Cost-utility of oral methylprednisolone in the treatment of multiple sclerosis relapses: Results from the COPOUSEP trial.

BACKGROUND: Studies have shown that oral high-dose methylprednisolone (MP) is non-inferior to intravenous MP in treating multiple sclerosis relapses in terms of effectiveness and tolerance. In order to assist with resource allocation and decision-making, its cost-effectiveness must also be assessed. Our objective was to evaluate the cost-utility of per os high-dose MP as well as the cost-savings associated with implementing the strategy. METHODS: A cost-utility analysis at 28 days was carried out using data from the French COPOUSEP multicenter, double-blind randomized controlled non-inferiority trial and the statutory health insurance reimbursement database. Costs were calculated using a societal perspective, including both direct and indirect costs. An incremental cost-effectiveness ratio was calculated and bootstrapping methods assessed the uncertainty surrounding the results. An alternative scenario analysis in which MP was administered at home was also carried out. A budgetary impact analysis was carried at five years. RESULTS: In the conditions of the trial (hospitalized patients), there was no significant difference in utilities and costs at 28 days. The incremental cost-effectiveness ratio was €15,360 per quality-adjusted life-year gained. If multiple sclerosis relapses were treated at home, oral MP would be more effective, less costly and associated with annual savings up to 25 million euros for the French healthcare system. CONCLUSIONS: Oral MP is cost-effective in the treatment of multiple sclerosis relapses and associated with major savings.

Inaugural tumor-like multiple sclerosis: clinical presentation and medium-term outcome in 87 patients.

BACKGROUND: Tumefactive demyelinating lesions of the central nervous system can be the initial presentation in various pathological entities [multiple sclerosis (the most common), Balo's concentric sclerosis, Schilder's disease and acute disseminated encephalomyelitis] with overlapping clinical presentation. The aim of our study was to better characterize these patients. METHODS: Eighty-seven patients (62 women and 25 men) from different MS centers in France were studied retrospectively. Inclusion criteria were (1) a first clinical event (2) MRI showing one or more large demyelinating lesions (20 mm or more in diameter) with mass-like features. Patients with a previous demyelinating event (i.e. confirmed multiple sclerosis) were excluded. RESULTS: Mean age at onset was 26 years. The most common initial symptoms (67% of the patients) were hemiparesis or hemiplegia. Aphasia, headache and cognitive disturbances (i.e. atypical symptoms for demyelinating diseases) were observed in 15, 18 and 15% of patients, respectively. The mean largest diameter of the tumefactive lesions was 26.9 mm, with gadolinium enhancement in 66 patients (81%). Twenty-one patients (24%) had a single tumefactive lesion. During follow-up (median time 5.7 years) 4 patients died, 70 patients improved or remained stable and 12 worsened. 86% of patients received initial corticosteroid treatment, and 73% received disease-modifying therapy subsequently. EDSS at the end of the follow-up was 2.4 ± 2.6 (mean ± SD). CONCLUSION: This study provides further evidence that the clinical course of MS presenting with large focal tumor-like lesions does not differ from that of classical relapsing-remitting MS, once the noisy first relapsing occurred.

'Clinically definite benign multiple sclerosis', an unwarranted conceptual hodgepodge: evidence from a 30-year observational study.

BACKGROUND: Benign multiple sclerosis (BMS) is a controversial concept which is still debated. However identification of this kind of patients is crucial to prevent them from unnecessary exposure to aggressive and/or long term medical treatments. OBJECTIVES: To assess two definitions of 'clinically definite benign multiple sclerosis' (CDBMS) using long-term follow-up data, and to look for prognostic factors of CDBMS. METHODS: In 874 patients with definite relapsing-remitting MS, followed up for at least 10 years, disability was assessed using the Disability Status Scale (DSS). CDBMS was defined by either DSS score≤2 (CDBMS1 group) or DSS score≤ 3 (CDBMS2 group) at 10 years. We estimated the proportion of patients who were still benign at 20 and 30 years after clinical onset. RESULTS: CDBMS frequency estimates were 57.7% and 73.9% when using CDBMS1 and CDBMS2 definitions, respectively. In the CDBMS1 group, only 41.7% (105/252) of cases were still benign 10 years later, and 41.1% (23/56) after an additional decade, while there were 53.8% (162/301) and 59.5% (44/74) respectively in the CDBMS2 group. CONCLUSIONS: This 30-year observational study, which is one of the largest published series, indicates that favourable 10-year disability scores of DSS 2 or 3 fail to ensure a long-term benign course of multiple sclerosis. After every decade almost half of the CDBMS were no longer benign. CDBMS, as currently defined, is an unwarranted conceptual hodgepodge. Other criteria using new biomarkers (genetic, biologic or MRI) should be found to detect benign cases of MS.

Natalizumab and drug holiday in clinical practice: an observational study in very active relapsing remitting multiple sclerosis patients.

BACKGROUND: In order to reduce the risk of progressive multifocal leucoencephalopathy when using natalizumab for more than 12 months, a 6-month drug holiday has been discussed. However, the consequences on short term disease activity have been poorly assessed. OBJECTIVE: The aim of this study was to assess clinical and radiological disease activity within 6 months after stopping natalizumab in very active relapsing remitting Multiple Sclerosis (RRMS) patients. METHODS: In 8 hospitals from Western France, we retrospectively collected clinical and MRI data from consecutive RRMS patients treated with natalizumab for at least 6 months, and who stopped the drug for various reasons except therapeutic failure. Patients didn't receive any other disease modifying treatment after discontinuing natalizumab. RESULTS: A total of 27 patients with very active RRMS before natalizumab start (mean annualized relapse rate of 2.3, MRI activity in 21 of 27 patients) were studied. Within 6 months after discontinuing natalizumab, 18 patients (67%) experienced clinical relapse and 3 additional patients had radiological activity, without clinical relapse. Four patients (15%) experienced a rebound activity, with severe relapse and 20 or more gadolinium enhancing lesions on MRI. CONCLUSION: Such observational data didn't support the concept of drug holiday when using natalizumab in very active RRMS.

Dietary vitamin mix levels influence the ossification process in European sea bass (Dicentrarchus labrax) larvae.

The influence of dietary vitamins on growth, survival, and morphogenesis was evaluated until day 38 of posthatching life in European sea bass larvae (Dicentrarchus labrax). A standard vitamin mix (VM), at double the concentration of the U.S. National Research Council's recommendations, was incorporated into larval feeds at 0.5%, 1.5%, 2.5%, 4.0%, and 8.0% to give treatments VM 0.5, VM 1.5, VM 2.5, VM 4.0, and VM 8.0, respectively. The group fed the VM 0.5 diet all died before day 30. At day 38, the larvae group fed VM 1.5 had 33% survival, while the other groups, with higher vitamin levels, showed at least 50% survival. The higher the percentage VM in the diet, the lower the percentage of column deformities. High dietary vitamin levels positively influenced the formation of mineralized bone in larvae: the higher the dietary vitamin level, the higher the ossification status. In the larvae group fed at the highest vitamin levels, we observed a temporal sequence of coordinated growth factor expression, in which the expression of bone morphometric protein (BMP-4) preceded the expression of IGF-1, which stimulated the maturation of osteoblasts (revealed by high osteocalcin expression levels). In groups fed lower proportions of vitamins, elevated proliferator peroxisome-activated receptors (PPAR-gamma) expression coincided with low BMP-4 expression. Our results suggest that high levels of PPAR-gamma transcripts in larvae-fed diets with a low VM content converted some osteoblasts into adipocytes during the first two weeks of life. This loss of osteoblasts is likely to have caused skeletal deformities.

Long-term survival of patients with multiple sclerosis in West France.

In France no data have been published about comparing survival in multiple sclerosis (MS) patients with the general French population. We estimated survival probabilities in MS patients from a major centre for MS in West France. We also compared MS survival with the general population and assessed prognostic parameters. All patients with MS onset after January 1976 and classified as dead or alive on 1 January 2004 were included. One thousand eight-hundred and seventy-nine patients (sex ratio W: M 2.3; relapsing/progressive onset 77.4%/22.6%) fulfilled these criteria, disease duration ranged from one to 28 years. By 2004, 68 patients died (51 due to MS) and the 15 and 25-year survival probabilities were 96% and 88%. Male gender, progressive course (either primary or secondary), polysymptomatic onset, and increased annual relapse rate during the first two years of MS were related to a worse prognosis. After a mean follow-up duration of 12.7 years since clinical onset, MS increased the number of deaths compared with the general population. However taking into account disability status, we found that less disabled MS patients had a better survival and highly disabled patients a worse survival (eight-fold increase of mortality) compared with the French population.

Spontaneous resolution of arachnoid cysts: review and features of an unusual case.

Most intra-cranial arachnoid cysts are quiescent and remain asymptomatic throughout life. Within the natural course of arachnoid cyst evolution, spontaneous resolution has been known to occur rarely, but its frequency is probably underestimated due to lack of systematic detection and long-term observation. We illustrate the spontaneous regression of arachnoid cysts with a patient which was conjointly diagnosed with an arachnoid cyst and a post-traumatic epidural haematoma. Cyst regression was observed 16 months later, upon examination following a second benign cranial trauma. Mechanisms underlying the resolution of the arachnoid cyst are discussed.

[Mitoxantrone as induction therapy in aggressive relapsing remitting multiple sclerosis: a descriptive analysis of 100 consecutive patients]. / Etude observationnelle de la mitoxantrone dans les formes rémittentes actives de sclérose en plaques: suivi à long terme d'une cohorte de 100 patients consécutifs.

INTRODUCTION: On the basis of the French and British (FB) MS Trial, Mitoxantrone (MITOX) was approved by the AFSAPPS in October 2003 in patients with aggressive multiple sclerosis (MS), given as induction therapy monthly for 6 months (ELSEP). We report an observational study of 100 aggressive relapsing remitting (RR) MS patients treated by induction therapy with MITOX and followed up to 5 years. METHODS: One hundred patients with aggressive RR MS received an induction therapy with MITOX 20 mg monthly combined with methylprednisolone 1 g for 6 months. MRI data within 12 months before and 6 months after MITOX induction were collected (mean cumulative dose 65 mg/m2). Clinical evaluation was performed every 6 months and data (relapses and EDSS scores) were prospectively recorded in the EDMUS Database. After MITOX, a maintenance therapy was given to 57 patients (MITOX every 3 months: 21; Interferon beta: 13; Azathioprine: 14; Methotrexate: 7; Glatiramer acetate: 2). The mean follow-up period was of 3.8 years. RESULTS: Patients were treated at a mean age of 27 +/- 9 years after 5 +/- 3 years of MS duration. Within the 12 months preceding MITOX onset, the annual relapse rate (ARR) was 3.2, the mean EDSS increased by 2.2 +/- 1 points (to a score of 4 at M0), 87 patients worsened by 1 point EDSS or more and 85 percent of patients had Gd enhancing lesions on MRI. During the 12 months following MITOX onset, the inflammatory activity of the disease dropped dramatically with a reduction of the ARR by 91 percent whereas 76 percent of patients were free of new relapse and MRI activity was reduced by 89 percent. In addition, the mean EDSS decreased by 1.2 points (p<10-6) and 60 percent of patients improved by 1 point EDSS or more. At a longer term, the reduction of the ARR was confirmed (0.28-0.37 up to 5 years) and the median time to the first relapse was 2.8 years. A significant improvement of disability was maintained until 4 years and got back to the initial level at year 5. The ARR was significantly lower (0.09) for patients treated with MITOX every 3 months as maintenance therapy than for patients treated by other disease modifying therapies (0.33-0.39) or not (0.43) after the induction. Three patients presented an asymptomatic decrease of the left ventricular ejection fraction under 50 percent, reversible in one case. CONCLUSION: MITOX as induction therapy monthly for 6 months was safe and had a rapid and strong impact on the inflammatory process and on the evolution of disability. The drug might be a good candidate as induction therapy followed by a maintenance therapy in patients with aggressive MS.

Multiple Sclerosis Severity Score: using disability and disease duration to rate disease severity.

BACKGROUND: There is no consensus method for determining progression of disability in patients with multiple sclerosis (MS) when each patient has had only a single assessment in the course of the disease. METHODS: Using data from two large longitudinal databases, the authors tested whether cross-sectional disability assessments are representative of disease severity as a whole. An algorithm, the Multiple Sclerosis Severity Score (MSSS), which relates scores on the Expanded Disability Status Scale (EDSS) to the distribution of disability in patients with comparable disease durations, was devised and then applied to a collection of 9,892 patients from 11 countries to create the Global MSSS. In order to compare different methods of detecting such effects the authors simulated the effects of a genetic factor on disability. RESULTS: Cross-sectional EDSS measurements made after the first year were representative of overall disease severity. The MSSS was more powerful than the other methods the authors tested for detecting different rates of disease progression. CONCLUSION: The Multiple Sclerosis Severity Score (MSSS) is a powerful method for comparing disease progression using single assessment data. The Global MSSS can be used as a reference table for future disability comparisons. While useful for comparing groups of patients, disease fluctuation precludes its use as a predictor of future disability in an individual.

Dietary arginine degradation is a major pathway in ureagenesis in juvenile turbot (Psetta maxima).

Recent studies indicate that urea excretion is responsive to protein intake and that turbot, Psetta maxima, appear to differ from other species by their urea excretion pattern and levels. This study was undertaken to evaluate the influence of dietary nitrogen and arginine on ureagenesis and excretion in turbot. Juvenile turbot (29 g) were fed semi-purified diets containing graded levels of nitrogen (0-8% dry matter) and arginine (0-3% dry matter) for 6 weeks. Growth data showed that turbot have high dietary nitrogen (123 mg/kg metabolic body weight/day) and very low dietary arginine (9.3 mg/kg metabolic body weight/day) requirements for maintenance. Requirements for unit body protein accretion were 0.31 g and 0.15 g for nitrogen and arginine respectively. Post-prandial plasma urea levels and urea excretion rates showed that urea production was significantly (P<0.05) influenced by dietary arginine levels. While hepatic arginase (EC 3.5.3.1) activity increased significantly (P<0.05) with increasing dietary arginine levels, activities of other enzymes of the ornithine urea cycle were very low. Our data strongly suggest that the ornithine urea cycle is not active in the turbot liver and that dietary arginine degradation is a major pathway of ureagenesis in turbot.

Protein and arginine requirements for maintenance and nitrogen gain in four teleosts.

Besides being an indispensable amino acid for protein synthesis, arginine (Arg) is also involved in a number of other physiological functions. Available data on the quantitative requirement for Arg in different teleosts appear to show much variability. So far, there are very limited data on the maintenance requirements of indispensable amino acids (IAA) in fish. In the present study, we compared N and Arg requirements for maintenance and growth of four finfish species: rainbow trout (Oncorhynchus mykiss), turbot (Psetta maxima), gilthead seabream (Sparus aurata) and European seabass (Dicentrarchus labrax). Groups of fish having an initial body weight close to 5-7 g were fed semi-purified diets containing graded levels of N (0 to 8 % DM) and Arg (0 to 3 % DM) over 4 to 6 weeks. For each species, N and Arg requirements for maintenance and for growth were calculated regressing daily N gain against daily N or Arg intakes. N requirement for maintenance was estimated to be 37.8, 127.3, 84.7 and 45.1 mg/kg metabolic body weight per d and 2.3, 2.2, 2.6 and 2.5 g for 1 g N accretion, in rainbow trout, turbot, gilthead seabream and European seabass respectively. The four species studied appear to have very low or no dietary Arg requirements for maintenance. Arg requirement for g N accretion was calculated to be 0.86 g in rainbow trout and between 1.04-1.11 g in the three marine species. Turbot required more N for maintenance than the other three species, possibly explaining its reputedly high overall dietary protein requirement. Data suggest a small but sufficient endogenous Arg synthesis to maintain whole body N balance and differences between freshwater and marine species as regards Arg requirement. It is worth verifying this tendency with other IAA.

[Is immunosuppression a future therapeutic strategy for multiple sclerosis?]. / L'immunosuppression est-elle une stratégie thérapeutique d'avenir dans la sclérose en plaques?

Although in previous studies no clear demonstration was found of the efficacy of azathioprine, cyclophosphamide and methotrexate as immunoprophylactic agents in cases of multiple sclerosis (MS), over the past five years a number of well-designed clinical trials utilizing immunosuppressive and immunomodulatory agents have shown partial efficacy regarding the drugs involved, but they have not been able to determine in what way these drugs can modify the natural course of this disease. Among the immunosuppressors, mitoxantrone is of particular interest as during the past two years three controlled trials have taken place in Europe and have demonstrated its efficacy both as regards clinical (frequency of symptoms, progression of the disease) and magnetic resonance imaging (MRI) criteria. Due to its potentially severe cardiotoxicity related to total cumulative dose, mitoxantrone is only prescribed for a limited period, and its use is limited to selected patients with a high relapse rate and incomplete remission, or to those who do not respond to beta-interferon treatment. The immunomodulatory agents have less immediate efficacy, but because they are well tolerated they can be used early in the course of the disease and over a prolonged period of time. The beta-interferons (1a or 1b) have been given market approval for use in the treatment of MS: three large, randomized, double-blind studies have demonstrated their capacity to reduce by 30% the frequency of symptoms and the appearance of disabilities associated with relapse and with the progression of the disease. Glatirameracetate or copolymer 1, which is available in France (ATU), has been found to reduce the frequency of relapse by 30%. It constitutes an alternative immunomodulatory treatment for relapsing-remitting patients without major functional disabilities and who suffer from severe side effects with beta-interferon treatment. In the future, the early use of immunomodulatory agents and therapeutic drug combinations may be introduced. Therapeutic trials are currently in progress to determine the viability of this approach.

Hepatic ascorbic acid saturation is the most stringent response criterion for determining the vitamin C requirement of juvenile European sea bass (Dicentrarchus labrax).

Our main objective was to verify whether the dietary ascorbic acid (AA) requirement of juvenile European sea bass (Dicentrarchus labrax) varies as a function of different physiological needs. Practical diets with eight (0, 5, 10, 20, 40, 80, 160, 320 mg AA/kg diet) levels of ascorbic acid polyphosphate were fed to sea bass (mean weight: 0.7 g) for 15 wk. At the beginning and at the end of the feeding trial, tissues were sampled for vitamin C and hydroxyproline (HyPro) analysis. Dose-dependent responses of skin and whole body HyPro concentrations and hepatic AA concentration to dietary vitamin C levels were observed. Skin and whole body HyPro concentrations were low in sea bass fed AA-deficient diet, 217 and 15 nmol/g tissue, respectively. HyPro levels increased with increasing dietary levels, reaching plateaus of 297 and 45 nmol/g tissue in the skin and whole body at dietary vitamin C levels of at least 5 and 31 mg AA/kg. Hepatic AA level increased with increasing dietary levels, reaching a plateau of 474 pmol/g tissue in juveniles fed at least 121 mg of AA/kg. We concluded that hepatic AA saturation is the most stringent response criterion for determination of the vitamin C requirement in juvenile European sea bass.

[Evolution and surveillance of multiple sclerosis]. / Evolution et surveillance de la sclérose en plaques.

Multiple sclerosis is a highly complex disease due to the great diversity of symptoms and signs from disseminated demyelinating CNS lesions which lead to different levels of handicap, and to the different types of evolution (exacerbations or slow progression). Most of the patients with multiple sclerosis have a normal longevity. The main concern is the accumulation of disabilities. In order to follow accurately the progression of these disabilities, specific scales, especially EDSS, have been validated allowing more uniformity in method of collecting data from multiple sclerosis.