All About Multiple Sclerosis

More MS news articles for April 2003

American Academy of Neurology (AAN)
55th Annual Meeting
Speakers' Abstracts about Multiple Sclerosis

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

March 29-April 5, 2003
Honolulu


[S21.005]

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 


[P03.104]

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 


[S44.004]

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 


[P01.122]

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 


[P06.109]

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 


[P02.139]

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 


[S43.003]

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 


[P04.095]

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 


[P04.085]

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 


[S55.006]

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 


[P02.150]

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 


[P02.130]

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 


[P03.107]

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 


[P01.121]

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 


[P03.001]

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 


[P01.108]

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 


[P05.137]

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 


[P01.053]

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 


[P05.133]

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 


[P04.005]

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 


[P04.089]

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 


[S51.002]

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 


[S61.001]

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 


[S25.003]

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 


[S25.001]

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 


[P06.123]

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 


[P04.002]

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 


[P03.103]

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 


[P01.109]

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 


[P05.121]

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 


[P02.133]

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 


[P03.114]

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 


[S55.004]

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 


[S04.001]

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 


[P06.119]

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 


[P01.111]

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 


[S65.005]

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 


[P06.116]

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 


[P03.112]

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 


[P01.113]

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 


[S65.004]

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 


[P04.004]

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 


[P03.113]

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 in the presence of MBP. 3.7 4.0 x 107 cells were injected into the tail vein of recipient SJL/J mice. Disease presented as initial acute ascending paralysis (onset 8-10 days, remission 18-20 days after LNC transfer) and a relapsing-remitting disease course thereafter.

Results:

Nitrendipine, a selective ,dihydropyridine-type, voltage-gated Ca2+-channel blocker (2.5 mg/kg/day), started on day 0, ameliorated AT-EAE significantly (p0.05) compared to vehicle alone. Similarly, Bepridil, a non-dihydropyridine Ca2+ channel blocker (3 mg/kg/day), significantly reduced the average clinical score of AT-EAE by 1.5-2 points (out of 5; p0.05) compared with vehicle control, when started on day 0, or, also, when started on day 3 post-LNC transfer. Histopathologically, Bepridil reduced white matter pathology, but not peripheral monocyte infiltration in to the CNS. Finally, long-term treatment of relapsing-remitting EAE with bepridil seems to decrease the number of relapses.

Conclusions:

The fact that both calcium channel blockers provided similar benefits suggests that a common target, likely voltage gated Ca2+ channels, are associated with white matter damage in EAE, and, possibly, MS. However, we cannot rule out an effect of on the immune reaction since LNC, when incubated with bepridil before transfer to recipient animals, delayed onset and led to a more benign course of the disease when compared to vehicle treated cells.

Supported By:

Supported by NIH (NS-41056) to P.W.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P01.104]

A Prospective Study of Infection with Chlamydia pneumoniae and Risk of Multiple Sclerosis in Two Large US Cohorts

Kassandra L. Munger, Boston, MA, Rosanna W. Peeling, Winnipeg, MB, Canada, Lynn I. Levin, Mark V. Rubertone, Charles A. Peck, Washington, DC, Gerald N. DeLorenze, Oakland, CA, Joseph H. Vogelman, New York, NY, Alberto Ascherio, Boston, MA

Objective:

To examine prospectively the association between Chlamydia pneumoniae (Cpn) infection and risk of multiple sclerosis (MS).

Background:

Cpn has been proposed as a possible etiologic agent in MS. However, previous studies were cross-sectional and could not assess whether Cpn infection preceded the onset of MS.

Design/Methods:

We conducted a prospective nested seroepidemiological case-control study among over 3 million US Army personnel and over 120,000 members of the Kaiser Permanente Medical Care Program (KPMCP) cohort. At least one serum sample collected prior to onset was available for 83 MS cases in the Army and 46 in the KPMCP cohort and all were included in this study. Two controls were matched to each case on age and sex. Army controls were further matched to cases on race and date of blood collection. Microimmunofluoresence was used to measure serum IgM and IgG antibody titers to Cpn and previous infection with Cpn was defined as having IgG titers 1:16.

Results:

Among the Army cases, average age of MS onset was 27 and average time between serum collection and onset was 4 years; in the KPMCP cohort, mean age of onset was 46 and serum samples were collected on average 15 years prior to onset. Seropositivity for Cpn was not associated with an increased risk of MS. Of the cases, 69% and 63% were IgG seropositive in the Army and the KPMCP, respectively, versus 66% and 53% of the controls. (OR (95% CI): Army: 1.1 (0.6, 2.1); KPMCP: 1.6 (0.69, 3.5)). In the Army, geometric mean Cpn IgG titer (GMT) levels among seropositive cases and controls did not significantly differ between all cases and controls (77 vs. 95, p=0.14), relapsing-remitting cases (n=28) and controls (91 vs. 108, p=0.33), or primary progressive cases (n=7) and controls (105 vs. 77, p=0.58). In the KPMCP cohort, however, GMT levels were overall significantly higher in the Cpn seropositive cases than controls (146 vs. 64, p=0.009). This difference was stronger for progressive (includes both primary and secondary) cases (n=14) (156 vs. 61, p=0.04) than for relapsing-remitting cases (n=4) and controls (128 vs. 91, p=0.42).

Conclusions:

Our results do not support a role for Cpn in the etiology of MS. However, the possibility that infection with Cpn prior to onset may promote a progressive disease course cannot be excluded.

Supported By:

NIH grant no. NS42194 and by a pilot grant from the National Multiple Sclerosis Society

Category - MS and Related Diseases

SubCategory - Epidemiology 


[S31.006]

Diffuse Axonal Injury as a Cause of Fatigue in Multiple Sclerosis

M. C. Tartaglia, S. Narayanan, S. J. Francis, Mtl, QC, Canada, N. De Stefano, Siena, Italy, R. Arnaoutelis, Y. Lapierre, D. L. Arnold, Mtl, QC, Canada

Objective:

We hypothesized that diffuse cerebral axonal damage could be associated with fatigue and used proton magnetic resonance spectroscopy (HMRS) to non-invasively measure axonal injury in the brains of Multiple Sclerosis (MS) patients. Our aim was to evaluate the relationship between central brain N-acetylaspartate (NAA) and fatigue.

Background:

Fatigue is a common complaint of MS patients and is considered by many of them to be one of their most disabling symptoms. Patients suffering from fatigue complain of a lack of energy and a sense of tiredness not related to muscle weakness. Although the mechanisms responsible for fatigue in MS patients are still not known, there is increasing evidence that fatigue has a central origin and that the problem lies rostral to the corticospinal tracts and could be due to cortico-subcortical interconnection damage or disseminated demyelination.1

Design/Methods:

In this cross-sectional study, data from 73 MS patients who had undergone HMRS imaging and completed the Fatigue Severity Scale (FSS) questionnaire were analyzed. The FSS was used to quantify subjective, general fatigue. The patients were divided into two fatigue groups based on their FSS scores: low fatigue group (FSS4) N=26 and high fatigue group (FSS5) N=34. Thirteen patients with an FSS score between 4 and 5 were excluded from the between group analysis but retained for correlation analyses.

Results:

NAA/Creatine (Cr) was significantly lower in the high fatigue group than the low fatigue group, (2.690.29 and 2.990.33, respectively, p=0.001). The low fatigue group had a significantly lower EDSS 2.692.2 than the high fatigue group 3.812.2, (p=0.018). There was a trend towards a difference in the ages of the two groups, with a mean age of 38.0910.2 for the low fatigue group versus 42.126.9 for the high fatigue group, (p=0.092). There was no significant difference in disease duration or T2 lesion volumes between the two groups. An ANCOVA performed with EDSS and age as covariates still revealed a significantly lower NAA/Cr in the high fatigue group as compared to the low fatigue group, (p=0.004). There was a significant linear correlation between FSS and NAA/Cr (Spearman Rank rho=-0.361, p=0.001).

Conclusions:

The results of this study suggest that diffuse periventricular axonal injury is associated with increased fatigue in MS patients. Independent of EDSS, T2 lesion volume, age and disease duration, NAA/Cr was significantly lower in the high fatigue group as compared to the low fatigue group. Moreover, a significant correlation was present between fatigue and NAA/Cr. We hypothesize that fatigue in MS patients could be related to the need for compensatory increases in cortical activation due to axonal injury.

References:

1. MSCfCP. Fatigue and multiple sclerosis: evidence based strategies for fatigue in MS. Washington: Paralyzed Veterans of America 1998.

Supported By:

McGill University Research bursaries, MRC, MS Society Canada.

Category - MS and Related Diseases

SubCategory - Imaging 


[P01.110]

Multiple Sclerosis Quality of Life Project: An Exurban Needs Assessment

Gerard M. Lehrer, Joy M. Smith, Lotte Marcus, Carmel, CA, Natinoal MS Society

Objective:

Quantify disability, Measure financial and psychosocial burden of people with MS (PWMS); Examine medication costs; Quantify utilization/satisfaction with health care services/community resources; Describe living arrangements of PWMS; Measure burden of primary caregivers (CG); Quantify future needs of PWMS and CG; Establish a database of PWMS in the tri-county area of Monterey, San Benito and Santa Cruz.

Background:

People concerned about the plight of PWMS set out to define needs of PWMS in exurban CA with diverse medical systems, cultural milieu, housing, employment opportunities and community resources. The sample was heterogeneous in disability, financial stability, access to health care, resources and availability of support, education and rehabilitation services.

Design/Methods:

80 PWMS and 25 CG were interviewed in home or care setting by 4 RN and PT in depth to assure questions were understood and answers were complete. Standard DATA COLLECTION TOOLS (DCT) and questionnaires were used Data from PWMS were analyzed as a group; and by disability: (ambulatory N=48; wheelchair/bedbound N=32). CD data were analyzed as a complete cohort (N=25).

Results:

Most PWMS need assistance in maintaining independence and enhancing quality of life and medical care. Unmet needs are broad. PWMS and CG need help in financial, medical, psychosocial, educational needs. 50% of PWMS and. 62.5% wheelchair/bed-bound were single, divorced or widowed. 40% lived alone or in skilled nursing facilities and lacked advocates and help in safeguarding and enhancing their well being. Most disabling were fatigue, vision deficits and weakness. 50% were not on disease modifying therapy and were taking medications irregularly or not at all. 46% had no plan for negative change in their finances and felt need for help in maximizing their resources. Most had Medicare and/or MediCal, systems designed primarily for acute care, often not meeting prescription and living expenses of chronic illness. Many are not getting entitlement due to complexities of the system, lack of stamina, visual acuity and the maze of details. Most found care by multiple specialists was fragmented and uncoordinated. PWMS in skilled nursing facilities had rare physicians visits and were managed by a medical director of the facility with no expertise in MS, often without psychosocial experts; yet 30% were on antidepressants. Only 20%, all ambulatory, had mental health care. The more disabled had none.

Conclusions:

Many PWMS and CG have no adequate medical and psychiatric supervision and need better, unified coordination of professional services. Almost 1/2 of PWMS are not receiving disease modifying therapy. A model is being developed for case management, coordinated by a caring social worker.

Supported By:

An independent group concerned about PWMS in this tri-county area and The Silicon Valley Chapter of the National Multiple Sclerosis Society

Category - MS and Related Diseases

SubCategory - Other 


[S51.004]

Ring-Enhancement Pattern Predict Short-Term Brain Atrophy Changes in Relapsing-Remitting Multiple Sclerosis

Laura Locatelli, Robert Zivadinov, Trieste, Italy, Francesca Bagnato, Rome, Italy, Davide Nasuelli, Trieste, Italy, Stefano Bastianello, Licia Finamore, Rome, Italy, Alessio Bratina, Attilio Grop, Mauro Catalan, Trieste, Italy, Alessandro Clemenzi, Enrico Millefiorini, Rome, Italy, Marino Zorzon, Trieste, Italy

Objective:

To establish whether monthly brain atrophy changes predict physical disability changes in a group of relapsing-remitting (RR) multiple sclerosis (MS) patients monitored over a short time period. To assess the value of monthly gadolinium (Gd)-enhanced MRI and of different Gd-enhancement patterns as predictors of brain atrophy.

Design/Methods:

We studied 30 patients with RR MS (mean disease duration 4.9 years, mean age 34.4 years and mean EDSS 1.4). Patients were assessed at baseline and monthly for a period of three months with clinical, EDSS and MRI examinations. Calculations of baseline and monthly absolute and percent changes of MRI measures have been obtained, i.e. number of brain lesions in T2-, FLAIR- and Gd-enhanced T1-weighted images, T2-, T1 Gd-enhancing-, T1- and FLAIR-lesion load (LL) and brain parenchymal fraction (BPF). In patients presenting Gd-enhancing lesions, the evaluation of different Gd-enhancement patterns was performed.

Results:

Mean absolute and percent changes of BPF did not significantly differ at any timepoint of the study, although BPF slightly decreased from baseline to month 3 (-0.0004 [0.05%], p= 0.093). In ring-enhancement positive patients there was a significant difference between baseline and month 3 changes of FLAIR-LL, BPF, EDSS and number of relapses. Moreover, this difference was significantly greater than that of patients with homogeneously enhancing lesions. Changes in BPF were not correlated with changes in EDSS and number of relapses at any time point of the study. Longitudinally, multiple regression analysis demonstrated that the only clinical or MRI parameter that predicted BPF decrease was the mean absolute change of ring-enhancing-LL (R=0.62, p=0.003).

Conclusions:

The noteworthy findings of this study are: 1) the observation that a significant brain atrophy progression can not be detected over a three months period in RR MS patients at the earliest stages of the disease, 2) the lack of relationship between physical disability, clinical disease activity and brain atrophy changes in a short-term period, 3) the lack of relationship between the presence and duration of Gd-enhancement activity and brain volume changes in the short term, 4) the demonstration that the ring-enhancement pattern may contribute to more severe brain tissue loss in the short term.

Category - MS and Related Diseases

SubCategory - Imaging 


[P04.007]

MMP-9 Microsatellite Polymorphism and Multiple Sclerosis

Nicola Fiotti, Robert Zivadinov, Nicola Altamura, Davide Nasuelli, Maria Antonietta Tommasi, Antonio Bosco, Laura Locatelli, Attilio Grop, Giuseppe Cazzato, Carlo Giansante, Marino Zorzon, Trieste, Italy

Objective:

To determine if matrix metalloproteinase 9 (MMP-9) microsatellite polymorphism (PM) is associated with multiple sclerosis (MS) susceptibility and with clinical and magnetic resonance imaging (MRI) characteristics of MS.

Background:

MMP-9 plays an important role in MS pathophysiology. A PM in the microsatellite (14-27 AC repeats) of the promoter region modulates its expression.

Design/Methods:

In 95 MS patients and 95 age- and sex- matched controls, MMP-9 PM has been determined. In MS patients, clinical (age, age of onset, disease duration, EDSS) and MRI (brain parenchymal fraction, T1- and T2- lesion load) characteristics have been evaluated according to MMP-9 PM.

Results:

Patients with MS had different patterns of microsatellite PM (i.e. higher numbers of AC repeats) than controls (p0.0001). Prevalence of more than 22 AC repeats in at least one allele was higher in patients than in controls (OR 3.4, 95% CI 1.7- 6.8, p0.0001). There was no difference between the main clinical or MRI disease activity outcomes when the patients were stratified according to the number of repeats in the MMP-9 promoter region. In multiple regression analysis we found that the only variable that independently predicted the presence of at least one allele with more than 22 AC repeats in the MMP-9 promoter region was younger age at disease onset (R= 0.29, p= 0.023).

Conclusions:

The PM in the microsatellite (more than 22 AC repeats) of the MMP-9 promoter region is associated with an increased risk of MS and with disease onset at younger age. Further studies are needed to confirm and elucidate our results.

Category - MS and Related Diseases

SubCategory - Genetics 


[P06.101]

Treatment of Multiple Sclerosis with a Humanized Monoclonal Antibody Specific for IL-2 Receptor Chain

John W. Rose, Salt Lake City, UT

Objective:

Daclizumab (Zenapax) is a humanized monoclonal antibody specific for the interleukin 2 receptor chain (IL-2R) that inhibits IL-2 mediated activation of lymphocytes. In this investigation we assess the safety profile and efficacy of daclizumab in patients with relapsing/remitting and secondary progressive multiple sclerosis (MS).

Background:

The interleukin-2 receptor (IL-2R) is an important target for therapy of immune mediated diseases. Previous studies with IL-2R specific therapy have resulted in dramatic suppression of autoimmune disease models including relapsing and remitting experimental autoimmune encephalomyelitis. The development of a humanized monoclonal antibody specific for IL-2R has resulted in an effective agent for treatment of renal transplant rejection. Daclizumab has shown considerable efficacy in autoimmune uveitis and has been investigated at NIH as a therapy concomitant with interferon beta in multiple sclerosis.

Design/Methods:

Patients with relapsing/remitting and secondary progressive MS were started on open-label therapy with daclizumab at entry and at two weeks followed by monthly treatments. Eight patients (4 relapsing/remitting and 4 secondary progressive) with EDSS 2.5 to 6.5 have been started on therapy at 1mg/kg at each infusion according to an NIH protocol. Prior to initiating daclizumab infusions, six patients were failing therapy with interferon or interferon with immunosuppressive agents and two were on no therapy.

Results:

Six patients have been treated for 2 to 12 months. Improved clinical status (1.0 to 4.0 points on EDSS) has been observed in four patients with the other 2 patients stablized. One patient had a severe attack coinciding with the initiation of therapy and after 2 weeks required immunosuppressive therapy, plasmapheresis and chemotherapy to partially recover. This patient has restarted daclizumab with improving clinical status. A patient discontinued treatment because of discomfort in the hands, which occurred following the second infusion. Four patients experienced paraesthesias after the second to fourth treatments. These sensory complaints resolved with continuing treatment. Mild leukopenia was observed once in a single patient. A mild rash has occurred in two patients. Five of the seven patients continuing on daclizumab therapy are currently on no other immunotherapies and the other two are on IFN1b in conjunction with the monoclonal antibody. Improvement in lesion burden and absence of new enhancing lesions has been documented in two patients studied so far with serial MRIs.

Conclusions:

The therapy with daclizumab in MS patients is very well tolerated. The side effect profile is favorable when compared to other agents. Treatment can result in substantial improvement in clinical status even in patients failing other immunotherapies. Improvement in MRIs can be observed in patients on daclizumab treatment. The potential of this humanized IL-2R specific monoclonal antibody as a combined therapy or monotherapy is being further explored in ongoing phase II trials with MRI outcome measures.

Supported By:

Neurovirology Lab VASLCHCS and West. Inst. for Biomedical Res.

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P01.023]

Comparision of Visual Function Tests in an MS Cohort

Laura J. Balcer, Ligia Nano-Schiavi, Dina A. Jacobs, Clyde E. Markowitz, Dorothea C. Pfohl, Steven L. Galetta, Maureen G. Maguire, Philadelphia, PA

Objective:

To determine which clinical measures best distinguish patients with multiple sclerosis (MS) from disease-free controls on the basis of visual function.

Background:

The quantitative assessment of visual impairment in MS clinical trials has been traditionally limited to Snellen acuity. Previous investigations suggest that contrast letter acuity and contrast sensitivity are the most sensitive clinical measures of visual dysfunction in MS, even among patients with Snellen acuities of 20/20 or better.

Design/Methods:

In this cross-sectional study, MS patients and disease-free controls underwent testing using 5 measures: visual acuity (ETDRS chart), contrast letter acuity (Sloan charts), contrast sensitivity (Pelli-Robson chart), color vision (LAnthony D-15 desaturated test - D15-DS), and Esterman visual field (HVF II). Tests were administered binocularly; detailed protocol refractions were performed prior to testing.

Results:

Median binocular Snellen acuities were better than 20/20 in both the MS (N=125, mean age 469) and control groups (N=75, mean age 3811 years). Comparison of ROC curve areas (probability/capacity for each test to correctly classify participants as MS vs. controls) revealed that Sloan charts and Pelli-Robson best distinguished MS patients from controls, and that only Sloan charts distinguished MS patients to a degree that was significantly better than visual acuity (significance level p0.01 used since multiple comparisons performed):

Visual Acuity (VA): ROC curve area (95% CI) = 0.68 (0.60, 0.76)

Sloan Charts: ROC curve area (95% CI) = 0.83 (0.77, 0.88), p0.0001 vs. VA curve

Pelli-Robson: ROC curve area (95% CI) = 0.80 (0.74, 0.88), p=0.01 vs. VA curve

D-15 DS: ROC curve area (95% CI) = 0.69 (0.63, 0.75)

Esterman VF: ROC curve area (95% CI) = 0.56 (0.43, 0.69)

Accounting simultaneously for age, Sloan charts and Pelli-Robson again demonstrated the greatest capacity to distinguish MS patients vs. controls (p0.001), even within the lowest age quartile (21-34 years, p=0.002 for Sloan charts, p=0.01 for Pelli-Robson).

Conclusions:

Among clinical outcome measures, tests of contrast letter acuity (Sloan charts) and contrast sensitivity (Pelli-Robson) best distinguish patients with MS from disease-free controls on the basis of visual function. These measures thus demonstrate the greatest capacity to identify visual loss among MS patients in cross-sectional analyses.

NIH-EY 013273 and National MS Society RG3208-A-1.

Category - Neuro-Ophthalmology/Neuro-Otology

SubCategory - Epidemiology 


[P03.002]

Neurological Manifestations in Sjgrens Syndrome (1). Clinical and Biological Findings in a Cohort of 82 Patients

Sophie Delalande, LIlle, France, Jerome de Seze, Anne Laure Fauchais, Eric hachulla, Tanya Stojkovic, Didier Ferriby, Pierre Yves Hatron, Patrick Vermersch, Lille, France

Objective:

To describe the clinical and laboratory features of SS patients with neurological manifestations.

Background:

Neurological involvement occurs in approximately 20% of patients with primary Sjgrens syndrome (SS) . However, the diagnosis is sometimes difficult and central nervous system (CNS) manifestations have rarely been described.

Design/Methods:

Eighty-two patients (65 women and 17 men) with neurological manifestations associated with primary SS, as defined by the American-European criteria (Vitali et al., 2002), were studied.

Results:

The mean age at neurological onset was 54 years. Neurological involvement frequently preceded the diagnosis of SS (81% of patients). Fifty-six patients had CNS disorders mostly focal or mutifocal. Twenty-nine patients had spinal cord involvement (acute myelopathy [n=12], chronic myelopathy [n=16] and motor neuron disease [n=1]). Thirty-three patients had brain involvement and 13 patients had optic neuropathy. The disease mimicked relapsingremitting multiple sclerosis (MS) in 10 patients and primary progressive MS in 13 patients. We also recorded diffuse CNS symptoms: seizures (n=7), cognitive dysfunction (n=9) and encephalopathy (n=2). Fifty-one patients had peripheral nervous system involvement (PNS). Symmetric axonal sensorimotor polyneuropathy with a predominance of sensory symptoms or pure sensory neuropathy occurred most frequently (n=29), followed by cranial nerve involvement affecting trigeminal, facial or cochlear nerves (n=16). Multiple mononeuropathy (n=7), myositis (n=2) and polyradiculoneuropathy (n=1) were also observed. Patients with PNS manifestations had frequent extraglandular complications of SS . Anti-Ro (SSA) or anti La (SSB) antibodies were detected in 21% of patients at the diagnosis of SS and in 43% of patients during the follow-up (mean follow-up: 10 years). Hypergammaglobulinemia was detected in 31% of patients, lymphopenia in 42%, cryoglobuminemia in 39% and rheumatic factor in 34%. Biological abnormalities were more frequently observed in patients with PNS than in those with CNS involvement (p0.01).

Conclusions:

Our study underlines the diversity of neurological complications of SS. The frequency of neurological manifestations revealing SS and negative biological features, especially in the event of CNS involvement, could explain why it is frequently misdiagnosed. Screening for SS should be systematically performed in cases of acute or chronic myelopathy, axonal sensorimotor neuropathy or cranial nerve involvement

Category - Neurologic Manifestations of Systemic Disease

SubCategory - Other 


[P02.131]

Treatment of Progressive Forms of Multiple Sclerosis by Cyclophosphamide. A Cohort Study of 490 Patients

Helene Zephir, Jerome de Seze, Alain Duhamel, Lille, France, Marc Debouverie, Nancy, France, Patrick Hautecoeur, Lomme, France, C. Lebrun, Nice, France, I. Malikova, M. Pelletier, Marseille, France, Patrick Vermersch, Lille, France

Objective:

From retrospective data of patients with progressive multiple sclerosis (MS) , we studied clinical patterns that predicted a good response to cyclophosphamide (CYC) treatment. Secondly, we compared the therapeutic response of secondary progressive MS (SPMS) and primary progressive MS (PPMS) patients.

Background:

There are no definite disease-modifying drugs for progressive forms of multiple sclerosis (MS). Some MS centers use cyclophosphamide (CYC) in secondary progressive (SP) forms of MS, especially after interferon beta-1b treatment failure. Moreover, there are currently no approved drug for primary progressive (PP) MS.

Design/Methods:

Data from 490 MS patients were collected. All patients presented SP (n=362) or PP (n=128) forms and 476 had been treated for at least one year by monthly pulse of CYC. Evolution was evaluated by the Expanded Disability Status Scale (EDSS) at baseline and after 6 months (M6) and 12 months (M12) of treatment.

Results:

The therapeutic response at M12 was not related to any clinical factor, such as a short ( 2 years) progressive time course, relapses one year before baseline, or EDSS at baseline. Logistic procedures did not find any predictive factor for a good response to CYC. We observed that poor responders at M6 did not respond at M12 (p0.0001). After 12 months of CYC treatment, 80.42% of SPMS and 73.5% of PPMS patients had stabilized or improved their EDSS score. Response to CYC was not significantly different in the two progressive forms of MS (p=0.26). Twenty-two patients presented noticeable side effects, one of whom withdrew from the treatment due to intolerance.

Conclusions:

This large cohort study did not confirm previous results that suggested that a good response could be seen in earlier aggressive inflammatory MS. Despite the lack of predictive factors for a good response to CYC, there was a correlation between response at M6 and M12. Lastly, we showed that the response to CYC is not significantly different between the two progressive forms of MS. As a high percentage of patients were stabilized by the treatment, CYC should be proposed in PPMS as for SPMS.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P04.099]

Diagnostis of Acute Disseminated Encephalomyelitis (ADEM) with Proton MR Spectroscopic Imaging

Ali Fatemi, Peter B. Barker, Eric H. Kossoff, Gerald V. Raymond, Baltimore, MD, Alberto Bizzi, Milan, Italy, Alena Horska, Hugo W. Moser, Thomas O. Crawford, Baltimore, MD

Objective:

To assess the diagnostic value of quantitative MR Spectroscopic Imaging (MRSI) findings in childhood ADEM by comparing with normal controls and X-linked adrenoleukodystrophy.

Background:

ADEM often manifests with striking neurologic signs and symptoms, yet the diagnosis itself is woefully vague. Lack of a well defined nosology, and the absence of specific diagnostic testing, has hampered research into pathophysiology and treatment. Although the differential diagnosis is large, ADEM is most frequently compared to multiple sclerosis (MS). Early differentiation of these two disorders is important, as prognosis and treatment differs.

Design/Methods:

MRSI findings were compared between five children with ADEM (age: 6-15 years), 15 healthy control children (age: 3-19 years) and seven patients with X-ALD (age: 5-15). All patients were scanned on a 1.5 T clinical system. Diagnosis of ADEM was based on the clinical characteristics and MR Imaging findings. All patients made a complete recovery at follow-up. The lesions in X-ALD were limited to the parieto-occipital periventricular white matter. The MR protocol consisted of routine brain MRI (Sagittal T1W, Axial T2W images) and quantitative 3 or 4 slice proton MRSI (TR4slice 2300, TR3slice 1700, TE 280, 32x32x256 matrix, 15 mm slice thickness) in the axial plane. Metabolic images of N-acetyl aspartate (NAA), creatine (Cr) and choline (Cho) were generated and metabolite concentrations were determined.

Results:

The mean NAA concentration in ADEM lesions was lower than in healthy controls in the frontal and parietal white matter, in the dorsal parietal, motor, and medial premotor cortices, and the putamen (all p 0.01). NAA was also reduced in ALD lesions compared to healthy controls (p 0.0001). NAA levels were not significantly different between ADEM and ALD lesions. There was no significant difference in choline between ADEM and healthy controls, but choline was significantly higher in ALD lesions than in both healthy controls and ADEM lesions (p 0.01). Regions of the brain with normal T2-weighted MRI appearance in patients with ADEM also had significantly lower NAA than healthy controls (p 0.05). Only one ADEM lesion showed elevated lactate, while lactate was detected in lesions in 4 out of 7 X-ALD patients.

Conclusions:

Our results demonstrate NAA reduction in ADEM. As opposed to demyelinating diseases such as X-ALD or multiple sclerosis, no choline elevation was detected in ADEM. T2 hyperintensity on MRI with normal levels of choline suggest that the underlying pathology is related more to edema and axonal injury rather than demyelination. Metabolite changes were also observed outside the ADEM lesions suggesting more diffuse pathology than observed by MRI. Proton MRSI may be helpful is establishing an early diagnosis of ADEM in patients who will have a good clinical outcome.

Category - MS and Related Diseases

SubCategory - Imaging 


[S11.003]

Therapeutic Intervention of Multiple Sclerosis with a CD40 Ligand Antagonist: A Phase I Clinical Trial

Camilo E. Fadul, Kathleen A. Ryan, Randolph J. Noelle, Heather A. Wishart, Andrew J. Saykin, Alexander C. Mamourian, Lebanon, NH, Mark C. Totoritis, San Diego, CA, William F. Hickey, Lebanon, NH, Aron D. Thall, San Diego, CA, Tor D. Tosteson, Lloyd H. Kasper, Lebanon, NH

Objective:

The objective of this trial was to determine safety and feasibility of blocking CD154 in patients with Multiple Sclerosis (MS).

Background:

The interaction between antigen presenting cells and T cells by engagement of CD40 and its ligand, CD154 (CD40L) is essential for the activation of T cells. Pre-clinical studies have suggested the importance of this co-stimulatory interaction in the pathogenesis of MS.

Design/Methods:

In a Phase I study designed to establish the safety of proposed therapeutic doses of humanized CD154 (IDEC-131), four sequential cohorts of 3 patients with relapsing-remitting MS received four biweekly doses of 1, 5, 10, or 15 mg/kg respectively. Clinical, laboratory, MRI, and neuropsychological evaluations were performed at serial time points to assess toxicity with immunological and pharmacokinetic assays as secondary outcomes.

Results:

Multiple doses of CD154 (IDEC-131) were found to be safe for all levels tested in 12 patients with relapsing-remitting multiple sclerosis. Fifteen adverse events, all of mild to moderate severity were considered to be of possible relationship to treatment. There was no evidence of toxicity as measured by EDSS, relapse rate, laboratory parameters or other clinical indicators.

Conclusions:

These observations suggest that CD154 is safe and well tolerated in patients with relapsing-remitting disease; the safety profile provides rationale for a larger scale controlled efficacy study of this potential therapy for MS.

Supported By:

Supported by a grant from IDEC Pharmaceuticals. Grants from the National MS Society, the Hitchcock Foundation and the Ira DeCamp Foundation provided partial support of this research.

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P03.102]

Transfer of Severe EAE by IL-12 & IL-18 Potentiated T Cells Is Estrogen Sensitive

Agata Matejuk, Portland, OR, Atsushi Ito, Kyoto, Japan, Jami Dwyer, Arthur A. Vandenbark, Halina Offner, Portland, OR

Objective:

The aim of this study was to evaluate the roles of IL-18 and IL-12 in potentiating encephalitogenic activity of T cell lines specific for myelin oligodendrocyte glycoprotein (MOG)-35-55.

Background:

Experimental autoimmune encephalomyelitis (EAE) is a paralytic disease of the CNS induced by immunizing susceptible animals with myelin antigens or peptides, or by adoptive transfer with activated T cells specific for myelin antigen. The first step in the development of disease is thought to be activation of specific T cells followed by differentiation into Th1 cells, which produce high levels of IFN-, IL-2, TNF- and lymphotoxin. IL-12 and IL-18 are both strong inducers of Th1 cells and have been known as important factors regulating the induction of EAE.

Design/Methods:

For passive transfer MOG-specific T cell lines were generated from C57BL/6 mice, stimulated with CD3/CD28 antibodies and in the presence or absence of IL-12, IL-18 or the combination of both. ELISA and intracellular staining were used to measure the level of IFN- and TNF-. RPA was used to detect the level of mRNA for chemokine receptors. 15 or 2.5 mg 17-estradiol pellets were used to observe the anti-inflammatory effect of hormone therapy.

Results:

MOG-specific T cells stimulated with CD3 and CD28 in the presence of IL-12 or IL-18 alone transferred only mild EAE into a low percentage of recipients. However, T cells co-cultured with both cytokines transferred aggressive EAE into all recipients. Co-culture of T cells with IL-12 enhanced secretion of IFN- but not TNF-, whereas co-culture with IL-18 enhanced secretion of TNF- but not IFN-. However, co-culture with both IL-18 and IL-12 induced high levels of both TNF- and IFN-. Additionally, IL-12 selectively enhanced mRNA expression of chemokine receptor CCR5, whereas IL-18 selectively enhanced expression of CCR4 and CCR7. Finally, estrogen treatment, known previously to inhibit both TNF- and IFN- production, completely abrogated all signs of passive EAE.

Conclusions:

These data demonstrate that optimal potentiation of encephalitogenic activity can be achieved by conditioning MOG-specific T cells with the combination of IL-12 and IL-18, which respectively induce secretion of IFN-/CCR5 and TNF-/CCR4/CCR7, and that estrogen treatment, known to inhibit both pro-inflammatory cytokines, can completely ablate this aggressive form of passive EAE.

Supported By:

This work was supported by grants AI42376, NS23221 and NS23444 from the National Institutes of Health and grants from the National Multiple Sclerosis Society, the Nancy Davis Center Without Walls, and the Department of Veterans Affairs. Dr. Agata Matejuk is a postdoctoral fellow of the National Multiple Sclerosis Society.

Category - MS and Related Diseases

SubCategory - MS: Animal Models 


[P06.100]

Safety of Mitoxantrone Plus Dexrazoxane in Multiple Sclerosis Patients: 1+ Year Follow-Up

Daniel D. Mikol, Oscar LaHoud, Evanthia Bernitsas, Ann Arbor, MI

Objective:

To evaluate safety and tolerability of mitoxantrone plus dexrazoxane; to monitor cardiotoxicity by serial troponin-I and left ventricular ejection fraction (LVEF) measurements.

Background:

Cardiotoxicity is a potential dose-dependent adverse effect of anthracyclines and anthracenediones, including mitoxantrone (Mito, Novantrone), which limits its use in MS patients. It is recommended that the cumulative Mito dose not exceed 140 mg/m2, beyond which the occurrence of congestive heart failure (CHF) is ~1-2%. Subclinical decreases in LVEF can be detected prior to overt CHF. The mechanism of Mito-associated cardiotoxicity is unknown, but histological changes are similar to those seen with anthracycline-induced cardiomyopathy. Dexrazoxane (Dex, Zinecard) is a cardioprotective agent indicated for reducing anthracycline-associated cardiomyopathy. In animal models, Dex reduces Mito-associated cardiotoxicity, which can be predicted by an increase in post-infusion troponin levels, but troponin appears not to be increased until a relatively high cumulative Mito dose (4-6 infusions; 2-3 mg/kg). We wish to explore the efficacy of Dex in suppressing Mito-associated cardiotoxicity in humans, as measured by MUGA, and the ability of troponin-I to predict toxicity before CHF occurs.

Design/Methods:

This work is an extension of the study of Mito (12 mg/m2) and Dex (600 mg/m2) combination therapy given every 3rd month that was presented at AAN 2002. Baseline LVEF is measured by multigated angiography (MUGA). Complete blood count is checked before and 8-12 days after infusion, around the nadir of leukopenia. Patients receive Mito +/- Dex. All patients have troponin-I measured just before and 24-72 hours after infusion. In addition, they undergo follow-up MUGA scans after a cumulative Mito dose of 48 mg/m2. We present these new MUGA results.

Results:

At the time of abstract submission, 32 relapsing MS patients have been enrolled and have received 2-8 Mito +/- Dex infusions. Symptoms of CHF have not been observed. Fourteen patients have had a MUGA scan after reaching a cumulative dose of 48 mg/m2 Mito. LVEF decreases of 3-9% have been observed; decreases are highest in patients not randomized to receive Dex and correlate weakly with post-infusion troponin-I values. The absolute neutrophil count transiently fell to 500 in ~20% of patients, whether or not Dex was administered. Six cases of urinary tract infection were reported, five responded well to oral antibiotics and one required IV treatment. Mild nausea, asthenia, and hair thinning were noted infrequently. No other significant toxicity occurred.

Conclusions:

Our results show that Mito +/- Dex combination therapy has a favorable safety/tolerability profile. If Dex proves to be cardioprotective in Mito-treated patients, the cumulative Mito dose threshold might be increased. However, given the low occurrence of cardiotoxicity and its dependence on cumulative dose, Dexs protective effect may not become apparent until cumulative Mito doses exceed 100 mg/m2.

Supported By:

Supported in part by Immunex.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P01.105]

The Significant Influence of Binding Antibodies on Outcome Measures in IFN Beta-Treated Multiple Sclerosis Patients

Ebrima Gibbs, Helen Tremlett, Penelope Smyth, Tariq Aziz, Joel Oger, Vancouver, BC, Canada

Objective:

To determine the time-course of binding antibodies (BABs) to IFN-1b and IFN-1a in treated multiple sclerosis (MS) patients, and to evaluate the effect of BABs on the IFN-induced surrogate marker, MxA, and on clinical outcomes of patients.

Background:

The mainstay of MS therapy are the beta interferons, which differ in formulation and dosage. At present BABs are only used as a screening tool for predicting neutralizing antibodies (NABs), but we have previously shown that BABs are biological and clinically relevant. For patients to benefit from therapy, IFN has to be biologically available and lymphocyte MxA serves as a measure for IFN bioavailability.

Design/Methods:

133 patients receiving IFN-1b (sc) and 90 receiving IFN-1a (sc) were evaluated serially for binding anti-IFN antibodies using a sandwich ELISA. NABs were referred out blindly to IDL (Cal.) on 49 randomly chosen patients using MxA-inhibition assay.Lymphocyte MxA was determined in 29 IFN-1b-treated patients. Clinical information was available only for the 125 patients on IFN-1b and they were stratified by a blinded neurologist into treatment successes (no relapse and no change in EDSS) and non-successs (conversely) for the first two years of therapy.

Results:

BABs were present in 69% (92/133) of IFN-1b-treated patients, as compared to 29% (26/90) in IFN-1a- treated patients. BAB levels peaked at month 5 in IFN-1b-treated MS, and between months 9 and 12 for IFN-1a-treated patients . Furthermore, peak positive frequencies were 92% (mo 4 to 6) and 81% (after mo 36) among the BAB+ patients, in the IFN-1b and IFN-1a patients respectively. BAB positivity was found to predict NAB positivity, with 23/35 BAB+ patients becoming NAB+, and 13/14 BAB+ patients were NAB (2=13.72, p0.0005). BAB levels were also higher in the NAB+ than in the NAB, peaking an average of 11months before NABs. Among IFN-1b-treated patients, peak BABs levels corresponded to a significant reduction in lymphocyte MxA in BAB+ than in BAB- (Mann-Whitney, p=0.018). In BABpatients, there was a significant increase (p0.05) in lymphocyte MxA values at each time period during treatment. In the BAB+ patients, similarly, there was a significant difference at each time point, except for month 4 to 6 which coincides with the peak of BABs. In IFN-1b-treated patients, BAB-positive patients tended to benefit less from IFN therapy (2=7.51, p=0.006).

Conclusions:

We demonstrated that the BAB profiles of IFN-1b and IFN-1a-treated patients are different with anti-IFN-1b antibodies emerging and peaking earlier. We also showed that BABs are an excellent predictor of NAB positivity. Most importantly, for the first time, we have demontrated that IFN bioavailability (lymphocyte MxA levels) is significantly affected by the presence of BABs. Finally BAB-positive patients tended towards treatment failure in comparison to patients who did not develop BABs.

Supported By:

Berlex, Canada and Schering, AG

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[S41.002]

Viral Studies in Pediatric Multiple Sclerosis

Brenda L. Banwell, Suad Al-Otaibi, Helen Heurter, Raymond Tellier, Toronto, Canada

Objective:

To compare seropositivity for common viruses between pediatric multiple sclerosis (MS) patients and controls.

Background:

Infection by a common virus, such as Epstein Barr virus (EBV), in a genetically pre-disposed host has been postulated as a pathobiological mechanism for MS. Adults with MS have higher seropositivity for EBV that do controls, EBV infection has been associated with optic neuritis and central nervous system demyelination, and acute mononucleosis in adulthood is known to increase the risk of MS several-fold. However, seropositivity for EBV is nearly universal by adulthood, limiting comparative analysis between adult MS patients and controls. If exposure to EBV is important in MS pathobiology, then pediatric MS patients would be expected to be EBV-positive at an age when their healthy peers may not yet have had exposure to the virus. We thus performed a comparative study of EBV and other common viruses in pediatric MS patients and healthy age-matched controls.

Design/Methods:

Serum samples were obtained from 25 children with clinically definite MS (as defined by Poser et al), and 75 age-matched controls (matched 3:1 for year of birth for each MS patient). Control samples were obtained from previously healthy children for whom serology was drawn due to acute symptoms of abdominal pain, pharyngitis, or rash. All 100 samples were analyzed for Epstein Barr virus capsid antigen (EBV-VCA), EBV nuclear antigen (EBV-EBNA), and EBV early antigen (EBV-EA). The 25 MS samples and a random sampling of 15 age-matched control samples were also analyzed for parvovirus B19 (parvo B19), cytomegalovirus (CMV), and varicella zoster (VZV). All samples were coded, analyzed in a uniform manner by the ELISA technique (as per manufacturers instructions), and the study virologist (RT) interpreted results in a blinded manner.

Results:

Seropositivity for EBV differed markedly between pediatric MS patients and age-matched controls: 89% of pediatric MS patients were positive for EBV-VCA and EBV-EBNA indicating remote infection, compared to 31% of controls (p0.0004). Three pediatric MS patients were negative for all three EBV antigens (12%). Seropositivity for the other viruses did not differ between MS patients and controls: parvovirus B19 (49% vs 64%, p=NS); CMV (42% vs 64%, p=NS); and VZV (88% vs 92%, p=NS).

Conclusions:

Remote infection with EBV occurs in nearly 90% of pediatric MS patients, which differs markedly from the rate of prior exposure to EBV in age-matched controls. (p0.0004) This finding is considerably more robust than studies of EBV in adult MS patients, demonstrating the advantage of comparative studies in which healthy subjects are relatively environmentally-naive. Exposure to other common viruses does not differ between pediatric MS patients and controls, suggesting that the association between MS and EBV may be specific. EBV has a lifelong effect on B cell proliferation and T cell surveillance, and may play a pivotal role in promoting the autoimmune milieu in pediatric MS patients.

Supported By:

The Hospital for Sick Children Foundation

Category - MS and Related Diseases

SubCategory - Epidemiology 


[S41.004]

Two Genome-Wide Linkage Disequilibrium Screens in Scandinavian Multiple Sclerosis Patients Reveal Association to Chromosome Regions 1p34, 6p21, 11q23, 12q23 and 19q13

Pameli Datta, Copenhagen, Denmark, Hanne F. Harbo, Anne Spurkland, Oslo, Norway, Lars Ryder, Copenhagen, Denmark, Stephen Sawcer, Cambridge, United Kingdom, Eva Aakesson, Huddinge, Sweden, Elisabeth Celius, Oslo, Norway, Helena Modin, Huddinge, Sweden, Magnhild Sandberg-Wollheim, Lund, Sweden, Kjell-Morten Myhr, Bergen, Norway, Oluf Andersen, Goteborg, Sweden, Jan Hillert, Huddinge, Sweden, Per S. Sorensen, Arne Svejgaard, Copenhagen, Denmark, Alastair Compston, Cambridge, United Kingdom, Frode Vartdal, Oslo, Norway, Annette Oturai, Copenhagen, Denmark

Objective:

To identify gene regions containing putative susceptibility genes in MS in a genetically homogenous Scandinavian population.

Background:

Multiple sclerosis (MS) is a chronic inflammatory disease. Unknown genetic factors contribute to the susceptibility to the disease.

Design/Methods:

Two independent Scandinavian genome-wide screens for linkage disequilibrium have been performed, using pooled DNA and a dense map of 6000 microsatellite. In the first screen, 199 cases were compared with 200 controls; in the second, a further 201 cases were compared with a second set of 200 controls.

Results:

Statistical data were achieved from 4041 markers in the first and 4228 markers in the second screen. Results for both screens were available in the same 3360 markers. Twenty-three markers showed statistically significant differences between case-control allele image patterns (AIP) in both screens, among these the HLA marker D6S2447. When additional AIPs were generated for these 23 markers, statistical significance was retained for the markers MYCL1 at 1p34, D6S2447 at 6p21, D11S1986 at 11q23, D12S377 at 12q23 and D19S552 at 19q13.

Conclusions:

We identified four novel genetic regions possibly contributing to the genetic susceptibility to MS among Scandinavians. Further work is needed to dissect which genes are actually responsible for the observed association.

Supported By:

We are grateful to everyone who donated blood samples to this study, and to the many neurologists who introduced patients. Efrosini Setakis and David Clayton, MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Cambridge, UK, developed and provided access to the software used for statistical analyses. The project received financial support from the European Commission (project number CT97-2422); Norwegian Foundation for Health and Rehabilitation (project number 1998/273); The Norwegian Research Council, Norway; Odd Fellow MS Society, Norway; Medinnova, Norway; The Danish Multiple Sclerosis Society (project number 01/001), Denmark; Gerda and Aages Foundation, Denmark; and the Wellcome Trust, United Kingdom (grant 022549).

Category - MS and Related Diseases

SubCategory - Genetics 


[P04.082]

Progressive Callosal Atrophy in Patients with Clinically Isolated Syndromes Suggestive of Multiple Sclerosis. A Prospective Study

Jean Pelletier, Jean Philippe Ranjeva, Bertrand Audoin, Sylviane Confort-Gouny, Marseille, France, Irina Malikova, MArseille, France, Yann Le Fur, Andre Ali Cherif, Patrick J. Cozzone, Marseille, France

Objective:

to characterize on MRI in a prospective study the corpus callosum of patients who underwent clinically isolated syndromes suggestive of multiple sclerosis (CISSMS).

Background:

atrophy of corpus callosum (CC) and presence of demyelinating lesions in callosal or subcallosal areas are common findings in patients with MS. The extent of callosal atrophy has been correlated with the severity of white matter changes observed by MRI in patients with relapsing-remitting MS early in the disease.

Design/Methods:

Thirty patients with CISSMS were compared to 22 age and sex matched controls. All subjects were explored every six months during one year on a 1.5T Vision Plus MR imager (Siemens, Erlangen, Germany). The MRI protocol included transverse T2 weighted images, coronal fast FLAIR images and a post-injection MPRAGE acquisition. Exploration of CC was conducted before Gadolinium injection using a sagittal T1-weighted Flash sequence. Four regions of interest (ROI) in the corpus callosum were delineated on the medialsagittal slice and referred as the genum, the central anterior part, the central posterior part and the splenium. Areas of CC and the four ROI were determined and T2 lesion load was assessed with a semi-automated method while callosal or subcallosal lesions were recorded on the FLAIR images.

Results:

Baseline data revealed no statistical differences in the total CC and the four ROI areas between CISSMS patients and normal controls. No differences were observed between the CISSMS subgroups with and without callosal or subcallosal lesions and T2 lesion load did not influence global and segmental areas of CC. At the 1 year time point, a significant decrease of area was detected in the genum of CC in the CISSMS group (p0.1) compared to normal controls. No significant correlation was found between atrophy of the genum and T2 lesion load, and no differences were detected between the CISSMS subgroups with and without callosal or subcallosal lesions.

Conclusions:

This study confirmed that atrophy of CC can be detected at the very early stage of MS. The lack of association between lesions and callosal atrophy does not exclude that atrophy of CC may be partially related to focal tissue damage, but this result suggests that atrophy may also develop by other mechanisms.

Supported By:

Association de la Recherche sur la Sclrose en Plaques (ARSEP), CNRS, Fondation Jean et Odette Duranton de Magny - Fondation de France

Category - MS and Related Diseases

SubCategory - Imaging 


[P05.132]

Blocking Effects of Serum-Reactive Antibodies Induced by Glatiramer Acetate Treatment in Patients with Multiple Sclerosis

Ying C. Q. Zang, Hassan H. Salama, Houston, TX, Azza El-Mongui, Mansura, Egypt, Egypt

Objective:

To determine whether serum antibodies induced during glatiramer acetate (GA) treatment in multiple sclerosis (MS) patients diminish the biological activity of GA as measured by T cell proliferation and cytokine production.

Background:

Long-term GA treatment is known to induce a serum antibody response in 100% of patients. However, the biological effects and therapeutic implications of these antibodies in MS patients are not known.

Design/Methods:

Serum specimens from 42 patients, taken prior to and following treatment with GA, were tested for antibody reactivity to GA. Samples from six of the patients who had high titers of GA antibodies were identified and further evaluated for their ability to block GA-stimulated immunoregulatory effects in vitro. Proliferation of peripheral blood mononuclear cells (PBMC) and GA-specific T cells was determined using 3H thymidine assays and the levels of IL-10, IL-4, IL-12 and TNFa were measured using enzyme-linked immunosorbent assay (ELISA). A preliminary assessment of the clinical relevance of these antibodies was made by measuring serum cytokine levels in MS patients treated with GA for 3 to 5 years.

Results:

Forty-two MS patients were evaluated for the presence of GA antibodies prior to and following GA treatment. Forty-eight percent of patients were found to be positive for GA antibodies with 33% developing high antibody titers (antibody binding index 16 to 64) and 14% developing low antibody titers (antibody binding index 4 and 16). Patients with high antibody titers showed deterioration in Expanded Disability Status Scale (EDSS) scores from pretreatment to posttreatment compared with patients with low antibody titers and the same length of treatment. Results from in vitro assays demonstrate that GA-induced antibodies blocked the stimulatory effects of GA on proliferation of PBMC and GA-specific T cells. In addition, the increase in IL-10 and IL-4 levels and the decrease in IL-12 and TNFa levels, normally seen with GA stimulation, were reversed in the presence of GA antibodies. Cytokine levels were also measured in sera from patients with either high or low antibody titers following GA treatment for 3-5 years. A posttreatment increase in IL-10 and reduction in TNFa and IL-12 levels were observed in patients with low antibody titers. In contrast, patients with high GA antibody titers failed to show any change in IL-10 serum levels and the levels of TNFa and IL-12 were reversed.

Conclusions:

This study shows that GA treatment can elicit an antibody response in MS patients. Serum from patients with high titers of GA antibodies can block the immunomodulatory effects of GA in vitro. Preliminary data also indicate that high levels of GA antibodies in serum may diminish the therapeutic effects of GA in patients with MS.

Supported By:

Ministry of Education of Egyptian Government and The Richardson Foundation

Category - MS and Related Diseases

SubCategory - Basic Science 


[P03.119]

Elevated Serum Zonulin and Multiple Sclerosis: A Potential Modulator of Endothelial Tight Junctions

Alireza Minagar, Shreveport, LA, Maria Grazia Clemente, Baltimore, MD, Roger E. Kelley, Jonathan Steven Alexander, Shreveport, LA, Alessio Fasano, Baltimore, MD

Objective:

To assess cerebral endothelial barrier dysfunction in MS, as measured by serum zonulin levels, in patients with relapsing remitting MS (RRMS) and to determine the clinical significance of elevated serum zonulin levels in patients with RRMS.

Background:

The intercellular tight junctions (TJs) of endothelial cells represent the major barrier for the permeability of the blood brain barrier (BBB). Endothelial cell activation and dysfunction and transendothelial migration of inflammatory cells and cytokines through TJs play a significant role in pathogenesis of MS. However, the regulatory mechanisms that underlie the opening of TJs and their changes during inflammatory cascade of MS are still incompletely understood. A novel protein, zonulin, serves as a modulator of endothelial TJs and likely plays a pivotal role in regulation and loss of TJs during development of MS lesions, adjusting movement of leukocytes and macromolecules between the peripheral circulation and brain. We have devised a new method to measure serum zonulin levels in RRMS patients, which as a moderator of endothelial barrier permeability, and may serve as a surrogate marker of disease activity.

Design/Methods:

Serum from 29 patients with RRMS (16 in relapse and 13 in remission) and 171 controls were studied. The average age of MS patients was 35 years and 60% of patients were female. Serum levels of zonulin were measured by a quantitative sandwich enzyme linked immunosorbent assay. Total serum proteins were measured by Bradfords assay. Zonulin concentration was expressed as pg/mg of total serum proteins. All patients underwent neurological examination as well as brain MRI with contrast.

Results:

Serum from patients with relapsing-remitting MS in exacerbation showed more than 2-fold elevation (0.78 ng/mg protein) of zonulin, as compared with those in remission (0.36 ng/mg protein), and returned to near normal control values (0.29 ng/mg protein) (p0.03). The high levels of serum zonulin concentration revealed only a positive association with the presence of gadolinium enhancing lesions in 60% of MS patients in exacerbation.

Conclusions:

Cerebral endothelial dysfunction during exacerbations of MS correlates with increased release of zonulin into the serum. Measurement of serum zonulin may serve as a surrogate marker of disease activity in RRMS. Our data indicate that such excessive release of serum zonulin may have a role in pathogenesis of MS.

Category - MS and Related Diseases

SubCategory - Basic Science 


[P05.136]

Unbiased Identification of Antigen Specificities of Cerebrospinal Fluid-Infiltrating T Cells in Multiple Sclerosis

Mireia Sospedra, Yingdong Zhao, Gregg Blevins, Carlos Mora, Richard Simon, Bethesda, MD, Clemencia Pinilla, San Diego, CA, Roland Martin, Bethesda, MD

Objective:

To study the antigen specificity of cerebrospinal fluid (CSF)-infiltrating T cells in multiple sclerosis (MS) patients after unspecific expansion and subsequent testing with combinatorial peptide libraries. These studies shall identify potential novel autoantigenic targets in MS and assess which foreign agents might have activated CSF-infiltrating T cells.

Background:

MS is a T cell-mediated disorder of the central nervous system (CNS). The foreign agents that might trigger MS are at present not known. With respect to disease pathogenesis, myelin autoantigens are the most likely targets, however, in analogy to other autoimmune diseases, ubiquitous self proteins could also be relevant. These considerations prompted us to examine the antigen-specificity of cerebrospinal fluid (CSF)-infiltrating lymphocytes in an unbiased way.

Design/Methods:

Assuming that CSF more closely reflects the autoimmune process in MS than peripheral blood, we cloned CSF T cells from MS patients by limiting dilution after activation with PHA, a broad and unspecific stimulus. Subsequently, we analyzed the TCR expression of CSF T cells, their CD4- versus CD8 phenotype, the expression of other surface markers and finally their antigen specificity. For that purpose, T cell cultures that had been obtained from seeding 0.3- and 3 cells/well were tested with synthetic combinatorial peptide libraries in the positional scanning format (ps-SCL). Employing the data from the testing of the ps-SCL in combination with a search algorithm recently described by Zhao et al. (JI,2001, 167: 2130 we predicted peptides from the entire human- bacterial- and viral protein databases that could be recognized by each T cell clone.

Results:

A high proportion of CSF-infiltrating T cells respond to highly complex combinatorial peptide libraries. Potential viral- and bacterial triggers as well as putative autoantigens from human proteins have been identified. Candidate peptides were synthesized and tested for antigen reactivity.

Conclusions:

The high proportion of CSF-infiltrating T cells responding to highly complex combinatorial peptide libraries argue for degenerate specificity of these cells. The data obtained will be discussed in the context of molecular mimicry and existing pathogenetic hypotheses in MS.

Category - MS and Related Diseases

SubCategory - Basic Science 


[P05.131]

Continuous Oral Corticosteroid Therapy Restores the Reduced Natural Kller (NK) T Cell Frequency in Multiple Sclerosis

Manabu Araki, Takashi Yamamura, Kodaira, Tokyo, Japan

Objective:

To investigate whether therapeutic agents such as corticosteroid and IFN- may restore the reduced frequency of natural killer (NK) T cells in multiple sclerosis (MS).

Background:

CD1d-restricted NKT cells, expressing an invariant V24 chain preferentially paired with V11, would explosively produce large amounts of IL-4 and IFN- . Prior studies indicate their role in the immune regulation of autoimmune conditions. We have showed that NKT cells are reduced in number in the peripheral blood of MS. However the nature of the reduction is still unclear.

Design/Methods:

We examined 64 patients of relapsing-remitting type of MS (52 in remission; 12 in relapse) and 19 healthy control subjects (HS). The patients in remission included 32 who had not been given any immunosuppressive agents (MS-rem), 10 treated with prednisolone ( 5mg/day) at least for six months prior to examination (MS-PSL), and 10 treated with IFN- for three months (MS-IFN-). None of the patients had been given other immunosuppressive agents or combination of corticosteroid and IFN-. The frequency of NKT cells in peripheral blood mononuclear cells (PBMC) was measured by flow cytometry. The cells were stained with combination of anti-TCR V24, -TCR V11, -CD4 and -CD8 mAbs. The frequency of total NKT (V24+V11+), CD4+ NKT and CD4-CD8- (double negative, DN) NKT were examined in parallel. For functional analysis of NKT cells, we generated short-term cell lines enriched in NKT cells. The lines were generated by stimulating the PBMCs with -galactosylceramide (-GC) and expanded in the presence of IL-2 and IL-7. On days 20-30, we isolated the CD4+and CD4- NKT cells from the line cells by using cell sorter. Each population was stimulated with anti-CD3/anti-CD28 coated microbeads. Two day later we measured the concentrations of IL-4 and IFN- in the supernatant by ELISA.

Results:

When compared with HS, the total frequency of NKT cells was significantly reduced in MS-rem (p0.001). The similar level of reduction was also seen in MS-IFN-. However, the reduction was not significant in MS-PSL (p=0.98). DN NKT cells were also reduced in MS-rem (p0.001) and MS-IFN- (p0.05), but the reduction was not significant in MS-PSL (p=0.78). In contrast, CD4+ NKT cells were not significantly reduced in the three remission groups compared with HS. Whereas CD4+ NKT cell lines expanded from HS tended to produce a larger amount of IL-4 than did CD4- NKT cell lines, CD4+ NKT cell lines from MS-rem were further polarized for secreting IL-4. The cytokine profile of CD4+ NKT cell lines did not differ between MS-rem and MS-PSL. However, CD4- NKT lines from MS-PSL showed a trend for Th2 bias.

Conclusions:

These results demonstrate that oral corticosteroid (but not IFN-) would correct the reduction of NKT cells in MS. The restoration appears to be beneficial with regard to cytokine balance. It is possible that therapeutic effects of corticosteroid may partially mediate NKT cells.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[S31.004]

Efficacy of Thalamic Stimulation in Multiple Sclerosis Tremor

Hassan Hosseini, Creteil, France, Emmanuelle Waubant, Pierre Jedynak, Bruno Stankoff, Didier Dormont, Luc Mallet, Yves Agid, Catherine Lubetzki, Olivier Lyon-Caen, Paris, France, Ayman Tourbah, Paris, France, Jean Denis Degos, Pierre Cesaro, Jean Paul Nguyen, Creteil, France

Objective:

To determine efficacy and safety of ventrointermediate nucleus (VIM) stimulation in patients with disabling arm tremor related to MS.

Background:

Deep cerebral stimulation may be a better option than thalamotomy to treat patients with arm tremor due to multiple sclerosis (MS). We hypothesized that we could dissociate tremor from cerebellar dysfunction and that best results of stimulation would be obtained in patients with severely disabling tremor but little cerebellar dysfunction.

Design/Methods:

9 patients with severe arm tremor that did not improve with treatments such as propranolol or primidone were offered unilateral stimulation of the VIM controlateral to the most disabled limb. Patients had to have stable clinically definite MS, slight or no homolateral dyssynergia measured by the rebound sign, proximal homolateral upper limb motor strength of 4/5 or more, MMS score of 24 or more, no thalamic T2 bright signal, no major cerebral atrophy , 2 or less gadolinium enhancing lesions. Evaluations were performed one month before, and 1, 3 and 6 months after surgery. Patient scoring Off and On stimulation included tremor (modified Fahn scale), motricity, EDSS. Neuropsychological tests and quality of life were evaluated On stimulation

Results:

9 patients have been operated and evaluated up to 6 months after surgery. Mean age before surgery was 38.9 9 years, median EDSS at entry was 7.1. One month after surgery, median scores Off and On were respectively 12 and 6 for postural tremor; 12 and 10.5 for kinetic tremor score; 12 and 7.5 for manual capacity; 22 and 20 for functional handicap. Similar results were observed at M3. Six month after surgery, median scores Off and On were respectively 10.4 and 4 for postural tremor, 12 and 7.8 for kinetic tremor. The only severe adverse event was a relapse that occurred within two weeks after surgery

Conclusions:

VIM stimulation for treatment of disabling tremor in MS may improve more the postural than the kinetic component and is well tolerated in selected patients.

Supported By:

Assistance Publique - Hpitaux de Paris, PHRC 97304

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P06.114]

Betaferon/ Betaseron (Interferon Beta-1b) in Early Treatment of Multiple Sclerosis: The Benefit Study

Mark S. Freedman, Ottawa, ON, Canada, Gilles Edan, Rennes, France, Hans-Peter Hartung, Dusseldorf, Germany, Ludwig Kappos, Basel, Switzerland, David Miller, London, United Kingdom, Xavier Montalban, Barcelona, Spain, Chris Polman, Frederik Barkhof, Amsterdam, Netherlands, Lars Bauer, Marianne Ghazi, Rupert Sandbrink, Berlin, Germany

Objective:

The BENEFIT (Betaferon/Betaseron in Newly Emerging MS for Initial Treatment) study has been designed to: (i) investigate the efficacy of high dose/high frequency interferon (IFN) beta-1b initiated after the first clinical event relative to placebo, assessed by onset of a second clinical event, development of new MRI lesions, changes in EDSS and MSFC, and quality of life; (ii) explore long-term effects beyond those on the second event and MRI lesion development; (iii) reveal the relationship of the two primary endpoints (time to diagnosis of MS according to the McDonald criteria, and time to clinically definite MS (CDMS) according to the Poser criteria) in the presence or absence of immunomodulatory treatment; and, (iv) compare treatments initiated before and after conversion to CDMS and evaluate the prognostic relevance of new lesions on follow-up MRI scans, as well as of molecular prognostic factors.

Background:

Evidence from clinical studies indicates that treatment of patients with a first demyelinating event suggestive of MS and an abnormal MRI with once weekly IFN beta produces effects on clinical and MRI parameters. However, the long-term impact of IFN beta treatment at the first episode and the benefits of a high dose/high frequency treatment have yet to be evaluated. A high dose/high frequency treatment was recently shown to be more efficacious than a once weekly treatment in established relapsing-remitting MS (INCOMIN, EVIDENCE).

Design/Methods:

BENEFIT is a randomised, double-blind, placebo-controlled, parallel group, multicenter, phase III study in patients with a first demyelinating event suggestive of MS and an abnormal MRI. Approximately 400 patients from Europe, Israel, and Canada will be enrolled, 150 to receive placebo and 250 to receive 250 g (8 MIU) IFN beta-1b every other day (e.o.d.). The maximum duration of the double-blind phase will be 2 years, or until both primary endpoints are reached (i.e. after CDMS). Patients with CDMS, and all patients completing the 2-year study, will enter a long-term follow-up study, and will be offered open-label IFN beta-1b e.o.d. for at least 3 years. It is the goal to maintain all patients in the extension study regardless of therapy.

Results:

A range of measurements has been defined to allow assessment of the various objectives described above. Recruitment is expected to be complete by early 2003 with results available by mid-2005.

Conclusions:

BENEFIT is the first study providing data on the effects of higher dose, more frequently administered IFN beta on conversion to CDMS, also incorporating a long-term follow-up.

Supported By:

Schering AG, Germany

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[S21.001]

Placebo-Controlled Double-blinded Dose Ranging Study of Fampridine-SR in Multiple Sclerosis

Andrew D. Goodman, Rochester, NY, Andrew Blight, Hawthorne, NY, Jeffrey A. Cohen, Cleveland, OH, Anne H. Cross, St. Louis, MO, Mitchell Katz, Hawthorne, NY, Marco A. Rizzo, Timothy Vollmer, New Haven, CT

Objective:

The primary aim of this trial was to determine the safety and tolerability of escalating doses of a sustained release (SR) formulation of the potassium channel blocker, fampridine (4-aminopyridine), given orally to patients with MS. The secondary aim was to explore efficacy over a broad dose range using measures of fatigue and motor function.

Background:

Previous studies of 4-aminopyridine in MS have reported improvement in various aspects of neurological function and possible adverse effects including tremor, paresthesia, and rarely seizure. However, the safety and efficacy of higher doses are not known.

Design/Methods:

Inclusion criteria required were clinically definite MS with EDSS 6.5 and Fatigue Severity scores 4. Thirty-six patients at 4 centers were randomized to active (25) and placebo (11) treatment cohorts. The parallel group, dose escalation protocol started with a placebo run-in for the first week, 20 mg/day (10mg po BID) the second week, and then increased in weekly increments of 10 mg/d up to 80mg/d during week 8.

Results:

The most common adverse effects reported at least once at any dose level in the fampridine-treated group were dizziness (36%), insomnia (36%), and paresthesia (32%). Five subjects withdrew because of seizure (2), tremor (1), dizziness and nausea (1), and leg pain (1). Adverse effects tended to be more severe at doses of 50 mg/day and higher including the 2 occurrences of seizure (at doses of 60 and 70 mg per day). The fampridine-SR group showed statistically significant improvement from baseline compared to placebo in functional measures of mobility (timed 25 walking speed; p=0.04) and lower extremity strength (manual muscle testing; p=0.01). Dose response curves showed increasing benefit in both measures in the 20 to 50 mg/day range. No other measures showed significant treatment effects.

Conclusions:

The safety profile of fampridine SR was consistent with previous experience. Doses above 50 mg added little benefit and increased adverse effects. There was significant improvement in measures of mobility and muscle strength.

Supported By:

Acorda Therapeutics, Hawthorne, NY

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P06.105]

Onset of Clinical Benefit of Glatiramer (Copaxone) Acetate in 255 Patients with Relapsing Remitting Multiple Sclerosis (RRMS)

Judith Haas, Berlin, Germany

Objective:

To evaluate the time course of early clinical effects of glatiramer acetate (GA) in reducing relapse rate in patients with RRMS when compared to other disease modifying agents (DMAs).

Background:

Early and sustained treatment with various DMAs with different mechanism of action is recommended for RRMS. The onset of action of these agents can be assessed by their effect on several biologic, imaging and clinical parameters.

Design/Methods:

The effect of sc administration of GA 20 mg QD on reducing relapse rate was evaluated in an ongoing prospective, controlled open-label trial comparing the effect of beta interferons (-1a IM, -1a sc, and -1b sc) and glatiramer acetate in 255 patients with RRMS. Regular quarterly and as needed clinic visits were performed to assess outcome and relapse events. Changes and differences in relapse rates between the groups and/or in comparison to pre-study values, were analyzed using one way analysis of variance (ANOVA) for comparing differences between and within the four treatments. The time course of effect on relapse rate with GA treatment compared to other agents was evaluated.

Results:

The annualized pre-study relapse rate ranges from 1.06 to 1.20 for all DMAs and all groups were comparable at baseline. The beneficial treatment effect of GA treatment on decreasing relapse rate at month 6 was -0.70 compared to prior to the study relapse rate (p0.001). Similarly the changes in relapse rate for all beta interferons (Interferon beta 1a IM: -0.36, Interferon beta 1a sc: -0.51, Interferon beta 1b sc: -0.52) at month 6 were statistically significant at the p0.02 level compared to prior to the study relapse rate. After 12 and 24 months, the treatment effects of GA on decreasing relapse rate were -0.73 and -0.81 (p0.05), respectively, compared to pre-study relapse rate. The reduction in relapse rate for glatiramer acetate after 24 months was larger than than of all beta interferons (p0.05).

Conclusions:

The clinical benefit of GA in reducing relapse rate is sustained at 12 and 24 months and is apparent as early as 6 months similar to the beta interferons.

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P06.113]

Single Centre, DBPC, Randomised Trial of Interferon 1b in Primary Progressive and Transitional Progressive Multiple Sclerosis: An Exploratory Phase II Study

Xavier Montalban, Luis Brieva, Mar Tintore, Cecilia Borras, Jordi Rio, Carlos Nos, Xavier Aymerich, Julio Alonso, Rosalia Horno, Maria Jose Vicente, Alex Rovira, Barcelona, Spain

Objective:

To investigate safety and efficacy hints of interferon 1b given to patients with primary and transitionalprogressive multiple sclerosis (PPMS and TPMS)

Background:

Beneficial effects of interferon have been shown only for patients in the relapsing phase of MS as its role in the treatment of SPMS patients still remains controversial. The single phase II randomized controlled trial on PPMS using IFN 1a(IM) shows no significant treatment effect on EDSS though some effect on T2 lesion load

Design/Methods:

73 patients (49 PPMS, 24 TPMS) with EDSS scores of 3.0 to 7.0, were randomized to receive 8 million IU of IFN 1b or placebo every other day, subcutaneously for 2 years. Safety parameters including the Ashworth spasticity, Krupp fatigue and Depression Inventory scales and blood tests were performed three monthly. Clinical outcomes (EDSS and MS Functional Composite - MSFC) were also performed three monthly and the Sickness Impact Profile six monthly. MRI measures (T2 and T1-weighted brain lesion load, brain parenchymal fraction, active lesions, spinal cord atrophy, MTR and spectroscopy) and neuropsychological assessment (BRNB) were done annually.

Results:

Adverse events significantly associated with IFN included injection-site reaction, flu-like symptoms and lymphopenia. One patient on placebo died of pulmonary infection. In all, 96% of the patients reached study end and 93% completed the treatment period. Treatment groups were comparable on all baseline variables. The proportion of patients with confirmed progression measured by EDSS at 3 months was 27.8% in the IFN arm and 37.8% in the placebo arm (p= 0.3135). Statistically significant differences were found for MSFC (PASAT 3, 9-HPT and AI (p=0,03), T2 (p=0.006) and T1 (p=0.001) lesion load and number of active lesions (p=0.005) in favor of the IFN-treated group.

Conclusions:

IFN 1b is safe in treating patients with PPMS and TPMS. Our study seems to be the first indicating a beneficial effect of IFN in these patients.

Supported By:

Schering Espaa, SA

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P05.125]

Increased Production of Osteopontin in Secondary Progressive Multiple Sclerosis Patients

Manuel Comabella, Imma Pericot, Robert Goertsches, Mireia Castillo, Xavier Montalban, Barcelona, Spain

Objective:

To investigate osteopontin production in multiple sclerosis (MS) patients with different clinical forms of the disease and healthy controls.

Background:

Osteopontin is a proinflammatory cytokine that enhances interferon- and interleukin 12 (IL-12) production and diminishes IL-10. Recent experiments in the animal model of MS, experimental autoimmune encephalomyelitis (EAE), have shown that osteopontin-deficient mice are resistant to progressive EAE and have frequent remissions compared with wild-type mice. Thus, osteopontin may play an important role in the modulation of Th1 immune responses and in the course of the disease in MS and EAE.

Design/Methods:

Levels of osteopontin in plasma samples were measured with ELISA using a commercially available kit (TiterZyme-EIA, Assay Designs, Inc., USA) in 183 MS patients and 27 healthy controls. In the MS group there were 40 patients with relapsing-remitting MS (RRMS), 13 patients with secondary progressive MS (SPMS), 67 patients with primary and transitional progressive MS (PP/TP-MS), 16 MS patients in relapse, and 47 patients treated with IFN.

Results:

Osteopontin levels in plasma [mean ng/ml (SD)] were 90.0 ng/ml (SD 31.1) in SPMS patients, 58.1 ng/ml (SD 18.6) in RRMS patients, 61.5 ng/ml (SD 17.4) in PP/TP-MS patients, 67.9 ng/ml (SD 16.5) in MS patients treated with IFN, 71.6 ng/ml (SD 20.1) in MS during relapse, and 57.0 ng/ml (SD 25.3) in healthy controls. There was a statistically significant increase of plasma osteopontin levels in SPMS compared to RRMS (p= 0.001), PP/TP-MS (p= 0.001), IFN treated patients (p= 0.012), and healthy controls (p=0.004). Finally, patients in relapse had higher osteopontin plasma levels compared to RRMS patients (p= 0.03).

Conclusions:

Even though the data are preliminary and need to be confirmed with higher number of patients, our findings point to a role of osteopontin in the progressive phase of the disease, and support previous studies on the influence of osteopontin in the course of the disease in the EAE model. Additionally, these results seem to indicate that osteopontin could be a potential biological marker for disease progression.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P01.118]

Pregnancy Outcomes in Patients with Multiple Sclerosis Treated with Glatiramer Acetate (Copaxone)

P. K. Coyle, Stony Brook, NY, Kenneth Johnson, Baltimore, MD, Lillian Pardo, Kansas City, MO, Yafit Stark, Netanya, Israel

Objective:

To review pregnancy outcomes in women treated with Glatiramer Acetate (GA) (Copaxone) during clinical trials and postmarketing surveillance data.

Background:

GA is an effective immunomodulator disease modifying treatment (DMT) for relapsing remitting multiple sclerosis (RRMS) as measured by clinical/MRI outcomes. The RRMS population is comprised of a high % of women of childbearing age, yet little is known about DMT safety during pregnancy. Of the currently available DMTs, interferons (IFNs) are assigned FDA Category C due to abortifacient effects in animal studies. GA is in FDA Category B, since animal studies have not shown adverse effects on fetal development, delivery or offspring growth. It is possible GA is more frequently used in RRMS patients of childbearing age due to its less restrictive FDA category. A survey of women neurologists indicated they are less likely to recommend discontinuation of GA than of the IFNs in women contemplating pregnancy.1

Design/Methods:

Patient data was reviewed from 21 global clinical trials of GA (including placebo-controlled and open label trials). Postmarketing pregnancy registry reports for GA were reviewed from 1996 to September 2002.

Results:

During clinical trials 3400 patients received GA; 70% were female. Despite pregnancy exclusions and a requirement for adequate birth control, 40 pregnancies were reported. There were 18 elective abortions, five spontaneous abortions, and seven live births. A single case of a baby with cleft-lip was attributed to maternal carbamazapine use by the patients physician. Ten other cases in European open label trials were lost to follow-up. During postmarketing surveillance, 345 pregnancies were reported. The majority of the women discontinued GA upon diagnosis of pregnancy. Most (90%) had GA exposure during the first trimester only and a small number terminated their pregnancies. The 215 pregnancies with known outcomes involved healthy live births (n=155), spontaneous abortions (n=43), elective abortions (n=9), ectopic pregnancy (n=1), and stillbirth (n=1). One hundred thirty cases were either lost to follow-up or not yet reached their due date. Only six cases involved congenital anomalies such as single reports of failure to thrive, finger anomaly, cardiomyopathy, urethrostenosis, anencephaly, and left adrenal cyst.

In the general population, the risk of congenital anomalies is estimated at 3%, and the incidence of spontaneous abortions is 15% to 20% in recognized pregnancies.2

Conclusions:

Available data suggests no increased risk of adverse fetal or pregnancy outcomes associated with GA use. The rate of reported outcomes is within the expected risk observed in the general population.2,3,4

References:
1. Coyle, PK, et al. MS Gender Issues: Clinical Practices of Women Neurologists. MS 2002;8:S29-S30.
2. March of Dimes Perinatal Center 2000.
3. Ventura SJ, et al: Births:Final data for 1998. Natl Vital Stat Reports 2000;48(3):13-21.
4. National Center on Birth Defects and Developmental Disabilities 2002.

Category - MS and Related Diseases

SubCategory - Other 


[P02.137]

Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis: Importance of Disease Stage on Outcome

Richard K. Burt, Bruce A. Cohen, Chicago, IL, Lorri Lobeck, Milwaukee, WI, Ann E. Traynor, Chicago, IL, Christopher Bredeson, Milwaukee, WI

Objective:

To elucidate the appropriate patient candidates with multiple sclerosis for autologous hematopoietic stem cell transplantation.

Background:

MS is an inflammatory demyelinating and axonal degenerative disorder of the CNS without curative therapy. The results of Phase I studies have suggested that intense immune suppression and reconstitution with hematopoietic precursors (hematopoietic stem cell transplantation, HSCT) can completely suppress brain inflammation. Whether HSCT exerts a beneficial effect on slowing or stopping clinical progression of disability related to axonal degeneration is currently unknown.

Design/Methods:

Twenty-eight patients with MS (all secondary progressive, except one relapsing-remitting) were treated with autologous HSCT at either Northwestern Memorial Hospital or Froedtert Memorial Hospital (Chicago, IL and Milwaukee, Wisconsin, respectively). Patients were selected for a 1.0 EDSS increase over the prior year if their EDSS was 5.5 and a 1.5 point increase if their EDSS was 5.5. Peripheral blood stem cells (PBSC) were mobilized with 2.0 g/m2 cyclophosphamide (Cy) and 10 ug/kg G-CSF, collected by apheresis, and enriched by CD34+ selection. A combination of high dose Cy (120 mg/kg) and total body irradiation (1200cGy with 50% lung shield) conditioning was followed by infusion of CD34+ selected cells.

Results:

Transplants were relatively uncomplicated. Median follow-up is 2 years (range 6 months to 6 years). Of eighteen patients whose pre-transplant EDSS was 6.0, ten have progressed by 1.0 or more EDSS points including two patients who were lost to follow-up in nursing homes and subsequently died from complications of progressive disease at 12 and 18 months post HSCT. Of 10 patients whose EDSS was 6.0, no patient has progressed by 1.0 or more EDSS steps. The only patient with relapsing remitting MS is also the only patient whose EDSS improved by more than 1.0 EDSS points going from 3.5 to 1.5.

Conclusions:

HSCT does not prevent further progression in patients with progressive disease and high disability scores (EDSS 6.0). Future HSCT studies should focus on patients earlier in disease course with active inflammatory disease (active relapses).

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P06.112]

The Prisms (the Prevention of Relapses and Disability by Interferon-beta-1-a Subcutaneously in Multiple Sclerosis) Study - Report on Neutralising Antibodies up to Year 6 of Treatment

Magnhild Sandberg-Wollheim, Lund, Sweden, Margaretha Stam-Moraga, Jonathan C. Alsop, Judith A. Abdalla, Geneva, Switzerland

Objective:

To assess the long-term (up to 6 years) rate of development of neutralising antibodies (NAbs) to IFN beta-1a (Rebif, Serono).

Background:

The PRISMS study showed significant efficacy of IFN beta-1a at two doses (44 mcg tiw and 22mcg tiw) at 2 years on relapse rate, disability and MRI compared to placebo. Placebo-randomised patients were re-randomised at month 24 to one of the two doses of active treatment. Dose-blinded extension data to 4 years demonstrated sustained treatment benefit with increasing evidence of dose effect over time. Safety evaluations up to 6 years support the overall safety without dose limiting tolerability problems. NAb rates up to 4 years have been reported.

Design/Methods:

Blood for binding antibody (BAb) determinations were collected every 6 months during the PRISMS study. Those samples which were BAb-positive were assessed for NAb status. Patients were counted as NAb-positive if they had a NAb titre 20 NU/ml at any time during the study. No efficacy data were collected during years 5 and 6.

Results:

560 patients enrolled in the original cohort. 74% (412) of the 560 patients initially enrolled completed 4 years on study. 57% entered year 5 and 48% completed 6 years on dose-blinded therapy. Over six years of the study, 29.3% of patients who had received Rebif 22 mcg tiw at any time were classified as NAb-positive, and 21.8% of those who had received Rebif 44 mcg tiw at any time were classified as NAb-positive, at least once. Most patients who developed NAb did so during the first two years of active treatment. None developed NAbs after more than 4 years of IFN-beta-1a. 55 (26.5%) of the patients originally randomised to 22 mcg tiw (ITT 22) had a positive NAb at any point in the study, up to year 6. 35 (18.7%) of the patients originally randomised to 44 mcg tiw (ITT 44) had a positive NAb at any point in the study. Of the 90 ITT 22 or 44 patients classified as NAb-positive, 33 (36.7%) had negative NAb results at their last assessment (at any point during the 6-year study). 22/182 (12.1%) patients in ITT 44 and who had Nab testing performed beyond study day 1, had a positive Nab value at last assessment; the corresponding figure for ITT 22 was 35/186 (18.8%). Of those who had an assessment in years 5-6, the rate of NAb positivity at last assessment was 15.0% (33/220): (15/109) 13.8% in patients who had received 44 mcg tiw at any time, and 16.2% (18/111) in patients who had received 22 mcg tiw at any time.

Conclusions:

Neutralising antibodies tend to develop in the first 4 years of treatment (and in most patients, in the first 2 years) and, in up to one-third of cases, disappear over time. Long term studies are required to elucidate the nature of interferon beta 1a-induced antigenicity and its ultimate impact on clinical outcomes over the course of a chronic disease like MS.

Supported By:

Serono International S.A.

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P04.006]

Interferon--Responsive Genes in Multiple Sclerosis

Jun-ichi Satoh, Fumiko Koike, Tokyo, Japan, Toshiyuki Fukazawa, Sapporo, Japan, Mitsuru Kawai, Takashi Yamamura, Tokyo, Japan

Objective:

To identify the interferon-beta (IFN)-responsive genes (IRGs) in peripheral blood mononuclear cells (PBMC) of relapsing-remitting multiple sclerosis (RRMS) patients following treatment with IFN.

Background:

Although IFN reduces clinical exacerbation and disease activity in MS, the underlying molecular mechanisms remain to be fully characterized. IRG-encoding proteins would mediate the therapeutic effects of IFN. We previously showed that IFN regulatory factor-7 (IRF-7), a key transcription factor for IFN production following virus infection, is induced specifically by IFN in human astrocytes in culture (Satoh and Kuroda. Neurology 2001;57:681-685).

Design/Methods:

By using a cDNA microarray containing 1,263 genes of various functional classes (Hitachi Life Science), the gene expression profile was studied in CD3+ T cells and CD3- non-T cells separated from PBMC of 13 Japanese, clinically definite RRMS patients, before treatment with IFN1b and at 3 and 6 months after starting the treatment. IRGs were identified by analyzing the gene regulation index in individual genes with a regularized t-test.

Results:

IFN treatment significantly altered the expression of 21 genes in T and/or non-T cell fractions mostly at 3 months. They included 9 IRGs with IFN-responsive promoter elements, such as IRF-7, IFN-induced 15-kDa protein (ISG15), IFN-induced 56-kDa protein (IFI56), and IFN-inducible cDNA 6-16 (IFI6-16), that were up-regulated in both fractions. By contrast, IRGs identified by this analysis did not include the markers characteristic of either T helper type 1 (Th1) or Th2 cells. The expression of TNF-stimulated gene-6 (TSG-6), a secretory protein with a potent antiinflammatory activity, was elevated in non-T cells at 3 months, whereas the levels of IL-3, potentially involved in the induction of inflammatory demyelination, were reduced in both fractions at 6 months.

Conclusions:

Microarray analysis identified a battery of known and heretofore unreported IRGs which might represent validated research targets for understanding the therapeutic effects of IFN.

Supported By:

a grant from the Ministry of Health, Labour and Welfare of Japan.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P06.104]

Glatiramer Acetate Slows Sustained Accumulated Disability in Relapsing Multiple Sclerosis: Meta-Analysis Results of Three Double-Blind, Placebo-Controlled Clinical Trials

Jerry S. Wolinsky, Houston, TX, Kenneth P. Johnson, Baltimore, MD, Giancarlo Comi, Milan, Italy, Aaron E. Miller, Brooklyn, NY, David Ladkani, Petah Tiqva, Israel, Galia Shifroni, Yafit Stark, Netanya, Israel, Massimo Filippi, Milan, Italy

Objective:

To assess the efficacy of glatiramer acetate (GA) in slowing accumulating disability (sometimes called sustained progression) in a large sample of patients enrolled in controlled trials.

Background:

Three double-blind, placebo-controlled, randomized clinical trials of GA in patients with relapsing-remitting MS (RRMS) have shown beneficial effects of GA on clinical and MRI measures of disease evolution and burden.

Design/Methods:

Pooled data from the three published trials provided a total of 540 subjects for the meta-analysis. All patients had at least one relapse in the two years prior to enrollment and a baseline EDSS score of 0 6 inclusive. Subjects were randomly assigned to GA (n=269), 20 mg daily by subcutaneous injection or to placebo (n=271). The treatment effect, defined as the Odds Ratio in the proportion of subjects developing 1 or more EDSS steps sustained after 90 days between the GA treated group and the placebo group of the pooled patient population was assessed using the Cochran-Mantel-Henzel statistic. The time to accumulating this level of disability was estimated by Kaplan Meier survival curve analysis.

Results:

The proportion of GA treated patients accumulating 1 or more EDSS steps (confirmed for 90 days) was reduced when compared to placebo (Odds Ratio 0.57, 95% confidence interval 0.36 0.91, p 0.02, Cochran-Mantel-Henzel) in the pooled group of 540 subjects from the Bornstein, USA pivotal, and the European/Canadian trials. The Kaplan Meier estimate of the time to 25% of the placebo treated subjects accumulating sustained disability was 521 days, the GA treated subjects did not reach this milestone (p 0.03, log rank test); neither group reached a 50% endpoint. GA nearly doubled the time to confirmed progression when compared to placebo in this population (ratio estimate 1.88, p 0.02, Weibull regression).

Conclusions:

This analysis suggests that GA consistently slowed accumulation of disability sustained for at least 90 days across three double-blind, placebo-controlled studies.

Supported By:

Teva Pharmaceutical, Ltd.

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P04.001]

Detection of the 14-3-3 Protein in the Cerebrospinal Fluid of Multiple Sclerosis

Jun-ichi Satoh, Tokyo, Japan, Kazuhiro Kurohara, Motohiro Yukitake, Hiroshi Takashima, Yasuo Kuroda, Saga, Japan, Takashi Yamamura, Tokyo, Japan

Objective:

To investigate the possible association of the amounts of 14-3-3 protein in the cerebrospinal fluid (CSF) with the clinical severity of multiple sclerosis (MS).

Background:

Detection of the CSF 14-3-3 protein, which is enriched in neuronal cell bodies and processes, has been utilized as a biochemical marker for the premortem diagnosis of Creutzfeldt-Jacob disease in the context of differential diagnosis of progressive dementia (Hsich et al. N Engl J Med 1996;335:924-930). Recent studies indicate that this protein is also detectable in the CSF of acute transverse myelitis and the clinically isolated syndrome preceding MS, suggesting that it is derived from neuronal components following axonal injury (Irani and Kerr. Lancet 2000;355:901; Martnez-Ylamos et al. Neurology 2001;57:722-724). Since the degree of axonal injury correlates with permanent neurological deficits in MS, the CSF 14-3-3 protein might provide an indicator for the progression of the disease from relapsing-remitting MS (RRMS) to secondary progressive MS (SPMS).

Design/Methods:

The levels of 14-3-3 protein were determined by Western blot (Satoh et al. Eur Neurol 1999;41:216-225) in the CSF of the patients with RRMS (n = 10), SPMS (n = 7), primary progressive MS (n = 2), and non-MS inflammatory diseases of the central nervous system (CNS) (n = 5).

Results:

The 14-3-3 protein was identified in 7 CSF samples, including those of 4 patients with SPMS in acute relapse, one with RRMS in acute relapse, one with SPMS accompanied with fresh cerebral infarction, and one with HTLV-I-associated myelopathy. The cases positive for the 14-3-3 protein showed higher levels of pleocytosis, protein, IgG, 2-microglobulin, and neuron-specific enolase in the CSF, more severe disability on the Expanded Disability Status Scale (EDSS), and more extensive lesions chiefly distributed in the spinal cord on magnetic resonance imaging (MRI), compared with the cases negative for its immunoreactivity.

Conclusions:

Detection of the 14-3-3 protein in the CSF provides a marker for severe inflammation-induced extensive damage of the CNS tissues which is responsible for the irreversible neurological deficits in MS.

Supported By:

the grants to J.-I.S. from the MS Society of Japan, the Naito Foundation, and Chiyoda Mutual Life Foundation.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[S21.003]

Application of Different Criteria for Clinical Response to beta-Interferon in Relapsing-Remitting Multiple Sclerosis

Etienne Roullet, Dominique Pez, Pierre Le Canuet, Jean-Christophe Ouallet, Claire Giannesini, Iliu-Florin Trifan, Olivier Heinzlef

Objective:

In a well-defined, prospectively-followed population of Relapsing-remitting Multiple Sclerosis (RRMS) patients: to evaluate the rate of responders after one year of Beta Interferon (IFN-) therapy; and to search for clinical predictors of response.

Background:

There is a growing need for definition of clinical response to IFN- therapy in RRMS. Several sets of criteria have been proposed recently, but their sensitivity has not been evaluated.

Design/Methods:

Patient inclusion criteria were: RRMS; EDSS: 0 to 5.5; initiation of IFN- treatment as first-ever disease-modifying drug in our MS clinic; 2 relapses during the last 2 years; follow-up by the same neurologist: 18 months or longer. Response to therapy was analysed at one year according to different criteria for treatment failure. They were either based solely on relapses (A: at least one relapse [similar to the on-going Antegren add-on trial inclusion criteria]; B: same or higher relapse-rate than during the 1 or 2 years preceding treatment [Waubant E et al, Neurology, 2002. 58: A166]), or on a combination of relapse and disability (C: recent National MS Society criteria; D: cyclophosphamide rescue trial inclusion criteria [Smith DR et al, Neurology, 2001; 56: A356]).We also defined what we considered as an unequivocal response at one year; responders (UR): no relapse and stable EDSS; non-responders (NR): 1 full point increment in EDSS (0.5 if initial EDSS 5 or 5.5); other patients were classified as partial responders (PR)

Results:

Patients (n=116) received IM (n=59) or SC (n=33) IFN- 1-a, or SC IFN- 1-b (n=24). Their characteristics were similar to those of pivotal phase III studies of IFN-. IFN- was stopped before one year because of patients choice (n=2) or side-effects (n=4), inefficacy (n=8) or both (n=2). Expectedly, the rate of responders varied widely, with some consistency, however, between the most stringent criteria: A: 33%; B: 67.3%; C.73.3%; D.66.6 %. The pre-treatment characteristics of responders and non responders were generally not different, except for relapse rate, which was lower (criteria A and C) or higher (B) in responders than in responders (D: not different). When using unequivocal criteria, NR (n=20) tended to have more active MS than UR (n=34), with higher pre-treatment relapse rate (2.3 1.4 vs. 1.6 0.7, p= 0.05) and higher EDSS (3.4 1.4 vs. 2.8 1.1, p= 0.07). The application of relapse-only criteria (A and B) to the PR group (stable EDSS at one year but still relapsing, n=53) gave results similar to those of the whole group.

Conclusions:

The rate of responders, and the pre-treatment factors indicative of response, to IFN- in RRMS are dependent on the choice of criteria for assessment of response. The inconsistency of results obtained by using available criteria based on the response/no response paradigm supports a 2-step approach leading to an operational definition of partial responders.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P06.102]

Study Designs of Two Phase III Trials To Determine the Safety and Efficacy of Natalizumab (Antegren) Alone and When Added to Interferon Beta 1a (Avonex) in Patients with Relapsing-Remitting Multiple Sclerosis

Richard A. Rudick, Cleveland, OH, Alfred Sandrock, Michael Panzara, Cambridge, MA, Chris Polman, Amsterdam, Netherlands

Objective:

To report the design of trials to evaluate efficacy and safety of monthly intravenous (IV) infusions of natalizumab (Antegren) alone and in combination with weekly intramuscular (IM) injections of interferon beta 1a (Avonex).

Background:

Despite the use of currently approved disease modifying drugs in MS, some patients experience side effects or continued disease activity. It has been demonstrated that leukocyte trafficking across the blood-brain-barrier involves interaction of the cell adhesion molecule -4 integrin with its endothelial counter receptor, VCAM-1. In a recent Phase II study in patients with RR-MS, natalizumab, an -4 integrin antagonist, was shown to be well-tolerated and was associated with significant reduction in the formation of new gadolinium (Gd)-enhancing lesions and clinical relapses (Miller,D et al, 2001, Mult.Scler. 7(suppl 1), s16). Furthermore, natalizumab was shown to be safe and well-tolerated in MS patients when added to Avonex therapy (Vollmer et al, Rev Neurol (Paris) 2000 (Suppl 3)). These studies suggest that natalizumab can be safely combined with Avonex, and may be effective, either alone or in combination.

Design/Methods:

Based on results from the Phase II studies, two large, randomized, double-blind, placebo-controlled, multicenter, Phase III efficacy studies were designed to further evaluate the potential of natalizumab as an MS therapy. The AFFIRM study will include over 900 patients. The study is designed to evaluate the effectiveness of natalizumab as monotherapy for patients with relapsing-remitting MS. The SENTINEL study will evaluate the therapeutic potential of natalizumab in combination with Avonex. A total of 1200 patients with relapsing-remitting MS who have experienced a clinical relapse while on Avonex therapy will be randomized to receive natalizumab or placebo, and will continue Avonex treatment. The study will evaluate the efficacy of the combination versus Avonex alone. It is the largest trial conducted thus far to explore the use of combination therapy as a potential therapeutic approach to the treatment of MS. The primary objectives for both of these 2-year trials are to determine whether natalizumab is effective in reducing the number of clinical relapses and slowing the progression of disability as measured by the Expanded Disability Status Scale (EDSS).

Results:

Both studies remain blinded and are currently underway. Study details will be presented.

Conclusions:

Phase II results suggest that natalizumab holds promise as a treatment for MS. Phase III studies of natalizumab, designed based on a strong scientific rationale and promising preliminary data, will determine the effects of natalizumab, alone and in combination with Avonex, on relapse, disability progression, and a variety of other MRI and clinical measures.

Supported By:

Biogen, Inc., Elan Pharmaceuticals

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[S31.002]

Clinical Impact of Mitoxantrone in 64 Primary Progressive Multiple Sclerosis

Marc Coustans, Emmanuelle Le Page, Emmanuelle Leray, Evariste Fanorena, Blandine Cormier, Gilles Edan, Rennes, France

Objective:

To determine the disability progression in patients with primary progressive (PP) multiple sclerosis (MS) that received mitoxantrone (MITOX).

Background:

There is no approved treatment for PPMS. In the natural history of PPMS, previous data indicated that 50 % of PPMS worsened of 1 point EDSS every year at EDSS between 3 and 5 and 20% of PPMS worsened of 0.5 point EDSS at EDSS between 5.5 and 6.5. These data might help for a first step evaluation of the efficacy of potential treatment in PPMS.

Design/Methods:

In this open study, 64 clinically definite PPMS patients were treated with MITOX 20 mg IV either monthly for 6 months (34 patients) or every 3 monthly for up to 24 months (30 patients). Mean cumulative dose of MITOX was 65 mg/m2. Sex ratio (M/F) was 1.1, mean age at onset of the disease was 37 years. Disease duration before MITOX treatment was 6.8 years and mean EDSS at initiating treatment was 5.6. EDSS was performed every 6 months before treatment and for 2 years after initiating MITOX.

Results:

Within the 12 months before MITOX, 44 % deteriorated of 1 point EDSS and 56% didnt change EDSS rate, with a mean EDSS increasing from 5 to 5.6. At MITOX onset treatment, 38% had EDSS between 3 and 5 and 48% a EDSS between 5.5 and 6.5. During treatment, mean EDSS remained stable at 5.6 at years 1 and 2 . Between baseline and year 1, 19% deteriorated 1 point EDSS and 24% improved. Between year 1 and year 2, 25% deteriorated and 5% improved. Between year 2 and baseline 34% deteriorated and 24% improved 1 point EDSS. Among the 29 patients recruited with EDSS6, no patients (out of 16) deteriorated 1 point EDSS at year 1 in the monthly MITOX treated group, compared with 4 patients (out of 13) in the 3 monthly treated group (p0.05).

Conclusions:

Although the EDSS progression rate before MITOX was in the range of that of natural history data, during treatment with MITOX the yearly 1 point EDSS progression was reduced of more than 50%, suggesting a clinical impact of MITOX on disability progression. This is encouraging to promote a phase III trial with mitoxantrone in PPMS patients, especially in PPMS patients with EDSS less than 6.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P04.098]

White Matter Integrity in Multiple Sclerosis and Its Relationship to Cognitive Processing Speed: A Diffusion Tensor Imaging Study

Glenn T. Stebbins, George Katsamakis, Maria C. Carrillo, Dusan Stefoski, Katherine J. Bangen, Chicago, IL, Michael E. Moseley, John D. E. Gabrieli, Stanford, CA

Objective:

To assess changes in microstructural integrity of MRI-based normal appearing cerebral white matter (mNAWM) in patients with multiple sclerosis (MS) compared to matched healthy controls (NC) using diffusion tensor imaging (DTI). To assess the relationship between mNAWM integrity and behavioral measures of processing speed on a voxel-by-voxel basis.

Background:

Slowing of processing speed is one of the earliest and most common behavioral impairment in MS. MS related decrements in white matter integrity may cause processing speed slowing. MS changes in white matter integrity is well documented, but the relationship between behavior and microstructural white matter integrity has not been fully investigated. We used DTI to measure microstructural integrity (fractional anisotropy: FA) of mNAWM in MS and tests its relationship to processing speed on a voxel-by-voxel basis.

Design/Methods:

Nine mildly affected relapsing-remitting MS patients (mean age 31.4 4.7 years) and nine healthy control (mean age 31.7 2.6 years) right-handed subjects participated. Scanning was performed on a 1.5T GE MRI with LX upgrade. DTI was performed using a diffusion weighted single-shot spin-echo echo-planar sequence. DTI data were processed to provide a measure of anisotropy (FA). FA maps were masked for normal appearing white matter using T2 weighted images to exclude regions with abnormal signal. Immediately before scanning, each subject was tested on a measure of psychomotor processing speed (Symbol Digit Modalities Test: SDMT). Group differences in FA were assessed using a two sample t-test (p .05, corrected). Relationship between FA and processing speed was assessed with regression analysis (p .05, corrected). This study was approved by the Institutional Review Board at Rush-Presbyterian-St. Lukes Medical Center.

Results:

FA was significantly decreased in mNAWM in the MS sample (p .001). Voxel-based comparisons revealed significant decreases in FA in the frontal forceps, sub-gyral cingulate, and sub-gyral parietal white matter in MS. Processing speed significantly correlated with FA (SDMT r = .85, p .01). Voxel-based regression between mNAWM FA and processing speed performance revealed significant associations in sub-gyral cingulate and sub-gyral parietal white matter.

Conclusions:

These results demonstrate a regional decrease in the microstructural integrity of mNAWM in patients with MS compared to NC. The regional association between processing speed performance and decreased mNAWM FA suggests a role of decreased white matter integrity in disruption of attentional and executive processing cognitive networks in MS.

Supported By:

Rayman Family Research Fund

Category - MS and Related Diseases

SubCategory - Imaging 


[S11.004]

An Open-Label, Single Arm Study of Simvastatin as a Therapy for Multiple Sclerosis (MS)

Timothy Vollmer, Phoenix, AZ, Valerie Durkalski, William Tyor, Charleston, SC, John Corboy, Denver, CO, Jana Preiningerova, Silva Markovic-Plese, Marco Rizzo, New Haven, CT, Lyndon Key, Inderjit Singh, Charleston, SC

Objective:

To assess the safety and efficacy by MRI of oral treatment with simvastatin at one daily dose(80mg q.d.) in relapsing-remitting (RR) MS patients.

Background:

Studies in the murine EAE model indicate that members of the statin class of drugs e.g.,simvastatin, can inhibit CD4+ TH-1 T cell function,enhance CD4+ TH-2 T cell activity,and inhibit the increased expression of iNOS and TNF-alpha in CNS inflammatory lesions. These studies indicate that statins may have a therapeutic value for the treatment of MS.

Design/Methods:

Three centers participated in an open-label,single-arm trial. Subjects age 18-55 years who were clinically diagnosed with RR-MS were invited to participate. Subjects underwent a pre-treatment period of three months. Subjects that had at least one Gd-enhanced lesion were eligible for six months of treatment with simvastatin. During the study period, neurological assessments and blood values were collected as well as additional brain MRIs. The primary outcome for efficacy was the difference in the mean number of Gd-enhancing lesions obtained from three monthly cranial MRIs performed during pre-treatment and from three performed at Months 4,5 and 6 of treatment. A blinded central reader evaluated MRI films. Secondary outcomes included safety data,MRI measures(i.e.,volumes of Gd-lesions and lesions,number of new Gd-lesions),change from baseline in neurological assessments, and cytokine activity. The study was approved by the Institutional Review Board at each participating center.

Results:

Forty-five subjects (33 female/12 male) were enrolled into the pre-treatment phase of the study. Baseline median values included: age of 45,EDSS of 3.0,MSFC z-score of 0.133, and duration of disease of five years. Thirty subjects were enrolled into the treatment phase. Three did not complete the study (2 withdrew consent;1 lost to followup). Of the treated subjects,the annualized rates of clinically significant relapses during pre- and post-treatment were 0.43 and 0.32,respectively. Preliminary analysis of pre- and post-treatment MRI data for treated subjects indicated a decrease in the mean number of Gd-lesions (p=0.0001) and in the mean volume of Gd-lesions (p=0.0016). The pre-treatment means(sd) for number and volume of Gd-lesions were 2.35(1.94) and 237.96(337.44),respectively. Post-treatment means were 1.31(1.30) and 141.52(292.42),respectively. Safety data showed no serious adverse events related to the study drug. Final quality assurance checks and analyses are currently being conducted.

Conclusions:

Preliminary data suggest that daily treatment with 80mg of simvastatin may be safe and effective for the treatment of RR-MS. Randomized-controlled studies will need to be conducted to definitively ascertain the effectiveness of this treatment.

Supported By:

An unrestricted educational grant from Merck, Inc.

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[S55.008]

Identification of New Target Antigens in Multiple Sclerosis by Protein Array Technology

Sabine Cepok, Dun Zhou, Stefan Nessler, Konrad Buessow, Norbert Sommer, Bernhard Hemmer, Marburg, Hesse, Germany Multiple sclerosis (MS) is a chronic inflammatory and demyelinating disease of the central nervous system (CNS) with an as yet unknown aetiology. Studies on immune cells in the cerebrospinal fluid (CSF) and CNS lesions of MS patients have demonstrated oligoclonal expansion of B cells and hypermutations of the B-cell receptor genes compatible with extensive antigen maturation. Similarly, oligoclonal intrathecal immunoglobulin G (IgG) synthesis is observed in most MS patients. Both findings are consistent with an ongoing humoral immune response in the CNS of MS patients. Based on findings in infectious diseases it is likely that the immune response targets disease relevant antigens expressed in CNS tissue. To investigate antigen specificity of the local humoral antibody response in MS patients we applied a novel protein array technology. E. coli expression arrays, comprising of 37,000 cDNA inserts from a human foetal brain library, were probed with CSF and serum of 15 MS patients and 5 controls. Immune responses to 25 proteins were identified in MS patients, which were not or to a lesser extent observed in controls. Further analysis disclosed a higher reactivity in the CSF of MS patients than controls for most of the possible target antigens. Interestingly, most of the immune reactivities fall in three different, largely non overlapping patterns indicating that they comprise three main but distinct target antigens. Two of the patterns were mapped by extensive peptide scan analysis disclosing their recognition motif. Furthermore, oligoclonal intrathecal IgG were specific for these potential target antigens. Currently experiments are under way to generate monoclonal antibodies and molecular probes to determine the presence of these epitopes in MS lesions.

In summary, we demonstrate that the protein array approach is highly efficient for the identification of antigens, which may be involved in the pathogenesis of MS.

Category - MS and Related Diseases

SubCategory - Basic Science 


[P06.117]

Neuropsychological Assessment of Multiple Sclerosis Patients: The Construct Validity of Computerized Testing 12 Months into Treatment

Jeffrey A. Wilken, Washington, DC, Robert L. Kane, Baltimore, MD, Cynthia L. Sullivan, Mitchell T. Wallin, Julie B. Usiskin, Quig E. Mary, Washington, DC, Simsarian James, Saunders Carol, Fairfax, VA, Douglas Kerr, Baltimore, MD, Raul Mandler, Heidi Crayton, Washington, DC, Kathleen Fuchs, Charlottesville, VA, Dennis Reeves, San Diego, CA

Objective:

The current study is part of a continuing research program to evaluate the use of Automated Neuropsychological Assessment Metrics (ANAM) as a brief, cost-effective method of monitoring the neurocognitive status of MS patients. The main objective was to assess whether ANAM maintains its high predictive validity as the disease progresses.

Background:

ANAM is a short, computerized battery designed for repeated-measures assessment of multiple cognitive domains. In an earlier study with RR MS patients (Wilken et al., in press), it was demonstrated that, prior to the initiation of interferon -1a (Avonex) treatment, performance on ANAM correlated highly with performance on traditional neuropsychological measures. Six months post treatment initiation, correlations remained strong and ANAM accurately predicted neurocognitive impairment as assessed by the traditional battery (Wilken et al., AAN Poster Presentation, 2001).

Design/Methods:

Prior to initiation of interferon -1a (Avonex) treatment, subjects participated in a neuropsychological evaluation consisting of both traditional and computerized measures. Subjects were re-tested 12 months after the baseline assessment as part of a two-year longitudinal study.

Results:

Consistent with prior results, moderate to high correlations were found between computerized and traditional measures of pertinent cognitive domains. ANAM also predicted performance on key traditional tests (e.g., PASAT) with a high degree of accuracy and continued to be highly predictive of performance on the much longer traditional neuropsychological battery.

Conclusions:

This study provides further support for the use of ANAM in monitoring the cognitive status of RR MS patients over time. Benefits related to cost-effectiveness, efficiency, and increased accessibility to neuropsychological assessment are discussed.

Supported By:

Funding for this research was provided by Biogen, Inc.

Category - MS and Related Diseases

SubCategory - Other 


[S55.007]

Myeloid Dendritic Cells from Patients with Secondary Progressive Multiple Sclerosis Polarize Naive T Cells into Pro-Inflammatory T Cells and Are Activated by Serum Factors Including Interferon-

Arnon Karni, Michal Abraham, Rob McGilp, Samia J. Khoury, Howard L. Weiner, Boston, MA

Objective:

To study the activation and function of myeloid dendritic cells (DCs) in multiple sclerosis (MS).

Background:

DCs are professional antigen presenting cells which have the unique capacity to induce primary immune responses. Myeloid DC from patients with secondary progressive (SP) MS express high pro-inflammatory costimulatory molecules (CD80and CD40), low anti inflammatory costimulatory molecule (PDL-1) and an increased proportion of DCs produce IL-12 and TNF-.

Design/Methods:

Serum from MS patients or controls was co-cultured with DCs from HCs with or without the presence of anti-IFN- blocking antibody, and measurement of production of IL-12 and TNF- was studied by flow cytometry.The polarizing effect of MS DCs on naive T -cells was studied by mixed- lymphocyte reaction (MLR) of irradiated DCs with naive CD4+CD45+T cells, T cell stimulation with -CD3/CD28 Ab and measurement of IL-4, IL-10, IL-13, IFN- and TNF- by ELISA and intracytoplasmic staining/flow cytometry. The gene expression profile of CD11c+ myeloid cells was performed utilizing Motorolas CodeLink UniSet Human-I bioarray. 28 untreated relapsing remitting MS (RR-MS), 15 untreated SP-MS patients and 17 HC were studied.

Results:

(1) Increased IL-12 was detected in DC that were incubated with serum from SP-MS (3.5 2.4%) compared to RR-MS (1.3 1.0%, p=0.036),or HC (0.8 0.7%, p=0.007). To identify serum factors that enhanced activation of DC we tested serum for cytokines known to promote maturation or activation of DCs (IL-1, IL-4, IL-6, IL-7,IFN-, IFN-{gamma] and TNF-). Only IFN- was consistently detected. Serum IFN- levels were higher in RR-MS (50.122.2pg/ml, p=0.001) and SP-MS (67.119.7pg/ml, p=0.03)compared to HC (3.712.2pg/ml). Blocking IFN- lead to decrease of IL-12 producing cells (from 3.142.15 to 0.840.79, p=0.008). (2) MLR stimulation of T cells revealed that those that were polarized with DCs of RR or SP-MS secreted increased IFN-, TNF- and IL-2 as compared to HC. T cells that were polarized with DC from RR-MS also secreted significantly higher levels of IL-4, IL-13 and IL-10. Similar results were obtained by measuring single cell cytokine production by flow cytometry. (3) Gene expression revealed 78 genes expressed in MS myeloid cells at greater than twice or less than half of that of the controls. Among these genes are CD83, a known maturation marker of DCs and cyclin-dependent kinase inhibitor 1A that has been implicated as an effector of TGF- and glycocorticoid-induced apoptosis.

Conclusions:

Activated myeloid DCs of SP-MS polarize naive T-cells into proinflammatory T-cells and therefore may play a key role in inducing continous priming of T helper type-1 autoimmune responses in MS. Serum factors including IFN- from SP-MS patients contribute to DC activation.

Supported By:

NIH grant, National MS Society and Nancy Davis Foundation Without Walls.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P01.107]

Evaluation of a Vision Test for Contrast Letter Acuity for Inclusion in the Multiple Sclerosis Functional Composite

Monika L. Baier, Golden, CO, Richard A. Rudick, Cleveland, OH, Gary R. Cutter, Reno, NV

Objective:

To evaluate contrast letter acuity (CLA) measured with Low Contrast Sloan Letter Charts (LCSLC) as a visual test in patients with MS. To assess whether addition of this test improves performance of the Multiple Sclerosis Functional Composite (MSFC) as outcome measure in clinical trials.

Background:

Measures of 4 clinical dimensions were recommended for inclusion in the MSFC - leg, arm, visual, and cognitive function. However, there was no data on which to base a recommendation for a visual function test. Therefore, the current version of the MSFC contains tests of leg, arm, and cognitive function only. The Optic Neuritis Treatment Trial showed that contrast sensitivity was more often impaired than visual acuity, visual field loss or color vision in the affected eyes. Consequently, we evaluated a vision test for CLA for possible inclusion in the MSFC.

Design/Methods:

Two study cohorts were available. Study 1 was a follow-up to the AVONEX Registration Study, which validated the MSFC (Rudick et al. Neurology 2001;56:1324-30). Of the 172 patients eligible for follow-up 137 patients were seen. CLA was assessed cross-sectionally at the follow-up visit only. Study 2 was a 2-year clinical trial to determine whether weekly intramuscular treatment with AVONEX, when compared to a placebo, was effective in slowing secondary progressive MS, as determined by the MSFC. In a sub-study to Study 2, CLA was assessed in 65 patients. Outcome measures available in both studies were EDSS, and MSFC. MRI measures were available in Study 1. CLA was measured similar to a Snellen chart at 100%, 5%, 1.25%, and 0.6% contrast and recorded as number of letters read correctly with a maximum score of 60.

Results:

Visual acuity at high contrast (equivalent to 100% chart) did not change over the course of a clinical trial. The 0.6% chart suffered from a floor effect with nearly 50% of the patients unable to read any letter on this chart. Consequently, only the 5% and 1.25% charts were evaluated. Patients who were still ambulatory (EDSS 6) had significantly better CLA at the 5% and the 1.25% contrast, p0.0001 and p=0.0013, respectively. Both contrast levels showed the expected correlations with the EDSS, MSFC (and its components), Brain Parenchymal Fraction (BPF), and Sickness Impact Profile (SIP) when evaluated cross-sectionally (p0.05). In Study 2, CLA using the 1.25% contrast was predictive of EDSS or MSFC change. The addition of CLA to the MSFC did not explain more of the variance in EDSS cross-sectionally, nor was addition of CLA to MSFC able to predict subsequent EDSS worsening better than MSFC alone. However, contrast letter acuity at both contrasts predicted subsequent absolute change in EDSS after controlling for change in MSFC.

Conclusions:

The LCSLCs have previously been shown to have good reliability. Here they showed good construct validity as well as good predictive validity beyond the MSFC. Larger studies will be required before recommending addition of tests of CLA to MSFC, but these preliminary results suggest this will be fruitful.

Category - MS and Related Diseases

SubCategory - Other 


[P03.117]

A Mitochondrion-Driven Mechanism of Neurodegeneration in Multiple Sclerosis

Bernadette Kalman, New York, NY, Mary Selak, Thomas P. Leist, Philadelphia, PA

Objective:

To propose a mitochondrion-driven mechanism of neurodegeneration in multiple sclerosis (MS).

Background:

Neurodegeneration is the major pathological correlate of disability in MS. Cytokines, immunoglobulins, nitric oxide (NO) and reactive oxygen species (ROS) have been implicated in the observed cellular and axonal loss, with the immune mediated forms of apoptosis being in the center of investigations. Our studies suggest that a mitochondrion-driven tissue loss also develops secondary to inflammation. We have previously shown that activated immune cells of MS patients release increased amounts of ROS. In association with inflammation, we demonstrated significantly higher degrees of oxidative damage to mitochondrial (mt)DNA in active plaques as compared to corresponding normal appearing white matter (NAWM) specimens. Here we present consequences of oxidative damage on oxidative phosphorylation (OXPHOS), and discuss its potential contribution to neurodegeneration in MS.

Design/Methods:

Specimens: Frozen postmortem tissue pairs of chronic active plaque and NAWM from ten patients with secondary progressive MS were obtained from the Rocky Mountain MS Tissue Bank. Oxidative damage to mtDNA was previously determined in these specimens.

Methods:

We measured the activity of mitochondrial enzyme complexes I, I+III, II+III, IV and citrate synthase, in the ten paired homogenates of active plaques and NAWMs, and calculated the specific activity of enzymes. We reviewed the final common pathway of neurodegeneration related to increased ROS production, oxidative damage to macromolecules and impairment of OXPHOS ultimately leading to apoptosis or necrosis.

Results:

In association with inflammation and oxidative damage to mtDNA, we detected a decreased activity of the NADH-dehydrogenase component of Complex I in 70% of active plaques as compared to corresponding NAWM specimens. In the same specimens, a likely compensatory increase in the activity of Complex IV was also observed.

Conclusions:

Our previous and present data suggest a mitochondrial component of tissue loss in MS, similar to that decribed in neurodegeneration of various origins. Cell survival is closely linked to energy metabolism. Electrons generated by the oxidation of substrates pass through four mitochondrial enzymes (Complex I-IV) before arriving to ATP synthase (Complex V). OXPHOS provides energy for pumping protons out of the matrix into the inter-membranous space, which defines the mitochondrial trans-membrane potential (MTMP). Impaired activity of OXPHOS enzymes leads to a decrease in ATP synthesis, drop of MTMP and opening of the permeability transition pore (PTP). The open PTP allows the release o pro-apoptotic molecules from the mitochondrial inter-membrane space to the cytoplasm to activate the caspase cascade of apoptotic cell death. The observed tissue loss in MS may be related, at least in part, to this biochemical pathway initiated by an inflammation-induced oxidative damage to macromolecules and Complex I impairment.

Category - MS and Related Diseases

SubCategory - Basic Science 


[P01.120]

Multiple Sclerosis Disease Activity in Patients of Different Ethnic Origin: Data from the Evidence Trial

Bruce C. Cree, Douglas S. Goodin, Jorge R. Oksenberg, Lisa F. Barcellos, Stephan L. Hauser, San Francisco, CA

Objective:

This is a subgroup analysis comparing multiple sclerosis (MS) disease activity in African American (AA) and Caucasian American (CA) patients who participated in the EVIDENCE trial.

Background:

MS is thought to be less common in AA than in CA patients. In addition, there seems to be phenotypic and genotypic differences in the MS experienced by these patient populations and there may be differences in their responses to therapy.

Design/Methods:

We examined MS disease activity in AA (n=36) and CA (n=616) patients with MS who participated in the EVIDENCE trial. This previously-reported trial was a large multi-center study comparing the efficacy of interferon beta-1a (IFN-1a) 44 mcg thrice-weekly (Rebif) with IFN-1a 30 mcg once weekly (Avonex) over 48 weeks of therapy.

Results:

In CA patients, as in the entire EVIDENCE data set, there was a significant benefit to high-dose, frequently-administered, IFN-1a compared to once-weekly IFN-1a. In AA patients this therpeutic difference was less evident, despite the fact that the AA patients were, if anything, less active at baseline than the CA population with respect to the mean number of combined unique (CU) lesions (2.3 vs 2.6) and the mean attack-rate in the prior 2 years (2.4 vs 2.5). After therapy, AA patients did numerically (but not statistically) worse than CA patients on all outcome measures including the mean number of CU lesions over the first 24 weeks of therapy (1.37 vs 0.97), the exacerbation-free status (56% vs 70% at 24 weeks; 47% vs 57% at 48 weeks), and the mean exacerbation number (0.47 vs 0.33 at 24 weeks; 0.73 vs 0.57 at 48 weeks).

Conclusions:

MS disease activity seems to differ between CA and AA MS patients with a suggestion of reduced response to IFN-1a therapy in the AA group. Although this conclusion in based on a very small sample, this possibility has important implications and deserves further investigation.

Supported By:

Serono, Inc.

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P05.134]

Th-1 to Th-2 Immune Shift in Female Multiple Sclerosis Patients Treated with the Pregnancy Hormone Estriol

Samantha S. Soldan, Nancy L. Sicotte, Ana Isabel Alvarez Retuerto, Rochelle Klutch, Rhonda R. Voskuhl, Los Angeles, CA

Objective:

To examine the immunomodulatory effects of oral estriol treatment on T helper 1 (Th-1) and T helper 2 (Th-2) profiles in peripheral blood mononuclear cells (PBMC) of MS patients.

Background:

Pregnancy is associated with decreased relapse rates in MS patients and an amelioration of experimental autoimmune encephalomyelitis (EAE), an animal model for MS. The protective effect of pregnancy in both MS and EAE is thought to be mediated by the T helper 1 to T helper 2 immune shift. The hormone estriol increases throughout pregnancy and is concurrent with the TH-1 to TH-2 shift in immune response. A pilot trial involving 10 nonpregnant female MS patients (6 RR and 4 SP) was completed. Following a 6 month pretreatment period, patients were treated for 6 months with oral estriol. The 6 month treatment phase was followed by a 6 month postreatment period. An extension retreatment phase with estriol plus progesterone was conducted in the RR group. Levels of serum estriol during the treatment and retreatment phases approximated third trimester pregnancy levels. Treated RR patients demonstrated significant decreases in gadolinium enhancing lesion numbers and volumes on monthly cerebral magnetic resonance images. When estriol treatment was stopped, enhancing lesions increased to pretreatment levels. Moreover, when estriol treament was reinstituted, enhancing lesions were again decreased.

Design/Methods:

PBMC were cryopreserved every three months throughout the pretreatment, treatment, postreatment, and retreatment phases. Cryopreserved PBMC were thawed and stimulated in vitro with anti-CD3, glatiramer acetate, recall antigens (tetanus toxoid, Candida albicans lysate) and PHA. Cytokine production was measured after 24 hours by intracellular cytokine staining (IL-5, IL-10, IL-12 p40, TNF-a, and IFN-g) and after 48 hours in culture supernatants by cytometric bead array (IL-2, IL-4, IL-5, IL-10, TNF-a, IFN-g).

Results:

Significant increases IL-5 and IL-10 and significantly decreased levels of TNF-a were observed in stimulated PBMC during in vivo estriol treatment and retreatment by intracellular cytokine staining and cytometric bead array. No changes were observed in secreted levels of IL-2, IL-4, or IFN-g or in intracellular levels of IL-12 p40 or IFN-g. Changes in cytokine profiles were observed in both RR and SP MS patients. In RR patients, cytokine changes correlated with changes in lesion volume. Subpopulations of circulating immune cells were altered during in vivo estriol treatment in RR and SP MS.

Conclusions:

Oral estriol treatment was associated with a partial TH-1 to TH-2 shift. Although estriol treatment had an anti-inflammatory effect in both RR and SP MS, improvement was only observed in the RR group, which underscores differences in the immunopathogenesis of these disease phases. Further study of oral estriol treatment in RR MS and other TH-1 mediated autoimmune disorders is warranted.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[S61.002]

Quantitative 1H-MRS Measurement of Glutamate Levels in Multiple Sclerosis Lesions

Jeffrey I. Greenstein, Sinclair A. Smith, Uday S. Kanamalla, Jin Luo, Philadelphia, PA

Objective:

In a previous study glutamate levels were evaluated qualitatively in MS brain. Glutamate peak heights and areas were elevated significantly. However, using ratios of glutamate peaks to creatine produced variable responses because creatine levels were elevated in MS compared with normal controls. In order to ascertain whether glutamate levels are unequivocally elevated in MS brain they were measured quantitatively by 1H-MRS in normal control white matter as well as in gadolinium-enhancing, T2 and T1 hypodense lesions in MS.

Background:

Elevated CSF levels of glutamate have been found in MS. In addition, infiltrating macrophages associated with oligodendroglial loss and dystrophic axons have high levels of glutamate synthase; suggesting that they are a major source of glutamate production in MS lesions. AMPA receptor antagonists afford neuroprotection without reducing inflammation in EAE. Therefore, glutamate excitotoxicity may play a role in the pathogenesis of MS by producing both oligodendroglial loss and axonal dystrophy and potentially contributing to disease progression. Therapeutically, glutamate antagonism may possibly protect myelin, oligodendrocytes and axons in MS and may offer additional benefits when added to currently available immune-modulators.

Design/Methods:

Sixty MS patients (RRMS=36, SPMS=24) and 10 normal controls were studied. Eighty five MS lesions and 10 normal white matter areas were examined using single voxel 1H-MRS. All studies were performed with a GE 1.5TLx MRI using TE=35msec, TR=1150msec. A point-resolved spectroscopy sequence (PRESS) was used. Alpha (3.56ppm) and beta/gamma (2.05-2.45ppm) glutamate peaks were resolved and quantitated by comparing them with spectra from a phantom containing 12.5mM glutamate. Gadolinium-enhancing, T2+T1- and T2+T1+ lesions were resolved and compared with normal control white matter.

Results:

Compared with normal controls, all three glutamate peaks as well as the sum of the three peaks were elevated in all MS lesion types examined. Levels were higher in gadolinium-enhancing lesions than in T2+T1- and T2+, T1+ lesions. All three peaks were highly significantly elevated in each lesion type except for the beta peak in T1 lesions (p=0.09) where there was increased variability of levels.

Conclusions:

Significantly elevated levels of glutamate are present in all MRI visible MS lesions. This provides the first quantitation of glutamate elevations in MS lesions and confirms and extends the prior pathologic studies demonstrating increased glutamate synthetic enzyme levels. Increased levels of glutamate could contribute both to acute and chronic tissue injury and to the pathogenesis of disease progression in MS. Glutamate antagonism may offer a novel approach to MS therapy particularly when added to immunomodulators.

Category - MS and Related Diseases

SubCategory - Imaging 


[S61.005]

Towards a Multimodal Magnetic Resonance Surrogate for Disability in Multiple Sclerosis

Sridar Narayanan, Simon Francis, D. Louis Collins, M. Carmela Tartaglia, Yves Lapierre, Douglas L. Arnold, Montreal, QC, Canada

Objective:

To assess the potential of combined magnetic resonance measures of brain and spinal cord pathology in MS to explain the observed variance in clinical disability.

Background:

Magnetic resonance imaging (MRI) has allowed the macroscopic lesions of MS to be sensitively detected, but correlations between the volume of lesion quantified on conventional T2-weighted MRI and clinical disability have been modest. Newer magnetic resonance (MR) acquisition and analysis techniques have provided more specific surrogates of pathology. In particular, MR spectroscopy (MRS) has enabled the assessment of axonal integrity by monitoring levels of N-acetylaspartate (NAA), while measures of brain and spinal cord atrophy can be computed from appropriately acquired structural images. Individually, these measures have shown better correlations with disability than T2-weighted lesions, but a large proportion of the variance in disability remains unexplained by any one measure. We hypothesized that combining a measure of axonal dysfunction and density loss with measures of brain and spinal cord tissue loss would provide a better correlate of clinical disability in MS.

Design/Methods:

We performed combined MR imaging and spectroscopy examinations on 35 patients with relapsing-remitting (RR) MS, 12 patients with secondary progressive (SP) MS and 17 healthy control subjects. Resonance intensities of NAA relative to creatine (Cr) were obtained from a volume of interest centered on the corpus callosum. The Brain to IntraCranial Capacity Ratio provided a skull-normalized measure of brain volume. Spinal cord cross-sectional area at the level of C2 was computed from high-resolution images of the cervical spinal cord. Clinical disability was assessed using the Expanded Disability Status Scale. A composite score of tissue injury and loss was computed for each subject by taking the ratio of each quantity (NAA/Cr, BICCR and spinal cord cross-sectional area) to the mean of that quantity in normal controls, and then multiplying the three ratios. The Spearman rank correlation coefficient (SRCC) of EDSS with the composite score and each individual metric was compared.

Results:

The EDSS scores of the patients spanned the range from 0 to 9. The SRCC between EDSS and the composite score, NAA/Cr, BICCR and spinal cord cross-sectional area were, respectively, 0.65 (p0.001), 0.37 (p=0.011), -0.54 (p0.001) and 0.62 (p0.001). The composite also better separated the control, RR and SP groups than the individual metrics (ANOVA).

Conclusions:

The relevance to disability of different MR markers of pathology can be expected to vary between individuals and with the stage of disease. A composite index combining measures reporting on different aspects of MS pathology can correlate better with disability over the whole EDSS range, and may provide a more sensitive means of detecting progressive changes over time.

Supported By:

Canadian Institutes of Health Research and the MS Society of Canada.

Category - MS and Related Diseases

SubCategory - Imaging 


[P06.110]

An Open-Label Study Comparing the Effect of IFN-1a and IFN-1b in 130 Relapsing-Remitting Multiple Sclerosis Patients: Analysis of Outcome and Possible Predictors of Efficacy

Giovanni Coppola, Roberta Lanzillo, Salvatore Ascione, Vittorio Schiavone, Giovanni Vacca, Elena Salvatore, Giuseppe Orefice, Vincenzo Brescia Morra, Vincenzo Bonavita, Naples, Italy

Objective:

To study two groups of RRMS patients, treated with IFN-1a (Rebif) and IFN-1b (Betaferon); to identify possible predictors of good clinical outcome in this cohort of patients.

Background:

Although both -1a and -1b interferons have been shown to reduce disease progression in multiple sclerosis, few comparative studies are to date available. Furthermore, it would be clinically relevant to identify possible predictors of satisfactory therapeutic response.

Design/Methods:

An open-label study was conducted, in order to evaluate the clinical outcome in a cohort of Interferon -treated RRMS patients. One-hundred and thirty consecutive RRMS patients recruited in Naples, Italy, were included in the study. Forty-two received IFN-1a 22 mcg, s.c. thrice weekly, and 36 IFN-1b, 250 mcg s.c. on alternate days. We evaluated baseline characteristics (onset age, disease duration, EDSS basal score, annual prior relapse rate), clinical outcome in the group reaching a 2-year follow-up (EDSS, relapse rate and relapse-free proportion of patients), time to EDSS 1-point progression and time to first relapse during the treatment. We also evaluated the influence of baseline parameters (prior annual relapse rate, baseline EDSS score) on the outcome measures.

Results:

Mean follow-up time SD was 25 20 months (range 1-77). A follow-up longer than 24 months was available for 57% of IFN-1a and for 41% of IFN-1b treated patients. Baseline characteristics were similar in the two groups. After a 2-year follow up, both groups presented similar EDSS change and relapse-free proportion, and a statistically significant relapse rate reduction on therapy.

Survival analysis in 130 patients showed no statistically significant differences in the two groups, in both time to 1-point EDSS worsening and time to first relapse on therapy. When we divided the patients according to baseline prior relapse-rate, we observed a better outcome in IFN-1a treated group for patients with baseline relapse rate 2, and a better outcome in IFN-1b treated group for patients with baseline relapse rate 2, either considering time to progression or time to first relapse (p0.05).

Patients treated with IFN-1b discontinued treatment more frequently for voluntary decision and side effects, whereas most of the IFN-1a dropouts were due to disease activity (disability and relapses).

Conclusions:

Both IFN-1a and IFN-1b are effective on disease activity and progression in this cohort. We observed a better outcome in IFN-1a treated patients with low baseline relapse-rate, and in IFN-1b treated patients with high baseline relapse-rate.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[S51.006]

The Paradox of Primary Progressive Multiple Sclerosis Unsolved

Zografos Caramanos, Simon J. Francis, Sridar Narayan, M. Carmela Tartaglia, Montreal, QC, Canada, A. Carlos Santos, Ribeirao Preto, Sao Paolo, Brazil, Daniel Pelletier, San Francisco, CA, D. Louis Collins, Yves Lapierre, Douglas L. Arnold, Montreal, QC, Canada

Objective:

To compare clinical and sophisticated, quantitative neuroimaging data in multiple sclerosis (MS) patients with relapsing-remitting (RR), secondary progressive (SP), or primary progressive (PP) disease in order to better understand the nature of PPMS.

Background:

Unlike in RR- and SP-MS, disability in PP-MS progresses from disease onset without any initial relapses or remissions. As of yet, standard neuroimaging data have been unable to explain these differences.

Design/Methods:

42 RR, 14 SP, and 9 PP cases underwent conventional T1, T2, and PD MRI, as well as 1H-MRSI and MT imaging. Neuroimaging measures included (i) total T1 and T2 lesion volumes, (ii) brain (BICCR, brain to intra-cranial capacity ratio) and upper cervical spinal cord atrophy, (iii) median MT ratios within both lesions and NAWM, and (iv) NA/Cr and Cho/Cr in a callosum-centered brain slab.

Results:


[Mean (SD), in order respective of group mention; significance from LSD post hoc tests following significant 1-way ANOVA; a=0.05; lesion volumes were logged; ns, not significant]. Clinical: PP cases had a later mean age of onset [47.7 (8.9)] than either RR or SP [35.8 (8.8), 41.8 (9.4), ns]. Nevertheless, as measured by mean EDSS scores, PP cases were equally disabled as SP [5.7 (2.1), 6.2 (1.8), ns]; both of which were more disabled than RR [2.3 (1.4)]. Imaging: As opposed to the clinical findings, PP cases had mean lesion loads similar to RR [T1: 2.2 cc (3.9), 2.4 (4.9), ns; T2: 7.0 (11.0), 11.2 (13.9), ns], both of which were lower than in SP [T1: 7.9 (11.7); T2: 21.6 (29.1)]. Similarly, PP cases had mean C2 spinal cord cross-sectional areas that were similar to RR [75.3 mm2 (7.3), 76.1 (9.8), ns]; both of which were less affected than in SP [61.9 (13.1)]. On the other hand, whereas SP cases had lower mean BICCR values [81.7 (5.2)] than RR [85.1 (4.3), PP cases did not differ from either group [82.2. (4.6) ns]. All three patient groups had similar lesional MTr [RR: 24.4 (2.8); SP: 22.2 (3.1); PP: 24.5 (2.5); ns] and NAWM MTr values [RR: 35.6 (1.5); SP: 35.3 (1.4); PP: 35.4 (1.1); ns], as well as similar central-brain NA/Cr [RR: 2.86 (0.4); SP: 2.72 (0.3); PP: 2.88 (0.3); ns] and Cho/Cr values [RR: 1.48 (0.2); SP: 1.58 (0.2); PP: 1.51 (0.1); ns].

Conclusions:

Whereas patients with PP-MS were as disabled as those with SP-MS, this level of disability was not reflected in quantitative measures of their cerebral lesion load, of their cerebral or spinal cord atrophy, or of their white matter or neuronal integrity (upon which they more closely resembled patients with RR-MS). Thus, the disability-neuroimaging paradox in PP-MS still remains unsolved. Perhaps future, closer examination of grey matter integrity in these patients will help solve this riddle.

Category - MS and Related Diseases

SubCategory - Imaging 


[P03.100]

Structural Requirements for Therapeutic and Immunologic Effects of -Lipoic Acid in an Animal Model of Multiple Sclerosis

Gail H. Marracci, Gabriel P. McKeon, Whitney E. Marquardt, Richard E. Jones, Dennis N. Bourdette, Portland, OR

Objective:

To identify the structural requirements necessary for derivatives of -lipoic acid (ALA) to retain their therapeutic effects in EAE

Background:

We have demonstrated that ALA can suppress and treat EAE and inhibit matrix metalloproteinase-9 (MMP-9; J. Neuroimm. 131: 104-114, 2002), and are currently performing a dose finding study of ALA in MS. Development of more potent derivatives of ALA to treat MS requires a better understanding of the structural components necessary for the therapeutic effect of ALA.

Design/Methods:

EAE was induced in SJL mice by immunization with PLP 139-151 peptide in CFA. ALA, its reduced form, dihydrolipoic acid (DHLA), an amide derivative of ALA, lipoamide (LPM), and S,S-dimethyl lipoic acid (Me2LA), or vehicle were injected daily commencing on day 7 to suppress EAE. As the molecules all had comparable molecular weights, they were tested at a dose of 20mg/kg/day, which is the approximate IC50 dose of ALA. ALA and its derivatives were evaluated in vitro to determine their effects on proliferation, MMP-9 activity, and expression of LFA-1 and CD25.

Results:

ALA, DHLA and LPM, but not Me2LA, suppressed EAE in PLP immunized SJL mice. ALA, DHLA and LPM reduced the 10-day cumulative disease score by 36-49% and the mean maximum disease score by 25-39%. Co-culture of ALA, DHLA and LPM with PLP specific T cells demonstrated a dose-dependent (10-400g/ml) inhibition of proliferation and MMP-9 activity. At 50g/ml ALA, DHLA and LPM inhibited proliferation by 27-44%. DHLA was a more potent inhibitor of MMP-9 than either ALA or LPM. At 10g/ml DHLA indirectly inhibited MMP-9 activity by 81%, whereas ALA and LPM inhibited MMP-9 activity at a concentration of 400g/ml by 61% and 35%, respectively. Direct inhibition of MMP-9 by ALA, DHLA and LPM was also demonstrated to be dose dependent (10-1000g/ml). DHLA at 10g/ml inhibited MMP-9 activity by 35%, whereas ALA and LPM reduced MMP-9 activity by 22-51% at concentrations of 400-1000g/ml, respectively. Finally, in vitro treatment of PLP specific T lymphocytes with ALA, DHLA and LPM (10-400g/ml) reduced expression of the adhesion molecule LFA-1 and activation marker CD25 in a dose dependent fashion (33-75% at 400g/ml and 44-73% at 400g/ml, respectively).

Conclusions:

The results presented here indicate that active sulfhydryl groups on ALA and its derivatives are required for suppression of EAE while a carboxyl group is not. In addition, DHLA is more potent than either ALA or LPM in inhibiting MMP-9 activity and suppressing T cell activation in vitro. These observations are consistent with the hypothesis that DHLA is the active form of ALA that mediates the therapeutic effects of ALA in vivo. These data provide critical structural information needed for designing more potent lipoate derivatives for the ultimate treatment of MS.

Supported By:

the Department of Veterans Affairs, NIH/NCCAM P50AT00066-01 and Nancy Davis Center without Walls.

Category - MS and Related Diseases

SubCategory - MS: Animal Models 


[P01.116]

Measuring Disease Progression in Primary Progressive Multiple Sclerosis

Robert J. Fox, Cleveland, OH, Peter Bacchetti, San Francisco, CA, Jeffrey A. Cohen, Cleveland, OH, Donald E. Goodkin, Mariko Kita, Seattle, WA, Daniel Pelletier, Jerome Stone, Scott S. Zamvil, San Francisco, CA

Objective:

To evaluate the ability of 9-hole peg test (9HPT) and 25-foot walk (25FW) to detect clinical progression in primary progressive multiple sclerosis (PPMS).

Background:

PPMS usually involves progressive myelopathy, which may not be captured well by the traditional EDSS rating scale despite its emphasis on ambulation. The MS Functional Composite includes 2 components that may be useful in measuring progressive myelopathy: 9HPT and 25FW. Recently, Schwid et al (Neurology 2002;58:1294) reported less than 17% day-to-day variation in 9HPT and 25FW times. They suggested that a 20% increase in 9HPT and 25FW is more than expected by normal variation, and that this threshold may reliably indicate a true change in the function for an individual. We tested the ability of this threshold to detect a change in neurologic impairment over time in a group of PPMS subjects.

Design/Methods:

Subjects from a double-blind, placebo-controlled, 2-year clinical trial of mitoxantrone in PPMS were evaluated for sustained clinical progression at tri-monthly visits. Results are from the two study arms combined, because the study remains blinded. Subjects with 48 weeks of follow-up were evaluated for sustained progression, defined as a sustained worsening from baseline at two sequential visits on EDSS (1.0 point for baseline EDSS 3.5-5.0, and 0.5 for baseline EDSS 5.5-6.5), 9HPT (20% increase), and 25FW (20% increase).

Results:

48 (79%) of 61 originally-enrolled subjects have attained 48 weeks of follow-up. Of those 48 subjects, 26 (54%) have confirmed progression by 1 or more of the end-points: 12 (25%) by EDSS, 8 (17%) by 9HPT, and 22 (46%) by 25FW. Progression in only one measure was seen in 1 (2%) subject by 9HPT, 2 (4%) by EDSS, and 11 (23%) by 25FW. Of the 12 subjects with EDSS progression, 5 also demonstrated 9HPT progression, 9 had 25FW progression, and 2 did not have confirmed progression on either 9HPT or 25FW. Of the 2 subjects with EDSS progression alone, 1 had progressive leg monoparesis that increased pyramidal and cerebellar functional system scores, and 1 had decreased endurance from motor fatigue.

Conclusions:

Adding 9HPT and 25FW to EDSS significantly increased the percentage of subjects with identified progressive neurologic impairment from 25% to 54%. The majority of this increased detection was due to 25FW: of all subjects with clinical progression, 85% had 25FW progression and 23% had progression on 25FW alone. It is likely that the superior accuracy and reproducibility of the 25FW and 9HPT over EDSS allows one to define smaller changes in neurologic impairment, and thus allows increased sensitivity to change. This may increase the sensitivity to detect a treatment effect of experimental therapeutic interventions in PPMS, and should result in increased statistical power and reduced sample sizes.

Supported By:

The clinical trial is supported by Immunex/Amgen.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P01.115]

Interobserver Agreement on the Posers and the New McDonalds Diagnostic Criteria for Multiple Sclerosis

Valentina Zipoli, Emilio Portaccio, Gianfranco Siracusa, Marco Moretti, Giovanni Pracucci, Sandro Sorbi, Maria Pia Amato, Florence, Florence, Italy

Objective:

To assess the interobserver agreement on the diagnosis of Multiple Sclerosis (MS) using the Posers and the new McDonalds criteria.

Background:

An accurate and reliable diagnosis since the beginning of the disease is essential for both clinical practice, to allow timely therapeutic interventions, and research purposes. Nevertheless, few authors have specifically assessed the interobserver agreement in the diagnosis of MS using different sets of diagnostic criteria, and published studies until now have dealt with criteria developed before 1983.

Design/Methods:

The study sample consisted of 44 patients, including 41 MS cases, 15 relapsing-remitting, 2 secondary progressive, 5 primary progressive and 19 patients presenting their first clinical attack. In 3 subjects the diagnostic work-up pointed to an alternative diagnosis. Clinical information was recorded in standardized forms. Four neurologists with comparable clinical experience were asked to make a diagnosis according to the Posers and the McDonalds criteria. Two neurologists had also previously undergone a specific training in MRI. Moreover, the four neurologists and a neuroradiologist independently assessed MRI scans according to the McDonalds guidelines. The level of interobserver agreement was measured using the kappa statistic (k).

Results:

We found a moderate agreement on the overall diagnosis using both the Posers and McDonalds criteria (k respectively 0.57 and 0.52). Analysing the agreement for distinct diagnostic categories, we observed a moderate to substantial reliability for the three McDonalds categories (range of k values 0.49-0.64) and a fair to substantial agreement for the nine Posers categories (range of k values 0.37-0.67). To better identify possible sources of disagreement, we further measured the agreement level on specific diagnostic items. Taking into account clinical information, the agreement on dissemination over time was substantially higher (k=0.69) than that found on dissemination over space (k=0.46). On the contrary, for MRI assessment, the agreement for spatial dissemination was substantial (k=0.74) compared to the fair reliability (k=0.25) yielded by dissemination over time. Finally, we observed a moderate to excellent agreement among the neuroradiologist and the two neurologists who had previously undergone a specific training in MRI (range of k values 0.66-1.00).

Conclusions:

In comparison with the Posers classification, the new McDonalds criteria allow us to anticipate the diagnosis yielding a good diagnostic reliability. However, implementation of these criteria in everyday clinical practice will require considerable effort, both by neurologists and neuroradiologists, to improve the accuracy of MRI assessment.

Category - MS and Related Diseases

SubCategory - Epidemiology 


[P06.122]

Evoked Potentials Help Differentiate White Matter Lesions in the Antiphospholipid Syndrome from Multiple Sclerosis

Joab Chapman, Vivian E. Drory, Amos D. Korczyn, Ori Elkayam, David Levartovsky, Irena Litinsky, Dan Caspi, Yoram Segev, Daphna Paran, Tel Aviv, Israel

Objective:

To assess the usefulness of electrophysiological studies in differentiating APS from MS.

Background:

The CNS manifestations of the antiphospholipid syndrome (APS) can mimic multiple sclerosis (MS) both clinically and radiologically. Objective tests would help differentiate the two diseases and offer some insight into their pathogenesis.

Design/Methods:

Twenty five APS patients with CNS manifestations, fulfilling the Sapporo criteria, and 21 definite MS patients underwent electrophysiological studies including visual (VEP), somatosensory (SEP) evoked potentials and sympathetic skin response (SSR). The groups were stratified for disability as measured by the expanded disability status scale, (EDSS), and by quantification of lesion load on T2 weighted brain MRI images.

Results:

The percentage of pathological SEP, VEP and SSR tests in the MS group (70%, 57%, and 35% respectively) was significantly higher than in the APS group (28%, 12% and 4%, p=0.003, p=0.0005 and p=0.005 respectively by Fishers exact test). In patients with more severe disability (EDSS2.0), there were more pathological SEP (p=0.04), VEP (p=0.001) and SSR tests (p=0.04) in the MS compared to APS groups. There were no significant differences between the less disabled MS and APS patients. Similarly, in patients matched for higher lesion burden there were more pathological SEP (p=0.02), VEP (p=0.04) and SSR (p=0.02) tests in the MS group. In patients with low lesion burden only pathological VEP tests were significantly more common in the MS patients (p=0.02).

Conclusions:

Electrophysiological testing may be useful in differentiating MS from APS, especially in more severely affected patients. This may indicate that demyelination is more widespread and severe in MS compared to APS patients or that the distribution of lesions is signficantly different.

Category - MS and Related Diseases

SubCategory - Clinical Neurophysiology 


[S61.004]

Potentially Adaptive Functional Changes for Cognitive Processing in Multiple Sclerosis

Allyson M. Parry, Richard B. Scott, Palace Jacqueline, Matthews M. Paul, Oxford, Oxfordshire, United Kingdom

Objective:

A combined quantitative approach using FMRI and structural MRI measures of disease burden to determine; (i) whether patients with MS recruit different regions of the brain to healthy controls during the performance of the Counting Stroop task, a test of selective attention. (ii) the relationship between disease burden (normalised brain parenchymal volume[NBPV]) and the pattern of FMRI activation.

Background:

The weak relationship between neuropschological deficits and conventional measures of disease burden in MS may reflect adaptive functional compensation.

Design/Methods:

Eleven MS patients, eleven healthy controls.

Counting Stroop paradigm ; Block design [REST (30secs)- 8 x (AB) REST (30secs)].

A= Neutral animal words (e.g., cat, dog)

B= Interference number words (e.g., one, two). Report via button press the number of words (1-4) on the screen, regardless of word meaning.

The Stroop effect (mean reaction time during the Interference task- mean reaction time during the Neutral task ) and the number of errors was recorded.

Group FMRI analysis; random effect model , Z = 2.0, cluster significant threshold p = 0.05.

Two between-group analysis using the contrast Interference-Neutral; 1-(patients-controls) and, 2-(controls-patients).

Region of interest approach using brain regions identified in the group analyses to determine the mean signal intensity for each region/subject.

Results:

No significant effect of subject group on either the magnitude of the Stroop effect or on the number of errors during the task performance (p=0.28).

FMRI

(patients-controls); left superior frontal gyrus (-15, 34, 40, p = 0.001). This region was not activated in a within-group analysis of the control subjects.

(controls-patients); opercula surface of the right inferior frontal gyrus (29, 20, 9). This region was not activated in a within-group analysis of the patients. Bilateral superior parietal lobe(-42, -26, 66), and (46, -27, 63).

For each patient, an FMRI laterality index (LI) was calculated (mean signal intensity in left superior frontal gyrus / mean signal intensity in right inferior frontal gyrus), such that the higher the LI value, the greater the difference in frontal lobe laterality between the patients scan and the control group. There was an inverse correlation between the LI value and the NBPV (r=-0.71, p=0.02).

Conclusions:

There was a marked laterality difference in the frontal lobe regions activated by MS patients and controls. We hypothesise that reduction of right frontal activation is a direct consequence of the brain injury from MS and that abnormal left frontal brain activation observed in the patient group represents a secondary adaptive response to this. This hypothesis is supported by the significant correlation between the LI and the NBPV.

Supported By:

P.M. and J. P gratefully acknowledge the support of the MS Society of Great Britain and Northern Ireland. Work in the FMRIB Centre is supported by the MRC.

Category - MS and Related Diseases

SubCategory - Imaging 


[S31.001]

Open-Label Trial of Minocycline in Active Relapsing-Remitting Multiple Sclerosis

L. M. Metz, V. W. Yong, M. Yeung, D. G. Patry, R. B. Bell, Y. Zhang, S. B. Patten, P. Duquette, C. Wallace, R. Sevick, J. Antel, A. Bar-Or, R. B. Mitchell

Objective:

The primary outcome of this trial is to evaluate the safety and tolerability of minocycline in people with relapsing-remitting MS (RRMS). A secondary goal is to estimate the effect of treatment on MRI enhancing lesion number and volume, as well as T1 and T2 volume.

Background:

While partially effective therapies are available to treat RRMS all are expensive, none can be taken orally, and many patients fail to respond. Minocycline is a second-generation tetracycline that is well absorbed orally and diffuses well into the CNS independent of BBB inflammation. It has been available for over 30 years and, in the United Kingdom alone, over 6.5 million people have been treated with it for an average of 9 months, mostly for acne. Therefore, the expected adverse events and their frequency have been well described. Minocycline has recently been found to have many immune modulating properties and to attenuate EAE (Brain 125:1297, 2002). It is widely available in a generic format and is relatively inexpensive. These features make minocycline an excellent candidate to be evaluated for treatment of MS.

Design/Methods:

Between Oct 2001 and June 2002, ten patients with active RRMS were enrolled in this nine-month IRB approved, open-label trial of minocycline. All had declined proven therapy or discontinued treatment at least six months prior to enrolment. After a three-month observation period, treatment with minocycline, 100 mg po bid, was initiated. Clinical and laboratory safety assessment, EDSS, and MSFC were completed at three-month intervals. MR imaging was completed at four-week intervals; four scans were obtained pre-treatment and six were obtained post-treatment. FSE proton density weighted, T2, and T1 (before and after gadolinium contrast) images were obtained. Monthly scans were analysed to determine the total T1 and T2 lesion burden and the number and volume of enhancing lesions using a computer-assisted lesion quantification algorithm.

Results:

Eighty percent (8/10) of participants were women, mean age was 42.8 years (SD 4.0), and mean MS duration was 11.8 years (SD 6.3). Median EDSS was 2.5 and mean relapse rate in the two years prior to enrolment was 2.6. During the three month pre-treatment period the 10 patients experienced 3 confirmed relapses (equal to a one year relapse relate of 1.2). During the pre-treatment period 5/10 patients had active scans defined as the presence of gadolinium enhancing lesions. To date all patients have been adherent with therapy and there have been no safety concerns.

Conclusions:

This study will be complete in early March 2003. Data cleaning and analysis is ongoing. Pre-treatment monitoring has found the sample to be as active as predicted during study design. To date treatment has been well tolerated and safety monitoring has been unremarkable. Safety and MRI outcomes will be presented.

Supported By:

Canadian Institute of Health Research- Indisciplinary Health Research Team Grant.

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P04.009]

H Magnetic Resonance Spectroscopy and Brain Atrophy Measurements in Relation with apoE Genotypes of Patients with Multiple Sclerosis

Daniel Pelletier, David Brassat, Joonmi Oh, Amy R. Swerdlin, Steve L. Hauser, Jorge R. Oksenberg, Sarah J. Nelson, San Francisco, CA

Objective:

To investigate the extent of axonal injury and brain atrophy in patients with multiple sclerosis (MS) in relationship with their apolipoprotein E (apoE) genotypes.

Background:

Clinical and imaging reports have suggested a disease modifying effect of the apoE genotype in MS. MS patients carrying an apoE 4 allele were more likely to experience a more severe course, a faster progression of disability and a higher proportion of brain T1-hypointense lesions. This effect may be related to more tissue destruction or lack of efficient repair in apoE 4 carriers that might be detected by brain atrophy measurement and proton magnetic resonance spectroscopy imaging (HMRSI).

Design/Methods:

Long-echo HMRSI (TE=144 ms) were acquired on 108 subjects to measure levels of N-acetylaspartate (NAA) derived from a large brain region of interest centered at the corpus callosum. 88 MS patients diagnosed with either relapsing-remitting (RR), secondary (SP) or primary progressive (PP) MS and 20 healthy age-matched controls (HC) were included. Volumetric high resolution images were also acquired to derive an index of brain atrophy (IBA). The Expanded Disability Status Scale (EDSS) was used a measure of clinical disability. The apoE polymorphisms were detected on all MS patients using allele-specific, Tm-shift, genotyping-base assays, in an ABI 7900HT sequence detector system. Patients with at least one apoE 4 allele were included in an apoE 4 group, all other patients were included in a non-apoE 4 group. Mann-Whitney statistical analysis was used to compare patient groups and HC.

Results:

Both non-apoE 4 (n=66) and apoE 4 (n=22) MS groups did not differ with regard to age, disease duration and EDSS. Both patient groups showed significant reduction of NAA/Cr ratios (1.890.25;p0.0001, 1.850.17;p0.0001 respectively) compared to HC (1.990.14) but no NAA/Cr differences were seen between apoE and non-apoE 4 groups (p=0.2). Similarly, both patient groups showed more brain atrophy (0.7010.069;p0.0001, 0.7140.073;p0.006 respectively) compared to HC (0.7620.051) but no differences between the patient groups (p=0.2). Removing the PP patients from the analysis did not affect any of the results.

Conclusions:

Despite a relatively large cohort of well defined MS patients for which NAA data, IBA measurements and apoE genotypes were gathered, we did not find more axonal injury or brain atrophy in carriers of apoE 4 versus non-apoE 4 patients. This preliminary analysis indicates that the effect size of apoE genotype on NAA and brain atrophy seems modest, if any, and would require a larger sample to detect subtle differences between these two patient populations. Evaluation of longitudinal NAA and brain atrophy changes are on-going.

Supported By:

NMSS grants RG-2655B6/1 and RG-2901, NIH grant RO1 NS39529.

Category - MS and Related Diseases

SubCategory - Imaging 


[S31.005]

Differentiating Primary from Secondary Fatigue in Multiple Sclerosis

Susan Forwell, Joel Oger, Sandra Brunham, Nancy Bogle, Shannon Tentzerakis, Helen Tremlett, Wendy Morrison, Vancouver, BC, Canada

Objective:

To differentiate and quantify the frequency of primary MS fatigue from secondary MS fatigue and other causal factors in adults with MS.

Background:

Fatigue is reported as the worst symptom in 50-60% of MS patients. Primary fatigue has been defined as a lassitude that interferes with daily life, in the absence of other causal factors. Secondary MS fatigue is defined as related to mobility or respiratory impairments. Other reported causes of fatigue are, among others, iatrogenic factors, depression, and sleep disturbances. Differentiating causes of fatigue requires a thorough assessment that leads to a specific therapeutic action. The algorithm developed by the MS Council in 1998 in the Clinical Practice Guidelines for Fatigue and MS is among the first to propose a detailed screening for fatigue. However the validity of this algorithm has not been tested nor the prevalence rates known for the fatigue categories identified by the algorithm.

Design/Methods:

Subjects who met the inclusion were invited to participate. The fatigue assessment included standardized screening tools for depression (Beck Depression Inventory-18), sleepiness (Epworth Sleepiness Scale), fatigue severity and impact (Fatigue Severity Scale, Modified Fatigue Impact Scale), as well as sleep and fatigue questionnaires, a mobility screen, and a dyspnea scale. A pharmacist assessed the possible contributions of prescriptive and non-prescriptive substances on level of fatigue. Data was coded and descriptive statistics were used in the analysis. As defined by the algorithm, primary MS fatigue was identified in the absence of other significant contributing factors.

Results:

Fifty-nine subjects were invited to participate and 51 completed the screening. Fatigue was ranked as the number one problem in 35 (69%) subjects. Forty-nine (96%) subjects described fatigue as present for longer than 6 months and 40 (78%) reported that fatigue was exacerbated by heat. Primary MS fatigue was present in only 14 (28%) participants. Secondary MS fatigue was present in 32 (63%) while 44 (86%) experienced other causal factors. The three most common causes of non-primary MS fatigue were sleep problems, mobility limitations, and depression.

Conclusions:

Fatigue has been reported to be present in 75-95% of those with MS. This study showed that primary MS fatigue could be identified in less than a third of this cohort while for the majority fatigue was related to secondary MS fatigue or other causes. Our findings point to the need to differentiate primary MS fatigue from fatigue caused by other factors particularly in intervention research and in clinical evaluation and treatment. Any attempt to study or manage fatigue in MS should be preceded by an attempt to identify treatable causes before focusing on primary MS fatigue.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P06.103]

Levetiracetam (Keppra) Improves Cerebellar Tremor in Multiple Sclerosis

Raul N. Mandler, Joseph M. Choi, Elizabeth R. Kingery, Arkady M. Barber, Washington, DC

Objective:

To report improvement of severe cerebellar tremor with Levetiracetam (LEV) (Keppra) in multiple sclerosis (MS).

Background:

Tremor is a common and disabling symptom in people with MS. Current medical and rehabilitative therapies have had little, if any success in treating MS cerebellar tremor. LEV is a pyrrolidine derivative with strong specific binding to cerebellar receptors. It has been approved by the FDA as add-on therapy in partial-onset seizures and it is chemically related to piracetam, which is used in the treatment of myoclonus. Anecdotal reports indicate that LEV has improved post-anoxic and palatal myoclonus. Because of these reports, good tolerability and paucity of side effects, we explored whether off-label use of LEV is effective in the treatment of severe MS cerebellar tremor.

Design/Methods:

Observational study/case reports. The first patient, a 20 y/o African-American young woman, had severe, late-infantile MS with marked, disabling appendicular and axial cerebellar tremor. MRI showed large white matter plaques in brainstem and cerebellum. Over the past 2 years she had been treated with Betaseron, IVmethylprednisolone(IVMP), IVIG, plasmapheresis, Novantrone and many symptomatic medications, with no effects on the tremor. The second patient, a 34 y/o Caucasian woman from Iran, had onset of MS symptoms at the age of 20, with prominent appendicular and truncal cerebellar tremor, and also large demyelinating lesions in the posterior fossa. She had been treated with Betaseron, Novantrone, IVIG and symptomatic therapy, which did not control the tremor. The third patient, a 27 y/o woman from Southern India with severe MS of the spinal-optic variant, developed severe ataxia with titubation and appendicular tremor unresponsive to IVMP, oral prednisone, Imuran, or symptomatic therapy.

Results:

All 3 patients were informed and consented with the use of LEV in this off-label approach, and received starting doses of 125-250 mg bid, with progressive increase as needed. Subjective Visual Scale (SVS) and Objective Neurological Exam Scale (ONES) were used. The first patient reported significant improvement in the cerebellar tremor with 250 mg bid of LEV. The SVS went from 10 (worse) to 4.5. ONES supported this observation. The good response obtained in patient 1 prompted the use of LEV in patients 2 and 3 , who have just started the medication. So far, no clinical or laboratory side effects have occurred.

Conclusions:

LEV may be a promising medication for the treatment of cerebellar tremor in patients with MS, because of possible effectiveness and lack of side effects at doses given. Controlled clinical studies are required to ascertain safety and efficacy.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P04.094]

Predictors of Atrophy during Treatment with rIFN-beta 1a IM in Relapsing Multiple Sclerosis: A Three Year Follow-Up

Martin Hardmeier, Basel, Switzerland, Stefan Wagenpfeil, Munich, Germany, Elizabeth Fisher, Richard A. Rudick, Cleveland, OH, Mariska Kooijmans, Cambridge, MA, Michel Clanet, Toulouse, France, Ernst W. Radue, Ludwig Kappos, Basel, Switzerland

Objective:

To evaluate predictors for development of atrophy in a cohort of patients treated with rIFN-beta-1a IM (Avonex).

Background:

Atrophy is regarded as a measure of destructive changes in MS, but the factors influencing the pace of atrophy are not established. Rate of atrophy in relapsing MS has been shown to predict more severe EDSS-progression (Fisher, 2002).

Design/Methods:

The MRI cohort (n=386) of the European study comparing two doses of rIFN-beta-1a IM (Clanet, 2002) had annual scans over three years. Brain parenchymal fraction (BPF) was used to measure whole brain atrophy (Rudick, 1999). Volume of T1-Gd-enhancing (T1Gd), T1-hypo-intense (T1bh) and T2 hyper-intense lesions (T2LL) was evaluated. Multiple linear regression analysis was performed to determine independent predictors of atrophy in two models (i.e., relative change in BPF from baseline to year three (model 1) and from year one to year three (model 2)), since pace of atrophy in the 1st year was different to 2nd and 3rd year. Age, gender, disease duration, dosage group and baseline values of EDSS, BPF, T1Gd, T1bh, T2LL were included as variables, in model 2 also changes in MR-measures from baseline to year one.

Results:

Median EDSS was 3.5 (range 2.0-5.5); mean age: 37.0 ( 7.4) years; median disease duration (DD) 5 years. Mean BPF decreased significantly from year to year (0.828 ( 0.028), 0.822 ( 0.029), 0.819 ( 0.031) 0.816 ( 0.032)). Mean BPF change was -0.686% ( 0.79), -0.377% ( 0.77) and -0.378 ( 0.73) in the 1st, 2nd and 3rd year, respectively. Change in BPF was significantly lower in the 2nd and the 3rd year of treatment compared to the 1st year. After variable selection age, DD, BPF and T1Gd remained in model 1, BPF, T1Gd, DD and change in T1Gd in model 2. Significant (p0.001) were BPF and T1Gd in model 1 (R2 = 0.255), T1Gd in model 2 (R2 = 0.115).

Conclusions:

BPF and T1Gd were the only significant predictors of atrophy in model 1, explaining 26% of variance. In model 2, T1Gd was the only significant predictor, explaining 12% of variance. The first finding shows that atrophy is likely to progress once it has occurred. The second finding indicates that inflammation likely has a remote effect on irreversible volume loss, which is transmitted even under the condition of immuno-modulating anti-inflammatory treatment. Comparison of BPF changes between different time points suggests that the pace of atrophy is slowed in the 2nd and the 3rd year of treatment with rIFN-beta-1a IM, but not fully stopped. The principal factors driving atrophy were not identified in this study.

Supported By:

Biogen Inc., Cambridge, MA, USA; Swiss MS Society

Category - MS and Related Diseases

SubCategory - Imaging 


[S55.002]

Mechanism of Action of Multiple Sclerosis Treatment by Zenapax, a Humanized Monoclonal Antibody against the Interleukin-2 Receptor Alpha Chain

Bibiana Bielekova, Susan Reichert-Scrivner, Henry McFarland, Roland Martin, Bethesda, MD

Objective:

To elucidate the mechanism of action of Zenapax in MS by ex-vivo immunopharmacology and correlation with the clinical responses in order to discover a predictive biomarker.

Background:

Preliminary results of a phase II open-label, crossover trial of Zenapax (humanized monoclonal antibody against the IL-2R -chain, CD25) add-on therapy in MS patients with incomplete response to IFN- indicate that this approach is safe and leads to significant suppression of brain-inflammatory activity in these difficult-to-treat patients. The mechanism of action of Zenapax in MS is not understood and merits investigation, particularly since IL-2 KO mice develop a fatal autoimmune syndrome and that an important subpopulation of immunoregulatory T-cells is characterized by surface expression of CD25, the molecular target of Zenapax.

Design/Methods:

Monthly blood samples from 10 patients enrolled in the clinical trial were examined both pre-treatment and during Zenapax dosing. By flow cytometry analysis we tested changes in subpopulations of immune cells, surface expression of IL-2R chains, activation markers, and selected chemokine receptors and costimulatory molecules. CD4+ and CD8+ T cell proliferation to polyclonal stimuli was assessed by a cytometry-based CFSE-dilution method, as well as responsiveness of T cells to interleukins that share signaling molecules with IL-2. In addition, we performed in-vitro immunopharmacological studies on peripheral blood mononuclear cells (PBMC) to explore the functional relevance of the changes observed during Zenapax administration.

Results:

Zenapax does not suppress significantly either polyclonal stimulation of CD4+ or CD8+ T cells nor antigen-specific T cell responses. It does not lead to significant changes in subpopulations of immune cells, and neither leads to significant alterations in immunoglobulin subtypes. However, Zenapax therapy results in increased consumption of exogenously added IL-2 and IL-4 from the culture media by PBMC that have efficient blockade of CD25. These changes, especially for IL-4 consumption, appear to correlate with clinical outcomes of the therapy. In addition, Zenapax therapy leads to significant upregulation of CTLA-4, a major negative costimulatory molecule, on CD4+ T cells.

Conclusions:

Zenapax therapy leads to 70% suppression of brain inflammatory activity, despite its lack of overt immunosuppression. Understanding how these slight functional immune changes lead to such a profound therapeutic efficacy will enhance our understanding of the disease process in MS. We identified several potentially crucial mechanisms of action of Zenapax in MS. The increased consumption of IL-4 from the culture media suggests that T cells under long-term CD25 blockade adjust their IL-2R signaling efficiency through the - and -chains and thus enhance T cell responsiveness to cytokines that share these signaling chains, like IL-4, IL-7, IL-9 and IL-15. We are currently investigating this hypothesis in detail.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P05.135]

Tracking the Fate and Functional Profile of Myelin-Directed T Cells in Patients with Multiple Sclerosis (MS) Treated with Immune Ablation and Hematopoeitic Stem Cell Transplant (HSCT)

Amit Bar-Or, Ho Jin Kim, Rachel Corsini, Remi Cheynier, Rafick P. Sekaly, Montreal, QC, Canada, Harry Atkins, Mark Freedman, Ottawa, ON, Canada, Farzaneh Jalili, Montreal, QC, Canada, Marjorie Bowman, Ottawa, ON, Canada, the Canadian MS/BMT Study Group

Objective:

To assess the impact of immune ablation and HSCT on immune cell subsets including myelin-reactive T cells in patients with MS.

Background:

Proinflammatory T cells targeting CNS elements including myelin basic protein (MBP), likely participate in MS pathogenesis. Treatment of aggressive MS with immune ablation and HSCT may reset the immune system and abolish auto-aggressive cells. However, the diversity and function of MBP-reactive T cell clones that may re-emerge during immune reconstitution are important to define.

Design/Methods:

Patients in the Canadian MS/BMT Study are evaluated before and after immune ablation and T cell depleted HSCT. Flow cytometry and novel TREC (T cell receptor excision circle) analyses are used to define the impact of immune ablation and reconstitution of immune cell subsets. MBP-reactive T cells of confirmed specificity are generated in an IL-7 based split well assay and their cytokine profiles are defined by ELISA. Immunoscope technique is used to characterize TCR diversity and elucidate MBP specific T cell clones by their unique CDR3 sequences.

Results:

We generated 117 confirmed MBP-reactive T cell lines, at baseline, from the first 5 patients enrolled in our study. Immunoscope analysis of these lines revealed oligoclonality across Vbeta families. In each patient, identical bands (representing the same unique T cell clones) were identified in different MBP-reactive lines generated at the same time, and at different pre-treatment times. These MBP-reactive lines secreted higher levels of IFN (mean 36542317 pg/ml) than IL-5 (154332 pg/ml). In 84 of 117 lines, only IFN was detected; no lines secreted only IL-5. Post-treatment, flow cytometry and TREC analyses confirmed complete immune ablation. We anticipate completion of 1-year follow-up including tracking immune cell subsets during reconstitution and comprehensive immunoscope analysis of MBP-reactivity in these patients.

Conclusions:

This is our first report on the immunology of patients with aggressive MS treated with immune ablation and HSCT in the Canadian MS/BMT Study. Using cytometry and a novel TREC approach we confirm immune ablation, and track the fate of immune cell subsets during reconstitution. We established an immunoscope approach to elucidate TCR diversity of MBP-reactive T cells and identified, at baseline, distinct MBP-reactive clones that appear expanded in vivo and have a largely proinflammatory (Th1) cytokine profile. We will report on the diversity and cytokine profile of MBP-reactive T cell clones that re-emerge in these patients at 1-year post HSCT.

Supported By:

MS Society of Canada

Category - MS and Related Diseases

SubCategory - Basic Science 


[S55.005]

Multiple Sclerosis: Longterm Persistence of Identical Expanded Plasma Cell Clones in Brain Tissue and CSF of MS Patients

Norbert Goebels, Heidrun Weber, Munich, Germany, Claudia Berek, Berlin, Germany, Reinhard Hohlfeld, Munich, Germany

Objective:

Goal of this study was to investigate, whether brain tissue and CSF of MS patients contains distinct or identical B cell repertoires and whether the pool of persisting cells is composed of memory B cells or plasma cells.

Background:

Although the the precise molecular targets and the immune components responsible in multiple sclerosis (MS) are still unidentified, expanded lymphocyte populations have been implied in the pathogenesis. Previously we and others have demonstrated the presence of expanded B cell clones in brain tissue and the longterm persistence of expanded B cell clones in the cerebrospinal fluid (CSF) of MS patients.

Design/Methods:

We employed a PCR - based method to identify and characterize clonally expanded B cell populations. The method (CDR3 spectratyping) relies on the natural length variation of the third hypervariable region (CDR3) of the rearranged immunoglobulin (Ig) gene: whereas a polyclonal B cell population shows a random, Gauss-distributed length variation of the CDR3, a clonally expanded population has a uniform CDR3 length. Using clone specific primers of expanded clones and Ig constant region primers, which can differentiate between secretory and membrane bound Ig forms, we could attribute the expanded clones to the plasma and memory B cell population, respectively.

Results:

We analysed matched pairs of cDNA from CSF cells and brain tissue of two MS patients, who underwent brain biopsy for diagnostic reasons in the initial phase of their disease. Additionally we analysed cDNA of repeat CSF taps of 2 additional patients. CSF cells were obtained 6 months (patient A) and 5 years (patient B) after brain biopsy, repeat CSF taps of patients C and D were performed 2 years after the initial sampling. Using CDR3-spectratyping, we repeatedly detected identical expanded B cell clones both in the CSF and brain tissue compartments, as well as expanded, longterm persisting B cell clones in the CSF. All of these persisting clones turned out to be plasma cells.

Conclusions:

For the first time we have shown that CSF and brain tissue of MS patients contains partly identical repertoires of expanded B cell clones. This is especially remarkable since the time intervall between brain biopsy and spinal tap was up to 5 years. We also demonstrated that this longterm persistence is provided by longlived plasma cells. These findings strongly support that spinal fluid plasma cells at least partially represent disease relevant plasma cells infiltrating MS brain tissue.

Supported By:

Deutsche Forschungsgemeinschaft (SFB 571/A3), University of Munich and Hermann und Lilly Schilling Stiftung.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P04.087]

Evidence for Early Gray Matter Involvement in Relapsing Remitting Multiple Sclerosis from Whole Brain N-Acetylaspartate Proton Magnetic Resonance Spectroscopy

Matilde Inglese, Oded Gonen, New York, NY, Massimo Filippi, Milan, Italy, Yulin Ge, Robert I. Grossman, New York, NY

Objective:

To ascertain the extent of gray-matter (GM) involvement in multiple sclerosis (MS), a disease traditionally considered a white-matter (WM) disorder, from the concentration of N-acetyl-Aspartate (NAA), a metabolite found almost exclusively in neurons and axons, over the whole brain of MS patients versus their matched healthy controls.

Background:

MS has been regarded for over a hundred years as an inflammatory demyelinating disease affecting white matter (WM) of the central nervous system. Only in the past decade has this perception been expanded to accommodate mounting pathological and MRI evidence of axonal injury in WM lesions in the brain and cord. This damage was shown to extend beyond the macroscopic lesions into the so-called normal-appearing WM (NAWM) at varying extent. However, progressive clinical cognitive deficits on top of motor dysfunction have always suggested GM involvement. Although evidence that the GM is not spared has been available for over 30 years, only recently have studies shown that cortical lesions, missed by T2-weighted MRI , are relatively frequent at post-mortem of deceased MS patients. Neuronal cell damage can be evaluated in vivo through 1H-MRS quantification of the amino acid derivative NAA. Its loss has been reported in both lesions and WM. Whole-brain NAA (WBNAA) quantification facilitates assessment of the entire organ and a previous comparison of (RR) MS patients with matched controls showed upwards of 10% NAA deficits as a function of age. Since in RR MS, T2 lesions usually account for less than 3% of the brain volume, such losses could only be explained by NAWM involvement. The extent of these deficits motivated this study

Design/Methods:

WBNAA concentration: The ratio of this metabolites amount, obtained with non-localizing proton MR spectroscopy, by the parenchymal volume from high resolution MRI, was measured in 71 RR MS patients (51 women, 20 men, 25-55 years old) and 41 controls (27 women, 14 men, 2355 years old).

Results:

The average WBNAA difference between the patients and the controls was -2.9 mM ( 22%, p0.0001) range, +1.2 to 7.8 mM (+8% to -63%).

Conclusions:

Since WM and GM constitute approximately 30% and 60% of the brain volume, respectively, and NAA concentration in the former is 2/3 the latters, then NAA loss greater than 32% cannot be explained in terms of WM (axonal) pathology alone and must include widespread GM (neuronal) deficits. Furthermore, since RR represents the earlier stage of MS, such GM involvement may occur during relative clinical silence and from the early phase of MS and may be responsible or contribute to its frequent clinical manifestation of cognitive impairment. Therefore, the concept of MS as a WM disease might need to be expanded to be reclassified as a diffuse whole brain disorder.

Supported By:

NIH grants EB01015, NS37739 and NS29029 and a grant from the Fondazione Italiana Sclerosi Multipla.

Category - MS and Related Diseases

SubCategory - Imaging 


[S61.003]

Proton Magnetic Resonance Spectroscopy and Imaging of Global Metabolic Variations as Indicators of Disease Activity in Relapsing Remitting Multiple Sclerosis

Oded Gonen, Matilde Inglese, Henry Rusinek, James S. Babb, Robert I. Grossman, New York, NY

Objective:

To ascertain the presence and the extent of disease activity in the normal-appearing white matter (NAWM) in the brain of patients with relapsing-remitting multiple sclerosis (RR MS).

Background:

Inter-patient variability of clinical symptoms in MS and poor future course prediction, make markers of disease activity capable of identifying high risk of early deterioration and optimal treatment regimen, highly desirable. While T1 & T2 weighted MRI have greatly improved our ability to detect macroscopic MS pathology, they lack pathologic specificity and sensitivity to occult pathology. This diffuse pathogenesis in the normal-appearing-white-matter (NAWM) leads to global neuronal/axonal damage and persists even during periods of clinical remission, reflecting in formation of new lesions and enlargement of old ones. To investigate these occult processes, quantitative, proton MR spectroscopy (1H-MRS) has been utilized and shown that changes in the NAWM may (a) precede lesion formation; (b) occur in all MS phenotypes; and (c) correlate with physical disability and cognitive impairment. This study aims to assess the metabolic characteristics of RR MS in a comprehensive (480 ml) brain volume, by comparing the amount of atrophy and concentrations of N-acetylaspartate (NAA), choline(Cho) and creatine (Cr), with their matched controls, in order to test whether: (i) de- and/or re-myelinating processes are diffusely active, even during clinical remission; (ii) this activity is reflected by Cho and Cr abnormalities; and (iii) the end-stage indicators for the pathogenesis are axonal damage, reflected by NAA loss, and atrophy.

Design/Methods:

The absolute levels of NAA, Cr and Cho in the NAWM, were compared between RR MS patients and controls. Metabolite concentrations were obtained with 3-dimensional proton MR spectroscopy at 1.5 T, in a 480 cm3 volume-of-interest (VOI), centered about the corpus callosum of 11 patients (median disease duration 6.9 years, EDSS 2.5) and 9 matched controls. Gray/white-matter/CSF/lesion-volumes were obtained from MRI segmentation.

Results:

Controls average tissue volume (TV), 447.78.8 cm3, and metabolite levels, NAA=6.920.47, Cr=2.950.23, Cho=2.440.23 mM, were different from the patients by +6%, +9%, 19% and 24% (p0.0001, 0.04, 0.001, 0.001), respectively. The Cho level and TV were the only single metrics differentiating patients from controls at 100% specificity and 90% sensitivity.

Conclusions:

The metabolic level information indicates that even the clinically-silent phase of the disease is characterized by abnormal metabolic activity. Specifically, the elevated Cho and Cr probably reflect microscopic inflammation/demyelination and remyelination processes. Therefore, they are potential measures of disease activity and prognostic indicators.

Supported By:

NIH Grants EB01015, NS37739, NS29029 and a grant from the Fondazione Italiana Sclerosi Multipla.

Category - MS and Related Diseases

SubCategory - Imaging 


[P05.123]

Sex-Hormone Levels of Multiple Sclerosis Patients Clearly Differ to Healthy Controls and Correlate with Disease Activity and Disability

Gerald Niederwieser, Raphael M. Bonelli, Heinz Sternad, Wolfgang Buchinger, Juan J. Archelos-Garcia, Graz, Styria, Austria

Objective:

To determine the levels of sex-hormones of female and male multiple sclerosis (MS) patients in comparison with healthy controls and to correlate them with disease activity and disability.

Background:

The influence of sex-hormones, especially estrogen, on the disease course of MS is a very fascinating issue meanwhile. Recently, positive effects of estriol treatment of female MS patients at a pregnancy dose are reported. Estradiol and progesterone inhibit nitric oxide and TNF-alpha production by activated microglia in mice. These hormones could exert protective properties in MS.

Design/Methods:

30 female MS patients (24 relapsing-remitting: RRMS and 6 secondary progressive: SPMS) 19 female controls, 19 male MS patients (14 RRMS, 5 SPMS) and 7 male controls were included in this prospective study. We investigated the levels of 17-estradiol (E2), progesterone (P4), testosterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin by an electro-chemi-luminescence immuno assay (ECLIA, Elecsis Immunoassay, Boehringer Mannheim, Germany). After subscribing informed consent, blood was drawn from men and menopausal women two times with an interval of one month. Women with a regular menstrual cycle were investigated in their follicular and luteal phase. Expanded disability status scale (EDSS) was assessed always by the same physician. Disease activity was determined by the relaps rate in the last two years.

Results:

In male MS patients we found lower E2 and P4 levels, especially in SPMS. Testosterone was lower only in SPMS patients. Prolactin was lower in RRMS patients but higher in SPMS. FSH and LH values were not different. In female MS patients with regular menstrual cycles, E2 was lower in the follicular phase. SPMS females had clearly higher P4 levels in their follicular phase. Luteal phase revealed high E2 levels of SPMS patients. Prolactin was higher in all female patients in luteal phase. Menopausal women with MS had lower E2 levels, SPMS patients had also lower P4 levels. Prolactin was lower in all menopausal MS females. Both sexes with higher EDSS values had lower E2, P4, prolactin and testosterone levels. Whereas FSH and LH values were higher in this circumstance. Relaps rate was higher in those male patients with lower E2, testosterone and prolactin levels and P4, FSH and LH were higher. In females despite prolactin, all the other hormones were lower in case of higher relaps rate.

Conclusions:

MS patients have lower E2 and P4 values, especially with a higher degree of disability and in active phase of disease. On the other hand FSH and LH levels were higher in comparison to healthy people. Further studies should reveal if there is primary or secondary hypogonadism in MS. Hormonal substitution of combined E2 and P4, also in male patients, might be of clinical benefit.

Supported By:

We thank Mrs.Elfi Brunner for excellent technical support.

Category - MS and Related Diseases

SubCategory - Other 


[S55.003]

Immunological Mechanisms of Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis

Paolo A. Muraro, Daniel C. Douek, Riccardo Cassiani Ingoni, Henry F. McFarland, Bethesda, MD, Richard K. Burt, Chicago, IL, Roland Martin, Bethesda

Objective:

To elucidate the mechanism of action of hematopoietic stem cell transplantation as a therapy for multiple sclerosis with aggressive clinical course.

Background:

Multiple sclerosis (MS) is an inflammatory demyelinating disorder of the CNS. At present, neither approved nor experimental therapies offer a cure for MS, particularly in patients with rapidly progressing disease. Phase I studies have suggested that immune ablation and reconstitution with hematopoietic precursors (hematopoietic stem cell transplantation, HSCT) can completely suppress brain inflammation and arrest or slow the progression of disease in the majority of high risk patients. Whether HSCT exerts its clinical effects through immunosuppression only, through the ablation of a dysfunctional immune system, or through the reconstitution of a tolerant immune repertoire, however, is currently unknown.

Design/Methods:

Seven patients with MS (six secondary progressive, one relapsing-remitting) were treated with autologous HSCT at Northwestern Memorial Hospital, Chicago, IL. Peripheral blood stem cells (PBSC) were mobilized with cyclophosphamide (Cy) and G-CSF, collected by lymphapheresis, and purified by CD34+ selection. A conditioning regimen with high dose Cy and total body irradiation was followed by PBSC support. Peripheral blood mononuclear cells (PBMC) for immunological studies were collected before mobilization and at 6 and 12 months post-transplant. To assess phenotypic changes, we evaluated relevant leukocyte surface markers by 4-color flow cytometry (FACS). To study immune reconstitution, we analyzed T cell receptor (TCR) repertoires by FACS using TCR beta chain V region-specific antibodies.

Results:

CD4/CD8 ratios were significantly decreased at 6 mo post-HSCT (P 0.05, paired t-test). T cells expressing CD45RO+ were increased at 6 mo follow-up, particularly in the CD8+ subset (P 0.05) and regressed towards baseline levels at 12 mo. CD8+CD28-CD57+ T cells were significantly (P 0.01) increased at 6 mo post-HSCT. TCR V beta analysis showed a post-transplant reconstitution of overall similar T cell repertoires. Five of six patients tested, however, had superimposed expansions of cells expressing a single TCR V beta specificity post-HSCT, predominantly in the CD8+ subset (4 of 5). TCR specificities of expansions were BV1 (two patients), BV8, BV17 and BV23 (one patient each). The expansions were not associated with clinical manifestations of infection.

Conclusions:

Early immunological changes post-HSCT included a switch of T lymphocyte markers towards memory/effector phenotypes and the appearance of oligoclonal expansions, suggesting de novo antigenic re-experiencing in MS patients. Our preliminary data support the notion that HSCT induces immune reconstitution in MS. To understand how tolerance is restored and maintained, additional work including measurement of thymopoietic capacity, gene microarray analysis and the study of responses to myelin self-antigens is underway.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[S55.001]

Impaired Function of Regulatory T Cells in Patients with Multiple Sclerosis

Brigitte Wildemann, Andreas Hug, Brigitte Storch-Hagenlocher, Juergen Haas, Heidelberg, Germany

Objective:

To study the functional properties of immunoregulatory T cells in patients with relapsing remitting multiple sclerosis (RRMS) and to identify their relevance for the development of central nervous system autoimmunity.

Background:

MS is an autoimmune mediated demyelinating disease of the central nervous system (CNS). A prerequisite for the induction of demyelination is the activation and extravasation of circulating self-reactive T cells with specificity for myelin components. Since myelin-specific autoreactive T cells are uniformly present in the peripheral T cell repertoire in both patients with MS and healthy persons the failure of peripheral immune-tolerance mechanisms may be critically involved in the emergence of autoimmunity within the CNS. In experimental animal models the maintenance of immune-tolerance towards self-antigens correlates with a specific T cell subset that actively downregulates the activation and proliferation of self-reactive T lymphocytes. These professional immunoregulatory T cells are also present in humans, coexpress the CD4 and CD25 surface molecules and comprise 2-5% of peripheral CD4+ T cells. Their relevance for the development of human autoimmune disease is undefined.

Design/Methods:

18 treatment-naive patients with active RRMS and 20 age-matched healthy persons were included in the study. CD4+CD25+ T cells were isolated from peripheral blood mononuclear cells (PBMC) by combined negative and positive immunomagnetic selection. To assess the inhibitory effect of immunoregulatory T cells on the proliferative response of effector T cells, 105 cultured CD4+CD25- T cells were stimulated with 105 irradiated allogeneic PBMC in the absence or presence of increasing numbers of CD4+CD25+ T lymphocytes. On day 5, after 16h pulsing with 3[H] thymidine, 3[H] incorporation was measured by scintillation counting.

Results:

Unlike CD4+CD25- effector T cells CD4+CD25+ immunoregulatory T cells from both patients with MS and control donors proliferated only modestly upon stimulation with irradiated allogeneic PBMC. The suppressive effect of CD4+CD25+ T lymphocytes on stimulated CD4+CD25- effector T cells in vitro was significantly lower in patients with MS as compared to controls. The maximum inhibition rate (defined as percent of maximal CD4+CD25- T cell proliferation) mediated by CD4+CD25+ T cells isolated from patients with MS and healthy donors ranged from 0-61 (median 7) versus 12-91 (median 48). Thus, in individuals with MS the regulatory properties of CD4+CD25+ T cells were 7-fold reduced.

Conclusions:

Immunoregulatory CD4+CD25+ T cells derived from patients with MS exhibit a markedly reduced suppression of general T cell proliferative responses when isolated during an acute relapse. The impaired regulatory properties may affect the control of circulating autoreactive T cells and implicates that the dysfunction of this specialized T cell subset may contribute to the emergence of autoimmunity within the CNS.

Supported By:

Gemeinnuetzige Hertie-Stiftung (1.319.110/01/11)

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P05.129]

Multilabel Analysis of NK Cell Subsets in Relapsing-Remitting Multiple Sclerosis: Effect of Treatment with IFN-b-1a or Glatiramer Acetate

Lorne F. Kastrukoff, Richard S. Wee, Allen S. Lau, Donald W. Paty, Vancouver, BC, Canada

Objective:

Using multilabel analysis, to identify natural killer (NK) cell subset abnormalities in relapsing-remitting multiple sclerosis (RRMS) and determine their response in-vitro to treatment with IFN--1a and glatiramer acetate.

Background:

Although NK cells are implicated in the pathogenesis of MS, results of functional and phenotypic analysis reported by a number of investigators have not been consistent. One reason might be the use of single label analysis to evaluate heterogeneous populations of cells.

Design/Methods:

We have used the approach of Jonges et al. (2001) to characterize NK cell subsets in the peripheral blood. Two panels of 3 mAbs are used to identify 12 subsets of cells in 10 stable clinically definite RRMS patients and 10 age and sex matched controls.

Results:

MS patients are characterized by a significant increase in the size of the NK2 subset (CD56dimCD57dimCD16bri) (P0.05) and a significant decrease in the size of NK4 (CD56briCD57-CD16-), NK7 (CD56dimCD57-CD94bri), NK9 (CD56dimCD57bri CD94bri), and NK 12 (CD56briCD57-CD94bri) compared with controls (P0.05). Treatment of NK cell cultures in-vitro with IFN--1a (Avonex) at various concentrations had no effect on 5 NK cell subsets, a similar effect in patients and controls in 6 subsets but significantly decreased the size of the NK 2 subset in RRMS (P0.05). Treatment of NK cell cultures in-vitro with glatiramer acetate (Copaxone) at various concentrations had no effect on 5 NK cell subsets and a similar effect in patients and controls in 3. In contrast, it decreased the size of NK1 (CD56dimCD57-CD16bri) and NK2 but increased the size of NK5 (CD56briCD57-CD16dim) compared with controls (P0.05) but only at the highest concentration of glatiramer acetate. Treatment also decreases the size of NK4 in RRMS but increases the size in controls (P0.05).

Conclusions:

These results suggest that specific subsets of NK cells are altered in stable RRMS patients. At least in-vitro, IFN--1a and glatiramer acetate can affect these subsets with the effects of the later being particularly complex. It is of interest that both IFN--1a and glatiramer acetate decrease the size of NK2, a subset of NK cells significantly elevated in RRMS patients.

Supported By:

Study supported in part by Biogen Canada

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P04.083]

Ring-Enhancement Pattern May Contribute to More Severe Disability Progression and Higher Disease Activity in the Short Term in Relapsing-Remitting Multiple Sclerosis

Marino Zorzon, Robert Zivadinov, Trieste, Italy, Francesca Bagnato, Stefano Bastianello, Rome, Italy, Laura Locatelli, Alessio Bratina, Davide Nasuelli, Trieste, Italy, Licia Finamore, Rome, Italy, Attilio Grop, Mauro Catalan, Trieste, Italy, Bruno Di Pofi, Enrico Millefiorini, Rome, Italy

Objective:

To investigate which magnetic resonance imaging (MRI) measure change is the best predictor of physical disability accumulation and occurrence of new relapses in a group of relapsing remitting (RR) multiple sclerosis (MS) patients monitored over a short-time period and to assess the value of different gadolinium (Gd) -enhancement patterns as predictors of short-term disability progression and clinical disease activity.

Background:

In phase II studies, when therapeutic agents expected to have an impact on the evolution of destructive MS pathology are tested, MRI protocols should not be based only on MRI measures that detect acute inflammatory disease activity, but should also enclose non-conventional MRI techniques able to examine the pathological substrates of MS lesions and to assess global irreversible tissue damage of the brain.

Design/Methods:

Thirty patients with RR MS (mean disease duration 4.9 years, mean age 34.4 years and mean EDSS 1.4) were included in the study. The evaluation was performed at baseline and monthly for a period of three months with clinical and MRI examinations. Calculations of baseline and monthly absolute and percent changes of MRI measures have been obtained, i.e. number of brain lesions in T2-, FLAIR- and Gd-enhanced T1-weighted images, T2-, T1 Gd-enhancing-, T1- and FLAIR-lesion load (LL) and brain parenchymal fraction (BPF). In patients presenting Gd-enhancing lesions, the evaluation of different Gd-enhancement patterns was performed.

Results:

Mean absolute number of brain lesions in T2-weighted and FLAIR images significantly increased from baseline to month 3: +1 (4.9%), p= 0.004 and +1.2 (4.7%), p= 0.007, respectively. In ring-enhancement positive patients there was a significant difference between baseline and month 3 changes for FLAIR-LL: +0.4 ml (1.1%), p= 0.01, BPF: 0.002 (0.3%), p= 0.038, EDSS: +0.4 (25%), p= 0.018 and number of relapses: +0.8, p= 0.004. This difference was significantly greater than that of patients with homogeneously enhancing lesions. Longitudinally, mean absolute changes of ring-enhancing-LL (R= 0.44, p= 003) predicted the EDSS changes, whereas mean absolute changes of Gd-enhancing lesions (R= 0.49, p= 0.028) and ring-enhancing-LL (R= 0.41, p= 0.047) predicted the number of new relapses.

Conclusions:

Gd-enhancement remains the best monitoring tool for determining and predicting short-term clinical disease activity. The ring-enhancement pattern may contribute to more severe disability progression and higher disease activity in the short term.

Category - MS and Related Diseases

SubCategory - Imaging 


[S41.001]

Molecular Mimicry between Myelin Basic Protein and Human Herpesvirus-6: Implication for Multiple Sclerosis

Jingwu Z. Zhang, Houston, TX

Objective:

The objective is to study the potential role of HHV-6 infection/re-activation in the activation of autoimmune reactivity to myelin protein and possible implication in the pathogenesis of multimule sclerosis.

Background:

Viral infections are though to play an important role in the pathogenesis of multiple sclerosis (MS) potentially through molecular mimicry.

Design/Methods:

An identical sequence was found in both myelin basic protein (MBP, residues 96-102), a candidate autoantigen for MS, and human herpesvirus-6 (HHV-6 U24, residues 4-10) that is a suspected etiologic agent for MS.

Results:

In this study, we revealed that greater than 50% of T cells recognizing MBP93-105 cross-reacted with and could be activated by a synthetic peptide corresponding to residues 1-13 of HHV-6 U24 in MS patients. The estimated precursor frequency of these cross-reactive T cells recognizing both peptides, MBP93-105 and HHV-6 (U24)1-13, was significantly elevated in MS patients compared to that in healthy controls. These cross-reactive CD4+ T cells represented the same Th1 phenotype as that of mono-specific T cells recognizing MBP93-105. There were increased antibody titers for both peptide HHV-6 (U24)1-13 and peptide MBP93-105 in the same patients with MS compared to those in healthy controls, suggesting of B cell sensitization to the antigens in MS patients.

Conclusions:

The study provides important evidence in the understanding of the potential role of HHV-6 infection/re-activation in the activation of autoimmune reactivity to MBP and its implication in the pathogenesis of MS.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[S25.005]

Multiple Sclerosis (MS) - An Acquired Channelopathy; Growing Evidence from Experimental and Human Studies

Matthew J. Craner, Joel A. Black, New Haven, CT, David Baker, Jia Newcombe, M. Louise Cuzner, London, United Kingdom, Stephen G. Waxman, New Haven, CT

Objective:

Assess the contribution of dysregulated sodium channel expression in cerebellum and optic nerve in experimental model of MS and in human MS.

Background:

MS is recognized to involve demyelination and axonal atrophy but accumulating evidence suggests that sodium channel dysregulation may contribute to the pathophysiology of MS. Recent studies have demonstrated that sodium channel Nav1.8, normally absent within the CNS, is up-regulated in cerebellar Purkinje cells in experimental allergic encephalomyelitis (EAE) and MS. The temporal pattern of Nav1.8 upregulation and the expression of proteins that interact with Nav1.8, such as annexin II/p11 which facilitates its insertion into the neuronal membrane, have not yet been studied.

We therefore examined the expression of Nav1.8 and p11 in EAE and MS, and extended our examination of sodium channel expression to retinal ganglion cells (RGC) and their axons within the optic nerve, which is commonly affected in MS.

Design/Methods:

Tissue obtained from Biozzi mice with varying disease length EAE or post-mortem from patients with disabling secondary progressive MS was processed for immunocytochemistry and/or in situ hybridization. Random digital images of sections were quantified and subjected to statistical analysis

Results:

Expression of Nav1.8 in Purkinje neurons shows a positive correlation with disease length (49.24.7% Nav1.8+ve neurons at 113.6710.2 days of EAE vs. 12.251.49% Nav1.8+ve neurons at 241.68 days of EAE). p11 is significantly upregulated in Purkinje cells in EAE (719.0% vs. 21.34.9% in controls) and in MS (65.51.6% vs. 21.86.2% in controls). There is a high degree of co-expression of p11 and Nav1.8 (84.88.9%). We also report upregulation of Nav1.8 and p11 in RGCs in EAE

In optic nerve we observed a significant reduction of Nav1.6 nodal clusters of 9.81.7 (EAE) vs. 112.212.1 per field of view (FOV) in control. There is a significant shift to Nav1.2 expression at nodal regions in EAE with 49.45.7 per FOV demonstrating immunostaining vs. 21.63.5 per FOV in control. These changes are paralleled by downregulation (45%) of Nav1.6 protein and mRNA and upregulation (29%) of Nav1.2 protein and mRNA in retinal ganglion cell neurons of EAE mice.

Conclusions:

Our results extend the evidence for altered ion channel expression within neurons and their axons in MS. Dysregulated expression of voltage-gated sodium channels may lead to abnormal firing properties of affected neurons and/or impaired action potential propagation along axons thus contributing to the pathophysiology of MS.

Supported By:

National Multiple Sclerosis Society (RG-1912) and the Rehabilitation Research Service and Medical Research Service, Department of Veterans Affair. Paralyzed Veterans of America and the Eastern Paralyzed Veterans Association and Nancy Davis Foundation.

Category - MS and Related Diseases

SubCategory - Basic Science 


[P05.127]

Immune Regulatory Properties and Interactions of Copolymer-I and Beta-Interferon 1a in Multiple Sclerosis

Ying C. Q. Zang, Jian Hong, Rachel R. Robinson, Sufang Li, Victor M. Rivera, Jingwu Z. Zhang, Houston, TX

Objective:

In order to better understand the properties and interactions of beta-interferon (beta-IFN) and Copolymer-1 (COP-1), the two drugs were studied individually or in combination regarding their effect on auto-reactive T cells from MS patients and control subjects.

Background:

The treatment efficacy of beta-interferon (beta-IFN) and Copolymer-1 (COP-1) for multiple sclerosis (MS) is potentially attributable to the immune regulatory properties of the drugs.

Design/Methods:

In this study, we compared the regulatory effects and examined interactions between beta-IFN-1a and COP-1 on the functions of T cells derived from MS patients and healthy controls.

Results:

COP-1 activated both Th1 and Th2 cells, which was partially inhibited by the addition of beta-IFN-1a. Both drugs were found to regulate cytokine profile of unprimed T cells with distinct properties. COP-1 induced the production of both Th1 and Th2 cytokines in CD4+ T cells while beta-IFN-1a predominantly up-regulated IL-10 production of CD4+ T cells. Furthermore, the T cell responses to myelin basic protein (MBP), a candidate myelin autoantigen for MS, could be inhibited in cultures after exposure to beta-IFN-1a and COP-1 used either individually or in combination. In vitro treatment with beta-IFN-1a resulted in decreased T cell frequency and more profound up-regulation of Th2 cytokine production in surviving MBP-reactive T cells than those treated with COP-1.

Conclusions:

The findings suggest that beta-IFN-1a interacts antagonistically with COP-1, providing important insights into the distinct regulatory mechanisms and the interactions of the two drugs.

Supported By:

Biogen, Inc.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[S41.003]

Genetic Polymorphisms of Osteopontin (Eta-1) in Association with Multiple Sclerosis in Japanese Patients

Masaaki Niino, Toshiyuki Fukazawa, Seiji Kikuchi, Kunio Tashiro, Sapporo, Hokkaido, Japan

Objective:

To investigate the role of osteopontine (OPN) genes in the pathogenesis of multiple sclerosis (MS).

Background:

OPN is one of the major non-collagenous bone matrix proteins produced by osteoblasts and osteoclastes. Previous studies indicated that OPN also acts as a key cytokine involved in the regulation of tissue repair and inflammation, and labeled OPN as early T cell activation-1 (Eta-1). Abundant transcripts for OPN are present in brains of patients with MS. In experimental autoimmune encephalomyelitis (EAE), OPN is mainly expressed in microglia during both relapse and remission from the disease, and this expression is predominantly near perivascular inflammatory lesions. In addition to OPN expression on glia, expression is detected in neurons during the acute stage of the disease and relapse, but not during remission. OPN-/- mice are resistant to progressive EAE and show frequent remissions. Taken together, OPN seems to play an important role in the pathogenesis in MS and EAE. The human gene of OPN is located on chromosome 4q21-25. In the OPN gene, three single-nucleotide polymorphisms (SNPs) in the exon have been described in Japanese individuals. Two of those SNPs were in the coding region of exon 6 (8090th) and exon 7 (9250th) and the other was in the 3 untranslated region of exon 7 (9583rd).

Design/Methods:

Polymorphisms at 8090th, 9250th, and 9583rd positions in OPN were detected by PCR-RFLP from DNAs of 116 MS Japanese patients and 124 healthy controls.

Results:

The C/C genotype at 8090th position in exon 6 was more prevalent in MS than in control (p 0.0001), and C allele was more prevalent in MS than in control (p 0.0001, OR = 2.57, 95% CI = 1.65-4.00). For 9583rd position polymorphism in exon 7, patients with G/G genotype (age; 32.1 12.5 yrs, mean SD) showed a later disease onset than G/A (age; 25.9 7.8 yrs, p = 0.01) and A/A (age; 25.2 8.9 yrs, p = 0.01) genotypes. There were no significant correlations between OPN gene polymorphisms and clinical course and disease progression.

Conclusions:

Our results suggest that 8090th polymorphism might be associated with susceptibility to MS, while 9583rd polymorphism might be associated with age of onset of MS.

Category - MS and Related Diseases

SubCategory - Genetics 


[P01.119]

Chlamydia Pneumoniae Infections Are Associated with Increased Disease Activity in Multiple Sclerosis

Rogier Q. Hintzen, Roel P. Verkooyen, Wim Hop, E. van der Zwaan, Pieter A. van Doorn, Dragan Buljevac, Rotterdam, Netherlands

Objective:

To test the effect of serologically defined Chlamydia pneumoniae (CP) infections on disease activity in relapsing remitting (RR) MS.

Background:

Studies on the role of CP infection in the pathogenesis of MS have been contradictory. We and others have shown that mild upper respiratory tract infections (URI) trigger MS exacerbations. Such mild URI appear to be of viral origin on clinical grounds. However, also URI caused by the emerging bacterial pathogen CP bear clinical characteristics of viral infections. The influence of CP infections on MS disease activity has never been tested.

Design/Methods:

Patients with RR MS were followed prospectively for an average of 1.7 years in the Rotterdam Study on Exacerbations (ROSE study; Buljevac et al, Brain 2002). Patients were seen at regular visits every 8 weeks. Additional two visits (three weeks apart) were arranged for patients in case of exacerbation or clinically apparent infection. EDSS was assessed at every visit and blood was collected. A total of 1001 sera were tested by ELISA for anti CP IgG, -A or -M (Medac Germany). As control antibodies were assessed against Chlamydia trachomatis, Mycoplasma pneumoniae and anti-staphylolysine. At 32 infection visits a nasopharyngeal swab was taken. These swabs were tested with a CP specific PCR.

Results:

During a total follow up of 6466 weeks, 17 out of 73 patients underwent at least one episode in which a significant titre increase of occurred of IgG, -A or M against CP. Of these 17 patients 442 out of 1633 follow up weeks showed positive CP serology. During these seropositive weeks the risk rate ratios for exacerbation was 2.3 (95 % C.I. 1.1-4.6, p= 0.015), as compared with the seronegative weeks in the same patients. Control antibodies were not increased during the CP seropositive episodes, so the possible phenomenon of mere co-activation of Ig production during enhanced disease activity was ruled out. In addition, PCR was positive for CP in 9 out of 12 nasopharyngeal swabs of the CP seropositive patients versus only 1 positive in 20 swabs of the CP negative patients (p0.01).

Conclusions:

Transient serologically defined Chlamydia pneumoniae (re)infections occur with the same frequency in RR MS patients as has been described for the healthy population in other studies. In MS patients these periods of CP infections are associated with an increased risk for exacerbation. CP is the first bacterium that has been shown to be associated with MS disease activity.

Supported By:

Erasmus MC, Preventiefonds and Dutch MS foundation

Category - MS and Related Diseases

SubCategory - Other 


[P06.120]

Motor Fatigue [F] during 30 Seconds of Sustained Maximal Voluntary Contraction [MVIC] Was Accompanied by Normal Shift in EMG Median Frequency [MFS] in Relapsing-Remitting [RR] but Not in Progressive [P] Multiple Sclerosis [MS]

Momammed Sanjak, Daryn S. Belden, Richard A. Konapacki, Aaron P. Frye, Andrew J. Waclawik, Benjamin Rix Brooks, Madison, WI

Objective:

To study the nature of F in RR and P MS.

Background:

We previously showed a higher F in MS patients was accompanied with a normal MFS. The shift in S-EMG power spectrum to lower frequency has been considered to be an indicator of local (peripheral) F. A decrease in muscle fiber action potential conduction velocity (MFCV) was shown to be the major factor causing the spectrum to shift to lower frequencies. Many factors contribute to this decrease in MFCV including the accumulation of lactic acid due to impairment of circulation, and hypoxia, and is greater in fast than slow twitch muscle fibers. Reported pathological transformation in the muscle fibers of the MS patients from slow to fast motor units could contribute to F in MS, and may be responsible for that MFS. We now compared the nature of F in RR as compared to P form of MS.

Design/Methods:

MVIC was sampled in 17 normal (N) subjects, as well as 13 RR and 12 P MS patients, using a load cell attached via a strap to the elbow flexors. Muscle electrical activity was measured by connecting an EMG preamplifier with integral electrodes to the surface of the skin overlaying the tested muscle group with a reference electrode placed on the back of the hand. The custom made preamplifier is a low-noise, low-bias current, semiconductor-based instrumentation amplifier which allows the stainless-steel electrodes to be placed directly on the skin with minimal surface preparation. The EMG signal is amplified (gain = 1000) and filtered (band pass = 25 to 250 Hz) before being sampled. Motion artifact is minimized.given that the task is isometric in nature and by filtering the low frequencies (below 25 Hz). Both signal voltages are connected to the computer via 12-bit data acquisition board for displayed, digital signal processing (plotting and analyzing) implemented using custom made software developed with Visual Basic. Decline in force was expressed as FFI = 100 * [1 minus (AUC 25 to30 / AUC 2 to 7)].The compression in the power spectrum of the myoelectric signal in the last 5 second as compared to the first 5 seconds was tracked by Fast Fourier Analysis. The MFS was calculated as MFS = 100 * [1 minus (MF 25 to 30 / MF 2 to 7)].

Results:

FFI was significantly [p0.05] higher in both RR and P MS as compared to N indicating excess F. MFS, was significantly [p0.05] lower in P MS [6.1%] compared with RR MS [18%] and N [15%].

Conclusions:

The high and low MFS in RR and P MS, respectively, indicate different peripheral factors in the pathogenesis of F in MS. Atrophy due to loss of motor units may dominate in P MS, while motor units transformation from slow to fast characteristics may dominate in RR MS causing these opposite changes in MFCV.

Supported By:

B.R.B. is supported in part by Department of Veterans Affairs.

Category - MS and Related Diseases

SubCategory - Clinical Neurophysiology 


[S51.008]

Dynamics of MRI Lesion Development in a Murine Model of Multiple Sclerosis

Moses Rodriguez, Istvan Pirko, Aaron J. Johnson, Jeff Gamez, Slobodan I. Macura, Rochester, MN

Objective:

The aim of our study was to determine whether lesion development in Theilers Murine Encephalitis Virus (TMEV) infection follows a specific pattern.

Background:

Theilers Murine Encephalitis Virus (TMEV) is a murine model of demyelinating diseases. Depending on the strain, it can cause various degrees of pathology, ranging from full resistance to severe fulminant demyelinating disease. In interferon-gamma receptor knockout mice (G-129) a subacute demyelinating disease of the brain stem and the brain is observed. The disease has a uniformly fatal outcome in 4-6 weeks, with substantial changes on pathology. Whether the multifocal lesion formation seen on histology is a result of simultaneously appearing and gradually enlarging lesions or a result of lesions that appear at different timepoints over the disease course was not known. Whether lesions can resolve during the course of this illness was also unknown.

Design/Methods:

We followed six G-129 mice with serial imaging studies from the time of infection until death. Images were obtained every few days using a 7 Tesla vertical bore magnet, manufactured by Bruker Biopsin. The scanner was equipped with a small animal probe. Inhalational anesthesia was used with isofluran during imaging. A thermocouple based system maintained the core temperature of the scanner to avoid hypothermia.

The applied pulse sequences included T1 weighted 3D spin echo studies with gadolinium contrast as well as T2 weighted 3D RARE studies to determine overall lesion load. Brain volume calculations were conducted based on a seed growing segmentation algorithm using the Analyze 4.0 software package.

Results:

New contrast enhancing lesions were only seen in the first 2 weeks after infection. We did not find any spontaneously resolving lesions. Most lesions increased in size with time on T2 weighted studies. We also observed new lesion formation in the absence of contrast enhancement. As the lesions grew in size and number, worsening brain atrophy was observed. Numerical data as well as images and time-lapse movies will be presented.

Conclusions:

We conclude that in G129 mice TMEV is a progressive demyelinating condition with no interim resolution of lesions; the initial appearance of lesions changes with time; and contrast enhancement is not an obligatory part of lesion formation.

Category - MS and Related Diseases

SubCategory - Imaging 


[P03.110]

Disappearing T1 Black Holes in an Animal Model of Multiple Sclerosis

Istvan Pirko, Aaron J. Johnsons, Slobodan I. Macura, Moses Rodriguez, Rochester, MN

Objective:

Magnetic Resonance Imaging of the brain in multiple sclerosis (MS) frequently shows areas of T1 black holes - low signal areas in the white matter on T1 weighted sequences. These areas are thought to be consistent with irreversible axonal loss. In this study similar T1 black holes were followed and characterized in a murine model of MS.

Background:

Theilers Murine Encephalitis Virus (TMEV) infection is an established model of demyelinating diseases in mice. The spectrum of TMEV is very broad in different mouse strains: progressive myelopathy, brainstem disease, brain lesions, transient demyelinating episodes and full resistance against the infection have also been described. B6 mice are known to be susceptible for early TMEV infection: they develop a self-limited brain disease, which fully resolves within 4-6 weeks.

Design/Methods:

In this study, we followed six B6 mice with serial MRI imaging and MR spectroscopy after TMEV infection, on days 0,1,7,14,21,30 and 45. The MRI studies were performed in a Bruker Biospin 7 Tesla vertical bore magnet, equipped with imaging probes to accomodate small rodents. T1 weighted 3D spin-echo sequences and T2 weighted 3D RARE sequences were used for image acquisition. For MR spectrocopy, a VSEL (PRESS) sequence was used with water suppression pulses. The animals were anesthetized by inhalational isofluran, their core temperature was monitored and maintained by a thermocouple-based system. Brain volumetry and image post-processing was done with the Analyze 4.0 software package.

Results:

Brainstem, cervical cord and periventricular/parahippocampal brain pathology was seen even after 3 days, with decreasing NAA/Cre ratio on MRS. The extent of demyelination was most severe on day 14, when several areas of T2 weighted high signal lesions as well as T1 black holes were seen, along with low NAA/Cre ratio. Classically, T1 black holes are thought to be consistent with areas of irreversible axonal loss. This dogma is challenged by our observations of resolution of T1 black holes by day 30. This is concomitant with the normalization of the MRS findings in the areas of interest.By using 3D volume acquisition techniques, we performed semi-automated brain volumetry by using a seed-growing algorithm. A slight decrease of brain volumes was seen in mice that recovered from the illness, but it failed to reach statistical significance.

Conclusions:

We conclude that T1 black holes may represent a transient phenomenon in demyelinating diseases. The recovery of these areas studied with MR spectroscopy suggests an active repair mechanism. A mild ex-vacuo atrophy may also contribute to the signal normalization as proven by volumetric studies.

Category - MS and Related Diseases

SubCategory - Imaging 


[P01.024]

Abnormal Eye Movements Predict Disability in Multiple Sclerosis (MS): Two-Year Follow-Up

Joy A. Derwenskus, Cleveland, OH, Alessandro Serra, Sassari, Sardinia, Italy, Deborah L. Downey, Janet C. Rucker, R. John Leigh, Cleveland, OH

Objective:

To compare progression of general disability in MS over a 2-year period in two groups of patients, with either normal or abnormal eye movements.

Background:

We previously reported that 22/50 patients showing abnormalities of eye movements were more disabled than those with a normal ocular motor examination, even though age and duration of disease were similar in the two groups. We now present results of follow-up evaluations after about 2 years.

Design/Methods:

During both the initial and follow-up examinations, we tested: (1) ocular alignment; (2) fixation stability (noting any nystagmus); (3) saccades(noting accuracy, speed, and conjugacy); (4) smooth pursuit; (5) vestibulo-ocular reflex, using head thrusts in the horizontal and vertical canal planes; (6) vergence responses. A normal ocular motor score (NOM) allowed for nystagmus on eccentric gaze, and mild impairment of smooth pursuit, which many normals show; greater scores were classified as abnormal (AOM). Vision was also tested, and patients were graded using Kurtzke Functional Neurological Status (FSS), and Expanded Disability Status Scale (EDSS). MRI scans were available in 45 patients originally evaluated.

Results:

We were able to re-examine 40/50 patients initially tested after a median period of 27.5 months (range 19-38). Ages ranged 28-74 years and disease duration 3-39 years; 36 patients received immunotherapy. 70% showed progression of their EDSS scores (paired t-test p 0.05) . Mean EDSS scores of NOM patients (n=23) progressed from 3.1 to 4.2, and of AOM patients (n=17) progressed from 5.3 to 6.8. Thus, 2 years after the initial examination, the AOM group remained more disabled than the NOM group (p0.001). Ocular motor scores worsened in the AOM group (p=0.011), but not in the NOM group. When patients were re-grouped according to their 2002 examination, the AOM group (n=20) had significantly greater (p0.001) disability (median EDSS 6.7) than the NOM group (median EDSS 4.2). Visual acuity was significantly worse (p0.001) in the AOM than the NOM group during both the 1999 and 2002 evaluations, but neither group showed deterioration during the 2-year period. MRI scans showed abnormal signals in the brainstem or cerebellum of 60% of AOM patients and 28% of NOM patients.

Conclusions:

MS patients with abnormal eye movements are more disabled than those with normal eye movements, and this difference is sustained over 2 years of follow-up. Abnormalities on eye movements tests that we performed are caused by brainstem and cerebellar disease, and MRI data showed a greater burden of disease at these locations in our AOM patients. Eye movement abnormalities themselves usually cause minor disability, but their presence indicates brainstem or cerebellar disease that limits walking. There is a role for routine examination of eye movements in patients with MS, including saccades and the vestibulo-ocular reflex.

Supported By:

NIH EY06717,Veterans Affairs, Evenor Armington Fund

Category - Neuro-Ophthalmology/Neuro-Otology

SubCategory - Clinical Neurophysiology 


[P02.132]

Rapidly Transitional Multiple Sclerosis Patients Treated with Combination of Cyclophosphamide and Interferon Beta: Follow-Up 36 Months after Discontinuation of Therapy

Francesco Patti, Ester Reggio, Teresa Fiorilla, Alessandra Nicoletti, Filippo Palermo, Arturo Reggio, Catania, Sicily, Italy

Objective:

Clinical and MRI follow-up 36 months after the end of 18 months combination therapy with interferon beta (IFNB) and cyclophosphamide (CTX) in a group of very active multiple sclerosis (MS) patients.

Background:

Literature data suggest that CTX is efficacious in MS when inflammation predominates over degenerative process of CNS and it is active on relapses and on gadolinium enhancing lesions at MRI. We previously demonstrated the effectiveness of a combination of IV monthly pulses of CTX and standard regimen of IFNB in patients with rapidly transitional MS.

Design/Methods:

Ten very active MS patients previously treated with IFNB refractory to this therapy were treated with CTX + IFNB for 18 months. After combination therapy patients continued to assume IFNB. Complete neurological examination with EDSS every 3 months, brain MRI every 12 months were performed. Safety: blood and urine analysis, ECG and chest Rx, ecography of liver, spleen, kidney, bladder, uterus and lymph nodes and mammography were obtained.

Results:

Follow-up at 54 months of the 10 MS patients (6 women), mean age 28.8 (SD 2,68), mean onset age 21.3 (SD 2.6), mean duration disease 7.6 years (SD 0.84) showed that relapse rate (0.13 p0.001), EDSS (mean 2.35 p0.001), T2 MRI burden of lesion (mean 22.7 p0.001) and lesion number at T2 images (mean 41.8 p0.001) were maintained. No gadolinium enhancing lesion was detected. No adverse events were recorded but one case of mammal adenoma.

Conclusions:

These follow-up data strongly suggest that CTX+IFNB was able to shift patients from rapidly transitional form into a relapsing-remitting course of MS and that standard-doses of IFNB maintains and prolongs CTX anti-inflammatory property. No patient had severe side effects.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P01.112]

Screening for Cognitive Impairment in Multiple Sclerosis Using the Crossing - Off Test

Gilles Chopard, Catherine Creus, Eugeniu Revenco, Jean A. Galmiche, Lucien Rumbach, Besancon, France

Objective:

To evaluate the crossing-off test (COT) as a marker of psychomotor slowing at the early stage of Multiple Sclerosis (MS) or in less disabled patients.

Background:

The speed of information processing often slows down in MS. This slowness has been related to motor disability but also to cognitive deterioration. Several tests are used to evaluate this slowing: the Paced Auditory Serial Audition Test (PASAT), the Trail Making Tests (TMT), the Stroop Tests, and simple and choice reaction time measures. The COT has already been used to assess psychomotor slowing in the early stages of Alzheimers disease. The aim of our study was to evaluate the value of this test in measuring the speed of information processing in MS.

Design/Methods:

The study was conducted in 20 patients with relapsing remitting MS in the early phase who were working at the time of the study (mean EDSS score : 0.70 0.80 ; mean disease duration : 4.2 2.7 yrs). None of them had a motor or visual deficit. Controls were 20 healthy subjects matched individually with the patients by age , education , verbal intelligence (IQ) , and gender (male/female). The cognitive performance was measured by a neuropsychological battery: Grober test, digit span, alpha span , working memory, flexibility, divided and focused attention derived from the Attention Test Battery, Stroop test, TMT A and B, phonological and semantic verbal fluency, PASAT 2.0 sec and the COT . The patients received two deterioration points if their performance on any of the tests (except the COT) was below -2 SD.

Results:

Significant statistical differences appeared in several tests between patients and controls : COT (223.45 vs 283.75, p : 0.00001) ; phonological verbal fluency (16.4 vs 23, p : 0.00001) ; TMT B (68.75 sec. vs 55.25 sec., p : 0.009) and mean reaction time of the divided attention task (707 ms vs 662, t(38) : 2.15, p : 0.04). The correlations between the COT and the other tests were respectively : r : 0.41 (p 0.05), r : 0.56 (p 0.01), r : 0.49 (p 0.02). Among the 6 MS patients who were cognitively impaired, 4 had a significant slowing on the COT (- 2 SD below the mean of control group) whereas among the 14 cognitively preserved MS patients, only 2 had a significant slowing.

Conclusions:

These data show a highly significant psychomotor slowing in less disabled MS patients in the early stage of the disease. This slowing is not related to motor or visual disability. The COT is quickly performed (around 1 min.), easy to use and to score, and well accepted by patients. Even though the COT is a low level attention test , it showed a significant slowing in MS as in the higher level attention tests (TMT B, phonological verbal fluency, reaction time of the divided attention task). These results require further study in order to evaluate the value of the COT not only as a screening tool for speed of information processing and but perhaps also for cognitive deterioration in the early stage of MS.

Category - MS and Related Diseases

SubCategory - Other 


[P02.136]

Bone Marrow Transplantation after Maximum T-Cell Depletion in Rapidly Progressive Multiple Sclerosis

Johnny P. Samijn, Peter A. te Boekhorst, Zwenneke H. Flach, Pieter A. van Doorn, Bob Lowenberg, Rogier Q. Hintzen, Rotterdam, Netherlands

Objective:

To evaluate the safety and effects of bone marrow transplantation after maximum T-cell depletion in MS patients with an aggressive disease course.

Background:

Autologous stem cell transplantation (SCT) may be an effective therapy for aggressive types of MS. Different phase I/II studies have used different conditioning reagimens but most have not focussed on maximum T-cell depletion.

Design/Methods:

Patients were selected by predefined criteria: definite MS according to Posers criteria, expanded disability status score (EDSS) 3 within two years and progression of disability in the years prior to inclusion with current EDSS between 5 and 7. Patients received total body irradiation (2x5Gy) and cyclophosphamide (120 mg/kg). Anti-thymocyte immunoglobulins were administered for in vivo T-cell depletion. CD34 selected cells were reinfused using bone marrow as stem cell source.

Results:

Twelve patients (7 female/age 23-50 yr) were included. General malaise, elevated liver enzymes, mucositis and moderate to severe toxicodermia were observed in most patients. There were no life-threatening bacterial infections. Five patients developed an Epstein Barr virus reactivation several months after SCT, as shown by real time PCR monitoring, but were able to clear the virus themselves, without developing lymphoma. One patient suffered from Clostridium difficile gastro-enteritis. Current follow-up ranges from 3 to 48 months. EDSS scores for patients with a follow-up beyond one year (n=8) are improved in two patients (65 and 5.55), stable in one whereas five patients have a worse score. Clinical relapse was seen only in patients with EDSS deterioration. Gadolinium enhancement was completely abrogated both in brain and spinal cord. Evolution of T1 and T2 lesion volumes showed moderate correlation with EDSS course.

Conclusions:

This protocol for maximum T-cell depletion succeeded in abrogation of CNS inflammation as observed with gadolinium MRI. Despite severe immunosuppression some patients still deteriorated, which could be a result of radiation induced neurotoxicity or due to ongoing axonal loss. Side effects were acceptable. Longer follow-up and a randomized trial are needed to see if patients with rapidly progressive MS can benefit from this treatment.

Supported By:

1) Erasmus MC Rotterdam 2) Foundation Friends of MS Research (Dutch: Stichting Vrienden MS Research).

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[S51.003]

Gray Matter MRI T2 Hypointensity Predicts Longitudinal Brain Atrophy in Multiple Sclerosis: Effect of Intramuscular Interferon Beta-1a Treatment

Robert A. Bermel, Srinivas R. Puli, Andrew J. Fabiano, Buffalo, NY, Elizabeth Fisher, Richard A. Rudick, Cleveland, OH, Bianca Weinstock-Guttman, Buffalo, NY, Jack H. Simon, Denver, CO, Frederick E. Munschauer, Rohit Bakshi, Buffalo, NY

Objective:

To determine if treatment with interferon-beta impacts on the relationship between baseline gray matter MRI T2 hypointensity (T2H) and subsequent brain atrophy over 2 years in MS.

Background:

Brain atrophy has been described early in MS and may be partially prevented by treatment with intramuscular interferon beta-1a. MRI T2H, a marker of pathologic iron deposition, has been described in the gray matter MS patients, and is related to clinical and MRI markers of disease progression. T2H has predicted brain atrophy longitudinally, suggesting a link between iron deposition and brain atrophy in MS.

Design/Methods:

We analyzed MR images collected from patients who completed 2 years of follow-up in a randomized double blind phase III treatment trial of relapsing MS. Eighty-one patients received treatment with intramuscular interferon-beta-1a (Avonex, 30ug per week), and 78 patients received placebo. Normalized conventional spin echo T2H was determined in the thalamus, caudate, globus pallidus, putamen, red nucleus, and dentate nucleus at the Buffalo Neuroimaging Analysis Center. Whole brain atrophy (brain parenchymal fraction-BPF) was measured at the Cleveland Clinic, and total T2 hyperintense (T2LV), gadolinium enhancing, and T1 black holes volumes were determined at the University of Colorado.

Results:

Across all patients, T2H in bilateral caudate, putamen, globus pallidus, red nucleus, and thalamus was correlated with BPF at baseline (r=.19-.39, p=.001-.029). Placebo group: Baseline T2H in the thalamus (r=.33, p=.006), left putamen (r=.30, p=0.012), and left globus pallidus (r=.26, p=.032) was associated with percent decrease in BPF over 2 years. T2H in the thalamus was chosen first by stepwise regression as predictive of 2-year change in BPF (partial R2=.10, p=.009); left dentate, left putamen, and red nucleus added predictive value (model R2 =.33, p.0001). Treatment Group: BPF decreased 55% less in the second year compared with the placebo group (p0.05). There were no associations between baseline T2H and 2-year BPF change; stepwise regression selected baseline T2LV as the best predictor of 2-year change in BPF (partial R2 =.29, p.0001). Within subject T2H did not significantly change over 2 years in either group.

Conclusions:

Baseline gray matter T2H is predictive of 2-year progression of atrophy in placebo but not interferon-treated patients. One explanation for this finding is that intramuscular interferon-beta exerts its effect on brain atrophy by reducing a cascade of events involving iron mediated neurotoxicity. However, further studies are warranted to investigate this potential neuroprotective mechanism of action.

Supported By:

Alpha Omega Alpha Student Grant (R. Bermel, A. Fabiano), AAN SIGN Scholarship (R. Bermel), and NIH-NINDS 1 K23 NS02210-01 (R. Bakshi)

Category - MS and Related Diseases

SubCategory - Imaging 


[S65.002]

TNF-Related Apoptosis Inducing Ligand (TRAIL) as a Potential Response Marker for IFN-Beta Therapy in Multiple Sclerosis

Klaus Peter Wandinger, Jan D. Lunemann, Oliver Wengert, Judith Bellmann-Strobl, Orhan Aktas, Klaus D. Wernicke, Frauke Zipp, Berlin, Germany

Objective:

To examine the functional relevance of TNF-related apoptosis inducing ligand (TRAIL) for clinical therapy response in multiple sclerosis (MS) patients treated with interferon-beta (IFN-b).

Background:

A substantial number of MS patients fail to respond to IFN- b, widely used as immunomodulatory therapy in this disease. TRAIL was recently shown to be selectively upregulated by IFN-b and not by other type-I interferons and to exert potent antiinflammatory properties at the T cell level. In order to examine the functional relevance of TRAIL induction for the mechanism of action of IFN-b in vivo, we linked its gene and protein expression profile with clinical disease activity in MS patients treated for 1 year.

Design/Methods:

Total RNA was extracted from the peripheral immune cells of 82 MS patients, either non-treated or participating in clinical trials of IFN-b 1a. Samples were obtained from all patients prior to IFN-b treatment as well as longitudinally within the first year of therapy. Patients were classified either as first year responders (n=42) or first-year non-responders (n=31) to IFN-b due to lack of relapses and in a subgroup stable MRI. Gene expression was quantified by realtime-PCR. Protein levels were determined in 252 corresponding serum samples by ELISA. TRAIL gene and protein expression was correlated with clinical activity markers.

Results:

Early and sustained TRAIL gene induction could be correlated with IFN-b therapy response in MS patients. In the presence of NAB, upregulation of TRAIL gene expression was abrogated. In line with our findings on the TRAIL RNA expression, elevated levels of soluble TRAIL protein in patients sera prior to the start of therapy allowed prediction of the treatment response in the first year.

Conclusions:

Our data indicate that TRAIL expression is a candidate for pretreatment assessment and might thus be used as prognostic marker of IFN-b therapy response in MS. Furthermore, our observations have implications for the development of future immunoregulatory strategies in MS therapy.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P04.092]

Interferon Beta Therapy Does Not Affect Duration in Time of Gd-Enhancing Lesions and Black Holes in Relapsing Remitting Multiple Sclerosis

Francesca Bagnato, Bethesda, MD, Neal Jeffries, Bethesda, MS, Nancy Richert, Ohayon Joan, Stone Roger, Creg Bash, Henry F. McFarland, Joseph A. Frank, Bethesda, MD

Objective:

To evaluate the role of Interferon beta 1b (IFN1b) in shortening the duration in time of both contrast enhancing lesions (CELs) and black holes (BHs) in relapsing-remitting multiple sclerosis (RRMS) patients

Background:

CELs are considered as a specific sign of inflammatory activity in MS whereas T1BHs are a marker of tissue damage and axonal loss. The latter have the highest correlation with the Expanded Disability Status Scale (EDSS) clinical score. A longer duration in time of both those lesions is considered as a sign of a more severe underlying pathology.

Design/Methods:

Ten RRMS patients (8 females and 2 males, mean SD age 37.94.3, EDSS 2.91.9, MS duration 9.46.9) underwent 36 monthly MRIs. Eighteen scans were obtained over a natural history follow-up and 18 were performed during a treatment phase. Dual echo, pre and postcontrast [gadolinium (Gd), 0.1 mmolKg] images were obtained. The number of Gd-lesions and of BHs in the corresponding unenhanced scan was evaluated. The volume of those lesions will be evaluated as well. A BH was defined as any hypo intense region visible on the T1WI corresponding to a region of high signal intensity on the T2WI. IFN1b at the dosage of 8 MIU three times a week was injected subcutaneously in each individual. Chi squared test evaluated the probability of a CEL to convert to a BH before and during therapy, whereas a survival analysis analyzed differences in time duration of CELs and BHs arising before and during therapy.

Results:

A total of 360 scans was obtained and analyzed. There was no difference in the chance of a given CEL to convert as a BH during the natural history or the treatment phase. In addition, results of survival analysis showed no difference in time duration of both CELs (p=0.26) and BHs (p=0.15) arising before and after treatment commitment.

Conclusions:

These preliminary results show that IFN1b does not reduce either the proportion of CELs evolving to a BH or the duration that either CELs or BHs can exhibit after their arising. The observations are consistent with a mechanism of action of IFN1b that does not affect the outcome of a given lesion once it has been formed.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[S31.003]

An Active Scan at 12th Month of Therapy Is Associated with a Worse Response to IFN Beta over the Subsequent Five Years of Treatment in RRMS

Elisabetta Giugni, Andrea Paolillo, Valentina Tomassini, Caterina Mainero, Claudio Gasperini, Pier Luigi Russo, Francesca Bagnato, Stefano Bastianello, Carlo Pozzilli, Rome, Italy

Objective:

To extent our previous findings by analyzing the ability of the Gd-activity MRI scan obtained at the12th month of therapy with IFN beta 1a in predicting the clinical outcome over the subsequent five years of treatment in relapsing remitting multiple sclerosis (RRMS).

Background:

We have previously demonstrated the role of the MRI scan performed 12 months after IFN beta treatment in predicting a better clinical outcome over the second year of therapy, RRMS. The presence of Gd-activity 12 months after therapy commitment was associated (91%) with either a higher relapse rate or an increase of at least one point in Expanded Disability Status Scale (EDSS) during the second year of treatment (Pozzilli et al. J Neurol 1998; 285: 384).

Design/Methods:

This study was an extension of an open-label short-term trial aimed to evaluate the clinical and MRI efficacy of recombinant IFN beta 1a, three times a week injected in RRMS patients. Sixty-seven RRMS patients were clinically assessed by the means of the EDSS score every six months and the number of relapses was recorded for the whole time period (i.e. six years). MRI scans were available for all the patients at time 0 (i.e. before treatment commitment) and at month 12 (i.e. one year after therapy). We defined as responder those patients who have been found with no Gd-activity at month 12, regardless of the Gd-activity at the baseline MRI scan.

Results:

Fifty-one (76.1 %) patients were found to be responder after one year of therapy; whereas 16 (23.9%) showed at least one enhancing lesions at the 12-month MRI scan. Mean relapse rate from year two to year six was 0.38 (S.D. 0.37), for responder patients and 0.78 (S.D. 0.49) for non-responder group (p=0.001). The mean EDSS changes did not significantly differ between the two groups of patients. The presence of Gd-activity at month 12 was associated with a higher number of relapses over the same time frame [beta= -0.40, standard error (SE) = 0.12; p=0.001 by using a multivariate analysis] but not with a worse EDSS score.

Conclusions:

The extension of our findings confirm the role of the 12-month scan in predicting the clinical outcome, as measured by the means of the relapse rate, over a longer follow-up period of six years. We believe that the presence of the Gd-activity after 12 months of IFN beta therapy should be a helpful tool for clinicians to make decision in therapy continuation over time.

Category - MS and Related Diseases

SubCategory - Imaging 


[S51.007]

Imaging of ICAM-1 in Experimental Autoimmune Encephalomyelitis (EAE) with a Specific Ultrasound Contrast Agent

Mathias Maurer, Ralf Linker, Wuerzburg, Germany, Peter Hauff, Micheal Reinhard, Andreas Briel, Michael Schirner, Berlin, Germany, Klaus V. Toyka, Weurzburg, Germany, Georg Becker, Homburg, Germany, Peter Rieckmann, Wuerzburg, Germany

Objective:

To proof sensitivity and specificity of a specific ultrasound contrast agent (USCA) for ultrasound imaging of ICAM-1 in experimental autoimmune encephalomyelitis (EAE):

Background:

Expression of cellular adhesion molecules (CAMs) is an early disease event in EAE and parenchymal infiltration is paralleled by an up-regulation of ICAM-1 on blood vessels. This is why endothelial ICAM-1 expression is an interesting target to monitor disease activity. However current detection methods are generally limited to in vitro assays.

Design/Methods:

Adoptive-transfer EAE (AT-EAE) was induced by intravenous injection of 3 x 106 freshly activated MBP-specific T-cell blasts in 8 weeks old female Lewis rats. At disease maximum animals received either ICAM-1-specific USCA (polymer stabilized air-filled microparticles) or unspecific USCA. Specificity was achieved by synthesis of anti-ICAM-1 antibodies onto the surface of USCA-microparticles. In addition healthy control rats were treated with the specific USCA. In some experiments animals were treated with corticosteroids. Thirty minutes after injection of USCA animals were killed and CNS tissue was examined with ultrasound (ATL-UM9, L10-5, color Doppler) for USCA specific stimulated acoustic emission (SAE) signals. SAE signals were recorded and compared between the different groups. ICAM-1 expression in the CNS was controlled by immunohistochemistry.

Results:

The spinal cord and brain tissue obtained from EAE animals that received ICAM-1-specific USCA showed clear SAE signals, whereas almost no signal was detectable in the two control groups. Pre-treatment with anti-ICAM-1 antibodies clearly diminished the SAE signals from the CNS tissue of EAE animals, demonstrating the specificity of the ICAM-1-specific USCA. Finally we could demonstrate a clear signal reduction in EAE animals that were treated with corticosteroids before the application of the ICAM-1-specific USCA. The imaging results of all experiments were confirmed by immunohistochemistry.

Conclusions:

We have demonstrated that site-specific USCA can be used to visualize ICAM-1 upregulation in inflammatory disease in intact nervous system tissue. The ICAM-1-specific USCA were shown to be specific and sensitive. Our results lays the groundwork for in vivo imaging studies of endothelial molecules involved in the pathogenesis of multiple sclerosis.

Supported By:

Schering AG, Berlin, Germany

Category - MS and Related Diseases

SubCategory - Imaging 


[S65.001]

Myelin Autoantigens Presentation by MHC Class II Is Promoted and Enhanced by Inducible Heat Shock Protein 70

Marcin P. Mycko, Hanna Cwiklinska, Jacek Szymanski, Bozena Szymanska, Lodz, Poland, Celia F. Brosnan, Bronx, NY, Krzysztof W. Selmaj, Lodz, Poland

Objective:

The aim of this study was to investigate the role of heat shock proteins (hsps) in the pathogenesis of multiple sclerosis (MS) by investigated the role of HSP70, the inducible form of heat shock protein 70, in the presentation of myelin basic protein (MBP), in the context of appropriate MHC class II expression.

Background:

Hsps are known to facilitate the generation of specific immune responses by chaperoning proteins and peptides involved in T cell activation. Most of the previous studies demonstrated the involvement of hsps in the response that was restricted by MHC class I molecules. Since hsps, including HSP70, have also been shown to be strikingly elevated in MS lesions we decided to analyze the potential role of HSP70 in the promotion of MHC class II mediated presentation of major putative autoantigen in MS, MBP.

Design/Methods:

The in vitro interaction of MBP and MBP peptides and HSP70 were measured by plasmon surface resonance and by co-immunoprecipitation of proteins extracted from antigen presenting cells (APCs) pulsed with MBP. Functional significance of MBP-HSP70 complexes was tested by analysis of MBP specific T cell hybridoma line recognition of MBP presented by APCs with upregulated or downregulated expression of HSP70.

Results:

By co-immunoprecipitation experiments, we found that MBP associates with HSP70 in antigen presenting cells (APC). The major immunodominant epitopes of MBP: MBP 85-99 and 80-99 were shown to bind selectively and specifically to HSP70 by surface plasmon resonance. The functional significance of MBP interaction with HSP70 was demonstrated by enhanced responses of an MBP-specific T cell hybridoma to MBP and MBP peptide 80-99 presented by APC expressing DRA*0101, DRB1*1501 (DR1501) with increasing levels of HSP70. Conversely, T cell hybridoma responses to MBP presented by APC with diminished HSP70 expression induced by transfection with an adenoviral vector containing anti-sense HSP70 was significantly reduced. When MBP peptide 85-99 was used as the stimulus, T cell hybridoma responses were not enhanced by HSP70 overexpression within APC suggesting that HSP70 contributes to antigen processing rather than antigen presentation. The importance of a direct association between MBP and HSP70 in the presentation pathways was demonstrated by enhanced efficacy of MBP presentation by APC transfected with a plasmid vector encoding a fusion MBP-HSP70 protein.

Conclusions:

We have shown here an involvement of inducible HSP70 in MHC class II dependent antigen processing by APC and demonstrated autoantigen-enhanced presentation by HSP. It implicates that aberrant HSP expression may lead to the induction of autoimmunity.

Supported By:

Supported by grant from KBN nr 4 P05A 005 19 to MPM.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P05.124]

The Use of Nitric Oxide Oxidation Products as Marker of Disease Activity in MS Patients

Lou Brundin, Magnus Andersson, Stockholm, Sweden, Alexandre Danilov, St Petersburg, Russian Federation, Tomas Olsson, Peter N. Wiklund, Stockholm, Sweden

Objective:

To study whether nitric oxide (NO) production in Multiple Sclerosis (MS) is related to clinical disease activity in MS we have determined the concentrations of nitrite and nitrate in the CSF and plasma of 61 MS patients.

Background:

NO is a free radical which has been shown to be involved in several important patophysiological mechanisms. In inflammatory disorders NO is formed as a consequence of induction of the i-NOS enzyme. In aqueous solutions it is rapidly oxidized to nitrite and in the presence of hemoglobin it is further oxidized to nitrate. The levels of nitrite and nitrate will thereby reflect NO synthesis, and are used to measure NO formation in biological systems.

Design/Methods:

61 MS patients were recruited consecutively though the out patient service at the neurology department of Karolinska Hospital. All patients included in the study had clinically definite MS according to the Poser criteria and presented routine CSF parameters (oligoclonal bands and elevated IgG index). The patients were divided into three groups, remission (n=17), progression (n=20) and exacerbation (n=24), on the basis of the clinical activity of the disease as scored by an independent neurologist. Headache patients (n=8) and healthy controls (n=11) were also studied.The NO oxidation products, nitrite and nitrate, were measured by capillary electrophoresis.

Results:

The total levels of NO oxidation products were significantly increased in all MS groups as compared to healthy and headache controls. CSF nitrite levels were highest in the exacerbation group, intermediately elevated in progressive patients and lowest in the remission patients. Five primary progressive patients were included in the progressive group, the levels of nitric oxide products in these patients did not differ significantly from the other progresssive patients (n=15). At exacerbation the CSF nitrite levels exceeded plasma levels. Plasma levels of nitrite and nitrate did not correlate to disease activity.

Conclusions:

Our data supports the idea that the inflammatory processes in MS lesions are ongoing also in the clinically stabile phases of MS. The finding that CSF nitrite leves exceeds the plasma level at exacerbation is indicative of increased intrathecal NO formation. Furthemore NO production may be involved in the pathogenesis of MS and determination of the nitrite level can be used as an objective maker for the inflammatory status in MS patients.

Category - MS and Related Diseases

SubCategory - Basic Science 


[S13.004]

Screening for CADASIL Mutations in Leukoencephalopathies

Maria T. Dotti, Silvia Bianchi, Nicola De Stefano, Carla Battisti, Francesco Sicurelli, Maria L. Stromillo, Alessandra Rufa, Monica De Santis, Edoardo Malfatti, Domenico Inzitari, Antonio Federico, Siena, Italy

Objective:

To screen for Notch3 mutations in patients with leukoencephalopathy of unknown causes.

Background:

Undefined leukoencephalopaties account for the greatest portion of adult onset white matter disorders. CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is considered to be a rare hereditary cause of recurrent stroke, TIAs, migraine, ad psychiatric disturbances, leading to progressive neurological impairment and cognitive decline. The spectrum of phenotype is wide even in the same family. The white matter abnormalities detected on MRI might be undistinguishable from other neurological disorders such as multiple sclerosis, lacunar stroke with leukoaraiosis, and adult onset leukoencephalopathies. CADASIL results from mutations in Notch3 gene. The disease is probably under diagnosed in the wider population with diffuse white matter abnormalities on MRI.

Design/Methods:

We included in this study 103 adult patients with leukoencephalopathy of unknown causes and with variable clinical spectrum, followed in our Neurometabolic Unit in the last four years. The absence of a positive family history for neuropsychiatric symptoms or stroke was not a criteria of exclusion. The most common genetic leukoencephalopaties were excluded. All patients were screened for mutations in exons 3, 4, and 19 by direct sequencing and in exon 11 by DG-DGGE. Mutations in these four exons are known to account for the great majority of cases (approximately 85%).

Results:

Five different mutations were identified in five unrelated patients (age range 42-60 years), including a novel small deletion on exon 4. One of the patients resulted homozygous for the C183S mutation on exon 4. We found the overall frequency of CADASIL mutations in the leukoencephalopathy population to be about 5%. Retrospectively, all the CADASIL patients showed a positive family history for a wide clinical spectrum of neurological disorders. In one case, only psychiatric symptoms were found in a first degree relative

Conclusions:

Notch3 mutations are not rare in a selected population with unknown leukoencephalopathy. Notch3 mutation screening should bee included in the diagnostic protocol of leukoencephalopathy.

Supported By:

MURST ex-40% to MTD, Ministero della Salute to AF

Category - Cerebrovascular Disease

SubCategory - Clinical Aspects 


[S51.001]

Cortical Atrophy in Early Relapsing Remitting MS Patients with Incipient Cognitive Impairment

Maria Pia Amato, Florence, Florence, Italy, Maria Letizia Bartolozzi, Empoli, Florence, Italy, Valentina Zipoli, Emilio Portaccio, Florence, Florence, Italy, Marzia Mortilla, Siena, Siena, Italy, Benedetta Nacmias, Florence, Florence, Italy, Leonello Guidi, Empoli, Florence, Italy, Gianfranco Siracusa, Florence, Florence, Italy, Paolo Lambruschini, Empoli, Florence, Italy, Sandro Sorbi, Florence, Florence, Italy, Antonio Federico, Nicola De Stefano, Siena, Siena, Italy

Objective:

To evaluate the correlation between incipient cognitive decline and MR measures of cortical atrophy in patients at the early stages of multiple sclerosis (MS).

Background:

Although cognitive dysfunction in MS has been associated with several MRI indicators of brain damage, little is known about the specific contribution of cortical pathology to MS-related cognitive impairment.

Design/Methods:

The study sample was represented by 41 relapsing remitting (RR) MS patients with disease duration 10 years and Expanded Disability Status Scale (EDSS) score 4.0, and 15 demographically matched normal controls (NC). Conventional proton T1-weighted MR images were used to assess cortical brain volumes normalized for head size by using a method for computing measurement of regional brain volume (SIENA). The neuropsychological (NP) performance of MS patients was assessed using the Rao Brief Battery (RBR). Patients were considered to have incipient cognitive decline when scores on at least one subtest were two standard deviations under normal values.

Results:

The whole MS patient group showed significant decreases in normalized cortical volumes (NCV) with respect to the NC group (NCV in MS patients = 60353cc, NCV in NC = 63622 cc, p = 0.01). NP assessment allowed the identification of 18 cognitively preserved (MS-cp) and 23 cognitively impaired (MS-ci) MS patients . The two patient groups did not differ for disease duration and EDSS score, whereas MS-ci patients were significantly older than MS-cp patients (MS-cp mean age =31 years, MS-ci mean age= 38 years, p0.01). After correction for age differences (using the z-score transformation), the comparison of MS-ci, MS-cp and NC groups showed the presence of significantly (p = 0.02) lower NCV in MS-ci patients than in both NC and MS-cp patient groups (NCV z-score in MS-ci = -2.025; NCV z-score in MS-cp = -1.033), whereas NCV values of the MS-cp group were not different from those of NC (p = 0.2). Finally, in MS-ci patients, NCV values showed close relationships with measures of verbal memory (r=0.50, p = 0.02), verbal fluency (r=0.51, p = 0.01) and attention/concentration (r=0.65, p 0.001).

Conclusions:

In the early stages of MS, cortical atrophy is selectively present in cognitively impaired patients. MR measures of cortical volumes correlate well with measures of verbal memory, attention/concentration and verbal fluency. These data suggest that neocortical grey matter pathology may occur early in the course of MS. MR measurement of cortical volumes can be good indicator of cognitive involvement in MS.

Category - MS and Related Diseases

SubCategory - Imaging 


[P04.014]

Clinical Measures in Friedreich Ataxia

David R. Lynch, Jennifer M. Farmer, Robert B. Wilson, Laura J. Balcer, Philadelphia, PA

Objective:

Define clinical measures that quantitatively assess progressive neurological dysfunction in Friedreich ataxia (FA).

Background:

FA is a progressive neurodegenerative disease of children and adults. While the genetic basis of FA is well understood, clinical heterogeneity of FA complicates serial clinical analysis. Patients can present as late as age 50, and clinical features include spasticity as well as ataxia. Traditional scales for assessment of ataxia are based on subjective quantification of the neurological exam, and have lacked sensitivity and reliability. In this study, we sought to define quantitative neurological markers of FA using simple functional measures derived from the Multiple Sclerosis Functional Composite (MSFC).

Design/Methods:

Patients with genetically confirmed FA (n=27) were examined using two components of the current MSFC, the timed 25 foot walk (T25W) and nine hole peg test (9HPT), and low contrast Sloan letter charts (Sloan charts). The T25W and 9HPT were scored according to standard methods; the summary measure for the Sloan charts was obtained by calculating the total number of letters identified correctly for each of four charts (100%, 5%, 1.25%, and 0.6% contrast levels). The relation of scores to patient age, shorter triplet repeat length, and symptomatic disease duration was examined using rank-correlation and linear regression analyses.

Results:

Scores for each test (T25W, 9HPT, Sloan charts) correlated significantly with disease duration (9HPT: rS=0.74, p0.0001; T25W: rS =0.71, p=0.0001; Sloan charts: rS=-0.54, p=0.006). In linear regression models, the combination of age and shorter triplet repeat length was a significant predictor of scores for the Sloan charts (R2=0.57, p=0.0001), 9HPT (R2=0.44, p=0.002), and T25W (R2=0.50, p=0.0005). Correlations between measures were moderate in magnitude, demonstrating a potential role for each as a component in the evaluation of neurological function in FA (Sloan charts vs. 9HPT: rS =-0.71; Sloan charts vs. T25W: rS =-0.58; 9HPT vs. T25W: rS =0.79).

Conclusions:

These results suggest that a combination of simple functional measures of ambulation, arm function, and vision may be useful in the clinical evaluation of FA patients. A composite score derived from these tests may also provide the best overall measure for clinical trials of therapies for FA.

Supported By:

Friedreich Ataxia Research Alliance, Seek a Miracle Foundation.

Category - Neurogenetics and Gene Therapy

SubCategory - Epidemiology 


[P04.091]

Movement-Associated Functional MRI Changes in Patients at Presentation with Clinically Isolated Syndromes Suggestive of MS

Maria A. Rocca, Domenico M. Mezzapesa, Andrea Falini, Milan, Italy, Angelo Ghezzi, Gallarate (MI), Italy, Vittorio Martinelli, Giuseppe Scotti, Giancarlo Comi, Massimo Filippi, Milan, Italy

Objective:

To investigate, using functional magnetic resonance imaging (fMRI), whether movement-associated functional changes of the brain are present in patients that, most likely, are at the earliest stage of MS.

Background:

Although functional adaptive cortical changes have been detected in patients with established multiple sclerosis (MS), it is less clear how early in the course of the disease does this functional reorganization occur and which are the pathological mechanisms underlying it.

Design/Methods:

We studied 16 right-handed patients at presentation with CIS suggestive of MS and paraclinical evidence of dissemination in space within three months from the onset of the clinical symptomatology (F/M=10/6, mean age=31.7 years, 12 patients had an EDSS score of 0.0, and four had residual visual deficits, which resulted in an EDSS score of 1.0) and 15 healthy volunteers. Functional MR images were acquired using a T2*-weighted EPI sequence. A dual-echo sequence was also acquired from all the subjects. All the subjects were scanned while performing four different motor tasks: task#1) repetitive flexion-extension of the last four fingers of the right hand; task#2) repetitive flexion-extension of the last four fingers of the left hand; task#3) repetitive flexion-extension of the right foot; task#4) performance of the task#1-3 symultaneously in a phasic manner. FMRI data were analyzed using SPM99.

Results:

Compared to healthy volunteers, CIS patients had increased activations of the contralateral primary sensorimotor cortex (SMC), secondary somatosensory cortex (SII) and inferior frontal gyrus (IFG), when performing a simple motor task with the dominant hand. The increased recruitment of the contralateral primary SMC was also found during the performance of the same motor task with the non-dominant hand and with the dominant foot. In this latter case, an anterior shift of the center of activation of this region was also detected. During the performance of a more complex motor task with the dominant upper and lower limbs, CIS patients had an increased recruitment of a widespread network (including the frontal lobe, the insula, the thalamus), usually considered to function in motor, sensory and multimodal integration processing. The comparison of brain activations during the performance of motor tasks with different degrees of complexity showed that the movement-associated somatotopic organization of the cerebral and cerebellar cortices was retained in patients with CIS.

Conclusions:

Cortical reorganization does occur in patients at presentation with CIS highly suggestive of MS. Local synaptic reorganization, recruitment of parallel existing pathways and reorganization of distant sites are all likely to contribute to the genesis of cortical adaptive changes since the earliest phase of MS.

Category - MS and Related Diseases

SubCategory - Imaging 


[P03.101]

IL-12P35-Deficient Mice Are Susceptible to Experimental Autoimmune Encephalomyelitis: IL-12 Is Not Required for the Induction of Inflammatory Demyelination in the Central Nervous System

Bruno Gran, Guang-Xian Zhang, Shuo Yu, Jifen Li, Malek Kamoun, A. M. Rostami, Philadelphia, PA

Objective:

The objective of this study was to determine the requirement for Interleukin-12 (IL-12) in the induction of experimental autoimmune encephalomyelitis (EAE).

Background:

EAE serves as a model for multiple sclerosis and is considered a CD4+, Th1-cell mediated autoimmune disease. IL-12 is a heterodimeric cytokine, composed of a p40 and a p35 subunit, which is thought to play an important role in the development of Th1 cells. It has been shown to increase the encephalitogenicity of myelin-reactive T cells in adoptive transfer EAE and to induce disease relapses when administered to immunized rodents in vivo. IL-12p35-deficient (-/-) mice lack functional IL-12, whereas IL-12p40-/- mice are also deficient for the IL-12-related cytokine, IL-23, which shares the p40 subunit and certain proinflammatory functions with IL-12.

Design/Methods:

We induced chronic EAE with myelin oligodendrocyte glycoprotein MOG peptide 35-55 (MOG35-55) in wild type, IL-12p35-/-, and IL-12p40-/-, C57BL/6 mice. Immunized mice were observed for clinical course of EAE; central nervous system (CNS) inflammatory infiltration and demyelination were studied on histological sections by H-E and Luxol fast blue staining; antigen-specific cytokine production was measured by ELISA after culture of draining lymph node and spleen cells with MOG35-55; cytokine production was also studied by intracytoplasmic staining and flow cytometry in draining lymph nodes, spleen, and CNS-infiltrating and resident mononuclear cells of immunized and control mice.

Results:

We observed typical chronic EAE in wild type mice, whereas IL-12p40-deficient (-/-) mice were resistant to EAE. Chronic EAE was observed in IL-12p35-/- mice, with a tendency to higher disease severity. Typical spinal cord mononuclear cell infiltration and demyelination were observed in wild type and IL-12p35-/- mice, whereas IL-12p40-/- mice had normal spinal cords. A Th1-type response to MOG35-55 was observed in the draining lymph node and the spleen of wild type mice. A weaker MOG35-55-specific Th1 response was observed in IL-12p35-/- mice, with lower production of IFN-g. By contrast, a Th2-type response to MOG35-55 correlated with disease resistance in IL-12p40-/- mice. Nitric oxide production was higher in IL-12p35-/- and wild type than in IL-12p40-/- mice. Production of TNF-a by microglia, central nervous system-infiltrating macrophages, and CD4+ T cells was detected in wild type and IL-12p35-/-, but not in IL-12p40-/- mice.

Conclusions:

These data demonstrate that IL-12 is not required for the induction of autoimmune inflammatory demyelination in the CNS and suggest that the IL-12 related cytokine, IL-23, plays a more critical role in the pathogenesis of EAE.

Category - MS and Related Diseases

SubCategory - MS: Animal Models 


[P04.084]

Changes in Cortical Gray Matter in Untreated Relapsing-Remitting MS Patients: A Follow Up Study

Celia Oreja-Guevara, Marco Rovaris, Domenico Caputo, Rossella Cavarretta, Maria P. Sormani, Pasquale Ferrante, Giancarlo Comi, Massimo Filippi, Milan, Italy

Objective:

To investigate over a 18 follow up period the dynamic evolution of damage in normal-appearing brain tissue in untreated patients with relapsing-remitting multiple sclerosis (RRMS) using diffusion tensor (DT) MRI.

Background:

Cross-sectional studies with different quantitative MRI techniques have shown diffuse tissue damage in normal-appearing white matter (NAWM) and normal appearing gray matter (NAGM) of RRMS.

Design/Methods:

We followed up 26 patients with clinically definite MS and a relapsing- remitting course (RRMS) for 18 months. The mean duration of disease was 10 years. The median score of EDSS at entry was 1.5. During the follow-up period, there were 28 relapses. All relapses were treated with steroids. None of the patients had had other immunosuppressive or immunomodulating treatments before or during the study. Brain MR measurements were performed on a 1.5 T scanner at baseline and every three months. During each session, the following images were acquired without moving the patient from the scanner: 1) dual-echo turbo spin-echo 2) pulsed-gradient spinecho (PGSE) echoplanar pulse sequence with diffusion gradients applied in nine noncollinear directions 3) postcontrast T1-weighted CSE 5 minuted after the injection of 0.1 mmol/kg of Gadolinium-DTPA. At follow-up patients were carefully repositioned in the scanner following published guidelines. We produced mean diffusivity (MD) and fractional anisotropy (FA) histograms of the NAWM and NAGM. Average lesion MD and FA were also calculated. A random effect regression model was used to evaluate the time trend of histogram and lesion volume evolution. Correlations were studied using the Spearman rank correlation coefficient.

Results:

Average lesion FA, NAGM-FA and NAGM-MD histogram peak heights significantly decreased over time. Also a significantly increased in brain T2 lesion volumes and average NAGM mean diffusivity were found. We found trends toward increased average lesion MD, NAWM-MD and T1 lesion volumes with time. No significant correlations were found between the observed percentage changes of these parameters over the study. There were no significant differences between the percentage changes of DT MRI histogram-derived metrics and lesion volumes in patients with and without relapses.

Conclusions:

This study confirms the involvement of the NAGM and NAWM in patients with RRMS. It also shows that there is a significant increase of gray matter pathology in RRMS patients over time.

Category - MS and Related Diseases

SubCategory - Imaging 


[S11.006]

Treatment of Aggressive MS Using Immunoablative Treatment with Autologous Stem Cell Rescue: One Year Clinical and Laboratory Follow-Up of the First Six Treated Patients

Mark S. Freedman, Harold L. Atkins, Ottawa, ON, Canada, Douglas Arnold, Montreal, QC, Canada, Marjorie J. Bowman, Ottawa, ON, the Canadian MS/BMT Study Group

Objective:

To demonstrate the safety and efficacy of immunoablative treatement followed by autologous stem cell transplantation (ASCT) in patients with early aggressive MS.

Background:

Immunosuppression with chemotherapeutic agents has been shown to transiently reduce disease activity both clinically and by MRI studies. The continued presence of potentially disease causing immune cells would predictably lead to disease recurrence. We postulate that if a complete immunoablation can be accomplished with minimal morbidity, it will produce a long-lasting remission of disease activity.

Design/Methods:

A tri-center phase II non-randomized staggered entry trial of complete immunoablation followed by ASCT in 32 patients with early aggressive MS; 24 receiving full therapy and 8 controls receiving best medical therapy. After informed consent, a back-up bone marrow harvest is followed by stem cell mobilization with 4.5g/m2 i.v. cyclophosphamide (cyclo) and 10-days of 10g/kg/day G-CSF s.c. Leukophoresed stem cells are depleted of T cells using Miltenyii immunomagnetic CD34 positive selection. Immunoablation is accomplished using i.v. cyclo 200 mg/kg, dose adjusted oral busulfan (maximum dosage 16 mg/kg) and rabbit anti-thymocyte globulin (5 mg/kg). Engraftment is aided by treatment with 5g/kg/day G-CSF s.c. Medical, neurological (clinical and MRI) and immunological follow-up assessments are conducted at regular intervals. Neurological assessments include the EDSS and MSFC performed by an independent examiner. A full spectrum of neuroimaging is performed on each patient, including the controls.

Results:

The results of the first 6 patients are presented, including one year follow-up of the first 3. Flow cytometry and immune assays indicate that grafts were devoid of T cells and immunoablation was complete. Median time to engraftment (neutrophil recovery) post transplant is 10 days. Several transient minor (grade I-II) predictable early toxicities (day 30) ensued (e.g. stomatitis, GI disturbance), and longer term toxicities included gonadal failure. Early infections were few and easily treated, but Herpes Zoster infections (shingles) occurred later. Clinical stabilization/improvement was seen in the majority of patients. MRI studies showed the absence of any enhancing lesions, a reduction in T2 lesions and stabilization of pre-treatment increase in brain atrophy. Repeat CSF testing at one year shows the presence but alteration in the pattern of oligoclonal bands present.

Conclusions:

Immunoablative treatment followed by ASCT can be accomplished with minimal but predictive toxicity. Early evaluation at one year post transplant indicates both clinical and MRI stabilization of disease in patients who pre-transplant were actively and rapidly progressing. These results are preliminary but very encouraging.

Supported By:

Multiple Sclerosis Foundation of Canada.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P05.139]

Qualitative and Quantitative Detection of Chlamydia Pneumoniae DNA in Cerebrospinal Fluid

Subramaniam Sriram, Song-Yi Yao, Haijing Li, Charles Stratton, William M. Mitchell, Shufang Meng, Yi-Wei Tang, Nashville, TN

Objective:

A diagnostic test for the detection and quantitation of Chlamydia pneumoniae DNA in cerebrospinal fluid (CFS) is needed because of the association of C. pneumoniae with a number of neurological disorders including multiple sclerosis (MS).

Background:

There is controversy regarding the association between the role of C.peumoniae in the spinal fluid and the development of MS. Since there are no validated methods of PCR analysis for the detection of chlamydia in the CSF, differences in the sensitivity between laboratories is to be expected. If the detection of C. pneumoniae in body fluids is to be widely available, a user friendly assay system is needed.

Design/Methods:

We developed and validated a qualitative colorimetric microtiter plate-based PCR-enzyme linked amplification and hybridization assay (MTP-PCR) and a real-time quantitative PCR assay (TaqMan) for detection of C. pneumoniae DNA in CSF specimens from MS patients and controls. The two methods were evaluated in comparison to a touchdown nested PCR (n-PCR) assay on a total of 137 CSF specimens which inlcuded 80 MS patients and 57 other neurologic disease controls.

Results:

The sensitivity, specificity, and concordance of the MTP-PCR assay were 88.5%, 93.2%, and 90.5%, respectively. MTP-PCR presented a significantly higher sensitivity in MS patients (p=0.008) and a higher specificity in other neurological diseases (p=0.018). Test reproducibility of the MTP-PCR assay was statistically related to the volumes of extract DNA included in the test (p=0.033); a high volume, which was equivalent to 0.1 ml of CSF per reaction, yielded a concordance of 96.8% between two medical technologists running the test at different times. The TaqMan quantitative PCR assay detected 26 of 59 (44.1%) CSF specimens that tested positive by both MTP-PCR and n-PCR qualitative assays. None of the CSF specimens that were negative by the two qualitative PCR methods were detected by the TaqMan quantitative PCR. MTP-PCR assay detected a minimum of 25 copies/ml C. pneumoniae DNA in plasmid-spiked CSF, which was at least 10 times more sensitive than TaqMan.

Conclusions:

These data indicated that the MTP-PCR assay possessed an equivalent sensitivity to nested procedures for the detection of C. pneumoniae DNA in CSF. Due to the low C. pneumoniae copies that exist in the majority of CSF specimens from MS patients, the TaqMan system may not be sensitive enough for diagnostic purposes, but may be useful as a marker in prospectively following neurological diseases such as MS.

Supported By:

NIH

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[S35.001]

Cerebral Atrophy in Young, Otherwise Healthy Patients with Type I Diabetes Mellitus

Jitendra Sharma, Rohit Bakshi, Buffalo, NY, Donald Lee, Vladimir Hachinski, London, ON, Canada, Richard K. T. Chan, Buffalo, NY

Objective:

To determine the prevalence of cerebral atrophy among patients with juvenile-onset insulin-dependent diabetes mellitus (DM).

Background:

Earlier studies suggested that cognitive dysfunction is common in DM. The pathological basis of the cognitive dysfunction is not known. Our pilot study showed that a high proportion of DM patients had cerebral atrophy. Loss of brain tissue may account for the cognitive impairment reported among diabetics.

Design/Methods:

The Study of Cognitive Impairment and MRI Abnormality among Diabetics (SCIMAD) is on-going to determine the prevalence of cognitive impairment and its neuroimaging/clinical correlates among young, otherwise healthy patients with DM. Patients are between 18 and 50 years old, have insulin-dependent DM diagnosed before age 18 and have DM for 10 years or more. Patients who have contraindication to MRI were excluded. Subjects who met these criteria but who have no DM were recruited as controls. All subjects were recruited from the community through newspaper advertisements and flyers. All subjects, among other study procedures, received brain MRI using a protocol suitable for quantitative analysis. Whole brain atrophy was determined from axial T1-weighted images using the Brain Parenchymal Fraction (BPF), which we have recently characterized and validated in a multiple sclerosis population. BPF was defined as the total brain parenchymal volume divided by the volume of the brain surface contour and was obtained by a semi-automated computer assisted approach at the Buffalo Neuroimaging Analysis Center. Student t-test, Chi-square test or Fishers Exact Test were used, where appropriate, to compare different variables in the two groups. The study will recruit 100 diabetics and 100 normal subjects by early 2003. The abstract contains preliminary data from this study. Results of the completed study will be presented at the meeting.

Results:

There were 26 diabetic and 24 non-diabetic subjects, with mean age of 34.1 (SEM 1.8) and 32.8 (1.5) years, respectively (p=0.429). The BPF was 0.879 (0.002) among the non-diabetics and 0.851 among the diabetics (p=0.002). The median (50th percentile) BPF was 0.885 among the control subjects. 23 of 26 (88.5%) diabetic subjects had BPF that were lower than the 50th percentile for non-diabetics (p=0.005). The intrarater, interrater, and scan-rescan BPF variability (COV) was 0.31%, 0.34%, and 0.41% and the accuracy against a phantom was 99.1%.

Conclusions:

Cerebral atrophy is common among young, otherwise healthy patients with juvenile-onset insulin-dependent DM. The loss of brain tissue may be an important contributor to cognitive impairment.

Supported By:

Juvenile Diabetes Research Foundation International #1-2000-853 (R. Chan). National Institutes of Health NIH-NINDS 1 K23 NS42379-01 (R. Bakshi).

Category - Neurologic Manifestations of Systemic Disease

SubCategory - Imaging 


[P01.047]

Understanding Pattern of Motor Reorganization Using Functional Resonance Imaging

Jun Wang, Hier Barnet Daniel, Chicago, IL

Objective:

Our purpose is to identify the pattern of motor reorganization in the brain with motor deficit from neurological disorders (e.g stroke, multiple sclerosis (MS) and cerebral palsy (CP)) using functional magnetic resonance imaging (fMRI).

Background:

Cortical recruitment for simple finger movements can change both quantitatively and qualitatively in the sensory-motor cortices of Stroke and MS patients, suggesting that cortical reorganization or unmasking of latent pathways can contribute to functional recovery. Little is know about motor reorganization in CP patients. fMRI offers an opportunity to evaluate and visualize the pattern of motor reorganization and how recovery occurs.

Design/Methods:

Thirty-three subjects were recruited from the Neurology and Rehabilitation Service of the University of Illinois at Chicago with the approval of the Institutional Review Board. Subjects studied included six control subjects, eight stroke subjects, six CP subjects and eleven MS subjects. All the subjects performed the same motor task that utilized a classic block paradigm that involved opening and closing of each hand unilaterally at the rate of once every three secs. We used a whole body 3.0 T scanner (General Electric) to collect functional Echo planar (EPI), standard anatomical (3DSPGR), and FLAIR images. Data analysis was carried out on an Intel PC workstation using AFNI. We analyzed individual and group data on the basis of network ratio (NR).

Results:

For normal control subjects, the classical pattern of motor activation involves the contralateral primary motor and ipsilateral cerebellum. Activation in these two areas accounts for 80% of activation in controls. In contrast, activation in Stroke, MS and CP patients was significantly less than 80% in these two areas, around 60%, also T2- lesion volume is correlated with the activation changes in these two areas, indicating motor reorganization to other brain areas and the impact of the lesion. One-way ANOVA shows the significant difference between the groups (p0.05). Other areas activated included the ipsilateral sensori-motor cortex, the supplementary motor cortex, and the premotor cortex.

Conclusions:

Our observations suggest that changes in activation patterns occur in all neurological disorder (Stroke, MS and CP) patients during motor recovery and may be induced by the extent of the lesion. The results of the study help us design better rehabilitation plans and further our knowledge in understanding the motor network and the mechanisms involved in motor reorganization from neurological disorder.

Supported By:

University of Illinois at Chicago with the approval of the Institutional Review Board

Category - Neural Repair/Rehabilitation

SubCategory - Imaging 


[S51.005]

The Macromolecular Proton Fraction in Post-Mortem MS Brain: A Correlative MT-MRI/Histology Study

Klaus Schmierer, Francesco Scaravilli, Gerard R. Davies, Daniel J. Tozer, Gareth J. Barker, Paul S. Tofts, David H. Miller, London, England, United Kingdom

Objective:

To detect, quantify and correlate myelin content and axonal density in MS brain using quantitative magnetisation transfer (qMT) MRI and digital image analysis (DIA) of post-mortem (PM) specimens.

Background:

Validation of MR techniques for MS research may be achieved by directly investigating pathological changes in brain tissue that underlay signal changes detected by MRI. MT ratio (MTR) is a composite measure derived from more fundamental MR indices like the proton fraction of macromolecules (f) and the bound pool T2 relaxation time (T2B). We explored the potential of these indices to quantitate functionally important pathological components of MS, i.e. myelin content and axonal density, in PM brain using DIA of histological sections which is likewise a quantitative method.

Design/Methods:

Fresh PM brain slices of seven patients with MS were studied. T1-, T2-, PD-weighted, and fast FLAIR scans were acquired along with data sets to produce T1 maps (T1-rt). The qMT sequence consisted of a MT pulse applied before a 2D spoiled gradient echo sequence. Ten separate MT pulse offsets and amplitudes were used to provide data sets from which f and T2B where calculated on a region of interest (ROI) basis. A stereotactic system was used to co-register ROIs in the specimens which were dissected according to their co-ordinates on MRI. Tissue blocks were processed for embedding in paraffin and sections stained (H&E, Luxol-Fast blue, Bielschowskys silver impregnation). A Leica Q500MC image analyser was used for DIA. Transmittance (T) was obtained separately for LFB- and Bielschowsky-stained slides.

Results:

29 ROIs (22 lesions, 12 of which T1-hypointense; 7 NAWM) were investigated. There were 16 demyelinated, and 6 remyelinated lesions. Two lesions were active, 4 chronic active and 16 chronic inactive. MTR was 32.4pu (4.5) and 23.8pu (SD 6.3), T1-rt was 689ms (126) and 958ms (266), f was 13.9pu (2.3) and 10.4pu (2.5), T2B was 17.5s (1.3) and 16.1s (1.2) in NAWM and lesions, respectively. Significant differences between demyelinating and remyelinating lesions were detected for MTR, T1-rt, f, T2B, myelin content (TLFB), and axonal density (TBiel). f correlated strongly with T1-rt, and less strongly with MTR, T2B, and TLFB. T2B correlated with MTR and T1-rt; T1-rt correlated with TLFB.

Conclusions:

The combined use of Q-MT MRI and DIA of histology delivers robust data that provide detailed insights into MS tissue pathology. All quantitative indices (T1-rt, f, T2B, and MTR) were within a range similar to in vivo measurements. Further studies in a larger sample are underway to more fully characterise the pathological correlates of each qMT measure.

Supported By:

The MS NMR Research Unit is supported by the National Multiple Sclerosis Society of Great Britain and Northern Ireland.

Category - MS and Related Diseases

SubCategory - Imaging 


[P06.098]

Interventions To Improve Memory in MS: The Aricept in MS Study (AIMS): 24 Week Data

Lauren B. Krupp, Christopher Christodoulou, Patricia Melville, Leigh E. Elkins, Mohamed Hussein, the AIMS Study Group, Stony Brook, NY

Objective:

To evaluate the efficacy of donepezil (Aricept) for the treatment memory and cognitive dysfunction in patients with multiple sclerosis (MS).

Background:

Donepezil and other cholinesterase inhibitors have been shown to be effective in dementias of the Alzheimers type as well as other condition associated with cognitive impairment such as traumatic brain injury and Parkinsons disease. At least two studies have found that donepezil improved cognitive functioning in MS patients who participated in an open label pilot study. To date no study applying a randomized masked clinical trial design in MS patients selected for mild cognitive deficits has been successfully completed. A recent clinical trial that enrolled severely cognitive impaired MS patients was prematurely terminated due to failure to reach enrollment goals. We present baseline and 24-week treatment data with donepezil in the first successfully completed clinical trial of MS patients with mild to moderate cognitive impairment treated with a cholinesterase inhibitor.

Design/Methods:

This was a prospective, double blind, parallel group, placebo controlled clinical trial of 69 MS patients randomized to treatment with either donepezil 10 mg daily or placebo. After a screening neurological and cognitive evaluation, patients underwent a baseline neuropsychological assessment, which was repeated after 24 weeks of treatment. Clinical, neurological, and safety assessments were performed at 4, 14, and 24 weeks, and as needed for safety assessment or at the time of a relapse. Dosing was begun at 5 mg daily and titrated to 10 mg at week 4. The primary outcome measure was change score on the Selective Reminding Test of verbal memory function. Secondary outcomes were individual and composite change scores on the MS specific Brief Repeatable battery of neuropsychological tests, as well as clinician and patient reported impressions of global change.

Results:

Of the 69 patients enrolled, 35 were randomized to donepezil and 34 to placebo. Adherence to study drug at 24 weeks was 91% for the entire group. The most common causes for stopping therapy were adverse events (gastrointestinal symptoms), which occurred in 2 donepezil and 2 placebo patients. Two patients (1 donepezil and 1 placebo) were lost to follow-up. Data will be presented from group comparisons on primary and secondary outcomes, as well as safety.

Conclusions:

This is the first randomized, double-blinded, placebo controlled clinical trial of donepezil for MS patients selected for cognitive deficits. Patient adherence to the study and investigator adherence to the protocol were excellent. The data collected at 24 weeks provide important clinical information on the potential benefit of cholinesterase inhibition therapy for improving memory and cognition in MS.

Supported By:

National Institutes of Health

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P06.099]

Oral Prednisone Taper Has No Effect on Neurologic Recovery Following Intravenous Methylprednisolone for the Treatment of an MS Relapse

Christina Caon, Wendy Ching, Alexandros Tselis, Robert Lisak, Omar Khan, Detroit, MI

Objective:

To examine the effect of oral prednisone taper (OPT) on neurologic outcome after treatment with intravenous methylprednisolone (IVMP) for a relapse in relapsing-remitting multiple sclerosis (RRMS) patients compared to patients who received no oral prednisone taper after treatment with IVMP.

Background:

MS relapses are often treated with IVMP with or without OPT. Selection of OPT following IVMP depends on several factors including the severity of the relapse and the practicing habits of the neurologist. However, it is not clear if treatment with OPT improves neurologic outcome during recovery from a relapse.

Design/Methods:

This was a retrospective analysis of 285 consecutive relapses in patients with MS who received treatment with IVMP at a dose of one gram a day for five days with or without OPT (which was typically started at 80 mg/day and tapered off over 14 to 21 days). Entry into the study required a diagnosis of CDMS (Poser criteria), patient age between 18-50 years, treatment with disease-modifying therapy for at least six months, and neurologic examination immediately prior to, six, and 12 months after treatment with IVMP.

Results:

285 relapses were confirmed with neurologic examination including worsening on EDSS by 1 or more points in 264 RRMS patients and treated with IVMP with or without OPT. Mean age and disease duration (DD) were 35.6 years and 5.6 years. 179 patients were women. Mean baseline EDSS (n=264) recorded 3 to 6 months prior to relapse was 2.29 (range 1.5 to 3.5) and at the time of confirmation of relapse was 4.33. Mean EDSS (n=264) was 3.21 and 3.17 at 6 and 12 months, respectively, after treatment with IVMP. To examine the effect of OPT, patients were divided into two groups. 152 (57.6%) of 264 patients received OPT following IVMP for the treatment of 171 (60%) of 285 relapses. Mean age and DD were 37.4 and 5.9 years. EDSS at baseline, relapse confirmation, and at 6 and 12 months after treatment with IVMP was 2.37, 4.42, 3.31, and 3.24, respectively. In the group receiving no OPT (n=112 patients with 114 relapses), mean age and DD were 35.4 and 5.3 years, respectively. Mean EDSS at baseline, relapse confirmation, and at 6 and 12 months after treatment with IVMP was 2.28, 4.29, 3.28, and 3.14, respectively. There was no difference in the mean EDSS between the two groups at any time point before or after treatment with IVMP (p0.05). However, 12 months after treatment, there was a significant increase in the mean EDSS in both groups compared to baseline (p0.05).

Conclusions:

Oral prednisone taper after treatment with IVMP for an MS relapse appears to have no effect on neurologic disability after one year of follow up. Our study suggests that relapses are a significant factor in accumulating neurologic disability at lower levels of EDSS irrespective of the treatment regimen used for treating relapses.

Supported By:

Wayne State University Neuroscience Program

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P06.108]

Effect of Neutralizing Antibodies (NAbs) on the Clinical Efficacy of Interferon -1a: Results from the European Dose-Comparison Study

Michel Clanet, Toulouse, France, Ludwig Kappos, Basel, Switzerland, Qunming Dong, Mariska F. Kooijmans-Coutinho, Cambridge, MA, European Interferon Beta-1a (Avonex) Dose-Comparison Study Investigators

Objective:

To determine the incidence and clinical significance of neutralizing antibody (NAb) formation in relapsing multiple sclerosis (MS) patients who participated in the European Interferon -1a (IFN-1a; Avonex) Dose-Comparison Study.

Background:

The use of IFN has been associated with the formation of NAbs. NAbs block the binding of IFN to its target receptor and some studies have indicated that the development of NAbs reduces the therapeutic efficacy of IFN.

Design/Methods:

In this multicenter, double-blind study, patients were randomized to receive IM IFN-1a (Avonex) 30 mcg or 60 mcg once weekly for up to 4 years. Serum samples obtained at baseline and every 3 months were screened for the presence of IFN binding antibodies by enzyme-linked immunosorbent assay (ELISA). Sero-positive patients by ELISA were screened for the presence of neutralizing antibodies using a sensitive antiviral cytopathic effect assay. Patients were considered to be positive for NAbs if they had titers 20 LU/mL on at least one sample. Only patients who tested negative at baseline (titer = 0) were included in the analysis.

Results:

Overall, a lower proportion of patients in the 30-mcg group (9/400 patients [2.3%]) than in the 60-mcg group (23/395 patients [5.8%]) had at least one NAb titer 20 LU/mL (p = 0.011). Patients did not begin to become NAb-positive until 6 months after treatment initiation. The mean (SD) time to appearance of NAbs was 15.06 (8.76) months. An analysis of the effects of NAbs on clinical outcomes will be presented.

Conclusions:

The incidence of NAbs during therapy with IM IFN-1a was low, and consistent with previous findings showing lower immunogenicity compared with other IFN formulations.

Supported By:

Biogen, Inc.

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[P06.124]

Aspartoacylase, the Hydrolytic Enzyme for N-Acetylaspartate, Is an Oligodendrocyte Protein: Implications for Myelination

James Garbern, Kiran Jjajj, Geethani Jayasundera, Detroit, MI, Rueben Matalon, Galveston, TX

Objective:

To demonstrate which cells in the central nervous system express aspartoacylase (aspa).

Background:

N-acetyl aspartate (NAA) is an abundant compound in the mammalian central nervous system, yet its function(s) and regulation are not understood. NAA is synthesized predominantly in neurons and is used as a clinical marker for neuronal integrity since it can be measured using magnetic resonance spectroscopy.

Although NAA is synthesized in neurons, we propose that NAA is essential for myelination. Indirect evidence for this includes: 1) expression of aspartate-N-acetyltansferase (ANAT), the NAA biosynthetic enzyme, rises in parallel with classical myelin proteins, 2) expression of aspartoacylase (aspa), the enzyme that hydrolyzes NAA, parallels that of classical myelin proteins, 3) radiolabeled NAA can be incorporated into myelin lipids, 4) mutations in the aspa gene cause Canavan disease, a fatal infantile white matter disease. Together, these observations suggest that NAA, although made neuronally, is transferred to oligodendrocytes, which can then utilize the compound as a precursor for myelin lipid biosynthesis. A critical test of this hypothesis is to identify which cells in the central nervous system express aspa.

Design/Methods:

Antisera directed against a region of aspa conserved between rodents and man were generated in rabbits and used for immunocytochemistry. In situ hybridization was performed according to standard protocols using digoxigenin-labeled riboprobes to detect aspa mRNA.

Results:

Our antiserum against aspa: 1) specifically detects a brain protein of predicted mass, and 2) stains oligodendrocytes in wild type, but not aspa deficient mice. We have also studied aspa gene expression and have found that it resides in oligodendrocytes, and that it furthermore depends upon axonal contact.

Conclusions:

Aspartoacylase expression behaves biologically like that of classical myelin proteins such as proteolipid protein. Our findings provide strong support for an important glial-axonal interaction that is fundamental to myelination. We propose that NAA is a critical, axonally supplied substrate for myelin lipid synthesis.

Supported By:

National Multiple Sclerosis Society (RG3204A)

Category - MS and Related Diseases

SubCategory - Basic Science 


[P06.024]

Childhood Mesial Temporal Sclerosis

Yu-tze Ng, Roger Bird, Dawn C. Duane, Phoenix, AZ, Amy L. McGregor, James W. Wheless, Houston, TX

Objective:

To study the prevalence and clinical characteristics of children with mesial temporal sclerosis (MTS) as diagnosed by magnetic resonance imaging (MRI).

Background:

MTS has not been well-studied in children. MTS is believed to be uncommon and not a major cause of epilepsy in children, although no studies have been performed on its childhood prevalence and incidence.

Design/Methods:

All brain MRI reports of children less than 14 years of age were reviewed from two tertiary institutions. A 52-month period (1997 to 2002) from one institution and a 37-month period (1999 to 2002) from the other were reviewed. All reports of definite or possible MTS were noted. These patients MRI scans were then reviewed by a pediatric neurologist (YN) and another pediatric neurologist (JW) or pediatric neuroradiologist (RB) to confirm the MRI diagnostic criteria of MTS. The charts of the patients who satisfied these criteria were then reviewed in detail.

Results:

3100 brain MRI reports were reviewed. 26 reports of MTS were found. 24 of the 26 films satisfied the criteria of MTS by MRI after the films were reviewed. The prevalence amongst all pediatric brain MRI studies was 0.78%. The 24 children consisted of 14 males. The average age was 6.9 years at time of initial MRI diagnosis of MTS. 12 patients had MTS on the right, ten on the left and two had bilateral involvement. 23 of the 24 patients had been imaged utilizing a specific epilepsy protocol. 12 patients had other MRI pathology including, periventricular leukomalacia (PVL), gray matter heterotopia and schizencephaly. All 24 children presented with seizures i.e. there were no incidental findings of MTS. The patients seizure types were available in 22 patients; consisting mainly of complex partial (n = 15), generalized tonic-clonic (n = 5) and two seizure types in two patients. Only four patients had a history of febrile seizures (16.7%). At the latest follow-up, histopathology results were available on six patients. This showed MTS and surrounding gliosis and/or dysplasia in five patients and isolated gliosis in one. Three patients had a likely cause of their MTS; due to encephalitis in one (bilateral MTS) and head trauma in two patients. Of the 20 available perinatal histories, 16 were normal and four were preterm or abnormal. Associated comorbidities were seen in 14 patients and included, developmental delay, behavioural problems, Lennox-Gastaut and Gorlin syndromes.

Conclusions:

MTS is an uncommon finding in children. Asymptomatic MTS or MTS not presenting as seizures did not occur in our series. Febrile seizures occurred in only four of the 24 children, so unlike MTS in adults, this may be a low association. Histopathology in six children confirmed MTS in five. Associated comorbidities and/or other MRI abnormalities occurred in about half the patients. In children, MTS often occurs in the setting of multiple pathology, has associated comorbidities, seizure types other than complex partial and can be reliably detected by MRI if an epilepsy protocol is used.

Category - Epilepsy

SubCategory - Imaging 


[P03.109]

Induction of Experimental Autoimmune Encephalomyelitis in IL-12 Receptor-Beta2-Deficient Mice: IL-12 Responsiveness Is Not Required in the Pathogenesis of Inflammatory Demyelination in the Central Nervous System

A. M. Rostami, Bruno Gran, J. F. Li, S. Yu, G. X. Zhang, Philadelphia, PA

Objective:

To study the role of IL-12 receptor 2 in the pathogenesis of experimental autoimmune encephalomyelitis (EAE), a Th1 cell-mediated autoimmune disorder of the central nervous system (CNS).

Background:

IL-12 exerts its effects through a receptor (IL-12R) composed of two chains, IL-12R1 and IL-12R2. IL-12 is suggested to be crucial for the development of EAE. However, little is known thus far about the role of IL-12 receptors in the pathogenesis of EAE. Although in vitro studies indicate that the expression of IL-12R2 correlates with the differentiation of Th1 type myelin-reactive cells, the role of IL-12R2 in the induction of EAE has not been investigated.

Design/Methods:

Eight- to 10-week-old (B6 x 129) mice homozygous for IL-12Rb2 mutation and their wild type controls were injected subcutaneously with 300 ug MOG35-55 in CFA. 75 ng pertussis toxin was given i.v. on days 0 and 2 post immunization (p.i.). Clinical EAE was monitored daily. On day 21 p.i, mice were extensively perfused, and following parameters were determined. 1) Spinal cords histology; 2) MNCs in the CNS by flow cytometry; 3) Proliferation and cytokine production induced by MOG; 4) Anti-MOG and anti-PLP IgG, IgG1 and IgG2a in sera; 5) CD4+ T cell apoptosis by TUNEL. 6) IL-18Ra expression and IL-18 production; and 7) IL-12p40, IL-12p35, and IL-23p19 mRNA expression in splenocytes and brain tissues by real-time quantitative PCR.

Results:

Contrary to the expectation that the absence of IL-12R2 would protect from EAE, we found that IL-12R2-deficient mice developed earlier and more severe disease, with extensive demyelination and CNS inflammation. The inflammatory cells were mainly composed of CD4+ T cells, monocyte/macrophages, and dendritic cells. IL-12R2-deficient mice exhibited significantly increased autoantigen-induced proliferative response and production of TNF-a, GM-CSF, and nitric oxide. In addition, we found significantly increased levels of IL-18Ra expression on CD4+ T cells, IL-18 production and IL23p19 mRNA expression in spleen cells from immunized IL-12R2-/- mice compared with wild type mice.

Conclusions:

IL-12 responsiveness is not required in the pathogenesis of inflammatory demyelination in the CNS. In the absence of IL-12R2, increased biological activity of IL-18 and IL-23 may be responsible for increased severity of EAE.

Supported By:

This work was supported by grants from the National Institutes of Health and the National Multiple Sclerosis Society.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[S47.006]

Potentials of the Subthalamic Nucleus and Nucleus Ventrointermedius of the Thalamus Preceding Self-Paced and Externally Cued Movements

Guillermo Paradiso, Danny Cunic, Anthony E. Lang, Andrs M. Lozano, Robert Chen, Toronto, ON, Canada

Objective:

To assess the role of the subthalamic nucleus (STN) and the nucleus ventrointermedius of the thalamus (Vim) in the preparation of internally and externally triggered movements.

Background:

Akinesia in Parkinsons disease may be related to abnormalities in movement preparation. Premotor activity in both self-paced and externally triggered movements are mediated by the primary motor cortex and the supplementary motor area. However, these tasks may involve different subcortical circuits. The STN is part of the cortico-basal ganglia-thalamo-cortical loop, whereas the Vim is involved in the cerebello-dentato-thalamocortical circuit. In PD patients the CNV is more affected than the BP. We previously showed that STN and Vim are involved in self-paced movements, but their role in the preparation of externally cued movements is not known.

Design/Methods:

We studied 10 patients with surgically implanted quadripolar electrodes for therapeutic deep brain stimulation (DBS). The stereotaxic target was the STN in 6 Parkinsons disease (PD) patients and the Vim in 4 patients with tremor (3 essential tremor, one multiple sclerosis). We recorded simultaneously from scalp and DBS electrodes during self-paced movements and after an externally cued paradigm consisting of a warning signal followed by an imperative go or no-go signal.

Results:

With self paced movement, all patients showed scalp Bereitschaftspotential (BP), as well as STN and Vim premovement potentials. With the externally triggered paradigm, scalp contingent negative variation (CNV) was present in all patients and every STN recording showed premovement potentials. In contrast, no activity was recorded from Vim contacts prior to the externally triggered movements. In the STN, the maximum amplitude of potentials preceding self-paced and externally triggered movements occurred in different contacts.

Conclusions:

These findings suggest that preparation for self-paced and externally cued activity are mediated by different subcortical circuits. Self-paced movements involve both the cortico-basal ganglia-thalamocortical and the cerebello-dentato-thalamo-cortical pathways whereas for externally triggered movement the cerebello-dentato-thalamo-cortical circuit does not appear to be involved. Greater impairment of CNV than BP in PD patients is consistent with our findings since the cortico-basal ganglia-thalamocortical pathway is more likely to be impaired than the cerebello-dentato-thalamocortical circuit in PD.

Category - Clinical Neurophysiology

SubCategory - Basic Science 


[P04.088]

Cerebral MRI T1 Histograms Efficiently Summarize Total Disease Burden in MS Brain

William D. Rooney, Upton, NY, Patricia K. Coyle, Stony Brook, NY, Xin Li, Upton, NY, Maria Taylor, Stony Brook, NY, Frank W. Telang, Charles S. Springer, Jr., Upton, NY

Objective:

To investigate the utility of MRI T1 histogram analysis to compare brain tissue properties between controls and multiple sclerosis subjects.

Background:

Water proton MRI T1 mapping offers a precise way to characterize brain tissue in vivo and has potential for objective evaluation of macroscopic and microscopic disease burden in MS. Water proton T1 values differ between gray matter (GM), white matter (WM) and CSF water. These differences give T1 histograms definable structure, and thus can be used to generate naturally segmented brain images. In MS, brain T1 values are often increased, markedly in lesions, and slightly in normal appearing white matter (NAWM). Macroscopic pathologies, such as atrophy and lesion development, are expected to decrease the WM volume fraction. A subtle increase in water to macromolecule ratio is a well known characteristic of MS NAWM, and could serve as a measure of microscopic disease. This is expected to be manifest as a shift of the WM peak position to a larger T1 value. Histogram analysis provides an efficient method to summarize large data sets, and has been useful when applied to whole brain magnetization transfer ratio data in defining disease burden in MS.

Design/Methods:

Twelve relapsing-remitting or secondary progressive MS subjects [mean age (SD), 38 (8) years] and nineteen healthy controls [37 (12) years] were studied on a 4.0 T MRI instrument. Quantitative T1 maps were collected using a Look-Locker multislice inversion recovery pulse sequence. Twenty-six axial slices were collected with 1 mm in-plane resolution and a 3 mm slice thickness. The WM and GM peaks were fitted by Gaussian functions to obtain peak positions, and fixed integration limits were used to obtain WM, GM, and CSF areas. Normalized volume fractions were obtained by dividing the integrated areas by the total histogram integral. Non-parametric statistics were used and the unit of analysis was the subject.

Results:

The average WM peak position was shifted to a larger T1 value for the MS group [1086 ( 62) msec] compared to the control group [1026 ( 27) msec; P=0.002]. The average WM volume fraction was significantly reduced in MS [0.315 (0.049)] compared to the value for the control group [0.387 (0.037) P=0.001]. The average CSF volume fraction was increased in MS [0.166 (0.049)] compared to the control value [0.101 (0.050); P=0.001). There was no significant difference in the GM peak position or volume fraction.

Conclusions:

Display of MRI T1 data in histogram format provides an efficient summary of overall brain characteristics. For MS, it is the normalized WM volume fraction and the WM peak position that are of particular interest. Taken together, these two measures, which can be readily obtained and easily analyzed, represent an efficient method to characterize total MS disease burden. [NMSS RG 3168A1, NIH RO1 NS40801, DOE(KP-14-01-03)]

Category - MS and Related Diseases

SubCategory - Imaging 


[P04.003]

A Study of B Cell Clonal Expansion in the Cerebrospinal Fluid of Patients with Clinically Isolated Syndrome Suggestive of MS. A Diagnostic Application

Yufen Qin, Irvine, CA, Pierre Duquette, Montreal, QC, Canada, Michael Olek, Reng-Rong Da, Yiping Zhang, Stanley van den Noort, Irvine, CA

Objective:

To evaluate the potential diagnostic application of B cell clonal expansion in the cerebrospinal fluid of patients with clinically isolated syndrome suggestive of MS.

Background:

Intrathecal IgG oligoclonal bands (OCB) and magnetic resonance imaging (MRI) has long time been the most important criteria for MS diagnosis. However, B cells, antibody producing plasma cells are also present in chronic and active MS plaques/lesions. All implicates the B cell and B cell secreted antibodies are directly involved in the pathogenesis of MS. We have shown the B cell clonal expansion in CSF of MS patients with or without OCBs, indicating B cell analysis is a sensitive technique and may have a diagnostic value for MS

Design/Methods:

Cerebrospinal fluid cells from thirty patients with clinically isolated syndrome suggestive of MS (CIS) were analyzed to study B cell-mediated humoral immunity using two methods: 1) RT-PCR for the amplification of immunoglobulin variable heavy chain (Ig-VH) genes; 2) gene sequencing for the detection of B cell clonality and VH gene somatic hypermutation.

Results:

Seventeen out of thirty CIS patients (57%) showed an intrathecal B cell clonal expansion. Twelve of these patients (40%) showed had three or more MRI lesions, and nine (30%) showed positive OCBs. The intrathecal B cell clonality analysis gave a higher sensitivity overall. Of the seventeen patients with intrathecal B cell clonal expansion, only twelve had more than three MRI lesions in their head, three had one spinal lesion, two had normal MRI; nine showed a positive OCBs and eleven showed a negative OCBs.

After 6 months to 5 years follow-up, 14 of 17 (82%) CIS patients with clonal or polyclonal B cell expansion converted to clinically definite MS (CDMS). Of these 14 cases, 9 have more than 3 MRI lesions including 6 with positive OCBs and 3 with negative OCBs; 2 have 1 MRI lesion all with positive OCBs; 2 had normal MRI and with negative OCBs. All thirteen patients without detectable Ig VH gene did not show further neurological symptoms.

Conclusions:

Our findings indicate that the B cell clonal expansion in the CSF is an early immune-mediated inflammatory event. These techniques provide a significant alternative to detect abnormalities in CIS patients who have few or no MRI lesions and/or are without OCBs. It also provides an additional tool for the investigation of patients presenting with a CIS and could help in establishing their prognosis.

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 


[P06.121]

High Resolution Magnetization Transfer Profile MRI of the Dorsal Column in Adrenomyeloneuropathy

Seth Smith, Ali Fatemi, Gerald Raymond, Peter van Zijl, Hugo Moser, Xavier Golay, Baltimore, MD

Objective:

To develop a Magnetic Resonance Imaging (MRI) method for in vivo assessment of white matter abnormalities of the cervical spine in humans.

Background:

Spinal cord pathology, such as demyelination and axonal loss, is a common feature in a number of diseases of the central nervous system, for instance, multiple sclerosis. However, the small diameter and the signal-contamination of the surrounding bone tissue limit the in vivo visualization and quantification of spinal cord white matter in humans. Development of methods to quantify spinal cord pathology establishes a correlation with sensitive measures of neurological function and may provide an innovative assessment of the benefits of therapeutic agents.

Design/Methods:

MR examinations were performed on six healthy adults (mean age 31y) and three patients with Adrenomyeloneuropathy (mean age 27y) who had severe sensory loss in the distal extremities. All studies were performed on a 1.5-T Philips Intera-NT system (Philips Medical Systems, Best, The Netherlands). Magnetization Transfer (MT) sequences were obtained using a 3D-Gradient Echo (GRE) acquisition technique (TR / TE / = 50 ms / 12 ms / 7), with a sinc-shaped MT pre-pulse of 15 ms, and 10 RF offsets logarithmically sampled between 1 and 60 kHz plus a reference scan (0 MT-prepulse). Other parameters were: FOV = 225x225x48 mm, matrix = 512x512x32, and a total scan time 37 min. The highest slice was acquired at the level of foramen magnum. From the MT-weighted images, the Magnetization Transfer Profile (MTP) was defined as the integral of the MT() curve calculated between = 1 and 60kHz normalized by the average CSF value in the reference scan. The dorsal column was then carefully selected manually in every slice using house-designed software, and the average MTP was calculated for the selected region of interest.

Results:

The processed MR images showed a sharp separation between the butterfly shaped gray matter and the white matter columns in the cervical cord. All three AMN patients showed an increased signal intensity concomitantly with a decreased segregation between grey and white matter in the processed images. The mean MTP signal of the dorsal column was 54.0 kHz (SD 3.1) while the mean MTP signal of the AMN patients (67.1, 68.4, and 68.4 kHz) was more than four standard deviations higher than the controls.

Conclusions:

We describe a new MR imaging and processing technique for visualization and quantitative assessment of white matter columns in the cervical spine within a reasonable clinical scan time. Using this methodology we were able to detect white matter abnormalities in the dorsal columns of patients with adrenomyeloneuropathy. This method can serve as a non-invasive tool for in vivo structural analysis of the spinal cord and can be applied to various CNS disorders.

Supported By:

Study funded by JHU GCRC (M01 RR 00052) and NIH/NIBIB (EB00991-01)

Category - MS and Related Diseases

SubCategory - Imaging 


[P01.099]

Intravenous Immunoglobulin Utilization in the Home Infusion Setting

Vinay Chaudhry, Baltimore, MD

Objective:

To assess intravenous immune globulin (IVIG) utilization in the home infusion setting and compare it with evidence based model guidelines for IVIG use.

Background:

A number of IVIG products have received marketing approval from the Food and Drug Administration (FDA) for primary humoral immunodeficiency, idiopathic thrombocytopenic purpura, chronic lymphocytic leukemia, HIV infection in children, bone marrow transplant, and Kawasaki syndrome. However, off-label (not specified in the FDA-approved label) use of IVIG appears to be more common and continues to expand despite lack of properly designed clinical trials. The frequency in which this medication is given in the home environment is increasing.

Design/Methods:

Five-year data on the use of IVIG were collected from 3 home infusion companies for 6835 patients (3558M; 3277F; Mean Age 40). Recommendations from consensus guidelines published by University Health System Consortium (JAMA 1995;21;273:1865-70) were used to categorize patients who received IVIG into four groups: I- labelled uses; II- off-label, recommended; III- off-label recommended as alternative; and IV- off-label, not recommended.

Results:

Overall, 1325 (19%) received IVIG for labelled indications, 5266 (77%) for off-label indications, and for 244 (4%) the IVIG therapy was not defined. A total of 2141 (31%) were for neurological and 4694 (69%) were for non-neurological indications. Amongst the neurological indications, there was no patient in group I; Group II (GBS, CIDP, MMN) patients numbered 1257 (59%); Group III (myasthenia gravis, Lambert-Eaton myasthenic syndrome, polymyositis, dermatomyositis, stiff person syndrome, multiple sclerosis) 463 (22%); and Group IV (motor neuron disease, other neuropathies/radiculopathis, inclusion body myositis) 299 (14%). The different brands used were gammagard (32%), polygam (20%), Gammaimmune (18%) Panglobulin (8%), Gammar-P (6%), Sandoblobulin-ZLB (2%), Venoglobulin (1%), and others (13%). The adverse reaction rate was obtainable for13988 infusions and was 0.9%, was rate related and consisted of headache, mild fever, flushing, rash, chills, nausea, myalgias, fatigue, back pain, and chest tightness.

Conclusions:

The above data show that IVIG is most often used for off-label indications in the home infusion setting. Even though IVIG is relatively safe, indiscriminate use of IVIG should be discouraged given the high cost, limited availability, and potential for serious adverse reactions.

References:
1. Wiles CM et al. IVIG in neurological disease: a specialist review. J Neurol Neurosurg Psychiatry 2002;72:440-8
2. Bril, V. et al. IGIV in neurology--evidence and recommendations. Can J Neurol Sci 1999;26:139-52
3. Dalakas MC. IVIG in the treatment of autoimmune neuromuscular diseases: present status and practical therapeutic guidelines. Muscle Nerve 1999;22:1479-97

Acknowledgement:

The author wishes to thank Coram Healthcare, Denver, CO; IgG America, Millersville, MD; and Crescent Healthcare, Inc., Anaheim, CA for sharing the above-presented data.

Category - Neuroepidemiology/Health Services and Outcomes Research

SubCategory - Therapeutics 


[P06.118]

A Single-Blinded, Randomized, Controlled Trial of Acupuncture for Symptomatic Therapy of Bladder Dysfunction in Mutlitple Sclerosis

Sandra Brunham, Joel Oger, Mary Watterson, Vancouver, BC, Canada, Yue Wang, Vancouver, BC, Acupuncture Group Tzu Chi Institute, Vancouver, Canada

Objective:

To compare effest of acupuncture versus best MS clinic practice, on bladder function in MS using a single blinded, randomized, controlled design.

Background:

We have shown (AAN 1999) that a large number of MS patients undergo acupuncture and report benefit.With a team of TCM (Traditional Chinese Medicine) practitioners we developed a protocol, meeting the criteria of evidence based medicine as well as TCM principles.

Design/Methods:

41 CDMS with bladder symptoms and a post-void residual (PVR) greater than 50cc. were included. A factorial design assessed 2 active treatments in 4 randomized groups: 1) no add-on , 2) best bladder care added by an MS clinic neurologist; 3) acupuncture added; 4) both added. Two acupuncturists, blinded to group assignment, made a TCM diagnosis for all subjects pre and post study. Acupuncture was pre-determined and standardized using TCM principles. Acupuncture was 45 min. twice weekly for 16 weeks. The non-acupuncture groups attended similarly but performed a battery of outcome measures. Assessment was performed blindly pre and post-study. PVR was the primary endpoint.Secondary outcomes included: frequency and urgency of urination, SF36 and self assessment of incontinence. Three blinded TCM practitioners ranked differences in pre vs post study according to TCM global assessment.

Results:

The 41 subjects were recruited had usual demographics except female /male ratio at 9:1 but similar across groups. EDSS 3.5, duration of disease was 12 years, 24 patients were relapsing, 13 were SP and 1 was PP. One subject withdrew due to painful needling. Four subjects withdrew from the non-acupuncture groups. Adverse events: spaticity increased in medical treatment (p=.05) and sexual satisfaction declined with acupuncture (p=.07). PVR improved for all 4 groups (p=0.05) regardless of intervention.Bbeneficial effects were found in the acupuncture groups for bladder urgency (p=0.05) and bladder diary (p0.001). Results of treatment by TCM physicians indicated that medical treatment was beneficial only in the absence of acupuncture, and conversely, that acupuncture was beneficial only in the absence of medical treatment (p=0.05).All groups had significant improvement in the Physical and Mental Health composite scores of the SF36 (p.001).

Conclusions:

The first report of acupuncture effect on bladder dysfunction in MS. Placebo effect was strong for all the patients resulting in improved PVR, Quality of life. Acupuncture appears to provide benefit for bladder urgency and decreased incontinence episodes. A TCM ranking developed for this feasibility study appears to be sensitive to TCM treatments and could be clarified in a larger study. Acupuncture costed $1,600.00 per patient; cost benefit ratio appears low.

Supported By:

Multiple Sclerosis Association of America (Canada)

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[S25.004]

Blockade of the PD1 T Cell Costimulatory Pathway Exacerbates Experimental Autoimmune Encephalomyelitis in WT and CD28 Deficient Mice

Tanuja Chitnis, Alan D. Salama, Boston, MA, Hisaya Akiba, Hideo Yagita, Tokyo, Japan, Mohamed H. Sayegh, Samia J. Khoury, Boston, MA

Objective:

To examine the effects of the PD1 pathway on the regulation of disease induction in experimental autoimmune encephalomyelitis (EAE).

Background:

Negative costimulatory regulators are found on the surface of T cells and play an important role in limiting the immune response. CTLA4 is the prototypic molecule in this class; however, another novel negative regulatory molecule has recently been described. Programmed death-1 (PD1) is found on activated CD4+ and CD8+ T cells. PD1 binds to two known ligands PDL1 and PDL2, which are found on antigen presenting cells (APC) and on parenchymal cells. Ligation of the PD1 receptor leads to diminished IL-2 production. PD1 deficient animals develop diverse autoimmune conditions. This pathway may play a central role in the maintenance of peripheral tolerance towards autoantigens. We used a blocking antibody to PD1 was to investigate whether this pathway plays a role in the regulation of EAE.

Design/Methods:

We used CD28 deficient mice on a C57BL/6 background and wild-type C57BL/6 mice. EAE was induced via immunization with peptide 35-55 of myelin oligodendrocyte glycoprotein (MOGp35-55). Anti-PD1 antibody or control Ig was administered in vivo to mice postimmunization. Clinical disease was assessed daily. The frequency of cytokine producing primed T cells was measured by ELISPOT assay. Expression of PD1 and infiltrates in the CNS was examined using immunohistology.

Results:

PD1 expression in the CNS was minimal in nave wild-type mice, and during early EAE (days 0-17). However, expression sharply increased between days 21-30 coinciding with the peak of clinical disease. Wild-type mice treated with anti-PD1 antibody experienced a more severe form of EAE than those treated with control Ig, with an earlier day of onset and a higher mean maximal disease grade (2.941.3 versus 1.751.0 in the control group). CD28 deficient mice are normally resistant to disease induction, however following treatment with anti-PD1 antibody CD28 deficient mice developed a severe form of EAE (mean maximal disease grade of 2.1 versus 0.42 in the control group). Treatment of both wild-type and CD28 deficient mice resulted in increased frequencies of IFN--producing MOGp35-55 reactive lymphocytes compared with control mice. Histological examination of spinal cord sections from both wild-type and CD28 deficient mice treated with anti-PD1 demonstrated increased cellular infiltrates. There was an excess of CD8 cells in the CNS of mice treated with PD1 blockade compared with controls.

Conclusions:

Blockade of the PD1 pathway exacerbates the clinical course of EAE even in the absence of CD28 costimulatory signals. The PD1 pathway may serve as an important regulator of peripheral tolerance for both CD28 and CD28-independently activated T cells. Manipulation of the PD1 pathway may be an important target in the treatment of multiple sclerosis.

Supported By:

Nancy Davis Center Without Walls (TC-Young Investigator Award)

Category - MS and Related Diseases

SubCategory - MS: Animal Models 


[P04.097]

Serial Studies of Fiber Tracts Affected by MS Lesions Using Diffusion Tensor Imaging

Roland G. Henry, Jeffrey Berman, Daniel Pelletier, San Francisco, CA

Objective:

To characterize the serial changes on specific white matter tracts associated with acute and chronic MS lesions using diffusion tensor imaging fiber tracking. In particular, to record serial changes in diffusion parameters in specific white matter tracts encompassing brain lesions.

Background:

Diffusion tensor imaging (DTI) fiber tracking allows delineation of specific white matter tracts. The effects of MS lesions on these tracks can be investigated in order to determine possible distal effects that may be associated with normal appearing white matter (NAWM) abnormalities and to characterize the changes in the tract near the lesion. DTI has shown changes in the NAWM in MS patients and can be used to identify structural changes like demyelination and/or wallerian degeneration indicated by diffusion parallel and perpendicular to the fiber tracts.

Design/Methods:

Ten patients who presented with clinically isolated syndromes (CIS) of neurologically dysfunction and brain MRI lesions are being studied serially using MRI. The MRI includes T1-weighted, T2-weighted and hi-resolution diffusion tensor imaging. Specific fiber tracts encompassing either enhancing or non-enhancing lesions were identified and delineated using DTI fiber tracking. The tracks were overlayed on aligned serial diffusion images. Diffusion parameters including ADC, anisotropy, and eigenvalues were calculated in the tracks and compared with the follow-up exams.

Results:

We have preliminary results on the first time point of serial studies of 3 corticospinal tracts and an optical tract. The data are for the first follow-up time point at 6 - 8 weeks after the baseline scan at presentation. In 3 cases non-enhancing lesions were found at baseline and in one case an enhancing lesion was found at baseline. All non-enhancing lesions on corticospinal tracts had increased ADC and decreased anisotropy compared to normal tissue and showed no significant change at follow-up. The chronic lesion on the corticospinal tract was non-enhancing at follow-up and exhibited decreased ADC and increased anisotropy relative to the baseline values. For the acute lesion, diffusion transverse to the tracts increased in all abnormal MRI regions. However, diffusion parallel to the tract decreased only the the peripheral inflammatory regions and did not change in the core of the lesion.

Conclusions:

Diffusion tensor imaging fiber tracking allows delineation of specific fiber tracts that can be investigated for changes due to MS lesions. Our preliminary data indicates that while there are no early changes in diffusion parameters associated with non-enhancing lesions, acute lesions can be characterized in terms of regions of peripheral inflammation that return towards normal and a lesion core that may lead to chronic demelination. This methodology can be used to follow the evolution and possible degenerative effects of MS lesions on specific white matter tracts in the brain.

Supported By:

National Multiple Sclerosis Society RG3240A1

Category - MS and Related Diseases

SubCategory - Imaging 


[P03.108]

Efficient Induction of Monophasic Experimental Autoimmune Encephalomyelitis (EAE) in CXCR3 Deficient Mice

Masaru Matsui, Kyoto, Japan, Hirohito Kobayashi, Cleveland, OH, Bao Lu, Boston, MA, Jennifer Weaver, Tao He, Robert L. Fairchild, Cleveland, OH, Craig Gerard, Boston, MA, Richard M. Ransohoff, Cleveland, OH

Objective:

To study the role of CXCR3 in Experimental Autoimmune Encephalomyelitis (EAE)

Background:

T-cell recruitment and retention in the central nervous system has been implicated the pathogenesis of multiple sclerosis (MS) and its animal models, including EAE. CXC chemokine receptor type3 (CXCR3) was expressed by approximately 90% of all CSF CD4+ T-cells in MS patients. Virtually all lymphocytic cells in the perivascular infiltrates found in MS brain sections were CXCR3-positive. One CXCR3 ligand, IP-10, was expressed by astrocytes in MS and EAE lesions. We proposed that CXCR3 might be required for retention of T-cells in the CNS compartment during inflammation.

Design/Methods:

Our hypothesis was examined by comparing the course of monophasic EAE in male mice that expressed or lacked CXCR3, which are not strict orthologs in humans and mice. Acute-monophasic EAE was induced by immunization with the peptide MOG35-55 in CXCR3+ male mice and CXCR3- male mice. We evaluated clinical severity, histological inflammation, chemokine and chemokine receptors by RNase protection assay and T-cell subsets by flow cytometry.

Results:

We induced acute-monophasic EAE in CXCR3+ mice and CXCR3- mice. Mean disease scores (3.30.6 in CXCR3+ mice and 3.40.5 in CXCR3- mice), day of disease onset (9.92.5 in CXCR3+mice and 9.31.5 in CXCR3-mice), and peak score (4.10.4 in CXCR3+ mice and 4.30.5 in CXCR3- mice) in the two groups were not different. CNS cell infiltrates were similar in CXCR3+ and CXCR3- mice. In RNase protection assays, CCR1, CCR2 and CCR5 mRNAs were upregulated in EAE spinal cords, with no difference between wild type and knockout mice. To evaluate the efficacy of recruiting either CD4+ or CD8+ T-cells to the CNS, we analyzed these populations in CNS-infiltrating cells at the peak of EAE, using paired CXCR3+ and CXCR3- mice in each experiment. The percentage of spinal cord CD4+ and CD8+ T-cells varied but there was no systematic difference between CXCR3+ mice and CXCR3- mice.

Conclusions:

These findings indicate that T-cell retention in the CNS can occur in the absence of CXCR3 signaling. Our current efforts focus on discriminating how the response of CXCR3 to lymphoid chemokine CCL21 (observed in mice but not humans) affects its function in EAE and how these results might be applied to understanding MS.

Supported By:

This study was supported by the National Institutes of Health (3RO1 NS32151 to RMR).

Category - MS and Related Diseases

SubCategory - MS: Animal Models 


[P04.086]

Quantification of Global Brain N-Acetylaspartate Concentration in Relapsing-Remitting MS: Evidence for Different Clinical Cohorts

Oded Gonen, New York, NY, Clyde M. Markowitz, Philadelphia, PA, Belinda S. Li, James S. Babb, Robert I. Grossman, New York, NY

Objective:

To quantify the rate of concentration decline of the neuronal cell marker N-acetylaspartate (NAA) in the entire brain of relapsing-remitting (RR) multiple sclerosis (MS) patients in relation to healthy, age matched controls.

Background:

MS, the leading cause of non-traumatic neurological disability in young and middle-aged adults, is the most common demyelinating disease of the central nervous system, affecting over 2 million people worldwide. Roughly 85% of its, two thirds of whom are women, experience acute symptoms followed by partial or complete remission, entering the RR stage. These cycles continue, leading to accumulating clinical disability from incomplete remissions. Unfortunately, there are currently no reliable prognostic indices to predict future disease course. Laboratory markers , such as oligoclonal bands, have been only moderately useful and are invasive. MRI although highly sensitive to lesions, provides little prognostic information due to the variable course and pathological heterogeneity of the disease. It has been suggested that axonal damage, followed by neuronal cell death by wallerian degeneration is the probable cause of permanent neurological deficits . This can be assessed directly by proton magnetic resonance spectroscopy (1H-MRS) quantification of NAA, found almost exclusively in neuronal cells. However, MS pathology is by its nature diffuse. Therefore, NAA assessment of the entire parenchyma is crucial to evaluate the full extent of the disease. Indeed, a new 1H-MRS method to quantify the whole-brain NAA (WBNAA) concentration has recently shown that the latter can be more than 20% lower in RR MS patients than in their healthy contemporaries and declines x10 faster with age.

Design/Methods:

Whole-brain NAA (WBNAA) concentration was quantified in 49 RR MS patients, using MRI and 1H-MRS. It was statistically analyzed using Spearman rank correlation coefficients to test the within-group relationship between WBNAA and Expanded Disability Status Scale (EDSS) score and Mann Whitney analyses to test for differences between the groups EDSS scores versus previously published WBNAA values of healthy subjects, disease duration, and age.

Results:

The analyses indicated three subgroups of WBNAA dynamics: Of the 49 patients 10 were Stable, exhibiting an insignificant change of ~0% per year of clinically definite disease duration (p=0.54); 27 showed a Moderate decline, 2.8%/yr (p0.01); and 12 experienced Rapid, 27.9%/yr (p0.01) loss. No correlation was found between WBNAA deficit, EDSS score, or age.

Conclusions:

Ascertaining an individuals NAA concentration dynamics might : (a) provide an early forecast of disease course; (b) since reflect disease severity, hence, influence treatment decisions; and (c) improve clinical trial efficiency by selecting candidates based on WBNAA dynamics in addition to clinical status.

Supported By:

NIH grants NS33385, EB01015 and NS29029

Category - MS and Related Diseases

SubCategory - Basic Science 


[P03.116]

Production and Neuroprotective Functions of Fractalkine in the Central Nervous System

Tetsuya Mizuno, Akio Suzumura, Nagoya, Japan

Objective:

To examine the production, receptor expression and the function of fractalkine in neural cell in vitro.

Background:

The CX3C-chemokine, fractalkine is expressed in the central nervous system, and up-regulated in certain pathological conditions, such as HIV encephalopathy and multiple sclerosis. However, the producing cells in the brain as well as the function of fractalkine are still controversial.

Design/Methods:

The producton of fractalkine and its receptor expression were examined by RT-PCR with specific primers, and production was also evaluated with ELISA. The neuroprotective function of fractalkine was investigated by co-culturing neurons with microglia in transwell.

Results:

Both fractalkine and its receptor, CX3CR1, were expressed constitutively in neurons, microglia, and astrocytes. Neither the producton of fractalkine nor its receptor expression was up-regulated by lipopolysaccaride (LPS), as measured by mRNA expression and protein synthesis. Fractalkine dose-dependently suppressed the production of nitric oxide(NO), interleukin(IL)-6 and tumor necrosis factor (TNF)- by activated microglia. It also significantly suppressed neuronal cell death induced by microglia activated with LPS and interferon-, in a dose dependent manner.

Conclusions:

These results suggest the possible functions of fractalkine as an intrinsic inhibitor against neurotoxicity by activated microglia.

Category - MS and Related Diseases

SubCategory - Basic Science 


[S25.002]

Treatment of Chronic EAE in Transgenic DR2 Mice with Recombinant TCR Ligands

Arthur A. Vandenbark, Cathleen Rich, Jeff Mooney, Halina Offner, Richard E. Jones, Gregory G. Burrows, Portland, OR

Objective:

Evaluate therapeutic potential of recombinant TCR ligands in a new chronic EAE model in transgenic (Tg) DR2 mice.

Background:

We have recently developed recombinant TCR ligands (RTLs) containing the 11 domains of a multiple sclerosis risk-related DR2 allele (DRB1*1501), covalently linked to encephalitogenic myelin peptides. These RTLs can inhibit human T cell clones in an MHC/peptide specific manner by delivering partial agonist signals through the TCR. To evaluate their therapeutic activity, we now utilize an RTL containing DR2/MOG-35-55 peptide to treat chonic EAE in a newly developed model of EAE in Tg HLA-DR2 mice.

Design/Methods:

Chronic EAE was induced in Tg DR2 mice by injecting MOG-35-55 peptide in CFA + pertussis toxin. RTLs were injected i.v. daily for 8 days at indicated doses after onset of clinical signs of EAE, and the course of EAE was monitored for up to 54 days post induction. T cell responses to MOG-35-55 peptide were evaluated in lymph node cells and antibody responses were evaluated in serum from treated and control mice.

Results:

Severe chronic EAE was induced in Tg DR2 mice with MOG-35-55 peptide in CFA + P.t., and was mediated by CD4+ T cells but not antibodies specific for MOG-35-55. Treatment with RTLs produced a dose-dependent reversal of moderate to severe clinical EAE with doses as low as 10g/injection. Mice treated with higher doses (33 or 100g) became essentially non-symptomatic, even after treatment was stopped, for the duration of the study. In contrast, some mice treated with the 10g dose or those treated with free peptide relapsed after cessation of treatment, but these mice could be re-treated successfully with higher doses of RTLs. RTL treatment reduced T cell proliferation and production of inflammatory cytokines, but did not inhibit antibody responses to MOG-35-55.

Conclusions:

RTL therapy using a human DR2/MOG peptide construct reversed established signs of EAE induced by MOG-35-55 peptide in Tg DR2 mice and induced long term remission even after cessation of treatment. This therapy inhibited inflammatory responses of MOG-specific T cells but did not affect antibody responses. The striking therapeutic effect of a humanized RTL on chronic EAE validates the potential of this novel approach for treating patients with MS and other T cell mediated autoimmune diseases.

Supported By:

The Department of Veterans Affairs, NIH Grant NS41965, The Nancy Davis Foundation, and Virogenomics, Inc.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[P01.155]

A Comparison of Upper and Lower Motor Neuron Physiology in Primary Lateral Sclerosis (PLS) and Amyotrophic Lateral Sclerosis (ALS)

Heather G. Stewart, Andrew A. Eisen, Vancouver, BC, Canada

Objective:

To compare upper motor neuron (UMN) and lower motor neuron (LMN) physiology in PLS and ALS using transcranial magnetic stimulation (TMS), needle electromyography (EMG) and motor unit number estimates (MUNE).

Background:

ALS and PLS are generally considered to be a spectrum of the same disease. However, the electrophysiologic LMN abnormalities in PLS are modest. MUNEs in PLS have not been previously reported, but may give insight into the mechanisms responsible for the subclinical LMN involvement.

Design/Methods:

ALS patients (n=30) met El Escorial criteria for clinically definite or probable disease. PLS patients (n=20) had slow progression over 3+ years, significant upper motor neuron but no clinical lower motor neuron signs, unremarkable imaging, and sparse or no evidence of active denervation on EMG. Manual muscle testing (MRC) and the ALS Functional Rating Scale were used to grade strength and measure disability. Motor evoked potentials (MEPs) following TMS, MUNEs using the multiple point stimulation technique, and EMG were recorded from thenar muscles. MUNEs were also done on age matched, normal controls (n=25).

Results:

ALS and PLS patients were similar in age (mean ages: 63 and 61 years respectively). Mean duration of symptoms for ALS was 14 months (range: 4-48 months), and for PLS 71 months (range: 36-150 months, p0.01). Eighty-three percent of PLS patients and 41% of ALS patients were MRC grade 5 (p0.005). All PLS patients and 65% of ALS patients had obvious UMN signs in the arm tested (p0.004), however ALSFRS total and arm subscores were modestly but equally reduced in both groups (ALSFRS total score= 38.5, arm subscore= 13.2). EMG of the APB was abnormal in 78% of ALS patients and 45% of PLS patients (p0.05). PLS patients did not have active denervation. MEPs were recordable in 100% of ALS patients, but absent in 57% of PLS patients (p0.01). MEP cortical thresholds were higher in PLS than ALS (60% and 50% maximum stimulator output respectively, p0.05), but MEP latencies and central motor conduction times (23.0msec and 7.7msec respectively) were equal in PLS and ALS. MUNEs were reduced in both ALS and PLS relative to controls (86, 123 and 180 respectively, p0.05). Single motor unit potential (SMUP) thresholds were higher in PLS than ALS or controls (p0.05). MUNEs fell by a mean of 40% in 20 ALS patients 3-4 months later; however, PLS MUNEs fell on average 14% in 5 patients, but were unchanged or slightly increased in 10 patients.

Conclusions:

In PLS, reduced MUNEs may reflect either a modest loss (death) of spinal anterior horn cells, or a transient reduction in the number of functional (and excitable) motor units. The other clinical and electrophysiologic findings in our PLS group (slow progression, relatively preserved strength, subtle EMG abnormalities, absent or high threshold MEPs, higher SMUP thresholds, and minimal MUNE decrement with time) are partly supportive of the latter hypothesis. This would imply some different etiologic processes in PLS and ALS.

Category - Anterior Horn and Peripheral Nerve

SubCategory - ALS: Clinical Studies 


[P01.025]

The Effect of Valsalva on Opening CSF Pressure

Lawrence H. Neville, Robert A. Egan, Portland, OR

Objective:

To evaluate the effect of valsalva on opening cerebrospinal fluid (CSF) pressure.

Background:

Patients with an elevated CSF opening pressure and a headache are sometimes referred with the presumed diagnosis of idiopathic intracranial hypertension (IIH). These patients often have no other signs or symptoms suggestive of IIH such as pulsatile tinnitus, transient visual obscurations, or papilledema. We hypothesize that many patients with headache may artificially elevate their CSF opening pressure. This study strove to ascertain whether individuals with normal opening pressure could artificially elevate their intracranial pressure (ICP) to a pathologic level by performing a valsalva maneuver.

Design/Methods:

We performed opening CSF pressure measurements on ten consecutive patients undergoing lumbar puncture at a University Hospital. We measured CSF pressure by manometry in the standard lateral decubitus position with legs and knees extended and abdomen relaxed and then again during a valsalva maneuver with hip flexion and bearing down against a closed glottis. Patients with an initial opening pressure over 20 cm water were excluded from the study, and a pathologic opening pressure was considered to be greater than 20 cm water. If the spinal fluid level rested behind the white joint adaptor of the manometer tube between 36 and 39 cm of water, the pressure was recorded as 36 cm of water.

Results:

Ten consecutive patients were enrolled; three were female. Their mean age was 47 (18-69). Reasons for lumbar puncture included evaluation for multiple sclerosis, encephalopathy, progressive supranuclear palsy, orbital pseudotumor, retinitis, and Behcets disease. The average standard opening pressure was 14.5 cm water (11-18). The mean valsalva CSF pressure was 30.7 cm water (26-36). This represents an average increase of 16.2 cm water. No patient was able to elevate their opening pressure to 40 cm of water or greater.

Conclusions:

All patients were able to elevate their CSF opening pressure with a valsalva maneuver to a level considered pathologic. Although our sample size is limited, this study confirms that CSF opening pressure can be elevated artifactually almost to 40 cm water. This suggests that basing the diagnosis of IIH solely on elevated CSF opening pressure should be viewed with caution

Category - Neuro-Ophthalmology/Neuro-Otology

SubCategory - Other 


[P05.130]

Glatiramer Acetate Specific T Cell Reactivity Correlates with Clinical and MRI Response to Therapy

Claudia Weder, Gabriel M. Baltariu, Kuno A. Wyler, Hans-Juergen Gober, Basle, Switzerland, Carmen Lienert, Bern, Switzerland, Myriam Schluep, Lausanne, Switzerland, Ernst W. Radue, Gennaro De Libero, Ludwig Kappos, Petra W. Duda, Basle, Switzerland

Objective:

To test whether clinical and MRI responses to glatiramer acetate (GA) therapy correlate with GA-specific immune responses.

Background:

GA treatment beneficially affects relapse rate and MRI parameters in relapsing remitting multiple sclerosis (MS) patients. Its mechanism of action is not entirely understood, but a number of effects on the immune system have been observed, including decreased GA specific proliferative response and induction of Th2 and regulatory cytokines. These changes are thought to lead to clinical benefit by downregulation of pathogenic autoreactive Th1 T cells and possibly other immune cells.

Design/Methods:

GA specific proliferative and cytokine responses were compared with clinical and MRI data in MS patients with standard GA therapy at 20 mg s.c. daily (n=9) and untreated MS patients (n=5). Assessment by EDSS and MRI (Gd+, T1 and T2 lesions) was done prior to and after 1 year, and relapse rate was calculated. Treated patients were grouped into responders or non-responders by predefined criteria. Proliferative and cytokine (IL-5, IL-10 and IFN) response was measured by 3H thymidine incorporation and ELISPOT assays. Primary responses of freshly isolated PBMCs against GA 1-300g/ml and PPD 1-10g/ml were tested prior to and at 2, 4, 6, and 12 months of therapy. Nonparamertric statistics were used for analysis throughout.

Results:

2 (9) treated and 3 (5) untreated patients fulfilled the criteria for clinical and MRI non-response. Proliferative response to GA was significantly decreased at all concentrations tested (p0.05) and IL-5 was increased (p0.05 at 300 g/ml) after one year in treated patients. IL-10 and IFN were unchanged. GA specific proliferative responses at the time of first GA injection were significantly higher in the two non-responders than in the responders at all concentrations of GA above 3g/ml (p0.05). Fluctuation of the GA-specific proliferative response (average difference between consecutive assessments in cpm) was significantly lower in treated responders than in the two non-responders or untreated patients. Both effects appear to be GA-specific, as responses to PPD did not correlate with clincial and MRI outcome. There was also no correlation between decrease of proliferative or increase of IL-5 response to GA, and clincial and MRI response. No significant immunological changes were seen in untreated patients.

Conclusions:

Patients with high GA-specific reactivity at treatment initiation may have impaired therapeutic response. We speculate that the immunomodulatory activity of GA may be reduced under these more immunogenic conditions and that attempts could be made at improving outcome by decreased initial dosing.

Supported By:

Swiss MS Society, Aventis Pharma Switzerland

Category - MS and Related Diseases

SubCategory - Clinical Trials 


[S41.005]

Identical Twins Discordant for MS Have a Shift in Their CDR3 Repertoires

David G. Haegert, Montreal, QC, Canada, Dante Galutira, St. Johns, NF, Canada, T. J. Murray, Halifax, NS, Canada, Paul OConnor, Toronto, ON, Canada, Veerabhadra Gadag, St. Johns, NF, Canada

Objective:

To determine whether MS patients have a shift in their CDR3 T-cell receptor (TCR) repertoires which precedes the onset of MS.

Background:

We found previously that identical twin pairs discordant for MS have a major shift in their T-cell receptor (TCR) repertoires when compared with a group of healthy twin pairs. We did not explore whether this shift occurred only in MS patients, or in their healthy co-twins, or in both. For the current study, we hypothesize that only MS patients have a shift in their TCR repertoires. Most TCR diversity occurs in the CDR3 regions, and here, we study the CDR3 repertoires of unstimulated naive CD4 T-cells. Because the TCR repertoires of these cells are largely unaffected by disease, any shifts in the CDR3 repertoires should precede the onset of disease. We also study these T-cells as they have a central role in the autoimmune response that leads to MS.

Design/Methods:

We study the CDR3 spectratypes of three different TCR V beta (TCRBV) segments in naive CD4 T-cells from healthy identical twin pairs, from identical twin pairs discordant for MS, from unrelated MS pairs, and from healthy unrelated pairs. We use the correlation coefficient (r value) as a measure of similarity of CDR3 spectratype distributions in each pair of individuals. We then use Fishers Z transformation, or a modification of this, to test for the significance of the differences between the values of r from the different pairs.

Results:

The correlations between CDR3 spectratypes of the discordant twin pairs differ significantly from those of the healthy twin pairs for two of the three TCRBV segments. Both MS patients and their healthy co-twins have significantly different CDR3 spectratype distributions, when compared separately with healthy unrelated pairs formed from the healthy twin pairs.

Conclusions:

Naive CD4 T-cells from both MS patients and their healthy co-twins have major shifts in their CDR3 repertoires. As genetics has minimal influence on the CDR3 spectratype distributions of healthy identical twins, the findings imply further that the CDR3 repertoire shifts have a non-genetic basis. Because we study naive CD4 T-cells, and both MS patients and their healthy co-twins have altered CDR3 spectratype distributions, these CDR3 repertoire shifts may precede MS and predispose to MS, but may be insufficient by themselves to cause MS.

Supported By:

Multiple Sclerosis Society of Canada

Category - MS and Related Diseases

SubCategory - Basic Science 


[P05.138]

Secondary Progressive (SP) MS: Immunological Effects of Intravenous Immunoglobulin G (IVIG) Therapy

Alessandra Ricci, Alessandra Oggero, Torino, Italy, Raffaella Clerici, Milano, Italy, Angele Cucci, Marinella Clerico, Elisabetta Verdun, Antonio Pipieri, Torino, Italy, Elio Scarpini, Milano, Italy, Luca Durelli, Torino, Italy

Objective:

To study in vitro immunoglobulin (Ig) and cytokine production of peripheral blood mononuclear cells (PBMC) of SP MS patients treated with IVIG or placebo.

Background:

The efficacy of IVIG in autoimmune-mediated diseases has been frequently reported. Several studies investigated the clinical and MRI effects of IVIG treatment in MS patients and demonstrated beneficial effects in relapsing remitting MS. IVIG treatment seems to modulate immune functions in various ways.

Design/Methods:

In the double blind, placebo-controlled European-Canadian study on IVIG treatment in multiple sclerosis (ESIMS), MS patients with an SP course were randomized to be treated with monthly infusions of 10% IgG, 1g/kg bodyweight or with placebo for 27 months. The 12 patients enrolled in the ESIMS study by Torino and Milano centers have been studied. Blood samples were taken at baseline and at month 3, 6, 9, 12, 18, 24 on treatment. The whole blood lymphocyte phenotype was studied by cytofluorimetry and the production of IgM, IgG, interleukine(IL)-10, tumor necrosis factor(TNF)-alpha, and interferon(IFN)-gamma in supernatant of PBMC culture by ELISA.

Results:

Six patients were on active treatment and six on placebo. The baseline demographic, clinical and immunological characteristics were similar in the two treatment groups. Lymphocyte phenotype: Compared to baseline, on treatment T CD3+, T CD3+ HLA DR+, and T CD3+ CD4+ lymphocyte percentages were significantly higher in placebo patients (p0.02). Ig production: Compared to baseline, IgM production was significantly reduced in IVIg-treated patients during the 2nd year (p=0.002). No difference in IgG production was shown in the two treated groups. Cytokine production: Compared to baseline, pro-inflammatory cytokines IFN-gamma and TNF-alpha increased during all the study in placebo group, significantly during the 2nd year (IFN-gamma, p=0.04; TNF-alpha, p0.001); on the contrary, anti-inflammatory cytokine IL-10 progressively increased in the IVIg and decreased in the placebo group, reaching statistical significance at study month 24 (p0.001).

Conclusions:

The ESIMS study has shown that there was no significant difference between IVIg patients and placebo patients from a clinical and MRI point of view, demonstrating that IVIg treatment is not capable of reducing the disease progression in SP SM patients. The lack of efficacy was not due to an absence of immunological effects. In our 12 patients we, in fact, showed significant differences in lymphocyte phenotype, IgM and cytokine production between placebo and IVIg patients, particularly during the 2nd year of treatment.

Supported By:

Bayer AG, Leverkusen

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P02.102]

Tamoxifen [Tri-Phenylethylene Protein Kinase Inhibitor] Phase II Dose-Escalation Clinical Trial in Amyotrophic Lateral Sclerosis [ALS] - Study Design and Safety Results in First 50 Patients

Benjamin Rix Brooks, Mohammed Sanjak, Kathryn A. Roelke, Jennifer H. Parnell, Shirley M. Peper, Ann M. Houdek, Daryn S. Belden, Selim Dogan, Aaron P. Frye, Andrew J. Waclawik, Madison, WI

Objective:

To evaluate the safety and tolerability of tamoxifen in the treatment of ALS patients.

Background:

A large array of activated protein kinases and their phosphorylated protein subtrates have been found in the spinal cord of ALS patients. Tamoxifen, a demonstrated inhibitor of protein kinases in murine spinal cord, significantly delays, in a dose-dependent fashion, the appearance of clinical signs and disease progression to death in retrovirus-induced motor neuron degeneration.

Design/Methods:

This phase II randomized dose-escalation treatment clinical trial is projected to enter 100 subjects [20 subjects per each of 5 dose levels] to have a power of 0.85 at two-sided p value = 0.05 to find an increase or stabilization in percent-predicted isometric muscle strength over 12 months of treatment. Blocks of 5 subjects were constituted according to ALS FRS-R, age and gender at baseline and randomized to tamoxifen 10mg weekly or 10,20,30 or 40mg/day. Subjects were followed by telephone in the first 8 weeks of drug administration to assess any side effects of tamoxifen treatment. All patients were followed up at quarterly intervals to assess safety and efficacy parameters.

Results:

At the safety analysis after entry of the first 50 patients [25 M; 25 F], dose levels were well-balanced with respect to age, site of onset, length of disease prior to diagnosis, length of disease from diagnosis to study entry, riluzole use, albuterol use, creatine use and BiPAP utilization. Tamoxifen 40mg/d was discontinued due to sterile hematuria after 6 weeks therapy in 1/50 patients. Serious adverse events requiring hospitalization occurred in 5/50 patients [ pneumonia - 2 (10mg/wk); dizziness/dehydration - 1(10mg/wk); frontal lobe behaviour - 1 (10mg/d); salpingo-oophorectomy for multiple follicular cysts and adhesions - 1 (20mg/d)]. Hot flashes occurred in 3/25 males [pre-existing - 2/3] [10mg/wk, 20mg/d, 40mg/d] and 4/25 females [pre-existing - 2/4][10mg/d, 20 mg/d, 30 mg/d, 40 mg/d]. Pre-existing hot flashes increased in frequency and intensity transiently for 4-6 weeks before returning to baseline. ALS continued to progress in already involved areas with increased isometric muscle strength percent-predicted in anatomic areas not already involved with ALS.

Conclusions:

Tamoxifen was well-tolerated in 49/50 treated ALS patients with only one dose discontinuation. All of 50 patients treated showed statistically, but not clinically, significant increases in percent-predicted isometric muscle strength at 3 months. The clinical trial is continuing with a recruitment goal of 20 patients per dose level and 12 months follow-up.

Supported By:

Muscular Dystrophy Association - ALS Division, NIGMS GCRC [M01 RR03186], and Department of Veterans Affairs

Category - Anterior Horn and Peripheral Nerve

SubCategory - Therapeutics 


[P01.069]

The Relationship between Neurologic Education and Primary Care Management of Neurologic Disease

Cassandra E. Chen, Lubitz M. Robert, Williams S. Linda, Indianapolis, IN

Objective:

The objective of this study was to survey graduating primary care residents from all programs in one metropolitan area to determine their experience and comfort with evaluating and treating patients with neurologic diseases.

Background:

Because neurologic disease is becoming more prevalent in our aging patient population, and because primary care providers will continue to provide front-line assessment, treatment, and referral of patients with neurologic symptoms, it is critical to determine the current neurology education needs of primary care physicians and the degree of comfort these physicians have in evaluating and managing neurologic symptoms and disease.

Design/Methods:

An anonymous survey was completed by graduating residents from both private and academic family practice, internal medicine, and combined medicine/pediatric training programs in Indianapolis. All surveys were completed in the final month of residency training. The survey asked about neurology education in medical school and residency, and about their clinical experience caring for patients with neurologic disease. Questions were asked regarding their comfort with specific aspects of the neurologic physical exam, experience with and comfort level of treating patients with specific neurologic diseases and in interpreting common neurologic tests, and their desire for more training in neurology and other specialty areas. For analysis, the responses very comfortable and somewhat comfortable were collapsed.

Results:

Of 58 eligible residents, 47 completed the survey; only two residents did not have any neurologic training in either medical school or residency. Over 25% of graduating residents would like more training in all aspects of the bedside neurologic exam, and more than 48% would like more training in the motor, sensory, cerebellar and gait portions of the exam. In caring for patients with neurologic disease, over 40% are uncomfortable in caring for patients with their first seizure, epilepsy, multiple sclerosis, Parkinsons disease, tremor, and muscular dystrophy. Likewise, over 40% of those surveyed are uncomfortable interpreting results of EMG/NCS, EEG, brain MRI, spine CT, and spine MRI. Almost 75% would like more training in neurology, with neurology second only to dermatology as the medical specialty in which most primary care residents desire more training.

Conclusions:

Most graduating primary care residents desire more neurology training, and almost half feel uncomfortable managing patients with common neurologic conditions and interpreting common neurologic tests. If replicated in other programs, these data suggest that neurologic education should be formally integrated into primary care residency training.

Category - Neurologic Education

SubCategory - Other 


[P04.010]

IGG Subclass Profile of Relapsing Neuromyelitis Optica

Ichiro Nakashima, Kazuo Fujihara, Juichi Fujimori, Koichi Narikawa, Tatsuro Misu, Shigeru Sato, Sadao Takase, Yasuto Itoyama, Sendai, Japan

Objective:

To investigate the IgG subclass profile in the CSF and serum of relapsing neuromyelitis optica (RNMO) and compare it with that of the conventional type of multiple sclerosis (MS).

Background:

RNMO, also reported as the optic-spinal form of MS, is characterized by the selected involvement of the optic nerves and spinal cord. A female predominance, higher age of onset, frequent pleocytosis, and lack of oligoclonal IgG bands (OB) have been reported as its features. Among IgG subclasses, IgG1 is known to be elevated in the cerebrospinal fluid (CSF) of MS patients. An IgG1 predominance was reported to be associated with helper T cell type 1 (Th1) immunity. However, it remains unclear if there also exists an IgG1 or other IgG subtype predominance in the CSF and serum of RNMO patients.

Design/Methods:

Paired sera and CSF samples were collected from 9 RNMO patients (all females) and 8 clinically definite, OB-positive, MS patients (7 females and 1 male). All of the samples were obtained during the acute phase of the disease and before steroid or interferon treatment. As controls, seven paired sera and CSF samples were collected from patients with tension type headache or somatoform disorder. A human IgG subclass profile ELISA kit (Zymed, South San Francisco, CA) was used according to the instructions.

Results:

The onset age of RNMO patients (41.411.1 years) was higher than that of MS patients (29.411.3 years), but the difference was not significant. CSF cell count, CSF total protein level, disease duration, and EDSS score did not differ between the two groups. CSF cell counts of RNMO patients (5.83.8/l) and MS patients (5.45.1/l) were both significantly higher than those of controls (0.40.5/l) (p0.01). The total CSF IgG concentration was lower in RNMO patients (35.819.1 g/ml) than in MS patients (40.110.6 g/ml), but the difference was not significant. However, the values in RNMO and MS were significantly higher than in controls. The IgG index was significantly lower in RNMO patients (0.590.21) than in MS patients (1.090.52) (p0.01). Among the CSF IgG subclasses, the percentage of IgG1 was significantly lower in RNMO patients (63.28.2%) than in MS patients (77.28.0%) (p0.01), and the percentage of IgG2 was significantly higher in RNMO patients (p0.01). The IgG1 index was significantly lower in RNMO patients (0.490.19) than in MS patients (1.281.04) (p0.005), and its correlation with the IgG index was significant (p0.001). The CSF IgG subclass profile of RNMO patients did not differ from that of controls.

Conclusions:

We confirmed that IgG1 was elevated in the CSF of MS. However, RNMO lacked such an elevation of IgG1, which may suggest that Th1 immunity contributes much less to the pathology in RNMO than in MS.

Supported By:

This study was supported by the research subsidy of Japan Foundation for Neuroscience and Mental Health, and by Kanae Foundation for Life & Socio-Medical Science.

Category - MS and Related Diseases

SubCategory - Clinical Immunology 


[P02.108]

Onset of Amyotrophic Lateral Sclerosis [ALS] Is Delayed, but Course Is Not Altered, in ALS Patients with Pre-Existing Bone and Joint Disease: Neuroepidemiological Insights from the ALS Care Database

James M. Vann, Benjamin Rix Brooks, Andrew J. Waclawik, Madison, WI, Frederick A. Anderson, Jr., Neelam Gowda, Worcester, MA, the ALS CARE Study Group

Objective:

To evaluate, in the largest currently available national database of ALS patients, whether the presence of pre-existing bone and joint disease affects the onset and progression of adult onset motor neuron degeneration.

Background:

Epidemiological studies have suggested that bone and joint disease requiring treatment with non-steroidal anti-inflammatory drugs [NSAIDS] may significantly delay the onset of neurodegenerative diseases such as Alzheimers disease [AD]. Current clinical trials of NSAIDS are ongoing in AD and have been initiated in ALS. Previous cohort epidemiological studies in US Army military veterans have suggested that large bone fractures were a risk factor for the development of ALS [Kurtzke].

Design/Methods:

The Patient Care Database of the ALS Clinical Assessment, Research and Education Program [ALS CARE Database] initiated in 1996 contained validated data [87.0%] on 3257 of 3742 patients entered to the point that this analysis was completed. ALS patients who had documented and treated bone and joint disease were compared to ALS patients wihout this pre-existing co-morbidity with respect to gender [male, female] and mean age of onset of ALS. The chi-square statistic, analysis of variance or t-test were used to assess the significance of differences between the groups. Multivariate analysis was performed using backward stepwise multiple logistic regression for further analyses of other clinical parameters including survival.

Results:

Bone and joint disease requiring treatment was more commonly present [chi-square; p 0.05] in 392 of 1307 females [30.0%] compared with 300 of 1950 males [15.4 %]. The mean age of onset [57.6 yr] of ALS in females with bone and joint disease was significantly [t test; p = 0.0014] later than the mean age of onset [53.2 yr] in females without preexisting disease. Age of ALS onset [55.8 yr] in males with bone and joint disease was significantly [t test; p 0.0001] delayed compared with males [49.8 yr] free of pre-exisitng bone and joint disease. Despite delayed onset, the course of ALS, measured by survival, was not significantly altered in ALS patients with pre-existing bone and joint disease.

Conclusions:

The age of onset of ALS is delayed significantly in both male and female ALS patients with pre-existing bone and joint disease. Factors [treatment, type of co-morbidity] associated with presence of pre-existing bone and joint disease may protect patients from developing ALS but do not seem to affect the course of ALS once it has commenced.

Supported By:

The ALS Patient Care Database is supported by an unrestricted educational grant from Aventis Pharmaceuticals and the ALS Association. B.R.B. is supported in part by the Department of Veterans Affairs

Category - Anterior Horn and Peripheral Nerve

SubCategory - Epidemiology 


[P06.022]

Surgical Treatment and Outcome in Children with Tuberous Sclerosis Complex and Intractable Epilepsy in Relation to [11C]MethylLTryptophan PET

Kenji Kagawa, Eishi Asano, Csaba Juhasz, Otto Muzik, James Janisse, Aashit Shah, Sandeep Sood, Thomas J. Mangner, Pulak K. Chakraborty, Harry T. Chugani, Diane C. Chugani, Detroit, MI

Objective:

To analyze retrospectively the relationship between surgical outcome and - [11C]methyl-L-tryptophan (AMT) uptake ratio on PET in children with tuberous sclerosis complex (TSC) who underwent epilepsy surgery, and to validate the clinical utility of presurgical AMT PET in these patients.

Background:

TSC is commonly associated with medically intractable epilepsy, which is attributed to the presence of multiple cortical tubers and adjacent dysplastic cortex. Due to the difficulty in differentiating between epileptogenic and non-epileptogenic tubers using MRI or 2-deoxy-2-[18F]fluoro-D-glucose (FDG) PET, precise presurgical localization of epileptogenic regions is challenging in TSC patients in the presence of multifocal epileptiform activity on EEG. We have recently demonstrated that high uptake of AMT on PET characterizes a subset of epileptogenic tubers, despite multifocal EEG and FDG PET abnormalities.

Design/Methods:

Between November 1996 and September 2002, 15 children (mean age: 6.1 4.1 years) with TSC and intractable epilepsy underwent epilepsy surgery guided by EEG, AMT and FDG PET, at Childrens Hospital of Michigan. In each patient, AMT uptake values of all tubers were obtained, and were divided by the value for normal cortex to obtain an AMT uptake ratio for each tuber. Tubers with AMT uptake ratio above 1.0 have been considered to have increased AMT uptake. The correlation between surgical outcome (Engel class I - IV), EEG and AMT PET localization was analyzed.

Results:

Eleven (73 %) patients had seizure-free outcome (class I), 2 patients had class III, and 2 had class IV outcome (follow-up: 3 - 54 months; median: 11 months). All patients with class I outcome had tuber(s) with increased AMT uptake in the lobe of the focus, concordant with the scalp ictal EEG localization. In two cases AMT PET further localized the ictal onset, as confirmed by intracranial EEG. Further, contralateral (but less prominent) increase of tuber AMT uptake occurred in 3 patients without ictal EEG correlate. These tubers were not resected, but all 3 patients are seizure-free. In 3/4 patients who continued to have seizures postoperatively, tubers with increased AMT uptake or the immediate surrounding cortex had been incompletely resected due to involvement of eloquent cortex or presence of large tubers in the contralateral homologous area.

Conclusions:

Surgical treatment can be highly effective in alleviating seizures in selected TSC patients, and resection of the tubers with an AMT uptake greater than the mean cortical AMT uptake value is highly desirable provided there is EEG concordance to achieve a favorable surgical outcome.

Supported By:

NIH Grant NS 38324

Category - Epilepsy

SubCategory - Imaging 


[P04.081]

Serial Monthly Brain MRI with Triple Dose GD-DTPA Anticipate the Diagnosis of MS Within the First Months in CIS Patients

Isabella F. Pestalozza, Rome, Italy, Silvia Di Legge, Roma, Italy, Maria C. Piattella, Patrizia Pantano, Francesca Caramia, Patrizio Pasqualetti, Luigi Bozzao, Gian Luigi Lenzi, Carlo Pozzilli, Rome, Italy

Objective:

To assess the ability of triple dose Gd-DTPA and serial monthly brain MRI to predict clinically definite multiple sclerosis (CDMS) or combined CDMS/MRI outcomes in a cohort of patients with Clinically Isolated Syndrome (CIS). This is of relevance in identifying those patients at high risk of MS who are appropriate candidates for early treatment.

Background:

The CHAMPS study demonstrated that 84% of the patients with a diagnosis of CIS, who have a positive MRI scan at clinical presentation, develop CDMS or at least one or new enlarging lesion at brain MRI within the following 18-month period. The role of serial MRI in predicting clinical and MRI activity in relapsing remitting MS is well established and the use of triple dose Gd increases the sensitivity in detecting disease activity up to 60%. Combination of monthly MRI and triple dose Gd may assist the clinician in anticipating a diagnosis of MS to the first few months following the clinical onset.

Design/Methods:

This is a 3-year observational, ongoing study on a series of consecutive CIS patients with at least 3 brain MRI lesions suggestive of MS. Patients underwent monthly triple dose Gd-enhanced brain MRI for 6 consecutive months after enrollement. Further brain MRI were scheduled at 12, 18, 24 and 36 months after inclusion. CDMS was defined as the occurrence of a second clinical episode. Patients who developed CDMS over the study-period did not undergo further MRI. MRI conversion to MS was based on the presence of at least one new or enlarging T2 lesion over 3 months.

Results:

Currently, 60 have been studied at baseline: 39F and 21M, mean age of 28.7 yrs, time since clinical onset of 4.5 months, and baseline EDSS of 1.2. Of them, 56 at 24 months, and 42 at 36 months. Baseline MRI showed less than nine T2 lesions in 15% and at least one enhancing lesion 52% of patients. During the observation period 48.3% of patients developed a second clinical episode while 91.7% showed MRI conversion to MS. Of them, MRI conversion was found in 58.3% at 1-month, in 75.0% at 2-month and 81.7% at 3-month scan. If we combined the presence of Gd-enhancement at baseline and at least one new or enlarging T2 lesion at the follow-up, 73.3% converted at 1-month, 75.0% at the 2-month scan, 81.7% at the 3-month scan.

Conclusions:

Most of CIS are in the earliest stage of MS. With the present study we demonstrated that it is possible to detect clinical and/or MRI conversion to MS in the first months of clinical onset. The combined use of a triple dose of Gd and serial monthly brain MRI increases the likelihood to detect a progression to CDMS/MRI. In particular, the presence of Gd-enhancement at baseline and at least one new or enlarging T2 lesion at 1-month scan may predict conversion to CDMS/MRI in more than 70% of CIS patients.

Category - MS and Related Diseases

SubCategory - Imaging 


[P03.105]

MHC Class II Transactivator (CIITA)-Driven Class II Expression and Antigen Presentation by Astrocytes in CNS Autoimmune Disease

Olaf Stuve, San Francisco, CA, Sawsan Youssef, Stanford, CA, Anthony J. Slavin, South San Francisco, CA, Chelsea L. King, Juan Carlos Patarroyo, San Francisco, CA, David L. Hirschberg, Stanford, CA, June W. Brickey, Chapel Hill, NC, Jeanne M. Soos, Prussia, PA, Janet F. Piskurich, Macon, GA, Harold A. Chapman, Scott S. Zamvil, San Francisco, CA

Objective:

To examine the role of the MHC class II transactivator (CIITA) in central nervous system (CNS) class II expression and antigen (Ag) presentation by astrocytes and in experimental autoimmune encephalomyelitis (EAE) susceptibility.

Background:

The role of astrocytes in Ag presentation and T cell activation in CNS inflammatory disease is controversial. We tested the hypothesis that CIITA-directed class II expression is necessary for T cell activation in CNS inflammation.

Design/Methods:

CIITA-transfected astrocytes, newly generated transgenic (Tg) mice that utilized the glial fibrillary acidic protein (GFAP) promoter to target astrocyte expression of (CIITA), and CIITA-deficient mice were utilized for this study.

Results:

CIITA-transfected astrocytes upregulated class II molecules, whereas IFNg-activated CIITA-deficient astrocytes did not. CIITA-deficient mice were resistant to EAE by immunization with CNS autoantigen. CIITA-deficient APC were capable of presenting peptide to wild-type CD4+ T cells, indicating the presence of CIITA-independent mechanisms for peripheral T cell priming. Adoptive transfer of wild-type CNS autoantigen-specific CD4+ T cells into CIITA-deficient mice did not induce EAE, indicating that CIITA-dependent class II expression was required for CNS antigen presentation. GFAP-CIITA-Tg mice did not develop spontaneous EAE, or more severe EAE than control mice when immunized with encephalitogenic peptide. Whereas IFNg-activated astrocytes could present peptide or native antigen, CIITA-transfected astrocytes could present peptide only, indicating that CIITA-transfected astrocytes could not process native antigen. IFNg-activated astrocytes also upregulated cathepsin (Cat) S, whereas unstimulated, CIITA-transfected astrocytes did not.

Conclusions:

Our results demonstrate that although CIITA-directed class II expression is required for CNS Ag presentation and EAE induction, CIITA-directed class II expression alone in astrocytes is not sufficient for Ag processing and does not support induction of CNS autoimmune disease.

Category - MS and Related Diseases

SubCategory - Basic Science 


[P03.111]

Detection of Magnetically Labeled Encephalitogenic T-Cells in Mouse Spinal Cord by Cellular Magnetic Resonance Imaging

Stasia A. Anderson, Shukaliak-Quandt Jacqueline, Elaine K. Jordan, Ali S. Arbab, Roland Martin, Henry McFarland, Joseph A. Frank, Bethesda, MD

Objective:

The aim of this study is to use MR microscopy (MRM) to monitor the temporal-spatial migration of magnetically labeled encephalitogenic T-cells in the spinal cord in the experimental autoimmune encephalomyelitis (EAE) SJL mouse.

Background:

EAE is an inflammatory, demyelinating disease of the CNS which is known to be immune mediated. The initiating event in the inflammatory process is the entry of encephalitogenic, activated T-cells into the CNS. Information on the trafficking of encephalotigenic T-cells into the CNS would be valuable to provide a further understanding of the disease. Intracellular labeling with iron oxides provides the ability to monitor the trafficking of cells in vivo by MRI due to susceptibility effects of iron in the cells. We have applied this method to EAE to determine if T-cell infiltration can be visualized in the CNS by in vivo MRM.

Design/Methods:

EAE was induced by proteolipid protein (PLP 139-151) sensitized T-cells that were intracellularly labeled with superparamagnetic iron-oxide nanoparticles (SPIO). Lymph node cultures from immunized donor mice were incubated with SPIO (Feridex, Berlex Laboratories)- Poly-L-lysine (PLL) complex. 20M labeled cells were adoptively transferred into recipient mice. Proliferation response and intracellular cytokine production by the labeled and unlabeled cells cultures was determined in parallel. In vivo and ex vivo MRM was performed on the mouse spinal cords using T2*W, 2D and 3D gradient-echo sequences at 7 Tesla (Bruker) during the first disease exacerbation. In vivo studies were performed at 75x75x300 micron resolution and ex vivo studies were performed at 30x30x50 microns. Prussian blue for the presence of iron in cells and routine histology was performed.

Results:

Labeled and unlabeled T-cells showed strong proliferation in response to PLP antigen and similar interferon-g production, indicating the labeled and unlabeled T-cells are immunologically comparable. Both magnetically labeled and unlabeled T-cells induced EAE in mice. MRM of labeled animals with clinical score 3 demonstrated hypointense areas in the thoracic and lumbar cord, which are not observed in unlabeled mice. Histology showed cellular infiltrate on H&E and Prussian blue (iron) positive mononuclear cells with perivascular cuffing in white matter and nerve roots. These results indicate moderate to severe EAE with the presence of iron labeled cells in the lesions.

Conclusions:

Magnetically labeled T-cells present in spinal cord lesions in EAE mice were detected by MRM and on histology. These results provide the basis for tracking the timing and location of T-cells in live animals. It can potentially be used to label specific T-cell sub-types and monitor the response to immune modulating therapies. This method could be used to further our understanding of EAE and other T-cell mediated autoimmune diseases.

Category - MS and Related Diseases

SubCategory - Imaging 


[P03.115]

Novel Low Affinity Fc Receptor Ligands (FcRLs) Suppress Experimental Autoimmune Encephalomyelitis (EAE)

Mark A. Jensen, David M. White, Barry G. W. Arnason, Chicago, IL

Objective:

To examine the role of Fc receptors in EAE using novel recombinant proteins that ligate low affinity Fc receptors.

Background:

Fc receptors are involved in immune system regulation. Fc receptors have either high or low affinities for Ig. Low affinity receptors (CD32 and CD16) require simultaneous binding of several Igs for receptor ligation and cellular activation. We have engineered novel recombinant proteins (FcRLs) that contain multiple copies of the Fc binding region (HCH2) from human IgG1. The HCH2 polymers modulate function of human and murine immunocytes (NK cells, B cells, monocytes) expressing low affinity Fc gamma receptors. Modulation correlates with HCH2 number expressed in the polymer.

Design/Methods:

Tripartite fusion proteins were engineered to contain reiterated sequences of the Fc binding region of IgG1. The carboxyl- framework domain contains the hinge, CH2 and CH3 domains of human IgG1 to provide stability, permit dimerization, and single-step purification. The central region contains multiple linear copies of HCH2. The amino region contains domain 1 of human serum albumin (HSA). The effect on EAE of two recombinant proteins, HSAR0 and HSAR4, was examined. HSAR0 contains dimerized framework and HSA domain 1 chains. HSAR4 contains 4 additional iterated HCH2 regions in each chain. SJL/J mice were immunized with PLP peptide 139-151 (100 ug) in CFA administered i.d. at the tail base. Mice received pertussis toxin (200 ng), 1 and 3 days after immunization. FcRLs were administered as: 1) 3 injections (3 days prior to and 1 and 3 days after immunization); 2) as a single injection shortly after disease onset. 50 ug of FcRL protein in 0.15 ml of saline was administered each time. Control mice received saline alone. Disease activity was scored on a scale of increasing severity from 0 to 5 (0, normal; 1; flaccid tail; 2, flaccid tail with hind limb weakness; 3, hind limb paralysis, 4, hind limb paralysis with fore limb weakness or paralysis; 5, moribund).

Results:

EAE began on day 9 post immunization. Saline treated controls developed profound hind limb paralysis from days 10 through 14 followed by a lessening of severity but disease remained chronic with an average score of 2.5 following the acute phase. Early administration of HSAR4 greatly reduced disease severity throughout the entire 60 days of observation compared to saline and HSAR0 treated mice (p 0.001). Mice treated with HSAR4 after disease onset displayed abrupt reduction of disease activity compared to saline treated mice.

Conclusions:

Ligation of low affinity Fc receptors by administration of novel FcRLs inhibits EAE. Therapeutic targeting of low-affinity Fc receptors using FcRLs represents a new strategy in MS therapy.

Supported By:

The Alan Friend MS Research Fund.

Category - MS and Related Diseases

SubCategory - Therapeutics 


[S65.003]

Minocycline Acts on T Cells To Decrease Microglia Activation

Fabrizio Giuliani, Wee Yong, Calgary, AB, Canada

Objective:

To determine whether minocycline can interfere with the activation of microglia by T lymphocytes

Background:

We have previously shown that activated T cells can stimulate microglia to produce inflammatory cytokines such as TNF and IL-1; this interaction may promote a pro-inflammatory milieu within the CNS. We have also demonstrated that U937, a myelomonoblast-like human lymphoma cell line, can be used as a model of adult human microglia to study cytokine production in their interactions with activated T cells (Chabot et al. 2001). Minocycline is used as an antibiotic where a good safety record for prolonged oral use has been established. We have recently reported that Minocycline can attenuate the symptoms of experimental autoimmune encephalomyelitis (EAE), a model of MS (Brundula et al. 2002). Minocycline is commonly referred to as an inhibitor of microglia activation while its effects on T cells are less understood. The current study seeks to investigate whether minocycline can alter T cell functions and thereby downregulate the activation of microglia by T lymphocytes.

Design/Methods:

We used a co-culture system of either U937 cells or human fetal microglia interacting with T cells from the peripheral blood of human donors. T cells were activated with an anti-CD3 antibody (OKT3) for 72h and then incubated with microglia. Some of the activated T cells were pretreated with minocycline (2 - 100 g/ml) for the same length of time. Following a pre-determined period of co-culture, supernatants or cell lysates were collected and levels of TNF and IL-1 were measured by ELISA or real time-PCR. Levels of IFN and BrdU incorporation were measured to assess the activation state of T cells.

Results:

When activated T lymphocytes were added to microglia or U937 cells, the increase of proinflammatory cytokines occurred promptly. When T lymphocytes were pre-treated with minocycline (10 - 100 g/ml), the levels of TNF and IL-1 were decreased in the co-culture compared to untreated co-cultures. Treatment of U937 cells with minocycline was not adequate to reduce cytokine production in subsequent T cell - U937 encounter, suggesting that the activity of minocycline was directed on T cells. In correspondence, minocycline reduced the production of IFN and the proliferation of activated T cells in parallel with its efficacy on the attenuation of cytokine production in the co-culture system.

Conclusions:

These data demonstrate that the modulation of microglia activation by minocycline is driven by a direct effect of the drug on T cell activation. This mechanism may mediate the anti-inflammatory effect of minocycline in the CNS and suggests its potential utility as a therapeutic agent for diseases such as MS.

Supported By:

Canadian Institutes of Health Research

Alberta Heritage Foundation for Medical Research

Category - MS and Related Diseases

SubCategory - Therapeutics 


[8BS.008]

Practical Symptom Management of Multiple Sclerosis

Barbara Giesser, MD

Seminar description:

Optimal management of the person with multiple sclerosis incorporates effective symptom control, as well as use of disease modifying agents (DMA). DMA themselves have side effect profiles which also impact function and quality of life. Faculty will present information about novel treatment strategies for addressing refractory spasticity and movement disorders in MS, as well as protocols for managing and monitoring side effects of DMA. Lecture format and video case presentations will be utilized.

Upon completion:

Participants should be able to identify, refer, and counsel appropriate candidates for intrathecal baclofen pump for spasticity associated with multiple sclerosis and candidates for neurotoxin treatment of movement disorders associated with multiple sclerosis; discuss outcomes and side effects of deep brain stimulation when used for treatment of tremor associated with multiple sclerosis; and list effective strategies for ameliorating side effects seen with DMA. 


[2BS.009]

Pediatric Multiple Sclerosis

Lauren Krupp, MD

Seminar description:

An increasing number of children and adolescents in whom the diagnosis of Multiple Sclerosis is being considered. These statistics have risen since early diagnosis and treatment in adults is associated with improved outcome. Yet, many diagnostic and treatment issues remain unanswered for pediatric multiple sclerosis. Faculty will review the current literature regarding early onset MS (<18 years), discuss differential diagnosis (including the entities of acute disseminated encephalomyelitis (ADEM), review issues unique to this age group (effects of MS on behavior and learning), MRI characteristics and treatment options. Case discussions and clinical vignettes will be integrated throughout the program to facilitate interaction between faculty and attendees.

Upon completion:

Participants should be able to identify children and adolescents with multiple sclerosis; be aware of the diagnostic issues between ADEM, recurrent ADEM, and MS; have familiarity with current medications being used in pediatric MS, including dosages and routes of administration; and be familiar with the current and past medical and scientific literature on these topics. 


[2FC.005]

Update on Multiple Sclerosis

Aaron Miller, MD

Course description:

This program will build on participants' existing understanding of MS to update their knowledge of several key aspects of the disease. While some basic research will be addressed, the emphasis of the program will be on clinical issues. Participants will have the opportunity to use their knowledge through a series of interactive case vignettes. These will address not only points raised in the formal lectures, but other areas as well. A debate format will be used to highlight some areas of current controversy.

Upon completion:

Participants should be able to understand the pathogenesis, imaging features, and management of multiple sclerosis; recognize controversy regarding the role of infectious agents in multiple sclerosis and the use of MRI in managing MS; and apply their knowledge to specific case scenarios. 


[3BS.004]

Gender Issues in Multiple Sclerosis

Patricia Coyle, MD

Seminar description:

Gender-based approach to disease is increasingly recognized as important. Multiple sclerosis (MS) offers an excellent example of a neurologic disease where sex has important implications for diagnosis, management, and insights into disease pathogenesis. Faculty will provide brief, targeted, up-to-date reviews covering the impact of gender on the nervous, immune, and endocrine systems, and a variety of sex-related topics in MS. Case discussions and practical applications will be emphasized.

Upon completion:

Participants should have a better awareness of how to care for male and female patients with MS. 


[6TP.003]

Multiple Sclerosis Therapy

Robert Lisak, MD

Program description:

Faculty will cover several important areas of evolving therapy in MS, including clinically isolated syndromes, early diagnosis of MS, and implications of recent studies on early treatment; current understanding of the mechanisms of action of immunomodulatory therapies and their effects on MS; possible therapeutic approaches to the patient with rapidly progressive or worsening MS; and the current status of combination strategies.

Upon completion:

Participants should be able to have a rational approach to evaluation and treatments of patients with clinically isolated syndromes and early MS; understand the mechanisms of action and of immunomodulatory agents in relapsing-remitting MS; have familiarity with possible treatments for patients with rapidly progressive MS; and understand the current knowledge and efficacy of combining therapies in MS. 


[7BS.008]

MS and Its Masquerades: Making the Diagnosis, Considering the Differential Diagnosis

John Fleming, MD

Seminar description:

Correct diagnosis is the first step to effective management, especially when a disease such as multiple sclerosis (MS) is suspected, where diagnosis can be challenging, and an extensive differential diagnosis may need to be considered. Recent research in neuroimaging and other neurosciences has led to advances with great relevance to MS diagnosis and differential diagnosis. Faculty will integrate new research findings into the traditional understanding of MS diagnosis based on clinical dissemination in time and space. The emphasis will be on evidence-based and common-sense approaches with practical utility for neurological clinicians. Application of the new guidelines recommended by the International Panel on the Diagnosis of Multiple Sclerosis (McDonald Committee) will be discussed in detail.

Upon completion:

Participants should be able to apply a stratified approach to different types of patients suspected of MS; understand and apply formal clinical and MRI criteria for MS, such as those of the McDonald Committee; consider the differential diagnosis in terms of relevant diseases mimicking MS; and apply appropriate, cost-effective screening tests, as well as definitive tests or referral as indicated. 


[2BS.007]

APOE Polymorphism and Neurological Disease

Barry Jordan, MD

Seminar description:

Apolipoprotein E (APOE) polymorphism has a clinical influence on several neurological disorders and may be a significant disease modifier. In addition to being a risk factor for Alzheimer's disease, APOE genotype influences the outcome and/or risk of acute and chronic traumatic brain injury, multiple sclerosis, vascular dementia, stroke, and amyotrophic lateral sclerosis.

Upon completion:

Participants should be able to understand how the outcome and/or risk of selected neurolgical diseases can be influenced by APOE genotype. In addition, knowledge of potential pathophysiological mechanisms of disease modification by APOE will be acquired. 


[3AC.005]

MS: New Developments in Neurologic and Rehabilitation Care

Mindy Aisen, MD

Course description:

Faculty will focus on practical management and the comprehensive care of multiple sclerosis (MS) patients. Immunosuppressive strategies, outcome instruments and means for treating the neurologic and medical complications of MS will be discussed. Current practice and the underlying basis and evidence for existing clinical guidelines will be reviewed. An overview of recent fundamental and clinical research findings will be presented as will questions that beg further clinical investigation. The program will blend the expertise of neurologists and physiatrists.

Upon completion:

Participants should be able to provide comprehensive care to MS patients with an understanding of the most recent developments in practice guidelines (and evidence underlying practice guidelines) and have a working knowledge of recent research development relevant to the care of patients with MS. 


[3AS.006]

Case Studies in Neurogenetics

Louis Ptacek, MD

Seminar description:

This program will be formatted for presentation of neurogenetics cases by the audience. The main focus will be on clinical diagnosis of disorders, molecular insights into such genetic disorders, and molecular diagnosis: power and pitfalls of new technology. Genetics plays an important role in many disease processes from disorders where a single mutation is causative to complex disease where genetic variants predispose to various disorders such as epilepsy, multiple sclerosis, or headache. The speed with which new genetic technologies and discoveries have come to bear on our understanding of neurologic disease is astounding. This format will allow an opportunity for participants to share their own cases and to stimulate lively discussion regarding new developments in molecular genetics, genetic testing capabilities, and limitations of such technologies. Emphasis will be placed on the role of genetic testing as a complement to careful clinical evaluation in the appropriate setting and which to use such testing. Case discussions will raise questions and issues related to ethical considerations in this rapidly moving field.

Upon completion:

Participants will be brought up-to-date about pitfalls encountered in the field of neurogenetic testing and new developments in neurogenetics and be able to use this information in guiding their own decisions regarding genetic testing. 


[3DS.009]

Deep Brain Stimulation Programming for Movement Disorders

Helen Bronte-Stewart, MD, MSE

Seminar description:

During the last decade there has been renewed interest in stereotactic surgery for medically refractory movement disorders. The introduction of deep brain stimulation (DBS) as a reversible and adjustable alternative to neuroablation has provided a precisely targeted and flexible therapy. Three deep brain structures are currently being targeted by DBS for treatment of movement disorders, the thalamus (VIM) for treatment of medically refractory tremor in patients with Parkinson's disease (PD), essential tremor, and multiple sclerosis; the subthalamic nucleus (STN) for treatment of advanced, medically refractory PD; and the globus pallidus pars interna (GPi) for treatment of advanced PD and generalized dystonia. DBS therapy requires a basic understanding of principles of pulse generator programming. The results of DBS therapy depend not only on the neurosurgeon's skills in implanting the device but also on the neurologist's ability to properly manage this therapy and medication following surgery. Faculty will provide an overview of the anatomical and physiological background of DBS and its role in the management of movement disorders. Criteria for patient selection, results of surgery, and principles of surgical technique will be discussed followed by a detailed review of DBS programming. Clinical problems and specific programming issues related to the three main targets of DBS (VIM, STN and GPi) will be presented in detail.

Upon completion:

Participants should be able to properly select eligible patients for DBS therapy, to understand and apply the principles of DBS programming for each basal ganglia target; and will become familiar with common problems and troubleshooting strategies associated with this new therapeutic option for movement disorders. 


[5PC.001]

Complementary and Alternative Medicine in Neurologic Disorders

Barry Oken, MD

Course description:

Complementary and alternative medicine use has been increasing rapidly in the U.S. as well as other countries. Faculty will provide an overview to this field and then discuss specific applications within neurology practice. Faculty will discuss the use of commonly used alternative therapies, including chiropractic, acupuncture, botanicals (e.g., ginkgo biloba, feverfew), and orthomolecular compounds (e.g., riboflavin, magnesium, and anti-oxidant vitamins). Focus will be on specific, common neurological disorders: dementia, multiple sclerosis, and headache, and specific alternative therapies. Treatments will be reviewed in a formal manner to allow the clinician to accurately judge the evidence for and against the various treatments as well as the potential risks (including botanical-drug interactions).

Upon completion:

Participants should gain an introductory understanding of the overall field of complementary and alternative medicine; and be able to recommend to their patients the use or non-use of some commonly used alternative therapies for various neurological disorders based on knowledge of clinical trial evidence of efficacy. 


[3FC.003]

Neurology Update I

Mark Hallett, MD

Course description:

This program is designed to provide practicing clinicians, academicians, residents, and fellows with the most recent developments in pathogenesis and treatment in selected areas of neurology. The information should be helpful in keeping neurologists up to date in broad areas. Areas covered are stroke, epilepsy, multiple sclerosis, Parkinsonís disease and movement disorders, dementia, neuromuscular disorders, dizziness, and headache. Neurology Update II, 7FC.002, covers very similar topics and is scheduled on Friday, April 4.

Upon completion:

Participants should be up to date on the most recent developments in core areas of neurology to ensure better patient care. 


[7FC.002]

Neurology Update II

Mark Hallett, MD

Course description:

This program is designed to provide practicing clinicians, academicians, residents, and fellows with the most recent developments in pathogenesis and treatment in selected areas of neurology. The information should be helpful in keeping neurologists up to date in broad areas. Areas covered are stroke, epilepsy, neuro-ophthalmology, multiple sclerosis, Parkinsonís disease and movement disorders, dementia, neuromuscular disorders, and headache. Neurology Update I, 3FC.003, covers very similar topics and is scheduled on Monday, March 31.

Upon completion:

Participants should be up to date on the most recent developments in core areas of neurology to ensure better patient care.
 

© Copyright 2003, American Academy of Neurology