Video

NASHVILLE, Tenn. – Gadolinium-based contrast agents (GBCAs) are necessary for the accurate initial diagnosis of patients experiencing a first clinical attack of symptoms consistent with multiple sclerosis and for following patients with highly active disease or sudden, unexpected declines.

But according to new guidelines issued by the Consortium of Multiple Sclerosis Centers, GBCAs are optional – although helpful – in many other clinical scenarios, especially when noncontrast MRI can provide answers.

“The key is that there is an optional role for gadolinium,” David Li, MD, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. Although a GBCA is still “essential” for some clinical scenarios in clinically isolated syndrome and MS, the new guidelines suggest that standard, high-quality MRI without contrast can adequately identify the majority of new MS lesions over time.

“But I would like to remind you that if you need to know about ongoing, current activity,” in settings of acute change, then gadolinium is still necessary, Dr. Li of the University of British Columbia, Vancouver, said in a video interview.

The guideline is an update of CMSC’s 2015 document, which endorsed a more liberal use of GBCAs. This more conservative stance reflects new research on the agents and an update in 2017 from the Food and Drug Administration that required a class-wide warning about gadolinium retention.

The agency began investigating gadolinium in 2015. In May 2017, it issued a statement confirming that gadolinium accumulates in neural tissue and can be retained for an extended period. However, in reviewing the evidence, FDA found no concerning safety signals. Despite the presumed lack of toxicity, the agency issued the warning and recommended limiting the contrast agent’s use – a move reflected in CMSC’s new MRI protocol guidelines.

“While there is no known CNS toxicity, these agents should be used judiciously, recognizing that gadolinium continues to play an invaluable role in specific circumstances related to the diagnosis and follow-up of individuals with MS,” the document notes.

[email protected]

NASHVILLE, Tenn. – Gadolinium-based contrast agents (GBCAs) are necessary for the accurate initial diagnosis of patients experiencing a first clinical attack of symptoms consistent with multiple sclerosis and for following patients with highly active disease or sudden, unexpected declines.

But according to new guidelines issued by the Consortium of Multiple Sclerosis Centers, GBCAs are optional – although helpful – in many other clinical scenarios, especially when noncontrast MRI can provide answers.

“The key is that there is an optional role for gadolinium,” David Li, MD, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. Although a GBCA is still “essential” for some clinical scenarios in clinically isolated syndrome and MS, the new guidelines suggest that standard, high-quality MRI without contrast can adequately identify the majority of new MS lesions over time.

“But I would like to remind you that if you need to know about ongoing, current activity,” in settings of acute change, then gadolinium is still necessary, Dr. Li of the University of British Columbia, Vancouver, said in a video interview.

The guideline is an update of CMSC’s 2015 document, which endorsed a more liberal use of GBCAs. This more conservative stance reflects new research on the agents and an update in 2017 from the Food and Drug Administration that required a class-wide warning about gadolinium retention.

The agency began investigating gadolinium in 2015. In May 2017, it issued a statement confirming that gadolinium accumulates in neural tissue and can be retained for an extended period. However, in reviewing the evidence, FDA found no concerning safety signals. Despite the presumed lack of toxicity, the agency issued the warning and recommended limiting the contrast agent’s use – a move reflected in CMSC’s new MRI protocol guidelines.

“While there is no known CNS toxicity, these agents should be used judiciously, recognizing that gadolinium continues to play an invaluable role in specific circumstances related to the diagnosis and follow-up of individuals with MS,” the document notes.

[email protected]

NASHVILLE, Tenn. – Gadolinium-based contrast agents (GBCAs) are necessary for the accurate initial diagnosis of patients experiencing a first clinical attack of symptoms consistent with multiple sclerosis and for following patients with highly active disease or sudden, unexpected declines.

But according to new guidelines issued by the Consortium of Multiple Sclerosis Centers, GBCAs are optional – although helpful – in many other clinical scenarios, especially when noncontrast MRI can provide answers.

“The key is that there is an optional role for gadolinium,” David Li, MD, said at the annual meeting of the Consortium of Multiple Sclerosis Centers. Although a GBCA is still “essential” for some clinical scenarios in clinically isolated syndrome and MS, the new guidelines suggest that standard, high-quality MRI without contrast can adequately identify the majority of new MS lesions over time.

“But I would like to remind you that if you need to know about ongoing, current activity,” in settings of acute change, then gadolinium is still necessary, Dr. Li of the University of British Columbia, Vancouver, said in a video interview.

The guideline is an update of CMSC’s 2015 document, which endorsed a more liberal use of GBCAs. This more conservative stance reflects new research on the agents and an update in 2017 from the Food and Drug Administration that required a class-wide warning about gadolinium retention.

The agency began investigating gadolinium in 2015. In May 2017, it issued a statement confirming that gadolinium accumulates in neural tissue and can be retained for an extended period. However, in reviewing the evidence, FDA found no concerning safety signals. Despite the presumed lack of toxicity, the agency issued the warning and recommended limiting the contrast agent’s use – a move reflected in CMSC’s new MRI protocol guidelines.

“While there is no known CNS toxicity, these agents should be used judiciously, recognizing that gadolinium continues to play an invaluable role in specific circumstances related to the diagnosis and follow-up of individuals with MS,” the document notes.

[email protected]

NASHVILLE, TENN. – Armed with new statistics, neurologist Joseph R. Berger, MD, has a message for colleagues about the widely feared risk of progressive multifocal leukoencephalopathy (PML) in multiple sclerosis: It’s not as inevitable as you might think.

“You can actually prevent this disease from occurring because we have risk-limiting strategies in many circumstances,” said Dr. Berger of the University of Pennsylvania, Philadelphia, in a presentation on PML at the annual meeting of the Consortium of Multiple Sclerosis Centers.

Unlike other conditions such as HIV, MS itself is not linked to a higher risk of PML, said Dr. Berger, a leading PML researcher. Instead, it’s the medications that spark the condition, he said, with at least three and possibly four drugs posing a risk to patients.

Natalizumab (Tysabri) is especially risky. “We know that the risk with natalizumab is incredibly high in the context of JC [John Cunningham] virus antibody positivity and prolonged therapy,” Dr. Berger said in an interview after his presentation.

Still, “you can safely give natalizumab for a short period of time when treating patients with aggressive MS,” he said. “I will frequently employ that strategy even in the context of JC virus antibody positivity.”

According to Dr. Berger, there’s no risk of PML when natalizumab is used for under 8 months (Mult Scler Relat Disord. 2017 Feb;12:59-63).

However, “if you leave people on the drug indefinitely, there is a substantial risk of developing PML,” he said. “Individuals who have been left on the drug for 2 years, who’ve seen prior immunosuppressant therapy, who are JC virus antibody positive – that group of individuals develops PML at rates of 1 in 50 to 1 in 100.”

NASHVILLE, TENN. – Armed with new statistics, neurologist Joseph R. Berger, MD, has a message for colleagues about the widely feared risk of progressive multifocal leukoencephalopathy (PML) in multiple sclerosis: It’s not as inevitable as you might think.

“You can actually prevent this disease from occurring because we have risk-limiting strategies in many circumstances,” said Dr. Berger of the University of Pennsylvania, Philadelphia, in a presentation on PML at the annual meeting of the Consortium of Multiple Sclerosis Centers.

Unlike other conditions such as HIV, MS itself is not linked to a higher risk of PML, said Dr. Berger, a leading PML researcher. Instead, it’s the medications that spark the condition, he said, with at least three and possibly four drugs posing a risk to patients.

Natalizumab (Tysabri) is especially risky. “We know that the risk with natalizumab is incredibly high in the context of JC [John Cunningham] virus antibody positivity and prolonged therapy,” Dr. Berger said in an interview after his presentation.

Still, “you can safely give natalizumab for a short period of time when treating patients with aggressive MS,” he said. “I will frequently employ that strategy even in the context of JC virus antibody positivity.”

According to Dr. Berger, there’s no risk of PML when natalizumab is used for under 8 months (Mult Scler Relat Disord. 2017 Feb;12:59-63).

However, “if you leave people on the drug indefinitely, there is a substantial risk of developing PML,” he said. “Individuals who have been left on the drug for 2 years, who’ve seen prior immunosuppressant therapy, who are JC virus antibody positive – that group of individuals develops PML at rates of 1 in 50 to 1 in 100.”

NASHVILLE, TENN. – Armed with new statistics, neurologist Joseph R. Berger, MD, has a message for colleagues about the widely feared risk of progressive multifocal leukoencephalopathy (PML) in multiple sclerosis: It’s not as inevitable as you might think.

“You can actually prevent this disease from occurring because we have risk-limiting strategies in many circumstances,” said Dr. Berger of the University of Pennsylvania, Philadelphia, in a presentation on PML at the annual meeting of the Consortium of Multiple Sclerosis Centers.

Unlike other conditions such as HIV, MS itself is not linked to a higher risk of PML, said Dr. Berger, a leading PML researcher. Instead, it’s the medications that spark the condition, he said, with at least three and possibly four drugs posing a risk to patients.

Natalizumab (Tysabri) is especially risky. “We know that the risk with natalizumab is incredibly high in the context of JC [John Cunningham] virus antibody positivity and prolonged therapy,” Dr. Berger said in an interview after his presentation.

Still, “you can safely give natalizumab for a short period of time when treating patients with aggressive MS,” he said. “I will frequently employ that strategy even in the context of JC virus antibody positivity.”

According to Dr. Berger, there’s no risk of PML when natalizumab is used for under 8 months (Mult Scler Relat Disord. 2017 Feb;12:59-63).

However, “if you leave people on the drug indefinitely, there is a substantial risk of developing PML,” he said. “Individuals who have been left on the drug for 2 years, who’ve seen prior immunosuppressant therapy, who are JC virus antibody positive – that group of individuals develops PML at rates of 1 in 50 to 1 in 100.”

NASHVILLE, TENN. – Physical activity appears to have profound rehabilitative effects – both physical and cognitive – upon patients with multiple sclerosis, but the body of evidence remains largely based on small, sometimes problematic studies, Alan Thompson, MD, said at the annual meeting of the Consortium of Multiple Sclerosis Centers.

There are compelling animal data that exercise promotes a number of beneficial neuronal changes that improve patient-reported outcomes, said Dr. Thompson, the Garfield Weston Professor of Clinical Neurology and Neurorehabilitation at University College London (England).

“A lot of animal work suggests that exercise can have a major impact on repair and recovery in neurons, synaptic signaling, dendritic branching, long-term potentiation,” and can beneficially affect inflammation and demyelination, he said. Besides the direct effect on nerves, exercise builds up muscle mass, strengthens connective tissue, improves movement, and reduces cardiovascular risk. “Exercise improves inactivity, but also may improve the underlying disease process,” he said. “The effect can be quite profound, and we are building a very good evidence base to support the use of exercise in MS.”

Unfortunately, the existing body of literature remains unimpressive, Dr. Thompson admitted. He compared research in physical activity to that of medicinal therapeutics. Disease-modifying therapeutics research is highly regulated, very well funded, adequately powered and replicated, and – once it shows positive results – receives substantial marketing and sales effort. “As a result, there can be a substantial impact on care.”

Research on rehabilitation and symptom management, with physical activity and other similar interventions, is not well funded, relies on diverse outcome measures, has small cohort numbers, and often is unreplicated. Even positive results “are just left to lie there,” he said. “Thus, it has a modest impact on care. I would like to see equal resources for both research areas.”

The recent surge in stroke rehabilitation is an excellent example of how academic focus can change practice for neurologic illness, he said. A 2017 research letter in Lancet Neurology described the current state of research on exercise in MS (Lancet Neurol. 2017;16[10];848-56). An accompanying editorial compared the MS literature to that in stroke (Lancet Neurol. 2017;16[10]:768-9).

During 1990-2005, there were almost no clinical studies in rehabilitation for stroke, Parkinson’s disease, spinal cord injury, and MS. Around 2005, things began to change in stroke, with close to 60 publications in just 1 year. During 2010-2015, the pace of research accelerated dramatically. Researchers, clinicians, and patients began to see the immediate and long-term benefits of early poststroke rehabilitation. These interventions have now been encoded in practice guidelines and are a core part of clinical care, Dr. Thompson said.

[email protected]

NASHVILLE, TENN. – Physical activity appears to have profound rehabilitative effects – both physical and cognitive – upon patients with multiple sclerosis, but the body of evidence remains largely based on small, sometimes problematic studies, Alan Thompson, MD, said at the annual meeting of the Consortium of Multiple Sclerosis Centers.

There are compelling animal data that exercise promotes a number of beneficial neuronal changes that improve patient-reported outcomes, said Dr. Thompson, the Garfield Weston Professor of Clinical Neurology and Neurorehabilitation at University College London (England).

“A lot of animal work suggests that exercise can have a major impact on repair and recovery in neurons, synaptic signaling, dendritic branching, long-term potentiation,” and can beneficially affect inflammation and demyelination, he said. Besides the direct effect on nerves, exercise builds up muscle mass, strengthens connective tissue, improves movement, and reduces cardiovascular risk. “Exercise improves inactivity, but also may improve the underlying disease process,” he said. “The effect can be quite profound, and we are building a very good evidence base to support the use of exercise in MS.”

Unfortunately, the existing body of literature remains unimpressive, Dr. Thompson admitted. He compared research in physical activity to that of medicinal therapeutics. Disease-modifying therapeutics research is highly regulated, very well funded, adequately powered and replicated, and – once it shows positive results – receives substantial marketing and sales effort. “As a result, there can be a substantial impact on care.”

Research on rehabilitation and symptom management, with physical activity and other similar interventions, is not well funded, relies on diverse outcome measures, has small cohort numbers, and often is unreplicated. Even positive results “are just left to lie there,” he said. “Thus, it has a modest impact on care. I would like to see equal resources for both research areas.”

The recent surge in stroke rehabilitation is an excellent example of how academic focus can change practice for neurologic illness, he said. A 2017 research letter in Lancet Neurology described the current state of research on exercise in MS (Lancet Neurol. 2017;16[10];848-56). An accompanying editorial compared the MS literature to that in stroke (Lancet Neurol. 2017;16[10]:768-9).

During 1990-2005, there were almost no clinical studies in rehabilitation for stroke, Parkinson’s disease, spinal cord injury, and MS. Around 2005, things began to change in stroke, with close to 60 publications in just 1 year. During 2010-2015, the pace of research accelerated dramatically. Researchers, clinicians, and patients began to see the immediate and long-term benefits of early poststroke rehabilitation. These interventions have now been encoded in practice guidelines and are a core part of clinical care, Dr. Thompson said.

[email protected]

NASHVILLE, TENN. – Physical activity appears to have profound rehabilitative effects – both physical and cognitive – upon patients with multiple sclerosis, but the body of evidence remains largely based on small, sometimes problematic studies, Alan Thompson, MD, said at the annual meeting of the Consortium of Multiple Sclerosis Centers.

There are compelling animal data that exercise promotes a number of beneficial neuronal changes that improve patient-reported outcomes, said Dr. Thompson, the Garfield Weston Professor of Clinical Neurology and Neurorehabilitation at University College London (England).

“A lot of animal work suggests that exercise can have a major impact on repair and recovery in neurons, synaptic signaling, dendritic branching, long-term potentiation,” and can beneficially affect inflammation and demyelination, he said. Besides the direct effect on nerves, exercise builds up muscle mass, strengthens connective tissue, improves movement, and reduces cardiovascular risk. “Exercise improves inactivity, but also may improve the underlying disease process,” he said. “The effect can be quite profound, and we are building a very good evidence base to support the use of exercise in MS.”

Unfortunately, the existing body of literature remains unimpressive, Dr. Thompson admitted. He compared research in physical activity to that of medicinal therapeutics. Disease-modifying therapeutics research is highly regulated, very well funded, adequately powered and replicated, and – once it shows positive results – receives substantial marketing and sales effort. “As a result, there can be a substantial impact on care.”

Research on rehabilitation and symptom management, with physical activity and other similar interventions, is not well funded, relies on diverse outcome measures, has small cohort numbers, and often is unreplicated. Even positive results “are just left to lie there,” he said. “Thus, it has a modest impact on care. I would like to see equal resources for both research areas.”

The recent surge in stroke rehabilitation is an excellent example of how academic focus can change practice for neurologic illness, he said. A 2017 research letter in Lancet Neurology described the current state of research on exercise in MS (Lancet Neurol. 2017;16[10];848-56). An accompanying editorial compared the MS literature to that in stroke (Lancet Neurol. 2017;16[10]:768-9).

During 1990-2005, there were almost no clinical studies in rehabilitation for stroke, Parkinson’s disease, spinal cord injury, and MS. Around 2005, things began to change in stroke, with close to 60 publications in just 1 year. During 2010-2015, the pace of research accelerated dramatically. Researchers, clinicians, and patients began to see the immediate and long-term benefits of early poststroke rehabilitation. These interventions have now been encoded in practice guidelines and are a core part of clinical care, Dr. Thompson said.

[email protected]

NASHVILLE, TENN. – Pediatric multiple sclerosis is a confirmed clinical entity, which virtually always presents as relapsing-remitting disease, Brenda Banwell, MD, said at the at the annual meeting of the Consortium of Multiple Sclerosis Centers.

“MS in children is the same disease as MS in adults,” said Dr. Banwell, chief of neurology at Children’s Hospital of Philadelphia and the Grace R. Loeb Endowed Chair in Neurosciences there. And although she is unaware of a single case of childhood MS presenting as primary progressive disease, the impact of relapsing-remitting childhood MS may ultimately be progressive damage.

Pediatric MS is also quite rare, a characteristic that makes therapeutic progress challenging. Recruiting sufficient patients for a definitive phase 3 trial is incredibly difficult, especially when multiple trials are commencing simultaneously, not only in the United States but around the world.

Nevertheless, there has been excellent news, Dr. Banwell said in a video interview. Fingolimod (Gilenya), the immunomodulator approved for adult relapsing-remitting MS, gained a pediatric approval under the breakthrough therapy designation on May 11, 2018, on the basis of the successful phase 3 PARADIGMS study.

Compared with intramuscular interferon beta-1a, fingolimod cut the annualized relapse rate by 82%. It also was associated with a 53% annualized reduction in new or newly enlarged T2 lesions and 66% decrease in gadolinium-enhancing T1 lesions.

This big win is prompting researchers and clinicians to rethink the pediatric MS treatment paradigm, Dr. Banwell said. Traditional thinking falls along a dose-escalation pattern that follows relapses. However, “we may take a cue from our rheumatology colleagues, who have seen the benefit of starting with more aggressive treatment and higher doses, getting disease control, and then slowly tapering off.”

Whether this option could actually modify disease progression, as it seems to do in some other inflammatory disorders, is an intriguing – but unproven – possibility, she said.

Dr. Banwell disclosed that she received financial remuneration as a central MRI reviewer for the Novartis-sponsored PARADIGMS study.

[email protected]

NASHVILLE, TENN. – Pediatric multiple sclerosis is a confirmed clinical entity, which virtually always presents as relapsing-remitting disease, Brenda Banwell, MD, said at the at the annual meeting of the Consortium of Multiple Sclerosis Centers.

“MS in children is the same disease as MS in adults,” said Dr. Banwell, chief of neurology at Children’s Hospital of Philadelphia and the Grace R. Loeb Endowed Chair in Neurosciences there. And although she is unaware of a single case of childhood MS presenting as primary progressive disease, the impact of relapsing-remitting childhood MS may ultimately be progressive damage.

Pediatric MS is also quite rare, a characteristic that makes therapeutic progress challenging. Recruiting sufficient patients for a definitive phase 3 trial is incredibly difficult, especially when multiple trials are commencing simultaneously, not only in the United States but around the world.

Nevertheless, there has been excellent news, Dr. Banwell said in a video interview. Fingolimod (Gilenya), the immunomodulator approved for adult relapsing-remitting MS, gained a pediatric approval under the breakthrough therapy designation on May 11, 2018, on the basis of the successful phase 3 PARADIGMS study.

Compared with intramuscular interferon beta-1a, fingolimod cut the annualized relapse rate by 82%. It also was associated with a 53% annualized reduction in new or newly enlarged T2 lesions and 66% decrease in gadolinium-enhancing T1 lesions.

This big win is prompting researchers and clinicians to rethink the pediatric MS treatment paradigm, Dr. Banwell said. Traditional thinking falls along a dose-escalation pattern that follows relapses. However, “we may take a cue from our rheumatology colleagues, who have seen the benefit of starting with more aggressive treatment and higher doses, getting disease control, and then slowly tapering off.”

Whether this option could actually modify disease progression, as it seems to do in some other inflammatory disorders, is an intriguing – but unproven – possibility, she said.

Dr. Banwell disclosed that she received financial remuneration as a central MRI reviewer for the Novartis-sponsored PARADIGMS study.

[email protected]

NASHVILLE, TENN. – Pediatric multiple sclerosis is a confirmed clinical entity, which virtually always presents as relapsing-remitting disease, Brenda Banwell, MD, said at the at the annual meeting of the Consortium of Multiple Sclerosis Centers.

“MS in children is the same disease as MS in adults,” said Dr. Banwell, chief of neurology at Children’s Hospital of Philadelphia and the Grace R. Loeb Endowed Chair in Neurosciences there. And although she is unaware of a single case of childhood MS presenting as primary progressive disease, the impact of relapsing-remitting childhood MS may ultimately be progressive damage.

Pediatric MS is also quite rare, a characteristic that makes therapeutic progress challenging. Recruiting sufficient patients for a definitive phase 3 trial is incredibly difficult, especially when multiple trials are commencing simultaneously, not only in the United States but around the world.

Nevertheless, there has been excellent news, Dr. Banwell said in a video interview. Fingolimod (Gilenya), the immunomodulator approved for adult relapsing-remitting MS, gained a pediatric approval under the breakthrough therapy designation on May 11, 2018, on the basis of the successful phase 3 PARADIGMS study.

Compared with intramuscular interferon beta-1a, fingolimod cut the annualized relapse rate by 82%. It also was associated with a 53% annualized reduction in new or newly enlarged T2 lesions and 66% decrease in gadolinium-enhancing T1 lesions.

This big win is prompting researchers and clinicians to rethink the pediatric MS treatment paradigm, Dr. Banwell said. Traditional thinking falls along a dose-escalation pattern that follows relapses. However, “we may take a cue from our rheumatology colleagues, who have seen the benefit of starting with more aggressive treatment and higher doses, getting disease control, and then slowly tapering off.”

Whether this option could actually modify disease progression, as it seems to do in some other inflammatory disorders, is an intriguing – but unproven – possibility, she said.

Dr. Banwell disclosed that she received financial remuneration as a central MRI reviewer for the Novartis-sponsored PARADIGMS study.

[email protected]

ORLANDO – Dermatologists and rheumatologists are mistaken if they think interface dermatitis is the sine qua non biopsy finding of dermatomyositis (DM), according to David Fiorentino, MD, PhD, professor of dermatology, rheumatology, and immunology at Stanford (Calif.) University.

Interface dermatitis on skin biopsy is “felt to be almost required by many people to make the diagnosis,” but he and his associates found that it was not present in about a quarter of a cohort of patients with DM. “We don’t want a clinician” to rule out the diagnosis based on its absence on a biopsy, “when its actually quite possible that the patient could have disease,” Dr. Fiorentino said at the International Conference on Cutaneous Lupus Erythematosus.

In general, skin biopsies in DM are tricky. “All of us take them, but we don’t really know how to interpret the information that comes back ... because we don’t really know how often many of [the associated] findings are seen” in DM patients, he noted.

One of the main concerns is to rule out lupus, but interface dermatitis is found in many of its cutaneous forms, as well as in graft-versus-host disease and other diseases.

So what’s a clinician to do? Fortunately, direct immunofluorescence can help. A positive lupus band test helps rule out DM, and the membrane attack complex helps rule it in, both with a good degree of certainty. In a video interview, Dr. Fiorentino explained these tests and how to use them.

Dr. Fiorentino had no relevant disclosures.

[email protected]

ORLANDO – Dermatologists and rheumatologists are mistaken if they think interface dermatitis is the sine qua non biopsy finding of dermatomyositis (DM), according to David Fiorentino, MD, PhD, professor of dermatology, rheumatology, and immunology at Stanford (Calif.) University.

Interface dermatitis on skin biopsy is “felt to be almost required by many people to make the diagnosis,” but he and his associates found that it was not present in about a quarter of a cohort of patients with DM. “We don’t want a clinician” to rule out the diagnosis based on its absence on a biopsy, “when its actually quite possible that the patient could have disease,” Dr. Fiorentino said at the International Conference on Cutaneous Lupus Erythematosus.

In general, skin biopsies in DM are tricky. “All of us take them, but we don’t really know how to interpret the information that comes back ... because we don’t really know how often many of [the associated] findings are seen” in DM patients, he noted.

One of the main concerns is to rule out lupus, but interface dermatitis is found in many of its cutaneous forms, as well as in graft-versus-host disease and other diseases.

So what’s a clinician to do? Fortunately, direct immunofluorescence can help. A positive lupus band test helps rule out DM, and the membrane attack complex helps rule it in, both with a good degree of certainty. In a video interview, Dr. Fiorentino explained these tests and how to use them.

Dr. Fiorentino had no relevant disclosures.

[email protected]

ORLANDO – Dermatologists and rheumatologists are mistaken if they think interface dermatitis is the sine qua non biopsy finding of dermatomyositis (DM), according to David Fiorentino, MD, PhD, professor of dermatology, rheumatology, and immunology at Stanford (Calif.) University.

Interface dermatitis on skin biopsy is “felt to be almost required by many people to make the diagnosis,” but he and his associates found that it was not present in about a quarter of a cohort of patients with DM. “We don’t want a clinician” to rule out the diagnosis based on its absence on a biopsy, “when its actually quite possible that the patient could have disease,” Dr. Fiorentino said at the International Conference on Cutaneous Lupus Erythematosus.

In general, skin biopsies in DM are tricky. “All of us take them, but we don’t really know how to interpret the information that comes back ... because we don’t really know how often many of [the associated] findings are seen” in DM patients, he noted.

One of the main concerns is to rule out lupus, but interface dermatitis is found in many of its cutaneous forms, as well as in graft-versus-host disease and other diseases.

So what’s a clinician to do? Fortunately, direct immunofluorescence can help. A positive lupus band test helps rule out DM, and the membrane attack complex helps rule it in, both with a good degree of certainty. In a video interview, Dr. Fiorentino explained these tests and how to use them.

Dr. Fiorentino had no relevant disclosures.

[email protected]

NASHVILLE, Tenn. – Recent research into comorbidities in multiple sclerosis – including head-scratching findings about lower cancer rates – is shedding light on the links between the disease and other illnesses, according to an epidemiologist specializing in MS.

“People should be mindful that if they look at having a positive impact on those comorbidities, they may have the ability to benefit patients in context of their MS,” Helen Tremlett, PhD, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. She is the Canada Research Chair in Neuroepidemiology and Multiple Sclerosis at the University of British Columbia, Vancouver.

In recent years, research into comorbidities in MS has risen dramatically. Dr. Tremlett found that the number of papers per year in PubMed that address MS and comorbidity has risen from roughly 30 in 2007 to about 80 in 2015, although the numbers dipped to about 50 and 60, respectively, in 2016 and 2017.

A 2015 systematic review of research into MS and comorbidities reported that while “findings were inconsistent overall,” studies suggested that “meningiomas and possibly urinary system cancers, inflammatory bowel disease, irritable bowel syndrome, epilepsy, depression, anxiety, bipolar disorder, early cataracts, and restless legs syndrome were more common than expected in the MS population.” (Mult Scler. 2015 Mar;21[3]:263-81).

Notably, most cancers are missing from this list. In fact, Dr. Tremlett cowrote a 2012 study that found lower risks of all cancers and several specific types of cancer – breast, lung, colorectal, prostate, and melanoma – in MS patients, compared with age- and gender-matched controls (Brain. 2012 Oct;135[Pt 10]:2973-9).

According to Dr. Tremlett, there are several theories about the apparent lower cancer risk in patients with MS. Perhaps their immune systems are hypervigilant, or maybe MS diagnoses inspire healthier lifestyles.

Researchers have been intrigued by another possibility – that cancer diagnoses are being delayed in patients with MS. Indeed, the 2012 study found that tumor sizes at diagnosis in patients with MS were larger than expected in breast, prostate, lung, and colorectal cancer (P = .04).

“We couldn’t record why that’s the case, but there may be some so-called ‘diagnostic neglect,’ ” she said. “You could imagine a scenario where a typical person with MS goes to see their physician and says, ‘I’m tired. I have fatigue,’ and the physician says, ‘Yes, you have MS, that’s what you should expect.’ Someone in the general population might get additional investigation, get blood work done, and their cancer might be found earlier.”

It’s also possible, she said, that cancer isn’t picked up earlier because it can be difficult to screen people with disabilities. “It’s only recently that physicians can offer the Pap smear to women in a wheelchair.”

On another front, there’s evidence linking comorbidities to worsening MS. A 2018 study coauthored by Dr. Tremlett found that patients with more comorbidities had more disability. Specifically, ischemic heart disease and epilepsy were associated with greater Expanded Disability Status Scale scores (Neurology. 2018 Jan 3. doi: 10.1212/WNL.0000000000004885).

Other research coauthored by Dr. Tremlett has linked comorbidities in MS – specifically, hyperlipidemia, migraine, and three or more comorbidities – to higher risk of MS relapse (Neurology. 2017 Dec 12;89[24]:2455-61).

Dr. Tremlett reported having no relevant disclosures.

NASHVILLE, Tenn. – Recent research into comorbidities in multiple sclerosis – including head-scratching findings about lower cancer rates – is shedding light on the links between the disease and other illnesses, according to an epidemiologist specializing in MS.

“People should be mindful that if they look at having a positive impact on those comorbidities, they may have the ability to benefit patients in context of their MS,” Helen Tremlett, PhD, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. She is the Canada Research Chair in Neuroepidemiology and Multiple Sclerosis at the University of British Columbia, Vancouver.

In recent years, research into comorbidities in MS has risen dramatically. Dr. Tremlett found that the number of papers per year in PubMed that address MS and comorbidity has risen from roughly 30 in 2007 to about 80 in 2015, although the numbers dipped to about 50 and 60, respectively, in 2016 and 2017.

A 2015 systematic review of research into MS and comorbidities reported that while “findings were inconsistent overall,” studies suggested that “meningiomas and possibly urinary system cancers, inflammatory bowel disease, irritable bowel syndrome, epilepsy, depression, anxiety, bipolar disorder, early cataracts, and restless legs syndrome were more common than expected in the MS population.” (Mult Scler. 2015 Mar;21[3]:263-81).

Notably, most cancers are missing from this list. In fact, Dr. Tremlett cowrote a 2012 study that found lower risks of all cancers and several specific types of cancer – breast, lung, colorectal, prostate, and melanoma – in MS patients, compared with age- and gender-matched controls (Brain. 2012 Oct;135[Pt 10]:2973-9).

According to Dr. Tremlett, there are several theories about the apparent lower cancer risk in patients with MS. Perhaps their immune systems are hypervigilant, or maybe MS diagnoses inspire healthier lifestyles.

Researchers have been intrigued by another possibility – that cancer diagnoses are being delayed in patients with MS. Indeed, the 2012 study found that tumor sizes at diagnosis in patients with MS were larger than expected in breast, prostate, lung, and colorectal cancer (P = .04).

“We couldn’t record why that’s the case, but there may be some so-called ‘diagnostic neglect,’ ” she said. “You could imagine a scenario where a typical person with MS goes to see their physician and says, ‘I’m tired. I have fatigue,’ and the physician says, ‘Yes, you have MS, that’s what you should expect.’ Someone in the general population might get additional investigation, get blood work done, and their cancer might be found earlier.”

It’s also possible, she said, that cancer isn’t picked up earlier because it can be difficult to screen people with disabilities. “It’s only recently that physicians can offer the Pap smear to women in a wheelchair.”

On another front, there’s evidence linking comorbidities to worsening MS. A 2018 study coauthored by Dr. Tremlett found that patients with more comorbidities had more disability. Specifically, ischemic heart disease and epilepsy were associated with greater Expanded Disability Status Scale scores (Neurology. 2018 Jan 3. doi: 10.1212/WNL.0000000000004885).

Other research coauthored by Dr. Tremlett has linked comorbidities in MS – specifically, hyperlipidemia, migraine, and three or more comorbidities – to higher risk of MS relapse (Neurology. 2017 Dec 12;89[24]:2455-61).

Dr. Tremlett reported having no relevant disclosures.

NASHVILLE, Tenn. – Recent research into comorbidities in multiple sclerosis – including head-scratching findings about lower cancer rates – is shedding light on the links between the disease and other illnesses, according to an epidemiologist specializing in MS.

“People should be mindful that if they look at having a positive impact on those comorbidities, they may have the ability to benefit patients in context of their MS,” Helen Tremlett, PhD, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. She is the Canada Research Chair in Neuroepidemiology and Multiple Sclerosis at the University of British Columbia, Vancouver.

In recent years, research into comorbidities in MS has risen dramatically. Dr. Tremlett found that the number of papers per year in PubMed that address MS and comorbidity has risen from roughly 30 in 2007 to about 80 in 2015, although the numbers dipped to about 50 and 60, respectively, in 2016 and 2017.

A 2015 systematic review of research into MS and comorbidities reported that while “findings were inconsistent overall,” studies suggested that “meningiomas and possibly urinary system cancers, inflammatory bowel disease, irritable bowel syndrome, epilepsy, depression, anxiety, bipolar disorder, early cataracts, and restless legs syndrome were more common than expected in the MS population.” (Mult Scler. 2015 Mar;21[3]:263-81).

Notably, most cancers are missing from this list. In fact, Dr. Tremlett cowrote a 2012 study that found lower risks of all cancers and several specific types of cancer – breast, lung, colorectal, prostate, and melanoma – in MS patients, compared with age- and gender-matched controls (Brain. 2012 Oct;135[Pt 10]:2973-9).

According to Dr. Tremlett, there are several theories about the apparent lower cancer risk in patients with MS. Perhaps their immune systems are hypervigilant, or maybe MS diagnoses inspire healthier lifestyles.

Researchers have been intrigued by another possibility – that cancer diagnoses are being delayed in patients with MS. Indeed, the 2012 study found that tumor sizes at diagnosis in patients with MS were larger than expected in breast, prostate, lung, and colorectal cancer (P = .04).

“We couldn’t record why that’s the case, but there may be some so-called ‘diagnostic neglect,’ ” she said. “You could imagine a scenario where a typical person with MS goes to see their physician and says, ‘I’m tired. I have fatigue,’ and the physician says, ‘Yes, you have MS, that’s what you should expect.’ Someone in the general population might get additional investigation, get blood work done, and their cancer might be found earlier.”

It’s also possible, she said, that cancer isn’t picked up earlier because it can be difficult to screen people with disabilities. “It’s only recently that physicians can offer the Pap smear to women in a wheelchair.”

On another front, there’s evidence linking comorbidities to worsening MS. A 2018 study coauthored by Dr. Tremlett found that patients with more comorbidities had more disability. Specifically, ischemic heart disease and epilepsy were associated with greater Expanded Disability Status Scale scores (Neurology. 2018 Jan 3. doi: 10.1212/WNL.0000000000004885).

Other research coauthored by Dr. Tremlett has linked comorbidities in MS – specifically, hyperlipidemia, migraine, and three or more comorbidities – to higher risk of MS relapse (Neurology. 2017 Dec 12;89[24]:2455-61).

Dr. Tremlett reported having no relevant disclosures.

NASHVILLE, TENN. – Jeffrey B. English, MD, of the MS Center of Atlanta, knows which quality measures physicians and their patients with multiple sclerosis think are important. After all, he and his colleagues have surveyed them about that very topic.

But he has little time to monitor these measures since he’s too busy with a more overwhelming task: keeping track of unrelated quality measures as required by the federal government.

“When they developed quality measures under the MACRA law, they were not thinking about MS people in general. They were very primary care based,” Dr. English said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers.

In terms of MS, he said, “no one really knows what the correct outcome measures are.”

Dr. English knows more than most about quality measures preferred by neurologists and patients. At the annual CMSC meeting last year, he presented results from a survey of 11 physicians and 423 patients about the measures of care they consider most important. The patient survey asked about several measures recommended by the American Academy of Neurology plus other measures recommended by the physicians.

The two groups – physicians and patients – agreed on the top four measures: change observed via MRI, change observed via exam, quality of life, and fatigue. However, they disagreed on the ranking within the top four spots.

The least important measures for patients were exercise levels, depression, medication compliance, and relapses.

Dr. English wants to “be able to follow what the patients want me to follow.” However, he hasn’t been able to do so since “25% of my time with patients, in between patients and after hours, is spent trying to comply with outcome measures from the new health care system that are of no benefit to the patient,” he said.

He’s referring to the quality measures that many physicians are tracking to get reimbursed by Medicare and Medicaid.

Value-based care posts other challenges for MS physicians, he said, since MS care is especially expensive. Accountable Care Organizations are looking at cost savings in closed systems, he said, and that could spell trouble because patients with MS cost more.

As a 2015 report noted, first-generation disease-modifying therapies (DMTs) for MS cost about $60,000, and “costs for these agents have increased annually at rates 5 to 7 times higher than prescription drug inflation. Newer DMTs commonly entered the market with a cost 25%-60% higher than existing DMTs” (Neurology. 2015 May 26;84[21]:2185-92).

“If I’m in an ACO, and I’m taking care of a lot of MS patients, I’ll already lose money for the accountable care system,” Dr. English said. “They may not necessarily want an MS center inside an ACO.”

What can doctors do? “Advocacy efforts are pretty difficult for physicians,” Dr. English said. “Our hope is that the CMSC will be a clearinghouse for doctors who have ideas and efforts and advocacy, and somehow channel that into the actual provision of care. You have people advocating for medications and for research and for patients, but there’s nobody advocating for the actual care that’s going on, the boots-on-the-ground care. That’s where CMSC should play a big role.”

Dr. English disclosed that he has served as a consultant for multiple pharmaceutical companies.

NASHVILLE, TENN. – Jeffrey B. English, MD, of the MS Center of Atlanta, knows which quality measures physicians and their patients with multiple sclerosis think are important. After all, he and his colleagues have surveyed them about that very topic.

But he has little time to monitor these measures since he’s too busy with a more overwhelming task: keeping track of unrelated quality measures as required by the federal government.

“When they developed quality measures under the MACRA law, they were not thinking about MS people in general. They were very primary care based,” Dr. English said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers.

In terms of MS, he said, “no one really knows what the correct outcome measures are.”

Dr. English knows more than most about quality measures preferred by neurologists and patients. At the annual CMSC meeting last year, he presented results from a survey of 11 physicians and 423 patients about the measures of care they consider most important. The patient survey asked about several measures recommended by the American Academy of Neurology plus other measures recommended by the physicians.

The two groups – physicians and patients – agreed on the top four measures: change observed via MRI, change observed via exam, quality of life, and fatigue. However, they disagreed on the ranking within the top four spots.

The least important measures for patients were exercise levels, depression, medication compliance, and relapses.

Dr. English wants to “be able to follow what the patients want me to follow.” However, he hasn’t been able to do so since “25% of my time with patients, in between patients and after hours, is spent trying to comply with outcome measures from the new health care system that are of no benefit to the patient,” he said.

He’s referring to the quality measures that many physicians are tracking to get reimbursed by Medicare and Medicaid.

Value-based care posts other challenges for MS physicians, he said, since MS care is especially expensive. Accountable Care Organizations are looking at cost savings in closed systems, he said, and that could spell trouble because patients with MS cost more.

As a 2015 report noted, first-generation disease-modifying therapies (DMTs) for MS cost about $60,000, and “costs for these agents have increased annually at rates 5 to 7 times higher than prescription drug inflation. Newer DMTs commonly entered the market with a cost 25%-60% higher than existing DMTs” (Neurology. 2015 May 26;84[21]:2185-92).

“If I’m in an ACO, and I’m taking care of a lot of MS patients, I’ll already lose money for the accountable care system,” Dr. English said. “They may not necessarily want an MS center inside an ACO.”

What can doctors do? “Advocacy efforts are pretty difficult for physicians,” Dr. English said. “Our hope is that the CMSC will be a clearinghouse for doctors who have ideas and efforts and advocacy, and somehow channel that into the actual provision of care. You have people advocating for medications and for research and for patients, but there’s nobody advocating for the actual care that’s going on, the boots-on-the-ground care. That’s where CMSC should play a big role.”

Dr. English disclosed that he has served as a consultant for multiple pharmaceutical companies.

NASHVILLE, TENN. – Jeffrey B. English, MD, of the MS Center of Atlanta, knows which quality measures physicians and their patients with multiple sclerosis think are important. After all, he and his colleagues have surveyed them about that very topic.

But he has little time to monitor these measures since he’s too busy with a more overwhelming task: keeping track of unrelated quality measures as required by the federal government.

“When they developed quality measures under the MACRA law, they were not thinking about MS people in general. They were very primary care based,” Dr. English said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers.

In terms of MS, he said, “no one really knows what the correct outcome measures are.”

Dr. English knows more than most about quality measures preferred by neurologists and patients. At the annual CMSC meeting last year, he presented results from a survey of 11 physicians and 423 patients about the measures of care they consider most important. The patient survey asked about several measures recommended by the American Academy of Neurology plus other measures recommended by the physicians.

The two groups – physicians and patients – agreed on the top four measures: change observed via MRI, change observed via exam, quality of life, and fatigue. However, they disagreed on the ranking within the top four spots.

The least important measures for patients were exercise levels, depression, medication compliance, and relapses.

Dr. English wants to “be able to follow what the patients want me to follow.” However, he hasn’t been able to do so since “25% of my time with patients, in between patients and after hours, is spent trying to comply with outcome measures from the new health care system that are of no benefit to the patient,” he said.

He’s referring to the quality measures that many physicians are tracking to get reimbursed by Medicare and Medicaid.

Value-based care posts other challenges for MS physicians, he said, since MS care is especially expensive. Accountable Care Organizations are looking at cost savings in closed systems, he said, and that could spell trouble because patients with MS cost more.

As a 2015 report noted, first-generation disease-modifying therapies (DMTs) for MS cost about $60,000, and “costs for these agents have increased annually at rates 5 to 7 times higher than prescription drug inflation. Newer DMTs commonly entered the market with a cost 25%-60% higher than existing DMTs” (Neurology. 2015 May 26;84[21]:2185-92).

“If I’m in an ACO, and I’m taking care of a lot of MS patients, I’ll already lose money for the accountable care system,” Dr. English said. “They may not necessarily want an MS center inside an ACO.”

What can doctors do? “Advocacy efforts are pretty difficult for physicians,” Dr. English said. “Our hope is that the CMSC will be a clearinghouse for doctors who have ideas and efforts and advocacy, and somehow channel that into the actual provision of care. You have people advocating for medications and for research and for patients, but there’s nobody advocating for the actual care that’s going on, the boots-on-the-ground care. That’s where CMSC should play a big role.”

Dr. English disclosed that he has served as a consultant for multiple pharmaceutical companies.

NASHVILLE, TENN. – A new computer tablet application puts cognitive screening literally in the hands of patients with multiple sclerosis.

The Multiple Sclerosis Performance Test (MSPT), created specifically for iPad, presents patients with four assessments that they can complete in a short time before any clinic visit, according to Stephen M. Rao, PhD, who helped develop the tool. After patients complete the test battery, the program translates their results into adjusted normative data and feeds them directly into the individual electronic medical record. When the clinic visit begins, everything is ready for the physician and patient to review together. The program not only provides a solid baseline assessment, but can also, over time, create a longitudinal profile of a patient’s cognitive status, and help to guide management decisions, Dr. Rao said at the annual meeting of the Consortium of Multiple Sclerosis Centers.

“About half of people with MS do have cognitive problems, which, above and beyond the physical problems, can result in major challenges with work, the ability to engage in social activities, and the need for personal assistance,” said Dr. Rao, who is the Ralph and Luci Schey Chair and director of the Schey Center for Cognitive Neuroimaging at the Cleveland Clinic. “But despite that, even comprehensive MS care centers rarely screen for cognitive dysfunction using objective neuropsychological tests.”

Time is the issue for most clinics, he said. Although the paper-and-pencil screening tools out there take only 10 minutes or so, most centers don’t have the luxury of carving out those extra moments or dedicating a staff member to administer the test and handle the data.

The MSPT attempts to sidestep the problem of time and manpower. In Dr. Rao’s center and the other 10 in the United States and Europe that now use the tool, patients simply arrive a bit early for their appointment and complete the three components: a structured patient history; the Neurological Quality of Life assessment; and an electronic adaptation of the MS Functional Composite.

It assesses cognition with a processing speed test based on the Symbol Digit Modalities Test, which has long been validated for MS patients. A contrast sensitivity test assesses visual acuity. A simple manual-dexterity test, in which patients move peg symbols into “holes,” tests upper extremity function, and a video-recorded walking speed test assesses lower extremity function.

The system was validated in 165 patients with MS and 217 healthy controls. It correlated well with the paper-and-pencil Symbol Digits Modalities Test, and correlated more highly than that test with cerebral T2 lesion load (MS Journal. 2017;23:1929-37).

[email protected]

SOURCE: Rao SM et al. CMSC 2018. doi: 10.1177/1352458516688955

NASHVILLE, TENN. – A new computer tablet application puts cognitive screening literally in the hands of patients with multiple sclerosis.

The Multiple Sclerosis Performance Test (MSPT), created specifically for iPad, presents patients with four assessments that they can complete in a short time before any clinic visit, according to Stephen M. Rao, PhD, who helped develop the tool. After patients complete the test battery, the program translates their results into adjusted normative data and feeds them directly into the individual electronic medical record. When the clinic visit begins, everything is ready for the physician and patient to review together. The program not only provides a solid baseline assessment, but can also, over time, create a longitudinal profile of a patient’s cognitive status, and help to guide management decisions, Dr. Rao said at the annual meeting of the Consortium of Multiple Sclerosis Centers.

“About half of people with MS do have cognitive problems, which, above and beyond the physical problems, can result in major challenges with work, the ability to engage in social activities, and the need for personal assistance,” said Dr. Rao, who is the Ralph and Luci Schey Chair and director of the Schey Center for Cognitive Neuroimaging at the Cleveland Clinic. “But despite that, even comprehensive MS care centers rarely screen for cognitive dysfunction using objective neuropsychological tests.”

Time is the issue for most clinics, he said. Although the paper-and-pencil screening tools out there take only 10 minutes or so, most centers don’t have the luxury of carving out those extra moments or dedicating a staff member to administer the test and handle the data.

The MSPT attempts to sidestep the problem of time and manpower. In Dr. Rao’s center and the other 10 in the United States and Europe that now use the tool, patients simply arrive a bit early for their appointment and complete the three components: a structured patient history; the Neurological Quality of Life assessment; and an electronic adaptation of the MS Functional Composite.

It assesses cognition with a processing speed test based on the Symbol Digit Modalities Test, which has long been validated for MS patients. A contrast sensitivity test assesses visual acuity. A simple manual-dexterity test, in which patients move peg symbols into “holes,” tests upper extremity function, and a video-recorded walking speed test assesses lower extremity function.

The system was validated in 165 patients with MS and 217 healthy controls. It correlated well with the paper-and-pencil Symbol Digits Modalities Test, and correlated more highly than that test with cerebral T2 lesion load (MS Journal. 2017;23:1929-37).

[email protected]

SOURCE: Rao SM et al. CMSC 2018. doi: 10.1177/1352458516688955

NASHVILLE, TENN. – A new computer tablet application puts cognitive screening literally in the hands of patients with multiple sclerosis.

The Multiple Sclerosis Performance Test (MSPT), created specifically for iPad, presents patients with four assessments that they can complete in a short time before any clinic visit, according to Stephen M. Rao, PhD, who helped develop the tool. After patients complete the test battery, the program translates their results into adjusted normative data and feeds them directly into the individual electronic medical record. When the clinic visit begins, everything is ready for the physician and patient to review together. The program not only provides a solid baseline assessment, but can also, over time, create a longitudinal profile of a patient’s cognitive status, and help to guide management decisions, Dr. Rao said at the annual meeting of the Consortium of Multiple Sclerosis Centers.

“About half of people with MS do have cognitive problems, which, above and beyond the physical problems, can result in major challenges with work, the ability to engage in social activities, and the need for personal assistance,” said Dr. Rao, who is the Ralph and Luci Schey Chair and director of the Schey Center for Cognitive Neuroimaging at the Cleveland Clinic. “But despite that, even comprehensive MS care centers rarely screen for cognitive dysfunction using objective neuropsychological tests.”

Time is the issue for most clinics, he said. Although the paper-and-pencil screening tools out there take only 10 minutes or so, most centers don’t have the luxury of carving out those extra moments or dedicating a staff member to administer the test and handle the data.

The MSPT attempts to sidestep the problem of time and manpower. In Dr. Rao’s center and the other 10 in the United States and Europe that now use the tool, patients simply arrive a bit early for their appointment and complete the three components: a structured patient history; the Neurological Quality of Life assessment; and an electronic adaptation of the MS Functional Composite.

It assesses cognition with a processing speed test based on the Symbol Digit Modalities Test, which has long been validated for MS patients. A contrast sensitivity test assesses visual acuity. A simple manual-dexterity test, in which patients move peg symbols into “holes,” tests upper extremity function, and a video-recorded walking speed test assesses lower extremity function.

The system was validated in 165 patients with MS and 217 healthy controls. It correlated well with the paper-and-pencil Symbol Digits Modalities Test, and correlated more highly than that test with cerebral T2 lesion load (MS Journal. 2017;23:1929-37).

[email protected]

SOURCE: Rao SM et al. CMSC 2018. doi: 10.1177/1352458516688955

Since ProPublica launched Lost Mothers, we’ve covered many facets of the U.S. maternal mortality crisis. Despite spending more per capita on health care than any other country, the U.S. has the highest rate of deaths related to pregnancy and childbirth in the industrialized world.

Source: Vox and ProPublica

But what makes maternal health care in other affluent countries look so different than the U.S.? Among other things, midwives. Midwives in the U.S. participate in less than 10 percent of births. But in Sweden, Denmark and France, they lead around three-quarters of deliveries. In Great Britain, they deliver half of all babies, including all three of Kate Middleton’s. So if the midwifery model works for royal babies, why not our own?

Check out the video to find out how midwives have been at the center of a culture war that’s deeply rooted in race and class in America.

Today we see vestiges of that history in states with restrictive midwifery laws and barriers to entry for midwives. Earlier this year, one study was the first systematic look at how and where they practice, offering new evidence that empowering them could significantly boost maternal and infant health. Many of the states with poor health outcomes and hostility to midwives also have large black populations. And with black mothers three to four times more likely to die in pregnancy or childbirth, the study raises the possibility that greater use of midwives could reduce racial disparities in maternal health.
 

This story makes up the eighth installment in Vox’s collaboration with ProPublica. You can find this video and all of Vox’s videos on YouTube. Subscribe and stay tuned for more from our partnership.

Since ProPublica launched Lost Mothers, we’ve covered many facets of the U.S. maternal mortality crisis. Despite spending more per capita on health care than any other country, the U.S. has the highest rate of deaths related to pregnancy and childbirth in the industrialized world.

Source: Vox and ProPublica

But what makes maternal health care in other affluent countries look so different than the U.S.? Among other things, midwives. Midwives in the U.S. participate in less than 10 percent of births. But in Sweden, Denmark and France, they lead around three-quarters of deliveries. In Great Britain, they deliver half of all babies, including all three of Kate Middleton’s. So if the midwifery model works for royal babies, why not our own?

Check out the video to find out how midwives have been at the center of a culture war that’s deeply rooted in race and class in America.

Today we see vestiges of that history in states with restrictive midwifery laws and barriers to entry for midwives. Earlier this year, one study was the first systematic look at how and where they practice, offering new evidence that empowering them could significantly boost maternal and infant health. Many of the states with poor health outcomes and hostility to midwives also have large black populations. And with black mothers three to four times more likely to die in pregnancy or childbirth, the study raises the possibility that greater use of midwives could reduce racial disparities in maternal health.
 

This story makes up the eighth installment in Vox’s collaboration with ProPublica. You can find this video and all of Vox’s videos on YouTube. Subscribe and stay tuned for more from our partnership.

Since ProPublica launched Lost Mothers, we’ve covered many facets of the U.S. maternal mortality crisis. Despite spending more per capita on health care than any other country, the U.S. has the highest rate of deaths related to pregnancy and childbirth in the industrialized world.

Source: Vox and ProPublica

But what makes maternal health care in other affluent countries look so different than the U.S.? Among other things, midwives. Midwives in the U.S. participate in less than 10 percent of births. But in Sweden, Denmark and France, they lead around three-quarters of deliveries. In Great Britain, they deliver half of all babies, including all three of Kate Middleton’s. So if the midwifery model works for royal babies, why not our own?

Check out the video to find out how midwives have been at the center of a culture war that’s deeply rooted in race and class in America.

Today we see vestiges of that history in states with restrictive midwifery laws and barriers to entry for midwives. Earlier this year, one study was the first systematic look at how and where they practice, offering new evidence that empowering them could significantly boost maternal and infant health. Many of the states with poor health outcomes and hostility to midwives also have large black populations. And with black mothers three to four times more likely to die in pregnancy or childbirth, the study raises the possibility that greater use of midwives could reduce racial disparities in maternal health.
 

This story makes up the eighth installment in Vox’s collaboration with ProPublica. You can find this video and all of Vox’s videos on YouTube. Subscribe and stay tuned for more from our partnership.