University of California, San Francisco
Neurology

Author Of 6 Presentations

Internet and Social Media Poster Presentation

LB1161 - Teleneurology for MS care at two large academic centers before and during the-COVID-19 pandemic (ID 1394)

Speakers
Presentation Number
LB1161
Presentation Topic
Internet and Social Media

Abstract

Background

Teleneurology has the potential to improve patient access to specialized multiple sclerosis (MS) centers. MS patients face multiple barriers to receiving in-clinic care including physical limitations, driving restrictions, and financial limitations. The COVID-19 pandemic further highlighted the need to re-evaluate healthcare delivery models.

Objectives

To describe the teleneurology populations at two large MS centers (Cleveland Clinic (CC) and University of California, San Francisco (UCSF)) and the changes that occurred in teleneurology use before and during the COVID-19 pandemic.

Methods

In this cross-sectional study we identified all teleneurology visits conducted at our two centers between 01-2019 and 04-2020. We compared group demographics, visit characteristics, and MS disease characteristics using T-tests and chi-squared tests for normally distributed variables and Kruskal-Wallis test for non-parametric variables.

Results

2268 patients completed 2579 teleneurology visits during the study period across the two sites (mean age 48.3±12.3 years, 72.9% female); 78.1% had an MS diagnosis. Among MS patients, age and sex were similar (p>0.1 for each) but a greater proportion of patients seen at UCSF were non-white (74.8% vs 87% white, p=<0.001), had RRMS (78.7% vs 74.5%, p=.015), were on infusible DMTs (45.5% vs 35.2%, p=<0.001), walked independently (78.4% vs 72.7% p=<0.001), and lived closer to the Center (50.0 vs 57.2 miles, p=<0.005). CC had a higher proportion of advanced practice providers (APP) conducting visits (62.3% vs 2.6%, p=<0.001) and new patient visits (15.4% vs 4.0% p=<0.001). The post-COVID population (patients seen after March 15) across both sites had a higher proportion of African Americans (12.7% vs 5.0%, p=<0.001) and shorter driving distance (35.6 vs 130 miles, p=<0.001) compared to the pre-COVID population. The populations pre- and post-COVID did not differ on sex, current DMT, disease course, or disability level.

Conclusions

Teleneurology visits at baseline reflected the organizational and teleneurology reimbursement patterns across our Centers. Following precautionary measures and expanded reimbursement for telemedicine associated with the COVID-19 pandemic, we significantly increased utilization of specialized MS teleneurology care for local and African American patients. These findings illustrate the potential for societal factors to rapidly change disparities in technology adoption and access to specialized MS care.

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Clinical Trials Poster Presentation

P0188 - A Tablet-Based Cognitive Battery to Assess Cognitive Function in People with MS: Sensitivity to Change in A Randomized Controlled Trial (ID 270)

Speakers
Presentation Number
P0188
Presentation Topic
Clinical Trials

Abstract

Background

Cognitive impairment (CI) is one of the most debilitating manifestations of multiple sclerosis (MS), and digital tools provide promising approaches to overcoming barriers to access to cognitive remediation. Developing reliable, unsupervised tools is an unmet need.

Objectives

To determine the validity and efficacy of a novel digital tool to both query cognitive impairment in MS and capture sensitivity to change after cognitive remediation.

Methods

Fifty-three participants with MS (24 with CI and 29 without CI) and 24 non-MS participants were assessed with a tablet-based cognitive battery (Adaptive Cognitive Evaluation, ACE) and standard cognitive measures: Symbol Digit Modalities Test (SDMT) and the Paced Auditory Serial Addition Test (PASAT). Associations between performance in ACE and SDMT/PASAT were explored, with group comparisons to assess if ACE modules can capture group-level differences. All 53 MS participants were then randomized to complete either a tablet-based, closed-loop digital therapeutic delivered through a video game-like interface (AKL-T03, N=27) or a control game (AKL-T09, N=26) at home for 25 minutes a day, 5 days a week, for 6 weeks. ACE assessment was repeated post-treatment. The primary outcome was performance on an attention task of ACE.

Results

Correlations between performance in SDMT/PASAT and ACE were observed (SDMT vs. ACE: R=-0.57, p<0.001; PASAT vs. ACE: R=-0.39, p=0.005). Compared to non-MS and non-CI MS participants, CI MS participants showed a slower reaction time (p=0.001) and a higher attention cost (p=0.001). Unlike the active control program, the AKL-T03 treatment program significantly improved attention task performance in MS by showing a reduced reaction time from pre- to post-treatment (p<0.001).

Conclusions

These results suggest that ACE, an adaptive, tablet-based cognitive battery, could provide reliable unsupervised cognitive assessment for people with MS. They also support our prior findings that AKL-T03 is an effective home-based cognitive remediation program for MS.

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Patient-Reported Outcomes and Quality of Life Poster Presentation

P1005 - An electronic, unsupervised Patient Reported Expanded Disability Status Scale for Multiple Sclerosis (ID 1921)

Speakers
Presentation Number
P1005
Presentation Topic
Patient-Reported Outcomes and Quality of Life

Abstract

Background

In persons with multiple sclerosis (MS), the Expanded Disability Status Scale (EDSS) is the criterion standard for assessing disability, but its in-person nature constrains patient participation in research and clinical assessments.

Objectives

To develop and validate a scalable, electronic, unsupervised patient-reported EDSS (ePR-EDSS) that would capture MS-related disability across the spectrum of severity.

Methods

We enrolled 136 adult MS patients, split into a preliminary testing Cohort 1 (n=50), and a validation Cohort 2 (n=86), which was evenly distributed across EDSS groups. Each patient completed an ePR-EDSS either immediately before or after a MS clinician’s Neurostatus EDSS (NS-EDSS) evaluation. The final ePR-EDSS version includes 23 questions, takes between 7-12 minutes to complete (based on time measured for Cohort 2 participants), and can be accessed at https://openmsbioscreen.ucsf.edu/predss/about.

Results

In Cohort 2, mean age was 50.6 years (range 26-80) and median EDSS was 3.5 (IQR 1.5, 5.5). The ePR-EDSS and EDSS agreed within 1-point for 86% of examinations; kappa for agreement within 1-point was 0.85 (p<0.001). The correlation coefficient between the two measures was 0.91 (<0.001). For individual functional systems, complete agreement was highest for the brainstem score (55.8%) and lowest for the sensory score (31.4%). In sensitivity analyses adjusted for NS-EDSS, the absolute difference between ePR-EDSS and NS-EDSS was not significantly related to age, sex, disease duration, years of education, or the timepoint at which the ePR-EDSS tool was assessed (before/after neurological exam).

Conclusions

The ePR-EDSS is unique compared to other published tools - it can be accessed and performed by the patient without any supervision, is freely and openly available, has built-in logic to calculate functional system and total scores, and is validated over a wide NS-EDSS range. It demonstrated high correlation with NS-EDSS, with good agreement even at lower EDSS levels. For clinical care, the ePR-EDSS could enable the longitudinal monitoring of a patient’s disability. For research, it provides a valid and rapid measure across the entire spectrum of disability and permits broader participation with fewer in-person assessments.

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Symptom Management Poster Presentation

P1107 - Proactively evaluating and treating changes in function in people with multiple sclerosis: the CoachMS pilot study (ID 1488)

Speakers
Presentation Number
P1107
Presentation Topic
Symptom Management

Abstract

Background

In current disease management models for multiple sclerosis (MS), symptoms are treated separately, by multiple specialists, despite the fact that many symptoms interact and exacerbate one another. Impairments in bladder function, ambulation, and mood (BAM) are a common and often debilitating triad of symptoms with compounded detrimental effect.

Objectives

Assess the feasibility of CoachMS: a novel closed-loop, remote, interdisciplinary symptom management platform that integrates specific behavioral approaches to encourage patient self-management.

Methods

We enrolled 21 participants from the University of California, San Francisco MS Center with clinician- or self-reported symptoms in at least 2 of the 3 BAM domains. To quantitatively measure BAM symptoms, participants were given a Fitbit Flex2 to wear for the duration of the study and assessed with weekly, online surveys. At 2 weeks, together with the study team, individual goals were set for each participant. A simple 1:1 randomization allocated participants to either Coach or control groups. The CoachMS group received targeted interventions throughout the remainder of the study if they failed to meet their individual BAM goals, or displayed worsening. The control group was monitored without intervention. Our primary outcome was feasibility; secondary outcomes included proportion of recommended treatments pursued, and changes in BAM symptom severity.

Results

12 participants (55%) completed the study. These participants demonstrated excellent adherence to study protocol and reported satisfaction with the pilot platform. Coach participants demonstrated greater follow-through with clinical recommendations from the 2-week goal setting stage than controls (OR 9.33, 95% CI (0.89, 97.62)). As a cohort, a trend towards improvement in each BAM symptom was noted although the CoachMS and control groups did not differ. One control participant, reporting suicidality in the weekly questionnaires but not to her primary clinicians, was urgently evaluated per protocol, and hospitalized.

Conclusions

The CoachMS platform, a closed-loop system for managing MS symptoms, was feasible; retention can be further optimized with lower questionnaire burden. Reminders and contact from study team improved recommendation follow-though in the Coach group, particularly for outside referrals. The CoachMS protocol could represent a viable, accessible and cost-effective tool to monitor and treat MS symptoms in near real-time; a larger trial is planned.

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Reproductive Aspects and Pregnancy Poster Presentation

P1117 - Clinical and radiologic disease activity in pregnancy and postpartum in multiple sclerosis  (ID 1930)

Speakers
Presentation Number
P1117
Presentation Topic
Reproductive Aspects and Pregnancy

Abstract

Background

Multiple sclerosis (MS) typically begins between the ages of 20 to 40 years and has a female to male ratio of 3:1. As such, MS is primarily diagnosed in women of reproductive age. Several studies have demonstrated that women experience fewer MS relapses during the immunotolerant state of pregnancy; however, an increase in relapses has been observed postpartum. As clinical inflammatory activity postpartum could be confused with other common neurological conditions, magnetic resonance imaging (MRI) detects new inflammatory lesions objectively. No large case series of MRI-defined postpartum inflammatory activity have been published, to our knowledge.

Objectives

To evaluate clinical and radiological inflammatory activity in women with multiple sclerosis during pregnancy and postpartum.

Methods

We performed a retrospective analysis of prospectively collected clinical and MRI reports for women who became pregnant while followed at the UCSF Multiple Sclerosis Center between 2005 and 2018. Annualized relapse rate (ARR) and proportion of brain MRIs with new T2-hyperintense or gadolinium enhancing (Gd+) lesions were compared before, during and after pregnancy.

Results

We identified 155 pregnancies in 119 women (median EDSS 2.0). For the 146 live birth pregnancies, pre-pregnancy ARR was 0.33; ARR decreased during pregnancy, particularly the third trimester (ARR 0.10, p=0.017) and increased in the three months postpartum (ARR 0.61, p=0.012); 16.5% of women experienced a clinically meaningful increase in EDSS. Among 70 pregnancies with paired brain MRIs available, 52.5% had new T2 and/or Gd+ lesions postpartum compared to 32.2% pre-pregnancy (P=0.023). Postpartum clinical relapses were associated with Gd+ lesions (p<0.0001). However, for patients without postpartum relapses, surveillance brain MRIs revealed new T2 and/or Gd+ lesions in 30.9%. Protective effects of exclusive breastfeeding for ≥3 months (odds ratio (OR)=0.20, 95% CI 0.047-0.82) and early initiation of MS therapy (OR=0.28, 0.080-0.98) were observed for relapses.

Conclusions

We confirm prior reports of decreased relapse rate during pregnancy and increased rate in the three months postpartum. We report a significant association between this clinical activity and inflammation on MRI, as well as postpartum radiologic activity even in the absence of relapses. Both clinical and radiologic reassessment may inform optimal treatment decision-making during the high-risk early postpartum period.

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Reproductive Aspects and Pregnancy Poster Presentation

P1135 - Risk factors for peripartum depression in women with multiple sclerosis (ID 1419)

Speakers
Presentation Number
P1135
Presentation Topic
Reproductive Aspects and Pregnancy

Abstract

Background

Peripartum depression (PPD), i.e. depression in late pregnancy to 1 year postpartum, occurs in 7-19% of women. There are limited data on PPD in multiple sclerosis (MS).

Objectives

To evaluate the prevalence of PPD in women with MS, and to evaluate risk factors for PPD in MS, both factors associated with PPD in the general population, as well as disease-related factors.

Methods

We performed retrospective analysis of prospectively collected clinical data. Women with MS followed at UCSF MS Center who became pregnant from 2015-2018 were identified in the electronic medical record. The primary outcome was PPD determined by clinical record review. Prevalence of PPD was estimated with logistic regression with generalized estimating equations (GEE), accounting for women with multiple pregnancies. Univariable analyses with GEE logistic regression evaluated predictors of PPD (age, marital status, parity, delivery season, prematurity, birth weight, delivery mode, premorbid depression/anxiety, antidepressant discontinuation, sleep disturbance, breastfeeding). Factors significant in univariable analyses were included in multivariable analysis. GEE logistic regression evaluated association between inflammatory disease activity (relapses in pregnancy/postpartum; gadolinium enhancing lesions postpartum), disease severity (Expanded Disability Status Scale, EDSS) and PPD.

Results

We identified 143 pregnancies (age 33.1+/-4.7 years; 93% relapsing remitting MS, 7% clinically isolated syndrome; 45% premorbid depression) in 111 women who had live birth outcomes and known PPD status. PPD was present in 12.6% (95% CI 7.3-17.8) of pregnancies. In univariable analyses, statistically significant factors associated with PPD included older age (OR 1.16, 95% CI 1.03-1.32 for 1-year increase), primiparity (OR 4.02, 95% CI 1.14-14.23), premorbid depression (OR 3.70, 95% CI 1.27-10.01), postpartum sleep disturbance (OR 3.23, 95% CI 1.17-8.91) and breastfeeding difficulty (OR 3.58, 95% CI 1.27-10.08). Maternal age (OR 1.17, 95% CI 1.02-1.34), primiparity (OR 8.10, 95% CI 1.38-47.40) and premorbid depression (OR 3.89, 95% CI 1.04-14.60) remained associated with PPD in multivariable analyses. Relapses, MRI activity and EDSS were not associated with PPD.

Conclusions

PPD in MS was similar to the general population, but was likely underestimated due to lack of standardized screening. PPD could influence maternal self-management of MS. Prospective evaluation with screening for PPD is needed.

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Presenter Of 1 Presentation

Patient-Reported Outcomes and Quality of Life Poster Presentation

P1005 - An electronic, unsupervised Patient Reported Expanded Disability Status Scale for Multiple Sclerosis (ID 1921)

Speakers
Presentation Number
P1005
Presentation Topic
Patient-Reported Outcomes and Quality of Life

Abstract

Background

In persons with multiple sclerosis (MS), the Expanded Disability Status Scale (EDSS) is the criterion standard for assessing disability, but its in-person nature constrains patient participation in research and clinical assessments.

Objectives

To develop and validate a scalable, electronic, unsupervised patient-reported EDSS (ePR-EDSS) that would capture MS-related disability across the spectrum of severity.

Methods

We enrolled 136 adult MS patients, split into a preliminary testing Cohort 1 (n=50), and a validation Cohort 2 (n=86), which was evenly distributed across EDSS groups. Each patient completed an ePR-EDSS either immediately before or after a MS clinician’s Neurostatus EDSS (NS-EDSS) evaluation. The final ePR-EDSS version includes 23 questions, takes between 7-12 minutes to complete (based on time measured for Cohort 2 participants), and can be accessed at https://openmsbioscreen.ucsf.edu/predss/about.

Results

In Cohort 2, mean age was 50.6 years (range 26-80) and median EDSS was 3.5 (IQR 1.5, 5.5). The ePR-EDSS and EDSS agreed within 1-point for 86% of examinations; kappa for agreement within 1-point was 0.85 (p<0.001). The correlation coefficient between the two measures was 0.91 (<0.001). For individual functional systems, complete agreement was highest for the brainstem score (55.8%) and lowest for the sensory score (31.4%). In sensitivity analyses adjusted for NS-EDSS, the absolute difference between ePR-EDSS and NS-EDSS was not significantly related to age, sex, disease duration, years of education, or the timepoint at which the ePR-EDSS tool was assessed (before/after neurological exam).

Conclusions

The ePR-EDSS is unique compared to other published tools - it can be accessed and performed by the patient without any supervision, is freely and openly available, has built-in logic to calculate functional system and total scores, and is validated over a wide NS-EDSS range. It demonstrated high correlation with NS-EDSS, with good agreement even at lower EDSS levels. For clinical care, the ePR-EDSS could enable the longitudinal monitoring of a patient’s disability. For research, it provides a valid and rapid measure across the entire spectrum of disability and permits broader participation with fewer in-person assessments.

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