Early vs. late diagnosis of multiple sclerosis

What impact does early diagnosis of multiple sclerosis have on patient outcomes compared to late diagnosis? Researchers recently released some preliminary answers in a newstudy published in the journal神经研究that suggests the criteria currently used to diagnose MS may be the bigger question.

“Most of the research from the past 10 years has said that MS patients who are treated earlier have better outcomes as far as their EDSS score, which means less disability in the next 10 years to 15 years,” saidJikku Zachariah博士，神经科医生，Penn State Milton S. Hershey Medical Centerand assistant professor,宾夕法尼亚州立医学院神经病学系。“我们同意这个概念，但是在我们的研究期间，我们发现这确实基于对早期攻击的定义。”

The heart of the study

经典MS通常首先出现，并在公认的临床孤立综合征（CIS）发作后被诊断出来，其中神经系统症状和症状持续至少24小时。Zachariah和他的同事旨在确定在CIS症状发作后不久出现的MS患者是否具有可识别的临床特征，包括较差的预后，而MS患者稍后出现。

Zachariah说：“通常，所有临床试验都包括经典CIS症状的患者，其中包括患有视神经炎，部分脊髓炎和脑干综合征的患者 - MS的经典症状。”“这些患者在疾病进展的早期接受治疗时，往往会产生更好的结局。”

The researchers looked at a cohort of 207 patients who first presented with MS from 1989 to 2005 and followed their progress through 2012. A little more than half of the patients were in an early presentation (EP) group after a CIS, while the other half were later presenters.

“We included patients who have prodromal symptoms or patients with mild, nonspecific symptoms, such as fatigue, depression and some pain — things that likely would not qualify them for MS clinical trials,” Zachariah said. “However, when we included all those patients in that early presenting group and compared it to the patients who were presenting to the late presenting group, the outcomes were similar in both groups after 10 to 15 years.”

研究的含义

The researchers were surprised to find little difference in long-term outcomes between the two groups. Early presenters were much more likely to have frequent attacks specifically in the two years after the onset of MS.

Zachariah说：“与晚期组的人相比，早期表现组的患者确实患有更严重的疾病 - 意味着更多的复发和更多的攻击 - 他们的生命早期就有更多的良性疾病。”“拥有积极进取的MS的人将有更多的复发，应更加积极地对待，并尽快转诊至MS诊所。”

然而，尽管早期和积极的治疗，结果并未改善患者的长期预后。该研究对此进行了思考：“可能是早期攻击频率和其他未识别风险的已知危险因素的结合被我们的EP组的早期治疗所抵消，以掩盖早期治疗的好处。”

研究人员还惊讶地发现，后来的患者（大多数人已经误诊多年）仍然有类似的结果。

“Even though treatment did not change outcomes, these patients should be diagnosed, as the importance of having a diagnosis and then serially following these patients is important,” Zachariah said. “In general, we think we need to treat everyone early so that they will have the same prognosis at 10 to 15 years.”

未来的诊断含义

Zachariah希望这项研究对未来的MS患者具有诊断和临床意义。

“All the clinical trials for all the new drugs enroll only patients with classic MS symptoms,” he said. “But there could be some benefit to enrolling patients with milder symptoms, too.”

The study found that later-presenting patients often had five to 10 years of prodromal symptoms like fatigue and generalized weakness before getting a diagnosis of MS.

“They had been going to doctors for years, but the diagnoses were continually missed,” Zachariah says. “While their MS may not be as aggressive as early presenting patients, and they may not need the same types of medical treatment, we have got to figure out a better way to get answers for these patients who have these nonspecific symptoms.”

后来的介绍患者还向诊断之前看到这么多医疗专家的保险索赔也大量收费。该研究发现，在患者经历了第一次经典脱髓鞘事件之前的五年内，住院和保险索赔在24％至26％之间增加了。

扎卡里亚说：“其他医生应该更加意识到，MS可以出现其他非特异性症状，而不是经典的症状，例如视神经炎和部分脊髓炎。”“初级保健医生应牢记的对前驱症状的认识提高，例如严重的疲劳和无法解释的发烧，因此我们可以在所有患者的早期诊断MS。”

作为唯一的宾夕法尼亚州中部的专用MS诊所, Penn State Health is at the forefront of treatment.

“My plan next year is to launch an MS Pathway Clinic, where we have more of a nuanced approach to early diagnosis and treatment,” Zachariah said, noting the use of neurofilament lights as biomarkers to help with earlier diagnosis.

“We plan to work with regional physicians for referrals to better diagnose patients early and start them on a treatment early because, as our research shows, these are tough diagnoses that can get missed in the community.”