Efficacy and safety of IVIG in CIDP: Combined data of the PRIMA and PATH studies

Intravenous immunoglobulin (IVIG) is a potential therapy for chronic inflammatory demyelinating polyneuropathy (CIDP). To investigate the efficacy and safety of the IVIG IgPro10 (Privigen) for treatment of CIDP, results from Privigen Impact on Mobility and Autonomy (PRIMA), a prospective, open‐label, single‐arm study of IVIG in immunoglobulin (Ig)‐naïve or IVIG pre‐treated subjects (NCT01184846, n = 28) and Polyneuropathy And Treatment with Hizentra (PATH), a double‐blind, randomized study including an open‐label, single‐arm IVIG phase in IVIG pre‐treated subjects (NCT01545076, IVIG restabilization phase n = 207) were analyzed separately and together (n = 235). Efficacy assessments included change in adjusted inflammatory neuropathy cause and treatment (INCAT) score, grip strength and Medical Research Council (MRC) sum score. Adverse drug reactions (ADRs) and ADRs/infusion were recorded. Adjusted INCAT response rate was 60.7% in all PRIMA subjects at Week 25 (76.9% in IVIG pre‐treated subjects) and 72.9% in PATH. In the pooled cohort (n = 235), INCAT response rate was 71.5%; median time to INCAT improvement was 4.3 weeks. No clear demographic differences were noticed between early (responding before Week 7, n = 148) and late responders (n = 21). In the pooled cohort, median change from baseline to last observation was −1.0 (interquartile range −2.0; 0.0) point for INCAT score; +8.0 (0.0; 20.0) kPa for maximum grip strength; +3.0 (1.0; 7.0) points for MRC sum score. In the pooled cohort, 271 ADRs were reported in 105 subjects (44.7%), a rate of 0.144 ADRs per infusion. This analysis confirms the efficacy and safety of IgPro10, a recently FDA‐approved IVIG for CIDP, in a population of mainly pre‐treated subjects with CIDP [Correction added on 14 March 2019 after first online publication: the INCAT response rate has been corrected.].

Cladribine induces long lasting oligoclonal bands disappearance in relapsing multiple sclerosis patients: 10-year observational study

BACKGROUND

There has been long-term interest in cladribine as a drug for the treatment of MS. The current study focused on the effect of cladribine on oligoclonal bands (OCB) expression in the CSF in relapsing-remitting MS (RRMS) patients observed over 10 years.

METHODS

29 treatment-naive subjects with RRMS were prospectively enrolled and received induction therapy with subcutaneous parenteral cladribine (at a cumulative dose of 1.8 mg/kg; divided into 6 courses every 5 weeks given for 4-6 days, depending on patients' body weight). Selected patients received maintenance doses in the follow-up period.

RESULTS

Isoelectric focusing revealed that 55% of patients did not have OCB in CSF after cladribine treatment as compared to baseline testing when 100% of patients were positive for OCB. There were no significant differences in Expanded Disability Status Scale scores at baseline and at the end of treatment cycle between OCB-positive vs. OCB-negative subgroups. At the last follow-up, OCB-negative patients had lower disability compared to OCB-positive patients (p = 0.03).

CONCLUSION

Cladribine-induced immune reconstitution leads to long lasting suppression of intrathecal humoral response, which might be an additional mechanism that enhances the therapeutic effect on disease progression in RRMS patients.

046 Efficacy and safety of intravenous immunoglobulin (IVIG) IGPRO10 in chronic inflammatory demyelinating polyneuropathy (CIDP)

Introduction

We analysed the efficacy and safety of IVIG IgPro10 (CSL Behring) in two CIDP studies: PRIMA and PATH.

Methods

PRIMA was a prospective, open-label, single-arm study in 28 CIDP patients (n=13 IVIG-pretreated; n=15 untreated) investigating efficacy and safety of IgPro10 for induction (2 g/kg) and maintenance therapy (1 g/kg every 3 weeks for 21 weeks). This regimen was also used for 207 IVIG-pretreated patients during the 10–13 week pre-randomization phase of the PATH study (before randomization to subcutaneous immunoglobulin maintenance therapy or placebo). Both studies investigated a 1-point decrease in adjusted Inflammatory Neuropathy Cause and Treatment (INCAT) disability score as a response parameter, and evaluated changes in mean grip strength and Medical Research Council (MRC) score. Treatment-emergent adverse events (AEs) were assessed.

Results

Response rate was 76.9% (95% confidence interval [CI] 49.7–91.8) in PRIMA (IVIG-pretreated patients) at week 21% and 72.9% (95%CI 66.5–78.5) in PATH at week 13; median time to first INCAT response was 3.0 and 3.7 weeks, respectively. Median (Q1;Q3) improvements in outcome measures (baseline to last observation) for PRIMA pre-treated patients and PATH, respectively, were: INCAT, −2.0 (-3.0;−1.0) and −1.0 (-2.0;0.0) points; grip strength, 5.0 (-9.0;22.0) and 9.4 (1.3;18.8) kPa; and MRC score, 5.0 (3.0;10.0) and 3.0 (0.0;6.0) points. In the PRIMA safety population (n=28), 108 AEs occurred in 22 (78.6%) patients (0.417/infusion); 284 AEs in 100 (48.3%) patients (0.175/infusion) were reported in the PATH safety population (n=207). Headache was the most frequent AE. Causally related serious AEs in PRIMA and PATH occurred in 2 and 7 patients, respectively.

Conclusion

Similar efficacy results of IgPro10 in CIDP were observed in PRIMA and the PATH pre-randomization period. IgPro10 is well tolerated, with clinically meaningful improvement in disability in CIDP patients.

Study Support

CSL Behring

Standards in neurosonology. Part III

The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specific brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specific clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-to-left shunts, confirmation of the arrest of the cerebral circulation, an assessment of the functional efficiency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity).

Standards in neurosonology. Part II

The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specific brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specific clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-to-left shunts, confirmation of the arrest of the cerebral circulation, an assessment of the functional efficiency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity).

Standards in neurosonology. Part I

The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specific brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specific clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-toleft shunts, confirmation of the arrest of the cerebral circulation, an assessment of the functional efficiency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity).

Aggressive behavior as a rare side effect of subthalamic stimulation in Parkinson's disease

Although deep brain stimulation (DBS) has a well-established position in the treatment of Parkinson's disease (PD), it may be accompanied by different side effects including behavioral changes. We present a patient with advanced PD after bilateral stimulation of the subthalamic nucleus (STN) who developed attacks of aggressive behavior. The patient with a 12 year history of PD underwent the procedure of DBS with one-stage bilateral stereotactic approach using the Leksel G stereotactic frame. For STN identification microrecording technique was applied (5 microelectrodes). Four weeks after surgery STN stimulation was switched on. With increasing the amplitude of stimulation on the right (active contacts 1 and 2) the patient experienced transient episodes of aggression. Change of stimulation mode led to withdrawal of all side effects. We hypothesize that aggression episodes in the patient were caused by stimulation of limbic circuit probable within STN although we cannot exclude simultaneous stimulation of neighboring structures. Aggression episodes are rare side effect of STN-DBS, nevertheless they may be expected in more posteromedial placement of the electrode within STN. The presented case extends the evidence for non-motor functions of STN and highlights its role as an integrating structure within the basal ganglia system.

[Evaluation of the effectiveness of add-on therapy with tiagabine and evaluation of cognitive functions after application of this therapy in patients with drug-resistant focal epilepsy - an observational study (GABI-EPI)]

OBJECTIVE

To assess the efficacy of add-on therapy with tiagabine and cognitive functions in patients with drug-resistant focal epilepsy, when used in everyday clinical practice.

MATERIALS AND METHODS

The total number of 437 patients with drug-resistant epilepsy with focal seizures were observed; 436 patients were treated with tiagabine as add-on therapy at a dose of 5-50 mg per day. During the study a number visits were secheduled: Visit V0 - upon enrolment of tiagabine-treated patients into the observational study, visit V1 - four weeks after reaching the initial dose of tiagabine, visit V2 - four weeks after reaching the target dose of tiagabine. The type and number of epileptic seizures, antiepileptic therapy used, concomitant treatment and adverse events were analysed. Analyses were performed using McNemar's, Wilcoxon's, Mann-Whitney's and Fisher's tests. The patients'cognitive functions were assessed using the MM SE scale.

RESULTS

The mean observation time was 90 days. Men accounted for 48.3% of the study population and their average age was 41,5±14,0 and women accounted for 51.7% and their average age was 43.4±13.9. About 80% of the patients received valproic acid or carbamazepine before administration of tiagabine. Other most commonly used drugs included acetylsalicylic acid and ramipril. In the group of 185 patients who used drugs inducing liver enzymes before administration of tiagabine, 13% received a dose below 30 mg of tiagabine and 87% above 30 mg. In the group of patients treated with drugs which do not induce liver enzymes, 91.6% received tiagabine in a dose below 30 mg and 8.4% in a dose above 30 mg. The percentage of patients experiencing epileptic seizures was reduced from 72.2% between visits V0-V1 to 58.7% between visits V1-V2 (p<0.001). A decrease in the population of patients who experienced seizures and a reduction of the number of seizures were observed in all age groups. In the youngest age group, the number of seizures since the last visit went down from 5.4 to 3.7 (the average difference amounted to 1.7), in the 40-59 years age group, the number of seizures went down from 4.0 to 3.1 (the average difference amounted to 0.9) and in patients above the age of 60, from 3.0 to 2.1 (the average difference amounted to 0.9) (p<0.001; p=0.001 and p<0.001, respectively). Adverse events occurred in 4 (i.e. 0.9%) patients, dizziness being the most common. The Mini Mental State Examination (MM SE) was performed in 25% of patients. Cognitive functions did not deteriorate. The average MM SE score corresponded to a mild level of cognitive impairment.

CONCLUSIONS

Tiagabine is a well tolerated drug providing effective control of focal seizures and in a sub-population of 25% patients whose cognitive functions were evaluated using MM SE, no significant adverse effect of the drug on such functions was observed.

Disappearance of white matter lesions on MRI and clinical recovery after initiating antiretroviral therapy in a case of HIV infection presenting as spastic paraparesis

We present a case of a 30-year-old Polish female who presented with increasing for about 2 years spastic paraparesis and urinary incontinence. She denied any risky sexual behaviors, drug abuse, there was no history of surgery or blood transfusions. MRI of the brain showed diffuse, hyperintensive in T2, poorly defined lesions in the white matter. About 3 months later paraparesis increased and control MRI showed progression of previously described lesions. She was then diagnosed with HIV infection. There was a suspicion of progressive multifocal leucoencephalopathy (PML) or vacuolar myelopathy in the course of HIV infection. Antiretroviral treatment was initiated leading, together with rehabilitation, to a progressive improvement of symptoms. Pathological lesions on brain MRI completely disappeared. In conclusion, HIV test should be done in every patient with neurological signs of unknown cause.

Quality of life in Polish patients with multiple sclerosis

PURPOSE

This study is a pilot evaluation of the quality of life (QoL) in Polish patients with multiple sclerosis (MS).

MATERIAL/METHODS

Data from 21 centers in Poland were collected from May 2008 to January 2009. QoL was assessed using the questionnaire Euro Quality of Life (EQ-5D), with Polish population norms. Demographic profile of patients, duration/form/relapsing activity of the disease, disability and comorbidity were also analyzed.

RESULTS

Data from 3521 patients (F/M ratio 2.4:1) were collected. The average EQ-5D index was 0.8 ± 0.27 and the mean score in a visual analog scale (EQ-VAS) was 65.6 ± 21.5. There was a highly significant positive correlation between both indices (r=0.7334, p<0.0001). The mean patient age was 40.7 years (11.2-92.3 years) and disease duration was 10.3 ± 8.8 years (0.04-53 years). 74.2% of subjects had relapsing-remitting form of MS, while 17.2% were classified as secondary progressive and 8.6% as primary progressive. In the group of relapsing-remitting MS subjects there were 2.5% patients with "benign MS". The average degree of disability on EDSS scale was 3.6 ± 2.2, while disability ≥6 was observed in 20.3% of patients. Most patients did not have other diseases besides MS.

CONCLUSIONS

This is the first large study of QoL in patients with MS in Poland (approximately 18% of all patients). Our results confirm a reduction in QoL compared with the general population. Further studies are indicated to identify the modifiable risk factors (e.g. type of treatment) that may affect QoL.

Impact of cladribine therapy on changes in circulating dendritic cell subsets, T cells and B cells in patients with multiple sclerosis

BACKGROUND

Cladribine causes sustained reduction in peripheral T and B cell populations while sparing other immune cells. We determined two populations of dendritic cells (DCs): namely CD1c(+)/CD19(-) (myeloid DCs) and CD303(+)/CD123(+) (plasmacytoid DCs), CD19(+) B lymphocytes, CD3(+) T lymphocytes and CD4(+) or CD8(+) subpopulations in patients with multiple sclerosis after cladribine therapy.

METHODS

We examined 50 patients with secondary progressive multiple sclerosis (SP MS) according to McDonalds et al.'s criteria, 2001 [15]. Blood samples were collected before the initiation of cladribine therapy and after 1st, 2nd, 3th, 4th and 5th courses of treatment. DC subsets, T and B cells were analyzed by flow cytometry.

RESULTS

During cladribine treatment the myeloid DCs CD1c(+)/CD19(-) did not change (p=0.73175), and the plasmacytoid DCs CD303(+)/CD123(+) significantly increased (p=0.00034) which resulted in significant changes in the ratio of myeloid DCs to plasmacytoid DCs (p=0.00273). During therapy, B lymphocyte CD19(+) significantly decreased (p=0.00005) and significant changes in CD4(+) cells (p=0.00191), changes in CD8(+) cells (p=0.05760) and significant changes in CD3(+) (p=0.01822) were found.

CONCLUSIONS

We noticed significant trend to increase the CD303(+) circulating the dendritic cells. This population produces large amounts of IFN-alfa. We found significant and rapid decrease in B cells and CD4(+) Th cells. Our results suggest two possible ways of beneficial cladribine influence on immune system in MS. Induction of IFN-alfa producing cells and their predominance over BDCA-1(+) DCs, which are associated with cytotoxic response. Additionally, cladribine could influence two populations of lymphocytes: B cells and Th lymphocytes responsible for induction of immune response against myelin antigens.

Paraoxonase 1 activity in multiple sclerosis patients during mitoxantrone therapy

OBJECTIVES

It has been implicated in many studies that reactive oxygen species play a role in the development of demyelination in multiple sclerosis (MS). Paraoxonase 1 (PON1) is an antioxidant enzyme that protects cell membranes against oxidative modification. Mitoxantrone is a cytotoxic drug approved for the treatment of MS with adverse effects associated potentially with an increased level of oxidative stress. The aim of this study was to assess the influence of mitoxantrone therapy on PON1 activity in patients with MS.

METHODS

A studied group included 26 patients with secondary progressive MS, 16 women and 10 men. The blood was collected before the beginning of the therapy as well as after 6 and 12 months. Patients were receiving mitoxantrone every 12 weeks. Serum PON1 activity was assayed using two synthetic substrates: paraoxon and phenyl acetate.

RESULTS

Paraoxonase 1 activity toward paraoxon and phenyl acetate and lipid profile did not change significantly in patients receiving mitoxantrone.

CONCLUSIONS

Mitoxantrone therapy does not influence PON1 activity.

Efficacy and safety of Privigen(®) in patients with chronic inflammatory demyelinating polyneuropathy: results of a prospective, single-arm, open-label Phase III study (the PRIMA study)

This prospective, multicenter, single-arm, open-label Phase III study aimed to evaluate the efficacy and safety of Privigen(®) (10% liquid human intravenous immunoglobulin [IVIG], stabilized with L-proline) in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). Patients received one induction dose of Privigen (2 g/kg body weight [bw]) and up to seven maintenance doses (1 g/kg bw) at 3-week intervals. The primary efficacy endpoint was the responder rate at completion, defined as improvement of ≥1 point on the adjusted Inflammatory Neuropathy Cause and Treatment (INCAT) disability scale. The preset success criterion was the responder rate being ≥35%. Of the 31 screened patients, 28 patients were enrolled including 13 (46.4%) IVIG-pretreated patients. The overall responder rate at completion was 60.7% (95% confidence interval [CI]: 42.41%-76.43%). IVIG-pretreated patients demonstrated a higher responder rate than IVIG-naïve patients (76.9% vs. 46.7%). The median (25%-75% quantile) INCAT score improved from 3.5 (3.0-4.5) points at baseline to 2.5 (1.0-3.0) points at completion, as did the mean (standard deviation [SD]) maximum grip strength (66.7 [37.24] kPa vs. 80.9 [31.06] kPa) and the median Medical Research Council sum score (67.0 [61.5-72.0] points vs. 75.5 [71.5-79.5] points). Of 108 adverse events (AEs; 0.417 AEs per infusion), 95 AEs (88.0%) were mild or moderate in intensity and resolved by the end of study. Two serious AEs of hemolysis were reported that resolved after discontinuation of treatment. Thus, Privigen provided efficacious and well-tolerated induction and maintenance treatment in patients with CIDP.

Reduction of thalamic tremor with deep brain stimulation performed for post stroke chronic central pain

Deep brain stimulation (DBS) of the sensory thalamus and the periventricular/ peri-aqueductal grey area complex may be applied for the treatment of intractable neuropathic pain syndrome. The presented study concerns a patient who experienced ischemic stroke within the posterolateral part of the left hypothalamus, with subsequent severe burning pain localized in the right upper limb, predominantly within the hand, and thalamic tremor which occurred 4 months after the stroke. After 2 years of ineffective pain treatment, the patient was offered implantation of electrodes to the periventricular grey matter (PVG)/periaqueductal grey matter (PAG), as well as implantation of an electrode to the ventroposterolateral thalamic nucleus (VPL). Soon after starting simultaneous PAG/PVG and PVL stimulation, significant alleviation of the patient's thalamic tremor in the hand was observed, which persisted over subsequent months. The presented study discusses possible mechanism underlying tremor suppression in the patient concerned, probably at the level of the cerebellar outflow pathways. The study highlights the fact that DBS provide more insight into the functional anatomy of the thalamus, which used to be available only from animal studies.

Neurofilament heavy chain and heat shock protein 70 as markers of seizure-related brain injury

PURPOSE

  Status epilepticus (SE) has deleterious effects on brain tissue, but whether brief recurrent seizures may also damage neurons represents a matter of controversy. Therefore, it remains a central area of epilepsy research to identify individuals at risk where disease progression can be potentially prevented. Biomarkers may serve as tools for such identification. Thus the present study aimed at analyzing the levels of heat shock protein 70 (HSP-70, also designated as HSPA1A) and neurofilament heavy chain protein (NfH(SMI35) ) in cerebrospinal fluid (CSF) of patients with seizures of different severity.

METHODS

  Forty-one patients were included, of whom 20 patients had a single generalized tonic-clonic seizure (GTCS) episode (SS), 11 had repetitive GTCS (RS), and 10 experienced convulsive SE. The control group consisted of 18 subjects. HSP-70 levels were measured using a conventional enzyme-linked immunosorbent assay (ELISA), whereas the NfH(SMI35) protein levels were detected by an electrochemiluminescence (ECL) immunoassay.

KEY FINDINGS

  Patients with SE (p < 0.001) and RS (p < 0.05) had significantly higher NfH(SMI35) levels than controls, and SE was associated with increased concentrations when compared with SS (p < 0.001). NfH(SMI35) levels in SS did not differ from controls. Patients with SE had significantly raised HSP-70 levels compared to RS (p < 0.05), SS (p < 0.05), and controls (p < 0.001). SS and RS did not differ from each or from controls. Levels of NfH(SMI35) and HSP-70 showed a significant correlation (r = 0.34; p = 0.007) in the group of all study subjects, which was not apparent when controls and patients with seizures were considered separately. The correlation between NfH(SMI35) and HSP-70 tended to be inverse in patients with SE, but it did not reach statistical significance (r = -0.3; p > 0.05).

SIGNIFICANCE

  Studying biochemical markers as additional quantitative tools for the measurement of neuronal damage (especially subclinical), complementary to available techniques of imaging, and clinical assessment might prove useful for identifying patients at risk of accumulating neuronal injury resulting from uncontrolled seizures. NfH(SMI35) and HSP-70 are of potential value as sensitive and specific biomarkers of seizure-related pathologic events. Future longitudinal studies are needed to monitor such patients by correlating biochemical, neuroimaging, and clinical methods of assessment.

Factors predicting quality of life in a group of Polish subjects with multiple sclerosis: accounting for functional state, socio-demographic and clinical factors

OBJECTIVES

Quality of life (QoL) has presently a firmly established position as an important endpoint in medical care. Multiple sclerosis (MS) is a chronic neurological disease with considerable effect on patients' QoL. QoL of MS patients from many European countries has already been assessed but little is known on health-related QoL of Polish subjects with MS. Few studies have taken into consideration multiple predictors of QoL. The aim of this study was to elicit the most relevant factors that determine QoL of Polish group of MS patients. Socio-demographic and clinical factors as well as the influence of disability level were analyzed in this study.

PATIENTS AND METHODS

173 MS patients and 86 healthy controls underwent assessment using the Mini Mental Status Examination, WHOQOL-100, Beck Depression Inventory and Fatigue Severity Scale. Data were analyzed by a stepwise linear regression analysis.

RESULTS

MS patients had significantly worse global QoL and worse QoL in physical and psychological health domains, lower level of independence, worse social relations and were less satisfied with the surrounding environment they lived in compared with healthy controls (p<0.05). MS subjects had also higher level of depression and fatigue compared to healthy controls (p<0.05).

CONCLUSIONS

The study determined that the strongest predictors of global QoL of Polish MS patients were depression, disability level and fatigue.

Validation analysis of the Polish version of the Multiple Sclerosis International Quality of Life Questionnaire (MusiQoL)

BACKGROUND AND PURPOSE

The aim of this study was to perform a validation analysis of the Polish adaptation of the Multiple Sclerosis International Quality of Life Questionnaire, MusiQoL.

MATERIAL AND METHODS

Validation analysis included the translation of the original English version into Polish according to translation principles and the analysis of convergent validity, internal reliability and reproducibility of the Polish version of MusiQoL. The study included 150 randomly chosen patients (109 women and 41 men) with definite multiple sclerosis (MS) diagnosed according to McDonald criteria. Mean age of patients was 41 ± 10 years and mean disease duration was 11.7 ± 7.2 years. The patients completed the examined MusiQoL, the Functional Assessment of Multiple Sclerosis (FAMS) and the Multiple Sclerosis Impact Scale (MSIS-29). Data regarding sociodemographic status and MS history were collected. The disability of the patients was assessed according to the Expanded Disability Status Scale (EDSS). The examination was repeated after 28 ± 4 days.

RESULTS

The internal reliability, convergent validity and reproducibility of MusiQoL were satisfactory. The dimensions of the scale exhibited high internal consistency (Cronbach's alpha from 0.67 to 0.90). The MusiQoL correlated with FAMS (positive correlations), EDSS and MSIS-29 (negatively).

CONCLUSIONS

Psychometric-statistical analysis showed that the Polish version of MusiQoL is a valuable measure to examine the health-related quality of life of Polish MS patients.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

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

Impact of cladribine on soluble adhesion molecules in multiple sclerosis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

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

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

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

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

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

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

Objective

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

Design

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

Results

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

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

BACKGROUND AND PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Paraoxonase 1 activity in different types of multiple sclerosis

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

[Fatigue in multiple sclerosis]

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

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

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

[Oxidative stress in cerebral stroke]

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