Pediatric acquired demyelinating syndromes: a nationwide validation study of the Danish National Patient Register

Neonatal outcomes in women with Multiple Sclerosis - Influence of disease activity: A Danish nationwide cohort study

BACKGROUND

Maternal Multiple Sclerosis (MS) has been associated with an increased risk of adverse birth outcomes. We hypothesized that active disease during conception and pregnancy plays an important role in this context, which this study aims to address.

METHODS

We used the Danish registers to conduct a nationwide cohort study. Information on maternal disease activity during pregnancy was retrieved using proxies from the linked registers (hospitalization, magnetic resonance imaging of the brain, and use of systemic corticosteroids during pregnancy). Neonates, exposed in utero to maternal disease activity constituted the exposed cohort and the unexposed cohort constituted neonates without in utero exposure to maternal disease activity. The examined outcomes were preterm birth, small for gestational age, low 5-minute Apgar score, and major congenital anomalies. In logistic regression models we estimated the odds ratios (OR) with adjustment for confounders such as maternal age, comorbidities, parity, smoking, calendar year of birth, and disease-modifying treatment.

RESULTS

Among the study population of 2492 children of mothers with MS we identified 273 (11 %) neonates exposed to maternal disease activity during pregnancy, and 2219 (89 %) neonates without exposure to disease activity. The adjusted odds ratios (aOR) for preterm birth, small for gestational age, low 5-minute Apgar score, and major congenital anomalies among children born to women with disease activity during pregnancy were 0.92 (95 % confidence interval (95 % CI) 0.53-1.60), aOR 1.19 (95 % CI 0.62-2.26), aOR 2.57 (95 % CI 0.93-7.15) and aOR 0.93 (95 % CI 0.48-1.83), respectively.

CONCLUSIONS

Women with MS having disease activity during pregnancy did not have a statistically significantly increased risk of adverse neonatal outcomes compared to women with MS without disease activity, which is overall reassuring results. We believe, that this will be useful knowledge for patients and clinicians in planning a pregnancy and preparing a birth plan.

Clinical outcomes and Anti-MOG antibodies in pediatric optic neuritis: A prospective observational study

OBJECTIVES

The objective of this study was to look at the clinical outcomes, and to determine the proportion of children with visual recovery after the first demyelinating event of optic neuritis (ON).

METHODOLOGY

In this observational study, children with the first clinical event of optic neuritis at an age less than 18 years were evaluated. High-contrast visual acuity, colour vision, Expanded Disability Status Scale (EDSS), Anti-MOG and AQP-4 antibodies were assessed.

RESULTS

Of the 55 screened, 45 children (77 eyes), median age-98 months, 30 (67%) bilateral were enrolled. Fifty of 77 eyes (67%) had Snellen visual acuity less than 6/60. Twelve children (27%) were MOG seropositive and 3 had AQP-4 positivity. At median follow up of 35 months, 10 (22%) children had one or more relapses. At follow up, the median (IQR) visual acuity improved from nadir of 2.1 (1-2.7) logMAR to 0 (0-0.18) logMAR and 64/77 eyes (83%) had visual recovery. The diagnosis at last follow up was isolated ON in 39/45 (86.6%), relapsing ON (5, 11%), AQP-4 positive NMOSD (3, 7%), MOG antibody associated demyelination (12, 27%), dual seronegative ON (30,67%) and Multiple sclerosis (1, 2%).

CONCLUSIONS

Most children with first demyelinating event as ON have a monophasic illness. Despite severe acute-phase visual loss, most eyes with ON will recover good visual functions. The risk of AQP-4 disease and multiple sclerosis is low in this group.

Accuracy of International Classification of Diseases Codes for Identifying Acute Optic Neuritis

BACKGROUND

The accuracy of International Classification of Diseases (ICD) codes for identifying cases of acute optic neuritis (aON) is not known. A prior study reported 61% accuracy for ICD code plus MRI consistent with aON within 2 months. This study determined accuracy for ICD code plus MRI within 2 months regardless of results.

METHODS

Retrospective chart review was conducted using a medical record research repository of a tertiary care institution from 1998 to 2019. Subjects with ICD-9/10 codes for ON and an MRI brain and/or orbits within 2 months of earliest (initial) ICD code were included. MRI was classified as positive or negative for aON based on report noting gadolinium-contrast enhancement. Clinical diagnosis at the time of initial code was classified as aON, prior ON, considered ON, alternative diagnosis, or unknown based on review of physician authored clinical notes within 7 days of the initial code. Accuracy of ICD code for aON, acute or prior ON, and acute, prior, or considered ON were calculated for all subjects and stratified based on MRI result.

RESULTS

Two hundred fifty-one subjects had MRI results within 2 months of their initial ON ICD code (49 positive MRI [previously reported]; 202 negative MRI). Among those with negative MRI, 32 (16%) had aON, 40 (20%) had prior ON, 19 (9%) considered ON as a diagnosis, 92 (46%) had other confirmed diagnoses, and 19 (9%) had unknown diagnosis at time of code. Considering all subjects, accuracy for ICD code was 25% for acute ON, 41% for acute or prior ON, and 48% for acute, prior, or considered ON. Positive MRI, increased number of ON ICD codes, a code given by an ophthalmologist or neurologist within 2 months, and the presence of a neurology encounter within 2 months were associated with an increased accuracy for clinical aON diagnosis.

CONCLUSIONS

In the setting of an MRI within 2 months, ICD codes for ON have low accuracy for acute ON and only slightly better accuracy for acute or prior ON. Accuracy is higher for cases with a positive MRI than those with a negative MRI, suggesting positive MRI in conjunction with ICD codes may help more accurately identify cases. Reliance on ICD and Current Procedural Terminology codes alone to identify aON cases may introduce substantial misclassification bias in claims-based research.

Incidence of Pediatric Acute Disseminated Encephalomyelitis During the Coronavirus Disease 2019 Pandemic in South Korea

BACKGROUND

Acute disseminated encephalomyelitis (ADEM) is an immune-mediated demyelinating disorder of the central nervous system that is usually triggered by infections. We aimed to determine the temporal trends in the incidence of ADEM before and during the pandemic and their correlation with viral epidemiology.

METHODS

We conducted a nationwide, population-based, retrospective, ADEM cohort study by using the Health Insurance Review and Assessment Service database. New-onset ADEM was defined as a patient (age <19 years) who was hospitalized with a diagnostic code of G04.0, G36.8, and G36.9 and a prescription of intravenous methylprednisolone. The National Infectious Disease Surveillance System was used to collect the nationwide viral epidemics.

RESULTS

A total of 185 new-onset pediatric ADEM cases were included. The mean patient age was 7.0 ± 4.9 years. The incidence of ADEM was 0.34 to 0.48 of 100,000 persons per year before the pandemic, which dropped to 0.22 of 100,000 persons per year during the first pandemic year. The risk of ADEM occurrence was approximately 1.74% higher during the prepandemic years compared with the first pandemic year (odds ratio = 1.017, P = 0.009). There was a weak positive correlation between acute respiratory viral infection and ADEM incidence (r = 0.28, P = 0.03).

CONCLUSION

This study demonstrates how infection control during the early coronavirus disease 2019 (COVID-19) pandemic influenced the incidence of ADEM. The low incidence of ADEM in the early COVID-19 pandemic may be related to the decline in acute respiratory viral infections, which are potential triggers of ADEM.

Neuromyelitis optica spectrum disorders: a review with a focus on children and adolescents

Neuromyelitis optica spectrum disorder (NMOSD) is a rare and severe inflammatory disorder of the central nervous system (CNS). It is strongly associated with anti-aquaporin 4 antibodies (AQP4-IgG), and it mainly affects young women from non-white ethnicities. However, ∼ 5 to 10% of all cases have onset during childhood. Children and adolescents share the same clinical, radiologic, and laboratory presentation as adults. Thus, the same NMOSD diagnostic criteria are also applied to pediatric-onset patients, but data on NMOSD in this population is still scarce. In seronegative pediatric patients, there is a high frequency of the antibody against myelin oligodendrocyte glycoprotein (MOG-IgG) indicating another disease group, but the clinical distinction between these two diseases may be challenging. Three drugs (eculizumab, satralizumab, and inebilizumab) have been recently approved for the treatment of adult patients with AQP4-IgG-positive NMOSD. Only satralizumab has recruited adolescents in one of the two pivotal clinical trials. Additional clinical trials in pediatric NMOSD are urgently required to evaluate the safety and efficacy of these drugs in this population.

School performance and psychiatric comorbidity in childhood absence epilepsy: A Danish cohort study

The aim was to determine school performance and psychiatric comorbidity in children with childhood absence epilepsy (CAE). We reviewed the medical records in children with ICD-10 codes for idiopathic generalized epilepsy before 18 years of age, and pediatric neurologists confirmed the International League Against Epilepsy criteria for CAE were met. Control groups were the general pediatric population or children with non-neurological chronic disease. Outcomes were from nationwide and population-based registers on school performance and psychiatric comorbidity. We compared the mean grade point average using linear regression and estimated hazard ratios (HR) using Cox regression for the other outcomes. Analyses were adjusted for the child's sex, and year of birth, and parental highest education, receipt of cash benefits or early disability pension. We included 114 children with CAE with a median age at onset of 5.9 years (interquartile range = 4.5-7.3 years). Compared with both population controls and non-neurological chronically ill children, children with CAE had increased hazard of special needs education (HR = 2.7, 95% confidence interval (CI) = 1.8-4.1, p < 0.0001), lower grade point average at 9th grade by 1.7 grade points (95% CI = -2.5 to -1.0, p < 0.001), increased ADHD medicine use (HR = 4.4, 95% CI = 2.7-7.2, p < 0.001), increased sleep medicine use (HR = 2.7, 95% CI = 1.7-4.3, p < 0.001), and increased psychiatry visits (HR = 2.1, 95% CI = 1.1-4.0, p = 0.03). In conclusion, children with CAE have increased psychiatric comorbidity and a considerable proportion of these children receive special needs education in primary/secondary school, albeit insufficient to normalize their considerably lower grade point average in the 9th grade.

Spectrum of pediatric acquired demyelinating syndromes (PADS) of the central nervous system in a tropical developing country: A 10-year retrospective study

BACKGROUND

Epidemiological data on the pediatric acquired demyelinating syndromes (PADS) in the Philippines has not been described previously in the literature. There may be geographic differences in frequencies of PADS where true disease burden is not known or underestimated in resource-limited settings due to lack of case recognition and/or diagnostic facilities. The purpose of this study was to determine the frequencies and clinical characteristics of the different subtypes of PADS at our institution and compare these with those in published literature.

METHODS

We conducted a retrospective cross-sectional study of children diagnosed with PADS who were admitted at the Philippine General Hospital from January 2009 to December 2018. Charts of these patients were reviewed to determine frequencies, clinical profile, diagnostic findings and outcomes.

RESULTS

A total of 77 patients were identified with PADS using the appropriate diagnostic criteria. The frequencies of the PADS subtypes were the following: transverse myelitis (n = 21; 27.3 %); acute disseminated encephalomyelitis (n = 20, 26.0 %); multiple sclerosis (n = 17, 22.1 %); optic neuritis (n = 13, 16.9 %); clinically isolated syndrome (n = 4, 5.2 %); and neuromyelitis optica spectrum disorder (n = 2, 2.6 %). Overall, the mean age at initial event and at diagnosis were 10.6 ± 4.6 years. Female:male ratio was 1.02:1. On admission, the majority of patients had motor paralysis (n = 49, 63.6 %) while several patients manifested with sensory deficits (n = 31, 40.3 %), visual changes (n = 26, 33.8 %) and brainstem involvement (n = 20, 26.0 %). Nearly all patients had evidence of lesions in magnetic resonance imaging (n = 72, 93.5 %) located in spinal cord (n = 25; 32.5 %), cerebral white matter (n = 24; 31.2 %), and optic nerve (n = 12, 15.6 %). Among patients who underwent cerebrospinal fluid analysis (n = 34), 7 patients had abnormal findings (20.6 %). The most utilized treatment regimens during admission were intravenous methylprednisolone (n = 53, 68.8 %) and oral prednisone (n = 43, 55.8 %). The majority had partial recovery (n = 56, 72.7 %) and 16 experienced full recovery (20.8 %) at discharge. Five patients died (6.5 %).

CONCLUSIONS

Our study provided the first comprehensive summary on the clinical features of children with PADS admitted in a Philippine tertiary hospital with limited resources. Our study highlights the value of using clinical diagnostic criteria in improving case recognition especially in low-and middle-income countries. Regional disparities in disease burden warrant international registries with wider geographic representation in order to come up with diagnostic and management guidelines suitable for various levels of care.

School performance and psychiatric comorbidity in juvenile absence epilepsy and juvenile myoclonic epilepsy: a Danish population-based cohort study

BACKGROUND

We aimed to determine school performance and psychiatric comorbidity in juvenile absence epilepsy (JAE), juvenile myoclonic epilepsy (JME), and generalized tonic-clonic seizures (GTCS) alone.

METHODS

All children (< 18 years) fulfilled International League Against Epilepsy criteria after review of their medical records. Control groups were the pediatric background population or children with non-neurological chronic disease. Outcomes were on school performance and psychiatric comorbidity. We compared mean grade point averages using linear regression and estimated hazard ratios using Cox regression in the remaining analyses. We adjusted for the child's sex, age, and year of birth; and parental highest education, receipt of cash benefits or early retirement.

RESULTS

We included 92 JAE, 190 JME, 27 GTCS alone, 15,084 non-neurological chronic disease controls, and population controls. JAE had two times increased hazard for special needs education compared with age-matched population controls (hazard ratio 2.2, 95% CI = 1.1‒4.6, p = 0.03); this was not seen in JME. Compared with population controls, both JAE and JME had lower grade point average in secondary and high school (JME: 9th grade:  - 0.5 points, 95% CI = -0.9 to -0.06, p = 0.03; high school:  - 0.6 points, 95% CI = -1.3 to -0.1, p = 0.04), and 8% fewer JME and 15% fewer JAE attended high school. Both JME and JAE had higher hazard for redeeming sleep medication compared with non-neurological chronic disease; additionally, JAE had increased hazard for ADHD medicine redemptions.

CONCLUSIONS

Both JAE and JME had marginally poorer school performance; performance seemed worse in JAE than in JME. Both JAE and JME had increased use of sleep medication.

Employment, health visits, mental health, and mortality in parents with a chronically ill child: a Danish nationwide population-based cohort study

Chronic diseases in children can impact their parents; this may be overlooked in a clinical setting. Our aim was to investigate associations of chronic diseases in children with their parents' employment, health care utilization, mental health, and mortality. In a matched cohort study using nationwide and population-based data in Denmark, we included parents to children (< 18 years) with acute disseminated encephalomyelitis, multiple sclerosis, type 1 diabetes, inflammatory bowel disease, and rheumatoid arthritis/juvenile idiopathic arthritis during 2008-2015. The reference group was parents to unaffected children. Outcomes were parental employment (early retirement, cash benefits, income), health care utilization (e.g., general practitioner, or hospital visits), mental health (visits to psychiatry/psychology clinics, antidepressant drug redemptions), and mortality. We included 13,769 parents with a chronically ill child and 138,606 control parents. Annual income was unaffected for two-parent families after the child's disease onset, but two-parent families had increased hazard of early retirement of 25% (95% CI = 1.01-1.54; p = 0.04). Parents with a chronically ill child had (a) increased rate of antidepressant drug redemptions or psychology/psychiatry visits (hazard ratio 1.37; 95% CI = 1.28-1.46 at 1-year follow-up); (b) increased health care utilization, with an increased marginal mean in primary care of 1% (95% CI = 1.00-1.02; p = 0.005), hospital-affiliated visits of 19% (95% CI = 1.14-1.24; p < 0.0001), and hospital admissions of 14% (95% CI = 1.09-1.20; p < 0.0001); and (c) 69% increased mortality hazard (95% CI = 1.30-2.18; p < 0.0001) in parents younger than 50 years with no comorbidities, albeit small in absolute numbers.

CONCLUSION

Pediatric chronic diseases were negatively associated with parental employment, mental health, and mortality, and increased health care utilization.

WHAT IS KNOWN

• Studies on the impact of pediatric chronic diseases on parental health are qualitative. • Knowledge is unavailable regarding the impact on parental work, health care utilization, and mortality.

WHAT IS NEW

• Among 13,769 parents with a chronically ill child and 138,606 control parents, parents with a chronically ill child had 37% increased antidepressant drug redemptions, and these parents <50 years without comorbidities had 69% increased mortality hazard. • Medical doctors should consider the parental health condition and societal challenges related to having child with a chronic disease.

Magnetic resonance imaging criteria at onset to differentiate pediatric multiple sclerosis from acute disseminated encephalomyelitis: A nationwide cohort study

BACKGROUND

MRI of the nervous system is the critical in distinguishing pediatric MS from acute disseminated encephalomyelitis (ADEM). Our aim was to propose MRI criteria to distinguish MS from monophasic ADEM based on the first MRI and to validate previously proposed MRI criteria.

METHODS

A neuroradiologist undertook retrospective evaluation of the MRI at the first demyelinating event in children (<18 years) with medical record-validated MS and ADEM in Denmark during 2008-15. We used forward stepwise logistic regression to identify MRI categories that differed significantly between MS and ADEM. We estimated accuracy statistics for all MRI criteria to distinguish MS from ADEM.

RESULTS

The monophasic ADEM cohort (n=46) was nationwide and population-based during 2008-15; the median age at onset of 5.3 years (range 0.8‒17.2) and children had at least five years of follow-up to ensure a monophasic disease course. Children with MS (n=67) had a median age at onset of 16.3 years (range 3.3‒17.9). Having at least two categories best distinguished MS from monophasic ADEM by an area under the curve of 83% to 89%: (a) corpus callosum long axis perpendicular lesion; (b) only well-defined lesions; (c) absence of basal ganglia or thalamus lesion OR, (a) corpus callosum long axis perpendicular lesion; (b) only well-defined lesions; (c) absence of diffuse large lesions; (d) black holes. The Callen, KIDMUS, and IPMSSG criteria performed well. The McDonald 2017, Barkhof, MAGNIMS, and Verhey criteria had poorer performance.

CONCLUSION

This study provides Class II evidence that MRI has good performance in differentiating MS from monophasic ADEM at onset.

Validation of MRI radiological reports in pediatric MS according to the McDonald 2017 criteria: A Danish nationwide multicenter cohort study

BACKGROUND

MRI allows demonstration of dissemination in space and time at the first demyelinating event. However, no pediatric MS study has investigated the validity of MS-specific outcomes described in MRI radiological reports that clinicians rely on to make the MS diagnosis and to assess the MS treatment effect. Our aim was to validate MS-specific outcomes in hospital MRI reports in pediatric MS by comparing MS-specific outcomes in MRI reports with secondary MRI review.

METHODS

A senior consultant and a resident neurologist extracted data on MS-specific outcomes from MRI reports at baseline and follow-up in children with MS onset during 2008-15 in Denmark. Gold standard was an expert neuroradiologist's secondary MRI review. We estimated percent agreement and Kappa values by comparing data extracted from hospital MRI reports (what we wanted to test) with results from the secondary MRI reviews (our gold standard).

RESULTS

Among 55 children with MS, we included 44 baseline and 48 follow-up MRIs. The median age at MS onset was 16.3 years (range 9.2‒17.9). Agreement between the MRI reports and the secondary MRI review ranged 68%-100% for MS-specific outcomes; agreement was higher when MRI outcomes were present. Kappa values ranged from 0.42 ("moderate") to 1.00 ("excellent"). Kappa for fulfillment of the McDonald 2017 criteria was 0.60 on baseline MRI, and 0.53 on follow-up MRI. Kappa for a new lesion on follow-up MRI was 0.41.

CONCLUSION

Agreement was moderate to good for most MS-specific outcomes between MS neurologists' data extraction from hospital MRI radiological reports compared with a neuroradiologist's secondary MRI review. The agreement was moderate for both fulfilling the McDonald 2017 criteria and acquiring a new lesion on follow-up MRI. We recommend structured MRI reporting in children suspected of acquired demyelinating syndromes to increase validity of hospital MRI reports and clinical use.

Acute Demyelinating Syndromes: A report of child neurology department of Sfax University Hospital

INTRODUCTION

The yearly incidence of Acute Demyelinating Syndromes (ADS) in a multiethnic cohort of children published by Langer-Gould and al in 2011 was estimated at about 1.66 per 100,000. Nevertheless, the real incidence for these disorders is still underestimated as the iterative revision for diagnosis criteria have failed to classify a significant number of children with ADS.

PURPOSE

This work was aimed to describe clinical and paraclinical characteristics of ADS in a pediatric population.

MATERIAL AND METHODS

Demographic, clinical and paraclinical data of 42 children (24 females; 18 male; SR = 1.33), were collected from the medical records of patients admitted to the child neurology department of Sfax University Hospital between 2008 and 2021 for clinical events with presumed inflammatory origin. Next, patients were categorized as per M. N. Nouri and al. up dated classification for ADS. Finally, characteristics of different ADS categories were compared.

RESULTS

The mean age onset was 6 years (± 3.5 years). For a mean follow-up period of 28 months, 69% of patients had a monophasic course. ADS in our pediatric population were Acute disseminated encephalomyelitis (ADEM) (36%), Clinically isolated syndrome (CIS) (24%), Multiple sclerosis (MS) (19%), Neuromyelitis optica spectrum disorder (NMOSD) (7%), Myelin oligodendrocyte glycoprotein antibodies-associated diseases (MOGAD) (2%) and Recurrent demyelinating disease not otherwise specified (RD-NOS) (10%). At presentation, patients showed different clinical picture according to ADS-subtype with more patients with epileptic seizure in ADEM-group (53.3%), optic neuritis in CIS-group (70%), motor deficit in MS-group (62.5%), area postrema syndrome in NMOSD-group (33.3%) and vesico-sphincter dysfunction in RD-NOS-group (75%). Among patients presenting with visual impairment (21.4%), Visual evoked potential (VEP) guided the diagnosis of NMOSD in 22.2% by objectifying axonal optic nerve damage. Different ADS subtypes were identified according to MRI results in 100% of ADEM-patients and 75% of MS-patients and on antibody testing in three patients. The ADS-subtype was recognized based on antibody testing in three patients. Two patients from CIS-group: the first with isolated optic neuritis (ON) was positive for antiaquaporin 4 antibodies (anti-AQP4) and the other with clinically polyfocal ADS was positive for antinuclear antibodies (ANA) type anti-RNP. The remaining patients who presented with ADEM-phenotype was positive for anti-myelin oligodendrocyte glycoprotein (anti-MOG).

SIGNIFICANCE

Recognizing distinctive features of each ADS category may improve diagnosis accuracy as well as the indication of suitable treatment.

Management of pediatric post-infectious neurological syndromes

BACKGROUND

Post-Infectious Neurological Syndromes (PINS) are heterogeneous neurological disorders with post or para-infectious onset. PINS diagnosis is complex, mainly related to the absence of any recognized guidelines and a univocal definition.

AIM OF THE STUDY

To elaborate a diagnostic guide for PINS.

MATERIALS AND METHODS

We retrospectively analysed patients younger than 14 years old admitted to Bambino Gesù Children's Hospital in Rome for PINS from December 2005 to March 2018. Scientific literature using PubMed as research platform was analysed: the key words "Post-Infectious Neurological Syndromes" were used.

RESULTS

A polysymptomatic presentation occurred in a percentage of 88% of the children. Motor signs and visual disturbances the most observed symptoms/signs were the most detached, followed by fever, speech disturbances, sleepiness, headache and bradipsychism. Blood investigations are compatible with inflammation, as a prodromal illnesses was documented in most cases. Normal cerebral spinal fluid (CSF) characteristics has been found in the majority of the study population. Magnetic resonance imaging (MRI) was positive for demyelinating lesions. Antibiotics, acyclovir and steroids have been given as treatment.

DISCUSSION

We suggest diagnostic criteria for diagnosis of PINS, considering the following parameters: neurological symptoms, timing of disease onset, blood and CSF laboratory tests, MRI imaging.

CONCLUSIONS

We propose criteria to guide clinician to diagnose PINS as definitive, probable or possible. Further studies are required to validate diagnostic criteria.

Magnetic resonance imaging at baseline and follow-up to differentiate between pediatric monophasic acquired CNS demyelination and MS

BACKGROUND

It is essential to distinguish acute disseminated encephalomyelitis (ADEM) from MS early. Our aim was to determine MRI features at baseline and follow-up to distinguish pediatric ADEM from MS stratified according to age at onset.

METHODS

Using hospital ICD-10 codes for acquired demyelinating syndromes from a nationwide register and subsequent chart review, we identified 52 children (<18 years) with ADEM and 66 children with MS. We undertook a retrospective analysis of MRI scans at onset and at follow-up. The MRI rater was a senior neuroradiologist blinded to clinical characteristics.

RESULTS

At baseline, children with ADEM had more diffuse poorly demarcated lesions, particularly in the basal ganglia/thalamus (p = 0.001) and cerebellar peduncles (p < 0.0001). Further, longitudinal extensive transverse myelitis was strongly associated with ADEM (p<0.0001). Children with ADEM had fewer contrast-enhancing lesions (p = 0.0004), occipital lesions (p = 0.01), optic nerve lesions (p = 0.01), periventricular lesions, well-defined lesions only (p<0.0001), and fewer fulfilled dissemination in time according to the McDonald 2017 criteria (p = 0.005). On baseline MRI, dissemination in space and time was fulfilled in 17% of children with ADEM and in 34% of children with MS (p = 0.06), and 60% of children with ADEM fulfilled the criterion for dissemination in space. The mean time from baseline MRI to follow-up MRI was 1.0 year for children with ADEM and 2.1 years for children with MS. On follow-up MRI, 85% of children with ADEM had partial or complete T2 lesion resolution, but in the 58% without complete resolution lesions were predominantly frontal. Only 47% of children with MS had partial or complete T2 lesion resolution, and therefore more MRI features differed between children with ADEM and MS on follow-up. MRI had the greatest distinguishing value after age 11 years because MS is exceptional in the first decade of life.

CONCLUSION

Age at onset and the timing of MRI in relation to disease onset are critical in the interpretation of MRI to distinguish between ADEM and MS.

School performance, psychiatric comorbidity, and healthcare utilization in pediatric multiple sclerosis: A nationwide population-based observational study

Background:

Pediatric multiple sclerosis (MS) may hamper educational achievements due to psychiatric comorbidity and cognitive impairment. Our aims were to investigate school performance, psychiatric comorbidity, and healthcare utilization following pediatric MS and to differentiate between disability in MS and that arising from a non-brain-related chronic disease.

Methods:

We included all children (<18 years) with MS onset during 2008–2015 in Denmark with a medical record–validated MS diagnosis. The control groups were children from the general population or children with non-brain-related chronic diseases. Outcomes were register-based on 9–12 grade point average, psychiatric comorbidity, and healthcare visits.

Results:

Cohorts were children with MS ( n = 92), control children matched to children with MS ( n = 920), children with non-brain-related chronic diseases ( n = 9108), and “healthy” children with neither MS nor brain-related chronic disease ( n = 811,464). School performance in grades 9–12 was similar, but children with MS compared to those with non-brain-related chronic disease had an almost doubled hazard for psychiatric comorbidity (hazard ratio = 1.87; 95% confidence interval = 1.38–2.53; p < 0.0001) and a higher rate of all hospital visits ( p < 0.0001) but a lower rate of hospital admissions ( p = 0.001).

Conclusion:

Children with MS have a seemingly standard school performance but increased psychiatric comorbidity and a high rate of healthcare utilization.

Prevalence of mental disorders is higher in patients with multiple sclerosis than in the general population or in patients with rheumatoid arthritis in France

Background

Mental disorders (MDs) in multiple sclerosis (MS) patients decreases treatment adherence and quality of life, and increases the risk of disability progression and care consumption.

Objective

This study was to assess the prevalence of MDs in MS patients compared with healthy controls (HC) of the French general population and rheumatoid arthritis (RA) patients.

Methods

The 2015 prevalence of MDs for MS patients, RA patients and general population was estimated using a random population-based data sample from ‘National Inter-Scheme Information System on Health Insurance’ in the 2011–2015 period. Two control groups (1:5 ratio for the HC and 1:1 for the RA group) were matched to the MS group for year of birth, gender, area of residence and health insurance scheme.

Results

A total of 1145 MS patients were identified (sex ratio of 2.5 (F/M); median age 50 years). The prevalence of MDs was higher in the population of patients with MS (37.3%) than in the French general population (13.6%), and to a lesser extent in the RA group (21.1%) leading to the prevalence ratios of 2.8 (95% confidence intervals (CIs) 2.5–3.0) and 1.9 (95% CI 1.7–2.3), respectively.

Conclusions

This study confirmed that MS patients are at a higher risk of MDs than the French general population or RA patients.

Validity of International Classification of Diseases Codes for Identifying Neuro-Ophthalmic Disease in Large Data Sets: A Systematic Review

BACKGROUND

Administrative health claims data have been used for research in neuro-ophthalmology, but the validity of International Classification of Diseases (ICD) codes for identifying neuro-ophthalmic conditions is unclear.

EVIDENCE ACQUISITION

We performed a systematic literature review to assess the validity of administrative claims data for identifying patients with neuro-ophthalmic disorders. Two reviewers independently reviewed all eligible full-length articles and used a standardized abstraction form to identify ICD code-based definitions for 9 neuro-ophthalmic conditions and their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). A quality assessment of eligible studies was also performed.

RESULTS

Eleven articles that met criteria for inclusion are as follows: 3 studies of idiopathic intracranial hypertension (PPV 54%-91% and NPV 74%-85%), 2 studies of giant cell arteritis (sensitivity 30%-96% and PPV 94%), 3 studies of optic neuritis (sensitivity 76%-99%, specificity 83%-100%, PPV 25%-100%, and NPV 98%-100%), 1 study of neuromyelitis optica (sensitivity 60%, specificity 100%, PPV 43%-100%, and NPV 98%-100%), 1 study of ocular motor cranial neuropathies (PPV 98%-99%), and 2 studies of myasthenia gravis (sensitivity 53%-97%, specificity 99%-100%, PPV 5%-90%, and NPV 100%). No studies met eligibility criteria for nonarteritic ischemic optic neuropathy, thyroid eye disease, and blepharospasm. Approximately 45.5% provided only one measure of diagnostic accuracy. Complete information about the validation cohorts, inclusion/exclusion criteria, data collection methods, and expertise of those reviewing charts for diagnostic accuracy was missing in 90.9%, 72.7%, 81.8%, and 36.4% of studies, respectively.

CONCLUSIONS

Few studies have reported the validity of ICD codes for neuro-ophthalmic conditions. The range of diagnostic accuracy for some disorders and study quality varied widely. This should be taken into consideration when interpreting studies of neuro-ophthalmic conditions using administrative claims data.

Epidemiology of Pediatric NMOSD in Germany and Austria

Background: Neuromyelitis optica spectrum disorders (NMOSD) are severe inflammatory demyelinating disorders of the central nervous system mainly characterized by recurrent episodes of uni- or bilateral optic neuritis (ON), transverse myelitis (TM) and brainstem syndromes (BS). The majority of adult patients has serum antibodies directed against the water channel protein aquaporin 4 (AQP4-abs). In pediatric patients, AQP4-abs are less, while antibodies against myelin oligodendrocyte glycoprotein (MOG-abs) are more frequently detectable than in adults. Some children with NMOSD have neither AQP4- nor MOG-ab (double-seronegative).

Objective: Evaluation of epidemiological data regarding incidence and prevalence of pediatric NMOSD in Germany and Austria.

Methods: We recruited pediatric NMOSD patients between 1 March 2017 and 28 February 2019 with five different tools: (1) ESPED (Surveillance Unit for Rare Pediatric Disorders in Germany), (2) ESNEK (Surveillance for Rare Neurological Disorders during Childhood), (3) pediatric neurology working group within the Austrian Society of Pediatrics and Adolescent Medicine, (4) BIOMARKER Study and (5) NEMOS (Neuromyelitis optica Study Group). We requested data regarding clinical symptoms, antibody status, therapy regimen and response via a standardized questionnaire.

Results: During the 2-year recruitment period, 46 (both incidental and prevalent) patients with a suspected diagnosis of NMOSD were brought to our attention. Twenty-two of these patients did not fulfill the inclusion criteria. Of the remaining 24 children, 22 had a median age at onset of 11 (range 3–17) years and 16/22 were female (72.7%) (no data in two patients). Sixteen of 24 patients were AQP4-ab positive (67%), 4/24 MOG-ab positive (16.7%), three children were double-seronegative and in one patient no antibody testing was done. We calculated an incidence rate of 0.022 per 100,000 person-years for Germany, while there was no incidental case in Austria during the recruitment period. The prevalence rate was 0.147 and 0.267 per 100,000 persons in Germany and Austria, respectively.

Conclusion: Pediatric NMOSD, with and without associated antibodies, are very rare even considering the different limitations of our study. An unexpected finding was that a considerable proportion of patients was tested neither for AQP4- nor MOG-abs during diagnostic work-up, which should prompt to establish and disseminate appropriate guidelines.

Diagnostic Value of Oligoclonal Bands in Children: A Nationwide Population-Based Cohort Study

OBJECTIVE

We evaluated the diagnostic value of cerebrospinal fluid oligoclonal bands in individuals less than 18 years of age.

METHODS

In a nationwide population-based setting, we retrieved data on 2055 children's oligoclonal band examination, including concordant cerebrospinal fluid biomarkers, during 1994 to 2017. Case ascertainment was by review of medical records and diagnostic codes. We used Fisher's exact test to explore distribution differences of oligoclonal band positivity in acquired demyelinating syndromes (ADS) before and after age 12 years and calculated the sensitivity, specificity, positive predictive value, and negative predictive value of oligoclonal bands to distinguish ADS from the other diagnostic groups.

RESULTS

Median age at oligoclonal band examination was 15.2 years (range = 1.8 to 18.0), and 10% had presence of cerebrospinal fluid oligoclonal bands. Oligoclonal band positivity was the highest in ADS (52%), but it was age dependent: 21% in children with ADS before age 12 years and 68% in children aged 12 through 17 years (P < 0.0001) owing to the higher incidence of multiple sclerosis in the latter. Cerebrospinal fluid oligoclonal bands were not predictive of ADS before age 12 years compared with the other diagnostic groups. However, cerebrospinal fluid oligoclonal bands in children aged 12 through 17 years were highly predictive of ADS compared with central nervous system infections and non-ADS immune-mediated central nervous system diseases (positive predictive value: 0.89; 95% confidence interval = 0.82 to 0.94; P < 0.0001), but negative oligoclonal bands were not discriminatory (negative predictive value: P = 0.17).

CONCLUSIONS

In a clinical setting, cerebrospinal fluid oligoclonal band examination may be of higher yield in children aged 12 through 17 years if there is clinical suspicion of multiple sclerosis, and in such circumstances a positive test supports a diagnosis of multiple sclerosis.

Pediatric autoimmune encephalitis in Denmark during 2011-17: A nationwide multicenter population-based cohort study

BACKGROUND

The incidence of pediatric autoimmune encephalitis (AIE) is unknown. Our aim was to assess the incidence of pediatric AIE in Denmark 2011-17.

METHODS

In a nationwide population-based setting, we retrieved data on all children tested for AIE before age 18 years. We reviewed medical records in a) children with AIE antibodies (n = 18) to assess whether children fulfilled the AIE consensus criteria, b) children tested negative for AIE antibodies who were registered with an AIE diagnostic code to estimate the incidence of "antibody negative but probable AIE", and c) a reference cohort (n = 596) to determine the positive predictive value of International Classification of Diseases (ICD) codes used for anti-NMDAR encephalitis.

RESULTS

375 children were tested for AIE 2011-17 (median age 11.1 years; 54% girls); 18 children (5%) had AIE antibodies (percentage tested positive): CSF GAD₆₅-IgG (3.1%), plasma NMDAR-IgG (2.8%), CSF NMDAR-IgG (1.8%), plasma GAD₆₅-IgG (1.0%), and plasma CASPR2-IgG (0.4%). Five children fulfilled the criteria for probably/definite anti-NMDAR encephalitis (incidence: 0.07/100,000 person-years; 95% CI = 0.03-0.17), and 4 children with anti-GAD₆₅ associated AIE (incidence = 0.055/100,000 person-years, 95% CI = 0.021-0.15). The incidence of "antibody negative but probable AIE" was 0.055/100,000 person-years (95% CI = 0.021-0.15). The positive predictive value of ICD diagnostic codes used for anti-NMDAR encephalitis was 8%.

CONCLUSIONS

We diagnosed only children with anti-NMDAR, anti-GAD₆₅, and "antibody negative but probable AIE". Before examining AIE antibodies, clinical presentation, paraclinical studies (CSF, EEG, and MRI), and incidence of pediatric AIEs should be considered. Updating the ICD to include AIE codes is warranted.

Pediatric acquired demyelinating syndrome (ADS) in inpatient hospital settings: The hospitalization rate, costs, and outcomes in the US

BACKGROUND

Although relatively rare among pediatric patients, acquired demyelinating syndromes of the central nervous system (ADS) is a potentially disabling condition that warrants hospitalization and long-term follow-up. As such, a better understanding of the epidemiology and hospital utilization for this condition could provide critical information for health care planning and resource allocation.

OBJECTIVE

To evaluate the trends of hospital utilization and resource use associated with pediatric ADS in the US.

METHOD

We conducted a serial cross-sectional trend analysis with complex sampling and weighting using nationally representative hospital discharge records, from the Kids´ Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality coded with International Classification of Diseases (Healthcare Cost and Utilization Project (HCUP) 2018), Ninth Revision (ICD-9-CM) for the years 2003, 2006, 2009, and 2012. We also conducted a cross-sectional study for the KID2016 dataset coded with ICD10-CM to estimate the pediatric ADS-related hospital utilization for the year. EXCLUDING TRANSFERRING DISCHARGES: we evaluated the discharge records for those aged 0 to 19 years diagnosed with any of ADS of central nervous systems including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), acute disseminated encephalomyelitis (ADEM), optic neuritis (ON), transverse myelitis (TM) and demyelinating disease not specified (DDNS). For the trend analysis, we used variance-weighted regression and Poisson regression for the annual hospitalization rate, total hospital charges and hospital days associated with the ADS hospitalizations for the year 2003 to 2012.

RESULTS

We estimated a total of 1,292 ADS-related hospitalizations (95%CI: 1127-1,458) in 2003, 2104 hospitalizations (95%CI: 1823-2385) in 2006, 2851 hospitalizations (95%CI: 2499-3203) in 2009, and 3501 hospitalizations (95%CI: 3058-3945) in 2012 among those aged 19 years or younger with diagnoses of ADS. There was an increase in the proportion of the inpatient hospital cost attributed to ADS from 0.06% in 2003 to 0.20% in 2012. The annual hospitalization rates relative to pediatric ADS were 1.59/100,000 (95%CI: 1.51-1.68) in 2003 and 4.21/100,000 (95%CI: 4.07-4.35) in 2012. In the cross-sectional analysis for the year 2016 coded by ICD10-CM, the number of pediatric ADS related hospitalizations were 4,568, constituting 0.30% of the total pediatric hospitalization cost. The annual hospitalization rate for the year 2016 was estimated to be 5.51/100,000.

CONCLUSION

Hospital utilization by pediatric patients with ADS increased during the period 2003 through 2012. The cross-sectional analysis for the year 2016 indicated that the trend could be ongoing, although the direct comparison was not feasible due to the changes in the coding system of the dataset from ICD9-CM to ICD10-CM. Although relatively rare, pediatric ADS warrant long-term follow-ups and hospitalizations, impacting the developmental trajectory of the affected children and the lives of their family members. Th potentially increasing trend of pediatric ADS hospital utilization should be acknowledged when allocating and planning future resources and supporting programs.

Incidence of pediatric neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease in Denmark 2008‒2018: A nationwide, population-based cohort study

BACKGROUND

The incidence of pediatric neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease have not been reported previously. Our aim was to estimate the incidence of pediatric NMOSD and the occurrence of anti-MOG antibody-associated disease in Denmark during 2008-18, and to evaluate the diagnostic usefulness of antibodies against MOG and aquaporin-4 (AQP4) in children <18 years.

METHODS

We undertook a nationwide, population-based, multicenter cohort study using data from the Danish National Patient Register, the Danish Multiple Sclerosis Registry, and laboratories providing anti-AQP4 and anti-MOG antibody analyses. Diagnoses were confirmed by review of the medical records, including blinded MRI review in most children with acute disseminated encephalomyelitis (ADEM).

RESULTS

In children with acquired demyelinating syndromes, anti-AQP4 antibodies were detected in 4% and anti-MOG antibodies in 18%, including in the two children with ADEM who relapsed. We identified four children with NMOSD, equivalent to an incidence of 0.031/100,000 (95% confidence interval = 0.011‒0.082). In anti-MOG antibody-positive children, 32% relapsed during follow-up.

CONCLUSIONS

Pediatric NMOSD and MOG antibody-associated disease are rare, but one-third of anti-MOG-positive children relapsed. In pediatric ADEM, only anti-MOG antibody-positive children relapsed, but the overall risk of relapse after pediatric ADEM was low.

Predictors of treatment outcome in patients with paediatric onset multiple sclerosis

BACKGROUND

Disease-modifying therapies (DMT) are increasingly used for children with multiple sclerosis (MS) even though most double-blinded randomized controlled trials evaluating efficacy, safety and dosing strategy of a specific drug have included adults.

OBJECTIVE

To investigate predictors of treatment outcomes in patients with paediatric onset MS treated with DMTs.

METHODS

Prospective cohort study from the nationwide Danish Multiple Sclerosis Registry including all patients with a MS diagnosis who initiated treatment with an approved DMT before the age of 18 (N = 137) and followed until their 25th birthday. Selected baseline predictors were tested in univariate and multivariate regression models.

RESULTS

Multivariate analyses showed that being female and having disease duration for 2 or more years prior to DMT initiation predicted a higher relapse rate. In addition, disease duration and baseline expanded disability status scale (EDSS) predicted both confirmed disability worsening and improvement. We found no difference in treatment outcome between children with MS onset before and after the age of 13 years.

CONCLUSIONS

The efficacy of DMT in paediatric onset MS patients is comparable to that seen in adult onset MS patients. Earlier treatment start is associated with a beneficial prognosis in the paediatric cohort.