Friday, 17 April 2015

Diagnosis in MS Central one Scottish Name they Don't Do

Lumley R, Davenport R, Williams A. Most Scottish neurologists do not apply the 2010 McDonald criteria when diagnosing multiple sclerosis. J R Coll Physicians Edinb. 2015;45(1):23-26. doi: 10.4997/JRCPE.2015.106.

BACKGROUND:The diagnostic criteria for multiple sclerosis have evolved over time and currently the 2010 McDonald criteria are the most widely accepted. These criteria allow the diagnosis of multiple sclerosis to be made at the clinically isolated syndrome stage provided certain criteria are met on a single magnetic resonance brain scan. Our hypothesis was that neurologists in Scotland did not use these criteria routinely.
METHOD: We sent a SurveyMonkey questionnaire to all Scottish neurologists (consultants and trainees) regarding the diagnosis of multiple sclerosis.
RESULTS: Our questionnaire response rate was 65/99 (66%). Most Scottish neurologists were aware of the criteria and 31/58 (53%) felt that they were using these routinely. However, in a clinical vignette designed to test the application of these criteria, only 5/57 (9%) of neurologists appeared to use them.
CONCLUSION: Scottish neurologists' use of the 2010 McDonald criteria for diagnosis of multiple sclerosis varies from practitioners' perception of their use of these criteria.

To get treated you need to get diagnosed and it seems that neuros from MS central need to up their game, because it seems that they will be diagnosing slowly.Do they need to do better?

The McDonald criteria are diagnostic criteria for multiple sclerosis (MS). These criteria are named after neurologist W. Ian McDonald. In April 2001, an international panel in association with the National Multiple Sclerosis Society (NMSS) of America recommended revised diagnostic criteria for MS. They discourage the previously used terms such as "clinically definite" and "probable MS", and propose as diagnostic either "MS", "possible MS", or "not MS".They have undergone revisions in 2005 and 2010.

They make use of advances in magnetic resonance imaging (MRI) techniques and are intended to replace the Poser criteria and the older Schumacher criteria. The new criteria facilitate the diagnosis of MS in patients who present with signs and symptoms suggestive of the disease. These include monosymptomatic disease, disease with a typical relapsing-remitting course or insidious progression but no clear attacks and remissions.

The McDonald criteria for the diagnosis of multiple sclerosis were revised in 2005 to clarify exactly what is meant by an "attack", "dissemination" and a "positive MRI", etc.

For some people McDonald's criteria are a clinical definition, being therefore 100% sensitive respect themselves. For others, they are just some diagnosis criteria and therefore have to be evaluated against other more basic criteria, like biopsies or autopsies. Currently sensitivity and specificity of McDonald's criteria are 46% and 63% respect the criterium "conversion to definite in 40 months".and the sensitivity can be around 25% slower respect pathological MS because of silent MS cases

There is an ongoing discusion about whether MS should be considered a pathological or clinical entity. The original article of McDonald states that "MS is a clinical entity and therefore should be diagnosized with clinical and paraclinical criteria". Nevertheless, they acknowledge the existence of lesion-based MS definition, saying that some other groups consider that "the only proved diagnosis of MS can be made upon autopsy, or occasionally upon biopsy, where lesions typical of MS can be directly detected through standard histopathological techniques".

The 2010 McDonald criteria are regarded as the gold standard for MS diagnosis.

Diagnostic Criteria
Clinical PresentationAdditional Data Needed
* 2 or more attacks (relapses)
* 2 or more objective clinical lesions
None; clinical evidence will suffice (additional evidence desirable but must be consistent with MS)
* 2 or more attacks
* 1 objective clinical lesion
Dissemination in space, demonstrated by:
* MRI
* or a positive (cerebrospinal fluid) CSF and 2 or more MRI lesions consistent with MS
* or further clinical attack involving different site
* 1 attack
* 2 or more objective clinical lesions
Dissemination in time, demonstrated by:
* MRI
* or second clinical attack
* 1 attack
* 1 objective clinical lesion
(monosymptomatic presentation)
Dissemination in space demonstrated by:
* MRI
* or positive CSF and 2 or more MRI lesions consistent with MS
and
Dissemination in time demonstrated by:
* MRI
* or second clinical attack
Insidious neurological progression
suggestive of MS
(primary progressive MS)
One year of disease progression (retrospectively or prospectively determined) and
Two of the following:
a. Positive brain MRI (nine T2 lesions or four or more T2 lesions with positive VEP)
b. Positive spinal cord MRI (two focal T2 lesions)
c. Positive CSF

2010 Revisions

In 2010, the International Panel on Diagnosis of MS met in Dublin, Ireland for a third time to discuss and revise the McDonald diagnostic criteria above Reasons for revisions to the criteria included the simplification of demonstration of CNS lesions in space and time via imaging

Revised Diagnostic Criteria (2010)

Clinical PresentationAdditional Data Needed
* 2 or more attacks (relapses)
* 2 or more objective clinical lesions
None; clinical evidence will suffice (additional evidence desirable but must be consistent with MS)
* 2 or more attacks
* 1 objective clinical lesion
Dissemination in space, demonstrated by:
* MRI
* or a positive CSF and 2 or more MRI lesions consistent with MS
* or further clinical attack involving different site.
New criteria: Dissemination in Space (DIS) can be demonstrated by the presence of 1 or more T2 lesions in at least 2 of 4 of the following areas of the CNS: Periventricular, Juxtacortical, Infratentorial, or Spinal Cord.
* 1 attack
* 2 or more objective clinical lesions
Dissemination in time (DIT), demonstrated by:
* MRI
* or second clinical attack
New criteria: No longer a need to have separate MRIs run; Dissemination in time, demonstrated by: Simultaneous presence of asymptomatic gadolinium-enhancing
and nonenhancing lesions at any time; or A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or Await a second clinical attack. [This allows for quicker diagnosis without sacrificing specificity, while improving sensitivity.]
* 1 attack
* 1 objective clinical lesion
(clinically isolated syndrome)
New criteria: Dissemination in space and time, demonstrated by:
For DIS: 1 or more T2 lesion in at least 2 of 4 MS-typical regions of the CNS (periventricular, juxtacortical, infratentorial, or spinal cord); or Await a second clinical attack implicating a different CNS site; and For DIT: Simultaneous presence of asymptomatic gadolinium-enhancing and nonenhancing lesions at any time; or A new T2 and/or gadolinium-enhancing lesion(s) on follow-up MRI, irrespective of its timing with reference to a baseline scan; or Await a second clinical attack.
Insidious neurological progression
suggestive of MS
(primary progressive MS)
New criteria: One year of disease progression (retrospectively or prospectively determined) and
two or three of the following:
1. Evidence for DIS in the brain based on 1 or more T2 lesions in the MS-characteristic (periventricular, juxtacortical, or infratentorial) regions
2. Evidence for DIS in the spinal cord based on 2 or more T2 lesions in the cord
3. Positive CSF (isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index)
McDonald WI; Compston A; Edan G et al. (2001). "Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis". Ann. Neurol. 50: 121–7.

Polman, CH; Reingold, SC; Banwell, B; Clanet, M; Cohen, JA; Filippi, M; Fujihara, K; Havrdova, E; Hutchinson, M; Kappos, L; Lublin, FD; Montalban, X; O'Connor, P; Sandberg-Wollheim, M; Thompson, AJ; Waubant, E; Weinshenker, B; Wolinsky, JS (February 2011). "Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria.". Annals of neurology 69 (2): 292–302.




7 comments:

  1. Untreated patients would surely have a potential case for complaint legal or otherwise if they were left undiagnosed and also therefore untreated surely? But before that people need to act together and complain about lack of diagnosis and treatment.

    Does the diagnostic nihilism reflect their lack of belief in treatments for the disease (at least the standard first line drugs)?

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  2. Maybe they should change the name so that we actually know what criteria we're talking about. Furthermore the 2005 criteria, or even the Poser criteria was simpler to remember (and I don't mean understand!).

    I have this suspicion that if we're being (as neurologists) are being truthful, based on the clinical history backed up by a few white dots on the scan (our radiologists will tell us it's suspicious of inflammation) we diagnose MS. This makes the application of a criteria superfluous.

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    1. What happens for you when there are no overt lesions on MR?

      Say in a person who has one objectively assessable CIS episode then repeated symptomatic episodes lasting weeks or months, but subjectively described by the person (e.g. sensory loss, parasthesia, episodic balance issues, episodic urinary issues, but the episdoes lasting weeks or months then subsiding)?

      The 2010 criteria at least allow for a diagnosis in this case when you read the absolute letter of the criteria, but I'm not convinced many neurologists diagnose based on this, and this could potentially be to the detriment of patients, if the treatments truly do work.

      People in this category could potentially have either the most to gain from early effective treatment, or the least to gain. I'm thinking of the Queen Square study slide that Prof G likes to post where the "No lesion" cohort have a large jump in EDSS after the 15 to 20 year mark - if this is them presenting with the progressive phase of disease then the preventing of early, frequent small relapses may be a way of stopping this from happening.

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  3. Most neurologists don't use the Mcdonald criteria; we found this out when we did our national survey a few years ago. The McDonald criteria are only there for clinical trials and to be ticked to make sure someone is eligible for DMTs.

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    Replies
    1. Personally, I would rather have the common sense of a brilliant and compassionate neurologist than simply rigid adherance to a tick box system, which smacks of civil servant methodology. I have full confidence in my neurologist, and I'm in Scotland. :o)

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