| 作者：Allison Gandey | | 出處：WebMD醫學新聞 |
October 29, 2008 — 新研究顯示，病患原有的病症可能會造成新的神經症狀誤診；在10月29日神經學期刊線上報導中，研究者描述共病症如何延遲多發性硬化症(MS)的診斷，與如何增加診斷能力。
主要研究者、Manitoba大學的Ruth Ann Marrie醫師向Medscape Neurology & Neurosurgery表示，我們的研究認為醫師必須仔細考慮任何會增加的新的神經症狀，不要立刻認為症狀是因為現有的疾病引起。
研究者探究了8,983名北美多發性硬化症研究委員會的病患資料，其中超過2,300名病患在MS診斷後兩年內分類為輕微的、中度的或者嚴重失能。
研究者發現，有血管、自體免疫、肌肉骨骼、胃腸、視力或心智共病症者，需要一至十年才會診斷出MS，肥胖或抽菸患者也會延遲診斷。
研究者發現，中度與輕微失能者校正風險因素後，有血管共病症或肥胖者的診斷增加，嚴重與輕微失能者的風險相比，有肌肉骨骼或心智共病症者增加。
【MS因共病症影響中度或嚴重失能診斷之風險】 共病症 | 勝算比 | 95% CI | 血管 | 1.51 | 1.12 – 2.05 | 肥胖 | 1.38 | 1.02 – 1.87 | 肌肉骨骼 | 1.81 | 1.25 – 2.63 | 心智 | 1.62 | 1.23 – 2.14 |
Marrie醫師在訪問中表示，我們的發現引起諸多何以如此的疑問；有許多可能的解釋。她指出，醫師可能將MS症狀誤認為原有的病症，延長了發生症狀到確定診斷的時間，因而在診斷時已經發生失能。
作者寫道，當統計模式包括支持此觀念的診斷延遲時，有些觀察的關聯變薄弱，但是必須進一步研究。
另一個可能是，共病症會在病理生理上增加疾病惡化；舉例來說，血管狀況與增加週邊發炎有關，升高細胞激素與腦病變有關。另外，有兩個以上各自會引起類似缺損的共病症，會增加失能。
研究者認為這是相當重要的，他們發現診斷時較嚴重失能的病患，有共病症的病患會增加診斷時已經失能的機會，將需要用到更多的健康資源，對藥物的順服性也將有所不同，甚至對藥物的反應也不同，他們也可能有MS治療不足的風險。
Marrie醫師指出，此研究有諸多限制，包括樣本是自願參與登記的人，研究對象大多數為白人，無反應者之社會經濟地位較低；因此研究發現無法推論到一般族群。
研究者寫道，這些發現需要於族群基礎世代研究再現，後續研究需評估這些關聯的潛在機轉，確認如何治療有共病症的MS患者比較適當。
Ruth Ann Marrie醫師接受國家健康研究中心、國際財團多發性硬化症中心、Serono, Berlex, Sanofi-Aventis與BioMS Technology等支持研究。共同作者的宣告列於報告中。
Neurology。線上發表於2008年10月29日。
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Comorbidities Delay Multiple Sclerosis Diagnosis
By Allison Gandey
Medscape Medical News
October 29, 2008 — Patients with preexisting medical conditions are more likely to have new neurological symptoms misdiagnosed, a new study shows. Reporting online October 29 in Neurology, researchers outline how comorbidities may contribute to diagnostic delay in multiple sclerosis (MS) and increased disability at diagnosis.
"Our study suggests that clinicians should carefully consider any new neurological symptoms that may arise," lead investigator Ruth Ann Marrie, MD, from the University of Manitoba, in Winnipeg, told Medscape Neurology & Neurosurgery. "They shouldn't automatically assume that symptoms can be attributed to existing disease."
Investigators studied the records of 8983 patients from the North American Research Committee on Multiple Sclerosis Registry. More than 2300 of these patients were classified as having mild, moderate, or severe disability within 2 years of MS diagnosis.
Researchers found that it took 1 to 10 years longer for people who had vascular, autoimmune, musculoskeletal, gastrointestinal, visual, or mental comorbidities to be diagnosed with MS. There was also a diagnostic delay for patients who were obese or who smoked.
Investigators found the adjusted odds of moderate compared with mild disability at diagnosis increased in participants with vascular comorbidity or obesity. The odds of severe compared with mild disability increased with musculoskeletal or mental comorbidity.
Risk of Moderate or Severe Disability at MS Diagnosis by Comorbidity | Comorbidity | Odds Ratio | 95% CI | | Vascular | 1.51 | 1.12 – 2.05 | | Obesity | 1.38 | 1.02 – 1.87 | | Musculoskeletal | 1.81 | 1.25 – 2.63 | | Mental | 1.62 | 1.23 – 2.14 |
"Our findings raise many questions as to why this may occur," Dr. Marrie said in an interview. "And several possible explanations exist."
Clinicians could mistakenly attribute MS symptoms to a preexisting condition, increasing the time from symptom onset to diagnosis, and consequently disability at diagnosis, she noted.
"The attenuation of some of the observed associations when the statistical models included the diagnostic delay supports this idea, but this must be evaluated further," the authors write.
Another possibility is that comorbidities could act pathophysiologically to increase disease progression. Vascular conditions, for example, are associated with increased peripheral inflammation, and elevated cytokines have been linked to brain atrophy. Alternatively, having 2 or more comorbidities that independently cause similar impairments may increase disability.
"Our finding of more severe disability at diagnosis in persons with comorbidity could be important for several reasons," the researchers suggest. "Patients with comorbidity and increased disability at diagnosis might need or use more healthcare resources, might adhere differently to medication, or might respond differently to medication. They may also be at risk of undertreatment of their MS."
The study has several limitations, Dr. Marrie points out. The sample is composed of people who volunteered to participate in the registry. Participants were largely white, and nonresponders had lower socioeconomic status. The findings may not therefore be generalizable to other groups.
"These findings need to be replicated in population-based cohorts," the researchers write. "Future studies should evaluate the underlying mechanisms of these associations and determine how treatment of persons with MS and comorbidity can be optimized."
Dr. Ruth Ann Marrie received research support from the National Institutes of Health, the Consortium of Multiple Sclerosis Centers, Serono, Berlex, Sanofi-Aventis, and BioMS Technology. Disclosures for the coauthors are listed in the paper.
Neurology. Published online October 29, 2008.
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[ 本帖最後由 goodcat1111 於 2008-11-8 21:29 編輯 ] |
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