Prognostic indicators for long-term disability in multiple sclerosis patients Alfredo Damasceno ⁎, Felipe Von Glehn, Carlos Otávio Brandão, Benito Pereira Damasceno, Fernando Cendes Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil abstract article info Article history: Received 19 June 2012 Received in revised form 28 August 2012 Accepted 17 September 2012 Available online 13 October 2012 Keywords: Expanded Disability Status Scale Long-term disability Multiple sclerosis Prognosis Relapses Risk factor Background: Daily practice is still faced with uncertainty in predicting the long-term disability of multiple sclerosis (MS). Most information comes from northern hemisphere cohorts, but in South America this infor- mation is scarce, and race, genetic and environmental factors could play an important role in the heteroge- neity observed in disease outcomes. Methods: We evaluated 197 patients attending our MS Center gathering clinical and demographic informa- tion. Outcome measures analyzed were time from first clinical symptom to EDSS of 6, 7 and 8. For survival analysis we employed Cox regression models and the Kaplan–Meier method. Results: Time to EDSS 6 was 25.83 years (95% CI 15.36–36.31), and 36.25 years (95% CI 20.72–51.78) for EDSS 7. Male sex was associated with a 4.63 and 4.69 fold increased risk to EDSS 6 and 7, respectively (p b 0.001 and p = 0.006). Motor and brainstem symptoms at onset were also associated with an 8.1 and 13.1 fold increased risk to EDSS 6, respectively (p = 0.04 and p = 0.01). The number of relapses in five and ten years of disease onset was associated with a slightly increased risk to EDSS 8 (1.28 and 1.19, respectively; p = 0.032 and p = 0.015). Conclusions: Male patients presenting with frequent relapses, especially those with motor and brainstem in- volvement, deserve close observation and should be cautiously monitored to early signs of treatment failure. © 2012 Elsevier B.V. All rights reserved. 1. Introduction Evolving clinical and neuroimaging criteria have allowed an earli- er and more accurate diagnosis of multiple sclerosis (MS) in clinical practice [1]. The concepts of disease dissemination in space and time can now be apprehended in a single MRI. However, despite major advances in neuroimmunology and neuroimaging, daily prac- tice is still faced with uncertainty in predicting the long-term course and disability of MS at the individual level. Patients are often concerned with their clinical status in the long-run, but few measures correlate reliably with disability after ten or more years of disease. At the group level, frequent relapses in the first years of disease, male sex or a short interval between the first and the second attack have been associated with a worse disease course, although most informa- tion come from large North America and European cohorts and some clinical predictors remain controversial [2,3]. In South America this information is scarce, and race, genetic and environmental factors could also play an important role in the heterogeneity observed in disease outcomes, besides influencing treatment response [4,5]. Therefore, emerging therapies with high short-term impact in disease exacerbations, yet sometimes with undesirable side effects, may be tailored to patients at higher risk for worse prognosis [6]. In this setting, we analyzed clinical and demographical factors re- lated to shorter times to disability milestones in a Brazilian sample of multiple sclerosis patients, addressing similarities and differences to other cohorts reported in the literature. 2. Methods 2.1. Patient selection We evaluated all patients attending our outpatient clinic of the MS center at UNICAMP University Hospital, Campinas, Brazil. MS was di- agnosed according to 2005 revised Macdonald criteria [7]. Patients are followed every 3 or 4 months, and the majority lives in Campinas metropolitan area or nearby cities. All patients were seen since the first visit on the center by one of the authors (B.P.D.). We included all patients with a relapsing–remitting and secondary progressive course attending our MS center since 1984. Patients with a primary progressive course or those who fulfilled diagnostic criteria for neuro- myelitis optica were excluded. The study was approved by the ethics committee of the Faculty of Medical Sciences of University of Campinas and patients provided written informed consent. 2.2. Clinical factors and outcome measures We reviewed medical records gathering clinical and demographic information regarding sex, educational level (assigned as fundamen- tal, intermediate, and superior level) and self-reported skin color Journal of the Neurological Sciences 324 (2013) 29–33 ⁎ Corresponding author at: Departamento de Neurologia, FCM, UNICAMP, 13083-970 Campinas, SP, Brazil. Tel./fax: +55 19 3521 7372. E-mail address: alfredodamasceno@hotmail.com (A. Damasceno). 0022-510X/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jns.2012.09.020 Contents lists available at SciVerse ScienceDirect Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns