Olaf Stuve by LeeHarland


									Reviewer's report

Title: Analysis of NAMCS data for Multiple Sclerosis, 1998-2004

Version: 1 Date: 3 January 2007

Reviewer: Olaf Stuve

Reviewer's report:


The authors of this article, “Analysis of NAMCS data for Multiple Sclerosis, 1998-2004”, performed
retrospective analyses on National Ambulatory Medical Survey (NAMCS) data for MS patient visits between
1998 and 2004. The results reveal the number of patient visits, and the usage of disease modifying
therapies, or immunomodulatory agents (IMSa).

Major Compulsory Revisions (that the author must respond to before a decision on publication can be

1. The main concern of this reviewer is the authors’ interpretation and conclusions of their data. Particularly,
that the use of IMAs in the management of multiple sclerosis (MS) should be improved, meaning increased.
The authors base their statement on the assumption that IMAs slow down disease progression. In reality,
the long-term efficacy of any of the currently approved medications is unknown. As the authors mention, MS
is a very heterogeneous disorder. It is currently impossible to predict, who will have a benign disease
course, and who will experience very rapid disease progression. In addition, it appears that there are
responders and non-responders for all agents currently used. Treatment response is currently ill-defined,
and ultimately the patient and the treating physician have to decide whether there is any detectable
treatment benefit. How many patients respond to which particular therapy is currently unknown. The number
may be relatively low, and it may be reflected in the data presented in this manuscript. In the absence of a
treatment response, it would be illogical to continue therapy. This reviewer feels strongly that the
Background section, discussion, and Limitation in our data analyses sections should not overemphasize the
importance of treating every patient with IMAs.
2. Background section: It is wrong that there have been four IMAs since 1990. Since 2004, there have been
six FDA-approved therapies available in the U.S. In 2003, there were five (mitoxantrone in addition to the
agents mentioned by the authors).
3. Background section: Second paragraph, first sentence: This sentence should be rephrased. It is true that
there are four different clinical phenotypes of MS. It is not necessarily true that the number of lesions has an
impact on the disease course.
4. Method section: This section should be shortened considerably. There is a website run by the CDC that
explains NAMCS. The authors should refer the reader to that website for details.
5. Method section: The number of patient visits should be shown in the Results section (see abstract).
6. The legend of Table 1 explains that the patient data was not analyzed with regard to ethnicity. However,
in the first paragraph, patient visits are stratified by Caucasian and African-American patients. This is a
contradiction. This reviewer believes that it would be important to show patient behavior by ethnic group.

Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author
can be trusted to correct)

Discretionary Revisions (which the author can choose to ignore)

Which journal?: Appropriate or potentially appropriate for BMC Medicine: an article of importance in its
What next?: Accept for publication in BMC Medicine after minor essential revisions

Quality of written English: Acceptable

Statistical review: No

Declaration of competing interests:

I have no competing interests.

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