CT volume/density ratio as the marker of ischaemic brain injury

OBJECTIVES

We believe that the CT volume/density ratio (VDR) of infarcted area reflects the degree of brain tissue damage during ischaemic stroke (IS).

PATIENTS AND METHODS

Forty six patients with IS were prospectively enrolled into the study. CT scan was performed on days 1 and 10 of hospitalization. S100BB serum level, gelatinase activities (MMP-2 and MMP-9) and neurological examination (NIHSS) were performed on days 1, 5 and 10 of IS. After 3 months, 42 patients were examined by functional disability scales: Barthel index (BI) and modified Rankin scale (mRS).

RESULTS

The VDR of ischaemic focus correlated well with the average S100BB serum level, MMP-9 serum activity and NIHSS score. The weak but statistically significant relationships were noticed between the VDR vs BI and mRS estimated 3 months after stroke.

CONCLUSION

VDR reflects well the damage ratio of brain tissue during IS. In addition, the study underlines the relationship between VDR vs patients' neurological status and disability after IS.

Total tau and S100b proteins in different types of multiple sclerosis and during immunosuppressive treatment with mitoxantrone

PURPOSE

Brain-specific proteins are biochemical markers of neurodegeneration. The aim of this study was to estimate the role of biomarkers in neuronal and glial damage as a potent marker of efficiency of immunosuppressive treatment.

MATERIAL AND METHODS

The levels of total Tau protein (tTau) and S100b protein were measured using the ELISA method in serum and cerebrospinal fluid (CSF) of 30 patients with RRMS, 24 patients with SPMS and 30 healthy subjects. Additionally, serum levels of tTau and S100b were assayed every 6 months during the 24-month mitoxantrone therapy.

RESULTS

In CSF and serum of patients with MS, both tTau and S100b were increased compared to control group; however, no significant difference was found between respective MS types. In serum of mitoxantrone-treated patients, both proteins showed to decrease after 24 months, yet the difference was statistically significant only for S100b.

CONCLUSIONS

CSF levels of tTau and S100b are elevated in patients with MS and can reflect an axonal and glial pathology. Measurement of serum concentrations of S100b may be useful for monitoring immunosuppressive therapy and may support clinical assessment. In contrast, tTau concentration did not prove to be a useful marker of mitoxantrone therapy.

A randomized, double-blind, placebo-controlled, parallel-group, enriched-design study of nabiximols* (Sativex(®) ), as add-on therapy, in subjects with refractory spasticity caused by multiple sclerosis

BACKGROUND

  Spasticity is a disabling complication of multiple sclerosis, affecting many patients with the condition. We report the first Phase 3 placebo-controlled study of an oral antispasticity agent to use an enriched study design.

METHODS

  A 19-week follow-up, multicentre, double-blind, randomized, placebo-controlled, parallel-group study in subjects with multiple sclerosis spasticity not fully relieved with current antispasticity therapy. Subjects were treated with nabiximols, as add-on therapy, in a single-blind manner for 4weeks, after which those achieving an improvement in spasticity of ≥20% progressed to a 12-week randomized, placebo-controlled phase.

RESULTS

  Of the 572 subjects enrolled, 272 achieved a ≥20% improvement after 4weeks of single-blind treatment, and 241 were randomized. The primary end-point was the difference between treatments in the mean spasticity Numeric Rating Scale (NRS) in the randomized, controlled phase of the study. Intention-to-treat (ITT) analysis showed a highly significant difference in favour of nabiximols (P=0.0002). Secondary end-points of responder analysis, Spasm Frequency Score, Sleep Disturbance NRS Patient, Carer and Clinician Global Impression of Change were all significant in favour of nabiximols.

CONCLUSIONS

  The enriched study design provides a method of determining the efficacy and safety of nabiximols in a way that more closely reflects proposed clinical practice, by limiting exposure to those patients who are likely to benefit from it. Hence, the difference between active and placebo should be a reflection of efficacy and safety in the population intended for treatment.

[Processes of free radical lipid peroxidation with a particular regard to the role of paraoxonase-1 in the pathogenesis of multiple sclerosis]

Oxidative stress is an imbalance between free radicals production and antioxidant defences. Reactive oxygen species (ROS) and reactive nitrogen species (RNS) can attact and demage a variety of critical biological molecules, including lipids, essential cellular proteins and DNA and may be exert in pathogenesis of many disorders. Products of lipid peroxidation can be easily reliably detected in biological fluids and tissues, yielding sensitive and specific signals of lipid peroxidation occurred in vivo. Those products are: isoprostanes (isoP) dimalonealdehyde (MDA), 4-hydroxynonenal (4-HNE). Paraoxonase-1 (PON-1) play a key role in defence of lipid peroxidation. PON-1 is an serum enzyme bound up with high density lipoproteins (HDL). The aim of this work is to discuss the role of oxidative stress in the pathogenesis of multiple sclerosis.

Some markers of neuronal damage in cerebrospinal fluid of multiple sclerosis patients in relapse

In this paper the performance of cerebrospinal fluid (CSF) protein biomarkers important for monitoring damage of brain astrocytes and neurons for MS is reviewed. We estimated neurofilament, tau and phospho-tau proteins, β-APP, Aβ, S-100B and neuron-specific enolase in CSF of MS patients during relapse. We noted elevation of neurofilament, tau and phospho-tau proteins, S-100B, neuron-specific enolase and c-terminal epitopes of β-APP; concomitantly decrease of Aβ was observed. These CSF biomarkers for MS relapse should reflect the central pathogenic processes in the brain, i.e., axonal and neuronal degeneration.

[Efficacy and tolerability of dose-escalation with generic gabapentin--a multicenter, non-interventional study]

The aim of this study was to determine the efficacy and tolerability of 1800-2400 mg/day of generic gabapentin (Gabapentin Teva) as add-on treatment for refractory partial - onset epilepsy. This was a multicenter, open-label, dose-escalation study of patients with refractory epilepsy (median age of 45.5 years [41-50; 25-75% percentile range], male 45.6%, female 47.8%). The inclusion criteria were insufficient partial-onset epilepsy control, defined as at least 1 seizure per month, while on adjunctive therapy with gabapentin used on daily doses below 1200 mg. The baseline seizure number was assessed over 3 months of observation in patients being on stable doses of their AED therapy and those subjects who met the inclusion criteria were enrolled into the study by their neurologist (Visit 0). Subsequently, patients were seen, and their data were evaluated at Visit I i.e. after the target dose of 1800 mg per day was achieved (mean duration of 3.6 [0.1-28.3] weeks) and 4 weeks later at Visit II, after the target dose up to 2400 mg per day. Primary efficacy was assessed by seizure frequency (number/month). Tolerability was assessed by adverse events and clinical evaluations. All the study periods were completed by 916 patients. A substantially lower median seizure frequency was observed at all gabapentin dosing periods (visit I - 2.0 [0-40] seizures per month and visit II - 1.0 [0-13] seizures per month; median and range) compared with the baseline period (3.0 [1-20] seizures per month) (Wilcoxon test p<0.001). In addition, the gradual increase of GBP dose led to raising proportion of patients rendered seizure free (Visit I - 1.1% and Visit II - 28.5%) compared with the baseline period 0.0% (McNemar test p<0.001). The dose escalation with GBP was well tolerated by the majority of patients. The most common adverse events during visit II were somnolence (2.8%) and dizziness (1.8%). In conclusion, gabapentin dose escalation to a dose range of 1800-2400 mg/d over 8 [1-32] week period proved to be an effective and well tolerated in patients with insufficient seizure control on lower doses with partial-onset epilepsy.

Impact of cladribine on soluble adhesion molecules in multiple sclerosis

BACKGROUND

Soluble forms of vascular cell adhesion molecule-1 (VCAM-1), intracellular adhesion molecule-1 (ICAM-1) and E-Selectin play a role in the regulation of blood-brain barrier damage and represent markers of the clinical course of multiple sclerosis (MS) and magnetic resonance imaging activity. We determined sICAM, sVCAM and sE-Selectin concentrations in the cerebrospinal fluid (CSF) and serum of patients with remitting-relapsing multiple sclerosis before and after cladribine treatment as well as in a control group.

METHODS

We examined 17 patients diagnosed according to McDonald's criteria. Thirteen healthy age-matched subjects served as controls. The ELISA method was used to measure sICAM-1, sVCAM-1 and sE-Selectin.

RESULTS

The concentration of sICAM and sE-Selectin decreased in sera (difference between patients and controls was statistically significant, in the former P < 0.04, in the latter P < 0.0003) but not in the CSF of MS patients after cladribine treatment.

CONCLUSIONS

The reduction in sICAM and sE-Selectin concentrations after cladribine treatment indicates an immuno-suppressive effect of the drug. The changes in levels of sICAM and sE-Selectin after cladribine treatment reflect disease activity and indicate a reduction in the inflammatory reaction.

Matrix metalloproteinase-9 contributes to the increase of tau protein in serum during acute ischemic stroke

Previous studies indicate that tau protein, a marker of damage to neurons, is present in the serum of healthy patients at a concentration approximately 40 percent that of patients with ischemic stroke We assumed that increased serum activity of gelatinases (matrix metalloproteinase [MMP]-2 and MMP-9) can influence the level of tau protein in serum, probably due to disruption of the blood-brain barrier. We obtained blood sera from 31 patients admitted within the first 24 hours of ischemic stroke on days 1, 5 and 10, following the onset of stroke. Tau protein was detected in the serum of 12 patients (38.7 percent). The highest MMP-9 activity was recorded on day 5 (p < 0.05). Serum gelatinase activity did not differ between tau protein-positive or -negative individuals. However, a high degree of correlation between mean MMP-9 activity and the maximum tau protein level was observed for patients with detectable tau protein (r = 0.71, p = 0.009). Our study suggests that MMP-9 can increase the tau protein level in the sera of patients during acute ischemic stroke.

Immunomodulatory effects of vitamin D on monocyte-derived dendritic cells in multiple sclerosis

In order to evaluate the effects of vitamin D3 on monocyte-derived dendritic cells (DCs) of relapsing-remitting multiple sclerosis patients, DCs differentiation and maturation were evaluated in vitro based on surface phenotypic changes. The expression of CD14, CD83, CD1a, CD80, CD86, CD206 and C209 was analysed by fluorescence-activated cell sorting. The results reveal that vitamin D3 inhibits both the differentiation and maturation of DCs. Moreover, inhibits the secretion of IL 23/12p40 and increases the secretion of CCL2. The data suggest that one of the mechanisms of the beneficial action of vitamin D3 in multiple sclerosis may be associated with its influence on DCs.

Serum bilirubin and uric acid levels as the bad prognostic factors in the ischemic stroke

Bilirubin (Bil) and uric acid (UA) are the endogenous antioxidant compounds possibly involved in the pathogenesis of ischemic stroke (IS). Our goal was to find the relationship between serum Bil and UA levels with clinical presentation and outcomes of patients suffering from IS. Forty-three patients (mean age: 71.9 years, +/- 12.1; women: 48.8%) with confirmed IS were enrolled. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS) after 1, 3, 5, and 10 days and functional disability was assessed three months after stroke onset using the Barthel Index (BI). Serum Bil and UA levels were measured 1, 3, 5, and 10 days after stroke. The difference between NIHSS scores from days 1 and 10 (improvement ratio) inversely correlated with the average UA serum level (r = -0.48, p < .01) but not with the average Bil level. Negative correlations were observed between the BI measured three months after stroke compared to the average Bil serum level (r = -0.5, p < .01). However, no relationship between BI and UA level was observed. Our results indicated that Bil and UA levels are poor prognostic factors for ischemic stroke.

Free radical peroxidation products in cerebrospinal fluid and serum of patients with multiple sclerosis after glucocorticoid therapy

Multiple sclerosis (MS) patients were found to have elevated thiobarbituric acid reactive material levels, increased soluble sulfhydryl groups and reduced protein sulfhydryl groups in cerebrospinal fluid and serum, and slightly reduced superoxide dismutase in serum, which suggested disease activating free radical peroxidation. Moreover, levels of these varied across methylprednisolone (MP) therapy. We observed significant differences in the levels of peroxidation products between MS patients and controls. These changes were most evident in relapse. After MP therapy, levels of these indicators approached control values, especially in the remission period. Our findings suggest that MP protects against free radical attack.

B-type natriuretic peptide as a marker of subclinical heart injury during mitoxantrone therapy in MS patients--preliminary study

The aim of this study was to evaluate the plasma level changes of B-type natriuretic peptide (BNP), biochemical marker of heart failure, and echocardiographic parameters during mitoxantrone treatment in 22 multiple sclerosis (MS) patients (8 males, 14 females, mean age 37.1+/-6.6). Mitoxantrone (after mean cumulative dose of 58.0+/-7.0 mg/m(2)) did not alter left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), posterior wall thickness (PWT) and left ventricular end-diastolic volume (LVEDV). However, mean plasma level of BNP raised from 14.53+/-3.29 pg/ml at the baseline to 16.79+/-3.05 pg/ml and 18.83+/-4.90 pg/ml (P<0.01) after mean mitoxantrone dose of 30.7+/-5.9 mg/m(2) and 58.0+/-7.0 mg/m(2), respectively. These results strongly suggest subclinical myocardial dysfunction in mitoxantrone-treated group. We assume, that low-cost, repeated BNP measurements may be a good alternative for detection of early subtle myocardial injury in MS patients during routine mitoxantrone therapy.

Effect of parenteral cladribine on relapse rates in patients with relapsing forms of multiple sclerosis: results of a 2-year, double-blind, placebo-controlled, crossover study

Objective

This randomized, 2-year, double-blind, placebo-controlled, crossover study evaluated cladribine for relapsing forms of multiple sclerosis.

Design

Patients ( n = 84) received seven 5-day courses of subcutaneous cladribine at 5 mg/day (group A) or placebo (group B) in year 1; treatment was reversed in year 2.

Results

Cladribine was well tolerated and associated with a favorable safety profile. Mean Expanded Disability Status Scale scores remained stable. In group A, mean relapse rates were 0.15 in year 1 (cladribine) and 0.42 in year 2. In group B, relapse rates were 0.61 in year 1 and 0.50 in year 2 (cladribine). Patients required fewer steroid courses during cladribine periods. The therapeutic efficacy of cladribine was associated with a sustained reduction in lymphocyte count.

[Validation analysis of selected psychometric features of Polish version of Modified Fatigue Impact Scale--preliminary findings]

BACKGROUND AND PURPOSE

Fatigue is one of the most frequent and most disabling symptoms in multiple sclerosis (MS), disturbing patients' daily life. The Modified Fatigue Impact Scale (MFIS) is composed of 21 items; it evaluates the impact of fatigue on three dimensions of quality of life of patients with multiple sclerosis: physical, cognitive and psychosocial. MFIS is easy and quick to perform. The patient scores between 0 and 84 points - the higher the score, the stronger the impact of fatigue on the patient's quality of life.

MATERIAL AND METHODS

One hundred and twenty-two patients with clinically definite MS, according to McDonald criteria, were qualified for the study. All patients had neurological examination and their disability was assessed according to the Expanded Disability Status Scale (EDSS). Patients were asked to complete the MFIS, the Polish version of the generic scale SF-36, and a sociodemographic questionnaire. Clinical data related to the course of the disease and exacerbation of particular symptoms were collected by using a special questionnaire with the participation of a neurologist. Reliability analysis was done by estimating internal consistency of the scale using Cronbach's coefficient alpha. The theoretical validity was assessed by analysing correlations between MFIS scores and SF-36 and EDSS scores as well as convergent validity.

RESULTS

MFIS scale and its subscales correlate with Vitality and Mental Health in the highest degree. According to the strongest correlations between MFIS subscales, Physical Subscale correlates with generic subscales connected with physical functioning, Cognitive Subscale correlates with Mental Health and Psychosocial Subscale with Vitality and Social Functioning.

CONCLUSIONS

Both the reliability and validity of MFIS are satisfactory; the scale seems to be a valuable tool to evaluate the impact of fatigue on quality of life of patients with MS.

Paraoxonase 1 activity in different types of multiple sclerosis

Background

Paraoxonase 1 (PON1) is an antioxidant enzyme bound to plasma high-density lipoproteins and is also present in the brain.

Objective

The aim of this study was to estimate the activity of PON1 in patients with different types of MS.

Methods

The PON1 activity toward paraoxon and phenyl acetate and lipid profile was examined in 40 relapsing-remitting (RR) patients in relapse, in 42 RR patients in remission, in 55 progressive MS patients and in 40 healthy individuals.

Results

PON1 activity did not differ in MS patients compared to control group. PON1 activity in relapse was significantly lower in comparison to the other MS groups. Hypercholesterolemia was observed in MS patients.

Conclusion

PON1 activity does not change in the course of stable and progressive type of MS and is decreased by the relapse of MS.

[Fatigue in multiple sclerosis]

Fatigue is one of the most common symptoms of multiple sclerosis (MS) and is associated with reduced quality of life. The fatigue syndrome is characterized by uncontrollable apathy, exhaustion, fatigability and lack of energy. The mechanisms underlying fatigue in MS are still poorly understood but studies suggest that immune and neuroendocrine factors may play a causative role in the development of fatigue. The first step in management of MS-related fatigue is identifying and eliminating any secondary causes (adverse effects of drugs, infections, sleep disorders, metabolic diseases). As the fatigue syndrome in patients with MS cannot be evaluated objectively in the routine clinical setting, a number of scales have been developed. The Fatigue Severity Scale is a general scale. Additional scales that have been tested in MS include the Fatigue Impact Scale. Therapy of fatigue syndrome consists of modafinil, amantadine, pemoline and non-pharmacological management.

Simvastatin inhibits the increase in serum tau protein levels in the acute phase of ischemic stroke

Our goal was to analyze the effects of treatment with a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (simvastatin, 40 mg/day) on serum S100BB and tau protein levels during the acute ischemic stroke (IS). Twenty four patients with IS were divided into two equal groups; treated and untreated with simvastatin. Blood was obtained four times during acute IS. Tau protein was noticed in six patients from treated group and in five patients from untreated group. The serum tau protein levels significantly increased on the 10th day only in patients untreated with simvastatin (p < 0.05). Simvastatin did not exert an effect on serum S100BB protein levels.

[Oxidative stress in cerebral stroke]

Free radicals are molecules or ions containing non-paired electrons on the external orbit, which ensures their high chemical activity. In systemic homeostasis, free radicals are inactivated by endo- and exogenous antioxidants and do not have destructive effects. The human organism possesses protective mechanisms, i.e. enzymatic systems (peroxide dismutase, glutathione peroxidase, catalase) and non-enzymatic systems (vitamin C and E selenium, coenzyme Q, lipoid acid, bilirubin). Imbalance between continuous production of reactive oxygen forms and their elimination due to enzymatic and non-enzymatic neutralization reactions as well as effects of exogenous antioxidants is defined as oxidative stress. Recent studies demonstrated a significant role of inflammatory processes and oxidative stress in the pathomechanism of cerebral stroke. Increased production of free radicals was observed in both the ischaemic and haemorrhagic strokes and oxidative stress was shown to be one of the causative mechanisms of tissue damage in these diseases. This was confirmed by numerous studies assessing the concentration of oxidative stress biomarkers and levels of plasma antioxidants (enzymatic and non-enzymatic). At present, studies are being carried out about the use of antioxidative substances for the therapy of cerebral stroke. The present study reports current findings concerning oxidative stress issues in patients with stroke.