01]). The mCCI cut-off value of 3 reached a sensitivity and specificity of 88.1% and 77.8%, respectively, for the recognition of EDSS 4, while the mCCI cut-off of 4 reached a sensitivity of 83.1% and a specificity of 80.7% for the recognition of EDSS 6 and a sensitivity and a specificity of 76.8% and 87.5%, respectively, for the recognition of SPMS conversion.

CONCLUSION

mCCI appeared a simple and fast tool for the prediction of MS prognosis since the first patient's visit and its best cut-off values showed higher sensitivity and specificity for the recognition of patients who undergo disability worsening and SPMS conversion.

Conformal prediction enables disease course prediction and allows individualized diagnostic uncertainty in multiple sclerosis

Accurate assessment of progression and disease course in multiple sclerosis (MS) is vital for timely and appropriate clinical intervention. The gradual transition from relapsing-remitting MS (RRMS) to secondary progressive MS (SPMS) is often diagnosed retrospectively with a typical delay of three years. To address this diagnostic delay, we developed a predictive model that uses electronic health records to distinguish between RRMS and SPMS at each individual visit. To enable reliable predictions, conformal prediction was implemented at the individual patient level with a confidence of 93%. Our model accurately predicted the change in diagnosis from RRMS to SPMS for patients who transitioned during the study period. Additionally, we identified new patients who, with high probability, are in the transition phase but have not yet received a clinical diagnosis. Our methodology aids in monitoring MS progression and proactively identifying transitioning patients. An anonymized model is available at https://msp-tracker.serve.scilifelab.se/ .

Standardized Definition of Progression Independent of Relapse Activity (PIRA) in Relapsing-Remitting Multiple Sclerosis

Importance

Progression independent of relapse activity (PIRA) is a significant contributor to long-term disability accumulation in relapsing-remitting multiple sclerosis (MS). Prior studies have used varying PIRA definitions, hampering the comparability of study results.

Objective

To compare various definitions of PIRA.

Design, Setting, and Participants

This cohort study involved a retrospective analysis of prospectively collected data from the MSBase registry from July 2004 to July 2023. The participants were patients with MS from 186 centers across 43 countries who had clinically definite relapsing-remitting MS, a complete minimal dataset, and 3 or more documented Expanded Disability Status Scale (EDSS) assessments.

Exposure

Three-hundred sixty definitions of PIRA as combinations of the following criteria: baseline disability (fixed baseline with re-baselining after PIRA, or plus re-baselining after relapses, or plus re-baselining after improvements), minimum confirmation period (6, 12, or 24 months), confirmation magnitude (EDSS score at/above worsening score or at/above threshold compared with baseline), freedom from relapse at EDSS score worsening (90 days prior, 90 days prior and 30 days after, 180 days prior and after, since previous EDSS assessment, or since baseline), and freedom from relapse at confirmation (30 days prior, 90 days prior, 30 days before and after, or between worsening and confirmation).

Main Outcome and Measure

For each definition, we quantified PIRA incidence and persistence (ie, absence of a 3-month confirmed EDSS improvement over ≥5 years).

Results

Among 87 239 patients with MS, 33 303 patients fulfilled the inclusion criteria; 24 152 (72.5%) were female and 9151 (27.5%) were male. At the first visits, the mean (SD) age was 36.4 (10.9) years; 28 052 patients (84.2%) had relapsing-remitting MS, and the median (IQR) EDSS score was 2.0 (1.0-3.0). Participants had a mean (SD) 15.1 (11.9) visits over 8.9 (5.2) years. PIRA incidence ranged from 0.141 to 0.658 events per decade and persistence from 0.753 to 0.919, depending on the definition. In particular, the baseline and confirmation period influenced PIRA detection. The following definition yielded balanced incidence and persistence: a significant disability worsening compared with a baseline (reset after each PIRA event, relapse, and EDSS score improvement), in absence of relapses since the last EDSS assessment, confirmed with EDSS scores (not preceded by relapses within 30 days) that remained above the worsening threshold for at least 12 months.

Conclusion and Relevance

Incidence and persistence of PIRA are determined by the definition used. The proposed standardized definition aims to enhance comparability among studies.

Progression independent of relapse activity and relapse-associated worsening in seronegative NMOSD: an international cohort study

BACKGROUND

Previous studies have indicated that progression independent of relapse activity (PIRA) is uncommon in patients with aquaporin- 4 antibody-positive (AQP4-IgG) neuromyelitis optica spectrum disorder (NMOSD). However, the patterns of disability accumulation in seronegative NMOSD are unknown. This study aimed to evaluate the prevalence of PIRA and relapse-associated worsening (RAW) in seronegative NMOSD.

METHODS

We conducted a retrospective, multicentre cohort study of seronegative NMOSD patients from the MSBase registry. Inclusion criteria required at least three recorded expanded disability status scale (EDSS) scores: baseline, progression, and 6 months confirmed disability progression (CDP). For those with 6-month CDP, the presence or absence of relapse between baseline and progression determined the classification as RAW or PIRA, respectively. Descriptive statistics were employed to present the data.

RESULTS

This study included 93 patients, with a median follow-up duration of 5.0 years (Q1 2.8, Q3 8.4). The cohort predominantly consisted of female patients (77.4%), with a median age of onset of 33.9 years (Q1 26.1, Q3 41.2). PIRA was observed in 1 case (1.1%), whilst RAW was documented in 7 cases (7.5%).

CONCLUSION

This international cohort study confirms that CDP is uncommon in seronegative NMOSD. Given more than three quarters of CDP occur due to RAW, therapeutic strategies should focus primarily on preventing relapses.

Economic burden of secondary progressive multiple sclerosis: DISCOVER study

BACKGROUND

To estimate the socioeconomic burden of people with secondary progressive multiple sclerosis (pwSPMS), considering direct health care, direct non-health care, and indirect costs, and to evaluate the relationship between costs and patients' functional outcomes.

METHODS

Observational, cross-sectional, multicenter study with retrospective real-life clinical practice data collection from pwSPMS visiting the neurology services of 34 hospitals during 2019-2020. Clinical data included Expanded Disability Status Scale scores, number of relapses, magnetic resonance imaging, disease-modifying treatment (DMT), symptoms, and comorbidities from 24 months before the study visit. Resource use and allied costs were collected 12 months before the study visit. Patient-reported outcomes, functional and cognitive scales were also collected.

RESULTS

70% of pwSPMS used primary care services, and nearly 50% needed assistance in a daycare or rehabilitation center. Almost 60% of the participants were receiving DMT at the study visit, and 80% needed support for domestic/housekeeping tasks. More than 90% were inactive at work, with nearly 80% taking early retirement. The estimated total annual cost per pwSPMS in Spain was almost €41,500, of which more than 50% (€21,400) were indirect costs, followed by direct health care costs (30%, €11,300), and, finally, direct non-health care costs (about 20%, €8,800). Older patients with severe disabilities and worse functional outcomes incurred higher costs.

CONCLUSIONS

SPMS is a major burden on health care systems, patients, and society as a whole. Health care and societal policies should be aimed at improving the SPMS care pathway and minimizing patients' funding of direct non-health care costs.

TRIAL REGISTRATION

The trial is a non-interventional study. The NCC code is CBAF312AES01/NOV-EMS-2019-01.

The Phenotypes of Multiple Sclerosis Differ Significantly in Relative and Excess Mortality

BACKGROUND

Patients With Multiple Sclerosis (MS) Have Higher Mortality Than Matched Background Populations. We Compare Relative and Excess Mortality in MS Over the Matched Background Populations Between Primary Progressive MS (PPMS), relapsing Onset MS (ROMS), and Secondary Progressive MS (SPMS).

METHODS

We included all patients from the nationwide and complete Danish MS Registry with onset 1994-2022 and compared the extra mortality of the MS phenotypes in terms of relative and excess mortality, with adjustment for sex, age at onset, disease-modifying treatment, and number of recorded relapses. We calculated the adjusted ratios of relative and excess mortalities between PPMS and ROMS and between PPMS and SPMS.

RESULTS

The initial course was unknown in 221, leaving 1412 cases with PPMS (which includes progressive relapsing MS) and 12,449 cases with ROMS. 627 had died during follow-up by the end of 2022. After adjustment, both ratios between PPMS and ROMS came close to unity, indicating that the excess mortality is equal for PPMS and ROMS in the long run. The adjusted relative and additive mortalities were factors 6.05 (95% CI 4.42-8.27) and 1.90 (95% CI 1.65-2.18) higher in SPMS than in PPMS.

CONCLUSIONS

Compared with the matched population, the adjusted relative and excess mortalities are the same for PPMS and ROMS. However, SPMS had a higher relative and excess mortality than PPMS, probably in part owing to the burden of disease carried over from the pre-progressive phase. This underlines the need for effective treatment in this later stage of the disease and more attention to comorbidity.

Dynamic 18 F-FDG PET to detect differences among patients with progressive and relapsing multiple sclerosis: a pilot study

BACKGROUND

Patients with multiple sclerosis (MS) may remain in a relapsing-remitting (RRMS) course despite long-standing disease, while others will develop secondary progression (SPMS). Chronic inflammation and changes in the blood-brain barrier resulting in perturbed glucose metabolism may account for these differences. PET-MRI with kinetic analysis of 2-deoxy-2(18 F)fluoro-d-glucose (18 F-FDG) provides insight into glucose metabolism and has proven useful in several chronic inflammatory diseases. However, to our knowledge, it has never been studied in MS.

OBJECTIVE

To explore potential differences in glucose distribution kinetics among individuals with long-standing SPMS and RRMS using dynamic 18-F-FDG PET-MRI.

METHODS

Dynamic 18-F-FDG PET-MRI scans were obtained in 11 patients with long-standing MS: 4 with RRMS and 7 with SPMS. Kinetic analysis of PET data was performed using a three-compartment model equation that represents plasma, tissue and 18 F-FDG phosphorylation. Individual rate constants of 18-F-FDG across the compartments were calculated.

RESULTS

Patients with SPMS exhibited a trend towards an increased net influx rate of glucose (p = 0.059) and an increased rate constant representing glucose phosphorylation. Together, the data suggest increased uptake of glucose and glycolysis in these patients.

CONCLUSION

Dynamic 18 F-FDG PET-MRI is a feasible technique that may show information in vivo of glucose metabolism in MS. Although preliminary data suggest a potential radiological marker of progression in MS, further studies are required to confirm this hypothesis.

Choroid Plexus Enlargement in Secondary Progressive MS: phenotype comparison

Background

The choroid plexus (CP) is increasingly recognised as a contributor to chronic inflammation in multiple sclerosis (MS). While CP enlargement is reported in early MS, its role in secondary progressive MS (SPMS) is poorly understood.

Objective

We aimed to quantify CP volume in SPMS and compare it to relapsing-remitting MS (RRMS) and clinically isolated syndrome (CIS), and to assess associations with disease severity and progression.

Methods

CP volumes were manually segmented and normalised to intracranial volume. Age correction was applied using a healthy control cohort. Cross-sectional and longitudinal analyses evaluated relationships with ventricular volume, lesion burden, and brain atrophy.

Results

CP volume increased significantly across MS phenotypes: SPMS patients showed 26% higher CP volume than CIS (p=0.010) and 17% higher than RRMS (p=0.034). CP enlargement in SPMS was independent of ventricular size, indicating distinct underlying mechanisms. While lesion burden was the primary determinant of brain atrophy in SPMS, longitudinal data revealed significant associations between CP volume, chronic lesion expansion (r2=0.31), and brain volume loss (r2=0.52).

Conclusion

CP enlargement is a progressive feature of MS, not driven by ventricular expansion. In SPMS, it may reflect ongoing inflammation contributing to tissue damage, supporting its role as a biomarker.

Current challenges in secondary progressive multiple sclerosis: diagnosis, activity detection and treatment

Approximately 50% diagnosed with relapsing-remitting multiple sclerosis (RRMS) transition to secondary progressive multiple sclerosis (SPMS) within 20 years following disease onset. However, early diagnosis of SPMS and effective treatment remain important clinical challenges. The lack of established diagnostic criteria often leads to delays in identifying SPMS. Also, there are limited disease-modifying therapies (DMTs) available for progressive forms of MS, and these therapies require evidence of disease activity to be initiated. This review examines the challenges in diagnosing SPMS at an early stage and summarizes the current and potential use of biomarkers of disease progression in clinical practice. We also discuss the difficulties in initiating the DMTs indicated for active SPMS (aSPMS), particularly in patients already undergoing treatment with DMTs that suppress disease activity, which may mask the presence of inflammatory activity required for the therapy switch. The article also addresses the DMTs available for both active and non-active SPMS, along with the clinical trials that supported the approval of DMTs indicated for aSPMS or relapsing MS in Europe, which includes aSPMS. We also offer insights on when discontinuing these treatments may be appropriate.

Different Treatment Outcomes of Multiple Sclerosis Patients Receiving Ocrelizumab or Ofatumumab

OBJECTIVE

B-cell-depletion via CD20 antibodies is a safe and effective treatment for active relapsing multiple sclerosis (RMS). Both ocrelizumab (OCR) and ofatumumab (OFA) have demonstrated efficacy in randomized controlled trials and are approved for treatment of RMS, yet nothing is known on their comparative effectiveness, especially in the real-world setting.

METHODS

This prospective cohort study includes patients that were started on either OCR or OFA between September 2021 and December 2023. Patients were followed until June 2024 and recruited at 3 large tertiary centers in Germany (Duesseldorf, Essen, and Giessen). Propensity-score-matching was used to address baseline imbalances among patients. Clinical relapses, presence of new or enlarging MRI lesions and 6-month confirmed disability worsening were evaluated. Non-inferiority of OFA compared to OCR was evaluated through comparison of Kaplan-Meier-estimates.

RESULTS

A total of 1,138 patients were initially enrolled in the cohort. Following patient selection and propensity-score-matching, 544 OCR and 417 OFA patients were included in the final analysis. In our primary analysis, OFA was non-inferior to OCR in terms of relapses, disability progression, and accrual of MRI lesions. Subgroup analyses confirmed findings in previously naïve and platform-treated patients. Potential differences between OFA and OCR were seen in patients switching from S1P receptor modulators or natalizumab.

CONCLUSION

We here provide comparative data on the effectiveness of OCR and OFA in patients with active RMS. OFA was non-inferior to OCR in the overall cohort. Potential differences observed in patients switching from S1P receptor modulators or natalizumab require further validation. ANN NEUROL 2025;97:583-595.

Spatial structural abnormality maps associated with cognitive and physical performance in relapsing-remitting multiple sclerosis

OBJECTIVES

We aimed to characterize the brain abnormalities that are associated with the cognitive and physical performance of patients with relapsing-remitting multiple sclerosis (RRMS) using a deep learning algorithm.

MATERIALS AND METHODS

Three-dimensional (3D) nnU-Net was employed to calculate a novel spatial abnormality map by T1-weighted images and 281 RRMS patients (Dataset-1, male/female = 101/180, median age [range] = 35.0 [17.0, 65.0] years) were categorized into subtypes. Comparison of clinical and MRI features between RRMS subtypes was conducted by Kruskal-Wallis test. Kaplan-Meier analysis was conducted to investigate disability progression in RRMS subtypes. Additional validation using two other RRMS datasets (Dataset-2, n = 33 and Dataset-3, n = 56) was conducted.

RESULTS

Five RRMS subtypes were identified: (1) a Frontal-I subtype showing preserved cognitive performance and mild physical disability, and low risk of disability worsening; (2) a Frontal-II subtype showing low cognitive scores and severe physical disability with significant brain volume loss, and a high propensity for disability worsening; (3) a temporal-cerebellar subtype demonstrating lowest cognitive scores and severest physical disability among all subtypes but remaining relatively stable during follow-up; (4) an occipital subtype demonstrating similar clinical and imaging characteristics as the Frontal-II subtype, except a large number of relapses at baseline and preserved cognitive performance; and (5) a subcortical subtype showing preserved cognitive performance and low physical disability but a similar prognosis as the occipital and Frontal-II subtypes. Additional validation confirmed the above findings.

CONCLUSION

Spatial abnormality maps can explain heterogeneity in cognitive and physical performance in RRMS and may contribute to stratified management.

KEY POINTS

Question Can a deep learning algorithm characterize the brain abnormalities associated with the cognitive and physical performance of patients with RRMS? Findings Five RRMS subtypes were identified by the algorithm that demonstrated variable cognitive and physical performance. Clinical relevance The spatial abnormality maps derived RRMS subtypes had distinct cognitive and physical performances, which have a potential for individually tailored management.

Modulation of NCX1 expression in monocytes associates with multiple sclerosis progression

Ionic imbalance and functional heterogeneity of monocytes play key roles in multiple sclerosis (MS) progression. A better understanding of monocyte response in the context of ionic dysregulation during MS course may have relevant implications for understanding of disease pathogenesis and treatments. The sodium calcium exchanger NCX1 influences monocyte-derived macrophages reactivity under inflammation; however, little is known about its monocyte-specific expression during MS course. By means of RT-PCR, flow cytometry, and confocal analyses, we determined the expression profiling of NCX1 exchanger in monocytes of patients during relapsing-remitting MS (RRMS) and secondary progressive MS (SPMS) course. NCX1 expression was significantly upregulated in monocytes from transitional RRMS subjects. Conversely, it was significantly reduced in all monocyte subsets after RRMS conversion to SPMS. Interestingly, NCX1 levels in monocytes significantly correlated with the percentage and growth ability of the regulatory T cell (Treg) subset, whose derangement underlies MS progression. Perturbation of transcripts encoding the Ca2+-ATPase isoform 1 and 4, the Na+/K+-ATPase α1 subunit, and the long non-coding RNA SLC8A1-AS1 associated with NCX1 changes in peripheral blood mononuclear cells (PBMC) during MS. Our findings demonstrated a stage-specific dysregulation of NCX1 exchanger in monocytes during MS progression and suggested that ionic imbalance in monocytes may influence not only their functional response but also the immune regulatory network during MS course. These data may be relevant for the identification of novel biomarkers and/or therapeutic targets in MS.

A review on multiple sclerosis: Unravelling the complexities of pathogenesis, progression, mechanisms and therapeutic innovations

Multiple sclerosis (MS) is a chronic, inflammatory demyelinating disorder of the central nervous system (CNS) targeting myelinated axons. Pathogenesis of MS entails an intricate genetic, environmental, and immunological interaction. Dysregulation of immune response i.e. autoreactive T & B-Cells and macrophage infiltration into the CNS leads to inflammation, demyelination, and neurodegeneration. Disease progression of MS varies among individuals transitioning from one form of relapsing-remitting to secondary progressive MS (SPMS). Research advances have unfolded various molecular targets involved in MS from oxidative stress to blood-brain barrier (BBB) disruption. Different pathways are being targeted so far such as inflammatory and cytokine signaling pathways to overcome disease progression. Therapeutic innovations have significantly transformed the management of MS, especially the use of disease-modifying therapies (DMTs) to reduce relapse rates and control disease progression. Advancements in research, neuroprotective strategies, and remyelination strategies hold promising results in reversing CNS damage. Various mice models are being adopted for testing new entities in MS research.

Effect of vestibular rehabilitation on kinetic and kinematic parameters of gait in patients with multiple sclerosis: A single-blind randomized controlled study

BACKGROUND

Multiple sclerosis (MS) patients frequently experience gait disturbances, which can be exacerbated in those with vestibular involvement. Various exercise approaches are available to address gait difficulties in this patient population, and the use of vestibular rehabilitation, in particular, has increased recently. However, the effects of this specific exercise approach on gait in MS patients remain unclear. Considering that gait comprises temporospatial, kinetic, and kinematic components, it is evident that existing research in this area is fairly limited. Therefore, our study aimed to evaluate the effect of a vestibular rehabilitation program compared to a conventional exercise program on kinetic and kinematic parameters of gait in patients with MS.

METHODS

MS patients aged 25-60 years with an EDSS score between 3.5 and 6.5 were included in the study. Participants were randomly assigned to either the vestibular rehabilitation group or the conventional exercise group. All participants underwent primary evaluation with Three-dimensional gait analysis and secondary assessments using the 2-Minute Walk Test, 10-Meter Walk Test, 5-Times Sit to Stand Test, and Visual Acuity Test.

RESULTS

The study was completed with 22 participants [age: 45.18 ± 10.22, EDSS: 4.00 (3.50 - 5.00)]. Pelvic tilt range of motion, knee varus/valgus, ankle maximum external rotation, mean ankle rotation angles and the peak knee extension moment in the 30-60 % cycle of gait showed statistically greater improvement in the vestibular rehabilitation group compared to the conventional exercise group in post-treatment. After exercise trainings, there was no significant difference in temporospatial data between the two groups.

DISCUSSION

It was concluded that supporting the rehabilitation programs of MS patients with VR exercises contributed to the improvement of various kinetic and kinematic parameters of gait.

Towards a biological view of multiple sclerosis from early subtle to clinical progression: an expert opinion

The classification of multiple sclerosis (MS) into the two distinct phases of relapsing-remitting and progressive, including primary progressive and secondary progressive phenotypes (PPMS and SPMS, respectively) has long been accepted; however, there are several unmet needs associated with this particular model. The observation that both inflammation and neurodegeneration are present from the onset of MS has resulted in a paradigm shift towards MS as a disease continuum driven by pathological mechanisms underlying clinical progression. Here we report the results from a meeting of Italian MS specialists, exploring the evolving perception of MS pathobiology and its implications for diagnosis and treatment. Insights garnered from the expert panel advocate for a redefined understanding of MS. This expert opinion paper reviews the disease continuum and the intertwined nature of inflammatory and neurodegenerative processes. Also, the need for changes in diagnostic criteria and treatment strategies, including the development of novel biomarkers and new therapies targeting smouldering disease, is discussed.

MRI versus relapse: optimal activity monitoring for management of progressive multiple sclerosis

Secondary progressive multiple sclerosis is often categorized as 'active'/'non-active' based on inflammatory activity on MRI, or relapse; however, the value of MRI/relapse as indicators of disease activity in real-world and clinical trial settings merits further investigation. We separately analysed retrospective data from patients with clinically diagnosed secondary progressive multiple sclerosis in the Adelphi Real-World Disease Specific Programme (a cross-sectional survey) in multiple sclerosis (Adelphi: n = 2554) and the placebo group of the Phase III EXploring the efficacy and safety of siponimod in PAtients with secoNDary progressive multiple sclerosis (EXPAND) trial, [EXPAND-PBO (placebo group of the EXPAND): n = 546] to assess: differences between active/non-active disease in the real-world (characteristics; monitoring); the value of MRI and relapse to indicate disease activity; and the number and characteristics of non-active patients with disease activity in the clinical study. In Adelphi, 1889 patients had 'active' disease (≥1 relapse in the year before index date and/or ≥1 new lesion on most recent MRI) versus 665 with 'non-active' disease (no relapses in the previous year and no new lesions on MRI); median age was 48 versus 53 years; 73.5 versus 87.8% had moderate-to-severe disease; 75.7 versus 54.3% were taking disease-modifying treatment; 87.7 versus 58.7% had received an MRI in the past year. Most active cases (n = 1116; 59.1%) were identified by MRI versus 239 (12.7%) by relapse and 534 (28.3%) by MRI plus relapse. In EXPAND-PBO, 263 patients were classified 'active' (≥1 relapse in 2 years before screening and/or ≥1 gadolinium-enhancing lesion) and 270 'non-active' (no relapse in the 2 years before screening and no gadolinium-enhancing lesion[s]) at baseline; similar proportions of these groups had received disease-modifying treatment prior to placebo: 77.2 and 80.7%. Of non-active patients, 53.0% had disease activity on study; in these patients, 74.1% had disease activity identified by MRI, 8.4% by relapse, and 17.5% by MRI plus relapse. In patients classified non-active at baseline: age and percentage with Expanded Disability Status Scale score 6.0-6.5 were similar between patients with disease activity on study versus patients who remained non-active: 48 versus 52 years; 49.7 versus 56.7%, respectively. In real-world and clinical trial settings, MRI could be a better option than relapse for the identification of disease activity. However, in the real-world, fewer non-active patients had received an MRI in the last year than active patients, which is concerning given that most disease activity in EXPAND-PBO was identified via MRI. We highlight difficulties in consistently identifying disease activity and the negative implications of infrequent monitoring of non-active disease.

Identifying Cladribine prescription pattern in MS: an Italian multicentre study

Background

Characterizing Cladribine tablets prescription pattern in daily clinical practice is crucial for optimizing multiple sclerosis (MS) treatment.

Objectives

To describe efficacy, safety profile and new disease-modifying therapy (DMT) prescriptions following Cladribine treatment.

Design

Independent retrospective cohort study in patients followed at six Italian MS centres.

Methods

Patients diagnosed with relapsing MS (RMS) according to 2017 McDonald criteria, who initiated Cladribine between January 2019 and May 2023, were included. A generalized linear regression model was built for the outcome DMT after Cladribine course. Heatmaps were generated based on weighted pivot tables to visualize the proportion of patients requiring DMT post-Cladribine.

Results

A total cohort of 352 patients was enrolled, 134 naïve to any DMT, 218 switchers from other DMTs. The last DMT was an injectable first-line DMT for 48 (22%) patients, oral first-line DMT for 141 (64.7%) patients, SP1 inhibitor-Fingolimod for 23 (10.6%) patients, and Natalizumab for 6 (2.7%) patients. Overall, Cladribine was efficacious and well tolerated, 12% of patients required a new DMT prescription after a median time of 24 months. The regression model revealed that patients aged >40 years at Cladribine prescription had a 16% decrease in likelihood of receiving a new DMT. Heatmaps showed patients previously on Fingolimod had a lower rate (72.2%) of being free from therapy after Cladribine.

Conclusion

In our multicentric real-world Italian study, Cladribine therapy is generally effective during the investigated follow-up period. Understanding key characteristics of patients responding best to Cladribine can help tailor therapeutic strategies for optimal outcomes.

No Relation Between Cognitive Impairment, Physical Disability and Serum Biomarkers in a Cohort of Progressive Multiple Sclerosis Patients

Despite significant efforts, there is still an existing need to identify diagnostic tools that would enable fast and reliable detection of the progressive stage of multiple sclerosis (MS) and help in monitoring the disease course and/or treatment effects. The aim of this prospective study in a group of people with progressive MS was to determine whether changes in the levels of selected serum biomarkers and in cognitive function may predict disease progression, and therefore refine the decision-making process in the evaluation of MS patients. Forty two (42) patients with progressive MS completed all the study procedures; the mean duration of follow-up was 12.97 months. During the observation period, serum concentration of chitinase-3 like-protein-1 (CHI3L1/YKL-40) decreased significantly in the whole study group (from 4034.95 ± 262.62 to 2866.43 ± 173.37; p = 0.0005), as well as in subgroups of people with secondary progressive and primary progressive MS (SPMS: from 3693.81 ± 388.68 to 2542.76 ± 256.59; p = 0.0207; and PPMS: from 4376.09 ± 353.27 to 3190.09 ± 233.22; p = 0.0089, respectively). A significant worsening of Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) scores was detected in the whole study group (from 1.18 ± 0.14 to 1.34 ± 0.15; p = 0.0331) as well as in the PPMS subgroup (from 1.04 ± 0.18 to 1.26 ± 0.20; p = 0.0216). No correlations between the analyzed molecular parameters or the results of neuropsychological tests and physical disability were observed. In conclusion, an emphasis should be placed on furthering the search for multimodal biomarkers of disease progression, especially in the PMS population, based on simultaneous analysis of several factors, such as blood biomarkers and cognitive profiles.

Machine learning for refining interpretation of magnetic resonance imaging scans in the management of multiple sclerosis: a narrative review

Multiple sclerosis (MS) is an autoimmune disease of the brain and spinal cord with both inflammatory and neurodegenerative features. Although advances in imaging techniques, particularly magnetic resonance imaging (MRI), have improved the process of diagnosis, its cause is unknown, a cure remains elusive and the evidence base to guide treatment is lacking. Computational techniques like machine learning (ML) have started to be used to understand MS. Published MS MRI-based computational studies can be divided into five categories: automated diagnosis; differentiation between lesion types and/or MS stages; differential diagnosis; monitoring and predicting disease progression; and synthetic MRI dataset generation. Collectively, these approaches show promise in assisting with MS diagnosis, monitoring of disease activity and prediction of future progression, all potentially contributing to disease management. Analysis quality using ML is highly dependent on the dataset size and variability used for training. Wider public access would mean larger datasets for experimentation, resulting in higher-quality analysis, permitting for more conclusive research. This narrative review provides an outline of the fundamentals of MS pathology and pathogenesis, diagnostic techniques and data types in computational analysis, as well as collating literature pertaining to the application of computational techniques to MRI towards developing a better understanding of MS.

Measuring Disease Progression in Multiple Sclerosis Clinical Drug Trials and Impact on Future Patient Care

Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system characterised by inflammation, demyelination and neurodegeneration. Although several drugs are approved for MS, their efficacy in progressive disease is modest. Addressing disease progression as a treatment goal in MS is challenging due to several factors. These include a lack of complete understanding of the pathophysiological mechanisms driving MS and the absence of sensitive markers of disease progression in the short-term of clinical trials. MS usually begins at a young age and lasts for decades, whereas clinical research often spans only 1-3 years. Additionally, there is no unifying definition of disease progression. Several drugs are currently being investigated for progressive MS. In addition to new medications, the rise of new technologies and of adaptive trial designs is enabling larger and more integrated data collection. Remote assessments and decentralised clinical trials are becoming feasible. These will allow more efficient and large studies at a lower cost and with less burden on study participants. As new drugs are developed and research evolves, we anticipate a concurrent change in patient care at various levels in the foreseeable future. We conducted a narrative review to discuss the challenges of accurately measuring disease progression in contemporary MS drug trials, some new research trends and their implications for patient care.

Fatigue and depression influence the prevalence of anxiety in patients with multiple sclerosis

BACKGROUND

There is scarce information in Middle-Eastern Europe regarding the prevalence of anxiety in patients with multiple sclerosis (pwMS) and its association with different clinical-demographic factors.

OBJECTIVE

We aimed to determine the prevalence of anxiety in Hungarian MS patients and to analyze associated factors.

MATERIALS AND METHODS

We evaluated 260 PwMS with the STAI-5 anxiety questionnaire. Fatigue (FIS), depression (BDI-II) and cognition (BICAMS) were also measured. Patients underwent standard neurological evaluations to evaluate Expanded Disability Status Scale (EDSS), and also measured the fine motor skills of the hand with the 9-hole peg test (9HPT), and the walking distance with the 25-foot walking test (T25FW).

RESULTS

We identified 23.1% (N = 60) of the patients with anxiety (only state, trait or both forms concurrently). According to our two univariate, multivariable logistic regression analysis, fatigue and depression are strongly associated with both state and trait anxiety. In the absence of fatigue, the odds of trait anxiety are 82% lower (OR: 0.18; 95% CI: 0.06-0.53; p = 0.002), while in the case of pwMS without depression, the odds are reduced by 81% (OR: 0.19; CI95%= 0.07-0.51, p = 0.001). This association with fatigue (OR: 0.33; CI95%= 0.13-0.85, p = 0.021) and depression (OR: 0.14; CI95%=0.06-0.35; p < 0.001) can also be statistically verified on state anxiety. Importantly, a significant association with state anxiety was found in SPSM patients as well (OR: 34.94; CI95%=2.55-479.61; p = 0.008).

CONCLUSIONS

Anxiety was strongly associated with fatigue, depression, and secondary progressive disease form. These results emphasize the burden of psychiatric morbidity in pwMS.

A digital version of the nine-hole peg test: Speed may be a more reliable measure of upper-limb disability than completion time in patients with multiple sclerosis

BACKGROUND

A digital adaptation of the nine-hole peg test (9HPT) was developed with the potential to provide novel disability features for patients with multiple sclerosis (PwMS).

OBJECTIVES

The objectives were to evaluate the 9HPT features based on reliability, prognosis, and discrimination between treatment groups.

METHODS

The MS partners Advancing Technology and Health Solutions (MS PATHS) cohort data were used to derive new features including completion time and speed. Association and reliability between features and clinical outcomes were tested by intraclass correlation coefficients (ICCs) with repeated measures. The added prognostic value of the features for a clinically meaningful decline was assessed by time-to-event analyses with likelihood ratio tests. The estimated effect size between treatment efficacy groups was acquired from linear mixed-effects models. Sample size was calculated for a hypothetical randomized clinical trial.

RESULTS

For the 10,843 PwMS, speed and completion time were associated with MS disability. Compared with time, speed showed higher reliability (ICC = 0.78 vs 0.74), added benefits in predicting disability worsening (p < 0.001), better discrimination between high- and low-efficacy groups (effect size: 0.035 vs 0.015), and an 18% reduction in required sample size for a 1-year clinical trial.

CONCLUSION

Integrating horizontal hand distances traveled over the 9HPT pegboard can be a more reliable measure of hand function.

Prevalence of Progression Independent of Relapse Activity and Relapse-Associated Worsening in Patients With AQP4-IgG-Positive NMOSD

OBJECTIVES

In aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-IgG NMOSD), disability accrual is mostly attributed to relapses. This study aimed to assess the prevalence of progression independent of relapse activity (PIRA) and relapse-associated worsening (RAW) in AQP4-IgG NMOSD.

METHODS

This was a retrospective cohort study of patients with AQP4-IgG NMOSD enrolled in the MSBase international data registry. Patients required a minimum of 3 recorded Expanded Disability Status Scale (EDSS) scores: baseline, event, and a 6-month confirmation score. Presence and absence of relapses between the baseline and event EDSS scores determined RAW and PIRA, respectively. Descriptive statistics were used to present the results.

RESULTS

A total of 181 patients followed for a median of 4.5 years (Q1 1.7, Q3 7.8) were included. Most patients were female (88.4%), and the median age at disease onset was 38.1 years. Overall, 4 patients (2.2%) developed 5 incidences of PIRA and 13 patients developed RAW (7.2%).

DISCUSSION

This multicenter study highlights that PIRA is very rare in AQP4-IgG NMOSD. Limitations of this study include the sole focus of overall EDSS to measure disability, lack of requirement for a second EDSS score to confirm baseline EDSS, and the absence of magnetic resonance imaging information for all patients.

Patterns and predictors of multiple sclerosis phenotype transition

Currently, there are limited therapeutic options for patients with non-active secondary progressive multiple sclerosis. Therefore, real-world studies have investigated differences between patients with relapsing-remitting multiple sclerosis, non-active secondary progressive multiple sclerosis and active secondary progressive multiple sclerosis. Here, we explore patterns and predictors of transitioning between these phenotypes. We performed a cohort study using data from The Danish Multiple Sclerosis Registry. We included patients with a relapsing-remitting phenotype, registered changes to secondary progressive multiple sclerosis and subsequent transitions between relapsing and non-relapsing secondary progressive multiple sclerosis, which was defined by the presence of relapses in the previous 2 years. We analysed predictors of transitioning from relapsing-remitting multiple sclerosis to relapsing and non-relapsing secondary progressive multiple sclerosis, as well as between the secondary progressive states using a multi-state Markov model. We included 4413 patients with relapsing-remitting multiple sclerosis. Within a median follow-up of 16.2 years, 962 were diagnosed with secondary progressive multiple sclerosis by their treating physician. Of these, we classified 729 as non-relapsing and 233 as relapsing secondary progressive multiple sclerosis. The risk of transitioning from relapsing-remitting to non-relapsing secondary progressive multiple sclerosis included older age (hazard ratio per increase of 1 year in age: 1.044, 95% confidence interval: 1.035-1.053), male sex (hazard ratio for female: 0.735, 95% confidence interval: 0.619-0.874), fewer relapses (hazard ratio per each additional relapse: 0.863, 95% confidence interval: 0.823-0.906), higher expanded disability status scale (hazard ratio per each additional point: 1.522, 95% confidence interval: 1.458-1.590) and longer time on disease-modifying therapies (hazard ratio per increase of 1 year in treatment, high-efficacy disease-modifying therapy: 1.095, 95% confidence interval: 1.051-1.141; hazard ratio, moderate-efficacy disease-modifying therapy: 1.073, 95% confidence interval: 1.051-1.095). We did not find significant predictors associated with the transition from relapsing secondary progressive multiple sclerosis to non-relapsing secondary progressive multiple sclerosis, whereas older age (hazard ratio per increase of 1 year in age: 0.956, 95% confidence interval: 0.942-0.971) prevented the transition from non-relapsing secondary progressive multiple sclerosis to relapsing secondary progressive multiple sclerosis. Our study suggests that transitioning from relapsing-remitting multiple sclerosis to non-relapsing secondary progressive multiple sclerosis depends on well-known factors affecting diagnosing secondary progressive multiple sclerosis. Further transitions between non-relapsing and relapsing secondary progressive multiple sclerosis are only affected by age. These findings add to the knowledge of non-active secondary progressive multiple sclerosis, a patient group with unmet needs in terms of therapies.

BCL3, GBP1, IFI16, and CCR1 as potential brain-derived biomarkers for parietal grey matter lesions in multiple sclerosis

Multiple Sclerosis (MS) is a chronic autoimmune disease of the central nervous system, progressing from Relapsing-Remitting MS (RRMS) to Secondary Progressive MS (SPMS) in many cases. The transition involves complex biological changes. Our study aims to identify potential biomarkers for distinguishing SPMS by analyzing gene expression differences between normal-appearing and lesioned parietal grey matter, which may also contribute to understand the pathogenesis of SPMS. We utilized public datasets from the Gene Expression Omnibus (GEO), applying bioinformatics and machine learning techniques including Weighted Gene Co-expression Network Analysis (WGCNA), Kyoto Encyclopedia of Genes and Genomes (KEGG), Gene Ontology (GO) enrichment analysis, protein-protein interaction (PPI) networks, the Least Absolute Shrinkage and Selection Operator (LASSO), and Random Forest (RF) for predictive model construction. Our study also included analyses of immune cell infiltration. The study identified 359 DEGs, with 105 up-regulated and 254 down-regulated. WGCNA identified 264 common genes, which were subjected to KEGG and GO enrichment analyses, highlighting their role in immune response and viral infection pathways. Four genes (BCL3, GBP1, IFI16, and CCR1) were identified as key biomarkers for SPMS, supported by LASSO regression and RF analyses. These genes were further validated through receiver operating characteristic (ROC) curves, demonstrating significant predictive potential for SPMS. Our study provides a novel set of biomarkers for SPMS from lesioned grey matter of SPMS cases, offering potential for diagnosis and targeted therapeutic strategies. The identified biomarkers link closely with SPMS pathology, especially regarding immune system modulation.

Validation of a Set of Clinical Criteria for the Diagnosis of Secondary Progressive Multiple Sclerosis

Background/Objectives: Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system characterized by progressive impairment of neuronal transmission due to focal demyelination. The most common form is RRMS (relapsing-remitting multiple sclerosis), which, under the influence of certain factors, can progress to SPMS (secondary progressive multiple sclerosis). Our study aimed to validate the criteria proposed by a working group of the Romanian Society of Neurology versus the criteria proposed by a group of experts from Spain, Karolinska, and Croatia concerning the progression from RRMS to SPMS. Methods: This was done by gathering epidemiological data (age, gender) and by applying clinical tests such as the 9HPT (9-hole peg test), 25FWT (25-foot walk test), and EDSS (expanded disability status scale) tests and the SDMT test (symbol digit modalities test). The present research is a cohort study that included a number of 120 patients diagnosed with MS according to the McDonald Diagnostic Criteria 2017. The study was carried out between January 2023 and April 2024, including patients hospitalized in the Neurology Clinic of the Clinical Rehabilitation Hospital from Iasi, Romania. The data were collected at baseline (T0) and at a 12-month interval (T1). Results: The statistical analysis was conducted using Kaiser-Meyer-Olkin analysis, which indicated a value of 0.683, thus validating the clinical tests used. The correlation matrix and the linear regression for all the tests showed highly significant statistical results. Furthermore, the ROC curve analysis of the criteria suggested by the working group of the Romanian Society of Neurology demonstrated that the EDSS, 9HPT, and 25FWT are highly sensitive in diagnosing SPMS, an opinion that is shared with the Spanish experts, but not with the Karolinska expert panel. Using the criteria given by the Croatian expert group in the ROC curve analysis showed that only the EDSS was strongly significant for the progression to the SPMS phase. Conclusions: In conclusion, all clinical methods used demonstrated that they are valid and can contribute to identifying patients with an increased risk of progression. The model proposed by the Romanian Society of Neurology working group is similar to other countries' expert opinions and can be used to detect the risk of disease progression and establish a more tailored therapeutic management of SPMS.

Advanced Quantitative MRI Unveils Microstructural Thalamic Changes Reflecting Disease Progression in Multiple Sclerosis

BACKGROUND AND OBJECTIVES

In patients with multiple sclerosis (PwMS), thalamic atrophy occurs during the disease course. However, there is little understanding of the mechanisms leading to volume loss and of the relationship between microstructural thalamic pathology and disease progression. This cross-sectional and longitudinal study aimed to comprehensively characterize in vivo pathologic changes within thalamic microstructure in PwMS using advanced multiparametric quantitative MRI (qMRI).

METHODS

Thalamic microstructural integrity was evaluated using quantitative T1, magnetization transfer saturation, multishell diffusion, and quantitative susceptibility mapping (QSM) in 183 PwMS and 105 healthy controls (HCs). The same qMRI protocol was available for 127 PwMS and 73 HCs after a 2-year follow-up period. Inclusion criteria for PwMS encompassed either an active relapsing-remitting MS (RRMS) or inactive progressive MS (PMS) disease course. Thalamic alterations were compared between PwMS and HCs and among disease phenotypes. In addition, the study investigated the relationship between thalamic damage and clinical and conventional MRI measures of disease severity.

RESULTS

Compared with HCs, PwMS exhibited substantial thalamic alterations, indicative of microstructural and macrostructural damage, demyelination, and disruption in iron homeostasis. These alterations extended beyond focal thalamic lesions, affecting normal-appearing thalamic tissue diffusely. Over the follow-up period, PwMS displayed an accelerated decrease in myelin volume fraction [mean difference in annualized percentage change (MD-ApC) = -1.50; p = 0.041] and increase in quantitative T1 (MD-ApC = 0.92; p < 0.0001) values, indicating heightened demyelinating and neurodegenerative processes. The observed differences between PwMS and HCs were substantially driven by the subgroup with PMS, wherein thalamic degeneration was significantly accelerated, even in comparison with patients with RRMS. Thalamic qMRI alterations showed extensive correlations with conventional MRI, clinical, and cognitive disease burden measures. Disability progression over follow-up was associated with accelerated thalamic degeneration, as reflected by enhanced diffusion (β = -0.067; p = 0.039) and QSM (β = -0.077; p = 0.027) changes. Thalamic qMRI metrics emerged as significant predictors of neurologic and cognitive disability even when accounting for other established markers including white matter lesion load and brain and thalamic atrophy.

DISCUSSION

These findings offer deeper insights into thalamic pathology in PwMS, emphasizing the clinical relevance of thalamic damage and its link to disease progression. Advanced qMRI biomarkers show promising potential in guiding interventions aimed at mitigating thalamic neurodegenerative processes.

A Clinical Care Algorithm for Detecting Progression in Multiple Sclerosis: RetratEMos Project

OBJECTIVE

The diagnosis of secondary progressive multiple sclerosis (SPMS) is often established retrospectively leading to a delay in detection. This work presents a clinical care algorithm that aims to facilitate the recognition of the secondary progressive phase of the disease, analyzing its usefulness and the feasibility of its implementation in routine clinical practice.

METHODS

The algorithm was developed in four phases: 1) choice of validated diagnostic tools for the detection of progression; 2) assessment of these tools based on experience of use, applicability, time consumed, perceived usefulness and suitability for a profile of a patient in transition to SPMS; 3) framework and final sequence of application; 4) feasibility evaluation through application in clinical practice.

RESULTS

A hierarchical algorithm was developed with an initial screening phase to detect warning signs and establish suspicion of progression (which included the tests "Your Multiple Sclerosis (Your MS)," "MSProDiscuss," and "Nomogram") and a second phase conditional on a positive result in the first, including a functional examination with the Symbol Digit Modalities Test (SDMT), 9-Hole Peg Test (9-HPT), and Timed 25-Foot Walk (T25FW) tools. The algorithm was applied to 373 patients with Expanded Disability Status Scale (EDSS) ≥ 2. The mean time spent per patient in the screening was eight minutes and 20.4 minutes for the complete algorithm. The perceived usefulness of the process by the neurologists was 3.1 (range of 1-4, with 4 being the maximum). In 46% of the cases, the algorithm detected the need for additional functional exploration.

CONCLUSIONS

From our experience, this clinical care algorithm is effective and feasible for detecting progression in MS, although its implementation requires proper organization and can be uneven depending on the resources of each center.

Neurofilaments light chains as a diagnostic and predictive biomarker for Tunisian Multiple Sclerosis patients

BACKGROUND

Multiple Sclerosis (MS) course was shown to be more severe among North Africans compared to Caucasians. Validation of prognostic biomarkers of disease activity and severity is a priority in our practice.

OBJECTIVE

We aimed to investigate the association between baseline cerebrospinal fluid (CSF) and serum NfL (sNFL) levels and disease activity and disability accrual in a cohort of Tunisian patients with MS.

METHODS

A cross-sectional study was conducted, in the department of Neurology of Razi Hospital, including patients diagnosed with MS. Patient's data were retrieved from our local MS database. Blood and CSF sampling were performed at the first visit. sNFL levels were measured using the Enzyme-Linked Immuno-Sorbent Assay (ELISA) sandwich technique.

RESULTS

Three hundred MS patients were enrolled (sex-ratio= 3.05; mean age at MS onset=28.83 years+9.55, mean MS course = 10.21 years+8.96). MS phenotype was predominately relapsing (73%). CSF NfL levels were significantly correlated to the serum ones. NfL concentrations were significantly associated with MS activity (p = 0.012), disease progression (p = 0.001), and higher Multiple Sclerosis Severity Scores (MSSS) (p = 0.0017, r = 0.28).

CONCLUSIONS

These results support the value of NfL as a sensitive and clinically meaningful CSF and blood biomarker to evaluate MS activity and outcomes among Tunisian MS patients.

Markers of secondary progression in multiple sclerosis

INTRODUCTION

There is no globally accepted definition of Secondary Progressive Multiple Sclerosis (SPMS) or set of unambiguous clinical, radiological, or other criteria that can accurately identify patients who transition to SPMS. Thus, the SPMS diagnosis is almost always a retrospective and frequently delayed process.

OBJECTIVE

The aim of this study was to elucidate the current understanding of phenotypic changes throughout MS course and provide insights into the detection of SPMS from the available literature on this diagnostic landscape.

METHODS

Comprehensive literature review aiming at detecting the transition from RRMS to SPMS. A search for relevant publications was conducted across different databases, scrutinizing studies that investigated tools and biomarkers for an accurate diagnosis of SPMS.

RESULTS

62 studies from the past two decades were included. The EDSS-plus was shown to be more sensitive than the EDSS alone in identifying disability progression. We found some helpful indicators for diagnosing SPMS, including cognitive impairment, particularly on working memory, information processing speed, and verbal fluency; presence of slowly expanding lesions on MRI; thinning of retinal layers on OCT. Also, glial markers as Glial Fibrillary Acidic Protein and Chitinase-3-like protein 1 might be more suitable to identify the conversion to progressive disease than Neurofilament light chain. Certain subjective symptoms seem to be more prevalent in the SPMS phase, although further studies are needed to understand whether patient reported outcomes' measures (PROMs) and which ones could be useful in detecting the transition to a progressive phenotype.

CONCLUSION

Our review highlights the emergence of useful biomarkers in early detection of progression of MS, such as cognitive impairment, MRI, and glial markers. We are getting closer to revolutionising the SPMS diagnosis and clinical management as we get a deeper understanding of these biomarkers.

Identification of alemtuzumab-suitable multiple sclerosis patients in Slovakia and sequencing of post-alemtuzumab immunomodulatory treatment

Background

Alemtuzumab (ALEM) is a humanised monoclonal antibody that depletes circulating lymphocytes by selectively targeting CD52, which is expressed in high levels on T- and B-lymphocytes. This depletion is followed by lymphocyte repopulation and a cytokine expression shift towards a lesser inflammatory profile, both of which may contribute to prolonged efficacy. National recommendations for enrolling and treating multiple sclerosis (MS) patients with ALEM have been established. However, there are no recommendations in place for the treatment of MS reactivation after the ALEM treatment.

Objectives

To evaluate the effectiveness and safety of the use of ALEM and to analyse subsequent disease-modifying treatments (DMTs). A multidimensional prediction model was developed to make a patient-specific prognosis regarding the response to ALEM.

Design

A multicentre, prospective, non-controlled, non-interventional, observational cohort study.

Methods

Relapsing multiple sclerosis patients (RMSp) who received ⩾1 dose of ALEM were enrolled. In each treatment year, the following baseline and prospective data were collected: age, MS history, number, type and duration of previous disease-modifying treatment (PDMT), relapse rate (REL), expanded disability status scale (EDSS), magnetic resonance imaging and serious adverse events (AE). In cases of reactivation of MS, all data about the subsequent DMT were collected.

Results

A total of 142 RMSp from 10 MS Slovak Centres fulfilled the inclusion criteria. The average age was 35 years (standard error 8.56). The overall average EDSS was 3.87 (1.46) when ALEM was started. The average duration of PDMT was 6.0 (4.04) years, and the median number of PDMTs was 3 (0-5), while the patients were mostly treated with 2 or 3 DMTs (>65.00%). Post-ALEM treatment was needed in 39 cases (27.46%). The most frequent post-ALEM treatment indicated was ocrelizumab, followed by natalizumab (NAT), siponimod and cladribine. The ocrelizumab and NAT treatment bring little benefit to patients. Siponimod showed less EDSS increase in contrast to ocrelizumab and NAT. Another repopulation therapy, cladribine, may also be an effective option. Statistically significant predictors for the expected EDSS are age (p-value <0.0001), number of ALEM cycles (0.0066), high number of PDMT (0.0459) and the occurrence of relapses (<0.0001). There was no statistically significant effect on the patient's gender (0.6038), duration of disease-modifying treatment before alemtuzumab (0.4466), or the occurrence of AE (0.6668).

Conclusion

The study confirms the positive effect of ALEM on clinical and radiological outcomes. We need more data from long-term sequencing studies.

Tyzzerella nexilis strains enriched in mobile genetic elements are involved in progressive multiple sclerosis

Multiple sclerosis (MS) is an autoimmune-demyelinating disease with an inflammatory pathology formed by self-reactive lymphocytes with activated glial cells. Progressive MS, characterized by resistance to medications, significantly differs from the non-progressive form in gut microbiome profiles. After confirming an increased abundance of "Tyzzerella nexilis" in various cohorts of progressive MS, we identified a distinct cluster of T. nexilis strains enriched in progressive MS based on long-read metagenomics. The distinct T. nexilis cluster is characterized by a large number of mobile genetic elements (MGEs) and a lack of defense systems against MGEs. Microbial genes for sulfate reduction and flagella formation with pathogenic implications are specific to this cluster. Moreover, these flagellar genes are encoded on MGEs. Mono-colonization with MGE-enriched T. nexilis made germ-free mice more susceptible to experimental autoimmune encephalomyelitis. These results indicate that the progression of MS may be promoted by MGE-enriched T. nexilis with potentially pathogenic properties.

At home e-based physical exercise programs in patients with multiple sclerosis: a scoping review

Introduction

Physical exercise (PE) improves symptoms and quality of life in people with multiple sclerosis (pwMS). However, incorporating PE into daily lives of pwMS pose difficulties. As an alternative to in-person PE, e-based PE has been proposed because of its advantages in terms of accessibility and convenience.

Objective

To synthesize existing evidence on e-based PE at home in adults MS and discuss study designs, rehabilitation programs, intervention effects and possible knowledge gaps.

Methods

In this scoping review, a systematic search in electronic databases including Embase, Medline, CINAHL and Cochrane Library was conducted following the PRISMA guidelines. Peer-reviewed articles in English on e-based PE interventional studies at home involving adult pwMS, published from 2008 until April 2023, were identified and exported to Covidence. Data from the included studies were extracted and synthesized. This scoping review identified different types of e-based PE interventions used in pwMS across different study designs, but when evaluating intervention effects, this review focused solely on randomized controlled trials (RCTs).

Results

A total of 3,006 studies were retrieved and 179 studies were screened in full text, resulting in the inclusion of 54 studies with a total of 2,359 pwMS. Of those, 33 were RCTs and three were qualitative studies. The studies reported on various e-based interventions including video-based programs, telerehabilitation, and web-based programs. The interventions evaluated muscle strength, cardiorespiratory fitness, walking speed, endurance, balance, and fatigue, as well as symptoms of depression and cognitive dysfunction. E-based PE interventions at home in RCTs demonstrated improvement of depressive symptoms and anxiety, while inconsistent results were reported for fatigue, walking speed and balance. No significant benefits were observed regarding dexterity. Results were generally heterogeneous and were limited by small sample sizes. Several limitations were identified, such as lack of physical activity assessment prior to the intervention and poor reporting of duration, intensity, frequency and adherence to e-based PE interventions.

Conclusion

E-based PE interventions in pwMS may improve MS-related symptoms, but the study quality is generally low, and findings are often inconsistent. Several important limitations of the existing literature have been identified in the present review, which can guide future research.

Circulatory Indicators of Lipid Peroxidation, the Driver of Ferroptosis, Reflect Differences between Relapsing-Remitting and Progressive Multiple Sclerosis

Ferroptosis, a lipid peroxidation- and iron-mediated type of regulated cell death, relates to both neuroinflammation, which is common in relapsing-remitting multiple sclerosis (RRMS), and neurodegeneration, which is prevalent in progressive (P)MS. Currently, findings related to the molecular markers proposed in this paper in patients are scarce. We analyzed circulatory molecular indicators of the main ferroptosis-related processes, comprising lipid peroxidation (malondialdehyde (MDA), 4-hydroxynonenal (4-HNE), and hexanoyl-lysine adduct (HEL)), glutathione-related antioxidant defense (total glutathione (reduced (GSH) and oxidized (GSSG)) and glutathione peroxidase 4 (GPX4)), and iron metabolism (iron, transferrin and ferritin) to estimate their contributions to the clinical manifestation of MS and differences between RRMS and PMS disease course. In 153 patients with RRMS and 69 with PMS, plasma/serum lipid peroxidation indicators and glutathione were quantified using ELISA and colorimetric reactions, respectively. Iron serum concentrations were determined using spectrophotometry, and transferrin and ferritin were determined using immunoturbidimetry. Compared to those with RRMS, patients with PMS had decreased 4-HNE (median, 1368.42 vs. 1580.17 pg/mL; p = 0.03). Interactive effects of MS course (RRMS/PMS) and disease-modifying therapy status on MDA (p = 0.009) and HEL (p = 0.02) levels were detected. In addition, the interaction of disease course and self-reported fatigue revealed significant impacts on 4-HNE levels (p = 0.01) and the GSH/GSSG ratio (p = 0.04). The results also show an association of MS course (p = 0.03) and EDSS (p = 0.04) with GSH levels. No significant changes were observed in the serum concentrations of iron metabolism indicators between the two patient groups (p > 0.05). We suggest circulatory 4-HNE as an important parameter related to differences between RRMS and PMS. Significant interactions of MS course and other clinically relevant parameters with changes in redox processes associated with ferroptosis support the further investigation of MS with a larger sample while taking into account both circulatory and central nervous system estimation.

Siponimod following Alemtuzumab in secondary progressive MS: investigating sequential therapy-A case series

Alemtuzumab, a humanized anti-CD52 monoclonal antibody, is approved for treatment of highly active relapsing multiple sclerosis (MS) but requires vigilant post-treatment monitoring due to associated risks. The prescription of subsequent therapies following Alemtuzumab, as mandated by label guidance for a treatment-free period of at least 5 years, presents a complex challenge, particularly if there is concurrent conversion to secondary progressive disease course. We described a case-series of five patients starting therapy with Siponimod and followed up for 12 months period converted to secondary progressive MS previously exposed to Alemtuzumab. All patients received Siponimod 2 mg. Clinical evaluation measured with Expanded Disability Status Scale and cognitive evaluation measured with Brief International Cognitive Assessment for Multiple Sclerosis were stable after 12 months on therapy. No severe lymphopenia was recorded, nor serious adverse events. In conclusion, the long-term management of patients treated with Alemtuzumab transitioning to secondary progressive MS requires a proactive and multidisciplinary approach. By addressing the challenges associated with treatment limitations and short-term monitoring recommendations while considering alternative therapeutic options like Siponimod, clinicians can optimize outcomes and ensure continuity of care for individuals with MS.

Serum miR-34a-5p, miR-103a-3p, and miR-376a-3p as possible biomarkers of conversion from relapsing-remitting to secondary progressive multiple sclerosis

Relapsing-remitting (RR) Multiple Sclerosis (MS) is the most common form of the disease; RRMS patients can maintain their clinical phenotype throughout life or can develop a secondary progressive (SP) course over time. We investigated whether circulating miRNAs can predict RR-to-SPMS conversion. A serum miRNAs profile was initially analyzed in a cross-sectional study by qPCR in 16 patients (8 RRMS and 8 SPMS) (Discovery cohort). Three miRNAs, i.e. miR-34a-5p, miR-103a-3p and miR-376a-3p, were significantly up-regulated in SPMS compared to RRMS patients (p < 0.0 5). Serum concentration of the same miRNAs was subsequently analyzed in a retrospective study by ddPCR at baseline in 69 RRMS patients who did (N = 36 cSPMS) or did not (N = 33) convert into SPMS over a 10-year observation period (Study cohort). The results showed that these miRNAs were significantly increased at baseline only in those RRMS patients who converted to SPMS over time. miR-34a-5p and miR-376a-3p alone were significantly increased in cSPMS sera at the end of the 10-years period too. Serum concentration of miR-34a-5p, miR-103a-3p and miR-376a-3p is increased in RRMS patients several years before their conversion to SPMS. These miRNAs might be useful biomarkers to predict the conversion from RRMS to SPMS.

Accuracy of MSBase criteria to diagnose secondary progressive multiple sclerosis in large German real-world patient cohort

BACKGROUND AND OBJECTIVES

Accurate diagnosis of secondary progression in multiple sclerosis (MS) remains a challenge since standardized criteria are missing. In 2016, the MSBase registry presented an algorithm that enabled the diagnosis of secondary progressive multiple sclerosis (SPMS) more than three years earlier compared to diagnosis by neurologists. This work aimed to test whether this approach is equally effective in a real-world cohort of MS patients.

METHODS

This longitudinal retrospective study analyzed clinical data of outpatients with MS recorded until October 2020 in the NeuroTransData registry, a Germany-wide network of 153 certified neurologists. Patient data had been captured in time during clinical visits employing a defined standardized clinical data set in the webbased NeuroTransData patient management platform DESTINY®. The time between the diagnosis of relapsing-remitting multiple sclerosis (RRMS) to SPMS onset was compared with one determined using MSBase criteria (MSBC). Group 1 consisted of patients diagnosed with SPMS during the observation period, whereas group 2 included RRMS patients who did not convert to SPMS during the observation period.

RESULTS

Of 21,281 patients with MS included in our registry, 194 and 9506 patients were allocated to groups 1 and 2, respectively. 10.3% of patients with RRMS were diagnosed with SPMS simultaneously, whereas 60.8% were diagnosed with SPMS at least 3 months earlier by treating neurologists compared to the MSBC. In group 1, the MSBC showed a low sensitivity of 32.0% and an accuracy of 61.4% but a high specificity of 89.6%. In group 2, the MSBC identified 7.8% of patients with SPMS at some point during the observation time. Moreover, test-retest variability remains a challenge since 29.4% of patients diagnosed with SPMS by treating physicians did not fulfil the MSBC at a later point in time.

DISCUSSION

These results are inconsistent with earlier SPMS diagnosis using the MSBC compared to clinical diagnosis by treating physicians. Therefore, there remains a need for an operational, structured, and validated approach to SPMS diagnosis.

Rituximab in secondary progressive multiple sclerosis: a meta-analysis

OBJECTIVE

To evaluate the efficacy of rituximab (RTX) in stabilizing disability progression in secondary progressive multiple sclerosis (SPMS).

METHODS

A systematic review was conducted, encompassing studies from inception to April 2023, utilizing the MEDLINE and EMBASE databases. Inclusion criteria comprised studies with a minimum of 3 SPMS patients receiving intravenous RTX in at least one infusion, with a follow-up duration of at least 6 months. Primary outcome measures included changes in Expanded Disability Status Scale (EDSS) scores. Mean differences in pre- and post-RTX EDSS scores were analyzed using a random-effects model. Meta-regression examined age at RTX initiation, pre-RTX EDSS scores, disease duration, and outcome reported time as variables. Secondary outcomes assessed changes in the annualized relapse rate (ARR).

RESULTS

Thirteen studies, involving 604 SPMS patients, met the inclusion criteria. Following a mean follow-up of 2 years, the mean difference in EDSS scores (ΔEDSS = EDSSpre-RTX - EDSSpost-RTX) was -0.21 (95% CI -0.51 to 0.08, p = 0.16), indicating no significant variation. Multivariable meta-regression identified significant associations between EDSS score mean difference and pre-RTX EDSS scores, disease duration at RTX initiation, and outcome reported time. However, age at RTX initiation showed no significant association. Pre- and post-RTX ARR data were available for 245 out of 604 SPMS patients across seven studies, revealing a mean difference in ARR (ΔARR = ARRpre-RTX - ARRpost-RTX) of 0.74 (95% CI 0.19-1.29, p = 0.008).

INTERPRETATION

RTX demonstrates efficacy in reducing relapse frequency and exhibits potential in stabilizing disability progression over a 2-year follow-up, particularly among individuals with shorter disease duration.

Clinical characteristics and impact on patient-reported outcomes and quality of life of people with ambulatory secondary progressive multiple sclerosis: DISCOVER study

BACKGROUND

People with secondary progressive multiple sclerosis (pwSPMS) experience increasing disability, which impacts negatively on their health-related quality of life (HRQoL). Our aims were to assess the impact of secondary progressive multiple sclerosis (SPMS) on functional status and HRQoL and describe the clinical profile in this population.

METHODS

DISCOVER is an observational, cross-sectional, multicenter study with retrospective data collection in real-world clinical practice in Spain. Sociodemographic and clinical variables, functional and cognitive scales, patient-reported outcomes (PROs), and direct healthcare, and non-healthcare and indirect costs were collected.

RESULTS

A total of 297 evaluable pwSPMS with a EDSS score between 3-6.5 participated: 62.3 % were female and 18.9 % had active SPMS. At the study visit, 77 % of them presented an Expanded Disability Scale Score (EDSS) of 6-6.5. Nearly 40 % did not receive any disease-modifying treatment. Regarding the working situation, 61.6 % were inactive due to disability. PROs: 99.3 % showed mobility impairment in EuroQoL-5 Dimensions-5 Levels, and about 60 % reported physical impact on the Multiple Sclerosis Impact Scale-29. Fatigue was present in 76.1 %, and almost 40 % reported anxiety or depression. The Symbol Digit Modalities Test was used to assess cognitive impairment; 80 % of the patients were below the mean score. Participants who presented relapses two years before and had high EDSS scores had a more negative impact on HRQoL. PwSPMS with a negative impact on HRQoL presented a higher cost burden, primarily due to indirect costs.

CONCLUSIONS

PwSPMS experience a negative impact on their HRQoL, with a high physical impact, fatigue, cognitive impairment, and a high burden of indirect costs.

Active and non-active secondary progressive multiple sclerosis patients exhibit similar disability progression: results of an Italian MS registry study (ASPERA)

'Active' and 'non-active' secondary progressive MS (SPMS) have distinct pathophysiological mechanisms and clinical characteristics, but there is still no consensus regarding the frequency of these MS forms in the real-world setting. We aimed to evaluate the frequency of 'active' and 'non-active' SPMS in a large cohort of Italian MS patients and the differences in terms of clinical and MRI characteristics and disease progression. This multicenter study collected data about MS patients who have transitioned to the SP form in the period between 1st January 2014 and 31st December 2019 and followed by the MS centers contributing to the Italian MS Registry. Patients were divided into 'active SPMS' and 'non-active SPMS', based on both reported MRI data and relapse activity in the year before conversion to SPMS. Out of 68,621, 8,316 (12.1%) patients were diagnosed with SPMS. Out of them, 872 (10.5%) were classified into patients with either 'active' or 'non-active' SPMS. A total of 237 were classified into patients with 'active SPMS' (27.2%) and 635 as 'non-active SPMS' (72.8%). 'Non-active SPMS' patients were older, with a longer disease duration compared to those with 'active SPMS'. The percentages of patients showing progression independent of relapse activity (PIRA) at 24 months were similar between 'active' and 'non-active' SPMS patients (67 [27.4%] vs 188 [29.6%]; p = 0.60). In the 'active' group, 36 (15.2%) patients showed relapse-associated worsening (RAW). Comparison of the survival curves to EDSS 6 and 7 according to disease activity did not show significant differences (p = 0.68 and p = 0.71). 'Active' and 'non-active' SPMS patients had a similar risk of achieving disability milestones, suggesting that progression is primarily attributed to PIRA and only to a small extent to disease activity.

Serum Vitamin D3 as a Potential Biomarker for Neuronal Damage in Smoldering Multiple Sclerosis

Permanent inflammatory demyelinating and neurodegenerative processes lead to neurological disability in patients with multiple sclerosis (MS). The anti-inflammatory properties of vitamin D3 (VitD) are well established, but its role in neurodegeneration is still uncertain. The usefulness of the serum concentration of VitD as a potential biomarker in evaluating brain injury in terms of recently known smoldering MS was under consideration. Methods: We assessed the concentrations of the parameters of brain injury (NF-H, GPAF, S100B, UCHL1) in the cerebrospinal fluid (CSF) of relapsing-remitting (RRMS, n = 123) and progressive MS (PMS, n = 88) patients in the group with normal levels of VitD (VitDn) and in the VitD deficiency group (VitDd). The levels of NF-H and UCHL1 were higher in the group of VitDd compared to VitDn. The higher serum levels of VitD were correlated with lower concentrations of GFAP, NF-H and S100B in the CSF of the whole group of MS patients and in women with MS as opposed to the levels of UCHL1. In men, there were noted negative correlations between the levels of serum VitD and GFAP and NF-H in CSF but not between VitD and S100B and UCHL1. The negative correlations were observed between VitD and the selected parameters of brain injury in MS patients, in women as well as in men. The concentrations of serum VitD together with selected parameters of brain injury in CSF seem to be promising biomarkers of neurodegeneration processes in smoldering MS.

Characterization of Japanese multiple sclerosis patients with progression independent of relapse activity: A 2-year multicenter cohort study

Progression independent of relapse activity (PIRA) is prevalent among Caucasian patients with relapsing and remitting multiple sclerosis (RRMS). However, there is limited knowledge regarding the characteristics of PIRA in Asian patients with RRMS. Therefore, we retrospectively analyzed the clinical and radiological progression of 95 Japanese patients with RRMS during a 2-year observation period. PIRA was observed in three patients who were characterized by young age, large T2 lesion volume, and great reduction in brain volume. Despite having highly active disease, fewer patients with PIRA (33.3%) were treated with high-efficacy drugs compared with those without disease activity (60.7%).

Can Selected Parameters of Brain Injury Reflect Neuronal Damage in Smoldering Multiple Sclerosis?

BACKGROUND

Inflammatory demyelination and impaired recovery processes result in permanent neurodegeneration and neurological disability in patients with multiple sclerosis (MS). In terms of smoldering MS, chronic neuroinflammation develops in the early period of the disease and leads to confirmed disability accumulation. There is a great need to identify biomarkers of neurodegeneration and disease progression.

METHODS

A single-center prospective observational study was performed. The median age of the patients was 40 (31-52) years. Women comprised 64% of the study population. We evaluated the concentrations of the parameters of brain injury (NF-H, GFAP, S100B and UCHL1) in the cerebrospinal fluid (CSF) and the selected interleukins (ILs) in serum of 123 relapsing-remitting MS (RRMS) and 88 progressive MS (PMS) patients.

RESULTS

The levels of GFAP, S100B and UCHL were higher in the PMS group than the RRMS group, in contrast to the levels of NF-H. We observed a positive correlation between the selected pro-inflammatory cytokines and the parameters of brain injury. The Expanded Disability Status Scale (EDSS) score increased with GFAP and NF-H levels and was correlated with the selected ILs. The concentrations of S100B, UCHL1 and NF-H reflected the duration of MS symptoms.

CONCLUSIONS

The levels of brain injury parameters in the CSF and the selected serum ILs in MS patients seem to be promising biomarkers to determine neurodegeneration and neuroinflammation in smoldering MS. Further studies are warranted in this respect.

Serum NfL and GFAP are weak predictors of long-term multiple sclerosis prognosis: A 6-year follow-up

BACKGROUND

Serum neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) are promising biomarkers that might be associated with clinical and radiological markers of multiple sclerosis (MS) severity. However, it is not known whether they can accurately identify patients at risk of disability progression in the medium and long term.

OBJECTIVES

We wanted to determine the association between sNfL and sGFAP, Expanded Disability Status Scale score changes, and conversion to secondary progressive MS (SPMS) in a cohort of 133 patients with relapsing remitting MS.

METHODS

Blood samples were collected at inclusion to measure SNfL and sGFAP by single molecule array and their prognostic value was assessed using a linear mixed model.

RESULTS

In this cohort, 37 patients (27.8 % of 133) experienced disability progression and 12 patients (9.0 %) converted to SPMS during the follow-up (mean follow-up duration: 6.4 years). Only sNfL (p = 0.03) was associated with conversion to SPMS, and neither SNfL nor sGFAP was associated with disability progression.

CONCLUSION

Serum NfL and GFAP do not seem to accurately predict MS outcome in the long term. More studies are needed to determine how serum biomarkers, associated with other clinical and MRI biomarkers, might be used to improve MS prognostication.