While it is acknowledged that exclusive breastfeeding has well-established benefits for both infant/child and mother health, evidence on the relationships between breastfeeding and disease course in ...women with multiple sclerosis (MS) is still controversial. On one hand, in the post-partum period, a disease worsening is possible, particularly in women with more active MS. On the other hand, the use of disease modifying drugs is currently contraindicated during lactation. In this topical review, we describe available evidence on the relationship between breastfeeding and disease activity in MS. In some studies, a possible protective role for exclusive breastfeeding against the risk of post-partum relapse has been suggested, while, in others, its impact was neutral. Waiting for definitive evidence on this topic, we propose a pragmatic approach to breastfeeding choice, on a case-by-case basis, considering the disease characteristics before and during pregnancy and the patient therapeutic history.
To assess whether it is feasible to establish specific cut-off values able to discriminate 'physiological' or 'pathological' brain volume rates in patients with multiple sclerosis (MS).
The study was ...based on the analysis of longitudinal MRI data sets of patients with MS (n=206, 87% relapsing-remitting, 7% secondary progressive and 6% primary progressive) and healthy controls (HC; n=35). Brain atrophy rates were computed over a mean follow-up of 7.5 years (range 1-12) for patients with MS and 6.3 years (range 1-12.5) for HC with the SIENA software and expressed as annualised per cent brain volume change (PBVC/y). A weighted (on the follow-up length) receiver operating characteristic analysis and the area under the curve (AUC) were used for statistics.
The weighted PBVC/y was -0.51±0.27% in patients with MS and -0.27±0.15% in HC (p<0.0001). There was a significant age-related difference in PBVC/y between HC older and younger than 35 years of age (p=0.02), but not in patients with MS (p=0.8). The cut-off of PBVC/y, as measured by SIENA that could maximise the accuracy in discriminating patients with MS from HC, was -0.37%, with 67% sensitivity and 80% specificity. According to the observed distribution, values of PBVC/y as measured by SIENA that could define a pathological range were above -0.52% with 95% specificity, above -0.46% with 90% specificity and above -0.40% with 80% specificity.
Our evidence-based criteria provide values able to discriminate the presence or absence of 'pathological' brain volume loss in MS with high specificity. Such results could be of great value in a clinical setting, particularly in assessing treatment efficacy in MS.
Cognitive impairment is a common and disabling feature of multiple sclerosis (MS), but a precise characterization of cognitive phenotypes in patients with MS is lacking.
To identify cognitive ...phenotypes in a clinical cohort of patients with MS and to characterize their clinical and magnetic resonance imaging (MRI) features.
This multicenter cross-sectional study consecutively screened clinically stable patients with MS and healthy control individuals at 8 MS centers in Italy from January 1, 2010, to October 31, 2019. Patients with MS and healthy control individuals who were not using psychoactive drugs and had no history of other neurological or medical disorders, learning disability, severe head trauma, and alcohol or drug abuse were enrolled.
Participants underwent a neurological examination and a cognitive evaluation with the Rao Brief Repeatable Battery and Stroop Color and Word Test. A subgroup of participants also underwent a brain MRI examination. Latent profile analysis was used on cognitive test z scores to identify cognitive phenotypes. Linear regression and mixed-effects models were used to define clinical and MRI features of each phenotype.
A total of 1212 patients with MS (mean SD age, 41.1 11.1 years; 784 women 64.7%) and 196 healthy control individuals (mean SD age, 40.4 8.6 years; 130 women 66.3%) were analyzed in this study. Five cognitive phenotypes were identified: preserved cognition (n = 235 patients 19.4%), mild-verbal memory/semantic fluency (n = 362 patients 29.9%), mild-multidomain (n = 236 patients 19.5%), severe-executive/attention (n = 167 patients 13.8%), and severe-multidomain (n = 212 patients 17.5%) involvement. Patients with preserved cognition and mild-verbal memory/semantic fluency were younger (mean SD age, 36.5 9.8 years and 38.2 11.1 years) and had shorter disease duration (mean SD 8.0 7.3 years and 8.3 7.6 years) compared with patients with mild-multidomain (mean SD age, 42.6 11.2 years; mean SD disease duration, 12.8 9.6 years; P < .001), severe-executive/attention (mean SD age, 42.9 11.7 years; mean SD disease duration, 12.2 9.5 years; P < .001), and severe-multidomain (mean SD age, 44.0 11.0 years; mean SD disease duration, 13.3 10.2 years; P < .001) phenotypes. Severe cognitive phenotypes prevailed in patients with progressive MS. At MRI evaluation, compared with those with preserved cognition, patients with mild-verbal memory/semantic fluency exhibited decreased mean (SE) hippocampal volume (5.42 0.68 mL vs 5.13 0.68 mL; P = .04), patients with the mild-multidomain phenotype had decreased mean (SE) cortical gray matter volume (687.69 35.40 mL vs 662.59 35.48 mL; P = .02), patients with severe-executive/attention had higher mean (SE) T2-hyperintense lesion volume (51.33 31.15 mL vs 99.69 34.07 mL; P = .04), and patients with the severe-multidomain phenotype had extensive brain damage, with decreased volume in all the brain structures explored, except for nucleus pallidus, amygdala and caudate nucleus.
This study found that by defining homogeneous and clinically meaningful phenotypes, the limitations of the traditional dichotomous classification in MS can be overcome. These phenotypes can represent a more meaningful measure of the cognitive status of patients with MS and can help define clinical disability, support clinicians in treatment choices, and tailor cognitive rehabilitation strategies.
Background:
The spread of Coronavirus disease-19 (COVID-19) poses unique challenges in the management of people with multiple sclerosis (PwMS).
Objectives:
To collect data about the impact of ...COVID-19 emergency on access to care for PwMS and on MS treatment practices.
Methods:
Between March and July 2020, the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) promoted an online survey covering patient access to care, management of relapses and visits, disease-modifying therapy (DMT) and experience with COVID-19.
Results:
Three-hundred and sixty neurologists from 52 countries (68% from Europe) completed the survey. 98% reported COVID-19-related restrictions. Telemedicine was adopted to overcome the limited access to care and was newly activated (73%) or widely implemented (17%). 70% reported changes in DMT management. Interferons and glatiramer were considered safe. Dimethyl fumarate, teriflunomide and fingolimod were considered safe except for patients developing lymphopenia. No modifications were considered for natalizumab in 64%, cladribine in 24%, anti-CD20 in 22% and alemtuzumab in 17%; 18% (for alemtuzumab and cladribine) and 43% (for anti-CD20) considered postponing treatment.
Conclusion:
The ECTRIMS survey highlighted the challenges in keeping standards of care in clinical practice. Telemedicine clearly needs to be implemented. Gathering data on DMT safety will remain crucial to inform treatment decisions.
Prevalence estimates of cognitive impairment in multiple sclerosis (MS) range from 40% to 65%, depending on the research setting. Cognitive dysfunction virtually encompasses all the disease stages ...and types of clinical course, although it is generally less frequent in relapsing–remitting (RR) patients compared with secondary progressive (SP) patients, and tends to be less frequent in primary progressive (PP) patients. Moreover, it causes role limitations in work and social life, independently of the degree of physical disability. Relatively little is known about the evolution of cognitive impairment in MS, particularly starting from the early stages of the disease. Controlled studies, however, have clearly shown that cognitive deterioration tends to progress over time. Among clinical predictors, incipient cognitive decline seems to be the major risk factor for further deterioration in the short-term. In the long-term, the likelihood increases that also patients with initial cognitive preservation may deteriorate. As for magnetic resonance imaging (MRI), there are consistent, albeit moderate, correlations between the progression of cognitive impairment and increasing brain lesion load and brain atrophy. The aim of this paper is to provide a review of existing cross-sectional and longitudinal studies on cognitive deterioration in MS.
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