Epidemiology of multiple sclerosis

RhoA Drives T-Cell Activation and Encephalitogenic Potential in an Animal Model of Multiple Sclerosis

T-cells are known to be intimately involved in the pathogenesis of multiple sclerosis (MS) and its animal model experimental autoimmune encephalomyelitis (EAE). T-cell activation is controlled by a range of intracellular signaling pathways regulating cellular responses such as proliferation, cytokine production, integrin expression, and migration. These processes are crucial for the T-cells’ ability to mediate inflammatory processes in autoimmune diseases such as MS. RhoA is a ubiquitously expressed small GTPase well described as a regulator of the actin cytoskeleton. It is essential for embryonic development and together with other Rho GTPases controls various cellular processes such as cell development, shaping, proliferation, and locomotion. However, the specific contribution of RhoA to these processes in T-cells in general, and in autoreactive T-cells in particular, has not been fully characterized. Using mice with a T-cell specific deletion of the RhoA gene (RhoA^fl/flLckCre⁺), we investigated the role of RhoA in T-cell development, functionality, and encephalitogenic potential in EAE. We show that lack of RhoA specifically in T-cells results in reduced numbers of mature T-cells in thymus and spleen but normal counts in peripheral blood. EAE induction in RhoA^fl/flLckCre⁺ mice results in significantly reduced disease incidence and severity, which coincides with a reduced CNS T-cell infiltration. Besides presenting reduced migratory capacity, both naïve and autoreactive effector T-cells from RhoA^fl/flLckCre⁺ mice show decreased viability, proliferative capacity, and an activation profile associated with reduced production of Th1 pro-inflammatory cytokines. Our study demonstrates that RhoA is a central regulator of several archetypical T-cell responses, and furthermore points toward RhoA as a new potential therapeutic target in diseases such as MS, where T-cell activity plays a central role.

Multiple Sclerosis Re-Examined: Essential and Emerging Clinical Concepts

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system characterized by exacerbations of neurological dysfunction due to inflammatory demyelination. Neurologic symptoms typically present in young adulthood and vary based on the site of inflammation, although weakness, sensory impairment, brainstem dysfunction, and vision loss are common. MS occurs more frequently in women and its development is complex-genetics, hormones, geography, vitamin D, and viral exposure all play roles. Early MS is characterized by relapsing-remitting course and inflammation of the white matter, although as patients age, the disease often transitions to a pathologically distinct secondary progressive phase with gradual disability accrual affecting gait, coordination, and bladder function. A minority of patients (10%) have disease that is progressive at onset. In the past decade, there has been a remarkable expansion in disease-modifying therapy for MS, but treatment of progressive disease remains a challenge. This article reviews foundational concepts in MS and emerging work that has reshaped understanding of the disease, providing new insight for therapeutic advance.

NLR-Dependent Regulation of Inflammation in Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) associated with inappropriate activation of lymphocytes, hyperinflammatory responses, demyelination, and neuronal damage. In the past decade, a number of biological immunomodulators have been developed that suppress the peripheral immune responses and slow down the progression of the disease. However, once the inflammation of the CNS has commenced, it can cause serious permanent neuronal damage. Therefore, there is a need for developing novel therapeutic approaches that control and regulate inflammatory responses within the CNS. Nucleotide-binding oligomerization domain (NOD)-like receptors (NLRs) are intracellular regulators of inflammation expressed by many cell types within the CNS. They redirect multiple signaling pathways initiated by pathogens and molecules released by injured tissues. NLR family members include positive regulators of inflammation, such as NLRP3 and NLRC4 and anti-inflammatory NLRs, such as NLRX1 and NLRP12. They exert immunomodulatory effect at the level of peripheral immune responses, including antigen recognition and lymphocyte activation and differentiation. Also, NLRs regulate tissue inflammatory responses. Understanding the molecular mechanisms that are placed at the crossroad of innate and adaptive immune responses, such as NLR-dependent pathways, could lead to the discovery of new therapeutic targets. In this review, we provide a summary of the role of NLRs in the pathogenesis of MS. We also summarize how anti-inflammatory NLRs regulate the immune response within the CNS. Finally, we speculate the therapeutic potential of targeting NLRs in MS.

Whose Preferences Matter? A Patient-Centered Approach for Eliciting Treatment Goals

BACKGROUND

Patients facing a high-stakes clinical decision are often confronted with an overwhelming array of options. High-quality decisions about treatment should reflect patients' preferences as well as their clinical characteristics. Preference-assessment instruments typically focus on pre-selected clinical outcomes and attributes chosen by the investigator.

OBJECTIVE

We sought to develop a patient-centered approach to elicit and compare the treatment goals of patients with multiple sclerosis (MS) and healthcare providers (HCPs).

METHODS

We conducted five nominal group technique (NGT) meetings to elicit and prioritize treatment goals from patients and HCPs. Five to nine participants in each group responded silently to one question about their treatment goals. Responses were shared, consolidated, and ranked to develop a prioritized list for each group. The ranked lists were combined. Goals were rated and sorted into categories. Multidimensional scaling and hierarchical cluster analysis were used to derive a visual representation, or cognitive map, of the data and to identify conceptual clusters, reflecting how frequently items were sorted into the same category.

RESULTS

Five NGT groups yielded 34 unique patient-generated treatment goals and 31 unique HCP-generated goals. There were differences between patients and HCPs in the goals generated and how they were clustered. Patients' goals tended to focus on the impact of specific symptoms on their day-to-day lives, whereas providers' goals focused on slowing down the course of disease progression.

CONCLUSIONS

Differences between the treatment goals of patients and HCPs underscore the limitations of using HCP- or investigator-identified goals. This new adaptation of cognitive mapping is a patient-centered approach that can be used to generate and organize the outcomes and attributes for values clarification exercises while minimizing investigator bias and maximizing relevance to patients.

Evaluation of idiopathic transverse myelitis revealing specific myelopathy diagnoses

Objective

To evaluate specific myelopathy diagnoses made in patients with suspected idiopathic transverse myelitis (ITM).

Methods

A total of 226 patients 18 years and older were referred to Mayo Clinic Neurology for suspected ITM from December 1, 2010, to December 31, 2015. Electronic medical records were reviewed for detailed clinical presentation and course, laboratory and electrophysiologic investigations, and neuroimaging to determine the etiology. Current diagnostic criteria for ITM and alternative myelopathy diagnoses were applied. All cases where any discrepancy was suspected from the final reported clinical diagnosis were reviewed by each author and a consensus final diagnosis was made.

Results

The diagnostic criteria for ITM were met in 41 of 226 patients (18.1%). In 158 patients (69.9%), an alternative specific myelopathy diagnosis was made: multiple sclerosis or clinically isolated syndrome, 75; vascular myelopathy, 41; neurosarcoidosis, 12; neuromyelitis optica spectrum disorder, 12; myelin oligodendrocyte glycoprotein myelopathy, 5; neoplastic, 4; compressive, 3; nutritional, 3; infectious, 2; and other, 2. A myelopathy was not confirmed in 27 patients. Time from symptom onset to final clinical diagnosis in patients without ITM was a median of 9 months (range 0–288). Fifty-five patients (24%) required treatment changes according to their final clinical diagnosis.

Conclusions

The majority of patients with suspected ITM have an alternative specific myelopathy diagnosis. A presumptive diagnosis of ITM can lead to premature diagnostic conclusions affecting patient treatment.

Sex/gender influences on the nervous system: Basic steps toward clinical progress

A Commentary highlighting the progress that sex-based data and research have made in neuroscience and the complexities that research has revealed thus far. Basic and preclinical neuroscientific research that considers sex as a biological variable will continue to build on the foundation of knowledge that has been started by multiple predecessors. The expansion of knowledge in preclinical neuroscience that integrates the study of both sexes will have a significant role in informing clinical trial design. We applaud the efforts of the editors and authors who have contributed to this issue. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Effect of visual biofeedback cycling training on gait in patients with multiple sclerosis

INTRODUCTION

Gait alterations are present in a high percentage of patients with multiple sclerosis (MS). They appear from early stages of the disease and can limit patients' capacity to perform basic activities of daily living, affecting their quality of life. Visual biofeedback cycling training appears to be a useful tool in treating these impairments. This study aims to evaluate the short-term effect of visual biofeedback cycling training on gait in patients with MS.

MATERIAL AND METHODS

A total of 61 patients with mild to moderate MS were randomly assigned to a control group and an intervention group. The intervention group received visual biofeedback cycling training (MOTOmed viva2 system) once per week for 3 months, and a home exercise program. The control group only received the home exercise program. Both groups were evaluated using the GAITRite® Walkway gait assessment system before the intervention, during the first month of the programme, and after the intervention.

RESULTS

In the intervention group, the analysis revealed statistically significant differences between Functional Ambulation Profile (FAP) scores before and during the intervention (P=.014), and before and after the intervention (P=.002). A statistically significant improvement was observed in step length in the intervention group between pre- and post-intervention scores (P=.001) and between first-month and post-intervention scores (P=.004).

CONCLUSIONS

Visual biofeedback cycling training improved specific gait parameters in the short term and appears to be a therapeutic option for gait retraining in patients with MS.

Neuroketotherapeutics: A modern review of a century-old therapy

Neuroketotherapeutics represent a class of bioenergetic medicine therapies that feature the induction of ketosis. These therapies include medium-chain triglyceride supplements, ketone esters, fasting, strenuous exercise, the modified Atkins diet, and the classic ketogenic diet. Extended experience reveals persons with epilepsy, especially pediatric epilepsy, benefit from ketogenic diets although the mechanisms that underlie its effects remain unclear. Data indicate ketotherapeutics enhance mitochondrial respiration, promote neuronal long-term potentiation, increase BDNF expression, increase GPR signaling, attenuate oxidative stress, reduce inflammation, and alter protein post-translational modifications via lysine acetylation and β-hydroxybutyrylation. These properties have further downstream implications involving Akt, PLCγ, CREB, Sirtuin, and mTORC pathways. Further studies of neuroketotherapeutics will enhance our understanding of ketone body molecular biology, and reveal novel central nervous system therapeutic applications.

Multiple sclerosis in pregnancy: prevalence, sociodemographic features, and obstetrical outcomes

OBJECTIVE

We sought to describe the prevalence, sociodemographic features, and antenatal/peripartum outcomes of multiple sclerosis (MS) in pregnancy.

STUDY DESIGN

A retrospective cohort study was performed using deliveries in California from 2001 to 2009. Cases of MS as well as other morbidities were identified via ICD-9-CM code. Logistic regression was performed to adjust for potential confounders.

RESULTS

About 1185 out of 4,424,049 deliveries were complicated by MS. MS prevalence increased with maternal age, with Caucasians comprising a higher proportion of MS subjects. MS subjects were older and more likely to have private insurance. Women with MS were more likely to have preexisting medical conditions such as asthma, chronic hypertension, thyroid disease, or cardiac disease. However, no significant antepartum and peripartum morbidities were found to be increased in patients with MS. Urinary tract infection, cesarean delivery, and induction of labor were slightly increased in MS patients.

CONCLUSIONS

MS is a rare condition which is more likely to affect older Caucasian women of higher socioeconomic status and is associated with several preexisting medical conditions. MS, however, does not appear to pose significant increases in adverse pregnancy outcome. This suggests that pregnant patients with MS may likely experience an uneventful pregnancy.

The effects of Tai Chi on physical and psychosocial function among persons with multiple sclerosis: A systematic review

OBJECTIVES

Conduct a systematic review to evaluate the effects of Tai Chi on physical and psychosocial function among individuals with Multiple Sclerosis.

METHODS

An electronic literature search of 12 databases using controlled vocabulary function and keywords from inception through August 2016. All Tai Chi intervention studies assessing physical and psychosocial function among persons with Multiple Sclerosis were included. Study quality was scored using an established tool examining 16 study elements (range=0-32).

RESULTS

A total of 91 articles were retrieved, with 3 additional articles identified through reviewing bibliographies of relevant articles. A total of 8 studies (randomized controlled trials, n=3; quasi-experimental, n=5) enrolled 193 participants with Multiple Sclerosis. Studies were conducted in the USA (n=3), Europe (n=3), Iran, (n=1), and India (n=1). A total of 3 studies reported using the Yang style of Tai Chi (not specified, n=5 studies). The Tai Chi intervention averaged 27 sessions over 11 weeks. Study quality scores for the randomized controlled trials had a mean score of 23 (range 19-26), while quality scores for quasi-experimental studies had a mean score of 20 (range 13-26). Overall, participants enrolled in Tai Chi had better balance, gait and flexibility, less fatigue and depression, and better quality of life after the intervention; though mixed results were reported.

CONCLUSION

The results indicate that Tai Chi is likely safe and may provide physical and psychosocial benefits in individuals with Multiple Sclerosis. Further research is needed using more rigorous study designs to assess the benefits of Tai Chi for individuals with Multiple Sclerosis.

Cerebrospinal Fluid in a Small Cohort of Patients with Multiple Sclerosis Was Generally Free of Microbial DNA

Multiple sclerosis (MS) is a common cause of non-traumatic neurologic disability with high incidence in many developed countries. Although the etiology of the disease remains elusive, it is thought to entail genetic and environmental causes, and microbial pathogens have also been envisioned as contributors to the phenotype. We conducted a metagenomic survey in cerebrospinal fluid (CSF) from 28 MS patients and 15 patients suffering other type of neurological conditions. We detected bacterial reads in eight out of the 15 non-MS patients and in a single MS patient, at an abundance >1% of total classified reads. Two patients were of special interest: one non-MS patient harbored ~73% bacterial reads, while an MS patient had ~83% bacterial reads. In the former case, Veillonella parvula, a bacterium occasionally found associated with meningitis was the predominant species, whilst Kocuria flava, apparently an environmental bacterium, predominated in the latter case. Thirty-four out of 43 samples contained <1% bacterial reads, which we regard as cross- or environmental contamination. A few viral reads corresponding to Epstein-Barr virus, cytomegalovirus, and parvovirus were also identified. Our results suggest that CSF of MS patients is often (but not always) free of microbial DNA.

Oral versus intravenous methylprednisolone for the treatment of multiple sclerosis relapses: A meta-analysis of randomized controlled trials

BACKGROUND

Intravenous glucocorticoids are recommended for multiple sclerosis (MS). However, they can be inconvenient and expensive. Due to their convenience and low cost, oral glucocorticoids may be an alternative treatment. Recently, several studies have shown that there is no difference in efficacy and safety between oral methylprednisolone (oMP) and intravenous methylprednisolone (ivMP).

OBJECTIVES

We sought to assess the clinical efficacy, safety and tolerability of oral methylprednisolone versus intravenous methylprednisolone for MS relapses in this meta-analysis.

METHODS

Randomized controlled trials (RCTs) evaluating the clinical efficacy, safety and tolerability of oral methylprednisolone versus intravenous methylprednisolone for MS relapses were searched in PubMed, Cochrane Library, Medline, EMBASE and China Biology Medicine until October 25, 2016, without language restrictions. The proportion of patients who had improved by day 28 was chosen as the efficacy outcome. We chose the risk ratio (RR) to analyze each trial with the 95% confidence interval (95% CI). We also used the fixed-effects model (Mantel-Haenszel approach) to calculate the pooled relative effect estimates.

RESULTS

A total of 5 trials were identified, which included 369 patients. The results of our meta-analysis revealed that no significant difference existed in relapse improvement at day 28 between oMP and ivMP (RR 0.96, 95% CI 0.84 to 1.10). No evidence of heterogeneity existed among the trials (P = 0.45, I2 = 0%). Both treatments were equally safe and well tolerated except that insomnia was more likely to occur in the oMP group compared to the ivMP group.

CONCLUSION

Our meta-analysis reveals strong evidence that oMP is not inferior to ivMP in increasing the proportion of patients experiencing clinical improvement at day 28. In addition, both routes of administration are equally well tolerated and safe. These findings suggest that we may be able to replace ivMP with oMP to treat MS relapses.

A group-delivered self-management program reduces spasticity in people with multiple sclerosis: A randomized, controlled pilot trial

BACKGROUND

Spasticity affects more than 80% of people with multiple sclerosis (MS), affecting activity, participation, and quality of life. Based on an international guideline, an MS spasticity group education and stretching program, MS Spasticity: Take Control (STC), has been developed.

OBJECTIVE

The objective of this paper is to determine whether STC with home stretching is associated with greater changes in spasticity than usual care (UC), consisting of an illustrated stretching booklet and home stretching but without group instruction or support, in people with MS.

METHODS

Ambulatory MS patients with self-reported spasticity interfering with daily activities were randomized to STC or UC. Individuals completed questionnaires regarding MS, spasticity, walking, fatigue and mood, and physical measures of spasticity and walking.

RESULTS

Thirty-eight of 40 participants completed both assessments. Mean total score and scores on two subscales of the MS Spasticity Scale-88 improved more with STC than with UC (p < 0.03). There was no significant change in the Modified Ashworth Scale in either group. Mean scores on the Modified Fatigue Impact Scale, the Beck Depression Inventory-II, and the physical component of the Multiple Sclerosis Impact Scale-29 showed statistically and clinically significant improvements in the STC group only.

CONCLUSIONS

Participation in STC improved self-reported impact of spasticity more than UC and provided encouraging improvements in other measures.

Assessment of Serum Nitrogen Species and Inflammatory Parameters in Relapsing-Remitting Multiple Sclerosis Patients Treated with Different Therapeutic Approaches

The role of nitric oxide and its reactive derivatives (NO _x ) is well known in the pathogenesis of multiple sclerosis, which is an inflammatory disease while NO _x seems to be important in coordinating inflammatory response. The purpose of the present study was to assess serum NO _x as one of the nitrogen species and inflammatory parameters in relapsing-remitting multiple sclerosis patients and to compare the effectiveness of various types of disease-modifying therapies that reduce nitric oxide and inflammatory biomarkers. Elevated NO _x level was observed in patients who received the first-line disease-modifying therapy (interferons beta-1a and beta-1b) in comparison with the subjects treated with the second-line disease-modifying therapy (natalizumab; fingolimod) and healthy controls without significant differences in C-reactive protein and interleukin-1 beta. A negative correlation was observed between serum NO _x level and the duration of multiple sclerosis confirmed in the whole study population and in subjects treated with the first-line agents. Only serum NO _x , concentration could reveal a potential efficacy of disease-modifying therapy with a better reduction in NO _x level due to the second-line agents of disease-modifying therapy.

RISK FACTORS FOR MULTIPLE SCLEROSIS IN VOLYN REGION (UKRAINE)

The prevalence rate of multiple sclerosis (MS) in Volyn Region (101.0 per 100000) is the highest in Ukraine. To study MS risk factors in Volyn Region, special questionnaires were distributed among all MS patients residing in Volyn region. Results were obtained from 227 respondents including 154 women and 73 men of mean age 43±10.6 years. The control group included 105 healthy respondents inhabiting Volyn region. We found associated risk factors for MS to be: mother of Volyn origin, maternal age after 27 years old and paternal age after 29 years old at birth of respondent, subject's born as a third child, brestfeeding for less than one year, living in the zone of industrial pollution, near mobile, TV- and radio re-translators, full traffic automobile roads, time spending outdoors less than one hour in winter and less than eight hours in summer, consumption of fruit and vegetables less than 5 times a week, of beef less than 3 times a week, poultry meet less than 3, berries less than 3, cereals less than 4 times a week, chronic stressful situations in life. Patients with MS more frequently reported AVRI, hepatitis and herpes simplex virus. Among patients with MS there were fewer respondents with history of chickenpox, rubella and DPT (diphtheria, pertussis, tetanus), BCG immunizations. Here, we introduced a novel study of MS risk factors within Volyn Region. The Registry established in 2012 is being constantly updated and can be a database for a long-term retrospective study involving a large number of patients.

Epigenetic Drugs for Multiple Sclerosis

There is increasing evidence that abnormalities in epigenetic mechanisms of gene expression contribute to the development of multiple sclerosis (MS). Advances in epigenetics have given rise to a new class of drugs, epigenetic drugs. Although many classes of epigenetic drugs are being investigated, at present most attention is being paid to two classes of epigenetic drugs: drugs that inhibit DNA methyltransferase (DNMTi) and drugs that inhibit histone deacetylase (HDACi). This paper discusses the potential use of epigenetic drugs in the treatment of MS, focusing on DNMTi and HDACi. Preclinical drug trials of DNMTi and HDACi for the treatment of MS are showing promising results. Epigenetic drugs could improve the clinical management of patients with MS.

From trash to treasure: The untapped potential of endothelial microparticles in neurovascular diseases

Discovered in 1947, microparticles (MP) represent a group of sub-micron cell-derived particles isolated by high speed centrifugation. Once regarded as cellular 'trash', in the past decade MP have gained tremendous attention in both basic sciences and medical research both as biomarkers and mediators of infection, injury and response to therapy. Because MP bear cell surface markers derived from parent cells, accumulate in extracellular fluids (plasma, serum, milk, urine, cerebrospinal fluid) MP based tests are being developed commercially as important components in 'liquid biopsy' approaches, providing valuable readouts in cardiovascular disease and cancer, as well as stroke, Alzheimer's disease and Multiple Sclerosis. Importantly, MP have been reported as mobile transport vectors in the intercellular transfer of mRNAs, microRNAs, lipids and proteins. Here we discuss MP structure, properties and functions with particular relevance to neurological and neurovascular diseases.

Big data to smart data in Alzheimer's disease: Real-world examples of advanced modeling and simulation

Many disease-modifying clinical development programs in Alzheimer's disease (AD) have failed to date, and development of new and advanced preclinical models that generate actionable knowledge is desperately needed. This review reports on computer-based modeling and simulation approach as a powerful tool in AD research. Statistical data-analysis techniques can identify associations between certain data and phenotypes, such as diagnosis or disease progression. Other approaches integrate domain expertise in a formalized mathematical way to understand how specific components of pathology integrate into complex brain networks. Private-public partnerships focused on data sharing, causal inference and pathway-based analysis, crowdsourcing, and mechanism-based quantitative systems modeling represent successful real-world modeling examples with substantial impact on CNS diseases. Similar to other disease indications, successful real-world examples of advanced simulation can generate actionable support of drug discovery and development in AD, illustrating the value that can be generated for different stakeholders.

Retinyl Palmitate Supplementation Modulates T-bet and Interferon Gamma Gene Expression in Multiple Sclerosis Patients

Vitamin A derivatives such as retinoic acid may improve the impaired balance of CD4+ T cells in autoimmune and inflammatory diseases. This study is a double-blind randomized trial to evaluate the effect of vitamin A (as form of retinyl palmitate) supplementation on multiple sclerosis (MS) patients. Thirty-nine patients were enrolled and randomly assigned to two groups. Both groups were followed for 6 months. The experimental group received 25,000 IU of retinyl palmitate daily, while the control group received a placebo. Before and after the study, the expression of interferon gamma (IFN-γ) and T-bet genes was evaluated in peripheral blood mononuclear cells of patients by RT-PCR. The results showed that after 6 months of supplementation, expression of IFN-γ and T-bet was significantly decreased. These data suggest that retinyl palmitate supplementation can modulate the impaired balance of Th1 and Th2 cells and vitamin A products that may be involved in the therapeutic mechanism of vitamin A in MS patients. This study provides information regarding the decreased gene expression of IFN-γ and T-bet in MS by retinyl palmitate supplementation.

Vitamin D and Risk of Multiple Sclerosis: A Mendelian Randomization Study

BACKGROUND

Observational studies have demonstrated an association between decreased vitamin D level and risk of multiple sclerosis (MS); however, it remains unclear whether this relationship is causal. We undertook a Mendelian randomization (MR) study to evaluate whether genetically lowered vitamin D level influences the risk of MS.

METHODS AND FINDINGS

We identified single nucleotide polymorphisms (SNPs) associated with 25-hydroxyvitamin D (25OHD) level from SUNLIGHT, the largest (n = 33,996) genome-wide association study to date for vitamin D. Four SNPs were genome-wide significant for 25OHD level (p-values ranging from 6 × 10-10 to 2 × 10-109), and all four SNPs lay in, or near, genes strongly implicated in separate mechanisms influencing 25OHD. We then ascertained their effect on 25OHD level in 2,347 participants from a population-based cohort, the Canadian Multicentre Osteoporosis Study, and tested the extent to which the 25OHD-decreasing alleles explained variation in 25OHD level. We found that the count of 25OHD-decreasing alleles across these four SNPs was strongly associated with lower 25OHD level (n = 2,347, F-test statistic = 49.7, p = 2.4 × 10-12). Next, we conducted an MR study to describe the effect of genetically lowered 25OHD on the odds of MS in the International Multiple Sclerosis Genetics Consortium study, the largest genetic association study to date for MS (including up to 14,498 cases and 24,091 healthy controls). Alleles were weighted by their relative effect on 25OHD level, and sensitivity analyses were performed to test MR assumptions. MR analyses found that each genetically determined one-standard-deviation decrease in log-transformed 25OHD level conferred a 2.0-fold increase in the odds of MS (95% CI: 1.7-2.5; p = 7.7 × 10-12; I2 = 63%, 95% CI: 0%-88%). This result persisted in sensitivity analyses excluding SNPs possibly influenced by population stratification or pleiotropy (odds ratio [OR] = 1.7, 95% CI: 1.3-2.2; p = 2.3 × 10-5; I2 = 47%, 95% CI: 0%-85%) and including only SNPs involved in 25OHD synthesis or metabolism (ORsynthesis = 2.1, 95% CI: 1.6-2.6, p = 1 × 10-9; ORmetabolism = 1.9, 95% CI: 1.3-2.7, p = 0.002). While these sensitivity analyses decreased the possibility that pleiotropy may have biased the results, residual pleiotropy is difficult to exclude entirely.

CONCLUSIONS

A genetically lowered 25OHD level is strongly associated with increased susceptibility to MS. Whether vitamin D sufficiency can delay, or prevent, MS onset merits further investigation in long-term randomized controlled trials.

Opioid growth factor and low-dose naltrexone impair central nervous system infiltration by CD4 + T lymphocytes in established experimental autoimmune encephalomyelitis, a model of multiple sclerosis

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS), characterized by infiltrating myelin-reactive T lymphocytes and demyelinating lesions. Experimental autoimmune encephalomyelitis (EAE) is the animal model widely utilized to study MS. EAE is mediated by CD4(+) T cells and can be induced in EAE-susceptible mice through immunization with a myelin antigen, such as proteolipid protein 139-151 (PLP139-151) in SJL mice. In this PLP-induced EAE model, autoreactive CD4(+) T cells migrate from peripheral tissues into the CNS where they are reactivated resulting in CNS damage. Th1 and Th17 cells produce the pro-inflammatory cytokines IFNγ and IL-17, respectively, that have been shown to have pathogenic roles in EAE and MS. Anti-inflammatory Th2, IL-4 secreting cells, have been indicated to inhibit EAE exacerbation. However, given the inflammatory environment of EAE, Th2 effector cells are outnumbered by Th1/Th17 cells. Regulatory CD4(+) T cells suppress immune reactions and have been demonstrated to be dysfunctional in MS patients. Opioid growth factor (OGF), chemically termed [Met(5)]-enkephalin, is a negative growth factor that interacts with the OGF receptor. The OGF-OGFr axis can be activated through exogenous administration of OGF or a low dosage of naltrexone (LDN), an opioid antagonist. We have previously demonstrated that modulation of the OGF-OGFr axis results in alleviation from relapse-remitting EAE, and that CNS-infiltrating CD3(+) T cells are diminished with exogenous OGF or intermittent blockade with LDN administration. In this paper, we aimed to determine whether OGF or LDN alter the Th effector responses of CD4(+) T lymphocytes within the CNS in established EAE. We report in these studies that the numbers of CD4(+) T lymphocytes in the CNS of EAE mice are decreased following treatment with OGF for five days but not LDN. However, modulation of the OGF-OGFr axis did not result in changes to CD4(+) Th effector cell responses in the CNS of EAE mice.

Barriers and Facilitators Related to Rehabilitation Stays in Multiple Sclerosis: A Qualitative Study

BACKGROUND

Studies have shown the positive effects of multidisciplinary rehabilitation on disability and health-related quality of life in multiple sclerosis (MS). However, many patients do not seek such treatment, even if it is available free of charge. The aim of this study was to identify facilitators and barriers related to use of such treatment options.

METHODS

Five focus group interviews with 27 MS patients were conducted. Three groups included patients who had been admitted to a multidisciplinary MS rehabilitation institution, and two groups included outpatients of a university hospital who had not applied for specialized rehabilitation. Interviews were audiotaped and transcribed, and were analyzed qualitatively by means of a modified form of systematic text condensation.

RESULTS

Important factors influencing the use of an MS rehabilitation service were 1) the availability and suitability of initial information about the disease and the service, 2) assumptions and expectations about such a service, and 3) practical barriers in the patient's life. The prospect of having a retreat from work and family was described as a motivational factor. Lack of reorientation after diagnosis, fears and perceptions of being labeled as an MS patient, or having information overload and being confronted with disabled individuals were identified as barriers.

CONCLUSIONS

Communication skills, including information-giving skills, of neurologists in relation to newly diagnosed MS patients need improvement. Rehabilitation programs for MS patients should include stays of different durations and purposes to fit patients' needs. Health-care authorities should take measures to secure equal access to information about rehabilitation options across institutions and practicing physicians.

Calcium-phosphate metabolism in patients with multiple sclerosis

INTRODUCTION AND OBJECTIVES

The purpose of this study was to evaluate the concentration of 25-hydroxycholecalciferol and parameters of calcium-phosphate metabolism at different periods of relapsing-remitting multiple sclerosis (RRMS).

MATERIALS AND METHODS

Forty-five patients, residents of Poland (49°-50°, N), were enrolled in the study, i.e. 15 immediately after the diagnosis of RRMS, 15 at the early stage and 15 at the advanced stage of RRMS. The results were compared to values obtained in 20 age- and sex-matched controls.

RESULTS

Lower serum concentrations of 25-hydroxycholecalciferol and ionised calcium were found in patients compared to the control group. In patients with the disease duration of 5-6 years, concentrations of 25-hydroxycholecalciferol and ionised calcium were lower than in patients in the earlier period of RRMS. The inverse and clearer direction of changes was found in parathormone serum concentration in patients compared to the controls. In patients with a longer disease duration, a significantly lower 25-hydroxycholecalciferol concentration was found in female patients compared to male patients. In patients, more frequent 25-hydroxycholecalciferol and unsaturated fatty acids' supplementation was observed compared to the controls.

CONCLUSIONS

In RRMS patients, calcium-phosphate metabolism is disturbed which increases during disease progression.

Exacerbation of autoimmune neuroinflammation by dietary sodium is genetically controlled and sex specific

Multiple sclerosis (MS) is a debilitating autoimmune neuroinflammatory disease influenced by genetics and the environment. MS incidence in female subjects has approximately tripled in the last century, suggesting a sex-specific environmental influence. Recent animal and human studies have implicated dietary sodium as a risk factor in MS, whereby high sodium augmented the generation of T helper (Th) 17 cells and exacerbated experimental autoimmune encephalomyelitis (EAE), the principal model of MS. However, whether dietary sodium interacts with sex or genetics remains unknown. Here, we show that high dietary sodium exacerbates EAE in a strain- and sex-specific fashion. In C57BL6/J mice, exposure to a high-salt diet exacerbated disease in both sexes, while in SJL/JCrHsd mice, it did so only in females. In further support of a genetic component, we found that sodium failed to modify EAE course in C57BL6/J mice carrying a 129/Sv-derived interval on chromosome 17. Furthermore, we found that the high-sodium diet did not augment Th17 or Th1 responses, but it did result in increased blood-brain barrier permeability and brain pathology. Our results demonstrate that the effects of dietary sodium on autoimmune neuroinflammation are sex specific, genetically controlled, and CNS mediated.

Exacerbation of autoimmune neuroinflammation by dietary sodium is genetically controlled and sex specific

Multiple sclerosis (MS) is a debilitating autoimmune neuroinflammatory disease influenced by genetics and the environment. MS incidence in female subjects has approximately tripled in the last century, suggesting a sex-specific environmental influence. Recent animal and human studies have implicated dietary sodium as a risk factor in MS, whereby high sodium augmented the generation of T helper (Th) 17 cells and exacerbated experimental autoimmune encephalomyelitis (EAE), the principal model of MS. However, whether dietary sodium interacts with sex or genetics remains unknown. Here, we show that high dietary sodium exacerbates EAE in a strain- and sex-specific fashion. In C57BL6/J mice, exposure to a high-salt diet exacerbated disease in both sexes, while in SJL/JCrHsd mice, it did so only in females. In further support of a genetic component, we found that sodium failed to modify EAE course in C57BL6/J mice carrying a 129/Sv-derived interval on chromosome 17. Furthermore, we found that the high-sodium diet did not augment Th17 or Th1 responses, but it did result in increased blood-brain barrier permeability and brain pathology. Our results demonstrate that the effects of dietary sodium on autoimmune neuroinflammation are sex specific, genetically controlled, and CNS mediated.

Patient preferences for attributes of multiple sclerosis disease-modifying therapies: development and results of a ratings-based conjoint analysis

BACKGROUND

Timely individualized treatment is essential to improving relapsing-remitting multiple sclerosis (RRMS) patient health outcomes, yet little is known about how patients make treatment decisions. We sought to evaluate RRMS patient preferences for risks and benefits of treatment.

METHODS

Fifty patients with RRMS completed conjoint analysis surveys with 16 hypothetical disease-modifying therapy (DMT) medication profiles developed using a fractional factorial design. Medication profiles were assigned preference ratings from 0 (not acceptable) to 10 (most favorable). Medication attributes included a range of benefits, adverse effects, administration routes, and market durations. Analytical models used linear mixed-effects regression.

RESULTS

Participants showed the highest preference for medication profiles that would improve their symptoms (β = 0.81-1.03, P < .001), not a proven DMT outcome. Preventing relapses, the main clinical trial outcome, was not associated with significant preferences (P = .35). Each year of preventing magnetic resonance imaging changes and disease symptom progression showed DMT preferences of 0.17 point (β = 0.17, P = .002) and 0.12 point (β = 0.12, P < .001), respectively. Daily oral administration was preferred over all parenteral routes (P < .001). A 1% increase in death or severe disability decreased relative DMT preference by 1.15 points (P < .001).

CONCLUSIONS

Patient preference focused on symptoms and prevention of progression but not on relapse prevention, the proven drug outcome. Patients were willing to accept some level of serious risk for certain types and amounts of benefits, and they strongly preferred daily oral administration over all other options.

Single-use autoinjector for once-weekly intramuscular injection of IFNβ-1a

INTRODUCTION

IFNβ products and glatiramer acetate are established treatment first-line options in long-term disease-modifying therapy of multiple sclerosis (MS). These self-injectable medications are used once weekly to once daily. Injection-related issues are common patient-cited reasons for nonadherence. Autoinjectors have been shown to support long-term adherence to injectable medications. The ability to self-inject in MS patients has been associated with a reduced risk of missed injections and drug discontinuation, and a beneficial effect on patient independence.

AREAS COVERED

The recently introduced easy-to-use prefilled once-weekly pen is a safe and effective device for intramuscular (IM) IFNβ-1a application and provides a convenient method for self-injection. We reviewed the available published evidence on the characteristics of this device. The once-weekly pen facilitates self-injection and was preferred over prefilled syringes by patients in a prospective open-label, multicenter Phase IIIb trial in MS patients who had been using IM IFNβ-1a in prefilled syringes.

EXPERT OPINION

The simple and safe handling, shielded short needle, single-use disposable design and virtually painless injection by the device may contribute to adherence, quality of life and independence in patients using IM IFNβ-1a.

Reliability of spatial-temporal gait parameters during dual-task interference in people with multiple sclerosis. A cross-sectional study

PURPOSE

To evaluate the reliability and minimum detectable change (MDC) of spatial-temporal gait parameters in subjects with multiple sclerosis (MS) during dual tasking.

METHOD

This cross-sectional study involved 25 healthy subjects (mean age 49.9 ± 15.8 years) and 25 people with MS (mean age 49.2 ± 11.5 years). Gait under motor-cognitive and motor-motor dual tasking conditions was evaluated in two sessions separated by a one-day interval using the GAITRite Walkway System. Test-retest reliability was assessed using intraclass correlation coefficients (ICCs), standard errors of measurement (SEM), and coefficients of variation (CV). MDC scores were computed for the velocity, cadence, step and stride length, step and stride time, double support time, the % of gait cycle for single support and stance phase, and base of support.

RESULTS

All of the gait parameters reported good to excellent ICCs under both conditions, with healthy subject values of >0.69 and MS subject values of >0.84. SEM values were always below 18% for both groups of subjects. The gait patterns of the people with MS were slightly more variable than those of the normal controls (CVs: 5.88-41.53% vs 2.84-30.48%).

CONCLUSIONS

The assessment of quantitative gait parameters in healthy subjects and people with MS is highly reliable under both of the investigated dual tasking conditions.

Gender-related protection from or vulnerability to severe CNS diseases: gonado-structural and/or gonado-activational? A meta-analysis of relevant epidemiological studies

BACKGROUND

A vast scientific literature has dealt with gender-specific risk for brain disorder. That field is evolving toward a consensus to the effect that the estrogen hormone family is outstandingly and uniquely neuroprotective. However, the epidemiology relevant to this general outlook remains piecemeal.

METHOD

The present investigation strategically formats the relevant epidemiological findings around the world in order to quantitatively meta-analyze gender ratio of risk for a variety of relevant severe central nervous system (CNS) diseases at all three gonadal stages of the life cycle, pre pubertal, post adolescent/pre menopausal, and post menopausal.

RESULTS

The data quantitatively establish that (1) no single epidemiological study should be cited as evidence of gender-specific neuroprotection against the most common severe CNS diseases because the gender-specific risk ratios are contradictory from one study to the other; (2) risk for severe CNS disease is indeed significantly gender-specific, but either gender can be protected: it depends on the disease, not at all on the age bracket.

CONCLUSION

Our assay of gender-specific risk for severe brain disease around the world has not been able to support the idea according to which any one gender-prevalent gonadal steroid hormone dominates as a neuroprotective agent at natural concentrations.

Patient centered decision making: use of conjoint analysis to determine risk-benefit trade-offs for preference sensitive treatment choices

Understanding patient preferences facilitates shared decision-making and focuses on patient-centered outcomes. Little is known about relapsing-remitting multiple sclerosis (RRMS) patient preferences for disease modifying therapies (DMTs). We use choice based conjoint (CBC) analysis to calculate patient preferences for risk/benefit trade-offs for hypothetical DMTs.

METHODS

Patients with RRMS were surveyed between 2012 and 2013. Our CBC survey mimicked the decision-making process and trade-offs of patients choosing DMTs, based on all possible DMT attributes. Mixed-effects logistic regression analyzed preferences. We estimated maximum acceptable risk trade-offs for various DMT benefits.

RESULTS

Severe side-effect risks had the biggest impact on patient preference with a 1% risk, decreasing patient preference five-fold compared to no risk. (OR=0.22, p<0.001). Symptom improvement was the most preferred benefit (OR=3.68, p<0.001), followed by prevention of progression of 10 years (OR=2.4, p<0.001). Daily oral administration had the third highest DMT preference rating (OR=2.08, p<0.001). Patients were willing to accept 0.08% severe risk for a year delayed relapse, and 0.22% for 4 vs 2 year prevented progression.

CONCLUSION

We provided patient preferences and risk-benefit trade-offs for attributes of all available DMTs. Evaluation of patient preferences is a key step in shared decision making and may significantly impact early drug initiation and compliance.

Sex-specific control of central nervous system autoimmunity by p38 mitogen-activated protein kinase signaling in myeloid cells

OBJECTIVE

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS), characterized by a global increasing incidence driven by relapsing-remitting disease in females. Investigators have described p38 mitogen-activated protein kinase (MAPK) as a key regulator of inflammatory responses in autoimmunity, but its role in the sexual dimorphism in MS or MS models remains unexplored.

METHODS

Toward this end, we used experimental autoimmune encephalomyelitis (EAE), the principal animal model of MS, combined with pharmacologic and genetic inhibition of p38 MAPK activity and transcriptomic analyses.

RESULTS

Pharmacologic inhibition of p38 MAPK selectively ameliorated EAE in female mice. Conditional deletion studies demonstrated that p38α signaling in macrophages/myeloid cells, but not T cells or dendritic cells, mediated this sexual dimorphism, which was dependent on the presence of adult sex hormones. Analysis of CNS inflammatory infiltrates showed that female but not male mice lacking p38α in myeloid cells exhibited reduced immune cell activation compared with controls, whereas peripheral T-cell priming was unaffected in both sexes. Transcriptomic analyses of myeloid cells revealed differences in p38α-controlled transcripts comprising female- and male-specific gene modules, with greater p38α dependence of proinflammatory gene expression in females.

INTERPRETATION

Our findings demonstrate a key role for p38α in myeloid cells in CNS autoimmunity and uncover important molecular mechanisms underlying sex differences in disease pathogenesis. Taken together, our results suggest that the p38 MAPK signaling pathway represents a novel target for much needed disease-modifying therapies for MS.

Multiple sclerosis in malaysia: demographics, clinical features, and neuroimaging characteristics

Background. Multiple sclerosis (MS) is an uncommon disease in multiracial Malaysia. Diagnosing patients with idiopathic inflammatory demyelinating diseases has been greatly aided by the evolution in diagnostic criterion, the identification of new biomarkers, and improved accessibility to neuroimaging in the country. Objectives. To investigate the spectrum of multiple sclerosis in Malaysia. Methods. Retrospective analysis with longitudinal follow-up of patients referred to a single tertiary medical center with neurology services in Malaysia. Results. Out of 245 patients with idiopathic inflammatory demyelinating disease, 104 patients had multiple sclerosis. Female to male ratio was 5 : 1. Mean age at onset was 28.6 ± 9.9 years. The Malays were the predominant racial group affected followed by the Chinese, Indians, and other indigenous groups. Subgroup analysis revealed more Chinese having neuromyelitis optica and its spectrum disorders rather than multiple sclerosis. Positive family history was reported in 5%. Optic neuritis and myelitis were the commonest presentations at onset of disease, and relapsing remitting course was the commonest disease pattern observed. Oligoclonal band positivity was 57.6%. At disease onset, 61.5% and 66.4% fulfilled the 2005 and 2010 McDonald's criteria for dissemination in space. Mean cord lesion length was 1.86 ± 1.65 vertebral segments in the relapsing remitting group as opposed to 6.25 ± 5.18 vertebral segments in patients with neuromyelitis optica and its spectrum disorders. Conclusion. The spectrum of multiple sclerosis in Malaysia has changed over the years. Further advancement in diagnostic criteria will no doubt continue to contribute to the evolution of this disease here.

Prevalence and predictors of depression in Iranian patients with multiple sclerosis: a population-based study

Depression is a frequent symptom in multiple sclerosis (MS) which has a negative impact on quality of life and cognitive status. The purpose of this study was to determine the prevalence and associated factors of depression, and status of antidepressant use in Iranian MS patients. One-hundred and sixty patients with definite MS were included. Demographic and clinical characteristics were recorded. Fatigue and depression were evaluated using the fatigue severity scale and Beck depression inventory-II. Cognitive performance and disability were examined by mini-mental status examination and expanded disability status scale. Multiple logistic regressions were used to determine the associated factors of depression and antidepressant use. The prevalence of depression and severe depression was 59.4 and 18.1 %, respectively. However, only 21.1 % of patients were on antidepressant treatment, while the prevalence of unrecognized/untreated depression was found to be as high as 44.1 %. Multivariable analysis showed that fatigue (P < 0.0001, OR = 5.98, 95 % CI = 2.9-12.3) and older age (P = 0.027, OR = 2.24, 95 % CI = 1.09-4.6) were associated with depression in MS patient. A significant association was found between fatigue and antidepressant use (P = 0.001, OR = 6.81, 95 % CI = 2.26-20.48). Our findings demonstrate that depression is significantly associated with fatigue and older age, regardless of other factors. Moreover, despite the high prevalence of depression in MS, most patients do not receive adequate treatment.

Immunomodulatory effects of helminths and protozoa in multiple sclerosis and experimental autoimmune encephalomyelitis

Multiple sclerosis is a chronic inflammatory CNS disease, which affects about 1 in 1000 individuals in the western world. During the last couple of decades, epidemiological data have accumulated, pointing towards increases in incidence. This has been suggested to be linked to the relatively high hygiene standards that exist in the western world, with reduced exposure to various pathogens, including parasites, as a consequence. Parasites are known to employ various immunomodulatory and anti-inflammatory strategies, which enable them to evade destruction by the immune system. This is most likely one of the reasons for the disease-dampening effects, reported in numerous studies investigating parasite infections and autoimmunity. This review will focus on recent advances in the field of parasites as beneficial immunomodulators, in multiple sclerosis and the animal model experimental autoimmune encephalomyelitis.

Ischemic colitis with type I interferons used in the treatment of hepatitis C and multiple sclerosis: an evaluation from the food and drug administration adverse event reporting system and review of the literature

OBJECTIVE

To better characterize the association between type I interferons and ischemic colitis (IC) in patients with the hepatitis C virus (HCV) and multiple sclerosis (MS), by analyzing reports submitted to the Food and Drug Administration (FDA) Adverse Event Reporting System (AERS) and the published literature.

DATA SOURCES

A total of 2,562,390 reports of adverse events between January 2003 and June 2011 were downloaded from the FDA AERS. A literature review was performed on PubMed (January 1966-August 2012) using the MeSH terms interferon or interferon alfa or interferon beta and ischemic colitis separated by the Boolean operator "and" between the first 3 terms and the last term. Additional literature was identified by conducting a hand search of the reference list of the published literature identified in the initial search.

STUDY SELECTION AND DATA EXTRACTION

Cases were restricted to those with an indication of HCV or MS, a primary suspect drug of a type I interferon, and a reaction of IC. Full-length reports were requested and organized by type of interferon, age, sex, concomitant drugs, and comorbidities. The Naranjo probability scale was used to define cases as definite, probable, possible, or doubtful drug-induced adverse events.

DATA SYNTHESIS

Type I interferons, including interferon alfa (IFN-α) and interferon beta (IFN-β), are approved for the treatment of HCV and MS. IFN-α has been shown to induce IC, but a relationship between type I interferons and IC has not been clarified in the medical literature. Fifty-six primary suspect reports of type I interferons associated with IC in patients with HCV or MS were identified from the FDA AERS. Seventeen cases were reported with IFN-α and 39 cases were reported with IFN-β. The majority of the cases were in females (80%) and those between the ages of 50 and 65 years (52%). The Naranjo probability scale identified 13 probable and 4 possible cases of IFN-α-induced IC, and 19 probable and 20 possible cases of IFN-β-induced IC. In the literature, 11 cases of IFN-α-induced IC were reported, while there were no reports with IFN-β.

CONCLUSIONS

Our study suggests a possible association between treatment with type I interferons and the development of IC. Further research to determine the mechanism of this association is warranted.

From genes to characteristics of multiple sclerosis

Multiple sclerosis (MS) is an inflammatory, demyelinating heterogeneous disease of the central nervous system, probably caused by an interaction of common genetic and environmental factors. Much progress has been made through the last few years in genetic studies of MS, and a growing list of genetic risk factors is now available. Biobanking and large collaborations have been prerequisites for this research, and detailed genetic and molecular characterizations are underway, with hopes for to translating new knowledge about MS pathogenesis and characteristics of the disease to personalized, better treatment options for each patient with MS.

The effects of cognitive loading on balance control in patients with multiple sclerosis

The aim of this study was to compare the effects of concurrent cognitive task (silent backward counting) on balance performance between two groups of multiple sclerosis (MS) (n=23) and healthy (n=23) participates. Three levels of postural difficulty were studied on a force platform, i.e. rigid surface with eyes open, rigid surface with eyes closed, and foam surface with eyes closed. A mixed model analysis of variance showed that under difficult sensory condition of foam surface with eyes closed, execution of concurrent cognitive task caused a significant decrement in variability of sway velocity in anteroposterior direction for the patient group (P<0.01) while this was not the case for healthy participants (P=0.22). Also, the variability of sway velocity in mediolateral direction was significantly decreased during concurrent execution of cognitive task in patient group (P<0.01) and not in healthy participants (P=0.39). Furthermore, in contrast to single tasking, dual tasking had the ability to discriminate between the 2 groups in all conditions of postural difficulty. In conclusion, findings of variability in sway velocity seem to confirm the different response to cognitive loading between two groups of MS and healthy participants.