Incidence and prevalence of multiple sclerosis in Olmsted County, Minnesota, 1985-2000

Shifting patterns of multiple sclerosis treatment in a highly prevalent United States population

OBJECTIVE

Our objectives were to (1) obtain the prevalence and demography of people with multiple sclerosis (MS) in a representative Colorado population, and (2) to assess the utilization of disease-modifying therapy within this prevalent cohort.

METHODS

This is a retrospective, observational study of patients that had contact with the University of Colorado Health System from 2012 to 2020. We queried Health Data Compass, a data warehouse, for patient data and applied the MS Prevalence Workgroup Algorithm to generate a prevalent cohort. We calculated prevalence as of 31 December 2020, and stratified by age, sex, race, and ethnicity. Payer information and treatment exposure were obtained from linked claims from the Colorado All Payers Claim Database. Disease-modifying therapies were classified as highly effective and moderately effective based on the clinical trial, TREAT-MS (NCT03500328).

RESULTS

From a population of 1,382,821 individuals, 8557 people with MS were captured. Age-adjusted prevalence of MS as of 31 December 2020 was 572.3 per 100,000 with a mean age of 47.36. Prevalence varied between demographic subgroups, with the lowest prevalence in Hispanic men (215.6) and highest in White (824.1) and Black women (820.1). Overall disease-modifying therapy exposure was 62.4%, with increased highly effective therapy use and a corresponding decrease in moderately effective therapy use on a yearly basis.

INTERPRETATION

MS is highly prevalent in a representative Colorado cohort. Overall treatment and proportion of highly effective therapy exposure increased significantly during a critical period of MS therapeutic advances, indicating a shift in disease management driven sharply by the availability of on-label anti-CD20 therapy.

Multiple sclerosis prevalence and its relationship with economic status in Afyonkarahisar, Turkey

BACKGROUND

Over the past decade, the prevalence of Multiple Sclerosis (MS) has increased in Turkey. However, the prevalence of MS in Middle Anatolia, specifically Afyonkarahisar, remains unknown. Additionally, the potential link between economic status and MS has not yet been explored in Turkey.

METHODS

A stratified sampling method was employed to select samples from the population residing in Afyonkarahisar City Center, taking into account demographic factors such as income level, sex, and age. The sample size was calculated using the formula N = p.q.Zα2/d2, where an average prevalence rate of 70/100,000 was considered based on previous studies. The minimum sample size was 29,858. Considering incomplete, inaccurate, and low-reliability data, data were collected from 30,500 individuals and 30,408 individuals were evaluated.

RESULTS

The prevalence of Multiple Sclerosis in the center of Afyonkarahisar was 105.2 per 100,000 individuals. Upon investigating the association between economic status and MS prevalence, the findings revealed rates of 193.6 per 100,000 in individuals with high income, contrasting with 80.2 per 100,000 in those with low income. Notably, a heightened prevalence of MS is evident among individuals with higher income levels.

CONCLUSION

This study revealed a significantly elevated prevalence of MS in Afyonkarahisar, the highest in Turkey. The inverse correlation between the prevalence of MS and socioeconomic status is intriguing. Possible reasons for the high prevalence include the relatively new and specific geologic and environmental conditions in the area.

A Catastrophic Biodiversity Loss in the Environment Is Being Replicated on the Skin Microbiome: Is This a Major Contributor to the Chronic Disease Epidemic?

There has been a catastrophic loss of biodiversity in ecosystems across the world. A similar crisis has been observed in the human gut microbiome, which has been linked to "all human diseases affecting westernized countries". This is of great importance because chronic diseases are the leading cause of death worldwide and make up 90% of America's healthcare costs. Disease development is complex and multifactorial, but there is one part of the body's interlinked ecosystem that is often overlooked in discussions about whole-body health, and that is the skin microbiome. This is despite it being a crucial part of the immune, endocrine, and nervous systems and being continuously exposed to environmental stressors. Here we show that a parallel biodiversity loss of 30-84% has occurred on the skin of people in the developed world compared to our ancestors. Research has shown that dysbiosis of the skin microbiome has been linked to many common skin diseases and, more recently, that it could even play an active role in the development of a growing number of whole-body health problems, such as food allergies, asthma, cardiovascular diseases, and Parkinson's, traditionally thought unrelated to the skin. Damaged skin is now known to induce systemic inflammation, which is involved in many chronic diseases. We highlight that biodiversity loss is not only a common finding in dysbiotic ecosystems but also a type of dysbiosis. As a result, we make the case that biodiversity loss in the skin microbiome is a major contributor to the chronic disease epidemic. The link between biodiversity loss and dysbiosis forms the basis of this paper's focus on the subject. The key to understanding why biodiversity loss creates an unhealthy system could be highlighted by complex physics. We introduce entropy to help understand why biodiversity has been linked with ecosystem health and stability. Meanwhile, we also introduce ecosystems as being governed by "non-linear physics" principles-including chaos theory-which suggests that every individual part of any system is intrinsically linked and implies any disruption to a small part of the system (skin) could have a significant and unknown effect on overall system health (whole-body health). Recognizing the link between ecosystem health and human health allows us to understand how crucial it could be to maintain biodiversity across systems everywhere, from the macro-environment we inhabit right down to our body's microbiome. Further, in-depth research is needed so we can aid in the treatment of chronic diseases and potentially change how we think about our health. With millions of people currently suffering, research to help mitigate the crisis is of vital importance.

Defining the natural history of tumefactive demyelination: A retrospective cohort of 257 patients

OBJECTIVE

To describe demographic, clinical, and radiographic features of tumefactive demyelination (TD) and identify factors associated with severe attacks and poor outcomes.

METHODS

Retrospective review of TD cases seen at Mayo Clinic, 1990-2021.

RESULTS

Of 257 patients with TD, 183/257 (71%) fulfilled the 2017 multiple sclerosis (MS) McDonald criteria at the last follow-up, 12/257 (5%) had myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), 0 had aquaporin-4-IgG seropositive neuromyelitis optic spectrum disorders (AQP4+ NMOSD), and 62/257 (24%) were cryptogenic. Onset before age 18 was present in 18/257 (7%). Female to male ratio was 1.3:1. Cerebrospinal fluid oligoclonal (CSF) bands were present in 95/153 (62%). TD was the first demyelinating attack in 176/257 (69%). At presentation, 59/126 (47%) fulfilled Barkhof criteria for dissemination in space, 59/100 (59%) had apparent diffusion coefficient (ADC) restriction, and 57/126 (45%) had mass effect. Despite aggressive clinical presentation at onset, 181/257 (70%) of patients remained fully ambulatory (Expanded Disability Status Scale [EDSS] ≤4) after a 3.0-year median follow-up duration. Severe initial attack-related disability (EDSS ≥4) was more common in patients with motor symptoms (81/143 vs. 35/106, p < 0.0001), encephalopathy (20/143 vs. 2/106, p < 0.0001) and ADC restriction on initial MRI (42/63 vs. 15/33, p = 0.04). Poor long-term outcome (EDSS ≥4) was more common in patients with older onset age (41.9 ± 15 vs. 36.8 ± 15.6, p = 0.02) and motor symptoms at onset (49/76 vs. 66/171, p < 0.0001).

INTERPRETATION

Most TD patients should be considered part of the MS spectrum after excluding MOGAD and NMOSD. Motor symptoms and older age at presentation portend a poor outcome.

Visual Outcomes Following Plasma Exchange for Optic Neuritis: An International Multicenter Retrospective Analysis of 395 Optic Neuritis Attacks

PURPOSE

To evaluate the effectiveness of plasma exchange (PLEX) for optic neuritis (ON).

METHODS

We conducted an international multicenter retrospective study evaluating the outcomes of ON following PLEX. Outcomes were compared to raw data from the Optic Neuritis Treatment Trial (ONTT) using a matched subset.

RESULTS

A total of 395 ON attack treated with PLEX from 317 patients were evaluated. The median age was 37 years (range 9-75), and 71% were female. Causes of ON included multiple sclerosis (108), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) (92), aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4+NMOSD) (75), seronegative-NMOSD (34), idiopathic (83), and other (3). Median time from onset of vision loss to PLEX was 2.6 weeks (interquartile range [IQR], 1.4-4.0). Median visual acuity (VA) at the time of PLEX was count fingers (IQR, 20/200-hand motion), and median final VA was 20/25 (IQR, 20/20-20/60) with no differences among etiologies except MOGAD-ON, which had better outcomes. In 81 (20.5%) ON attacks, the final VA was 20/200 or worse. Patients with poor outcomes were older (P = .002), had worse VA at the time of PLEX (P < .001), and longer delay to PLEX (P < .001). In comparison with the ONTT subset with severe corticosteroid-unresponsive ON, a final VA of worse than 20/40 occurred in 6 of 50 (12%) PLEX-treated ON vs 7 of 19 (37%) from the ONTT treated with intravenous methylprednisolone without PLEX (P = .04).

CONCLUSION

Most ON attacks improved with PLEX, and outcomes were better than attacks with similar severity in the ONTT. The presence of severe vision loss at nadir, older age, and longer delay to PLEX predicted a worse outcome whereas MOGAD-ON had a more favorable prognosis. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Multiple sclerosis incidence temporal trend in the Northeast of Iran: Using the Empirical Bayesian method

BACKGROUND

In recent years dramatic changes in multiple sclerosis (MS) incidence have been reported in different provinces in Iran. This study was conducted to assess MS incidence temporal trends from March 21, 2005, to March 20, 2020, and provide a forecast until the end of 2025 in Shahroud county.

METHODS

This longitudinal study was carried out based on the data obtained from the MS registration system in Shahroud county. First, the annual incidence rates were calculated based on the year of diagnosis and smoothed using the Empirical Bayesian Method. Then temporal trends and annual percent change (APC) of MS incidence were analyzed using Joinpoint (JP) regression. Finally, the univariate time series model analysis was used to estimate the MS incidence trend until the end of 2025.

RESULTS

A total of 234 newly diagnosed cases (60 [25.64%] males and 174 [74.36.4%] females) were examined in this study. The mean age of patients at the time of diagnosis was 31.40 ± 3.78. It was 32.01 ± 6.35 and 30.66 ± 4.27 years for males and females, respectively (P<0.22). The mean annual MS incidence was 5.99 ± 1.46, 3.03 ± 0.21, and 8.98 ± 2.79 per 100,000 in overall, males and females respectively. The MS incidence increased significantly from 5.67 (95% CI: 3.63-7.99) in 2005 to 7.58 (95% CI: 5.17-10.28) in 2020 with an APC of 4.5 (2.8 - 6.1). The MS incidence had a non-linear time trend in the study period and the best time trend fitted to the annual MS incidence trend was the non-linear quadratic curve. Based on this model, the annual MS incidence is expected to increase until the end of 2025.

CONCLUSION

Shahroud county is one of the high-risk areas for MS and the increasing trend of MS incidence in it is similar to regional and global changes. This study, also, showed that MS incidence in Shahroud county will be increasing in the coming years.

Racial and Ethnic Disparities in Multiple Sclerosis Prevalence

BACKGROUND AND OBJECTIVES

The goal of this work was to determine whether the prevalence of multiple sclerosis (MS) varies by race and ethnicity.

METHODS

We conducted a retrospective cohort study of >2.6 million adults from the multiethnic, community-dwelling members of Kaiser Permanente Southern California. The complete electronic health records of individuals with at least 1 ICD-9 code for MS between January 1, 2008 and December 31, 2010 were reviewed. MS prevalence and 95% CIs stratified by age, sex, and race and ethnicity among 2010 members were estimated with binomial regression. Age- and sex-standardized prevalence was estimated according to the 2010 US Census population.

RESULTS

We identified 3,863 patients with MS. The average age of patients with prevalent MS was 51.7 years (SD 13.1 years), and 76.8% were women. The female preponderance was more pronounced among Black (81.2%) and Asian (83.6%) than White (76.3%) or Hispanic (74.5%) individuals with MS. Age- and sex-standardized MS prevalence per 100,000 was similarly high among Black (225.8, 95% CI 207.1-244.5) and White (237.7, 95% CI 228.2-247.2) and significantly lower among Hispanic (69.9, 95% CI 64.4-75.5) and Asian (22.6, 95% CI 17.1-28.1) persons. MS prevalence was highest between the ages of 35 and 64 years and declined after 65 years of age across all racial and ethnic groups. Among adults 18 to 24 years of age, the crude MS prevalence was low but was highest among Black and Hispanic young adults, lower in White people, and lowest in Asian/Pacific Islander individuals (48.5, 25.0, 18.0, and 7.1 per 100,000, respectively).

DISCUSSION

MS prevalence varies by race and ethnicity, being similarly high in White and Black and significantly lower in Hispanic and Asian persons in Southern California. Taken together with previous studies, these findings indicate that the burden of MS in the US Black community has long been underrecognized. More studies are needed to determine whether MS is an emerging disease among US Hispanic adults and whether MS susceptibility and prevalence vary among Hispanic or Asian individuals from different cultures or ancestral backgrounds.

Population-based incidence and clinico-radiological characteristics of tumefactive demyelination in Olmsted County, Minnesota, United States

BACKGROUND AND PURPOSE

Tumefactive demyelination (TD) presents with large inflammatory lesions mimicking tumors or other space-occupying lesions. Limited epidemiological, clinical and radiological data exist for TD. We aimed to report the incidence rate, and clinical and radiological features of TD in Olmsted County, Minnesota.

METHODS

We retrospectively reviewed patients with central nervous system inflammatory demyelination-related diagnostic codes (January 1, 1998 to December 31, 2018) in the Rochester Epidemiology Project database, and adjusted incidence rates by age and sex to the 2010 US total population. We used the Expanded Disability Status Scale (EDSS) to assess outcomes (index attack and last follow-up).

RESULTS

Of 792 multiple sclerosis (MS) patients, 15 (eight males, seven females) had tumefactive MS, representing 1.9% of the MS population. The median (range) age at attack onset was 34.2 (2-61) years. Tumefactive lesion was the first clinical MS attack in 8/16 patients. Cerebrospinal fluid oligoclonal bands (OCBs) were present in 8/12 patients and 11/16 patients met the Barkhof criteria for dissemination in space. Most patients remained fully ambulatory (EDSS score ≤4 in 13/16 patients [81%]) after a median (range) follow-up duration of 10.5 (1-20.5) years. Age-adjusted annual incidence rates were 0.46/100,000 (95% confidence interval [CI] 0.12-0.81) for female patients, 0.66/100,000 (95% CI 0.23-1.02) for male patients, and 0.56/100,000 [95% CI 0.28-0.83] overall. When age- and sex-adjusted to the 2010 US total population, the overall annual incidence rate was 0.57 (95% CI 0.28-0.84). Despite aggressive clinical presentation at disease onset, most patients remained fully ambulatory (EDSS score ≤4 in 13/16 patients) with a relapsing-remitting course.

CONCLUSIONS

Although incidence is rare, TD should be suspected in patients presenting with subacutely progressive neurological deficits associated with magnetic resonance imaging findings of ring enhancement, apparent diffusion coefficient restriction, and OCB on spinal fluid analysis.

Non-infectious mechanisms of neurological damage due to infection

Infections of the nervous system is a growing aspect of clinical neurology. Accumulating knowledge in early diagnosis, course, therapy and prognosis is enlarging the clinical tools required for effective therapy. Of special importance is the ability to differentiate between proper infections, where anti-microbial agents, when available, should be introduced and used and post infectious conditions where therapy is mainly directed against the host immune system. The two conditions sometimes overlap, a situation that requires the ability to combine clinical skills with the use of laboratory tools such as polymerase chain reaction (PCR), serology, and antigenic detection. In the era of the SARS-CoV-2 pandemic, the need to make this distinction is emphasized as correct diagnosis of post infectious conditions and expedited therapy is important and sometimes lifesaving. We here attempt to present several infectious agents and their possible indirect damage to the nervous system causing in some cases significant neurological deficits. We try to limit our focus on those mechanisms which do not involve the direct tissue damage by the infectious agents but rather are connected to para- and post-infectious mechanisms. We attempt to delineate the features that will enable to tailor the correct diagnosis and following the effective therapy.

Fatigue is associated with physical inactivity in people with multiple sclerosis despite different environmental backgrounds: Merging and comparing cohorts from Turkey and Israel

BACKGROUND

Examining leisure-time physical activity in people with multiple sclerosis (PwMS) from different environmental backgrounds might increase understanding and awareness of inactivity in PwMS. Therefore, the study objective was twofold; to compare the level of physical activity in PwMS in Israel and Turkey and to examine the relationship between the level of physical activity with common disease-related symptoms and demographical characteristics of PwMS.

METHODS

Cross-sectional data collected by two centers were combined. The physical activity level was determined by the Godin Leisure-Time Exercise Questionnaire, and subsequently, classified into one of three subgroups: "active", "moderately active" and "insufficiently active". Logistic regressions determined the risks of insufficiently active PwMS, according to age, gender, body mass index, disability, impact of walking impairment, disease duration, type of MS and perceived fatigue. The analysis of variance test determined the differences between countries in terms of outcome variables.

RESULTS

The study comprised 458 patients from Israel and 575 from Turkey; 68.2% Turkish PwMS were classified as insufficiently active compared with 52.0% of Israeli PwMS. The percentage of insufficiently active PwMS was significantly higher in those categorized as fatigued compared to non-fatigued in the total cohort (72.4% vs. 51.9%, p<0.001) and in each country separately. Based on the regression analysis, fatigue was the main factor associated with the insufficiently physically active group; odds ratio=1.968.

CONCLUSION

PwMS with increased fatigue tend to participate in less leisure-time physical activities compared with the non-fatigued. This observation is supported by the merged data collected from two countries, Turkey and Israel, representing PwMS from different environmental backgrounds.

Apparent changes in the epidemiology and severity of multiple sclerosis

Multiple sclerosis (MS) is an immunological disease that causes acute inflammatory lesions and chronic inflammation in the CNS, leading to tissue damage and disability. As awareness of MS has increased and options for therapy have come into use, a large amount of epidemiological data have been collected, enabling studies of changes in incidence and disease course over time. Overall, these data seem to indicate that the incidence of MS has increased, but the course of the disease has become milder, particularly in the 25 years since the first disease-modifying therapies (DMTs) became available. A clear understanding of these trends and the reasons for them is important for understanding the factors that influence the development and progression of MS, and for clinical management with respect to prevention and treatment decisions. In this Review, we consider the evidence for changes in the epidemiology of MS, focusing on trends in the incidence of the disease over time and trends in the disease severity. In addition, we discuss the factors influencing these trends, including refinement of diagnostic criteria and improvements in health-care systems that have increased diagnosis in people with mild disease, and the introduction and improvement of DMT.

Effects of Combined Endurance and Resistance Training in Women With Multiple Sclerosis: A Randomized Controlled Study

Purpose: To test the hypothesis that combined resistance and endurance training would improve muscle strength, fatigue, depression, and quality of life in persons with MS.

Methods: Twenty-seven women with MS were randomly assigned to either control (CON, n = 13) or the experimental (EXP, n = 14) group. The participants in the EXP group trained twice a week for 12 weeks, followed by 12 weeks of detraining. Both CON and EXP groups were tested before and after 12 weeks of the intervention period, as well as 12 weeks after training cessation (follow-up), where measures of muscle strength, fatigue, depression, and quality of life were evaluated.

Results: There were significant changes in maximal voluntary isometric contraction (MVIC), 1RM leg extension, and 1RM chest press following the intervention period in the EXP group (P < 0.05), but not in the CON group (P > 0.05). These changes persisted after 12 weeks of detraining. Similar findings were found for fatigue, depression, and physical and mental composites of quality of life.

Conclusion: These results suggest that combined exercise training, at a minimum, prevents the disease-related deterioration of muscular performance and quality of life and well-being in persons with MS.

Long-term clinical, MRI, and cognitive follow-up in a large cohort of pathologically confirmed, predominantly tumefactive multiple sclerosis

BACKGROUND

Limited studies have described long-term outcomes in pathology confirmed multiple sclerosis (MS).

OBJECTIVES

To describe long-term clinical-radiographic-cognitive outcomes in a prospectively followed cohort of patients with pathologically confirmed CNS demyelinating disease, consistent with MS.

METHODS

Subjects underwent clinical assessment, standardized 3T-MRI brain, and cognitive battery.

RESULTS

Seventy-five patients were included. Biopsied lesion size was ⩾ 2 cm in 62/75. At follow-up, median duration since biopsy was 11 years. Median EDSS was 3 and lesion burden was large (median 10 cm³). At follow-up, 57/75 met MS criteria, 17/75 had clinically isolated syndrome, and 1 radiographic changes only. Disability scores were comparable to a prevalence cohort in Olmsted County (p < 0.001, n = 218). Cognitive outcomes below age-normed standards included psychomotor, attention, working memory, and executive function domains. Total lesion volume and index lesion-related severity correlated with EDSS and cognitive performance. Volumetric cortical/subcortical GM correlated less than lesion metrics to cognitive outcomes.

CONCLUSION

Despite early aggressive course in pathologically confirmed MS, its long-term course was comparable to typical MS in our study. Cognitive impairment in this group seemed to correlate strongest to index lesion severity and total lesion volume. It remains to be established how the aggressive nature of the lesion, biopsy, and treatment affect clinical/cognitive outcomes.

U.S. Population-Based background incidence rates of medical conditions for use in safety assessment of COVID-19 vaccines

The Coronavirus Disease 2019 (COVID-19) pandemic has had a devastating impact on global health, and has resulted in an unprecedented, international collaborative effort to develop vaccines to control the outbreak, protect human lives, and avoid further social and economic disruption. Mass vaccination campaigns are underway in multiple countries and are expected worldwide once more vaccine becomes available. Some early candidate vaccines use novel platforms, such as mRNA encapsulated in lipid nanoparticles, and relatively new platforms, such as replication-deficient viral vectors. While these new vaccine platforms hold promise, limited safety data in humans are available. Serious health outcomes linked to vaccinations are rare, and some outcomes may occur incidentally in the vaccinated population. Knowledge of background incidence rates of these medical conditions is a critical component of vaccine safety monitoring to aid in the assessment of adverse events temporally associated with vaccination and to put these events into context with what would be expected due to chance alone. A list of 22 potential adverse events of special interest (AESI), including neurologic, autoimmune, and cardiovascular disorders, was compiled by subject matter experts at the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention. The most recently available U.S. background rates for these medical conditions, overall and by age, sex, and race/ethnicity (when available), were sourced from reported statistics (data published by medical panels/ associations or federal government reports), and literature reviews in PubMed. This review provides estimates of background incidence rates for medical conditions that may be monitored or studied as AESI during safety surveillance and research for COVID-19 vaccines and other new vaccines.

CNS demyelination with TNFα inhibitor exposure: A retrospective cohort study

OBJECTIVE

To study long-term outcomes in patients with CNS demyelinating events exposed to TNFa-inhibitors (TNFai), including subsequent clinical relapse, MRI lesions, and use of disease modifying therapy (DMT) for MS.

METHODS

Adult patients evaluated for a CNS demyelinating disease during TNFai use were identified at Mass General Brigham [01/1998-08/2020] and analyzed in clinically-relevant subgroups. Inclusion criteria required a first neurological event while taking a TNFai, MRI lesions consistent with demyelination, and the absence of a more probable alternative diagnosis.

RESULTS

21 cases (mean age 44 years, 20 female, 14 ≥ 2 MS risk factors) had an index neurological event (INE) at a median of 12 months (range 1-176) from onset of TNFai use (adalimumab in 10, etanercept 6, infliximab 5). MRI lesions were most often present in periventricular (16/20, 80%) and spinal zones (10/20, 50%); 37% (7/19) met ≥ 2 Barkhof criteria at onset. CSF testing was abnormal in 64% (7/11). 67% (10/15) with available follow-up MRIs developed new lesions by a median of 29.5 months of MRI surveillance (median MRI surveillance 60 months); 55% (11/20) met ≥ 2 Barkhof criteria. 47% (8/17) suffered a clinical relapse by a median of 40.5 months of clinic follow-up (median clinic follow-up since INE: 26 months). In patients discontinuing TNFai (18/21, 86%) at INE onset, 56% (10/18) had further evidence of CNS demyelination. Six patients (6/21, 29%) started an MS disease modifying therapy (DMT) at INE of whom 50% (3/6) had subsequent disease activity. Continuing or restarting TNFai was followed by relapse in 75% (3/4). 65% (13/20) met 2017 McDonald criteria for MS at INE with another 10% (15/20, 75%) by study conclusion.

CONCLUSIONS

With extended follow-up, a majority of patients had a relapsing CNS demyelinating disorder-as evidenced by new MRI lesions or clinical relapses-despite TNFai discontinuation.

Multiple sclerosis-like NMOSD patients suffer severe worsening of status after fingolimod initiation

BACKGROUND

Initial clinical manifestations of NMOSD may rarely overlap with MS. Fingolimod may trigger severe attacks in patients with NMOSD previously misdiagnosed as MS. These cases are rare and their pathophysiology remains elusive.

METHODS

We recruited all NMOSD patients treated by fingolimod in a single-center cohort of Afro-Caribbean neuro-inflammatory patients in Fort-de-France (French West Indies). Six patients were collected from the literature.

RESULTS

Among 622 patients followed locally for MS, 101 received fingolimod and two suffered severe attacks revealing a typical NMOSD presentation. These two patients were found to have AQP4-IgG. The risk of misdiagnosed NMOSD in MS in our high-risk Afro-Caribbean patients was estimated to be 1.9% (0 to 4.7%). Among the whole cohort, relapses occurred within a month after fingolimod initiation in five patients. All attacks were severe and contrasted with previously benign attacks, suggesting a shift to a more severe disorder. An unusual finding in these patients was large brain lesions.

CONCLUSION

AQP4-IgG should be obtained before initiation of fingolimod in high-risk patients, especially in those from areas of high NMOSD prevalence.

Identification of blood-derived candidate gene markers and a new 7-gene diagnostic model for multiple sclerosis

Background

Multiple sclerosis (MS) is a central nervous system disease with a high disability rate. Modern molecular biology techniques have identified a number of key genes and diagnostic markers to MS, but the etiology and pathogenesis of MS remain unknown.

Results

In this study, the integration of three peripheral blood mononuclear cell (PBMC) microarray datasets and one peripheral blood T cells microarray dataset allowed comprehensive network and pathway analyses of the biological functions of MS-related genes. Differential expression analysis identified 78 significantly aberrantly expressed genes in MS, and further functional enrichment analysis showed that these genes were associated with innate immune response-activating signal transduction (p = 0.0017), neutrophil mediated immunity (p = 0.002), positive regulation of innate immune response (p = 0.004), IL-17 signaling pathway (p < 0.035) and other immune-related signaling pathways. In addition, a network of MS-specific protein–protein interactions (PPI) was constructed based on differential genes. Subsequent analysis of network topology properties identified the up-regulated CXCR4, ITGAM, ACTB, RHOA, RPS27A, UBA52, and RPL8 genes as the hub genes of the network, and they were also potential biomarkers of MS through Rap1 signaling pathway or leukocyte transendothelial migration. RT-qPCR results demonstrated that CXCR4 was obviously up-regulated, while ACTB, RHOA, and ITGAM were down-regulated in MS patient PBMC in comparison with normal samples. Finally, support vector machine was employed to establish a diagnostic model of MS with a high prediction performance in internal and external datasets (mean AUC = 0.97) and in different chip platform datasets (AUC = (0.93).

Conclusion

This study provides new understanding for the etiology/pathogenesis of MS, facilitating an early identification and prediction of MS.

Incidence of multiple sclerosis in China: A nationwide hospital-based study

BACKGROUND

Multiple sclerosis (MS) is a leading cause of disability among young adults and effects considerable social and economic burdens. Data of MS incidence in China at the national level is lacking. We conducted the first nationwide hospital-based study to estimate the incidence and hospitalization burden of MS in China.

METHODS

This study is based on an administrative database of the National Hospital Quality Monitoring System, which covers all 1665 tertiary hospitals in mainland China. The "Medical Record Homepage" of all patients, including 346 variables including demographic characteristics, diagnoses, procedures, and expenses etc., were uniformly collected across each tertiary hospital via standard protocol. MS was defined by the 2010 International Panel criteria for MS and was identified by ICD-10 code (G35•0).

FINDINGS

We identified 27,336 hospital admissions for 15,060 MS patients from 2016 to 2018; amongst these patients, 9,879 were newly diagnosed. The age- and sex-adjusted incidence per 100,000 person-years is 0•235 (95% confidence interval [CI] 0•230-0•240), with 0•055 (0•050-0•060) in children and 0•288 (0•282-0•294) in adults, respectively. The female to male ratio is 2•02; the peak disease onset is age of 40-49 years. Residents in high-latitude and high-altitude areas are more likely to develop MS (F = 8•99; p < 0•001). Prevalent comorbidities include hypertension (18•8%), diabetes (7•2%), stroke (14•7%), depression or anxiety (3•7%), and autoimmune disease (2•3%). Through 2016-2018, 104 adults and 2 children died, with a hospital mortality rate of 9•9 per 1,000 person-years.

INTERPRETATION

For the first time, we obtain the national incidence of MS as 0.055 in children and 0.288 in adults per 100,000 in China. The geographical distribution of MS incidence presented a north-south latitude gradient and a west-east altitude gradient.

FUNDING

National Science Foundation of China (81801199, 91642205, and 81830038); Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing.

Imaging Biomarkers of Alzheimer Disease in Multiple Sclerosis

Objective

To investigate β‐amyloid and tau depositions using Pittsburgh compound B (PiB) positron emission tomography (PET) and AV1451 tau PET imaging in aging multiple sclerosis (MS) patients.

Methods

Patients with MS (n = 16) and controls (n = 80) matched for age, sex, and APOE ε4 status from the population‐based Mayo Clinic Study of Aging who underwent PiB PET imaging were studied. Of these individuals, 12 patients with MS and 60 matching controls also underwent AV1451 tau PET. Cortical PiB and AV1451 standard uptake value ratios (SUVrs) from the entire cortex and previously determined Alzheimer disease (AD) signature regions in the same population were calculated for group comparisons and testing for associations with age.

Results

AD signature PiB SUVr (odds ratio [OR] [95% confidence interval (CI)] = 0.52 [0.27–0.98], p = 0.044), total cortical PiB SUVr (OR [95% CI] = 0.52 [0.28–0.99], p = 0.048), and the frequency of abnormal PiB SUVrs (OR [95% CI] = 0.10 [0.01–0.90], p = 0.040) were lower in MS than controls. Although AD‐signature and total cortical AV1451 SUVrs were not different between the groups, the frequency of abnormal AV1451 SUVrs was higher (OR [95% CI] = 10.65 [1.10–103.35], p = 0.041) in MS than controls. The association of AD signature PiB SUVr with age was steeper in the controls compared to patients with MS (estimate [95% CI] = −0.14 [−0.023 to −0.006], p = 0.002). Similarly, the association of total cortical PiB SUVr with age was steeper in the controls compared to patients with MS (estimate [95% CI] = −0.13 [−0.021 to −0.005], p = 0.002). There was no difference in the association of AV1451 SUVr findings with age between the MS patients and controls.

Interpretation

Although both β‐amyloid and tau are biomarkers of cognitive aging and AD, cortical β‐amyloid deposition was lower in MS than age‐matched controls, suggesting that some aspect of MS pathobiology retards the accumulation of β‐amyloid but not the accumulation of tau. ANN NEUROL 2020;87:556–567

Epidemiology and treatment of multiple sclerosis in elderly populations

The prevalence of multiple sclerosis (MS) and the age of affected patients are increasing owing to increased longevity of the general population and the availability of effective disease-modifying therapies. However, ageing presents unique challenges in patients with MS largely as a result of their increased frequency of age-related and MS-related comorbidities as well as transition of the disease course from an inflammatory to a neurodegenerative phenotype. Immunosenescence (the weakening of the immune system associated with natural ageing) might be at least partly responsible for this transition, which further complicates disease management. Currently approved therapies for MS are effective in preventing relapse but are not as effective in preventing the accumulation of disability associated with ageing and disease progression. Thus, ageing patients with MS represent a uniquely challenging population that is currently underserved by existing therapeutic regimens. This Review focuses on the epidemiology of MS in ageing patients. Unique considerations relevant to this population are discussed, including the immunology and pathobiology of the complex relationship between ageing and MS, the safety and efficacy of disease-modifying therapies, when discontinuation of treatment might be appropriate and the important role of approaches to support wellness and cognition.

Increasing prevalence of multiple sclerosis in Tuscany, Italy

BACKGROUND AND RATIONALE

An increase of prevalence and incidence of multiple sclerosis (MS) has been reported in several countries, especially taking into account a long-term evaluation. This increasing trend often reflects improved case identification and ascertainment due to the refinement of diagnostic criteria. The aim of this study was to update the prevalence rate of MS in Tuscany (central Italy) as of 2017, and to assess if there has been an increasing trend of prevalence in this Region considering a short period of analysis, from 2014 to 2017.

METHODS

To capture prevalent cases, a case-finding algorithm based on administrative data, previously created and validated, was used. As data sources, we considered hospital discharge records, drug-dispensing records, disease-specific exemptions from copayment to health care, home and residential long-term care, and inhabitant registry.

RESULTS

As of January 1, 2017, 7809 cases were identified, of which 69.4% were females and 30.6% were males. Considering temporal variation, an increasing trend was observed, with standardized rates rising from 189.2 in 2014 to 208.7 per 100,000 in 2017.

CONCLUSIONS

Results confirm that prevalence increases every year, probably mainly due to the difference between incidence and mortality, resulting in an increasing trend. Moreover, administrative data may accurately identify MS patients in a routinary way and monitor this cohort along disease care pathways.

Incidence of multiple sclerosis in Iran: a nationwide, population-based study

OBJECTIVES

The incidence of multiple sclerosis (MS) is not well known in Iran. This study was conducted to estimate the trends in annual MS incidence in Iran from March 21, 2010, to March 20, 2016.

STUDY DESIGN

Longitudinal study.

METHODS

In this longitudinal study, data for all MS patients fulfilling McDonald criteria were obtained from a national registry, coordinated by the Ministry of Health (MOH). In Iran, all MS patients are eligible to receive public care and treatment services based on their records in this registry, and thus nearly all MS patients are registered in this database. The annual incidence rates were calculated based on year of diagnosis and were standardized using the World Health Organization (2000-2025) population as a standard.

RESULTS

In this registry, 36,287 (8202 [22.6%] males and 28,085 [77.4%] females) confirmed MS cases were registered by the MOH between 2010 and 2016. The female-to-male ratio was 3.11. The mean age of patients was 31.6 ± 0.9 years at the time of diagnosis. It was 31.3 ± 0.8 and 32.3 ± 0.9 for females and males, respectively. Overall incidence rate was 6.7/100,000 population (95% confidence interval [CI]: 6.2-7.2); 10.5 and 3.0 in females and males, respectively. The age-adjusted incidence rates increased significantly from 4.4 (95% CI: 4.3-4.6) in 2010 to 5.8 (95% CI: 5.7-6.0) in 2016, with its peak at 6.5 (95% CI: 6.3-6.6) in 2014.

CONCLUSIONS

This study revealed that Iran is a high-risk area for MS disease and that MS incidence and female-to-male ratio are more or less comparable with the dominant patterns in developed countries. Also, this study showed that the incidence trend of MS in Iran is similar to regional and global observed patterns.

Optimization of a 40-mer Antimyelin DNA Aptamer Identifies a 20-mer with Enhanced Properties for Potential Multiple Sclerosis Therapy

We previously reported the in vitro selection and characterization of a DNA aptamer capable of stimulating remyelination in a mouse model of multiple sclerosis. This aptamer was selected for its ability to bind to suspensions of crude murine myelin in vitro. Our initial studies in vitro and in vivo involved a 40-nucleotide derivative (LJM-3064) of the original 100-nucleotide aptamer. LJM-3064 retained robust myelin-binding properties. Structural characterization of LJM-3064 revealed that the guanosine-rich 5' half of the sequence forms different G-quadruplex-type structures that are variably stable in the presence of physiologically relevant ions. We hypothesized that this structured domain is sufficient for myelin binding. In this study, we confirm that a 20-nucleotide DNA, corresponding to the 5' half of LJM-3064, retains myelin-binding properties. We then optimize this minimal myelin-binding aptamer via systematic evolution of ligands by exponential enrichment after sparse rerandomization. We report a sequence variant (LJM-5708) of the 20-nucleotide myelin-binding aptamer with enhanced myelin-binding properties and the ability to bind cultured human oligodendroglioma cells in vitro, providing the first evidence of cross-species reactivity of this myelin-binding aptamer. As our formulation of DNA aptamers for in vivo remyelination therapy involves conjugation to streptavidin, we verified that the myelin-binding properties of LJM-5708 were retained in conjugates to avidin, streptavidin, and neutravidin. DNA aptamer LJM-5708 is a lead for further preclinical development of remyelinating aptamer technologies.

Glial cells as therapeutic targets in progressive multiple sclerosis

Introduction: Multiple sclerosis is a serious demyelinating disease of the central nervous system (CNS) with treatments generally restricted to immunosuppression to reduce attack rate and for symptom management. Glial cells may be useful targets for future CNS regenerative therapies to reverse disease. Areas covered: In this review, the authors cover currently available multiple sclerosis treatments and examine potential upcoming therapies targeting glial cells. The potential for new therapeutic approaches in the treatment of progressive multiple sclerosis is examined. Expert opinion: Microglia, astrocytes, and oligodendrocytes are each promising targets for the disease-altering treatment of multiple sclerosis. Though challenging, the opportunities presented have great potential for CNS regeneration and further investigation of glial cells in therapy is warranted. Patient-specific combinatorial therapy targeting the three glial cell types is expected to be the future of MS treatment.

Self-efficacy and Physical and Cognitive Function in Older Adults with Multiple Sclerosis

Background

There is evidence of a demographic shift in the prevalence of multiple sclerosis (MS) such that it is now common in older adults. Older adults with MS undergo declines in function, and aging with MS may compromise one's perception of confidence for managing this disease and its manifestations. This cross-sectional study examined the associations between self-efficacy and physical and cognitive function in older (≥ 60 years) adults with MS.

Methods

The sample included 40 older adults with MS who completed the Multiple Sclerosis Self-efficacy (MSSE) Scale, undertook measures of physical and cognitive function, and wore an accelerometer for 7 days. The data were analyzed using partial Spearman correlations and linear regression.

Results

Correlation analyses indicated that function, but not control, subscale scores on the MSSE Scale correlated with all measures of physical, but not cognitive, function. Linear regression analyses indicated that the function subscale of the MSSE Scale was the only variable that consistently explained variance in physical function outcomes.

Conclusions

The findings are novel evidence of the association between self-efficacy for function and physical function outcomes in older adults with MS. Future research on self-efficacy is warranted with the goal of improving physical function in older adults with MS.

A new way to estimate neurologic disease prevalence in the United States: Illustrated with MS

OBJECTIVE

Considerable gaps exist in knowledge regarding the prevalence of neurologic diseases, such as multiple sclerosis (MS), in the United States. Therefore, the MS Prevalence Working Group sought to review and evaluate alternative methods for obtaining a scientifically valid estimate of national MS prevalence in the current health care era.

METHODS

We carried out a strengths, weaknesses, opportunities, and threats (SWOT) analysis for 3 approaches to estimate MS prevalence: population-based MS registries, national probability health surveys, and analysis of administrative health claims databases. We reviewed MS prevalence studies conducted in the United States and critically examined possible methods for estimating national MS prevalence.

RESULTS

We developed a new 4-step approach for estimating MS prevalence in the United States. First, identify administrative health claim databases covering publicly and privately insured populations in the United States. Second, develop and validate a highly accurate MS case-finding algorithm that can be standardly applied in all databases. Third, apply a case definition algorithm to estimate MS prevalence in each population. Fourth, combine MS prevalence estimates into a single estimate of US prevalence, weighted according to the number of insured persons in each health insurance segment.

CONCLUSIONS

By addressing methodologic challenges and proposing a new approach for measuring the prevalence of MS in the United States, we hope that our work will benefit scientists who study neurologic and other chronic conditions for which national prevalence estimates do not exist.

The prevalence of MS in the United States: A population-based estimate using health claims data

OBJECTIVE

To generate a national multiple sclerosis (MS) prevalence estimate for the United States by applying a validated algorithm to multiple administrative health claims (AHC) datasets.

METHODS

A validated algorithm was applied to private, military, and public AHC datasets to identify adult cases of MS between 2008 and 2010. In each dataset, we determined the 3-year cumulative prevalence overall and stratified by age, sex, and census region. We applied insurance-specific and stratum-specific estimates to the 2010 US Census data and pooled the findings to calculate the 2010 prevalence of MS in the United States cumulated over 3 years. We also estimated the 2010 prevalence cumulated over 10 years using 2 models and extrapolated our estimate to 2017.

RESULTS

The estimated 2010 prevalence of MS in the US adult population cumulated over 10 years was 309.2 per 100,000 (95% confidence interval [CI] 308.1-310.1), representing 727,344 cases. During the same time period, the MS prevalence was 450.1 per 100,000 (95% CI 448.1-451.6) for women and 159.7 (95% CI 158.7-160.6) for men (female:male ratio 2.8). The estimated 2010 prevalence of MS was highest in the 55- to 64-year age group. A US north-south decreasing prevalence gradient was identified. The estimated MS prevalence is also presented for 2017.

CONCLUSION

The estimated US national MS prevalence for 2010 is the highest reported to date and provides evidence that the north-south gradient persists. Our rigorous algorithm-based approach to estimating prevalence is efficient and has the potential to be used for other chronic neurologic conditions.

Prevalence of multiple sclerosis in an urban population of Sivas province in Turkey

Background/aim

Multiple sclerosis (MS) is a common neurological disorder that can be a leading cause of nontraumatic disability in several countries. Recent reports have indicated a moderate to high risk of MS in European countries. In this study, we examined the prevalence of MS in a well-defined urban population of provincial center in Sivas Province in Turkey.

Materials and methods

This study sampled all registered residents of urban areas of provincial center in Sivas Province in April 2017 and 2018 January. All the included patients met the McDonald 2010 criteria. Medical records were reviewed, including all available previously acquired magnetic resonance imaging data. All patients were subsequently subjected to neurologic examination to confirm the MS diagnosis.

Results

We identified 21 possible MS patients, with MS diagnosis confirmed in 19. The prevalence of MS was 288 per 100,000 inhabitants.

Conclusion

For future studies, these high ratio results can be used in regional and national comparisons to determine cofactors contributing to the high prevalence of MS in our region and can help health-decision makers to better plan healthcare policies to improve neurological services and awareness about multifaceted clinical presentations of MS.

Geographic variations of multiple sclerosis in Iran: A population based study

BACKGROUND

The epidemiology of Multiple sclerosis (MS) has changed in recent decades. Considering that the incidence and geographical variations of MS is not well known in Iran. The present study was conducted to investigate the incidence of MS and its geographic variations in Iran.

METHODS

Data from a national registry, coordinated by the Ministry of Health (MOH), were collected for this study. In Iran, all MS patients are eligible to receive care and treatment services based on their records in this registry. Therefore, it seems that the related data are comprehensive with very high coverage, particularly in recent years. In this study, the annual incidence rates were calculated based on year of diagnosis of MS.

RESULTS

In this registry, 32,633 new cases were recorded between 2011 and 2016. After standardized for age, the mean annual incidence rate was 6.5 per 100,000 populations. It was 10.2 and 2.9 in women and men respectively. This incidence ranged from 1.7 to 12.8 in provincial level, with a higher intensity in the central part of the country.

CONCLUSION

It seems that the incidence rate of MS and its ratio in females and males are more or less comparable with the dominant patterns in developed countries, although its variation within the country is very considerable.

Age is a critical determinant in recovery from multiple sclerosis relapses

Objective:

To evaluate the impact of age on recovery from multiple sclerosis relapses.

Background:

Increasing disability in multiple sclerosis is a consequence of progressive disease and incomplete relapse recovery.

Methods:

The first and last-ever relapse data (357 relapses in 193 patients) from the Olmsted County population-based multiple sclerosis cohort were systematically reviewed for age, fulminance, location (optic nerve, brainstem/cerebellar, spinal cord), peak deficit, and maximum recovery. Three different relapse-outcome measures were studied both as paired analyses and as an overall group effect: change from peak deficit to maximum recovery in raw functional system score related to the relapse (ΔFSS), a previously published FSS-based relapse-impact model, and change from peak deficit to maximum recovery in Extended Disability Status Scale (ΔEDSS) score.

Results:

Older age was linearly associated with worse recovery in the ΔFSS outcome ( p = 0.002), ΔEDSS outcome ( p < 0.001), and the FSS-based relapse-impact model ( p < 0.001). A multivariate analysis of ΔFSS outcome linked poor recovery to older age ( p = 0.015), relapse location (transverse myelitis or brainstem/cerebellar syndrome; p < 0.001), and relapse fulminance ( p = 0.004).

Conclusion:

Multiple sclerosis-relapse recovery declines in a linear fashion with increased age, which should be considered when making treatment decisions.

Fear of falling, not falls, impacts leisure-time physical activity in people with multiple sclerosis

BACKGROUND

There is a consensus that physical activity is imperative for people with MS (PwMS). However, regardless of the benefits, many PwMS do not participate in any meaningful physical activity.

AIM

To examine the relationship between leisure-time physical activity with clinical characteristics and common symptoms in PwMS.

METHODS

The sample included 190 PwMS (107 women), mean age 40.8 (S.D = 13.1) and mean disease duration of 6.4 (SD = 8.3) years since diagnosis. Outcome measures included the Godin Leisure-Time Exercise Questionnaire (GLTEQ), Four Square Step Test (FSST), 2-Minute Walk test (2 mWT), Timed Up and Go test (TUG), Timed 25-Foot Walk test (T25FW), fall status, Falls Efficacy Scale International (FES-I), Modified Fatigue Impact Scale (MFIS), walking speed and the Multiple Sclerosis Walking Scale self-reported questionnaire (MSWS-12).

RESULTS

Eighty-six PwMS were classified as active (GLTEQ = 31.6 (S.D = 16.7); 104 were insufficiently active (GLTEQ = 3.0 (S.D = 4.3). Insufficiently active PwMS demonstrated a slower walking speed, elevated fatigue, more concerns of falling and additional walking difficulties compared to active PwMS. Non-significant differences between groups were observed in the TUG, 2 mWT, FSST, T25FWT and fall status. According to the linear regression, by utilizing the FES-I we observed a 12.2% variance related to leisure-time physical activity. The independent variables: EDSS, MSWS-12, fatigue and walking speed were non-significant.

SIGNIFICANCE

The present findings highlight the impact of concern of falling on physical activity in PwMS. This knowledge may represent an opportunity to improve care and enhance physical activity in the MS population.

Role of Ionizing Radiation in Neurodegenerative Diseases

Ionizing radiation (IR) from terrestrial sources is continually an unprotected peril to human beings. However, the medical radiation and global radiation background are main contributors to human exposure and causes of radiation sickness. At high-dose exposures acute radiation sickness occurs, whereas chronic effects may persist for a number of years. Radiation can increase many circulatory, age related and neurodegenerative diseases. Neurodegenerative diseases occur a long time after exposure to radiation, as demonstrated in atomic bomb survivors, and are still controversial. This review discuss the role of IR in neurodegenerative diseases and proposes an association between neurodegenerative diseases and exposure to IR.

Pittsburgh compound-B PET white matter imaging and cognitive function in late multiple sclerosis

BACKGROUND

There is growing interest in white matter (WM) imaging with positron emission tomography (PET).

OBJECTIVES

We studied the association of cognitive function in late multiple sclerosis (MS) with cortical and WM Pittsburgh compound-B PET (PiB-PET) binding.

METHODS

In the population-based Mayo Clinic Study of Aging, 24 of 4869 participants had MS (12 underwent PiB-PET). Controls were age and sex matched (5:1). We used automated or semi-automated processing for quantitative image analyses and conditional logistic regression for group differences.

RESULTS

MS patients had lower memory ( p = 0.03) and language ( p = 0.02) performance; smaller thalamic volumes ( p = 0.003); and thinner temporal ( p = 0.001) and frontal ( p = 0.045) cortices on magnetic resonance imaging (MRI) than controls. There was no difference in global cortical PiB standardized uptake value ratios between MS and controls ( p = 0.35). PiB uptake was lower in areas of WM hyperintensities compared to normal-appearing white matter (NAWM) in MS ( p = 0.0002). Reduced PiB uptake in both the areas of WM hyperintensities ( r = 0.65; p = 0.02) and NAWM ( r = 0.69; p = 0.01) was associated with decreased visuospatial performance in MS.

CONCLUSION

PiB uptake in the cortex in late MS is not different from normal age-matched controls. PiB uptake in the WM in late MS may be a marker of the large network structures' integrity such as those involved in visuospatial performance.

Evaluation of Intervention Fidelity in a Multisite Clinical Trial in Persons With Multiple Sclerosis

BACKGROUND

Careful consideration of intervention fidelity is critical to establishing the validity and reliability of research findings, yet such reports are often lacking in the research literature. It is imperative that intervention fidelity be methodically evaluated and reported to promote the translation of effective interventions into sound evidence-based practice.

PURPOSE

The purpose of this article is to explore strategies used to promote intervention fidelity, incorporating examples from a multisite clinical trial, that illustrate the National Institutes of Health Behavior Change Consortium's 5 domains for recommended treatment practices: (1) study design, (2) facilitator training, (3) intervention delivery, (4) intervention receipt, and (5) intervention enactment. A multisite randomized clinical trial testing the efficacy of a computer-assisted cognitive rehabilitation intervention for adults with multiple sclerosis is used to illustrate strategies promoting intervention fidelity.

METHODS

Data derived from audiotapes of intervention classes, audits of computer exercises completed by participants, participant class attendance, and goal attainment scaling suggested relatively high fidelity to the intervention protocol.

CONCLUSION

This study illustrates how to report intervention fidelity in the literature guided by best practice strategies, which may serve to promote fidelity monitoring and reporting in future studies.

Epidemiology of NMOSD in Catalonia: Influence of the new 2015 criteria in incidence and prevalence estimates

BACKGROUND

Population-based studies on neuromyelitis optica spectrum disorders (NMOSD) are limited, and it is unclear whether the rates have changed with the implementation of the new 2015 criteria.

OBJECTIVES

To estimate the incidence and prevalence of NMOSD in Catalonia (Spain), using both the 2006 and the 2015 criteria.

METHODS

In this clinic-based retrospective study, patients diagnosed with NMOSD between 2006 and 2015 were identified using multiple sources, including direct contact to all Catalan hospitals, identification of cases through the Catalan Health Surveillance System, and registry of antibodies to aquaporin-4 (AQP4-IgG) and myelin oligodendrocyte glycoprotein (MOG-IgG) in a reference laboratory. The incidence rate was calculated for the period 1 January 2006-1 January 2016 and prevalence for the date 1 January 2016.

RESULTS

We identified 74 patients (by the 2015 criteria). Most patients were Caucasian (81%), and female (76%) with a median age at disease onset of 42 years (range, 10-76 years). In total, 54 (73%) patients were positive for AQP4-IgG, 11 (15%) double-seronegative, and 9 (12%) MOG-IgG-positive. Rates of incidence and prevalence (0.63/1,000,000 person-years and 0.89/100,000, respectively) were 1.5-fold higher than those reported by the 2006 criteria. Lowest rates were seen in children and elder people and highest in women and middle-aged people (40-59 years). The female predominance was lost in incident AQP4-IgG-seronegative children and AQP4-IgG-positive elder people. MOG-IgG and double-seronegativity contributed similarly but did not influence the long-term outcome.

CONCLUSION

The new criteria increase the estimates, but NMOSD remains as a rare disease. The differences in age- and sex-specific estimates highlight the importance of the serologic classification.

Epidemiology of Multiple Sclerosis in Austria

BACKGROUND

To assess the incidence rate and prevalence ratio of multiple sclerosis (MS) in Austria.

METHODS

Hospital discharge diagnosis and MS-specific immunomodulatory treatment prescriptions from public health insurances, covering 98% of Austrian citizens with health insurance were used to extrapolate incidence and prevalence numbers based on the capture-recapture method.

RESULTS

A total of 1,392,629 medication prescriptions and 40,956 hospitalizations were extracted from 2 data sources, leading to a total of 13,205 patients. The incidence rate and prevalence ratio of MS in Austria based on the capture-recapture method were 19.5/100,000 person-years (95% CI 14.3-24.7) and 158.9/100,000 (95% CI 141.2-175.9), respectively. Female to male ratio was 1.6 for incidence and 2.2 for prevalence.

CONCLUSIONS

Incidence rates and prevalence ratios of MS in our study are within the upper range of comparable studies across many European countries as well as the United States.

Prevalence of multiple sclerosis in Latin America and its relationship with European migration

Multiple sclerosis (MS) is a chronic, degenerative autoimmune inflammatory disease of the central nervous system. The prevalence is different in every continent, changing according to geographical and environmental characteristics. The areas with the highest prevalence in the world are Europe and North America. In Latin America, the prevalence is higher in areas where there was greater European migration, as in the case of Argentina, Chile, Brazil, Uruguay and Mexico, and there have been no identified cases amongst native Indian populations. It should be considered that environmental factors may influence the prevalence of MS in Latin America, and it seems as if there are protective factors such as exposure to ultraviolet radiation and the presence of parasitosis.

Self-efficacy and Walking Performance in Persons With Multiple Sclerosis

BACKGROUND AND PURPOSE

Impairment of walking function is a prevalent and burdensome feature of multiple sclerosis (MS), and represents a primary focus of rehabilitation research and clinical care. Research examining self-efficacy as a correlate of walking performance in MS is lacking; self-efficacy represents a theory-based, modifiable target of rehabilitation approaches for improving walking outcomes. This cross-sectional study examined the association between self-efficacy and walking performance in persons living with MS.

METHODS

The sample included 69 persons with MS who completed the Multiple Sclerosis Self-Efficacy (MSSE) Scale and Exercise Self-Efficacy (EXSE) Scale and undertook the Timed 25-Foot Walk (T25FW) and the 6-Minute Walk (6MW) tests. The data were analyzed using the Pearson product moment correlation coefficients and linear regression.

RESULTS

Correlation analysis indicated that function subscale scores on the MSSE correlated more strongly with T25FW (r = 0.55) than did the control subscale (r = 0.40) and EXSE (r = 0.38) scores, and both function (r = 0.67) and control (r = 0.53) subscale scores on the MSSE correlated more strongly with 6MW than did EXSE scores (r = 0.40). Linear regression analyses indicated that (1) function MSSE subscale, but not control subscale, explained significant variance in T25FW speed and 6MW distance and (2) function MSSE subscale, but not EXSE, explained significant variance in T25FW speed and 6MW distance.

DISCUSSION AND CONCLUSIONS

We provide the first evidence of an association between self-efficacy, particularly for functioning with MS, and objective walking performance in MS. Future research to replicate and extend these results can inform rehabilitation efforts that target improvement of walking performance in persons with MS.Digital Abstract available for more insights from the authors (see Slides, Supplemental Digital Content 1, http://links.lww.com/JNPT/A171).

Differential diagnosis of neuromyelitis optica spectrum disorders

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder of the central nervous system (CNS) mostly manifesting as optic neuritis and/or myelitis, which are frequently recurrent/bilateral or longitudinally extensive, respectively. As the autoantibody to aquaporin-4 (AQP4-Ab) can mediate the pathogenesis of NMOSD, testing for the AQP4-Ab in serum of patients can play a crucial role in diagnosing NMOSD. Nevertheless, the differential diagnosis of NMOSD in clinical practice is often challenging despite the phenotypical and serological characteristics of the disease because: (1) diverse diseases with autoimmune, vascular, infectious, or neoplastic etiologies can mimic these phenotypes of NMOSD; (2) patients with NMOSD may only have limited clinical manifestations, especially in their early disease stages; (3) test results for AQP4-Ab can be affected by several factors such as assay methods, serologic status, disease stages, or types of treatment; (4) some patients with NMOSD do not have AQP4-Ab; and (5) test results for the AQP4-Ab may not be readily available for the acute management of patients. Despite some similarity in their phenotypes, these NMOSD and NMOSD-mimics are distinct from each other in their pathogenesis, prognosis, and most importantly treatment. Understanding the detailed clinical, serological, radiological, and prognostic differences of these diseases will improve the proper management as well as diagnosis of patients.

Validation of the Disease-specific Questionnaire MSQoL-54 in Bosnia and Herzegovina Multiple Sclerosis Patients Sample

INTRODUCTION

The purpose of this study was to validate Bosnian translation of disease specific quality of life measure MSQoL-54 which is widely used in practice.

MATERIAL AND METHODS

Previously translated and culturally adopted MSQoL-54 questionnaire used in this study has been provided and licensed by Optum Inc. The questionnaire was validated in 62 MS patients seen at Neurology clinic at University Clinical Center Sarajevo, during April 2016 until May 2016. Internal reliabilities of Bosnian version MSQoL-54 were assessed for multiple item scales by using Cronbach's alpha coefficient. Clinical validity was assessed comparing means of the two summary MSQoL-54 scores by the EDSS score. Pearson's (r) correlation coefficient was used to investigate the relationship between the composite scores and the main clinical and demographic variables.

RESULTS

Patients' participation was satisfactory and all scales fulfilled the usual psychometric standards. Highly significant inverse relationship was found between both composite scores and clinical characteristics of the disease and the EDSS. The lowest internal consistency reliability is found on social function scale (0.743), overall quality of life (0.782) and pain (0.833). The highest internal consistency reliability is found on role limitations due to physical problems (0.959), physical health (0.962) and role limitations due to emotional problems (0.966). The mean value of MSQoL-54 PHC (Physical Health Composite) and MHC (Mental Health Composite) were 49.82±18.90 (36.05-61.38) 51.84±22.22 (34.93-70.20) respectively. Our study has shown that the Bosnian version of MSQoL-54 is easy to administer and well accepted by patients and may be useful as clinical outcome measures in patients with MS.

Could Heterozygous Beta Thalassemia Provide Protection Against Multiple Sclerosis?

Background

Heterozygous beta thalassemia (HBT) has been proposed to increase the risk of developing autoimmune disease. Our aim in this study was to examine the prevalence of HBT among multiple sclerosis (MS) patients.

Material/Methods

HBT frequency was investigated in our MS group (243 patients with MS). Hemoglobin electrophoresis (HE) was carried out if MS patients had a mean corpuscular volume of (MCV) <80 fL and a mean corpuscular hemoglobin level of (MCH) <27 pg/L according to a complete blood count (CBC). If MCV was lower than 80 fL, MCH was lower than 27 pg/L, and Hemoglobin A2 equal to or higher than 3.5%, a diagnosis of HBT was established. The frequency of patients with HBT in our MS patient group was statistically compared with the prevalence of HBT in the city of Istanbul, where our MS patients lived.

Results

The HBT prevalence was 0.823% (2 patients) in the MS patient group. The prevalence of HBT in Istanbul has been reported to be 4.5%. According to the z-test, the HBT prevalence in our MS patient group was significantly lower than that in Istanbul (Z=6.3611, two-sided p value <0.0001, 95% confidence interval of prevalence of HBT in our MS patient group: 0.000998–0.029413).

Conclusions

Contrary to our hypothesis at the outset of study, the reduced HBT prevalence in the MS group compared to HBT frequency in the city of Istanbul might indicate that HBT is protective against MS.

Focused Ultrasound Treatment of Cervical Lymph Nodes in Rats with EAE: A Pilot Study

In this pilot study, focused ultrasound (FUS) was used to produce hyperthermia in cervical lymph nodes of rats having experimental autoimmune encephalomyelitis (EAE) to alleviate symptoms associated with EAE. EAE was induced in dark agouti rats, and EAE scores were recorded over 21 d. At the onset of EAE symptoms, rats were treated with FUS to induce temperatures of 43-44°C for 20 min in the superficial cervical lymph nodes. An EAE remittance score was tallied for all rats, defined as the maximum EAE score observed minus the minimum EAE score observed after the maximum EAE was reached. On average, the peak remittance score for FUS-treated rats was 1.14 ± 0.48 versus 0.33 ± 0.27 for sham-treated rats. These differences were statistically significant (p = 0.037). Therefore, FUS treatment of cervical lymph nodes in rats with EAE resulted in a significant reduction in EAE score.

Programmed Death-1 Culls Peripheral Accumulation of High-Affinity Autoreactive CD4 T Cells to Protect against Autoimmunity

Self-reactive CD4 T cells are incompletely deleted during thymic development, and their peripheral seeding highlights the need for additional safeguards to avert autoimmunity. Here, we show an essential role for the coinhibitory molecule programmed death-1 (PD-1) in silencing the activation of high-affinity autoreactive CD4 T cells. Each wave of self-reactive CD4 T cells that escapes thymic deletion autonomously upregulates PD-1 to maintain self-tolerance. By tracking the progeny derived from individual autoreactive CD4 T cell clones, we demonstrate that self-reactive cells with the greatest autoimmune threat and highest self-antigen affinity express the most PD-1. Reciprocally, PD-1 deprivation unleashes high-affinity self-reactive CD4 T cells in target tissues to exacerbate neuronal inflammation and autoimmune diabetes. Reliance on PD-1 to actively maintain self-tolerance may explain why exploiting this pathway by cancerous cells and invasive microbes efficiently subverts protective immunity, and why autoimmune side effects can develop after PD-1-neutralizing checkpoint therapies.

Epidemiology of Multiple Sclerosis

The epidemiology of multiple sclerosis (MS) includes a consideration of genetic and environmental factors. Comparative studies of different populations have revealed prevalence and incidence rates that vary with geography and ethnicity. With a prevalence ranging from 2 per 100,000 in Japan to greater than 100 per 100,000 in Northern Europe and North America, the burden of MS is similarly unevenly influenced by longevity and comorbid disorders. Well-powered genome-wide association studies have investigated the genetic substrate of MS, providing insight into autoimmune mechanisms involved in the etiopathogenesis of MS and elucidating possible avenues of biological treatment.

Rationale and design of a randomized controlled clinical trial of functional electrical stimulation cycling in persons with severe multiple sclerosis

BACKGROUND

This randomized controlled trial (RCT) will examine the efficacy of supervised functional electrical stimulation (FES) cycling on walking performance and physiological function among persons with multiple sclerosis (MS) with severe mobility disability.

METHODS/DESIGN

This RCT will recruit 16 persons with MS that require unilateral or bilateral assistance for ambulation (i.e., Expanded Disability Status Scale (EDSS) score = 6.0-6.5). Participants will be randomized to one of two conditions: supervised FES cycling or passive cycling. The FES cycling condition will involve mild electrical stimulation that will generate an activation pattern that results in cycling the leg ergometer. The passive cycling condition will not provide any electrical stimulation, rather the movement of the pedals will be controlled by the electrical motor. Both conditions will be delivered 3 days/week for the same duration, over 6 months. Primary outcomes will include walking performance assessed as walking speed, endurance, and agility. Secondary outcomes will include physiological function assessed as cardiorespiratory fitness, muscular strength, and balance. Assessments will take place at baseline, mid-point (3-months), and immediately following the intervention (6-months).

DISCUSSION

This study will lay the foundation for the design of a future RCT by: (1) providing effect sizes that can be included in a power analysis for optimal sample size estimation; and (2) identifying cardiorespiratory fitness, muscular strength, and balance (i.e., physiological function) as mechanisms for the beneficial effects of FES cycling on walking performance. This trial will provide important information on a novel exercise rehabilitation therapy for managing walking impairment in persons with severe MS.