Diurnal variations in vision and relations to circadian melatonin secretion in multiple sclerosis

Effect of melatonin intake on postural balance, functional mobility and fall risk in persons with multiple sclerosis: a pilot study

AIM

To assess the safety and the effect of a nocturnal melatonin (MEL) ingestion on postural balance, functional mobility and fall risk the following morning in adults with multiple sclerosis (MS).

METHODS

Fourteen adults with relapsing-remitting MS (RR-MS) (28.36 ± 6.81 years) were evaluated before and after nocturnal ingestion of MEL (6 mg) or placebo (PLA). Evaluations included a posturographic test of static bipedal postural balance with dual-task in eyes open (EO) and eyes closed conditions, and a clinical test of unipedal balance. The physical performance tests were: Timed Up and Go test (TUGT) (mobility), Four Square Step Test (FSST) (fall risk), and Timed 25-foot walk test (T25FWT) (walking speed). Cognitive performance [Montreal Cognitive Assessment (MoCA) and Simple Reaction Time (SRT) tests] and sleep quality [Spiegel's sleep questionnaire (SSQ)] were also assessed.

RESULTS

In EO condition, MEL decreased the posturographic parameters [center of pressure (CoP) sway area (CoPAr), CoP path length (CoPL) and CoPL in the mediolateral axis (CoPLX)] more than PLA by 15.82% (p = 0.0006), 12.48% (p  = 0.0004) and 14.25% (p = 0.0002), respectively. Durations of TUGT and FSST decreased following MEL session more than the PLA one by 14.52% (p = 0.017) and 19.85% (p = 0.0006), respectively. MEL increased the unipedal stance time, SSQ and MoCA scores more than PLA by 49.81% (p = 0.04), 32.21% (p = 0.004) and 11.87% (p = 0.008), respectively.

CONCLUSION

This pilot study showed that acute nocturnal MEL ingestion seems to be safe for enhancing postural balance, fun mobility and fall risk in RR-MS adults probably through improving sleep quality and cognitive function.

State and trait of finger tapping performance in multiple sclerosis

Finger tapping tests have been shown feasible to assess motor performance in multiple sclerosis (MS) and were observed to be strongly associated with the estimated clinical severity of the disease. Therefore, tapping tests could be an adequate tool to assess disease status in MS. In this study we examined potential influencing factors on a maximum tapping task with the whole upper-limb for 10 s in 40 MS patients using linear mixed effects modelling. Patients were tested in three sessions with two trials per body-side per session over the course of 4–27 days of inpatient rehabilitation. Tested factors were the expanded disability scale (EDSS) score, laterality of MS, age, sex, hand dominance, time of day, session, trial (first or second), time between sessions, and the reported day form. A second model used these factors to examine the self-reported day form of patients. Linear mixed effects modelling indicated the tapping test to have a good inter-trial (proportional variance < 0.01) and inter-session reliability (non-significant; when controlling for time between sessions), an influence of hand-dominance (proportional variance 0.08), to be strongly associated with the EDSS (eta² = 0.22, interaction with laterality of MS eta² = 0.12) and to be not associated with the reported day form. The model explained 87% (p < 0.01) of variance in tapping performance. Lastly, we were able to observe a positive effect of neurologic inpatient rehabilitation on task performance obvious from a significant effect of the time between sessions (eta² = 0.007; longer time spans between sessions were associated with higher increments in performance). Day form was only impacted by EDSS and the time of the day (p < 0.01, R² = 0.57, eta²_TIME = 0.017, eta²_EDSS = 01.19). We conclude that the tapping test is a reliable and valid assessment tool for MS.

Preventive neurology concepts for training the next-generation and closing gaps in real-world Multiple Sclerosis Care

The field of Multiple sclerosis (MS) has entered an area of growth in the understanding of the MS immune dysregulation that has led to an impressive therapeutics expansion. However, results of surveys and proceedings of the American Academy of Neurology (AAN) support the notion that US neurology residents have fragmented exposure to MS training during residency, resulting in learning gaps in diagnosis, management and follow up of patients with MS. There are annual educational offerings by MS academic societies but limited and tailored to trainees interested in MS/neuroimmunology subespecialization. Therefore, the acquisition of MS clinical skills by all neurology residents is essential for the practice of unsupervised neurology after board certification. Here, we review the current elements and goals of care that are critical for the learning of trainees. We present these elements in a framework focused on current unmet needs to avoid progression in MS in a real-world setting, tailored to preventive and personalized care: The "Multiple Sclerosis 4-square Educational Matrix". This approach could help training neurologist and patients through the essential steps of care. The trainee side emphasizes a goal-oriented approach to satisfy the educational and management components of MS in four areas: burden of symptoms, burden of disease activity, personalized risk factors and personalized patient education. The patient side is similar but simplified for their benefit. This structured approach is based on the principles of personalized preventive neurology and could be useful to solidify trainees and patient education, promoting proactive participation of patients in vital areas of their care, in an anticipatory, and goal-oriented manner. We aim to improve the unmet needs at an individual level and the value of care of populations at risk for progression and disability in MS.

Melatonin reduces inflammatory response in peripheral T helper lymphocytes from relapsing-remitting multiple sclerosis patients

Multiple sclerosis (MS) is a neuroinflammatory disease of the central nervous system in which the immune system plays a central role. In particular, effector populations such as T helper (Th) 1, Th9, Th17, and Th22 cells are involved in disease development, whereas T regulatory cells (Tregs) are associated with the resolution of the disease. Melatonin levels are impaired in patients with MS, and exogenous melatonin ameliorates the disease in MS animal models by modulating the Th1/Th17/Treg responses and also improves quality of life and several symptoms in patients with MS. However, no study has examined melatonin's effect on T cells from relapsing-remitting MS (RR-MS) patients. Therefore, the objectives of the present study were to evaluate the effects of the in vitro administration of melatonin to peripheral blood mononuclear cells (PBMCs) from 64 RR-MS patients and 64 sex- and age-matched healthy subjects on Th1, Th9, Th17, Th22, and Treg responses and to analyze the expression of the melatonin effector/receptor system in these cells. Melatonin decreased Th1 and Th22 responses in patients, whereas it did not affect the Th17 and Treg subsets. Melatonin also promoted skewing toward a more protective cytokine microenvironment, as shown by an increased anti-inflammatory/Th1 ratio. Furthermore, for the first time, we describe the overexpression of the melatonin effector/receptor system in PBMCs from patients with MS; this alteration might be relevant to the disease because acetylserotonin O-methyltransferase expression significantly correlates with disease progression and T effector/regulatory responses in patients. Therefore, our data suggest that melatonin may be an effective treatment for MS.

[Melatonin as an inducing factor for multiple sclerosis]

Melatonin is one of the most multifunctional regulators in the organism. It plays a key role in the control of nerve, endocrine, and immune systems. Due to hormone neuroprotective activity, the possibility is now discussed on its clinical usage in treating neurodegenerative diseases, including multiple sclerosis. At the same time, melatonin is an effective regulator of immune reactions, in part, the reactions toward autoantigens. In this respect, the subset ofT lymphocytes producing IL-17 (Th17) is of special interest. As the Th17 subset plays a key role iri multiple sclerosis pathogenesis, the immunomodulating hormone effects toward Th17, may, in theory, nullify its positive neuroprotective activity.

Melatonin as potential inducer of Th17 cell differentiation

The subset of T lymphocytes producing IL-17 (Th17) plays a key role in the immune system. It has been implicated in host defense, inflammatory diseases, tumorigenesis, autoimmune diseases, and transplant rejection. Careful analysis of the data available holds that Th17 cell subpopulation should be under the direct control of pineal hormone melatonin: the key Th17 differentiation factor RORα serves in the meantime as a high-affinity melatonin receptor. Since the levels of melatonin have diurnal and seasonal variation, as well as substantial deviations in some physiological or pathological conditions, melatonin-dependent regulation of Th17 cells should implicate multiform manifestation, such as influencing the outcome of infectious challenge or determining predisposition, etiology and progression of immune-related morbidities. Another important reason to raise a point of the new melatonin effects is current considering the possibilities of its clinical trials. Especially, the differentiation of Th17 upon melatonin treatment must aggravate the current recession in autoimmune diseases or induce serious complications in pregnancy.

Melatonin: buffering the immune system

Melatonin modulates a wide range of physiological functions with pleiotropic effects on the immune system. Despite the large number of reports implicating melatonin as an immunomodulatory compound, it still remains unclear how melatonin regulates immunity. While some authors argue that melatonin is an immunostimulant, many studies have also described anti-inflammatory properties. The data reviewed in this paper support the idea of melatonin as an immune buffer, acting as a stimulant under basal or immunosuppressive conditions or as an anti-inflammatory compound in the presence of exacerbated immune responses, such as acute inflammation. The clinical relevance of the multiple functions of melatonin under different immune conditions, such as infection, autoimmunity, vaccination and immunosenescence, is also reviewed.

A telemetric study of physiologic changes in mice with induced autoimmune encephalomyelitis

Dysfunction of the autonomic nervous system may be an important component of disease progression in multiple sclerosis (MS), a paralytic inflammatory autoimmune disease of the central nervous system. Using the experimental autoimmune encephalomyelitis mouse model of MS, the authors carried out a pilot study to investigate whether telemetric monitoring might be a feasible approach for detecting disturbances in the autonomic control of heart rate and blood pressure after disease induction. Telemetric monitoring devices that were implanted in mice provided useful information regarding the physiologic changes that accompanied disease induction and progression. Changes were observed in heart rate, blood pressure, heart rate variability and diurnal rhythm immediately before and after disease onset. The device implantation procedure did not seem to alter the course of disease. Further investigation may establish these methods as a system for studying the relationships between MS progression and autonomic regulation of physiological status.

Chronotherapy using corticosteroids for multiple sclerosis relapses

BACKGROUND

The activity of the immune system displays a circadian rhythm. In diseases characterised by aberrant immune activity, chronotherapy (a treatment regimen tailored to diurnal body rhythms) may increase the efficiency, safety and tolerability of drugs.

AIM

To compare the outcomes of intravenous corticosteroid administration during the day or night, for treatment of acute multiple sclerosis relapses.

METHODS

17 patients with multiple sclerosis were included in the study. Clinical assessment of disability was performed at trial entry, and at days 7 and 30 from the initiation of treatment. Adverse events and preference of night-time versus daytime treatment were assessed at the end of the treatment course.

RESULTS

After night-time treatment, clinical recovery was significantly (p<0.001) enhanced and the mean number of side effects was significantly (p = 0.007) lower. Furthermore, most patients expressed a preference for night-time versus daytime treatment.

CONCLUSIONS

The study suggests a potential benefit for implementation of chronotherapy using steroid treatment for acute multiple sclerosis relapse, with implications for other immune-mediated disorders.

I. Role of the pineal gland in multiple sclerosis: a hypothesis

Despite intensive research over the past several decades, the etiology and pathogenesis of multiple sclerosis (MS) remain elusive. The last 20 years have seen only meager advances in the treatment of the disease in part because too much attention has been devoted to the process of demyelination and its relationship to the neurologic symptoms and recovery of the disease. A host of biological phenomena associated with the disease involving interactions among genetic, environmental, immunologic, and hormonal factors, cannot be explained on the basis of demyelination and, therefore, require refocusing attention on alternative explanations, one of which implicates the pineal gland as the pivotal mover of the disease. This review summarizes the evidence linking dysfunction of the pineal gland with the epidemiology, pathogenesis, clinical manifestations, and course of the disease. The pineal hypothesis of MS also provided the impetus for the development of a novel and highly effective therapeutic modality, one that involves the transcranial application of AC pulsed electromagnetic fields in the picotesla flux density.