Recommendations by the Scientific Department of Neuroimmunology of the Brazilian Academy of Neurology (DCNI/ABN) and the Brazilian Committee for Treatment and Research in Multiple Sclerosis and Neuroimmunological Diseases (BCTRIMS) on vaccination in general and specifically against SARS-CoV-2 for patients with demyelinating diseases of the central nervous system / Recomendações do Departamento Científico de Neuroimunologia da Academia Brasileira de Neurologia (DCNI/ABN) e do Comitê Brasileiro de Tratamento e Pesquisa em Esclerose Múltipla e Doenças Neuroimunológicas (BCTRIMS) sobre vacinação em geral e contra a SARS-CoV-2 para pacientes com doenças desmielinizantes do sistema nervoso central

ABSTRACT The Scientific Department of Neuroimmunology of the Brazilian Academy of Neurology (DCNI/ABN) and Brazilian Committee for Treatment and Research in Multiple Sclerosis and Neuroimmunological Diseases (BCTRIMS) provide recommendations in this document for vaccination of the population with demyelinating diseases of the central nervous system (CNS) against infections in general and against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19. We emphasize the seriousness of the current situation in view of the spread of COVID-19 in our country. Therefore, reference guides on vaccination for clinicians, patients, and public health authorities are particularly important to prevent some infectious diseases. The DCNI/ABN and BCTRIMS recommend that patients with CNS demyelinating diseases (e.g., MS and NMOSD) be continually monitored for updates to their vaccination schedule, especially at the beginning or before a change in treatment with a disease modifying drug (DMD). It is also important to note that vaccines are safe, and physicians should encourage their use in all patients. Clearly, special care should be taken when live attenuated viruses are involved. Finally, it is important for physicians to verify which DMD the patient is receiving and when the last dose was taken, as each drug may affect the induction of immune response differently.

RESUMO O DC de Neuroimunologia da ABN e o BCTRIMS trazem, nesse documento, as recomendações sobre vacinação da população com doenças desmielinizantes do sistema nervoso central (SNC) contra infecções em geral e contra o coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2), causador da COVID-19. Destaca-se a gravidade do atual momento frente ao avanço da COVID-19 em nosso País, o que torna mais evidente e importante a criação de guia de referência para orientação aos médicos, pacientes e autoridades de saúde pública quanto à vacinação, meio efetivo e seguro no controle de determinadas doenças infecciosa. O DCNI/ABN e o BCTRIMS recomendam que os pacientes com doenças desmielinizantes do SNC (ex., EM e NMOSD) sejam constantemente monitorados, quanto a atualização do seu calendário vacinal, especialmente, no início ou antes da mudança do tratamento com uma droga modificadora de doença (DMD). É importante também salientar que as vacinas são seguras e os médicos devem estimular o seu uso em todos os pacientes. Evidentemente, deve ser dada especial atenção às vacinas com vírus vivos atenuados. Por fim, é importante que os médicos verifiquem qual DMD o paciente está em uso e quando foi feita a sua última dose, pois cada fármaco pode interagir de forma diferente com a indução da resposta imune.

Migraine in 746 patients with multiple sclerosis.

Migraine adds to the burden of patients suffering from multiple sclerosis (MS). The ID-migraine is a useful tool for screening migraine, and the Migraine Disability Assessment questionnaire can evaluate disease burden. The aim of the present study was to assess the presence and burden of migraine in patients with MS. METHODS Patients diagnosed with MS attending specialized MS units were invited to answer an online survey if they also experienced headache. RESULTS The study included 746 complete responses from patients with MS and headache. There were 625 women and 121 men, and 69% of all the patients were aged between 20 and 40 years. Migraine was identified in 404 patients (54.1%) and a moderate-to-high burden of disease was observed in 68.3% of the patients. CONCLUSION Migraine is a frequent and disabling type of primary headache reported by patients with MS.

Migraine in 746 patients with multiple sclerosis / Enxaqueca em 746 pacientes com esclerose múltipla

ABSTRACT Migraine adds to the burden of patients suffering from multiple sclerosis (MS). The ID-migraine is a useful tool for screening migraine, and the Migraine Disability Assessment questionnaire can evaluate disease burden. The aim of the present study was to assess the presence and burden of migraine in patients with MS. Methods: Patients diagnosed with MS attending specialized MS units were invited to answer an online survey if they also experienced headache. Results: The study included 746 complete responses from patients with MS and headache. There were 625 women and 121 men, and 69% of all the patients were aged between 20 and 40 years. Migraine was identified in 404 patients (54.1%) and a moderate-to-high burden of disease was observed in 68.3% of the patients. Conclusion: Migraine is a frequent and disabling type of primary headache reported by patients with MS.

RESUMO Enxaqueca piora o sofrimento do paciente que tem esclerose múltipla (EM). ID-migraine é uma ferramenta útil para seleção de pacientes com enxaqueca e Migraine Disability Assessment (MIDAS) é um questionário que avalia o impacto da doença. O objetivo do presente estudo foi avaliar a presença e impacto de enxaqueca em pacientes com EM. Métodos: Pacientes diagnosticados com EM e tratados em clínicas especializadas foram convidados a responder um questionário online se também apresentassem cefaleia. Resultados: O estudo incluiu 746 participantes com cefaleia e EM que preencheram completamente as respostas. Foram 625 mulheres e 121 homens, sendo 69% dos pacientes com idade entre 20 e 40 anos. Enxaqueca foi identificada em 404 pacientes (54,1%) e moderado a grave impacto da doença foi observado em 68,3% dos casos. Conclusão: Enxaqueca é uma cefaleia primária frequente e incapacitante relatada por pacientes com EM.

Dermatoses in parkinsonism: the importance of multidisciplinary follow-up.

Parkinsonism is characterized by bradykinesia with rigidity and/or resting tremor, in addition to non-motor symptoms, which include dermatological manifestations. The objective of this study is to evaluate the main dermatoses in patients with parkinsonism found at the Philanthropic Association of Curitiba - PR. A cross-sectional descriptive study was carried out with the application of a questionnaire and dermatological evaluation of the patients. The sample consisted of 386 patients and was composed mainly by men (55.4%), between 60-74 years old (51.6%), with complete primary education (45.3%), disease diagnosis time between 5-10 years (35%) and in use of medication (96.6%). The most prevalent dermatoses were pigmented nevus (36.3%), warts (25.1%), actinic keratosis (22%), seborrheic keratosis (21.5%), seborrheic dermatitis (20.5%), and rosacea (19.2%). Among the 13 cases (3.4%) of malignant cutaneous neoplasms confirmed by biopsy, 2 were melanomas. Regarding patients' sex, there was a higher prevalence of inflammatory dermatoses (OR 1.64, 95% CI 1.08-2.51, p = 0.025) and benign cutaneous neoplasms (OR 1.77, 95% CI 1.16-2.69, p = 0.01) in men. As to age, patients aged between 60-74 years had more pre-malignant skin lesions (OR 2.60, 95% CI 1.05-6.44, p <0.001) and seborrheic keratosis (OR 2.52, 95% CI 1.02-6.25, p = 0.001) and, in those older than 75 years, actinic keratosis was more frequent (OR 5.43, 95% CI 2.17-13.6, p <0.001). The results of the study show that it is fundamental to dermatologically evaluate and monitor these patients, aiming at diagnosis and early treatment of lesions, especially of skin cancer.

Dermatoses in parkinsonism: the importance of multidisciplinary follow-up

Summary Parkinsonism is characterized by bradykinesia with rigidity and/or resting tremor, in addition to non-motor symptoms, which include dermatological manifestations. The objective of this study is to evaluate the main dermatoses in patients with parkinsonism found at the Philanthropic Association of Curitiba - PR. A cross-sectional descriptive study was carried out with the application of a questionnaire and dermatological evaluation of the patients. The sample consisted of 386 patients and was composed mainly by men (55.4%), between 60-74 years old (51.6%), with complete primary education (45.3%), disease diagnosis time between 5-10 years (35%) and in use of medication (96.6%). The most prevalent dermatoses were pigmented nevus (36.3%), warts (25.1%), actinic keratosis (22%), seborrheic keratosis (21.5%), seborrheic dermatitis (20.5%), and rosacea (19.2%). Among the 13 cases (3.4%) of malignant cutaneous neoplasms confirmed by biopsy, 2 were melanomas. Regarding patients' sex, there was a higher prevalence of inflammatory dermatoses (OR 1.64, 95% CI 1.08-2.51, p = 0.025) and benign cutaneous neoplasms (OR 1.77, 95% CI 1.16-2.69, p = 0.01) in men. As to age, patients aged between 60-74 years had more pre-malignant skin lesions (OR 2.60, 95% CI 1.05-6.44, p <0.001) and seborrheic keratosis (OR 2.52, 95% CI 1.02-6.25, p = 0.001) and, in those older than 75 years, actinic keratosis was more frequent (OR 5.43, 95% CI 2.17-13.6, p <0.001). The results of the study show that it is fundamental to dermatologically evaluate and monitor these patients, aiming at diagnosis and early treatment of lesions, especially of skin cancer.

RESUMO Parkinsonismo é caracterizado por bradicinesia e/ou tremor de repouso, além de sintomas não motores, entre os quais se destacam as manifestações dermatológicas. O objetivo desse trabalho é conhecer as principais dermatoses em pacientes portadores de parkinsonismo atendidos em uma associação filantrópica de Curitiba/PR. Foi realizado um estudo descritivo transversal com aplicação de questionário e avaliação dermatológica dos pacientes. A amostra estudada consistiu de 386 pacientes e foi composta principalmente por homens brancos (55,4%), entre 60-74 anos (51,6%), ensino fundamental completo (45,3%), tempo de diagnóstico da doença entre 5-10 anos (35%) e em uso de medicação (96,6%). As dermatoses mais encontradas na inspeção dermatológica foram manchas pigmentadas (36,3%), verrugas (25,1%), ceratose actínica (22%), ceratose seborreica (21,5%), dermatite seborreica (20,5%) e rosácea (19,2%). Entre os 11 casos (2,8%) de neoplasias cutâneas malignas confirmados por biópsia, dois eram melanomas. Em relação ao sexo, houve prevalência em homens de dermatoses inflamatórias (OR 1,64, IC 95% 1,08-2,51; p=0,025) e neoplasias cutâneas benignas (OR 1,77, IC 95% 1,16-2,69; p=0,01). Quanto à idade, pacientes entre 60-74 anos apresentaram mais lesões cutâneas pré-malignas (OR 2,60, IC 95% 1,05-6,44; p<0,001) e a ceratose seborreica (OR 2,52, IC 95% 1,02-6,25; p=0,001); naqueles acima de 75 anos foi mais frequente a ceratose actínica (OR 5,43, IC 95% 2,17-13,6; p<0,001). Os resultados encontrados no estudo evidenciam que são fundamentais a avaliação e o monitoramento dermatológico desses pacientes, visando diagnóstico e tratamento precoce das lesões, em especial do câncer de pele.

Clinical Characteristics of Patients With Neuromyelitis Optica Spectrum Disorders With Early Onset.

Neuromyelitis optica spectrum disorder is a severe and disabling disease that manifests with severe relapses of optic neuritis, longitudinally extensive myelitis, and/or brainstem syndromes. The disease is complex and, although onset typically occurs in middle age, children and adolescents may be affected. The present study adds to the literature through detailed clinical data from 36 Brazilian patients with neuromyelitis optica spectrum disorder starting before age 21. This was a retrospective assessment of medical records from 14 specialized units in Brazil. The results showed that the course of neuromyelitis optica spectrum disorder was worse in patients with disease onset before the age of 12 years. Gender and ethnic background did not influence disability accumulation. Over a median period of 8 years, 14% of the patients who presented the initial symptoms of neuromyelitis optica spectrum disorder before the age of 21 years died. In conclusion, the present study adds to the reports from other authors examining the severity of early-onset neuromyelitis optica spectrum disorder.

Safety of switching from natalizumab straight into fingolimod in a group of JCV-positive patients with multiple sclerosis.

OBJECTIVE: To assess safety of the switch between natalizumab and fingolimod without a washout period. METHODS: Prospective data on 25 JCV positive patients who underwent this medication switch were collected and analyzed. RESULTS: After a median period of nine months from the medication switch, there were no safety issues to report. The patients had good disease control and no adverse events were reported. CONCLUSION: Washout may not be necessary in daily practice when switching from natalizumab to fingolimod. Expertise on multiple sclerosis management, however, is essential for drug switching.

Safety of switching from natalizumab straight into fingolimod in a group of JCV-positive patients with multiple sclerosis / Segurança na mudança direta de natalizumabe para fingolimode em um grupo de pacientes com esclerose múltipla e positivos para JCV

ABSTRACT Objective To assess safety of the switch between natalizumab and fingolimod without a washout period. Methods Prospective data on 25 JCV positive patients who underwent this medication switch were collected and analyzed. Results After a median period of nine months from the medication switch, there were no safety issues to report. The patients had good disease control and no adverse events were reported. Conclusion Washout may not be necessary in daily practice when switching from natalizumab to fingolimod. Expertise on multiple sclerosis management, however, is essential for drug switching.

RESUMO Objetivo Avaliar a segurança na mudança entre natalizumabe e fingolimode sem período de washout. Métodos Dados prospectivos de 25 pacientes positivos para vírus JC que tiveram sua medicação modificada foram coletados e analisados. Resultados Após uma mediana de nove meses da troca de medicação, não havia aspectos de segurança a relatar. Os pacientes estavam com bom controle da doença e não foram relatados eventos adversos. Conclusão Washout pode não ser necessário na prática diária para a mudança entre natalizumabe e fingolimode. No entanto, expertise no manejo de esclerose múltipla é essencial para esta troca entre medicações.

Real-life experience with fampridine (Fampyra®) for patients with multiple sclerosis and gait disorders.

BACKGROUND: Fampridine is a broad-spectrum voltage-dependent potassium channel blocker that enhances synaptic transmission. The drug has been shown to be able to ameliorate conduction in demyelinated axons, thereby leading to improved gait in patients with multiple sclerosis (MS). OBJECTIVE: To assess the "real-life" efficacy and safety of fampridine prescribed for gait disorders in MS. This was an observational and prospective study carried out at MS Units participating in the Brazilian Multiple Sclerosis Study Group. METHODS: Patients with MS and gait disorders were prescribed fampridine (10 mg twice a day), irrespectively of the degree of disability determined by MS. Neurological disability determined by MS was assessed with the expanded disability scale score (EDSS). Outcomes for efficacy and safety of the drug were evaluated by the 25 foot-walk test and by the adverse events of fampridine. RESULTS: The time taken to walk 25 feet decreased by 20% or more in 62 patients (70%). Twenty-five patients were considered to be non-responders to this treatment. Improvement in walking speed was independent of improvement of disability. Mild or moderate adverse events were reported in 8% of patients. CONCLUSION: Fampridine is an efficient and safe therapeutic option for patients with MS and gait disorders.