What’s New in MS Research: September 2019
If you have any doubts about the breadth and depth of ongoing research into the causes, nature, and treatment of multiple sclerosis (MS), the 12 items that follow should entirely allay those concerns. This latest edition of “What’s New in MS Research” reports on findings from the depths of the seas to the aisles of your local supermarket, and then to laboratories, hospitals, and MS clinics.
From insights into families with MS, employment and MS, and the latest recommendations on vaccinations, to virtual house calls and unexpected avenues of research, the synopses below outline a number of informative study results of interest to the MS community. That evidence-based empowerment is central to the mission of the Multiple Sclerosis Association of America (MSAA). Beyond whatever nuggets you may glean from reviewing the several updates that follow, please remember that MSAA is here for you and committed to helping meet your MS-related information and support needs. If you have a question, concern, or idea, please do not hesitate to contact us at (800) 532-7667 or email us at MSquestions@mymsaa.org.
A small pilot study found that increasing high-density lipoprotein cholesterol (HDL-C) – the so-called “good cholesterol” – was associated with a significant reduction in fatigue.1
The research involved 18 people with progressive multiple sclerosis (MS). They followed a diet that featured high intake of fruits and vegetables, as well as animal-based and plant-based protein; dairy, eggs, and grains that contain gluten were excluded. In addition, they participated in a program of exercise, neuromuscular stimulation, and stress reduction.
After 12 months, study participants had an average increase of 6.0 mg/dL in their good cholesterol and saw their Fatigue Severity Scale (FSS) scores decline from an average of 5.51 at baseline to 3.03. They also saw improvements in their total cholesterol (TC) level (mean decline of 29.2 mg/dL), low-density lipoprotein cholesterol (LDL-C) or “bad cholesterol” (mean decline of 10.4 mg/dL), and body mass index (BMI) (mean decline of 2.6 kg.m2). The association between reduced fatigue and increased HDL-C was statistically significant, as was the association between the lower fatigue score and lower TC.
While stressing the need to replicate their findings on a larger scale, the investigators noted that the prevalence and impact of fatigue in MS, as well as the limited effectiveness of current treatment options for fatigue, underscore the importance of identifying dietary and other interventions that may help address the challenges that reduced energy levels pose for so many people with MS.
People with MS who have a first-degree relative also diagnosed with MS tend to have a slower onset of disease, but experience more exacerbations and disability than MS patients who do not have close relatives also affected by the condition. That’s the main finding of a Lithuanian study that examined disease course in 38 patients who had a parent, sibling, or child also diagnosed with MS (familial group) and 66 patients with no such family ties (control group).2
While people in the control group (with no family ties) were more likely to report an acute onset of MS, their subsequent course tended to be smoother than that of the familial group. People in the familial group had a higher number of average annual exacerbations (1.4 vs. 0.8) and a greater degree of disability, as measured on the Expanded Disability Status Scale and Multiple Sclerosis Severity Score instrument, than the controls.
In keeping with those clinical findings, patients with a family history had a higher incidence of MRI changes in the brainstem (74% vs. 30%) and cerebellum (58% vs. 30%) compared to controls. All of the clinical and MRI findings cited were statistically significant, as were findings that a higher proportion of people with MS experienced headache (37% vs. 9%) and backache (32% vs. 9%) than controls.
Although this study was relatively small, it provides further evidence of the impact that heredity has on MS, and provides investigators with additional insights as they work to identify factors that may enable them to better predict the course of a person’s MS and individualize care accordingly.
Working the night shift for 20 years or longer more than doubles the risk for developing MS, according to an analysis of almost 200,000 women participating in the Nurses Health Study (NHS) and Nurses Health Study II (NHSII).3
Researchers at the Medical University of Vienna and Harvard Medical School undertook the analysis to examine persistent concerns that night-shift work might predispose people to MS. They examined data for 83,992 women participating in the NHS study and 114,427 women in the NHSII study. They categorized those subjects by the number of years they had engaged in night-shift work, which they defined as working three or more nights per month. There were 407 definite cases of new-onset MS during the study period.
The investigators found no association between one-to-nine years or 10-19 years of night-shift work and an increased risk of MS. However, in examining data for the NHSII study, they found that women who worked overnight for 20 or more years were 2.62-times more likely than their peers to develop MS.
While the authors did not identify a specific cause for the increased risk, they speculated that disruption of circadian rhythms, or sleep/wake cycles, that play a key role in physiological processes including rest and immune function might be involved.
Editor’s note: In addition to the circadian rhythms that the authors mention, other factors may also be involved with working night shifts and an increased risk of MS. These might include an overall lower amount of sleep per day, lack of exercise, and reduced exposure to sunlight and Vitamin D, among other possibilities not yet investigated. Future studies may be able to explain why the risk is increased with this type of work.
While aspects of a person’s employment may increase the risk for multiple sclerosis (MS), as Austrian (and Bostonian) researchers showed in the just-referenced study, aspects of MS may increase a person’s risk for unemployment, as well. This was shown by Australian researchers in a recently released study.4
The investigators surveyed people with MS in 2012, and then followed up with them in 2015. More than 1,200 people completed both surveys.
In the 2.5 years between the first and second surveys, the proportion of study participants who were employed full-time or part-time fell from 61.4% to 57.1%. A higher level of disability at baseline and a lower level of education predicted loss of employment at follow-up. Overall, 25.5% of people experienced some change in employment status during the period between completing the first and second survey, with changes including involuntary loss of employment, retirement, and a shift from full-time work to part-time employment or vice-versa. At the time of the follow-up survey, almost 36% of participants were working full-time, about 25% had part-time employment, 3% were unemployed and seeking work, 16% were not in the labor force, and 20% had retired due to disability. The researchers found that having to retire because of disability was predictive of a lower mental health-related score on measures of quality of life. Almost two-thirds of respondents – 62% – said that MS had impacted their employment over their lifetime.
In analyzing their findings, the study’s authors concluded: “Employment status was negatively impacted by MS for most participants. We showed for the first time that employment loss was prospectively associated with poorer mental health related quality of life. Employment support including vocational services, reasonable flexibility in the workplace, and legal protection against discrimination should be widely available to assist people with MS, especially for those with progressive onset MS, [as well as those with] higher disability and lower levels of education, who are at higher risk of employment loss.”
Think of how far we’ve come in the treatment of multiple sclerosis (MS) since the mid-1990s. Scientists have a much deeper understanding of the disease process, imaging, and other assessments, which have improved tremendously, while the number of disease-modifying therapies (DMTs) available has grown from zero to 17.5
Given how much has occurred in the interim, the American Academy of Neurology recently updated its practice guidelines on vaccine-preventable infections and immunization in MS. An international panel analyzed the relevant evidence and issued several recommendations, advising clinicians to do the following:
- Recommend annual influenza vaccination to people with MS, unless a patient had a previous severe reaction or other specific reason not to receive the vaccine
- Weigh the local (that is, specific to the area in which the patient lives) risks of a vaccine-preventable illness in counseling people with MS about getting a vaccine to prevent that illness
- Recommend that people with MS follow the local vaccine guidelines that apply to them, again taking into consideration any specific reason that a patient should not get a particular vaccine
- Counsel people with MS about infection risks associated with specific immunosuppressive or immunomodulating (ISIM) medications, and about the treatment-specific vaccination guidance contained in the prescribing instructions for those agents
- If indicated based on local vaccine guidelines, vaccinate patients with MS at least four-to-six weeks before initiating ISIM therapy
- Screen for specific infections (e.g., hepatitis, tuberculosis, and varicella zoster virus [VZV]) based on prescribing information before initiating an ISIM medication, and treat patients testing positive for latent infections (e.g., hepatitis and tuberculosis) before MS treatment, again in keeping with the guidance in the MS medication’s prescribing information
- Recommend against using live-attenuated vaccines in people with MS who currently receive ISIM therapies or have recently discontinued these therapies, except in situations where the risk of infection is high and other vaccines are unavailable
- Delay vaccinating people with MS who are experiencing a relapse until clinical resolution or until the relapse is no longer active, which often may be many weeks after relapse onset
The guidelines also stressed the importance of sharing the latest evidence on vaccines, MS, and MS medications with patients, along with exploring patients’ views, preferences, and questions regarding immunization. Please note that the Multiple Sclerosis Association of America (MSAA) and the Consortium of MS Centers (CMSC) officially endorsed these recommendations.
Having multiple sclerosis (MS) does not increase a person’s risk of developing cancer, according to a Finnish study that tracked more than 1,000 people with MS and more than 10,000 of their peers without MS.6
The study followed 1,074 people in southwest Finland who were treated for MS from 2004 through 2012. Researchers compared the incidence of cancer among those people with that of randomly selected people who were matched to the MS patients by birth year and gender. During the study period, 5.7% of the MS group (61 people) and 7.0% of the control group (757 people) were diagnosed with cancer. That difference in cancer incidence was not statistically significant, the investigators noted.
Interestingly, while breast cancer occurred at roughly the same rate between the women with MS and women in the control group, the average age at which women with MS were diagnosed with breast cancer was higher – 61.7 years vs. 55.7 years – and that difference was statistically significant, researchers said. The analysis found that risk for other types of cancers varied somewhat between MS patients and their peers, being higher for people with MS for oral cavity cancer and colon cancer, and lower among MS patients for prostate cancer, but the researchers cautioned that the numbers of people affected by each of these cancers were too small to allow for reliable conclusions.
The investigators noted that larger studies conducted over longer periods of time and with longer exposure to various MS therapies are needed to further evaluate the issues they examined, particularly in terms of breast cancer risk. Meanwhile, people with MS can draw reassurance from the study’s main finding of no overall increased risk of cancer associated with MS.
Access to a neurologist remains a challenge for many people with multiple sclerosis (MS), particularly those who live in rural areas or who cannot drive. A recent study conducted by researchers at the University of Rochester suggests that the connectivity of this digital age may hold the key to overcoming those obstacles.7
The study involved 36 people with MS. One-half of the group saw a clinician in-person at the university’s MS clinic during the first part of the study, and then switched to “virtual house calls” (VHCs), in which they communicated with the clinician from their homes via an audio-visual connection, for the remainder of the study. The other half of the patients reversed that pattern – having virtual visits initially followed by in-person sessions.
At the conclusion of the study, 97.1% of participants reported that they would recommend telemedicine visits to others, and 94.3% said that it was easy for them to connect with a clinician via telemedicine. One reason for the high degree of patient satisfaction, researchers noted, was the time and cost savings provided by virtual visits.The investigators concluded “VHCs were found to be feasible, cost-effective, and appealing to persons with MS and physicians, supporting their utility as a care delivery method for MS.”
When people consider the health benefits attributed to fish, they tend to think of a lean filet grilled to perfection, or perhaps a capsule of fish oil. But recent research suggests that the lowly can of tuna long consigned to lesser prominence in supermarket aisles, may actually be key to reducing the risk of a first demyelinating event.8
In this 2019 study, Australian researchers drew on data from the 2003-2006 Ausimmune Study, a case-control investigation of risk factors for a first clinical diagnosis of central nervous system demyelination (FCD) to look for possible associations between fish consumption and an FCD, which is a common precursor to multiple sclerosis (MS).
They found that higher total fish consumption, defined as 30 grams per day, or roughly two servings per week, was associated with an 18% reduction in the risk for FCD. Further analysis found no significant association between eating grilled or fried fish and reduced risk of a first demyelinating event. However, higher consumption of “tinned fish” (Aussie for fish that comes in a can) was associated with a 41% reduction in the risk of an FCD.
The researchers noted that, “Tinned fish is predominantly oily, whereas grilled and fried fish are likely to be a combination of oily and white types. Oily fish is high in Vitamin D and very long chain polyunsaturated omega-3 fatty acids, both of which may be beneficial in relation to MS.”
Speaking of sea creatures and multiple sclerosis (MS), an Iranian neuroscientist has made a case for including the octopus among the animals that researchers study in seeking insights into the nature and treatment of MS.9
Writing in the October 2019 issue of the journal Medical Hypotheses, Abdorreza Naser Moghadasi, MD, notes that while scientists often study mice and other small animals to explore the pathophysiology of MS and potential therapies, octopuses have distinct features that can open up new avenues of inquiry.
In particular, he points to the fact that octopuses can regenerate defective tissue in both their central and peripheral nervous system. That capability, along with the ability to monitor the connection between specific activities and neurons in the brain of an octopus, “raise the question of what features can an octopus show when it is used as an organism to create experimental autoimmune encephalomyelitis (EAE) [the laboratory-induced correlate to MS in humans].”
Whether or not researchers will employ the octopus as a possible animal model for MS has not yet been determined, but the publication of this concept illustrates how scientists are looking beyond conventional practices to learn more about the pathophysiology of MS. Ideally, such studies will assist with the development of potential new treatments that will not only stop the disease, but also repair damaged nerves and return lost function.
Dr. Moghadasi, who is on staff at the Research Center of the Neuroscience Institute at Tehran University of Medical Sciences, maintains that studying the octopus may prove particularly useful in seeking to prevent the degenerative processes that are hallmarks of MS.
For general information or to speak with a trained Client Services Specialist, please call MSAA’s Helpline at (800) 532-7667, extension 154. Questions to MSAA’s Client Services department may also be emailed to MSquestions@mymsaa.org.
Written by Tom Garry, Medical Writer
Reviewed by Dr. Barry Hendin, MSAA Chief Medical Officer
Edited by Susan Wells Courtney, MSAA Senior Writer
1 Maxwell KF, Wahls T, Browne RW, et al. Lipid profile is associated with decreased fatigue in individuals with progressive multiple sclerosis following a diet-based intervention: results from a pilot study. PLoS One. 2019. https://doi.org/10.1371/journal.pone.0218075.
2Andrijauskis D, Balnyte R, Keturkaite I, Vaitkus A. Clinical and diagnostic features of patients with familial multiple sclerosis. Med Hypotheses. 2019. Oct;131:109310. doi: 10.1016/j.mehy.2019.109310. Epub 2019 Jul 13.
3 Papantoniou K, Massa J Devore E, et al. Rotating night sift work and risk of multiple sclerosis in the Nurses’ Health Studies. Occup Environ Med. 2019. Aug 12. pii: oemed-2019-106016. doi: 10.1136/oemed-2019-106016. [Epub ahead of print].
4 Marck CH, Aitken Z, Simpson S Jr., et al. Predictors of change in employment status and associations with quality of life: a prospective international study of people with multiple sclerosis. J Occup Rehabil. 2019 Aug 7. doi: 10.1007/s10926-019-09850-5. [Epub ahead of print]
5 Farez MF, Correale J, Armstrong MJ, et al. Practice guideline update summary: Vaccine-preventable infections and immunization in multiple sclerosis Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2019;93:1-11. doi:10.1212/WNL.0000000000008157
6 Hongell K, Kurki S, Sumelahti ML, Soilu-Hanninen M. Risk of cancer among Finnish multiple sclerosis patients. Mult Scler Relat Disord. 2019;5(35):221-227.
7 Robb JF, Hyland MH, Goodman AD. Comparison of telemedicine versus in-person visits for persons with multiple sclerosis: a randomized crossover study of feasibility, cost, and satisfaction. Mult Scler Relat Disord. 2019 May 6;36:101258. doi: 10.1016/j.msard.2019.05.001. [Epub ahead of print]
8 Black LJ, Zhao Y, Peng YC, et al. Higher fish consumption and lower risk of central nervous system demyelination. Eur J Clin Nutr. 2019 Aug 8. doi: 10.1038/s41430-019-0476-z. [Epub ahead of print]
9 Moghadasi AN. When an octopus has MS: Application of neurophysiology and immunology of octopuses for multiple sclerosis. Med Hypotheses. 2019 Oct;131:109297. doi: 10.1016/j.mehy.2019.109297. Epub 2019 Jul 1.