Validity of the design
The introduction cites quality evidence on the epidemiology, typical disease course, and challenges in diagnosing the secondary progressive phase of MS. The study critically reviews the methodological framework of the study, its analytical strength, and the implications of its findings in the overall context of MS studies. Shawky et al. (2024) developed science-backed research objectives and presented the key elements of the design early in the paper to create a sense of direction for the case-control study. The setting, participants, and variables are well-outlined systematically as recommended in the STROBE guideline for case-control studies (Ghaferi et al., 2021). The internal validity of the study was high due to the use of matched controls. The cases and the controls were matched for gender and age, thus enhancing the factors associated with the outcomes and reducing the risk of confounding in the associations between the exposures and outcomes.
Methodological Approach
The matched case-control design is appropriate for comparing exposure histories and clinical characteristics between patient groups: matching cases and controls on age and sex controls for potential confounding by these variables. The inclusion and exclusion criteria are explicitly defined. The sample size calculation indicates adequate statistical power.
Data collection relied extensively on medical records, which have limitations if documentation needs to be completed. Contacting patients and relatives helped mitigate the missing data. Standard neurological and disability assessments provided systematic clinical data, adding to the methodological rigour. MRI protocols and interpretation are not standardized, which could impact reliability.
Statistical analysis is adequately described, with statistical significance set at 0.05. Chi-square and t-tests are appropriate for categorical and continuous data. Multivariate regression examined the predictive value of timed walking and cognition scores (Shawky et al., 2024). Overall, the methods are reasonably rigorous and controlled for limitations that are typical of retrospective studies.
Study Results.
The SPMS cohort exhibited a slightly older mean age and higher BMI than RRMS controls. Though statistically significant due to the large sample size, a 1-2-year age difference and a 3-unit BMI difference may lack clinical significance. Shawky et al. (2024) did not contextualize whether these marginal discrepancies impart meaningful biological effects that cumulatively impact MS progression. Further explanation of noteworthy effect sizes would aid in determining the relevance of minor statistically significant differences.
This case-control study has a relatively large sample size. Shawky et al. (2024) used a sample size of 300 patients. For an observational study, such a sample size can be leveraged to generate reliable results (Skrivankova et al., 2021). Considering that MS is a rare disease, the sample size of 300 patients is large. However, the predictors identified in the research may be relevant to MS patients included in the sample. The results may be used for further studies on patients of other demographics due to the low generalizability of the results.
Reliability of the Findings
By contextualizing results within prior literature, the researchers enhance the credibility of concordant findings like the predictive value of smoking, vitamin D deficiency, and lesion localization. Cited studies affirm these as likely genuine predictive factors. However, the authors do not critically examine inconsistent MRI results compared to some past studies. Alternative explanations for associations warrant further exploration; disability may increase unemployment in SPMS groups. Retrospective data limits determining causal relationships fully. An additional balanced discussion of discrepant results could strengthen interpretive rigour. While unemployment may theoretically accelerate progression through psychosocial mechanisms, temporality is impossible to establish in retrospective analyses (Shawky et al., 2024). Discussion of the potential bidirectionality would significantly strengthen interpretive quality.
Limitations and Critique
As is typical of retrospective studies, this design cannot establish causality or temporality between predictors and SPMS development. Documentation inconsistencies may create information biases. While matching and statistical controls help account for confounders, residual confounding from additional variables may persist. Cohort heterogeneity and a modest sample size could impact generalizability. Stricter eligibility criteria and enrollment procedures may have minimized these issues. Additionally, implementing standardized MRI protocols, clinical measurements, and time points could improve accuracy and quality.
Moreover, selection bias was apparent in the study. Recruitment of participants from a specific MS cohort may have increased selection bias. Purposive sampling commonly reduces the representativeness of a sample, thus limiting generalizability (Skrivankova et al., 2021). Thus, the findings can only be generalized to the patients in the cohort from which the sample was selected.
Implications and Future Research
The exploratory evidence could help Egyptian neurologists identify higher-risk MS patients needing more aggressive treatment before irreversible progression. Counselling on smoking and vitamin deficiencies is also warranted. Methodologically rigorous prospective studies should evaluate whether lifestyle modifications and early therapy based on prognostic indicators delay disability. The cost-effectiveness of serial MRI screenings and their optimal sequences for SPMS prediction requires study. Besides validating findings in enlarged samples, future research might incorporate multivariate models combining clinical and imaging predictors to enhance predictive accuracy.
Conclusion
This retrospective matched case-control study provided exploratory data on possible predictor factors of secondary progressive multiple sclerosis progression among the Egyptian patients at the end. As findings may one-day help guide prognostic screening and early intervention, the observational design cannot indicate causality. In the meantime, prospective studies validating results in larger and more diverse samples are needed before clinical use—simple subject choice.
References
Ghaferi, A. A., Schwartz, T. A., & Pawlik, T. M. (2021). STROBE reporting guidelines for observational studies. JAMA surgery, 156(6), 577-578.
Ghazaiean, M., Darvishi-Khezri, H., & Baghbanian, S. M. (2023). Relationship between medical history and multiple sclerosis: A case-control study. Medicine, 102(23).
Shawky, M. A., Menecie, T. I., Saif El Deen, E. M., & Rashad, M. H. (2024). Predictors of progression of multiple sclerosis in a sample of Egyptian patients. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery, 60(1), 1.
Skrivankova, V. W., Richmond, R. C., Woolf, B. A., Davies, N. M., Swanson, S. A., VanderWeele, T. J., … & Richards, J. B. (2021). Strengthening the reporting of observational studies in epidemiology using Mendelian randomization (STROBE-MR): explanation and elaboration. BMJ, 375.
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