MS Abstracts 03d-2g5

Background
Multiple Sclerosis (MS) is a common disease with considerable risk for disability. Optic Neuritis (ON) is a common first symptom of MS but it can also remain an isolated episode.

Therefore, predicting the outcome of ON has gained in importance, particularly in light of current discussions of early disease modifying treatments in individuals at risk of developing MS.

We reported previously on our cohort of 86 patients with Acute MonoSymptomatic UniLateral ON of whom 33 had progressed to MS after up to 18 years.

Three patients had died. The present study extends the observation period to 31 years.

Methods
Patients were followed for up to 31 years or until a diagnosis of MS was made. CerebroSpinal Fluid (CSF) was examined at onset.

HLA Class I and II Antigens were determined. Magnetic Resonance Imaging (MRI) was performed during follow up.

Findings
Only one of 50 patients at risk developed clinical manifestations of MS during the extended follow up period.

The estimated 15-year-risk of MS was 40 % (confidence interval [CI] 31%-52%). Most cases, 20 of 34 or 60%, occurred within three years.

Among factors present at onset, CSF with MonoNuclear Pleocytosis and/or OligoClonal Ig increased the risk for subsequent MS significantly, 49% (CI 38%-65%) compared with 23 % (CI 12%-44%) for those with normal CSF, p = 0.02.

Younger patients and those with winter onset also had greater risk. Recurrence of ON similarly elevated the risk significantly, p < 0.001.

After 19-31 years MRI lesions suggestive of DeMyelinating Disease were detected in 20 of 30 individuals although no clinical manifestations of MS had occurred.

Conclusion
The risk of MS in this large population-based prospective ON patient series was 40% and significantly higher in those with inflammatory CSF abnormalities at onset.

Clinically silent MRI lesions suggestive of MS were detected in a majority of those with "ON-only".

This finding should be taken into account when discussing prognosis and early intervention in patients with Clinically Isolated ON.

T₁ Black Holes (BH) have been found to represent focal areas of substantial Central Nervous System tissue damage in Multiple Sclerosis (MS) patients.

We examined the development of T₁ BH over a three-year period of treatment with Interferon-ß-1b (IFN-ß-1b) in a group of 20 patients with Relapsing/Remitting MS.

The number of Contrast-Enhancing Lesions (CEL) after one year of treatment predicted a change in the T₁ BH volume in the following two years.

In patients without CEL, the T₁ BH volume remained stable, whereas it increased in patients with CEL. The occurrence of CEL in patients treated with IFN-ß may indicate a heightened risk of accumulating T₁ BH.

Background
The short-term effect of CorticoSteroids on MRI measures of Multiple Sclerosis (MS) is not well understood and may have a significant impact when using these quantitative measures to evaluate disease activity and changes following other therapeutic interventions.

Objective
To determine the impact of a course of IntraVenous MethylPrednisolone (IVMP) on quantitative measures of disease activity and tissue injury in MS patients.

Methods
We prospectively measured Brain Parenchymal Fraction (BPF), Magnetization Transfer Ratio (MTR, lesional and Whole Brain), and lesion volumes.

On nine weekly Brain MRI studies, in ten MS patients receiving a course of IVMP. A group of nine MS patients not receiving IVMP served as controls.

Results
In comparison to untreated controls, BPF declined over the eight weeks following IVMP treatment (P < 0.02).

BPF decline was most prominent in patients with Secondary/Progressive MS (SPMS, P < 0.03), and was not seen in Relapsing/Remitting (RR) MS patients.

Short-term change in BPF correlated with baseline BPF (r =0.62, P =0.05) and short-term change in lesional MTR (r = -0.55, P =0.03), but not with change in enhancing lesion volume.

Short-term change in lesional MTR inversely correlated with baseline lesional and Whole Brain MTR (r = -0.79, P =0.04 for both).

There was no significant difference between treated and control patients in measures of MTR or T₂, T₁ or enhancing lesion volumes.

Conclusions
Patients with SPMS showed a greater decline in BPF following IVMP than RRMS patients.

A correlation between changes in BPF and MTR suggest that these changes are secondary to altered water content within MS lesions.

Differential response to a standardized therapeutic intervention in RRMS and SPMS suggests that responses to therapy may differ due to a fundamental pathologic difference between early and late stage MS.

Objective
To assess Brain Atrophy in Multiple Sclerosis (MS) patients during different disease stages and to investigate by PET and [11C]PK11195, a marker of Microglial activation, the relationship between inflammation, Atrophy and clinically relevant measures.

Methods
Eight healthy subjects and 22 MS patients were included. Semiquantitative [11C]PK11195 uptake values, with normalization on Cortical Gray Matter, were measured for Magnetic Resonance Imaging T₂- and T₁-lesions and Normal-Appearing White Matter (NAWM).

As Atrophy index, we used the ratio of the amount of White and Gray Matter divided by the Ventricular size, using an optimized a priori based segmentation algorithm (SPM99).

Results
Atrophy was significantly greater in MS patients compared to age-matched controls.

A significant correlation was found between Brain Atrophy and both disease duration and disability, as measured with the Expanded Disability Status Scale.

For NAWM, [11C]PK11195 uptake increased with the amount of Atrophy, while T₂-lesional [11C]PK11195 uptake values decreased according to increasing Brain Atrophy.

Conclusions
The present study suggests that Brain Atrophy, correlating with disease duration and disability, is directly related to NAWM and T₂-lesional inflammation as measured by Microglial activation.

Two patients with Multiple Sclerosis developed symptomatic Chronic Inflammatory DeMyelinating Polyneuropathy with massive Spinal or Cranial Nerve HyperTrophy revealed by NeuroImaging.

Sural Nerve biopsy in one showed only moderate DeMyelination, Axonal Loss, and onion-bulb formation, illustrating dichotomy between severe proximal and milder distal Nerve involvement.

Patients with coexistent Central and Peripheral DeMyelination usually are symptomatic from dysfunction at one site or the other, but not from both.

Our patients showed minimal response to Steroids, IntraVenous ImmunoGlobulin, or Azathioprine.

These cases suggest that the mechanism of disease in symptomatic Central and Peripheral DeMyelination may differ from that of disease in only one region, and that optimal therapy in this situation must be explored further.

Background
A number of studies found that patients with Multiple Sclerosis (MS) have low Serum levels of Uric Acid. It is unclear whether this represents a primary deficit or secondary effect.

Uric Acid is a scavenger of Peroxynitrite, which is the product of Nitric Oxide (NO) and Superoxide.

Because Peripheral Blood Leukocyte NO production and NO metabolites in Serum are raised in MS patients, associations might be expected between Serum Uric Acid levels and Peripheral NO production.

Methods
Serum levels of Uric Acid and NO production by Peripheral Blood Leukocytes were measured in 60 patients with MS without a relapse in the past 3 months, and 30 age- and sex-matched healthy controls.

Uric Acid was determined with the uricase PAP method, and NO production was assayed by measuring Nitrite concentration in supernatants of lysed Leukocytes.

Results
Serum Uric Acid levels were not different between MS patients and controls. Compared to controls, patients with MS had significantly higher Peripheral Blood Leukocytes Nitrite concentrations (p < 0.001).

There was no correlation between Leukocyte Nitrite concentration and Serum Uric Acid levels.

Conclusions
Our findings suggest that in MS patients there is no primary deficit in Serum Uric Acid. NO production by Peripheral Blood Leukocytes is increased, but there is no association with Serum Uric Acid levels.

Purpose
To evaluate the effectiveness of Visual Evoked Potentials (VEPs), Frequency-Doubling Perimetry (FDP), Standard Achromatic Perimetry (SAP), Contrast Sensitivity (CS) test, and Magnetic Resonance Imaging (MRI), isolated or in combination, in detecting Subclinical Impairment of Visual function in Multiple Sclerosis (MS).

Methods
Twenty-two eyes of 11 patients affected by Clinically Definite MS, without a history of Optic Neuritis and asymptomatic for visual disturbances, underwent full Ophthalmic Examination and, in addition, VEPs, FDP, SAP, CS, and MRI.

Abnormal results were taken to be as follows:
1. VEPs, a P100 latency >115 ms
2. FDP, abnormal Mean Deviation (MD) or pattern SD (PSD)
3. SAP, abnormal MD or PSD; for CS, abnormal CS at one spatial frequency, at least
4. MRI, evidence of at least one DeMyelinating plaque along the Visual Pathway

Results
VEPs showed abnormal results in 12 eyes (54.4%), FDP in 11 (50%), SAP in 14 (63.6%), CS in 17 (77.1%), and MRI in 16 (72.7%). In only two (9.1%) eyes of the same patient was no abnormality found.

No single test detected all the abnormal eyes. Four (18.2%) eyes had pure Optic Nerve involvement and the remaining 16 (72.7%) had both Pre- and PostChiasmal involvement.

Conclusions
In patients affected by Clinically Definite MS without history of Optic Neuritis and no Visual symptoms, there is a large prevalence of Visual Pathway involvement that can be diagnosed only by performing multiple tests.

The comparison of the tests is also useful to detect the presence of multiple lesions in the same patient.

Multiple Sclerosis (MS) is a complex genetic disease associated with inflammation in the Central Nervous System (CNS) White Matter and is thought to be mediated by AutoImmune processes.

Clonal expansion of B-Cells, their AntiBody products, and T-Cells, hallmarks of inflammation in the CNS, are found in MS.

The association of the disease with Major HistoCompatibility Genes, the inflammatory White Matter infiltrates, similarities with animal models.

And the observation that MS can be treated with ImmunoModulatory and ImmunoSuppressive Therapies support the hypothesis that AutoImmunity plays a major role in the disease pathology.

This review discusses the ImmunoPathology of MS with particular focus given to regulatory T-Cells and the role of B-Cells and AntiBodies, ImmunoModulatory Therapeutics, and finally new directions in MS research.

Particularly new methods to define the molecular pathology of human disease with high-throughput examination of germline DNA Haplotypes, RNA expression, and protein structures.

That will allow the generation of a new series of hypotheses that can be tested to develop better understandings and therapies for this disease.

We analyzed the Serum and CerebroSpinal Fluid (CSF) Leptin secretion and the interaction between Serum Leptin and CD4⁺CD25⁺ regulatory T-Cells (TRegs) in naive-to-therapy Relapsing/Remitting Multiple Sclerosis (RRMS) patients.

Leptin production was significantly increased in both Serum and CSF of RRMS patients and correlated with IFN- secretion in the CSF.

T-Cell lines against human Myelin Basic Protein (hMBP) produced ImmunoReactive Leptin and up-regulated the expression of the Leptin Receptor (ObR) after activation with hMBP.

Treatment with either AntiLeptin or AntiLeptin-Receptor Neutralizing AntiBodies inhibited in vitro proliferation in response to hMBP.

Interestingly, in the RRMS patients, an inverse correlation between Serum Leptin and percentage of circulating TRegs was also observed.

To better analyze the finding, we enumerated TRegs in Leptin-deficient (ob/ob) and Leptin-Receptor-deficient (db/db) mice and observed the significant increase in TRegs.

Moreover, treatment of WT mice with soluble ObR fusion protein (ObR:Fc) increased the percentage of TRegs and ameliorated the clinical course and progression of disease in ProteoLipid Protein Peptide (PLP139-151)-induced Relapsing-Experimental Autoimmune Encephalomyelitis (R-EAE), an animal model of RRMS.

These findings show an inverse relationship between Leptin secretion and the frequency of TRegs in RRMS and may have implications for the pathogenesis of and therapy for Multiple Sclerosis.

Objective
To evaluate concurrent and predictive validity for Low-Contrast Letter Acuity (L-CLA) testing as a candidate Visual Component for the Multiple Sclerosis Functional Composite (MSFC).

Methods
L-CLA testing was conducted in two MS patient cohorts. In the MSFC Validation Study, 137 participants from a Phase III trial of Inteferon-beta-1a (Avonex) for Relapsing/Remitting MS were followed.

A second cohort included 65 patients with Secondary/Progressive MS who participated in a substudy of the International MS Secondary Progressive Avonex Controlled Trial (IMPACT).

The total number of letters read correctly at four contrast levels (100, 5, 1.25, and 0.6%) was correlated with Expanded Disability Status Scale (EDSS), MSFC, Sickness Impact Profile, Multiple Sclerosis Quality of Life Inventory, and Brain Parenchymal Fraction (BPF), as determined by MRI.

Results
Low- and high-contrast letter Acuity Scores correlated with BPF at follow-up in the MSFC Validation Study (5%: r = 0.40, p < 0.0001; 100%: r = 0.31, p = 0.0002).

L-CLA also correlated with EDSS (5%: r = -0.35, p < 0.0001; 1.25%: r = -0.26, p = 0.0003) and MSFC (5%: r = 0.47, p < 0.0001; 1.25%: r = 0.45, p < 0.0001).

In the IMPACT Substudy, change in L-CLA scores from baseline to year 1 predicted subsequent change in the EDSS from year 1 to 2 at the 5% (p = 0.0142) and the 1.25% (p = 0.0038) contrast levels, after adjusting for change in MSFC scores from baseline to year 1.

Conclusions
Low-Contrast Letter Acuity (L-CLA) scores demonstrate concurrent and predictive validity in patients with Relapsing/Remitting and Secondary/Progressive Multiple Sclerosis (MS).

L-CLA testing provides additional information relevant to the MS disease process that is not entirely captured by the Multiple Sclerosis Functional Composite.

Background
Laquinimod is a novel ImmunoModulatory substance developed as an orally available disease modifying treatment in Multiple Sclerosis (MS).

The purpose of this study was to evaluate safety, tolerability, and efficacy on MRI lesions of two different doses of Laquinimod compared with placebo in patients with Relapsing MS.

Methods
In this multicenter, double-blind, randomized trial, patients with Relapsing MS received 0.1 mg or 0.3 mg Laquinimod or placebo as three daily tablets for 24 weeks.

Gadolinium-enhanced Brain MRI scans were performed at screening, every eighth week during treatment, and 8 weeks after end of treatment.

The primary efficacy variable was the cumulative number of active lesions over 24 weeks. Safety measures included adverse events, physical examination, and laboratory variables.

Results
Of 256 screened patients, 209 were randomized (67 to 74 patients per group) in 20 centers.

There was a significant difference between Laquinimod 0.3 mg and placebo for the primary outcome measure (mean cumulative number of active lesions reduced by 44%).

In the subgroup of patients with at least one active lesion at baseline the reduction was slightly more pronounced (52%).

No differences with respect to clinical variables (relapses, disability) were found. The safety profile was favorable; there were no clinical signs of undesired inflammatory manifestations.

Conclusion
Oral Laquinimod in a dosage of 0.3 mg daily was well tolerated and effective in suppressing development of active lesions in Relapsing Multiple Sclerosis.

Complexes of the Tyrosine Kinase Ephrin Ligands (Ephrins) and their Receptors (Ephs) provide critical cell recognition signals in CNS development.

Complementary Ephrin/Eph expression gradients present topographic guidance cues that may either stimulate or repulse Axon growth.

Some Ephrin/Ephs are upregulated in adult CNS injury models. To assess their involvement in Multiple Sclerosis (MS), Ephrin A1-5 and Eph A1-8 expression was analyzed in CNS tissues using ImmunoHistoChemistry.

Control samples showed distinct expression patterns for each Ephrin/Eph on different cell types.

PeriVascular MonoNuclear Inflammatory Cells, reactive Astrocytes and Macrophages expressed Ephrin A1-4, Eph A1, -A3, -A4, -A6 and -A7 in active MS lesions.

Axonal Ephrin A1 and Eph A3, -A4, and -A7 expression was increased in active lesions and was greater in Normal-Appearing White Matter (NAWM) adjacent to active lesions than within or adjacent to chronic MS lesions, in ContraLateral NAWM, or in control samples.

As in development, therefore, there are temporally dynamic, lesion-associated Axonal Ephrin/Eph A expression gradients in the CNS of MS patients.

These results indicate that Ephrin/Eph As are useful cell markers in human CNS tissue samples. They likely are involved in the ImmunoPathogenesis of active lesions and in NeuroDegeneration in MS NAWM; and they represent potential therapeutic targets in MS.