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Pilotto S, Gencarelli J, Bova S, Gerosa L, Baroncini D, Olivotto S, Alfei E, Zaffaroni M, Suppiej A, Cocco E, Trojano M, Amato MP, D'Alfonso S, Martinelli-Boneschi F, Waubant E, Ghezzi A, Bergamaschi R, Pugliatti M. Etiological research in pediatric multiple sclerosis: A tool to assess environmental exposures (PEDiatric Italian Genetic and enviRonment ExposurE Questionnaire). Mult Scler J Exp Transl Clin 2021; 7:20552173211059048. [PMID: 34868629 PMCID: PMC8640303 DOI: 10.1177/20552173211059048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background The etiology of pediatric-onset multiple sclerosis is unknown although putative genetic and environmental factors appear to be involved. Among children multiple sclerosis onset occurs closer to the susceptibility window thank in adults and the exposure to etiological environmental factors is more informative. An Italian multicentre case-control study (the PEDiatric Italian Genetic and enviRonment ExposurE, PEDIGREE study) was designed to investigate environmental exposures in pediatric-onset multiple sclerosis and their interaction with genetics. Objectives To collect evidence on exposures to environmental risk factors in pediatric-onset multiple sclerosis, a questionnaire was developed for the Italian population (PEDIGREE Questionnaire) and is presented. Methods PEDIGREE Questionnaire develops from an existing tool used in case-control studies on pediatric-onset multiple sclerosis in US Americans, and was translated, adapted and tested for the contents perceived relevance, acceptability, feasibility and reliability in a population of Italian pediatric subjects and their parents recruited from clinics and general population. Results PEDIGREE Questionnaire contents were overall deemed relevant by the study population, acceptable for 100% participants and feasible for at least 98%. PEDIGREE Questionnaire degree of reliability ranged 56% to 72%. Conclusion PEDIGREE Questionnaire proves to be an efficient tool to assess environmental exposures in the Italian pediatric population. We encourage the dissemination of population-specific questionnaires and shared methodology to optimize efforts in MS etiological research.
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Affiliation(s)
- Silvy Pilotto
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Jessica Gencarelli
- Department of Medical Sciences - Pediatric Section, University of Ferrara, Ferrara, Italy
| | - Stefania Bova
- Pediatric Neurology Unit, V. Buzzi Children's Hospital, Milan, Italy
| | - Leonardo Gerosa
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | | | | | - Enrico Alfei
- Pediatric Neurology Unit, V. Buzzi Children's Hospital, Milan, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Centre, ASST Valle Olona, Gallarate, Italy
| | - Agnese Suppiej
- Department of Medical Sciences - Pediatric Section, University of Ferrara, Ferrara, Italy
| | - Eleonora Cocco
- Department Medical Science and Public Health, University of Cagliari, Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Italy
| | | | | | | | - Emmanuelle Waubant
- Department of Neurology, UC San Francisco, San Francisco, California, USA
| | - Angelo Ghezzi
- Multiple Sclerosis Centre, ASST Valle Olona, Gallarate, Italy
| | | | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, Interdepartmental Research Center for the Study of Multiple Sclerosis and Inflammatory and Degenerative Diseases of the Nervous System, University of Ferrara, Ferrara, Italy
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Cohen JA, Trojano M, Mowry EM, Uitdehaag BMJ, Reingold SC, Marrie RA. Leveraging real-world data to investigate multiple sclerosis disease behavior, prognosis, and treatment. Mult Scler 2020; 26:23-37. [PMID: 31778094 PMCID: PMC6950891 DOI: 10.1177/1352458519892555] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/10/2019] [Indexed: 12/21/2022]
Abstract
Randomized controlled clinical trials and real-world observational studies provide complementary information but with different validity. Some clinical questions (disease behavior, prognosis, validation of outcome measures, comparative effectiveness, and long-term safety of therapies) are often better addressed using real-world data reflecting larger, more representative populations. Integration of disease history, clinician-reported outcomes, performance tests, and patient-reported outcome measures during patient encounters; imaging and biospecimen analyses; and data from wearable devices increase dataset utility. However, observational studies utilizing these data are susceptible to many potential sources of bias, creating barriers to acceptance by regulatory agencies and the medical community. Therefore, data standardization and validation within datasets, harmonization across datasets, and application of appropriate analysis methods are important considerations. We review approaches to improve the scope, quality, and analyses of real-world data to advance understanding of multiple sclerosis and its treatment, as an example of opportunities to better support patient care and research.
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Affiliation(s)
- Jeffrey A Cohen
- Department of Neurology, Mellen Center for
Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland
Clinic, Cleveland, OH, USA
| | - Maria Trojano
- Department of Basic Medical Sciences,
Neurosciences and Sense Organs, University of Bari “Aldo Moro,” Bari,
Italy
| | - Ellen M Mowry
- Department of Neurology, School of Medicine, The
Johns Hopkins University, Baltimore, MD, USA
| | - Bernard MJ Uitdehaag
- Department of Neurology, Amsterdam University
Medical Center, Amsterdam, The Netherlands
| | | | - Ruth Ann Marrie
- Departments of Internal Medicine (Neurology) and
Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College
of Medicine, University of Manitoba, Winnipeg, MB, Canada
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van Rensburg SJ, Peeters AV, van Toorn R, Schoeman J, Moremi KE, van Heerden CJ, Kotze MJ. Identification of an iron-responsive subtype in two children diagnosed with relapsing-remitting multiple sclerosis using whole exome sequencing. Mol Genet Metab Rep 2019; 19:100465. [PMID: 30963028 PMCID: PMC6434495 DOI: 10.1016/j.ymgmr.2019.100465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/16/2019] [Accepted: 03/16/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Multiple sclerosis is a disorder related to demyelination of axons. Iron is an essential cofactor in myelin synthesis. Previously, we described two children (males of mixed ancestry) with relapsing-remitting multiple sclerosis (RRMS) where long-term remission was achieved by regular iron supplementation. A genetic defect in iron metabolism was postulated, suggesting that more advanced genetic studies could shed new light on disease pathophysiology related to iron. METHODS Whole exome sequencing (WES) was performed to identify causal pathways. Blood tests were performed over a 10 year period to monitor the long-term effect of a supplementation regimen. Clinical wellbeing was assessed quarterly by a pediatric neurologist and regular feedback was obtained from the schoolteachers. RESULTS WES revealed gene variants involved in iron absorption and transport, in the transmembrane protease, serine 6 (TMPRSS6) and transferrin (TF) genes; multiple genetic variants in CUBN, which encodes cubilin (a receptor involved in the absorption of vitamin B12 as well as the reabsorption of transferrin-bound iron and vitamin D in the kidneys); SLC25A37 (involved in iron transport into mitochondria) and CD163 (a scavenger receptor involved in hemorrhage resolution). Variants were also found in COQ3, involved with synthesis of Coenzyme Q10 in mitochondria. Neither of the children had the HLA-DRB1*1501 allele associated with increased genetic risk for MS, suggesting that the genetic contribution of iron-related genetic variants may be instrumental in childhood MS. In both children the RRMS has remained stable without activity over the last 10 years since initiation of nutritional supplementation and maintenance of normal iron levels, confirming the role of iron deficiency in disease pathogenesis in these patients. CONCLUSION Our findings highlight the potential value of WES to identify heritable risk factors that could affect the reabsorption of transferrin-bound iron in the kidneys causing sustained iron loss, together with inhibition of vitamin B12 absorption and vitamin D reabsorption (CUBN) and iron transport into mitochondria (SLC25A37) as the sole site of heme synthesis. This supports a model for RRMS in children with an apparent iron-deficient biochemical subtype of MS, with oligodendrocyte cell death and impaired myelination possibly caused by deficits of energy- and antioxidant capacity in mitochondria.
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Key Words
- CNS, central nervous system
- CoQ, Coenzyme Q
- DFO, desferroxamine mesylate
- DIS, dissemination in space
- DIT, dissemination in time
- DMT, disease modifying therapy
- EDSS, Expanded Disability Status Scale
- ETC, electron transport chain
- GWAS, genome-wide association study
- Genetic variants
- HDL, high density lipoprotein
- HERV-W, human endogenous retrovirus W
- HLA, human leukocyte antigen
- HREC, human research ethics committee
- IPMSSG, International Pediatric Multiple Sclerosis Study Group
- IRE, iron-response element
- Iron deficiency
- MGA1, juvenile hereditary megaloblastic anemia 1
- MRI, magnetic resonance imaging
- MS, Multiple sclerosis
- MSRV, MS-associated retrovirus
- MST1R, macrophage stimulating-1 receptor
- Mitochondria
- Oxidative stress
- PSGT, pathology supported genetic testing
- Pediatric onset multiple sclerosis
- ROS, reactive oxygen species
- RRMS, relapsing-remitting MS
- SAMe, S-adenosyl methionine
- SDHB, iron-protein subunit of Complex II
- TF, transferrin
- TMPRSS6, transmembrane protease, serine 6
- WES, whole exome sequencing
- Whole exome sequencing
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Affiliation(s)
- Susan J. van Rensburg
- Division of Chemical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Armand V. Peeters
- Division of Anatomical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ronald van Toorn
- Paediatric Medicine and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Johan Schoeman
- Paediatric Medicine and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kelebogile E. Moremi
- Division of Chemical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carel J. van Heerden
- Central Analytical Facility (CAF), DNA Sequencing Unit, Stellenbosch University, Stellenbosch, South Africa
| | - Maritha J. Kotze
- Division of Chemical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, National Health Laboratory Service (NHLS), Cape Town, South Africa
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