Correlates and trajectories of relapses in relapsing-remitting multiple sclerosis

BACKGROUND AND AIMS

In people with relapsing-remitting multiple sclerosis (pwRRMS), data from studies on non-pharmacological factors which may influence relapse risk, other than age, are inconsistent. There is a reduced risk of relapses with increasing age, but little is known about other trajectories in real-world MS care.

METHODS

We studied longitudinal questionnaire data from 3885 pwRRMS, covering smoking, comorbidities, disease-modifying therapy (DMT), and patient-reported outcome measures, as well as relapses during the past year. We undertook Rasch analysis, group-based trajectory modelling, and multilevel negative binomial regression.

RESULTS

The regression cohort of 6285 data sets from pwRRMS over time showed that being a current smoker was associated with 43.9% greater relapse risk; having 3 or more comorbidities increased risk and increasing age reduced risk. Those diagnosed within the last 2 years showed two distinct trajectories, both reducing in relapse frequency but 25.8% started with a higher rate and took 4 years to reduce to the rate of the second group. In the cohort with at least three data points completed, there were three groups: 73.7% followed a low stable relapse rate, 21.6% started from a higher rate and decreased, and 4.7% had an increasing then decreasing pattern. These different trajectory groups showed significant differences in fatigue, neuropathic pain, disability, health status, quality of life, self-efficacy, and DMT use.

CONCLUSIONS

These results provide additional evidence for supporting pwRRMS to stop smoking and underline the importance of timely DMT decisions and treatment initiation soon after diagnosis with RRMS.

University education facilitates uptake of disease-modifying therapies for multiple sclerosis: A community-based study using the UK MS Register

BACKGROUND

Higher education is associated with better job opportunities and higher income.

OBJECTIVES

Herein, the impact of education on the uptake of disease-modifying therapies (DMTs) for multiple sclerosis (MS) in a publicly funded health care system was examined using the UK MS Register.

METHODS

All adult participants with relapsing remitting MS diagnosed between 2008 and 2021 were included. Those without data regarding their education levels were excluded. Binary, multinomial and Cox regression models were used to examine the association between education levels and uptake of DMTs.

RESULTS

A total of 6317 participants fulfilled all inclusion and exclusion criteria. A total of 1826/2923 (62%) participants with a university education were treated with DMTs, compared to 1788/3394 (53%) participants with school/diploma received DMTs with an odds ratio of 1.318 (1.178-1.473). Participants with a university education were more likely to be treated with both moderate- and high-efficacy DMTs, compared to others, with odds ratios of 1.227 (1.087-1.385) and 1.545 (1.325-1.802), respectively. University education was also a positive predictor for faster initiation of DMTs, and, importantly, higher-efficacy DMTs.

CONCLUSION

In a publicly funded health care system, despite intended equality of access, university education was associated with a higher uptake of DMTs.

Ethnic disparities in the epidemiological and clinical characteristics of multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS) is a neuroinflammatory disorder which affects 2.8 million people world-wide. A growing body of evidence shows ethnic disparities in MS. This review aims to evaluate differences, based upon ethnic background, in the incidence, prevalence, disease course, and efficacy of disease-modifying therapies (DMTs) among people with MS (PwMS).

METHOD

Ethnicities were classified as White, Black, Hispanic, Asian, and Middle Eastern and North African (MENA). A literature search was conducted using the PubMed search engine to identify articles on MS and ethnicity that were published in the English language between 01/01/2005 and 31/05/2022.

RESULTS

101 studies met all inclusion criteria. Although the incidence and prevalence of MS varied among ethnicities, findings were inconsistent and depended on the continent of the study. Ethnicity may have an impact on the disease course. PwMS from Black, Hispanic, and MENA, but not Asian ethnicities, appeared to accumulate physical disability at a faster rate than those from White ethnicity. Although there was a lack of studies evaluating the relative safety and efficacy of DMTs among various ethnicities, interferon-beta was found to be less efficacious in PwMS from Black ethnicity.

CONCLUSIONS

Further studies, with more uniform definitions of ethnicity are required to comprehensively understand ethnic disparities in MS, in particular to identify underlying causes, to facilitate the delivery of personalised medical care and avoid inequity.

Multiple Sclerosis vision questionnaire (MSVQ-7): Reliability, validity, precision and discrimination

BACKGROUND

Visual dysfunction is common in people with Multiple Sclerosis (pwMS), associated with a variety of visual symptoms. Capturing the patient experience of these complex patterns of visual pathology is challenging. A valid and reliable patient reported measure, capable of detecting clinically significant change, would have considerable research and clinical benefits. We examined the properties of the MS Vision Questionnaire (MSVQ-7) in a large MS population.

METHODS

Data were collected from participants in the UK-wide Trajectories of Outcome in Neurological Conditions-MS (TONiC-MS) study: MS subtype and Expanded Disability Status Scale (EDSS) band from the clinical team, as well as serial packs including the MSVQ-7 and questionnaires on depression, anxiety and stigma. A calibration sample of 1000 pwMS contributing several years of follow-up were split into training and validation samples for a Confirmatory Factor Analysis and Rasch analysis. The Minimal Detectable Change (MDC) was computed as well as the Minimal Clinically Important Change (MIC), by an anchor-based method, for different MS subtypes.

RESULTS

The MSVQ-7 is unidimensional and can be fit to the Rasch model with a solution discarding 3% of variance. Providing all 7 items are answered, the total can be converted to an interval-level metric for calculation of change scores and other parametric analyses. The % of missing values did not exceed 1.7%. Among 5478 pwMS, 80% reported visual problems. MSVQ-7 scores were categorised as mild for 36.1%, moderate for 33.6% and severe for 10.3%, and varied by MS subtype. In the follow-up sample of 2227 pwMS, 42.5% changed MSVQ-7 category between baseline and first follow-up (mean 22.6 months). The MIC exceeded the MDC so clinically significant change exceeds measurement error. While MDC was identical for relapsing and progressive MS, MIC varied by MS subtype, with smaller MIC in relapsing MS. Over one-quarter of the follow-up sample reported a clinically significant change in MSVQ-7: 12.2% improved and 13.5% deteriorated. For pwMS recruited within 2 years of diagnosis, 17.3% reported significant change on follow-up, all improving. MSVQ-7 scores showed strong associations with anxiety, depression and stigma (effect sizes>0.8). Duration, EDSS band and MS subtype all had effect sizes 0.2-0.49. A multinomial logistic regression exploring vision disturbance and depression, adjusted for age, gender, MS subtype, duration and disability, showed vision is the strongest significant predictor of depression. Each unit increase in interval MSVQ-7 increases risk by 10% of 'possible' and by 17% of 'probable' depression.

CONCLUSIONS

The MSVQ-7 is a brief self-report measure of visual problems for pwMS. It can easily be converted to interval-level measurement for change scores or power calculations and has good precision and discrimination. Visual problems were reported by 80% of pwMS and changed over time, evidencing the need for regular monitoring. MIC varied by MS subtype, indicating that perception of impact changes over the disease course. Visual dysfunction significantly affects depression risk and perceived stigma, highlighting the importance of routine assessment of visual problems in comprehensive care. The MSVQ-7 has strong psychometric properties for adoption as a measure for vision in clinical and research settings.

Measuring disability in multiple sclerosis: the WHODAS 2.0

INTRODUCTION

Reliable measurement of disability in multiple sclerosis (MS) using a comprehensive, patient self-reported scale, such as the World Health Organization Disability Assessment Schedule (WHODAS) 2.0, would be of clinical and research benefit.

METHODS

In the Trajectories of Outcome in Neurological Conditions-MS study, WHODAS 2.0 (WHODAS-36 items for working, WHODAS-32 items if not working, WHODAS-12 items short-form) was examined using Rasch analysis in 5809 people with MS.

RESULTS

The 36- and 32-item parallel forms, and the cognitive and physical domains, showed reliability consistent with individual or group use. The 12-item short-form is valid for group use only. Interval level measurement for parametric statistics can be derived from all three scales which showed medium to strong effect sizes for discrimination across characteristics such as age, subtype, and disease duration. Smallest detectable difference for each scale was < 6 on the standardised metric of 0-100 so < 6% of the total range. There was no substantial differential item functioning (DIF) by age, gender, education, working full/part-time, or disease duration; the finding of no DIF for time or sample supports the use of WHODAS 2.0 for longitudinal studies, with the 36- and 32-item versions and the physical and cognitive domains valid for individual patient follow-up.

CONCLUSIONS

Disability in MS can be comprehensively measured at interval level by the WHODAS 2.0, and validly monitored over time. Routine use of this self-reported measure in clinical and research practice would give valuable information on the trajectories of disability of individuals and groups.

Measuring coping in multiple sclerosis: The Coping Index-MS

BACKGROUND

Coping in multiple sclerosis (MS) refers to cognitive and behavioural efforts to manage stresses imposed by the illness. Existing generic and disease-specific coping scales do not meet modern guidelines for scale development and cannot produce interval-level metrics to allow for change scores.

OBJECTIVE

The main aim of this study was to develop a brief patient-reported outcome measure for coping in MS, capable of interval-level measurement.

METHODS

Qualitative work in 43 people with MS leads to a draft scale which was administered to 5747 participants, with longitudinal collection in 2290. A calibration sample of 1000 subjects split into development and validation sets was used to generate three scales consistent with Rasch model expectations.

RESULTS

The total Coping Index-MS (CI-MS-T), CI-MS-Internal (CI-MS-I) and CI-MS-External (CI-MS-E) cover total, internal and externally focused coping. All three scales are capable of interval-level measurement. Trajectory analysis of 9000 questionnaires showed two trajectories in CI-MS-T: Group 1 showed a low level of coping with slight decline over 40 months, while Group 2 had a better and stable level of coping due to improving CI-MS-I which compensated for the deteriorating CI-MS-E over time. CI-MS-T < 30 identified group membership at baseline.

CONCLUSION

The CI-MS-T, CI-MS-I and CI-MS-E, comprising 20 items, provide interval-level measurement and are free-for-use in not-for-profit settings.

The association between deprivation and the access to disease modifying therapies for multiple sclerosis: An England wide community-based study in the UK MS Register

BACKGROUND

Deprivation can impact the access to health interventions in publicly funded health systems where cost is not the dominant barrier. In this study we examined whether deprivation affected the access to disease modifying therapies (DMTs) for multiple sclerosis (MS).

METHODS

All English adults on the UK MS register with relapsing remitting MS who were diagnosed between 2010 and 2017, and after the age of 29 years were included. Deprivation was measured using postcode-based 2015 English index of multiple deprivation (IMD), which was divided into quintiles.

RESULTS

A total of 1449 participants were eligible and 531/1449 (36.6%) received DMTs. Participants who lived in more deprived areas, based on their IMD scores, were significantly less likely to receive DMTs (odds ratio = 0.69, 95% Confidence interval = 0.49 to 0.98); barriers to housing and services contributed to this disparity. The Nagelkerke R² value of these models showed that 2% of variation in accessing DMTs were dependant on deprivation.

CONCLUSIONS

Deprivation, as measured by IMD, negatively influences the access to DMTs in England. Our findings also suggest that the lack of access to local MS DMT clinics in deprived areas may contribute to this disparity.

Relationship between intervention dosage and success of resource connections in a social needs intervention

OBJECTIVES

Social needs interventions in medical settings aim to mitigate the effects of adverse social circumstances on health outcomes by connecting vulnerable patients with resources. This study examined the relationship between intervention dosage and the success of resource connections using data from a social needs intervention in multiple clinical settings across the US.

STUDY DESIGN

The intervention uses a case management approach to connect patients with unmet needs to resources and services in the community. Intervention dosage was conceptualized as the number of contacts between the navigator and the patient, categorized as direct contact (phone vs. in person) and indirect contact (initiated by the navigator vs. patient). Success of the intervention was conceptualized as 'none,' 'partial,' or 'optimal' for each patient, based on the number of social needs the resource connections addressed.

METHODS

Administrative data were extracted for 38,404 unique patients who screened positive for unmet resource needs between 2012 and 2017. Owing to the large sample size, statistical corrections were made to reduce type I error.

RESULTS

Multinomial logistic regression analyses showed that higher intervention dosage was related to greater success of resource connections, after adjusting for the patient and site characteristics, and the number of needs (odds ratios ranged from 1.62 to 2.89). In-person contact, although received by only 25% of the patients, was associated with the highest probability of optimal success.

CONCLUSIONS

This study demonstrates a feasible way to conceptualize an intervention dose for a social needs intervention that uses a case management approach and has implications for how intervention delivery may improve success of resource connections.

Sexual functioning in multiple sclerosis: Relationships with depression, fatigue and physical function

Background:

Sexual dysfunction (SD) is common among people with multiple sclerosis, but there is limited information on its relationships.

Objective:

This national study examines the relationships between sexual function with demographic factors, physical function, fatigue and depression.

Methods:

Participants in the Trajectories of Outcomes in Neurological Conditions (TONiC) study completed the measures of fatigue, physical function and depression together with the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 (MSISQ-15), which covers sexual function (primary), symptoms that interfere with sexual function (secondary) and psychological issues (tertiary). All ordinal scores from the measures were converted to interval scale latent estimates via the Rasch model and used as single indicator latent variables in path analysis.

Results:

From 722 patients, 538 were sexually active of whom 431 (80.1%) answered questions on sexual functioning. Of these, only 18.5% reported no impact on any aspect of sexual function. Dysfunction was linked to disease subtype and Expanded Disability Status Scale (EDSS). Subtype influenced the relationship between symptoms and sexual function, which was fully mediated by psychological factors in secondary progressive patients. Depression was not directly associated with sexual functioning, but appeared as a consequence of the psychological issues associated with SD.

Conclusion:

SD is common among participants in this UK-wide study, and psychological aspects of SD contributed to depression.

Validation and Reliability of the Neuropathic Pain Scale (NPS) in Multiple Sclerosis

OBJECTIVE

Central neuropathic pain occurs in around 28% of patients with multiple sclerosis (MS). The Neuropathic Pain Scale (NPS) has received preliminary validation in peripheral neuropathic pain conditions. The aim of this study was to validate its use in MS central pain syndromes.

METHODS

We administered the NPS to 141 patients with MS, together with the Short Form McGill Pain Questionnaire (SFMPQ), the Hospital Anxiety and Depression Scale (HADS), and Short Form 36 Health Survey (SF-36).

RESULTS

Cronbach's alpha was 0.78 (95% CI 0.69; 0.83), implying a high degree of internal consistency. Three factors, "Familiar," "Superficial," and "Alien Perception," were extracted, accounting for 64% of the variance. The NPS 10-item total correlates with: the SFMPQ 15-item total score, rho=0.63 (95% CI 0.49; 0.74), its Visual Analog Scale, rho=0.49 (95% CI 0.33; 0.64), the transformed Pain domain of the SF-36 rho=-0.49 (95% CI -0.63; -0.32), but not with its remaining seven health domains, or with either the HADS anxiety or the depression scores. Limits of agreement for short-term test or re-test reliability of the 100 point NPS total (median 2 days, range 1 to 7) were -12 to 14 and when administered to 78 patients who rated their neuropathic pain the "Same" [median interval 33 days (range 19 to 126), the long-term test or re-test correlation coefficient was 0.71 (95% CI 0.6; 0.79)].

DISCUSSION

The NPS appears a useful tool in the assessment of neuropathic pain in MS patients and possibly in measuring outcomes of therapeutic interventions.

Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis

BACKGROUND

Central pain in multiple sclerosis (MS) is common and often refractory to treatment.

METHODS

We conducted a single-center, 5-week (1-week run-in, 4-week treatment), randomized, double-blind, placebo-controlled, parallel-group trial in 66 patients with MS and central pain states (59 dysesthetic, seven painful spasms) of a whole-plant cannabis-based medicine (CBM), containing delta-9-tetrahydrocannabinol:cannabidiol (THC:CBD) delivered via an oromucosal spray, as adjunctive analgesic treatment. Each spray delivered 2.7 mg of THC and 2.5 of CBD, and patients could gradually self-titrate to a maximum of 48 sprays in 24 hours.

RESULTS

Sixty-four patients (97%) completed the trial, 34 received CBM. In week 4, the mean number of daily sprays taken of CBM (n = 32) was 9.6 (range 2 to 25, SD = 6.0) and of placebo (n = 31) was 19.1 (range 1 to 47, SD = 12.9). Pain and sleep disturbance were recorded daily on an 11-point numerical rating scale. CBM was superior to placebo in reducing the mean intensity of pain (CBM mean change -2.7, 95% CI: -3.4 to -2.0, placebo -1.4 95% CI: -2.0 to -0.8, comparison between groups, p = 0.005) and sleep disturbance (CBM mean change -2.5, 95% CI: -3.4 to -1.7, placebo -0.8, 95% CI: -1.5 to -0.1, comparison between groups, p = 0.003). CBM was generally well tolerated, although more patients on CBM than placebo reported dizziness, dry mouth, and somnolence. Cognitive side effects were limited to long-term memory storage.

CONCLUSIONS

Cannabis-based medicine is effective in reducing pain and sleep disturbance in patients with multiple sclerosis related central neuropathic pain and is mostly well tolerated.

Implementation of the homeless families program: 1. Service models and preliminary outcomes

The implementation and early outcomes of a large-scale, services-enriched housing program for homeless families are evaluated and examined across nine metropolitan sites. Differing models of case management and service access are described. Early reports on families' residential stability are high across all service models.

Implementation of the homeless families program: 2. Characteristics, strengths, and needs of participant families

The characteristics and needs of homeless families participating in a large-scale services-enriched housing program are examined. Although not a representative sample, participants constitute one of the largest subsets of homeless families in the literature. Moreover, the sample, which encompasses nine sites, is focused on families with multiple problems who have been recurrently homeless. Differing constellations of needs and implications for service delivery are explored.

Mental health services for homeless mentally ill persons. Federal initiatives and current service trends

Recent research suggests that approximately one third of the population of homeless single adults suffer from severe mental illnesses. Despite multiple health, mental health, and social welfare needs, this population is often unable to obtain necessary housing and community-based services. For this reason, since 1982, the National Institute of Mental Health (NIMH) has undertaken a number of federal initiatives to encourage research and assist states and localities in improving services focused on this vulnerable subgroup of the homeless population. This article describes the target population, NIMH research findings, and current mental health service trends--with particular emphasis on two mental health programs established under the Stewart B. McKinney Homeless Assistance Act. Proposed future directions for federal research and evaluation efforts in this area are also discussed.

Mental health services for homeless mentally ill persons: Federal initiatives and current service trends

Recent research suggests that approximately one third of the population of homeless single adults suffer from severe mental illnesses. Despite multiple health, mental health, and social welfare needs, this population is often unable to obtain necessary housing and community-based services. For this reason, since 1982, the National Institute of Mental Health (NIMH) has undertaken a number of federal initiatives to encourage research and assist states and localities in improving services focused on this vulnerable subgroup of the homeless population. This article describes the target population, NIMH research findings, and current mental health service trends--with particular emphasis on two mental health programs established under the Stewart B. McKinney Homeless Assistance Act. Proposed future directions for federal research and evaluation efforts in this area are also discussed.

The feedback research approach to evaluation: a method to increase evaluation utility

The utilization of evaluation results continues to be a great concern among professionals in the field. To increase the potential usefulness of evaluation, the feedback research approach is proposed as a method that is especially helpful in studies that fail to find program effectiveness. Going beyond the bounds of the evaluation framework and studying the problem for which the program was designed to ameliorate, evaluations that incorporate a feedback research component can provide clients with valuable information to guide further program development. This paper provides a description of the approach and an illustration of its use in an evaluation of a major international corporation's health improvement/stress management program.

The psychiatric halfway house: how is it measuring up?

To obtain data on the effectiveness of the psychiatric halfway house and to update information about such facilities, 26 recent statistical reports were examined. Only two studies include control group comparisons. In addition to descriptive information, data are reported in terms of employment or school attendance and independent living as contrasted with rehospitalization. Results indicate that a median of approximately 80 per cent of halfway house residents adjusts to community living. Despite differences among halfway houses in resident selection, length of stay, rehabilitative criteria, and nature of follow-up, data suggest that rehospitalization rates are lower after residence in a halfway house. Some cautions are drawn regarding evaluative studies and potential attenuation of halfway house facilities to low-quality custodial care.