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Moyer H, Mellett R, Vigneault K, McKeown M, Karlawish J, Augustine E, Schneider L, Kimmelman J. Prevalence and Impact of Bypassing or Overriding Phase 2 Trials in Neurologic Drug Development. Neurology 2024; 103:e209533. [PMID: 38833654 PMCID: PMC11226307 DOI: 10.1212/wnl.0000000000209533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/09/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pivotal trials for neurologic drugs in clinical development are often initiated without a phase 2 trial ("bypass") or despite a negative phase 2 efficacy result ("override"). Such practices may degrade the risk/benefit ratio of phase 3 trials. The aim of this study is to estimate the proportion of phase 3 trials for 10 neurologic diseases started without a positive phase 2 trial, to identify factors associated with this practice, and to investigate any association with unfavorable phase 3 trial outcomes. METHODS We searched ClinicalTrials.gov for phase 3 trials completed during 2011-2021, with at least 1 research site in the United States, Canada, the European Union, the United Kingdom, or Australia, and investigating drugs or biologics for treatment of 10 neurologic conditions. Our primary objective was to assess the prevalence of phase 2 bypass/override by searching for preceding phase 2 trials. We used Fisher exact tests to determine whether phase 3 trial characteristics and trial results were associated with phase 2 bypass/override. RESULTS Of the 1,188 phase 3 trials captured in our search, 113 met eligibility for inclusion. Of these, 46% were not preceded by a phase 2 trial that was positive on an efficacy endpoint (31% bypassed and 15% overrode phase 2 trial). Phase 2 bypass/override was not associated with industry funding (77% vs 89%, 95% CI 0.75-7.55, p = 0.13) or testing already approved interventions (23% vs 15%, 95% CI 0.60-5.14, p = 0.33). Overall, phase 3 trials based on phase 2 bypassed/override were statistically significantly less likely to be positive on their primary outcome (31% vs 57%, respectively, 95% CI 1.21-6.92, p = 0.01). This effect disappeared when indications characterized by nearly universal positive or negative results were excluded. Trials that bypassed/overrode phase 2 trials were not statistically significantly more likely to be terminated early because of safety or futility (29% vs 15%, respectively, 95% CI 0.15-1.18, p = 0.11) and did not show increased risk of adverse events in experimental arms (RR = 1.46, 95% CI 1.19-1.79, vs RR = 1.36, 95% CI 1.10-1.69, respectively, p = 0.65). DISCUSSION Almost half of the neurologic disease phase 3 trials were initiated without the support of a positive phase 2 trial. Although our analysis does not establish harm with bypass/override, its prevalence and the scientific rationale for phase 2 trial testing favor development of criteria defining when phase 2 bypass/override is justified.
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Affiliation(s)
- Hannah Moyer
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Robyn Mellett
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Karine Vigneault
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Maya McKeown
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Jason Karlawish
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Erika Augustine
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Lon Schneider
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
| | - Jonathan Kimmelman
- From the Department of Equity, Ethics and Policy (H.M., R.M., K.V., M.M., J. Kimmelman), McGill University, Montreal, Quebec, Canada; Penn Memory Center (J. Karlawish), University of Pennsylvania, Philadelphia; Clinical Trials Unit (E.A.), Kennedy Krieger Institute, Baltimore, MD; Departments of Psychiatry and Behavioral Sciences and Neurology, Keck School of Medicine (L.S.), and L. Davis School of Gerontology (L.S.), University of Southern California, Los Angeles
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Mascarenas-Garcia M, Rivero-de-Aguilar A, Pérez-Ríos M, Ruano-Raviña A, Llaneza-Gonzalez MA, Candal-Pedreira C, Rey-Brandariz J, Varela-Lema L. Best practices in phase III clinical trials on DMTs for multiple sclerosis: a systematic analysis and appraisal of published trials. J Neurol Neurosurg Psychiatry 2024; 95:333-341. [PMID: 37541785 DOI: 10.1136/jnnp-2023-331733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/26/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Great advances have been made in the field of multiple sclerosis (MS) therapy due to the publication of numerous randomised clinical trials (RCTs). In this study, we carried out a critical appraisal of phase III RCTs of disease-modifying therapies (DMTs) for MS published after 2010, intending to identify critical areas of improvement. METHODS We performed a systematic search of published RCTs on MS from January 2010 until December 2021. RCTs were assessed using an ad-hoc tool. This tool was developed based on existing generic methodological instruments and MS-specific guidelines and methodological papers. It included 14 items grouped in 5 domains: methodological quality, adequacy and measurement of outcomes, adverse event reporting, applicability and relevance of results, and transparency and conflict of interest. RESULTS We identified 31 phase III RCTs. Most of them were fully compliant in terms of sample size (87%), randomisation (68%), blinding (61%), participant selection (68%), adverse event reporting (84%) and clinical relevance (52%). Only a few were compliant in terms of participant description (6%), comparison (42%), attrition bias (26%), adequacy of outcome measures (26%), applicability (23%), transparency (36%) and conflict of interest (6%). None were compliant in terms of analysis and reporting of outcomes. The most common limitations related to the absence of comorbidity data, unjustified use of placebo, inadequacy of outcomes design and absence of protocol and/or prospective registration. CONCLUSIONS RCTs for DMTs in MS have relevant and frequent limitations. These should be addressed to enhance their quality, transparency and external validity.
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Affiliation(s)
- Marta Mascarenas-Garcia
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Preventive Medicine and Public Health, University Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Alejandro Rivero-de-Aguilar
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Department of Neurology, University Hospital Complex of Pontevedra, Pontevedra, Spain
| | - Mónica Pérez-Ríos
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Madrid, Spain
| | - Alberto Ruano-Raviña
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Madrid, Spain
| | | | - Cristina Candal-Pedreira
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Santiago de Compostela, Spain
| | - Julia Rey-Brandariz
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Leonor Varela-Lema
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Madrid, Spain
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Aboseif A, Roos I, Krieger S, Kalincik T, Hersh CM. Leveraging Real-World Evidence and Observational Studies in Treating Multiple Sclerosis. Neurol Clin 2024; 42:203-227. [PMID: 37980116 DOI: 10.1016/j.ncl.2023.06.003] [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] [Indexed: 11/20/2023]
Abstract
Randomized controlled trials (RCTs) are essential for regulatory approval of disease-modifying therapies (DMTs), yet their strict selection criteria often lead to limited generalizability. Observational studies using real-world data (RWD) allow for more inclusive heterogeneous cohorts resulting in higher external validity to inform treatment practices. As reviewed in this article, well-designed comparative effectiveness studies are an important application of RWD. Although, like RCTs, observational studies have their own set of limitations, including various biases that may confound results, advanced statistical methods can mitigate many of these limitations. A focus on personalized treatment will continue to add value to individualize MS care.
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Affiliation(s)
- Albert Aboseif
- Department of Neurology, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue S10, Cleveland, OH 44195, USA
| | - Izanne Roos
- Department of Neurology, Neuroimmunology Centre, Royal Melbourne Hospital, L7 635 Elizabeth Street, Melbourne 3000, Australia; Department of Medicine, CORe, University of Melbourne, Melbourne, Australia
| | - Stephen Krieger
- Corinne Goldsmith Dickinson Center for MS Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1138, New York, NY 10029, USA
| | - Tomas Kalincik
- Department of Medicine, CORe, University of Melbourne, Melbourne, Australia; Department of Neurology, Neuroimmunology Centre, Royal Melbourne Hospital, L6 635 Elizabeth Street, Melbourne 3000, Australia
| | - Carrie M Hersh
- Lou Ruvo Center for Brain Health, Cleveland Clinic, 888 West Bonneville Avenue, Las Vegas, NV 89106, USA.
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Noor NM, Love SB, Isaacs T, Kaplan R, Parmar MKB, Sydes MR. Uptake of the multi-arm multi-stage (MAMS) adaptive platform approach: a trial-registry review of late-phase randomised clinical trials. BMJ Open 2022; 12:e055615. [PMID: 35273052 PMCID: PMC8915371 DOI: 10.1136/bmjopen-2021-055615] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND For medical conditions with numerous interventions worthy of investigation, there are many advantages of a multi-arm multi-stage (MAMS) platform trial approach. However, there is currently limited knowledge on uptake of the MAMS design, especially in the late-phase setting. We sought to examine uptake and characteristics of late-phase MAMS platform trials, to enable better planning for teams considering future use of this approach. DESIGN We examined uptake of registered, late-phase MAMS platforms in the EU clinical trials register, Australian New Zealand Clinical Trials Registry, International Standard Randomised Controlled Trial Number registry, Pan African Clinical Trials Registry, WHO International Clinical Trial Registry Platform and databases: PubMed, Medline, Cochrane Library, Global Health Library and EMBASE. Searching was performed and review data frozen on 1 April 2021. MAMS platforms were defined as requiring two or more comparison arms, with two or more trial stages, with an interim analysis allowing for stopping of recruitment to arms and typically the ability to add new intervention arms. RESULTS 62 late-phase clinical trials using an MAMS approach were included. Overall, the number of late-phase trials using the MAMS design has been increasing since 2001 and been accelerated by COVID-19. The majority of current MAMS platforms were either targeting infectious diseases (52%) or cancers (29%) and all identified trials were for treatment interventions. 89% (55/62) of MAMS platforms were evaluating medications, with 45% (28/62) of the MAMS platforms having at least one or more repurposed medication as a comparison arm. CONCLUSIONS Historically, late-phase trials have adhered to long-established standard (two-arm) designs. However, the number of late-phase MAMS platform trials is increasing, across a range of different disease areas. This study highlights the potential scope of MAMS platform trials and may assist research teams considering use of this approach in the late-phase randomised clinical trial setting. PROSPERO REGISTRATION NUMBER CRD42019153910.
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Affiliation(s)
| | | | - Talia Isaacs
- Institute of Education, University College London, London, UK
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Sabsabi S, Mikhael E, Jalkh G, Macaron G, Rensel M. Clinical Evaluation of Siponimod for the Treatment of Secondary Progressive Multiple Sclerosis: Pathophysiology, Efficacy, Safety, Patient Acceptability and Adherence. Patient Prefer Adherence 2022; 16:1307-1319. [PMID: 35637684 PMCID: PMC9148218 DOI: 10.2147/ppa.s221882] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/05/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION A number of disease-modifying therapies have been approved for use in relapsing-remitting multiple sclerosis (MS) in the past two decades. However, only few treatment options are available for patients with secondary progressive multiple sclerosis (SPMS). Siponimod has recently been approved for use in patients with active forms of SPMS (who experience clinical relapses or new lesions on MRI superimposed on secondary progression independent of relapse activity). OBJECTIVE The aim of this article is to provide a comprehensive review on the mechanism of action, efficacy, safety, cost effectiveness and patient adherence with siponimod. METHODS We performed a PubMed search using the search terms: "siponimod", "secondary progressive multiple sclerosis", "sphingosine 1-phosphate modulators". Titles and abstract were screened and selected for relevance to the key section of this article. FINDINGS Siponimod is an oral sphingosine-1-phosphate receptor (S1PR) modulator with selectivity to S1PR-1 and 5. Modulation of this receptor on lymphocytes causes its internalization and degradation, preventing their egress from lymphoid tissues to the blood. In the pivotal Phase 3 randomized controlled trial EXPAND, siponimod was superior to placebo in reducing the risk of disability progression confirmed at 3 and 6 months, as well as the development of new MRI lesions and the rate of brain volume loss. Secondary analysis also showed a benefit on measures of cognitive functioning. The risk of lymphopenia and first-dose bradycardia appears to be lower with siponimod compared to non-selective S1P1R modulators. Different CYP2C9 genotypes affect the metabolism of siponimod; hence, genetic testing is required to adapt the titration and final dose accordingly. CONCLUSION Long-term extension and real-world studies will allow further evaluation of efficacy and safety in this population. Future research should focus on better defining SPMS, and identifying biomarkers of progression and outcome measures of treatment response in this category of patients.
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Affiliation(s)
- Sajida Sabsabi
- Department of Neurology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Elio Mikhael
- Department of Internal Medicine, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Georges Jalkh
- Department of Neurology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH, USA
- Correspondence: Mary Rensel, Email
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Rojas JI, Carnero Contentti E, Abad P, Aguayo A, Alonso R, Bauer J, Becker J, Bustos AK, Carcamo CA, Carra A, Correa Diaz EP, Correale J, Cristiano E, Diaz AJ, Fernandez Liguori N, Flores J, Fruns M, Garcea O, Giachello SM, Godoy MD, Gracia F, Hamuy VF, Henestroza PR, Navarra JA, Navas C, Patrucco L, Perez Bruno M, Prato AS, Rivera VM, Rosa Martinez AR, Vanotti S, Vazquez M, Vizcarra D, Ysrraelit MC, Alonso Serena M. Research priorities in multiple sclerosis in Latin America: A multi-stakeholder call to action to improve patients care: Research priorities in MS in LATAM. Mult Scler Relat Disord 2021; 53:103038. [PMID: 34090128 DOI: 10.1016/j.msard.2021.103038] [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: 03/30/2021] [Accepted: 05/13/2021] [Indexed: 11/26/2022]
Abstract
As human and economic resources are limited, especially in Latin America (LATAM), it is important to identify research priorities to improve multiple sclerosis (MS) patients care in the region. The objective was to generate a multidisciplinary consensus on research priorities in MS for patients care in LATAM by involving healthcare professionals and MS patient associations. METHODS: consensus was reached through a four-step modified Delphi method designed to identify and rate research priorities in MS in LATAM. The process consisted of two qualitative assessments, a general ranking phase and a consensus meeting followed by a more detailed ranking phase RESULTS: a total of 62 participants (35 neurologists, 4 nurses, 12 kinesiologists, 7 neuropsychologists and 4 patient association members) developed the process. At the final ranking stage following the consensus meeting, each participant provided their final rankings, and the top priority research questions were outlined. 11 research priorities were identified focusing on healthcare access, costs of the disease, physical and cognitive evaluation and rehabilitation, quality of life, symptoms management, prognostic factors, the need of MS care units and patient's management in emergencies like COVID-19. CONCLUSION: this work establishes MS research priorities in LATAM from multiple perspectives. To pursue the actions suggested could launch the drive to obtain information that will help us to better understand the disease in our region and, especially, to better care for affected patients.
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Affiliation(s)
- Juan I Rojas
- Centro de Esclerosis Múltiple de Buenos Aires, Argentina; Servicio de Neurología, Hospital Universitario CEMIC, Buenos Aires, Argentina.
| | - Edgar Carnero Contentti
- Neuroimmunology Unit, Department of Neuroscience, Hospital Alemán de Buenos Aires, Argentina
| | - Patricio Abad
- Servicio Neurologia, Hospital Metropolitano de Quito, Ecuador
| | - Adriana Aguayo
- Departamento de Neurociencias. Centro Universitario Ciencias de la Salud. Universidad de Guadalajara, México
| | - Ricardo Alonso
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía, Buenos Aires, Argentina; Servicio de Neurología, Hospital Universitario Sanatorio Guemes, Buenos Aires, Argentina
| | - Johana Bauer
- EMA, esclerosis múltiple Argentina, Buenos Aires, Argentina
| | - Jefferson Becker
- Brain Institute of Rio Grande do Sul, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brasil
| | | | - Claudia A Carcamo
- Departamento de Neurologia, Pontificia Universidad Católica de Chile, Chile
| | - Adriana Carra
- MS Section. Hospital Britanico Buenos Aires, Argentina
| | | | - Jorge Correale
- Departamento de Neurologia, FLENI, Buenos Aires, Argentina
| | - Edgardo Cristiano
- Servicio de Neurología, Hospital Universitario CEMIC, Buenos Aires, Argentina
| | | | - Nora Fernandez Liguori
- Servicio de Neurología, Hospital Universitario Sanatorio Guemes, Buenos Aires, Argentina; Hospital Enrique Tornu, Buenos Aires, Argentina
| | - Jose Flores
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | | | - Orlando Garcea
- Servicio de Neurología, Hospital Universitario Sanatorio Guemes, Buenos Aires, Argentina
| | - Susana M Giachello
- ALCEM - Asociacion de Lucha contra la Esclerosis Multiple, Buenos Aires, Argentina
| | | | - Fernando Gracia
- Clinica de Esclerosis Multiple, Servicio de Neurologia Hospital Santo Tomas, Panama
| | | | - Paula R Henestroza
- ALCEM - Asociacion de Lucha contra la Esclerosis Multiple, Buenos Aires, Argentina
| | | | - Carlos Navas
- Clinica Enfermedad Desmielinizante Clinica Universitaria Colombia, Colombia
| | - Liliana Patrucco
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Argentina; Unidad de Esclerosis Múltiple y enfermedades desmielinizantes, Hospital Italiano de Buenos Aires, Argentina
| | | | | | | | | | - Sandra Vanotti
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía, Buenos Aires, Argentina
| | - Macarena Vazquez
- Departamento de Neurología, Escuela de Medicina Pontificia Universidad Católica de Chile, Chile
| | - Darwin Vizcarra
- Hypnos Instituto del Sueño, Clínica San Felipe, Universidad Peruana Cayetano Heredia, Lima, Peru
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Postural stability is a valid and meaningful disability metric in progressive MS with potential for use in neuroprotective therapy trials. Mult Scler Relat Disord 2021; 52:102946. [PMID: 33901968 DOI: 10.1016/j.msard.2021.102946] [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: 02/03/2021] [Revised: 03/24/2021] [Accepted: 04/07/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Balance impairment is observed in up to 70% of people with MS (pwMS) and worsens with disease progression. Posturography using a force platform is the current gold standard in the measurement of balance. However, posturography has not been adequately studied or widely accepted for use as a disability outcome measure for pwMS. Importantly, the recent emergence of both successful and failed neuroprotective therapy trials in progressive MS has emphasised the need for new disability outcome measures for people with progressive MS. The main objectives of this study were to evaluate the clinical validity, reliability and feasibility of posturography as a disability metric in progressive MS. METHODS This was a prospective cross-sectional study. We recruited 73 people with progressive MS (age 18-65 years, EDSS 3.5-6.0). Participants stood in the centre of a force platform, feet comfortably apart, under various conditions: (i) eyes open (EO), (ii) eyes closed (EC) - a single task, each lasting ninety seconds; and simultaneous EO with a cognitive test: (iii) N-Back, a three-minute test whereby participants were instructed to click the mouse when two identical letters were displayed consecutively on a screen, (iv) Sustained Attention Response Task, a five-minute test whereby participants were instructed to click the mouse for every number "1″ to "9″ except "3″ - i.e., dual-tasks. Additionally, we performed a battery of validated physical and cognitive outcome measures. Posturographic data was processed using Matlab. Statistical analysis was performed using SPSS version 26. We used multiple linear regression modelling to determine whether significant univariate correlations between posturography and clinical metrics were independent of covariates that may influence the associations seen. A two-tailed significance level of 0.05 was used. RESULTS Of 73 participants, mean age 52.4 (8.5) years, mean MS disease duration 13.8 (10.3) years, median EDSS 5.0 (IQR 4.0-6.0), 44 (60.4%) were female. EO-Path-Length independently predicted upper extremity function (9-Hole-Peg-Test) with a larger effect size (adjusted R2=20.0%, p = 0.001) than that for walking measures (Timed 25-Foot Walk, adjusted R2=1.6%, p = 0.01; Two-Minute Walk Test, adjusted R2=7.2%, p = 0.002), while controlling for age, disease duration, height, weight, and sex. The addition of EO-Mediolateral-Displacement to the MS Functional Composite (MSFC) created a four-component z-score that increased the variance explained for quality of life (QOL) by 62.1%. Postural stability was significantly lower with mediolateral vs anteroposterior direction of sway, removal of vision, increased body weight, male sex, and fampridine use. Postural stability improved during dual-tasks compared to EO single task. Posturography detected significant worsening of balance over a single prolonged stance. CONCLUSION Postural stability independently predicted a wide range of clinical metrics including upper extremity function, walking ability, cognition and QOL, therefore establishing construct and concurrent validity as a disability outcome measure for people with progressive MS. Additionally, posturography is a quantitative, non-invasive, quick-and-easy-to-administer, and highly sensitive device, demonstrating its high feasibility for use as a time- and resource-efficient disability metric in neuroprotective therapy trials for progressive MS.
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Brandstadter R, Ayeni O, Krieger SC, Harel NY, Escalon MX, Katz Sand I, Leavitt VM, Fabian MT, Buyukturkoglu K, Klineova S, Riley CS, Lublin FD, Miller AE, Sumowski JF. Detection of subtle gait disturbance and future fall risk in early multiple sclerosis. Neurology 2020; 94:e1395-e1406. [PMID: 32102980 DOI: 10.1212/wnl.0000000000008938] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 10/05/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To test the hypothesis that higher-challenge gait and balance tasks are more sensitive than traditional metrics to subtle patient-reported gait dysfunction and future fall risk in early multiple sclerosis (MS). METHODS Persons with early MS (n = 185; ≤5 years diagnosed) reported gait function (MS Walking Scale) and underwent traditional disability metrics (Expanded Disability Status Scale [EDSS], Timed 25 Foot Walk). Patients and healthy controls (n = 50) completed clinically feasible challenge tasks of gait endurance (2-Minute Walk Test), standing balance (NIH Toolbox), and dynamic balance (balance boards; tandem walk on 2 ten-foot boards of different widths, 4.5 and 1.5 in). MRI assessed global and regional brain volumes, total T2 lesion volume (T2LV), infratentorial T2LVs and counts, and cervical cord lesion counts. Falls, near falls, and fall-related injuries were assessed after 1 year. We examined links between all tasks and patient-reported gait, MRI markers, and fall data. RESULTS Patients performed worse on higher challenge balance, but not gait, tasks compared with healthy controls. Worse patient-reported gait disturbance was associated with worse performance on all tasks, but only dynamic balance was sensitive to mild patient-reported gait difficulty. Balance tasks were more correlated with MRI metrics than were walking tasks or EDSS score. Thirty percent of patients reported either a fall or near fall after 1 year, with poor dynamic balance as the only task independently predicting falls. CONCLUSIONS Balance plays a leading role in gait dysfunction early in MS. Clinically feasible higher-challenge balance tasks were most sensitive to patient-reported gait, MRI disease markers, and risk of future falls, highlighting potential to advance functional outcomes in clinical practice and trials.
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Affiliation(s)
- Rachel Brandstadter
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Oluwasheyi Ayeni
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Stephen C Krieger
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Noam Y Harel
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Miguel X Escalon
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Ilana Katz Sand
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Victoria M Leavitt
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Michelle T Fabian
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Korhan Buyukturkoglu
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Sylvia Klineova
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Claire S Riley
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Fred D Lublin
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Aaron E Miller
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - James F Sumowski
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY.
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9
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Oh J, Alikhani K, Bruno T, Devonshire V, Giacomini PS, Giuliani F, Nakhaipour HR, Schecter R, Larochelle C. Diagnosis and management of secondary-progressive multiple sclerosis: time for change. Neurodegener Dis Manag 2019; 9:301-317. [PMID: 31769344 DOI: 10.2217/nmt-2019-0024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Identifying the transition of relapsing-remitting multiple sclerosis (MS) to the secondary-progressive MS form remains a clinical challenge due to the gradual nature of the transition, superimposed relapses, the heterogeneous course of disease among patients and the absence of validated biomarkers and diagnostic tools. The uncertainty associated with the transition makes clinical care challenging for both patients and physicians. The emergence of new disease-modifying treatments for progressive MS and the increasing emphasis of nonpharmacological strategies mark a new era in the treatment of progressive MS. This article summarizes challenges in diagnosis and management, discusses novel treatment strategies and highlights the importance of establishing a clear diagnosis and instituting an interdisciplinary management plan in the care of patients with progressive MS.
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Affiliation(s)
- Jiwon Oh
- Division of Neurology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Tania Bruno
- Division of Physiatry, Department of Medicine, University Health Network - Toronto Rehabilitation Institute, University of Toronto, Toronto, ON M4G 1R7, Canada
| | - Virginia Devonshire
- Division of Neurology, Department of Medicine, University of British Columbia MS/NMO Center, Vancouver, BC V6T 1Z3, Canada
| | - Paul S Giacomini
- Department of Neurology, Montreal Neurological Institute, McGill University, Montreal, QC H3A 2B4, Canada
| | - Fabrizio Giuliani
- Division of Neurology, Neuroscience & Mental Health Institute, University of Alberta, Edmonton, AB T6G 2B7, Canada
| | | | - Robyn Schecter
- Novartis Pharmaceuticals Canada, Montreal, QC H9S 1A9, Canada
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10
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Sample Size for Oxidative Stress and Inflammation When Treating Multiple Sclerosis with Interferon-β1a and Coenzyme Q10. Brain Sci 2019; 9:brainsci9100259. [PMID: 31569668 PMCID: PMC6826871 DOI: 10.3390/brainsci9100259] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/23/2019] [Accepted: 09/25/2019] [Indexed: 11/16/2022] Open
Abstract
Studying multiple sclerosis (MS) and its treatments requires the use of biomarkers for underlying pathological mechanisms. We aim to estimate the required sample size for detecting variations of biomarkers of inflammation and oxidative stress. This is a post-hoc analysis on 60 relapsing-remitting MS patients treated with Interferon-β1a and Coenzyme Q10 for 3 months in an open-label crossover design over 6 months. At baseline and at the 3 and 6-month visits, we measured markers of scavenging activity, oxidative damage, and inflammation in the peripheral blood (180 measurements). Variations of laboratory measures (treatment effect) were estimated using mixed-effect linear regression models (including age, gender, disease duration, baseline expanded disability status scale (EDSS), and the duration of Interferon-β1a treatment as covariates; creatinine was also included for uric acid analyses), and were used for sample size calculations. Hypothesizing a clinical trial aiming to detect a 70% effect in 3 months (power = 80% alpha-error = 5%), the sample size per treatment arm would be 1 for interleukin (IL)-3 and IL-5, 4 for IL-7 and IL-2R, 6 for IL-13, 14 for IL-6, 22 for IL-8, 23 for IL-4, 25 for activation-normal T cell expressed and secreted (RANTES), 26 for tumor necrosis factor (TNF)-α, 27 for IL-1β, and 29 for uric acid. Peripheral biomarkers of oxidative stress and inflammation could be used in proof-of-concept studies to quickly screen the mechanisms of action of MS treatments.
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11
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Chataway J, Weir CJ, Fox RJ. The FLUOX-PMS trial: Underestimating the challenge in progressive multiple sclerosis trials. Mult Scler 2019; 25:1697-1699. [DOI: 10.1177/1352458519856985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
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12
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Zhang Y, Salter A, Wallström E, Cutter G, Stüve O. Evolution of clinical trials in multiple sclerosis. Ther Adv Neurol Disord 2019; 12:1756286419826547. [PMID: 30833985 PMCID: PMC6391540 DOI: 10.1177/1756286419826547] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 12/17/2018] [Indexed: 01/08/2023] Open
Abstract
Clinical trials have advanced the treatment of multiple sclerosis (MS) by demonstrating the safety and efficacy of disease-modifying therapies (DMTs). This review discusses major changes to MS clinical trials in the era of DMTs. As treatment options for MS continue to increase, patients in modern MS trials present earlier and with milder disease compared with historic MS populations. While placebo-controlled trials for some questions may still be relevant, DMT trials in relapsing–remitting MS (RRMS) are no longer ethical. The replacement of the placebo arm by an active comparator arm in trials have raised the cost of trials by requiring larger sample sizes to detect on-study changes in treatment effects. Efforts to improve trial efficiency in RRMS have focused on exploring adaptive designs and relying on sensitive magnetic resonance imaging measures of disease activity. In trials for progressive forms of MS (PMS), the lack of sensitive outcome measures that can be used in shorter-term trials have delayed the development of effective treatments. Recent shifting of the focus to advancing trials in PMS has identified paraclinical outcome measurements with improved potential, and the testing of agents for neuroprotection and remyelination is in progress.
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Affiliation(s)
- Yinan Zhang
- Department of Neurology and Neurotherapeutics, the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amber Salter
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Erik Wallström
- Sanofi Genzyme, Neuro and Gene Therapy, Cambridge, MA, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Olaf Stüve
- Neurology Section, VA North Texas Health Care System, Medical Service, 4500 South Lancaster Rd., Dallas, TX 75216, USADepartment of Neurology, Klinikum rechts der Isar, Technische Universität München, Germany
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13
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Treatment of progressive multiple sclerosis: Challenges and promising perspectives. Rev Neurol (Paris) 2018; 174:441-448. [DOI: 10.1016/j.neurol.2018.01.370] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/04/2018] [Indexed: 11/21/2022]
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14
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Metz LM, Liu WQ. Effective treatment of progressive MS remains elusive. Lancet 2018; 391:1239-1240. [PMID: 29576503 DOI: 10.1016/s0140-6736(18)30426-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 02/14/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Luanne M Metz
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 2T9, Canada.
| | - Wei-Qiao Liu
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 2T9, Canada
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