DO ORAL CONTRACEPTIVES REDUCE THE RISK OF MS?

Hormonal changes that occur during oral contraceptive use may be associated with a reduced risk of multiple sclerosis (MS), according to Alvaro Alonso, MD, PhD, and colleagues. They also found that pregnancy might also be associated with a reduced risk of MS, while the postpartum period might be associated with a short-term increase in the risk of MS. Details of their findings were published in the September Archives of Neurology.

The investigators identified 106 women younger than 50 with MS from the UK General Practice Research Database and compared them with 1,001 age-matched controls. They found that during the previous three years, the incidence of MS in women who used oral contraceptives had been 40% lower than in those who did not use oral contraceptives.

Compared with nonuse, odds ratios for MS risk were 0.6, 0.9, and 0.7 for use of third-generation oral contraceptives, second-generation oral contraceptives, and other oral contraceptives, respectively. Compared with nonuse, the odds ratios for use of any oral contraceptives were 0.6 for a relapsing-remitting course at MS onset and 1.2 for primary progressive MS. Repeated use of emergency contraception was associated with an insignificant increase in the risk of MS.

The researchers also noted that women had a higher risk of developing signs of MS during the six months following a pregnancy and an insignificant lower risk during pregnancy, compared with those women with no pregnancy. “This is consistent with studies on the effect of pregnancy in patients with MS and the immunological changes associated with pregnancy,” said the researchers. No relationship was found between the number of children born to a women and risk of MS.

“The bottom line is that if a woman wants to take oral contraceptives, that decision should not be influenced by fears of increased risk of MS,” said Dr. Alonso.

Suggested Reading
Alonso A, Jick SS, Olek MJ, et al. Recent use of oral contraceptives and the risk of multiple sclerosis. Arch Neurol. 2005;62:1362-1365.

PREVALENCE OF BIPOLAR SYMPTOMS IN PATIENTS WITH EPILEPSY

Bipolar symptoms occur at a higher rate in patients with epilepsy than in patients with other chronic disorders, according to a report in the August 23 Neurology. In addition, bipolar symptoms in patients with epilepsy are commonly unrecognized by physicians.

Alan B. Ettinger, MD, and colleagues sent the Mood Disorder Questionnaire, as well as questions about current health problems, to a sample of 127,800 people. A total of 85,358 people 18 or older returned the survey with usable data; 1,236 had epilepsy, 8,994 had migraine, 7,951 had asthma, 7,342 had diabetes, and 57,172 served as controls.

The researchers found that patients with epilepsy were 1.6 to 2.2 times more likely to have bipolar symptoms than were patients with migraine, asthma, or diabetes, and 6.6 times more likely to have bipolar disorder than were controls. Almost half of the epilepsy patients (47.9%) with a positive screen for bipolar symptoms reported a prior diagnosis of bipolar disorder. However, 26.3% of these patients who screened positive for bipolar symptoms had received a diagnosis of unipolar depression, and 25.8% had been given neither a unipolar nor bipolar depression diagnosis.

A family history of bipolar disorder was a significant predictor of a positive screen within all study groups, present in 20.6% of patients with epilepsy, 19.9% of patients with migraine, 15.5% of patients with asthma, 11.1% of patients with diabetes, and 8.3% of controls.

“Explanations for the disparity between anecdotal experience and these findings include the low probability that most clinicians are screening for bipolar disorder, physician awareness of psychiatric symptoms but failure to attribute significance to them, the failure of some bipolar patients to recognize their symptoms as being pathologic, or patients’ disinclination to raise these issues when the typical focus of an office visit is upon seizure control,” said the researchers. They also suggested that some commonly prescribed antiepileptic drugs might treat bipolar symptoms, therefore masking the disorder.

Dr. Ettinger’s team emphasized, “Clinicians should also bear in mind that while this study has focused upon bipolar symptoms, many other forms of psychopathology (such as depression, anxiety, and psychosis) have been reported in epilepsy and rates of some of these symptoms may actually exceed bipolar symptoms.”

Suggested Reading
Ettinger AB, Reed ML, Goldberg JF, Hirschfeld RMA. Prevalence of bipolar symptoms in epilepsy vs other chronic health disorders. Neurology. 2005;65:535-540.

NEW MEASUREMENT SYSTEM TO REPLACE THE GLASGOW COMA SCALE?

Researchers have developed a new, easy-to-use coma measurement system—a proposed replacement for the Glasgow Coma Scale. A description of the new scoring system, called the FOUR (Full Outline of UnResponsiveness) score, was published in the October issue of Annals of Neurology.

“There are far too many drawbacks with the Glasgow Coma Scale; it’s missing key and essential elements of a neurological exam of comatose patients,” said Eelco Wijdicks, MD, a Mayo Clinic neurologist. According to Dr. Wijdicks and colleagues, shortcomings of the Glasgow Coma Scale include failure to assess verbal score in intubated patients and the inability to test brain-stem reflexes.

When using the FOUR score, evaluators assign a score of 0 to 4 in each of four categories—eye, motor, brain stem, and respiration function. A score of 4 represents normal functioning in each category, whereas a score of 0 indicates nonfunctioning.

Dr. Wijdicks’ team compared the accuracy of the FOUR score with that of the Glasgow Coma Scale in 120 intensive care patients. Evaluators included neuroscience nurses, neurology residents, and neurointensivists.

They found that interrater reliability was excellent for the FOUR score and cited the following advantages of the new measurement system:

• Critically ill patients who are intubated remain fully testable.
• Brain stem reflexes can be tested, providing information about stages of brain stem injury that is unavailable with the Glasgow Coma Scale and allowing for immediate intervention and prognosis.
• Recognition of a locked-in syndrome and a possible vegetative state.
• Attention to respiratory patterns and brain herniation can help identify a need for respiratory support and can provide indicators of coma depth.
• Scores have better correlation with outcomes (eg, patients with the lowest FOUR score ratings had a higher probability of in-hospital mortality).

“It would be of interest to test the FOUR score in emergency physicians, trauma surgeons, medical or surgical intensivists, and allied nursing staff,” the researchers commented.

Suggested Reading
Wijdicks EFM, Bamlet WR, Maramattom BV, et al. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005. E-pub ahead of print.

DOES INTERFERON BETA-1B AFFECT DURATION OF BLACK HOLE LESIONS IN MS?

Although treatment with interferon beta-1b reduces the frequency of new black hole formations, it does not appear to decrease their duration, according to results of a study published online on September 12 in Archives of Neurology.

Francesca Bagnato, MD, and colleagues analyzed the effects of interferon beta-1b in six patients with relapsing-remitting multiple sclerosis (MS) (mean disease duration, six years). MRI scans were obtained in the 36 months prior to interferon beta-1b therapy (natural history phase) and 36 months after the start of therapy (therapy phase). Numbers of contrast-enhanced lesions and newly formed black holes were counted on each MRI scan. Because one patient did not form any black holes during the second phase of the study, analyses were restricted to the remaining five patients.

At baseline, patients ranged in age from 32 to 42 and had an EDSS score from 1.5 to 3.5 and a disease duration range of one to nine years. The number of contrast-enhanced lesions ranged from one to five, and the number of preexisting black holes ranged from three to 18.

The researchers found that the number of new black holes increased for each patient during both the natural history phase and the therapy phase. However, the rate of accumulation of new black holes was substantially lower in the therapy phase than in the natural history phase.

Dr. Bagnato and her colleagues said that although the rate of black hole accumulation decreased with interferon beta-1b treatment, Kaplan-Meier models revealed that the duration of black holes did not shorten. “A large percentage of the black holes during the natural history phase and the therapy phase persisted to the end of the observation periods, and thus, these black holes were assumed to last to the end of the observation phases,” they said.

The researchers noted that “larger cohorts of patients over longer periods are required to minimize potential bias because of the high heterogeneity of disease expression in individual cases.”

Suggested Reading
Bagnato F, Gupta S, Richert ND, et al. Effects of interferon beta-1b on black holes in multiple sclerosis over a 6-year period with monthly evaluations. Arch Neurol. September 12, 2005. E-pub ahead of print.

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