The Kurtzke EDSS rank stability increases 4 years after the onset of multiple sclerosis: results from the MSBase Registry

Disease-modifying therapies in managing disability worsening in paediatric-onset multiple sclerosis: a longitudinal analysis of global and national registries

BACKGROUND

High-efficacy disease-modifying therapies have been proven to slow disability accrual in adults with relapsing-remitting multiple sclerosis. However, their impact on disability worsening in paediatric-onset multiple sclerosis, particularly during the early phases, is not well understood. We evaluated how high-efficacy therapies influence transitions across five disability states, ranging from minimal disability to gait impairment and secondary progressive multiple sclerosis, in people with paediatric-onset multiple sclerosis.

METHODS

Longitudinal data were obtained from the international MSBase registry, containing data from people with multiple sclerosis from 151 centres across 41 countries, and the Italian Multiple Sclerosis and Related Disorders Register, containing data from people with multiple sclerosis from 178 Italian multiple sclerosis centres. People younger than 18 years at the onset of multiple sclerosis symptoms were included, provided they had a confirmed diagnosis of relapsing-remitting multiple sclerosis and at least four Expanded Disability Status Scale (EDSS) scores recorded within 12-month intervals. The primary outcome was the time to change in disability state: minimal disability (EDSS scores 0, 1·0, and 1·5), mild disability (EDSS scores 2·0 and 2·5), moderate disability (EDSS scores 3·0 and 3·5), gait impairment (EDSS scores ≥4·0), and clinician diagnosed secondary progressive multiple sclerosis. A multi-state model was constructed to simulate the natural course of multiple sclerosis, modelling the probabilities of both disability worsening and improvement simultaneously. The impact of high-efficacy disease-modifying therapies (alemtuzumab, cladribine, daclizumab, fingolimod, mitoxantrone, natalizumab, ocrelizumab, rituximab, or autologous haematopoietic stem cell transplantation) and low-efficacy disease-modifying therapies (dimethyl fumarate, glatiramer acetate, interferon beta, or teriflunomide), compared with no treatment, on the course of disability was assessed. Apart from recruitment, individuals with lived experience of multiple sclerosis were not involved in the design and conduct of this study.

FINDINGS

A total of 5224 people (3686 [70·6%] female and 1538 [29·4%] male) with mean age at onset of multiple sclerosis 15·24 years (SD 2·52) were included. High-efficacy therapies reduced the hazard of disability worsening across the disability states. The largest reduction (hazard ratio 0·41 [95% CI 0·31-0·53]) was observed in participants who were treated with high-efficacy therapies while in the minimal disability state, compared with those remained untreated. The benefit of high-efficacy therapies declined with increasing disability. Young people with minimal disability who received low-efficacy therapy also experienced a reduced hazard (hazard ratio 0·65 [95% CI 0·54-0·77]) of transitioning to mild disability, in contrast to those who remained untreated.

INTERPRETATION

Treatment of paediatric-onset relapsing-remitting multiple sclerosis with high-efficacy therapy substantially reduces the risk of reaching key disability milestones. This reduction in risk is most pronounced among young people with minimal or mild disability when treatment began. Children with relapsing-remitting multiple sclerosis should be treated early with high-efficacy therapy, before developing significant neurological impairments, to better preserve their neurological capacity.

FUNDING

National Health and Medical Research Council, Australia; MSBase Foundation Fellowship; MS Australia Postdoctoral Fellowship.

Modelling Disease Progression of Multiple Sclerosis in a South Wales Cohort

OBJECTIVES

The objective of this study was to model multiple sclerosis (MS) disease progression and compare disease trajectories by sex, age of onset, and year of diagnosis.

STUDY DESIGN AND SETTING

Longitudinal EDSS scores (20,854 observations) were collected for 1,787 relapse-onset MS patients at MS clinics in South Wales and modelled using a multilevel model (MLM). The MLM adjusted for covariates (sex, age of onset, year of diagnosis, and disease-modifying treatments), and included interactions between baseline covariates and time variables.

RESULTS

The optimal model was truncated at 30 years after disease onset and excluded EDSS recorded within 3 months of relapse. As expected, older age of onset was associated with faster disease progression at 15 years (effect size (ES): 0.75; CI: 0.63, 0.86; p: <0.001) and female-sex progressed more slowly at 15 years (ES: -0.43; CI: -0.68, -0.18; p: <0.001). Patients diagnosed more recently (defined as 2007-2011 and >2011) progressed more slowly than those diagnosed historically (<2006); (ES: -0.46; CI: -0.75, -0.16; p: 0.006) and (ES: -0.95; CI: -1.20, -0.70; p: <0.001), respectively.

CONCLUSION

We present a novel model of MS outcomes, accounting for the non-linear trajectory of MS and effects of baseline covariates, validating well-known risk factors (sex and age of onset) associated with disease progression. Also, patients diagnosed more recently progressed more slowly than those diagnosed historically.

Multiple Sclerosis Severity Score (MSSS) improves the accuracy of individualized prediction in MS

Background:

The MSBase prediction model of treatment response leverages multiple demographic and clinical characteristics to estimate hazards of relapses, confirmed disability accumulation (CDA), and confirmed disability improvement (CDI). The model did not include Multiple Sclerosis Severity Score (MSSS), a disease duration-adjusted ranked score of disability.

Objective:

To incorporate MSSS into the MSBase prediction model and compare model accuracy with and without MSSS.

Methods:

The associations between MSSS and relapse, CDA, and CDI were evaluated with marginal proportional hazards models adjusted for three principal components representative of patients’ demographic and clinical characteristics. The model fit with and without MSSS was assessed with penalized r2 and Harrell C.

Results:

A total of 5866 MS patients were started on disease-modifying therapy during prospective follow-up (age 38.4 ± 10.6 years; 72% female; disease duration 8.5 ± 7.7 years). Including MSSS into the model improved the accuracy of individual prediction of relapses by 31%, of CDA by 23%, and of CDI by 24% (Harrell C) and increased the amount of variance explained for relapses by 49%, for CDI by 11%, and for CDA by 10% as compared with the original model.

Conclusion:

Addition of a single, readily available metric, MSSS, to the comprehensive MSBase prediction model considerably improved the individual accuracy of prognostics in MS.

Perivascular space is associated with brain atrophy in patients with multiple sclerosis

BACKGROUND

Perivascular space (PVS) is associated with neurodegenerative and neuroimmune diseases. Multiple sclerosis (MS) is traditionally a neuroimmune disease. However, studies show neurodegeneration also plays a vital role in MS. At present, most studies conclude severer PVS in MS is an imaging marker of neuroinflammation, while a 7T MRI study suggests that PVS in MS is associated with neurodegeneration.

METHODS

In this study, 82 MS patients (n=82) and 32 healthy controls (n=32) were enrolled. The following indexes were measured: the number, size and distribution of PVS, the PVS score, corpus callosum index (CCI), corpus callosum area (CCA), the ratio of the corpus callosum to the cranium (CCR), aligned third ventricle width (a3VW), and unaligned third ventricle width (u3VW).

RESULTS

The PVS score (4 vs. 3, P=0.041), PVSs number (103.280±45.107 vs. 87.625±30.139, P=0.035), and enlarged perivascular spaces (EPVSs) number (9 vs. 1, P<0.001) of MS patients were significantly higher than in the healthy controls. PVSs number (23.5 vs. 13) and EPVSs number (1 vs. 0) in the basal ganglia (BG), and EPVSs number (3 vs. 0) in centrum semiovale (CSO) of MS patients were significantly higher than in the healthy controls, P<0.001. In MS patients, PVS was correlated with age and hypertension but not to the extended disability status scale (EDSS) score and other clinical data. In MS patients, PVS score was correlated with CCA (rs=0.272; P=0.013) and the CCR (rs=0.219; P=0.048), and PVSs number was correlated with CCA (rs=0.255; P=0.021), the correlation disappeared after adjusting hypertension and age. In MS patients in remission, PVSs number was correlated with CCA (rs=0.487; P=0.019), CCR (rs=0.479; P=0.021), and PVS score was correlated with CCA (rs=0.453; P=0.03). After adjustment of hypertension and age, the total number of PVSs was correlated with CCA (rs=0.419; P=0.049).

CONCLUSIONS

The PVS load in MS patients was heavier than healthy people, especially in BG and CSO. PVS was not correlated with EDSS in MS patients. The PVS of MS patients was associated with CCA and CCR, and PVSs number was independently related with CCA in MS patients in remission.

Early High Efficacy Treatment in Multiple Sclerosis Is the Best Predictor of Future Disease Activity Over 1 and 2 Years in a Norwegian Population-Based Registry

Background: Moderate and high efficacy disease modifying therapies (DMTs) have a profound effect on disease activity. The current treatment guidelines only recommend high efficacy DMTs for patients with highly active MS. The objective was to examine the impact of initial treatment choice in achieving no evidence of disease activity (NEDA) at year 1 and 2.

Methods: Using a real-world population-based registry with limited selection bias from the southeast of Norway, we determined how many patients achieved NEDA on moderate and high efficacy DMTs.

Results: 68.0% of patients who started a high efficacy DMT as the first drug achieved NEDA at year 1 and 52.4% at year 2 as compared to 36.0 and 19.4% of patients who started a moderate efficacy DMT as a first drug. The odds ratio (OR) of achieving NEDA on high efficacy drugs compared to moderate efficacy drugs as a first drug at year 1 was 3.9 (95% CI 2.4–6.1, p < 0.001). The OR for high efficacy DMT as the second drug was 2.5 (95% CI 1.7–3.9, p < 0.001), and was not significant for the third drug. Patients with a medium or high risk of disease activity were significantly more likely to achieve NEDA on a high efficacy therapy as a first drug compared to moderate efficacy therapy as a first drug.

Conclusions: Achieving NEDA at year 1 and 2 is significantly more likely in patients on high-efficacy disease modifying therapies than on moderate efficacy therapies, and the first choice of treatment is the most important. The immunomodulatory treatment guidelines should be updated to ensure early, high efficacy therapy for the majority of patients diagnosed with MS.

Comparison of susceptibility weighted imaging with conventional MRI sequences in multiple sclerosis plaque assessment: A cross-sectional study

Background:

The current study was performed to compare susceptibility-weighted imaging (SWI) with magnetic resonance imaging (MRI) methods of T2-weighted (T2W) and fluid-attenuated inversion recovery (FLAIR) imaging in multiple sclerosis (MS) plaque assessment

Materials and Methods:

This cross-sectional study was conducted among 50 MS patients referred to Shafa Imaging Center, Isfahan, Iran. Patients who fulfilled McDonald criteria and were diagnosed with MS by a professional neurologist at least 1 year before the study initiation were included in the study. Eligible patients underwent brain scans using SWI, T2W imaging, and FLAIR. Plaques’ number and volume were detected separately for each imaging sequence. Moreover, identified lesions in SWI sequence were evaluated in terms of iron deposition and central veins

Results:

Totally 50 patients (10 males and 40 females) with a mean age of 28.48 ± 5.25 years were included in the current study. Majority of patients (60%) had a disease duration of >5 years, and mean expanded disability status score was 2.56 ± 1.32. There was no significant difference between different imaging modalities in terms of plaques’ number and volume (P > 0.05). It was also found that there was a high correlation between SWI and conventional imaging techniques of T2W (r = 0.97, 0.91, P < 0.001) and FLAIR (r = 0.99, 0.99, P < 0.001) in the estimation of both the number and volume of plaques (P < 0.001)

Conclusion:

The results of the present study indicated that SWI and conventional MRI sequences have similar efficiency for plaque assessment in MS patients.

Cognitive Event-Related Potentials-The P300 Wave Is a Prognostic Factor of Long-Term Disability Progression in Patients With Multiple Sclerosis

PURPOSE

Multiple sclerosis (MS) is a chronic disorder with a variable course. The aim of our study was to find out whether cognitive event-related potentials are prognostic for patient disability at the 15-year follow-up.

METHODS

In the observed cohort of patients with MS, we examined the event-related potentials at baseline (2003). Functional status (Expanded Disability Status Scale score) was then assessed 15 years later, and the prognostic model was developed using binary logistic regression analysis. The independent variables included demographic (age, sex, and education), clinical (disability in 2003), radiologic (MRI lesion load), and event-related potentials parameters. The prognostic accuracy of the proposed model was evaluated by calculating the area under the receiver-operating characteristics curve.

RESULTS

The study sample consisted of 85 patients with MS. The mean age was 35.5 (SD, 11.2) years, and the median disability score was 3.0 (1-7) in 2003 and 5.0 (1.5-9.5) in 2018. The significant prognostic factors of poor Expanded Disability Status Scale are higher baseline Expanded Disability Status Scale, longer MS duration, and prolonged P300 latency. The sensitivity and specificity of the cutoff at 5.0 for the disability score were 94% and 89%, respectively, with the area under the receiver-operating characteristics curve 0.94 (95% confidence interval, 0.889-0.984; P < 0.001).

CONCLUSIONS

The results show that out of event-related potentials, the P300 wave latency is a prognostic of long-term disability progression in patients with MS.

Multiple Sclerosis Severity Score: Concept and applications

Severity score represents disease duration-adjusted mean rank of disability in multiple sclerosis (MS) patients from the reference population. This measure allows one to compare the relative rates of disease progression among patients, patient subgroups, and across epochs, which opens up new question of what accounts for the observed differences in severity, and can be used to assess correlation between disease severity and clinical, radiologic, immunologic, genetic, and environmental variables of interest. Severity score can also prove useful for developing prognostic tools in MS. This article discusses the diverse applications of severity score concept in MS research, and (re)introduces Herbert's proposal of severity-based MS classification in the context of variability of MS severity.

Lipid-related genetic polymorphisms significantly modulate the association between lipids and disability progression in multiple sclerosis

OBJECTIVE

To investigate whether lipid-related or body mass index (BMI)-related common genetic polymorphisms modulate the associations between serum lipid levels, BMI and disability progression in multiple sclerosis (MS).

METHODS

The association between disability progression (annualised Expanded Disability Status Scale (EDSS) change over 5 years, ΔEDSS) and lipid-related or BMI-related genetic polymorphisms was evaluated in a longitudinal cohort (n=184), diagnosed with MS. We constructed a cumulative genetic risk score (CGRS) of associated polymorphisms (p<0.05) and examined the interactions between the CGRS and lipid levels (measured at baseline) in predicting ΔEDSS. All analyses were conducted using linear regression.

RESULTS

Five lipid polymorphisms (rs2013208, rs9488822, rs17173637, rs10401969 and rs2277862) and one BMI polymorphism (rs2033529) were nominally associated with ΔEDSS. The constructed lipid CGRS showed a significant, dose-dependent association with ΔEDSS (p_trend=1.4×10^-6), such that participants having ≥6 risk alleles progressed 0.38 EDSS points per year faster compared with those having ≤3. This CGRS model explained 16% of the variance in ΔEDSS. We also found significant interactions between the CGRS and lipid levels in modulating ΔEDSS, including high-density lipoprotein (HDL; p_interaction=0.005) and total cholesterol:high-density lipoprotein ratio (TC:HDL; p_interaction=0.030). The combined model (combination of CGRS and the lipid parameter) explained 26% of the disability variance for HDL and 27% for TC:HDL.

INTERPRETATION

In this prospective cohort study, both lipid levels and lipid-related polymorphisms individually and jointly were associated with significantly increased disability progression in MS. These results indicate that these polymorphisms and tagged genes might be potential points of intervention to moderate disability progression.

The MSBase registry: Informing clinical practice

Over the last decade, clinical registries have significantly contributed to the pool of evidence that supports management decisions in patients with multiple sclerosis. Being the largest international registry of multiple sclerosis and neuroimmunological disorders, MSBase collects demographic, clinical and limited paraclinical information from patients managed in different regions and under various circumstances. In this review, we will provide an overview of its published output, with focus on the information with impact on the management of multiple sclerosis.

Management of multiple sclerosis patients in central European countries: current needs and potential solutions

Multiple sclerosis (MS) experts in Europe are facing rapidly rising demands of excellence due to the increasing complexity of MS therapy and management. A central European expert board of MS experts met to identify needs and obstacles with respect to raising quality of MS care in central and Eastern European countries. There are substantial variations across countries regarding delivery of care and its cost structure, as well as access to treatment. To date, Eastern European countries are often less able to afford reimbursement of immunomodulatory agents than Western countries. Overall, approximately 40% of working-age patients are not working due to MS. Costs rise steeply with increasing disability; indirect costs constitute the bulk of the financial burden in patients with severe MS. Magnetic resonance imaging (MRI) assessment is meanwhile obligatory as the diagnostic interface in the management of MS patients. Recommended measures directed at improving quality of care include the collection of patient data in registries, enhanced education of healthcare professionals, implementation of national strategies aiming at reducing regional variation, optimization of approval processes, and removal of administrative barriers. Local partnerships with authorities such as those that represent the interests of employees can contribute to leverage the importance of epidemiological data. The need for education extends to (neuro)radiologists who are responsible for reporting MRI findings in expert quality. Dissemination of the Magnetic Resonance Imaging in MS (MAGNIMS) protocol would be an important step in this context. Also, clinical freedom of choice is rated as essential. Physicians should have access to a range of treatment options due to the complexity of disease. Guidelines such as the upcoming EAN-ECTRIMS clinical practice guideline also aim at providing a basis for argumentation in negotiations with national health authorities.

Modelling disease progression in relapsing-remitting onset multiple sclerosis using multilevel models applied to longitudinal data from two natural history cohorts and one treated cohort

BACKGROUND

The ability to better predict disease progression represents a major unmet need in multiple sclerosis (MS), and would help to inform therapeutic and management choices.

OBJECTIVES

To develop multilevel models using longitudinal data on disease progression in patients with relapsing-remitting MS (RRMS) or secondary-progressive MS (SPMS); and to use these models to estimate the association of disease-modifying therapy (DMT) with progression.

DESIGN

Secondary analysis of three MS cohorts.

SETTING

Two natural history cohorts: University of Wales Multiple Sclerosis (UoWMS) cohort, UK, and British Columbia Multiple Sclerosis (BCMS) cohort, Canada. One observational DMT-treated cohort: UK MS risk-sharing scheme (RSS).

PARTICIPANTS

The UoWMS database has > 2000 MS patients and the BCMS database (as of 2009) has > 5900 MS patients. All participants who had definite MS (RRMS/SPMS), who reached the criteria set out by the Association of British Neurologists (ABN) for eligibility for DMT [i.e. age ≥ 18 years, Expanded Disability Status Scale (EDSS) score of ≤ 6.5, occurrence of two or more relapses in the previous 2 years] and who had at least two repeated outcome measures were included: 404 patients for the UoWMS cohort and 978 patients for the BCMS cohort. Through the UK MS RSS scheme, 5583 DMT-treated patients were recruited, with the analysis sample being the 4137 who had RRMS and were eligible and treated at baseline, with at least one valid EDSS score post baseline.

MAIN OUTCOME MEASURES

EDSS score observations post ABN eligibility.

METHODS

We used multilevel models in the development cohort (UoWMS) to develop a model for EDSS score with time since ABN eligibility, allowing for covariates and appropriate transformation of outcome and/or time. These methods were then applied to the BCMS cohort to obtain a 'natural history' model for changes in the EDSS score with time. We then used this natural history model to predict the trajectories of EDSS score in treated patients in the UK MS RSS database. Differences between the progression predicted by the natural history model and the progression observed at 6 years' follow-up for the UK MS RSS cohort were used as indicators of the effectiveness of the DMTs. Previously developed utility scores were assigned to each EDSS score, and differences in utility also examined.

RESULTS

The model best fitting the UoWMS data showed a non-linear increase in EDSS score over time since ABN eligibility. This model fitted the BCMS cohort data well, with similar coefficients, and the BCMS model predicted EDSS score in UoWMS data with little evidence of bias. Using the natural history model predicts EDSS score in a treated cohort (UK MS RSS) higher than that observed [by 0.59 points (95% confidence interval 0.54 to 0.64 points)] at 6 years post treatment.

LIMITATIONS

Only two natural history cohorts were compared, limiting generalisability. The comparison of a treated cohort with untreated cohorts is observational, thus limiting conclusions about causality.

CONCLUSIONS

EDSS score progression in two natural history cohorts of MS patients showed a similar pattern. Progression in the natural history cohorts was slightly faster than EDSS score progression in the DMT-treated cohort, up to 6 years post treatment.

FUTURE WORK

Long-term follow-up of randomised controlled trials is needed to replicate these findings and examine duration of any treatment effect.

FUNDING DETAILS

The National Institute for Health Research Health Technology Assessment programme.

Coping strategies and adjustment to multiple sclerosis among recently diagnosed patients: the mediating role of sense of coherence

Objective:

To examine the relationship between coping strategies (problem solving, emotional release, and avoidance) and adjustment (health-related quality of life, depression, and affective well-being) in a group of recently diagnosed multiple sclerosis patients (up to three years since diagnosis), and to explore the mediating role of sense of coherence between coping strategies and adjustment.

Design:

Cross-sectional.

Setting:

Multiple Sclerosis Clinic Centre.

Subjects:

A total of 102 patients (61.8% women; age (years): M = 35.8, SD = 11.9; 95% with a relapsing–remitting form of multiple sclerosis; Expanded Disability Status Scale score, between 1 and 4).

Interventions:

Not applicable.

Main measures:

Coping with multiple sclerosis (problem solving, emotional release, and avoidance), sense of coherence, health-related quality of life (SF-12), depression (CES-D), and affective well-being (PANAS).

Results:

Problem solving was linked to higher mental health ( β = 0.28) and higher affective well-being ( β = 0.36), emotional release was related to lower depression ( β = −0.22); avoidance was associated to higher mental health ( β = 0.25), higher affective well-being ( β = 0.24), and lower depression ( β = −0.29 ) (all betas were significant at p < 0.05). Sense of coherence mediated the relationship between emotional release and depression (Sobel z-value = −2.00; p < 0.05) and the relationship between avoidance and all the indicators of adjustment (mental health: Sobel z-value = 1.97; depression: Sobel z-value = −2.02; affective well-being: Sobel z-value= 2.05; p < 0.05).

Conclusions:

Emotional and avoidant coping strategies seem to be adaptive among recently diagnosed multiple sclerosis patients. A mediating role between coping strategies and adjustment is played by sense of coherence.

Central Atrophy Early in Multiple Sclerosis: Third Ventricle Volumetry versus Planimetry

BACKGROUND AND PURPOSE

Cerebral atrophy has been suggested to be a reliable magnetic resonance imaging (MRI) predictor of subsequent disability in all stages of multiple sclerosis (MS). However, no accepted methodology for routine clinical use exists to date. We sought an easy to apply and fast technique to evaluate cerebral ventricular volume in patients with MS with similar accuracy as a semiautomatic volumetric method.

METHODS

The study included 104 patients, 61 diagnosed with MS and 43 with clinically isolated syndrome. In addition, 30 healthy controls were enrolled. Physical disability was assessed with the expanded disability status scale and cognitive disability with the Multiple Sclerosis Inventory Cognition (MUSIC) test. All subjects received standardized 3-dimensional (3D) MR-imaging on a 3 T scanner. Third ventricle volume (3VV) was obtained from 3D T1-weighted images using a semiautomated technique, and compared against planimetric assessment of the width of the third ventricle aligned (a3VW) and unaligned (u3VW) to anatomical landmarks.

RESULTS

a3VW was obtained within seconds with excellent intra- and interrater agreement, and outperformed volumetric measurements regarding the differentiation of MS patients from healthy controls. a3VW had the strongest correlations with 3VV (r = .78, P < .001) and showed moderate inverse correlation with MUSIC cognition score (r = -.310, P < .005).

CONCLUSIONS

a3VW is a time-effective and robust biomarker that has strong correlations with volumetric measurements and can be established as standard in the MRI quantification of central brain atrophy in patients with early MS.

Role of genetic susceptibility variants in predicting clinical course in multiple sclerosis: a cohort study

BACKGROUND

The genetic drivers of multiple sclerosis (MS) clinical course are essentially unknown with limited data arising from severity and clinical phenotype analyses in genome-wide association studies.

METHODS

Prospective cohort study of 127 first demyelinating events with genotype data, where 116 MS risk-associated single nucleotide polymorphisms (SNPs) were assessed as predictors of conversion to MS, relapse and annualised disability progression (Expanded Disability Status Scale, EDSS) up to 5-year review (ΔEDSS). Survival analysis was used to test for predictors of MS and relapse, and linear regression for disability progression. The top 7 SNPs predicting MS/relapse and disability progression were evaluated as a cumulative genetic risk score (CGRS).

RESULTS

We identified 2 non-human leucocyte antigen (HLA; rs12599600 and rs1021156) and 1 HLA (rs9266773) SNP predicting both MS and relapse risk. Additionally, 3 non-HLA SNPs predicted only conversion to MS; 1 HLA and 2 non-HLA SNPs predicted only relapse; and 7 non-HLA SNPs predicted ΔEDSS. The CGRS significantly predicted MS and relapse in a significant, dose-dependent manner: those having ≥5 risk genotypes had a 6-fold greater risk of converting to MS and relapse compared with those with ≤2. The CGRS for ΔEDSS was also significant: those carrying ≥6 risk genotypes progressed at 0.48 EDSS points per year faster compared with those with ≤2, and the CGRS model explained 32% of the variance in disability in this study cohort.

CONCLUSIONS

These data strongly suggest that MS genetic risk variants significantly influence MS clinical course and that this effect is polygenic.

["Time is brain" in relapsing remitting multiple sclerosis. Current treatment concepts in immunotherapy]

BACKGROUND

Despite highly divergent time scales of disease evolution in multiple sclerosis (MS) and ischemic stroke, clear analogies are apparent that may point the way to optimization of MS treatment. Inflammatory disease activity and neurodegeneration may induce potentially irreversible damage to central nervous system structures and thus lead to permanent disability. For the treatment of MS early detection of disease activity and early immunotherapy or treatment optimization are pivotal determinants of long-term outcomes. Such therapeutic concepts may be described with the catchy phrase "time is brain" as coined for the acute thrombolytic treatment of ischemic stroke.

RESULTS AND DISCUSSION

For MS a "time is brain" concept would comprise an early initiation of first line therapy as well as sensitive and structured monitoring of disease activity under therapy in conjunction with a low threshold for timely treatment optimization to achieve sustained freedom from measurable disease activity. This approach may substantially improve the long-term outcome in patients who show insufficient response to platform therapies. The intersectorial collaboration in regional MS care networks involving office-based neurologists and specialized MS centers may facilitate the timely use of highly active therapies with their specific benefit-risk profiles thus supporting sustained stabilization of patient quality of life.

A genetic basis for multiple sclerosis severity: Red herring or real?

Multiple Sclerosis (MS) is an autoimmune degenerative disease of the central nervous system, characterized by multifocal demyelination and neurodegeneration. The genetic architecture of MS is complex, where genetic risk has been attributed to over 100 polymorphic loci each with small odds ratios. MS is a highly heterogeneous disease with numerous clinical and paraclinical endophenotypes. To-date, no genetic variant has been associated with clinical outcome, however, evidence exists that MS outcomes, like risk, are to an extent also controlled by genetic variation. Here we summarise the current evidence for genetic determination of disease outcomes and make recommendations for future research directions.

Brain health: time matters in multiple sclerosis

INTRODUCTION

We present international consensus recommendations for improving diagnosis, management and treatment access in multiple sclerosis (MS). Our vision is that these will be used widely among those committed to creating a better future for people with MS and their families.

METHODS

Structured discussions and literature searches conducted in 2015 examined the personal and economic impact of MS, current practice in diagnosis, treatment and management, definitions of disease activity and barriers to accessing disease-modifying therapies (DMTs).

RESULTS

Delays often occur before a person with symptoms suggestive of MS sees a neurologist. Campaigns to raise awareness of MS are needed, as are initiatives to improve access to MS healthcare professionals and services. We recommend a clear treatment goal: to maximize neurological reserve, cognitive function and physical function by reducing disease activity. Treatment should start early, with DMT and lifestyle measures. All parameters that predict relapses and disability progression should be included in the definition of disease activity and monitored regularly when practical. On suboptimal control of disease activity, switching to a DMT with a different mechanism of action should be considered. A shared decision-making process that embodies dialogue and considers all appropriate DMTs should be implemented. Monitoring data should be recorded formally in registries to generate real-world evidence. In many jurisdictions, access to DMTs is limited. To improve treatment access the relevant bodies should consider all costs to all parties when conducting economic evaluations and encourage the continuing investigation, development and use of cost-effective therapeutic strategies and alternative financing models.

CONCLUSIONS

The consensus findings of an international author group recommend a therapeutic strategy based on proactive monitoring and shared decision-making in MS. Early diagnosis and improved treatment access are also key components.

A longitudinal model for disease progression was developed and applied to multiple sclerosis

Objectives

To develop a model of disease progression using multiple sclerosis (MS) as an exemplar.

Study Design and Settings

Two observational cohorts, the University of Wales MS (UoWMS), UK (1976), and British Columbia MS (BCMS) database, Canada (1980), with longitudinal disability data [the Expanded Disability Status Scale (EDSS)] were used; individuals potentially eligible for MS disease-modifying drugs treatments, but who were unexposed, were selected. Multilevel modeling was used to estimate the EDSS trajectory over time in one data set and validated in the other; challenges addressed included the choice and function of time axis, complex observation-level variation, adjustments for MS relapses, and autocorrelation.

Results

The best-fitting model for the UoWMS cohort (404 individuals, and 2,290 EDSS observations) included a nonlinear function of time since onset. Measurement error decreased over time and ad hoc methods reduced autocorrelation and the effect of relapse. Replication within the BCMS cohort (978 individuals and 7,335 EDSS observations) led to a model with similar time (years) coefficients, time [0.22 (95% confidence interval {CI}: 0.19, 0.26), 0.16 (95% CI: 0.10, 0.22)] and log time [−0.13 (95% CI: −0.39, 0.14), −0.15 (95% CI: −0.70, 0.40)] for BCMS and UoWMS, respectively.

Conclusion

It is possible to develop robust models of disability progression for chronic disease. However, explicit validation is important given the complex methodological challenges faced.

Quantification of multiple-sclerosis-related brain atrophy in two heterogeneous MRI datasets using mixed-effects modeling

Brain atrophy, measured by MRI, has been proposed as a useful surrogate marker for disease progression in multiple sclerosis (MS). However, it is conventionally assumed that the accurate quantification of brain atrophy is made difficult, if not impossible, by changes in the parameters of the MRI acquisition, which are almost inevitable over the course of a longitudinal study since MRI technology changes rapidly. This state of affairs can negatively affect clinical trial design and limit the use of historical data. Here, we investigate whether we can coherently estimate brain atrophy rates in a heterogeneous MS sample via linear mixed-effects multivariable regression, incorporating three critical assumptions: (1) using age at time of scanning, rather than time since baseline, as the regressor of interest; (2) scanning individuals with a variety of techniques; and (3) introducing a simple additive correction for major differences in MRI protocol. We fit the model to several measures of brain volume as the outcome in two MS populations: 1123 scans from 195 cases acquired for over approximately 7 years in two natural history protocols (Cohort 1), and 1331 scans from 69 cases seen for over 11 years who were primarily treated with two specific MS disease-modifying therapies (Cohort 2). We compared the mixed-effects model with additive correction for MRI acquisition parameters to a model fit without this correction and performed sample-size calculations to provide an estimate of the number of participants in an MS clinical trial that might be required to see a therapeutic effect of treatment using the approach described here. The results show that without the additive correction for T1-weighted protocol parameters, atrophy was underestimated and subject-specific estimates were more narrowly distributed about the population mean. Ventricular CSF is the most consistently estimated brain volume, with a mean of 2.8%/year increase in Cohort 1 and 4.4%/year increase in Cohort 2. An interesting observation was that gray matter volume decreased and white matter volume remained essentially unchanged in both cohorts, suggesting that changes in ventricular CSF volume are a surrogate for changes in gray matter volume. In conclusion, the mixed-effects modeling framework presented here allows effective use of heterogeneously acquired and historical data in the study of brain atrophy in MS, potentially simplifying the design of future single- and multi-site clinical trials and natural history studies.

•

We model brain atrophy in two heterogeneously acquired MS MRI datasets.

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Mixed-effects regression effectively adjusts for major MRI differences.

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Ventricular CSF tracks with gray matter but is more reliably estimated.

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The method would allow reasonable sample sizes in MS therapeutic trials.

Exploring the predictive value of the evoked potentials score in MS within an appropriate patient population: a hint for an early identification of benign MS?

BACKGROUND

The prognostic value of evoked potentials (EPs) in multiple sclerosis (MS) has not been fully established. The correlations between the Expanded Disability Status Scale (EDSS) at First Neurological Evaluation (FNE) and the duration of the disease, as well as between EDSS and EPs, have influenced the outcome of most previous studies. To overcome this confounding relations, we propose to test the prognostic value of EPs within an appropriate patient population which should be based on patients with low EDSS at FNE and short disease duration.

METHODS

We retrospectively selected a sample of 143 early relapsing remitting MS (RRMS) patients with an EDSS < 3.5 from a larger database spanning 20 years. By means of bivariate logistic regressions, the best predictors of worsening were selected among several demographic and clinical variables. The best multivariate logistic model was statistically validated and prospectively applied to 50 patients examined during 2009-2011.

RESULTS

The Evoked Potentials score (EP score) and the Time to EDSS 2.0 (TT2) were the best predictors of worsening in our sample (Odds Ratio 1.10 and 0.82 respectively, p=0.001). Low EP score (below 15-20 points), short TT2 (lower than 3-5 years) and their interaction resulted to be the most useful for the identification of worsening patterns. Moreover, in patients with an EP score at FNE below 6 points and a TT2 greater than 3 years the probability of worsening was 10% after 4-5 years and rapidly decreased thereafter.

CONCLUSIONS

In an appropriate population of early RRMS patients, the EP score at FNE is a good predictor of disability at low values as well as in combination with a rapid buildup of disability. Interestingly, an EP score at FNE under the median together with a clinical stability lasting more than 3 years turned out to be a protective pattern. This finding may contribute to an early identification of benign patients, well before the term required to diagnose Benign MS (BMS).