MS Abstracts: 3d-2g

Recent MRI studies in Multiple Sclerosis have highlighted the potential role of Brain Brain Atrophy evaluation as a putative marker of disease progression.

In the present study, we evaluated the SupraTentorial and InfraTentorial Brain Volume in patients with Relapsing/Remitting Multiple Sclerosis (RR MS) and in healthy subjects.

Moreover, we determined whether Brain Volumes of MS patients are associated with different aspects of Brain MRI abnormalities and clinical findings.

Two-dimensional acquired MRI was performed on 52 Relapsing/Remitting Multiple Sclerosis and 30 healthy subjects. The volume of SupraTentorial and InfraTentorial structures was measured in selected representative slices.

Gd-enhancement, T₂ HyperIntense, T₁ HypoIntense (i.e. 'black holes') total lesion load, as well as the area of Corpus Callosum was calculated in the MS group and related to Brain Volume measures.

Correlations between MRI parameters and clinical features were also considered. MS patients had significantly lower SupraTentorial, InfraTentorial Brain Volume and Corpus Callosum area than healthy subjects (P<0.01).

SupraTentorial Brain Volume was significantly related to Corpus Callosum area (r=0.58; P<0.01) and T₁ HypoIntense Lesion load (r=0.48; P<0.01), but not with T₂ HyperIntense lesion load.

InfraTentorial/SupraTentorial ratio was significantly associated with disease duration and EDSS score (r=-0.34; P=0.02 and r=-0.49; P<0.01, respectively).

This study documents that Brain Atrophy is an early MRI finding in RR MS and it is closely related to 'Black Holes' burden.

The use of relative values (InfraTentorial/SupraTentorial ratio) may increase the conspicuity of correlation between clinical and MRI findings.

Objectives
Recent Phase III Clinical Trials of ImmunoModulatory therapies in Relapsing/Remitting Multiple Sclerosis have shown significant benefits of active treatment on relapse related end points, but effects on disability outcomes have been inconsistent.

These apparent discrepancies could be due to differences in the clinical end points employed, the behavior of placebo cohorts, or both.

Methods
Disability data from the placebo cohorts of two large Phase III Studies, the United States Glatiramer Acetate Trial (Copolymer-1 Multiple Sclerosis Study Group) and the multinational (Rebif) Interferon-beta-1a trial (PRISMS Study Group) were combined and masked (n=313).

Two groups of disability outcome measures were assessed.

• Firstly, measures of disability change (2 year EDSS difference and area under the EDSS/time curve, AUC) were calculated.

• Secondly, conventional disease progression end points ("confirmed progression" and "worsening to EDSS 6.0") were evaluated by using Kaplan-Meier analysis and compared with a categorical classification based on EDSS trends.

Results
The average increase in Disability for the entire cohort as assessed by mean 2 year EDSS change (<0.5 EDSS point) or mean AUC (+0.57 EDSS-years) was small.

For the "confirmed progression" end points, increasing the stringency of the definition lowered their incidence (from 32% with 1.0 point at 3 months, to 9% with 2.0 points at 6 months), but did not improve the positive predictive accuracy for "sustained progression" maintained to the end of the study.

The error rate for this outcome was about 50%. Worsening to EDSS 6.0 was a more reliable end point, but had even lower sensitivity (incidence <10%).

EDSS trend analysis showed markedly heterogeneous disease courses, which were then categorized into "stable" (26%), "Relapsing/Remitting" (59%), and "Progressive" (15%) courses.

Patients with the last course had deteriorated considerably by the end of 2 years (mean worsening of 2.0 EDSS points).

Conclusion
In Relapsing/Remitting Multiple Sclerosis treatment trials, the conventional measure of mean EDSS change has low sensitivity, whereas the widely applied confirmed progression end points have high error rates regardless of their definition stringency.

Alternative methods with better data utilisation include AUC summary measures and categorical disease trend analysis.

The Heterogeneity of Disability outcomes in short trials, combined with unreliable clinical end points, diminishes the credibility of therapeutic claims aimed at reducing irreversible Neurological Deficits.

The behavior of patients treated with placebo should be carefully analyzed before conclusions are drawn on the efficacy of putative treatments.

Mechanisms that contribute to increased female susceptibility to Multiple Sclerosis can be studied in the murine model of Experimental AutoImmune EncephaloMyelitis (EAE).

In this report, we compared Oral Tolerance induction in male and female B10.PL mice using fed Myelin Basic Protein (MBP) Ac1-11 peptide or a high-affinity analogue, Ac1-11[4Y].

We found that fed Ac1-11[4Y] Peptide, but not native Ac1-11, could limit cellular infiltration into the Central Nervous System (CNS) and protect male mice from EAE.

An effect that was completely obviated by castration. In contrast, female mice could not be Orally Tolerized or protected from EAE with either Peptide.

Tolerance induction in males was reflected by the appearance of Ac1-11[4Y]-reactive Splenocytes that produced a sharply increased ratio of Transforming Growth Factor-beta (TGF-beta):InterLeukin-2 (IL-2) and induced bystander suppression.

These data directly demonstrate gender differences in regulatory T-Cells, and support the concept that Androgens are involved in governing Oral Tolerance to EAE.

Copyright 1999 Wiley-Liss, Inc.

We investigated the effect of Amantadine on Cognitive processing in patients with Multiple Sclerosis (MS) and Fatigue with objective ElectroPhysiological measures.

Behavioral methods (Reaction Time, RT) and two different Event Related Potential (ERP) components measuring i) stimulus selection (Selection Negativity, SN) and ii) response selection (Lateralized Readiness Potential, LRP) were employed.

Twenty-four patients with clinical definite MS (10 Relapsing/Remitting and 14 Secondary/Progressive) and confirmed Fatigue in the past three months (Fatigue Severity Scale (FSS) > 4) were included.

Patients were randomized in a double-blind, placebo-controlled cross-over design. We found a difference between the two treatments for ERP measures to stimuli with relevant colour starting at about 200 ms.

This negativity had a higher amplitude during Amantadine treatment regardless of treatment order. The RT did not differ significantly between the treated and untreated groups.

Additional analysis indicated that patients with a disease duration of less than 7 years had a significant test position (practice effect), but no treatment effect, while patients with a longer MS duration showed no practice effect.

But, rather an improved reaction speed and increased ERP amplitude effects when treated with Amantadine.

The present findings suggest that Amantadine exerts beneficial effects on early Cognitive processes in patients with MS, but appears to be limited to subjects with a longer duration of the disease.

Objective
To review the clinical, laboratory, and radiological findings of 9 patients who had Progressive Idiopathic Myelopathy with evidence of Spinal Cord Necrosis.

Design And Methods
We reviewed personally examined cases of Myelopathy that fulfilled the following criteria:

1. Regional loss of reflexes, flaccidity, and muscle Atrophy
   
2. Magnetic Resonance Imaging showing a shrunken or Cavitated Cord without evidence of AterioVenous malformation
   
3. ElectroMyogram showing denervation over several contiguous Spinal Cord Segments with preservation of sensory potentials in some cases
   
4. The absence of evidence of Systemic Disease or Neoplasm

Results
The illness began in these patients after the age of 40 years, with prominent burning or tingling limb pain, occasionally with radicular features or with less well-defined back, neck, or abdominal pain.

Leg or infrequently arm weakness appeared concurrently or soon after the onset of pain. The most distinctive feature was a saltatory progression of symptoms, punctuated by both acute and subacute worsenings approximately every 3 to 9 months, culminating in Paraplegia or Tetraplegia.

The distinguishing clinical findings, together indicative of destruction of Gray Matter elements of the Cord, were limb Atrophy, persistent Areflexia, and Flaccidity.

The concentration of CerebroSpinal Fluid protein was typically elevated between 500 g/L and 1000 g/L, without OligoClonal Bands, accompanied infrequently by Pleocytosis.

Magnetic Resonance Imaging showed features suggesting Cord Necrosis, specifically swelling, T₂-weighted HyperIntensity, and Gadolinium enhancement over several Spinal Cord segments, succeeded months later by Atrophy in the same regions.

Necrosis of the Cord was found in biopsy material from one patient and postmortem pathology in another case, but Inflammation and blood vessel abnormalities were absent.

Only 2 patients had prolonged Visual Evoked Responses. The disease progressed despite ImmuneModulating treatments although several patients had brief epochs of limited improvement.

Conclusions
The saltatory course, prolonged Visual Evoked Responses in 2 patients, and a Cranial abnormality on Magnetic Resonance Imaging in another, raised the possibility of a link to Multiple Sclerosis.

However, the normal Cranial Magnetic Resonance Imaging scans in 6 other patients, uniformly absent OligoClonal Bands, and poor response to treatment were atypical for Multiple Sclerosis.

On the basis of shared clinical and laboratory features, Idiopathic Progressive Necrotic Myelopathy is indistinguishable from a limited form of Devic Disease.

We studied CD10 Ag of Neutral EndoPeptidase (NEP) and CD13 Ag of AminoPeptidase N (APN) expression on Peripheral Blood MonoNuclear Cells (PBMC), as cells activation markers and for their TransEndothelial migration properties in three groups of MS patients (total 58);

1. With Acute Exacerbation of MS (n = 18)
2. Primary/Progressive MS (n = 17)
3. With MS Remission (n = 23)

The control group (OND) consisted of 24 patients, suffering from Other NonInflammatory Neurological Diseases. CD10 Ag and CD13 Ag expression on PBMC was higher in clinically active MS (Acute Exacerbation and Progressive MS) compared to MS Remission and OND groups.

Our study suggests that CD10 Ag and CD13 Ag can be useful MonoNuclear Cell activation markers in the course of MS. CD13 Ag expression on PBMC may be also the sensitive marker of these cells TransEndothelial migration properties.

We analyzed longitudinally the numbers of CD3-CD16⁺(Natural Killer Cells, NK) and CD3-CD57⁺Cells (a subset of NK) in 15 IFN-ß-1b- and 12 IFN-ß-1a-treated Relapsing/Remitting Multiple Sclerosis (RRMS) patients.

IFN-ß-1b (Betaferon((R)))-treated RRMS patients showed a rapid and marked reduction in the number of both NK subsets which started 1 month after therapy initiation, and reached highest significance after 3 months (P=0.000); however, figures reverted to pre-treatment values following the appearance of Anti-IFN-ß AntiBodies.

In IFN-ß-1a (Avonex)-treated RRMS patients, the decrease in both CD3-CD16⁺and CD3-CD57⁺Cell number was slower but more persistent; anti-IFN-ß AntiBodies were only rarely detected in these patients, and at lower Titers than in IFN-ß-1b-treated ones.

Our findings suggest that NK cells might be one of the major Immunological targets of IFN-ß-based treatments.

The human Gelatinase B (MMP-9) Gene promoter region contains a CA microsatellite repeat and a single Nucleotide polymorphism which are known to influence transcriptional activity.

These two polymorphisms were used to investigate the existence of an association between Multiple Sclerosis (MS) susceptibility and the MMP-9 gene.

In a case-control analysis of 345 Swedish individuals and in a study of 125 Sardinian simplex families no Genetic associations between the Gelatinase B Gene polymorphisms and MS susceptibility were found.

These data reinforce the suggestion of Epistasis in the regulation of the MetalloProteinase-inhibitor balance in MS.

Tumor Necrosis Factor-alpha (TNF-) has been proposed as one of the key mediators of inflammatory diseases of the CNS such as Multiple Sclerosis.

It has been shown to induce the expression of Adhesion Molecules which is a prerequisite for the transmigration of Immune Cells through the Blood-Brain Barrier.

We therefore investigated the role of TNF- in the expression and release of Vascular Cell Adhesion Molecule-1 (VCAM-1) in cultures of Human Cerebral Endothelial Cells (HCEC).

In comparison with Peripheral Blood MonoNuclear Cells (PBMC).

A time- and dose-dependent expression of VCAM-1 and release of soluble VCAM-1 was detected in HCEC but not PBMC.

TNF--induced release of soluble VCAM-1 was further increased by cotreatment with Interferon-ß (IFN-ß), while IFN-ß alone did not affect VCAM-1 expression or the release of soluble VCAM-1.

In addition, we observed that preincubation of PBMC with soluble VCAM-1 completely blocked their adhesion to HCEC.

In conclusion, the ProInflammatory effect of TNF- on HCEC, which involves the induction of VCAM-1 expression and cellular adhesion, is followed by the consecutive effects of soluble VCAM-1 release in blocking adhesion and downregulating further cellular infiltration.