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Leon Betancourt A, Hoepner R, Hammer H, Chan A, Salmen A. Sex- and age-related shift of relapse phenotypes in a cohort of relapsing multiple sclerosis patients: Post hoc analysis from the OPERA phase 3 trials. Eur J Neurol 2024; 31:e16396. [PMID: 38925580 DOI: 10.1111/ene.16396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/01/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND AND PURPOSE Relapse presentation in relapsing multiple sclerosis (RMS) differs between sexes, leading to differential outcomes. An influence of age seems likely but is less well investigated separately for women and men. METHODS Using the large well-defined dataset of the pivotal trials of ocrelizumab in RMS, OPERA I and II, and their open-label extension, we performed a post hoc analysis to investigate relapse phenotypes for sex- and age-related differences in n = 929 relapses in 534 subjects (171 men, 363 women). Frequencies of affected functional systems were analyzed separated by sex and for three age strata (<35, 35-44, ≥45 years). Exact p-values are given for this exploratory analysis. RESULTS Frequencies of mono- versus polysymptomatic relapse presentations were different neither between sexes nor in different age groups. Cerebellar symptoms were more frequent in relapses in men (female [f]: 23.1%, male [m]: 33.0%, p = 0.002), and women's relapses included more sensory (f: 53.8%, m: 32.3%, p < 0.001) and fatigue symptoms (f: 22.6%, m: 14.7%, p = 0.006). Whereas the sex difference for sensory involvement was present over all age groups (<35 years: f: 58.3%, m: 30.4%, p < 0.001; 35-44 years: f: 53.7%, m: 36.0%, p = 0.003; ≥45 years: f: 47.8%, m: 28.8%, p = 0.009), the difference for cerebellar involvement diminished with age (<35 years: f: 20.1%, m: 33.3%, p = 0.009; 35-44 years: f: 22.7%, m: 34.2%, p = 0.034; ≥45 years: f: 27.8%, m: 30.3%, p = 0.750). Relapse presentation seemed to shift with age in women only. CONCLUSIONS We describe sex-specific relapse presentations and an influence of age only for women. Underlying causal factors warrant further investigations.
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Affiliation(s)
- A Leon Betancourt
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Helly Hammer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Mallucci G, Ferraro OE, Trojano M, Amato MP, Scalfari A, Zaffaroni M, Colombo E, Rigoni E, Iaffaldano P, Portaccio E, Saraceno L, Paolicelli D, Razzolini L, Montomoli C, Bergamaschi R. Early prediction of unfavorable evolution after a first clinical episode suggestive of multiple sclerosis: the EUMUS score. J Neurol 2024; 271:3496-3505. [PMID: 38532143 DOI: 10.1007/s00415-024-12304-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Predicting disease progression in patients with the first clinical episode suggestive of multiple sclerosis (MS) is crucial for personalized therapeutic approaches. This study aimed to develop the EUMUS score for accurately estimating the risk of early evidence of disease activity and progression (EDA). METHODS Retrospective analysis was conducted on data from 221 patients with a first clinical MS episode collected from four Italian MS centers. Various variables including socio-demographics, clinical features, cerebrospinal fluid analysis, evoked potentials, and brain MRI were considered. A prognostic multivariate regression model was identified to develop the EUMUS score. The optimal cutoff for predicting the transition from no evidence of disease activity (NEDA3) to EDA was determined. The accuracy of the prognostic model and score were tested in a separate UK MS cohort. RESULTS After 12 months, 61.54% of patients experienced relapses and/or new MRI lesions. Younger age (OR 0.96, CI 0.93-0.99; p = 0.005), MRI infratentorial lesion(s) at baseline (OR 2.21, CI 1.27-3.87; p = 0.005), positive oligoclonal bands (OR 2.89, CI 1.47-5.69; p = 0.002), and abnormal lower limb somatosensory-evoked potentials (OR 2.77, CI 1.41-5.42; p = 0.003) were significantly associated with increased risk of EDA. The EUMUS score demonstrated good specificity (72%) and correctly classified 80% of patients with EDA in the independent UK cohort. CONCLUSIONS The EUMUS score is a simple and useful tool for predicting MS evolution within 12 months of the first clinical episode. It has the potential to guide personalized therapeutic approaches and aid in clinical decision-making.
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Affiliation(s)
- Giulia Mallucci
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland.
| | - Ottavia Eleonora Ferraro
- Department of Public Health, Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
| | - Maria Trojano
- Department of Translational Biomedicines and Neurosciences University of Bari, A. Moro, Bari, Italy
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Antonio Scalfari
- Centre of Neuroscience, Department of Medicine, Imperial College London, Charing Cross Hospital, London, UK
| | - Mauro Zaffaroni
- Neuroimmunology Unit and Multiple Sclerosis Center, ASST della Valle Olona, Hospital of Gallarate, Gallarate, VA, Italy
| | | | | | - Pietro Iaffaldano
- Department of Translational Biomedicines and Neurosciences University of Bari, A. Moro, Bari, Italy
| | | | - Lorenzo Saraceno
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Damiano Paolicelli
- Department of Translational Biomedicines and Neurosciences University of Bari, A. Moro, Bari, Italy
| | | | - Cristina Montomoli
- Department of Public Health, Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
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Hecker M, Fitzner B, Koczan D, Klehmet J, Grothe M, Schwab M, Winkelmann A, Meister S, Dudesek A, Ludwig-Portugall I, Eulitz K, Zettl UK. Differential gene expression in B cells and T helper cells following high-dose glucocorticoid therapy for multiple sclerosis relapse. Biomed Pharmacother 2024; 175:116721. [PMID: 38749180 DOI: 10.1016/j.biopha.2024.116721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Despite remarkable advances in the therapy of multiple sclerosis (MS), patients with MS may still experience relapses. High-dose short-term methylprednisolone (MP) remains the standard treatment in the acute management of MS relapses due to its potent anti-inflammatory and immunosuppressive properties. However, there is a lack of studies on the cell type-specific transcriptome changes that are induced by this synthetic glucocorticoid (GC). Moreover, it is not well understood why some patients do not benefit adequately from MP therapy. METHODS We collected peripheral blood from MS patients in relapse immediately before and after ∼3-5 days of therapy with MP at 4 study centers. CD19+ B cells and CD4+ T cells were then isolated for profiling the transcriptome with high-density arrays. The patients' improvement of neurological symptoms was evaluated after ∼2 weeks by the treating physicians. We finally analyzed the data to identify genes that were differentially expressed in response to the therapy and whose expression differed between clinical responders and non-responders. RESULTS After MP treatment, a total of 33 genes in B cells and 55 genes in T helper cells were significantly up- or downregulated. The gene lists overlap in 10 genes and contain genes that have already been described as GC-responsive genes in the literature on other cell types and diseases. Their differential expression points to a rapid and coordinated modulation of multiple signaling pathways that influence transcription. Genes that were previously suggested as potential prognostic biomarkers of the clinical response to MP therapy could not be confirmed in our data. However, a greater increase in the expression of genes encoding proteins with antimicrobial activity was detected in CD4+ T cells from non-responders compared to responders. CONCLUSION Our study delved into the cell type-specific effects of MP at the transcriptional level. The data suggest a therapy-induced ectopic expression of some genes (e.g., AZU1, ELANE and MPO), especially in non-responders. The biological consequences of this remain to be explored in greater depth. A better understanding of the molecular mechanisms underlying clinical recovery from relapses in patients with MS will help to optimize future treatment decisions.
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Affiliation(s)
- Michael Hecker
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany.
| | - Brit Fitzner
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Dirk Koczan
- Institute of Immunology, Rostock University Medical Center, Rostock, Germany
| | - Juliane Klehmet
- Center for Multiple Sclerosis, Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany
| | - Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Schwab
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Alexander Winkelmann
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Stefanie Meister
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Ales Dudesek
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | | | | | - Uwe Klaus Zettl
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
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Pagalilauan AM, Everest E, Rachimi S, Reich D, Waldman AD, Sadovnick AD, Vilariño-Guell C, Lenardo MJ. The Canadian Collaborative Project on Genetic Susceptibility to Multiple Sclerosis cohort population structure and disease etiology. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.18.24305992. [PMID: 38712288 PMCID: PMC11071557 DOI: 10.1101/2024.04.18.24305992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Previous genetic and epidemiological studies have examined subpopulations from the Canadian Collaborative Project on Genetic Susceptibility to Multiple Sclerosis (CCPGSMS) patient cohort, but an encompassing analysis of the study population has not yet been carried out. Objective This study examines patterns of multiple sclerosis (MS) prevalence in 13,663 cohort members, including 4,821 patients with MS or suspected MS and 8,842 family members. Methods We grouped participants into epidemiologic subgroups based on age of MS onset, clinical stage at diagnosis, symptom type at disease onset, sex, proband status, disability as measured by the EDSS, and ancestry based on reported ethnicity. Results We observed a 2.7:1 MS prevalence ratio of women to men, though disease severity was greater for male patients. Variation in the age of disease onset between patients was only slightly associated with sex and strongly associated with disease type. Specific types of clinical symptoms at disease onset were associated with the prognosis. Regional residence did not correlate with disease onset, type, or severity. Conclusion Population trends, as presented here, are not explained by environmental factors alone, highlighting the need for a comprehensive genetic analysis to understand disease variance across families.
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Baba C, Abasiyanik Z, Simsek Y, Ozdogar AT, Sagici O, Ozakbas S. Predictors of relapse severity in multiple sclerosis. Acta Neurol Belg 2024; 124:581-589. [PMID: 38238606 DOI: 10.1007/s13760-023-02456-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 12/08/2023] [Indexed: 03/27/2024]
Abstract
BACKGROUND The severity of relapses is one of the determinants of residual disability in multiple sclerosis (MS), contributing to the final progressive state. However, the factors that predict the severity of relapses are not fully understood. AIM To predict relapse severity in MS and investigate the relationship between relapse severity and the degree of improvement in physical, cognitive, and social tests. METHODS This observational single-center study prospectively assesses relapse severity in patients with MS. Relapses were classified as mild, moderate, and severe. Before relapse treatment and 1 month into remission four physical tests, four cognitive tests, and six surveys were performed. Multinomial regression analyses were applied to predict relapse severity. RESULTS A total of 126 relapses were studied prospectively. Twenty-two were lost to follow-up. Multiple sclerosis International Quality of Life (MusiQol) questionnaire (r = 0.28, p = 0.006) and Symbol Digit Modalities Test (SDMT, r = 0.23, p = 0.022) improvement statuses were correlated with the severity of the relapse. Higher cases with improvement were observed in the severe relapse group on both MusiQol and SDMT, but no difference for those with a mild relapse. In the predictive model, only disease duration [Odds Ratio (OR) 0.808 95% confidence ınterval (CI) 0.691 to 0.945; p = 0.008] and Body Mass Index (BMI, OR 1.148 95% CI 1.018 to 1.294; p = 0.024) were associated with relapse severity. CONCLUSION Only disease duration was found to be predictive of relapse severity among disease-related variables. On the other hand, BMI may be a modifiable patient-related factor to consider in the management of exacerbations in MS.
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Affiliation(s)
- Cavid Baba
- Institute of Health Sciences, Dokuz Eylul University, Yenikale Mahallesi Sutculer Caddesi N7 D7 Narlıdere, Izmir, Turkey.
| | - Zuhal Abasiyanik
- Institute of Health Sciences, Dokuz Eylul University, Yenikale Mahallesi Sutculer Caddesi N7 D7 Narlıdere, Izmir, Turkey
| | | | - Asiye Tuba Ozdogar
- Institute of Health Sciences, Dokuz Eylul University, Yenikale Mahallesi Sutculer Caddesi N7 D7 Narlıdere, Izmir, Turkey
| | - Ozge Sagici
- Institute of Health Sciences, Dokuz Eylul University, Yenikale Mahallesi Sutculer Caddesi N7 D7 Narlıdere, Izmir, Turkey
| | - Serkan Ozakbas
- Department of Neurology, Dokuz Eylul University, Izmir, Turkey
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Pelletier J, Sugar D, Koyfman A, Long B. Multiple Sclerosis: An Emergency Medicine-Focused Narrative Review. J Emerg Med 2024; 66:e441-e456. [PMID: 38472027 DOI: 10.1016/j.jemermed.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/15/2023] [Accepted: 12/11/2023] [Indexed: 03/14/2024]
Abstract
BACKGROUND Multiple sclerosis (MS) is a rare but serious condition associated with significant morbidity. OBJECTIVE This review provides a focused assessment of MS for emergency clinicians, including the presentation, evaluation, and emergency department (ED) management based on current evidence. DISCUSSION MS is an autoimmune disorder targeting the central nervous system (CNS), characterized by clinical relapses and radiological lesions disseminated in time and location. Patients with MS most commonly present with long tract signs (e.g., myelopathy, asymmetric spastic paraplegia, urinary dysfunction, Lhermitte's sign), optic neuritis, or brainstem syndromes (bilateral internuclear ophthalmoplegia). Cortical syndromes or multifocal presentations are less common. Radiologically isolated syndrome and clinically isolated syndrome (CIS) may or may not progress to chronic forms of MS, including relapsing remitting MS, primary progressive MS, and secondary progressive MS. The foundation of outpatient management involves disease-modifying therapy, which is typically initiated with the first signs of disease onset. Management of CIS and acute flares of MS in the ED includes corticosteroid therapy, ideally after diagnostic testing with imaging and lumbar puncture for cerebrospinal fluid analysis. Emergency clinicians should evaluate whether patients with MS are presenting with new-onset debilitating neurological symptoms to avoid unnecessary testing and admissions, but failure to appropriately diagnose CIS or MS flare is associated with increased morbidity. CONCLUSIONS An understanding of MS can assist emergency clinicians in better diagnosing and managing this neurologically devastating disease.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Davis Sugar
- Department of Neurology, Virginia Tech Carilion, Roanoke, Virginia
| | - Alex Koyfman
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Brit Long
- SAUSHEC (San Antonio Uniformed Services Health Education Consortium), Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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Thränhardt P, Veselaj A, Friedli C, Wagner F, Marti S, Diem L, Hammer H, Radojewski P, Wiest R, Chan A, Hoepner R, Salmen A. Sex differences in multiple sclerosis relapse presentation and outcome: a retrospective, monocentric study of 134 relapse events. Ther Adv Neurol Disord 2024; 17:17562864241237853. [PMID: 38532803 PMCID: PMC10964455 DOI: 10.1177/17562864241237853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/07/2024] [Indexed: 03/28/2024] Open
Abstract
Background Reporting of sex-specific analyses in multiple sclerosis (MS) is sparse. Disability accrual results from relapses (relapse-associated worsening) and independent thereof (progression independent of relapses). Objectives A population of MS patients during relapse treated per standard of care was analyzed for sex differences and short-term relapse outcome (3-6 months) as measured by Expanded Disability Status Scale (EDSS) change. Design Single-center retrospective study. Methods We analyzed 134 MS relapses between March 2016 and August 2020. All events required relapse treatment (steroids and/or plasma exchange). Demographic, disease, and paraclinical characteristics [cerebrospinal fluid (CSF) and magnetic resonance imaging (MRI)] were displayed separated by sex. Multivariable linear regression was run to identify factors associated with short-term EDSS change. Results Mean age at relapse was 38.4 years (95% confidence interval: 36.3-40.4) with a proportion of 71.6% women in our cohort. Smoking was more than twice as prevalent in men (65.8%) than women (32.3%). In- and after-relapse EDSSs were higher in men [men: 3.3 (2.8-3.9), women: 2.7 (2.4-3.0); men: 3.0 (1.3-3.6); women: 1.8 (1.5-2.1)] despite similar relapse intervention. Paraclinical parameters revealed no sex differences. Our primary model identified female sex, younger age, and higher EDSS at relapse to be associated with EDSS improvement. A higher immunoglobulin G (IgG) quotient (CSF/serum) was associated with poorer short-term outcome [mean days between first relapse treatment and last EDSS assessment 130.2 (79.3-181.0)]. Conclusion Sex and gender differences are important in outcome analyses of MS relapses. Effective treatment regimens need to respect putative markers for a worse outcome to modify long-term prognosis such as clinical and demographic variables, complemented by intrathecal IgG synthesis. Prospective trials should be designed to address these differences and confirm our results.
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Affiliation(s)
- Pauline Thränhardt
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Admirim Veselaj
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Friedli
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, Waikato Hospital, Hamilton, New Zealand
| | - Franca Wagner
- University Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Translational Imaging Center, Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland
| | - Stefanie Marti
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lara Diem
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Helly Hammer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Piotr Radojewski
- University Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Translational Imaging Center, Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland
| | - Roland Wiest
- University Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Translational Imaging Center, Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, St Josef-Hospital Bochum, Ruhr-University Bochum, Gudrunstrasse 56, Bochum 44791, GermanyDepartment of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Zinganell A, Göbel G, Berek K, Hofer B, Asenbaum-Nan S, Barang M, Böck K, Bsteh C, Bsteh G, Eger S, Eggers C, Fertl E, Joldic D, Khalil M, Langenscheidt D, Komposch M, Kornek B, Kraus J, Krendl R, Rauschka H, Sellner J, Auer M, Hegen H, Pauli FD, Deisenhammer F. Multiple sclerosis in the elderly: a retrospective cohort study. J Neurol 2024; 271:674-687. [PMID: 37855871 DOI: 10.1007/s00415-023-12041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND There is a lack of knowledge of disease course, prognosis, comorbidities and potential treatments of elderly MS patients. OBJECTIVE To characterize the disease course including disability progression and relapses, to quantify the use of DMTs and to identify comorbidities and risk factors for progression in elderly multiple sclerosis (MS) patients. METHODS This is a retrospective study of 1200 Austrian MS patients older than 55 years as of May 1st, 2017 representing roughly one-third of all the MS patients of this age in Austria. Data were collected from 15 MS centers including demographics, first symptom at onset, number of relapses, evolvement of disability, medication, and comorbidities. RESULTS Median observation time was 17.1 years with 957 (80%) relapsing and 243 (20%) progressive onsets. Average age at diagnosis was 45 years with a female predominance of 71%. Three-hundred and twenty-six (27%) patients were never treated with a DMT, while most treated patients received interferons (496; 41%) at some point. At last follow-up, 420 (35%) patients were still treated with a DMT. No difference was found between treated and never-treated patients in terms of clinical outcome; however, patients with worse disability progression had significantly more DMT switches. Pyramidal onset, number of comorbidities, dementia, epilepsy, and psychiatric conditions as well as a higher number of relapses were associated with worse outcome. The risk of reaching EDSS 6 rose with every additional comorbidity by 22%. In late and very-late-onset MS (LOMS, VLOMS) time to diagnosis took nearly twice the time compared to adult and early onset (AEOMS). The overall annualized relapse rate (ARR) decreased over time and patients with AEOMS had significantly higher ARR compared to LOMS and VLOMS. Four percent of MS patients had five medications or more fulfilling criteria of polypharmacy and 20% of psychiatric drugs were administered without a matching diagnosis. CONCLUSIONS In this study, we identified number of comorbidities, pyramidal and cerebellar signs, and a higher number of relapses as unfavorable prognostic factors in elderly MS patients filling gaps of knowledge in patients usually underrepresented in clinical trials and may guide future therapeutic studies.
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Affiliation(s)
- Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Georg Göbel
- Department of Medical Statistics, Informatics and Health Economics, Medical University Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Barbara Hofer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | | | - Matin Barang
- Department of Neurology, Hospital of St. Pölten, St. Pölten, Austria
| | - Klaus Böck
- Department of Neurology, Kepler Universitätsklinikum, Linz, Austria
| | | | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stephan Eger
- Department of Neurology, Kepler Universitätsklinikum, Linz, Austria
| | - Christian Eggers
- Department of Neurology, Kepler Universitätsklinikum, Linz, Austria
| | - Elisabeth Fertl
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Damir Joldic
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Michael Khalil
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Martina Komposch
- Department of Neurology, Hospital of Klagenfurt, Klagenfurt, Austria
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jörg Kraus
- Neurologist, Zell Am See, Austria
- Department of Laboratory Medicine, Paracelsus Medical University and Salzburger Landeskliniken, Salzburg, Austria
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Reinhard Krendl
- Department of Neurology, Hospital of Villach, Villach, Austria
| | - Helmut Rauschka
- Department of Neurology, Klinik Donaustadt, Vienna, Austria
- Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Department of Neurology, Klinik Donaustadt, Vienna, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach, Mistelbach, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Florian Deisenhammer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Wang H, Zhang X, Li H, Sun Z, Zhong Y. Gender differences in the burden of multiple sclerosis in China from 1990 to 2019 and its 25-year projection: An analysis of the Global Burden of Diseases Study. Health Sci Rep 2023; 6:e1738. [PMID: 38033712 PMCID: PMC10685393 DOI: 10.1002/hsr2.1738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/02/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023] Open
Abstract
Background and Aims Multiple sclerosis (MS) is a crippling, chronic, gender-related disease that causes burdens to individuals and society. China has a considerable and increasing population of MS. We aim to analyze the gender disparities in the burden of MS in China and predict the trends. Methods The study was conducted based on the Global Burden of Disease Study 2019. Data on incidence, prevalence, deaths, and disability-adjusted life years (DALYs) of MS in China from 1990 to 2019 was descriptively analyzed by year, gender, and age group. The Nordpred package in R (version 4.2.2) was used for age-period-cohort analysis to predict the all-ages numbers and age-standardized rates of incidence, prevalence, deaths, and DALYs in China from 2020 to 2044. Results The number of prevalent cases of MS in 2019 reached 18,143.56 (95% uncertainty intervals [UI]: 13,997.71-22,658.60) in males and 24,427.11 (95% UI: 18,906.02-30,530.21) in females in China. The peak age of prevalence was shifted from 40-44 years in 1990 to 45-49 years in 2019 in females but remained unchanged in males. In contrast to the increased age-standardized prevalence rate, the age-standardized death rate (ASDR) and age-standardized DALYs rate showed downward trends, which were more significant in females. Different from the global, Chinese males showed lower prevalence but higher deaths and DALYs than females for age-standardized rates and numbers. In the next 25 years, the patient population will remain large and peak around 44,599.78 in 2025-2029. The ASDR, age-standardized DALYs rate, and DALYs number were expected to decrease. The improvements in deaths and DALYs will be more significant in females. Conclusion Males with MS had a lower prevalence but higher deaths and DALYs than females in China. The ASDR and age-standardized DALYs rate have reduced over the past 30 years and were expected to continue decreasing, especially in females. The burden of MS will remain notable in the next 25 years.
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Affiliation(s)
- Heng Wang
- Department of Ophthalmology, Peking Union Medical College HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Xia Zhang
- Department of Ophthalmology, Peking Union Medical College HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Heyan Li
- Beijing Tongren Eye Center, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
| | - Zixi Sun
- Department of Ophthalmology, Peking Union Medical College HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Yong Zhong
- Department of Ophthalmology, Peking Union Medical College HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
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Wang M, Liu C, Zou M, Niu Z, Zhu J, Jin T. Recent progress in epidemiology, clinical features, and therapy of multiple sclerosis in China. Ther Adv Neurol Disord 2023; 16:17562864231193816. [PMID: 37719665 PMCID: PMC10504852 DOI: 10.1177/17562864231193816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 07/24/2023] [Indexed: 09/19/2023] Open
Abstract
Multiple sclerosis (MS) is a demyelinating disease of the central nervous system characterized by inflammation, demyelination, and neurodegeneration. It mainly affects young adults, imposing a heavy burden on families and society. The epidemiology, clinical features, and management of MS are distinct among different countries. Although MS is a rare disease in China, there are 1.4 billion people in China, so the total number of MS patients is not small. Because of the lack of specific diagnostic biomarkers for MS, there is a high misdiagnosis rate in China, as in other regions. Due to different genetic backgrounds, the clinical manifestations of MS in Chinese are different from those in the West. Herein, this review aims to summarize the disease comprehensively, including clinical profile and the status of disease-modifying therapies in China based on published population-based observation and cohort studies, and also to compare with data from other countries and regions, thus providing help to develop diagnostic guideline and the novel therapeutic drugs. Meanwhile, we also discuss the problems and challenges we face, specifically for the diagnosis and treatment of MS in the middle- and low-income countries.
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Affiliation(s)
- Meng Wang
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Caiyun Liu
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Meijuan Zou
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Zixuan Niu
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Jie Zhu
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, No. 1, Xinmin Street, Changchun 130021, China
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm 171 64, Sweden
| | - Tao Jin
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, No. 1, Xinmin Street, Changchun 130021, China
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11
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Zanghì A, Galgani S, Bellantonio P, Zaffaroni M, Borriello G, Inglese M, Romano S, Conte A, Patti F, Trojano M, Avolio C, D'Amico E. Relapse-associated worsening in a real-life multiple sclerosis cohort: the role of age and pyramidal phenotype. Eur J Neurol 2023; 30:2736-2744. [PMID: 37294976 DOI: 10.1111/ene.15910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/27/2023] [Accepted: 06/05/2023] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND PURPOSE The overall disability in patients with relapsing-remitting multiple sclerosis is likely to be partly rather than entirely attributed to relapse. MATERIALS AND METHODS The aim was to investigate the determinants of recovery from first relapse and relapse-associated worsening (RAW) in relapsing-remitting multiple sclerosis patients from the Italian MS Registry during a 5-year epoch from the beginning of first-line disease-modifying therapy. To determine recovery, the functional system (FS) score was used to calculate the difference between the score on the date of maximum improvement and the score before the onset of relapse. Incomplete recovery was defined as a combination of partial (1 point in one FS) and poor recovery (2 points in one FS or 1 point in two FSs or any other higher combination). RAW was indicated by a confirmed disability accumulation measured by the Expanded Disability Status Scale score confirmed 6 months after the first relapse. RESULTS A total of 767 patients had at least one relapse within 5 years of therapy. Of these patients, 57.8% experienced incomplete recovery. Age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.04; p = 0.007) and pyramidal phenotype were associated with incomplete recovery (OR = 2.1, 95% CI 1.41-3.14; p < 0.001). RAW was recorded in 179 (23.3%) patients. Age (OR = 1.02, 95% CI 1.01-1.04; p = 0.029) and pyramidal phenotype (OR = 1.84, 95% CI 1.18-2.88; p = 0.007) were the strongest predictors in the multivariable model. CONCLUSIONS Age and pyramidal phenotype were the strongest determinants of RAW in early disease epochs.
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Affiliation(s)
- Aurora Zanghì
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Simonetta Galgani
- Centro Sclerosi Multipla, Az. Osp. S. Camillo Forlanini, Rome, Italy
| | | | - Mauro Zaffaroni
- Multiple Sclerosis Center, Gallarate Hospital, ASST della Valle Olona, Gallarate, Italy
| | | | - Matilde Inglese
- Centro Per Lo Studio E La Cura Della Sclerosi Multipla E Malattie Demielinizzanti, Dipartimento Di Neuroscienze, Riabilitazione, Oftalmologia, Genetica E Scienze Materno-Infantili, Clinica Neurologica-Ospedale Policlinico San Martino (DiNOGMI), Genoa, Italy
| | - Silvia Romano
- Neurology Unit, NESMOS Department, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Antonella Conte
- Multiple Sclerosis Center, Policlinico Umberto I, Sapienza, University of Rome, Rome, Italy
| | - Francesco Patti
- Department "G.F. Ingrassia", MS Center, University of Catania, Catania, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Carlo Avolio
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Emanuele D'Amico
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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12
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Hosny HS, Shehata HS, Ahmed S, Ramadan I, Abdo SS, Fouad AM. Predictors of severity and outcome of multiple sclerosis relapses. BMC Neurol 2023; 23:67. [PMID: 36782141 PMCID: PMC9926556 DOI: 10.1186/s12883-023-03109-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 02/07/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Multiple Sclerosis (MS) is a demyelinating disease of the central nervous system (CNS). The most common type of MS is the relapsing-remitting MS (RRMS) where relapses are the main component of the disease course. However, the relationship between the characteristics of the relapses on one hand and their severity and outcome on the other hand has not been fully characterized. OBJECTIVES To explore the characteristics of relapses among a cohort of Egyptian MS patients and their relation to the severity and outcome of the disease. SUBJECTS AND METHODS We analyzed 300 attacks from 223 patients in a retrospective study to identify demographic, clinical and paraclinical (laboratory and radiological) factors affecting: 1- Severity of relapses (the difference between the EDSS at the day of maximum worsening and the EDSS before the onset of the attack). 2- Outcome of relapses (the difference between the EDSS at the day of maximum improvement and the EDSS before the onset of the relapse). RESULTS Severe attacks were most likely to occur in patients who are males, single, presenting with poly-symptomatic presentation, slower tempo of evolution of attack symptoms, longer duration of the attack, absence of DMTs at the time of the attack. The risk of having a severe relapse is more than 3 times when the patient is single. Regarding attack outcome, poorly recovered attacks were more common in patients with older age at disease onset and at attack onset, male sex, higher number of relapses, longer duration of illness prior to the attack, severe relapses, polysymptomatic presentation, associated cognitive symptoms, slower tempo of symptom evolution, longer duration of the attack, patients on OCPs, smoking, and presence of black holes in brain MRI. The risk of having relapses with partial or no recovery is more than five times when the patient has black holes in brain MRI and more than 4 times when the patient is a smoker. CONCLUSION Bearing in mind the demographic characteristics as well as the clinical and paraclinical characteristics of each attack and their relation to attack severity and outcome are a key to understanding the individual disease course of every patient and hence tailoring the best therapeutic plan suitable for his individual needs. In other words, prompt, rapid intervention in male patients, polysymptomatic attacks, slower tempo of evolution of attack symptoms and longer duration of the attack should be adopted since these factors are predictive of severe relapses as well as poor relapse outcome.
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Affiliation(s)
- Hassan Saad Hosny
- grid.7776.10000 0004 0639 9286Neurology Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Hatem Samir Shehata
- grid.7776.10000 0004 0639 9286Neurology Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Sandra Ahmed
- grid.7776.10000 0004 0639 9286Neurology Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ismail Ramadan
- grid.7155.60000 0001 2260 6941Neurology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Sarah Sherif Abdo
- grid.7776.10000 0004 0639 9286Neurology Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Amr Mohamed Fouad
- Neurology Department, Faculty of Medicine, Cairo University, Giza, Egypt.
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13
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Howlett-Prieto Q, Oommen C, Carrithers MD, Wunsch DC, Hier DB. Subtypes of relapsing-remitting multiple sclerosis identified by network analysis. Front Digit Health 2023; 4:1063264. [PMID: 36714613 PMCID: PMC9874946 DOI: 10.3389/fdgth.2022.1063264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
We used network analysis to identify subtypes of relapsing-remitting multiple sclerosis subjects based on their cumulative signs and symptoms. The electronic medical records of 113 subjects with relapsing-remitting multiple sclerosis were reviewed, signs and symptoms were mapped to classes in a neuro-ontology, and classes were collapsed into sixteen superclasses by subsumption. After normalization and vectorization of the data, bipartite (subject-feature) and unipartite (subject-subject) network graphs were created using NetworkX and visualized in Gephi. Degree and weighted degree were calculated for each node. Graphs were partitioned into communities using the modularity score. Feature maps visualized differences in features by community. Network analysis of the unipartite graph yielded a higher modularity score (0.49) than the bipartite graph (0.25). The bipartite network was partitioned into five communities which were named fatigue, behavioral, hypertonia/weakness, abnormal gait/sphincter, and sensory, based on feature characteristics. The unipartite network was partitioned into five communities which were named fatigue, pain, cognitive, sensory, and gait/weakness/hypertonia based on features. Although we did not identify pure subtypes (e.g., pure motor, pure sensory, etc.) in this cohort of multiple sclerosis subjects, we demonstrated that network analysis could partition these subjects into different subtype communities. Larger datasets and additional partitioning algorithms are needed to confirm these findings and elucidate their significance. This study contributes to the literature investigating subtypes of multiple sclerosis by combining feature reduction by subsumption with network analysis.
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Affiliation(s)
- Quentin Howlett-Prieto
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, United States
| | - Chelsea Oommen
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, United States
| | - Michael D. Carrithers
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, United States
| | - Donald C. Wunsch
- Department of Electrical and Computer Engineering, Missouri University of Science and Technology, Rolla, MO, United States
| | - Daniel B. Hier
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, United States,Department of Electrical and Computer Engineering, Missouri University of Science and Technology, Rolla, MO, United States,Correspondence: Daniel B. Hier
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Mavandadi S, Moghaddami M, Meysami AP, Sahraian MA, Paybast S, Ghajarzadeh M, Maemodan FG, Nahayati MA, Azimi A. Therapeutic Plasma Exchange (TPE) Complications in Patients With Multiple Sclerosis (MS) and Clinically Isolated Syndrome (CIS): A Report From a Tertiary Center. Neurologist 2023; 28:1-4. [PMID: 35302053 DOI: 10.1097/nrl.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) is a conventional second-line treatment for patients with multiple sclerosis (MS) or clinically isolated syndrome with steroid-refractory relapses. METHODS MS and clinically isolated syndrome patients with a steroid-refractory relapse, who fulfilled the indications for TPE were enrolled in this study. An expert nurse recorded the data comprising age, sex, type of MS, disease modifying therapy, disease duration, relapse rate, vital signs at the beginning, during and at the end of each plasma exchange session, plasma exchange volume, normal saline volume, and TPE complications. Ultimately, the statistical association was estimated amongst the variables. RESULTS A total of 122 cases were assessed. Twelve cases (9.8%) received plasmapheresis for the second time. The mean age was 32.2±8.7 years and 107 (87.7%) were female. In total, 609 plasma exchange sessions were completed. Hypotension and skin reaction were the most clinical complications. Hemoglobin loss and hypokalemia were the most laboratory complications. Fifty-four cases (44.3%) had no complications, 40 (32.8%) had 1 complication, 21 (17.2%) 2 complications, 6 (4.9%) had 3 complications, and 1 (0.8%) disclosed 4 complications. The relapse rate in the past 12 months and the mean plasma volume exchange were significantly different between the groups. CONCLUSIONS We revealed that TPE could be considered as a safe second-line therapy in MS relapses. Hypotension, skin reaction, hemoglobin loss, and hypokalemia were the most complications of TPE in our patients.
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Affiliation(s)
| | | | | | | | - Sepideh Paybast
- Neuroscience Research Center, Qom University of Medical Sciences, Qom
| | - Mahsa Ghajarzadeh
- Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran
| | | | - Mohammad A Nahayati
- Department of Neurology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirreza Azimi
- Multiple Sclerosis Research Center, Neuroscience Institute
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15
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The Role of Epigenetics in Neuroinflammatory-Driven Diseases. Int J Mol Sci 2022; 23:ijms232315218. [PMID: 36499544 PMCID: PMC9740629 DOI: 10.3390/ijms232315218] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
Neurodegenerative disorders are characterized by the progressive loss of central and/or peripheral nervous system neurons. Within this context, neuroinflammation comes up as one of the main factors linked to neurodegeneration progression. In fact, neuroinflammation has been recognized as an outstanding factor for Alzheimer's disease (AD), amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD), and multiple sclerosis (MS). Interestingly, neuroinflammatory diseases are characterized by dramatic changes in the epigenetic profile, which might provide novel prognostic and therapeutic factors towards neuroinflammatory treatment. Deep changes in DNA and histone methylation, along with histone acetylation and altered non-coding RNA expression, have been reported at the onset of inflammatory diseases. The aim of this work is to review the current knowledge on this field.
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16
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Controversies in neuroimmunology: multiple sclerosis, vaccination, SARS-CoV-2 and other dilemas. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2022; 42:78-99. [PMID: 36322548 PMCID: PMC9714524 DOI: 10.7705/biomedica.6366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Indexed: 12/04/2022]
Abstract
Neuroimmunology is a discipline that increasingly broadens its horizons in the understanding of neurological diseases. At the same time, and in front of the pathophysiological links of neurological diseases and immunology, specific diagnostic and therapeutic approaches have been proposed. Despite the important advances in this discipline, there are multiple dilemmas that concern and filter into clinical practice. This article presents 15 controversies and a discussion about them, which are built with the most up-to-date evidence available. The topics included in this review are: steroid decline in relapses of multiple sclerosis; therapeutic recommendations in MS in light of the SARS-CoV-2 pandemic; evidence of vaccination in multiple sclerosis and other demyelinating diseases; overview current situation of isolated clinical and radiological syndrome; therapeutic failure in multiple sclerosis, as well as criteria for suspension of disease-modifying therapies; evidence of the management of mild relapses in multiple sclerosis; recommendations for prophylaxis against Strongyloides stercolaris; usefulness of a second course of immunoglobulin in the Guillain-Barré syndrome; criteria to differentiate an acute-onset inflammatory demyelinating chronic polyneuropathy versus Guillain-Barré syndrome; and, the utility of angiotensin-converting enzyme in neurosarcoidosis. In each of the controversies, the general problem is presented, and specific recommendations are offered that can be adopted in daily clinical practice.
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17
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Sharmin S, Malpas CB, Roos I, Diouf I, Alroughani R, Ozakbas S, Izquierdo G, Eichau S, Horakova D, Havrdova EK, Patti F, Terzi M, Boz C, Yamout B, Khoury SJ, Onofrj M, Lugaresi A, Altintas A, Prat A, Girard M, Duquette P, Sá MJ, La Spitaleri D, Sidhom Y, Gouider R, Mrabet S, Soysal A, Turkoglu R, Amato MP, Fragoso YD, Kalincik T. Early predictors of disability in paediatric multiple sclerosis: evidence from a multi-national registry. J Neurol Neurosurg Psychiatry 2022:jnnp-2022-329713. [PMID: 36180218 DOI: 10.1136/jnnp-2022-329713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/28/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Early recognition of markers of faster disability worsening in paediatric-onset multiple sclerosis (MS) is a key requisite of personalised therapy for children with MS at the earliest possible time. OBJECTIVE To identify early predictors of rapid disability accrual in patients with paediatric-onset MS. METHODS Using the global MSBase registry, we identified patients who were <18 years old at the onset of MS symptoms. The clinico-demographic characteristics examined as predictors of future MS Severity Score (MSSS) included sex, age at symptom onset, absence of disability at the initial assessment, maximum Expanded Disability Status Scale (EDSS) score, relapse frequency and presence of brainstem, pyramidal, visual or cerebellar symptoms in the first year. A Bayesian log-normal generalised linear mixed model adjusted for cumulative proportion of time on higher-efficacy disease-modifying therapies (DMTs) was used to analyse the data. RESULTS 672 patients (70% female) contributing 9357 visits were included. The median age at symptom onset was 16 (quartiles 15-17) years. Older age at symptom onset (exp(β)=1.10 (95% CI 1.04 to 1.17)), higher EDSS score (1.22 (1.12 to 1.34)) and pyramidal (1.31 (1.11 to 1.55)), visual (1.25 (1.10 to 1.44)) or cerebellar (1.18 (1.01 to 1.38)) symptoms in the first year were associated with higher MSSS. MSSS was reduced by 4% for every 24% increase in the proportion of time on higher-efficacy DMTs (0.96 (0.93 to 0.99)). CONCLUSIONS A relatively later onset of MS in childhood, higher disability and pyramidal, visual or cerebellar symptoms during the first year predicted significant worsening in disability in patients with paediatric-onset MS. Persistent treatment with higher-efficacy DMTs was associated with a reduced rate of disability worsening.
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Affiliation(s)
- Sifat Sharmin
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Charles B Malpas
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Izanne Roos
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ibrahima Diouf
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | - Serkan Ozakbas
- Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Guillermo Izquierdo
- Multiple Sclerosis Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Sara Eichau
- Multiple Sclerosis Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva K Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Francesco Patti
- Department of Medical and Surgical Sciences and Advanced Technologies, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Murat Terzi
- Medical Faculty, 19 Mayis University, Samsun, Turkey
| | - Cavit Boz
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | - Bassem Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
- Neurology Department, American University of Beirut, Beirut, Lebanon
| | - Samia J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio, Chieti, Italy
| | - Alessandra Lugaresi
- UOSI Riabilitazione Sclerosi Multipla, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Alexandre Prat
- CHUM MS Center and Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Marc Girard
- CHUM MS Center and Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Pierre Duquette
- CHUM MS Center and Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Maria José Sá
- Department of Neurology, Centro Hospitalar Universitario de Sao Joao, Porto, Portugal
| | | | - Youssef Sidhom
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Riadh Gouider
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Saloua Mrabet
- Clinical Investigation Center Neurosciences and Mental Health, Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - Aysun Soysal
- Department of Neurology, Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | - Recai Turkoglu
- Department of Neurology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Florence, Italy
| | - Yara D Fragoso
- Department of Neurology, Universidade Metropolitana de Santos, Santos, Brazil
| | - Tomas Kalincik
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology, Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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18
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Van Wijmeersch B, Hartung HP, Vermersch P, Pugliatti M, Pozzilli C, Grigoriadis N, Alkhawajah M, Airas L, Linker R, Oreja-Guevara C. Using personalized prognosis in the treatment of relapsing multiple sclerosis: A practical guide. Front Immunol 2022; 13:991291. [PMID: 36238285 PMCID: PMC9551305 DOI: 10.3389/fimmu.2022.991291] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
The clinical course of multiple sclerosis (MS) is highly variable among patients, thus creating important challenges for the neurologist to appropriately treat and monitor patient progress. Despite some patients having apparently similar symptom severity at MS disease onset, their prognoses may differ greatly. To this end, we believe that a proactive disposition on the part of the neurologist to identify prognostic “red flags” early in the disease course can lead to much better long-term outcomes for the patient in terms of reduced disability and improved quality of life. Here, we present a prognosis tool in the form of a checklist of clinical, imaging and biomarker parameters which, based on consensus in the literature and on our own clinical experiences, we have established to be associated with poorer or improved clinical outcomes. The neurologist is encouraged to use this tool to identify the presence or absence of specific variables in individual patients at disease onset and thereby implement sufficiently effective treatment strategies that appropriately address the likely prognosis for each patient.
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Affiliation(s)
- Bart Van Wijmeersch
- Universitair Multiple Sclerosis (MS) Centrum, Hasselt-Pelt, Belgium
- Noorderhart, Revalidatie & Multiple Sclerosis (MS), Pelt, Belgium
- REVAL & BIOMED, Hasselt University, Hasselt, Belgium
- *Correspondence: Bart Van Wijmeersch,
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Palacky University Olomouc, Olomouc, Czechia
| | - Patrick Vermersch
- University Lille, Inserm U1172 LilNCog, Centre Hospitalier Universitaire (CHU) Lille, Fédératif Hospitalo-Universitaire (FHU) Precise, Lille, France
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
- Unit of Clinical Neurology, San Anna University Hospital, Ferrara, Italy
| | - Carlo Pozzilli
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Nikolaos Grigoriadis
- B’ Department of Neurology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mona Alkhawajah
- Neuroscience Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Laura Airas
- Turku University Hospital and University of Turku, Turku, Finland
| | - Ralf Linker
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Cliínico San Carlos (IDISSC), Madrid, Spain
- Department of Medicine, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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19
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Kular L, Klose D, Urdánoz-Casado A, Ewing E, Planell N, Gomez-Cabrero D, Needhamsen M, Jagodic M. Epigenetic clock indicates accelerated aging in glial cells of progressive multiple sclerosis patients. Front Aging Neurosci 2022; 14:926468. [PMID: 36092807 PMCID: PMC9454196 DOI: 10.3389/fnagi.2022.926468] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022] Open
Abstract
Background Multiple sclerosis (MS) is a chronic inflammatory neurodegenerative disease of the central nervous system (CNS) characterized by irreversible disability at later progressive stages. A growing body of evidence suggests that disease progression depends on age and inflammation within the CNS. We aimed to investigate epigenetic aging in bulk brain tissue and sorted nuclei from MS patients using DNA methylation-based epigenetic clocks. Methods We applied Horvath’s multi-tissue and Shireby’s brain-specific Cortical clock on bulk brain tissue (n = 46), sorted neuronal (n = 54), and glial nuclei (n = 66) from post-mortem brain tissue of progressive MS patients and controls. Results We found a significant increase in age acceleration residuals, corresponding to 3.6 years, in glial cells of MS patients compared to controls (P = 0.0024) using the Cortical clock, which held after adjustment for covariates (Padj = 0.0263). The 4.8-year age acceleration found in MS neurons (P = 0.0054) did not withstand adjustment for covariates and no significant difference in age acceleration residuals was observed in bulk brain tissue between MS patients and controls. Conclusion While the findings warrant replication in larger cohorts, our study suggests that glial cells of progressive MS patients exhibit accelerated biological aging.
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Affiliation(s)
- Lara Kular
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Lara Kular,
| | - Dennis Klose
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Amaya Urdánoz-Casado
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Neuroepigenetics Laboratory, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Ewoud Ewing
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Nuria Planell
- Translational Bioinformatics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - David Gomez-Cabrero
- Translational Bioinformatics Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
- Unit of Computational Medicine, Department of Medicine, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Mucosal and Salivary Biology Division, King’s College London Dental Institute, London, United Kingdom
- Biological and Environmental Sciences and Engineering Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
| | - Maria Needhamsen
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Maja Jagodic
- Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- *Correspondence: Maja Jagodic,
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20
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Nytrova P, Dolezal O. Sex bias in multiple sclerosis and neuromyelitis optica spectrum disorders: How it influences clinical course, MRI parameters and prognosis. Front Immunol 2022; 13:933415. [PMID: 36016923 PMCID: PMC9396644 DOI: 10.3389/fimmu.2022.933415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
This review is a condensed summary of representative articles addressing the sex/gender bias in multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). The strong effects of sex on the incidence and possibly also the activity and progression of these disorders should be implemented in the evaluation of any phase of clinical research and also in treatment choice consideration in clinical practice and evaluation of MRI parameters. Some relationships between clinical variables and gender still remain elusive but with further understanding of sex/gender-related differences, we should be able to provide appropriate patient-centered care and research.
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Affiliation(s)
- Petra Nytrova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czechia
- *Correspondence: Petra Nytrova,
| | - Ondrej Dolezal
- Department of Neurology, Dumfries and Galloway Royal Infirmary, NHS Scotland, Dumfries, United Kingdom
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21
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Yang Y, Wang M, Xu L, Zhong M, Wang Y, Luan M, Li X, Zheng X. Cerebellar and/or Brainstem Lesions Indicate Poor Prognosis in Multiple Sclerosis: A Systematic Review. Front Neurol 2022; 13:874388. [PMID: 35572921 PMCID: PMC9099189 DOI: 10.3389/fneur.2022.874388] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple sclerosis is a serious neurological disease that affects millions of people worldwide. Cerebellar and brainstem symptoms are common in the course of multiple sclerosis, but their prognostic value is unclear. This systematic review aimed to determine the relationship between the location of lesions in the cerebellum and/or brainstem and the prognosis in multiple sclerosis. In this systematic review, we searched and comprehensively read articles related to this research topic in Chinese and English electronic databases (PubMed, Embase, Cochrane Library, CNKI, and CBM) using search terms “multiple sclerosis,” “cerebellum,” “brainstem,” “prognosis,” and others. Cerebellar and brainstem clinically isolated syndromes and clinically definite multiple sclerosis were important predictors of transformation (hazard ratio, 2.58; 95% confidence interval, 1.58–4.22). Cerebellar and/or brainstem lesions indicate a poor overall prognosis in multiple sclerosis, but because of inconsistency, more clinical data are needed.
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Affiliation(s)
- Yuyuan Yang
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meng Wang
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lulu Xu
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meixiang Zhong
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yajuan Wang
- Department of Geriatric Medicine, The Qingdao Eighth People's Hospital, Qingdao, China
| | - Moxin Luan
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xingao Li
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xueping Zheng
- Department of Geriatric Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Xueping Zheng
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22
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McCombe PA. The role of sex and pregnancy in multiple sclerosis: what do we know and what should we do? Expert Rev Neurother 2022; 22:377-392. [PMID: 35354378 DOI: 10.1080/14737175.2022.2060079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is more prevalent in women than in men. The sex of the patient, and pregnancy, are reported to be associated with the clinical features of MS. The mechanism of this is unclear. AREAS COVERED This review summarizes data about sex differences in MS and the role of pregnancy. Possible mechanisms for the effects of sex and pregnancy are summarized, and practical suggestions for addressing these issues are provided. EXPERT OPINION There is considerable interdependence of the variables that are associated with MS. Men have a worse outcome of MS, and this could be due to the same factors that lead to greater incidence of neurodegenerative disease in men. The possible role of parity on the long-term outcome of MS is of interest. Future studies that look at the mechanisms of the effects of the sex of the patient on the outcome of MS are required. However, there are some actions that can be taken without further research. We can concentrate on public health measures that address the modifiable risk factors for MS and ensure that disease is controlled in women who intend to become pregnant and use appropriate disease modifying agents during pregnancy.
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Affiliation(s)
- Pamela A McCombe
- The University of Queensland, Centre for Clinical Research, Royal Brisbane and Women's Hospital, Herston, Australia
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23
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Liang L, Kim N, Hou J, Cai T, Dahal K, Lin C, Finan S, Savovoa G, Rosso M, Polgar-Tucsanyi M, Weiner H, Chitnis T, Cai T, Xia Z. Temporal trends of multiple sclerosis disease activity: Electronic health records indicators. Mult Scler Relat Disord 2022; 57:103333. [PMID: 35158446 PMCID: PMC8849591 DOI: 10.1016/j.msard.2021.103333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 10/03/2021] [Accepted: 10/14/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Long-term data on multiple sclerosis (MS) inflammatory disease activity are limited. We examined electronic health records (EHR) indicators of disease activity in people with MS. METHODS We analyzed prospectively collected research registry data and linked EHR data in a clinic-based cohort from 2000 to 2016. We used the trend of the yearly incident relapse rate from the registry data as benchmark. We then calculated the temporal trends of potentially relevant EHR measures, including mean count of the MS diagnostic code, mentions of MS-related concepts, MS-related health utilizations and selected prescriptions. RESULTS 1,555 MS patients had both registry and EHR data. Between 2000 and 2016, the registry data showed a declining trend in the yearly incident relapse rate, parallel to an increasing trend of DMT usage. Among the EHR measures, covariate-adjusted frequency of diagnostic code of MS, procedure codes of MS-related imaging studies and emergency room visits, and electronic prescription for steroids declined over time, mirroring the temporal trend of the benchmark yearly incident relapse rate. CONCLUSION This study highlights EHR indicators of MS relapse that could enable large-scale examination of long-term disease activities or inform individual patient monitoring in clinical settings where EHR data are available.
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Affiliation(s)
- Liang Liang
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Nicole Kim
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jue Hou
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Tianrun Cai
- Division of Rheumatology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kumar Dahal
- Division of Rheumatology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Chen Lin
- Clinical Natural Language Processing Program, Boston Children’s Hospital, Boston, MA, USA
| | - Sean Finan
- Clinical Natural Language Processing Program, Boston Children’s Hospital, Boston, MA, USA
| | - Guergana Savovoa
- Clinical Natural Language Processing Program, Boston Children’s Hospital, Boston, MA, USA
| | - Mattia Rosso
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Howard Weiner
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Tianxi Cai
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA,Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Zongqi Xia
- Department of Neurology and Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
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24
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Gebhardt M, Kropp P, Hoffmann F, Zettl UK. Headache in multiple sclerosis - pharmacological aspects. Curr Pharm Des 2021; 28:445-453. [PMID: 34551691 DOI: 10.2174/1381612827666210922114100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/19/2021] [Indexed: 12/11/2022]
Abstract
For decades, headache was not considered a typical symptom of multiple sclerosis (MS) and was construed as a "red flag" for important differential diagnoses such as cerebral vasculitis. Meanwhile, several studies have demonstrated an increased prevalence of headache in MS compared to the general population. This is due to the heterogeneity of headache genesis with frequent occurrence of both primary and secondary headaches in MS. On the one hand, MS and migraine are often comorbid. On the other hand, secondary headaches occur frequently, especially in the course of MS relapses. These are often migraine-like headaches caused by inflammation, which can improve as a result of MS-specific therapy. Headaches are particularly common in the early stages of chronic inflammatory CNS disease, where inflammatory activity is greatest. In addition, headache can also occur as a side effect of disease-modifying drugs (DMDs). Headache can occur with most DMDs and is most frequently described with interferon-beta therapy. The aim of this work is to present the prevalence of headache and describe the heterogeneity of possible causes of headache in MS. In addition, important therapeutic aspects in the treatment of MS patients in general will be presented as well as different approaches to the treatment of headache in MS depending on the etiological classification.
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Affiliation(s)
- Marcel Gebhardt
- Krankenhaus Martha-Maria Halle-Dölau, Klinik für Neurologie, Röntgenstraße 1, 06120 Halle. Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, Medical Faculty, University of Rostock, Gehlsheimer Straße 20, 18147, Rostock. Germany
| | | | - Uwe K Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock. Germany
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25
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Smets I, Aboulwafa M, Mah H, Giovannoni G. Missed MS or MIMS not prodromal MS: Expanding the diagnostic MS spectrum. Mult Scler Relat Disord 2021; 55:103223. [PMID: 34507272 DOI: 10.1016/j.msard.2021.103223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 08/22/2021] [Indexed: 10/20/2022]
Affiliation(s)
- I Smets
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom.
| | - M Aboulwafa
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - H Mah
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - G Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom; Department of Neurology, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
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26
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Noffs G, Boonstra FMC, Perera T, Kolbe SC, Stankovich J, Butzkueven H, Evans A, Vogel AP, van der Walt A. Acoustic Speech Analytics Are Predictive of Cerebellar Dysfunction in Multiple Sclerosis. THE CEREBELLUM 2021; 19:691-700. [PMID: 32556973 DOI: 10.1007/s12311-020-01151-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Speech production relies on motor control and cognitive processing and is linked to cerebellar function. In diseases where the cerebellum is impaired, such as multiple sclerosis (MS), speech abnormalities are common and can be detected by instrumental assessments. However, the potential of speech assessments to be used to monitor cerebellar impairment in MS remains unexplored. The aim of this study is to build an objectively measured speech score that reflects cerebellar function, pathology and quality of life in MS. Eighty-five people with MS and 21 controls participated in the study. Speech was independently assessed through objective acoustic analysis and blind expert listener ratings. Cerebellar function and overall disease disability were measured through validated clinical scores; cerebellar pathology was assessed via magnetic resonance imaging, and validated questionnaires informed quality of life. Selected speech variables were entered in a regression model to predict cerebellar function. The resulting model was condensed into one composite speech score and tested for prediction of abnormal 9-hole peg test (9HPT), and for correlations with the remaining cerebellar scores, imaging measurements and self-assessed quality of life. Slow rate of syllable repetition and increased free speech pause percentage were the strongest predictors of cerebellar impairment, complemented by phonatory instability. Those variables formed the acoustic composite score that accounted for 54% of variation in cerebellar function, correlated with cerebellar white matter volume (r = 0.3, p = 0.017), quality of life (r = 0.5, p < 0.001) and predicted an abnormal 9HPT with 85% accuracy. An objective multi-feature speech metric was highly representative of motor cerebellar impairment in MS.
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Affiliation(s)
- Gustavo Noffs
- Centre for Neuroscience of Speech, University of Melbourne, Melbourne, Australia. .,Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.
| | - Frederique M C Boonstra
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Thushara Perera
- The Bionics Institute, East Melbourne, Australia.,Department of Medical Bionics, University of Melbourne, Melbourne, Australia
| | - Scott C Kolbe
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia.,Florey Institute of Neuroscience and Mental Health, Parkville, Australia
| | - Jim Stankovich
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Andrew Evans
- Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.,The Bionics Institute, East Melbourne, Australia
| | - Adam P Vogel
- Centre for Neuroscience of Speech, University of Melbourne, Melbourne, Australia.,The Bionics Institute, East Melbourne, Australia.,Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,Redenlab Inc, Melbourne, Australia
| | - Anneke van der Walt
- Department of Neurology, Royal Melbourne Hospital, Parkville, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia.,The Bionics Institute, East Melbourne, Australia
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27
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Abstract
The relationship between headache and multiple sclerosis (MS) has been a matter of controversy for over 60 years. Headaches are still rated as a "red flag", indicating alternative diagnoses to MS, although in the last few years numerous studies have shown a frequent association between headache and MS. In recent studies on MS patients, a link was found between lower age/shorter disease duration of MS and frequent headaches. A study of 50 patients manifesting MS for the first time showed the highest headache prevalence in MS of 78% reported so far.Headaches can also be a possible side effect of most disease-modifying MS drugs. In many cases, however, the headache appears to be a symptom of MS in terms of secondary headache. This is also supported by pathophysiological implications, for example, by detecting B cell follicles in the meninges of MS patients.Migraine is the most common type of headache in MS. In some cases, this is a comorbidity of two diseases with many similarities, but headaches caused by inflammatory MS lesions also appear to be phenomenologically very similar to classic migraines; thus, distinguishing between them is often only successful with the help of thorough differential diagnostics (cerebrospinal fluid, MRI etc.).The task of future studies must be to specify the phenomenology of headache in MS even more precisely, in order to, to gain knowledge in, among others, patients with radiologically isolated syndrome, who often suffer from headache, because in these patients a considerable differential diagnostic and therapeutic uncertainty exists.
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28
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Novotna M, Tvaroh A, Mares J. Clinical Parameters to Predict Future Clinical Disease Activity After Treatment Change to Higher-Dose Subcutaneous Interferon Beta-1a From Other Platform Injectables in Patients With Relapsing-Remitting Multiple Sclerosis. Front Neurol 2020; 11:944. [PMID: 32982947 PMCID: PMC7492204 DOI: 10.3389/fneur.2020.00944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 07/21/2020] [Indexed: 11/30/2022] Open
Abstract
Objective: To identify predictors of clinical disease activity after treatment change to higher-dose interferon beta-1a in relapsing-remitting multiple sclerosis (MS). Methods: This was a retrospective-prospective observational multicenter study. We enrolled patients with at least one relapse on platform injectable therapy who were changed to 44 μg interferon beta-1a. Our primary endpoint was the clinical disease activity-free (cDAF) status at 6, 12, 18, and 24 months. Secondary endponts included relapse-free status and disability progression-free status at different timepoints. The primary predictor of interest was the monosymptomatic vs. polysymptomatic index relapse, based on the number of affected functional systems from the Kurtzke scale during the last relapse prior to baseline. Other secondary predictors of clinical disease activity were analyzed based on different demographic and relapse characteristics. Kaplan-Meier estimates of the cumulative probability of remaining in cDAF status were performed. The time to clinical disease activity was compared between groups using univariate Kaplan-Meier analysis and multivariate Cox regression. Multivariate analyses were processed in the form of CART (Classification & Regression Trees). Results: A total of 300 patients entered the study; 233 (77.7%) of them completed the 24-month study period and 67 patients (22.3%) terminated early. The proportion of patients in cDAF status was 84.7, 69.5, 57.5, and 54.2% at 6, 12, 18, and 24 months. After 2 years of follow-up, 55.9% of patients remained relapse-free and 87.8% of patients remained disability progression-free. At all timepoints, the polysymptomatic index relapse was the most significant predictor of clinical disease activity of all studied variables. Hazard ratio of cDAF status for patients with monosymptomatic vs. polysymptomatic index relapse was 1.94 (95% CI 1.38–2.73). CART analyses also confirmed the polysymptomatic index relapse being the strongest predictor of clinical disease activity, followed by higher number of pre-baseline relapses with the most significant effect in the monosymptomatic index relapse group. The next strongest predictors of clinical disease activity were cerebellar syndrome as the most disabled Kurtzke functional system for the monosymptomatic relapse group, and age at first MS symptom ≥ 45 for the polysymptomatic relapse group. Conclusions: Patients with a polysymptomatic index relapse and/or higher number of relapses within 2 years prior to baseline are at high risk of clinical disease activity, despite treatment change to higher-dose interferon beta-1a from other platform injectable therapy. Trial registration: State Institute of Drug Control (SUKL), URL: http://www.sukl.eu/modules/nps/index.php?h=study&a=detail&id=958&lang=2, registration number 1205090000.
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Affiliation(s)
- Martina Novotna
- Department of Neurology and Center of Clinical Neuroscience, General University Hospital, Charles University, Prague, Czechia
| | - Ales Tvaroh
- Merck spol. s r.o, Prague, Czechia.,Department of Neurology, Krajska zdravotni, a.s.-Nemocnice Teplice, o.z., Teplice, Czechia
| | - Jan Mares
- Department of Neurology, MS Center, Faculty Hospital, Palacky University, Olomouc, Czechia
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29
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Lejeune F, Chatton A, Laplaud DA, Le Page E, Wiertlewski S, Edan G, Kerbrat A, Veillard D, Hamonic S, Jousset N, Le Frère F, Ouallet JC, Brochet B, Ruet A, Foucher Y, Michel L. SMILE: a predictive model for Scoring the severity of relapses in MultIple scLErosis. J Neurol 2020; 268:669-679. [PMID: 32902734 DOI: 10.1007/s00415-020-10154-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/21/2020] [Accepted: 08/10/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND In relapsing-remitting multiple sclerosis (RRMS), relapse severity and residual disability are difficult to predict. Nevertheless, this information is crucial both for guiding relapse treatment strategies and for informing patients. OBJECTIVE We, therefore, developed and validated a clinical-based model for predicting the risk of residual disability at 6 months post-relapse in MS. METHODS We used the data of 186 patients with RRMS collected during the COPOUSEP multicentre trial. The outcome was an increase of ≥ 1 EDSS point 6 months post-relapse treatment. We used logistic regression with LASSO penalization to construct the model, and bootstrap cross-validation to internally validate it. The model was externally validated with an independent retrospective French single-centre cohort of 175 patients. RESULTS The predictive factors contained in the model were age > 40 years, shorter disease duration, EDSS increase ≥ 1.5 points at time of relapse, EDSS = 0 before relapse, proprioceptive ataxia, and absence of subjective sensory disorders. Discriminative accuracy was acceptable in both the internal (AUC 0.82, 95% CI [0.73, 0.91]) and external (AUC 0.71, 95% CI [0.62, 0.80]) validations. CONCLUSION The predictive model we developed should prove useful for adapting therapeutic strategy of relapse and follow-up to individual patients.
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Affiliation(s)
- F Lejeune
- Neurology Department and CIC 0004, Nantes University Hospital, Nantes, France.,Centre de Recherche en Transplantation et Immunologie, INSERM U1064, Nantes, France
| | - A Chatton
- MethodS in Patient-Centred Outcomes and HEalth ResEarch (SPHERE) Unit, INSERM, Universities of Nantes and Tours, Nantes, France
| | - D-A Laplaud
- Neurology Department and CIC 0004, Nantes University Hospital, Nantes, France.,Centre de Recherche en Transplantation et Immunologie, INSERM U1064, Nantes, France
| | - E Le Page
- Clinical Neuroscience Centre, CIC_P1414 INSERM, Rennes University Hospital, Rennes University, Rennes, France
| | - S Wiertlewski
- Neurology Department and CIC 0004, Nantes University Hospital, Nantes, France.,Centre de Recherche en Transplantation et Immunologie, INSERM U1064, Nantes, France
| | - G Edan
- Clinical Neuroscience Centre, CIC_P1414 INSERM, Rennes University Hospital, Rennes University, Rennes, France
| | - A Kerbrat
- Clinical Neuroscience Centre, CIC_P1414 INSERM, Rennes University Hospital, Rennes University, Rennes, France
| | - D Veillard
- Epidemiology and Public Health Department, Rennes University Hospital, Rennes, France
| | - S Hamonic
- Epidemiology and Public Health Department, Rennes University Hospital, Rennes, France
| | - N Jousset
- Nantes Clinical Investigation Centre, Nantes University Hospital, Nantes, France
| | - F Le Frère
- Nantes Clinical Investigation Centre, Nantes University Hospital, Nantes, France
| | - J-C Ouallet
- Neurology Department, Magendie Neurocentre, Bordeaux University Hospital, INSERM U1215, Bordeaux, France
| | - B Brochet
- Neurology Department, Magendie Neurocentre, Bordeaux University Hospital, INSERM U1215, Bordeaux, France
| | - A Ruet
- Neurology Department, Magendie Neurocentre, Bordeaux University Hospital, INSERM U1215, Bordeaux, France
| | - Y Foucher
- MethodS in Patient-Centred Outcomes and HEalth ResEarch (SPHERE) Unit, INSERM, Universities of Nantes and Tours, Nantes, France.,Nantes University Hospital, Nantes, France
| | - Laure Michel
- Clinical Neuroscience Centre, CIC_P1414 INSERM, Rennes University Hospital, Rennes University, Rennes, France. .,Microenvironment, Cell Differentiation, Immunology and Cancer Unit, INSERM, Rennes I University, French Blood Agency, Rennes, France. .,Neurology Department, Rennes University Hospital, Rennes, France.
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30
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Yap SM, Dillon M, Crowley RK, McGuigan C. Alemtuzumab-related thyroid disease in people with multiple sclerosis is associated with age and brainstem phenotype at disease onset. Mult Scler J Exp Transl Clin 2020; 6:2055217320933928. [PMID: 32612846 PMCID: PMC7307483 DOI: 10.1177/2055217320933928] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/22/2020] [Indexed: 11/24/2022] Open
Abstract
Background Autoimmune thyroid disease (AITD) occurs in 40%–50% of alemtuzumab-treated persons with
multiple sclerosis (pwMS), most of whom will develop Graves’ Disease (GD). Objective To explore contributory factors for alemtuzumab-related AITD in pwMS. Methods A retrospective patient chart review was performed. Results Sixteen out of 52 (30.8%) pwMS developed AITD. GD occurred in 56.3%
(n = 9), the majority (n = 7, 77.8%) symptomatic. All
but one (85.7%) pwMS with symptomatic GD developed atypical, large and rapid
fluctuations in thyroid hormone levels unexplained by effect of anti-thyroid medication
alone. All symptomatic GD cases were age ≤32 years when starting alemtuzumab (ɸ = 0.60,
p = 0.03). PwMS who started alemtuzumab at a younger age developed
thyroid disease earlier (r = 0.51, p = 0.04). PwMS
with clinical and radiological evidence of brainstem involvement at onset of multiple
sclerosis were 11 times more likely to develop symptomatic GD compared with those with
other phenotypes (p < 0.01). Conclusion Alemtuzumab-induced reconstitution GD may result from early and increased
cross-reactivity between antigens common to the brainstem and thyroid, or presence of
shared Human Leukocyte Antigen (HLA) alleles that determine brainstem and thyroid
involvement. We suggest cautious use of alemtuzumab in younger (≤32 years) pwMS with
early brainstem involvement, especially those actively planning pregnancy, where
alternative therapies are readily available.
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Affiliation(s)
- Siew Mei Yap
- Department of Neurology, St. Vincent's University Hospital, Dublin, Ireland
| | - Mary Dillon
- Department of Neurology, St. Vincent's University Hospital, Dublin, Ireland
| | - Rachel K Crowley
- Department of Endocrinology, St. Vincent's University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
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Abstract
Multiple sclerosis (MS), a chronic inflammatory demyelinating and neurodegenerative disease of the central nervous system, is today a leading cause of unpredictable lifelong disability in young adults. The treatment of patients in progressive stages remains highly challenging, alluding to our limited understanding of the underlying pathological processes. In this review, we provide insights into the mechanisms underpinning MS progression from a perspective of epigenetics, that refers to stable and mitotically heritable, yet reversible, changes in the genome activity and gene expression. We first recapitulate findings from epigenetic studies examining the brain tissue of progressive MS patients, which support a contribution of DNA and histone modifications in impaired oligodendrocyte differentiation, defective myelination/remyelination and sustained neuro-axonal vulnerability. We next explore possibilities for identifying factors affecting progression using easily accessible tissues such as blood by comparing epigenetic signatures in peripheral immune cells and brain tissue. Despite minor overlap at individual methylation sites, nearly 30% of altered genes reported in peripheral immune cells of progressive MS patients were found in brain tissue, jointly converging on alterations of neuronal functions. We further speculate about the mechanisms underlying shared epigenetic patterns between blood and brain, which likely imply the influence of internal (genetic control) and/or external (e.g. smoking and ageing) factors imprinting a common signature in both compartments. Overall, we propose that epigenetics might shed light on clinically relevant mechanisms involved in disease progression and open new avenues for the treatment of progressive MS patients in the future.
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Affiliation(s)
- L Kular
- From the, Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - M Jagodic
- From the, Department of Clinical Neuroscience, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
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32
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Le M, Malpas C, Sharmin S, Horáková D, Havrdova E, Trojano M, Izquierdo G, Eichau S, Ozakbas S, Lugaresi A, Prat A, Girard M, Duquette P, Larochelle C, Alroughani R, Bergamaschi R, Sola P, Ferraro D, Grammond P, Grand' Maison F, Terzi M, Boz C, Hupperts R, Butzkueven H, Pucci E, Granella F, Van Pesch V, Soysal A, Yamout BI, Lechner-Scott J, Spitaleri DLA, Ampapa R, Turkoglu R, Iuliano G, Ramo-Tello C, Sanchez-Menoyo JL, Sidhom Y, Gouider R, Shaygannejad V, Prevost J, Altintas A, Fragoso YD, McCombe PA, Petersen T, Slee M, Barnett MH, Vucic S, Van Der Walt A, Kalincik T. Disability outcomes of early cerebellar and brainstem symptoms in multiple sclerosis. Mult Scler 2020; 27:755-766. [PMID: 32538713 DOI: 10.1177/1352458520926955] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cerebellar and brainstem symptoms are common in early stages of multiple sclerosis (MS) yet their prognostic values remain unclear. OBJECTIVE The aim of this study was to investigate long-term disability outcomes in patients with early cerebellar and brainstem symptoms. METHODS This study used data from MSBase registry. Patients with early cerebellar/brainstem presentations were identified as those with cerebellar/brainstem relapse(s) or functional system score ⩾ 2 in the initial 2 years. Early pyramidal presentation was chosen as a comparator. Andersen-Gill models were used to compare cumulative hazards of (1) disability progression events and (2) relapses between patients with and without early cerebellar/brainstem symptoms. Mixed effect models were used to estimate the associations between early cerebellar/brainstem presentations and expanded disability status scale (EDSS) scores. RESULTS The study cohort consisted of 10,513 eligible patients, including 2723 and 3915 patients with early cerebellar and brainstem symptoms, respectively. Early cerebellar presentation was associated with greater hazard of progression events (HR = 1.37, p < 0.001) and EDSS (β = 0.16, p < 0.001). Patients with early brainstem symptoms had lower hazard of progression events (HR = 0.89, p = 0.01) and EDSS (β = -0.06, p < 0.001). Neither presentation was associated with changes in relapse risk. CONCLUSION Early cerebellar presentation is associated with unfavourable outcomes, while early brainstem presentation is associated with favourable prognosis. These presentations may be used as MS prognostic markers and guide therapeutic approach.
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Affiliation(s)
- Minh Le
- CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Charles Malpas
- CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Sifat Sharmin
- CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Dana Horáková
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | | | - Sara Eichau
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | - Alessandra Lugaresi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOSI Riabilitazione Sclerosi Multipla, Bologna, Italy/Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Alexandre Prat
- Centre hospitalier de l'Universite de Montreal (CHUM), Montreal, QC, Canada
| | - Marc Girard
- Centre hospitalier de l'Universite de Montreal (CHUM), Montreal, QC, Canada
| | - Pierre Duquette
- Centre hospitalier de l'Universite de Montreal (CHUM), Montreal, QC, Canada
| | | | - Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Sharq, Kuwait
| | | | - Patrizia Sola
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Diana Ferraro
- Department of Neuroscience, Azienda Ospedaliera Universitaria, Modena, Italy
| | | | | | - Murat Terzi
- Faculty of Medicine, 19 Mayis University, Samsun, Turkey
| | - Cavit Boz
- Farabi Hospital, KTU Faculty of Medicine, Trabzon, Turkey
| | | | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Eugenio Pucci
- UOC Neurologia, Azienda Sanitaria Unica Regionale Marche-AV3, Macerata, Italy
| | - Franco Granella
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Aysun Soysal
- Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey
| | - Bassem I Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jeannette Lechner-Scott
- School of Medicine and Public Health, The University of Newcastle Australia, Newcastle, NSW, Australia
| | - Daniele LA Spitaleri
- Azienda Ospedaliera di Rilievo Nazionale, San Giuseppe Moscati - Avellino, Avellino, Italy
| | | | - Recai Turkoglu
- Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | | | | | | | - Youssef Sidhom
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Riadh Gouider
- Department of Neurology, Razi Hospital, Manouba, Tunisia
| | - Vahid Shaygannejad
- Isfahan University of Medical Sciences, Isfahan, Iran, Islamic Republic of
| | | | - Ayse Altintas
- School of Medicine, Koc University, Istanbul, Turkey
| | | | | | | | - Mark Slee
- Flinders University, Adelaide, SA, Australia
| | - Michael H Barnett
- Brain and Mind Centre, The University of Sydney, Camperdown, NSW, Australia
| | | | - Anneke Van Der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Tomas Kalincik
- CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
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Rooney S, Albalawi H, Paul L. Exercise in the management of multiple sclerosis relapses: current evidence and future perspectives. Neurodegener Dis Manag 2020; 10:103-115. [PMID: 32352357 DOI: 10.2217/nmt-2019-0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Relapses are a common feature of multiple sclerosis; however, recovery from relapses is often incomplete, with up to half of people experiencing residual disabilities postrelapse. Therefore, treatments are required to promote recovery of function and reduce the extent of residual disabilities postrelapse. Accordingly, this Perspective article explores the role of exercise in relapse management. Current evidence from two studies suggests that exercise in combination with steroid therapy improves disability and quality of life postrelapse, and may be more beneficial in promoting relapse recovery than steroid therapy alone. However, given the small number of studies and methodological limitations, further studies are required to understand the effects of exercise in relapse management and the mechanism through which exercise influences relapse recovery.
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Affiliation(s)
- Scott Rooney
- School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom, G4 0BA
| | - Hani Albalawi
- College of Applied Medical Sciences, University of Tabuk, Tabuk, Saudi Arabia, 47713
| | - Lorna Paul
- School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom, G4 0BA
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Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations. Can J Neurol Sci 2020; 47:437-455. [DOI: 10.1017/cjn.2020.66] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract:The Canadian Multiple Sclerosis Working Group has updated its treatment optimization recommendations (TORs) on the optimal use of disease-modifying therapies for patients with all forms of multiple sclerosis (MS). Recommendations provide guidance on initiating effective treatment early in the course of disease, monitoring response to therapy, and modifying or switching therapies to optimize disease control. The current TORs also address the treatment of pediatric MS, progressive MS and the identification and treatment of aggressive forms of the disease. Newer therapies offer improved efficacy, but also have potential safety concerns that must be adequately balanced, notably when treatment sequencing is considered. There are added discussions regarding the management of pregnancy, the future potential of biomarkers and consideration as to when it may be prudent to stop therapy. These TORs are meant to be used and interpreted by all neurologists with a special interest in the management of MS.
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Tsantes E, Leone MA, Curti E, Cantello R, Vecchio D, Granella F. Location of first attack predicts the site of subsequent relapses in multiple sclerosis. J Clin Neurosci 2020; 74:175-179. [PMID: 32107149 DOI: 10.1016/j.jocn.2020.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 02/10/2020] [Indexed: 11/26/2022]
Abstract
Predictors of attack location in relapsing-remitting multiple sclerosis (RRMS) are poorly known. It has been suggested that the site of the first relapse may influence the location of the subsequents. We aimed to ascertain this hypothesis in a sample of patients consecutively recruited in two Italian MS Centres, with at least two MS attacks. The following data were collected from medical records: demographic data, locations involved in the first two (or three) MS attacks (optic nerve, spinal cord, brain stem/cerebellum, cerebral hemispheres, according to symptoms presented), time elapsed between relapses and onset of disease-modifying treatment (DMT). We enrolled 199 patients (67% females; MS onset age 30.0 ± 8.69 years), in 148 of whom we could define the precise attack location. In 70/148 patients (47%) the second attack involved exactly the same location as the first. There was an increased risk of relapsing in the same location of the first attack when this involved the optic nerve (OR 4.5, 95% CI 2.2-9.2, p < 0.0001), the brainstem/cerebellum (OR 3.5, 95% CI 1.7-6.9, p < 0.0001), or the spinal cord (OR 3.0, 95% CI 1.5-5.9, p = 0.001). The location of third relapse (N = 90) was equally influenced by the site of first attack. In 24 patients with optic neuritis in both the two first attacks, the side coincided in 50% of cases. The location of first attack has a major role in influencing the site of subsequent ones in RRMS.
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Affiliation(s)
- Elena Tsantes
- Neurosciences Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Maurizio A Leone
- Neurology Unit, Department of Medical Sciences, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy; Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), Novara, Italy
| | - Erica Curti
- Neurosciences Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Roberto Cantello
- Neurological Department, AOU Maggiore della Carità and "A. Avogadro University of Piemonte Orientale", Novara, Italy; Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), Novara, Italy
| | - Domizia Vecchio
- Neurological Department, AOU Maggiore della Carità and "A. Avogadro University of Piemonte Orientale", Novara, Italy; Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), Novara, Italy
| | - Franco Granella
- Neurosciences Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Mayne K, White JA, McMurran CE, Rivera FJ, de la Fuente AG. Aging and Neurodegenerative Disease: Is the Adaptive Immune System a Friend or Foe? Front Aging Neurosci 2020; 12:572090. [PMID: 33173502 PMCID: PMC7538701 DOI: 10.3389/fnagi.2020.572090] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/31/2020] [Indexed: 12/11/2022] Open
Abstract
Neurodegenerative diseases of the central nervous system (CNS) are characterized by progressive neuronal death and neurological dysfunction, leading to increased disability and a loss of cognitive or motor functions. Alzheimer's disease, Parkinson's disease and amyotrophic lateral sclerosis have neurodegeneration as a primary feature. However, in other CNS diseases such as multiple sclerosis, stroke, traumatic brain injury, and spinal cord injury, neurodegeneration follows another insult, such as demyelination or ischaemia. Although there are different primary causes to these diseases, they all share a hallmark of neuroinflammation. Neuroinflammation can occur through the activation of resident immune cells such as microglia, cells of the innate and adaptive peripheral immune system, meningeal inflammation and autoantibodies directed toward components of the CNS. Despite chronic inflammation being pathogenic in these diseases, local inflammation after insult can also promote endogenous regenerative processes in the CNS, which are key to slowing disease progression. The normal aging process in the healthy brain is associated with a decline in physiological function, a steady increase in levels of neuroinflammation, brain shrinkage, and memory deficits. Likewise, aging is also a key contributor to the progression and exacerbation of neurodegenerative diseases. As there are associated co-morbidities within an aging population, pinpointing the precise relationship between aging and neurodegenerative disease progression can be a challenge. The CNS has historically been considered an isolated, "immune privileged" site, however, there is mounting evidence that adaptive immune cells are present in the CNS of both healthy individuals and diseased patients. Adaptive immune cells have also been implicated in both the degeneration and regeneration of the CNS. In this review, we will discuss the key role of the adaptive immune system in CNS degeneration and regeneration, with a focus on how aging influences this crosstalk.
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Affiliation(s)
- Katie Mayne
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
| | - Jessica A. White
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
| | | | - Francisco J. Rivera
- Laboratory of Stem Cells and Neuroregeneration, Institute of Anatomy, Histology and Pathology, Faculty of Medicine, Universidad Austral de Chile, Valdivia, Chile
- Center for Interdisciplinary Studies on the Nervous System (CISNe), Universidad Austral de Chile, Valdivia, Chile
- Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, Salzburg, Austria
| | - Alerie G. de la Fuente
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
- *Correspondence: Alerie G. de la Fuente,
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37
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Abstract
PURPOSE OF REVIEW This article provides an overview of the clinical and pathologic features of multiple sclerosis (MS) relapses and reviews evidence-based approaches to their treatment. RECENT FINDINGS Despite the increasing number and potency of MS treatments, relapses remain one of the more unpredictable and disconcerting disease aspects for many patients with MS, making their accurate recognition and treatment an essential component of good clinical care. The expanding range of relapse treatments now includes oral corticosteroids, comparable in efficacy to IV methylprednisolone at a fraction of the cost. While this development improves access to prompt treatment, it also underscores the importance of recognizing mimics of MS relapses to reduce corticosteroid overuse and its attendant risks. SUMMARY Like MS itself, MS relapse remains primarily a clinical diagnosis. The treatment options for MS relapse include corticosteroids, adrenocorticotropic hormone (ACTH), plasma exchange, and rehabilitation, used singly or sequentially, with the goal of limiting the duration and impact of associated disability. Even when treated promptly and effectively, clinical or subclinical sequelae of MS relapses frequently remain.
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38
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Skorupka N, Miclea A, Jalowiec KA, Bocksrucker C, Kamber N, Chan A, Mansouri Taleghani B, Hoepner R, Salmen A. Visual Outcomes of Plasma Exchange Treatment of Steroid-Refractory Optic Neuritis: A Retrospective Monocentric Analysis. Transfus Med Hemother 2019; 46:417-422. [PMID: 31933571 DOI: 10.1159/000504027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/10/2019] [Indexed: 12/28/2022] Open
Abstract
Introduction In acute inflammatory optic neuritis (ON) as a typical onset of multiple sclerosis (MS), only few studies have investigated plasma exchange (PLEX) as a sequential treatment after insufficient response to high-dose intravenous glucocorticosteroids. Therefore, we aimed to investigate treatment outcome on visual acuity (VA) with PLEX in patients with steroid-refractory ON. Methods In our retrospective monocentric study, medical records were screened for patients with acute ON as their first relapse with sequential MS diagnosis or with an established MS diagnosis from the Bern University Hospital (Switzerland) that were treated with PLEX between 2016 and 2018 due to lacking steroid response. VA prior to steroid administration, and before and after PLEX were assessed and compared using the Friedman multiple comparison test. Results In total, 18 patients were included in the analysis. Interval from symptom onset to PLEX was 20.3 days (mean, 95% CI 14.8-25.9). Relevant functional improvement (VA of ≥0.5, after a mean of 15.9 (13.3-18.5) days after start of PLEX) was detected in 16/18 (88.9%) with a significant amelioration as compared to VA before glucocorticosteroids and before PLEX (p < 0.0001). VA improvement at a later time point (38.1 weeks, 25.2-51.0) was present in 15/16 (93.8%) patients. No serious adverse events were detected. PLEX could be performed via peripheral access in 13/18 patients (72.2%). Conclusion Our study demonstrates significant improvements of VA with PLEX in a cohort of MS patients with steroid-refractory ON. High response rates may be due to the timely treatment initiation. Despite the small sample size, our data support the early use of PLEX in steroid-refractory ON with a favorable safety profile.
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Affiliation(s)
- Nic Skorupka
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrei Miclea
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Christoph Bocksrucker
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Kamber
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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39
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Signoriello E, D'Amico A, Fratta M, Ugga L, Altobelli C, Conchiglia G, Barbarulo AM, Di Pietro A, Anastasio P, Rossi F, Lus G. Alemtuzumab significantly improves posterior fossa syndrome presented as a relapse of multiple sclerosis. Mult Scler Relat Disord 2019; 38:101518. [PMID: 31778927 DOI: 10.1016/j.msard.2019.101518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 11/07/2019] [Accepted: 11/10/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Posterior fossa syndrome (PFS) is a rare manifestation of ponto-mesencephalic lesions frequently reported in post-surgical pediatric tumors, rarely described as a consequence of vascular, infective or inflammatory lesions. OBJECTIVE The aim of this article is to report the clinical and neuroradiological characteristics of a patient with an acute PFS presentation as a relapse in relapsing-remitting MS, significantly responsive to Alemtuzumab treatment. CASE REPORT 24-year-old patient affected by multiple sclerosis developed motor-cognitive and behavioral syndrome related to an extensive ponto-mesencephalic lesion under Fingolimod treatment. CONCLUSION Our case highlights the significant and rapid effect of Alemtuzumab therapy on both cognitive and motor symptoms occurring during a MS relapse with atypical neuroradiological localization.
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Affiliation(s)
- E Signoriello
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy.
| | - A D'Amico
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - M Fratta
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - L Ugga
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - C Altobelli
- Unit of Nephrology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - G Conchiglia
- Alma Mater, Villa Camaldoli Hospital, Naples, Italy
| | - A M Barbarulo
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - A Di Pietro
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - P Anastasio
- Unit of Nephrology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - F Rossi
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - G Lus
- Multiple Sclerosis Center, II Division of Neurology, University of Campania Luigi Vanvitelli, Naples, Italy
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40
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Scott TF, Diehl D, Elmalik W, Gettings EJ, Hackett C, Schramke CJ. Multiple sclerosis relapses contribute to long-term disability. Acta Neurol Scand 2019; 140:336-341. [PMID: 31314902 DOI: 10.1111/ane.13149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatments affect both relapse-related disability and short-term disability change, but measurements of their impact on long-term outcomes remain a challenge. OBJECTIVE To ascertain the contribution of relapse-associated disability to overall disability in relapse-onset multiple sclerosis (RMS) using long-term data collected in our clinic. MATERIALS AND METHODS Retrospective study of a cohort of newly diagnosed patients with RMS, (n = 176) was undertaken, measuring all confirmed changes in disability up to 15 years after onset. Worsening was assessed yearly and in 5-year epochs and was attributed to either relapse (RW) or slow progression (PW). RESULTS At data lock, 139/176 (81%) of patients were still actively followed, with Expanded Disability Status Scale (EDSS) available for 10 years post-onset in 145/176 (82%) patients and 15 years post-onset EDSS in 83 patients (mean follow-up entire group 12.7 years post-onset). RW accounted for a large amount of worsening seen in the first 15 years of RMS. RW was less frequent over time, but accounted for most EDSS changes in the first decade of MS (167/267, 63% of EDSS changes), and remained important even in years 11-15 (17/50, 34% of EDSS changes). Median change in disability due to RW vs PW was similar over the entire 15 years. CONCLUSIONS Worsening of treated MS was associated with relapses in many RMS patients throughout the first 15 years after onset, suggesting an opportunity for long-term benefit through relapse reduction.
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Affiliation(s)
- Thomas F. Scott
- Neurology and Neuroscience Institute Allegheny General Hospital Allegheny Health Network Pittsburgh PA USA
- Neurology Drexel University College of Medicine Philadelphia PA USA
| | - Daniel Diehl
- Neurology and Neuroscience Institute Allegheny General Hospital Allegheny Health Network Pittsburgh PA USA
| | - Wisam Elmalik
- Neurology and Neuroscience Institute Allegheny General Hospital Allegheny Health Network Pittsburgh PA USA
| | | | - Chris Hackett
- Neurology and Neuroscience Institute Allegheny General Hospital Allegheny Health Network Pittsburgh PA USA
| | - Carol J. Schramke
- Neurology and Neuroscience Institute Allegheny General Hospital Allegheny Health Network Pittsburgh PA USA
- Neurology Drexel University College of Medicine Philadelphia PA USA
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41
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Abstract
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.
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Affiliation(s)
- Tomas Kalincik
- CORe, Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia/Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Helmut Butzkueven
- Central Clinical School, Monash University, Melbourne, VIC, Australia
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42
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Marques VD, Passos GRD, Mendes MF, Callegaro D, Lana-Peixoto MA, Comini-Frota ER, Vasconcelos CCF, Sato DK, Ferreira MLB, Parolin MKF, Damasceno A, Grzesiuk AK, Muniz A, Matta APDC, Oliveira BESD, Tauil CB, Maciel DRK, Diniz DS, Corrêa EC, Coronetti F, Jorge FMH, Sato HK, Gonçalves MVM, Sousa NADC, Nascimento OJM, Gama PDD, Domingues R, Simm RF, Thomaz RB, Morales RDR, Dias RM, Apóstolos-Pereira SD, Machado SCN, Junqueira TDF, Becker J. Brazilian Consensus for the Treatment of Multiple Sclerosis: Brazilian Academy of Neurology and Brazilian Committee on Treatment and Research in Multiple Sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 76:539-554. [PMID: 30231128 DOI: 10.1590/0004-282x20180078] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 05/16/2018] [Indexed: 12/21/2022]
Abstract
The expanding therapeutic arsenal in multiple sclerosis (MS) has allowed for more effective and personalized treatment, but the choice and management of disease-modifying therapies (DMTs) is becoming increasingly complex. In this context, experts from the Brazilian Committee on Treatment and Research in Multiple Sclerosis and the Neuroimmunology Scientific Department of the Brazilian Academy of Neurology have convened to establish this Brazilian Consensus for the Treatment of MS, based on their understanding that neurologists should be able to prescribe MS DMTs according to what is better for each patient, based on up-to-date evidence and practice. We herein propose practical recommendations for the treatment of MS, with the main focus on the choice and management of DMTs, as well as present a review of the scientific rationale supporting therapeutic strategies in MS.
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Affiliation(s)
- Vanessa Daccach Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas de Ribeirão Preto, Ribeirão Preto SP, Brasil
| | | | - Maria Fernanda Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | - Dagoberto Callegaro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | - Marco Aurélio Lana-Peixoto
- Universidade Federal de Minas Gerais, Centro de Investigação em Esclerose Múltipla de Minas Gerais, Belo Horizonte MG, Brasil
| | | | | | | | | | | | | | | | | | | | | | - Carlos Bernardo Tauil
- Universidade de Brasília, Brasília DF, Brasil.,Universidade Católica de Brasília, Brasília DF, Brasil
| | | | | | | | | | - Frederico M H Jorge
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | | | | | | | | | | | - Renan Domingues
- Senne Líquor Diagnóstico, São Paulo SP, Brasil.,Hospital Cruz Azul, São Paulo SP, Brasil.,Faculdade São Leopoldo Mandic, Campinas SP, Brasil
| | - Renata Faria Simm
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brasil
| | | | | | | | | | | | | | - Jefferson Becker
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre RS, Brasil.,Universidade Federal Fluminense, Niterói RJ, Brasil
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43
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Scalfari A. MS progression is predominantly driven by age-related mechanisms – YES. Mult Scler 2019; 25:902-904. [DOI: 10.1177/1352458518820633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Antonio Scalfari
- Divisions of Brain Sciences and Experimental Medicine, Department of Medicine, Centre for Neuroscience and Charing Cross Hospital, Imperial College London, London, UK
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44
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Abstract
Multiple sclerosis (MS), a chronic autoimmune disorder, affects the central nervous system (CNS). It affects the brain, spinal cord, and optic nerve, leading to problems with vision, balance, muscle control, and other basic bodily functions. MS relapse (MSR) involves an acute inflammatory demyelinating reaction within the CNS. This review focuses on the main factors involved in MSR based on a detailed literature search. Evidence suggests that MSR is influenced by age, sex, pregnancy, serum levels of Vitamin D, interactions between genetic and environmental factors, and infectious diseases. Many of these factors are modifiable and require the attention of patients and health-care providers if favorable outcomes are to be realized. Identification of MSR risk factors can help in the development of therapies that could be used to manage MS and MSR.
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Affiliation(s)
- Fatemah Omar Kamel
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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45
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Wynford-Thomas R, Jacob A, Tomassini V. Neurological update: MOG antibody disease. J Neurol 2018; 266:1280-1286. [PMID: 30569382 PMCID: PMC6469662 DOI: 10.1007/s00415-018-9122-2] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 12/25/2022]
Abstract
Myelin oligodendrocyte glycoprotein (MOG) antibody disease (MOG-AD) is now recognised as a nosological entity with specific clinical and paraclinical features to aid early diagnosis. Although no age group is exempt, median age of onset is within the fourth decade of life, with optic neuritis being the most frequent presenting phenotype. Disease course can be either monophasic or relapsing, with subsequent relapses most commonly involving the optic nerve. Residual disability develops in 50-80% of patients, with transverse myelitis at onset being the most significant predictor of long-term outcome. Recent advances in MOG antibody testing offer improved sensitivity and specificity. To avoid misdiagnosis, MOG antibody testing should be undertaken in selected cases presenting clinical and paraclinical features that are felt to be in keeping with MOG-AD, using a validated cell-based assay. MRI characteristics can help in differentiating MOG-AD from other neuroinflammatory disorders, including multiple sclerosis and neuromyelitis optica. Cerebrospinal fluid oligoclonal bands are uncommon. Randomised control trials are limited, but observational open-label experience suggests a role for high-dose steroids and plasma exchange in the treatment of acute attacks, and for immunosuppressive therapies, such as steroids, oral immunosuppressants and rituximab as maintenance treatment.
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Affiliation(s)
- Ray Wynford-Thomas
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, University Hospital of Wales, Heath Park, Cardiff, CF14 4XN, UK.,Helen Durham Centre for Neuroinflammation, University Hospital of Wales, Cardiff, UK
| | - Anu Jacob
- Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Valentina Tomassini
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, University Hospital of Wales, Heath Park, Cardiff, CF14 4XN, UK. .,Helen Durham Centre for Neuroinflammation, University Hospital of Wales, Cardiff, UK. .,Cardiff University Brain Research Imaging Centre (CUBRIC), School of Psychology, Cardiff, UK.
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46
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Nazareth TA, Rava AR, Polyakov JL, Banfe EN, Waltrip II RW, Zerkowski KB, Herbert LB. Relapse prevalence, symptoms, and health care engagement: patient insights from the Multiple Sclerosis in America 2017 survey. Mult Scler Relat Disord 2018; 26:219-234. [DOI: 10.1016/j.msard.2018.09.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/05/2018] [Indexed: 11/17/2022]
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47
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Musella A, Gentile A, Rizzo FR, De Vito F, Fresegna D, Bullitta S, Vanni V, Guadalupi L, Stampanoni Bassi M, Buttari F, Centonze D, Mandolesi G. Interplay Between Age and Neuroinflammation in Multiple Sclerosis: Effects on Motor and Cognitive Functions. Front Aging Neurosci 2018; 10:238. [PMID: 30135651 PMCID: PMC6092506 DOI: 10.3389/fnagi.2018.00238] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/20/2018] [Indexed: 01/09/2023] Open
Abstract
Aging is one of the main risk factors for the development of many neurodegenerative diseases. Emerging evidence has acknowledged neuroinflammation as potential trigger of the functional changes occurring during normal and pathological aging. Two main determinants have been recognized to cogently contribute to neuroinflammation in the aging brain, i.e., the systemic chronic low-grade inflammation and the decline in the regulation of adaptive and innate immune systems (immunosenescence, ISC). The persistence of the inflammatory status in the brain in turn may cause synaptopathy and synaptic plasticity impairments that underlie both motor and cognitive dysfunctions. Interestingly, such inflammation-dependent synaptic dysfunctions have been recently involved in the pathophysiology of multiple sclerosis (MS). MS is an autoimmune neurodegenerative disease, typically affecting young adults that cause an early and progressive deterioration of both cognitive and motor functions. Of note, recent controlled studies have clearly shown that age at onset modifies prognosis and exerts a significant effect on presenting phenotype, suggesting that aging is a significant factor associated to the clinical course of MS. Moreover, some lines of evidence point to the different impact of age on motor disability and cognitive deficits, being the former most affected than the latter. The precise contribution of aging-related factors to MS neurological disability and the underlying molecular and cellular mechanisms are still unclear. In the present review article, we first emphasize the importance of the neuroinflammatory dependent mechanisms, such as synaptopathy and synaptic plasticity impairments, suggesting their potential exacerbation or acceleration with advancing age in the MS disease. Lastly, we provide an overview of clinical and experimental studies highlighting the different impact of age on motor disability and cognitive decline in MS, raising challenging questions on the putative age-related mechanisms involved.
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Affiliation(s)
- Alessandra Musella
- Laboratory of Synaptic Immunopathology, IRCCS San Raffaele Pisana, Rome, Italy.,San Raffaele University of Rome, Rome, Italy
| | - Antonietta Gentile
- Laboratory of Synaptic Immunopathology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Unit of Neurology, Istituto Neurologico Mediterraneo (IRCCS Neuromed), Pozzilli, Italy
| | - Francesca Romana Rizzo
- Laboratory of Synaptic Immunopathology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Francesca De Vito
- Laboratory of Synaptic Immunopathology, IRCCS San Raffaele Pisana, Rome, Italy.,Laboratory of Synaptic Immunopathology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Diego Fresegna
- Laboratory of Synaptic Immunopathology, IRCCS San Raffaele Pisana, Rome, Italy.,Laboratory of Synaptic Immunopathology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Silvia Bullitta
- Laboratory of Synaptic Immunopathology, IRCCS San Raffaele Pisana, Rome, Italy.,Laboratory of Synaptic Immunopathology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Vanni
- Laboratory of Synaptic Immunopathology, IRCCS San Raffaele Pisana, Rome, Italy.,Laboratory of Synaptic Immunopathology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Livia Guadalupi
- Laboratory of Synaptic Immunopathology, IRCCS San Raffaele Pisana, Rome, Italy
| | | | - Fabio Buttari
- Unit of Neurology, Istituto Neurologico Mediterraneo (IRCCS Neuromed), Pozzilli, Italy
| | - Diego Centonze
- Laboratory of Synaptic Immunopathology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Unit of Neurology, Istituto Neurologico Mediterraneo (IRCCS Neuromed), Pozzilli, Italy
| | - Georgia Mandolesi
- Laboratory of Synaptic Immunopathology, IRCCS San Raffaele Pisana, Rome, Italy.,San Raffaele University of Rome, Rome, Italy
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48
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Evangelopoulos ME, Miclea A, Schrewe L, Briner M, Salmen A, Engelhardt B, Huwiler A, Chan A, Hoepner R. Frequency and clinical characteristics of Multiple Sclerosis rebounds after withdrawal of Fingolimod. CNS Neurosci Ther 2018; 24:984-986. [PMID: 29898493 DOI: 10.1111/cns.12992] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Maria Eleftheria Evangelopoulos
- Department of Neurology, Eginition University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, Bern University Hospital and University of Bern, Switzerland
| | - Andrei Miclea
- Department of Neurology, Bern University Hospital and University of Bern, Switzerland
| | - Lisa Schrewe
- Department of Neurology, Bern University Hospital and University of Bern, Switzerland
| | - Myriam Briner
- Department of Neurology, Bern University Hospital and University of Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Bern University Hospital and University of Bern, Switzerland
| | | | - Andrea Huwiler
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Andrew Chan
- Department of Neurology, Bern University Hospital and University of Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Bern University Hospital and University of Bern, Switzerland
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49
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von Bismarck O, Dankowski T, Ambrosius B, Hessler N, Antony G, Ziegler A, Hoshi MM, Aly L, Luessi F, Groppa S, Klotz L, Meuth SG, Tackenberg B, Stoppe M, Then Bergh F, Tumani H, Kümpfel T, Stangel M, Heesen C, Wildemann B, Paul F, Bayas A, Warnke C, Weber F, Linker RA, Ziemann U, Zettl UK, Zipp F, Wiendl H, Hemmer B, Gold R, Salmen A. Treatment choices and neuropsychological symptoms of a large cohort of early MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e446. [PMID: 29511705 PMCID: PMC5833336 DOI: 10.1212/nxi.0000000000000446] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 01/12/2018] [Indexed: 11/17/2022]
Abstract
Objective To assess clinical characteristics, distribution of disease-modifying treatments (DMTs), and neuropsychological symptoms in a large cohort of patients with early-stage MS. Methods The German National MS Cohort is a multicenter prospective longitudinal cohort study that has recruited DMT-naive patients with clinically isolated syndrome (CIS) and relapsing-remitting MS (RRMS) since 2010. We evaluated their baseline characteristics and the prevalence of neuropsychological symptoms. Results Of 1,124 patients, with a 2.2:1 female-to-male ratio and median age at onset of 31.71 years (interquartile range [IQR]: 26.06–40.33), 44.6% and 55.3% had CIS and RRMS, respectively. The median Expanded Disability Status Scale (EDSS) score at baseline was 1.5 (IQR: 1.0–2.0). A proportion of 67.8% of patients started DMT after a median time of 167.0 days (IQR 90.0–377.5) since the first manifestation. A total of 64.7% and 70.4% of the 762 patients receiving early DMT were classified as CIS and RRMS, respectively. Fatigue, depressive symptoms, and cognitive dysfunction were detected in 36.5%, 33.5%, and 14.7% of patients, respectively. Conclusion Baseline characteristics of this large cohort of patients with early, untreated MS corroborated with other cohorts. Most patients received early DMT within the first year after disease onset, irrespective of a CIS or RRMS diagnosis. Despite the low EDSS score, neuropsychological symptoms affected a relevant proportion of patients.
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Affiliation(s)
- Olga von Bismarck
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Theresa Dankowski
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Björn Ambrosius
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Nicole Hessler
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Gisela Antony
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Andreas Ziegler
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Muna-Miriam Hoshi
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Lilian Aly
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Felix Luessi
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Sergiu Groppa
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Luisa Klotz
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Sven G Meuth
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Björn Tackenberg
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Muriel Stoppe
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Florian Then Bergh
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Hayrettin Tumani
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Tania Kümpfel
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Martin Stangel
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Christoph Heesen
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Brigitte Wildemann
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Friedemann Paul
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Antonios Bayas
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Clemens Warnke
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Frank Weber
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Ralf A Linker
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Ulf Ziemann
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Uwe K Zettl
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Frauke Zipp
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Heinz Wiendl
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Bernhard Hemmer
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Ralf Gold
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
| | - Anke Salmen
- Department of Neurology (O.v.B., B.A., R.G., A.S.), St. Josef-Hospital, Ruhr-University Bochum; Institute of Medical Biometry and Statistics (T.D., N.H., A.Z.), University of Lübeck, University Hospital Schleswig-Holstein, Campus Lübeck; Central Information Office (CIO) (G.A.), Philipps-University Marburg, Germany; School of Mathematics (A.Z.), Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Department of Neurology (M.-M.H., L.A., B.H.), Klinikum rechts der Isar, Technical University of Munich; Munich Cluster for Systems Neurology (SyNergy) (L.A., B.H.); Department of Neurology (F.L., S.G., F.Z.), University Medicine Mainz, Johannes Gutenberg University Mainz; Department of Neurology (L.K., S.G.M., H.W.), University Hospital Münster; Department of Neurology (B.T.), Philipps-University Marburg; Department of Neurology (M.Stoppe, F.T.B.), University of Leipzig; Department of Neurology (H.T.), University of Ulm; Clinic of Neurology Dietenbronn (H.T.), Schwendi; Institute of Clinical Neuroimmunology (T.K.), Ludwig Maximilian University of Munich; Department of Neurology (M.Stangel), Hannover Medical School; Institut für Neuroimmunologie und Multiple Sklerose (C.H.), Universitätsklinikum Hamburg-Eppendorf; Department of Neurology (B.W.), University of Heidelberg; NeuroCure Clinical Research Center and Experimental and Clinical Research Center (F.P.), Charité-University Medicine Berlin and Max Delbrueck Center for Molecular Medicine; Department of Neurology (A.B.), Klinikum Augsburg; Department of Neurology (C.W.), Heinrich-Heine-University, Düsseldorf; Department of Neurology (C.W.), University Hospital Köln; Neurology (F.W.), Max-Planck-Institute of Psychiatry, Munich; Neurological Clinic (F.W.), MATERNUS Kliniken AG, Bad Oeynhausen; Department of Neurology (R.A.L.), University Hospital Erlangen; Department of Neurology & Stroke (U.Z.), Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tübingen; Department of Neurology (U.K.Z.), University of Rostock, Germany; and Department of Neurology (A.S.), Inselspital Bern, University Hospital and University of Bern, Switzerland
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50
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Berger T, Adamczyk-Sowa M, Csépány T, Fazekas F, Hojs Fabjan T, Horáková D, Illes Z, Klimová E, Leutmezer F, Rejdak K, Rozsa C, Šega Jazbec S, Szilasiová J, Turčáni P, Vachová M, Vécsei L, Havrdová E. Management of multiple sclerosis patients in central European countries: current needs and potential solutions. Ther Adv Neurol Disord 2018; 11:1756286418759189. [PMID: 29511382 PMCID: PMC5826096 DOI: 10.1177/1756286418759189] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/04/2017] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Monika Adamczyk-Sowa
- Department of Neurology in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Tünde Csépány
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Tanja Hojs Fabjan
- Department of Neurology, University Medical Centre Maribor, Maribor, Slovenia
| | - Dana Horáková
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Zsolt Illes
- Department of Neurology, University of Southern Denmark, Odense, Denmark
| | - Eleonóra Klimová
- Department of Neurology, University of Prešov and Teaching Hospital of JA Reiman, Prešov, Slovakia
| | - Fritz Leutmezer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Csilla Rozsa
- Department of Neurology, Jahn Ferenc Dél-pesti Hospital, Budapest, Hungary
| | - Saša Šega Jazbec
- Department of Neurology, University of Ljubljana, Ljubljana, Slovenia
| | - Jarmila Szilasiová
- Department of Neurology, Pavol Jozef Šafárik University and University Hospital L Pasteur, Košice, Slovakia
| | - Peter Turčáni
- Department of Neurology, Comenius University, Bratislava, Slovakia
| | | | - László Vécsei
- Department of Neurology and MTA-SZTE Neuroscience Research Group, University of Szeged, Szeged, Hungary
| | - Eva Havrdová
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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