Young multiple sclerosis in Italy: attitude towards present life and expectations for the future

Background

Multiple sclerosis (MS) is usually diagnosed between 20 and 40 years, affecting the most productive and active period of life.

Aim

To analyse the health perception of young people with MS and to compare the present results with a previous one.

Methods

A descriptive cross-sectional study was conducted in 2017. A validate and anonymous questionnaire was administered to 613 Italian young, aged 18-40, affected by MS (women 78.5%).

Results

Analyzing the declared health status, most of young MS defined good health status (76% good or excellent health) with differences between age class (82% at 25-29 years vs 71% at 35-40) and with a reverse trend with the increasing of disability (92% in subject with no disability vs 34% in ones with a medium or severe disability). The comparison against 2004 data highlights an improvement in the health conditions perceived, also for ones with a serious disability. Regarding the time elapsed from diagnosis, the trend was not linear, since respondents with a diagnosis <1 year indicated a worst health condition than those with a diagnosis from 5 to 10 years. Significant percentage of them paid attention to positive attitudes in health promotion: 71% practiced physical activity, 70% controlled smoke and alcohol consumption, 38% was on a special diet.

Conclusions

Diagnosis and disability constitute a decisive factor in the assessment of the state of health, but the perception goes to stabilize with time, even if the conditions tend to worsen. In this regard, the worst declared conditions in patients with a recent diagnosis seem to be influenced by psychological factors. So, the moment of diagnosis need a better management. Only 30% got adult vaccination (vs 61% in young Italians) due to lack of information on vaccine safety in MS patients. The improvement of perceived health in young with MS is another proof of the progress of MS treatments, which appears transversal to all the conditions of disability.

Key messages

The perception of health is strongly related to disability and to time elapsed from diagnosis. In the last 15 years the progress of MS management improved well-being of all MS young patients.

Box and block test, hand grip strength and nine-hole peg test: correlations between three upper limb objective measures in multiple sclerosis

BACKGROUND AND PURPOSE

Limited data are available in the literature for upper limb impairment in multiple sclerosis (MS). This study aimed to report the distribution of values of hand grip strength (HGS), of the box and block test (BBT) and of the nine-hole peg test (9HPT) correlated with demographic and clinical data in subjects with MS.

METHODS

This study involved five Italian neurological centres. The inclusion criteria were age ≥ 18, MS diagnosis, stable disease phase, right-hand dominance. All subjects underwent HGS, BBT and 9-HPT evaluation.

RESULTS

In all, 202 subjects with MS were enrolled: 137 females; mean age 48.4 years; mean Expanded Disability Status Scale (EDSS) 4.17; mean disease duration 14.12 years; disease course 129 relapsing-remitting, 21 primary progressive and 52 secondary progressive MS subjects; mean right HGS 25.3 kg, left 23.2 kg; mean right BBT 45.7 blocks, left 44.9 blocks; mean right 9-HPT 30.7 s, left 33.4 s. All results were statistically significantly different compared to healthy controls. HGS, BBT and 9-HPT were associated with age, EDSS and disease duration, whilst disease course correlated with BBT and 9-HPT. The BBT and 9-HPT scores significantly differed according to level of disability (EDSS ≤3.0, 3.5-5.5, ≥6.0).

CONCLUSION

Hand grip strength and BBT value distribution in a large MS population is reported. Correlations between HGS, BBT and 9-HPT were generally low.

Nine Hole Peg Test asymmetry in refining upper limb assessment in multiple sclerosis

BACKGROUND

The Expanded Disability Status Scale (EDSS) is the most frequently used scale to measure neurologic impairment and quantify the level of disability in Multiple Sclerosis (MS) even though the scale focuses on ambulation and undervalues upper limb (UL) impairment. The 9-Hole Peg Test (9-HPT) is the gold standard for UL assessment in MS, calculating a mean score from right and left arms, even though subjects with MS often show a lateralization of neurological deficit.

OBJECTIVE

The study aimed to determine whether an interaction exists between mean right-left 9-HPT scores or 9HPT score asymmetry (difference between right and left side) in predicting EDSS in MS subjects.

METHODS

Demographic and disease variables and 9-HPT scores were obtained from medical records of individuals with MS collected in an ad-hoc database. Subjects with 9-HPT score ≤180 s for each arm were included. An asymmetry score was represented as the absolute value of the difference between 9-HPT scores for both arms.

RESULTS

549 subjects were included: 67.8% female, mean age 45±13.14 years, mean EDSS 3.98±2.12, 356 relapsing-remitting, 68 primary and 125 secondary progressive, mean 9-HPT scores: right arm 30.20 ± 19.99 s, left arm 31.80 ± 20.35 s. Mean asymmetry was 9.35±18.20 s. Correlation between mean right-left 9-HPT scores and EDSS was 0.58 (p<.001). Significant interaction between mean right-left 9-HPT scores and 9-HPT asymmetry in predicting EDSS scores was found. Regression slope of EDSS on mean right-left 9-HPT score decreases as asymmetry value increases (non-significance area values ≥ 40.93 s).

CONCLUSIONS

Findings suggest interaction exists between mean right-left 9-HPT scores and asymmetry in predicting EDSS. A consequence of this is that, by disregarding information about asymmetry, studies exploring the association between mean right-left 9-HPT scores and global measures of disability may provide biased results. The bias tends to increase as asymmetry increases, and to be most prevalent among patients with EDSS scores > 6.

Efficacy of levetiracetam on upper limb movement in multiple sclerosis patients with cerebellar signs: a multicenter double-blind, placebo-controlled, crossover study

BACKGROUND AND PURPOSE

The literature provides contrasting results on the efficacy of levetiracetam (LEV) in multiple sclerosis (MS) patients with cerebellar signs. It was sought to evaluate the efficacy of LEV on upper limb movement in MS patients.

METHODS

In this multicenter double-blind placebo-controlled crossover study, MS patients with prevalently cerebellar signs were randomly allocated into two groups: LEV followed by placebo (group 1) or placebo followed by LEV (group 2). Clinical assessments were performed by a blinded physician at T0 (day 1), T1 (day 22), T2 (2-week wash-out period, day 35) and T3 (day 56). The primary outcome was dexterity in the arm with greater deficit, assessed by the nine-hole peg test (9HPT). Secondary clinical outcomes included responders on the 9HPT (∆9HPT >20%), tremor activity of the daily living questionnaire and self-defined upper limb impairment, through a numeric rating scale. Kinematic evaluation was performed using a digitizing tablet, providing data on normalized jerk, aiming error and centripetal acceleration.

RESULTS

Forty-eight subjects (45.2 ± 10.4 years) were randomly allocated into two groups (n = 24 each). 9HPT significantly improved in the LEV phase in both groups (P < 0.001). The LEV treatment phase led to a significant improvement (P < 0.01) of all clinical outcomes in group 1 and in dexterity in group 2. No significant changes were reported during both placebo phases in the two groups. Considering the kinematic analysis, only normalized jerk significantly improved after treatment with LEV (T0-T1) in group 1.

CONCLUSIONS

Levetiracetam treatment seems to be effective in improving upper limb dexterity in MS patients with cerebellar signs.

Peer support groups in multiple sclerosis: current effectiveness and future directions

Peer support programs have become a common method of providing support for patients with chronic illness. Utilizing peers as resources has been proposed as an effective means for coping with a stressful life experience and for gaining support from others who share a common factor, although data are somewhat mixed on the efficacy of peer support. The aim of the present study was to evaluate the effectiveness of eight weeks of a standard form of peer support in improving quality of life and reducing depressive symptoms in 44 patients with multiple sclerosis (MS). O ne person from each of six groups participated in a training course in order to learn basic principles of peer support. Eight weekly sessions were held and patients completed self-administered questionnaires pre- and post- treatment assessing quality of life and depression. Results showed that support groups do not provide consistent improvement in quality of life or depression in patients with MS and suggest that patients who have better mental health functioning could be at risk for deterioration in support groups.

Implementation of the ‘Sapere Migliora’ information aid for newly diagnosed people with multiple sclerosis in routine clinical practice: a late-phase controlled trial

Background:

The SIMS-Trial showed that the ‘Sapere Migliora’ information aid (IA) for newly diagnosed people with multiple sclerosis (PwMS) effectively improved patient knowledge and satisfaction with care.

Objectives:

The objectives of this paper are to assess the effectiveness of the IA in clinical practice and to compare the whole IA with the take-home booklet/website component alone.

Methods:

After updating the IA and replacing the CD with a website, a prospective, open-label non-randomised controlled trial compared the whole IA (group A, five SIMS-Trial centres) to take-home (group B, 16 centres). One month after the intervention, participants completed the MS Knowledge Questionnaire (MSKQ), care satisfaction questionnaire (COSM-R) (primary study outcomes), Hospital and Anxiety Depression Scale, and ad hoc questionnaire appraising the IA.

Results:

We enrolled 159 newly diagnosed PwMS (May 2012–March 2013). Drop-outs were four of 77 (5%, group A) and 11/82 (13%, group B). Primary endpoint (highest tertile both for MSKQ and COSM-R section 2 scores) was achieved by 38/77 (49%) group A and 33/82 (40%) group B ( p = 0.25). Attainment of secondary outcomes was also similar between groups.

Conclusions:

This study shows that the entire IA is not superior to the booklet/website alone, and that both are comparable in efficacy to the intervention arm of the SIMS-Trial.

Trial registration number:

ISRCTN78940214.

Lack of information about multiple sclerosis in children can impact parents' sense of competency and satisfaction within the couple

The psychosocial consequences for parents of children with MS have not been studied.

OBJECTIVES

to assess aspects of coping with family crisis and individual states of distress in couples with a child with MS compared to couples of healthy children.

METHODS

fifteen couples with a child with MS and 29 couples with healthy children were assessed using self-administered scales on anxiety, depression, coping, marital and family aspects, quality of life and MS knowledge.

RESULTS

parents of children with MS were less satisfied with their parenting role and had a lower sense of parenting competence than control parents. While their depression scores were higher than control parents, they scored within the normal range. Mothers of children with MS were more worried than fathers and were more likely to use diverse coping strategies. Less knowledge of MS was correlated with less satisfaction with the couple relationship and with the quality of communication. There was a correlation between limited knowledge about the child's illness and the overall sense of competence as a parent.

CONCLUSIONS

lack of information about MS can impact family functioning, anxiety and parents' sense of competency. Parents require support in becoming more knowledgeable about MS in order to feel competent and satisfied in their role and to cope successfully.

Factors that influence the employment status of people with multiple sclerosis: a multi-national study

Paid employment is valuable for society and for the individual. A diagnosis of a chronic illness such as multiple sclerosis (MS) can influence a person's employment status. Previous studies have reported that demographic and disease-related aspects can predict whether a person with MS will leave their job. The aim of the study was to assess the factors that people with MS believe to contribute to their employment status and to determine whether any of these differentiate people with MS who are employed from those who are not employed. A multinational questionnaire assessed aspects related to employment that facilitate or hinder job maintenance. Data was collected in 18 European countries. A total of 1,141 questionnaires were completed. Of those responding, 694 (61%) subjects were employed and 477 (39%) were unemployed. The items that significantly differentiated the groups were related to MS symptoms, workplace environment and financial considerations. While MS influences employment status for many people who face difficult symptoms, aspects like a flexible work schedule and financial security are important and perhaps key to promoting job maintenance among people with MS.

An information aid for newly diagnosed multiple sclerosis patients improves disease knowledge and satisfaction with care

Background: Patients report information deficits in the period surrounding diagnosis of multiple sclerosis (MS). We assessed the effectiveness of an add-on information aid for newly diagnosed MS patients.

Methods: We randomly assigned 120 newly diagnosed MS patients from five Italian centres to diagnosis disclosure (current practice at the centre) or current practice plus information aid (ISRCTN81072971). The information aid consisted of a personal interview with a physician using a navigable compact disc and a take-home booklet. The primary composite endpoint was score in the highest tertile of MS knowledge and satisfaction with care questionnaires. Other endpoints were safety; treatment adherence; extra contacts/consultations; switching of care centre; and changes in Hospital Anxiety and Depression Scale and Control Preference Scale scores.

Results: At 1 month, 30/60 intervention and 8/60 control patients achieved the primary endpoint (odds ratio [OR] 6.5, 95% CI 2.6—16.0; p < 0.001; number needed to treat [NNT] 3). Figures at 6 months were 26/60 intervention and 11/60 control patients (OR 3.4, 95% CI 1.5—7.8; p = 0.04; NNT 4). There were no adverse events. No significant treatment effects were seen on secondary outcomes.

Conclusion: The information aid was safe and significantly associated with attainment of the primary outcome at 1 and 6 months.

Development and validation of a patient self-assessed questionnaire on satisfaction with communication of the multiple sclerosis diagnosis

Background: We describe the development and clinical validation of a patient self-administered tool assessing the quality of multiple sclerosis diagnosis disclosure.

Method: A multiple sclerosis expert panel generated questionnaire items from the Doctor’s Interpersonal Skills Questionnaire, literature review, and interviews with neurology inpatients. The resulting 19-item Comunicazione medico-paziente nella Sclerosi Multipla (COSM) was pilot tested/debriefed on seven patients with multiple sclerosis and administered to 80 patients newly diagnosed with multiple sclerosis. The resulting revised 20-item version (COSM-R) was debriefed on five patients with multiple sclerosis, field tested/debriefed on multiple sclerosis patients, and field tested on 105 patients newly diagnosed with multiple sclerosis participating in a clinical trial on an information aid. The hypothesized monofactorial structure of COSM-R section 2 was tested on the latter two groups.

Results: The questionnaire was well accepted. Scaling assumptions were satisfactory in terms of score distributions, item—total correlations and internal consistency. Factor analysis confirmed section 2’s monofactorial structure, which was also test—retest reliable (intraclass correlation coefficient [ICC] 0.73; 95% CI 0.54—0.85). Section 1 had only fair test—retest reliability (ICC 0.45; 95% CI 0.12—0.69), and three items had 8—21% missed responses.

Conclusions: COSM-R is a brief, easy-to-interpret MS-specific questionnaire for use as a health care indicator.

The Multiple Sclerosis Knowledge Questionnaire: a self-administered instrument for recently diagnosed patients

There are few studies on patient knowledge in multiple sclerosis (MS), and only two published questionnaires. The objective of this article was to develop and validate the MS Knowledge Questionnaire (MSKQ), a self-assessed instrument for newly diagnosed MS patients. Thirty multiple-choice statements, conceived to test MS knowledge, were produced by a multidisciplinary panel and pre-tested on three MS patients, resulting in an intermediate 26-item version. This was tested on 54 MS patients for internal consistency, content and construct validity (validation sample I). The final (25-item) MSKQ was a primary outcome measure in the SIMS-Trial on an information aid to newly diagnosed MS patients. Postal responses of SIMS-Trial participants to the MSKQ a month after intervention (validation sample II) were analysed. Median MSKQ scores in validation samples I and II were, respectively, 18 (range 9-23) and 17 (range 3-24). Acceptability, internal consistency (Kuder-Richardson-20 formula 0.76) and content validity were good. Educational attainment and receiving the information aid were the main independent predictors of MS knowledge. Other predictors were female sex (positive association) and disease duration (negative association). In conclusion, the MSKQ has good clinimetric properties and is sensitive to an educational intervention. We propose the MSKQ as a brief instrument for clinical practice and research.

Communicating the diagnosis of multiple sclerosis - a qualitative study

Studies on communicating the diagnosis of multiple sclerosis (MS) are few, and all reveal communication and information deficits. We explored the personal experience of diagnosis communication of people with MS and health professionals, using a qualitative methodology. Data were obtained from two sets of focus group meetings (FGM) with people with MS (total 23; 16 females; age range: 23-70) and one FGMs with health professionals (four neurologists, three psychologists, two nurses). The methods of framework analysis were applied to meeting transcripts to identify key topics and categories. The experience of communicating/receiving an MS diagnosis was highly varied; all patients reported the moment as powerfully evocative and unforgettable. Very poor levels of support and information were sometimes given. Although diagnosis communication had improved in more recent experience, all felt it should be further improved with appropriate setting (privacy, no interruptions, sufficient time), information tailored to the individual, and continuity of care. Such improvements imply a more meaningful patientneurologist relationship, and also structural and organisational changes. Multiple Sclerosis 2007; 13: 763-769. http://msj.sagepub.com

Prevalence of oedema of the lower limbs in multiple sclerosis patients: a vascular and lymphoscintigraphic study

The aim of the study was to evaluate the frequency of oedema of the lower limbs in multiple sclerosis (MS) patients utilizing a multidisciplinary approach. A total of 205 patients with definite MS were included in the study. Seventy-five were male and 130 female, with a mean age of 50.53, mean Expanded Disability Status Scale (EDSS) score of 5.27 and mean disease duration of 16.6 years. Seventy-one patients had a relapsing-remitting (RR) disease course, 85 were secondary progressive (SP) and 49 were primary progressive (PP). Ninety-three patients (45%) showed oedema at the examination. EDSS, disease duration and disease course, but not gender, were statistically different between oedema and non-oedema patients. Out of 93 patients with oedema, 69 agreed to undergo a vascular examination. Of 69 patients, 45 (65.2%) had a CEAP score (specific rating scale for oedema) of 3 (presence of oedema) and 24 (34.8%) had a score of 4 (presence of a trophic disorder). Out of 69 subjects, 33 agreed to undergo a lymphoscintigraphy, which was normal in only 29 extremities out of 66. Lower limb oedema is common in MS patients, especially in those with reduced mobility. Early screening is advised in patients with an elevated EDSS.

An interdisciplinary approach to evaluating the need for assistive technology reduces equipment abandonment

Assistive technology makes up a substantial portion of the direct cost of multiple sclerosis (MS). Equipment abandonment results in the needs of the disabled individual being unmet and places stress on the resources available for the funding of such equipment. The aim of the study was to demonstrate whether an interdisciplinary approach to evaluating and prescribing assistive technology reduces equipment abandonment in persons with MS. Data concerning assistive devices acquired by patients being followed at a rehabilitation centre in northern Italy from January 1997 to December 2002, were included in the study. Through December 1999, a physician in physical medicine and rehabilitation prescribed equipment based on a recommendation from the physical therapist. From 2000 to 2002, patients were evaluated following a standardized protocol implemented by an interdisciplinary team comprised of a physical therapist, occupational therapist, physician in physical medicine and rehabilitation and psychologist. Assistive technology obtained during the study period was divided into two datasets based on the year that the aid was obtained: pre-intervention (January 1997 to December 1999) and intervention (January 2000 to December 2002). The analysis included a comparison of the two datasets on number and types of equipment abandoned, timing of abandonment and reasons why devices were abandoned. Fifty-four subjects obtained 151 assistive devices during the study period, 67 devices during pre-intervention and 84 with the intervention. The majority of devices were abandoned immediately or within the first year following obtainment in both groups. A comparison of the number of devices obtained during pre-intervention with those obtained during the intervention showed that the rate of equipment abandonment decreased significantly from 37.3 to 9.5%. An interdisciplinary approach to evaluating assistive technology needs does decrease the risk of equipment abandonment, although it does not completely solve the problem.

Antiepileptic medications in multiple sclerosis: adverse effects in a three-year follow-up study

Neuropathic pain and paroxysmal symptoms are common in multiple sclerosis (MS) patients, although no double-blind clinical trial has been conducted to support antiepileptic medications (AED) use in MS. The aim of the study was to evaluate the frequency of AED utilisation and reported adverse events, in a cohort of MS patients. For a period of 3 years the rationale for prescribing AED, adverse effects, treatment duration and reasons for discontinuation were recorded in a database. Carbamazepine (CBZ) was prescribed in 36 patients, with adverse effects reported in 20 cases, of which 12 mimicked a relapse. Gabapentin (GBP) was prescribed in 94 patients, with adverse effects reported in 16 cases and in one case mimicked a relapse. Lamotrigine (LMT) was prescribed in 22 patients, with adverse effects reported in 4 cases, none mimicking a relapse. The present study found a significantly higher incidence of adverse effects in patients treated with CBZ, with a high rate of discontinuation at low dosages and episodes of evident worsening of neurological functioning compared to GBP or LMT.

The prevalence of multiple sclerosis in the north?west Italian province of Genoa

The objective of this study was to assess the prevalence of multiple sclerosis (MS), calculated as point prevalence on 31 December 1997, in the province of Genoa, North-western Italy.

METHODS

The province of Genoa is located in North-western Italy, an area of 1,835 km(2). On the point prevalence day the population consisted of 913,218 inhabitants. MS cases were identified by analysing archives of the hospitals with neurological or rehabilitation wards, neurologists serving the community, files of local chapters of the Italian MS society, all requests for oligoclonal bands analysis on CSF in the studied area. Patients included in the study were MS cases diagnosed before 31 December 1997 according to the Poser criteria resident in the province under study.

RESULTS

A total of 857 subjects were alive and residing in the province of Genoa on the prevalence day. The overall crude prevalence rate was 94 per 100,000 (95% CI 88-100); 291 were males (34%) with a crude prevalence of 67 per 100,000 (95 % CI 60-76) and 566 were females (66%) with a prevalence of 118 per 100,000 (95% CI 108-128). The female/male ratio was 1.9. When age and sex were adjusted to the Italian standard population of 1991 prevalence was 85 per 100,000. Five hundred and thirty two out of the 857 patients agreed to be interviewed. The interviewed sample was representative of the prevalence sample: sex and gender distributions were identical in the two samples. The overall mean age was 48 (+/-13) years (48 +/-12 years in males; 48+/-14 years in females). Mean disease duration was 15 (+/-10) years for males and 16 (+/-11) years for females. Two hundred and ninety one (55 %) subjects had a relapsing remitting (RR) clinical course, 150 (28%) were secondary progressive (SP) and 91 (17%) were primary progressive (PP). Mean EDSS score was 5 (+/- 2; median 5). The mean age at time of onset was 33 (+/-10) years for males and 32 (+/- 11) years for females. The disease onset was monosymptomatic in 76% (n=407) patients and polysymptomatic in 24% (n=125). The mean length of time between clinical onset and diagnosis was 5 (+/- 6) years.

CONCLUSION

We confirmed that the province of Genoa is a very high risk area for MS. We found a high rate of patients with a PP course; also the proportion of patients with high disability scores is greater compared to previous studies.

Certification of multiple sclerosis nurses: an international perspective

The Multiple Sclerosis Nursing International Certification Board was formed as a special initiative of the International Organization of Multiple Sclerosis Nurses (IOMSN). The aim was to develop a certification examination for MS nursing practice. This certification should achieve the vision of the IOMSN and unite MS nurses worldwide through standard practices. Such practices are based on common knowledge and skills, and tasks that encourage the best outcome for the nurse-patient collaborative relationship. Certification allows recognition of an individual nurse's skill level, establishes a standard for all nurses treating patients with MS, improves patient care, and also benefits the neurological community. The Multiple Sclerosis Certified Nurse is revolutionary, as certification is an international effort to enhance and standardize MS care and develop MS nurse professionalism across borders.

Symptomatic medication use in multiple sclerosis

Multiple sclerosis (MS) is one of the most studied neurological diseases, although scarce attention has been placed on symptomatic therapy. The aim of the study was to evaluate the frequency of medication prescription for the major symptoms related to MS in order to better understand the needs of patients. The study was conducted during an epidemiological survey in the province of Genoa, Italy. Out of 856 patients with MS in the study area, 665 agreed to participate in a structured interview. Two hundred and forty-nine (37%) subjects, with a mean age of 53 years and a mean Expanded Disability Status Scale (EDSS) score of 5.2, were taking at least one symptomatic medication. Four hundred and sixteen (63%) subjects, with a mean age of 49 years and a mean EDSS score of 4.5, were not using symptomatic therapy. The most commonly treated symptoms were pain (28%), spasticity (27%) and mood disorder (16%), while bladder dysfunction (8%) and fatigue (3%) were less frequently treated with medication. Seventy-seven patients (12%) were taking medications for reasons not directly related to MS. This cross-sectional study underlines the frequency of medication prescription for symptoms such as spasticity and pain, while other common symptoms, such as bladder dysfunction and fatigue, may perhaps be undertreated. The present findings also underline the need for clinical trials on symptomatic therapies.

The interdisciplinary approach to the treatment of multiple sclerosis patients in Italy: an aspiration or a reality?

The aim of the study was to assess whether the components necessary for an interdisciplinary approach to the treatment of multiple sclerosis (MS) patients exist in Italian MS clinics and to identify factors that make the difference between reality and aspiration for this type of approach. One hundred two out of 147 neurology departments with MS clinics throughout Italy compiled a questionnaire about characteristics and organizational structure of the clinic, type and number of professionals and resource needs. Eight hundred twenty-three healthcare professionals are currently working in MS clinics: 50% (412) neurologists, 28.7% (236) nurses, 15.1 % (124) physical therapists, 3.4% (28) psychologists and 2.8% (23) social workers. Neurologists are evenly distributed between northern and southern parts of the country even though there are nearly double the number of patients followed in northern clinics compared to those in the south. Physicians reported themselves as most in need of continuing education, twice that which the same physicians reported for any other professional. The study has identified issues that contribute to the difficulty in developing and applying an interdisciplinary approach to providing care and services to Italian MS patients. Several factors have been delineated that require significant reshaping in order for this approach to begin to develop. Multiple Sclerosis (2002) 8, 36-39

Low-dose gabapentin combined with either lamotrigine or carbamazepine can be useful therapies for trigeminal neuralgia in multiple sclerosis

Paroxysmal symptoms occur frequently in multiple sclerosis (MS). Usually they are treated with carbamazepine (CBZ) and phenytoin, although these medications are often interrupted due to adverse effects. We report 11 MS patients with trigeminal neuralgia (TN): 6 intolerant to a therapeutic dosage of CBZ, showing serious adverse effects and subsequently treated with a combination of low-dose CBZ and gabapentin (GBP) (group 1); 5 treated with lamotrigine (LMT), showing adverse effects and subsequently treated with GBP (group 2). Subjective pain level and impairment in performing daily activities were rated utilizing a 3-point scale at time 0 and at optimal dosage time (T1). GBP was initiated at 300 mg daily and titrated, until pain control was achieved without new adverse effects, to a maximum dose of 1,200 mg daily. CBZ or LMT were reduced to a level which no longer produced adverse effects, although resulting in a lack of efficacy in relieving pain. Pain control was obtained in all patients but 1, with no side effects. The plasma level analysis, performed in 5 patients, resulted in normal values. The mean dosages at T1 were: group 1 CBZ 400 mg and GBP 850 mg daily; group 2 LMT 150 mg and GBP 780 mg daily. Combining drugs with complementary modes of action may provide a rational pharmacological approach to the management of TN in MS.

Gabapentin is effective in treating nocturnal painful spasms in multiple sclerosis

In-patients with MS nocturnal spasms (NPS) occur frequently, primarily during the night and may influence the ability to and/or quality of sleep. We enrolled in an open label trial with GBP (up to 600 mg/day) 24 MS patients with NPS. We obtained patient reports of subjective discomfort at pre-treatment and following 2- (T1) and 8 weeks (T2), utilizing a 3-point analogue scale. Twenty of the 22 patients who completed the study reported resolution or amelioration of discomfort. Clinical improvement occurred 1 - 5 days following initial treatment. Three patients experienced adverse effects but completed the minimal follow-up period (2 weeks). Two patient dropped out of the study due to no compliance or adverse effects. A very low dose of GBP may be effective treatment for MS patients with NPS who may benefit from rapid improvement of discomfort with minimal risk of adverse effects.

A cost evaluation of multiple sclerosis

As a chronic and disabling disease, multiple sclerosis (MS) is extremely costly, both for the individual and the family, as well as for the society. Early onset, long duration and effects on employment contribute to the extensive costs related to the illness. Thus far, studies conducted in developed countries have demonstrated that direct costs, including treatment (prior to the approval of beta interferon), medical visits, hospitalization, assistance, etc., are much lower in respect to indirect costs, such as loss of income from reduction of work activity for patients and carers, which account for up to 75% of the total cost. Informal care represents a heavy burden for the families of disabled persons and little is known about the 'intangible' costs of MS, such as those related to the influence of the disease on quality of life. In addition, the cost/benefit ratio for expensive new therapies, such as beta interferon, remains to be determined.

The SMile Card: a computerised data card for multiple sclerosis patients. SMile Card Scientific Board

The SMile Card was developed as a means for computerising clinical information for the purpose of transferability, accessibility, standardisation and compilation of a national database of demographic and clinical information about multiple sclerosis (MS) patients. In many European countries, centres for MS are organised independently from one another making collaboration, consultation and patient referral complicated. Only the more highly advanced clinical centres, generally located in large urban areas, have had the possibility to utilise technical possibilities for improving the organisation of patient clinical and research information, although independently from other centres. The information system, developed utilising the Visual Basic language for Microsoft Windows 95, stores information via a 'smart card' in a database which is initiated and updated utilising a microprocessor, located at each neurological clinic. The SMile Card, currently being tested in Italy, permits patients to carry with them all relevant medical information without limitations. Neurologists are able to access and update, via the microprocessor, the patient's entire medical history and MS-related information, including the complete neurological examination and laboratory test results. The SMile Card provides MS patients and neurologists with a complete computerised archive of clinical information which is accessible throughout the country. In addition, data from the SMile Card system can be exported to other database programs.

A patient with multiple sclerosis and Down's syndrome with a rare paroxysmal symptom at onset

Down's syndrome (DS) is often associated with autoimmune diseases, although an association with multiple sclerosis (MS) has not been previously reported. A 49-year-old male with DS experienced progressively worsening gait and bladder dysfunction. Following Poser criteria, the patient was diagnosed with laboratory-supported definite MS. Ten days following diagnosis the patient experienced dysestetic paroxysmal pain at the pelvic level (an uncommon complaint in MS) which was initially addressed with carbamazepine, resulting in mild relief and adverse effects consisting of increased motor deficit and decreased daytime alertness. A titration combination of lamotrigine and gabapentin, two relatively new antiepileptic drugs which have been utilized individually for a number of neurological symptoms, resulted in significant reduction in pain frequency and intensity, with no adverse effects. This case study presents details of the first reported association of DS and MS, between which the pathogenetic relationship remains unclear. The presence of a rare symptom complaint in MS, as well as the effective combination of lamotrigine and gabapentin for treating this symptom, without adverse effects is an additional interesting aspect of this case.

An open-label trial of gabapentin treatment of paroxysmal symptoms in multiple sclerosis patients

We conducted an open-label trial of gabapentin (GBP) as therapy for paroxysmal symptoms (PS) in 21 MS patients, including trigeminal neuralgia (6 patients), painful tonic spasms (11), dysesthetic or paresthetic symptoms (3) and ocular ataxia (1). Complete resolution of symptoms or partial improvement was obtained, respectively, in 14 and 4 of 18 patients who ended the study. Sustained improvement with minor side effects was obtained at dosages ranging from 600 to 1200 mg/d. Our findings suggest that GBP may be effective for PS in MS and warrant a further study in a double-blind placebo-controlled trial.

A phase II study of i.v. methylprednisolone in secondary-progressive multiple sclerosis

OBJECTIVE

To compare the tolerability and efficacy of two doses of i.v. methylprednisolone in patients with secondary-progressive MS.

METHODS

I.v. methylprednisolone administered in high or low dose every other month for up to 2 years to 108 patients with secondary-progressive MS.

RESULTS

No significant difference in efficacy with the primary outcome, a comparison of the proportions of patients in each treatment group who experienced sustained progression of disability. A relative treatment effect was detected with the high-dose regimen as measured by the preplanned secondary analysis, a comparison of time to onset of sustained progression of disability. Drug-related adverse events were observed more frequently in high-dose recipients but serious drug-related adverse events were uncommon, and cessation of study drug was only required in one patient.

CONCLUSION

The results of the secondary analysis of this study suggest that a phase III trial of corticosteroids for secondary-progressive MS is warranted.