Author Of 4 Presentations
P0188 - A Tablet-Based Cognitive Battery to Assess Cognitive Function in People with MS: Sensitivity to Change in A Randomized Controlled Trial (ID 270)
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.
P1113 - Underutilization of Physical Therapy Resources for Symptomatic Women with MS During and Following Pregnancy (ID 1240)
Abstract
Background
Patients with MS continue to have symptoms of their disease even when inflammatory activity is reduced by DMTs. Although this activity is reduced during pregnancy - especially in the third trimester – women with MS can experience ongoing symptoms during pregnancy, or new ones in the immediate post-partum period, that degrade quality of life. Many MS-related and postpartum symptoms can be improved with physical therapy (PT), but there are no guidelines on pregnancy-related rehabilitation in MS.
Objectives
To evaluate the prevalence of PT-amenable symptoms and patterns of PT referrals in a cohort of UCSF MS Clinic patients who became pregnant.
Methods
Data collected prospectively between 09-2005 to 08-2019 were retrospectively extracted from electronic medical records (EMR) for the year before conception, during pregnancy, and year postpartum. This included clinical visits, MS therapies and symptoms (as defined by the National MS Society). PT and pelvic floor PT orders and notes were also extracted.
Results
We included 142 live birth pregnancies from 118 women. During the course of their pregnancy and within the year postpartum, 107 women (75.4%) reported at least one PT-amenable symptom. A total of 30 (28.0%) referrals were made to PT, with attendance confirmed for 10 (33.3%). Symptoms most commonly triggering a referral for PT evaluation were numbness and urinary incontinence. Falls were reported after 10 of the pregnancies; 4 resulted in a referral to PT. Forty-one women reported urinary incontinence: 11 (26.8%) were referred to PT, and 2 to pelvic floor PT. Nineteen women experienced a documented relapse during pregnancy and/or postpartum: 11 received a PT referral, and 4 attended PT.
Conclusions
While women with MS recorded at least 1 PT-amenable during or following 75.4% of their pregnancies, only 28% of these were referred to PT – and only a third attended PT. Of significance was the 4.9% referral rate for pelvic floor PT in postpartum women with a record of urinary incontinence. Pelvic floor PT is a mainstay of general postpartum care in many European countries. These data illustrate critical gaps in rehabilitation referral, access and use at the intersection of neurological conditions and pregnancy in a large US-based MS clinic. They lend support for quality improvement efforts to improve care pathways and for telerehabilitation innovations to reduce barriers to access and improve synergistic care between PT, MD and urologic care.
P1117 - Clinical and radiologic disease activity in pregnancy and postpartum in multiple sclerosis (ID 1930)
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.
P1135 - Risk factors for peripartum depression in women with multiple sclerosis (ID 1419)
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.
Presenter Of 1 Presentation
P1117 - Clinical and radiologic disease activity in pregnancy and postpartum in multiple sclerosis (ID 1930)
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.