If you want to make a real difference in this world, it's a lot harder than it seems

As I watched Larissa Sansour's short exhibition entitled "In the Future, They Ate From the Finest Porcelain" at the Barbican today, it dawned on me that science, medicine, and new discoveries all create alternative realities. A reality that cannot be predicted precisely by historians or politicians come to that. In essence, the work becomes a historical intervention - a de facto truth of the future, and not the past.


"We are depositing facts in the ground for future archaeologists to evacuate. These facts will confirm the existence of this people we are positing.
So only in the future will people learn that the civilization ate from the finest porcelain?
Yes, only then.
Very few raptures are instantaneous."

In practice I have often used the PRISMS-15 study (see below for the abstract, 15y outcome of the original RRMS trial in PwMS receiving interferon beta-1a, 44ug or 22ug, three times a week compared to placebo) as evidence that higher dose exposure and longer time on treatment, improves clinical outcomes. The proportion of individuals with EDSS≽4 in the high dose group (31.8%) was almost half that in the low dose group (60.7%), while the proportion with EDSS≽6 was a quarter in the high dose (13.9%) of that seen in the low dose group (52.1%). Around half of the low dose group (52.1%) converted to secondary progressive MS compared to a fifth in the high dose group (20.8%). The 15 year analysis also revealed that change in EDSS from start of the trial to 24 months and medication possession ratio (calculated as 100 x time [in days] on treatment from the start to the 15y visit) predicted secondary progressive MS conversion, suggesting that early treatment and adherence to treatment were important factors in obtaining good clinical outcomes. 

This real-world data is very informative; information that would not have been known back in 1998 when the original study was published. My hope is that more clinicians and PwMS adopt these principles when managing MS rather than living in the past.

J Neurol Neurosurg Psychiatry. 2015 Nov;86(11):1202-7. doi: 10.1136/jnnp-2014-310024. Epub 2015 Sep 15.
 

Factors influencing long-term outcomes in relapsing-remitting multiple sclerosis: PRISMS-15.


Kappos L, Kuhle J, Multanen J, Kremenchutzky M, Verdun di Cantogno E, Cornelisse P, Lehr L, Casset-Semanaz F, Issard D, Uitdehaag BM.

Abstract
 

AIM:

An exploratory study of the relationship between cumulative exposure to subcutaneous (sc) interferon (IFN) β-1a treatment and other possible prognostic factors with long-term clinical outcomes in relapsing-remitting multiple sclerosis (RRMS).
 

METHODS:

Patients in the original PRISMS study were invited to a single follow-up visit 15 years after initial randomisation (PRISMS-15). Outcomes over 15 years were compared in the lowest and highest quartile of the cumulative sc IFN β-1a dose groups, and according to total time receiving sc IFN β-1a as a continuous variable per 5 years of treatment. Potential prognostic factors for outcomes were analysed.
 

RESULTS:

Of 560 patients randomised in PRISMS, 291 returned for PRISMS-15 and 290 (51.8%) were analysed. Higher cumulative dose exposure and longer treatment time appeared to be associated with better outcomes on: annualised relapse rate, number of relapses, time to Expanded Disability Status Scale (EDSS) progression, change in EDSS, proportions of patients with EDSS ≥ 4 or ≥ 6, ≤ 5 relapses and EDSS <4 or <6, and time to conversion to secondary-progressive MS (SPMS). Higher dose exposure was associated with lower proportions of patients with EDSS progression and conversion to SPMS, and longer time on treatment with lower risk of first relapse. Change in EDSS from baseline to 24 months was a strong predictor of evaluated clinical outcomes over 15 years.
 

CONCLUSIONS:

These findings suggest that higher cumulative exposure to sc IFN β-1a may be associated with better clinical outcomes, and early change in EDSS score may have prognostic value, over many years, in RRMS.

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