Real-world persistence of multiple sclerosis disease-modifying therapies

BACKGROUND AND PURPOSE

Treatment persistence is the continuation of therapy over time. It reflects a combination of treatment efficacy and tolerability. We aimed to describe real-world rates of persistence on disease-modifying therapies (DMTs) for people with multiple sclerosis (pwMS) and reasons for DMT discontinuation.

METHODS

Treatment data on 4366 consecutive people with relapse-onset multiple sclerosis (MS) were pooled from 13 UK specialist centres during 2021. Inclusion criteria were exposure to at least one MS DMT and a complete history of DMT prescribing. PwMS in blinded clinical trials were excluded. Data collected included sex, age at MS onset, age at DMT initiation, DMT treatment dates, and reasons for stopping or switching DMT. For pwMS who had received immune reconstituting therapies (cladribine/alemtuzumab), discontinuation date was defined as starting an alternative DMT. Kaplan-Meier survival analyses were used to express DMT persistence.

RESULTS

In 6997 treatment events (1.6 per person with MS), median time spent on any single maintenance DMT was 4.3 years (95% confidence interval = 4.1-4.5 years). The commonest overall reasons for DMT discontinuation were adverse events (35.0%) and lack of efficacy (30.3%). After 10 years, 20% of people treated with alemtuzumab had received another subsequent DMT, compared to 82% of people treated with interferon or glatiramer acetate.

CONCLUSIONS

Immune reconstituting DMTs may have the highest potential to offer a single treatment for relapsing MS. Comparative data on DMT persistence and reasons for discontinuation are valuable to inform treatment decisions and in personalizing treatment in MS.

Prodromal multiple sclerosis: considerations and future utility

A multiple sclerosis (MS) prodrome has recently been described and is characterised by increased rates of healthcare utilisation and an excess frequency of fatigue, bladder problems, sensory symptoms and pain, in the years leading up to clinical onset of disease. This important observation may have several potential applications including in the identification of risk factors for disease, the potential to delay or prevent disease onset and early opportunities to alter disease course. It may also offer possibilities for the use of risk stratification algorithms and effective population screening. If standardised, clearly defined and disease specific, an MS prodrome is also likely to have a profound influence on research and clinical trials directed at the earliest stages of disease. In order to achieve these goals, it is essential to consider experience already gleaned from other disorders. More specifically, in some chronic neurological disorders the understanding of disease pro-drome is now well advanced and has been successfully applied. However, understanding of the MS prodrome remains at an early stage with key questions including the length of the prodrome, symptom specificity and potential benefits of early intervention as yet unanswered. In this review we will explore the evidence available to date and suggest future research strategies to address unanswered questions. In addition, whilst current understanding of the MS prodrome is not yet sufficient to justify changes in public health policy or MS management, we will consider the practical utility and future application of the MS prodrome in a wider health care setting.

Relevance of Multiple Sclerosis Severity Genotype in Predicting Disease Course: A Real-World Cohort

OBJECTIVE

Currently, 233 genetic loci are known to be associated with susceptibility to multiple sclerosis (MS). Two independent pivotal severity genome-wide association studies recently found the first genome-wide significant single-nucleotide variant (SNV; rs10191329A ) and several other suggestive loci associated with overall disability outcomes. It is now important to understand if these findings can influence individual patient management.

METHODS

We assessed whether these progression SNVs are associated with detailed clinical phenotypes in a well-characterized prospective cohort of 1,455 MS patients. We used logistic regression, survival analysis, and propensity score matching to predict relevant long-term clinical outcomes.

RESULTS

We were unable to detect any association between rs10191329A and a range of clinically relevant outcomes (eg, time to Expanded Disability Status Scale milestones, age-related MS severity score, anatomical localization at onset or during subsequent relapses, annualized relapse rate). In addition, an extremes of outcome case-control analysis using a propensity score matching for genotype detected no association between disease severity and rs10191329A . However, we were able to replicate the association of two suggestive SNVs (rs7289446G and rs868824C ) with the development of fixed disability, albeit with modest effect sizes, and the association of HLA-DRB1*1501 with age at onset.

INTERPRETATION

Identification of rs10191329A and other suggestive SNVs are of considerable importance in understanding pathophysiological processes associated with MS severity. However, it is unlikely that individual genotyping can currently be used in a clinical setting to guide disease management. This study shows the importance of independent replication of genome-wide association studies associated with disease progression in neurodegenerative disorders. ANN NEUROL 2024;95:459-470.

Modelling Disease progression of Multiple Sclerosis in a South Wales Cohort

OBJECTIVES

To model multiple sclerosis (MS) disease progression and compare disease trajectories by sex, age of onset, and year of diagnosis.

STUDY DESIGN AND SETTINGS

Longitudinal EDSS scores were collected since 1985 for relapse-onset MS patients at MS clinics in South Wales and modelled using a multilevel model (MLM). The MLM adjusted for baseline covariates (sex, age of onset, year of diagnosis, and disease modifying treatments (DMTs)), and included interactions between baseline covariates and time variables.

RESULTS

The optimal model was truncated at 30 years after disease onset and excluded EDSS recorded within 3 months of relapse. As expected, older age of onset was associated with faster disease progression at 15 years (effect size (ES): 0.75; CI: 0.63, 0.86; P: <0.001) and female sex progressed more slowly at 15 years (ES: -0.43; CI: -0.68, -0.18; P: <0.001). Patients diagnosed more recently (defined as 2007-2011 and >2011) progressed more slowly than those diagnosed historically (<2006); (ES: -0.46; CI: -0.75, -0.16; P: 0.006) and (ES: -0.95; CI: -1.20, -0.70; P: <0.001), respectively.

CONCLUSION

We present a novel model of MS outcomes, accounting for the nonlinear trajectory of MS and effects of baseline covariates, validating well-known risk factors (sex and age of onset) associated with disease progression. Also, patients diagnosed more recently progressed more slowly than those diagnosed historically.

Risk of COVID-19 in people with multiple sclerosis who are seronegative following vaccination

BACKGROUND

People with multiple sclerosis (pwMS) treated with certain disease-modifying therapies (DMTs) have attenuated IgG response following COVID-19 vaccination; however, the clinical consequences remain unclear.

OBJECTIVE

To report COVID-19 rates in pwMS according to vaccine serology.

METHODS

PwMS with available (1) serology 2-12 weeks following COVID-19 vaccine 2 and/or vaccine 3 and (2) clinical data on COVID-19 infection/hospitalisation were included. Logistic regression was performed to examine whether seroconversion following vaccination predicted risk of subsequent COVID-19 infection after adjusting for potential confounders. Rates of severe COVID-19 (requiring hospitalisation) were also calculated.

RESULTS

A total of 647 pwMS were included (mean age 48 years, 500 (77%) female, median Expanded Disability Status Scale (EDSS) 3.5% and 524 (81%) exposed to DMT at the time of vaccine 1). Overall, 472 out of 588 (73%) were seropositive after vaccines 1 and 2 and 222 out of 305 (73%) after vaccine 3. Seronegative status after vaccine 2 was associated with significantly higher odds of subsequent COVID-19 infection (odds ratio (OR): 2.35, 95% confidence interval (CI): 1.34-4.12, p = 0.0029), whereas seronegative status after vaccine 3 was not (OR: 1.05, 95% CI: 0.57-1.91). Five people (0.8%) experienced severe COVID-19, all of whom were seronegative after most recent vaccination.

CONCLUSION

Attenuated humoral response to initial COVID-19 vaccination predicts increased risk of COVID-19 in pwMS, but overall low rates of severe COVID-19 were seen.

Life expectancy in multiple sclerosis by EDSS score

The median survival time of newly-diagnosed MS patients without severe disabilities is approximately 30-35 years. The prognosis after the onset of severe disability has not been reported. Based on Harding et al.'s 2018 study of the Southeast Wales MS registry, we calculated life expectancies according to the Expanded Disability Status Scale (EDSS). Upon loss of independent ambulation (EDSS 6-6.5; mean age 51.2) life expectancy was 13.3 additional years. At EDSS 9-9.5 (mean age 70.8) life expectancy was 1.1 additional years. These figures provide an empirical basis for discussions of advanced MS care planning.

663 BEHAVIOUR CHANGE INTERVENTIONS TO INCREASE PHYSICAL ACTIVITY IN HOSPITALISED PATIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction

Low physical activity levels are a major problem for people in hospital and are associated with adverse outcomes. This systematic review, meta-analysis and meta-regression aimed to determine the effect of behaviour change interventions on physical activity levels in hospitalised patients.

Methods: Randomised controlled trials of behaviour change interventions to increase physical activity in hospitalised patients were searched from MEDLINE, EMBASE, PsychINFO, CINAHL, Cochrane Register of Controlled Trials and PEDr, supplemented by citation tracking. After application of selection criteria and data extraction, data were synthesised with random effects meta-analyses and pre-specified subgroup and meta-regression analyses. The primary outcome was Objectively measured physical activity. Secondary outcomes were patient-related outcomes (e.g. mobility), hospital-level outcomes (e.g. length of stay), adverse events and patient satisfaction.

Results

Eighteen randomised controlled trials (n = 2,197 participants) of behaviour change interventions were included and were associated with increased physical activity levels (SMD 0.36, 95% CI 0.15 to 0.57). Findings in relation to mobility and length of stay were inconclusive. Adverse events and patient satisfaction were poorly reported. Meta-regression found that the behaviour change technique of goal setting was independently associated with increased physical activity (SMD 0.35, 95% CI 0.11 to 0.60).

Conclusion

Targeted behaviour change interventions are associated with small to moderate increases in physical activity in hospitalised patients. Goal setting was the behaviour change technique that worked best in increasing physical activity.

COVID-19 Vaccine Response in People with Multiple Sclerosis

Objective

The purpose of this study was to investigate the effect of disease modifying therapies on immune response to severe acute respiratory syndrome‐coronavirus 2 (SARS‐CoV‐2) vaccines in people with multiple sclerosis (MS).

Methods

Four hundred seventy‐three people with MS provided one or more dried blood spot samples. Information about coronavirus disease 2019 (COVID‐19) and vaccine history, medical, and drug history were extracted from questionnaires and medical records. Dried blood spots were eluted and tested for antibodies to SARS‐CoV‐2. Antibody titers were partitioned into tertiles with people on no disease modifying therapy as a reference. We calculated the odds ratio of seroconversion (univariate logistic regression) and compared quantitative vaccine response (Kruskal Wallis) following the SARS‐CoV‐2 vaccine according to disease modifying therapy. We used regression modeling to explore the effect of vaccine timing, treatment duration, age, vaccine type, and lymphocyte count on vaccine response.

Results

Compared to no disease modifying therapy, the use of anti‐CD20 monoclonal antibodies (odds ratio = 0.03, 95% confidence interval [CI] = 0.01–0.06, p < 0.001) and fingolimod (odds ratio = 0.04; 95% CI = 0.01–0.12) were associated with lower seroconversion following the SARS‐CoV‐2 vaccine. All other drugs did not differ significantly from the untreated cohort. Both time since last anti‐CD20 treatment and total time on treatment were significantly associated with the response to the vaccination. The vaccine type significantly predicted seroconversion, but not in those on anti‐CD20 medications. Preliminary data on cellular T‐cell immunity showed 40% of seronegative subjects had measurable anti‐SARS‐CoV‐2 T cell responses.

Interpretation

Some disease modifying therapies convey risk of attenuated serological response to SARS‐CoV‐2 vaccination in people with MS. We provide recommendations for the practical management of this patient group. ANN NEUROL 20219999:n/a–n/a

Non-motor phenotypic subgroups in adult-onset idiopathic, isolated, focal cervical dystonia

BACKGROUND

Non-motor symptoms are well established phenotypic components of adult-onset idiopathic, isolated, focal cervical dystonia (AOIFCD). However, improved understanding of their clinical heterogeneity is needed to better target therapeutic intervention. Here, we examine non-motor phenotypic features to identify possible AOIFCD subgroups.

METHODS

Participants diagnosed with AOIFCD were recruited via specialist neurology clinics (dystonia wales: n = 114, dystonia coalition: n = 183). Non-motor assessment included psychiatric symptoms, pain, sleep disturbance, and quality of life, assessed using self-completed questionnaires or face-to-face assessment. Both cohorts were analyzed independently using Cluster, and Bayesian multiple mixed model phenotype analyses to investigate the relationship between non-motor symptoms and determine evidence of phenotypic subgroups.

RESULTS

Independent cluster analysis of the two cohorts suggests two predominant phenotypic subgroups, one consisting of approximately a third of participants in both cohorts, experiencing increased levels of depression, anxiety, sleep impairment, and pain catastrophizing, as well as, decreased quality of life. The Bayesian approach reinforced this with the primary axis, which explained the majority of the variance, in each cohort being associated with psychiatric symptomology, and also sleep impairment and pain catastrophizing in the Dystonia Wales cohort.

CONCLUSIONS

Non-motor symptoms accompanying AOIFCD parse into two predominant phenotypic sub-groups, with differences in psychiatric symptoms, pain catastrophizing, sleep quality, and quality of life. Improved understanding of these symptom groups will enable better targeted pathophysiological investigation and future therapeutic intervention.

Socioeconomic status and disability progression in multiple sclerosis: A multinational study

OBJECTIVE

To examine the association between socioeconomic status (SES) and disability outcomes and progression in multiple sclerosis (MS).

METHODS

Health administrative and MS clinical data were linked for 2 cohorts of patients with MS in British Columbia (Canada) and South East Wales (UK). SES was measured at MS symptom onset (±3 years) based on neighborhood-level average income. The association between SES at MS onset and sustained and confirmed Expanded Disability Status Scale (EDSS) 6.0 and 4.0 and onset of secondary progression of MS (SPMS) were assessed using Cox proportional hazards models. EDSS scores were also examined via linear regression, using generalized estimating equations (GEE) with an exchangeable working correlation. Models were adjusted for onset age, sex, initial disease course, and disease-modifying drug exposure. Random effect models (meta-analysis) were used to combine results from the 2 cohorts.

RESULTS

A total of 3,113 patients with MS were included (2,069 from Canada; 1,044 from Wales). A higher SES was associated with a lower hazard of reaching EDSS 6.0 (adjusted hazard ratio [aHR] 0.90, 95% confidence interval [CI] 0.89-0.91), EDSS 4.0 (aHR 0.93, 0.88-0.98), and SPMS (aHR 0.94, 0.88-0.99). The direction of findings was similar when all EDSS scores were included (GEE: β = -0.13, -0.18 to -0.08).

CONCLUSIONS

Lower neighborhood-level SES was associated with a higher risk of disability progression. Reasons for this association are likely to be complex but could include factors amenable to modification, such as lifestyle or comorbidity. Our findings are relevant for planning and development of MS services.

Multiple sclerosis: long-term outcomes in ethnic minorities. Analysis of a UK population-based registry

BACKGROUND AND PURPOSE

Multiple sclerosis (MS) is most frequent in Caucasian populations. However, studies of MS in other ethnic groups may offer unique insights into genetic and environmental influences on the disease, and data on long-term outcomes in these patients is limited. In this work clinical features and time to disability milestones were investigated in ethnic minority (EM) patients with MS in a UK population and comparisons were made to a Caucasian cohort from the same region.

METHODS

In all, 1949 MS patients (1866 Caucasian, 83 EM) were identified from a regional disease registry. Cox proportional hazards regression was used to analyse the time to Expanded Disability Status Scale (EDSS) 3.0, 4.0 and 6.0.

RESULTS

Ethnic minority patients were younger at disease onset (28.6 years vs. 32.8 years, P = 0.001), and primary progressive MS was less common (EM 4.8%, Caucasian 11.6%, P = 0.03). After correction for clinical variables, ethnicity was associated with time to EDSS 3.0 [EM: hazard ratio (HR) 1.75, P < 0.0001] and 4.0 (HR 1.46, P = 0.03), but not 6.0 (HR 1.5, P = 0.05).

CONCLUSIONS

Ethnic minority patients reach early levels of fixed disability more rapidly than Caucasian patients, but this effect diminishes at later stages of the disease. This has implications for clinical management of these patients.

Tissue microarray methodology identifies complement pathway activation and dysregulation in progressive multiple sclerosis

The complement pathway has potential contributions to both white (WM) and grey matter (GM) pathology in Multiple Sclerosis (MS). A quantitative assessment of complement involvement is lacking. Here we describe the use of Tissue MicroArray (TMA) methodology in conjunction with immunohistochemistry to investigate the localization of complement pathway proteins in progressive MS cortical GM and subcortical WM. Antibodies targeting complement proteins C1q, C3b, regulatory proteins C1 inhibitor (C1INH, complement receptor 1 (CR1), clusterin, factor H (FH) and the C5a anaphylatoxin receptor (C5aR) were utilised alongside standard markers of tissue pathology. All stained slides were digitised for quantitative analysis. We found that numbers of cells immunolabelled for HLA-DR, GFAP, C5aR, C1q and C3b were increased in WM lesions (WML) and GM lesions (GML) compared to normal appearing WM (NAWM) and GM (NAGM), respectively. The complement regulators C1INH, CR1, FH and clusterin were more abundant in WM lesions, while the number of C1q+ neurons were increased and the number of C1INH+, clusterin+, FH+ and CR1+ neurons decreased in GM lesions. The number of complement component positive cells (C1q, C3b) correlated with complement regulator expression in WM, but there was no statistical association between complement activation and regulator expression in the GM. We conclude that TMA methodology and quantitative analysis provides evidence of complement dysregulation in MS GML, including an association of the numerical density of C1q+ cells with tissue lesions. Our work confirms that complement activation and dysregulation occur in all cases of progressive MS and suggest that complement may provide potential biomarkers of the disease.

Tissue microarray methodology identifies complement pathway activation and dysregulation in progressive multiple sclerosis

The complement pathway has potential contributions to both white (WM) and grey matter (GM) pathology in Multiple Sclerosis (MS). A quantitative assessment of complement involvement is lacking. Here we describe the use of Tissue MicroArray (TMA) methodology in conjunction with immunohistochemistry to investigate the localization of complement pathway proteins in progressive MS cortical GM and subcortical WM. Antibodies targeting complement proteins C1q, C3b, regulatory proteins C1 inhibitor (C1INH, complement receptor 1 (CR1), clusterin, factor H (FH) and the C5a anaphylatoxin receptor (C5aR) were utilised alongside standard markers of tissue pathology. All stained slides were digitised for quantitative analysis. We found that numbers of cells immunolabelled for HLA-DR, GFAP, C5aR, C1q and C3b were increased in WM lesions (WML) and GM lesions (GML) compared to normal appearing WM (NAWM) and GM (NAGM), respectively. The complement regulators C1INH, CR1, FH and clusterin were more abundant in WM lesions, while the number of C1q+ neurons were increased and the number of C1INH+, clusterin+, FH+ and CR1+ neurons decreased in GM lesions. The number of complement component positive cells (C1q, C3b) correlated with complement regulator expression in WM, but there was no statistical association between complement activation and regulator expression in the GM. We conclude that TMA methodology and quantitative analysis provides evidence of complement dysregulation in MS GML, including an association of the numerical density of C1q+ cells with tissue lesions. Our work confirms that complement activation and dysregulation occur in all cases of progressive MS and suggest that complement may provide potential biomarkers of the disease.

Alemtuzumab for multiple sclerosis: Long term follow-up in a multi-centre cohort

Background:

Alemtuzumab has recently been approved for treatment of relapsing MS, but concerns remain about its use since long-term studies of adverse events remain limited. Furthermore, a clear understanding of its application and durability of effect in clinical practice has yet to evolve.

Objectives:

To investigate long-term efficacy and safety outcomes in a multicentre cohort of patients treated with alemtuzumab.

Methods:

Patients treated from 2000 and followed-up at three regional centres were identified. Baseline and prospective data were obtained and validated by clinical record review.

Results:

One hundred patients were identified with a mean follow-up of 6.1 years (range 1–13). Forty patients were retreated with at least one further treatment cycle. Annualized relapse rates fell from 2.1 to 0.2 ( p<0.0001) post-treatment and were sustained for up to eight years of follow-up. Mean change in EDSS score was +0.14. Forty-seven patients developed secondary autoimmunity.

Conclusion:

Observed reduction in relapse rates reflected those reported in clinical trials, but we were unable to corroborate previous observations of disability reversal. 40% of patients required additional treatment cycles. Autoimmune adverse events were common, occurring at a higher rate than previously reported, but were largely predictable, and could be managed effectively within a rigorous monitoring regime.

Specific timely appointments for triage reduced waiting lists in an outpatient physiotherapy service

OBJECTIVES

Waiting lists with triage systems are commonly used in outpatient physiotherapy but may not be effective. Could an alternative model of access and triage reduce waiting times over a sustained period with no additional resources?

DESIGN

Observational study comparing retrospective data for 11 months prior to the introduction of a new model of access compared with data for the equivalent 11 months afterwards.

PARTICIPANTS

Patients referred to a physiotherapy outpatient department at an outer metropolitan hospital before (n=721) and after (n=707) the introduction of the new model.

INTERVENTION

A model of access and triage known as 'specific timely appointments for triage' (STAT), in which appointment slots are preserved in advance specifically for new patients based on calculation of average demand.

OUTCOME MEASURES

Time from referral to first assessment, number of appointments per patient, occasions of non-attendance and total length of stay in the service.

RESULTS

Median time from referral to first appointment was 18 days [interquartile range (IQR) 11 to 33 days] in the pre-intervention group, compared with 14 days (IQR 9 to 21 days) in the post-intervention group (P<0.01). The number of physiotherapy appointments also reduced (IQR 2 to 6 vs IQR 1 to 4; P<0.01). There were no changes in non-attendance rates or total time in the service.

CONCLUSION

Waiting time for outpatient physiotherapy was 22% lower in the year following the introduction of the STAT model. While acknowledging the limitations of a pre- and post-measurement design, this model may have potential for reducing waiting times for outpatient physiotherapy without additional resources.

DISEASE MODIFYING TREATMENTS IN MS: INDUCTION OR ESCALATION?

Background

It is currently unclear whether aggressive induction or stepwise escalation of DMTs provides optimum long term outcomes for patients with MS.

Objective

Compare clinical outcomes in clinical practice amongst unmatched patient groups receiving either initial monoclonal induction, injectable DMT only or escalation from injectable DMT.

Methods

A subset of a population-based cohort identified 268 patients, with a median follow up post treatment of 5.4 years. Time to disability end points (EDSS) were examined using survival analysis.

Results

Monoclonals (25%) pre and post treatment annual relapse rate reduced from 2.28 (±1.92) to 0.28 (±0.42) 88% reduction; injectables (62%) from 1.08 (±0.97) to 0.4 (±1.03), 63% reduction; escalation (13%) had elevated rates of 1.72 (±2.04) to 0.64 (±0.54), only 63% reduction. Time to EDSS4 was shorter for monoclonal against injectable and escalation strategies: 5.7 vs 12 vs 6.8 years, p=0.0002. Time to EDSS6 was similar for the treatment strategies respectively: 14.6 vs 16.4 vs 13.3 years, p=0.13.

Conclusions

Patients requiring escalation had relatively worse outcomes, and could be identified as having higher disease activity on treatment initiation. This data suggest that initial selection of DMT class does not significantly affect long term outcome to EDSS6, or conversely, aggressive induction slows the rate of disability progression to EDSS6.

Modelling the natural history of primary progressive multiple sclerosis

BACKGROUND

A minority of patients with multiple sclerosis (MS) have primary progressive disease (PPMS). Treatment options are currently limited, but as prospects for interventional studies become more realistic, understanding contemporary outcome data will be key to successful trial design.

METHODS

234 PPMS patients were identified from a population-based cohort of 2131 (11.0%) and mean follow-up of 13.1 years. Time to established disability endpoints was compared with patients with relapsing-onset MS (ROMS) using survival analysis, and Cox regression employed to explore factors contributing to disability accumulation. Results were used to create predictive power models for clinical trials in PPMS.

RESULTS

Time to fixed disability milestones was shorter than in ROMS (Expanded Disability Status Scale (EDSS) 4.0:8.1 vs. 17.1 years, p<0.001; EDSS 6.0: 9.6 vs. 22.1 years, p<0.001; EDSS 8.0: 20.7 vs. 39.7 years, p<0.001), but there were no differences in age-related disability. Age and cerebellar symptoms at onset affected rate of progression. Modelling of these data indicated that trials employing EDSS change of 1.0 as the primary outcome measure would be powered to detect a 20% difference in progression using 600 patients with initial EDSS of 4.0 per trial arm, or 400 patients with initial EDSS of 5.0 per arm. However, trials including patients with fixed EDSS of ≥6.0 will be underpowered even with large numbers or prolonged duration.

CONCLUSIONS

Disability progression in PPMS is variable and influenced by age at onset. Although progression is more rapid, age-related disability milestones are identical to relapsing-onset disease. These data offer a contemporary paradigm for clinical trial design in progressive MS.

Site-specific clinical disease onset in multiple sclerosis

BACKGROUND AND PURPOSE

Multiple sclerosis is a chronic inflammatory disorder of the central nervous system characterized by acute episodes of neurological dysfunction thought to reflect focal areas of demyelination occurring in clinically eloquent areas. These symptomatic relapses are generally considered to be random clinical events occurring without discernible pattern. The hypothesis that relapses may follow a predetermined sequence and may provide insights into underlying pathological processes was investigated.

METHODS

Employing prospective clinical database data from 1482 patients who had experienced one or more consecutive relapses were analysed. Using regression analysis, site and symptom of index event were compared with those of first relapse.

RESULTS

It is demonstrated that following disease ignition subsequent relapses may not be random events but dependent on characteristics of the index event. All anatomical sites were more likely to be affected in the first relapse if that site had been involved in the index event with a similar association observed when comparing by symptoms.

CONCLUSION

These findings have importance in understanding the evolution of the disease and predicting individual disease progression and may aid with patient counselling and management.

The aetiology of acute neurological decline in multiple sclerosis: Experience from an open-access clinic

Background:

Multiple sclerosis (MS) relapses contribute to disability and influence treatment decisions. Many centres now provide open access to specialist services for patients with new symptoms. However, there is scarce literature on the spectrum of presentations encountered in this setting.

Objective:

The objective of this paper is to characterise presentations to an open, rapid-access MS relapse clinic and the impact on disease management.

Methods:

A retrospective review of outpatient episodes over a three-year period was conducted. Demographic and service data, symptoms, disability, diagnosis and management were recorded according to a standardised proforma.

Results:

A total of 371 attendances were analysed. A new MS relapse was diagnosed in 216 (58%) episodes, of which 56 (26%) patients had an additional diagnosis which had also contributed to their presentation. Of 266 reports of non-relapse-related symptoms, 73 were unrelated to MS. Treatment interventions were made in almost all relapsing patients and in 70% of patients presenting with acute, non-relapse-related symptoms of MS. Changes to disease-modifying therapies were considered in 28% of consultations.

Conclusion:

Diagnosing MS relapses is crucial for disease management and yet remains challenging. Clinicians should be aware of differential diagnoses and confounding factors. The high incidence of therapeutic interventions observed suggests that rapid-access clinics represent an effective platform for responsive disease management.

Pheromone interactions and ionic communication in gametes of aquatic fungusAllomyces macrogynus

The flagellate male and female gametes of the aquatic fungusAllomyces macrogynus are each attracted to a sexual pheromone produced by the opposite gamete type. The sperm attractant, sirenin, causes chemotaxis to female gametes. Examination of sperm chemotaxis shows that the pheromone influences the frequency of directional changes and the duration of a chemotactic run. Physiological experiments using tertiary amine local anesthetics or calcium chelators such as EGTA demonstrate that sirenin stimulates the influx of calcium ions (Ca(2+)) into the sperm cytoplasm. Radiological experiments with(45)CaCl2 have demonstrated this calcium flux directly. Structurally, sirenin is an oxygenated sesquiterpene that consists of a cyclopropyl ring attached onto an isohexenyl side chain. The pheromone displays a threshold concentration for attraction at 10 pM in chemotaxis bioassays. Structure-activity relationships with racemic sirenin and sirenin analogs indicate that biological activity requires a terminal hydroxymethyl group on the side chain. In addition, a hydrophobic group must be present at the other end of the sirenin molecule. Besides sirenin, the sperm cells ofA. macrogynus produce a female attractant, parisin. While the molecular nature of this attractant is not completely resolved, some general features of the molecule suggest it may be similar structurally to sirenin.

Demographic and clinical factors associated with changes in employment in multiple sclerosis

OBJECTIVE

The objective of this paper is to investigate demographic and disease factors associated with changes in employment role and status in multiple sclerosis (MS).

METHODS

Questionnaires on current symptoms, employment status and factors associated with changes in employment were sent to a community sample of 566 MS patients.

RESULTS

A total of 221 completed questionnaires were analysed. Of 169 employed at diagnosis, 43.3% had left employment at a mean of 11.9 years after disease onset. Of those still employed, 55% had changed their role or working hours to accommodate symptoms relating to their disease. These patients reported greater fatigue (p = 0.001), pain (p = 0.033) and memory problems (p = 0.038) than those whose employment had remained unaffected. Multinomial logistic regression revealed the factors most strongly predictive of employment status were disability level, years of education, disease duration and fatigue (p = 0.032).

CONCLUSIONS

Despite changes to public perceptions and legislative protection over the last 20 years, high rates of MS patients still leave the workforce prematurely, reduce working hours or change employment roles. These data have significant implications when considering social and economic impacts of MS, support the value of employment metrics as long-term outcome measures, and demonstrate the need to improve employment requirements and flexibility of working practices in individuals with MS.

Long-term outcome of paediatric-onset multiple sclerosis: a population-based study

BACKGROUND

Age of onset of multiple sclerosis (MS) peaks in the 3rd and 4th decades and is rarely less than 18. Robust longitudinal studies in paediatric-onset MS (POMS) are limited, and a clearer understanding of outcome could optimise management strategies.

METHODS

Patients with disease onset <18 years were identified from a prospective population-based register. Clinical features including presenting symptoms, time to Expanded Disability Status Scale (EDSS) 4.0, 6.0 and 8.0 and onset of secondary progression were compared with patients with adult-onset MS (AOMS).

RESULTS

111 POMS patients were identified from a cohort of 2068. No significant differences in sex ratio, familial recurrence, relapse rate, ethnicity or clinical symptoms at presentation were identified between POMS and AOMS. However, interval to second relapse was longer (5 vs 2.6 years, p=0.04) and primary progressive disease was less common (0.9% vs 8.5%, p=0.003) in POMS than in AOMS. POMS patients also took longer to develop secondary progressive disease (32 vs 18 years, p=0.0001) and to reach disability milestones (EDSS 4.0, 23.8 vs 15.5 years, p<0.0001; EDSS 6.0, 30.8 vs 20.4 years, p<0.0001; EDSS 8.0, 44.7 vs 39 years, p=0.02), but did so between 7.0 and 12 years younger than in AOMS.

CONCLUSIONS

5.4% of patients with MS have POMS (2.7% <16 years; 0.3% <10 years) and have distinct phenotypic characteristics in early disease. Furthermore, while patients with POMS take longer to reach disability milestones, they do so at a younger age than their adult counterparts and could be considered to have a poorer prognosis. Management strategies for these patients should take account of these data.

Multiple sclerosis relapses and depression

OBJECTIVE

The expression of clinically significant depression symptoms during and post multiple sclerosis (MS) relapse was investigated. The point prevalence of possible depression during a confirmed MS relapse and at 2 and 6months post-relapse was examined and the influence of disability on the time course of depression symptoms post-relapse determined.

METHODS

132 sequential patients were recruited from an open access relapse clinic. Clinical data including disability (Expanded Disability Status Scale: EDSS) and depression symptoms (Hospital Anxiety and Depression Scale depression subscale: HADS-D) were recorded at 0, 2 and 6months post-relapse.

RESULTS

Prevalence of possible depression (HADS-D score of≥8) was 44.5% during relapse, reducing to 29.2% at 2months and 34.4% at 6months post-relapse. HADS-D scores were significantly lower at follow-up than during relapse. Possible depression at relapse was significantly related to a higher likelihood of possible depression at 2month follow-up (OR 12.12) and improvement in EDSS was related to a lower likelihood (OR 0.51). EDSS at relapse (OR 1.47) and possible depression at relapse (OR 11.87) were significantly associated with possible depression 6months post-relapse.

CONCLUSIONS

High rates of possible depression were observed during relapse. Although depression scores reduced significantly post-relapse, rates of possible depression at follow-ups remained high. The results suggest that although improvements in disability may influence depression symptoms over the short-term, once depression symptoms are elevated at relapse then depression symptoms become persistent. Further studies are required on the relationship between relapses and depression and whether targeted psychological interventions are beneficial.

Neurohypophysial hormones and renal function in fish and mammals

The two major basic neurohypophysial peptides, arginine vasopressin (AVP) of mammals and arginine vasotocin (AVT) of all non-mammalian vertebrates, share common structure and major roles in regulating renal function. In this review the complexity of AVP actions within the mammalian kidney is discussed and comparisons are made with the emerging picture of AVT's renal effects in fish. It has become apparent that the antidiuretic action of the neurohypophysial hormones is an ancient phylogenetic phenomenon, although this is based upon reduced glomerular filtration in fish by comparison with predominant tubular effects in mammals. Nonetheless, there appears to be retention of AVP effects upon the functional heterogeneity of nephron populations in mammals. Preliminary evidence for the possible existence of V(2)-type (tubular) neurohypophysial hormone receptors in fish, implies possible AVT actions which parallel those in mammals on tubular ion transport. Further insight from recent mammalian tubule microperfusion studies suggests that in teleost fish both apical (tubular lumen) and basolateral (blood borne) AVT have the potential to modulate renal function, though this remains to be examined.

Effects of Analogs of the Fungal Sexual Pheromone Sirenin on Male Gamete Motility in Allomyces macrogynus

The ability of various structural analogs of the sexual pheromone sirenin to attract male gametes of the aquatic fungus Allomyces macrogynus was determined. Previous studies had shown that several structural analogs and stereoisomers of natural l-sirenin were devoid of activity at physiological concentrations. We now report the discovery of a structural analog that exhibits biological activity indistinguishable from the natural pheromone. The bioassay system used to determine chemotaxis was calibrated using synthetic, racemic sirenin, which exhibited a threshold concentration for gamete attraction at an applied concentration of 10 picomolar. The new synthetic monohydroxy analog of sirenin also had a threshold concentration of 10 picomolar. In the process of developing a new total synthesis of sirenin, a variety of other analogs were prepared and tested. All of these analogs exhibited threshold concentrations at 1 micromolar or higher, although attraction at these higher concentrations still varied according to their structural resemblance to sirenin. Thus, the results of these studies demonstrate that the hydroxymethyl group attached to the six-membered ring of sirenin is not essential for biological activity at physiological concentrations. The studies with other analogs demonstrate that biological activity at any concentration involves a balance between hydrophilic hydroxyl groups and hydrophobic hydrocarbon groups in the structure.