Positive correlation between functional disability, excessive daytime sleepiness, and fatigue in relapsing-remitting multiple sclerosis

Pain, physical symptoms and functional assessment in progressive neurological disease in palliative care

OBJECTIVES

The aim of the research was to identify the most frequent symptoms of patients with progressive neurological disease (PND) in relation to their functional state. Another objective was to determine the effects of consultations with a multidisciplinary palliative team on mitigating the symptoms burden, subjective evaluation of health, disease progression and improvement of the functional state.

METHODS

The interventional control study included 151 patients with PND (98 patients in the intervention group, 53 patients in the control group). The intervention group was provided with consultations of a multidisciplinary palliative team. The symptoms scale of the progressive neurological diseases quality of life was used to collect data. The patients completed the questionnaire before the provided intervention and 3 months after that.

RESULTS

Pain and fatigue were identified as the symptoms that trouble the patients the most. After the intervention, there was a determined statistically significant improvement in the evaluation of 9 out of 11 symptoms (except excretion and urination) among the patients from the intervention group compared with the control group. When assessed again, the patients from the intervention group showed an improvement with respect to six symptoms (pain, fatigue, tremor, stiffness, cramps, excretion), while the patients from the control group had six symptoms that deteriorated (drowsiness, dyspnoea, stiffness, swallowing, salivation, excretion). There was not any confirmed positive impact of the intervention on the cognitive functions of the patients.

CONCLUSION

The provision of consultations with the multidisciplinary palliative team to patients with PND in an advanced stage of disease resulted in decreasing their symptoms burden and improving their functional state.

The complex syndrome of functional neurological disorder

BACKGROUND

Patients with functional neurological disorders (FND) often present with multiple motor, sensory, psychological and cognitive symptoms. In order to explore the relationship between these common symptoms, we performed a detailed clinical assessment of motor, non-motor symptoms, health-related quality of life (HRQoL) and disability in a large cohort of patients with motor FND. To understand the clinical heterogeneity, cluster analysis was used to search for subgroups within the cohort.

METHODS

One hundred fifty-two patients with a clinically established diagnosis of motor FND were assessed for motor symptom severity using the Simplified Functional Movement Disorder Rating Scale (S-FMDRS), the number of different motor phenotypes (i.e. tremor, dystonia, gait disorder, myoclonus, and weakness), gait severity and postural instability. All patients then evaluated each motor symptom type severity on a Likert scale and completed questionnaires for depression, anxiety, pain, fatigue, cognitive complaints and HRQoL.

RESULTS

Significant correlations were found among the self-reported and all objective motor symptoms severity measures. All self-reported measures including HRQoL correlated strongly with each other. S-FMDRS weakly correlated with HRQoL. Hierarchical cluster analysis supplemented with gap statistics revealed a homogenous patient sample which could not be separated into subgroups.

CONCLUSIONS

We interpret the lack of evidence of clusters along with a high degree of correlation between all self-reported and objective measures of motor or non-motor symptoms and HRQoL within current neurobiological models as evidence to support a unified pathophysiology of 'functional' symptoms. Our results support the unification of functional and somatic syndromes in classification schemes and for future mechanistic and therapeutic research.

Sleep disorders in multiple sclerosis: a case-control study using the São Paulo Epidemiologic sleep study (Episono) database

BACKGROUND

Sleep disorders such as obstructive sleep apnea and restless legs syndrome are prevalent in the general population and patients with chronic diseases such as multiple sclerosis (MS).

OBJECTIVES

This study compared the prevalence of sleep disorders complaints, fatigue, depression, and chronotype of adult patients with multiple sclerosis (PwMS) to a representative sample of São Paulo city residents.

METHODS

A comparative study was made between PwMS and volunteers from the São Paulo Epidemiologic Sleep Study (Episono) study. We compared the scores of sleep questionnaires using the multivariate analysis of variance (MANOVA) test to evaluate the effects and analysis of variance (ANOVA) as a follow-up test. Covariates were age, sex, and physical activity. The Pearson correlation test was performed to measure the correlation between Expanded Disability Status Scale (EDSS) and the scores of the sleep questionnaires. Finally, we applied propensity score matching to reduce bias in estimating differences between the two groups. Analyses were performed using Stata 14 (StataCorp, College Station, TX, USA) and IBM SPSS Statistics for Windows version 22.0 (IBM Corp., Armonk, NY, USA).

RESULTS

The Episono group had worse sleep quality, and more excessive daytime sleepiness than PwMS. Obstructive sleep apnea and restless legs syndrome were more frequent in the Episono group. There was no difference in chronotype between the two groups, with morning and intermediate preference. There was no correlation between EDSS and sleep complaints. Fatigue was intensively present among PwMS.

CONCLUSIONS

Disease Modifying Drug (DMD)-treated PwMS had a lower frequency of sleep complaints, no difference in chronotype, and a higher prevalence of fatigue than a sample of São Paulo city residents. The immunomodulatory drugs commonly used to treat MS may have contributed to these findings.

Fatigue, sleepiness and depression in multiple sclerosis: defining the overlaps for a better phenotyping

BACKGROUND AND OBJECTIVES

To define the boundaries and the overlaps between fatigue, sleepiness and depression in patients with multiple sclerosis (MS) by using different tools for each dimension, including instrumental sleep analysis.

METHODS

In this cross-sectional, observational study, 71 MS patients (males/females: 20/51; mean age: 48.9 ± 10.5 years) filled in clinical questionnaires and performed polysomnography followed by maintenance of wakefulness test (MWT). Frequency and reciprocal overlap of sleepiness, fatigue and depression in MS were expressed by Eulero-Venn diagrams; standard multiple regression was used to assess the ability of symptoms to predict each other.

RESULTS

There was a high percentage of fatigued (70%), somnolent (45%) and depressed (27%) patients. Fatigue had the strongest overlap and correlated with both depression (beta: 0.52, p < 0.001) and sleepiness (beta: 0.74, p < 0.001). Somnolence and depression were nearly always accompanied by fatigue and were well differentiated from each other by MWT. Four MS subgroups were identified that had: (1) fatigue only; (2) fatigue and sleepiness (3) fatigue and depression; (4) fatigue, sleepiness and depression.

DISCUSSION

The subjective and objective tools are not able to clearly distinguish fatigue from sleepiness and depression, while only a test of vigilance can be helpful in separating somnolence and depression from each other.

Idiopathic Hypersomnia and Depression, the Challenge for Clinicians and Researchers

The review deals with idiopathic hypersomnia, focusing mostly on the research findings about the presence, onset and severity of excessive daytime sleepiness and depressive symptoms in patients with idiopathic hypersomnia.

Possible Role of Butyrylcholinesterase in Fat Loss and Decreases in Inflammatory Levels in Patients with Multiple Sclerosis after Treatment with Epigallocatechin Gallate and Coconut Oil: A Pilot Study

(1) Background. Multiple sclerosis (MS) is characterised by the loss of muscle throughout the course of the disease, which in many cases is accompanied by obesity and related to inflammation. Nonetheless, consuming epigallocatechin gallate (EGCG) and ketone bodies (especially β-hydroxybutyrate (βHB)) produced after metabolising coconut oil, have exhibited anti-inflammatory effects and a decrease in body fat. In addition, butyrylcholinesterase (BuChE), seems to be related to the pathogenesis of the disease associated with inflammation, and serum concentrations have been related to lipid metabolism. Objective. The aim of the study was to determine the role of BuChE in the changes caused after treatment with EGCG and ketone bodies on the levels of body fat and inflammation state in MS patients. (2) Methods. A pilot study was conducted for 4 months with 51 MS patients who were randomly divided into an intervention group and a control group. The intervention group received 800 mg of EGCG and 60 mL of coconut oil, and the control group was prescribed a placebo. Fat percentage and concentrations of the butyrylcholinesterase enzyme (BuChE), paraoxonase 1 (PON1) activity, triglycerides, interleukin 6 (IL-6), albumin and βHB in serum were measured. (3) Results. The intervention group exhibited significant decreases in IL-6 and fat percentage and significant increases in BuChE, βHB, PON1, albumin and functional capacity (determined by the Expanded Disability Status Scale (EDSS)). On the other hand, the control group only exhibited a decrease in IL-6. After the intervention, BuChE was positively correlated with the activity of PON1, fat percentage and triglycerides in the intervention group, whereas these correlations were not observed in the control group (4). Conclusions. BuChE seems to have an important role in lipolytic activity and the inflammation state in MS patients, evidenced after administering EGCG and coconut oil as a βHB source.

Quality of sleep and fatigue in patients with the relapsing-remitting multiple sclerosis during the coronavirus disease-2019 pandemic

ОBJECTIVE: Sleep disturbances and fatigue are frequent symptoms in multiple sclerosis patients. The aim was to assess the quality of sleep (QoS) and fatigue in patients with the relapsing-remitting multiple sclerosis (RRMS), during the coronavirus disease-2019 (COVID-19) pandemic.

METHODS

The study included 67 patients with RRMS and 85 healthy control subjects. RRMS patients, who were tested in first half of 2019, were retested in April and May 2020, during the COVID-19 pandemic. We collected sociodemographic and clinical data, and also used the following questionnaires: Pittsburgh sleep quality index (PSQI), Fatigue Severity Scale (FSS), and Multiple Sclerosis Quality of Life-54 Instrument (MSQOL-54).

RESULTS

The FSS score and PSQI global score were significantly higher in patients with RRMS than in the control group (p < 0.01). We noticed a statistically significant difference between the results obtained a year ago and the results during the COVID-19 pandemic in PSQI global score (p < 0.01) and all subscores. Higher disability status was an independent predictor of the worse PSQI scores.

CONCLUSION

During the COVID-19 outbreak worse QoS were noticed in RRMS patients than in healthy individuals. Also, QoS of RRMS patients is more affected during the COVID-19 pandemic than in regular circumstances. High levels of sleep disturbance and fatigue in RRMS patients correlates with worse life quality, female gender, lower educational level and partner status. The results of the present study provide evidence in support of regular screening and monitoring of fatigue and QoS in this patient population, especially during the pandemic states.

Relationship between Fatigue and Physical Activity in a Polish Cohort of Multiple Sclerosis Patients

Background and objectives: Fatigue is one of the most common and disabling symptoms of multiple sclerosis (MS). It can be defined as a subjective lack of physical and mental energy. The aim of this study was to evaluate the frequency and severity of fatigue in patients with MS and its relationship with overall physical activity and disease-related disability. Materials and Methods: The study included 100 patients with a clinical relapsing-remitting form of MS. Patients with severe depression were excluded. Neurological impairment was rated using the Expanded Disability Status Scale (EDSS). Fatigue was assessed using the Modified Fatigue Impact Scale (MFIS) and the Fatigue Severity Scale (FSS), with FSS scores greater than 36 indicating patients with fatigue. Physical activity was evaluated with the International Physical Activity Questionnaire (IPAQ) and categorized on three levels: low, moderate, and high, using standard metabolic equivalents (MET). Results: The average FSS and MFIS scores were (mean ± SD) 31.3 ± 15.2 and 30.1 ± 17.0, respectively. The mean EDSS score was 2.5 ± 1.5. 42%. Patients were classified as fatigued based on FSS. Fatigued patients had higher mean EDSS scores than non-fatigued (3.0 ± 1.6 vs. 2.2 ± 1.4, respectively, p = 0.002). Low, moderate, and high levels of physical activity were reported in 35%, 20%, and 45% of patients, respectively. Higher scores of fatigue in FSS and MFIS were inversely correlated with the intensity of physical activity (r = -0.38, p < 0.001 and r = -0.33, p < 0.001, respectively). Conclusions: In patients with MS, fatigue is a common symptom. Patients with lower physical activity and greater MS-related disability have a higher severity of fatigue, which negatively affects cognitive, psychosocial, and physical functioning.

Multiple Sclerosis: Melatonin, Orexin, and Ceramide Interact with Platelet Activation Coagulation Factors and Gut-Microbiome-Derived Butyrate in the Circadian Dysregulation of Mitochondria in Glia and Immune Cells

Recent data highlight the important roles of the gut microbiome, gut permeability, and alterations in mitochondria functioning in the pathophysiology of multiple sclerosis (MS). This article reviews such data, indicating two important aspects of alterations in the gut in the modulation of mitochondria: (1) Gut permeability increases toll-like receptor (TLR) activators, viz circulating lipopolysaccharide (LPS), and exosomal high-mobility group box (HMGB)1. LPS and HMGB1 increase inducible nitric oxide synthase and superoxide, leading to peroxynitrite-driven acidic sphingomyelinase and ceramide. Ceramide is a major driver of MS pathophysiology via its impacts on glia mitochondria functioning; (2) Gut dysbiosis lowers production of the short-chain fatty acid, butyrate. Butyrate is a significant positive regulator of mitochondrial function, as well as suppressing the levels and effects of ceramide. Ceramide acts to suppress the circadian optimizers of mitochondria functioning, viz daytime orexin and night-time melatonin. Orexin, melatonin, and butyrate increase mitochondria oxidative phosphorylation partly via the disinhibition of the pyruvate dehydrogenase complex, leading to an increase in acetyl-coenzyme A (CoA). Acetyl-CoA is a necessary co-substrate for activation of the mitochondria melatonergic pathway, allowing melatonin to optimize mitochondrial function. Data would indicate that gut-driven alterations in ceramide and mitochondrial function, particularly in glia and immune cells, underpin MS pathophysiology. Aryl hydrocarbon receptor (AhR) activators, such as stress-induced kynurenine and air pollutants, may interact with the mitochondrial melatonergic pathway via AhR-induced cytochrome P450 (CYP)1b1, which backward converts melatonin to N-acetylserotonin (NAS). The loss of mitochnodria melatonin coupled with increased NAS has implications for altered mitochondrial function in many cell types that are relevant to MS pathophysiology. NAS is increased in secondary progressive MS, indicating a role for changes in the mitochondria melatonergic pathway in the progression of MS symptomatology. This provides a framework for the integration of diverse bodies of data on MS pathophysiology, with a number of readily applicable treatment interventions, including the utilization of sodium butyrate.

Disability as a determinant of fatigue in MS patients

ABSTRACT Fatigue is one of the most frequent and disabling symptoms in multiple sclerosis (MS). Central, psychological, and peripheral factors may contribute to the occurrence of fatigue. Objectives: The current study aimed to evaluate potential fatigue determinants in patients with relapsing-remitting MS with a low functional impairment. Methods: We compared inflammatory markers, respiratory pressures, disability, and quality of life in 39 relapsing-remitting MS patients with and without fatigue. Results: Patients with relapsing-remitting MS with fatigue had higher Expanded Disability Status Scale scores (p = 0.002). We observed a significant association between the results of the Guy Neurological Disability Scale, the Functional Assessment of MS Quality of Life Rating Scale and the presence of fatigue (p < 0.05). Conclusions: The degree of functional impairment is a determinant for the presence of fatigue in MS patients, but respiratory function and inflammatory markers are not.