Causes of death in patients with multiple sclerosis and matched referent subjects: a population-based cohort study

Multiple sclerosis and vascular nexus: A systematic review and meta-analysis of incidence and mortality

BACKGROUND

Vascular diseases (VDs) are increasingly studied in multiple sclerosis (MS) due to their significant impact on disability and mortality. Our aim was to evaluate VD incidence rates and determine the prevalence of VD-related mortality.

MATERIAL AND METHODS

Our study followed the PRISMA 2020 guidelines. We searched PubMed, Google Scholar, Europe PMC, and Web of Science from the inception up to April 30th, 2024. Data analysis was performed using the R statistics package program. Sensitivity analysis, subgroup analysis, and meta-regression were conducted for significant heterogeneity.

RESULTS

We collected 23 studies. Patients with MS exhibited significantly higher rates of VD compared with controls. Patients with MS showed a significantly higher rate of heart failure (HF), venous thromboembolism (VTE), peripheral vascular disease (PVD), and stroke, although the incidence rate of atrial fibrillation/flutter was significantly lower compared with controls. High blood pressure tended to be lower compared with controls. The highest rate of VD was within the first 10years of follow-up, significantly for myocardial infraction, VTE, and stroke, compared with controls. Regarding mortality, the prevalence of VD-related mortality among deceased individuals with MS was 16.7% [95% CI 11.8;22.0].

CONCLUSION

Our meta-analysis revealed a significant dynamic nexus between MS and VD. MS may act as an independent risk factor for certain VDs, yet it could also be a protective factor against others. Physicians should consider VD and mortality related to VD when managing patients with MS.

Blood Flow Restriction and Veterans With Multiple Sclerosis and Advanced Disability: Protocol for a Randomized Controlled Trial

OBJECTIVE

The purpose of this study will be to determine the efficacy of low intensity lower extremity resistance training with and without blood flow restriction (BFR) on quadriceps muscle strength and thickness in veterans with advanced multiple sclerosis (MS).

METHODS

This will be an assessor-blinded, 2-group (1 to 1 allocation) randomized controlled trial targeting an enrollment of 58 participants with advanced MS as defined by Patient-Determined Disease Steps scale levels 4 to 7. Both groups will complete 10 weeks of twice weekly low-load resistance training (20%-30% of 1-repetition max) targeting knee and hip extension, knee flexion, and ankle plantarflexion. The intervention group will perform all training using BFR, with limb occlusion pressures between 60% and 80% of maximal limb occlusion pressure. Primary outcomes will be quadriceps muscle strength and thickness. Secondary outcomes will include knee flexion and ankle plantarflexion strength, functional mobility, physical activity, and patient-reported measures. All outcomes will be assessed at baseline before the intervention, immediately after the intervention, and at a 2-month follow-up assessment. The change between groups postintervention and after the 2-month follow-up will be reported for all outcomes. All analyses will assume a 2-sided test of hypothesis (α = .05).

IMPACT

There is very little evidence for the efficacy of exercise interventions in people with MS who have advanced mobility disability. Resistance training with BFR may be an important approach for people with advanced MS who may not tolerate more conventional, moderate-to-high intensity resistance training. The results of this study will inform clinicians regarding exercise decisions for people with advanced MS and future investigations on the role of BFR in people with MS.

Clinical correlates of respiratory disorders in patients with severe multiple sclerosis: A cross-sectional cohort

BACKGROUND

Respiratory disorders remain incompletely described in multiple sclerosis (MS), even though they are a frequent cause of death.

METHODS

The objective was to describe respiratory disorders in MS patients with Expanded Disability Status Score (EDSS) ⩾ 6.5. Diaphragm dysfunction was defined by at least two of the seven criteria: clinical signs, inspiratory recruitment of neck muscles during wakefulness, reduced upright vital capacity (VC) < 80%, upright-to-supine VC ⩾ 15% of upright VC, decrease in Maximal Inspiratory Pressure < 60%, phasic activation of inspiratory neck muscles during sleep, and opposition of thoracic and abdominal movements during sleep. Cough weakness was defined by a peak cough flow < 270 L/min and/or need for cough assist. Sleep apnea syndrome was defined by an apnea-hypopnea index ⩾ 15.

RESULTS

Notably, 71 MS patients were included: median age 54 [48, 61] years; median disease duration 21.4 [16.0, 31.4] years. Of these, 52 patients had one or more respiratory disorders; diaphragm dysfunction was the most frequent (n = 34). Patients with diaphragm dysfunction and cough weakness were more disabled. The fatigue score and the cognitive evaluations did not differ between the groups. Five patients required non-invasive ventilation.

CONCLUSION

Respiratory disorders are frequent in severe MS, mostly diaphragm dysfunction. Of interest, instrumental interventions are available to address these disorders.

Comparison of 2 Methods for Estimating Multiple Sclerosis-Related Mortality

BACKGROUND AND OBJECTIVES

Determining whether multiple sclerosis (MS) causes death is challenging. Our objective was to contrast 2 frameworks to estimate probabilities of death attributed to MS (PMS) and other causes (Pother): the cause-specific framework (CSF), which requires the causes of death, and the excess mortality framework (EMF), which does not.

METHODS

We used data from the Observatoire Français de la Sclérose en Plaques (OFSEP, n = 37,524) and from a comparative subset where causes of death were available (4,004 women with relapsing-onset MS [R-MS]). In CSF, the probabilities were estimated using the Aalen-Johansen method. In EMF, they were estimated from the excess mortality hazard, which is the additional mortality among patients with MS as compared with the expected mortality in the matched general population. PMS values were estimated at 30 years of follow-up, (1) with both frameworks in the comparative subset, by age group at onset, and (2) with EMF only in the OFSEP population, by initial phenotype, sex, and age at onset.

RESULTS

In the comparative subset, the estimated 30-year PMS values were greater using EMF than CSF: 10.9% (95% CI 8.3-13.6) vs 8.7% (6.4-11.8) among the youngest and 20.4% (11.3-29.5) vs 16.2% (8.7-30.2) for the oldest groups, respectively. In the CSF, probabilities of death from unknown causes ranged from 1.5% (0.7-3.0) to 6.4% (2.5-16.4), and even after their reallocation, PMS values remained lower with CSF than with EMF. The estimated probabilities of being alive were close using the 2 frameworks, and the estimated POther (EMF vs CSF) was 2.6% (2.5-2.6) vs 2.1% (1.2-3.9) and 18.1% (16.9-19.3) vs 26.4% (16.5-42.2), respectively, for the youngest and oldest groups. In the OFSEP population, the estimated 30-year PMS values ranged from 7.5% (6.4-8.7) to 24.0% (19.1-28.9) in patients with R-MS and from 25.4% (21.1-29.7) to 36.8% (28.3-45.3) in primary progressive patients, depending on sex and age.

DISCUSSION

EMF has the great advantage of not requiring death certificates, their quality being less than optimal. Conceptually, it also seems more relevant because it avoids having to state, for each individual, whether death was directly or indirectly caused by MS or whether it would have occurred anyway, which is especially difficult in such chronic diseases.

Stroke risk in multiple sclerosis: a critical appraisal of the literature

Observational studies suggest that the occurrence of stroke on multiple sclerosis (MS) patients is higher compared to the general population. MS is a heterogeneous disease that involves an interplay of genetic, environmental and immune factors. The occurrence of stroke is subject to a wide range of both modifiable and non-modifiable, short- and long-term risk factors. Both MS and stroke share common risk factors. The immune mechanisms that underlie stroke are similar to neurodegenerative diseases and are attributed to neuroinflammation. The inflammation in autoimmune diseases may, therefore, predispose to an increased risk for stroke or potentiate the effect of conventional stroke risk factors. There are, however, additional determinants that contribute to a higher risk and incidence of stroke in MS. Due to the challenges that are associated with their differential diagnosis, the objective is to present an overview of the factors that may contribute to increased susceptibility or occurrence of stroke in MSpatients by performing a review of the available to date literature. As both MS and stroke can individually detrimentally affect the quality of life of afflicted patients, the identification of factors that contribute to an increased risk for stroke in MS is crucial for the prompt implementation of preventative therapeutic measures to limit the additive burden that stroke imposes.

Respiratory issues in patients with multiple sclerosis as a risk factor during SARS-CoV-2 infection: a potential role for exercise

Coronavirus disease-2019 (COVID-19) is associated with cytokine storm and is characterized by acute respiratory distress syndrome (ARDS) and pneumonia problems. The respiratory system is a place of inappropriate activation of the immune system in people with multiple sclerosis (MS), and this may cause damage to the lung and worsen both MS and infections.The concerns for patients with multiple sclerosis are because of an enhance risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The MS patients pose challenges in this pandemic situation, because of the regulatory defect of autoreactivity of the immune system and neurological and respiratory tract symptoms. In this review, we first indicate respiratory issues associated with both diseases. Then, the main mechanisms inducing lung damages and also impairing the respiratory muscles in individuals with both diseases is discussed. At the end, the leading role of physical exercise on mitigating respiratory issues inducing mechanisms is meticulously evaluated.

Comparing the risk of serious infections in patients with and without MS: A German claims data analysis

BACKGROUND

Research suggests that serious infections (SIs), comorbidities, and advanced disability represent key drivers of early death in people with Multiple Sclerosis (pwMS). Nevertheless, further research is warranted to better characterize and quantify the risk of SI among pwMS compared to the general population.

METHODS

Our study consisted of a retrospective analysis of claims data provided by a German statutory health insurance fund, AOK PLUS, covering 3.4 million individuals in Saxony and Thuringia from 01/01/2015-31/12/2019. A propensity score (PS) matching method was used to compare the incidence of SIs among people with and without MS. PwMS were required to have ≥1 inpatient or ≥2 confirmed outpatient diagnoses of MS (ICD-10 G35) from a neurologist from 01/01/2016-31/12/2018, while people from the general population could not have any inpatient/outpatient codes for MS during the entire study period. The index date was defined as the first observed MS diagnosis or, in the case of the non-MS cohort, a randomly assigned date within the inclusion period. For both cohorts a PS was assigned, corresponding with their probabilistic likelihood of having MS based on observable factors including patient characteristics, comorbidities, medication use and other variables. People with and without MS were matched using a 1:1 nearest neighbor strategy. An exhaustive list of ICD-10 codes was created in association with 11 main SI categories. SIs were those recorded as the main diagnosis during an inpatient stay. ICD-10 codes from the 11 main categories were sorted into smaller classification units, used to distinguish between infections. A 60-day threshold for measuring new cases was defined to account for the potential risk of re-infection. Patients were observed until the end of the study period (31/12/2019) or death. Cumulative incidence, incidence rates (IRs) and IR ratios (IRRs) were reported during follow-up and at 1-, 2- and 3-years post-index.

RESULTS

A total of 4250 and 2,098,626 patients were included in the unmatched cohorts of people with and without MS. Ultimately, one match was identified for all 4,250 pwMS, corresponding with a final population of 8,500 patients. On average, patients were 52.0/52.2 years in the matched MS/non-MS cohorts; the gender breakdown was 72% female. Overall, IRs of SIs per 100 patient years (PY) were higher in pwMS than in those without MS (1 year: 7.6 vs. 4.3; 2 years: 7.1 vs. 3.8; 3 years: 6.9 vs. 3.9). During follow-up, the most common infection types in pwMS were of a bacterial/parasitic origin (2.3 per 100 PY), followed by respiratory (2.0) and genitourinary (1.9) infections. Respiratory infections were most common in patients without MS (1.5 per 100 PY). Differences in the IRs of SIs were statistically significant (p<0.01) at each measurement window, with IRRs ranging from 1.7-1.9. PwMS had a higher risk of hospitalized genitourinary infections (IRR: 3.3-3.8) and bacterial/parasitic infections (2.0-2.3).

CONCLUSIONS

The incidence of SIs is much higher in pwMS, than comparators from the general population in Germany. Differences in hospitalized infection rates were largely driven by higher levels of bacterial/parasitic and genitourinary infections in the MS population.

Association between multiple sclerosis and prostate cancer risk: A systematic review and meta‑analysis

Prostate cancer (PCa) risk in patients with multiple sclerosis (MS) remains to be elucidated. The present study conducted a meta-analysis to assess the relationship between MS and PCa. PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched to identify studies on the PCa risk in patients with MS up to September 2022. A random effects meta-analyses model was performed to estimate the relative risk (RR) and the 95% confidence intervals (CI). All eight studies involving 210,943 patients with MS were identified and included in the meta-analysis. The present study revealed that there was no significant association between MS and the risk of PCa (RR=0.78, 95% CI: 0.56-1.08, P<0.0001). Subgroup analyses verified this conclusion when stratified by regions. However, after adjusting for potential confounders, the findings suggested conflicting results. The current evidence shows that compared with the population control, patients with MS have no relationship with PCa risk and further large samples and long-term trials are needed to verify these results.

Cancer related mortality in multiple sclerosis. A population based cohort study

BACKGROUND

Cancer is a major cause of death, but how cancer influences mortality risk in Multiple Sclerosis (MS) is unclear.

OBJECTIVES

Determine all-cause mortality and mortality following a cancer diagnosis among MS patients compared with matched population controls.

METHODS

Norwegian MS patients born 1930 - 1979 (n= 6950) followed-up 1953 - 2016, were matched with 37 922 controls. We compared incident cancer diagnosis from the Cancer Registry of Norway, date of death from the Cause of Death Registry, education from the National Education Database, by multivariate Cox proportional hazard regression.

RESULTS

Hazard ratio (HR) and 95% confidence interval (CI) for all-cause mortality among MS patients was 4.97 (4.64 - 5.33), and 2.61 (2.29 - 2.98) for mortality following a cancer diagnosis. Mortality in MS was highest following urinary- (2.53: 1.55 - 4.14), colorectal- (2.14: 1.47 - 3.11), hematological- (1.76: 1.08 - 2.88), ovarian - 2.30 (1.73-3.06) and breast cancer diagnosis (2.61: 1.85 - 3.68), compared to controls. High education was inversely associated with mortality among MS patients.

CONCLUSIONS

All-cause mortality was five- fold and mortality following a cancer diagnosis was two- fold increased among MS patients. Mortality following specific cancers raises the possibility of diagnostic neglect.

Mapping the risk of infections in patients with multiple sclerosis: A multi-database study in the United Kingdom Clinical Practice Research Datalink GOLD and Aurum

BACKGROUND

People with multiple sclerosis (pwMS) have an increased risk of infections; risk factors include underlying disease, physical impairment and use of some disease-modifying treatments.

OBJECTIVE

To quantify changes in population-level infection rates among pwMS and compare these to the general population and people with rheumatoid arthritis (pwRA), and identify patient characteristics predictive of infections after MS diagnosis.

METHODS

We conducted a multi-database study using data on 23,226 people with MS diagnosis from the UK Clinical Practice Research Datalink Aurum and GOLD (January 2000-December 2020). PwMS were matched to MS-free controls and pwRA. We calculated infection rates, and estimated incidence rate ratios (IRR) and 95% confidence intervals (CI) of predictors for infections ⩽ 5 years after MS diagnosis using Poisson regression.

RESULTS

Among pwMS, overall infection rates remained stable - 1.51-fold (1.49-1.52) that in MS-free controls and 0.87-fold (0.86-0.88) that in pwRA - although urinary tract infection rate per 1000 person-years increased from 98.7 (96.1-101) (2000-2010) to 136 (134-138) (2011-2020). Recent infection before MS diagnosis was most predictive of infections (1 infection: IRR 1.92 (1.86-1.97); ⩾2 infections: IRR 3.00 (2.89-3.10)).

CONCLUSION

The population-level elevated risk of infection among pwMS has remained stable despite the introduction of disease-modifying treatments.

Risk of stroke in multiple sclerosis and neuromyelitis optic spectrum disorder: a Nationwide cohort study in South Korea

BACKGROUND

People with multiple sclerosis (MS) are more likely to develop stroke than those without. However, little is known about the association between neuromyelitis optica spectrum disorder (NMOSD) and the risk of stroke. We aimed to estimate the risk of stroke in patients with MS and NMOSD in South Korea.

METHODS

Data from the Korean National Health Insurance between January 2010 and December 2017 were analysed. A total of 1541/1687 adult patients with MS/NMOSD, who were free of stroke were included. Matched controls were selected based on age, sex and the presence of hypertension, diabetes mellitus and dyslipidaemia.

RESULTS

The risk of developing stroke was 2.78 times higher (adjusted HR (aHR), 95% CI 1.91 to 4.05) in patients with MS compared with controls matched by age, sex, hypertension, diabetes mellitus and dyslipidaemia. The risk of stroke in NMOSD was also higher than that in matched controls (aHR=1.69, 95% CI 1.10 to 2.61) and not statistically different from that of MS (p=0.216). The patients with MS had a higher risk for either of ischaemic or haemorrhagic stroke (HR=2.63 and 2.93, respectively), whereas those with NMOSD had a higher risk for ischaemic stroke (HR=1.60) with marginal statistical significance.

CONCLUSIONS

The risk of stroke is increased in patients with MS and NMOSD and seemed comparable between the two conditions. This is the first study that estimates the risk of stroke in patients with MS and NMOSD within the same population.

Association of multiple sclerosis with risk of mortality among a nationally representative sample of adults in the United States

Background

Multiple sclerosis (MS) has been associated with increased mortality ratios, but few studies have investigated the independent association of MS with mortality.

Objective

To examine the prospective association of MS with risk of mortality in a nationally representative sample of U.S. adults.

Methods

This prospective study included 23,053 adults aged 45–79 years who participated in the National Health Interview Survey in 2002 and 2008. Physician-diagnosed MS was reported by participants during household interviews. These participants were linked to death records from survey date through December 31, 2015.

Results

Among the 23,053 participants included in this study, 120 reported a physician’s diagnosis of MS, with a higher prevalence in females (0.85%) than in males (0.31%). During on average 9.4 years (maximum 13.8 years) of observation, 4208 deaths occurred. After adjustment for age, sex, race/ethnicity, socioeconomic factors, lifestyle factors, and BMI, participants with MS had an 80% higher risk of mortality (HR 1.80; 95% CI, 1.11–2.92), compared with those without MS. The association remained significant (HR 1.75; 95% CI, 1.07–2.87) after further adjustment for baseline diabetes, cardiovascular disease, chronic lung disease, and cancer.

Conclusion

In this nationally representative sample of U.S. adults, MS was associated with an increased risk of mortality.

Standardized mortality ratios in multiple sclerosis: Systematic review with meta-analysis

OBJECTIVE

To perform a meta-analysis of all-cause, cause-specific and gender-specific standardized mortality ratio and crude mortality rate for people with multiple sclerosis. We also examined the temporal trends in this data.

METHODS

Medline, Cochrane Library and Scopus were searched. Keywords were "multiple sclerosis" and "standardized mortality ratio" or "Standardized Mortality Ratio". We included longitudinal studies with available data on the number of deaths, follow-up period, person years and reports of standardized mortality ratio (SMR). Crude mortality ratio (CMR) was calculated and SMR was extracted. CMRs and log-SMR were pooled by the method of inverse variance. Meta-regression models were used to investigate temporal trends.

RESULTS

Fifty-seven articles were screened. Fifteen studies were included covering a period 1949-2013 (160,000 patients; 21,225 deaths). The all-cause SMR for people with MS was 2.61 (95% CI 2.58 to 2.65). For men this was 2.47 (95% CI 2.42 to 2.52) and for women 2.57 (95% CI 2.53 to 2.61). The CMR was 13.45/1000 person years. Cause-specific SMR was 1.74 (1.67 to 1.81) for CVD, 4.70 (4.45 to 4.87) for respiratory disease and infection, 1.81 (1.64 to 2.0) for accident and suicide and 0.99 (0.93 to 1.06) for cancer. Meta-regression analysis of the SMR compared to midpoint follow-up year revealed no relationship (co-efficient 0.001, p = .98).

CONCLUSIONS

People with multiple sclerosis (MS) have reduced overall survival and increased risk of death from cardiovascular, respiratory and infectious disease as well as accidents and suicide. This does not appear to have changed over the last 65 years.

Vascular dysfunction and dyslipidemia in multiple sclerosis: are they correlated with disease duration and disability status?

BACKGROUND

There is strong evidence that vascular dysfunction is considered one of the possible causes of morbidity and mortality in patients suffering from multiple sclerosis (MS). This work aimed at assessing the arterial function and serum lipids in MS patients and correlating them with clinical and radiological findings.

RESULTS

This case-control study included 50 patients with MS and 50 age- and sex-matched controls. The arterial function was significantly reduced in MS patients, confirmed by significantly higher pulse wave velocity (PWV) and augmentation index (AIX), while the carotid IMT did not show significant difference between the two groups with no plaques in any of our patients. A significant positive correlation was found between PWV and both disease duration and disability. MS patients had significantly higher serum levels of T-cholesterol and triglycerides, and significantly lower serum levels of HDL-cholesterol, compared to controls. No significant correlation was found between serum lipids and either disease duration or disability.

CONCLUSIONS

There was a significant impairment in arterial function (assessed by the brachial cuff-based method via Mobil-O-Graph device) in MS patients compared to controls. Such impairment was significantly correlated with both disease duration and disability. MS patients had also significantly higher levels of T-cholesterol and triglycerides, compared to controls with no significant correlation between serum lipids and either disease duration or disability.

End of life in multiple sclerosis: Disability, causes and place of death among cases diagnosed from 1981 to 2010 in Pirkanmaa hospital district in Western Finland

BACKGROUND

Mortality risk and causes of death have been widely studied in MS. Surveys on conditions related to approaching death have not been conducted before in Finland.

OBJECTIVE

Our aim was to sort out the possible needs for end of life (EOL) care in MS by examining causes, place of death and level of hospitalization by age and MS related disability before approaching death.

MATERIALS

Data included information for MS patients diagnosed from 1981 to 2010 in a Finnish university hospital district. Information on place and causes of death and care prior to death was based on death certificates from Statistics Finland. Decedents initial disease course, disease modifying treatment (DMT) use and MS related disability status by using EDSS were achieved from hospital records.

RESULTS

Data included 113 decedents. Level of disability showed EDSS 6.0 or higher in 54% of the patients. In relapsing onset MS (N 93, 80%) DMTs were used in 11%. Infections, respiratory or other, were the main immediate cause of death (51.3%, n 58) among cases with varying disability. Central or university hospital (42.5%) or community hospital ward (28.3%) were places of death in majority of cases and nursing home (13.3%), home (9.7%) or hospice (3.7%) less often. Place of death did not significantly differ between age-groups (Chi square p = 0.86). Mean age at death was 57 years (range 28-90, SD 13.86). Cardiovascular causes of death were reported mainly in age group 60 years or more and suicide in age group younger than 50 years.

CONCLUSION

The level of hospitalization was high at end of life in all age-groups. High MS related disability and immobility among decedents likely relates to infections as the most common cause of death. Along with our and earlier surveys in this field, we showed that places of death and level of disability before death share similarities in both younger and older age groups highlighting the need of palliative care and end of life care plans in all MS patients with triggers of poor survival. The recently published consensus definition featuring palliative care guideline in MS is aimed at improving end of life care in MS. Our results point at need for future studies in order to assess the impact of palliative care treatment guidelines in MS.

Potential risk of disease modifying therapies on neoplasm development and coadjutant factors in multiple sclerosis outpatients

Neoplasm development in Multiple Sclerosis (MS) patients treated with disease-modifying therapies (DMTs) has been widely discussed. The aim of this work is to determine neoplasm frequency, relationship with the prescription pattern of DMTs, and influence of the patients’ baseline characteristics. Data from 250 MS outpatients were collected during the period 1981–2019 from the medical records of the Neurology Service of the HUPM (Hospital Universitario Puerta del Mar)—in Southern Spain—and analysed using Cox models. Neoplasm prevalence was 24%, mainly located on the skin, with cancer prevalence as expected for MS (6.8%). Latency period from MS onset to neoplasm diagnosis was 10.4 ± 6.9 years (median 9.30 [0.9–30.5]). During the observation period β-IFN (70.4% of patients), glatiramer acetate (30.4%), natalizumab (16.8%), fingolimod (24.8%), dimethyl fumarate (24.0%), alemtuzumab (6.0%), and teriflunomide (4.8%) were administered as monotherapy. Change of pattern in step therapy was significantly different in cancer patients vs unaffected individuals (p = 0.011) (29.4% did not receive DMTs [p = 0.000]). Extended Cox model: Smoking (HR = 3.938, CI 95% 1.392–11.140, p = 0.010), being female (HR = 2.006, 1.070–3.760, p = 0.030), and age at MS diagnosis (AGE-DG) (HR = 1.036, 1.012–1.061, p = 0.004) were risk factors for neoplasm development. Secondary progressive MS (SPMS) phenotype (HR = 0.179, 0.042–0.764, p = 0.020) and treatment-time with IFN (HR = 0.923, 0.873–0.977, p = 0.006) or DMF (HR = 0.725, 0.507–1.036, p = 0.077) were protective factors. Tobacco and IFN lost their negative/positive influence as survival time increased. Cox PH model: Tobacco/AGE-DG interaction was a risk factor for cancer (HR = 1.099, 1.001–1.208, p = 0.049), followed by FLM treatment-time (HR = 1.219, 0.979–1.517). In conclusion, smoking, female sex, and AGE-DG were risk factors, and SPMS and IFN treatment-time were protective factors for neoplasm development; smoking/AGE-DG interaction was the main cancer risk factor.

Risk of cancer in multiple sclerosis (MS): A systematic review and meta-analysis

OBJECTIVE

To assess the pooled risk of cancer in patients with multiple sclerosis.

METHODS

We searched PubMed, Scopus, EMBASE, Web of Science, Ovid, google scholar and gray literature (references of studies, conference abstracts) which were published up to September 2019. The search strategy included the MeSH and text words as ((cancer) OR tumor) OR neoplasm) OR "malignant neoplasm) OR "benign neoplasm) AND (Multiple Sclerosis OR Sclerosis, Multiple) OR Sclerosis, Disseminated) OR Disseminated Sclerosis) OR MS (Multiple Sclerosis)) OR Multiple Sclerosis, Acute Fulminating).

RESULTS

The first literature search revealed 18,996 articles. After deletion of duplicate articles, finally, 264 articles remained. Excluding non-relevant articles, resulted in including 5 articles which met inclusion criteria. The RR estimated between 0.7 and 1.67 in included articles. The pooled RR estimated as 0.83 (95% CI:0.73-0.96) (I² = 90%, P < 0.001). Two studies provided prevalence of different cancers. The pooled prevalence of breast cancer in two studies was 2% (95%CI:2%-2%) (I² = 0%). The pooled prevalence of digestive system cancer in two studies was 2% (95%CI:1%-2%) (I² = 0%). The pooled prevalence of skin cancer in two studies was 1% (95%CI:0%-1%) (I² = 0).

CONCLUSION

The result of this systematic review showed that the risk of cancer in patients with MS is less than the general population.

Evaluating functional electrical stimulation (FES) cycling on cardiovascular, musculoskeletal and functional outcomes in adults with multiple sclerosis and mobility impairment: A systematic review

BACKGROUND

People with Multiple Sclerosis (PwMS) are at an increased risk of diseases associated with low levels of physical activity (PA). Deconditioning may lead to an acceleration in the development of secondary complications from MS, impairing physical function and exacerbating disease progression. Functional Electrical Stimulation (FES) Cycling may provide a suitable lower limb exercise intervention for PwMS with mobility impairment. The effects of FES cycling on cardiovascular, musculoskeletal and functional outcomes for PwMS with mobility impairment are yet to be investigated to date.

OBJECTIVE

The objective of this review was to systematically examine the outcomes of PwMS with mobility impairment following FES cycling intervention.

METHODS

A systematic search of four electronic databases (MEDLINE, Web of Science, CINAHL and PEDro) from their inception to 8th January 2019 was performed. Inclusion criteria was (1) include human participants with definite diagnosis of MS (2) participants had to be aged 18 years or older (3) include participants with mobility impairment (determined as an average participant EDSS ≥ 6.0) (4) evaluate FES cycling as an intervention study.

RESULTS

Initial searches found 1163 studies. 9 of which met the full inclusion criteria: 5 pre-post studies with no control group, 2 randomised controlled trials (RCTs), 1 retrospective study and 1 case study. Two studies had the same participant group and intervention but reported different outcomes. Outcome data was available for n = =76 unique participants, with n = =82 completing a FES cycling intervention. Of the n = =4 papers with clear dropout rates, pooled dropout rate was 25.81%. Two papers reported non-significant improvements in aerobic capacity following a FES cycling intervention. Four papers reported no change in lower limb strength and two papers reported significant reductions in spasticity post training. Four studies failed to provide information regarding adverse events with the other studies reporting n = =10 adverse events across 36 participants.

CONCLUSION

Findings suggest FES cycle training may reduce CVD risk alongside trends for a reduction in spasticity post training, however the low quality of the literature precludes any definitive conclusions. FES cycle training appears to be well tolerated in PwMS with mobility impairment, with no serious adverse events.

Association between suicide and multiple sclerosis: An updated meta-analysis

BACKGROUND

Whether multiple sclerosis is associated with a higher rate of suicide remains controversial. Therefore, we aimed to evaluate the risk of suicide in multiple sclerosis patients based on meta-analysis of previously published data.

METHODS

We searched for studies that measured the suicide risk in multiple sclerosis patients compared with general population that were published up to 1 December 2018 in PubMed, EMBASE, and Web of Science databases. Sixteen studies fulfilled the eligibility criteria. We performed random-effects meta-analyses to calculate suicide rate ratio (SRR) and 95% confidence intervals (CIs) for patients with multiple sclerosis.

RESULTS

The association between suicide and multiple sclerosis was statistically significant with a pooled SRR 1.72 (95%CI 1.48-1.99, I-squared = 55.0%). Risk of suicide at diagnosis of multiple sclerosis (SRR 2.12, 95% CI 1.84-2.46; I-squared = 4.4%) was higher than the risk of suicide at symptom onset (SRR 1.69; 95% CI 1.43-2.00; I-squared = 0.0%). Gender may exert an influence on the impact of sex on the association between MS multiple sclerosis and suicide, but this requires is controversial and need more further studies to demonstrate.

CONCLUSION

Our meta-analysis shows a significant association between suicide and multiple sclerosis, although ethnic and geographical differences were not considered. These findings should be confirmed and extended in future large studies.

Effects of cigarette smoke on immunity, neuroinflammation and multiple sclerosis

Cigarette smoking is the most prominent significant cause of death and morbidity. It is recognised as a risk factor for a number of immune mediated, inflammatory diseases including multiple sclerosis (MS). Here, we review the complex immunological effects of smoking on the immune system, which include enhancement of inflammatory responses with a parallel reduction of some immune defences, resulting in an increased susceptibility to infection and a persistent proinflammatory environment. We discuss the effect of smoking on the susceptibility, clinical course, disability, and mortality in MS, the likely benefits of smoking cessation, and the specific immunological effects of smoking in MS. In conclusion, smoking is an important environmental risk factor for MS occurrence and outcome, and it acts in significant part through immunological mechanisms.

A contemporary study of mortality in the multiple sclerosis population of south east Wales

BACKGROUND

Mortality studies in multiple sclerosis (MS) are valuable to identify changing disease patterns and inform clinical management. This study examines mortality in a British MS cohort.

METHODS

Patients were selected from the southeast Wales MS registry. Hazard of death was analysed using Cox proportional hazards regression, adjusted for onset age, annualised relapse rate, initial disease course, time to EDSS 4.0, sex, socioeconomic status, and onset year. Age- and sex-stratified standardised mortality ratios (SMRs) were calculated by EDSS scores.

RESULTS

Median time from MS diagnosis to death was 35.5 years and median age 73.9. Older onset age (hazard ratio [HR] 1.05, 95% confidence interval 1.03-1.06) was associated with increased hazard of death. Primary progressive course was associated with increased hazard of death in women (HR 2.04, 1.15-3.63) but not men (HR 1.23, 0.61-2.47). Slow time to EDSS 4.0 (HR 0.41, 0.28-0.60) and high socioeconomic status (HR 0.54, 0.37-0.79) were associated with reduced hazard of death. SMR increased from EDSS 6.0 (3.86, 2.63-5.47) but more substantially at EDSS 8.0 (22.17, 18.20-26.75).

CONCLUSIONS

Risk of death in MS varies substantially with degree of disability. This has important implications for clinical management and health economic modelling.

Impaired Cardiac Function in Patients with Multiple Sclerosis by Comparison with Normal Subjects

Multiple sclerosis (MS), neurologic disease affecting young population, may cause cardiovascular dysfunction, due to autonomous nervous dysfunction, physical invalidity, increased oxidative stress, and systemic inflammatory status. However, cardiovascular function is rarely evaluated in these patients. We assessed left and right ventricular (LV and RV) function by 2D, 3D, tissue Doppler, and speckle tracking echocardiography, and vascular function by remodeling, stiffness, and endothelial dysfunction parameters in patients with MS, compared to control subjects. 103 subjects (35 ± 10 years,70 women) were studied: 67 patients with MS and 36 control subjects. Patients with MS had decreased LV systolic function, confirmed by lower 2D and 3D ejection fraction, mitral annular plane systolic excursion, longitudinal myocardial systolic velocities, and 2D and 3D global longitudinal strain. The RV function was also decreased, as demonstrated by lower fractional area change, tricuspid annular plane systolic excursion, longitudinal systolic velocities, and longitudinal strain. Additionally, LV diastolic and left atrial (LA)  function were decreased compared to controls. The parameters of arterial and endothelial function were similar between groups. Patients with MS have impaired biventricular function by comparison with normal subjects, with reduced LA function, but normal arterial and endothelial function. The noninvasive echocardiographic techniques might help to determine patients with MS at risk of developing cardiovascular dysfunction.

Wellness and the Role of Comorbidities in Multiple Sclerosis

Multiple sclerosis (MS) is a demyelinating and neurodegenerative disorder of the central nervous system, for which disease modifying therapies (DMTs) are the mainstay treatment approach to reduce inflammatory disease activity and slow worsening disability. In addition to conventional pharmacologic therapy, there is growing interest in the use of lifestyle strategies to support wellness and mitigate disease-related complications in MS. This interest stems from a growing appreciation of the role of certain comorbidities and lifestyle factors on disease activity, disability, mortality, and overall quality of life. While the current literature is not conclusive, there is evidence to suggest a potential role for vitamin D supplementation, tobacco smoking cessation, routine exercise, a plant-based, anti-inflammatory diet, and maintenance of emotional well-being as adjunct therapies to DMTs. In addition to DMTs, lifestyle strategies should be emphasized as part of a management plan focused on overall health and well-being.

Association between multiple sclerosis, cancer risk, and immunosuppressant treatment: a cohort study

BACKGROUND

The association between multiple sclerosis (MS) and cancer has long been investigated with conflicting results. Several reports suggest an increased cancer risk among MS patients treated with immunosuppressant (IS) drugs.

METHODS

We performed a cohort study including MS patients recruited at the Neurological Department of the University of Palermo. Mean follow-up period was ten years for the whole cohort. We calculated cancer incidence among patients treated with IS. Incidence rates were compared in the cohort by calculating the relative risk according to length and dose of exposure to IS. Cancer incidence among MS patients was compared to cancer incidence in the general population of Sicily in similar age groups.

RESULTS

On an overall cohort of 531 MS patients (346 women and 185 men) exposed to IS, we estimated a crude incidence rate for cancer of 2.26% (2.02% in women, 2.7% in men). Cancer risk was higher compared to rates observed among an equal number of patients not exposed to IS, and to the risk in the general population in Sicily at similar age groups (adjusted HR: 11.05; CI 1.67-73.3; p = 0.013).

CONCLUSION

The present study showed a higher cancer risk in MS patients associated only to previous IS exposure. Studies on long-term outcomes are essential to evaluate the possibility that treatment options that need to be considered for a long time-period may modify risk for life threatening diseases.

Comorbidity and metabolic syndrome in patients with multiple sclerosis from Asturias and Catalonia, Spain

BACKGROUND

The impact of comorbidity on multiple sclerosis (MS) is a new area of interest. Limited data on the risk factors of metabolic syndrome (MetS) is currently available. The aim of this study was to estimate the presence of comorbid conditions and MetS in a sample of adult patients with MS.

METHODS

A retrospective, cohort study was conducted using electronic medical records from 19 primary care centres in Catalonia and Asturias, Spain. The number of chronic diseases (diagnoses), the Charlson Comorbidity Index and the individual Case-mix Index were used to assess general comorbidity variables. MetS was defined using the National Cholesterol Education Program Adult Treatment Panel III. Patients were distributed into two groups according to the Expanded Disability Status Scale (EDSS) score: 0-3.5 and 4-10.

RESULTS

A total of 222 patients were studied (mean age = 45.5 (SD 12.5) years, 64.4% were female and 62.2% presented a diagnosis of relapsing-remitting MS). Mean EDSS score was 3.2 (SD 2.0). Depression (32.4%), dyslipidaemia (31.1%), hypertension (23.0%) and obesity (22.5%) were the most common comorbidities. Overall MetS prevalence was 31.1% (95% CI: 25.0-37.2%). Patients with an EDSS ≥ 4.0 showed a significantly higher number of comorbidities (OR=2.2; 95% CI: 1.7-3.0; p<0.001).

CONCLUSION

MS patients had a high prevalence of MetS. Screening for comorbidity should be part of standard MS care. Further studies are necessary to confirm this association and the underlying mechanisms of MS and its comorbidities.

Mortality trends for multiple sclerosis patients in Sweden from 1968 to 2012

OBJECTIVE

To assess trends in mortality and causes of death for patients with multiple sclerosis (MS) relative to those without MS in Sweden.

METHODS

Patients with an MS diagnosis in Sweden between 1964 and 2012 were identified with the Patient Register and the Multiple Sclerosis Register. For this cohort study, each patient with MS (n = 29,617) was matched with 10 individuals without MS (n = 296,164) on sex, year of birth, vital status, and region of residence at the time of MS diagnosis with the Total Population Register. The Causes of Death Register was used to identify causes of death. Cox proportional hazard models were constructed to assess whether risk of mortality was increased for patients with MS.

RESULTS

The hazard ratio (HR) for patients with MS was 2.92 (95% confidence interval [CI] 2.86-2.99) for all-cause mortality over the entire study period. The largest differences between the cohorts were death resulting from respiratory (HR 5.07, 95% CI 4.87-5.26) and infectious (HR 4.07, 95% CI 3.70-4.47) diseases. Overall and for each specific cause, there have been improvements for the MS group and a subsequent reduction in the HR. The HR decreased from 6.52 (95% CI 5.79-7.34) for the period of 1968 to 1980 to 2.08 (95% CI 1.95-2.22) for the time period of 2001 to 2012. An interaction between time period and MS exposure showed that the decrease in mortality over time was statistically significant, with a larger decrease for patients with MS than their matched comparators.

CONCLUSIONS

There has been a substantial improvement in mortality overall and for each specified cause of death for patients with MS compared with individuals without MS; however, large differences still remain.

Multiple sclerosis and suicide

Mortality rates are elevated in people with multiple sclerosis (MS) relative to the general population. There is, however, some uncertainty whether suicide contributes to this. Epidemiological data suggest that the standardized mortality ratio (SMR) for suicide in MS is approximately twice that of the general population with younger males in the first few years following diagnosis most at risk. Rates of suicidal intent, a potential harbinger of more self-destructive behavior, are also elevated, but the frequency with which intent is followed by suicide is not known. Depression, severity of depression, social isolation, and alcohol abuse are associated with thoughts of suicide. The variables linked with suicide and suicidal intent are therefore well defined and should be readily available from routine clinical inquiry. While vigilance on the part of clinicians is required, particularly in the context of high-risk patients, it is also recognized that prevention is dependent on full disclosure of intent.

An excessive risk of suicide may no longer be a reality for multiple sclerosis patients

BACKGROUND

Few recent studies have shown that there is no longer an increased risk of suicide in patients affected with multiple sclerosis (MS).

OBJECTIVES

To describe suicide cases within a large French MS cohort and assess whether MS patients are at a higher risk of suicide compared with the general population.

METHODS

Data derives from a study on long-term mortality of 27,603 prevalent cases from 15 MS specialist centres. Of 1,569 deceased MS patients (5.7%) on 1 January 2010, 47 were suicides.

RESULTS

The mean time between MS clinical onset and death was 13.5 years (standard deviation (SD): 9.3 years; none within the first 3 years) and was significantly shorter than for MS patients who had died from other causes (mean = 21.4 (SD = 11.6), p < 0.0001). Age at death was also lower (46.3 vs 56.7). The standardized mortality rates were around 1 in several sensitivity analyses, reflecting no excess mortality in MS compared with general population.

CONCLUSION

Our findings indicate that an excess suicide risk may no longer be true for MS patients and highlight the changing profile of cases, occurring later in the disease course. Further studies in population-based registries are needed to confirm and explain these potential changes (e.g. treatments' impact?).

Relapsing-remitting multiple sclerosis patients display an altered lipoprotein profile with dysfunctional HDL

Lipoproteins modulate innate and adaptive immune responses. In the chronic inflammatory disease multiple sclerosis (MS), reports on lipoprotein level alterations are inconsistent and it is unclear whether lipoprotein function is affected. Using nuclear magnetic resonance (NMR) spectroscopy, we analysed the lipoprotein profile of relapsing-remitting (RR) MS patients, progressive MS patients and healthy controls (HC). We observed smaller LDL in RRMS patients compared to healthy controls and to progressive MS patients. Furthermore, low-BMI (BMI ≤ 23 kg/m²) RRMS patients show increased levels of small HDL (sHDL), accompanied by larger, triglyceride (TG)-rich VLDL, and a higher lipoprotein insulin resistance (LP-IR) index. These alterations coincide with a reduced serum capacity to accept cholesterol via ATP-binding cassette (ABC) transporter G1, an impaired ability of HDL₃ to suppress inflammatory activity of human monocytes, and modifications of HDL₃’s main protein component ApoA-I. In summary, lipoprotein levels and function are altered in RRMS patients, especially in low-BMI patients, which may contribute to disease progression in these patients.

CNS-targeted autoimmunity leads to increased influenza mortality in mice

The discovery that central nervous system (CNS)-targeted autoreactive T cells required a process of licensing in the lung revealed an unexpected relationship between these organs. The clinical and immunological significance of this finding is bidirectional in that it showed not only a mechanism by which T cells become pathogenic before entering the CNS, but also the potential for this process to influence lung immunity as well. Epidemiological studies have shown that people with multiple sclerosis (MS) suffer from increased morbidity and mortality from infectious diseases, independent of immunosuppressive therapies. Respiratory infections account for a large percentage of deaths of people with MS. In this study, to investigate the mechanisms responsible for this enhanced susceptibility, we established a comorbid model system in which mice with experimental autoimmune encephalomyelitis (EAE) were administered a sublethal dose of influenza. Whereas mice with either EAE alone or influenza alone survived, 70% of comorbid mice died as a result of uncontrolled viral replication. Immunological analyses revealed that the induction of EAE led to a surprising alteration of the lung milieu, converting an effective stimulatory influenza-reactive environment into a suppressive one. These results provide mechanistic information that may help to explain the unexpected immunological interactions.

Fatigue and depression in multiple sclerosis: pharmacological and non-pharmacological interventions

Multiple sclerosis (MS) is a neuroinflammatory condition with a prominent progressive neurodegenerative facet that typically affects young- or middle-aged adults. Although physical disabilities have been in the foreground by being easier to assess, there is an increasing interest in mental disabilities and psychiatric co-morbidities, which have a disproportionally high impact on important outcome measures such as quality of life and occupational disability. In particular, cognitive impairment, depression and mental fatigue, which mutually interact with each other, seem to be of importance in this context. In recent decades, major efforts have been invested in developing more effective disease modulatory treatments. This has resulted in novel therapeutic options and awareness of the importance of early intervention. In comparison, good quality and adequately powered studies on symptomatic treatments of fatigue and psychiatric co-morbidities in MS are rare, and awareness of treatment options is much lower. We here review the existing evidence base for symptomatic treatment of fatigue and depression in MS patients. With regard to fatigue, off-label prescription of alertness improving drugs is common, in spite of all but absent evidence of efficacy. In contrast, a number of smaller studies suggest that physical exercise and fatigue management courses may have some clinical benefit. Very few studies have addressed the efficacy of antidepressants and non-pharmaceutical interventions specifically in MS patients. Therefore, treatment guidelines largely rely on data from non-MS populations. In the future, there is a strong motive to direct additional resources to the study of these important aspects of MS.

Muscular, cardiac, ventilatory and metabolic dysfunction in patients with multiple sclerosis: Implications for screening, clinical care and endurance and resistance exercise therapy, a scoping review

In the treatment of multiple sclerosis (MS), exercise training is now considered a cornerstone. However, most clinicians tend to focus on neurologic deficits only, and thus prefer to prescribe rehabilitation programs specifically to counteract these deficits. However, the present comprehensive review shows that patients with MS (pwMS) also experience significant muscular, cardiac, ventilatory and metabolic dysfunction, which significantly contribute, next to neurologic deficits, to exercise intolerance. In addition, these anomalies also might increase the risk for frequent hospitalization and morbidity and can reduce life expectancy. Unfortunately, the impact of exercise intervention on these anomalies in pwMS are mostly unknown. Therefore, it is suggested that pwMS should be screened systematically for muscular, cardiac, ventilatory and metabolic function during exercise testing. The detection of such anomalies should lead to adaptations and optimisation of exercise training prescription and clinical care/medical treatment of pwMS. In addition, future studies should focus on the impact of exercise intervention on muscular, cardiac, ventilatory and metabolic (dys)function in pwMS, to contribute to improved treatment and care.

Examining the joint effect of disability, health behaviors, and comorbidity on mortality in MS

BACKGROUND

In multiple sclerosis (MS), comorbidities have been associated with disability progression and an increased risk of mortality. We investigated the association between comorbidities and mortality in MS after accounting for disability and health behaviors.

METHODS

We followed North American Research Committee on Multiple Sclerosis (NARCOMS) Registry participants who completed the Fall 2006 survey on comorbidities until death (reported or matched in the National Death Index) or date of last follow-up in 2014. We used proportional hazards regression to investigate the association between comorbidities and mortality, controlling for demographic, clinical, health behavior, and disability factors.

RESULTS

Of 9,496 participants meeting the inclusion criteria, 502 (5.3%) were deceased. Most participants reported having ≤3 comorbid conditions (70.9% survivors, 76.9% decedents). In individual regression models, vascular, visual, and mental comorbidities were associated with increased mortality risk after adjustment for factors associated with survival. When combined into a single model, vascular (hazard ratio 1.269; 1.041-1.547), visual (1.490; 1.199-1.852), and mental comorbidities (excluding anxiety, 1.239; 1.024-1.499) remained independently associated with an increased risk of mortality.

CONCLUSIONS

Presence of comorbidities was independently associated with an increased risk of mortality as compared to absence of comorbidities after adjusting for factors associated with survival. Specifically, vascular, visual, and mental comorbidities increased the risk of mortality. This highlights the need for clinicians to attend to these comorbidities, which can be modified by treatments or other interventions, and potentially reduce the risk of mortality in persons with MS who have these conditions.

Estimating epidemiological data of Multiple sclerosis using hospitalized data in Shandong Province, China

Background

Multiple sclerosis (MS) is a rare chronically debilitating disease. There are few reports on the burden of disease of MS and prevalence in China. The authors intended to estimate disease burden and prevalence of MS in Shandong Province using available epidemiologic data.

Methods

Prevalence was calculated using DISMOD II software based on incidence extrapolated from hospitalization data, case fatality and remission rate from literature as input indexes. Disability-adjusted life year (DALY) was computed with epidemiologic indexes estimated by DISMOD II program.

Results

The prevalence of MS was estimated to be 3.7(95 % CI: 1.65–5.8) and 6.7(95 % CI: 2.7–9.56) cases per 100,000 people for males and for females, respectively. The mean age at onset of MS was 36.0(43.0 ± 30.0 years in males and 33.7(43.4 ± 29.7) years in females. Duration of the disease was estimated to be 34.0 (31.6 ± 21.0) years for males and 39.5(34.9 ± 21.8) years for females. The disease burden in disability-adjusted life years was 3316, comprised of 903 (27.2 %) years of life lost (YLL) and 2413 (72.8 %) years lived with disability (YLD).

Conclusions

Our study highlighted that population in Shandong Province had a high prevalence of MS and the patients had a heavy disease burden. It also revealed that the results obtained in this paper would be useful to provide a reference for establishing specific healthcare policies for this rare disease in Shandong Province.

Critical Illness in Patients with Multiple Sclerosis: A Matched Case-Control Study

BACKGROUND

Over the course of multiple sclerosis (MS) several conditions may arise that require critical care. We aimed to study the reasons for admission and outcome in patients with MS admitted to a neuro-intensive care unit (NICU).

METHODS

We retrospectively searched the electronic charts of a 9-bedded NICU in a tertiary hospital for patients with a diagnosis of multiple sclerosis (MS) from 1993-2015, and matched them to NICU controls without MS based on age and gender. Conditional logistic regression was used to compare admission causes, Charlson's Comorbidity Index, indicators of disease severity, and survival between MS and non-MS patients.

RESULTS

We identified 61 MS patients and 181 non-MS controls. Respiratory dysfunction was the most frequent reason for NICU admission among MS patients (34.4%), having infectious context as a rule. In a matched analysis, after adjusting for co-morbidities and immunosuppressive medications, patients with MS were more likely to be admitted to the NICU because of respiratory dysfunction (OR = 7.86, 95% CI 3.02-20.42, p<0.001), non-respiratory infections (OR = 3.71, 95% CI 1.29-10.68, p = 0.02), had a higher rate of multiple NICU admissions (OR = 2.53, 95% CI 1.05-6.05, p = 0.04) than non-MS patients. Mortality after NICU admission at a median follow-up time of 1 year was higher in MS than control patients (adjusted OR = 4.21, 95% CI 1.49-11.85, p = 0.04).

CONCLUSION

The most common reason for NICU admission in MS patients was respiratory dysfunction due to infection. Compared to non-MS patients, critically ill MS patients had a higher NICU re-admission rate, and a higher mortality.

Mortality in multiple sclerosis: meta-analysis of standardised mortality ratios

OBJECTIVE

There are inconsistent data on mortality in people with multiple sclerosis (MS). We performed a meta-analysis of all-cause, cause-specific and gender-specific crude mortality rates (CMRs), and standardised mortality ratios (SMRs) in MS, and estimated the rate of change of CMR and SMR over the past 50 years.

METHODS

Medline, Embase and the Cochrane Library were searched.

KEYWORDS

'Multiple Sclerosis' and ('standardised mortality' or 'standardized mortality').

INCLUSION CRITERIA

availability of data on the number of deaths; mean or median patient follow-up or reports of SMRs; being a longitudinal study. 12 studies were included covering the period 1949-2012 (27 423 patients; 6628 deaths; 437 832 person-years follow-up). CMR was calculated. SMRs were extracted. CMRs and natural logarithm of SMRs were pooled by the method of the inverse of the variance. Meta-regression models were used to investigate the secular trends.

RESULTS

Pooled CMR was 9.78/1000 person-years (95% CI 6.81 to 14.02). Pooled all-cause SMR was 2.80 (95% CI 2.74 to 2.87). All-cause SMR was 2.56 (95% CI 2.47 to 2.66) in males and 3.06 (95% CI 2.97 to 3.17) in females. SMR due to cancer was 0.89 (95% CI 0.83 to 0.97). SMRs due to cardiovascular diseases, suicide, infection and respiratory diseases were 1.29 (95% CI 1.20 to 1.38), 2.13 (95% CI 1.80 to 2.51) and 2.91 (95% CI 2.60 to 3.26). There was no trend in CMRs, all-cause, and gender-specific SMRs.

CONCLUSIONS

The excess mortality in MS relative to the general population has not changed over the past 50 years. Female patients with MS have higher survival disadvantage compared to that of males. Death due to cardiovascular diseases, suicide and infection is higher in patients with MS compared to the general population.

What role does tobacco smoking play in multiple sclerosis disability and mortality? A review of the evidence

There is increasing evidence of tobacco smoking as an associative factor in multiple sclerosis (MS). Numerous studies have been conducted investigating the effects of smoking before the onset of MS as well as its impact on disease course. This special report reviews the available evidence and summarizes the contribution of smoking to increased mortality in patients with MS. It also explores some putative mechanisms for the involvement of tobacco constituents in the pathology of MS and the effects of smoking on disease-modifying treatments.

Balancing Early Aggression Against Risk of Progression in Multiple Sclerosis

Multiple sclerosis is a chronic demyelinating disease characterized by focal and diffuse inflammation of the central nervous system resulting in significant physical and cognitive disabilities. Disease-modifying therapies targeting the dysfunctional immune response are most effective in the first few years after disease onset, indicating that there is a limited time window for therapy to influence the disease course. No evidence of disease activity is emerging as a new standard for treatment response and may be associated with improved long-term disability outcomes. An aggressive management strategy, including earlier use of more potent immunomodulatory agents and close monitoring of the clinical and radiologic response to treatment, is recommended to minimize early brain volume loss and slow the progression of physical and cognitive impairments in patients with relapsing-remitting multiple sclerosis.

Cognitive and psychiatric comorbidities in neuromyelitis optica

OBJECTIVE

Our primary objective was to examine the neuropsychological and psychopathological profile of patients with neuromyelitis optica (NMO) and compare these to multiple sclerosis (MS) and healthy control (HC) groups. We also examined for relationships between cognitive and psychiatric variables and clinical factors including accumulated neurological disability and disease duration.

METHODS

A neuropsychological test battery was administered along with a structured psychiatric interview and quantitative measures of mood symptoms.

RESULTS

42 NMO, 42 MS and 42 HC participants were assessed. Cognitive impairments were observed in 67% of NMO patients. The prevalence and profile of cognitive impairments and lifetime prevalence of depression was similar between NMO and MS groups. However, significantly higher rates of recurrent depression and suicidality were observed in NMO patients. Correlational analyses revealed higher levels of anxiety symptoms were associated with shorter disease duration in NMO, while higher depression symptom levels were associated with higher neurological disability and poorer cognition.

CONCLUSIONS

Our results demonstrate substantial cognitive and psychiatric comorbidities in NMO patients. Similar rates of lifetime and current depression between NMO and MS appear to mask greater underlying psychiatric burden in NMO and further understandings of the course of neurobehavioural comorbidities is required to better comprehend the additional morbidity in NMO. Our data support a role for cognitive and psychiatric assessments in the comprehensive care of NMO patients.

Multiple Sclerosis and Risk of Infection-Related Hospitalization and Death in US Veterans

BACKGROUND

This study estimated the risk of infection-related hospitalizations and death in patients with and without multiple sclerosis (MS).

METHODS

We identified adults with MS in the US Department of Veterans Affairs (VA) system between 1999 and 2010. Each veteran with MS was matched, on age and sex, with up to four veterans without MS. Multivariable Cox proportional hazards regression models were performed to assess the influence of MS on the development of serious and fatal infections.

RESULTS

The cohort included 7743 veterans with MS and 30,972 veterans without MS. Mean (SD) age was 53.8 (13.3) years, and 80.8% were male. The incidence per 1000 person-years of overall serious infections was 19.2 (95% confidence interval [CI], 17.6-20.8) for those with MS and 10.3 (95% CI, 9.8-10.9) for those without MS. Fatal infection incidence rates were 1.2 (95% CI, 0.8-1.7) for patients with MS and 0.5 (95% CI, 0.3-0.6) for patients without MS. Regression models showed that veterans with MS were at greater risk for overall serious (hazard ratio [HR] = 1.52, P < .01) and fatal (HR = 1.85, P = .03) infections and serious respiratory (HR = 1.31, P = .01), urinary tract (HR = 4.44, P < .01), and sepsis-related infections (HR = 2.56, P < .01).

CONCLUSIONS

This study provides evidence that VA patients with MS are more likely than those without MS to be hospitalized and die of infection.

Prevalence of overweight, obesity and metabolic syndrome components in multiple sclerosis patients with significant disability

BACKGROUND AND PURPOSE

Information about metabolic comorbidities in patients with multiple sclerosis (MS) is scarce. Our aim was to examine the prevalence of the metabolic syndrome (MetS) and its components in patients with long duration of MS and significant disability.

METHODS

Demographic and clinical data, weight, height, waist circumference, blood pressure, and levels of fasting glucose, triglycerides and high density lipoprotein cholesterol (HDL-C) were obtained from 130 MS patients with Extended Disability Status Scale (EDSS) score ≥3.0.

RESULTS

Seventy-two percent were female, mean ± SD age 55.8 ± 6.0, range 45-65 years, disease duration 18.2 ± 10.1 years, EDSS 5.5 ± 1.0. Obesity [body mass index (BMI) ≥ 30 kg/m(2) ] was present in 18.5% and overweight (BMI 25.0-29.9 kg/m(2) ) in 34.6%. The prevalence of the MetS was 30% with no gender difference. Fifty-six percent had central obesity by waist circumference, 28% treated hypertension, 45.8% elevated blood pressure, 11% type 2 diabetes mellitus, 31.4% treated dyslipidemia, 28.8% elevated triglyceride levels and 31.4% had low HDL-C. MS patients with MetS were significantly older (59.0 ± 5.5 vs. 53.8 ± 5.5, P < 0.0001) and heavier (BMI 29.0 ± 6.9 vs. 25.1 ± 4.7, P = 0.0009). There were no differences between the groups in neurological disability by the EDSS (5.7 ± 1.0 vs. 5.4 ± 1.0), disease duration (18.4 ± 9.9 vs. 18.2 ± 10.2 years) and number of steroid courses received (6.6 ± 9.5 vs. 6.3 ± 8.4).

CONCLUSIONS

Compared to the general population, adult disabled MS patients had lower rates of obesity and overweight, as assessed by BMI. Despite these reduced rates, the prevalence of the MetS was similar to the general population. Specifically higher rates of increased waist circumference were found, suggesting that the lower BMI may be misleading in terms of health risk.

Mortality and comorbidities in patients with multiple sclerosis compared with a population without multiple sclerosis: An observational study using the US Department of Defense administrative claims database

BACKGROUND

Data are limited for mortality and comorbidities in patients with multiple sclerosis (MS).

OBJECTIVES

Compare mortality rates and event rates for comorbidities in MS (n=15,684) and non-MS (n=78,420) cohorts from the US Department of Defense (DoD) database.

METHODS

Comorbidities and all-cause mortality were assessed using the database. Causes of death (CoDs) were assessed through linkage with the National Death Index. Cohorts were compared using mortality (MRR) and event (ERR) rate ratios.

RESULTS

All-cause mortality was 2.9-fold higher in the MS versus non-MS cohort (MRR, 95% confidence interval [CI]: 2.9, 2.7-3.2). Frequent CoDs in the MS versus non-MS cohort were infectious diseases (6.2, 4.2-9.4), diseases of the nervous (5.8, 3.7-9.0), respiratory (5.0, 3.9-6.4) and circulatory (2.1, 1.7-2.7) systems and suicide (2.6, 1.3-5.2). Comorbidities including sepsis (ERR, 95% CI: 5.7, 5.1-6.3), ischemic stroke (3.8, 3.5-4.2), attempted suicide (2.4, 1.3-4.5) and ulcerative colitis (2.0, 1.7-2.3), were higher in the MS versus non-MS cohort. The rate of cancers was also higher in the MS versus the non-MS cohort, including lymphoproliferative disorders (2.2, 1.9-2.6) and melanoma (1.7, 1.4-2.0).

CONCLUSIONS

Rates of mortality and several comorbidities are higher in the MS versus non-MS cohort. Early recognition and management of comorbidities may reduce premature mortality and improve quality of life in patients with MS.