MS Abstracts 02c-2g6

The authors assessed the ability of Diffusion Tensor MRI to grade Cervical Cord damage in 10 patients with Devic's NeuroMyelitis Optica, 10 patients with Multiple Sclerosis, and 10 healthy controls.

The three groups differed in terms of average Mean Diffusivity (p = 0.008) and average Fractional Anisotropy (p = 0.04). There was a correlation between the Expanded Standard Disability Status Scale score and Cord average Mean Diffusivity (r = 0.52, p = 0.02).

Tissue damage, inflammation or injury of the Nervous System may result in chronic Neuropathic Pain characterised by increased sensitivity to painful stimuli (Hyperalgesia), the perception of innocuous stimuli as painful (Allodynia) and spontaneous Pain.

Neuropathic Pain has been described in about 1% of the US population, is often severely debilitating and largely resistant to treatment.

Animal models of Peripheral Neuropathic Pain are now available in which the mechanisms underlying Hyperalgesia and Allodynia due to Nerve injury or Nerve inflammation can be analyzed.

Recently, it has become clear that inflammatory and Immune mechanisms both in the Periphery and the Central Nervous System play an important role in Neuropathic Pain.

Infiltration of inflammatory cells, as well as activation of resident Immune Cells in response to Nervous System damage, leads to subsequent production and secretion of various inflammatory mediators.

These mediators promote NeuroImmune activation and can sensitise primary afferent Neurons and contribute to Pain hypersensitivity.

Inflammatory cells such as Mast Cells, Neutrophils, Macrophages and T-Lymphocytes have all been implicated, as have Immune-like Glial Cells such as Microglia and Astrocytes.

In addition, the Immune Response plays an important role in DeMyelinating Neuropathies such as Multiple Sclerosis (MS), in which Pain is a common symptom, and an animal model of MS-related Pain has recently been demonstrated.

Here, we will briefly review some of the milestones in research that have led to an increased awareness of the contribution of Immune and inflammatory systems to Neuropathic Pain and then review in more detail the role of Immune Cells and inflammatory mediators.

Objective
To assess overall resource consumption, work capacity and quality of life of patients with Multiple Sclerosis in nine European countries.

Methods
Information on resource consumption related to Multiple Sclerosis, informal care by relatives, productivity losses and overall quality of life (utility) was collected with a standardized pre-tested questionnaire from 13,186 patients enrolled in National Multiple Sclerosis Societies or followed up in Neurology clinics.

Information on disease included disease duration, self-assessed disease severity and relapses. Mean annual costs per patient (Euro, 2005) were estimated from the societal perspective.

Results
The mean age ranged from 45.1 to 53.4 years, and all levels of disease severity were represented.

Between 16% and 29% of patients reported experiencing a relapse in the 3 months preceding data collection. The proportion of patients in early retirement because of Multiple Sclerosis ranged from 33% to 45%.

The use of direct medical resources (eg, hospitalisation, consultations and drugs) varied considerably across countries.

Whereas the use of non-medical resources (eg, walking sticks, wheel chairs, modifications to house and car) and services (eg, home care and transportation) was comparable.

Informal care use was highly correlated with disease severity, but was further influenced by healthcare systems and family structure. All types of costs increased with worsening disease.

The total mean annual costs per patient (adjusted for gross domestic product purchasing power) were estimated at Euro 18,000 for mild disease (Expanded Disability Status Scale (EDSS) < 4.0), Euro 36,500 for moderate disease (EDSS 4.0-6.5) and Euro 62,000 for severe disease (EDSS > 7.0).

Utility was similar across countries at around 0.70 for a patient with an EDSS of 2.0 and around 0.45 for a patient with an EDSS of 6.5. Intangible costs were estimated at around Euro 13,000 per patient.

Chemokine Receptors and Adhesion Molecules are used selectively for the transmigration of Leukocytes across the Blood-Brain Barrier (BBB) during NeuroInflammation.

We established an Activated In Vitro BBB (aIVBBB) using physiological concentrations of Cytokines.

We studied CCL5-driven migration as a model to determine how Chemokine Receptors and Adhesion Molecules regulate T-Cell and Monocyte migration across the aIVBBB.

Increased expression of CCL5 and its Receptors, CCR1 and CCR5 have been described in the PeriVascular Space of Multiple Sclerosis (MS) lesions.

Elucidating the determinants of CCL5-mediated MonoNuclear Cell migration may clarify appropriate targets for therapeutic modulation in NeuroInflammatory conditions.

In response to CCL5, there was a significant increase in total MonoNuclear Cell migration across the aIVBBB.

Neutralizing MonoClonal Antibodies to CCR1 and CCR5 abrogated CCL5-driven transmigration, suggestive of non-redundant Receptor usage in MonoNuclear Cell migration to this Chemokine in vitro.

CCL5-driven transmigration was also dependent on alpha(4)beta(1) Integrin/Fibronectin Connecting Segment-1 (FN CS-1) and alpha(L)beta(2) Integrin/Intercellular Adhesion Molecule (ICAM-1) interactions.

Monocyte migration to CCL5 was solely dependent on alpha(4)beta(1) Integrin/FN CS-1 while T-Cell migration required both alpha(L)beta(2) Integrin/ICAM-1 and alpha(4)beta(1) Integrin/FN CS-1 interactions.

These findings provide plausible molecular targets for the selective inhibition of MonoNuclear Cell trafficking during the acute Immune Effector phases of MS and other NeuroInflammatory Diseases.

To investigate whether peripheral Immune abnormalities are associated with Brain inflammation in Multiple Sclerosis.

And, whether differences in MRI activity are paralleled by changes in Leukocyte composition, we conducted a prospective longitudinal study in patients at their clinical onset.

Twenty patients presenting a first inflammatory event in the Central Nervous System suggestive of Multiple Sclerosis underwent.

Every 45 days for one year, ImmunoPhenotyping of 98 blood cell subsets together with Brain MRI and clinical evaluation.

Six patients showed intense MRI activity, six patients did not display MRI activity, while the remaining 8 patients had low (i.e. intermediate) MRI activity during the follow-up.

Our results show that MRI-active and MRI-inactive patients display significant differences in ten Lymphocyte subsets.

Among these, there are both:
• Effector Lymphocytes:
  • CCR7-CD45RA-CD4⁺ alphabeta T-Cells
  • CCR5⁺ gammadelta T-Cells
• Regulatory Lymphocytes:
  • DN CD28⁺ alphabeta T-Cells
  • CD25⁺CD8⁺ alphabeta T-Cells

Pertaining to the Innate and the Acquired arms of the Immune System.

Moreover, these differences, upon employment of a class prediction procedure based on "support vector machines" algorithm:

Utilizing leave-one-out cross validation procedures, were able to correctly assign patients to their respective MRI activity group.

All 6 MRI-active and 6 MRI-inactive patients were correctly classified.

And, upon application of a class prediction model in an unsupervised manner to the 8 patients with intermediate MRI activity, 6 were predicted as MRI-active and 2 as MRI-inactive patients.

Also, when the mean values of the first three time points (T0, T1 and T2) were used for the prediction of all patients.

The selected Lymphocyte subsets correctly classified 90% of patients. Sensitivity was 91.7% and specificity was 87.5%.

These results provide evidence showing that Brain inflammation in Multiple Sclerosis is associated with distinct changes in peripheral Lymphocyte subsets.

And raise the possibility that the identified subsets may, after adequate validation, assist in the prediction of MRI activity in the early stages of Multiple Sclerosis.

The trend to start disease-modifying therapy early in the course of Multiple Sclerosis makes it important to establish whether the Benign form is a real entity.

In previous studies, measures of Magnetization Transfer (MT) ratio (MTr) have been shown to provide good estimates of the amount of tissue damage occurring in Multiple Sclerosis Brains.

Thus, with the hypothesis that if Benign Multiple Sclerosis patients were really Benign, sensitive measures of subtle tissue damage would be less pronounced in these patients than in very early Relapsing-/Remitting (RR) Multiple Sclerosis patients.

We carried out conventional MRI and MT imaging in 50 patients with Benign Multiple Sclerosis [defined as having Kurtzke Expanded Disability Status Score (EDSS) < 3 and disease duration > 15 years].

And in 50 early RR patients selected to have similar disability (EDSS < 3) and short disease duration ( < 3 years).

Data were compared with those of 32 demographically-matched normal controls.

We used a fully automated procedure to measure lesional-MTr, PeriLesional-MTr, Normal-Appearing White Matter (NAWM) MTr and Cortical-MTr.

We found that, after correction for common effects of age, Lesional-MTr and PeriLesional-MTr of Benign patients were significantly (P < 0.0001) lower than WM of normal controls.

But significantly (P < 0.0001) higher than corresponding tissues of RR patients.

In NAWM and Cortex, MTr values of Benign patients were similar to those of normal controls (P > 0.5) and significantly higher than those of the RR patients (P < 0.0001 and P < 0.01, respectively).

Similar differences in MTr measures between Benign and RR patients were found when patient groups were selected to have no disability (EDSS < or = 2) and, for Benign Multiple Sclerosis, very long disease duration ( > 20 years).

Or when both groups were matched for high lesion load (T₂-weighted lesion volume > 10 cm3).

We conclude that lesional and non-lesional MTr values can be significantly less pronounced in Benign Multiple Sclerosis than in a cohort of RR patients at their earliest disease stages.

Suggesting that Brain tissue damage is milder in Benign Multiple Sclerosis than in early RR disease.

This can be due to an extraordinary beneficial response to DeMyelination of Benign patients.

And, may represent the evidence that Benign Multiple Sclerosis truly exists and might be differentiated from other forms of this illness.

Changes in the Blood-Brain Barrier (BBB) are crucial to the pathogenesis of Multiple Sclerosis (MS).

There are currently few established treatments for MS, and Interferon-beta (IFN-ß) therapy is one of the most promising - proposed to act as an ImmunoModulator of the Cytokine network reducing inflammatory damage.

However, there is increasing evidence that direct effects on the BBB could also be relevant. This review surveys the evidence that IFN-ß stabilizes the BBB, and that this process itself might be the key target.

Understanding IFN-ß-derived changes at the BBB will not only provide new insights in the pathogenesis of MS but will also be helpful to develop new, more-specific drugs for MS treatment.

Exercise for individuals with Multiple Sclerosis (MS) has been shown to improve CardioVascular function, increase strength and endurance, and reduce fatigue.

The impact of exercise on Immune function in the disease, however, remains mostly unexplored.

Ten female MS patients participated in an 8 week programme of twice-weekly progressive resistance training, with pre- and post-training assessment of serum concentrations of Cytokines IL-2, IL-4, IL-6 IL-10, CRP, TNF- and IFN-γ.

After training, IL-4, IL-10, CRP and IFN-γ showed statistically reduced resting concentrations in blood.

While TNF- showed non-significant reductions and IL-2 and IL-6 remained unchanged.

These results suggest that progressive resistance training may have an impact on Cytokine concentrations in individuals with MS and should be confirmed in studies with stronger statistical power.

The impact of these changes on overall Immune function in MS and on disease status and prognosis remains to be determined.

MBP8298 is a synthetic Peptide with a sequence corresponding to Amino Acid residues 82-98 of human Myelin Basic Protein (DENPVVHFFKNIVTPRT).

It represents the ImmunoDominant target for both B-Cells and T-Cells in Multiple Sclerosis (MS) patients with HLA haplotype DR2.

Its administration in accordance with the principle of high dose Tolerance:

Results in long-term suppression of Anti-Myelin Basic Protein (MBP) AutoAntiBody levels in the CerebroSpinal Fluid (CSF) of a large fraction of Progressive MS patients.

MBP8298 was evaluated in a 24-month placebo-controlled double-blinded Phase II clinical trial in 32 patients with Progressive MS.

The objective was to assess the clinical efficacy of 500 mg of MBP8298 administered intravenously every 6 months, as measured by changes in Expanded Disability Status Scale (EDSS) scores.

Contingency analysis for all patients at 24 months showed no significant difference between MBP8298 and placebo-treatments (n = 32, P = 0.29).

Contingency analysis in an HLA Class II defined subgroup showed a statistically significant benefit of MBP8298 treatment compared with placebo in patients with HLA haplotypes HLA-DR2 and/or DR4 (n = 20, P = 0.01).

Long-term follow-up treatment and assessment of patients in this responder group showed a median time to progression of 78 months for MBP8298 treated patients.

Compared with 18 months for placebo-treatment (Kaplan-Meier analysis, P = 0.004; relative rate of progression = 0.23).

Anti-MBP AutoAntiBody levels in the CSF of most MBP8298 treated patients were suppressed, but AntiBody suppression was not predictive of clinical benefit.

Anti-MBP AutoAntibodies that reappeared in the CSF of one patient at 36 months, while under treatment with MBP8298, were not reactive with the MBP8298 peptide in vitro.

The identification of a responder subgroup (62.5% of the patients in this study) enables a more efficient design of a large confirmatory clinical trial of MBP8298.

The probability that patients with other less common HLA-DR haplotypes will respond to this treatment should not be ignored.

Inflammation, a self-defensive reaction against various pathogenic stimuli, may become harmful self-damaging process.

Increasing evidence has linked chronic inflammation to a number of NeuroDegenerative disorders including Alzheimer's Disease (AD), Parkinson's Disease (PD), and Multiple Sclerosis.

In the Central Nervous System, Microglia, the resident Innate Immune cells play major role in the inflammatory process.

Although they form the first line of defense for the Neural Parenchyma, uncontrolled activation of Microglia may be directly toxic to Neurons.

By releasing various substances such as inflammatory Cytokines (IL-1beta, TNF-, IL-6), NO, PGE(2), and SuperOxide.

Moreover, our recent study demonstrated that activated Microglia phagocytose not only damaged cell debris but also neighboring intact cells.

It further supports their active participation in self-perpetuating Neuronal damaging cycles.

In the following review, we discuss Microglial responses to damaging Neurons, known activators released from injured Neurons and how Microglia cause Neuronal Degeneration.

In the last part, Microglial activation and their role in PD are discussed in depth.

Several experimental and human studies suggest that the Chemokines CCL2 and CXCL10 may play a role in the pathogenesis of Multiple Sclerosis (MS).

Here, we evaluated the effect of IntraVenous MethylPrednisolone (IVMP) therapy on the levels of CCL2 and CXCL10 in the CerebroSpinal Fluid (CSF) and Serum of patients with active MS.

Serum and CSF samples were obtained from 14 patients with active Relapsing/Remitting MS (age +/- SD years, 37.0 +/- 8.1; M/F, 6/8) and age- and gender-matched control subjects.

All patients were submitted to IVMP treatment (500 mg daily for 5 days).

Blood and CSF sampling were performed at admission, i.e. before treatment (day 0), at the end of the treatment (day 6) and 30 days after treatment (day 30).

The clinical status of MS patients was also assessed. CCL2 and CXCL10 were measured by Enzyme-Linked Immunosorbent Assay.

Multiple Sclerosis patients had lower CCL2 and higher CXCL10 in CSF when compared with control subjetcs.

After treatment with MethylPrednisolone, MS patients showed clinical improvement and the CSF concentrations of CCL2 and CXCL10 modified toward normal values.

The clinical improvement of active MS following the treatment with MethylPrednisolone was associated with the modification of CSF levels of CCL2 and CXCL10.

Suggesting that these Chemokines may be useful markers of response to treatment and relapses in MS patients.

The pathological hallmarks of Secondary/Progressive (SP) Multiple Sclerosis (MS) include slowly expanding DeMyelination and Axonal Damage with less inflammation.

To elucidate the pathomechanisms of Secondary/Progressive (SP) Multiple Sclerosis (MS), we have investigated the expression of Chemokines, Chemokine Receptors, Matrix MetalloProteinase-9 (MMP-9) and ImmunoGlobulins in the DeMyelinating plaques.

ImmunoHistoChemical analysis revealed that numerous hypertrophic Astrocytes were observed at the rim, but not in the center, of the chronic active lesions.

Microglia/Macrophages Phagocytosing Myelin debris were also found at the lesion border. In contrast, T-Cell infiltration was minimal in these plaques.

Characteristically, at the rim of the lesions, there were abundant ImmunoReactivities for Monocyte ChemoAttractant Protein-1 (MCP-1)/CCL2.

And Interferon-gamma inducible protein-10 (IP-10)/CXCL10 and their Receptors, CCR2 and CXCR3, while these ImmunoReactivities were weak in the center, thus forming a Chemokine gradient.

Double immunofluorescense staining demonstrated that cellular sources of MCP-1/CCL2 and IP-10/CXCL10 were hypertrophic Astrocytes.

And, that both Astrocytes and Microglia/Macrophages expressed CCR2 and CXCR3. MMP-9 was also present at the rim of the lesions.

These results suggest that MCP-1/CCL2 and IP-10/CXCL10 produced by Astrocytes may activate Astrocytes in an Autocrine or Paracrine manner.

And, direct reactive Gliosis followed by migration and activation of Microglia/Macrophages as effector cells in DeMyelinating lesions.

Targeting Chemokines in SPMS may therefore be a powerful therapeutic approach to inhibit lesional expansion.