RESUMO
BACKGROUND: A contemporary understanding of disability evolution in multiple sclerosis (MS) is an essential tool for individual disease management and planning of interventional studies. We have used prospectively collected longitudinal data to analyse disability progression and variation in a British MS cohort. METHODS: Cox proportional hazards regression was used to estimate hazard of Expanded Disability Status Scale (EDSS) 4.0 and 6.0. A continuous Markov model was used to estimate transitional probabilities for individual EDSS scores. Models were adjusted for age at MS onset, sex and disease-modifying treatments (DMTs) exposure. RESULTS: 2135 patients were included (1487 (70%) female, 1922 (89%) relapsing onset). 865 (41%) had used DMTs. Median time to EDSS 4.0 and 6.0 was 18.2 years (95% CI 16.3 to 20.2) and 22.1 years (95% CI 20.5 to 24.5). In the Markov model, the median time spent at EDSS scores of <6 (0.40-0.98 year) was shorter than the time spent at EDSS scores of ≥6 (0.87-4.11 year). Hazard of change in EDSS was greatest at EDSS scores <6 (HR for increasing EDSS: 1.02-1.33; decreasing EDSS: 0.34-1.27) compared with EDSS scores ≥6 (HR for increasing EDSS: 0.08-0.61; decreasing EDSS: 0.18-0.54). CONCLUSIONS: These data provide a detailed contemporary model of disability outcomes in a representative population-based MS cohort. They support a trend of increasing time to disability milestones compared with historical reference populations, and document disability variation with the use of transitional matrices. In addition, they provide essential information for patient counselling, clinical trial design, service planning and offer a comparative baseline for assessment of therapeutic interventions.
Assuntos
Pessoas com Deficiência , Esclerose Múltipla Recidivante-Remitente , Esclerose Múltipla , Humanos , Feminino , Masculino , Esclerose Múltipla/epidemiologia , País de Gales/epidemiologia , Progressão da Doença , Avaliação da Deficiência , Esclerose Múltipla Recidivante-Remitente/tratamento farmacológicoRESUMO
OBJECTIVES: The prevalence and definition of benign multiple sclerosis (BMS) remain controversial. Most definitions are based on the Expanded Disability Status Scale (EDSS), not encompassing the wider impact of disease. The explanation for favourable outcomes remains unclear. We aim to provide a detailed characterisation of patients with low EDSS scores at long disease durations. METHODS: We screened a population-based registry containing 3062 people with MS to identify individuals with unlimited walking ability at disease durations >15 years. A representative cohort underwent detailed clinical assessment and classified as having BMS according to EDSS score <3, no significant fatigue, mood disturbance, cognitive impairment or disrupted employment, and had not received a disease-modifying therapy. We determined patient-reported perceptions of MS status and made comparisons with EDSS-based definitions. RESULTS: Of 1049 patients with disease duration of >15 years, 200 (19.1%) had most recent EDSS score <4.0. Detailed contemporary clinical assessment of a representative sample of 60 of these patients revealed 48 (80%) had an EDSS score of <4.0, 35 (58%) <3.0 and 16 (27%) <2.0. Only nine (15%) fulfilled our criteria for BMS; impaired cognition (57%) and effects on employment (52%) the most common causes for exclusion. Meanwhile, 33/60 (69%) patients considered their disease benign. Population frequency for BMS was estimated at 2.9% (95% CI 2.0 to 4.1). CONCLUSIONS: Comprehensive assessment reveals a small minority of people with MS who appear genuinely benign after 15 years. Study of such individuals may uncover insights about disease pathogenesis. However, discrepancy between patient perception and clinician perception of BMS undermines use of the term 'benign' in clinical settings.
Assuntos
Esclerose Múltipla/complicações , Esclerose Múltipla/epidemiologia , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/diagnóstico , Prevalência , Sistema de Registros , Autoimagem , Fatores Socioeconômicos , Reino UnidoRESUMO
PURPOSE: The purpose of the study was to report a case of multiple sclerosis (MS)-associated uveitis refractory to conventional immunosuppressants, with subsequent remission following treatment with alemtuzumab. METHODS: Case report Patient was treated with intravenous alemtuzumab, a lymphocyte depleting anti-CD52 monoclonal antibody that has recently been approved for use in relapsing MS. RESULTS: A 17-year-old female presented with bilateral optic neuritis and subsequently bilateral intermediate uveitis and secondary macular oedema. She was diagnosed with active relapsing MS for which she received treatment with alemtuzumab. The intraocular inflammation previously refractory to conventional immunosuppressants responded to alemtuzumab, inducing remission. CONCLUSIONS: To our knowledge, this is the first such report of alemtuzumab treatment in MS-associated ocular inflammatory disease and may demonstrate a potential utility for this drug in related conditions.
Assuntos
Alemtuzumab/administração & dosagem , Esclerose Múltipla/complicações , Uveíte/tratamento farmacológico , Adolescente , Antineoplásicos Imunológicos/administração & dosagem , Encéfalo/diagnóstico por imagem , Relação Dose-Resposta a Droga , Feminino , Angiofluoresceinografia , Fundo de Olho , Humanos , Imageamento por Ressonância Magnética , Esclerose Múltipla/diagnóstico , Esclerose Múltipla/tratamento farmacológico , Indução de Remissão , Tomografia de Coerência Óptica , Uveíte/diagnóstico , Uveíte/etiologiaRESUMO
We report a cluster of atypical Guillain-Barré syndrome in 10 adults temporally related to a cluster of four children with acute flaccid paralysis, over a 3-month period in South Wales, United Kingdom. All adult cases were male, aged between 24 and 77 years. Seven had prominent facial diplegia at onset. Available electrophysiological studies showed axonal involvement in five adults. Seven reported various forms of respiratory disease before onset of neurological symptoms. The ages of children ranged from one to 13 years, three of the four were two years old or younger. Enterovirus testing is available for three children; two had evidence of enterovirus D68 infection in stool or respiratory samples. We describe the clinical features, epidemiology and state of current investigations for these unusual clusters of illness.
Assuntos
Enterovirus/isolamento & purificação , Síndrome de Guillain-Barré/epidemiologia , Paralisia/complicações , Paralisia/epidemiologia , Paralisia/etiologia , Adolescente , Adulto , Idoso , Surtos de Doenças , Enterovirus/classificação , Infecções por Enterovirus/diagnóstico , Infecções por Enterovirus/epidemiologia , Infecções por Enterovirus/virologia , Feminino , Síndrome de Guillain-Barré/complicações , Síndrome de Guillain-Barré/microbiologia , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Distribuição por Sexo , Fatores de Tempo , Reino Unido/epidemiologia , País de Gales/epidemiologiaRESUMO
BACKGROUND: Multiple sclerosis (MS) relapses contribute to disability and influence treatment decisions. Many centres now provide open access to specialist services for patients with new symptoms. However, there is scarce literature on the spectrum of presentations encountered in this setting. OBJECTIVE: The objective of this paper is to characterise presentations to an open, rapid-access MS relapse clinic and the impact on disease management. METHODS: A retrospective review of outpatient episodes over a three-year period was conducted. Demographic and service data, symptoms, disability, diagnosis and management were recorded according to a standardised proforma. RESULTS: A total of 371 attendances were analysed. A new MS relapse was diagnosed in 216 (58%) episodes, of which 56 (26%) patients had an additional diagnosis which had also contributed to their presentation. Of 266 reports of non-relapse-related symptoms, 73 were unrelated to MS. Treatment interventions were made in almost all relapsing patients and in 70% of patients presenting with acute, non-relapse-related symptoms of MS. Changes to disease-modifying therapies were considered in 28% of consultations. CONCLUSION: Diagnosing MS relapses is crucial for disease management and yet remains challenging. Clinicians should be aware of differential diagnoses and confounding factors. The high incidence of therapeutic interventions observed suggests that rapid-access clinics represent an effective platform for responsive disease management.
Assuntos
Progressão da Doença , Esclerose Múltipla/fisiopatologia , Índice de Gravidade de Doença , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/terapia , RecidivaRESUMO
BACKGROUND: Age of onset of multiple sclerosis (MS) peaks in the 3rd and 4th decades and is rarely less than 18. Robust longitudinal studies in paediatric-onset MS (POMS) are limited, and a clearer understanding of outcome could optimise management strategies. METHODS: Patients with disease onset <18 years were identified from a prospective population-based register. Clinical features including presenting symptoms, time to Expanded Disability Status Scale (EDSS) 4.0, 6.0 and 8.0 and onset of secondary progression were compared with patients with adult-onset MS (AOMS). RESULTS: 111 POMS patients were identified from a cohort of 2068. No significant differences in sex ratio, familial recurrence, relapse rate, ethnicity or clinical symptoms at presentation were identified between POMS and AOMS. However, interval to second relapse was longer (5 vs 2.6 years, p=0.04) and primary progressive disease was less common (0.9% vs 8.5%, p=0.003) in POMS than in AOMS. POMS patients also took longer to develop secondary progressive disease (32 vs 18 years, p=0.0001) and to reach disability milestones (EDSS 4.0, 23.8 vs 15.5 years, p<0.0001; EDSS 6.0, 30.8 vs 20.4 years, p<0.0001; EDSS 8.0, 44.7 vs 39 years, p=0.02), but did so between 7.0 and 12 years younger than in AOMS. CONCLUSIONS: 5.4% of patients with MS have POMS (2.7% <16 years; 0.3% <10 years) and have distinct phenotypic characteristics in early disease. Furthermore, while patients with POMS take longer to reach disability milestones, they do so at a younger age than their adult counterparts and could be considered to have a poorer prognosis. Management strategies for these patients should take account of these data.
Assuntos
Progressão da Doença , Esclerose Múltipla/diagnóstico , Esclerose Múltipla/epidemiologia , Adolescente , Adulto , Fatores Etários , Idade de Início , Criança , Pré-Escolar , Estudos de Coortes , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , País de Gales/epidemiologiaRESUMO
OBJECTIVE: The objective of this paper is to investigate demographic and disease factors associated with changes in employment role and status in multiple sclerosis (MS). METHODS: Questionnaires on current symptoms, employment status and factors associated with changes in employment were sent to a community sample of 566 MS patients. RESULTS: A total of 221 completed questionnaires were analysed. Of 169 employed at diagnosis, 43.3% had left employment at a mean of 11.9 years after disease onset. Of those still employed, 55% had changed their role or working hours to accommodate symptoms relating to their disease. These patients reported greater fatigue (p = 0.001), pain (p = 0.033) and memory problems (p = 0.038) than those whose employment had remained unaffected. Multinomial logistic regression revealed the factors most strongly predictive of employment status were disability level, years of education, disease duration and fatigue (p = 0.032). CONCLUSIONS: Despite changes to public perceptions and legislative protection over the last 20 years, high rates of MS patients still leave the workforce prematurely, reduce working hours or change employment roles. These data have significant implications when considering social and economic impacts of MS, support the value of employment metrics as long-term outcome measures, and demonstrate the need to improve employment requirements and flexibility of working practices in individuals with MS.
Assuntos
Emprego/estatística & dados numéricos , Esclerose Múltipla/economia , Esclerose Múltipla/epidemiologia , Adulto , Fatores Etários , Idade de Início , Idoso , Intervalos de Confiança , Avaliação da Deficiência , Progressão da Doença , Escolaridade , Fadiga/etiologia , Feminino , Humanos , Masculino , Transtornos da Memória/etiologia , Transtornos da Memória/psicologia , Transtornos Mentais/etiologia , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Esclerose Múltipla/psicologia , Razão de Chances , Qualidade de Vida , Análise de Regressão , Caracteres Sexuais , Fatores Socioeconômicos , Inquéritos e Questionários , Reino Unido/epidemiologiaRESUMO
BACKGROUND: Relapse is a characteristic clinical feature of multiple sclerosis (MS) and is commonly employed as a measure of efficacy following therapeutic intervention. However, less is known about the temporal evolution of subsequent disability or factors predicting recovery. OBJECTIVES: The objective of this study was to assess the pattern of recovery following relapse and identify factors which predict recovery and residual disability following relapse. METHODS: A total of 226 relapses were studied prospectively in a cohort of 144 patients with standardised clinical assessments of physical disability including Expanded Disability Status Scale (EDSS), 10-m timed walk, 9-hole peg test and Multiple Sclerosis Impact Scale (MSIS-29) at 0, 2, 6 and 12 months. A total of 82 patients completed 12 months of follow up without further relapse. RESULTS: Thirty per cent of relapses were severe (change in EDSS >2.0) of which 11% failed to recover. All measures showed significant improvement at 2 months but additional improvement was also observed in 9-hole peg test and MSIS-29 up to 12 months following initial assessment. Mean time to second relapse was 382 days. The only predictor of relapse severity in the model tested was younger age; however, increasing age and initial relapse severity were also predictors of poor outcome. CONCLUSIONS: This study shows that the majority of improvement in physical disability following relapse occurs by 2 months but that more subtle recovery can take place over 12 months in a small sub-group of patients. These data will aid in patient counselling and will also inform the timing of therapeutic intervention and physical support.
Assuntos
Avaliação da Deficiência , Esclerose Múltipla/diagnóstico , Esclerose Múltipla/terapia , Adolescente , Adulto , Idoso , Análise de Variância , Teste de Esforço , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Atividade Motora , Esclerose Múltipla/fisiopatologia , Testes Neuropsicológicos , Razão de Chances , Valor Preditivo dos Testes , Estudos Prospectivos , Recuperação de Função Fisiológica , Recidiva , Indução de Remissão , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , País de Gales , Caminhada , Adulto JovemRESUMO
Multiple sclerosis has a variable phenotypic presentation and subsequent disease course that, although unpredictable at disease onset, is of crucial importance in guiding interventions. Effective and accessible biomarkers are required in order to stratify patients and inform treatment. We examined whether the complement regulator factor H and its Tyr402His polymorphism, recently implicated as biomarkers in other chronic inflammatory central nervous system conditions, might identify or predict specific pathological processes and outcomes in multiple sclerosis. Employing novel assays, we measured factor H and its His402 variant in serum from 350 patients with multiple sclerosis classified according to disease course and relapse status. Serum factor H levels were significantly higher in progressive disease (P < 0.001) compared to controls and relapsing patients, after controlling for variables including disease duration, age, gender, disability and treatment. Serum factor H levels were capable of distinguishing secondary progressive from relapsing remitting disease (excluding patients in clinical relapse) with a sensitivity of 89.41%, specificity of 69.47% and a positive predictive value of 72.38%. Acute relapse was also associated with transiently increased factor H levels (P = 0.009) compared to stable relapsing disease. In clinically stable patients, factor H levels remained constant over 1 year (coefficient of variation percentage = 6.8), however, in patients in transition from relapsing to progressive disease, factor H levels significantly increased over a period of 2 years (P = 0.007). Concentration of the His402 variant in heterozytgotes was significantly higher in secondary progressive (P < 0.01) and primary progressive (P < 0.05) disease, suggesting altered expression or consumption of variants when factor H is upregulated. Serum factor H may be an effective indicator of progression and a practical and accessible biomarker and stratifying tool in determining disease course, providing objective evidence to help guide therapeutic decisions.
Assuntos
Fator H do Complemento/metabolismo , Esclerose Múltipla Crônica Progressiva/sangue , Esclerose Múltipla Recidivante-Remitente/sangue , Adulto , Biomarcadores/sangue , Biomarcadores/líquido cefalorraquidiano , Biomarcadores/metabolismo , Fator H do Complemento/líquido cefalorraquidiano , Fator H do Complemento/genética , Feminino , Frequência do Gene , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla Crônica Progressiva/diagnóstico , Esclerose Múltipla Crônica Progressiva/genética , Esclerose Múltipla Recidivante-Remitente/diagnóstico , Esclerose Múltipla Recidivante-Remitente/genética , Polimorfismo Genético , Sensibilidade e Especificidade , Fatores de TempoRESUMO
OBJECTIVE: Alemtuzumab is potentially a highly effective treatment for relapsing multiple sclerosis (MS) acting via complement-mediated lysis of circulating lymphocytes. Variability in posttreatment lymphocyte recovery time is observed, with some patients showing striking durability in the efficacy of treatment. This study aims to establish whether this observed variation affects clinical and imaging parameters of disease activity. METHODS: A total of 56 patients were followed for a median of 39.5 months post alemtuzumab treatment with interval clinical assessments, lymphocyte immunophenotyping, and MRI. Timing and degree of CD4+, CD8+, and CD19+ recovery were correlated with the re-emergence of disease activity defined as clinical relapse, increasing disability, and new T2/enhancing lesions on MRI. RESULTS: New disease activity was recorded in 14% of patients. Mean time to CD19+, CD8+, and CD4+ reconstitution was 6, 10, and 36 months. No differences were observed in CD8+ and CD19+ reconstitution between patients with active disease and those in remission. Patients with active disease showed an accelerated recovery of CD4+ cells (p = 0.001) with a difference in absolute CD4+ counts at 24 months (p = 0.009). CD4+ counts <388.5 × 10(6) cells/mL predicted MRI stability. CONCLUSIONS: Differential lymphocyte recovery in MS following alemtuzumab may be a biomarker for relapse and also inform monitoring and treatment protocols. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that differential lymphocyte reconstitution after alemtuzumab treatment may be a biomarker for relapse.
Assuntos
Anticorpos Monoclonais Humanizados/uso terapêutico , Antígenos CD19/efeitos dos fármacos , Linfócitos T CD4-Positivos/efeitos dos fármacos , Linfócitos T CD8-Positivos/efeitos dos fármacos , Imunofenotipagem/estatística & dados numéricos , Contagem de Linfócitos/estatística & dados numéricos , Esclerose Múltipla Recidivante-Remitente/tratamento farmacológico , Adulto , Alemtuzumab , Anti-Inflamatórios/uso terapêutico , Contagem de Linfócito CD4/estatística & dados numéricos , Avaliação da Deficiência , Feminino , Humanos , Imunofenotipagem/métodos , Imageamento por Ressonância Magnética/métodos , Imageamento por Ressonância Magnética/estatística & dados numéricos , Masculino , Esclerose Múltipla Recidivante-Remitente/sangue , Neuroimagem/métodos , Neuroimagem/estatística & dados numéricos , Recidiva , Fatores de TempoRESUMO
OBJECTIVE: The expression of clinically significant depression symptoms during and post multiple sclerosis (MS) relapse was investigated. The point prevalence of possible depression during a confirmed MS relapse and at 2 and 6months post-relapse was examined and the influence of disability on the time course of depression symptoms post-relapse determined. METHODS: 132 sequential patients were recruited from an open access relapse clinic. Clinical data including disability (Expanded Disability Status Scale: EDSS) and depression symptoms (Hospital Anxiety and Depression Scale depression subscale: HADS-D) were recorded at 0, 2 and 6months post-relapse. RESULTS: Prevalence of possible depression (HADS-D score of≥8) was 44.5% during relapse, reducing to 29.2% at 2months and 34.4% at 6months post-relapse. HADS-D scores were significantly lower at follow-up than during relapse. Possible depression at relapse was significantly related to a higher likelihood of possible depression at 2month follow-up (OR 12.12) and improvement in EDSS was related to a lower likelihood (OR 0.51). EDSS at relapse (OR 1.47) and possible depression at relapse (OR 11.87) were significantly associated with possible depression 6months post-relapse. CONCLUSIONS: High rates of possible depression were observed during relapse. Although depression scores reduced significantly post-relapse, rates of possible depression at follow-ups remained high. The results suggest that although improvements in disability may influence depression symptoms over the short-term, once depression symptoms are elevated at relapse then depression symptoms become persistent. Further studies are required on the relationship between relapses and depression and whether targeted psychological interventions are beneficial.