Inhibition of experimental autoimmune encephalomyelitis by an antibody to the intercellular adhesion molecule ICAM-1

Experimental autoimmune encephalomyelitis (EAE) was induced in Lewis rats by active immunization with myelin from guinea pig spinal cord by the encephalitogenic myelin basic protein or by adoptive transfer using myelin basic protein-specific CD4-positive T cells. Treatment with purified monoclonal antibody (1A-29) to the intercellular adhesion molecule-1 and its F(ab')2 fragments efficiently suppressed active EAE. Control treatment with an irrelevant antibody or saline did not alter the course of the disease. Histological sections of the central nervous system showed a pronounced reduction of inflammatory infiltrates during treatment with antibody to intercellular adhesion molecule-1. In the adoptive transfer model of EAE, 1A-29 had only a minor effect. Proliferation assays on lymph node cells ex vivo from 1A-29- and saline-treated animals were performed. Administration of 1A-29 suppressed antigen-specific T-cell proliferation. The differential effects in EAE versus adoptive transfer EAE suggest that 1A-29 acts predominantly on the induction phase of the immune response and, to a lesser extent, on the transendothelial migration of T cells. We conclude that intercellular adhesion molecule-1-dependent pathways are critically involved in the pathogenesis of EAE and that antibodies to leukocyte adhesion molecules could be a novel therapeutic approach to autoimmune disease of the central nervous system.

Iron accumulation in the substantia nigra in rats visualized by ultrasound

In recent studies, we have found a marked increase in substantia nigra (SN) echogenicity in patients with Parkinson's disease (PD) using transcranial ultrasound. Because a substantial body of evidence has accumulated indicating a selective elevation of iron in the SN from patients with PD, we set out to test the hypothesis that trace metals like iron could lead to the observed increase of SN echogenicity in PD. Rat brains were scanned after stereotactic injection of iron in different concentrations into the SN and after injecting ferritin, zinc and 6-OHDA alone, and after the addition of desferrioxamine. The amount of iron in the SN was measured spectroscopically. For iron, and partly for 6-OHDA, in different concentrations, a dose-dependent increase of SN echogenicity could be visualized, corresponding to an increase of iron measured by spectroscopy. No increase of echogenicity was visualized after the injection of ferritin and the addition of desferrioxamine to 6-OHDA, though an increase of iron was measured by spectroscopy. Therefore, we conclude that iron not bound to these proteins may lead to an increase of echogenicity of the SN.

Preserved myelin integrity and reduced axonopathy in connexin32-deficient mice lacking the recombination activating gene-1

Mice heterozygously deficient for myelin protein zero (P0) mimicking human Charcot-Marie-Tooth (CMT) disease 1B show T-lymphocyte and macrophage upregulation in peripheral nerves, which aggravates and modulates the genetically mediated demyelinating neuropathy. In connexin32 (cx32)-deficient (cx32(def)) mice, which mimic the X-linked dominant form of CMT (CMTX), T-lymphocyte and macrophage numbers are also significantly elevated in peripheral nerves. To test the hypothesis that immune cells are indeed pathogenic in this model, we cross-bred cx32(def) mice with recombination activating gene-1 (RAG-1)-deficient mice, which lack mature T- and B-lymphocytes. In these immunoincompetent double mutants, the number of endoneurial macrophages was reduced. Furthermore, features indicative of myelin degeneration and axonopathic changes were mitigated in the RAG-1-deficient double mutants, whereas enlarged periaxonal Schwann cell collars, a hallmark specific for cx32-mutants, were not reduced. Since both cx32- and P0 deficiency lead to similar immunopathogenic processes, we conclude that immune-mediated demyelination may be a feature common to many CMT-like neuropathies independent of the genetic origin.

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

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

The correlation between ventricular diameter measured by transcranial sonography and clinical disability and cognitive dysfunction in patients with multiple sclerosis

CONTEXT

Magnetic resonance imaging (MRI) data suggest that the extent of brain atrophy in patients with multiple sclerosis (MS) is related to the severity of disease.

OBJECTIVE

To evaluate whether ventricular diameter determined by transcranial sonography (TCS) is a marker of brain atrophy and is correlated with disability, cognitive performance, and mood.

SUBJECTS AND METHODS

We examined 74 subjects with MS and 74 age- and sex-matched control subjects with TCS and assessed the transverse diameter of the third ventricle and the frontal horns of the lateral ventricles. Quantitative neurological examination was performed in subjects with MS using the Expanded Disability Status Scale. All subjects with MS underwent MRI, the Brief Repeatable Battery of Neuropsychological Tests for MS, and standardized tests for mood disorders.

RESULTS

Transcranial sonographic measurements of ventricular diameter closely matched MRI measurements (Spearman rank correlation, r=0.7-0.9; P<.01). The ventricular diameters were significantly larger in subjects with MS than in healthy age- and sex-matched control subjects. The measurement of the diameter of the third ventricle obtained by TCS or MRI and the measurement of disability obtained with the Expanded Disability Status Scale were significantly correlated (Spearman rank correlation, r = 0.4; P<.01). The correlation between the diameter of the frontal horns and disability was substantially lower for both neuroimaging techniques. In addition, TCS and MRI data correlated significantly with the majority of neuropsychological tests; no correlation was found between the diameter of the ventricles and depression scales.

CONCLUSION

As ventricular diameter is related to the status of disability and may also indicate disease progression, we propose measurement of the diameter of the third ventricle with TCS as a quick and easy surrogate marker for serial follow-up examinations in patients with MS.

Measurement of cerebral blood flow volume by extracranial sonography

Measurement of global cerebral blood flow (CBF) using extracranial duplex sonography has been described, but normal values are still lacking. In 85 healthy adults (median age 43.4 years, range 20 to 80 years), CBF was determined by duplex sonographic examination of both internal carotid arteries and vertebral arteries. The mean global CBF was 630+/-97 mL/min. Global CBF declined with age; sex did not influence the total CBF. When measurements were repeated, the intraindividual variability was low. This noninvasive sonographic measurement of CBF is reproducible, and values correspond closely to those obtained with positron emission tomography and magnetic resonance imaging.

Multiple sclerosis relapses are not associated with exercise

Since multiple sclerosis (MS) often affects physically active young individuals, it is important to know if exercise can result in increased disease activity. Therefore we used a self-report questionnaire to examine the relationship of different levels of sports activity and relapses in 632 patients with MS. In order to analyse whether subjective recall might have biased the results, we performed, in a subgroup of our sample, an objective assessment of clinical data and physical fitness parameters. We were unable to find any association between sports activity and clinical relapses in either of the two analyses. The group with highest activity even shows the lowermost mean values, standard deviations and range concerning the number of relapses. Our data suggest that physical activity has no significant influence on clinical disease activity.

Differentiation between intracerebral hemorrhage and ischemic stroke by transcranial color-coded duplex-sonography

BACKGROUND AND PURPOSE

The differential diagnosis of intracerebral hemorrhage versus ischemic stroke has critical implications for stroke management. Transcranial color-coded duplex sonography (TCCS) has been shown to identify intracerebral hemorrhages and intracerebral vessel occlusions. We conducted this study to evaluate the sensitivity and specificity of TCCS in this differential diagnosis and in the detection of stroke complications.

METHODS

One hundred fifty-one patients (58 women, 93 men; mean age, 65.6 years [range, 32 to 89 years] ) with acute hemiparesis were enrolled in this prospective study. On admission all patients had a complete neurological examination. A cranial CT scan and a sonographic examination of the brain parenchyma and all extracranial and intracranial cerebral arteries were conducted. The sonographer was blinded for the radiological findings.

RESULTS

According to CT criteria, 60 patients had an intracerebral hemorrhage and 67 patients had an ischemic stroke, and in 24 patients CT findings were inconclusive, showing neither bleeding nor an ischemic stroke. On sonographic examination, 18 patients (12%) had no sufficient acoustic bone window. Of the remaining 133 patients, 126 (95%) were diagnosed correctly by sonography in agreement with CT. Sonography missed 3 atypical bleedings (2 with upper parietal location). In 4 patients without bleeding, an intracerebral hemorrhage was suspected by TCCS because of increased white matter echo density due to microangiopathy. Stroke complications depicted by CT (disturbance of cerebrospinal fluid circulation, hemorrhagic transformation, midline shift, ventricular bleeding) (n=54) were correctly shown by TCCS in 45 patients (83%). No complication was missed that would have required further treatment.

CONCLUSIONS

In comparison to the "gold standard" of CT, TCCS identified stroke complications and differentiated between intracerebral hemorrhage and ischemic stroke with reasonable sensitivity. Thus, if CT is not readily available, TCCS may complement clinical examination in patients with acute stroke. In addition, it may also be useful in detecting stroke complications in the follow-up of stroke patients.

Suppression of experimental allergic neuritis by an antibody to the intracellular adhesion molecule ICAM-1

Experimental allergic (autoimmune) neuritis (EAN) was induced in Lewis rats either by inoculation with bovine spinal root myelin or injection of neuritogenic P2-specific T cells. Injection of a purified monoclonal antibody (1A-29) to the intercellular adhesion molecule-1 (ICAM-1) prevented or transiently suppressed myelin-induced EAN depending on the timing of antibody application. Administration of 1A-29 suppressed moderate adoptive transfer EAN (AT-EAN) but not severe AT-EAN. In contrast, treatment with phosphate buffered saline or an unrelated IgG1 had no effect on the course of the disease. Histological sections of the peripheral nervous system (PNS) showed a marked reduction of inflammatory infiltrates and perivascular demyelination in rats injected with 1A-29. The effect of 1A-29 on the concanavalin A (Con A)- and P2-dependent proliferation of neuritogenic P2-specific T cells was studied in vitro. Our data suggest that antibodies to ICAM-1 act on the induction and effector phase of the immune response by inhibiting both early interactions between immunocompetent cells after exposure to foreign antigen and transendothelial migration of primed T cells into the peripheral nerve. Treatment with antibodies to leucocyte adhesion molecules could be a useful therapeutic approach to autoimmune disease of the PNS.

Genetic variation at position -1082 of the interleukin 10 (IL10) promotor and the outcome of multiple sclerosis

Interleukin-10 is a potent immunomodulatory cytokine with possible implications for the pathogenesis of multiple sclerosis. Increased IL10 mRNA expression is associated with stable disease. The interleukin 10 gene is highly polymorphic and certain haplotypes result in differential interleukin-10 expression. The presence of guanine instead of adenine at position -1082 in the IL10 promotor was shown to result in a higher IL10 production. We analysed this diallelic polymorphism in patients with multiple sclerosis but did not find any association between a certain -1082 IL10 genotype and susceptibility to or severity of multiple sclerosis.

Bone marrow transfer from wild-type mice reverts the beneficial effect of genetically mediated immune deficiency in myelin mutants

Inherited demyelinating neuropathies are chronically disabling human disorders caused by various genetic defects, including deletions, single site mutations, and duplications in the respective myelin genes. We have shown in a mouse model of one distinct hereditary demyelinating neuropathy (heterozygous P0-deficiency, P0+-) that an additional null mutation in the recombination activating gene-1 (RAG-1--) leads to a substantially milder disorder, indicating a disease modifying role of T-lymphocytes. In the present study, we addressed the role of lymphocytes in the mouse model by reconstituting bone marrow of P0+-/RAG-1-- mice with bone marrow from immunocompetent wild-type mice. We compared the pathology and nerve conduction in double mutant mice (P0+-/RAG-1-- on a C57BL/6 background) with that in double mutants after receiving a bone marrow transplant. We found that the milder demyelination seen in the lymphocyte-deficient P0+-/RAG-1-- mutants was reverted to the more severe pathology by reestablishing a competent immune system by bone marrow transfer. These data corroborate the concept that the immune system contributes substantially to the pathologic process in this mouse model and may open new avenues to ameliorate human hereditary neuropathies by exploiting immunosuppressive treatments.

Ultrasound derived imaging and quantification of cell adhesion molecules in experimental autoimmune encephalomyelitis (EAE) by Sensitive Particle Acoustic Quantification (SPAQ)

Molecular imaging requires, not only the identification of an appropriate marker, but also its quantitative analysis. We used the Sensitive Particle Acoustic Quantification (SPAQ) technology - a novel ultrasound technique - for detection and quantification of cell adhesion molecules in isolated tissue and in live animals. By conjugating gas-filled microparticles (MPs) with antibodies to intercellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1), we were able to depict and quantify ICAM-1 and VCAM-1 in isolated brain and spinal cord from rats with autoimmune encephalomyelitis (EAE), an established inflammatory disease model of human multiple sclerosis (MS). Depiction and quantification of specific MPs were also feasible in living animals with AT-EAE with similar results. After treatment with methylprednisolone, the measured number of targeted anti-ICAM-1 and VCAM-1-MPs was significantly lower (P<0.01) compared to untreated animals demonstrating the high sensitivity of this imaging technique. Depending on the antibody linked to the surface of the MPs, the technique can be used to quantify the expression of any accessible antigen expressed on the luminal surface of endothelial cells and is therefore a promising tool for the non-invasive and dynamic assessment of disease-related molecules.

Gene polymorphism at position -308 of the tumor necrosis factor alpha promotor is not associated with disease progression in multiple sclerosis patients

Tumor necrosis factor-alpha (TNFalpha) is a pluripotent proinflammatory cytokine and is thought to play an important role in the inflammatory process of multiple sclerosis (MS). A G-->A transition in the TNFalpha promotor at position -308 (TNF2 allele) has been shown to be associated with increased TNFalpha production. This study was designed to detect wether the TNF2 allele is associated with disease progression in MS. We examined the TNFalpha -308 polymorphism with an allelic discrimination PCR to detect the G-->A transition in the genomic DNA of 283 MS patients from Germany and in 72 patients with amyotrophic lateral sclerosis (ALS) and 66 with stroke from the same genetic background who served as controls. Disease severity was defined by the progression index (PI) and by progression to the important clinical landmarks of Extended Disability Status Score (EDSS) 3.5 and 6. In addition, we evaluated the TNFalpha mRNA expression in whole blood with quantitative PCR. No differences were found between the presence of the TNF2 allele in MS, ALS, or stroke patients. Among the MS patients the TNF2 allele was not associated with a certain disease course. No association was found between the accumulation of neurological deficits and progression to clinical landmarks. Although MS patients with the TNF2 allele tended to progress more rapidly from EDSS 3.5 to EDSS 6 this difference was nonsignificant (P = 0.2). Nevertheless, we observed significantly higher TNFalpha mRNA expression in blood cells of stable patients carrying the TNF2-allele in comparison to the group with the wild type (P = 0.024). To examine the effect of genetic background we examined the DNA of 60 MS patients and 20 healthy controls in a Cypriot population of Greek origin. There was a significantly lower frequency of the TNF2 allele in the Cyprus population than in Germans (P = 0.01). No significant differences were found between the frequencies of the TNF2 allele in Cypriot MS patients and controls. Although the TNF2 allele is associated with higher TNFalpha mRNA baseline levels, our data indicate that this allele appears not to contribute to MS susceptibility or severity. In addition our data demonstrate that the TNFalpha -308 polymorphism is segregated differentially in two European populations of different genetic origin.

Postoperative neuroimaging of high-grade gliomas: comparison of transcranial sonography, magnetic resonance imaging, and computed tomography

BACKGROUND

A precise and comprehensive knowledge of tumor burden and its extent and growth pattern in the pre- and postsurgical states is required to optimize tumor therapy and to determine treatment success and failure. This prospective study compares the diagnostic potential of computed tomography (CT), magnetic resonance imaging (MRI), and transcranial sonography (TCS) in the postoperative follow-up of brain tumors.

METHOD

Twenty-six patients with high-grade gliomas were included in the study. After tumor debulking, a total of 31 biopsy specimens were obtained from the resection margin in 21 patients and histological findings were compared with the findings of early postoperative TCS, CT, and MRI. Findings indicating residual tumor tissue were nonlinear contrast enhancement at the resection site revealed by CT or MRI or hyperechogenic lesions revealed by TCS. Follow-up examinations using all three imaging techniques were performed every 3 months. The end points of the follow-up were tumor recurrence as defined by CT and MRI, death, or severe clinical deterioration.

RESULTS

On the basis of the above criteria, TCS identified residual tumor more often than did CT or MRI. In the group of 19 patients with histologically proven tumor remnants, residual tumor tissue was identified by TCS in all patients, whereas MRI and CT failed to show contrast enhancement in three and eight patients, respectively. However, the results of the TCS were false positive for one patient because of hemorrhage into the resection site. The average time to identification of tumor regrowth was 27 weeks using TCS, 29 weeks using CT, and 33 weeks using MRI. Only the differences between TCS and MRI reached statistical significance. For one patient, multicentric tumor recurrence was not detected using TCS.

CONCLUSION

TCS may complement CT and MRI in the postoperative follow-up of patients with high-grade gliomas. Because none of these modalities alone is both sensitive and specific, an integrated analysis of imaging findings is recommended.

Randomised multicentre trial on safety and efficacy of rivastigmine in cognitively impaired multiple sclerosis patients

BACKGROUND

Cognitive decline has been recognised as a frequent symptom in multiple sclerosis (MS). Cholinesterase inhibitors (ChEIs) are employed for the treatment of Alzheimer's disease, but there is some evidence that ChEIs might also be effective in MS patients with cognitive deficits, particularly deficits of memory function.

OBJECTIVE

The aim of this study was to evaluate efficacy on memory function and safety of the ChEI rivastigmine in MS patients with cognitive deficits as measured by the change from baseline of the total recall score of the selective reminding test (SRT) after 16 weeks of treatment.

METHODS

Efficacy and safety of rivastigmine were analysed in a 16-week, multicentre, double-blind, randomised, placebo-controlled study, followed by an optional one-year open-label treatment phase. Effects of rivastigmine and placebo were compared by an analysis of covariance.

RESULTS

In total, 86 patients were enrolled. Patients who received rivastigmine (n = 43) showed a non-significant increase in total recall score (sum of all words immediately recalled over all six trials) over placebo (n = 38) after 16 weeks of treatment (p = 0.2576). Other outcome measures provided no evidence supporting benefits of rivastigmine. Treatment with rivastigmine was well tolerated.

CONCLUSIONS

With the results of this study, the need for an effective therapy in cognitively impaired MS patients is still required. Thus, intensive and continued clinical research is required to explore therapeutic options for cognitive deficits in MS patients.

Quality of teaching radiation oncology in Germany-where do we stand? : Results from a 2019 survey performed by the working group "young DEGRO" of the German Society of Radiation Oncology

Purpose

Medical students’ knowledge of radiation oncology (RO) is of increasing importance with a rising prevalence of malignancies. However, RO teaching in medical schools is heterogeneous and has not been analyzed at a federal level yet. Therefore, the following survey aims to provide a national overview of RO teaching in Germany.

Methods

A questionnaire containing multiple-choice and free-text questions covering the extent and topics of RO teaching was sent to RO departments of all university hospitals in Germany and was answered by the heads of department/main lecturers.

Results

24/35 (68.6%) RO departments returned completed forms. Most faculties employ lectures (91.7%), seminars (87.5%), and practical/bedside training (75.0%), whereas training in radiation biology and medical physics are rare (25% and 33.3%, respectively). Main topics covered are general RO (100%), radiation biology (91.7%), and side effects (87.5%). Regarding RO techniques and concepts, image-guided and intensity-modulated radiotherapy are taught at all faculties, followed by palliative and stereotactic techniques (87.5% each). Notably, all departments offered at least a partial rotation in RO in conjunction with radiology and/or nuclear medicine departments in the last year of medical school, while only 70.8% provided a complete rotation in RO. In addition, 57.1% of the departments have taken measures concerning the upcoming National Competence-Based Learning Objectives Catalogue (NKLM) for medical education.

Conclusion

RO plays an integral but underrepresented role in clinical medical education in Germany, but faces new challenges in the development of practical and competence-based education, which will require further innovative and interdisciplinary concepts.

Electronic supplementary material

The online version of this article (10.1007/s00066-020-01623-x) contains supplementary material, which is available to authorized users.

Early postoperative transcranial sonography (TCS), CT, and MRI after resection of high grade glioma: evaluation of residual tumour and its influence on prognosis

PURPOSE

In this prospective study the results of multimodal postoperative neuro-imaging were related to the survival of patients with high grade gliomas.

METHODS

All 73 patients included underwent microsurgical tumour resection and had postoperative CT and transcranial sonography (TCS) examinations. In addition, 35 of the 73 patients received an early postoperative MRI. Patients were followed up for at least one year.

FINDINGS

At the end of the 7 year study period 56 patients had died. The median survival time was 371 days. Survival rate was significantly higher in patients with anaplastic astrocytomas and inpatients displaying complete tumour resection on MRI (log-rank-test, p < 0.05) or a small postoperative residual tumour bulk on TCS (log-rank-test, p < 0.05). Cox proportional hazards model identified histological tumour grade, postoperative Karnofsky index, complete resection based on MRI and small postoperative residual tumour mass on TCS as independent predictors of survival.

INTERPRETATION

This study demonstrates that early postoperative neuro-imaging has prognostic implications for the survival of patients with high grade gliomas. According to our results postoperative imaging with MRI and TCS is a valuable prognostic with regard to patient survival and should therefore be implemented in postoperative follow-up. It also helps to evaluate the efficacy of adjuvant therapy.

Analysis of the C/T(-1) single nucleotide polymorphism in the CD40 gene in multiple sclerosis

The costimulatory CD40-CD40L pathway plays a critical role in the generation and maintenance of adaptive immune responses. Genetic interference of CD40-CD40L interactions strongly influences the onset and course in many autoimmune disease models including experimental autoimmune encephalomyelitis. We analysed the association of a single nucleotide polymorphism of the CD40 gene (C/T(-1)) in 287 patients with multiple sclerosis (MS) and 184 matched controls. No significant differences were found in the frequency of the C/T(-1) polymorphism between the patients with MS and the controls (53% vs 49%) or among different MS subtypes. Cell surface expression of CD40 did not differ within the different genotypes, but carriers of the T allele showed a trend for a lower stimulatory index compared with individuals with the CC genotype. Although these subtle differences indicate functional consequences in the immune stimulatory capabilities related to the CD40 C/T(-1) polymorphism, our population-based study found no association with disease susceptibility or disease course in MS.

Impact of the Asp299Gly polymorphism in the toll-like receptor 4 (tlr-4) gene on disease course of multiple sclerosis

In multiple sclerosis patients, infection is often associated with disease deterioration. Lipopolysaccharide (LPS) from gram-negative bacteria signals via the toll-like receptor 4 (TLR-4) pathway. Therefore, we investigated the role of an Asp299Gly mutation in the TLR-4 receptor in 890 MS patients with multiple sclerosis and 350 healthy controls. No association of different genotypes with MS susceptibility, MS subtypes, or disease severity was found. In vitro LPS stimulation studies showed a significantly lower proliferation of PBMCs from donors heterozygous for the Asp299Gly mutation in comparison to PBMCs from individuals with the wild-type genotype (p=0.01). However, these functional changes seem not to have any impact on the clinical presentation of MS patients with different TLR-4 genotypes.

Transcranial sonography of the brain parenchyma: comparison of B-mode imaging and tissue harmonic imaging

Transcranial color-coded Duplex sonography (TCCS) has been used for the identification of cerebrovascular disorders. Recently, its value in the diagnosis of disorders of the brain parenchyma has been proposed. The object of this study was to determine systematically the echo pattern of the brain parenchyma and to compare conventional B-mode imaging with tissue harmonic imaging (THI). Transcranial sonography (TCS) was performed in 54 healthy individuals through the temporal bone window using conventional B-mode imaging and THI by two experienced investigators. Identification rates for several brain structures were assessed, and the quality of depiction of each method was graded semiquantitatively. In addition, several parts of the ventricular system and the basal cerebral cisterns were measured. Four subjects did not have an adequate bone window for transcranial examination. In the remaining people, the bone window was assessed to be adequate (59%) or excellent (33%). In the majority (> 80%), TCS allowed an unequivocal identification of various brain structures. Inter-rater variability of the assessments of tissue echogenicity and measurements of the ventricular width were found to be low for several structures (e.g., brainstem, thalamus, or 3rd ventricle). The echo pattern of brain tissue in THI is identical to that described for B-mode imaging. Using THI, contours of brain structures were typically visualized more clearly and the reproducibility of measurements was more consistent. In our experience, insonation of the contralateral lobes was limited when depths were higher than 12 cm using THI. In conclusion, TCS allowed the sonographic examination of the brain parenchyma in the majority of our subjects. THI substantially improves the identification of parenchymal structures when the depth is below 12 cm.

Analysis of interleukin-4 receptor alpha chain variants in multiple sclerosis

A recent candidate gene study employing microsatellite markers suggested a possible linkage of multiple sclerosis (MS) with the interleukin-4 receptor (IL4R) gene. Consequently, we investigated the association of different IL4R variants with MS in 341 German MS patients and 305 healthy controls. Analysis of the first 100 MS patients for six IL4R variants showed an increased frequency of the R551 variant in MS patients versus healthy controls and carriage of the same IL4R variant was weakly associated with myelin oligodendrocyte glycoprotein (MOG) autoantibody production. However, further analysis of all 341 MS patients did not confirm the finding that this IL4R variant represents a general genetic risk factor for MS but revealed an increased frequency of the R551 variant in MS patients with primary progressive MS (PPMS, n=48) as compared to patients with relapsing remitting MS or secondary progressive MS (RR/SPMS n=284; P=0.005 for genotype differences) and to 305 healthy controls (P=0.001 for genotype differences). This association was statistically independent of the presence of the well-known MS susceptibility allele HLA-DRB1*15. After correction for multiple comparisons only the genotype differences between PPMS patients and healthy controls remained statistically significant. These results indicate, that the IL4R variant R551 may influence the genetic predisposition for PPMS but does not represent a general genetic risk factor for MS.

[Multiple sclerosis and exercise : effects of physical activity on the immune system]

Multiple sclerosis is a chronic inflammatory CNS disease which accounts for functional impairment and lasting disability in young adults. Current studies demonstrate that physical activity in patients with MS counteracts depression and fatigue and may improve quality of life. Interventional studies have described a reduction of the functional impairment in MS patients. This report presents information on the effects of physical activity on the immune system and the release of neurotrophic factors, and highlights current data on a potential immunomodulatory effect of exercise in multiple sclerosis.

Health care situation of patients with relapsing-remitting multiple sclerosis receiving immunomodulatory therapy: a retrospective survey of more than 9000 German patients with MS

BACKGROUND AND PURPOSE

First-line immunomodulatory treatment with interferon-beta or glatiramer acetate is accepted as effective basic therapy in patients with relapsing-remitting multiple sclerosis (RRMS). However, a considerable portion of patients does not benefit from treatment.

METHOD

To test basic immunomodulatory treatment under real-life conditions, we retrospectively analyzed clinical and subclinical disease activity within the last 12 months in a cohort of 9916 patients with RRMS, of which 7896 patients were receiving immunomodulatory treatment. In addition, factors associated with treating physicians' consideration of a switch of current treatment were assessed.

RESULTS

The majority of treated patients (approximately 66%) experienced no relapse during the last 12 months. However, in line with common clinical study findings, about one-third (approximately 34%) of patients had relapses. When MRI data were taken into account, approximately one-quarter (24%) of patients would qualify for therapy escalation to monoclonal antibody natalizumab. Relapse rate in the preceding year (the year directly prior to the start of retrospective data collection) was strongly associated with considering a switch of current treatment. In addition, therapy switch was more often considered in younger patients. The relationship between MRI findings in the absence of clinical symptoms and consideration of a treatment switch was not as clear.

CONCLUSIONS

This analysis confirms that disease progression occurs in a considerable proportion of patients with RRMS. These patients should be considered for therapy escalation.