GABI-balance--a non-interventional observational study on the effectiveness of tiagabine in add-on therapy in partial epilepsy

BACKGROUND AND PURPOSE

Effectiveness of tiagabine (TGB) in open-label studies tends to be higher than in controlled, especially premarketing, studies. This article presents results of an open-label prospective study GABI-balance carried out in Poland and designed to evaluate effectiveness of TGB in add-on therapy of refractory partial and/or secondarily generalized epilepsy.

MATERIAL AND METHODS

Data of 1979 patients (54%--M, 46%--F, mean age 39.2 years) with a mean history of 10.9 years of epilepsy were analyzed. Total initial number of epileptic seizures (n = 12,162) included simple partial seizures (n = 4702; 38.7%), complex partial seizures (n = 7083; 58.7%) and/or secondarily generalized partial seizures (n = 6408; 52.7%). The mean 4-week seizure rate per patient during the period preceding TGB therapy was 6.4. TGB was used over 16 weeks, starting from 5 mg/day with subsequent upwards titration. Results of the treatment were evaluated after 8 and 16 weeks. Assessments included reduction of mean monthly seizure rate, percentage of responders with seizure rate reduction of 50% or more, number of patients who completed the study, adverse effects, and Clinical Global Impression (CGI) scale.

RESULTS

The mean initial seizure rate per patient (6.4) decreased to 3.3 after 8 weeks and to 1.8/month after 16 weeks. The mean initial dose of TGB--9.2 mg/day--was contemporarily increased to 23.4 and 29.9 mg/d, respectively. Percentage of responders with > or = 50% reduction of seizure rate reached 52% after 8 weeks and 77.2% after 16 weeks; 93.7% of patients were still observed after 16 weeks. Adverse effects, reported by 12.7% of patients after 8 weeks and 8.6% after 16 weeks, were mild or moderate. No serious adverse events were observed. The most frequent were somnolence/fatigue, headache/nausea, anxiety/mood disorders. According to treating physicians, add-on therapy with tiagabine in the GABI-balance study was highly effective in more than 80% of patients.

CONCLUSIONS

Our results indicate that in everyday neurological outpatient practice, the add-on TGB therapy in patients with active partial and/or secondarily generalized epilepsy improved efficacy of the treatment with high safety maintained. Higher doses resulted in better effects of the therapy, and adverse effects were mild and less frequent with treatment duration.

Acute stroke-elicited epilepsia partialis continua responsive to intravenous sodium valproate

We present an interesting case of epilepsia partialis continua (EPC) responsive to valproate treatment as an acute manifestation of cortical ischaemia in the course of vasospasm after subarachnoid bleeding A 72-year-old, right-handed woman suffering a subarachnoid haemorrhage complicated with intracerebral left hemispheric haematoma was admitted to our Department of Neurology In the disease course acute vasospasm developed, affecting the contralateral hemisphere Epilepsia partialis continua (EPC) ensued as an acute complication, with clonic jerks of the left side of the face and left upper limb This was related to epileptiform ictal activity which was followed by periodic lateralized epileptiform discharges (PLEDs) from the right frontal lobe When the standard treatment with benzodiazepines and phenytoin failed, the infusion of sodium valproate (VPA) was started This completely abolished seizure activity, bringing an improvement of the patient's neurological condition EPC may be an acute complication of cortical ischaemic damage and valproate intravenous preparation is an interesting alternative for the treatment of this poorly studied condition.

Tumour-like lesions in multiple sclerosis

The presence of tumefactive lesions on magnetic resonance imaging (MRI) in multiple sclerosis (MS) patients can cause diagnostic difficulties. It requires differential diagnosis between tumefactive demyelinating lesion (TDL) and the coexistence of neoplasm; it also implies further management. The precise assessment of such lesions at the first clinical manifestation of the disease is particularly important. We present three cases of MS presenting with tumour-like lesions of the brain. Based on serial MRI studies, stereotactic biopsy and the response to treatment with corticosteroids, the diagnosis of TDL was established in every case.

Cerebrospinal fluid brain specific proteins in relation to nitric oxide metabolites during relapse of multiple sclerosis

This study investigated the cerebrospinal fluid (CSF) levels of ferritin, S100B as biomarkers for glial activation and NfH(SM135)--a biomarker of axonal damage--in relation to nitric oxide (NO) metabolites: nitrate and nitrite (NOx) during acute multiple sclerosis (MS) relapse. Thirty-four relapsing-remitting MS (RR-MS) patients during acute relapse and 12 controls were enrolled. Patients were assessed on Expanded Disability Status Scale (EDSS) and underwent lumbar puncture within two weeks following relapse. Twenty patients were available for further follow-up and were assessed on EDSS 6-8 weeks since the relapse onset. The CSF NOx (P<0.0001), NfH(SM135) (P=0.01) and S100B (P=0.009) but not ferritin (P>0.05) were significantly raised in MS group. There was a significant correlation between CSF ferritin and S100B in RR-MS group (P=0.004). CSF NOx did not correlate with S100B and ferritin in study groups. RR-MS patients with detectable NfH(SM135) levels had higher NOx compared with subjects having undetectable NfH(SM135) (P=0.03). In the follow-up study, raised baseline levels of NOx (P=0.016) or NfH(SM135) (P=0.04) inversely correlated with the clinical recovery grade expressed as relative EDSS change between baseline and follow-up. In conclusion, NO metabolites were increased and because of their correlation with a biomarker of axonal degeneration (neurofilaments) and a measure for clinical disability (EDSS), relapse-related nitrosative stress is likely to be relevant to the development of sustained disability in an individual patient.

[Validation of selected aspects of psychometry of the Polish version of the Multiple Sclerosis Impact Scale 29 (MSIS-29)]

BACKGROUND AND PURPOSE

Because of the small number of self-reported measures of disease impact on the quality of patients' life used in Poland and specific for multiple sclerosis (MS), the aim of the study was to validate selected aspects of psychometry of the Polish adaptation of the Multiple Sclerosis Impact Scale 29, MSIS-29.

MATERIAL AND METHODS

MSIS-29 was first published by Hobart and Thompson in 2001, and consists of 29 questions, the first 20 of which address the physical impact component and 9 assess the psychological impact. The higher the score, the worse is the impact of the disease on quality of patient's life. Validation analysis consisted of translation of the original English version into Polish according to all necessary translation principles and of assessment of convergent validity and internal reliability of the Polish version of MSIS-29. 104 randomly selected patients with definite MS (according to McDonald criteria) were examined: 77 women and 27 men; mean age was 36.9+/-9.4 years, and the mean disease duration was 9.05+/-6.68 years. The disability of the patients was assessed according to the Expanded Disability Status Scale (EDSS). Apart from the examined measure (MSIS-29) subjects were also asked to complete the Functional Assessment of Multiple Sclerosis (FAMS), Beck's Depression Inventory (BDI-II) and the Fatigue Severity Scale (FSS).

RESULTS

MSIS-29 correlated with EDSS, FAMS, BDI-II and FSS. Internal consistency of MSIS-29 was satisfactory.

CONCLUSIONS

Psychometric-statistical analysis showed that the Polish version of MSIS-29 is a valuable measure to examine the impact of disease on patients' life. The studies should be continued taking into account other aspects of psychometry.

[Multiple sclerosis and other autoimmune diseases]

Autoimmune diseases are caused by a defect of the human immune system characterised by an inability to recognize their own antigens and by a pathological response against these antigens. Although the aetiology of these diseases is unknown, there is a number of cellular and molecular mechanisms which can underlie these reactions. Complex interactions between genetic, infectious and/or environmental factors probably contribute to the presence of these diseases. Autoimmune diseases affect 3-8% of the general population; women account for 78-85% of all patients with autoimmune diseases. Although most of those diseases are systemic, some of them primarily affect a single organ or structure. Rarely, a few autoimmune diseases coexist in one person, which can suggest similar pathogenetic mechanisms. In this article we present a review of the literature on coexistence of multiple sclerosis and other autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, chronic active hepatitis, type 1 diabetes mellitus, uveitis, pemphigus, psoriasis, Crohn's disease, inflammatory bowel disease, anaemia and autoimmune thyroiditis.

Astrocytic activation in relation to inflammatory markers during clinical exacerbation of relapsing-remitting multiple sclerosis

The study aimed to assay the cerebrospinal fluid (CSF) levels of protein S100B, a biomarker of astrocyte activation in relation to kynurenic acid (KYNA) and nitric oxide (NO) metabolites, nitrate/nitrite (NOx) concentrations in acute relapse multiple sclerosis (MS) patients. Twenty relapsing-remitting MS (RR-MS) patients and 10 controls were enrolled. RR-MS patients were assessed on the expanded disability status scale (EDSS) and underwent lumbar puncture. The CSF KYNA, NOx and S100B levels were significantly higher in RR-MS group compared to controls (p = 0.01, 0.001, 0.04, respectively). There was a significant correlation between CSF S100B and KYNA (p = 0.01) but not NOx (p > 0.05) in RR-MS. CSF KYNA, NOx or S100B concentrations did not correlate with disease characteristics of MS patients. Our study suggests the activation of the kynurenine pathway leading to the increase of neuroprotective KYNA in the CSF of MS patients during acute relapse what contrasts with chronic phases of the disease.

[Multiple ischemic foci of the brain in female patient with cardiac myxoma and numerous vascular anomalies]

The ischemic stroke is the most frequent neurological pathology. It's etiology is quite complex. Around 20% of the ischemic stroke cases are caused by arteriosclerosis, 25% by lacunar stroke, remaining 30% are strokes with unclear etiology, around 20%--emboli, and 5% include other causes. The ischemic stroke, especially in younger patients suggests that a detailed and multidimensional diagnostic should be carried out. Presented the case of a female patient with multiple ischemic foci of the brain, whom cardiac myxoma and numerous vascular anomalies were detected. Ischemic foci of the brain might be caused by myxoma, but one cannot excluded other mechanism of their occurrence.

Simvastatin-induced prevention of the increase in TNF-alpha level in the acute phase of ischemic stroke

Like other proinflammatory cytokines, TNF-alpha may play an important role in the development of central nervous system injury following ischemic stroke. The aim of this study was to evaluate the influence of early treatment with simvastatin, an HMG-CoA reductase inhibitor, on serum TNF-alpha level in acute ischemic stroke (AIS). Patients with AIS (n = 36) were randomly assigned to the two groups: Group I (n = 18) treated with simvastatin 40 mg/day within 24 h after the onset of stroke and Group II (n = 18) not treated with the statin. Blood samples were obtained on days 1, 3 and 7 after stroke onset. Serum TNF-alpha level was significantly elevated on day 3 after the stroke onset in comparison to day 1 only in the simvastatin-treated group (increase in median values by 16.2% [p = 0.028] and 6.1% within 3 days in Group II and I, respectively). These findings indicate that simvastatin given within 24 h after the onset of stroke could prevent the increase in serum TNF-alpha level within 3 days.

Increased urinary excretion of nitric oxide metabolites in longitudinally monitored migraine patients

This study evaluated a relationship between nitric oxide (NO) and migraine attacks in order to gain insight into migraine pathomechanism. The study groups consisted of 12 migraineurs and eight controls. All subjects collected morning urine samples for 40 consecutive days. Urinary NO metabolites, nitrite/nitrate (NO(x)) levels were measured with the vanadium-based assay, whilst creatinine (Cr) and neopterin were determined with high-performance liquid chromatography. The mean urinary NO(x)/Cr ratio and number of NO(x) peaks was significantly greater in the migraine group compared with controls (P = 0.01 and P = 0.007, respectively). In the second approach, high NO(x) values were re-assessed in relation to raised neopterin, a marker of systemic infection or inflammation, and were excluded. The excretion of NO(x) persisted being pulsatile, and migraineurs had more peaks compared with controls (P = 0.01). In seven patients, NO(x) peaks coincided with headache days. This was more frequent than expected by random association in four patients (Monte-Carlo simulation; odds ratios: 2.16-7.77; no overlap of 95% CI). In four patients, NO(x) peaks preceded or followed headache days. Although there is a difference in the pattern of urinary NO(x) excretion between control and migraine populations, the variable temporal association of NO(x) peaks and headaches suggests a complex role of NO in this condition.

The interleukin-10 levels as a potential indicator of positive response to interferon beta treatment of multiple sclerosis patients

OBJECTIVES

Only a part of MS patients treated with interferon beta (IFN) respond positively to the applied treatment and to date no parameter predicting the response to treatment has been found. The aim of the study was to determine whether the levels of interleukin-10 and -12 (IL-10 and IL-12) might be the parameters enabling us to distinguish those patients who would best respond to therapy before the IFN treatment.

PATIENTS AND METHODS

The study included 29 patients with clinically definite relapsing-remitting MS treated with IFN beta. In all of them the levels of IL-10 and IL-12 in blood serum and cerebrospinal fluid were determined before treatment using ELISA method. After the 2-year therapy the patients responding and nonresponding to IFN therapy were distinguished on the basis of clinical parameters.

RESULTS

In the patients responding positively to IFN treatment the level of IL-10 in blood serum before treatment was found to be significantly lower (p<0.05) and distinctively differentiated responders from nonresponders. The IL-12 levels were similar both in cerebrospinal fluid and serum and no significant differences between responders and nonresponders were found.

CONCLUSION

Our observations suggest that IL-10 level may be a useful parameter to identify the patients potentially responding to IFN therapy.

[Multiple sclerosis--difficult answers to easy questions]

Multiple sclerosis is an autoimmune disease of the nervous system leading to irreversible disability. The illness affects young, professionally and socially active adults. Patients ask their neurologists many questions concerning prognosis and their future lifestyle. The paper discusses factors enabling us to predict the course of the disease based on clinical data and findings of additional examinations. The authors present the effects of external factors such as temperature, stress, infections and preventive vaccination on relapse as well as their importance for long-term progression of the disease. Moreover, the current results of examinations evaluating the influence of pregnancy and delivery on the risk of relapse and deterioration of disability in the immediate and remote postpartum period and the importance of diet and rehabilitation are presented.

CSF nitric oxide metabolites are associated with activity and progression of multiple sclerosis

OBJECTIVE

To investigate the relationship of CSF and the serum nitric oxide metabolites nitrite and nitrate (NOx) to disease activity and progression in patients with multiple sclerosis (MS).

METHODS

The study was divided into cross-sectional and follow-up. In the cross-sectional study, 20 patients with relapsing-remitting (RR), 21 with secondary progressive (SP), and 10 with primary progressive (PP) MS and 14 control subjects were included. Patients were assessed on clinical (Expanded Disability Status Scale [EDSS], Ambulation Index [AI], 9-Hole Peg Test [9-HPT]) and MRI measurements. In the follow-up study, 34 MS patients from the cross-sectional study agreed to be assessed again after an average of 3.0 +/- 0.5 years. NOx was measured using a vanadium-based assay.

RESULTS

In the cross-sectional study, CSF NOx was raised in patients with RR-MS (p = 0.001) and PP-MS (p = 0.02) vs controls. Higher CSF NOx levels were found in patients with mild disability (AI < or = 6.0; EDSS < or = 4.0; Multiple Sclerosis Severity Score [MSSS] < or = 4.8) vs patients with advanced disease (AI > 6.0 [p = 0.002]; EDSS > 4.0 [p = 0.02]; MSSS > 4.8 [p = 0.01]). In the subgroup of patients having Gd-enhancing MRI lesions (n = 11), correlation between the volume of enhancement and CSF NOx was found (r = 0.74, p = 0.01). In the follow-up study, patients with disability progression had higher baseline CSF NOx levels than those who were stable on EDSS (p = 0.02) or AI (p = 0.03). A positive correlation was found between baseline CSF NOx and the change in MR T2-weighted lesion load (r = 0.4, p = 0.03).

CONCLUSIONS

CSF nitrite and nitrate levels were increased in mildly disabled patients with MS and found to correlate with the volume of Gd-enhanced lesions on MRI. Raised baseline CSF NOx was associated with clinical and MRI progression in MS patients over 3-year follow-up.

Simvastatin could prevent increase of the serum MMP-9/TIMP-1 ratio in acute ischaemic stroke

MMP-9 plays an important role in the pathogenesis of AIS and predicts haemorrhagic transformation of the ischaemic focus. The aim of our study was to analyse both serum MMP-9 and its most specific endogenous inhibitor (TIMP-1) levels in AIS and to check whether HMG-CoA reductase inhibitor (simvastatin) affects the MMP-9/TIMP-1 ratio value. Fifty patients with AIS were randomly divided into two groups: Group I (N = 25) treated with 40 mg/day with simvastatin within 24 hours after the onset of stroke and Group II (N = 25) non-treated with statin. To evaluate MMP-9 and TIMP-1 serum levels, the ELISA method was used. The serum MMP-9 level was significantly elevated on the 7th day of stroke in both groups (from 668 to 862 ng/ml and 670 to 855 ng/ml, respectively, in Group I and II). The serum TIMP-1 level was also elevated on the 7th day of stroke in both groups but the results were not significant. The MMP-9/TIMP-1 ratio was elevated on the 7th day of stroke in both groups, but the result was significant only in the Group II (P < 0.01). These findings indicate that simvastatin given during 24 hours after the onset of stroke could have an influence on the MMP-9/TIMP-1 ratio during AIS.

The CSF levels of total-tau and phosphotau in patients with relapsing-remitting multiple sclerosis

Total-tau protein is considered the marker of axon damage whereas the abnormally phosphorylated tau forms are mainly associated with Alzheimer's disease. An increase in total-tau levels was observed in neurodegenerative diseases, including multiple sclerosis (MS). In order to find out whether the phosphorylated tau forms occur in MS patients and to evaluate their clinical significance, the levels of total-tau (t-tau) and tau phosphorylated at Thr 181 (p-tau) were determined in 60 MS patients (40 during relapse including 18 with the first relapse and 20 stable) and in 18 age-matched controls. The determinations were conducted in the cerebrospinal fluid (CSF) using the ELISA method. The levels of t-tau and p-tau were higher in MS patients than in controls; however, increased levels were not related to the clinical activity of the disease. In CSF of the patients with the first relapse the level of t-tau was significantly increased whilst the level of p-tau was not elevated.

[Change of interleukin-4 and interleukin-12 levels after therapy of multiple sclerosis relapse with methylprednisolone]

BACKGROUND AND PURPOSE

In the pathomechanism of multiple sclerosis (MS), a vital role is attributed to autoimmune responses. Higher activity of the disease is connected with an increased activity of proinflammatory cytokines while in remissions anti-inflammatory cytokines dominate. The aim of the study was to evaluate the effects of methylprednisolone treatment on the level of IL-4 and IL-12 and to determine whether their levels are related to the degree of disability and may be prognostic factors in the assessment of relapse sequelae.

MATERIAL AND METHODS

The study included 32 patients with MS (according to McDonald's criteria) with relapses and remissions (17 patients with relapse who received methylprednisolone in the dose of 1.0 g i. v. on 5 consecutive days and 15 patients in remission). The control group consisted of 15 patients with non-inflammatory diseases of the nervous system. The levels of cytokines were determined by ELISA method using the Pharmingen kits. The examinations of patients in relapse were conducted before and after steroid therapy; the remaining patients were examined only once.

RESULTS

In the relapse a visible increase in serum IL-12 level (p<0.05) was observed; its level after methylprednisolone treatment was found to be significantly decreased (p<0.001). The level of IL-4 was not significantly affected by steroid therapy. There was no relation between the severity of disability and cytokine levels.

CONCLUSIONS

The level of IL-12 increases in MS relapses and decreases after methylprednisolone therapy. The changes in IL-4 and IL-12 levels are the manifestations of inflammatory reactions connected with the relapse; however, they do not directly indicate the extent of damage to CNS. They cannot be treated as a prognostic factor allowing to anticipate the consequences of the relapse.

Escalating immunotherapy of multiple sclerosis--new aspects and practical application

Recent clinical studies in multiple sclerosis (MS) provide new data on the treatment of clinically isolated syndromes, on secondary progression, on direct comparison of immunomodulatory treatments and on dosing issues. All these studies have important implications for the optimized care of MS patients. The multiple sclerosis therapy consensus group (MSTCG) critically evaluated the available data and provides recommendations for the application of immunoprophylactic therapies. Initiation of treatment after the first relapse may be indicated if there is clear evidence on MRI for subclinical dissemination of disease. Recent trials show that the efficacy of interferon beta treatment is more likely if patients in the secondary progressive phase of the disease still have superimposed bouts or other indicators of inflammatory disease activity than without having them. There are now data available, which suggest a possible dose-effect relation for recombinant beta-interferons. These studies have to be interpreted with caution, as some potentially important issues in the design of these studies (e. g. maintenance of blinding in the clinical part of the study) were not adequately addressed. A meta-analysis of selected interferon trials has been published challenging the value of recombinant IFN beta in MS. The pitfalls of that report are discussed in the present review as are other issues relevant to treatment including the new definition of MS, the problem of treatment failure and the impact of cost-effectiveness analyses. The MSTCG panel recommends that the new diagnostic criteria proposed by McDonald et al. should be applied if immunoprophylactic treatment is being considered. The use of standardized clinical documentation is now generally proposed to facilitate the systematic evaluation of individual patients over time and to allow retrospective evaluations in different patient cohorts. This in turn may help in formulating recommendations for the application of innovative products to patients and to health care providers. Moreover, in long-term treated patients, secondary treatment failure should be identified by pre-planned follow-up examinations, and other treatment options should then be considered.

The levels of chemokines CXCL8, CCL2 and CCL5 in multiple sclerosis patients are linked to the activity of the disease

Chemokines are small cytokines with selective chemoattractant properties. They contribute to the T-cell-mediated pathogenesis of multiple sclerosis (MS). In order to ascertain whether different types and stage of disease correlate with a varying level of chemokines, the levels of CXCL8, CCL2 and CCL5 were measured in serum and the cerebrospinal fluid (CSF) of the MS patients. ELISA method was used to examine 56 patients with different types of MS alongside the 29 patients of the control group. The levels of CXCL8 and CCL2 in both groups were higher in CFS than in serum whilst the level of CCL5 measured higher in serum than in CSF. A significant rise in the levels of CXCL8 and CCL5 was observed during relapse, as against the level of CCL2 which was lower when compared with the control and other MS groups. No significant differences were observed in the levels of chemokines between the stable relapsing-remitting MS and progressive MS. The different levels of chemokines are linked to relapse of the disease. No separate, specific pattern of chemokine production dependent on the type of MS could be ascertained.

[Role of matrix metalloproteinases in the pathogenesis of multiple sclerosis]

Multiple sclerosis (MS) is an autoimmune disease whose features include a massive lymphocyte recruitment into the central nervous system and segmental demyelinization of the white matter. One of the MS development factors is an increase of matrix metalloproteinases (MMPs) activity with a coincidental decrease of tissue inhibitors of MMPs (TIMPs) activity. Investigations of serum, cerebrospinal fluid and brain tissue of patients showed an increase of MMP-1, -2, -3, -7, -9 and MMP-12 activity. MMPs disrupt the blood-brain barrier (BBB), increase lymphocyte migration into the central nervous system and are involved in degradation of myelin proteins. MMPs induce the appearance of an active form of tumor necrosis factor alpha, a strong proinflammatory cytokine. The drugs used in MS treatment decrease MMPs expression. Multiple actions of MMPs prove their involvement in the pathogenesis and treatment of MS.