More MS news articles for Sep 2001

17th ECTRIMS Conference, Dublin - Platform Abstracts

http://128.242.218.10/fs2/wd5745/wd238/platformsO-21-O39.pdf

September 12th-15th, 2001

O-21
DOES ALTERED FUNCTIONAL ACTIVATION IN MS PATIENTS REFLECTS LOSS OR PRESENCE OF COMPENSATORY BRAIN MECHANISMS?
Penner IK a , Rausch M b , Kappos L a , Radü EW a
a University Hospital Basel, Basel, Switzerland
b Novartis Pharma AG, Basel, Switzerland

About 45-65% of all patients with Multiple Sclerosis (MS) suffer from cognitive impairment. Attention and memory are the most frequently affected functions. The present study tried to reveal if reduced attention and memory performance correlates with altered functional brain activation. In ten MS patients and seven healthy controls functional magnetic resonance imaging (fMRI) was performed while they underwent tasks of tonic alertness, focused attention and working memory. All subjects were prefamiliarized with the tasks in a computer session prior to the fMRI investigation. The neuropsychological results revealed not only significant differences in performance between normals and MS patients but also within our patient group. Corresponding differences were found for the functional imaging data. Compared to controls patients with average performance (43<T<56) showed increased and additional activation for alertness but diminished activation for focused attention and working memory. Patients with performance below average (T<43) showed an increase in activation as task complexity increased. These findings might indicate that 1. MS patients need the interconnectivity of several brain structures (posterior and frontal) to compensate attentional problems and to solve a cognitive task as well as healthy controls 2. MS patients who are able to compensate cognitive impairment undergo changes in brain activation and 3. compensatory changes in brain activation are missing in patients with increased cognitive impairment.

O-22
BDNF AND GP145TRKB IN MULTIPLE SCLEROSIS BRAIN LESIONS: NEUROPROTECTIVE INTERACTIONS BETWEEN IMMUNE AND NEURONAL CELLS?
Stadelmann C a , Kerschensteiner M b,c , Misgeld T b,c , Brück W a , Hohlfeld R b,c , Lassmann H d
a Institute for Neuropathology, Charité, Berlin, Germany;
b Institute for Clinical Neuroimmunology, LMU, Munich, Germany;
c Department of Neuroimmunology, MPI for Neurobiology, Martinsried, Germany;
d Department of Neuroimmunology, Brain Research Institute, University of Vienna, Vienna, Austria

Recent immunohistological and imaging studies emphasize the crucial role of axonal injury in determining the extent of permanent neurological deficits in patients with multiple sclerosis (MS). We could recently show that human immune cells are capable of producing the neurotrophin BDNF, which can prevent axonal and neuronal damage after various pathological insults. BDNF imported into the CNS by immune cells would thus be an attractive candidate for mediating neuroprotective effects in MS. The aim of the present study was to perform a detailed immunohistochemical analysis of the expression of BDNF and its receptor gp145trkB in brain lesions of 9 MS patients. Our data show that various types of neurons throughout the brain are BDNF immunopositive in MS patients as well as in controls. Furthermore, in MS lesions, BDNF is primarily present in immune cells (T cells, macrophages/microglia) and reactive astrocytes. The number of BDNF immunopositive cells correlates with lesional demyelinating activity. The BDNF receptor gp145trkB is found in neurons in the immediate vicinity of MS plaques as well as in reactive astrocytes within the lesion, but not in immune cells. Our results demonstrate that both BDNF and gp145trkB are expressed in MS lesions. This suggests that BDNF and the BDNF receptor trkB are involved in immune-mediated neuroprotective interactions in MS and supports the concept that immune cells produce both damaging and protective factors in MS lesions.

O-23
cDNA VACCINATION WITH CD 44v INHIBITES LYMPHOCYTE HOMING INTO THE BRAIN PARENCHYMA AND INDUCES APOPTOSIS IN EXPERIMENTAL AUTOIMMUNE ENCEPHALOMYELITIS
Karussis D a , Rubinstein A b , Nedvetzki S b , Grigoriadis N c , Mizrachi-Koll R a , Milonas I c , Abramsky O a , Nahor D b .
a Dept. of Neurology, and the
b Lautenberg Centre for General and Tumour Immunology, Hadassah-Hebrew University, Jerusalem.
c B’ Dept. of Neurology, Aristotle University, Thessaloniki.

Acute experimental autoimmune encephalomyelitis (EAE) serves as a model of the acute, inflammatory stage of multiple sclerosis (MS). CD44 is a lymphocyte surface marker which functions as an hyaluronic acid receptor and therefore is implicated in lymphocyte homing and trafficking through the extracellular matrix. Variant isoforms of CD44 (CD44v), especially the v6 and the v10 were found to be significantly associated with / responsible for the metastatic potential of tumour cells and the inflammatory ability of autoimmune cells in rheumatoid arthritis. Inhibition of both CD44 and L-selectin was recently reported to suppress EAE. cDNA vaccination may induce the production of anti-CD44 antibodies and therefore, secondarily suppress EAE. We vaccinated SJL/J mice with cDNA of CD44 and of CD44v isoforms twice, on days –7 and +6. On day 0, EAE was induced with mouse spinal cord homogenate and adjuvant together with pertussis toxin injections. Vaccinated animals developed significantly less severe EAE; this suppression was more prominent in mice vaccinated with the CD44v. The histopathological analysis did not reveal any significant reduction of the perivascular infiltrations but showed an increased number of apoptotic cells in the lesions of treated animals. The in vitro proliferations of lymphocytes were only marginally suppressed in the successfully treated animals. It seems that the main mechanism of EAE-suppression involves inhibition of the migration of lymphocytes through the extracellular matrix and induction of apoptosis, and less through downregulation of the peripheral activation of lymphocytes.

O-24
CENTRAL NERVOUS SYSTEM INFLAMMATION TRIGGERS COUNTER-REGULATORY PROTECTIVE MECHANISMS IN AUTOIMMUNE DEMYELINATION
Martino G, Furlan R, Brambilla E, Ruffini F, Bergami A, Adorini L, Comi G. Dept. of Neuroscience, San Raffaele Hospital, and Roche Milano Ricerche, Milan, Italy

The exclusive detrimental role of pro-inflammatory cytokines in demyelinating diseases of the CNS, such as multiple sclerosis (MS), is controversial. Here, we show that the intrathecal delivery of an HSV-1-derived vector engineered with the mouse IFN? gene leads to persistent (up to 4 weeks) CNS production of IFN? and inhibits the course of a chronic-progressive form of experimental autoimmune encephalomyelitis (EAE) induced in C57BL/6 mice by myelin oligodendrocyte glycoprotein (MOG)35-55. Mice treated with the IFN?-containing vector before EAE onset showed an earlier onset but a milder course of the disease compared to control mice treated with the empty vector. In addition, 83% of IFN?-treated mice completely recovered within 25 days post immunization (p.i.) while control mice did not recover up to 60 days p.i. Mice treated with the IFN?-containing vector within one week after EAE onset, partially recovered from the disease within 25 days after vector injection, while control mice worsened. Recovery from EAE in mice treated with IFN?? was associated with a significant increase of CNS-infiltrating lymphocytes undergoing apoptosis. During the recovery phase, the mRNA level of TNF receptor I was also significantly increased in CNS-infiltrating cells from IFN?-treated mice compared to controls. Our results further challenge the exclusive detrimental role of IFN? in the CNS during EAE/MS, and indicate that CNS-confined inflammation may induce protective immunological counter-mechanisms leading to a faster clearance of encephalitogenic T cells by apopotosis, thus restoring the immune privilege of the CNS.

O-25
HIGH-DOSE IMMUNOABLATIVE THERAPY WITH AUTOLOGOUS HAEMATOPOETIC STEM CELL SUPPORT IN PATIENTS WITH MALIGNANT COURSE OF MULTIPLE SCLEROSIS
Havrdova E, Kozak T, Pitha J, Kobylka J, Ticha V, Novakova I, Horakova D, Gregora E, Maaloufová J .
MS Center, Dpt. of Neurology, Dpt. of Haemathology, Charles University, Praha, Czech Republic.

Introduction: In Czech Republic the program of bone marrow transplantation in multiple sclerosis (MS) started in January 1998. It has been offered to MS patients who failed to react to convention therapies including immunosuppressive regimens.

Method: 16 patients (5males, 11 females, age 38+/-9.5, Kurtzke EDSS 6.5+/-1.5) were included and signed informed consent. Mobilisation with 4g of cyclophosphamide was followed by collection of peripheral progenitor cells, two step T cell depletion of PBSC graft, isolation of CD34+ stem cells and cryopreservation. Immunoablative therapy (BEAM) was followed by stem cell reinfusion.

Results: 4 patients failed to mobilise stem cells due to recent intensive immunosuppressive treatment. In all patients but two neurological status worsened transiently including bladder dysfunction during the chemotherapy and slowly returned to previous level during several months. Improvement, if any, have started after 4-6 months after SC transplantation and needed sustained rehabilitation effort. All patients suffered from severe fatigue several months after the procedure. 8 patients stopped progression, the first one who is followed more than 3 years improved 2 steps of Kurtzke EDSS. One patient with previous most severe motor dysfunction of lower extremities stopped walking at all immediately after the mobilisation. She steadily worsened and died 2.5 yrs after BMT due to peritonitis. One patient worsened 1.5 steps of EDSS and is slowly recovering now. No unexpected complications of the procedure itself have occurred. Immune reconstitution has shown expected lymphopenia with low rates of CD8+ cells predominating during the first year. MRI activity was present in 4 patients.

Conclusions: Preliminary data indicate usefulness of this therapeutic approach in carefully selected patients with remaining motor function, rapid progressive MS and failure of convention therapies. Two step T cell depletion may help to avoid the autoaggressive immunocompetent cells.

O-26
SAFETY PROFILE OF MITOXANTRONE IN A COHORT OF 800 MULTIPLE SCLEROSIS PATIENTS
Edan G*1 , Brochet B* 2 , Clanet M*3 , Clavelou P*4 , Confavreux C* 5 , Debouverie M*6 , Heinzleff O* 7 , Lebrun C*8 , Lubetzki C * 9 , Pelletier J*10 , Madigand M*11 , Rumbach L*12, Le Page E * 1 Department of neurology CHU * 1 Rennes,*2 Bordeaux, * 3 Toulouse, * 4 Clermont-Ferrand, * 5 Lyon, * 6 Nancy,*7 Paris-Tenon, * 8 Nice, * 9 Paris-Salpétrière , , * 10 Marseille, * 11 St Brieuc, * 12 Besancon.

Introduction : Mitoxantrone (MITOX) is the first immunossuppressant approved by the Food and Drug Administration for worsening relapsing-remitting, secondary-progressive and progressive-relapsing multiple sclerosis.

Objectives : Although the long term safety profile is well defined in patients with cancer, similar data are not available in MS patients. For this reason, we examined the experience of 12 French MS centers with mitoxantrone from 1992 to 2001 to evaluate the safety profile of this agent.

Methods : safety data were collected in each French MS center. Echocardiograms were performed before and after MITOX treatment. The patients had a blood cell count performed before every mitoxantrone course and during the follow-up until the last six months. Data concerning severe infections, amenorrhea, alopecia, and other serious events were collected.

Results : The analysis of the first 300 patients showed no instances of clinically significant toxicity. The complete results are still examined and should be available in September 2001.

O-27
NOVANTRONE PLUS DEXRAZOXANE THERAPY IN MULTIPLE SCLEROSIS PATIENTS: A SAFETY AND TOLERABILITY PILOT STUDY
Mikol DD, Bernitsas E.
University of Michigan, Department of Neurology, Ann Arbor, Michigan, USA

Background: Cardiotoxicity is a dose-dependent adverse side effect of anthracyclines and anthracenediones, including mitoxantrone (Novantrone, NOVA), and it is recommended that cumulative NOVA dose should not exceed 140 mg/m 2 . The mechanism underlying cardiotoxicity from NOVA is unknown, but histological changes are similar to those seen with anthracycline-induced cardiomyopathy. Dexrazoxane (Zinecard, DEX) is a cardioprotective agent indicated for reducing anthracycline-associated cardiomyopathy.

Aim: We speculate that DEX may be cardioprotective in NOVA-treated multiple sclerosis (MS) patients and explore the safety of combination therapy.

Patients and Methods: Baseline complete blood count (CBC), liver panel, and echocardiogram or multigated radionuclide angiography (MUGA) were obtained, and CBC and liver panel were drawn prior to each infusion. CBC was typically checked 8-12 days post- infusion, around the nadir of leukopenia. In general, patients received intravenous DEX (600 mg/m 2 ) followed by NOVA (12 mg/m 2 ) every third month. Follow-up MUGA is planned at 12 and 24 months.

Results: At the time of abstract submission, 15 MS patients have been enrolled, receiving between 1-5 NOVA/DEX infusions each. No signs of congestive heart failure have been observed. In some cases, the absolute neutrophil count transiently fell to ~500-1,500 per ?l; no infections were reported. There was otherwise no evidence of toxicity.

Conclusion: Our results demonstrate the safety and tolerability of NOVA/DEX combination therapy in MS patients, although controlled trials are required to assess whether DEX is cardioprotective in NOVA-treated MS patients, in which case the cumulative NOVA dose threshold might be increased.

O-28
COMPARISON OF NEW IMMUNOMODULATORY TREATMENTS IN THE EARLY STAGES OF MS
Haas J a , Firzlaff M a , Schmidt M a. .
a Department of Neurology Jewish Hospital Berlin, Teaching Hospital of the CHARITE, Germany

Introduction: In the last five years three INF beta preperations were licensed in Germany. Glatirameracetate (GLAT) and immunoglobulines (IVIG) are available. MS patients with exacerbating-remitting course have the choice between three INF beta products and in case of contradiction,side effects or ineffectiveness between GLAT, IVIG and azathioprine.

Methods: To compare the new immunological agents we evaluated prospectively the course of the disease in 363 MS patients (EDSSS 0 – 3,5) treated with INFb 1b n=86 ,INFb 1a i.m. n=88, INFb 1a s.c. n=54, Glat n=86, IVIG n=49. The baseline data and the follow up data (EDSS, number of exacerbations, side effects) were documented (data base MUSIS) and evaluated with statistical methods.

Results: The baseline data were comparable concerning mean age (range 36.0 – 36.7), mean duration of disease (range 6,7 –9,6), relapse rates (2,2 –2,1), EDSS (range2.0 – 2.2). Scheduled visits were every 3 months in the first year and every 6 months in the second one . Until now we evaluated the first 12 months of observation. All applied agents reduced the relapse rates. The relapse rates ranged from 0.43 (GLAT) and 0.9 (INFb1b). The mean percentage of relapse free patients was 58% (range 67% GLAT to 46% IVIG). The mean percentage of patients free of progression was 87% (range 93% INF 1a s.c. to 82% INF 1b). The mean discontinuation rate was 17% (range 13% GLAT to 26% INF 1a s.c).

Conclusions: The so far 12 month analysis revealed a benefit concerning relapse rates, freedom of relapses and progression for all applied immunomodulatory agents. The 18 months data and the 24 months data will be evaluated and presented.

O-29
PREDICTIVE VALIDITY OF THE MS FUNCTIONAL COMPOSITE IN PROGRESSIVE MS
Cohen JA a , Baier ML b , Cutter GR b , Kolb RE a , Rudick RA a .
a Cleveland Clinic, Cleveland, OH, USA and
b AMC Cancer Center, Lakewood, CO, USA.

Background: Followup of subjects in the U.S. Phase 3 study of Interferon beta-1a in relapsing MS showed baseline MS Functional Composite (MSFC) and 2-year change to be highly predictive of longterm disability, conversion to progressive MS, and brain atrophy.

Aim: To assess the predictive validity of the MSFC in progressive MS.

Methods: In a previously reported study carried out 7/89-8/93, 60 subjects with progressive MS and Expanded Disability Status Score 3.5-6.5 were randomized to oral methotrexate or placebo for 2 years. Baseline MSFC Z-scores and 1-year change were calculated retrospectively. Chart review or phone interview in 2/01 assessed whether the subjects were alive vs. date and cause of death, living situation, and ambulation status.

Results: Followup included all 60 subjects 10.0 +/- 1.5 years after baseline. The mean baseline MSFC was –2.26 +/- 2.04 for 41 subjects nonambulatory/dead at followup vs. –1.28 +/- 1.67 for 19 still ambulatory subjects (p=0.0127). One subject with a baseline MSFC of –3.88 due to poor PASAT performance remained able to walk unassisted but became severely demented. Mean 1-year MSFC change (available on 42 subjects) was –2.90 +/-5.09 for 29 subjects now nonambulatory/dead vs. +0.36 +/- 0.62 for 13 subjects still ambulatory (p=0.002). Logistic regression analysis of baseline MSFC vs. current ability to walk (19 ambulatory, 41 nonambulatory/dead) yielded estimated risk coefficient=0.396, p=0.018, odds ratio=1.49, 95% confidence interval=1.07-2.06. Logistic regression analysis of 1-year MSFC change vs. current ability to walk (13 ambulatory, 29 nonambulatory/dead) yielded estimated risk coefficient=0.465, p=0.068, odds ratio=1.59, 95% confidence interval=0.97-2.62.

Conclusions: Baseline MSFC and 1-year change in 60 subjects with progressive MS predicted disability 10 years later, supporting the predictive validity of the MSFC.

O-30
THE MSFC: A SENSITIVE OUTCOME MEASURE FOR IDENTIFYING CHANGES IN NEUROLOGICAL FUNCTION DURING TREATMENT OF RELAPSES IN MS PATIENTS
Patzold T, Schwengelbeck M, Ossege LM, Malin JP, Sindern E.
Department of Neurology, Ruhr-University Bochum, Germany

The Multiple Sclerosis Functional Compsite (MSFC) has been developed as a new outcome measure in multiple sclerosis (MS). We examined the responsiveness of the MSFC compared to the Expanded Disability Status Scale (EDSS) during treatment of relapses in patients with multiple sclerosis (MS).

27 patients received 1000mg intravenous methylprednisolone (IV-MP) for 5 days, followed by oral methylprednisolone for 14 days. The MSFC and the EDSS-score were assessed on day 0, before the first corticosteroid treatment, on day 5, after the last course of IV-MP, and on day 20 after the treatment was finished. Before the first administration of the MSFC, patients were trained for the PASAT performing 3 test trials. In order to analyse practice effects, 10 MS patients without an acute exacerbation were tested three times under the same conditions as the treated group.

The median EDSS-score was 2.5 in both groups. On day 5 it remained unchanged in all treated patients, on day 20 a decrease of 0.5 EDSS point was observed in 5 patients, and in 2 patients an improvement with a decrease of more than 0.5 point occurred. There was no statistically significant difference between the EDSS-scores on day 0, 5 and 20. The mean MSFC-score in the treated group was –0.14 ± 0.63 on day 0, 0.17 ± 0.66 on day 5, and 0.42 ± 0.59 on day 20. On the last study day, 26 patients improved compared to day 0 with a mean change of 0.56 ± 0.37. The differences between the MSFC-scores at the three points of time were statistically significant for the treated group (p<0.001), but not for the control group.

The improvement in MSFC during treatment of relapses in MS patients seems to be real and not only the result of a practice effect. The MSFC appears to be more sensitive in detecting changes in neurological function than the EDSS.

O-31
HEALTH-RELEATED QUALITY OF LIFE IN SECONDARY-PROGRESSIVE MS PATIENTS: RESULTS FROM THE IMPACT STUDY
MILLER, DM A , COHEN, J A , TSAO, E B , KOOIJMANS, M B , SIMONIAN, N B . FOR THE IMPACT STUDY GROUP A MELLEN CENTER, CCF, CLEVELAND, OH, USA, B BIOGEN, INC.,CAMBRIDGE, MA., USA.

Background: As reported, the IMPACT study has demonstrated the benefit of Interferon beta-1a (INF$-1a) (Avonex) on disease progression as measured by the Multiple Sclerosis Functional Composite (MSFC) in patients with secondary progressive multiple sclerosis (SP-MS). The effect of treatment on quality of life (QOL) in this study has not been reported in detail.

Objective: To evaluate differences in QOL between treated and placebo subjects and to assess if the MSQLI provides data distinct from the objective measures.

Methods: The MSQLI includes the generic SF-36 (2 scales), and 9 disease specific measures. MSFC, EDSS and MSQLI were collected at baseline and months 12, 15 and 24.

Results: 436 subjects were
enrolled, 219 to placebo and 217 to INF$-1a. Eight of 11 MSQLI scales were statistically better and other 3 trended to improvement in the treatment group. The placebo group trended to worsening in 10 of 11 scales. The generic component of the MSQLI was moderatly correlated with an objective measure ( SF-36 Physical Component Score at 24 month and the 24 month Timed 25-foot Walk (T25W), r=0.37, p<.0001). As expected, correlations between disease specific QOL components and the objective measures were weaker but with predictable associations, e.g., 24-month Impact of Visual Impairment and 24 month Nine Hole Peg Test, r=-0.18, p=.0022.

Conclusion: Patients who received Avonex had substantially better QOL . QOL assessment represents a unique endpoint.

O-32
RESULTS OF A DOUBLE-BLIND, RANDOMIZED, PLACEBO-CONTROLLED,{TC \L 1 ""}PHASE II TRIAL OF ANTEGREN™??NATALIZUMAB) IN SUBJECTS WITH RELAPSING MULTIPLE SCLEROSIS (MS){TC \L 1 ""}
Miller D 1 , Khan O 2 , Sheremata W 3 , Blumhardt L 4 , Rice G 5 , O’Connor P 6 , the International Antegren MS Trial Group.
Institute of Neurology UK 1 , Detroit USA 2 , Miami USA 3 , Nottingham
UK 4 , London Canada 5 , Toronto Canada 6 .

Background: Adhesion of lymphocytes to endothelium plays a critical role in the trafficking of these cells into tissue. Antegren, a recombinant humanized monoclonal antibody, binds to a key alpha-4-integren, VLA-4 found on lymphocytes, and blocks its interaction with its receptor, VCAM-1 present on endothelium. A previous trial of Antegren in relapsing MS demonstrated that short term blockade of this pathway reduces new inflammatory lesions in the brain.

Aim: To assess the effect of six, monthly IV administrations of Antegren (3.0 or 6.0 mg/kg) vs placebo on brain lesion activity in patients with relapsing MS.

Patients and methods: 213 patients with relapsing MS were randomized to receive either Antegren at 3 or 6 mg/kg or placebo IV every 4 weeks for 6 months followed by a 6 month safety follow-up. Inclusion criteria included relapsing disease with 2 relapses within the last 2 years, an EDSS of 2.0 to 6.5 and no concomitant treatment with interferon or glatiramer acetate. T1 Gadolinium (Gd)-enhanced and T2-weighted imaging was performed pretreatment and every 4 weeks during the 6 month treatment period. The primary endpoint was the number of new Gd-lesions over the 6 month treatment period. Clinical measures included the number of relapses, EDSS, MSFC, and a global visual analogue measure of patient self-reported well-being.

Results: The patients in the three treatment groups were balanced for baseline demographic parameters; the mean age was 43.5 years, mean EDSS was 4.3 and 68% were relapsing-remitting and 32% secondary progressive. The mean number of new Gd-lesions was reduced by over 88% with Antegren compared to placebo; (p<0.0001). The reduction in Gd-lesions was apparent within 4 weeks of treatment. The proportion of relapse-free subjects was significantly higher in both Antegren treatment groups (p=0.03). Antegren was well tolerated with a similar number of subjects experiencing treatment-emergent adverse events in each of the treatment groups. On a global measure of patient well-being, Antegren-treated patients felt significantly better compared to placebo (p=0.03).{tc \l 2 ""}

CONCLUSION: BLOCKADE OF THE VLA-4 PATHWAY IN MS WITH ANTEGREN RESULTS IN A RAPID AND PROFOUND REDUCTION IN NEW INFLAMMATORY LESIONS IN THE BRAIN. SIGNIFICANT REDUCTIONS IN RELAPSES WERE ALSO OBSERVED. REPEATED INFUSIONS OF ANTEGREN WERE SAFE AND WELL TOLERATED. PIVOTAL STUDIES WITH ANTEGREN IN MS ARE CURRENTLY PLANNED.

O-33
NEW DIAGNOSTIC CRITERIA FOR MULTIPLE SCLEROSIS
Thompson AJ, McDonald WI, Compston DAS, Edan G, Goodkin D, Hartung H-P, Lublin FD, McFarland HF, Paty D, Polman CH, Reingold SC, Sandberg-Wollheim M, Sibley W, van den Noort S, Weinshenker B, Wolinsky JS.
Institute of Neurology, London, UK

Background: The most commonly used MS diagnostic criteria were developed almost twenty years ago, but do not incorporate the increasingly useful information provided by Magnetic Resonance Imaging (MRI) or satisfactorily address the diagnostic issues surrounding primary progressive MS.

Aim: An international group of experts reviewed the existing criteria in the light of recent clinical and MR related advances with a view to recommending revisions as appropriate.

Results: New evidence based diagnostic criteria were developed. They continue to emphasize the need for dissemination in time and space of lesions expressed clinically or by paraclinical tests. Barkhof’s MRI criteria provide the basis for determining dissemination in space and time using imaging. The roles of CSF analysis and visual evoked potentials are placed into context. Criteria for diagnosis of primary progressive MS are included. Finally, the possible outcome of a diagnostic evaluation is considered to be ‘MS’, ‘possible MS’, or ‘not MS’.

Conclusion: These new criteria help refine the role of paraclinical tests in assisting the clinical diagnosis of MS. It is anticipated that the criteria will be updated as new information becomes available.

O-34
DIAGNOSIS OF MULTIPLE SCLEROSIS IN PATIENTS WITH CLINICALLY ISOLATED SYNDROMES USING THE NEW (MCDONALD) MRI CRITERIA AT THREE MONTHS.
Dalton CM, Brex PA, Miszkiel KA, O’Riordan JI, Thompson AJ, Miller DH.
NMR Research Unit, Dept. Of Clinical Neurology, Institute of Neurology, Queen Square, London WC1N 3BG.

Thirty-eight patients with clinically isolated syndromes (CIS) suggestive of multiple sclerosis (MS) were recruited since 1995 in an ongoing study. Patients were imaged at baseline, three months, one-year and three years.

All fifteen patients with CIS who developed clinical MS using the Poser criteria (14 definite, 1 probable) at three years had an abnormal baseline MRI. Twenty-three patients with CIS had no further neurological symptoms: sixteen had an abnormal MRI and seven had a normal baseline MRI.

The baseline and three-month MRI scans were retrospectively analyzed to see how many patients fulfilled the new (McDonald) MRI diagnostic criteria for MS. Five patients fulfilled these criteria with the required baseline MRI brain abnormalities and new gadolinium enhancing lesions at three months: 4/5 developed clinically definite MS and one had no further symptoms at three years.

In summary, using only the baseline and three-month scans, the new (McDonald) MRI criteria identified five of the 15 patients who developed clinical MS within three years of follow-up, and they were positive in only a small number of all CIS patients (7.9%). Not surprisingly, the criteria had a low sensitivity (27%) but high specificity (96%) and high positive predictive value (80%) for developing clinical MS.

O-35
SAFETY, TOLERABILITY AND EFFICACY OF ORALLY ADMINISTERED CANNABINOIDS IN MULTIPLE SCLEROSIS: A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED, TWO-FOLD CROSSOVER STUDY
Killestein J 1 , Hoogervorst ELJ 1 , Reif M 2 , Kalkers NF 1 , Van Loenen AC 1 , Staats PGM 3 , Gorter RW 4 , Uitdehaag BMJ 1 , Polman CH 1 .
1 VU Medical Center, Amsterdam, 3 TNO Prevention and Health, Leiden, The Netherlands. 2 European Institute for Oncological and Immunological Research, Berlin, Germany. 4 University of California, San Francisco Medical School, USA.

Anecdotal reports, preclinical and clinical data suggest that cannabis (marijuana) can alleviate symptoms like muscle spasticity, tremor and pain in multiple sclerosis (MS). We investigated safety, tolerability and efficacy of orally administered cannabinoids in MS.

Sixteen patients presenting with severe spasticity were enrolled. They received dronabinol (Marinol ® = delta-9-tetrahydrocannabinol (THC)), Cannabis sativa plant-extract and placebo capsules for 4 weeks each. Treatment periods were separated by 4 weeks wash-out. Safety and a wide variety of efficacy parameters were assessed every 2 weeks; visual analogue scales (VAS) on signs and symptoms were filled in daily by the patients themselves.

No safety concerns emerged during the trial. Although adverse events were more common during plant-extract treatment, their large majority was mild. Compared to placebo, neither four weeks THC, nor four weeks plant-extract treatment produced an objective reduction in muscle tone, nor a subjective reduction in spasticity as rated by VAS. THC treatment resulted in worsening of the MS Functional Composite score, mainly due to a significant worsening in arm/hand function. This study failed to demonstrate improvement of signs and symptoms in MS patients treated with orally administered cannabinoids. Therefore, at this moment, we can only caution against ‘off label’ usage of cannabinoids in MS.

O-36
SUCCESSFUL TREATMENT WITH IFN-BETA1B IN RELAPSING-REMITTING MULTIPLE SCLEROSIS (MS) PATIENTS IS ASSOCIATED WITH NORMALIZATION OF THE NUMBER OF IL-10 PRODUCING CD4 + T CELLS
van Boxel-Dezaire AHH ab , Smits M a , Uitdehaag BMJ b , Polman CH b , Nagelkerken L a .
a TNO Prevention and Health, Division of Immunological and Infectious Diseases, Leiden, The Netherlands
b Department of Neurology, University Hospital Vrije Universiteit, Amsterdam, The Netherlands

It is generally believed that the balance between Th1 and Th2 cells is disturbed in MS. However, the picture is unclear and increasingly challenged by observations that are inconsistent with the Th1/Th2 paradigm. Although IFN-beta is now widely used for treatment of MS, its mode of action still remains unclear; recent studies do not support a shift in the Th1/Th2 balance. We hypothesized that numbers of a putative regulatory T cell subset that is characterized by IL-10 production are decreased in MS patients and restored by successful IFN-beta1b treatment. In relapsing-remitting MS patients, numbers of Th2 cells were not different as compared with controls and did not change during treatment. In contrast, numbers of IL-10 producing CD4 + T cells were significantly decreased prior to treatment. Notably, normalization of the number of such T cells correlated with successful IFN-beta1b treatment. In contrast, treatment decreased the number of IL-10 producing monocytes in both clinical responders and nonresponders and did not affect the number of CD8 + T cells that produced IL-10. In conclusion, enhancement of the number of CD4 + T cells that spontaneously produce IL-10 may be an important mechanism in the therapeutic effect of IFN-beta1b. We therefore suggest that the CD4 + T cells that spontaneously produce IL-10 represent an important target for treatment of MS in particular, but may also represent pivotal cells in the regulation of a wider selection of autoimmune diseases.

O-37
INTRAVESICAL APPLICATION OF THE ENDOGENOUS CANNABINOID ANANDAMIDE IN THE RAT MODEL: PRELIMINARY DATA
Ost D, Van der Aa F, De Ridder D.
Dept. of Urology, UZ Gasthuisberg Leuven, Belgium

Background: Systemic administration of CB1 agonists such as d9-THC (known as the active compound in hasjies) is known to improve multiple sclerosis patients tremor, spasticity and bladder symptomatology.

Aim: Our aim was to test whether intravesical application of the endogenous cannabinoid anandamide could influence the urodynamic parameters in the long-term catheterised rat model.

Materials and methods: 14 male whistar rats (all weighing 350-400g) were implanted with a PE-50 catheter was in the bladder dome. On day 14 post-operatively anandamide was administered in a 10µM solution in seven rats, whilst the others received the vehicle (ethanol 94% in 1//10 aqueous solution). Urodynamics were performed before administration, right after and two days after administration.

Results: Comparing the urodynamic findings before and right after administration of anandamide there was a significant decrease in maximal detrusor pressure (p=0.0025). On the other hand there was a significant increase in volume (p=0.02) and an increase in the interval between two voiding cycles (p=0.02). In the alcohol group there was a significant increase in maximal detrusor pressure (p=0.0008) and maximal voiding pressure (p=0.016). On day 2 after administration there was no significant difference in the alcohol group anymore. In the anandamide group the increase in volume (p<0.0001) and time between voiding cycles (p=0.05) was still significantly present.

Conclusion: Our data show that intravesical administration of CB-1 agonists such as anandamide influences the urodynamic parameters in the catheterised rat. Additional research in neurogenic bladder models and using long acting agonists is warranted.

O-38
ABNORMAL ENDOTHELIAL TIGHT JUNCTIONS IN ACTIVE LESIONS AND NORMAL-APPEARING WHITE MATTER IN
MULTIPLE SCLEROSIS
Kirk J a , Plumb J b , McQuaid S b , Mirakhur M b.
a CIIR, Queen’s University School of Medicine, Belfast, UK
b Neuropathology Lab. Royal Group of Hospitals Trust, Belfast, UK.

Background: Increased blood-brain barrier permeability is a characteristic feature of new and expanding inflammatory lesions in relapsing-remitting (RR) and chronic progressive (CP) multiple sclerosis (MS). The pathological mechanism for this increased permeability has not been demonstrated.

Materials and Methods: Frozen sections from neuropathologically characterised active plaques in 8 cases of MS were graded according to the relative abundance of oil-red O–positive cells. Using single and double immunofluorescence and confocal scanning laser microscopy the TJ-associated proteins ZO-1 and occludin were examined in relation to: endothelial integrity (Ulex), blood-brain barrier (BBB) leakage (fibrinogen), gliosis (GFAP), lymphocytic infiltration (LCA) and macrophage / microglial activation (HLA-DR). Blood vessels (10 per section) were systematically scanned to acquire image datasets for offline analysis.

Results: TJ abnormalities (i.e. beading, interruption or absence of fluorescence, separation or opening of junctions) were frequent (affecting 40% of vessels) in ORO-positive active plaques but less frequent in both chronic inactive lesions and normal-appearing white matter (NAWM, earlier data, <5%) and in normal and neurological controls (<2%). ‘Open’ junctions were seen both in active ORO-positive lesions and in microscopically inflamed blood vessels in NAWM.

Conclusions: Open and disrupted TJs, arising during the acute inflammatory phase of MS could be responsible for much of the BBB leakage seen in enhancing MRI lesions in vivo. Re-tightening of TJs is one likely outcome of corticosteroid therapy. Leakage and abnormal junctions are less evident in chronic inactive lesions, suggesting that restoration of TJs occurs naturally in the long term.

O-39
RE-EXPRESSION OF PSA-NCAM BY DEMYELINATED AXONS INHIBITS REMYELINATION IN MULTIPLE SCLEROSIS
Charles P a , Seilhean D b , Reynolds R C , Liblau R d , Zalc B a , Lubetzki C a, e
a INSERM U-495, ,
b Laboratoire de Neuropathologie, Hopital de la Salpêtrière, Paris;
C MS Brain Bank, Imperial College, Charing Cross Hospital, London,
d INSERM U-456,
e Fédération de Neurologie, Hôpital de la Salpêtrière, Paris.

IN THE EARLY PHASE OF MULTIPLE SCLEROSIS (MS) REMYELINATION MAY OCCUR. HOWEVER, MYELIN REPAIR IS IN MOST CASES INCOMPLETE. ONE POSSIBLE EXPLANATION TO ACCOUNT FOR THE FAILURE OF REMYELINATION WOULD BE THE EXISTENCE OF MECHANISMS INHIBITORY TO MYELIN REPAIR. DURING DEVELOPMENT, THE SIALYLATED FORM OF NCAM, PSA-NCAM, IS EXPRESSED AT THE AXONAL SURFACE AND ACTS AS A NEGATIVE REGULATOR OF MYELINATION. WE THUS QUESTIONED WHETHER IN MS, RE-EXPRESSION OF PSA-NCAM BY AXONS COULD OCCUR, AND THEREFORE ACCOUNT FOR THE FAILURE OF REMYELINATION. HERE WE SHOW, ON 40 DIFFERENT LESIONS FROM 25 MS BRAINS, THAT PSA-NCAM IS RE-EXPRESSED ON DEMYELINATED AXONS, WHEREAS IT IS ABSENT FROM THE PERIPLAQUE AND NORMAL APPEARING WHITE MATTER. IN CONTRAST, IN THE 10 SHADOW PLAQUES ANALYZED, REMYELINATED AXONS WERE NOT EXPRESSING PSA-NCAM. THESE DATA SUGGEST THAT PSA-NCAM COULD BE ONE OF THE AXONAL INHIBITORS OF MYELIN REPAIR. IN ADDITION , PRELIMINARY DATA ON AXONAL PSA-NCAM EXPRESSION IN EAE WILL BE PRESENTED.