YI1 - Young Investigators 1
YI1.1 The novel TH17-associated cytokine IL-26 mediates BBB breakdown and neuroinflammation
B Broux1, L Hachehouche1, H Kebir1, S Terouz1, L Bourbonniere1, A Prat1
1Université de Montréal, CRCHUM, Montréal, QC, Canada
Background: It is well established that TH17 lymphocytes are crucial in the pathogenesis of the chronic autoimmune disease multiple sclerosis (MS). However, the importance of IL-17 in MS is still under debate, and other TH17-associated cytokines are likely more crucial in the initiation and maintenance of neuroinflammation.
Objectives: In this study, we addressed the function of IL-26 and its role as TH17-associated cytokine in blood brain barrier (BBB) breakdown and neuroinflammation.
Methods: To establish that IL-26 is a TH17-associated cytokine, qPCR for IL-26 and established TH17 markers was performed on differentiated TH17 cells. The expression of IL-26 was confirmed by western blot (WB) and immunohistofluorescence (IHF). ELISA was used to determine expression of IL-26 in serum and cerebrospinal fluid (CSF) of MS patients and controls, and to analyze supernatant of human blood brain barrier endothelial cells (BBB-ECs) after IL-26 treatment. Expression of the IL-26R (IL-10Rbeta/IL-20Ralpha) and tight junction proteins on BBB-ECs was analyzed using WB and IHF. Permeability of BBB-EC monolayers after IL-26 treatment was assessed using dextran and BSA diffusion assays. In vivo permeability after i.p. IL-26 treatment of C57Bl/6 mice was assessed by IHF (Evans Blue, fibrinogen and ICAM-1) and 2-photon microscopy (fluorescent dextran).
Results: We demonstrate that IL-26 is specifically produced by human TH17 lymphocytes and that it correlates strongly to other TH17-associated markers. IL-26 is increased in the serum and CSF of untreated MS patients, as compared to controls or to treated MS patients. Human BBB-ECs express a functional IL-26R both in vitro and in situ, since they respond to IL-26 treatment by secreting IL-8 and IP-10. IL-26 treatment of BBB-EC monolayers increases their permeability and decreases expression of the tight junction molecule occludin. In vivo, IL-26 treatment increases Evans Blue extravasation in the CNS. Furthermore, we find a significant perivascular accumulation of fibrinogen 2 to 8 hours after IL-26 injection, an upregulation of ICAM-1 on the surface of BBB-ECs, and perivascular accumulation of immune cells in the CNS. This was confirmed by in vivo two-photon microscopy, showing leakage of fluorescent dextran after injection of IL-26.
Conclusions: Taken together, these data strongly suggest that IL-26 i) is a TH17-associated cytokine, ii) is correlated to MS disease activity and iii) increases BBB permeability and transmigration of TH lymphocytes, and possibly other immune cells.
YI1.2 DICAM: a novel molecular effector in neuroinflammation
S Ghannam1, J Alvarez2, H Kebir2, L Bourbonniere1, A Prat1
1CRCHUM, Neuroimmunology, Montreal, QC, Canada, 2CRCHUM, Montreal, QC, Canada
Background: TH17 lymphocytes, are important contributors of multiple sclerosis (MS) lesion formation. Pathogenic TH17 lymphocytes express pro-inflammatory cytokines and factors and are known to migrate more readily across CNS barrier, including the blood-brain barrier (BBB). We performed proteomic profiling of human TH17 lymphocytes, and compared it to TH1 and TH2 lymphocytes. We found that Dual Ig domain containing Cell Adhesion Molecule (DICAM) is specifically up-regulated in TH17 lymphocytes. DICAM is a new member of the immunoglobulin superfamily known to interact with avb3 integrin expressed by endothelial cells (ECs).
Objectives: While expression and function of DICAM in autoimmune neuroinflammation remains unexplored. In the current study, we sought to evaluate the role of DICAM in CNS inflammation, in the migration of encephalitogenic TH17 lymphocytes to the CNS.
Methods: To identify expression of DICAM, we used qPCR and flow cytometry of differentiated TH1 and TH2 and TH17 lymphocytes and on different subset of human immune cells, using blood from healthy donors and MS patients. By immunohistochemistry, we evaluated DICAM expression by using our large collection of CNS material collected from EAE animals, MS patients and controls.
Results: We demonstrated that DICAM is mainly expressed by TH17 lymphocytes. We showed that the expression of DICAM is strongly associated with expression of ROR-γ, IL-23R, IL-17, IL-22, GM-CSF and GZMB expression in human CD4+ lymphocytes, and to a lesser extent with TH1 CD4+ lymphocytes. DICAM was not expressed by CD19+ B lymphocytes, CD14+ monocytes or CD83+ Dendritic cells. These data are the first to demonstrate that DICAM is specifically expressed on the surface of potentially encephalitogenic TH17 lymphocytes and that expression of DICAM is regulated by IL-23, IL-1 and IL-6, cytokines which are involved in CNS autoimmune diseases. Confocal microscopy of MS brain lesions revealed the presence of DICAM-expressing CD4+ T lymphocytes in active demyelinating lesions and in some early pre-active lesions. DICAM-expressing cells were found to co-express IL-17. Finally, qPCR analysis of DICAM expression in CD4+ and CD8+ T lymphocytes collected from the blood of MS patients revealed a significant up-regulation of DICAM in untreated RRMS patients, as compared to healthy donors.
Conclusions: These data are in strong support of the role that DICAM could play in the transmigration and the recruitment of TH17 lymphocytes across CNS vascular barriers.
YI1.3 Clinical disease burden predicts myelin water fraction in multiple sclerosis
E Monohan1, SM Hurtado Rúa2, K Fujimoto1, S Pandya3, EM LoCastro3, M Dayan3, J Perumal1,4, N Nealon1, T Vartanian1,4, TD Nguyen3, A Raj3, SA Gauthier1,4
1Weill Cornell Medical College, Department of Neurology, New York, NY, United States, 2Weill Cornell Medical College, Department of Public Health, New York, NY, United States, 3Weill Cornell Medical College, Department of Radiology, New York, NY, United States, 4Weill Cornell Medical College, Feil Family Brain and Mind Research Institute, New York, NY, United States
Background: An imaging marker that can accurately and specifically ascertain myelin content is essential to investigate myelin variability within lesions and normal appearing white matter (NAWM) and to explore predictors of these differences among MS patients. T2 relaxometry is an MRI technique in which the contribution of water associated with myelin can be represented as myelin water fraction (MWF).
Objectives: In this study we applied our fast whole brain T2 acquisition (T2prep SPIRAL) to a large cohort of patients with multiple sclerosis (MS) and investigated the distribution and predictors of MWF.
Methods: One hundred and forty one MS patients and 10 age-matched healthy controls (HC’s) had T2prep 3D SPIRAL sequence acquired. The SPIRAL data was analyzed with a spatially constrained multi-Gaussian post-processing algorithm to create MWF maps. For each patient, the distribution of MWF values was modeled using a mixture of two gamma distributions. Multi-variate linear regression models were utilized to predict white matter MWF distribution.
Results: Among all patients, the mean NAWM MWF (0.12 ± 0.05) was significantly higher compared to lesion MWF (0.05 ± 0.05), p ≈ 0 in a voxel-based analysis. Individual whole brain white matter MWF in patients was modeled and followed a bi-model modeled distribution (94%) as compared to HC’s (10%). The strongest predictive model (adjusted R2 = 0.89, p< 2.2 x 10-16) revealed a significant association with increasing EDSS (p = 3.84 x 10-5) and longer disease duration (p = 0.0122) with lower MWF values in lower curve of the bi-model distribution.
Conclusions: Through our technique, we efficiently assessed whole brain white matter MWF in a large cohort of MS patients. The distribution of white matter MWF follows a bi-model distribution, likely reflecting lesion and NAWM. Increasing clinical burden of disease predicts lower MWF values which suggests a progressive loss of myelin with accumulating disease. Our results represent one of the first quantitative studies characterizing the distribution of whole brain white matter MWF distribution, and relating these measures to clinical disease burden. Importantly, we have identified factors that may potentially contribute to lower WM myelin values; these variables and potentially others will need to be considered when designing remyelination treatment trials.
YI1.4 In vivo 7T MRI characterization of leptomeningeal enhancement in multiple sclerosis
L Vuolo1,2, P Sati1, M Absinta1,3, I Cortese4, DS Reich1
1National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS), Translational Neuroradiology Unit, Bethesda, MD, United States, 2University of Florence, Departments of Neurology and Radiology, Florence, Italy, 3Scientific Institute, Vita-Salute San Raffaele University, Neuroimaging Research Unit, Institute of Experimental Neurology, Milan, Italy, 4National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS), Bethesda, MD, United States
Background: Leptomeningeal inflammation has been described and pathologically documented in multiple sclerosis (MS). Typically, clusters of inflammatory cells in the cerebral leptomeninges are closely associated with meningeal vessels. Within the subarachnoid space, focal gadolinium (gad)-enhancement on T2-FLAIR 3T MRI has recently been recognized to be a potential in vivo marker of leptomeningeal inflammation in MS. However, the structural correlates of this enhancement have remained elusive, probably due to the small dimensions of the inflammatory clusters.
Objectives: Structural in vivo characterization of leptomeningeal enhancement (LME) in multiple sclerosis (MS) via 7 tesla (7T) MRI.
Methods: On a 7T MRI system, we studied 7 cases with known LME based on prior 3T scans. We acquired whole-brain 3D T2-FLAIR and T1-weighted magnetization-prepared rapid gradient echo (T1-MPRAGE) scans, as well as high-resolution multislice gradient-echo scans providing T2* contrast (voxel size=0.2x0.2x1 mm) and acquired in two planes. Sequences were repeated before and after injection of 0.1 mmol/kg of gadolinium contrast.
Results: In all cases, LME was stable since the 3T scan and was clearly detectable on post-gad T2-FLAIR. In all cases, LME was seen to be closely related to one or more meningeal vessels, which were clearly depicted on the T2* sequence. Despite the high spatial- resolution scans, no structural finding was found. However, after gad injection, focal bright signal strictly adjacent to a vessel was seen on both T2-FLAIR and T2*. This finding is compatible with leakage of gad from this vessel, with subsequent local flow within the CSF near the vessel. Repetition of the T2-FLAIR scan over the first hour following gad injection demonstrated that the shape and size of the enhancing focus remained constrained.
Conclusions: No soft-tissue correlates of LME in MS are seen even on high-resolution 7T MRI scans. However, images acquired post gad suggest that LME detected on T2-FLAIR MRI is probably due to focal opening of the blood-CSF barrier. In visualized foci, spread of gad is limited in space, perhaps by an inflammatory scar. Our findings remain consistent with the pathological description of organized meningeal inflammation described in MS.
YI1.5 Multiple sclerosis deep grey matter: the relation between demyelination, neurodegeneration, inflammation and iron
JM Frischer1, L Haider1, C Simeonidou2, G Steinberger1, S Hametner1, N Grigoriadis2, G Deretzi2, GG Kovacs3, A Kutzelnigg1, H Lassmann1
1Medical University Vienna, Center for Brain Research, Vienna, Austria, 2Aristotle University of Thessaloniki, Thessaloniki, Greece, 3Medical University Vienna, Institute of Neurology, Vienna, Austria
Background: In Multiple Sclerosis, diffuse degenerative processes in the deep grey matter have been associated with clinical disabilities.
Objectives: Our aim was to analyze DGM pathology in MS patients with a focus on the incidence and topographical distribution of lesions, their relationship to inflammation, and the underlying mechanisms of demyelination and neurodegeneration.
Methods: We performed a systematic study on a total sample of 75 MS autopsy patients and twelve controls. In addition, detailed analyses of inflammation, acute axonal injury, iron deposition, and oxidative stress were performed on a subsample of MS and control patients.
Results: MS deep grey matter was affected by two different processes: the formation of focal demyelinating lesions and diffuse neurodegeneration. Deep grey matter demyelination was most prominent in the caudate nucleus and hypothalamus and could already be seen in early MS stages. Lesions developed on the background of inflammation. Deep grey matter inflammation was intermediate between low inflammatory cortical lesions and active white matter lesions. Demyelination and neurodegeneration were associated with oxidative injury. Iron was stored primarily within oligodendrocytes and myelin fibres and released upon demyelination. In addition to focal demyelinated plaques, the MS deep grey matter also showed diffuse and global neurodegeneration. This was reflected by a global reduction of neuronal density, the presence of acutely injured axons, and the accumulation of oxidised phospholipids and deoxyribonucleic acid in neurons, oligodendrocytes, and axons. Neurodegeneration was associated with T-cell infiltration, expression of inducible nitric oxide synthase in microglia, and profound accumulation of iron.
Conclusions: In conclusion, we show that the DGM is profoundly involved in the disease progression of MS patients and appears to contribute significantly to the global accumulation of disability in MS patients. In addition to focal demyelination, a diffuse neurodegenerative process occurs in the DGM and is associated with clinical disability. This process may be related to increased oxidative injury and anterograde or retrograde degeneration in a brain area with exceptionally high iron content.
YI1.6 Regional thalamic damage and cognitive impairment in patients with multiple sclerosis: a multicenter study
A Bisecco1, MA Rocca1,2, E Pagani1, F Barkhof3, N Muhlert4, N De Stefano5, C Enzinger6, A Gallo7, HE Hulst3, K Abdel-Aziz4, ML Stromillo5, F Fazekas6, G Tedeschi7, G Comi2, M Filippi1,2
1San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Neuroimaging Research Unit, Institute of Experimental Neurology, Milan, Italy, 2San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Department of Neurology, Milan, Italy, 3VU Medical Centre, Radiology and Image Analysis Centre (IAC), Amsterdam, Netherlands, 4Institute of Neurology, UCL, NMR Research Unit, London, United Kingdom, 5University of Siena, Dept. of Medicine, Surgery & Neuroscience, Siena, Italy, 6Medical University of Graz, Department of Neurology, Graz, Austria, 7Second University of Naples, Department of Neurology, Naples, Italy
Background: Cognitive impairment affects a large proportion of MS patients and has been related to atrophy and diffusivity abnormalities of the thalamus.
Objectives: In this multicenter study, we explored the contribution of regional thalamic structural connectivity abnormalities to cognitive impairment in MS patients.
Methods: Brain dual-echo, 3D T1-weighted, and diffusion tensor (DT) MRI sequences were collected from 52 relapsing-remitting MS patients and 57 healthy controls (HC) from six European centers. RAO’s neuropsychological battery and Wisconsin Card Sorting Test were assessed. Patients with ⩾2 abnormal neuropsychological tests were considered cognitively impaired (CI). Thalamic subdivision in connectivity defined regions (CDRs) according to cortical projections was performed using Diffusion Tractography-Based Parcellation. Selected target regions were: frontal (F), motor (M), post-central (PC), posterior parietal (PP), temporal (T) and occipital (O) regions. A probabilistic atlas of CDRs was created from HC images and applied to all subjects to derive average values of fractional anisotropy (FA) and mean diffusivity (MD). Between-group differences of global and CDRs thalamic FA/MD values, adjusted for centre, were investigated. Correlations between FA/MD values with global and specific cognitive Z scores were also assessed.
Results: Twenty-two (43%) MS patients were CI. Compared to HCs, MS patients had: 1) reduced thalamic volume, bilaterally (p< 0.0001); 2) increased FA of the bilateral (B) global thalamus, B F-CDRs, B M-CDRs and B O-CDRs (0.003< p< 0.04); 3) decreased FA of B T-CDRs (0.0001< p< 0.008); 4) increased MD of B F-CDR, B T-CDR and B O-CDRs (0.0001< p< 0.009). Compared to cognitively preserved patients, CI patients had: 1) reduced B thalamic volumes (p< 0.0001); 2) increased FA of B global thalamus and left F-CDRs, B M-CDRs, B PC-CDRs and B O-CDRs (0.0004< p< 0.05); 3) increased MD of left PC-CDRs, B T-CDRs and B O-CDRs (0.03< p< 0.002). Significant correlations were found between global/specific cognitive Z scores and thalamic volumetric and diffusivity abnormalities.
Conclusions: Thalamic involvement in MS is a result of a complex balance between damage to the gray matter (GM) (as detected by increased FA) and white matter (WM) (as detected by reduced FA), with a different distribution in thalamic subregions. The involvement of GM in anterior (F-/M-areas connected) and lateral (P-/O-areas connected) thalamic subregions contributes to cognitive impairment in these patients.
YI1.7 Changes in thalamic resting-state functional connectivity induced by a home-based cognitive rehabilitation program in patients with multiple sclerosis
L De Giglio1, F Tona1, N Petsas1, F De Luca1, L Prosperini1, C Pozzilli1, P Pantano1
1Sapienza University of Rome, Rome, Italy
Background: Mechanisms underlying cognitive dysfunction and recovery in Multiple sclerosis (MS) are still matter of debate. Recently we demonstrated that thalamic Resting State Network (RSN) is disrupted in MS and that decreased performance in cognitive tests is associated with alteration of thalamo-cortical functional connectivity (FC) (Tona et al. Radiology 2014).
Objectives: The aim of the present study is to investigate with resting state (RS) fMRI changes in thalamic connectivity induced by cognitive rehabilitation (CR). For this purpose we used the videogame “Dr. Kawashima Brain Training” (DKBT, Nintendo, Japan), which we have recently shown to be effective in improving attention, processing speed and working memory in patients with MS (De Giglio et al. ECTRIMS 2013)
Methods: This was a randomised, wait-list control study. MS patients with failure of at least one between Stroop Test (ST), Paced Auditory Serial Addition Test (PASAT), Symbol Digit Modalities Test (SDMT), were submitted to an 8-week home-based CR program playing DKBT. They underwent clinical evaluation and 3Tesla RS-fMRI at baseline (T0) and after CR (T1). FMRI data were analyzed using a seed-based method to identify the thalamic RSN. Between-group analysis of RSN changes at T1 was performed using a two-sample t-test model (unpaired, cluster level p< 0.05, FWE corrected) with the FSL software. Clinical variables were entered into a one-sample model to calculate correlations with FC in the patient group (cluster level p< 0.05, FWE corrected).
Results: Twenty-four patients were randomly assigned to either intervention group (n=12) or control group (n=12). We found a significant effect of DKBT on PASAT (F=6.616, p=0.018) and ST (F=5.325, p=0.030). At T1, thalamo-cortical FC showed significant different patterns in the intervention group when compared with controls. Moreover we observed that an improvement in PASAT and ST scores after intervention was related with an increased thalamic FC in specific brain areas.
Conclusions: Our study underlines the relevance of thalamic regulation of the brain networks involved in cognitive processes. We suggest that thalamic FC modifications may be considered as a functional substrate for clinical improvement induced by cognitive rehabilitation.
YI2 - Young Investigators 2
YI2.1 Is focal leptomeningeal enhancement an in vivo imaging biomarker for meningeal inflammation?
M Absinta1,2, L Vuolo1, G Nair1, P Sati1, M Dragan3, MI Reyes-Mantilla4, M Filippi2, PA Calabresi4, CA Pardo4, DS Reich1,4
1Translational Neuroradiology Unit, National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, United States, 2Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy, 3Flow Cytometry Core Facility, Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, United States, 4Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
Background: Meningeal inflammation might contribute to myelin-specific immunological response and supial cortical injury in MS. A spectrum of meningeal pathological findings, typically varying degrees of inflammatory cell clustering, has been described, however a validated imaging correlate is lacking. Recently, our lab has identified stable foci of leptomeningeal enhancement on post-Gad T2-FLAIR scans in 33% of progressive MS patients.
Objectives: To investigate the histopathological correlate of in vivo leptomeningeal enhancement and its spatial relationship with demyelinated cortical lesions in the formalin-fixed brain of two progressive MS patients.
Methods: Accurate in vivo 3T and postmortem 7T MRI-guided pathology to the targets was achieved using an individualized, MRI-designed and 3D-printed cutting box for fixed brains. Ten-µm cryosections were stained for H&E and LFB-PAS and compared with the 7T postmortem MRI from the same location. Immunohistochemistry was performed with a multiplex of primary antibodies (including CD45, CD3, CD8, CD68, IBA1, myelin/PLP, fibrinogen, MAP2, DAPI) on representative sections.
Results: Four foci of meningeal enhancement were detected on longitudinal post-Gad FLAIR scans in these patients. These foci were located in cerebral sulci affected by demyelinated cortical lesions as seen on the postmortem 7T MRI and confirmed with myelin/PLP immunofluorescence. Diffuse leptomeningeal perivascular inflammation (including CD8 T cells, B cells, and macrophages) was detected in the meninges where in vivo meningeal enhancement was discovered. Two sulci, negative for in vivo meningeal enhancement, did not show perivascular clusters of inflammatory cells, regardless of the presence of cortical pathology.
Conclusions: In vivo focal leptomeningeal enhancement is a marker of perivascular meningeal inflammation, which is prevalent in MS. The perivascular nature of this inflammation, and in particular its association with abnormal vascular permeability, suggests that there is persistent communication between peripheral and central nervous system immunity, even in progressive MS. Improvement in subpial cortical lesion detection in vivo, investigation of the effect of anti-inflammatory therapies on enhancement, and additional characterization of enhancing and nonenhancing foci of leptomeningeal inflammation, might help further elucidate the pathophysiological relevance.
YI2.2 Retinal measures reflect global neurodegeneration and inflammation; a 4-year longitudinal study of optical coherence tomography and MRI in MS
S Saidha1, O Omar Al-Louzi1, J Ratchford1, P Bhargava1, J Oh1, S Newsome1, J Prince2, D Pham3, S Roy3, P Van Zijl4, L Balcer5, E Frohman6, D Reich7, C Crainiceanu8, P Calabresi1
1Johns Hopkins University School of Medicine, Dept of Neurology, Baltimore, MD, United States, 2Johns Hopkins University School of Medicine, Dept of Electrical and Computer Engineering & Dept of Computer Science, Baltimore, MD, United States, 3Johns Hopkins University School of Medicine, Dept of Electrical and Computer Engineering & Dept of Radiology and Radiological Sciences, Baltimore, MD, United States, 4Johns Hopkins University School of Medicine, Dept of Radiology and Radiological Sciences, Baltimore, MD, United States, 5New York University Langone Medical Center, Dept of Neurology, New York, NY, United States, 6University of Texas Southwestern, Dept of Neurology and Ophthalmology, Dallas, TX, United States, 7National Institute of Neurological Disorders and Stroke, Translational Neuroradiology Unit, Bethesda, MD, United States, 8Johns Hopkins University, Dept of Biostatistics, Baltimore, MD, United States
Background: Optical coherence tomography (OCT) segmentation derived ganglion cell layer+inner plexiform layer (GCIP) thickness has superior structure-function relationships than conventional peripapillary retinal nerve fiber layer (RFNL) thickness in MS. Although RNFL and GCIP thicknesses correlate with whole brain volume cross-sectionally in MS, it is unclear whether atrophy within retinal and brain compartments are related longitudinally. Baseline inner nuclear layer (INL) thickness might predict inflammatory activity, but how these relate over time is unknown.
Objectives: To determine whether atrophy of specific retinal structures is associated with atrophy of specific brain sub-structures and accumulation of lesions in MS.
Methods: Cirrus-HD OCT (with automated segmentation) and clinical testing was performed in 107 MS patients bi-annually (mean follow-up: 42-months). MRI brain scans (3T) were performed annually (mean follow-up: 35 months). Brain sub-structure volumes were determined using Lesion-TOADS. Linear regression was used to estimate individual-specific rates of change in retinal and brain-subcompartment measures. These rates were correlated, adjusting for age, sex, disease duration, and optic neuritis history. The impact of measurement error was assessed using the simulation-extrapolation method.
Results: GCIP atrophy rate and rates of whole brain (r=0.41, p< 0.001), gray matter (GM; r=0.34, p< 0.001), white matter (WM; r=0.26, p=0.007) and thalamic (r=0.36, p< 0.001) atrophy over time were associated. RNFL atrophy rate was less robustly associated with whole brain (r=0.29, p=0.003), GM (r=0.25, p=0.01), and thalamic atrophy (r=0.33, p< 0.001) rates. GCIP and whole brain atrophy rates were more strongly associated in secondary progressive MS (r=0.74) and primary progressive MS (r=0.44), than relapsing-remitting MS (RRMS; r=0.30). Similar trends according to MS subtype were observed between rates of GCIP, GM and WM atrophy. In RRMS, lesion accumulation rate was associated with rates of GCIP (r=−0.30, p=0.01) and INL (r=−0.28, p=0.02) atrophy.
Conclusions: Retinal changes mirror global central nervous system processes in MS. GCIP atrophy reflects whole brain, and in particular GM atrophy, especially in progressive MS. Beyond gleaning information regarding neurodegeneration, tracking OCT provides insight regarding inflammatory activity in RRMS, with perhaps the INL being most useful for this purpose. Our findings validate OCT measures, both for clinical monitoring and as an outcome in clinical trials.
YI2.3 A comparison of cognitive performances between multiple sclerosis patients with pediatric- versus adult-onset disease
B Hakiki1, C Niccolai1, E Portaccio1, B Goretti1, M Giannini1, L Pastò1, C Pecori1, ML Stromillo2, A Giorgio2, F Rossi2, N De stefano2, MP Amato1
1University of Florence, Department NEUROFARBA, Section Neurosciences, Florence, Italy, 2University of Siena, Department of Medicine, Surgery and Neuroscience, Siena, Italy
Background: there is limited information on cognitive impairment (CI) in pediatric-onset MS (POMS) which represents 3-5% of the whole MS population. CI has been reported in 30 to 50% of POMS subjects: it is unknown, however, whether, in their adult life, pediatric-onset patients may present a different cognitive outcome as compared with adult-onset patients.
Objectives: to compare cognitive performances between a group of RRMS patients with pediatric-onset and a demographically matched group of patients with adult-onset disease.
Methods: neuropsychological performances were assessed through the Rao’s Brief Repeatable battery (BRB) and the Stroop test in 14 RR POMS and 30 demographically matched RR AOMS patients. CI was defined as the failure of at least two tests using the Italian normative data. Group comparison was performed using the Mann-Whitney test and the χ2 test when appropriate.
Results: The two patient groups were matched for age (25.6±4.5 and 27.3±3.1 years), education (13.5±2.5 and 13.8±2.7 years) and physical disability on the Expanded Disability Status Scale (1.7±1.5 and 1.5±0.6) (p>0.1). As expected, disease duration was longer in POMS than in AOMS subjects (9.8±5.1 versus 3.7±2.2 years, p=< 0.01). The two groups were not significantly different both in terms of mean scores on the neuropsychological tests and number of test failed. In particular, 14% were classified as cognitively impaired in the POMS and 27% in the AOMS group(p=0.36). The pattern of deficit was consistent, showing prominent involvement of test exploring the information processing speed (symbol digit modalities test and Paced Auditory Serial Addition Test 3).
Conclusions: overall, cognitive outcome was similar in adult patients with pediatric- or adult-onset disease. Since disease onset in a period of active brain growth and maturation may render pediatric-onset subjects more vulnerable to cognitive issues, our findings suggest good compensatory/recovery abilities in these subjects, possibly related with enhanced brain plasticity in early life.
YI2.4 Normal visual acuity is retained in a subset of pediatric patients with demyelinating disease of the optic nerve
S Hughes1,2, D Conger1,2, A Conger1, T Frohman1, E Frohman1, B Greenberg1,2, D Graves1,2
1UT Southwestern Medical Center, Dallas, TX, United States, 2Children’s Medical Center, Dallas, TX, United States
Background: Ocular Coherence Tomography (OCT) is a non-invasive imaging method which uses infrared light to generate high-resolution cross-sectional images of the peripapillary and macular regions. OCT has become increasingly used in demyelinating diseases. Retinal nerve fiber layer (RNFL) becomes thinned most dramatically after optic neuritis (ON) but also during the course of multiple sclerosis (MS) in the absence of ON. Multiple studies have shown a strong correlation between OCT measurements and both high and low contrast visual acuity. A RNFL threshold of 75µm has been demonstrated to predict persistent visual dysfunction. While the utility of OCT in adults has been well-established with consistent correlation with outcomes not only of visual acuity but also with MRI disease burden and disability, these measures have not yet been well-established in children.
Objectives: To highlight a subset of pediatric patients with optic nerve damage but retained visual acuity.
Methods: Visual acuity and OCT data were collected from patients referred to the Pediatric Demyelinating Disease Clinic at Children’s Medical Center in Dallas, TX. These data were collected from 190 right eyes (OD) and 188 left eyes (OS) from 2009 to 2014. Each RNFL was compared to its high contrast visual acuity (100%VA) and its low contrast visual acuity (2.5%VA).
Results: Of the 256 eyes with RNFL measuring 85-110µm, 175 eyes (87 OD, 88 OS) had 2.5%VA>=25 (average=35; range=25-50), with a corresponding 100%VA average of 59 (range=23-70). Of the 97 eyes with RNFL< 75µm (range=55-73µm), 23 eyes (10 OD, 13 OS) had 2.5%VA>=25 (average=33; range=25-45), with a corresponding 100%VA average of 57 (range=49-63). Of note, 9 of the eyes had RNFL measuring 55-59µm and had an average 2.5%VA of 36 (range=30-45) and an average 100% VA of 56 (range=50-63).
Conclusions: There is a clear subset of pediatric demyelinating disease patients with significant RNFL damage who have both high and low contrast visual acuities similar to patients with normal RNFL values. This appears unique from studies in adults but it is unclear as to why this occurs in some children. Other variables should be analyzed including patient age and sex, time to treatment, and type of treatment to see if there is any significant correlation between these factors and retained visual acuity. Understanding how cases such as these recover from optic nerve damage could lead to greater insight into best treatment options and a better understanding of brain plasticity and neural networking.
YI2.5 An investigation of cervical spinal cord lesion location and extent in subtypes of multiple sclerosis
H Kearney1, KA Miszkiel2, MC Yiannakas1, DR Altmann1,3, O Ciccarelli1,4, DH Miller1,4
1UCL Institute of Neurology, NMR Research Unit, London, United Kingdom, 2National Hospital for Neurology and Neurosurgery, Department of Neuroradiology, London, United Kingdom, 3London School of Hygeine and Tropical Medicine, Medical Statistics Department, London, United Kingdom, 4NIHR University College London Hospitals Biomedical Research Centre, London, United Kingdom
Background: Pathology studies of the spinal cord in multiple sclerosis (MS) have shown lesions of varying size and location, with variable involvement of white matter columns and gray matter (GM). The relationship of lesion location and extent with clinical MS subtype and disability is uncertain.
Objectives: To investigate the location and extent of cervical spinal cord lesions seen on axial magnetic resonance images (MRI) and their relationship with MS subtype and disability.
Methods: We recruited 120 people: 25 clinically isolated syndrome, 35 relapsing remitting (RR), 30 secondary progressive (SP) and 30 primary progressive (PP) MS. Disability was estimated using the expanded disability status scale (EDSS). We performed 3T axial MRI scans in the cervical cord using 3D-fast field echo and phase sensitive inversion recovery sequences with 0.5 x 0.5 mm2 in-plane resolution. Focal lesions were classified as follows: type Ia - lesions restricted to a single white matter column, type Ib - lesion in one column and involving GM, type II - lesions involving 2 columns, type III - lesions involving 3 columns. The GM was involved in all type II and III lesions. We noted all diffuse abnormalities seen. Associations with disability were investigated using regression analysis.
Results: We identified 374 focal lesions: SPMS (136 lesions, 100% subjects), PPMS (107, 96%), RRMS (99, 85%) and CIS (32, 40%). Lesions involved the GM in 96.6% of SPMS cases, 73.3% PPMS, 73.5% RRMS and 29.2% CIS. Type II and III lesions were seen in 58.6% and 24.1% respectively of SPMS cases, 30% and 16.7% in PPMS, 32.4% and 2.9% in RRMS, 8.3% and 0% in CIS. Diffuse abnormalities were more frequent in PPMS (56.7% of subjects) and SPMS (55.1%) than RRMS (17.6%) and CIS (0%). The presence of lateral column lesions involving the GM (coefficient = 1.11, p = 0.009, 95% CI 0.28, 1.94) and the number of columns a lesion involved (coefficient = 0.53, p = 0.016, 95% CI 0.10, 0.97) were associated with EDSS, independently of age, gender and disease duration.
Conclusions: Our study shows that higher disability and progressive subtypes of MS are associated with more frequent and extensive focal cervical cord lesions that involve multiple white matter columns and GM, and with more frequent diffuse abnormalities. The study identifies new approaches for analyzing cervical spinal cord lesions in MS that have potential to be useful outcome measures in future treatment trials aimed at preventing disease progression.
YI2.6 VLA-4 blockade promotes differential routes into human CNS involving PSGL-1-rolling of T-cells and MCAM-adhesion of TH17-cells
T Schneider-Hohendorf1, J Rossaint2, J Breuer1, A Zarbock2, N Schwab1, H Wiendl1
1University of Muenster, Neurology, Muenster, Germany, 2University of Muenster, Anaesthesiology, Muenster, Germany
Background: CNS immune cell infiltration takes place, also under immune-modulating conditions using distinct routes, cellular structures and molecules, which differ from the ones employed under healthy or non-treated conditions.
Objectives: Characterization of T-cell extravasation involving VLA-4, PSGL-1 and MCAM with special regard to blood-brain-barrier routes and TH17 pathology in RRMS patients under continuous VLA-4 blocking conditions (natalizumab therapy).
Methods: Immune cells isolated from peripheral blood or CSF of RRMS patients (n=381) long-term (>18 months) treated with natalizumab (LTNT) and CNS autopsy tissue were characterized by flow cytometry, immune-histochemistry, and super resolution microscopy for cellular lineages, tissue localization and adhesion molecule expression. In vitro experiments under flow conditions with primary human endothelial cells were performed to challenge the phenotypical findings for their functional relevance under VLA-4, PSGL-1, LFA-1 and MCAM (TH17 cell signature molecule) blockade.
Results: The CSF of LTNT patients contained detectable numbers of lymphocytes with a normalized central-memory/effector-memory ratio comparable to healthy controls. However, these T cells lacked CD49d, but showed enhanced MCAM expression. PSGL-1 expression on peripheral T cells continuously increased with LTNT. VCAM-1 was ubiquitously found on all endothelial CNS barriers while P-selectin could only be detected in the choroid plexus and to a low extent in meningeal vessels of MS patients. Fitting with the data above, LTNT patients’ cells showed increased PSGL-1-mediated rolling and residual adhesion in spite of VLA-4-blocking conditions. TH17 cells could adhere to endothelium under VLA-4 blockade. However, blockade of VLA-4 and MCAM together abrogated their adhesion. MCAM+ cells were detected in situ in active white matter lesions of MS patients, as well as in gray matter.
Conclusions: Lymphocyte infiltration of the CNS under continousVLA-4 blockade still occurs, favoring the TH17 phenotype and the choroid plexus as primary CNS entry site and introducing MCAM being involved in the migratory cascade of TH17 cells.
PS1 - Cell-based therapies
PS1.1 How stem cells speak with the host immune system
S Pluchino
1
1John van Geest Centre for Brain Repair and Wellcome Trust-Medical Research Council Stem Cell Institute, Cambridge, United Kingdom
Advances in stem cell biology have raised great expectations that diseases of the central nervous system may be ameliorated by the development of non-haematopoietic stem cell medicines. Yet, the application of stem cells as therapeutics is challenging and the interpretation of some of the outcomes ambiguous. The initial idea that stem cell transplants work only via structural cell replacement has been challenged by the observation of consistent intercellular information exchange between the graft and the host. . Sustained stem cell graft-to-host exchange of signals has led to remarkable trophic effects on endogenous brain cells and beneficial modulatory actions on innate and adaptive immune responses that ultimately promote the healing of the injured CNS. Among a number of promising candidate stem cell sources, mesenchymal/stromal stem cells (MSCs) and neural stem/precursor cells (NPCs) are being extensively investigated for their capacities to signal to the immune system upon transplantation in experimental CNS diseases.
Here, we focused on defining whether the form of cellular signalling mediated by extracellular membrane vesicles (EVs) exists for neural stem/precursor cells (NPCs), and on its molecular signature and functional relevance on target cells. We also investigated whether the EV cargo molecules are modulated by extracellular pro- or anti-inflammatory cytokines, determined the key elements responsible for this novel mechanism of EV-mediated intercellular communication, and finally reflected on the forthcoming challenges related to the translation of these exciting experimental proofs into ready-to-use clinical medicines for inflammatory CNS diseases.
PS1.2 Assessing myelin repair in multiple sclerosis: Is imaging useful? Usable? Are we there yet?
C Laule
1
1University of British Columbia, Radiology / Pathology & Laboratory Medicine, Vancouver, BC, Canada
Imaging myelin repair in vivo would clearly be useful for evaluating remyelination-targeted therapies. Conventional MRI’s low pathological specificity and poor sensitivity for non-lesional disease drive the development of advanced imaging techniques, which may be better suited to assess cell-based therapies. Magnetization transfer imaging (MTI) examines the interaction between macromolecules and water. It is influenced by myelin, but inflammation, edema, axonal loss and gliosis are confounders. MTI is sensitive and commonly available but is not standardized between vendors. Diffusion tensor imaging (DTI) measures water motion. Measures are affected by myelin, but also reflect axonal density, fibre orientation and membrane permeability. MS lesions and edema make tractography and interpretation difficult. While simple DTI acquisition techniques are commonly available, newer approaches, which may be more specific, are not. Magnetic resonance spectroscopy (MRS) measures brain metabolites: N-acetylaspartate is an axonal marker, choline reflects membrane turnover and free lipid indicates active demyelination. While standard on MR systems, MRS has limited resolution and volumetric coverage. Multi-echo T2 based myelin water imaging (MWI) measures water trapped within myelin bilayers. It is specific for myelin, but water compartment exchange may be a confounder. Recent advances enable whole brain coverage in clinically feasible times. MWI is not yet commonly available. mcDESPOT (multi-component driven equilibrium single pulse observation of T1 and T2) is a proposed alternative for quantifying myelin water. It is more commonly available and offers high volumetric coverage, but analysis is complicated. There is currently discrepancy between MWI and mcDESPOT measures. Frequency shift imaging is an emerging high-resolution MR method. Frequency shifts are influenced by iron but also reflect tissue microstructure including myelin. While commonly available, its specificity for MS pathology is unknown. Finally, positron emission tomography (PET) is a non-MR method that requires injection of a radioisotope labelled to a specific biological target. Tracers for myelin, activated microglia and macrophages exist. PET is sensitive and specific, but ionizing radiation limits study frequency; limited availability and cost remain a challenge. This presentation will provide an overview of these techniques and review their usefulness and usability for measuring myelin repair in MS.
PS1.3 Injection of next-generation directly-induced neural stem cells (iNSCs) induces recovery in a chronic mouse model of multiple sclerosis
L Peruzzotti-Jametti1, G Mallucci1,2, G Tannahill1, B Huang1, YB Lakes3, E Giusto1, M Donegà1, B Balzarotti1, F Edenhofer3,4, S Pluchino1
1University of Cambridge, Department of Clinical Neurosciences, Cambridge, United Kingdom, 2University of Pavia, National Neurological Institue Mondino, Pavia, Italy, 3University of Bonn, Institute of Reconstructive Neurobiology, Bonn, Germany, 4University of Würzburg, Institute for Anatomy and Cell Biology, Würzburg, Germany
Background: Advances in neural stem cell (NSC) biology have raised great expectations that diseases of the CNS may be ameliorated by stem cell therapies. Part drugs and part devices, NSCs work as naturally occurring disease modifying agents that sense signals, migrate to specific sites in the body and execute complex response behaviors. Still, the major limitations of human NSCs therapies are the source from which stem cells are derived (either embryonic or foetal), the immunogenicity of the allogeneic graft and the genotypic instability over extensive passaging in vitro. The direct conversion of somatic cells (e.g. skin fibroblasts) into induced NSCs (iNSCs) is a promising alternative to conventional stem cell treatments. iNSCs cell reprogramming is direct, highly efficient, and rapid. It requires only one step that is completed within 18 days in vitro, and yields almost 100% colonies of multipotent, stably expandable and autologous NSCs.
Objectives: The aim of this work was to assess the therapeutic potential of the intracerebroventricular (icv) transplantation of syngeneic iNSCs in mice affected by chronic experimental autoimmune encephalomyelitis (EAE) as pre-clinical model of multiple sclerosis (MS).
Methods: iNSCs from C57BL/6J somatic skin mouse fibroblasts were grown both as spheres and as adherent monolayers and studied for self-renewal, migratory capacity, multipotency and immune modulation in vitro. We then injected icv 10^6 GFP+ iNSCs, or equal numbers of somatic SVZ-derived GFP+ NSCs, in myelin oligodendrocyte glycoprotein (MOG) 35-55 induced EAE mice at disease peak. Behavioral and histopathological outcomes were collected up to 30 days post transplantation.
Results: iNSCs showed a significantly high expression of CD44, as well as of the pro-inflammatory chemokine receptors CCR2 and CXCR1 in vitro. iNSCs also displayed significantly high intrinsic migratory features and anti-inflammatory capacity, when co-cultured (transwell) with LPS-activated macrophages. The icv injection of iNSCs ameliorated chronic EAE in mice. Tissue pathology revealed iNSCs at the level of the injection needle track, close to reactive astrocytes, and within the ventricular system, intermingled with activated microglial cells.
Conclusions: While the generation of human iNSCs is envisaged, future experiments will help to understand the role of immunomodulation vs tissue trophism as main mechanisms of iNSC-mediated tissue protection in chronic EAE.
PS1.4 Neural precursors derived from mouse iPS cells extensively remyelinate the demyelinated central nervous system
S Mozafari1,2,3, C Laterza4, A Marteyn1,2,3, C Deboux1,2,3, G Martino4, A Baron-Van Evercooren1,2,3
1INSERM U1127, Centre de Recherche de l’Institut du Cerveau et de la Moelle Epinière, Paris, France, 2Sorbonne Universités UPMC Univ Paris 06, UM 75, Paris, France, 3CNRS, UMR 7225, Paris, France, 4Institute of Experimental Neurology-DIBIT 2, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
Background: Experimental studies have shown that loss of myelin, results in axonal loss and disability. Furthermore, remyelination can restore lost electrical conductance in demyelinated axons. Finding of an expandable, autologous and reliable source of myelin-forming cells to enhance remyelination is a priority in treating the degenerative component of demyelinating diseases like Multiple Sclerosis (MS). Induced pluripotent stem cell-derived neural progenitor cells (iPSC-NPCs) have been developed recently from reprogrammed somatic cells. However, the remyelination potential and safety of these cells remain to be well-addressed.
Objectives: The main goal of this study is to fully characterize mouse [and human (healthy vs MS)] iPS-NPCs in vitro and in vivo after transplantation.
Methods: We first used mouse embryonic neural progenitor cells (mENPCs) as control and characterized iPS-NPCs derived from mouse fibroblasts for their expression of major markers of immature or mature neural cells. Moreover, to investigate the behavior of cells in demyelination context, we induced a focal area of demyelination using Lysolecithin in the spinal cord of adult ShivererRag mouse and transplanted the cells in the lesion site 48 hours after demyelination. Animals were sacrificed 1, 2, 6 and 10 weeks post graft to assess survival, migration and differentiation potential of the grafted cells.
Results: Our results show that miPS-NPCs similarly to mE-NPCs expressed the immature markers of naturally committed neural progenitor cells in vitro at the level of both protein and mRNA transcripts. Moreover, our data from transplantation studies in demyelination context revealed that the grafted iPS-NPCs similar to embryonic cells survived, integrated, timely migrated, and extensively differentiated from immature to mature cells. Grafted cells remyelinated the host axons as confirmed by immunostaining and electron microscopy. Furthermore, no tumor was observed following engraftment. In vitro and in vivo characterization of human derived cells (control vs MS) are ongoing.
Conclusions: There is a competitive differentiation into bona fide mature myelinating oligodendrocytes. No obvious difference was observed between mE-NPCs vs miPS-NPCs.
Our work should help increasing the knowledge about biology of both mouse and human iPS-NPCs and/or the pathophysiology of MS derived cells and establish whether these cells are a useful tool for testing personalized therapies or in regenerative biomedicine in demyelinating diseases like MS.
PS1.5 Phase I trial of intravenous autologous culture-expanded mesenchymal stem cell transplantation in multiple sclerosis
JA Cohen1, PB Imrey2, SM Planchon1, RA Bermel1, E Fisher3, RJ Fox1, A Bar-Or4, SL Sharp1, TT Skaramagas1, P Jagodnik3, M Karafa2, S Morrison2, J Reese Koc5,6, SL Gerson5,6, HM Lazarus5,6
1Cleveland Clinic, Mellen Center, Cleveland, OH, United States, 2Cleveland Clinic, Quantitative Health Sciences, Cleveland, OH, United States, 3Cleveland Clinic, Biomedical Engineering, Cleveland, OH, United States, 4McGill University, Montreal Neurological Institute, Montreal, QC, Canada, 5Case Western Reserve University, Case Comprehensive Cancer Center and National Center for Regenerative Medicine, Cleveland, OH, United States, 6University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, OH, United States
Background: Mesenchymal stem cells (MSCs) have potent immunomodulatory, tissue-protective, and repair-promoting properties in vitro and in animal models. Clinical trials support the safety and efficacy of MSC transplantation in several human conditions. Published experience in multiple sclerosis (MS) is modest.
Objectives: To assess feasibility, safety, tolerability, and efficacy of autologous mesenchymal stem cell MSC transplantation in MS.
Methods: 24 participants with relapsing forms of MS, Expanded Disability Status Scale (EDSS) 3.0-6.5, clinical or radiographic disease activity in the prior 2 years, and optic nerve involvement were enrolled. Bone-marrow-derived MSCs were culture-expanded in low glucose DMEM containing 10% fetal bovine serum and 10 ng/ml human fibroblast growth factor-2, then cryopreserved. After confirmation of release criteria, 1-2x106 MSCs/kg were thawed and administered IV. Primary outcomes were feasibility, safety, and tolerability with Data Safety Monitoring Committee review after every 4 participants. Relapses, EDSS, MS Functional Composite, low-contrast letter acuity, MRI (T2 lesions, T1 lesions, gadolinium [Gd]-enhancing lesions, whole brain and gray matter atrophy, diffusion tensor imaging, and magnetization transfer imaging), optical coherence tomography, visual evoked potentials, and patient self-reported global health status were monitored serially for 2 months pre- and 6 months post-infusion to explore efficacy. Peripheral blood mononuclear cells were isolated at 2 pre- and 3 post-infusion times for ancillary immunologic mechanistic studies.
Results: 2 patients withdrew pre-infusion due to culture failure and Gd allergy, respectively, and were replaced. We infused 16 women and 8 men, 10 relapsing-remitting and 14 secondary progressive MS, mean age 46.5 and EDSS 5.2, and 25% with Gd-enhancing brain lesions. Mean cell dosage (requiring 1-3 passages) was 1.9x106 MSCs/kg (range 1.3-2.0) with post-thaw viability ≥95%. Cell infusion was well tolerated. There were no treatment-related severe or serious adverse events. All planned clinical, imaging, and laboratory assessments were performed (except 1 blood test). Neither disease activation nor significant improvement was observed. Detailed exploratory analyses of efficacy measures and immunologic mechanistic studies are ongoing.
Conclusions: This Phase I trial supports the feasibility, safety, and tolerability of autologous MSC transplantation in MS. Future trials adequately powered to assess efficacy more definitively are warranted.
PS1.6 Intrathecal administration of mesenchymal stem cell-neural progenitors in multiple sclerosis: an interim analysis of a phase i clinical trial
SA Sadiq1, VK Harris1, T Vyshkina1, S Chirls1
1Tisch MS Research Center of New York, New York, NY, United States
Background: Cell-based therapies with regenerative potential are an emerging therapeutic strategy for treating disability associated with progressive MS. Mesenchymal stem cell-neural progenitors (MSC-NPs) are an autologous bone marrow-derived population of regenerative cells currently under investigation as a novel MS treatment targeting CNS repair and regeneration. In preclinical studies in mouse EAE, we established that intrathecal (IT) delivery of MSC-NPs given in three separate doses was associated with cell migration to lesion areas, suppression of local inflammatory response, and trophic support for damaged cells at the lesion site. These pathological features were associated with improvement in clinical scores of EAE. The initial clinical experience with IT administration of autologous MSC-NPs in seven MS patients also supported the dosing, safety, feasibility, and potential efficacy of this therapeutic approach. Based on these promising pre-clinical and early clinical data, the FDA approved the initiation of a phase I clinical trial investigating IT autologous MSC-NPs in 20 patients with MS.
Objectives: To evaluate safety, tolerability, and preliminary efficacy of three IT administrations of autologous MSC-NPs in patients with progressive MS.
Methods: The study is a 20 patient, open-label, phase I clinical study of autologous MSC-NPs administered IT in three doses of up to 10 million cells per injection, spaced three months apart. Pre-administration quality testing of autologous MSC-NPs expanded from bone marrow aspirates included analysis of sterility, purity, identity, and chromosomal stability. Primary safety outcomes include adverse event assessments. Secondary outcomes to observe trends in efficacy include neurological exam, MRI, evoked potentials, and urodynamics testing.
Results: The study enrolled 20 MS patients with established disability (average EDSS 6.0, range 3.5 to 8.5) and relatively stable disease as evidenced by less than 1.0 point change in EDSS in the last year, and stable MRI disease burden with no enhancing lesions in the last six months. Bone marrow MSCs from all study subjects were isolated, expanded, and tested according to release criteria. Preliminary safety outcomes in the first five study subjects indicate safety and tolerability of the treatment.
Conclusions: The MSC-NP trial is the first of its kind to test IT administration of neural progenitors as a regenerative therapy for MS.
PS2 - MS subpopulations and disease variants
PS2.1 Radiologically isolated syndrome
C Lebrun
1
1Hopital Pasteur, Neurology, Nice, France
Even prior to the introduction of RIS criteria, longitudinal clinical data from individuals with incidentally identified T2 lesions suggestive of multiple sclerosis (MS) were described. Healthy individuals who do not exhibit signs of neurological dysfunction commonly have brain MRI studies performed for a reason other than an evaluation for MS that reveal unexpected anomalies highly suggestive of demyelinating plaques given their size, location, and morphology. These healthy subjects lack symptomatology suggestive of MS and fulfill formal criteria for radiologically isolated syndrome (RIS), a recently described MS subtype that expands upon the phenotype of at-risk individuals for future demyelinating events. A formal description of RIS was first introduced in 2009 by Okuda et al., to define this relevant cohort of individuals who are at risk for future demyelinating events.
In European or North American observational studies, the authors have found that up to 30-45% of patients presenting with a RIS will present clinical progression.Most patients who develop clinical symptoms had prior radiological progression.
Cortical lesions are present in up to 40% of RIS patients and their presence are more frequent in those patients with positive oligoclonal bands CSF, cervical cord lesions and dissemination in time on a follow-up brain MRI. Cognitive impairment is observed in RIS patients, and 2 studies demonstrated a significant proportion of patients with cognitive decline compared to healthy controls. The consortium studying epidemiology of RIS worldwide (RISC) presented their first retrospective cohort last year. The mean age at RIS diagnosis was 37.2 years with mean clinical follow-up time of 4.4 years.The 5-year observed conversion rate to the first clinical event was 34%. Of converters within this time period, 9.6% fulfilled criteria for primary progressive MS. In the multivariate model, age, sex (male), and lesions within the cervical or thoracic spinal cord were identified as significant predictors for the development of a first clinical event.
Despite advancements in the characterization of RIS subjects and in our understanding of risk factors for initial symptom development, the natural course of such cases and risk-profiles for a seminal neurological event remain unclear. Prospective study is mandatory to increase our knowledge about these asymptomatic patients.
PS2.2 NMO spectrum disorders: evolution and current concept
K Fujihara
1
1Tohoku University Graduate School of Medicine, Department of MS Therapeutics, Sendai, Japan
More than a century has passed since the first report of neuromyelitis optica (NMO) or Devic’s disease. The discovery of NMO-specific aquaporin-4 (AQP4)-IgG or NMO-IgG has truly accelerated clinical and experimental research of NMO, and contributed to establishing “NMO spectrum disorders (NMOSD)”, a wider clinical spectrum than a typical severe opticomyelitis in the original description. Epidemiological date on NMOSD are still insufficient, but the prevalence is estimated to be 1-5/100,000 in most parts of the world.
New international consensus diagnostic criteria of NMOSD, which is expected to be published later this year, is essentially based on AQP4-IgG serostatus and core characteristics of NMOSD, namely, optic neuritis, acute myelitis, and area postrema and some other brain syndromes, although alternative diagnoses should be carefully ruled out. Unlike AQP4-IgG-positive NMOSD requiring only one core clinical feature, two or more core clinical characteristics are needed for diagnosing NMOSD in cases without AQP4-IgG or those with unknown serostatus, but we need to be careful that this group may be heterogeneous. We anticipate that the new criteria will facilitate early diagnosis and treatment which will eventually improve the long-term prognosis. NMO has long been discussed in the category of inflammatory demyelinating diseases, but accumulated pathological and experimental evidence strongly suggests that AQP4-IgG-associated NMOSD is an autoimmune astrocytopathic disease.
On the other hand, the development of highly sensitive specific assays of AQP4-IgG has enabled us to identify AQP4-IgG-seronegative NMOSD with some features distinct from seropositive cases. Recently, antibodies to myelin oligodendrocyte glycoprotein (MOG) have been detected in a fraction of cases of AQP4-IgG-seronegative NMOSD. It is interesting to find out whether the detection of MOG-IgG has pathogenetic and therapeutic implications.
Despite lack of high-level evidence, treatment of NMOSD has made significant progress in the past decade, and a variety of immunesuppressants and monoclonal antibodies are being administered or developed in clinical practice. Some disease modifying drugs for multiple sclerosis are deleterious in NMOSD for reasons not fully understood. There have been active discussions on advantages and disadvantages in various clinical trial designs for this intractable disease.
An overview of NMOSD including above-mentioned issues will be provided in this session.
PS2.3 Bright spotty lesions of spinal cord: another MRI clue for neuromyelitis optica spectrum disorder?
J-W Hyun1, S-H Kim1, IH Jeong1, SH Lee2, HJ Kim1
1National Cancer Center, Neurology, Goyang, Korea, Republic of, 2National Cancer Center, Radiology, Goyang, Korea, Republic of
Background: Bright spotty lesions (BSLs) on spinal MRI were recently reported to be a discriminative finding of neuromyelitis optica spectrum disorder (NMOSD) from multiple sclerosis (MS), in combination of longitudinally extensive transverse myelitis (LETM).
Objectives: We aimed to determine whether BSLs can discriminate NMOSD from MS as well as idiopathic transverse myelitis (ITM).
Methods: One-hundred twenty-seven spinal MRIs taken at acute phase from 59 patients with NMOSD (n=62 MRIs), 31 with MS (n=32 MRIs) and 24 with ITM (n=33 MRIs) were reviewed independently by one neuroradiologist and two neurologists without knowledge of the diagnosis. The presence of BSLs, lesion length, axial location and the presence of gadolinium enhancement were evaluated. BSLs were defined as very hyperintense spotty lesions on axial T2-weighted imaging (WI), which signals are at least as high as surrounding CSF on T2WI, but not as low as CSF on T1WI. In order to investigate whether the BSLs may represent attack severity, EDSS scores at nadir of myelitis attacks were analyzed.
Results: The male:female ratio (16:8 vs. 8:51 vs. 15:16; p < 0.001) and mean age of onset (44.0±9.6 vs. 35.9±11.4 vs. 34.2±9.8 ; p< 0.001) were higher in ITM than NMOSD and MS patients. BSLs were exclusively founded in patients with NMOSD (17/62, 27.4%). None of the patients with MS and ITM revealed BSLs. In contrast, LETM was commonly found both in ITM (26/33, 78.8%) and NMOSD (58/59, 93.5%) patients, while very rare in MS patients (2/32, 6.3%). Among 17 NMOSD patients who had BSLs, follow-up MRIs were available in 10 patients and BSLs were disappeared after 6 months in all patients. The median EDSS score at nadir, lesion length and the presence of enhancement were not significantly different between patients with and without BSLs.
Conclusions: BSLs on spinal MRI were not so commonly found in patients with NMOSD as previously reported. If present, however, BSLs can help differentiate NMOSD from ITM and MS.
PS2.4 Assessment of iron deposition pattern in multiple sclerosis and neuromyelitis optica lesions with ultra-high field quantitative susceptibility mapping
S Chawla1, I Kister2, J Herbert3, JC Brisset1, P Dusek3, JT Wuerfel3, F Paul3, Y Ge1
1New York University Langone Medical Center, Radiology, New York, NY, United States, 2New York University Langone Medical Center, Neurology, New York, NY, United States, 3Universitätsmedizin Göttingen, Radiology, Berlin, Germany
Background: Multiple sclerosis (MS) and neuromyelitis optica (NMO) are autoimmune disorders of central nervous system. Quantitative susceptibility mapping (QSM) is a novel technique that enables to detect and quantify iron deposition. Ultra-high field MRI has markedly improved sensitivity in detecting tissue susceptibility differences. Pathologic iron accumulation has been reported in MS, but there are no studies on iron content in NMO lesions.
Objectives: To characterize and compare iron deposition in MS and NMO lesions using ultra-high-field QSM MRI.
Methods: Fourteen MS and 11 NMO patients underwent imaging at 7T MRI (Siemens) using a 24-channel head coil. The imaging protocol included T2, GRE-T2*,T1-weighted, and FLAIR images. QSM Imaging was performed using high resolution (in plane resolution: 0.23x0.23mm2) 3D susceptibility weighted imaging. An in-house developed susceptibility weighting imaging map algorithm was used to reconstruct QSM maps. The patterns of different lesions were assessed on T2/T2* and QSM images based on the presence of QSM hyperintensity associated with iron deposition.
Results: A total of 124 lesions were observed in MS patients (mean 8.8 lesions/patient) versus 25 lesions in NMO patients (2.2/patient). Of MS patients, 13/14 had at least one hyperintense lesion on QSM, while none of 11 NMO patients showed hyperintensity in lesions (p< 0.0001). In 14 MS patients, all lesions on T2*/T2 images with hypointense components were observed as hyperintense on QSM (Type A, n=26), reflecting iron accumulation in these lesions. Some T2/T2* lesions without hypointensity (Type B, n=16) also showed hyperintense iron component on QSM, suggesting QSM is more sensitive than T2*/T2 for subtle iron deposition detection. QSM values for Type A lesions (45.8±19.6ppb) were significantly higher than that of Type B lesions (23.4±9.1ppb, p< 0.0002). However, most MS lesions (Type C, n=82) without hypointense signal on T2/T2* did not show any hyperintensity on QSM, without indication of iron deposition in these lesions. We believe the different patterns of QSM signal are attributed to the combined effects from iron accumulation (paramagnetic) and myelin (diamagnetic) loss since both causes hyperintensity on QSM.
Conclusions: Absence of QSM hyperintensity in NMO suggests that, iron deposition is not a feature of NMO lesions. QSM may be useful for differentiating MS from NMO and offers insight into the pathogenesis of tissue injury and lesion evolution in MS.
PS2.5 Autoantibodies against MOG and aquaporin-4 identify distinct neuromyelitis optica spectrum disorders subgroups
DK Sato1, D Callegaro2, MA Lana-Peixoto3, PJ Waters4, S Tanaka5, FMH Jorge2, T Takahashi1, T Misu6, SL Apostolos-Pereira2, N Talim3, RF Simm2, I Nakashima1, K Nomura5, M Aoki1, K Fujihara6
1Tohoku University, Neurology, Sendai, Japan, 2University of Sao Paulo, Neurology, São Paulo, Brazil, 3Federal University of Minas Gerais, CIEM MS Research Center, Belo Horizonte, Brazil, 4Oxford University, Nuffield Department of Clinical Neurosciences, Oxford, United Kingdom, 5Saitama Medical University, Neurology, Saitama, Japan, 6Tohoku University, Multiple Sclerosis Therapeutics, Sendai, Japan
Background: Neuromyelitis optica spectrum disorder (NMOSD) is characterized by severe attacks of optic neuritis and longitudinally extensive transverse myelitis (LETM). More than half of NMOSD patients are positive for aquaporin-4 (AQP4)-antibodies, but seronegative patients require further characterization and clarification of underlying pathogenesis. Autoantibodies against myelin-oligodendrocyte glycoprotein (MOG) were recently reported in AQP4-antibody seronegative NMOSD.
Objectives: To compare the clinical characteristics and prognosis of patients with MOG antibodies to those from AQP4-antibody positive and seronegatives in a large cohort clinically diagnosed as NMOSD.
Methods: We enrolled 290 pediatric and adult NMOSD cases from 4 tertiary centers from Japan and Brazil. Sera were tested for AQP4-antibodies and MOG-antibodies using cell based assays with transfected living cells.
Results: One hundred sixty-six NMOSD patients were positive for AQP4-antibodies and 134 were negative. Only 16.3% (27/166) of the patients with AQP4 antibodies had a single attack. Among the AQP4-antibody seronegative NMOSD, 26.1% (35/134) patients were positive for MOG antibodies, and 42.9% (15/35) had a single attack. None was positive for both antibodies. Patients with MOG-antibodies usually had a more limited phenotype than seronegative and AQP4-antibody positive patients. In contrast to patients with AQP4-antibodies, patients with MOG-antibodies and seronegatives did not have female predominance and brainstem lesions with nausea or hiccups were uncommon. Patients with MOG-antibodies who had attacks limited to recurrent or bilateral simultaneous optic neuritis usually had a good recovery of visual acuity, and those patients with myelitis had more often spinal cord lesions distributed in the lower portion of the spinal cord. Although patients with MOG antibodies had optic neuritis with severe loss of visual acuity (below 20/200) or transverse myelitis during attacks, they had low presence of painful tonic spasms, and usually recovered better (visual and motor) with less sustained disability than the other serological groups.
Conclusions: NMOSD patients with MOG-antibodies have distinct clinical features and less disability than seronegative and AQP4-antibody positive patients, suggesting different underlying mechanisms. Identification of MOG-antibody positive patients may be useful in the diagnosis and prognostication of the disease in patients who were seronegative for AQP4-antibodies.
PS2.6 Anti-MOG immune response characterizes a subgroup of AQP4-seronegative patients with a NMO phenotype
A-K Pröbstel1,2, G Rudolf3, N Sanderson2, K Dornmair4, N Collongues3, J-B Chanson3, L Kappos1,2, J de Seze3, T Derfuss1,2
1University Hospital Basel, Department of Neurology, Basel, Switzerland, 2University Basel, Department of Biomedicine, Basel, Switzerland, 3Hopitaux Universitaires de Strasbourg, Hopital de Hautpierre, Department of Neurology, Strasbourg, France, 4University Hospital Grosshadern, Institute of Clinical Neuroimmunology, Munich, Germany
Background: Neuromyelitis optica (NMO) is a clinically defined autoimmune inflammatory disorder of the central nervous system. Antibodies against aquaporin-4 (AQP4) are present in 50-90% of the patients. Recent evidence hints at the presence of anti-myelin oligodendrocyte glycoprotein (MOG) antibodies in some AQP4-seronegative patients. However, the frequency as well as the pathogenic, diagnostic and prognostic relevance of these anti-MOG antibodies remains unclear.
Objectives: To determine the frequency of antibodies against native MOG in AQP4-seronegative and -seropositive NMO and multiple sclerosis (MS) patients and to correlate anti-MOG antibody findings with clinical and MRI characteristics. Moreover, we also aimed at investigating the cellular immune response against MOG.
Methods: We analyzed the presence of anti-MOG immunoglobulins (IgG) in a total of 101 sera from patients with NMO (n=53) and MS (n=48) in a blinded fashion. Anti-MOG IgG reactivity was determined by the ratio of the geometric mean channel fluorescence (GMCF) of the transfected and the untransfected cell lines in flow cytometry. The cut-off was calculated to be 1.45 (mean GMCF ratio plus two standard deviations of a control group measured in parallel). Immunofluorescent stainings with anti-MOG IgG and analysis of the cellular immune response against MOG are carried out in parallel.
Results: 6 out of 53 patients with clinically definite NMO tested positive for IgG against native conformational MOG. All of them are anti-AQP4 seronegative. The anti-MOG IgG positive patients differed from anti-AQP4 IgG positive patients in terms of epidemiological (MOG vs. AQP4 reactivity: female 67 vs. 74%; mean age 50 vs. 45 years), clinical (first presentation with both myelitis and optic neuritis 50 vs. 16%, presence of OCBs 60 vs. 16%, median EDSS at sample date/follow-up 3.8/2.8 vs. 3.0/3.0) and MRI features (brain lesions 50 vs. 16%, longitudinally extensive transverse myelitis 83 vs. 87%). None of the 48 patients with MS had anti-MOG IgG.
Conclusions: Presence of anti-MOG IgG characterizes a subgroup (6/22, 27.3%) of AQP4-seronegative patients with NMO, but is absent in AQP4-seropositive NMO and MS patients. Anti-MOG IgG positive patients seem to have a distinct clinical phenotype compared to anti-AQP4 IgG positive patients with a more severe initial presentation but more favorable outcome.
PS3 - MRI
PS3.1 Ultra-high-field MRI
DS Reich
1
1National Institute of Neurological Disorders and Stroke, NIH, Translational Neuroradiology Unit, Bethesda, MD, United States
In this short talk, I will attempt to bring a critical perspective to the study of MS using 7 tesla MRI. I will comment on the unique advantages of 7T, focusing primarily on high-resolution imaging with particular sensitivity to magnetic susceptibility, and to a lesser extent on spectroscopy. I will also consider major disadvantages, including artifacts related to magnetic field inhomogeneities. I will review important results that have derived from 7T studies of MS to date, both in vivo and ex vivo, and will briefly touch on imaging studies of animal models. Finally, I will propose salient research questions that may benefit from 7T studies over the next few years.
PS3.2 Advanced imaging of the spinal cord: current applications and future developments
O Ciccarelli
1
1UCL, Institute of Neurology, London, United Kingdom
Advanced imaging of the spinal cord is technically challenging, but recent developments have allowed us to classify spinal cord lesions, improve their anatomical characterisation, obtain insights into the pathological changes underlying the development of disability, improve our understanding of the mechanisms of functional adaptation, and develop biomarkers for use in clinical trials. The limitations of advanced spinal cord imaging biomarkers and their current clinical applications in people with MS will be discussed. Future opportunities and directions will be highlighted.
PS3.3 Longitudinal change in quantitative spinal cord MRI in multiple sclerosis patients: preliminary results of a 2-year study
J Oh1,2, M Chen3, A Vidal-Jordana2,4, A Carass3, SD Newsome2, M Diener-West5, S Saidha2, K Zackowski2,6,7, CK Jones8,9, PCM van Zijl8,9, J Prince3,10, PA Calabresi2, DS Reich2,9,11
1University of Toronto, Neurology, Toronto, ON, Canada, 2Johns Hopkins University, Neurology, Baltimore, MD, United States, 3Johns Hopkins University, Electrical and Computer Engineering, Baltimore, MD, United States, 4Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Neurology, Barcelona, Spain, 5Johns Hopkins University, Biostatistics, Baltimore, MD, United States, 6Johns Hopkins University, Physical Medicine and Rehabilitation, Baltimore, MD, United States, 7Kennedy Krieger Institute, Motion Analysis Laboratory, Baltimore, MD, United States, 8Kennedy Krieger Institute, F.M. Kirby Center for Functional Brain Imaging, Baltimore, MD, United States, 9Johns Hopkins University, Radiology and Radiological Science, Baltimore, MD, United States, 10Johns Hopkins University, Computer Science, Baltimore, MD, United States, 11National Institute of Neurological Disorders and Stroke, Translational Neuroradiology Unit, Bethesda, MD, United States
Background: Spinal cord(SC) pathology is common in multiple sclerosis(MS). Prior studies have shown that quantitative SC-MRI measures, including diffusion-tensor and magnetization-transfer indices, and SC-cross-sectional area(CSA), correlate with MS-related clinical disability. To date, the evaluation of longitudinal change in quantitative SC-MRI in MS has been limited.
Objectives: To assess quantitative SC-MRI measures over a median follow-up period of 2 years, and to characterize the relationship between changes in quantitative SC-MRI with clinical disability.
Methods: 74 MS patients underwent annual longitudinal 3T SC-MRI and clinical assessment including: expanded disability status scale(EDSS), vibration-sensation threshold(VST), and hip-flexion strength(HFS). Regions-of-interest circumscribing axial SC cross-sections at C3-C4 were used to obtain:CSA, fractional anisotropy(FA), mean, perpendicular, parallel diffusivity(MD, λ⊥, λ||,) and magnetization-transfer ratio(MTR). Mixed-effects regression incorporating subject-specific intercepts and slopes was utilized to assess longitudinal change in individual SC-MRI measures. Pearson’s correlation coefficient(r) assessed relationships between subject-specific slopes and follow-up clinical measures.
Results: In 74 MS patients:MTR and SC-CSA decreased(p< 0.01,p=0.06), whereas MD increased(p=0.08), over a median follow-up of 726 days(inter-quartile range=372-754). There were moderately strong correlations between subject-specific slopes of individual SC-MRI indices and follow-up clinical measures. For EDSS: r with FA=−0.31(p< 0.01); MD=0.32(p< 0.01); λ⊥=0.34(p< 0.01); λ||=0.15(p=0.06), MTR=−0.27(p< 0.01); SC-CSA=−0.44(p< 0.01). For HFS: r with FA=0.30(p< 0.001); MD=−0.36(p< 0.001); λ⊥=−0.31(p< 0.001); λ||=−0.21(p=0.009); MTR=0.30 (p< 0.001); SC-CSA=0.42(p< 0.001) with comparable observations for VST. Individuals with accelerated rates of change in FA, MD, λ||, and MTR vs. the study population mean showed substantially stronger correlations with follow-up clinical measures.
Conclusions: In MS, quantitative SC-MRI indices change over a median follow-up period of 2 years, likely reflecting ongoing pathological processes. Of clinical relevance is that subject-specific trajectories of SC-MRI index change are relevant to disability at follow-up, suggesting that individual dynamics of change should be assessed in the interpretation of longitudinal SC-MRI measures, and to expand the practical utility of these techniques in clinical settings.
PS3.4 Functional brain networks: linking thalamic atrophy to clinical disability in multiple sclerosis
P Tewarie1, M Schoonheim1, D Schouten1, CH Polman1, BM Uitdehaag1, JJG Geurts1, A Hillebrand1, F Barkhof1, CJ Stam1
1VU University Medical Center, Amsterdam, Netherlands
Background: Thalamic atrophy and disruption of cortical functional networks have both been linked to clinical and cognitive dysfunction in Multiple Sclerosis (MS). As the thalamus is highly connected to many cortical areas, this suggests that thalamic atrophy may be associated with disruption of cortical functional networks.
Objectives: We investigated this thalamo-cortical loop and hypothesized that understanding of this loop is important to explain the presence of clinical and cognitive problems.
Methods: (Functional) magnetic resonance imaging ((f)MRI) and magnetoencephalography (MEG) were performed in 86 MS patients and 21 healthy controls. We estimated thalamic volumes by FIRST; cortical functional networks for fMRI and MEG by computing either pearson correlations or the phase lag index between time signals of AAL regions and thalamo-cortical functional connectivity with fMRI. We computed conventional network metrics and analyzed the minimum spanning tree (MST), a sub-network containing the strongest connections.
Results: MS patients showed marked thalamic atrophy. We further found a shift for MEG functional networks towards a more random network topology or a more path-like topology in terms of the MST. This shift in functional network topology was positively associated with thalamic atrophy but also with increased thalamo-cortical functional connectivity. Importantly, this affected thalamo-cortical loop was associated with worse cognitive and clinical status (EDSS).
Conclusions: These findings are step towards a integrated and translational framework that clarifies how thalamic atrophy in MS are related to widespread disruption of brain networks how the interplay between these eventually lead to clinical and cognitive problems.
PS3.5 Double Inversion Recovery (DIR) sequence of the cervical spinal cord in multiple sclerosis
I Riederer1, DC Karampinos2, M Settles2, C Preibisch1,3, JS Bauer1, J Kleine1, M Mühlau3,4, C Zimmer1
1Klinikum rechts der Isar, Technische Universität München, Department of Neuroradiology, Munich, Germany, 2Klinikum rechts der Isar, Technische Universität München, Department of Diagnostic and Interventional Radiology, Munich, Germany, 3Klinikum rechts der Isar, Technische Universität München, TUM-NIC, TUM Neuroimaging Center, Munich, Germany, 4Klinikum rechts der Isar, Technische Universität München, Department of Neurology, Munich, Germany
Background: The Double Inversion Recovery (DIR) sequence allows to suppress simultaneously the signal from both the cerebrospinal fluid (CSF) and normal white matter. In contrast, inflammatory lesions remain unsuppressed and appear hyperintense in DIR images. Several studies have shown that this sequence is very sensitive towards MS lesions in the brain, especially with respect to intracortical lesions.
Objectives: Spinal cord imaging in MS is still challenging, though very important for diagnosis and prognosis. An analogous DIR sequence for spinal cord imaging, however, has not yet been established in the clinical routine, so far. In order to improve spinal MR imaging we optimized and evaluated a 3D DIR sequence for the examination of the cervical spinal cord and compared it with a conventional 2D T2-weighted turbo-spin-echo (T2w-TSE) sequence at 3T.
Methods: On a 3 Tesla MR scanner we examined 30 patients with MS, clinically isolated syndromes (CIS) or myelitis and 10 healthy controls. 3D DIR and conventional 2D axial and sagittal T2w-TSE images of the cervical spinal cord were acquired. Axial, sagittal and coronal multiplanar reconstructions (MPR) were performed as post processing of the DIR sequence. Two neuroradiologists assessed the scans in pseudo-randomized order for lesion number independently. Afterwards, an additional consensus reading delivered the definite lesion count. Furthermore, the standardized contrast to noise ratio (sCNR) was calculated in representative lesions of each patient. Additionally, image quality was rated on a five-point scale.
Results: Overall, 28% more lesions could be detected with 3D DIR than with conventional T2w-TSE images (119 versus 93). On average, the sCNR was significantly higher (p< 0.001) in DIR than in T2w-TSE images. In 2 out of 18 cases (= 11%) the DIR sequence had an essential influence on decision making of the primary diagnosis and the clinical management. No false positive lesions were found in the control group.
Conclusions: For the detection of MS lesions in the cervical spinal cord, the novel 3D-DIR sequence is more sensitive than a conventional T2w-TSE sequence.
PS3.6 Magnetisation transfer ratio of intracortical lesions and normal-appearing cortical grey matter in multiple sclerosis subtypes
Ö Yaldizli1,2, M Pardini1,3,4, V Sethi1, N Muhlert5, Z Liu1, TA Yousry1,6,7, DJ Tozer1, RS Samson1, C Wheeler-Kingshott1, DH Miller1, DT Chard1
1University College London, Institute of Neurology, Department of Neuroinflammation, NMR Research Unit, London, United Kingdom, 2University Hospital Basel, Department of Neurology, Basel, Switzerland, 3University of Genoa, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Genoa, Italy, 4University of Genoa, Magnetic Resonance Research Centre on Nervous System Diseases, Genoa, Italy, 5Cardiff University, School of Psychology, Cardiff, United Kingdom, 6University College London, Institute of Neurology, Department of Brain Repair and Rehabilitation, London, United Kingdom, 7National Hospital for Neurology and Neurosurgery, Lysholm Department of Neuroradiology, London, United Kingdom
Background: In multiple sclerosis (MS), grey matter (GM) lesions can be extensive, particularly in people with secondary progressive (SP) disease. Conventional magnetic resonance imaging (MRI) techniques detect very few GM lesions, and so in previous work the majority of such lesions will have been included in apparently normal appearing (NA) GM. Different quantitative MRI techniques have been used to detect subtle changes in the NAGM in MS including magnetisation transfer ratio (MTR) measurement. However, it is uncertain how much NAGM abnormalities relate to, or are independent of, GM lesions.
Objectives: To compare MTR in intracortical (IC) lesions and cortical (c) NAGM in different subtypes of MS, and assess associations with neurological and cognitive function.
Methods: Expanded Disability Status Scale (EDSS), MS functional composite (MSFC) scores and MRI data from 46 people with relapsing-remitting (RR), 26 SP, 20 primary-progressive (PP) MS and 36 matched healthy controls (HCs) were included in this study. We used phase-sensitive inversion recovery (PSIR) imaging to identify and segment IC lesions. Cortical GM was segmented from T1-weighted volumetric (1 mm isotropic) scans, and IC lesions removed from this to produce cNAGM masks. These were registered to MTR maps (1 mm isotropic).
Results: The mean age of RRMS patients was 42±10, SPMS 51±7, and PPMS 53±10 years, disease duration 11±8, 20±9, and 14±7 years respectively, and median EDSS score 2 (range 0-7), 6.5 (4-8.5), and 6 (2.5-8). SPMS patients had higher IC lesion volumes than RRMS (p=0.027), whereas IC lesion volumes were not different in the PP and RRMS. Overall, MTR in MS cNAGM was lower than in HCs GM (p< 0.001) and lower in SP than RRMS (p=0.005), but not different in PP compared with RRMS. Similarly, MTR in IC lesions was lower in SP than RR (p< 0.001) or PPMS (p=0.02) even when controlled for lesion size and changes in cNAGM. In the whole MS group, MTR of IC lesions (r=0.34, p< 0.001) and cNAGM (r=0.34, p< 0.001) correlated with the EDSS and MTR in cNAGM with the MSFC scores (r=0.62, p< 0.001).
Conclusions: We found greater structural abnormalities in both cortical lesions and cNAGM in SPMS than in RRMS and PPMS. The findings are consistent with cortical pathology contributing to progression, especially in SPMS. Correlations with disability scores were most consistent with cNAGM rather than IC lesion measures, which highlights the independent role of cNAGM in disability accrual in MS.
PS4 - EAE and other animal models
PS4.1 What can EAE teach us about MS?
JM Goverman1, MC Johnson1, ER Pierson1, SB Simmons1
1University of Washington, Immunology, Seattle, WA, United States
Using the experimental autoimmune encephalomyelitis (EAE) animal model, we studied the role of IL-17 and IFN-g signalling in shaping neuroinflammatory patterns in the CNS. We compared manifestation of EAE induced by adoptive transfer of myelin-specific T cells into wild-type, IL-17receptor A and IFN-g receptor knock-out mice. Our data indicate that these cytokines exert very different effects on inflammation in the brain compared to the spinal cord. In the brain, we found that IL-17 signalling promoted, but IFN-g signalling inhibited, induction of the ELR+ chemokine CXCL2, which correlated with neutrophil recruitment to this region. Neutrophil recruitment to the brain was required for tissue injury. In contrast, IFN-g promoted CXCL2 induction and recruitment of neutrophils to the spinal cord and IL-17 signalling was not required. Surprisingly, tissue injury in the spinal cord did not exhibit the same dependence on neutrophil recruitment that was seen in the brain. These data in EAE suggest that the brain and spinal cord exhibit distinct sensitivities to mediators of tissue damage that are recruited subsequent to initial IL-17 and IFN-g signalling. In MS, many patients exhibit lesions in the brain with minimal involvement of the spinal cord, and a small percentage of patients exhibit lesions predominantly in the spinal cord with less lesion involvement in the brain. We have begun analysing the frequency of MBP-specific IL-17 and IFN-g producing T cells in the blood of these two types of patients to determine if patients with MS that exhibit distinct neuroinflammatory patterns differ in the relative abundance of myelin-specific TH17 and TH1 cells. Our preliminary findings reveal significant differences in the TH17 and TH1 cells between these patient groups. The implication of these findings will be discussed.
PS4.2 New animal models and human studies are necessary to understand MS
H Lassmann
1
1Medical University of Vienna, Center for Brain Research, Wien, Austria
Experimental models of inflammatory demyelinating diseases of the central nervous system have provided major contributions to our understanding of immune surveillance of the brain and on the mechanisms of brain inflammation. They have also served as the basis for the development of current anti-inflammatory and immune-modulatory therapies in multiple sclerosis (MS). However, their value to unravel the mechanisms involved in demyelination and neurodegeneration in MS lesions has been limited. MS like widespread primary demyelination can be induced in experimental models by cytotoxic T-lymphocytes directed against oligodendrocyte antigens as well as by demyelinating antibodies. However, evidence from clinical and neuropathological studies in MS patients for involvement of cytotoxic T-cells and demyelinating auto-antibodies is sparse and this is particularly the case in patients with progressive disease. Recent immunopathological data indicate that microglia activation, oxidative injury and mitochondrial damage and dysfunction play a major role in propagating demyelination, oligodendrocyte death and neurodegeneration in MS lesions. This constellation appears to be unique in MS lesions and is not present in other inflammatory diseases of the human brain, nor in current experimental virus induced or autoimmune models of the disease. A direct immunopathological comparison of MS lesions with those seen in experimental models suggests differences in the patterns of inflammation and oxidative burst activation of microglia. Furthermore, potential amplification factors for neurodegeneration in the human brain, related to aging and accumulation of disease burden, which are prominent in the progressive stage of MS, are not seen even in the most chronic experimental models of inflammatory demyelinating disease. The potential role of such amplification factors in conditions of brain inflammation can, however, in part be analyzed in new models of autoimmune encephalomyelitis induced in animals with genetic dysfunction of mitochondria or disturbed iron metabolism. The further development of such new models will be instrumental for pre-clinical testing of drugs targeting the progressive stage of MS.
PS4.3 The multiple sclerosis risk gene IL22RA2 contributes to a more severe murine autoimmune neuroinflammation
H Laaksonen1, A Ortlieb1, M Zeitelhofer Adzemovic1, R Parsa1, M Zeitelhofer1, M Jagodic1, T Olsson1
1Karolinska Institutet, Stockholm, Sweden
Background: The gene interleukin-22 receptor alpha 2 (IL22RA2) is associated to MS susceptibility in two large international studies and has furthermore been a candidate gene affecting severity of a rat model of MS in our lab. IL22RA2 codes for the IL-22 binding protein (IL-22BP), which is known to bind strongly to IL-22 effectively inhibiting signaling through the IL-22 receptor. IL-22 has been found in MS plaques and in lesions of experimental MS models but it is not known what role it plays in central nervous system (CNS) pathology.
Objectives: To investigate the role of IL22RA2 in experimental autoimmune encephalitis (EAE) using Il22ra2 knockout mice.
Methods: As a mouse model of MS we used myelin oligodendrocyte glycoprotein (MOG) induced EAE. To study immunological and pathological processes in the mice we used histological staining, flow cytometry, and quantitative polymerase chain reaction (qPCR).
Results: Il22ra2 knockout mice, after induction of EAE, have less severe clinical disease manifestations, less severe CNS pathology, and less immune cell infiltration. Furthermore we show that Il22ra2 gene expression is found in secondary lymphoid tissues in the mouse, where expression is confined to CD11b+ cells. We also confirm the presence Il22ra2 protein product in the lymph nodes by immunofluorescence technique. After EAE induction, however, Il22ra2 gene expression is reduced in the lymph nodes draining the site of immunization and a concomitant rise in IL-22 expression occurs.
Conclusions: Deletion of the ortholog of the MS risk gene Il22ra2 in mice has beneficial effects on EAE, which may be considered in new therapeutic strategies for treating neuroinflammation.
PS4.4 In vivo administration of Clostridium perfringens epsilon toxin targets cells associated with multiple sclerosis
J Linden1, KR Rumah1, T Vartanian1
1Weill Cornell Medical College, New York, NY, United States
Background: Clostridium perfringens (C. perfringens) epsilon toxin (ε-toxin) is a candidate for initiating nascent lesion formation in Multiple Sclerosis (MS). We purpose that ε-toxin producing C. perfringens strains colonize the human gastrointestinal tract and activated ε-toxin causes intestinal permeability. Intestinal permeability allows entry of the toxin into the blood stream where it can travel to the brain and specifically target the brain microvasculature and oligodendrocytes, resulting in the pathologic hallmarks of the newly forming MS lesion: blood brain barrier permeability (BBB) and oligodendrocyte cell death. However, ε-toxin›s effect on other cell types associated with MS inflammation has not been evaluated.
Objectives: In this study, we sought to determine what cells ε-toxin targets in vivo.
Methods: Mice were administered fluorescently labeled ε-toxin via tail vein injection. Specificity of ε-toxin binding and tissue damage was evaluated by microscopy.
Results: We demonstrate that ε-toxin binds to intestinal endothelial cells and also confirm ε-toxin›s ability to bind to brain endothelial cells and cause BBB permeability. Furthermore, we provide new evidence that ε-toxin binds to the retinal vasculature and causes blood retinal barrier (BRB) permeability; observations consistent with MS related retinal periphlebitis and macular edema. In addition, ε-toxin also binds to the blood vessels and myelin of the optic nerve, possibly explaining the high incidence of optic neuritis in MS patients. Finally, we demonstrate that ε-toxin binds to the vasculature of brain-associated meninges and kills meningeal cells; perhaps elucidating a mechanism of MS related meningeal inflammation.
Conclusions: Taken together, these observations indicate that ε-toxin specifically targets the same cells associated with MS inflammation, providing more evidence that ε-toxin may be responsible for initiating MS.
PS4.5 Co-expressed astrocytic ECGF1/TP and VEGF-A cooperatively promote blood-brain barrier breakdown in inflammatory CNS disease
A Tadesse Argaw1, C Chapouly1, S Horng1, K Castro2, G John1
1Corinne Goldsmith Dickinson Center for MS, Friedman Brain Institute and Neurology, Mount Sinai School of Medicine, New York, NY, United States, 2Corinne Goldsmith Dickinson Center for MS, Neurology, Mount Sinai School of Medicine, New York, NY, United States
Background: In inflammatory CNS conditions such as multiple sclerosis (MS), breakdown of the blood-brain barrier (BBB) correlates with lesion activity and neurologic exacerbation, and contributes to tissue damage. Recently, we identified reactive astrocyte-derived vascular endothelial growth factor-A (VEGF-A) as a critical factor driving BBB disruption.
Objectives: Here, we now show that reactive astrocytes also co-express a second key driver of endothelial plasticity, endothelial cell growth factor-1/thymidine phosphorylase (ECGF1/TP), and that VEGF-A and ECGF1/TP cooperatively promote BBB opening.
Methods: These studies used unbiased transcriptional analysis of primary human astrocyte cultures, and in vivo cortical IL-1β-induced inflammatory lesions and the MS model EAE in mice.
Results: In human astrocytes, ECGF1/TP and VEGF-A are co-induced NFκB-dependently by the inflammatory cytokine interleukin-1β (IL-1β). ECGF1/TP acts via production of 2-deoxy-D-ribose 1-phosphate (DDR), and in human CNS microvascular endothelial cultures (CMVEC) DDR and VEGF-A produce distinct transcriptional program. These include induction of drivers of plasticity and permeability, and repression of tight junction proteins, notably CLN-5, a critical determinant of barrier integrity. Individually, DDR and VEGF-A differentially promote endothelial migration, proliferation and permeability, and produce additive outcomes in combination. Their introduction into mouse cortex individually produces CLN-5 downregulation, BBB opening and neuronal loss, and together they exacerbate these outcomes. In cortical IL-1β-induced inflammatory lesions in mice, and in the MS model EAE, ECGF1/TP and VEGF-A co-localize to reactive astrocytes, and correlate with BBB disruption and neuropathology. In CMVEC, conditioned media from IL-1β-treated astrocytes produces CLN-5 downregulation and permeability. Silencing of astrocytic ECGF1/TP or VEGFA is partially protective, and co-silencing abrogates astrocyte-induced permeability.
Conclusions: Collectively, these findings suggest that astrocytic ECGF1/TP and VEGF-A act cooperatively to drive BBB breakdown and tissue damage in inflammatory CNS lesions in conditions including MS.
PS4.6 Cerebellar changes in synaptic plasticity are mediated by the MyD88 signaling pathway in a toxic murine model of demyelination
A Barrantes Freer1, LS Mortensen2, M Lohrberg3, C Stadelmann1
1University Medical Center Göttingen, Neuropathology, Göttingen, Germany, 2Max-Planck Institute of Experimental Medicine, Molecular Neurobiology, Göttingen, Germany, 3University Medical Center Göttingen, Master’s Program Molecular Medicine, Göttingen, Germany
Background: Multiple sclerosis (MS) is the most common cause of non-traumatic neurological disability in young adults. MS presents in up to 80% of the cases with a mostly refractory cerebellar symptomatic. Electrophysiological studies in the experimental autoimmune encephalomyelitis (EAE) mouse model of MS suggest that cerebellar pathology might be in part characterized by an early reduction in basal cerebellar synaptic transmission. Moreover, the inflammatory milieu present in the central nervous system (CNS) of EAE animals has been proposed as a key determinant of early synaptic plasticity. However, the individual contributions of innate and adaptive immune systems are difficult to dissect in the context of EAE. Also, the effects of inflammation on relevant aspects of synaptic transmission, such as synaptic plasticity remain poorly understood.
Objectives: In the present work we studied the influence of the innate immune system on synaptic plasticity.
Methods: We performed electrophysiological measurements of synaptic facilitation in acute cerebellar slices at the parallel fiber - Purkinje cell synapse and histological analysis in the cuprizone-induced demyelination model. Th cuprizone model is characterized by extensive demyelination in the background of an intact blood brain barrier. Further we studied synaptic transmission in hippocampal autaptic neurons cultured in the presence of cuprizone.
Results: We measured a reduced cerebellar facilitation in cuprizone-fed animals. This phenotype was abolished in cuprizone-treated MyD88 deficient mice (MyD88-/-). Importantly, the extent of cerebellar demyelination and microglia infiltration were similar in both MyD88-/- and wt animals. Neither the acute nor long term treatment with cuprizone induced changes in synaptic transmission in in vitro autaptic neuronal cultures.
Conclusions: Our results indicate that microglial inflammatory mediators reduce cerebellar facilitation in a MyD88 dependent manner.
PS5 - Comorbidities and risk behaviors
PS5.1 Effects of comorbid disease and health behaviors on MS susceptibility and prognosis
RA Marrie
1
1University of Manitoba, Internal Medicine, Winnipeg, MB, Canada
Multiple sclerosis (MS) is a complex disease in which genetic and environmental factors act together to cause disease. Multiple factors are also likely to account for the well-recognized heterogeneity in disease outcomes in MS. Comorbidities, such as mental illness have been recognized as common in MS for many years, with a 50% lifetime prevalence of depression, while physical comorbidities are gaining increasing recognition. A past history of smoking as well as of overweight or obesity are also common. These health behaviors and comorbidities constitute potentially modifiable factors that may influence susceptibility to disease and disease progression after onset. Recent work suggests that obesity in adolescence is associated with an increased risk of MS and that it may influence phenotype after onset. Smoking adversely influences disability progression. Comorbidity is associated with greater disability at diagnosis and more rapid disability progression after diagnosis. Given the frequency of comorbidity with MS, it is imperative that we develop a better understanding of the bidirectional interactions of comorbidity and all aspects of MS.
PS5.2 Leptin and other adipokines in EAE and MS
AH Cross
1
1Washington University School of Medicine, Neurology, Saint Louis, MO, United States
MS is a presumed autoimmune disease thought to target CNS myelin, but its exact cause is unknown. It is becoming clear that environmental factors play a role in risk of MS development. Diet and obesity are implicated as risk factors. Several recent studies have suggested that being overweight as an adolescent or young adult increases risk of later MS development. Dietary risk factors have been more difficult to define, but may include diets of higher saturated fat content. Adipose tissue is the source of a group of cytokines collectively known as adipokines; these include leptin, adiponectin, and resistin. IL-6 is also made by adipose tissue. Although most adipokines are elevated with increased visceral fat depots, adiponectin is increased during fasting states. Most adipokines are pro-inflammatory, but adiponectin has anti-inflammatory effects. Experimental autoimmune encephalomyelitis (EAE) is a main animal model for MS. We and others found that calorie restriction by 40% in two strains of mice greatly reduced the susceptibility to and severity of EAE. Calorie restricted mice in our studies had reduced leptin and IL-6, while displaying elevated adiponectin and corticosterone. The “pro-inflammatory” adipokine leptin appears requisite for EAE induction in C57BL/6 mice; mice with a genetic deletion of leptin do not develop EAE. In contrast, adiponectin appears to ameliorate clinical and histologic EAE in mice. In our studies, mice genetically deficient in adiponectin had worse EAE, with greater inflammation, demyelination and axon injury in the CNS by histology. Lymphocytes from adiponectin deficient (ADP KO) mice proliferated more, and produced more pro-inflammatory cytokines (IFNg, TNFa and IL-6) in vitro than lymphocytes from wild-type (WT) mice. In vivo, passive transfer of encephalitogenic ADP KO lymphocytes induced more severe EAE than a comparable number of WT lymphocytes upon transfer to naïve recipients, suggesting that adiponectin acts in EAE during the induction phases of T cell priming. At EAE peak, fewer regulatory T cells were apparent in ADP KO mice than in WT mice, suggesting that one mechanism by which adiponectin may modulate autoimmunity is through up-regulation of T-regulatory cells. Based on these results, we have embarked upon a small safety study of intermittent fasting in relapsing MS patients.
PS5.3 Dietary patterns not associated with the risk of multiple sclerosis
DL Rotstein1, S Chiuve2, T Chitnis1, T Fung2, KL Munger2
1Brigham and Women’s Hospital, Harvard Medical School, Neurology, Boston, MA, United States, 2Harvard School of Public Health, Boston, MA, United States
Background: With the exception of vitamin D, previous studies on diet and multiple sclerosis (MS) risk have yielded null or inconsistent results.
Objectives: To determine whether there is any association between measures of overall diet quality (dietary indices/patterns) and the risk of MS. These measures have been associated with reduced risks of other chronic diseases, including cardio- and cerebrovascular disease, dementia, and diabetes.
Methods: Over 185,000 women in the Nurses’ Health Study (NHS) and Nurses’ Health Study II (NHSII) completed semi-quantitative food frequency questionnaires (FFQ) every 4 years beginning in 1984 (NHS) or 1991 (NHSII). There were 480 incident cases of MS identified and validated between baseline and 2004 (NHS) or 2009 (NHSII). Scores on the Alternative Healthy Eating Index-2010 (AHEI-2010), Alternate Mediterranean Diet (aMED) index, and Dietary Approaches to Stop Hypertension (DASH) index were calculated from the FFQs. Principal components analysis was used to derive major dietary patterns. Using a Cox proportional hazards model, we calculated the relative risk (RR) of MS and 95% confidence intervals. Multivariate analyses were adjusted for age, latitude of residence at age 15, ethnicity, body mass index at age 18, supplemental vitamin D intake, and cigarette smoking.
Results: None of the dietary indices, AHEI-2010, aMED, or DASH, at baseline were statistically significantly related to the risk of MS. Specifically, the multivariate-adjusted pooled RR of MS comparing the highest to lowest quintile was 0.89 (p for trend=0.77) for the AHEI-2010, 1.10 (p=0.19) for aMED, and 1.30 (p=0.23) for DASH. The principle components analysis identified two dietary patterns, “western” and “prudent”, neither of which was associated with MS risk (western, top vs. bottom quintile RR=0.71 (p=0.1) for, and prudent, 1.09 (p=0.57). When the analysis was repeated using the cumulative average dietary pattern scores, the results were likewise null.
Conclusions: This is the first large, prospective, population-based study to investigate whether overall diet quality may contribute to the development of MS, and no evidence for such an association was found.
PS5.4 Smokers run increased risk of developing anti-natalizumab antibodies
T Olsson1, AK Hedström2, L Alfredsson2, M Ryner1, A Fogdell-Hahn1, J Hillert1
1Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden, 2Karolinska Institutet, Institute of Environmental Medicine, Stockholm, Sweden
Background: Smoking may contribute to the induction of neutralizing antibodies to interferon β-1a.
Objectives: In this study, we aimed to investigate the influence of smoking on the risk of developing antibodies to natalizumab, another biological drug in the treatment of multiple sclerosis.
Methods: This report is based on 1338 natalizumab-treated multiple sclerosis patients included in either of two Swedish case-control studies in which information on smoking habits was collected. Using logistic regression, patients with different smoking habits were compared regarding risk of developing anti-natalizumab antibodies, by calculating odds ratios with 95% confidence intervals.
Results: Compared with non-smokers, the odds ratio of developing anti-natalizumab antibodies was 2.4 (95% CI 1.2-4.4) for patients who smoked at the time of screening, and a significant trend showed higher risk of developing antibodies with higher intensity of smoking. When smoking within two years prior to screening was considered, the odds ratio of developing anti-natalizumab antibodies was 2.7 (1.5-5.1).
Conclusions: The finding strengthens our hypothesis of the lungs as immune-reactive organs upon irritation in relation to autoimmune responses, and may also be of clinical relevance since antibodies against natalizumab abrogate the therapeutic effect of the treatment.
PS5.5 Level of education and multiple sclerosis risk after adjustment for known risk factors: the EnvIMS study
K Bjørnevik1,2, T Riise1,2, J Kirkeleit3, M Cortese1,2,4, T Holmøy5,6, MT Kampman7,8, S Magalhaes9, K-M Myhr2,4, C Wolfson10, M Pugliatti1,11
1University of Bergen, Department of Global Public Health and Primary Care, Bergen, Norway, 2Haukeland University Hospital, Department of Neurology, Norwegian Multiple Sclerosis Competence Center, Bergen, Norway, 3University of Bergen, Department of Clinical Science, Bergen, Norway, 4University of Bergen, KG Jebsen Centre for MS-Research, Department of Clinical Medicine, Bergen, Norway, 5University of Oslo, Institute of Clinical Medicine, Faculty of Medicine, Oslo, Norway, 6Akershus University Hospital, Department of Neurology, Lørenskog, Norway, 7University of Tromsø, Department of Clinical Neurology, Tromsø, Norway, 8University Hospital of North Norway, Department of Neurology, Tromsø, Norway, 9McGill University, Department of Epidemiology, Biostatistics and Occupational Health, Montreal, QC, Canada, 10McGill University, Research Institute of the McGill University Health Centre, Montreal, QC, Canada, 11University of Sassari, Department of Clinical and Experimental Medicine, Sassari, Italy
Background: Several recent studies have found a higher risk of MS among persons with low level of education. This has been suggested to reflect an effect of smoking and factors related to lower vitamin D status in the social class associated with lower levels of education.
Objectives: To investigate the association between level of education and MS risk adjusted for known risk factors such as smoking, infectious mononucleosis and indicators of low level of vitamin D including supplementation of cod liver oil, low dietary intake of fish, little sun exposure and large body size.
Methods: Within the case-control study on Environmental risk factor In MS (EnvIMS), 953 MS patients and 1717 healthy controls from Norway reported educational level and the history of exposure to putative environmental risk factors. This was based on a self-administered questionnaire previously tested for acceptability, feasibility and reliability. Cases with less than 10 years disease duration were selected from the Norwegian MS-registry, while controls were randomly selected from a population-based registry and frequency-matched on sex and age.
Results: A significant association was found between level of education and MS risk with dose-response relationship (p-trend=0.001) and with an OR of 1.79 (95% CI 1.39-2.33) comparing those with the lowest to highest level of education. This association was only moderately reduced after adjusting for known risk factors (OR 1.64, 95% CI 1.16-2.27). To evaluate a possible reverse causation we repeated the analysis including cases with onset after 30 years only. No major change in the estimates was found.
Conclusions: These findings suggest that factors related to lower social class other than smoking and vitamin D related factors are associated with MS risk.
PS5.6 Impact of parental multiple sclerosis on early childhood development, a retrospective cohort study
N Razaz1, H Tremlett1, WT Boyce2, M Guhn1, KS Joseph1, RA Marrie3
1University of British Columbia, Vancouver, BC, Canada, 2University of California, San Francisco, CA, United States, 3University of Manitoba, Winnipeg, MB, Canada
Background: Exposure to parental chronic illness has been found to be negatively associated with numerous developmental outcomes in children. However, little is known about the impact of having a parent with multiple sclerosis (MS) on childhood development.
Objectives: We examine the association between parental MS, mental health comorbidity, and childhood developmental outcomes.
Methods: We conducted a retrospective cohort study in Manitoba, Canada, using linked population-based health administrative and education-related databases. The outcome of interest was childhood development, expressed as vulnerability (absent vs present) on 5 areas of childhood development at 5 years of age: physical health, social competence, emotional maturity, language development and communication skills, measured by the Early Child Development Instrument (EDI). We compared children who had a parent with MS, were born between 1999 and 2006, and had an EDI assessment to children with parents not affected with MS, who were matched on sex, region and year of the EDI assessment. Adjusted odds ratios (aOR) were estimated using multivariable conditional logistic regression adjusting for potential confounders such as, socioeconomic status (SES), maternal age at birth, age of the child at EDI assessment, number of siblings, and parental mental morbidity.
Results: Of 3116 individuals who had MS, 153 had a child with EDI and 876 children formed the matched comparison cohort. The MS-affected parents were older at the time of childbirth, had a higher SES and more likely to have mental health morbidity (77/153 [50.3%] vs. 309/876 [35.3%], p< 0.001) than parents in the general population. However, children with an MS parent did not differ significantly from the general population on all EDI domains. Determinants of vulnerability on EDI domains included, parental mental morbidity, SES and the number of siblings. Compared with MS parents without mental comorbidity, MS parents with mental comorbidity were more likely to have a child who was vulnerable on the social competence (aOR 5.06 95% CI 1.02-25.08) or emotional maturity (aOR 3.00 95% CI 1.04-8.67) domains.
Conclusions: The presence of parental MS was not associated with adverse developmental outcomes at 5 years of age. However, children whose MS parent was also affected by mental health comorbidity were at higher risk of developmental vulnerability. Health professionals need to be aware of the impact of mental health in MS on childhood development.
PS6 - Risk management with MS therapies
PS6.1 PML with novel immunotherapies: Is there light at the end of the tunnel?
R Gold
1
1Ruhr University Bochum, Bochum, Germany
Progressive multifocal leukoencephalopathy (PML) is a rare opportunistic infection of the central nervous system caused by the human polyoma JC virus. Whereas it was originally described in immunosuppressed lymphoma patients and later in HIV infection, It has now afflicted more than 450 MS patients receiving longterm natalizumab treatment. In this context also recently approved novel therapies such as fingolimod and fumarates have entered the discussion on putative PML association.
Triage procedures for identifying patients at risk include prior immunosuppression, length of natalizumab exposure and anti-JC antibody levels as measured by an improved ELISA screening. In addition, the intrathecal JC antibody-specific immune response and the L-Selectin (CD62L) flow cytometric assay may help to identify people at risk or increase specificity of the diagnosis. Some ‹benign› PML cases have been observed, and there is no doubt that there are variants with only radiological signs albeit their pathophysiology is not well understood. In addition we often observe carry-over effects when patients were switched from natalizumab to fingolimod or fumarates, and initial signs of natalizumab PML were overlooked by non-experienced radiologists or an MRI was not performed.
The evidence is growing that survival in natalizumab associated PML is much better than in HIV sufferers. The gross survival in natalizumab associated PML is around 80% but may be clearly higher in specialized departments. Still there is the concern that functional outcome as measured by Karnofsky is very much dependent on the initial site of JC infection. Especially in longterm natalizumab recipients there is predominant infratentorial affliction, which translates into more severe residual disability. With the experience of 258 natalizumab PML cases we still recommend to restore the immune system by plasma exchange procedures, yet also consider appropriate management of IRIS and associated seizures. Surprisingly MS stays calm for at least one year after PML.
So far there is no clear evidence for PML primarily associated with fingolimod, or Tecfidera approved for treatment of relapsing MS. Yet the ‹old› German fumaderm used in psoriasis is clearly associated with rare PML cases which are milder and sometimes exhibit atypical lesions on MRI.
PS6.2 Rebound after natalizumab discontinuation
BAC Cree
1
1University of California San Francisco, Neurology, San Francisco, CA, United States
Although highly efficacious as a disease modifying therapy natalizumab is also associated with development of progressive multi-focal encephalopathy (PML) and with herpes simplex encephalitis. As a consequence of inhibition of lymphocyte transmigration into the central nervous system, reduced immune surveillance is thought to cause these frequently disabling, and sometimes fatal, brain virus infections. In the case of PML, patients who have been previously exposed to the JC virus, the cause of PML, incur a dose dependent risk that appears to plateau sometime after two years of treatment. Prior treatment with immune suppressants is an additional risk factor. The risk of developing PML varies considerably across patients with a risk of < 1:10,000 for patients who test seronegative for anti-JCV antibodies to a risk of ~1:90 for patients who are JCV seropositive, have had prior exposure to immune suppressant and who have been treated with natalizumab for more than 2 years. Patients and clinicians will electively discontinue natalizumab treatment if the risk of developing PML is thought to outweigh the benefits of ongoing treatment. Treatment discontinuation has been associated with recurrence of disease activity. Recurrence of disease activity coincides with restoration of immune function as measured by the proportion of VLA4 receptors that are bound by natalizumab. Highly inflammatory disease activity as evidenced by relapse severity and multiple contrast enhancing lesions identified on brain MRI has been reported in some patients. This occurrence of inflammation is described as “rebound” and some have suggested that the extent of inflammation in these cases occurs as an unintended consequence of natalizumab treatment. In contrast, others have proposed that “rebound” is return of disease activity that was previously blocked by natalizumab treatment and that the extent of inflammation was not directly influenced by natalizumab treatment. Data will be presented both for and against the case of “rebound”. Selection of treatment following natalizumab discontinuation and the timing of such treatment, i.e. whether a period of no-treatment or a “washout” should be used, will also be discussed.
PS6.3 Natalizumab-associated JC virus granule cell neuronopathy complicated by immune reconstitution inflammatory syndrome in a patient with MS
S Agnihotri1, X Dang2, J Carter3, T Fife3, E Bord2, S Batson2, I Koralnik1
1Beth Israel Deaconess Medical Center, Neurology, Boston, MA, United States, 2Beth Israel Deaconess Medical Center, Boston, MA, United States, 3University of Arizona College of Medicine, Neurology, Phoenix, AZ, United States
Background: Natalizumab blocks trafficking of leukocytes to the brain, and has been associated with reactivation of JC virus (JCV) leading to progressive multifocal leukoencephalopathy (PML) in multiple sclerosis (MS) patients. JCV can also infect cerebellar granule cell neurons resulting in JCVgranule cell neuronopathy (JCV GCN).
Objectives: To describe the clinical, neuroimaging, immunological and virological characteristics of JC virus -associated granule cell neuronopathy (JCV GCN) in a natalizumab-treated patient with multiple sclerosis (MS) who developed immune reconstitution inflammatory syndrome (IRIS) after natalizumab withdrawal.
Methods: We obtained longitudinal clinical data as well as MRI and proton- MR spectroscopy (1H-MRS) from this MS patient. We measured JCV-specific cellular immune response in his peripheral blood by intracellular cytokine staining and sequenced a fragment of JCV VP1 capsid gene detected in his CSF. We contrast our findings with the first recently reported case.
Results: This patient presented with worsening cerebellar symptoms and progressive cerebellar atrophy without new MS lesions on MRI after 63 months of natalizumab monotherapy. JCV DNA was detected in his CSF by PCR and harbored novel GCN-type mutations in the VP1 gene. He developed IRIS upon discontinuation of natalizumab and plasma exchange, which manifested itself by a worsening of clinical symptoms and contrast-enhancement in the cerebellum on MRI. Treatment with corticosteroids resulted in resolution of IRIS, as demonstrated by 1H-MRS. The patient had a strong JCV-specific T cell response in his peripheral blood and remains alive after 15 months from symptoms onset, although with significant disability. He did not have MS relapse on glatiramer acetate.
Conclusions: JCV GCN should be considered in patients on natalizumab presenting with progressive cerebellar symptoms and cerebellar atrophy without white matter lesions, and is associated with mutations in the JCV VP1 gene. Natalizumab withdrawal may be complicated by JCV GCN IRIS, and require treatment with corticosteroids.
PS6.4 Pathogenesis of JC virus reactivation during natalizumab treatment
S Chalkias1, X Dang1, E Bord1, M Stein1, RP Kinkel1, J Sloan1, M Donnelly1, C Ionete2, M Houtchens3, G Buckle3, S Batson1, I Koralnik1
1Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States, 2University of Massachusetts Memorial Medical Center, Boston, MA, United States, 3Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
Background: Polyoma JC virus (JCV) is the cause of progressive multifocal leukoencephalopathy (PML), a devastating demyelinating disease of the brain that rarely occurs in natalizumab-treated multiple sclerosis (MS) patients. Natalizumab, a monoclonal antibody against α4β1 and α4β7 integrin receptors, prevents trafficking of leukocytes out of the blood stream.
Objectives: The pathogenesis of JCV reactivation is poorly understood and we sought to determine JCV reactivation events during prolonged exposure to natalizumab.
Methods: We enrolled 43 JCV seropositive MS patients, including 32 on natalizumab monotherapy >18 months, 6 on interferon β-1a monotherapy >36 months and 5 untreated controls. We performed QPCR in cerebrospinal fluid (CSF), blood and urine for JCV DNA and we determined JCV-specific T cell responses using enzyme-linked immunospot (ELISpot) and intracellular cytokine staining (ICS) assays, ex vivo and after in vitro stimulation with JCV peptides.
Results: JCV DNA was detected in the CSF of 2/27 (7.4%) natalizumab-treated MS patients tested who had no symptoms or MRI lesions consistent with PML. JCV DNA was detected in blood of 12/43 (27.9%) subjects. Viral load was higher in CD34+ cells compared to B (p=0.006), T (p=0.004) and polymorphonuclear (PMN) cells (p=0.002) and in monocytes compared to T cells (p=0.005) and PMN (p=0.004). JCV was detected in urine of 11/43 (11.6%) subjects. Neither of the two patients with JCV DNA in CSF was found to be viremic or viruric. JCV-specific CD4+ T cells were detected ex vivo more frequently in natalizumab-treated patients who were viremic (p=0.05). JCV-specific CD4+ T cells were more frequently detected than CD8+ T cells after in vitro stimulation [43/43 (100%) versus 38/43 (88.4%); p=0.05].
Conclusions: Asymptomatic JCV reactivation may occur in CSF of natalizumab-treated MS patients and therefore, in the absence of new clinical or radiographic findings, JCV DNA detection in CSF is not equivalent to PML. JCV reactivation also occurs in blood and multiple leukocyte subpopulations harbor the virus, but viral load is substantially higher in CD34+ cells and monocytes. Viremia might trigger a JCV-specific CD4+ mediated response. Cellular immune response against the virus is highly prevalent in all MS patients, regardless of treatment, and it is mediated by CD4+ and CD8+ T cells. Our findings shed light to JCV pathogenesis.
PS6.5 JCV index and L-selectin for natalizumab-associated PML risk stratification
N Schwab1, T Schneider-Hohendorf2, J Breuer2, A Posevitz-Fejfar2, H Wiendl2
1University of Münster, Neurology, Münster, Germany, 2University of Münster, Münster, Germany
Background: Long-term treatment with and the presence of anti-JCV antibodies in serum is associated with the risk to develop-induced PML. Recent data suggest that the level of anti-JCV antibodies in serum (JCV antibody index>0.9) and/or the lack of L-selectin (CD62L) on cryopreserved CD4+ T cells (%CD62L+ cells of CD4+ T cells< 21.6) could be biomarkers for higher PML risk.
Objectives: To compare and correlate PML risk stratification parameters during natalizumab therapy including the assessment of their relationship.
Methods: Up to 1921 patients (number depending on data set completion) were analyzed for CD62L and JCV antibody index. Patient cohorts were grouped according to age, previous immune-suppression (IS), or JCV seropositivity and subsequently correlation between the two risk parameters
JCV index and
CD62L value was assessed.
Results: JCV seropositivity correlates with age, whereas CD62L values correlate with age and with duration of treatment. Interestingly, IS patients show a stronger correlation between CD62L values and treatment duration, suggesting CD62L as a first biological marker explaining why IS patients are at higher risk to develop PML over time. CD62L and JCV antibody index only correlated in patients not previously IS (n=226; p=0.02). Risk stratification with the two markers alone set 43.37% at risk (JCV index>0.9 and IS JCV+ patients), or 3.74% (CD62L< 21.6). Synergy of the two markers reduced the percentage of patients at risk in our cohort (n=273) to 2.18%.
Conclusions: This data set suggests a statistical correlation between CD62L and JCV index, indicating a possible biological link between the two parameters. However, this link only exists without previous IS, which is in line with the observation that IS patients do not have higher JCV indices before developing PML. For patients with previous IS CD62L therefore seems favorable for risk stratification. For non-IS patients, the presented correlation and synergy between the two markers might have implications for the research of biological mechanisms leading to PML and can also help to further individualize risk stratification in long-term natalizumab patients.
PS6.6 Evolving dark band on T2* weighted high resolution MRI is characteristic of PML
V Sethi1, P Sati1, G Nair1, M Absinta1, G van Geldern2, BE Dewey1, J Ohayon1, I Cortese1, A Nath3, DS Reich1
1NINDS, NIH, Translational Neuroradiology Unit, Neuroimmunology Branch, Bethesda, MD, United States, 2NINDS, NIH, Bethesda, MD, United States, 3NINDS, NIH, Section of Infections of the Nervous System, Bethesda, MD, United States
Background: White matter (WM) lesions are seen in progressive multifocal leukoencephalopathy (PML), a demyelinating disease due to reactivation of JC virus in the setting of an altered immune system. PML lesions are common at the junction of the gray(GM) and WM. Using a rapid high-resolution susceptibility based magnetic resonance imaging(MRI) technique at 3Tesla(3T), we investigated the characteristics and temporal evolution of PML lesions on T2*weighted (T2*w)contrast.
Objectives: To study characteristics of progressive multifocal PML lesions using T2*w imaging.
Methods: MRI scans were acquired for 9 PML patients (4 natalizumab treated MS, 2 lymphoma, 1 with idiopathic low CD4 and 2 with HIV infection) on a Siemens 3T scanner using a 32 channel head coil. Whole brain 3D T2*w images [0.65 mm isotropic; TR=64ms; TE=29ms; 256 slices; FA=10 degree, EPI factor=15, acquisition time(aq.t) ~4 min] and 3D T1-weighted MPRAGE images [1mm isotropic, TR=3000ms; TE=3.03ms; TI=900ms; FA=9 degree, aq.t ~6 min] were acquired. Scans were repeated at an additional time point (interval ranging from 1 to 7 months) for 5 patients. All images were co-registered. T2*w images were studied to determine the
presence of a hypointense band at the periphery of the WM lesions and
its evolution with time. With co-registered T1w images, we determined the
location of the dark band with respect to the gray-white junction.
Results: In all patients, PML lesions were clearly visible as asymmetric WM hyperintensities on T2*w images and a starkly T2*-hypointense band was also noted adjacent to the PML lesions, encompassing them at least partially. The band had a variable thicknesses (0.3mm - 3.5mm), and was never seen in association with pre-existing MS lesions. After a mean[SD] follow up of 7.8[5.2] months, this dark T2* band increased in length by 22.5[13.2]mm. Using co-registered T1w images, the band was found to involve subcortical regions and the deeper layers of the cortex. Clinically, there was no appreciable change in the disability during the duration of follow-up (n=5).
Conclusions: A hypointense T2* band at the gray-white junction is characteristic of PML irrespective of the underlying etiology and could be diagnostically very helpful in distinguishing PML lesions from new MS lesions. The band has a trend to spread over time. Further work should establish the evolution and pathological substrate of the band, and in particular to determine whether it represents a
HT1 - Genetics of MS
HT1.1 Genetics of adult-onset MS and interaction with enviromental risk factros for MS
I Kockum
1
1Karolinska Insitutet, Clinical Neuroscience, Stockholm, Sweden
Multiple sclerosis (MS) is a multifactorial disease where both environmental and genetic risk factors play a role. The heritability has been estimated to be 64% and the familial aggregation for sibling is 7.1. The polymorphisms associated with the largest risk for MS, such as HLA-DRB1*15:01 with and odds ratio (OR) of 3, are found on chromosome 6 in the Major histocompatibility complex (MHC).
More than 100 genetic polymorphisms outside the MHC have been identified in association with MS mostly by mapping close to genes involved in immunoregulation. For many of these polymorphisms it remains to be established how they affect the risk of developing MS. A first step towards such an understanding may be to investigate the control of expression of genes near the associated polymorphisms. This has shown that it is not always the expression of the gene closest to the polymorphism that is affected.
Several environmental factors have been associated to risk for developing MS including smoking, obesity, EBV infections and lack of sun exposure. Interactions between major genetic risk factors and environmental exposures have been observed making it possible to begin to form groups of risk factors that are jointly involved in MS pathogenesis.
HT1.2 Genetic studies of pediatric onset MS
LF Barcellos
1,2
1University of California, School of Public Health, Berkeley, CA, United States, 2Kaiser Permanente, Division of Research, Oakland, CA, United States
Multiple sclerosis (MS) is a severe autoimmune inflammatory disease of the central nervous system that affects approximately 400,000 individuals in the United States and more than a million individuals worldwide. Disease onset typically occurs between the ages of 20 and 40, although approximately 2-5% of all MS patients have symptom onset before 18 years. Disease course in children with MS is similar to adults with important exceptions. Compared to adults, disease typically progresses more slowly using the EDSS, although permanent disability can result at a younger age. Young children with MS are more likely to develop seizures and ataxia during the course of the disease; males are equally affected compared to females within the youngest pediatric MS cases. In addition, pediatric MS cases almost exclusively have a relapsing-remitting course, and are less likely to be of White/European ancestry. Exact mechanisms involved in pediatric MS pathogenesis are unknown; however, similar to adult MS, both genetic and environmental factors such as Epstein-Barr virus and exposure to cigarette smoking have been strongly implicated in disease susceptibility. Variation within major histocompatibility complex (MHC) genes on chromosome 6p21 confers the greatest risk of MS, primarily within the human leukocyte antigen HLA-DRB1 locus (specifically, the HLA-DRB1*15:01 allele). Through recent International Consortium efforts, genome-wide association (GWAS) and replication studies have identified at least 110 adult MS susceptibility loci with modest effects. We have investigated these risk variants and genes within the MHC for a role in pediatric MS using a large, well characterized dataset of cases and controls. Our results provide strong support for HLA-DRB1 in pediatric MS susceptibility. In addition, several established adult MS variants were strongly associated with risk of pediatric MS and demonstrated larger effect sizes. Finally, we performed the first GWAS and pathway analysis in pediatric MS and identified evidence for new variants in pediatric MS susceptibility.
HT1.3 HLA-DRB1*15:01/03 modifies association of vitamin D level with relapse rate in pediatric MS
J Graves1, L Barcellos2, M Milazzo3, E Mowry4, A Belman3, M Rodriguez5, B Weinstock-Guttman6, M Gorman7, L Benson8, J Ness9, T Lotze10, G Aaen11, T Chitnis12, J Rose13, TC Casper13, L Krupp3, E Waubant14, U.S. Network of Pediatric MS Centers
1UCSF, San Francisco, CA, United States, 2University of California, Berkeley, Berkeley, CA, United States, 3Stonybrook University, Stonybrook, NY, United States, 4Johns Hopkins University, Baltimore, MD, United States, 5Mayo Clinic, Rochester, NY, United States, 6The Pediatric MS Center of the Jacobs Neurological Institute at the University of Buffalo, Buffalo, NY, United States, 7Children’s Hospital Boston, Boston, MA, United States, 8Boston Children’s Hospital, Boston, MA, United States, 9The Center for Pediatric-Onset Demyelinating Diseases at Children’s Hospital of Alabama, Birmingham, AL, United States, 10Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States, 11Loma Linda University, San Bernadino, CA, United States, 12The Partners Pediatric MS Center at the Massachusetts General Hospital for Children, Boston, MA, United States, 13Department of Pediatrics, University of Utah, Salt Lake City, UT, United States, 14The Regional Pediatric MS Center at the University of California at San Francisco, San Francisco, CA, United States
Background: The strongest genetic risk factor for multiple sclerosis is presence of at least one copy of HLA-DRB1*15:01 (or 15:03 in those of African descent). Vitamin D level is one of the strongest environmental risk factors consistently identified for MS risk and severity in children and adults. The effect of genetic risk factors on relapse rate is largely unknown, though a recent study in adults suggests susceptibility alleles may modify the association of vitamin D level and relapse rate (Lin et al, MSJ 2013).
Objectives: To determine if HLA-DRB1*15 status modifies the association of vitamin D level with relapse rate in children with MS.
Methods: HLA-DRB1*15:01/03 carrier allele status was determined by Taqman assay for 185 MS or clinically isolated syndrome patients from the Pediatric MS Centers at Stony Brook and UCSF who had received prospective clinical follow-up for relapses. HLA-DRB1*15 status modification of the 25-OH vitamin D level association with relapse hazard was assessed using repeated events Cox regression models. Adjustments were made for disease-modifying therapy use, genetic markers of ancestry and gender. Schoenfeld’s residuals test was used to verify assumption of proportional hazards.
Results: Over 511 patient-years of follow-up, 435 relapses were captured. HLA-DRB1*15 status modified the association of vitamin D level with relapse rate (p=0.006). A 10 unit lower vitamin D level was only associated with increased hazard to relapse in those carrying at least one copy of 15:01 or 15:03 (HR 1.53, 95% CI 1.19-1.98, p=0.001), adjusting for gender and genetic ancestry. In those with negative HLA-DRB1*15 status, there was no association of vitamin D level with relapse hazard (HR 0.96, 95% CI 0.85-1.09, p=0.55). Addition of disease modifying therapy use to the models did not change results.
Conclusions: Ours is the first study to suggest an interaction of the strongest genetic risk factor with vitamin D level in effect on relapse rate in children with MS. Vitamin D level may be most relevant to disease course in those with positive HLA-DRB1*15 status. These data support a previous finding in adults that HLA-DRB1*15 status modifies the association of vitamin D level with development of new MRI lesions (Mowry et al., Ann Neurol 2012).
HT2 - New routes of drug development
HT2.1 Repurposing drugs for disease modification in multiple sclerosis
K Schmierer
1
1Queen Mary, University of London, Blizard Institute (Neuroscience & Trauma), London, United Kingdom
Repurposing of drugs has served people with multiple sclerosis (pwMS) for over 20 years since the introduction of beta-interferons revolutionised the management of relapsing-remitting disease. Significant advances in our understanding of MS pathogenesis have underpinned the development of a number of molecules (or slightly altered versions thereof) that were previously used in other diseases, for the treatment of pwMS. Examples of such repurposing include Teriflunomide (Aubagio), Fingolimod (Gilenya), Dimethyl-Fumarate (Tecfidera), Alemtuzumab (Lemtrada), oral cladribine (Movectro), Laquinimod, Ocrelizumab, Daclizumab, and 4-aminopyridine (Fampyra). Whilst repurposed drugs are thus the mainstay of current MS disease modifying therapy, the more recent discussion around repurposing has focussed on generic drugs that may not only be safe and effective, but also more affordable treatments for pwMS. There is virtually no incentive for manufacturers to (i) fund & perform appropriately designed trials and (ii) apply for (and maintain) a license when at the end of such a development programme the license holder is to keep the cost at a generic (ie. low) level. On the other hand, publicly funded health care systems are under significant financial strain and thus highly incentivised to make safe and effective drugs for pwMS available at low cost. However, whilst some public and charity funding is available to perform investigator-led trials of generic drugs, there is no clear pathway to licensing, the key hurdle to make repurposed drugs available for pwMS at low cost. This presentation will summarize a few past and current initiatives to repurpose generic drugs for pwMS at different stages of the disease, and provide a framework for discussion of the implications of such initiatives for pwMS, funding bodies and healthcare providers.
HT2.2 A perspective on generic medications to treat MS
JA Cohen1
1Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
Ten medications currently have regulatory approval as disease therapy for multiple sclerosis (MS). All are very expensive, and medications are a major contributor to the high societal cost of caring for MS. Patent protection for some of these agents (so-called innovator drugs) soon will expire, creating the opportunity for development and regulatory approval of generic versions, with anticipated cost savings to patients and third party payers based on the more limited testing required for approval and resultant reduced development costs. However, there are a many factors complicating the determination of whether generic versions of MS disease therapies are comparably safe and effective as the innovators on which they are based. In general, regulatory approval of "simple" generics (i.e. small molecules) can be based on demonstration of pharmaceutical equivalence and bioequivalence. However, some MS disease therapies are biologics with highly complex chemical structures (e.g. the interferons or monoclonal antibodies) or, in the case of glatiramer acetate, highly complex peptide mixtures. Subtle changes in such things as composition, tertiary structure, aggregation, post-translational modification, etc. could affect efficacy, tolerability, or antigenicity in ways that would be difficult to predict from biochemical analyses (even sophisticated approaches), in vitro studies, or animal studies. For most MS therapies, no biologic response marker that relates to efficacy has been validated. However, the clinical endpoints utilized in MS pivotal trials are relatively insensitive, necessitating large trials extending over several years to show benefit. Requiring comparable trials to approve generics probably would create an insurmountable disincentive to sponsors to develop them. Thus, while clinical trials of complex generics seem unavoidable, it would advantageous for more sensitive outcomes to be accepted when appropriate, e.g. MRI lesion activity when the innovator has a well characterized effect on those parameters. Finally, testing of generics to show equivalence to the innovator drug involves trial designs and statistical analyses that are distinct from those used to demonstrate superiority of an innovator drug vs. placebo or an active comparator. In summary, the development of complex generics involves an interesting balance between a number of considerations, many of which are relatively unfamiliar to MS clinicians and investigators.
HT2.3 From genetic findings to drug discovery: taking the first step
NA Patsopoulos1,2,3, JM Replogle1,2,3
1Brigham & Women’s Hospital, Neurology, Boston, MA, United States, 2Harvard Medical School, Boston, MA, United States, 3Broad Institute, Cambridge, MA, United States
Background: Multiple Sclerosis (MS) is a demyelinating inflammatory disease with a strong genetic component. So far more than 100 genetic loci influencing MS susceptibility have been identified by genome-wide association studies (GWAS), with expectations to double this number in the near future. These findings have been integral to understanding the mechanisms and pathways of MS etiology, but an ultimate goal of the genetic era is to translate these findings into drug discoveries in order to improve patient outcomes.
Objectives: To explore the potential of GWAS-identified genes in MS for drug targeting and to examine the overlap of these genes with targets of currently MS-approved treatments.
Methods: We used the most recently published large-scale genetic studies in MS to examine the associated genetic loci. Within these regions we identified genes genes putatively associated with MS based on proximity. Then we leveraged drug-gene interaction data (druggable genome; DGIdb ) to identify genes that either are targeted by a drug or have the potential to be. In a sensitivity analysis we expanded the list of tested genes by using information on direct protein-protein interactions (PPIs). Finally, we used the DrugBank v4.0 database to identify the gene targets of drugs currently approved for the management of MS.
Results: We identified 160 genes within 111 genome-wide published loci in MS. One fifth of these (n=33) had at least one known interaction with a drug or chemical compound, i.e. are druggable, with overall 138 distinct interactions. These included daclizumab, dinoprostone (prostaglandin E2), abatacept, and the general interferon family. Interestingly there were interactions with drugs that have MS as reported side effect, e.g. adalimumab. In the sensitivity analysis, we identified 793 genes with direct PPIs to MS-genes. Thirty percent (n=241) of these had at least one drug interaction, with ~2,000 interactions overall. In this level we identified MS-approved drugs (interferon betas and natalizumab), and several drugs under investigation for use in MS, e.g. masitinib, rituximab, memantine, alemtuzumab, etc.
Conclusions: We report the druggable potential of the GWAS-identified MS-genes via leveraging information on targets of drugs and chemical compounds. There is evidence that the currently approved or investigational MS drugs are directly or indirectly associated with GWAS-findings. We discuss how this information can be used in drug discovery and drug repositioning.
HT3 - Symptomatic and rehabilitative strategies
HT3.1 Cognitive impairment
MP Amato
1
1University of Florence, Dept. Neurofarba, Firenze, Italy
Cognitive impairment in multiple sclerosis (MS) is common, debilitating and burdensome. Behavioural and pharmacological interventions on cognition reported in published studies will be reviewed. Recent, well designed studies evaluating behavioural treatment or computerized training for impairment in learning and memory, deficits of attention and executive function have demonstrated some improvement. Controlled studies in relapsing remitting MS indicate interferon (IFN) α-1b and IFN α-1a were associated with modest cognitive improvement. The effects of symptomatic therapies such as anti-fatigue drugs, psychostimulants and Alzheimer’s drugs are mainly inconsistent or negative. A few studies yielding positive findings have significant methodological difficulties, limiting the confidence in making any broad treatment recommendations. Since data linking cognitive rehabilitation, symptomatic treatment or disease modifying treatment, to either reducing cognitive decline or improving impaired cognition are limited to date, this field needs to remain a key research focus, identifying new interventions and improving clinical trial methodology.
HT3.2 Cannabinoids as symptomatic and neuroprotective therapy
CS Constantinescu
1
1University of Nottingham, Neurology, Nottingham, United Kingdom
Cannabinoids (phytocannabinoids, synthetic cannabinoids and endocannabinoids) are a group of molecules that act on the cannabinoid receptors (CBR) and produce a variety of biological and pharmacological effects. The herb Cannabis sativa has been used for centuries for medicinal purposes, but the discovery of the endocannabinoid system, formed of the endocannabinoids, the CBR and the associated enzymes, which regulates multiple functions in the nervous and immune system, endocrine network, gastrointestinal tract, circulation, etc., has triggered renewed interest in the use of cannabinoids as medicines.
In multiple sclerosis (MS), an immune mediated demyelinating disease cannabinoids have been used to ameliorate symptoms such as muscle spasticity, pain, and bladder disturbances, for a long time. In addition to their role as symptomatic therapy, cannabinoids’ beneficial effects in MS may also be through neuroprotective and immunomodulatory mechanisms.
This presentation provides a review of the clinical studies of cannabinoids in MS. Such studies have used smoked cannabis, plant extracts, the main cannabinoid tetrahydrocannabinol (THC), or mixtures of THC and cannabidiol (CBD).
Overall, the studies of cannabinoids for symptomatic relief yielded mixed results, often with side effects outweighing the benefits, in particular due to psychotropic effects of cannabinoids. However, a positive effect on spasticity, pain and some symptoms of bladder dysfunction were seen, mainly on patient-based outcomes, especially with the mucosal spray combination of 1:1 THC and CBD. This drug (nabiximols) is currently approved for treatment of MS spasticity as an add-on to conventional anti-spasticity treatment.
In view of potential neuroprotective effects, a large randomised controlled trial (CUPID) assessed the effects of dronabinol (THC) on MS progression over 5 years. The study did not show an effect on progression, but the progression rate was slower than expected for both dronabinol and placebo groups during the trial.
In conclusion, cannabinoids, in particular when used in combinations that reduce their side effects and unwanted psychotropic effects, currently are useful for symptomatic relief of spasticity, pain, and some sphincter disturbances in MS. Neuroprotective and immunomodulatory effects could not be demonstrated in clinical trials but combinations that neutralise side effects or enhance their delivery to the immune system may in future be effective.
HT3.3 Autonomic symptom burden is associated with MS-related fatigue and quality of life
M Cortez1,2, B Goodman1, S Nagi Reddy3, J Carter1, D Wingerchuk1
1Mayo Clinic Arizona, Neurology, Scottsdale, AZ, United States, 2University of Utah, Neurology, Salt Lake City, UT, United States, 3Mayo Clinic Arizona, Scottsdale, AZ, United States
Background: Non-specific symptoms such as dizziness, heat-intolerance and fatigue are common among MS patients. In some, these symptoms may reflect autonomic dysfunction, with important treatment implications. Though autonomic dysfunction has been described in MS, there are few quantitative reports, and little is known about the relationship of autonomic symptoms and quality of life.
Objectives: Assess the impact of autonomic symptom burden on disease specific health-related quality of life and its relationship with disease factors such as fatigue severity, disability and disease duration.
Methods: 100 consecutive MS patients seen in subspecialty clinic prospectively completed a questionnaire to assess: quality of life (MSQOL-54); fatigue severity (FSS); autonomic symptoms (COMPASS-31). Exclusion criteria: EDSS > 7.5; inability to complete questionnaire; unestablished diagnosis. Clinical data was collected via retrospective review of the electronic medical record. Pearson correlations were used to assess the relationship between autonomic symptoms and fatigue, quality of life, disability and disease duration.
Results: Of the 100 patients, mean age was 48 years (SD 11), 78% female; 84% were relapsing-remitting, mean disease duration 14.7 years (SD 9); EDSS 2.5 (SD 2). Questionnaire completion rate was over 71% for all calculations. Mean COMPASS-31 score was 27/100 (n=81) and mean FSS score was 5 (SD 1.6; n=94). The composite scores for MSQOL-54 were 58 physical health (SD 20; n=87) and 65 mental health (SD 21; n=98). COMPASS-31 correlated with MSQOL-54 composites (physical R=−0.60, n=71; mental -0.54, n=79; p< 0.001) and FSS (R=0.51; p< 0.001; n=77). There was no significant relationship between COMPASS-31 and EDSS (R=0, p=0.97, 95% CI=−0.21 to 0.22) or disease duration (R=−0.02, p=0.84, 95% CI=−0.24 to 0.2) (n=81). The relationship of autonomic symptoms and QOL was independent of marital status, fatigue-causing medications and depression.
Conclusions: Autonomic symptom burden is correlated with decreased quality of life and increased fatigue, but not disability or disease duration. Autonomic symptoms are present at early stages of disease and at low levels of disability, and may reflect either non-disease-specific factors or aspects of disease burden that are not well-captured by current disability measures. Further research will investigate disease-specific domains of autonomic dysfunction.
FC1 - Free Communication 1
FC1.1 Primary results of DECIDE: a randomized, double-blind, double-dummy, active-controlled trial of daclizumab HYP vs. Interferon β-1a in RRMS patients
L Kappos1, K Selmaj2, DL Arnold3,4, E Havrdová5, A Boyko6, M Kaufman7, H Wiendl8, J Rose9, S Greenberg10, E Demirhan11, M Sweetser11, K Riester11, J Elkins11
1University Hospital, Basel, Switzerland, 2Medical University of Lodz, Lodz, Poland, 3NeuroRx Research, Montreal, QC, Canada, 4McGill University, Montreal, QC, Canada, 5First School of Medicine, Charles University, Prague, Czech Republic, 6Moscow Multiple Sclerosis Center, Moscow, Russian Federation, 7Carolinas Medical Center, Charlotte, NC, United States, 8University of Münster, Münster, Germany, 9University of Utah Medical School, Salt Lake City, UT, United States, 10Abbvie Biotherapeutics Inc, Redwood City, CA, United States, 11Biogen Idec, Cambridge, MA, United States
Background: Daclizumab high-yield process (DAC HYP) is a humanized IgG1 monoclonal antibody specific for the alpha subunit (CD25) of the human high-affinity interleukin-2 (IL-2) receptor in clinical development for relapsing forms of multiple sclerosis (MS). A previous randomized trial showed a 54% reduction in the annualized relapse rate (ARR) of DAC HYP 150mg once-monthly compared with placebo.
Objectives: To test the hypothesis that DAC HYP 150mg is superior to IFN β-1a in reducing MS activity in patients with relapsing-remitting MS (RRMS).
Methods: We conducted a randomized, double-blind, double-dummy, active-controlled trial comparing DAC HYP 150mg subcutaneous (SC) injection once every 4 weeks with IFN β-1a 30mcg intramuscular (IM) injection once weekly for 96 to 144 weeks. The primary endpoint was the ARR. Secondary endpoints were the number of new T2 lesions at week 96, the proportion of subjects with sustained disability progression, the proportion of subjects relapse-free and the proportion of subjects with a ⩾7.5 point decline on the Multiple Sclerosis Impact Scale-29 (MSIS-29) physical scale.
Results: Patients (n=1841) were randomized between May 11, 2010 and April 16, 2012 across 245 study centers in 28 countries. Baseline characteristics for all subjects (DAC HYP and IFN β-1a groups) were: mean age 36.3 years, mean (median) EDSS was 2.5 (2.0), and 68% of patients were female. The mean number of relapses within the past year was 1.6. The mean number of new T2 lesions was 50.5 and the number of Gd+ lesions was 2.1. Final results will be presented.
Conclusions: The DECIDE trial provides an assessment of the efficacy of DAC HYP in RRMS.
FC1.2 Generic glatiramer acetate is equivalent to copaxone on efficacy and safety: results of the randomized double-blind GATE trial in multiple sclerosis
JA Cohen1, A Belova2, K Selmaj3, C Wolf4, JJL Oberyé5, ERW van den Tweel5, NP Koper5, G Voortman5, F Barkhof6, on behalf of the GATE Study Group
1Cleveland Clinic, Mellen Center, Cleveland, OH, United States, 2Research Institute of Traumatology and Orthopaedy, Functional Diagnostics, Nizhniy Novgorod, Russian Federation, 3Medical University of Lodz, Lodz, Poland, 4Lycalis sprl, Brussels, Belgium, 5Synthon B.V., Clinical Development, Nijmegen, Netherlands, 6VU Medical Center, Radiology, Amsterdam, Netherlands
Background: Generic alternatives to the currently approved therapies for relapsing-remitting multiple sclerosis (RRMS) are needed. Because glatiramer acetate (COP, Teva) is a complex polypeptide mixture, precluding pharmacokinetic comparison, a generic version should demonstrate equivalence in efficacy and safety.
Objectives: The GATE trial aimed to show that generic glatiramer acetate (GTR, Synthon B.V.) was equivalent to COP measured by MRI and clinical endpoints, safety, and tolerability in RRMS.
Methods: Ambulatory RRMS patients age 18-55 years with ⩾1 relapse in the year prior to screening and 1-15 gadolinium-enhanced (GdE) brain lesions were randomized 4.3:4.3:1 in a multicenter, double-blind, placebo (PLC)-controlled trial to receive 20 mg GTR, 20 mg COP, or PLC by daily subcutaneous injection for 9 months. The primary endpoint was combined number of GdE lesions over months 7, 8, and 9. Additional efficacy endpoints included other MRI parameters, annualized relapse rate (ARR), Expanded Disability Status Scale (EDSS), and freedom from disease activity. Safety and tolerability were assessed through monitoring of adverse events, injection site reactions, and routine blood laboratory tests.
Results: 794 patients were randomized and treated with GTR (n= 353), COP (n=357), or PLC (n=84). 735 patients (92.5%) completed the 9-month double-blind treatment period. The estimated geometric mean numbers of GdE lesions were 0.42 (GTR) and 0.39 (COP), resulting in an estimated GTR/COP GdE lesion ratio of 1.097 with a 95% confidence interval of 0.884-1.362, which is within the pre-defined equivalence margin. The estimated geometric mean numbers of GdE lesions for both the GTR and COP groups were lower than the PLC group (p< 0.001), confirming assay sensitivity. ARRs were 0.31 (GTR), 0.41 (COP), and 0.39 (PLC). Comparable proportions of patients treated with GTR and COP were free from disease activity. EDSS was stable in all three groups. The incidence, spectrum, and severity of reported adverse events, including injection site reactions, were similar in the GTR and COP groups.
Conclusions: GTR is equivalent to COP in reducing the number of GdE lesions, a clinically relevant endpoint in RRMS. Both active treatments were superior to PLC. Other efficacy outcomes, safety, and tolerability also were comparable. GTR is the first generic glatiramer acetate with an efficacy and safety profile demonstrated to be equivalent to the currently marketed product.
FC1.3 Long-term follow-up of laquinimod in patients with relapsing-remitting multiple sclerosis
G Comi1, TL Vollmer2, N Ashtamker3, Y Sidi4, D Ladkani4, T Gorfine3, PS Sørensen5
1San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy, 2University of Colorado, Aurora, CO, United States, 3Teva Pharmaceutical Industries, Netanya, Israel, 4Teva Pharmaceutical Industries, Petach Tiqva, Israel, 5Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
Background: Two phase III, 24-month studies of oral laquinimod (LAQ) 0.6mg once-daily (QD) demonstrated a reduction in relapse-related parameters and pronounced reductions in confirmed disability progression (CDP) and brain volume loss. Identified risks of LAQ are back and neck pain, appendicitis, and mild asymptomatic laboratory changes that occur soon after treatment initiation and then stabilize or return to baseline. Laboratory changes include liver enzymes elevations, CRP increase, fibrinogen increase, hemoglobin decrease, WBC increase, and platelet decrease.
Objectives: To evaluate the long-term safety and efficacy of LAQ in patients with RRMS treated with LAQ for 2 or more years (yrs).
Methods: Long-term safety was assessed for all patients exposed to LAQ 0.6mg QD for ⩾2 yrs in open-label extensions of the phase II LAQ5063 and phase III ALLEGRO and BRAVO trials, regardless of original treatment assignment during the initial core study periods. Long-term efficacy evaluation included patients from ALLEGRO and BRAVO (except patients who switched from IFNβ-1a to LAQ) using an intention-to-treat approach.
Results: Assessments were based on 1009 patients with mean (±SD) LAQ exposure of 3.7 (±1.0) yrs. Adverse event (AE) and serious AE rates were lower during open-label extension than in the core studies. Less than 3% of patients discontinued treatment due to AEs during the open-label extension. No new common AE was identified. Musculoskeletal AE rate was lower during long-term follow-up than during the core studies (25.5%/100 patient-years, vs. 31.9% and 26.0% for LAQ and placebo, respectively, during the core phases). Shifts to potentially significant laboratory values were considerably lower in patients exposed to ⩾2 yrs of LAQ: 1.18% reached >3xULN ALT vs. 4.72% for LAQ and 2.6% for placebo during the core study. Laboratory parameters showed no increase in incidence over time. Thus, long-term safety follow-up supports core study findings that identified risks occur during the first months of treatment. No increase in incidence of malignancies, pericarditis, pleuritis, MI, peritonitis, pancreatitis, or infections was seen. Long-term efficacy analyses were based on 1764 patients (total exposure 5831.4 patient-years). Patients continue to have low relapse and CDP rates. Those always on LAQ show fewer relapses and less CDP overall than those who switched to LAQ from placebo.
Conclusions: The safety profile and benefits of LAQ described in the core studies are maintained during long-term follow-up.
FC1.4 Disease-free outcomes with alemtuzumab: 3-year follow-up of the CARE-MS studies
E Havrdová1, DL Arnold2,3, J Palmer4, DH Margolin4, on behalf of CARE-MS I and CARE-MS II Study Investigators
1Charles University, Prague, Czech Republic, 2Montreal Neurological Institute and Hospital, Montreal, QC, Canada, 3NeuroRx Research, Montreal, QC, Canada, 4Genzyme, a Sanofi Company, Cambridge, MA, United States
Background: In 2 two-year, phase 3, head-to-head trials in active relapsing-remitting multiple sclerosis (RRMS) patients who were treatment naive (Comparison of Alemtuzumab and Rebif Efficacy in Multiple Sclerosis [CARE-MS] I; NCT00530348) or relapsed on prior therapy (CARE-MS II; NCT00548405), alemtuzumab significantly improved clinical and MRI outcomes compared to subcutaneous interferon beta-1a, with a consistent and manageable safety profile. Alemtuzumab-treated patients were more likely to be free of detectable clinical, magnetic resonance imaging (MRI), and MS (clinical or MRI) disease activity after 2 years. In an extension study, durable effects on clinical efficacy were observed with alemtuzumab 1 year later.
Objectives: To examine the effect of alemtuzumab on the proportion of patients who were clinical, MRI, and MS disease activity-free after 3 years.
Methods: Patients who received alemtuzumab (12 mg/d intravenously on 5 consecutive days; 3 consecutive days 1 year later) in CARE-MS studies continued uninterrupted follow-up in an extension study (NCT00930553) and were eligible for alemtuzumab re-treatment on evidence of disease activity. Clinical disease activity (⩾1 relapse or 6-month sustained accumulation of disability [SAD]), MRI activity (⩾1 new gadolinium [Gd]-enhancing lesion or new/enlarging T2-hyperintense lesion), and MS disease activity (clinical or MRI activity) were assessed at Year 3 and cumulatively from Year 0-3.
Results: 349 CARE-MS I and 393 CARE-MS II alemtuzumab patients entered the extension; 18% and 20%, respectively, received re-treatment in Year 3. The majority of patients were free of clinical disease activity (CARE-MS I: 83%; CARE-MS II: 76%) and MRI activity (CARE-MS I: 72%; CARE-MS II: 68%) in Year 3. More than half of patients were free of MS disease activity (CARE-MS I: 64%; CARE-MS II: 55%) in Year 3. After 3 years of follow-up, 65%, 40%, and 30% of CARE-MS I patients and 50%, 40%, and 23% of CARE-MS II patients were free of clinical disease activity, MRI activity, and MS disease activity, respectively.
Conclusions: The majority of patients were free of detectable clinical, MRI, and MS disease activity 3 years after initiatiing treatment with alemtuzumab, although most patients received no treatment in Year 3. These findings support the durable efficacy of alemtuzumab in RRMS patients who were either treatment naive or who relapsed on prior therapy.
FC1.5 Inclusion of brain volume loss in a revised measure of multiple sclerosis disease-activity freedom: the effect of fingolimod
L Kappos1, E-W Radue2, MS Freedman3, B Cree4, MP Sormani5, N Sfikas6, G Francis7, D Tomic6, D Piani Meier6, N De Stefano8
1University Hospital Basel, Basel, Switzerland, 2University Hospital Basel, Medical Image Analysis Centre, Basel, Switzerland, 3University of Ottawa and the Ottawa Hospital, Research Institute, Ottawa, ON, Canada, 4University of California San Francisco, Department of Neurology, San Francisco, CA, United States, 5University of Genoa, Biostatistics Unit, Department of Health Sciences, Genoa, Italy, 6Novartis Pharma AG, Basel, Switzerland, 7Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States, 8University of Siena, Department of Medicine, Surgery and Neuroscience, Siena, Italy
Background: Brain volume loss (BVL) is accelerated in multiple sclerosis (MS), starts in the earliest stages and reflects both diffuse and focal tissue damage. BVL was consistently reduced by fingolimod in three phase 3 studies. Composite measures of MS disease activity are increasingly used to capture overall treatment benefit. Definitions of disease-activity-free (DAF) or no evidence of disease activity (NEDA) currently comprise three domains: disability progression, relapses, and active MRI lesions (both T2 and Gd+ T1), but do not include MRI outcomes related directly to irreversible damage.
Objectives: To assess the impact of including BVL in the definition of DAF on the proportions of fingolimod- or placebo-treated DAF patients.
Methods: The proportions of DAF patients receiving fingolimod 0.5 mg (n=783) or placebo (n=773) were compared in a pooled population from the two 2-year, phase 3 trials, FREEDOMS/FREEDOMS II. The revised DAF composite includes two clinical measures reflecting disease activity and severity (i.e. confirmed relapses and 6-month confirmed disability progression, defined as an increase in EDSS score of 1.5 points for patients with a baseline score of 0 or of 1.0 point for those with a baseline score of ⩾1.0), one measure of MRI activity (new/enlarging T2 lesions) and BVL, defined as an annual percentage brain volume change (PBVC) of ⩾−0.4% (a value between the ranges of mean annual BVL in healthy adults [0.1-0.3%] and MS patients [0.5-1.35%]). Other BVL thresholds were tested (−0.2% to −1.2% PBVC) or BVL was omitted. Patients were classified as DAF only in the absence of activity in all clinical/MRI measures.
Results: Without inclusion of BVL, the respective proportions of DAF patients for fingolimod and placebo were 31.0% vs 9.9% (odds ratio [OR], 4.07; p< 0.0001). Adding BVL (PBVC, −0.4% per annum), the respective proportions of DAF patients were smaller, but the between-group OR remained significant and was numerically higher (19.7% vs 5.3%; OR, 4.41; p< 0.0001). Notably, across the range of thresholds tested with BVL added, the difference in DAF status always favoured fingolimod over placebo (OR, 4.01-4.41; p< 0.0001).
Conclusions: Compared with the previous DAF composite, inclusion of BVL increased the stringency of the measure without decreasing its sensitivity to treatment effects in these studies. Using the 0.4% PBVC threshold in the DAF composite, 3.72-fold more patients treated with fingolimod remained DAF compared with placebo.
FC2 - Free Communication 2
FC2.1 Maximal lifetime brain growth (estimated with intracranial volume) predicts disability progression measured with the expanded disability status scale
JF Sumowski1, MA Rocca2, VM Leavitt3, J Dackovic4, S Mesaros4, J Drulovic4, G Riccitelli2, CS Riley5, G Comi2, M Filippi2
1Kessler Foundation, Neuropsychology and Neuroscience, West Orange, NJ, United States, 2Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan, Italy, 3Manhattan Memory Center, New York, NY, United States, 4University of Belgrade, Clinic of Neurology, Faculty of Medicine, Belgrade, Serbia, 5Columbia University Medical Center, Neurology, New York, NY, United States
Background: Physical disability is prevalent but variable across patients with multiple sclerosis (MS), even among patients with comparable disease burden (e.g., lesion volume). It is therefore difficult to predict future disability for any given patient, which is an obstacle for the science and practice of early intervention / preventative medicine. The brain reserve hypothesis states that larger maximal lifetime brain growth (MLBG; easily estimated with intracranial volume) protects against cognitive disability, but no research has ever investigated whether larger MLBG also protects against physical disability.
Objectives: We examined whether larger MLBG protects against physical disability within independent cross-sectional and longitudinal samples. That is, we investigated MLBG as a sorely needed, readily available biomarker / predictor of physical disability in MS patients.
Methods: Physical disability was evaluated with the Expanded Disability Status Scale (EDSS) in a cross-sectional sample of 240 MS patients (139 women). MRI measured MLBG (estimated with intracranial volume), disease burden (T2 lesion volume, normalized volumes of gray, white, total brain, thalamus, caudate, putamen, cerebellum). Stepwise regression predicted EDSS with demographics, disease burden (above), and MLBG. Next, we investigated whether larger MLBG moderates/attenuates disability progression (EDSS) from baseline to 4.5-year follow-up in an independent longitudinal sample of 40 MS patients (28 women). Finally, we explored whether smaller MLBG may be a risk factor for secondary-progressive (relative to relapsing-remitting) disease course.
Results: Larger MLBG was associated with less physical disability in women (R2Δ=.044, p=.004), but not men (p=.737), in our cross-sectional sample. Physical disability progression in our longitudinal sample was moderated by MLBG (p=.008, ηp2=.171) whereby patients with larger MLBG suffered less disability progression over time. Finally, MLBG was smaller in women with a secondary-progressive relative to relapsing-remitting course (p=.011).
Conclusions: We provide the first evidence that larger MLBG provides reserve against physical disability. Consideration of MLBG (easily estimated with intracranial volume) may improve prediction of physical disability progression (i.e., EDSS), which will inform clinical treatment as well as the design, analysis, and interpretation of future research, including clinical trials.
FC2.2 Alemtuzumab improves MRI outcomes in treatment-naive active relapsing-remitting multiple sclerosis patients: three-year follow-up from CARE-MS I
DL Arnold1,2, F Barkhof3, JA Cohen4, EJ Fox5, KW Selmaj6, DH Margolin7, J Palmer7, E Fisher8, on behalf of CARE-MS I Investigators
1NeuroRx Research, Montréal, QC, Canada, 2Department of Neurology and Neurosurgery, Montréal Neurological Institute, McGill University, Montréal, QC, Canada, 3VU University Medical Centre, Amsterdam, Netherlands, 4Mellen Center and Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, United States, 5University of Texas Medical Branch, Round Rock, TX, United States, 6Medical University of Łódź, Department of Neurology, Łódź, Poland, 7Genzyme, a Sanofi Company, Cambridge, MA, United States, 8Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, United States
Background: In the phase 3, head-to-head CARE-MS I trial in treatment-naive patients with active relapsing-remitting multiple sclerosis (RRMS), alemtuzumab had superior efficacy versus subcutaneous interferon beta-1a including the reduction in magnetic resonance imaging (MRI) activity and brain volume loss over 2 years. In an extension study, durable effects on clinical efficacy were still observed at Year 3.
Objectives: Examine the effect of alemtuzumab on MRI outcomes over 3 years in patients who participated in CARE-MS I and entered the ongoing extension study.
Methods: Patients who received alemtuzumab (12 mg/day intravenously on 5 consecutive days and on 3 consecutive days 12 months later) in CARE-MS I (NCT00530348) continued in an extension study (NCT00930553), during which they were eligible for alemtuzumab re-treatment on evidence of disease activity. MRI scans were acquired at baseline, and at 1, 2, and 3 years. MRI measurements included proportions of patients with gadolinium (Gd)-enhancing, new or enlarging T2-hyperintense, and new T1-hypointense lesions; proportion of patients MRI activity-free (absence of Gd-enhancing and T2 lesions); T2 and T1 lesion volume; and brain volume loss (brain parenchymal fraction change).
Results: 349 of 376 formerly treatment-naive patients who received alemtuzumab 12 mg in the CARE-MS I core study entered the extension; 63 (18%) received alemtuzumab re-treatment in Year 3. Proportions of patients with new or active lesions were low and did not differ between Years 2 and 3 for Gd-enhancing lesions (7.0% [95% CI: 4.3, 9.6] vs 9.8% [6.6, 13.0]), new/enlarging T2 lesions (22.2% [17.9, 26.5] vs 27.7% [22.8, 32.6]) or new T1 lesions (6.7% [4.1, 9.3] vs 10.8% [7.4, 14.1]). The majority of patients were MRI activity-free at Year 3 (72%). Median T2 and T1 lesion volumes were significantly reduced vs baseline at Year 3 (-6.8% [IQR: -19.2, 3.41]; p< 0.0001 and -14.8% [-54.6, 27.1]; p=0.0093, respectively). The median rate of brain volume loss decreased progressively over time (Year 0-1: -0.59% [95% CI: -0.75, -0.52], Years 1-2: -0.25% [-0.34, -0.18], Years 2-3: -0.19% [-0.28, -0.08]).
Conclusions: The majority of formerly treatment-naive patients were free of MRI lesion activity in the third year after initiating treatment with alemtuzumab. T2 and T1 lesion volume remained below baseline and brain volume loss continued to slow in Year 3. Most patients received no additional alemtuzumab nor other DMT in their third year, supporting the durable efficacy of alemtuzumab in RRMS.
FC2.3 Brain volume change by quartile and disability progression in multiple sclerosis: a 4-year analysis of the phase 3 FREEDOMS trial and its extension
D Jeffery1, E Verdun2, D Piani Meier2, S Ritter3, P Chin3, E-W Radue4, W Camu5
1Cornerstone Heath Care, Advance, NC, United States, 2Novartis Pharma AG, Basel, Switzerland, 3Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States, 4University Hospital Basel, Medical Image Analysis Centre, Basel, Switzerland, 5Hôpital Gui de Chauliac, Neurology Department, Montpellier, France
Background: Brain volume loss (BVL) is a feature of multiple sclerosis (MS), reflecting diffuse and focal neurological damage. Studies have shown significant correlations between BVL and disability progression in MS.
Objectives: To investigate whether the extent of BVL at month 24 associates with, and is prognostic of, disability progression over 48 months in the phase 3 FREEDOMS trial and its extension.
Methods: Patients (N = 1029) were categorized post hoc from baseline (BL) to month 24 (M24) by quartile of total percentage BV change (PBVC), assessed using ‘Structural Image Evaluation, using Normalization, of Atrophy’ (SIENA), and mean annualized PBVC from BL to M24 was determined in each quartile. Patient characteristics at BL were also determined in each quartile, as were the proportions of patients at M24 and at M48 with: Expanded Disability Status Scale (EDSS) score ⩾ 4.0 or ⩾ 6.0 at any time and disability progression (an increase in EDSS score of ⩾ 1.0 if BL EDSS ⩽ 5.0, or of 0.5 if BL EDSS ⩾ 5.5) confirmed over 3 months (CDP3) or over 6 months (CDP6). Mean change in EDSS score was also calculated from BL to either M24 or M48.
Results: Quartile ranges of PBVC at M24 were: Q1 (n = 256), −13.5% to −1.7%; Q2 (n = 254), −1.7% to −0.8%; Q3 (n = 257), −0.8% to −0.2%; and Q4 (n = 262), −0.2% to 3.0%. Respective mean (standard deviation [SD]) annualized PBVC (BL-M24) was −1.5% (0.7%), −0.6% (0.1%), −0.2% (0.1%) and 0.2% (0.3%). Comparing Q1 and Q4 at BL, there were proportionately more women (74.6% vs 68.7%), mean (SD) EDSS was greater (2.7 [1.3] vs 2.1 [1.2]), as were T2 lesion volume (11.3 [10.2] cm3 vs 3.3 [4.4] cm3), T1 hypointense lesion volume (3.6 [4.2] cm3 vs 1.0 [1.9] cm3) and number of Gd+ lesions (3.1 [5.6] vs 0.6 [1.3]). The respective proportions of patients in Q1 and Q4: with EDSS ⩾ 4.0 were (M24) 30.3% and 11.4%, and (M48) 35.8% and 13.8%; with EDSS ⩾ 6.0 were (M24) 14.8% and 1.1%, and (M48) 19.2% and 3.1%; with CDP3 were (M24) 22.7% and 13.4%, and (M48) 28.8% and 17.9%; and with CDP6 were (M24) 19.1% and 10.7%, and (M48) 24.2% and 15.4%. Respective mean (SD) changes in EDSS scores in Q1 and Q4 were 0.1 (1.1) and −0.1 (0.8) for BL-M24, and 0.2 (1.2) and 0.0 (0.9) for BL-M48.
Conclusions: The quartile of patients with greatest BVL at 24 months (Q1) had the greatest disease activity and severity at BL, and the most disability progression at both 24 and 48 months. This suggests that 24-month BVL is associated with long-term disability evolution.
FC2.4 Safety and pharmacokinetics of MOR103, a human antibody to granulocyte-macrophage colony-stimulating factor, in patients with multiple sclerosis
CS Constantinescu1, A Asher2, W Fryze3, W Kozubski4, F Wagner5, JJ Aram1, R Tanasescu6, RP Korolkiewicz7, S Steidl8, T Sprenger9, WE Radue9
1University of Nottingham, Queen’s Medical Centre, Division of Clinical Neuroscience, Research Group in Clinical Neurology, Nottingham, United Kingdom, 2MAC Clinical Research Ltd., Manchester, United Kingdom, 3Pomorskie Centrum Traumatologii im. M. Kopernika w Gdansku, Oddzial Neurologiczny i Udarowy, Gdansk, Poland, 4Medical University of Poznan, Oddzial Kliniczny Neurologii, Poznan, Poland, 5Charité Research Organisation GmbH, Berlin, Germany, 6Queen’s Medical Center, Nottingham, United Kingdom, 7Morphosys AG, Clinical Research, Planegg, Germany, 8Morphosys AG, Preclinical Research, Planegg, Germany, 9MIAC AG, Basel, Switzerland
Background: Studies in experimental autoimmune encephalomyelitis suggest that inhibiting GM-CSF activity might be an effective therapy for multiple sclerosis (MS). MOR103 is a high-affinity recombinant human monoclonal antibody that binds specifically to human GM-CSF, neutralizing its function.
Objectives: To determine the safety, pharmacokinetics (PK) and immunogenicity of MOR103 in patients with relapsing-remitting MS (RRMS) or secondary progressive MS (SPMS) with relapses.
Methods: In this 20-week, double-blind, placebo-controlled, phase Ib dose escalation study (NCT01517282), adults with RRMS or SPMS were randomised and received an intravenous infusion of placebo (n=6) or 0.5 (n=8), 1 (n=8) or 2 (n=9) mg/kg MOR103 every 2 weeks for 10 weeks. Patients had to have 10 or fewer gadolinium (Gd)-enhancing brain lesions on T1-weighted MRI at baseline. The primary endpoint was safety assessed by adverse events (AEs), physical examinations, vital signs, clinical laboratory data, electrocardiograms (ECGs), pulmonary function tests (PFTs), and MS relapses. Secondary endpoints included serum MOR103 levels and immunogenicity.
Results: Most treatment-emergent AEs (TEAEs) were mild to moderate in severity. The most frequent were nasopharyngitis and headache. TEAEs were reported in all patients in the placebo, 0.5 mg/kg and 1 mg/kg groups, and 89% of patients in the 2mg/kg group. Differences in the numbers of TEAEs were small between groups. There were no TEAE-related study discontinuations, infusion-related reactions or deaths. Nine patients experienced MS relapses: 3, 5 and 1 patient(s) in the placebo, 0.5mg/kg and 1mg/kg groups, respectively; no patients relapsed in the 2 mg/kg group. A few new T1 and/or T2 Gd-enhancing lesions were observed in most groups at most visits, and slight decreases in T2 lesion volume were seen in the 2 mg/kg group. No clinically significant changes were observed in vital signs, clinical laboratory parameters, ECGs and PFTs.
No anti-MOR103 antibodies were detected. A terminal half-life of approximately 17 days was observed, with dose linear increases in maximum observed serum concentration and area under the time-drug concentration curve, and low/no drug accumulation over time.
Conclusions: MOR103 was generally safe and well tolerated in patients with RRMS or SPMS, with a PK profile in line with expectations for a human immunoglobulin G1. No signs of immunogenicity were observed.
FC2.5 Clinical efficacy of peginterferon beta-1a in relapsing-remitting multiple sclerosis: 2-year data from the phase 3 ADVANCE study
PA Calabresi1, BC Kieseier2, DL Arnold3,4, L Balcer5, A Boyko6, J Pelletier7, S Liu8, Y Zhu8, SI Sheikh8, A Seddighzadeh8, A Deykin8, S Hung8
1Johns Hopkins University, Department of Neurology, Baltimore, MD, United States, 2Heinrich-Heine University, Department of Neurology, Düsseldorf, Germany, 3Montreal Neurological Institute, McGill University, Montreal, QC, Canada, 4NeuroRx Research, Montreal, QC, Canada, 5New York University School of Medicine, Departments of Neurology and Population Health, New York, NY, United States, 6Moscow MS Center at RSMU, Moscow, Russian Federation, 7CHU Timone, Departments of Neurology and Research (CRMBM), Marseille, France, 8Biogen Idec Inc., Cambridge, MA, United States
Background: At Year 1 of ADVANCE, subcutaneous peginterferon beta-1a (125 µg every 2 [Q2W] or 4 [Q4W] weeks) significantly reduced annualized relapse rate [ARR; primary endpoint], risk of relapse, and risk of 12-week confirmed disability progression versus placebo. Safety profiles were similar for Q2W and Q4W treatment arms, and consistent with established interferon beta-1a therapies.
Objectives: To evaluate the efficacy of peginterferon beta-1a over 2 years on relapse and disability endpoints in patients with relapsing-remitting multiple sclerosis (RRMS) in the Phase 3 ADVANCE study.
Methods: After Year 1, patients randomized to placebo were re-randomized to 125 µg peginterferon beta-1a administered Q2W or Q4W for Year 2. Patients randomized to peginterferon beta-1a in Year 1 remained on the same dosing regimen in Year 2. All efficacy analyses were performed on data from the intent-to-treat population (all randomized patients who received at least one dose of active study treatment over 2 years). Statistical analysis of proportion of patients with disability progression (patients in the original placebo arm in Year 1 versus patients on peginterferon beta-1a dosing regimens over both years) was pre-specified whereas all remaining statistical analyses were post-hoc.
Results: In Year 2, ARR was further reduced in patients receiving Q2W (Year 1: 0.230 [95% CI 0.183-0.291], Year 2: 0.178 [0.136-0.233]) and was maintained for patients treated with Q4W (Year 1: 0.286 [0.231-0.355], Year 2: 0.291 [0.231-0.368]). Compared to patients originally randomized to placebo in Year 1, reductions were seen for patients on peginterferon beta-1a during both Years 1 and 2 in ARR (Q2W 37% [p< 0.0001], Q4W 17% [p=0.0906]), risk of relapse (Q2W 39% [p< 0.0001], Q4W 19% [p=0.0465]) and risk of disability progression (12-week confirmed: Q2W 33% [p=0.0257], Q4W 25% [p=0.0960]; 24-week confirmed: Q2W 41% [p=0.0137], Q4W 9% [p=0.6243]). Over 2 years, relative to Q4W dosing, greater reductions were observed with Q2W dosing in ARR (24%, p=0.0209), risk of relapse (24%, p=0.0212), and risk of disability progression (12-week confirmed: 11%, p=0.5665 and 24-week confirmed: 36%, p=0.0459).
Conclusions: 2-year results support the maintained benefits of peginterferon beta-1a beyond 1 year in RRMS, with significantly greater efficacy seen for Q2W versus Q4W across relapse endpoints.
FC3 - Free Communication 3
FC3.1 Characteristics of PML cases in multiple sclerosis patients switching to fingolimod from natalizumab
N Putzki1, DB Clifford2, D Bischof1, A Moore1, BG Weinshenker3, MS Freedman4
1Novartis Pharma AG, Basel, Switzerland, 2Washington University School of Medicine, St. Louis, MO, United States, 3College of Medicine, Mayo Clinic, Rochester, MN, United States, 4University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
Background: Natalizumab treatment in multiple sclerosis (MS) patients has been associated with progressive multifocal leukoencephalopathy (PML). Patients on natalizumab who are at increased risk for developing PML by virtue of JC virus (JCV) seropositivity or treatment duration longer 24 months are often switched to other disease modifying therapies. However, the long elimination half-life of natalizumab may result in persisting PML risk post-discontinuation, a warning of which is included in the product information for natalizumab in Europe.
Objectives: To investigate characteristics of PML cases in MS patients during treatment with fingolimod following natalizumab discontinuation.
Methods: We analyzed PML cases retrieved from Novartis safety reporting database for fingolimod.
Results: Exposure of MS patients to fingolimod exceeds 135,800 patient-years as of 28 February 2014. Approximately 15-20% fingolimod treated patients were previously exposed to natalizumab. Eleven natalizumab-associated cases of PML have been reported already; results of CSF JCV PCR were available for 6 patients and positive in 4. Overall, patients (mean age 44.5 years) were exposed to natalizumab for a mean duration of about 4 years (median 5 years). The onset of PML was either confirmed prior to switch (in retrospect) or occurred within 6 months after switch to fingolimod in all cases (median 75 days). One additional case (no previous natalizumab exposure) was reported as PML after 7 months of fingolimod treatment; clinical features and MRI evolution were consistent with neuromyelitis optica; the PML diagnosis was made based on the results of CSF showing low copy number of JCV.
Conclusions: Vigilance for PML is warranted following natalizumab discontinuation, especially in patients who may be at increased risk (JCV antibody positive, prior exposure to immunosuppressants and long-term [>24 months] natalizumab exposure). Baseline neurological examination and MRI scan before initiating fingolimod may assist, at least retrospectively, in attribution of causality to natalizumab versus fingolimod. Experience with more than 91,500 patients treated with fingolimod thus far does not indicate a PML risk attributable to fingolimod.
FC3.2 GLACIER: open-label, randomized safety/tolerability study of glatiramer acetate 40mg/mL three times weekly versus 20mg/mL daily in RRMS
JS Wolinsky1, DW Dietrich2, TE Borresen3, BF Gilder4, JR Steinerman5, Y Sidi6, A Vainstein6, S Kolodny7, V Knappertz5,8, GLACIER Study Group
1University of Texas, Health Science Center at Houston, Houston, TX, United States, 2Advanced Neurological Specialists, Great Falls, MT, United States, 3Mecklenburg Neurological Associates, Charlotte, NC, United States, 4Swedish Medical Center, Littleton, CO, United States, 5Teva Pharmaceutical Industries, Frazer, PA, United States, 6Teva Pharmaceutical Industries, Netanya, Israel, 7Teva Pharmaceutical Industries, Cleveland, OH, United States, 8Heinrich-Heine Universität Düsseldorf, Düsseldorf, Germany
Background: Improving injection tolerability and patient (pt) experience will support adherence to safe, effective RRMS treatments (Tx) such as glatiramer acetate (GA). Reducing the number of required injections could improve convenience and reduce the burden and adverse events (AEs) associated with daily injections.
Objectives: To compare the safety and tolerability of subcutaneous GA 20mg/mL (GA20) daily (QD) and GA 40mg/mL (GA40) 3 times weekly (TIW) in the open-label phase IIIb GLatiramer Acetate low frequenCy safety and patIent ExpeRience (GLACIER) study in pts with RRMS.
Methods: Pts age ⩾18 years (yrs) with diagnosed RRMS (McDonald, 2010) and EDSS score 0-5.5 treated with GA20 for ⩾6 months before screening were eligible. Pts were randomized 1:1 to continue GA20 or convert to GA40, for a 4-month Tx period, and were assessed at baseline (BL) and months 1, 2, and 4. The primary endpoint was annualized rate of injection-related AEs (IRAEs); ie, all local injection-site reactions (ISRs) and symptoms related to immediate post-injection reactions (IPIR; eg, flushing, palpitations, anxiety, dyspnea). Pts recorded occurrence and severity of IRAEs on daily diary cards. The risk ratio (RR) for annualized rate of IRAEs (total number of IRAEs/pt-yr of GA exposure) with GA40 vs. GA20 was analyzed by BL-adjusted quasi-likelihood (over-dispersed) Poisson regression. A similar post hoc analysis assessed RR for annualized rate of moderate (interferes with normal daily activity) and severe (prevents normal daily activities) IRAEs.
Results: Most pts (GA40 n=108, GA20 n=101) were female (82%) and Caucasian (94%). Mean (±SD) age was 51 (10) yrs. In both groups, ⩾75% Tx compliance was achieved by 99% of pts. Only 10 pts withdrew before completing the 4-month Tx phase and only 1 (GA40 group) withdrew due to an AE. The primary endpoint was achieved, with a 50% reduction in adjusted mean [SE] annualized rate of IRAEs (35.3 [7.3] in the GA40 group vs. 70.4 [12] in the GA20 group); RR=0.50 (95%CI 0.34, 0.74), p=.0006. A 60% reduction in adjusted mean [±SE] annualized rate of moderate/severe IRAEs was attained with GA40 vs. GA20 (0.88 [0.65] vs. 2.2 [1.5], respectively); RR=0.40 (95%CI 0.23, 0.72), p=.0021.
Conclusions: Results provide head-to-head evidence that GA 40mg TIW leads to half as many IRAEs as GA 20mg QD, and reduces moderate/severe IRAEs to an even greater extent.
FC3.3 A combination trial of estriol plus glatiramer acetate in relapsing-remitting multiple sclerosis: effect on disabilities
R Voskuhl1, H Wang1, G Lee1, B Giesser1, CH Tse1, R Elashoff1, Estriol Relapse Trial Study Group
1University of California, Los Angeles, CA, United States
Background: Pregnancy is known to be a period of relative protection from MS relapses. Estriol is an estrogen which gradually increases during pregnancy, reaching high levels in the last trimester. Beneficial effects of estrogen treatment, including estriol, have included both anti-inflammatory and neuroprotective mechanisms in MS models. In a recently completed Phase II trial in women with relapsing remitting MS (RRMS), relapse rates were decreased in subjects treated with the combination of estriol plus glatiramer acetate as compared to placebo plus glatiramer acetate. Treatment was safe and well tolerated.
Objectives: Given the known neuroprotective effects of estrogens in nonMS conditions, particularly as related to cognition, secondary outcomes in the completed trial were investigated for effects of treatment on cognitive and other MS disabilities.
Methods: Analyses of secondary endpoints were done on data from a randomized, double-blind, multicenter, placebo-controlled (1:1) trial of oral estriol 8 mg per day in RRMS women, age 18-50 years. Estriol was an add-on therapy. Thus, all subjects began glatiramer acetate injections within 2 months or less of randomization and received either estriol versus placebo pills to take in combination. Treatment duration was 2 years. The primary endpoint was annualized relapse rate.
Results: The estriol plus glatiramer acetate group as compared to the placebo plus glatiramer acetate group had improved cognitive testing scores after 12 months of treatment as demonstrated by the Paced Auditory Serial Addition Test (PASAT). After 24 months of treatment, test scores remained high in the estriol plus glatiramer acetate group, while scores in the placebo plus glatiramer acetate group also improved. Effects on the Selective Reminding Test and the Spatial Recall Test were examined in the context of effects on the PASAT. Trends for improvement in the Expanded Disability Status Scale (EDSS) were seen at 24 months in the estriol plus glatiramer acetate group, but not in the placebo plus glatiramer acetate group. Effects on the 25 foot walk test were examined in the context of effects on the EDSS. Correlations between serum estriol levels and effects on MS disabilities were also investigated.
Conclusions: Effects of treatment of RRMS women with a dose of estriol physiologic with pregnancy will be discussed with respect to known neuroprotective effects of estrogens in other conditions.
FC3.4 Treatment with cyclic oral methylprednisolone in progressive multiple sclerosis - results of an open-label phase 2A proof-of-concept study
R Ratzer1, J Romme Christensen1, L Börnsen1, C Ammitzbøll1, P Iversen2, TB Dyrby2, HR Siebner2, C Gøbel Madsen2, E Garde2, B Andersen3, L Hyldstrup4, PS Sørensen1, F Sellebjerg1
1Rigshospitalet, Neurology, Copenhagen, Denmark, 2Hvidovre Hospital, Danish Research Center for Magnetic Resonance, Hvidovre, Denmark, 3Rigshospitalet, Neurophysiology, Copenhagen, Denmark, 4Hvidovre Hospital, Endocrinology, Hvidovre, Denmark
Background: Approximately 15% of multiple sclerosis (MS) patients have primary progressive (PPMS) at onset, and the majority of patients presenting with relapsing-remitting MS will eventually evolve into secondary progressive MS (SPMS). Unfortunately no or very few treatment possibilities are available for patients with PPMS and SPMS. Methylprednisolone (MP) dampens inflammation and crosses the blood-brain barrier; hence, we hypothesised that treatment of progressive MS patients with pulsed oral MP would lower intrathecal inflammation, demyelination and axonal loss.
Objectives: To evaluate the efficacy and safety of pulsed oral MP as treatment for progressive multiple sclerosis.
Methods: The study was carried out as a single center, open-label phase 2A, proof-of-concept study; 15 PPMS and 15 SPMS patients received pulsed oral MP (500 mg QD) for 3 days every 4 weeks for 60 weeks. Written informed consent was obtained from all study participants before inclusion and the study was registered at clinicaltrials.gov, NCT01305837. The primary outcome measure was change in the cerebrospinal fluid (CSF) concentration of osteopontin (OPN) (a marker of intrathecal inflammation); secondary outcome measures were changes in CSF concentrations of neurofilament light chain (NfL) and other markers of inflammation and demyelination. Furthermore, we evaluated changes in MRI measures, clinical measures and motor evoked potentials (MEP). Safety measures were adverse events (AE) and dual-energy X-ray absorptiometry (DXA) scans for monitoring bone mineral density (BMD).
Results: We found no significant change in the CSF concentration of OPN or NfL after 60 weeks of treatment. We observed some significant improvement in clinical scores. MTR values for normal appearing white matter (NAWM), grey matter (GM) and lesions increased significantly and we found a significant decrease in mean diffusivity for both NAWM and GM. No change was detected in MEP. Known side effects of steroid treatment were common adverse events, but there were no severe AEs considered to be related to treatment. A slight, but significant increase was seen in T-score of the lumbar spine, p=0.022, indicating a higher BMD.
Conclusions: Treatment with pulsed MP was safe in patients with progressive MS but had no beneficial effect on primary outcomes in the CSF markers of neuroinflammation and neurodegeneration. However, secondary MRI parameters suggest some effect on tissue integrity.
FC3.5 Long-term follow-up of the effect of delayed-release dimethyl fumarate on no evident disease activity in patients with multiple sclerosis
G Giovannoni1, R Gold2, RJ Fox3, L Kappos4, T Phillips5, A Zhang6, NC Kurukulasuriya6, E Havrdova7
1Queen Mary University of London, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, United Kingdom, 2St. Josef Hospital, Ruhr University, Bochum, Germany, 3Cleveland Clinic, Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland, OH, United States, 4University Hospital, Basel Neurology, Basel, Switzerland, 5Baylor Institute for Immunology Research, Multiple Sclerosis Program, Dallas, TX, United States, 6Biogen Idec Inc., Cambridge, MA, United States, 7Charles University, Department of Neurology, First Faculty of Medicine, Prague, Czech Republic
Background: Delayed-release dimethyl fumarate (DMF) demonstrated efficacy and safety in patients with relapsing-remitting multiple sclerosis (RRMS) in the Phase 3 DEFINE and CONFIRM studies. ENDORSE is an ongoing, 5-year, dose-blind extension study of DEFINE/CONFIRM.
Objectives: Report long-term effects of delayed-release DMF on no evident disease activity (NEDA) in patients with RRMS enrolled in ENDORSE.
Methods: Patients initially randomized to delayed-release DMF 240 mg twice (BID) or three times daily (TID) in the parent study were continued on the same dosage of delayed-release DMF in ENDORSE. Those initially randomized to placebo (PBO) or glatiramer acetate (GA) were re-randomized in ENDORSE to either delayed-release DMF BID or TID. Patients were assessed annually and those fulfilling the following criteria were considered to have NEDA: no relapses, no 24-week Expanded Disability Status Scale (EDSS) sustained progression, no gadolinium-enhancing lesions, and no new or enlarging T2 hyperintense lesions. Results from patients receiving delayed-release DMF BID in ENDORSE are reported (data as of June 12, 2013), as this represents the approved dosage in the United States, Canada, Australia, and the European Union.
Results: Of 1,736 patients enrolled in ENDORSE, 718 had both clinical and MRI assessments. Of those, 350 were treated with BID (n=206 [BID/BID], 96 [PBO/BID], and 48 [GA/BID]). The BID/BID group showed consistent efficacy each year over 4 years; the proportions of patients with NEDA during Years 1 and 2 in the parent studies and during Years 3 and 4 in ENDORSE were 37.9%, 51.5%, 51.9%, and 53.0%, respectively. Switching from PBO to BID (PBO/BID) resulted in an improvement in NEDA; proportions of NEDA patients during Year 1 and Year 2 in parent studies and Year 3 and Year 4 in ENDORSE were 21.9%, 25.0%, 25.0%, and 43.5%, respectively. Patients switching from GA to BID (GA/BID) also demonstrated improvements after switching; corresponding proportions with NEDA were 16.7%, 27.1%, 33.3%, and 47.7%, respectively.
Conclusions: Favorable NEDA outcomes are maintained over 4 years among patients continuing treatment with delayed-release DMF BID. Patients in the PBO/BID and GA/BID groups demonstrated improved NEDA after switching to delayed-release DMF BID; the data also suggest early DMF BID treatment will have positive benefit on NEDA, despite the sample size of the GA group. Results support the potential for delayed-release DMF as a long-term treatment option for RRMS.
FC4 - Free Communication 4
FC4.1 MCAM defines a subpopulation of inflammatory CD8 T lymphocytes presenting a high encephalitogenic potential and cytotoxic capacity
C Larochelle1,2, M-A Lécuyer1, JI Alvarez1, M Charabati1, O Saint-Laurent1, H Kebir1, R Cayrol1, P Duquette2, J Poirier2, K Flanagan3, N Arbour1, A Prat1,2
1CRCHUM-Université de Montréal, Montréal, QC, Canada, 2CHUM Multiple Sclerosis Clinic-Université de Montréal, Neurology, Montreal, QC, Canada, 3Prothena, San Francisco, CA, United States
Background: Genetic and pathologic studies have established a role for CD8 T cells in MS. However, the identification and contribution to MS lesion formation of different subsets of CD8 T lymphocytes is still a matter of debate. Identification of specific surface markers and adhesion molecules expressed by pathogenic CD8 T lymphocytes would allow further characterization of this subset and could provide new therapeutic targets in MS.
Objectives: We hypothesize that MCAM is a surface marker and adhesion molecule used by auto-aggressive CD8 T lymphocytes to access the CNS.
Methods: MCAM was identified in a proteomic screen of human blood-brain barrier endothelial cells (BBB-ECs) and on a subset of T lymphocytes. We characterized the phenotype and function of MCAM+ CD8 T lymphocytes ex vivo, in vitro, in situ and in vivo, using human and mouse material obtained from healthy controls, MS subjects and Experimental Autoimmune Encephalomyelitis (EAE) animals.
Results: MCAM is expressed by human BBB-ECs and effector memory CD62L-CCR7-CD28+CD45RO+CD161+CCR6+ CD8 T lymphocytes. MCAM is strongly up-regulated in human on CD8+ T lymphocytes during MS relapses, while immunomodulatory treatments decrease MCAM expression. CD8 MCAM+ lymphocytes from MS subjects express more IL-17, IL-22, IFN-ɣ, GM-CSF and TNF than MCAMneg lymphocytes ex vivo. In situ, MCAM+ CD8 T lymphocytes are present in perivascular infiltrates of MS and EAE CNS specimen. Upon activation in vitro, MCAM+ CD8 T lymphocytes express more IL-17, GzB and perforin but less IL-4, FoxP3 and IL-10. Contact with human oligodendrocytes increases MCAM expression on activated CD8 T lymphocytes and increases CD107a preferentially in the MCAM+ subset. MCAM-depleted CD8 T lymphocytes display lower killing capacity of oligodendrocytes and neurons, and MCAM blockade reduces CD8 transmigration across human BBB-ECs. Furthermore, expression of MCAM is up-regulated on CD8 T lymphocytes in MOG-induced EAE and in the TCR1640 transgenic mice, a model of spontaneous EAE. In vivo, depletion of MCAM+ cells from reactivated CD8 T lymphocytes decreases clinical symptoms in CD4/CD8 co-transfer EAE. Finally, blocking MCAM in both MOG35-55-induced and spontaneous primary progressive EAE attenuates chronic neurological deficits.
Conclusions: Our data demonstrate that encephalitogenic TC17/TC1 CD8 lymphocytes with high effector and killing capacity express MCAM, and that MCAM could serve as a biomarker for MS and a valuable target to restrict access of pathogenic CD8 T lymphocytes to the CNS.
FC4.2 Exploring phase contrast mechanisms of multiple sclerosis lesions at 7T
W Ban1, BAC Cree2, Y Li1, R Schlaeger2,3, A Zhu2, A Jakary1, D Leppert4, N Seneca4, SJ Nelson1,5, RG Henry1,2,5
1University of California San Francisco, Radiology and Biomedical Imaging, San Francisco, CA, United States, 2University of California San Francisco, Department of Neurology, San Francisco, CA, United States, 3University of Basel, Department of Neurology, Basel, Switzerland, 4F. Hoffmann-La Roche Ltd, Basel, Switzerland, 5University of California San Francisco, Bioengineering and Therapeutic Sciences, San Francisco, CA, United States
Background: MR phase imaging is a novel imaging methodology used to characterize multiple sclerosis (MS) lesions1. However, its contrast mechanism is unclear. The speculation that the source of phase contrast is iron accumulation has been challenged by recent studies2-3 which suggest that myelin/axonal integrity could also contribute to changes in phase shifts. Changes in myelin/axonal integrity may be indicated by N-acetyl aspartate (NAA) level, which is measured using MR spectroscopic imaging (MRSI). Therefore MRSI may provide evidence to support the hypothesis that degenerative in addition to inflammatory processes affect phase contrast in MS lesions.
Objectives: To study the correlation between the phase shift and NAA level in MS lesions.
Methods: MRI was performed on a GE 7T scanner. Phase images were obtained using a 2D gradient echo sequence and reconstructed using a previous method1. The parameters of the sequence were as follows: TE/TR=12/250ms, resolution=0.46x0.46x3mm, and 22 slices. MRSI was obtained using a spin echo slice selection with TE/TR=20/2000ms, resolution=1cc and spectra array= 18x22x8. The spectra were reconstructed using in-house software4 and quantified by LCModel. MS lesions were defined on T2-weighted images that had been registered to phase images. Thirteen lesions (volume>1cc) were retrospectively selected from 6 relapsing MS patients enrolled in a Phase III trial of ocrelizumab (Roche ORCHESTRA programs). For each lesion, a single MRSI voxel was selected and measured for NAA level (peak area normalized by the average value from 7 normal volunteers) and mean phase shift (with vein excluded). The Spearman correlation between NAA level and phase shift was calculated.
Results: The average (standard deviation) of normalized NAA concentration and mean phase shift from 13 lesions were 0.65 (0.20) and 0.19Hz (0.36Hz), respectively. NAA concentration was inversely correlated with phase shift (p = 0.039, Spearman rho = −0.58).
Conclusions: We found NAA to be inversely correlated with mean phase shift within MS lesions, supporting the recent hypothesis that both myelin/axonal integrity and iron contribute to phase contrast with opposite signs.
References
1. Hammond KE, et al., Annal Neurol 2008(64);
2. Yablonskiy DA, et al., PNAS 2012(109);
3. Yao B, et al., Radiology 2012(262);
4. Li Y, et al. Proc. Intl. Soc. Mag. Reson. Med. 2012(20)
FC4.3 Two-year follow-up study assessing cortical and deep gray matter loss in benign multiple sclerosis
A Ruet1, K Bendfeldt2, T Sprenger3,4, A Versteeg1, S Magon3, Y Naegelin3, MH Klieverik-Sombekke5, L Kappos3, E-W Radue2, BMJ Uitdehaag5,6,7, F Barkhof1,6, H Vrenken1,6,8
1VU University Medical Center, Department of Radiology and Nuclear Medicine, Amsterdam, Netherlands, 2University Hospital Basel, Medical Image Analysis Centre, Basel, Switzerland, 3University Hospital Basel, Department of Neurology, Basel, Switzerland, 4University Hospital Basel, Department of Radiology, Division of Neuroradiology, Basel, Switzerland, 5VU University Medical Center, Department of Neurology, Amsterdam, Netherlands, 6Neuroscience Campus Amsterdam, Amsterdam, Netherlands, 7VU University Medical Center, Department of Epidemiology and Biostatistics, Amsterdam, Netherlands, 8VU University Medical Center, Department of Physics and Medical Technology, Amsterdam, Netherlands
Background: Gray matter (GM) atrophy predicts clinical disability in multiple sclerosis (MS). In benign MS (BMS), characterized by long-standing relapse-onset MS (ROMS) and low physical disability, GM atrophy behavior is not well known.
Objectives: To compare GM changes over time and space between BMS, non-benign relapsing-remitting MS (RRMS) and secondary progressive MS (SPMS).
Methods: A 2-year follow-up study was performed in Basel and Amsterdam in patients with long disease duration (DD) ROMS (⩾15 years from disease onset chosen in accordance to BMS definition). Patients underwent standardized clinical assessment including the Expanded Disability Status Scale (EDSS) and were classified as BMS if they had RRMS and their EDSS score did not exceed 3 and non BMS (nBMS) otherwise. Brain MRI was acquired at 1.5 Tesla. Lesion masks were obtained from proton density scans using a semi-automated threshold contour method and used for FSL-lesion filling. The FreeSurfer longitudinal pipeline (version 5.3.) was used to measure global and regional cortical thickness (cTh) and deep GM (DGM) volumes.
Results: 113 ROMS patients were recruited including 34 BMS, 35 nBMS and 44 SPMS. Mean age (46.9±16.6, 49.1±8.9, and 54.8±6.9 years in BMS, nBMS and SPMS) and mean DD (21.9±6.1, 20.4±5.1, 24.3±6.6 years, respectively) differed between groups (p< 0.01 and p< 0.05). The same was true for sex ratio (p< 0.05).The baseline T2 WM lesion load was not different between groups (p=0.06). Mean whole-brain cTh (in mm) at baseline and at year 2 differed between BMS (2.365±0.093 and 2.358±0.091) nBMS (2.298±0.087 and 2.288±0.100) and SPMS (2.262±0.127 and 2.260±0.144), (p< 0.01 and p< 0.05 for each time point; ANCOVA adjusting for age, DD and gender). Using the same covariates, the normalized DGM volumes (NDGMV) expressed in fraction at each time point were different between BMS (3.40±0.34 and 3.35±0.34) nBMS (3.20±0.31 and 3.17±0.31) and SPMS (3.20±0.28 and 3.17±0.30) (p< 0.01 and p< 0.05, respectively). After 2 years, in BMS only DGM atrophy (p⩽0.001) but no significant global and regional cortical atrophy was observed in contrast to nBMS and SPMS in whom DGM atrophy (both p< 0.01) and regional cortical thinning in temporal lobes (p< 0.01 and p< 0.05, respectively) were found. The annual rates of change of mean cTh and NDGMV did not differ between groups.
Conclusions: This study provides evidence that both GM atrophy rates and spatial distribution may follow different patterns in long standing BMS as compared to nBMS and SPMS.
FC4.4 Vitamin D as a predictor of multiple sclerosis activity and progression in patients with multiple sclerosis on interferon beta-1b
A Ascherio1, K Fitzgerald1, K Munger1, K Kochert2, B Arnason3, S Cook4, G Comi5, M Filippi6, D Goodin7, H-P Hartung8, D Jeffery9, P O’Connor10, G Suarez11, R Sandbrink2,8, L Kappos12, C Pohl2,13, The BEYOND Study Group
1Harvard School of Public Health, Boston, MA, United States, 2Bayer Pharma AG, Berlin, Germany, 3University of Chicago Surgery Brain Research Institutes, Department of Neurology, Chicago, IL, United States, 4Rutgers, The State University of New Jersey, Department of Neurology and Neurosciences, Newark, NJ, United States, 5Università Vita-Salute San Raffaele, Department of Neurology and Institute of Experimental Neurology, Milan, Italy, 6Neuroimaging Research Unit, Division of Neuroscience, Scientific Institute and University Hospital San Raffaele, Milan, Italy, 7University of California, Department of Neurology, San Francisco, CA, United States, 8Heinrich-Heine University, Department of Neurology, Düsseldorf, Germany, 9Wake Forest University School of Medicine, Winston-Salem, NC, United States, 10Division of Neurology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada, 11Bayer HealthCare Pharmaceuticals, Whippany, NJ, United States, 12University of Basel and University Hospital, Basel, Switzerland, 13University Hospital of Bonn, Department of Neurology, Bonn, Germany
Background: Low serum 25-dihydroxy vitamin D (25[OH]D) levels predict an increased risk of multiple sclerosis (MS) and are associated with increased disease activity and rate of progression in clinically isolated syndromes and early MS.
Objectives: To examine the relation between 25(OH)D and disease activity and prognosis in patients with relapsing remitting MS treated with interferon beta-1b (IFNB-1b).
Methods: The study was conducted among participants in BEYOND, a large, Phase III, prospective, multicenter, blinded, randomized clinical study. Eligible patients included the 1,482 participants randomized to 250µg or 500µg IFN-1b with at least two 25(OH)D measurements spaced 6 months apart. Patients were followed for at least 2 years. Clinic visits were scheduled every 3 months, and MRI was performed at baseline and annually thereafter. Main outcomes included cumulative number of new active lesions (T2 lesions and gadolinium enhancing lesions), change in normalized brain volume, relapse rate, and EDSS progression. All analyses were adjusted for age, sex, randomized treatment (IFNB-1b 250 or 500µg), region (North America, Western Europe, Russia/Eastern Europe and the Southern Hemisphere), disease duration, and EDSS score at baseline.
Results: Mean 25(OH)D levels varied by geography, with the lowest levels found in Russia (median 38.9 nmol/L) and the highest in North America (median 70.8 nmol/L). Overall, average 25(OH)D levels were significantly inversely correlated with the cumulative number of active lesions between baseline and the last MRI, with a 50 nmol/L higher serum 25(OH)D levels predicting a 27% lower rate of new lesions (p=0.008). This inverse association was significant also in analyses restricted to those patients with 25(OH)D levels > 50 nmol/L (41% lower rate for a 50 nmol/L increase; p=0.003). The lowest rate of new lesions was observed among patients with 25(OH)D levels > 100 nmol/L. No significant associations were found between 25(OH)D levels and change in brain volume, relapse rates, or change in EDSS during the follow-up. Further results on other clinical and MRI outcomes and dose-response analyses to identify the optimal 25(OH)D levels in MS will be presented later.
Conclusions: Among MS patients treated with IFNB-1b, higher 25(OH)D levels were associated with lower rates of MS activity on MRI, but not with brain atrophy or clinical progression.
FC4.5 Assessment of 2010 and 2005 McDonald criteria for diagnosis of multiple sclerosis in patients with clinically isolated syndromes
G Arambide1, M Tintoré1, C Auger2, E Simón1, J Sastre-Garriga1, J Castilló1, J Río1, À Vidal-Jordana1, I Galán1, F Palavra1, L Negrotto1, C Nos1, M Comabella1, Á Rovira2, X Montalban1
1Vall Hebron University Hospital, Multiple Sclerosis Centre of Catalonia, Neuroimmunology Department, Barcelona, Spain, 2Vall Hebron University Hospital, Magnetic Resonance Unit, Neuroradiology Department, Barcelona, Spain
Background: The 2010 McDonald criteria have been compared to the 2005 version using only Barkhof-Tintore criteria (BTc) to define 2005 dissemination in space (DIS).
Objectives: To compare the performance of the 2010 and 2005 McDonald criteria using both BTc alone and their combination with >=2 T2 lesions plus oligoclonal bands (OCB) in the 2005 version.
Methods: Clinical and MR data were prospectively acquired from a CIS cohort. Brain MR was performed at 3-5 months and at 1 year of follow-up. Baseline spinal cord (SC) MR was obtained systematically since 2007. MR at 3.0 T is in use since 2010 and at 1.5T beforehand. From this cohort, patients with a follow-up of at least 3 years or who converted to clinically definite multiple sclerosis (CDMS) within 3 years of the CIS were included. Available baseline and 1 year MRs were assessed. For the 2010 criteria, DIS was defined excluding the symptomatic lesion and DIT as simultaneous presence of gadolinium (Gd)-enhancing and non-enhancing lesions on brain or SC MR or new T2/Gd-enhancing lesions on follow-up MR. For the 2005 version, DIS was defined as fulfillment of 3-4 BTc alone or of 3-4 BTc or >=2 T2 lesions plus OCB. DIT was defined using only brain MR as presence of Gd-enhanced lesions at least 3 months after the CIS or new T2 lesions. The proportion of patients fulfilling DIS, DIT and DIS plus DIT was assessed. Sensitivity, specificity and accuracy were calculated with CDMS as the outcome.
Results: Of 507 patients, 345 (68.0%) were female and mean (SD) age was 32.0 (7.9) years with a follow-up of 83.6 (34.9) months; 192 (37.9%) had SC MR and 57 (11.5%) had MR at 3.0T. The 2010 DIS version was fulfilled in 284/467 (60.8%) cases, 2005 DIS with 3-4 BTc in 258/467 (55.2%) and with BTc or >=2 T2 lesions plus OCB in 313/467 (67.0%); DIT was fulfilled in 254/450 (56.4%) for 2010 and in 248/450 (55.1%) for 2005; DIS plus DIT was fulfilled in 218/449 (48.5%) for 2010 and in 228/449 (50.8%) for 2005 when considering the combined DIS version. Seventeen (3.8%) patients met exclusively the 2005 criteria and 7 (1.5%) fulfilled only the 2010 criteria. Sensitivity, specificity and accuracy (%) were 67.9, 73.7 and 70.6 for the 2010 and 71.2, 72.7 and 71.9 for the 2005 criteria.
Conclusions: When selecting MRs at 3-5 months and 1 year of the CIS and when considering OCB in the DIS definition, performance of the 2005 and 2010 McDonald criteria is similar, reinforcing the more evidence-based 2010 criteria.
PS7 - Biomarkers
PS7.1 Cholesterol and related molecules: potential biomarkers for treatment safety and disease progression in multiple sclerosis
C Teunissen
1
1VU University Medical Center Amsterdam, Neurochemstry Laboratory and Biobank, Dept of Clinical Chemistry, Amsterdam, Netherlands
Cholesterol is an important constituent of myelin sheets and long axonal membranes in the central nervous system. Cholesterol is also a precursor of vitamin D, and a recent study showed associations between cholesterol and vitamin D on the biomarker level in MS as well. High serum cholesterol is furthermore related to several characteristic changes in MS, including reduced retinal nerve fiber layer thickness, lower baseline brain volume and increased lesion numbers at follow-up. Cholesterol has a brain specific metabolite, 24S-hydroxycholesterol, whose serum levels are decreased in MS and correlate to brain volume as a reflection of disease progression. Moreover, serum levels of this oxysterol change before the appearance of clinical signs and changes in cholesterol precursors in the acute EAE animal model. Thus, there are multiple lines of evidence to suggest that cholesterol homeostasis is affected in MS.
Treatment of EAE animals with the cholesterol lowering statins has lead to positive effects, though results from clinical trials seem disappointing. The positive effects of statins in animal models may be through immunomodulation rather than via cholesterol lowering, since statins have pleiotrophic effects, i.e. also on T-lymphocytes and antigen presenting cells. Treatment with statins will anyway affect the already disturbed cholesterol homeostasis in MS. Moreover, clear negative effects of statins on process outgrowth and branching of oligodendrocyte remyelination have been reported. It therefore seems that positive effects of statins on immunomodulation are not outweighed by their negative effect on cholesterol homeostasis.
Thus, cholesterol and related compounds can be measured as body fluid biomarkers to monitor or predict pathological changes in MS. Moreover, these body fluid sterols should be used as safety biomarkers to monitor changes in cholesterol homeostasis during treatments potentially affecting this pathway.
PS7.2 Biomarkers of treatment response to MS disease therapies
S Dhib-Jalbut
1
1Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
Clinical response to DMTs in MS is variable. Hence the importance of developing predictive biomarkers of treatment response. Several immunological, pharmacogenomics and proteomics studies have not so far been able to identify reliable biomarkers. We have recently identified two HLA-class II haplotypes as potential biomarkers of clinical response to Glatiramer acetate(GA): HLA DR 15+DQ6+; DR17-DQ2- was associated with a favorable response (71%) where as HLA DR15-DQ6-;DR17+DQ2+ was associated with a poor response (17%). A simplified binary predictor (AUC 0.81-0.85) of response to GA involving an increase in IL-10 or IL-4, and reduction in IL18, caspase 1, or TNF-a at 3-6 months into treatment will be presented.
We have also found in patients treated with IFNβ-1b for 12 months significantly higher IL-17A levels at Month 6 (p=0.036) in relapsing subjects while BDNF levels were significantly higher at Month 3 (p=0.028) in relapse-free subjects. Change from baseline in IL-4 levels inversely correlated with disability score whereas change from baseline in IL-10/IFN-gamma ratio inversely correlated with occurrence of relapses. CXCR3+CD8+ T-cells tended to be higher but declined with treatment in relapse-free compared with relapsing subjects.
Promising potential biomarkers of response to Natalizumab includes T-cell VLA-4 expression, sVCAM-1, CSF neurofilament light and heavy chains, CSF feutin-A, CSF CD5+B-cells and blood CD34+ cells.
PS7.3 Immunological biomarkers that identify MS patients with high probability of being free of disease activity if treated with IFN-beta
JC Alvarez-Cermeño1,2, R Alenda3, L Costa-Frossard1, R Alvarez-Lafuente4, C Picon3, M Espiño3, E Roldan3, R Arroyo4, E Rodriguez-Martin3, LM Villar3
1Hospital Ramon y Cajal, Neurology, Madrid, Spain, 2Universidad Alcala de Henares, Medicine, Alcala de Henares, Spain, 3Hospital Ramon y Cajal, Immunology, Madrid, Spain, 4Hospital Clínico San Carlos, Neurology, Madrid, Spain
Background: Interferon beta (IFNB) has proven to be a safe treatment that induces a very good response in a number of MS patients. To identify patients who will optimal responders to this treatment is very important to achieve personalized MS therapies.
Objectives: To identify biomarkers that predict freedom of disease activity (FRDA) upon IFNB treatment in MS.
Methods: 119 RRMS patients who initiated IFNB were prospectively included in the study and followed two years. We monitored patient outcome by measuring the EDSS score, the number of new relapses, and the onset of new lesions on annual MRI scans. Sixteen patients abandoned IFNB treatment, and 4 were lost during follow-up. The remaining 99 completed the study. Blood samples were collected before treatment initiation and after 6 and 12 months on therapy. Serum and peripheral blood mononuclear cell were obtained and stored frozen until their use. Surface lymphoid markers were explored in complete fresh blood and intracellular expression of FoxP3 and IL-10 (regulatory cells), TNF alpha, IFN gamma and IL-17 (Inflammatory responses) and perforin (cytotoxic responses) in frozen samples. The presence of neutralizing antibodies anti IFNB, soluble cytokines, activin A, and vitamins A, D and E was studied in serum.
Results: The only clinical or demographic factor associated with a higher probability of FRDA was female sex (OR=4.35, p=0.005).
Nine patients (9.1%) developed neutralising antibodies. No one showed a complete response to IFNB.
We classified the remaining 90 in two groups depending if they were FRDA (n=34, 37.8%) or showed active disease during treatment (n=56, 62.2%).
FRDA associated with lower percentages of CD5+ B cells (p=0.0002), and CD4+CD25hi, FoxP3+ cells (p=0.01). It also associated with higher percentage of CD8+DR+ T cells (p=0.0002) and CD8+, perforin+ T cells (p=0.006) before treatment initiation. During IFN beta treatment, patients with FRDA showed a significant increase in the percentages of three monitored regulatory subsets: CD56bright (p=0.0008), CD4+,CD25+,FoxP3 (p=0.01) and CD19+IL-10+ cells (p=0.002).
CD19+, CD5+ percentage measured in complete blood before treatment initiation was the best factor to predict freedom of disease activity (OR=15.8, p< 0.0001).
Conclusions: Low blood percentages of CD5+B cells identify before treatment initiation MS patients with high probability of optimal response to IFNB treatment.
PS7.4 Role of high mobility group box protein 1 (HMGB1) in patients with multiple sclerosis
S Malhotra1, NM Fissolo1, J Castilló1, À Vidal-Jordana1, X Montalban1, M Comabella1
1Vall Hebron University Hospital, Multiple Sclerosis Centre of Catalonia, Neuroimmunology Department, Barcelona, Spain
Background: High mobility group box protein 1 (HMGB1) is a DNA-binding non-histone protein that acts as transcriptional regulator and nucleosomal stabilizer. When released from activated immune cells or dying cells during necrosis or apoptosis, HMGB1 may drive pro-inflammatory responses through binding to cell-surface receptors such as the receptor of advanced glycation end-products, Toll-like receptors (TLR) 2 and 9, and the intracellular receptor TLR-9. Recent studies have shown associations between HMGB1 and autoimmune disorders such as rheumatoid arthritis, systemic lupus erythematosus, and Sjögren’s syndrome. In multiple sclerosis (MS), HMGB1 expression was found to be up-regulated in brain active lesions from patients. In the animal model of MS, experimental autoimmune encephalomyelitis (EAE), neutralization of HMGB1 ameliorated clinical severity and EAE pathology in the central nervous system. Studies of HMGB1 in peripheral blood from MS patients are lacking.
Objectives: We aimed to investigate the role of HMGB1 in peripheral blood mononuclear cells (PBMC) from MS patients with different clinical forms of the disease.
Methods: Gene expression levels of HMGB1 were determined by real time PCR in PBMC of 29 healthy controls (HC) and 57 untreated MS patients (25 with relapsing-remitting MS - RRMS; 14 with secondary progressive MS - SPMS; and 18 with primary progressive MS - PPMS). Serum levels of HMGB1 were measured by ELISA in 18 HC and 37 untreated MS patients (12 with RRMS; 15 with SPMS; and 10 with PPMS).
Results: mRNA expression levels for HMGB1 were significantly increased in PBMC from the whole MS group compared with HC (p=0.036). Further stratification of the MS group into different clinical forms revealed a significant increase in HMGB1 expression by PBMC from patients with relapse-onset MS compared to PPMS (p=0.0003 for RRMS and p=0.003 for SPMS) and the control group (p=0.002 for RRMS and p=0.03 for SPMS). Serum levels of HMGB1 were also found to be elevated in patients with relapse-onset MS compared to the PPMS group (p=0.001 for RRMS and p=0.03 for SPMS). Levels of HMGB1 in serum were also increased in RRMS patients compared with HC (p=0.007).
Conclusions: These results point to a role of HMGB1 in patients with RRMS and SPMS. The mRNA expression levels in PBMC or serum levels of HMGB1 may be used as disease activity biomarkers to discriminate the more inflammatory relapse-onset forms of MS from the less inflammatory PPMS form of the disease.
PS7.5 Anoctamin 2, a novel autoimmune target candidate in multiple sclerosis
B Ayoglu1, N Mitsios2, M Khademi3, L Alfredsson4, M Uhlén1, J Mulder2, T Olsson3, JM Schwenk1, P Nilsson1
1Scilifelab, KTH-Royal Institute of Technology, Affinity Proteomics, Stockholm, Sweden, 2Scilifelab, Karolinska Institute, Affinity Proteomics, Stockholm, Sweden, 3Karolinska Institute, Neuroimmunology Unit, Department of Clinical Neuroscience, Stockholm, Sweden, 4Karolinska Institute, Institute of Environmental Medicine, Stockholm, Sweden
Background: Affinity proteomic strategies for broad and unbiased exploration of the autoimmunity repertoire hold a great promise towards identification and confirmation of novel antigenic targets in multiple sclerosis (MS).
Objectives: We previously profiled IgG reactivity in an MS-related plasma sample cohort on protein microarrays with 11,520 protein fragments (representing 7,500 unique human proteins), which were generated within the Human Protein Atlas. Out of these, 51 were recognized differentially across the MS subtypes and non-diseased controls (Ayoglu B. et al., Mol Cell Proteomics, 2013). Here, we aimed to verify the significance of reactivities against these 51 targets, as well as other targets suggested from literature (e.g. KIR4.1), using plasma samples from a larger and independent cohort.
Methods: Following the use of planar protein microarrays for the initial discovery stage, we here utilized suspension bead arrays for a multiplex profiling of IgG reactivity in 2,210 plasma samples against a set of 384 antigens while consuming less than a microliter of neat sample per analysis.
Results: Comparison of IgG reactivity in plasma from 1,106 MS patients and 1,104 non-diseased controls revealed anoctamin 2 (ANO2), a calcium-activated chloride channel also known as transmembrane protein 16B (TMEM16B), as a strong autoimmune target candidate, which originated from our unbiased discovery approach. A statistically significant difference in positive reactivity between MS cases and non-diseased controls was found in particular for the intracellular N-terminal region of ANO2 (FDR-adjusted Fisher’s exact p-value=2x10-21). Further studies with commercially available ANO2 antibodies in human post-mortem MS brain tissue revealed moderate staining in neuronal cell bodies and more prominent staining in reactive astrocyte-like structures from various parts of the tissue.
Conclusions: A proteomic-based screening approach facilitated the discovery of anoctamin 2 (ANO2) as a novel autoimmune target candidate in multiple sclerosis, which was here verified in an independent set of 2,210 plasma samples. Subsequent efforts will reveal the contribution of the identified target to disease pathogenesis.
PS7.6 Potassium channel Kir4.1: a novel target for neuromyelitis optica autoantibodies?
R Marignier1,2, A Ruiz1, S Cavagna1, C Benetollo3, F Durand-Dubief2, S Vukusic1,2, P Giraudon1
1INSERM, Unit 1028 ONCOFLAM, Lyon, France, 2Hospices Civils de Lyon, Neurologie A - Hopital Neurologique, Lyon-Bron, France, 3Lyon Neuroscience Research Centre, Plateau Neurogénétique Fonctionnelle & Optogénétique, Lyon, France
Background: Autoantibodies directed against the potassium channel Kir4.1 have been recently identified in the sera of multiple sclerosis (MS) patients. As Kir4.1 is mainly expressed by astrocyte and associated to aquaporin4 (AQP4) at the membrane, we hypothesized that such autoantibodies could also be present in neuromyelitis optica (NMO) patients.
Objectives: Our objectives were first to develop a new method for Kir4.1 autoantibodies detection to identify conformational epitopes, and second to test their interest in a cohort of MS and NMO patients.
Methods: We set up an in-house method for the detection of Kir 4.1 by cell based assay (CBA) with live HEK cells transiently transfected with a His-Kir 4.1 plasmid. We then tested sera from 56 NMO patients, 171 MS patients and 19 healthy donors. A proportion of samples were also tested for Kir4.1 expression by western blot after chronic exposure to rat astrocyte primary culture.
Results: We found a relatively high proportion of NMO patients tested positive for Kir4.1 autoantibodies (16/56, 28.5%), mainly in the AQP4-IgG positive group (13/36, 36%). By contrast, only 3/171 MS sera (1.75 %) were tested positive using our in-house CBA. None of the control samples were considered positive. We also found that purified IgG from Kir4.1 autoantibodies positive NMO serum have the ability to downregulate Kir4.1 expression after 24h exposure to astrocyte primary culture, suggesting a pathogenic effect of those auto-antibodies.
Conclusions: Using a new method for the detection of Kir4.1 autoantibodies, even though we cannot reproduce the findings on MS, we demonstrated a potential high interest of such autoantibodies in NMO.
PS8 - Assessing neuroprotection
PS8.1 Pathways to neurodegeneration: insights from imaging in MS and other neurodegenerative disorders
M Inglese
1
1Icahn School of Medicine at Mount Sinai, Neurology, New York, NY, United States
The prevalence of neurodegenerative diseases is increasing as a consequence of the growing aging population; however the exact pathophysiological mechanisms leading to these diseases remains poorly understood. Multiple Sclerosis (MS), an autoimmune disease of the Central Nervous System and the most frequent cause of disability among young people after traumatic brain injury, is characterized by inflammatory/demyelinating and neurodegenerative processes that occurr earlier in life. Therefore, MS provides the unique opportunity to study neurodegeneration and the underlying pathophysiological processes in earlier stages than in classical neurodegenerative diseases. This presentation will summarize mechanisms of neurodegeneration common to MS and to Alzheimer disease, Parkinson disease, and Amiotrophic Lateral Sclerosis, and will provide a brief overview of the neuroimaging techniques to investigate and monitor neurodegeneration in both MS and classical neurodegenerative diseases.
PS8.2 Update on completed and ongoing neuroprotection and repair trials
J Chataway
1
1Queen Square Multiple Sclerosis Centre, National Hospital for Neurology and Neurosurgery, London, United Kingdom
In clear contrast to the success of disease modification in relapsing-remitting multiple sclerosis (MS), the situation in progressive MS unfortunately remains limited. This is despite a large effort over the last three decades (>8500 subjects in phase 3 trials alone) involving a variety of approaches.
In this talk, I outline some of the lessons that can be learnt from this experience including: the phase 2-3 relationship, cohort entry criteria and anticipated progression rates. Suggestions are made going forward in trial design, in particular with regard to new and emerging neuro-protective strategies.
PS8.3 Retinal ganglion cell injury in MS occurs most rapidly early in the course of disease
LJ Balk1, A Cruz-Herranz2, P Albrecht3, S Arnow2, JM Gelfand2, P Tewarie1, J Killestein1, CH Polman1, BM Uitdehaag1, A Petzold1, A Green2
1VU University Medical Centre, Amsterdam, Netherlands, 2UCSF, San Francisco, CA, United States, 3Heinrich Heine University, Düsseldorf, Germany
Background: Recent cross-sectional studies have demonstrated evidence of injury to inner retinal layers (peripapillary retinal nerve fibre layer [pRNFL], ganglion cell-inner plexiform layer [GCIPL], inner nuclear layer [INL]) in MS and established that this injury is correlated with clinical disability. However, the pace and timing of this injury remains to be elucidated.
Objectives: To investigate longitudinal changes in pRNFL, GCIPL and INL thickness in a broadly representative cohort of patients with MS and to explore whether changes over time are dependent on disease duration.
Methods: In this longitudinal multi-center observational study, 135 patients with MS underwent spectral-domain OCT at baseline and were retested after 2 years. In addition, patients underwent clinical and ophthalmological evaluations for assessment of function. Following OCT quality control, automated segmentation of the pRNFL, GCIPL and INL were performed. Generalized estimation equations were used to analyze longitudinal changes and associations with disease duration and clinical measures.
Results: Patients had a mean disease duration of 15.7±10.6 years (range 0.1-45.4). Nearly half (44%) had previously experienced a clinically identified episode of optic neuritis (ON).
In eyes of MS patients without a history of ON (MSNON eyes), SD-OCT clearly demonstrated significant progressive thinning of the pRNFL (0.9 µm, 95%CI -1.4 to 0.4, p< 0.001) and GCIPL (1.0 µm, 95%CI 1.4 to 0.6, p< 0.001) thickness over a period of 2 years. In eyes with one or more previous events of ON before the observational period (MSON eyes), longitudinal changes in pRNFL (1.8 µm, 95%CI 2.6 to 1.0, p< 0.001) and GCIPL (1.4 µm, 95%CI 2.1 to 0.6, p< 0.001) were even more evident. For INL thickness, no significant changes were observed over the course of two years in either MSNON (0.07 µm, 95%CI 0.4 to 0.2, p=0.614) or MSON eyes (0.03 µm, 95%CI 0.4 to 0.3, p=0.879). Importantly, thinning of the pRNFL and GCIPL was significantly associated with disease duration, showing the most rapid decline early in the disease course.
Conclusions: This study showed that over 2 years, significant thinning of the pRNFL and GCC was observed throughout the course of the disease. Importantly, these changes were most pronounced early in the disease course, suggesting that significant neuronal and axonal injury occurs during the earliest stages of MS and provides support for early intervention to prevent or forestall this injury.
PS8.4 Thalamic and basal ganglia volumes correlate with walking performance in multiple sclerosis
RW Motl1, B Sutton1, E Hubbard1, N Sreekumar1, LA Pilutti1, JJ Sosnoff1, RH Benedict2
1University of Illinois at Urbana-Champaign, Urbana, IL, United States, 2SUNY Buffalo School of Medicine, Buffalo, NY, United States
Background: The thalamus and basal ganglia are associated with a wide range of clinical manifestations in multiple sclerosis (MS), including cognitive and motor functions. Volumes of these deep grey matter (DGM) structures based on magnetic resonance imaging (MRI) have been correlated with information processing speed (IPS) in MS. There is less known about the association between volumes of the thalamus and basal ganglia with walking performance in MS. This is noteworthy considering
evidence of cognitive motor coupling between tests of IPS and walking performance and
the importance of identifying DGM structures as possible neural targets and mechanisms of walking changes with rehabilitation.
Objectives: This study examined the associations among volumes of the thalamus and basal ganglia with walking performance based on the 6-minute walk (6MW) in MS.
Methods: We enrolled 50 persons with MS who underwent 3T brain MRI and neuropsychological testing of IPS using the Symbol Digit Modalities Test (SDMT), and completed the 6MW. Using 3D T1-weighted images from a Siemens Trio, 3T MRI scanner, volumes of the thalamus, caudate, putamen, and globus pallidus were automatically calculated by the FMRIB’s Integrated Registration and Segmentation Tool (FIRST)-algorithm FMRIB’s Software Library (FSL). We examined associations using bivariate (r) and partial (pr) correlations and multiple linear regression analyses.
Results: 6MW performance correlated significantly with volumes of the thalamus (r=.40), caudate (r=.38), and globus pallidus (r=.43), but not putamen (r=.27). SDMT performance correlated significantly with 6MW performance (r=.59) and volumes of the thalamus (r=.48), caudate (r=.43), globus pallidus (r=.44), and putamen (r=.52). The association between 6MW and SDMT was independent of thalamic and basal ganglia volumes (pr=.59). Multiple linear regression analyses with age entered in Block 1 and forward stepwise entry of thalamic and basal ganglia volumes in Block 2 indicated that globus pallidus independently explained 17% of variance in 6MW performance (β=.41), whereas putamen independently explained 24% of variance in 6MW performance (β=.49).
Conclusions: We provide evidence of a possible role of DGM structures in walking performance in MS. There may be subtle differences in the DGM structures associated with IPS and walking performance, and these could be examined in subsequent clinical trials of cognitive and motor rehabilitation.
PS8.5 [11C]-PBR28 MR-PET imaging detects in vivo inflammation in normal appearing white matter and cortical sulci in multiple sclerosis
C Giannì1, ST Govindarajan1, AP Fan1,2, C Louapre1, M Loggia1, C Catana1, E Tinelli3, J Hooker1, J Sloane4, RP Kinkel4, C Mainero1
1Athinoula A.Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States, 2Massachusetts Institute of Technology, Cambridge, MA, United States, 3Sapienza, University of Rome, Rome, Italy, 4Beth Israel Deaconess Medical Center, Boston, MA, United States
Background: Histopathological studies have implicated activation of microglia and macrophages in both white matter (WM) and cortical lesions pathogenesis in multiple sclerosis (MS), as well as in normal appearing WM (NAWM) diffuse damage. Activated microglia and macrophages upregulate expression of the 18kDa translocator protein (TSPO), which can be imaged in vivo with [11C]PBR28, a second generation TSPO ligand.
Objectives: To assess the presence of activated microglia and macrophages within different lesional and non-lesional brain tissue compartments in MS by combining [11C]PBR28 PET imaging with 7 Tesla (T) MRI.
Methods: Seven MS patients (5 SPMS and 2 RRMS) and 7 healthy controls (HC) matched for age, gender and TSPO affinity binding underwent 90 minutes of [11C]PBR28 imaging on a high resolution Siemens BrainPET scanner. Anatomical MR images were simultaneously acquired for FreeSurfer cortical surface reconstruction and MR-PET image registration. In each subject, standardized uptake value (SUV) maps were created for 60 to 90-minute PET frame (1.25 mm3 isotropic resolution). Lesions were segmented from T2*-weighted images (0.33×0.33×1 mm3) acquired on a separate 7T MRI session: WM lesions in all MS subjects; cortical (reaching the pial surface) and leukocortical (extending across GM and WM without reaching the pial surface) lesions in 3 SPMS subjects. Lesion, cortical sulci and gyri masks were co-registered to each [11C]-PBR28 map to extract SUVs. In HC, SUVs were obtained in the cortex (sulci and gyri) and in WM. SUVs were compared between patients and HC using a paired t-test.
Results: Relative to HC, in patients there was a ~24% increase in SUVs (mean±SD) in NAWM (MS=0.711±0.2; HC=0.575±0.1), a ~11% increase in lesional WM (MS=0.641±0.2), ~20% increase in cortical sulci (MS=0.784±0.2; HC=0.653±0.1), and 13% increase in cortical gyri (MS=0.769±0.2; HC=0.679±0.1). In patients, increase in SUVs reached statistical significance relative to HC for NAWM (p< 0.03) and cortical sulci (p< 0.05). SPMS subjects showed, relative to RRMS, a 17%, 23%, 20% and 14% increase in lesional WM, NAWM, cortical sulci and gyri, respectively. There was no difference between lesional and non-lesional cortical SUVs.
Conclusions: High resolution [11C]PBR28 MR-PET imaging is a promising tool for assessing in vivo microglia and macrophages activation within brain tissue compartments in MS including NAWM and cortical sulci. The latter have been reported as the main location of neuroinflammation and demyelination by post-mortem studies.
PS8.6 Differentiation and quantification of inflammation, demyelination, and axon injury in human multiple sclerosis using diffusion basis spectrum imaging
Y Wang1, P Sun1, Q Wang1, C-W Chiang2, RE Schmidt3, RT Naismith4, AH Cross4, S-K Song1
1Washington University in St. Louis, Radiology, Saint Louis, MO, United States, 2Washington University in St. Louis, Chemistry, Saint Louis, MO, United States, 3Washington University in St. Louis, Pathology, Saint Louis, MO, United States, 4Washington University in St. Louis, Neurology, Saint Louis, MO, United States
Background: Axon injury/loss, demyelination, and inflammation are the main pathologies coexisting in multiple sclerosis (MS) lesions. Available quantitative magnetic resonance imaging (MRI) methods are not ideal to quantify axon and myelin integrity in the presence of inflammation.
Objectives: To address the limitations of available MRI methods, we developed diffusion basis spectrum imaging (DBSI) to differentiate and quantify axonal injury, demyelination, and inflammation. To validate DBSI, we examined the correlation between DBSI biomarkers and quantified histology images using autopsied MS specimens. To assess clinical feasibility, we applied DBSI to characterize the pathologies underlying various lesion types in MS patients.
Methods: DBSI models axons as anisotropic diffusion tensors, and models cells and edema as isotropic tensors of varying diffusivities (low for cells, higher for edema). Silver, Luxol Fast Blue (LFB), and H&E stains were down-sampled and rigid-registered to MR images. Positive stains were extracted and quantified based on the color features. Clustered linear models were used to describe the correlation between quantitative histology and DBSI maps. White matter lesions [6 black holes (BH), 6 non-black holes (NBH), and 4 Gadolinium-enhanced (Gd+)] were labeled based on MPRAGE, T1W and FLAIR to compare the ability of DBSI vs. diffusion tensor imaging (DTI) to distinguish lesion types.
Results: Silver stains correlated well with DBSI Fiber ratio (r=0.65) and DBSI axial diffusivity (AD) (r=0.59), and weakly with DTI AD (r=0.23). LFB stains correlated better with DBSI radial diffusivity (RD) (r=0.68) than DTI RD (r=0.52). In addition, cells enumerated by H&E correlated strongly with DBSI restricted isotropic fraction (r=0.89), consistent with our prior findings in an animal model of MS.
All p< = 10-4. A 6% increase of DBSI restricted isotropic ratio was observed in Gd+ lesions as compared to 6% and 4% decrease in BH and NBH respectively, in accord with active inflammation being a distinctive feature of Gd+ lesions. DBSI also found more severe axonal injury (decreased AD: -0.28 vs. -0.1 µm2/ms), demyelination (increased RD: 0.14 vs. 0.1 µm2/ms), and edema (increased extra-axonal water 44% vs. 18%) in BH than NBH.
Conclusions: DBSI-derived quantitative biomarkers were specific and consistent with histology. DBSI has great potential to reflect underlying tissue in clinical trials of reparative agents, to improve understanding of MS progression and to facilitate individual patient treatments.
PS9 - Treatment strategies in clinical practice
PS9.1 Is no evidence of disease activity a realistic treatment target?
H-P Hartung
1
1Heinrich-Heine-University, Department of Neurology, Düsseldorf, Germany
Short of curing the disease, controlling disease activity is a generic goal in disroders across disciplines. Achieving remission clinically and containing pathobiological disease activitywill prevent progression of diease and accumulation of disability.
First introduced in the MS therapeutic arena in an analysis of the AFFIRM tysabri trial by Havradova et al, freedom from disease was defined as the absence of relapses, disability progression and on MRI absence of gadolinium enhancing T1esions and new or enlarging T2 lesions. To date this composite measure has been analyzed for cladribine, fingolimod, dimethylfumarate, alemtuzumab and the combination of IFNß1a and GLAT. The advantage of the composite is to detect a therapeutic effect with more sensitivity. With the current definition of disease activity free status or no evidence of disease activity one has to realize the major contriibution of MR to this aggregate measure.. One would also need to consider that much of this MR information relates to inflammatory aspects and would not capture necessarily progressive neruodegenerative effects.
At any rate, currently based on results from pivotal trials freedom from detectable disease activity can be achieved in up to half ot the patients . Further improvement can be achieved with a stronger antiinflammatory activity of a drug and more powerful anti.degenerative actions.
References:
Havradova E et al, Lanc Neurol 2009; 8: 254–260
Giovannoni G et al. Lanc Neurol 2011; 10: 329–337
Bevan CJ, Cree BAC. JAMA Neurol 2014; 71: 269–270
Hartung HP, Aktas O. Lanc Neurol 2011; 10:293–295
PS9.2 Treatment algorithms in patients with ongoing disease activity
X Montalban
1
1University Hospital Vall d’Hebron, Neurology-Neuroimmunology, Barcelona, Spain
Today, the span of multiple sclerosis (MS) therapy options is diverse; management is though somewhat complex. The evidence and experience rapidly generated with new drugs is phenomenal, precluding strong recommendations on given treatment algorithms. Evidence indicates that presence of inflammation: relapses and/or new T2 or enhancing lesions, in patients on interferon beta (IFN) or glatiramer acetate (GA) is associated to poor long term prognosis (Rudick et al, Rio et al). Also there are inconclusive data trying to establish a relation between drug effects on brain atrophy and eventual benefit. Therefore, proper identification of inflammation and disability progression is nowadays most important for MS neurologists. In fact, the new phenotype classification takes activity and progression as key patient classification items (Lublin et al).
It can be argued that higher numbers of follow-up visits and MR exams can increase the number of inflammatory events identified. Typically, an MR exam every 6-12 months is recommended, although great variability occurs in different clinical practice. Although in theory the objective of full supression of inflammation may be desirable, evidence indicates it is probably unrealistic and even unnecessary. Some require relapses and new MR lesions to consider switching and others only new MR lesions.
Patients with mild inflammation on IFN or GA may switch transversally or to orals (teriflunomide (TFM), dimethyl fumarate (DFT) or fingolimod (FGD)). Patients with higher inflammation tend to be treated with the second line drugs -as they are tagged in EU: fingolimod and natalizumab (NTZ). Also, alemtuzumab (ALZ) is now an option on inflammation. Other compassionate drug uses occur in some clinical practices like rituximab. There are many switching possibilities, but evidence is still limited.
Nature of the drug may influence future options mainly for safety. For instance. using TFM or FGD may influence the risk of PML if NTZ is used later. Washout period is also important. No washout is recommended after or before IFN or GA. After NTZ a period of at least 1-2 months is recommended to start FGD or DFT. Other periods are speculative.
There are many other factors to be taken into account when switching: concomitant disorders, age, pregnancy, JCV status, etc. Cost and accessibility are now two very important factors in decision making and vary hugely between countries.
PS9.3 Efficacy and safety of oral versus intravenous high-dose methylprednisolone in multiple sclerosis relapses, a randomized double blind trial (COPOUSEP)
E Le Page1, D Veillard2, D Laplaud3, R Wardi4, C Lebrun5, F Zagnoli6, S Wiertlewki3, V Deburghgraeve1, M Coustans7, G Edan1, West Neurosciences Network of Excellence (WENNE)
1University Hospital Pontchaillou, Neurosciences, Rennes, France, 2University Hospital Pontchaillou, Epidemiology & Public Health, Rennes, France, 3University Hospital, Neurosciences, Nantes, France, 4General Hospital, Neurosciences, St Brieuc, France, 5General Hospital, Neurosciences, Nice, France, 6Army Hospital, Neurosciences, Brest, France, 7General Hospital, Neurosciences, Quimper, France
Background: Intravenous (IV) high-dose Methylprednisolone (MP) for 3-5 days are recommended to accelerate Multiple Sclerosis (MS) relapses recovery. Oral MP would simplify and consistently minimize the treatment-related costs, but to date, reported data are insufficient.
Objectives: To compare efficacy and safety of oral versus IV MP in MS relapses treatment.
Methods: COPOUSEP is a French multicenter non inferiority double blinded controlled trial (NCT00984984). Patients were randomized to receive MP 1g/day for 3 days per os (PO) or IV. Main inclusion criteria were: Relapsing remitting MS (RRMS); residual EDSS 0-5 before relapse; time from relapse onset of 15 days or less; at least one Kurtzke EDSS scale functional system increased at minimum 1 point (score of 2 or more) but for sensory function a score of 3 or more. EDSS scores were measured at 3, 8, 28 and 180 days, new relapses were recorded prospectively; tolerance was evaluated by auto-questionnaires and safety data were collected up to 180 days. Primary end-point was the percentage of patients improved at day 28 (decrease by at least 1 point of the most affected functional system), without retreatment with MP. Intention To Treat (ITT) and Per protocol analysis were performed.
Results: 198 out of 200 randomized patients were included in the ITT analysis (98, IV group; 100, PO group). The IV and PO groups had similar characteristics at baseline (age 35.8 vs 35.5 years old, mean time from MS onset 7.1 vs 7.6 years, mean time from relapse onset 7.3 vs 7.0 days, mean EDSS increased from 1.5 to 3.4 vs 1.4 to 3.4, type of function most affected by the relapse. The hypothesis of non-inferiority was confirmed by the primary endpoint at day 28: 73 patients (77.7%) of the IV vs 74 (77.9%) of the PO group improved. Other results were similar in the IV and PO groups at day 28: 16% vs 12.6% of patients required further treatment with MP before day 28; 76.6% vs 74.7% improved by at least 1 point EDSS; 42.6% vs 38.9% of patients had totally recovered; EDSS score improved by 1.4 vs 1.3 point. The median time to total recovery was 20 vs 23.5 days. Up to 6 months of follow-up, 28.3% vs 30.0% of patients presented at least 1 new relapse treated by MP. Tolerance was similar in the 2 groups.
Conclusions: Per os high-dose MP was not inferior to high-dose intravenous in the treatment of MS relapses.
PS9.4 Factors that determine disease course: early changes contribute to predict long-term prognosis, the ’Barcelona inception cohort’
M Tintoré1, Á Rovira2, S Otero-Romero1,3, G Arrambide1, C Tur1, M Comabella1, C Nos1, M-J Arévalo1, L Negrotto1, I Galán1, À Vidal-Jordana1, J Castilló1, F Palavra1, E Simón1, R Mitjana2, C Auger2, J Sastre-Garriga1, X Montalban1
1Vall Hebron University Hospital, Multiple Sclerosis Centre of Catalonia, Neuroimmunology Department, Barcelona, Spain, 2Vall Hebron University Hospital, Magnetic Resonance Unit, Neuroradiology Department, Barcelona, Spain, 3Vall Hebron University Hospital, Preventive Medicine and Epidemiology Department, Barcelona, Spain
Background: In a previous study in clinically isolated syndromes (CIS) we found that baseline characteristics could be categorized into low (demographics and topography), medium (presence of OB) and high-impact prognostic factors (brain MRI and early treatment).
Objectives: To determine the impact of clinical and brain MRI “first year changes” on conversion to multiple sclerosis (MS) and disability accumulation in a prospective cohort of patients with CIS.
Methods: From 1995 to 2013, 1015 CIS patients underwent clinical and brain MRI follow-up. We selected patients with at least 12 months of follow-up and studied the influence on the risk of clinically definite MS (CDMS) and disability accumulation (EDSS 3.0) of first year clinical (incomplete recovery defined as EDSS ≥ 2.0 at year one; second attack during the first year) and MRI changes (presence of new T2; gadolinium enhancing -Gd-lesions at year one). Uni (hazard ratio-HR) and multi (adjusted HR-aHR) were obtained after adjusting Cox regression model by age, gender, topography, presence of oligoclonal bands (OB), number of baseline T2 lesions on brain MRI, and disease modifying treatment (DMT).
Results: We finally included 887 patients followed for a mean of 92.0 (SD 53) months. Comparing patients not converting to CDMS to patients developing CDMS: mean number of new T2 was 0.87 (SD 4.2) compared to 4.2 (SD 6.3) (p< 0.0001) and mean number of Gg lesions was 0.2 (SD 0.7) compared to 0.6 (SD 1.0) (p< 0.0001). Comparing patients not reaching EDSS 3.0 to patient developing EDSS 3.0: mean number of new T2 was 1.99 (SD 4.4) and 4.4 (SD 6.3) (p< 0.0001) and mean number of Gd lesions was 0.5 (SD 1.4) and 0.8 (SD 1.98)(p=0.1). Patients with new T2 lesions (1-3; 4-9 and 10 or more) at 12 months had a higher risk of CDMS (HR 3.99 [2.90-5.49]) (HR 5.50 [3.77-8.02]) (HR 7.52 [4.50-12.57]) and disability progression (HR 2.02 [1.09-3.73]), (HR 4.47 [2.48-8.06]), (HR 3.12 [1.37-7.10]). Presence of Gd lesions at year 1 increased the risk of CDMS (HR 3.29; [2.18- 4.97]). In the multivariate analysis, significant predictors of CDMS were baseline lesions, new T2 lesions and treatment before second attack; significant predictors of EDSS 3.0 were baseline lesions, incomplete recovery, presence of OB and treatment before second attack.
Conclusions: Clinical and MRI first year changes further improve the estimation of individual prognosis.
PS9.5 Independent predictors of time to relapse after CIS in high-risk patients
T Spelman1, C Meyniel2, M Trojano3, A Lugaresi4, G Izquierdo5, F Grand’Maison6, C Boz7, R Alroughani8, E Havrdova9, G Iuliano10, P Duquette11, M Terzi12, P Grammond13, JA Cabrera-Gomez14, R Hupperts15, J Lechner-Scott16, H Butzkueven1, on behalf of the MSBASIS (an MSBase Substudy) Investigators
1University of Melbourne, Melbourne Brain Centre, Parkville, Australia, 2CHU Nantes, Nantes, France, 3University of Bari, Department of Basic Medical Sciences, Neuroscience and Sense Organs, Bari, Italy, 4University ‘G. d’Annunzio’, MS Center, Department of Neuroscience and Imaging, Chieti, Italy, 5Hospital Universitario Virgen Macarena, Sevilla, Spain, 6Neuro Rive-Sud, Hôpital Charles LeMoyne, Greenfield Park, QC, Canada, 7Karadeniz Technical University, Trabzon, Turkey, 8Amiri Hospital, Kuwait, Kuwait, 9General University Hospital and Charles University, Department of Neurology and Center of Clinical Neuroscience, Prague, Czech Republic, 10Ospedali Riuniti di Salerno, Salerno, Italy, 11Hôpital Notre Dame, Montreal, QC, Canada, 12Mayis University, Samsun, Turkey, 13Center de Réadaptation Déficience Physique Chaudière-Appalache, Levis, QC, Canada, 14Centro Internacional de Restauracion Neurologica, Havana, Cuba, 15Orbis Medical Centre, Sittard-Geleen, Netherlands, 16John Hunter Hospital, Newcastle, Australia
Background: The first relapse post-clinically isolated syndrome (CIS) marks the conversion from CIS to clinically definite multiple sclerosis. Establishing optimal timing for initiating disease-modifying drug (DMD) therapy following CIS is difficult. Clinical and para-clinical factors may assist in predicting patients who are at higher risk of a subsequent second attack and conversion, and thus benefit from early treatment intervention.
Objectives: To examine demographic, treatment and examination characteristics as predictors of time to second attack following CIS.
Methods: Patients were sourced from the MSBase Incident Study (MSBASIS) subset of the MSBase global registry. Predictors of time to second attack were analysed using a Cox proportional hazards regression.
Results: 3296 patients across 22 countries contributing a total of 5379 person-years of data were analysed. 1953 (59.3%) patients recorded a second attack. Every 5 years of age older at CIS was associated with a 10% reduction in the risk of relapse (Hazard Ratio 0.90, 95% CI 0.88, 0.92). Patients managed in Dutch clinics were associated with higher rates of second attack compared with other locations. Any exposure to DMT was associated with a 42% reduction in the relapse rate compared with DMT-naïve patients (HR 0.58, 95% CI 0.46, 0.73) whilst increasing proportion of follow-up time on DMD was associated with a 65% reduction in the rate of relapse (HR 0.35, 95% CI 0.25, 0.49). At least 1 T1 gadolinium enhancing lesion was associated with 1.29 times the relapse rate (95% CI 1.14, 1.47). At least 1 infratentorial and at least 1 juxtacortical lesion on cerebral MRI were associated with 1.29 and 1.16 times the rate of second attack respectively. The presence of oligoclonal bands on baseline CSF examination was associated with 1.43 times the rate of subsequent relapse compared with absence of OCB (HR 1.43, 95% CI 1.15, 1.77).
Conclusions: This large prospective study suggests that DMD exposure, age at CIS onset, country, MRI lesion load and the oligoclonal bands on CSF examination are all independently associated with the probability and timing of second attack. Early identification of patients who are at risk of conversion to CDMS based on demographic and disease characteristics may enable the clinician to closely monitor such patients and consider early treatment intervention which may result in better patient outcomes. To our knowledge, our study is the largest to prospectively assess patients in clinical practice from CIS onset.
PS9.6 Early on-treatment T2 and T1 subtraction MRI predicts imaging and clinical outcomes in the CombiRx cohort
L Freeman1, F Lalys1, TD Staewen2, JA Lincoln1, F Nelson1, S Datta2, PA Narayana2, SS Cofield3, T Gustafson4, GR Cutter3, FD Lublin4, JS Wolinsky1, CombiRx Investigators
1University of Texas Health Science Center, Neurology, Houston, TX, United States, 2University of Texas Health Science Center, Diagnostic and Interventional Imaging, Houston, TX, United States, 3University of Alabama at Birmingham, Biostatistics, Birmingham, TX, United States, 4Icahn School of Medicine at Mount Sinai, Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology & Friedman Brain Institute, New York, NY, United States
Background: Estimates of cross-sectional lesion burden show only modest correlation with disability in MS. Subtraction imaging allows detection of longitudinal changes in MS lesions and may improve the prediction of patient outcome. However its relevance and applicability in large multicenter cohorts remain unexplored.
Objectives: To investigate the predictive value of early on-treatment T2 and T1 subtraction MRI (sMRI) on imaging and clinical outcomes at 3 years in relapsing-remitting multiple sclerosis (RRMS) patients.
Methods: Analyses were carried out using the 3-year data from 931 RRMS subjects enrolled in the CombiRx trial, a multi-center, phase-III investigation of combination therapy. Serial co-registered sets of fully processed T2 and T1 images were used to perform sMRI between 6 months (M6)-baseline(M0) and between 12 months (M12)-M0. The volume of new and vanished T2 lesion voxels was calculated as well as the volume of persistent black holes (PBH). Multivariable modeling controlling for confounding factors was used to estimate the association between whole brain sMRI changes and 1) clinical outcomes at 36 months: EDSS, clinical activity free status (CAFS), disease activity free status (DAFS) and on-trial sustained progression, and 2) subsequent MRI changes in T1 and T2 lesion volumes (T1Lv, T2Lv), burden of disease (BOD), grey and white matter volume (GMv, WMv) and normalized cerebrospinal fluid volume (nCSF). Tract-specific analyses were carried out in the motor and visual pathways to evaluate the relationship between sMRI metrics and EDSS functional system (FS) scores.
Results: M6-M0 and M12-M0 T2 lesion changes measured by sMRI predicted subsequent EDSS (p=0.04, p=0.03), DAFS (p< 0.001), T2Lv (p< 0.001), T1Lv (p< 0.001), WMv (p< 0.001), nCSF (p< 0.001, p=0.01) and BOD (p< 0.001 for M12-M0 changes only) but did not predict GMv changes, CAFS or on-trial progression. PBH in the first 6 or 12 months predicted subsequent EDSS (p=0.03), DAFS (p=0.01, p=0.05), WMv (p< 0.001) and nCSF (p=0.02, p=0.005), but did not predict GMv, BOD, CAFS or progression. T2 sMRI activity in motor pathways predicted later EDSS (p=0.002). Finally, PBH in visual pathways predicted later visual FS metrics (p=0.05, p=0.03).
Conclusions: sMRI provides a robust and sensitive tool to predict longer term imaging and clinical outcomes in large cohorts of treated MS patients. Its applicability in atlas-defined white-matter pathways may increase our understanding of tract-specific pathology and its clinical relevance in MS.
PS10 - Immune mechanisms
PS10.1 Circulating miRNAs as disease biomarkers in multiple sclerosis
HL Weiner1
1Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, United States
Background: MicroRNA (miRNAs) are single stranded, small non-coding RNA molecules that regulate gene expression and protein synthesis and are involved in fundamental biological processes. Stable expression of miRNA in plasma and serum, makes them ideal potential immune biomarker.
Objective: To determine circulating miRNA based biomarkers in MS patients.
Method: We categorized MS patients into different group categories based upon clinical and magnetic resonance imaging (MRI) parameters and analyzed circulating miRNA expression using nanostring arrays containing 800miRNAs. These group categories include
Relapsing Remitting (RRMS), Primary Progressive (PPMS) and Secondary Progressive MS patients (SPMS),
Benign MS patients,
MS patients with (GD+) or without (GD-) Gadolinium enhancing lesions (paired samples from 12 MS patients).
Results:
We found miRNAs that were differentially expressed in MS compared to other neurologic diseases and other autoimmune diseases
We also found of miRNAs that could differentiate RRMS from progressive MS.
Although untreated multiple sclerosis leads to neurologic disability in the majority of patients, there is a well-recognized subset of patients that have a benign form of the disease. These are patients who are untreated and at 15 years after diagnosis have not accumulated disability. Based upon the circulating miRNA analysis, we found that the benign MS patients were more similar to disease duration matched RRMS but have differential miRNAs expression compared to both EDSS matched MS patients or healthy controls.
Brain Magnetic resonance imaging (MRI) imaging indicates a measure of disease activity in MS. Gadolinium enhancing lesions in MRI demonstrate an acute inflammatory process that is represented by infiltration of autoreactive immune cells into the central nervous system. We performed circulating miRNA analysis in serum samples from untreated patients that had a blood sample available within 3 days of MRI with a gadolinium-enhancing lesion (Gd+) and paired sample of same patient with inactive MRI activity (Gd-). We identified miRNAs that were differentially expressed in GD+ samples compared to the GD- samples.
Conclusion: Expression of miRNAs can be used to differentiate MS patients from control and other neurologic diseases and also to differentiate among clinical subgroups groups of MS patients. Specific miRNAs associated with the various subgroups will be presented.
PS10.2 Fibrin and microglia in MS
K Akassoglou
1
1University of California, Department of Neurology & Gladstone Institute of Neurological Disease, San Francisco, CA, United States
Blood-brain barrier disruption, microglial activation and neurodegeneration are hallmarks of multiple sclerosis (MS). Studies in human MS have identified abundant deposition of the blood coagulation factor fibrinogen throughout the course of disease, not only in active and chronic plaques, but also in early lesions prior to demyelination. In accordance, proteomic analysis has revealed increased coagulation activity in MS plaques. However, whether plasma proteins and the coagulation cascade contribute to neuroinflammation and neuronal damage remains poorly understood. Our laboratory identified fibrinogen as a key player in the activation of CNS innate immunity and induction of axonal damage in neuroinflammation. We showed that fibrinogen is a potent pro-inflammatory mediator in the nervous system by activating the CD11b/CD18 integrin receptor (also known as Mac-1 and complement receptor 3) in microglial cells. Using in vivo two-photon microscopy, we showed that in Experimental Autoimmune Encephalomyelitis (EAE), a model of MS, microglia rapidly perform constant surveillance of blood vessel walls and specifically cluster around blood vessels with fibrin deposition. By developing a novel molecular probe to detect coagulation activity in the CNS, we demonstrated in EAE early activation of coagulation and fibrin deposition even before disease onset. Intriguingly, fibrin is sufficient to induce in microglia release of reactive oxygen species, which contribute to neurodegeneration. Pharmacologic or genetic disruption of the fibrin/CD11b interaction suppresses microglial cluster formation, neurologic symptoms, inflammation, demyelination, and axonal damage in EAE. Overall, our studies identified the blood coagulation factor fibrinogen as a novel activator of CNS innate immunity that promotes neurodegeneration. Fibrin has the potential for selective drug targeting to suppress its damaging functions in the nervous system without affecting its beneficial effects in hemostasis. Fibrin-selective inhibition of innate immunity may offer novel strategies to combat axonal damage in neuroinflammatory disease.
PS10.3 Demyelinating lesions in multiple sclerosis: experimental evidence indicating why, how and where they may form
RA Desai1, AL Davies1, M Kasti1, F Laulund1, KJ Smith1
1UCL Institute of Neurology, Neuroinflammation, London, United Kingdom
Background: Pathological studies have distinguished a “primary”, “pre-phagocytic” or “Pattern III” demyelinating lesion in MS, but the mechanism(s) responsible for the initiation of this early lesion remain unclear. An energy deficit arising from nitric oxide-mediated mitochondrial inhibition has been suggested.
Objectives: To explore the mechanisms responsible for Pattern III demyelination using an animal model of the early lesion.
Methods: The demyelinating lesion was induced in the rat dorsal column by the unilateral microinjection of lipopolysaccharide (Felts et al, Brain 2005;128:1649) and examined immunohistochemically at different stages of development.
Results: A large, focal Pattern III demyelinating lesion appeared 7-14 days after injection, as expected. Surprisingly, this lesion is not centred on the injection site, as typically occurs, but rather it forms at the border between the white and grey matter, extending to the watershed region at the base of the dorsal columns. Histological examination of the spinal cord during the first days after lesion induction revealed that the grey matter and dorsal columns at the site of injection were severely hypoxic: oligodendrocytes labelled particularly strongly. The precise site that later became demyelinated also labelled strongly for the overlapping production of superoxide and nitric oxide, with immunoreactivity for nitrotyrosine indicating the presence of the strong oxidant peroxynitrite. The location of the demyelinating lesion corresponded with a watershed region of inherent susceptibility to hypoxia, as revealed by exposure of naïve animals to a hypoxic environment. Oligodendrocytes succumbed in this region, resulting in the subsequent Pattern III demyelination.
Conclusions: The evidence shows that Pattern III demyelination arises from activation of innate immune mechanisms that result in an environment characterised by hypoxia, and reactive oxygen and nitrogen species. The coincident presence of these factors at sites rendered vulnerable by the vascular architecture results in oligodendrocyte loss, demyelination and some axonal degeneration. Similar mechanisms may be responsible for the initiation of Pattern III lesions in multiple sclerosis.
PS10.4 Molecular characterisation and suppressive capacity of human CD4+HLA-G+ regulatory T cells
T Ruck1, S Pankratz1, S Bittner1, AM Herrmann1, SG Meuth1,2, H Wiendl1
1University of Muenster, Neurology, Muenster, Germany, 2University of Muenster, Institute of Physiology I - Neuropathophysiology, Muenster, Germany
Background: Regulatory T cells (Treg) are essential for the induction and maintenance of peripheral immune tolerance. Decreased Treg frequencies and/or impaired function have been associated with the pathogenesis of several autoimmune diseases. CD4+CD25+FoxP3+ Tregs (FoxP3+) are the best characterized population of thymus-derived Treg (tTreg) cells. Recently, CD4+HLA-G+ (HLA-G+) have been described as another CD4+ tTreg subpopulation characterized by the expression of the non-classical human leukocyte antigen G (HLA-G). In contrast to FoxP3+ tTregs, HLA-G+ tTregs exert their suppressive function in a cell-contact independent manner. In multiple sclerosis HLA-G+ tTregs have a strong propensity to cross the blood-brain barrier (BBB) and are enriched at sites of inflammation, possibly contributing to parenchymal immune homeostasis. The molecular features underlying their suppressive capacity of HLA-G+ cells are still largely unknown.
Objectives: Our aim was to further elucidate the molecular and functional properties of HLA-G+ cells underlying their suppressive function in multiple sclerosis and other autoimmune disorders.
Methods: Flow cytometry, immunohistochemistry, western blot, q-PCR, calcium imaging, cAMP and electrophysiological measurements were performed for a detailed in vitro characterization of HLA-G+ cells compared to FoxP3+ cells. Furthermore, the suppressive potential of HLA-G+ cells was validated in a humanized mice model of xenogeneic-graft-versus-host-disease (xGvHD) in vivo.
Results: HLA-G+ and FoxP3+ cells were characterized by reduced activation of early signaling molecules and reduced calcium influx upon TCR stimulation and a hyperpolarization of the plasma membrane compared to conventional CD4+ T cells. However, both subsets clearly differed in phenotype and pattern of secreted cytokines resulting in distinct mechanisms of suppression: HLA-G+ cells secreted high levels of inhibitory molecules (IL-10, soluble HLA-G, IL-35), while FoxP3+ cells provided their suppressive function mainly in a contact-dependent manner via cyclic adenosine monophosphate (cAMP). Moreover, HLA-G+ tTregs exerted a comparable suppressive capacity to FoxP3+ tTregs in vitro and in vivo as demonstrated in a xGvHD model.
Conclusions: CD4+HLA-G+ tTregs are an independent and unique population of regulatory T cells, which are capable to suppress immune responses in vivo and might therefore be a promising candidate for future therapeutic strategies in multiple sclerosis and other autoimmune diseases.
PS10.5 Deep sequencing of T-cell receptor repertoire reveals enrichment of highly expanded clonotypes in cerebrospinal fluid from multiple sclerosis patients
A De Paula Alves Sousa1,2, R Nicholas2, K Johnson3, S Darko4, D Price5, DC Douek4, S Jacobson1, PA Muraro2
1National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States, 2Imperial College, London, United Kingdom, 3National Institute of Neurological Disorders and Stroke, Bethesda, United Kingdom, 4National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States, 5University of Cardiff, Cardiff, United Kingdom
Background: Immunological studies have demonstrated that inflammatory T cells in the central nervous system play a fundamental role in the development of multiple sclerosis (MS). However, in-depth clonal composition profiling of these T cells, that may reflect perturbations of the adaptive immune response, has been poorly understood due to technological limitations. Advances in high-throughput sequencing of T-cell receptors have provided a powerful tool to explore the depth and complexity of the immune response and may also serve to evaluate the frequency of specific T-cells in compartments such as peripheral blood (PB) and cerebrospinal fluid (CSF).
Objectives: Our object was evaluated the T-cell repertoire in the PB and CSF compartments from MS patients and controls.
Methods: We have used an unbiased molecular approach called 5’rapid amplification of cDNA ends to amplify the V-D-J genes of unsorted T-cells obtained from PB and CSF of 5 patients with MS and 5 individuals classified as non-inflammatory neurological disease (NIND), and evaluated the TCR repertoire using high-throughput DNA-sequencing technology.
Results: A total of 80 million short sequence in-frame reads covering the TCR hypervariable regions were generated through HiSeq2500 Illumina system platform. The data was analyzed using a bioinformatics program that align and match the human TCR beta-chain nucleotide sequences through IMGT database. We observed that number of distinct TCR based on V-D-J sequences rearrangement and the diversity of T-cell clonotypes of the PB was much higher compared to CSF compartment for both groups of individuals. Surprisingly, the diversity of T-cell repertoire of CSF compartment in patients with MS was not significantly different from NIND controls. However, when we looked at the frequency of expanded clonotypes within the CSF compartment, MS patients showed a statistically increased number of highly expanded clones compared to NIND controls. As expected, the majority of MS patients also showed a significantly expansion of clones in the CSF compared to the PB compartment. Importantly, analysis of the most shared expanded clones in both compartments revealed that very few T-cell clones from the circulating PB infiltrate the CSF compartment.
Conclusions: Our findings strongly demonstrate a biased T-cell repertoire in the CSF compartment of MS patients and the feasibility of in-depth high throughput deep sequencing to comprehensively study the T-cell repertoire in patients with neurological immune-mediated disease.
PS10.6 Combinatorial actions of Tgfβ and Activin ligands promote oligodendrocyte development and CNS myelination
DJ Dutta1,2,3, A Zameer1,2,3, JN Mariani1,2,3, J Zhang1,2,3, L Asp1,2,3, J Huynh1,2,3, S Mahase1,2,3, BM Laitman1,2,3, A Tadesse Argaw1,2,3, N Mitiku1,2,3, M Urbanski4, CV Melendez-Vasquez4, P Casaccia2,3,5, F Hayot1,3,6, EP Bottinger7,8, CW Brown9,10, GR John1,2,3
1Icahn School of Medicine at Mount Sinai, Neurology, New York, NY, United States, 2Icahn School of Medicine at Mount Sinai, Corinne Goldsmith Dickinson Center for MS, New York, NY, United States, 3Icahn School of Medicine at Mount Sinai, Friedman Brain Institute, New York, NY, United States, 4Hunter College, Biological Sciences, New York, NY, United States, 5Icahn School of Medicine at Mount Sinai, Neuroscience, New York, NY, United States, 6Icahn School of Medicine at Mount Sinai, Systems Biology, New York, NY, United States, 7Icahn School of Medicine at Mount Sinai, Nephrology, New York, NY, United States, 8Icahn School of Medicine at Mount Sinai, Charles Bronfman Institute for Personalized Medicine, New York, NY, United States, 9Baylor College of Medicine, Molecular and Human Genetics, Houston, TX, United States, 10Baylor College of Medicine, Pediatrics, Houston, NY, United States
Background: Development of myelin-forming oligodendrocytes is limited by bone morphogenetic proteins (Bmp), which form one arm of the transforming growth factor-β family and signal canonically via Smads1/5/8. Tgfβ ligands and Activins comprise the other arm and signal via Smads2/3. They have been implicated as promoting differentiation and myelin repair in models of multiple sclerosis, but their roles in oligodendrocyte development are incompletely characterized.
Objectives: Here, we report that Tgfβ ligands and Activin B (ActB) act in concert in the embryonic mammalian spinal cord to promote oligodendrocyte generation and myelination.
Methods: We isolated primary mouse oligodendrocyte progenitors (OLP), exposed them to Tgfβ and ActB, and examined them for markers of pathway activation and oligodendrocyte development. Spinal cords of wildtype, ActB-deficient Inhbb-/- and Smad3-/- embryos were examined via confocal microscopy.
Results: In mouse spinal cord, newly-specified OLP are first exposed to Tgfβ ligands in isolation, then later in combination with ActB during maturation. In primary OLP cultures, Tgfβ1 and ActB differentially activate canonical Smad3 and non-canonical MAP kinase signaling. Both ligands enhance viability, and Tgfβ1 promotes proliferation whereas ActB supports maturation. Importantly, co-treatment strongly activates both signaling pathways, producing an additive effect on viability and enhancing both proliferation and differentiation, such that mature oligodendrocyte numbers are strongly increased. Co-treatment promotes myelination in OLP-neuron co-cultures, and maturing oligodendrocytes in spinal cord white matter display strong Smad3 and MAP kinase activation. In spinal cords of ActB-deficient Inhbb-/- embryos, apoptosis in the oligodendrocyte lineage is increased and OLP numbers transiently reduced, but numbers, maturation and myelination recover during the first postnatal week. Smad3-/- mice display a more severe phenotype, including diminished viability and proliferation, persistently reduced mature and immature cell numbers, and delayed myelination.
Conclusions: Collectively, these findings suggest that in mammalian spinal cord, Tgfβ ligands and ActB together support oligodendrocyte development and myelin formation.
PS11 - Gray matter pathology and mechanisms of progression
PS11.1 Heterogeneity and significance of gray matter pathology
JJ Geurts
1
1VU University Medical Center, Dept. of Anatomy & Neurosciences, Section of Clinical Neuroscience, Amsterdam, Netherlands
Over the past few years, it has been consistently shown that gray matter pathology is both common and widespread in MS. The neocortex is typically affected by several different lesion types, but gray matter demyelination may also be found in non-(neo)cortical areas such as the hippocampus, thalamus, basal ganglia, cerebellar cortex and the spinal cord gray matter. Demyelination may be extensive, with cerebellar cortical demyelination affecting up to 90% of the total surface area in some published cases. Clinical correlates of demyelination in the gray matter have been more difficult to study, as conventional magnetic resonance imaging (MRI) techniques were insufficiently equipped to visualize gray matter lesions. Newer techniques, like double inversion recovery (DIR) and phase-sensitive inversion recovery (PSIR), as well as imaging at higher field-strengths, have improved lesion detection. Nevertheless, correlations between cortical lesions and clinical disability, including cognitive impairment, remained moderate at best. Gray matter atrophy, which develops largely independently of (overt) gray matter demyelination, might be a better (and more reliable) imaging candidate for explaining clinicocognitive disability and progression. Atrophy of the neocortex is initially seen in temporal and prefrontal cortical regions, and the earliest signs of atrophy of the gray matter are found in deep gray matter structures such as the thalamus. In terms of explaining cognition, pathology of the thalamus and of (anterior) tracts emanating from the thalamus may play an important role. Given the ‹centrality› of this structure in the brain›s overall network, advanced network analysis may be expected to provide new and crucial insight into cognitive impairment and decline in MS.
PS11.2 Is primary progressive MS a distinct disease?
S Vukusic
1
1Hôpital Neurologique, Bron cedex, France
Primary progressive multiple sclerosis (PPMS) represents 10 to 15% of patients with MS. They are more likely to be men, with an older age at onset (40 years compared to 30 years in relapsing-remitting MS (RRMS)), and have a worse evolution of disability. Immunoactive treatments have failed to demonstrate any efficacy in preventing disability progression, contrasting with the increasing therapeutic arsenal in RRMS. Therefore, whether PPMS is a distinct disease has been a matter of controversy for many years.
We will review epidemiological, imaging and pathological data to bring some insights into this debate.
PS11.3 Is GABA abnormal in progressive multiple sclerosis?
N Cawley1, B Solanky1, N Muhlert2, T Schneider1, C Wheeler-Kingshott1, A Thompson1,3, O Ciccarelli1,3
1Institute of Neurology, London, United Kingdom, 2Cognitive Neuroscience, Cardiff University, Cardiff, United Kingdom, 3NIHR University College London Hospitals, Biomedical Research Centre, London, United Kingdom
Background: Gamma-aminobutyric acid (GABA) is the main inhibitory neurotransmitter in the human brain, which contributes to motor control, cognitive functions and other cortical functions.
Objectives: We tested the hypothesis that GABA levels in the sensory motor cortex, pre-frontal cortex and hippocampus differ between patients with progressive Multiple Sclerosis and healthy controls using a spectroscopic protocol (MEGA-PRESS) at 3T. In patients, we also explored the relationship between GABA levels in the cortical regions and cognitive, motor and sensory functions.
Methods: 28 patients with secondary progressive MS (SPMS) (21F, 7M), mean age 51yrs (SD 9.6), and 16 healthy controls (9F, 7M), mean age 43 (SD 12.5) were recruited. Median patient EDSS was 6 (range=4.0-6.5). All MR experiments were performed on a 3T Achieva (Philips Medical Systems, Best), with a 32-channel head coil. As GABA is heavily overlapped by other metabolites, a J-editing sequence (MEGA-PRESS) was used with a TE=68ms and editing pulses centered at 1.9 and 7.5ppm2. MOIST water suppression was performed. A non-water suppressed scan was also acquired and the water scaled MRS data were quantified for GABA using TARQUIN. An independent sample t-test was used to test for group differences in the concentration of GABA. Linear regression models were used to examine the relationship between cognitive, motor and sensory scores and GABA concentration in these three regions, when adjusting for gender, age and grey matter fraction within the spectroscopic voxel.
Results: SPMS patients showed lower GABA levels in the sensorimotor cortex (mean=1.23±0.35 in patients; mean=1.52±0.47 in controls, p=0.04) and in the hippocampus (mean=1.08±0.35 in patients; mean=1.44±0.50 in controls, p=0.04) between SPMS patients and healthy controls. In patients, lower GABA levels in the sensorimotor cortex correlated with higher motor disability, as measured by the MRC scoring system for muscle strength (regression coefficient [RC]=5.95, 95% confidence interval [CI]=0.014, 11.92, p=0.05) and the 9-hole peg test (regression coefficient [RC]=0.016,95% confidence interval[CI]=0.002, 0.031, p=0.02).
Conclusions: We have demonstrated a significant reduction in the concentration of GABA in the sensorimotor cortex and in the hippocampus of progressive MS patients. The reduced GABA concentration in these regions may reflect neuronal and synaptic loss, and in the sensorimotor cortex it was associated with motor dysfunction.
PS11.4 The loss of neurons over the whole MS neocortex
D Carassiti1, M Papachatzaki1, F Scaravilli1, B Pakkenberg2, K Schmierer1
1Queen Mary University London, Experimental Medicine, Neuroscience and Trauma, London, United Kingdom, 2Bispebjerg University Hospital, Research Laboratory for Stereology and Neuroscience, Copenhagen, Denmark
Background: Neuro-axonal loss appears to be the major substrate of chronic and irreversible functional deterioration in people with multiple sclerosis (pwMS). Significant variation has been reported regarding the degree cortical neuronal loss. Accurate quantification of cell populations including neurons is of fundamental importance to better understand MS cortical pathophysiology and the significance of changes detected using non-invasive techniques, such as brain atrophy using MRI.
Objectives: To quantify the total number of neocortical neurons across the entire cortical grey matter in MS and control brain.
Methods: Formalin fixed brain hemispheres of five people with MS (4 women, one man, aged 74±7 years, disease duration = 30±9 years) and three reference cases (men, age 83±3 years) were studied. Hemispheres were dissected into 1.1 cm thick coronal slices. Neurons were identified on Giemsa-stained 40µm-thick sections (x60 oil immersion) using a microscope equipped with stage controlled by stereology software. The area of interest (AOI) was outlined to include the whole cortex on each section and disectors were placed using a random grid. The total number of neocortical neurons (TNNN) was calculated as NV x VREF in each slab, where NV= neurons counted/volume of dissectors quantified and VREF= AOI x slab thickness (t), adjusted for tissue shrinkage, and multiplied by 2.
Results: TNNN was 14.1 ± 2.9 billion in MS and 23.6 ± 3.1 billion in controls brains (p= 0.078), suggesting an overall neuronal loss of 40%. Strong correlation was detected between TNNN and cortical volume (r= 0.85, p= 0.0082). All brains were quantified using the same frequency of dissectors (mean ± SEM, MS= 466 ± 37; controls= 464 ± 24, p = 0.95).
Conclusions: MS affects the entire CNS. To the best of our knowledge, this is the first study to accurately estimate neuronal loss throughout the MS cortex. The mean TNNN in our (male) controls was very similar to figures previously reported. The apparent 40% reduction of neocortical neurons in pwMS is biased by the fact that 4 out of 5 pwMS were women whilst our control cases were all men. However, the previously reported TNNN in women is 21.4 billion, thus 34% higher than our TNNN in pwMS. Though requiring confirmation in a larger and more balanced cohort, this data shows the loss of functionally important brain cells is massive and suggests strong correlation of TNNN with neocortical volume loss.
PS11.5 Complement activation is associated with synaptic alterations in the multiple sclerosis hippocampus
I Michailidou1, JGP Willems1,2, E-J Kooi3, C van Eden2, JJG Geurts3, F Baas1, I Huitinga2, V Ramaglia1,2
1Academic Medical Center, Department of Genome Analysis, Amsterdam, Netherlands, 2Netherlands Institute for Neuroscience, Department of Neuroimmunology, Amsterdam, Netherlands, 3VU University Medical Center, Department of Anatomy and Neurosciences, Amsterdam, Netherlands
Background: Deterioration of memory function in multiple sclerosis (MS) has been associated with demyelination, loss of synapses and decreased neuronal proteins essential to synaptic plasticity and neurotransmission. The molecular basis of these synaptic alterations is unknown. Accumulating evidence suggest that components of the complement system, C1q and C3, can mediate elimination of synapses in the developing or neurodegenerating brain.
Objectives: To identify evidence of complement activation in relation to demyelination and synaptic alterations in the human MS hippocampus.
Methods: We analysed the expression and localization of C1q and C3 in myelinated and demyelinated hippocampi from post-mortem brains of MS donors with progressive disease, in relation to neuropathological changes, and compared the findings to hippocampus tissue of Alzheimer’s disease (AD) donors and non-neurological controls.
Results: We detected substantial axonal, synaptic and neuronal alterations in both, myelinated and demyelinated MS hippocampi, as detected by loss of SMI312-positive axons and synaptophysin-positive synapses, and increased mitochondrial heat shock protein 70-positive neurons, compared to non-neurological controls. Protein expression of C1q was increased in the MS hippocampus compared to non-neurological controls and localized at neurons and synapses with neurons being the major source of C1qA mRNA, as shown by in situ hybridization. The extent of C3 activation was comparable between myelinated and demyelinated MS, as shown by the substantial consumption of intact C3 compared to non-neurological controls. Deposition of the C3 activation product, C3d, was detected at neurons and synapses. In addition, C1q co-localized with HLA-positive cell processes, suggesting engulfment of C1q-positive synapses by microglia. Further, a significant correlation between C1q and synapses was seen in the myelinated MS hippocampi with progressive disease. Notably, hippocampi from patients with relapsing remitting disease had reduced amounts of C1q and C3d compared to progressive donors. Moreover, MS hippocampi were consistently negative for the terminal complement activation complex (C5b9) in contrast to AD hippocampi, which showed C1q, C3d and C5b9 deposition at amyloid plaques.
Conclusions: These data support a demyelination-independent mechanism of synaptic alterations in MS and suggest an involvement of the C1q-C3 complement axis to hippocampal pathology in progressive disease.
PS11.6 A link between neuronal degeneration and white matter demyelination in multiple sclerosis: vascular supply
L Haider1, T Zrzavy1, S Hametner1, H Lassmann1
1Medical University of Vienna, Center for Brain Research, Neuroimmunology, Vienna, Austria
Background: Magnetic resonance imaging derived data suggest grey matter atrophy to be a localized phenomenon of deep grey matter and certain cortical areas. In correlative approaches grey matter atrophy appeared to be largely independent from measurements of total white matter atrophy and the origins of neurodegeneration remain uncertain. Experimental evidence suggests hypoxia as a key factor in tissue destruction in multiple sclerosis.
Objectives: In arterial watersheds, decreased oxygen tension may facilitate demyelination and neurodegeneration. Our study focused on the distribution of demyelinating lesions and neurodegeneration in 51 multiple sclerosis patients.
Methods: We performed immunohistochemistry for SMI31 (phosphorylated neurofilament, a markers of neurodegeneration) and myelin proteins in 109 routine sized histological sections of 13 acute, 2 relapsing remitting, 25 secondary progressive, 10 primary progressive and one subclinical multiple sclerosis patient and 19 double hemispheric sections for cell counting and quantitative computer based probability maps.
Results: Cortex adjacent to large destructive subcortical- or leucocortical lesions carries significantly more neuronal somata reactive for SMI 31 than control-, or not lesioned multiple sclerosis patients cortex.
White matter demyelination is significantly increased in white matter areas that are border zones of the major cerebral arteries.
Probability maps for SMI 31 reactivity reveal neurodegeneration to be primarily located in sulci at the border zone between the arterial supply territories of major cerebral arteries, within deep grey matter nuclei and the hippocampus.
Conclusions: White matter lesions and neurodegeneration may be primed to areas of decreased oxygen tension in patients with multiple sclerosis, where atrophy has been localized by previous magnetic resonance imaging studies.
PS12 - Study design and endpoints
PS12.1 Patient-centered care: patient-reported health status and self-administered performance testing
RA Bermel1, RA Rudick2
1Cleveland Clinic, Mellen Center, Cleveland, OH, United States, 2Biogen Idec, Development Sciences, Cambridge, MA, United States
This presentation will focus on two approaches to standardized clinical outcomes assessment for MS patient care and clinical research. The Knowledge Program (KP) - was instituted within the Cleveland Clinic Neurological Institute. Each patient completes a set of validated functional status measures and patient reported outcomes prior to their clinic visit. MS patients complete the EQ5D, PHQ9, and MSPS. Data is available in the EHR for use during the patient visit, and simultaneously entered into a research database. KP has gained widespread support by clinicians and patients. Data from 20,000 patient visits per year has been collected, supporting a variety of clinical research studies. The Multiple Sclerosis Performance Test (MSPT) - was developed to provide quantitative neuroperformance data in a cost-efficient way. The MSPT, which runs on an iPad, consists of a number of tests designed to simulate the MSFC. iPad based testing was compared with traditional technician-based testing in 51 MS patients and 49 HCs, and shown to be valid, based on test-retest precision, correlation between iPad and technician based testing, sensitivity to MS and MS severity, and correlation with patient-reported outcomes (in press, Rudick, et al. Journal of Visual Experimentation, 2014). The MSPT can be self-administered, eliminating the need for clinician or technician testing.
For real world studies, new methods will be required to obtain reliable, meaningful, patient-centered data from patients participating in health care. The examples presented here can enable such data collection by using technology, and by placing the patient at the center of data collection, freeing up the clinician to spend their time discussing patient concerns, and making medical decisions, as opposed to collecting outcomes data. Patient reports and neuroperformance measures could then be combined with quantitative MRI data, integrated, and presented to the clinician using visualization software. Graphical user interfaces demonstrating an individual patient, contextualized to reference populations will enable individualized assessements, which in turn can be used for data-driven medical decisions. Systems to integrate, visualize, and contextualize the data will be illustrated. Ultimately, methods of this sort will transform the patient experience and simultaneously enable real world research.
PS12.2 Pragmatic clinical trials and observational studies
M Trojano
1
1Neuroscience and Sense Organs, Department of Basic Medical Sciences, Bari, Italy
In the complex scenario of Multiple Sclerosis (MS) treatment, studies addressing strategies to achieve a “personalized treatment” are becoming imperative. Results from both experimental studies, such as randomized controlled trials (RCTs) and pragmatic clinical trials (PCTs), and non-experimental studies, as retrospective and prospective non randomised observational trials (NROTs), are needed because each of these studies answers to different research questions. The purpose of traditional RCT is to answer the question “Can an intervention work under ideal conditions?” However data from RCTs do not always reflect real-world practice and outcomes and they cannot necessarily be assumed to apply to subpopulations not studied in those RCTs. The PCT is the best method for understanding the effectiveness of that therapy in the full spectrum of everyday clinical settings. The research question under investigation is “Can an intervention actually work in real life?”. PCTs are usually prospective, randomised studies and, as opposed to RCTs, use active comparators of the same or different class, broader inclusion criteria, large and diverse patient populations, and a wide spectrum of clinically relevant health outcomes mostly patient-centered. Therefore, PCTs overcome many limitations of RCTs, producing results that can be generalized and applied in routine practice settings. NROTs and registry studies are conducted in situations where experimental research is impractical or not feasible. In these study designs intervention is at the choice of doctors and patients. They include large populations who can potentially benefit from a treatment, or subgroups not typically included in initial RCTs, such as pregnant women, children, or patients with multiple co-morbidities and concomitant medications. Follow-up duration can be long to encompass delayed risks and long-term benefits of a drug and/or of various combinations and sequencing of treatments. They address practical questions such as “Which interventions are most effective for which patients under which circumstances?” The current availability of several worldwide MS registries collecting data on MS treatments represents a unique opportunity for NROTs. This presentation will focus on the value and future roles of various study types and emerging data sources in providing useful information to help physicians in the complex decision-making process of the treatment choice for MS patients.
PS12.3 Defining brain volume cut-offs to predict disability progression in MS: an analysis of a large cohort of relapsing-remitting MS patients
MP Sormani1, L Kappos2, EW Radue3, J Cohen4, F Barkhof5, T Sprenger2,3, D Piani Meier6, D Häring6, D Tomic6, N De Stefano7
1University of Genoa, Genoa, Italy, 2University Hospital, Department of Neurology, Basel, Switzerland, 3Medical Image Analysis Center (MIAC), University Hospital, Basel, Switzerland, 4Cleveland Clinic, Neurological Institute, Cleveland, OH, United States, 5VU University Medical Center, Amsterdam, Netherlands, 6Novartis Pharma AG, Basel, Switzerland, 7University of Siena, Siena, Italy
Background: Brain volume loss (BVL) correlates with the risk of disability progression in patients with relapsing-remitting multiple sclerosis (RRMS) at a group level. Whether BV values can be used on an individual patient basis to predict disability progression has never been evaluated.
Objectives: To define, in a large cohort of RRMS patients enrolled in three fingolimod phase III clinical trials, BV cut-offs at baseline, which can predict on-study disability progression.
Methods: The individually expected BV normalized for head size (NBV) was calculated based on the baseline characteristics of the patient (age, sex, T2 volume, Expanded Disability Status Scale [EDSS], disease duration) and the study identifier, using a multiple regression model (pooled intent-to-treat populations; FREEDOMS, N=1272; FREEDOMS II, N=1083; TRANSFORMS, N=1280). Patients were classified into three groups based on the differences between observed and expected NBV values: Medium BV (M-NBV): within ± 1 standard deviation (SD), Low BV (L-BV) : > 1 SD below mean and High NBV (H-NBV) :> 1 SD above mean. The risk of 3-month confirmed disability progression and the treatment effect over 2 years were analyzed.
Results: NBV data was available from 3592 patients (mean [SD] NBV: 1520cm3 [82]). In the pooled dataset, NBV depended significantly (all, p< 0.001) on the following baseline variables: T2 volume (t=−21.8), age (t=−21.4), EDSS (t=−7.0), disease duration (t=−6.9), and sex (t=−5.7). NBV values adjusted for these variables were comparable across trials. The SD from the distribution of NBV deviations was 68 cm3. On this basis, L-NBV, H-NBV and M-NBV patient groups included 532 (15%), 543(15%) and 2517 (70%) respectively. In the placebo group (n=770), patients with H-NBV had the lowest risk of disability progression over 2 years (16%), followed by M-NBV patients (24%) and patients with L-NBV (31%) (HR=1.5 test for trend, p=0.01). A significant effect of fingolimod treatment on disability progression was seen in patients with M-NBV (-38%, p< 0.001) and L-NBV (-50%, p< 0.001).
Conclusions: Individualized cut-offs derived from baseline NBV values adjusted for patients clinical and demographic characteristics may provide prognostic information that can be useful at the individual patient level. The therapeutic effect of fingolimod was evident particularly in patients with higher risk of disability progression determined by brain volume cut-offs.
PS12.4 Postural control analysis in multiple sclerosis with perceptive computing based on Microsoft’s Kinect
JR Behrens1, E Gusho1, S Mertens1, K Otte2, S Mansow-Model2, F Paul1, A Brandt1,2
1NeuroCure Clinical Research Center- Charite- Universitätsmedizin Berlin, Neurology, Berlin, Germany, 2Motognosis UG (haftungsbeschränkt), Berlin, Germany
Background: Postural control is an important key factor for secure and independent mobility. It is restricted in the vast majority of patients with multiple sclerosis (MS). Even if a patient does not yet suffer from functional disability - deficits of balance do already appear in the early phase of MS, but are not detected by standard examination and scoring procedures. Perceptive computing using data from consumer grade 3D sensors like the Microsoft Kinect allows motion tracking in everyday settings and promises exact and relatively low cost motor diagnostics.
Objectives: To develop a reliable and observer-independent method for quantification of postural control in patients with multiple sclerosis using perceptive computing.
Methods: We examined 99 patients with Clinically Isolated Syndrome (CIS) or MS (57 female, 42 male, mean±SD age 44±11 years, median EDSS 2.5) and 60 healthy controls (HC) with a custom built system using Microsoft’s Kinect. Subjects performed three measurements with comfortable, closed and tandem stance, each with eyes open the first 15 seconds and eyes closed the last 15 seconds. Roll speed along the medio-lateral axis, pitch speed along the anterior-posterior axis and sum of 3D movements were calculated. Patients were examined based on the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC). Self-reported walking disability was assessed using the MS walking scale questionnaire (MSWS-12).
Results: Already in comfortable stance with open eyes, MS patients showed significantly higher sum movements than HC (7.52±3.54 cm vs. 5.79±1.95 cm, p< 0.001), pitch speed (0.41±0.22 cm/sec vs. 0.30±0.10 cm/sec, p=< 0.001) and roll speed (0.26±0.15 cm/sec vs. 0.20±0.09 cm/sec, p=0.005). On average, MS patients worsened both with closed eyes as well as with increasing stance difficulty. Best correlations with disease severity and self-reported walking disability were achieved with closed stance and closed eyes for summed 3D movement (EDSS Spearman’s Rho=0.500, p< 0.001; MSWS-12 Rho=0.455, p< 0.001), pitch speed (EDSS Rho=0.478, p< 0.001, MSWS-12 Rho=0.426) and roll speed (EDSS Rho=0.455, p< 0.001; MSWS-12 Rho=0.420, p< 0.001).
Conclusions: Perceptive computing based assessment of postural control was fast, well tolerated and effective in detecting sway differences between HC and MS patients.
PS12.5 Reliability of clinically feasible gait analysis in multiple sclerosis
JJ Sosnoff1, RE Klaren1, L Pilutti1, D Dlugonski2, RW Motl1
1University of Illinois at Urbana-Champaign, Urbana, IL, United States, 2East Carolina University, Kinesiology, Greenville, NC, United States
Background: Gait impairment is ubiquitous in persons with MS, a marker of disability and commonly targeted in rehabilitation. It has been suggested that pressure sensitive walkways are clinically feasible and capable of detecting mild gait impairment in person with MS. However, the reliability of this gait analysis approach is not clear - especially over longer durations (e.g. 6 months) - that are important for clinical practice and research. Indeed, such reliability is critical for clinical decision-making and power analyses for designing randomized controlled trials (i.e., sample size estimates).
Objectives: To determine the reliability and stability of spatiotemporal measures from clinically feasible gait analysis in persons with MS over 6 months.
Methods: We enrolled 86 ambulatory persons (77% female) with MS. Self-reported disability as indexed by patient determined disease steps scale ranged from 0 to 6.0 (median = 3.0). Participants underwent gait assessment twice over 6 months in the absence of any intervention. Gait assessment included two trials of walking at a self-selected pace over a 4.9 m pressure sensitive mat (GAITRITE™). Reliability was based on intra-class correlation coefficients (ICC) and 95% confidence interval (CI) for gait velocity, functional ambulation profile (FAP) score, cadence, step time and double support percentage. Stability was based on paired-sample t-tests.
Results: Double support percentage had the lowest ICC of 0.75 (95% CI = 0.61-0.84), whereas gait velocity, step time, and cadence all had ICC’s of 0.95 (95% CIs = 0.93-0.97. FAP score had an ICC of 0.94 (95%=0.90-0.96)). The t-tests identified that gait velocity was significantly slower at follow-up testing by 7.4 cm/s [t(1,73)=−5.1;p< .05] and this coincided with a reduction in cadence [t(1,73)=−5.4;p< .05] and increase in step time [t(1,73)=3.1;p< .05]. There was no significant change in FAP score or double support percentage over 6-months.
Conclusions: We provide evidence that spatiotemporal gait parameters collected with a clinically feasible pressure sensitive walkway demonstrated good to excellent reliability over a 6-month period. We observed a significant, albeit small reduction in gait speed and related gait metrics over this period.
PS12.6 Evaluation of common criteria of progression of disability in a large observational cohort
T Kalincik1,2, V Jokubaitis1, T Spelman2, D Horakova3, E Havrdova3, M Trojano4, G Izquierdo5, M Girard6, P Duquette6, A Lugaresi7, F Grand’Maison8, P Grammond9, R Hupperts10, C Oreja-Guevara11, E Pucci12, C Boz13, R Bergamaschi14, J Lechner-Scott15, R Alroughani16, V Van Pesch17, G Iuliano18, M Rio19, R Fernandez-Bolanos20, C Ramo21, M Terzi22, T Petersen23, M Slee24, D Spitaleri25, MP Amato26, F Verheul27, E Cristiano28, J Sanchez-Menoyo29, M Fiol30, O Gray31, J Cabrera-Gomez32, S Hodgkinson33, M Barnett34, M Saladino35, S Vucic36, C Shaw37, F Moore38, E Van Munster39, C Rozsa40, P McCombe41, H Butzkueven1, MSBase Study Group
1University of Melbourne, Department of Medicine, Melbourne, Australia, 2Royal Melbourne Hospital, Department of Neurology, Melbourne, Australia, 3Charles University in Prague, Prague, Czech Republic, 4University of Bari, Bari, Italy, 5Hospital Universitario Virgen Macarena, Sevilla, Spain, 6Hôpital Notre Dame, Montreal, QC, Canada, 7University ‘G. d’Annunzio, Chieti, Italy, 8Hôpital Charles LeMoyne, Quebec, QC, Canada, 9Hotel-Dieu de Levis, Quebec, QC, Canada, 10Orbis Medical Center, Sittard, Netherlands, 11University Hospital San Carlos, Madrid, Spain, 12Ospedale di Macerata, Macerata, Italy, 13Karadeniz Technical University, Trabzon, Turkey, 14National Neurological Institute C. Mondino, Pavia, Italy, 15John Hunter Hospital, Newcastle, Australia, 16Amiri Hospital, Kuwait, Kuwait, 17Cliniques Universitaires Saint-Luc, Brussels, Belgium, 18Ospedali Riuniti di Salerno, Salerno, Italy, 19Hospital CUF, Porto, Portugal, 20Hospital Universitario Virgen de Valme, Sevilla, Spain, 21Hospital Germans Trias i Pujol, Barcelona, Spain, 22Mayis University, Samsun, Turkey, 23Aarhus University Hospital, Aarhus C, Denmark, 24Flinders University and Medical Centre, Adelaide, Australia, 25AORN San Giuseppe Moscati, Avellino, Italy, 26University of Florence, Florence, Italy, 27Groen Hart Ziekenhuis, Gouda, Netherlands, 28Hospital Italiano, Buenos Aires, Argentina, 29Galdakao Hospital, Vizcaya, Spain, 30FLENI, Buenos Aires, Argentina, 31Craigavon Area Hospital, Portadown, United Kingdom, 32Centro Internacional de Restauracion Neurologica, Havana, Cuba, 33Liverpool Hospital, Liverpool, Australia, 34Brain and Mind Research Institute, Sydney, Australia, 35INEBA, Buenos Aires, Argentina, 36Westmead Hospital, Sydney, Australia, 37Geelong Hospital, Geelong, Australia, 38Jewish General Hospital, Montreal, QC, Canada, 39Jeroen Bosch Ziekenhuis, ‘s-Hertogenbosch, Netherlands, 40Jahn Ferenc Teaching Hospital, Budapest, Hungary, 41Royal Brisbane and Women’s Hospital, Brisbane, Australia
Background: Confirmed progression of disability is an outcome traditionally used by the trials studying the effect of disease modifying therapy in multiple sclerosis (MS). Given that various definitions of confirmed disability progression are being used, a comprehensive evaluation of their performance in a large population representative of clinical practice at MS centres is needed.
Objectives: To compare performance of various definitions of confirmed progression of MS disability.
Methods: Using MSBase, a large international, observational MS registry, we identified all patients with at least 3 visits with recorded disability quantified with Expanded Disability Status Scale (EDSS). We evaluated various aspects of disability progression criteria:
minimum sustained progression (over 3, 6, 12 or 24 months),
the requirement of sustained progression until censoring (i.e. the end of follow-up),
EDSS step (as 1.5 steps at EDSS 0, and 1 step at EDSS >0 vs. 1.5 steps at EDSS 0, 1 step at EDSS >0 and 0.5 step at >5.5) and
various definitions of baseline EDSS (i.e. the first recorded EDSS vs. the minimum 3-month confirmed baseline EDSS vs. their combination).
In addition, we estimated individual burden of disability in time (and its change) as the area under EDSS-time curve (AUC, and its change relative to baseline).
Results: As at November 2013, 16,368 eligible patients were identified within the MSBase registry. The characteristics of the studied cohort included: 70% females, age 38±11 years (mean±SD), 66% with relapsing-remitting MS, 6% with primary progressive MS, median follow-up duration 5.8 years (quartiles 3.0-9.6), cumulative follow-up 111,263 patient-years. Both treated and untreated patients were included. The median change in the AUC was +0.7 EDSS-years (quartiles -0.7-5.8). The proportions of patients with confirmed disability progression varied between 17% and 47%, with the progression rates of 0.34-1.00 per 10 years, depending on the criterion. The most stringent criteria involved progression confirmed at 24 months, 3-month minimum confirmed baseline EDSS and 1.5-1-step EDSS change.
The least stringent criteria involved progression confirmed at 3 months, first or minimum confirmed baseline EDSS and 1.5-0.5-step EDSS change.
Conclusions: A significant variability exists among disability progression rates based on various definitions of confirmed disability progression. This variability should be considered by randomised trials as well as observational studies.
HT4 - Remyelination
HT4.1 Epigenome-wide studies: what can we learn from them?
P Casaccia
1
1Icahn School of Medicine at Mount Sinai, New York, NY, United States
The epigenome refers to modifications of chromatin components, microRNAs and DNA methylation changes that are induced by the environment (i.e. life style, diet, exercise, smoking, etc.). These modifications have been shown to alter gene expression, independently of any change in DNA sequence. In contrast to genetic information (i.e. DNA sequence is the same in all the cells of the same individual), epigenetic changes are remarkably tissue and cell specific. Our laboratory has been interested in characterizing these changes in rodent models and in post-mortem human brains.
The results of these analyses will be presented, with an emphasis on a better understanding of the potential implications of these findings for remyelination and therapy responsiveness.
HT4.2 Remyelination in the adult central nervous system: mechanisms and perspectives
C Lubetzki
1
1Salpetriere Hospital, Paris 6 University, Paris, France
The influence of remyelination on the prevention of axonal damage and loss has been highlighted by different experimental approaches, as well as by analysis of multiple sclerosis lesions. However, although this repair process is efficient in many experimental models of demyelination, it often fails in MS, leaving denuded, hence vulnerable, axons. Oligodendrocyte progenitor cells (OPCs), disseminated within the adult central nervous system, are the major contributors to remyelination. These immature cells are first activated, then migrate to the demyelinated lesion where they differentiate into oligodendrocytes, before wrapping new myelin sheaths around naked axons. These different steps have to be orchestrated at the right time and the right place to allow successful repair.
To gain insight into the mechanisms involved in activation and recruitment of adult OPCs, we analyzed the gene expression profile of adult OPCs purified by flow cytometry from adult murine PDGF-aR brains and demonstrated that adult OPCs have a transcriptome more similar to that of oligodendrocytes than to neonatal OPCs, but revert to a neonatal-like transcriptome when activated. We then showed that part of the activation response involves increased expression of two genes of the innate immune system, IL1β and CCL2. Using in vitro and in vivo experiments, we demonstrated that OPCs expressing IL1β or CCL2 are more motile, a crucial capacity to enable them to be directed to the demyelinated lesion by guidance cues.
In parallel, we have investigated the influence of guidance cues on the recruitment of adult OPCs and focused on class 3 semaphorins and Netrin 1. We showed that these guidance cues:
are upregulated after demyelination in the adult central nervous system, both in experimental models and in MS lesions;
influence adult OPCs migration/recruitment, with a repellent effect of Semaphorin 3A and Netrin 1, contrasting with an attractant effect of Semaphorin 3F.
Finally, we demonstrated that modulation of OPCs recruitment influence remyelination rate. These proof of concept studies showing that OPC recruitment influence repair, modify the current view on remyelination strategy, as speeding this repair process is crucially needed to prevent irreversible axonal damage.
These different studies pave the way for identification of potential therapeutic targets for repair strategies in multiple sclerosis patients.
HT4.3 Fluorosamine that targets scar components is a novel therapeutic that promotes myelin regeneration and reduces inflammation in demyelination models
M Keough1, J Rogers1, P Zhang1, S Jensen1, E Stephenson1, J Plemel1, M Hurlbert1, C-C Ling1, VW Yong1
1University of Calgary, Calgary, AB, Canada
Background: While there are currently several available disease-modifying immunotherapies for multiple sclerosis (MS), new therapeutics are needed not only to reduce detrimental inflammation but also to enhance the endogenous process of remyelination. Components of the lesion-associated glial scar, including the chondroitin sulfate proteoglycans (CSPGs), are promising drug targets as they are known inhibitors of axonal regeneration as well as remyelination.
Objectives: We assessed the efficacy of a novel, fluorinated analog of N-acetylglucosamine (fluorosamine) to reduce CSPG synthesis following experimental demyelination in order to enhance remyelination. Additionally, we determined if fluorosamine has immunomodulatory properties in an inflammatory demyelinating model.
Methods: Focal toxin-induced demyelination was produced in mice via injection of lysolecithin into the spinal cord dorsal column. Inflammatory demyelination was produced using the experimental autoimmune encephalomyelitis (EAE) model. Animals were treated with fluorosamine after injury and repair was assessed by measuring disability burden and new myelin sheath formation. Cellular mechanisms were verified with isolated cells in culture, including oligodendrocyte precursor cells (OPCs), astrocytes, and splenocytes.
Results: The differentiation and maturation of OPCs is impaired in the presence of a CSPG substrate. Astrocytes produce CSPGs when stimulated in culture, which is perturbed with fluorosamine; after lysolecithin injury, fluorosamine reduces CSPG synthesis, resulting in greater generation of oligodendrocytes and new myelin sheaths. Splenocytes in culture are activated in response to CSPGs and their proliferation rate is diminished in the presence of fluorosamine; after induction of EAE, fluorosamine reduces disease scores when treatment is initiated from onset of clinical signs or from peak clinical disability.
Conclusions: CSPGs are a barrier to endogenous remyelination after injury. Reducing their synthesis with fluorosamine provides a more conducive environment to new myelin formation. The additional immunomodulatory properties of fluorosamine may have an added benefit of reducing new lesion formation and disease burden. We believe that a two-pronged approach of immunomodulation and remyelination by overcoming lesion-associated CSPGs expands the therapeutic options in MS.
HT5 - Inflammation and neurodegeneration
HT5.1 Metabolomics, mitochondria and energy imbalance in MS
PA Calabresi
1
1Johns Hopkins University, Neurology, Baltimore, MD, United States
A common disabling symptom of MS is fatigue, yet the mechanisms underlying fatigue remain poorly understood. Both inflammation and neuronal dysfunction likely contribute to the sensation of fatigue, and the molecular basis for this process is beginning to be elucidated through studies of metabolic disarray in the blood and CNS. Demyelination increases energy demands in axons, which results in a short-term mitochondrial proliferative response that temporarily compensates for the increased demands. However, this strategy ultimately fails if demands exceed mitochondrial function and the resulting ATP deficit causes ionic and oxidative stress leading to axonal degeneration.
The importance of metabolism in immune cells was also highlighted in recent studies, which showed that effector memory cells switch from oxidative phosphorylation to aerobic glycolysis in a well-described process called the Warburg effect. The switch to glycolysis was initially thought to be a consequence of mitochondrial damage, but recent data suggest glycolysis may provide an advantage to proliferating cells by facilitating effector functions. A recent metabolomic study uncovered 44 metabolites and six major metabolic pathways that were altered in EAE and correlated with disease severity, suggesting several novel therapeutic targets related to bioenergetics of immune cells.
Glycolysis is also relevant in the CNS where lactate is a major source of energy for neurons. Lactate is shuttled to neurons by the monocarboxylate transporter (MCT-1), which is highly expressed on oligodendrocytes. Remarkably when MCT-1 is conditionally deleted or repressed in the oligodendrocytes of mice, the impaired transfer of lactate to neurons results in neurodegeneration confirming their critical role in neuronal survival. Further, this result suggests that axonal degeneration may precede demyelination and can occur as the result of dysfunctional oligodendrocytes.
Accurate and sensitive methods to measure important metabolites are critical to further understanding of the cellular processes involved in pathogenesis. Metabolomics has been facilitated by the increased availability of high throughput, sensitive, yet highly specific mass spectrometry methods. I will discuss recent data regarding metabolism and energy demands in both the peripheral blood and the CNS, which may provide important clues to disease pathogenesis and also novel avenues for therapeutic intervention in MS.
HT5.2 Parasitic infections and MS
J Correale
1
1FLENI, Neurology, Buenos Aires, Argentina
MS incidence has significantly increased during the second half of the 20th century, generating considerable interest in analyzing the basis for this rise in the developed world. Particular emphasis is being placed on the role infections might play in exacerbating or preventing disease onset. Epidemiological data suggest that improvement in sanitation conditions and reduced exposure to infection might explain, at least in part, these changes. The hygiene hypothesis is not new and is often used to explain the increasing incidence of allergies and other autoimmune diseases observed at present. Because helminths are powerful modulators of host immunity, some authors hypothesize that reduced parasite exposure due to improved hygiene conditions may favor MS development. Supporting these findings, recent investigations demonstrate a dichotomous relationship between regional distribution of MS and that of the parasite Trichuris trichiura, a common human pathogen. In line with these observations, our group demonstrated that helminth-infected MS patients showed significantly lower number of relapses, minimal changes in disability scores and significantly lower disease activity on MRI compared to uninfected individuals with MS. Parasite-driven protection was associated with induction of regulatory T cells secreting IL-10 and TGF-β, as well as of CD4+CD25+ FoxP3+ T cells displaying significant suppression function, while simultaneously inhibiting T-cell proliferation and suppressing IFN-γ and IL-12 production. In addition, helminth infections also induced IL-10-producing regulatory B cells, capable of dampening the immune response. Interestingly, when some of these patients received antihelminthic drug treatment for worsening of parasite-associated symptoms, significant increase in clinical and radiological MS activity was observed. Flares were accompanied by substantial increase in IFN-γ and IL-12 producing cell numbers and a decline in IL-10, TGF-β and regulatory T cells, providing evidence of direct suppression of the autoimmune response as a result of helminth infection.
During this presentation I will discuss epidemiological, experimental, clinical and molecular data supporting the protective role of helminthes against MS. Better understanding of host-parasite interactions caused by specific parasite molecules with immunomodulatory effects will help combat allergies and autoimmune disease without the price of untoward infection as a side-effect.
HT5.3 Neuro-axonal damage in MS may be mediated by interaction of innate immunity and anti-axonal antibodies
JD Black1,2, MS Freedman1,2,3
1University of Ottawa, Biochemistry, Microbiology & Immunology, Ottawa, ON, Canada, 2Ottawa Hospital Research Institute, Neuroscience, Ottawa, ON, Canada, 3Ottawa Hospital, Neurology, Ottawa, ON, Canada
Background: There are many purported mechanisms of immune-mediated damage to central nervous system (CNS) neurons and axons involving both adaptive and innate immunity. We have been interested in the potential role of γδ T-cells in MS immunopathogenesis. Axon-specific neurofascin (Nfasc) antibodies are found particularly in MS serum and cerebrospinal fluid (CSF). Antibodies that may not be directly pathogenic can bind to Fc receptors (FcR) on innate immune cells, such as γδ T-cells, and mediate damage via a mechanism termed antibody-dependent cellular cytotoxicity (ADCC).
Objectives: To investigate a possible role for γδ T-cells and anti-Nfasc antibody in mediating neuro-axonal injury via ADCC.
Methods: Anti-Nfasc antibodies were quantitated by ELISA in the CSF of MS patients. HeLa cells were transfected to express Nfasc-186, and used as targets for γδ T-cell-mediated ADCC assays in the presence of MS patient-derived anti-Nfasc antibodies.
Results: CSF anti-Nfasc antibody titers were elevated in relapsing/remitting MS compared to other neurological disease (OND) controls (p< 0.001). Most of the anti-Nfasc antibody was of the IgG1 and IgG2 isotype (i.e., not superior activators of complement). When co-cultured with FcR-bearing (CD16+) γδ T-cells in the presence of MS patient-derived anti-Nfasc antibodies, the % specific lysis of the transfected HeLa cells was increased by nearly 2 orders of magnitude compared to the non-transfected cells, indicating specific cytolytic kill via ADCC.
Conclusions: We demonstrate that both γδ T-cells and anti-Nfasc antibody can come together to mediate damage to Nfasc-expressing target cells via ADCC. Since both are present in the CNS of MS patients, this offers an additional mechanism whereby neuro-axonal injury can be mediated by cells of the innate immune system in the presence of even non-pathogenic antibody.
HT6 - Society and MS
HT6.1 The interaction among patients and their advocates, medicine, science, the media, social media, politics, and granting agencies: the complicated new world of medicine in the Facebook era in which anecdotes can trump reason and science, and in which millions of dollars must be expended to disprove biologically implausible hypotheses
M Rasminsky
1
1McGill University, Neurology and Neurosurgery, Montreal, QC, Canada
Until recently, new purported treatments for MS have mostly come and gone under the radar of public attention. This is no longer the case. The history of so-called chronic cerebrospinal venous insufficiency (CCSVI), a new postulated cause of MS, offers a striking example of the now complex interactions among the various players enumerated above. The CCSVI saga illustrates how such interactions can play a major role in determining public attitudes and allocation of resources, and should serve as a cautionary tale in relation to other putative but questionable treatments for MS and other diseases that may surface in the future.
The superficially attractive idea that CCSVI was a treatable cause of MS had a particularly warm reception in Canada, one of the world’s highest risk areas for MS, after its introduction to the general public by a vigorously advertised news magazine presentation on a national TV network, newspaper and magazine stories, and subsequent wide dissemination on the internet. The public pressures brought to bear by this publicity inexorably led to the funding by the Canadian and American MS Societies of several studies to determine if CCSVI in fact exists in patients with MS, and the subsequent funding by the Canadian MS Society and the Canadian Institutes of Health Research of a multi-centered study to assess the effects of treatment of CCSVI.
Several factors account for the enthusiasm for CCSVI and the generation of enormous pressures to fast track its study: 1) the understandable frustration of MS patients with what is perceived as the slow rate of progress in finding a definitive cure for MS; 2) the attractiveness of an apparently simple explanation for a complex problem; 3) suspicion among some members of the MS patient community of the motives of physicians prescribing expensive drugs to treat MS; 4) a vigorous and highly penetrant MS social network; 5) the perception by some advocates for MS patients that government, responsible for health care in a single payer system, would be susceptible to public pressures; 6) the irresponsibility of elements of the media in publishing ostensible news stories that walked close to or over the line of advocacy journalism.
MS physicians have a responsibility proactively but respectfully to address with patients the implausibility of panaceas poorly grounded in any biologic rationale, while acknowledging that the long-term efficacy of the promising new disease-modifying therapies is as yet unproven.
HT6.2 Patients as partners in clinical research - Does the Internet harm or help?
P Wicks
1
1PatientsLikeMe, Cambridge, MA, United States
Since the invention of the Mosaic web browser in 1993 the Internet has evolved to a consumer-focussed web of specialised services across digital devices, with great benefits for medical education, patient support groups, and advocacy. Yet the stereotype remains of the “Internet-savvy patient” who brings reams of printout with them to their clinical appointment to enquire after exotic therapies of dubious origin or discuss scientific theories without possessing the required technical skills.
Fortunately, the advent of “Patient Powered Research Networks” (PPRNs) has advanced the field considerably in a short space of time. What was once a series of narrative anecdotes swapped between anonymous message boards and blogs is now a structured quantitative dataset supported by medical ontology, with capture of relevant demographics, treatments, symptoms, and validated outcomes that can be combined together to create datasets high enough in quality to be published in peer-reviewed scientific journals. Furthermore because such PPRNs have the potential to display complex medical data in simple and customisable graphical interfaces, patients are increasingly understanding the context of their own condition over time (improving self-management) and understanding the challenges in conducting clinical research.
When seeking to understand the burden of disease, developing new patient reported outcomes (PROs) or gaining feedback on clinical trial protocols, having rapid access to hundreds or even thousands of patients research participants can vastly accelerate research. A more intriguing possibility lies in the potential of truly participant-led research (PLR) where patients themselves conceive a scientific question, harness other patients like them in a PPRN, and with sufficient support from software and technical experts can conduct their own scientific research studies - examples include the lithium study in ALS.
The widespread use of smartphones with integrated sensors such as accelerometers and GPS may provide new forms and channels of data with which to assess the efficacy of treatments, and it may well be that in bringing together the high touch clinical visit and the high tech digital device that patients themselves will be our most effective champions to advance the field. Such potential is not without its own challenges, including privacy concerns, data quality, ethical oversight, business models, and regulatory hurdles, but the benefits may be great.
HT6.3 Parents’ experience of pediatric multiple sclerosis
D Rintell1, T Cross2, A Shanks1, C Fico1, L Duffy3, S Camposano3, T Chitnis1
1Massachusetts General Hospital, Partners Pediatric Multiple Sclerosis Center, Boston, MA, United States, 2University of Illinois at Urbana-Champaign, Children and Family Research Center, Urbana, IL, United States, 3Boston Childrens Hospital, Boston, MA, United States
Background: The onset of MS occurs before the age of 18 in app.5% of patients. A growing literature has reported on the psychosocial sequelae of Pediatric Onset MS (POMS) (Weisbrot et al 2014), but the experience of parents of POMS patients has not been previously descirbed.
Objectives: Since so little is known about parents of children with POMS, we conducted a qualitative, interview-based study to describe parents’ experience, in order to inform clinicians who provide medical and psychosocial care to this population, and to generate hypotheses about this population to be utilized in further research.
Methods: A community-based participatory research model was employed (Berge, Mendenhall, & Doherty, 2009). A focus group of parents of POMS patients who are now young adults was convened to generate interview questions generate interview questions to capture the experience of parents of POMS. 20 interviews with parents of children and teens with MS were conducted during the Spring of 2014, and analyzed using the methodology of thematic analysis proposed by Braun and Clarke (2006).
Results: Preliminary Results:
First symptoms:
Symptoms cause parents to “think the worst”
Some relieved at first by dx of MS
Varying time to diagnosis, longer time more difficult
Dealing with the Diagnosis:
Parents had a traumatic reaction to diagnosis
Parental anxiety and sleep problems
Attempt to continue with usual activities
Disclosing diagnosis to others was difficult
Living with MS:
Prominent fears about the child’s future
Disabled adults with MS frightened parents
Teen autonomy vs dependence
Sibs often receive reduced attention
Parents’ tendency to “smother” children
School issues common
Interactions with Health Care Providers:
Frustration about time to diagnosis
HCPs did not expect MS, unfamiliar with POMS
Need to try a number of HCPs
Conclusions: Parents have a strong reaction to their child’s diagnosis of MS and are deeply affected by living with MS over time. Parents must manage family issues while negotiating treatment and care with child and adolescent patients. Treatment should focus not only on the child/adolescent patient, but on the family unit.
