Temporal trends in the incidence of multiple sclerosis: a systematic review

Azathioprine for people with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an immune-mediated, chronic, inflammatory demyelinating disease of the central nervous system, impacting around 2.8 million people worldwide. Characterised by recurrent relapses or progression, or both, it represents a substantial global health burden, affecting people, predominantly women, at a young age (the mean age of diagnosis is 32 years). Azathioprine is used to treat chronic inflammatory and autoimmune diseases, and it is used in clinical practice as an off-label intervention for MS, especially where access to on-label disease-modifying treatments (DMTs) for MS is limited. Given this, a review of azathioprine's benefits and harms would be timely and valuable to inform shared healthcare decisions.

OBJECTIVES

To evaluate the benefits and harms of azathioprine (AZA) for relapsing and progressive multiple sclerosis (MS), compared to other disease-modifying treatments (DMTs), placebo or no treatment. Specifically, we will assess the following comparisons. AZA compared with other DMTs or placebo as first-choice treatment for relapsing forms of multiple sclerosis AZA compared with other DMTs or placebo for relapsing forms of MS when switching from another DMT AZA compared with other DMTs or placebo as first-choice treatment for progressive forms of MS AZA compared with other DMTs or placebo for progressive forms of MS when switching from another DMT SEARCH METHODS: We conducted an extensive search for relevant literature using standard Cochrane search methods. The most recent search date was 9 August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) lasting 12 months or more that compared azathioprine versus DMTs, placebo or no intervention in adults with MS. We considered evidence from non-randomised studies of interventions (NRSIs) as these studies may provide additional evidence not available from RCTS. We excluded cluster-randomised trials, cross-over trials, interrupted time series, case reports and studies of within-group design with no control group.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. There were three outcomes we considered to be critical: disability, relapse and serious adverse events (SAEs, as defined in the studies). We were also interested in other important outcomes: quality-of-life (QoL) impairment (mental score), short-term adverse events (gastrointestinal disorders), long-term adverse events (neoplasms) and mortality.

MAIN RESULTS

We included 14 studies: eight RCTs (1076 participants included in meta-analyses) and six NRSIs (1029 participants). These studies involved people with relapsing and progressive MS. Most studies included more women (57 to 83%) than men, with participants' average age at the onset of MS being between 29.4 and 33.4 years. Five RCTs and all six NRSIs were conducted in Europe (1793 participants); two RCTs were conducted in the USA (126 participants) and one in Iran (94 participants). The RCTs lasted two to three years, while NRSIs looked back up to 10 years. Four studies received some funding or support from commercial interests and five were funded by government or philanthropy; the other five provided no information about funding. There are three ongoing studies. Comparison groups included other DMTs (interferon beta and cyclosporine A), placebo or no treatment. Below, we report on azathioprine as a 'first choice' treatment compared to interferon beta for people with relapsing MS. None of the studies reported on any critical or important outcome for this comparison for progressive MS. No study was retrieved comparing azathioprine to placebo or other DMTs for either relapsing or progressive MS. Furthermore, the NRSIs did not provide information not already covered in the RCTs. Azathioprine as a first-choice treatment compared to other DMTs (specifically, interferon beta) for relapsing MS - The evidence is very uncertain about the effect of azathioprine on the number of people with disability progression over two years compared to interferon beta (risk ratio (RR) 0.19, 95% confidence interval (CI) 0.02 to 1.58; 1 RCT, 148 participants; very low certainty evidence). - Azathioprine may decrease the number of people with relapses over a one- to two-year follow-up compared to interferon beta (RR 0.61, 95% CI 0.43 to 0.86; 2 RCTs, 242 participants; low-certainty evidence). - Azathioprine may result in a possible increase in the number of people with SAEs over two years in comparison with interferon beta (RR 6.64, 95% CI 0.35 to 126.27; 1 RCT, 148 participants; low-certainty evidence). - The evidence is very uncertain about the effect of azathioprine on the number of people with the short-term adverse event of gastrointestinal disorders over two years compared to interferon beta (RR 5.30, 95% CI 0.15 to 185.57; 2 RCTs, 242 participants; very low certainty evidence). We found no evidence comparing azathioprine to other DMTs for QoL impairment (mental score), long-term adverse events (neoplasms) or mortality.

AUTHORS' CONCLUSIONS

Azathioprine has been proposed as an alternative treatment for MS when access to approved, on-label DMTs is limited, especially in resource-limited settings. The limited evidence available suggests that azathioprine may result in a modest benefit in terms of relapse frequency, with a possible increase in SAEs, when compared to interferon beta-1b, for people with relapsing-remitting multiple sclerosis. The evidence for the effect on disability progression and short-term adverse events is very uncertain. Caution is required in interpreting the conclusions of this review since our certainty in the available evidence on the benefits and harms of azathioprine in multiple sclerosis is low to very low, implying that further evidence is likely to change our conclusions. An important limitation we noted in the available evidence is the lack of long-term comparison with other treatments and the failure of most studies to measure outcomes that are important to people with multiple sclerosis, such as quality of life and cognitive decline. This is especially the case in the evidence relevant to people with progressive forms of multiple sclerosis.

Psychometric properties of patient-reported outcome measures, measuring fatigue in patients with multiple sclerosis, a systematic review

BACKGROUND

Multiple sclerosis (MS) is a chronic, inflammatory, degenerative disease of the central nervous system. One of the most common and disabling symptoms is fatigue. More than 80% of people with MS experience fatigue, which has a negative impact on their quality of life and level of independence in daily activities. The multidimensional nature of fatigue makes it essential to understand its impact from the patient's perspective. Patient-reported outcomes (PROs), defined by the FDA as "any report of a patient's health status that comes directly from the patient, without interpretation of the patient's response by the physician or other health care professional," were created to address this need.

OBJECTIVES

To identify and describe patient-reported outcomes (PROs) that measure the level of fatigue specific to patients with multiple sclerosis. To evaluate and analyze the quality of psychometric properties, methodological quality, and risk of bias of patient-reported outcomes that measure the level of fatigue specific to patients with multiple sclerosis.

METHODS

A systematic psychometric review was conducted and framed according to the standards of the Consensus for the Selection of Measurement Instruments (COSMIN) (Mokkink et al., 2010).

RESULTS

A total of 34 studies were included, from which a total of 40 references were extracted, as some studies reported two or more PROMs simultaneously. The evaluation and analysis of the risk of bias shows that the studies present a heterogeneous classification depending on the psychometric property evaluated, i.e. while the frequency of studies classified with low risk of bias is higher in measurement properties such as; structural validity; 25 studies (64.10%), internal consistency 25 studies (64.10%), criterion validity: 29 studies (74.36%). There is also a high frequency of studies rated as high or unclear risk of bias, mainly in psychometric properties such as reliability 19 studies (48.71%), cross-cultural validity measurement invariance 13 studies (33.33%).

CONCLUSIONS

PRO instruments are the best way to know the patients' perception of their symptomatology in this case of fatigue, which will undoubtedly contribute to a better approach and better intervention strategies in a personalized way, another component in the improvement of the quality of care and in line with the new paradigm of patient-centered care, which requires an assessment of fatigue by means of a PRO instrument. Therefore, it is of utmost importance to consider the current standards in the development of these instruments for a correct use and interpretability of their results.

Microglial Mayhem NLRP3 Inflammasome's Role in Multiple Sclerosis Pathology

INTRODUCTION

This review delves into the intricate relationship between NLR inflammasomes, particularly the NLRP3 inflammasome, and the immune-mediated neurodegenerative disease, multiple sclerosis (MS). While the precise etiology of MS remains elusive, compelling research underscores the pivotal role of the immune response in disease progression. Notably, recent investigations highlight the significant involvement of NLRP3 inflammasomes in various autoimmune diseases, prompting an in-depth exploration of their impact on MS.

METHOD

The review focuses on elucidating the activation mechanism of NLRP3 inflammasomes within microglia/macrophages (MG/MФ), examining how this activation promotes an inflammatory response that exacerbates neuronal damage in MS. A comprehensive analysis of existing literature and research findings forms the basis for understanding the intricate interplay between NLRP3 inflammasomes and MS pathogenesis.

RESULTS

Synthesizing current research, the review provides insight into the pivotal role played by NLR inflammasomes, specifically NLRP3, in MS. Emphasis is placed on the inflammatory response orchestrated by activated MG/MФ, elucidating the cascade that perpetuates neuronal damage in the disease.

CONCLUSIONS

This review concludes by consolidating key findings and offering a nuanced perspective on the role of NLRP3 inflammasomes in MS pathogenesis. The detailed exploration of the activation process within MG/MФ provides a foundation for understanding the disease's underlying mechanisms. Furthermore, the review sets the stage for potential therapeutic strategies targeting NLRP3 inflammasomes in the pursuit of MS treatment.

Age and sex as key determinants of multiple sclerosis incidence in Spain: a comprehensive analysis using the global burden of disease database (1990-2019)

AIM

To explore trends in multiple sclerosis incidence rates in Spain between 1990 and 2019.

METHODS

We use data from the Global Burden of Disease Study 2019 to calculate age-standardised incidence rates of multiple sclerosis and identify significant changes over time using the Joinpoint regression model. We also use the Age-Period-Cohort model to understand the separate influences of age, historical period, and birth cohort on these trends.

RESULTS

Between 1990 and 2019, Spain reported 31,152 cases of multiple sclerosis, with an average annual growth rate of 1.3%, slightly higher in men (1.40%) than in women (1.28%). Joinpoint analysis revealed non-parallel trends of incidence between sexes, with men experiencing increases and declines along five differentiated periods, while women showed increasing rates until 2015, followed by stabilization. The incidence of multiple sclerosis increased over time in both sexes achieving an average annual increase of 1.6% for men and 1.4% for women. Individuals born in the early to mid-20th century experienced a different trajectory compared to later generations. For both sexes, their MS risk steadily climbed from the mid-20th century, reaching a peak in the 1970s and 1980s for men and potentially later in the 1990s for women. This peak was then followed by a plateauing of risk in subsequent years.

CONCLUSIONS

Overall, this study offers valuable insights into MS incidence trends in Spain, highlighting sex disparities, age effects, and generational patterns. Further research is needed to understand the complex interplay of age, period, and cohort effects, as well as regional and environmental factors contributing to risk of new cases of multiple sclerosis.

NINJ1: A new player in multiple sclerosis pathogenesis and potential therapeutic target

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) characterized by demyelination. Current treatment options for MS focus on immunosuppression, but their efficacy can be limited. Recent studies suggest a potential role for nerve injury-induced protein 1 (NINJ1) in MS pathogenesis. NINJ1, a protein involved in cell death and inflammation, may contribute to the infiltration and activation of inflammatory cells in the CNS, potentially through enhanced blood-brain barrier crossing; enhancing plasma membrane rupture during cell death, leading to the release of inflammatory mediators and further tissue damage. This review explores the emerging evidence for NINJ1's involvement in MS. It discusses how NINJ1 might mediate the migration of immune cells across the blood-brain barrier, exacerbate neuroinflammation, and participate in plasma membrane rupture-related damage. Finally, the review examines potential therapeutic strategies targeting NINJ1 for improved MS management. Abbreviations: MS, Multiple sclerosis; CNS, Central nervous system; BBB, Blood-brain barrier; GSDMD, Gasdermin-D; EAE, Experimental autoimmune encephalitis; HMGB-1, High mobility group box-1 protein; LDH, Lactate dehydrogenase; PMR, Plasma membrane rupture; DMF, Dimethyl fumarate; DUSP1, Dual-specificity phosphatase 1; PAMPs, Pathogen-associated molecular patterns; DAMPs, Danger-associated molecular patterns; PRRs, Pattern recognition receptors; GM-CSF, Granulocyte-macrophage colony stimulating factor; IFN-γ, Interferon gamma; TNF, Tumor necrosis factor; APCs, Antigen-presenting cells; ECs, Endothelial cells; TGF-β, Transforming growth factor-β; PBMCs, Peripheral blood mononuclear cells; FACS, Fluorescence-activated cell sorting; MCP-1, Monocyte chemoattractant protein-1; NLRP3, Pyrin domain-containing 3; TCR, T cell receptor; ROS, Reactive oxygen species; AP-1, Activator protein-1; ANG1, Angiopoietin 1; BMDMs, Bone marrow-derived macrophages; Arp2/3, actin-related protein 2/3; EMT, epithelial-mesenchymal transition; FAK, focal adhesion kinase; LIMK1, LIM domain kinase 1; PAK1, p21-activated kinases 1; Rac1, Ras-related C3 botulinum toxin substrate 1; β-cat, β-caten; MyD88, myeloid differentiation primary response gene 88; TIRAP, Toll/interleukin-1 receptor domain-containing adapter protein; TLR4, Toll-like receptor 4; IRAKs, interleukin-1 receptor-associated kinases; TRAF6, TNF receptor associated factor 6; TAB2/3, TAK1 binding protein 2/3; TAK1, transforming growth factor-β-activated kinase 1; JNK, c-Jun N-terminal kinase; ERK1/2, Extracellular Signal Regulated Kinase 1/2; IKK, inhibitor of kappa B kinase; IκB, inhibitor of NF-κB; NF-κB, nuclear factor kappa-B; AP-1, activator protein-1; ASC, Apoptosis-associated Speck-like protein containing a CARD; NEK7, NIMA-related kinase 7; NLRP3, Pyrin domain-containing 3; CREB, cAMP response element-binding protein.

Optical coherence tomography angiography of the retina and choroid in systemic diseases

Optical coherence tomography angiography (OCTA) has transformed ocular vascular imaging, revealing microvascular changes linked to various systemic diseases. This review explores its applications in diabetes, hypertension, cardiovascular diseases, and neurodegenerative diseases. While OCTA provides a valuable window into the body's microvasculature, interpreting the findings can be complex. Additionally, challenges exist due to the relative non-specificity of its findings where changes observed in OCTA might not be unique to a specific disease, variations between OCTA machines, the lack of a standardized normative database for comparison, and potential image artifacts. Despite these limitations, OCTA holds immense potential for the future. The review highlights promising advancements like quantitative analysis of OCTA images, integration of artificial intelligence for faster and more accurate interpretation, and multi-modal imaging combining OCTA with other techniques for a more comprehensive characterization of the ocular vasculature. Furthermore, OCTA's potential future role in personalized medicine, enabling tailored treatment plans based on individual OCTA findings, community screening programs for early disease detection, and longitudinal studies tracking disease progression over time is also discussed. In conclusion, OCTA presents a significant opportunity to improve our understanding and management of systemic diseases. Addressing current limitations and pursuing these exciting future directions can solidify OCTA as an indispensable tool for diagnosis, monitoring disease progression, and potentially guiding treatment decisions across various systemic health conditions.

Real-world persistence and adherence of ofatumumab versus oral and injectable disease-modifying therapies in patients with multiple sclerosis

BACKGROUND

Ofatumumab (OMB) was approved as a self-injectable disease-modifying therapy (DMT) for relapsing multiple sclerosis (MS) in August 2020. This study aimed to examine treatment persistence and adherence of OMB to oral and platform self-injectable DMTs in a real-world setting.

METHODS

This was a retrospective cohort study using IQVIA Pharmetrics Plus® in adults diagnosed with MS and treated with OMB, oral DMTs, or platform self-injectable DMTs (index treatment) between August 2020 and November 2021. Patients had at least 12 months of continuous enrollment before the index date and 6 months of follow-up after the index date; the index date was defined as the date of the first pharmacy claim for an index treatment. Inverse probability of treatment weighting (IPTW) analysis was used to account for differences in baseline characteristics among patients initiating OMB versus oral DMTs and, separately, OMB versus platform self-injectable DMTs. Persistence was defined as the number of days from the index date until the earliest time of discontinuation (>60-day gap) or switch to a new DMT. Adherence was calculated based on proportion of days covered (PDC) with adherence defined as PDC ≥0.8. Persistence and adherence were compared between OMB versus oral DMTs and OMB versus platform self-injectable DMTs. Persistence was assessed via Kaplan-Meier analyses of the weighted sample, and log-rank tests were used to compare time to treatment discontinuation and treatment switch. The proportion of patients adherent at 6 and 12 months post index were compared using chi-square tests.

RESULTS

A total of 11,167 patients were identified with an incident claim of OMB, an oral DMT, or a platform self-injectable DMT. After applying all inclusion and exclusion criteria and IPTW, two sets of study cohorts were created. For the oral DMT analysis, 577 patients treated with OMB and 2,468 patients treated with oral DMTs were identified. For the self-injectable DMT analysis, 574 patients treated with OMB and 578 patients treated with a platform self-injectable DMT were identified. At 6- and 12-month follow-up, the proportion of patients who were persistent on DMT was higher in the OMB cohort compared with the oral DMT cohort (6 months: 79.9% vs. 75.4 %, 12 months: 71.4% vs. 62.9 %; p < 0.05), as well as in the OMB cohort compared with the self-injectable DMT cohort (6 months: 79.3% vs. 60.4 %, 12 months: 71.5% vs. 48.7 %; p < 0.0001). A similar proportion of patients were adherent to OMB versus oral DMTs at 6- and 12-months post index, whereas a higher proportion of patients treated with OMB versus platform self-injectable DMTs were adherent at 6- and 12-months post index.

CONCLUSIONS

OMB showed better persistence and adherence compared with platform self-injectable DMTs, as well as better persistence compared with oral DMTs. This real-world analysis provides additional insights into OMB utilization among patients with MS in clinical practice and demonstrates that OMB is a valuable treatment option for these patients.

Review of evidence linking exposure to environmental stressors and associated alterations in the dynamics of immunosenescence (ISC) with the global increase in multiple sclerosis (MS)

Historical survey confirms that, over the latter part of the 20th century, autoimmune-based diseases, including multiple sclerosis (MS), have shown a worldwide increase in incidence and prevalence. Analytical population studies have established that the exponential rise in MS is not solely due to improvements in diagnosis and healthcare but relates to an increase in autoimmune risk factors. Harmful environmental exposures, including non-communicable social determinants of health, anthropogens and indigenous or transmissible microbes, constitute a group of causal determinants that have been closely linked with the global rise in MS cases. Exposure to environmental stressors has profound effects on the adaptive arm of the immune system and, in particular, the associated intrinsic process of immune ageing or immunosenescence (ISC). Stressor-related disturbances to the dynamics of ISC include immune cell-linked untimely or premature (p) alterations and an accelerated replicative (ar) change. A recognised immune-associated feature of MS is pISC and current evidence supports the presence of an arISC during the disease. Moreover, collated data illustrates the immune-associated alterations that characterise pISC and arISC are inducible by environmental stressors strongly implicated in causing duplicate changes in adaptive immune cells during MS. The close relationship between exposure to environmental risk factors and the induction of pISC and arISC during MS offers a valid mechanism through which pro-immunosenescent stressors may act and contribute to the recorded increase in the global rate and number of new cases of the disease. Confirmation of alterations to the dynamics of ISC during MS provides a rational and valuable therapeutic target for the use of senolytic drugs to either prevent accumulation and enhance ablation of less efficient untimely senescent adaptive immune cells or decelerate the dysregulated process of replicative proliferation. A range of senotherapeutics are available including kinase and transcriptase inhibitors, rapalogs, flavanols and genetically-engineered T cells and the use of selective treatments to control emerging and unspecified aspects of pISC and arISC are discussed.

Prenatal and Postnatal Opinions and Experiences of Women With Multiple Sclerosis: A Phenomenological Study

BACKGROUND

Multiple sclerosis is an irreversible autoimmune disease with significant physical, psychological, and social impacts. Understanding the lived experiences of pregnant women with multiple sclerosis is vital for healthcare professionals to provide better care to these women.

PURPOSE

This study was designed to explore the lived experiences of pregnant women with multiple sclerosis.

METHODS

A descriptive phenomenological study was conducted at the University of Jaén and included 17 women from different Spanish provinces who were recruited using intentional and snowball sampling methods via national patient associations and social networks. In-depth interviews were conducted, audio-recorded, transcribed, and analyzed using Martins' three steps. The ATLAS.ti 7.0 program was used for data analysis.

RESULTS

Two themes and seven subthemes were identified that highlighted the experiences of women in pregnancy with multiple sclerosis: (a) the influence of the disease on the decision to be a mother, with subthemes "The disease determines when to be a mother" and "Considering alternatives to spontaneous pregnancy," and (b) the vision of motherhood with multiple sclerosis, with subthemes "Worry about how the disease can affect the pregnancy," "Worry about how the pregnancy can affect the disease," "Concerns about childbirth," "Difficulty with breastfeeding," and "Worry about the transmission of the disease."

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Women with multiple sclerosis often face a difficult decision regarding whether to become pregnant. The period of pregnancy and puerperium can be fraught with anxiety, especially in terms of concerns about their ability to raise children. In light of the limited scientific evidence regarding the relationship between multiple sclerosis and pregnancy and the conflicting advice often given to these women, the findings of this study may be used to help improve the quality of the care provided to this population.

NMOSD and MOGAD: an evolving disease spectrum

Neuromyelitis optica (NMO) spectrum disorder (NMOSD) is a relapsing inflammatory disease of the CNS, characterized by the presence of serum aquaporin 4 (AQP4) autoantibodies (AQP4-IgGs) and core clinical manifestations such as optic neuritis, myelitis, and brain or brainstem syndromes. Some people exhibit clinical characteristics of NMOSD but test negative for AQP4-IgG, and a subset of these individuals are now recognized to have serum autoantibodies against myelin oligodendrocyte glycoprotein (MOG) - a condition termed MOG antibody-associated disease (MOGAD). Therefore, the concept of NMOSD is changing, with a disease spectrum emerging that includes AQP4-IgG-seropositive NMOSD, MOGAD and double-seronegative NMOSD. MOGAD shares features with NMOSD, including optic neuritis and myelitis, but has distinct pathophysiology, clinical profiles, neuroimaging findings (including acute disseminated encephalomyelitis and/or cortical encephalitis) and biomarkers. AQP4-IgG-seronegative NMOSD seems to be a heterogeneous condition and requires further study. MOGAD can manifest as either a monophasic or a relapsing disease, whereas NMOSD is usually relapsing. This Review summarizes the history and current concepts of NMOSD and MOGAD, comparing epidemiology, clinical features, neuroimaging, pathology and immunology. In addition, we discuss new monoclonal antibody therapies for AQP4-IgG-seropositive NMOSD that target complement, B cells or IL-6 receptors, which might be applied to MOGAD in the near future.

The association between vitamin D deficiency and multiple sclerosis: an updated systematic review and meta-analysis

BACKGROUND

Although there is evidence of a link between vitamin D status and risk of multiple sclerosis (MS), there has been no systematic review where the exposure measure was vitamin D deficiency rather than 25 hydroxy vitamin D (25(OH)D) concentration. We conducted an updated systematic review and meta-analysis to estimate the association between vitamin D deficiency, defined in most studies as a serum 25(OH)D concentration of < 50 nmol L-1, and MS.

METHODS

We searched the MEDLINE, EMBASE, and CINAHL databases to identify relevant publications. We estimated the pooled odds ratio (OR) using a random effects model for the association between vitamin D deficiency and MS, overall and stratified by several factors, including whether or not studies included participants who were taking vitamin D supplements. We also analysed the association between mean 25(OH)D concentration and MS, and used meta-regression to assess the effects of vitamin D supplementation, latitude, age, ethnicity, vitamin D definition and seasonality on the OR estimates. The Newcastle-Ottawa Scale was used to assess study quality.

RESULTS

Results were pooled across 14 case-control studies published between 2007 and 2021 (n = 4130 cases, n = 4604 controls). Persons with vitamin D deficiency had a 54 % higher risk of multiple sclerosis than those with sufficient vitamin D status (OR 1.54; 95 % CI 1.05, 2.24). In studies that excluded participants taking vitamin D supplements (N = 7), the OR was 2.19 (95 % CI: 1.44, 3.35), whereas, in studies that did not exclude participants taking supplements, there was no increase in risk (OR 0.82; 95 % CI: 0.43, 1.58). Mean age (R2 = 27.4 %) and inclusion/exclusion of participants taking supplements (R2 = 33.4 %) contributed most to variability in the OR of vitamin D deficiency and MS.

CONCLUSION

Vitamin D deficiency is associated with an increased likelihood of multiple sclerosis. Maintaining sufficient vitamin D may be an important modifiable risk factor for MS.

Projected number of people with multiple sclerosis in Germany between 2015 and 2040

BACKGROUND

The global prevalence of multiple sclerosis has shown a marked rise in recent decades, with Germany reporting the highest prevalence among European countries. This study aims to project the future number of people with multiple sclerosis in Germany until 2040 which is necessary for effective resource allocation and health care planning.

METHODS

Based on data from the German statutory health insurance, the age- and sex-specific prevalence of multiple sclerosis was estimated applying mathematical relations between prevalence, incidence rate, and mortality rate. Subsequently, the projected prevalence was applied to the age structure of the German population between 2015 and 2040 to calculate the future number of people with multiple sclerosis. Several temporal trend scenarios pertaining to the incidence and mortality rate were compared.

RESULTS

Application of current age-specific prevalence estimates combined with the projected population structure in 2040, results in a decline of 8% in the number of people with multiple sclerosis. More realistic scenarios that reflect on trends in mortality and incidence rates, project between 453,000 (+75%) and 477,000 (+85%) multiple sclerosis cases in 2040. It is expected that females will be affected nearly 2.5 times more frequently than males in 2040.

CONCLUSION

The findings indicate a substantial rise in the prevalence of multiple sclerosis, ranging from 75% to 85% in 2040 compared to 2015. Assuming a constant age-specific prevalence between 2015 and 2040 without any temporal trends in mortality and incidence rates may underestimate the actual number of cases and consequently, future requirements for healthcare resources.

Optimization of Interleukin-10 incorporation for dendritic cells embedded in Poly(ethylene glycol) hydrogels

Translational research in biomaterials and immunoengineering is leading to the development of novel advanced therapeutics to treat diseases such as cancer, autoimmunity, and viral infections. Dendritic cells (DCs) are at the center of these therapeutics given that they bridge innate and adaptive immunity. The biomaterial system developed herein uses a hydrogel carrier to deliver immunomodulatory DCs for amelioration of autoimmunity. This biomaterial vehicle is comprised of a poly (ethylene glycol)-4 arm maleimide (PEG-4MAL) hydrogels, conjugated with the immunosuppressive cytokine, interleukin-10, IL-10, and cross-linked with a collagenase-degradable peptide sequence for the injectable delivery of immunosuppressive DCs to an anatomical disease-relevant site of the cervical lymph nodes, for intended application to treat multiple sclerosis. The amount of IL-10 incorporated in the hydrogel was optimized to be 500 ng in vitro, based on immunological endpoints. At this concentration, DCs exhibited the best viability, most immunosuppressive phenotype, and protection against proinflammatory insult as compared with hydrogel-incorporated DCs with lower IL-10 loading amounts. Additionally, the effect of the degradability of the PEG-4MAL hydrogel on the release rate of incorporated IL-10 was assessed by varying the ratio of degradable peptides: VPM (degradable) and DTT (nondegradable) and measuring the IL-10 release rates. This IL-10-conjugated hydrogel delivery system for immunosuppressive DCs is set to be assessed for in vivo functionality as the immunosuppressive cytokine provides a tolerogenic environment that keeps DCs in their immature phenotype, which consequently enhances cell viability and optimizes the system's immunomodulatory functionality.

Assessment of vitamin D status and associated risk factors in high-altitude populations affected by multiple sclerosis: A case-control study

Several studies have suggested a correlation between serum vitamin D (VitD) level and multiple sclerosis (MS). MS has a known latitudinal distribution pattern, with greater incidence, prevalence, and mortality rates at higher latitudes. This study aims to assess levels of VitD and serum potassium in subjects with MS and the impact of gender and age as disease risk factors. A cross-sectional case-control study was conducted in a high-altitude region of Saudi Arabia. VitD deficiency was defined as serum 25 (OH)D level of ≤20 ng/mL and insufficiency as a serum level between >20 ng/mL and <30 ng/mL. Two hundred patients with MS volunteered for the study, and 160 healthy participants served as controls. VitD and serum potassium were measured in patients and controls. Student t test and regression analysis were used to analyze the data. The average MS patient age was 37.37 ± 10.8 years. Most (73.02%) MS patients suffered from deficient vitamin D, while insufficiency (20-29 ng/mL) was found in 12.17%. Only 6.35% had sufficient vitamin D (30-40 ng/mL). VitD was significantly decreased in MS patients compared to the healthy controls (17.036 vs 25.01 ng/mL, P < .001), while serum potassium was also decreased (4.278 vs 4.329 mmol/L, P = .269). Risk factors found to have a statistically significant association with MS included female gender (odd ratio [OR] = 1.72, 95% confidence interval: 1.016-2.915; P = .044) and patient age < 40 years (OR = 1.04, 95% confidence interval: 1.023-1.054; P = .044). VitD was significantly lower in MS patients. The prevalence of MS was higher among women and younger individuals in a high-altitude population in Saudi Arabia.

Retinal microglia express more MHC class I and promote greater T-cell-driven inflammation than brain microglia

Introduction

Macrophage function is determined by microenvironment and origin. Brain and retinal microglia are both derived from yolk sac progenitors, yet their microenvironments differ. Utilizing single-cell RNA sequencing (scRNA-seq) data from mice, we tested the hypothesis that retinal and brain microglia exhibit distinct transcriptional profiles due to their unique microenvironments.

Methods

Eyes and brains from 2-4 month wildtype mice were combined (20 eyes; 3 brains) to yield one biologically diverse sample per organ. Each tissue was digested into single cell suspensions, enriched for immune cells, and sorted for scRNA-seq. Analysis was performed in Seurat v3 including clustering, integration, and differential expression. Multi-parameter flow cytometry was used for validation of scRNA-seq results. Lymphocytic choriomeningitis virus (LCMV) Clone 13, which produces a systemic, chronic, and neurotropic infection, was used to validate scRNA-seq and flow cytometry results in vivo.

Results

Cluster analysis of integrated gene expression data from eye and brain identified 6 Tmem119 + P2ry12 + microglial clusters. Differential expression analysis revealed that eye microglia were enriched for more pro-inflammatory processes including antigen processing via MHC class I (14.0-fold, H2-D1 and H2-K1) and positive regulation of T-cell immunity (8.4-fold) compared to brain microglia. Multi-parameter flow cytometry confirmed that retinal microglia expressed 3.2-fold greater H2-Db and 263.3-fold more H2-Kb than brain microglia. On Day 13 and 29 after LCMV infection, CD8+ T-cell density was greater in the retina than the brain.

Discussion

Our data demonstrate that the microenvironment of retina and brain differs, resulting in microglia-specific gene expression changes. Specifically, retinal microglia express greater MHC class I by scRNA-seq and multi-parameter flow cytometry, resulting in a possibly enhanced capability to stimulate CD8+ T-cell inflammation during LCMV infection. These results may explain tissue-specific differences between retina and brain during systemic viral infections and CD8+ T-cell driven autoimmune disease.

Proportion of Life Spent in Canada and the Incidence of Multiple Sclerosis in Permanent Immigrants

BACKGROUND AND OBJECTIVES

While immigrants to high-income countries have a lower risk of multiple sclerosis (MS) compared with host populations, it is unknown whether this lower risk among immigrants increases over time. Our objective was to evaluate the association between proportion of life spent in Canada and the hazard of incident MS in Canadian immigrants.

METHODS

We conducted a population-based retrospective cohort study in Ontario, using linked health administrative databases. We followed immigrants, who arrived in Ontario between 1985 and 2003, from January 1, 2003, to December 31, 2016, to record incident MS using a validated algorithm based on hospital admission or outpatient visits. We derived proportion of life spent in Canada based on age at arrival and time since immigration obtained from linked immigration records. We used multivariable proportional hazard models, adjusting for demographics and comorbidities, to evaluate the association between proportion of life in Canada and the incidence of MS, where proportion of life was modelled using restricted cubic spline terms. We further evaluated the role of age at migration (15 or younger vs older than 15 years), sex, and immigration class in sensitivity analyses.

RESULTS

We included 1.5 million immigrants (49.9% female, mean age 35.9 [SD 14.2] years) who had spent a median of 20% (Q1-Q3 10%-30%) of their life in Canada. During a mean follow-up of 13.9 years (SD 1.0), 934 (0.44/100,000 person-years) were diagnosed with MS. Compared with the median, a higher risk of MS was observed at higher values of proportion of life spent (e.g., hazard ratio [70% vs 20% proportion of life] 1.38; 1.07-1.78). This association did not vary by sex (p(sex × proportion of life) = 0.70) or immigration class (p(immigration class × proportion of life) = 0.13). The results did not vary by age at migration but were statistically significant only at higher values of proportion of life for immigrants aged 15 years or younger at arrival.

DISCUSSION

The risk of incident MS in immigrants varied with the proportion of life spent in Canada, suggesting an acculturation effect on MS risk. Further work is required to understand environmental and sociocultural factors driving the observed association.

Increasing age of multiple sclerosis onset from 1920 to 2022: a population-based study

OBJECTIVE

To study the age at onset of relapsing-remitting multiple sclerosis (RRMS) during the past century.

METHODS

This is a population-based cohort study of persons diagnosed with RRMS in Hordaland, Møre, and Romsdal counties, Western Norway, from 1920 to 2022. Individual patient data were available and assessed from previously conducted prevalence and incidence studies in addition to hospital records up until October 31, 2022. Participants were categorized according to onset period and analyzed for temporal trends in age at onset, time from onset to diagnosis, and distribution of onset over time.

RESULTS

We identified 3364 persons with confirmed RRMS. The mean age at onset significantly increased (p < 0.001) throughout the study period, despite a decrease in time from symptom onset to diagnosis (p < 0.001). The proportion of persons with MS onset after 50 years of age increased from 2.6% before 1970 to 11.9% after 2010. We also found a trend toward a bimodal distribution of age at onset that peaked at around 30 years and 40-45 years of age in the latest period.

CONCLUSION

Age at onset of MS significantly increased throughout the study period. This was mainly due to an increasing number of persons with MS, predominantly female, experiencing onset after 40-45 years of age. This bimodal distribution could indicate different susceptibility periods of MS or changes in exposure to risk factors during the observation period.

Immunomodulators and immunosuppressants for relapsing-remitting multiple sclerosis: a network meta-analysis

BACKGROUND

Different therapeutic strategies are available for the treatment of people with relapsing-remitting multiple sclerosis (RRMS), including immunomodulators, immunosuppressants and biological agents. Although each one of these therapies reduces relapse frequency and slows disability accumulation compared to no treatment, their relative benefit remains unclear. This is an update of a Cochrane review published in 2015.

OBJECTIVES

To compare the efficacy and safety, through network meta-analysis, of interferon beta-1b, interferon beta-1a, glatiramer acetate, natalizumab, mitoxantrone, fingolimod, teriflunomide, dimethyl fumarate, alemtuzumab, pegylated interferon beta-1a, daclizumab, laquinimod, azathioprine, immunoglobulins, cladribine, cyclophosphamide, diroximel fumarate, fludarabine, interferon beta 1-a and beta 1-b, leflunomide, methotrexate, minocycline, mycophenolate mofetil, ofatumumab, ozanimod, ponesimod, rituximab, siponimod and steroids for the treatment of people with RRMS.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, and two trials registers were searched on 21 September 2021 together with reference checking, citation searching and contact with study authors to identify additional studies. A top-up search was conducted on 8 August 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that studied one or more of the available immunomodulators and immunosuppressants as monotherapy in comparison to placebo or to another active agent, in adults with RRMS.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies and extracted data. We considered both direct and indirect evidence and performed data synthesis by pairwise and network meta-analysis. Certainty of the evidence was assessed by the GRADE approach.

MAIN RESULTS

We included 50 studies involving 36,541 participants (68.6% female and 31.4% male). Median treatment duration was 24 months, and 25 (50%) studies were placebo-controlled. Considering the risk of bias, the most frequent concern was related to the role of the sponsor in the authorship of the study report or in data management and analysis, for which we judged 68% of the studies were at high risk of other bias. The other frequent concerns were performance bias (34% judged as having high risk) and attrition bias (32% judged as having high risk). Placebo was used as the common comparator for network analysis. Relapses over 12 months: data were provided in 18 studies (9310 participants). Natalizumab results in a large reduction of people with relapses at 12 months (RR 0.52, 95% CI 0.43 to 0.63; high-certainty evidence). Fingolimod (RR 0.48, 95% CI 0.39 to 0.57; moderate-certainty evidence), daclizumab (RR 0.55, 95% CI 0.42 to 0.73; moderate-certainty evidence), and immunoglobulins (RR 0.60, 95% CI 0.47 to 0.79; moderate-certainty evidence) probably result in a large reduction of people with relapses at 12 months. Relapses over 24 months: data were reported in 28 studies (19,869 participants). Cladribine (RR 0.53, 95% CI 0.44 to 0.64; high-certainty evidence), alemtuzumab (RR 0.57, 95% CI 0.47 to 0.68; high-certainty evidence) and natalizumab (RR 0.56, 95% CI 0.48 to 0.65; high-certainty evidence) result in a large decrease of people with relapses at 24 months. Fingolimod (RR 0.54, 95% CI 0.48 to 0.60; moderate-certainty evidence), dimethyl fumarate (RR 0.62, 95% CI 0.55 to 0.70; moderate-certainty evidence), and ponesimod (RR 0.58, 95% CI 0.48 to 0.70; moderate-certainty evidence) probably result in a large decrease of people with relapses at 24 months. Glatiramer acetate (RR 0.84, 95%, CI 0.76 to 0.93; moderate-certainty evidence) and interferon beta-1a (Avonex, Rebif) (RR 0.84, 95% CI 0.78 to 0.91; moderate-certainty evidence) probably moderately decrease people with relapses at 24 months. Relapses over 36 months findings were available from five studies (3087 participants). None of the treatments assessed showed moderate- or high-certainty evidence compared to placebo. Disability worsening over 24 months was assessed in 31 studies (24,303 participants). Natalizumab probably results in a large reduction of disability worsening (RR 0.59, 95% CI 0.46 to 0.75; moderate-certainty evidence) at 24 months. Disability worsening over 36 months was assessed in three studies (2684 participants) but none of the studies used placebo as the comparator. Treatment discontinuation due to adverse events data were available from 43 studies (35,410 participants). Alemtuzumab probably results in a slight reduction of treatment discontinuation due to adverse events (OR 0.39, 95% CI 0.19 to 0.79; moderate-certainty evidence). Daclizumab (OR 2.55, 95% CI 1.40 to 4.63; moderate-certainty evidence), fingolimod (OR 1.84, 95% CI 1.31 to 2.57; moderate-certainty evidence), teriflunomide (OR 1.82, 95% CI 1.19 to 2.79; moderate-certainty evidence), interferon beta-1a (OR 1.48, 95% CI 0.99 to 2.20; moderate-certainty evidence), laquinimod (OR 1.49, 95 % CI 1.00 to 2.15; moderate-certainty evidence), natalizumab (OR 1.57, 95% CI 0.81 to 3.05), and glatiramer acetate (OR 1.48, 95% CI 1.01 to 2.14; moderate-certainty evidence) probably result in a slight increase in the number of people who discontinue treatment due to adverse events. Serious adverse events (SAEs) were reported in 35 studies (33,998 participants). There was probably a trivial reduction in SAEs amongst people with RRMS treated with interferon beta-1b as compared to placebo (OR 0.92, 95% CI 0.55 to 1.54; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

We are highly confident that, compared to placebo, two-year treatment with natalizumab, cladribine, or alemtuzumab decreases relapses more than with other DMTs. We are moderately confident that a two-year treatment with natalizumab may slow disability progression. Compared to those on placebo, people with RRMS treated with most of the assessed DMTs showed a higher frequency of treatment discontinuation due to AEs: we are moderately confident that this could happen with fingolimod, teriflunomide, interferon beta-1a, laquinimod, natalizumab and daclizumab, while our certainty with other DMTs is lower. We are also moderately certain that treatment with alemtuzumab is associated with fewer discontinuations due to adverse events than placebo, and moderately certain that interferon beta-1b probably results in a slight reduction in people who experience serious adverse events, but our certainty with regard to other DMTs is lower. Insufficient evidence is available to evaluate the efficacy and safety of DMTs in a longer term than two years, and this is a relevant issue for a chronic condition like MS that develops over decades. More than half of the included studies were sponsored by pharmaceutical companies and this may have influenced their results. Further studies should focus on direct comparison between active agents, with follow-up of at least three years, and assess other patient-relevant outcomes, such as quality of life and cognitive status, with particular focus on the impact of sex/gender on treatment effects.

Cell and gene therapy for amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a fatal and incurable neurodegenerative disorder with rapidly progressive skeletal muscle weakness, which can also cause a variable cognitive deficit. Genetic causes are only identified in approximately 10% of all cases, with complex genotype-phenotype associations, making it challenging to identify treatment targets. What further hampers therapeutic development is a broad heterogeneity in mechanisms, possible targets, and disturbances across various cell types, aside from the cortical and spinal motor neurons that lie at the heart of the pathology of ALS. Over the last decade, significant progress in biotechnologic techniques, cell and ribonucleic acid (RNA) engineering, animal models, and patient-specific human stem cell and organoid models have accelerated both mechanistic and therapeutic discoveries. The growing number of clinical trials mirrors this. This chapter reviews the current state of human preclinical models supporting trial strategies as well as recent clinical cell and gene therapy approaches.

The experiences of speech pathology referral and communicative participation in adults with cerebellar ataxia

PURPOSE

The purpose of this study was to identify potential barriers to speech pathology referral in ataxia, as well as potential factors influencing satisfaction with speech pathology and communicative participation.

METHOD

An online survey study included questions about participant demographics, referral and access to speech pathology, satisfaction with speech pathology, and communicative participation via the Communicative Participation Item Bank (CPIB).

RESULTS

We analysed 118 eligible responses from individuals with ataxia. Results from Bayesian regression models indicated that the overall referral rate to speech pathology was 64% for the respondents with a speech impairment, predicted by lower income, less education, and greater self-perceived speech severity. Additionally, sex, self-perceived speech severity, and length of speech impairment predicted more restricted communicative participation. For the respondents who were referred for speech pathology, overall satisfaction with speech pathology was neutral to high but most individuals reported little to no improvement in their speech.

CONCLUSION

Referral rate to speech pathology was low given that dysarthria and dysphagia are highly likely to occur in ataxia. Considerations should be made for perceived speech severity, sex, and length of speech impairment in evaluating communicative participation. Lastly, there is a vital need for evidence-based treatment for ataxic dysarthria.

"Heads Up" for Creatine Supplementation and its Potential Applications for Brain Health and Function

There is emerging interest regarding the potential beneficial effects of creatine supplementation on indices of brain health and function. Creatine supplementation can increase brain creatine stores, which may help explain some of the positive effects on measures of cognition and memory, especially in aging adults or during times of metabolic stress (i.e., sleep deprivation). Furthermore, creatine has shown promise for improving health outcome measures associated with muscular dystrophy, traumatic brain injury (including concussions in children), depression, and anxiety. However, whether any sex- or age-related differences exist in regard to creatine and indices of brain health and function is relatively unknown. The purpose of this narrative review is to: (1) provide an up-to-date summary and discussion of the current body of research focusing on creatine and indices of brain health and function and (2) discuss possible sex- and age-related differences in response to creatine supplementation on brain bioenergetics, measures of brain health and function, and neurological diseases.

Male and female are not the same: a multicenter study of static and dynamic functional connectivity in relapse-remitting multiple sclerosis in China

Background

Sex-related effects have been observed in relapsing-remitting multiple sclerosis (RRMS), but their impact on functional networks remains unclear.

Objective

To investigate the sex-related differences in connectivity strength and time variability within large-scale networks in RRMS.

Methods

This is a multi-center retrospective study. A total of 208 RRMS patients (135 females; 37.55 ± 11.47 years old) and 228 healthy controls (123 females; 36.94 ± 12.17 years old) were included. All participants underwent clinical and MRI assessments. Independent component analysis was used to extract resting-state networks (RSNs). We assessed the connectivity strength using spatial maps (SMs) and static functional network connectivity (sFNC), evaluated temporal properties and dynamic functional network connectivity (dFNC) patterns of RSNs using dFNC, and investigated their associations with structural damage or clinical variables.

Results

For static connectivity, only male RRMS patients displayed decreased SMs in the attention network and reduced sFNC between the sensorimotor network and visual or frontoparietal networks compared with healthy controls [P<0.05, false discovery rate (FDR) corrected]. For dynamic connectivity, three recurring states were identified for all participants: State 1 (sparse connected state; 42%), State 2 (middle-high connected state; 36%), and State 3 (high connected state; 16%). dFNC analyses suggested that altered temporal properties and dFNC patterns only occurred in females: female patients showed a higher fractional time (P<0.001) and more dwell time in State 1 (P<0.001) with higher transitions (P=0.004) compared with healthy females. Receiver operating characteristic curves revealed that the fraction time and mean dwell time of State 1 could significantly distinguish female patients from controls (area under the curve: 0.838-0.896). In addition, female patients with RRMS also mainly showed decreased dFNC in all states, particularly within cognitive networks such as the default mode, frontoparietal, and visual networks compared with healthy females (P < 0.05, FDR corrected).

Conclusion

Our results observed alterations in connectivity strength only in male patients and time variability in female patients, suggesting that sex-related effects may play an important role in the functional impairment and reorganization of RRMS.

Breaking Stereotypes: A Unique Presentation of New-Onset Multiple Sclerosis

Multiple sclerosis (MS) is a chronic demyelinating disorder resulting in demyelination, neuroaxonal degeneration, and sclerosis. This often-debilitating disease affects young females mainly. Literature describing the pathology and phenotypic features is vast. Although there are extensive descriptions of new-onset MS presentations, few document the initial presentation as a transient ischemic attack or ischemic stroke. The case we present highlights the rarity of such presentation. In the literature, we found scarce reports about MS as presenting as a stroke mimicker with some studies quoting from 2.2% to 4.4% of the cases having MS. Our case serves as a reminder that MS can mimic acute ischemic strokes and the importance of maintaining MS apart of the differential in a young female with no significant history present with acute neurological deficits to reduce the complications of MS and the healthcare-associated costs.

An Atypical Presentation of Progressive Multiple Sclerosis in a Young Black Male

Multiple sclerosis (MS) is an autoimmune disease primarily affecting the central nervous system, commonly diagnosed in women and individuals of European ancestry. It most commonly presents in the form of relapsing-remitting MS, which is characterized by exacerbations with partial to complete recovery. Far less common is the primary progressive form of MS, which involves the progression of neurological symptoms that gradually worsen with time. We present an atypical case of progressive MS in a 26-year-old incarcerated Black male. Initially diagnosed in 2019, he experienced bilateral upper extremity weakness and phasic spasticity, with subsequent worsening of symptoms including lower extremity spasticity, vision impairment, and difficulties with mobility and writing. With progressing symptoms, unintentional weight loss, and declining motor function, he was admitted to the hospital in March 2023. This case emphasizes the importance of considering MS as a differential diagnosis in any patient with progressive neurological dysfunction because, unlike the more prevalent relapsing-remitting type of MS, primary progressive MS has a more insidious onset with no recovery between exacerbations. It addresses the patient's symptom history, medication compliance challenges, and the need for improved education and awareness of MS in diverse patient populations.

Longitudinal epidemiology of multiple sclerosis in Townsville, Queensland, Australia, 2012-2022

BACKGROUND

Townsville (population=195,564, latitude=19.3°S) is the largest city in the Northern Queensland region of Australia, an area previously defined as a low/medium-prevalence zone for multiple sclerosis (MS). However, the epidemiology of MS in this region since 1981 is unknown.

AIMS

To assess the 2012 to 2022 epidemiology of MS in Townsville.

METHODS

Demographic/clinical data extracted from medical records of MS cases identified by public and private clinicians. Prevalence, and incidence and mortality rates estimated for 2012 and 2022 and age-standardised to the 2022 Australian population. Differences in estimates assessed by Poisson regression.

RESULTS

Females and relapsing-remitting MS comprised most cases. The 2012 prevalence was 45.0/100,000 (50.4/100,000 age-standardised, F/M sex ratio=2.0). Prevalence increased by 188% in 2022, with a crude prevalence of 86.9/100,000 (91.7/100,000 age-standardised, F/M sex ratio=2.7). 2012-22 MS onset incidence rate was 3.8/100,000 person-years (age-standardised 3.5/100,000, F/M sex ratio=2.7). Mean age increased from 49.4 to 57.3 years. Age-standardised mortality rate was 0.9/100,000 person-years, with standardised mortality ratio=1.0.

DISCUSSION

These results show that Townsville is a high-frequency region for MS, with prevalence and incidence on par with that seen at higher latitudes in Australia. These results have implications for clinical practice in the region and for organisational resource allocation.

Novel therapeutic for multiple sclerosis protects white matter function in EAE mouse model

Multiple sclerosis (MS) is a chronic demyelinating disease with prominent axon dysfunction. Our previous studies in an MS mouse model, experimental autoimmune encephalomyelitis (EAE), demonstrated that major histocompatibility complex Class II constructs can reverse clinical signs of EAE. These constructs block binding and downstream signaling of macrophage migration inhibitory factors (MIF-1/2) through CD74, thereby inhibiting phosphorylation of extracellular signal-regulated kinase (ERK) activation and tissue inflammation and promoting remyelination. To directly assess the effects of a novel third generation construct, DRhQ, on axon integrity in EAE, we compared axon conduction properties using electrophysiology on corpus callosum slices and optic nerves. By using two distinct white matter (WM) tracts, we aimed to assess the impact of the EAE and the benefit of DRhQ on myelinated and unmyelinated axons as well as to test the clinical value of DRhQ on demyelinating lesions in CC and optic myelitis. Our study found that EAE altered axon excitability, delayed axon conduction and slowed spatiotemporal summation correlated with diffuse astrocyte and microglia activation. Because MS predisposes patients to stroke, we also investigated and showed that vulnerability to WM ischemia is increased in the EAE MS mouse model. Treatment with DRhQ after the onset of EAE drastically inhibited microglial and astrocyte activation, improved functional integrity of the myelinated axons and enhanced recovery after ischemia. These results demonstrate that DRhQ administered after the onset of EAE promotes WM integrity and function, and reduces subsequent vulnerability to ischemic injury, suggesting important therapeutic potential for treatment of progressive MS.

Is cancer risk reduced in multiple sclerosis? Results from a tertiary referral center

BACKGROUND

Multiple sclerosis (MS) patients may be protected against cancer because of increased immune surveillance. However, aberrant T/B cell functioning in MS may increase the risk of cancer. We aimed to compare the frequency of cancer among patients with MS with an appropriate control group matched by the variables such as age, gender, tobacco smoking history, body mass index (BMI), and family history of cancer.

METHODS

The MS patients who were registered and followed up at the MS Center in Hacettepe University Hospitals and appropriately matched with controls were included. A self-administered questionnaire with links to the online survey was delivered.

RESULTS

Overall, 1037 responses out of 2074 in MS patients and 506 responses out of 1500 control group were included. Fourteen (1.35%) of MS patients and 18 (3.6%) of the controls were diagnosed with cancer. The odds ratio of having cancer in patients with MS compared to the control group was 0.389 (95% CI = 0.161-0.940, p < 0.05).

DISCUSSION

There was no statistically significant difference in age, gender, tobacco smoking, and BMI between the groups after propensity score matching. The odds of having cancer were lower in our MS patients compared to the controls. The autoimmune changes responsible for the pathogenesis of MS may be responsible for the decrease in cancer risk.

Risk factors for multiple sclerosis in the context of Epstein-Barr virus infection

Compelling evidence indicates that Epstein Barr virus (EBV) infection is a prerequisite for multiple sclerosis (MS). The disease may arise from a complex interplay between latent EBV infection, genetic predisposition, and various environmental and lifestyle factors that negatively affect immune control of the infection. Evidence of gene-environment interactions and epigenetic modifications triggered by environmental factors in genetically susceptible individuals supports this view. This review gives a short introduction to EBV and host immunity and discusses evidence indicating EBV as a prerequisite for MS. The role of genetic and environmental risk factors, and their interactions, in MS pathogenesis is reviewed and put in the context of EBV infection. Finally, possible preventive measures are discussed based on the findings presented.

Environmental Influences on Risk and Disease Course in Pediatric Multiple Sclerosis

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

Genetic Basis of Inflammatory Demyelinating Diseases of the Central Nervous System: Multiple Sclerosis and Neuromyelitis Optica Spectrum

Demyelinating diseases alter myelin or the coating surrounding most nerve fibers in the central and peripheral nervous systems. The grouping of human central nervous system demyelinating disorders today includes multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) as distinct disease categories. Each disease is caused by a complex combination of genetic and environmental variables, many involving an autoimmune response. Even though these conditions are fundamentally similar, research into genetic factors, their unique clinical manifestations, and lesion pathology has helped with differential diagnosis and disease pathogenesis knowledge. This review aims to synthesize the genetic approaches that explain the differential susceptibility between these diseases, explore the overlapping clinical features, and pathological findings, discuss existing and emerging hypotheses on the etiology of demyelination, and assess recent pathogenicity studies and their implications for human demyelination. This review presents critical information from previous studies on the disease, which asks several questions to understand the gaps in research in this field.

Utility of optical coherence tomography in patients of central immune mediated demyelinating diseases - A prospective study

Optical coherence tomography (OCT) is a non-invasive tool to measure thickness of various layers of retina. Recently, retinal nerve fibre layer (RNFL) and ganglion cell and inner plexiform layer (GCIP) thinning has been observed in OCT in patients with multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD), This study compared OCT profile, along with visual acuity (VA), color vision (CV), contrast saturation (CS) and visual evoked potentials (VEP) in two main cohorts of MS and NMOSD and with controls, during acute episode of optic neuritis (ON), at 3 and 6 months. We found that changes of ON were present in 75% of MS eyes and in 45% of NMOSD patients. Of these, subclinical involvement was present in 56.25% of MS eyes and only in 5% of NMOSD eyes suggesting frequent subclinical involvement in the former. Mean RNFL was 95.23 ± 15.53 in MS and 66.14 ± 43.73 in NMOSD after 6 months of ON episode. Thinning of NQ and IQ was observed in NMOSD eyes in the immediate period after ON attack. At 6 months relative sparing of RNFL in TQ was observed in NMOSD ON eyes and MS ON showed predilection for involvement of TQ.

Real-life outcomes for oral disease-modifying treatments of relapsing-remitting multiple sclerosis patients: Adherence and adverse event profiles from Marmara University

BACKGROUND

Disease-modifying treatments (DMT) are used to prevent future relapses and disability. High long-term adherence to treatment is important to achieve disease control. This study aims to investigate and compare adherence, adverse event (AE) profiles, and frequencies, main reasons for treatment discontinuation under Teriflunomide (TERI), Dimethyl Fumarate (DMF), and Fingolimod (FNG) for relapsing-remitting MS (RRMS) patients. This study is designed to explore patient-reported experiences in real-life settings.

METHODS

Patients who were older than 18 years with a definite diagnosis of RRMS and no history of stem-cell transplantation were included. Outpatient clinic data files at the Neurology Department of Marmara University from June 2012 to June 2019 were examined retrospectively.

RESULTS

One hundred and ninety MS patients were enrolled. 118 FNG, 51 DMF, 44 TERI treatment cycles were recorded. Time sincedisease onset, time since diagnosis, and treatment duration were significantly longer for FNG (p = 0.012, p = 0.004, p < 0.001). 72.8% of all the treatment cycles were continued. There was no significant difference in treatment continuity between the 3 DMT groups. The most common reasons for treatment discontinuation in order of frequency were adverse events, the progression of the disease, and the persistence of relapses. No significant difference was found for treatment discontinuation reasons. 32% of the patients reported at least one AE. 28% FNG, 49 % DMF, and 27.3% TERI using patients reported AEs. AEs were much more frequently reported for DMF (p = 0.015). The most common adverse events for each DMT were alopecia (n = 6, 13.6%) for TERI, flushing for DMF (n = 20, 39.2%), and persistent lymphopenia for FNG (n = 9, 7.6%). No severe or life-threatening AE was reported for DMF, one patient experienced pancreatitis under TERI, and 11 (9.3%) patients using FNG had to stop treatment due to serious or life-threatening AEs including cardiac adverse events, opportunistic infections, and dysplasia.

DISCUSSION

Overall treatment discontinuation because of AEs is as low as 10.3% in this study. However, AEs are still the main reason for treatment drop-out.

Co-modulation of TNFR1 and TNFR2 in an animal model of multiple sclerosis

BACKGROUND

Tumour necrosis factor (TNF) is a pleiotropic cytokine and master regulator of the immune system. It acts through two receptors resulting in often opposing biological effects, which may explain the lack of therapeutic potential obtained so far in multiple sclerosis (MS) with non-receptor-specific anti-TNF therapeutics. Under neuroinflammatory conditions, such as MS, TNF receptor-1 (TNFR1) is believed to mediate the pro-inflammatory activities associated with TNF, whereas TNF receptor-2 (TNFR2) may instead induce anti-inflammatory effects as well as promote remyelination and neuroprotection. In this study, we have investigated the therapeutic potential of blocking TNFR1 whilst simultaneously stimulating TNFR2 in a mouse model of MS.

METHODS

Experimental autoimmune encephalomyelitis (EAE) was induced with myelin oligodendrocyte glycoprotein (MOG_35-55) in humanized TNFR1 knock-in mice. These were treated with a human-specific TNFR1-selective antagonistic antibody (H398) and a mouse-specific TNFR2 agonist (EHD2-sc-mTNF_R2), both in combination and individually. Histopathological analysis of spinal cords was performed to investigate demyelination and inflammatory infiltration, as well as axonal and neuronal degeneration. Retinas were examined for any protective effects on retinal ganglion cell (RGC) degeneration and neuroprotective signalling pathways analysed by Western blotting.

RESULTS

TNFR modulation successfully ameliorated symptoms of EAE and reduced demyelination, inflammatory infiltration and axonal degeneration. Furthermore, the combinatorial approach of blocking TNFR1 and stimulating TNFR2 signalling increased RGC survival and promoted the phosphorylation of Akt and NF-κB, both known to mediate neuroprotection.

CONCLUSION

These results further support the potential of regulating the balance of TNFR signalling, through the co-modulation of TNFR1 and TNFR2 activity, as a novel therapeutic approach in treating inflammatory demyelinating disease.

The Areola study: design and rationale of a cohort study on long-term health outcomes in women with implant-based breast reconstructions

BACKGROUND

Implant-based breast reconstructions contribute considerably to the quality of life of breast cancer patients. A knowledge gap exists concerning the potential role of silicone breast implants in the development of so called 'breast implant illness' and autoimmune diseases in breast cancer survivors with implant-based reconstructions. Breast implant illness (BII) is a constellation of non-specific symptoms reported by a small group of women with silicone breast implants.

METHODS/DESIGN

The Areola study is a multi-centre retrospective cohort study with prospective follow-up aiming to assess the risk of BII and autoimmune diseases in female breast cancer survivors with and without silicone breast implants. In this report, we set out the rationale, study design and methodology of this cohort study. The cohort consists of breast cancer survivors who received surgical treatment with implant-based reconstruction in six major hospitals across the Netherlands in the period between 2000 and 2015. As comparison group, a frequency-matched sample of breast cancer survivors without breast implants will be selected. An additional group of women who received breast augmentation surgery in the same years will be selected to compare their characteristics and health outcomes with those of breast cancer patients with implants. All women still alive will be invited to complete a web-based questionnaire covering health-related topics. The entire cohort including deceased women will be linked to population-based databases of Statistics Netherlands. These include a registry of hospital diagnostic codes, a medicines prescription registry and a cause-of-death registry, through which diagnoses of autoimmune diseases will be identified. Outcomes of interest are the prevalence and incidence of BII and autoimmune diseases. In addition, risk factors for the development of BII and autoimmune disorders will be assessed among women with implants.

DISCUSSION

The Areola study will contribute to the availability of reliable information on the risks of BII and autoimmune diseases in Dutch breast cancer survivors with silicone breast implants. This will inform breast cancer survivors and aid future breast cancer patients and their treating physicians to make informed decisions about reconstructive strategies after mastectomy.

REGISTRATION

This study is registered at ClinicalTrials.gov on June 2^nd 2022 (NCT05400954).

Incidence and prevalence of multiple sclerosis in China and other Asian countries

The prevalence of multiple sclerosis (MS) in Asian countries is thought to be lower than in Western countries, with Asian populations presenting 80% less risk of MS than white populations. Incidence and prevalence rates in Asian countries are therefore not well defined and their association with rates in neighboring countries, as well as with ethnic, environmental, and socioeconomic factors, are not well understood. We performed a comprehensive literature review of epidemiological data from China and neighbouring countries to study the frequency of the disease, focusing on prevalence, and the progression over time and the influence of sex-related, environmental, dietary, and sociocultural factors. Prevalence rates in China range between 0.88 cases/100,000 population in 1986 and 5.2 cases/100,000 population in 2013, with a non-significant upwards trend (p = .08). The increase observed in Japan, where figures ranged between 8.1 and 18.6 cases/100,000 population was highly significant (p < .001). Prevalence rates in countries with predominantly white populations are considerably higher and have increased over time, reaching 115 cases/100,000 population in 2015 (r² = 0.79, p < .0001). In conclusion, the prevalence of MS in China appears to have risen in recent years, although Asian populations (including Chinese and Japanese populations, among others) appear to present less risk than other populations. Within Asia, geographical latitude appears not to be a determining factor for developing MS.

The prevalence and incidence of multiple sclerosis over the past 20 years in northern Japan

OBJECTIVES

The prevalence of multiple sclerosis (MS) in East Asia is thought to be lower than in Western countries. Globally, there is a trend of increasing MS prevalence. We investigated the changes in the prevalence and clinical phenotype of MS in the Tokachi province of Hokkaido in northern Japan, from 2001 to 2021.

METHODS

Data processing sheets were sent to all related institutions inside and outside the Tokachi area of Hokkaido island in Japan and were collected from April to May 2021. The prevalence according to the Poser's diagnostic criteria for MS was determined on March 31, 2021.

RESULTS

In 2021, the crude MS prevalence in northern Japan was 22.4/100,000 (95% confidence interval, 17.6-28.0). The prevalences of MS standardized by the Japanese national population in 2001, 2006, 2011, 2016, and 2021 were 6.9, 11.5, 15.3, 18.5, and 23.3, respectively. The female/male ratio was 4.0 in 2021, increased from 2.6 in 2001. We checked the prevalence using the 2017 revised McDonald criteria, and found only additional male patient who had not fulfilled Poser's criteria. The age- and sex-adjusted incidence of MS per 100,000 individuals increased from 0.09 in 1980-1984 to 0.99 in 2005-2009; since then, it has remained stable. The proportions of primary-progressive, relapsing-remitting, and secondary-progressive MS types in 2021 were 3%, 82%, and 15%, respectively.

CONCLUSION

Our results demonstrated a consistent increase in the prevalence of MS among the northern Japanese over 20 years, particularly in females, and consistently lower rates of progressive MS in northern Japan than elsewhere in the world.

Optical coherence tomography angiography measurements in multiple sclerosis: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Recent literature on multiple sclerosis (MS) demonstrates the growing implementation of optical coherence tomography-angiography (OCT-A) to discover potential qualitative and quantitative changes in the retina and optic nerve. In this review, we analyze OCT-A studies in patients with MS and examine its utility as a surrogate or precursor to changes in central nervous system tissue.

METHODS

PubMed and EMBASE were systematically searched to identify articles that applied OCT-A to evaluate the retinal microvasculature measurements in patients with MS. Quantitative data synthesis was performed on all measurements which were evaluated in at least two unique studies with the same OCT-A devices, software, and study population compared to controls. A fixed-effects or random-effects model was applied for the meta-analysis based on the heterogeneity level.

RESULTS

The study selection process yielded the inclusion of 18 studies with a total of 1552 evaluated eyes in 673 MS-associated optic neuritis (MSON) eyes, 741 MS without optic neuritis (MSNON eyes), and 138 eyes without specification for the presence of optic neuritis (ON) in addition to 1107 healthy control (HC) eyes. Results indicated that MS cases had significantly decreased whole image superficial capillary plexus (SCP) vessel density when compared to healthy control subjects in the analyses conducted on Optovue and Topcon studies (both P < 0.0001). Likewise, the whole image vessel densities of deep capillary plexus (DCP) and radial peripapillary capillary (RPC) were significantly lower in MS cases compared to HC (all P < 0.05). Regarding optic disc area quadrants, MSON eyes had significantly decreased mean RPC vessel density compared to MSNON eyes in all quadrants except for the inferior (all P < 0.05). Results of the analysis of studies that used prototype Axsun machine revealed that MSON and MSNON eyes both had significantly lower ONH flow index compared to HC (both P < 0.0001).

CONCLUSIONS

This systematic review and meta-analysis of the studies reporting OCT-A measurements of people with MS confirmed the tendency of MS eyes to exhibit reduced vessel density in the macular and optic disc areas, mainly in SCP, DCP, and RPC vessel densities.

Death following rapidly progressive demyelinating disorder in a young female-a case report

Multiple sclerosis (MS) is a debilitating, demyelinating disease of the central nervous system, with manifestations ranging from numbness and blindness to paralysis. Typical MS is a slowly progressive demyelinating disease, causing significant morbidity spanning over many years. In contrast, "Marburg's disease" is a rare variant of MS which demonstrates a malignant monophasic disease progression leading to death within weeks to months. We present a rapidly fatal demyelinating disease with the clinicopathological findings on par with the handful of reported cases of "Marburg's disease" in the literature. A previously healthy 30-year-old mother of two children was extensively investigated for focal neurological signs succumbing to death 5 weeks after the onset. Antemortem investigations for tuberculosis, autoimmune diseases, and viral studies were negative. Magnetic resonance imaging of the brain showed hyperintense lesions with contrast enhancement compatible with MS. Histopathologic examination confirmed numerous inflammatory and demyelination foci scattered throughout the brain and brain stem predominantly involving the white matter. There were extensive perivascular inflammatory cell cuffs containing lymphocytes admixed with histiocytes. Also, a few foci of vasculitis with fibrinoid necrosis, mediated by lymphocytes and neutrophils were noted associated with parenchymal haemorrhages. Considered a rare variant of MS, the case of Marburg's disease presented here shows an infrequent association with active vasculitis and haemorrhage, described only a few times in the literature. This wide spectrum of rapidly fatal demyelinating diseases consisting of rare variants with overlapping clinicopathological features makes diagnosis challenging. Therefore, it is important to correlate clinical-radiological and histopathological findings to arrive at an accurate final diagnosis.

Direct Health Care Costs Associated With Multiple Sclerosis: A Population-Based Cohort Study in British Columbia, Canada, 2001-2020

BACKGROUND AND OBJECTIVES

Multiple sclerosis (MS), a leading cause of nontraumatic neurologic disability in young adults, exerts a substantial economic burden on the health care system. The objective of this study was to quantify the excess health care costs of MS in British Columbia, Canada.

METHODS

A retrospective-matched cohort study of patients with MS was conducted using population-based administrative health data from 2001 to 2020. Patients with MS who satisfied a validated case definition were matched to 5 unique controls without MS on sex, age, and cohort entry date. Patients and controls were followed to the end of 2020 or to their last health care resource use, whichever came first. We calculated the direct medical costs for each individual, including outpatient services use, hospital admissions, and dispensed medications. We used generalized linear models with an identity link and normal distribution to estimate the excess cost of MS as the mean cost difference between patients with MS and controls. All costs were reported in 2020 Canadian dollars.

RESULTS

A total of 17,071 patients with MS were matched to 85,355 controls. Overall, 72.4% were female, and the mean age at cohort entry date was 46.1 years. The excess cost of MS was $6,881 (95% CI: $6,713, $7,049) per patient-year. Inpatient, outpatient, and medication costs accounted for 25%, 10%, and 65% of excess costs, respectively. Excess costs were higher in patients with MS with at least one disease-modifying therapy (DMT) prescription ($13,267; 95% CI: $12,992-$13,542) compared with non-DMT users ($3,469; 95% CI: $3,297-$3,641) and even higher among frequent DMT users ($24,835; 95% CI: $24,528-$25,141). Patients with MS with a history of at least one relapse requiring hospitalization had higher excess costs ($10,543; 95% CI: $10,136-$10,950) compared with patients with MS without a relapse; hospitalizations accounted for 51% of the costs in this group. The excess cost of hospitalizations was $1,391 lower among frequent DMT users than non-DMT users.

DISCUSSION

The economic burden of MS is considerable, with medications, particularly DMTs, being the largest cost driver. Future studies should investigate how disease management strategies, including early diagnosis and timely use of DMTs, could offset future and ongoing costs while improving patients' quality of life.

Ongoing increase in incidence and prevalence of multiple sclerosis in south-eastern Iran: A three decade study

BACKGROUND

Prevalence of multiple sclerosis has been increased during the last decades throughout the world. Epidemiological studies could improve our understanding relating to its intrinsic and extrinsic causes.

OBJECTIVES

The current study has been conducted to determine the epidemiological features of MS in south-eastern Iran which is a semi-tropical area with different ethnicities.

METHODS

This longitudinal descriptive study was carried out in south-eastern Iran, based on information of MS patients registered at Zahedan University of Medical Sciences database from 1990 to 2020.

RESULTS

A total of 1045 cases were enrolled into the study. The age-standardized prevalence ratio of MS increased to 42.2/100,000 population by 2020. These figures showed increasing trends both in females and males and reached to 61.5 and 22.6 per 100,000 population, respectively by the year 2020. Likewise, the total incidence rate grew to its maximum amount of 4.5 in 2015. Female incidence also revealed an upward trend and peaked in 2016 to 6.4 while male incidence rate reached at its highest level of 1.8 in 2009.

CONCLUSION

MS prevalence ratios and incidence rates in south-eastern Iran have been increasing steadily, especially in women during the last three decades. The south-eastern part of Iran should be considered a high-risk region.

Oxidative stress-related risk of the multiple sclerosis development

Background

Multiple sclerosis (MS) is characterized by inflammation, demyelination and axonal degeneration. Oxidative stress (OS) plays a significant role in the pathogenesis of the disease. The aim of the study was to examine the association between OS and smoking on the MS development.

Methods

The study included 175 patients with relapsing-remitting multiple sclerosis (RRMS) (76 males, 99 females) and 254 healthy subjects (81 males and 173 females). Oxidative stress biomarkers in serum, Total Antioxidant Status (TAS) and Total Oxidative Status (TOS) were determined spectrophotometrically. Oxidative Stress Index (OSI) was calculated as the ratio of TOS and TAS. Urinary 8-oxo7,8-dihydro-2'-deoxyguanosine were determined by HPLC-MS/MS and expressed as 8-oxodG/creatinine.

Results

In females with RRMS were higher TOS, OSI and 8-oxodG/creatinine than in females in control group. The group of males with RRMS had lower level of TAS than the males in control group. Higher levels of 8-oxodG/creatinine was obtained in active, passive and former smokers with RRMS than in control group with the same exposition to tobacco smoke. Independent predictors of MS are passive smoking, increased OSI and increased levels of urinary 8-oxodG/creatinine.

Conclusions

Our results demonstrate that the OS parameters should be included in the assessment of the risk for MS development. Due to the more sensitivity to oxidative stress, females may be at higher risk of MS development. This data indicates the importance of introducing the antioxidant therapy as a complementary treatment in patients with RRMS.

Palliative care in multiple sclerosis

Main target in palliative care (PC) is burden care of patients and their families, with the aim to reduce suffering through the management of symptoms, rehabilitation, psychosocial issues, and spiritual well-being, using a multidisciplinary approach. Multiple sclerosis (MS) is a chronic disease which induces physical and psychosocial symptoms, with a significant impact on the quality of life. As a consequence, despite advances in research in disease-modifying drugs, MS remains a life-limiting disease with symptoms negatively impacting the lives of MS patients and their families. PC has been developed for end-of-life treatment in oncology, being little used in MS. Specific issues in MS, like pain due to spasticity, requires a different approach respect to cancer pain management. Moreover, it is difficult to anticipate life expectancy in people with severe MS, who often need palliative care for a long extended period. PC teams are trained to keep open full and competent lines of communication about symptoms and disease progression, advanced care planning, and end-of-life issues and wishes. Many studies investigated the effects of home-based PC in advanced MS, showing weak evidences about the efficacy of PC versus usual care in MS. However, current evidence does not support or refute the routine use of PC interventions for people with MS.

Sex Difference in Spinal Muscular Atrophy Patients - are Males More Vulnerable?

BACKGROUND

Sex is a significant risk factor in many neurodegenerative disorders. A better understanding of the molecular mechanisms behind sex differences could help develop more targeted therapies that would lead to better outcomes. Untreated spinal muscular atrophy (SMA) is the leading genetic motor disorder causing infant mortality. SMA has a broad spectrum of severity ranging from prenatal death to infant mortality to normal lifespan with some disability. Scattered evidence points to a sex-specific vulnerability in SMA. However, the role of sex as a risk factor in SMA pathology and treatment has received limited attention.

OBJECTIVE

Systematically investigate sex differences in the incidence, symptom severity, motor function of patients with different types of SMA, and in the development of SMA1 patients.

METHODS

Aggregated data of SMA patients were obtained from the TREAT-NMD Global SMA Registry and the Cure SMA membership database by data enquiries. Data were analyzed and compared with publicly available standard data and data from published literature.

RESULTS

The analysis of the aggregated results from the TREAT-NMD dataset revealed that the male/female ratio was correlated to the incidence and prevalence of SMA from different countries; and for SMA patients, more of their male family members were affected by SMA. However, there was no significant difference of sex ratio in the Cure SMA membership dataset. As quantified by the clinician severity scores, symptoms were more severe in males than females in SMA types 2 and 3b. Motor function scores measured higher in females than males in SMA types 1, 3a and 3b. The head circumference was more strongly affected in male SMA type 1 patients.

CONCLUSIONS

The data in certain registry datasets suggest that males may be more vulnerable to SMA than females. The variability observed indicates that more investigation is necessary to fully understand the role of sex differences in SMA epidemiology, and to guide development of more targeted treatments.

Feasibility, Acceptability, and Efficacy of Mindfulness Training in People With Upper Motor Neuron Disorders: A Systematic Review

OBJECTIVES

This systematic review aims to gain a comprehensive understanding of the feasibility, acceptability, and efficacy of mindfulness-based interventions (MBIs) on depression, anxiety, fatigue, and health-related quality of life among individuals with upper motor neuron disorders (UMNDs).

DATA SOURCES

PubMed, PsycINFO, Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature were searched for relevant studies published between January 2001 and June 2021.

STUDY SELECTION

Clinical trials published in English evaluating MBIs in adults with the 4 most common UMNDs (multiple sclerosis, brain injury including stroke, spinal cord injury, amyotrophic lateral sclerosis) were included.

DATA EXTRACTION

Two reviewers independently performed the risk of bias assessment using standardized tools and extracted desired data electronically.

DATA SYNTHESIS

A total of 44 studies were included: 26 randomized controlled trials, 10 nonrandomized controlled trials, and 8 pre-post intervention studies. The average ± SD duration of MBIs was 8±2 weeks. On average, 85%±14% of participants completed the MBI, and the retention rate at follow-up was 80%±16%. Only 14% of the studies delivered MBIs virtually, and feasibility metrics were similar to in-person studies. Among studies reporting acceptability data, most participants reported satisfaction with the MBI. Randomized controlled trials that evaluated the effects of MBI on depression, anxiety, fatigue, and quality of life revealed greater relative improvement in these outcomes among MBI participants compared with controls, with differences greater when compared with passive control than active control participants. None of the studies included in this review studied dose response.

CONCLUSIONS

Based on current data, MBIs are feasible and offer a promising approach to address the biopsychosocial needs of individuals with UMNDs. MBIs are associated with a high acceptance rate among participants, with notable improvements in depression, anxiety, fatigue, and quality of life post intervention. Future studies are needed to evaluate alternate models of delivery of MBIs and the dose-response relationship.

Prevalence of neurodegenerative/demyelinating disorders in patients with achalasia

Introduction

Esophageal achalasia is a primary motility disorder. Although the exact pathogenesis is unknown, autoimmune, and neurodegenerative processes seem to be involved similarly to neurodegenerative and/or demyelinating disorders (NDDs). We hypothesized that the prevalence of NDD may be higher among patients with achalasia and vice versa as the background pathogenetic mechanisms are similar.

Methods

This was a prospective, comparative questionnaire-based study. Patients with achalasia and patients with NDD were enrolled. Selected patients with achalasia were thoroughly examined by a neurologist and selected patients with NDD were examined by a gastroenterologist to confirm or rule out NDD or achalasia. We assessed the prevalence of both achalasia and NDD and compared them with their prevalence in general population.

Results

A total of 150 patients with achalasia and 112 patients with NDD were enrolled. We observed an increased prevalence of NDD among patients with achalasia (6.0% (9/150); 95% CI (confidence interval): 3.1–11.2%) as compared to the estimated 2.0% prevalence in general population (p = 0.003). Although 32 out of 112 patients (28.6%) with NDD reported dysphagia, we did not observe significantly increased prevalence of achalasia in these patients (1.8% (2/112) vs 0.8% in general population, p = 0.226).

Conclusion

The prevalence of NDD was significantly higher among patients with achalasia (6.0%) compared to general population (2.0%), suggesting an association of these disorders. Large-volume studies are necessary to confirm this finding.

Tekrarlayan ve düzelen multipl sklerozda mizaç ve karakter: klinik faktörler ve psikiyatrik bozukluklarla ilişkisi

Amaç: Yaşam kalitesi üzerindeki etkilerine rağmen, multipl sklerozda mizaç ve karakter yeterince araştırılmamıştır. Mizaç ve karakter boyutlarını, i, bunların klinik özelliklerle ilişkisini ve depresyon şiddetini etkileyen faktörleri tekrarlayan ve düzelen multiple skleroz (TDMS) hastalarında incelemeyi amaçladık. Gereç ve Yöntem: Bu kesitsel çalışmaya, elverişli örnekleme yöntemiyle 67 hasta (erkek/kadın=12/55) (medyan yaş=30 (18-53)) ve yaş ve cinsiyet açısından eşleştirilmiş 50 sağlıklı kontrol (SK) (erkek/kadın=16/34) (medyan yaş= 26.5 (18-60)) alındı. Mizaç ve Karakter Envanteri, Beck Depresyon ve Beck Anksiyete Envanterleri, DSM-Eksen I Bozuklukları için Yapılandırılmış Klinik Görüşme uygulandı. Bulgular: Hasta grubu içinde, psikiyatrik komorbiditesi olan 45 (MSP), psikiyatrik komorbiditesi olmayan (MSO) 22 hasta bulunuyordu. MSP grubu, MSO grubuna ve SK’lere göre daha yüksek kendilik kaybı gösterdi. MSP grubu ve MSO grubu toplam zarardan kaçınma puanları SK’lere kıyasla yüksekti. Toplam kendini yönetme puanları MSP grubunda SK’lerden düşüktü. EDSS, hastalık süresi, toplam nüks sayısı depresyon şiddetini etkilemezken; yüksek anksiyete (Β=0,416) ve düşük amaçlılık düzeyleri (Β=-1,565) depresyon düzeyini anlamlı derecede etkilemekteydi (R2=0.50, F=32.459). Sonuç: Komorbid psikiyatrik bozukluğu olan ve olmayan hastalar arasında mizaç ve karakter özellikleri açısından farklılıklar gözlendi. Artmış anksiyete düzeyleri; anlamlı hedefler belirleme ve bunlara ulaşmada güçlük, artmış depresyon düzeyleriyle ilişkili olabilir. Gelecek çalışmalar, daha geniş örneklemlerde, baş etme, sağlık davranışları ve dayanıklılığın kendilik kaybı ve psikiyatrik bozukluklar arasındaki aracı ve düzenleyici rolünü inceleyerek, psikiyatrik bozukluklara yönelik müdahalelerin tanımlanmasına yardımcı olabilir. Anksiyete belirtilerinin etkin tedavisi ve yaşam amaçlarının ele alınması, davranışsal müdahalelerin planlanması için olası hedeflerdir.

Sex and gender differences in autoimmune demyelinating CNS disorders: Multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and myelin-oligodendrocyte-glycoprotein antibody associated disorder (MOGAD)

Multiple sclerosis (MS), Neuromyelitis optica spectrum disorder (NMOSD) and Myelin-Oligodendrocyte-Glycoprotein antibody associated disorder (MOGAD) are demyelinating disorders of the central nervous system (CNS) of autoimmune origin. Here, we summarize general considerations on sex-specific differences in the immunopathogenesis and hormonal influences as well as key clinical and epidemiological elements. Gender-specific issues are widely neglected starting with the lacking separation of sex as a biological variable and gender comprising the sociocultural components. As for other autoimmune diseases, female preponderance is common in MS and NMOSD. However, sex distribution in MOGAD seems equal. As in MS, immunotherapy in NMOSD and MOGAD is crucial to prevent further disease activity. Therefore, we assessed data on sex differences of the currently licensed disease-modifying treatments for efficacy and safety. This topic seems widely neglected with only fragmented information resulting from post-hoc analyses of clinical trials or real-world post-marketing studies afflicted with lacking power and/or inherent sources of bias. In summary, biological hypotheses of sex differences including genetic factors, the constitution of the immune system and hormonal influences are based upon human and preclinical data, especially for the paradigmatic disease of MS whereas specific data for NMOSD and MOGAD are widely lacking. Epidemiological and clinical differences between men and women are well described for MS and to some extent for NMOSD, yet, with remaining contradictory findings. MOGAD needs further detailed investigation. Sex-specific analyses of safety and efficacy of long-term immunotherapies need to be addressed in future studies designed and powered to answer the pressing questions and to optimize and individualize treatment.

Quantitative effect of sex on disease activity and disability accumulation in multiple sclerosis

OBJECTIVE

To quantify sex differences in activity and severity of multiple sclerosis (MS) and how it depends on disease duration and time since clinical onset.

METHODS

All Danish citizens with onset of relapsing MS since 1996 who have received disease-modifying therapy have been followed with annual or biannual control visits with mandatory notification of the Danish Multiple Sclerosis Registry. Men and women were compared by the inverse probability of being female. Relapse rates and changes in the Expanded Disability Status Scale (EDSS) scores were analysed with weighted general linear models, and we used weighted Cox regression for HRs between men and women for different EDSS endpoints.

RESULTS

We included 3028 men and 6619 women. The weighted female:male relapse rate ratio was 1.16 (95% CI: 1.10 to 1.22) but after age 50 years, the difference disappeared. The annualised increase in EDSS was 0.07 in men (95% CI: 0.05 to 0.08) and 0.05 in women (95% CI: 0.04 to 0.06); p=0.017. With women as reference, the HR for reaching EDSS 4 was 1.34 (95% CI: 1.23 to 1.45; p<0.001), and for reaching EDSS 6 it was 1.43 (95% CI: 1.28 to 1.61; p<0.001). The diagnostic delay did not differ significantly between the sexes.

CONCLUSION

Women have more inflammatory disease activity in terms of relapses than men up to the age of menopause indicating that sex hormones may play a role. Men are more subject to the neurodegenerative component of MS than women, particularly after the age of 45 years.

The effect of Zingiber Officinale Extract on Preventing Demyelination of Corpus Callosum in a Rat Model of Multiple Sclerosis

Background

Multiple sclerosis (MS) is the most prevalent neurological disability of young adults. Anti-inflammatory drugs have relative effects on MS. The anti-inflammatory and antioxidative effects of Zingiber officinale (ginger) have been proven in some experimental and clinical investigations. The aim of this study was to evaluate the effects of ginger extract on preventing myelin degradation in a rat model of MS.

Methods

Forty nine male Wistar rats were used in this study and divided into four control groups: the normal group, cuprizone-induced group, sham group (cuprizone [CPZ] + sodium carboxymethyl cellulose [NaCMC]), standard control group (fingolimod + cuprizone), including three experimental groups of CPZ, each receiving three different doses of ginger extract: 150, 300, and 600mg/kg /kg/day.

Results

Ginger extract of 600 mg/kg prevented corpus callosum from demyelination; however, a significant difference was observed in the fingolimod group (p < 0.05). Difference in the CPZ group was quite significant (p < 0.05).

Conclusion

Treatment with ginger inhibited demyelination and alleviated remyelination of corpus callosum in rats. Therefore, it could serve as a therapeutic agent in the MS.

Nuclear hormone receptors in demyelinating diseases

Demyelination results from the pathological loss of myelin and is a hallmark of many neurodegenerative diseases. Despite the prevalence of demyelinating diseases, there are no disease modifying therapies that prevent the loss of myelin or promote remyelination. This review aims to summarize studies in the field that highlight the importance of nuclear hormone receptors in the promotion and maintenance of myelination and the relevance of nuclear hormone receptors as potential therapeutic targets for demyelinating diseases. These nuclear hormone receptors include the estrogen receptor, progesterone receptor, androgen receptor, vitamin D receptor, thyroid hormone receptor, peroxisome proliferator-activated receptor, liver X receptor, and retinoid X receptor. Pre-clinical studies in well-established animal models of demyelination have shown a prominent role of these nuclear hormone receptors in myelination through their promotion of oligodendrocyte maturation and development. The activation of the nuclear hormone receptors by their ligands also promotes the synthesis of myelin proteins and lipids in mouse models of demyelination. There are limited clinical studies that focus on how the activation of these nuclear hormone receptors could alleviate demyelination in patients with diseases such as multiple sclerosis (MS). However, the completed clinical trials have reported improved clinical outcome in MS patients treated with the ligands of some of these nuclear hormone receptors. Together, the positive results from both clinical and pre-clinical studies point to nuclear hormone receptors as promising therapeutic targets to counter demyelination.