Do Early Relapses Predict the Risk of Long-Term Relapsing Disease in an Adult and Paediatric Cohort with MOGAD?

OBJECTIVE

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) can be monophasic or relapsing, with early relapse being a feature. However, the relevance of early relapse on longer-term relapse risk is unknown. Here, we investigate whether early relapses increase longer-term relapse risk in patients with MOGAD.

METHODS

A retrospective analysis of 289 adult- and pediatric-onset patients with MOGAD followed for at least 2 years in 6 specialized referral centers. "Early relapses" were defined as attacks within the first 12 months from onset, with "very early relapses" defined within 30 to 90 days from onset and "delayed early relapses" defined within 90 to 365 days. "Long-term relapses" were defined as relapses beyond 12 months. Cox regression modeling and Kaplan-Meier survival analysis were used to estimate the long-term relapse risk and rate.

RESULTS

Sixty-seven patients (23.2%) had early relapses with a median number of 1 event. Univariate analysis revealed an elevated risk for long-term relapses if any "early relapses" were present (hazard ratio [HR] = 2.11, p < 0.001), whether occurring during the first 3 months (HR = 2.70, p < 0.001) or the remaining 9 months (HR = 1.88, p = 0.001), with similar results yielded in the multivariate analysis. In children with onset below aged 12 years, only delayed early relapses were associated with an increased risk of long-term relapses (HR = 2.64, p = 0.026).

INTERPRETATION

The presence of very early relapses and delayed early relapses within 12 months of onset in patients with MOGAD increases the risk of long-term relapsing disease, whereas a relapse within 90 days appears not to indicate a chronic inflammatory process in young pediatric-onset disease. ANN NEUROL 2023;94:508-517.

029 The evaluation of pain and pain management in patients with multiple sclerosis

Methods/Results

Data was obtained using The Brief Pain Inventory and Pain Detect questionnaires and clinic letters were reviewed. 63% of MS patients reported pain. Pain was on average 6/10 at worst and 2/10 at best. 30% used simple analgesia, 43% used prescription analgesia with 56% pain relief at best. Pain interfered with activity levels, mood, sleep, relationships, and enjoyment of life. 26% had neuropathic pain and 35% had non-neuropathic pain. Pain was mentioned in 56% of clinic letters for those reporting pain. 36% had a pain management plan documented.

Conclusion

Pain is a prevalent symptom associated with MS that interferes significantly with quality of life. Pain was not always adequately or accurately addressed in MS clinic. To improve management, we suggest pain questionnaires &/or Apps are used to provide ongoing objective pain measures.

vcjwallace@gmail.com

Factors Associated With Relapse and Treatment of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease in the United Kingdom

IMPORTANCE

Longer-term outcomes and risk factors associated with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) are not well established.

OBJECTIVE

To investigate longer-term risk of relapse and factors associated with this risk among patients with MOGAD.

DESIGN, SETTING, AND PARTICIPANTS

This large, single-nation, prospective cohort study was conducted among 276 patients with MOGAD at 5 health care centers in the UK. Data from January 1973 to March 2020 were collected from 146 patients at Oxford and its outreach sites, 65 patients at Liverpool, 32 patients at a children's hospital in Birmingham, 22 patients at a children's hospital in London, and 11 patients at Cardiff, Wales. Data were analyzed from April through July 2020.

MAIN OUTCOMES AND MEASURES

Risk of relapse and annualized relapse rate were evaluated according to different baseline features, including onset age, onset phenotype, and incident vs nonincident group, with the incident group defined as patients diagnosed with antibodies against myelin oligodendrocyte glycoprotein before a second attack. Time to next relapse among patients experiencing relapse was measured and compared between the maintenance therapy subgroup and each first-line treatment group. The no-treatment group was defined as the off-treatment phase among patients who were relapsing, which could occur between any attack or between the last attack and last follow-up.

RESULTS

Among 276 patients with MOGAD, 183 patients were identified as being part of the incident group. There were no differences in mean (SD) onset age between total and incident groups (26.4 [17.6] years vs 28.2 [18.1] years), and female patients were predominant in both groups (166 [60.1%] female patients vs 106 [57.9%] female patients). The most common presentation overall was optic neuritis (ON) (119 patients among 275 patients with presentation data [43.3%]), while acute disseminated encephalomyelitis (ADEM), brain, or brainstem onset was predominant among 69 patients aged younger than 12 years (47 patients [68.1%]), including 41 patients with ADEM (59.4%). In the incident group, the 8-year risk of relapse was 36.3% (95% CI, 27.1%-47.5%). ON at onset was associated with increased risk of relapse compared with transverse myelitis at onset (hazard ratio [HR], 2.66; 95% CI, 1.01-6.98; P = .047), but there was no statistically significant difference with adjustment for a follow-on course of corticosteroids. Any TM at onset (ie, alone or in combination with other presentations [ie, ON or ADEM, brain, or brain stem]) was associated with decreased risk of relapse compared with no TM (HR, 0.41; 95% CI, 0.20-0.88; P = .01). Young adult age (ie, ages >18-40 years) was associated with increased risk of relapse compared with older adult age (ie, ages >40 years) (HR, 2.71; 95% CI, 1.18-6.19; P = .02). First-line maintenance therapy was associated with decreased risk of relapse when adjusted for covariates (prednisolone: HR, 0.33; 95% CI, 0.12-0.92; P = .03; prednisolone, nonsteroidal immunosuppressant, or combined: HR, 0.51; 95% CI, 0.28-0.92; P = .03) compared with the no-treatment group.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that onset age and onset phenotype should be considered when assessing subsequent relapse risk and that among patients experiencing relapse, prednisolone, first-line immunosuppression, or a combination of those treatments may be associated with decreased risk of future relapse by approximately 2-fold. These results may contribute to individualized treatment decisions.

OPTIMISE: MS study protocol: a pragmatic, prospective observational study to address the need for, and challenges with, real world pharmacovigilance in multiple sclerosis

INTRODUCTION

The power of 'real world' data to improve our understanding of the clinical aspects of multiple sclerosis (MS) is starting to be realised. Disease modifying therapy (DMT) use across the UK is driven by national prescribing guidelines. As such, the UK provides an ideal country in which to gather MS outcomes data. A rigorously conducted observational study with a focus on pharmacovigilance has the potential to provide important data to inform clinicians and patients while testing the reliability of estimates from pivotal trials when applied to patients in the UK.

METHODS AND ANALYSIS

The primary aim of this study is to characterise the incidence and compare the risk of serious adverse events in people with MS treated with DMTs. The OPTIMISE:MS database enables electronic data capture and secure data transfer. Selected clinical data, clinical histories and patient-reported outcomes are collected in a harmonised fashion across sites at the time of routine clinical visits. The first patient was recruited to the study on 24 May 2019. As of January 2021, 1615 individuals have baseline data recorded; follow-up data are being captured and will be reported in due course.

ETHICS AND DISSEMINATION

This study has ethical permission (London City and East; Ref 19/LO/0064). Potential concerns around data storage and sharing are mitigated by the separation of identifiable data from all other clinical data, and limiting access to any identifiable data. The results of this study will be disseminated via publication. Participants provide consent for anonymised data to be shared for further research use, further enhancing the value of the study.

Subcutaneous cladribine to treat multiple sclerosis: experience in 208 patients

Objective:

To report on safety and effectiveness of subcutaneous cladribine (Litak®) in multiple sclerosis (MS) patients.

Methods:

Litak® was offered to MS-patients irrespective of disease course. Litak® 10 mg was administered for 3–4 days during week 1. Based on lymphocyte count at week 4, patients received another 0–3 doses at week 5. A second course was administered 11 months later. Follow-up included adverse events, relapses, expanded disability status scale (EDSS), 9-hole-peg and Timed-25-foot-walking tests, no-evidence-of-disease-activity (NEDA), no-evidence-of-progression-or-active-disease (NEPAD), MRI, cerebrospinal fluid (CSF) neurofilament light chain (NfL), and lymphocyte counts.

Results:

In all, 208 patients received at least one course of treatment. Age at baseline was 44 (17–72) years and EDSS 0–8.5. Cladribine was generally well tolerated. One myocardial infarction, one breast cancer, and three severe skin reactions occurred without long-term sequelae. Two patients died (one pneumonia, one encephalitis). Lymphopenia grade 3 occurred in 5% and grade 4 in 0.5%. In 94 out of 116 pwMS with baseline and follow-up (BaFU) data after two treatment courses, EDSS remained stable or improved. At 18 months, 64% of patients with relapsing MS and BaFU data ( n = 39) had NEDA. At 19 months, 62% of patients with progressive MS and BaFU data ( n = 13) had NEPAD. Of n = 13 patients whose CSF-NfL at baseline was elevated, 77% were normalised within 12 months.

Conclusions:

Litak® was well tolerated. Effectiveness in relapsing MS appeared similar to cladribine tablets and was encouraging in progressive MS. Our data suggest cladribine may be safe and effective in MS-patients irrespective of their disease stage.

#3100 A service evaluation of the experiences of patients with functional neurological disorders within the NHS

Objectives/Aims

Previous research into Functional Neurological Disorder (FND) has shown that there are significant barriers in providing multidisciplinary, patient-centred care for these patients, including stigmatising attitudes, poor knowledge about FND, and a lack of structured care pathways. However, there has been no specific research into patient experiences of care for FND within NHS services to date, and whether these experiences meet the standards of care expected for long-term neurological conditions (LTNCs). The current study thus aimed to investigate the types of problems experienced by FND patients, and whether they differed in frequency and type to patients with another LTNC, multiple sclerosis (MS).

Methods

Both FND (n = 40) and MS patients (n = 37) were recruited from tertiary neurology clinics at an NHS hospital and completed two questionnaires on their experiences of health and social care services and on their level of disability.

Results

The results indicated significant differences in experiences of care between the two patient groups, with FND patients reporting significantly more problems (p<0.001)overall. These problems were reported in relation to their diagnosis and treatment, relationships with healthcare professionals, and difficulties in accessing services. This was despite FND patients reporting significantly higher levels of disability (p=0.001), highlighting the burden of care experienced by FND patients as a result of these difficulties in accessing and receiving care. A small sample size, specificity to a single neurology centre, and a cross-sectional design are acknowledged as limitations.

Conclusions

Together, these results suggest that current care for FND patients is not meeting the standards expected for LTNCs, and highlight the need for further research and the development of structured, multidisciplinary pathways with a patient-centred approach.

A Service Evaluation of the Experiences of Patients With Functional Neurological Disorders Within the NHS

Previous research into Functional Neurological Disorder (FND) has shown that there are significant barriers in providing patient-centred care. However, there has been no specific research into whether patient experiences of care for FND meet the current standards of care. This study aimed to investigate the types of problems experienced by FND patients, and whether these differed to patients with multiple sclerosis (MS). FND (n = 40) and MS patients (n = 37) were recruited from NHS tertiary neurology clinics and completed questionnaires on their experiences of health care services. Significant differences in experiences of care between the two patient groups were found, with FND patients reporting significantly more problems in their diagnosis and treatment (p = 0.003), patient-centred care (p < 0.001), relationships with healthcare professionals (p < 0.001), and in accessing community care (p = 0.001). Limitations include a small sample size, specificity to a single centre, and cross-sectional design. The results suggest that current care for FND patients is not meeting expected standards for long-term neurological conditions, highlighting the need for structured care pathways and patient-centred care.

Assessment of patients with lower urinary tract symptoms where an undiagnosed neurological disease is suspected: A report from an International Continence Society consensus working group

AIM

Lower urinary tract symptoms (LUTS) are a common urological referral, which sometimes can have a neurological basis in a patient with no formally diagnosed neurological disease ("occult neurology"). Early identification and specialist input is needed to avoid bad LUTS outcomes, and to initiate suitable neurological management.

METHODS

The International Continence Society established a neurological working group to consider: Which neurological conditions may include LUTS as an early feature? What diagnostic evaluations should be undertaken in the LUTS clinic? A shortlist of conditions was drawn up by expert consensus and discussed at the annual congress of the International Neurourology Society. A multidisciplinary working group then generated recommendations for identifying clinical features and management.

RESULTS

The relevant conditions are multiple sclerosis, multiple system atrophy, normal pressure hydrocephalus, early dementia, Parkinsonian syndromes (including early Parkinson's Disease and Multiple System Atrophy) and spinal cord disorders (including spina bifida occulta with tethered cord, and spinal stenosis). In LUTS clinics, the need is to identify additional atypical features; new onset severe LUTS (excluding infection), unusual aspects (eg, enuresis without chronic retention) or "suspicious" symptoms (eg, numbness, weakness, speech disturbance, gait disturbance, memory loss/cognitive impairment, and autonomic symptoms). Where occult neurology is suspected, healthcare professionals need to undertake early appropriate referral; central nervous system imaging booked from LUTS clinic is not recommended.

CONCLUSIONS

Occult neurology is an uncommon underlying cause of LUTS, but it is essential to intervene promptly if suspected, and to establish suitable management pathways.

A canine vaccine against Leptospira serovars Icterohaemorrhagiae, Canicola and Grippotyphosa provides cross protection against Leptospira serovar Copenhageni

Efficacy of the Leptospira components of multivalent vaccine DAPPi-L was previously demonstrated against virulent challenge with three serovars of Leptospira interrogans (Canicola, Icterohaemorrhagiae and Grippotyphosa) carried out 14 days after primary vaccination. In this study we demonstrate that this vaccine provides, two weeks after vaccination, an additional protection (prevention of mortality, clinical signs, renal infection, bacterial excretion, renal carriage and renal lesions) against fatal leptospirosis due to Leptospira interrogans serovar Copenhageni (serovar of major medical importance).

Cortical thickness, surface area and volume measures in Parkinson's disease, multiple system atrophy and progressive supranuclear palsy

Objective

Parkinson's disease (PD), Multiple System Atrophy (MSA) and Progressive Supranuclear Palsy (PSP) are neurodegenerative diseases that can be difficult to distinguish clinically. The objective of the current study was to use surface-based analysis techniques to assess cortical thickness, surface area and grey matter volume to identify unique morphological patterns of cortical atrophy in PD, MSA and PSP and to relate these patterns of change to disease duration and clinical features.

Methods

High resolution 3D T1-weighted MRI volumes were acquired from 14 PD patients, 18 MSA, 14 PSP and 19 healthy control participants. Cortical thickness, surface area and volume analyses were carried out using the automated surface-based analysis package FreeSurfer (version 5.1.0). Measures of disease severity and duration were assessed for correlation with cortical morphometric changes in each clinical group.

Results

Results show that in PSP, widespread cortical thinning and volume loss occurs within the frontal lobe, particularly the superior frontal gyrus. In addition, PSP patients also displayed increased surface area in the pericalcarine. In comparison, PD and MSA did not display significant changes in cortical morphology.

Conclusion

These results demonstrate that patients with clinically established PSP exhibit distinct patterns of cortical atrophy, particularly affecting the frontal lobe. These results could be used in the future to develop a useful clinical application of MRI to distinguish PSP patients from PD and MSA patients.

Diffusion tensor imaging of Parkinson's disease, multiple system atrophy and progressive supranuclear palsy: a tract-based spatial statistics study

Although often clinically indistinguishable in the early stages, Parkinson's disease (PD), Multiple System Atrophy (MSA) and Progressive Supranuclear Palsy (PSP) have distinct neuropathological changes. The aim of the current study was to identify white matter tract neurodegeneration characteristic of each of the three syndromes. Tract-based spatial statistics (TBSS) was used to perform a whole-brain automated analysis of diffusion tensor imaging (DTI) data to compare differences in fractional anisotropy (FA) and mean diffusivity (MD) between the three clinical groups and healthy control subjects. Further analyses were conducted to assess the relationship between these putative indices of white matter microstructure and clinical measures of disease severity and symptoms. In PSP, relative to controls, changes in DTI indices consistent with white matter tract degeneration were identified in the corpus callosum, corona radiata, corticospinal tract, superior longitudinal fasciculus, anterior thalamic radiation, superior cerebellar peduncle, medial lemniscus, retrolenticular and anterior limb of the internal capsule, cerebral peduncle and external capsule bilaterally, as well as the left posterior limb of the internal capsule and the right posterior thalamic radiation. MSA patients also displayed differences in the body of the corpus callosum corticospinal tract, cerebellar peduncle, medial lemniscus, anterior and superior corona radiata, posterior limb of the internal capsule external capsule and cerebral peduncle bilaterally, as well as the left anterior limb of the internal capsule and the left anterior thalamic radiation. No significant white matter abnormalities were observed in the PD group. Across groups, MD correlated positively with disease severity in all major white matter tracts. These results show widespread changes in white matter tracts in both PSP and MSA patients, even at a mid-point in the disease process, which are not found in patients with PD.

Distributed modal command for a two-deformable-mirror adaptive optics system

The design of future single-altitude conjugated adaptive optics (AO) systems may include at least two deformable mirrors (DMs) instead of one as in the current AO system. Each DM will have to correct for a specific spatial frequency range. A method is presented to derive a DM modal basis based on the influence functions of the DM. The modal bases are derived such that they are orthogonal to a given set of modes that restrict the DM correction to a spatial frequency domain. The modal bases have been tested on the woofer-tweeter test bench at the University of Victoria. It has been shown that the rms amplitude of the woofer DM and tweeter DM stroke can be reduced by factors of 3 and 9, respectively, when making the transition from a zonal-driven closed loop to a modal-driven closed loop with the same performance in both cases.

Improving detection of alcohol misuse in patients presenting to an accident and emergency department

OBJECTIVES

To assess and improve deployment of a brief test for alcohol misuse: the Paddington Alcohol Test (PAT). Design-Prospective study of the effects of audit feedback.

SETTING

An urban accident and emergency department.

SUBJECTS

Senior house officers (SHO) (n = 13).

OUTCOME MEASUREMENTS

PAT use and categorisation of patients for each SHO; observational analysis of presenting complaints according to PAT.

RESULTS

1062 of 1737 patients (61.1%) were defined as PAT possible-that is, presented with > or = one complaint listed on the PAT test proforma. In month 1, PAT uptake was poor. PAT use improved significantly when feedback was instituted (p<0.0001). The response to audit and feedback showed marked inter-SHO variation. When feedback was withdrawn (month 4), there was a significant reduction in PAT use (p=0.003). Three other indices of detection followed this trend: (a) number of PAT positive patients identified, (b) proportion of PAT possible patients identified as PAT positive, and (c) number of PAT positive patients referred to the alcoholic health worker. The 10 most common PAT positive categories, accounting for 77% of all PAT positive complaints were: fall > collapse (including "fit", "blackout") > head injury (including "facial injury") > assault (including "domestic violence" and 'other') > nonspecific gastrointestinal problem > "unwell" > psychiatric (including "depression", "overdose", "confusion") > cardiac (including "chest pain" and "palpitations") > self neglect > repeat attendance.

CONCLUSIONS

Ongoing audit with feedback improves both PAT use and detection of alcohol misuse. The PAT is now simpler including only 10 conditions, which should further aid its use.

Heavy metals in human and animal bones from ancient and contemporary France

The concentrations of Cd, Pb, Zn, Ba, Mg and Ca have been determined in 180 human bones from the last five millenia, and in 22 contemporary and 20000-50000-year-old animal bones. The original concentrations of Cd and Zn in the ancient human bones were not changed by fossilization processes, whereas Pb and Mg tended to migrate out of the bones, and Ba and Ca concentrations increased with the age of the bones. The distribution of metals in the structure of both the ancient and contemporary bones is not uniform, and neglecting this may render it difficult to compare results obtained from different studies. In Europe and Peru in the late Middle Ages the concentration of Pb in human bones increased by one order of magnitude. The high level of Pb persisted in Europe for several centuries and only recently decreased by an order of magnitude. The concentration of Cd has increased in human bones in the 20th century, to about ten times above the pre-industrial level. The concentration of Pb in contemporary cow bones from France is below analytical detection limits, probably due to competition of Pb with Ca and P which are added to cow fodder as mineral additives.