• Multiple sclerosis

• Review

If you take a wander through your local hospital emergency department, you will generally not find any similarity to what you see on TV. It will not look like an episode of ‘ER’, with ambulances pulling up at breakneck speed and doctors yelling instructions in an attempt to save a life. Generally, the atmosphere is more sedate and if you look around there is one thing that becomes very clear-the general atmosphere of confusion. No, I am not talking about the medical staff but rather about the patients. Confused, delirious patients are very common in hospital and while diagnosing and treating delirium may not sound sexy, it is unbelievably important. There are lots of causes for delirium including medication side effects, infection and stroke but one of the most difficult things to do is to actually be able diagnose delirium effectively. Sounds easy, but it is far from it.

In this issue of JNNP, O’Regan and colleagues have undertaken an interesting study looking at simple ways of assessing delirium http://jnnp.bmj.com/content/85/10/1122.abstract . Their study shows that a simple test, naming the months of the year backwards, was a reliable way of diagnosing delirium. The screening tests were undertaken by junior medical doctors, who are the people that are generally faced with the initial assessment of delirious patients.

This is an interesting paper that has very clear and immediate clinical application.

Progression in MS has been associated with cortical atrophy.  Consequently, the holy grail of trying to prevent diability development in MS is to slow or even prevent the rate of cortical atrophy.  In this issue of JNNP, Zivadinovs groups elegantly demonstrate that cortical atrophy evolves over a 10 year period, being more pronounced in those patients developing disability.  This is an important study, especially when drug therapies are considered.

Read more at:  http://jnnp.bmj.com/content/85/10/1109.abstract

• Multiple sclerosis

• Research paper

In the new ear of MS drugs, safety has been an important consideration.  The risk of cancer in patients treated with IFNs has been raised, although never proven.  In this issue of JNNP, a large study from British Columbia categoricaly excludes the association of any cancers with MS.  Interestingly, there was a non-signifcant increase in the risk of breast cancer, most likely a chance occurence.

Must read more at:  http://jnnp.bmj.com/content/85/10/1096.abstract

• Multiple sclerosis

• Research paper

It is no secret that treatment options in Neurology are rapidly evolving. It is also no secret that for many chronic neurological disorders, there is no way we can even begin to think about a cure. For many conditions, the mechanisms that cause the disease are only just being identified and this is of course the start of any journey towards treatments that have curative intent. Although researchers in any field may be buoyed by the speed of progress in their own highly specialised area, it is well known that clinical implementation of any treatment takes on average about 15 years from its initial discovery. For patients, this may not be a lifetime but it certainly can feel like one. This is even more distressing if the condition is progressive, as many patients who have longstanding disease may not be suitable for a particular treatment by the time one is discovered. You can apply this to any degenerative disorder, from motor neuron disease, through to Parkinson’s Disease and Alzheimer’s Disease.

Multiple sclerosis is another such condition. In contrast to many other chronic neurological disorders, MS patients tend to be young, highly informed and heavily engaged with social media. So when a media outlet says that stem cell transplantation in Russia can cure MS, they may very well trigger a stampede. In some cases, you have to wonder if this is indeed the media’s intent and any question about the procedure’s scientific basis is deftly pushed to the side. In light of these reports about ‘stem cell’ treatment in MS, it is nice to see a reputable scientific journal such as JNNP publish a study that provides…wait for it….data!! Yes, it exists!!

In this month’s issue, the journal contains a Swedish study of autologous stem cell transplantation in MS http://jnnp.bmj.com/content/85/10/1116.abstract . A quick word for those who are from a non-medical background. What we are talking about here is not embryonic stem cells injected into a patient with MS, but rather about a procedure that has been used in the treatment of haematological malignancy for decades and which is reliant on initial high dose chemotherapy as a means of ablating the immune system.

In the Swedish study, patients had predominantly relapsing-remitting disease, although some patients with progressive disease were also studied. While retrospective in nature, the study nevertheless shows that this treatment may be effective (and safe) in certain patients with severe disabling MS. As noted by the authors, it sets the scene for future larger prospective clinical trials that may provide important insights into the risks and benefits of this treatment and which may also shed light on the patient characteristics that are most likely to predict a beneficial response.

Salt intake has been shown to modulate the activity of Th 17 cells, the very cells that drive the inflammatory response in MS.  Consequently, the question is raised whether high salt intake is associated with MS activity/relapses.  In an upcoming issue of JNNP, Farez and colleagues demonstrate a link between high salt intake and MS exacerbations.  In addition, the radiological burden was also increased by high salt intake.  So I guess we should advise our patients on a low salt dies.

Must read http://jnnp.bmj.com/content/early/2014/07/23/jnnp-2014-307928.full

HIV and multiple sclerosis (MS) are chronic conditions that, despite a massive amount of research, remain essentially incurable. The marked progress in treatment for these conditions has meant that both are now treatable, with the goal of treatment focussing on maintaining independence and quality of life. In the case of HIV, ensuring prolonged survival is an additional critical endpoint.

In JNNP online first, Gold and colleagues have presented an interesting study that explores the question of why patients with HIV never seem to get MS http://jnnp.bmj.com/content/early/2014/07/16/jnnp-2014-307932.abstract . As they mention in their report, there has only ever been one case reported of MS having developed in an HIV positive individual and that patient’s MS symptoms improved when treatment for HIV was commenced. The question raised in that report was whether there may be a virus linked to MS development that was being successfully treated with HIV medication. If so, could this be an avenue for future treatment?

In their study, Gold et al have undertaken a large cohort study using a British database. The major finding from their study is that HIV infection is associated with a lower risk of developing MS. They propose a number of different reasons for this association, including the fact that immunosuppression due to HIV infection may be reducing MS development. From a treatment perspective, the other possibility is that HIV treatments may also be reducing the impact of other viruses that are associated with the development of MS.

This is an interesting study that explores MS from a completely different angle. Well worth the read.