The joint meeting of the Americas and European Committees for Treatment and Research in Multiple Sclerosis held September 18-21, 2002 at the Baltimore Marriott Waterfront Hotel, in Baltimore, Maryland, USA.
http://www.actrimsectrims2002.nmss.org/images/meetingAbstracts.pdf
Oral Presentations
Wednesday, September 18, 2002
Young Scientific Investigator Session
Prat Ea, Kwok WWb, Kruse Nc, Pujol-Borrell Rd, Bettinotti MPe, McFarland HFa, Martin Ra
aNeuroimmunology Branch, NINDS, National Institutes of Health, Bethesda, Maryland, USA; bVirginia Mason Research Center, Seattle, Washington, USA; cInstitut Virion\Serion GmbH, Wurzburg, Germany; dImmunology Division, University Hospital "Germans Trias i Pujol", Badalona, Spain; eDTM/Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
Background: The major histocompatibility complex region shows the strongest association to multiple sclerosis (MS) and in Caucasians, HLADR15Dw2 and -DQw6 are the closest associated to the disease. In the HLADR15 haplotype, two b-chains HLA-DRB1*1501 and -DRB5*0101 are coexpressed resulting in two different surface MHC class II ab heterodimers. They both can serve as antigen presenting molecules for myelin basic proteinspecific T cells and they are able to differentially influence T cell effector functions. These findings point out that it is important to dissect which of the two alleles is functionally relevant for MS.
Objectives: The purpose of this study is to analyze the mRNA and surface expression of HLA-DRB5*0101 and -DRB1*1501 in antigen-presenting cells (APC) obtained from healthy donors (HD) and MS patients.
Methods: Peripheral blood mononuclear cells, monocytes, B cells and dendritic cells were obtained from a total of 8 HD and 14 MS patients. Three samples of thymic tissue were also analyzed. The expression of HLA-DRB5*0101 and -DRB1*1501 was evaluated by FACS and by real-time quantitative RTPCR, using specific oligonucleotides and plasmid DNA standard curves. In B cells and monocytes alleles expression was analyzed under basal conditions and after stimulation with IL-4 and IFNg in time-course (T-C) experiments.
Results: In all APC, transcripts were a few times more abundant for HLADRB5* 0101 than for HLA-DRB1*1501, while FACS experiments showed that surface expression for the two alleles was different in different APC. In TC experiments they were similarly modulated. No major differences were observed between MS patients and HD.
Conclusions: HLA-DRB5*0101 expression was overall comparable to the one of -DRB1*1501, providing further evidence for a role of this allele that is usually not considered in the pathogenesis of MS. Different surface expression patterns of the two alleles in various APC are currently being evaluated as they might be important for shaping the T cell receptor repertoire.
Disclosure: E Prat has nothing to disclose.
Funding: Elisabetta Prat was supported by a postdoctoral fellowship
from the National Multiple Sclerosis Society. The two antibodies anti-HLA-DRB1*1501
and anti-HLA-DRB5*0101 were kindly made available by Dr. Jarhow Lee from
One Lambda Inc.
Laplaud DAa,b, Wiertlewski Sb, Guillet Ma, Ruiz Ca, Melchior Ba, Edan Gc, Damier Pa,b, Soulillou Ja
aINSERM U 437, Nantes, France; bDepartment of Neurology, Nantes, France; cDepartment of Neurology, Rennes, France
Background: MS is an autoimmune demyelinating disease of the CNS associated with T-cells autoreactive for myelin components. The (auto)antigenic peptide is recognized by the T-cell through its hypervariable region on the TCR (Vb chain).
Objectives: The aim of this study was to explore the possible presence of a peripheral immune component in MS. We analysed the Vb transcriptome at a qualitative and quantitative level in the blood of MS patients using a new method designed in our laboratory (TcLand). This method allows to detect alterations in the T-cell repertoire and to estimate the T-cell pool size expressing a given altered Vb family. No further cell manipulation is performed during this procedure avoiding selection biases due to cell culture.
Methods: Two groups of patients were analyzed. The first group (n= 10) was composed of patients at early onset of MS. The second group (n=10) was composed of patients examined for a second or a third relapse of the disease. A group of healthy volunteers was also analyzed as a reference. First, peripheral blood mononuclear cells were isolated, the RNA was extracted and reverse transcribed to obtain single strand cDNA. Specific primers for 26 Vb families were used to carry out the combined qualitative and quantitative analysis of the TCR. The results were integrated to give colored coded vision of the whole Tcell repertoire refered as T-cell Landscapes (TcLand). After identification of the altered Vb family(ies) for each patient, the cells bearing the altered TCR can be separated with Vb family-specific antibodies. RNA was then extracted and mRNA cytokine production can be analysed in a quantitative manner (TaqMan).
Results: Our data suggest that there are more alterations in the MS group than in the healthy volunteer group. The alterations seem to be more frequent in MS patients at the second or third relapse than at the early onset of the disease. In addition, in preliminary experiments, we show that sorting of the cells bearing the altered TCR for transcriptional analysis is possible.
Conclusions: We suggest that this approach may open new opportunities for understanding the magnitude and the type of the immune component in MS.
Disclosure: D Laplaud has nothing to disclose.
Funding: Supported by ARSEP (Association pour la Recherche sur
la Sclerose en Plaques), supported by le College des Enseignants de Neurologie.
Geurts JJa, Kamphorst Wb, van der Valk Pb, Aronica EMc
aRadiology, MR Center for MS Research, VU Medical Center, Amsterdam, Noord-Holland, Netherlands; bPathology, MR Center for MS Research, VU Medical Center, Amsterdam, Noord-Holland, Netherlands; c(Neuro)Pathology, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands
Background: Metabotropic glutamate receptors (mGluRs) have been implicated in the regulation of synaptic plasticity, cell proliferation and cell death. Moreover, mGluRs seem to play a role in pathological processes like glutamate excitotoxicity and neurodegeneration. They are also involved in the regulation of amyloid precursor protein (APP) metabolism, a protein that is now widely regarded as a marker for (early) neuronal dysfunction in multiple sclerosis.
Objectives: to investigate the expression of group I (mGluR1a and mGluR5) and group II (mGluR2/3) mGluRs in multiple sclerosis brain.
Methods: we used immunohistochemistry in a total of 10 MS cases and 7 non–neurological controls. We also compared the MS cases to other conditions exhibiting neurodegeneration.
Results: Upregulation of both group I and II mGluRs was found in the MS cases, relative to healthy controls. A diffuse increase in expression of mGluR5 and mGlur2/3 was observed in reactive astrocytes. mGluR1a was found in a subpopulation of vimentin-positive reactive astrocytes and was strongly expressed in axons of the subcortical white matter. However, no distinct differences between MS lesion types were observed. Axonal immunopositivity was also observed in normal appearing white matter (NAWM) of MS tissue as well as in other neuropathological conditions like cerebral infarction and diffuse axonal injury. Moreover, in cortical neurons located in the proximity of a lesion, atypical clusters of mGluR1a immunoreactivity were observed.
Conclusions: group I and II mGluRs are upregulated in MS brain. This may underline the importance of glutamate excitotoxicity as a part of the pathophysiological process of multiple sclerosis and possibly also of other conditions showing neurodegeneration.
Disclosure: J Geurts has nothing to disclose.
Funding: Stichting Vrienden MS Research The Netherlands Brain
Bank.
Ciccarelli Oa, Hickman SJa, Toosy ATa, Parker GJb, Wheeler-Kingshott CAa, Barker GJa, Miller DHa, Thompson AJa
aUCL, Institute of Neurology, London, United Kingdom; bImaging Science, University of Manchester, Manchester, UK, United Kingdom
Background: Fast marching tractography (FMT) uses diffusion tensor (DT) imaging data to trace the white-matter tracts in vivo within the brain. Tractography group mapping allows the construction of anatomical connectivity maps of the optic radiation (OR) that compensate for the normal inter-subject variability.
Objectives: The aim of this study was to investigate the changes in the OR of patients affected by isolated optic neuritis (ON) using tractography group mapping.
Methods: Seven patients (mean age 37.3 ±9.4, all women) 1 year after isolated ON (4 R, 3 L) and 21 age-matched controls (mean age 33 ±9.7, 11 women and 10 men) were studied. Whole-brain DT imaging was performed and the FMT algorithm was used to trace the ORs in each individual. The OR fractional anisotropy (FA) and volume were calculated, and differences between patients and controls assessed using the t-test. Group connectivity maps of the ORs were created using SPM99, and VBM was employed to investigate the differences in the left and right OR connectivity between the two groups. A simple regression model was used to investigate whether the OR connectivity in patients are correlated with VEP amplitudes and latencies of the affected and unaffected eyes and with the number of lesions within the OR.
Results: Patients had lower OR FA (mean 0.29 ±0.03) and volume (mean 4.5 cm3 ±1.2) than controls (FA: mean 0.31 ±0.03, volume: mean 5.3cm3 ±1.3), but these differences were not statistically significant (FA: p=0.12; volume: p=0.13). VBM detected significant differences between patients and controls for the right and left OR connectivity maps (right OR: p=0.02, left OR: p=0.05, after SVC (small volume correction)). In patients, VEP amplitude and latency of the affected eye correlated with the left OR connectivity (p=0.007 corrected for whole brain and p=0.03 after SVC respectively). No correlations were found for the VEP of the unaffected eye or for the number of lesions within the ORs.
Conclusions: Tractography group mapping detects differences in the ORs between normal subjects and patients affected by ON. The relationship between the clinical findings and the extent of OR connectivity may be secondary to the ON or due to pathological damage within the OR.
Disclosure: O Ciccarelli has nothing to disclose.
Funding: O. Ciccarelli is supported by TEVA Ltd. S. Hickman is
supported by The Wellcome Trust. A. Toosy is supported by Action Research.
The NMR Research Unit is supported by the Multiple Sclerosis Society of
Great Britain and Northern Ireland.
von Büdingen H, Hauser SL, Fuhrmann A, Nabavi CB, Genain CP
Neurology, University of California, San Francisco, San Francisco, California, USA
Background: Disseminated CNS demyelination reminiscent of that seen in human multiple sclerosis (MS), is a hallmark feature of marmoset experimental allergic encephalomyelitis (EAE) following immunization with the recombinant form of myelin oligodendrocyte glycoprotein (MOG). Autoreactive antibodies against MOG play an important role in lesion pathogenesis in both this MS model and rodent EAE, however, little is known about the molecular and structural basis for pathogenicity.
Objectives: To characterize the diversity of MOG-specific humoral immune responses in a primate model of MS.
Methods: MOG-reactive antibody populations from animals immunized with MOGaa1-125 (rMOG), or 20mer MOG-derived peptides were fractionated by affinity chromatography according to specificity for linear or conformational MOG-epitopes. Monoclonal, MOG-reactive Fab fragments were selected from combinatorial IgGk-Fab libraries generated from rMOG-immune marmosets, and analyzed for immunoglobulin gene usage and MOG-epitope recognition. CNS tissue was obtained at euthanasia and was stained with Luxol Fast-Blue/Periodic Acid Schiff.
Results: Animals immunized with the MOG-derived peptides displayed antibody reactivity exclusively directed against linear determinants of MOG. In contrast, animals immunized with rMOG developed a humoral repertoire directed against both conformational and linear epitopes. Neuropathologically, MOG peptide-immune animals developed very few lesions with scarce demyelination, in stark contrast to animals immunized with rMOG. A limited number of heavy and light chain variable region genes appear to be used by the marmoset immune system to target a number of different conformational epitopes of MOG. These epitopes are consistently found in MOG-immune antibody repertoires in this species, as demonstrated by competition experiments with monoclonal Fab fragments from the antibody libraries against native anti-MOG antibodies.
Conclusions: In conclusion, these studies provide the first detailed description of MOG-specific antibody responses in an outbred primate, and suggest that conformation-dependent anti-MOG antibodies play a predominant role in the pathogenesis of CNS demyelination.
Disclosure: H von Büdingen has nothing to disclose.
Funding: Supported by the National Institutes of Health (NIAID
AI43073 to SLH, NS1-996-02 to HCvB), the Nancy Davis Foundation, the New
York Community Trust, the German Hertie Foundation, the German Multiple
Sclerosis Society, and the National Multiple Sclerosis Society (JF2087-A-2
to CPG).
Enzinger Ca, Ropele Sb, Strasser-Fuchs Sa, Kapeller Pa,b, Seifert Ta, Poltrum Ba, Schmidt Hc, Schmidt Ra, Fazekas Fa,b
aNeurology, Karl-Franzens-University Graz, Graz, Styria, Austria; bMRI Centre, Karl-Franzens-University, Graz, Styria, Austria; cInsititute of Biomed., Karl-Franzens-University, Graz, Styria, Austria
Background: The Apolipoprotein E e4-allele (e4) has been associated with clinical worsening in multiple sclerosis (MS) and more pronounced tissue damage on magnetic resonance imaging (MRI) and proton MR spectroscopy.
Objectives: We attempted to consolidate this assumption by using serial MRI of the brain to follow the evolution of black holes which are regarded as a putative marker of matrix destruction and axonal loss.
Methods: 99 individuals with clinically definite relapsing-remitting MS (age 35.3+/-9.5 yrs, disease duration 6.6+/-7.2 yrs, Expanded Disability Status Scale score 1.5+/-1.2) underwent genotyping and clinical examination. T2- and T1-weighted axial MRI of the brain (1.5 T, TR/TE=2500/30 and 90; 600/15) for semi-automated lesion segmentation was performed at baseline and after 2.7+/- 1.1 yrs. Black holes were defined as T1-lesions with a signal intensity between cortical grey matter and cerebrospinal fluid.
Results: At baseline, T2- and T1-lesion loads (LL) were non-significantly higher in patients with e4 (n=23; T2-LL: 11.8+/-11.4; T1-LL: 1.2+/-2.3 ccm) than in those without e4 (n=76; T2-LL: 8.9+/-9.5; T1-LL: 0.7+/-1.8 ccm), despite a shorter disease duration (4.2+/-5.2 vs. non-e4: 7.4+/-7.6 yrs, p=0.06) and the absence of significant differences in clinical variables between groups. During follow-up, T2-LL significantly enlarged in patients without e4 (10.6+/- 11.0 ccm; p=0.001), whereas it remained unchanged in e4-carriers (11.3+/-11.7 ccm). In contrast, T1-LL significantly increased in the e4-subgroup (1.7+/-2.7 vs. non-e4: 0.8+/-1.5 ccm, p=0.039). Moreover, the proportion of black-holes [(T1LL/T2LL)x100] increased significantly from 5.5+/-7.7 % to 12.4+/-13.9 % (p=0.005) in e4-patients whereas it did not change significantly in non-e4 patients (baseline: 5.0+/-7.9 %, follow-up: 5.7+/-7.3 %, p=0.37).
Conclusions: The observed higher proportion of MRI brain lesions that develops into black holes in MS patients with e4 provides further support for a more aggressive disease course in e4 carriers.
Disclosure: C Enzinger has nothing to disclose.
Rocca MAa, Mezzapesa Da, Falini Ab, Ghezzi Ac, Martinelli Vd, Rodegher Md, Scotti Gb, Comi Gd, Filippi Ma
aNeuroimaging Research Unit, Department of Neuroscience, Scientific Institute and University HSR, Milan, Italy; bDepartment of Neuroradiology, Scientific Institute and University HSR, Milan, Italy; cDepartment of Neurology, Ospedale di Gallarate, Gallarate, 81, Italy; dClinical Trials Unit, Department of Neurology, Scientific Institute and University HSR, Milan, Italy
Background: Recent MRI and pathologic studies have demonstrated the presence of axonal loss and dysfunction even in the early stages of MS.
Objectives: To assess, using fMRI, the brain pattern of movement-associated cortical activations in patients at presentation with clinically isolated syndromes (CIS) suggestive of MS. To investigate the correlation between the extent of functional cortical activations and the extent of MS-related pathology, measured using conventional MRI and whole brain N-acetylaspartate (WBNAA) 1-HMRS.
Methods: From 16 right-handed patients at presentation with CIS and 15 controls, we obtained: a) fMRI (repetitive flexion-extension of the last four fingers of the right hand), b) dual-echo scans, c) 1H-MRS to assess WBNAA levels. FMRI data were analyzed using SPM99.
Results: Compared to controls, patients with CIS had decreased whole brain NAA levels (p<0.001). They also had more significant activation of the contralateral primary somatomotor cortex (SMC), secondary somatosensory cortex and inferior frontal gyrus. Relative activation of the contralateral primary SMC was correlated with whole brain NAA levels (r=-0.78, p<0.001).
Conclusions: This study demonstrates that functional cortical changes can be detected in patients at presentation with CIS. These changes might have a favorable role in limiting the impact of axonal pathology on subsequent disease evolution.
Disclosure: M Rocca has nothing to disclose.
Bagnato Fa, Jeffries Nb, Ohayon Ja, Stone Ra, Richert Nc, Bash Cc, McFarland HFa, Frank JAc
aNeuroimmunology Branch NINDS, NIH, Bethesda, Maryland, USA; bBiostatistics Branch NINDS, NIH, Bethesda, Maryland, USA; cNeuroimmunology Branch NINDS, NIH, Bethesda, Maryland, USA; dNeuroimmunology Branch NINDS, NIH, Bethesda, Maryland, USA; eLaboratory of Diagnostic Radiology Research, NIH, Bethesda, Maryland, USA; fLaboratory of Diagnostic Radiology Research, NIH, Bethesda, Maryland, USA; gNeuroimmunology Branch NINDS, NIH, Bethesda, Maryland, USA; hLaboratory of Diagnostic Radiology Research, NIH, Bethesda, Maryland, USA
Background: Interferon beta (IFNb) reduces inflammatory activity and the accumulation of permanent damage in Multiple Sclerosis (MS), as measured by the number of contrast enhancing lesions (CELs) and persisting Black Holes (PBHs) on T1 weighted (T1w) images. Nevertheless, the effect of IFNb on the duration of PBHs has not been investigated.
Objectives: To evaluate the influence of IFNb-1b on the duration of PBHs in 10 MS patients followed monthly for 18 months before and after treatment with IFNb-1b.
Methods: Ten MS patients were treated with IFNb-1b and followed with monthly Magnetic Resonance Images (MRI) for 18 months prior to (baseline) and after starting therapy (treatment). Baseline characteristics of the patients were as follow: male/female: 9/3, mean ±SD age 34.4 ±5.5, EDSS 3.0 ±1.5, MS duration 7.2 ±7.2 years, MS type: 7 relapsing-remitting, 1 relapsing-progressive, 2 secondary-progressive. The number of CELs and PBHs in the corresponding un-enhanced T1w scan was evaluated. A PBH was defined as any hypo intense region visible on the T1w with hyperintensity on the T2w and without a CEL. Only PBHs with a previously identified CELs were considered for the analysis. The student T-test compared the mean number of CELs before and during therapy. The Kaplan Meier Survival Analysis (KMS) analyzed differences in the length of time of PBHs in the two arms. P values were based on two-tailed statistical tests, with a significance level of 0.05.
Results: Although the number of CELs was significantly reduced during therapy, results of the KMS showed no difference in terms of PBHs duration between lesions developing during the baseline or treatment periods.
Conclusions: These results provide further insights into the mechanisms of IFNb-1b. Although the drug decreases the inflammatory activity, the events that follow the acute lesion formation appear not to be affected IFNb-1b. The observation is consistent with a mechanism of action that acts primarily at the level of the blood brain barrier.
Disclosure: F Bagnato has nothing to disclose.
Penner Ia, Kappos Lb, Rausch Mc, Opwis Ka, Radü Ed
aCognitive Psychology, University of Basel, Basel, Switzerland; bNeurology, University Hospital Basel, Basel, Basel Stadt, Switzerland; cNovartis Pharma AG, Central Technologies, Basel, Basel Stadt, Switzerland; dNeuroradiology, University Hospital Basel, Basel, Basel Stadt, Switzerland
Background: Little is known about the effects a cognitive training might induce on the brain organisation and its possible visualization by fMRI.
Objectives: Our aim is to analyse the effects of a cognitive training on attention with functional MRI and to relate baseline and follow up fMRI findings with the result of training.
Methods: We assessed different attention domains with a neuropsychological test battery (TAP) in twelve MS patients and seven healthy controls. According to the patients’ performance on the tests, they were classified as mildly and severely impaired. After the baseline examination, all patients underwent a cognitive training program for the most impaired attentional function. To determine the brain structures induced by the attention tasks before and after training, all subjects were investigated by fMRI.
Results: Training facilitated functional activation of brain structures that were not responding initially. Those were located mainly in the frontal and parietal cortex. This effect was found in all tasks in mildly impaired patients who were able to compensate for their deficits even in the tasks with high complexity; in the more severely impaired patients additional activation and compensation was restricted to the simplest task. However, when improvement in performance in the attention tasks was chosen as dependent variable instead of absolute degree of dysfunction, the patients with improvements showed a decrease in brain activation after training while the patients without improvement showed a significant increase in activation.
Conclusions: Effects induced by a cognitive training can be visualized by functional MRI. The amount of performance improvement after retraining however, seems to depend on the brain’s capacity to establish new interconnections. Successful training might be dependent on the individuals ability to focus on relevant brain structures while failure to improve after training might be related to waste non-focused brain activation. Supported by the Swiss MS Society.
Disclosure: I Penner has nothing to disclose.
Bielekova Ba, Reichert-Scrivner Sa, Wuerfel Ja, Ohayon Ja, McCartin Ja, Richert Nb, Frank Jb, Waldmann Tc, McFarland Ha, Martin Ra
aNeurology, Institute of Neurology, Cambridge, United Kingdom; bLaboratory of Diagnostic Radiology Research, NIH/CC, Bethesda, Maryland, USA; cMetabolism Branch, NIH/NCI, Bethesda, Maryland, USA
Background: MS is an immune-mediated demyelinating disorder of the CNS. Current treatments of MS are based on immunosuppressive or immunomodulatory strategies and are only partially effective in majority of patients. The experience with one of these therapies, IFN-beta, clearly demonstrated that the therapeutic effect is dose-dependent. It is therefore likely that, depending on the level of activation of the immune system, multimodal approaches will be required in some patients to reach optimal therapeutic effect.
Objectives: We tested the hypothesis, whether in patients with only partial therapeutic response to IFN-beta addition of humanized antibody against Interleukin-2 receptor alpha chain (Zenapax) would result in further decrease in contrast-enhancing brain MRI lesions.
Methods: This was an unblinded, baseline (IFN-beta alone)-versus add-on treatment (IFN-beta + Zenapax) crossover phase II trial, with total of 10 MS patients. Inclusion criteria included clinical and/or MRI definitions for partial response to IFN-beta. Patients have been followed by monthly clinical-, MRIand immunological measures for 4 months of baseline and 9 months of treatment. Primary outcome measure was the change in number of contrast-enhancing MRI lesions. Number of additional MRI, clinical and immunological parameters served as secondary outcome measures.
Results: Zenapax add-on therapy was tolerated extremely well and led to over 50% additional reduction in MRI contrast-enhancing lesions in the majority of patients. Zenapax did not cause general immunosuppression, nor did it significantly decrease the proliferation of peripheral blood T-lymphocytes to strong polyclonal stimuli or recall antigens.
Conclusions: We anticipate that Zenapax will become a treatment alternative in MS, however, it needs to be studied whether Zenapax acts in concert with IFN-beta or by itself.
Disclosure: Dr. Thomas Waldman holds a patent for the use of
an antibody to the IL-2 receptor for treating malignancy and autoimmune
disorders. Other authors have nothing to disclose. Thursday, September
19, 2002 Keynote Address
Ludwin SK
Department of Pathology, Queens University and Kingston General Hospital, Kingston, Ontario, Canada
Abstract Body: Multiple Sclerosis is characterized by demyelination, inflammation, gliosis and axonal loss. In recent years it has become obvious that axonal loss accounts for a major amount of the symptomatology and disability, especially in progressive cases. Etiopathogenesis of the axonal loss has become of prime importance, as prevention and regeneration strategies will become part of the Multiple Sclerosis physician’s armamentarium. Although axonal damage in acute cases can be well accounted for by the marked cellular infiltration, together with its resultant chemical toxic factors, continuing and progressive axonal damage in chronic lesions is less easy to understand. Possible mechanisms include susceptibility of demyelinated axons to continual insult from ongoing inflammation, axonal degeneration following lack of trophic support from oligodendroglia and myelin, and primary damage and degeneration to the neurons. It is possible that one or more of these mechanisms may result in axonal damage. The relationship between these factors and axon loss may vary from case to case, and also during varying timepoints within each case. Experimental models where the elements such as inflammation, demyelination and gliosis can be dissected and examined in isolation may assist in elucidating possible mechanisms for this axonal loss. The axon may be differentially affected in animal models which are predominantly either inflammatory or demyelinating as in toxic disorders; models of ischemia and edema may under different conditions damage the axon and at times the myelin sheath or both. These relationships can also be studied in human diseases where the same elements are prominent, such as hereditary leukodystrophies, toxic diseases such as carbon monoxide, and ischemic lesions. Each of these groups of diseases may have varying combinations of these elements. Careful examination of the distribution of lesions may also help to determine the role of neuronal dysfunction in causing axonal loss. Patterns with a distal-proximal gradient along tracts may suggest neuronal dysfunction with a dying-back picture, as opposed to Wallerian distribution. The role of gliosis as an alternative neuroprotectant in various experimental and clinical conditions may also render clues as to glial trophic protection.
Disclosure: S Ludwin has nothing to disclose.
Funding: CIHR/MRC MS Society of Canada.
Session I
Inflammation, Demyelination and Axonal Loss: Insights
From Pathology
Trapp BDa, Bjartmar Ca, Peterson Ja,c, Chang Aa, Rudick Ra,b
aDepartment of Neurosciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA; bDepartment of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA; cNeuroscience Graduate Studies Program, Ohio State University, Columbus, Ohio, USA
Abstract Body: This presentation will summarize pathological studies from our laboratory that describe axonal pathology and axonal degeneration in postmortem MS brains. Three mechanisms of axonal loss will be discussed. The first is axonal transection in the setting of inflammatory demyelination. This mechanism of axonal loss begins at disease onset, predominates in early stages of relapsing-remitting MS and is often clinically silent because the brain compensates for axonal loss. The topological relationship between axonal transection and inflammatory demyelination suggests that demyelinated axons are vulnerable to components of the inflammatory environment. Proteolytic enzymes, cytokines, oxidative products and free radicals produced by activated immune and glial cells may cause axonal transection by reducing energy metabolism, ATP synthesis and Ca+ homeostasis. The second mechanism is progressive degeneration of chronically demyelination axons. This process results in the inexorable progression of neurological disability that so commonly complicates the secondary progressive stages of MS, when brain inflammation often subsides. Myelin or myelin-forming cells provide trophic support to the axon and chronic loss of myelin can result in degeneration. The possibility has also been raised that the redistribution and abnormal expression of Na+ channel subunits on demyelinated axolemma may render axons vulnerable to degeneration. An acquired channelopathy, therefore, may also contribute to degeneration of chronically demyelinated axons. The third mechanism of axonal loss occurs in the setting of demyelination of the cerebral cortex. Transected axons and dendrites are abundant in cortical lesions and they correlate with the degree of microglia activation. Infiltration of hematogenous leukocytes and perivascular cuffs are not features of cortical lesions. Recent studies indicate that significant areas (over 25%) of cerebral cortex are demyelinated in many MS patients. A better understanding of the dynamics of cortical lesion formation is needed to fully appreciate their role in the pathogenesis of neurological disability in MS.
Disclosure: B Trapp has nothing to disclose.
Funding: Supported by National Institutes of Health (NS38667)
National Institutes of Health (NS35058)
Brueck W
Institut fur Neuropathologie, Berlin, Berlin, Germany
Abstract Body: Multiple sclerosis (MS) is characterized morphologically by the key features demyelination, inflammation, gliosis, and axonal damage. In recent years it has become more evident that axonal damage is the major morphological substrate of permanent clinical disability. In our study we investigated the occurrence of acute axonal damage determined by immunocytochemistry for amyloid precursor protein (APP) which is produced in neurons and accumulates at sites of recent axon transection or damage. The extent of acute axonal damage was correlated with the stage of demyelinating activity, disease duration and course as well as numbers and components of the inflammatory infiltrate. Most APP positive axons were detected within the first year after disease onset, but acute axonal damage was also detected to a minor degree in lesions of patients with a disease duration of 10 years and more. This effect was not due to the lack of active demyelinating lesions in the chronic disease stage. Late remyelinated lesions (so-called shadow plaques) did not show signs of axon destruction. The number of inflammatory cells showed a similar decrease over time like the number of APP positive axons. There was a significant correlation between the extent of axon damage and the numbers of CD8-positive cytotoxic T cells and macrophages/microglia. Our results indicate that a putative axon-protective treatment should start as early as possible and include strategies preventing T cell/macrophage mediated axon destruction and leading to remyelination of axons.
Disclosure: W Brueck has nothing to disclose.
Funding: Supported by: Gemeinnützige Hertie-Stiftung
Mycko MPa, Papoian Rc, Boschert Uc, Raine CSb, Selmaj KWa,b
aDepartment of Neurology, Medical University of Lodz, Lodz, Poland; bSerono Research Institute, Serono, Geneva; cAlbert Einstein College of Medicine, Department of Pathology (Neuropathology), New York, New York, USA
Background: Multiple sclerosis (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. Histopathologically MS lesions are divided into acute, chronic active and chronic inactive plaques.
Objectives: 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.
Methods: Differential gene expression (DGE) was performed by cDNA microarray analysis of CNS tissue from 4 multiple sclerosis (MS) subjects in which different regions of chronic active (n=2) and chronic silent lesions (n=2) were compared.
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 nonactive type of lesions. 14 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. To compare differences between chronic active and silent lesions, we performed DGE comparison of the pooled data from both types of lesions. The major DGE occurred at the lesion margin, 156 (26; 5%), the greater number representing upregulated genes at the margin of active lesions (15%).
Conclusions: We have identified a set of genes to be differentially expressed within the MS chronic type lesions that may be related with the activity of the MS chronic lesions. Thus, using microarray analysis we were able to highlight a genes associated with lesion activity in MS, many of them not previously linked with the disease.
Disclosure: K Selmaj has nothing to disclose.
Lindberg RLa, De Groot CJb, Certa Uc, Ravid Rd, Hoffmann Fa, Kappos La, Leppert Da
aNeurology and research, Neuroimmunology, Pharmazentrum, Basel, BS, Switzerland; bMedical Centre, MS Centre for Research and Care, Vrije Universiteit, Amsterdam, Netherlands; cDept. Roche Genetics, F. Hoffmann-La Roche, Basel, BS, Switzerland; dNetherlands Brain bank, Amsterdam, Netherlands
Background: Modern MRI techniques reveal an array of changes reflecting substantial loss of axons and myelin damage in the normal appearing white matter (NAWM). These changes develop already in early phases of MS, and are independent of lesion formation.
Objectives: However, little is known about the underlying molecular mechanisms that lead to these NAWM changes.
Methods: We compared the gene expression profile in brain tissue from active lesions and donor-matched NAWM in autopsy samples from patients with secondary progressive MS (n=6) with that from controls (n=12) without neurological disease using a 13,000 gene microarray.
Results: We identified 112 (34 up- and 78 down-regulated) and 41 (26 upand 15 down-regulated) genes that were differentially expressed in lesions and NAWM, respectively, as compared to controls. 95 RNA sequences coded for known and 58 for unknown genes. 140/153 (91.5%) of genes differentially expressed in lesions or NAWM showed similar transcriptional changes in the respective other tissue compartment, as opposed to 12 genes that were up- or down-regulated exclusively in lesions. We categorized differentially expressed known genes into five groups functional for a) transcriptional control, b) immune response/extracellular matrix remodeling, c) glial and d) neuronal homeostasis, and e) enzymes. Similar to lesions, 17/23 of differentially expressed genes in NAWM grouped for category b), 14/17 of these genes related to signaling, activation and migration of immune cells. In NAWM we found a higher prevalence of genes related to the cellular immune response, while in lesions genes controlling immunoglobulin production prevail.
Conclusions: These results support the concept that MS represents a generalized inflammatory disease of the CNS and that focal Ig production is critical for plaque formation.
Disclosure: Raija Lindberg has nothing to disclose.
Funding: Supported by SNSF grant 31-63666, Baasch-Medicus Foundation,
Lichtenstein Foundation and the Swiss MS Society.
Goebels Na,b, Weber Ha, Hofbauer Ma, Wekerle Hb, Hohlfeld Ra,b
aInstitute for Clinical Neuroimmunology, Klinikum Grosshadern, Muenchen, Bavaria, Germany; bDepartment of Neuroimmunology, Max-Planck-Institute for Neurobiology, Martinsried, Bavaria, Germany
Background: Multiple sclerosis (MS) is a multifocal inflammatory disease of the central nervous system (CNS) characterized by demyelination and axonal damage. Although the responsible components of the immune system and the precise molecular targets 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 in the cerebrospinal fluid (CSF) of MS patients.
Objectives: To study, whether brain tissue and CSF of MS patients contains distinct or identical B cell repertoires.
Methods: We employed a PCR - based method to identify and characterize clonally expanded B cells. The method ("CDR3 spectratyping") relies on the natural length variation of the third hypervariable region (CDR3) of the rearranged immunoglobulin 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, which can be identified as a single band on a sequencing gel. The identity of these exanded B cell clones can often be determined by subsequent cycle sequencing.
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. Histological examination of the brain tissue, CSF and clinical/MRI follow up supported the diagnosis of multiple sclerosis. CSF cells were obtained 6 months (patient A) and 5 years (patient B) after brain biopsy. Using CDR3-spectratyping, we repeatedly detected identical clonally expanded B cell clones both in the CSF and brain tissue compartments.
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. Whereas some B cell clones maintained identical CDR3 region sequences, others showed signs of ongoing hypermutation. These findings strongly support that spinal fluid B cells at least partially represent disease relevant lymphocytes infiltrating MS brain tissue.
Disclosure: N Goebels has nothing to disclose.
Funding: Supported by Deutsche Forschungsgemeinschaft (SFB 571/A3),
University of Munich, Hermann und Lilly Schilling Stiftung, Max-Planck-Gesellschaft.
Giuliani F, Yong V
Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Background: MS is considered a T cell-mediated autoimmune disease of the CNS. MS lesions are characterized by infiltration of inflammatory cells, demyelination, axonal loss and neuronal degeneration. It has been reported by others that CD8+ T cells can induce the apoptosis of rodent neurons via an MHC-I mediated mechanism; MHC-I expression on neurons was induced by treatment with IFNg and tetrodotoxin. Given that neurons are usually negative for MHC-I expression in vivo, the current study seeks to investigate whether human neurons are also susceptible to T cell cytotoxicity and whether this can occur through a bystander mechanism.
Objectives: To determine whether activated human T cells can kill human neurons and to elucidate the mechanisms of this toxicity.
Methods: We used a co-culture system of human fetal neurons and T cells from allogeneic PBMC or syngeneic splenocytes. T cells were activated with an anti-CD3 antibody for 72h and then incubated with neurons. After, neurons were stained with mouse anti-MAP-2 antibody conjugated to Cy3. The number of surviving MAP-2 positive neurons was counted. In some experiments, neutralizing antibodies to defined antigens were introduced to the co-culture system to modify the killing.
Results: When activated T lymphocytes were added to neuronal cultures, they aggregated around neuronal elements and death to neurons occurred promptly. By 3h of co-culture, the number of MAP-2 positive neurons was reduced by 50% when compared to controls. Neuronal toxicity required the activation of T cells since unactivated T lymphocytes did not produce any death. Allogeneic or syngeneic activated T cells were equally deleterious to neurons. The mechanism of T cell mediated neuronal toxicity required cell-cell contact, and was attenuated by neutralizing antibodies to FasL, LFA-1 and CD40. Finally, no T cell cytotoxicity was evident on oligodendrocytes or astrocytes.
Conclusions: These data demonstrate that activated human T cells can kill human neurons in vitro without the apparent need for MHC-I. Toxicity is not a result of a graft-versus-host response as demonstrated using syngeneic co-culture. Furthermore, cytotoxicity is selective for neurons. We suggest that when T cells are activated, they enter the CNS to induce disruption of neural elements and cause neuronal death.
Disclosure: F Giuliani has nothing to disclose.
Funding: Supported by Alberta Heritage Foundation for Medical
Research - Canadian Institutes of Health Research.
Butzkueven H, Zhang J, Soilu-Hanninen M, Bartlett PF, Kilpatrick TJ
Neurobiology and Development, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
Background: Current therapies for MS reduce relapse rate but do not suppress progressive clinical disability. An alternative approach would be to inhibit mechanisms that drive the neuropathology of MS, which includes oligodendrocyte death. Identification of molecular mechanisms that mediate the survival response of injured oligodendrocytes could identify new targets for therapy.
Objectives: To study the clinical effect and mechanism of action of the neurotrophic cytokine Leukaemia Inhibitory Factor (LIF) in Experimental Autoimmune Encephalomyelitis (EAE).
Methods: We tested the effect of LIF in EAE (PLP EAE in SJL/J and MOG EAE in C57/B6 mice), including degree of spinal cord inflammation and oligodendrocyte numbers, and performed an analysis of EAE in mice deficient in LIF receptor signalling.Weused immuno-histochemistry to study LIF Receptor (LIFR) expression and IP/Western blotting to delineate LIF signaling events in the spinal cord.
Results: LIF reduced disease severity in both mouse models of EAE by 1.1 points on the EAE scale (p<0.01). Delayed therapy was equally effetcive. It had no effect on inflammation, including cord infiltration, disease onset, relapse rate, splenocyte proliferation/cytokine production, or passive transfer efficiency. However, LIF prevented the 30% oligodendrocyte loss seen in our EAE models, both in grey and white matter. Immuno-histochemistry revealed up-regulation of LIFR on oligodendrocytes in EAE. Western blots confirmed increased expression of LIFR, and showed that LIF both accessed the spinal cord and induced phosphorylation of both LIFR and STAT-3. Mice doubly heterozygous for the LIFR beta deletion and a gp130 truncation exhibited delayed, marked worsening of EAE with 100% lethality. This correlated with a three-fold increase in oligodendrocyte apoptosis in spinal cord, and a 60% reduction in white matter oligodendrocytes (p<0.001).
Conclusions: This study identifies that LIF directly prevents oligodendrocyte death in EAE. We also demonstrate that this therapeutic effect complements endogenous LIF receptor signalling, which already serves to limit oligodendrocyte loss during immune attack. Our work suggests that oligodendroglial protection may provide a novel approach to the treatment of MS.
Disclosure: TJ Kilpatrick has acted as a consultant to AMRAD, which owns relevant LIF patents.
Funding: Supported by The National Health and Medical Research
Council of Australia and AMRAD Corporation.
Bruno Sa,b, Frederic Na, Marie Stephane Aa, Bernard Za, Catherine La acentre d’investigation clinique, hôpital de la Salpêtrière, Paris, France; bInserm U 495, Hôpital de la Salpêtrière, Paris, France
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
Objectives: Using a newly developed enzymatic index of myelination, we screened different neurotrophic factors for their ability to enhance myelination.
Methods: Neurotrophic factors were added to the culture medium of myelinating cocultures between 11 and 25 days 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.
Disclosure: S Bruno has nothing to disclose.
Funding: Supported by Inserm (institut national de la santé
et de la recherche médicale), and ARSEP (association de recherche
sur la sclérose en plaques).
Session II
Impact of Relapses on Disability: Natural History
and Clinical Trials Data
Lublin Fa, Cutter Gb, Baier Mc
aCorinne Goldsmith Dickinson Center for MS, Mount Sinai Medical Center, New York, New York, USA; bPythagoras, Inc., Reno, Nevada, USA; cAMC Cancer Center, Denver, Colorado, USA
Abstract Body: Although it is intuitively obvious that repeated exacerbations may lead to step-wise worsening of neurological function in patients with MS, the actual role of exacerbations has not been quantified. For this study, we queried a database of placebo patients from several completed clinical trials of relapsing forms of MS to determine the effect of exacebation on clinical course. In these trials, patients had periodic (usually q 3 month) assessments and also examinations at the time of exacerbation. Thus, we had a pre-exacerbation assessment of EDSS and Scripps score, intra-exacerbation scores and follow-up evalautions. We found that there was a mean worsening of 0.4 EDSS units. This finding persisted when patients were assessed more than 30 days after an exacerbation. Of those patients with exacerbations, 45% had residual impairment. The finding were similar for the Scripps score, with an average worsening of 2 points. The percent of patients with residual deficits increased with the length of time between the exacerbation and the follow-up visit, supporting the permanence of the effect. These results indicate that exacerabtions in MS can leave residual deficit, in a step-wise fashion, and as such are an important therapeutic target. The results are consistent with the outcomes of clinical trials in RR MS.
Disclosure: F Lublin has nothing to disclose.
Confavreux C
aNeurology A, Hôpital Neurologique, Lyon, France; bEDMUS Coordinating Center, Lyon, France
Abstract Body: There is good evidence that relapses in MS are the clinical counterpart of acute focal inflammation of the central nervous system whereas progression is that of chronic diffuse neurodegeneration. The classical view is to consider that MS is an organ-specific auto-immune disease, i.e. that inflammation is the cause of the neurodegeneration. The succession of relapses eventually leads to accumulation of disability and clinical progression could result from infraclinical relapses. A series of recent observations tend to challenge this classical concept. Interferons beta have well-known effects in MS. They lead to a 30 % reduction in the relapse rate and to a more than 50 % reduction in conventional MRI activity. Despite this strong effect on inflammation, the effect of interferons on disability is only marginal and possibly relapse-reduction driven. Administration of Campath-1H to MS patients results in a profound and prolonged lymphopenia, and the suppression of clinical and MRI activity. In spite of this, progression of clinical disability and cerebral atrophy still occurs. The relapse rate decreases dramatically during pregnancy, notably during the third trimester. By contrast, the three-month post-partum period is characterized by a 60 % increase of the relapse rate. Despite these dramatic changes in the frequency of relapses, progression of disability goes on. Striking results have also come from the study of the natural history of MS in the Lyon MS Cohort. Progression of irreversible disability from the assignment of a score of 4 on the DSS Kurtzke scale to the assignment of a score of 6 or 7 is unaffected by the presence or the absence of a relapsing-remitting phase before the progressive phase of MS. The same observation is true regarding the presence or the absence of superimposed relapses during the progressive phase, either primary or secondary. All these observations give some credit to the fact that relapses do not essentially influence irreversible disability in the long term in MS. They are consistent with what has been shown at the individual level in the 70’s by performing serial quantitative neurological examinations over several years, and with what is currently emerging from early and serial structural brain MRI studies.
Disclosure: Christian Confavreux has participated in meetings sponsored by pharmaceutical companies marketing treatments for multiple sclerosis and received grants from them. He has received fees and honoraria for his expertises and lectures from phamaceutical companies marketing or developping programmes for the treatment of multiple sclerosis. The Department of Neurology A has received financial support for taking part in randomized, controlled trials from these pharmaceutical companies.
Funding: Biogen, Schering, Serono, Teva Pharma laboratories.
Johnson KPa, Brooks BRb, Ford CCc, Goodman Ad, Guarnaccia JBe, Lisak RPf, Myers LWg, Panitch HSh, Pruitt AAi, Kachuck Nj, Wolinsky JSk, and the Copolymer 1 MS Study Group
aUniversity of Maryland, Baltimore, Maryland, USA; bUniversity of Wisconsin, Madison, Wisconsin, USA; cUniversity of New Mexico, Albuquerque, New Mexico, USA; dUniversity of Rochester, Rochester, New York, USA; eYale University, New Haven, Connecticut, USA; fWayne State University, Detroit, Michigan, USA; gUniversity of California, Los Angeles, California, USA; hUniversity of Vermont, Burlington, Vermont, USA; iUniversity of Pennsylvania, Philadelphia, Pennsylvania, USA; jUniversity of Southern California, Los Angeles, California, USA; kUniversity of Texas, Houston, Texas, USA
Background:RRMS is a chronic debilitating disease requiring early and sustained treatment. Various agents with distinct mechanisms of action and effects are currently available for the treatment of RRMS. The onset of action of these agents can be measured by their effect on several biologic, imaging, and clinical parameters.
Objectives:To evaluate the time course of early clinical effects of glatiramer acetate (GA) in decreasing the rate of relapse in patients with RRMS.
Methods:The effect of SC administration of GA 20 mg QD on decreasing the primary endpoint of relapse rate was evaluated in a randomized, placebo controlled trial of 251 patients with RRMS. Regular quarterly and as needed clinic visits were performed to assess outcome and relapse events with a standardized criteria. Mean relapse rate was analyzed using ANCOVA, with tests for studydrug-by-center interaction and including the priori-defined covariates: sex, disease duration (years), prior 2 year relapse rate, and baseline EDSS to evaluate the time course of effect on relapse rate with GA treatment compared to placebo.
Results:The beneficial treatment effect of GA treatment compared to placebo on decreasing relapse rate at month 3 was 17%, p=NS; month 6 was 27%, p=.074; month 9 was 25%, p=.047; month 12 was 27%, p=.018; month 15 was 24%, p=.034; month 18 was 27%, p=.014; month 24 was 29%, p=.007; and at approximately 30 months was 32%, p=.002.
Conclusions:The clinical benefit of GA on decreasing relapse rate is seen relatively quickly with widening divergence at 6 months and statistically significant divergence seen at 9 months. Sustained and increasing benefit was observed throughout the 30 month follow-up.
Disclosure: KP Johnson is a consultant for Aventis Pharm., Amrad Corporation Ltd., Berlex Laboratories, Teva Pharm., Wyeth Ayerst. KP Johnson is on the Speakers Bureau for Berlex Laboratories and Teva Pharm. KP Johnson receives research support from Berlex Laboratories and Teva Pharm.
Funding: Supported by: Federal Food and Drug Administration Orphan
Drug Program, the National Multiple Sclerosis Society, and Teva Pharmaceutical
Industries Ltd.
Comi Ga, Filippi Ma, Barkhof Fb, Durelli Lc, Edan Gd, Fernandez Oe, Hartung Hf, Seeldrayers Pg, Soelberg Sorensen Ph, Hommes Oi
aClinica Neurologica, Ospedale San Raffaele; bFree University Hospital, Amsterdam, Netherlands; cClinica Neurologica, Torino, Italy; dCentre Hospitalier Universitaire Pontchaillou, Rennes, France; eHospital Regional De Málaga, Málaga, Spain; fHeinrich-Heine Universitat, Dusseldorf, Germany; gCHU Charleroi, Charleroi, Charleroi, Belgium; hRigshospitalet, Copenhagen, Denmark; iEuropean Charcot Foundation, Nijmegen, Netherlands
Background: The ETOMS Study showed a beneficial effect of IFN beta-1a Rebif 22 mcg ow on conversion to clinically definite MS (CDMS) amongst patients with clinically isolated syndromes and MRI scans suggestive of MS.
Objectives: The study was extended to 4 years to assess longer term outcome.
Methods: 308 patients were randomized to double blind-treatment with IFNbeta-1a 22 mcg s/c qw or placebo for 2 years, followed by a two-year extension with open-label treatment (IFN beta-1a 22 mcg ow). Patients who reached the primary endpoint, conversion to CDMS, could stay in the study or withdraw and start best available therapy, at the physician’s discretion.
Results: Fewer patients initially randomized to IFN converted to CDMS compared to those randomized to placebo, over the 4 years (67/154 (43.5%) vs 79/154 (51.3%). Although the difference at 2 years was statistically significant, it was not at 4 years (p=0.115). The time to conversion (40th percentile) was prolonged but not significantly (27.9 months IFN vs 16.3 placebo, p=0.114). Annualised relapse rate was not significantly different between treatment groups over four years. Of the 263 patients who entered year 3, 174 (66%) had not converted to CDMS before the end of year 2 (96 IFN, 78 placebo). Of these, 25 (14%) 15 (16%) randomised to IFN and 10 (13%) randomised to placebo converted to CDMS during years 3 or 4 (p=0.604). The global conversion rate dropped from 47% in the first two years to 14% in the second 2 years.
Conclusions: During the extension phase the conversion rate was lower in both groups, compared to the double blind phase. The benefit of low doses of IFN seem to be limited to the early phases of the disease.
Disclosure: Professor Comi has served as a Consultant to Serono.
Funding: Sponsored by Serono Intenational.
Sorensen PSa, Koch-Henriksen Nb, Ross Cc, Clemmesen KMc, Svenson Mc, Bendtzen Kc, Frederiksen Jb, Jensen Kb, Kristensen Ob, Petersen Tb, Stenager Eb, and Db
aNeurology 2082, Rigshospitalet, Copenhagen, Denmark; bDanish Multiple Sclerosis Study Group, MS Registry, Copenhagen, Denmark; cInstitute for Inflammation Research, Rigshospitalet, Copenhagen, Denmark
Background: Therapy-induced neutralizing antibodies (NAB) against IFNbeta may interfere with treatment efficacy. Reported frequencies and clinical impact of anti-IFN-beta NAB vary depending on the IFN-beta preparation and administration.
Objectives: To evaluate the effect of different serum concentrations of NAB on the therapeutic efficacy in all IFN-beta treated patients in Denmark, using different sensitivities of the bioassay.
Methods: We measured NAB every 6 months for up to 48 months in 422 consecutive MS patients who from 1996 to 1998 started treatment with a commercial IFN-beta preparation. Measurements of NAB were performed in a blinded fashion, using anti-viral neutralization (A549/EMC) bioassays with high (3 LU/ml), medium (10 LU/ml), and low (100 LU/ml) sensitivity and employing different neutralizing capacities as cut-off value for definition of NAB-positive samples.
Results: NAB generally appeared within 12 months after start of treatment and faster with IFN- beta-1b than IFN-beta-1a. However, after 36 months of treatment we observed a significant reduction in the number of NAB-positive patients treated with IFN-beta-1b. The presence of NAB had a significant effect on the relapse rate. During NAB-positive periods, we found a significantly higher relapse rate with odds ratios from 1.42 to 1.55 (p<0.01) that were relatively independent of the sensitivity of the assay (medium or low) and cutoff values for neutralizing capacity between 20% and 50%. The time to first relapse in NAB-negative patients was significantly increased by 270 days in Kaplan-Meier analysis of the probability of remaining exacerbation-free (log rank test p=0.028). In this short study, we found a trend but no significant effect of the presence of NAB on disease progression measured on EDSS.
Conclusions: The results document that the occurrence of NAB reduces the clinical effect. The frequency of NAB against IFN-beta depends on the sensitivity the neutralizing assay. In patients who are not doing well on IFN-beta therapy, the presence of NAB should raise the question about change of treatment.
Disclosure: PSS has received honoraria for lecturing and advisory
councils, travel expenses for attending meetings, and financial support
for his department from Biogen, Schering and Serono.
Noseworthy JH and SLCMSR Staff, Scientific Oversight Committee and Working Groups
Neurology, Mayo Clinic, Rochester, Minnesota, USA
Background: The SLCMSR was founded in 2001 at the Technical University of Munich following an international competition. The centre is sponsored by the MS International Federation, multiple national MS societies and private donors. This centre originated from a desire by international investigators to define meaningful treatment responses to experimental agents and to guide future research activities in the complex setting of partially-effective agents (the end of the placebo-era). The goal was to access existing natural history data sets and data from completed randomized clinical trials (RCTs) to permit statistical modeling and meta-analyses to advance RCT methodology. A specific effort will be the exploration of laboratory marker data to understand disease course.
Objectives: To expedite the discovery of effective therapies by improving RCT design and conduct and by the validation of markers of disease activity. Analyses will be conducted to maintain anonymity of the data sets.
Methods: Nineteen data sets (7000 patients; 30,000 years follow-up) are housed at the SLCMSR and a similar number of contracts are being negotiated for further data donation. The Scientific Director, Professor A. Neiss together with his staff, an international Scientific Oversight Committee, and two working groups (Clinical Trials Working Group [CTWG] and MRI WG), eight initial projects for study have been identified.
Results: The CTWG studies focus on the influence of clinical and MRI parameters on the short- and long-term disease course (factors contributing to stability, improvement, transient and unremitting worsening and the development of secondary progression) and the behaviors of placebo groups across RCTs. The MRI WG is addressing interactions of clinical variables with MRI markers of disease activity. The SLCMSR will issue a Request for Proposals in the final quarter of 2002 inviting grant applications to address questions aligned with the strategic goals of the centre.
Conclusions: The SLCMSR has acquired substantial informative data sets from investigators and industry sponsors. Significant progress has been made in the short time since inception. The resources of the SLCMSR will soon be more widely available to investigators to address additional clinical research questions.
Disclosure: J Noseworthy received an honorarium from LFB-France in 2001 and is currently an investigator in studies funded by Pfizer and Teva. All SLCMSR staff and members of the Scientific Oversight Committee and Working Groups (approximately 40 members) are required to complete a disclosure form to participate in the activities of the SLCMSR. This information is kept at the SLCMSR.
Funding: Supported by the SLCMSR.
Session III
Inflammation, Demyelination and Axonal Loss: Insights
From Imaging
Frank JA
LDRR/NIH, National Institutes of Health, Bethesda, Maryland, USA
Abstract Body: Contrast enhancing lesions (CEL) are a marker of acute inflammation and have provided an understanding of the pathophysiology of multiple sclerosis (MS). CEL have also been used as outcome measures to monitor MS activity, either natural or modified by experimental treatments and increases in CEL are correlated to clinical exacerbations. The relationship between CEL and axonal loss or permanent tissue damage is not completely elucidated, as it is apparent that there is continued tissue damage and atrophy that occurs independent of detected inflammation by MRI. Serial monthly MRI studies have shown a modest relationshipto T1 "Black Holes" (i.e., demyelination, axonal loss, gliosis and possibly remyelination) and relatively weak correlation to the progression of cerebral atrophy over short term (i.e., < 2 years). However, long-term follow-upsuggests that MS patients with increasing numbers of CEL have a greater degree of atrophy at 8 years. Therefore it is necessary to explore the natural history of CEL, the progression and relationship of these lesions to T1 hypointensities over long follow-up periods and determine if there is a relationshipbetween CEL and exacerbations or clinical outcome with time. Lastly, the long term (i.e., 8 years) relationshipCEL and cerebral atrophy (a cumulative measure of both microscopic and macroscopic disease activity) will be discussed.
Disclosure: J Frank has nothing to disclose.
Caramanos Z, Arnold DL
McGill University, Montreal, Quebec, Canada
Abstract Body: Introduction Although conventional MR techniques allow us to image MS lesions with great sensitivity, they are not capable of fully characterizing and quantifying the extent of damage to specific cells and tissue types. Recently-developed MR techniques are, however, better suited for such a role. These techniques include: (i) magnetization transfer imaging (MTI), (ii) short T2 imaging, (iii) proton magnetic resonance spectroscopy (MRS), (iv) diffusion weighted imaging (DWI), (v) diffusion tensor imaging (DTI), and (vi) MR-based measures of brain atrophy. Imaging Myelin Integrity MTI provides contrast based on the exchange of magnetization between water bound to macromolecules, which is normally MR-invisible, and bulk water. In cerebral white matter, MTI is relatively specific for myelin because most of the exchange originates from myelin. Quantitative MTI is technically more demanding than standard MTI but has the advantage that it is not affected by edema. Short T2 imaging quantifies water trapped within the layers of the myelin sheath and appears to specifically measure the amount of myelin (both normal and abnormal) that is present. Increases in MRS-measured choline, a metabolite associated with membrane turnover, and MRS-measured mobile lipids are associated with active myelin breakdown. Imaging Axonal Integrity MRS measurement of the neuronal marker, N-acetylaspartate (NA), provides a specific surrogate of axonal integrity but at much lower spatial resolution than that available from water-based imaging. Imaging Structural Integrity DWI and DTI provide contrast based on the structural integrity of both myelin and axons. MR-based measures of brain atrophy show loss of tissue that includes myelin and axons; importantly, however, any such observed volume loss is attenuated by any co-occurring gliosis or expansion of extracellular spaces. Findings in MS When appropriately applied, the above methods show abnormalities, not only of MR-visible lesions, but also of normal-appearing white and grey matter. Furthermore, changes in MT, DWI, and MRS may precede the development of MR-visible lesions. The correlations between these different surrogates, as well as between these measures and disability, indicate that they measure aspects of MS pathology that are related but not necessarily the same.
Disclosure: D Arnold has nothing to disclose.
Funding: Supported by: CIHR and MSSC
Barkhof F
VU Medical Centre, Amsterdam, Netherlands
Abstract Body: Little is know about the imaging appearance of remyelination. While postron emission tomography (PET) may have the required sensitivity to visualize remylination, no tracer is available for in vivo imaging. Magnetic resonance (MR)imaging is very sensitive to alterations in brain composition, but lacks histopathological speicifity. Remyelinated lesions have increased signal on T2-weighted images, and a mildly decreased signal on T1-weighted images. Serial images reveal a decrease in T1-signal intensity after cessation of enhancement, suggestive, but certainly not spcific for, remyelination. For the magnetic transfer ratio (MTR), a similar temporal profile has been linked in animal models to the occurence of remyelination.
Disclosure: F Barkhof has nothing to disclose.
Grossman R
University of California, San Francisco, California, USA
Abstract Body: It is clear that the normal appearing white matter (NAWM) on conventional magnetic resonance (MR) imaging is not "normal" at all. The term NAWM is misleading. What is normal at 0.3 tesla is not normal at 1.5 tesla. What is normal at 1.5 tesla is clearly not normal at 7 or 8 tesla. Images at such high field strengths clearly reveal tiny MS lesions. What is normal by imaging is not normal by diffusion or spectroscopy. It is just as important to distinguish what the abnormalities represent as to detect them. As MR methodology becomes more powerful and resolving power improves there will be much less discussion of NAWM and much more characterization of what is abnormal. Biophysical measures including magnetization transfer and diffusion clearly reveal abnormalities that cannot be detected on conventional images. Higher field imaging (3 T or ) will enable better delineation of these abnormalities. Magnetic resonance spectroscopy can detect metabolic equivalents of structural abnormalities including low levels of N-acetyl aspartate and elevated levels of choline in what is now considered NAWM. Abnormalities in what is today considered NAWM appear to be diffuse in nature and contribute to the neurological deficit. They are potentially the most interesting aspect of the MS lesion for this may represent an early reversible component of the disease. How we quantitate and characterize such lesions will allow us to detect treatment effects and potentially provide prognostic information in rapid and accurate fashion. Our reseach goals must be to exploit all MR techniques that facilitate improving our sensitivity and specificity with respect to the so-called "NAMW".
Disclosure: R Grossman has nothing to disclose.
Funding: NIH grants - R37-NS29029, R01-NS39135, 1 RO1-NS37I739
Comi Ga, Inglese Mb, De Stefano Nc, Smith Sd, Barkhof Fe, Durelli Le, Edan Ge, Fernandez Oe, Hartung HPe, Matthews PMd, Seeldrayers Pe, Sorensen PSe, Martinelli Va, Hommes ORe, Filippi Mb
aClinical Trials Unit, Department of Neurology, Scientific Institute and University HSR; bNeuroimaging Research Unit, Department of Neuroscience, Scientific Institute and University HSR, Milan, Italy; cUniversity of Siena, Siena, Italy; dUniversity of Oxford, Oxford, UK, United Kingdom; eThe ETOMS Study Group, Nijmegen, Netherlands
Background: Two phase III, double-blind, placebo-controlled trials of patients at presentation with suspected multiple sclerosis (SMS) have demonstrated that interferon beta-1a is effective in delaying the onset of a second relapse leading to a diagnosis of clinically definite MS. They also showed positive treatment effect on MRI-derived metrics.
Objectives: This study reports the results of normalized brain volume (NBV) measurements from patients at presentation with SMS recruited in the ETOMS trial.
Methods: Of the original 309 patients, electronic MRI data for NBV assessment were available for 131 patients randomized to receive 22mg of interferon beta-1a (Rebif, Ares Serono) subcutaneously once a week and 132 identical placebo. The study duration was 24 months. NBV was measured using a fullyautomated technique called SIENA.
Results: Mean NBV at study entry were 1503 ml (SD=89 ml) for placebo and 1496 ml (SD=122 ml) for treated patients. The mean percentage changes of NBV from baseline to month 24 were significant for both placebo and treated patients (p<0.001). However, the mean percentage reduction of NBV over the 24 month study period was significantly higher for placebo (-1.68%) than for treated (-1.18%) patients (p=0.003). Over the entire study period, significant correlations were found between the NBV percentage change and the number of enhancing lesions (r=-0.18, p=0.006) and the number of new T2 lesions (r=-0.26, p<0.001). The number of enhancing (r=-0.21, p=0.003) and new T2 (r=-0.29, p<0.001) lesions formed during the first year correlated significantly with brain volume changes during the second year of the study.
Conclusions: The rate of brain tissue loss in the SMS patients is close to that reported in patients with more advanced disease and an early treatment with interferon beta-1a is able to reduce the rate of brain tissue loss in these patients.
Disclosure: G Comi has nothing to disclose.
Funding: The ETOMS Study was supported by Serono Pharma.
Minneboo Aa, Barkhof Fa, Polman CHb, Uitdehaag BMb, Knol Dc, Castelijns JAa
aRadiology, MR Center for MS Research, VU Medical Center, Amsterdam, Noord-Holland, Netherlands; bneurology, Center for MS Research, VU Medical Center, Amsterdam, Noord-Holland, Netherlands; cClinical Epidemiology and Biostatistics, VU Medical Center, Amsterdam, Noord-Holland, Netherlands
Background: Abnormalities on baseline brain MRI in CIS are known to predict outcome in terms of conversion to clinically definite multiple sclerosis (CDMS) and disability. However no long-term follow-up data exist on the role of enhanced lesions and "black holes".
Objectives: To assess the long-term predictive value of baseline MRI parameters including location of the lesions, gadolinium-enhancement and "black holes" in patients presenting with a clinically isolated syndrome (CIS) for mild disability as defined by EDSS >= 3.
Methods: After a median follow-up period of 8.7 years, hospital charts of 42 patients presenting with CIS were reviewed and assessed for date of conversion to CDMS, date at which EDSS 3 or 6 was reached and EDSS at last follow-up. MRI parameters were dichotomized according to maximum accuracy and subsequentely hazard ratios were calculated.
Results: Conversion rate to CDMS was observed in 26 patients (62%) of which 14 patients progressed to EDSS >= 3. Infratentorial lesions are the best predictors for long-term disability (hazard ratio 6.3). Predictive value of enhanced lesions and "black holes" seems limited.
Conclusions: Infratentorial lesions predict long-term disability and may help to identify patients at high risk for progressive disease.
Disclosure: A Minneboo has nothing to disclose.
Funding: A. Minneboo is supported by a grand (98-348 MS) of the
Dutch Foundation for the Support of MS Research.
Bagnato Fa, Jeffries Nb, Ohayon Ja, Stone Ra, Frank JAc, McFarland HFa
aNeuroimmunology Branch NINDS, NIH, Bethesda, Maryland, USA; bBiostatistics Branch NINDS, NIH, Bethesda, Maryland, USA; cLaboratory of Diagnostic Radiology Research, NIH, Bethesda, Maryland, USA
Background: A Black Hole (BH) is a possible evolution of a contrast-enhancing lesion (CEL) in Multiple Sclerosis (MS), and when they persist BHs are believed to represent a marker of axonal loss. However, why some CEL are more likely to form a persistent BH over time is not completely understood. The duration of the inflammatory process is a possible explanation for this observation.
Objectives: To evaluate the influence of duration in time of a CEL on the duration in time of a BH over the natural history of MS patients followed monthly for four years.
Methods: Eight MS patients (male/female: 7/1, mean ±SD age 35.2 ±5.9, EDSS 2.4 ±1.4, MS duration 3.8 ±5.0) had 48 monthly MRIs. The number of CEL and of BH in the corresponding un-enhanced scan was evaluated. A BH was defined as any hypointense region visible on the T1-Weighted Images (WI) with high signal intensity on the T2-WI and without enhancement in the correspondent post-contrast scans. Only BHs with a previously identified CEL were considered for the analysis. Cox Proportion Hazards models were used to evaluate the effect of enhancing time on BH duration.
Results: Out of 878 new CEL, 158 turned into a BH (17.9%). The mean duration in time of these BHs was 9.3 ±9.7 months. The results of Cox Regression Analysis showed that among those CEL that formed a BH the increase in the duration of the enhancement significantly influenced the duration of the corresponding BHs (p=0.04), with each additional month of enhancement leading to a 22% reduction in the rate at which BHs disappear.
Conclusions: The enhancement duration is an important factor in BH duration. The longer the duration of the enhancement in a given active lesion, the higher is the chance to persist as a BH over time, thus accumulating a permanent damage and disability in MS.
Disclosure: F Bagnato has nothing to disclose.
Session IV
The Blood Brain Barrier as a Target for Treatment
Antel JP, Biernacki K, Seguin R, Prat A
Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
Abstract Body: Cellular immune trafficking across the blood brain barrier (BBB) involves a series of molecular interactions between such cells and the cells and extra cellular matrix (ECM) that comprise the BBB. These interactions include the processes of cell-cell adhesion; chemoattraction, and ECM degradation by matrix metalloproteinases (MMPs). With specific regard to adhesion molecules, expression of these molecules is up-regulated on lymphocytes and monocytes when such cells are activated, as is observed to occur in concert with active phases of multiple sclerosis (MS). In situ studies of central nervous system (CNS) microvessels derived from MS cases, demonstrate upregulation of the ligands for a number of adhesion molecules on endothelial cells (ECs) when compared to ECs from non-inflammatory control cases. To model the role of cell-cell adhesion in cell trafficking across the BBB, we have examined the interaction of lymphocytes and monocytes derived from the peripheral blood of MS patients and controls with human brain (HB)ECs derived from non-inflammatory surgical tissue specimens. These HBECs constitutively express moderate levels of ICAM-1 but only very low levels of VCAM-1. Expression of both of these adhesion molecules is up-regulated when the HBECs are exposed to supernatants from Th1 cytokine producing CD4 T cell lines. Th2 cytokine producing cell lines neither up-regulate nor inhibit adhesion molecule expression. Using a Boyden chamber assay system, we can demonstrate that both lymphocyte and monocyte migration across a barrier of HBECs grown on a fibronectin matrix can be inhibited by antibodies directed at ICAM-1 but not VCAM-1. Antibodies directed at the VCAM-1 ligand VLA-4 do inhibit migration, implicating VLA-4 binding to an alternate ligand (Connecting Segment (CS-1) fragment of fibronectin) as the functional event. Adhesion molecules remain targets for therapeutic intervention in MS (eg anti-VLA-4 antibodies). Neither Copaxone nor intereferon b (IFNb) directly modulate adhesion molecule expression on HBECs. However, IFNb treated lymphocytes induce VCAM on the HBECs with a subsequent release of soluble VCAM-1 (sVCAM) ( Calabrese et al 2001). sVCAM binding to its ligand VLA-4 would provide a means to down-regulate trans-endothelial migration.
Disclosure: J Antel has received honoraria from TEVA Marion, Schering, Biogen and Serona
Funding: Supported by Multiple Sclerosis Society of Canada
Ransohoff RM
aNeurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA; bDepartments of Neurosciences and Neurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Abstract Body: Chemokines are small peptides that govern leukocyte trafficking and activation. There is a substantial and growing literature concerning their biological functions in development, inflammation and degeneration of the nervous system. The core hypothesis of our research is that chemokines and their receptors are significantly involved in leukocyte invasion, differentiation, activation, tissue destruction and repair in the nervous system. Furthermore, resident neuroepithilial cells both make and respond to chemokines. To address this hypothesis and identify the molecular targets for therapeutic endeavors, we examine chemokine and chemokine receptor expression and function. These studies comprise material from patients with neurological disorders, disease models in mice, and tissue culture studies. We make extensive use of transgenic and knockout mice to clarify how chemokines exert their remarkably specific effects in vivo in the face of apparent functional redundancy in vitro.
Additional Reading: (1) Huang DR, Wang J, Kivisakk P, Rollins BJ, Ransohoff RM. Absence of monocyte chemoattractant protein 1 in mice leads to decreased local macrophage recruitment and antigen-specific T helper cell type 1 immune response in experimental autoimmune encephalomyelitis. J Exp Med 2001; 193(6): 713-726.(2) Trebst C, Ransohoff RM. Investigating chemokines and chemokine receptors in patients with multiple sclerosis: opportunities and challenges. Arch Neurol 2001; 58(12): 1975-1980.(3) Kivisakk P, Trebst C, Eckstein DJ, Kerza-Kwiatecki AP, Ransohoff RM. Chemokine-based therapies for MS: how do we get there from here? Trends Immunol 2001; 22(11): 591-593. (4) Trebst C, Sorensen TL, Kivisakk P, Cathcart MK, Hesselgesser J, Horuk R et al. CCR1+/CCR5+ mononuclear phagocytes accumulate in the central nervous system of patients with multiple sclerosis. Am J Pathol 2001; 159(5): 1701-1710. (5) Han Y, He T, Huang DR, Pardo CA, Ransohoff RM. TNF-alpha mediates SDF-1 alpha-induced NF-kappa B activation and cytotoxic effects in primary astrocytes. J Clin Invest 2001; 108(3): 425-435. (6) Kieseier B, Tani M, Mahad D, Oka N, Ho T, Woodroofe N, Griffin JW, Toyka K, Ransohoff RM, Hartung H-P. Chemokines and chemokine receptors in inflammatory demyelinating neuropathies: a central role for IP-10. Brain 2002; 125(4): 823-834.
Disclosure: RM Ransohoff is a member of the Scientific Advisory Board of Chemocentryx, San Carlos, CA and has received honoraria for scientific consultation from several companies including Aventis, Berlex, Biogen, Merck and Millenium.
Funding: Supported by the NIH (PO1 NS38667; RO1 NS35121, NS36674),
the Fogarty International Center (FIRCA TW00724) and the NCI (PO1 CA62220).
Yong V
Oncology & Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Abstract Body: Matrix metalloproteinases (MMPs) are implicated in MS (reviewed in Yong et al., Nature Reviews Neuroscience 2: 502-511, 2001). This presentation will review the evidence that MMPs have a role in the pathology and the progression of disease in MS. It will also address which MMP family members (of 26) may be important to consider as having important roles in MS. Evidence will be presented that in experimental autoimmune encephalomyelitis (EAE), an animal model of MS, specific MMP members are expressed at the initiation of clinical disease while others become prominent during the evolution of the disease. The mechanisms by which MMPs may contribute to CNS pathology will be discussed. It is important to appreciate that some MMP members may be expressed following injury in an attempt to limit destruction or to attempt repair. In this regard, it is worthy of consideration that during myelinogenesis, the extension of oligodendrocyte processes through a CNS matrix may require MMPs to remodel the extracellular environment. Evidence will be presented that MMP-9 plays a role in process formation by oligodendrocytes and that there is deficient remyelination in MMP-9 null mice following lysolecithin induced demyelination of the mouse spinal cord. In summary, MMPs have important roles in the pathology of MS. Inhibitors of MMP activity are appropriate therapeutic agents to consider in the disease. Nonetheless, caution is advised that specific MMPs, under particular circumstances, may have reparative roles.
Disclosure: V.W. Yong has received honoraria from Teva Neuroscience,
Serono, and Berlex Laboratories. V.W. Yong has received research grants
from Teva Neuroscience and Berlex Laboratories.
Miller D
NMR Research Unit, Institute of Neurology, London, United Kingdom
Abstract Body: Several lines of evidence implicate blood brain barrier (BBB) abnormality as an important component in the development of multiple sclerosis lesions. New lesions exhibit BBB breakdown and perivascular lymphocytic infiltrates. The location of lesions around cerebral venules suggests that BBB breakdown may have a key role in lesion genesis. Serial MRI studies using gadolinium-chelate contrast agents have demonstrated BBB breakdown as a consistent feature of new lesions in relapse onset MS. However, new or enlarging lesions may develop without BBB breakdown in primary progressive MS and possibly in other forms of the disease. Diffuse abnormalities of the normal appearing white matter also occur, and the relationshipof these to BBB breakdown is uncertain. It is however, likely that BBB breakdown is more extensive than the regions of gadolinium enhancement that are detectable to the eye. There is good evidence for low grade leakage in chronic lesions, and it may also exist in normal appearing white matter. Using gadolinium enhanced MIR, there is a relationshipof BBB leakage with relapses, but not with progressive MS. Many immunosuppressive and immunomodulatory treatments have been shown to suppress new areas of focal BBB leakage. High dose intravenous steroids have a similar but transient effect on pre-existing and new enhancing lesions. Recently, the monoclonal antiadhesion molecule antibody, anti-VLA4 (natalizumab), has shown dramatic effects in reducing by 90% the frequency of new areas of BBB leakage, but unlike intravenous steroids, does not effect the existing areas of leakage. Natalizumab treated patients also experienced a reduced relapse rate by 50% in the 6 month placebo controlled exploratory trial, and exhibited increased well being compared to those on placebo. Two year studies of this agent are now underway to evaluate its long term safety and efficacy, and in particular the effect on disability. Such long term studies are important, in view of the uncertain relationship between focal BBB changes and progressive disability.
Disclosure: D Miller has received grants from Elan and Biogen for MRI analysis in clinical trials of Natalizumab
Funding: MS Society of Great Britain and Northern Ireland. Friday,
September 20, 2002 Keynote Address
Snyder E
Harvard University, Boston, Massachusetts, USA
ABSTRACT NOT AVAILABLE FOR PUBLICATION
Session V
Neuroprotection
Raine CS, John G, Brosnan CF
Pathology (Neuropathology), Neurology and Neuroscience, Albert Einstein College of Medicine, Bronx, New York, USA
Abstract Body: Although CNS remyelination in MS is well-known, that its occurrence and extent is not more widespread has perplexed investigators for many years. Among frequently proposed causes of incomplete remyelination in MS, scarring astroglia, inflammation, macrophage activity and serum factors are the most studied, but to date, no satisfactory explanation has emerged. During an investigation of gene expression by astrocytes in vitro following activation by the inflammatory cytokine, TGFb1 (John et al., submitted), induced expression was noted of Jagged1, a transmembrane protein shown to suppress the differentiation of oligodendrocytes, through activation of Notch1. Since TGFb1 expression and reactive astrocytes are common features of active MS, we conducted a study on MS lesions displaying demyelination and remyelination. By immunocytochemistry, a broad zone of reactive, hypertrophic astrocytes surrounded acute and chronic active lesions lacking remyelination, and these cells displayed decreasing expression of Jagged1 away from the lesion. These Jagged1 positive astrocytes were invariably associated with a population of small rounded cells revealed by immunocytochemistry to be oligodendrocytes expressing PDGFRa, O4 and some NG2, indicative of an immature, precursor phenotype. These oligodendrocytes expressed Notch1 and Hes5, a downstream gene in the Jagged1/Notch1 pathway also associated with inhibition of differentiation. On the other hand, within remyelinated lesions adjacent to active lesions, astrocytes displayed negligible expression of Jagged1, and oligodendrocytes were negative for Notch pathway activation. Thus, oligodendrocytes at the margins of active MS lesions may be inhibited from maturing into myelinating cells by the activation of Notch1 on their surface by the ligand, Jagged1, on astrocytes and this molecular inhibition may account for the limited remyelination in active MS lesions. Attempts to enhance CNS remyelination in MS may consider targeting this novel molecular pathway. Supported by NMSS FG 1355 to G.J.; NMSS RG 1001-J-10 to C.S.R.; and NS 11920 to C.S.R. and C.F.B.
Disclosure: C Raine has nothing to disclose.
Funding: Supported by NINDS.
Shin MLa,b, Rus Ha,b
aPathology, University of maryland School of Medicine, Baltimore, Maryland, USA; bPathology, University of Maryland School of medicine, Baltimore, Maryland, USA
Abstract Body: We showed that the membrane attack complex C5b-9 causes myelin vesiculation and demyelination of explant cultures. Myelin lacking complement inhibitory CD55 allows C5b-9 assembly 4.5-fold more than CD55-expressing membranes, like oligodendrocyte (OLG). Myelin damage, therefore, may be induced in vivo by C5b-9 without OLG death. Myelin also activates complement, which is amplified 50-fold by anti-myelin Ab. Thus, C5b-9-dependent demyelination can be more prevalent in vivo in the presence of Ab. This hypothesis is supported by recent works by Mead and by Tran, using EAE in C6-deficient rats. This detrimental role on myelin contrasts with the OLG survival actually enhanced by sublytic C5b-9. In defined medium, OLG progenitors differentiate and undergo apoptosis. We found that C5b-9 rescues OLG from serum deprivation- and TNF-induced death, by regulating apoptosis at multiple levels, by increasing BCL-2 synthesis, inhibiting caspase 3 and 9, preventing cytochrome c release, and reducing BAD-BCL-Xl complex. They are in part regulated by PI-3 kinase/Akt pathways and associated with BAD phosphorylation at Ser112 and 136. We then examined the role of C5b-9 on remyelination and apoptosis with C. Raine and S. Weerth, using DNA microarray of EAE induced in C5(-) and C5(+) mice. Inflammation and demyelination were more restricted in C5(-) mice, as expected. Noteworthy is our our finding that the lesions of chronic EAE were replaced with gliotic scar in C5(-) mice, but showed robust remyelination in C5(+) mice. Acute EAE spinal cords of these mice were compared for the mean expression of each 96 genes of apoptosis. Of 96, 23 showed 2.5-fold difference in expression. In C5(-) mice, 17 of 20 genes expressed higher were pro-apoptotic families of BCL-2, caspase, TNF/TNFR, and CRADD/CAD, while only 4 of 10 in C5(+) mice were pro-apoptotic. Hierarchical clustering of samples and differentiatlly expressed genes revealed, with a few exception, that C5(-) mice clustered separately from C5(+) mice. Together, our data support the beneficial role of C5b-9 in demyelinating disorders by down-regulating apoptotic gene expression and promoting OLG survival and remyelination.
Disclosure: M Shin has nothing to disclose.
Funding: Supported by NIH grants; NINDS (NS15662, NS36231, NS42011
to MLS and HR), MS pilot Award (pp-696 to HR).
Hohlfeld R
Institute for Clinical Neuroimmunology, University of Munich, Bavaria, Germany
Abstract Body: Recent evidence suggests that inflammatory reactions in the CNS can have beneficial and even neuroprotective effects. Intriguingly, immune cells are capable of producing neuroprotective molecules of the neurotrophin family. The concept of "neuroprotective immunity" has profound consequences for the pathogenesis and treatment of neuroinflammatory diseases like multiple sclerosis (MS), and is also important for neurodegenerative disorders, in which inflammatory reactions often occur. In MS lesions immune cells produce brain-derived neurotrophic factor (BDNF), whereas neurons and astrocytes express the appropriate tyrosine kinase receptor TrkB. This observation together with functional evidence for the neuroprotective effects of immune cells support the concept of "neuroprotective immunity". In addition a protective role of endogenous CNTF has recently been demonstrated in EAE by comparing the severity of EAE in wild-type and CNTF-knockout mice. Several neurotrophic and growth factors have been employed for the treatment of EAE. Pilot studies clearly demonstrated that growth factors like NGF, IGF-1, or GGF-2 can have beneficial effects in EAE. However, some of these effects seem to be primarily mediated by immunomodulation rather than primary CNS protection or repair. These observations have important implications for the treatment of multiple sclerosis.
Disclosure: R Hohlfeld has nothing to disclose.
Linker RAa, Maurer Ma, Gaupp Sa, Martini Ra, Holtmann Bb, Lassmann Hc, Toyka KVa, Sendtner Mb, Gold Ra
aDepartment of Neurology, University of Wurzburg, Wurzburg, Bavaria, Germany; bDepartment of Clinical Neurobiology, University of Wurzburg, Wurzburg, Bavaria, Germany; cBrain Research Institute, University of Vienna, Vienna, Austria
Background: Not much is known about the genetic factors determining disease progression and outcome in multiple sclerosis (MS). Ciliary neurotrophic factor (CNTF) is a survival factor that also promotes differentiation of oligodendrocytes. 3% homozygous deletions in the CNTF gene exist in the European population.
Objectives: We compared clinical course and neuropathological features in CNTF-knockout and wild-type C57BL/6 mice using experimental autoimmune encephalomyelitis (EAE) as a model for MS.
Methods: EAE was induced by immunization with MOG peptide 35-55. Animals were clinically scored and weighed on a daily basis. At various time points spinal cord, brain and optic nerves were analyzed by histo- and immunoimmunocyto-chemistry. For quantification, coded sections were counted by blinded observers. To investigate the peripheral priming and induction of the immune response, lymph node proliferation assays were performed.
Results: CNTF deficient mice exhibited a significantly earlier onset of disease (p<0.005, 80 mice per group) and showed enhanced disability during the course of disease until day 100 p.i. (p=0.002). Histopathologic changes were mostly confined to the anterior and lateral columns of the spinal cord with prominent vacuolation and myelin destruction. In early and later stages of the disease, CNTF deficiency was associated with histopathological features indicative of oligodendrocyte cell death. Increased apoptosis of oligodendrocytes was seen on semithin sections and by TUNEL assay. In parallel proliferation of oligodendrocyte precursor cells was decreased by 60% in CNTF knockout mice. The severe vacuolar pathology in CNTF deficient mice could be prevented by treatment with an antiserum against TNF-alpha. No significant differences in proliferative response to MOG in primed lymphocytes or in numbers of infiltrating T-cells and macrophages could be observed between CNTF-knockout and wild-type mice.
Conclusions: These results underscore the critical role of CNTF for oligodendrocyte integrity in the inflamed CNS. CNTF may serve as a modulator of lesion severity in MS. Back-to-back-submission with ID13400.
Disclosure: R. Linker has nothing to disclose.
Funding: Supported by DFG SFB 581 TP A1.
Dhib-Jalbut Sa,b, Makar TKb, Wilt Sb, Dong Zc, Fishman Pa,b, Mouradian Md
aNeurology, University of Maryland; bNeurology, Department of Veterans Affairs, Baltimore, Maryland, USA; cCell Biology, University of Texas, Houston, Texas, USA; dGenetic Pharmacology Unit, NIH, Bethesda, Maryland, USA
Background: The peripheral delivery of Interferon-beta (IFNb) for the treatment of central nervous system (CNS) diseases is only partially effective because of the blood-brain barrier. This is true for multiple sclerosis where IFNb does not reach inflammation sites.
Objectives: To circumvent this problem, we evaluated the feasibility of genetically altering bone marrow cells ex-vivo, and using them as vehicles to transfer the IFNb cDNA into the mouse CNS.
Methods: An IFNb retroviral expression vector (pLXSN-IFNb) was used to stably transfect PA317 cells (Producer cells). The supernatant from these producer cells, which contain IFNb-expressing provirus, were used to infect mouse bone marrow cells. IFNb-transduced marrow cells were then transplanted into irradiated SJL mice via intravenous injection. IFNb expression was subsequently examined in the CNS by RT-PCR and immunocytochemistry.
Results: IFNb-engineered marrow cells accessed the CNS and expressed IFNb mRNA and protein. Marrow cells transduced with a control neomycin vector entered the brain and expressed the neomycin but not IFNb gene. In the CNS, IFNb delivered by marrow cells induced the mRNA expression of 2-5 oligoadenylate synthetase (2-5-OAS) indicating biological activity.
Conclusions: Our findings demonstrating that bone marrow cells can serve as a delivery system for IFNb cDNA into the CNS could have implications for the treatment of neurological disorders such as multiple sclerosis, viral encephalitis and brain tumors. Preliminary therapeutic results in experimental allergic encephalomyelitis will be presented.
Disclosure: S Dhib-Jalbut has nothing to disclose.
Funding: Supported by grants from the National Multiple Sclerosis Society
and Departmnet of Veteran’s Affairs.
Havrdova Ea, Kozak Tb, Kobylka Jc, Pitha Je, Fiedler Jf, Koza Vg, Maaloufova Jb, Horakova Da, Ticha Va, Novakova Ia, Vodvarkova Sb, Gregora Eb, Medova Ee
aDpt.of Neurology, Charles University, Praha, Czech Republic; bDpt. of Hematology, 3.LF, Charles University, Praha, Czech Republic; cInstitute for Hematology and Blood Transfusion, Charles University, Praha, Czech Republic; dDpt. of Internal Medicine, 1.LF, Charles University, Praha, Czech Republic; eDpt. of Neurology, 3.LF, Charles University, Praha, Czech Republic; fDpt. of Neurology, Charles University, Plzen, Czech Republic; gDpt. of Hematology, Charles University, Plzen, Czech Republic
Background: The program of bone marrow transplantation in multiple sclerosis (MS) started in Czech Republic in January 1998. It has been offered to MS patients who failed to react to convention therapies including immunosuppressive regimens.
Objectives: To prove the manipulation of immune system with high-dose immunoablation and autologous stem cell (SC) support is both tolerable and stabilizing therapeutic access in malignant MS.
Methods: 26 pts (15 females, 11 males, age 36.3 ± 7.4, EDSS 6.3 ± 0.6) with SP MS, rapid progression (>=1.0 EDSS/last year), failure of steroids and at least one salvage regimen (interferon beta, cyclophosphamide, mitoxantrone), and no major organ dysfunction were involved in the study, signed informed concent and underwent mobilization of SC with cyclophosphamide 4g/m2 and GCSF. 23 were succesfully harvested, 22 underwent immunoablation with SC therapy (SCT).
Results: Efficacy: 13 patients with SCT are followed 2-4 years, 9 of them either stable or with improved EDSS, 1 pt died 30 months after SCT (from peritonitis). 4 pts are followed 12 months, all are stable. MRI has revealed no activity in 10 pts. Improvement, if any, have started after 4-6 months after SCT and needed sustained rehabilitation effort. 3 pts failed to mobilize stem cells, 1 pt improved after mobilization and refused immunoablation. Safety: Peritransplantation morbidity: 2 pts underwent life threatening events: 1 pt with brainstem impairment had severe mucositis and respiratory distress, needed 7 days of supportive ventilation, recovered, but deteriorated by 1.5 EDSS. 1 pt had CMV pneumonia and gut bleeding, needed 12 days of supportive ventilation, deteriorated by 2 EDSS. 1 pt developed factor VIII inhibitor syndrome 1 yr after SCT.
Conclusions: High-dose immunoablation with SCT may stabilize or improve the course of MS in some pts with malignant course. The procedure itself may represent high risk for patients with brainstem involvement, high EDSS and intensive immunosuppressive pretreatment.
Disclosure: E Havrdova has nothing to disclose.
Funding: Supported by Research grant IGA MZ CR No NF/6560-3.
Session VI
Hot Topics in Neuroimmunology
Weiner H, Khoury SJ
Harvard University, Boston, Massachusetts, USA
Abstract Body: MS is an inflammatory disease of the CNS presumed to be Th1 type cell mediated autoimmune disease. There is increased IL-12 by intracytoplasmic staining and anti-CD3 stimulation and IL-12 is increased more in progressive than relapsing-remitting (RR) disease MS. Increased IL-12 is linked to increased IFN-g and the interaction between T cells and APCs via CD40-CD40L interactions. There are twice as many IL-12 secreting cells in the peripheral blood if there is Gadolinium enhancement on MRI. Cyclophosphamide decreases IL-12 inMSwhich is related to clinical response to therapy. Patients with elevated IL-12 may not respond as well to IFN-beta. IL-18 is increased in RR and progressive MS. In controls and RR MS neutralizing anti-IL-12 and anti-IL-18 alone equally suppressed IFN-g production whereas in progressive MS, maximum suppression was only observed when neutralizing anti-IL-12 and anti-IL-18 were given together, suggesting that in progressive MS, IL-12 and IL-18 function in a nonlinked manner to induce IFN-g. Elevated IL-18 production was also dependent on CD40-CD40L interactions and IL-18 levels correlated with disease duration in progressive MS. We found a defect in regulation of both IL-12 and IFN-g by endogenous IL-10 in progressive MS which could contribute to the transition of MS from the relapsing to the progressive stage. Dendritic cells also may contribute to the cytokine milieu in MS and the increased Th1 milieu in progressive MS as dendritic cells from progressive MS are polarized in a Th1 type pattern. INF-g levels are linked to MRI measures of disease activity and polarization of dendritic cells. Th1 type chemokine receptor expression (CXCR3 and CCR5) is increased in MS and to a greater extent in progressive MS. Taken together, a predominant Th1 type cytokine milieu exists in MS that is linked to clinical and MRI measures and is more pronounced in progressive MS. Currently used immunomodulatory drugs appear to act in part by decreasing this Th1 polarization and further development of treatments that decrease Th1 and increase the Th2 and Th3 (TGF-b) cytokine milieu are likely to benefit MS. Increased immune dysfunction in progressive MS must be reconciled with the disease becoming more degenerative progressive MS and less responsive to immunomodulatory therapy.
Disclosure: H Weiner is a consultant to and a speaker for Teva, Biogen, Immunex.
Funding: Supported by the NIH, Multiple Sclerosis Society, Nancy
Davis Foundation.
Martin R
Neuroimmunology Branch, NINDS, National Institutes of Health, Bethesda, Maryland, USA
Abstract Body: Specific intervention with the T cell-mediated autoimmune process in multiple sclerosis (MS) and other autoimmune diseases has long been an attractive goal. Such therapies require a sound understanding of the specificity/ies of pathogenic T cells and the development of effective therapeutic strategies that allow to selectively target these cell populations. Both in the animal model of MS, experimental autoimmune encephalomyelitis (EAE), there is good evidence that certain myelin proteins including myelin basic protein (MBP) have pathogenic potential in EAE and are immunogenic in MS patients in the context of disease-associated HLA-DR2- and other DR alleles. In EAE, the definition of individual encephalitogenic peptides served as a basis for establishing various specific immunotherapies. These included the induction of antigen-specific apoptosis, anergy induction, T cell receptor (TCR) peptide vaccination, T cell vaccination, oral tolerization, and the induction of bystander suppression via altered peptide ligands (APL), but also other approaches. A few of the above therapies are also in clinical testing in MS or have already been explored in the past. So far, the evidence for efficacy and/or safety of specific immunotherapies in MS is sparse. Oral tolerization was not effective in a large phase III trial, an APL peptide based on MBP (83-99) raised safety concerns, to give only two examples. The current state and future perspectives of specific immunomodulation in MS will be discussed.
Disclosure: Roland Martin has a consulting agreement with Teva Pharmaceuticals
Funding: Research efforts describing the testing of an altered
peptide ligand in MS have been supported by a collaborative research and
development agreement between NIH and Neurocrine and Novartis.
Vandenbark AA
aNeuroimmunology, Portland VA Medical Center, Portland, Oregon, USA; bNeurology and Microbiology and Immunology, Oregon Health and Science University, Portland, Oregon, USA
Abstract Body: Inflammatory Th1 cells reacting to myelin antigens likely contribute to the pathogenesis of diseases such as MS, rheumatoid arthritis (RA), and psoriasis. One regulatory mechanism that may be useful for treating autoimmune diseases involves an innate second set of Th2 cells specific for portions of the TCR of pathogenic Th1 cells. These Th2 cells recognize internally processed V region peptides from the TCR expressed on the Th1 cell surface in association with MHC molecules. As assessed by ELISPOT, TCR-reactive T cells constitute nearly 8% of the T cell repertoire in healthy individuals, but are significantly reduced in MS patients, potentially allowing unregulated clonal expansion of Th1 cells. We have used a variety of strategies to identify disease-associated V genes present on pathogenic Th1 cells, including BV5S2, BV6S5 & BV13S1 in MS, BV3, BV14 & BV17 in RA, and BV3 & BV13S1 in psoriasis. TCR peptides corresponding to the mid region of these BV genes were found to be consistently immunogenic in vivo when administered either i.d. in saline or i.m. in incomplete Freund’s adjuvant. In MS patients, injection of low doses of peptides (100-300µg) significantly boosted the number of TCR-reactive Th2 cells, and the strength of response to TCR vaccination was correlated with clinical benefit. Once the regulatory Th2 cells were specifically activated, they non-specifically inhibited activation of other CD4+ T cells via mechanisms involving cell-cell contact (as for CD4+CD25+ Treg cells) and inhibitory cytokines including IL-10. These findings indicate the potential of regulatory Th2 cells to inhibit not only the target Th1 cells, but also bystander Th1 cells expressing different V genes specific for other autoantigens. TCR peptide vaccines have been used in our studies to treat a total of 200 MS patients (7 trials), 484 RA patients (7 trials), and 177 psoriasis patients (2 trials). Based on treatment of almost 900 patients with autoimmune diseases, TCR peptide vaccination is safe and well tolerated, and can produce significant clinical improvement in a subset of patients that respond to immunization. TCR peptide vaccination represents a promising approach that is well-suited for treating complex autoimmune diseases.
Disclosure: A Vandenbark is consultant for and holds stock options in The Immune Response Corp.
Funding: Supported by NMSS RG3039-A-2, NIH NS23221.
Steinman L
Stanford University, Stanford, California, USA
Abstract Body: I shall review results on large scale transcriptional and proteomic analysis of MS tissue. These analyses yield new targets for potential therapy.
Disclosure: I have nothing to disclose.
Funding: Supported by the NIH
Pryce G, O’Neill JK, Amor S, Baker D, Giovannoni G
NMR unit, Institute of Neurology, Queen Square, London, United Kingdom
Background: Leukocyte depletion and myelin-Ag delivery in MS have been attempted independently with limited success. In relapsing EAE, transient T cell deletion, using CD4-specific mAb, delays the return of disease. Similarly, myelin Ag i.v. induces a readily reversible unresponsiveness.
Objectives: To test whether the combination of transient T cell deletion and i.v. myelin Ag induces tolerance that prevents relapsing EAE. To test whether leukocyte depletion with a cytotoxic agent (mitoxantrone) can replace mAbmediated deletion.
Methods: Depleting/blocking CD4-specific mAb and mitoxantrone was used in actively induced mouse EAE. Ag-specific tolerance was induced by a single injection i.v. of myelin Ag either alone or attached to fixed cellcarriers.
Results: In contrast to non-depleting agents, a combination of transient CD4 T cell deletion and i.v. myelin Ag, administered during the period when primed T cells are regenerating, induce tolerance that is resistant to further disease induction and inhibits relapsing EAE. This was achieved by depleting with either anti-CD4 mAb or mitoxantrone. Dependent on the immunizing Ag, single peptides were effective or ineffective. Recombinant myelin proteins were effective and require no knowledge of the pathogenic epitopes.
Conclusions: Translation of this strategy into MS may go some way towards halting the immunological disease process and provide a platform for additional neuroprotective and repair strategies. The observation that mitoxantrone, a drug already licensed for use in MS, can substitute for CD4+ T cell depletion has the potential advantage of targeting pathogenic B cell responses, which in part are responsible for some of the adverse reactions following myelin Ag administration.
Disclosure: G Giovannoni has nothing to disclose.
Funding: Supported by The MS Society of Great Britain and Northern
Ireland.
Allie Ra, Yun Sa, Calabresi PAa, Wullf Hb, Chandy Kb, Pennington Mc
aNeurology, University of Maryland, Baltimore, Maryland, USA; bPhysiology, University of California Irvine, Irvine, California, USA; cBachem Bioscience, King of Prussia, Pennsylvania, USA
Background: Activated T cells maintain high levels of intracellular calcium by upregulating K+ channels that allow for a counter regulatory efflux of potassium. T cells acutely activated with mitogen upregulate the K+ channel IKca, but not Kv1.3, whereas in chronically activated T cell lines (TCL) the converse situation occurs with marked upregulation of Kv1.3. ShK is a high affinity peptide antagonist for Kv1.3 and has been shown to ameliorate EAE.
Objectives: To determine whether myelin reactive TCL from MS patients differed in their expression of Kv1.3 depending on their stage of differentiation, as well as compared to TCL from healthy controls. Further, we wished to study the functional effects of the peptide antagonist ShK on Kv1.3 hi TCL.
Methods: Myelin reactive TCL were generated from 15 MS patients and 10 healthy controls. Antigen specific TCL were phenotyped by FACS using monoclonal antibodies for CD4,CD45RA,CD45RO, and CCR7. IKca and Kv1.3 channel number was determined by patch clamp analysis and fluorescence microscopy. The functional effects of ShK were studied by tritiated thymidine proliferation assays and cytokine analysis.
Results: In healthy controls Ikca was upregulated on acutely activated (2-3 stimulations) myelin reactive T cells, but Kv1.3 was not upregulated until TCL had been restimulated greater than 7 times. The expression of Kv1.3 correlated strongly with conversion from central memory T cells (Tcm=CD45RA-/CCR7+) to effector memory T cells (Tem=CD45RA-/CCR7-). Myelin reactive T cells from MS patients expressed high channel numbers of Kv1.3 after only 3 stimulations and were phenotypically Tem. ShK selectively inhibited proliferation of Tem, but not Tcm in keeping with the observed K channel patterns on these cells.
Conclusions: We conclude that Kv1.3 is a functional marker of Tem, but is not expressed on acutely activated naive T cells. Our preliminary data suggest that acutely stimulated myelin reactive T cells derived from MS patients have the Tem/Kv1.3 phenotype, which is not present on myelin reactive TCL from healthy controls. The Kv1.3 peptide antagonist, ShK, may specifically target Tem and should be considered as a potential therapy in MS.
Disclosure: KG Chandy has received ShK peptide from Michael Pennington at Bachem Bioscience
Funding: Supported by NIH (NS41435) and NMSS.
Session VII
Methodological Issues in Clinical Trials
Wolinsky JS
University of Texas, Houston, Texas, USA
Abstract Body: The International Panel on the Diagnosis of MS (IP) recommended revised diagnostic criteria for the disease (McDonald et al., Ann Neurol 50:121, 2001). The focus of the new guidelines remains on the objective demonstration of dissemination of lesions in both time and space. Advances in MRI mandated its integration with clinical and other sensitive paraclinical diagnostic methods. The revised criteria clearly facilitate the diagnosis of MS in patients with a variety of presentations, including the clinically isolated syndromes (CIS) or "monosymptomatic" disease suggestive of MS, and disease with a typical relapsing remitting course. Previously used terms such as "clinically definite" and "probable MS" are no longer recommended, with the outcome of a diagnostic evaluation designated as MS, "possible MS" (for those at risk for MS, but for whom diagnostic evaluation remains equivocal), or "not MS." Stringent guidelines for diagnosis of disease with insidious progression, without clear attacks or remissions were also formulated that require characteristic CSF abnormalities. The near term specificity and negative predictive value of the IP MRI criteria at first presentation of CIS are well supported by several studies (Tintore et al. MS 7:359, 2001), and the serial use of MRI to provide earlier evidence of dissemination over time than can clinical events is well-established in CIS subjects with two or more lesions on their presenting cerebral MRI (Beck et al., Ann Neurol 51:481, 2002). Nevertheless, several issues are raised by the IP criteria that may impact clinical trial designs that use them. The proportion of subjects with CIS and negative MRI may range to 37% (Brex et al. NEJM 346:158, 2002). While superb placebo data now exist for modeling sample size projections for relapsing MS with two or more clinical attacks and CIS with 2 cerebral MRI lesions, similar data are not available for subjects meeting minimal IP criteria for relapsing MS, or for CIS with less than 2 cerebral lesions. Nor is it clear whether the IP criteria for primary progressive MS (PPMS) that exclude all CSF negative cases and some other subjects fulfilling the "probable PPMS" category of proposed certainty trees (Thompson et al., Ann Neurol 47:831, 2000), are suitable as clinical trial entry criteria.
Disclosure: J Wolinsky has nothing to disclose.
Tintore Ma, Rovira Ab, Rio Ja, Nos Ca, Grive Eb, Sastre-Garriga Ja, Pericot Ia, Sanchez Eb, Comabella Ma, Montalban Xa
aClinical Neuroimmunology Unit, University Hospital Vall d’Hebron, Barcelona, Catalonia, Spain; bMagnetic Resonance Unit - IDI, University Hospital Vall d, Barcelona, Spain
Background: Patients presenting with a first demyelinating attack may be diagnosed of MS when MRI shows dissemination in space (DIS) and dissemination in time (DIT) according to new MS diagnostic criteria (McDonald criteria).
Objectives: To apply the new MS diagnostic criteria in patients with clinically isolated syndromes (CIS) suggestive of MS.
Methods: 139 patients with CIS, followed for a median of three years, underwent brain MRI within three months of the onset of first attack and after 12 months. Number and topography of lesions at baseline, alone or coupled with CSF analysis, provided evidence for DIS and new T2 lesions at follow up for DIT. Diagnosis of clinically definite MS (CDMS) based on Poser criteria was compared to diagnosis of MS incorporating MRI (McDonald criteria). Accuracy of new diagnostic criteria was evaluated.
Results: At 12 months, 11% had CDMS according to Poser compared to 37% who had MS according to McDonald MRI definitions for DIS and DIT. Eighty percent of patients fulfilling these MRI definitions and followed for at least three years, converted to CDMS. The McDonald MRI criteria (DIS and DIT) showed a sensitivity of 74%, specificity of 86% and accuracy of 80% in predicting conversion to CDMS after three years. Specificity for DIS decreased when adding CSF abnormalities to MRI definitions.
Conclusions: McDonald criteria more than triple the diagnosis of MS at one year. Specially when CSF analysis is not considered, evidence of DIS and DIT using MRI accurately predicts conversion to CDMS, demonstrating the usefulness of these criteria in anticipating MS diagnosis.
Disclosure: X Montalban has nothing to disclose.
Noseworthy JH
Neurology, Mayo Clinic, Rochester, Minnesota, USA
Abstract Body: Randomized controlled clinical trials (RCTs) have demonstrated partial efficacy in reducing clinical (relapse-related measures) and MRI (new and enhancing lesions) evidence of inflammatory-demyelinating disease activity for several agents in MS. There remains less certainty that these or other agents influence mid- and long-term clinical (disability) and MRI (atrophy) measures of disease progression. Multiple recent RCTs have exploited short-term markers of inflammation (relapses, MRI activity) to assess treatment benefit in trials lasting less than ttree years. Positive findings suggest bio-logical benefit but this remains unproven by confirmatory studies of adequate length and rigor. The desire to hasten the approval and subsequent availability of effective agents for patients must be balanced with the need to confirm that short-term measures of efficacy predict long-term benefit. Positive findings from short-term trials provide treatment options but disrupt equipoise making confirmatory, controlled, long-term RCTs difficult to conduct and complete. The major challenges to short-term trials in chronic diseases include: 1. Methodological issues: accelerated enrollment, large sample size, limited eligibility spectrum (generalizability), 2. Biological issues: time limitations both for change in major outcome measures in the control group and for therapeutic agents to influence measures of axonal degeneration and regeneration despite potential to measure benefits on short-term markers of inflammation, 3. Safety monitoring: limited time for important, rare or delayed toxicities to appear. Although prognostic markers in relapsing-remitting MS provide guidance for estimates of time to disability, studies to date have not shown that treatmentrelated reduction in these variables (including relapse frequency, severity, new and active MRI lesions) will change time to and degree of clinical disability (or MRI atrophy). Contemporary short-term trials have provided evidence of biological benefit upon markers of inflammation in MS resulting in drug approval. These studies, however, have not been followed by definitive, confirmatory, trials to measure the presence or magnitude of clinically relevant effects on disability.
Disclosure: J Noseworthy received a consulting fee from LFB-France
in 2001 and is a site co-investigator in studies funded by Teva Pharmaceuticals,
Pythagoras and Pfizer.
McFarland H
Neuroimmunology Branch, National Institutes of Health, Bethesda, Maryland, USA
Abstract Body: After the demonstration of the remarkable sensitivity of MRI to detect abnormalities in the brains of patients with MS nearly two decades ago, it was assumed that MRI would be a better measure of disease than clinical measures and that MRI would be a sensitive outcome measure in testing new therapies in MS. Unfortunately, the relationship between MRI and clinical disease has been found to be weaker than expected and the role of MRI as a surrogate marker in clinical trials more problematic than initially thought. The most important criterion for a potential surrogate is that the marker must predict future clinical disease. Early in the course of disease, the extent of change on MRI does have value in predicting the course of disease over a period of several years. However as patients who are further into the disease course are studied, the relationship between these conventional MRI measures and disability as measured by EDSS is poor in a cross-sectional analysis and seems to fail in predicting future course. Thus, conventional imaging falls far short of being a validated surrogate. Several techniques have been shown to be more sensitive for assessing the changes ascribed to destructive MS lesions including spectroscopy, MTR, T1 hypointensities, and atrophy. Although the correlations between some of these measures and disability does improve as compared to measures of T2 lesion load and although the correlations between MRI measures and other measures of disability such as the composite score are better than with EDSS, the correlations remain less robust than hoped and long term data which would allow assessment of the predictive value of the techniques is not available. Thus, MRI is not, at present, an appropriate surrogate for clinical disability. Despite the failures, evidence is accumulating which indicates that disability is related to irreversible damage to myelin and axonal loss. Imaging techniques that can accurately identify these processes early in the disease course should eventually prove capable of predicting future disability. Long term follow-up of patients initially assessed with a MRI evaluation using validated and reproducible techniques is, in the end, necessary to determine the value of MRI as a surrogate in MS.
Disclosure: Dr.McFarland has served as a consultant for Berlex,
Biogen, Teva, Schering, AG, Immunex, Wyeth
Paty Dc, Li DKd, Traboulsee Ac, Simon Ja, Frank Jb
aDepartment of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; bDepartment of Radiology, University of British Columbia, Vancouver, British Columbia, Canada; cRadiology, University of Colorado, Denver, Colorado, USA; dNational Institutes of Health, Bethesda, Maryland, USA
Abstract Body: Purpose: MRI is used in the diagnosis of multiple sclerosis (MS) as it reveals neurologically asymptomatic lesions that may satisfy the criteria for dissemination of disease in space and time. MRI has potential in the follow-upof patients, yet there are no standards for MRI use in clinical practice. A consensus meeting was convened and considered guidelines for a standard brain and spinal cord MRI protocol. Methods and Materials: An international groupof experienced MS neurologists and radiologists, along with representatives from the AAN, the ASNR, and the RSNA met in Vancouver, November 3-4, 2001. The working groups developed detailed guidelines, and the meeting culminated by a joint clinical-MRI consensus session. Results: Results were: (i) when available, a brain MRI based on a standardized protocol should be acquired for diagnosis and initial evaluation of suspected MS; (ii) when presenting symptoms are at the level of the spinal cord, a spinal cord and brain MRI are required;(iii) when brain MRI provides equivocal results, spinal cord imaging may be justified;(iv)in the absence of clinical indications, routine follow-upMRI scans are not recommended. Clinical indications for follow-upMRI include unexpected clinical worsening, reassessment of disease burden for initiation of treatment, suspicion of secondary diagnosis;( v)follow-up MRI by standardized protocol should be compared to previous studies; (vi) contrast enhanced MRI recommended for diagnosis, but optional otherwise. The full protocol will be available on the Consortium web site (http: //www.mscare.org) Conclusion: Uniform imaging standards and guidelines should improve the quality, yield and value of MS follow-up. These recommendations are a part of a continuing quality improvement process based on interactions of the neurology and radiology communities.
Disclosure: D Paty has nothing to disclose.
Session VIII
Genetics and Hormonal Influence
Compston Aa, Sawcer Sa,b
aNeurology, Institute of Neurology, Cambridge, United Kingdom; band the GAMES Consortium, New York, USA
Abstract Body: The Genetic Analysis of Multiple sclerosis in EuropeanS (GAMES) set out to identify genetic factors conferring susceptibility to multiple sclerosis by screening the genome indirectly for linkage and association using markers for susceptibility genes evenly distributed at a density of c0.5 - 10 centiMorgans. We argued that independent identification of the same chromosomal regions, using different genetic tactics, would increase confidence in their candidature as susceptibility loci. GAMES has co-ordinated genetic studies in 19 European populations. Results are available on a dedicated web-site (http: //www.mrc-bsu.cam.ac.uk/MSgenetics). Linkage analyses included in the GAMES project provide whole genome screening (using a sub-set of 400 microsatellite markers) in 521 multiplex families from the United Kingdom, Italy, Sardinia, Scandinavia, Turkey and Australia. Associations have been screened by comparing 5893 cases and 5903 controls from the 19 populations (23 cohorts) using a standard set of 6000 microsatellite markers spaced to provide a 0.5cM map of the genome typed in samples of pooled DNA. Provisional analysis has identified linked and associated regions on chromosomes 1p, 5q, 6p (MHC), 11p, 17q and 19q. Because cases were not typed individually, GAMES is concerned only with genes conferring disease susceptibility and not those influencing disease progression or the clinical course.
Disclosure: Prof. Compston no disclosure of interest for genetics of MS
Funding: The Wellcome Trust.
Ebers GCb,c, Sadovnick Dd, Risch Na
aClinical Neurology, Radcliffe Infirmary, Oxford, United Kingdom; bClinical Neurology, University of Oxford, Oxford, United Kingdom; cUniversity of British Columbia, Vancouver, British Columbia, Canada; dStanford University, Palo Alto, California, USA
Abstract Body: The Canadian Collaborative Study in Genetic Susceptibility to Multiple Sclerosis involves 18 Canadian sites, each staffed by neurologists whose special interest is in MS. To date there are nearly 20,000 patients in the CCSGSMS database. For many clinics, the patient population can be considered "population based" because contemporaneous prevalence studies have shown that the proportion of patients identified in the region is extremely high. These have allowed for a concentric approach to all studies. The ability to carry out population-based studies in large numbers of patients has been beneficial for answering a number of questions relating to the genetic epidemiology of MS. The frequency of familial occurrence gradually increases in clinics proportional to some degree to the background prevalence rate of patients and has approached 25% in several sites. More than 2700 families having more one case of MS have been identified including three families with more than 11 affected individuals in a single pedigree. More than 40 families have been identified with four or more affected individuals. These families may hold special value in looking for susceptible genes in MS and their similarities and differences to sporadic cases will be outlined. In a single pedigree having more than 15 cases who are affected, the mode of inheritance appears to be autosomal dominant and may differ both from other familial cases and from those with sporadic MS. The female predominance is generally lower in such complex families, the contribution from the MHC may be larger (always transmitted from heterozygous parents), and the phenotype appears to be surprisingly broad. Studies of phenotype in concordant monozygotic twins imply the existence of genes influencing outcome as distinct from those determining susceptibility.
Disclosure: Member of the MS Forum which is an educational activity funded by an unrestricted grant from Schering . This group puts on research symposia twice a year. I am a member of a educational group funded by Schering called MS Forum which supports research symposia twice yearly
Funding: Supported by the UK Government. Supported by the MS Foundation
of Canada.
Hauser Sb, Barcellos LFb, Pericak-Vance MAc, Haines JLa, Lincoln RRb, Schmidt Sc, Swerdlin Ab, Oksenberg JRb
a, University of California, San Francisco, California, USA; bDuke University Medical Center, Durham, North Carolina, USA; cVanderbilt University, Nashville, Tennessee, USA
Abstract Body: The etiology of MS is complex, involving both genetic and environmental components. Linkage to the HLA-DR locus, and association with the DR2 haplotype (DRB1*1501-DQB1*0602) within the class 2 subregion of the MHC on ch.6p21 has been consistently demonstrated. In a North American MS dataset, intrafamilial concordance for early manifestations was present, but was not associated with HLA-DR2. A more detailed screen of 6p21, using 24 markers spanning approximately 20Mb, indicated that associations to other markers could be attributed to close proximity to the DR locus and that no evidence for a second MS susceptibility locus distinct from the class 2 region could be found. A dose effect of DR2 haplotypes on MS risk was also observed, indicating that individuals who inherit two copies of a DR2 haplotype are at greater MS risk than those who inherit a single copy only. Furthermore DR2 homozygotes were significantly less frequent in patients with a benign disease course, demonstrating a disease modifying role for HLA-DR2. A recently completed follow-up whole genome screen demonstrated that evidence of linkage to the 6p21 region was restricted to DR2+ families and that, by controlling for HLA influences, additional candidate loci emerged. These findings shed new light on the complex molecular mechanisms that underlie HLA contributions to MS pathogenesis.
Disclosure: S Hauser has nothing to disclose.
Funding: NIH, National Multiple Sclerosis Society, The Nancy Davis Foundation.
Voskuhl R
Neurology, UCLA, Los Angeles, California, USA
Abstract Body: Hormonal influences in multiple sclerosis include the two widely accepted clinical observations that (1) young men are less susceptible to disease than young women and (2) that disease activity in multiple sclerosis (MS) is decreased during late pregnancy. In vitro and in vivo data suggest that high levels of testosterone are immunomodulatory and therefore may be protective in young males. On the other hand, the protective effect of late pregnancy may be due to high levels of estrogens. Estriol is the predominant estrogen of pregnancy. It is normally not detectable, but during pregnancy it is made by the fetal placental unit and gradually increases to reach its peak during late pregnancy. In pre-clinical studies, when estriol was administered to mice with EAE, disease was ameliorated and a favorable shift in the immune response was observed which recapitulated, at least in part, that which occurs during pregnancy. Oral estriol was then given in a pilot trial of female multiple sclerosis patients in an attempt to recapitulate the beneficial effect of pregnancy. As compared to pretreatment baseline, relapsing remitting patients treated with oral estriol (8mg/day) demonstrated significant decreases in delayed type hypersensitivity (DTH) responses to tetanus. In addition, interferon-g levels in peripheral blood mononuclear cells (PBMCs) were decreased significantly. Finally, during estriol treatment, gadolinium enhancing lesion numbers and volumes on monthly cerebral MRIs were decreased as compared to pretreatment baseline. Further, when estriol treatment was stopped, enhancing lesions increased to pretreatment levels. When estriol treatment was re-instituted, enhancing lesions were again significantly decreased. Based on these results, a larger, placebo-controlled trial of oral estriol is warranted in women with relapsing remitting multiple sclerosis. In summary, clinical observations of alterations in disease activity which correlate with alterations in hormone levels should be viewed as invaluable clues to the identification of modulators of disease which can then be explored as novel therapies.
Disclosure: R Voskuhl has nothing to disclose.
Funding: National MS Society.
Koski CLa, Hila Sa, Popescue Ta, Hoffman Gb
aNeurology, University of Maryland School of Medicine, Baltimore, Maryland, USA; bAnatomy & Neurobiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
Background: Our previous data indicate estrogen (E) improves neuron survival in an animal model of multiple sclerosis, experimental allergic encephalomyelitis. In striking contrast, progesterone (P) makes neurons more vulnerable to death during inflammation.
Objectives: To investigate possible mechanisms for our in vivo data in an in vitro model of TNFa-mediated neuronal cell death.
Methods: PC12 cells were differentiated with NGF. Cell death was determined with a TUNEL assay and FACS analysis. Protein expression was detected by binding of specific antibodies, FACS and Western blot.
Results: TNFa (0-150 ng/ml) induced death of up to 80% of PC12 cells in a dose dependent manner. Cell death was prevented by a 72 hr preincubation of cells with physiologic levels of E (1 nM); in contrast, a similar preincubation with P (100 nM) increased cell death by two fold over cells treated with TNFa alone (50-100 ng/ml). 24 hr pre-treatment with E prior to TNF exposure was required to achieve maximum neuroprotection, wereas P was able to enhance cell death within 30 min. E preincubation for 72 hrs increased ERa expression and BCL-xL expression greater than 2 and 3.6 fold respectively while reducing TNFR1 to 19% of control. P (72 hr) decreased ERa expression to 29% of control, did not effect BCL-xL levels, but increased TNFR1 greater than 2 fold. A peptide inhibitor of c JUN N terminal kinase, JNK1, a pivotal kinase in a pathway implicated in neuronal apoptosis, abrogated the ability of a 30 min P pretreatment to enhance TNFa induced injury of PC12 cells but did not effect death induced by TNFa alone.
Conclusions: These results are consistent with the hypothesis that during inflammation, E may regulate neuron survival via transcriptional mechanisms while P increases neuronal cell death via a dual mechanism: activation of JNK1 which augmented the TNF mediated death signal cascade and up-regulation of TNFR1 expression.
Disclosure: C Koski has nothing to disclose.
Funding: Supported by NMSS-PP0754.
Greene C, Crusio R, Chen L, Rose C, Connelly D, Grekova M, Richert JR
Microbiology and Immunology, Georgetown University Medical Center, Washington, District of Columbia, USA
Background: Multiple Sclerosis (MS) is an inflammatory, demyelinating disease of the central nervous system that is thought to be an autoimmune consequence of a microbial infection in a genetically susceptible host.
Objectives: To evaluate abnormal gene expression in MS immune cells directly or indirectly related to environmental influences.
Methods: Differential display was performed to screen peripheral blood mononuclear cells (PBMCs) from identical twins who are discordant for MS. Genes found to be differentially expressed in the twins were then evaluated in larger populations of MS patients and controls.
Results: A gene with no significant homology with any known gene family was identified in the MS twin. Real-time RT-PCR studies showed it to be expressed 5.25-fold higher in the MS population compared to the healthy control group. Preliminary data also suggest that it is overexpressed in rheumatoid arthritis (RA) PBMCs, and under-expressed in other autoimmune diseases and in healthy subjects post-vaccination. Study of a panel of normal tissues revealed ubiquitous expression with levels ranging from low (breast) to moderate (lung, kidney, spleen) to high (pancreas, liver, prostate). Northern blot analysis in healthy PBMCs revealed five transcripts: approximately 4.9, 2.6, 1.8, 1.2, and 1.0 kb in size. 5’ and 3’ RACE studies have revealed the 2.6 and 1.3 kb transcript sequences to date.
Conclusions: This gene that is overexpressed in MS and RA requires further evaluation regarding its function and control of its expression.
Disclosure: J Richert has nothing to disclose.
Funding: Supported by the Dominion Guild Fund. C Greene was supported
by an NIH pre-doctoral fellowship. Saturday, September 21, 2002
Session IX
Long-term Management Issues
Feinstein A
University of Toronto, Toronto, Ontario, Canada
Abstract Body: Multiple Sclerosis is associated with a host of neuropsychological disorders. These may be divided into two broad categories, namely disorders of mood and cognition. The commonest mood problem is major depression which has a lifetime prevalence approaching 50%, 3-4 times the rate in the general population. Depression is associated with a suicide rate well above that in most other neurological disorders. Regional lesion laod on brain MRI accounts for ~40% of the depression scoe variance, psychosocial factors making up the remainder. There are a paucity of treatment data relating to depression in MS, but anecdotal evidence and open label trials suggest symptoms respond well to the SSRI anti-depressants. Sexual dysfunction as a side effect may prove troubling. Psychotherapy that focuses on coping mechanisms may be equally effective. Bipolar Affective Disorder occurs twice as commonly in MS patients than the general population, a fact that cannot be attributed to use of steroids. Mania should be distinguished from euphoria, a state of physical well being that is found in a median of 25% of patients, usually those with advance physical disability, extensive lesion load on MRI (most prominent in frontal regions), and significant cognitive difficulties. Pathological laughing and crying (PLC) occurs in 10% os MS patients and responds well and quickly to low dose amitriptyline or an SSRI. Cognitive dysfunction affects 40% of community based MS patients. The deficits are primarily subcortical and are characterized by slowed information processing speed, memory dysfunction, attention deficits and problems with abstrat thinking. The clinical picture thus differs substantially from cortical dementing illnesses such as Alzheimer’s disease and the more subtle presentation means that the diagnosis may be missed. Cognitive abnormalities correlate with total and regional lesion load on brain MRI, whereas associations with disease duration, physical disability and disease course are poor or absent. Cognitive decline over time is not invariable, shows considerable individual variation and is linked to a deteriorating brain lesion load. Unlike depression or PLC, cognitive dysfunction is harder to treat. Cognitive rehabilitation that is compensatory, utilizing residual cognitive strengths can prove beneficial.
Disclosure: A Feinstein has nothing to disclose.
Funding: Supported by a grant form the Canadian Institute of
Health Research.
Comi G, Leocani L, Rossi P, Colombo B
Neurology, Università Vita-Salute S.Raffaele, Milan, Italy
Abstract Body: Fatigue is a common symprom of patients with multiple sclerosis (MS). It is reported by about one-third of patients, and for many fatigue is the most disabling symptom. Fatigue may be associated with motor disturbances and/or mood disorders, which maked it very difficult to determine whether the fatigue is an aspect of these features or a result per se of the disease. Although peripheral mechanisms have some role in the pathogenesis of fatigue, in MS there are clear inidications that the more important role is played by "central" abnormalities. Neurophysiological studies have shown that faticue does not depend on involvement of the pyramidal tracts and implicate impairment of volitional drive of the descending motor pathways as a physiopathological mechanism. Metavolic abnormalities of the frontal cortez and vasal ganglia revealed by positronemission tomography and correlations between fatigue and magnetic resonance imaging lesion burden support this hypothesis. Some recent studies also suggest that pro-inflammatory cytokines contribute to the sense of tiredness. Nospecific treatments are available. Management strategies include medications, exercise, and behavioural therapy; in most cases a combined approach is appropriate.
Disclosure: G Comi has nothing to disclose.
Montgomery EB
Neurology and Neuroscience, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Abstract Body: Stereotactic surgery for the relief of severe action tremor has been performed for many years. Enthusiasm for the ablative thalamotomy had been modest at best because of the then poor prognosis of multiple sclerosis, surgical risks, and high recurrence rates. However, recent advances on several fronts have rekindled interest and include treatments that may alter the natural history of multiple sclerosis, improvement in surgical techniques, and the development of deep brain stimulation (DBS). A number of clinical studies have been published attesting to the clinical efficacy of thalamic DBS. In our own published clinical study of 15 patients there were statistically significant reductions in tremor. Resting tremor was virtually abolished. Postural tremor was reduced to nearly 0 on Clinical Tremor Rating Scales (zero equals no tremor, four means severe to the point where the patient is unable to perform the task). Action tremor such as bringing the finger to the tip of the nose was reduced from an average value of 4 preoperative to 1 postoperatively. Tremor with bringing a cup to the lip improved from an average of four preoperatively to 0.8 postoperatively. Patients often developed tolerance requiring frequent adjustment of the simulator that nearly always resulted in regained improvement. Long-term follow-up is not available. Our clinical impressions suggest that if patients can continue frequent simulator adjustments their tremors can remain improved. However, it is been our experience that as the disabilities associated with the multiple sclerosis continue to increase, their ability to make the frequent visits diminishes especially in view of the limited availability of clinics to adjust the DBS stimulators. When assessing a patient’s candidacy for DBS, it is very important to have a realistic set of expectations. Our goal is to improved tremor in one arm so that the patient has greater independence. Unfortunately, clinical trials utilizing large inventories of assessments will not detect significant improvements in the quality of life associated with tremor reduction in one arm. Our criteria for candidacy include tremor that is significantly disabling, reasonably intact speech and swallowing, good strength and sensation in the upper extremity, and no significant exacerbations in the previous six months.
Disclosure: E Montgomery Jr. is a consultant to and has received
research support from Medtronic, Inc.
Renoux Ca, Mikaeloff Yb, Vukusic Sa, Gignoux La, Durand-Dubief Fa, Achiti Ia, Confavreux Ca
aNeurologie A, Hôpital Neurologique, Lyon Cedex 03, France; bNeuro Pédiatrie, Hôpital Saint Vincent de Paul, Paris, ., France
Background: There are very few data on the natural history of MS with childhood onset. Their overall prognosis has been shown to be better than adult onset MS, but these results are still discussed.
Objectives: The aim of this study, that is a part of the KIDMUS project (a European cooperative study on childhood onset MS), was firstly to describe the natural history of MS with onset under 16 years of age and secondly to identify prognostic factors of the evolution to a disability of 6 on the Kurtzke’s DSS and to compare this evolution with adult-onset MS.
Methods: We studied a cohort of MS patients with an onset under the age of 16, from the Lyon MS database. This database, created in 1976, contains informations about all patients seen in our department since 1957. We collected demographic data (age at onset of the disease, sex), clinical data ( relapsingremitting or progressive course at onset, initial symptoms, interval between the first two relapses, number of relapses during the first 2 and 5 years of the disease, date at entry into irreversible DSS 4, 6 and 7). All data were validated in the medical file, especially the date and characteristics of the first clinical event whenever possible. Statistical analysis was done by Kaplan-Meier method and Cox model for survival data.
Results: One hundred and eleven patients fulfilled the inclusion criteria. Eighty (72%) were female. Mean age at onset of MS was 13.5 years (range 5.5 - 16 years). Mean disease duration was 18 years at the date of the latest news. Sixty four (57.7%) patients had a relapsing-remitting course, 42 (37.8%) a secondary progressive one and 5 (4.5%) a primary progressive one with or without superimposed relapses.
Conclusions: Analysis is still in progress. Final results will be available at the meeting in September 2002.
Disclosure: C Renoux has nothing to disclose.
Johnson M, Ford H, Denton S
Dept of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom
Background: In most series, about 20% of patients started on disease modifying treatments for M.S. will, for various reasons,stop treatment. Patient disappointment and waste of scarce resources would be avoided if some of these treatment failures could be prevented.
Objectives: To investigate whether practical measures in a clinical setting could be used to predict treatment discontinuation.
Methods: All patients treated with interferon beta in the Leeds Multiple Sclerosis Treatment Programme had a comprehensive pre-treatment assessment. This included a self-report disease-specific measure of quality of life, the Leeds Multiple Sclerosis Quality of Life Scale (LMSQoL) and the Guy’s Neurological Disability Scale (GNDS). These measures were repeated at intervals on treatment. The Expanded Disability Status Scale (EDSS) was assessed annually. Patients eligible for treatment had clinically definite relapsing remitting (RR) or secondary progressive (SP) multiple sclerosis. Patients with RRMS had at least two disabling relapses in the previous two years and those with SPMS had active secondary progression with superimposed relapses or a 1 point deterioration in the EDSS in the previous year. Those patients who discontinued treatment were compared with those who stayed on treatment at two or more years.
Results: At the end of two years, 20 out of 73 (27%) patients had stopped treatment. 3 had stopped because of pregnancy, 4 had stopped or reduced the dose because of side-effects and are now back up to full doses. Of 57 patients treated for RRMS, 11 (19%) stopped because of treatment failure, (relapses or progression). Of 16 patients treated for secondary progressive disease, 7 (44%) stopped because of treatment failure. Patients in whom treatment failed were, as a group, no different on measures of quality of life or disability when they started treatment but they did not show any improvement. They did have generally higher EDSS scores on starting treatment.
Conclusions: Patients with relapsing remitting MS are more likely to stay on treatment with Interferon and less likely to be counted as treatment failures than secondary progressive patients. In relapsing remitting patients, a higher EDSS score does not confer a greater risk of treatment failure in the first two years.
Disclosure: Dr. Johnson serves on an advisory committee for Teva
Pharmaceuticals for which he receives an honorarium. Dr. Johnson and Dr
Ford have received unrestricted educational grants from Biogen and Schering
Pharmaceutical companies.
Rudick RAa, Cutter Gb, Baier Mc, Dougherty Dd, Weinstock-Guttman Be, Mass Mf, Fisher Ea, Miller DMa, Sandrock Ag, Simon Jh
aMellen Center, Cleveland Clinic Foundation, Cleveland, OH, Ohio, USA; bUniversity of Nevada, Reno, Nevada, USA; cAMC Cancer Center, Denver, Colorado, USA; dThomas Jefferson University, Philadelphia, Pennsylvania, USA; eSUNY-Buffalo, Buffalo, New York, USA; fOHSU, Portland, Oregon, USA; gBiogen, Inc., Cambridge, Massachusetts, USA; hUCHSC, Denver, Colorado, USA
Background: Gadolinium lesion frequency is a primary outcome measure in phase II MS trials, and an important secondary outcome in definitive trials. This measure has not been validated as a surrogate marker for clinical benefit.
Objectives: 1.To classify patients from the IFNb1a (AVONEX) RR-MS trial as "complete responders" or "non-responders" based on gadolinium lesions at baseline and 1 year. 2. To determine the proportion of responders and nonresponders for the two treatment arms. 3. To correlate 8-year EDSS, MSFC, and BPF change with these categories.
Methods: 172 patients followed for 2 years in the phase III IFNb1a trial were evaluated 8.1 years after randomization. EDSS was calculated in 163 pts; MSFC in 137; and BPF in 134. Complete responder was defined as a patient with lesions at baseline but not at year 1; non-responder was defined as a patient with more enhancing lesions at year 1 compared to baseline. EDSS, MSFC, and BPF change over 8 yrs were compared in responders and nonresponders.
Results: 42% of IFN and 46% of plc patients were complete responders or non-responders. There were more complete responders in the IFN group (27% vs 21%); and more non-responders in the plc group (25% vs 15%). Over the 8-year study period, complete responders did better than non-responders in the IFN group - mean EDSS worsening 1.1 vs 3.0; mean MSFC worsening -0.78 vs -2.5; and mean atrophy worsening -2.3% vs -3.2%. In contrast, complete responder and non-responder groups did not differ in the plc arm - mean EDSS worsening 2.6 vs 2.2; mean MSFC worsening -1.1 vs -1.1; mean BPF worsening -3.9% vs -3.7%.
Conclusions: 1. Responder or non-responder status as defined correlates with 8-year EDSS, MSFC, and BPF change; 2. Gadolinium change correlated with long-term outcome more strongly in the IFN than the plc arm, suggesting that gadolinium change is a marker of therapeutic response to IFN. The results support use of gadolinium as a surrogate marker in MS trials, and provide support for biological studies that classify IFN responders based on gadolinium activity.
Disclosure: Dr. Al Sandrock is an employee of Biogen, Inc.
Funding: Supported by The original IFNb-1a Study was supported
by the NIH (NINDS), the National MS Society, and Biogen, Inc.; The follow-up
study was Supported by Biogen, Inc.
Weinstock-Guttman B, Feichter J, Bakshi R, Brownscheidle C, Lincoff N
Neurology, Buffalo General Hospital, Baird MS Center, Jacobs Neurological Institute, Buffalo, New York, USA
Background: Neuromyelitis optica (NMO) is a severe demyelinating disease involving the optic nerves and the spinal cord, usually sparing brain parenchyma. Patients with recurrent NMO (R-NMO) generally do not respond adequately to treatment trials with glucocorticosteroids, cyclophosphamide, interferon beta, or azathioprine. Following treatment with mitoxantrone (MITO, Novantrone) we observed improvement in disability (EDSS from 6.0 to 4.0) in one patient with R-NMO. This prompted a pilot trial of MITO in R-NMO.
Objectives: To determine the benefit of MITO therapy in patients with RNMO.
Methods: We are evaluating the effect of 2-year MITO therapy in 5 patients with R-NMO. Entry criteria included recurrent longitudinally extensive myelitis with or without optic neuritis and normal brain MRI. The treatment protocol consists of IV MITO infusions 12mg/m2 (maximum 20 mg)with methylprednisolone 1,000 mg monthly for 3 months followed by every 3 month up to 2 years (maximum dose 140mg/m2). Neurological assessment (EDSS) is performed every 3 months and during relapses. Brain and spinal cord MRIs are performed at baseline, 3, 6, 12, 18, and 24 months. Visual evoked potentials and ophthalmologic evaluations are performed at baseline and annually. Treatment failure is defined as: one severe relapse (complete paraplegia or blindness); 2 relapses with change in EDSS; four documented relapses but without change in EDSS during a 12 month interval, or step-wise disability progression sustained for 6 months.
Results: Five patients are already enrolled: 3F; 2M; age range 22-51 years; disease duration: 4 months to 19 years; EDSS 2.5 to 6. Previous treatments: repeated cycles of steroids, azathioprine, and plasmapheresis. Number of MITO infusions per patient: 3 to 4, follow-up 4-5 months. One patient, 4 months after an initial substantial benefit became treatment failure. The remaining patients are stable or improved by clinical and MRI parameters. The therapy was well tolerated by all patients.
Conclusions: Our preliminary results suggest a beneficial effect of MITO for R-NMO.
Disclosure: B. Weinstock-Guttman has received honoraria from Immunex Corporation.
Funding: Supported by a grant from Immunex Corporation.
Session X
Late Breaking News
ECTRIMS Lecture
Hommes OR
European Charcot Foundation, Nijmegen, Netherlands
Abstract Body: Scientific progress is strongly dependent on political aspects. It is reflected in societies’ willingness to direct attention and funding to specific fields of research. For health care, poliomyelitis and HIV are good examples. In the European Union research developments in general are lagging behind Japan and USA. Neurological and specifically MS research remain at lower organisational and political scales. Since 1990, when the first Concerted Action on MS Research was funded by the Commission of the European Communities, developments of European co-operation in MS Research have been slow. Reasons can be found in the fact that overall national activities and interests prevail over the European dimensions. Two organisations, ECTRIMS and the European Charcot Foundation, are endeavours for MS Research on a European scale, each with different, but fully complementary aspects. MS research expertise in Europe is high, and a number of excellent MS Research Centers have been developed. These developments could be enhanced by a strong organisation of MS Research on a European level. Prerequisites, structure and funding of such an organisation are discussed, with emphasis on clinically and politically relevant goals, fund-raising and governance. Such an organisation is required now as the European Parliament on May 15, 2002 accepted the 6th cadre-programme (2003-2006) doted with 17.5 billion, of which 2.2 billion will go to life science research and health care. European MS Research should and could be a strong contender in this field.
Disclosure: O Hommes has nothing to disclose.
Thursday, September 19, 2002
Posters
Surrogate Markers
Adam P, Sobek O, Taborsky L, Vesela B, Prucha M
Neuroimmunology, Homolka Hospital, Prague, Czech Republic
Background: Till now, the biological role of many CSF proteins is not known. In the group of 7849 patients with neurological disorders, concentrations of CSF and serum proteins were measured using laser nephelometry.
Objectives: Concentrations of CSF immunoglobulins (IgG, IgA, IgM), albumin, prealbumin, transferrin, haptoglobin, CRP, complement (C3c, C4), orosomucoid, apolipoproteins (apo A-I, apo B), fibrinogen, beta2-microglobulin and proteinase inhibitors (antitrypsin, antithrombin III)were evaluated to find outif there is some specific biological role of these proteins present in CSF.
Methods: As method of measurement, immunonephelometry was used to find out the CSF and serum concentrations of these proteins. Measurements were followed by statistical analysis of data.
Results: Majority of these proteins has specific biological meaning which enabled to define their subgroups as inflammatory, destructive and tumorous markers.
Conclusions: Complete CSF proteinogram comprising evaluation of the functional state of CSF-blood barrier and evaluation of intrathecal synthesis of immunoglobulins followed by analysis of specific CSF protein markers, i.e. CSF Protein Status, enables to improve the quality of CSF investigation and diagnostics of inflammatory and autoimmune diseases of CNS.
Disclosure: P Adam has nothing to disclose.
Bartosik-Psujek H, Mitosek-Szewczyk K, Belniak E, Stelmasiak Z
Neurology, Medical School, Lublin, Poland
Background: Only part of multiple sclerosis (MS) patients treated with interferon b preparations, positively responded to applied treatment. Up to now, no parameters were found which could enable the determination before treatment if the patient would respond positively. Interleukin-12 ( IL-12 ) is the inflammatory cytokine, necessary for lymphocyte differentiation and interleukin-10 ( IL-10 ) is it’s main inhibitor. Dependence between IL-10 and IL-12 is of key importance in immunopathogenesis of MS and is also recognised to be very substantial in the mechanism of interferon beta operation.
Objectives: The aim of the study was to investigate the dependence between IL-10 and IL-12 levels before treatment and the clinic condition during the 2 years period of the use of interferon beta preparation.
Methods: The study included 21 patients (14 women, 7 men, aged 26.9 ± 8.5) with clinically convinced relapsing-remitting MS. All patients were in a remission phase and during at least 8 weeks they weren’t being received any steroid therapy because of disease aggravation. The patients were given interferon beta-1a (30µ im once a week). Before the commence of the treatment with ELISA method, levels of IL-10 and IL-12 in the serum and cerebrospinal fluid had been determined. After 24 months of treatment, groups of patients positively and negatively reacted to the therapy, were distributed on the basis of clinical criteria.
Results: clinical criteria. Results: 15 patients positively responded to treatment and 6 patients - negatively. Patients who didn’t react, had higher level of IL-12 in serum (p<0.05) before treatment and coefficient IL-12 in fluid / IL-12 in a serum significantly differed in both groups ( p<0.05 ). However we didn’t observe significant differences in IL-10 level both in serum and cerebrospinal fluid. Measured IL-10 / IL-12 coefficient was markedly lower in patients with negative response to treatment ( p<0.05 ).
Conclusions: Definition of the dependence between levels of IL-10 and IL-12 in serum might be helpful in a distinction of patients with potentially positive response to interferon treatment.
Disclosure: H Bartosik-Psujek has nothing to disclose.
Funding: Drug supply Supported by Schering Plough
Batocchi Aa, Rotondi Mb, Caggiula Ma, Frisullo Ga, Odoardi Fa, Nociti Va, Carella Cb, Tonali Pa, Mirabella Ma
aNeurology, Catholic University, Rome, Italy; bInstitute of Endocrinology, II University of Naples, Naples, Italy
Background: Interferonb (IFNb) therapeutic effects in relapsing-remitting multiple sclerosis (RR-MS) seem to be related to a change in Th1/Th2 cytokine balance. Leptin directly activates the production of Th1 cytokines and is required for inducing EAE.
Objectives: To investigate whether leptin can be used as a marker of MS activity and clinical outcome in patients under IFNb therapy and correlates with peripheral blood mononuclear cell proinflammatory cytokine production.
Methods: We studied 24 patients affected by RR-MS, who underwent IFNb 1a therapy. Case report documentation, body mass index (BMI) and blood samples were obtained at baseline and after 2, 6, 12 months of treatment. At the end of the follow-up period, patients were divided into two groups according to the occurrence of clinical relapses. Serum leptin levels were measured by RIA and unstimulated peripheral blood mononuclear cell cytokine production (IL2, IL10, IL12, TNFa, TGFb, IFNg) was assayed by ELISA.
Results: Eleven patients had no relapses and 13 patients had one or more relapses. Baseline leptin levels were found comparable between relapse-free patients and relapsing ones. There was no main time effect in both groups of patients on BMI. Serum leptin level significantly decreased in relapse-free patients at all time points since two months after starting therapy. There was no main time effect in the group of relapsing patients on leptin concentration but serum leptin measured before the first clinical relapse occurring during the follow-up were significatly higher as compared with baseline values. A trend toward a decrease in IL12/IL10 ratio was observed in relapse-free patients and a significant decrease was evidenced after one year of treatment vs. baseline values. In relapsing patients a significant increase in IL12/IL10 ratio was observed after 6 months of therapy as compared with the control performed right before. At that time 6 out of 12 patients showed a relapse.
Conclusions: 1. leptin can be a useful predictive marker of clinical outcome and response to therapy in RR-MS patients under IFNb 1a treatment; 2. IL12/IL10 ratio correlates with disease activity, as previously suggested in MS patients, also under IFNb 1a treatment.
Disclosure: A Batocchi has nothing to disclose.
Ehling R, Reindl M, Schanda K, Wanschitz J, Deisenhammer F, Berger T
Neurology, University of Innsbruck
Background: Axonal pathology seems not only to be the major cause of permanent disability in multiple sclerosis (MS), but may also be crucial for the development of the progression of the disease. Axonal damage and loss are basic features in the pathogenesis of MS, but there are currently no established in-vivo markers for monitoring axonal pathology in MS patients. We sought to investigate the association between axonal pathology and serum antibodies to the light (L) and the heavy (H) subunit of neurofilament (NF) in patients with relapsing remitting (RR), primary and secondary progressive forms of MS.
Objectives: . Serum samples of 149 MS patients were investigated for antibodies to NF and compared to patients with neurodegenerative diseases, patients with Guillain-Barre syndrom (GBS), patients with other inflammatory neurological diseases (IND), patients with other neurological diseases (OND; including back pain, headache and stroke) and to healthy controls.
Methods: Recombinant NF-L and NF-H cDNAs were amplified from human brain cDNA by PCR. All cDNAs were cloned into pTrcHis2-TOPO-vector and overexpressed in E. coli TOP 10 F. Proteins were purified using affinity and hydroxylapatite chromatography. Human NF-L and NF-H were prepared from human white matter by the axonal floating technique and purified by hydroxylapatite chromatography and consecutive electro-elution from bis-tris SDS polyacrylamide gels. Serum NF antibodies were measured with an established sandwich ELISA.
Results: Serum-autoantibodies to NF-L were found to be significantly increased in MS patients with a progressive disease course. In addition, serumautoantibodies to NF-L were significantly increased in patients with GBS, IND and OND, whereas serum-autoantibodies to NF-H did not differ significantly among the investigated probands.
Conclusions: Our findings suggest that elevated levels of antibodies to NF-L are associated with the disease course in MS and are valuable biological markers for monitoring disease progression in MS, which may allow for the identification of at least a subgroup of MS patients. Though the diagnosis of SP-MS is yet still a retrospective one, anti NF-L antibodies might be used for prospective monitoring of disease progression in MS in the future.
Disclosure: T Berger has nothing to disclose.
Funding: This study was Supported by a grant from the Austrian
Federal Ministry of Science (GZ 70.059/2-Pr/4/99).
Cohen JAa, Goodman ADb, Heidenreich FRc, Kooijmans MFd, Sandrock AWd, Simon JHe, Tsao ECd
aMellen Center, Cleveland Clinic; bNeurology, University of Rochester, Rochester, New York, USA; cNeurology, Hannover Medical School, Hannover, Germany; dBiogen, Inc., Cambridge, Massachusetts, USA; eRadiology, University of Colorado, Denver, Colorado, USA
Background: IMPACT was a randomized, double-blind, placebo-controlled, Phase 3 trial of interferon beta-1a (IFNb-1a, Avonex®) in secondary-progressive MS (SP-MS). Benefit of IFNb-1a was shown on the primary endpoint, 2-year MS Functional Composite (MSFC) change. Benefit also was shown on relapse rate, MRI, and quality of life, but not on Expanded Disability Status Scale (EDSS).
Objectives: These analyses assessed the relationship between measures of neurologic impairment and MRI parameters.
Methods: 436 subjects with SP-MS and EDSS 3.5-6.5 were randomized to IFNb-1a (60 mcg) or placebo IM weekly for 2 years. MSFC and EDSS were measured every 3 months. MRI was performed annually. T2-hyperintense lesion volume (T2vol), T1-hypointense lesion volume (T1vol), and brain parenchymal fraction (BPF) were determined using computer-assisted technology. Significant Spearman rank correlations for the pooled treatment groups are reported.
Results: Baseline T2vol and MSFC correlated moderately (r=-0.48), while EDSS correlated weakly (r=0.20). Among MSFC components, T2vol correlated best with Paced Auditory Serial Addition Test (PASAT, r=-0.47), compared to 9-Hole Peg Test (9HPT, r=-0.35) and Timed 25-foot Walk (T25FW, r=-0.20). Baseline T1vol also correlated better with baseline MSFC (r=-0.41) than EDSS (r=0.20) with the same pattern among the MSFC components. Baseline BPF showed a similar pattern of correlations with clinical measures: MSFC (r=0.41), PASAT (r=0.45), 9HPT (r=0.26), T25FW (r=0.18), EDSS (r=-0.20). The strengths and patterns of cross-sectional MRI-clinical correlations at Years 1 and 2 were similar to baseline. 2-year 9HPT change was the best correlate of T2vol change (r=-0.26) and T1vol change (r=-0.17). 2-year BPF change correlated only with PASAT change (r=0.13).
Conclusions: In this SP-MS cohort, T2 lesion volume, volume of T1 holes, and whole brain atrophy correlated substantially better with MSFC than EDSS. Among MSFC components, measures of cognition and arm function correlated with MRI better than did ambulation. These findings provide additional support for the validity of the MSFC as a clinical outcome measure.
Disclosure: J Cohen, A Goodman, F Heidenreich, and J Simon have served as speakers and consultants, and have received honoraria from Biogen, Inc. M Kooijmans, A Sandrock, and E Tsao are employees of Biogen, Inc.
Funding: Supported by Biogen, Inc.
Finamore la, Zivadinov Rb, Cecchinelli Dc, Pichi Aa, Pierallini Aa, Bastianello Sd, Nasuelli Db, Bratina Ab, Locatelli Lb, GropAb, Reale Mc, Zorzon Mb, Millefiorini Ea
aNeurological Sciences, University "La Sapienza", Rome, Italy; bClinical Medicine and Neurology, University of Trieste, Trieste, Italy; cPathology and Experimental Medicine, University "La Sapienza", Rome, Italy; dEuropean Biomedical Foundation, Rome, Italy
Background: The calcium binding S100 protein (S100p) constitutes the major component of the citosol in glial cells. Neuron Specific Enolase (NSE) is a soluble cytoplasmatic protein localized mainly in neurons. Both these proteins have been reported to increase in blood concentration in patients with Multiple Sclerosis (MS) and other neurological disorders. T1 Black Holes (BH) and brain atrophy on Magnetic Resonance Images (MRI) are considered as radiological signs of axonal loss in MS.
Objectives: To investigate the role of serum levels of S100p and NSE as biological marker of tissue destruction in MS.
Methods: Thirthy MS patients (male/female: 10/20, mean ±SD age 34.8 ±9.2, EDSS 1.4 ±0.6, MS duration 5.4 ±5.1) were included. Patients were clinically assessed and imaged for four consecutive months. Samples’ sera were concomitantly collected for the evaluationof S100p and NSE, by the means of an enzyme-linked immunosorbant assay (ELISA).
Results: A mean monthly value of 0.05 ±0.004 ngr/ml of S100p and of 8.9 ±0.9 ng/ml of NSE were found in the sera of these MS patients. Such values were both within the range already reported in healthy subjects. A mean monthly 2.3 ±1.1 cm3 in T1BH lesion load and a mean monthly value of 0.769 ± 0.766 for brain parenchymal fraction was found in the MRI of these MS patients.
Conclusions: S100pand NSE do not increase in patients with MS even in the presence of radiological signs of axonal loss. Thus such proteins cannot be considered a sensitive biological marker of tissue distruction for patients with MS.
Disclosure: l Finamore has nothing to disclose.
Gonen Oa, Moriarity DMa, Li BSa, Babb JSa, Markowitz CMb, Grossman RIa
aRadiology, New York University Scholl of Medicine, New York, New York, USA; bNeurology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
Background: Evidence is mounting that axonal damage, followed by neuronal cell death by Wallerian degeneration is the cause of permanent neurological deficits in MS. This can be assessed non-invasively by proton magnetic resonance spectroscopy (1H-MRS) quantification of the aminoacid derivative N-acetylaspartate (NAA), found almost exclusively in neurons and axons. Since MS pathology is diffuse, 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) 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.
Objectives: To quantify the rate of concentration decline of the neuronal marker NAA in the entire brain of relapsing-remitting (RR) MS patients in relation to healthy, age-matched controls.
Methods: WBNAA was quantified in 49 RR MS patients, using MRI and 1HMRS. 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 WBNAA values of healthy subjects, disease duration and age.
Results: The analyses indicated three subgroups of WBNAA dynamics: Ten patients were "Stable," exhibiting an insignificant change of ~0% per year of disease duration (p=0.54); 27 showed a "Moderate" decline, -2.8%/yr (p<0.01); and 12 experienced "Rapid," ~27.9%/yr (p<0.01) loss. The avreage EDSS in each of the subgroups, however, was the same - 2.0. No correlation was found between WBNAA deficit, EDSS score, or age.
Conclusions: MS metabolic progression is highly variable even in a cohort of patients of similar, mild, clinical impairment (average EDSS of 2). Consequently, ascertaining an individual’s NAA concentration dynamics might: (a) provide an early forecast of disease course; (b) reflect disease severity, hence, influence treatment decisions; and (c) improve clinical trial efficiency by selecting candidates based on individual WBNAA dynamics in addition to their clinical status.
Disclosure: O Gonen has nothing to disclose.
Funding: NIH Grants NS29029, NS33385 and NS37739
Havrdova Ea, Horakova Da, Krasensky Jb, Dusek Lc, Vaneckova Mb, Seidl Zb, Ticha Va, Novakova Ia, Tyblova Ma
aDpt. of Neurology, First School of Medicine, Charles University, Praha, Czech Republic; bDpt. of Radiology, First School of Medicine, Charles University, Praha, Czech Republic; cCenter of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
Background: Monitoring of occurrence and severity of relapses is a key factor in the clinical evaluation of disease development, commonly based on ordinal EDSS score.
Objectives: To stratify relapses or progression according to MRI measures, a new - quantified - view into the course of disease in individual patients.
Methods: 183 pts planned for the study. 90 pts were already enrolled (27 males, 63 females, age 29+/-4.5yrs, Kurtzke EDSS 1.8+/-1), signed informed consent and were randomized into 3 groups receiving either i.m. IFNB + AZA 50mg/d + prednisone 10mg every other day, or IFNB + AZA 50mg/d + placebo S, or IFNB + placebo A + placebo S. MRI done every 8 weeks (T1, T2 and PD weighted images, 1-2mm slices, automatic measurement of lesion load and atrophy) enables to follow the development of lesions and atrophy. The study is planned for 2 years and data on MRI used for multivariate analyses were routinely monitored every 2 months during 1st year of the follow up. Survival analysis: time-toevent data were primarily based on EDSS score and censored at the point of sustained change.
Results: MRI parameters (volume of lesions) were found to be highly significantly correlated with changed EDSS status of each individual (p < 0.010) and on average level it clearly distinguished pts with repeated relapses or progression (group R) from cases without relapses (group W). Volume of lesions increased by nearly 65% in the group R (12 months follow-up with statistical significance of time-related trend: p < 0.01), while it remained within 100-111% of initial level in group W and reached statistically negligible trend changes.
Conclusions: Although MRI measures correlated positively with increasing EDSS score (with the best cut off at EDSS >= 2.5), the MRI parameters provide more detailed and intrinsically multivariate information related to time-related changes. Using pilot multivariate analysis, the MRI-based score was used as effective covariate for survival analysis modelling time to the first relapse or progression.
Disclosure: E Havrdova has nothing to disclose.
Funding: Supported by Research project MSM CR 111100001, and
Schering-Plough, Praha, CR (MRI part of the study).
Masterman Ta, Leoni Vb,c, Diczfalusy Ub, Melzi d’Eril Gc, Hillert Ja, Björkhem Ib
aNeurotec, Division of Neurology, Karolinska Institutet, Stockholm, Sweden; bClinical Chemistry, Karolinska Institutet, Stockholm, Sweden; cExperimental and Clinical Biomedical Science, University of Insubria, Varese, Italy
Background: 24S-hydroxycholesterol (24S-OH-chol) is colocalized with cholesterol in the myelin-sheath membranes of oligodendrocytes. It is produced from cholesterol by cholesterol 24S-hydroxylase, an enzyme synthesized in neurons throughout the brain. Plasma 24S-OH-chol is derived almost exclusively from the brain; it can thus be used as a marker of cholesterol turnover in the CNS. Any process that damages myelin would be expected to lead to a transitory increase of 24S-OH-chol in plasma and CSF, with a long-term loss of neurons resulting instead in reduced enzymatic formation of 24S-OH-chol. In MS one would thus expect elevated levels of 24S-OH-chol during periods of active inflammation, and reduced levels, from an atrophied CNS, during the final, progressive stages of the disease.
Objectives: We assayed 24S-OH-chol in plasma and CSF from 118 MS patients and in plasma alone from 183 age-matched controls, with a view to comparing levels in, first, patients and controls subgrouped by age, and, second, patients subgrouped according to the results of brain MRI.
Methods: Blood and CSF were taken after an overnight fast. MRI scans were considered positive if judged by a neuroradiologist to be consistent with MS. Only scans performed within two months before or two months after sampling were assessed with regard to gadolinium (Gd) enhancement.
Results: In the oldest patient subgroups, plasma 24S-OH-chol levels were significantly lower than in age-matched controls. Spikes (levels more than 2 SD higher than the mean in the age-matched control subgroup) were found exclusively in patients with positive brain MRI scans, and CSF levels in patients with Gd-enhancing lesions were significantly higher than in patients without such lesions.
Conclusions: Compared to levels in controls, plasma 24S-OH-chol is increased in younger patients with MS and decreased in older patients, perhaps corresponding to the occurrence of inflammatory relapses in the former and of degenerative progression in the latter. Measurement of plasma 24SOH-chol may thus represent a convenient method for evaluating different phases of MS.
Disclosure: T Masterman has nothing to disclose.
Funding: Supported by The Swedish Medical Research Council, The
Swedish Heart-Lung Foundation, The Swedish Association of Neurologically
Disabled
Sastre-Garriga Ja, Comabella Ma, Rovira Àb, Aymerich Xb, López Ca, Téllez Na, Montalban Xa
aClinical Neuroimmunology Unit, University Hospital Vall d’Hebron, Barcelona, Catalonia, Spain; bMagnetic Resonance Unit, University Hospital Vall d’Hebron, Barcelona, Catalonia, Spain
Background: Inflammatory mechanisms are less prominent in primary and transitional progressive (PP/TP) multiple sclerosis (MS). Matrix metalloproteinase-9 (MMP-9) is an enzyme that degrades the extracellular matrix, and has been involved as part of the inflammatory cascade of MS. The role of MMP-9 in PP/TPMS has not been assessed.
Objectives: 1. To determine pro and active MMP-9 levels in PP/TPMS patients, relapsing-remitting (RR) MS patients, and healthy controls (HC). 2. To correlate the values of pro and active MMP-9 in PP/TPMS patients with clinical and radiological variables.
Methods: Seventy-three PP/TPMS, 50 RRMS patients (non-treated and stable for at least 3 months), and 46 HC were included. MMP-9 determinations (pro and active forms but not TIMP-complexed) were performed on serum samples using a commercial ELISA kit (MMP-9 activity assay system; RPN 2634, Biotrak, Amersham-Pharmacia-Biotech, Little Chalfont, UK). EDSS scores were recorded at the time of blood sampling for PP/TPMS cases. T2- and T1-weighted MR scans for the PP/TPMS group were obtained at the time of blood sampling and one year later; increase in T1 and T2 lesion load and new or enlarging lesions at 12 months were determined.
Results: Mean MMP-9 levels were 6.32 ng/ml (SD: 3.47) for PP/TPMS, 7.5 ng/ml (SD: 3.48) for RRMS, and 8.57 ng/ml (SD: 4.32) for HC. Mean MMP-9 levels in PP/TPMS MS were significantly lower (Mann-Whitney’s U) when compared to HC (p=0.01) and RRMS (p=0.026). No statistically significant correlations between MMP-9 and EDSS scores or radiological parameters were found in the PP/TPMS group, although a trend for a correlation (p=0.06; r=0.312) between baseline T1 lesion load and MMP-9 levels was observed.
Conclusions: MMP-9 activity is different in PP/TPMS and RRMS. MMP-9 seems to be unrelated to clinical or MR variables in PP/TPMS, except for a possible role in brain tissue loss.
Disclosure: X Montalban has nothing to disclose.
Petzold Aa, Eikelenboom MJb, Keir Ga, Lazeron RCb, Polman CHb, Uitdehaag BJb, Thompson EJa, Giovannoni Ga
aNMR unit, Institute of Neurology, Queen Square, London, United Kingdom; bClinical Neurology, VU, Amsterdam, -, Netherlands
Background: Neurofilaments (Nf) are principal components of the axoskeleton released during axonal injury.
Objectives: To identify Multiple Sclerosis (MS) patients with high cerebrospinal fluid (CSF) levels of Nf and relate them to disability and progression in their disease.
Methods: Twenty-eight MS patients were included into this 3-year follow-up study along with 9 control patients. CSF levels of the phosphorylated Nf (NfHSMI35) and extensively phosphorylated Nf (NfH-SMI34) heavy chains were quantified at baseline and 3-year follow-up using ELISA technique. Patients were stratified into relapsing remitting ‘RR’ or progressive ‘SP/PP’ disease. Patients >=1 point increase in the EDSS over 3-years were classified as clinically advancing. Levels of NfH phosphoforms, degree of phosphorylation (ratio) and changes between baseline and followup (delta) were related to phenotype, EDSS, ambulation index (AI) and 9 hole peg test (9HPT).
Results: 74% of patients with SP/PP disease experienced an increase in delta NfH-PP compared to 20% maintaining RR disease (p<0.05, Fishers exact test). SP/PP patients at baseline (80.5 pg/mL) and followup (131 pg/mL) had higher NfH-SMI35 levels than stable RRMS patients (below assay sensitivity, p<0.05). Median NfH-PP levels were significantly higher in clinically advancing RR (123 pg/mL) versus stable RRMS patients (below assay sensitivity, p<0.001). NfH-SMI35 correlated with the EDSS (R=0.54, p<0.01), the AI (r=0.42, p<0.05) and the 9HPT (R=0.59). No correlations were found for NfHSMI34.
Conclusions: This study demonstrated that NfH-phosphoforms might predict the development of disability in RRMS, supporting the concept that early axonal injury is a poor prognostic sign. During the progressive phase of the disease an increase of NfH was observed, suggesting cumulative axonal damage. The correlation of NfH-SMI35 with all 3 clinical scales finally suggests that axonal pathology in MS is a dynamic process.
Disclosure: A Petzold has nothing to disclose.
Funding: Multiple Sclerosis Society of Great Britain and Northern
Ireland
Rejdak Ka,b, Petzold Aa, Chard Da, Griffin Ca, Miszkiel KAa, Davis Ga, Rashid Wa, Miller DHa, Stelmasiak Zb, Thompson EJa, Giovannoni Ga
aNeuroinflammation, Institute of Neurology, London, United Kingdom; bNeurology, Medical University, Lublin, Poland
Background: Nitric oxide (NO) is a reactive compound involved in acute inflammatory processes. Increased levels of the NO metabolites, nitrate and nitrite (NOx), are found in MS patients. The role of NO in the pathogenesis of MS is complex and remains unclear.
Objectives: To elucidate the relationship of serum NOx levels to disease activity measured using Gd-enhanced MRI and disease progression.
Methods: Twenty-five patients with early relapsing-remitting MS (RRMS) were enrolled in a longitudinal study. Patients were on average followed upfor 12 months and underwent a series of clinical (EDSS) and magnetic resonance (MRI) assessments. Serum samples were obtained at each visit for measurement of total serum NOx using a vanadium-based assay.
Results: Mean serum NOx was raised in patients who had enhancing MRI lesions compared to those without or with very low enhancement (<260mm3) during the study period as well as to healthy controls (45.7+/-11.5uM vs. 35.0+/-8.1uM and 32.7+/-13.3uM; p=0.02, p=0.004; respectively). Similarly, patients who progressed on EDSS assessment during the study had higher serum NOx levels compared to stable patients (46.6+/-12.5uM vs. 35.3+/-10.0uM; p=0.02). There was no correlation between serum NOx levels and other MRI parameters of disease progression.
Conclusions: Serum NOx levels appear to be increased in the early relapsingremitting phase of MS and are associated with MRI apparent inflammatory disease activity.
Disclosure: K Rejdak has nothing to disclose.
Funding: K. Rejdak is a Marie Curie Fellow.
Rinaldi La, Motta Ma, Calabrese Mb, Guglielmo Ac, Ranzato Fb, Tiberio Mb, Dalle Carbonare Ma, Leon Aa, Gallo Pb
aResearch & Innovation, Padova, PD, Italy; bDept. of Neurological and Phychiatric Sciences, University of Padova, First Neurology Clinic, MS center, Padova, PD, Italy; cEuganea Medica, Diagnostic Centre, Padova, PD, Italy
Background: Autoimmune aggression to myelin antigens is currently thought to be responsible for MS immuno-pathology and MS still today remains orphan of immunological markers of diagnostic/prognostic relevance.
Objectives: We designed a clinical protocol for the study of circulating immune parameters in MS, in attempt to correlate possible ongoing immunological changes with disease activity assessed by EDSS score and MRI burden.
Methods: The protocol entails a one year follow-up of 20 newly diagnosed untreated MS patients, that, every 45 days, undergo clinical examination and cerebral MRI. At the same time points, immunophenotyping (FACS) of a broad-spectrum of lymphocyte subsets is performed: NKT, T regulatory, central/ effector T memory, Th1/Th2, Tc1/ Tc2, NK and T CD8+ expressing KIRs, and CD1d+ APC.
Results: To date 18 patients have been recruited and initial results show that each MS patient is characterised by an individual pattern of lymphocyte subsets, the general features of which are maintained throughout the follow-up. Nevertheless subgroups of patients are distinguishable on the basis of the percentage of circulating lymphocytes (e.g., NK, gd T) or the preferential expression of KIRs on NK and CD8+ T cells. In addition, preliminary evidence suggests an association between increased MRI lesion load, increasing EDSS score and fluctuations in the frequency of NKT cells, CD4+CD25+ T cells, CXCR3+CCR5+CD4+ and CXCR3+CCR5+CD8+ T cells, and NK and CD8+ T cells expressing one or more KIRs.
Conclusions: Although the study is still in progress, results currently available show the occurrence in MS of a complex immunological interplay, which may underlie the observed MRI changes. This favours the possibility that welldefined immunophenotypic panels may be used in monitoring the immunopathological events of MS.
Disclosure: L Rinaldi has nothing to disclose.
Funding: Supported by Italian Ministry of Education, University
and Research (MIUR)(project n° 3933).
Schwid SR, Weinstein A, Goodman AD, Scheid EA, Tyler CM, McDermott MP
University of Rochester, New York , USA
Background: Fatigue is common in MS, but difficulty quantifying fatigue severity has impeded studies of its characteristics, mechanisms, and therapeutics. Motor fatigue can be objectively measured as the decline in strength occurring during sustained contractions. Analogous declines in cognitive performance occur during tasks requiring sustained attention.
Objectives: To objectively measure cognitive fatigue as a decline in performance during administration of the PASAT (3-second version), which requires sustained attention for 3 minutes.
Methods: Patients with clinically stable MS (n=20) and healthy controls (n=21) matched for age, gender, and education completed the PASAT at 2 identical test sessions separated by 4-10 days, within a month after 2 practice sessions. A cognitive fatigue index (CFI) was calculated from the number of correct responses in each block of 10 PASAT items. Reliability of the CFI was determined from the intraclass correlation coefficient (ICC), and validity was evaluated from correlations with self-reported fatigue (Fatigue Severity Scale [FSS], Modified Fatigue Impact Scale [MFIS], Rochester Fatigue Diary), cognition (PASAT total score, MMSE), and overall neurological impairment (EDSS, MS Functional Composite).
Results: MS patients had a mean of 9.3 items correct on the first 10 items of the PASAT and 8.5 on the last 10 items (CFI of 12%, p=0.01 rejecting the hypothesis CFI=0). Mean CFIs for MS patients were similar at both sessions, but within-patient reproducibility was relatively low (ICC=0.49). The CFI correlated with the FSS (r=0.58, P=0.008), but not with other measures of selfreported fatigue, including the cognitive subscale of the MFIS. Cognitive fatigue scores correlated with total PASAT (r=-0.68, p=0.001) and MMSE scores (r=-0.47, p=0.04) in MS patients but not in controls. Cognitive fatigue scores were not associated with overall neurological impairment, and there were no significant differences between patients with relapsing and progressive MS. Control patients did not demonstrate significant declines in performance.
Conclusions: MS patients, but not controls, have measurable cognitive fatigue during administration of the PASAT. Comparison with measures of selfreported fatigue, cognition, and impairment further establish the construct validity of this entity.
Disclosure: S Schwid has nothing to disclose.
Funding: Supported: A grant from the The National MS Society.
Schwid SR, Goodman AD, Scheid EA, McDermott MP
University of Rochester, New York , USA
Background: Time to walk 25 feet (T25FW) was selected as the test of LE function for the MS Functional Composite (MSFC) based on a dataset with limited information about 2 continuous and 3 ordinal tests.
Objectives: To determine the relative sensitivity of T25FW and other measures of LE function for progression of disability in patients with MS.
Methods: Thirty patients with MS, worsening LE symptoms in the past year, and measurable LE weakness were tested on five consecutive days during a period of clinical stability to establish baseline variability, and after 3, 6, 9, 12, 18, and 24 months to determine change over time. Relative sensitivity for progression was determined by t-tests (or Wilcoxon signed rank tests for ordinal measures) of the mean changes from baseline for measures of ambulation (T25FW, maximum distance walked [Dmax, up to 500m], velocity on 500m walk [V500], AI), strength (manual motor testing in 18 muscles [MMT]), and coordination (foot taps in 5 seconds [FT], timed balance test [TBT]. Composite measures (EDSS, MSFC, Scripps Neurological Rating Scale [SNRS]) were also assessed. The 95% confidence interval for the within-patient variability on each outcome measure during the baseline period was used to determine the number of patients worsening.
Results: Participants had mean age 51.9 (sd=8.6) years, relapsing (n=11), primary (n=2) or secondary progressive (n=17) courses, mean MS duration 13.8 (10.6) years, and baseline EDSS 2.5-6.5. They were taking a variety of course-modifying and symptomatic therapies, and 70% were women. Mean T25FW scores were significantly worse than baseline at the 9-month visit (p= 0.01) and thereafter, with 8-12 patients demonstrating worsening beyond their baseline variability at each visit. None of the other measures demonstrated worsening as early, although V500 and AI were more sensitive to worsening (p= 0.002 and 0.009) and had a higher number of worsened patients (n = 14 and 9) by 24 months. Of the 19 patients who had worsened T25FW at least once, 4 (21%) were worse than baseline at only one visit. Eight (42%) remained worse than baseline at all subsequent visits.
Conclusions: Change from baseline evolves more rapidly for T25FW than for other measures of LE impairment, but it may not be the most responsive to change at later time points.
Disclosure: S Schwid has nothing to disclose.
Funding: Spoorted by: National MS Society.
Teunissen CEa, Dijkstra CDa
aMol. Cell Biology, VU Medical Centre Amsterdam, Netherlands; bMol. Cell Biology, VU Medical Centre Amsterdam, Noord Holland, Netherlands
Background: Cytochrome P46 (CYP46) is a brain-specific CYP450 enzyme catalyzing the formation of 24S-hydroxy-cholesterol. Oxidation of cholesterol into 24S-hydroxy-cholesterol likely is an important route for cholesterol transportation out of the brain, and this oxysterol is almost specifically formed in the brain. A recent report showed a decrease of CYP46 in neuronal cell bodies, axonal structures and oligodendrocytes in the cortex of patients with Alzheimer’s disease compared to controls. In astrocytes, in contrast, increased presence of CYP46 was observed. Since in MS axonal loss, demyelinization as well as astrogliosis occur, it may be expected that the presence of CYP46 in neuronal axons or oligodendrocytes may be decreased and the presence of CYP46 in astroglia may be increased in this disease.
Objectives: The objective of our experiments was to investigate if CYP46 could be a suitable marker for neurodegeneration in MS.
Methods: The expression of CYP46 will be studied in MS lesions. Experimental autoimmune encephalomyelitis (EAE) stands as an animal model for MS and we will use this model to investigate if the axonal presence of CYP46 is altered in EAE. Both acute monophasic as well as chronic EAE will be studied for CYP46 expression in the brain and spinal cord. The aim of the present experiment was to study the immunocytochemical CYP46 staining in control brain tissue sections of humans, rats and mice.
Results: The results showed the presence of the CYP46 staining in large neurones in the human grey matter. CYP46 staining was also present in endothelial cells, oligodendrocytes and microglia. In mice and rat brain, CYP46 staining was observed in neuronal structures in the hippocampus, cortex, striatum and thalamus.
Conclusions: The results obtained in control brain tissue of humans and rodents show that CYP46 staining is present in different neuronal subtypes known to be affected in MS lesions.
Disclosure: C Teunissen has nothing to disclose.
Clinical Aspects of MS (Part 1)
Avasarala JR, Cross A, Trinkaus K
Neurology, Washington U School of Medicine, St Louis, Missouri, USA
Background: Screening for depression in patients with MS currently includes Beck Depression Inventory (BDI), a 21 item self-report rating inventory that measures characteristic attitudes and symptoms of depression. However, BDI might not be the most appropriate instrument if simpler techniques can be used to screen for depression. We compared the accuracy of a Yale single question screen (YSQ) response against BDI to screen for depression in MS patients.
Objectives: To examine if depression in MS can be accurately recognized using YSQ as compared to BDI, a 21-item self-report rating scale for depression.
Methods: One-hundred twenty consecutive MS patients seen in our MS Clinic were screened for depression by asking patients the YSQ - "Do you frequently feel sad or depressed?" followed by BDI administration. Depression was defined as a score of 13 on the BDI.
Results: Of the 120 patients studied, a total of 49/120 were clinically depressed as defined by a BDI cut-off of 13; 71/120 were not. The sensitivity of YSQ was 32/49 = 65.3% with a 95% confidence interval (0.50, 0.78), specificity was 62/71 = 87.3% (0.77, 0.94), positive predictive value was 32/41 = 78.0% (0.62, 0.89) and negative predictive value was 62/79 = 78.5% (0.68, 0.87). Of the 49 patients depressed by BDI criteria, 17 patients responded ‘no’ to YSQ, yielding a false-negative rate of 34.7 % (0.22, 0.50).
Conclusions: Our results show that YSQ cannot replace BDI as an instrument for screening for depression in MS. YSQ could not identify 34.7% of patients who were depressed by BDI criteria.
Disclosure: J Avasarala has nothing to disclose.
Funding: J. Avasarala is a postdoctoral fellow of the National
MS Society.
Balc´y BP, Yayla V, Özer F
Neurology, Haseki Hospital, Istanbul, Turkey
Background: Multiple sclerosis (MS) occurs with immune-mediated mechanisms and its pathogenesis is not known accurately. Coexistence with other autoimmune diseases reported. Although the real prevalence of association is unknown, there are some case reports of MS associated with autoimmune thyroid diseases.
Objectives: We present the clinical data of two patients who fulfilled Hashimoto’s thyroiditis diagnostic criteria.
Methods: Among 106 consecutive patients who fulfilled the diagnostic criteria of Poser for definite MS, two patients who had the diagnosis of Hashimoto’s thyroiditis by the determination of T3, TSH and antithyroidal antibodies were presented.
Results: We had two MS patients associated with Hashimoto’s thyroiditis (1.89%). The patients were 35 and 38 years old women and had relapsing remitting (RR) MS of benign course and secondary progressive form respectively. None of them were under interferon treatment. In both of them Hashimoto’s thyroiditis diagnosis was previous to MS diagnosis. Clinical manifestation of hypothyroidism was mild in both of the patients.
Conclusions: Hashimoto’s thyroiditis is relatively common in MS patients, especially in women (4.3%). This high association was not related to the interferon in our series. Thyroid autoimmune diseases should be carefully determined in patients suffering MS.
Disclosure: B Balc´y has nothing to disclose.
Barak Y, Achiron A
Psychogeriatrics, Abarbanel Hospital, Bat-Yam, NA, Israel
Background: Multiple sclerosis (MS) is recognised as a central nervous system disease also affecting cognition. The rate of cognitive dysfunction in MS is in the range of 45-65% and adversely affect the quality of life.
Objectives: To evaluate the effect of 1 year of treatment with interferon-beta-1b (IFN -1b) on cognitive functions in patients suffering from relapsing-remitting
Methods: A battery of cognitive tests was used to assess verbal learning, delayed recall, visual learning and recall, complex attention, concentration and verbal fluency at baseline and after 1 year of treatment with IFN -1b. A group of 23 relapsing-remitting MS patients matched for neurological disability served as controls.
Results: Eighteen of 23 patients treated with IFN -1b (74%) completed the study. In the IFN -1b-treated group, complex attention, concentration as well as visual learning and recall improved significantly (p = 0.024, p = 0.006 and p = 0.005, respectively), while no deterioration was observed in the other dimensions. In the control group, complex attention, verbal fluency, as well as visual learning and recall deteriorated significantly (p = 0.02, p = 0.004 and p = 0.01, respectively), while no deterioration was observed in the other dimensions.
Conclusions: Immunomodulating drugs that reduce the relapse rate and slow the disease progression also inhibit cognitive deterioration in patients with MS.
Disclosure: Y BARAK has nothing to disclose.
Funding: The study was Supported by an educational grant from
Schering, Germany.
Brooks BRa,b, Sanjak Ma,c, Belden Da,c, Dogan Sa,c, Konopacki Ra, Roelke Ka,c,
Peper Sa,c, Parnell Ja,c
aMotor Performance Lab, Dept Neurology, University of Wisconsin-Madison Med Sch, Madison, Wisconsin, USA; bNeurol Svc, Wm S Middleton Memorial VA Med Ctr, Madison, Wisconsin, USA; cMS Clinical Research Ctr, Dept Neurology, University of Wisconsin Hospital & Clinics, Madison, Wisconsin, USA
Background: Clinical changes occur within Expanded Disability Status Scale steps that may be crucial to patient function such as walking or transfers. Prospective longitudinal measurement of maximum voluntary isometric contraction [MVIC] in 10 arm and 10 leg muscles, as well as 2 neck muscles has been ongoing at the University of Wisconsin Hospital & Clinics and VA Medical Center MS Clinics [http: //www.neurology.wisc.edu/MPL/index.htm] in 279 [227F/70M] MS patients.
Objectives: To identify [1] change in arm and leg MVIC during exacerbation, [2] correlation of arm and leg MVIC cross-sectionally and longitudinally with EDSS and AI and [4] mean percent predicted arm and leg MVIC distinguishing those patients with wheelchair requirement.
Methods: CIMS measurement of participating MS patients occurred at each clinic visit. MVIC was transformed to muscle-specific percent predicted muscle strength according to equations developed by the National Isometric Muscle Strength (NIMS) Database Consortium for use of normal isometric strength data for weakness assessment [Archives of Physical Medicine & Rehabilitation. 77(12): 1251-5, 1996]. MS patients were studied cross-sectionally by age, gender(sex), site of disease onset, disease duration, EDSS, AI. MS patients were studied longitudinally by these parameters, as well as developement of exacerbation or progresssion,treatment and response to treatment.
Results: MVIC decreases significantly in motor exacerbations involving arm and leg and, like recovery seen in poliomyelitis, seldom achieves recovery to normal MVIC. Leg MVIC correlates better with EDSS and AI than arm MVIC. In MS patients who require wheelchairs arm MVIC decreases from 87.04 ±24.21 [SD] percent predicted to 73.45 ±21.83 percent predicted [p<0.00018] while leg MVIC decreases from 86.54 ±26.34 percent predicted to 57.74 ±28.58 percent predicted [p<0.00001].
Conclusions: Longitudinal changes in MVIC may be studied in MS as a function of treatment with anti-inflamatory agents, immunosuppressive agents, immunomodulatory agents, anti-fatigue agents, anti-spasticity agents, antitremor agents.
Disclosure: BR Brooks has served as a consultant to Teva Neurosciences, Biogen, Berlex, Serono, Elan, Sanofi, Covance, Regeneron, Amgen, Avanir
Funding: Supported in part by Great Lakes Veterans Integrated
Service Network [VISN 12], Department of Veterans Affairs.
Casanova Ba, Coret Fb, Bernat Ab, García Ea, Pascual Ab, Valero Ca, De Vera Aa
aNeurology, Hospital La Fe, València, Valencian Country, Spain; bNeurology Service, Hospital Clíni Universitari, València, Valencian Country, Spain
Background: The MSFC a recent develope outcome mesure for clinical trials is a sensitive scale to measure disability in MS, because it integrates three dimensions; the arms function, the legs function and the cognitve function
Objectives: To explore the utility of the MSFC in the differents clinical forms of MS patients, and its relation with the disability (mild, moderate or severe) and the EDSS
Methods: 217 clinically definitive MS patients have been studied, mean age 39.5 years old (17-67), mean evolution time 9.08 years (1-46) and mean EDSS 3.4 (0-8.5), 32.3% males and 67.7% females. Distribution in clinical forms was as follow: 61.3% RRMS, 31.3% SPMS and 7.4% PPMS. The MSFC was calculated at the same time as the EDSS, and then compared with the normalized population of the NMSS task force data base. Disability was grouped in mild if EDSS was <4.0; 130 cases, moderate if EDSS was between 3.5 and 6.5; 71 cases, and severe if EDSS was 6.5; 16 cases
Results: Correlations between our series and the normalized series was 0.997 (Spermann rank corrleations). The correlation to the mean evolution time was of -0.534 and to the EDSS was of -0.710 (Spermann rank), we found, also, a correlation with the compounds of the MSFC and the EDSS, Spermann rank to the arms: -0.710, to the legs: 0.716 and to th e PASAT-3: -0.388. Also we found a correlation between the Z-score of the MSFC and its compounds for the three clinical evolutive forms of MS, except for the PASAT-3 in the PPMS patients. Correlations were reached for the Z-score of the MSFC and its three compounds in mild disability patients, while in moderate disability patients the PASAT-3 didnn’t correlate with the EDSS, finally in the severe disability patients corrrelation only was reached to the Z-score from the arms
Conclusions: The MSFC is a reproducible and sensitive scale, in our study a correlation of 0.997 in relation to the population was reached by the NMSS task force, and as in the pivotal study from Cutten, a significant correlation between the EDSS and the mean evolution time for the three compounds and the total Z-score of the MSFC was demonstrated
Disclosure: B Casanova has nothing to disclose.
Casanova Ba, Coret Fb, García Ea, Bernat Ab, Valero Ca, De Vera Aa, Pascual Ab
aNeurology, Hospital La Fe, València, Valencian Country, Spain; bNeurology, Hospital Clínic, València, Valencian Country, Spain
Background: The MSFC has been proposed as a more sensitive form to measure the clinical state from MS patients, but the first exams may be biased by practice, as has been demonstrated by Cohen who noted continous improvement in the MSFC in the first three examns
Objectives: To study the effect of training on the MSFC for one year in an early population of MS patients
Methods: We have studid 30 consecutives MS patients with clinical definitive MS (22) or problable MS (8) according to the Poser criteria, mean age 26 years old, mean evolution time 18 months and 1.4 of EDSS to PMS and 1.8 of EDSS to CDMS, with no statistical differences between groups. The Z-score from the FCMS has been calculated at basal time and each sixs months, in two ways; one in relation to the Task Force Database to allow comparison between studies, and another to longitudinal studies with the follow formula: ((Mean (1/9 NPHT)-Basal mean (1/9 NPHT) / Basal DS (1/9 NPHT)-(mean 8m - basal mean 8m) / Basal DS 8m + (PASAT3 -Basal mean PASAT3 / Basal DS PASAT3) / 3, according to the guidelines published by the NMSS.The Z-scores values have been compared between the two differents populations of MS patients, at basal time and after one year of evolution. We have used the Wilcoxon test, t-test for independent variables analysis of means and the Spermann rank for correlations
Results: Correlations between our series and the normalized population was 0.892 (p<0.0001) at first examination, and 0.923 (p<0.000001) one year after (after undergoing two previous exams). At the baseline a significant difference for Zscore was demonstrated between PMS and CDMS patients (p=0.01), with no correlation with the EDSS (Spermann rank -.188, p=0.3). In the follow up the Z-score improved slightly from 0.004 to 0.11, with no differences between patients that had suffered from brouts or remained as PMS. The differences between the basal Zscore and the Z-score measure after one year wasn’t statistically significant (p<0.7)
Conclusions: The MSFC is a sensitive measure of the activity in MS patients, even in the beginning of the disease, but a training of almost two exams are necessary to compensate for practice effects and improve the sensitivity
Disclosure: B Casanova has nothing to disclose.
Clerc Ca, Chevalier Ya, Bataillard Ma, Rumbach Lb, Richard Pa
aService de neurologie, C.H. Boulloche, Montbeliard, France; bService de neurologie, CHU Minjoz, Besancon, France
Background: Adverse cutaneous effects described after interferon-beta 1b injections are numerous and appear mostly near to the injection site. However sarcoid-like subcutaneous nodules are rarely reported.
Objectives: Description of an unusual adverse cutaneous effect during interferon-beta 1b therapy.
Methods: Case report
Results: A 49 years old woman was diagnosed with multiple sclerosis (MS) 20 years ago. In january and november 1999, she presented two attacks. Interferon beta-1b (8 MUI self-administered by subcutaneous injections every other day) was started in march 2000. Ten months later, she developped subcutaneous nodules on her forearms. Biopsy showed features compatible with sarcoidosis and the serum angiotensin-converting enzyme level was elevated. After interferon beta-1b therapy disruption, cutaneous lesions disappeared.
Conclusions: Interferon alpha has already been implicated in the development or exacerbation of auto-immune diseases including sarcoidosis. According to this case report, the possible role of interferon beta-1b in the pathogenesis of sarcoidosis is discussed.
Disclosure: C Clerc has nothing to disclose.
Cocco EE, Lai MM, Marchi PP, Floris GG, Fadda LL, Sanna SS, Marrosu MM
neuroscience, University of Cagliari, Cagliari, Italy
Background: Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system, which affects predominantly individuals in their most productive period of life. MS course and its clinical outcome could be extremely heterogeneus ranging from death in few weeks from onset to disease discovered casually at autopsy. Benign MS is defined by the presence of minimal or no disability in the long term, but there is lack of agreement in quantitative terms.
Objectives: To evaluate the frequency and characteristics of "benign MS" in MS Sardinian patients with long disease history.
Methods: Among all (1402) clinically defined MS Sardinian patients followed at the Multiple Sclerosis Centre of Cagliari, we selected patients with a long duration of disease (20 years or longer). We considered as "benign" patients presenting a disability measured by Kurtke EDSS scale <3 after 20 years of disease.
Results: Among 1402 Sardinian MS patients 276 (19.7%) had a disease duration longer than 20 years and 55 (3.9% of total patients and 19.9% of patients having 20 years of disease duration) of them presented disability <3, thus fulfilling definition of benign MS. Thirty three were female an 22 were male, the median age was 47.2 years (DS +/-7), the age at onset was 22.4 years (DS+/- 6.6) the median duration of the disease was 24.8 (DS +/-4.5). There no statistical difference between benign MS and the other MS patients for sex, age at onset and age at observation.
Conclusions: Our results sustain the existence of "benign MS" in Sardinian patients having more than 20 years of disease duration. However the percentage of benign patients is relatively small, thus suggesting than only in few cases MS in long term does not cause a consistent disability. The availability of disease modifying treatments for MS and the increasing evidence of the utility of early treatment sustains the need of a good definition of "benign MS" and of early predictive markers for its detection.
Disclosure: E Cocco has nothing to disclose.
Cordonnier Ca, de Seze Ja, Breteau Ga, Ferriby Da, Michelin Eb, Stojkovic Ta, Pruvo Jb, Vermersch Pa
aneurology, university, Lille, lille, France; bneuroradiology, university, Lille, lille, France
Background: Clinical and radiological characteristics of myelopathy in multiple sclerosis (MS) are relatively well known. Nevertheless, it remains difficult for the clinician to ascertain an evolution into MS after a first episode of acute partial transverse myelitis (APTM).Furthermore, there is a need for predictive factors of bad evolution in order to decide which patients should be treated by immunomodulatory drugs early in the course of the disease.
Objectives: The aims of this study were to define predictive criteria of conversion into clinically definite MS after an APTM and to define predictive factors of severe disability progression.
Methods: Between 1994 and 2001, we prospectively included 55 APTM (28.85% men, 71.15% women, mean age of 35 years). Three patients were lost during the follow-up. We evaluated clinical, spinal cord and brain MRI, cerebrospinal fluid (CSF) and visual evoked potentials (VEP) at admission. Mean duration of follow-up was 35 months (range 12-86). At endpoint we evaluated diagnosis and among the MS subgroup, severity of the disease.
Results: Among the 52 APTM who completed the study, 30 became definite MS (23.33% men, 76.67% women, mean age 33 years, mean follow-up37 months) and 22 remained of unknown aetiology (36.36% men, 63.64% women, mean age of 37.8 years, mean follow-up31.5 months). All the MS patients remained in the relapsing remitting form of MS.The discriminating factors for the evolution in MS were: initial sensorial symptoms (p=0.009), latero-posterior spinal cord lesion (p=0.01), abnormal brain MRI (p=0.002), oligoclonal bands in CSF (p=0.003), but not VEP. In the clinically definite MS subgroup, we did not find any predictive factors of severe disability progression.
Conclusions: Our study demonstrates that clinical symptoms, CSF, spinal cord and brain MRI are highly predictive of an evolution of APTM into clinically definite MS. These patients should be selected for an early treatment by immunomodulatory drugs.
Disclosure: C Cordonnier has nothing to disclose.
Coyle PK, Christie S, Fodor P, Fuchs K, Giesser B, Gutierrez A, Lynn J, Weinstock-Guttman B, Pardo LG
Women Neurologist’s MS Initiative, WNMSI, New York, USA
Background: Lack of data on gender issues impacts female MS patients.The Women Neurologist’s MS Initiative(WNMSI) is a group of women neurologists interested in gender-based MS issues.
Objectives: To assess clinical practices of women neurologists regarding gender-related MS issues.
Methods: A 4-pg 16 question survey,mailed to 419 US Board Certified/eligible women neurologists(from academic,private practice,or MS centers).Nonrespondents received 1 reminder after 6 wks.
Results: A total of 147 surveys were returned(35%).The majority were from private practitioners(68%),treating 50-100 MS patients/yr(23%)or100 patients/yr(39%).91% treated>=10 MS patients of child-bearing age/yr,with 57% treating >=2 MS pregnancies/yr.Respondents ranked FDA Pregnancy Category, company insert,and published data as 3 key factors guiding disease modifying therapy(DMT)use in pregnancy.52% insist patients cease DMT immediately if pregnant,while 36% discourage use.In patients planning pregnancy,81% recommend ceasing interferon therapy prior to pregnancy,14% recommend continuing to conception.With glatiramer therapy,70% recommend ceasing therapy before pregnancy,22% recommend continuing to conception. Of DMTs,glatiramer acetate was described as safest in pregancy by 52%,48% felt there was no difference. When DMTs were not used during pregnancy, respondents restart therapy immediately after delivery or breastfeeding( 53%),or within 1-3 menstrual cycles(43%). With regard to breastfeeding,nearly half(49%)make no specific recommendation,38% recommend it,and 13% discourage it.DMTs were usually not recommended during breastfeeding(88%).With regard to contraception 2/3 of respondents do not recommend specific methods,but refer patients to an OB/GYN(100%)or internist(13%).Most MS patients use oral contraceptive,tubal ligation,or barrier methods.Menstrual irregularities were reported in<25% of MS patients. In the survey 36% recommend HRT very frequently or frequently,23% occasionally or rarely,and 42% never recommend it;92% refer patients to an OB/GYN.
Conclusions: Surveyed neurologists show a high interest in MS gender issues.Over 90% of respondents would participate in a prospective study.However, results indicate no real consensus on current clinical practices.Future goals involve development of a consortium,database,and provide for future studies.
Disclosure: P Coyle has nothing to disclose.
de seze Ja, Lebrun Cb, Stojkovic Ta, Ferriby Da, Chatel Mb, Vermersch Pa
aNeurology, CHRU de Lille, Lille, Nord, France; bNeurology, CHU de Nice, Nice, Cote d’azur, France
Background: Devic neuromyelitis optica (NMO) associates optic neuritis and myelitis without other neurological signs. Many patients with NMO may be diagnosed as having multiple sclerosis (MS), optic neuritis and myelitis being the inaugural symptom in 20% and 5% of MS cases, respectively. However, there have been no previous studies comparing these two pathologies and it is still unclear if NMO is a separate entity or a syndrome including MS, systemic or infectious diseases.
Objectives: To compare NMO patients with MS patients revealing by optic neuritis or myelitis, in order to determine the place of NMO in the spectrum of MS.
Methods: We retrospectively studied 30 patients diagnosed with NMO. We compared these patients with 50 consecutive MS cases revealed by optic neuritis (n=26) or acute myelitis (n=24). Patients were diagnosed as MS only if a second relapse occurred demonstrating time and space dissemination. We compared the groups in terms of clinical presentation, initial laboratory findings (MRI, visual evoked potentials and CSF) and clinical outcome (evaluated by the expanded disability status scale (EDSS) and the index of progression (IP) =EDSS/duration of the disease).
Results: NMO patients were older and more frequently female than MS patients but the differences were not significant. CSF and MRI data were different: oligoclonal bands were found in 23% of NMO cases and 88% of MS (p<0.001), abnormal brain MRI data following Barkhof et al. criteria were observed in 10% of NMO cases and 66% of MS cases (p<0.001). Clinical outcome was evaluated as more severe in the NMO group (p<0.001 for both EDSS and IP). If we include MRI data only two of the NMO patients met criteria for MS and one of the MS patients met the criteria for NMO.
Conclusions: Our study demonstrates that NMO and MS should be considered as two different entities. This finding could have implications for future therapeutic trials.
Disclosure: J de seze has nothing to disclose.
de seze Ja,b, Dubucquoi Sb, Matthias Tc, Lefranc Db, Dussart Pb, Vermersch Pa, Witte Tc
aNeurology, CHRU de Lille, Lille, Nord, France; bImmunology, CHRU de Lille, Lille, Nord, France; cImmunology, University of Hanover, Germany
Background: Sjogren syndrome (SS) with neurological manifestations raised a major problem for the diagnosis because anti-Ro (SSA) and anti-LA (SSB) antibodies are found in less than 50% of cases. Furthermore, SS with neurological manifestations may mimic multiple sclerosis (MS) and especially in the primary progressive forms of MS (PPMS). We previously observed that SS could be misdiagnosed with PPMS in around 15% of cases. A recent study underlined the interest of a new biological marker for SS, showing IgA or IgG autoantibodies (aAb) against alpha-fodrin in almost 70% of patients with primary SS and in less than 5% of blood donors.
Objectives: To investigate the interest of aAb against alpha-fodrin in order to discriminate SS and MS patients especially PPMS.
Methods: We tested alpha-fodrin aAb, with an ELISA method, in 30 SS patients with neurological manifestations, 60 MS patients without SS (20 patients with relapsing-remitting MS, 20 patients with PPMS and 20 patients with secondary progressive MS) and 10 patients who responded both to PPMS and SS criteria.
Results: IgA and/or IgG levels against alpha-fodrin were observed in 19 of the 30 SS patients (63%) with neurological disease, in 8 of the 60 MS patients without SS (13.3%) unrelated with the clinical form of MS, and in 6 of the 10 patients with PPMS and SS criteria (60%). The frequency of anti-alpha-fodrin autoantibodies was statistically higher in this last group compared with MS patients without SS criteria both when we considered all MS patients (p<0.01) and the 20 PPMS without the SS criteria (p<0.05).
Conclusions: Our study confirmed that aAb against alpha-fodrin are reliable markers for SS and may differentiate MS and SS, especially in the progressive form of MS. These results are consistent with the fact that SS and PPMS are different diseases rather than PPMS could be associated with SS.
Disclosure: J de seze has nothing to disclose.
Dogan S, Konopacki R, Brooks BR
Neurology, University of Wisconsin-Madison, Madison, Wisconsin, USA
Background: Tremor is the most common movement disorder found in multiple sclerosis [MS] due to pathological changes in specific white matter tracts during the illness. Detailed clinical, neurophysiological, and motor control studies of such patients are infrequent, limited, and have rarely followed patients longitudinally.
Objectives: Evaluate the sensitivity, specificity, and reliability of quantitative computerized tremor testing in determining the prevalence, type, change over time, and response to treatment of tremor in MS patients.
Methods: We have determined the prevalence and tremor type in 321 patients in the UW- Hospital and Clinics/VA Medical Center MS Program. Each patient underwent a standard computerized tremor assessment. Bilateral upper extremities were tested for postural, intention, rest, action tremor by standard algorithms employing uniaxial accelerometer input for computer analysis. Isometric tremor was measured with a force transducer providing computer input of the amplitude in grams. Patients were assessed longitudinally over 1-12 years.
Results: The 321 MS patients [253 F/68 M] with an average age of 48 years [range: 16-89] had clinically definite/laboratory confirmed MS [223 F/63 M; Kurtzke EDDS Score ranging from 2.0-8.0] or atypical/possible MS [30 F/5 M]. Tremor was detected in 93% patients. Multiple tremor type were seen 70% of the patients. Intention tremor was most common [73%] with 40 unilateral and 194 bilateral arm tremors. Action tremor was present in 80 patients with 32 unilateral and 48 bilateral tremors. Postural tremor was present in 90 patients, while 13 patients had rest tremor and 10 patients had orthostatic tremor. Isometric tremor was present in the limbs of 67 patients. Tremor types were stable after the initial evaluation except for the appearance of new tremors with exacerbations and the evolution of intention tremor into action tremor as the MS progressed in 25 patients.
Conclusions: Quantitative computerized tremor testing identifies cerebellar and other tremor type in MS patients with increased diagnostic sensitivity and specificity. It is a reliable means to follow tremor evolution and response to treatment over the course of MS.
Disclosure: S Dogan has nothing to disclose.
Funding: Supported by In part by Great Lakes Veterans Integrated
Service Network [VISN 12], Department of Veteran Affairs.
Eraksoy M, Turan N, Kurtuncu M, Akman-Demir G, Yapici Z, Deniz E, Ozcan H
Neurology, Istanbul University, Faculty of Medicine, Istanbul, Turkey
Background: The selective involvement of optic nerve(s) and spinal cord may be encountered in the spectrum of inflammatory demyelinating diseases. There has been some debate on the classification and the naming of these groupof diseases.
Objectives: The objective of this study was to determine the clinical, neuroimaging, cerebrospinal fluid and other laboratory findings of 26 patients with inflammatory demyelinating disease presented with opticospinal involvement.
Methods: The case records of patients seen in our department between June, 1987 and April 2002 and diagnosed as Devic’s syndrome, Devic’s neuromyelitis optica, Devic’s disease, opticneuropathy/ transverse myelopathy and opticospinalMSwere reviewed.We classified patients who met the criteria set by O’Riordan at al.The findings of these patients were compared with the clinically definite multiple sclerosis( CDMS) patients presented with uni- or bilateral optic neuropathy(ON/BON).
Results: There were 21 women and 5 men with a mean age 26 (range 4-52) years.This study revealed that most of the patients in this group developed multiphasic Devic’s neuromyelitis optica(DNO), small group of patients had monophasic DNO, and the remaining patients had a transitional form between multiphasic DNO and opticospinal MS at the last follow-up. Mean interval between first and second relapses was shorter in multiphasic DNO than CDMS patients with the onset of ON/BON or TM.The prognosis of multiphasic DNO group was relatively poor than the other two MS groups. However, a statistically significant difference was not found between three groups in terms of reaching the Kurtzke’s score of 6.0.
Conclusions: This study revealed that the occurence of opticospinal involvement in inflammmatory demyelinating diseases seemed a result of different etiopathogenetic factors. Some of the clinical and laboratory clues showed that there has been a close relationshipbetween inflammatory demyelinating diseases,vasculitis and DNO showing opticospinal presentation. The genetic and environmental factors which modify the acuteness and tempo of the process might explain the differences of the syndrome presented with opticospinal involvement.
Disclosure: M Eraksoy has nothing to disclose.
Fazio MC, Musolino R, Buccafusca M, Dattola V, Scalfari A, Girlanda P, Messina C
Neurosciences, Psychiatry and Anaesthesiolgy, University of Messina, Messina, Italy
Background: Syncopal episodes are relatively underestimated presenting symptom of Multiple Sclerosis (MS). The cause and the pathophysiology of these episodes and their incidence in MS are unknown. In literature only two isolated cases are reported (Sakakibara et al. 1997, Funakawa et al. 1998).
Objectives: We describe two patients, who presented with recurrent episodes of loss of consciousness. Case report: a male and a female, 51 and 31 years old respectively. The first patient had been presenting syncopal episodes for five years and the second one for twelve years before our observation. They both had not consulted a neurologist and had received the diagnosis of "sincopal episodes". Due to an increase of episodes, the patient were adressed to neurological evaluation.
Methods: Neurological examination, brain and spinal cord MRI, visual and somatosensory evoked potential and cerebrospinal fluid examination were performed in both patients.
Results: The neurological examination revealed in the male patient mild tendon hyperreflexia and a left Babinski sign; the female patient had tendon hyperreflexia, decreased deepsensation and mild ataxia. The brain and spinal cord MRI showed in both the presence of tipical lesions of a demyelinating disease. In both patients one lesion in the paramedian tegmentum and another one in the high cervical spinal cord (C1-C2) with enhanced gadolinium were found. Visual and somatosensory evoked potential were also abnormal and cerebrospinal fluid examination revealed oligoclonal bands. The patients were treated with high dose IV methylprednisolone and syncopal episodes did not recur after more than one year.
Conclusions: We underline that syncopal episodes can be presenting symptom of MS. A possible relationship with localization of demyelinating lesions in brainstem and high cervical spinal cord has been hypotized.
Disclosure: M Fazio has nothing to disclose.
Ghezzi Aa, Bergamaschi Rb, Martinelli Vc, Filippi Mc, Tola Rd, Trojano Me, Zaffaroni Ma, Comi Gc,a
aCentro Studi SM, Gallarate, (VA), Italy; bClinica Neurologica, Pavia, (PV), Italy; cClinica Neurologica, Milano, (MI), Italy; dClinica Neurologica, Ferrara, (FE), Italy; eClinica Neurologica, Bari, (BA), Italy
Background: It is not clear whether Devic’s Neuromyelitis Optica (DNO) is a form of MS or a separate syndrome. Apart from one study (Wingerchuk et al. 1999) data are not available on the clinical and laboratory characteristics of DNO.
Objectives: Our study was undertaken to evaluate these aspects: in this study clinical findings at onset will be presented
Methods: several Italian neurologicsl departments involved in MS research were invited to collect patients with DNO, diagnosed on a clinical ground, according to these characteristics: clinical attack suggesting involvement of optic nerve/spinal cord, no other site of CNS involvement. Brain MRI was required to be normal in initial stages of the disease (or with < 3 lesions). Cases with intrathecal IgG synthesis and brain MRI lesions were considered as affected by MS and were nor included. Fifteen neurological departments participated to the study.
Results: 45 subjects were collected. The mean age was 40.2 years (+/- 15.1) with a peak at age 30-39 ys and a second peak at age 59ys. Nine were males (20%). Symptoms suggesting spinal cord involvement were found in 17 subjects, suggesting optic nerve involvement in 26, both spinal cord and optic nerve in 2. EDSS at onset was 3.9 +/- 1.5 during the acute phase, the residual score was 2.1 +/- 1.9. Concomitant diseases: fever or viral infections in 5 subjects, ANA positivity in 4, thyroid dysfunction in 3, HCV positivity in 3, epilepsy in 2, myasthenia gravis in 1.
Conclusions: Our results show a strong preponderance of females affected (80%), a bimodal distribution of age at onset, with a first peak at age 30-39 ys. and a second peak at age 59 ys., a frequent association with infectious/autoimmune/thyroid dysfunction
Disclosure: A Ghezzi has nothing to disclose.
Ghezzi Aa, Bergamaschi Rb, Filippi Mc, Martinelli Vc, Tola Rd, Trojano Me, Zaffaroni Ma, Comi Gc,a
aCentro Studi SM, Gallarate, (VA), Italy; bClinica Neurologica, Pavia, (PV), Italy; cClinica Neurologica, Milano, (MI), Italy; dClinica Neurologica, Ferrara, (FE), Italy; eClinica Neurologica, Bari, (BA), Italy; fCentro Studi SM, Gallarate, (VA), Italy
Background: It is not clear wheter Devic’s neuromyelitis optica (DNO) is a form of MS or a separate syndrome. Apart from a few studies, data are not available on the long term evolution of this disease.
Objectives: Our study was undertaken to evaluate the course and prognosis of DNO.
Methods: 45 patients affected by DNO were collected by 15 Italian neurological departments. Patients were included if presenting optic nerve/spinal cord involvement in a mono/multiphasic pattern (for details see the presentation: Part 1)
Results: The duration of follow up was 8.8 +/- 7.0 years (range 1-26 ys). The number of attacks was 6.3 +/- 3.5 (range 2-16). The number of attacks/year was 1.3 +/- 1.2 (range 0.4-5.5). The inter-attack interval between the first 6 attacks was 16-17 months for each interval. Kurtzke’s EDSS during the acute phase was 3.9, 4.4, 4.9, 5.4, 6.3 in the first 6 attacks, the residual score was respectively: 2.1, 3.0, 3.9, 4.3, 4.6, 5.4. The % of reduction was respectively: 46%, 32%, 20%, 20%, 18%, 14%. Data concerning 103 brain MRI scans and 91 spinal cord MRI scans will be presented.
Conclusions: The clinical course was variable but, in general, disability increased progressively with time, with a tendency to a poor recovery. The prognostic value of different variables (age, gender, inter-attack interval, initial EDSS score) will be presented.
Disclosure: A Ghezzi has nothing to disclose.
Heesen Ca, Bruegmann Mb, Koch Ea, Gold SMa, Moench Aa, Gbadamosi Ja
aNeurology, University Hospital Eppendorf, Hamburg, Germany; bHematology and Oncology, University Hospital Eppendorf, Hamburg, Germany
Background: In 2000, mitoxantrone (mitox) was approved for treatment of progressive relapsing-remitting and secondary progressive multiple sclerosis (MS) in the US. Therapy related leukemia (tAL) is a rare but serious adverse event of mitoxantrone therapy described in about 1% of mitoxantrone treated cancer patients. We report the case of a patient out of 59 treated at our center who developed acute myelogenous leukemia (AML) after 108 mg mitoxantrone.
Objectives: To describe a case of therapy-related leukemia (tAL) under mitoxantrone treatment.
Methods: Casereport.
Results: A now 34-year old patient developed relapsing-remitting MS 16 years ago. After disability ratings worsened considerably in 1998 (EDSS 5.0 to 6.0), mitoxantrone therapy was initiated at a 12mg/m2 dose every third month. Medication was well tolerated. Mitoxantrone was administered 6 times until November 2000. In April 2001, the patient presented with fever, fatigue and marked leukocytosis. Bone marrow biopsy and immunophenotyping led to the diagnosis of AML, French-American-British Groupclassification type (FAB) M4Eo. Cytogenetic analysis showed an inversion of chromosome 16. Chemotherapy and autologous stem cell support chemotherapy were performed. Up to now, no recurrence of leukemic cells could be detected. At her last presentation in April 2002, she reported increased fatigue but EDSS was stable at 6.0, no deterioration of hand function or cognitive dysfunction were seen.
Conclusions: This is the third reported case of t-AL in MS patients treated with mitox. We conclude from these studies that MS patients should not only be educated about the risk of cardiomyopathy but also about the risk of t-AML, which might be in the range between 0.05-1%. However, since only three cases have been described so far, the empirical evidence does not allow for definite conclusions to be drawn. Cytogenetic studies may helpto clarify a causal relation to therapy and identify prognostic factors.
Disclosure: S Gold has nothing to disclose.
Guerrero A, Bueno V, Hernández M, Martín-Serradilla J, Díez S, Calvo A
Neurology Unit, Hospital Río Carrión, Palencia, Spain
Background: There have been recently proposed revised criteria for the diagnosis of multiple sclerosis (MS). According with these criteria, a monosymptomatic demyelinating disease can be diagnosed as MS, when it fulfills criteria of dissemination in time and space.
Objectives: We retrospectively analyzed our patients with a isolated demyelinating disease, in order to apply in the usual clinical parameters, these new criteria.
Methods: In January 2002 we analyzed 12 cases seen in our unit among April 1997 and January 2001 due to a clinically isolated demyelinating disease. None of them suffered a new clinical episode during the follow-up. Accordin to the new recommended criteria we analyzed the RMN performed during clinical event, and a new one performed later in all the cases
Results: Among our 12 cases, 3 clinically corresponded to spinal cord lesions, 5 to infratentorial ones, and 4 were optic neuritis. Only 2 of our patients presented space and time dissemination, so fullfilling MS new diagnostic criteria. Five more presented dissemination only in space and one dissemination in time
Conclusions: The analysis of the patients seen in our unit due to monosymptomatic demyelinating disease, leads us, according to the new recommended criteria, to diagnose two new cases of MS, as well as to identify 6 more in which dissemination either in space or in time will lead us to observe more carefully the evolution of these patients
Disclosure: A Guerrero has nothing to disclose.
Jean Pa,b, Bertrand Aa,b, Laurent Sa, Jean Philippe Rb, Sylviane Cb, Patrick Cb, Andre Aa
aNeurology, CHU Timone, Marseille, France; bLaboratoir de Neurophysiologie et de Neuropsychologie, Faculté de Médecine
Background: The clinical course of multiple sclerosis (MS) presenting with large brain focal tumor-like lesions at the onset of the disease remains uncertain.
Objectives: A follow-upstudy was performed to determine the clinical course in a group of patients presenting with large brain focal tumor-like lesions.
Methods: The population consisted of 20 patients (13 women, 7 males; age: 27 (17-44)) presented with large (more than 2 cm) demyelinating lesions on brain MRI performed at the first clinical episode (T2 and T1 with and without gadolinium injection weighted sequences). Cerebrospinal fluid (CSF) analysis was performed for each patient and brain biopsy in 9 cases. Exclusion of alternative diagnoses was performed in all cases.
Results: Clinical presentation was acute or subacute in 17 cases. Motor signs were present in 10 cases, cerebellar dysfunction in 7, sensitive impairment in 6, headaches in 5 patients and cognitive dysfunction in 4 cases. At presentation, mean EDSS score was 4 (2-8). Initial brain MRI was strongly suggestive of MS in 15 cases (Barkhof criteria) and gadolinium enhancement was present in 17 patients. CSF analysis showed oligoclonal bands in 16 patients. The follow-up period was 8 years (4-11ys) and mean EDSS score was 3.5 (1-10) at this time. During this follow-upp eriod, 16 patients presented one or more exacerbations and time to the first recurrence was 14 months (1-28). One patient died after a monophasic history (26 months).
Conclusions: This study confirms that clinical course of MS presenting with large focal tumor-like lesions seems not to differ from classical relapsingremitting course of the disease.
Disclosure: P Jean has nothing to disclose.
Jean Pa,b, Bertrand Aa,b, Jean Philippe Rb, Laurent Sa, Alban Da, Sylviane Cb, Patrick Cb, Andre Aa
aNeurology, CHU Timone, Marseille, France; bLaboratoir de Neurophysiologie et de Neuropsychologie, Faculté de Médecine
Background: The risk of progression to multiple sclerosis (MS) after an episode of acute non compressive episode involving the spinal cord remain uncertain.
Objectives: To determine the risk of progression to MS in a population of 50 patients presenting with clinically isolated lesions of the spinal cord, and to evaluate the clinical course of these patients in a long term followupstudy.
Methods: The population consisted of 50 patients (30 women, 20 males; median age : 26 / 9,2 ys) presenting with a first clinically isolated acute syndrome of the spinal cord suggestive of MS. At baseline, spinal cord and brain MRI (T2 and T1 with and without gadolinium injection weighted sequences), cerebrospinal fluid (CSF) analysis, evoked potentials (VEPs, BAEPs, SEPs) were performed. During the follow-up, brain MRI was performed in all cases.
Results: Spinal cord MRI demonstrated cervical lesions in 78% of the cases. Initial brain MRI was strongly suggestive of MS in 25 cases (Barkhof criteria) and normal in 7 cases. 40% of the patients presented abnormalities on evoked potentials (VEPs and/or BAEPs and/or SEPs) while CSF analysis showed oligoclonal bands (OB) in 80%. During the follow-up period (7/3 ys ), 76% of the patients presented one or more exacerbations and time to the first recurrence was 23/12 months. Among these patients, 90% had CSF OB and initial brain MRI was strongly suggestive of MS 65%. During this follow-up period, brain MRI showed emergence of lesions in 5 of the 7 cases with normal initial examination.
Conclusions: This study confirm the predictive value of brain MRI and CSF OB for the diagnosis of MS in patients presenting with clinically isolated acute syndrome of the spinal cord.
Disclosure: P Jean has nothing to disclose.
Khan O, Caon C, Ching W, Sonenvirth E, Tselis A, Zvartau-Hind M
Neurology, Wayne State University, Detroit, Michigan, USA
Background: PPMS represents 15% of all MS patients. New diagnostic criteria for PPMS were proposed by Thompson et al. We examined the usefulness of these criteria in a clinical setting outside the context of clinical trials.
Objectives: To apply the diagnostic criteria proposed by Thompson et al. and study the clinical profile of PPMS patients.
Methods: PPMS patients followed at a large urban hospital MS Clinic were evaluated. Detailed history was obtained. Investigations including brain and cervical spine MRI, CSF, and evoked potentials (EP) were evaluated. Kurtzke’s EDSS were recorded. Clinical course was analyzed retrospectively. Diagnostic criteria proposed by Thompson et al. were applied. At the time of neurological assessment, no patient had received therapy with disease modifying potential. Our clinic has a large African-American (AA) MS patient population who were also analyzed as a subgroup.
Results: 67 patients with PPMS were identified. 37 (55.2%) of 67 patients were women with a female to male ratio of 1.23 : 1.0. Mean age was 51.6 years, mean age of onset was 40.4 years, and mean EDSS was 5.4. 44 (65.6%) of 67 fulfilled the Thompson criteria for definite PPMS. However, with the addition of somatosensory (tibial) EP to the criteria, 53 (79%) of 67 fulfilled the criteria for definite PPMS. 62 of 67 patients had undergone lumbar puncture for CSF studies. In one case, results could were not available. Review of CSF abnormalities i.e. presence of OCB(greater than 2) and/or raised IgG index (n=46 or 75.4%) revealed no effect on the clinical course compared to the CSF negative (n=15 or 24.6%) PPMS patients. Additional analyses of brain and cervical spine MRI abnormalities will also be presented. 16 (23.8%) of 67 were AA. Details of this sub-cohort will also be presented.
Conclusions: Diagnostic criteria for PPMS by Thompson et al. are applicable in a clinic setting. However, the addition of SSEP may increase the diagnostic yield for definite PPMS. Based on the current understanding of disease mechanisms in PPMS, it is not clear if CSF abnormalities should be a mandatory requirement for definite PPMS. PPMS appears to be more aggressive in AA.
Disclosure: O Khan has nothing to disclose.
Lienert C, Lechner-Scott J, Müller U, Kappos L
Neurology, University Hospitals, Basel, Switzerland
Background: The EDSS of Kurtzke is the most widely used outcome measure in clinical trials
Objectives: to improve reliability of Kurtzke` EDSS and FS assessment in clinical trials by standardised training
Methods: 721 neurologists and neurologists in training participating in four ongoing multicenter trials, underwent either EDSS-training sessions at 11 different investigator meetings(ETS, n= 494), including detailed verbal instructions of EDSS and FS rating and demonstration of video vignettes, or used a training CD-rom for self-training and assessment(ECD, n=227).Level of knowledge about EDSS and FS scoring was assessed with a questionnaire, containing 25 questions.Participants were asked to fill in questionnaires before and after the ETS, ECD trained participants after training. A score of 2 was allocated for the correct answer, a score of 1 for the second best, thus resulting in a maximum score of 50. A minimum score of 31 was required for passing the test.
Results: Post-training results were significantly better than pre-training results in the ETS group. Mean-score pre-training: 33.98; mean score post-training: 38.36; p<0.001, Wilcoxon-test. This overall result was confirmed in the evaluation of each separate meeting, but in different magnitude. Performance at post-training tests was not statistically different in ETS and ECD.
Conclusions: Standardised training improves level of knowledge for EDSS and FS scoring. Post-ECD results did not differ significantly from post ETSresults, indicating that self-training with CD-rom may be as effective as participation in training sessions, although the different environment at completion of the questionnaires must be taken into account.
Disclosure: C Lienert has nothing to disclose.
Milo Ra,b, Katz Ta, Corat-Simon Jb
aNeurology, Barzilai Medical Center, Ashkelon, Israel; bAssaf Harofeh Medical Center, Zerifin, Israel
Background: Most clinically definite MS patients show multiple hyperintense lesions on T2W MRI images in the white matter of the brain. However, up to 10% of patients with spinal cord lesions may have no, or few, brain lesions. The number of MRI lesions at presentation is predictive of the development of MS and the long-term outcome.
Objectives: To characterize MS patients with initial spinal demyelinating events and normal brain MRI.
Methods: Among 150 consecutive patients with definite or probable MS, 48 (32%) presented initially with demyelinating lesions in the spinal cord. These were further divided according to brain MRI to those with positive scans compatible with MS, and those with negative (normal) scans, which were followed up for clinical and MRI findings.
Results: Sixteen patients (F-10, M-6) with an initial clinical spinal demyelinating episode and a corresponding MRI lesion but normal brain MRI were detected. Their mean age was 31.8 (19-47), mean EDSS at presentation 2.9 (1.5-6.5) and mean EDSS during first remission 1.1 (0-2.5). Location was cervical in 12, thoracic in 3 and conus cauda in 1. During the follow-up period of 7-130 (average 35.3) months, 12 (75%) converted to clinically definite MS, while 4 did not have further relapses. All patients showed the relapsing-remitting form of MS. Although most patients continued to have spinal relapses, the optic nerve, brainstem or cerebellum were involved in 50%. In only 4 patients, a second brain MRI became positive within a year; in the other 12 patients, additional 1-4 scans performed 3-84 months after the first one were still negative. Disease progression was usually slow, with EDSS = 1.5 (0-6.5) after 7-130 months. Oligoclonal bands in the CSF were detected in 1/15 (7%) only.
Conclusions: A considerable number of patients with an initial spinal demyelinating event have normal brain MRI scans at presentation. Albeit high conversion rate to clinically definite MS, most of them show normal brain scans repeatedly. This group of patients is characterized by a relapsing-remitting and relatively benign course of the disease (despite repeated spinal relapses), and by the absence of oligoclonal bands in the CSF. We speculate that these characteristics may be associated with a relatively minor activity of the disease in the brain.
Disclosure: R Milo has nothing to disclose.
Pakdaman Ha, Pakdaman Rb
aNeurology, Beheshti University, Tehran, Iran; bNourology, Beheshti University
Background: Multiple Sclerosis is one of the most common neurologic disorders in young adult. It is noted because of making disability and disfunction in youth.Epidemyologic studies show that there are differences in prevalence,manifestation and disability condition between various races and geographical locations.
Objectives: From four years ago, three clinics of MS established in Tehran (which has high prenalence of MS) in order to syudy on sign and symptoms and disabilities of patients which some of the results discussed.
Methods: This is a prospectine cross-sectional study, which is carried out during 1997-2001. The patients with MS announced to these three MS clinics.After taking history and complete examination, computerized data analyzed with statistical method EPI.6.
Results: In this study 2412 patients were diagnosed as having MS as based on Poser criteria.Mean age of patints was 32/2. 71% of patints were female (F/M =2.4). 64% of patients were educated.26% were single and 73% were married.Family history was positive in 7.7% . Mean duration of disease was 5.7 years . Initial symptoms were weakness(50%), parestesia( 30%), sensory deficit(23%), diplopia(21%), ataxia(14%), vertigo (11%), bladder dysfunction (11%). The course of disease is relapsingremission in 56% and progressive in 31%of cases. Mean EDSS - Kurtzke number- was 4.2.
Conclusions: According to results obtained in this study, it seems that clinical manifestation and symptoms in Iranian patients with MS are similar to those in developed countries.More incidences of MS in high-educated persons are considerable. In spite of mean duration of disease (5.7 years) Kurtzte number in our patients is 4.2 which is exactly equal with the number in other countries. So, it does not seem to be significant difference in MS prognosis in Iran and other countries.
Disclosure: H Pakdaman has nothing to disclose.
Radu TDa, Marc Da, Rene Ab, Luc Ta, Herve Va
aNeurology, Nancy Central Hospital, Nancy, 81, France; bNeuroradiology, Nancy Central Hospital, Nancy, 81, France
Background:
Objectives: We report the case of a 70-year-old woman with cognitive impairment and Magnetic Resonance Imaging (MRI) and Cerebrospinal Fluid (CSF) criteria for Multiple Sclerosis (MS).
Methods: The patient had a family history of MS (father) and was treated for hypercholesterolemia. In March 1998, she presented with alexia during 30 minutes. MRI showed multiple and disseminated periventricular hypersignal on T2 weighted images and a CSF oligoclonal profile was found. In April 1999, a new MRI performed because of aphasia showed right frontal and left parietal enhancing lesions. The neuropsychological examination found a pattern of frontal subcortical cognitive dysfunction. In April 2001 paresthesia, central vestibular syndrom and VI paralysis led to realize a new MRI. This exam showed new lesions located at subcortical fronto-parietal, right temporal, left frontal and central with contrast enhancement. Spinal cord MRI revealed enhancing lesions at cervical and thoracic levels. The vascular investigations (cardiac and cervical vascular ultrasonography) and immunological profile (inflammatory markers, autoantibodies including ANCAp, ANCAc, Antids-DNA, AntissDNA, Anti Ro/ss-A, Anti La/ss-B, Anti-ribosomal P, anticardiolipines andantiphospholipides antibodies, VDRL etc.) were negative, except a minimal monoclonal gammapathy and non significant values of ANA (1/160).
Results:
Conclusions: The interest of this case is given by the presence of typical MacDonald criterias for MS in an old patient with cognitive impairment, without any other immunological or inflammatory definite disorder.
Disclosure: T Radu has nothing to disclose.
Berger E, Chopard G, Vidry E, Rebenco E, Moulin T, Rumbach L
Neurology, CHU Minjoz, Besancon, France
Background: A large proportion of patients with MS are cognitively impaired memory deficits are the most frequently reported. MS can impair speech production but aphasia is considered to be uncommon.
Objectives: To describe 4 patients with MS whose main cognitive complaints were aphasia that appeared at onset (1 case) or during (3 cases) the disease
Methods: The clinical and imaging pictures of 4 patients with aphasia are described.
Results: Case 1. A 28-year-old man presented with the acute onset of right arm decreased sensation, an inability with speaking ; he also reported problems in comprehending spoken language. Exam showed right Babinski sign. MRI demonstrated several white matter lesions and CSF showed oligoclonal bands. Case 2. A 45-year-old man was diagnosed as having MS for 10 years. He experienced several relapses ; he has been treated by Interferon for 5 years. In July 2000, his main complaint was speaking difficulties ; he also had a right hemiparesis. MRI showed several lesions and a new large frontal one. He did not recover. Case 3. A 28-year-old man had a typical relapsing-remitting MS history for 4 years. In one of his relapse he presented word-finding problems, speech abnormalities with normal comprehension. Case 4. A 40-year-old man had 5 previous episodes of relapses. Five years after the disease onset, a relapse was characterized by difficulties in reading and comprehending spoken language.
Conclusions: Although memory impairments have been the most reported, theses cases stress the involvement of other cognitive domains.
Disclosure: L RUMBACH has nothing to disclose.
Stoian CA, Metz LM
University of Calgary, Calgary, Alberta, Canada
Background: Patients with MS often play a role in determining which immune modulating therapy they will use. However, little is known about which factors influence their decisions.
Objectives: To determine which factors influence patients’ treatment choices.
Methods: This was an observational cohort study of 104 adults with RRMS from 3 Canadian provinces. Consenting subjects completed self-administered questionnaires after patient education and prior to initiation of one of four MS therapies (Copaxone, Rebif, Betaseron, Avonex). Patients were asked to rank the three most important factors that influenced their choice of therapy.
Results: Sample characteristics: median time since diagnosis was 0.7 years, mean age was 39 years, and 82% were women. Physician recommendation was the most common factor influencing choice of therapy (71.2%) with no statistical differences between the four drugs (p = 0.378). The two most frequently reported factors to influence choice of therapy, by treatment, were: (1) physician recommendation (76.7%) and tolerability (75.0%) for Copaxone (n = 60, 58%); (2) physician recommendation (64%) and pre-filled syringes (52%) for Rebif (n = 25, 24%); (3) physician recommendation (80%) and tolerability (60%) for Betaseron (n = 5, 5%); and (4) injection frequency (85.7%) and physician recommendation (57.1%) for Avonex (n = 14, 13%). When available, the following devices were also rated as important: auto-injectors - Copaxone (50%), Rebif (44%) and pre-filled syringes - Rebif (52%). Relapse data, disability data, MRI data, type of injection, cost, availability of more than one dose, and ‘other’ were infrequently identified.
Conclusions: While the sample size of this study limits the precision of the reported frequencies, physician recommendation is fairly consistently the most frequently reported factor that influenced patients’ choice of MS immune modulating therapy. Tolerability, injection frequency, and the availability of autoinjectors and pre-filled syringes are, however, also important to patients.
Disclosure: This study was designed and Supported by TEVA Neuroscience. L. Metz and her research team (C. Stoian) coordinated data management, analysis and interpretation.
Funding: Supported by TEVA Neuroscience.
Stoian CA, Metz LM
University of Calgary, Calgary, Alberta, Canada
Background: Adherence to immune modulating therapy is often challenging.
Objectives: To identify factors associated with difficulty initiating and maintaining therapy over the first month of treatment.
Methods: This was an observational cohort study of 104 people with RRMS. Consenting subjects completed self-administered questionnaires after patient education and prior to initiation of therapy. Ease of therapy initiation was defined as reporting "somewhat" to "very easy" to maintain therapy, tolerance of full dose, and feeling normal or better over the first month of treatment. Failure to meet these criteria defined difficulty of therapy initiation. Interferon (Avonex, Betaseron or Rebif), glatiramer acetate (Copaxone), age, disease duration, impaired vision, impaired fine motor skills, use of an injection device, anxiety level, number of significant concerns about therapy initiation, expectations, and commitment to therapy were examined as predictors of difficult therapy initiation using logistic regression.
Results: Sample characteristics: median time since diagnosis was 0.7 years, mean age was 39 years, and 82% were women. Therapy initiation was difficult for 38.5%. Impaired vision and having any significant concerns about therapy initiation were associated with difficulty initiating therapy. Patients with impaired vision (difficulty reading newsprint) were more likely to find therapy initiation difficult than those without (OR=3.7, 95% CI: 1.2-10.9, p= 0.019). The odds ratios of reporting difficulty initiating therapy were higher for people "very concerned" about any of 18 listed potential treatment concerns compared to those with no "very concerned" ratings and increased with the increase in the number of "very concerned" ratings. The odds ratio of experiencing difficulty was 7.6 (95% CI: 2.1-27.8, p=0.002) for those with 1 to 5 "very concerned" ratings and 18 (95% CI: 3.6-89.6, p<0.001) for those with 6 to18 ratings compared to those with no "very concerned" ratings.
Conclusions: Patients with ‘impaired vision’ or ‘significant concerns’ may benefit from additional support during therapy initiation and early treatment.
Disclosure: This study was designed and Supported by TEVA Neuroscience. L. Metz and her research team (C Stoian) coordinated data management, analysis and interpretation.
Funding: Supported by TEVA Neuroscience.
Tremlett H, Oger J, Special Therapies Group M
Medicine (Neurology), University of British Columbia, Vancouver, British Columbia, Canada
Background: The beta-interferons (IFNB) are long-term treatments for MS. Drug adherence is essential to maximize cost-effectiveness. Identification of patients that are likely to stop treatment and reasons for non-adherence may help in the prescribing, patient-counseling and education process.
Objectives: 1) To identify why MS patients stopped an IFNB 2) To ascertain if particular demographic factors (age, gender, disease duration, EDSS) were predictors of non-adherence
Methods: In December 2001 we reviewed the charts of MS patients who had started on one of the three IFNBs between July 1st 1995 and May 31st 2001. IFNB trial patients were excluded.
Results: 590 patients were identified whom had been prescribed an IFNB ‘firstline’ and 585 charts were reviewed. Mean treatment length was 1.8 years (range 7 days to 6.3 years). In all, 190 patients were non-adherent (ie had stopped treatment for at least one month). Of these, 60/190 (32%) were non-adherent by 6 months, and 103 (54%) by one year. The most frequently cited reason for drug cessation was perceived lack of efficacy (63/190 33%) followed by injection site reactions (62; 14%), ‘flu like symptoms (16; 8%), depression (16; 8%), headache (14; 7%) and abnormal liver enzymes (13; 7%). No reason was documented for 5 patients. Compared to the adherent group, the non-adherent group had a significantly higher median baseline EDSS (2.5 versus 3.5; Mann-Whitney p=0.001) and longer disease duration (mean 12.1 versus 14.5 years; Fishers exact test p=0.001). There were no differences between the groups for age or gender (p0.05). Of the non-adherent patients, 19/190 (10%) were re-started on the same IFNB; 73 (38%) on a different IFNB and 29 (15%) on glatiramer acetate. Overall, 69/585 (12%) totally discontinued immunomodulatory drug therapy, averaging 6% of patients per year.
Conclusions: Lack of efficacy was the single most frequently cited reason for non-adherence, followed by injection site reactions. EDSS score and disease duration were both significant factors for non-adherence to the IFNBs indicating that those more disabled at the start of treatment were more likely to cease therapy. The low discontinuation rate found was attributed to the compulsory education session and frequent follow-up with trained nurses for all patients.
Disclosure: JO has received consulting fees and honoraria for speaking from Berlex, Biogen and Serono, although none in support of this abstract. HT has a fellowship from the MS Society, Canada.
Funding: HT has a fellowship from the MS Society, Canada. Posters
S36 Multiple Sclerosis
Vorobeychik Ga, Anderson Da,b, Lindley Ja,b, Paty DWa, UBC MS Clinic ta
aNeurology, UBC, Vancouver, British Columbia, Canada; bOphthalmology, UBC, Vancouver, British Columbia, Canada
Background: Optic neuritis (ON) and diplopia are common presenting symptoms in patients with multiple sclerosis (MS). There is little published experience on long-term assessment of visual function for these patients.
Objectives: To compare visual function in clinically definite MS (CDMS) patients 20 years after onset, who presented with ON or diplopia
Methods: We included patients from the UBC MS Clinic computerized database (MS-COSTAR) who met the following criteria (i) had CDMS, (ii) initial manifestation was ON or diplopia, (iii) visual function was assessed (by neurologist) 20 or more years after onset. The groups were compared for course of MS, age of onset, and sex ratio.
Results: ON was a presenting symptom in 13.2% (479/3617) and diplopia in 6.5% (234/3617) cases with CDMS in the UBC MS Clinic (September 1980-May 2000). The mean age of onset, duration of observation, and sex ratio was similar in the ON (104 patients) and the diplopia (45 patients) groups with follow up for 20 or more years after onset. The proportion of patients with primary progressive course of MS (PPMS) was lower in the ON group (3/104 patients, 2.8%) than in the diplopia group (6/45, 13%, p=0.01). The precentage of patients that switched to secondary progressive (SP) MS during observation period was similar in both groups (61% in ON and 67% in diplopia group). Visual acuity remained 20/40 or better in majority of patients in both groups (69.2% in ON and 84.4% in diplopia group). Severe decrease of visual acuity to 20/200 was rare in both groups(13/104, 12.5% in ON group and 3/45, 6.7% in diplopia group). However, optic atrophy was more frequently noted in ON group (81/102, 79.4%) than in patients with diplopia onset (22/41, 53.7%, p=0.002). The frequency of internuclear opthalmoplegia (INO) after 20 years of disease was similar in both groups (28/97, 28.9% in ON and 16/42, 38.1 % in diplopia group)
Conclusions: CDMS patients who presented with ON have less frequently PPMS than those who presented with diplopia. 2/3 of both groups switched to SPMS during observation period. Majority of the patients in both groups have good visual acuity after 20 years of disease. Only very small proportion of patients become legally blind after 20 years of disease.
Disclosure: G Vorobeychik has nothing to disclose.
Epidemiology
Balc´y BP, Yayla V, Özer F
Neurology, Haseki Hospital, Istanbul, Turkey
Background: The diagnosis of MS is relied upon the accumulation of information, Neurological examination and laboratory findings. Until date, Poser criteria were used most for MS classification, recommended in 1983. By 2001, after Recommended Diagnostic Criteria for Multiple Sclerosis: Guidelines from the International Panel on the Diagnosis of Multiple Sclerosis published by McDonald et. al, these criteria are taken into consideration for diagnostic approach.
Objectives: The aim of this study is to determine the status of the patients followed up in Haseki Educational and Research Center - Neurology Department as definite MS according to Poser criteria by McDonald criteria.
Methods: Total 106 patients (62 women, 44 men) age ranged 19 - 67 (mean: 35) diagnosed as definite MS according to Poser criteria were reassessed by the new criteria, taking disease duration into consideration.
Results: By McDonald criteria 88 (83%) of 106 patients who previously diagnosed as definite MS by Poser criteria (92 CDMS, 14 LSDMS) were diagnosed as MS. 81% of the patients diagnosed as MS by McDonald criteria were CDMS and 2% wer LSDMS. The mean duration of the disease was 6.17 years for 106 patients with definite MS according to Poser and 7.06 years for 88 patients diagnosed MS according to McDonald.
Conclusions: Difficulties of diagnostic approach at the onset period of the disease continue by McDonald criteria. By McDonald criteria the diagnosis gets easier with longer disease duration.
Disclosure: B Balc´y has nothing to disclose.
Coustans M, Le Page E, Le Duff F, Leray E, Sartori E, Edan G
Neurology, CHU Pontchaillou, Rennes, France
Background: Benign multiple sclerosis (BMS) has been variably defined in quantitative terms and no consensus had been reached to define this entity. BMS commonly defined as EDSS <= 2 or 3 after 10 years (y) of disease duration is questionable.
Objectives: To determine the best definition of BMS taking eitheir EDSS <= 2 or 3 at 10, 20, 30 y of disease duration.
Methods: In our EDMUS (European database for multiple sclerosis) database, among 1019 clinically definite relapsing remitting MS (RR MS), 695 patients had a disease duration more than 10 y. We analysed evolution of BMS with two definitions : RR MS population with an EDSS <=2 and EDSS <=3 after 10 y of disease duration and we examinated these two groups of patients at 20 y and 30 y disease duration.
Results: Among the 695 RR MS patients followed more than 10 y, 280 were followed more than 20 y and 100 more than 30 y. Proportion of BMS defined as EDSS <=3 was respectively 62.3%, 36.4% and 25%. Proportion of BMS defined as EDSS <=2 was respectively 48%, 26% and 16%. Moreover among the 433 patients with a definition of BMS as EDSS <=3 after 10 y of disease duration, 217 had a disease duration more than 20 y, only 47% (102) of them were still BMS. Among these 102 still BMS patients at 20 y, 49 had 30 y follow-up and only 51% (25) of them were still BMS. For BMS with an EDSS <=2 at 10 y (334), 184 had a disease duration more than 20 y, 73 (39.7%) were still BMS. Among these 73 BMS patients, 41 had 30 y follow-up, only 16 (39%) were still BMS.
Conclusions: In the population of BMS defined as either EDSS <=2 or EDSS <=3 at 10 y, a majority of these patients had a worsening of their disability when they are followed at 20 and 30 y and so did not deserve the term of benign MS. Benign MS is a questionable entity.
Disclosure: M Coustans has nothing to disclose.
Cristiano Ea, Patrucco LBa, Soriano ERb, Videla GCa, Figar Sb, Hares Db, Bauso Toselli PLa
aNeurology, Hospital Italiano de Buenos Aires, Buenos Aires, Capital Federal, Argentina; bEpidemiology, Hospital Italiano de Buenos Aires, Buenos Aires, Capital Federal, Argentina
Background: There is a lack of incidence and prevalence studies in Multiple Sclerosis (MS) in Latin-america.
Objectives: To estimate the incidence and prevalence of MS in an HMO in Buenos Aires, Argentina. (Lat 34 38’S; long 58 28’W)
Methods: Population: the population at risk was all members of a Hospital based HMO, who were affiliated at least since December 1992 or at least twelve months before the date of diagnosis of each case included upto December 2001. Each person was followed until voluntary desenrollment, death or finalization of the study (final dates), contributing time at risk since December 1992 or enrollment date (whichever occurred later) to that final date.Case ascertainment: multiple methods for case finding were used to ensure complete ascertainment: a)patients included in neurologists databases, b)patients with the ICPC(International Classification for Primary Care) code N86 in the HMO Computer-based Patient Record System, patients with ICD 9 codes 340-341 on admission to Hospital, and d)patients receiving MS specific drugs. Medical records of all patients found were reviwed and only cases with MS definite diagnosis(Poser) were included. For incident cases the date of diagnosis was considered. To be included, cases must have been affiliated to the HMO at least 12 months before diagnosis. Statistical analysis: incidence density was calculated with 95% confidence intervals. Prevalence was estimated at December 2001, and the denominator population was the number of active members at December 31, 2001.
Results: In the study period 120,442 patients were followed for a total of 446,842 persons-year, of whom 10 developed MS. The incidence density rate(IR) was 2.24/100,000 (95%CI: 0.85-3.62/100,000). On December 2001, 21 prevalent cases (13 females) were identified, among 81,855 members. Prevalence: 25.6/100,000(95%CI: 17-38/100,000); 27.2 for females and 23.5 for males/100,000. Mean age at diagnosis of these patients was 35.6 years (20-56 years).
Conclusions: Incidence rate estimated in this selected population was similar to countries with median risk for MS. Prevalence detected was higher than reported in previous studies in our country.
Disclosure: E Cristiano has nothing to disclose.
Patrucco LB, Cristiano E, Videla GC, Bauso Toselli PL
Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Capital Federal, Argentina
Background: Argentina is a country of medium risk for developing MS (prevalence: 18-25/100,000). In Latin-america there is a lack of epidemiological data regarding NMO.
Objectives: To determine the proportion of NMO regarding a population of MS patients followed in our MS center and to describe some of its clinical and epidemiological features.
Methods: We reviewed the clinical charts of 569 patients followed up at our MS clinic. Patients who developed definite MS (Poser) and NMO (Wingerchuk) between January 1996 and March 2002 were included. We compared initial symptoms, sex prevalence and age at onset between both groups. In the NMO group we also analyzed clinical evolution and paraclinical findings.
Results: Of 134 patients who fulfilled the inclusion criteria, 124 (77 females) were definite MS (92.54%) and 10 (7 females) NMO (7.46%). The MS: NMO ratio was 12.4 : 1. The mean age of onset was 29.6 for MS and 40.6 for NMO. 30 (24.1%) MS patients presented spinal symptoms at the beginning of the disease (18 males and 12 females), and 14 (11.3%) optic neuritis (2 males and 12 females). In the NMO group, 3 (2 males) out of 10 patients presented spinal symptoms and 7 (6 females) optic neuritis at onset. Clinical presentation in NMO was monophasic (less than 3 months between initial symptoms) in 3 patients and polyphasic in 7. During the follow up period (0.4-6.2 years), 5 out of 10 NMO patients suffered one or more relapses (5 myelitis and 5 ON) with partial recovery of spinal symptoms and minimal recovery of visual function. In the acute period, pleocytosis with increased neutrophil count in CSF, abscence of oligoclonal bands in all patients, extensive spinal cord lesions and normal brain MRI, were the main paraclinical findings in NMO patients.
Conclusions: In this stydy the proportion of NMO compared with MS patients was higher than expected according to published data. In NMO the age of onset was greater, ON was the most frequent onset symptom, polyphasic clinical presentation showed a clear female predominance and 50% of the patients suffered relapses during this follow up period. Further studies are needed to clarify the prevalence and relative incidence of NMO compared with MS in different areas and its clinical features.
Disclosure: E Cristiano has nothing to disclose.
Cristiano Ea, Patrucco La, Rivera Vc, Gold Ld, Correale Jb, Videla Ga
aNeurology, Hospital Italiano de Buenos Aires, Buenos Aires, Capital Federal, Argentina; bNeurology, FLENI, Buenos Aires, Capital Federal, Argentina; cNeurology, Baylor College of Medicine, Houston, Texas, USA; dNeurology, Hospital Britanico, Buenos Aires, Capital Federal, Argentina
Background: At present there are partial and incomplete data about incidence and prevalence of MS, degrees of medical care and distribution of professionals and centers involved or interested in MS in the Latin American countries. Lack of economic resources, low population density and geographical isolation do not allow retrieving the necessary information by conventional methods.
Objectives: To communicate the development of an ongoing census as an effective tool in order to know the number and geographical distribution of professionals and centers involved in MS in Latin America, with the aim of performing systematic studies in the next future.
Methods: We elaborated an electronic application form structured in HTML format, available on www.esclerosismultiple.org/censo, divided in 3 main areas: 1- Demographic information 2- Specific information on MS (number of treated patients, complexity of the center, diagnostic resources, etc.) 3- Electronic dispatch of the application form to other colleagues Confidential data will be stored and processed in a host resident database
Results: Preliminary results of this survey will allow, in the short term: 1.to design local and tailored epidemiologic strategies to know the prevalence of MS 2.to establish a better communication among participants. 3.to promote active participation between professionals and centers in a network, in order to optimize care, medical education and research in MS 4.to propose new projects to the members 5.to publish a Directory of professionals and centers, at a community level in different countries, in order to get better accessibility for patients. The general results (number of professionals per city, country and region, degrees of specialization, participation in clinical or basic studies, estimated number of patients seen by area, etc.) of the Census will be periodically informed to the participants and to the Scientific Committee of Lactrims
Conclusions: This census will allow the gathering of fast and economic information regarding the availability of resources for MS
Disclosure: E Cristiano has nothing to disclose.
Eleonora Ka, Jarmila Sa
aNeurology, Teaching Hospital and Medical Faculty, Kosice, Slovakia; bTeaching Hospital and Medical Facultx, Kosicr, Slovakia
Background: Optic neuritis (ON) as early manifestation of multiple sclerosis (MS) is prognostically favorable factor in following course of the disease.
Objectives: To find out the occurrence of ON as onset of MS in our patients and in accordance with clinical course to determine the forms of the disease and the value of disability, expressed by Kurtzke EDSS.
Methods: In retrospective analysis of 159 patients, with clinically defined or probable MS, who were admitted to our Department of Neurology from 1987 to 2000 - we followed the occurrence ogf ON in relation to clinical course. In each patient we have investigated the age of occurence of the initial symptoms of MS, clinical forms, duration and degree of disability.These findings were compared in two groups of patients - with initial ON and without ON ( non- ON) in onset of MS.
Results: ON as an isolated initial symptom was in 29 cases ( 18,2%). Average age of patients in the time of occurence of ON was 27,9 years of age, what is in comparison with non-ON group2,8 years less. In ON -groupthere were 73 % of patients with RRMS and their EDSS was about 2 degrees better than in non -ON group, 27%with SPMS and PPMS was not observed. Average duration of the disease upto December 2000 is in in ON-group9,4 years, in non-ON group11,7 years.
Conclusions: First retrospective analysis of ON as early manifestation of MS in East Slovakia. Our results do not exclude the upper opinion in background.
Disclosure: K Eleonora has nothing to disclose.
Fernández Va, Mayorga Cb, Leyva Lb, Guerrero Rb, Arnal Cc, Hens Md, Luque Ga, Fernández Oa
aNeurology, Hospital Regional Universitario Carlos Haya, Málaga, Spain; bResearch Unit, Hospital Regional Universitario Carlos Haya, Málaga, Spain; cNeurology, Hospital Virgen de las Nieves, Granada, Granada, Spain; dNeurology, Hospital Ciudad de Jaén, Jaén, Spain
Background: There are occasional reports about the low prevalence of multiple sclerosis (MS) among Gypsies. Few HLA studies have been carried out in the MS gypsy population.
Objectives: To study MS prevalence and HLA class II distribution among MS gypsies in Malaga.
Methods: MS gypsy patients in our geographical area were actively searched with a yield of 12 cases. The HLA class II DRB1 and DQB1 were investigated by PCR/SSO and PCR/SSP. HLA distribution of a healthy control gypsy group from the same geographical area was taken from published data.
Results: Estimated MS prevalence for gypsy population in Malaga is 52/100.000. DRB1*1404,DQB1*0503 was a frequent allele combinationin our gypsy patients(25%). Just one positive association was detected between MS gypsy patients and the allele DQB1*0602 (41,7% vs. 2,5%, corrected p= 0,0009)
Conclusions: These results indicates that in Malaga population, MS prevalence in gypsies is about the same as in caucasians (53/100.000 in 1991). Gypsies from Malaga have the same anthropological origin as other European Gypsy groups. We have detected a positive association of HLA class II allele DQB1*0602 with MS gypsy patients.
Disclosure: V Fernández has nothing to disclose.
Frederiksen J
Neurological department, glostrup university hospital, Glostrup, Denmark
Background: We underwent a population based epidemiologic study of patients with multiple sclerosis (MS) from the County of Copenhagen with about 610.000 inhabitants and two departments of neurology.
Objectives: The aim was to create a clinical database for research purposes with demographic data, date of onset og MS, date and result of various paraclinical examinations, and informations about course and degree of disability og MS. The previous and actual immunomodulatory and immunosuppressive treatment is registrated. Patients were consecutively refferred, either as in- or outpatients, to Gentofte or Glostrup University Hospital during a three years period from March 1, 1999 to Feb. 28, 2002.
Methods: Patients were identified based on the diagnose of MS, G 35.9 based on the ICD-10 code system. We also went through files of patients diagnosed with opticus neuritis (H 46.9) to see if they fulfilled the Poser criteria of definite MS.
Results: At the time of the ECTRIMS congress we expect to have classified the patients according to course (relapsingremitting, primary progressive and secondary progressive, benign) of MS and to have registrated the disability on the Kurtzke EDSS scale. We will calculate the frequency of patients with relapsing-remitting MS and secondary progressive MS, who are treated with betainterferon or copaxone. Likewise, we will judge how many would have been eligible for such treatment but did not want to receive it, and the characteristics of theese patients. In addition, we will analyse how many patients who stopped the above mentioned treatment and the reason why.
Conclusions: Based on the prevalence of MS in Denmark we expect to registrate about 700 patients. As the study population is population based from a well defined geographical area with free admittance to the local neurological departments and to immunomodulatory treatment, the results may be representative for a population of patients with MS.
Disclosure: J Frederiksen has nothing to disclose.
Izquierdo G, Navarro G, Garcia Moreno J, Durán E, Gamero M, Ruiz-Peña J, Dinca L, Páramo D
Neurology, Hospital Virgen Macarena, Sevilla, Spain
Background: The prevalence of Multiple Sclerosis (MS) is well known in south Europe, but the actual data for MS frequency depend on incidence and not prevalence data. The incidence data are missing in our region.
Objectives: We studied incidence and prevalence rate in a well-delimited area of our region.
Methods: Patients were included as MS when fulfill the Poser et al. 1983, criteria. The incidence data were studied in a prospective study in a nine-year period (from January the first 1993 to December 31th, 2001) in the province of Seville (Spain) in a well-delimited rural area depending of our hospital. The total population of the area was the 142,776 inhabitants in 16 villages.
Results: Seventy patients were detected in the area, 62 of them were diagnosed in the follow-up period. The global prevalence of the area was 49.02 per 100,000. The annual incidence rate changes from 1.5 to 8.3 per 100,000 inhabitants. The mean annual incidence rate of the 9-year period was 5.2 per 100,000 inhabitants.
Conclusions: The incidence and prevalence rates are not concordant. Missing cases of pre-study period explain these differences. The frequencies of MS in our region are higher than that has been previously reported.
Disclosure: G Izquierdo has nothing to disclose.
Lana-Peixoto MA, Frota E, Campos GB, Botelho CM, Aragão AL
CIEM MINAS UFMG Center for Investigation of Multiple Sclerosis, Brazilian Committee for Treatment and Research in Multiple Sclerosis, Belo Horizonte, MG, Brazil
Background: The epidemiology of MS in South America is largely unknown. In a recently published study the prevalence of MS in Sao Paulo city was found as 15.0/100 000 inhabitants.
Objectives: To describe the prevalence of MS in Belo Horizonte, Brazil.
Methods: The city of Belo Horizonte is the capital of the state of Minas Gerais in Southeastern Brazil. The city covers an area of 330.9 Km2 at a mean altitude of 858 m and is situated at a latitude of 19 55S and a longitude of 43 56E. The climate is subtropical. The estimate population in the prevalence day (July 1, 2001) was 2258,857 inhabitants. Case ascertainment was done through most of neurologists, most of the hospitals in the city area, two local societies of patients, the Brazilian Association of Multiple Sclerosis and the State Health Department. Only patients living in the city area and with the diagnosis of CDMS were included.
Results: This search provided a list of 453 patients, 409 of whom qualified for inclusion. The MS prevalence was 18.1/100 000 population. There were 95 men and 314 women; 243 were white, 63 mulatto and 11 black. The age at onset was below 20 years in 13.5%, between 20 and 39 in 65.5% and 40 years or above in 20.9% (median 36 years). The most frequent symptoms and signs at presentation were motor (28.1%), sensory (27.7%), optic neuritis (20.6%) and brainstem/cerebellar (20.0%). There were 216 patients with RRMS, 84 with SPMS and 39 with PPMS. The EDSS was 3.5 or below in 49.0%; 4.0 to 6.5 in 36.6%; 7.0 and 7.5 in 6.5% and 8 or above in 7.9%.
Conclusions: This study adds strength to previous investigations on the prevalence of MS in Southeastern Brazil.
Disclosure: M Lana-Peixoto has nothing to disclose.
Funding: Supported by Serono Brasil.
Lana-Peixoto MA, Araujo CR, Macedo R, Haase VG
CIEM MINAS UFMG Center for Investigation of Multiple Sclerosis, Brazilian Committee for Treatment and Research in Multiple Sclerosis, Belo Horizonte, MG, Brazil
Background: The understanding of MS has had a striking progress in the last decade as a result of an increasing number of investigations dealing with different basic and clinical features of the disease.
Objectives: To analyze the growth of the scientific production on MS in different parts of the world.
Methods: The search was conducted through the MEDLINE from 1991 to 2000. All publications containing the key word Multiple Sclerosis as a major topic were considered. The search was conducted for each country separately in the Americas, Europe, Asia, Africa, Australia and New Zealand. In the search strategy the term affiliation was used to indicate the country of origin of the institution the first author was affiliated to.
Results: The MEDLINE contains 6816 citations of papers on MS published during the last decade. In 4919 papers the system provided information about the country and institution the first author was affiliated to. The origin of the papers are as follows: 2098 came from countries in the American continent, 2511 from Europe, and 310 from Asia, Australia and New Zealand. There is no paper from African countries. There has been a regular growth in the number of papers from 1991 (495) to 2000 (1018). This trend is observed in all continents and most countries. As individual countries are concerned the largest number of papers came from the USA (1735 in the decade; 96 in 1991 and 259 in 2000). Canada (298), Brazil (28), Mexico (14), Cuba (10) and Chile (5) followed the USA in the American continent. The most productive countries in Europe have been Italy (561), UK (478), Germany (254) and France (228). They were followed by The Netherlands, Sweden, Denmark and Spain. Russia (4), Portugal (3) and Luxemburg (1) were the least productive countries. Most papers from Asia came from Japan (143) and Israel (87). Investigators from Australia published 49 papers and from New Zealand 10.
Conclusions: Interest in the study of MS has markedly increased during the last decade. Other factors in addition to differences in prevalence may play a role encouraging investigators in different parts of the world to conduct studies on MS.
Disclosure: M Lana-Peixoto has nothing to disclose.
Lana-Peixoto MA, Callegaro D, Moreira MA, Gama PD, Maciel D, Sá PN
CIEM MINAS UFMG Center for Investigation of Multiple Sclerosis, Brazilian Committee for Treatment and Research in Multiple Sclerosis, Belo Horizonte, MG, Brazil
Background: There has been an increasing interest in the study of MS in Brazil.Its prevalence has been described in Sao Paulo and Belo Horizonte, two of the largest cities in Southeastern Brazil which share common features regarding immigration, genetic background and economical development.
Objectives: To describe the demographic, clinical and disability features in a sample of MS patients in Southeastern and Southern Brazil.
Methods: Cases were randomly ascertained from Belo Horizonte, Sao Paulo, Sorocaba, Florianopolis and Londrina. All patients had CDMS, and the disability was assessed according to the EDSS.
Results: The study comprised 1035 cases, 156 of them were discarded. Analysis of the remaining 859 cases showed that 633 were women and 226 men; median age at onset was 29 years; Whites comprised 82.4%, Mulattos 13.8%, Blacks 2.4% and Orientals 1.3%. The mean duration of the disease was 10.9 years. MS presentation was monosymptomatic in 87.8% of the cases with motor symptoms and signs in 31%, sensory in 26.1%, brainstem and cerebellar dysfunction in 19.7% and optic neuritis in 13.5%. The clinical course was relapsing-remitting in 74%, secondary progressive in 14% and primary progressive in 12%. The mean frequency of relapses was 1.6 in the first year, 2.6 in the first three years and 3.6 in the first five years after onset. Cross-section analysis of disability showed that 305 patients were full ambulatory, 388 had minimal to severe ambulation disability,94 were bound to wheelchair, and 46 were bedridden.
Conclusions: The present study fulfills the methodological requirements for reliability as it derives from an extensive database, a geographically defined population and cases were selected at random.Further analysis of this database will provide more detailed information about the natural history of MS in Brazil.
Disclosure: M Lana-Peixoto has nothing to disclose.
Funding: Supported by Serono Brasil.
Soriani M, Lebrun C, Bourg V, Chatel M
Neurology, CHU Pasteur, Nice, Am, France
Background: The course of multiple sclerosis (MS) was assessed in a group of 500 consecutive patients observed in our neurological department. The data were collected using EDMUS between May 2000 and April 2002.
Objectives: To evaluate the clinical characteristics and the evolution of our MS patients and to compare among them prognosis of 2 subgroups classified according to the number of relapses during the first year of evolution.
Methods: According to Mc Donald criteria, 462 patients (92.4%) presented a definite MS. Among them, 166 (36%, M/F ratio=1/2.4) had an activeMSdefined by an interval fromMS onset to second event <1 year (groupA). 249 patients (54%, M/F ratio=1/3.1) had at least 2 relapses with an interval 1 year (group B) and 47 (10%) had primary progressive course. Student test was performed for statistical analysis.
Results: The mean age at onset was 32.2+/-10.1 years (median 30.7 ; group A) and 30.2+/-9.6 years (median 29.5 ; group B) (p<0.05). Record of sequellae after the first relapse was not determinant between the 2 groups (28.3% group A/26.5% group B). Time to progression in RR with sequellae and in secondary progressive (SP) forms was significantly shorter in group A (2.4+/-3.4 years) than in group B (8.3+/-6.2 years ; p<0.001); SP : group A (8.3+/-7.2 years), group B (12.6+/-6.9 years ; p=0.05). The most common symptom at onset was lower limbs involvement (motor or sensitive): 51.5% (group A)/47.8% (group B ;p=ns), sensory 41 .9% (group A)/39.2% (group B ;p=ns), upper limbs involvement (motor or sensitive) : 34.1% (group A)/24.9% (group B ; p<0.05), and optic neuritis : 19.8% (groupA)/36.5% (group B ;p<0.05). After a 5 and 10 years follow-up, more patients with active or progressive form had reached EDSS 3 : group A =13.2% and 24.1%, group B = 8.8% and 2.8%, group C = 29.8% and 51.1%. This difference was still observed for time to reached EDSS 7 at 10 years: group A =24.7%, group B=4.4%, group C=10.6%.
Conclusions: Our study confirm that patients presented an active MS had a different clinical profile and a more severe prognosis than those who have a remittent course with a two-first relapses interval 1 year.
Disclosure: c lebrun has nothing to disclose.
Luetic GG
Multiple Sclerosis, Sanatorio Britanico, Rosario, Santa Fe, Argentina
Background: MS is a complex disease. It has been strongly suggested that influence of environmental factors early in life may play a key role in the latter development of the disease. There is a great variability in environment features between different seasons (sunlight hours, weather, viral agents, diet). There are few studies regarding the association between birth’s season and MS, and the results are controversial.
Objectives: To investigate season of birth in a Multiple Sclerosis population
Methods: The study was performed in Santa Fe Province (Argentina). Our MS database of over 200 patients is very representative of our MS overall population. We designed a descriptive study. 123 definite MS patients were included. The control group was the siblings of these patients to rule out any bias. Season’s definition used was the standard for the south’s latitudes. At enrollment, birth date and MS clinical course (relapsing-remitting, secondary-progressive, primary-progressive) were assessed. For the evaluation of statistical significance we used chi-square test (c2).
Results: Of the 123 MS patients studied, we found that 20.3% were born in autumn; 48% in winter; 14.6% in spring and 17.1% in summer (c2=31,4; p=0,0000007). The number of winter births was significantly higher in the MS population than in control group (c2=29,4; p=0).
Conclusions: MS patients in Santa Fe Province, showed a greater tendency to be born in winter as compared with other seasons and with their own siblings used as control group. 48% of our MS patients were born in winter (p=0,0000007). They were exposed to certain environmental conditions typical of this season (viral agents, less sunlight hours, adverse weather conditions) in a moment of their life, when their immune system (IS) was still immature. In a disease process like MS, where IS (especially T cells) plays such an important role, this finding could be of great implication.
Disclosure: G Luetic has nothing to disclose.
Luetic GG
Multiple Sclerosis, Sanatorio Britanico, Rosario, Santa Fe, Argentina
Background: Early in life, in predisposed individuals, environmental factors seems to play an important role in the ethiopathogenesis of MS. Myelin is the target of the immune mediated damage in MS and as we know myelination is an essentially post-birth process. There are many diseases linked with birth weight variations.
Objectives: To study birth weight (BW) in a Multiple Sclerosis population.
Methods: This study took place in Santa Fe Province (Argentina). Our local database is very representative of our MS population. We designed a descriptive study to compare birth weight of definite MS patients with that of the general population (GP). Data from those patients with diabetic mothers was excluded. We considered: sex, clinical course of MS, season of birth, number of siblings and birth weight. 86 patients were included in this study. For statistical analysis we used t-Student, ANOVA or Kruskall Wallis test.
Results: Of the 86 patients studied we found that MS male (n=34) had significantly higher birth weights than MS women (n=52): 3720.6 ± 146 grs and 3361 ± 92 grs respectively (P=0.03 t-Student’s test). When we compared BW of MS patients with those of the GP, we found that MS male patients showed significantly higher BW. This difference was evident from 30o percentile of the BW curve and was greater between 50o and 90o percentile of weight curve (P<0.0003 t-Student’s test). Differences of 500 grs in favour of MS patients were noted (p<0.0003). We couldn’t reproduce this finding when comparing birth weight in women groups.
Conclusions: Birth weight in MS male patients was significantly higher than in general population in our area. Myelinogenesis is an active and essentially post-birth process that depends on both intrinsic properties of the cells (oligodendrocytes) and extracellular signals. Environmental changes could affect myelin synthesis. Some studies have shown that dietary fatty acids can be positively involved in the control of CNS myelinogenesis. One possible explanation for this finding could be that myelin from this patients were different in its constitution, maybe varying in the amount or quality of its components in a subtle way. This could make it more susceptible to latter immuno-mediated damage when joined to other environmental factors.
Disclosure: G Luetic has nothing to disclose.
Marrie Ra, Cohen JAa, Hadjimichael Ob, Vollmer Tb
aMellen Center, Cleveland Clinic Foundation, Cleveland, OH, Ohio, USA; bNeurology, Yale University Medical School, New Haven, Connecticut, USA
Background: Alternative providers are used by MS patients. There are few studies exploring the predictors of use of these therapies. These studies have been small, or limited to a single geographic region, and have identified few predictors.
Objectives: To determine frequency of use of alternative providers (AP) among MS patients, and factors which predict such use, using data from the North American Research Committee on Multiple Sclerosis (NARCOMS) Patient Registry.
Methods: We examined the cohort of MS patients enrolled in the NARCOMS registry residing in the U.S. We used self-reported data on demographics, disability, disease status and use of AP to create a binary multivariate logistic regression model for the use of AP.
Results: Data regarding the use of AP was provided by 17018 patients. Lifetime use of AP was 55%, and current use was 18%. Chiropractors (42%), massage therapists (37%), and nutritionists (16%) were the most commonly used AP. Current use of any AP was statistically significantly associated with being female (OR=1.23), having had a relapse in the last year (OR=1.17), income over $50,000 (OR=1.32), living in the Western U.S. (OR=1.33), having at least some college education (OR=1.24), and being unmarried (OR=1.20). Predictive power of the model was poor (c-index=0.57), despite being a good fit for the data.
Conclusions: Demographic factors play a minimal role in predicting the use of AP in this MS population. There must be other factors involved that may include cost of therapy, accessibility, social acceptability and cultural factors. Given the frequency of use of AP by this patient population, characterization of these factors is important.
Disclosure: R Marrie has nothing to disclose.
McGuigan C, McCarthy A, Hutchinson M
Dept. of Neurology, St Vincents, Dublin, Co. Dublin, Ireland
Background: Ireland has been recognized as a high risk area for MS since the work of Allison and Millar in the 1950s. Recent studies have indicated a high and rising prevalence in the north of the island. A study in County Antrim, northeast Ireland, reported a prevalence rate of 168.7 per 100,000 in 1998. By contrast, prevalence figures for the south of Ireland have remained relatively low with published figures ranging from 48.4 - 73 per 100,000.
Objectives: To establish the prevalence of MS in two Irish counties: Donegal in northwest Ireland and Wexford in the southeast.
Methods: Patients with clinically definite or probable MS (Poser criteria) who were resident within the county borders on the 1st of January 2001 were considered prevalent cases. Sources of case ascertainment included a postal survey of General Practitioners, County Physicians, Consultant Neurologists, Respite Facilities and local MS charities. Hospital coding lists and interferon prescription lists were also reviewed. Patient examination and / or review of clinical case records confirmed the diagnosis of MS.
Results: In County Donegal, 217 prevalent cases were identified resulting in a prevalence rate of 166.9 per 100,000 (95% confidence limits: 145.5 - 190.7). In County Wexford there were 126 cases giving a prevalence figure of 120.7 per 100,000 (95% confidence limits: 100.5 - 143.7).
Conclusions: The southeast of Ireland has a higher prevalence of MS than previously reported, however, the rate remains significantly lower than that for northern counties. This is possibly due to genetic variations within the background populations of the two regions. HLA typing of the background populations in Donegal and Wexford is ongoing to test this hypothesis.
Disclosure: C McGuigan has nothing to disclose.
Sastre-Garriga Ja, Munteis Eb, Rio Ja, Pericot Ia, Tellez Na, Tintore Ma, Montalban Xa
aClinical Neuroimmunology Unit, University Hospital Vall d’Hebron, Barcelona, Catalonia, Spain; bNeurology Service, Hospital del Mar, Barcelona, Catalonia, Spain
Background: Use of unconventional therapies (UT) is growing in western countries. Prevalence studies as well as knowledge of why they are used IN MS are needed.
Objectives: To assess the prevalence of UT use among MS patients and to explore associations with clinical, demographical and other variables.
Methods: Structured self-administered questionnaires were given to 380 consecutive patients seen at two hospital-based MS clinics. At the time of questionnaire dispensation, clinical data were recorded: duration of disease, time from diagnosis, clinical course of MS, EDSS, and use of disease-modifying treatments. The questionnaire recorded socio-demographical features (including education and income) and inquired on use of UT for MS.
Results: The response rate was 50.78%. Clinical and demographical features were not statistically different between patients who responded and those who did not respond. Of the patients who answered the questionnaires 40.9% admitted to using UT in the previous year. Lower degrees of satisfaction with medicine in general, lower degrees of satisfaction with the results of medicine for MS and higher EDSS scores were associated (p<0.05) with higher use of UT in the last year.
Conclusions: We found a 40% prevalence of UT use by MS patients in the Barcelona area (similar to that found in a USA survey). UT users have higher EDSS scores and are less satisfied with conventional medicine than non-users. We cannot demonstrate an association with income or educational levels as found in other surveys. Cultural and public health system organisation differences could explain these different findings.
Disclosure: X Montalban has nothing to disclose.
Papayannis CEa, Ferreira Ja, Caceres Fa, Fernandez Liguori Na, Sandoval Ga, Tenembaum Sb, Garcea Oa
aNeurology, Hospital Ramos Mejia, Buenos Aires, Argentina; bNeurology, Hospital Garrahan, Buenos Aires, Argentina
Background: ADEM is an ussually monophasic inflammatory condition of the CNS, typically occurring after infections or vaccinations. Young adults and children are more frecuently affected.
Objectives: To assess the prevalence of ADEM in an adult population of a Clinic for demyelinating diseases. To analyze the clinical data, the results of complementary studies and prognosis comparing with another pediatric ADEM population (PAP) in the same area.
Methods: 590 clinical records registered between 1989-2002 in the Demyelinating Clinic were reviewed. 9 cases were selected with the diagnosis of ADEM (prevalence of 15,2 cases per 1000 clinical records), 8 of these were analysed. The PAP was of 79 patients with a mean age of 5,6 years (0,4-16); 60% were male, 90 % of them experienced complete recovery. We analized: preceding infections or vaccinations; symptons at onset, results of MRI and CSF, treatment and evolution.
Results: The mean age at ADEM onset was 32,8 (20-54), 50% were male with a mean time of follow up of 4 months (6-120). 8 cases (87,5%) had a preceding infection (2 of them were EBV; 2 nonspecific viruses and another 3 of bacterial origin), 2 to 30 days (mean time 16) before the neurological manifestation. The symptoms at onset were disturbed conciousness in 6 cases (75%); motor involvement 6 (75%); headache 4 (50%); cranial nerve involvement 4 (50%); sensory disturbances 3 (37,5%); menigism 1 (12,5%), seizures 1 (12,5%). In 4 cases brain MRI showed small and multiple lesions; 3 cases large and multiple and 1 patient no lesions. Gray matter involvement was found in 50 %.CSF pleocytosis in 3 cases. Oligoclonal bands in 20%. 6 cases showed a monophasic pattern, 2 of them had no sequel, 2 had nondisabling symptoms and 2 had moderate deficits. One patient developed a clinical definite Multiple Sclerosis (CDMS) and another a multiphasic course (recurrent ADEM).
Conclusions: The prevalence of ADEM in this adult population was significantly lower than in a PAP in the same area. Only one patient developed CDMS and another one recurrent ADEM. According to these data ADEM in adults could have a worse prognosis in terms of sequels.
Disclosure: C Papayannis has nothing to disclose.
Rocha FCa, Herrera LCa, Morales RRa, and the Brazilian Committee for Z
aNeurology Department, Medical School of Unesp, Botucatu, São Paulo, Brazil
Background: Population target: Urban people of Botucatu, Brazil s southwestern small city (22.5°S latitude), who had fulfilled multiple sclerosis (MS) diagnostic criteria.
Objectives: Study of prevalence and clinical presentation of MS patients in that population.
Methods: All patients with symptoms suggestive of MS were personally examined by authors and submitted to paraclinical tests: MRI, CSF, visual evoked potential (VEP), HIV, HTLV, syphilis serology; collagen, inflammatory, infectious and vascular disorders were excluded. Only patients between 15 and 59 years at onset of disease, who had filled diagnostic criteria (McDonald et al. 2001), were included.
Results: 17 patients had diagnostic of MS in 103,793 inhabitants (prevalence day: 2001 June 1st). Female: 14; male: 3 (4.6: 1). Caucasians: 16; Negro: 1. 13 (76.5%) have European ancestral. Age at onset: 19 to 59 years (mean: 34.9). Evolution forms: relapsing-remitting (RR) (9 patients), primary progressive (PP) (3 p), secondary progressive (SP) (3 p), benign (2 p). Percentage of initial presentation: sensory (29.4%), pyramidal motor (29.4%), diplopia or vertigo (29.4%), paraparesis (23.5%), ataxia (17.7%), optic neuritis (17.7%). Spinal cord syndrome was prominent in PP type and optic neuritis in benign form. EDSS range 1.0 to 7.0.
Conclusions: Prevalence of MS in Botucatu - 22.5°S (17/100,000) is similar of Sao Paulo - 23.5°S, Brazil (15/100,000 - Callegaro, 1999) and Buenos Aires 34°S, Argentina (16.5/100,000 - Cristiano, 1997) both in South America. This suggests that these cities have higher risk to MS than reported in literature (Kurtzke, 1998). Frequency of disease is close to south of USA and southern countries of Europe. Factors like geographical location and ethnic background (Caucasians with European ancestry) may be relevant. Clinical distribution corresponded to that described by others in our country (Lana-Peixoto et al, Moreira et al, Tilbery et al). Spinal and cerebellar presentation were associated with worse prognostic, otherwise optic neuritis was associated with better prognostic. Further population studies in Brazil might be accomplished to corroborate this one.
Disclosure: F Rocha has nothing to disclose.
Waubant ELa, Vukusic Sb, Gignoux Lb, Durand-Dubief Fb, Achiti Ib, Blanc Sb, Renoux Cb, Confavreux Cb
aNeurology, University of California, San Francisco, San Francisco, California, USA; bNeurologie A, Hôpital Neurologique, Lyon, France
Background: There is no consensus to define what constitutes poor response to IFNB in patients with MS. This is why the percentage of MS patients who do not respond to IFNB therapy and the predictors of clinical response are unknown.
Objectives: To describe clinical characteristics of patients with RRMS on IFNB therapy in the Lyon EDMUS database, and to determine whether responders and non-responders to IFNB differ clinically.
Methods: The prospectively up-dated EDMUS database in Lyon was used to obtain information on patients treated with IFNB for MS for 6 or more months. Data on all RRMS patients who received one of the 3 IFNB approved in Europe was extracted from the database in March 2001. Non-responders to IFNB were defined as patients who experienced higher or identical annualized relapse rate on IFNB therapy compared to the two years and/or the year prior to IFNB therapy.
Results: A total of 200 RRMS patients having received IFNB for at least 6 consecutive months were identified. 63 of the 200 RRMS patients (31.5%) experienced higher or identical annualized relapse rate on IFNB therapy compared to 2 years and/or the year prior to IFNB therapy. Non-responders and responders were similar for mean age when MS started, disability levels when IFNB was initiated, and sex ratio. Responders were older and had a longer mean disease duration than non-responders at the time IFNB was initiated. Responders also had a higher mean annualized relapse rate during the year prior IFNB therapy. Less often responders converted to secondary progressive MS, or progressed during IFNB therapy compared to non-responders. The mulivariate logistic regression showed that annualized relapse rate was the strongest clinical predictor of response to IFNB (OR=0.59, 95%CI: 0.42-0.82). However, MS duration and age when IFNB was initiated also predicted to a lesser extent IFNB response (respectively, OR [95%CI]: 0.90 [0.85-0.96] and 0.96 [0.92-1.0]).
Conclusions: Although the clinical activity of the disease preceding IFNB use may be the strongest clinical predictor of response to therapy, the MRI profile and the biological mechanisms underlying this poor response to IFNB are still unknown.
Disclosure: All the authors have recieved honoraria for educational
presentations from the three interferon beta companies (Schering, Biogen,
Serono) and Teva.
Imaging (Part 1)
Cassol Ea,b, Ibarrola Da, Ranjeva Ja, Manelfe Ca, Clanet Mc, Berry Ib
aBiophysics and Nuclear Medecine, University Hospitals Toulouse, Toulouse, 31, France; bNeuroradiology-MRI, University Hospitals Toulouse, Toulouse, 31, France; cNeurology, University Hospitals Toulouse, Toulouse, 31, France
Background: In Multiple Sclerosis (MS), a lack of specificity has been previously reported in derived imaging parameters (such as lesion load quantified on T2-weighted images and Gadolinium enhancement) in order to predict the disease course.
Objectives: Our aim is to determine the reproducibility of Diffusion Tensor Imaging (DTI) in healthy volunteers and to evaluate its capability to monitor patients with Multiple Sclerosis over one year of follow-up.
Methods: Diffusion Tensor Imaging was performed at 1.5 tesla (Magnetom Vision; Siemens Erlangen, Germany). Six non colinear directions of gradients were acquired to obtain the whole diffusion tensor with an Echo-Planar Imaging (EPI) single-shot sequence (b-factor = 506 s.mm-2). Seven MS patients (3 with a Relapsing Remitting form, RR-MS and 4 with a Secondary Progressive, SP-MS) underwent three-monthly MRI examinations over one year of followup. All were chosen with a limited cerebral lesion load on T2-weighted images. Seven age and sex matched normal controls underwent three examinations and thirteen controls were also studied once. The mean diffusivity is assessed with the Trace of the tensor (Tr=l1+l2+l3) and the directionality is described with an index of anisotropy (Ani=3.l1/Tr). Both were quantified over the whole brain and fully described with histograms.
Results: In volunteers, differences were found for both trace (Tr) and anisotropy (Ani) according to the age and the sex of the subjects, but remain stable over the time. In patients, Tr is higher whereas Ani is lower (p<0.0001) than in matched controls. There is no evidence of difference when comparing the mean global Tr value in patients with different MS phenotypes. However, on longitudinal histograms of Ani, a recovery is emerging in RR-MS whereas there is a worsening in SP-MS.
Conclusions: DTI is reproducible and sensitive to modifications in cerebral diffusion in MS patients. The Anisotropy parameter seems to be more sensitive to assess the longitudinal modifications over one year of follow-up than mean diffusivity and may better reflect the progressive phase of the disease.
Disclosure: I Berry has nothing to disclose.
Funding: Supported by Association de Recherche contre la Sclérose
En Plaques (ARSEP).
Dousset V, Deloire-Grassin M, Touil T, Petry KG, Brochet B
EA 2966 (Neurobiology of Myelin Disorders Laboratory), University Victor Segalen, Bordeaux, Bordeaux Cedex, France
Background: Antibodies against adhesion molecule VLA4 have been shown to reduce clinical and histological signs of experimental autoimmune encephalomyelitis (EAE) most probably by reducing blood-brain-barrier (BBB) damage. Anti-VLA4 antibodies are under testing in MS patients (Natulizumab). The new contrast agent ultra-small-particle-iron-oxide (USPIO) is able to disclose. by MRI, in vivo, macrophage containing lesions in EAE. USPIO have been successfully applied to detect active lesions in MS patients.
Objectives: To evaluate the usefulness of USPIO imaging in EAE rats treated by anti-VLA4 antibodies or placebo.
Methods: Acute EAE was induced in Lewis rats by immunization by guinea pig cord homogenates in complete Freund adjuvant. 8 rats were treated by a monoclonal anti rat VLA4 antibody (CD49d) (gift of Biogen, Cambridge, MA) and 8 rats by a placebo. MRI was performed on a 1,5 T magnet. T1 weighted images were performed before and after gadolinium-DTPA (Gd) infusion. T2 and T2* weighted images were also acquired . After the first MRI, rats received USPIO infusion (sinerem®, gift of Guerbet, France) and a second MRI was performed 24 hours after this infusion to detect cellular enhancement. Rats were sacrificed after this MRI to study EAE histological signs and macrophage recruitment by immunohistochemistry.
Results: 3 out of 8 anti-VLA4 antibody treated rats and 7 out of 8 placebo treated rats developed EAE (p<0.03). Mean clinical scores were significantly reduced in the active treatment group (0.24 ±0.44) compared to the placebo group (1.7 ±1.1) (p<0.01). The disease was delayed by the treatment (13.5 ±0.9 against 10.4 ±1.5 days) (p<0.003 ). MRI 24 hours after USPIO infusion showed abnormalities in 3 rats treated by anti-VLA4 and 6 rats treated by placebo. A good correlation was observed between clinical and USPIO MRI signs. Macrophage infiltrates were significantly reduced in rats treated by the antibody (5.9 ±2.6) compared to placebo (11 ±3.2) (p<0.02).
Conclusions: Both MRI with USPIO and histology showed that anti-VLA4 antibody treatment reduces macrophage infiltrates in EAE. USPIO may be a useful tool to monitor biological efficacy of this treatment. Acknowledgements: A Sandrock, Biogen, C Corot Guerbet.
Disclosure: B Brochet has nothing to disclose.
Deloire-Grassin M, Dousset V, Touil T, Petry KG, Brochet B
EA 2966 (Neurobiology of Myelin Disorders Laboratory), University Victor Segalen, Bordeaux, Bordeaux Cedex, France
Background: Phagocytic activity of cells within inflammatory lesions of the central nervous system can be visualized in vivo by MRI using new contrast agents like Ultra small particle iron oxide (USPIO). This has been shown in both experimental autoimmune encephalomyelitis (EAE) and Multiple Sclerosis (MS) using Sinerem®, a first generation USPIO
Objectives: To compare a newly available USPIO, called 7228 to sinerem ® for the detection of EAE lesions.
Methods: Acute EAE was induced in 8 Lewis rats by immunization by guinea pig cord homogenates in complete Freund adjuvant. MRI was performed at the peak of EAE clinical signs on a 1,5 T magnet. T1, T2 and T2* weighted images (w.i.) were acquired 24 hours after USPIO infusion: AMI 227 (Sinerem®, gift of Guerbet, France) for 4 rats and USPIO 7228 (gift of Guerbet, France) for 4 rats. Rats were sacrificed after this MRI to study EAE histological signs and macrophage recruitment by immunohistochemistry
Results: No difference was observed between sinerem® and 7228 to detect EAE lesions on T1 w.i. However, 7228 was more sensitive on T2 and T2* w.i. Immunohistochemistry confirmed that lesions enhanced by 7228 contained macrophage infiltrates. Perls staining showed iron deposits in macrophages more easily after 7228 than after sinerem® infusion.
Conclusions: USPIO 7228 appears to be more sensitive to detect macrophages in EAE lesions by MRI Acknowledgements: C Corot, Guerbet, France.
Disclosure: B Brochet has nothing to disclose.
Funding: Supported by Guerbet, France.
Callegaro Da, Otaduy Mb, Lacerda Mb, Costa Mb, Bacheschi La, Leite Cb
aNeurology, Medical School of the University of São Paulo, São Paulo, Brazil; bRadiology, Medical School of the University of São Paulo, São Paulo, Brazil
Background: Diffusion MRI is sensitive to the microscopic randomic translational motion of water molecules in biological tissue. Pathological tissue in MS is commonly characterized by an increase in diffusion. The histogram analysis of diffusion images provides global parameters for the patient, which measure both the lesions and NAWM. It is important to address what is the relation between these parameters and the lesion load measured on conventional images.
Objectives: To correlate whole-brain diffusion MR histogram results to total lesion load (TLL) in MS patients.
Methods: Fifteen patients (mean age = 32 ± 8 years) with MS were examined with conventional and diffusion-weighted MR imaging. Studies were performed on a 1.5 T MRI scanner. Axial 5 mm thick T2, T1 and PD weighted images were acquired. Diffusion was measured by obtaining axial 5 mm thick SE echo-planar images (EPI) (TE/TR= 105.3 ms/ 10000 ms) with matrix resolution of 95 x 128 and with two different b values: 0 and 1000 s/mm2. Apparent diffusion coefficient (ADC) maps were generated off-line assuming a monoexponential decrease of signal intensity with b value. From these maps diffusion histograms were calculated after removal of the extracerebral tissue and CSF. TLL was measured off-line on PD weighted images. After applying a treshold lesions were selected manually on each image by two radiologists and the area was automatically calculated by the software Scion (NIH, USA).
Results: Mean lesion load was 1261 ± 1545 mm2 (range 20 to 5564 mm2). From diffusion histograms following parameters were calculated: mean ADC 1000 ± 44 x 10-6 mm2/s (range 945 to 1075 x 10-6 mm2/s), mean ADC peak position 803 ± 31 x 10-6 mm2/s (range 757 to 877 x 10-6 mm2/s) and mean ADC peak height 43.9 ± 6.1 (range 34 to 52). Mean ADC and ADC peak height showed a strong and significant correlation with TLL (0.7355; p = 0.002 and - 0.7678; p < 0.001 respectively), but the correlation between ADC peak position and TLL was not significant.
Conclusions: Whole brain diffusion histograms can be a reliable and fast method to control disease evolution in MS patients.
Disclosure: D Callegaro has nothing to disclose.
Davies G, Hadjiprocopis A, Altmann D, Rashid W, Griffin C, Chard D, Kapoor R, Thompson A, Miller D
NMR Unit, Institute of Neurology, UCL, Queen Square, London, United Kingdom
Background: Cross sectional histogram analysis has shown that T1 relaxtion time measurement can detect abnormality in normal appearing white matter (NAWM) early in the course of multiple sclerosis (MS).
Objectives: The question as to whether diffuse abnormality occurs prior to or following the first clinical episode may provide valuable insight into pathological mechanisms in MS. To investigate the evolution of abnormalities with time we have studied longitundinally a cohort of early relapsing MS (RRMS) subjects using T1 histogram analysis.
Methods: Nineteen subjects (6 male and 13 female, mean age 38) with early RRMS (mean disease duration 2.1 years) and eight controls (6 male and 2 female, mean age 38) were imaged six monthly. Mean follow up was 22.5 month (range 12-36 months). Dual fast spin echo (FSE) sequences were obtained along with a gradient echo data set (PD and T1 weighted images) permitting the calculation of a T1 map. Lesions were contoured on the FSE image following registration of this image to the T1 image. Using these regions and SPM derived masks, NAWM segments were generated from the T1 map. Remaining CSF was removed with a 1000ms threshold and 2 sequential erosions. Normalized histograms were generated from the NAWM segments of the T1 map and mean T1 was extracted from the histogram. A hierachical regression model was used to assess the difference in mean T1 between MS subjects and to look for a gradient of increase in T1 with time. Gender differences were accounted for.
Results: The mean T1 relaxation time was 669.5ms in MS subjects (standard deviation (SD) 22.8ms) and 630.8ms in controls (SD 15.2ms), p<0.001. No significant change in T1 was observed during follow up although at baseline, values were significantly related to disease duration. Results suggest that, assuming a linear relationship, the T1 relaxation times increase by 1.14ms per month between disease onset and the first data point. Projecting back from these observations suggests that at the time of disease onset, abnormalities are already present.
Conclusions: This study confirms the presence of diffuse T1 relaxation time abnormalities early in the clinical course of MS and suggests that these are present prior to clinical onset.
Disclosure: G Davies has nothing to disclose.
Funding: Supported by MS society programme grant (MS society
of Great Britain and Northern Ireland). Posters S44 Multiple Sclerosis
Durand Dubief Fa, Pachai Cb, Vukusic Sa, Gignoux La, Renoux Ca, Cotton Fc, Froment Jd, Confavreux Ca
aNeurologie A, Hôpital Neurologique, Lyon Cedex 03, France; bTheralys, Lyon, France; cNeuroradiologie, CH Lyon Sud, Lyon, France; dNeuroradiologie, Hôpital Neurologique, Lyon, France
Background: Numerous studies have been done to quantify the severity and the evolution of brain tissue damage in multiple sclerosis (MS). Brain atrophy measured by MRI techniques is a potential way to monitor disease progression in MS.
Objectives: The objective of the study was to determine the evolution of the whole brain atrophy in MS patients by annual MRI acquisitions.
Methods: 3D MRI T1 weighted sequences covering the whole brain from the foramen magnum to the vertex, pre and post-Gadolinium enhancement were performed on a yearly basis (matrix 256.256.170 ; resolution : 1mm). Serial 3D data sets were spatially registered for each patient using a fully automatic algorithm. Intracranial volume, brain parenchyma volume and ventricular volume were automatically segmented. A mask representing artery and vein structures was obtained for each patient by segmenting Gadolinium enhanced acquisitions. These vascular structures were removed from the final brain mask. Two parallel anatomical planes at anterior/posterior commisural level and internal auditory meatus level were interactively defined. These planes were considered as the quantification cut-off. We quantified different volumes of interest such as the volume above the anterior/posterior commisural plane, volume above the internal auditory meatus, whole brain volume and Brain Parenchymal Fraction.
Results: Seventeen patients with clinically definite MS have been included in the study. Eight patients had a relapsing-remitting course and nine a secondary progressive one. Mean disease duration at the first MRI was 13 years (Range : 0 - 34). Mean follow-up duration was 3.8 years (Range : 3 - 5). Mean number of MRI assessments for each patient was 3.5. The different volumes were compared to identify the more informative one. The percentage of brain atrophy was evaluated for each patient over at least 3 years.
Conclusions: Analysis is still in progress
Disclosure: F Durand Dubief has nothing to disclose.
Hickman SJa,b, Toosy ATa,b, Miszkiel KAc, Jones SJd, Altmann Da, MacManus DGa, Barker GJa, Plant GTb, Thompson AJa, Miller DHa
aNMR Research Unit, Institute of Neurology, University College London, United Kingdom; bDept. of Neuro-Ophthalmology, Moorfields Eye Hospital, London, United Kingdom; cLysholm Radiological Dept., The National Hospital for Neurology and Neurosurgery, London, United Kingdom; dDept. of Clinical Neurophysiology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom; eInstitute of Neurology, University College London, United Kingdom
Background: In multiple sclerosis (MS) reductions in magnetization transfer ratio (MTR) are thought to be due to demyelination and axonal loss.
Objectives: To follow serial changes in MTR in optic neuritis lesions to further validate optic neuritis as a model for MS relapses.
Methods: 26 patients were recruited with acute unilateral optic neuritis. Their optic nerves were imaged a mean 14 days since the onset of visual symptoms with a fat saturated fast spin echo (FSE) sequence and a 3D gradient echo magnetization transfer sequence. 17 of them had serial imaging after 2, 4, 8, 12, 26 and 52 weeks. A blinded observer segmented the optic nerves from the MTR maps. Lesions were then defined on the acute FSE images and from the coordinates the mean lesion MTR was calculated for each time point.
Results: The mean lesion MTR at baseline was 47.3pu compared with 48.2pu in the contralateral healthy nerve (p=0.03). The serial lesion data were analysed using a hierarchical model with a quadratic term which gave the best fit. In the acute phase mean lesion MTR fell rapidly. The coefficient in the linear term was -0.029pu per day (standard error [SE] 0.005), 95% confidence intervals (CI) -0.039 to -0.019, p<0.0001. The quadratic term coefficient was 0.000063 (SE 0.000014), 95% CI 0.000033 to 0.000093, p<0.0001. The rate of decrease lessened over time with the suggestion of a nadir of mean lesion MTR at about 200 days and a small increase in MTR subsequently.
Conclusions: The early fall in MTR is consistent with demyelination and acute axonal damage. The subsequent late rise in mean lesion MTR suggests that this technique may be able to demonstrate remyelination.
Disclosure: S Hickman has nothing to disclose.
Funding: SJH is Supported by The Wellcome Trust. ATT is Supported
by Action Research. The NMR Research Unit is Supported by The Multiple
Sclerosis Society of Great Britain and Northern Ireland.
Hickman SJa,b, Kapoor Rc, Jones SJd, Altmann Da, Plant GTb,c, Miller DHa aNMR Research Unit, Institute of Neurology, University College London,
United Kingdom; bDept. of Neuro-Ophthalmology, Moorfields Eye Hospital, London, United Kingdom; cDept. of Neurology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom; dDept. of Clinical Neurophysiology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
Background: Optic nerve atrophy has been shown to develop following optic neuritis. There has been recent interest in the use of corticosteroids as neuroprotective agents. Pulsed corticosteroid treatment has been shown to reduce the development of cerebral atrophy in multiple sclerosis.
Objectives: To assess whether corticosteroids prevent the development of optic nerve atrophy following optic neuritis.
Methods: Optic nerve shorttau inversion recovery images from a recent randomized placebo controlled trial of intravenous methylprednisolone in acute optic neuritis were evaluated. Imaging was performed before randomization and six months later. Mean optic nerve area was measured by an observer blinded to image identity, acquisition order and treatment status from two consecutive orbital slices using a semi-automated contouring technique.
Results: At baseline optic nerve mean area was 18.4mm2 in affected optic nerves and 17.8mm2 in unaffected optic nerve (n=45, p=0.3). After six months optic nerve mean area was 16.4mm2 in affected optic nerves and 17.4mm2 in unaffected optic nerves (n=59, p=0.019). The mean area of affected optic nerves in the corticosteroid group was 15.9mm2 (n=30) compared with 16.9mm2 (n=29) in the placebo group (p=0.29). The mean measurement coefficient of variation was 3.8%.
Conclusions: This technique was able to demonstrate optic nerve atrophy following optic neuritis. There is no evidence from these data that intravenous methylprednisolone prevents the short-term development of optic nerve atrophy following optic neuritis.
Disclosure: S Hickman has nothing to disclose.
Funding: SJH is Supported by The Wellcome Trust. The NMR Research
Unit is Supported by The Multiple Sclerosis Society of Great Britain and
Northern Ireland.
Hickman SJa,b, Toosy ATa,b, Miszkiel KAc, Jones SJd, MacManus DGa, Plant GTb, Thompson AJa, Miller DHa
aNMR Research Unit, Institute of Neurology, University College London, United Kingdom; bDept. of Neuro-Ophthalmology, Moorfields Eye Hospital, London, United Kingdom; cLysholm Radiological Dept., The National Hospital for Neurology and Neurosurgery, London, United Kingdom; dDept. of Clinical Neurophysiology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
Background: Triple dose gadolinium (Gd) increases the sensitivity for detecting enhancing lesions in multiple sclerosis.
Objectives: To assess whether the use of triple dose Gd in optic nerve imaging can help in predicting the prognosis for visual recovery following optic neuritis.
Methods: 28 patients were examined a median 13 (range 8-21) days after onset of their first episode of acute unilateral optic neuritis. After administration of intravenous triple dose Gd the patients’ optic nerves were images with a fat saturated T1-weighted spin echo sequence. A blinded observer identified and measured the length of any enhancing nerve lesions on the images. Serial imaging was performed on 15 of the patients and the duration of enhancement noted. A clinical assessment was carried out at baseline and again after one year.
Results: The symptomatic lesion was identified in 27/28 cases. The median lesion length at baseline was 30mm (range 0-39mm). Patients with longer lesions (>=30mm) had worse initial 30-2 Humphrey visual field mean deviations (p=0.009) and central field visual evoked potential amplitudes (p=0.05) compared with those patients with shorter lesions. The median duration of enhancement was 63 days (range 0-113 days). Neither the length of the initial lesion nor the duration of enhancement were correlated significantly with final visual outcome.
Conclusions: The initial lesion length in optic neuritis appears to be important in determining the amount of initial visual impairment. The extent and duration of the initial inflammatory lesion does not, however appear to affect prognosis.
Disclosure: S Hickman has nothing to disclose.
Funding: SJH is Supported by The Wellcome Trust. ATT is Supported
by Action Research. The NMR Research Unit is Supported by The Multiple
Sclerosis Society of Great Britain and Northern Ireland.
Kallmann B, Rieckmann P, Toyka KV, Mäurer M
Neurolog.Klinik, Wuerzburg, Germany
Background: In multiple sclerosis, brain atrophy was shown to correlate with disability and is considered to represent the net effect of tissue destruction. As a parameter for assessment of brain atrophy we could recently show that determination of ventricular width by transcranial ultrasound correlated well with MRI measurements of the ventricular system. Moreover, ultrasound revealed larger ventricular diameters in MS patients in comparison to age and sex matched control patients. It was further shown that brain atrophy determined by ultrasound correlated with EDSS and several neuropsychological tests.
Objectives: We conduct a longitudinal follow up of measurements of ventricular width with transcranial ultrasound in comparison to MRI in MS patients.
Methods: 38 patients (mean age 36+/-9 years) were included in this 2 year study. Patients were investigated clinically (EDSS, 9 hole peg test), with transcranial ultrasound and MRI at baseline, 12 and 24 months follow up.
Results: A first evaluation with 22 patients who completed the first year was done. The EDSS at baseline was 3.8+/-1.5 and showed only a minor change to 3.9+/-2 after one year (not significant). The width of the III. ventricle at baseline was 5.5+/-2.9 mm. In accordance with the stable clinical situation the diameter of the third ventricle remained nearly unchanged (5.6+/-3.3 mm, not significant). Ventricular diameter was determined by two independent examiners and revealed highly reproducible results.
Conclusions: These preliminary results from a longitudinal study underline the value of transcranial ultrasound as an easily applicable method for evaluation of brain atrophy in MS patients.
Disclosure: B Kallmann has nothing to disclose.
Langkilde ARa, RostrupEa, Frederiksen Jb, Olsen Db, Jensen Jb, Lauritzen Mc, Larsson HBd
aMR 340, DRCMR, Hvidovre Hospital, Hvidovre, Denmark; bNeurolgy, Glostrup University Hospital, Glostrup, Denmark; cClinical Neurophysiology, Glostrup University Hospital, Glostrup, Denmark; dMR Centeret, Trondheim Central Hospital, Trondheim, Norway
Background: Functional MRI (fMRI) studies have suggested that adaptive cortical changes take place during the recovery from MS attacks, and that these changes have the potential to augment clinical recovery. . When visually stimulating eyes, previously affected with acute optic neuritis (ON), the activated volume in the visual cortex was smaller compared to healthy controls, and correlated with visual acuity.
Objectives: In the present serial fMRI study changes in visual cortical function was studied in patients with first episode of acute unilateral ON. It was expected that the volume of visual cortical activation would correlate to the visual function, when stimulating the affected eye. Since the visual function is based on both eyes working in collaboration, it was hypothesized that an adaptive change of cortical activation would be detected, when stimulating the unaffected eye,(monocularly or binocularly) during the period of visual impairment.
Methods: Subjects: Eleven patients with acute monosymptomatic ON (4 men,7 women), median age 38 years, nine healthy subjects(3 men, 6 women),median age 32 years. Methods: Patients: Four serial sessions, each comprising fMRI, Snellen visual acuity and visual evoked potentials. Sessions were performed at mean 10 (range 4 - 18),34,70,and 432 days after symptom onset. Healthy controls had fMRI on two occasions. Eyes were stimulated separately and together using ep imaging in eleven slices, covering the visual cortex. The visual stimulus was a black/white checkerboard reversing at 8 Hz.
Results: When stimulating binocularly a significant increase in activated volume was detected in the second session (34 days), at the same time as improvement of visual function had started. During the four sessions the mean results of the Snellen visual acuity and of the VEP amplitude correlated significantly to the volume of cortical activation. There was no significant diffence between fMRI results on the two occasions in healthy controls.
Conclusions: The large increase in cortical activated volume when stimulating binocularly in the second session may represent dynamic adaptive functional changes augmenting recovery from unilateral ON.
Disclosure: A Langkilde has nothing to disclose.
Laule Ca,b, Traboulsee Ab, Keogh Cc, MaGuire Jd, RedekopGe, MacKay Aa,c
aPhysics, University of British Columbia, Vancouver, British Columbia, Canada; bMedicine, University of British Columbia, Vancouver, British Columbia, Canada; cRadiology, University of British Columbia, Vancouver, British Columbia, Canada; dPathology, University of British Columbia, Vancouver, British Columbia, Canada; eSurgery, University of British Columbia, Vancouver, British Columbia, Canada
Background: Clinical deterioration is expected in most patients with multiple sclerosis (MS) due to relapses or secondary progression. Routine MRI is not often done to determine if this is due to a secondary diagnosis. We report a woman with clinically definite MS for 9 years who had unexpected worsening due to a large CNS mass.
Objectives: To investigate possible causes of unexpected deterioration in a patient with MS using both standard and novel MRI techniques.
Methods: A 53 year old woman with MS who presented with a 3 month history of anorexia and vomiting had a standard neurologic exam. Prior to biopsy, gadolinium enhanced MRI, proton MR spectroscopy (MRS) and a 48 echo T2 relaxation measurement were performed using a 1.5T GE scanner.
Results: MRI demonstrated a left frontal mass (60cm^3) with mixed signal intensity, edema, significant mass effect and irregular ring enhancement. (One year prior, the patient had a large frontal plaque extending into the corpus callosum. No mass effect was evident at that time). The lesion spectrum was dominated by large peaks around 1ppm, likely due to lipid. T2 measurements showed heterogeneous decreases in myelin water and prolonged relaxation times. At least 3 T2-distinguishable volumes were found within the mass, with intermediate mean T2 times (~130ms) and myelin signal remaining in the central core, while the periphery tended to have almost no myelin signal and longer relaxation times (250-450ms). Histopathology showed characteristics typical of a giant cell glioblastoma (grade IV astrocytoma).
Conclusions: MRI is indicated for MS patients with unexpected deterioration to exclude a secondary diagnosis. For more pathologically specific information, MRS and T2 measurements are valuable.
Disclosure: C Laule has nothing to disclose.
Funding: MS Society of Canada.
Li Da, Traboulsee Ab, Paty Db, Work Group on Standardized MRI Protocol Cc
aRadiology, University of British Columbia, Vancouver, British Columbia, Canada; bNeurology, University of British Columbia, Vancouver, British Columbia, Canada; cConsortium of MS Centers, Teaneck, New Jersey, USA
Background: The use of magnetic resonance imaging (MRI) has become routine in the diagnostic workup of patients with multiple sclerosis (MS). There are however no guidelines for the use of MRI in practice. Standardized MRI protocols would help maximize the value of individual scans, as well as allow systematic data collection for clinical and comparison studies.
Objectives: To develop consensus guidelines for standardized MRI protocols and indications for their use in the diagnosis and follow up of patients with MS.
Methods: An expert consensus meeting on ‘MRI Protocols for the Diagnosis and Follow Up of MS’, sponsored by the Consortium of MS Centers (CMSC) was convened November 3–4, 2001 in Vancouver, Canada. Participants included MS neurologists and radiologists from North America, Europe, and New Zealand, with representation from the American Academy of Neurology, American Society of Neuroradiology, and Radiological Society of North America.
Results: 10 guidelines were recommended with specific proposals concerning baseline evaluation, diagnosis and follow-up, indications for spinal imaging, use of gadolinium, appropriate requests, reports and archiving. The guidelines proposed standardized MRI protocols to image the brain and spinal cord, with specified required and optional features. Scans should be obtained, if possible, on a 1 Tesla or higher machine, using a slice thickness of 3mm or less (1.5mm or less for 3D sequences), without gaps, with scans oriented along the subcallosal line using a 3 plane localizer if available. Routine follow up MRI’s in practice were not recommended, until standardization. A prototype radiology report was suggested using standardized and consistent common language, describing such features as lesion number, location, size, shape, and character. A copy of the MRI should be retained permanently for future comparison.
Conclusions: Consensus guidelines will be posted for review on the CMSC website (www.mscare.org) for discussion and comment. The development of these recommendations is only the beginning of what has to be a continuing process, requiring modification, implementation, evaluation and continued updating and improvement.
Disclosure: D Li has nothing to disclose.
Funding: Supported by Consortium of MS Centres.
Ramo Ca, Amo Cb, Fernandez Sb, Carmen Mb, Maestú Fb, Fernandez Ab, Ortiz Tb
aNeurology, Hospital de la Princesa, Madrid, Spain; bCentro MEG, Complutense University of Madrid, Madrid, Spain
Background: Magnetoencephalogrphy (MEG) is a non-invasive technique that allows us to detect the magnetic dendritic activity and the anatomical localization in MRI images.
Objectives: The objetive of this estudy is to detect and measure the abnormal low frequency magnetic activity (ALFMA) and epileptogenic-like activity in multiple sclerosis patients and evaluate their clinical applications as a complementary diasnostic technique.
Methods: Twenty one patiens were selected according to the followin criteria: twenty one relapsing-remitting (RR) MS patients. All the RR patients were recently diagnosed whith at least 2 relapsing episodes whithin the last two years. Mean age 31.6 (range 22-45). Mean EDSS 1.5 (range 0-3.5). None of them were on corticoid therapy in the last 3 months before the MEG or were on innmunosupressor treatment. Spontaneous awake simultaneous MEG-EEG recording was measured using a 148 channel biomagnetic system with a MAGNES 2500W device, performing an equivalent current dipole analysis and superimposing on a corresponding 3D weighted MRI.
Results: The results reveal that on all the patient MEG recordings appear focal slow waves (theta & delta) activity; in 17 patients (81%), of wich had slow waves in rolandic areas (frontal and parietal ascendant circumbolutions), in addition of the same group, 52% had slow waves in other parietal areas. Others frequently affected areas were frontal and temporal lobes. Also, epileptogeniclike activity was found indepently in MEG records (simultaneous EEG was normal in all patients) in 12 patients (57%). The most affected areas were frontal and parietal ascendant circumbolutions (52%)and other parietal areas (43%). Oter areas with infrequent epileptogenic-like activity were frontal and temporal lobes.
Conclusions: The MEG detects the presence of abnormal activities in well limited areas of the brain cortex. Epileptogenic-like activity in a high percent of patients (57%) has been found. This activity was not foun in conventional simultaneous EEG records. This sharp MEG activity has no correlation whith clinical features, degree of lesional load, degree of motor disability and multiple sclerosis evolution time. The presence of this activity is related whith brain cortex affectation. This results could be explained in future studies.
Disclosure: D Martin C. recibes a grant from Serono laboratories.
Funding: Supported by Serono laboratories.
Redmond ita, Tench CRb, Blumhardt LDb
aNeurology, Hope Hospital, Salford, Greater Manchester, United Kingdom; bDivision of Clinical Neurology, University hospital Notttingham, Nottingham, Nottinghamshire, United Kingdom
Background: The emphasis on axonal damage as the pathological substrate of disability in MS has focussed attention on black holes. To date, the majority of clinial studies of black hole volumes have used moderately T1-weighted spinecho (T1 SE) sequences. It has been postulated that the use of heavily T1-weighted sequences, such as Magnetization Prepared Rapid Acquisition Gradi- ent Echo (MPRAGE), that provide greater T1 contrast will reduce the pathological specificity of black holes.
Objectives: To investigate black hole volumes using moderately T1-weighted T1 SE and heavily T1-weighted MPRAGE, and, to investigate the pathological specificity of such lesions as quantified using the Magnetization Transfer ratio (MTR).
Methods: For 12 patients with secondary progressive MS, T2 SE and MTR images, and post contrast T1 SE and MPRAGE images, were acquired. MPRAGE images were reformatted to the same voxel dimensions as the spin echo sequences and co-registered using image correlation. Black hole and T2 lesion volumes were estimated using a seeded region growing technique.
Results: Median lesion loads were: T2 10146mm3, T1 1178mm3, MPRAGE 4491mm3. The mean MTR of lesions identified on T1 SE was 0.316, significantly lower than those identified on T2 (0.344, p=0.0004) or MPRAGE (0.33, p=0.03). The mean MTR of MPRAGE elsions was significantly lower than for T2 lesions (p=0.03). Individual lesions were significantly larger on MPRAGE (207mm3) than T1 SE (159mm3, p=0.005). MPRAGE signal intensity(normalised to signal intensity of narmal appearing white matter) of lesions visible on MPRAGE but not T1 SE was 0.88, significantly higher than those visible on both T1 SE and MPRAGE (0.88, p=0.05).
Conclusions: Heavily T1 weighted Gradient Echo sequences yield greater black hole volumes than T1 SE. Lesions visible on MPRAGE but not T1 SE are smaller and less hypointense than lesions detected on both sequnces. MTR values of MPRAGE lesions are higher than T1 (but lower than T2) suggesting that the greater sensitivity of MPRAGE is at the expense of pathological specifiity. MPRAGE lesions may not be as pathologically heterogeneous as T2 lesions.
Disclosure: i redmond has nothing to disclose.
Schmierer Ka, Scaravilli Fb, Barker GJa, MacManus DGa, Miller DHa
aNeuroinflammation, NMR Research Unit, Institute of Neurology, London, England, United Kingdom; bNeuropathology, Institute of Neurology, London, England, United Kingdom
Background: Several groups have examined the pathological substrate of MRI in post-mortem (PM) MS brain. However, no standardised method has been developed so far to accurately match the areas of changes visible on MRI with the tissue specimens.
Objectives: To investigate whether a stereotaxic navigation system is a useful tool to co-register lesions on MRI and pathologically in PM brain slices of patients with MS.
Methods: PM tissue specimens of seven patients (4 women, 3 men; age: 59.4 +/- 18.7 years) with MS were studied. Formalin fixed coronal slices (thickness: 1 cm) of one cerebral hemisphere were placed on a grid that was attached to a stereotaxic navigation system. Spin echo T2- weighted MRI and FLAIR scans of 5 mm slice thickness were obtained. Lesions visible on MRI were matched with previously obtained scans of the same, but fresh, specimens. Guided by the target points calculated from coordinates of the localizer frame, the dissection of the brain slice was performed. Blocks were cut in halves (thickness: 5 mm) with the cut surface corresponding with the imaging plane. After processing of the blocks for embedding in paraffin, sections were stained with H&E and Luxol-Fast blue.
Results: On MRI of fixed brain specimens, 26 areas suspected to be MS lesions were detected, 24 of which were confirmed histologically. Two confirmed lesions detected on MRI of the fresh slices were not visible on the MRI of the fixed slice. Four additional areas that appeared to be lesions on MRI of the fresh specimens could not be matched, either with the scan after fixation or histologically. 13 microscopically confirmed lesions were not visible on macroscopic examination of the tissue during the dissection procedure.
Conclusions: The co-registration of MRI and histopathology in PM brain tissue of patients with MS using a stereotaxic system is feasible. This novel approach improves the accuracy of MR guided sampling of tissue specimens and may increase the yield of tissue that can be used for the correlation of MRI and pathological markers. This method may thus reduce the number of brain specimens needed in such studies. With regard to a suggested homogeneity of lesions within individual MS patients, this approach may be helpful to collect representative samples from individual cases.
Disclosure: Dr. Schmierer is Supported by Serono Pharma GmbH, Unterschleissheim, Germany.
Funding: The NMR Research Unit is Supported by the National Multiple
Sclerosis Society of Great Britain and Northern Ireland.
Schmierer Ka, Scaravilli Fb, Griffin CMa, Barker GJa, Miller DHa
aNeuroinflammation, NMR Research Unit, Institute of Neurology, London, England, United Kingdom; bNeuropathology, Institute of Neurology, London, England, United Kingdom
Background: Recent studies have shown that there has been considerable overlap between lesions at various stages with regard to measures of MRI and histopathology in post mortem (PM) MS brain. To better quantify the pathological components of MS, there is a need to improve the ability of MRI to depict these features more specifically.
Objectives: To quantify and correlate the myelin content and axonal density in MS brain using MRI and digital image analysis (DIA) of histological sections.
Methods: Five fresh coronal PM MS brain slices (1cm thick) were studied. T1-, T2-, PD-weighted, and FLAIR scans were performed. T1-relaxation time (T1-R), and magnetisation transfer ratio (MTR) maps were produced. After scanning, the specimens were cut so that the cut surface resembled the imaging plane. Tissue blocks were processed for embedding in paraffin and sections were stained (H & E, Luxol-Fast blue (LFB), Bielschowsky). Immunohistochemistry included glial fibre associated protein (GFAP), CD68, and anti myelin basic protein (MBP). We used a Leica Q500MC image analyser for DIA of the slides. Light transmittance (LT) was obtained separately for LFB and Bielschowsky stained slides.
Results: Of 33 lesions detected on MRI, 19 could be analysed whereas 14 could not be matched with the specimens. Normal appearing white matter (NAWM) of each brain slice served as an intraindividual reference. Lesions were chronically inactive, three were classified as remyelinated. Reduced MTR correlated strongly with axonal loss and demyelination as reflected by high LT values in Bielschowsky- and LFB-stained slides. MTR and LT also correlated strongly with T1 hypointensity whereas T1-R did not. The latter may be due to an increase of T1-R in PM brain (mean T1-R of NAWM, 740 ms). No difference for any measure of MRI or DIA was detected between demyelinating and remyelinating lesions, probably due to the small sample size in this study.
Conclusions: These preliminary results show that DIA is a promising tool to quantify specific components of MS pathology in PM brain tissue. Its exact role needs to be confirmed in a larger sample and in combination with other quantitative MRI measures (e.g. fractional anisotropy, bound water fraction).
Disclosure: Dr. Schmierer is Supported by Serono Pharma GmbH, Unterschleissheim, Germany
Funding: The NMR Research Unit is Supported by the National Multiple
Sclerosis Society of Great Britain and Northern Ireland.
Simon JHa, Cohen JAd, Goodman Ac, Heidenreich Fe, Kooijmans Mb, Sandrock Ab, Tsao ECb, IMPACT Investigators .a
aRadiology/MRI, University of Colorado HSC, Denver, Colorado, USA; bBiogen,Inc, Cambridge, Massachusetts, USA; cNeurology, University of Rochester, Rochester, New York, USA; dMellon Center, Cleveland Clinic, Cleveland, Ohio, USA; eNeurology, Hannover Medical School, Hannover, Germany
Background: The IMPACT Trial evaluated the effect of treatment in patients with secondary progressive MS with EDSS 3.5 to 6.5 randomized to treatment with interferon beta-1a (IFN beta-1a; AVONEX) or placebo by weekly intramuscular injection (60mcg) for two years. Prior MRI analyses have shown that new or enlarging T2 lesions and gadolinium enhancing lesions (inflammatory activity) are significantly reduced in treated patients at one and two years (p < 0.001).
Objectives: To determine the effect of treatment and to define the natural history of T2 burden of disease (T2 lesion volume) and more destructive tissue changes based on T1-hypointense lesions (T1-black holes) in secondary progressive MS.
Methods: T2 lesion volume and T1 hypointense lesion volume were determined at baseline, year one and two years for all evaluable studies. Differences between treatment groups were determined based on nonparametric analysis of variance, stratified by baseline EDSS and number of enhancing lesions on baseline MRI.
Results: The T2-lesion volumes and T1-lesion volumes were well balanced at baseline. A treatment effect in favor of treatment with IFN beta-1a was seen with a significant reduction in change from baseline T2 volume at both one and two years(p < 0.001 and p < 0.001, respectively). A similar treatment effect was seen with T1 hypointense lesion volume with group differences favorable for treatment for change from baseline at both one and two year intervals, with a significant change over the two year timepoint (p = 0.02).
Conclusions: These results extend the positive MRI observations from previous analyses of the IMPACT Trial to include measures of T2 burden of disease and the more destructive and likely irreversible injury indicated by T1 black holes, and are supportive of the clinical findings of positive effects of treatment on MS Functional composite progression, relapses and quality of life.
Disclosure: J Simon and several co-authors have received honoraria as consultant or for speaking for Biogen, Inc. M. Kooijmans,E Tsao, A Sandrock are employees of Biogen,Inc.
Funding: Supported by Biogen,Inc. Cambridge MA.
Coombs Bb, Corboy Ja, Simon JHb
aRadiology/MRI, University of Colorado HSC, Denver, Colorado, USA; bNeurology, University of Colorado HSC, Denver, Colorado, USA
Background: Prior studies have revealed that acute focal MS lesions may be the source of secondary abnormalities observed on high resolution T2 weighted (T2W) MRI images including transcallosal bands and corticospinal tract patterns that traverse long white matter pathways. We have hypothesized that these are the result of neuronal tract degeneration.
Objectives: Test the hypothesis that diffusion tensor derived measures (mean diffusivity and fractional anisotropy) are sensitive to abnormality in the corpus callosum independent of the visually detected and defined tract degeneration patterns detected by high resolution T2W images.
Methods: Diffusion tensor analyses based on mean diffusivity (MD) and fractional anisotropy index(FA)calculated in a pilot study with 10 consecutive MS patients (EDSS 1.5 to 8) compared to normal controls. MR acquisition included spin-echo echo-planar (EP) navigator-echo phase-corrected series with effective b-values of 0 and 1000 s/mm2 with six diffusion encoding gradient directions. Regional analysis of corpus callosum based on five midline sagittal slices per subject with EP data mapped by a bilinear geometric transformation onto T2-weighted images used as the basis of lesion, ie abnormal appearing white matter (AAWM) versus normal appearing white matter (NAWM) segmentation.
Results: In established MS transcallosal bands in some cases involved a substantial fraction of the midline callosum on T2W imaging. Abnormal increased MD was detected in both the NAWM (mean, 95% CI) (0.93, 0.84-1.02) and AAWM fractions (1.24, 0.91- 1.57). These abnormalities corresponded to abnormal decreased FA in NAWM (0.70, 0.65-0.75) and AAWM 0.56, 0.48-0.65) fractions.
Conclusions: This pilot data suggests that the diffusion tensor derived MD and FA measures are sensitive to pathology in the NAWM in MS in the corpus callosum suggesting the possibility of several classes or degrees of abnormal tissue, some potentially the result of secondary tract degeneration. The corpus callosum provides a volume of relatively homogeneous white matter well-suited for the detailed study of tract degeneration in early MS.
Disclosure: J Simon has nothing to disclose.
Funding: Supported by National MS Society(RG 3307-A-1).
Stoliarov Ia, Ilves Aa, Prakhova La, Kataeva Ga, Totolian Nb
aInstitute of Human Brain, St.Petersburg, Russian Federation; bState Medical University, St.Petersburg, Russian Federation
Background: GA is an approved treatment for the relapsing-remitting form of MS (RRMS). However, the mechanisms of action of GA are incompletely understood and effects of GA on metabolic processes at the grey matter are unknown. MR imaging is currently the technique of choice for evaluating structural brain lesions in patients with MS. Positron emission tomography (PET) unlike MRI assesses real biochemical and physiological process in the cortex and subcortical brain structures in vivo.
Objectives: To evaluate the effect of one year treatment with GA on regional cerebral metabolic rate of glucose (rCMRglu) in RRMS patients.
Methods: 17 RRMS patients were studied with FDG-PET at baseline and after one year of treatment with GA. A groupof 9 untreated RRMS patients and 13 healthy volunteers served as controls. All patients were assessed using the Expanded Disability Status Score (EDSS) and Functional Systems (FS) Score. RCMRglu differences were evaluated by Mann-Witney U-statistics, and the relationships between PET and clinical data - with Spearman’s rank correlation coefficients.
Results: Significant reduction of rCMRglu in both patients’ group was found in the frontal cortex (Brodmann areas 44,45,9,8) and supramarginal gyrus of the left hemisphere (p<0.01). Negative correlations between FS2 and glucose metabolism were found for the right and left cerebellar hemisphere (r = -0.51, p<0.01). After 12 months the GA treatment group showed substantial stability of rCMRglu. By contrast, the control group demonstrated progressive decline on FDG-PET.
Conclusions: Our results suggest that in addition to axonal injuring, MS patients suffer from grey matter metabolic alterations that are at least partially reversible with GA therapy. Further investigation is warranted to determine the value of cerebral metabolism measured by FDG-PET as an objective marker for monitoring disease activity and to provide prognostic information.
Disclosure: I Stoliarov has nothing to disclose.
Immunology (Part 1)
Altintas Aa, Demir Gb, Siva Aa
aNeurology, Istanbul University, Cerrahpasa School of Medicine, Istanbul, Turkey; bOncology, Istanbul University, Cerrahpasa School of Medicine, Istanbul, Turkey
Background: Mitoxantrone is anthracenedione antineoplastic agent that intercalates with DNA and is a potent inhibitor of both DNA and RNA synthesis. In multiple sclerosis (MS), mitoxantrone treatment has been used largely to downregulate the immune response non-specifically. The immunosupressive function of mitoxantrone is diverse, with selective effects on various cellular components and functions of the immune system. In vivo and in vitro studies show that mitoxantrone reduces T cell numbers and suppresses humoral immunity.
Objectives: Our objective was to report the early changes in immune cell counts following mitoxantrone treatment in severely progressive MS patients.
Methods: In our study, four relapsing progressive and two secondary progressive MS cases not responding to other treatments ( IV methylprednisolone, interferons, plasma exchange, IV immunoglobulin or azathioprine) were included. Before enrollment, patients underwent a general medical history, physical and neurologic examination. Screening blood tests, urinalysis, cardiac tests were performed. The mean age of the patients was 36.6 years (range: 23-61), mean duration of the disease was 13 years (range: 4-30) and mean EDSS was 5.7 (range: 4.0-6.5). According to our protocol, most of the patients were treated in the Oncology outpatient clinic. Blood samples were withdrawn immediately before first and second mitoxantrone infusions (12 mg/m2). The interval between two infusions was 4-8 weeks. Peripheral immune typing including white blood cell, lymphocyte, monocyte, CD4, CD8, CD3, CD2, CD19, CD16, CD4/CD45RA, CD4/CD45RO was done by using flow cytometry.
Results: While total lymphocyte and CD4 count did not show any prominent change, CD8, CD3, CD16, CD4/CD45RA and CD4/CD45RO cell counts showed a tendency to decrease after a single IVmitoxantrone infusion.
Conclusions: Our preliminary study is limited. Detailed longitudinal immunologic studies could be helpful to understand better the mechanism of action of mitoxantrone in MS patients.
Disclosure: A Altintas has nothing to disclose.
Belniak E, Bartosik-Psujek H, Mitosek-Szewczyk K, Stelmasiak Z
Neurology, Medical School, Lublin, Poland
Background: Multiple sclerosis is a chronic, autoimmune, demyelinating disease of central nervous system. The pathological process underlying MS involve dysregulation of the immune system and it is predominantly T cellmediated immune disorder.
Objectives: The aim of our study was evaluation of some select T-cells subpopulations: CD4, CD8, CD45RO and CD45RA cells in patients with MS treated with INF b 1a (30µg im once a week). Methods: We investigated 15 patients (6 men and 9 women aged 32,3 ±8,4) with RRMS. Peripheral blood samples were collected before therapy and after 9 and 24 months after therapy initiation. Expression of C4, CD8, CD45RO and CD45RA were evaluated by flow cytometry method. Comparisons were made with 20 control patients matched in age.
Methods: We investigated 15 patients (6 men and 9 women aged 32,3 ±(8,4) with RRMS. Peripheral blood samples were collected before therapy and after 9 and 24 months after therapy initiation. Expression of C4, CD8, CD45RO and CD45RA were evaluated by flow cytometry method. Comparisons were made with 20 control patients matched in age.
Results: Compared to the controls the MS patients showed statistically significant (p<0,01) lower expression of CD8, higher (p<0,001) expression of memory cells (CD4+45RO+) and they had statistically significant higher (p<0,001) index CD4/CD8). Expression of CD4+45RO+ cells increased after 9 months and was still increased after 24 months after therapy initiation. Compared to controls expression of CD4+45RA+ cells didn’t differed and it didn’t show any significant fluctuations during therapy.
Conclusions: Our findings suggest that after 24 months of INF b 1a therapy there are no normalisation of CD8 and CD4+45RO+ cells disturbances in MS patients.
Disclosure: E Belniak has nothing to disclose.
Funding: Drug supply supported by Schering Plough Disclosure:
Ewa Belniak has nothing to disclose.
Cepok S, Zhou D, Vogel F, Sommer N, Hemmer B
Department of Neurology, University of Marburg, Marburg, Hesse, Germany
Background: Multiple sclerosis is a chronic inflammatory and demyelinating disease of the central nervous system. Although the aetiology of MS is still unknown, it is widely believed that T cells play a central role in its pathogenesis. Recent studies demonstrated oligoclonal expansion of CD8+ T cells in MS lesions and cerebrospinal fluid of MS patients.
Objectives: To identify and follow disease associated CD8+ T cells in the peripheral blood of multiple sclerosis patients. To correlate their frequency in the peripheral blood with clinical disease parameters.
Methods: We determined clonal expansion on CD8+ CSF T cells in 6 patients. Blood samples of these patients were analyzed for T-cell receptor V-beta chain expression on CD8+ memory T cells monthly over a period of at least 1 year. Quantitative rtPCR was performed to follow CD8+ CSF clonotypes in the blood of three patients over time. All patients were monitored for clinical disease activity.
Results: Using flow cytometry for T-cell receptor V-beta chain expression and clone-specific rtPCR we demonstrate the occurrence and persistence of the CNS expanded clonotypes in the peripheral blood of several patients. CSF accumulated T cells were found at higher frequency in the peripheral blood during and after acute relapses.
Conclusions: Our findings support the role of CD8+ T cells in the pathogenesis of MS and favour the idea of an ongoing immune response in the peripheral lymphoid system of MS patients. Further studies are aimed to (a) address the antigen specificity of the clonotypes and (b) correlate the clonotype frequency in the peripheral blood with disease activity in a larger group of patients.
Disclosure: B Hemmer has nothing to disclose.
Funding: Deutsche Forschungsgemeinschaft.
Hooper DC, Spitsin SV, Scott GS
Microbiology and Immunology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
Background: Lesions in the CNS tissues of patients with multiple sclerosis (MS) and animals with either experimental allergic encephalomyelitis (EAE) or neurotrophic virus-induced CNS inflammation often contain evidence of peroxynitrite formation. In these diverse animal models of neuroinflammation, inactivation of peroxynitrite-decomposition radicals with urate inhibits not only peroxynitrite-mediated damage but also inflammatory cell accumulation in CNS tissues. This is especially noteworthy as MS patients generally have serum urate levels that are lower than normal.
Objectives: The aim of this study is to use urate as a probe to elucidate peroxynitrite-dependent effects on processes that facilitate inflammatory cell invasion into the CNS.
Methods: The effects of urate treatment on blood-brain barrier (BBB) integrity, adhesion molecule and proinflammatory cytokine expression in the CNS tissues of mice with EAE were assessed as changes in these parameters have been associated with CNS inflammation.
Results: Urate treatment prior to the onset of CNS inflammation inhibited BBB permeability changes as well as the upregulation of ICAM-1 and TNF-a expression in CNS tissues. The therapeutic effects of similar treatment of animals with ongoing EAE were also associated with restoration of BBB integrity. In no case were inhibitory effects on peripheral immune functions, including the activation of monocytes to produce peroxynitrite, detected.
Conclusions: Invasion of inflammatory cells from the periphery into CNS tissues is promoted by peroxynitrite-dependent changes in BBB permeability mediated, at least in part, by matrix metalloproteinase activity. Other processes central to CNS inflammation, such as ICAM-1 upregulation and TNF-a expression in CNS tissues, are evidently dependent on these initial peroxynitrite-dependent and urate sensitive permeability changes. The likelihood that similar mechanisms contribute to the pathogenesis of MS is Supported by recent evidence that serum urate levels in relapsing-remitting MS patients are inversely correlated with disease activity and BBB dysfunction. This suggests that elevation of urate levels in MS patients may have therapeutic benefit.
Disclosure: D Hooper has nothing to disclose.
Funding: Supported by the National Multiple Sclerosis Society
and by a grant from the Commonwealth of Pennsylvania to the Biotechnology
Foundation Laboratories.
Killestein Ja, Hintzen Rb, Uitdehaag Ba, van Lier Rc, Polman Ca
aNeurology, VU Medical Center, Amsterdam, NL, Netherlands; bNeurology, EMCR, Rotterdam, NL, Netherlands; cExperimental immunology, AMC, Amsterdam, NL, Netherlands
Background: Measuring proliferative responses of T lymphocytes in whole blood is a simple, reproducible and widely used assay of immune competence. Evidence suggests a role of T-cell reactivity in several infectious and autoimmune diseases.
Objectives: We aimed to compare proliferative T-cell responses in the different clinical subgroups of MS. In addition, it was assessed whether this assay could serve as a predictor of clinical responsiveness to immunomodulatory therapy with Beta-interferon(IFN).
Methods: Proliferative responses of T lymphocytes were measured in whole blood of 189 MS patients (65 RR, 70 SP and 54 PPMS) and 249 healthy controls (HC). Forty-eight relapse-onset patients started treatment with IFN. Based on EDSS progression and number of relapses and steroid interventions in 2 years before initiation of treatment compared to 2 years under treatment, patients were classified as either clinical responder or non-responder to IFN.
Results: T-cell proliferation in samples from both relapse-onset and PPMS patients was increased compared to HC. Furthermore, the proliferative response of whole blood T lymphocytes to phytohaemagglutinin (PHA), correctly predicted 83% of the clinical responders and non-reponders to IFN.
Conclusions: Compared to HC, MS patients show increased peripheral blood T-cell reactivity. The level of T-cell proliferation was related to the likelihood of a favorable response to IFN. If these findings are confirmed, baseline proliferative T-cell responses to PHA stimulation have the potential to become a clinically useful prognostic marker for responsiveness to IFN therapy in MS.
Disclosure: J Killestein has nothing to disclose.
Kraus Ja,b, Ling AKa, Hamm Sa, Kim KSc, Voigt Kb, Oschmann Pb, Engelhardt Bd
aVascular Cell Biology, Max-Planck Institute, Bad Nauheim, Hesse, Germany; bNeuology, Justus-Liebig University, Giessen, Hesse, Germany; cInfectious Diseases, John Hopkins University School of Medicine, Baltimore, Maryland, USA; dVascular Biology, Max-Planck Institute, Muenster, Westfalia, Germany
Background: BBB breakdown is an early event in the pathogenesis of inflammatory CNS diseases like MS or its animal model EAE. Besides clinical benefits, serial MRI scans from interferon-b (IFN-b) treated MS patients show a reduction of Gadolinium-enhancing lesions. This indicates an IFN-b associated stabilization of the BBB in these patients.
Objectives: To test the influence of IFN-b on the paracellular permeability in anin vitro BBB model.
Methods: We applied a co-culture BBB model consisting of bovine brain capillary endothelial cells (BBCEC) and rat astrocytes. In this model, we investigated the influence of human recombinant IFN-b on the paracellular permeability for 3H-inulin and 14C-sucrose in different conditions. Furthermore, we assessed the paracellular permeability for 3H-inulin and 14C-sucrose in immortalized cell lines (human brain microvascular endothelial cells [HBMEC], murine brain endotheliomas [b.End 5]).
Results: In thein vitro BBB model, co-culture of BBCEC and astrocytes leads to the induction of a barrier, whereas removal of astrocytes results in a breakdown of this permeability barrier function. However, addition of IFN-b to thein vitro BBB model maintains the barrier even in the absence of astrocytes. In the HBMEC and b.End 5 systems, pre-incubation with IFN-b significantly ameliorated the increase in the paracellular permeability after histamine challenge.
Conclusions: In ourin vitro BBB model, application of IFN-b prevents the breakdown of the permeability barrier. However, the molecular mechanisms of IFN-b induced BBB stabilization remain to be investigated.
Disclosure: J Kraus has nothing to disclose.
Carvalho Ac, Liem AMa, Santos CCc, Sant’Anna Gc, Frugulhetti Ic, Leon SVa,b, Quirico-Santos Tc
aNeurology, Hospital Universitário Clementino Fraga Filho - UFRJ, Rio de Janeiro, Rio de Janeiro, Brazil; bNeurology, Universidade do Rio de Janeiro; cDepartment of Cellular and Molecular Biology, Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
Background: Multiple sclerosis (MS) is a chronic inflammatory disease of the human central nervous system characterized by demyelination and pronounced B-cell responses to myelin components MBP and proteolipid (PLP). Susceptibility to MS is associated with class II allele expression that confers preferential binding to specific immunodominant myelin epitopes.
Objectives: To determine IgA and IgG antibodies to myelin epitopes associated to HLA class II alleles.
Methods: We determined by ELISA, the levels of IgG and IgA antibodies to myelin epitopes associated to the following alleles DR*1501 (MBP 86-95 and PLP 95-116); DR*0401 (MBP 89-98), DR*0301 (MBP 90-98) and MBP 86-98. It was included 34 patients with clinically definite MS and 59 age-matched healthy individuals. Genomic analysis was performed by amplification of DNA isolated from peripheral leukocytes using PCR followed by SSOP hybridization.
Results: MS patients showed strong (p< 0.001) association with DQA1*0102 and DQB1*0602. Regardless stage of the disease MS patients showed a marked specific oligoclonal IgG production to MBP and PLP fragments. Yet, higher IgA levels was observed for MBP 86-98 sequence with promiscuous overlapping 20 aminoacids which encompass the binding frame recognized by DR molecules *1501,*0401,*0301 and PLP 95-116 with DRB1*1501.
Conclusions: Since MS patients showed low frequency of DRB1*1501 and DRB1*1503 expression, the results suggest that epitope specificity of B cell response to MBP and PLP in this MS population may be influenced by immune recognition associated to DRB1*0401, DRB1*0301 in association with DQB1*0602 and DQA1*0102.
Disclosure: S Leon has nothing to disclose.
Funding: Supported by CNPQ,CAPES (Brazilian Research Foundation).
Lochmanova Aa, Dolezil Db, Zapletalova Ob, Hradilek Pb
aImmunology, Regional Institute of Hygiene, Ostrava, Czech Republic; bNeurological Clinic, University Hospital, Ostrava, Czech Republic
Background: Multiple sclerosis (MS) is considered to be a T-cell mediated autoimmune disease with various degrees of myelin and axonal damage in the central nervous system (CNS). The expansion of autoreactive T cells targeting the CNS is essential element in inflammatory demyelinisation.The disease is primarily mediated by T cells that secrete the inflammatory cytokines IL-2 and IFN-g referred as Thl cells. The therapies which decrease T cells producing IFN-g or increase IL-4 production would be expected to have an ameliorating effect on MS.
Objectives: Corticoids and immunosuppression remain the main therapy of MS. More subtle strategies of immunomodulation such as the use of interferonb (IFN-b) and glatirameracetate in the treatment of MS are well accepted.
Methods: In order to better understand the mechanism of action of IFN-b and glatirameracetate 14 MS patients treated with these drugs were studied. The number of CD3, CD4, CD8, Tcells, CD19 B and NK cells, CD4CD45RA, CD4CD45RO cells and secretion patterns of IFN-g and IL-4 examined before starting the therapy and in month 1,3,6 and 12.
Results: We did not find any significant changes in the number of T, B and NK cells. IFN-g secretion after the treatment both with IFN-b and glatirameracetate was reduced. IFN-g secreting cells and decline kinetics fluctuated a lot among patients. No change in the frequency of IL-4 secreting cells was seen.The high number of IFN-g producing cells accompanied with slight decline during the therapy was observed in patients with high number of memory CD4CD45RO cells.
Conclusions: The study demonstrates that both IFN-b and glatirameracetate can induce variations in cytokine secretion levels and it also stresses the role played by TH1 cells in the ethiopathogenesis of MS.
Disclosure: A Lochmanova has nothing to disclose.
Lyons Ja, Yeager Ma, Luecking La, Wang Qa, Porcelli Sb, Trotter Ja
aNeurology, Washington University, Saint Louis, Missouri, USA; bMicrobiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
Background: CD1 expression by antigen presenting cells has been recognized for years. Recent data has demonstrated CD1 molecules are capable of presenting lipid antigens to T cells. Autoreactive T cells specific for CNS myelin are thought to mediate MS pathology, and CNS myelin is 70% lipid.
Objectives: The role of CD1, particularly CD1c, in relapsing/remitting MS (RRMS) was investigated. The phenotype of CD1c-expressing cells isolated from the peripheral blood over the course of RRMS was characterized and compared to healthy controls. Also investigated was the CD1-restricted response to myelin lipids of peripheral blood mononuclear cells (PBMC) isolated from MS patients and healthy controls.
Methods: Heparinized whole blood was collected by venipuncture. PBMC were isoloated by Ficoll density gradient centrifugation. When necessary, monocytes/macrophages and T cells were purified from gradient-purified cells by magnetic cell separation. The phenotype of CD1c-expressing cells was characterized by flow cytometry. The lymphocyte response to myelin lipids was characterized by ELISA, ELISpot, and proliferation assays.
Results: Flow cytometry of PBMC revealed changes in the phenotype of CD1c-expressing cells during RRMS. In patients experiencing a clinical relapse, a decrease in CD1c+ CD19+ B cells as compared to normal controls and stable MS patients was observed. This was accompanied by a relative increase in CD1c+ CD4+ cells. Flow cytometry revealed this population to be CD1c+ CD4+ CD11c+ monocytes/macrophages. In vitro assays of reactivity to galactocerebroside, sulfatide and total CNS myelin lipids by PBMC isolated from MS patients and normal controls revealed myelin lipid-reactive T cells in both populations, with a higher precursor frequency detected in MS patients. Assays performed with CD1-transfected HeLa cells demonstrated that at least a portion of this response was restricted to CD1 molecules.
Conclusions: CD1-mediated presentation of myelin lipids may be important to MS pathology.
Disclosure: J Lyons has nothing to disclose.
Funding: Supported by National Multiple Sclerosis Society USA,
(RG-3032-A-7).
Muraro PA, Wandinger K, Bielekova B, McFarland HF, Martin R
Neuroimmunology Branch, National Institutes of Health, Bethesda, Maryland, USA
Background: Current evidence suggests that T cell responses to myelin antigens such as myelin basic protein (MBP) may be important in the pathogenesis of MS. However, the kinetics of frequency of MBP-specific T cell clones during the course of disease, particularly during clinical exacerbations, is still poorly understood.
Objectives: Our goal was to track candidate pathogenic MBP-specific T cell clones in patients with relapsing-remitting MS and assess a potential relationship of their frequency with the course of disease.
Methods: We developed a highly specific and sensitive technique to measure the frequency of single T cell clones by real-time PCR quantification of clonal T cell receptor (TCR) CDR3 transcripts. We used this novel method to track in a patient with MS a CD4+ T helper 1 clone, P2-10, that recognized the immunodominant myelin epitope MBP(83-99) with high functional avidity. We measured the clonal frequency in PBMC obtained before and during a clinical trial with an altered peptide ligand of MBP(83-99). As controls, we tracked the frequency of other antigen-specific T cell clones in PBMC from a healthy donor and from patients with other neurological disorders.
Results: The frequency of T cell clone P2-10 in PBMC increased 5-fold compared to baseline at one week before the clinical onset of a severe exacerbation, reaching an absolute frequency of 1 cell in ~1,800 PBMC. Clonal frequency had already decreased at baseline levels on the day of onset of new clinical symptoms, when brain MRI showed a sharp increase in the number of contrastenhancing lesions. In contrast, tracking of control T cell clones in peripheral blood from a healthy subject and from a patient with HAM/TSP showed very stable clonal frequencies over time.
Conclusions: The dynamics of frequency of an autoreactive Th1 clone in a clinical relapse of MS closely resembled the kinetics of encephalitogenic T cells in animal models, that reach their highest frequency before the onset of disease and rapidly decrease in the peripheral compartments following massive migration into the CNS. These data suggest that significant increases of the frequency of autoreactive effector T cells in MS might be only detectable during a short period of time preceding clinical exacerbations.
Disclosure: P Muraro has nothing to disclose.
Demir Acar Ga, ´ Ydiman Fa, ´ Ydiman Ea, K?rkal? Gb, Çakmakç? Hc, Özakbas Sa
aDept. of Neurology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey; bBiochemistry, Dokuz Eylül University School of Medicine, ´ Yzmir, ´ Yzmir, Turkey; cRadiology, Dokuz Eylül University School of Medicine, ´ Yzmir, ´ Yzmir, Turkey
Background: Multiple sclerosis (MS) is an autoimmune disease which is the most common cause of morbidity in young adults. Toxic damage on myelin, oligodendroglia and axon is a result of increased concentration of cytokines, chemokines as well as nitric oxide (NO). Although NO is an important mediator/ messenger molecule of immune system which acts neuroprotective under physiologic conditions, when secreted in high amounts in autoimmune diseases NO acts as a neurotoxic molecule. There are several studies reporting that NO metabolites are produced in high amounts in cerebrospinal fluid during relapse of MS opatients.
Objectives: In this study we aimed to investigate if NO metabolites are markers of disease activity and whether they are correlated with active lesion existence in cranial magnetic resonanve imaging (MRI) and increased immunglobulin (Ig) G index.
Methods: Twenty-four (15 female, 9 male) definite MS patients and 18 (10 female, 8 male) healthy control subjects were included in the study.serum and CSF samples were obtained from MS patients during relapse and remission without receiving any kind of treatment following cranial MRI with triple dose gadolinium. Griess reaction which is a spectrophotometric method was used for nitrite and nitrate measurements.
Results: Nitrite and nitrate levels (NNLs) measured in CSF was 11,6+/-8,60 micromol/ml during relapse, 6,72+/-3,50 micromol/mol during remission; in serum 12,89+/-7,62 micromol/ml during relapse and 12,35+/-6,62 micromol/ ml during remission. In healthy subjects NNL measurements in serum and CSF were 4,37+/-1,63 micromol/ml and 7,42+/-2,81 micromol/ml, respectively. Non-parametric Wilcoxon test was used for statistical analysis.
Conclusions: Nitrite and nitrate levels during relapse period were very significantly higher than remission period and also healthy subjects (p=0,000).There was no significant difference in serum NNLs between relapse and remission. As a result nitrite and nitrate measurement test is a highly specific (94 %) marker of the disease, however it’s sensitivity is mild (62,5 %). Increased NNLs are also significantly correlated with active lesion existence in cranial MRI and increased IgG index (p<0,05).
Disclosure: S Özakbas has nothing to disclose.
Pelfrey CM, Moldovan IR, Cotleur AC, Born SE, Karafa M, Lee J, Fisher E, Rudick RA
Cleveland Clinic Foundation, Cleveland, Ohio, USA
Background: Myelin-specific immune responses can be found in both MS patients and healthy controls. Consequently, the relevance of these immune responses to MS disease progression is not clear. Few studies have examined which features of the immune response to myelin relate specifically to MS disease progression over time.
Objectives: To examine longitudinal cytokine responses to myelin antigens in MS patients and healthy controls in order to understand the role of persistence and spreading of immune responses in disease progression.
Methods: We performed a 1 yr longitudinal study measuring cytokine responses every 3 mo in 20 relapsing-remitting MS patients and 27 age/gender matched controls. We determined ex-vivo IFN-g and IL-10 production by PBMC in response to 9-mer overlapping peptides that span the entire PLP and MBP molecules. At each time-point, we obtained the number and location of epitopes that induced cytokine responses, the magnitude of the response, and if there was preferential induction of IFN-g or IL-10. We examined possible correlations between cytokine expression patterns and clinical/MRI parameters.
Results: At baseline, MS patients had significantly higher PLP-induced IL-10 responses and MBP-induced IFNg responses, compared with controls (p = 0.019 and 0.02, respectively). MS patients showed a significant negative correlation between both PLP- and MBP-IFNg responses and clinical disability (as measured by the MS Functional Composite, MSFC)(p = 0.01 and p = 0.004, respectively). No correlation was observed in controls. HLA DR17 (DRB1*0301) expression was associated with significantly elevated MBP- and PLP-induced cytokine secretion. Persistent PLP responses (present at more than one time-point) were associated with MS-associated HLA alleles DR4, DR15, and DR17.
Conclusions: Our results suggest that clinical disability correlates with IFNg responses. For certain myelin antigens/cytokines, we can observe significant differences between MS patients and Controls using the ELISPOT assay. These findings suggest that persistent cytokine responses to the same myelin epitopes over time may distinguish MS patients’ responses from controls. This is a ongoing study that will include several more longitudinal time-points with corresponding clinical and MRI data.
Disclosure: C Pelfrey has nothing to disclose.
Funding: Supported by National Multiple Sclerosis Society grant
#RG3005-A-2 Supported by NIH grant #NS 38667-02.
Roed Ha, Olsen Da, Langkilde Ab, Frederiksen Ja, Sellebjerg Fa
aNeurology, university hospital Glostrup Denmark, Glostrup, Denmark; bUniversity hospital of Hvidovre, Hvidovre, Europe, Denmark
Background: Fatigue is a common and often incapacitating symptom in multiple sclerosis. No clear correlation with markers of inflammation or MRI lesions has yet been established.
Objectives: We hypothesized that relationships between fatigue, inflammation or MRI disease activity would be most apparant at onset of disease, and studied these variables in a series of patients with clinically isolated optic neuritis (ON).
Methods: We studied 40 patients with ON, 25 patients with secondary progressive MS (SPMS) and 20 healthy controls. Fatigue was measured by the fatigue severity scale FSS, and a FSS score of 5 or more was considered abnormal. ON patients underwent lumbar puncture and MRI studies. MRI studies comprised T2-weighed sequenses and T1-weighed sequenses before and after the administration of Gd-DTPA. T cell activation in blood and CSF was measured by studying T cells expression of CCR2, CCR5, CD25, CD26, CD122, CD154, CXCR3, and HLA-DR by flow cytometry
Results: FSS scores of 5 or more were observed in 40% of patients with ON (n=40), 68% of patients with SPMS and 0% of healthy controls (n=20: p<0,001 compared to ON and SPMS). FSS scores did not differ significantly in ON and SPMS. In ON there was no correlation between FSS scores and the number of lesions on T2-weighed MRI or the number of Gd-enhancing lesions. Neither did FSS scores correlate with the CSF leukocyte count, The IgG index of T cell activation on CSF or blood as assessed by flow cytometry studies.
Conclusions: Fatigue is signifikantly more frequent in patients presenting with ON than in healthy controls and is not signifikantly less common than in patients with SPMS. However even in this patient group we found no evidence of an assotiation between fatigue, inflammation or even the precence of MRI lesions in patients with ON.
Disclosure: The study was funded by unrestricted research grants by the danish multiple sclerosis society, Biogen, Serono and Schering
Funding: Supported by unrestricted researchgrants from the danish
multiple sclerosis socity biogen serono Schering.
Sharief MK, Noori MA
Dept of Neuroimmunology, GKT School of Medicine, London, UK, United Kingdom
Background: There is emerging evidence that failure of apoptosis (programmed cell death) of potentially pathogenic T lymphocytes may be involved in the pathogenesis of multiple sclerosis (MS). The commitment of T lymphocytes to die is partly regulated by the Bcl-2 family proteins, which act as a checkpoint upstream of mitochondrial dysfunction. These proteins include the death antagonists Bcl-2 and Bcl-XL, and death agonists Bax and Bad. Recent studies suggest that altered expression of Bcl-2 family proteins in T lymphocytes is involved in promoting cellular resistance to apoptosis in patients with MS.
Objectives: In this study we examined the relationshipbetween alterations in Bcl-2 family proteins expression and clinical disease activity in patients with MS.
Methods: We analyzed the expression ratios of pro-apoptosis (Bax and Bad) to anti-apoptosis (Bcl-2 and Bcl-XL) proteins in peripheral T cells from patients with clinically active MS and compared the results with corresponding ratios in patients with stable MS and relevant control groups.
Results: We observed a significant reduction in the expression ratios of pro- to anti-apoptosis Bcl-2 members in peripheral lymphocytes from patients with active MS when compared to corresponding ratios in patients with stable MS or other controls. This imbalance in the cellular expression ratios of pro- and antiapoptosis proteins was functionally active in reducing cellular susceptibility to apoptosis in active MS. It also correlated with clinical features of disease activity, such as the number of gadolinium enhancing MRI lesions and clinical relapses.
Conclusions: Our findings indicate that dysregulated expression of Bcl-2 family proteins in peripheral lymphocytes is a feature of clinically active multiple sclerosis.
Disclosure: MK Sharief has received honoraria from Serono International
MK Sharief has received honoraria from Serono International
Sharief MK, Seidi OA
Dept of Neuroimmunology, GKT School of Medicine, London, UK, United Kingdom
Background: The pathogenesis of multiple sclerosis (MS) is thought to involve T and B lymphocyte-mediated autoimmunity. However, the mechanisms that regulate lymphocyte activity in MS are poorly understood. In normal circumstances, programmed cell death (apoptosis) contributes to the maintenance of lymphocytes homeostasis and the deletion of autoreactive cells. Cellular commitment to apoptosis is partly regulated by the cell death receptor Fas, and the anti-apoptosis proteins Bcl-2 and FLIP.
Objectives: Although there is emerging evidence that dysregulations of apoptotic pathways play a role in T cell autoimmunity in MS, the expression of apoptosis- regulatory proteins in B cells from MS patients is largely unknown. In this study, we sought to examine the expression of several apoptosis regulatory proteins in peripheral B lymphocytes from patients with MS.
Methods: In this study, we used a combination of dot-blot immunoassays and Western blotting to analyze the expression profiles of Fas, Bcl-2, and FLIP proteins in peripheral B lymphocytes from patients with relapsing remitting and progressive MS, and from appropriate controls.
Results: We observed a significant upregulation of Bcl-2 and FLIP proteins in B cells from relapsing remitting MS when compared to corresponding expression in progressive MS, or in non-inflammatory neurologic controls and healthy individuals. This cellular overexpression of Bcl-2 and FLIP proteins was not affected by treatment with interferon-b, but was also observed in B cells from patients with systemic inflammatory diseases.
Conclusions: Our findings suggest that cellular overexpression of the apoptosis-inhibitory proteins in patients with relapsing MS may promote apoptotic resistance of potentially pathogenic, autoreactive B lymphocytes and consequently, may allow for continuing autoimmune tissue destruction.
Disclosure: MK Sharief has received honoraria from Serono International
Sharief MKa, Zoukos Yb
aDept of Neuroimmunology, GKT School of Medicine, London, UK, United Kingdom; bNeurology Dept, St Thomas Hospital
Background: Treatment with interferon beta reduces clinical exacerbations in MS through several immunomodulatory mechanisms that involve the augmentation of programmed cell death (apoptosis) of peripheral T lymphocytes. The expression of survivin, a cell cycle-regulated antiapoptosis protein, is up-regulated in mitogen-stimulated T lymphocytes from patients with MS, and this expression correlates with MS disease activity.
Objectives: To evaluate the effect of interferon beta on the expression of survivin and other apoptosis regulatory molecules in peripheral T lymphocytes from patients with MS.
Methods: In a prospective, clinical and immunologic study, we evaluated the expression of survivin, Bcl-2 protein, and the death receptor Fas in mitogenstimulated T lymphocytes from 26 patients with MS, before and serially after treatment with interferon beta-1a. We also investigated the long-term effects of interferon beta-1a on cellular expression of these proteins and T-lymphocyte apoptosis in a cross-sectional study of 19 patients with MS receiving long-term interferon beta-1a therapy.
Results: Treatment with interferon beta-1a reduced the expression of survivin in in vitro stimulated T lymphocytes. This reduced expression correlated with augmented T-cell susceptibility to apoptosis and with clinical response to treatment. In contrast, interferon beta-1a therapy did not alter cellular expression of Bcl-2 protein Fas. This down-regulatory effect of interferon beta-1a on cellular expression of survivin was maintained after long-term therapy.
Conclusions: Our observations suggest that interferon beta exerts a regulatory effect on peripheral T lymphocytes through an antiapoptosis mechanism that involves the down-regulation of cellular survivin expression.
Disclosure: MK Sharief has received honoraria from Serono International
Sindern E, Patzold T, Ossege LM, Gisevius A, Malin JP
Neurology, Kliniken Bergmannsheil, Bochum, Germany
Background: There is accumulating evidence that chemokines are important in trafficking, retention and activation of T-cells in active multiple sclerosis (MS) lesions. In immunohistochemical studies of autopsy brain sections containing active MS lesions CXCR3- and interferon-ginducible protein 10- (IP-10) positive cells were found in the perivascular space around nearly all inflamed vessels within MS lesions.
Objectives: To evaluate the chemokine CXCR3 expression on T-cells and levels of its ligand IP-10 in blood and cerebrospinal fluid (CSF) of patients with relapsing remitting MS (RR-MS) in association with magnetic resonance imaging (MRI) disease activity.
Methods: 22 newly diagnosed definite RR-MS patients underwent Gdenhanced-MRI examinations and diagnostic lumbar puncture in a short time interval, ranging from 1-24 hours. Chemokine expression was measured by flow cytometry and levels of IP-10 were determined by ELISA.
Results: IP-10was strong intrathecally released, but did not change in association with MRI activity. CXCR3 positive T-cells were enriched in the CSF compared with peripheral blood and more than 75% of T-cells in the CSF expressed CXCR3 receptor (p<0,0001). CXCR3 expression was lower in the peripheral blood of RR-MS patients compared to healthy controls (p<0,005) and was increased in the CSF of RR-MS patients undergoing acute attacks, as illustrated by Gd-enhancing lesions on MRI, compared to patients without enhancing lesions (p<0,005).
Conclusions: Our results suggest that MRI documented disease activity is associated with an increase of CXCR3 positive T-cells in the CSF of patients with RR-MS, possibly due to the migration of activated T-cells from the circulation into the CSF.
Disclosure: E Sindern has nothing to disclose.
Sophie Ga, Christian Sa, Myriam Sb, Thierry Dc, H. Hd
aNeurology and Neurochemistry Laboratory, Cliniques Universitaires Saint-Luc, Brussels, Belgium; bNeurology, Centre Hospitalo-Universitaire Vaudois, Lausanne, Switzerland; cNeuroradiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium; dClinical Chemistry Laboratory, Centre Hospitalo-Universitaire Vaudois, Lausanne, Switzerland
Background: In a previous study, we reported a similar frequency in the occurrence of either CSF-specific oligoclonal free kappa or CSF-specific oligoclonal IgG (92%) in a group of 48 MS patients. In the present work, we specifically studied the presence of CSF free kappa bands in a group of 33 clinically suspected MS patients with no or only a single IgG band. CSF data were compared with the clinical characteristics and MRI scans.
Objectives: Relevance of free kappa chains in CSF.
Methods: Oligoclonal IgG and free kappa bands were determined by an immunoaffinity blot technique (1). Brain MRI was performed within one month after lumbar puncture in all patients ; spinal cord MRI was done only in case of a relevant clinical picture. Positive MRI for MS fulfilled the criteria of Barkhof et al (2) and Tintore et al (3). MS suggestive MRI displayed 2 or more lesions consistent with MS, either in the brain or in the spinal cord.
Results: Oligoclonal free kappa bands were observed in 18 cases out 33 (55%), especially in patients with motor dysfunction (5/6, 83%), optic neuritis (7/11, 64%) and sensory impairment (3/7, 43%). Positive MRI was found in 6 cases, all with oligoclonal free kappa bands. The latter were present in 7/11 (64%) patients with MS suggestive MRI, but only in 5/16 (31%) of patients with normal or aspecific MRI.
Conclusions: CSF oligoclonal free kappa bands can be substituted for CSF oligoclonal IgG when the latter are not detectable. (1) Sindic CJ, Laterre EC. - Oligoclonal free kappa and lambda bands in the cerebrospinal fluid of patients with multiple sclerosis and other neurological diseases. An immunoaffinitymediated capillary blot study. J. Neuroimmunol. 33: 63-72, 1991. (2) Barkhof F et al.- Comparison of MRI criteria at first presentation to predict conversion to clinically definite multiple sclerosis. Brain 120: 2059-2069, 1997. (3) Tintore M et al.-Isolated demyelinating syndromes: comparison of different MR imaging criteria to predict conversion to clinically definite multiple sclerosis. Am J Neuroradiol 21: 702-706,2000.
Disclosure: G Sophie has nothing to disclose.
Wiendl Ha, Neuhaus Ob, Mehling Ma, Wintterle Sa, Schreiner Ba, Weissert Ra, Weller Ma, Hartung Hc, Tolosa Ea, Melms Aa
aNeurology, Uni.Tuebingen, Tuebingen, BW, Germany; bNeurology, KFU, Graz, —, Austria; cNeurology, HHU, Düsseldorf, —, Germany
Background: ICOS is an inducible CD28-related costimulatory molecule with relevance for T cell differentiation and effector function and a possible role in autoimmune diseases like Multiple Sclerosis (MS).
Objectives: To characterize the expression and functional relevance of ICOS in healthy donors and patients with MS.
Methods: FACS staining, proliferation assays, real time PCR, ELISA
Results: After nonspecific or antigen-specific stimulation, ICOS was preferentially expressed on CD4+ Th2 T cells. Blocking experiments with antigen-specific T cell lines as well as SAg-stimulated CD4 T cells demonstrated that ICOS-costimulation affected the production of both Th1 and Th2 cytokines whereas T cell proliferation, expression of T cell activation markers or chemokine receptor expression were unaffected. Interestingly, the effects on cytokine secretion were observed in the absence or presence of B7-1/2, suggesting that ICOS costimulation modulates cytokine secrection also independently of CD28 costimulation. Levels of constitutive and inducible ICOS expression on human T cell subsets from peripheral blood were quantified in healthy donors (n=16) and MS patients (n=10). Constitutive expression of ICOS varied between 0.12 and 12.35%. No significant differences were noted between both groups concerning the constitutive expression or inducibility of ICOS on T cells. Cells constitutively expressing ICOS did not represent the CD4+/CD25+ regulatory T cell subset. ICOS expression on CSF T lymphocytes in patients with acute MS relapses or acute neuroborreliosis showed that the frequency of ICOS-positive cells was not elevated compared with peripheral blood. Whereas neither IFN-b nor glatiramer acetate altered baseline expression of ICOS on T cells, antiinflammatory cytokines such as IL-10 or TGF-b both slightly downregulated ICOS on PHA-stimulated T-cells.
Conclusions: In summary, ICOS costimulation affects both Th1 and Th2 cytokine production in the presence and absence of B7-costimulation. Since ICOS is rapidly induced on T cells after antigen-specific stimulation, this molecule qualifies as a suitable target aimed at specifically modulating T cell cytokine responses in CNS inflammation.
Disclosure: H Wiendl has nothing to disclose.
Wiendl Hb, Meuth Sa, Duyar Hb, Elbs Mc, Landgraf Pa, Weller Mb, Weissert Rb, Budde Ta
aDepartment of Neurology, Eberhard-Karls-University Tübingen, Tübingen, Baden-Würtemberg, Germany; bInstitute of Physiology, Otto-von-Guericke-University, Magdeburg, Sachsen-Anhalt, Germany; cDepartment of Cell Biology, Eberhard-Karls-University, Tübingen, Baden-Würtemberg, Germany
Background: Demyelination and inflammation both contribute to the neurological deficits characteristic of multiple sclerosis (MS). Although conduction deficits attributable to inflammatory demyelination are well known, soluble factors may also contribute to neurological dysfunction. QYNAD is a pentapeptide detected in the CSF of patients with MS that has been proposed to influence symptomatic changes or the disease course in MS by putative blockade of sodium channel action.
Objectives: To further clarify the potential relevance of QYNAD for MS, we characterized the in vitro and in vivo properties of this pentapeptide.
Methods: We performed experiments in 1) acutely isolated thalamic neurons and 2) in a model of myelin oligodendrocyte glycoprotein (MOG)-induced experimental allergic encephalomyelitis (EAE).
Results: QYNAD blocks sodium channels in acutely isolated neurons by shifting their steady-state inactivation to more negative potentials. QYNAD putatively acts via direct action at the sodium channel as demonstrated by confocal laser scanning microscopy using fluorescently labeled, bioactive QYNAD together with a type II sodium channel specific antibody. We explored the influcence of QYNAD in MOG-induced EAE in DA/OlaHsd rats. QYNAD itself was not encephalitogenic. QYNAD neither altered the onset of disease nor disease severity when given repeatedly (qid) from day 0 to 15 after MOG immunization. Furthermore QYNAD did not influence the severity or frequency of relapses when given after disease onset.
Conclusions:QYNADspecifically blocks neuronal sodium channel action with a limiting concentration at 10 microM. Taking into consideration published values on CSF QYNAD concentrations in MS (9 to 34 microM), our in vitro and in vivo experiments make a correlation of QYNAD concentrations with the clinical status unlikely. Although QYNAD might still be a contributing factor causing rapidly waxing and waning symptoms in MS, a role for permanent axonal damage and thus relevance for overall disease severity in MS is not Supported by this work.
Disclosure: H Wiendl has nothing to disclose.
Experimental Allergic Encephalomyelitis (Part 1)
Marracci Ga,b, Jones Ra,b, McKeon Ga, Winter Ra,d, Riscoe Ma,c, Bourdette Da,b
aPortland VAMC, Portland, Oregon, USA; bNeurology, Oregon Health & Science University, Portland, Oregon, USA; cBiochemistry, OHSU, Portland, Oregon, USA; dChemistry, PSU, Portland, Oregon, USA
Background: Oxygen and nitrogen free radicals are important to the pathogenesis of MS and EAE. a-lipoic acid (ALA) and its reduced form dihydrolipoic acid (DHLA) are antioxidants. ALA treated and suppressed EAE in SJL mice by inhibition of T cell trafficking into the CNS and directly inhibited matrix metalloproteinase-9 (MMP-9) activity (manuscript submitted). As MMP-9 facilitates T lymphocyte transmigration across the subendothelial basement membrane, its inhibition may be especially relevant to the therapeutic benefit of ALA.
Objectives: To elucidate the mechanism of action of ALA in suppressing EAE.
Methods: SJL mice were immunized with PLP139-151 peptide in CFA and given daily injections of ALA, DHLA or S,S’-dimethyl lipoic acid (Me2LA) commencing on day 7 to suppress EAE. Supernatants were collected from PLP-specific T cells after 48 hours in culture with ALA, DHLA or Me2LA (10-1000µg/ml). Zymographic analyses were performed in the presence of ALA, DHLA or Me2LA (10-1000µg/ml) in buffer or buffer alone.
Results: The mean maximum EAE score and mean 10-day CDS after suppression with ALA and DHLA were reduced significantly (p=0.01 and 0.02, respectively) below those of saline, while Me2LA did not suppress EAE. Zymographic analyses revealed direct, dose dependent suppression of MMP-9 activity by ALA and DHLA (up to 99%), while Me2LA did not. DHLA was more potent than ALA in directly inhibiting MMP-9. ALA and DHLA, but not Me2LA, inhibited the production of MMP-9 in vitro by up to 94%, in a dose dependent fashion, suggesting that ALA and DHLA can indirectly suppress T cell production of MMP-9.
Conclusions: DHLA is a more potent inhibitor of MMP-9 than ALA, but has an equal ability to suppress EAE. Since ALA is rapidly reduced to DHLA in vivo, these data suggest that DHLA is the therapeutically active molecule in vivo. Me2LA, unlike DHLA, lacks free sulfhydryl groups and did not inhibit EAE or MMP-9, suggesting that DHLA functions by reducing MMP-9. ALA and DHLA are capable of indirectly inhibiting T cell production of MMP-9, perhaps by inhibiting activation of nuclear transcription factor NF-kB. ALA and DHLA appear to suppress EAE through direct and indirect inhibition of MMP-9 activity.
Disclosure: G Marracci has nothing to disclose.
Funding: Supported by NIH grant (P50AT00066). Supported by Department
of Veterans Affairs. Supported by Nancy Davis Center Without Walls.
Offen DYa, Gilgun-sherki Ya, Hodengreber Va, Panet Ha, Melamed Eb,a
aFelsenstein Medical Research Center, Tel Aviv University, Petah Tikva,Israel; bNeurology, Rabin Medical Center, Petah Tikva, Israel
Background: The accumulated experience with glatiramer acetate (GA) (COP-1) confirms its efficacy in the treatment of relapsing-remitting multiple sclerosis. Although the immune response to GA has been intensively examined, its possible effects on the axonal damage in animal models has not yet been investigated.
Objectives: To study whether treatment with GA provides a beneficial effect on central neuronal damage in chronic experimental autoimmune encephalomyelitis (EAE) induced by myelin oligodendrocyte glycoprotein (MOG).
Methods: Mice (C57/b, n=20) were injected s.c. twice with pMOG 35-55 (12.5 mg/kg x2) and GA (25 mg/kg x2 s.c.), on days 1 and 8. CNS tissue sections were examined for integrity of axons and myelin by silver and Luxol Fast Blue staining. Immunofluorescence staining with the antibodies against non phosphorylated neurofilament, SMI-32, and amyloid precursor protein (APP), were used to examine axonal damage.
Results: MOG-treated mice developed significant clinical manifestations with complete hind limb paralysis while the GA-treated mice showed only very mild and delayed clinical signs (clinical score 4.1+/-0.4 vs. 0.3+/- 0.1, p<0.001). The beneficial effect in GA-treated animals was maintained until sacrifice at 50 days following MOG injection. Multifocal areas of perivascular lymphohistiocytic inflammation with loss of myelin were shown in the controlmice, while only rear areas of focal inflammation were demonstrated in the GA-treated mice. Massive axonal loss and damage was found in controls, while in GA-treated mice there was only minimal damage. Moreover APP and SMI-32 immunostaining in spinal cord sections, analyzed by image-j software, indicates for high axonal injury in the control mice as compared to undamaged axons in GA-treated mice.
Conclusions: Our study suggests that GA may provide neuroprotective effects attenuating the induced axonal damage in a chronic EAE model.
Disclosure: D Offen has nothing to disclose.
Funding: Supported in part by Teva Pharmaceutical Industries
Piccio La,b, Scarpini Ea, Rossi Bb, Ciabini Db, D’Ambrosio Dc, Ottoboni Lb, Go Ac, Homeister JWd, Lowe JBd, Constantin Gb
aDept Neurological Sciences, Ospedale Maggiore Policlinico, Milano, Italy; bDept of General Pathology, University of Verona, Verona, Italy; cBioxell, DIBIT, Milano, Italy; dDept of Patholgy, University of Michigan, Ann Arbor, Michigan, USA
Background: Lymphocyte recruitment into the central nervous system is a critical event in the pathogenesis of multiple sclerosis and experimental autoimmune encephalomyelitis (EAE). Alpha(1,3) fucosyltrasferases (FucT) catalyze glycosylation of glycans that ligate endothelial E- and P-selectin and are responsible for leukocyte recruitment to inflammatory sites. Recent evidences suggest that downregulation of FucT activity may represent an attractive target for therapeutic intervention aimed at blockade of chronic inflammatory diseases.
Objectives: The goal of this study was to determine the effect of different FucT deficiency on lymphocyte recruitment in brain venules and on the induction of EAE.
Methods: FucT-deficient mice (FucT-/-) for FucT-IV, FucT-VII and double deficient mice for FucT-IV&FucT-VII were generated on C57Bl/6 genetic background. Intravital microscopy studies were performed in inflamed brain vessels. EAE was induced in wt or FucTs deficient mice by using MOG35-55 peptide.
Results: Th1 lymphocytes produced from FucT-IV-/- mice efficiently tethered and rolled in brain postcapillary venules when compared with cells isolated from wt mice. In contrast, primary adhesion of Th1 lymphocytes obtained from FucT-VII-/- or Fuc-VII-/- & FucT-IV-/- mice was drastically reduced, suggesting that FucTVII is critical for the recruitment of Th1 cells in brain microcirculation. The onset of actively-induced EAE in Fuc-VII-/-, but not FucT-IV-/-, mice was delayed. Disease was significantly inhibited in Fuc-VII-/- & FucT-IV-/- mice when compared with wt mice. Immunohistochemistry studies revealed interesting differences in the composition of the inflammatory infiltrates between wt mice and FucT-/- mice.
Conclusions: Our data unveil a critical role for FucT-VII in the recruitment of Th1 lymphocytes in brain venules, and suggest that FucT-VII together FucTIV play a significant role in the pathogenesis of EAE.
Disclosure: L Piccio has nothing to disclose. Posters S56 Multiple
Sclerosis
Puerta C, Sánchez A, Baranda P, Ortiz P, Garcia-Merino A
Neuroimmunology Unit, Clinica Puerta de Hierro, Madrid, Spain
Background: Experimental allergic encephalomyelitis (EAE) is a useful model of multiple sclerosis (MS). Members of the NF-kB family are transcription factors involved in the regulation of proinflammatory cytokine and matrix metalloproteinase 9 (MMP-9) genes, that are closely related to the extravasation of immune cells and tissue destruction during EAE. Rolipram (a type IV phosphodiesterase inhibitor) amielorates EAE by inducing a delay in the entry of inflammatory cells into the CNS, but the precise mechanisms of this drug remain elusive.
Objectives: To investigate the expression of MMP-9 and the in vivo regulation of NF-kB activation after treatment of EAE with rolipram. To determine if rolipram can modulate NF-kB-driven promoter activity and MMP-9 enzymatic activity.
Methods: Lewis rats were immunized with guinea pig myelin basic protein, and treated daily with rolipram. MMP-9 gene expression was determined by semiquantitative RT-PCR. The activation of NF-kB was assessed by electrophoretic mobility supershift assay in cells from the lymph nodes (LNC) upon anti-CD3 engagement. Jurkat cells were transfected with the kB-pGL3-prom plasmid, which contains the NF-kB binding site of the MMP-9 gene, stimulated with PMA in the presence of rolipram and the transcriptional activity was assessed by luciferase activity. MMP-9 activity was assayed by gelatin zymography in the supernatant of MBP-reactive cells.
Results: In vivo, rolipram reduces the MMP-9 gene expression, both in LNCs and CNS, and impairs the nuclear translocation of NF-kB in lymphocytes from EAE rats. PDE-IV inhibition decreases promoter activity in a construct containing the NF-kB binding sequence of the MMP-9 gene and reduces IL-2 induced MMP-9 enzymatic activity in MBP-specific rat lymphocytes.
Conclusions: Rolipram may be an interesting agent to be used in combination with IFN-a with the purpose of better controlling the production of MMP-9, as its action on the promoter region of that gene involves a nuclear factor different from that of IFN-a
Disclosure: A Sánchez has nothing to disclose.
Funding: Supported by Fondo de Investigacion Sanitaria (98/0038),
Comunidad de Madrid (08.5/0001/97), and Fundacion Salud 2000.
Scott GS, Brimer CM, Kean RB, Hooper D
Microbiology and Immunology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
Background: The blood-brain barrier (BBB) maintains central nervous system (CNS) homeostasis. However, a breakdown of the normal function of the BBB has been demonstrated in multiple sclerosis and its animal correlate, experimental allergic encephalomyelitis (EAE). This would not only enhance factor exchange between the blood and the CNS, but could facilitate inflammatory cell infiltration into CNS tissues.
Objectives: The present study uses knockout mice lacking a variety of genes relevant to immune function to examine the relationship between BBB breakdown and the evolution of neurological disease signs following immunization with myelin oligodendrocyte glycoprotein (MOG).
Methods: Groups of mice were immunized with MOG and examined for disease signs. BBB permeability was assessed by measuring the uptake of sodium fluorescein into spinal cord tissue.
Results: Mice with targeted disruptions in the genes for IFN-ab receptors, IFN-g receptors, NF-kB and iNOS developed neurological signs of EAE which varied in incidence, onset and severity between the groups. Nevertheless, all MOG-immunized animals exhibited some degree of increased BBB permeability and, irrespective of the strain, the extent of BBB permeability directly correlated with disease signs.
Conclusions: Our results indicate that the appearance of clinical signs of EAE is critically dependent on BBB breakdown, regardless of the immunological status of the animal. BBB breakdown could not only contribute to disease development by permitting communication between the circulation and the CNS, but may also induce fluid phase shifts resulting in edema formation and neurological dysfunction.
Disclosure: G Scott has nothing to disclose.
Funding: This investigation was supported in part by the National
Multiple Sclerosis Society and by a grant from the Commonwealth of Pennsylvania
to the Biotechnology Foundation Laboratories.
Bagaeva La, Williams LPa, Segal BMa,b
aNeurology, University of Rochester, Rochester, New York, USA; bMicrobiology and Immunology, University of Rochester School of Medicine, Rochester, New York, USA
Background: The administration of neutralizing antibodies against the Th1 polarizing monokine IL-12 protects otherwise susceptible mice from clinical EAE and the development of inflammatory infiltrates in the central nervous system (CNS). Paradoxically, mice deficient in the signature Th1 cytokine, IFN gamma, remain highly susceptible to EAE; however disease is also suppressed in these animals by IL-12 blockade. Collectively these results suggested that IL-12 might stimulate myelin-reactive T cells to home to the CNS by an IFN gamma independent pathway.
Objectives: To test our hypothesis IL-12 directly stimulates myelin-reactive T cells to upregulate chemokine receptors that are critical for CNS migration.
Methods: We performed RNAse protection assays to measure the expression of a panel of chemokine receptors by lymph node cells (LN cells) that had been primed in vivo with a peptide fragment of proteolipid protein (PLP) emulsified in Incomplete Freund’s Adjuvant (IFA) and challenged in vitro with antigen either in the absence or presence of recombinant IL-12 and/ or a neutralizing antibody against IFN gamma. In parallel experiments we measured the expression of selected chemokines and chemokine receptors in spinal cords from the adoptive transfer recipients of PLP-specific T cells that were treated as described above.
Results: PLP/IFA primed LN cells only transfer EAE only following ex vivo challenge with antigen and IL-12. IL-12 directly induces expression of CCR5, but not CCR1-4 or CXCR3, by these PLP-specific T cells. Neutralization of IFN gamma does not suppress IL-12 induced CCR5 expression. The chemokines RANTES, MIP-1 alpha, MIP-1 beta and MCP-1 and their receptors CCR1, CCR2 and CCR5 are upregulated in the spinal cords of mice following the injection of IL-12 stimulated effector cells in direct association with the development of inflammatory demyelinating lesions.
Conclusions: Our findings suggest that IL-12 might promote the encephalitogencity of myelin-reactive T cells by the direct induction of CCR5.Expression of CCR5 most likely facilitates the homing of autoimmune effector cells to the CNS since its ligands are expressed in EAE lesions.
Disclosure: B Segal has nothing to disclose.
Funding: Supported by The National Institutes of Health (RO1
NS41562-1) and the National Multiple Sclerosis Society (Harry Weaver Junior
Faculty Award) to BMS.
Segal BMb, Ichikawa HTb
aNeurology, University of Rochester School of Medicine, Rochester, New York, USA; bMicrobiology and Immunology, University of Rochester School of Medicine, Rochester, New York, USA
Background: Myelin-reactive CD4+ T cells, the mediators of experimental autoimmune encephalomyelitis (EAE) and presumably of multiple sclerosis, have been detected in the normal peripheral T cell repertoire.Nonetheless, most individuals do not succumb to autoimmune disease. There is growing evidence that while peripheral APCs stimulate immune responses against foreign antigens in the setting of tissue destruction and "danger", they actually maintain tolerance against self antigens under steady state conditions. The activation state of APCs is critical in deciding an outcome of T cell priming versus tolerization.
Objectives: To test our hypothesis that tolerance against a candidate myelin autoantigen could be reversed by activation of APCs via CD40 or TLR 9 signaling.
Methods: Adult SJL mice injected i.p. with a peptide fragment of proteolipid protein (PLP) emulsified in Incomplete Freund’s Adjuvant fail to mount lymphoproliferative or cytokine responses and are protected from EAE upon subsequent challenge with the antigen combined with adjuvants. We harvested LN cells from such PLP-tolerized mice and reactivated them ex vivo in the presence of either an agonist monoclonal antibody against CD40, isotype matched rat IgG, a CpG-containing oligonulceotide (ODN) that binds TLR-9, or a control ODN.
Results: Tolerized PLP-specific CD4+ T cells regain the ability to divide, differentiate along a Th1 lineage and transfer EAE only when reactivated in the presence of agonistic antibodies against CD40 or CpG oligonucleotides. The effects of both anti-CD40 and CpG oligonucleotides are dependent upon induction of IL-12. In parallel experiments, we found that systemic injections of mice with anti-CD40 prevent tolerance induction and increase susceptibility to EAE.
Conclusions: Our findings suggest two mechanisms to explain the well documented association between infectious illnesses and flare ups of multiple sclerosis. Microbial pathogens could: (i) release molecules that bind TLRs and/ or (ii) stimulate microbe-specific T cells to upregulate CD40 ligand, thereby licensing APCs that bear both microbial and auto-antigens to break tolerance.
Disclosure: B Segal has nothing to disclose.
Funding: Supported by The National Institutes of Health (R01
NS41562-1) and the National Multiple Sclerosis Society (Harry Weaver Junior
Faculty Award) to B.M.S.
Walczak A, Szymanska B, Selmaj K
Dept. of Neurology, Medical University, Lodz, Poland
Background: Vaccination with naked DNA, has been shown by us and others, to generate protective immunity against experimental autoimmune encephalomyelitis (EAE).
Objectives: We have compared the effect of DNA vaccination with plasmids encoding different myelin proteins on the subsequent development of EAE.
Methods: Plasmid vectors, encoding proteolipid protein (pVaxPLP) and myelin oligodendrocyte glycoprotein (pVaxMOG) genes, were used for the study. We assessed the effect of DNA pre-immunization on subsequent EAE course in SJL/J mice, evoked with PLP peptide 139-151 and in C57Bl6 mice, evoked with MOG peptide 35-55. Both clinical and pathologic measures of EAE have been applied to assess the course of the disease.
Results: The EAE course, in mice pre-immunized with pVaxMOG 4 and 12 weeks prior to EAE induction, was significantly ameliorated. In contrast, in mice pre-immunized with pVaxPLP 4 weeks prior EAE induction, more severe disease was observed and only 12 weeks after DNA vaccination, the EAE course was ameliorated. Prevention of EAE was associated with a decrease in T cell proliferation in response to encephalitogenic peptides and with diminished Th1-type cytokine response in both groups of DNA preimmunized mice in comparison to EAE animals pre-immunized with empty vector (pVax).
Conclusions: These results indicate that kinetic of tolerization of EAE with DNA vaccination, involving T cell unresponsiveness, depends on antigen and/or mouse genetic background. In further studies mechanism of differences in generation of DNA-induced EAE tolerance should be evaluated.
Disclosure: A Walczak has nothing to disclose.
Weaver Aa, Pennington CJb, Nuttall Rb, Hogan Ab, Edwards DRb, Yong VWa
aNeuroscience, University of Calgary, Calgary, Alberta, Canada; bBiological Sciences, University of East Anglia, Norwich, Norfolk, United Kingdom
Background: Matrix Metalloproteinases (MMPs) are a family of at least 25 zinc-containing proteolytic enzymes that play an important physiological role in degradation of extracellular matrix (ECM). However, MMPs are also implicated pathologically in cancer and inflammatory diseases such as Multiple Sclerosis (MS). In MS and its animal model, experimental autoimmune encephalomyelitis (EAE), several groups have reported increased expression of specific MMP members (MMP-2, -3, -7, -9 and -19). Nonetheless, an extensive analysis of the involvement of other MMP members has not been conducted.
Objectives: To examine a profile of MMPs and ADAMs (a related metalloproteinase) during the course of EAE, and to use genetically deficient mice to understand the role of a highly expressed MMP.
Methods: Female 129/SvEv mice were induced with EAE using myelin oligodendrocyte glycoprotein in complete Freunds Adjuvant, producing a relapsing-remitting model of MS. Animals were sacrificed at various stages of the disease and spinal cord samples were analsyed. Taq-Man Polymerase Chain Reaction (PCR) was used to profile mRNA levels when animals had hindlimb paralysis, while RNase Protection Assay (RPA) was used to evaluate spinal cords over the course of EAE. As a result of the increase in MMP-12 that was observed, MMP-12 null mice were utilized to analyse phenotypic characteristics.
Results: The Taq-man PCR data displayed an increase in MMP-8 (20 fold), - 10 (20 fold), 14 (2 fold), -19 (5 fold) and TIMP-1 (150 fold); impressively, MMP-12 was elevated 1000 fold in EAE-afflicted mice compared to healthy animals. RPA further confirmed the dramatic increase of MMP-12 over the course of disease. ADAM-10, -15, -17 and -28 were unchanged in EAE versus controls.
Conclusions: The data demonstrate that specific MMPs, other than previously examined MMP-2, -7 and -9, need to be pursued for their involvement in EAE and MS. In particular, MMP-12 appears to be important over the course of EAE. EAE experiments in MMP-12 knock out mice are currently underway to explore the clinical phenotype. These results will lead to the further understanding of MMPs in EAE and MS and may help to resolve the issue of selective inhibition of particular MMPs.
Disclosure: A Weaver has nothing to disclose.
Neurobiology/Neurophysiology
Amina Bc, J. Da, R. Gb, B. Ob, B. Hb, T. Sa, D. Fa, P. Va
aNeurology, CHU H.MONDOR, CRETEIL, Ile de France, France; bNeurology, CHRU Lille, LILLE, Nord, France; cBiochemistry Laboratory, CHRU Lille, LILLE, Nord, France
Background: The presence of oligoclonal immunoglobulin G bands restricted to CSF is one of the most consistent laboratory abnormalities for the diagnosis of multiple sclerosis (MS).
Objectives: To confirm the diagnostic value of isoelectrofocusing (IEF) in a large cohort and to evaluate the various neurological diseases likely to present the same profile.
Methods: The cerebrospinal fluid of 1000 patients with neurological was studied by IEF. The infectious diseases without microbiological confirmation and/or not fulfilling the classically definite diagnostic criteria for the various neurological diagnoses were excluded. After a follow upof 2 to 36 months, 407 patients were diagnosed as MS and 593 patients as others neurological diseases.
Results: The best sensibility and specificity was obtained with 3 oligoclonal bands. 380 patients had oligoclonal bands including 335 with MS and 50 with others neurological diseases. Our results showed a sensitivity of 83% and a specificity of 92%. The positive and negative predictive values were 87 % and 90% respectively. Inflammatory and infectious disorders of the central nervous system represent the main affections associated with oligoclonal bands in particular Sjogren syndrome, HIV encephalitis and Lyme disease.
Conclusions: IEF of the CSF is a reliable method for the diagnosis of MS with both good sensitivity and specificity. CSF is therefore of particular interest especially after a clinical isolated syndrome.
Disclosure: B Amina has nothing to disclose.
Anlar O-, Tombul T-, Kisli M
Neurology, Yuzuncu Yil University, Medical School, Van, Turkey
Background: Peripheral nerve abnormalities are uncommon in multiple sclerosis (MS). When present, they are usually attributed to factors associated with advanced disease, such as malnutrition or cytotoxic drugs or hereditary factors. However, a combination of MS and neuropathy has been reported.
Objectives: To evaluate the combination between MS and peripheral neuropathy we studied nerve conduction velocity (NCV) in a group of MS patients and in a group of healthy subjects.
Methods: We studied sensory and motor NCV and amplitude in the ulnar, median, tibial, peroneal and sural nerves in one side, right or left, in 20 definite MS patients diagnosed according to the criteria of Poser Scale and in 15 healthy subjects. The total number of studied nerves were 91 in patients group and 69 in contol group.
Results: The most frequent electrophysiologic abnormalities noted in patients group were low amplitudes of the ulnar and sural nerves and slow conduction velocities of the tibial and sural nerves. Electrophysiologic abnormalities were found in 15 of 91 nerves examined (16.5%). The neurologic disability was not associated with the presence of electrophysiologic abnormalities. The electrophysiologic abnormalities in control group subjects were found in 2 of 69 nerves examined (2.9%). There were a slight slowness in sural nerve conduction in two healthy subjects.
Conclusions: Our findings indicate a high frequency of sensory and motor neuropathy in a selected group of MS.
Disclosure: O Anlar has nothing to disclose.
Bruno Sa,b, Sonia Bc, Julien Ac, Celine Ja, Gilles Ba, Marie-Stephane Aa, Pierre Sc, Bernard Za, Catherine La
aInserm U495, hôpital de la Salpêtrière, Paris, France; bcentre d’investigation clinique, hôpital de la Salpêtrière, Paris, France; cInserm U 109, centre Paul Broca, hôpital Sainte Anne,, Paris, France
Background: Edg-2 is a member of the Edg seven transmembrane G-protein coupled receptor family, which, to date, contains 8 members (Edg-1-Edg-8). These receptors are mainly involved in bioactive lipids signaling : Edg-1, Edg-3, Edg-5 and Edg-8 have been proposed to act as sphingosine-1-phosphate receptors, whereas lysophosphatidic acid (LPA) has been proposed as the ligand for Edg-2, Edg-4 and Edg-7.
Objectives: To assess the expression of Edg receptors in oligodendrocytes, and the biological effects of Edg-2 putative ligand, LPA.
Methods: The expression of Edg-2 receptor in oligodendrocytes was studied in vivo and in vitro.
Results: We show that both in vitro and in vivo, Edg-2 receptors are not detected during early stages of oligodendroglial development, but are expressed only in mature oligodendrocytes, shortly before the onset of myelination. We also provide evidence that other members of the Edg family are expressed in oligodendrocytes. Whereas LPAhas been reported to be a ligand of Edg-2 receptor in different cell types, it had no effect on either survival, maturation or cytoskeleton organization in oligodendroglial cultures. In myelinating oligodendrocyte-neuron co-cultures, LPA did not influence myelinogenesis. In addition, LPA failed to induce Ca2+ mobilization and had no effect on forskolin-induced cAMP accumulation. Phosphorylation of the ERK1/ERK2 MAP kinases was the only response elicited by LPA in oligodendrocytes.
Conclusions: Therefore, in contrast to other cell types, in which LPA exerts pleiotropic effects, Edg-2 positive post-mitotic oligodendrocytes display a restricted responsiveness to LPA. Nevertheless it is so far the only G proteincoupled receptor identified to date whose expression is restricted to mature oligodendrocytes and myelin in the post-natal CNS.
Disclosure: S Bruno has nothing to disclose.
Funding: Supported by INSERM (institut national de santé
et de recherche médicale) and ARSEP association de recherche sur
la sclérose en plaques).
de Andres de Frutos Ca, Lopez Esteban Pb, Peraita Adrados Rb
aNeurology, Hospital general Gregorio Marañon, Madrid, Spain; bSleep and Epilepsy Unit, Hospital general Gregorio Marañon, Madrid, Spain
Background: The sleep disorders in MS are not well-known
Objectives: 1. To determine the presence of sleep abnormalities in patients diagnosed with Multiple Sclerosis (MS) using polisomnography. 2. To detect the relationship between sleep disorders and the level of disability (EDSS), depression (Beck) and fatigue.
Methods: We studied 32 patients diagnosed with MS according to Posser’s criteria . The patients had not previously complained about the poor quality of their sleep; 12 men, 20 women; mean age 42.03, 10.6 years; Expanded disability status scale (EDSS) mean 2.95, 1.88; mean time of outcome of the illness 7.6, 6.43 years. All the patients were evaluated using the following questionnaires: Epworth sleepiness scale, Beck’s depression scale, Fisk’s fatigue impact scale, and general sleep disorder questionnaire (Montpellier). All patients underwent a standard nocturnal PSG recording (EEG, EOG, EKG, submental and both tibialis anterior EMGs, oro-nasal airflow, thoraco-abdominal effort and oxyhemoglobin saturation). The results of the PSG were compared with those of 14 healthy controls matched for age.
Results: Statistically significant differences were observed in comparison with the controls: longer sleep latency (p=0.016), shorter total sleep time (p=0.0001), lower sleep efficiency index (p=0.001), greater WASO (p=0.008) and greater sleep fragmentation index (p=0.079). We found periodic leg movements (PLM) in 48.87% of patients (p=0.019). No evaluable respiratory abnormalities were observed in these patients. A positive relation is observed between the duration of WASO and time of outcome of the disease, regardless of age. The sleep fragmentation index is the parameter with the greatest correlation with the level of depression, according to the Beck scale and the total and social fatigue impact scale. There is a negative relation between the total sleep time and the degree of disability measured by EDSS.
Conclusions: 1. Sleep disorders are underevaluated in patients diagnosed with MS. 2. There exists a relation between the physical factors and the polysomnography alterations in these patients
Disclosure: C de Andres de Frutos has nothing to disclose.
K´yl´ynç M, Can U, Benli S, Özlüolu L, Akkuzu B
aNeurology, Ba?kent University, Ankaran, Turkey; bEar, Nose and Throat, Ba?kent University, Ankaran, Turkey
Background: Electronystagmography (ENG) records the changes in eye position indicated by the polarity of the cornea-retinal potential relative to each electrode placed beside the eye. Since the vestibular aparatus contributes significantly to the control of eye movements, these movements can be exploited to examine the activity of the peripheral vestibular end organs and their central vestibulo-ocular pathways. Therefore, ENG can be used to reveal small lesions located in the brain stem, and cerebellum.
Objectives: Our objective was to present and correlate the ENG findings of a group of MS patients with clinical and MRI findings.
Methods: Eighteen clinically definite MS patients with or without vertigo were evaluated with neurological and otological examination along with ENG test battery and contrast enhanced cranial MRI. The ENG test battery included saccades, gaze, sinusoidal tracking, optokinetic nystagmus, positional test, Dix-Hallpike maneuver and calorics.
Results: The most prominent abnormality was detected by optokinetic stimulus, 88.8% of the patients had abnormal or asymmetric optokinetic nystagmus. Sinusoidal tracking was abnormal in 55.5%. Abnormalities in saccades were found in 44.4 %, and calorics in 27.7%. Gaze and positional tests were abnormal in 11.1% of the patients. Nystagmus could be elicited in none of the patients with Dix-Hallpike maneuver. Vertigo was a symptom in 50%of the patients. In cranial MRI 94.4% of the patients had supratentorial and 77.7% had infratentorial lesions. The lesions were located only in supratentorial regions in 22.2%, and only in infratentorial regions in 5.5%.Four of the patients (22.2%) had abnormal ENG findings although they did not have any infratentorial lesion. Three of these patients did not complain of vertigo, and two of them had no abnormality in brain stem and cerebellar examinations. In one of the patients (5.5%) there was only infratentorial lesions; she complained of vertigo, and she had abnormalities in ENG test results confirming the clinical symptoms and MRI findings.
Conclusions: We suggest that ENG can be used as a laboratory support in diagnosis and/or follow up of probable or definite MS patients with clinically silent and/or MR negative lesions.
Disclosure: M K´yl´ynç has nothing
to disclose.
Lana-Peixoto MA, Santos MA, Munhoz MS
CIEM MINAS UFMG Center for Investigation of Multiple Sclerosis, Brazilian Committee for Treatment and Research in Multiple Sclerosis, Belo Horizonte, MG, Brazil
Background: Abnormalities of the BAER in MS are characterized by prolongation of the interpeak intervals, absence of waves and poor reproducibility. The effect of the increase of the stimulus rate may increase the BAER sensitivity.
Results: MS patients and controls were not different regarding conventional auditory tests. BAER was significantly abnormal in the MS group in the following conditions: (1) at 11/s click rate regarding the latency of wave III (in males) and wave V; (2) at 31/s regarding latency of wave V; (3) at 51/s regarding latency of wave III, wave V and I-III interval (only in women); (4) at 61/s regarding latency of wave III, wave V and I-III interval (both in women and men); (5) at 71/s regarding latency of wave V in women. Conclusion: This study shows that high click stimulus rate increases significantly the sensitivity of the BAER and may be more helpful in detecting abnormalities in the auditory pathways in MS patients.
Objectives: To evaluate the effects of high stimulus repetition rate in the wave latencies and interpeak intervals of the BAER in MS patients.
Methods: The cohort comprised 20 women and 9 males with CDMS (mean age 43.8 and 38.2) and a control groupof 20 women and 9 men (mean age of 22.6 and 23.1) with no history or objective sign of neurological or otological disturbance. MS patients had no infratentorial MRI lesion. BAER was performed using a stimulus repetition rate of 11 clicks/s, 31, 51, 61 and 71 clicks/s.
Results: MS patients and controls were not different regarding conventional auditory tests. BAER was significantly abnormal in the MS groupin the following conditions: (1) at 11/s click rate regarding the latency of wave III (in males) and wave V; (2) at 31/s regarding latency of wave V; (3) at 51/s regarding latency of wave III, wave V and I-III interval (only in women); (4) at 61/s regarding latency of wave III, wave V and I-III interval (both in women and men); (5) at 71/s regarding latency of wave V in women.
Conclusions: This study shows that high click stimulus rate significantly increases the sensitivity of the BAER.
Disclosure: M Lana-Peixoto has nothing to disclose.
Leocani La, Martinelli Vb, Annovazzi Pa,b, Tickonova Ia, Possa Fb, Comi Ga,b
aClinical Neurophysiology, Hospital San Raffaele, Milan, Italy,; bNeurology, Hospital San Raffaele, Milan, Italy
Background: Cognitive impairment is a frequent complication of Multiple Sclerosis (MS), particularly related to frontal executive functions, reflecting a subcortical dementia. Frontal lobes are involved in motor planning and execution, reflected in the event-related desynchronization (ERD) of the EEG sensorimotor rhytms.
Objectives: In order to investigate neurophysiological correlates of executive function in MS, we evaluated ERD to self-paced movement and reaction times to the Stroop test (which evaluates frontal functions) in MS patients with and without frontal neuropsychological deficits.
Methods: Eleven MS patients, who failed in three or more frontal neuropsychological tests, were compared to 10 MS patients matched for age, handedness, disease duration and disability, who did not fail at any frontal test. EEG was recorded during self-paced movement paradigm. Manual reaction time to the Stroop test was also measured. Nine frontal patients and nine non frontal patients underwent follow-upexamination of both EEG and reaction time measurements.
Results: Stroop reaction times and ERD were significantly delayed in both MS groups compared to normal subjects and in frontal compared to non frontal MS patients. At follow-up, RT performance at the Stroop test were worsened in both groups of patients, but mostly in frontal patients. Patients with frontal dysfunction also showed changes in EEG parameters.
Conclusions: These data suggest that frontal cognitive involvement in MS corresponds to abnormal bioelectrical activity emerging also during a self-paced movement paradigm. Moreover, changes over time of both EEG and reaction times suggest a potential usefulness of these measurements in monitoring frontal function in MS.
Disclosure: L Leocani has nothing to disclose.
Christodoulou Ca, Constantinou Aa, Koptides Da, Paschalidou Mb, Georgiadis Nc, Chatzisotiriou Ab, Milonas Ib
aDepartment of Molecular Virology, The Cyprus Institute of Neurology and Genetics, Nicosia, -, Cyprus; b2nd University Department of Neurology, Aristotle University, Thessaloniki, Greece; cDepartment of Ophthalmology, Aristotle University, Thessaloniki, -, Greece
Background: Multiple sclerosis is one of the most venerable of neurological diseases and one of the most important by virtue of its frequency, chronicity and tendency to attack young adults. The etiology of MS remains unknown. Several epidemiological studies emphasize the importance of environmental, familial and genetic factors. There are supporting data over the years of research that viruses are possible agents triggering the autoimmune response. The initial event in the genesis of MS could be viral infection of nervous system, than some secondary factor must be operative in later life to activate the neurological disease and cause exacerbation. It is widely believed that this secondary mechanism is an autoimmune reaction.
Objectives: Our groupis interested not only in the viral etiology of MS but also in the way the possible viral agent enters the CNS. Our hypothesis concerns the eye as possible entry. To perform a preliminary study, we chose 13 patients with both optic neuritis and MS. Serology and molecular virology studies of Herpes simplex virus 1 (HSV1) were carried out in serum, tears and eye biopsies.
Methods: Methodology used for serology study was commercially available classical ELISA for the detection of IgG and IgM antibodies against HSV1. For the molecular study nested PCR was performed using primers specific to amplify a DNA fragment inside the DNA polymerase gene of HSV1. The PCR was followed by Southern blot and hybridization with specific radioactive probe.
Results: All of the patients presented IgG antibodies against HSV1. The molecular study showed that 9 out of 13 patients were positive for the DNA of HSV1 in serum. We investigated eye biopsy and tear samples of 5 patients. 4 of the patients presented HSV1 DNA in their tear sample and 3 out of 5 biopsies were positive for the HSV1 DNA.
Conclusions: We consider that these preliminary results suggest that the hypothesis of the eye being a possible entry for a neurotropic viral infection is worth to be investigated further.
Disclosure: M Paschalidou has nothing to disclose.
Roberto Áa, Virginia Da, Eduardo Va, Juan José Pb, Rafael Aa
aNeurology, Hospital Clínico San Carlos, Madrid, Spain; bMicrobiología, Hospital Clínico San Carlos, Madrid, Spain
Background: Recent studies have reported a possible association between MS and HHV-6, an ubiquitous infectious agent highly prevalent in the human population; however, other studies have not confirmed these results.
Objectives: To establish the DNA prevalence and viral load of HHV-6 (and both variants A and B) in MS patients and two control groups: healthy blood donnors (HBD) and patients with rheumatoid arthritis (RA).
Methods: We analyzed the whole DNA of blood and serum samples of 105 patients with relapsing remitting MS (RRMS), 70 HBD and 52 patients with RA by real time quantitative polymerase chain reaction (PCR) assay with a sensitivity of 1 copy to determine the presence of HHV-6 genomes. An absolute determination of the viral load was made with TaqMan probes and previously quantified HHV-6 DNA.
Results: Results. HHV-6 DNA prevalences were as follows: 1) In blood: i) RRMS patients: 57.1% for HHV-6, 21.9% variant A, 32.4% variant B, 2.8% variant A plus B; ii) HBD: 30.6% for HHV-6, 27.1% variant B, 3.5% variant A plus B; iii) RA patients: 34.6% for HHV-6, 9.6% variant A, 25% variant B. 2) In serum: i) RRMS patients: 17.1% for HHV-6, all of them variant A; ii) HBD: 0%; iii) RA patients: 9.6% for HHV-6, 7.7% variant A and 1.9% variant B. The mean HHV-6 viral load of the positive samples in HHV-6 genomes / microgr. of input DNA were: 1) In blood: 5.9 in RRMS patients, 5.6 in HBD and 6.2 g in RA patients. 2) In serum: 18.8 in RRMS patients and 27.4 in RA patients.
Conclusions: 1) HHV-6 DNA prevalence in blood was significantly higher in the MS patients group (p<0.01). 2) HHV-6 variant A is the responsible of that statistically significant difference in blood. 3) There is a 17.1% and a 9.6% of MS and RA patients suffering a HHV-6 active replication at the sampling. 4) Almost all the HHV-6 positive samples in serum were variant A, which leads us to think that is the only variant involved in MS. 5) Despite the difference in HHV-6 DNA prevalences, we did not find significant differences in the viral loads.
Disclosure: A Rafael has nothing to disclose.
Virginia Da, Roberto Áa, Eduardo Va, Juan José Pb, Rafael Aa
aNeurology, Hospital Clínico San Carlos, Madrid, Spain; bMicrobiología, Hospital Clínico San Carlos, Madrid, Spain
Background: Beta interferon (beta-IFN), an approved treatment for MS, may modify the clinical course of the disease, as demonstrate recent clinical trials. However, we do not completely know what immunomodulatory mechanisms may be involve in the mediation of its positive effects in the treatment of MS patients.
Objectives: To know if beta-IFN treatment affects: 1) the DNA prevalence of the HHV-6; 2) the HHV-6 viral load.
Methods: We made a prospective single center cohort study of 76 serum samples of 76 consecutive patients undergoing RRMS. Forty one patients were receiving beta-IFN treatment, but none received steroid treatment prior to blood sampling (14 were suffering an exacerbation at the time of blood drawing and 27 were on remission), and 35 did not receive beta-IFN treatment (17 in exacerbation and 18 on remission). To establish the presence of HHV-6 genomes and quantify the viral load, the DNA of these samples was studied by a real time quantitative polymerase chain reaction (PCR) assay.
Results: HHV-6 DNA prevalences were: 1) In beta-IFN treated patients: 14.9% for all the patients, 13.8% for MS patients in exacerbation, 15.7% for MS patients in remission. 2) In beta-IFN untreated patients: 19.6% for all the patients, 16.9% for MS patients in exacerbation, 20.9% for MS patients in remission. The viral loads (in HHV-6 genomes / microgr. of input DNA) were: 1) In beta-IFN treated patients: 16.7 for all the patients, 11.4 for MS patients in exacerbation, 18.1 for MS patients in remission. 2) In beta-IFN untreated patients: 20.4 for all the patients, 15.1 for MS patients in exacerbation, 19.3 for MS patients in remission.
Conclusions: 1) There is a statistically significant difference (p<0.01) in serum HHV-6 DNA prevalence between patients treated and non treated with beta-IFN; therefore, there is almost five per cent more of MS patients that suffer a HHV-6 active replication when they are not treated with beta-IFN. 2) There is no difference in viral load between MS patients beta-IFN treated and non treated once the virus begin an active replication. 3) beta-IFN treatment reduces in the same proportion the viral loads and the HHV-6 DNA prevalences of MS patients in exacerbation and in remission.
Disclosure: A Rafael has nothing to disclose.
Voigt KEa,b, Kraus JRa,b, Oschmann Pa, Engelhardt Bb
aDepartment of Neurology, University Hospital Giessen, Hessen, Germany; bMax-Planck-Institute for Physiological and Clinical Research, Bad Nauheim, Hessen, Germany
Background: Increased molecular transendothelial permeability has been suggested to be involved in the breakdown of the blood-brain barrier (BBB) which is part of the pathogenesis of multiple sclerosis.
Objectives: Radioactive permeability assays are tedious and expensive. Therefore, we compared different non-radioactive assays using Evans blue dye for diffusion across brain endothelial cell monolayers grown on tissue culture inserts coated with different matrices.
Methods: As anin vitro BBB model, the immortalized endothelial cell line bEnd5 from mouse brain capillaries was grown to confluence in DMEM for two days on semipermeable filters precoated with different matrices. Matrices included rat tail collagen, type IV collagen, and fibronectin dissolved in H2O or PBS. Culture media was replaced with colorless DMEM, and Evans blue dye solution was added to the upper compartment for a final concentration of 0.05%, before filters were successively transferred to other wells containing colorless DMEM at various time points. Spectrophotometric absorbance was measured at 650nm in aliquots from the lower compartments, and the results were calculated as optical density over time elapsed. Permeability was stimulated with either histamine or thrombin and was compared to unstimulated controls.
Results: Filters precoated with rat tail collagen exhibited an increase in paracellular permeability upon both histamine and thrombin stimulus. On type IV collagen coated filters, only thrombin but not histamine increased the permeability. Fibronectin did not lead to an elevated permeability across the endothelial monolayer.
Conclusions: The results indicate that Evans blue dye diffusion across monolayers of brain endothelial cells grown on tissue culture inserts coated with rat tail collagen can be applied as anin vitro transendothelial permeability assay of the BBB.
Disclosure: K Voigt has nothing to disclose.
New Clinical Trials (Part 1)
Bennett Da, Ludden Tb, Shah Jc, Floren Lc, Beckman Ea
aBiogen, Inc; bGlobomax LLC, Hanover, Maryland, USA; cElan, San Diego, California, USA
Background: The interaction of a4b1 integrin (VLA-4) with VCAM-1 appears to be important for autoreactive T cell migration across the blood brain barrier into MS lesions. Natalizumab is a monoclonal antibody in the class of selective adhesion molecule inhibitors (SAM-inhibitors) directed against the a4-subunit of VLA-4. Binding of natalizumab to VLA-4 and the resulting inhibition of binding to VCAM-1 may be a key element of the immunomodulatory effects of natalizumab. A clinical trial in which 213 relapsing MS patients were randomized to receive placebo, 3 mg/kg or 6 mg/kg of natalizumab monthly demonstrated that natalizumab treatment led to significant decreases in the formation of new Gd-enhancing lesions on brain MRI scan and in clinical relapses. There were no significant differences in tolerability or efficacy between the two dose groups.
Objectives: To establish the optimal dosing regimen, in terms of safety and efficacy, for natalizumab in phase III MS trials.
Methods: Population PK modeling was employed using PK and a4-integrin binding data from Phase II studies of natalizumab.
Results: The results of the population analysis indicate that there are only small changes in natalizumab clearance across a broad range of body weights. An analysis of serum natalizumab concentration and a4-integrin saturation levels demonstrated that a4-integrin saturation levels increase with serum natalizumab concentration, which was observed over a wide range of body weights. Significant overlap was seen between dose groups. The serum concentrations of natalizumab achieved maintained adequate receptor saturation throughout the treatment period corresponding with similar efficacy seen in both MRI and clinical endpoints. Pharmacokinetic modeling demonstrated that fixed dosing of natalizumab every 4 weeks achieves more consistent serum concentrations across a wide range of body weights than mg/kg dosing. The result is adequate a4-integrin saturation required for efficacy while keeping drug exposure levels within the defined safety ranges established in prior studies.
Conclusions: The PK features of natalizumab with its unique targeted mechanism of action correlated with efficacy data from the Phase II studies enabled fixed monthly dosing in the on-going Phase III natalizumab clinical trials.
Disclosure: D Bennett E Beckman Biogen staff T Ludden Globomax
staff J Shah L Floren Elan staff
Bever CT, for the EVIDENCE Study Group
Background: The EVIDENCE study showed that the efficacy of subcutaneous (sc) interferon (IFN) beta-1a 44 mcg (Rebif®) thrice weekly (tiw) was superior to intramuscular (IM) IFN beta-1a 30 mcg (Avonex®)once weekly (qw) at 24 and 48 weeks of treatment in patients with relapsing-remitting multiple sclerosis.
Objectives: We reviewed detailed 48-week safety data to determine whether the improved efficacy was achieved at the cost of lower safety or tolerability.
Methods: 677 patients with clinical or laboratory-supported definite MS were randomized to either IFN beta-1a 44 mcg sc tiw or 30 mcg IM qw. Clinical safety assessments were performed every 4 weeks to week 24 and then every 12 weeks to week 48. Blood tests were done at baseline and months 1, 3, 6, 9 and 12.
Results: 339 patients received IFN beta-1a 44 mcg sc tiw (high dose) and 337 received 30 mcg IMqw (low dose). Flu-like symptoms were common but did not differ significantly between groups either in terms of incidence or severity. Injection-site events were reported in 83% of high dose and 28% of low dose patients (p<0.001). 85% of injection site reactions on high dose were rated as mild and similar numbers of patients on high (n=4) and low (n=3) dose discontinued treatment because of injection site reactions. Overall, therapy was stopped in 25 high dose patients (7.4%) and 21 low dose patients (6.2%). The most common reason was for adverse events (16 high dose patients and 14 low dose patients). Elevation of serum alanine aminotransferase (ALT) was the most common hepatic adverse event (11.5% on high dose vs. 4.7% on low dose; p=0.001). Severe ALT elevations were seen in 6 patients in the high dose group (1.8%) and 4 in the low dose group(1.2%) with 3 dropouts on the high dose and 1 on the low dose for enzyme elevations. Leukopenia (6.2% high dose vs. 0.6% low dose; p<0.001) was the most common white blood cell adverse event. Severe leukopenia was not seen in either group. Depression (16% vs. 18%) and headache (38% vs. 32%; p=ns) were approximately equal. Only one death occurred during the study (a solo plane crash).
Conclusions: The advantage in efficacy seen clinically at 48 weeks with 44 mcg sc tiw compared to 30 mcg IM qw was not offset by clinically significant safety concerns or reduced adherence to therapy.
Disclosure: C Bever is on the speaker’s bureau and has received honoraria from the study sponsor, Serono Laboratories, Inc. In addition, some other members of the EVIDENCE Study Group receive support from the study sponsor.
Funding: Supported by Serono Laboratories, Inc. Posters S62 Multiple
Sclerosis
Goodkin DE, Flanders K, Leung J, Butine m, Stead R
Immunex Corporation, Seattle, Washington, USA
Background: The RENEW study is a multicenter (N=50), open-label, observational safety study of 500 patients with worsening RR, SP and PR MS who initiate commercially available NOVANTRONE according to guidelines in the package insert.
Objectives: To describe the cumulative dose and tolerability of NOVANTRONE® in the RENEW study.
Methods: Entry criteria: Patients with CD or LSD RR, SP, or PR MS who initiate NOVANTRONE 12mg/m2 within 3 months of site-IRB approval, platelets 100,000 cells/ml, granulocytes 2000 cells/ml, age 18-65 yrs, negative pregnancy test. Exclusion criteria: PPMS, history of CHF, left ventricular ejection fraction (LVEF) <50%, previous treatment with NOVANTRONE® or other anthracenediones or anthracyclines, mediastinal radiotherapy or TLI; AST, ALT, total bilirubin (LFTs) 2x ULN; current UTI or other severe untreated infection, nursing or pregnant women. Procedures: medical evaluation, CBC with platelet count, and LFTs are conducted every third month during treatment and every year thereafter (total 5 years). LVEF is determined at baseline, prior to each dose above a cumulative dose 100mg/m2, and annually after therapy is discontinued.
Results: RESULTS: The first patient was enrolled on 2/9/01. As of 2/11/2002: 261 patients enrolled, (69% female), mean age 46 (21-68), mean EDSS 5.9 (1.-9.0), mean LVEF baseline 62% (50-82), mean infusions 2 (range 1-5), mean cumulative dose 24.8mg/m2 (range 9.1-60.5), SAEs, 12, 5 of which are possibly therapy-related; patients with CHF 0, LVEF <50% 0, therapy related leukemia 0, death 1 (PE, unrelated to therapy). Results through 09/18/02 will be presented.
Conclusions: CONCLUSIONS: NOVANTRONE® has been generally well tolerated by patients enrolled in the RENEW study. Data from the RENEW provide rigorously collected data that reflect the tolerability of NOVANTRONE® as approved for use in clinical practice
Disclosure: All authors are employees of the Immunex Corporation
MS Inglese Ma, vanWaesberghe Jb, Rovaris Ma, Beckmann Kc, Barkhof Fb, Hahn Dd, Kappos Le, Miller Df, Polman Cb, Pozzilli Cg, Thompson Af, Yousry Th, Wagner Kc, Comi Ga, Filippi Ma
aDepartment of Neuroscience Scientific Institute and University Ospedale San Raffaele, Neuroimaging Research Unit, Milan, Italy; bMR-MS Centre, VU Medical Centre, Amsterdam, NE, Netherlands; cShering AG, Berlin, GE, Germany; dInstitut for Röntgendiagnostik, University of Wurzburg, Wurzburg, GE, Germany; eNeurology, University Hospitals, Kantonsspital, Basel, SW, Switzerland; fNMR Research Group, Institute of Neurology, London, UK, United Kingdom; gClinica Neurologica I, Università La Sapienza, Rome, IT, Italy; hNeuroradiology, Klinikum Grosshadern, Munich, GE, Germany
Background: Magnetization transfer magnetic resonance imaging (MT MRI) can provide in vivo markers reflecting the severity of irreversible, MS-related brain damage occurring within and outside T2-visible lesions.
Objectives: To assess the effect of interferon (IFN) b-1b treatment on the accumulation of brain damage in patients with SPMS, measured using MT MRI.
Methods: Eighty-two SPMS patients from five centers participating into a European, multi-center, double-blind, placebo-controlled trial of IFNb-1b in SPMS underwent brain T2-weighted and MT MRI at baseline. Follow up data were available for 75 patients at 12, 54 at 24 and 47 at 36 months. MT MRI scans were post-processed and analyzed to obtain histograms of MTR values from the whole brain. A ROI-based analysis of MTR values from the NAWM was also performed.
Results: In both the treatment arms, there was a decrease of average brain MTR values from baseline to month 24 (mean change=-4.9%) and month 36 (mean change=-4.3%). These changes were statistically significant for the placebo group at both the time-points and for the IFNb-1b group at month 24 only, with no significant treatment effect. A decrease of NAWM MTR was also observed, with no significant difference between the two treatment arms.
Conclusions: In this cohort of patients with SPMS, IFNb-1b as compared to placebo did not show an overall effect on the worsening of MT MRI measures. The data show that change in MTR is a promising tool for monitoring disease evolution in SPMS.
Disclosure: K Beckman and K Wagner serve on Schering, AG, Berlin. Miller was the MRI investigator of the Clinical Trial. C Pozzilli, L Kappos and C Polman were members of the Steering Committee. M. Inglese,J.H.T.M. vanWaesberghe, M. Rovaris, F. Barkhof, D. Hahn, A.J. Thompson, T.A. Yousry, G. Comi and M. Filippi have nothing to disclose.
Funding: Partially supported by Schering,AG,Berlin.
Montalban Xa, Brieva La, Tintore Ma, Borras Ca, Rio Ja, Nos Ca, Aymerich Xb, Alonso Jb, Horno Ra, Vicente Ma, Rovira Ab
aClinical Neuroimmunology Unit, University Hospital Vall d’Hebron, Barcelona, Catalonia, Spain; bMagnetic Resonance Unit - IDI, University Hospital Vall d, Barcelona, Spain
Background: The beneficial effects of IFN beta have been shown just for patients in the relapsing phase of MS. The role of interferon beta in the treatment of patients with secondary progressive MS still remains a controversial issue. The single phase II randomized controlled trial on PPMS using IFN beta 1a (IM) shows no significant treatment effect on EDSS though some effect on T2 lesion load.
Objectives: To investigate safety and hints of efficacy of interferon (IFN) beta1b given to patients with primary progressive (PPMS) and transitional progressive multiple sclerosis (TPMS).
Methods: 73 patients (49 PPMS/24 TPMS) with EDSS scores between 3.0 to 7.0, were enrolled and randomized to receive either 8MIU of IFN beta1b or placebo administered every other day subcutaneously for 2 years. Safety parameters including BDI and Ashworth’s and Krupp’s scales and blood tests were performed every three months. Clinical outcomes (EDSS and MS Functional Composite (MSFC)) were also performed every three months and the Sickness Impact Profile every six months. MRI measures (T2 and T1-weighted brain lesion load, brain parenchymal fraction (BPF), T2 active lesions, spinal cord atrophy, MTR and spectroscopy) and neuropsychological assessment (BRNB) were undertaken annually.
Results: Adverse events significantly associated with IFN-beta included injection-site reaction, flu-like symptoms and lymphopenia. One patient on the placebo arm died because of pulmonary infection. In all, 96% of the patients reached study end and 93% completed the treatment period of the study. Treatment groups were comparable on all baseline variables. The proportion of patients with confirmed progression at 6 months was 22.2% in the IFN arm and 32.4% in the placebo arm (p= 0.2). Statistically significant differences were found for T2 (p=0.006) and T1 (p=0.01) lesion load and number of active lesions (p=0.0005) in favor of the IFN-treated group. MSFC and BPF data will be presented.
Conclusions: IFN-beta 1b is safe in the treatment of patients with PPMS and TPMS. Our study seems to point to a beneficial effect of IFN beta1b on MRI parameters in this group of patients.
Disclosure: X Montalban has nothing to disclose.
Funding: Supported by Schering España, SA.
Pipieri A, Barbero P, Bergui M, Verdun E, Clerico M, Durelli L
Turin University, Torino, Italy
Background: The chronic administration of a drug on alternate days may affect patient compliance and encourage the decision to reduce IFN beta dose. A study of clinical and MRI effects associated with the reduction of IFN beta dose is needed
Objectives: To evaluate the MRI-effects of reducing IFN beta dose in patients with RRMS in chronic treatment with IFN beta-1b and with clinical-MRI stabilization
Methods: Prospective one year follow-up of 27 RRMS patients randomised to gradually switch from on-alternate-day IFN beta-1b to once-a-week IFN beta-1a (13 patients), or to continue on IFN beta-1b (14 patients). Before IFN beta reduction the patients had to be on chronic IFN beta treatment for at least 3 years, and without clinical and MRI signs of disease activity during the last 2 years. MRI was performed before randomisation and at the end of the one year follow-up
Results: One year after the reduction of IFN beta dose clinical outcome measures were, for the group of patients switched to once-a-week IFN beta-1a, mean number of the new PD/T2 lesions 1.92 ±1.32, of the enlarging PD/T2 lesions 0.69 ±0.95, of the gadolinium-enhancing lesions 0.92 ±0.95; for group of patients continually treated with IFN beta-1b, mean number of the new PD/T2 lesions 0.57 ±0.94, of the enlarging PD/T2 lesions 0.21 ±0.8, of the gadoliniumenhancing lesions 0.35 ±0.74. All these outcome measures were significantly lower (p< 0.01) for the patients who continued on IFN beta-1b except for the mean number of the enlarging lesions
Conclusions: IFN beta treatment is a chronic one. The reduction of IFN beta-1b dose is not advisable even in patients with years of absence of disease activity
Disclosure: A Pipieri has nothing to disclose.
Wolansky LJa, Cadavid Db, Cook SDb, Skurnick Jc, Biswal Ba, Pachner Ab, Hill Jb
aRadiology, UMDNJ, Newark, New Jersey, USA; bNeurosciences, UMDNJ, Newark, New Jersey, USA; cPreventive Medicine Biostatistics/Epidemiology, UMDNJ, Newark, New Jersey, USA
Background: Currently approved immunomodulatory therapies for relapsingremitting multiple sclerosis (RR-MS) include two forms of interferon beta (interferon beta-1a and 1b) and glatiramer acetate (GA, Copaxone®), a synthetic polymer that mimics the structure of myelin basic protein. While recent comparative studies have demonstrated the superiority of higher frequency, higher dose interferon beta formulations in the treatment ofRR-MS, there have to date been no direct randomised comparisons of the efficacy and tolerability of interferon beta and GA.
Objectives: The purpose of this presentation is to announce the initiation of a randomised, single-blind, 48-week study to compare the effects of interferon beta-1b vs. GA on MRI and clinical disease measures in patients with RR-MS.
Methods: 110 patients will be recruited to the study and receive the approved dose of either interferon beta-1b (250 µ [8 million international units] subcutaneously [sc] every other day) or GA (20 mg sc daily). MRI scans will be conducted 4 weeks before baseline, at baseline, and then every four weeks thereafter for a period of 48 weeks, while clinical assessments will be performed at baseline, week 4 and every 12 weeks thereafter. All MRI scanning will be carried out using ultra-high magnetic field strength (3 Tesla) and triple-dose gadolinium (Gd).
Results: The primary endpoint variable will be the total number of combined-active lesions (Gd enhancing + new long TR lesions) over the twelve, monthly scans with patient as the unit of analysis. Secondary endpoints will include volumetric analysis, diffusion tensor imaging, neurocognitive function and clinical disease activity (relapses and progression of disability).
Conclusions: Enrolment is expected to be complete by August 2003, with the results expected in 2005.
Disclosure: L Wolansky has nothing to disclose.
Funding: Supported by Berlex Laboratories.
Genetics (Part 1)
Datta Pa, Harboe Hb, Spurkland Ab, Ryder Lc, Sawcer Sd, Åkesson Ee, Celilus Ef, Modin He, Sandberg-Wollheim Mg, Myhr Kh, Andersen Oi, Hillert Je, Solberg Sorensen Pa, Svejgaard Ac, Compston Ad, Vartdal Fb, Oturai Aa
aMultiple Sclerosis Research Unit, Copenhagen University Hospital, Copenhagen, Denmark; bInstitute of Immunology, Oslo National Hospital, Oslo, Norway; cClinical Immunology, Copenhagen University Hospital, Copenhagen, Denmark; dUniversity of Cambridge Neurology unit, Addenbrookes Hospital, Cambridge, CB2 2QQ, United Kingdom; eDepartment of Neurology, Huddinge University Hospital, Huddinge, Sweden; fDepartment of Neurology, Ullevål University Hospital, Oslo, Norway; gDepartment of Neurology, Lund University Hospital, Lund, Sweden; h8Department of Neurology, Haukeland Hospital, Bergen, Norway; iDepartment of Neurology, Gothenburg University Hospital, Gothenburg, Sweden
Background: Multiple sclerosis (MS) is a chronic inflammatory disease. Unknown genetic and environmental factors contribute to the disease.
Objectives: The present study is based on a genetic homogenous Scandinavian population and part of a Genetic Analysis of Multiple sclerosis in EuropeanS study (GAMES).
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. Thirteen 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 the most promising of these markers, statistical significance was retained for two markers - the D1S1601 marker (1q42) and the D11S1986 marker (11q23). These two novel genomic regions may contain susceptibility genes for multiple sclerosis.
Conclusions: Two novel genetic regions possibly contributing to the genetic susceptibility to MS among Scandinavians has been identified. Further work is needed to dissect which genes are actually responsible for the observed association.
Disclosure: P Datta has nothing to disclose.
Funding: 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).
Fernández Va, Leyva Lb, Mayorga Cb, Matesanz Fc, Fedetz Mc, Alcina Ac, Guerrero Md, León Aa, Luque Ga, Fernández Oa
aNeurology, Hospital Regional Universitario Carlos Haya, Málaga, Spain; bResearch Unit, Hospital Regional Universitario Carlos Haya, Málaga, Spain; cImmunology and Cellular Biology, Instituto de Parasitología y Biomedicina Lopez Neyra, Granada, Granada, Spain; dNeurology, Hospital Clínico San Cecilio, Granada, Granada, Spain
Background: Interleukin-2 (IL2) is an immunoregulatory cytokine with a key role in maintenance of self tolerance and in CNS. Recent findings suggest that IL2-2RB locus contributes to the genetic susceptibility in some multiple sclerosis (MS) patients. So far, only two il-2 polymorphisms have been identified, at position -384 and 114 and it would be interesting to analyse their association with susceptibility to MS
Objectives: To investigate the association of -384 polymorphisms in the IL-2 with the susceptibility to MS and its clinical characteristics (clinical form, gender, age at onset, symptoms at onset, disease duration, EDSS score at the moment of study, response to interferon therapy) as well as with HLA class II alleles
Methods: DNA was collected from 90 patients with clinically definite MS (56 with relapsing-remitting (RR)and 34 with secondary-progressive (SP) clinical form) and 153 controls, and was extracted by standard procedures. The sequence containing -384 polymorphisms was amplified with oligonucleotide IP46 modified to create a restriction site for the Bfa-1 enzyme with the G allele. The forward primer was IP47. Amplification yielded a band of 131 bp that, after digestion with Bfa-1, gave products of 110 and 21 bp, that were separated on 12 % polyacrylamide gel electrophoresis, stained with ethidium bromide and visualized with ultraviolet light. The HLA class II subregions DRB1, DQA1 and DQB1 were investigated by commercial molecular biology methods
Results: No significant differences in the genotype frequencies between MS group and controls were found. A positive association between the heterozygous -384 genotype (G/T) and the SP clinical form (57% vs. 43%, p=0,009) was detected. There was a trend of association (p= 0,07) between the homozygous genotype (T/T) and the RR clinical form (66% vs. 47%). No association of any of the three genotypes with any of the other clinical characteristics studied or with the HLA class II alleles was observed (p 0,05)
Conclusions: -384 (G/T) polymorphism of the IL-2 is associated with the SP clinical form of MS, and not with other clinical characteristics or HLA alleles
Disclosure: V Fernández has nothing to disclose.
Heggarty SVa, Silversides Ja, Vandenbroeck Kb, McDonnell Gc, Hawkins Sc, Graham Ca
aRegional Genetics Centre, Belfast City Hospital Trust, Belfast, Co. Antrim, United Kingdom; bSchool of Pharmacy, Queens University of Belfast, Belfast, Co. Antrim, United Kingdom; cDept. of Neurology, Royal Victoria Hospital, Belfast, Co. Antrim, United Kingdom
Background: Polymorphisms within the cytotoxic T lymphocyte associated (CTLA-4)gene have been implicated in a number of autoimmune diseases ranging from type 1 diabetes mellitus, Graves disease as well as multiple sclerosis. The CTLA-4 and CD28 molecules are co-stimulatory T cell receptors that are involved in the control of T cell activation. CD28 upregulates cellular activity by its interaction with the B7 ligand of the antigen presenting cell while CTLA-4 provides the necessary down regulatory signal to reduce the ongoing immune response. CTLA-4 is therefore a good candidate gene for investigation in autoimmune disorders.
Objectives: The human CTLA-4 gene is located on chromosome 2q33. From literature the CTLA-4 gene contains the polymorphisms at positions - 318(C/T) in the promoter (Genbank#M74363), +49(A/G) of exon 1 coding for threonine or alanine respectively (Genbank#M74363),and a dinucleotide (AT)n repeat sequence in the 3’- untranslated region of exon 4 at position 642 (Genbank#M37243). A case control study was proposed to determine the influence of these polymorphisms in the N. Ireland population on MS risk.
Methods: Alleles of the polymorphism within the promoter (-318C/T) were identified by PCR using sequence specific primers, the exon 1 (49A/G) polymorphism was typed using PCR/RFLP while the microsatellite was genotyped using fluorescently labelled PCR primers and sized on an ABI3100. Statistical analysis was carried out by the Chi-squared test.
Results: The promoter and exon 4 polymorphisms showed no significant differences between case and control populations however a strong association to the A allele of the +49A/G polymorphism of exon 1 of the gene was demonstrated. There were significantly more homozygous A allele patients (42%) in comparison to the control population(29%; p=0.0031).
Conclusions: The fact that different alleles of the same polymorphism show a positve association in different populations would suggest that these polymorphism do not influence susceptibilty but that another as yet untested loci is involved.
Disclosure: S Heggarty has nothing to disclose.
Funding: Supported by MS Society of Ireland.
Kantarci OHa, Hebrink DDa, Achenbach SJb, Elizabeth AJb, McMurray CTc, Weinshenker BGa
aNeurology, Mayo Clinic & Foundation, Rochester, Minnesota, USA; bDepartment of Health Sciences Research, Mayo Clinic & Foundation, Rochester, Minnesota, USA; cDepartments of Pharmacology, Biochemistry and Molecular Biology and Molecular Neuroscience Program, Mayo Clinic & Foundation, Rochester, Minnesota, USA
Background: Fas and FasL expression leads to antigen activation-induced apoptosis of T-cells. Mutations in Fas and FasL cause autoimmunity and lymphoproliferation in mice and humans. Others have reported association of polymorphisms adjacent to or inFas andFasL with MS susceptibility.
Objectives: To study the association ofFas andFasL polymorphisms with susceptibility to, gender bias, age at onset, course and severity (based on EDSS and duration) of MS.
Methods: Three single nucleotide polymorphisms (SNPs) per gene were selected from the SNP database to establish haplotypes that span the genes. Genotyping was performed in a population-based sample of 122 cases and 244 gender, age and ethnicity-matched controls using restriction fragment length polymorphism methodology. Results were not corrected for multiple comparisons in this preliminary analysis.
Results: There was linkage disequilibrium (LD) between 5’(-670) and Exon7(74) SNPs ofFas in both cases and controls (p<0.00001). Homozygosity for 5’(-670*A) (p=0.034; OR: 1.78, 95%CI: 1.04-3.03) and for Exon7(74)*C (p=0.019; OR: 1.84, 95%CI: 1.10-3.07), the two specific alleles in LD, was associated with increased risk of MS in women but not men. There was a trend to association of the haplotype defined by these alleles with increased risk of MS in women (p=0.053; OR: 1.66, 95%CI: 0.99-2.78). There was a trend to association of homozygotes for Exon7(74)*C with primary progressive versus bout onset disease (p=0.057; OR: 3.92, 95%CI: 0.88-14.43). None of theFas polymorphisms was associated with disease severity or age at onset. There was LD between 5’(-663), Intron2(1153) and Intron2(2776) SNPs ofFasL in both cases and controls (p<0.00001). Being a carrier for 5’(-663)*T was associated with susceptibility to MS (p=0.005; OR: 2.02, 95%CI: 1.23-3.32), the effect being primarily due to a difference in the frequency of heterozygotes. None of theFasL polymorphisms was associated with age of onset, severity or course.
Conclusions: Two SNPs ofFas in LD with one another and a 5’ region SNP ofFasL may be associated with susceptibility to MS. In the case of theFas SNPs, the effect was evident only in homozygous women.
Disclosure: O Kantarci has nothing to disclose.
Funding: National MS Society (RG-2870-A-2 )
Lucas Ma, Zayas MDa, Costa AFa, Solano Fa, Durán Eb, Izquierdo Gb
aMolecular Biology, University Hospital, Sevilla, Andalucía, Spain; bNeurology, University Hospital, Sevilla, Andalucía, Spain
Background: Interaction between Fas and FasL is a crucial mechanism for clonal deletion and immune tolerance and privilege, control of T cell expansion during immune responses and killing by cytotoxic T lymphocytes. We have recently published the association of a CA repeats polymorphism of the FasL gene to relapsing multiple sclerosis.
Objectives: The purpose of the present work was the search of intragenic markers of Fas since a polymorphic marker could be very useful in the study of the hypothetical association of the Fas death system to multiple sclerosis.
Methods: The groups consisted of 172 healthy unrelated and 195 relapsing MS patients of Caucasian origin. The unknown intronic sequence of intron IV of the Fas gene was amplified with primers designed from the flanking sequences and the sense and antisense strands of the amplified DNA were sequenced. SNP is detectable by endonuclease restriction analysis with MaeI that easily allowed the screening of a large number of DNA.
Results: The sequencing of both the sense and antisense strands of a 907 bp stretch, within the unknown sequence of intron IV of the Fas gene, identified a novel single-nucleotide polymorphism (SNP) A/T(735)G/C. By the endonuclease restriction procedure, we determined the allele frequencies in 344 chromosomes of healthy individuals and 390 chromosomes of relapsing MS patients. We found a higher frequency of the heterozygous TC genotype in MS patients than in healthy controls. The FasMaeI polymorphism was not associated to