ABSTRACT
Natalizumab, a humanized anti-alpha4-integrin antibody, is a valuable therapeutic option for relapsing-remitting multiple sclerosis and has been widely used in this indication since 2006. The growing body of data on its high efficacy and safety profile, both from randomised trials and clinical practice, has allowed to identify risk factors for progressive multifocal leukoencephalopathy and to develop a preventive algorithm, which increased the therapeutic safety. Natalizumab also seems relatively safe in pregnant women as there is no indication in the available literature suggesting that exposure to this drug has a significant impact on pregnancy outcomes. However, adequate and well-controlled studies are still lacking and natalizumab should only be used in pregnancy if clearly needed. The mechanism of action of natalizumab also proved successful during the COVID-19 pandemic. Most patients receiving this therapy experienced only mild infection and developed normal vaccine-induced immunity after immunisation. We present a description of 15 patients with relapsing-remitting multiple sclerosis treated with natalizumab in 15 different centres throughout Poland. The drug was included both due to first-line treatment failure and in cases of rapidly progressing, severe form of multiple sclerosis. The patients differed in terms of disease duration, the length of natalizumab therapy, and JCV serological status. The described cases include patients from the natalizumab registration trial, women who became pregnant while on the therapy, and patients who developed COVID-19. The presented case reports summarise the experience to date with the use of natalizumab in the treatment of relapsing-remitting multiple sclerosis in PolandCopyright © 2022 Buchajewicz et al.
ABSTRACT
Background: Coronavirus Disease 2019 (COVID-19) poses many workflow challenges for healthcare systems. Elective cardiovascular magnetic resonance (CMR) exams were postponed until safety protocols were instituted. Since reopening, imaging labs are managing COVID-19 safety triaging, exam backlog, and increased referrals, thus innovative solutions for process improvement are needed. Purpose: An accelerated compressed sensing (CS) real-time (RT) technique offers dynamic cardiac imaging with high spatial and temporal resolution without image degradation. We sought to evaluate the efficiency of a rapid RT CMR protocol with a goal to decrease scan time without compromising study quality and comprehensiveness. Methods: We retrospectively evaluated 219 CMRs (Siemens Magnetom Sola 1.5T) performed 09/01/2020-10/15/2020. After excluding 81 exams due to heterogeneous protocols (Figure 1), we analyzed 138 CMR exams using standard cardiomyopathy or myocarditis protocols. CMR studies utilized either a rapid RT short axis (SAX) cine (spatial resolution of 2.5 mm2 or better and temporal resolution of 55 ms or better) or standard breath-held (BH) SAX cine protocol (Figure 2). Protocols were chosen by the interpreting physician. Previous internal quality control demonstrated similar volumetric quantification between RT and BH SAX cines. RT cines were reconstructed inline using a CS-based method. We analyzed the length of time needed to complete each protocol and the number of series performed. Statistical analysis included student t-test with p value <0.05 considered significant. Results: of 138 analyzed CMR exams, there were 23 rapid protocols and 115 standard protocols performed. The mean image acquisition time for the rapid protocol was significantly shorter at 26 ± 6 minutes (range 18-44 min) vs 33 ± 6 minutes (range 22-49 min) for the standard protocol, p < 0.001. This represents a mean relative reduction in scan time of 21%. More time was saved in rapid myocarditis (scan time 25 ± 6 min vs 34 ± 6 min, p = 0.01;relative time reduction 26%) vs rapid cardiomyopathy protocols (scan time 27 ± 6 min vs 31 ± 6 min, p = 0.04;relative time reduction 13%). There was no significant difference in the number of series performed (62 ± 14 series in rapid vs 67 ± 11 series in standard protocols, p = 0.09). T1 and T2 maps constituted the same percentage of acquired images regardless of protocol used (T1 maps 1.8% vs 1.7% for cardiomyopathy, 1.4% vs 1.4% for myocarditis in standard vs rapid protocols respectively;T2 maps 1.8% vs 1.7% for cardiomyopathy, 5.6% vs 5.8% for myocarditis in standard vs rapid protocols respectively). Conclusions: A rapid CMR protocol utilizing a CS-based RT imaging is significantly shorter as compared to the standard protocol with adequate diagnostic quality. Rapid CMR protocols are an effective tool for process improvement during the COVID-19 pandemic.