MS Abstracts 6b-2g

IntraCerebral infection of susceptible mice with Theiler's murine EncephaloMyelitis Virus results in Immune-mediated Inflammatory DeMyelination in the White Matter and consequent clinical symptoms.

This system has been utilized as an important Virus model for human Multiple Sclerosis.

Although the potential involvement of Virus-specific Th Cells Cells has been studied extensively, very little is known about the nature of T-Cells infiltrating the CNS during Viral infection and their role in the development of DeMyelinating Disease.

In this study, the clonal nature of T-Cells in the Spinal Cord during the disease course was analyzed using size spectratyping and sequencing of the TCR ß-chain CDR3 region.

These studies clearly indicate that T-Cells are clonally expanded in the CNS after Viral infection, although the overall TCR repertoire appears to be diverse.

The clonal expansion appears to be Ag-driven in that it includes Th Cells specific for known Viral Epitopes.

Interestingly, such restricted accumulation of T-Cells was not detectable in the infiltrates of mice with ProteoLipid Protein Peptide-induced Experimental AutoImmune EncephaloMyelitis.

The initial T-Cell repertoire (7-9 days postinfection) seems to be more diverse than that observed in the later stage (65 days) of virally induced DeMyelination, despite the more restricted utilization of Vß subfamilies.

These results strongly suggest continuous stimulation and clonal expansion of Virus-specific T-Cells in the CNS of Theiler's murine EncephaloMyelitis Virus-infected mice during the entire course of DeMyelinating Disease.

The prevalence of Multiple Sclerosis in the Australian-born population in five different regions of Australia has a strong correlation with latitude, the disease becoming increasingly prevalent with increasing south latitude.

In this study, the prevalence in the migrant population from the UK and Ireland (UKI) in the different regions also showed a significant correlation with latitude, but this relationship was strongly influenced by the high prevalence in Hobart.

Except for Hobart, the prevalence in migrants was considerably less than that in their countries of origin.

The prevalence of Multiple Sclerosis among those migrating before the age of 15 years, from the high-risk UKI to lower-risk Australia was not significantly different to that among those migrating at or after that age.

And this finding was confirmed in a case-control study which demonstrated little association between age at migration and risk of developing Multiple Sclerosis.

These findings suggest that the risk from environmental factors in Multiple Sclerosis may operate over a period of many years and not only in childhood and early adult life.

We analyzed the effects of Glatiramer Acetate (GA) therapy on in vitro proliferative responses and Cytokine production by Lymphocytes derived from Multiple Sclerosis patients receiving this therapy.

We confirmed that Lymphocytes derived from GA naive patients show a high frequency of response when initially exposed to GA in vitro; this frequency decreased following GA therapy.

The frequency of Lymphocytes responding to whole MBP stimulation did not change with GA therapy.

GA- and MBP-specific T-Cell lines generated from these patients by repeated cycles of in vitro stimulation did not cross react. Some (23%) whole MBP-reactive T-Cell lines did cross react with MBP peptide 83-99.

The mean levels of Interferon-gamma (IFN-) secretion and the mean ratio of IFN-/IL-5 were lower for GA-reactive cell lines, derived from patients both prior to and during GA therapy, compared to MBP-reactive T-Cell lines.

The proportion of IFN- cells in unfractionated Lymphocyte preparations derived from the GA-treated patients did not differ from that found for healthy controls.

Our findings indicate that GA-reactive T-Cell lines derived from GA-treated MS patients continue to show a relative Th2 Cytokine bias consistent with a Bystander Suppressor Function.

GA treatment is not associated with a Cytokine phenotype shift in the total T-Cell or MBP-reactive T-Cell populations.

Identifying and quantifying AutoAggressive responses in Multiple Sclerosis (MS) has been difficult in the past due to the low frequency of AutoAntigen-specific T-Cells, the high number of putative determinants on the AutoAntigens, and the different Cytokine signatures of the AutoReactive T-Cells.

We used single-cell resolution enzyme-linked immunospot (ELISPOT) assays to study, directly ex vivo, ProteoLipid Protein (PLP)-specific Memory Cell reactivity from MS patients and controls.

Overlapping 9-aa-long peptides, spanning the entire PLP molecule in single Amino Acid steps, were used to determine the frequency and fine specificity of PLP-specific Lymphocytes as measured by their IFN- and IL-5 production.

MS patients (n = 22) responded to 4 times as many PLP peptides as did healthy controls (n = 22).

The Epitopes recognized in individual patients, up to 22 peptides, were scattered throughout the PLP molecule, showing considerable Heterogeneity among MS patients.

Frequency measurements showed that the number of PLP peptide-specific IFN--producing cells averaged 11 times higher in MS patients than in controls.

PLP peptide-induced IL-5-producing T-Cells occurred in very low frequencies in both MS patients and controls.

This first comprehensive assessment of the Anti-PLP-Th1/Th2 response in MS shows a greatly increased Th1 Effector Cell mass in MS patients.

Moreover, the highly IFN--polarized, IL-5-negative Cytokine profile of the PLP-reactive T-Cells suggests that these cells are committed Th1 Cells.

The essential absence of uncommitted Th0 Cells producing both Cytokines may explain why therapeutic strategies that aim at the induction of Immune deviation show little efficacy in the established disease.

Objective
To assess the technique, efficacy and complications of the Ultraflex(R) Urethral stent (Boston Scientific Corp., Boston, MA) for the treatment of Detrusor-Striated Sphincter DysSynergia (DSD).

Patients And Methods
Forty consecutive patients with DSD who had a Ultraflex(R) stent placed in the membranous Urethra were evaluated prospectively.

DSD was caused by Spinal Cord Injury in 30, Multiple Sclerosis in six and Other Neurological Diseases in four.

All patients were either Tetraplegic or Paraplegic and unable to use intermittent self-catheterization.

Previous Bladder management consisted of an indwelling catheter in 15 patients, chronic suprapubic catheters in two, intermittent catheterization in nine, and trigger reflex micturition in 14.

The Ultraflex stent was placed under local anaesthesia. The stents were 50 mm long in 36 patients, 45 mm in two and 40 mm in two. The mean (SD) follow-up was 16.9 (13.8) months.

Results
The mean (SD) residual urine decreased from 245.9 (117) mL before stenting to 65.2 (19.3) mL at 12 months afterward (n = 19).

One stent was removed at 13 months for chronic prostatic and Urinary Tract Infection leading to Autonomic Dysreflexia. There was no stent stenosis and 17 of 18 stents had > 75% epithelial coverage at one year.

None of the stents migrated. Seven patients underwent secondary Bladder Neck incision through the stent.

The stent length was increased in four patients using a second overlapping distal stent, twice during the first procedure and twice within 6 months because the Sphincter was inadequately covered.

Conclusions
The Ultraflex(R) stent achieved the expected results for a prosthetic Sphincterotomy and appears to be an appropriate but less invasive treatment for DSD.

Aims
To determine the use of nonprescription medicines in a cohort of Multiple Sclerosis (MS) patients and to identify a subgroup of patients liable to spend more on nonprescription medicines.

Methods
A questionnaire was given to MS patients attending a Neurology out-patients clinic during the previous year.

Medicines from a General Practitioner (GP), pharmacy and 'other' sources utilized in the last month were determined, along with demographic data. Additional information was obtained from hospital notes.

Results
One hundred and seventeen MS patients responded to the questionnaire, giving a response rate of 79% (117/148).

Responders differed from nonresponders only in age, with responders being significantly older than nonresponders (P = 0.011).

Over one-third of medicines taken in the last month were nonprescription medicines (35%; 219/627). A Gamolenic Acid containing preparation was the most popular, purchased by 28% of patients.

Fifteen percent (17/117) of MS patients had exceeded the recommended daily allowance of a vitamin (frequently vitamins A, D and E), and one exceeded the upper safe level for daily self-supplementation of vitamin A and D.

Females spent significantly more than males in the previous month ( pound10.09 compared with pound5.53, respectively; P = 0.022).

Patients who were older, reported worsening MS symptoms in the last year and those who exhibited greater disability were more likely to have been prescribed medicines by a GP (P < 0.0005), although they were not more likely to self-prescribe or take alternative remedies (P > 0.05).

However, those with poorer mobility were significantly less likely to have purchased a pharmacy medicine in the last month (P = 0.033).

Conclusions
MS patients were high users of nonprescription medicines.

A typical subgroup of MS patients that spent more on nonprescription medicines could not be identified, aside from females.

Furthermore, the strong predictors for increased use of prescription medicines (increasing age, severity of symptoms in the last year and poorer mobility) were not found for nonprescription medicines.

Excessive intake of the fat soluble vitamins could lead to HyperVitaminosis, the effects of which could exacerbate or mimic MS symptoms.

Health professionals should be aware of these issues and counsel the MS patient accordingly, particularly as the majority purchased products from 'other' sources where typically there is no health-professional available to give advice.

The limited use of pharmacy medicines by the more disabled patient could indicate a problem with access to the pharmacy, or could reflect the greater use of nonprescription medicines.

Normal subjects use an Open-Loop Motor Control Strategy in handwriting, but they are able to switch to Closed-Loop Motor Control when the demands on accuracy increase.

These closed-loop handwriting movements of normal subjects resemble the inefficient movements found in Writing-Impaired patients.

The hypothesis that such movement deficits may in fact reflect the use of a Closed-Loop strategy was tested in a group of Writing-Impaired patients with Multiple Sclerosis (MS).

The handwriting movements of 10 MS patients and 20 control subjects were examined with a digitizing tablet.

Three conditions were used: a standard writing task (expt 1), a Closed-Loop condition (expt 2), and an Open-Loop condition (expt 3).

Individual stroke movements were analyzed. Stroke duration and segmentation were increased for MS patients in the standard writing task.

The same was found for control subjects when they wrote under Closed-Loop conditions. However, under Open-Loop conditions, the handwriting movements of the MS patients were as fast and fluent as that of control subjects.

The results support the hypothesis that the movement characteristics of the Writing-Impaired MS patients reflect an inadequate use of a Closed-Loop Motor Control Strategy.

The Immunological effects of high-dose MethylPrednisolone in attacks of Multiple Sclerosis and acute Optic Neuritis have only been examined in a few randomized, controlled trials.

We studied Immunological changes in 50 patients with Optic Neuritis or Multiple Sclerosis who underwent Lumbar Puncture before and 1 week after completing a 15-day course of oral high-dose MethylPrednisolone treatment.

Treatment resulted in:

1. Decrease in the concentration of MBP
2. Decrease in the Serum concentration of
   • ImmunoGlobulin G (IgG)
   • Intrathecal IgG synthesis
3. Increase in the CerebroSpinal Fluid concentration of Transforming Growth Factor-beta1
4. Changes in the expression of CD25, CD26, and HLA-DR on CD4⁺ T-Cells

No effect was seen on the CerebroSpinal Fluid Leucocyte count or the CerebroSpinal Fluid activity of Matrix MetalloProteinase-9 (MMP-9).

The lack of a persistent effect on CerebroSpinal Fluid Leukocyte recruitment and MMP-9 activity, despite changes in IgG synthesis, T-Cell activation, and Cytokine production suggests:

That modulation of the function of inflammatory cells may contribute to the clinical efficacy of oral high-dose MethylPrednisolone treatment in Optic Neuritis and Multiple Sclerosis.

Multiple Sclerosis (MS) is a DeMyelinating Disease of the Central Nervous System with a presumed AutoImmune PathoGenesis involving AutoAntigen-specific⁺T-Cells and Cytokines.

A similar frequency of T-Cells responding to Myelin Basic Protein (MBP), a putative target in MS, has been observed in MS patients and controls.

To dissect the differences between MBP-specific T-Cells in patients and controls, we have analyzed the Cytokine secretion profile of such AutoReactive T-Cells.

MBP-specific T-Cell Clones (TCC) were isolated from the peripheral blood of MS patients and controls by limiting dilution.

Expression of mRNA for IFN-IFN- (IFN-), InterLeukin-4, InterLeukin-10 (IL-4), IL-10, Tumor Necrosis Factor-alpha (TNF-) and Transforming Growth Factor-beta (TGF-ß) was assessed by polymerase chain reaction whereas secretion of Cytokine protein was measured by ELISA.

MBP-specific TCC exhibited a heterogeneous Cytokine secretion profile with Clones displaying Th1, Th2 and Th0 phenotypes.

A significant difference in the distribution of the Cytokine profile was noted between MS patients and controls.

Although the frequency of Th1 secreting MBP-reactive TCC was similar between MS patients and controls, stable MS patients had a significant association with the Th0 phenotype whereas healthy individuals were associated with the Th2 phenotype.

In comparison to control TCC, MBP-specific TCC from MS patients secreted increased amounts of IFN-IFN-, IL-4 and IL-10 and decreased quantities of TGF-ß.

Thus, these studies suggest that there is a DysRegulation in the balance between ProInflammatory Th1 and AntiInflammatory Th2 Cytokines in MS.

It appears that the presence of Th1 secreting AutoReactive T-Cells in healthy individuals may be counterbalanced by the presence of cells secreting Th2 Cytokines.

And by the augmented production of the ImmunoSuppressive Cytokine TGF-ß, whereas in MS there is a decrease in these AntiInflammatory agents.

Multiple Sclerosis (2000) 6, 69 - 77