Neuraxial analgesia is not associated with an increased risk of post-partum relapses in MS

Background:

Obstetrical analgesia remains a matter of controversy because of the fear of neurotoxicity of local anesthetics on demyelinated fibers or their potential relationship with subsequent relapses.

Objective:

To assess the impact of neuraxial analgesia on the risk of relapse during the first 3 months post-partum, with a focus on women who experienced relapses during pregnancy.

Methods:

We analyzed data of women followed-up prospectively during their pregnancies and at least 3 months post-partum, collected in the Pregnancy in Multiple Sclerosis (PRIMS) and Prevention of Post-Partum Relapses with Progestin and Estradiol in Multiple Sclerosis (POPARTMUS) studies between 1992–1995 and 2005–2012, respectively. The association of neuraxial analgesia with the occurrence of a post-partum relapse was estimated by logistic regression analysis.

Results:

A total of 389 women were included, 215 from PRIMS and 174 from POPARTMUS. In total, 156 women (40%) had neuraxial analgesia. Overall, 24% experienced a relapse during pregnancy and 25% in the 3 months post-partum. Women with a pregnancy relapse were more likely to have a post-partum relapse (odds ratio (OR) = 1.83, p = 0.02), independently of the use of neuraxial analgesia. There was no association between neuraxial analgesia and post-partum relapse (OR = 1.08, p = 0.78).

Conclusion:

Neuraxial analgesia was not associated with an increased risk of post-partum relapses, whatever multiple sclerosis (MS) activity during pregnancy.

Neuromyelitis optica in France: a multicenter study of 125 patients

BACKGROUND

There have been few epidemiologic studies on neuromyelitis optica (NMO) and none used the recent 2006 diagnostic criteria. Here we describe the clinical, laboratory, MRI, and disability course of NMO in a French cohort of 125 patients.

METHODS

We performed an observational, retrospective, multicenter study. Data were collected from September 2007 through August 2008, corresponding to the endpoint of the study. We identified 125 patients fulfilling the 2006 NMO criteria. Selection was made using hospital files and a specific clinical questionnaire for NMO.

RESULTS

Mean age at onset was 34.5 years (range 4-66) with a mean disease duration of 10 +/- 7.8 years at the endpoint. The patients were mainly (87%) Caucasian, with a female:male ratio of 3:1. In 90% of cases, the association of optic neuritis, longitudinal extensive myelitis, and a Paty-negative initial brain MRI was sufficient to fulfill the supportive criteria. Eighty-eight percent of patients were treated with immunosuppressive therapies. Median delay from onset to Expanded Disability Status Scale (EDSS) score 4 was 7 years; score 6, 10 years; and score 7, 21 years. The first episode of myelitis was immediately followed by an EDSS score > or = 4 in 37.3% of cases, and a severe residual visual loss was observed in 22% of patients after the first episode of optic neuritis. Multivariate analysis did not reveal any predictors of a poor evolution other than a high number of MRI brain lesions at diagnosis, which were predictive of a residual visual acuity < or = 1/10.

CONCLUSIONS

Our demographic data provide new data on disability in patients with neuromyelitis optica, most of whom were receiving treatment.

L’évaluation médico-économique dans la sclérose en plaques

In multiple sclerosis, evaluation of quality of life is important because the patients are usually confronted with a decrease in physical, cognitive and social functioning. Apart from the personal suffering, the financial consequences for these patients and their family and the economic burden for society are enormous. Measurement of health related quality of life is important for the understanding of disease burden and the impact of specific MS treatments. Rising costs associated with new treatments and spending limits have prompted a search for gratter efficiency. Although health economics research can suggest ways to maximize health benefits within fixed budgets it is currently underused in MS. The purpose of this review of the literature is to explain some of the basic principles underlying both quality of life and economic evaluations, and analyse their contribution to understanding and managing patients with MS. Neurologists should not underestimate how dramatic their contributions can be to this maturing field that will influence the future of MS patients care.

[Neurological manifestations of leprosy]

Leprosy, also known as Hansen's disease, is a chronic, infectious disease caused by Mycobacterium leprae. Bacilli localize preferentially in the skin and peripheral nerves and have a propensity to cause nerve damage. The resulting disability has caused great suffering for victims in many countries. Despite recent advances in the immunopathogenesis, epidemiology and prognostic factors of leprosy nerve damage, many aspects of the disease have remained enigmatic. The spectrum of clinical and pathological manifestations of the disease ranges from lepromatous to tuberculoid, depending on the host's T-cell-mediated immune response. Diagnosis is based on three criteria: characteristic skin lesions in association with thickened nerves, demonstration of acid fast bacilli in slit skin smears, and histopathology of skin biopsies. Nerve biopsy is necessary to establish the diagnosis of pure "neural leprosy". In developed countries, the diagnosis is suspected when a patient who has stayed in an endemic area suffers from a peripheral neuropathy of unknown etiology. To facilitate determination of the appropriate antibiotic regimen, patients are classified as either paucibacillary or multibacillary. Some patients may have multibacillary leprosy in nerves and paucibacillary leprosy in skin, which emphasizes the usefulness of nerve biopsy. The course of the disease is often complicated by immune mediated "reactions", which can rapidly lead to further nerve damage, namely reversal reaction and erythema nodosum leprosy. However, nerves are often functionally impaired before developing obvious symptoms such as skin reactions or nevralgia (silent neuropathy). Early recognition and prompt treatment with corticosteroids of leprous reactions and "silent neuropathies" is very important to prevent disability with all its attendant problems. Research progress from clinical trials may improve current methods of prevention and treatment of nerve damage in leprosy.

[The application of magnetic resonance imaging transfer to the study of multiple sclerosis patients: review and analysis of literature]

The purpose of this review of the literature is to analyze the contribution of magnetization transfer (MT) imaging techniques in understanding the various characteristics of multiple sclerosis. MT imaging allows contrast augmentation by use of magnetization transfer contrast. MT imaging allows lesion characterization by means of quantification of the degree of signal loss due to magnetization transfer contrast by a magnetization transfer ratio. It is used as an indicator of tissue destruction; in particular, to demyelination. Both applications of MT imaging in multiple sclerosis are studied in this review, as well as the methodological and technical limitations.

Automated segmentation of multiple sclerosis lesions in multispectral MR imaging using fuzzy clustering

A method is presented for fully automated detection of Multiple Sclerosis (MS) lesions in multispectral magnetic resonance (MR) imaging. Based on the Fuzzy C-Means (FCM) algorithm, the method starts with a segmentation of an MR image to extract an external CSF/lesions mask, preceded by a local image contrast enhancement procedure. This binary mask is then superimposed on the corresponding data set yielding an image containing only CSF structures and lesions. The FCM is then reapplied to this masked image to obtain a mask of lesions and some undesired substructures which are removed using anatomical knowledge. Any lesion size found to be less than an input bound is eliminated from consideration. Results are presented for test runs of the method on 10 patients. Finally, the potential of the method as well as its limitations are discussed.

Correlation of magnetic resonance imaging parameters with clinical disability in multiple sclerosis: a preliminary study

Magnetic resonance imaging (MRI) is frequently used to monitor new treatments in multiple sclerosis (MS), but its role is limited by the uncertain relationship between MRI parameters and clinical disability. A brain MRI study using nine MRI parameters was undertaken in 15 MS patients with a wide spectrum of disability to evaluate the relationship between each parameter and disability. A strong correlation was found between disability (measured using Kurtzke's EDSS) and total lesion load on both proton density (PD; r = 0.79) and T1 (r = 0.71) weighted sequences. There was also a strong correlation of disability with average lesion magnetisation transfer ratio (MTR; r = -0.74) and calculated T1 (r = 0.71) but not with calculated T2 or the average signal intensity of lesions on the conventional T1-weighted, PD-weighted and heavily T2-weighted images. Thus, four parameters which measured either the extent of lesions (PD lesion load) or their pathological severity (MTR, calculated T1, hypointense T1-lesion load) were correlated significantly with disability. While this suggests that such parameters will be useful in treatment trial monitoring, further multi-parameter MRI studies, of larger cohorts and using a wider range of techniques, are indicated.

[Multiple sclerosis and pregnancy: clinical issues]

Multiple sclerosis (MS) is the most common chronic disabling neurological disease affecting young women. Paradoxically, our knowledge of the relationship between pregnancy and MS is limited. However, several conclusions emerge from the literature: 1) The rate of relapse in MS decreases during pregnancy, and it rises significantly during the first three months post partum before coming back to its level prior to pregnancy. 2) Although pregnancy and delivery cause changes of the relapse rate, they have no influence on mid and long term residual disability. 3) Breast-feeding and epidural analgesia do not seem to have any deleterious effect on the disease. 4) Lastly, MS does not seem to influence pregnancy, delivery or the child's health. The studies available to date suffer from methodological limitations. They need to be confirmed by prospective studies. This is the purpose of the study entitled "Pregnancy in multiple sclerosis, PRIMS", which has been carried out since 1992 at the European level.

[A brachial form of motor neuropathy caused by lead poisoning]

We report the case of a 48-year-old patient who developed acute onset bilateral, peripheral motor dysfunction in the arms and forearms. Clinical history, electromyography and laboratory tests confirmed the diagnosis of peripheral neuropathy caused by lead poisoning from the domestic water supply. The EMG showed axonal alterations. Improvement was observed after treatments with chelating agents and removal of the source of poisoning. This case provides the opportunity to recall the traditional 1889 Dejerine classification of lead-related peripheral neuropathies and is a warning signal that lead poisoning remains a problem in peri-urban areas of developed countries.

[Is it possible to predict the evolution of multiple sclerosis?]

Three characteristic features describe our understanding of the clinical course and outcome in multiple sclerosis: a validated statistical model of disease progression, wide interindividual variability, and a fixed rate of progression in an individual patient. However for and individual patient, it is still impossible to derive a precise and exact prediction of disease outcome, the only reliable method is the deterministic approach developed by Fog and Linneman in 1970 which consists in objective quantitative neurological examinations performed at three month intervals over several years in the same patient. In routine practice, this method in rather unrealistic. Bran MRI data with conventional techniques are also poorly discriminant. Conversely, it may be anticipated that new magnetic resonance techniques, more sensitive to axonal loss, demyelinization and gliosis, will provide reliable answers to this issue upon which therapeutic decisions depend.

A pyramidal approach for automatic segmentation of multiple sclerosis lesions in brain MRI

Quantitative assessment of Magnetic Resonance Imaging (MRI) lesion load of patients with multiple sclerosis (MS) is the most objective approach for a better understanding of the history of the pathology, either natural or modified by therapies. To achieve an accurate and reproducible quantification of MS lesions in conventional brain MRI, an automatic segmentation algorithm based on a multiresolution approach using pyramidal data structures is proposed. The systematic pyramidal decomposition in the frequency domain provides a robust and flexible low level tool for MR image analysis. Context-dependent rules regarding MRI findings in MS are used as high level considerations for automatic lesion detection.

Effect of training and different measurement strategies on the reproducibility of brain MRI lesion load measurements in multiple sclerosis

In this study, we evaluated the intra- and interobserver variabilities in measuring lesion load of brain MRI abnormalities present on proton-density scans from patients with MS, using using both manual outlining or a semiautomated local thresholding technique (LTT). We also evaluated how these variabilities were affected by the use of standard rules for lesion load measurements, training, and different measurement strategies. The intraobserver variabilities obtained after establishing rules for lesion load measurements and training were not significantly different from those obtained before any consensus among the observers, both for manual outlining and for the LTT. On the contrary, the interobserver variabilities obtained with manual outlining or the LTT were significantly reduced when rules for lesion load measurements were used. For manual outlining, the intraobserver variability did not significantly change when the measurements were performed after an experienced radiologist identified lesions or when using adjacent slices and the corresponding T2-weighted images as reference for lesion identification. On the contrary, for the LTT, the intraobserver variability was significantly reduced by the use of the radiologic marking. The interobserver variabilities for both manual outlining and the LTT were reduced compared with the free condition when these measurement strategies were used. Our findings demonstrate that both lesion identification and outlining are important sources of variation for MRI lesion load measurements in MS and that there are simple strategies to reduce such variation that might be useful when planning clinical trials.

[MRI in the study of multiple sclerosis]

Magnetic resonance imaging (MRI) has provided considerable insight into the pathological process and disease activity and progression in multiple sclerosis. MRI has become an important tool for the diagnosis of multiple sclerosis, and increasingly for monitoring treatment trial. The growing use of MRI calls for careful consideration in applications so that the technology is not misused. Here we propose a summary of the literature on MRI in application in clinical neurology.

Risk of cancer from azathioprine therapy in multiple sclerosis: a case-control study

An increased risk of cancer has been reported in patients treated with azathioprine. To assess the long-term risk of neoplasia in azathioprine-treated multiple sclerosis (MS) patients, we conducted a case-control study using the Lyon Multiple Sclerosis Database. From the 1,191 MS patients included in the database, we identified patients who developed cancer before December 31, 1991. Each case was then matched to three cancer-free MS controls by gender, date of birth, and date of MS onset. A matched analysis was performed to compare cases and controls for exposure to azathioprine therapy during the same follow-up period. Twenty-three MS patients with cancer were identified: 17 solid tumors, 2 skin carcinomas, 4 hematopoietic cancers. Cases had a mean age of 34.5 years +/- 10.2 (+/- SD) at clinical onset of MS and have been followed up for an average 13.8 years +/- 8.1 before being diagnosed with cancer. Fourteen cases (61%) and 34 controls (49%) had been treated with azathioprine for at least 1 month after being diagnosed with MS (adjusted odds ratio = 1.7; 95% confidence interval [CI], 0.6 to 4.6). When assessing risk associated with different durations of azathioprine therapy compared with no treatment at all, we found that MS patients had an increase in cancer risk of 1.3 (95% CI, 0.4 to 4.0) when treated less than 5 years, of 2.0 (95% CI, 0.4 to 9.1) when treated 5 to 10 years, and of 4.4 (95% CI 0.9 to 20.9) when treated more than 10 years. Similar results were obtained when assessing cancer risk associated with cumulative doses of azathioprine ever taken. This case-control study suggests that the overall long-term risk of cancer from azathioprine is low in MS patients. The results are suggestive of a dose-response relationship with no significant risk during the first years of treatment and a possible increased risk after about 10 years of continuous therapy. Further studies are needed to better assess the risk-benefit ratio of azathioprine in MS.

Quantification of MRI lesion load in multiple sclerosis: a comparison of three computer-assisted techniques

Several computer-assisted techniques for measuring multiple sclerosis lesion load on MR images have been developed to provide a quantitative and sensitive means for monitoring disease activity, particularly in the context of treatment trials. We have evaluated three techniques: manual outlining (similar to that of the North American interferon beta-1b trial), semiautomated lesion contouring (local lesion based threshold), and intensity-based thresholding for the whole brain. Contiguous, 5 mm-thick, axial, T2-weighted images of the brain were obtained on a 1.5T MR imager in eight patients with clinically definite multiple sclerosis. Analyses of the scans were performed twice, independently by three operators, using the three different techniques. The coefficient of variation of the measurement techniques was: (a) intrarater precision, 9.0 +/- 5.2 (mean +/- SD) (range 0.4-18.5) for the manual outlining, 2.5 +/- 2.1 (0.1-7.7) for the contour technique, and 7.5 +/- 6.9 (0.2-22.0) for the global threshold technique; (b) interrater precision, 11.0 +/- 5.8 (4.9-21.7) for the manual outlining, 4.5 +/- 1.6 (1.8-6.6) for the contour technique, and 11.4 +/- 4.9 (2.8-19.2) for the global threshold technique (0.0 = perfect precision). The absolute lesion loads measured were very similar using the manual outlining and the contour techniques but were significantly smaller using the global threshold technique. We conclude that the contour technique is a promising tool for use in treatment trials. Further studies are needed to assess sensitivity to changes in lesion load over time.

Signal intensity on MRI of basal ganglia in multiple sclerosis

It has been reported that a relative reduction in signal intensity on T2 weighted MRI may be seen in the basal ganglia of patients with multiple sclerosis and furthermore that this is due to excessive iron deposition. The basal ganglia are, however, rarely involved clinically or pathologically in multiple sclerosis, casting some doubt on this finding. Therefore MRI was carried out in 46 patients with definite multiple sclerosis and 42 age matched controls. Contiguous, 5 mm thick axial dual echo spin-echo images of the brain were obtained on a 1.5T imager. Visual rating scales were used to measure the lesion load as well as the signal intensity of the globus pallidus, putamen, caudate nucleus, substantia nigra, red nucleus, and thalamus. There was a mild degree of low signal intensity in the patient group in the thalamus only. The signal intensity of the thalamus and putamen was never lower than that of the globus pallidus. Low signal in the basal ganglia is rarely, if ever, found in multiple sclerosis and is not a useful radiological sign.

Substrate specificity of the lipase from Candida parapsilosis

Substrate specificity of the acyltransferase activity of the lipase (EC 3.1.1.3) from Candida parapsilosis CBS 604 was studied in aqueous media. The specificity toward both acid and alcohol parts of a large number of acylglycerols and aliphatic esters was investigated. This lipase showed a high activity in the presence of esters with long-chain fatty acids and particularly unsaturated fatty acids with a cis-delta 9 double bond. It was observed that the activity profile depended not only on the alcohol part of the acyl ester, but also on the temperature of the reactant medium. The best lipid substrates had their melting point between -40 to +20 degrees C, 14 to 18 carbon atoms in the acyl group and 1 to 4 carbon atoms in the alkyl group. The enzyme, defined as an acyltransferase in a previous paper, showed a high affinity for primary and secondary alcohols with a short carbon chain (1 to 5 carbon atoms) as acyl acceptors. The influence of free alcohols in the reactant medium on the hydrolysis and alcoholysis activities of the enzyme is discussed. Two phenomena seem to be involved, depending on the alcohol: competition with water for the acyltransfer reaction and lipid substrate dilution when the alcohol places at the oil/water interface.

[Segmental ulnar nerve conduction in Hansen's disease]

In leprosy, ulnar neuritis is considered to be selectively localised at the elbow and is often treated by surgical decompression when pain and/or neurological deficit occurs. The aim of this prospective study is to assess the prevalence, localisation and severity of ulnar nerve damage in leprosy. Motor nerve conduction velocity (MNC) was measured at 3 different segments: arm, elbow and forearm, and was expressed both in meters/second and percentage of the mean normal values found in our laboratory or as reported in other studies. The patient group consisted of 123 consecutive new leprosy sufferers (228 ulnar nerves only) who attended the Institut de Léprologie Appliquée de Dakar over the period of one year. Diagnosis and classification were based on Ridley & Jopling's criteria, including skin and nerve biopsy. Mean MNC was reduced by 13.5 m/s at the arm, 19.8 m/s at the elbow and 7.8 m/s at the forearm as compared to the mean normal values. Increased distal latency as an isolated finding was rare (0.9%). Mean MNC was more reduced in the BL, LL (lepromatous) than in the TT, BT (tuberculoid) subgroups, despite similar disease durations (22.3 +/- 18.7 months and 24.2 +/- 26.4 months respectively (n.s.). Using different normal MNC values did not affect the conclusion: we did not see any selective slowing of ulnar MNC at the elbow suggesting that nerve damage is not primarily related to mechanical factors.

[How to detect neuropathy in leprosy]

In leprosy, the early detection of peripheral nerve damage is essential for the prevention of disability. To date, there is no consensus on what is the best clinical test to reveal such abnormalities. In this prospective study we examined the effectiveness of five clinical tests to assess radial cutaneous nerve (RCN) damage (the most frequently involved). Light touch was assessed by two nylon threads (based on the Semmes-Weinstein monofilaments testing technique) bent on the skin at a pressure of 0.5 (N. 4 nylon) and 0.2 gram (N. 5 nylon). Pinprick and cooling sensations were examined by a needle and a drop of ether. The nerve thickness was assessed by palpation. Sensory findings were then compared to sensory nerve conduction values of the RCN and a sensitivity analysis was performed. The patient group consisted of 108 consecutive new leprosy sufferers (138 RCN) who attended the Institut de Léprologie Appliquée de Dakar during one year. Diagnosis and classification were based on Ridley and Jopling's criteria (clinical examination, skin smears and biopsy). Normal values were determined among 22 healthy subjects (44 RCN). The best tests in term of sensitivity were palpation (.60), N. 5 nylon (.65) and N. 5 + palpation (.79). Their positive predictive values were .84 (palpation), .94 (N. 5 nylon) and .83 (N. 5 + palpation). The best tests in term of area under the curve were palpation (.66), N. 5 nylon (.71) and N. 5 + palpation (.78). The results remain the same for the lepromatous or tuberculoid leprosy patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Epidemiological study of HIV seroprevalence in a leprosy patient population in Senegal]

We report the findings of an epidemiological study conducted between June 1989 and February 1990 on a population of leprosy patients in southern Senegal (Bignona major endemic disease sector). Two types of population were studied: patients living in urban areas and inmates of leprosaria. The global HIV seroprevalence (HIV 2 in all cases) of the leprosy-patient population was 1.15% (3/257): 0.8% (1/130) for the urban group and 1.5% (2/127) for the leprosaria. The seroprevalence rate does not differ significantly from that for the control group studied and for blood donors (1/221). The diagnosis of leprosy in the seropositive subjects had been established before 1980. None of them showed any sign of relapse. The immunodepression associated with the presence of HIV was only moderate: it was reflected in a lowering of the CD4 count and of the CD4/CD8 ratio, but with no clinical sign of AIDS.

T cell response to purified filtrate antigen 85 from Mycobacterium bovis Bacilli Calmette-Guérin (BCG) in leprosy patients

T cell proliferation and IFN-gamma production of peripheral blood mononuclear cells from 25 healthy controls and 39 leprosy patients were tested against BCG-bacilli and culture filtrate. Mycobacterium leprae and purified antigen 85 (the major secreted 30-32 kD protein antigen) from M. bovis strain BCG. In lepromin negative healthy controls, blastogenesis was low to M. leprae and completely negative to antigen 85. IFN-gamma levels were very low, close to detection limits. In all lepromin positive controls, significant proliferation and IFN-gamma secretion was found in response to M. leprae and antigen 85. In the group of lepromatous leprosy (LL) patients, 25/29 of patients (with either positive (13) or negative (12) lymphoproliferative response to BCG) were unreactive to M. leprae or to antigen 85. Four LL patients with positive T cell response to BCG responded with detectable lymphoproliferative response and IFN-gamma secretion to antigen 85. All tuberculoid (TT) leprosy patients responded to BCG, M. leprae and antigen 85. Hence, T cells from leprosy patients and controls demonstrate a marked parallelism of responsiveness towards whole M. leprae and purified antigen 85 from M. bovis BCG, suggesting strong cross-reactivity between the two species and underlining the biological importance of such secreted antigens.

An improved method for the colorimetric assay of lipase activity using an optically clear medium

Lipase activity can be spectrophometrically measured in an optically clear medium using long chain fatty thioesters of 1-mercapto-2,3-propanediol or 2-mercaptoethanol as substrates. With hexamethylphosphoric triamide solutions of these thiosubstrates, the Michaëlis-Menten constants of lipase from Rhizopus arrhizus were determined. The effects of calcium chloride and of bovine serum albumin on the enzyme activity were established.