ObjectiveTo evaluate radiologic and clinical inflammatory activity in women with MS during pregnancy and postpartum.MethodsWe performed a retrospective analysis of prospectively collected clinical and MRI reports for women who became pregnant while followed at the University of California, San Francisco MS Center between 2005 and 2018. Proportion of brain MRIs with new T2-hyperintense or gadolinium enhancing (Gd+) lesions (primary outcome) and annualized relapse rate (ARR; secondary) were compared before and after pregnancy.ResultsWe identified 155 pregnancies in 119 women (median Expanded Disability Status Scale [EDSS] 2.0). For the 146 live birth pregnancies, prepregnancy ARR was 0.33; ARR decreased during pregnancy, particularly the third trimester (ARR 0.10, p = 0.017) and increased in the 3 months postpartum (ARR 0.61, p = 0.012); and 16% of women experienced a clinically meaningful increase in EDSS. Among 70 pregnancies with paired brain MRIs available, 53% had new T2 and/or Gd+ lesions postpartum compared with 32% prepregnancy (p < 0.001). Postpartum clinical relapses were associated with Gd+ lesions (p < 0.001). However, even for patients without postpartum relapses, surveillance brain MRIs revealed new T2 and/or Gd+ lesions in 31%. Protective effects of exclusive breastfeeding for ≥3 months (odds ratio = 0.3, 95% confidence interval 0.1–0.9) were observed for relapses.ConclusionsBuilding on previous reports of increased relapse rate in the first 3 months postpartum, we report a significant association between inflammation on MRI and this clinical activity. We also detected postpartum radiologic activity in the absence of relapses. Both clinical and radiologic reassessment may inform optimal treatment decision-making during the high-risk early postpartum period.
setts General Hospital, 2 MGH. RATIONALE: NRH has been correlated with increased morbidity and mortality in CVID patients. Liver biopsy is the gold standard for NRH diagnosis, however, ideal would be an earlier, noninvasive diagnostic technique. We hypothesized that FibroscanÒ (vibration controlled transient liver elastography) may facilitate the diagnosis of NRH in CVID patients. METHODS: Using a published MGH CVID cohort, we identified CVID patients with biopsy-confirmed NRH ('NRH'), elevated liver biochemistries without biopsy-confirmed NRH ('at risk for NRH'), and non-elevated liver biochemistries ('control'). Patients with chronic viral hepatitis, non-alcoholic steatohepatitis, chronic alcohol use, and/or primary biliary cirrhosis were excluded. We reviewed both clinical Fibroscans, from the electronic medical record, and research-based Fibroscans. Fibroscan-obtained liver stiffness measurements (LSM, kPa) were compared using a two-tailed Student's t-test. RESULTS: Within the MGH CVID cohort, 'control' patients (n53) had a median LSM of 4.9 kPa (range 4.1-5.8 kPa), 'NRH' patients (n54) had a median LSM of 11.2 kPa (range 7.0-26.1 kPa), and 'at risk for NRH' patients (n52) had a median LSM of 11.5 kPa (range 9.8-13.1 kPa). Compared to control CVID, LSMs were significantly elevated in CVID patients with known or suspected NRH (P 5 0.031). CONCLUSIONS: These preliminary data suggest the diagnostic utility of Fibroscan in CVID patients with known or suspected NRH. Elevated liver biochemistries and LSMs may prompt liver biopsy and immediate immunosuppressive intervention. Further studies will extend these findings to the full CVID cohort, correlate Fibroscan reads with NRH disease severity on biopsy, and increase monitoring of liver stiffness following immunosuppressive therapy.
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