Consensus statement on the treatment of multiple sclerosis by the Spanish Society of Neurology in 2016. / Consenso para el tratamiento de la esclerosis múltiple 2016. Sociedad Española de Neurología.

With the advent of new disease-modifying drugs, the treatment of multiple sclerosis is becoming increasingly complex. Using consensus statements is therefore advisable. The present consensus statement, which was drawn up by the Spanish Society of Neurology's study group for demyelinating diseases, updates previous consensus statements on the disease. The present study lists the medications currently approved for multiple sclerosis and their official indications, and analyses such treatment-related aspects as activity, early treatment, maintenance, follow-up, treatment failure, changes in medication, and special therapeutic situations. This consensus statement includes treatment recommendations for a wide range of demyelinating diseases, from isolated demyelinating syndromes to the different forms of multiple sclerosis, as well as recommendations for initial therapy and changes in drug medication, and additional comments on induction and combined therapy and practical aspects of the use of these drugs.

Quality of life in caregivers of children with asthma: Validity and reliability of the IFABI-R questionnaire.

BACKGROUND: Parents'/caregivers' quality of life is an important aspect to consider when handling paediatric asthma, but there is a paucity of valid and reliable instruments to measure it. The Family Impact of Childhood Bronchial Asthma (IFABI-R) is a recently developed questionnaire to facilitate the assessment of asthma-related parents'/caregivers' quality of life. This study researches the psychometric properties of IFABI-R. METHODS: Parents/main caregivers of 462 children between 4 and 14 years of age with active asthma were included in the sample. IFABI-R was administered on two different occasions and a number of other variables related to the parents'/caregivers' quality of life were measured: child's asthma control, family functioning, and parents'/caregivers' perception of asthma symptoms in the child. IFABI-R evaluative and discriminative properties were analysed, and the minimal important change in the IFABI-R score was identified. RESULTS: IFABI-R showed high internal consistency (Cronbach's alpha=0.941), cross-sectional construct validity (correlation with the degree of child's asthma control, family functioning and parent/caregiver perception of the child's asthma symptoms), longitudinal construct validity (correlation of changes in the IFABI-R with changes in asthma control and changes in the perception of symptoms), sensitivity to change and test-retest reliability. An absolute change of 0.3 units in IFABI-R related to a minimal significant change in the parents'/caregivers' quality of life. CONCLUSIONS: IFABI-R is a reliable and valid instrument to study the quality of life of parents/caregivers of children with asthma.

Regulation of cannabinoid receptor gene expression and endocannabinoid levels in lymphocyte subsets by interferon-ß: a longitudinal study in multiple sclerosis patients.

Evidence suggests the involvement of the cannabinoid system in the pathogenesis of multiple sclerosis (MS). We studied cannabinoid receptor (CB)1 and CB2 receptor gene expression in B, natural killer (NK) and T cells from MS patients before and after 1 year of interferon beta therapy, and compared these levels to those of healthy controls. We also measured the production of the endocannabinoids anandamide (AEA) and 2-arachidonoylglycerol (2-AG) and the gene expression of the endocannabinoid-degrading enzyme fatty acid amide hydrolase (FAAH) in these cells. Prior to interferon therapy, MS patients showed significantly elevated CB2 expression in B cells, but not in T or NK cells. These levels decreased gradually within 6 months to 1 year of interferon treatment. CB1 expression was elevated in all cell subsets, but only reached statistical significance in T cells; all levels decreased progressively over time. Before treatment, AEA but not 2-AG levels were significantly elevated in the three cell populations; after 1 year of treatment, all values decreased to control levels. The expression of FAAH was unchanged. The different expression of cannabinoid receptor genes and the increased level of AEA in lymphocytes point to a possible role of the cannabinoid system in MS immune response and its modulation by interferon.

Consensus Statement on medication use in multiple sclerosis by the Spanish Society of Neurology's study group for demyelinating diseases.

Treatments for multiple sclerosis therapy are rapidly evolving. It is believed that new drugs will be approved in the near future, thereby changing current indications for treatment. In this context, the Spanish Society of Neurology's study group on demyelinating diseases, which evaluates medication use in MS, has decided to draw up a consensus statement on the current indications and guidelines for multiple sclerosis treatment.

Neuroprotective agents: cannabinoids.

Chronic inflammation and neurodegeneration are the main pathological traits of multiple sclerosis that coexist in all stages of the disease course, with complex and still nonclarified relationships. Currently licensed medications have efficacy to control aspects related to inflammation, but have been unable to modify pure progression. Experimental work has provided robust evidence of the immunomodulatory and neuroprotective properties that cannabinoids exert in animal models of multiple sclerosis. Through activation of the CB2 receptor, cannabinoids modulate peripheral blood lymphocytes, interfere with migration across the blood-brain barrier and control microglial/macrophage activation. CB1 receptors present in neural cells have a fundamental role in direct neuroprotection against several insults, mainly excitotoxicity. In multiple sclerosis, several reports have documented the disturbance of the endocannabinoid system. Considering the actions demonstrated experimentally, cannabinoids might be promising agents to target the main aspects of the human disease.

Incidence and prevalence of multiple sclerosis in Spain: a systematic review.

INTRODUCTION: Greater understanding of the prevalence and incidence of multiple sclerosis in Spain and their temporal trends is necessary to improve the allocation of healthcare resources and to study aetiological factors. METHODS: We performed a systematic search of the MedLine database and reviewed the reference lists of the articles gathered. We collected studies reporting prevalence or incidence rates of multiple sclerosis in any geographical location in Spain, with no time limits. In 70% of cases, data were extracted by 2 researchers (FGL and EAC); any discrepancies were resolved by consensus. RESULTS: We identified 51 prevalence and 33 incidence studies published between 1968 and 2018. In the adjusted analysis, the number of prevalent cases per 100 000 population increased by 26.6 (95% confidence interval [CI], 21.5-31.8) every 10 years. After adjusting for year and latitude, the number of incident cases per 100 000 population increased by 1.34 (95% CI, 0.98-1.69) every 10 years. We observed a trend toward higher prevalence and incidence rates at higher latitudes. CONCLUSIONS: The prevalence of multiple sclerosis in Spain has increased in recent decades, although case ascertainment appears to be incomplete in many studies. Incidence rates have also increased, but this may be due to recent improvements in the detection of new cases.

Consensus statement on the use of alemtuzumab in daily clinical practice in Spain.

INTRODUCTION: Alemtuzumab is a highly effective drug approved by the European Medicines Agency as a disease-modifying drug for the treatment of relapsing-remitting multiple sclerosis. OBJECTIVE: A consensus document was drafted on the management of alemtuzumab in routine clinical practice in Spain. DEVELOPMENT: A group of multiple sclerosis specialists reviewed articles addressing treatment with alemtuzumab in patients with multiple sclerosis and published before December 2017. The included studies assessed the drug's efficacy, effectiveness, and safety; screening for infections and vaccination; and administration and monitoring aspects. The initial proposed recommendations were developed by a coordinating group and based on the available evidence and their clinical experience. The consensus process was carried out in 2 stages, with the initial threshold percentage for group agreement established at 80%. The final document with all the recommendations agreed by the working group was submitted for external review and the comments received were considered by the coordinating group. CONCLUSION: The present document is intended to be used as a tool for optimising the management of alemtuzumab in routine clinical practice.

Consensus statement on the use of alemtuzumab in daily clinical practice in Spain. / Consenso de expertos sobre el uso de alemtuzumab en la práctica clínica diaria en España.

INTRODUCTION: Alemtuzumab is a highly effective drug approved by the European Medicines Agency as a disease-modifying drug for the treatment of relapsing-remitting multiple sclerosis. OBJECTIVE: A consensus document was drafted on the management of alemtuzumab in routine clinical practice in Spain. DEVELOPMENT: A group of multiple sclerosis specialists reviewed articles addressing treatment with alemtuzumab in patients with multiple sclerosis and published before December 2017. The included studies assessed the drug's efficacy, effectiveness, and safety; screening for infections and vaccination; and administration and monitoring aspects. The initial proposed recommendations were developed by a coordinating group and based on the available evidence and their clinical experience. The consensus process was carried out in 2 stages, with the initial threshold percentage for group agreement established at 80%. The final document with all the recommendations agreed by the working group was submitted for external review and the comments received were considered by the coordinating group. CONCLUSION: The present document is intended to be used as a tool for optimising the management of alemtuzumab in routine clinical practice.

Monoclonal antibodies. Basic features.

INTRODUCTION: Monoclonal antibodies are a powerful tool in laboratory diagnosis and are increasingly used in the treatment of several diseases. DEVELOPMENT: Antibody development and characterization has a long history and goes back to immunology itself. The present article provides a historical introduction to humoral immunity until the discovery of monoclonal antibodies and reviews concepts relating to the structure and function of antibodies, as well as to the generation of diversity, activation and maturation of B lymphocytes. The main techniques for producing monoclonal antibodies are outlined and some of their applications in human disease are described. CONCLUSIONS: Since their discovery, monoclonal antibodies have revolutionized the diagnosis and treatment of numerous diseases. The use of human and humanized monoclonal antibodies has markedly improved their tolerability. Current technology for manufacturing these antibodies allows new designs that may broaden their possible applications in medicine.

Multidisciplinary Management of the Adverse Effects of Apremilast. / Manejo de los efectos adversos de apremilast desde un abordaje multidisciplinar.

We present a series of general and specific recommendations based on pathophysiologic considerations for managing the most common adverse effects of apremilast that lead to treatment discontinuation: diarrhea, nausea, and headache. The recommendations are based on a review of the literature and the experience of a multidisciplinary team of 14 experts including dermatologists, rheumatologists, neurologists, gastroenterologists, pharmacists, and nurses. We propose a series of simple algorithms that include clinical actions and suggestions for pharmacologic treatment. The adverse effects of apremilast can be managed from a multidisciplinary approach. The purpose of optimizing management is to bring clinical benefits to patients.

The cannabinoid receptor 1 gene (CNR1) and multiple sclerosis: an association study in two case-control groups from Spain.

Different studies point to the implication of the endocannabinoid system in multiple sclerosis (MS) and animal models of MS. The purpose of this study was to evaluate a possible association of MS with polymorphic markers at the CNR1 gene, encoding the cannabinoid 1 (CB(1)) receptor. We have performed a genetic analysis of an AAT repeat microsatellite localized in the downstream region of the CNR1 gene, in two case-control groups of MS patients and healthy controls (HC) from Spain (Madrid and Bilbao). MS patients with primary progressive MS (PPMS) had more commonly long ((AAT) > or = (13)) alleles and genotypes with a significant difference for genotype 7/8 in Madrid (p = 0.043) and in the sum of both groups (p = 0.016); short alleles were less frequently found in PPMS with a significant difference for allele 5 in the analysis of both groups together (p = 0.039). In patients with relapsing MS, no consistent differences in allele and genotype distribution were found. Disease severity and progression was unrelated to AAT repeat variations. In conclusion, long (AAT) > or = (13) CNR1 genotypes could behave as risk factors for PPMS.

Clinical correlates and determinants of airway inflammation in pediatric asthma.

BACKGROUND: Airway inflammation is a key component in the pathophysiology of asthma. However, neither its role in the clinical features of asthma nor the factors affecting the degree of inflammation have been fully defined. METHODS: We determined the fractional exhaled nitric oxide concentration (FE(NO)) using a portable device (NIOX-MINO, Aerocrine, Solna, Sweden) in a consecutive sample of 149 asthmatic children aged 6 to 14 years. In order to establish an association with FE(NO), we analyzed symptoms, spirometric parameters before and after a bronchodilator test, and the impact of asthma on quality of life during the previous 4 weeks. We also investigated how clinical variables that regulate inflammation affected FE(NO). RESULTS: In patients not treated with inhaled corticosteroids (ICs), FE(NO) was higher when specific symptoms (wheeze and cough) had been present during the previous 4 weeks; however, we were unable to establish a relationship with symptom frequency, bronchodilator use, asthma crises, hospital admissions, limitation of daily activities, or spirometry results. In patients treated with ICs, FE(NO) was not related to the clinical expression of asthma, except for a reduced ratio of forced expiratory volume in 1 second to forced vital capacity, both before and after bronchodilation. The main determinant of FE level in untreated patients was sensitization to house dust mite. In patients treated with ICs, FE(NO) was only associated with adherence to therapy. CONCLUSION: Airway inflammation, as determined by FE(NO), is only weakly associated with the clinical expression of asthma and spirometry results. Adherence to treatment is the main determinant of the degree of inflammation in patients taking ICs.

Diet and prevalence of atopic eczema in 6 to 7-year-old schoolchildren in Spain: ISAAC phase III.

BACKGROUND: The prevalence of atopic dermatitis (AD), a chronic skin disease, has increased substantially in recent decades, and different factors have been implicated in its etiology. Although dietary habits are being investigated, few conclusive findings have been reported. Nevertheless, increased consumption of polyunsaturated fatty acids (PUFA) and a diet poor in antioxidants have been related to AD. OBJECTIVES: The objectives of this study were to investigate the association between AD, the intake of different foods, and the effect of a Mediterranean diet among Spanish schoolchildren aged 6 to 7. METHODS: We performed a cross-sectional study with 20 106 schoolchildren aged 6-7 years from 10 different areas of Spain. The participation rate was 76.50%. The prevalence of AD was assessed using the International Study of Asthma and Allergies in Childhood questionnaire and the criteria of the Spanish Academy of Dermatology. To calculate the Mediterranean diet score, we classified food into 2 groups: Mediterranean food, including fruit, seafood, vegetables, pulses, cereals, pasta, rice, and potatoes; and non-Mediterranean food, including meat, milk, and fast food. RESULTS: Milk was negatively associated with AD. Butter and nuts also were negatively associated, although statistical significance was only reached when these foods were consumed 3 or more times a week. CONCLUSIONS: We found no association between the Mediterranean diet score and AD and a positive association between AD and obesity.

Multiple sclerosis associates with LILRA3 deletion in Spanish patients.

The genetic susceptibility to multiple sclerosis (MS) is only partially explained, and it shows geographic variations. We analyse here two series of Spanish patients and healthy controls and show that relapsing MS (R-MS) is associated with a gene deletion affecting the hypothetically soluble leukocyte immunoglobulin (Ig)-like receptor A3 (LILRA3, 19q13.4), in agreement with an earlier finding in German patients. Our study points to a gene-dose-dependent, protective role for LILRA3, the deletion of which synergizes with HLA-DRB1(*)1501 to increase the risk of R-MS. We also investigated whether the risk of suffering R-MS might be influenced by the genotypic diversity of killer-cell Ig-like receptors (KIRs), located only approximately 400 kb telomeric to LILRA3, and implicated in autoimmunity and defence against viruses. The relationship of LILRA3 deletion with R-MS is not secondary to linkage disequilibrium with a KIR gene, but we cannot exclude some contributions of KIR to the genetic susceptibility to R-MS.

[Feasibility of FeNO measurement in asthmatic children in the primary care setting. CANON Study]. / Factibilidad de la medición en atención primaria de la fracción exhalada de óxido nítrico en niños con asma. Estudio CANON.

AIM: Asses the feasibility of exhaled nitric oxide (FeNO) measurement in asthmatic children using a hand-held device in the primary care setting. METHODS: Multicentre study performed in the paediatric clinics in seven Spanish primary health care centres. Each centre consecutively included 6-14 year-old children with doctor-diagnosed asthma. Children were asked to obtain two valid measurements of FeNO with the hand-held device NIOX MINO (Aerocrine AB, Solna, Sweden). Feasibility analysis included: (a) percentage of children able to perform the manoeuvre, (b) time required to obtain a successful determination, (c) number of attempts needed, and (d) acceptability of the technical procedure by clinical personnel involved in their guidance. RESULTS: The Study enrolled 151 children. A total of 149 (98.7%) were able to perform the FeNO manoeuvre. The majority (55%) of children had previous experience of using the hand-held device. The Overall median (and Interquartile Range, IQR) of attempts needed to reach a first valid measurement was 2 (1-3) and median (IQR) of time taken was 4 min (3-5). Nurses considered the overall procedure was very easy or easy in 87.8% (teaching) and 86.5% (performing) of children. Children with previous experience performed the manoeuvre in less attempts, less time and more easily than children without experience. CONCLUSIONS: Measurement of FeNO using NIOX MINO device is technically feasible and acceptable for children and staff in the clinical context of asthma management in primary health care. Previous experience had a positive, learning effect, in teaching and performing the FeNO manoeuvre.

How the presence of rhinoconjunctivitis and the severity of asthma modify the relationship between obesity and asthma in children 6-7 years old.

BACKGROUND: The association between asthma and obesity in children, and the effect modification of allergy on this association have not been fully established. Aims The objective of the study was to know the effect modification of the severity of asthma and of the coexistence of rhinoconjunctivitis (RC) in the relationship between obesity and asthma. METHODS: A cross-sectional study of 17 145 schoolchildren 6-7 years old from eight Spanish cities who had completed information on height and weight of the ISAAC phase III questionnaire, which also included questions about asthma and RC symptoms and on various risk factors. Body mass index (BMI) was used to define obesity according to international standards. Two different logistic regressions, using current occasional asthma (COA) and current severe asthma (CSA) as dependent variables, were made stratifying for gender and for the coexistence of RC and controlling for age, older and younger siblings, exercise, mother's education, truck traffic, cat/dog during the first year of life and smoking father or mother. RESULTS: Obesity was a risk factor of CSA without RC, both for boys (1.92, CI 95% 1.13-3.25) and for girls (2.99, CI 95% 1.68-5.32). Every BMI unit increment increased by 6.7% the risk of CSA without RC in boys and by 12.4% in girls. Obesity was not a risk factor for CSA with RC. The association between COA and obesity was weaker and the coexistence of RC did not modify it greatly. CONCLUSIONS: Obese schoolchildren are more at risk of suffering from non-allergic asthma than the non-obese subjects.

Planes de atención a niños y adolescentes con asma en España, un análisis por comunidades autónomas / Care plans for children and adolescents with asthma in Spain, an analysis by autonomous communities

Introducción y objetivo: describir cómo realizan los pediatras de Atención Primaria (PAP) el manejo de los niños y adolescentes con asma en España. Material y métodos: estudio transversal, observacional y descriptivo para conocer los planes/guías de atención al asma en edad pediátrica por comunidades autónomas (CC. AA.), y ciudades autónomas de Ceuta y Melilla, la inclusión de esta actividad en sus carteras de servicios (CS) y cómo se registra en la historia clínica informatizada del paciente, mediante encuesta telemática a las asociaciones autonómicas de PAP, y telefónica para Ceuta y Melilla. En los planes encontrados, se evaluó la presencia de criterios diagnósticos, tratamiento y seguimiento del asma, recursos disponibles e indicadores de calidad asistencial, de acuerdo con un protocolo definido y adaptado a las recomendaciones de las guías de práctica clínica, y el grado de variabilidad de los mismos. Resultados: el 50% de las CC. AA. españolas tienen planes para el manejo de niños y adolescentes con asma, en diez se incluye esta actividad en su CS y 11 disponen de módulo de registro informático específico. De los nueve documentos encontrados, tres son planes y seis guías. Los primeros obtienen mayor puntuación global al aplicar el protocolo. De los parámetros estudiados, solo tener documento escrito y clasificar la gravedad del asma al diagnóstico figuran en todos los planes. Conclusiones: en España hay una gran variabilidad en la atención al asma en Pediatría y no todas las CC. AA. tienen implementados planes de trabajo, ni registro informatizado de esta actividad. Para garantizar la equidad en el manejo de estos pacientes convendría que todas las regiones implantasen un plan integral de atención actualizado (AU)

Introduction and objective: to describe the management of children and adolescents with asthma by primary care paediatricians (PCPs) in Spain.Materials and methods: we conducted a cross-sectional descriptive study to assess the paediatric asthma care plans/guidelines of the autonomous communities (ACs) of Spain and Ceuta and Melilla, the inclusion of an asthma care pathway in the list of services covered by regional health systems and the documentation of asthma care in health records. The study was performed through an online survey of regional primary care paediatrics associations and by telephone for the autonomous cities of Ceuta and Melilla. We evaluated the identified documents using a reference protocol that we developed based on current clinical practice guidelines and included items pertaining to asthma diagnosis, treatment, and monitoring, available resources and care quality indicators, and assessed the differences in these documents.Results: We found that 50% of ACs in Spain have care plans/guidelines for the management of asthma in children and adolescents. In 10 ACs, asthma care is included in the official list of health care services, and in 11, the electronic health records included a specific module devoted to asthma. Of the 9 asthma care documents identified in the survey, 3 were care plans and 6 were guidelines. The former achieved higher global scores in the comparison with the reference. Of all parameters under study, the only 2 fulfilled by all the plans/guidelines were the existence of a print asthma management document and the classification of the severity of asthma at diagnosis... (AU)

Assessment of the reproducibility of oligoclonal IgM band detection for its application in daily clinical practice.

BACKGROUND: The presence of oligoclonal IgM bands (OCMB) in cerebrospinal fluid (CSF) is an unfavourable prognostic marker in multiple sclerosis. There is no commercial test to investigate OCMB status. However, a sensitive and specific isoelectrofocusing (IEF) and western blot method was described. We aimed to study the inter-centre reproducibility of this technique, a necessary condition for a reliable test to be incorporated into clinical practice. METHODS: The presence of OCMB was analysed by IEF and western blot with prior reduction of pentameric IgM. We assayed the reproducibility of this test in a blinded multicentre study performed in 13 university hospitals. Paired-CSF and serum samples from 52 neurological patients were assayed at every centre. RESULTS: Global analysis rendered a concordance of 89.8% with a kappa value of 0.71. CONCLUSION: These data indicate that OCMB detection by means of IEF and western blot with IgM reduction shows a good interlaboratory reproducibility and thus can be used in daily clinical setting.

Presence and isotype of anti-ganglioside antibodies in healthy persons, motor neuron disease, peripheral neuropathy, and other diseases of the nervous system.

Antibodies of the IgM, IgG and IgA class against GM1, asialo-GM1, GD1b and GM2 gangliosides were determined in the sera of patients with motor neuron disease (MND), peripheral neuropathy, other neurological diseases (OND) and healthy individuals. Antibodies of the three immunoglobulin classes were present in healthy persons. MND patients did not differ from OND or controls in anti-GM1 titers of the three isotypes. In the group of peripheral neuropathy, no elevations of antibody titers were observed in patients with sensory or sensory-motor neuropathy; however, four out of 12 patients with the motor variety had very high levels of IgM or IgG antibodies. Two of these four patients also had increased titers of IgA antibodies, but no patients exhibited high titers restricted to this isotype.

IgG anti-ganglioside antibodies and their subclass distribution in two patients with acute and chronic motor neuropathy.

IgG anti-ganglioside antibodies were found in two patients with motor neuropathy. The first patient had a chronic axonal neuropathy with persistently elevated anti-GM1 antibodies. The second patient had an acute axonal neuropathy with anti-GM1, GD1b and asialoGM1 antibodies. In both, the IgG subclass study showed that the antibodies belonged to the IgG1 subclass. An enzyme-linked immunosorbent assay (ELISA) for light chains revealed anti-ganglioside antibodies of the lambda type.