RESUMO
Untreated multiple sclerosis (MS) irretrievably leads to severe neurological impairment. In European health care systems, patient access to disease modifying therapies (DMT) is often confined to more advanced stages of the disease because of restrictions in reimbursement. A discrepancy in access to DMTs is evident between West and East European countries. In order to improve access to DMTs for people with MS (pwMS) living in Croatia, the Croatian Neurological Society issued new recommendations for the treatment of relapsing MS. The aim of this article is to present these recommendations. The recommendations for platform therapies are to start DMT as soon as the diagnosis is made. If poor prognostic criteria are present (≥9 T2 or FLAIR lesions on the initial brain and spinal cord magnetic resonance imaging [MRI] or ≥3 T1 lesions with postcontrast enhancement on the initial brain and spinal cord MRI or Expanded Disability Status Scale after treatment of the initial relapse ≥3), high-efficacy DMT should be initiated. If pwMS experience ≥1 relapse or ≥3 new T2 lesions while on platform therapies, they should be switched to high-efficacy DMT. Further efforts should be made to enable early and unrestricted access to high-efficacy DMT with a freedom of choice of an appropriate therapy for expert physicians and pwMS. The improvement of access to DMT achieved by the implementation of national treatment guidelines in Croatia can serve as an example to national neurological societies from other Eastern European countries to persuade payers to enable early and unrestricted treatment of pwMS.
Assuntos
Esclerose Múltipla , Encéfalo , Croácia , Humanos , Imageamento por Ressonância Magnética , Esclerose Múltipla/diagnóstico por imagem , Esclerose Múltipla/tratamento farmacológico , RecidivaRESUMO
BACKGROUND: Ocrelizumab is the only disease-modifying therapy (DMT) approved for the treatment of people with primary progressive multiple sclerosis (pwPPMS). OBJECTIVES: To provide real-world evidence of ocrelizumab effectiveness and safety in pwPPMS in Croatian MS centers. METHODS: A retrospective observational multi-center study of pwPPMS who were started on ocrelizumab in 7 MS centers in Croatia. RESULTS: We identified 230 pwPPMS of whom 176 fulfilled the inclusion criteria. The median follow-up of the cohort was 2.73 (0.51-5.77) years. During the follow-up, 50 (28.4%) pwPPMS experienced confirmed disability worsening (CDW) and 19 (10.8%) stopped treatment with ocrelizumab. Baseline EDSS >5 was a statistically significant positive predictor for the development of CDW and/or stop of the treatment due to any cause (OR 2.482, 95% C.I. 1.192-5.166, p = 0.015). However, there was no significant difference in the development of CDW and/or stop of the treatment due to any cause if stratifying the patients based on active PPMS, age at treatment start (≤55 years vs >55 years), disease duration at treatment start (≤10 years vs >10 years), or EDSS at treatment start (≤5.0 vs >5.0). During the follow-up, 26 (14.8%) pwPPMS experienced infusion reactions, 64 (36.4%) had an infection and 4 (2.3%) developed a tumor. The percentage of pwPPMS with low levels of IgG was persistently above 10% and with low levels of IgM was persistently above 20% after cycle 4. CONCLUSION: Our real-world data support the use of ocrelizumab in a much broader pwPPMS population than in the original randomized controlled trial.
Assuntos
Anticorpos Monoclonais Humanizados , Fatores Imunológicos , Esclerose Múltipla Crônica Progressiva , Humanos , Anticorpos Monoclonais Humanizados/efeitos adversos , Anticorpos Monoclonais Humanizados/administração & dosagem , Esclerose Múltipla Crônica Progressiva/tratamento farmacológico , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Imunológicos/administração & dosagem , Fatores Imunológicos/efeitos adversos , Fatores Imunológicos/farmacologia , Adulto , SeguimentosRESUMO
AIM: To determine the importance of accurate topological diagnostics of the otolith and the differentiation of certain clinical forms of benign paroxysmal positional vertigo (BPPV). METHODS: A prospective study was conducted at the County General Hospital Vukovar in the period from January 2011 till January 2012. A total of 81 patients with BPPV, 59 females (72.84%) and 22 (27.16%) males (p less than 0.001), mean age 60.1 (± 12.1) were examined. The diagnosis was confirmed and documented by videonystagmography (VNG). The disability due to disease and risk of falling were monitored by filling in the Dizziness Handicap Inventory (DHI) and Activities-specific Balance Confidence Scale (ABC) questionnaires at the beginning and at the end of the repositioning treatment. RESULTS: In 79 (97.3%) patients posterior semicircular canal was affected, and in a small number of patients, two (2.47%) the lateral one. After the repositioning procedures were performed, there was a significant reduction or complete elimination of symptoms in the majority of subjects, 76 (93.82%). The median total DHI sum amounted to 50.5 (± 22.2) at the beginning and 20.4 (± 18.5) at the end of the study (p less than 0.00). Similarly, the results of ABC questionnaires at the beginning of the study demonstrated a result of 59.2% (± 22.4%), and at the end of the treatment the average result of examinees was significantly higher, 84.9% (± 15.2%) (p less than 0.00). CONCLUSION: Although a subjectively positive Dix-Hallpike or a "supine roll" test is sufficient for the diagnosis of BPPV, it is necessary perform the VNG as well in order to precisely determine the exact localization of the otolith, so that an appropriate repositioning procedure can be applied.