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Salter A, Lancia S, Kowalec K, Fitzgerald KC, Marrie RA. Comorbidity and Disease Activity in Multiple Sclerosis. JAMA Neurol 2024:2823966. [PMID: 39291661 PMCID: PMC11411448 DOI: 10.1001/jamaneurol.2024.2920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Importance Multiple studies suggest that comorbidity worsens clinically relevant outcomes in multiple sclerosis (MS), including the severity of disability at diagnosis and rate of disability worsening after diagnosis. However, less is known regarding the association of comorbidity with measures of disease activity, such as relapse rate and magnetic resonance imaging lesion accrual, which are relevant to clinicians and clinical trialists. Objective To evaluate the association of comorbidities with disease activity in clinical trials of disease-modifying therapies (DMTs) in populations with MS. Design, Setting, and Participants A 2-stage meta-analytic approach was used in this cohort study of individual participant data from phase 3 clinical trials of MS DMTs that had 2 years of follow-up and were conducted from November 2001 to March 2018. Data were analyzed from February 2023 to June 2024. Exposure Comorbidity burden and individual comorbidities present at trial enrollment, including hypertension; hyperlipidemia; functional cardiovascular disease, ischemic heart, cerebrovascular, and peripheral vascular disease; diabetes; autoimmune thyroid and miscellaneous autoimmune conditions; migraine; lung and skin conditions; depression; anxiety; and other psychiatric disorders. Main Outcomes and Measures The main outcome was evidence of disease activity (EDA) over 2 years of follow-up, defined as confirmed relapse activity, disability worsening, or any new lesions on magnetic resonance imaging. Results A total of 16 794 participants with MS were included from 17 clinical trials (67.2% female). Over the 2-year follow-up, 61.0% (95% CI, 56.2%-66.3%; I2 = 97.9%) of the pooled trials had EDA. After adjusting for multiple factors, the presence of 3 or more comorbidities was associated with an increased hazard of EDA (adjusted hazard ratio [AHR], 1.14; 95% CI, 1.02-1.28) compared with no comorbidity. Presence of 2 or more cardiometabolic conditions was also associated with an increased hazard of EDA (AHR, 1.21; 95% CI, 1.08-1.37) compared with no cardiometabolic comorbidity. Presence of 1 psychiatric disorder was associated with an increased hazard of EDA (AHR, 1.07; 95% CI, 1.02-1.14). Conclusions and Relevance In this study, a higher burden of comorbidity was associated with worse clinical outcomes in people with MS, although comorbidity could potentially be a partial mediator of other negative prognostic factors. Our findings suggest a substantial adverse association of the comorbidities investigated with MS disease activity and that prevention and management of comorbidities should be a pressing concern in clinical practice.
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Affiliation(s)
- Amber Salter
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, Texas
- Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas
| | - Samantha Lancia
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, Texas
| | - Kaarina Kowalec
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Epidemiology & Biostatistics, Karolinska Institutet, Solna, Sweden
| | | | - Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Wicks TR, Jakimovski D, Reeves J, Bergsland N, Dwyer MG, Weinstock-Guttman B, Zivadinov R. Comorbid onset of cardiovascular diagnosis and long-term confirmed disability progression in multiple sclerosis: A 15-year follow-up study. J Neurol Sci 2024; 464:123156. [PMID: 39096837 DOI: 10.1016/j.jns.2024.123156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/24/2024] [Accepted: 07/27/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND People with multiple sclerosis (pwMS) have greater prevalence of comorbid cardiovascular diseases (CVD) when compared to the general population despite similar frequency of CV risk factors. OBJECTIVE Determine the impact of comorbid-onset of CVD diagnosis on long-term confirmed disability progression (CDP). METHODS 276 pwMS (29 clinically isolated syndrome, 130 relapsing-remitting and 117 progressive) were clinically followed an average of 14.9 years, with a mean of 14.4 clinical visits. Retrospective electronic medical records (EMR) review determined CVD diagnoses (hypertension, hyperlipidemia, diabetes, and heart disease) at baseline and over the follow-up. CDP was determined with ≥1.0 point Expanded Disability Status Scale (EDSS) increase from EDSS <5.5, or ≥ 0.5-point increase from ≥5.5, and was sustained on next clinical visit. RESULTS A significantly shorter time to overall CDP was detected in 213 pwMS who had an existing (28 pwMS) or developed new onset (185 pwMS) of CVD, compared to 63 CVD-healthy pwMS over the follow-up (13.4 vs 15.9 years, Mantel-Cox p < 0.001), independent of baseline age and EDSS score. The CVD diagnosis preceded the CDP in 103 pwMS (55.7%), occurred after CDP in 71 pwMS (38.4%) and was concurrent in 11 pwMS (5.9%). Using mixed-effect models adjusted for significant age (F = 56.5, p < 0.001) and time effects (F = 67.8, p < 0.001), the CVD-onset diagnosis was associated with greater accrual of disability, as measured by longitudinal increase in EDSS score (F = 4.207, p = 0.04). Sex was not significant predictor of future disability in our cohort. CONCLUSION PwMS with an existing or new onset of comorbid CVD diagnosis showed accelerated disability worsening over long-term. There was no temporal relationship between the onset of CVD and CDP within the group that had CVD-onset diagnosis.
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Affiliation(s)
- Taylor R Wicks
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Jack Reeves
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Michael G Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Center for Biomedical Imaging at the Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA.
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Etemadifar M, Alaei SA, Salari M, Sedaghat N. Span of spleen is associated with disability status in multiple sclerosis: a cross-sectional abdominopelvic ultrasonography study. Sci Rep 2024; 14:15297. [PMID: 38961187 PMCID: PMC11222531 DOI: 10.1038/s41598-024-66216-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 06/28/2024] [Indexed: 07/05/2024] Open
Abstract
Characteristics of livers and spleens of people with multiple sclerosis (pwMS) could constitute good biomarkers of MS-related characteristics such as the disability status. To test the hypothesis "the gross anatomical features of livers and spleens, are not similar between pwMS with different disease characteristics" a cross-sectional study was conducted on pwMS seen at the Isfahan MS clinic, Iran, from February until December 2023. Definitive, otherwise-healthy, pwMS were enrolled after an initial laboratory evaluation. Presence/absence and grading of non-alcoholic fatty liver disease (NAFLD) and the span of spleen were determined by a radiologist using high-resolution abdominopelvic ultrasonography. 193 pwMS (160 women) were enrolled. Of whom, 143 (74.1%) were receiving first-line disease-modifying therapies (DMTs), 24 (12.4%) fingolimod, and 26 (13.5%) rituximab. The span of spleen was negatively associated with EDSS (adjusted β [SE] - 4.08 [1.52], p < 0.01), as well as 6 m-CDW (adjusted β [SE] - 6.94 [3.56], p = 0.05), unlike age, DMTs, and MS duration (all with p > 0.05). Receiver operating characteristic analysis showed, spleen span performs significant but poor in discrimination of EDSS > 1 from EDSS = 1 (area under curve [AUC] 0.62, SE 0.05, p < 0.01), yet, significant and fair in discrimination of presence from absence of 6 m-CDW (AUC 0.72, SE 0.06, p < 0.01). Other findings were unremarkable. Further longitudinal, prospective studies are warranted to confirm whether smaller spleens are predictive of higher disability accrual rate in pwMS. Particularly, findings require further validation in untreated/treatment-naïve pwMS, and ones with higher EDSS scores.
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Affiliation(s)
- Masoud Etemadifar
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyyed-Ali Alaei
- Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehri Salari
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nahad Sedaghat
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.
- Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran.
- Student Research Committee, Kashan University of Medical Sciences, Kashan, Iran.
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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Kowalec K, Harder A, Dolovich C, Fitzgerald KC, Salter A, Lu Y, Bernstein CN, Bolton JM, Cutter G, Fisk JD, Gelernter J, Graff LA, Hägg S, Hitchon CA, Levey DF, Lublin FD, McKay KA, Patten S, Patki A, Stein MB, Tiwari HK, Wolinsky JS, Marrie RA. Polygenic liability for anxiety in association with comorbid anxiety in multiple sclerosis. Ann Clin Transl Neurol 2024; 11:1393-1404. [PMID: 38715244 PMCID: PMC11187942 DOI: 10.1002/acn3.52025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 02/03/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE Comorbid anxiety occurs often in MS and is associated with disability progression. Polygenic scores offer a possible means of anxiety risk prediction but often have not been validated outside the original discovery population. We aimed to investigate the association between the Generalized Anxiety Disorder 2-item scale polygenic score with anxiety in MS. METHODS Using a case-control design, participants from Canadian, UK Biobank, and United States cohorts were grouped into cases (MS/comorbid anxiety) or controls (MS/no anxiety, anxiety/no immune disease or healthy). We used multiple anxiety measures: current symptoms, lifetime interview-diagnosed, and lifetime self-report physician-diagnosed. The polygenic score was computed for current anxiety symptoms using summary statistics from a previous genome-wide association study and was tested using regression. RESULTS A total of 71,343 individuals of European genetic ancestry were used: Canada (n = 334; 212 MS), UK Biobank (n = 70,431; 1,390 MS), and the USA (n = 578 MS). Meta-analyses identified that in MS, each 1-SD increase in the polygenic score was associated with ~50% increased odds of comorbid moderate anxious symptoms compared to those with less than moderate anxious symptoms (OR: 1.47, 95% CI: 1.09-1.99). We found a similar direction of effects in the other measures. MS had a similar anxiety genetic burden compared to people with anxiety as the index disease. INTERPRETATION Higher genetic burden for anxiety was associated with significantly increased odds of moderate anxious symptoms in MS of European genetic ancestry which did not differ from those with anxiety and no comorbid immune disease. This study suggests a genetic basis for anxiety in MS.
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Affiliation(s)
- Kaarina Kowalec
- Rady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
- Department of Medical Epidemiology & BiostatisticsKarolinska InstitutetSolnaSweden
| | - Arvid Harder
- Department of Medical Epidemiology & BiostatisticsKarolinska InstitutetSolnaSweden
| | - Casandra Dolovich
- Department of Internal MedicineMax Rady College of Medicine, Rady Faculty of Health Sciences, University of ManitobaWinnipegCanada
| | | | - Amber Salter
- Department of NeurologyUT SouthwesternDallasTexasUSA
| | - Yi Lu
- Department of Medical Epidemiology & BiostatisticsKarolinska InstitutetSolnaSweden
| | - Charles N. Bernstein
- Department of Internal MedicineMax Rady College of Medicine, Rady Faculty of Health Sciences, University of ManitobaWinnipegCanada
| | - James M. Bolton
- Department of PsychiatryMax Rady College of Medicine, Rady Faculty of Health Sciences, University of ManitobaWinnipegCanada
| | - Gary Cutter
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - John D. Fisk
- Nova Scotia Health and Departments of Psychiatry, Psychology & Neuroscience, and MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | - Joel Gelernter
- Department of PsychiatryYale University, School of MedicineNew HavenConnecticutUSA
- Department of PsychiatryVA Connecticut Healthcare SystemNew HavenConnecticutUSA
| | - Lesley A. Graff
- Department of Clinical Health PsychologyMax Rady College of Medicine, Rady Faculty of Health Sciences, University of ManitobaWinnipegCanada
| | - Sara Hägg
- Department of Medical Epidemiology & BiostatisticsKarolinska InstitutetSolnaSweden
| | - Carol A. Hitchon
- Department of RheumatologyMax Rady College of Medicine, Rady Faculty of Health Sciences, University of ManitobaWinnipegCanada
| | - Daniel F. Levey
- Department of PsychiatryYale University, School of MedicineNew HavenConnecticutUSA
- Department of PsychiatryVA Connecticut Healthcare SystemNew HavenConnecticutUSA
| | - Fred D. Lublin
- Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Kyla A. McKay
- Department of Clinical NeuroscienceKarolinska InstitutetSolnaSweden
| | - Scott Patten
- Department of Community Health SciencesCumming School of Medicine, University of CalgaryCalgaryCanada
| | - Amit Patki
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Murray B. Stein
- Department of PsychiatryMax Rady College of Medicine, Rady Faculty of Health Sciences, University of ManitobaWinnipegCanada
- Department of PsychiatryUniversity of California San DiegoLa JollaCaliforniaUSA
| | - Hemant K. Tiwari
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jerry S. Wolinsky
- Department of NeurologyMcGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth)HoustonTexasUSA
| | - Ruth A. Marrie
- Department of Internal MedicineMax Rady College of Medicine, Rady Faculty of Health Sciences, University of ManitobaWinnipegCanada
- Department of Community Health SciencesMax Rady College of Medicine, Rady Faculty of Health Sciences, University of ManitobaWinnipegCanada
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Simpson AC, Hu C, Mowry EM, Naismith RT, Fitzgerald KC, Nourbakhsh B. Structural MRI measures are associated with fatigue severity and persistence in a large, real-world cohort of people with multiple sclerosis. Mult Scler 2024; 30:738-746. [PMID: 38525561 DOI: 10.1177/13524585241239473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND Results of research on radiological hallmarks of multiple sclerosis (MS) fatigue have been conflicting. OBJECTIVE To investigate the associations of lesion and brain compartment volumes with fatigue severity and persistence in people with multiple sclerosis (PwMS). METHODS The Multiple Sclerosis Partners Advancing Technology and Health Solutions (MS PATHS) network collects standardized data during routine care of PwMS from 10 healthcare institutions. Magnetic resonance imaging (MRI) predictors included baseline brain parenchymal (BPF) and gray matter fractions (GMF) and T2 lesion volume (T2LV). The Quality of Life in Neurological Disorders (Neuro-QOL) fatigue subscore was analyzed linearly and categorically using T-score cutpoints, with a period of elevated symptoms defined as T-score ⩾ mean + 0.5 SD over follow-up. RESULTS At baseline, of 4012 participants (average age: 45.6 ± 11.8 years; 73% female; 31% progressive MS), 2058 (51%) had no fatigue, 629 (16%) had mild fatigue, and 1325 (33%) had moderate-to-severe fatigue. One SD greater baseline BPF and GMF were associated with 0.83 (p < 0.001) and 0.38 (p = 0.02) lower values in the baseline Neuro-QOL fatigue T-score. A 1 SD lower log of total T2LV was associated with a 0.49 (p < 0.001) lower baseline fatigue T-score. Higher BPF and lower T2LV at baseline were associated with lower odds of subsequent periods of elevated fatigue. CONCLUSION Baseline lesion burden and lower generalized whole-brain volumes were associated with MS fatigue in cross-sectional and longitudinal analyses in a large, real-world cohort of PwMS.
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Affiliation(s)
- Alexandra C Simpson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chen Hu
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA/ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert T Naismith
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA/ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bardia Nourbakhsh
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Young CA, Rog DJ, Sharrack B, Tanasescu R, Kalra S, Harrower T, Tennant A, Mills RJ. Correlates and trajectories of relapses in relapsing-remitting multiple sclerosis. Neurol Sci 2024; 45:2181-2189. [PMID: 37976012 PMCID: PMC11021238 DOI: 10.1007/s10072-023-07155-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 10/21/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND AIMS In people with relapsing-remitting multiple sclerosis (pwRRMS), data from studies on non-pharmacological factors which may influence relapse risk, other than age, are inconsistent. There is a reduced risk of relapses with increasing age, but little is known about other trajectories in real-world MS care. METHODS We studied longitudinal questionnaire data from 3885 pwRRMS, covering smoking, comorbidities, disease-modifying therapy (DMT), and patient-reported outcome measures, as well as relapses during the past year. We undertook Rasch analysis, group-based trajectory modelling, and multilevel negative binomial regression. RESULTS The regression cohort of 6285 data sets from pwRRMS over time showed that being a current smoker was associated with 43.9% greater relapse risk; having 3 or more comorbidities increased risk and increasing age reduced risk. Those diagnosed within the last 2 years showed two distinct trajectories, both reducing in relapse frequency but 25.8% started with a higher rate and took 4 years to reduce to the rate of the second group. In the cohort with at least three data points completed, there were three groups: 73.7% followed a low stable relapse rate, 21.6% started from a higher rate and decreased, and 4.7% had an increasing then decreasing pattern. These different trajectory groups showed significant differences in fatigue, neuropathic pain, disability, health status, quality of life, self-efficacy, and DMT use. CONCLUSIONS These results provide additional evidence for supporting pwRRMS to stop smoking and underline the importance of timely DMT decisions and treatment initiation soon after diagnosis with RRMS.
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Affiliation(s)
- Carolyn A Young
- Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, Liverpool L9 7LJ, UK, University of Liverpool, Liverpool, UK.
| | - David J Rog
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Basil Sharrack
- Academic Department of Neurology, University of Sheffield, Sheffield, UK
| | | | - Seema Kalra
- University Hospital of North Midlands NHS Trust, Stoke-On-Trent, UK
| | | | - Alan Tennant
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Roger J Mills
- Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, Liverpool L9 7LJ, UK, University of Liverpool, Liverpool, UK
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Gralha de Caneda MA, Batista Oliveira Silva C, Aragon de Vecino MC. The Prevalence of Comorbidities and Their Association With Disability Progression in Individuals With Multiple Sclerosis: A Study From Brazil. Int J MS Care 2024; 26:239-246. [PMID: 39246686 PMCID: PMC11377689 DOI: 10.7224/1537-2073.2023-103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
BACKGROUND Comorbidities negatively impact the course of multiple sclerosis (MS). Identifying them is essential, as they represent potentially modifiable prognostic factors that can adversely influence the disease course. However, comorbidity prevalence remains underexplored in certain populations, including in individuals in Brazil. METHODS In this cross-sectional study, we describe the frequency of comorbidities and their correlation with MS disability progression in a Brazilian population by reviewing the medical records of patients from a single MS center in Brazil. Preexisting comorbidities and those present at the time of MS diagnosis were screened. We assessed the prevalence of comorbidities, their prevalence ratios (PR) and the association between them, their number, and the confirmed disability worsening (CDW) that emerged during the follow-up visits. RESULTS Comorbidities were present in 68.9% of individuals. The most prevalent comorbidities included cardiovascular diseases (19.3%), migraine (13.3%), psychiatric disorders (12.4%), smoking (12.4%), autoimmune diseases (12.0%), respiratory diseases (10.3%), and neoplasms (5.6%). Patients with 1 comorbidity and those with multiple comorbidities (≥ 3) had a significant PR for CDW (2.67, P = .01; 1.25, P = .03, respectively). Cardiovascular and autoimmune diseases presented significant PR for CDW (2.28, P = .03; 4.2, P = .004, respectively). CONCLUSIONS Comorbidities are more prevalent among Brazilian individuals with MS than in the general population and are associated with disease progression. Identifying and managing them may mitigate their adverse effects on disease course.
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Affiliation(s)
- Marco Aurélio Gralha de Caneda
- From the Multiple Sclerosis and Demyelinating Disorders Unit, Department of Neurology, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Maria Cecília Aragon de Vecino
- Multiple Sclerosis and Demyelinating Disorders Unit, Department of Neurology, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
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Mascarenas-Garcia M, Rivero-de-Aguilar A, Pérez-Ríos M, Ruano-Raviña A, Llaneza-Gonzalez MA, Candal-Pedreira C, Rey-Brandariz J, Varela-Lema L. Best practices in phase III clinical trials on DMTs for multiple sclerosis: a systematic analysis and appraisal of published trials. J Neurol Neurosurg Psychiatry 2024; 95:333-341. [PMID: 37541785 DOI: 10.1136/jnnp-2023-331733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/26/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Great advances have been made in the field of multiple sclerosis (MS) therapy due to the publication of numerous randomised clinical trials (RCTs). In this study, we carried out a critical appraisal of phase III RCTs of disease-modifying therapies (DMTs) for MS published after 2010, intending to identify critical areas of improvement. METHODS We performed a systematic search of published RCTs on MS from January 2010 until December 2021. RCTs were assessed using an ad-hoc tool. This tool was developed based on existing generic methodological instruments and MS-specific guidelines and methodological papers. It included 14 items grouped in 5 domains: methodological quality, adequacy and measurement of outcomes, adverse event reporting, applicability and relevance of results, and transparency and conflict of interest. RESULTS We identified 31 phase III RCTs. Most of them were fully compliant in terms of sample size (87%), randomisation (68%), blinding (61%), participant selection (68%), adverse event reporting (84%) and clinical relevance (52%). Only a few were compliant in terms of participant description (6%), comparison (42%), attrition bias (26%), adequacy of outcome measures (26%), applicability (23%), transparency (36%) and conflict of interest (6%). None were compliant in terms of analysis and reporting of outcomes. The most common limitations related to the absence of comorbidity data, unjustified use of placebo, inadequacy of outcomes design and absence of protocol and/or prospective registration. CONCLUSIONS RCTs for DMTs in MS have relevant and frequent limitations. These should be addressed to enhance their quality, transparency and external validity.
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Affiliation(s)
- Marta Mascarenas-Garcia
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Preventive Medicine and Public Health, University Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Alejandro Rivero-de-Aguilar
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Department of Neurology, University Hospital Complex of Pontevedra, Pontevedra, Spain
| | - Mónica Pérez-Ríos
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Madrid, Spain
| | - Alberto Ruano-Raviña
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Madrid, Spain
| | | | - Cristina Candal-Pedreira
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Santiago de Compostela, Spain
| | - Julia Rey-Brandariz
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Leonor Varela-Lema
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Madrid, Spain
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Salter A, Lancia S, Kowalec K, Fitzgerald KC, Marrie RA. Investigating the Prevalence of Comorbidity in Multiple Sclerosis Clinical Trial Populations. Neurology 2024; 102:e209135. [PMID: 38350062 PMCID: PMC11067694 DOI: 10.1212/wnl.0000000000209135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/16/2023] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Comorbidity is common in multiple sclerosis (MS) with the most prevalent conditions being depression, anxiety, hypertension, and hyperlipidemia. Limited information regarding the representation of comorbidity status is available from phase III clinical trials in MS leading to concern about the potential underrepresentation of individuals with comorbidity in clinical trials. The objective was to estimate the prevalence of comorbidities in MS clinical trial populations. METHODS Individual-level data from multiple sponsors were requested for a 2-stage meta-analysis of phase III clinical trials of MS disease-modifying therapies. To ensure consistency of our approach across trials, we followed the Maelstrom retrospective harmonization guidelines. Chronic comorbidities at clinical trial enrollment recommended by the International Advisory Committee on Clinical Trials in MS were considered (depression, anxiety, hypertension, hyperlipidemia, migraine, diabetes, chronic lung disease). Additional comorbidities were also classified. Classification was based on medical history data. Individual comorbidities were summed and categorized as 0, 1, 2, or ≥3. We report the pooled prevalence (95% confidence interval [95% CI]) of comorbidity. The pooled prevalence and prevalence ratios across age, sex, race, disability level, and treatment were also reported. Heterogeneity was assessed using the I2 statistic. RESULTS Seventeen trials involving 17,926 participants were included. Fourteen trials enrolled participants with relapsing MS (RMS) while 3 enrolled participants with progressive MS (PMS). The distributions of sex, age, and disability level were generally consistent within RMS and PMS trials. When pooled, almost half of trial participants (46.5%) had ≥1 comorbidity (1: 25.0%, 95% CI 23.0-27.0, I2 = 89.9; 2: 11.4% [9.3-14.0], I2 = 96.3; ≥3: 6.0% [4.2-8.4], I2 = 97.7). Depression (16.45% [12.96-20.88], I2 = 98.3) was the most prevalent comorbidity reported, followed by hypertension (10.16% [8.61-11.98], I2 = 93.2). Heterogeneity was high across trials. Older age and female participants were associated with increased number of comorbidities. Older individuals and male participants had a higher prevalence of hyperlipidemia, while older individuals and female participants had a higher prevalence of depression and anxiety. DISCUSSION Individuals with comorbidities are included in clinical trials, although they may still be underrepresented compared with the general MS population. Given the comorbidity prevalence in the trial populations and studies suggesting an association of comorbidities with disease activity, comorbidity may influence outcomes in clinical trials.
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Affiliation(s)
- Amber Salter
- From the Department of Neurology (A.S., S.L.), Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX; College of Pharmacy (K.K.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Medical Epidemiology and Biostatistics (K.K.), Karolinska Institutet, Sweden; Department of Neurology (K.C.F.), Johns Hopkins School of Medicine, Baltimore, MD; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Samantha Lancia
- From the Department of Neurology (A.S., S.L.), Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX; College of Pharmacy (K.K.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Medical Epidemiology and Biostatistics (K.K.), Karolinska Institutet, Sweden; Department of Neurology (K.C.F.), Johns Hopkins School of Medicine, Baltimore, MD; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Kaarina Kowalec
- From the Department of Neurology (A.S., S.L.), Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX; College of Pharmacy (K.K.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Medical Epidemiology and Biostatistics (K.K.), Karolinska Institutet, Sweden; Department of Neurology (K.C.F.), Johns Hopkins School of Medicine, Baltimore, MD; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Kathryn C Fitzgerald
- From the Department of Neurology (A.S., S.L.), Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX; College of Pharmacy (K.K.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Medical Epidemiology and Biostatistics (K.K.), Karolinska Institutet, Sweden; Department of Neurology (K.C.F.), Johns Hopkins School of Medicine, Baltimore, MD; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ruth Ann Marrie
- From the Department of Neurology (A.S., S.L.), Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX; College of Pharmacy (K.K.), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Medical Epidemiology and Biostatistics (K.K.), Karolinska Institutet, Sweden; Department of Neurology (K.C.F.), Johns Hopkins School of Medicine, Baltimore, MD; and Departments of Internal Medicine and Community Health Sciences (R.A.M.), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
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10
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Chataway J, Williams T, Li V, Marrie RA, Ontaneda D, Fox RJ. Clinical trials for progressive multiple sclerosis: progress, new lessons learned, and remaining challenges. Lancet Neurol 2024; 23:277-301. [PMID: 38365380 DOI: 10.1016/s1474-4422(24)00027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/04/2023] [Accepted: 01/12/2024] [Indexed: 02/18/2024]
Abstract
Despite the success of disease-modifying treatments in relapsing multiple sclerosis, for many individuals living with multiple sclerosis, progressive disability continues to accrue. How to interrupt the complex pathological processes underlying progression remains a daunting and ongoing challenge. Since 2014, several immunomodulatory approaches that have modest but clinically meaningful effects have been approved for the management of progressive multiple sclerosis, primarily for people who have active inflammatory disease. The approval of these drugs required large phase 3 trials that were sufficiently powered to detect meaningful effects on disability. New classes of drug, such as Bruton tyrosine-kinase inhibitors, are coming to the end of their trial stages, several candidate neuroprotective compounds have been successful in phase 2 trials, and innovative approaches to remyelination are now also being explored in clinical trials. Work continues to define intermediate outcomes that can provide results in phase 2 trials more quickly than disability measures, and more efficient trial designs, such as multi-arm multi-stage and futility approaches, are increasingly being used. Collaborations between patient organisations, pharmaceutical companies, and academic researchers will be crucial to ensure that future trials maintain this momentum and generate results that are relevant for people living with progressive multiple sclerosis.
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Affiliation(s)
- Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK; Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK.
| | - Thomas Williams
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Vivien Li
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Ruth Ann Marrie
- Departments of Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Conway DS, Sullivan AB, Rensel M. Health, Wellness, and the Effect of Comorbidities on the Multiple Sclerosis Disease Course: Tackling the Modifiable. Neurol Clin 2024; 42:229-253. [PMID: 37980117 DOI: 10.1016/j.ncl.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Multiple sclerosis (MS) is a disease of the central nervous system characterized by inflammatory demyelination and neurodegeneration. Numerous disease-modifying therapies for MS exist but are only partially effective, making it essential to optimize all factors that may influence the course of the disease. This includes conscientious management of both mental and physical comorbidities, as well as a comprehensive strategy for promoting wellness in patients with MS. Thoughtful engagement of those living with MS through shared decision making and involvement of a multidisciplinary team that includes primary care, relevant specialists, psychology, and rehabilitation is likely to lead to better outcomes.
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Affiliation(s)
- Devon S Conway
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Amy B Sullivan
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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12
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Zinganell A, Göbel G, Berek K, Hofer B, Asenbaum-Nan S, Barang M, Böck K, Bsteh C, Bsteh G, Eger S, Eggers C, Fertl E, Joldic D, Khalil M, Langenscheidt D, Komposch M, Kornek B, Kraus J, Krendl R, Rauschka H, Sellner J, Auer M, Hegen H, Pauli FD, Deisenhammer F. Multiple sclerosis in the elderly: a retrospective cohort study. J Neurol 2024; 271:674-687. [PMID: 37855871 DOI: 10.1007/s00415-023-12041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND There is a lack of knowledge of disease course, prognosis, comorbidities and potential treatments of elderly MS patients. OBJECTIVE To characterize the disease course including disability progression and relapses, to quantify the use of DMTs and to identify comorbidities and risk factors for progression in elderly multiple sclerosis (MS) patients. METHODS This is a retrospective study of 1200 Austrian MS patients older than 55 years as of May 1st, 2017 representing roughly one-third of all the MS patients of this age in Austria. Data were collected from 15 MS centers including demographics, first symptom at onset, number of relapses, evolvement of disability, medication, and comorbidities. RESULTS Median observation time was 17.1 years with 957 (80%) relapsing and 243 (20%) progressive onsets. Average age at diagnosis was 45 years with a female predominance of 71%. Three-hundred and twenty-six (27%) patients were never treated with a DMT, while most treated patients received interferons (496; 41%) at some point. At last follow-up, 420 (35%) patients were still treated with a DMT. No difference was found between treated and never-treated patients in terms of clinical outcome; however, patients with worse disability progression had significantly more DMT switches. Pyramidal onset, number of comorbidities, dementia, epilepsy, and psychiatric conditions as well as a higher number of relapses were associated with worse outcome. The risk of reaching EDSS 6 rose with every additional comorbidity by 22%. In late and very-late-onset MS (LOMS, VLOMS) time to diagnosis took nearly twice the time compared to adult and early onset (AEOMS). The overall annualized relapse rate (ARR) decreased over time and patients with AEOMS had significantly higher ARR compared to LOMS and VLOMS. Four percent of MS patients had five medications or more fulfilling criteria of polypharmacy and 20% of psychiatric drugs were administered without a matching diagnosis. CONCLUSIONS In this study, we identified number of comorbidities, pyramidal and cerebellar signs, and a higher number of relapses as unfavorable prognostic factors in elderly MS patients filling gaps of knowledge in patients usually underrepresented in clinical trials and may guide future therapeutic studies.
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Affiliation(s)
- Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Georg Göbel
- Department of Medical Statistics, Informatics and Health Economics, Medical University Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Barbara Hofer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | | | - Matin Barang
- Department of Neurology, Hospital of St. Pölten, St. Pölten, Austria
| | - Klaus Böck
- Department of Neurology, Kepler Universitätsklinikum, Linz, Austria
| | | | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stephan Eger
- Department of Neurology, Kepler Universitätsklinikum, Linz, Austria
| | - Christian Eggers
- Department of Neurology, Kepler Universitätsklinikum, Linz, Austria
| | - Elisabeth Fertl
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Damir Joldic
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Michael Khalil
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Martina Komposch
- Department of Neurology, Hospital of Klagenfurt, Klagenfurt, Austria
| | - Barbara Kornek
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jörg Kraus
- Neurologist, Zell Am See, Austria
- Department of Laboratory Medicine, Paracelsus Medical University and Salzburger Landeskliniken, Salzburg, Austria
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Reinhard Krendl
- Department of Neurology, Hospital of Villach, Villach, Austria
| | - Helmut Rauschka
- Department of Neurology, Klinik Donaustadt, Vienna, Austria
- Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Department of Neurology, Klinik Donaustadt, Vienna, Austria
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach, Mistelbach, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Florian Deisenhammer
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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13
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Jakimovski D, Bittner S, Zivadinov R, Morrow SA, Benedict RH, Zipp F, Weinstock-Guttman B. Multiple sclerosis. Lancet 2024; 403:183-202. [PMID: 37949093 DOI: 10.1016/s0140-6736(23)01473-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/08/2023] [Accepted: 07/12/2023] [Indexed: 11/12/2023]
Abstract
Multiple sclerosis remains one of the most common causes of neurological disability in the young adult population (aged 18-40 years). Novel pathophysiological findings underline the importance of the interaction between genetics and environment. Improvements in diagnostic criteria, harmonised guidelines for MRI, and globalised treatment recommendations have led to more accurate diagnosis and an earlier start of effective immunomodulatory treatment than previously. Understanding and capturing the long prodromal multiple sclerosis period would further improve diagnostic abilities and thus treatment initiation, eventually improving long-term disease outcomes. The large portfolio of currently available medications paved the way for personalised therapeutic strategies that will balance safety and effectiveness. Incorporation of cognitive interventions, lifestyle recommendations, and management of non-neurological comorbidities could further improve quality of life and outcomes. Future challenges include the development of medications that successfully target the neurodegenerative aspect of the disease and creation of sensitive imaging and fluid biomarkers that can effectively predict and monitor disease changes.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA; Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA; Center for Biomedical Imaging at the Clinical Translational Science Institute, State University of New York at Buffalo, Buffalo, NY, USA
| | - Sarah A Morrow
- Department of Clinical Neurological Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Ralph Hb Benedict
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
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14
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Doskas T, Dardiotis E, Vavougios GD, Ntoskas KT, Sionidou P, Vadikolias K. Stroke risk in multiple sclerosis: a critical appraisal of the literature. Int J Neurosci 2023; 133:1132-1152. [PMID: 35369835 DOI: 10.1080/00207454.2022.2056459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
Observational studies suggest that the occurrence of stroke on multiple sclerosis (MS) patients is higher compared to the general population. MS is a heterogeneous disease that involves an interplay of genetic, environmental and immune factors. The occurrence of stroke is subject to a wide range of both modifiable and non-modifiable, short- and long-term risk factors. Both MS and stroke share common risk factors. The immune mechanisms that underlie stroke are similar to neurodegenerative diseases and are attributed to neuroinflammation. The inflammation in autoimmune diseases may, therefore, predispose to an increased risk for stroke or potentiate the effect of conventional stroke risk factors. There are, however, additional determinants that contribute to a higher risk and incidence of stroke in MS. Due to the challenges that are associated with their differential diagnosis, the objective is to present an overview of the factors that may contribute to increased susceptibility or occurrence of stroke in MSpatients by performing a review of the available to date literature. As both MS and stroke can individually detrimentally affect the quality of life of afflicted patients, the identification of factors that contribute to an increased risk for stroke in MS is crucial for the prompt implementation of preventative therapeutic measures to limit the additive burden that stroke imposes.
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Affiliation(s)
- Triantafyllos Doskas
- Department of Neurology, Athens Naval Hospital, Athens, Greece
- Department of Neurology, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University Hospital of Larissa, Larissa, Greece
- Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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15
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Huang SY, Salomon M, Eikermann-Haerter K. Advanced brain MRI may help understand the link between migraine and multiple sclerosis. J Headache Pain 2023; 24:113. [PMID: 37596546 PMCID: PMC10439604 DOI: 10.1186/s10194-023-01645-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/04/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND There is a clinical association between migraine and multiple sclerosis. MAIN BODY Migraine and MS patients share similar demographics, with the highest incidence among young, female and otherwise healthy patients. The same hormonal constellations/changes trigger disease exacerbation in both entities. Migraine prevalence is increased in MS patients, which is further enhanced by disease-modifying treatment. Clinical data show that onset of migraine typically starts years before the clinical diagnosis of MS, suggesting that there is either a unidirectional relationship with migraine predisposing to MS, and/or a "shared factor" underlying both conditions. Brain imaging studies show white matter lesions in both MS and migraine patients. Neuroinflammatory mechanisms likely play a key role, at least as a shared downstream pathway. In this review article, we provide an overview of the literature about 1) the clinical association between migraine and MS as well as 2) brain MRI studies that help us better understand the mechanistic relationship between both diseases with implications on their underlying pathophysiology. CONCLUSION Studies suggest a migraine history predisposes patients to develop MS. Advanced brain MR imaging may shed light on shared and distinct features, while helping us better understand mechanisms underlying both disease entities.
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Affiliation(s)
- Susie Y Huang
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Marc Salomon
- Department of Radiology, New York University Langone Medical Center, 660 First Ave, New York, NY, 10016, USA
| | - Katharina Eikermann-Haerter
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Radiology, New York University Langone Medical Center, 660 First Ave, New York, NY, 10016, USA.
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16
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Marrie RA. The Barancik lecture: Comorbidity in multiple sclerosis-Looking backward, looking forward. Mult Scler 2023; 29:1049-1056. [PMID: 37125430 PMCID: PMC10413784 DOI: 10.1177/13524585231167740] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/11/2023] [Accepted: 03/19/2023] [Indexed: 05/02/2023]
Abstract
Comorbidity is highly prevalent in people with multiple sclerosis (MS) throughout their disease course. In the last 15 years, our understanding of the association between comorbidity and outcomes such as relapses, disability progressive, health-related quality of life, health care use, and mortality has grown substantially. The broad adverse impacts of comorbidity on these outcomes point to the need to prevent and treat comorbidity effectively in people with MS. This requires having the necessary tools to evaluate comorbidity, an understanding of how MS affects management of comorbidity now, testing of interventions tailored to people with MS, and determining the best models of care to optimize comorbidity management.
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Affiliation(s)
- Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada/Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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17
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Marrie RA, Fisk JD, Fitzgerald K, Kowalec K, Maxwell C, Rotstein D, Salter A, Tremlett H. Etiology, effects and management of comorbidities in multiple sclerosis: recent advances. Front Immunol 2023; 14:1197195. [PMID: 37325663 PMCID: PMC10266935 DOI: 10.3389/fimmu.2023.1197195] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/19/2023] [Indexed: 06/17/2023] Open
Abstract
Comorbid conditions commonly affect people with multiple sclerosis (MS). Population-based studies indicate that people with MS have an increased incidence of ischemic heart disease, cerebrovascular disease, peripheral vascular disease, and psychiatric disorders as compared to people without MS. People with MS from underrepresented minority and immigrant groups have higher comorbidity burdens. Comorbidities exert effects throughout the disease course, from symptom onset through diagnosis to the end of life. At the individual level, comorbidity is associated with higher relapse rates, greater physical and cognitive impairments, lower health-related quality of life, and increased mortality. At the level of the health system and society, comorbidity is associated with increased health care utilization, costs and work impairment. A nascent literature suggests that MS affects outcomes from comorbidities. Comorbidity management needs to be integrated into MS care, and this would be facilitated by determining optimal models of care.
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Affiliation(s)
- Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - John D. Fisk
- Nova Scotia Health and the Departments of Psychiatry, Psychology & Neuroscience, and Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kathryn Fitzgerald
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Kaarina Kowalec
- College of Pharmacy, University of Manitoba, Winnipeg, MB, Canada
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Colleen Maxwell
- Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Dalia Rotstein
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- St. Michael’s Hospital, Toronto, ON, Canada
| | - Amber Salter
- Department of Neurology, UT Southwestern, Dallas, TX, United States
| | - Helen Tremlett
- Department of Medicine (Neurology) and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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18
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Bridge F, Butzkueven H, Van der Walt A, Jokubaitis VG. The impact of menopause on multiple sclerosis. Autoimmun Rev 2023; 22:103363. [PMID: 37230311 DOI: 10.1016/j.autrev.2023.103363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023]
Abstract
Menopause, defined as the permanent cessation of ovarian function, represents a period of significant fluctuation in sex hormone concentrations. Sex hormones including oestrogen, progesterone, testosterone and anti-Mullerian hormone are thought have neuroinflammatory effects and are implicated in both neuroprotection and neurodegeneration. Sex hormones are thought to have a role in modifying clinical trajectory in multiple sclerosis (MS) throughout the lifespan. Multiple sclerosis predominantly effects women and is typically diagnosed early in a woman's reproductive life. Most women with MS will undergo menopause. Despite this, the effect of menopause on MS disease course remains unclear. This review examines the relationship between sex hormones and MS disease activity and clinical course, particularly around the time of menopause. It will consider the role of interventions such as exogenous hormone replacement therapy in modulating clinical outcomes in this period. Understanding the impact of menopause on multiple sclerosis is fundamental for delivering optimal care to women with MS as they age and will inform treatment decisions with the aim of minimising relapses, disease accrual and improving quality of life.
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Affiliation(s)
- Francesca Bridge
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.
| | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Anneke Van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Vilija G Jokubaitis
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
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19
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Graves JS, Krysko KM, Hua LH, Absinta M, Franklin RJM, Segal BM. Ageing and multiple sclerosis. Lancet Neurol 2023; 22:66-77. [PMID: 36216015 DOI: 10.1016/s1474-4422(22)00184-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 03/09/2022] [Accepted: 04/20/2022] [Indexed: 11/07/2022]
Abstract
The factor that is most relevant and strongly associated with the clinical course of multiple sclerosis is chronological age. Very young patients exclusively have relapsing remitting disease, whereas those with later onset disease face a more rapid development of permanent disability. For people with progressive multiple sclerosis, the poor response to current disease modifying therapies might be related to ageing in the immune system and CNS. Ageing is also associated with increased risks of side-effects caused by some multiple sclerosis therapies. Both somatic and reproductive ageing processes might contribute to development of progressive multiple sclerosis. Understanding the role of ageing in immune and neural cell function in patients with multiple sclerosis might be key to halting non-relapse-related progression. The growing literature on potential therapies that target senescent cells and ageing processes might provide effective strategies for remyelination and neuroprotection.
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Affiliation(s)
- Jennifer S Graves
- Department of Neurosciences, University of California, San Diego, CA, USA; Pediatric Multiple Sclerosis Center, Rady Children's Hospital, San Diego, CA, USA; Department of Neurology, San Diego VA Hospital, San Diego, CA, USA.
| | - Kristen M Krysko
- Division of Neurology, Department of Medicine, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Le H Hua
- Department of Neurology, Cleveland Clinic, Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Martina Absinta
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA; Division of Neuroscience, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Robin J M Franklin
- Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK
| | - Benjamin M Segal
- Department of Neurology and the Neuroscience Research Institute, The Ohio State University, Columbus, OH, USA
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20
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Selton M, Mathey G, Soudant M, Manceau P, Anxionnat R, Debouverie M, Jonas J. Prognostic impact of epileptic seizures in multiple sclerosis varies according to time of occurrence and etiology. Eur J Neurol 2022; 29:3537-3546. [PMID: 36083790 PMCID: PMC9826490 DOI: 10.1111/ene.15551] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Epileptic seizures occur more often in patients with multiple sclerosis (MS) than in the general population. Their association with the prognosis of MS remains unclear. This study was undertaken to evaluate whether epileptic seizures may be a prognostic marker of MS disability, according to when the seizure occurs and its cause. METHODS Data were extracted from a population-based registry of MS in Lorraine, France. Kaplan-Meier curves and log-rank tests were used to compare the probability of different levels of irreversible handicap during the course of MS in patients who experience epileptic seizures or do not, according to the chronology and the cause of the first epileptic seizure. RESULTS Among 6238 patients, 134 had experienced at least one epileptic seizure (2.1%), and 82 (1.2%) had seizures secondary to MS. Patients with epileptic seizure as a first symptom of MS (14 patients) had the same disease progression as other relapsing-remitting MS patients. Patients who developed epileptic seizures during the course of MS (68 patients) had a higher probability of reaching Expanded Disability Status Scale = 3.0 (p = 0.006), 6.0 (p = 0.003), and 7.0 (p = 0.004) than patients without an epileptic background. Patients with a history of epileptic seizures unrelated to MS also had a worse prognosis than patients without an epileptic background. CONCLUSIONS Epileptic seizures might be viewed as a "classic MS relapse" in terms of prognosis if occurring early in MS, or as a marker of MS severity if developing during the disease. Epileptic diseases other than MS may worsen the course of MS.
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Affiliation(s)
- Marion Selton
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance
| | - Guillaume Mathey
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance,INSERM, CIC‐1433 Epidemiologie CliniqueNancy Regional University Hospital Center, University of LorraineNancyFrance,EA 4360 APEMACUniversity of LorraineNancyFrance
| | - Marc Soudant
- INSERM, CIC‐1433 Epidemiologie CliniqueNancy Regional University Hospital Center, University of LorraineNancyFrance
| | - Philippe Manceau
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance
| | - René Anxionnat
- Department of Neuroradiology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance
| | - Marc Debouverie
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance,INSERM, CIC‐1433 Epidemiologie CliniqueNancy Regional University Hospital Center, University of LorraineNancyFrance,EA 4360 APEMACUniversity of LorraineNancyFrance
| | - Jacques Jonas
- Department of Neurology, Nancy Regional University Hospital CenterUniversity of LorraineNancyFrance,CNRS, CRANUniversity of LorraineNancyFrance
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21
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Abstract
Social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are the non-medical factors that influence health outcomes. Evidence indicates that health behaviours, comorbidities and disease-modifying therapies all contribute to multiple sclerosis (MS) outcomes; however, our knowledge of the effects of social determinants — that is, the ‘risks of risks’ — on health has not yet changed our approach to MS. Assessing and addressing social determinants of health could fundamentally improve health and health care in MS; this approach has already been successful in improving outcomes in other chronic diseases. In this narrative Review, we identify and discuss the body of evidence supporting an effect of many social determinants of health, including racial background, employment and social support, on MS outcomes. It must be noted that many of the published studies were subject to bias, and screening tools and/or practical interventions that address these social determinants are, for the most part, lacking. The existing work does not fully explore the potential bidirectional and complex relationships between social determinants of health and MS, and the interpretation of findings is complicated by the interactions and intersections among many of the identified determinants. On the basis of the reviewed literature, we consider that, if effective interventions targeting social determinants of health were available, they could have substantial effects on MS outcomes. Therefore, funding for and focused design of studies to evaluate and address social determinants of health are urgently needed. Here, the authors discuss the potential effects of social determinants of health on multiple sclerosis risk and outcomes. They suggest that addressing these determinants of health could substantially improve the lives of individuals with multiple sclerosis and call for more research. Addressing an individual’s social determinants of health — that is, the conditions under which they are born, grow, live, work and age — could provide opportunities to reduce the burden of living with multiple sclerosis (MS). Individual factors that may influence MS-related outcomes include sex, gender and sexuality, race and ethnicity, education and employment, socioeconomic status, and domestic abuse. Societal infrastructures, including access to food, health care and social support, can also affect MS-related outcomes. Awareness of the specific circumstances of a patient with MS might help neurologists deliver better care. Social determinants of health are not static and can change according to wider sociopolitical contexts, as highlighted by the COVID-19 pandemic. Rigorous studies of interventions to ameliorate the effects of poor social determinants on people with MS are urgently needed.
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22
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Yusuf FLA, Wijnands JMA, Karim ME, Kingwell E, Zhu F, Evans C, Fisk JD, Zhao Y, Marrie RA, Tremlett H. Sex and age differences in the Multiple Sclerosis prodrome. Front Neurol 2022; 13:1017492. [PMID: 36408518 PMCID: PMC9668896 DOI: 10.3389/fneur.2022.1017492] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/04/2022] [Indexed: 08/12/2023] Open
Abstract
Background and objectives Little is known of the potential sex and age differences in the MS prodrome. We investigated sex and age differences in healthcare utilization during the MS prodrome. Methods This was a population-based matched cohort study linking administrative and clinical data from British Columbia, Canada (population = 5 million). MS cases in the 5 years preceding a first demyelinating event ("administrative cohort;" n = 6,863) or MS symptom onset ("clinical cohort;" n = 966) were compared to age-, sex- and geographically-matched controls (n = 31,865/4,534). Negative binomial and modified Poisson models were used to compare the rates of physician visits and hospitalizations per international classification of diseases chapter, and prescriptions filled per drug class, between MS cases and controls across sex and age-groups (< 30, 30-49, ≥50 years). Results In the administrative cohort, males with MS had a higher relative rate for genitourinary-related visits (males: adjusted Rate Ratio (aRR) = 1.65, females: aRR = 1.19, likelihood ratio test P = 0.02) and antivertigo prescriptions (males: aRR = 4.72, females: aRR = 3.01 P < 0.01). Injury and infection-related hospitalizations were relatively more frequent for ≥50-year-olds (injuries < 30/30-49/≥50: aRR = 1.16/1.39/2.12, P < 0.01; infections 30-49/≥50: aRR = 1.43/2.72, P = 0.03), while sensory-related visits and cardiovascular prescriptions were relatively more common in younger persons (sensory 30-49/≥50: aRR = 1.67/1.45, P = 0.03; cardiovascular < 30/30-49/≥50: aRR = 1.56/1.39/1.18, P < 0.01). General practitioner visits were relatively more frequent in males (males: aRR = 1.63, females: aRR = 1.40, P < 0.01) and ≥50-year-olds (< 30/≥50: aRR = 1.32/1.55, P = 0.02), while differences in ophthalmologist visits were disproportionally larger among younger persons, < 50-years-old (< 30/30-49/≥50: aRR = 2.25/2.20/1.55, P < 0.01). None of the sex and age-related differences in the smaller clinical cohort reached significance (P ≥ 0.05). Discussion Sex and age-specific differences in healthcare use were observed in the 5 years before MS onset. Findings demonstrate fundamental heterogeneity in the MS prodromal presentation.
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Affiliation(s)
- Fardowsa L. A. Yusuf
- Division of Neurology, Department of Medicine, The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - José M. A. Wijnands
- Division of Neurology, Department of Medicine, The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Elaine Kingwell
- Division of Neurology, Department of Medicine, The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Research Department of Primary Care & Population Health, University College London, London, United Kingdom
| | - Feng Zhu
- Division of Neurology, Department of Medicine, The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada
| | - John D. Fisk
- Nova Scotia Health and the Department of Psychiatry, Psychology & Neuroscience, and Medicine, Dalhousie University, Halifax, NS, Canada
| | - Yinshan Zhao
- Division of Neurology, Department of Medicine, The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Ruth Ann Marrie
- Department of Internal Medicine and Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Health Sciences Centre, Winnipeg, MB, Canada
| | - Helen Tremlett
- Division of Neurology, Department of Medicine, The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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23
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Kinnett-Hopkins D, Motl R. Social cognitive correlates of device-measured and self-reported physical activity in Black and White individuals with multiple sclerosis. Disabil Health J 2022; 15:101344. [PMID: 35725690 DOI: 10.1016/j.dhjo.2022.101344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/09/2022] [Accepted: 05/18/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND There is increasing research interest regarding physical activity behavior among persons with multiple sclerosis (MS), yet there is little known about physical activity and its correlates in Black persons with MS. OBJECTIVE This cross-sectional study assessed associations among social cognitive theory (SCT) variables and device-measured and self-reported physical activity in samples of Black and White persons with MS. METHODS Participants included 67 Black and 141 White persons with MS who wore an ActiGraph accelerometer on a belt around the waist measuring moderate-to-vigorous physical activity (MVPA) for seven days and completed a battery of questionnaires. Questionnaires included demographic and clinical characteristics, leisure-time exercise, exercise self-efficacy, overcoming barriers self-efficacy, function, social support, exercise outcome expectations, and goal setting and planning. RESULTS Black participants with MS engaged in significantly less MVPA, but not sedentary behavior or light physical activity, than the White participants with MS. Black participants further had significantly lower levels of exercise self-efficacy and outcome expectations than the White sample. All SCT correlates were significantly correlated with self-reported physical activity, but only exercise and barriers self-efficacy, perceived function, and exercise goal setting were associated with device-measured MVPA. The difference in physical activity between Black and White participants with MS was accounted for by differences in exercise self-efficacy and outcome expectations. CONCLUSIONS Researchers should consider developing behavioral interventions that target exercise self-efficacy and outcome expectations as SCT variables for increasing physical activity in Black persons with MS.
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Affiliation(s)
| | - Robert Motl
- Department of Physical Therapy, The University of Alabama at Birmingham, Birmingham, AL, USA
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24
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Padarti A, Amritphale A, Kilgo W. Readmission Rates in Patients With Multiple Sclerosis: A Nationwide Cohort Study. Int J MS Care 2022; 24:218-223. [PMID: 36090236 PMCID: PMC9461718 DOI: 10.7224/1537-2073.2021-089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is an inflammatory central nervous system demyelinating disorder resulting in neurologic decline. Patients predominantly have a relapsing and remitting disease course requiring multiple hospitalizations and, occasionally, rehospitalizations. Hospitalization readmission rates are important metrics that have direct financial implications for hospitals and serve as an indicator of disease burden on patients and society. We sought to analyze hospital readmissions of patients with MS and identify the subsequent predictive characteristics/comorbidities for readmission. METHODS All hospital admissions due to MS were queried using the 2017 Nationwide Readmissions Database. All patients with nonelective rehospitalization within 30 days of discharge were examined. RESULTS The 30-day readmission rate for MS is 10.6% (range, 10.4%-10.8%). Female sex has a protective role in readmission rates, and age has no effect. Comorbidities, including heart failure, acute kidney injury, chronic obstructive pulmonary disease, chronic kidney disease, respiratory failure, substance abuse, diabetes, hypertension, peripheral artery disease, liver failure, anemia, coagulation disorders, cancer, depression, and infections, are predictive of readmissions, whereas sleep apnea is protective. No effect is seen with neurologic blindness, plasma exchange, or intravenous immunoglobulin treatment. CONCLUSIONS Several medical comorbidities are predictive of hospital readmission of patients with MS. Most rehospitalizations are due to infectious and neurologic etiologies; thus, targeted interventions may lead to lower readmission rates.
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Affiliation(s)
- Akhil Padarti
- From the Department of Neurology (AP, WK), University of South Alabama College of Medicine, Mobile, AL, USA
| | - Amod Amritphale
- From the Department of Internal Medicine (AA), University of South Alabama College of Medicine, Mobile, AL, USA
| | - William Kilgo
- From the Department of Neurology (AP, WK), University of South Alabama College of Medicine, Mobile, AL, USA
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25
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Abstract
PURPOSE OF REVIEW This article provides an overview of genetic, environmental, and lifestyle risk factors affecting the disease course of multiple sclerosis (MS) and reviews the pathophysiologic characteristics of both relapsing and progressive MS. RECENT FINDINGS The prevalence of MS has increased in recent decades, and costs of care for patients with MS have risen dramatically. Black, Asian, and Hispanic individuals may be at risk for more severe MS-related disability. Multiple genetic MS risk factors have been identified. Factors such as low vitamin D levels and a history of Epstein-Barr virus, smoking, and obesity, especially during childhood, also influence MS risk. Traditionally thought to be a T-cell-mediated disease, recent research has highlighted the additional roles of B cells and microglia in both relapsing and progressive MS. SUMMARY Complex interactions between genetic, environmental, and lifestyle factors affect the risk for MS as well as the disease course. People of color have historically been underrepresented in both MS clinical trials and literature, but current research is attempting to better clarify unique considerations in these groups. MS pathology consists of the focal inflammatory lesions that have been well characterized in relapsing MS, as well as a more widespread neurodegenerative component that is posited to drive progressive disease. Recent advances in characterization of both the inflammatory and neurodegenerative aspects of MS pathophysiology have yielded potential targets for future therapeutic options.
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26
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Sohn SY, Kim SY, Joo IS. Corticosteroid-induced bradycardia in multiple sclerosis and maturity-onset diabetes of the young due to hepatocyte nuclear factor 4-alpha mutation: A case report. World J Clin Cases 2022; 10:7415-7421. [PMID: 36158012 PMCID: PMC9353935 DOI: 10.12998/wjcc.v10.i21.7415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 04/08/2022] [Accepted: 06/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intravenous steroid pulse therapy is the treatment of choice for acute exacerbation of multiple sclerosis (MS). Although steroid administration is generally well-tolerated, cases of cardiac arrhythmia have been reported. Herein, we describe a young woman who developed marked sinus bradycardia and T-wave abnormalities after corticosteroid administration. We also present plausible explanations for the abnormalities observed in this patient.
CASE SUMMARY An 18-year-old woman experienced vertiginous dizziness and binocular diplopia 1 wk prior to admission. Neurological examination revealed left internuclear ophthalmoplegia with left peripheral-type facial palsy. The initial laboratory results were consistent with those of type 2 diabetes. Brain magnetic resonance imaging revealed multifocal, non-enhancing, symptomatic lesions and multiple enhancing lesions. She was diagnosed with MS and maturity-onset diabetes of the young. Intravenous methylprednisolone was administered. On day 5 after methylprednisolone infusion, marked bradycardia with T-wave abnormalities were observed. Genetic evaluation to elucidate the underlying conditions revealed a hepatocyte nuclear factor 4-alpha (HNF4A) gene mutation. Steroid treatment was discontinued under suspicion of corticosteroid-induced bradycardia. Her electrocardiogram changes returned to normal without complications two days after steroid discontinuation.
CONCLUSION Corticosteroid-induced bradycardia may have a significant clinical impact, especially in patients with comorbidities, such as HNF4A mutations.
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Affiliation(s)
- Sung-Yeon Sohn
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 16499, South Korea
| | - Shin Yeop Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 16499, South Korea
| | - In Soo Joo
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 16499, South Korea
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Marrie RA, Patel R, Figley CR, Kornelsen J, Bolton JM, Graff LA, Mazerolle EL, Helmick C, Uddin MN, Figley TD, Marriott JJ, Bernstein CN, Fisk JD. Effects of Vascular Comorbidity on Cognition in Multiple Sclerosis Are Partially Mediated by Changes in Brain Structure. Front Neurol 2022; 13:910014. [PMID: 35685743 PMCID: PMC9170886 DOI: 10.3389/fneur.2022.910014] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/03/2022] [Indexed: 01/09/2023] Open
Abstract
ObjectiveVascular comorbidities are associated with reduced cognitive performance and with changes in brain structure in people with multiple sclerosis (MS). Understanding causal pathways is necessary to support the design of interventions to mitigate the impacts of comorbidities, and to monitor their effectiveness. We assessed the inter-relationships among vascular comorbidity, cognition and brain structure in people with MS.MethodsAdults with neurologist-confirmed MS reported comorbidities, and underwent assessment of their blood pressure, HbA1c, and cognitive functioning (i.e., Symbol Digit Modalities Test, California Verbal Learning Test, Brief Visuospatial Memory Test-Revised, and verbal fluency). Test scores were converted to age-, sex-, and education-adjusted z-scores. Whole brain magnetic resonance imaging (MRI) was completed, from which measures of thalamic and hippocampal volumes, and mean diffusivity of gray matter and normal-appearing white matter were converted to age and sex-adjusted z-scores. Canonical correlation analysis was used to identify linear combinations of cognitive measures (cognitive variate) and MRI measures (MRI variate) that accounted for the most correlation between the cognitive and MRI measures. Regression analyses were used to test whether MRI measures mediated the relationships between the number of vascular comorbidities and cognition measures.ResultsOf 105 participants, most were women (84.8%) with a mean (SD) age of 51.8 (12.8) years and age of symptom onset of 29.4 (10.5) years. Vascular comorbidity was common, with 35.2% of participants reporting one, 15.2% reporting two, and 8.6% reporting three or more. Canonical correlation analysis of the cognitive and MRI variables identified one pair of variates (Pillai's trace = 0.45, p = 0.0035). The biggest contributors to the cognitive variate were the SDMT and CVLT-II, and to the MRI variate were gray matter MD and thalamic volume. The correlation between cognitive and MRI variates was 0.50; these variates were used in regression analyses. On regression analysis, vascular comorbidity was associated with the MRI variate, and with the cognitive variate. After adjusting for the MRI variate, vascular comorbidity was not associated with the cognitive variate.ConclusionVascular comorbidity is associated with lower cognitive function in people with MS and this association is partially mediated via changes in brain macrostructure and microstructure.
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Affiliation(s)
- Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- *Correspondence: Ruth Ann Marrie
| | - Ronak Patel
- Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Chase R. Figley
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Division of Diagnostic Imaging, Winnipeg Health Sciences Centre, Winnipeg, MB, Canada
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg Health Sciences Centre, Winnipeg, MB, Canada
| | - Jennifer Kornelsen
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Division of Diagnostic Imaging, Winnipeg Health Sciences Centre, Winnipeg, MB, Canada
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg Health Sciences Centre, Winnipeg, MB, Canada
| | - James M. Bolton
- Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Lesley A. Graff
- Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Erin L. Mazerolle
- Department of Psychology, St. Francis Xavier University, Antigonish, NS, Canada
| | - Carl Helmick
- Department of Psychiatry and Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Md Nasir Uddin
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Neurology, University of Rochester, Rochester, New York, NY, United States
| | - Teresa D. Figley
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - James J. Marriott
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Charles N. Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - John D. Fisk
- Nova Scotia Health and the Departments of Psychiatry, Psychology & Neuroscience, and Medicine, Dalhousie University, Halifax, NS, Canada
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28
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Gonzalez-Martinez A, Bose G, Chitnis T. Anti-CGRP therapies for migraine in multiple sclerosis patients. Mult Scler 2022; 28:2149-2150. [PMID: 35575242 DOI: 10.1177/13524585221096353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Alicia Gonzalez-Martinez
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Gauruv Bose
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,Brigham Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tanuja Chitnis
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,Brigham Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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29
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Krysko KM, Anderson A, Singh J, McPolin K, Rutatangwa A, Rowles W, Sadovnick AD, Houtchens MK, Bove R. Risk factors for peripartum depression in women with multiple sclerosis. Mult Scler 2022; 28:970-979. [PMID: 34498513 DOI: 10.1177/13524585211041108] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Peripartum depression (PPD) is underexplored in multiple sclerosis (MS). OBJECTIVE To evaluate prevalence of and risk factors for PPD in women with MS. METHODS Retrospective single-center analysis of women with MS with a live birth. Prevalence of PPD was estimated with logistic regression with generalized estimating equations (GEE). GEE evaluated predictors of PPD (e.g. age, marital status, parity, pre-pregnancy depression/anxiety, antidepressant discontinuation, sleep disturbance, breastfeeding, relapses, gadolinium-enhancing lesions, and disability). Factors significant in univariable analyses were included in multivariable analysis. RESULTS We identified 143 live births in 111 women (mean age 33.1 ± 4.7 years). PPD was found in 18/143 pregnancies (12.6%, 95% CI = 7.3-17.8). Factors associated with PPD included older age (OR 1.16, 95% CI = 1.03-1.32 for 1-year increase), primiparity (OR 4.02, CI = 1.14-14.23), pre-pregnancy depression (OR 3.70, CI = 1.27-10.01), sleep disturbance (OR 3.23, CI = 1.17-8.91), and breastfeeding difficulty (OR 3.58, CI = 1.27-10.08). Maternal age (OR 1.17, CI = 1.02-1.34), primiparity (OR 8.10, CI = 1.38-47.40), and pre-pregnancy depression (OR 3.89, CI = 1.04-14.60) remained significant in multivariable analyses. Relapses, MRI activity, and disability were not associated with PPD. CONCLUSION The prevalence of PPD in MS appeared similar to the general population, but was likely underestimated due to lack of screening. PPD can affect MS self-management and offspring development, and prospective studies are needed.
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Affiliation(s)
- Kristen M Krysko
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA/ Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada/Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Annika Anderson
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica Singh
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Kira McPolin
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Alice Rutatangwa
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - William Rowles
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - A Dessa Sadovnick
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada/Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Maria K Houtchens
- Department of Neurology, Partners MS Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
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30
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Shangraw K, Murchison CF, Silbermann E, Spain RI. Effect of Vascular Comorbidity on Visual and Disability Outcomes in a Secondary Progressive Multiple Sclerosis Clinical Trial Cohort. Int J MS Care 2022; 24:169-174. [DOI: 10.7224/1537-2073.2021-049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Abstract
Background:
Vascular comorbidity (VC) is associated with multiple sclerosis (MS) disease progression and visual dysfunction. The longitudinal effect of VC in people with secondary progressive MS (SPMS) is unclear. This study explored the impact of VC on standard clinical, MRI, and visual outcomes in people with SPMS enrolled in a clinical trial.
Methods:
Data were extracted from a 2-year randomized controlled trial (N = 51) testing the supplement lipoic acid in people with SPMS who underwent annual Expanded Disability Status Scale, Timed 25-Foot Walk test, MRI, visual acuity testing, and retinal nerve fiber layer (RNFL) and ganglion cell/inner plexiform layer (GCIPL) thicknesses per optical coherence tomography (OCT). Post hoc linear mixed-effects regression analysis compared baseline and annualized outcomes between participants without VC (VC–) and with 1 or more VCs (VC+) (hypertension, dyslipidemia, obesity, diabetes, peripheral or cardiovascular disease, tobacco use).
Results:
The VC– (n = 19) and VC+ (n = 28) participants were similar in age, sex, and MS disease duration and had comparable MS disability, mobility, and brain atrophy at baseline and throughout the 2-year parent study. The VC+ participants had worse baseline visual acuity than those in the VC– group by 0.13 logMAR (P = .041). No significant differences were detected in RNFL or GCIPL baseline thickness or atrophy between groups.
Conclusions:
In an SPMS cohort, VC had an inconsistent effect on standard clinical, MRI, and exploratory OCT outcomes, suggesting that the effect of VC may not be evident in smaller cohort studies. Using a more refined definition of VC in future, adequately powered investigations may help effectively elucidate and account for the interaction between vascular risk burden and MS disability.
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Affiliation(s)
- Kathleen Shangraw
- From the Department of Neurology, Oregon Health & Science University, Portland, OR, USA (KS, ES, RIS)
| | - Charles F. Murchison
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA (CFM)
| | - Elizabeth Silbermann
- From the Department of Neurology, Oregon Health & Science University, Portland, OR, USA (KS, ES, RIS)
| | - Rebecca I. Spain
- From the Department of Neurology, Oregon Health & Science University, Portland, OR, USA (KS, ES, RIS)
- Department of Neurology, Veterans Affairs Portland Health Care System, Portland, OR, USA (RIS)
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31
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Leekoff M, Culpepper W, Jin S, Lee-Wilk T, Wallin M. Impact of comorbid post traumatic stress disorder on multiple sclerosis in military veterans: A population-based cohort study. Mult Scler 2021; 28:1257-1266. [PMID: 34854320 DOI: 10.1177/13524585211058361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Very little is known regarding the impact of post traumatic stress disorder (PTSD) on the course of multiple sclerosis (MS). OBJECTIVES To explore the impact of pre-existing PTSD on MS relapses, magnetic resonance imaging (MRI) activity, and disability in a large population-based cohort. METHODS Military Veterans with MS and PTSD prior to symptom onset (MSPTSD, n = 96) were identified using the Department of Veterans Affairs MS databases. MSPTSD cases were matched to MS controls without PTSD (n = 95). Number of relapses, number of new T2 lesions and new gadolinium lesions on brain MRI, and neurological disability were abstracted between 2015 and 2019. RESULTS The mean annualized relapse rate was greater in the MSPTSD group versus controls (0.23 vs 0.06, respectively; p < 0.05), as was the annualized mean number of new T2 and gadolinium-enhancing lesions on brain MRI (0.52 vs 0.16 and 0.29 vs 0.08, respectively; p < 0.05). Disability accrual (time to Disability Status Scale 6.0) was more rapid (23.7 vs 29.5 years, p < 0.05) in relapsing MS patients with PTSD. CONCLUSION Patients with MSPTSD have higher disease activity and reach disability endpoints more rapidly than controls. This is the first study to show PTSD as a potentially modifiable risk factor for MS relapses, MRI activity, and disability.
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Affiliation(s)
- Mark Leekoff
- Multiple Sclerosis Center of Excellence, Veterans Affairs, Baltimore, MD, USA/Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Multiple Sclerosis Center of Excellence, Veterans Affairs, and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William Culpepper
- Multiple Sclerosis Center of Excellence, Veterans Affairs, Baltimore, MD, USA/Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.,Multiple Sclerosis Center of Excellence, Veterans Affairs, and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shan Jin
- Multiple Sclerosis Center of Excellence, Veterans Affairs, Baltimore, MD, USA /Department of Neurology,School of Medicine,University of Maryland,Baltimore, MD, USA.,Multiple Sclerosis Center of Excellence, Veterans Affairs, and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terry Lee-Wilk
- Multiple Sclerosis Center of Excellence, Veterans Affairs, Baltimore, MD, USA /Department of Neurology,School of Medicine,University of Maryland,Baltimore, MD, USA.,Multiple Sclerosis Center of Excellence, Veterans Affairs, and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mitchell Wallin
- Multiple Sclerosis Center of Excellence, Veterans Affairs, and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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32
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Parks NE, Andreou P, Marrie RA, Fisk JD, Bhan V, Kirkland SA. Comorbidity and persistence of disease-modifying therapy use in relapsing remitting multiple sclerosis. Mult Scler Relat Disord 2021; 56:103249. [PMID: 34517192 DOI: 10.1016/j.msard.2021.103249] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 07/29/2021] [Accepted: 09/01/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Comorbidity decreases the likelihood of initiating disease-modifying therapy (DMT) for multiple sclerosis (MS). Our objective was to characterize the relationship between comorbidity and initial DMT persistence along with reasons for DMT discontinuation. METHODS We identified individuals with relapsing remitting MS or clinically isolated syndrome starting a platform DMT (interferon-β, glatiramer acetate, dimethyl fumarate, teriflunomide) as initial therapy in the Canadian province of Nova Scotia from 2001 to 2016. Cases were identified using a clinic database for the only clinic providing specialty MS care in a province with universal publicly-funded health care. Comorbidity was determined by linkage of MS cases to provincial health administrative data using validated case definitions for mental health disorder, hypertension, hyperlipidemia, diabetes, chronic lung disease, ischemic heart disease, epilepsy, and inflammatory bowel disease. Cox proportional hazards models explored the relationship between comorbidity, as a count or individual comorbidities, and time to discontinuation of initial DMT. Logistic regression models explored reasons for DMT discontinuation. RESULTS Among 1464 individuals starting platform therapy as initial DMT, the median duration on first DMT was 4 years (95% CI 4 - 4). Comorbidity count (0, 1, ≥2) was not associated with time to discontinuation of initial DMT. However, the presence of a mental health disorder was associated with an increased hazard of discontinuing DMT (hazard ratio 1.22, 95% CI 1.03-1.44). Comorbidity count was not associated with discontinuation for lack of efficacy or lack of tolerability after adjusting for covariates. CONCLUSION Individuals with mental health comorbidity may have unique challenges that affect persistence on DMT after treatment initiation.
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Affiliation(s)
- Natalie E Parks
- Division of Neurology, Halifax Infirmary, Dalhousie University, 1796 Summer St, Room 3832, Halifax, NS B3H 3A7, Canada; Department of Community Health and Epidemiology, Dalhousie University, 5790 University Ave, Halifax, NS B3H 1V7, Canada.
| | - Pantelis Andreou
- Department of Community Health and Epidemiology, Dalhousie University, 5790 University Ave, Halifax, NS B3H 1V7, Canada
| | - Ruth Ann Marrie
- Department of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, Health Sciences Centre, University of Manitoba, GF 543-820 Sherbrook St, Winnipeg, MB R3A 1R9, Canada
| | - John D Fisk
- Nova Scotia Health Authority and the Departments of Psychiatry, Psychology and Neuroscience and Medicine, Dalhousie University, 5909 Veterans' Memorial Lane, Halifax, NS B3H 2E2, Canada
| | - Virender Bhan
- Division of Neurology, University of British Columbia, 3935 Kincaid St, Burnaby, BC V5G 2J6, Canada
| | - Susan A Kirkland
- Department of Community Health and Epidemiology, Dalhousie University, 5790 University Ave, Halifax, NS B3H 1V7, Canada
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33
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Moisset X, Giraud P, Dallel R. Migraine in multiple sclerosis and other chronic inflammatory diseases. Rev Neurol (Paris) 2021; 177:816-820. [PMID: 34325914 DOI: 10.1016/j.neurol.2021.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023]
Abstract
Migraine is a very prevalent disease worldwide and is a major cause of disability. As known for a long time, migraine is associated with neurogenic inflammation. Epidemiological studies have shown that migraine is comorbid with several chronic inflammatory diseases, including multiple sclerosis (MS), chronic inflammatory rheumatic diseases (CIRDs) and inflammatory bowel diseases (IBDs). This brief narrative review highlights some recent data supporting a link between migraine and these three chronic inflammatory diseases. Studies found that migraine prevalence is approximately two-fold higher in these diseases compared to the general population. The causal link between migraine and these chronic inflammatory diseases has not been identified yet. Here, we suggest that systemic mediators (such as cytokines) and gut microbiome make migraine worse or add significant risks. Systemic inflammation biomarkers and gut microbiome modification are certainly avenues worth exploring.
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Affiliation(s)
- X Moisset
- Inserm, Neuro-Dol, Université Clermont-Auvergne, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France.
| | - P Giraud
- Annecy-Genevois Hospital, 74370 Annecy, France
| | - R Dallel
- Inserm, Neuro-Dol, Université Clermont-Auvergne, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
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34
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Lakin L, Davis BE, Binns CC, Currie KM, Rensel MR. Comprehensive Approach to Management of Multiple Sclerosis: Addressing Invisible Symptoms-A Narrative Review. Neurol Ther 2021; 10:75-98. [PMID: 33877583 PMCID: PMC8057008 DOI: 10.1007/s40120-021-00239-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease of the central nervous system, leading to neurodegeneration and manifesting as a variety of symptoms. These can include "invisible" symptoms, not externally evident to others, such as fatigue, mood disorders, cognitive impairments, pain, bladder/bowel dysfunction, sexual dysfunction, and vision changes. Invisible symptoms are highly prevalent in people living with MS, with multifactorial etiology and potential to impact the disease course. Patient experiences of these symptoms include both physical and psychosocial elements, which when unaddressed negatively influence many aspects of quality of life and perception of health. Despite the high impact on patient lives, gaps persist in awareness and management of these hidden symptoms. The healthcare provider and patient author experiences brought together here serve to raise the profile of invisible symptoms and review strategies for a team-based approach to comprehensive MS care. We summarize the current literature regarding the prevalence and etiology of invisible symptoms to convey the high likelihood that a person living with MS will contend with one or more of these concerns. We then explore how open communication between people living with MS and their care team, stigma mitigation, and shared decision-making are key to comprehensive management of invisible symptoms. We recommend validated screening tools and technological advancements that may be incorporated into MS care to regularly monitor these symptoms, offering insight into how healthcare providers can both educate and listen to patients, with the goal of improved patient quality of life. By pairing clinical knowledge with an understanding and consideration of the patient perspective, providers will be equipped to foster a patient-centered dialogue that encourages shared decision-making. Invisible symptoms of MS.
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Affiliation(s)
- Lynsey Lakin
- The Neurology Group, 9120 Haven Ave, Rancho Cucamonga, CA, USA
- Comprehensive MS Center, The University of California Riverside, 3390 University Ave, Suite 100, Riverside, CA, USA
| | - Bryan E Davis
- Comprehensive MS Center, The University of California Riverside, 3390 University Ave, Suite 100, Riverside, CA, USA
| | - Cherie C Binns
- Accelerated Cure Project/iConquerMS, 187 Robinson Street, Wakefield, RI, USA
| | - Keisha M Currie
- Currie Consultancy Agency LLC., 11 M. R. Watson Court, Eastover, SC, USA
| | - Mary R Rensel
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA.
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35
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Jakimovski D, Eckert SP, Zivadinov R, Weinstock-Guttman B. Considering patient age when treating multiple sclerosis across the adult lifespan. Expert Rev Neurother 2021; 21:353-364. [PMID: 33595379 DOI: 10.1080/14737175.2021.1886082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: The successful development of anti-inflammatory disease-modifying treatments (DMT) significantly improved disease outcomes and longevity of persons with multiple sclerosis (pwMS). However, the shift toward an elderly MS population has resulted with new concerns regarding DMT efficacy and safety.Areas covered: This review summarizes the evidence of an age-based decrease in the efficacy of MS DMTs and increase in pharmacovigilance concerns. The age effects on pathophysiological MS processes, immunosenescence and its relevance to DMT selection or discontinuation are also reviewed. Lastly, the authors discuss the influence of age-associated comorbidities on DMT initiation and drug-induced events.Expert opinion: There is an age discrepancy between pwMS included in regulatory drug trials and an aging real-world MS population. Most trials demonstrate significantly diminished anti-inflammatory efficacy in patients older than 40 years old. Older age is associated with a greater risk for adverse events including serious infections. Age-associated comorbidities influence the risk-benefit analysis and sometimes cause patients to discontinue DMTs. Instead of chronological age cutoffs, therefore, studies should aim at promoting biologically-based age biomarkers.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.,Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, NY, USA
| | - Svetlana P Eckert
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.,Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, NY, USA.,Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, NY, USA
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36
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Nelson LM, Bourdette D. Two decades of research: Time to incorporate comorbidity management into the care of MS? Neurology 2020; 95:193-194. [PMID: 32554769 DOI: 10.1212/wnl.0000000000010036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lorene M Nelson
- From the Department of Epidemiology and Population Health (L.M.N.), Stanford University School of Medicine, CA; and Department of Neurology (D.B.), Oregon Health & Science University, Portland.
| | - Dennis Bourdette
- From the Department of Epidemiology and Population Health (L.M.N.), Stanford University School of Medicine, CA; and Department of Neurology (D.B.), Oregon Health & Science University, Portland
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