http://www.aan.com/professionals/

March 29-April 5, 2003
Honolulu

Campath-1H Treatment of Multiple Sclerosis

Alasdair Coles, Amanda Cox, Emmanuelle Le Page, Cambridge, United Kingdom, David Miller, London, United Kingdom, Geoff Hale, Herman Waldmann, Oxford, United Kingdom, Alastair Compston, Cambridge, United Kingdom

Objective:

To compare the efficacy of Campath-1H in the treatment of secondary progressive and relapsing-remitting multiple sclerosis.

Background:

Campath-1H is a humanised monoclonal antibody that depletes T cells. We previously reported that, in secondary progressive multiple sclerosis (SPMS), it powerfully suppresses inflammatory activity, but does not influence the mechanisms underlying established progression, axonal degeneration and cerebral atrophy. We hypothesise that Campath-1H treatment much earlier in the course of multiple sclerosis may prevent axonal degeneration and hence the onset of progression. This is the rationale for an imminent European-US trial of Campath-1H. Here we review our open-label experience of Campath-1H treatment of aggressive multiple sclerosis.

Design/Methods:

58 people with MS have received Campath-1H since 1991 (36 SPMS and 22 RRMS). RRMS patients were mostly treatment-nave, had less than 5 years of disease, and had experienced at least 3 relapses in the previous year. They were evaluated clinically every 3-6 months. Lymphocyte sub-populations and TRECs were assessed.

Results:

When treated, SPMS patients had means of 12 and 4 years since onset of disease and progression respectively. Their relapse rate remained suppressed during a mean of 7 years of follow-up but their disability continued to progress. There were no significant infective adverse effects, but 1/3 of patients developed Graves disease. Laboratory Studies. Campath-1H caused a profound initial T cell depletion. Increased thymic activity led to increased regulatory T cell numbers and recovery of CD8+ counts at 30 months and CD4+ numbers at 60 months. Restored T cells showed a reduction in mitogenic proliferation and IFN secretion. At treatment, RRMS patients had mean disease duration of 2.7 years. In the year before treatment, their mean relapse rate was 3/yr and their EDSS increased by 2.4 points. After treatment, relapse rate in the first year was 0.1/yr; in subsequent follow-up (mean 13 months, range 1-69 months) only one patient has relapsed. Their mean EDSS is now 0.5 points less disabled than before treatment.

Conclusions:

Campath-1H has greater efficacy when given during the early phase of multiple sclerosis, when clinical disease activity is attributable to inflammation. The critical therapeutic issue is whether this will slow or prevent axonal degneration and sustained accumulation of disability. This is being tested in a multi-centre European-US randomised trial comparing Campath-1H with Rebif 44mcg over three years in patients with relapsing-remitting multiple sclerosis of less than 3 years duration and EDSS less than 3.5.

Supported By:

Wellcome Trust, Multiple Sclerosis Society (UK), Ilex Oncology (San Antonio)

Category - MS and Related Diseases

SubCategory - Therapeutics 

PPAR Agonists as Therapy for Autoimmune Demyelination

Michael K. Racke, Rehana Z. Hussain, Sara Northrup, Asim Diab, Amy E. Lovett-Racke, Dallas, TX

Objective:

The main objective of this study was to determine whether peroxisome proliferator-activated receptor (PPAR)- agonists such as gemfibrozil would be effective in treating mice with experimental autoimmune encephalomyelitis (EAE), an animal model for the human disease multiple sclerosis (MS).

Background:

PPAR are members of a nuclear hormone receptor superfamily that includes receptors for steroids, retinoids, and thyroid hormone, all of which have been known to affect the immune response. Recent work by our group has shown that administration of the PPAR ligand 15-deoxy-12,14 prostaglandin J2 was effective in ameliorating the signs of EAE (J. Immunol. 168: 2508). Because PPAR agonists such as gemfibrozil are commonly used to treat human disorders such as hypertriglyceridemia, they would be attractive candidates to treat diseases such as multiple sclerosis.

Design/Methods:

Myelin basic protein (MBP) Ac1-11-specific TCR transgenic T cells activated in the presence of PPAR agonists gemfibrozil and ciprofibrate were examined for proliferative responses, cytokine production (measured by ELISA), and ability to transfer EAE. Wild type B10.PL and IL-4 deficient mice were induced to develop EAE by immunization with MBPAc1-11/CFA and fed PPAR agonists. Inflammation was evaluated by immunohistochemistry.

Results:

MBP-specific TCR transgenic T cells activated in the presence of antigen and PPAR agonists demonstrated a dose-dependent increase in the Th2 cytokines IL-4 and IL-10. Interestingly, IFN secretion was minimally affected. Oral administration of gemfibrozil ameliorated signs of EAE when fed starting at time of immunization and continued for 21 days. Administration of gemfibrozil was less effective in treating mice deficient in the ability to make IL-4, suggesting that IL-4 production may be important for the PPAR agonists therapeutic effect. Inflammation in the central nervous sytem was dramatically reduced in mice treated with PPAR agonist (gemfibrozil).

Conclusions:

PPAR agonists are able to alter cytokine secretion patterns of encephalitogenic T cells and reduce the clinical and histopathologic signs of EAE. These results suggest that PPAR agonists such as gemfibrozil and ciprofibrate may be novel therapeutic agents for diseases such as multiple sclerosis. In addition, our data would indicate that they exert their therapeutic effect by inducing immune deviation in the encephalitogenic T cell population. Because these agents have a long history in the treatment of human disorders as oral agents, they are attractive candidates as adjunctive therapy in suspected autoimmune diseases such as multiple sclerosis.

Supported By:

Supported by NIH and NMSS.

Category - MS and Related Diseases

SubCategory - MS: Animal Models 

Quantitative Evaluation of the Reaction of Coworkers to the Disclosure of Epilepsy

Cynthia L. Harden, Blagovest G. Nikolov, Susanne M. Vera, New York, NY

Objective:

The objective of this study is to evaluate the emotional reactions of persons in a workplace environment to finding out that a coworker has epilepsy, although a seizure has not occurred.

Background:

Employment is a primary concern to most adult Americans. Persons with epilepsy have higher rates of unemployment and underemployment, both in terms of hours worked and relative to job skills, compared to the general population. Persons with epilepsy often cite stigmatization of epilepsy as a cause for this. We sought to document and quantify the stigma of epilepsy in the workplace by surveying workers in several New York City companies regarding their reactions to coworkers with neurologic and psychiatric illnesses.

Design/Methods:

We distributed a 31 question survey entitled Perceptions of Medical Conditions in the Workplace to employees in divisions of the Catholic Guild for the Blind and the telecommunications division of the Group Health Insurance Company. Three vignettes were presented in the survey, describing new employees who eventually revealed that they had either depression, multiple sclerosis or epilepsy. The only vignette in which the subject had a visible manifestation of the illness was multiple sclerosis (walks slowly with a cane). Emotional reactions to the subject of each vignette including anxiety, worry, and comfort level providing first aid, and comfort level during routine job activities were assessed by a 3 to 4 degree scale.

Results:

Seventy-four surveys out of two hundred were returned (37% response). Respondents ranged in age from 19 to 67 years (median 43). Varying job levels were present in the sample (hourly, salaried, upper management). Fifteen percent of respondents reported much more anxiety at the idea of interacting with the person with epilepsy, compared to 11% with depression and 5.4% with MS. Twenty percent of respondents reported that they were very worried that the person with epilepsy would have sudden, unpredictable behavior, compared to 11% for depression and 5.4% for MS. Only 30% were very comfortable providing first aid for the person with epilepsy, compared to 50% for depression and MS. Level of comfort during routine job interactions was not different between illnesses, but for after-hours activities, 45% were very comfortable with the MS subject, compared to only 38% for depression and epilepsy. Social discomfort with all illnesses was significantly greater for persons at lower job levels than higher job levels, using bivariate correlations and chi-square analyses.

Conclusions:

1) Epilepsy, even when it is invisible, produces more anxiety and worry among coworkers.

2) Social discomfort will these three illnesses is greater at lower compared to higher job levels.

3) The idea of providing first aid for a person with epilepsy produces more discomfort than do depression or multiple sclerosis.

4) Epilepsy and depression may produce a greater degree of social discomfort than multiple sclerosis.

Supported By:

NA

Category - Epilepsy

SubCategory - Other 

Comparison of the Clinical Characteristics of African American and Caucasian American Multiple Sclerosis Patients

Bruce C. Cree, Jorge R. Oksenberg, Lisa F. Barcellos, San Francisco, CA, Omar A. Khan, Detroit, MI, Douglas S. Goodin, Amy Swerdlin, Robin Lincoln, Albert Seligman, San Francisco, CA, Michelle Mass, Dennis N. Bourdette, Portland, OR, Margaret A. Pericak-Vance, Durham, NC, Jonathan L. Haines, Nashville, TN, Stephan L. Hauser, San Francisco, CA, the Multiple Sclerosis Genetics Group (MSGG)

Objective:

This is a retrospective cohort study comparing the clinical characteristics of African American (AA) to Caucasian American (CA) patients with Multiple Sclerosis (MS).

Background:

AA patients are thought to develop MS less frequently than CA patients. However, on the basis of several case series it was suggested that the disease course in AA patients might be more severe.

Design/Methods:

We compared the clinical characteristics of AA (N=207) and CA (N=314) simplex patients with clinically definite MS participating in the MSGG for whom comprehensive clinical data was available.

Results:

Preliminary interim analysis revealed the following findings. The proportion of women was the same in AA and CA patients (83% VS 78%, p=0.157). There was no difference in the proportions of patients with relapsing remitting, secondary progressive, primary progressive, and relapsing progressive MS between AA and CA patients. The diagnosis of MS occurred 2.9 years after symptom onset in AA patients whereas in CA patients diagnosis occurred 4.0 years after symptom onset (Mann-Whitney rank sum, p=0.06). The age of onset was approximately two years later in AA than CA patients (34.0 VS 31.8 years, p=0.0046). Opticospinal MS occurred in 24% of AA patients compared to 5% of CA patients (Chi square, p0.0001). AA patients had a 1.73 fold greater risk for progression to EDSS=6.0 in comparison to CA patients, after adjusting for gender, age of onset, disease phenotype, and time to diagnosis from disease onset (Cox proportional hazards model, p=0.002). AA patients had a 1.74 fold greater risk for progression to EDSS=7.0 in comparison to CA patients, in the adjusted model (p=0.074). AA patients had a 2.32 fold greater risk for developing secondary progressive multiple sclerosis in comparison to CA patients, in the adjusted model (p=0.001). In addition, preliminary analysis of the HLA class I and class II polymorphisms confirmed the well documented association of the HLA DR2 haplotype with MS in both AA and CA patients.

Conclusions:

AA patients appear to have a more aggressive disease course than CA patients and are at higher risk for developing disability and secondary progressive MS, and presenting with opticospinal MS. Extension of these preliminary results to a confirmatory dataset and analysis of genotype-phenotype correlations are in progress.

Category - MS and Related Diseases

SubCategory - Epidemiology 

High Dose High Frequency Betaferon Treatment Is Effective in Early Stage Relapsing Remitting Multiple Sclerosis

Barry G. W. Arnason, Chicago, IL, the IFNB Multiple Sclerosis Study Group and the UBC MS/MRI Analysis Group

Objective:

To evaluate the efficacy of interferon beta-1b (Betaferon/Betaseron) in early or mild relapsing remitting (RRMS) by post-hoc subgroup analysis of the pivotal trial patient cohort.

Background:

Interferon beta-1b is an effective treatment for RR and early secondary progressive MS. However, the efficacy of high dose, high frequency interferon beta therapy in patients with low levels of disability or early stage RRMS has yet to be fully explored.

Design/Methods:

To investigate this, we performed a post-hoc subgroup analysis of the data from the original pivotal trial of interferon beta-1b (50 and 250 g) versus placebo in RRMS. Two subgroups were analysed, one with low levels of disability (EDSS score 2) the other with disease duration of 2 years.

Results:

In patients with low levels of disability [placebo 43, low-dose 49, high-dose 41], high dose interferon beta-1b produced significant reductions in mean relapse rate versus placebo (1.0 vs 1.5, p=0.013) and a significant decrease in MRI disease activity as measured by the mean percentage change in lesion area at 2 years (20.1% vs 54.1%, p=0.0001). There were also dose dependent trends for the median time to first relapse (370 vs 146 days) and the proportion of patients remaining relapse free (31.7% versus 14.0%) although neither was significant.

In patients with disease duration of 2 years [placebo 48, low-dose 48, high-dose 38], high dose interferon beta-1b treatment significantly reduced MRI disease activity, compared with placebo, as assessed by mean percentage change in lesion area (9% vs 52.5%, p=0.0001). There were also dose dependent trends in the proportion of patients remaining relapse free, median time to first relapse and mean relapse rate, although none of these achieved significance.

Conclusions:

The data indicate that 250 mcg interferon beta-1b administered every other day is effective in patients with either early stage RR-MS or little physical impairment, reinforcing the rationale for early high dose, high frequency treatment intervention.

Supported By:

Berlex Inc., Montvale, N.J.

Category - MS and Related Diseases

SubCategory - Clinical Trials 

A Randomized Study of Low Fat Diet with -3 Fatty Acid Supplementation in Patients with Relapsing-Remitting Multiple Sclerosis

Bianca Weinstock-Guttman, Buffalo, NY, Monika Baier, Denver, CO, Joan Feichter, Eileen Gallagher, Jaya Vekatraman, Kulwara Meksawan, Park Youngmin, Buffalo, NY, Richard Rudick, Cleveland, OH

Objective:

To determine the impact of a low fat diet supplemented with -3 long chain polyunsaturated fatty acids (PUFA) in addition to standard disease modifying therapy on the quality of life, neurological status and immunological parameters in patients with RRMS.

Background:

There is an increasing body of evidence suggesting interactions between the immune system and dietary manipulation. Derivatives of -3 PUFA represent potent regulatory molecules in cell function. The benefits of dietary intervention in MS in addition to disease modifying therapies have not been rigorously studied.

Design/Methods:

Patients with RRMS were randomized into a 1-year controlled study comparing two dietary interventions: Group 1 received a very low fat diet (below 15%) with supplemental -3 PUFA (6 fish oil capsules daily) and Group 2 received the AHA Step I diet (fat not exceeding 30%) with 6 olive oil capsules. Patients were on interferon or glatiramer acetate for at least 2 months before entering the study. The Physical Components from the Short Form Health Survey was the primary outcome supplemented by the Modified Fatigue Impact Scale and the Mental Health Inventory. Secondary outcome measures were the EDSS and relapse rate. Multiple immunological parameters were evaluated including ICAM, VCAM, RANTES, IL-1, IL-8, IL-4, IL-12, and IFN every 3 months.

Results:

Thirty-two patients were enrolled in this study but only 29 continued the study for at least 3 months. There were no significant baseline demographic differences between the 2 groups. Mean follow up was 9.8 months (SD=7.4), 14 patients had completed 1yr at time of analysis. There was a significant decrease in number of attacks only in Group1 with a mean difference of -0.86 (SD= 1.03) (p=0.0081), compared to 1 yr prior to the study. A significant impact of diet on EDSS was observed at 12 months (p= 0.043) with a decrease in EDSS of 0.4 in Group 1 but a worsening of 0.5 in Group 2. HDL remained stable or increased in Group1, while the Group 2 showed a mild decrease (p=0.0196). A significant correlation was observed between the calories at baseline and last visit and the change in EDSS only in the Group 1(p=0.0038 and p=0.0234 respectively). A significant decrease from baseline to last visit was observed for ICAM (p=0.0105) and for RANTES (p=0.0203) in the Group 1, while in the Group 2 only the ICAM levels reached significance (p=0.007). No significant changes over time or in between the groups were seen in different cytokine levels including IL-1, IL-4, IL-8, IL-12 as well as IFN .

Conclusions:

Our data suggests that the very low fat diet with supplemental -3 PUFA was well tolerated, and may have a beneficial additive effect to the standard therapy for multiple sclerosis.

Supported By:

National Multiple Sclerosis Society

Category - MS and Related Diseases

SubCategory - Clinical Trials 

Multi-Microinfarct Dementia: A Common Type of Vascular Dementia in the Honolulu-Asia Aging Study

Lon White, Helen Petrovitch, John Hardman, Honolulu, HI, Daron G. Davis, Lexington, KY, James Nelson, G. Webster Ross, Kamal Masaki, Honolulu, HI, Lenore Launer, Bethesda, MD, William R. Markesbery, Lexington, KY

Objective:

To identify the lesions most essentially related to vascular dementia in autopsied men in the Honolulu-Asia Aging Study.

Background:

Vascular dementia (VaD) has been attributed to one or a combination of several pathogenically distinct abnormalities, including multiple infarcts. While most cases are diagnosed on the basis of stepwise cognitive decline with clinical diagnoses of stroke or imaging evidence of multiple large or lacunar infarcts, there is no clear explanation for the occurrence of dementia in some persons with strokes, but not in others.

Design/Methods:

Information from brain autopsy, together with cognitive test scores and dementia evaluation data from examinations in the months or years prior to death were available for 290 decedent participants in the Honolulu-Asia Aging Study (HAAS). Large and lacunar infarcts were identified by gross examination of coronal sections of the cerebrum. Microinfarcts were identified in standard histologic sections of the cortex, basal ganglia, and thalamus. Diagnoses of dementia employed DSMIIIR criteria. The term definite cognitive impairment was used to designate subjects who died without a complete dementia evaluation, but whose cognitive test scores suggested dementia.

Results:

Among the 290 decedents, 76 were found to have non-vascular lesions to which dementia could be attributed, i.e., cortical Lewy bodies (n=30) hippocampal sclerosis (n=14), or high levels of neocortical neuritic plaques and/or tangles (n=32). Among the 76 decedents with non-vascular lesions, 78% had been demented or definitely impaired. The role of vascular lesions was examined among the 214 subjects without such non-vascular abnormalities. Although cerebral microinfarcts, lacunes, and large vessel infarcts were mutually associated (Spearman r=0.3-0.4), logistic and sequential linear multivariate analyses indicated microinfarcts to be most strongly and independently associated with cognitive impairment or dementia (p.005). Among 38 decedents with multiple microinfarcts in the neocortex and/or basal ganglia/thalamus, 21 (55%) had been demented or definitely impaired. Among decedents with 0 or only one microinfarct (n=163), there was no statistically significant association between the total number of lacunes or large infarcts and the last cognitive test score. In a different subset of decedents with no lacunes (n=121), 14% of the variance in the final cognitive test score was explained by the total number of microinfarcts counted (p.0001).

Conclusions:

Multiple cerebral microinfarcts appear to be the principal type of cerebrovascular lesion associated with dementia in this panel of decedent older Japanese-American men.

Supported By:

National Institutes of Health, National Institute on Aging (Grant N01-AG-4-2149, LRW; RO1 AG17155-03, LRW) and the U.S. Department of the Army (Grant DAMD 17-98-1-8621, GWR).

Category - Cerebrovascular Disease

SubCategory - Epidemiology 

Brain SPECT Is Abnormal in Multiple Sclerosis Patients with a Normal Brain MRI

Bianca Weinstock-Guttman, Michael Meyer, Robert Militech, Joan Feichter, Jitendra Sharma, Buffalo, NY, Monika Baier, Denver, CO, Frederick Munschauer, Rohit Bakshi, Buffalo, NY

Objective:

To determine if brain perfusion SPECT can detect abnormalities in patients with multiple sclerosis (MS), neuromyelitis optica (NMO) or isolated transverse myelitis (ITM) with essentially normal conventional brain MRI.

Background:

Although MRI detects white matter lesions of multiple sclerosis (MS) within the brain with high sensitivity a minority of patients have normal brain MRI scans. The diagnostic confirmation in these patients may be difficult requiring multiple repeated tests. Previous Neurolite-SPECT studies in MS patients showed frontal gray matter hypoperfusion that was significantly correlated with neurological and cognitive disability while FDG-PET showed widespread hypometabolism.

Design/Methods:

This is a retrospective evaluation of Neurolite (99mTc-Bicisate,ethyl cysteinate dimmer) SPECT performed in patients with spinal MS, NMO and ITM. The test was performed most often because of a diagnostic dilemma or because of complaints of memory problems or concentration difficulties. All the test reports were initially read by one experienced observer. An independent blind reader reevaluated the SPECT scans confirming the findings. The hypoperfusion abnormalities were rated mild to severe and ordinally rated on a scale from 0-5. All patients had a neurological evaluation (EDSS scoring), brain and spinal MRI within 2 months of SPECT testing.

Results:

Fifteen patients, (11F and 4 M), with spinal cord demyelinating disease were evaluated with Neurolite SPECT. The diagnosis included MS (N=8; 5 RR, 3 PP), NMO (N=3) and ITM (N=4). The mean age was 48.1 (SD. 9.83), disease duration 5.26 (SD 6.09) and the disability EDSS score 3.58 (SD 1.96). All patients had a myelopathy (clinically and by MRI) but a normal brain MRI. SPECT studies were abnormal in all patients including patchy, widespread, heterogeneous hypoperfusion of the cortex and white matter most marked in the frontal, occipital and parietal areas. The thalamus and cerebellum were also frequent affected. Significant correlation was found between EDSS, and hypoperfusion severity (r=0.68 p=0.0053). However, no clear differences were seen on SPECT abnormalities between ITM and MS (after correction for disease duration) while NMO patients had constantly abnormal occipital perfusion with or without abnormal visual evoked potentials.

Conclusions:

The abnormal brain hypoperfusion shown by Neurolite SPECT in our group of patients is suggestive of a more global widespread involvement of the brain than indicated by standard brain MRI. Defining an abnormal hypoperfusion pattern in the brain of MS patients in the absence of lesions in the routine MRI may increase diagnostic sensitivity and eventual develop a helpful prognostic tool for monitoring disease progression

Category - MS and Related Diseases

SubCategory - Imaging 

Brain Lesion Burden or Atrophy: Which MRI Measure Best Predicts Cognitive Impairment in Multiple Sclerosis?

Ralph H. B. Benedict, Bianca Weinstock-Guttman, Inna Fishman, Jin M. Kuwata, Jitendra Sharma, Chris W. Tjoa, Rohit Bakshi, Buffalo, NY

Objective:

Determine whether conventional measures of lesion burden and/or atrophy account for significant variance in predicting neuropsychological competence in MS patients.

Background:

The correlation between cognitive impairment and brain MRI abnormalities in multiple sclerosis is well established. It is not clear, however, whether lesion burden or atrophy accounts for more variance in MS associated cognitive impairment. These indices have been directly compared in only a few studies, and no such study has included measurement of the third ventricle, a simple measure that was strongly predictive of neuropsychological competence in the early literature.

Design/Methods:

We studied 37 MS patients (mean disease duration = 11.2+/-8.0 years, median EDSS = 2.5) and 28 controls matched on demographic variables. Correlations between neuropsychological tests and the following MRI indices were considered: Hypointense T1 lesion volume, hyperintense FLAIR lesion volume, third ventricle width [TVW], bicaudate ratio, and brain parenchymal fraction [BPF]. Regression models predicting neuropsychological testing were calculated while controlling for age, premorbid IQ, and depression. Only those tests discriminating MS patients from controls were considered.

Results:

MS patients were impaired on a range of NP tests emphasizing spatial perception (Judgement of Line Orientation [JLO] p .001), verbal learning (CVLT-II trials 1-5 p .001), verbal memory (CVLT-II delayed recall p .01), visual learning (BVMT-R trials 1-3 p .001), visual memory (BVMT-R delayed recall p .001), divided attention (Paced Auditory Serial Addition Test [PASAT] p .01), and processing speed (Symbol Digit Modalities Test [SDMT] p .001). MRI measures predicted all NP tests except JLO and BVMT-R Learning. After age and premorbid intelligence were entered in each model, TVW entered, accounting for variance in CVLT-II Learning (partial r = -.45), CVLT-II Delayed Recall (partial r = -.45), BVMT-R Delayed Recall (partial r = -.47), PASAT (partial r = -.57), and SDMT (partial r = -.71). Almost identical results were obtained when the depression scale was added to the analysis. TVW accounted for considerable variance in SDMT performance (multiple R2 = .57). When TVW was removed from consideration, BPF was the most powerful predictor of neuropsychological competence.

Conclusions:

Atrophy accounts for more variance than lesion burden in predicting MS cognitive performance, and central atrophy in particular is strongly associated with neuropsychological morbidity. This finding may be explained by atrophy of the thalamus, a deep gray matter structure that mediates cognitive function via multiple pathways to and from the cortex.

Supported By:

National Institutes of Health (NIH-NINDS) 1 K23 NS02210-01 (R. Bakshi) and unrestricted educational grant from Biogen, Inc and Consortium of MS Centers

Category - MS and Related Diseases

SubCategory - Imaging 

Clonotypic Evolution and Contraction of CD8+ T Cells during the Course of Multiple Sclerosis

Dun Zhou, Sabine Cepok, Friederike Vogel, Virpi Shiratori, Verena Grummel, Steffi Jaeckel, Siegfried Bien, Wolfgang H. Oertel, Norbert Sommer, Bernhard Hemmer, Marburg, Germany

Objective:

T cells are essentially involved in the pathogenesis of multiple sclerosis (MS) although it has not been possible to link a defined T cell population to disease activity. To identify and characterize disease relevant T cells in MS it is necessary to find evidence for a link between expansion and activation of a defined T cell population and clinical disease activity.

Background:

MS is a chronic inflammatory disease of the central nervous system (CNS) leading to demyelination and axonal damage. Histopathological studies demonstrate that acute MS lesions are characterized by activation of microglia, infiltration of T cells, B cells, and macrophages. B cells in brain and cerebrospinal fluid (CSF) of MS patients show clonal expansion and signs of antigen maturation of their B cell receptors. Similarly, the spectrum of CNS infiltrating T cells is restricted. Others and ourselves previously demonstrated clonal accumulation of CD8+ T cells in lesions and CSF of MS patients. While antigens derived from brain proteins or neurotropic microbes are among the candidates, the specificity of this highly focused local immune response is as yet unknown.

Design/Methods:

Here, we investigated alterations of the T-cell repertoire during the manifestation of multiple sclerosis. In order to identify and track disease relevant T cells during the disease course, we followed a two-step approach. First, we identified clonotypic T cells in the CSF compartment of MS patients with recent onset disease. Second, using flow cytometry for T cell receptor b chain (TCRBV) expression and clonotypic quantitative rtPCR, we monitored and characterized those cells in the peripheral blood of MS patients during the first years of disease.

Results:

In blood and cerebrospinal fluid, we observed significant repertoire changes for CD8+ but not CD4+ T cells. These changes were caused by clonotypic CD8+ T cells, which strongly expanded in the blood in relation to clinical relapses. During the expansion phase, these cells transiently changed their phenotype with upregulation of HLA-DR and LFA-1 and downregulation of CD28. Following clinical remission, the CD8+ T cell clonotypes contracted in the peripheral blood but persisted in the cerebrospinal fluid.

Conclusions:

Overall, our results imply an important role of CD8+ T cells in the pathogenesis providing a novel target for immune intervention strategies in multiple sclerosis.

Supported By:

Deutsche Forschungsgemeinschaft

Category - MS and Related Diseases

SubCategory - Clinical Immunology 

Further Support for the Analgesic Role of Lamotrigine in Neuropathic Pain

Miroslav M. Backonja, Madison, WI, Marilyn R. Semenchuk, Tucson, AZ

Objective:

To assess the analgesic effectiveness of lamotrigine in previously untreated as well as treated, poorly responsive chronic neuropathic pain patients.

Background:

Lamotrigine is a broad spectrum anticonvulsant marketed in the US since 1994 as adjunctive and first-line treatment for various seizure disorders. Although not currently indicated for treatment of pain, there is a large body of literature suggesting effectiveness in many pain conditions including diabetic neuropathy, neuropathy associated with human immunodeficiency virus as well as multiple sclerosis, trigeminal neuralgia, postherpetic neuralgia, neuralgiform headache, central pain and post-operative analgesia. Pain states associated with injury or disease affecting the peripheral or central nervous system remain among the most difficult to treat of the chronic pain syndromes. Treatment typically consists of sequential drug trials sometimes with limited success. Identification of patients who are more likely to respond to one treatment versus another would be extremely beneficial.

Design/Methods:

A retrospective chart review was conducted of 23 neuropathic pain patients who were treated with lamotrigine either first-line or following unsuccessful trials of other adjuvant analgesics. Diagnoses included peripheral neuropathy, post-stroke neuropathy, complex regional pain syndrome, trigeminal neuralgia, polyneuropathy, radiculopathy, neuropathy associated with multiple sclerosis among others. Patients were started on lamotrigine 25 mg/day and titrated upward on a weekly basis according to response and tolerability. Maximum dose was 400 mg/day. Analgesic effectiveness was assessed by change in pain score on a 0-10 numerical pain scale with 0 indicating no pain and 10 pain as bad as you can imagine.

Results:

There were 12 males and 11 females with an average age of 49.8 years (range 20-84 years). Four patients had never been treated while the remaining 19 patients had tried multiple agents including amitriptyline, nortriptyline, gabapentin, zonisamide, topiramate, opioids, and lidoderm with poor success. Following lamotrigine treatment, approximately half (48%) of the patients responded. Before and after pain scores were available for 19/23 patients. Average pain score in the responders prior to lamotrigine treatment was 7.1; following treatment average pain score decreased to 4.6. Although titration of the dose is currently ongoing in 9 patients the average maintenance dose for responders was approximately 250 mg/day. Benefit was noted in some patients at doses as low as 50 mg/day. Both previously untreated (2/4) as well as treatment refractory patients (9/19) responded. Nine patients discontinued lamotrigine treatment: 3 due to no change in their pain, 1 reason unknown and 5 due to mild/moderate side effects including headache, GI upset, dizziness, sedation, decreased appetite.

Conclusions:

Lamotrigine was found to be an effective agent for both previously untreated as well as treatment refractory neuropathic pain patients. Additional studies are needed to further characterize responders from nonresponders.

Supported By:

GlaxoSmithKline

Category - Headache and Pain

SubCategory - Therapeutics 

Treatment of Relapsing Remitting Interferon / Glatiramer Acetate Unresponsive Patients with Pulse Cyclophosphamide

Susan A. Gauthier, Padmanabhan Bharanidharan, Lynn Stazzone, Derek R. Smith, David M. Dawson, David A. Hafler, Samia J. Khoury, Howard L. Weiner, Boston, MA

Objective:

To investigate the effect of pulse cyclophosphamide (CTX) in relapsing remitting MS patients with continued disease activity.

Background:

Treatment of relapsing forms of multiple sclerosis (MS) with interferon (IFN) or glatiramer acetate (GA) is only partially effective in many patients. A major issue confronting MS therapy relates to rescue therapy in this category of patients. Cyclophosphamide has been used in worsening MS and factors associated with a response to therapy include rapidly progressive course, gadolinium positive lesions on MRI, relapses in the year prior to therapy, younger age and less than 2 years in the progressive phase. Thus we have employed pulse CTX in relapsing-remitting patients not responding to injectable therapy (IFN/GA).

Design/Methods:

47 consecutive patients, followed at our MS Center, were analyzed for charateristics associated with the use of rescue therapy. The study was retrolective, i.e. a retrospective review of prospectively collected data. All patients (21 men, 26 women) were evaluated initially and at 6 month intervals. Multiple parameters were collected including EDSS and MRI.

Results:

Patients were begun on rescue therapy with CTX plus IV methylprednisolone [CTX/MP] because of clinical progression (EDSS) [n=21] or changes on MRI [n=24] or a combination of both. Patients begun on CTX/MP had an average EDSS of 3.2 and a disease duration of 6.53 years. 80% were being treated with interferon-beta and 20% with GA. Prior to initiation of CTX/MP, patients had worsened from an EDSS of 2.23 to an EDSS of 3.2 (p0.0001). Patients had received multiple courses of IV steroids prior to initiation of CTX/MP therapy and were taken off their injectable therapy at the time CTX/MP was begun. Following initiation of pulse therapy, the EDSS stabilized at an average level of 3.28 at 6 months to 3 years on therapy. Of the patients treated, 34% improved, 44% stabilized and 12% worsened while on CTX/MP. MRI was performed on 27 patients prior to and following therapy. 51% had enhancing lesions or new T2 lesions prior to CTX/MP therapy. Following therapy there was a marked reduction in disease as measured by MRI in 75% of patients treated (72% with no new or enhancing lesions, 28% with a decrease in enhancing lesions). CTX/MP treatment was well tolerated with minimal side effects.

Conclusions:

Pulse cyclophosphamide was well tolerated in relapsing-remitting MS patients poorly responsive to interferon / glatiramer actetate therapy. Treatment halted progression of the disease in 78% of MS patients as measured by EDSS and stabilized MRI activity in 75%. CTX/MP may be considered as a therapeutic option in this category of patients.

Supported By:

Nancy Davis Foundation. MS Society fellowship (SG)

Category - MS and Related Diseases

SubCategory - Therapeutics 

Oral Ethinyl Estradiol Inhibits Recruitment of Inflammatory Cells into the CNS and Treats Relapsing EAE

Halina Offner, Agata Matejuk, Alex Zamora, Arthur A. Vandenbark, Sandhya Subramanian, Portland, OR

Objective:

To evaluate the efficacy and mode of action of oral treatment of relapsing EAE with ethinyl estradiol (EE).

Background:

There is much interest in the possible ameliorating effects of estrogen on various autoimmune diseases. We previously established the protective effects on EAE of relatively low doses (1/5 pregnancy levels) of 17-estradiol (E2), given subcutaneously in a timed release pellet. In this study, we investigated the therapeutic effects of EE on relapsing EAE. EE is a semi-synthetic estrogen compound used in birth control pills, and its chemical structure allows this compound to retain activity when given orally.

Design/Methods:

EAE was induced in SJL/J mice by injecting PLP-139-151 peptide in CFA. E2 and EE were administered either at disease induction or at onset of clinical signs of EAE. Immune responses, including T cell activation and cytokine secretion, expression of matrix metalloproteinase (MMP)-9, chemokines/receptors, and IgG2a levels were monitored in treated and control mice.

Results:

Orally administered EE, like timed release E2, drastically suppressed EAE in SJL/J mice when given at initiation of disease. However, unlike E2, EE reduced clinical severity when given after onset of clinical signs of EAE. Treatment with EE significantly decreased the secretion of pro-inflammatory cytokines (IFN-, TNF-, and IL-6) by activated T cells, as well as expression of MMP-9, disease-mediating chemokines/receptors, and IgG2a levels, but increased the expression of TGF-3 in the CNS.

Conclusions:

The absence of infiltrating lymphocytes, together with the suppression of cytokines, MMP-9, and chemokines/receptors suggests that EE, like E2, protects mice from EAE by inhibiting the recruitment of T cells and macrophages into the CNS. These results suggest that oral ethinyl estradiol might be a successful candidate for therapy of multiple sclerosis.

Supported By:

NIH grants AI42376, NS23221, and NS23444, The National Multiple Sclerosis Society, and The Department of Veterans Affairs. Dr. Matejuk is a post-doctoral fellow of The National Multiple Sclerosis Society.

Category - MS and Related Diseases

SubCategory - Therapeutics 

Characteristics of Clinically Isolated Syndrome and the Risk of Progression to Multiple Sclerosis in Chinese

Ka-Lock Shiu, Tak-Hong Tsoi, Kam-Ying Lau, Hong Kong

Objective:

To study the clinical presentation, cerebrospinal fluid (CSF) features, electrophysiological data and radiological findings in Chinese patients with clinically isolated syndrome and risk factors associated with subsequent relapse and development of multiple sclerosis (MS).

Background:

Multiple sclerosis is a rare disorder in Chinese from previous epidemiological studies. Results from the Optic Neuritis Treatment Trial, CHAMPS and ETOMS studies showed that the rate of development of MS is up to 50% in Caucasians from clinically isolated syndromes. However, Chinese subjects were few in all three studies.

Design/Methods:

All Chinese patients presenting with clinically isolated syndrome (cerebral/cerebellar/brainstem demyelination, transverse myelitis and optic neuritis) to our department over the period 1 Jan 1993 to 31 Jul 2002 were included. The hospital records were retrospectively reviewed and data on clinical features, CSF findings, evoked potentials and magnetic resonance imaging (MRI) of the brain and/or spinal cord were systemically analyzed. The progression to multiple sclerosis and the associated risk factors were studied. Differences between the groups of patients with MS and monophasic disease were analyzed: Chi-square test was used for non-parametric nominal variables, Mann-Whitney test was used for non-parametric ordinal variables, and ANOVA was used for parametric variables.

Results:

Thirty-six patients with clinically isolated syndrome were identified over the study period of 115 months: Twenty-five were females and mean age at onset was 38.1 years (range 16-73). The syndromes were: transverse myelitis (50%), cerebral/cerebellar/brainstem involvement (27.8%) and optic neuritis (22.2%). Autoimmune markers were universally negative. MRI of the brain/cervical spine showed the corresponding lesion in 28 patients (82.4%) and 14 patients (38.9%) had additional lesion(s) at other site(s). Oligoclonal band was positive in 4 patients (26.6%) out of 15 patients with lumbar puncture performed, and twenty-nine patients had electrophysiological studies done with abnormalities noted in 22 patients (75.9%). Thirty-one patients had good recovery, four had recovery with significant deficit, and one patient died a year later of unrelated cause. The treatment with pulse methylprednisolone was associated with good outcomes (complete recovery) in 19 patients (86.4%).

After a mean follow up of 26.6 months (range 5 to 84 months), 16 patients (44.4%) progressed to multiple sclerosis. The incidence of MS is estimated to be 0.28 per 100,000 per year. The risk factors associated with the development of MS were gadolinium enhancing lesion(s) (p=0.025), infra-tentorial lesion(s) (p=0.007), additional lesion(s) on initial MRI (p=0.049) and positive oligoclonal band (p=0.009).

Conclusions:

In Chinese transverse myelitis is the most common presentation for clinically isolated syndrome. The risk of progression to MS is similar to that of Caucasians.

Category - MS and Related Diseases

SubCategory - Epidemiology 

Neurological Manifestations in Sjgrens Syndrome (2). MRI, CSF and Outcome Profiles in a Cohort of 82 Patients

Jerome de Seze, Sophie Delalande, Emmanuel Michelin, Jean Yves Gauvrit, Anne Laure Fauchais, Eric Hachulla, Didier Ferriby, Tanya Stojkovic, Pierre Yves Hatron, Jean Pierre Pruvo, Patrick Vermersch, Lille, France

Objective:

To describe the radiological, neurophysiological and cerebospinal fluid (CSF) analysis of patients with neurological manifestations occurring during SS, and to report their clinical outcome.

Background:

Neurological involvement occurs in approximately 20% of patients with primary Sjgrens syndrome (SS) and can affect the peripheral (PNS) and central (CNS) nervous systems. CNS involvement can mimic multiple sclerosis (MS) and MRI frequently reveals white matter changes.

Design/Methods:

We studied 82 patients (65 women and 17 men, mean age : 54 years) with neurological manifestations associated with primary SS, as defined by the American-European criteria (Vitali et al., 2002), and evaluated the MRI, CSF and visual evoked potentials (VEP) and response to various treatments. We used the MOHS (Modified Oxford Handicap Scale) score to evaluate neurological disability.

Results:

Fifty-six patients had CNS disorders and 51 patients had PNS involvement. Thirty percent of patients (all with CNS involvement) had oligoclonal bands. The VEP were abnormal in 61% of the patients tested. Fifty-eight patients had a brain MRI. We observed white matter lesions in 70% of patients. MS radiological criteria were present in 40% of patients (44% fulfilled Patys criteria; 39% fulfilled Barkhof and Fazekas criteria). Lesions were found in 80% of patients with CNS involvement. We also observed gray matter lesions in the basal ganglia (17% of patients). Corpus callosum lesions were rarely observed (14%). Thirty-nine patients had a spinal cord MRI. Abnormalities were observed only in patients with spinal cord involvement. Among the 29 patients with myelopathy, 75% had T2-weighted hyperintensities (cervical in 82%, dorsal in 47% and terminal in 17%), 35% had extended lesions and 40% had centromedullar lesions. These abnormalities were more frequent in acute myelopathies. The mean neurological follow-up was 7 years. Twenty-six patients had relapses. Fifty-two percent of patients had severe disability, and were more likely to have CNS involvement than PNS involvement (p0.001). Treatment by cyclophosphamide allowed a partial recovery or stabilization in patients with myelopathy (92%) or multiple mononeuropathy (100%).

Conclusions:

White matter changes on MRI are frequent in SS but could be distinguished from MS because lesions in the corpus callosum are rare and the basal ganglia may be involved. Spinal cord MRI is also discriminant, showing more an extended and centromedullar hypersignal in SS than in MS. The outcome is frequently severe, especially in patients with CNS involvement. Our study underlines the potential efficacy of cyclophosphamide in myelopathy and multiple neuropathy occurring during SS.

Category - Neurologic Manifestations of Systemic Disease

SubCategory - Other 

Validity and Reliability of the MSQLI in Cognitively Impaired Patients with Multiple Sclerosis

Ruth Ann Marrie, Deborah Miller, Gordon Chelune, Jeffrey Cohen, Cleveland, OH

Objective:

To determine whether cognitive impairment negatively affects the validity and reliability of the Multiple Sclerosis Quality of Life Inventory (MSQLI).

Background:

Multiple sclerosis (MS) has important effects on quality of life (QOL) but it is not known how cognitive impairment affects the ability to assess or report this. Cognitive impairment is common in MS, and QOL measures are increasingly being used to follow patients and are being used as outcomes in clinical trials. The MSQLI is a disease-specific measure of health-related QOL that includes the SF-36, and scales measuring fatigue, pain, sexual satisfaction, bowel control, bladder control, impact of visual impairment, cognitive dysfunction, mental health and social support.

Design/Methods:

A sample of 90 MS patients referred for cognitive evaluation by their treating neurologists was administered a neuropsychological test battery. The Multiple Sclerosis Functional Composite (MSFC), a disability measure, and the Beck Depression Inventory were also administered. Results of the WAIS-III, WMS-III were used to define cognitively impaired and unimpaired groups within this sample. Discrepancy scores were calculated by taking the difference between the verbal comprehension index and the score on the cognitive test of interest. A patient was defined as cognitively impaired if he had any discrepancy score larger than the score expected to occur in 5% of the general adult population. The MSQLI was first administered in the week prior to neuropsychological testing. It was re-administered 1-4 weeks after first administration to allow measurement of test-retest reliability.

Results:

Thirty-four (38%) patients were determined to be cognitively impaired. Convergent and discriminant validity of the MSQLI did not differ between the cognitively impaired and unimpaired groups (p0.05 for all comparisons). Internal consistency reliability measured by Cronbachs alpha was significantly lower for the pain, and fatigue scales in the impaired group, but was still acceptable ( 0.73). Cronbachs alphas for the other scales ranged from 0.83-0.96 in the impaired group, and 0.86-0.97 in the unimpaired group. Test-retest reliability was significantly lower for the mental component score of the SF-36, and for the vision scale in the impaired group (r=0.55 for both), but for all other scales r 0.70. Power to detect a 0.25 difference in correlations at the =0.05 level ranged from 60-95%.

Conclusions:

Cognitive impairment, a common MS manifestation, does not appear to significantly reduce the reliability or validity of the MSLQI as a patient self report measure of health status and quality of life.

Supported By:

This research was supported by an National Multiple Sclerosis Society (NMSS) Physician Fellowship Award to RAM.

Category - MS and Related Diseases

SubCategory - Epidemiology 

Characterization of Immunorelevant Human Brain Antigens of Multiple Sclerosis Patients by Two-Dimensional Electrophoresis

Didier Lefranc, Lionel Almeras, Herv Drobecq, Sylvain Dubucquoi, Jrme de Seze, Patrick Vermersch, Lionel Prin, Lille, France

Objective:

To identify and characterize new immunorelevant antigens associated with multiple sclerosis.

Background:

Currently, none of the myelin-associated antigen targets conclusively discriminates between the immune response observed in multiple sclerosis (MS) patients and healthy subjects. A recent study in our laboratory found that the analysis of global IgG immune profiles to whole brain self-antigens discriminated MS subjects from healthy subjects, and could also differentiate between the three clinical forms of the disease. Indeed, respectively 17 and 29 brain antigens, defined according to their molecular weight, were described to support a discriminant immune response.

Design/Methods:

The protein identification of these discriminant bands was performed by one-dimensional and two-dimensional immunoblotting using MS patient sera, followed by mass spectrometry analysis and a database search.

Results:

By this approach, a total of 29 different immunorelevant antigenic bands were detected. These bands were broken up in more than 40 spots, further selected for mass spectrometric analysis: 21 of them were annotated.

Conclusions:

Serological proteome analysis (SERPA) may constitute a new tool for the identification of new MS-associated antigens.

Supported By:

This work was supported by Biogen. AL recieved a grant fellowship from the conseil rgional and the CHR of Lille

Category - MS and Related Diseases

SubCategory - Other 

Hypersomnia with Bilateral Hypothalamic Lesion Was Associated with Decreased CSF Hypocretin-1

Yasunori Oka, Jun Matsubayashi, Tatsuhide Ooga, Masaru Matsui, Kazumi Iseki, Takahiro Mezaki, Hidekazu Tomimoto, Akio Ikeda, Hiroshi Shibasaki, Kyoto, Japan, Takashi Kanbayashi, Akita, Japan, Tetsuo Shimizu, Kyoto, Japan

Objective:

To examine the CSF hypocretin-1 in hypersomnia due to hypothalamic lesion.

Background:

CSF hypocretin is reported to be markedly decreased in narcolepsy/cataplexy patients. Narcolepy is caused by hypothalamic lesion such as stroke with decreased CSF hypocretin-1. However, hypersomnia without any other narcolepsy-related symptoms due to hypothalamic lesion has not been well documented.

Design/Methods:

Two patients presented hypersomnia secondary to hypothalamic lesion. Clinical symptoms, brain MRI, and CSF hypocretin-1 level were correlated.

Results:

Case1. A 22 year old women suddenly developed hypersomnia. After the onset, her sleep time was 15 hours per day and fell asleep frequently even while eating, talking or riding bicycle. Brain MRI showed FLAIR hyperintensity on both sides of hypothalamus. She had the diagnosis of multiple sclerosis (MS) which had initially started with diplopia one year prior to the hypersomnia. Multiple sleep latency test (MSLT) revealed decreased mean sleep latency (2.8min) and five sleep onset REM periods (SOREMP) out of five sessions. CSF hypocretin-1 level was undetectable (40pg/ml). Hypersomnia improved within 2 weeks. Two and four months after the onset of hypersomnia, both MRI lesion and CSF hypocretin level recovered to normal.

Case2. A 42 year old women gradually developed hypersomnia in one year. She also developed forgetfulness. Brain MRI revealed FLAIR high intensity lesion in the bilateral hypothalamus and basal ganglia. MSLT showed decreased mean sleep latency (7.5 min) with no SOREMP. CSF hypocretin-1 level was decresed (117pg/dl).

Conclusions:

Decreased CSF hypocretin-1 in these cases may reflect degree of hypothalamic dysfunction selectively in hypocretin system, and it can explain the mechanism of hepersomnia.

Category - Sleep Disorders

SubCategory - Other 

Ibudilast, a Nonselective Phosphodiesterase Inhibitor, Regulates Th1/Th2 Blance and NKT Cell Subset in Patients with Multiple Sclerosis

Juan Feng, Tatsuro Misu, Kazuo Fujihara, Sendai, Japan, Saburo Sakoda, Yuji Nakatsuji, Osaka, Japan, Hikoaki Fukaura, Seiji Kikuchi, Kunio Tashiro, Sapporo, Japan, Akio Suzumura, Nagoya, Japan, Naoto Ishii, Kazuo Sugamura, Ichiro Nakashima, Yasuto Itoyama, Sendai, Japan

Objective:

To investigate the immunoregulatory effects of ibudilast in patients with multiple sclerosis (MS)

Background:

Multiple sclerosis is an inflammatory demyelinating disease of the central nervous system, and the immunological findings suggest that MS is a helper T cell type 1 (Th1)-dominant condition. Phosphodiesterase inhibitors (PDI) suppress Th1 responses in vitro and in animal studies and are candidate drugs to treat MS. However, much larger doses than those in clinical use and multiple PDI are often needed to achieve the Th1 suppression. Ibudilast, a nonselective PDI, has been administered to patients with stroke and bronchial asthma, and this PDI in relatively small doses ameliorated experimental autoimmune encephalomyelitis (EAE). We studied the effects of ibudilast monotherapy at a clinically applicable dose on Th1/Th2 balance and natural killer T (NKT) cells, a lymphocyte subset shown to suppress EAE, in MS patients.

Design/Methods:

Eleven patients with relapsing-remitting MS were orally administered ibudilast, 60mg (in 3 divided doses) a day, for 4 weeks. Peripheral blood was collected before and after the therapy. CD4+cells were isolated from the blood with a magnetic cell seperation system (autoMACS), and the purity was over 97%. One g of total RNA extracted from the CD4+cells was reverse-transcribed into cDNA. The cDNA was subjected to real-time PCR (TaqMan method) for interferon (IFN)-,tumor necrosis factor (TNF)-, interleukin (IL)-4 and IL-10, and the PCR products were quantified with ABI PRISM 7700 sequence detection system using a comparative threshold cycle method. -actin was used as a reference. The NKT cell subset (CD3+V24+) was analyzed with a flow cytometer (FACSCalibur). Informed consent was obtained prior to the study, and the study protocol was approved by the Institutional Review Board.

Results:

One patient had transient palpitation and the administration of ibudilast was discontinued, but the therapy was well tolerated in the rest of the patients. None had a relapse of MS during the therapy. After the therapy, there was a tendency for IFN- and TNF- to be downregulated and for IL-4 and IL-10 to be upregulated, and the IFN-/IL-4 and IFN-/IL-10 ratios decreased significantly (P0.05). The NKT cell subset significantly increased (P0.05) following the therapy.

Conclusions:

Our study showed that ibudilast monotherapy induced a shift in the cytokine profile from Th1 toward Th2 and increased the NKT cell subset in MS patients. Ibudilast may be promising for the treatment of MS, and it will be necessary to study its clinical effects.

Category - MS and Related Diseases

SubCategory - Clinical Trials 

cDNA Microarray Analysis in Multiple Sclerosis Lesions: Detection of Genes Associated with Disease Activity

Krzysztof W. Selmaj, Marcin P. Mycko, Lodz, Poland, Ruben Papoian, Ursula Boschert, Geneva, Switzerland, Cedric S. Raine, Bronx, NY

Objective:

The aim of this study was to identify the genes responsible for the activity of the demyelination process in the pathogenesis of multiple sclerosis (MS).

Background:

MS, primary autoimmune demyelinating disease of the central nervous system (CNS), is been characterized by the presence of the demyelinating lesions (plaques) within the CNS tissue. To understand the genes transcription status of the two most often MS lesions: chronic active and chronic inactive plaques we have performed a comparative cDNA microarray analysis of these two lesion types.

Design/Methods:

cDNA microarray analysis of CNS tissue from several multiple sclerosis (MS) subjects was performed. Analysis of the overlapping genes from different lesions yielded a list of genes consistently upregulated at the chronic active lesion edge. Furthermore, to compare differences between chronic active and silent lesions, we performed DGE comparison of the pooled data from both types of lesions. We have also analyzed the differences between gene expression profiles of different lesion types and normal appearing white matter (NAWM).

Results:

DGE analysis shown a significant differences between the lesion margin and lesion center in both types of lesions. Nearly 10% of the genes were differentially expressed in the lesion margins and centers in the chronic active of lesions whereas less then 2% in the chronic silent type of lesions. Several genes were identified as overlapping in the analysis of DGE genes from different active type of lesions. These genes were mostly of inflammatory characteristic or associated with activation of cell death. Combined comparative analysis of DGE genes between chronic active and inactive lesions yielded list of genes with significant overexpression of genes for members of TNF and TNF receptor superfamilies of proteins, like TNF, CD27, TRAIL, TNFr2. Several new genes, like FLT3 ligand, adenosine A1 receptor (ADORA1), epithelial discoidin domain receptor 1 (EDDR1) or early growth response protein 1 (EGR1) with so far unknown function within the CNS were shown to be present and significantly differentially expressed within the active versus inactive type of lesions.

Conclusions:

Thus we have identified a set of genes, mostly immune related to be differentially expressed within the MS chronic type lesions indicating that chronicity of MS lesion growth depends on prolonged immune/inflammatory reactions.

Supported By:

KBN grant nr 4 P05A 005 19 to M.P.M.; and HHS grants NS 11920 and NS 08952 to CSR

Category - MS and Related Diseases

SubCategory - Clinical Immunology 

Plasticity Associated with Motor Training in Patients with Multiple Sclerosis

Leonard G. Cohen, Bethesda, MD, Katrin Morgen, Giessen, Germany, Nadja Kadom, Lumy Sawaki, Alessandro Tessitore, Joan Ohayon, Henry F. McFarland, Joe A. Frank, Roland Martin, Bethesda, MD

Objective:

To investigate training-dependent changes in brain activation associated with performance of a motor task in patients with multiple sclerosis who experienced substantial motor recovery.

Background:

In healthy volunteers, motor training that results in encoding of an elementary motor memory is associated with a task-specific reduction in activation in the contralateral sensorimotor cortex. This finding has been interpreted as consistent with higher efficiency of neuronal resources required to generate the same output after training. Here, we studied fMRI activation patterns associated with performance of a motor task before and after motor training in a group of MS-patients with good motor recovery and age-matched controls.

Design/Methods:

Nine MS patients and nine age and gender matched healthy subjects participated in the study. During fMRI, patients and healthy subjects (1.5 T, TR 3s, TE 40ms; 22 6 x 3.75 x 3.75 mm axial slices) performed thumb flexion and extension movements before and after a 30-minute training period consisting of performance of voluntary thumb flexion movements at 1 Hz. FMRI data was analyzed using random effects analysis (SPM99). Motor kinematics of training motions and contralateral EMG were monitored with an accelerometer and surface EMG electrodes.

Results:

Kinematics of thumb movements before, during and after training was similar in the absence of mirror EMG activity. Before training, thumb movements elicited greater activation in contralateral dorsal premotor cortex (PMd, BA 6) in MS patients than in controls. After training, MS patients exhibited less task-specific reductions in activation in contralateral sensorimotor (SM1) and parietal association (BA 40) cortices than controls.

Conclusions:

These results indicate that patients (a) engage the contralateral PMd more than controls to sustain performance of a simple motor task in the absence of training, and (b) are less able than controls to experience a training-dependent decrease in activation within contralateral SM1 and BA 40, two expressions of cortical reorganization in multiple sclerosis.

Category - MS and Related Diseases

SubCategory - Imaging 

Annual Rate of Whole Brain Atrophy in Multiple Sclerosis: Comparison with Healthy Controls

Richard A. Rudick, Fisher Elizabeth, Jar-Chi Lee, Cleveland, OH

Objective:

To compare the rate of whole brain atrophy in different subtypes of multiple sclerosis patients with the rate in age- and gender-matched healthy controls.

Background:

Whole brain atrophy is increasingly used to monitor severity and progression in MS, and to monitor effects of therapy. No single longitudinal study has compared whole brain atrophy progression in different subtypes of MS with atrophy rates in healthy controls.

Design/Methods:

Patients were recruited for the study from the Mellen Center, and age- and gender-matched healthy controls were identified by the MS study participants. Study participants were examined to determine EDSS, MSFC, treatment history, relapse history, and had standardized quantitative MRI to determine brain parenchymal fraction (BPF). Patients were evaluated every 6 months, and healthy controls yearly. We studied 18 healthy controls (HC); 7 patients with clinically isolated syndromes without multicentric brain lesions (CIS-NoLesions); 7 with clinically isolated syndromes with multicentric brain lesions (CIS-Lesions); 34 with RR-MS; and 21 with SP-MS. While the study is ongoing, this report includes 1-year longitudinal data.

Results:

Baseline age was: 41.1 (HC); 38.8 (CIS-NoLesions); 41.4 (CIS-Lesions); 40.6 (RR-MS); and 50.5 (SP-MS). The MS and HC groups were well-matched for gender. Baseline BPF was: 0.865 +/- 0.011 (HC); 0.869 +/- 0.009 (CIS-NoLesions); 0.852 +/- 0.020 (CIS-Lesions); 0.839 +/- 0.026 (RR-MS); and 0.811 +/- 0.039 (SP-MS). The CIS group was not significantly different from the HC group, but BPF in both MS groups was significantly lower than HC or CIS groups (p0.01). BPF declined by 0.07% (median 0.02%) in the HC group during the one-year observation. Compared with HC, BPF decline in one year was 1.4-fold increased in CIS patients, 5.2-fold increased in RR-MS patients, and 6.3-fold increased in SP-MS patients. Age explained 45% of variance in BPF progression in the HC group, 27% in the CIS-NoLesion group, 5% in the CIS-Lesion group, 8% in the RR-MS groups, and 1% in the SP-MS group.

Conclusions:

The severity of whole brain atrophy, and the rate of atrophy progression were similar in HC and CIS patients in this study. In the RRMS and SPMS groups, atrophy at study entry was more severe compared with HC, and atrophy worsened 5.2-6.3 fold faster than the HC group. In the HC and the CIS-NoLesion groups, age explained a significant amount of the variance in atrophy progression, but very little in the CIS-Lesion and MS groups. This confirms that the MS pathologic process drives atrophy progression, and suggests that BPF is a valid and sensitive measure of the disease process.

Supported By:

National Institutes of Health (PO1 NS38667), National Multiple Sclerosis Society (NMSS RG3099), and the Nancy Davis Center Without Walls

Category - MS and Related Diseases

SubCategory - Imaging 

3,4-Diaminopyridine Modulates Motor Cerebral Activation and Motor Cortex Excitability in Patients with Multiple Sclerosis: A Combined fMRI-TMS Study

Caterina Mainero, Maurizio Inghilleri, Patrizia Pantano, Delia Lenzi, Antonella Conte, Vittorio Frasca, Maria Cristina Piattella, Carlo Pozzilli, Rome, Italy

Objective:

We combined functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) in order to investigate, in patients with multiple sclerosis (MS), the effects of a single dose of 3,4-diaminopyridine (3,4-DAP) on patterns of motor activation and on motor cortex excitability.

Background:

3,4-DAP, a potassium channel blocker, is able to improve fatigue and motor function in MS. The beneficial effects of 3,4-DAP have typically been attributed to the restoration of conduction to demyelinated axons. However, recent experimental data have showed 3,4-DAP is also effective in potentiating synaptic transmission. FMRI can be used to evaluate motor cerebral activation, whereas TMS in a paired pulse paradigm allows to test cortical excitability of separate inhibitory and excitatory interneuronal circuits at the level of the motor cortex.

Design/Methods:

Twelve right-handed women (mean, SD age of 40.9, 9.3 years; median, range EDSS of 2.5, 1.0-3.5; median, range disease duration of 8, 2-22 years) underwent fMRI in two separate occasions, one under 3,4-DAP and one under placebo while performing a sequential thumb to index finger opposition task with the right hand. FMRI data were analyzed with SPM99. After each fMRI study, all patients were evaluated by means of single TMS to test motor threshold, amplitude and latency of motor evoked potential (MEP), central conduction time and cortical silent period, and by means of paired TMS, according to the technique described by Kujirai et al., to investigate cortical excitability. Lastly, quantitative EMG during maximum voluntary contraction hold on for 120 s was obtained.

Results:

FMRI data demonstrated an increase in the extent of motor-evoked brain activation under 3,4-DAP compared to placebo. This increased activation was observed in all the motor areas activated under placebo. However the difference was statistically significant only in the primary motor cortex and in the SMA of the ipsilateral hemisphere (voxel level uncorrected p.001, cluster level corrected p.05 by paired t-test).

Paired-pulse TMS showed that MEP amplitude was greater under 3,4-DAP than under placebo both at 3 ms inter-stimulus interval, thus indicating a reduced intracortical inhibition, and at 10 ms inter-stimulus interval, thus indicating an enhanced intracortical facilitation (p.05 by paired t-test). At single TMS we did not find any significant difference in motor threshold, amplitude and latency of MEP, central conduction time and cortical silent period between placebo and 3,4-DAP. EMG at maximum voluntary contraction did not change.

Conclusions:

Our results suggest that 3,4-DAP is able to modulate brain motor activity in patients with multiple sclerosis by increasing the activity and/or the number of excitatory synapses.

Category - MS and Related Diseases

SubCategory - Imaging 

Intraventricular Transplantation of Neurospheres Attenuates Acute Experimental Allergic Encephalomyelitis

Tamir Ben-Hur, Ofira Einstein, Dimitrios Karussis, Nikolaos Grigoriadis, Rachel Mizrachi-Kol, Etti Reinhartz, Oded Abramsky, Jerusalem, Israel

Objective:

To study the clinical and pathological value of neural precursor cell transplantation in an animal model of Multiple sclerosis.

Background:

Multiple sclerosis (MS) is an immune-mediated demyelinating disease without known treatments to enhance myelin regeneration. Transplanted neural precursor cells (NPCs) can remyelinate efficiently acutely demyelinated focal lesions. However, the clinical-therapeutic value of cell transplantation in experimental autoimmune encephalomyelitis (EAE), an animal disease model of MS, is unknown. We therefore examined the effects of NPC transplantation on the clinical and pathological course of acute EAE in Lewis rats.

Design/Methods:

Newborn Lewis rat striatal NPCs were expanded in spheres as nestin+, PSA-NCAM+, NG2(-) cells, which could differentiate in vitro into astrocytes, oligodendrocytes and neurons. BrdU-tagged spheres were transplanted into the lateral ventricles of female Lewis rats, which were induced with EAE at the same day of transplantation. Severity of EAE was determined using standard clinical scores. The fate of transplanted cells was examined by double immunofluorescent-stainings for BrdU and GalC or NG2 or GFAP. Perivascular inflammatory infiltrates were counted on H&E stained brain sections and expression of intercellular adhesion molecule-1 (ICAM-1) and lymphocyte function antigen-1 (LFA-1) was determined by computerized image analysis of immunohistochemical stainings. Lymphocyte proliferation was determined by 3H-thymidine incorporation and cell death by TUNEL stains.

Results:

Transplanted NPCs migrated into inflamed white matter tracts and differentiated into oligodendroglial and astroglial lineage cells. NPC spheres transplantation attenuated the clinical severity of EAE, as determined by maximal clinical severity and by cumulative burden of disease. Sphere-transplanted rats also exhibited an attenuated inflammatory process in the CNS, as determined by a reduced number of perivascular infiltrates and decreased expression of ICAM-1LFA-1. NPC spheres also inhibited basal proliferation and proliferative responses to Concavalin-A (ConA) and to myelin oligodendrocyte glycoprotein (MOG) peptide of EAE ratderived lymphocytes in-vitro.

Conclusions:

Intraventricular transplantation of NPC spheres may attenuate the clinical course of EAE, probably via an immunomodulatory mechanism that inhibits inflammatory responses in vivo and in vitro.

Supported By:

Supported by the Israel Science Foundation, by the Betty Yablin grant and by the Zeev Aram grant for multiple sclerosis.

Category - MS and Related Diseases

SubCategory - MS: Animal Models 

Neuroprotection of Axons in Experimental Allergic Encephalomyelitis with a Sodium Channel Blocking Agent

Albert C. Lo, Joel A. Black, Stephen G. Waxman, West Haven, CT

Objective:

To test the neuroprotective effects of sodium channel blocking agent, phenytoin, on axon injury in EAE mice.

Background:

Axon injury and transection is now recognized as an important part of the pathology of multiple sclerosis, and it has been postulated that axon degeneration underlies the permanent disability accrued by MS patients. In previous studies we have shown that voltage-gated sodium channels are involved in axonal degeneration in white matter. Moreover, we have shown that pharmacologically blocking sodium channels with agents including phenytoin protects acutely injured white matter axons in vitro from irreversible dysfunction. To test whether the sodium channel blocking agent, phenytoin, has a protective effect on axons in an inflammatory autoimmue animal model of MS, we quantitated axon counts in the optic nerves and spinal cords of control mice, untreated EAE mice, and EAE mice treated with phenytoin.

Design/Methods:

C57/BL6 mice 6-10 weeks of age were used to induce EAE. Rat MOG peptide in an emulsion of complete Freunds was injected subcutaneluously into the flank. Two injections were given 7 days apart. Pertusiss toxin was also given at day 0 and 48 hours later. Ten days following the initial MOG injection a group of mice were feed phenytoin incorporated into their standard mice chow. Serum phenytoin levels were measured from two mice from each group on days 14 and 28 in order to confirm that serum phenytoin between groups were comparable. Untreated EAE mice and phenytoin treated naieve mice served as controls. Immunized mice were daily score for neurological deficits on a 0-6 scale. At days 27-28, all mice were perfused with paraformaldehyde and immunohistochemistry using neurofilament antibodies was used to label axons in the optic nerves and spinal cords. Axon counts were quantitated and compared.

Results:

We found dramatic axon loss within the optic nerve and spinal cords of EAE mice. In phenytoin-treated EAE mice there was a significant protective effect with prevervation of significant numbers of axons both within the optic nerve and spinal cord. Furthermore we show that untreated EAE mice develop progressive paralysis whereas phenytoin-treated EAE mice had significantly less severe neurological deficits.

Conclusions:

Our data suggests that sodium channel blocking agents may protect CNS white matter axons from degeneration in autoimmune demyelinating processes as well as ameliorate the severity of clinical deficits.

Supported By:

Department of Veterans Affairs Rehabilitation Research Service and Medical Research Service, National Multiple Sclerosis Society, Eastern Paralyzed Veterans Association, Paralyzed Veterans of America, and the Nancy Davis Foundation

Category - MS and Related Diseases

SubCategory - Therapeutics 

JNK3 Is Critically Involved in Oligodendrocyte Death

Anna Jurewicz, Mariola Matysiak, Dariusz Jaskolski, Krzysztof Selmaj, Lodz, Poland

Objective:

The objective of this study was to define the role of the JNK pathway and JNK isoforms in the death mechanism of mature adult human oligodendrocytes (OLs) in response to TNF-Rp55 ligation.

Background:

Depletion of OLs is a recognized feature of multiple sclerosis lesion. Several immune effector mechanisms, including TNF family proteins, have been shown to induce OLs death. The outcome of TNF interaction with p55 receptor involves activation of the mitogen activated protein kinases (MAPK), including both the c-jun NH2-terminal protein kinase (JNK) and p38 kinases. All three JNK isoforms, JNK-1, JNK-2 and JNK-3, are expressed in the brain, but their contribution to the mechanism of OLs death is not known.

Design/Methods:

Adult human OLs were prepared from human adult brain tissue resected during neurosurgical procedures. To assess OLs death TNF stimulation was used. The cells were staining with Annexin V and PI and analyzed by flow cytometry. TUNEL technique was used to confirm apoptptic cell death. JNK activation was analyzed by radiographic kinase assay and by antibodies against phosphorylated form of kinase and detecteted by Western blotting. The contribution of each of the JNK isoforms to OLs death was assessed by immunoprecipitations with antibodies against JNK-1, JNK-2 and JNK-3 prior to kinase assay and autoradiography. To confirm the role of JNK activation in TNF-induced death of OLs we used dominant-negative mutant of MKK4/SEK1 to inhibit activation of JNK. The constitutive active mutant of MEKK1 was used to enhance JNK activation. To assess mitochondrial dysfunction we measured changes in mitochondrial membrane permeability.

Results:

JNK activation, as measured by c-jun phosphorylation and induction of phosphorylated form of JNK, was enhanced, prolonged and correlated with cell death in hOLs exposed to TNF. Comparative autoradiography analysis revealed that JNK-3, but not JNK-1 or JNK-2, correlated with TNF-induced hOLs death. p38 was not activated during TNF-induced OLs death. Expression of dominat-negative mutant of JNK upstream kinase, MKK4/SEK1, inhibited apoptosis induced by TNF, whereas expression of constitutive active mutant of MEKK1, enhances TNF-induced apoptosis. JNK activation was detected prior to changes of mitochondrial membrane potential.

Conclusions:

These results demonstrate that TNF-induced death of adult hOLs is critically dependent on JNK-3 activation, and that JNK activation occurs prior to mitochondrial dysfunction. This is the first evidence that a JNK-3 isoform is involved in oligodendrocyte death and this observation might have significant importance in designing new molecules to protect hOLs demise in multiple sclerosis.

Supported By:

KBN grants 4PO5A 006.14, 4PO5A 083.18 and 4PO5A 009.14 and MU grant 502-11-368

Category - MS and Related Diseases

SubCategory - Basic Science 

Multiple Sclerosis-Associated HLA-DR Alleles Contribute to Persistence of Myelin Responses in MS Patients

Ioana R. Moldovan, Richard A. Rudick, Anne C. Cotleur, Sarah E. Born, Jar-Chi Lee, Matthew T. Karafa, Elizabeth Fisher, Clara M. Pelfrey, Cleveland, OH

Objective:

To examine factors that contribute to persistence and spreading of immune responses to myelin peptides in relapsing-remitting multiple sclerosis (MS) patients.

Background:

Myelin-specific immune responses have been implicated in the etiology of MS. However, the relevance of these immune responses to MS is not clear since myelin responses to PLP and MBP can be also found in healthy controls. In addition, it has been shown that in MS patients myelin responses tend to spread to new epitopes over time. The factors that influence epitope spreading are undefined.

Design/Methods:

We performed a 12 month longitudinal study measuring the ex-vivo IFN- and IL-10 production by peripheral blood mononuclear cells in response to 9 amino acid length peptides derived from PLP and MBP in 20 relapsing-remitting MS patients and 27 age- and gender-matched controls. Every 3 months we measured the number and location of epitopes that induced memory T cell responses by ELISPOT assay, as well as the number of cytokine secreting cells as an indicator of the magnitude of the response. The results were analyzed for persistence and spreading of immune responses between timepoints. Persistence was defined as positive responses to the same region of PLP or MBP at every timepoint. Emerging responses were defined as absent at baseline, but appearing at subsequent timepoints.

Results:

At baseline, MS patients had significantly higher PLP-induced IL-10 responses and MBP-induced IFN- responses compared with healthy controls (p = 0.02). PLP/IL-10 responses in MS patients maintained this trend over the next 6 months, while elevated MBP/IFN- responses were transient. MS-associated HLA-DR alleles (HLA-DR4, DR15 and DR17) were linked to persistent and emerging PLP/IL-10 responses in MS patients (p = 0.02 and p = 0.03 respectively), but not in healthy controls. According to the domain structure of PLP, IL-10 responses to the extracellular domain were significantly elevated in MS patients and maintained this pattern for at least 6 months.

Conclusions:

Our data suggest that in MS patients MBP/IFN responses are transient, whereas PLP/IL-10 responses, which persist over time, may represent regulatory responses following earlier PLP destruction. Persistent and emerging responses to myelin peptides in MS patients appear to be linked to MS-associated HLA-DR alleles.

Supported By:

National Multiple Sclerosis Grants RG 3005-A-2 and FA 1459-A-1

Category - MS and Related Diseases

SubCategory - Basic Science 

Humoral Autoimmunity Against Myelin/Oligodendrocyte Glycoprotein Is a Determining Factor for Phenotypic Expression of Inflammatory Central Nervous System Demyelination

Hans-Christian von Bdingen, Antje Fuhrmann, San Francisco, CA, Jean-Christophe Ouallet, Bordeaux, France, Naoyuki Tanuma, Tokyo, Japan, Til Menge, Stephen L. Hauser, Claude P. Genain, San Francisco, CA

Objective:

To investigate whether diversity of humoral responses against myelin/oligodendrocyte glycoprotein (MOG) according to recognition of linear vs. conformational antibody (Ab) determinants underlies differences in the expression of disease phenotype and antibody effector function in a primate model of human multiple sclerosis (MS).

Background:

MOG is an exposed antigen of central nervous system (CNS) myelin. Immune responses against MOG give rise to pathogenic antibodies in animal models of MS. In outbred species, anti-MOG antibodies show diversity of epitope recognition.

Design/Methods:

C. jacchus marmosets were actively immunized with either a recombinant form of the highly immunogenic extracellular domain (aa1-125) of rat MOG (rMOG1-125; n=4) or MOG-derived peptides spanning all or parts of the sequence of rMOG (n=9), emulsified in Complete Freunds Adjuvant. Animals were observed and clinical scores assessed over a period of 12 to 140 days. After euthanasia, CNS tissue was processed for immunopathology (Luxol Fast Blue staining), and immunohistochemical detection of macrophages (HAM56), IgG, and complement activation (C9neo). MOG-specific serum Abs from animals of both groups were fractionated according to recognition of conformational or linear MOG-epitopes by affinity chromatography, over Sepharose-columns containing 11 20mer overlapping peptides spanning aa1-120 of rMOG. Ab-specificities were analyzed by ELISA.

Results:

All animals developed clinical EAE. Neuropathologically, MOG-peptide-immunized animals had a greatly reduced white matter lesion burden compared to those immunized with rMOG (9.2 +/- 3.1 vs. 163 +/- 56.3 lesions, resp. p=0.0012), and limited dissemination. Sera from both rMOG1-125- and MOG peptide-immune animals displayed reactivity to rMOG1-125 and MOG-derived peptides. After complete removal of MOG peptide-specific Abs, sera from MOG peptide-immune animals lost all MOG-specific reactivity, while sera from rMOG1-125-immune animals retained strong reactivity to rMOG1-125. Immunohistochemically, macrophage activation was observed in lesions of both rMOG1-125- and MOG peptide-immune animals, while IgG deposition and complement activation was only detectable in lesions of animals immunized with rMOG1-125.

Conclusions:

Our findings demonstrate that epitope recognition of MOG is a critical factor that determines Ab effector functions and phenotypic expression of CNS demyelination. Humoral responses against conformation dependent determinants of MOG are closely linked with dissemination of demyelinating lesions throughout the CNS and activation of the complement pathway.

Supported By:

National Institutes of Health, the Nancy Davis Foundation, the New York Community Trust, and the National Multiple Sclerosis Society.

Category - MS and Related Diseases

SubCategory - Basic Science 

Quality of Life: Complementary Medicine and the People with Multiple Sclerosis

Raul N. Mandler, Susan Silver, John Pan, Washington, DC

Objective:

Outcomes research on complementary and alternative medicine (CAM) is in the early stages. Abundant anecdotal evidence suggests that CAM may alleviate pain, fatigue and depression, may promote relaxation, and may provide a general sense of control and well being. Among people with multiple sclerosis (MS), CAM usage is high, but documentation of its effectiveness in controlled trials is meager. The purpose of this quality of life (QOL), randomized, controlled study was to determine whether a benefit was found in those patients with MS randomized to receive a comprehensive battery of CAM treatments. As a subsidiary hypothesis, the project attempted to investigate whether caregivers received collateral QOL benefits.

Background:

The treatment of patients with MS is complex. Because of the heterogeneity of the MS syndrome and its wide variation in symptoms and severity, treatments require optimization. Whereas significant progress has been made with the use of interferons, glatiramer acetate, solumedrol and mitoxanthrone, pharmacological interventions may not suffice to improve the QOL of MS people. We have taken a novel approach by combining traditional, state-of- the-art immunomodulatory and symptomatic therapy with CAM therapy, to determine whether those patients receiving also CAM demonstrated improvement in QOL over MS control patients who only received conventional therapies. In addition, the effect of CAM on the caregivers well being was assessed.

Design/Methods:

A pilot, randomized, controlled study was carried out in which 14 MS patients were recruited. Seven patients were treated with standard conventional care (immunotherapy and symptomatic therapy) plus CAM (the treatment group), and the other 7 were treated with standard conventional care only. CAM modalities included nutritional counseling, guided imagery, meditation, yoga, spiritual direction, homeopathy, reiki, acupuncture and Alexander techniques. All modalities were used in each of the 7 randomized patients. Experimental and control groups were surveyed before and after treatment sessions with the MS quality of life instrument (MSQLI). Caregivers were surveyed with the SF-36. A change score was derived for both groups. Comparison between study and control groups was done with t-test and analysis of variance.

Results:

Experimental group patients completed 21 CAM sessions each, and both treatment and control group patients completed the QOL surveys. MSQLI statistical significant benefits were found in bowel control (p0.04), fatigue impact scale (MFIS)-5 (p0.04) and sexual satisfaction scale (p0.006). Bladder control showed a trend (p0.09). Other scales showed no significance. No differences were found in caregiver satisfaction.

Conclusions:

By using the MSQLI we found that people with MS treated with CAM benefited in the areas of bowel control, fatigue and sexual satisfaction, and possibly in bladder control as well. A larger, longer study using these benign, non-invasive holistic therapies might show benefits in other relevant domains.

Supported By:

Study supported by a grant from the National Multiple Sclerosis Society to Dr. Mandler

Category - MS and Related Diseases

SubCategory - Therapeutics 

Ciliary Neurotrophic Factor Enhances Myelin Formation: A Novel Role for CNTF and CNTF-Related Molecules

Bruno Stankoff, Marie-Stphane Aigrot, Bernard Zalc, Catherine Lubetzki, Paris, France

Objective:

To study wether endogenous neurotrophic factors may enhance myelin formation

Background:

In multiple sclerosis myelin repair is generally insufficient despite relative survival of oligodendrocytes within the plaques and recruitment of oligodendrocyte precursors. Promoting remyelination appears to be a crucial therapeutic challenge.

Design/Methods:

Using a newly developed enzymatic index of myelination, derived from transgenic mice containing the lacZ reporter gene under the control of a proximal portion of the MBP promoter, we screened different neurotrophic factors for their ability to enhance myelin formation in vitro.

Results:

Neurotrophins (NGF, NT-3, NT4/5, BDNF), GDNF related factors (GDNF, neurturin) and growth factors such as PDGF-AA, FGF-2, or insulin did not increase myelinogenesis. In contrast, among factors belonging to the CNTF family, CNTF, LIF, cardiotrophin-1, and oncostatin M induced a strong pro-myelinating effect. We provide evidence that CNTF acts on oligodendrocytes by favoring their final maturation, and that this effect is mediated through the gp-130 receptor common to the CNTF family, and transduced through the janus kinase pathway.

Conclusions:

Our results demonstrate a novel role for neurotrophic factors of the CNTF family, and raise the possibility that these factors might be of therapeutical interest to promote remyelination in multiple sclerosis.

Supported By:

INSERM (institut national de sant et de recherche mdicale)
ARSEP (association de recherche sur la sclrose en plaques)

Category - MS and Related Diseases

SubCategory - Basic Science 

Induction Treatment with Mitoxantrone in Worsening Relapsing Remitting Multiple Sclerosis: A Rescue Therapy for Sub-Optimal Responders to Interferon Beta? A Pilot Study

Emmanuelle Le Page, Emmanuelle Leray, Rennes, France, Marc Debouverie, Nancy, France, Jean Pelletier, Irina Malikova, Marseilles, France, Michel Clanet, Jean Tardy, Toulouse, France, Gilles Edan, Rennes, France

Objective:

To assess the potential action of mitoxantrone (MITOX) when given as a rescue therapy in patients with relapsing-remitting multiple sclerosis (MS) who experience a sub-optimal response to interferon beta 1a or 1b (IFN).

Background:

The last decade has witnessed the introduction of disease modifying therapies which can only be considered partially effective to alter the near term course of MS. MITOX as induction therapy for 6 months has been proved to reduce dramatically radiological and clinical markers of disease activity in patients with severe relapsing-remitting multiple sclerosis (RRMS) (Edan et al., 1997).

Design/Methods:

In this open retrospective multi-centre study, we studied 45 patients treated by IFN for at least 12 months prior to MITOX but who failed to respond and 50 patients naive of disease modifying therapy (DMT) for at least 12 months prior to MITOX. We compared their clinical evolution within the 12 months following an induction therapy with MITOX 20mg monthly for 6 months.

Results:

The mean age at treatment onset was similar in the IFN non responders and the DMT naive patients (respectively 33.3 and 34.4 years) but patients received MITOX after a longer duration of MS in the first group (7.9 vs 5.7 years respectively; p0.02). Disease activity within the 12 months preceding MITOX onset was characterised respectively in IFN non responders and DMT naive patients by an annual relapse rate (ARR) of 2.5 vs 2.8; a mean EDSS significantly deteriorated by 1.2 vs 2 points and raising a score of 4.5 vs 4.1 at MITOX onset. The mean deterioration of EDSS was lower in the IFN non responders who were already significantly more disabled 12 months before MITOX onset (mean EDSS at 3.3 vs 2.0). One year after MITOX onset, clinical benefits were similar in IFN non responders and DMT naive patients with an ARR of 0.20 in the 2 groups (significantly reduced by 92% vs 93%); 80% of relapse free patients in the 2 groups; a significant improvement of the mean EDSS by 0.9 vs 1.1 point; a significant reduction of the number of patients worsened by 96.7% vs 93%.

Conclusions:

MITOX may provide an alternative or rescue therapy for relapsing-remitting MS patients who experience a sub-optimal response to INF beta (continued frequent and severe relapses particularly with incomplete recovery).

Category - MS and Related Diseases

SubCategory - Therapeutics 

Induction of Remitting-Relapsing Experimental Autoimmune Encephalomyelitis in (C57BL/6 X SJL) F1 Mice with Myelin Oligodendrocyte Glycoprotein Peptide 35-55

G. X. Zhang, S. Yu, D. Calida, A. M. Rostami, Philadelphia, PA

Objective:

To establish a MOG-induced remitting-relapsing experimental autoimmune encephalomyelitis (RR-EAE) with C57BL/6 background, for the future studies of RR-EAE in gene-targeted mice.

Background:

RR-EAE is an ideal model for the study of autoimmune mediated demyelination and immunoregulatory events leading to relapses in human multiple sclerosis. MOG peptide 35-55 (MOG35-55) has been extensively used in the induction of EAE in C57BL/6 mice, which are extensively used for gene-targeted studies (transgenic or knockout). However, these mice develop chronic progressive EAE (CP-EAE), but not RR-EAE. In contrast, SJL mice develop typical RR-EAE when they are immunized with PLP139-151 in CFA.

Design/Methods:

We first immunized female F1 mice with 1) MOG35-55 + CFA; 2) PLP139-151 + CFA; and 3) mixture of MOG35-55 and PLP139-151 + CFA. Pertussis toxin was injected i.p. at day 0 and 2 p.i. We found that MOG35-55 + CFA induced typical RR-EAE and then focused on this method. B6 mice were studied in parallel for comparison. We observed: 1) clinical signs of EAE for 8 weeks; 2) demyelination and inflammation by histopathology; 3)MNC compounds in the CNS by flow cytometry; 4) cytokine profiles; 5) Epitope spreading by proliferative responses and production of IgG, IgG1, and IgG2a antibodies to MOG35-55 (primary epitope), MBP1-11 and PLP139-151 (seconsary epitopes).

Results:

C57BL/6 x SJL F1 (F1) mice are highly susceptible to MOG35-55-induced RR-EAE. Extensive demyelination and cell infiltration, was seen, composed of infiltrating CD4, CD8, macrophages, and B cells, as well as activated and unactivated resident microglia. Sera of F1 mice contained significant levels of total IgG, IgG1, and IgG2a against not only primary antigen MOG35-55, but also to secondary epitopes, e.g., PLP139-151 and MBP1-11. Peripheral immune cells in F1 mice proliferated vigrously to primary antigen MOG35-55 and to PLP139-151. Using the same protocol, parent C57BL/6 mice developed typical chronic progressive EAE, with similar T cell responses but lower antibody response to primary antigen MOG35-55, and marginal responses to secondary epitopes, e.g., PLP139-151 and MBP1-11.

Conclusions:

Our results indicate that 1) B6 x SJL F1 mice should prove valuable for the study of remitting-relapsing EAE; 2) antibody responses are higher and may play a more important role in RR-EAE than in progressive EAE; and 3) epitope spreading in both T and B cell responses may play a role in this RR-EAE model. Further, our study opens an opportunity to study RR-EAE in gene-targeted mice by backcorssing gene targrted-B6 mice with SJL mice.

Supported By:

This study was supported in part by grants from the US National Institute of Health and US National Multiple Sclerosis Society.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 

Ongoing B Cell Intraclonal Expansion in Lesions of Multiple Sclerosis: Evidence for a Role of Consistent Antigen Stimuli in B Cell Differentiation in MS Lesions

Yufen Qin, Reng-Rong Da, Irvine, CA, Pierre Duquette, Montreal, QC, Wallance W. Tourtellotte, Los Angeles, CA, Stanley van den Noort, Irvine, CA

Objective:

To further elucidate the role of antigen selection in B cell evolution of MS lesions.

Background:

Recent studies have shown that expanded B cell clones are dominant in cerebrospinal fluid (CSF) and plaques/lesions of multiple sclerosis (MS). These cells are hypermutated, postgerminal-center memory B cells. Whether these B lymphocytes undergo intraclonal differentiation is largely unknown.

Design/Methods:

We analyzed intraclonal variations of the immunoglobulin heavy-chain variable region (Ig VH) genes expressed in seventeen lesions from five MS brains. The Ig VH genes expressed in MS lesions were amplified by PCR using primers for consistent regions of Ig heavy chains and primer for VH family leader and then sequenced.

Results:

Our data show that B cell clonal expansion was characteristic of all 17 lesions. Clonally expanded B cells carried somatic hypermutations in their Ig VH genes. These mutations were highly concentrated in the complematory determinant regions (CDR) or framework (FR) regions; there was a clustering of replacement mutations in the CDRs but only a few in the FR regions. This indicates that these cells are post-germinal center B lymphocytes that have undergone antigen-driven selection. Moreover, intraclonal gene variations were found in the offspring of a dominant B cell clone in each of 17 lesions. Only one offspring from each lesion resulted in dominant expansion.

Conclusions:

The findings provide evidence that an ongoing antigen-driven selection may play an important role in lesion formation.

Supported By:

This research was supported by grant RG 3156A1/1 from National Multiple Sclerosis Society, and by grant RO1 NS40534-01A1 from the National Institute of Health.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 

Reorganization of Motor and Cognitive Function in Patients with Multiple Sclerosis

Steven C. Cramer, Irvine, CA, Roderick K. Mahurin, Melanie A. Burke, Ray S. Lee, Seattle, WA

Objective:

To address the hypothesis that, across a range of MS disease severities, best neurologic function is associated with specific patterns of brain reorganization, and that similarities exist in pattern of response for motor and cognitive tasks.

Background:

Clinical deficits in patients with multiple sclerosis (MS) are only partly explained by measures of brain injury, suggesting that reorganization of intact brain tissue might contribute to maintenance of neurologic status.

Design/Methods:

20 right-handed patients with relapsing-remitting MS and no exacerbation for 1 month were enrolled via a blocked design: early (EDSS 4 or less) or late (EDSS 4) disease. 10 age-matched controls were also enrolled. Functional MRI (fMRI) scan 1 alternated right index finger tapping (2/3rd maximum rate, no faster than 2 Hz) with rest. Scan 2 alternated Paced Auditory Serial Addition Test (PASAT-2, tap, if sum is 10) with a control task (tap, if you hear a 7). Activated voxels (Z3) were counted in 10 regions on each brain side. Random effects analysis identified activation foci that correlated significantly (p.01) with behavioral measures drawn from the MS Functional Composite (MSFC).

Results:

Control subject fMRI activation was consistent with prior reports, showing activation foci in leftright hemisphere systems for both tasks. Among patients, better dexterity (right-hand MSFC pegboard score) correlated with increased activation during motor task in several areas including left middle frontal gyrus and right precentral gyrus. Poorer dexterity correlated with increased activation in attention-related areas such as right inferior parietal, right DLPFC, and anterior cingulate cortex. Differences in fMRI do not likely reflect differences in tapping during fMRI, as prescan bilateral EMG and in-scan tapping force were consistent across patients. On voxel counting, greater brain atrophy correlated significantly (p.05) with increased activation in right parietal operculum and right DLPFC. Patient activation was bilaterally smaller than controls in multiple areas. Among patients, better cognitive status (MSFC PASAT-2 score) correlated with increased activation during cognitive task in right insula-parietal operculum. Poorer cognitive status correlated with increased activation in left orbitofrontal and right inferior parietal cortex. On voxel counting, greater brain atrophy correlated with smaller activations, eg left parietal operculum. There were no significant differences between patients and controls during PASAT fMRI.

Conclusions:

The current study evaluated brain reorganization in patients with MS during 2 tasks that are normally based in the left hemisphere. For both the motor and the cognitive task, preservation of function was associated with recruitment of areas not activated in controls, and loss of function was associated with increased activity in a different set of novel brain regions. However, each network was affected differently by atrophy, with increased (motor) vs. decreased (cognitive) activation.

Category - Neural Repair/Rehabilitation

SubCategory - Imaging 

Randomized Trial of Yoga and Exercise in Multiple Sclerosis: Improvements in Fatigue but Not Cognitive Function Compared to Control Group

Barry S. Oken, Shirley Kishiyama, Daniel Zajdel, Dennis Bourdette, Jane Carlsen, Mitchell Haas, Cinda Hugos, Dale Kraemer, Julie Lawrence, Michele Mass, Portland, OR

Objective:

To determine the effect of aerobic exercise and yoga on cognitive function, fatigue, mood and quality of life in multiple sclerosis

Background:

Many patients with MS take yoga classes and report high satisfaction. It is unknown whether taking yoga classes and practicing yoga has any impact on a persons physical or cognitive function, compared to other physical activities or compared to not doing anything.

Design/Methods:

Subjects with clinically definite multiple sclerosis and EDSS less than or equal to 6 were randomly assigned to one of 3 intervention groups lasting 6-months: weekly exercise class adapted for subjects with MS using a stationary bicycle along with home exercise; weekly Iyengar yoga class adapted for subjects with MS along with home practice; or a waiting-list control group. Outcome measures included a battery of cognitive measures; mood (Profile of Mood States, State-Trait Anxiety Inventory); fatigue as assessed on the POMS, Stanford Sleepiness Scale (SSS) and the Multi-Dimensional Fatigue Inventory; and health-related quality of life (SF-36). Outcome measures were assessed at baseline prior to randomization and at the end of the 6-month intervention period. Primary analyses were done on the 6-month outcome measures using ANCOVA with the baseline measure as the covariate. Gender, EDSS, and age were used as additional covariates when the relationships to outcome measures were significant.

Results:

69 subjects were recruited and randomized. 12 subjects did not finish the 6-month intervention (17% drop-out rate). There were no adverse events related to the intervention. There were no effects of the interventions on the cognitive outcome measures. There was improvement in several measures related to fatigue (General Fatigue and Physical Fatigue on the MFI and fatigue on the POMS, most p values comparing each group to control were less than .01). Several measures very related to fatigue were likewise improved in the intervention groups (vitality on the SF-36, p.0005, and SSS at the end but not at the beginning of a 3.5-4 hour assessment session, p.05). There were some changes in mood related to the interventions but these were less consistent than the fatigue measures (p values ranging from .01 to .1). Subjects in the intervention groups also reported their health in general to be better compared to a year ago than those in the control group (p.01).

Conclusions:

Subjects with MS participating in either a 6-month yoga class or exercise class showed significant improvement in several measures related to fatigue compared to a waiting-list control group. There was no improvement in cognition in either of the intervention groups although there was some suggestion for improvements in mood.

Supported By:

NIH AT00066

Category - MS and Related Diseases

SubCategory - Clinical Trials 

The Reconem Study: Cognitive Impairment in Multiple Sclerosis, a National Survey in Argentina

Fernando J. Caceres, Sandra I. Vanotti, Leonor Gold, Buenos Aires, Argentina, Stephen Rao, Milwaukee, WI, the RECONEM Work Group

Objective:

1) To assess the frequency of cognitive impairment (CI) in a clinic-based sample of patients with multiple sclerosis (MS) from representative regions all over the country
2) To compare MS patients with normal control, at the perfomance of the Brief Neuropsychological Screening Battery (BNSB) testing .
3) To correlate the BNSB results with other scales such as Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC)

Background:

CI occurs in 40-60% of patients with MS depending on weather the data are obtained from community-based studies or clinic-based studies.

The BNSB is a sensible and specific instrument to detect CI in MS patients

There are no data about the frequency of CI in ArgentinaMS patients, where the prevalence of MS is estimated at 18/100.000. Located between the 26 and 55 S latitude, Argentina represents the southern tip of the American continent.

Design/Methods:

This is a multicentric descriptive cross-sectional study. 28 MS centers from 8 different areas from Argentina participated. Each center randomly recruited 5 MS patients and 10 demographically matched healthy controls (2 per patient).The BNSB was administered in an specially adapted Spanish version. EDSS; MSFC and Beck Depression Inventory were other outcome measures.

Statistical analyses were performed using computer version for SPSS. The groups were compared using one and two tailed t tests with an alpha level of 0.05 for statistical significance.

Results:

Of 128 evaluated patients with definite MS, 84% were female. Age was 40.97 +/- 11.20 (mean 2 SD). Mean disease evolution time was 7.15 years (+/- 6.53 2SD).

Instruction level:

4.4% of the patients had 3 to 7 years of schooling; 32.7 % had 8 to 12 years and 62.8 % completed more than 13 years of instruction.

Clinical forms:

Relapsing-remitting 83%, secondary progressive 8% and primary progressive 9%. Mean EDSS was 3.25. Mean MSFC z-score was 0.61.

46% of MS patients had CI.

There was a statistically significant difference in all BNSB tests scores between MS patients and healthy controls.

MS patients were more frequently affected on measures of Attention (27 %), Recent Verbal Memory (26.54%); Long Term Memory (24.77 %) and Verbal Fluency (23.89 %): They were less frequently impaired on measuring of Visual Memory (14.15%).

Mean EDSS in MS patients with CI was 3.73 while in the normal BNSB group, it was 2.77 (p0.01). Mean MSFC z-score in the MS-CI group was 1.019 and in the normal BNSB group was 0.0593 (p 0.05).

Conclusions:

The frequency of CI in this MS population was slightly lower than the reported frequency in other studies with the same design.

The cognitive domains more frequently impaired were Short and Long-Term Memory, Attention and Verbal Fluency.

Mean EDSS and MSFC z-score were significantly higher in the MS group with CI.

This is the first report on MS-CI frequency in the region.

Category - MS and Related Diseases

SubCategory - Epidemiology 

A Marker Autoantibody Discriminates Neuromyelitis Optica from Multiple Sclerosis

Brian G. Weinshenker, Rochester, MN, Dean M. Wingerchuk, Scottsdale, AZ, Claudia F. Lucchinetti, Vanda A. Lennon, Rochester, MN

Objective:

To describe the association of a novel autoantibody (NMO-IgG) with neuromyelitis optica (NMO), and the value of seropositivity for discriminating NMO from typical forms of multiple sclerosis (MS).

Background:

Most patients with NMO experience relapsing optic neuritis (ON) and myelitis and have characteristic neuroimaging findings (longitudinally extensive cord lesions during myelitis attacks and normal brain MRI). Many patients also have multiple autoantibodies or systemic autoimmune disease, but no NMO-specific autoantibody has been recognized. One of us (V.L.) recently detected a novel IgG that is a frequent accompaniment of NMO. Here we report a prospective study of the frequency of NMO-IgG in patients suspected to have NMO.

Design/Methods:

We determined the frequency of NMO-IgG in 3 groups of patients: 1) clinically-defined NMO (using diagnostic criteria of varying grades of stringency); 2) high risk for NMO (bilateral ON or single or recurrent attacks of longitudinally extensive myelitis; each associated with negative brain MRI); and 3) MS presenting with ON or myelitis but relatively normal brain MRI. Sera were tested without knowledge of the clinical diagnosis. We collected demographic, clinical, imaging and other laboratory data.

Results:

We analyzed sera from 101 patients with potential NMO on clinical grounds; 93 (92.1%) were treated at Mayo Clinic. The detection rate of NMO-IgG was 26/48 (54.2%) for patients with definite or probable NMO (using the most stringent clinical diagnostic criteria that require longitudinally extensive cord lesions), 13/33 (39.4%) for high-risk patients, and 0/20 (0%) for those with MS. Three high-risk patients seropositive for NMO-IgG had recurrent, longitudinally extensive myelitis and subsequently developed clinically definite NMO.

Conclusions:

The autoantibody NMO-IgG is the first specific biological marker of NMO and is able to distinguish clinically-defined NMO from typical MS. Several seropositive high-risk patients later developed clinically definite NMO. When positive, this autoantibody should allow early diagnosis and initiation of treatment in cases of definite NMO and in patients at high risk to convert to NMO. These findings may extend the spectrum of NMO to include some patients with recurrent ON or longitudinally extensive transverse myelitis.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 

The Frequency of Depression in Primary Progressive Multiple Sclerosis

Rana K. Zabad, Scott B. Patten, Luanne M. Metz, Calgary, AB, Canada

Objective:

To compare the incidence of lifetime major depression in patients with relapsing and primary progressive multiple sclerosis (MS).

Background:

Depression is common in MS and often occurs relatively early in the course of the disease. While several studies document high rates of depression in relapsing forms of MS, none have specifically evaluated its frequency in primary progressive disease. Because there are many phenotypic differences between relapsing and purely progressive forms of MS, differences in the incidence of depression may shed some light on the bio-psycho-social factors that contribute to the development of depression in MS.

Design/Methods:

Prior to the availability of disease modifying therapies 136 patients with clinically definite MS from the University of Calgary MS Clinic participated in a cross-sectional study to evaluate the impact of depression on health related quality of life. Clinical data was obtained by interview, examination, and completion of questionnaires. The WHOs Composite International Diagnostic Interview (CIDI), which has good positive and negative predictive values ( 82% and 77-93% respectively), was used to diagnose lifetime major depression. MS course was defined according to Lublin et al. To determine the relative frequency of depression in patients with primary progressive MS compared to those with a history of relapses, a relapsing group was defined as including all patients with relapsing-remitting, secondary progressive or progressive relapsing MS. The incidence of depression was then compared to those with primary progressive MS. Group differences were evaluated using contingency tables and a two-sided Fischers exact test.

Results:

Twenty-six percent (30/136) of patients had primary progressive MS. Seventy three percent (99/136) were women and the mean age of the sample was 47.01 years. Median EDSS was 5.5 (0-9). Overall, 22.8% (31/136) had a lifetime history of major depression. This included 26.4% (28/106) of the relapsing patients and 10% (3/30) of the primary progressive patients. Despite the limited sample size the difference between the two group showed a trend toward statistical significance (p value 0.083).

Conclusions:

This study suggests that there may be a difference in the incidence of depression between people with relapsing forms of MS and those with purely progressive disease. Further study of larger samples is needed to confirm this finding and to evaluate the impact of other potential factors on the occurrance of depression. Biological factors could include demographic differences, the lower incidence of inflammation, smaller MR lesion load, and differences in the use of corticosteroids and symptomatic therapies. Psychological factors could relate to differences in adjustment to the disease given the abscence of relapses. Social factors, possibly related to demographic differences may also be important.

Supported By:

Canadian Institutes of Health Research, Multiple Sclerosis Society of Canada, Calgary Health Region, and the Alberta Heritage Foundation for Medical Research.

Category - MS and Related Diseases

SubCategory - Epidemiology 

The Role of the Wlds Phenotype in Protection against Wallerian Degeneration in Experimental Autoimmune Encephalomyelitis

Tanuja Chitnis, Jaime Imitola, Prianka Chawla, Maia Sharuk, Samia J. Khoury, Boston, MA

Objective:

To understand the role of Wallerian degeneration in propagating axonal loss during experimental autoimmune encephalomyelitis (EAE).

Background:

Axonal damage has been demonstrated in multiple sclerosis (MS) and may be a determinant of progressive disability. Similar observations have been made in EAE, the animal model of MS. In EAE, there is evidence that axonal damage correlates with chronic symptoms. Wallerian degeneration is a process by which injured axons undergo degeneration of the distal portions of the nerve. Wallerian degeneration may play an important role in propagating axonal damage in EAE and multiple sclerosis. Axons from mice with a spontaneously occurring mutation termed the slow Wallerian degeneration phenotype (Wlds) are relatively protected from Wallerian degeneration. The distal portion of the transected axons from these mice can conduct action potentials for up to 3 weeks, versus 24-48 hours in wild-type mice.

Design/Methods:

Wlds mice on a C57BL/6 background and wild-type C57BL/6 mice (WT) were obtained. EAE was induced via immunization with peptide 35-55 of myelin oligodendrocyte glycoprotein (MOGp35-55). Clinical disease was assessed daily. Axonal loss and demyelination was assessed using Bielschowsky and Luxol fast blue staining on fixed spinal cord tissue. Cytokine production was measured by ELISA. Confocal and immunofluorescence microscopy were used to detect the presence of various molecules in the CNS.

Results:

There was a statistically significant delay in onset of clinical disease in Wlds mice compared with WT. Wlds mice experience a milder form of EAE during the first 40 days of disease (Mean maximal grade days 0-20 WT 2.01.36 , Wlds 0.60.86 p=0.0081; days 20-40 WT 2.71.26, Wlds 1.71.35, p=0.02). After 40 days of EAE, approximately 50% of the Wlds mice experienced worsening EAE comparable to WT. Pathologically, there was decreased axonal loss in the white matter of spinal cords from Wlds mice that remained clinically protected from EAE, compared with wild-type mice, as demonstrated by Bielschowsky staining. Decreased axonal loss was accompanied with decreased demyelination. Cytokine profiles in splenocytes restimulated in vitro with MOGp35-55 were similar between the two groups. T cell infiltrates in the spinal cords of Wlds mice and WT mice were similar; however, a delay in microglia and macrophage accumulation were observed in Wlds mice compared with WT mice. This was associated with increased expression of CD200 in the CNS of Wlds mice.

Conclusions:

The Wlds phenotype confers relative protection against axonal damage in EAE, suggesting that Wallerian degeneration plays an important role in amplifying axonal damage in EAE. Protection from Wallerian degeneration is associated with delayed recruitment of in microglia/macrophages in the CNS, raising the question of whether signals from damaged axons facilitate microglia/macrophage recruitment, which in turn may propagate Wallerian degeneration.

Category - MS and Related Diseases

SubCategory - MS: Animal Models 

Late Onset Multiple Sclerosis: A Longitudinal Study

Galina Vorobeychik, Donald W. Paty, Vancouver, BC, Canada, the UBC MS Clinic Neurologists

Objective:

to evaluate the clinical course of multiple sclerosis (MS)in patients with onset after age 45.

Background:

Late onset multiple sclerosis (LOMS) is uncommon (5-10%) and rarely reported in large series with longitudinal disability measurements.

Design/Methods:

Patients with LOMS (n=271) and complete clinical information from the MS Clinic at the University of British Columbia (UBC Site) Hospital computerized database (MS-COSTAR) were included in this study.

Results:

The mean duration of observation was 10.3 0.38 years. In 125 of 271 patients (46.1%) MS started after age 50. A primary progressive (PP) MS was noted in 100 of 277 (37%) patients. 93 out of 171 (54.4%) patients with relapsing-remitting (RR) MS developed secondary progressive (SP) MS during the observation period. For patients with RRMS or SPMS the mean disease duration from onset to time of confirmed Expanded Disability Scale Score (EDSS) 3.0 was 7.7 0.3 years, to EDSS 6.0 was 8.7 0.33 years. The most common initial symptom in the PPMS patients was a slow deterioration of motor function.

Conclusions:

The course of late onset MS is often primary progressive. Older patients presenting with RRMS are likely to reach the secondary progressive stage earlier than typical (younger) RR patients.

Category - MS and Related Diseases

SubCategory - Epidemiology 

Identification of a Marker Autoantibody of Neuromyelitis Optica

Vanda A. Lennon, Claudia F. Lucchinetti, Brian G. Weinshenker, Rochester, MN

Objective:

To describe characteristics of an autoantibody that is highly associated with neuromyelitis optica (NMO, or Devics disease).

Background:

NMO is an uncommon and often devastating demyelinating disease that is restricted to optic nerves and spinal cord and predominantly affects women. Distinction from multiple sclerosis (MS) is occasionally difficult, although when fully established the disorders are usually readily distinguished by a combination of clinical, MRI imaging and spinal fluid cell and IgG characteristics. Neither disorder has a specific diagnostic marker. Unlike MS, NMO frequently coexists with classical autoimmune disorders and multiple autoantibodies. We therefore analyzed serum from patients classified as definite NMO or MS by clinical, imaging and spinal fluid criteria, and from control patients, for autoantibodies (Ab) that might bind selectively to CNS tissues.

Design/Methods:

Sera (coded at testing) were from patients with definite NMO (48), MS (20) and numerous control disorders, including paraneoplastic vision loss (16), Sjogrens syndrome (10), vasculitides (10) and myasthenia gravis (10). The assay was indirect immunofluorescence with a standard composite substrate of mouse brain, gut and kidney; sera were preabsorbed with liver extract (Ann. Neurol. 50:301, 2001).

Results:

IgG in 26 (54%) of 48 patients with NMO yielded a distinctive staining pattern (NMO-IgG) associated with capillaries throughout the cerebellar cortex and midbrain, and with pia and a subpial mesh (prominent in midbrain). The capillary pattern was not seen in gut mucosa, kidney or liver, and NMO-IgG was not noted in any other study group, but it was identified incidentally in 7 patients amongst thousands whose sera were submitted to Mayo Clinics Neuroimmunology Laboratory for paraneoplastic Ab service testing. Their histories revealed 1 had definite NMO, 3 were at high risk for NMO (i.e., compatible findings, but not fulfilling stringent criteria for definite NMO classification), 1 had new onset myelopathy, 1 had unclassified steroid-responsive CNS inflammatory disorder, and 1 had gastroesophageal cancer and akathisia.

Conclusions:

The novel autoantibody NMO-IgG appears to bind selectively to an element associated with CNS capillaries, pia and subpia. It holds promise as a tool for serological diagnosis of NMO at an early stage and for advancing the classification and therapy of related disorders. It also merits investigation as a candidate effector of NMO, which recent immunohistochemical studies suggest has a humoral and complement-mediated basis targeting CNS perivascular regions (Brain 125:1450, 2002).

Category - MS and Related Diseases

SubCategory - Clinical Immunology 

IgA+ B Cell Clonal Expansion in Silent Lesions of Multiple Sclerosis: A Correlation of IgA VH Gene Analysis with Immunohistochemistry Examination

Yiping Zhang, Reng-Rong Da, Irvine, CA, Pierre Duquette, Montreal, QC, Canada, Wallace W. Yourtellote, Los Angeles, CA, Stanley van den Noort, Yufen Qin, Irvine, CA

Objective:

To elucidate the role of IgA and IgA+ B cell in MS lesion formation.

Background:

The pathology of multiple sclerosis (MS) is more complicated than previously recognized. Neuropathological studies reveal that inflammatory cells especially T cells are not always present in the areas of active demyelination. There is accumulating evidence implicating antibody producing B cells in the pathogenesis of MS. The prominent deposition of immunoglobulins (Igs) and complement, accompany with a B lymphocyte clonal expansion, are frequently found at sites of active myelin destruction with few infiltrating T cells (silent MS lesion).

Design/Methods:

We analyzed variations of the Ig heavy-chain variable region (Ig VH) genes expressed in twenty-eight lesions from four MS brains. IgA VH genes were amplified by PCR using primers for IgA consistent regions (Ca) of Ig heavy chains and primer for VH family leader and then sequenced. Immunohistochemical staining (IgA, IgG, IgM, and CD3) was also performed on the same set of samples.

Results:

The results show that clonal expansion of IgA secreting B cells were expressed in eight MS lesions (28%) from three MS brains. These IgA secreting B lymphocytes carried somatic mutations on their Ig VH genes, indicating that these IgA+ B cells had differentiated from a mucosal immune response. Immunohistochemistry study of these lesions was consistent with the IgA gene analysis, namely enriched IgA positive cells in MS lesions with evidence of clonal IgA VH genes. Anti-IgA antibody bound to surface plasma cells in parenchyma, the areas with undergoing demyelination, the myelin networks around scattered axons, and droplets of myelin debris in parenchyma. The T cells in these lesions were minimal.

Conclusions:

This finding suggests that in certain circumstance, highly mutated IgA+ B cells derived from a mucosal immune response may be actively involved in lesion formation in MS. These IgA+ B cells and antibodies may play an important role in the pathogenesis of MS.

Supported By:

This research was supported by grant RG 3156A1/1 from National Multiple Sclerosis Society, and by grant RO1 NS40534-01A1 from the National Institute of Health.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 

Blockers of L-Type Ca2+ Channels Ameliorate Disease in a Mouse Model of Inflammatory Demyelination

Peter Werner, Elimor Brand-Schieber, Alessandro Di Rocco, New York, NY

Objective:

To determine whether Ca2+ L-channel blockers, currently used for the treatment of cardiovascular diseases, can ameliorate experimental autoimmune encephalomyelitis (EAE) in a mouse model of multiple sclerosis.

Background:

Influx of Ca2+ is implicated in CNS white matter conditions such as multiple sclerosis and spinal cord injury. We studied the effect of a dihydropyridine-type and a non-dihydropyridine Ca2+ channel blocker, nitrendipine and bepridil, both widely used for other diseases, on mouse adoptive-transfer EAE (AT-EAE), an animal model of MS.

Design/Methods:

Young adult female SJL/J were used. Lymphnode cells (LNC) were removed from donor mice, sensitized to a CNS antigen, MBP, and clonally expanded in vitro