Clinical practice patterns in multiple sclerosis management: Mexican consensus recommendations.

BACKGROUND: Multiple sclerosis affects more than 2 million people. Clinical decisions are performed under evidence-based medicine. The appearance of new disease-modifying therapies and changes in diagnostic criteria complicates the decision-making process in clinical practice. OBJECTIVES: To characterize the criteria for radiologically isolated syndrome (RIS), clinically isolated syndrome (CIS), and relapsing-remitting multiple sclerosis (RRMS) by Mexican neurologists in a real-world setting. METHODS: A two-round modified Delphi method (RAND/UCLA) was applied. RESULTS: In RIS, LP, spinal cord MRI and VEP should be included in diagnostic testing; DMT initiation is not necessary. A follow-up MRI within 3 months are recommended. In CIS, corticosteroid therapy should be initiated at first relapse; both simple and Gd-enhanced MRI is mandatory. LP, selective blood tests, and NMO-IgG/AQP4 antibodies should be performed as complementary. IFN beta or GA were the most suitable DMTs for treating high-risk CIS. Patients with RRMS should begin with DMT at diagnosis, include a follow-up MRI if a patient had 2 relapses within 6 months. GA and oral DMTs are the most eligible DMTs for mild RRMS. Monoclonal antibodies-based therapy is chosen when disability is present. Radiological criteria for switching DMT included >1 Gd+ lesion and >2 new T2 lesions. CONCLUSIONS: Although many coincidences, there are still many hollows in the medical attention of MS in Mexico. This consensus recommendation could be helpful to implement better evidence-based recommendations and guidelines in a real-world setting.

Air Pollution, Multiple Sclerosis and its Relevance to Mexico City.

Long-term exposure to air pollution has been linked with the development of neurodegenerative diseases. The proposed mechanisms include neuroinflammation and brain oxidative stress. Multiple sclerosis (MS) is a neurodegenerative disease with an auto-immune physiopathology and some studies have associated it with long-term exposure to airborne particulate matter. In this opinion we discuss the current body of knowledge regarding air pollution and the risk of MS as well as MS relapses. Also, its relevance in the case of Mexico City is discussed.

The genetics of multiple sclerosis in Latin America.

BACKGROUND: In today's globalised world, the heterogeneity of diseases such as multiple sclerosis has been studied since it has been suggested that ethnic differences, in conjunction with geographical and environmental factors, influence its incidence and prevalence. AIM: Based on this, an attempt has been made to identify the genetic factors that may confer risk or protection, not only for developing multiple sclerosis but also for determining the course of its evolution. RESULTS: In Latin America we have some data about this, which have been replicated in different populations in the entire region, with very different results compared with other regions, which could explain not only the different frequencies in some populations, such as Caucasians, but also the course of the disease and the response to actual treatments. However, in addition to these findings, other associated epigenetic mechanisms have also been found in our populations, such as levels of vitamin D, parasitic diseases, and indigenous populations. Therefore, the study of epigenetics plays a crucial role in understanding the physiopathology of multiple sclerosis. It must be studied in each population, especially in Latin America, due to its broad heterogeneity. CONCLUSION: It is very important to understand not only the genetic and external factors with these very specific effects in multiple sclerosis patients, but also the way they interact and are able to explain the frequency and some specific phenotypes of the disease in our populations besides the posibility to be a very specific treatment target.

[The absence of a relation between apolipoprotein E genotypes and the severity of multiple sclerosis in Mexican patients]. / Ausencia de relación entre los genotipos de apolipoproteína E y la gravedad de la esclerosis múltiple en pacientes mexicanos.

INTRODUCTION: The clinical course of multiple sclerosis (MS) varies widely. The natural history of the disease has shown that approximately 50% of patients that begin with a relapsing-remitting clinical course will have a progressive course about 10 years after disease onset and will need some kind of aid to walk. The expression of apolipoprotein E (ApoE) increases in nerve tissue undergoing regeneration and the ApoE epsilon-4 allele is associated with abnormal neural repair. Several different reports indicate that the ApoE epsilon-4 allele is associated with a greater progression of disability in patients with MS, although this is still a matter of debate. PATIENTS AND METHODS: We analyse the clinical characteristics of 99 patients diagnosed with MS, we describe the correlation between the presence or absence of the ApoE epsilon-4 allele and the age of onset, clinical subtype, progression of the disease, score on the Expanded Disability Status Scale and the relapse rate. We explore the impact of the presence of the epsilon-2 allele on the progress of the disease. RESULTS: In patients under 21 years of age, we observed a higher frequency of the presence of the epsilon-4 allele (p = 0.057). Nevertheless, no association was found between any of the ApoE alleles and the indices of disease progression. CONCLUSIONS: Our results do not suggest any association between the presence of the ApoE epsilon-4 allele and the progression of disability in patients with MS in our sample.

Ausencia de relación entre los genotipos de apolipoproteína E y la gravedad de la esclerosis múltiple en pacientes mexicanos / The absence of a relation between apolipoprotein E genotypes and the severity of multiple sclerosis

Introducción. El curso clínico de la esclerosis múltiple (EM) es muy variable. La historia natural de la enfermedad ha enseñado que aproximadamente el 50% de los pacientes que inician con un curso clínico brote-remisión tendrá un curso progresivo después de unos 10 años de evolución de la enfermedad y necesitará alguna ayuda para deambular. La expresión de la apolipoproteína E (ApoE) aumenta en el tejido nervioso en regeneración, y el alelo ApoE épsilon-4 está asociado con reparación neural anómala. Diversas comunicaciones indican que el alelo ApoE épsilon4 se asocia a una mayor progresión de la discapacidad en pacientes con EM, aunque es controvertido. Pacientes y métodos. Analizamos las características clínicas de 99 pacientes con diagnóstico de EM, describimos la correlación de la presencia o ausencia del alelo épsilon-4 de la ApoE con la edad de inicio, subtipo clínico, progresión de la enfermedad, puntuación de la Expanded Disability Status Scale y tasa de recaídas. Exploramos el impacto de la presencia del alelo épsilon-2 con la evolución de la enfermedad. Resultados. En pacientes menores de 21 años observamos una mayor frecuencia de la presencia del alelo épsilon-4 (p = 0,057), pero no encontramos ninguna asociación entre algún alelo de ApoE y los índices de progresión de la enfermedad. Conclusiones. Nuestros resultados no indican alguna asociación entre la presencia del alelo ApoE épsilon-4 en la progresión de discapacidad en pacientes con EM en nuestra muestra (AU)

Introduction. The clinical course of multiple sclerosis (MS) varies widely. The natural history of the disease has shown that approximately 50% of patients that begin with a relapsing-remitting clinical course will have a progressive course about 10 years after disease onset and will need some kind of aid to walk. The expression of apolipoprotein E (ApoE) increases in nerve tissue undergoing regeneration and the ApoE epsilon-4 allele is associated with abnormal neural repair. Several different reports indicate that the ApoE epsilon-4 allele is associated with a greater progression of disability in patients with MS, although this is still a matter of debate. Patients and methods. We analyse the clinical characteristics of 99 patients diagnosed with MS, we describe the correlation between the presence or absence of the ApoE epsilon-4 allele and the age of onset, clinical subtype, progression of the disease, score on the Expanded Disability Status Scale and the relapse rate. We explore the impact of the presence of the epsilon-2 allele on the progress of the disease. Results. In patients under 21 years of age, we observed a higher frequency of the presence of the epsilon-4 allele (p = 0.057). Nevertheless, no association was found between any of the ApoE alleles and the indices of disease progression. Conclusions. Our results do not suggest any association between the presence of the ApoE epsilon-4 allele and the progression of disability in patients with MS in our sample (AU)