Medicine & Research

Doctor's Notes

By MS Focus Senior Medical Advisor, Ben Thrower M.D.
The MS News column includes analysis from Ben Thrower, M.D., MS Focus Senior Medical Advisor. Dr Thrower draws from the top news stories of the quarter and explains what the news means to you, the person with MS.
Researchers link MS to gut bacteria
In a new study, researchers detected clear evidence of changes that tie together bacteria living in the gut and immunological disorders such as multiple sclerosis. Investigators from Brigham and Women's Hospital found that people with MS have different patterns of gut microorganisms than those of their healthy counterparts. In addition, patients receiving treatment for MS have different patterns than untreated patients.
The findings were published in the journal Nature Communications.
Thrower – The gastrointestinal (GI) tract may be a path to our immune system. The human GI tract is lined with lymphatic tissue and may be one of the first places that our immune system interacts with and reacts to the environment. The GI tract normally hosts a variety of “good” bacteria. This study shows that the bacteria living in the gut are different in a person with MS and normalize when on an MS therapy. So, what does this mean in the real world? Are the changes in the gut bacteria the result of, or part of, the cause of MS? Would strategies to keep normal bacteria in the gut (i.e. probiotics) be associated with a lower risk of developing MS? While human studies are lacking, a 2010 study in the animal model of MS did show that a probiotic containing three strains of Lactobacillus did have an anti-inflammatory effect.
New study suggests MS risk, obesity link
A new study suggests that elevated body mass index could be an important, and potentially modifiable, risk factor for MS. The authors said the findings provide more reason to address rising obesity rates and to investigate whether interventions that promote a healthy lifestyle may help to mitigate MS risk. Using data from the largest genome-wide association study consortia for MS and BMI, the researchers found evidence supporting elevated BMI as a causal risk factor for MS. A genetically determined change in the BMI category from overweight to obese was linked with a substantially higher risk of MS in this study.
The study was published in the journal PLoS One.
Thrower – MS results from a complex confluence of genetic and environmental factors. It is quite possible that there is more than one pathway to MS. Many of these risk factors are completely out of our control, such as genetics and common viral exposures. A few risk factors, including obesity, may be modifiable, however. This is not to minimize the struggle that many have with their weight.

While we have seen great advances in medication for MS, we also need to focus on the bigger picture of wellness. Research has shown that regular exercise is associated with better energy levels and an improved quality of life for people with MS.
Finally, think about healthy eating. We really don’t know what the “best” diet is for people with MS. Gluten-free? Dairy-free? Swank diet? Wahl’s diet? Nutrition researchers do agree on some basic principles though: portion control, more fruits and vegetables, less red meat. Try to get your vitamins/nutrients from food rather than a pill, with the exception for some being the need for extra vitamin D.
Study shows treating early symptoms may delay MS onset
A new study suggests that starting medication for multiple sclerosis in people who show the beginning signs of the disease is linked with prolonging the time before the disease is definitively diagnosed.
The study involved people who had a first episode that was suggestive of MS, such as numbness, vision problems or problems with balance, and an MRI that showed signs of possible MS. Up to 85 percent of people in this situation, which is called clinically isolated syndrome, will in time be diagnosed with MS. 
Those who received the early treatment were 33 percent less likely to be diagnosed with MS than those who received the delayed treatment. People in the early group also had more time before their first relapse of the disease than people in the delayed group. The early group also had a lower overall yearly relapse rate.
The study was published in online issue of Neurology.
Thrower – The importance of diagnosing MS early and initiating therapy is illustrated in this study. The damage seen with MS in the human brain and spinal cord has been compared to an iceberg. The part we see on the surface is dwarfed by what is under the surface. Another analogy might be a forest fire. The fire is much easier to put out when it’s small versus when it’s a raging inferno. Similarly, the immune attack of MS appears to be easier to control early. In addition, early inflammation in MS may lead to permanent damage in the central nervous system and irreversible disability. While research on neural repair looks promising, our best strategy is to prevent damage before it occurs.
Improper criteria use can lead to MS misdiagnosis
Clinicians and researchers have known for decades that multiple sclerosis misdiagnosis is a problem. The authors of a new study define the nature of medical conditions that lead to patients being misdiagnosed with MS, as well as possible reasons why they are misdiagnosed. They hope the study will encourage clinicians to be better educated on the proper use of MS diagnostic criteria and on the problem of MS misdiagnosis.
The authors examined the possible causes for misdiagnosis in the 110 patients in the study. They found the initial clinicians may not have used MS diagnostic criteria appropriately. A proper clinical diagnosis relies on a rigorous evaluation that includes careful interpretation of radiological data from an MRI. However, MRI misinterpretation can complicate misdiagnosis. Abnormalities that resemble those of MS show up on a scan for reasons other than MS, and nonspecific abnormalities may lead to a faulty diagnosis. The study identified patients misdiagnosed by both MS specialist neurologists and nonspecialists.
The study was published online in the journal Neurology.
Thrower – In the previous article, researchers showed the benefits of early treatment in MS. Treating MS early means diagnosing MS early. As we push to minimize the delays in diagnosing and treating MS, do we push too hard at times? The authors of this article show that we do. The challenge lies, in part, in the sometimes nonspecific nature of MS symptoms. For example, fatigue is listed as the most common and most severe MS symptom by many. Obviously, the list of medical conditions associated with fatigue is lengthy. In addition, not every white spot on brain MRI is because of MS. Migraine headaches and vascular risk factors, such as hypertension, can also be associated with white matter changes on MRI.
In the end, the accurate diagnosis of MS requires the right story, the right MRI findings, and an absence of a better explanation. Other tests, such as evoked potentials and spinal fluid examinations, may help too. In a perfect world, the diagnosis of MS would be straight forward. The world is rarely perfect. Some people may have a clinical history that is consistent with MS, but they have MRI and physical findings that may or may not be consistent with MS. Add to that mix the frustration and/or fear that the patient and family are experiencing because of the lack of a diagnosis and one can see how a misdiagnosis might occur. The implications of an incorrect MS diagnosis can be just as severe as those of a delayed correct diagnosis. Many of our MS therapies have significant side effects. The misdiagnosis of MS may also mean the missed diagnosis of another health condition that is treatable.