Multiple Sclerosis Disease Burden Research Articles

Retinal small vessel pathology is associated with disease burden in multiple sclerosis

Background: Alterations of the superficial retinal vasculature are commonly observed in multiple sclerosis (MS) and can be visualized through optical coherence tomography angiography (OCTA). Objectives: This study aimed to examine changes in the retinal vasculature during MS and to integrate findings into current concepts of the underlying pathology. Methods: In this cross-sectional study, including 259 relapsing–remitting MS patients and 78 healthy controls, we analyzed OCTAs using deep-learning-based segmentation algorithm tools. Results: We identified a loss of small-sized vessels (diameter < 10 µm) in the superficial vascular complex in all MS eyes, irrespective of their optic neuritis (ON) history. This alteration was associated with MS disease burden and appears independent of retinal ganglion cell loss. In contrast, an observed reduction of medium-sized vessels (diameter 10–20 µm) was specific to eyes with a history of ON and was closely linked to ganglion cell atrophy. Conclusion: These findings suggest distinct atrophy patterns in retinal vessels in patients with MS. Further studies are necessary to investigate retinal vessel alterations and their underlying pathology in MS.

Benefits of a mosaic approach for assessing cortical atrophy in individual multiple sclerosis patients.

Cortical gray matter (GM) atrophy plays a central role in multiple sclerosis (MS) pathology. However, it is not commonly assessed in clinical routine partly because a number of methodological problems hamper the development of a robust biomarker to quantify GM atrophy. In previous work, we have demonstrated the clinical utility of the "mosaic approach" (MAP) to assess individual GM atrophy in the motor neuron disease spectrum and frontotemporal dementia. In this study, we investigated the clinical utility of MAP in MS, comparing this novel biomarker to existing methods for computing GM atrophy in single patients. We contrasted the strategies based on correlations with established biomarkers reflecting MS disease burden. We analyzed T1-weighted MPRAGE magnetic resonance imaging data from 465 relapsing-remitting MS patients and 89 healthy controls. We inspected how variations of existing strategies to estimate individual GM atrophy ("standard approaches") as well as variations of MAP (i.e., different parcellation schemes) impact downstream analysis results, both on a group and an individual level. We interpreted individual cortical disease burden as single metric reflecting the fraction of significantly atrophic data points with respect to the control group. In addition, we evaluated the correlations to lesion volume (LV) and Expanded Disability Status Scale (EDSS). We found that the MAP method yielded highest correlations with both LV and EDSS as compared to all other strategies. Although the parcellation resolution played a minor role in terms of absolute correlations with clinical variables, higher resolutions provided more clearly defined statistical brain maps which may facilitate clinical interpretability. This study provides evidence that MAP yields high potential for a clinically relevant biomarker in MS, outperforming existing methods to compute cortical disease burden in single patients. Of note, MAP outputs brain maps illustrating individual cortical disease burden which can be directly interpreted in daily clinical routine.

Interferon beta treatment is a potent and targeted epigenetic modifier in multiple sclerosis.

Multiple Sclerosis (MS) has a complex pathophysiology that involves genetic and environmental factors. DNA methylation (DNAm) is one epigenetic mechanism that can reversibly modulate gene expression. Cell specific DNAm changes have been associated with MS, and some MS therapies such as dimethyl fumarate can influence DNAm. Interferon Beta (IFNβ), was one of the first disease modifying therapies in multiple sclerosis (MS). However, how IFNβ reduces disease burden in MS is not fully understood and little is known about the precise effect of IFNβ treatment on methylation. The objective of this study was to determine the changes in DNAm associated with INFβ use, using methylation arrays and statistical deconvolutions on two separate datasets (total ntreated = 64, nuntreated = 285). We show that IFNβ treatment in people with MS modifies the methylation profile of interferon response genes in a strong, targeted, and reproducible manner. Using these identified methylation differences, we constructed a methylation treatment score (MTS) that is an accurate discriminator between untreated and treated patients (Area under the curve = 0.83). This MTS is time-sensitive and in consistent with previously identified IFNβ treatment therapeutic lag. This suggests that methylation changes are required for treatment efficacy. Overrepresentation analysis found that IFNβ treatment recruits the endogenous anti-viral molecular machinery. Finally, statistical deconvolution revealed that dendritic cells and regulatory CD4+ T cells were most affected by IFNβ induced methylation changes. In conclusion, our study shows that IFNβ treatment is a potent and targeted epigenetic modifier in multiple sclerosis.

Factors associated with depressive mood at the onset of multiple sclerosis - an analysis of 781 patients of the German NationMS cohort.

Depression has a major impact on the disease burden of multiple sclerosis (MS). Analyses of overlapping MS and depression risk factors [smoking, vitamin D (25-OH-VD) and Epstein-Barr virus (EBV) infection] and sex, age, disease characteristics and neuroimaging features associated with depressive symptoms in early MS are scarce. To assess an association of MS risk factors with depressive symptoms within the German NationMS cohort. Cross-sectional analysis within a multicenter observational study. Baseline data of n = 781 adults with newly diagnosed clinically isolated syndrome or relapsing-remitting MS qualified for analysis. Global and region-specific magnetic resonance imaging (MRI)-volumetry parameters were available for n = 327 patients. Association of demographic factors, MS characteristics and risk factors [sex, age, smoking, disease course, presence of current relapse, expanded disability status scale (EDSS) score, fatigue (fatigue scale motor cognition), 25-OH-VD serum concentration, EBV nuclear antigen-1 IgG (EBNA1-IgG) serum levels] and depressive symptoms (Beck Depression Inventory-II, BDI-II) was tested as a primary outcome by multivariable linear regression. Non-parametric correlation and group comparison were performed for associations of MRI parameters and depressive symptoms. Mean age was 34.3 years (95% confidence interval: 33.6-35.0). The female-to-male ratio was 2.3:1. At least minimal depressive symptoms (BDI-II > 8) were present in n = 256 (32.8%), 25-OH-VD deficiency (<20 ng/ml) in n = 398 (51.0%), n = 246 (31.5%) participants were smokers. Presence of current relapse [coefficient (c) = 1.48, p = 0.016], more severe fatigue (c = 0.26, p < 0.0001), lower 25-OH-VD (c = -0.03, p = 0.034) and smoking (c = 0.35, p = 0.008) were associated with higher BDI-II scores. Sex, age, disease course, EDSS, month of visit, EBNA1-IgG levels and brain volumes at baseline were not. Depressive symptoms need to be assessed in early MS. Patients during relapse seem especially vulnerable to depressive symptoms. Contributing factors such as fatigue, vitamin D deficiency and smoking, could specifically be targeted in future interventions and should be investigated in prospective studies.

The landscape of targets and lead molecules for remyelination.

Remyelination, or the restoration of myelin sheaths around axons in the central nervous system, is a multi-stage repair process that remains a major need for millions of patients with multiple sclerosis and other diseases of myelin. Even into adulthood, rodents and humans can generate new myelin-producing oligodendrocytes, leading to the therapeutic hypothesis that enhancing remyelination could lessen disease burden in multiple sclerosis. Multiple labs have used phenotypic screening to identify dozens of drugs that enhance oligodendrocyte formation, and several hit molecules have now advanced to clinical evaluation. Target identification studies have revealed that a large majority of these hits share the ability to inhibit a narrow range of cholesterol pathway enzymes and thereby induce cellular accumulation of specific sterol precursors to cholesterol. This Perspective surveys the recent fruitful intersection of chemical biology and remyelination and suggests multiple approaches toward new targets and lead molecules to promote remyelination.

EDSS 0 is not normal: Multiple sclerosis disease burden below the clinical threshold

Little to no above-threshold deficits may be evident in early multiple sclerosis (MS). The Expanded Disability Status Scale (EDSS) is a standard measure of neurologic function, with an EDSS score of 0 defined as “neurologically normal.” The topographical model of MS proposes that sub-threshold disease is compensated for by functional reserve. In this short report, we found that physically high-challenge measures of balance and upper extremity coordination reveal sub-threshold deficits in patients with EDSS score of 0 compared with healthy controls. Challenge task performance was correlated with imaging markers of both lesional burden of disease and a volumetric measure of brain reserve.

Ultrasensitive immunoassay allows measurement of serum neurofilament heavy in multiple sclerosis

BackgroundNeurofilament heavy (NfH) is a promising biomarker for neuro-axonal damage in Multiple Sclerosis (MS). We compared the performance of high-sensitivity serum-NfH immunoassays, with as aim to investigate the value of serum-NfH as biomarker for MS. MethodsWe measured serum-NfH in 76 MS patients with Simoa (one commercial, one in-house) or Luminex assays. Serum-NfH measured by the immunoassay with greatest sensitivity was related to clinical and radiological outcomes with age and sex-adjusted linear regression analysis, and to biological outcomes cerebrospinal fluid (CSF)-NfH, serum neurofilament light (NfL) and CSF-NfL with Spearman's correlation analysis. ResultsWith the commercial Simoa assay, we obtained 100% serum-NfH detectability (in-house Simoa: 70%, Luminex: 61%), with lowest coefficient of variation (CV) between duplicates of 11%CV (in-house Simoa: 22%CV, Luminex: 30%CV). Serum-NfH quantified with the commercial Simoa assay was associated with disease duration (standardized beta (sβ) = 0.28, p = 0.034), T2 lesion volume (sβ = 0.23, p = 0.041), and tended to associate with black hole count (sβ = 0.21, p = 0.084) but not with Expanded Disease Disability Score (EDSS) or normalized brain volume (all: p>0.10). Furthermore, serum-NfH showed correlations with CSF-NfH (rho = 0.27, p = 0.018) and serum-NfL (rho=0.44, p < 0.001), but not with CSF-NfL. ConclusionsSerum-NfH can be quantified with high-sensitivity technology. Cross-sectionally, we observed some weak correlations of serum-NfH with MS disease burden parameters, suggesting there might be some utility for serum-NfH as biomarker for MS disease burden.

60/30: 60% of the Morbidity-Associated Multiple Sclerosis Disease Burden Comes From the 30% of Persons With Higher Impairments.

Background: Multiple sclerosis (MS) is the most common chronic, non-traumatic, neurologic disease in young adults. While approximate values of the disease burden of MS are known, individual drivers are unknown.Objective: To estimate the age-, sex-, and disease severity-specific contributions to the disease burden of MS.Methods: We estimated the disease burden of MS using disability-adjusted life years (DALYs) following the Global Burden of Disease study (GBD) methodology. The data sources consisted of the Swiss MS Registry, a recent prevalence estimation, and the Swiss mortality registry.Results: The disease burden of MS in Switzerland in 2016 was 6,938 DALYs (95%-interval: 6,018-7,955), which corresponds to 97 DALYs per 100,000 adult inhabitants. Morbidity contributed 59% of the disease burden. While persons in an asymptomatic (EDSS-proxy 0) and mild (EDSS-proxy >0–3.5) disease stage represent 68.4% of the population, they make up 39.8% of the MS-specific morbidity. The remaining 60.2% of the MS-specific morbidity stems from the 31.6% of persons in a moderate (EDSS-proxy 4–6.5) or severe (EDSS-proxy ≥7) disease stage.Conclusions: Morbidity has a larger influence on the disease burden of MS than mortality and is shared in a ratio of 2:3 between persons in an asymptomatic/mild and moderate/severe disease stage in Switzerland. Interventions to reduce severity worsening in combination with tailored, symptomatic treatments are important future paths to lower the disease burden of MS.

Rituximab in the treatment of multiple sclerosis in the Hospital District of Southwest Finland

BackgroundThere are already numerous B-cell depleting monoclonal anti-CD20 antibodies which have been used to reduce the inflammatory burden associated with multiple sclerosis (MS). We describe here our experience of treating MS-patients with B-cell depleting rituximab. Patients and methodsAll MS-patients (n = 72) who had received rituximab treatment for at least six months by January 2019 were identified from the patient charts at the Turku University Hospital. Information about MS disease subtype, disease severity, MR-imaging outcomes and B-cell counts were collected from the charts. ResultsRituximab was well received and well tolerated by the patients. There were no serious infusion-related side effects. The most serious adverse event that led to treatment discontinuation was neutropenia. After rituximab initiation the annual number of relapses was decreased in the relapsing remitting and secondary progressive MS groups and the mean number of gadolinium-enhancing lesions was decreased in relapsing remitting MS. Our study confirms the usability of rituximab treatment for MS in the Finnish health care environment. ConclusionsOff-label rituximab-treatment can be successfully used to reduce MS disease burden for the benefit of MS patients.

Automated volumetric assessment with artificial neural networks might enable a more accurate assessment of disease burden in patients with multiple sclerosis.

Patients with multiple sclerosis (MS) regularly undergo MRI for assessment of disease burden. However, interpretation may be time consuming and prone to intra- and interobserver variability. Here, we evaluate the potential of artificial neural networks (ANN) for automated volumetric assessment of MS disease burden and activity on MRI. A single-institutional dataset with 334 MS patients (334 MRI exams) was used to develop and train an ANN for automated identification and volumetric segmentation of T2/FLAIR-hyperintense and contrast-enhancing (CE) lesions. Independent testing was performed in a single-institutional longitudinal dataset with 82 patients (266 MRI exams). We evaluated lesion detection performance (F1 scores), lesion segmentation agreement (DICE coefficients), and lesion volume agreement (concordance correlation coefficients [CCC]). Independent evaluation was performed on the public ISBI-2015 challenge dataset. The F1 score was maximized in the training set at a detection threshold of 7mm3 for T2/FLAIR lesions and 14mm3 for CE lesions. In the training set, mean F1 scores were 0.867 for T2/FLAIR lesions and 0.636 for CE lesions, as compared to 0.878 for T2/FLAIR lesions and 0.715 for CE lesions in the test set. Using these thresholds, the ANN yielded mean DICE coefficients of 0.834 and 0.878 for segmentation of T2/FLAIR and CE lesions in the training set (fivefold cross-validation). Corresponding DICE coefficients in the test set were 0.846 for T2/FLAIR lesions and 0.908 for CE lesions, and the CCC was ≥ 0.960 in each dataset. Our results highlight the capability of ANN for quantitative state-of-the-art assessment of volumetric lesion load on MRI and potentially enable a more accurate assessment of disease burden in patients with MS. • Artificial neural networks (ANN) can accurately detect and segment both T2/FLAIR and contrast-enhancing MS lesions in MRI data. • Performance of the ANN was consistent in a clinically derived dataset, with patients presenting all possible disease stages in MRI scans acquired from standard clinical routine rather than with high-quality research sequences. • Computer-aided evaluation of MS with ANN could streamline both clinical and research procedures in the volumetric assessment of MS disease burden as well as in lesion detection.

Factors influencing daily treatment choices in multiple sclerosis: practice guidelines, biomarkers and burden of disease.

At two meetings of a Central European board of multiple sclerosis (MS) experts in 2018 and 2019 factors influencing daily treatment choices in MS, especially practice guidelines, biomarkers and burden of disease, were discussed. The heterogeneity of MS and the complexity of the available treatment options call for informed treatment choices. However, evidence from clinical trials is generally lacking, particularly regarding sequencing, switches and escalation of drugs. Also, there is a need to identify patients who require highly efficacious treatment from the onset of their disease to prevent deterioration. The recently published European Committee for the Treatment and Research in Multiple Sclerosis/European Academy of Neurology clinical practice guidelines on pharmacological management of MS cover aspects such as treatment efficacy, response criteria, strategies to address suboptimal response and safety concerns and are based on expert consensus statements. However, the recommendations constitute an excellent framework that should be adapted to local regulations, MS center capacities and infrastructure. Further, available and emerging biomarkers for treatment guidance were discussed. Magnetic resonance imaging parameters are deemed most reliable at present, even though complex assessment including clinical evaluation and laboratory parameters besides imaging is necessary in clinical routine. Neurofilament-light chain levels appear to represent the current most promising non-imaging biomarker. Other immunological data, including issues of immunosenescence, will play an increasingly important role for future treatment algorithms. Cognitive impairment has been recognized as a major contribution to MS disease burden. Regular evaluation of cognitive function is recommended in MS patients, although no specific disease-modifying treatment has been defined to date. Finally, systematic documentation of real-life data is recognized as a great opportunity to tackle unresolved daily routine challenges, such as use of sequential therapies, but requires joint efforts across clinics, governments and pharmaceutical companies.

Microvascular Decompression for Trigeminal Neuralgia in Patients with Multiple Sclerosis: Predictors of Treatment Success

Microvascular decompression (MVD) is highly effective in managing the neuropathic facial pain of trigeminal neuralgia (TN). Its utility in patients with TN and concurrent multiple sclerosis (MS) has been a subject of debate. The goal of this study was to identify demographic and perioperative variables associated with favorable outcome after MVD over the past 20 years in patients from our institution. A retrospective analysis of our cohort of 33 patients diagnosed with MS and TN who underwent MVD between 1997 and 2017 to treat neuropathic facial pain was performed. Perioperative variables included MS disease burden, findings on preoperative magnetic resonance imaging (MRI), TN pain severity, and the presence of intraoperative neurovascular compression. MS disease burden was quantified using the Expanded Disability Status Scale. Preoperative and postoperative pain severity was quantified using the Barrow Neurological Institute (BNI) pain severity scale. A total of 33 patients with TN and MS were treated with MVD at our institution (out of the 632 total MVDs performed) between 1997 and 2017. Twenty-two patients (67%) maintained a reduction in pain at a mean follow-up of 53.5 months. Higher preoperative BNI pain intensity score was associated with unfavorable outcome after MVD (P= 0.006). No associations were identified between MS disease burden, presence of neurovascular compression or pontine demyelinating plaques on MRI, or intraoperative findings of neurovascular compression and treatment outcomes. MVD is a reasonable treatment option for patients with TN and MS, although the rate of freedom from pain is lower than that for the general TN population. Preoperative pain severity may be a predictor of treatment success.

A Framework for Estimating the Burden of Chronic Diseases: Design and Application in the Context of Multiple Sclerosis.

Background: When population-based databases are unavailable, nationwide assessments of the disease burden of multiple sclerosis (MS) resort to clinical, administrative or convenience-sampled data sources, which may produce results of limited external validity. Our aim was to develop a framework for estimating measures of occurrence of chronic diseases, and more broadly disease burden, that mitigate these limitations and to apply this framework to estimate the prevalence of multiple sclerosis (MS) in Switzerland.Methods: We developed a 7-step framework which implements the combination of several data sources together with a resampling and critical appraisal approach. The framework was applied to estimate the MS prevalence for 2016 in Switzerland, for which four distinct data sources (Swiss MS registry, Swiss national MS treatment registry, MediService database, and Swiss MS cohort study) were combined. Results were reviewed by disease experts and compared to earlier Swiss estimates and current prevalence estimates from other countries.Results: We estimate that in the year 2016 between 14,650 and 15,700 persons with MS have been living in Switzerland, yielding a period prevalence of 174–187/100,000 inhabitants. Compared to the last estimate in 1986, we detected a substantial increase of MS diagnoses which coincides with a higher number of diagnoses in women below the age of 65.Conclusions: Internationally, Switzerland is a high-prevalence country for MS, although estimates were somewhat lower than recent evaluations of Northern European countries. In addition, we corroborate previous reports that the prevalence increase coincides with a higher number of MS diagnoses among women. The proposed framework has wide applicability and the potential to place estimates of disease occurrence and burden with imperfect data availability on more solid grounds.

Psychological resilience is linked to motor strength and gait endurance in early multiple sclerosis

Background: Psychologically resilient persons persist despite obstacles and bounce back after adversity, leading to better outcomes in non-neurologic populations. It is unknown whether psychological resilience relates to objective functional outcomes in multiple sclerosis (MS). Objective: To determine whether psychological resilience explains differential objective cognitive and motor functioning in persons with early MS. Methods: Psychological resilience was assessed in 185 patients with early MS and 50 matched healthy controls with the Connors-Davidson Resilience Scale (CDRS-10). Subjects completed the MS Functional Composite (MSFC) and a comprehensive neurobehavioral evaluation. Correlations assessed links between CDRS-10 and MSFC, motor indices (Total, Fine Motor, Gross Motor), and cognitive indices (Total, Cognitive Efficiency, Memory). Results: Higher CDRS-10 among patients was linked to better MSFC and motor outcomes (but not cognition), with the most robust relationships for gross motor function (grip strength, gait endurance). Findings were independent of mood and fatigue. CDRS-10 was unrelated to MS disease burden. CDRS-10 was also specifically linked to motor outcomes in healthy controls. Conclusion: Functional outcomes vary across persons with MS, even when disease burden and neurologic disability are low. These findings identify high psychological resilience as a non-disease-specific contributor to motor strength and endurance, which may explain differential outcomes across patients.

The disease burden of Multiple Sclerosis from the individual and population perspective: Which symptoms matter most?

BackgroundMS symptoms affect many functional domains. Knowing the specific impact of symptoms on health-related quality of life (HRQoL) is vital for successful disease and symptom management in MS. We aimed at investigating how specific MS symptoms contribute to the disease burden in individuals and from a population perspective. MethodsWe included 855 Swiss Multiple Sclerosis Registry participants with a relapsing-remitting form (RRMS) or a progressive form (PMS). HRQoL was measured with the EuroQol 5-Dimension EQ-5D-index and EQ-Visual Analogue Scale (EQ-VAS) on 0–100% scales. Their associations with 20 symptoms, socio-demographic and clinical information were explored in median regression models, stratified by RRMS and PMS. ResultsWe included 611 participants with RRMS and 244 with PMS. In RRMS, gait (−6.5%) and balance problems (−5.1%) had the largest EQ-5D-index reductions, and were also important at the population level (frequencies 45% and 52%). Fatigue, depression, and spasticity (frequencies 74.1%, 31%, 38%) also contributed to the population disease burden. In PMS, spasticity, paralysis, and bowel problems had the largest impact on EQ-5D-index, both at the individual and population levels. The largest impact on EQ-VAS at population level was associated in RRMS with balance problems, depression, dizziness, and spasticity, while in PMS with weakness, pain, and paralysis. ConclusionsWhile HRQoL at population level is most affected by balance problems, spasticity, and depression in RRMS, the biggest HRQoL losses in PMS are caused by spasticity, paralysis, weakness, and pain. Many symptoms with the largest effects in individuals substantially contribute to the population disease burden.

Lineage tracing reveals dynamic changes in oligodendrocyte precursor cells following cuprizone-induced demyelination.

The regeneration of oligodendrocytes is a crucial step in recovery from demyelination, as surviving oligodendrocytes exhibit limited structural plasticity and rarely form additional myelin sheaths. New oligodendrocytes arise through the differentiation of platelet-derived growth factor receptor α (PDGFRα) expressing oligodendrocyte progenitor cells (OPCs) that are widely distributed throughout the CNS. Although there has been detailed investigation of the behavior of these progenitors in white matter, recent studies suggest that disease burden in multiple sclerosis (MS) is more strongly correlated with gray matter atrophy. The timing and efficiency of remyelination in gray matter is distinct from white matter, but the dynamics of OPCs that contribute to these differences have not been defined. Here, we used in vivo genetic fate tracing to determine the behavior of OPCs in gray and white matter regions in response to cuprizone-induced demyelination. Our studies indicate that the temporal dynamics of OPC differentiation varies significantly between white and gray matter. While OPCs rapidly repopulate the corpus callosum and mature into CC1 expressing mature oligodendrocytes, OPC differentiation in the cingulate cortex and hippocampus occurs much more slowly, resulting in a delay in remyelination relative to the corpus callosum. The protracted maturation of OPCs in gray matter may contribute to greater axonal pathology and disease burden in MS.

Steroids Impact on Myelin Repair, Neurogenesis and Visual Pathway in Multiple Sclerosis: Preclinical Perspectives

Even though steroids have drawn significant therapeutic interests for decades, data about their benefits for neural regeneration are missing as current observational studies unfold progressive abnormalities in cerebral gray matter and cerebellum compartments, apart from demyelination lesions in white matter of the central nervous system (CNS) in multiple sclerosis (MS). This medical-scientific appraisal is based on a series of structured questions in part addressed in our investigative clinical review on the benefits and risks of glucocorticosteroids (GC), which highlights that steroids can intensify the disease progression, aside from other global side effects recognized in MS and associated optic neuritis (MS-ON). Corticosteroids treatments, whilst temporally and selectively suppress immune reactions, can interfere with the clearance of myelin debris and inhibit proliferation-migration of the myelinating cells, affecting the axonal repair and CNS functions. This review compiles and summarizes datasets extracted largely from complementary laboratory studies published in Medline, It discusses related pharmacologic and disease mechanisms and relevancies of the distinct MS disease models in rodents, with emphasis on the strengths and weaknesses of the associations of GCs use, glucocorticoid receptors sensitivity, and clinical outcomes. Based on these assessments, we conclude that steroids can suppress inflammation to the determent of neuronal remodeling in a mutually exclusive manner. Excess steroids can contribute to neuronal loss and retinal damage in optic pathology, and thus may expand cerebral atrophy and disease burden in multiple sclerosis.

Visual field impairment captures disease burden in multiple sclerosis.

Monitoring disease burden is an unmeet need in multiple sclerosis (MS). Identifying patients at high risk of disability progression will be useful for improving clinical-therapeutic decisions in clinical routine. To evaluate the role of visual field testing in non-optic neuritis eyes (non-ON eyes) as a biomarker of disability progression in MS. In 109 patients of the MS-VisualPath cohort, we evaluated the association between visual field abnormalities and global and cognitive disability markers and brain and retinal imaging markers of neuroaxonal injury using linear regression models adjusted for sex, age, disease duration and use of disease-modifying therapies. We evaluated the risk of disability progression associated to have baseline impaired visual field after 3 years of follow-up. Sixty-two percent of patients showed visual field defects in non-ON eyes. Visual field mean deviation was statistically associated with global disability; brain (normalized brain parenchymal, gray matter volume and lesion load) and retinal (peripapillary retinal nerve fiber layer thickness and macular ganglion cell complex thickness) markers of neuroaxonal damage. Patients with impaired visual field had statistically significative greater disability, lower normalized brain parenchymal volume and higher lesion volume than patients with normal visual field testing. MS patients with baseline impaired VF tripled the risk of disability progression during follow-up [OR = 3.35; 95 % CI (1.10-10.19); p = 0.033]. The association of visual field impairment with greater disability and neuroaxonal injury and higher risk of disability progression suggest that VF could be used to monitor MS disease burden.

Telemedicine for Monitoring MS Activity and Progression.

Telemedicine (TM) is defined as the exchange of medical information between two different physical places. The aims of TM are to provide services that cannot easily be provided face-to-face and improve the efficiency of existing ones. Multiple sclerosis (MS) is a chronic demyelinating disease characterized by a heterogeneous array of symptoms that can lead to severe impairment and may impact on accessibility to medical services, patient's ability to function, and overall health-related quality of life (HRQoL). The use of TM to clinically monitor MS patients has demonstrated benefits by improving HRQoL and reducing associated medical costs. Patient-reported outcome (PRO) measures have been used in TM interventions, registries, and cost-efficiency studies because they offer valuable information about patient's perspective of MS disease burden. Moreover, TM has shown acceptable reliability in the assessment of the neurological impairment by Kurtzke expanded disability status scale (EDSS) and has the potential to develop more sensitive measures, such as average daily walking activity, to closely monitor MS disease progression in real environment. It is likely that the use of TM will continue to increase in the following years but larger and controlled studies are necessary to confirm the beneficial effects of TM to deliver an optimal care for patients with MS.

Is it time for a new global classification of multiple sclerosis?

BackgroundThe geographic distribution of multiple sclerosis (MS) is classically divided into three zones based on frequency that were established by Kurtzke in the early 1970s. In recent years, an increasing number of epidemiological studies have shown significantly higher MS prevalence and incidence rates. ObjectiveThe aim of this study was to review and update the geographic distribution of MS using incidence, prevalence and disease duration from the latest epidemiology surveys. MethodsWe conducted a systematic review of articles on MS epidemiology published between January 1, 1990 and December 31, 2012. ResultsMS studies were grouped by continent: the Americas, Europe, Asia, Australia/New Zealand, and Africa. A total of 101 studies were identified according to the inclusion criteria, and 58 reported incidence estimates. Globally, the median estimated incidence of MS was 5.2 (range: 0.5–20.6) per 100,000p-yrs, the median estimated prevalence of MS was 112.0 (with a range of 5.2–335) per 100,000p-yrs, and the average disease duration was 20.2years (range: 7.6–36.2). ConclusionIn the past few decades, the global prevalence and incidence patterns of MS have changed dramatically. Regardless of the reason of increasing prevalence and incidence rate, we suggest the need for a novel classification system based on global MS disease burden. Adopting such a system would improve economic efficiency and prioritization in health policy planning for MS.