Time trends in the incidence and prevalence of multiple sclerosis in Norway during eight decades

Multiple sclerosis: emerging epidemiological trends and redefining the clinical course

Multiple sclerosis is a chronic, inflammatory, and neurodegenerative disease of the central nervous system and a major cause of neurological disability in young adults. Its prevalence and incidence are increasing, and it has been estimated at over 2.8 million cases worldwide, in addition to recent trends towards a shift in MS prevalence to older ages, with peak prevalence estimates in the sixth decade of life. Although historically the relapsing and progressive phases of the disease have been considered separate clinical entities, recent evidence of progression independent of relapse activity (PIRA) has led to a reconsideration of multiple sclerosis as a continuum, in which relapsing and progressive features variably coexist from the earliest stages of the disease, challenging the traditional view of the disease course. In this Series article, we provide an overview of how the traditional description of the clinical course of MS and epidemiological trends in Europe have evolved. For this purpose, we focus on the concept of PIRA, discussing its potential as the main mechanism by which patients acquire disability, how its definition varies between studies, and ongoing research in this field. We emphasise the importance of incorporating the assessment of hidden clinical manifestations into patient management to help uncover and quantify the PIRA phenomenon and the possible implications for future changes in the clinical classification of the disease. At the same time, we provide insights into overcoming the challenges of identifying and defining PIRA and adopting a new understanding of the clinical course of MS.

Contemporary study of multiple sclerosis disability in South East Wales

BACKGROUND

A contemporary understanding of disability evolution in multiple sclerosis (MS) is an essential tool for individual disease management and planning of interventional studies. We have used prospectively collected longitudinal data to analyse disability progression and variation in a British MS cohort.

METHODS

Cox proportional hazards regression was used to estimate hazard of Expanded Disability Status Scale (EDSS) 4.0 and 6.0. A continuous Markov model was used to estimate transitional probabilities for individual EDSS scores. Models were adjusted for age at MS onset, sex and disease-modifying treatments (DMTs) exposure.

RESULTS

2135 patients were included (1487 (70%) female, 1922 (89%) relapsing onset). 865 (41%) had used DMTs. Median time to EDSS 4.0 and 6.0 was 18.2 years (95% CI 16.3 to 20.2) and 22.1 years (95% CI 20.5 to 24.5). In the Markov model, the median time spent at EDSS scores of <6 (0.40-0.98 year) was shorter than the time spent at EDSS scores of ≥6 (0.87-4.11 year). Hazard of change in EDSS was greatest at EDSS scores <6 (HR for increasing EDSS: 1.02-1.33; decreasing EDSS: 0.34-1.27) compared with EDSS scores ≥6 (HR for increasing EDSS: 0.08-0.61; decreasing EDSS: 0.18-0.54).

CONCLUSIONS

These data provide a detailed contemporary model of disability outcomes in a representative population-based MS cohort. They support a trend of increasing time to disability milestones compared with historical reference populations, and document disability variation with the use of transitional matrices. In addition, they provide essential information for patient counselling, clinical trial design, service planning and offer a comparative baseline for assessment of therapeutic interventions.

Ongoing increase in incidence and prevalence of multiple sclerosis in south-eastern Iran: A three decade study

BACKGROUND

Prevalence of multiple sclerosis has been increased during the last decades throughout the world. Epidemiological studies could improve our understanding relating to its intrinsic and extrinsic causes.

OBJECTIVES

The current study has been conducted to determine the epidemiological features of MS in south-eastern Iran which is a semi-tropical area with different ethnicities.

METHODS

This longitudinal descriptive study was carried out in south-eastern Iran, based on information of MS patients registered at Zahedan University of Medical Sciences database from 1990 to 2020.

RESULTS

A total of 1045 cases were enrolled into the study. The age-standardized prevalence ratio of MS increased to 42.2/100,000 population by 2020. These figures showed increasing trends both in females and males and reached to 61.5 and 22.6 per 100,000 population, respectively by the year 2020. Likewise, the total incidence rate grew to its maximum amount of 4.5 in 2015. Female incidence also revealed an upward trend and peaked in 2016 to 6.4 while male incidence rate reached at its highest level of 1.8 in 2009.

CONCLUSION

MS prevalence ratios and incidence rates in south-eastern Iran have been increasing steadily, especially in women during the last three decades. The south-eastern part of Iran should be considered a high-risk region.

The Role of Transcranial Magnetic Stimulation as a Surrogate Marker of Disease Activity in Patients with Multiple Sclerosis: A Literature Review

OBJECTIVE

Multiple sclerosis (MS) is a chronic, immune-mediated inflammatory disease of the central nervous system (CNS) characterized by demyelination, axonal degeneration, and cognitive impairment. It also has an important impact on the quality of life of patients and their family members. We sought to determine if transcranial magnetic stimulation (TMS) is a valid instrument for determining disease progression activity in patients with MS.

METHODS

A literature search of the PubMed database was conducted using the terms "multiple sclerosis," "transcranial magnetic stimulation," and "neurophysiological parameters."

RESULTS

Neurophysiological parameters, such as sensitivity to demyelination and the strength of excitatory and inhibitory synaptic interactions in the cerebral cortex, can be identified through TMS in patients affected by MS. These objective parameters can be correlated with the progression of disease and provide reliable indices for the severity of illness and the efficacy of drugs used to treat MS in clinical trials.

CONCLUSION

The discovery of specific and detailed neurophysiological parameters as surrogate endpoints for disease activity could represent an important step in clinical trials. Changes in cortical connectivity have already been demonstrated in MS, but in clinical practice, other measures are typically used to evaluate disease activity. We speculate that TMS might be more effective in identifying disease progression that leads to long-term disability, compared to standard surrogate markers, since it represents a direct measure of synaptic transmission(s) in MS.

Novel Approaches in the Immunotherapy of Multiple Sclerosis: Cyclization of Myelin Epitope Peptides and Conjugation with Mannan

Multiple Sclerosis (MS) is a serious autoimmune disease. The patient in an advanced state of the disease has restrained mobility and remains handicapped. It is therefore understandable that there is a great need for novel drugs and vaccines for the treatment of MS. Herein we summarise two major approaches applied for the treatment of the disease using peptide molecules alone or conjugated with mannan. The first approach focuses on selective myelin epitope peptide or peptide mimetic therapy alone or conjugated with mannan, and the second on immune-therapy by preventing or controlling disease through the release of appropriate cytokines. In both approaches the use of cyclic peptides offers the advantage of increased stability from proteolytic enzymes. In these approaches, the synthesis of myelin epitope peptides conjugated to mannan is of particular interest as this was found to protect mice against experimental autoimmune encephalomyelitis, an animal model of MS, in prophylactic and therapeutic protocols. Protection was peptide-specific and associated with reduced antigen-specific T cell proliferation. The aim of the studies of these peptide epitope analogs is to understand their molecular basis of interactions with human autoimmune T-cell receptor and a MS-associated human leucocyte antigen (HLA)-DR2b. This knowledge will lead the rational design to new beneficial non-peptide mimetic analogs for the treatment of MS. Some issues of the use of nanotechnology will also be addressed as a future trend to tackle the disease. We highlight novel immunomodulation and vaccine-based research against MS based on myelin epitope peptides and strategies developed in our laboratories.

Joinpoint Regression Analysis of Trends in Multiple Sclerosis Incidence in Kuwait: 1980-2019

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory demyelinating and neurodegenerative disease of the central nervous system with unknown precise etiology. Temporally, a tendency for increasing MS incidence has been recorded worldwide. This cross-sectional cohort study sought to quantify trends in the age-standardized incidence rates (ASIRs) (per million person-years) of MS in Kuwait from 1980 to 2019, overall and by subcohorts defined by age at MS onset, sex, and nationality.

METHODS

MS incidence data from 1980 to 2019 were obtained from the Kuwait National MS Registry (KNMSR). Using midyear relevant Kuwait population as denominator and the World Standard Population as a reference, MS ASIRs overall and by subcohorts defined by age at onset (0-19, 20-39, and 40+ years), sex (male and female), and nationality (Kuwaiti and non-Kuwaiti) were computed. Joinpoint regression analysis was conducted to estimate average annual percent change (AAPC) and its 95% confidence interval (CI) overall and by subcohorts.

RESULTS

During 1980-2019, a total of 1,764 MS incident cases of 95.6 million person-years at-risk were diagnosed and registered in KNMSR. The overall MS ASIR (per million person-years) during the study period was 34.1 (95% CI: 16.1, 52.1). Between 1980 and 2010, in the total cohort, ASIRs of MS significantly increased by 13% (AAPC = 13.0; 95% CI: 10.8, 15.3; p < 0.001), followed by statistically nonsignificant declining trend during the ensuing period (AAPC = -3.8; 95% CI: -14.8, 8.8; p = 0.522). Joinpoint regression analysis revealed that 2 subcohorts of Kuwaiti females each with one joinpoint had significant increasing trends in MS ASIRs (0- to 19-year-old Kuwaiti females, AAPC: 1980-2009, 81.0; 95% CI: 58.2, 107.0; p = 0.001; 20- to 39-year-old Kuwaiti females, AAPC: 1980-1999, 131.7; 95% CI: 26.9, 322.8; p = 0.021). Additionally, of remaining 10, 6 subcohorts had significantly (p < 0.05) increasing trends in MS ASIRs from 1980 to 2019.

CONCLUSIONS

From 1980 to 2010, Kuwait has an overall significantly increasing trend in MS ASIRs followed by a nonsignificant declining drift in the ensuing period. The increasing trend in MS risk appeared to be driven by increased risk among Kuwaiti females younger than 40 years. The underlying factors modulating MS risk in Kuwait need further studies.

A new lipophilic amino alcohol, chemically similar to compound FTY720, attenuates the pathogenesis of experimental autoimmune encephalomyelitis by PI3K/Akt pathway inhibition

Experimental autoimmune encephalomyelitis (EAE) is one of the main animal models used for the study of Multiple Sclerosis (MS). Long-chain lipophilic amino alcohols with immunoregulatory activities have already been studied in some models of inflammatory diseases, but the action of these compounds in EAE and MS is still unknown. In this study, we investigated whether the lipophilic amino alcohol 4b would act to improve the clinical signs of EAE and reduce the demyelination process and the neuroinflammatory parameters in the spinal cord, as well as the inflammatory process in the inguinal lymph nodes, of C57Bl/6 mice induced with EAE after stimulation with MOG_35-55 and pertussis toxin. The 4b treatment (1.0 mg/kg/day) was orally administered, starting on the day of onset of clinical signs of the disease (10th) and ending on the 20th day after immunization. This treatment was able to reduce the cell count on the inguinal lymph nodes, the migration of inflammatory cells into the central nervous system (CNS), as well as the processes of microgliosis, astrogliosis, and the production of chemokines and pro-inflammatory cytokines, thus increasing the IL-10 anti-inflammatory cytokine levels in EAE mice. The inhibition of Akt phosphorylation in the CNS of EAE mice after treatment with 4b indicates that the immunoregulatory action of 4b is related to the PI3K/Akt signaling pathway. Our results indicate the immunoregulatory efficacy of the new compound 4b in the control of some inflammatory parameters and in the glial proliferation. In addition, 4b was able to reduce the demyelination of neurons and the worsening of clinical signs of EAE as effectively as the compound FTY720, the first oral drug approved by the FDA for the treatment of MS.

Changes in multiple sclerosis epidemiology in Finland over five decades

Finland is a high-risk region for multiple sclerosis (MS) with several epidemiological studies on the subject published since 1964, but these have not been comprehensively scrutinized. The objective of this study was to review previous studies of Finnish MS epidemiology, introduce new data on MS prevalence in western parts of Finland and do further analyses on data from previous studies. We performed a systematic search on articles regarding MS epidemiology in Finland in PubMed database, and all relevant articles were included in this review. MS prevalences in the western hospital districts of Vaasa, South Ostrobothnia and Pirkanmaa were calculated in 1980-2007 by using previously unpublished data obtained from a retrospective search from hospital administrative registries. To enhance comparability of the epidemiological figures, we calculated age-standardized prevalence of MS from the new data from western hospital districts and previous data from North Ostrobothnia, Southwest Finland and North Karelia. Marked regional differences in MS epidemiology were confirmed with concentration of the disease in the western and south-western parts of the country. The highest regional age-standardized MS prevalence of 288/100 000 was reported in South Ostrobothnia in 2007. A clear and stable increase in MS prevalence was observed through the decades, but the only marked increase in incidence happened in 1990s. Methodological differences hampered direct comparisons of different studies, highlighting the importance of common principles of reporting and standardizing the epidemiological figures. More comprehensive studies on MS epidemiology are still warranted to yield important information concerning the aetiology of the disease.

Incidence and prevalence of multiple sclerosis in Hungary based on record linkage of nationwide multiple healthcare administrative data

Objectives

As there were only regional studies in Hungary about the prevalence of multiple sclerosis (MS), we aimed to estimate its epidemiological features using data of Hungary’s single-payer health insurance system.

Methods

Pseudonymized database of claims reported by hospitals and outpatient services between 2004–2016 was analyzed and linked with an independent database of outpatient pharmacy refills between 2010–2016. We established an administrative case definition of MS and validated it on medical records of 309 consecutive patients. A subject was defined as MS-patient if received MS diagnosis (International Classification of Diseases, 10th edition, code G35) on three or more occasions at least in 2 calendar years and at least once documented by a neurologist. Patients were counted as incident cases in the year of the first submitted claim for MS. We allowed a 6-year-long run-in period, so only data between 2010–2015 are discussed.

Results

Sensitivity of the administrative case definition turned out to be 99%, while specificity was >99%. Crude prevalence of MS has increased from 109.3/100,000 in 2010 to 130.8/100,000 in 2015 (p-value = 0.000003). Crude incidence declined from 7.1/100,000 (2010) to 5.4/100,000 (2015) (p-value = 0.018). Direct standardization − based on European standard population and results of nationwide Hungarian census of 2011 − revealed that age standardized prevalence was 105.2/100,000 (2010), which has grown to 127.2/100,000 (2015) (p-value = 0.000001). Age standardized incidence rate declined from 6.7/100,000 (2010) to 5.1/100,000 (2015) (p-value = 0.016). The ratio of MS-patients receiving ≥1 prescription for disease modifying treatment increased from 0.19 (2010) to 0.29 (2015) (p-value = 0.0051). The female/male ratio of prevalent cases remained 2.6.

Discussion

The prevalence of MS in Hungary is higher than previously reported, the incidence rate is moderate. The prevalence is rising, the incidence rate shows decline. The proportion of patients receiving disease modifying treatment grows but was still around 30% in 2015.

Trends and characteristics of infection-related hospital admissions in multiple sclerosis patients in Southwest Finland in 2009-2018

BACKGROUND

Multiple sclerosis (MS) patients are at increased risk for infections. The aim of this study was to investigate the trends in hospital admissions of patients with MS and to identify the factors predisposing to infection-related admissions.

METHODS

Hospital admissions with MS as a primary or an auxiliary diagnosis in the hospital district of Southwest Finland in 2009-2018 were searched and MS patients with infection admissions compared with other MS patients in the hospital district. Data were derived from hospital registries, patient charts and the Finnish MS register. Group comparisons were performed using Pearson´s chi-squared test, Fisher´s exact test or Wilcoxon rank sum test. Overdispersion-adjusted Poisson regression was used to analyze the annual admission numbers and multivariable logistic regression to examine the predictors of infection-related admissions.

RESULTS

1380 hospital admissions for 532 patients were identified. The annual number of admissions decreased by 8.9% annually (p<0.001). Proportion of infection-related admissions declined from 26.5% to 19.5% (p = 0.049). The patients with infection admissions were on average 8.2 years older (p<0.001), more often male (p<0.001), had on average 5.3 years longer disease duration (p<0.001), more disability (median EDSS 5.0 vs. 2.0; p<0.001), more often progressive disease (p<0.001) and more comorbidities (p = 0.006) than other MS patients. Disease modifying therapies (DMTs) were used less often by patients with infection admissions (p<0.001). Infection admissions were not associated with the number of recent relapses. In-hospital mortality was higher in the infection-related admissions (3.57% vs 0.29%; p<0.001). Only 14.3% of patients with over two infection admissions had a DMT during the study period.

CONCLUSION

Hospital admissions, with or without an infection, have become more infrequent in MS patients of Southwest Finland over the decade from 2009 to 2018. Infection-related admissions were associated with lesser use of DMTs, older age, male gender and disability.

Pharmacotherapeutic considerations in women with multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a chronically progressive disease of the central nervous system. The relapsing form of the disease predominantly affects women with onset between the ages 20 to 40 years. Therefore, timing, choice, and treatment options should take pregnancy planning into consideration to accommodate both the needs and safety of the mother and health of the fetus.

AREAS COVERED

In this review, the authors discuss and summarize the recent evidence of different pharmacotherapeutic possibilities in the treatment of women with MS.

EXPERT OPINION

There is evidence that disease modifying therapy reduces the risk of relapses and diminishes disability progression in people with relapsing MS. The disease is often diagnosed in the childbearing years, and thus pregnancy planning can possibly be a part of the pharmacotherapeutic considerations. The management of women planning pregnancy requires a balancing of risks. The clinician must consider the risks related to treatment discontinuation versus the risk of exposing the developing fetus to drugs that are potential fetotoxic. Randomized controlled trials of medication safety - if used during pregnancy, are prohibited for ethical reasons; hence, the evidence is continuously gathered from observational data, post-authorization studies and pregnancy registries.

Microbiome in Multiple Sclerosis; Where Are We, What We Know and Do Not Know

An increase of multiple sclerosis (MS) incidence has been reported during the last decade, and this may be connected to environmental factors. This review article aims to encapsulate the current advances targeting the study of the gut-brain axis, which mediates the communication between the central nervous system and the gut microbiome. Clinical data arising from many research studies, which have assessed the effects of administered disease-modifying treatments in MS patients to the gut microbiome, are also recapitulated.

Multiple sclerosis prevalence in 2000 and 2010 in Western Finland

OBJECTIVE

To study ten-year change in MS prevalence in the Province of Western Finland in Tampere University Hospital District located in 62.7°N, 23.7°E.

METHODS

Age-standardized prevalence/10⁵ by using direct standardization in European Standard Population (ESP2013) and crude prevalence/10⁵ with 95% confidence interval (95% CI) were assessed among resident MS cases fulfilling Poser criteria by sex and disease course in 31.12.2000 and 31.12.2010. MS-related disability and disease-modifying treatment (DMT) use were estimated in 31.12.2010.

RESULTS

Crude prevalence increased 49% from 129/10⁵ (95% CI 121-137) in 2000 (N 1080) to 196/10⁵ (187-203) in 2010 (N 1666). Age-standardized prevalence increased 45% from 133/10⁵ (127-140) to 192/10⁵ (184-200) and peaked in 40- to 49-year age-group. Age-standardized prevalence increased 58% among women from 176/10⁵ (171-176) to 277/10⁵ (270-284) and 31% among men from 91/10⁵ (87-95) to 119/10⁵ (115-124). Increase in RRMS was 61% from 111/10⁵ (105-117) to 179/10⁵ (171-186), and decrease in PPMS was 14% from 21/10⁵ (19-24) to 18/10⁵ (15-21).  In 2010 among the 52% RRMS cases on DMT, MS-related disability was mild in 50%. In total, cohort disability was mild in 46%, moderate to severe in 47%, and information was not available in 14%.

CONCLUSION

A significant increase in prevalence was observed in Western Finland. Increase was higher among women and in relapsing-remitting onset MS. Disability showed age- and disease course-specific variation.

High incidence and prevalence of MS in Møre and Romsdal County, Norway, 1950-2018

Objective

To determine prevalence and longitudinal trends in incidence of MS in Møre and Romsdal County, Western Norway, from 1950 to 2018.

Methods

Retrospective longitudinal population-based observational study. All patients diagnosed, or living, with MS in Møre and Romsdal were identified as incident or prevalent cases from local, regional, and national sources. We compiled the data in the Norwegian Multiple Sclerosis Registry and Biobank and used the aggregated data set to calculate incidence and prevalence rates using population measures obtained from Statistics Norway.

Results

On January 1, 2018, the estimated prevalence was 335.8 (95% CI, 314.1–358.5) per 100,000 inhabitants, with a female:male ratio of 2.3. From 1950 through 2017, we observed a considerable (p < 0.001) increase in average annual incidence rates from 2.1 (95% CI, 1.3–3.3) to 14.4 (95% CI, 11.9–17.3) per 100,000. From 2005 through 2017, the incidence among women increased from 17.1 (95% CI, 14.0–20.7) to 23.2 (95% CI, 18.7–28.5) per 100,000, whereas the incidence among men declined from 10.3 (95% CI, 7.9–13.2) to 5.9 (95% CI, 3.4–8.8) per 100,000.

Conclusion

Møre and Romsdal County in Western Norway has the highest prevalence of MS reported in Norway. The incidence has steadily increased since 1950, and during the latest 15 years, we observed opposing trends in sex-specific incidence rates.

The changing course of multiple sclerosis: rising incidence, change in geographic distribution, disease course, and prognosis

PURPOSE OF REVIEW

This review provides a brief update of new research findings on the changing epidemiology, disease course, and prognosis of multiple sclerosis (MS).

RECENT FINDINGS

Evidence not only continues to support the female predominance in incidence and prevalence of the disease but also supports an increase in incidence of MS in geographic areas that were previously considered to be low incidence for the disease.

SUMMARY

An increased interest in population-based registries and databases will provide more valid epidemiological measures and observational studies conducted in well-defined study populations. Such studies are crucial for an accurate description of both changing prognosis of MS and differential characteristics of the various MS phenotypes.

Epidemiology and treatment of multiple sclerosis in elderly populations

The prevalence of multiple sclerosis (MS) and the age of affected patients are increasing owing to increased longevity of the general population and the availability of effective disease-modifying therapies. However, ageing presents unique challenges in patients with MS largely as a result of their increased frequency of age-related and MS-related comorbidities as well as transition of the disease course from an inflammatory to a neurodegenerative phenotype. Immunosenescence (the weakening of the immune system associated with natural ageing) might be at least partly responsible for this transition, which further complicates disease management. Currently approved therapies for MS are effective in preventing relapse but are not as effective in preventing the accumulation of disability associated with ageing and disease progression. Thus, ageing patients with MS represent a uniquely challenging population that is currently underserved by existing therapeutic regimens. This Review focuses on the epidemiology of MS in ageing patients. Unique considerations relevant to this population are discussed, including the immunology and pathobiology of the complex relationship between ageing and MS, the safety and efficacy of disease-modifying therapies, when discontinuation of treatment might be appropriate and the important role of approaches to support wellness and cognition.

Safety and efficacy of autologous hematopoietic stem cell transplantation for multiple sclerosis in Norway

Background:

Hematopoietic stem cell treatment (HSCT) is a promising treatment option for multiple sclerosis (MS), but detailed safety and efficacy measures are still scarce.

Objective:

To evaluate the efficacy and safety of HSCT in MS.

Methods:

Retrospective single-center observational study of all MS patients that underwent HSCT in Norway during January 2015 to January 2018. The primary outcome was no evidence of disease activity (NEDA-3) status.

Results:

A total of 30 patients with a median follow-up time of 26 months (range: 11–48) were evaluated. In total, 25 (83%) achieved NEDA-3 status, and none received disease-modifying treatment after HSCT. For 13 (43%) of the patients, there were sustained improvement in Expanded Disability Status Scale (EDSS) score, and 10 (33%) were working full time after the treatment, compared to only 1 (3%) before treatment. There were no serious treatment-related complications and was no mortality. Five patients (17%) were diagnosed with an autoimmune thyroid disease after the procedure, and 10 (43%) of the women had amenorrhea lasting >12 months and symptoms of ovarian failure.

Conclusion:

HSCT in MS is an effective and relatively safe treatment option, with few serious complications and no mortality in Norway, so far. However, long-term adverse event with amenorrhea is a common problem.

Effect of nutrition on neurodegenerative diseases. A systematic review

Neurodegenerative diseases are characterized by the progressive functional loss of neurons in the brain, causing cognitive impairment and motoneuron disability. Although multifactorial interactions are evident, nutrition plays an essential role in the pathogenesis and evolution of these diseases. A systematic literature search was performed, and the prevalence of studies evaluated the effect of the Mediterranean diet (MeDiet), nutritional support, EPA and DHA, and vitamins on memory and cognition impairment. The data showed that malnutrition and low body mass index (BMI) is correlated with the higher development of dementia and mortality. MeDiet, nutritional support, and calorie-controlled diets play a protective effect against cognitive decline, Alzheimer's disease (AD), Parkinson disease (PD) while malnutrition and insulin resistance represent significant risk factors. Malnutrition activates also the gut-microbiota-brain axis dysfunction that exacerbate neurogenerative process. Omega-3 and -6, and the vitamins supplementation seem to be less effective in protecting neuron degeneration. Insulin activity is a prevalent factor contributing to brain health while malnutrition correlated with the higher development of dementia and mortality.

A Framework for Estimating the Burden of Chronic Diseases: Design and Application in the Context of Multiple Sclerosis

Background: When population-based databases are unavailable, nationwide assessments of the disease burden of multiple sclerosis (MS) resort to clinical, administrative or convenience-sampled data sources, which may produce results of limited external validity. Our aim was to develop a framework for estimating measures of occurrence of chronic diseases, and more broadly disease burden, that mitigate these limitations and to apply this framework to estimate the prevalence of multiple sclerosis (MS) in Switzerland.

Methods: We developed a 7-step framework which implements the combination of several data sources together with a resampling and critical appraisal approach. The framework was applied to estimate the MS prevalence for 2016 in Switzerland, for which four distinct data sources (Swiss MS registry, Swiss national MS treatment registry, MediService database, and Swiss MS cohort study) were combined. Results were reviewed by disease experts and compared to earlier Swiss estimates and current prevalence estimates from other countries.

Results: We estimate that in the year 2016 between 14,650 and 15,700 persons with MS have been living in Switzerland, yielding a period prevalence of 174–187/100,000 inhabitants. Compared to the last estimate in 1986, we detected a substantial increase of MS diagnoses which coincides with a higher number of diagnoses in women below the age of 65.

Conclusions: Internationally, Switzerland is a high-prevalence country for MS, although estimates were somewhat lower than recent evaluations of Northern European countries. In addition, we corroborate previous reports that the prevalence increase coincides with a higher number of MS diagnoses among women. The proposed framework has wide applicability and the potential to place estimates of disease occurrence and burden with imperfect data availability on more solid grounds.

Fatigue in Multiple Sclerosis: General and Perceived Fatigue Does Not Depend on Corticospinal Tract Dysfunction

Background: Multiple sclerosis (MS) is an autoimmune disorder of the CNS in which inflammation, demyelination, and axonal damage of the central nervous system coexist. Fatigue is one of the most disabling symptoms in MS and little is known about the neurophysiological mechanisms involved. Methods: To give more mechanistic insight of fatigue in MS, we studied a cohort of 17 MS patients and a group of 16 age-matched healthy controls. Baseline Fatigue Severity Scales and Fatigue Rating were obtained from both groups to check the level of fatigue and to perform statistical correlations with fatigue-induced neurophysiologic changes. To induce fatigue we used a handgrip task. During the fatiguing task, we evaluated fatigue state (using a dynamometer) and after the task we evaluated the Borg Rating of Perceived Exertion Scale. Transcranial magnetic stimulation and peripheral electric stimulation were used to assess corticospinal tract and peripheral system functions before and after the task. Results: Clinically significant fatigue and central motor conduction time were greater in patients than in controls, while motor cortex excitability was decreased and maximal handgrip strength reduced in patients. Interestingly, fatigue state was positively correlated to perceived fatigue in controls but not in patients. Furthermore, in the presence of similar fatigue state over time, controls showed a significant fatigue-related reduction in motor evoked potential (a putative marker of central fatigue) whereas this effect was not seen in patients. Conclusions: in MS patients the pathogenesis of fatigue seems not driven by the mechanisms directly related to corticospinal function (that characterize fatigue in controls) but seems probably due to other "central abnormalities" upstream to primary motor cortex.

Multiple sclerosis epidemiology in Finland: Regional differences and high incidence

OBJECTIVES

Studies on the east-west gradient of multiple sclerosis (MS) are scarce. In Finland, epidemiological differences have been only partially elucidated, but the MS risk is high, and it has been claimed that the occurrence follows a longitudinal gradient. In this register-based study, we updated the MS epidemiology in southwest Finland (SwF) and compared it to the easternmost hospital district, North Karelia (NK), for which no previous data exist.

MATERIALS AND METHODS

Patients with ICD-10 code G35 were identified from hospital district administrative data. Patient records were reviewed to include only cases with a definitive diagnosis. Incidence period covered 5 years (2012-2016), and the prevalence date was December 31, 2016. Results were standardized using the direct method.

RESULTS

A total of 1184 persons had MS in SwF and 253 persons in NK at the end of 2016. The prevalence was 280/100 000 (95% CI 264-296) in SwF and 168/100 000 (95% CI 148-190) in NK (age-standardized for the European standard population 2013). During the incidence period, 211 new MS diagnoses were made in SwF and 49 in NK. The annual age-standardized (ESP 2013) incidence was 12.1/100 000 person-years (95% CI 10.5-13.8) in SwF and 8.6/100 000 person-years (95% CI 6.4-11.2) in NK in the age-group 10-69 years.

CONCLUSIONS

There are regional differences in MS epidemiology in Finland, possibly related to demographic, social, and genetic circumstances, but the retrospective nature and limited sample size of this study might introduce some uncertainty to the calculations. SwF is a region with a globally very high risk for MS.

A novel comprehensive paradigm for the etiopathogenesis of multiple sclerosis: therapeutic approaches and future perspectives on its treatment

It is well recognized that variation in the geographical distribution of prevalence of multiple sclerosis (MS) exists: increasing the latitude its prevalence increases as well, but the underlying causes of such dissimilarity still remained elusive as of today. Currently, the most accredited hypothesis is that the closer to the equator the more pronounced is the amount of sunlight which, in turn, increases the production of vitamin D. Cholecalciferol is indeed deficient in MS patients, but this factor does not explain by itself the etiopathogenesis of the disease. In the present study, to search for a pattern and provide a model of the disease's etiology consistent with this regional factor, as well with its changing ethnic, sex-ratio, lifestyle variations and the other unexplained aspects of MS, an extensive analysis of peer-reviewed literature and data was conducted. The arisen hypothesis was that, increasing the latitude, the factor that varies and can have the stronger effect on the human organism, is the continuous and ever-increasing diversity of the natural light-dark cycle. The consequent effort of the suprachiasmatic nucleus to entrain the organism's circadian rhythm affects the hypothalamic-pituitary-adrenal axis resulting in desynchronizing the central and peripheral circadian clocks and pathologizing the immunitary system. To verify such hypothesis, a theoretical framework of the etiopathogenesis, coherent with the gathered literature, was conceived and a demonstration to corroborate it was eventually devised and performed. The results underscored that people living in countries subjected to a further circadian disruptive factor, as daylight saving time, have a 6.35 times higher prevalence of MS than States placed on their same latitude that do not observe it, thus strongly supporting the hypothesis. As further reinforcement of the conclusions, it is worth mentioning that the levels of polyamines rise abruptly in autoimmune diseases. Moreover, among their numerous roles, these polycations participate to the regulation of the circadian clock so their sudden variation might disrupt it. Following these interesting findings, new perspectives in therapies are, therefore, proposed.

The Growing Incidence of Bullous Pemphigoid: Overview and Potential Explanations

Bullous pemphigoid (BP) is the most common type of subepidermal autoimmune bullous diseases. BP characteristically affects the elderly and is seen mainly in patients older than 70 years. While the annual incidence of BP has been estimated to be between 2.4 and 23 cases per million in the general population, it rises exponentially to 190-312 cases per million in individuals older than 80 years. In addition, a growing body of evidence reports a remarkable trend of increased incidence of BP, showing a 1.9- to 4.3-fold rise over the past two decades. This demonstrable increase warrants a higher awareness of the increased risk to develop BP. This review summarizes the current understanding of the epidemiological features of BP and sheds light on the putative explanations for its growing incidence.

Adult hospital admissions associated with multiple sclerosis in Finland in 2004-2014

INTRODUCTION

Treatment of multiple sclerosis (MS) has developed significantly and several new immunotherapeutic drugs have become available in Finland since 2004. We studied whether this is associated with changes in hospital admission frequencies and healthcare costs and whether admission rates due to infection have increased.

METHODS

The national Care Register for Health Care was searched for all discharges from neurological, medical, surgical, neurosurgical and intensive care units with MS as a primary diagnosis or an auxiliary diagnosis for primary infection diagnosis in 2004-2014. Only patients ≥16 years of age were included.

RESULTS

We identified 12,276 hospital admissions for 4296 individuals. The number of admissions declined by 4.6% annually (p = .0024) in both genders. Proportion of admissions with an infection as the primary diagnosis increased but no change in their frequency was found. They were longer than admissions with MS as the primary diagnosis and were associated with increased in-hospital mortality. The annual aggregate cost of hospital admissions declined by 51% during the study period.

CONCLUSIONS

This study shows that hospital admission rates and costs related to MS hospital admissions have markedly declined from 2004 to 2014 in Finland, which coincides with an increase in the use of disease-modifying therapies. Key message Hospital admission rates and costs related to MS hospital admissions have markedly declined from 2004 to 2014 in Finland. Proportion of admission related to infection has increased and they are associated with longer hospitalizations and increased in-hospital mortality pointing out the importance of infection prevention.

Nutritional intervention as an essential part of multiple sclerosis treatment?

Multiple sclerosis (MS) is a chronic inflammatory and demyelinating disease of the central nervous system. In addition to the genetic, epigenetic and immunological components, various other factors, e.g. unhealthy dietary habits, play a role in the MS pathogenesis. Dietary intervention is a highly appealing approach, as it presents a simple and relatively low risk method to potentially improve outcomes in patients with brain disorders in order to achieve remission and improvement of clinical status, well-being and life expectancy of patients with MS. The importance of saturated fat intake restriction for the clinical status improvement of MS patients was pointed for the first time in 1950s. Recently, decreased risk of first clinical diagnosis of CNS demyelination associated with higher intake of omega-3 polyunsaturated fatty acids particularly originating from fish was reported. Only few clinical trials have been performed to address the question of the role of dietary intervention, such is e.g. low saturated fat diet in MS treatment. This review summarizes current knowledge about the effect of different dietary approaches (diets low in saturated fat and dietary supplements such as fish oil, lipoic acid, omega-3 polyunsaturated fatty acids, seeds oils, high fiber diet, vitamin D, etc.) on neurological signs, patient's well-being, physical and inflammatory status. So far the results are not conclusive, therefore much more research is needed to confirm and to understand the effectiveness of these dietary interventions in the long term and well defined studies.

Which Environmental Factor Is Correlated with Long-Term Multiple Sclerosis Incidence Trends: Ultraviolet B Radiation or Geomagnetic Disturbances?

Background

Insufficient received ultraviolet B radiation (UV) is regarded as the main environmental risk factor (RF) for MS in vitamin D deficiency hypothesis. Nevertheless, geomagnetic disturbance (GMD) has also been proposed as a potential trigger for MS in GMD hypothesis. The aim of this study was to investigate which of these mentioned RF is correlated with long-term ultradecadal MS incidence.

Methods

After a systematic search, long-term incidence reports of the United Kingdom (UK), Denmark, Tayside County, Nordland County, the Orkney, and Shetland Islands were selected for this retrospective time-series study. Possible lead-lag relationships between MS incidence, GMD, and UV were evaluated by cross-correlation analysis.

Results

Significant positive correlations between GMD and MS incidence were seen in Tayside County (at lag of 2 years: r_S = 0.38), Denmark (peak correlation at lag of 2 years: r_S = 0.53), and UK (at lag of 1 year: r_S = 0.50). We found a positive correlation between received UV and MS incidences in the Nordland at lag of 1 year (r_S = 0.49).

Conclusion

This study found significant positive correlations between alterations in GMD with alterations in long-term MS incidence in three out of six studied locations and supports the GMD hypothesis. The observed significant correlation between MS and UV is positive; hence it is not supportive for UV related vitamin D deficiency hypothesis.

Time-trend analysis and developing a forecasting model for the prevalence of multiple sclerosis in Kohgiluyeh and Boyer-Ahmad Province, southwest of Iran

OBJECTIVE

This study was designed and implemented to assess the current situation and to estimate the time trend of multiple sclerosis (MS), as well as to explain potential factors associated with such a trend.

METHODS

This longitudinal study was carried out based on analysis of the data from the monitoring and treatment surveillance system for 421 patients with MS in Kohgiluyeh and Boyer-Ahmad Province, Iran, from 1990 to 2015. To this end, curve estimation approach was used to investigate the changes in prevalence and incidence of the disease, and univariate time series model analysis was applied in order to estimate the disease incidence in the next 10 years.

RESULTS

The mean and standard deviation of age were 29.78 and 8.5 years at the time of diagnosis, and the mean and 95% confidence interval of age were 29.18 (28.86-30.77) and 29.68 (28.06-31.30) at the time of diagnosis for women and men, respectively. The sex ratio (males to females) was estimated as 3.3, and the prevalence of the disease was estimated as 60.14 in 100,000 people. The diagram of the 35-year trend of the disease indicated three distinct patterns with a tendency to increase in recent years.

CONCLUSION

The prevalence and incidence trend of the disease in the study population is consistent with regional and global changes. Climatic and environmental factors such as extreme weather changes, dust particles, expansion of the application of new industrial materials, and regional wars with potential use of banned weapons are among the issues that may, in part, be able to justify the global and regional changes of the disease. Predictive models indicate a growing trend of the disease, highlighting the need for more regular monitoring of the disease trend in upcoming years.

The hygiene hypothesis in autoimmunity: the role of pathogens and commensals

The incidence of autoimmune diseases has been steadily rising. Concomitantly, the incidence of most infectious diseases has declined. This observation gave rise to the hygiene hypothesis, which postulates that a reduction in the frequency of infections contributes directly to the increase in the frequency of autoimmune and allergic diseases. This hypothesis is supported by robust epidemiological data, but the underlying mechanisms are unclear. Pathogens are known to be important, as autoimmune disease is prevented in various experimental models by infection with different bacteria, viruses and parasites. Gut commensal bacteria also play an important role: dysbiosis of the gut flora is observed in patients with autoimmune diseases, although the causal relationship with the occurrence of autoimmune diseases has not been established. Both pathogens and commensals act by stimulating immunoregulatory pathways. Here, I discuss the importance of innate immune receptors, in particular Toll-like receptors, in mediating the protective effect of pathogens and commensals on autoimmunity.

Therapeutic Targets for Multiple Sclerosis: Current Treatment Goals and Future Directions

Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system, and the most common cause of nontraumatic disability in young adults. Most patients have a relapsing-remitting course, and roughly half of them will eventually enter a degenerative progressive phase, marked by gradual accrual of disability over time in the absence of relapses. Early initiation of treatment has delayed the onset of disability progression. Thus, there is increased interest in treating to target in MS, particularly targeting no evidence of disease activity. This review will describe the most common treatment goals in MS: the Rio scores, disease-free survival, and no evidence of disease activity. We will also cover how well current disease-modifying therapies achieve no evidence of disease activity, and discuss future options for improving MS treatment targets.

Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

Comparable data on the global and country-specific burden of neurological disorders and their trends are crucial for health-care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study provides such information but does not routinely aggregate results that are of interest to clinicians specialising in neurological conditions. In this systematic analysis, we quantified the global disease burden due to neurological disorders in 2015 and its relationship with country development level.

METHODS

We estimated global and country-specific prevalence, mortality, disability-adjusted life-years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) for various neurological disorders that in the GBD classification have been previously spread across multiple disease groupings. The more inclusive grouping of neurological disorders included stroke, meningitis, encephalitis, tetanus, Alzheimer's disease and other dementias, Parkinson's disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, medication overuse headache, brain and nervous system cancers, and a residual category of other neurological disorders. We also analysed results based on the Socio-demographic Index (SDI), a compound measure of income per capita, education, and fertility, to identify patterns associated with development and how countries fare against expected outcomes relative to their level of development.

FINDINGS

Neurological disorders ranked as the leading cause group of DALYs in 2015 (250·7 [95% uncertainty interval (UI) 229·1 to 274·7] million, comprising 10·2% of global DALYs) and the second-leading cause group of deaths (9·4 [9·1 to 9·7] million], comprising 16·8% of global deaths). The most prevalent neurological disorders were tension-type headache (1505·9 [UI 1337·3 to 1681·6 million cases]), migraine (958·8 [872·1 to 1055·6] million), medication overuse headache (58·5 [50·8 to 67·4 million]), and Alzheimer's disease and other dementias (46·0 [40·2 to 52·7 million]). Between 1990 and 2015, the number of deaths from neurological disorders increased by 36·7%, and the number of DALYs by 7·4%. These increases occurred despite decreases in age-standardised rates of death and DALYs of 26·1% and 29·7%, respectively; stroke and communicable neurological disorders were responsible for most of these decreases. Communicable neurological disorders were the largest cause of DALYs in countries with low SDI. Stroke rates were highest at middle levels of SDI and lowest at the highest SDI. Most of the changes in DALY rates of neurological disorders with development were driven by changes in YLLs.

INTERPRETATION

Neurological disorders are an important cause of disability and death worldwide. Globally, the burden of neurological disorders has increased substantially over the past 25 years because of expanding population numbers and ageing, despite substantial decreases in mortality rates from stroke and communicable neurological disorders. The number of patients who will need care by clinicians with expertise in neurological conditions will continue to grow in coming decades. Policy makers and health-care providers should be aware of these trends to provide adequate services.

FUNDING

Bill & Melinda Gates Foundation.

Survival and cause of death in multiple sclerosis: a 60-year longitudinal population study

OBJECTIVE

Survival and causes of death (COD) in multiple sclerosis (MS) provide ultimate endpoints. We aimed to investigate survival and COD in a 60-year population-based MS cohort compared with the general population.

METHODS

All patients with incident multiple sclerosis (MS) (N=1388) with onset during 1953-2012 in Hordaland County, Western Norway, were included. Data were obtained from patient records at Haukeland University Hospital and linked to the Norwegian COD registry. Survival adjusted for sex, age and disease course were estimated by Kaplan-Meier analyses from birth and from disease onset. Mortality and COD in MS relative to the general population were examined by standardised mortality ratio (SMR).

RESULTS

Of 1388 patients, 291 had deceased, mainly of MS (56.4%). Median life expectancy was 74.7 years for MS and 81.8 years for the general population (p<0.001); 77.2 years for women with MS and 72.2 years for men with MS (p<0.001). Life expectancy for patients with relapsing remitting MS (RRMS) was 77.8 years and -71.4 years for primary progressive MS (PPMS) (p<0.001). Overall SMR was 2.7 (p>0.0001); 2.9 in women and 2.5 in men (p=0.0009). SMR was 2.4 in RRMS and 3.9 in PPMS (p<0.0001). SMR from disease onset during 1953-1974 was 3.1; 2.6 during 1975-1996 and 0.7 during 1997-2012 (p<0.0083). No difference in cause-specific deaths were found (p=0.0871).

CONCLUSION

We found a 7-year shorter life expectancy and almost threefold higher mortality in MS compared with the general population. A rise in survival in MS was observed during the entire observation period.

Multiple Sclerosis: Immunopathology and Treatment Update

The treatment of multiple sclerosis (MS) has changed over the last 20 years. All immunotherapeutic drugs target relapsing remitting MS (RRMS) and it still remains a medical challenge in MS to develop a treatment for progressive forms. The most common injectable disease-modifying therapies in RRMS include β-interferons 1a or 1b and glatiramer acetate. However, one of the major challenges of injectable disease-modifying therapies has been poor treatment adherence with approximately 50% of patients discontinuing the therapy within the first year. Herein, we go back to the basics to understand the immunopathophysiology of MS to gain insights in the development of new improved drug treatments. We present current disease-modifying therapies (interferons, glatiramer acetate, dimethyl fumarate, teriflunomide, fingolimod, mitoxantrone), humanized monoclonal antibodies (natalizumab, ofatumumb, ocrelizumab, alentuzumab, daclizumab) and emerging immune modulating approaches (stem cells, DNA vaccines, nanoparticles, altered peptide ligands) for the treatment of MS.

"Cure" for multiple sclerosis (MS)-Evolving views of therapy goals in patients on different stages of the disease: A pilot study in a cohort of Polish MS patients

INTRODUCTION

New aggressive treatments promise improvement of results in the treatment of multiple sclerosis (MS), however, with high risk of serious complications. In this study, we analyzed patients' acceptance for risks connected with the MS treatment.

METHODS

The study was designed as a prospective nonanonymous online questionnaire. Responders were asked about the definition of the "cure" for MS and crucial goals in the treatment.

RESULTS

One hundred and eighty patients filled in the questionnaire (129 women and 51 men), and the mean age was 33 years (SD = 10.29). The MS forms were as follows: relapsing-remitting (65%), secondary progressive (14%), primary progressive (10%), and other (11%), with mean EDSS score of 3 points (SD = 2.6). For 50% of the patients, relief of symptoms such as fatigue (72%), paresis (66%), and balance disorders (65%) was synonymous with "cure." The patients with faster progression of the disease were likely to accept risky "curative" treatments-with average 68% accepted mortality risk (p = .003). Over 81% of patients accepted mortality rates over 1% for the treatment that achieves self-defined cure.

CONCLUSION

The study shows that the MS patients are likely to accept even very risky treatments as long as they promise patient-defined "cure."

Viruses and Multiple Sclerosis: From Mechanisms and Pathways to Translational Research Opportunities

Viruses are directly or indirectly implicated in multiple sclerosis (MS). Here, we review the evidence on the virus-related pathophysiology of MS, introduce common experimental models, and explore the ways in which viruses cause demyelination. By emphasizing knowledge gaps, we highlight future research directions for effective MS diagnostics and therapies: (i) identifying biomarkers for at-risk individuals, (ii) searching for direct evidence of specific causative viruses, (iii) establishing the contribution of host genetic factors and viruses, and (iv) investigating the contribution of immune regulation at extra-CNS sites. Research in these areas is likely to be facilitated by the application of high-throughput technologies, the development of systems-based bioinformatic approaches, careful selection of experimental models, and the acquisition of high-quality clinical material for tissue-based research.

[Comorbid autoimmune pathology in patients treated with disease modifying drugs]

Because of intensive growth of the prevalence of multiple sclerosis (MS) and other autoimmune diseases (AID) during the last years, the comorbidity of MS and AID is not a rarity. In this literature review, the development of comorbid AID in patients with MS is considered to be the probable complication of disease modifying therapy with drugs of different groups. The authors present the own data on the prevalence of comorbid autoimmune pathology in patients with MS treated with disease modifying drugs.

Comments on the review article 'Time trends in the incidence and prevalence of multiple sclerosis in Norway during eight decades'

This article is a commentary to the Review article by Grytten et al, published in Supplement 132:29–36 (DOI: 10.1111/ane.12428).

Conclusion: National incidence and risk factor assessments may become a basis for the evaluation of prevention trials – prospects from the Third Nordic MS Symposium

This symposium started with an overview of recent incidence and prevalence data from the Scandinavian national registers and continued with a critical analysis of several alleged risk factors for MS. These risk factors are constantly changing and therefore might explain current incidence changes. In addition, they may be the subject of preventive measures.