Risk factors related to cardiovascular diseases and the metabolic syndrome in multiple sclerosis - a systematic review

Association of multiple sclerosis with incident diabetes: A nationwide cohort study

AIM

Diabetes mellitus (DM) and multiple sclerosis (MS) are two common diseases known to worsen the trajectory of each other, yet it is unknown whether MS is associated with incident DM.

METHODS

Using Danish nationwide registries, we identified all patients aged 18-99 with a first-time primary or secondary discharge diagnosis with MS between 2000 and 2018, with no known DM. These patients were matched with control subjects from the background population in a 1:5 ratio based on age and sex, to assess their risk of DM.

RESULTS

A total of 13,376 patients with MS and 66,880 matched control subjects were included (33 % men; median age, 42 years [25th-75th percentile, 33-51]). During a median follow-up of 8.3 years (25th-75th percentile, 4.0-13.3), 467 (3.5 %) patients with MS and 2397 (3.6 %) control subjects were diagnosed with DM. The cumulative incidence of DM was similar among patients with MS and control subjects (95 % confidence interval [CI] 6.5 % [5.7-7.2 %] vs. 7.3 % [95 % CI 6.9-7.9 %], respectively), and adjusted analysis yielded a hazard ratio (HR) of 0.98 [95 % CI 0.89-1.09]). The overall risk of incident type 1 diabetes was low and yielded a HR of 1.60 [95 % CI 0.98-1.40] in patients with MS compared with control subject (P = 0.07).

CONCLUSION

This study demonstrated that patients with MS had a similar risk of incident DM as compared to age- and sex matched controls from the background population.

Current understanding of cardiovascular autonomic dysfunction in multiple sclerosis

Autoimmune diseases, including multiple sclerosis (MS), are proven to increase the likelihood of developing cardiovascular disease (CVD) due to a robust systemic immune response and inflammation. MS can lead to cardiovascular abnormalities that are related to autonomic nervous system dysfunction by causing inflammatory lesions surrounding tracts of the autonomic nervous system in the brain and spinal cord. CVD in MS patients can affect an already damaged brain, thus worsening the disease course by causing brain atrophy and white matter disease. Currently, the true prevalence of cardiovascular dysfunction and associated death rates in patients with MS are mostly unknown and inconsistent. Treating vascular risk factors is recommended to improve the management of this disease. This review provides an updated summary of CVD prevalence in patients with MS, emphasizing the need for more preclinical studies using animal models to understand the pathogenesis of MS better. However, no distinct studies exist that explore the temporal effects and etiopathogenesis of immune/inflammatory cells on cardiac damage and dysfunction associated with MS, particularly in the cardiac myocardium. To this end, a thorough investigation into the clinical presentation and underlying mechanisms of CVD must be conducted in patients with MS and preclinical animal models. Additionally, clinicians should monitor for cardiovascular complications while prescribing medications to MS patients, as some MS drugs cause severe CVD.

The predictive capability of several anthropometric indices for identifying the risk of metabolic syndrome and its components among industrial workers

Metabolic syndrome (MetS) is closely associated with adverse cardiometabolic outcomes. The objective of this study was to identify practical methods that could enable the effective identification of MetS based on anthropometric indices. The basis of our study involved retrospective database obtained from routine medical prophylactic examinations. This was a cross-sectional study on the health status of male workers employed in hazardous working conditions at industrial enterprises in the Ural region conducted in 2019. A total of 347 male workers employed under hazardous working conditions were investigated. The presence of MetS was established by a healthcare professional in accordance with the guidelines of the International Diabetes Federation (IDF). Simple linear regression was used to evaluate the associations between anthropometric indices and MetS incidence. Logistic regression was used to determine the odds ratios of MetS in relation to increases in anthropometric indices. ROC curves were calculated to compare the ability of each anthropometric index to predict MetS and to determine the diagnostic thresholds of the indicators considered. According to the IDF criteria, 36.3% of the workers had MetS. A direct relationship was found between the individual components of MetS and the anthropometric indices studied. The highest OR was shown by the Body Roundness Index (BRI) of 2.235 (95% CI 1.796-2.781). For different age quartiles, the optimal cut-off values for predicting MetS were as follows: BRI, 4.1-4.4 r.u.; body shape index (ABSI), 0.080-0.083 m11/6 kg-2/3; and lipid accumulation product (LAP), 49.7-70.5 cm mmol/l. The most significant associations with MetS were observed where the values were greater than these cut-off points (Se = 97.4%). The results of this study demonstrated the rapid use of new anthropometric indicators, which have shown good predictive ability and are quite easy to use.

The association of fear of falling and falls with sedentary behavior in people with multiple sclerosis

OBJECTIVE

Sedentary behavior, falls, and fear of falling (FoF) are specific concerns for people with MS (pwMS). Considering the relatively high incidence and potential linkage, it is surprising that this triple relationship has as yet not been extensively investigated in pwMS. Thus, the present study aimed to examine the correlates of sedentary behavior with FoF and falls in pwMS.

METHODS

Fifty pwMS, 30 women, were admitted to this cross-sectional study. Primary outcome measures included physical activity and sedentary behavior metrics measured by accelerometry, fall status, and FoF. Additional measures included mobility clinical tests, cognition, perceived fatigue, depression, and anxiety. The sample was divided into two subgroups according to the daily Metabolic Equivalent of Task (MET) rate scores; <1.5 was defined as sedentary, ≥1.5 were defined as non-sedentary. Multivariate analysis of variance and linear regression analyses assessed the relationships by using an alpha of 0.05.

RESULTS

Sixty-four percent of the sample were classified as sedentary. The sedentary subgroup reported more FoF than the non-sedentary subgroup (32.5 (S·D. = 11.3) vs. 29.9 (S.D. = 9.5); however, no differences were found in fall status between the subgroups. No differences were found for depression, anxiety, cognition, and perceived fatigue between the subgroups. Furthermore, according to the linear regression analysis, FoF explained 23.9% of the variance pertaining to the daily MET rate when controlling for age, gender, disease duration, and disability.

CONCLUSIONS

Clinicians are encouraged to incorporate the issue of FoF during standard management, which may represent an opportunity to improve care and reduce sedentary behavior in pwMS.

Lipid Profile in Multiple Sclerosis: Functional Capacity and Therapeutic Potential of Its Regulation after Intervention with Epigallocatechin Gallate and Coconut Oil

BACKGROUND

Multiple sclerosis (MS) patients present dyslipidemia and functional disability. Epigallocatechin gallate (EGCG) and coconut oil have been shown to be effective against dyslipidemia.

OBJECTIVE

To analyze the relationship between lipid profiles, fat consumption, and functional disability in patients with MS after administering EGCG and coconut oil.

METHODS

A four-month pilot study was conducted on 45 MS patients, divided into an intervention group (IG) and a control group (CG). The IG received 800 mg of EGCG and 60 mL of coconut oil. Lipid profiles were measured before and after the intervention, along with other data such as dietary habits, inflammatory markers, and functional capacity.

RESULTS

Dyslipidemia did not correlate with the patients' fat consumption. After the intervention, triglycerides (TG) levels were lower in IG compared to CG. This decrease was positively correlated with an improvement in functional disability (determined by the Expanded Disability Status Scale (EDSS)) and negatively with high-density cholesterol (HDL) and apolipoprotein A1. Significant and positive correlations were observed between EDSS and C-reactive protein (CRP) in the IG. These changes in the IG could be related to body fat decrease, whose percentage shows a positive correlation with CRP and TG levels, and a negative correlation with HDL levels.

CONCLUSIONS

Patients with MS present a certain type of dyslipemia not associated with their nutritional habits. The administration of EGCG and coconut oil seems to decrease blood TG levels, which could explain the functional improvements.

Replacing sitting with light-intensity physical activity throughout the day versus 1 bout of vigorous-intensity exercise: similar cardiometabolic health effects in multiple sclerosis. A randomised cross-over study

PURPOSE

Persons with Multiple Sclerosis (PwMS) are physically inactive and spend more time in sedentary behaviours than healthy persons, which increases the risk of developing cardiometabolic diseases. In this randomised crossover study, the cardiometabolic health effects of replacing sitting with light-intensity physical activity (LIPA) and exercise (EX) were investigated.

MATERIALS AND METHODS

Twenty-eight mildly disabled PwMS performed four 4-day activity regimens in free-living conditions; CONTROL (habitual activity), SIT, LIPA, and EX. Plasma glucose and insulin (oral glucose tolerance test), plasma lipids, inflammation, resting heart rate, blood pressure, body weight, and perceived exertion were measured (clinical-trials.gov: NCT03919058).

RESULTS

CONTROL: 9.7 h sitting/day, SIT: 13.3 h sitting/day, LIPA: 8.3 h sitting, 4.7 h standing, and 2.7 h light-intensity walking/day, and EX: 11.6 h sitting/day with 1.3 h vigorous-intensity cycling. Compared to SIT, improvements (p < 0.001) after LIPA and EX were found for insulin total area under the curve (-17 019 ± 5708 and -23 303 ± 7953 pmol/L*min), insulin sensitivity (Matsuda index +1.8 ± 0.3 and +1.9 ± 0.4) and blood lipids (triglycerides: -0.4 ± 0.1 and -0.5 ± 0.1 mmol/L; non-high-density lipoprotein cholesterol: -0.3 ± 0.1 and -0.5 ± 0.1 mmol/L), with no difference between LIPA and EX. Perceived exertion was higher after EX compared to LIPA (Borg score [6-20]: +2.6 ± 3.3, p = 0.002).

CONCLUSION

Replacing sitting with LIPA throughout the day exerts similar cardiometabolic health effects as a vigorous-intensity exercise in PwMS.IMPLICATIONS FOR REHABILITATIONIncreasing light-intensity physical activity (LIPA) throughout the day improves cardiometabolic health to the same extent as one vigorous-intensity exercise sessionIncreasing LIPA induces less exertion than performing a vigorous-intensity exercise.

The Prevalence of Diabetes Mellitus Type II (DMII) in the Multiple Sclerosis Population: A Systematic Review and Meta-Analysis

Introduction: The interactions between Diabetes Mellitus type II (DMII) and Multiple Sclerosis (MS) lead to higher levels of fatigue, higher risk of physical disability, faster cognitive decline, and in general a lower quality of life and a higher frequency of depression compared to the general population. All of the above accelerate the disability progression of patients with MS, reduce the patients' functional capacity, and further increase their psychological and economic burden. Methods: This systematic review and meta-analysis aims to calculate the prevalence of DMII in the MS population. Following PRISMA guidelines, a thorough search of the Medline Pubmed, Cochrane Library, and Scopus databases was performed, focusing on the frequency of DMII in the MS population. Results: A total of 19 studies were included in the synthesis. The results of the main meta-analysis of random effects using R studio 3.3.0 for Windows and the Meta r package showed that the prevalence of DMII in the MS population is 5% (95% CI [0.03, 0.07], 19 studies, I2 = 95%, pQ < 0.001). Additional subgroup analysis based on region showed a difference of 4.4% (I2 = 95.2%, pQ < 0.001), psubgroupdifference = 0.003) between European and non-European participants, while demographic- and MS-specific characteristic (EDSS, Disease Duration) did not seem to affect the prevalence of DMII in the MS population (p = 0.30, p = 0.539, p = 0.19, p = 0.838). No publication bias was discovered (Egger's p test value: 0.896). Conclusions: Even though the prevalence of DMII in the MS population is lower than 10% (the reported prevalence of DMII in the general population) the interactions between the two conditions create significant challenges for MS patients, their caregivers, and physicians. DΜΙΙ should be systematically recorded in the case of MS patients to clearly delineate any potential relationship between the two conditions. Additionally, more structured studies investigating the interactions of MS and DMΙΙ as well as the direction of the causation between those two conditions are necessary in order to gain a deeper insight into the nature of the interaction between MS and DMII.

Environmental Influences on Risk and Disease Course in Pediatric Multiple Sclerosis

Pediatric multiple sclerosis (MS) accounts for 3%-10% of all patients diagnosed with MS. Complex interplay between environmental factors impacts the risk for MS and may also affect disease course. Many of these environmental factors are shared with adult-onset MS. However, children with MS are in closer temporal proximity to the biological onset of MS and have less confounding environmental exposures than their adult counterparts. Environmental factors that contribute to MS risk include: geographical latitude, viral exposures, obesity, vitamin deficiencies, smoking, air pollution, perinatal factors, gut microbiome, and diet. More recently, research efforts have shifted to studying the impact of these risk determinants on the clinical course of MS. In this article we will examine relevant environmental risk determinants of pediatric MS and review the current knowledge on how these factors may contribute to pediatric MS disease evolution.

Prevalence of comorbidities in patients with multiple sclerosis using administrative data from 2007 to 2016 in Iran

BACKGROUND

Research interest in the impact of comorbidities in MS has been expanding. Based on studies, certain comorbidities are more prevalent in MS population such as depression, anxiety, hypertension and hypercholesterolemia, diabetes, and hypothyroidism.

OBJECTIVE

This study aims to describe the prevalence of comorbidities in MS population based on the health insurance claims data.

METHOD

This retrospective database analysis was conducted using patient-level medicinal and pharmacy claims data from a leading insurance group (Iranian health insurance) in 2007-2016. MS population was identified based on their Disease Modifying Therapies prescribed by a neurologist (qualified to diagnose MS). Comorbidities in MS and non-MS population were assessed by their prescriptions. Crude and age-standardized prevalence rate (ASPR) of coverage of comorbidities in different age and sex groups and their odds ratio versus non-MS population were assessed.

RESULTS

The most common comorbidities were depression (15.50%) and anxiety (10.1%). Hypercholesterolemia, diabetes, hypertension, and hypothyroidism were prevalent in 6%, 3.6%, 3.5%, and 2.7% respectively. Anxiety and depression were more prevalent in middle age group (45-65 years old). But other comorbidities were more prevalent in older age groups. All comorbidities were more prevalent in female except hypertension in patients ≥45 years old. The odds of all comorbidities were higher for male patients with MS rather than their parallel age group in non-MS patients. These also applied for female patients with MS 18-44 years old (except hypertension).

CONCLUSION

Using claims data, the prevalence of taking treatment for selected comorbidities in MS population and their association with sex and age, can guide patients, healthcare providers, and policy makers to help improve MS patients' wellbeing.

Blood pressure and cognition in older adults with multiple sclerosis: preliminary examination

BACKGROUND

Comorbid conditions, particularly vascular comorbidity, are common in MS and may hasten the CNS damage and disease manifestations. We undertook a preliminary examination of the association between blood pressure (BP) and cognitive function in samples of older adults with MS and healthy controls.

METHODS

Older adults with MS (n = 29) and healthy controls (n = 29) completed the Brief International Cognitive Assessment for MS (BICAMS) battery and underwent assessment of BP. The data were analyzed using the Baron and Kenny approach for examining blood pressure as an explanatory variable for group differences in cognition.

RESULTS

The MS group, as expected, had significantly lower California Verbal Learning Test-II (CVLT-II) z-scores from the BICAMS and higher diastolic BP (DBP) than healthy controls. DBP had statistically significant correlations with CVLT-II z-scores in the overall sample (r =  - .42) and MS subsample (r =  - .51), but not healthy controls(r =  - .29); the correlation was not attenuated when controlling for age and disability status in the MS subsample (pr =  - .48). Group initially explained 6% of the variance in z-scores from the CVLT-II (β =  - 0.24). The inclusion of DBP accounted for an additional 14% of the variance in z-scores from the CVLT-II, and DBP(β =  - 0.39), but not group (β =  - 0.13), was a significant correlate of CVLT-II z-scores; the results were unchanged when controlling for anxiety and depression scores.

CONCLUSION

Our results provide preliminary, cross-sectional support for future population-based research examining DBP, hypertension, and verbal memory in older adults with MS.

Accelerometer measured physical activity and sedentary time in individuals with multiple sclerosis versus age matched controls: A systematic review and meta-analysis

BACKGROUND

People with Multiple Sclerosis (PwMS) find it more difficult to engage in physical activity (PA) than healthy controls. Accelerometers can be used to measure sedentary time and free-living physical activity, understanding the differences between PwMS and controls can help inform changes such as interventions to promote a more active lifestyle. This in turn will help prevent secondary conditions and reduce symptom progression.

OBJECTIVE

To conduct a systematic review and meta-analysis on accelerometer measured sedentary behavior and physical activity between PwMS and healthy controls.

METHODS

A systematic search of five databases (PubMed, Web of Science, Ovid, Science Direct and CINAHIL) from inception until 22nd November 2019. Inclusion criteria was (1) included a group of participants with a definite diagnosis of multiple sclerosis of any type; (2) have 3 or more days of PA monitoring using accelerometers during free living conditions; (3) include age matched healthy controls; (4) assess adults over the age of 18; (5) reported data had to have been reported in a manner suitable for quantitative pooling including: percent of time spent sedentary, minutes per day of sedentary, light, moderate, vigorous activity (moderate and vigorous totaled together), steps per day or counts per day.

RESULTS

Initial search produced 9021 papers, after applying inclusion criteria 21 eligible papers were included in the study. One paper was a longitudinal study from which only baseline data was included. One paper was a reliability and validity study, with data for PwMS versus controls in the validity section. All other papers are cross sectional, with one being a pilot study and another a random control study. One paper used two devices in unison, only one set of data is included in the statistics. Outcome data was available for 1098 participants, 579 PwMS and 519 healthy controls. Significant differences were seen in all categories tested: (1) sedentary time (min/day), standard mean difference -0.286, P = 0.044, n = 4 studies; (2) relative sedentary time (%/day), standard mean difference -0.646, P = 0.000, n = 5 studies; (3) LPA (min/day), standard mean difference 0.337, P = 0.039, n = 5 studies; (4) relative LPA (%/day), standard mean difference 0.211, P = 0.152, n = studies; (5) MVPA (min/day), standard mean difference 0.801, P = 0.000, n = 8 studies; (6) relative MVPA (%/day), mean difference 0.914, P = 0.000, n = 5 studies; (7) step count, standard mean difference 0.894, P = 0.000, n = 8 studies; (8) activity count, standard mean difference 0.693, P = 0.000, n = 13 studies.

CONCLUSION

PwMS are more sedentary and engage in less LPA, MVPA, steps per day and accelerometer counts per day than healthy controls when measured using accelerometers during free-living conditions.

A review of current rehabilitation practices and their benefits in patients with multiple sclerosis

Multiple sclerosis (MS) is a chronic, debilitating disease characterised by demyelination of the nerves of the central nervous system that results in patients progressively losing the ability to perform daily tasks. As there is no cure for this disease, rehabilitation therapy is an important aspect of care; assisting patients to regain or retain function and improve their physical, mental and social wellbeing. At present there is no current consistent model of care for MS, likely due to the variable symptom presentation. Various forms of rehabilitation therapy are available, and these include physical rehabilitation methods, such as balance and gait therapy, speech and respiration rehabilitation, and occupational therapy. Contrary to previous understanding, exercise-based therapies have shown various benefits for patients with MS, and in addition to improving MS-related physical symptoms, have been shown to reduce the risk of developing cardiovascular disease and can improve cognitive function. Cognition rehabilitation therapy specifically focuses on behavioural tasks and is divided into two main forms: compensatory rehabilitation, which offers cognitive functioning benefits, and restorative rehabilitation, which offers memory benefits. Excitation therapies include cranial stimulation and other stimulation rehabilitation methods such as focal muscle vibration therapy and these non-invasive techniques may improve patient's physical ability. Additionally, more novel rehabilitation methods include robot-assisted gait therapy and telerehabilitation, both of which are expected to play progressively more prominent roles in the future of rehabilitation therapy. The structure of the care team has been found to impact patient outcomes, and both in- and out-patient care settings have been found to be beneficial, dependant on the patient's circumstances, with certain patients better suited to a particular setting. While a single point of care is recommended for patients, a multidisciplinary care team and regular reassessment is recommended to manage changing symptoms and ensure continuity of care. The importance of the critical components of rehabilitation have been identified, and these are of vital importance in achieving beneficial outcomes. These components include the patients' participation in the treatment, goal setting with a multidisciplinary care team, a guiding-light purpose for the patient, which focusses on recognizing their personal potential and obtaining improvements through a tailored plan. The final critical component of rehabilitation is the results measurement, which highlights the need for a quantifiable reduction in impairment and improvement in activity and participation. Overall, a lack of standardisation in outcome measurements makes comparison challenging. This is particularly important when comparing standard methods of care with more novel rehabilitation techniques. However, within the broad area of rehabilitation therapies, it is clear that patients with MS can benefit from rehabilitation practices; physically, mentally and socially.

Protective effect of berberine against LPS-induced endothelial cell injury via the JNK signaling pathway and autophagic mechanisms

The role of autophagic mechanisms in the protective effect of berberine (BBR) on lipopolysaccharide (LPS)-induced injury in the endothelial cells human umbilical vein endothelial cells (HUVECs) and human pulmonary microvascular endothelial cells (HPMECs) was investigated. Cell viability, proliferation, and apoptosis were detected by the CCK-8 assay, the EdU kit, and flow cytometry, respectively, and autophagy-related protein expression, the number of autophagic vacuoles, and LC3 double-fluorescence were examined using western blot analysis, transmission electron microscopy, and confocal microscopy, respectively. LPS resulted in a decrease in the cell viability and proliferation of HUVECs and HPMECs and an increase in the number of apoptotic cells, while BBR treatment resulted in an increase in cell viability and proliferation, as well as a decrease in cell apoptosis. Furthermore, BBR could inhibit LPS-induced autophagy, as demonstrated by its inhibitory effects on the LC3-II/LC3-I ratio and Beclin-1 levels and its promotive effect on p62 expression. Addition of the autophagy inducer rapamycin (RAPA) aggravated LPS-induced injury, while treatment with the autophagy blocker 3-methyladenine (3-MA) attenuated the injury. Further, the protective effect of BBR was inhibited by rapamycin. JNK inhibition by SP600125 inhibited LPS-induced autophagy, and BBR could not alter the LPS-induced autophagy in HUVECs and HPMECs that were pretreated with SP600125. The present data indicate that BBR attenuated LPS-induced cell apoptosis by blocking JNK-mediated autophagy in HUVECs and HPMECs. Therefore, the JNK-mediated autophagy pathway could be a potential target for the prevention and treatment of cardiovascular disease.

Psoriasis as an Immune-Mediated and Inflammatory Systemic Disease: From Pathophysiology to Novel Therapeutic Approaches

Psoriasis is an immune-mediated inflammatory disease, with a chronic relapsing-remitting course, which affects 2–3% of the worldwide population. The progressive acquisitions of the inflammatory pathways involved in the development of psoriasis have led to the identification of the key molecules of the psoriatic inflammatory cascade. At the same time, psoriasis therapy has radically evolved with the introduction of target molecules able to modify the natural history of the disease, acting specifically on these inflammatory pathways. For these reasons, biologics have been demonstrated to be drugs able to change the disease’s natural history, as they reduce the inflammatory background to avoid irreversible organ damage and prevent systemic complications. However, several issues related to the use of biologics in patients with systemic comorbidities, remain open. All these data reflect the extraordinary potentiality of biologics, but also the unmet medical need to improve our knowledge on the long-term risk related to continuous use of these drugs, and their administration in special populations. This narrative review aims to highlight both the efficacy and safety profile of biologics in psoriasis, starting from pathophysiology and moving towards their clinical application.

Impact of Body Mass Index on the Age of Relapsing-Remitting Multiple Sclerosis Onset: A Retrospective Study

A BACKROUND: Multiple sclerosis (MS) is a complex chronic disease of the central nervous system (CNS). Body mass index (BMI), a component of metabolic syndrome (MetS), is considered among the risk factors for MS. However, its role in MS remains ambiguous. OBJECTIVE: To examine the impact of BMI on the age of onset in patients with relapsing-remitting MS (RRMS) in a Greek cohort. METHODS: Data from 821 Greek patients with RRMS were collected. The BMI values were considered as quartiles. Comparisons for the demographic characteristics between the quartiles were made by Pearson’s chi-square test for the categorical variables and by ANOVA for the continuous variables. An overall p-value was calculated corresponding to trend for association. In case of significant association, further post-hoc analysis was performed in order to identify differences in demographic characteristics between specific BMI quartiles groups. Linear regression analyses were used to assess the relationship between BMI and age at onset of MS. RESULTS: Comparisons of participant characteristics by quartiles of BMI revealed that participants with the highest BMI had an older age of disease onset. Results from linear regression analysis showed that with each increase of 1 BMI unit, the age of RRMS onset increases by 0.255 (95% CI 0.136 to 0.374) years, p < 0.001. CONCLUSIONS: Patients with higher BMI, as a parameter of MetS, exhibit increased age of RRMS onset. Our results may present an alternative personalized approach for diagnosis, prognosis, and/or prevention of RRMS.

Exercise and Sports Science Australia (ESSA) position statement on exercise for people with mild to moderate multiple sclerosis

OBJECTIVES

Multiple sclerosis (MS), the most common chronic and progressive neurological condition of the central nervous system, affects 26,000 Australian adults. Exercise training has beneficial effects on MS-related impairments including reduced muscular strength, poor aerobic capacity and impaired mobility, and in consequence can improve quality of life. This Position Statement provides evidence-based recommendations for exercise prescription and delivery of exercise training for people with MS with mild to moderate disability.

DESIGN AND METHODS

Synthesis of published works within the field of exercise training in MS.

RESULTS

Exercise provides many benefits to people with MS. There is strong evidence that resistance and aerobic training, performed 2 to 3 times per week at a moderate intensity, are safe and can improve muscle strength, cardiorespiratory fitness, balance, fatigue, functional capacity, mobility and quality of life in people with MS with mild to moderate disability (Expanded Disease Severity Scale (EDSS) ≤ 6.5). However, the evidence for those with severe disability (EDSS >6.5) is less clear. The effects of exercise on MS pathogenesis, central nervous structures and other outcomes such as depression and cognitive impairment, have not been adequately investigated. Effective exercise interventions to improve balance, joint contractures and reduce falls in people with MS are also urgently needed as well as investigations of long-term (≥1 year) effects of exercise training.

CONCLUSIONS

Resistance and aerobic training exercises are effective to alleviate some characteristic signs and symptoms in MS and should be supplemented by balance exercise to prevent falls. Exercise training programs should be prescribed and delivered by qualified exercise professionals. It is important to recognise and accommodate exercise-associated complications such as fatigue and heat sensitivity.

Effect of COVID-19 home confinement on sleep monitorization and cardiac autonomic function in people with multiple sclerosis: A prospective cohort study✰,✰✰

BACKGROUND

Low sleep quality, cardiac autonomic dysfunction and poor quality of life are some of the most prevalent symptoms in people with Multiple Sclerosis (MS). In addition to the progression of the disease, these symptoms are aggravated by physical inactivity. Therefore, home confinement due to COVID-19 pandemic restrictions could further worsen these symptoms. This study aims to analyze the effect of home confinement on objective and subjective sleep quality, cardiac autonomic control based on heart rate variability (HRV), and health-related quality of life in people with MS.

METHODS

Actigraphic and subjective sleep quality (Karolinska Sleep Diary, KSD), HRV (Polar-H7), and quality of life (Multiple Sclerosis Quality of Life-54) were measured before and after 2 months of home confinement in 17 people with MS (7:10 men/women; age: 43.41±10.88 years; body mass index: 24.87±3.31 kg/m²; Expanded Disability Status Scale: 2.85±1.34 a.u.).

RESULTS

Actigraphic sleep quality (sleep efficiency: ES=1.27, p = 0.01, sleep time: ES=0.81, p = 0.01) and subjective sleep quality (sleep quality: ES=-0.34, p = 0.05), sleep comfort: ES=0.60; p = 0.03, ease of falling asleep: ES=0.70; p = 0.01, ease of waking up: ES=0.87, p<0.01, and having enough sleep: ES=0.87, p<0.01) significantly decreased after home confinement. No differences were observed in HRV or quality of life variables (p ≥ 0.13).

CONCLUSIONS

Home confinement has worsened the sleep quality, but not in cardiac autonomic control or quality of life, in people with MS. These data highlight the importance of implementing home physical training programs in this population when situations similar to home confinement occur, thus minimizing the negative effects of physical inactivity and their associated comorbidities.

Cardiovascular risk estimated in individuals with multiple sclerosis: A case-control study

BACKGROUND

Patients with multiple sclerosis (MS) had a 1.5-fold increase in cardiovascular diseases (CVD) mortality, compared with those without MS. Therefore, the aim of this study was to assess the CVD risk in MS patients by multiple cardiometabolic indexes and to investigate associated factors.

METHODS

The MS group included 57 patients matched for age and sex to 57 healthy controls. They were evaluated for physical activity, smoking, anthropometric indices, blood pressure, and plasma biomarkers. Framingham risk score (FRS) and multiple cardiovascular risk indexes were calculated. Clinical course of disease, age at onset, disease duration, disease-modifying therapy, relapse rate, EDSS, physical and functional impairment were investigated.

RESULTS

The mean age was 34.6 years old. The majority (89.5%) in the MS group had a RRMS clinical course and a mild level of disability (EDSS=1.0). WC (p = 0.022) and FM% (p = 0.007) were different between the MS and control groups. The FRS was higher in the MS group (10% versus 0%) and this was related with high prevalence of dyslipidemia (43.8% versus 36.8%). The atherogenic index of plasma (AIP) (0.013) and Castelli risk indexes I (CRI-I) (p = 0.017) and II (CRI-II) (p = 0.008) and non-HDL-C (p = 0.044) were higher in the MS group.

CONCLUSION

MS patients, with controlled disease course, have a higher cardiovascular risk than comparable healthy individuals. We emphasize that the use of FRS, and the monitoring of CRI-I and II, as well as AIP, are important lipid markers to manage CVD risk in individuals with MS.

Long-term association of red meat consumption and lipid profile: A 13-year prospective population-based cohort study

OBJECTIVES

The long-term associations between red meat consumption and lipid profile are not completely known. This longitudinal study assessed the association of red meat consumption with lipid profile in healthy Iranian adults using repeated measurements of red meat intake.

METHODS

The population-based longitudinal study was conducted within the framework of the Isfahan Cohort Study on a subsample of 1376 healthy adults, aged ≥35 y, for whom complete information was available in all three phases of the study. A simplified qualitative 48-item food frequency questionnaire, blood pressure, anthropometric measurements, and fasting serum lipids and blood sugar were evaluated in three phases. Mixed-effects linear regression was applied to examine the longitudinal associations between red meat consumption and lipid profile.

RESULTS

After adjustment for potential confounders, each single-serving increase in red meat and organ meat consumption was significantly associated with an increment in triacylglycerol (β = 6.30; 95% confidence interval [CI], 3.97-8.63), total cholesterol (β = 3.03; 95% CI, 2.02-4.04), low-density lipoprotein (β = 3.40; 95% CI, 2.64-4.17), high-density lipoprotein (β = 0.60; 95% CI, 0.28-0.93), ratio of low-density to high-density lipoprotein (β = 0.03; 95% CI, 0.01-0.05), and non-high-density lipoprotein (β = 2.42; 95% CI, 1.41-3.43). However, processed meat consumption had no significant association with lipid profile.

CONCLUSIONS

Total red meat intake had a significant, direct association with lipid profile after a 13-year follow-up period in a cohort of the healthy Iranian population.

Risk of Psychiatric Disorders in Multiple Sclerosis: A Nationwide Cohort Study in an Asian Population

BACKGROUND

Multiple sclerosis (MS) is a demyelinating disease that can damage neurons in the brain and spinal cord and is associated with several psychiatric disorders. However, few studies have evaluated the risk of psychiatric disorders in patients with MS by using a nationwide database. This study investigated the association between MS and the risk of psychiatric disorders.

METHODS

Using data from the Taiwan National Health Insurance Research Database from 2000 to 2015, we identified 1066 patients with MS. After adjustment for confounding factors, Fine and Gray's competing risk model was used to compare the risk of psychiatric disorders during 15 years of follow-up.

RESULTS

Of the patients with MS, 531 (4622.86 per 10⁵ person years) developed psychiatric disorders; by contrast, 891 of the 3198 controls (2485.31 per 10⁵ person years) developed psychiatric disorders. Fine and Gray's competing risk model revealed an adjusted hazard ratio (HR) of 5.044 (95% confidence interval = 4.448-5.870, p < 0.001) after adjustment for all the covariates. MS was associated with depression, anxiety, bipolar disorder, sleep disorders, schizophrenia, schizophreniform disorder, and other psychotic disorders (adjusted HR: 12.464, 4.650, 6.987, 9.103, 2.552, 2.600, 2.441, and 2.574, respectively; all p < 0.001). Some disease-modifying drugs were associated with a lower risk of anxiety or depression.

CONCLUSION

Patients with MS were determined to have a higher risk of developing a wide range of psychiatric disorders.

PD-1 Blockade Reverses Obesity-Mediated T Cell Priming Impairment

Despite obesity reaching pandemic proportions, its impact on antigen-specific T cell responses is still unclear. We have recently demonstrated that obesity results in increased expression of PD-1 on T cells, and checkpoint blockade targeting PD-1/PD-L1 surprisingly resulted in greater clinical efficacy in cancer therapy. Adverse events associated with this therapy center around autoimmune reactions. In this study, we examined the impact of obesity on T cell priming and on autoimmune pathogenesis using the mouse model experimental autoimmune encephalomyelitis (EAE), which is mediated by autoreactive myelin-specific T cells generated after immunization. We observed that diet-induced obese (DIO) mice had a markedly delayed EAE onset and developed milder clinical symptoms compared to mice on control diet (CD). This delay was associated with impaired generation of myelin-specific T cell numbers and concurrently correlated with increased PD-L1 upregulation on antigen-presenting cells in secondary lymphoid organs. PD-1 blockade during the priming stage of EAE restored disease onset and severity and increased numbers of pathogenic CD4+ T cells in the central nervous system (CNS) of DIO mice to similar levels to those of CD mice. Administration of anti-PD-1 after onset of clinical symptoms did not increase EAE pathogenesis demonstrating that initial priming is the critical juncture affected by obesity. These findings demonstrate that obesity impairs antigen-specific T cell priming, but this can be reversed with PD-1 blockade. Our results further suggest that PD-1 blockade may increase the risk of autoimmune toxicities, particularly in obesity.

Non-infectious comorbidity in patients with multiple sclerosis: A national cohort study in Sweden

Background

Comorbidity is of significant concern in multiple sclerosis (MS). Few population-based studies have reported conditions occurring in MS after diagnosis, especially in contemporary cohorts.

Objective

To explore incident comorbidity, mortality and hospitalizations in MS, stratified by age and sex.

Methods

In a Swedish population-based cohort study 6602 incident MS patients (aged ≥18 years) and 61,828 matched MS-free individuals were identified between 1 January 2008 and 31 December 2016, using national registers. Incidence rates (IRs) and incidence rate ratios (IRRs) with 95% CI were calculated for each outcome.

Results

IRs of cardiovascular disease (CVD) were higher among MS patients than MS-free individuals, (major adverse CVD: IRR 1.42; 95% CI 1.12–1.82; hemorrhagic/ischemic stroke: 1.46; 1.05–2.02; transient ischemic attack: 1.65; 1.09–2.50; heart failure: 1.55; 1.15–2.10); venous thromboembolism: 1.42; 1.14–1.77). MS patients also had higher risks of several non-CVDs such as autoimmune conditions (IRR 3.83; 3.01–4.87), bowel dysfunction (2.16; 1.86–2.50), depression (2.38; 2.11–2.68), and fractures (1.32; 1.19–1.47), as well as being hospitalized and to suffer from CVD-related deaths ((1.91; 1.00–3.65), particularly in females (3.57; 1.58–8.06)).

Conclusion

MS-patients experience a notable comorbidity burden which emphasizes the need for integrated disease management in order to improve patient care and long-term outcomes of MS.

Neuroprotective effects of exercise in people with progressive multiple sclerosis (Exercise PRO-MS): study protocol of a phase II trial

Background

Neurodegeneration, rather than inflammation, plays a key role in the progressive phase of multiple sclerosis (MS). Current disease modifying treatment options for people with progressive MS (PMS) do not specifically target neurodegeneration. Preliminary evidence suggests that exercise therapy might have neuroprotective effects. However, neuroprotective effect studies of exercise interventions in PMS are scarce and the possible mode of action underlying neuroprotective effects of exercise are unknown and need to be elucidated. The main aim of this phase II trial is to assess whether progressive resistance training (PRT) and high intensity interval training (HIIT), can slow down neurodegeneration in people with PMS.

Methods

In a single-blinded phase II clinical trial with an extended baseline period, 60 people with PMS will be randomly assigned to PRT or HIIT. The participants should have had a relapse onset of MS with confirmed disease progression, however still ambulatory. The duration of the study is 48 weeks, consisting of 16 weeks baseline period (no intervention), 16 weeks intervention and 16 weeks follow-up. Patient-tailored training will be performed 3 times per week for one hour in groups, led by an experienced physiotherapist. The primary outcome measure is neurodegeneration, measured as whole brain atrophy on magnetic resonance imaging (MRI). Secondary outcome parameters will include other biomarkers associated with neurodegeneration (i.e. regional brain atrophy, lesion load, white matter integrity, resting state functional connectivity, blood biomarkers (brain derived neurotrophic factor (BDNF) and serum neurofilament light (sNFL)), patient functioning (physical and cognitive) and cardiovascular risk factors.

Discussion

Besides the primary outcome measures, this study will examine a large variety of biomarkers associated with neurodegeneration after an exercise intervention. Combining outcome parameters may help to elucidate the mode of action underlying neuroprotective effects of exercise.

Trial registration

This trial is prospectively registered at the Dutch Trial Registry (number NL8265, date 06-01-2020).

Germ-Free Swiss Webster Mice on a High-Fat Diet Develop Obesity, Hyperglycemia, and Dyslipidemia

A calorie-dense diet is a well-established risk factor for obesity and metabolic syndrome (MetS), whereas the role of the intestinal microbiota (IMB) in the development of diet-induced obesity (DIO) is not completely understood. To test the hypothesis that Swiss Webster (Tac:SW) mice can develop characteristics of DIO and MetS in the absence of the IMB, we fed conventional (CV) and germ-free (GF) male Tac:SW mice either a low-fat diet (LFD; 10% fat derived calories) or a high-fat diet (HFD; 60% fat derived calories) for 10 weeks. The HFD increased feed conversion and body weight in GF mice independent of the increase associated with the microbiota in CV mice. In contrast to CV mice, GF mice did not decrease feed intake on the HFD and possessed heavier fat pads. The HFD caused hyperglycemia, hyperinsulinemia, and impaired glucose absorption in GF mice independent of the increase associated with the microbiota in CV mice. A HFD also elevated plasma LDL-cholesterol and increased hepatic triacylglycerol, free fatty acids, and ceramides in all mice, whereas hypertriglyceridemia and increased hepatic medium and long-chain acylcarnitines were only observed in CV mice. Therefore, GF male Tac:SW mice developed several detrimental effects of obesity and MetS from a high-fat, calorie dense diet.

Lipoprotein profiling in early multiple sclerosis patients: effect of chronic inflammation?

Background

Inflammatory cytokines contribute to proatherogenic changes in lipid metabolism by reduction of HDL-cholesterol (HDL-C) levels, impairment of its antiinflammatory and antioxidant functions. Therefore, the protective actions of HDL-C can be limited in chronic inflammatory diseases such as multiple sclerosis (MS). The aim of this study was to assess the association between lipoprotein subfractions and inflammatory status in early stages of multiple sclerosis.

Methods

Polyacrylamide gel electrophoresis Lipoprint© System was used for lipoprotein profile analysis in 19 newly diagnosed MS patients, and in matched 19 healthy controls. Serum levels of interleukin (IL) 1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12 (p70), IL-13, IL-17, granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor, interferon-γ and TNF-α were measured by multiplex bead assay.

Results

Concentrations of the measured cytokines and lipoprotein subclasses were comparable between MS patients and controls. Male, but not female MS patients had significantly higher total HDL-C and small HDL-C subfraction than healthy controls. Large HDL-C negatively correlated with all measured cytokines except IL-17 in MS but not in controls. Intermediate HDL-C subfractions correlated positively with all measured cytokines except G-CSF in MS females but not in MS males or controls.

Conclusion

Our results of higher HDL-C and mainly its small HDL-C subfraction suggest that male MS patients are at higher risk of atherosclerosis and the subtle dyslipidemia is present in early stages of the disease. The correlations between specific HDL-C subfractions and the inflammatory cytokines demonstrate mutual links between systemic inflammation and lipid metabolism in MS.

Trial registration

ClinicalTrials.gov, Identifier: NCT 03052595 Registered on Feb 14, 2017.

[Comorbid pathology of the cardiovascular system in young patients with relapsing-remitting multiple sclerosis]

AIM

To study the state of the cardiovascular system and peripheral microcirculation in young patients with relapsing-remitting multiple sclerosis (MS).

MATERIAL AND METHODS

The study included 45 MS patients (17 men and 28 women, age 28 [24; 32] years, disease duration 5.5 [2; 7] years). The control group included healthy controls (age 30 [25; 33] years). Neurological and cardiologic examinations included 24-hour Holter ECG monitoring and 24-hour blood pressure monitoring with determination of the daily arterial vascular stiffness, echocardiography, laser doppler flowmetry followed by an occlusive test to assess the state of microvasculation, levels of serum vascular cellular adhesion molecule-1 (VCAM-1).

RESULTS

In MS group, the results of 24-hour blood pressure monitoring showed that the variability of systolic blood pressure and diastolic blood pressure during daytime hours was reduced compared to the control group (p<0.026 and p<0.002, respectively). The indicators of daily arterial stiffness in MS group were significantly increased (p<0.001). According to the results of Holter ECG monitoring, no heart rhythm disorder was detected in both groups, except an increase in the number of supraventricular extrasystoles in MS patients compared to the control group (p<0.005). There were no between group differences in echocardiography indicators. The level of VCAM-1 was significantly increased in MS group compared to controls (p<0.001).

CONCLUSION

Young MS patients are at risk of cardiovascular diseases associated with the variability of blood pressure and indexes of daily arterial vascular stiffness.

The Association between Body Mass Index and Leisure-Time Physical Activity in Adults with Multiple Sclerosis

(1) Purpose: Conflicting information exists regarding the relationship between obesity, leisure-time physical activity (PA), and disability in people with multiple sclerosis (PwMS). We aimed to investigate the association between leisure-time PA and weight status in a relatively large cohort of PwMS. Furthermore, we examined this relationship according to the level of neurological disability. (2) Methods: The study included 238 PwMS (138 women) with a mean Expanded Disability Status Scale (EDSS) score of 2.5 (standard deviation [SD] = 1.7), mean disease duration of 6.4 (SD = 8.2) years, and mean age of 40.5 (SD = 12.9) years. Obesity was defined using two different metrics, each based on body mass index (BMI). Leisure-time PA was determined by the Godin-Shephard leisure-time PA questionnaire. Statistical analyses included multivariate logistic regression, the chi-square test, and Pearson coefficient correlations. (3) Results: The unadjusted odds ratio (OR) between leisure-time PA and BMI based on the World Health Organization's (WHO) definition was 1.070 (p = 0.844) for overweight and 1.648 (p = 0.254) for obesity. The adjusted OR was 1.126 (p = 0.763) for overweight and 1.093 (p = 0.847) for obesity after adjustment for age, gender, and disability status. Chi-square analysis revealed no significant correlation between leisure-time PA and obesity (p = 0.564) according to the BMI threshold for PwMS. The unadjusted OR (95% confidence interval [CI]) between disability level and BMI based on the WHO definition was 1.674 (p = 0.220) for overweight and 0.618 (p = 0.460) for obesity. The adjusted OR was 1.130 (p = 0.787) for overweight and 0.447 (p = 0.234) for obesity after adjustment for age, gender, and leisure-time PA. Similarly, chi-square analysis revealed no significant correlation between disability level and obesity (p = 0.701) per the BMI threshold for PwMS. (4) Conclusions: No association was found between leisure-time PA and BMI in PwMS. An additional finding was the absence of any association between obesity and neurological disability level in the multiple sclerosis cohort.

Impact of insulin resistance and metabolic syndrome on disability in patients with multiple sclerosis

Background

Currently, little is known regarding the association of metabolic comorbidities and disability among multiple sclerosis (MS) patients.

Objectives

To evaluate insulin resistance (IR) and metabolic syndrome (MetS) in multiple sclerosis patients and their effect on disease progression and disability.

Subjects and methods

This case-control study was conducted on 50 MS patients and 25 healthy individuals. They were subjected to clinical evaluation and laboratory assessment for metabolic syndrome and insulin resistance. The homeostasis model assessment (HOMA) was used as a measurement of insulin sensitivity. Disability was evaluated by the Extended Disability Status Scale (EDSS).

Results

As compared to control group, MS patients had a significantly higher prevalence of metabolic syndrome (22% vs 8%, p = 0.04) and insulin resistance (46% vs 0%, p < 0.001). Patients group had significantly higher systolic blood pressure (p = 0.005), waist circumference (p < 0.001), fasting blood sugar (p < 0.001), insulin level (p = 0.001), low-density lipoproteins (p = 0.01), triglycerides (p = 0.02), HOMA-IR (p < 0.001), and significantly lower high-density lipoproteins (p = 0.01). No differences in neurological disability was reported between patients who have MetS (p = 0.7) or IR (p = 0.3) and those who do not.

Conclusion

Insulin resistance and metabolic syndrome are more prevalent among MS patients; however, their association with disability and disease progression is questionable.

Randomized controlled trial of SystemCHANGE™ weight management intervention in neurological conditions

OBJECTIVE

This randomized controlled pilot study examined the feasibility and efficacy of a SystemCHANGE™ (SC) weight management intervention in adults with either multiple sclerosis or stroke.

METHODS

Participants (n = 61) were randomized into two interventions: SC, which taught skills to modify personal environments, or active-control (AC), which taught health behavior guidelines. Sessions were held weekly for 12 weeks. Feasibility measures included recruitment and attrition rates. The primary outcome of body weight and secondary outcomes of emotional well-being and healthy behaviors were measured before and after the interventions.

RESULTS

Average recruitment rate was 3.6 participants per month. Attrition rate was 14.8%. On average, 9.1 sessions were completed for SC and 10.7 for AC. Differences in weight loss were non-significant between interventions (P = 0.182), but significantly declined across both interventions (P = 0.011). Physical activity (P = 0.002), depression (P < 0.001), anxiety (P = 0.023), and self-efficacy (P = 0.022) all significantly improved for SC compared to AC.

CONCLUSIONS

SC was feasible to implement and efficacious in improving secondary outcomes of emotional well-being and healthy behaviors, but was not efficacious in improving the primary outcome of weight loss. More research is needed to optimize SC.

PRACTICE IMPLICATIONS

SC might be an alternative approach to cognitive-behavioral therapy for promoting emotional well-being and healthy behaviors.

Ecological validity of walking capacity tests following rehabilitation in people with multiple sclerosis

Background

Walking capacity tests are commonly used to evaluate interventions aiming at reducing walking impairment in people with multiple sclerosis (pwMS). However, their ecological validity has recently been questioned. The aim of the present study was to investigate the ecological validity of the 2- and 6-minutes walking tests (2MWT and 6MWT) and the timed 25-foot walk (T25FW) after 28 days of multidisciplinary inpatient rehabilitation (MIR) in pwMS using accelerometry.

Methods

PwMS wore an accelerometer on 7 consecutive days within a 14-day period prior to MIR, performed 2/6MWT and T25FW at the beginning and at the end of MIR, followed by another 7 consecutive days of accelerometry.

Results

Significant improvements in 2/6MWT and T25FW after MIR in a cohort of 76 pwMS (mean age = 47.9, SD 8.3 years) were overall correlated to a significant gain in everyday life mobility (total steps/day). However, the correlation was strongly dependent on pre-existing walking disability defined by EDSS and only pwMS with “mild” walking impairment (EDSS 2–3.5) were able to transfer benefits measurable by walking capacity tests into improved everyday life mobility, while pwMS with “moderate to severe” walking disability (EDSS 4–6.5) were not.

Conclusion

Ecological validity of changes in walking capacity tests following MIR is strongly dependent on pre-existing walking impairment.

Impact of Metabolic Syndrome on Neuroinflammation and the Blood-Brain Barrier

Metabolic syndrome, which includes diabetes and obesity, is one of the most widespread medical conditions. It induces systemic inflammation, causing far reaching effects on the body that are still being uncovered. Neuropathologies triggered by metabolic syndrome often result from increased permeability of the blood-brain-barrier (BBB). The BBB, a system designed to restrict entry of toxins, immune cells, and pathogens to the brain, is vital for proper neuronal function. Local and systemic inflammation induced by obesity or type 2 diabetes mellitus can cause BBB breakdown, decreased removal of waste, and increased infiltration of immune cells. This leads to disruption of glial and neuronal cells, causing hormonal dysregulation, increased immune sensitivity, or cognitive impairment depending on the affected brain region. Inflammatory effects of metabolic syndrome have been linked to neurodegenerative diseases. In this review, we discuss the effects of obesity and diabetes-induced inflammation on the BBB, the roles played by leptin and insulin resistance, as well as BBB changes occurring at the molecular level. We explore signaling pathways including VEGF, HIFs, PKC, Rho/ROCK, eNOS, and miRNAs. Finally, we discuss the broader implications of neural inflammation, including its connection to Alzheimer's disease, multiple sclerosis, and the gut microbiome.

Evaluation the FLAIR Sensitivity and DWI Post-inject in Comparison with Delayed Enhancement T1w for Better Detection of Active MS Lesions

BACKGROUND

Multiple sclerosis (MS) is a chronic, typically progressive and most common autoimmune disease which damaged the central nervous system. According to the reports in 2008, this disorder has affected 2 and 2.5 million people globally. While the reason is not clear, proposed causes for this include immunologic, environmental, infectious and genetic factors, and sexuality. MS can cause many symptoms, including blurred vision, loss of balance, poor coordination, slurred speech, tremors, numbness, extreme fatigue, problems with memory and concentration, paralysis, blindness, and more. There are four distinguished illness fields in MS: relapsing-remitting MS (RRMS), primary-progressive MS (PPMS), secondary-progressive MS (SPMS), and progressive-relapsing. MRI is a great tool to identify the asymptomatic distribution of lesions in space and time.

MATERIALS AND METHODS

32 patients with MS plaques were evaluated by FLAIR and DWI pre- and post-Gadolinium injection compared with 15minutes delay T1w SE.

RESULTS

FLAIR post-inject had significantly better detection of the number and signal intensity of active MS lesions. DWI and ADC images detected active plaques different from non-active lesions without contrast.

CONCLUSION

The result of this study showed that FLAIR post-inject had the highest sensitivity in detection of active MS lesions due to the CSF signal suppression in FLAIR, thus offering enough TR time recovery in active enhanced plaques.

The effectiveness of interventions targeting physical activity and/or sedentary behaviour in people with Multiple Sclerosis: a systematic review

Background: Remaining physically active is important to maintain functional ability and reduce the incidence of co-morbidities in people with Multiple Sclerosis. The aim of this review was to evaluate the effectiveness of interventions on physical activity or sedentary behaviour in people with Multiple Sclerosis.Methods: A systematic search was conducted in May 2018 of the following databases: Web of Science Core Collections, Embase and Medline. Included studies were randomised controlled trials involving people with Multiple Sclerosis who completed an intervention, compared to any comparator. Outcomes included subjective or objective measures of physical activity or sedentary behaviour. Quality assessment was performed using the Physiotherapy Evidence Database scale.Results: Twenty-five trials were included covering 1697 participants, the majority of which had mild-moderate disability (average Physiotherapy Evidence Database score 6.2 ± 1.5). Experimental interventions included exercise prescription (n = 5), behaviour change interventions (n = 10), combined exercise, and behaviour change techniques (n = 7) and education (n = 3). Generally, subjective but not objective physical activity improved in those with mild-moderate disability. Insufficient data existed on the effectiveness on sedentary behaviour.Conclusions: A discrepancy seems to exists between the effectiveness of physical activity interventions in people with Multiple Sclerosis depending on whether physical activity was assessed objectively or subjectively, with the latter indicating effects. Effects on sedentary behaviour remain to be elucidated.Implications for RehabilitationRemaining physically active is important to maintain functional ability, independence, quality of life, and to reduce the incidence of co-morbidity.Exercise prescription, behaviour change interventions, combined exercise and behaviour change interventions, and health promotion education appear to subjectively improve physical activity in people with Multiple Sclerosis with mild-moderate disability, yet this is often not the case when measured objectively.There is a lack of evidence to support the effectiveness of these interventions on sedentary behaviour.

Ketogenic diets attenuate cyclooxygenase and lipoxygenase gene expression in multiple sclerosis

Background

Adapted ketogenic diet (AKD) and caloric restriction (CR) have been suggested as alternative therapeutic strategies for inflammatory, hyperproliferative and neurodegenerative diseases. Pro-inflammatory eicosanoids have been implicated in the pathogenesis of multiple sclerosis since they augment vascular permeability and induce leukocyte migration into the brain. We explored the impact of ketogenic diets on gene expression of biosynthetic enzymes for pro- (ALOX5, COX1, COX2) and anti-inflammatory (ALOX15) eicosanoids in patients with relapsing-remitting multiple sclerosis.

Methods

60 adults were prospectively recruited for this six months randomized controlled trial and the impact of dietary treatment on the Multiple Sclerosis Quality of Life-54 index (ClinicalTrials.gov (NCT01538355) has previously been published. Here we explored 24 patients (8 controls, 5 on CR and 11 on AKD). For statistical analysis we combined the two diet groups to a single pooled treatment group.

Findings

Inter-group comparison indicated that expression of the pro-inflammatory ALOX5 in the pooled treatment group was significantly (p < 0.05) reduced when compared with the control group. Moreover, intra-group comparison (same individuals before and after dietary treatment) suggested significantly impaired expression of other pro-inflammatory enzymes, such as COX1 (p < 0.001) and COX2 (p < 0.05). Finally, pretreatment cross-group analysis revealed a significant positive correlation between expression of pro-inflammatory ALOX5 and COX2 and an inverse correlation of ALOX5 and COX1 expression with the MSQoL-54 index.

Interpretation

Ketogenic diets can reduce the expression of enzymes involved in the biosynthesis of pro-inflammatory eicosanoids. Pharmacological interference with eicosanoid biosynthesis might constitute a strategy supplementing current therapeutic approaches for MS.

[The risk of ischemic stroke in patients with multiple sclerosis]

A brief literature review on risk factors of ischemic stroke in patients with multiple sclerosis (MS) is presented. A case of ischemic stroke in a MS patient was demonstrated, and risk factors were identified.

LDL and HDL lipoprotein subfractions in multiple sclerosis patients with decreased insulin sensitivity

Objectives. Increased metabolic and cardiovascular morbidity has been reported in multiple sclerosis (MS) patients. Previously, we have found decreased insulin sensitivity and hyperinsulinemia in a group of newly diagnosed MS patients. We hypothesize that these features may be associated with an altered lipid profile and low, intermediate, or high density lipoprotein (LDL, IDL, HDL) subclasses accelerating atherosclerosis and thus contributing to the cardiovascular risk increase in these patients.

Subjects and methods. In a group of 19 newly diagnosed untreated MS patients with previously found hyperinsulinemia and insulin resistance and a matched group of 19 healthy controls, the lipoprotein subclasses profile was determined. Polyacrylamide gel electrophoresis was used to separate and measure the LDL (large LDL and small dense LDL), HDL (large, intermediate and small), and IDL (A, B and C) subclasses with the Lipoprint© System (Quantimetrix Corporation, Redondo Beach, CA, USA).

Results. No difference was found either in the conventional lipid or lipoprotein subclasses profile between the MS patients and healthy controls. We found an inverse association between the level of IDL-B with fasting insulin (r=–0.504, p=0.032), the insulin resistance estimated by homeo-static model assessment – insulin resistance (HOMA-IR) (r=–0.498, p=0.035), insulin response expressed as area under the curve (AUC; r=–0.519, p=0.027), and area above the baseline (AAB; r=–0.476, p=0.045) and positive association with insulin sensitivity estimated by insulin sensitivity index (ISI) Matsuda (r=0.470, 0.048) in MS patients, but not in healthy controls suggesting the first signs in lipoprotein subclasses profile change.

Conclusions. Our data indicate that changes in lipoprotein profile and subclasses are preceded by insulin resistance and hyperinsulinemia in patients with newly diagnosed MS.

High intensity interval training for people with multiple sclerosis: A systematic review

BACKGROUND

Aerobic high intensity interval training (HIIT) is safe in the general population and more efficient in improving fitness than continuous moderate intensity training. The body of literature examining HIIT in multiple sclerosis (MS) is expanding but to date a systematic review has not been conducted. The aim of this review was to investigate the efficacy and safety of HIIT in people with MS.

METHODS

A systematic search was carried out in September 2017 in EMBASE, MEDline, PEDro, CENTRAL and Web of Science Core collections using appropriate keywords and MeSH descriptors. Reference lists of relevant articles were also searched. Articles were eligible for inclusion if they were published in English, used HIIT, and included participants with MS. Quality was assessed using the PEDro scale. The following data were extracted using a standardised form: study design and characteristics, outcome measures, significant results, drop-outs, and adverse events.

RESULTS

Seven studies (described by 11 articles) were identified: four randomised controlled trials, one randomised cross-over trial and two cohort studies. PEDro scores ranged from 3 to 8. Included participants (n = 249) were predominantly mildly disabled; one study included only people with progressive MS. Six studies used cycle ergometry and one used arm ergometry to deliver HIIT. One study reported six adverse events, four which could be attributed to the intervention. The other six reported that there were no adverse events. Six studies reported improvements in at least one outcome measure, however there were 60 different outcome measures in the seven studies. The most commonly measured domain was fitness, which improved in five of the six studies measuring aspects of fitness. The only trial not to report positive results included people with progressive and a more severe level of disability (Extended Disability Status Scale 6.0-8.0).

CONCLUSION

HIIT appears to be safe and effective in increasing fitness in people with MS and low levels of disability. Further research is required to explore the effectiveness of HIIT in people with progressive MS and in those with higher levels of disability.

Systemic Inflammation and Cardiovascular Comorbidity in Psoriasis Patients: Causes and Consequences

Psoriasis is a common inflammatory skin disease characterized by the appearance of red scaly plaques that can affect any part of the body. High prevalence, chronicity, disfiguration, disability, and associated comorbidity make it a challenge for clinicians of multiple specialties. Likewise, its complex pathogenesis, comprising inflammation, hyperproliferation, and angioneogenesis, intrigues numerous scientific disciplines, namely, immunology. From a clinical perspective, the severity of psoriasis is highlighted by its increased mortality, with cardiovascular diseases contributing the highest excess risk. From a scientific point of view, psoriasis has to be considered a systemic inflammatory condition, as blood biomarkers of inflammation are elevated and imaging techniques document sites of inflammation beyond the skin. While the association of psoriasis with cardiovascular diseases is now widely accepted, causes and consequences of this association are controversially discussed. This review comments on epidemiologic, genetic, and mechanistic studies that analyzed the relation between psoriasis and cardiovascular comorbidity. The hypothesis of psoriasis potentially being an independent cardiovascular risk factor, driving atherosclerosis via inflammation-induced endothelial dysfunction, will be discussed. Finally, consequences for the management of psoriasis with the objective to reduce the patients’ excess cardiovascular risk will be pointed out.

Sleep-Disordered Breathing in People with Multiple Sclerosis: Prevalence, Pathophysiological Mechanisms, and Disease Consequences

Sleep problems are common in people with multiple sclerosis (MS). Reported prevalence rates of sleep-disordered breathing (SDB) vary between 0 and 87%. Differences in recruitment procedures and study designs likely contribute to the wide variance in reported prevalence rates of SBD in MS. This can make attempts to compare SDB rates in people with MS to the general population challenging. Little is known about the pathophysiological mechanisms that contribute to SDB in people with MS or whether MS contributes to SDB disease progression. However, compared to the general obstructive sleep apnea (OSA) population, there are clear differences in the clinical phenotypes of SDB in the MS population. For instance they are typically not obese and rates of SDB are often comparable or higher to the general population, despite the high female predominance of MS. Thus, the risk factors and pathophysiological causes of SDB in people with MS are likely to be different compared to people with OSA who do not have MS. There may be important bidirectional relationships between SDB and MS. Demyelinating lesions of MS in the brain stem and spinal cord could influence breathing control and upper airway muscle activity to cause SDB. Intermittent hypoxia caused by apneas during the night can increase oxidative stress and may worsen neurodegeneration in people with MS. In addition, inflammation and changes in cytokine levels may play a key role in the relationship between SDB and MS and their shared consequences. Indeed, fatigue, neurocognitive dysfunction, and depression may worsen considerably if both disorders coexist. Recent studies indicate that treatment of SDB in people with MS with conventional first-line therapy, continuous positive airway pressure therapy, can reduce fatigue and cognitive impairment. However, if the causes of SDB differ in people with MS, so too may the optimal therapy. Thus, many questions remain concerning the relationship between these two disorders and the underlying mechanisms and shared consequences. Improved understanding of these factors has the potential to unlock new therapeutic targets.

Effects of an individual 12-week community-located “start-to-run” program on physical capacity, walking, fatigue, cognitive function, brain volumes, and structures in persons with multiple sclerosis

Background:

Exercise therapy studies in persons with multiple sclerosis (pwMS) primarily focused on motor outcomes in mid disease stage, while cognitive function and neural correlates were only limitedly addressed.

Objectives:

This pragmatic randomized controlled study investigated the effects of a remotely supervised community-located “start-to-run” program on physical and cognitive function, fatigue, quality of life, brain volume, and connectivity.

Method:

In all, 42 pwMS were randomized to either experimental (EXP) or waiting list control (WLC) group. The EXP group received individualized training instructions during 12 weeks (3×/week), to be performed in their community aiming to participate in a running event. Measures were physical (VO2max, sit-to-stand test, Six-Minute Walk Test (6MWT), Multiple Sclerosis Walking Scale-12 (MSWS-12)) and cognitive function (Rao’s Brief Repeatable Battery (BRB), Paced Auditory Serial Attention Test (PASAT)), fatigue (Fatigue Scale for Motor and Cognitive Function (FSMC)), quality of life (Multiple Sclerosis Impact Scale-29 (MSIS-29)), and imaging. Brain volumes and diffusion tensor imaging (DTI) were quantified using FSL-SIENA/FIRST and FSL-TBSS.

Results:

In all, 35 pwMS completed the trial. Interaction effects in favor of the EXP group were found for VO2max, sit-to-stand test, MSWS-12, Spatial Recall Test, FSMC, MSIS-29, and pallidum volume. VO2max improved by 1.5 mL/kg/min, MSWS-12 by 4, FSMC by 11, and MSIS-29 by 14 points. The Spatial Recall Test improved by more than 10%.

Conclusion:

Community-located run training improved aerobic capacity, functional mobility, visuospatial memory, fatigue, and quality of life and pallidum volume in pwMS.

Exercise therapy in multiple sclerosis and its effects on function and the brain

Exercise therapy is a promising nonpharmacological therapy in people with multiple sclerosis (MS). Although exercise training may induce a transient worsening of symptoms in some MS patients, it is generally considered safe and does not increase the risk of relapses. Exercise training can lead to clinically relevant improvements in physical function, but should be considered an adjunct to specific task-based training. Exercise has also shown positive effects on the brain, including improvements in brain volume and cognition. In summary, exercise therapy is a safe and potent nonpharmacological intervention in MS, with beneficial effects on both functional capacity and the brain.