Poster II

Intrathecal antibody synthesis in demyelinating disease cohort: can oligoclonal band status act as a surrogate for seperation in time?

P. Hardeman, L. Horton, S. Hughes, P. Chaudhry, E. Frohman, D. Graves, B. Greenberg

UT Southwestern Medical Center (Dallas, US)

Objective: To establish if oligoclonal bands (OCBs) can act as surrogate for separation in time when evaluating a patient for multiple sclerosis (MS).

Background: To make a diagnosis of MS, a patient must have a clinical history and paraclinical assesments [magnetic resonance imaging (MRI), cerebrospinal fluid (CSF)] that are consistent with MS with the exclusion of all mimics. To meet criteria for clinically definite multiple sclerosis (CDMS), a patient must have clinical or preclinical evidence of demyelinating events separated in time and space. MRI has been incorporated into diagnostic criteria as a surrogate for seperation in space and a surrogate for separation in time, but OCBs have only been used as a surrogate for separation in space. Determining the length of time OCBs remain present in the spinal fluid of MS patients would be the first step in considering OCBs as a potential surrogate marker for separation in time.

Design/Methods: A retrospective chart review was done on patients being evaluated for MS at a large MS center who have had CSF tested as part of their initial work-up. Patients charts were reviewed who had been consented as part of a biorepository . Clinically isolated syndrome (CIS) and CDMS patients were included in this review. If the exact date of symptoms was not known, the fifteenth of the month was used for onset of symptoms. Patients diagnosed with progressive forms of MS were excluded from this review. A small cohort of patients agreed to have repeat lumbar punctures for a repeat of CSF analysis.

Results: A total of 27 CIS and 18 CDMS patients’ charts were reviewed. Of the CDMS patients 50% were identified to have positive OCB and 50% as negative OCB. The average number of days from the onset of symptoms to CSF analysis was 2,513. Of the OCB positive MS patients, the average number of days from symptom onset to CSF analysis was 2,105. Of the 27 CIS patients, 17 (63%) were identified to have positive OCBs. The average number of days from onset of symptoms to CSF analysis in the CIS patients was 580 days.

Conclusion: The majority of patients had CSF analysis with postive OCBs years after their first event; suggesting that positive OCBs could be used to indicate a seperation in time. Thus, a CSF analysis obtained at a time distinct from symptom onset may be a useful tool for differentiating patients with singular demyelinating events from those who have had a first symptom of MS. We plan to follow our CIS patients over time to further investigate this phenomenon.

Paula Hardeman, Lindsay Horton, Samuel Hughes and Parul Chaudhry have nothing to diclose.

Elliot Frohman has received consulting fees from Biogen Idec, TEVA neurosciences, Athena and Abbott laboraties.

Donna Graves has received speaker fees from TEVA neurosciences, Novartis, Bayer, and Pfizer.

Benjamin Greenberg has recieved honoria from the MSAA, EMD Serono; consulting fees from DioGenix Inc, Greater Good Foundation; grants from the Accelerated Cure Project, Guthy-Jackson Charitable Foundation and holds equity in Diogenic.

Aquaporin-4 expression and supramolecular aggregation may determine tissue susceptibility to neuromyelitis optica

M. Matiello, D. Sun, J. Schaefer-Klein, B. Weinshenker

Mayo Clinic (Rochester, US)

Objective: To evaluate aquaporin-4 (AQP4) expression and supra-molecular aggregation in neuromyelitis optica (NMO) susceptible versus non-susceptible tissues and to compare AQP4 expression between a NMO patient tissues and controls.

Background: NMO is characterized by the presence of a specific and pathogenic autoantibody to AQP4, the binding of which is dependent on the existance of supramolecular aggregates of AQP4. The expression of AQP4 in human optic nerve and spinal cord in healthy individuals and in patients with NMO is poorly characterized.

Methods: Human CNS autopsy tissue was obtained from a seropositive patient with NMO and six control individuals. In four of the controls, only optic nerve was obtained. Kidney was studied as an AQP4-expressing neuromyelitis optica “non-susceptible” control. mRNA was measured both using Taqman-based hybridization probes and SYBR Green-based quantitative PCR. Protein expression was evaluated using SDS-polyacrylamide gel electrophoresis and densitometry. Blue-native polyacrylamide gel electrophoresis (BN-PAGE), a nondenaturing electrophoresis technique to evaluate supramolecular aggregation of AQP4.

Results: TaqMan and SYBR Green assays yielded similar ranking of tissues for mRNA expression. Optic nerve had the highest expression of total AQP4, followed by spinal cord (0.67), brain stem (0.27), brain cortex (0.07), kidney medulla (0.01) and liver (0.0001). Optic nerve and spinal cord had the greatest quantities of AQP4 protein per unit tissue mass and relatively more abundant highest order relative to lowest order supramolecular aggregate sizes of AQP4. No differences were identified between the mRNA and protein expression of AQP4 in an NMO case versus control individuals.

Conclusions: Tissues of greatest susceptiblity to NMO pathology have the highest expression and more prominent higher order supramolecular aggregates of AQP4 compared to other CNS or non-CNS tissues. These studies provide insight into the basis of tissue selectivity of NMO pathology.

Supported by: Dr. Matiello was supported by the National MS Society.

This research was supported by the Guthy-Jackson Charitable Foundation.

The authors have nothing to disclose.

A sound localisation test discriminates between controls and multiple sclerosis patients with no measurable disability

J.H. Bacon, T.E. Bacon, I. Kister, Y. Strauchler, G. Tsikhanovski Bochner, M. Omari, A. Bochkanova, J. Herbert

Yeshiva University (New York, US); NYU School of Medicine (New York, US)

Background: Sound lateralization is dependent upon precise timing of neuronal discharges in the auditory brainstem. Slowed processing speed in auditory brainstem pathways interferes with MS patients’ ability to lateralize sound. A test of sound lateralization may be useful for detecting subtle brainstem deficits even among minimally impaired MS subjects.

Objective: To determine whether a test of sound lateralization may be more sensitive to differences between controls and minimally impaired MS subjects than standard cognitive tasks.

Design/Methods: 16 healthy controls and 45 MS subjects were recruited. Patients were divided into three disability strata: No Disability (Expanded Disability Status Scale (EDSS) =0; N=15), Mild Disability (EDSS=1 to 3.5; N=17), and Moderate Disability (EDSS=4 to 6.5; N=13). Using an interleaved staircase method, the interaural time difference (ITD) to a dichotically presented 910 Hz tone burst was varied to determine ITD thresholds for the tone localized just to the right or just to the left of center. Two standard tests used to assess processing speed, the Paced Auditory Serial Addition Test (PASAT3 and PASAT2) and the Symbol Digit Modalities Test (SDMT), were also administered.

Results: Right and left threshold ITDs were averaged to provide a deviation score for each subject. The mean threshold ITD score was lowest for controls (M=196.9 µs, SD=76.4), increased for the No and Mild Disability groups (M=280.7 µs, SD=77.5 and M=268.8 µs, SD=105.3, respectively), and was greatest for the Moderate Disability group ( M=342.3 µs, SD=62.2). A MANOVA showed highly significant effects for IDT (p<.001, eta2=.28) and for the three other dependent variables (PASAT3, p<0.02; eta2=.23; PASAT2, p<.01, eta2=.18; SDMT, p<.001, eta2=.30). However, post hoc analysis showed that only the IDT test was sensitive to differences between controls and each MS group including, most importantly, the No Disability group(p<0.02).

Conclusions: In our study, sound localization was the only test sensitive to differences between controls and all MS groups, including the group with normal neurologic examination (EDSS=0). The results were significant in a small-cohort study suggesting that this technically-simple speed of processing test could be used to detect neurologic dysfunction in mild disease and as a clinical outcome measure to monitor treatment effects in phase I and II studies of, for example, neuroprotective or remyelination agents.

JH Bacon received research support from Bayer.

TE Bacon, Y Strauchler, G Tsikhanovski Bochner, M Omari and A Bochkanova have nothing to disclose.

I Kister received research support from EMDSerono/Pfizer, Inc. the National Multiple SclerosisSociety and Jackson-Guthy Charitable Foundation.

J Herbert has received personal compensation for activities with Biogen Idec, EMD Serono, Teva Neuroscience and Bayer as a consultant.

Dr Herbert has received research support from Teva Neuroscience, Novartis, Biogen Idec, Bayer, EMD-Serono/Pfizer, BioMS and INC Research.

A practical algorithm for differentiating neurosarcoidosis from multiple sclerosis with application to cases from NYU MS Centre

L. Zhovtis Ryerson, J. Herbert, I. Kister

NYU Langone Medical Center (New York, US)

Objective: To develop an algorithm for differentiating Neurosarcoidosis (NS) from Multiple Sclerosis (MS) on clinical and radiographic grounds, and to apply it to patients with a neurologic disorder and biopsy-proven extra-neuronal sarcoidosis (ENS) who presented to NYU MS clinic.

Background: Chronic central nervous system (CNS) disorder in a patient with extra-neural sarcoidosis may be due to sarcoid involvement of the CNS, or a co-morbid disorder, such as MS. Pathologic confirmation required to make definitive diagnosis is often not feasible, and a diagnostic approach based on clinical and radiographic evidence would be useful in practice.

Design/Methods: Through literature search, we identified clinical and radiographic syndromes that have been consistently attributed to NS. These syndromes were classified based anatomic level of involvement: basal meninges and adjacent structures; optic nerve; brain parenchyma only; spinal cord and root; peripheral nerve and muscle. The algorithm is based on matching clinical and radiographic features of patient’s presentation with those of specific NS syndromes. We applied our algorithm to 2 patients with biopsy-proven extra-neural sarcoidosis and 1 with biopsy-proven granulomatous uveitis identified through search of the electronic database of the NYU-MS Center.

Results: All 3 patients satisfied McDonald criteria for clinically-definite MS, and 2 patients also satisfied Zajicek criteria for possible NS. Sarcoidosis was an incidental finding on chest x-ray in one patient and quiescent for 8 years prior to neurologic disease onset in another. In both patients, relapsing course was followed by progressive phase. Third patient had granulomatous uveitis presenting 7 yrs prior to the diagnosis of relapsing CNS disorder. Clinical and radiographic disease evolution was highly typical of multiple sclerosis in all patients and atypical for any of the NS syndromes. After applying the proposed algorithm, diagnosis of co-morbid MS and sarcoidosis/granulomatous uveitis, rather than NS, was deemed more likely in all three cases.

Conclusions: Central nervous system disorder in patients with ENS may be due to NS or a co-morbid neurologic condition. Characterization and classification of clinical and radiographic features of NS syndromes described in the literature may be useful to clinicians who are evaluating patients with biopsy-proven granulomatous disorder and neurologic disease. Validation of proposed algorithm would require a prospective, multi-center study.

The authors have nothing to disclose.

Proteomic investigations on differential post-translational modifications of transthyretin in multiple sclerosis

D. Pieragostino, P. Del Boccio, M. di Ioia, L. Pieroni, V. Greco, G. De Luca, C. Di Ilio, D. Centonze, P. Sacchetta, A. Lugaresi, A. Urbani

University “G. d’Annunzio” of Chieti-Pescara (Chieti, IT); University of Rome Tor Vergata (Rome, IT); IRCCS-Foundation S. Lucia (Rome, IT)

Objective: Multiple Sclerosis (MS) is a multifactorial disease involving Central Nervous System (CNS) that results in global health issues. Thus, the need of understanding the molecular machinery involved in this pathology to develop more effective pharmacological therapeutics. Cerebrospinal Fluid (CSF) is a helpful biological fluid to study MS as it collects molecules released from various cell types as a result of the pathology. The aim of our work was to study proteome of CSF to highlight differential peaks of disease and to characterize them by a functional and structural point of view.

Results: By studying CSF of MS patients through proteomic approaches we described two non canonical oxidative post-translational modifications (PTMs) on CSF Transthyretin (TTR), a 55 KDa homo-tetrameric protein involved in Thyroid Hormone (TH) transport into CNS (up to 80% in man). These isoforms, belonging to S-sulfhydration (Cys-S-SH) and S-sulfonation (Cys-S-SO3H) of Cys in position ten, discriminate MS patients from OND subjects and subjects with Acute Disseminated Encephalomyelitis (ADEM). Moreover these non-canonical isoforms were not highlighted in serum of MS patients, showing a specific phenomenon of CNS. Western Blot analysis of TTR, in non-reducing conditions, showed a correlation between the modified TTR and an atypical TTR dimer in CSF samples. Moreover we found low levels of free T4 in CSF of MS patients suggestive of a potential role of these modifications on TH transport in the CNS.

Conclusion: TH physiologically helps oligodendrocytes precursor to turn into re-myelinating oligodendrocytes regulating fundamental cell activities, including cell cycle. Hence TTR redox imbalance may eventually modify TTR transport capacity in MS highlighting a probable alteration in TH transport in MS disease.

Damiana Pieragostino is supported by FISM Research Fellowship Cod.2010/B/14.

Maria Di Ioia is involved in clinical trials of Merck Serono S.A – Geneva and Teva Neuroscience.

Piero Del Boccio: has nothing to disclose.

Luisa Pieroni, Viviana Greco, Carmine Di Ilio, Diego Centonze, Andrea Urbani and Paolo Sacchetta: nothing to disclose.

Giovanna De Luca has received a researcher grant from: Merck Serono S.A. – Geneva and is involved in clinical trials of the same company, plus GlaxoSmithKline, Biogen-Dompé, Bayer Schering, Novartis and Teva.

Alessandra Lugaresi has received research and travel support or speaker fees from Biogen-Dompé, Bayer Schering, Merck-Serono, Novartis, Sanofi-Aventis and Teva.

A novel mutation of adult-onset Alexander disease mimics CNS demyelinating disease

C. Costanzi, N. De Rossi, R. Capra

MS Center- Montichiari (Brescia, IT)

The differential diagnosis of multiple sclerosis(MS) often focuses on CNS inflammatory demyelinating diseases(IDDs). However, a wider spectrum of conditions, including the genetic ones, can mimic CNS IDDs, therefore it is critical to consider whether symptoms, signs, imaging and/or response to therapies are compatible with the disease, prompting the right diagnostic approach.

This study is a case report. Neurological examination, MRI and serological investigations were performed as part of the routine care.

Case report: a case of a genetically confirmed adult-onset Alexander disease(AOAxD) in a 58-year-old woman presenting with a steroid-unresponsive CNS disorder characterized by presence of pyramidal signs and muscle weakness of the lower limbs since 4 years ago, initially associated with muscle pain, progressing in a mild paraparesis. The first brain and spine MRI was done within 9 months from the symptoms onset and revealed a T2W signal abnormality in the bulbo-spinal region and atrophy of the medulla oblongata and upper cervical spinal cord. Oligoclonal bands were absent and blood/liquoral screening for antibodies against neurotrophic viruses were negative. The patient reported a subjective mild improvement with methylprednisolone i.v., not confirmed by the neurological examination. Primary progressive MS diagnosis was made. One year later a new MRI revealed two new T2W hyperintense lesions in the mesencephalon. The mild paraparesis on the neurological examination was unchanged. The longitudinal transverse myelitis (LEMT) associated with relatively mild paraparesis raised the doubt of neuromyelitis optica. A slowly progressive course and the grade of atrophy added Alexander disease to the differential diagnosis. The NMO-IgG antibody was negative while the genetic test on the GFAP revealed a novel mutation in heterozygosis [missense substitution c1127G>T (p.R376L)]. After 4 years from the onset of the symptoms the patient is still able to walk alone with a very mild paraparesis.

AOAxD should be considered in the differential diagnosis of MS and NMO when there are cervico-medullary lesions with an extensive spinal atrophy associated with steroid-unresponsive mild paraparesis, slowly progressive course and absence of clinical relapses. MS usually doesn’t show a LEMT on MRI and NMO has recurrences in 90% of the patients and the course is not progressive. Moreover, the novel mutation of GFAP adds useful information about genetic screening of AOAxD.

The authors have nothing to disclose.

A Pilot Reproducibility Evaluation of CoSMo Study (PREP Study): methodological aspects

G Malferrari, M.L. Zedde, S. Sanguigni, D. Ciampanelli, P. Prati, C. Baracchini, N. Carraro, M. Del Sette, E. Stolz, L. Motti, G. Comi, G. Mancardi, M.A. Battaglia on behalf of CoSMo Study

Multiple sclerosis (MS) is considered an autoimmune disease of the Central Nervous System (CNS) characterized by inflammation, demyelination, and neurodegeneration. Recently the possible pathogenetic role of functional and structural abnormalities of cervical and intracranial veins has been postulated. Such a condition, called chronic cerebrospinal venous insufficiency (CCSVI) has been initially reported to occur in 100% of MS patients and very rarely in normal controls. To help addressing the conflicting reports and provide answers to MS patients the Italian MS Society, through its Foundation (FISM), has promoted and financed the CoSMo study. In the CoSMo study global hemodynamic of trascranial and extracranial venous system is evaluated using advanced Eco Color Doppler (ECD) parameters in addition to the 5 CCSVI criteria previously reported. To explore the variability between two different sonologists and to ensure a different external reference in this study we present the methodology used in a multicenter triple blinded pilot evaluation (PREP Study) of the CoSMo, concerning 60 patients with SM (RR) from four Center who underwent an ECD exam and after that an angioRM of the cerebral venous tree. The neurosonological and neuroradiological intracranial examinations are focused on Basal Vein of Rosenthal (BVR) and transverse sinus on both sides and the vessel identification, the flow direction and the presence of reflux was compared. The present study combines the high morphology capability of the Magnetic Resonance Venography (MRV) and the hemodynamic parameters such as blood flow velocity (BFV) and cerebral blood flow (CBF) allowed with the ECD. We compare the flow direction of the spectrum of the intracranial venous obtained by Transcranial Color-Coded Doppler (TCCD) with the spin results of the MRV. The primary aim of PREP study is to assess the inter-rater reliability of the neurosonologists. In fact, the four pairs of neurosonologists know the clinical condition of the patients but they are blinded to the ultrasound results of the other sonographer. Then, stored data are assessed offline by a second blinded investigator. Finally the directions of BVR and the transverse sinus, obtained using TCCD, are compared with the MRV direction. The present protocol may provide insights into the use of ECD as a new diagnostic tool to evaluate venous functions in Multiple Sclerosis and in other neurodegenerative diseases.

G Malferrari, M.L Zedde, S. Sanguigni, D. Ciampanelli, P. Prati, C. Baracchini, N. Carraro, M. Del Sette, E. Stolz, L. Motti and M.A. Battaglia have not conflict of interest declare; G. Comi has received consulting fees for participating on advisory boards from Novartis, Teva Pharmaceutical Ind. Ltd., Sanofi-Aventis, Merck Serono, and Bayer Schering; lecture fees from Novartis, Teva Pharmaceutical Ind. Ltd., Sanofi-Aventis, Merck Serono, Biogen Dompè, Bayer Schering and Serono Symposia International Foundation. He is member of the Board of Governors of the Italian Foundation for Multiple Sclerosis; G. Mancardi received honoraria for lecturing, travel expenses for attending meetings, and financial support for research from Bayer Schering, Biogen Idec, Sanofi-Aventis, Novartis and Merck Serono Pharmaceuticals. He is member of the Board of Governors of the Italian Foundation for Multiple Sclerosis.

Early clinical remission as a prognosis factor for medium term disability progression in multiple sclerosis

T. Moreau, M. Debouverie, C. Lebrun-Frenay, P. Clavelou, D. Brassat, O. Gout, D. Laplaud, J. De Sèze, B. Stankoff, P. Vermersch, S. Millot, F. Rollot, C. Bonithon-Kopp, C. Binquet

University Hospital of Dijon (Dijon, FR); University Hospital of Nancy (Nancy, FR); University Hospital of Nice (Nice, FR); University Hospital of Clermont-Ferrand (Clermont-Ferrand, FR); University Hospital of Toulouse (Toulouse, FR); Rothschild Fondation (Paris, FR); University Hospital of Nantes (Nantes, FR); University Hospital of Strasbourg (Strasbourg, FR); APHP - Tenon Hospital (Paris, FR); University Hospital of Lille (Lille, FR)

Objective: To estimate the impact of 3-year remission in the first five years following the diagnosis of Multiple Sclerosis on the delay of disability progression to EDSS ≥4.

Methods: The study population included 4176 patients diagnosed since 1995 with relapsing-remitting MS in 4 French EDMUS participating centres (Clermont-Ferrand, Dijon, Nancy and Nice). Patients had to be followed at least 5 years after their diagnosis (Poser criteria) and with EDSS below 4 at that time. Remission was defined as a 3-year period without any relapse or disability progression during the first 5 years following the diagnosis. Age at diagnosis, gender, initial symptoms, first inter-relapse interval, year of diagnosis, treatment duration by immuno-modulating or immuno-suppressive drugs were collected. Time-to-event techniques were used for analysis. The baseline was defined as the date of diagnosis + five years. Endpoint date was 31 December 2011. The outcome was the observation of a residual EDSS of 4 between the baseline and the endpoint date. For multivariate analyses, we used Cox proportional hazards and Abrahamowicz flexible models.

Results: 1869 patients (mean age 34 years ± 10 years; sex ratio: 3/1) fulfilled eligibility criteria. The median follow-up after the baseline date was 4.4 years ([IQR] =2.1-7.3 years). Among them, 44.3% were included after 2001. Initial symptoms were dysfunction of long tracts in 62.5%, brain stem in 27.8%, optic neuritis in 29.0%. The median of the first inter-relapse interval was 18 months (IQR=7-48 months). Treatments were prescribed to 73% of patients. 380 patients (20.3%) evolved to an EDSS 4, with a median delay of 3.0 years after the baseline date (IQR=1.5-5.0 years). Remission was observed in 45.5% of cases, and began immediately after MS diagnosis in 58.0%. In multivariate analysis, remission was associated with a better prognosis (RR=0.73; 95%-CI=0.59-0.9; p=0.003) as well as a recent diagnosis (RR=0.94 for each additional year since 1995; 95%-CI=0.90-0.98; p=0.004). Men had a poorer prognosis (RR=1.35; 95%-CI=1.08-1.69; p=0.009) as did older patients (RR=1.03, 95% CI=1.02-1.04 per each additional year of age at diagnosis; p<0.001). Neither treatment nor initial symptoms were significantly associated with patients’ prognosis.

Conclusion: A 3-year remission during the 5 years following the MS diagnosis is independently associated with delayed progression to EDSS ≥ 4.

This study was supported by Biogen Idec.

Long-term outcome of CLIPPERS in a consecutive series of 12 patients

P. Labauge, G. Taieb, C. Duflos, D. Renard, B. Audoin, E. Kaphan, J. Pelletier, N. Limousin, C. Tranchant, S. Kremer, J. De Seze, R. Lefaucheur, D. Maltete, D. Brassat, M. Clanet, P. Desbordes, E. Thouvenot, L. Magy, T. Vincent, J. Faillie, N. de Champfleur, G. Castelnovo, S. Eimer, D. Figarella Branger, E. Uro Coste

CHU de Montpellier (Montpellier, FR); CHU de Nimes (Nimes, FR); CHU de Marseille (Marseille, FR); CHU de Tours (Tours, FR); CHU de Strasbourg (Strasbourg, FR); CHU de Rouen (Rouen, FR); CHU de Toulouse (Toulouse, FR); CH de Dax (Dax, FR); CHU de Limoges (Limoges, FR); CHU de Bordeaux (Bordeaux, FR)

Objective: The aim of this study was to describe the disease course of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS).

Methods: A nationwide study (inclusion period: February to July 2011) was implemented to collect clinical, MRI, CSF and brain biopsy characteristics of CLIPPERS, and evaluate the therapeutic management of this new CNS inflammatory disease.

Results: Among the 12 included patients, 42 relapses were analysed. Relapses were characterized by 1) frequent cerebellar ataxia and diplopia 2) a mean duration of 2.5 months 3) a mean EDSS of 4. Besides typical findings of CLIPPERS, MR found brainstem mass effect (5 patients), extensive myelitis (3 patients), and closed ring enhancement (1 patient). Inconstant oligoclonal bands were found on CSF studies (4/ 12 patients) with increased CD4:CD8 T-cell ratio. Among 7 available brain biopsies, a perivascular CD4 T-lymphocytes staining was present in 5. 38/42 relapses were treated by pulse steroid therapy, leading to improvement with a mean residual EDSS of 1.9 (range 0-7). In untreated relapses, EDSS progressively increased until death (EDSS 10) in one case. In absence of long-term corticosteroid therapy (5 patients), the annualized relapse rate was 0.5 (0.25-3). For the 7 patients under oral steroids, no relapses occurred above 20 mg/d. No progressive course was observed. Final EDSS ≥ 4 (n=4), was correlated with previous severe relapses (EDSS ≥ 5), brainstem and spinal cord atrophy.

Conclusions: CLIPPERS is a relapsing-remitting disorder without progressive forms. Long-term disability is correlated with severity of previous relapses. Prednisolone treatment above 20 mg/d prevents new relapses.

The authors have nothing to disclose.

Cryopyrin-associated periodic syndrome (CAPS) in multiple sclerosis

E. Schuh, P. Lohse, M. Braun-Falco, R. Hohlfeld, T. Kümpfel

Ludwig-Maximilian University (Munich, DE); Institut für Labormedizin (Singen, DE)

Objective: We report three multiple sclerosis (MS) patients with an atypical clinical presentation, who were all heterozygous carriers of mutations in the NLRP3/CIAS 1 gene compatible with a cryopyrin-associated periodic syndrome (CAPS).

Background: CAPS is a rare autoinflammatory syndrome caused by autosomal dominant mutations in the NLRP3/CIAS 1 gene on chromosome 1q44 encoding for the cryopyrin protein, an important component of the inflammasome, leading to excessive production of interleukin-1β (IL-1ß). CAPS encompasses three different entities of variable clinical severity: familial cold auto-inflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS) and chronic infantile neurological cutaneous articular syndrome (CINCA)/ neonatal - onset multisystem inflammatory disease (NOMID). They are all characterised by recurrent episodes of systemic inflammation involving particularly skin, joints, central nervous system and eyes.

Cases: All three patients fulfilled the diagnostic criteria for MS according to McDonald et al. (2010) based on typical clinical presentations, MRI results (supra- and infratentorial white matter lesions) and CSF investigations (oligoclonal bands and mild pleocytosis). Furthermore, they all reported about episodes with at least two additional symptoms suggestive for an autoinflammatory syndrome: recurrent inflammation of eyes, headache, severe fatigue, myalgias, athralgias, tendinitis, abdominal pain and urticaria like exanthema. Laboratory examinations showed a hyper-IgM syndrome in one patient and recurrent increased levels of serum-amyloid-A (SAA) as well as C-reactive protein (CRP). One patient showed a marked cerebral atrophy on MRI. Genetic examination revealed a heterozygous Q703K substitution in two patients, and a V198M replacement in one patient in exon 3 of the NLRP3 gene. Other autoinflammatory syndromes (TRAPS, FMF) were excluded by moleculargenetic testing.

Conclusions: We identified three MS patients with unusual additional symptoms compatible with CAPS. All three had a mutation in exon 3 of the NLRP3 gene. CAPS and MS share common pathophysiological pathways via increased IL-1ß production. Thus, these mutations may have contributed to the risk of developing MS in these patients.

The authors have nothing to disclose.

Prediction of conversion from clinically isolated syndrome to multiple sclerosis according to baseline characteristics

B. Piri Cinar, S. Ozakbas, E. Idiman

Dokuz Eylul University (Izmir, TR)

Eighty-five per cent of patients with clinically isolated syndrome (CIS) convert to clinically definite multiple sclerosis (CDMS). Ideal predictive criteria help us for early diagnosis and to avoid false-positive diagnosis. The purpose of this study was to determine the predictor factor from CIS to CDMS on the basis of clinical, magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) findings, on a prospective cohort. Forty-one patients presenting with CIS suggestive of MS were included in the study and followed up for at least 2 years. All CIS patients were in attack period. They were evaluated based on clinical, CSF and MRI parameters. Thirty-five out of 41 CIS patients converted to MS at any time in two years follow-up. Mean conversion time to MS was 10 months. CIS patients were younger than patients converted to MS (p=0.02). Presence of oligoclonal bands (OBs) in CSF were more in converted group. Number of OBs and level of IgG index were not different significantly. 33 out of 41 patients fulfilled the Barkoff-Tintore criteria in the initial MRI. 30 of them converted to MS. On the basis of lesion localization, presence of callosal lesion had statistically significant meaning in terms of conversion to MS (p=0.04). Time to conversion to MS was studied in these parameters: Patients with OBs converted to MS earlier than patients without OBs (9.15 months and 12.66 months, respectively), but not significant. Patients with T1 hypointense lesion on initial MRI converted to MS earlier than patients with no T1 hypointense lesions (p=0.041). Patients with Gd-enhanced lesions on the initial MRI also converted to CDMS earlier than patients without Gd-enhanced lesions. Patients with fulfilled McDonald 2010 MRI criteria on the initial MRI converted earlier than patients did not (p=0.017). Our data indicate that CIS patients with abnormal baseline OB in CSF have a higher risk for developing CDMS. Presence of Gd-enhancing lesions and T1-hypointense lesions seems to be predictors for conversion to CDMS. Regarding conversion time to CDMS, when abnormal MRI was added to positive OB, patients converted earlier to MS. In conclusion, a carefully performed neurological assessment of symptoms and signs, evaluating lesions on MRI combined with CSF findings are important for defining the risk of conversion to CDMS. This information may be useful when considering treatment in CIS patients without waiting for conversion.

The authors have nothing to disclose.

Diffusion tensor imaging evaluations of visual pathways in multiple sclerosis patients with acute and chronic optic neuritis

A.O. Keskin, F. Idiman, A Ada, O. Alatas, E. Idiman, S. Ozakbas, A.O. Saatci

Dokuz Eylul University (Izmir, TR)

The current application of diffusion MRI in optic neuritis (ON) and multiple sclerosis (MS) shows that the method has enhanced our understanding of their pathophysiology. In this context, we performed diffusion tensor imaging (DTI) in total of 26 patients and 12 healthy control subjects. The patients have acute episode of ON in 17 eyes,chronic ON in 20 eyes and 15 unaffected eyes. In all participants visual afferent system was evaluated with neuro-opthalmological examinations, optical coherence tomography(OCT), visual evoked potential(VEP), orbital and cranial magnetic resonance imaging(MRI).

Fractional anisotropy (FA) values in optic nerve were found to be significantly lower in patients with acute ON(0.501±0.098)(p<0.05) and chronic ON(0.476±0.08)(p<0,05) than controls(0.601±0.076).Mean diffusivity (MD) values in patients with acute (121.45±23.82) and chronic ON(120.97±18.60) were significantly lower compared to unaffected eyes of patients(108.46±16.31)and controls (92.55±11.68)(p<0.05). Retinal nerve fiber layer thickness (RNLFT),P100 amplitude and latency measurements and visual acuity(VA) was significantly different between groups (P <0.01).Eyes with abnormal orbital MRI findings have statistically significant decrease in FA (p< 0.05), increase in MD(p <0.01),prolonged P100 latency (p <0.01) and decrease P100 amplitude (p<0.05), decrease in RNLFT(p < 0.05) and VA(p <0.01) compared to normal eyes.

The mean FA value measured in optic chiasm was not significantly decreased in FA patients compared to healthy controls(p>0.05), but MD values were significantly increased in patient group(p<0.05).

FA and MD values measured in optic tract was significantly different (p<0,05) between patients and controls.

In the correlation analysis; FA values in optic nerves were correlated with prolongation of P100 latency and decrease in RNLFT(p<0.05) in patients with acute ON. Furthermore MD values were correlated with RNLFT,VA(p<0.05) and P100 latency.RNLFT was correlated with VA in acute ON. FA values were correlated with MD values and VA(p<0.05). MD values were correlated with P100 amplitude and VA in chronic ON(p<0.05).

Briefly,the abnormalities of MD and FA in DTI for the optic nerve were more severe compared to chiasm and optic tract. Our results suggested that DTI derived measurements correlate with visual disability and tissue injury and therefore they are important both from a clinical point of view and understanding of pathological processes.

The authors have nothing to disclose.

Application of the revised version of the 2010 McDonald diagnostic criteria: retrospective comparison using the BENEFIT clinical study dataset

X. Montalbán, L. Kappos, M.S. Freedman, H.-P. Hartung, G. Edan, D.H. Miller, C.H. Polman, F. Barkhof, B. Stemper, J. Herrmann, C. Stolz, R. Sandbrink, C. Pohl, D. Pleimes

Hospital University Vall d’Hebron (Barcelona, ES); University Hospital Basel (Basel, CH); Ottawa Hospital Research Institute (Ottawa, CA); Heinrich-Heine University (Düsseldorf, DE); CHU-Hopital Pontchaillou (Rennes, FR); UCL Institute of Neurology (London, UK); VU Medical Center (Amsterdam, NL); Bayer HealthCare (Berlin, DE); PAREXEL International (Berlin, DE); Bayer HealthCare (Montville, US)

Background: BENEFIT examined early vs delayed interferon β-1b (IFNB-1b, Βferon®) treatment in 468 patients with clinically isolated syndrome (CIS). Early IFNB-1b treatment significantly delayed conversion to Poser multiple sclerosis (MS)/clinically definite MS (CDMS) and 2001 McDonald MS (McD MS). A diagnosis of McD MS requires MRI evidence of CNS lesions disseminated in time and space. Introduced in 2001, these criteria were revised twice to improve diagnostic sensitivity for early MS, without compromising specificity.

Methods: We estimated (1) the 5-year risk after CIS for MS diagnosis by 2010 McD vs 2001 McD criteria vs Poser criteria by Kaplan-Meier survival; (2) the 5-year predictive value of 2010 vs 2001 McD criteria, with respect to Poser MS development by proportional hazards regression; and (3) the effect of early vs delayed IFNB-1b use on development of 2010 McD MS by Kaplan-Meier survival estimate.

Results: McD 2010 criteria allow for demonstration of dissemination in time by an asymptomatic contrast-enhancing lesion at CIS presentation. At baseline, 33.5% satisfied 2010 criteria for dissemination in space and time-and thus MS. At the 50th percentile, an MS diagnosis was reached after 97 and 214 days per 2010 and 2001 criteria, respectively. The risk of a McD MS diagnosis converged over time (year 5: 88% and 87% per 2010 and 2001 criteria, respectively). At year 5 and relative to 2001, 2010 criteria increased the number of MS diagnoses by 13. The 5-year risk of CDMS increased by 1.647-fold for individuals with 2010 McD MS at baseline (p=0.0003), by 1.699-fold for those with 2010 McD MS at year 1 (p=0.0109), and by 1.621-fold for those with 2001 McD MS at year 1 (p=0.0133). Among patients without 2010 McD MS at baseline and relative to delayed treatment, early IFNB-1b use led to a 41.5% reduction (hazard ratio=0.585) in the 5-year risk of 2010 McD MS (p=0.0002).

Conclusions: We report on the application of 2010 McD criteria to a randomized, controlled population of CIS patients using a first-line disease-modifying therapy. Relative to 2001, 2010 criteria permit an earlier diagnosis of MS, with only minor differences over 5 years. Presence of 2010 and 2001 McD MS at year 1 similarly predicted CDMS progression over 5 years. The benefits of early IFNB-1b treatment on progression to CDMS remain in the same range as previously reported if patients fulfilling the more sensitive 2010 McD guidelines are already excluded.

Xavier Montalbán has received compensation for activities with Bayer Schering Pharma, Biogen Idec, EMD Serono, Genentech, Inc., Genzyme, Novartis, Sanofi Aventis, Teva Neuroscience, and Almirall.

The University Hospital Basel has received research support for activities of Ludwig Kappos with Actelion, Bayer HealthCare Pharmaceuticals, Bayer Schering-Pharma, Biogen-Idec, BioMarin, CLC Behring, Elan, Genmab, Genmark, GENeuro SA, GlaxoSmithKline, Lilly, Merck Serono, Novartis, Novonordisk, Peptimmune, Sanofi-Aventis, Santhera, Roche, Teva, UCB, and Wyeth. Dr. Kappos has received research support from the Swiss MS Society, the Swiss National Research Foundation, the European Union, the Gianni Rubatto, Novartis, and Roche Research Foundations.

Mark S. Freedman has received compensation for activities with Bayer Healthcare, Genzyme Corporation, EMD Canada, Novartis, Sanofi-Aventis Pharmaceuticals, Inc., Celgene, Glycominds, and Teva Canada Innovation.

Hans-Peter Hartung has received compensation from Biogen-Idec, TEVA, Sanofi-Aventis, Novartis Pharma, Merck Serono, and Bayer Schering Pharma for consulting services.

Gilles Edan has received compensation for activities with Biogen-Idec and Teva as a consultant. Dr Edan has received compensation for serving on the advisory board for BENEFIT and LFB. Dr Edan has received research support from Serono.

David H. Miller has received compensation for activities with Biogen Idec, GlaxoSmithKline, Novartis and Bayer Schering Pharma as a consultant and member of the advisory board. Dr Miller has research support from GlaxoSmithKline, Biogen Idec, and Novartis.

Chris H. Polman has received compensation for activities with Biogen Idec, Schering AG, Teva Neuroscience, EMD Serono, Novartis, GlaxoSmithKline, Inc., UCB Pharma, AstraZeneca Pharmaceuticals, Roche Diagnostics, Actelion and Antisense Therapeutics as a consultant or speaker. Dr. Polman has received research support from Biogen Idec, Schering AG, GlaxoSmithKline, Inc., Novartis, EMD Serono, and Teva Neuroscience.

Frederik Barkhof has received compensation for activities with Novartis, Biogen Idec, Sanofi-Aventis, Roche, Merck-Serono, and Bayer-Schering as a consultant.

Brigitte Stemper is a salaried employee of Bayer Healthcare Pharmaceuticals.

Julia Herrmann and Charlotte Stolz are salaried employees of PAREXEL International, which is a CRO contracted by Bayer HealthCare Pharmaceuticals.

Rupert Sandbrink, Christoph Pohl, and Dirk Pleimes are salaried employees of Bayer Healthcare Pharmaceuticals. Rupert Sandbrink holds stocks and stock options for Bayer AG.

Supported by: Bayer HealthCare Pharmaceuticals, Inc.

Motor-evoked potentials and gait analysis in patients with clinically isolated syndrome

I. López Gutiérrez, B. Rosado Peña, L. Dinca Avarvarei, B. Heredia Camacho, A. Hochsprung, C. Menéndez De León, G. Izquierdo Ayuso

Rey Juan Carlos Hospital (Madrid, ES); Virgen Macarena University Hospital (Seville, ES)

Introduction: We know that there is a strong relationship between the abnormalities of the motor evoked potentials (MEP) obtained by transcranial magnetic brain stimulation and the motor deficit in patients diagnosed of multiple sclerosis (MS). Gait analysis in these patients allow us to demonstrate abnormalities associated especially with motor disfunction.

Objective: The aim of the study was to evaluate the possible correlation between the MEP and gait analysis for the detection of pyramidal lesions, especially the clinically silent lesions in patients with clinically isolated syndrome (CIS).

Patients and methods: We have done MEP (motor threshold, latency and proportion of amplitude of the cortical MEP, central motor conduction time and silent period) and gait analysis using GAITRite system (step length/leg length ratio, mean normalized velocity and Functional Ambulation Profile (FAP)) in 21 consecutive CIS patients, diagnosed in our MS unit. The patients were 14 women and 7 men, with a mean age of 33.4 years and less than 6 months since the diagnosis. Subjects underwent a neurological examination using the Expanded Disability Status Scale (EDSS).

Results: From the 21 studied patients, five presented clinical motor symptoms at onset; all of them presented alterations in at least one MEP studied parameter and 40% of them presented abnormalities in gait analysis parameters. 75% of the 16 remaining patients presented MEP abnormalities; 13% of them also presented impairment in gait parameters, especially in FAP (37,5%). 25% of the patients without clinical motor symptoms presented abnormalities in gait analysis and MEP. Abnormal MEP and FAP score correlated with EDSS (p<0.001 and p<0,002 respectively), especially with the pyramidal functional score.

Conclusions: Analyzed together MEP and gait analysis using GAITRite system are very useful to detect and localize clinical and silent lesions in the pyramidal system and could have a predictive role in future disability in CIS patients.

The authors have nothing to disclose.

Overcoming chondroitin sulfate proteoglycan inhibition of oligodendrocyte-lineage cells and remyelination

L. Lau, M. Keough, F. Yong, V.W. Yong

Hotchkiss Brain Institute (Calgary, CA)

Objective:The extracellular matrix (ECM) has been shown to significantly influence neural cells. Chondroitin sulfate proteoglycans (CSPGs) are a family of ECM molecules that impede regenerating axons following traumatic CNS injury. Recently, we determined that CSPGs are highly upregulated in a mouse model of demyelination and that reduction of CSPG biosynthesis improved remyelination (Lau et al., Annals Neurol, in press). These findings led us to postulate that enzymatic degradation of CSPGs or targeting downstream signaling pathways would promote OPC and oligodendrocyte maturation and remyelination following a demyelinating insult.

Methods: We isolated oligodendrocyte precursor cells (OPCs) from adult human or neonatal mouse brains. We examined the impact of enzymatic degradation of CSPGs using ADAMTS-4 and chondroitinase ABC (ChABC) on OPCs and oligodendrocytes. Downstream signaling inhibitors of several pathways including ROCK, EGFR, and MAPK were also tested. The impact of in vivo infusion of ADAMTS-4 was tested on adult female mice subjected to lysolecithin demyelination.

Results: To investigate the selective effect of CSPGs, human oligodendrocytes were plated onto molds that alternated between albumin and CSPG stripes. Few oligodendrocytes and processes were found on CSPG compared to albumin stripes. The inhibitory effect of CSPGs on human OPC adhesion was overcome with the protease ADAMTS-4, which degrades the core protein of CSPGs, but not by ChABC, which removes only the glycosaminoglycan side chains. Both enzymes relieved CSPG inhibition of oligodendrocyte process outgrowth. These findings implicate the protein core of CSPGs as the inhibitory components for oligodendrocyte adhesion, and the glycosaminoglycan moieties as impediments of morphological maturation. The results of application of various signaling inhibitors in culture along with the effect of ADAMTS-4 on remyelination in vivo on the demyelinated spinal cords of mice are being tabulated.

Conclusions: Our results identify CSPGs as novel impediments to human oligodendrocytes and suggest that future remyelinating therapies may include reducing levels of CSPGs or targeting their signaling mechanisms.

This research was funded by an operating grant from the Multiple Sclerosis Society of Canada.

The authors have nothing to disclose.

Non-organ-specific auto-immunity disease in NMO-spectrum disorders – Brazilian experience

S. Apostolos-Pereira, F. Jorge, P. Zago, R. Simm, M. Fazzito, C. Galvao, C. Hobi, M. Lana-Peixoto, P. Marchiori, A. Dellavance, D. Callegaro on behalf of BCTRIMS

Background: Neuromyelitis optica (NMO) and NMO spectrum disorders (NMOSD) are associated with autoantibodies that target aquaporin-4. NMOSD, both myelitis and optic neuritis, can occur in the context of established rheumatologic diseases and other organ-specific autoimmune diseases and this association has diagnostic and therapeutically implications in clinical practice.

Objective: To report the prevalence of rheumatologic disease or serological evidence of immunological disorders in a Brazilian cohort of NMOSD including NMO, longitudinally extensive transverse myelitis (LETM), and recurrent optic neuritis (RON).

Methods: The authors studied 66 patients with diagnosis of NMO according to Wingerchuk’s criteria or NMOSD presented with high risk of NMO syndromes such as LETM and or RON. All patients fullfilled a interview to rheumatologic disease and serological research. NMO IgG were evaluated by indirect immunofluorescence.

Results: The sample consists of 43 NMO and 23 NMOSD patients (including 20 LETM and 3 RON), female preponderance (87%), mean age at onset was: 37 (range 10-70), mean duration of disease: 6 years (range 0,5-23), and 56 (81%) presents recurrents forms with mean relapsing time were 12 months (range 3 -192 ), median EDSS score at last visit: 5.0 (range 1- 8). NMO IgG Status was positive in 44 (67%) patients. 14 patients (18%) presents coexisting autoimmune conditions described as below: Systemic Erythematosus Lupus, (2) Myasthenia Gravis (2), Hypotireodism (5), Arthritis (4), allergic reaction(3), uveitis (7), vitiligo (4). Serological evidence of autoimmunity was found in 29 patients (42%), mainly ANA(12), SSA- antibody(4), anticardiolipin IgG(2), anticardiolipin IgM (3), Anti-TPO (3), AntiTG(3), TRAB(6), Rheumatoid factor (4), ANCA(2), Anti-receptor Ach(1). Laboratory auto-immunity was find in 54% of NMO IgG positive and 14% of NMO IgG negative patients.

Conclusion: Neuromyelitis optica spectrum disorders, mainly in seropositive NMO-IgG patients, are more frequently associated with autoimmune disease or non–organ-specific autoantibodies supporting the hypothesis that this coexisiting conditions expresses a higher susceptibility to autoimmunity in this patients.

Biogen Idec.

Antibodies against neuronal and non-neuronal autoantignes existing in inflammatory demyelinating disorders in Japan

M. Watanabe, T. Kageyama, A. Ozaki, K. Murakata, S. Matsumoto, T. Kondo

Kitano Hospital (Osaka, JP); Tenri Hospital (Osaka, JP)

In multiple sclerosis (MS) specific autoantibodies have not been identified although non-neuronal autoantibodies can be detected in a minor subgroup of MS. Although anti-neuronal antibodies have been growingly identified, little is known in MS. On the other hand, decisive roles of anti-aquaporine-4 (AQP4) antibody have been demonstrated in neuromyelitis optica (NMO) and NMO spectrum disorders (NMOSD). However, it remains unknown whether other anti-neuronal antibodies can participate in the pathogenesis of NMO/NMOSD.

Here we studied prevalence of anti-neuronal antibodies in inflammatory demyelinating disorders.

Methods: Patients: 28 MS, 22 NMO/NMOSD and 5 clinically isolated syndrome (CIS) patients were enrolled. Diagnosis of MS and NMO/NMOSD was based on the revised criteria of McDonald criteria, 2005, or the criteria advocated by Wingerchuck in 2006 and 2007. CIS here did not fit any criteria of NMO or MS.

Antibodies in serum: Anti-nuclear, -SSA, and -SSB antibodies were commercially analyzed (SRL, Japan). Anti-neuronal antibodies analyzed by Euroimmun (Lübeck, Germany) were anti-AQP4, -glutamate receptors (types NMDA and AMPA), -Hu, -Ri, -Yo, -Tr, -Ma/Ta, -GAD, -amphiphysin, -GABA-b receptors, -leucine-rich glioma-inactivated protein 1 (LGI1), -contactin-associated protein 2 (CASPR2), -glycine receptors, -myelin associated glycoprotein (MAG), and –myelin antibodies. Anti-myelin antibodies were detected by incubating serum samples on peripheral and CNS tissues with indirect immunofluorescence assay (IFA). The remaining neuronal antibodies were detected by indirect IFA using transfected HEK293 cell lines expressing the target antigens.

Results: Anti-NMDAR antibody was detected in two cases with NMOSD and one with MS. Only one of the three had an episode of convulsion and psychotic delusion possibly related to anti-NMDAR encephalitis, Anti-CASPR2 antibody was found in two NMO and one CIS with a midbrain lesion. Among them only one with NMO carried anti-AQP4 antibody. Anti-Ma-2/Ta antibody was detected in a case with MS. 7.1% of MS and 9.5% of NMO carried anti-myelin antibodies. One case with symmetrical hypothalamic lesions, known to be characteristic of NMO/NMOSD, did not carry anti-AQP4 antibody but anti-SSA antibody.

Conclusion: Our data suggest that immunity against multiple neuronal antigens can participate in the pathogenesis of demyelinating disorders. CASPR2 antibody may play a role in demyelinating disorders although further search is needed.

The authors have nothing to disclose.

Spinal cord lesions in CIS patients: a pivotal role in diagnosis and prognosis

M.H. Sombekke, M.P. Wattjes, L.J. Balk, J.M. Nielsen, H. Vrenken, B.M.J. Uitdehaag, C.H. Polman, F. Barkhof

VU University Medical Center (Amsterdam, NL)

Objective: Spinal cord (SC) lesions are frequently found in Multiple Sclerosis (MS), but are rare in healthy ageing and patients with ischemic disorders. Our aim was analyzing the contribution of SC involvement in Clinically Isolated Syndrome (CIS) in diagnosing MS according the McDonald 2010 criteria and in predicting conversion to Clinically Definite MS (CDMS).

Methods: We prospectively followed monofocal, relapsing onset CIS patients with either SC or brain symptom onset. MRI of the brain and SC were performed shortly after onset and patients were followed for 24-119 months (median 64). SC MRI findings were assessed for their contribution to the McDonald 2010 diagnostic criteria and their effect on conversion to CDMS.

Results: 121 patients were included (63 spinal-CIS). Based on the brain scan only, 36 patients fulfilled the McDonald criteria; by including SC findings 6 additional patients fulfilled these criteria. To diagnose one additional non-spinal CIS patient, the number needed to scan is 7. In non-spinal CIS patients that did not fulfil McDonald brain MRI criteria (n=42), presence of a SC lesion was associated with a higher risk of conversion to CDMS (OR: 14.4 (95% CI: 2.6 – 80.0) and shorter time to conversion to CDMS (Hazard ratio: 51.4 (95%- CI: 5.5 – 476.3).

Conclusions: Presence of SC lesions facilitates diagnosing MS and is predictive for conversion to CDMS, especially in non-spinal CIS patients that do not fulfill McDonald 2010 brain MRI criteria. We therefore recommend performing a SC scan in non-spinal CIS patients that do not fulfil McDonald brain MRI criteria.

The MS Center Amsterdam is supported by the Dutch MS Research Foundation (grant numbers 02-358b, 05-358c and 09-358d).

M.H. Sombekke, M.P. Wattjes, L.J. Balk and J.M. Nielsen report no disclosures.

H. Vrenken received grants from Merck Serono and Novartis and received payment for presentation at Novartis Innovations Exchange Lounge at Ectrims 2011.

B.M.J. Uitdehaag received payment for consultancy for Novartis, Merck Serono, Synthon and Danone Research.

C.H. Polman received payment for consultancy for Actelion, Biogen Idec, Bayer Schering, TEVA, Merck-Serono, Novartis, Glaxo SK, UCB, Roche, MorphoSys, received payment for expert Testimony of Biogen Idec and received grants from Biogen Idec, Bayer Schering, Teva, Merck-Serono, Novartis, Glaxo SK, UCB.

Prof. F. Barkhof serves as a board member of Brain, Eur Radiology, Neuroradiology, Multiple Sclerosis, J Neurol, J Neurol Neurosurg Psychiatry, received payment for consultancy for Bayer-Schering Pharma, Sanofi-Aventis, Biogen-Idec, UCB, Merck-Serono, Novartis, Roche, Synthon BV, Jansen Research, Lundbeck and received payment for development of educational presentations for Serono Symposium Foundation.

Four-year evolution of multiple sclerosis lesions using diffusion tensor imaging

D. Ontaneda, K. Sakaie, J. Lin, X. Wang, M. Lowe, M. Phillips, R. Fox

Mellen Center (Cleveland, US); Cleveland Clinic (Cleveland, US)

Objective: To evaluate the longitudinal changes in chronic lesional tissue in multiple sclerosis (MS) using diffusion tensor imaging (DTI) over 4 years.

Background: DTI is a magnetic resonance imaging (MRI) measure of brain tissue integrity which has been proposed as a metric for neuroprotection in clinical trials. Little is known regarding the long term longitudinal evolution of DTI measures in lesional tissue.

Methods: Twenty-one patients with MS starting natalizumab were imaged serially for up to 48 months. White matter T2 lesions (black holes (BH) and non black holes (NBH)) and 20 regions of interest from normal-appearing white matter (NAWM) were identified and followed longitudinally. After co-registration with FSL, average values within each region of interest were derived for fractional anisotropy (FA), mean diffusivity (MD) longitudinal diffusivity (LD) and transverse diffusivity (TD) using AFNI. Analysis was performed by using mixed-model regression analysis. ANOVA was used to compare T2 lesions and NAWM as well as BH and NBH.

Results: An increase in LD (p=0.0003) and MD (p=0.02) with stability of TD and FA was observed over time in T2 lesions. No significant changes were observed in NAWM for any of the DTI metrics. A significant difference in the evolution of T2 lesions as compared to NAWM was found over time for LD (p=0.0002) and MD (p=0.037). BH had a higher TD (p=0.006), lower FA (0.024) and higher MD (p=0.002) than NBH. LD was similar in BH and NBH (p=0.123). The longitudinal evolution of BH and NBH was statistically different for TD (p=0.036), with a progressive increase in BH and a progressive decrease in NBH. A similar difference was found for FA (p=0.012) with a progressive decrease in BH and a progressive increase in NBH. No significant differences in the evolution of MD or LD were observed between BH and NBH.

Conclusions: A progressive increase in LD was observed in chronic T2 lesions when compared with NAWM and this is a new finding, but similar to our previous results showing a progressive increase in gadolinium enhancing lesions. BH showed a progressive increase in TD overtime which may indicate ongoing demyelination while NBH showed recovery in TD suggesting remyelination. Our results indicate that progressive changes may still occur in chronic MS lesions and suggest DTI may be useful to measure CNS repair and remyelination.

Dr. Ontaneda has received personal consulting or speaking fees from Biogen Idec and is supported by NMSS FP 1769-A-1.

Dr. Fox has received personal consulting or speaking fees from Avanir, Biogen Idec, Novartis, and Questcor, and has served on clinical trial advisory committees for Biogen Idec.

Dr. Sakaie, Mrs.Lin, Dr. Wang, Dr. Lowe and Dr. Phillips have nothing to disclose.

Demographic and clinical features of familiar MS in Brazilian patients

R. Papais-Alvarenga, M. Bernardes, F. Costa-Pereira, M. Papais-Alvarenga, E. Batista, C. Vasconcelos

UNIRIO (Rio de Janeiro, BR)

Objective: To describe demographic and clinical features of familiar MS in Brazilian patients

Methods: The medical records of 808 patients with multiple sclerosis (MS) followed, from 1995 to 2012, by the medical staff of Hospital da Lagoa (Rio de Janeiro) were reviewed. The familiar cases were compared with sporadic MS cases.

Results: 37 (4,5%) of 808 MS patients informed one or more cases of the disease in their families. A total of 52 familial cases were identified affecting 23 families. We found among familial cases: 1 father (1,9%), 3 mothers (5,8%), 5 brothers (9,6%), 18 sisters (34,6%), daughters ( ) 2 uncle/aunt relatives (3,8%), 2 nephew/niece, 10 first-cousins (19,2%), 1 grand-uncle (1,9%). The families were classified in 3 groups, according to the kinships they gathered: first-degree associations (51,9%), first- and second-degree related (26,9%) and only second-degree pairs (21,2%). No clinical differences were found among the groups.

The clinical characteristics of the 52 patients with familial form (76,5% women; 23,5% men; 92,2% caucasian; 7,8% brazilian afrodescendants) were: a 28,27 mean age at onset (± 9,6 SD, 12-47 years); last evaluated EDSS median of 2,5 (0-10); mean disease duration time of 16,97 years (± 8,77 SD, 1-36,0 years); 84,6% of EMRR and 15,4% EMPP clinical courses.

Comparisons between the sporadic (n=272) and familial forms showed no differences in sex, age at onset, disease duration time and clinical courses. There was statistically significance difference for last evaluated EDSS (p=0.04) and race (p= 0.006).

Conclusion: MS familial forms in Rio de Janeiro, affects more frequently caucasians, with long term lower disability than sporadic MS. As stated in literature, first-degree relatives are most frequent affected.

The authors have nothing to disclose

Genetic susceptibility of idiopathic acute transverse myelitis in Brazilian patients from Rio de Janeiro

R. Papais-Alvarenga, M. Papais-Alvarenga, M. Alvarenga, L. Campanella, L. Levya, O. Fernandez

UNIRIO (Rio de Janeiro, BR)

Background: Recurrent idiopathic acute transverse acute myelitis is an uncommon disease of the CNS. IATM might be also the first episode of multiple sclerosis or neuromyelitis optica. Genetic susceptibility in MS is well established and recent studies found an association between NMO and DRB1*03 allele.

Objectives: Analyze the HLA class II alleles in an Brazilian series of IATM patients from Rio de Janeiro to determine different specific alleles or haplotypes of susceptibility or resistance.

Methods: DNA samples from 18 patients with Recurrent ATM treated in Hospital da Lagoa, were collected. Cranial MRI was normal or not suggestive of MS in all cases and LETM ocurred in 80%.30% of them had positivity for anti-AQP4 antibody. HLA class II alleles were compared with 103 healthy controls. High resolution HLA class II (DRB1, DQA1 and DQB1) was performed by PCR followed by sequence-specific oligonucleotide probe hybridization. DRB1*15/16 subtypes were identified with sequence-specific primers. Phenotypic frequency refers to the percentage of the sample population that expresses at least one allele.

Results:The IATM group 30 alleles DRB1, 12 alleles DQA1, 16 alleles DQB1 and 36 haplotypes were identified. Four HLA class II alleles showed higher frequencies in the IATM group than in controls, but the statistical significance was lost after Bonferroni correction: DRB1*1102 [11,1% in IATM X 1,9% in Controls; P = 0.045, DRB1*1103 [5,5% in IATM X 0% in Controls; P = 0.016; Pc = NS], DRB1*1502 [5,5% in IATM X 0% in Controls; P = 0.016; Pc = NS], DRB1*1601 [16,7% in IATM X 2.9% in Controls; P = 0.009; Pc = NS], DQB1*0502: [22,2% in IATM X 4.9% in Controls; P = 0.017; Pc = NS]. The DQA1*0105 allele showed a significant association with the disease: 16,7% IATM X 1.0% in Controls: P = 0.001; Pc= 0.012. The haplotype DRB1*0302, DQA1*0401, DQB1*0402 also showed association with IATM (5,5% in IATM X 0% in controls; P= 0,001; Pc= 0,036).

Conclusion: A genetic susceptibility was found among Brazilian IATM patients. These results differed from MS and NMO, suggesting that IATM could be a distinct demyelinating inflammatory idiopathic disease.

The authors have nothing to disclose

In-vivo identification of a novel retinal pathology in neuromyelitis optica

E.S. Sotirchos, S. Saidha, G. Byraiah, M.A. Mealy, M.A. Ibrahim, Y.J. Sepah, S.D. Newsome, J.N. Ratchford, E.M. Frohman, L.J. Balcer, Q.D. Nguyen, M. Levy, P.A. Calabresi

Johns Hopkins University School of Medicine (Baltimore, US); University of Texas Southwestern Medical Center (Dallas, US); University of Pennsylvania School of Medicine (Philadelphia, US)

Background: Neuromyelitis optica (NMO) is an inflammatory disorder of the central nervous system, associated with autoantibodies targeting aquaporin-4 (NMO-IgG), and predominantly manifests with recurrent episodes of longitudinally extensive transverse myelitis (LETM) and optic neuritis (ON). Studies utilizing optical coherence tomography (OCT) have demonstrated severe retinal axonal and neuronal loss in NMO-ON eyes, primarily thought to occur secondary to optic nerve injury. However, abnormalities of the retinal vasculature have been identified in NMO-ON eyes, suggesting that direct retinal vascular injury may also contribute to visual disability in NMO. Interestingly, aquaporin-4 is highly expressed in the retina, especially by Müller glial cells (of which the cell bodies are located in the inner nuclear layer [INL]), and may become accessible by an immune response following ON-related breakdown of the blood-retinal barrier. The primary objective of this study was to assess NMO eyes for primary retinal abnormalities utilizing OCT.

Methods: 40 patients with a diagnosis of definite NMO (n=29) or NMO-spectrum disease (n=11; defined as NMO-IgG seropositive LETM or ON) underwent retinal imaging with spectral-domain OCT. Macular scans were reviewed and segmented utilizing an automated segmentation algorithm. Letter acuity scores at 100%, 2.5% and 1.25% contrast were recorded.

Results: Microcystic macular edema (MME) of the INL was identified in 10 NMO patients (25% of patients; 14 eyes). All eyes that demonstrated MME had a history of ON. NMO-ON eyes with MME had significantly lower macular-retinal nerve fiber layer (m-RNFL; p=0.004) and ganglion cell layer+inner plexiform layer (GCIP; p=0.01) thicknesses, higher INL thicknesses (p<0.001) and lower letter-acuity scores (100% contrast: p=0.009; 2.5% contrast: p=0.004; 1.25% contrast: p=0.006) compared to NMO-ON eyes without MME.

Conclusions: We have identified a novel retinal phenotype that is common in NMO-ON eyes and is associated with severe axonal-neuronal loss and visual disability. These findings may be due to a trans-synaptic process occurring secondary to optic nerve injury or a primary retinal process occurring in conjunction with ON, and may account for the poor visual outcomes following NMO-ON. Further studies are warranted to investigate this retinal phenotype.

Dr. Sotirchos, Ms. Byraiah, Dr. Ibrahim and Dr. Sepah have nothing to disclose.

Dr. Saidha has received consulting fees from MedicalLogix for the development of continuing medical education programs in neurology, and has received educational grant support from TEVA Neuroscience.

Ms. Mealy has received honoraria from EMD Serono and Multiple Sclerosis Association of America, consulting fees from Novartis and Teva Neuroscience, and academic research support from Guthy Jackson Charitable Foundation.

Dr. Newsome has received consulting fees from Biogen Idec, Teva Neuroscience, and Novartis and speaker honoraria from Biogen Idec and Teva Neuroscience.

Dr. Ratchford has consulted for Bristol-Myers Squibb, received a speaking honorarium from TEVA, and receives research funding for clinical trials from Novartis and Biogen Idec.

Dr. Frohman has received speaker honoraria and consulting fees from Biogen Idec, Teva, and Athena. He has also received consulting fees from Abbott Laboratories.

Dr. Balcer has received speaking and consulting honoraria from Biogen Idec, Bayer, and Novartis.

Dr. Nguyen serves on the Scientific Advisory Board for Heidelberg Engineering, Inc. The Johns Hopkins University has received research support from Heidelberg to conduct studies; however, Heidelberg has had no inputs into the design, conduct, or analyses of the studies.

Dr. Levy has received commercial research support and honoraria from ApoPharma Inc, travel funding from Amplimmune, academic research support from Guthy Jackson Charitable Foundation, book royalties from Lippincott, and legal fees for expert witness services.

Dr. Calabresi has provided consultation services to Novartis, Teva, Biogen Idec, Vertex, Vaccinex, Genentech; and has received grant support from EMD-Serono, Teva, Biogen Idec, Genentech, Bayer, Abbott, and Vertex.

Human aquaporin 4 281-300 is the immunodominant linear determinant in the context of HLA-DRB1*03:01 – Relevance for diagnosing and monitoring patients with neuromyelitis optica

B. Arellano, R. Hussain, T. Zacharias, J. Yoon, C. David, S. Zein, L. Steinman, T. Forsthuber, B. Greenberg, D. Lambracht-Washington, A. Ritchie, J. Bennet, O. Stuve

University of Texas Southwestern Medical Center at Dallas (Dallas, US); Stanford University (Palo Alto, US); Mayo Clinic (Rocherster, US); University of Texas at San Antonio (San Antonio, US); VA North Texas Health Care System (Dallas, US); University of Colorado (Denver, US)

Objective: Human aquaporin 4 (hAQP4) is thought to be the autoantigen in patients with neuromyelitis optica (NMO). HLA haplotype analyses in patient cohorts suggest a positive association of NMO with HLA-DRB1*03:01 (HLA-DR17). This study aimed to identify immunodominant linear determinants of hAQP4 in the context of HLA-DRb1*03:01.

Design: Controlled study with humanized experimental animals. HLA-DR17 transgenic mice were immunized with whole-protein hAQP4 emulsified in complete Freund’s adjuvant. To test T cell responses, lymph node cells and splenocytes were cultured in vitro with twenty-amino acid-long synthetic peptides that overlap by ten amino acids across the entirety of hAQP4. The frequency of interferon γ, interleukin 17, granulocyte macrophage colony-stimulating factor, and IL-5 secreting CD4+ T cells was determined by ELISPOT assay. Quantitative immunofluorescence microscopy was performed to determine whether hAQP4281-300 inhibits the binding of anti HAQP4 recombinant antibody to surface full-length hAQP4.

Results: Peptide hAQP4281-300 generated a significantly (P-value<0.01) greater Th1 and Th17 immune response than any of the other linear peptides screened. This 20mer peptide contains two dominant immunogenic 15mer peptides. hAQP4284-298 induced predominantly an IL-17 and GM-CSF Th17 phenotype, whereas hAQP4285-299 resulted in a higher frequency of Th1 cells. hAQP4281-300 did not interfere with recombinant AQP4 autoantibody binding.

Conclusion: hAQP4281-330 is the dominant linear immunogenic determinant of hAQP4 in the context of HLA-DR17. Within hAQP4281-330 are two dominant immunogenic determinants that induce differential Th phenotypes. hAQP4 determinants identified in this study may serve as diagnostic biomarkers in patients with NMO, and may facilitate the monitoring of treatment responses to pharmacotherapies.

Future Direction: An animal model of NMO with the hAQP4 determinants identified in this study is currently under development in our laboratory. Perhaps more importantly, our observations may have immediate human applications. We are setting up assays to determine a potentially very low frequency of hAQP4284-298 and hAQP4285-299–specific CD4+ T cells in patients with NMO and controls together with other investigators. The biological relevance of linear hAQP4 determinants identified in this study, and in response of NMO patients to pharmacotherapies will ultimately have to be evaluated in controlled clinical trials.

Benjamin Arellano has nothing to disclose.

Olaf Stuve-Consultant: Teva Neuroscience, Biogen Idec, Roche, Genzyme, Novartis, Sanofi Aventis.

Speaker: Teva Neuroscience.

Editorial Board: Archives of Neurology, Therapeutic Advances in Neurological Disorders.

Recurrent hyperCKemia preceding neuromyelitis optica exacerbations

C.K. Grouse, R. Balabanov

Rush University Medical Center (Chicago, US)

Objective: To describe a case of recurrent hyperCKemia in association with neuromyelitis optica (NMO) exacerbations.

Background: Neuromyelitis optica is an inflammatory disease of the central nervous system involving optic neuritis and transverse myelitis. HyperCKemia is an elevation in creatine phosphokinase (CPK) levels with no known cause. An association between NMO and retrospectively recognized hyperCKemia has recently been described.

Design/Methods: Case Report

Results: A 50 year old female presented in 2005 with vision loss, thigh and arm pain, and a dramatically elevated CPK. She was treated with IV steroids with improvement of her symptoms. From 2005-2011 she repeatedly presented with vision loss and elevated CPK, responsive to steroids. Multiple NMO antibody tests were checked and found to be negative. In Spring of 2011 she presented with diffuse lower extremity weakness and numbness and was found to have an enhancing lesion on MRI from T9-T10. She was treated with IV steroids and plasmapheresis with improvement of symptoms. In June of 2011 she presented with elevated CPK and diffuse right-sided weakness and numbness. MRI of the cervical spine showed enhancing lesions from C5-C6; EMG demonstrated myopathic findings and muscle biopsies of the left deltoid and left vastus lateralis showed minimal nonspecific changes. Anti-double stranded DNA, anti-smooth muscle, and anti-neutrophil cytoplasmic antibodies were negative. She was treated with IV steroids and symptoms improved, with decrease of CPK. NMO antibody was rechecked and found to be positive at this time.

Conclusions: This patient had recurrent episodes of elevated CPK in association with NMO exacerbations. Although the pathological process underlying the occurrence of hyperCKemia with NMO exacerbations remains unclear, hyperCKemia may result from this autoimmune process. In some patients this association could prove to be useful as a potential warning abnormality of NMO-related CNS inflammation, and serum CPK could be revealing in NMO cases with diffuse or atypical muscle weakness.

Dr. C. K. Grouse has nothing to disclose.

Dr. Balabanov has received consulting fees in relation to clinical trials with Biogen Idec, TEVA Neuroscience, and Genzyme. His research has been sponsored by grants from the National Multiple Sclerosis Society.

Alemtuzumab for treatment of neuromyelitis optica

J.M. Gelfand, B.A. Cree

University of California, San Francisco (UCSF) (San Francisco, US)

Background: Neurological disability in neuromyelitis optica (NMO) results almost entirely from clinical relapses. Alemtuzumab (Campath) is a humanized monoclonal antibody against CD52 that depletes lymphocytes and monocytes and reduces relapse risk in multiple sclerosis.

Methods: We report one-year follow-up of a patient with NMO treated with alemtuzumab after experiencing break-through disease activity on alternate therapies.

Case Description: A 61 year-old woman with NMO (aquaporin-4 IgG seropositive) suffered 10 severe relapses over a four-year period despite immunosuppression with oral corticosteroids, mycophenolate mofetil (3000 mg/day po), Rituximab (2000 mg IV), IV cyclophosphamide and multiple acute courses of high dose corticosteroids and plasmapharesis. Relapses included 8 episodes of myelitis, 1 episode of intractable hiccups and 1 episode of post-chiasmal visual pathway injury. Her EDSS ranged from 7.5-8.0. She received alemtuzumab 12 mg IV x 5 days (total dose 60 mg) in March 2011 and continued oral prednisone 20 mg/day. At 14 months of follow-up, she had not experienced further clinical or radiological relapses. Prednisone was tapered to less than 10 mg/day. She was recently retreated with alemtuzumab 12 mg IV x 3 days (total dose 36 mg). The patient remains seropositive for anti-aquaporin-4 antibodies.

Conclusion: Alemtuzumab appears to be associated with a reduction in relapsing activity in a patient with severe, treatment-refractory NMO. Alemtuzumab may be a novel treatment option for NMO. A single-center, phase IIa trial to examine safety and efficacy of alemtuzumab in NMO is being planned.

Dr. Gelfand is funded by an American Academy of Neurology Clinical Research Training Fellowship.

Dr. Cree has received personal compensation for consulting from Sanofi-Aventis.

Ultra-high-field (7T) magnetic resonance imaging of brain lesions of neuromyelitis optica spectrum disorders and multiple sclerosis: a case-control study

I. Kister, J. Herbert, Y. Zhou, Y. Ge

NYU School of Medicine (New York, US)

Objectives: To compare supratentorial lesions in patients with neuromyelitis optica spectrum disorders (NMOsd) and multiple sclerosis (MS) on ultra-high-field (7-Tesla) MRI.

Background: Brain lesions are common in NMOsd. The distinction between NMOsd and MS is not always possible with conventional brain MRI. The aim of this study is to compare supratentorial lesions in NMOsd and MS on ultra-high-field (7-Tesla) MRI, and to attempt to develop criteria for differentiating the two conditions on neuro-radiologic basis.

Design/Methods: NMOsd and MS patients matched by age and disease duration were recruited from the NYU-MS Center. Imaging data were acquired on a 7T whole-body human MR system (MAGNETOM, Siemens). NMO and MS patients were scanned using identical imaging protocol that included a high-resolution 2D gradient echo sequence optimized to best visualize venous structures (TR/TE/flip angle = 500ms/25ms/35°, voxel size = 0.23x0.23x2 mm³). This sequence is highly sensitive to venous vasculature and is used to visually examine for presence of central venule in supratentorial brain lesions.

Results: 10 patients with NMOsd and 5 patients with MS underwent 7T brain MRI. NMOsd patients were all women, all NMO IgG-seropositive, with average age of 47.8±9.0 years and disease duration of 11.4±6.5 years. MS patients were 80% women, with mean age of 43.6±10.0 years, and disease duration of 15.5±10.1 years. NMOsd patients had a total of 74 supratentorial lesions (7.4 per patient), versus 152 in MS patients (30.4 per patient). There were striking differences in lesion distribution: in NMOsd, 93% of lesions were subcortical versus 30% in MS group; by contrast, only 1% of NMOsd lesions were periventricular v. 53% for MS. MS patients also exhibited more lesions in juxtocortical white matter (9% v. 3 % in NMOsd) and in corpus callosum (11% v. 3% in NMOsd). Importantly, we did not detect any cortical lesions in NMOsd, while 3 out of 5 MS patients had detectable cortical lesions. Central venule was found in 81% of MS lesions, but only 7% of NMOsd lesions.

Conclusions: Our preliminary results indicate that supratentorial lesions in NMOsd imaged with ultra-high field MRI differ considerably from lesions of MS with respect to distribution and characteristics (presence of central venule). Ultra-high-field 7T MRI may be a useful tool for differentiating NMO from MS. Updated results on NMOsd and MS cohorts matched by age and disease duration will be presented.

This work was supported by a research grant from the Jackson-Guthy Charitable Foundation.

I Kister received research support from EMDSerono/ Pfizer, Inc. the National Multiple Sclerosis Society and Jackson-Guthy Charitable Foundation.

J Herbert has received personal compensation for activities with Biogen Idec, EMD Serono, Teva Neuroscience and Bayer as a consultant. Dr Herbert has received research support from Teva Neuroscience, Novartis, Biogen Idec, Bayer, EMD-Serono/Pfizer, BioMS and INC Research.

Y Zhou and Y Ge have nothing to disclose.

A qualitative study investigating the experiences of affected persons and family members living with neuromyelitis optica

K.P. Mutch, A. Methley, J. Boot, A. Jacob

Walton Centre Neurology and Neurosurgery Foundation Trust (Liverpool, UK)

Introduction: Neuromyelitis Optica (NMO) is an inflammatory demyelinating disorder of the central nervous symptom characterised by relapses affecting optic nerves and longitudinal extensive transverse myelitis resulting in visual and physical disabilities. The unpredictable nature and diversity of NMO and often increasing level of disability can result in NMO being a difficult condition to live with, for both the person with NMO and their family/caregivers. The majority of research on NMO is medical in nature and no previous studies have been identified investigating the experience of living with NMO from the perspective of the patient or those close to them.

Objectives:

Methods: Patients attending The National NMO Centre in Liverpool, UK were invited to participate in this study. They nominated a family member to be invited to participate. All patients fulfilled the Wingerchuk criteria 2006 of NMO or NMO spectrum disorder. In total 14 patients (8 positive for aquaporin-4 antibodies) and 13 partners or parents participated aged from 24 years to 74 years, NMO diagnosis 2-13 years although initial relapse causing disability ranged from 4 years to 37 years ago.

Either a Specialist NMO Nurse or Assistant Psychologist interviewed participants using a semi-structured interview investigating the daily impact of their NMO symptoms (both physical and psychological), their experience of diagnosis, the changing nature of their NMO, their experiences of health care services and any benefits of their NMO diagnosis. Either

Results: Data was analysed using thematic analysis to identify major themes from the interviews. Early analysis includes themes such as ‘Fear of Relapse,’ ‘tiredness,’ ‘planning,’ ‘lack of control,’ ‘stability.’ These findings have major significance for clinical practice and care of both people with NMO and their families. This research highlights the importance of the subjective assessment of the impact of NMO, and clinicians should therefore investigate patient’s perceptions of NMO in addition to clinically relevant measures of disability and impact.

This poster will demonstrate themes highlighted by the qualitative interviews including their perception of quality of life for the person and family member living with NMO.

The authors have nothing to disclose.

Pain in neuromyelitis optica spectrum disease: a cross-sectional study in an English cohort

H.A.C. Leonard, J. Revis, L.A.E. Matthews, J. Kitley, M.I. Leite, J. Palace

Oxford University (Oxford, UK); John Radcliffe Hospital (Oxford, UK)

Introduction: Neuromyelitis Optica (NMO)/Neuromyelitis Optica Spectrum Disorders (NMOSD) are inflammatory demyelinating conditions of the central nervous system very often associated with Aquaporin-4 antibodies (AQP4-Abs). Severe pain is common in those with transverse myelitis (TM), and is difficult to assess and manage. Pain in NMOSD can severely affect patients’ quality of life (Kanamori et al 2011).

Aim: To characterise pain related to TM in NMOSD and to find correlates amongst the clinical data, patient pain self-assessment, AQP4-Ab status and MRI findings.

Method: The NMOSD database at the Oxford NMO Service was searched for patients with significant chronic pain. A quantitative self-assessment of patient pain was conducted using Brief Pain Inventory (BPI) and Pain Detect (PD) questionnaires. BPI generates a Pain Severity Index (PSI) and a Functional Interference Index (FII) for each patient; PD score classifies each patient’s pain as “likely”, “unclear”, or “unlikely” to be neuropathic. Patient notes and MRIs were reviewed. Statistical analyses were performed using Student’s T-test and Spearman’s correlation test.

Results: Of 80 NMOSD patients with TM (65 females), 32(40%) had significant and chronic pain. The age of the patients with pain was significantly higher than those without (medians 35.2 vs 51.9,p=0.001). The disease duration in those with/without pain was 71.5/51.7 months respectively.

In those with pain, the number of TM attacks was 1-10 (median 3.5). The AQP4-Ab status in those with/without pain was: 75%/63% positive respectively.

In those with pain, 62.5% were taking ≥2 analgesics, and 22%, ≥4. Of the 18 pain patients who returned both questionnaires, median PSI was 25.3(4-40) (maximum=40), median FII, 46.5(7-70) (maximum=70), and median PD score, 19.5(0-37) (maximum=38). PD scores correlated significantly with both PSI and FII scores (p=0.74,p<0.005. p=0.63,p<0.01). Neither BPI nor PD scores were significantly correlated with MRI lesion length, number of TM attacks, gender, age at first or latest TM attack, or number of analgesics. AQP4-Ab positivity was associated with higher PD, PSI and FII scores (21.5 vs 16,p=0.2. 48 vs 27,p=0.3. 29 vs 19,p=0.08).

Conclusion: We demonstrated that pain is frequent and significant in NMOSD and that AQP4-Abs are associated with a higher pain score, and greater functional interference. We are following this with a larger cohort, looking at more variables, to define predictive markers of pain and response to treatment.

The authors have nothing to disclose.

Seasonal pattern of variation in neuromyelitis optica relapses

L. Elsone, S. Luppe, J. Kitley, P. Chater-Lea, K. Harding, K. Mutch, M.I. Leite, J. Palace, N. Robertson, A. Jacob

The Walton Centre for Neurology and Neurosurgery, NHS Trust (Liverpool, UK); Cardiff University, University Hospital of Wales (Cardiff, UK); John Radcliffe Hospital (Oxford, UK); University of Oxford (Oxford, UK)

Introduction: Neuromyelitis optica (NMO) is a chronic neuroinflammatory antibody-mediated disorder clinically characterised by relapses with rapid accumulation of fixed disability. In common with other relapsing inflammatory diseases, in which seasonal patterns of relapses have been noted, NMO relapses occur following initiation of an immune cascade, resulting in neuroinflammation and clinical deterioration, although putative triggers of immune system activation have not yet been identified. To date, there have been no studies on whether relapses in NMO also exhibit a seasonal variation.

Objective: To examine whether seasonal variation in relapses of AQP4 antibody positive (AQP4 (+)) NMO or NMO spectrum disorder patients (NMOSD) exists.

Methods: Data was collected retrospectively on relapses in AQP4 (+) NMO and NMOSD patients from 3 centres in the United Kingdom. AQP4 negative cases were excluded. Poisson regression was used to assess total number of relapses per month within the whole cohort and by gender. Onset events per month and month of birth were also assessed. Statistical modelling was performed using R version 2.10.1.

Results: 693 relapses in 152 patients (85% female) followed for a mean of 7.1 years were analysed. Number of relapses per month ranged from 50 (June) to 74 (January). There were significantly fewer relapses in March (β = -0.37, p = 0.04) and June (β = -0.39, p = 0.03). There was no significant variation by gender. There was no significant seasonal variation in onset events or month of birth in this cohort.

Conclusions: Our results are consistent with a seasonal variation in NMO relapses, characterised by significantly fewer relapses in March and June. This is in contrast to the seasonal pattern in multiple sclerosis (MS), where relapses peak in summer months. These data imply that environmental factors may be relevant for relapse aetiology in NMO, and are distinct from those that are relevant in other neuroinflammatory diseases, such as MS. In view of the significant clinical sequelae of NMO relapses, future studies should aim to confirm this pattern using prospective data, which may help to elucidate mechanisms underlying relapse initiation and inform potential new therapeutic approaches.

The authors have nothing to disclose.

Brainstem manifestations in neuromyelitis optica

L. Kremer, M. Mealy, A. Jacob, I. Nakashima, P. Cabre, S. Bigi, P. Friedemann, S. Jarius, O. Aktas, M. Levy, Y. Takai, N. Collongues, B. Banwell, K. Fujihara, J. de Seze

Department of Neurology (Strasbourg, FR); Department of Neurology (Baltimore, US); Department of Neurology (Liverpool, UK); Department of Neurology (Tohoku, JP); Department of Neurology (Fort De France, FR); Department of Neurology (Toronto, CA); Department of Neurology (Berlin, DE); Department of Neurology (Heidelberg, DE); Department of Neurology (Düsseldorf, DE)

Introduction: Neuromyelitis optica (NMO) is a severe demyelinating disease of central nervous system with mainly spinal cord and optic nerve involvement. However, brainstem symptoms have been recently reported in NMO or NMO spectrum patients.

The aim of this study was to evaluate the frequency of brainstem symptoms in a prospective cohort of NMO patients and to better characterize brainstem signs NMO according to ethnic background and serologic status for anti-aquaporin4 (AQP4) antibodies. We also evaluated the time to onset of these signs in the history of the disease.

Methods: We conducted a prospective multicenter study in 258 NMO patients (214 women, 44 men, mean age 44.2 years, non Caucasian 50.8%, positive anti-AQP4 antibodies 79,5%) with NMO according to the Wingerchuck criteria. We evaluated prospectively (during an out/in patient clinic or by phone) the frequency, the caracterization and the date of onset of various brainstem signs in this population: hiccups, vomiting, pruritus, diplopia, deafness, facial palsy.

Results: Brainstem signs were observed in 81 patients (31.4%). The most frequently observed was intractable vomiting (33.1%), followed by intractable hiccups (22.3%), oculomotor signs (19.8%), intractable pruritus (12.4%), deafness (2.5%) and facial palsys (2.5%). There were also some cases of vestibular symptoms (1.7%), trigeminal neuralgia (2.5%) and other cranial nerves signs (3.3%). These signs were inaugural in 44 patients (54.3%). In other patients, time to onset of brainstem signs during the course of the disease extended from 1 to 257 months with a median of 15 months. We found a higher prevalence of brainstem signs in non-Caucasian population (36.6%) compared with Caucasian population (26%) (p<0.05). Prevalence of brainstem signs was higher in seropositive patients (32.7%) compared with serogative patients (26%) but the difference did not reach significance.

Discussion: These results confirms a relatively high frequency of brainstem signs in NMO (31.4%). We found a majority of vomiting and hiccups as previously described.

These symptoms seem to be more common in non-Caucasian populations, and in AQP-4 positive patients that could be explained by a genetic susceptibility. In the majority of patients, the brainstem signs were inaugural or appear early in the course of NMO.

Conclusion: Brainstem signs are relatively common in NMO and occur relatively early in the disease course with greater frequency in patients with non-Caucasian origin.

The authors have nothinge to disclose.

Long-term follow-up of patients with neuromyelitis optica treated with rituximab

T. Kümpfel, J. Havla, E. Schuh, H. Pellkofer, L.A. Gerdes, I. Meinl, R. Hohlfeld

Institute of clinical Neuroimmunology (Munich, DE)

Background: Neuromyelitis optica (NMO) is a severe autoimmune demyelinating disease targeting optic nerves and the spinal cord. The monoclonal anti-CD20+ B cell antibody rituximab (RITUX) is an emerging therapeutic option in NMO. However, long-term efficacy and safety data of RITUX therapy in NMO are lacking.

Objectives: To report long-term data of 12 patients with NMO who were treated with RITUX up to eight times.

Methods: Ongoing prospective, monocentric long-term cohort study.

Clinical examinations and determination of B cell counts as well as immunoglobulin levels were continuously performed every three months.

Results: All but two patients received RITUX therapy as second line therapy after they had failed to respond to at least one previous immunosuppressive therapy. Repeated RITUX therapy led to long-lasting depletion of B-cells and sustained clinical stabilization in all 12 NMO patients. However, we observed a decrease in serum immunoglobulin levels during long-term treatment in five patients associated with increased infection rates. One patient discontinued RITUX therapy due to recurrent bacterial (non-opportunistic) pneumonia.

Conclusion: Our data indicate that long-term therapy with RITUX up to eight times is effective in NMO patients with an overall acceptable safety profile without evidence for opportunistic infections.

T.K. has received travel expenses and personal compensations (speakers honoraria)from Bayer Schering Pharmacy, Teva, Sanofi-Aventis, Merck-Serono, Biogen-Idec and Novartis as well as grant support from Bayer-Schering AG.

J.H. received travel expenses and personal compensations from Merck-Serono, Teva, Bayer-Schering, Novartis and Biogen-Idec.

E.S. and H.P have nothing to disclose.

LA.G. received travel expenses and personal compensations from Merck-Serono, Bayer-Schering, Novartis and Biogen-Idec.

I.M. received travel expenses from Biogen-Idec.

R.H. is supported by the Deutsche Forschungsgemeinschaft (SFB 571, A1) and has received personal compensations from Bayer Schering Pharmacy, Teva, Merck-Serono, Biogen-Idec, and Novartis.

Interleukin-6 receptor blockade in neuromyelitis optica resistant to anti-CD20 therapy

I. Kleiter, I. Ayzenberg, A. Schröder, K. Hellwig, A. Chan, R. Gold

Ruhr-University (Bochum, DE)

Background: Neuromyelitis optica (NMO) is a rare, severely disabling autoimmune disease, preferentially affecting optic nerves and the spinal cord, structures highly expressing the target antigen aquaporin-4 (AQP4). Several small studies and case report series demonstrated moderate efficacy of immunosuppressive agents in NMO. More promising results have been shown for anti-CD20 therapy, however approximately 20% of patients experience relapses despite the complete depletion of B-cells. Recently, interleukin (IL6)-dependent activation of a specific AQP4-secreting plasma blast subpopulation has been described in NMO. The IL-6 receptor-blocking antibody tocilizumab could be a new therapeutic option for NMO.

Methods: We retrospectively studied the efficacy of tocilizumab in NMO patients diagnosed according to the revised Wingerchuk 2006 criteria, who failed to respond to a B-cell depleting therapy with rituximab. The annualized relapse rate (ARR), disability progression measured by the EDSS, and the spinal MRI activity were analysed.

Results: Here we report on 3 female patients with a median age of 39 (27-43) years and median disease duration of 7 (3-9) years. All patients had been treated with different immunosuppressive and immunomodulating agents followed by 1-3 cycles of rituximab for a median duration of 8 (5-25) months. Median number of relapses on rituximab therapy was 2 (1-5) with an ARR of 2.5 (2.4-3.0), despite complete B-cell depletion. The median EDSS increased from 5 (4.5-7) to 6.5 (5-7). After switch to tocilizumab therapy, which was given for a median duration of 13 (5-16) months, the median number of relapses decreased to 1 (0-1) with an ARR of 0.7 (0-2.4). A total of 2 relapses occurred during tocilizumab therapy and both involved mild sensory deficits. There were no contrast enhancing lesions on MRI and the median EDSS stabilized at 6.5 (4-7). There were no infections or other adverse events. Updated results will be presented at the congress.

Conclusion: An IL-6 receptor-blocking therapy can be effective in aggressive, therapy resistant cases of NMO. Larger studies with longer follow-up periods are needed to confirm the efficacy of tocilizumab in NMO.

Dr Kleiter reports travel reimbursements and speakers and consulting honoraria from Bayer Healthcare, Biogen Idec, Merck Serono, and Novartis as well as research support from Bayer Healthcare and Novartis.

Dr Hellwig reports speakers’ and consulting honoraria and scientific grants from Bayer Healthcare, Biogen Idec, Merck Serono, Novartis, and Teva-Aventis.

Dr. Gold reports speakers’ and consulting honoraria and scientific grants from Bayer Healthcare, Biogen Idec, Merck Serono, Novartis, and Teva Sanofi Aventis.

The other authors have nothing to disclose.

Predictors of the effectiveness of plasma exchange in NMO-IgG seropositive neuromyelitis optica spectrum disorders

Y.M. Lim, S.Y. Pyun, J. Kim, S.M. Kim, K.S. Park, K.K. Kim

University of Ulsan College of Medicine (Seoul, KR); Asan Medical Center (Seoul, KR); Seoul National University (Seoul, KR); College of Medicine (Seoul, KR)

Background: Although plasma exchange (PE) is an established rescue therapy for acute steroid-resistant attacks of neuromyelitis optica spectrum disorders (NMOSD), prognostic factors have been primarily investigated for a subset of heterogeneous demyelinating diseases of the central nervous system.

Objectives: We aimed to determine the clinical and radiographic predictors of PE response in NMO-IgG seropositive NMOSD.

Methods: We analyzed the clinical and MRI features of 31 NMO-IgG-positive patients (30 women; median age, 39 years; range, 9–62 years) receiving PE for acute attacks, and evaluated the relationship between these parameters and outcome.

Results: Acute exacerbations treated with PE included 20 myelitis attacks (64.5%), 9 optic neuritis (ON) attacks (29.0%) and 2 cerebral attacks (6.5%). The median Expanded Disability Status Scale (EDSS) score was 5.5 (range, 3.5 - 9.0)at the initiation of PE. The overall response rate was 58.1% at 1 month and 64.5% at 6 months. Non-ON attacks and preserved DTR were associated with improvment at 1 month [Odds Ratio (OR)= 22.31, p = 0.007; OR = 22.30, p = 0.023, respectively]. Nonetheless, these variables were not associated with long-term response. Functional improvement at 6 months was signigicantly associated with a basal EDSS score less than 3 (OR = 16.98, p = 0.040) in multiple logistic regression analysis. The EDSS score at the time of PE and the days until PE were not associated with outcome (p = 0.476 and p = 0.769, respectively). In spinal attacks, patients without cord atrophy had better response than patients with atrophy (OR = 26.0, p = 0.016). Clinical improvement was not associated with enhancement pattern, degree of cord swelling, or presence of T1 hypointensity. Directly after last PE, NMO-IgG seroconverted to negative in 85% of the patients, and dropped to less than 20% of the initial titer in 10% of the patients. Levels of NMO-IgG did not differ between responders and non-responders at the PE onset and after follow-up.

Conclusions: Our study demonstrates that PE is an effective treatment in severe attacks of NMO-IgG seropositive NMOSD. Minimal preexisting disability is a clinical parameter predicting therapeutic outcome after PE, and cord atrophy resulting from previous relapses was the radiographic predictor in spinal attacks. Taken together, the presence of cumulative neuronal damage prior to treatment is the primary determinant of the effectiveness of PE in NMO-IgG seropositive NMOSD.

The authors have nothing to disclose.

Anti-Ro/SSA antibody and anti-aquaporin4-antibody in neuromyelitis optica spectrum disorder

J.H. Park, J. Hwang, D. Lee, J.H. Min, B.J. Kim, E.S. Kang, K.H. Lee

Samsung Medical Center (Seoul, KR); Sungkyunkwan University School of Medicine (Seoul, KR)

Background: Neuromyelitisoptica (NMO) is frequently associated with non-organ specific autoimmune disease including Sjogren’ssyndrome. Anti-aquaporin-4 antibody (AQP4-Ab) plays an essential role for diagnosis of NMO, whereas anti-Ro/SSA antibody is the most frequent serologic marker for Sjogren’s syndrome. Herein, we aimed to evaluate the relationship between AQP4-Ab and anti-Ro/SSA antibody in NMO spectrum disorder.

Methods: We collected the 106 patients with NMO spectrum disorder (NMOSD) and reviewed clinical feature, laboratory data and MRI findings, retrospectively. All patients completedtest for AQP4-Ab using cell-based indirect immunofluorescence assay.

Results: Among 106 patients, 20 (18.8%) were positive for anti-Ro/SSA antibody. The AQP4-Ab positivity were 94.4% in patients with anti-Ro/SSA antibody, while 48.2% in patients without anti-Ro/SSA antibody (p<0.001). The sensitivity of anti-Ro/SSA antibody for AQP4-Ab was 20% and specificity was 98.0%. The final Expanded Disability Status Scale(EDSS) score [median (IQR): 3.5 (2-8) vs. 2 (1-5), p=0.007] were higher in patients with anti-Ro/SSA antibody than without anti-Ro/SSA antibody. In multiple logistic regression analysis, AQP4-Ab (OR 16.81, 95% CI 1.8-155.0, p=0.013), anti-Ro/SSA antibody (OR 5.2, 95% CI 1.3-20.7, p=0.019), disease duration(per year increase; OR 1.25, 95% CI 1.1-1.5, p=0.005)were independently associated withEDSS 6 or more. In MRI findings, patients with anti-Ro/SSA antibody were more associated with medullary lesions often contiguous with cervical lesions than patients without anti-Ro/SSA antibody (50.0% vs. 10.5%, p<0.001).

Conclusion: Presence of anti-Ro/SSA antibody seems to be associated with AQP4-Ab and poor prognosis.

The authors have nothing to disclose.

Outcome of repeated rituximab treatment in 81 patients with neuromyelitis optica spectrum disorder

S.-H. Kim, W. Kim, S.-Y. Huh, S.J. Lee, A.-R. Joung, H.J. Kim

Research Institute and Hospital of National Cancer Center (Goyangsi, KR)

Objectives: To evaluate the clinical response to rituximab treatment in terms of the relapse rate and disability in the largest cohort of neuromyelitis optica spectrum disorder (NMOSD).

Methods: Patients with NMOSD who had been treated with rituximab for more than 6 months at National Cancer Center, Korea were enrolled. The rituximab therapy consisted of induction (375 mg/m² once weekly for 4 weeks or 1000 mg twice with a 2-week interval), and maintenance therapy (re-infusion of rituximab (375 mg/m², once) whenever the frequency of reemerging CD27+ memory B cells in peripheral blood mononuclear cells exceeded 0.05% for the initial 2 years and >0.1% thereafter on flow cytometry. The outcome measures included the annualized relapse rate (ARR), disability (Expanded Disability Status Scale score), and safety of rituximab treatment.

Results: Eighty-one patients were included: 64 with NMO and 17 with NMOSD. The patients received their first infusion of rituximab at a median age of 35 years, which was a median of 52 months after the onset of NMO. Anti-aquaporin-4 antibodies were positive in 96% of the patients. Before rituximab, 33 patients were treated with other immunosuppressive agents and forty-eight patients were treatment naïve. At a median follow-up of 41 (range 7–74) months, patients received a median of five re-infusions at a median 26-week (range 6–62 weeks) interval. The median annualized relapse rate (ARR) declined significantly from 1.9 (range 0.4–12.0) to 0.0 (range 0–5.3), and 67% of the patients became relapse-free. Their disability either improved or stabilized in 96% of the patients. One switched to another treatment, due to four relapses during 9 months of rituximab treatment. Three patients switched to mitoxantrone a median of 14 months after starting rituximab due to the rapid repopulation of memory B cells in the peripheral blood, which necessitated very frequent administration of rituximab. After mitoxantrone therapy, three patients were switched back to rituximab, however, one patient showed persistent rapid repopulation of CD27+ memory B cells. The infusion-related reactions, noted in 39 of 80 patients (47%), were managed well with methylprednisolone. No clinically relevant adverse event leading to treatment discontinuation was observed.

Conclusion: Our study of 81 patients with NMOSD indicates that repeated treatment with rituximab is effective in more than 95% of patients with good tolerability.

The authors have nothing to disclose.

Three cases of neuromyelitis optica spectrum disorders with interstitial pneumonia

M. Sakamaki, T. Kanamaru, Y. Takayama, M. Kobayashi, A. Nogami, T. Kumagai, H. Nagayama, M. Yamazaki, Y. Katayama

Nippon Medical School (Tokyo, JP)

It was known that neuromyelitis optica (NMO) was characterized by recurrent attacks of optic neuritis and longitudinally extensive transverse myelitis (LESCL). In most cases of NMO, serum anti-aquaporin 4 (AQP4) antibody in which is a serum autoantibody maker is positive. It was little reported complication of transverse myelitis with anti-AQP4 and interstitial pneumonia. Few overlapping cases of Devic’s syndrome and SLE ware reported. We experienced three cases have this complication without SLE. In two cases, transverse myelitis occurred after tapering of oral predonisolone for interstitial pneumonia. First case was 59 years old man. He was admitted to another hospital at general fatigue and revealed interstitial pneumonia by chest CT. He could not walk few days after admission. MRI showed longitudinally extensive spinal cord lesion (LESCL). He would be able to move his legs by intravenous methylpredonisolone puls therapies. AQP4 antibody of his serum was positive. Second and third cases had have medication of oral predonisolone for interstitial pneumonia, until one month before they felt to walk. Spinal MRI showed LESCL. They had AQP4 antibody also.

AQP4 was distributed not only in central nerve system but also in lung. It is presumed that anti-AQP4 antibody is associated with both NMO and interstitial pneumonia.

The authors have nothing to disclose.

The effect of NMO-IgG and complement against primary human astrocytes in culture

S. Nishiyama, T. Misu, N. Sugeno, T. Takahashi, I. Nakashima, M. Aoki, K. Fujihara

Tohoku University School of Medicine (Sendai, JP); Yonezawa Hospital (Yonezawa, JP)

Background: Neuromyelitis optica (NMO) is characterized by severe optic neuritis and transverse myelitis. A disease-specific autoantibody against aquaporin (AQP) 4, mainly expressed in astrocytic foot processes, was found in the sera from patients with NMO. It is considered that NMO-IgG could act on the complement mediated cytotoxicity against astrocytes in vitro. However, there is a controversy about whether the astrocyte is damaged mainly by antibody or by complement, and the influence of complement regulatory protein.

Objective: To clarify the effect of NMO-IgG alone and complement with NMO-IgG against astrocytes in culture.

Methods: Purified IgG (10mg/ml) were obtained from 5 patients with AQP4 antibody-positive NMO, 3 with multiple sclerosis (MS), and 3 healthy controls. Confluent primary human astrocytes were incubated with the IgG (5% volume) for 30 minutes. After removing unbound IgG, the cells were further cultured with either human or rabbit complements, with or without heat inactivation. We observed the cytotoxicity by propidium iodide (PI) system and LDH assay.

Result: AQP4 antibody+IgG alone caused clustering degradation and following endocytosis of the membraneous AQP4, then induced decreased cellular adherent ability and shrinkage of astrocytic processes in 15 minutes to 2 hours. These changes were reversible by removing the IgG. The percentage of floating alive astrocytes in the media with NMO patients’ AQP4 antibody-positive IgG (34.5±7.80%) was significantly higher than those in control media without IgG (9.09±5.60%), or with MS patient-IgG (11.2±6.72%) or control-IgG (5.74±4.59%). By non-heated human complements in addition to NMO-IgG, the cell bodies and the nuclei started to swell. In 3 hours, many astrocytes lost mobility and adherence property, and floating balloon-like cells and cell debris increased in number as time went by. AQP4 antibody-negative IgG in MS or control did not induce the above-described changes. Using the siRNAs for CD55 and CD59 to astrocytes cocultured with NMO-IgG and non-heated human complement, PI positivity became higher. LDH assays confirmed these results. Protective effects of CD55 and CD59 are additive.

Conclusion: Our results showed that AQP4 antibody by itself can cause reversible but probably functionary significant morphological changes of human astrocytes, and alter AQP4 expression, and that with complements the antibodies irreversibly damage the cells, suggesting dual pathogenicities of AQP4 antibody to cause a unique astrocytopathy in NMO.

The authors confirm that there are no conflicts of interest.

Use of rituximab in Devic’s disease, two-year follow-up. Mexican experience

J. Flores, L. Aguirre, L. Salinas, Y. Rito, T. Corona

Instituto Nacional de Neurologia Y Neurocirugia (Mexico City, MX)

Introduction: Devic’s disease (DD) is an inflammatory autoimmune demyelinating disease of the central nervous system, characterized by the presence of an autoantibody that targets aquaporin-4 (AQP4), the most abundant water channel in the CNS. Is more common in meddle age women, affecting spinal cord and/or optical nerve in monophasic or relapsing. The disability in these patients is severe and the treatment selection prevents relapsing.

Objective: To evaluate the efficacy and safety of Rituximab therapy in Devic’s Disease Mexican patients.

Methods: We carried out a longitudinal study among patients with DD, who were attending at the Demyelinating Disorders Clinic at National Institute for Neurology and Neurosurgery (NINN) in Mexico City from January 2007 to June 2011. We recorded clinic and demographic variables in patients who follow the next schedule treatment of Rituximab (RTX): 1.5g IV as initial dose and after that 500mg each six months as follows. We used annualized relapse rates and Expanded Disability Status Scale (EDSS) to measure the effectiveness before and after the administration of treatment. Also we recorded the adverse effects during infusion and after.

Results: We studied 13 patients, which 92% (12) were women, and 8% (1) men, with an average age of 33.3 (SD±13.8) years old; at a median follow-up after finished treatment was 24 mouths (12-24); 3 subjects needed an extra doses of RTX (500mg) because one had relapsing and two lymphocytes CD19 count elevated. The median annualized pre treatment relapse rate was 1.0 (±0.8) and the post treatment rate was 0.1 (±0.3; p <0.05, Wilcoxon signed-rank test). The median EDSS score was 4.8 (±3.3) at the start of treatment and 2 (±3.3; p <0.05, Wilcoxon signed-rank test), at last follow-up. Rash occurred in 3 subjects during administration and one patient abandoned the treatment due to pregnancy 9 mouth after the first doses. No adverse effects were record in the newborn. No patient suspended treatment due to adverse effects.

Conclusion: The use of RTX in patients with DD relapsing is effective in reducing disability and the number of relapses at 24 months follow up.

The authors can confirm that there are no conflicts of interest.

Characterisation of NMO and HRS patients with a late onset

N. Collongues, R. Marignier, A. Jacob, A. Siva, F. Paul, H. Zephir, L.I. Leite, G. Akman-Demir, L. Elsone, S. Jarius, C. Papeix, K. Mutch, S. Saip, B. Wildemann, J. Kitley, R. Karabudak, O. Aktas, D. Kuscu, A. Altintas, J. Palace, J. de Seze on behalf on the EDEN project (including NOMADMUS, LNMO Turkish group, the UK cohort and German datasets)

Background: Neuromyelitis optica (NMO) is a rare inflammatory disease. Average age at onset is 35 years. Few data exist on patients with late-onset NMO (LONMO) or late-onset high risk syndrome (LOHRS), with disease onset after age 50 years.

Objective: To report the clinical and paraclinical features of patients with LONMO/HRS.

Design: Retrospective, multicenter study of patients with LONMO/HRS in adult medical centers.

Setting: Four national cohorts of NMO and HRS on behalf on NOMADMUS (France), German NMO centers, the Turkish LONMO group (Turkey) and the UK cohort. These cohorts take part into the EDEN (European DEvic Neuromyelitis optica) project.

Main outcome measure: Demographical, clinical, biological and radiological data in the LONMO/HRS population of patients. Disability was assessed using the EDSS score and the annualized relapse rate. The Kaplan-Meier technique was used to estimate time to assignment of EDSS scores and log rank test was used to compare this cohort with a cohort of 105 French NMO patients with an early onset < 50 years old (EONMO).

Results: 67 patients with LONMO and 48 with LOHRS were followed up during a mean 4.5 years. The LONMO/HRS cohort was mainly of Caucasian origin (90%), women (90%) and seropositive for anti-AQP4 antibody (82%). Median age was 56 years old and the eldest patient was 82.5 years old at NMO onset. Myelitis was the first attack in 61% of cases, followed by optic neuritis in 28%. A relapsing form was observed in 80% of cases and no progressive form was noted. Mean annualized relapse rate was 1.4 with a first inter-attack interval of 17.7 ± 24 months. The mean number of T2 lesion on initial brain MRI was 2.8 ± 3.9 and 8% of patients fulfilled Barkhof criteria. CSF oligoclonal bands were observed in 29% of patients. Median time to EDSS 4 in LONMO/HRS patients was 14 months [8.2-19.8] and the median time to immunosuppression was 1.25 years. No difference in term of demographical, clinical, radiological data and disability was evidenced when LONMO/HRS were compared to EONMO patients.

Conclusion: Clinical, paraclinical features and time to EDSS4 of LONMO/HRS patients are similar to EONMO patients.

The authors have nothing to disclose.

Good response to Ofatumumab in a child with severe relapsing Neuromyelitis Optica

S. Sedani, M. Absoud, D. Milford, M.I. Leite, M.G. Pike, A. Vincent, J. Palace, E. Wassmer

Birmingham Children’s Hospital (Birmingham, UK); University of Birmingham (Birmingham, UK); John Radcliffe Hospital (Oxford, UK)

Background: Immunomodulatory therapies with monoclonal antibodies such as Rituximab are now accepted treatments in Neuromyelitis optica (NMO). Rituximab (chimeric) and Ofatumumab (humanised) both bind to different epitopes on the extracellular CD20 receptor of B-cells causing B-cell lysis. Ofatumumab is thought to bind to a novel CD20 epitope producing more robust complement-dependent toxicity compared with Rituximab. To date, Ofatumumab has mainly been used for the treatment of refractory chronic lymphocytic leukaemia (CLL) and its use has not been reported in the treatment of NMO.

Aim: To describe the use of Ofatumumab in the treatment of a child with severe relapsing NMO.

Results: A 2 year, 9 months old male presented with relapsing ON and was treated with courses of intravenous methylpredniolsone. Azathioprine and oral prednisolone were commenced within 6 months of the first attack as he also then had a TM relapse. High AQP4-Ab levels persisted and he relapsed with a left hemi-syndrome within one year of first attack. Rituximab was added, but he developed progressively worse hypersensitivity reactions despite premedication, and hence treatment was suspended after the fourth incomplete dose. Two weekly cycles of plasma exchange (PLEX) was then initiated, azathioprine was stopped and daily oral prednisolone continued. Despite, significant reductions of AQP4-Ab levels (70%), he continued to have relapses (2 ON) and within 30 months of the first attack he had a severe ADEM like attack. Plasmapharesis frequency was increased to three times weekly and immunosupression with cyclophosphamide and then mycophenolate mofetil (MMF) were subsequently tried. He continued to relapse (2 TM episodes). He was started on Ofatumumab within 4 years of his first attack at the age of 6 years, with an initial intravenous dose of only 100mg, followed by a dose of 100mg three months later (recommended adult dose for CLL is 300mg then weekly 2000mg for eight weeks). CD19 counts decreased dramatically after ofatumumab treatment. AQP4-Ab levels have also decreased to their lowest levels and the child remains relapse free after 5 months. He is no longer on plasmapharesis but continues on oral prednisolone and MMF.

Conclusions: Our report demonstrates good efficacy and tolerability of a relatively low dose of Ofatumumab, and its first known use in NMO. Ofatumumab could be considered in NMO patients who develop hypersensitivity reactions to Rituximab. Further controlled trials are needed.

SS, MA, DM, MGP, MIL, AV, JP, EW have nothing to disclose.

Acknowledgements: NCG funded NMO team, JRH, Oxford.

Evaluation of vitamin D-related parameters in a multinational paediatric multiple sclerosis case-control study

H.E. Hanwell, B Bhan, M.R. Bardini, A. Belman, A. Boiko, O. Bykova, M.-E. Dilenge, K. Farrell, M. Freedman, J. Hahn, M. Iivanainen, J. Kennedy, M. Kremenchutzky, L. Krupp, J.K. Mah, J. Ness, M. Rensel, M. Ruggieri, M. Sevon, C. Stoian, E. Waubant, B. Weinstock-Guttman, S. Tenembaum, E.A. Yeh, R. Vieth, R.A. Marrie, A. Bar-Or, B. Banwell on behalf of the Wadsworth Pediatric Multiple Sclerosis Study Group

Context: Vitamin D is a putative environmental determinant of MS and modulator of MS disease activity. Vitamin D insufficiency is common in adults with MS but there are few data pertaining to vitamin D status and metabolism in paediatric MS. Whether sources of vitamin D or vitamin D metabolism differ in paediatric MS from other children are also unknown.

Objective: To compare vitamin D status (total serum 25-hydroxyvitamin D concentration, [25(OH)D total]), prevalence of vitamin D insufficiency (25(OH)D total <75 nmol/L), vitamin D catabolism (ratio of 24,25(OH)D3 to 25(OH)D total), and exposure to non-solar vitamin D (25(OH)D2 concentration) between children and adolescents with MS and controls from multiple countries.

Methods: Children and adolescents (<20y) were enrolled from Argentina, Canada, Finland, Italy, Russia, and the United States between 2003 and 2005. Serum vitamin D metabolite concentrations (25(OH)D2, 25(OH)D3, and 24,25(OH)2D) were determined via LC-MS/MS with a 2 nmol/L limit of detection. Differences between participants with MS and controls were evaluated using Mann Whitney U and Fisher’s Exact Test with a two-sided α of 0.05.

Results: Serum was available from 121 children with MS (all countries) and 119 control participants (Argentina, Canada, and US). Those with MS were significantly older than controls (median (interquartile range, IQR) 15.3y (11.9-17.1) vs. 13.5y (9.1-16.4), P=0.007) but were not significantly different in terms of percent females (59% vs. 54%). Overall, 72.1% of participants were vitamin D insufficient. Children with MS did not differ from control participants in terms of seasonally-adjusted vitamin D status (25(OH)D median (IQR), 58.9 (38.4-77.5) nmol/L vs. 57.2 (41.0-77.3) nmol/L), prevalence of vitamin D insufficiency (72% vs. 72%), nor the ratio of 24,25(OH)2D3:25(OH)D total (median (IQR) 0.32 (0.25-0.36) vs. 0.33 (0.29-0.38)). Children with MS were more likely to have detectable 25(OH)D2 levels than control participants (19.0% vs. 3.4%, P<0.001).

Conclusion: There is a high prevalence of vitamin D insufficiency in this multinational cohort of children, irrespective of MS diagnosis. Indicators of vitamin D status and catabolism did not differ between children with MS and controls. Few foods contain vitamin D2; thus, the higher frequency of 25(OH)D2 positivity among participants with MS may indicate more frequent intake of vitamin D2-containing supplements among paediatric MS patients.

This study was supported by the Wadsworth Foundation and the Canadian Multiple Sclerosis Scientific Research Foundation. H. Hanwell is supported by a Hospital for Sick Children Restracomp Fellowship and has received a Speaker’s Honorium from Teva unrelated to the present work. V. Bhan has no disclosures relevant to the present work. M.R. Bardini has no disclosures relevant to the present work. A. Belman has no disclosures relevant to the present work. A. Boiko has no disclosures relevant to the present work. O. Bykova has no disclosures relevant to the present work. M-E Dilenge has no disclosures relevant to the present work. K. Farrell has no disclosures relevant to the present work. M. Freedman has no disclosures relevant to the present work. J. Hahn has no disclosures relevant to the present work. M. Iivanainen has no disclosures relevant to the present work. J. Kennedy has no disclosures relevant to the present work. M. Kremenchutzky has no disclosures relevant to the present work. L. Krupp has no disclosures relevant to the present work. J.K. Mah has no disclosures relevant to the present work. J. Ness has no disclosures relevant to the present work. M. Rensel has no disclosures relevant to the present work. M. Ruggieri has no disclosures relevant to the present work. M. Sevon has no disclosures relevant to the present work. C. Stoian has no disclosures relevant to the present work. E. Waubant has no disclosures relevant to the present work. B. Weinstock-Guttman has no disclosures relevant to the present work. S. Tenembaum has no disclosures relevant to the present work. E.A. Yeh has no disclosures relevant to the present work. R. Vieth has received speaker honoraria from DiaSorin Inc., Merck Serono, Stiefel Laboratories, Inc., and Carlson Laboratories; is a paid consultant for Ortho Clinical Diagnostics and Merck Serono; has been paid by Wyeth to write an article in a newsletter; has served as a media representative for Yoplait Yoghurt; and is related to a person employed in the dietary supplement industry. R.A. Marrie has been involved with clinical trials supported by Bayer Inc., Sanofi-Aventis; these activities do not relate to the present work. A. Bar-Or has received personal compensation for consulting, serving on scientific advisory boards and/or speaking activities from: Bayer, Bayhill Therapeutics, Berlex, Biogen-IDEC, BioMS, Diogenix, Eli-Lilly, Genentech, GSK, Guthy-Jackson/GGF, Merck-Serono, Novartis, Ono Pharmacia, Roche, Sanofi Aventis, Teva Neuroscience, and Wyeth; and has received research funding from: Bayhill Therapeutics, Biogen- IDEC, Genentech, Teva Neuroscience, and Merck-Serono; none of these activities relate to the present work. B Banwell has received Speaker’s Honoraria from Biogen-Idec, Novartis, and Merk-Serono, and serves as an advisor for pediatric trials; none of these activities relate to the present work.

Subcutaneous interferon-β-1a in paediatric patients with multiple sclerosis: regional outcomes in an international retrospective study (REPLAY)

L.B. Krupp, D. Pohl, A. Ghezzi, A. Boyko, S. Tenembaum, M. Meinel, M. Stam Moraga, C. McIIroy, L. Lehr, B. Banwell on behalf of the REPLAY Study Group

Background: The REPLAY study has previously shown that adult doses of interferon (IFN) β-1a, 44 and 22 mcg subcutaneously (sc) three times weekly, were well tolerated and associated with a reduced clinical attack rate in paediatric patients with multiple sclerosis (MS).

Aim: To perform post hoc analyses of regional differences in treatment practice and outcomes in the REPLAY study.

Methods: This was an international study of patients who had received ≥1 injection of sc IFN β-1a for demyelinating events when aged <18 years. Data were obtained retrospectively from medical records. Outcomes included prespecified medical events (MEs) and medically confirmed clinical attacks. Baseline characteristics, treatment patterns and outcomes were compared in the USA and the rest of the world (RoW).

Results: Data from 307 patients were analysed: USA, n=139; RoW, n=168. At baseline, in the USA vs RoW, patients had a higher mean body mass index (26 vs 21 kg/m²), a shorter median time from first demyelinating event to first disease-modifying drug (DMD) treatment (0.7 vs 1.1 years), and were more likely to have received ≥1 other DMD prior to sc IFN β-1a initiation (33.8% vs 13.7%). The initial dose was 44 mcg in 88.9% and 24.3% of patients in the USA and RoW, respectively. In the USA vs RoW, patients had a shorter median time on treatment (1.07 vs 1.73 years), were less likely to be receiving ongoing sc IFN β-1a therapy at study end (58.3% vs 75.6%), and more likely to switch to another treatment (28.8% vs 13.1%). Overall, 54.7% of patients had ≥1 prespecified ME after initiation of sc IFN β-1a treatment (USA 52.5%; RoW 56.5%); there were only minor regional differences in prespecified MEs. Annualized attack rates were similar in the USA and RoW prior to sc IFN β-1a initiation (1.71 vs 1.84) and decreased in both groups after starting sc IFN β-1a treatment; however, rates were higher in the USA vs RoW during sc IFN β-1a treatment (0.75 vs 0.37), and from treatment initiation to study end (0.83 vs 0.39). Median time to first attack after treatment initiation was shorter in the USA vs RoW (14.2 vs 27.2 months).

Conclusions: Irrespective of region, sc IFN β-1a was well tolerated and associated with a reduction in clinical attacks in paediatric patients with MS. Regional differences in baseline characteristics and treatment patterns suggest that USA patients had more aggressive disease, possibly explaining the regional variation in clinical outcomes.

Study supported by Merck Serono S.A. – Geneva, Switzerland (a branch of Merck Serono S.A., Coinsins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany).

L.B. Krupp: personal compensation for activities as a speaker, consultant, and/or participant on an advisory board from Teva Neuroscience, Biogen-Idec, EMD Serono, the Multiple Sclerosis Association of America, Bayer Pharmaceuticals, Guidepoint Global, Pfizer, Axon Advisors, Sanofi-Aventis; royalty or license fee or contractual rights payments from Abbott Laboratories, Genzyme Corporation, Health Professions Conferencing Corp., Bristol-Myers Squibb, Johnson and Johnson, MedImmune, Novartis, Roche; grant support from the National Multiple Sclerosis Society; research support from Serono, Biogen-Idec.

D. Pohl: honoraria or support for travel and accommodation related to congress attendance from Bayer-Schering, Biogen-Idec, Merck Serono, Teva.

A. Ghezzi: honoraria for speaking from Biogen, Merck Serono, Novartis, Sanofi-Aventis; for consultancy from Merck Serono, Teva, Novartis; support for participation in national and international congresses from Bayer-Schering, Biogen-Dompè, Merck Serono, Novartis, Sanofi-Aventis.

A. Boyko: member of advisory boards and participant in clinical trials sponsored by Bayer Schering, Merck Serono, Teva, Novartis, Biogen, Nycomed, Genzyme, and other companies.

S. Tenembaum: honoraria for speaking from Biogen-Idec, Merck Serono; advisory group for Biogen-Idec, Merck Serono, Teva.

M. Meinel, M. Stam Moraga, L. Lehr: salaried employees of Merck Serono S.A. – Geneva, Switzerland.

C McIlroy: salaried employee of Merck Serono Ltd, Feltham, UK.

B. Banwell: honoraria from Biogen-Idec, Merck Serono, Bayer, Schering; advisory group for Biogen-Idec, Merck Serono.

Application of the 2010 criteria on baseline MRI in a paediatric cohort: does positivity at onset associate with a more aggressive clinical disease course?

S. Bigi, R.A. Marrie, B. Banwell

The Hospital for Sick Children (Toronto, CA); Health Sciences Centre (Winnipeg, CA)

Background: The diagnosis of Multiple Sclerosis (MS) requires dissemination in space (DIS) and time (DIT). The 2010 McDonald criteria allow the diagnosis of MS at first attack under certain circumstances. Whether meeting the 2010 criteria on baseline images identifies pediatric MS patients with a more aggressive clinical course is unknown.

Methods: We reviewed clinical report forms and MRIs for all pediatric patients consented as part of the Demyelinating Disease registry from 1999-2011 at the Hospital for Sick Children, Toronto, Canada. MS was diagnosed using the 2010 criteria, either at baseline, at the time of second attack (clinically definite MS) or at the time of new lesion accrual in MRI, whichever came first. Evaluation of 2010 criteria for DIS and DIT on baseline MRI was performed for all children with gadolinium (Gd)-enhanced MRIs performed less than 30 days from onset of first attack. Characteristics of interest included age at onset, sex, presenting phenotype, time to second clinical attack, number of relapses in the first two years, and EDSS at last follow-up.

Results: 102 pediatric MS patients were identified, of whom 60 were excluded, 48 due to absence of an MRI within 30 days of onset, and 12 for whom baseline MRI did not include gadolinium-enhanced images. Of the remaining 42 patients (55% female), 22 (52%) met 2010 criteria for DIS and DIT at baseline. Compared to the 20 (48%) patients who did not meet criteria at baseline, those meeting 2010 criteria at onset did not differ with respect to sex (64% vs. 45% female [p= 0.22]); presenting phenotype (monofocal 64% vs. 65%, polyfocal 32% vs. 15% and ADEM 5% vs. 20% [p= 0.22]); mean age at onset (12.9 vs. 12.1y [p= 0.56]); mean time to second attack (442 vs. 312 days [p =0.61]); or mean number of relapses during the first two years (2.1 vs. 1.9 [ p =0.49]). After a mean duration of follow-up of 3.8y (range 0.5-10.5y), the median EDSS was 1.5 in the 2010 baseline-positive group compared to 0.9 in the children who did not meet criteria at onset (p=0.04).

Conclusion: Pediatric MS patients meeting 2010 McDonald criteria at the time of first attack do not differ from patients diagnosed by second clinical attack or DIT on follow up scans in terms of clinical features or clinical outcomes.

Dr. S. Bigi has an educational grant from the Swiss MS society for her clinical fellow ship.

Dr. R.A. Marrie has received pharma funding for trials from sanofi aventis and Berlex and has other research funding (CIHR, MSS foundation, Health Research Foundation, HSC foundation, MHRC). She is in the editorial board of Neurology and Multiple Sclerosis Journal. None of these activities relate to the present work.

Dr. B. Banwell has received Speaker’s Honoraria from Biogen-Idec, Novartis, and Merk-Serono, and serves as an advisor for pediatric trials. None of these activities relate to the present work.

Retinal nerve fibre layer thickness in paediatric demyelinating disease: the Canadian Paediatric Disease Study Group

Y.A. Reginald, F. Costello, J. O’Mahoney, J.R. Buncic, B. Banwell on behalf of The Canadian Pediatric Demyelinating Disease Study

Purpose: To compare the average Retinal Nerve Fibre Layer (RNFL) thickness at Spectral Domain Optical Coherence Tomography (SD_OCT) of pediatric patients following demyelinating disease to normal age matched controls.

Method: The RNFL thickness measured at SD-OCT(Cirrus, Carl Zeiss) scanning 6 months following a demyelinating episode in 35 Canadian Pediatric Demyleinating Disease Study patients were compared to 20 age matched normal controls.

Eyes were categorized as;

1) First episode of optic neuritis (ON) as a clinically isolated syndrome (CIS)

2) Recurrent ON (2 or more clinically distinct episodes)

3) ON in the context of multiple sclerosis (MS)

4) Fellow eyes of ON patients (CIS or MS)

5) Asymptomatic eyes of CPDDS patients without clinical/radiological evidence of ON (MS/non-ophthalmic CIS)

Results:

1) RNFL is significantly lower in eyes following ON as a CIS (88.5um) compared with age matched normal controls (100.5um)

2) In recurrent ON (2 or more episodes)there is a progressive deductive effect (64.4um)which is significantly greater than that seen following a single episode of ON.

3) In ON in the context of MS there is asignificantly greater reduction (72.9um) in RNFL compared to ON in CIS (88.5um)

4) The RNFL thickness in fellow eyes of optic neuritis patients is reduced (96.3um)

5) There is also a reduction in RNFL thickness in pediatric patients without clinical or radiological evidence of ON during their demyelinating episode (94.8um)

Conclusion: Average RNFL thickness at SD-OCT scanning 6 months post pediatric ON is significantly reduced. Recurrent ON compounds previous RNFL loss. Fellow eyes of ON and eyes of MS patients without clinically or radiologically evident ON have reduced RNFL compared to age matched normal controls.

Disclosure: Dr. B. Banwell has received speaker’s honoraria from Merk-Serono, Teva Neuroscience, and Biogen-IDEC. Dr. B Banwell serves as an Editor for Multiple Sclerosis, for which she received no remuneration.

Brain growth rate is reduced in paediatric-onset multiple sclerosis

B. Aubert-Broche, V. Fonov, N. Guizard, B. Banwell, S. Narayanan, D.L. Arnold, D.L. Collins on behalf of the Canadian Pediatric Demyelinating Disease Network

Background: Reduced brain volumes have been previously reported in pediatric-onset MS (pMS) population compared to pediatric normal controls (pNC) in cross-sectional studies.

Objective: To evaluate how brain growth differs between subjects with pMS and pNC using longitudinal data.

Data: 80 MRI scans of 27 patients with relapsing-remitting pMS were acquired on a 1.5T MRI scanner at HSC. Each subject was scanned between 2 and 4 times, with ~1 year between scans. At the first visit, age was 15.31±2.28 years (mean±std) and disease duration was 2.37±2 years. Data for 20 pNC was acquired on the same scanner (2 scans with ~1 year between, age at the first scan=15.9±2 y). A total of 550 scans from 214 subjects from the NIH-funded MRI study of normal brain development (NIHPD) in the same age range (2 or 3 scans per subject, ~2 years between scans) were used to build brain growth models. Brain volume was estimated using BEaST.

Methods: Several mixed effect models were built using NIHPD and pMS groups. The best model was selected using the Akaike criterion. To ensure that there are no scanner effects, a model was also estimated using pNC and NIHPD groups.

Results: The best adjusted model consisted of fixed effects for age (intercept, linear and quadratic terms), sex and the interactions of age with sex and age with group (pMS and NIHPD). It also included random intercept and slope terms to account for within-subject variability. All the fixed effects were significant (p<0.0001) and the resulting mean brain growth models were:

NIHPD females: 1245.28-0.37*Age²+10.64*Age and males: 1308.72-0.37*Age²+15.70*Age

MS females: 1245.28-0.37*Age²+6.77*Age and males: 1308.72-0.37*Age²+11.83*Age.

Conclusion: No significant interaction of group*age was found with the adjusted model fitting brain volumes of pNC and NIHPD groups, indicating that the MRI data acquired at HSC is comparable to the NIHPD data.

As shown in the literature, the NIHPD+pMS model indicates that the brain volumes of males are significantly bigger compared to females (p=0.0005), and they increase at a faster rate (5.06cc/y, p<0.0001).

A significant group*age interaction indicates that pMS and NIHPD subjects have different growth curves, where the pMS brain volumes increase at a slower rate over time than normal healthy brains (p=0.005) with a difference in mean slope of -3.8 cc per year for the same age. These results indicate that there is smaller than expected brain growth in patients with pMS.

Dr Banwell has received Speaker’s Honoraria from Biogen-Idec, Novartis, and Merk-Serono, and serves as an advisor for pediatric trials. None of these activities relate to the present work.

Dr. Narayanan has received personal compensation from NeuroRx Research, Teva Neurosciences Canada and Biogen Idec Canada for consulting services.

Dr. Collins has received personal compensation from NeuroRx Research and Teva Neurosciences Canada.

Dr Aubert-Broche and Mr Guizzard have nothing to disclose.

Dr Fonov has received personal compensation from NeuroRx Research.

Dr. Arnold has served on advisory boards, received speaker honoraria, served as a consultant or received research support from Bayer, Biogen Idec, Coronado Biosciences, Consortium of Multiple Sclerosis Centers, Eli Lilly, EMD Serono, Genentech, Genzyme, GlaxoSmithKline, MS Forum, NeuroRx Research, Novartis, Opexa Therapeutics, Roche, Merck Serono, S.A.,Serono Symposia International Foundation, Teva, the Canadian Institutes of Health Research, and the Multiple Sclerosis Society of Canada; and holds stock in NeuroRx Research.

The funding came from the Canadian Multiple Sclerosis Scientific Research Foundation.

Paediatric multiple sclerosis and vitamin D status

N. Ben Achour, I. Kraoua, H. Touaiti, H. Benrhouma, A. Rouissi, I. Turki, N. Gouider- Khouja

UR 06/11 (Tunis, TN)

Background: Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system (CNS). The mechanisms underlying MS pathobiology remain incompletely understood. However, environmental risk factors are likely operative in this disorder. The increasing recognition of MS in children and adolescents has prompted study of vitamin D status.

Objective: To report the epidemiological, clinical data and vitamin D status in a Tunisian paediatric series of MS.

Methods: Over 7 years (2005-2012), 8 children (6 females, 2 males; mean age: 16 years) were followed in our department for MS. Serum 25-hydroxyvitamin D3 (25(OH)D) levels were measured in all patient. Vitamine D deficiency is defined as 25(OH)D levels less than 10 ng/ ml and vitamine D insufficiency is defined as 25(OH)D levels between 10 and 20 ng/ ml. Epidemiological, clinical data and vitamin D status are discussed.

Results: Five were born in spring and early summer (i.e pregnancy occured in autumn and winter). Three patients had associated type 1 diabetes that preceded the first demyelinating event in all of them. Median age at the initial episode was 13.5 years (range: 5- 17 years). Optic neuritis and pyramidal dysfunction were the most common clinical features. The (25(OH)D) levels were less than 20 ng/ ml in 6 patients (normal range: 25 to 60 ng/ml). We found vitamine D deficiency in 5 patients and vitamin D insufficiency in 1 patient.

Discussion and conclusion: Our results support the hypothesis that abnormal vitamine D status and limited sunlight in childhood are potential risk factors for MS. A lack of vitamin D in utero may explain correlation of MS to birth season (more people with MS being born in the spring). Association with type 1 diabetes in three of our patients support the concept of susceptibility to autoimmune disorders in vitamin D deficiency which require collaborative efforts to develop novel strategies for primary disease prevention.

The authors have nothing to disclose

Early onset multiple sclerosis, a population-based cross-sectional study

J.L. Frederiksen, E.B. Hoegh

Glostrup Hospital (Glostrup, DK)

Objective: The objective of this study was to investigate whether early onset multiple sclerosis (EOMS) differs from adult onset MS (AOMS) in a cross-sectional study of the patient population seen at the Multiple Sclerosis Clinic at Glostrup Hospital, University of Copenhagen.

Materials and methods: Patients with definite multiple sclerosis (MS) according to the Poser or McDonald criteria were selected from a cross-sectional population-based MS database of patients seen at the Multiple Sclerosis Clinic at Glostrup Hospital, University of Copenhagen, Denmark. Onset age distribution and clinical course were analysed, and afterwards demographic, clinical and paraclinical parameters were investigated for the patients having a relapsing-remitting course (RRMS) from onset.

Results and conclusions: 1035 patients were included. EOMS (onset age < 20 years) comprised 6.1%, the youngest 9 years at onset. Only two EOMS patients, both 19 years of age, had a primary progressive course (PPC). The progression of disability was significantly slower in EOMS; the time from onset until Extended Disability Status Scale (EDSS) score 6 was expected being 32 years against 12 years in AOMS. Further, EOMS patients waited significantly longer from onset of symptoms until a diagnosis of definite MS was reached. One may speculate if the diagnosis of MS is delayed in patients with EOMS compared to patients with AOMS, due to too little awareness of symptoms and signs, which presence may enable to make the diagnosis of MS earlier and to treat earlier.

The authors have nothing to disclose.

Support for the relapse disability paradox: higher relapse rates persist in paediatric compared to adult onset multiple sclerosis at six year follow-up

L. Benson, B. Healy, M. Gorman, N. Baruch, T. Gholipour, A. Musallam, T. Chitnis

Children’s Hospital Boston (Boston, US); Brigham and Women’s Hospital (Boston, US); Massachusetts General Hospital (Boston, US)

Objective: To compare relapse rates in pediatric onset multiple sclerosis (POMS) and adult onset multiple sclerosis (AOMS) over the first 6 years of the disease.

Background/Intro: The course of POMS and its relationship to AOMS are important both for understanding and for treating the disease.

Methods: POMS patients, with disease onset before their 18th birthday, were identified from the Massachusetts General Hospital Pediatric MS Center, Boston and the Partners MS Center, Brigham and Women’s Hospital, Boston (n=80). Data was prospectively gathered. AOMS patients were identified from the Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham (CLIMB) study at the Partners MS Center (n=263). Only patients with a relapsing remitting disease onset were included. The annualized relapse rate (ARR) for each individual year from year 1 to year 6 after disease onset and in three groups of years (1-3, 4-6 and 1-6) was compared between POMS and AOMS using Poisson regression. In addition, the expanded disability status scale (EDSS) score at the visit closest to each year interval was compared in the two groups using a Wilcoxon test.

Results: The ARR was significantly higher in the POMS compared to the AOMS groups for all individual years and groups of years (p<0.05). The risk ratio comparing the two groups was over 2 for all comparisons except year 4. Adjustment for gender, race and proportion of time on treatment, did not change the risk ratios and p-values except the difference between the groups at year 4 was no longer statistically significant. Despite the difference in ARR in the POMS and AOMS patients, no significant difference in the EDSS score was observed between the groups. In the POMS patients, age, gender, race and ADEM at onset did not have an effect on ARR or time to the second event (p>0.1 for all tests). There was no significant effect of relapse rate in the first 3 years on disability at year 5 in the pediatric patients.

Conclusions: Our findings are in line with prior studies demonstrating higher relapse rates in POMS relative to AOMS early in the disease. Despite a 2.42 times higher relapse rate over 6 years, EDSS between groups did not differ. This data can be applied when designing trials of disease modifying therapies for POMS and supports a potential disconnect between relapse rate and disability early in the disease course.

Dr. Leslie Benson received support from the US National MS Society, New England Chapter, for a Clinical Care Fellowship during the completion of this study.

Dr. Brian Healy recieves grant support from Merck Serono for work on the CLIMB study at Partners MS Center.

Mark Gorman, Natalie Baruch and Alexander Musallam, do not have any disclosures.

Taha Gholipour receives grant support from Merck Serono for work on the CLIMB study at Partners MS Center.

Dr. Chitnis recieves grant support from Merck Serono for work on the CLIMB study at Partners MS Center, has done consulting work for Biogen, Teva and Novartis and received support from the National MS Society - Regional Pediatric MS Centers of Excellence Award.

Natalizumab in paediatric multiple sclerosis: long-term results of 55 cases

A. Ghezzi, C. Pozzilli, L. Moiola, V. Brescia Morra, L.M.E. Grimaldi, G. Lus, F. Rinaldi, M. A. Rocca, M. Trojano, A. Bianchi, M. Filippi, G. Comi (also participated F. Bortolon, R. Capra, G. Coniglio, C. Gasperini, N. Milani, A. Lugaresi, L. Provinciali, E. Pucci, M.R. Rottoli, P. Sarchielli)

Background and Objectives: the treatment with Natalizumab (NA) can be an option in active pediatric MS patient (1,2). We describe the long term effect of NA in a large cohort of active pediatric MS patients.

Methods: Patients with definite MS before 18 years of age were treated with NA 300 mg every 28 days if they had had: a) at least two relapses in the previous two years or a severe relapse with incomplete recovery, during the immunomodulating treatment or b) an active disease evolution (at least two relapses in the last year and new T2 or gadolinium (Gd) enhancing lesions on brain MRI) without any prior treatment.

Fifty-five subjects were included (mean age=14.4 ± 2.6 years, mean number of attacks= 4.4 ± 2.4 during the pre-treatment phase of 25.5 ± 19.2 months, mean pre-treatment EDSS=2.7 ± 1.2 (range 1.0-6.5). After treatment initiation, patients were reassessed clinically every month; brain MRI was performed at baseline and every six months.

Results: Patients received a mean number of 23.5 ± 12.7 infusions, 30 subjects were treated for 24 months or more, receiving a mean of 32.9 infusions. In the whole group, three relapses occurred during the follow up. One girl continued to deteriorate in cognitive functioning. The mean EDSS decreased from 2.7 to 1.9 at the last visit (p< 0.001). EDSS decreased by at least 0.5 point in 7 cases, and by at least 1 point in 13 cases, by 1.5 or more in 18 cases, and increased by 0.5 in 3 cases. At baseline, 45 subjects showed Gd-enhancing lesions (mean number 4.5, range=1-25). During the follow up 35/55 (65%) patients remained free from MRI activity. Transient and mild clinical adverse events which resoleved spontaneously occurred in 20 patients, mild haematological abnormalities occurred in 7 cases. Anti-JCV antibodies were detected in 19/50 subjects (38 %)

Conclusions: This study provided class IV evidence that NA is effective and well tolerated in pediatric MS with active disease. A strong suppression of disease activity was observed in the large majority of subjects during the whole follow up duration.

References: 1-Yeh EA.& Weinstock-Guttman B. Ther. Adv. Neurol. Disord. 2010, 3:293 2-Ghezzi A. et al.Neurology. 2010, 75:912.

Dr. Ghezzi has served on scientific advisory boards for Merck Serono, Biogen Idec Teva Pharmaceutical Industries Ltd.; has received speaker honoraria from Merck Serono, Biogen Idec, Bayer Schering Pharma, and Novartis, Serono Symposia International; served as a consultant for Novartis; and receives research support from Sanofi-Aventis, Biogen Idec, and Merck Serono.

Prof. Pozzilli has served on scientific advisory boards for and has received speaker honoraria from Novartis, Merck Serono, Biogen Idec, Bayer Schering Pharma, and Sanofi-Aventis.

Dr. Moiola has received support to participate in National and International Congresses from Biogen-Dompè AG, Bayer Schering Pharma, Merck Serono, and Sanofi-Aventis.

Dr. Brescia-Morra has received funding for travel, speaker honoraria, and research support from Sanofi-Aventis, Bayer Schering Pharma, Merck Serono, and Biogen-Dompé AG.

Dr. Grimaldi has served on a scientific advisory board for Merck Serono; has received funding for travel or speaker honoraria from Merck Serono, Biogen Idec, Sanofi-Aventis, Bayer Schering Pharma, and Solvay Pharmaceuticals, Inc.; has received institutional research support from Teva Pharmaceutical Industries Ltd, Biogen Idec, Genzyme Corporation, sanofi-aventis, Merck Serono, Novartis, and Eisai Inc.; and has received research support from Merck Serono, Biogen Idec, and Ministero della Salute.

Dr. Lus has received speaker honoraria from Novartis,Sanofi-Aventis and and receives research support from Novartis, Sanofi-Aventis, Bayer Schering, Pharma, Biogen Idech.

Dr. Rinaldi reports no disclosures.

Dr. Rocca has serveed as consultant to Bayer Schering Pharma; received speakers’ bureaus for Biogen-Dompé and receives research support from Italian Ministry of Health.

Prof. Trojano has received speaker honoraria from Merck Serono, Sanofi-Aventis, Biogen Idec, Bayer Schering Pharma; has received research support from Merck Serono and Biogen Idec.

Dr. Bianchi reports no disclosures.

Prof. Filippi serves on scientific advisory boards for Teva Pharmaceutical Industries Ltd. and Genmab A/S; has received funding for travel from Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, and Teva Pharmaceutical Industries Ltd.; serves on editorial boards of the American Journal of Neuroradiology, BMC Musculoskeletal Disorders, Clinical Neurology and Neurosurgery, Erciyes Medical Journal, Journal of Neuroimaging, Journal of Neurovirology, The Lancet Neurology, Magnetic Resonance Imaging, Multiple Sclerosis, and Neurological Sciences; serves as a consultant to Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, and Teva Pharmaceutical Industries Ltd.; serves on speakers’ bureaus for Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, and Teva Pharmaceutical Industries Ltd.; and receives research support from Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, Teva Pharmaceutical Industries Ltd. and Fondazione Italiana Sclerosi Multipla.

Prof. Comi has served on scientific advisory boards for Bayer Schering Pharma, Merck Serono, Teva Pharmaceutical Industries Ltd., sanofi-aventis, Novartis, and Biogen Idec; has received speaker honoraria from Teva Pharmaceutical Industries Ltd., Sanofi-Aventis, Serono Symposia International, Foundation, Biogen Idec, Merck Serono, Novartis, and Bayer Schering Pharma.

Psychological distress in parents of children with multiple sclerosis

M. Messmer Uccelli, S. Traversa, M. Trojano, R.G. Viterbo, A. Ghezzi, A. Signori

Italian Multiple Sclerosis Society (Genoa, IT); University of Bari Multiple Sclerosis Center (Bari, IT); Gallarate Hospital MS Center (Gallarate, IT); University of Genoa (Genoa, IT)

Background: The onset of MS before the age of 16 is estimated to occur in 4.4 to 5% of cases. Over the long-term, paediatric MS patients can become disabled younger, thus, living more years with neurologic impairment. Children with MS demonstrate impairment in school activities and in family and social relationships. The psychosocial consequences for parents of children with MS have not been studied. Literature from other conditions report that having a chronically ill child can impact family functioning and the couple relationship, be a source of depression and anxiety and put parents at risk for impaired quality of life.

Objectives: To assess aspects of family functioning and individual states of distress in couples with a child with MS compared to couples of healthy children.

Methods: Fifteen couples with a child with MS and 29 couples with healthy children were assessed using self-administered scales on anxiety, depression, coping, marital and family aspects, quality of life and MS knowledge.

Results: MS parents scored significantly higher on the scale for depression and anxiety (HADS) (p=0.003) than control parents and scored significantly lower on the PSOC, a scale that measures a parent’s sense of competence and parenting satisfaction (p<0.001). MS mothers were significantly more worried than MS fathers (p=0.033). Less knowledge of MS was correlated with lower satisfaction in three areas: the couple relationship (r=0.43, p=0.022), the quality of communication (r=0.48, p=0.009) and conflict resolution (r=0.36, p=0.05).

Conclusions: Adequate and ongoing education and information has been demonstrated to be one of the most important factors protecting the couple relationship, and can improve anxiety, depression, quality of life, reduce a sense of fear that many parents experience and can facilitate successful coping. Lack of information about MS can impact family functioning, anxiety and parents’ sense of competency. Parents require support in becoming more knowledgeable about MS in order to feel competent and satisfied in their role and less anxious about their child’s condition.

A. Signori, M. Messmer Uccelli and S. Traversa have nothing to disclose.

M. Trojano received honoraria for consultancy or speaking from Biogen, Sanofi-Aventis, Merck Serono and Bayer-Schering and research grants from Merck Serono, Biogen and Novartis.

R.G. Viterbo serves on scientific advisory boards for Biogen-Idec and received honoraria for speaking from Novartis and Biogen.

A. Ghezzi received honoraria for speaking from Bayer-Schering, Biogen-Dompè, Merck-Serono, Novartis, Sanofi-Aventis, Allergan, for consultancy from Actelion, Merck-Serono, Teva and Novartis, received support for participation at national and international conferences from Bayer-Schering, Biogen-Dompè, Merck-Serono, Novartis, Sanofi-Aventis.

Natalizumab therapy in active paediatric multiple sclerosis

B. Kornek, F. Aboul-Enein, I.-R. Milos, I. Steiner, K. Rostasy, J. Penzien, K. Hellwig, K. Pitarokoili, K. Storm van’s Gravesande, M. Karenfort, A. Blaschek, A. Meyer, D. Debelic, R. Seidl, D. Prayer, K. Vass, W. Kristoferitsch, A. Bayas

Medical University (Vienna, AT); Donauspital (Vienna, AT); Medical University (Innsbruck, AT); Children’s Hospital Klinikum (Augsburg, DE); Ruhr University Bochum (Bochum, DE); Preyer’s Children’s Hospital (Vienna, AT); Heinrich Heine University (Düsseldorf, DE); Ludwig-Maximilians University (Munich, DE); ZfP Südwürttemberg (Ravensburg, DE); Klinikum Mistelbach-Gaenserndorf (Mistelbach, AT); Medical University of Vienna (Vienna, AT); Karl Landsteiner Institute (Vienna, AT); Klinikum Augsburg (Augsburg, DE)

Objective: To determine the safety, tolerability and efficacy of natalizumab in pediatric multiple sclerosis.

Design, setting and patients: We performed a retrospective analysis of 20 patients treated with natalizumab for active relapsing-remitting multiple sclerosis (mean age 16.7 ± 1.1 years, mean number of attacks 4.3 ± 1.3 during the pretreatment period of 1.5 ± 0.8 years, median pretreatment EDSS 2 (0-4)).

Intervention: Natalizumab was administered every 4 weeks at a dosage of 300mg.

Main outcome measure: Relapse rate, EDSS and magnetic resonance imaging findings before treatment onset and during treatment with natalizumab were recorded. Adverse events, the frequency of neutralizing antibodies and JCV-antibody status were determined.

Results: During natalizumab therapy 14 out of 20 patients remained free from relapse activity during a mean treatment period of 1.8 ± 1 years (range 0.4-3.5). The EDSS remained stable in 10 patients, improved in 9 patients und increased in one patient. Contrast-enhancing lesions did not occur during natalizumab therapy. On the last follow-up 12 patients were still on natalizumab therapy. Reasons for discontinuation in the remaining 8 patients were seropositivity for JC-virus (n=3), neutralizing antibodies against natalizumab (n=2), asthenia (n=1), and patients wish (n=2). The following adverse events were recorded: headache (n=4), asthenia (n=4), upper respiratory tract infection (n=3), urinary tract infection (n=3), larynxedema (n=1), orchitis (n=1). Laboratory abnormalities occurred in 7 patients. Data on following treatments are provided.

Conclusions: Our data provide further evidence for the efficacy of natalizumab in pediatric multiple sclerosis. In contrast to former reports on pediatric multiple sclerosis patients adverse events occurred more frequently in our cohort.

B. Kornek, K. Rostasy, K. Hellwig, K. Storm van’s Gravesande, A. Blaschek, K. Vass, W. Kristoferitsch, and A. Bayas received speaking honoraria and participated in an advisory boards from Biogen Idec, Merck Serono, Teva, Novartis and Bayer Schering.

F. Aboul-Enein, I. Milos, I. Steiner, D. Prayer, K. Pitarokoili, M. Karenfort, J. Penzien, R. Seidl and A. Meyer have nothing to disclose.

Cognitive relapse in the absence of new neurological symptoms: clinical utility of neuropsychological assessment in a case with juvenile multiple sclerosis

I.K. Penner, M. Hubacher, M. Rasenack, T. Sprenger, P. Weber, Y. Naegelin

University of Basel (Basel, CH); University Hospital of Basel (Basel, CH); University Childrens’ Hospital of Basel (Basel, CH)

Background: There is growing awareness about childhood onset multiple sclerosis (MS) and the relevance of psychosocial aspects such as cognitive functioning, fatigue and depression in this population.

Objectives: To highlight the clinical utility of neuropsychological testing in juvenile MS. Methods: A 16-year-old patient with relapsing-remitting multiple sclerosis presented at our clinic with severe fatigue. A neuropsychological examination was performed including quality of life instruments, depression and fatigue scales as well as several tests for cognitive functioning and intelligence.

Results: While fatigue and quality of life (QoL) values were clearly abnormal, no pathological findings were detectable in the cognitive domains. We re-examined the boy two weeks later. At this follow-up visit he reported to not feel well and to have minor balance problems. His neuropsychological profile revealed a statistically meaningful change in the performance of the alertness test, indicating severe slowing. In addition, fatigue and depression symptoms worsened compared to baseline. The cognitive slowing combined with the self-report of not feeling well and extreme exhaustion prompted a neurological referral and MRI scan of the brain. The EDSS was stable at 3.0 and no contrast enhancing lesions were detectable. However, three new T2 hyperintense lesions were found. Due to the acute change in alertness performance, the obvious subjective feeling of not being well and minor balance problems, we decided to consider the new symptoms as a clinically meaningful relapse and treated the patient with a three-day course of intravenous methylprednisolone. Three weeks later, the EDSS proved to be stable and the patient reported a subjective improvement of his physical and mental condition. This was confirmed by disappearance of balance problems and by stabilization of his cognitive profile after four weeks. However, alertness remained below baseline and was not yet back to normal after an additional follow-up period of three months.

Conclusion: Processing speed seems to be one of the most vulnerable and sensitive cognitive domains in paediatric MS. It is important to note that recovery after a cognitive relapse can take more than three months. The case suggests that neuropsychological testing in children and adolescents with MS is of utility in order to guide treatment decisions.

IK Penner has received research grants from Bayer AG Switzerland and the Swiss Multiple Sclerosis Society; has received honoraria forserving as speaker at scientific meetings, consultant, and as member of scientific advisory boards for Actelion, Bayer Pharma AG, Biogen Idec, Merck Serono, Roche, and Teva Aventis.

M Hubacher, M Rasenack, P Weber and Y Naegelin have nothing to disclose.

T. Sprenger served onadvisory boards for Mitsubishi Pharma, Eli Lilly, Biogen and Allergan. He received travel supportfrom Pfizer, Bayer Schering, Eli Lilly and Allergan.

Quality of life in paediatric and juvenile multiple sclerosis and its clinical correlations

R. Lanzillo, V. Magri, A. Napolitano, R. Liuzzi, G. Vacca, M. Ottobre, A. Filla, P. Valerio, A. Chiodi, V. Brescia Morra

Federico II University (Naples, IT)

Background: Quality of life (QoL) is a significant concern in multiple sclerosis (MS) but little is known about its clinical correlations in pediatric and juvenile MS.

Objectives: The present investigation aims to assess the relations between QoL and clinical factors in pediatric and juvenile MS.

We included 32 patients and QoL was self assessed by PedsQL Quality of Life Scale in two version, one for 13-18 years old patients and one for 19-25 years old patients. We recorded data on disease onset and diagnosis, EDSS was assessed and MSSS calculated. Associations between self -reported difficulties and clinical factors were examined via Spearman correlation analyses.

Results:Our patients were equally distributed in males and females (16/16) with a median age of 21 years (14-25), a median disease onset age of 18 years (13-24, a median EDSS of 2,5 (1,5-4,5) and median MSSS of 5,65 (1,89-9,09).Patients were all on Disease Modifing Therapies (21 on IFN β, 8 on Natalizumab and 3 on Fingolimod) al time of test administration. Median total score at PedsQoL scale was 29 (2-72). The most affected domain was the Emotional Functioning, while the more evident difficulties were low energies, fear of what will happen, memory problems and missing school or work for going to hospital or to doctors clinics.The total score related with the MSSS(p=0.007) and tended to inversely relate with younger age at onset (p=0.06). Emotional functioning related to MSSS and onset age (p=0,01) and inversely to disease duration (p=0,03). School or work functioning was related to MSSS and inversely to disease duration (p=0,03).

Conclusions: These data indicate that the QoL and its emotional aspects in pediatric and juvenile patients are affected most of all by the rapidity of achieving disability and by poor adaptation to disability status itself. Fatigue, memory problems and emotional aspects related to concern for their future are the most reported difficulties in juvenile MS. Younger onset age and longer disease durations are related to better emotional functioning.

A pediatric onset of MS might predict a better adaptation to a chronic pathology throughout life.

Roberta Lanzillo has received honoraries from Bayer Shering, Biogen, Merck-Serono and Novartis for lectures or scientific boards.

Raffaele Liuzzi, Valeria Magri, Anna Napolitano, Alessandro chiiodi, Paolo Valerio, alessandro Filla have nothing to disclose.

Giovanni Vacca has received honoraries from Bayer Shering for lectures or scientific boards.

Marianna Ottobre has received research grants from Novartis.

Vincenzo Brescia Morra has received honoraries from Bayer Shering, Biogen, Merck-Serono, TEVA, Aventis and Novartis for lectures or scientific boards.

Disability progression in multiple sclerosis is faster than observed

M.G. Brown, S. Kirby, M. Asbridge, R. McKelvey, T.J. Murray, L. Lethbridge, P. Andreou for the Dalhousie MS Research Group

Background: When modeling MS disability progression speed from incomplete observational data, analysts must make assumptions about when irreversible progression occurs. Progression speed estimates are sensitive to these assumptions.

Objective: To demonstrate the effect of three alternative censoring bias assumptions on estimates of progression speed. Study design: A population-based observational study.

Study population: Group A includes 976 Nova Scotia MS patients who had 4,344 EDSS clinic visit observations while receiving regular care in period Feb1979-July1998. Group B is a subgroup of 670 patients with at least two observations per patient, totaling 4,038.

Methods: Three censoring bias assumptions are examined. Analysts may assume that censoring bias is sufficiently small to ignore. A Kaplan-Meier model assumes maximum survival times, a common assumption when analyzing incomplete experimental data collected prospectively at frequent and regular intervals. A Golden Mean model assumes mid-way survival times, which is arguably a more appropriate assumption when analyzing incomplete observational data previously collected at infrequent and irregular intervals. Progression speed, as measured by rate of change, is estimated first from unadjusted observations and then from Golden Mean adjusted observations. Progression speed, as measured by survival distribution functions for irreversible disability endpoints, is estimated first using Kaplan-Meir censoring bias assumptions and then using Golden Mean censoring bias assumptions.

Results: MS disability progression speed, as measured by rate of change in range EDSS 0 to 6, is 38% faster when estimated using Golden Mean censoring bias assumptions rather than assuming that censoring bias may be ignored. Progression speed, as measured by median survival time at EDSS 3, is 37% slower (signifying faster progression) when estimated using Golden Mean censoring bias assumptions rather than Kaplan-Meier assumptions. The sensitivity of progression speed estimates to censoring bias assumptions is greater at less severe disability endpoints.

Conclusions: Progression speed estimates from observational data are sensitive to censoring bias assumptions. Estimates of MS disability progression natural history speed using Golden Mean model assumptions of mid-way survival times are faster, and arguably more relevant, than estimates using Kaplan-Meier model assumptions of maximum survival times.

The authors have nothing to disclose.

Predictors of disease progression in a large cohort of primary-progressive MS

J.-P. Stellmann, A. Neuhaus, C. Lederer, M. Daumer, C. Heesen

Institute for Neuroimmunology and Clinical Multiple Sclerosis Research (Hamburg, DE); Sylvia Lawry Centre for Multiple Sclerosis Research (Munich, DE)

Background: Primary-progressive Multiple Sclerosis (PPMS) is understood as the MS disease course with the highest neurodegenerative impact on disability progression. Identification of patients with a high short-term risk for disease progression may help to develop neuroprotective treatment designs. Till now, studies in PPMS used change of EDSS as endpoint. Within different cohort studies age at onset, gender, type of first symptoms and early EDSS changes were identified as predictors of disability progression measured by EDSS. These are yet insufficiently confirmed.

Objective: To analyse the impact of published predictors on EDSS disease progression in a large cohort of PPMS patients.

Methods: Individual case data from the Sylvia Lawry Centre (SLC) and the Hamburg MS patient database (HAPIMS) were pooled for a retrospective analysis of age at onset, gender, type of first symptoms and early EDSS changes on the annualized EDSS change (δ-EDSS). Beside descriptive statistics we performed Spearman’s rank correlations (r) and the Wilcoxon rank-sum test.

Results: 597 PPMS patients (54% female) with 2503 EDSS assessments had a mean follow-up of 4.4 years and mean worsening of EDSS (δ-EDSS) of 0.35. Age at onset was not correlated with δ-EDSS (r = -0.0359, p=0.4508). Groups split by gender or type of first symptoms did not differ in δ-EDSS (p=0.1996 and p=0.2418). There was no significant correlation between δ-EDSS in the first two years and δ-EDSS after the first two years (r= -0.0445, p=0.6536). Results did not differ for pooled dataset or each single cohort (SLC or HAPIMS).

Conclusion: None of the analysed variables were predictive for the disease progression measured by the annualized EDSS change. Whether disease progression in PPMS is still unpredictable or whether our results may be due to limitations of the EDSS cannot be answered. Future prospective studies with new endpoints are needed.

Christoph Heesen and Jan-Patrick Stellmann have received payment for lectures as well as travel/accommodation/meeting expenses from Bayer Healthcare, Merck-Serono, Novartis, BiogenIdec and Teva as well as Sanofi-Aventis. M. Daumer Scientific Director of the Sylvia Lawry Centre for Multiple Sclerosis Research e.V. and Managing Director of Trium Analysis Online GmbH, serves on the Editorial Board of /MedNous/ and holds Patent 102007 044 705.3-35, German patent and trade mark office 307 19 449.3/09. The Sylvia Lawry Centre received funding for travel from ECTRIMS, served on the advisory board for EPOSA study and as consultant for Biopartners; and received research grants from the following governmental entities: BMBF, FKZ 01Gl0920 (2009-2012);BMBF, FKZ 01Gl0904 (2009-2012); EU FP7, FP7-223865 (2008-2012); EU FP7, 215820-2 (2008-2012); Hertie Foundation Grant No: 101107011; Porticus Foundation Grant No 900.50578. Anneke Neuhaus has nothing to disclose.

Monocentric long-term follow-up of a cohort of patients with clinically isolated syndrome: descriptive data at baseline

N. Moll, I. Malikova, A. Rico, L. Crespy, A. Faivre, E. Robinet, L. Durante, D. Wybrecht, F. Reuter, W. Zaaraoui, P. Cozzone, J.-P. Ranjeva, B. Audoin, J. Pelletier

CHU Timone (Marseille, FR)

Background: There is an apparent need for longitudinal research assessing a complex of clinical and paraclinical parameters in CIS to identify reliable predictors of clinical outcome and long-term disability.

Objective: To set up a protocol of long-term follow-up of a cohort of CIS patients that consists of 1) clinical neurological evaluation, 2) MRI of the brain and spinal cord, 3) neuropsychological and 4) quality of life assessments.

Material & methods: 200 CIS patients were enrolled in the study in the period between 2000 and 2012 and followed up after 1, 3, 5, 7 and 10 years in our department of neurology. The inclusion criteria were as follows: (1) aged between 18 and 50 years; (2) occurrence of a first presumed inflammatory demyelinating event in the central nervous system (CNS) involving the optic nerve, the spinal cord, the cerebral hemisphere or the brainstem; (3) no previous history of neurological signs suggestive of demyelination; (4) exclusion of alternative diagnoses; (5) presence of oligoclonal bands in the cerebrospinal fluid; and (6) presence of ≥2 lesions located in the CNS on initial MRIs. Clinical evaluation consisted of expanded disability status score (EDSS) and Multiple Sclerosis Functional Composite (MSFC) score. MRI was performed at baseline and after 1, 3, 5, 7 and 10 years on a 1.5T scanner (Siemens). Neuropsychological evaluation was performed at each time point. MusiQoL questionnaire was used to evaluate patient’s quality of life.

Results: The studied cohort of 200 CIS patients consisted of 154 females and 46 males (M/F=1/3.3), age 37.4±7.7 years, age at baseline 30.5±7.2 years. The patients were followed-up after a mean of 6.4±3.4 years. Mean EDSS at baseline was 0.95±0.8 (0-4). Monofocal CIS presentation was observed in 92% of patients. First clinical episodes were characterized as acute myelitis (44%), brainstem syndromes (20%), optic neuritis (18.4%) or hemispheric lesion signs (9.5%). Simultaneous occurrence of optic neuritis and acute myelitis was found in 3.7%, brainstem syndromes and acute myelitis in 2.2%, optic neuritis and brainstem syndromes in 1.5% and optic neuritis and hemispheric signs in 0.7% of all studied patients.

Conclusions: This protocol is designed to determine early predictors (clinical, neuropsychological and MRI) of MS evolution. Our preliminary clinical and demographic analysis is in agreement with previously published data.

Fundings: This study was supported by grants from the Association pour la Recherche sur la Sclerose En Plaques (ARSEP) Fondation, CNRS, and unconditional grants from Merck Serono France, Bayer Schering France, Biogen Idec France, Sanofi Aventis France.

Natalia Moll, Irina Malikova, Audrey Rico, Lydie Crespy, Anthony Faivre, Emmanuelle Robinet, Laurence Durante, Delphine Wybrecht, Françoise Reuter, Waafa Zaaraoui, Patrick Cozzone, Jean Philippe Ranjeva, Bertrand Audoin have nothing to disclose.

Jean Pelletier received compensation for scientific advisory boards and steering committees for trials conducted by Merck Serono, Bayer Schering, Biogen Idec, Sanofi, Teva Neuroscience, and Novartis Pharma.

Cognitive reserve and symptom experience in multiple sclerosis: a buffer to disability progression over time?

B.R. Quaranto, B.C. Healy, T.L. Vollmer, R.H.B. Benedict, C.E. Schwartz

ΔQuest Foundation, Inc. (Concord, US); Harvard Medical School (Boston, US); University of Colorado Denver (Denver, US); University of Buffalo (Buffalo, US); Tufts University Medical School (Boston, US)

Objective: Research in MS has documented that enhanced cognitive reserve (CR) is associated with better health and well-being. Passive and active CR reflect past and current enrichment activities, respectively. This study investigated the relationship between CR and current and longitudinal symptom experience; and course of disease.

Methods: Secondary analysis of longitudinal data (n=860) from the North American Research Committee on MS registry (NARCOMS).

Measures: Passive CR: Sole-Padulles Childhood Enrichment Measure. Active CR: Stern Leisure Activities Measure of cultural, social, and physical enrichment activities. Outcomes: Symptom Inventory (SI) and Performance Scales (PS) measures collected bi-annually over 1 and 5 years, respectively.

Analyses: T-tests compared current SI means by CR median-split groupings. Linear regression compared PS trajectory scores by CR. Classification and Regression Tree (CART) modeling compared Stern item endorsement for mild, moderate and severe disability groups to address potential confounding between disability and active CR. Chi-squared analysis evaluated the association between CR and course of disease (Relapsing-Remitting (RRMS), Primary Progressive (PPMS), and Secondary Progressive (SPMS)).

Results: High-Active CR patients had lower levels of current symptoms than Low-Active and high- or low-passive CR patients (p<0.001). Among patients whose PS trajectories changed over time, active CR was associated with less deterioration (p<0.05) and passive CR was unrelated. CART analysis revealed that active CR scores across disability groups had a similar range but was comprised of different items for mild, moderate and severe disability groups, suggesting that patients maintain active CR with different activities as the disease progresses. CR grouping was associated with course of disease (x²=16.4, p<0.02), such that High Active (regardless of passive CR level) patients were over-represented among RRMS patients, and under-represented among SPMS patients. In contrast, Low Active Low Passive patients were under-represented among RRMS patients, but over-represented among PPMS and SPMS patients.

Conclusions: Our findings suggest that active CR is a buffer for functional limitation across disability groupings. This preliminary evidence generates hypotheses that high active CR provides a longer “runway” until disability accrual through cortical remodeling. CR may provide an alternative lens for thinking about MS course of disease.

The authors have nothing to disclose.

Impact of menopause on disease course in women with multiple sclerosis: a pilot study

R. Bove, A. Musallam, B. C. Healy, B. Glanz, M. Houtchens, P.L. De Jager, T. Chitnis

Partners Multiple Sclerosis Center, Brigham and Women’s Hospital (Boston, US)

Background: While menopause influences the incidence and course of other neurologic and autoimmune diseases, its impact on multiple sclerosis (MS) remains understudied. Retrospective studies have suggested patient-reported worsening of symptoms at menopause, but limited prospective data on clinical outcomes exist.

Goals: In this pilot study, we sought to characterize age at natural menopause (ANM) in women with MS, and to determine whether the menopausal transition is associated with changes in prospectively collected Expanded Disability Status Scale (EDSS) scores.

Methods: A questionnaire assessing women’s reproductive history was obtained from 133 women aged 20-75 treated at a large regional Northeastern United States MS referral center. Median ANM was estimated, from reported date of final menstrual period (FMP) for postmenopausal women, using survival analysis appropriate for left- and right- censored data. Then, to assess whether menopause led to a change in the rate of progression over time, EDSS scores were examined using a piecewise linear mixed model for a subset of women enrolled in a detailed prospective study (CLIMB).

Results: Respondents had a mean (SD) age of 45.8 (11.0). Median age at menarche for all women was 12, and 60% reported ever use of hormonal contraception. Reproductive status was as follows: 51% menstruating, 6% perimenopausal and 43% postmenopausal (following surgery in 15% and chemotherapy in 5%).

For women with natural menopause, median age of FMP was 50.7, with women reporting an average of 1.5 pregnancies (range 0-7) and 1.2 live births (range 0-4). Of all postmenopausal women, 44% reported use of hormone replacement therapies.

In our primary longitudinal analysis that included a random intercept and slope, change in EDSS significantly worsened after menopause (p=0.02, N=23); this remained significant when patients with pre- and post-menopausal measurements were included (p=0.005). In secondary analyses where an additional random effect was included for the post-menopausal change, the change in the slope after menopause was no longer statistically significant (p=0.11).

Conclusions: We found a significant effect of menopause on slope of EDSS change in our primary analysis, along with variable results when an alternative model was used, suggesting that larger prospective studies are warranted to clarify the role of menopause, and exogenous hormonal exposures, on the course of MS.

Dr. Bove reports no disclosures.

Mr. Musallam reports no disclosures.

Dr. Healy has received research support from Merck Serono.

Dr. Glanz has received research support from Merck Serono.

Dr. Houtchens served as a consultant for Biogen-Idec, Novartis, Accorda Therapeutics and Teva Neurosciences.

Dr. De Jager has served as a consultant for Teva Neurosciences and Biogen-Idec.

Dr. Chitnis has served as a consultant for Biogen-Idec, Sanofi Aventis, Novartis, EMD-Serono, and Teva Neurosciences, and has received grant support from Merck-Serono for unrelated activities.

The authors confirm that there are no conflicts of interest.

Temporal trends in the prevalence of co-morbidity in MS

R.A. Marrie, N. Yu, S. Leung, L. Elliott, P. Caetano, S. Warren, C. Wolfson, S. Patten, L. Svenson, J. Fisk, J. Blanchard, H. Tremlett on behalf of the CIHR Team in the Epidemiology and Impact of Comorbidity on MS

Background: Despite evidence of the importance of comorbidity on outcomes in multiple sclerosis (MS), few validated methods for their assessment exist. Comorbidity is of increasing importance for understanding the potential risks of disease-modifying therapies, but little is known about the prevalence of physical comorbidities in MS and how or if their prevalence are changing over time.

Objective: To first validate and apply administrative (health claims data) case definitions to identify a broad range of comorbidities and then to examine temporal trends in their prevalence for persons with MS.

Methods: A validated algorithm for administrative data was used to identify all persons with MS in the province of Manitoba, Canada. Comorbidity definitions were derived using hospital, physician and prescription claims, and were validated against medical records in 420 persons with MS for the following: autoimmune thyroid disease, psoriasis, inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), fibromyalgia, chronic lung disease, migraine and epilepsy. We then applied these definitions to evaluate temporal trends in the age-adjusted prevalence of these conditions from 1984-2005.

Results: When compared to medical records, administrative case definitions showed substantial agreement for thyroid disease, (κ [κ]=0.75); moderate agreement for psoriasis (κ =0.48), fibromyalgia (κ =0.48), lung disease (κ=0.41), migraine (κ =0.51), and epilepsy (κ =0.44). Agreement was fair for IBS (κ =0.36) and could not be calculated for IBD due to small sample size. The age-adjusted prevalence of thyroid disease was 1.6% in 1984 and 9.5% in 2005. Prevalence of the other comorbidities (in 1984 and 2005) was: psoriasis 0.3% and 3.5%; fibromyalgia 3.2% and 6.8%; chronic lung disease 0.7% and 15.6%; migraine 1.1% and 23.0%; IBS 4.5% and 12.2%; IBD 0.1% and 0.8%. The prevalence of epilepsy was 1.8% in 1996 and 4.0% in 2005. Some of the increased prevalence after 1996 reflected the availability of prescription claims which improved sensitivity of case definitions, but this did not entirely explain the observed increases.

Conclusion: Administrative data are a valid means of tracking temporal trends in the prevalence of thyroid disease, psoriasis, fibromyalgia, chronic lung disease, migraine and epilepsy in MS, but are not optimal for IBS. Physical comorbidities are common in MS, and their prevalence is increasing.

This study was funded in part by the Multiple Sclerosis Society of Canada, Canadian Institutes of Health Research,and Rx & D Health Research Foundation.

Ruth Ann Marrie receives research funding from: Canadian Institutes of Health Research, Public Health Agency of Canada, Manitoba Health Research Council, Health Sciences Centre Foundation, Multiple Sclerosis Society of Canada, Multiple Sclerosis Scientific Foundation, Rx & D Health Research Foundation, and has conducted clinical trials funded by Bayer Inc. and Sanofi-Aventis.

Nancy Yu receives research support from the Canadian International Development Agency, the Multiple Sclerosis Society of Canada, CIHR, and Manitoba Health and Healthy Living.

Stella Leung reports no disclosures.

Lawrence Elliott receives research support from the Canadian Institutes of Health Research, Health Sciences Centre Foundation, Public Health Agency of Canada, and the Multiple Sclerosis Society of Canada.

Sharon Warren receives research funding from the CIHR, the Canadian Health Services Research Foundation, Alberta Health Services and SSHRC.

Christina Wolfson receives research funding from the Multiple Sclerosis Society of Canada, Canadian Institutes of Health Research, Canada Foundation for Innovation, and Public Health Agency of Canada.

Patricia Caetano has worked on a research project funded by Amgen.

Scott Patten has received speaking fees from Teva and holds research grants from the Canadian Institutes for Health Research and the Institut of Health Economics. He is a Senior Health Scholar with Alberta Innovates, Health Solutions.

Larry Svenson reports no disclosures.

John Fisk is the Director of the endMS Atlantic Regional Research and Training Centre which is funded by the Multiple Sclerosis Society of Canada. He receives research funding from the Canadian Institutes of Health Research (CIHR) and in the past has received grants, honoraria and consultation fees from AstraZeneca, Bayer, Biogen-Idec Canada, Heron Evidence Development Limited, Hoffmann-La Roche, MAPI Research Trust, Novartis, Sanofi-Aventis, Serono Canada, and QualityMetric Incorporated.

James Blanchard receives research support from the Multiple Sclerosis Society of Canada, CIHR, Bill & Melinda Gates Foundation, Canadian International Development Agency and the United States Agency for International Development.

Helen Tremlett is funded by the Multiple Sclerosis Society of Canada (Don Paty Career Development Award), Michael Smith Foundation for Health Research and is the Canada Research Chair for Neuroepidemiology and Multiple Sclerosis. She has received: research support from the US National Multiple Sclerosis Society, CIHR, and UK MS Trust; speaker honoraria and/or travel expenses to attend conferences from the Consortium of MS Centres, US National MS Society, the University of British Columbia Multiple Sclerosis Research Program, Bayer Pharmaceutical (speaker, 2010, honoraria declined), Teva Pharmaceuticals (speaker 2011), ECTRIMS (2011), UK MS Trust (2011) and the Chesapeake Health Education Program, US Veterans Affairs (2012, honorarium declined). Unless otherwise stated, all speaker honoraria are either donated to an MS charity or to an unrestricted grant for use by her research group.

The new electronic, self-administered version of the Control Preference Scale

A. Giordano, J. Kasper, E. Pietrolongo, C. Antozzi, G. Moretti, M. Pugliatti, A. van Nunen, J. Drulovic, L. Vahter, S. Koepke, C. Heesen, A. Solari on behalf of the AutoMS project

Background: The Control Preference Scale (CPS) is one of the most widely used tools for assessing patients’ preferred involvement in medical decisions. The scale is administered by an examiner, and consists of five cards, each illustrating a different role in decision-making by means of a cartoon and a short descriptive statement. German and Italian CPS versions have been published in addition to the original US English instrument.

Objectives: To revise the cartoons and develop a new electronic, self-administered version (eCPS).

Methods: The study has 3 stages: (a) Production of new CPS cartoons and pilot testing in Italy and Germany. (b) Migration of the original CPS to eCPS, and assessment of the latter’s acceptability and reliability, in comparison to the original, in MS patients who received both versions in random order, over 4 weeks. (c) Translation/adaptation from US English into Dutch (Belgium), Estonian, French (France) and Serbian, following established guidelines.

Results: (a) New CPS cartoons were produced by a professional cartoonist (based on health professional and MS patient input/feedback and our previous findings) and successfully pilot tested on 26 MS patients. (b) The eCPS was well accepted by 50 Italian and 33 German MS patients. Test retest reliability of the two ways of administration was moderate (weighted Κ 0.54, 95% confidence interval 0.41-0.66) and similar in the Italian and German patients. Inconsistent choices were 3% for both face-to-face and eCPS in both countries. German patients had age (mean 39.1 [SD 11.2]) and gender (67% women) similar to those of Italian patients (38.1 [8.6]; 62%) but, as in our previous study, they reported higher percentages of autonomous role preference (58%) compared to Italian patients (16%; p<0.001). (c) Parallel translations have been successfully completed in all participating countries.

Conclusions: Six linguistically validated versions of the CPS are now available. The eCPS (with its improved cartoons) allows patient self-administration on a PC or mobile device (e.g. iPad), in a more efficient and standardized fashion. Our next stage will be to compare the role preferences of MS patients across AutoMS countries.

Acknowledgement: We are indebted with Leslie Degner (University of Manitoba, Canada), author of the original CPS, for her advice and support.

Conflicts of interest: JK has receved travel fees from Merk Serono.

JD has received research grant support from the Ministry of Education and Science, Republic of Serbia (project no. 175031), and has received speaker honoraria and travel support from Merck Serono S.A., Bayer, Richter Gedeon, Novartis.

CH has received travel grants and speaker honoraries from Biogen idec, Novartis, Merck Serono and Sanofi Aventis.

AS has received board membership fee from Novartis, Merck Serono, Biogen idec, and speaker honoraria from Sanofi Aventis.

AG, EP, CA, GM, MP, AVN, LV and SK have nothing to disclose.

Grants: The AutoMS project is supported by the Fondazione Italiana Sclerosi Multipla (FISM) (grant no. 2010/R/37) and by the Hertie Foundation (Germany). The FISM also supported AG with a research fellowship (2009/B/4).

A 10-year population-based cohort of patients from Brittany (France) having started Putative Incident Multiple Sclerosis (PIMS) in 2000-2001

A. Kerbrat, J. Yaouanq, E. Leray, S. Hamonic, I. Tron, G. Edan on behalf of the Collège InterRégional des Neurologues de l’Ouest (CIRNO) and Association des Neurologues Libéraux de Langue Française (ANLLF)

We previously defined Brittany as a high risk region with an annual incidence of Multiple Sclerosis (MS) onset at 5.1/100000 (Ectrims 2005, P411). In this study, we prospectively collected cases whose first neurological symptoms had occurred after 01.01.2000 and were possibly attributable to MS, which provides a large population-based cohort of Putative Incident MS (PIMS) open to longitudinal studies.

Objective: To describe the 10-year clinical outcome of PIMS including 313 consecutive cases with clinical onset in 2000-01 and living in Brittany (3 million people in 4 administrative areas called “départements”).

Methods: During this first decade, we collected clinical data: phenotype (disease onset and course), relapses number and type, disability scores, and outcome events (second relapse, secondary progression, irreversible DSS3 or 6) analysed as survival data (right-censored to the last visit or death).

Results: In the preliminary data of 218 PIMS patients (3 of the 4 “départements”; 89.4% with complete history for at least 9 y), there were 23 (10.5%) non-MS disease including 2 DEVIC’s disease, 26 (11.9%) Primary-Progressive MS (PPMS), 123 (56.4%) Relapsing-Remitting MS (RRMS, i.e. 2 or more relapses) and 46 (21.1%) Clinically Isolated Syndrom (CIS) at the last time of follow-up. Among the 195 MS and CIS combined (sex ratio 3.1, age at onset 34.2±10.7y), 115 had received disease-modifying drugs (DMD) for at least 6 months, i.e. 606 patient-years (33% of the total patient-years: 0.8% in CIS, 29.7% in RRMS, 2.5% in PPMS). Among treated patients, DMD including β-interferon (75.7%), glatiramer acetate (33.9%), mitoxantrone (31.3%), natalizumab (6.1%) or oral immunosuppressive agents (12.2%) were started on average 2.7±0.2y after onset, and the mean time spent treated was 52% of the total follow-up. At the last visit, 64 patients had reached irreversible DSS3, of whom 28 had reached DSS6. Ten patients died, 1 probably from MS. Among the 169 cases with relapsing onset (RRMS+CIS), the second relapse occurred in a median time of 1.7 y (1.0-2.1) after onset (probability to remain CIS: 24% at 10y), and only 16 (9.5%) converted to secondary progressive MS. Complete data from the 4 “départements” will be presented at ECTRIMS congress.

Conclusion: In this population-based study, we report the first decade of PIMS disease history during a period when the first approved treatments potentially influencing MS clinical outcome could be initiated.

G Edan has received compensation for activities with Biogen-Idec and Teva as a consultant. Dr Edan has received compensation for serving on the advisory board for BENEFIT and LFB. Dr Edan has received research support from Serono and Bayer.

All other authors have nothing to disclose.

Causes of death in US patients with multiple sclerosis

S. Reshef, H. Golub, D. Goodin, G. Cutter, D. Kaufman, D. Pleimes, M. Corwin

Bayer HealthCare (Montville, US); CareSafe (Boston, US); University of California (San Francisco, US); The University of Alabama (Birmingham, US); Boston University (Boston, US)

Background: Among patients with multiple sclerosis (MS), information on causes of death (CODs) and the role MS plays in the death process is sparse. Listing MS as the underlying COD for a patient, as frequently occurs, provides little insight on conditions that may more directly lead to death. More immediate conditions leading to death may be informative for understanding the reasons for death among MS patients.

Population: MS patients and non-MS matched controls from a US health plan database (OptumInsight Research [OIR]).

Objectives: 1) To create a standardized process to categorize the condition most directly leading to death (CLD) using death certificate information from the National Death Index and 2) to compare CLD in MS vs non-MS control patients.

Methods: In this retrospective cohort study, prevalent MS cases (follow-up: 1993-2009) were identified by ICD-9 codes and matched to controls on age at first MS identification in OIR, sex, and region. An algorithm identified the CLDs using predetermined criteria based on the patients’ death certificates. The condition closest to the time of death was utilized, while excluding uninformative CODs (eg, cardiac or respiratory arrest). Suicide was considered the CLD when listed anywhere. CLDs were categorized into MS, cancer, cardiovascular, infectious, suicide, accidental, pulmonary, other, or unknown. Underlying CODs on the death certificate were similarly categorized.

Results: 31,051 patients with MS were matched to 92,511 controls. Among MS subjects 1531 (4.9%) deaths occurred vs 2183 (2.4%) in the matched controls. MS was the underlying COD in 34.3% of patients, but the CLD in only 15.9% of patients. The highest difference in mortality rate/100,000 person years between MS and controls was observed in the infectious CLDs (146.7 [95% confidence interval, 129.9-165.2] vs 45.1 [39.7-50.9]). Other CLDs with higher rates in MS included cardiovascular (200.3 [180.5-221.6] vs 127.2 [118.1-137.0] and suicide/accidental (67.5 [56.2-80.3] vs 39.1 [34.1-44.6]).

Conclusions: Assessment of CLD rather than underlying COD in MS provides insight into pathways leading to early death among patients beyond what can be learned from underlying COD. Infections leading to death were observed in MS at a rate 3 times those of controls, and substantial increases in cardiovascular and suicide/accidental causes were seen. Insights on the conditions leading to death among MS patients may help improve survival-prolonging care in MS.

Shoshana Reshef is a salaried employee of Bayer Healthcare Pharmaceuticals.

Howard Golub has received personal compensation for activities with Bayer HealthCare Pharmaceuticals as a consultant.

Douglas Goodin has participated (or is currently participating) in several industry-sponsored clinical trials in multiple sclerosis; the sponsoring pharmaceutical companies for these trials have included (or do include) Ares-Serono, Merck Serono, Novartis, Berlex Laboratories, Bayer Schering HealthCare, Biogen Idec, Schering AG and Teva Neuroscience. He has also lectured at both medical conferences and in public on various aspects of the epidemiology, diagnosis, and management of multiple sclerosis and in many cases, these talks have been sponsored directly or indirectly by one or another of the above listed companies. He has served as a temporary ad hoc consultant to several of these organizations on several occasions.

Gary Cutter has consulted and/or participated in Data and Safety Monitoring Committees (DSMB) for the following companies: Apotek, Biogen, Cleveland Clinic, Eli Lilly, Glaxo Smith Klein Pharmaceuticals, Medivation, Merck, Modigenetech, NINDS, NMSS, NICHD, NHLBI (Protocol Review Committee), Ono Pharmaceuticals, Prolor, Sanofi-Aventis, and Teva. He has also served on Consulting & Advisory Boards for the following companies: Alexion, Abbott, Allozyne, Bayer, Celgene, Consortium of MS Centers (grant), Coronado Biosciences, Diogenix, Medimmune, Klein-Buendel Incorporated, Novartis, Nuron Biotech, Receptos, Somnus Pharmaceuticals, Spinifex Pharmaceuticals, St. Louis University, and Teva pharmaceuticals. Dr. Cutter is employed by the University of Alabama at Birmingham and President of Pythagoras, Inc. a private consulting company located in Birmingham AL.

David Kaufman has received personal compensation for activities with Bayer HealthCare Pharmaceuticals, McNeil Consumer Healthcare, and UCB as a consultant. Dr Kaufman has received research support from McNeil Consumer HealthCare.

Dirk Pleimes is a salaried employee of Bayer Healthcare Pharmaceuticals.

Michael Corwin has received personal compensation for activities with Bayer HealthCare Pharmaceuticals as a consultant.

Supported by: Bayer HealthCare Pharmaceuticals, Inc.

Comparative effectiveness of long-term users of disease-modifying therapy

A. Salter, Y. Tang, L. Hornung, S. Kolodny, D. Hurtukova, S. Glenski, S. Cofield, X. Zhang, G. Cutter

University of Alabama at Birmingham (Birmingham, US); Teva Pharmaceuticals Industries Ltd. (Kansas City, US)

Background: The North American Research Committee on Multiple Sclerosis (NARCOMS) has been collecting disease modifying therapy (DMT) information and long term outcome measures from a large number of persons with MS for almost two decades. Participants who remain on the same DMT presumably have their disease adequately controlled by the current DMT.

Objective: To describe the disease characteristics of persons with MS who have continuously taken the same DMT for a minimum of 5 years and to evaluate the likelihood of changes in Patient-Determined Disease Steps (PDDS) and Performance Scales (PS).

Methods: Considering only cancer-free US participants with at least one semiannual survey (5 to 10 surveys) collected each year for at least 5 consecutive years (2006-2010) indicating drug stability. The DMTs considered were interferon β-1a (administered intramuscularly; IM), interferon β-1a (administered subcutaneously; SC), interferon β 1b, and glatiramer acetate. Descriptive statistics were used to summarize the socio-demographic and clinical information of the registry participants. Longitudinal analyses were used to determine the patterns and probabilities of transitions from steps of the PDDS and PS and comparisons were made by DMT.

Results: Of the 6,137 with 5-10 surveys in 2006-2010, 1,755 (28.6%) were on the same, single DMT. The majority of participants were Caucasian (96.7%) and female (78.8%) with a mean (SD) age of 50.7 (8.7). Over 40% were on glatiramer acetate, 31.6% on interferon b1-a (IM), 10.4% on interferon b1-a (SC) and 16.7% on interferon b1-b. The median PDDS was 2 (Mild Disability) in 2006. The probability of staying in the same PDDS category from one 6 month interval to the next varied by PDDS level. For PDDS 2, there was a 0.49 chance of staying in the same PDDS category, a 0.28 chance of returning to a lower level, and a 0.23 chance of increasing PDDS level(s), indicating that participants who are progressing are likely switching drugs and not included in this sample. Participants at a PDDS 0 (Normal) had an 80% chance of staying in that level while participants at PDDS 4 (Early Cane) or higher had over a 75% chance. Comparisons by DMT will be shown.

Conclusion: The results suggest considerable disease stability or improvement amongst participants who remain on the same therapy for long durations. Clinicians thus appear to switch therapies in response to disease activity and progression with some slight differences by type of DMT.

Amber Salter, Ying Tang, Lindsey Hornung and Xiao Zhang have nothing to disclose.

Stacey Cofield received personal compensation from GlaxoSmithKline, Teva Pharmaceuticals, Orthotech Biotech, the Department of Defense and the American Academy for Orthopedic Surgery for consulting services, research funds and/or DSMB service.

Scott Kolodny is an employee of Teva Pharmaceuticals Industries Ltd.

Denisa Hurtukova is an employee of Teva Pharmaceuticals Industries Ltd.

Stephen Glenski is an employee of Teva Pharmaceuticals Industries Ltd.

Gary Cutter received compensation for participating in Data and Safety Monitoring Committees: Sanofi-Aventis, Cleveland Clinic, Daichi-Sankyo, Glaxo Smith Klein Pharmaceuticals, Genmab Biopharmaceuticals, Eli Lilly, Medivation, Modigenetech, Ono Pharmaceuticals, Teva, NHLBI, NINDS, NMSS and Consulting services: Abbott, Bayer, Novartis, Consortium of MS Centers (grant), Genzyme, Klein-Buendel Incorporated, Nuron Biotech, Biogen, Somnus Pharmaceuticals and Teva; Dr. Cutter is president of Pythagoras, Inc.; Dr. Cutter reports received CMSC task orders which involve research from various Pharma organizations.

Anti-body titres against Epstein-Barr virus are associated with increased risk of multiple sclerosis in Mexico City

J. Massa, K. Simon, R. Lopez-Ridaura, J Rivera-Flores, O. Silverman-Retana, I. Kagan, A. Ascherio

Harvard School of Public Health (Boston, US); National Institute of Public Health of Mexico (Mexico City, MX); National Institute of Neurology and Neurosurgery (Mexico City, MX); Parasitic Disease Consultants (Georgia, US)

Background: Epstein-Barr virus (EBV) maybe important in the etiology of multiple sclerosis (MS) however few studies have been conducted in regions of low MS prevalence. We chose to study whether serological antibody titers against EBV were related to MS risk in Mexico City, a large urban population undergoing a fast epidemiological transition. Additionally, we explored the association between markers of hygiene and intestinal parasite infection and MS prevalence.

Methods: We conducted a hospital based case-control study in Mexico City; 52 incident MS cases were recruited between February and May of 2010. Childhood and adult hygiene scores were created using personal and demographic information from questionnaires. 51 cases and 51 controls provided blood samples for biomarker analyses. Multivariable logistic regression models were used to calculate odds ratios to approximate relative risks (RRs) of MS and 95% confidence intervals (CIs).

Results: There was a 3-fold increase in risk of MS with each 1 unit increase in anti-EBNA1 titer (multivariable adjusted relative risks 3.02, 95% CI: 1.01-9.02). Increasing childhood and adult hygiene scores were associated with a modestly increased risk of MS (multivariable adjusted RR for childhood hygiene score 1.30, 95% CI: 1.07-1.59; multivariable adjusted RR for adult hygiene score 1.28, 95% CI: 1.04-1.58). We found no association between antibody titer to Stronglyloides and MS risk (multivariable adjusted RR positive vs negative 1.26, 95% CI: 0.34-4.64) nor to antibodies to Ascaris (multivariable RR postivite or reactive vs negative 0.53, 95% CI 0.21-1.37).

Conclusions: High anti-EBNA1 Ab titers appears to be associated with increased MS risk even in a region where MS had historically low incidence and IM is rare, providing further evidence of a causal role for EBV in MS etiology. We also found moderate support for a potential role of higher ‘hygiene’, but not parasitic infection, being associated with susceptibility to MS.

The authors have nothing to disclose.

Causes of death in multiple sclerosis patients from British Columbia, Canada

E. Kingwell, C. Evans, T. Duggan, F. Zhu, J. Oger, H. Tremlett

University of British Columbia (Vancouver, CA)

Background: Mortality rates are higher in people with multiple sclerosis (MS) than in the general population. However, the reasons for the shorter lifespan in people with MS are not well understood. We examined the underlying causes of death in a large Canadian MS cohort in comparison to the general population.

Methods: MS patients residing in British Columbia (BC), Canada, registered with a BC MS clinic up to December 2004 were selected from the BCMS database. Emigration and mortality information were obtained by linkage to health registration data from the BC Ministry of Health and cause-of-death data from the BC Vital Statistics Agency. Follow-up was from the most recent of first BCMS clinic visit or study start (January 1986), to the earlier of death, emigration from BC or study end (December 2009). Standardized mortality ratios (SMRs) were calculated from cause-specific mortality rates in the Canadian general population, stratified by 5-year age group, sex and calendar year.

Results: Of 6656 patients with 84433 patient-years of follow-up, 1083 had died by the study end (median age at death 61 years; range 21-95 years). MS was the underlying cause in 50.9% of deaths. Other major causes included cancer (14.5%); cardiovascular (13.5%); respiratory (including infections) (7.2%), suicides (2.5%) and accidents (1.9%). Relative to the general population, the risk of death was increased for respiratory illnesses (SMR 2.70; 95%CI 2.13-3.37), suicide (SMR 2.59; 95%CI 1.71-3.77) and cardiovascular disease (SMR 1.24; 95%CI 1.05-1.46). The risk of death due to cancer was somewhat lower than expected (SMR 0.86; 95% 0.73-1.01), although the confidence interval included unity. Rates of accidental death were similar to those in the general population (SMR 1.13; 95%CI 0.70-1.73).

Conclusions: The risks of death due to respiratory illness or to suicide, both of which may be attributable to MS, were over twice those expected in the MS cohort compared to the general population. MS patients were also at an increased risk of a cardiovascular-related death. On the other hand, there was a borderline decrease in the risk of death from cancer; this is consistent with reports of a reduced incidence of cancer in MS patients. MS itself was still the most frequently recorded underlying cause of death, accounting for more than half of all deaths. Identification of potential explanations for these different relative risks requires further research.

This study was funded by the Canadian Institutes of Health Research (MOP-82738).

EK is supported by Postdoctoral Fellowships from the MS Society of Canada and the Michael Smith Foundation for Health Research. She has had travel/accommodation costs reimbursed to present at and attend conferences from the endMS Research and Training Network (2008, 2011), the International Society for Pharmacoepidemiology (2010) and Bayer Pharmaceuticals (2010).

CE has received travel grants to present at and attend conferences from the endMS Research and Training Network (2011) and ECTRIMS (2011).

TD and FZ have nothing to disclose.

JO has received speaker honoraria, consulting fees, travel grants, research grants or educational grants from Aventis, Bayer, Biogen-Idec, BioMS, Genentech, Novartis, Serono, Shering, Talecris and Teva-neurosciences. He had contractual agreements with Bayer, Novartis and Biogen Idec to serve on advisory committees.

HT has received speaker honoraria or travel expenses to attend conferences from the Consortium of MS Centres, US National MS Society, the University of British Columbia Multiple Sclerosis Research Program, Bayer Pharmaceuticals (speaker, 2010, honoraria declined), Teva Pharmaceuticals (speaker 2011), ECTRIMS (2011), UK MS Trust (2011) and the Chesapeake Health Education Program, US Veterans Affairs (2012, honorarium declined). Unless otherwise stated, all speaker honoraria are either donated to an MS charity or to an unrestricted grant for use by her research group.

The authors have nothing to disclose.

Epidemiologic features of multiple sclerosis in south-western Iran

N. Majdinasab, A. Nakhostin-Mortazavi, M.H. Alemzadeh-Ansari

Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences (Ahvaz, IR)

Introduction: Multiple sclerosis (MS) is an inflammatory disease of the central nervous system. The aim of this study was determination of epidemiological features of MS in Khuzestan province, Iran.

Methods: An epidemiological study of 1057 patients registered with Khuzestan MS Society (KMSS), which is the only referral center for MS patients in the province from September 2005 to June 2011. All patients had definite MS according to McDonald’s criteria. Approximately all MS patients in Khuzestan province were registered with KMSS and were included in the analysis.

Results: Among the 1057 patients, 807 (76.3%) were female (female to male ratio: 3.228). The mean age of onset was 27.6±8.2 years (5-57 range years), and 69.7% patients aged between 15-35 years. Most patients were in graduate-level education (64.2%). 663 (62.7%) of patients were married. The most complaints were visual problems (39.8%). The most common and the rarest type of MS were relapsing remitting (849, 81.1%) and relapsing progressive (10, 1%) of MS, respectively. 42 (4%) of them was clinically isolated syndrome. Most patients were from Fars (418, 39.6%) and Arab (217, 20.6%) race. On ratio patients to population of city, most prevalence was seen same in Ahwaz and Behbahan (4 per 10,000) and the least prevalence was seen in Shadegan (0.2 per 10,000). Prevalence of MS in Khuzestan province was 25 (95%; CI: 16-34) per 100,000.

Conclusion: Based on our result, the most frequency of patients was female with age range of between 15-35 years, which married and had graduate study. Female to male ratio was very high in comparison to other references. Lower frequency in Arab race perhaps was due to nutritional and genetic factors. Higher prevalence in Behbahan perhaps was due to environmental factors.

There’s been NO interest or source of fundings in the Epidemiologic study of MS in Khuzestan.

Artificial neural network predicts paediatric-onset multiple sclerosis incidence rate

N. Latif-ol-tojar, P. Heydarpour, K. Mohammad, S.-R. Elhami, M-A. Sahraian

Amirkabir University of Technology (Tehran, IR); Tehran University of Medical Sciences (Tehran, IR)

Background: Multiple Sclerosis (MS)during adolescence and childhood is exclusively of a relapsing-remitting nature.Artificial Neural Networks (ANN) can recognize the rules to make right prediction and provide assistance for decision-making. Recently, backpropagation (BP) artificial neural network has been widely applied to a variety of problems in the field ofmedicine. In the present work, we applied several artificial neuralnetworks to the forecast of the incidence rate of pediatric MS in Tehran, Iran (Latitude: 35 ° North, Longitude: 51° East).

Methods:Iranian MS Society (IMSS) records were studied to obtain annual incidence data of patients who experienced a first attack under the age of 18 yearsin Tehran province during 1990-2011. The data from 1990 to 2004 were used as the training and verifying sets and the data from 2005 to 2011 were used as the test set. Neural network toolbox of MATLAB was used to construct,train and simulate the ANN.

Results:We found 702 cases (6.5 % of patients) with a recorded MS historyof a first attack under the age of 18 yearsduring 1990-2011, compared to 44.2 % of patients who experienced first symptoms between the ages of 25-35 years.To study the application of artificial neural network (ANN) in forecasting the incidence rate of pediatric MS,seventeen networks were tested and four were retained. The best network we found had excellent performance, its regression ratio was 0.67, and its correlation was 0.62. There were 2 input variables in the network, one was population, and the other was time. Our study consisted of 582 patients(82.9 %) in 15-18 years age group, 104patients (14.8 %) aging 11-14 years, 15 patients(2.2 %) aging 7-10 years and 1 patient(0.1 %) in 3-6 years group. Female to male ratio was 2 for 7-10 years old group, 4.8 for 11-14 years old and 4.3 for 15-18 years old compared to a gender proportion of 3 for 25-35 years. The prevalence of pediatric-onset MS was 13.25 per 100,000 in the population under 18 years in Tehran, with a crude incidence peak of 1.4per 100,000 in 2005.

Conclusion:Pediatric-onset MS is being widely recognized in the world and this study provides that ANN is an effective tool in processing time series data to predict the incidence rate of MS.

The authors have nothing to disclose.

Consanguineous marriage and multiple sclerosis

H. Maghzi, V. Moradi, M. Etemadifar, A.H. Maghzi

Isfahan Research Comitte of Multiple Sclerosis (Isfahan, IR); University of Mazandaran (Babolsar, IR); Isfahan University of Medical Science (Isfahan, IR)

Objective: This study was designed to study the association of consanguineous mating and multiple sclerosis (MS), in Isfahan province of Iran, which like other parts of Iran have relatively high rates of consanguineous marriage of first cousins.

Method: The clinical records of patients who were registered at Isfahan MS Society (IMSS) were reviewed. Patients whom their parents had a familial kinship were included in the study. IMSS database nearly consists of all MS patients in the province.

Result: From 3522 registered patients, 2716 (77.1%) were women. Data on parents’ kinship was not available for 105 patients. Among the remaining patients 752 were offspring of a consanguineous marriage (22%) which was significantly (p<0.001) lower than that reported amongst a large sample from the general population of Isfahan (5758 out of 22095; 26.1 %).

Conclusion: The results of this large study suggest that MS patients were less frequently children of consanguineous unions.

The authors have nothing to disclose.

Immunomodulatory treatment of multiple sclerosis in Switzerland - a nationwide follow-up of 8’046 patients, 1995 - 2010

C. Lienert, A. Schoetzau, S. Beer, L. Kappos, O. Yaldizli

Bruderholz Spital (Basel, CH); University of Basel (Basel, CH); Kliniken Valens (Valens, CH)

Background: Since 1995 for approximately 85% of the population, prescription of disease modifying drugs (DMD) in Switzerland is bound to the approval by the Swiss Federation for Common Tasks of Health Insurances (SVK) based on annual standardized documentation by a neurologist.

Objective: To provide data on the nationwide use of DMDs for the treatment of multiple sclerosis (MS) in Switzerland.

Methods: We evaluated the standardized forms submitted by the treating neurologists annually for reimbursement approval to the SVK. These clinical (including number of relapses, Expanded Disability Status Scale (EDSS), Functional Systems) and demographic data were quality controlled before entry into the database.

Results: From April 1995 until February 2010, 8046 MS patients started DMD treatment for MS: 70.6% women; mean age 39.6±11.3 y; 7.1% clinically isolated syndrome, 83.6% relapsing-remitting MS, 9.3% secondary-progressive MS, mean disease duration 7.2±8 years; mean EDSS 2.77±1.48; mean number of relapses in the previous 2 years 0.9±0.66. The mean annual number of new prescriptions was 541 per year (range: 252-937). Mean treatment duration was 4.4±3.9 years. From 2001 until 2010, when all three interferons (IFN) and glatiramer acetate (GA) were equally available and licensed for the treatment of RRMS, IFN-Β 1a s.c. three times per week was the drug most commonly prescribed for the treatment of RRMS (40.7%; n=1684), followed by IFN-Β 1b s.c. (26.2%, n=1084), IFN-Β 1a i.m. (22%, n=916) and GA (11%, n=458). Seven percent of all patients stopped treatment within the first year. From year 2 on annual discontinuation rates ranged from 1.2 to 7.8%. After 8 years 50% of the patients and after 15 years approximately 25% of the patients were still taking DMDs. Twenty-one percent (n=1693) switched DMD, 4.2% of these twice and 0.7% three times: 40% of the changes were within the IFN-Β group; 31% changed from IFN-Β to natalizumab, 25% from an IFN-Β to GA. The time to the first change was similar between the IFN-Β formulations and GA. At the end of the observation period, 4987 patients were taking a DMD.

Conclusions: With an estimated 10’000 MS patients in Switzerland, our data indicate that a great majority were exposed to DMD. Prescription of DMD was influenced by the introduction of new drugs and changes in indication.

CL, AS and Sb have nothing to disclose.

LK has participated in the last 24 months as principal investigator, member or chair of planning and steering committees or advisory boards in corporate-sponsored clinical trials in multiple sclerosis and other neurological diseases. The sponsoring pharmaceutical companies for these trials include Abbott, Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CSL Behring, Elan, Genmab, GeNeuro SA, Genmark, GlaxoSmithKline, Lilly, Merck Serono, Novartis, Novonordisk, Peptimmune, sanofi- aventis, Santhera, Roche, Teva, UCB and Wyeth. LK has also lectured at medical conferences or in public on various aspects of the diagnosis and management of multiple sclerosis. In many cases these talks have been sponsored by non-restricted educational grants to my institution from one or another of the above listed companies.

Honoraria and other payments for all these activities have been exclusively used for funding of research of my department. Research and the clinical operations (nursing and patient care services) of the MS Center in Basel have been supported by non-restricted grants from one or more of these companies. TS has consulted for Eli Lilly, Biogen, Mitsubishi Pharma

Europe and Allergan. Travel support: Pfizer, Bayer Schering, Eli Lilly, Allergan.

OY has received lecture fee from Teva and Bayer Schering which was exclusively used for funding of research and continuous education in the Department of Neurology at the University Hospital Basel.

Co-morbidities previous to multiple sclerosis

A. Fromont, C. Binquet, F. Rollot, R. Despalins, A. Weill, L. Clerc, C. Bonithon-Kopp, T. Moreau

University Hospital (Dijon, FR); INSERM CIE1 (Dijon, FR); French Public Health Insurance (Paris, FR); French Public Health Insurance (Dijon, FR)

Background: Few data exist about occurrence and nature of comorbidities in MS before its diagnosis and about an eventual influence on the delay of MS notification.

Objective: To determine nature and to appreciate the influence of comorbidities on Multiple Sclerosis (MS) notification.

Methods: In France, MS belongs to the 30 long-term illnesses (Affections de Longue Durée- ALD) for which patients are covered for 100 % of their health care costs. The main French health insurance system is the CNAMTS (Caisse Nationale d’Assurance Maladies des Travailleurs Salariés) which insured 87% of the French population (52,359,912 out of the 60,028,292 inhabitants in 2004). We performed a study among 22,087 patients who had contracted MS before their 45th birthday, registered between 1995 and 2004. Comorbidities diagnosed previous to MS were described. Age when MS was registered was compared with the existence or not of a previous comorbidity thanks to Student tests. We also calculated mean time elapsed between the ALD request for comorbidity and for MS.

Results: Between 1995 and 2004, 21,119 (95%) had ALD status for MS only, 492 (2%) had comorbidity status before MS. 86% of these comorbidities could be grouped into five main categories: psychiatric disease (42.3%), autoimmune disease with diabetes type 1 (27.2%), cardiovascular disease (12.8%), cancer (12.5%), and metabolic disease (6.9%). In comparison with general population of the same age, psychiatric disorders and diabetes (57.4% of the autoimmune diseases) were more frequent. The mean age upon request for ALD status for MS in patients with no comorbidity was 33.6 ± 7.2 years, whereas it was 36.8 ± 6.5 years when comorbidity had been declared. Age at request for ALD status for MS was delayed by 3.2 ± 6.5 years if a comorbidity existed.

Conclusions: The interpretation of this distribution is difficult. This association between comorbidity and MS could be due to coincidence. Otherwise, two explanations can be put forward. A comorbidity could already be a first atypical symptom of MS. It is well known that MS can be heralded by a period of depression or cognitive disorder can be misdiagnosed as a psychiatric disease. Another explanation for this non-random association between MS and comorbidity could be a common underlying mechanism as for diabetes and MS. In this case, underlying mechanisms may involve both genetic and environmental factors.

MS notification was delayed by the existence of comorbidity previous to MS.

The authors have nothing to disclose.

Multiple Sclerosis Registry in Catalonia: results after 3 years

S. Otero, J. Sastre-Garriga, E. Simón, C. Nos, L. Ramió-Torrentà, H. Perkal, A. Saiz, S. Llufriu, A. Escartín, C. Ramo, M. Marco, L. Brieva, E. Muteis, E. Bufill, M. Fragoso, I. Bonaventura, I. Pericot, A. Cano, A. Boltes, O. Carmona, G. Martín, J. Hernández, V. González, J. Bello, E. Moral, M. Tintoré, X. Montalban

Vall Hebron University Hospital (Barcelona, ES); Hospital Dr. J. Trueta (Girona, ES); Hospital Clínic (Barcelona, ES); Hospital Sant Pau (Barcelona, ES); Hospital German Trias i Pujol (Badalona, ES); Hospital Parc Taulí - Sabadell (Barcelona, ES); Hospital Arnau de Vilanova (Lleida, ES); Hospital del Mar (Barcelona, ES); Hospital de Terrassa (Barcelona, ES); Hospital Mútua de Terrassa (Barcelona, ES); Hospital Santa Caterina - Salt (Girona, ES); Consorci Sanitari del Maresme (Mataró, ES); Hospital General de Granollers (Barcelona, ES); Hospital de Figueras (Figueras, ES); Hospital Verge de la Cinta (Tortosa, ES); Hospital Sant Camil (Vilanova i la Geltrú, ES); Hospital Sant Joan de Déu (Esplugues de Llobregat, ES); Hospital General del Hospitalet de Llobregat (Barcelona, ES); Hospital Moisés Broggi (Sant Joan Despí, ES)

Introduction: A prospective multicenter MS Registry was established in January 2009 with a target population of all residents in Catalonia (7,565,000 inhabitants) in order to gather exhaustive information on MS new diagnoses and determine annual incidence, geographical distribution and trends. Objectives. To describe the demographic and clinical information collected in the registry during the first 3 years of operation (1st January 2009- 30th April 2012) as well the onset-adjusted incidence for 2009 and the estimated coverage.

Methods: The registry includes patients having experienced a first symptom suggestive of MS after 1st of January 2009 for relapsing onset and 1st of January 2006 for progressive onset. They are followed until their eventual conversion to MS based on the 2005 McDonald diagnostic criteria. The source of information is a wide network of specialized MS units and cases are declared on-line using proprietary software. The registry fulfils current requirements of patient data security.

Results: Within the period reported, a total of 703 patients (664 relapsing onset and 39 progressive onset) from 21 hospitals had been notified into the Registry. Mean age was 35 (SD 9), 63% were women and 89% were born in Spain. The most frequent clinical presentations at onset were: myelitis (35%), optic neuritis (25%) and brainstem-cerebellum syndromes (24%). Regarding patients with onset in 2009 (N=252), after at least 2 years of follow-up 75% of them fulfilled McDonald criteria (50%) or either DIS or DIT criteria (25%). The odds of conversion to MS were significantly higher in patients with abnormal MRI and presence of oligoclonal bands [log rank test P< 0,001]. In 2009, the incidence of MS was 1.7 increasing up to 3.4 if patients with a first attack in 2009 are counted regardless of fulfilment of McDonald criteria at follow-up. Based on small-area studies performed in Spain with MS incidence figures that range 2-4 cases per 100,000 and year, the estimated coverage of the registry would range from 42% to 85%.

Conclusion: The clinical and demographical characteristics of patients included are those to be expected from an unbiased population-based sample. The registry is a useful tool for data collection and will provide reliable epidemiological data. It is expected that accuracy will increase over the next years as coverage expands.

The authors have nothing to disclose.

Prevalence of multiple sclerosis in Verona, Italy: an epidemiologic and genetic study

A. Gajofatto, A. Stefani, M. Turatti, M.R. Bianchi, M. Gomez Lira, A. Salviati, M.D. Benedetti

University of Verona (Verona, IT)

Introduction: Recent multiple sclerosis (MS) prevalence studies have classified Italy as a high-risk area.

Objectives: To determine MS prevalence in Verona, Italy, and the frequency of myelin oligodendrocyte glycoprotein (MOG) gene G511C polymorphism and HLA-DRB1*15 locus in a sample of cases and healthy controls.

Methods: The study area population on the prevalence date (December 31st 2001) was 253,208 (133,508 women, 119,700 men). Multiple case sources were examined and medical records were reviewed to verify the diagnosis. Patients who fulfilled McDonald’s criteria (2001) for MS were included. Crude, age- and sex-specific prevalence rates were computed. MOG G511C polymorphism and HLA-DRB1*15 were determined by standard methods.

Results: We identified 270 MS cases yielding a crude prevalence rate of 106.6/100,000, 95%CI: 94-120). Prevalence was higher in women (140.8/100,000) than in men (68.5/100,000). The age-adjusted prevalence rate standardized to the European population was 96.0/100,000. Age-specific prevalence rates showed a peak in the age group 35–44 years in women and 55–64 years in men. Median Expanded Disability Status Scale (EDSS) score was 3.0 in women and 3.5 in men (range 0-9.5). MOG G511C polymorphism did not differ between cases and controls. HLA-DRB1*15 frequency was 38% in cases and 15.4% in controls (p<0.0001).

Conclusions: The high MS prevalence in Verona is in accordance with the most recent epidemiological findings. Similarly high prevalence was found throughout Italy, casting doubts on the existence of an MS latitude gradient in this country. HLA-DRB1*15 allele is confirmed as a relevant MS susceptibility locus in the Caucasian population.

The authors have nothing to disclose.

Study supported by an unrestricted grant from Merck-Serono Italy.

MSIF Atlas of MS database update: multiple sclerosis resources in the world 2013

A. J. Thompson, P. O. Browne, B. V. Taylor, M. A. Battaglia, L. Pandit, H. Tremlett, B. M. Uitdehaag, E. Holloway

University College London (London, UK); Multiple Sclerosis International Federation (London, UK); University of Tasmania (Hobart, AU); Associazione Italiana Sclerosi Multipla (Genoa, IT); Nitte University (Mangalore, IN); University of British Columbia (Vancouver, CA); VU University Medical Center (Amsterdam, NL); MS Society (London, UK)

Background: In September 2008 the World Health Organization (WHO) and the Multiple Sclerosis International Federation (MSIF) published the report Atlas: Multiple Sclerosis Resources in the World 2008, with the complete dataset made available in the online Atlas of MS Database (http://www.atlasofms.org/). This provided for the first time information and data on the epidemiology of MS, and the availability and accessibility of resources for people with MS at country, regional, and global levels.

Objectives: The Atlas of MS aims to raise awareness of the global MS situation, and to encourage further research and data collection.

The information presented in the Atlas of MS Database is now 5 years old, and consequently MSIF has launched an update program with the intention of publishing the updated database online in October 2013. In addition to updating the data supplied by the 112 countries that responded to the original survey, we hope to obtain data from a further 25 countries.

The update will improve upon and expand the original survey. For instance, individuals submitting data will be required to cite the data source. Each data source will then be quality rated for its level of evidence, and findings will be incorporated into the database.

Methods: An online questionnaire is being developed by the Atlas of MS Update coordinator and Atlas of MS Update Advisory Group.

A coordinator for each country will be identified through consultation with MSIF member societies, who will be responsible for the completion of the questionnaire. In the case of countries without an MS society, we will identify country coordinators through the World Federation of Neurology, contacts from the previous Atlas of MS survey, and the medical literature.

Each country’s coordinator will be asked to identify the key individuals and organizations in the country best qualified to complete individual sections of the questionnaire. Received data will be reviewed to ensure consistency with the published literature. Data will be standardized, coded, entered into a database and analyzed. Data will be organized in themes and presented as charts, maps and text, and presented on the Atlas of MS database website.

Conclusions: The findings reported in the updated Atlas of MS aim to aid the work of health professionals, patient groups, the health industry and governments. The Atlas of MS database is also intended to inform national and regional advocacy programs as well as facilitate policy development to improve outcomes in MS.

This project is funded by the Multiple Sclerosis International Federation.

A. J. Thompson has received honoraria for consultancy from Eisai Ltd, BTG International, Novartis; honoraria and support for travel for lecturing from Serono Symposia International Foundation and Novartis; support for travel for consultancy from MSIF; honorarium from Sage for editorship of Multiple Sclerosis Journal.

P. O. Browne, B. V. Taylor, M. A. Battaglia and L. Pandit have nothing to disclose.

H. Tremlett is funded by the Multiple Sclerosis Society of Canada (Don Paty Career Development Award), Michael Smith Foundation for Health Research and is the Canada Research Chair for Neuroepidemiology and Multiple Sclerosis. She has received: research support from the US National Multiple Sclerosis Society, CIHR, and UK MS Trust; speaker honoraria and/or travel expenses to attend conferences from the Consortium of MS Centres, US National MS Society, the University of British Columbia Multiple Sclerosis Research Program, Bayer Pharmaceutical (speaker, 2010, honoraria declined), Teva Pharmaceuticals (speaker 2011), ECTRIMS (2011), UK MS Trust and the Chesapeake Health Education Program, US Veterans Affairs (2012, honorarium declined). Unless otherwise stated, all speaker honoraria are either donated to an MS charity or to an unrestricted grant for use by her research group.

B. M. Uitdehaag has received consultation fees from Biogen Idec, Novartis, Merck Serono, Synthon and Danone Research.

E. Holloway has nothing to disclose.

Month of birth does not seem to interfere with the prevalence or disease progression in multiple sclerosis for South American patients, irrespectively of the latitude

Y. Fragoso, T. Adoni, F. Barbagelata-Aguero, S. Almeida, S. Alves-Leon, W. Arruda, J. Brooks, A. Carra, R. Claudino, E. Comini-Frota, E. Correa, A. Damasceno, B. Damasceno, E. Dias, D. Vizcarra-Escobar, A. Fiore, C. Franco, M. Giacomo, S. Gomes, M. Goncalves, A. Grzesiuk, J. Inojosa, D. Kaimen-Maciel, K. Lin, G. Lourenco, A. Martinez, M. Melcon, N. Morales, R. Morales, M. Moreira, S. Moreira, C. Oliveira, F. Oliveira, J. Ribeiro, S. Ribeiro, C. Rodriguez, L. Russo, J. Safanelli, K. Shearer, F. Siquineli

UNIMES (Santos, BR); Hospital Sirio Libanes (São Paulo, BR); Hypnos (Lima, PE); UFRJ (Rio de Janeiro, BR); INC (Curitiba, BR); Hospital Britanico (Buenos Aires, AR); UFSC (Florianópolis, BR); UFMG (Belo Horizonte, BR); IC (Brasilia, BR); UNICAMP (Campinas, BR); Pontificia Universidade Catolica de Chile (Santiago, CL); Sao Camilo (Santos, BR); HC (Recife, BR); Fundacao ABC (Sao Bernardo do Campo, BR); HBP and H Paulistano (São Paulo, BR); INJ (Joinville, BR); CRIDAC (Cuiaba, BR); UEL (Londrina, BR); FINEP (Buenos Aires, AR); UFU (Uberlandia, BR); FCMS/SUPREMA (Juiz de Fora, BR); HBP and Hospital Paulistano (Sao Paulo, BR); UFTM (Uberaba, BR); University of Aberdeen (Aberdeen, UK); FURB (Blumenau, BR)

Several studies have shown a relationship between an individual’s month of birth and development of multiple sclerosis (MS) later in life. This relationship, which might be due to the mother’s sun exposure and vitamin D metabolism, is clear in some countries at high Northern latitudes. So far, no similar studies have been carried out at Southern latitudes ranging from zero to 40 degrees. The objective of the present study was to assess the prevalence of MS in relation to patients’ month of birth, in order to observe any correlation with the latitude. Furthermore, disease progression was also considered in order to assess whether the place of birth had any relation with disease severity.

Methods: Data were collected from four South American countries (Argentina, Brazil, Chile and Peru) over a three-month period. A specific Excel file containing all pertinent details of the patient’s medical history was filled out by the neurologist in charge of that particular case. The control cases were males and females of similar ages, born at the same latitude levels. Two-way and one-way ANOVA, linear regression analysis, Pearson’s correlation and Student’s t-test were used to analyze the results.

Results: Analysis on data from 1,207 MS patients and 1,207 control subjects did not show any significant variation in MS prevalence in relation to month of birth, in any of the four latitude zones evaluated (zero to 10; 11 to 20; 21 to 30; and 31 to 40 degrees). As it would be expected, a definite correlation exists between EDSS score and length of the disease at all latitudes, as assessed by Pearson’s correlation testing. However, no significant differences exist between month of birth and disease progression using one-way ANOVA.

Conclusion: The results from this study show that children born from pregnancies at higher latitudes in South America do not show higher incidence of MS later in life, as is the case with the seasonal pattern observed in the Northern hemisphere. Therefore, it cannot be affirmed that there is a clear relationship between lower sun exposure in winter pregnancies and the development of MS later in the offspring’s life in South America. Several other factors, including genetic profiles and infections, may play a more important role in the development and severity of MS in the countries assessed.

Yára Dadalti Fragoso, Tarso Adoni, Fiorella Barbagelata Aguero, Sandra Maria Garcia de Almeida, Soniza Vieira Alves-Leon, Walter Oleschko Arruda, Joseph Bruno Bidin Brooks, Adriana Carra, Rinaldo Claudino, Elizabeth Regina Comini-Frota, Eber Castro Correa, Alfredo Damasceno, Benito Pereira Damasceno, Ethel Ciampi Díaz, Darwin Vizcarra Escobar, Ana Patrícia Peres Fiore, Clelia Maria Ribeiro Franco, Maria Cristina Baptista Giacomo, Sidney Gomes, Marcus Vinicius Magno Gonçalves, Anderson K. Grzesiuk, Jose Luiz Inojosa, Damacio Ramón Kaimen-Maciel, Katia Lin, Josiane Lopes, Gisele Alexandre Lourenço, Alejandra Diana Martinez, Mario Oscar Melcon, Nívea de Macedo Oliveira Morales, Rogério Rizo Morales, Marcos Moreira, Shirlene Vianna Moreira, Celso Luis da Silva Oliveira, Francisco Tomaz Menezes de Oliveira, João Batista Ribeiro, Sonia Beatriz Félix Ribeiro, Claudia Cárcamo Rodríguez, Liliana Russo, Juliana Safanelli, Kirsty D Shearer, Fabio Siquineli have nothing to disclose, this work was performed without any financial support.

Clinical and radiological characteristics of Korean patients with autoimmunity to Aquaporin-4 at onset

O. Kwon, H. J. Kim, W. J. Kim, B. J. Kim, B. J. Kim, J. H, Min, M. S. Park, K. S. Lee, J. Y. An, K. K. Kim, Y. M. Lim, S. M. Kim, H. Y. Shin, S. M. Cheon, J. G. Kim, S. Y. Kim, M. S. Park, B. S. Shin, J. S. Bae, J. Y. Cho, S. S. Lee, S. W. Ahn, E. H. Sohn, G. J. Park, J. G. Lim, J. Y. Oh, Y. H. Hong, K. H. Lee on behalf of the Korean MS Investigators Group

Early diagnosis of neuromyelitis optica (NMO) is crucial to offer optimal treatment to patient and secure better neurological function. Several studies have suggested various features distinguishing NMO from other demyelinating disorders, especially multiple sclerosis (MS). We investigated data of Korean Multiple Sclerosis Registry to sort out what features are associated with seropositivity of NMO-IgG or anti-aquaporin 4 antibody (anti-AQP4).

Demographical, clinical, radiological and serological data of Korean Multiple Sclerosis Registry which covered the whole spectrum of various central nervous system inflammatory disorders of clinically isolated syndrome (CIS), MS, NMO, acute disseminated encephalomyelopathy, and other autoimmune CNS inflammatory disease, were analyzed and their association with autoimmunity to AQP4 was examined.

Among total of 597 patients enrolled (M: F=1:1.71, onset age, 37.3±14.4 years, disease duration, 4.9±11.6 years) in the registry, sera of 373 patients were tested for NMO-IgG or anti-AQP4 and 120 (32%) were positive. Factors associated with autoimmunity to AQP4 at the onset were female gender (odds ratio (OD) 8.5, p<.001), longitudinally extensive spinal cord lesions (LESCLs) (OD 4.5, p<.001), and comorbid autoimmune or malignant disorders (OD 2.2, p <.05). On the contrary, type of inaugural event, brain MR at the onset, oligoclonal band (OCBs) in CSF did not serve as significant predictors of seropositivity.

This study shows that female and LESCL, but not normal brain MR or absence of OCBs, raise the possibility of NMO seropositivity in Korean patients that is acknowledged to have high relative prevalence of NMO. This finding might be due to different distribution of CNS inflammatory disorders in the region, and thus reflect difficulty in early diagnosis.

The authors have nothing to disclose.

Evidence for sub-clinical malnutrition in Kuwaiti patients with multiple sclerosis: relationship with clinical phenotypes, disease activity and outcome

S. Al-Shammri, A. Bhattacharya, R. Mathew, M. Girgis, C. Madala, A. Akanji

Kuwait University (Kuwait, KW)

Introduction: Multiple sclerosis(MS) is a chronic, immune-mediated demyelinating disorder of central nervous system, influenced by different genetic and environmental factors. Some findings suggest that MS Patients suffer from malnutrition which is often unrecognised causing fatigue and worsening major symptoms; many patients also use different dietary supplements in order to improve their health. This study aimed to investigate the level and patterns of changes in nutritional markers in relation to clinical phenotypes in patients with MS.

Methods: In this cross-sectional study,116 MS patients fulfilling Mc Donald criteria and 29 age and sex matched healthy controls were included. Each patient and control was interviewed by a questionnaire & clinically evaluated. Fasting blood sample was collected to assess different :i) nutritional markers namely: serum albumin(Alb), prealbumin (PAlb), urea, iron (Fe), Ferritin (Fr); and ii) inflammatory marker: C reactive protein (CRP).

Results: Results were available for 37 patients [79 patients taking VitD or multivitamin supplements were excluded] and 29 controls. The patients had significantly higher (P<0.001) BMI and waist-hip ratio, than controls. Most patients (94.65%) had relapsing remitting(RR)MS and were on immune-modulatory therapies (94.3%).Majority of them (83.8%) had an expanded disability status scale<3 with the serum levels of nutritional markers did not differ according to clinical phenotypes. Serum Alb, PAlb, and urea (P<0.001) and serum Fe levels (P<0.05) were lower in patients than controls, while serum Fr levels were higher in patients (P<0.001). CRP levels were similar for both groups.

Conclusion: These results suggest an abnormality in release of circulating iron from the tissue ferritin in MS patients. This change is associated by subclinical malnutrition as indicated by reduced pre-albumin and albumin level in the patients. These observation have potential therapeutic implications.

With reference to this abstracts all the authors( Al - Shammri SN,Bhattacharya A,Mathew R,Girgis M,Madala C, Akanji AO) have nothing to disclose.

This study was supported by a Kuwait University Research Administration Grant # MM03/09.

Disease course and oligoclonal band status among immigrants with multiple sclerosis in Oslo, Norway

P. Berg-Hansen, C. Smestad, L. Sandvik, H.F. Harbo, E.G. Celius

Oslo University Hospital (Oslo, NO)

Background: Norway has a high prevalence of multiple sclerosis (MS). The immigration from low-prevalence areas is increasing, and in the capital Oslo more than 20% of the inhabitants are of non-western origin. We have previously shown that immigrants from low-risk areas have an increased risk of MS after migration. Studies show that ethnicity may affect disease severity, and African Americans, Hispanics and Canadian aboriginals suffer a more severe disease. In the cerebrospinal fluid (CSF) most western patients show intrathecally produced oligoclonal immunoglobulin bands (OCBs). The prevalence of OCBs in Asian countries is lower, but the prevalence of OCBs in immigrants to western countries is unknown. The aims of our study were to investigate differences in disease severity and in the presence of OCBs between Norwegians and immigrants to Oslo.

Methods: From the Oslo-MS-registry 46 non-western immigrants were included in the study. They were scored according to the Kurtzke Expanded Disability Scale (EDSS), and a Multiple Sclerosis Severity Score (MSSS) was calculated. As controls 446 Norwegian patients and 48 immigrants from other western countries were included.

Results: The non-western immigrants had a significantly higher MSSS (mean 5.60, 95%CI: 4.74-6.46) compared to the Norwegian patients (mean 4.14, 95%CI: 3.86-4.42, p=0.002). Immigrants from other western countries had a MSSS comparable to the Norwegians (mean 3.98, 95%CI: 3.19-4.78, p=0.73, n.s.). The mean age of the non-western immigrants was 11 years lower than the Norwegian patients (36.3 vs 47.6, p<0.001). Age at onset was also lower among the immigrants (26.0 vs 29.9, p= 0.003). In a regression model adjusting for year of birth, age at onset, gender and disease course (relapsing-remitting or primary progressive MS), we found a mean difference of 2.05 in the MSSS-scores between the groups (95%CI:1.13-2.98, p<0.001). Non-western immigrants were CSF OCB positive in 89% of the cases. This was not statistically different from the Norwegian patients (88%) or the western immigrants (95%).

Conclusions: Our results show a more severe disease progression in MS among non-western immigrants in Oslo compared to native Norwegians and immigrants from other western countries. The non-western immigrants are also younger at disease onset. The presence of OCBs in the CSF of the immigrants was not different from the Norwegians, and higher than expected from studies performed in Asia.

P.Berg-Hansen has received an unrestricted research grant from Novartis, Norway for MS research.

C.Smestad and L.Sandvik have nothing to disclose.

H.F.Harbo and E.G.Celius have no conflicts of interest in relation to this study.

Sickness absence and disability pension among multiple sclerosis patients in Sweden

P. Tinghög, L. Kjeldgård, J. Hillert, K. Alexanderson

Department of Clinical Neuroscience (Stockholm, SE)

Multiple sclerosis (MS) is the most common neurological disease among younger adults and leads to substantial disability and costs. However, there are few studies about sick leave and disability pension among MS patients.

The aim of this study was to gain basic knowledge about the one-year prevalence of sickness absence and disability pension among MS patients, and whether this differed with gender or educational level.

Method: This population-based register study includes 9521 MS patients (71.2% women) who lived in Sweden in 2005 and were aged 16-64 years. The patients were identified using the nationwide in- and out-patient hospital registers; that is, those who had at least one such visits due to MS in the four years 2001-2004. Diagnoses-specific data on sick-leave spells >14 days and disability pension was obtained from the nationwide Social Insurance Agency’s MiDAS database. All people in Sweden are covered by the same social insurance.

Results: In 2005, 61.1% (n=5813) of these patients were on disability pension, and 75.0% of them had MS as their DP diagnosis. Information about disability pension diagnoses was missing for 10.3%, and the remaining 14.7% were disability pensioned with other diagnoses. The corresponding rate regarding having at least one sick-leave spell in 2005 was 27.5% (n=2621), and 28.8% of these had been on a sick leave due to other diagnoses than MS. Information regarding diagnosis was missing for 13.0% of the individuals on sick leave. Moreover, a higher rate of women than men with MS were on disability pension (62.8 vs. 56.7%, p<0.001). The same gender difference was observed with regard to sick leave (28.8 vs. 24.3% p<0.001). The MS patients with a lower educational level (≤12 years) had a markedly higher risk for being disability pensioned than those with higher education (>12 years of school) (67.9 vs. 47.2%, p<0.001). The corresponding proportions for having at least one sick-leave spell in 2005 was 25.7 vs. 31.3% (p<0.001).

Conclusion: One out of 7 disability pensions among MS patients were due to other diagnoses than MS. Both rates of sick leave and disability pension were lower among male MS patients, and disability pension was less common among the more highly educated MS patients. More MS specific research is required to better understand these findings.

Dr. Tinghög has no conflict of interest to declare and is funded by BiogenIdec.

MA Keldgård has no conflict of interest to declare and is funded by the Swedish Council of Working Life and Social Research.

Dr. Hillert received honoraria for serving on advisory boards for BiogenIdec and for speaker’s fees from BiogenIdec, Merck-Serono, Bayer-Schering, Teva and Sanofi-Aventis. He has served as P.I. for and received research support from BiogenIdec, Merck-Serono, TEVA and Bayer-Schering. His MS research is funded by the Swedish Research Council.

Dr. Alexanderson has no conflict of interest to declare and is funded by the Swedish Council of Working Life and Social Research.

High body mass index before age 20 is associated with increased risk for MS in both men and women: results from the Epidemiological Investigation of Multiple Sclerosis (EIMS)

L. Alfredsson, A.K. Hedström, J. Hillert, T. Olsson

Karolinska Hospital (Stockholm, SE)

Objective: The relationship between obesity during adolescence and MS risk has previously been investigated using two large cohorts of American women1 in which obese female adolescents displayed an increased risk of developing MS. The aim of this study was to investigate whether the finding could be replicated and if it applies to men as well as to women.

Methods: The report is based on a population-based, case-control study, with 1571 incident cases and 3371 controls matched by age, gender and residential area. By means of logistic regression, the occurrence of MS in subjects belonging to different BMI groups was compared with that of normal weight subjects with BMI between 18.5-21 kg/m².

Results: Subjects whose BMI exceeded 27 kg/m² at age 20 had an increased risk of developing MS compared with normal weight subjects with BMI ranging between 18.5 and 21 kg/m² (OR 2.2 (95% CI 1.6–3.0) among those who had BMI between 27 and 29, and OR 2.2 (95% CI 1.5–3.0) among those who were obese). MS risk in subjects with BMI between 25 and 27 kg/m² was modestly increased (OR 1.4, 95%, CI 1.1–1.8).

The pattern of association was similar among men and women and the observed trend of a higher BMI resulting in a higher risk of developing MS was significant for both groups. There was no difference in current BMI between cases and controls.

Interpretation: Speculatively, the obesity epidemic may explain part of the increasing MS incidence as recorded in some countries. Measures taken against adolescent obesity may thus be a preventive strategy against MS.

Dr. Alfredsson receives research support from the Swedish Medical Research Council and Swedish Council for Working life and Social Research.

Dr. Hedström receives research support from the Swedish Association for Persons with Neurological Disabilities.

Dr. Hillert received honoraria for serving on advisory boards for BiogenIdec, Merck-Serono and Novartis and for speaker’s fees from BiogenIdec, Merck-Serono, Bayer-Schering, Teva and Sanofi-Aventis. He has served as P.I. for and received projects supported by BiogenIdec, Merck-Serono, and Bayer-Schering. His MS research is funded by the Swedish Research Council, Bibbi and Nils Jensens Foundation and the European Commission.

Dr. Olsson served on scientific advisory boards for Merck-Serono, Biogen Idec, and SanofiAventis; served as Co-editor of Current Opinion in Immunology; received speaker honoraria from Novartis and Biogen; and receives research support from Bayer Schering, Sanofi-Aventis, Biogen Idec, the Swedish Research Council, EU fp6 Neuropromise, EURATools, the Söderberg Foundation, Bibbi and Nils Jensens Foundation, the Montel Williams Foundation, and the Swedish Brain Foundation.

The study was supported by grants from the Swedish Medical Research Council; from the Swedish Council for Working Life and Social Research, the fp6 EU program Neuropromise, Bibbi and Niels Jensens foundation, Montel Williams Foundation, the Söderberg foundation, and the Swedish Association for Persons with Neurological Disabilities.

Aquaporin-4 antibodies in Korean patients with idiopathic inflammatory demyelinating diseases of the central nervous system

H.R. Yang, S.M. Kim, P. Waters, M. Woodhall, S.W. Ahn, K.K. Kim, S.Y. Pyun, J.E. Kim, J.S. Kim, J.J. Sung, K.S. Park, K.W. Lee

Seoul National University Bundang Hospital (Gyeonggi-do, KR); Seoul National University College of Medicine (Seoul, KR); Neuroimmunology group (Oxford, UK); Joong-Ang University College of Medicine (Seoul, KR); University of Ulsan College of Medicine (Seoul, KR); Seoul Medical Center (Seoul, KR)

Objective: To evaluate the diagnostic utility of aquaporin-4 antibodies (AQP4-Ab) for idiopathic inflammatory demyelinating diseases (IIDDs) of the central nervous system in Korea.

Methods: In total, 153 consecutive patients with IIDDs from three major hospitals in Korea were included. All were tested for AQP4-Ab using a cell-based assay at the John Radcliffe Hospital, Oxford, UK. Patients were evaluated for neuromyelitis optica (NMO), other NMO spectrum disorder (OTHER NMOSD), and multiple sclerosis (MS) according to the 2010 International panel criteria.

Results: Fourteen patients fulfilled the criteria for NMO, 64 were identified as OTHER NMOSD, 25 fulfilled the criteria for MS and 50 had either clinically isolated syndrome (CIS) or topographically restricted IIDD. Patients with NMO required a mean follow-up duration of 37.3 month before experiencing both optic neuritis and myelitis. AQP4-Ab test positivity in patients with OTHER NMOSD was only 21.9%. Subgroup analysis revealed that the test positivity was relatively high in myelitis with typical brain lesions of NMO group (75%) and recurrent longitudinally extensive myelitis (LETM) group (46.7%), but low in monophasic LETM group (5.7%), and recurret or bilateral simultaneous optic neuritis group (20%). About 40% of patients with limited manifestations of NMO would have fulfilled the 2010 International panel criteria for MS, without the antibody test results. After exclsuion of NMO and OTHER NMOSD, Korean patients with MS were AQP4-Ab-negative and had similar characteristics to those of Western patients. Some patients were AQP4-Ab-positive (4% of patients who had features of neither NMO, OTHER NMOSD, nor MS), but were not identified using the current criteria.

Conclusions: The AQP4-Ab assay can be crucial in the differential diagnosis of IIDDs in Koreans, because it facilitated the early diagnosis of most NMOs, showed low positivity in Korean patients with OTHER NMOSD, could prevent limited NMO patients from being misdiagnosed with MS. In addition, because some IIDD patietns who did not have features of NMO or OTHER NMOSD can show the positive test results, clinical suspicion for the atypical manifestation of NMO or aquaporinopathy is needed.

Dr. Waters is a named inventor on a patent relating to assays for the detection of antibodies to Lgi1, Caspr2, and Contactin2 and may receive royalties for this technology. Dr. Waters receives research support from the Oxford NIHR Biomedical Research Centre and has received a speaker honorarium from Biogen Idec, Japan.

Dr. Yang Hye-Ran, Dr. Kim Sung-Min, Dr. Woodhall, Dr. Ahn Seok-Won, Dr. Kim Kwang-Kook, Dr. Pyun So Young, Dr. Kim Jee-Eun, Dr. Kim Jun-Soon, Dr. Sung Jung-Joon, Dr. Park Kyung Seok, and Dr. Lee Kwang-Woo has nothing to disclosure.

This work was supported by grant no. 2010-0024457 from the National Research Foundation of Korea Fund and by grant no. 800-20100089 from the Seoul National University, College of Medicine Research fund.

PW acknowledge funding from the Oxford NIHR Biomedical Research Centre. PW and MW acknowledge funding from the NHS National Commissioning Group for rare diseases.

The clinical outcomes associated with adherence to and discontinuation of disease-modifying treatments

J. Burks, E. Malangone, M. Jhaveri, S. Zhou, L. Stern, S. Bhurke, R. Casciano

Multiple Sclerosis Association of America (Cherry Hill, US); Analytica LA-SER International, Inc. (New York, US); Sanofi US (Bridgewater, US)

Background: Adherence to disease-modifying treatments (DMTs) may result in better clinical outcomes, such as lower rates of relapses and multiple sclerosis (MS)-related hospitalizations. However, “real world” evidence from US managed care is limited.

Objective: To compare clinical outcomes for MS patients who were non-adherent to or discontinued DMTs with adherent patients in a large US managed care database.

Methods: Medical and drug data from the MarketScan® Research Database were evaluated for eligible patients (diagnosis of MS [ICD-9 340.xx] or a prescription for interferon β-1a, interferon β-1b, glatiramer acetate, or natalizumab) from January 2005 through December 2010. The number of relapses (≥1 MS-related hospitalization or ≥1 outpatient visit plus corticosteroid use within 7 days) and level of resource utilization were examined during 12-months of follow-up for 4 patient groups, based on treatment adherence: untreated (no DMT claims during follow-up or baseline), adherent (≥1 DMT claim and DMT coverage ≥80% of follow-up), non-adherent (≥1 DMT claim and DMT coverage <80% of follow-up), and discontinued (no DMT for 6 months and no restart; no DMT in the last 6 months of follow-up).

Results: In the overall study population (n=43,054), 41.8% of patients were untreated, 37.4% were adherent, 13.5% were non-adherent, and 7.3% had discontinued. “Uncontrolled” MS (>1 relapse) during the 12-month follow-up was reported for 10.6% (1,702/16,114) of adherent patients, 13.9% (805/5794) of non-adherent patients, and 15.8% (499/3162) of discontinued patients. In the adherent, non-adherent, and discontinued groups, respectively, the mean (standard deviation [SD]) number of MS-related inpatient visits was 0.07 (0.34), 0.11 (0.48) and 0.16 (0.60), and the mean (SD) number of MS-related emergency room visits was 0.06 (0.38), 0.08 (0.38), and 0.11 (0.76), respectively. Based on a multivariate logistic regression model to account for relevant patient characteristics, the risk of MS-related relapse during follow-up was 38% higher for non-adherent and 54% higher for discontinued versus adherent patients (both P<0.0001). The risk of MS-related hospitalization during follow-up was 54% higher for non-adherent and 73% higher for discontinued versus adherent patients (both P<0.0001).

Conclusions: Patients who were adherent to their DMTs had a lower risk of relapse and MS-related hospitalization compared with those who were non-adherent to or discontinued therapy.

Jack Burks has served as a consultant and on speakers’ bureaus for Acorda, Allergan, Avanir, Bayer, Novartis, and Serono, and as a consultant for Sanofi-Aventis/Genzyme.

Elisabetta Malangone is an employee of Analytica LA-SER, which received funding from Sanofi for this work.

Mehul Jhaveri is an employee of Sanofi, US.

Steve Zhou is an employee of Sanofi, US.

Lee Stern is an employee of Analytica LA-SER, which received funding from Sanofi for this work.

Sharvari Bhurke is an employee of Analytica LA-SER, which received funding from Sanofi for this work.

Roman Casciano is an employee of Analytica LA-SER, which received funding from Sanofi for this work.

Comparison of time to discontinuation among multiple sclerosis patients receiving fingolimod and other first-line disease-modifying treatments

N. Agashivala, N. Wu, Y. Wu, E. Kim, L. Boulanger, D. Brandes

Novartis Pharmaceuticals Corporation (East Hanover, US); United BioSource Corporation (Lexington, US); Hope MS Center (Knoxville, US)

Background: Fingolimod, the first oral disease-modifying therapy (DMT) approved by the US Food and Drug Administration, has a different tolerability profile that may improve adherence to multiple sclerosis (MS) treatment compared to injectable DMTs.

Objective: To compare the time to treatment discontinuation between patients receiving fingolimod and other first-line DMTs indicated for the treatment of MS.

Methods: Using pharmacy claims from Medco Health Solutions, Inc, patients who initiated one of the following DMTs between October 2010 and February 2011 were identified: fingolimod, interferon β-1b, subcutaneous interferon β-1a, glatiramer acetate, and intramuscular interferon β-1a. Initiation was defined as no prescription fill for the same DMT in the prior 12 months. Patients who did not receive any DMT in 12 months before index date were considered as naïve DMT users. The proportion of patients discontinuing index DMT during the 12 months following initiation was compared between DMT cohorts where discontinuation was defined as a 60-day or longer gap of index DMT supply. A Cox proportional hazard model was estimated to compare time to discontinuation between the DMT cohorts.

Results: Of the 1,891 MS patients who initiated DMT (mean age: 45.7; female: 76.4%), 13.1% initiated fingolimod, 10.7% interferon β-1b, 20.0% intramuscular interferon β-1a, 18.8% subcutaneous interferon β-1a, and 37.4% glatiramer acetate. The proportion of patients discontinuing index DMT was significantly lower in the fingolimod cohort than other DMT cohorts (fingolimod: 27.8%; other DMT cohorts: 42.7-54.5%; all p<0.01). Cox models found that patients receiving injectable DMTs discontinued sooner than DMT users on fingolimod; the association was generally stronger in experienced DMT users (interferon β-1b: hazard ratio [HR]=2.83, 95% confidence interval [CI]: 1.62-4.93; intramuscular interferon β-1a: HR=2.43, 95% CI: 1.49-3.97; subcutaneous interferon β-1a: HR=2.42, 95% CI: 1.54-3.82; glatiramer acetate: HR=1.73, 95% CI: 1.11-2.69) than naïve users (interferon β-1b: HR=1.90, 95% CI: 1.25 -2.89; intramuscular interferon β-1a: HR=1.53, 95% CI: 1.03-2.28; subcutaneous interferon β-1a: HR=1.58, 95% CI: 1.05-2.38; glatiramer acetate: HR=1.53, 95% CI: 1.04-2.24).

Conclusions: Patients who initiated fingolimod were less likely to discontinue treatment and discontinued later than patients using injectable DMTs.

Neetu Agashivala has nothing to disclose. Ning Wu has nothing to disclose. You Wu has nothing to disclose. Edward Kim has nothing to disclose. Luke Boulanger has nothing to disclose. David Brandes is affiliated with the following organizations: Biogen Idec, Teva, Novartis, Genzyme, Sanofi, Acorda (advisory panels), Biogen Idec, Teva, Novartis, Acorda, Questcor, Avanir (speaking panels), Biogen Idec, Teva (research support).

This research was funded entirely by Novartis Pharmaceuticals Corporation.

Towards personalised MS patient care - The Finnish MS Register

N. Oksala, P. Hartikainen, K. Koivisto, M. Laaksonen, A. Remes, J. Ruutiainen, M. Soilu-Hänninen, M.-L. Sumelahti, P. Tienari, I. Elovaara

StellarQ Inc. (Turku, FI); University of Kuopio (Kuopio, FI); Seinäjoki Central Hospital (Seinäjoki, FI); Masku Neurological Rehabilitation Center (Masku, FI); University of Turku (Turku, FI); University of Tampere (Tampere, FI); University of Helsinki (Helsinki, FI)

Background: The incidence (6-12/100 000) and prevalence (100-200/100 000) of MS are high, geographically varying (2-fold incidence differences), and steadily increasing in Finland. Collection of real-life and -time data about the efficacy and safety of new and existing drugs is needed for cost-benefit evaluation. Information technology can be utilized to assess the natural history of untreated MS, to integrate stakeholders (experts, industry, patient organizations) and to control the quality of practice. Personalized MS care requires participation of the patient and tailoring the treatment according to patient biomarker and neuroimaging profile.

Present systems are not capable of providing these functions.

Goals: To integrate the broad Finnish MS community (experts, patient organization) by StellarQ technology project funded by Finnish Funding Agency for Technology and Innovation and industry (Biogen Idec Finland, Genzyme Inc, Novartis Finland, TEVA Finland) with the purpose to: 1) align standards of care, 2) monitor the quality and 3) cost-benefit of MS practice. To develop with a special emphasis on user interface (UI) design a cloud-based, structured data collection and real-time benchmarking platform with multi-user interfaces and clinical assessment tools.

Methods: After structured interview of MS key opinion leaders and patients, agile software project utilizing UI designers and programmers was initiated. The key features of UIs were conceptualized and developed.

Results: The project was launched in June 2011 and the StellarQMS software was developed in 2 weeks sprints within 4 months. The system provides the physician with global cloud based, secure and easy to use recording of patient background, medication, status, imaging and laboratory results and automated calculation of EDSS (StellarQ SmartEDSS) utilizing the structured data and reducing inter-rater variability. The program provides interactive benchmarking graphs with all the vital data in real time and the data can be entered in the system within 10 minutes per patient and monitored (without patient identification) by the national steering board.

Conclusions: Agile programming can be effectively utilized to develop user friendly mobile technology which will enable steps towards more personalized MS patient care. In ECTRIMS 2012, standardized MS cases will be presented and participants be asked to determine the EDSS utilizing the conventional methodology and by automated SmartEDSS system.

The authors have nothing to disclose.

www.msregistry.eu: interactive online registry for self-monitoring by people with multiple sclerosis and clinically isolated syndrome

P. Jongen, M. Heerings, A. Kool, E. Van Noort, A. Van der Zande

MS4 Research Institute (Nijmegen, NL); Nationaal MS Fonds (Maassluis, NL); Curavista (Geertruidenberg, NL)

Introduction: www.msregistry.eu is an interactive online registry for self-monitoring by people with (Pw) Multiple Sclerosis (MS) and Clinically Isolated Syndrome (CIS). It is initiated by the MS4 Research Institute and operated in collaboration with and financially supported by Nationaal MS Fonds and Curavista. Criteria for participation: Diagnosis MS or CIS; able to complete online questionnaires; access to the internet. Goals: (1) to enable long-term self-monitoring by PwMS, (2) to improve the quality and efficiency of care, (3) and to perform scientific research on disease course, therapeutic value of disease modifying and symptomatic treatments, and pharmaco-economs.

Methods: Assessment tools: Demographic and disease characteristics are recorded at registration. Symptoms and impact: Multiple Sclerosis Impact Profile (MSIP), an inventory and measure of disability (MSIP-D) and disability perception (MSIP-DP). Expanded Disability Status Scale (EDSS) is administered by phone. Health-related quality of life: MS Quality of Life-54 (MSQoL-54). Medication, adherence: Medication list. Frequency of assessments: 1) MSIP and MSQoL-54 every 6 months, 2) Medication list monthly. Calculated scores and graphs are made online available to participants. Participants may give care providers access to their data for evaluation of disease course or treatment effects. The online information may help to guide to adjustments in care or drug treatment in neurological practices with insufficient resources to systematically assess disability, impact and health-related quality of life.

Pilot results: In 2011 the questionnaires were successively implemented. PwMS or CIS were informed by the journal of the Nationaal MS Fonds and on the websites of MS organizations in the Netherlands. May 2012: 352 registered participants, 321 baseline assessments (91.2%); 41 care providers (1 in 8 participants) have access. Monthly medication assessment: 280, 271, 259, 251, 232, 220 at month 1 to month 6, respectively.

Conclusion and perspective: Pilot data indicate that 1) self-monitoring is feasible and 2) accepted by by PwMS or CIS, and that 3) care providers may be involved. Q2-Q3 2012: Full analysis of pilot data. Nationwide introduction of www.msregistry.eu to neurologists and nurses in the Netherlands.

Online availability of clinical scores may contribute to improved care in practices with limited resources. Aggregated data may inform on disease course and treatment effects.

P. Jongen has received honoraria from sanofi aventis, Teva, Merck Serono, Novartis, Bayer, Biogen Idec and Allergan for activities as speaker, advisory committee member or research support.

M.Heerings, A. Kool, E. Van Noort and A. Van der Zande have nothing to disclose.

Propensity score matching in large observational databases: a virtual trial comparing two doses of interferon-β-1a SC in MSBase

T. Kalincik, T. Spelman, H. Butzkueven on behalf of the MSBase Investigators

Background: International observational databases could be instrumental in obtaining answers to clinically relevant questions in large, representative populations.

Objective: To evaluate matching based on propensity scores in MSBase, an ongoing international MS registry.

Methods: MSBase comprises longitudinal clinical data over 100,000 patient-years from over 19,000 patients from 195 centres in 28 countries. The database was locked for analysis in February 2012. Inclusion criteria were as follows: treatment with interferon β 22ug or 44ug SC 3/week (Rebif, Merck Serono) as the first disease-modifying treatment, no change in commenced treatment and its dosage for at least 2 years and availability of baseline and follow-up (i.e. 2-year) clinical and demographic data. Propensity scores based on pre-treatment demographic, clinical and paraclinical variables for probability of allocation to the 22ug or 44ug dose of interferon were calculated and the patients were matched using the closest match algorithm in a 1:1 ratio. Clinical outcome measures (change in EDSS, annualised relapse rate and time to relapse) were compared between the matched groups.

Results: Patients fulfilling the inclusion criteria were n = 635 (22ug group) and n = 738 (44ug group). The baseline variables predicting higher probability of initial assignment to the 44ug treatment were: lower disability, 9 or more hyperintense T2 lesions on brain MRI, at least 1 Gd-enhancing brain lesion and absence of periventricular T2 lesions. Based on the calculated propensity score, 469 patients were matched in each group, with 358 non-matched patients excluded from the analysis. This resulted in very closely matched groups, as shown by all tested baseline variables (sex, age, MS duration, MS course, annualised relapse rate, disability, number of T2 and enhancing T1 brain and spinal cord lesions, numbers of periventricular, juxtacortical and infratentorial T2 lesions, cerebrospinal fluid status and family history of MS). We found no differences in EDSS change (median = 0, interquartile range = -0.5-0.5, both groups), annualised relapse rate (0.4±0.6, both groups) and time to first relapse between the two groups at the end of year 2.

Conclusion: Propensity score matching is feasible method of pseudo-randomisation in large observational registries. Treatment outcomes do not differ between patients receiving 22ug and 44ug of interferon β 3/week SC.

Supported by the MSBase Foundation: Tomas Kalincik received compensation for travel and honoraria from Biogen Idec, Sanofi Aventis, Teva and Merck Serono.

Tim Spelman received compensation for travel from Biogen Idec.

Helmut Butzkueven has served on scientific advisory boards for Biogen Idec, Novartis and Sanofi-Aventis, has served on steering committees for trials conducted by Biogen Idec and Novartis, received conference travel support from Novartis, Biogen Idec and Sanofi Aventis, and received research support from Merck Serono, Novartis and Biogen Idec in his capacity as honorary chair of the MSBase Foundation.

Impact of spasticity on healthcare resource utilisation: results of a cross-sectional study in the USA

R. Schapiro, D. Wynn, D. Lissin, A. AL-Sabbagh, E. Jones, J. Pike

The Schapiro Multiple Sclerosis Advisory Group (Eagle, US); Consultants in Neurology Ltd. (Northbrook, US); XenoPort, Inc. (Santa Clara, US); Adelphi Real World (Macclesfield, US); Adelphi Real World (Macclesfield, UK)

Background: Multiple sclerosis (MS) is a chronic, often progressive disease, frequently accompanied by functional impairment due to spasticity. It is hypothesised that as the severity of spasticity increases there is a corresponding impact on healthcare resource utilisation.

Objectives: To quantify the relationship between physician-reported severity of spasticity and use of healthcare resources specifically number of consultations with healthcare professionals and the requirement for a professional caregiver.

Methods: Data were drawn from the Adelphi MS Disease Specific Programme, a cross-sectional study of 125 neurologists in the USA, completing patient record forms for a total of 1641 consulting MS patients. Preliminary analysis using ANOVA with Bonferroni-corrected t-tests and Fisher’s Exact Test with Bonferroni corrections established that the most appropriate split was between the mild and moderate spasticity levels. Double robust estimates (combining propensity scoring with a weighted regression) were subsequently calculated to show the differences in healthcare resource use between patients with moderate or severe spasticity and those with no or mild spasticity. Confounding factors included Expanded Disability Severity Scale (EDSS), gender, age, body mass index, presence and number of concomitant conditions, compliance and MS type.

Results: Complete data were obtained for a total of 718 patients. Compared with patients with no or mild spasticity, the presence of moderate or severe spasticity was associated, over 12 months, with an additional 0.41 consultations with a neurologist (p<0.05), 0.97 additional consultations with an MS nurse (p<0.05) and 0.94 additional consultations with a physiotherapist (p<0.01). Across all healthcare professionals, moderate/severe spasticity was associated with a net increase of 1.49 visits over 12 months (p<0.01). It was also associated with an additional 0.12 emergency room visits over the same period (p<0.05). An additional 9.9% of moderate/severe spasticity patients required the assistance of a professional caregiver.

Conclusion: MS patients with moderate or severe spasticity increase the burden on the healthcare system compared with patients who have no or mild spasticity. Therefore a therapy that specifically addresses the severity of spasticity could have a positive socio-economic impact.

The authors have nothing to disclose.

Symptom profiles of individuals with multiple sclerosis grouped by levels of social support

K. Johnson, D. Amtmann, A. Verrall, V. Weir, A. Smith

University of Washington (Seattle, US)

Introduction: Social support has been associated with quality of life for people with multiple sclerosis (MS). Social support as a construct can represent both the adequacy of social relationships in patient’s lives as well as a metric for socio-economic status or a social determinant of health that is shaped by wider forces connected to health disparities and inequalities. The objective of this study was to examine symptom profiles including relative rates of pain, fatigue, physical and mental health, and psychological and cognitive functioning for individuals with MS grouped by high, medium, and low levels of social support.

Methods: PROMIS measures of depression, anxiety, fatigue, pain, sleep disturbance, wake disturbance, physical ability and Neuro-QoL measures of general and executive cognitive function were completed by 613 community-dwelling individuals with MS as part of a longitudinal survey (2008 - 2009). Scores were compared to US population norms by tertiles of the Multidimensional Scale of Perceived Social Support (MSPSS) low (N=209), medium (N=204) and high (N=200).

Results: Our data suggest an inverse relationship between symptom burden and social support. The low social support group reported higher levels of symptom burden on all measures as compared to the population norm (p < 0.001). The high social support group exhibited sleep and wake disturbance that were no different from the population norm (p > 0.05) and actually a reduction in anxiety and depression scores in contrast to the population norm (p < 0.001). In addition, we examined symptom burden by levels of self-efficacy with respect to MS management, which also revealed a similar pattern to social support (inverse relationship).

Conclusions: The striking finding that respondents who reported low levels of social support and low levels of MS Self Efficacy, reported high levels of emotional distress and overall symptom burden has clinical implications. It seems unlikely that addressing individual symptoms will result in significant change for individuals and that rather interdisciplinary interventions need be individualized and target multiple variables.

The authors have nothing to disclose.

A survey of patients with multiple sclerosis in Japan

T. Ohashi, S. Kurata, M. Kobayashi

Tokyo Women’s Medical University Yachiyo Medical Center (Chiba, JP)

In multiple sclerosis (MS), various sites of the central nervous system suffer damage. Therefore, both the combination and degree of such symptoms differ between each patient, and the influence that MS has on a patient’s daily life activities varies considerably.

We conducted a questionnaire survey in order to elucidate how MS patients deal with treatments and daily life activities to determine what kinds of support are needed.

The survey was conducted from October 28 to November 21, 2011 by postal mail. The patients could also complete the questionnaire at a special website established by the “MS Cabin” association. We analyzed the answers obtained from 785 patients who had been diagnosed as definite or probable MS. Most subjects (65%) were in their 30’s or 40’s, and the sex ratio was about 1 male to 3 females.

Common initial symptoms were motor weakness (47%), sensory disturbance (45%) and visual impairment (38%). Patients tended to visit ophthalmology or orthopedic clinicss first (19% and 18%, respectively). In 21% of the patients, it took more than 2 years until a diagnosis was made.

Although most patients (84%) realized that different treatments were needed in the acute and remission phases, 16% of them were not treated by disease-modifying therapies (DMT). The main reason was their physician had determined DMT to not be necessary (42%) since the symptoms had been mild. Additionally, DMT had been halted for some reason (various) in 16%, while 13% did not want to begin DMT.

The most troublesome symptoms were motor disturbance (50%), and a pricking or burning sensation (47%). In addition, vesicorectal disorders (32%) and visual impairment (20%) were also noted to be troublesome. In the workplace, 63% of patients were affected by physical disability, and a decline in their physical strength was a problem in 66% of them. In addition, 46% of the patients found it difficult to obtain sufficient understanding of their disease by their colleagues and superiors, because their symptoms were sometimes unclear to others.

The number of MS patients is increasing year by year in Japan, but, the prevalence is still quite low, and MS is still not widely recognized among the general public. MS still tends to be diagnosed late, and early treatment is not performed as often as necessary. We therefore need to educate the general public about MS in order to increase the understanding of MS in Japan.

The authors have nothing to disclose.

Fingolimod reduces magnetic resonance imaging inflammatory lesion activity versus placebo in patients with relapsing–remitting multiple sclerosis: results from the phase 3 FREEDOMS II study

E.-W. Radue, D. Goodin, D. Jeffery, L. Kappos, F.D. Lublin, K. Rammohan, A.T. Reder, T. Vollmer, M.A. Agius, L. Cappiello, T. Stites, B.B. Li, M. Malhotra, P. von Rosenstiel, P.A. Calabresi

University Hospital Basel (Basel, CH); University of California (San Francisco, US); Cornerstone Health Care (North Carolina, US); Mount Sinai Medical Center (New York, US); University of Miami (Miami, US); University of Chicago Medical Center (Chicago, US); University of Colorado Denver (Aurora, US); University of California at Davis (Davis, US); Novartis Pharmaceuticals Corporation (East Hanover, US); Novartis Pharma AG (Basel, CH); Johns Hopkins Hospital (Baltimore, US)

Background: Fingolimod significantly reduced inflammatory magnetic resonance imaging (MRI) lesion counts vs intramuscular interferon β-1a in TRANSFORMS or placebo (PBO) in FREEDOMS.

Objectives: To report MRI findings from FREEDOMS II, a phase 3, 2-year, PBO-controlled study of fingolimod 0.5mg and 1.25mg in relapsing–remitting multiple sclerosis.

Methods: Patients (n=1083) received fingolimod 0.5mg (n=358), 1.25mg (n=370), or PBO (n=355) for 24 months (M). MRI was performed at baseline and 6, 12 and 24M; endpoints included new/newly enlarged T2 and gadolinium-enhancing (Gd+) T1 lesion counts, and change from baseline in lesion volume for Gd+, T1 hypointense and T2 lesions. Between-group differences in number of new/newly enlarged T2 lesions were analysed using a negative binomial regression model adjusted for treatment and region. Gd+ T1 lesion count and lesion volume changes were analysed using a rank analysis of covariance model adjusted by treatment, region and baseline lesion count or volume, respectively.

Results: Fingolimod-treated patients had significantly fewer new/newly enlarged T2 lesions than patients receiving PBO as early as over 0–6M (mean number: 0.5mg, 0.8; 1.25mg, 0.8; placebo, 2.9; all p<0.001), over 0–12M (0.5mg, 1.2; 1.25mg, 1.2; placebo, 5.2; all p<0.001) and maintained over 0–24M (0.5mg, 2.3; 1.25mg, 1.6 PBO, 8.9; all p<0.001); more patients were free from new/newly enlarged T2 lesions with fingolimod vs PBO over 0–6M and over 0–24M (0.5mg, 50%; 1.25mg, 63%; PBO, 26%). Gd+ lesion count was significantly lower with fingolimod vs PBO (all p<0.001) at 6M (0.5mg, 0.2; 1.25mg, 0.2; PBO, 1.1), 12M (0.5mg, 0.2; 1.25mg, 0.2; PBO, 1.3) and 24M (0.5mg, 0.4; 1.25mg, 0.2; PBO, 1.2). More patients with fingolimod vs PBO were free from Gd+ lesions at each study time point up to 24M (0.5mg, 87%; 1.25mg, 96%; PBO, 65%). Gd+ lesion volume was significantly reduced vs PBO at 6M and remained stable up to 24M (p<0.001 at all time points). Median T2 lesion volume (mm3; absolute and per cent change) decreased from baseline over 24M with fingolimod (0.5mg, −91.6, −7%; 1.25mg, −163.1, −10%) and increased with PBO (31.5, 1%; both p<0.001). Median T1 hypointense lesion volume (mm3) decreased in all groups over 24M (0.5mg, −14.3, −9.9%; 1.25mg, −14.3, −10.9%; PBO, −5.7, −8.5%).

Conclusions: Fingolimod significantly reduced inflammatory activity in the brain as assessed by MRI versus PBO, with a rapid onset and sustained duration.

This study was funded by Novartis Pharma AG, Basel, Switzerland.

E W Radue has received research support (mainly for MS projects) and lecture fees from: Actelion, Basilea, Bayer Schering, Biogen Idec, Merck Serono, Novartis and others. Lecture fees have have been mainly used for research funding at the Medical Image Analysis Center (former MS MRI Evaluation Center), University Hospital Basel.

Douglas S Goodin has received research support and/or speaker fees from Ares-Serono, Merck-Serono, Novartis, Berlex Laboratories, Bayer Schering HealthCare, Biogen-Idec, Schering AG and Teva Neuroscience.

Dr. Calabresi has received personal compensation for consulting and serving on scientific advisory boards or research funding from Biogen Idec, Teva, EMD Serono, Novonordisk, Novartis; Vertex, Genentech, Abbott, and Bayer.

L. Kappos received research support from Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CLC Behring, Elan, Genmab, Genmark, GeNeuro SA, GlaxoSmithKline, Lilly, Merck Sereno, Medicinova, Novartis, Novo Nordisk, Peptimmune, Sanofi-Aventis, Santhera, Roche, Teva, UCB and Wyeth.

Douglas Jeffery has received honoraria for speaking and consulting from Bayer, Biogen, Teva, Novartis, Acorda, and Genzyme. He has received research support from Bayer, Biogen, Teva, Serono, Pfizer, Novartis, Genzyme, Roche, and Acorda.

Anthony T Reder has received compensation from many of the sources below and is on the advisory board/consultant for: Abbott Laboratories, American Medical Association, Astra Merck, Athena Neurosciences, Aventis Pharma, Bayer HealthCare Pharmaceuticals, Berlex Laboratories, BioMS Medical Corp, Biogen and Biogen/Idec, Blue Cross, Blue Shield, Boehringer Ingelheim Pharmaceuticals Inc, Caremark Rx, Centocor, Inc, Cephalon, Inc, Connectics/Connective Therapeutics, CroMedica Global Inc, Elan Pharmaceuticals, Inc, Eli Lilly and Company, Genentech, Genzyme Corporation, GlaxoSmithKline, Hoechst Marion Roussel Canada Research, Inc, Hoffman-LaRoche, Idec, Immunex, Institute for Health Care Quality, Johnson & Johnson, Pharmaceutical Research & Development, Medlink/Neurobase electronic journal – editor and author, NARCOMS, National MS Society, NMSS & Paralyzed Veterans of America Neurocrine Biosciences, Novartis Corporation, Parke-Davis, Pfizer Inc, NY, Pharmacia & Upjohn, Protein Design Labs, Inc, Quantum Biotechnologies, Inc., Quintiles, Inc, RENEW study (post-marketing study of Novantrone in MS); Serono, Sandoz (now Novartis) and Novartis, Sention, Inc, Schering, Serono, Smith Kline-Beecham, Specialized Therapeutics, a division of Berlipharm, Inc, Takeda Pharmaceuticals and Teva-Marion, and has also received research support from Bayer, Serono, Teva, and the US National MS Society.

F Lublin has received research funding from: Acorda Therapeutics, Inc.; Biogen Idec; Novartis Pharmaceuticals Corp; Teva Neuroscience, Inc.; Genzyme; Sanofi; Celgene; NIH; NMSS. Consulting Agreements/Advisory Boards/DSMB: Bayer HealthCare Pharmaceuticals; Biogen Idec; EMD Serono, Inc.; Novartis; Pfizer; Teva Neuroscience; Actelion; Sanofi-Aventis; Acorda; Questcor; Roche, Genentech; Celgene; Johnson & Johnson; Revalesio; Coronado Bioscience, Genzyme, MedImmune; Bristol-Myers Squibb.

Dr. Timothy Vollmer has received compensation as a consultant or for service on advisory boards and/or steering committees from Teva Neuroscience; Biogen Idec; Elan Pharmaceuticals; Hoffman-LaRoche, Accelerated Cure Project; Genzyme; Bristol-Myers Squbb; Novartis Pharmaceuticals; Acorda Pharmaceuticals and the Consortium of MS Centers, and has received research funding from Teva Neuroscience; Biogen Idec; Genzyme, Ono Pharmaceuticals, Lilly Research Laboratories, Novartis Pharmaceuticals, BioMS Technology Corp; Orasi, Sanofi Aventis, EMD Serono and the NIH.

K Rammohan: Consultant and advisory Board member for Acorda, Teva, Biogen, Genzyme, EMD Serono, Novartis, and Roche / Genentech. Grant support from Acorda, Biogen, Teva, Roche / Genentech and EMD Serono.

M Agius has received consultant or speaker fees or research support from Novartis, Teva, Biogen Idec, Genzyme, Roche, Actelion and Accorda.

M Malhotra was an employee of Novartis Pharmaceuticals Corporation at the time of the study and is now an employee of Takeda Pharmaceuticals.

P von Rosenstiel is an employee of Novartis Pharma AG.

L Cappiello, T Stites and B Li are employees of Novartis Pharmaceuticals Corporation.

Sexual disorders evaluation among people with multiple sclerosis: features and clinical correlations

C. Cornut-Chauvinc, M. Lauxerois, P. Clavelou on behalf of the Reseau SEP Auvergne

Objective: Sexual disorders (SD) are frequent, often underestimated and/or neglected by neurologists and patients. However SD affects young people and severely impacts their quality of life. Based on investigation of the frequency and the features of SD for multiple sclerosis (MS) patients, our study aims to establish relationship between clinical data and identify predictive factor of SD.

Methods: We developed a structured survey form sent by mail to eligible patients. Six questionnaires were selected, related to sexual dysfunction, (international index of erection function, sexual expectation evaluation in multiple sclerosis, multiple sclerosis intimacy and sexuality questionnaire-19), anxiety (STAI form YA and YB), depression, (Beck questionnaire) and quality of life (SEP-59). Inclusion criteria were: age comprised between 20 and 60, disability inferior to 7.0 measured by Expended Disability Status Scale (EDSS), no cognitive impairment and relapsing remitting MS.

Results: Out of three hundred eight eligible patients, hundred and forty one returned the questionnaires achieving a response level of 45, 7%. Sixty-eight patients ( 55, 3%), suffered from SD. 49, 5% of women reported sexual dysfunction. Decreased libido for 77, 7% of women, was the most frequent primary SD; problems with concentration, for 74, 8% of the cases, was the most frequent secondary symptoms; low self –esteem and deteriorated body image existed for 66.7% of MS patients. Depression, measured with Beck’s depression scale was positively correlated with SD for women. SD were found in 81, 8% for men. The most frequent primary SD was erectile dysfunction for 75% of men. 68% described problems of concentration, the most frequent secondary SD. The most frequent tertiary SD was fear to not satisfy their sexual partner. We showed a correlation between disability, quality of life, mainly in five domains: pain, sexual satisfaction, sexual function, bladder dysfunction and cognition and SD.

Conclusion: Sexual disorders are frequent and correlated with disability. Depression is most frequent for women with SD. Quality of life is altered in patient with SD. Physicians have to ask patients about their sexuality to make easier the discussion and help them find appropriate solutions.

The authors have nothing to disclose.

Interest of a programme of rehabilitation training on bicycle ergometer at home on fatigue in MS

R. Colamarino, P. Givron, F. Taithe, B. Pereira, A. Vieuxrochas, C. Collange, E. Coudeyre

Centre Hospitalier Jacques Lacarin (Vichy, FR); CHU (Clermont-Ferrand, FR); CMPR Notre Dame (Chamaliéres, FR); Reseau sep Auvergne (Beaumont, FR)

Objectives: To measure the impact at 2 months of a program of rehabilitation training on bicycle ergometer at home on a fatigue among a population of patients younger than 50 years, who have a relapsing-remitting MS

Materials and methods: Multicentre non-randomized pilot study evaluating the feasibility of a program of physical training at home on a bicycle ergometer. Were included the patient with RRMS, complaining of fatigue predominantly on the physical dimension of less than 50 years without cardiovascular indications against a reconditioning program in the effort, with an EDSS <4, without cognitive impairment, or thrust in the last three months. Excluded were patients with locomotor pathology, neurological or cardiovascular not allowing the normal stationary cycling, with no motivation for a program of re-entrainment.

The intervention was an educational short (one hour) to the repackaging effort on a cycle ergometer (home delivery) at ventilatory threshold, 25 min per session, 3 sessions per week for 8 weeks The primary endpoint was fatigue 2 (EMIF), secondary endpoints membership qualitative and quantitative, walking speed (7.5 m test) and endurance (6 min test), quality of life (SF-36). The number of subjects required was 30.

Results: Achieving a autoprogramme home exercise on bicycle ergometer by 25 patients, allowed a significant improvement of fatigue on the total EMIF, walking speed and endurance, without significant effect on the quality of life .

Discussion: This study demonstrated the feasibility of a good home reentrainment cycle ergometer with limited supervision. The main limitations are lack of control group, a limited number of subjects, a low EDSS. The effect on the continuation of a long-term physical activity is unknown in the absence of monitoring.

References

1. Dettmers C et al. Endurance exercise improves walking distance in MS patients with fatigue. Acta Neurol Scand 2009 : 120 : 251-257.

2. Debouverie M et al. Validity of a French version of the fatigue impact scale in multiple sclerosis : Multiple Sclerosis 2007; 13 :1026-32

The authors have nothing to disclose.

PIEVII 59/69: semiology of urinary tracts infections in MS patients with clean intermittent catheterisation

M.C. Scheiber-Nogueira, C. Donzé, H. Hautecoeur, V. Neuville, S. Vukusic, S. Demaille

Hospices Civils (Lyon, FR); Hospital St Philibert (Lomme, FR); Hospital St Vincent (Lille, FR); CH Maubeuge (Maubeuge, FR); University Claude Bernard Lyon (Lyon, FR)

Introduction: Urinary tract infections (UTIs) are common in multiple sclerosis (MS). UTIs semiology in patients with clean intermittent catheterization (CIC) is not yet defined and can differ from signs found among general population.

Objective: To identify and clarify semiology of UTIs in MS patients with urinary disorders requiring CIC.

Methodology: We proposed to identify predictive value of clinical signs of UTIs meeting the definition of UTI in urine culture (UC): bacteriuria ≥103 cfu/ml. Urinary, neurological and general symptoms were collected during any request for UC (systematic or UTIs suspicion). Comparative descriptive statistical analysis and logistic regressions were constructed to identify criteria predictive of UC results.

Results: 55 patients, (women 67.3%, 49.9 ± 10.3 years old, EDSS 5.5 ±1.3; disease duration: 15.3± 9.0 years, SPMS 63.6%) were included. Patients with progressive MS (p=0.044), high EDSS (p=0.025) and history of bowel disorders (p=0.04) were correlated with positive UC. “Cloudy”, “foul smell in the urine”, increased pollakiuria, leakage and pelvic heaviness were predictive of UTIs (p<0.05). Multivariate analysis showed that patients with a pattern “UC for suspected UTIs” are more likely to have positive UC (OR 9.76).

Discussion: In this study, the most accurate signs of UTIs in MS on CIC were “cloudy urine”, smelly urine,” and increase preexisting urinary signs. Their presence must be achieving a UC to offer appropriate treatment.

Conclusion: This study precise the clinical signs of UTIs among MS patients on CIC and lead physicians to treat only symptomatic but not asymptomatic UTIs to prevent multiresistance bacteria.

This study was support by AGIRSEP program.

MC scheiber Nogueira, C Donzé, S Vukusik, V Neuville, P Hautecoeur, S demaille have nothing to disclose.

The clinical characteristics of multiple sclerosis in Maori are homogeneous with that of the national cohort

S. Alla, J. Pearson, G. Clarke, B. Taylor, D. Mason

New Zealand Brain Research Institute (Christchurch, NZ); University of Otago (Christchurch, NZ); Menzies Research Institute (Tasmania, AU); Christchurch Hospital (Christchurch, NZ)

Background and aims: In New Zealand (NZ), multiple sclerosis (MS) has a lower prevalence in Maori (24.2 per 100,000) than non-Maori (73.1 per 100,000). The aim of this study is to describe the clinical and demographic features of MS in NZ Maori compared with the national MS population (NMP).

Methods: A descriptive study with data sourced from the NZMS prevalence study (conducted on census day in 2006). Demographic data including ethnicity was obtained from a self-administered survey questionnaire while clinical information was sourced from the person’s medical record. MS diagnosis was based on the McDonald criteria 2005 and was confirmed by study neurologists. Disability was assessed using the Expanded Disability Status Scale (EDSS).

Results: Of the 2917 persons with definite MS 63 self-identified as Maori. The female to male sex ratio was 3:1 in the NMP and 2.1:1 in Maori. The average age (years) at the onset of symptoms was 34.5 ± 11.4 for NMP and 33.9 ± 10.7 for Maori. The time delay between the onset of first symptom and diagnosis was 4.75 ± 6.5 and 4.44 ± 6.0 years respectively for NMP and Maori. The most common first symptom was of spinal cord origin in both NMP (36%) and Maori (50.8%); however a significant difference (p = 0.017) was noted between the groups (odds ratio: 1.84, 95% CI: 1.08 - 3.11). The second most common first symptom was optic neuritis in both (NMP- 17.1%; Maori- 15.9%). Relapsing-remitting type of MS was the most common phenotype in both NMP (50.6%) and Maori (54%). The mean EDSS was 3.9 ± 2.7 for NMP and 4.1 ± 2.9 for Maori.

Conclusion: The clinical characteristics of MS in Maori appear to be homogeneous with that of the NMP apart from the higher rate of disease with spinal onset. Unlike low prevalence groups in Asia the higher rate of spinal onset is not associated with a higher rates of optic neuritis.

The authors declare that there are no conflicts of interest.

Source of funding: The National MS Society of New Zealand, the New Zealand Brain Research Institute and the University of Otago, Christchurch, New Zealand.

Brain MRI correlates of cognitive function in early treated MS and clinically isolated syndrome

M. Cohen, H. Joly, B. Brochet, P. Clavelou, E. Lepage, P. Vermersch, C. Lebrun on behalf of Qualicis Study Group

Introduction: Cognitive impairment (CI) is frequent and can be detected early in clinically isolated syndrome (CIS) and multiple sclerosis (MS).

CI is considered to be mainly correlated to diffuse brain injury assessed by techniques such as brain atrophy or non-conventional MRI measures.

Whether a single test can detect CI in CIS and MS patients or not is still debated. However, Symbol Digit Modalities Test (SDMT) is considered as one of the easiest and most efficient test to detect alteration of information processing speed.

Objective: To compare correlation between brain MRI and SDMT in CIS and MS patients.

Method: Our 3-year, prospective longitudinal study included patients who had either CIS fulfilling 2005 McDonald criteria or clinically definite MS. Patients started their first disease modifying drug (DMD) at the inclusion (subcutaneous β interferon).

Annual assessment included EDSS score, SDMT, and 1.5T conventional brain MRI (T1 with and without gadolinium injection, T2 spin echo, proton density and FLAIR sequences). Images were analysed using the SepINRIA software to obtain T2 lesion load (LL) and brain parenchymal fraction (BPF).

Results: 60 patients were included. Mean age was 32 years (16-49), F/M sex ratio was 2.2. Mean baseline EDSS was 1 (0-5). Mean disease duration was 6 months in CIS group and 30 months in MS group (p<0.0001).

CIS patients (n=35) differed from MS group (n=25) by a lower EDSS score (0.8 vs. 1.7, p=0.003), a higher SDMT score (54.8 vs. 44.7; p=0.008) and a lower T2-LL (2.8 vs. 6.5 cc3, p=0.002). BPF was not significantly different between the two groups (91.7% vs 90.5%, p=0.2).

In the CIS group, SDMT was inversely correlated to T2-LL (R=-0.47; p=0.04). No correlation was found with BPF.

In the MS group, SDMT was correlated to BPF measure (R=0.62; p=0.01). No correlation was found with T2-LL.

Discussion: Both inflammatory and degenerative process seem to be relevant to explain cognitive dysfunction in MS. Impact of T2 lesions seems to be more important in early disease course. Brain atrophy may be difficult to measure during the first months of evolution but becomes relevant after a few years of evolution.

Longitudinal follow-up is ongoing to assess the impact of DMD on MRI parameters and cognitive function.

This study received a grand from Bayer Schering Pharma and Merck Serono.

Disability scale in multiple sclerosis and gait profile: a direct correlation

B. Heredia Camacho, A. Hochsprung, M. Castillo, G. Izquierdo

Virgen Macarena Hospital (Seville, ES)

Background: Gait alteration is one of the first symptoms which appear in Multiple Sclerosis (MS). Once diagnosis is confirmed, gait must be evaluated. At the same time, patients are classified according to the Expanded Disability Status Scale (EDSS), by Kurtzke.

Objectives: The goal of this study was to identify some gait parameters in MS and their correlation with patients’ disability classification.

Methods: Patients with confirmed MS diagnosis (n=108; 43 men; 65 women; between 17 years-old and 71 years-old), who signed an informed consent were included in this study. Gait analyses were conducted along an 8-metre electronic pathway, with or without aids. A Functional ambulatory profile (FAP) and some temporo-spatial parameters (Velocity and Cadence) were obtained.

They were divided into 14 groups based on EDSS scores, between EDSS=0.0 and EDSS=7.0. An average value was obtained from FAP, velocity and cadence, and it had a correlation between these three parameters and EDSS score. An ANOVA one-way test and a post-Bonferroni test were made with the SPSS statistical program, and a graphic was designed.

Results: There were decreased values in FAP score, velocity and cadence, while EDSS score was increased, confirming a negative correlation. The interaction between the three variables was significant (,000) (p<0,0001). The most significant decrease was between the group with an EDSS score of 2.0 and 2.5 in relation to FAP. Concerning Velocity and Cadence, the most significant decrease was between 2.5 and 3.0 EDSS score groups. Another important change is observed between an EDSS score of 5.0 and 5.5, becoming the highest decrease in EDSS score.

Conclusions: Concerning gait, significant functional differences seem to appear between an EDSS score of 2.0-2.5 and 3.0; and the same variation is observed between an EDSS score of 5.0 and 5.5.

Furthermore, functional gait analyses, especially including cadence, velocity and FAP in patients with MS, can be useful in order to manage changes in the functional state of the patients.

The authors have nothing to disclose.

PIEVII 59/69: semiology of urinary tracts infections in MS patients who don’t use clean intermittent catheterisation

C. Donzé, S. Demaille, P. Hautecoeur, V. Neuville, S. Vukusic, M.C. Scheiber Nogueira

Hospital St Philibert (Lomme, FR); Hospital St Vincent (Lille, FR); CH Maubeuge (Maubeuge, FR); University Claude Bernard Lyon (Lyon, FR); Hospices Civils (Lyon, FR)

Introduction: Urinary tract infections (UTIs) are common in multiple sclerosis (MS). Definition of UTIs includes a positive UC combined with clinical signs but in MS UTIs semiology varies and differs from signs usually found among general population.

Objective: To identify and clarify semiology of UTIs in MS patients with urinary disorders and evaluate predictive value of clinical signs of UTIs in this population.

Methodology: This prospective observational study included MS patients with urinary disorders but not using clean intermittent catheterization. It was conducted to identify predictive value of UTIs symptoms (clinical signs correlated with bacteriuria ≥103 cfu/ml). Urinary, neurological and / or general symptoms were collected during any request for urine culture (UC).

Results: 90 RRMS patients (40.2± 9 years old, EDSS 3.9 ± 1.7; disease duration: 10 ± 6.4 years) and 70 SPMS (49.8 years old, mean EDSS: 5.9 ± 0.8; mean disease duration: 15.8 ± 9.2yrs) were included. 30% of patients had urine culture for UTI’s suspicion in both group. In RRMS group, “smelly urine”, increased preexisting urinary symptoms and general signs (p<0.05) were correlated with UC positive. In SPMS, the same signs were found in addition to worsening neurological symptoms especially in case of hyperthermia (p<0.05).

Discussion: Worsening of pre-existing urinary signs, urine smelly, general symptoms were signs to be considered differently depending on clinical form of MS (RRMS /SPMS).

Conclusion: Semiology of UTI in MS differs from signs described among general population. Their presence must be achieving a UC to offer appropriate treatment.

This study was support by the AGIRSEP program.

C Donzé, S Demaille, S Vukusic, MC Scheiber Nogueira, P Hautecoeur, V neuville have nothing to disclose.

Final results from the Avonex(R) (intramuscular interferon-β-1a) pregnancy exposure registry

S. Tomczyk, S. Richman, K. Wallace, S. Liu, B. Sperling

Biogen Idec Inc. (Weston, US)

Background: The onset of multiple sclerosis (MS) typically occurs between the ages of 20 and 40 years, often affecting women during their reproductive years. The high prevalence of MS in women during their reproductive years means that use of disease-modifying therapies (DMTs) is likely to be widespread among women of childbearing potential. A formal pregnancy registry was established in the United States in January 2003 to prospectively evaluate the effects of intramuscular interferon β-1a (IM IFN β-1a) on pregnancy outcomes. This registry has been completed.

Objective: Analyze prospective pregnancy outcomes in women with MS who were exposed to IM IFN β-1a within approximately 1 week of conception or during the first trimester of pregnancy.

Methods: The AVONEX Pregnancy Exposure Registry was a prospective observational pregnancy registry conducted in the United States. Information on IM IFN β-1a exposure, potential confounding factors (eg, medical and gestational history, other medications, smoking, and/or alcohol use), and pregnancy outcomes was collected at registration (baseline), 4-5 months of pregnancy, and 8-12 weeks post partum (paediatric follow-up) in order to detect any evidence of teratogenic effects or increased risk of spontaneous loss in pregnancies exposed to IM IFN β 1a.

Results: At registry completion, there were 302 evaluable pregnant women and 306 evaluable outcomes. Of the 306 outcomes, which included 4 sets of twins counted separately, there were 272 live births, 28 spontaneous abortions, 5 induced abortions, and 1 stillbirth. The rate of spontaneous abortions in women who enrolled prior to 22 weeks of gestation was 10.5% (28 of 266 evaluable pregnancies; 95% confidence interval, 7.2%-15.0%). Birth defects (cases with at least 1 major defect) were reported in 17 of 306 known outcomes.

Conclusions: The AVONEX Pregnancy Exposure Registry is the largest prospective registry for IM IFN β-1a to date. The spontaneous abortion rate observed in the registry is consistent with the 15% spontaneous abortion rate in the US general population. No patterns suggesting an unusual distribution of defects were observed and no specific signals of concern were found. The long-term impact of MS therapy on birth outcomes is important to understand and should be taken into consideration when making risk/benefit assessments and treatment decisions.

Supported by Biogen Idec Inc.

Dr. Tomczyk, Dr. Richman, Ms. Wallace, Dr. Liu, and Dr. Sperling are employees of Biogen Idec Inc.

Use of Glatiramer acetate during pregnancy: offering women a choice

A.E. Miller, S. Rustgi, C. Farrell

Mt. Sinai School of Medicine (New York, US)

Objective: To determine the willingness of women to use glatiramer acetate (GA) during attempted conception and throughout pregnancy and to assess outcomes of pregnancy in women remaining on GA.

Background: Multiple Sclerosis frequently affects women who desire pregnancy. Those taking disease-modifying agents face a dilemma. If they discontinue medication prior to attempting to conceive, they will lose drug protection. However, continuing medication may have risks to the fetus. Because GA has a Category B rating, we have prospectively suggested that women consider remaining on GA while attempting conception and during pregnancy.

Methods: Women taking GA who were contemplating pregnancy were counseled, as part of our standard care, about the pros and cons of remaining on GA while attempting to conceive and during pregnancy. They were told (1) they would have no protection from MS while off medication. (2) pregnancy is associated with lower relapse rate compared to non-pregnancy periods. (3) relapse rate is higher during the post-partum period, and (4) resumption of medication immediately after delivery might not be adequately protective during that more vulnerable period. The term “Category B pregnancy rating” was explained and the difficulty of knowing whether GA was truly safe was emphasized. Patients then decided whether to continue GA. For this study, information was retrospectively reviewed to determine patients’ decisions about continuing therapy and for pregnancy outcomes.

Results: 44 women were counseled about the potential use of GA during pregnancy. Only 7 patients initially discontinued GA; 9 remained on GA, but discontinued when pregnant. Among the 28 women who remained on GA, 37 pregnancies have occurred; 28 resulted in normal children and 3 are ongoing. One minor congenital anomaly required no intervention. Two pregnancies were terminated because of Trisomy 21 fetuses, thought unrelated to GA. One ectopic pregnancy and 3 other spontaneous abortions occurred (2 in one patient including 1 after IVF).

Conclusion: Most women offered the option of remaining on GA for pregnancy choose to continue the medication. These results in a limited number of patients suggest that GA may be safely continued during pregnancy.

Aaron Miller has served as a consultant for sanofi-aventis, Biogen Idec, Genzyme, Glaxo Smith Kline, EMD Serono, Merck Serono, Novartis, ONO Pharmaceuticals, Acorda, Nuron Biotech, and Teva and has received research support from Acorda, Novartis, Genentech, Genzyme, sanofi-aventis, Biogen Idec, and Roche.

Sheila Rustgi and Colleen Farrell have nothing to disclose.

The Italian version of the Motherhood Choice: a decision aid for women with MS considering motherhood

E. Bianchi, A. Giordano, E. Pietrolongo, A. Lugaresi, G. Fulcher, C. Borreani, M. Messmer Uccelli, A. Solari

National Cancer Institute Foundation (Milan, IT); Foundation IRCCS Neurological Institute C. Besta (Milan, IT); University G. d’Annunzio of Chieti-Pescara (Chieti, IT); MS Australia ACT/NSW/VIC (Lidcombe, AU); Italian MS Society (Genoa, IT)

Context: Multiple sclerosis (MS) generally manifests in the second to fourth decades of life; women are affected 2-3 times more than men, and disease prognosis is uncertain. As a result, reproductive choices for MS women are especially complicated. The Motherhood Choice, first decision aid (DA) for MS women considering motherhood, proved effective in a randomized controlled trial in Australia.

Objective: To devise the Italian version of the DA.

Methods: The study has 4 stages: (a) Translation of the most recent (2011) version of the DA. (b) Evaluation of the provisional Italian DA using ad hoc questionnaires completed by MS women (age 20-40 years) and MS health professionals (HPs). (c) Qualitative appraisal of the DA by 3 focus group meetings (FGMs; one in each geographic area). (d) Production of the Italian DA.

Results: (a) Five MS investigators, one native English speaker fluent in Italian (MMU) and the others native Italian speakers fluent in English (AG, AL, AS, EP) translated the original booklet. (b) The resulting provisional DA and an evaluation questionnaire were sent to MS women/HPs living in Northern (n=24/25), Central (n=13/9) and Southern Italy (n=13/4). Sixty-nine percent of the MS women wanted children, 12% did not want children, and 19% were undecided. The DA was considered “clear” by 86% of the women and 73% of HPs, “useful” by 93% (women and HPs), and the “personal worksheet” valuable by 81% (women) and 77% (HPs); 93% of the women would recommend the DA to other MS patients. (c) The Milan and Bari FGMs took place in March/May 2012; the Chieti FGM will be held in June 2012. Both completed FGMs lasted 2 h, participants were 18 MS women overall (aged 26-38 years), a moderator (EB) and a co-moderator (AS). The DA was found valuable for obtaining information and increasing awareness about motherhood with MS. Women viewed the booklet as a useful aid for discussion and interaction with partner/relatives and neurologist/gynecologist. The “personal worksheet” was much appreciated, but was considered inadequate in terms of font size and layout. Other limitations were absence of information on adoption and specific content for the partner, too little information on MS inheritance and on drugs for relapses during pregnancy and lactation (one participant experienced a relapse during pregnancy).

Conclusions: This translation and adaption process is progressing well. By early 2013 the “Motherhood Choice” will be available to Italian women with MS.

AL is a Biogen idec, Merck Serono and Bayer Schering Advisory Board Member. She received travel grants and honoraria from Bayer Schering, Biogen Idec, Merck Serono, Novartis, Sanofi Aventis and Teva and research grants from Bayer Schering, Biogen Dompé, Merck Serono, Novartis and Sanofi Aventis. AL has also received travel and research grants from the Associazione Italiana Sclerosi Multipla and is a Consultant of “Fondazione Cesare Serono”.

AS has received board membership fee from Novartis, Merck Serono, Biogen idec, amd speaker honoraria from Genzyme.

EB, AG, EP, GF, CB and MMU have nothing to declare.

This study was supported by the Fondazione Italiana Sclerosi Multipla (FISM) (grant 2010/S/2). The FISM also supported AG with a research fellowship (2009/B/4).

Neuromyelitis optica in pregnancy: treatment with intravenous immunoglobulin

M. Houtchens, K.H. Vo, L. Stazzone, H. Weiner

Harvard Medical School (Boston, US)

Objective: Our objective was to describe case series of three women with Neuromyelitis Optica (NMO) who were successfully managed with Intravenous Immunoglobulin throughout pregnancy.

Background: NMO is an autoimmune disease of the central nervous system (CNS) that may affect women in reproductive age. NMO pathogenesis has been suggested to mediate humoral immunity involving AQP4 antibody. Management considerations in women with NMO who chose to become pregnant, or receive NMO diagnosis at the time of pregnancy, are important in the overall scope of NMO therapy. To date, there is no published literature on NMO treatment outcomes and safety in pregnancy. Immune globulin IV (IVIG) is a solution of immunoglobulin, primarily immunoglobulin G (IgG), prepared from pooled plasma, which provides immediate serum concentrations of antibodies. IVIG has been used during pregnancy and the postpartum period in pregnant patients with relapsing-remitting MS to reduce relapse rates after delivery. IVIG can cross the placenta, but no fetal adverse effects have been reported. Immune system functions were found to be normal in infants born to mothers treated with IVIG.

Methods/Results: We describe three pregnant patients diagnosed with NMO in our clinic. Diagnosis was suspected clinically and confirmed by MRI findings and presence of AQP4 antibody in serum and spinal fluid. Two patients were diagnosed in their first trimester of pregnancy, and one patient became pregnant following 5 years of disease. All patients had clinically active disease, with attacks of myelitis, poorly responsive to corticosteroids. Treatment with monthly IVIG (1 g/kg ideal body weight per dose) was initiated on pregnancy week 16 and continued until delivery. Average IVIG patient dose was 310gm (280-350). All patients remained neurologically stable and free of new clinical disease activity throughout pregnancy. One patient developed pneumonia on pregnancy week 36 and required intravenous antibiotics. All patients had term delivered and there were no adverse fetal outcomes.

Conclusions: Our experience indicates that IVIG may be used safely and effectively in pregnant NMO patients. The Food and Drug Administration (FDA) designates a Pregnancy Category C (All Trimesters) for IVIG due to limited data regarding the administration of immune globulins to pregnant women; therefore, the potential risks and benefits must be carefully assessed before initiating treatment.

Maria Houtchens served as a consultant for BiogenIdec, Teva Neuroscience, Accorda Therapeutics, Novartis;

Huy Vo has nothing to disclose;

Lynne Stazzone has served as a consultant for Novartis;

Howard Weiner has served as a consultant for Biogen Idec, Novartis.

Predictive factors for postpartum relapses in multiple sclerosis

P. Duquette, M. Asano, E. Roger, C. Larochelle, S. Scott, N. Mayo

Centre Hospitalier de l’Université de Montréal (Montreal, CA); McGill University Health Center (Montreal, CA)

Background: Although the reduction in relapse rate during pregnancy for women with Multiple Sclerosis (MS) is well documented, the risk of experiencing a relapse during postpartum period still remains a concern and bears on the decision of when to resume MS treatment after delivery.

Objective: The purpose of this study is to estimate the extent to which the relapse occurrences vary across different peri-pregnancy time periods and to identify factors contributing to excess risk.

Methods: An historical cohort was assembled from the data base maintained by the MS Clinic at Centre Hospitalier Université de Montréal (CHUM) covering 11 peri-pregnancy time periods of 3 months each (four pre-pregnancy, three during pregnancy, and four post-pregnancy). 122 women contributed one pregnancy and 27 women contributed two. Logistic regression within the Generalized Estimating Equations framework was used to model the probability of a relapse during and after pregnancy as a function of time and accounting for the clustering of data within persons and pregnancies.

Results: The mean age at delivery was 30 years. 75% of the sample had an EDSS of 2 or less. The relapse rate calculated over pregnancies was higher in the pre-pregnancy period (0.51) than the post-pregnancy period. (0.19). In comparison to the pre-pregnancy period, the three trimesters of pregnancy were associated with a significantly lower risk of relapse (all ORs < 0.6). The first post-pregnancy period showed a higher risk of relapse (OR: 2.1; 95% CI: 1.4-3.2); subsequent time periods post-pregnancy showed significantly reduced risk. Relapses during pregnancy were not predictive of postpartum relapses. Predictors of early post-pregnancy relapse were: relapse in immediate pre-pregnancy time period (OR: 3.5; 95% CI: 1.3-9.0); age <25 at delivery (OR: 4.4: 95% CI: 1.2-16.0); EDSS non 0 (OR: 6.24; 95% CI: 1.89-20.62). Estimates of individual risk ranged from 0.034 to 0.882 depending on risk profile.

Conclusion: These data suggest that recommending delay of pregnancy until after the age of 25 years and for 3 months after a relapse would reduce the risk of post-pregnancy relapse. Women with a high risk for post-pregnancy relapse may consider MS treatment immediately after birth to reduce their risk.

The authors have nothing to disclose.

Pregnancy outcomes from the teriflunomide clinical development programme: retrospective analysis of the teriflunomide clinical trial database

B. Kieseier, M. Benamor, H. Benzerdjeb, O. Stüve

Heinrich-Heine-University (Düsseldorf, DE); sanofi (Chilly Mazarin, FR); University of Texas Southwestern Medical Center (Dallas, US)

Introduction: Teriflunomide is a new, oral, once-daily disease-modifying therapy in development for relapsing forms of multiple sclerosis. Teriflunomide inhibits the mitochondrial enzyme dihydro-orotate dehydrogenase, required for de novo pyrimidine synthesis, reducing the number of stimulated T and B cells. Cells such as resting memory T cells, which largely rely on existing pyrimidine pools, are not significantly affected by teriflunomide. Potential foetal risks from teriflunomide have been observed in some animal models. Despite the requirement that women participating in teriflunomide clinical studies use contraception, a number of pregnancies have been reported across the programme. Upon learning of the pregnancy, teriflunomide was instructed to be rapidly eliminated by cholestyramine or activated charcoal.

Methods: Pregnancies in female study patients were reported in the teriflunomide clinical trial database (data cut-off: 27 April 2012). Information on pregnancy outcomes was collected from patient files using a Drug Via Parent form.

Results: A total of 65 pregnancies were reported in female study patients (aged 22–45 years) across seven clinical studies. Upon learning of her pregnancy, the patient was instructed to discontinue her study treatment and undergo an elimination procedure (cholestyramine or activated charcoal). Forty-three of the 65 pregnancies were reported in patients exposed to teriflunomide; the remaining pregnancies occurred in patients treated with placebo, interferon β or blinded therapy. The outcomes of the 43 pregnancies in teriflunomide-treated patients were as follows: induced abortion, n=20; spontaneous abortion, n=8; healthy newborn, n=12; ongoing pregnancy, n=2; outcome pending, n=1. In the healthy newborns, no structural defects or functional deficits have been reported to date. In newborns for whom data are available, birth weights ranged from 2780 g to 4150 g, and the duration of foetal exposure was up to 65 days.

Conclusions: No structural or functional deficits were reported in newborns with prenatal teriflunomide exposure following rapid elimination. More prospective data are needed with respect to pregnancy outcomes.

Study supported by sanofi.

BK: Honoraria for lecturing, travel expenses for attending meetings, and financial support for research from: Bayer Schering, Biogen Idec, Merck Serono, Novartis, Roche, sanofi aventis, Talecris and Teva neurosciences.

MB: An employee of sanofi.

HB: An employee of sanofi.

OS: speaker fees (Teva Neuroscience), served as a consultant (sanofi-aventis, EMD Serono, Novartis, Pfizer, Teva Neuroscience, Roche and Genzyme). Supported by Merit Award (Dpt of Veterans Affairs), research grant (Dallas VA Research Corporation), career development grant (Doris Duke Charitable Foundation).

Birth hospitalisation in mothers with multiple sclerosis and their newborns

E. Lu, Y. Zhao, F. Zhu, M. van der Kop, A. Synnes, L. Dahlgren, A.D. Sadovnick, A.-L. Sayao, H. Tremlett

University of British Columbia (Vancouver, CA)

Background: Recent studies have found no association between multiple sclerosis (MS) and adverse perinatal outcomes, but the duration of birth hospitalization in mothers with MS and their newborns was not examined. Prolonged birth hospitalization may increase the risk of hospital-acquired infection and further strain scarce healthcare resources.

Objective: To compare the duration of the birth hospitalization in mothers with MS and their newborns versus the general population and investigate the impact of MS-related clinical factors on the length of birth hospitalization stays.

Methods: This retrospective cohort study linked the British Columbia (BC) Perinatal Database Registry (which captures >99% of births in BC) and the BCMS database (capturing >80% of MS patients in BC). The demographics and duration of the birth hospitalization in mothers and newborns were compared between women with MS (n=432) and the general population (n=2,975), frequency-matched by maternal age (±1 year), local health authority and delivery year from 1998 to 2009. Clinical factors investigated included disease duration and disability, as measured by the Expanded Disability Status Scale. A multivariable model (generalized estimating equations) was used to analyze the association between MS and duration of the birth hospitalization, adjusting for factors such as maternal age, diabetes, hypertension and consecutive births to the same mother.

Results: The median maternal age in both the MS and general population was 32 years. Mothers with MS were more likely to be first time mothers (p=0.01), hypertensive (p=0.046), not diabetic (p=0.01), smoke prenatally (p=0.03), have a higher BMI (p=0.02) with more antenatal visits (p<0.001). Compared to the general population, the median duration of the birth hospitalization differed little in mothers with MS (50.0 hours vs. 51.5 hours, +1.5 hours difference, adjusted p=0.53) and their newborns (50.4 hours vs. 52.5 hours, +2.1 hours difference, adjusted p=0.48). The duration of the birth hospitalization was not associated with disease duration (adjusted p>0.7) or disability (adjusted p>0.5).

Conclusions: Birth hospitalization has been understudied in women with MS. Contrary to some older studies, we found that MS was not associated with a longer birth hospitalization. This study provides assurance to expectant mothers with MS, their families and health care providers.

This study was funded by the Canadian Institutes of Health Research (Operating Grant MOP-106607; PI: Dr. Helen Tremlett). The British Columbia Multiple Sclerosis database is funded by CIHR, MS Society of Canada, National MS Society, the UBC MS/MRI Research Group and an unrestricted grant from Dr. Donald Paty.

Ms. Lu is funded by the Canadian Institutes of Health Research (Canada Graduate Scholarships: Master’s and Doctoral Research Awards), the Multiple Sclerosis Society of Canada (MSc and PhD Research Studentships) and the University of British Columbia (Graduate Entrance Scholarship and Faculty of Medicine Graduate Awards).

Dr. Zhao, Mr. Zhu, Ms. van der Kop, Dr. Synnes and Dr. Dahlgren report no disclosures.

Dr. Sadovnick has received: research support from the MS Society of Canada Scientific Research Foundation, and CIHR; speaker honoraria and/or travel expenses to attend conferences from: Biogen-Idec, Merck-Serono, Teva Neurosciences, Bayer.

Dr. Sayao was funded by the Multiple Sclerosis Society of Canada (Postdoctoral Fellowship).

BC MS Clinic Neurologists (in αbetical order) included: D. Adams, MD, FRCPC (Kelowna MS Clinic); D. Craig, MD, FRCPC (Kelowna MS Clinic); L. Daly, MD, FRCPC (Prince George MS Clinic); V. Devonshire, MD, FRCPC (UBC MS Clinic); S. Hashimoto, MD, FRCPC (UBC and Victoria MS Clinics); J. Hooge, MD, FRCPC (UBC and Prince George MS Clinic); O. Hrebicek, MD, FRCPC(Victoria MS Clinic); L. Kastrukoff, MD, FRCPC (UBC and Prince George MS Clinic); S. Meckling, MD, FRCPC (Kelowna MS Clinic); J. Oger, MD, FRCPC (UBC MS Clinic); D. Parton, MD, FRCPC (Victoria MS Clinic); A-L. Sayao, MD, FRCPC (UBC MS Clinic); A. Traboulsee, MD, FRCPC (UBC MS Clinic).

Dr. Tremlett is funded by the Multiple Sclerosis Society of Canada (Don Paty Career Development Award), Michael Smith Foundation for Health Research and is the Canada Research Chair for Neuroepidemiology and Multiple Sclerosis. She has received: research support from the US National Multiple Sclerosis Society, CIHR, and UK MS Trust; speaker honoraria and/or travel expenses to attend conferences from the Consortium of MS Centres, US National MS Society, the University of British Columbia Multiple Sclerosis Research Program, Bayer Pharmaceutical (speaker, 2010, honoraria declined), Teva Pharmaceuticals (speaker 2011), ECTRIMS (2011), UK MS Trust (2011) and the Chesapeake Health Education Program, US Veterans Affairs (2012, honorarium declined). Unless otherwise stated, all speaker honoraria are either donated to an MS charity or to an unrestricted grant for use by her research group.

Assessing Relapse in Multiple Sclerosis (ARMS) questionnaire: initial pilot data

A. Williamson, J. Smrtka, T. Flemming Tracy, C. Saunders, C. Easterling, A. Perrin Ross, J. Niewoehner, N. Mutschler

Neurology Center of Fairfax (Fairfax, US); Fort Lauderdale MS Center (Pompano Beach, US); Tanner Center and Foundation for MS (Birmingham, US); Neurology Center (Oceanside, US); MS Care Center, Neurological Services of Orlando (Orlando, US); Loyola University (Maywood, US); Questcor Pharmaceuticals, Inc. (Hayward, US)

Background: While many assessment tools for evaluating patients with multiple sclerosis (MS) are available to clinicians, a specific tool to evaluate patients when they present with a relapse and assess relapse treatment effectiveness is lacking. Subjective assessments may result in overlooked symptoms or adverse events (AEs), suboptimal therapeutic response, or lack of patient satisfaction with treatment. A need exists for a brief but comprehensive objective assessment tool to help clinicians evaluate relapse symptoms and their impact on patients’ daily functioning and patients’ perceived response to relapse treatment.

Methods: A 2-part questionnaire-the Assessing Relapse in Multiple Sclerosis (ARMS) questionnaire-was developed by a panel of expert MS nurses. Part 1 consists of 7 questions designed to evaluate relapse symptoms, impact on daily activities and overall functioning, and response to past treatments for previous relapses. Part 2 consists of 7 questions to evaluate treatment response in terms of symptom relief, functioning, and tolerability. The questionnaire is currently being piloted in 5 clinical practice sites.

Results: As of May 11, 2012, 79 patients (68 women, 11 men; mean [SD] age: 42 [11] years) have been enrolled and have completed Part 1 of the ARMS questionnaire. The most commonly reported relapse symptoms were numbness/tingling (62%), fatigue (61%), leg/foot weakness (53%), difficulty walking (52%), and dizziness (49%). Over half of patients reported that activities of daily living or overall functioning were affected very much (46%) or severely (13%). A total of 69 patients (59 women, 10 men; mean [SD] age: 43 [10] years) have completed Part 2. Prescribed treatments included corticosteroids (IV or oral; n=57; 83%) and adrenocorticotropic hormone (n=12; 17%). The mean (SD) symptom-improvement score (on a Likert scale from 0 [not at all] to 10 [completely resolved]) was 6.0 (3.0) and mean (SD) score for return to baseline (0 [no improvement] to 10 [completely]) was 5.9 (2.9). The most commonly reported AEs were sleep disturbance (n=27; 39%), mood changes (n=20; 29%), weight gain (n=18; 26%), increased fatigue (n=16; 23%), increased appetite (n=16; 23%), stomach upset (n=15; 22%), and headache (n=14; 20%).

Conclusions: Systematic assessment of relapses and response to relapse treatment may help clinicians to optimize outcomes for patients. Additional data from the pilot study will help to evaluate the utility of the ARMS questionnaire.

Funding source: This study was supported by Questcor Pharmaceuticals, Inc.

JS is a consultant for CAN DO MS Organization, PRIME (CME Company), and Consensus Medical Corporation; has received payment for lectures including service on speakers bureaus for Acorda, Bayer, EMD Serono, Novartis, Pfizer, Genzyme, Questcor, and Teva; and has received payment for development of education presentations from PRIME.

AW has received honorarium or fees for participating on Advisory board for Bayer, EMD Serono, Novartis, Questcor, and Teva Pharmaceuticals.

CS has been a consultant for Questcor Pharmaceuticals.

TFT has nothing to disclose.

CE has served as a consultant for PRIME, ACHL, Questcor, Allergan, EMD Serono, Biogen and Teva Neuroscience and has received speaking honoraria from Acorda, Bayer, Biogen, EMD Serono, Pfizer, Questcor, Genzyme, and Teva Neuroscience.

APR has received a consulting fee or honorarium and support to travel to meetings from Questcor and is a consultant for Acorda, Allergan, Teva, Questcor, EMD Serono, and Genzyme.

JN is an employee of Questcor.

NM is an employee of Questcor.

Longitudinal measures of instrumented gait and balance in multiple sclerosis over 18 months

R. Spain, M. Mancini, R. St. George, D. Bourdette, F. Horak

Portland VA Medical Center (Portland, US); Oregon Health & Science University (Portland, US)

Background: While gait and balance impairments are hallmarks of of even early MS, current stopwatch-timed measures are insensitive and poorly reproducible. Body-worn sensors housing gyroscopes and accelerometers collect objective clinic-based gait and balance data. We previously demonstrated that these sensors distinguish people with mild MS from healthy controls when standard timed tests could not (Spain et al, Gait Posture 2012).

Objective: This study compares the abilities of body-worn sensors versus stopwatch-timed tests to reliably capture gait and balance changes in people with MS over 18 months.

Methods: MS subjects with normal walking speeds (N=31) and age- and sex-matched control subjects (N=19) were tested using wireless sensors on the lower legs, lumbar back, sternum and wrists for the Timed Up and Go test and during 30-second trials of quiet stance with eyes open (EO) and eyes closed (EC). Fifty gait and 42 sway metrics were calculated using automated software. Clinical tests included the Timed 25 Foot Walk (T25FW), and self-rated disability, gait and balance questionnaires. Tests were repeated at 6 month intervals for 18 months. To assess longitudinal changes in objective measures and group differences, we performed a linear mixed model analysis.

Results: Gait and balance parameters (e.g. excessive postural sway area EC, reduced jerkiness of sway EC, excessive trunk rotation during gait) that distinguished mild MS from controls at the baseline visit continued to do so for most follow-up visits. Parameters most consistently distinguishing MS from controls related primarily to balance (p values from each visit demonstrating significant group differences): sway range EC (0.01, 0.001, 0.03, 0.007), sway area ratio EO/EC (0.004, 0.004, 0.05, 0.02), and normalized Jerk EC (0.04, 0.03, 0.02). Stride velocity during gait (0.02, 0.05) and sway area EC (0.007, 0.02) less consistently distinguished MS from controls. The T25FW failed to separate MS from controls at all time points. While no parameter worsened over time using group analysis, one subgroup improved while another worsened. Further subgroup analysis will determine which subjects improved versus worsened over time.

Conclusions: Body-worn sensors consistently distinguished mild MS from controls over 18 months while stopwatch-timed tests could not. The availability of small, wireless, body-worn sensors may provide sensitive, reliable and feasible outcome measures for clinical trials and practice.

Rebecca Spain, Martina Mancini, Rebecca St. George and Dennis Bourdette have nothing to disclose.

Fay Horak has a financial interest in APDM, a company that created the software used to analyze the mobility data in this study.

This research was supported by a pilot grant from the National Multiple Sclerosis Society and support from the Oregon Clinical and Translational Research Institute (OCTRI), grant number UL1 RR024140 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Dr. Spain is supported by a career development award from the Rehabilitation Research & Development service of the Veteran’s Administration.

Do motor impairments detected on onset of multiple sclerosis suggest an early second attack?

A. Kalron, Z. Dvir, A. Achiron

Sheba Medical Center (Tel-Hashomer, IL); Tel-Aviv University (Tel-Aviv, IL)

Introduction: Multiple sclerosis(MS)usually begins with a clinically isolated syndrome(CIS). Factors determining the CIS patient’s likelihood of developing MS are important for the clinician who needs to identify patients warranting immunomodulatory treatments and to patients who want to be informed about their diagnosis and their prospects. In our previous reports, we characterized motor deficits of CIS patients.We continued to follow the disease progression of the CIS group for one year. At end of the follow up period our data was further analyzed by subdividing the CIS patient’s into two groups: Patients who suffered from a second demyelinating event within the first year and those who sustained there clinical status.

Aim: The aim of the study was to determine whether motor abnormalities on initial demyelinating event suggestive of MS, suggest increased risk of a second event within the first year.

Methods: Fifty-two early onset CIS patients (36 women and 16 men), mean age 35.2±1.3 years (range 20-45),volunteered to participate in the study. Motor parameters collected at onset included:(a)peak isometric strength and isometric fatigue index of the knee flexors, extensors, ankle plantar flexors and dorsiflexors(b)Temporal-spatial parameters of gait were studied using the GaitRite system (c) Balance control was evaluated using the Posture Analyzer Model (d) Lesion load and atrophy were measured on a 3.0T brain MRI using MSAnalyze computerized software. At end of one year, patients were subdivided into two groups: Patients, who experienced a second demyelinating attack suggestive of MS and those who maintained there clinical status.

Results: Forty-nine patients were included in final analysis. Within the first year, 24 patients experienced a second attack, 25 maintained there neurological status. In those patients who experienced a second attack, significant decreases were found for peak isometric torque of knee extensors, ankle plantar and dorsi flexors and fatigue index of knee flexors, compared with the patients who sustained their clinical status. Additionally, this group demonstrated a 20.0% reduction of overall lower limb peak strength (411.9 (S.E=32.1) vs. 514.8 (S.E=34.1); P=0.02). No differences were found between groups in terms of gait and balance parameters.

Conclusion: An initial demyelinating event characterized by reduced lower limb strength can possibly suggest an increased risk of an early second attack.

There is no funding, research contracts or conflicts of interest.

Assessment of prevalence and pathological response to orthostatic provocation in patients with relapsing-remitting multiple sclerosis in relapse and remitting phases

I. Adamec, I. Bach, A.K. Barusic, A. Mismas, M. Habek

Univesity Hospital Center Zagreb (Zagreb, HR)

Background and goals: Multiple Sclerosis (MS) is a chronic idiopathic inflammatory demyelinating disease of the central nervous system and one of the leading causes of neurological disability in young adults. Autonomic dysfunction and orthostatic intolerance has been reported in up to 50% of patients. We have not found a study that correlates specific types of autonomic dysfunction with the remission and relapse phases of RRMS. Our intention was to show the existence of this correlation. The aim of our study was to determine the prevalence of pathologic response to orthostatic challenge in patients with RRMS and the difference of the response in patients in relapse and remission.

Patients and methods: We included 112 patients who were investigated in our laboratory. All of the patients had the diagnosis of RRMS based on McDonald 2010 criteria, group 1 included 53 patients who were experiencing a relapse and group 2 contained 59 patients in remission. There were no statistically significant differences between the groups concerning age, sex, and disease duration. The head up tilt table test was used to provoke an orthostatic reaction.

Results: 71(63%) of our subjects had a pathological response to orthostatic provocation. 60.4% and 66% of relapse and remission subjects respectively had a pathological response to orthostatic provocation. There was significant correlation between the groups and the EDSS (Expanded Disability Status Score), 2.28 for group 1 and 1.54 in group 2 (p=0.001). Syncope was found to in 9 (17%) in group 1 compared to 22 (37.3%) in group 2 (p=0.014). POTS was found in 17 (32%) in group 1 compared to 4 (6.8%) in group 2 (p=0.001). There was no significant difference in the type of syncope between groups (p=0.568) or between pain provoked syncope between groups (p=0.394). The pearson correlation coefficients between the EDSS and POTS and syncope were -0.201 (p=0.034) and 0.190 (p=0.044) respectively.

Conclusion: Autonomic dysfunction in MS requires an increase in academic and clinical awareness with a goal of earlier recognition and treatment of these symptoms leading to an overall increase in the quality of life of MS patients.

The authors have nothing to disclose.

The Arm Function in Multiple Sclerosis Questionnaire (AMSQ): development and validation of a new tool

L.B. Mokkink, D.L. Knol, J.M. Sonder, F.A. van der Linden, M. D’Hooghe, B.M.J. Uitdehaag

VUmc (Amsterdam, NL); National MS Center (Melsbroek, BE)

Introduction: One of the physical disabilities a patient with MS may experience is limitations in arm and hand functioning. A new tool was developed to measure arm and hand function: the Arm Function in Multiple Sclerosis Questionnaire (AMSQ). Functioning is defined according to the International Classification of Functioning (ICF) as activity limitations, which are difficulties an individual may have in executing activities. Based on the literature of all existing scales measuring arm function (initial number of items was 257), and with involvement of both experts and patients, we developed a 31 item questionnaire. We aimed at developing a unidimensional scale containing enough items that it can be used as an itembank for future use as a Computer Adaptive Test (CAT). IRT like reliability was calculated. Construct validity of the AMSQ was investigated by assessing differential item functioning (DIF).

Methods: Patients were recruited from the MS Center Amsterdam, the Netherlands, and the National MS Center Melsbroek, Belgium. A confirmatory item factor analysis (CIFA) was performed in Mplus, by applying weighted least squares (WLS) method of estimation. Model fit was evaluated using the root mean square error of approximation (RMSEA), comparative-fit index (CFI), Tucker-Lewis index (TLI) fit index, and Standardized Root Mean Square Residual (SRMR).

DIF was investigated for type of MS and sex, using the graded response model (GRM), an Item Response Theory (IRT) model. For type of MS, patients were classified into (1) relapsing remitting MS or clinically isolated syndrome, and (2) secondary progressive or primary progressive MS. Subsequently, local independence and item goodness of fit were investigated using GRM. IRT like reliability was calculated. IRTPRO was used to perform all IRT analyses.

Results: CIFA resulted in a factor solution suggesting one factor: RMSEA (0.081), CFI (0.979), TLI (0.977), and SRMR (0.042). No items showed DIF for both type of MS and sex. Two pairs of items had high values for local dependence, probably because they were placed together in the questionnaire. All items showed a good form of the IRT curves (item goodness-of-fit statistics for all items above p>0.005). IRT reliability was 0.95.

Conclusion: AMSQ is a new unidimensional 31 item questionnaire for measuring arm function in MS. Because of a well fit in GRM, it is suitable as a CAT instrument.

The authors have nothing to disclose.

Early diagnosis of cognitive disorders in multiple sclerosis: the HV3 score

M. Laffon, G. Malandain, M. Cohen, C. Lebrun

Hôpital Pasteur (Nice, FR); INRIA (Sophia Antipolis, FR)

Background: Cognitive impairment in Multiple Sclerosis (MS) is common and affects the quality of life. Early detection is difficult.

Objective: To improve early detection of cognitive disorders in MS

Design/Methods: We prospectively recruited 75 Relapsing Remitting MS (RRMS) patients in the Centre de Recours Régional de la SEP in Nice, France. We also recruited 20 controls. All patients had a clinical exam every 6 months. The Paced Auditory Serial Addition Test (PASAT) was the only cognitive task used to detect patients with cognitive impairment. Any z-score below 2 standard deviations was considered impaired. At baseline and every year, a brain MRI was performed. We quantified T2 and T1 lesion volumes, cerebral white and gray matter volumes. Global brain atrophy was measured by the third-ventricle (V3) width (in millimeters), the bicaudate ratio, the lateral ventricle width and the brain diameter. An average anatomical model of the human brain was built from a control group of 20 patients. Each patient MRI was then compared to the average model using Jacobian integration to quantify regional volumetric changes. We compared demographic, clinical and MRI data in the MS group with and without cognitive impairment.

Results: At baseline, 16/75 (21.3%) patients had cognitive impairment. These patients had a higher Expanded Disability Status Scale score (p=0.021). T2 and T1 lesion volume and gray and white matter volumes were not different in both groups. An enlargement of the V3 width was observed in the cognitively impaired group (p=0.044) and V3 width was correlated with the PASAT score (r=-0.271; p=0.021). A composite score named HV3 was obtained by the sum of EDSS and V3 width in mm. A cutoff HV3 score over 5.5 identifies patients with cognitive impairment with a positive predictive value of 92.5%. HV3 was more correlated with the PASAT score than EDSS or V3 width separately (r=-0.325; p=0.006). Significant focal atrophy was measured in the supplementary motor area, in, the cingulate gyrus, the right thalamus and in inferior parietal lobules of patients with abnormal PASAT performance.

Conclusion: Specific brain morphological changes are associated with cognitive impairment in RRMS patients. The HV3 score is an easy tool, directly accessible by clinicians.

The authors have nothing to disclose.

FAME - FAmpyra outcome MEasure Study - an ongoing study

H.B. Jensen, U. Dalgas, M.H. Ravnborg, E. Stenager

MS Clinic of Southern Jutland, Sønderborg, Vejle, Esbjerg (Sønderborg, DK); Aarhus University (Aarhus, DK); Department of Neurology (Odense, DK)

Background: Fampridine-SR can improve walking speed in a subset of MS patients. The response rate is 35-43% measured by Timed 25 Foot Walk (T25FW). Fampridine-SR also improves muscle strength in the lower extremities.

The Six Spot Step Test (SSST) was developed to assess ambulation with higher accuracy and sensitivity than T25FW. No multiple outcome trial on the effects of Fampridine-SR has been conducted and no effect on cognition and upper extremity function has been demonstrated.

Aim: The aim is to compose a multiple outcome measure trial to evaluate the relative sensitivity of clinical tests for the identification of responders to Fampridine-SR treatment and compare the effect size when assessed with SSST and T25FW. Also it is to perform accurate measurement of muscle strength in the lower extremity by dynamometry.

Design and Methods: Double blind, randomized, placebo controlled parallel group design preceded by open label enrichment.

125 participants will enter the enrichment phase. All participants will be treated with Fampyra 10 BID for four weeks.

SSST, T25FW, Chair Rise Test, 9-Hole Peg Test and Symbol Digit Modalities Test will be performed on days 0 and 28. The responder group is defined as the 40% showing greatest improvement on SSST.

Responders go on to the intervention phase. After wash out participants will be randomized to Fampyra 10 mg BID or placebo BID for four weeks. The same measures as in the enrichment phase, as well as dynamometry, will be performed at days 0 and 28.

Inclusion Criteria: Patients with clinically definite multiple sclerosis diagnosed according to the McDonald criteria, aged 18-60 years, EDSS 4-7, pyramidal- FS > 2.

Exclusion Criteria: History of epileptic seizures, MS relapse or change in DMT within 60 days, cancer, clinically important systemic disease, pregnancy and treatment with carvedilol, propranolol and metformin.

Results: No results are available yet. Preliminary data will be available by october 2012 as the trial concludes mid september. By now 50 participants have been included.

Perspective: The perspective of this trial is to identify outcome measures that are more sensitive to the effects of Fampridine-SR treatment and convey more reliable informa than T25FW, and thereby assuring that MS patients that potentially benefit from treatment receive it. Furthermore this trial investigates the effect of Fampyra on cognition and upper extremity function in a responder group and thereby it can potentially prove effect in these domains.

Henrik Boye Jensen has received travel grants from Merck Serono, Novartis and Almirall.

Ulrik Dalgas, Mads Henrik Ravnborg and Egon Stenager have nothing to disclose.

Information processing in multiple sclerosis: a comparison of the paced serial addition test and Tens test

J. Silversteen, G. Greenberg, M. O’Neill, K. Greenbaum

Christiana Care MS Center (Newark, US); Christiana Care Hospital (Newark, US)

Objective: To evaluate a new measure of information processing (Tens Test) as a clinically sensitive and less aversive measure of information processing in MS patients than the Paced Serial Addition Test (PASAT).

Methods: We examined the sensitivity of the gold standard for assessing information processing(IP) impairment in MS, the Paced Auditory Serial Addition Test, with a new measure, the Tens Test. The Tens Test is an 8 minute measure of sustained and selective auditory information processing that was designed to be less aversive to the patient. This test requires the patient to indicate when they hear two spoken adjacent numbers add to 10. The number of hits as well as commission errors are tabulated into an Accuracy Index. We tested 40 patients and looked at the relationship between both measures of IP with neuroimaging data, patient and physician perceptions of illness burden, and patient assessment of IP stress and difficulty level.

Results: A Pearson product-moment correlation coefficient was computed to assess the relationship between the number of gadolinium-enhanced lesions and Information Processing tasks. A main finding was a significant correlation between the Tens Test Accuracy Index (r = -0.904, n = 13, p ≤ 0.001). Thus, the more lesions found the lower accuracy was observed on the Tens Test, but not the PASAT (r=-0.071, n=13, p= 0.819.)

Patients found the PASAT a more stressful and difficult information processing measure. Using a 10 point rating scale, the PASAT was perceived to be more stressful (M= 7.15, SD=2.623) and difficult (M=6.82, SD=2.545) than the Tens Test (M=5.60, SD=.627, and M=4.42, SD=2.032, respectively). The PASAT perceived difficulty showed a stronger positive correlation with PASAT perceived stress, r = 0.748, n = 20, p ≤0.001, than the Tens Test stress / difficulty ratings r = 0.542, n= 20, p = 0.014.

A Pearson product-moment correlation coefficient was computed to assess the relationship between education level and the patient’s perception of the stress and difficulty levels on the information processing tests. There was a negative correlation between the PASAT Stress level and education (r = -0.716, n = 9, p = 0.030).

Neither PASAT or Tens Test was correlated with EDSS.

Conclusion: The Tens Test represents a valid measure of information processing in people with MS. As compared to the PASAT,Tens test appears to be less aversive without the negative reactive impact of stress and educational level on test performance.

Dr. Greenberg, Melanie O’Neill and Kathy Greenbaum have nothing to disclose.

Dr. Silversteen has received honoraria as a speaker and/or consultant for Biogen-Idec, Acorda, Novartis, and EMD Serono.

Patient-determined MS Severity Scale: ranking disease severity based on patient-rated disability

I. Kister, E. Chamot, G. Cutter, A. Salter, T.E. Bacon, J. Herbert

NYU School of Medicine (New York, US); University of Alabama at Birmingham School of Public Health (Birmingham, US)

Background: Multiple Sclerosis Severity Score (MSSS; Roxburgh et al, Neurology; 64:1144) is a mean rank of Expanded Disability Status Scale (EDSS) among patients with same disease duration. MSSS has been used to compare disease severity in different patient populations and for monitoring treatment response in groups of patients. Clinical utility of MSSS is limited by the requirement for objective assessment of EDSS score by a trained MS specialist. Patient-Determined Disability Steps (PDDS).is a validated, nine-point disability scale that does not require clinician input. A ranking scale of PDDS, an analogue of MSSS, may be a practical and cost-effective tool for monitoring long-term outcomes in groups of patients.

Objective: To develop a ranking scale of Patient-Determined Disability Steps (PDDS) using the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry as the reference population.

Design/Methods: All NARCOMS registrants with known PDDS and disease duration of 1-45 years at PDDS were included in the study. Frequency-ranking methodology (Roxburgh, et al. Neurology; 64:1144) was applied to the NARCOMS dataset to derive disease duration-adjusted mean ranks of PDDS scores. We termed the new measure, ‘Patient-derived MS Severity Score’ (P-MSSS). We also calculated disease duration-adjusted maximum rank (or prevalence) of each PDDS. The data for mean rank (P-MSSS) and maximum rank (prevalence) of all PDDS scores for the first 45 years of disease was graphically represented in the form of P-MSSS Reference Table.

Results: The cohort was comprised of 27,918 NARCOMS enrollees, of whom 72.7% were female and 90.1% were White. Mean age of symptom onset was 30.1 (±10.1) years, and age at enrollment was 47.1 (±11.0) years. P-MSSS Reference Table represents frequency-rank of disability for each of the first 45 years since symptom onset. About half of the enrollees described their disability as “limiting daily activities” or worse just one year after disease, and two-thirds - after 5 years.

Conclusion: P-MSSS is a measure of relative disease severity that can be easily ascertained by patient or non-specialist care provider. P-MSSS may be used to compare patient subpopulations and to track disease progression and response to treatment in patient cohorts. P-MSSS Reference Table affords a unique, detailed view of disability progression over 45 years of disease from patients’ point of view.

This study was sponsored by a grant from the National Multiple Sclerosis Society.

I Kister received research support from EMD Serono/Pfizer, Inc., the National Multiple Sclerosis Society and the Guthy-Jackson Charitable Foundation.

E Chamot and A Salter have nothing to disclose.

G Cutter has served on scientifi;c advisory boards for and/or received funding for travel from Millenium Pharmaceuticals, Inc., Klein Buendel, Inc., Alexion Pharmaceuticals, Inc., Androclus Therapeutics, Inc., University of Illinois, Amgen, New York University, and Somnus Therapeutics, Inc.; receives royalties from publishing Evaluation of Health Promotion and Disease Prevention (The McGraw Hill Companies, 1984); has received honoraria from GlaxoSmithKline, Biogen Idec, Novartis,

Advanced Health Media Inc., Biogen Idec, EMD Serono Inc., EDJ Associates, Inc., the National Heart,Lung, and Blood Institute, National Institute of Neurological Diseases and Stroke, National Marrow Donor Program, Consortium of Multiple Sclerosis Centers; serves as a consultant to Peptimmune Inc.,Aegis Creative Marketing, Novartis, National Industrial Sand Association, Bayer Pharmaceuticals, and Teva Pharmaceuticals Industries Ltd.; has served on independent data and safety monitoring committees for Antisense Therapeutics Limited, Sanofi-Aventis, Bayhill Pharmaceuticals, BioMS Medical Corp, Daiichi-Sankyo Co. Inc., GlaxoSmithKline, Genmab, Medivation Inc., PTC Therapeutics Inc., Teva Pharmaceutical Industries Ltd., Vivus Inc., NHLBI, NINDS, NMSS; has received research support from ApopLogic Pharmaceuticals, LLC; receives research support from the NIH [NINDS 5U01NS042685-02.

(PI), NINDS U01 NS45719-01A1 (PI, Coord Center], NIAID Contract No HHSN266200400068C [Co-I], NHLBI 5R01 HL06991-02 [PI, Coord Center], NIAID N01AI30025 [Director, Coord Center], NIDR 3R01DE016684-03S109 [Co-I], NHLBI 5P50HL084923 030001 [Director, Coord Center], NIDDK 1R01DK078826 [Co-I], NIAID P30AI27767 [Co-Director, Biostat Core], NIDDK 1P30DK079337 [Director, Biostat Core] and from the Consortium of Multiple Sclerosis Centers [Director NARCOMS Data Center] and the National Multiple Sclerosis Society; and serves as President of Pythagoras, Inc.

T Bacon has nothing to disclose.

J Herbert has received personal compensation for activities with Biogen Idec, EMD Serono, Teva Neuroscience and Bayer as a consultant. He has received research support from Teva Neuroscience,Novartis, Biogen Idec, Bayer, EMD Serono/Pfizer, BioMS and INC Research.

A new path for the MS Walking Scale: MSWS-12 version 2

J. Hobart, S. Cano, W. Ingram, J. Zajicek

Peninsula Medical School (Plymouth, UK)

Background: The 12-item MS Walking Scale (MSWS-12) was developed using traditional psychometric methods. Analyses in two independent datasets (n=625; n=1069) based on a modern and superior psychometric method, Rasch measurement theory, subsequently identified anomalies. Specifically, 25% of the items had ordered ressponse categories that did not work as intended. This has notable implications for the interpretation of MSWS-12 scores, score changes and score differences. The findings prompted a review of the instrument with modifications incorporating qualitative and quantitative research into item response categories.

Aim: To evaluate version 2 of the MSWS-12 (MSWS-12v2) prospectively in a larg sample of people with MS.

Method: We performed a Rasch measurement analysis of MSWS-12v2 data from a UK longitudinal study of people with MS (n=4,731 questionnaires; 1,286 participants; 75% female; mean age 51 years; median MS duration 7 years). We examined: scale-to-sample targeting; response category ordering; nature of the measurement continuum; item cohesiveness, bias and consistency across groups; reliability; individuals’ score consistency; relationships between MSWS-12v2 scores and measurements; measurement error across the scale range.

Results: Examination of scale-to-sample targeting supported confident evaluations of scale performance and person measurement. Response categories for all items were ordered empirically as intended conceptually. The twelve MSWS-12v2 items: mapped a wide (7.7 logits) and regular measurement continuum; were cohesive statistically; had minimal scoring bias (2/66 residual correlations >±0.30), and performed consistently across different genders, ages, disease durations, and time-points. Reliability was high (PSI = 0.95), 96% of questionnaires had internally consistent response patterns, a change of one MSWS-12v2 point varied six-fold across the range of the scale, measurement error varied three-fold across the scale range.

Conclusion: The MSWS-12v2 is a psychometrically stronger and more clinically interpretable walking ability measure than MSWS-12v1. We provide novel evidence of MSWS-12v2’s inherent ability to detect change.

The South West Impact of MS study was funded by a local benefactor, Peninsula medical School Foundation, and the MS Society of Great Britain and Northern Ireland.

Jeremy Hobart: has received honoraria, consulting fees or, support for conferences from, or contributions towards research from: Acorda; Biogen Idec; Merck Serono, Bayer Schering, Teva, Critical Path Institute, and MAPI industries.

John Zajicek: has received consultancy fees from IKF and Bayer-Schering. He has received funding from the MRC and NIHR EME to conduct studies using cannabinoids. He is a named inventor in two patents regarding cannabinoid use in MS.

Stefan Cano: is director of ScaleReport.

Wendy Ingram: no conflict of interests.

No authors have conflicts of interest in relation to this study.

Is the Epworth Sleepiness Scale valid in multiple sclerosis?

R.J. Mills, C.A. Young

Royal Preston Hospital (Preston, UK); Walton Centre (Liverpool, UK)

Background: The Epworth Sleepiness Scale (ESS) is frequently used to assess daytime sleepiness in people with multiple sclerosis (MS) but has never been validated for this condition. In addition, there is concern regarding the suitability of the driving item (item 8) in disabling neurological conditions which preclude driving. A summed raw score of 10 or more (from a maximum of 24) signifies pathological sleepiness.

Objective: To determine the construct validity of the ESS by Rasch analysis and in particular whether omission of item 8 confounds the scale.

Method: A pack containing the Epworth Sleepiness Scale and questions regarding sleep and demographics was mailed to patients with MS attending two centres in the UK. Data were assessed for fit to the Rasch model.

Results: Data from 628 (51% response) records were analysed. 56 (8.9%) respondents omitted item 8. Overall fit to the Rasch model was reasonable with non-significant overall chi square. Items 3, 5 and 8 had disordered thresholds; SD of item fit residuals was slightly high but there was little in the way of local dependency and there was absence of differential item functioning for age and sex. The scale was shown to be unidimensional by post hoc t-test. The standard error of person locations was low at a summed raw score of 10 indicating the scale was providing the most information at the cut point. Equating person locations between the full scale and the scale without item 8 revealed that there was no difference in person locations below a summed raw score of 18. Item 8 was one of the most difficult items to affirm and it only became contributory at the highest levels of sleepiness.

Conclusion: The Epworth Sleepiness Scale has good construct validity for use in MS and is reliable at the cut point of 10. Any summed raw scores below 18 will be unaffected if those who cannot drive either score as zero or simply omit item 8. The scale is therefore robust for detecting cases of pathological sleepiness in anyone with MS but may not be suitable for measuring extremely high levels of sleepiness in non-drivers.

The authors have nothing to disclose.

A novel method of measuring subclinical neurological deficit in patients with a clinically isolated syndrome

M. Clough, J. Fielding, A. Ng, G. Egan, O. White

Monash Univeristy (Clayton, AU); Monash Biomedical Imaging (Clayton, AU); University of Melbourne (Parkville, AU)

In approximately 85% of patients who develop Multiple Sclerosis (MS) initial onset occurs with a subacute clinically isolated syndrome (CIS). The pathological processes occurring in CIS suggestive of MS (CISSMS) are not well understood, with neurological damage largely subclinical. As there is good evidence that early therapeutic intervention has the potential to delay and/or ameliorate long term clinical disability, there is a clinical imperative to identify patients who will develop MS early. unfortunately there are no widely accepted techniques sensitive to neurological dysfunction at the earliest disease stages, and little understanding of prognostic factors that determine disease evolution following a CIS. Eye movement parameters reflect the functional interplay of motor control and cognitive processes; programming and execution of saccades involves the relay of information across long-range tracts between frontal, parietal and subcortical brain regions. Our study used three discrete eye movement paradigms to evaluate subclinical deficit in CISSMS. Antisaccades (AS), endogenously cued saccades and memory guided (MG) saccades engage exogenous and endogenous processes, and require the resolution of response conflict. Performance CISSMS patients (n=19) was compared to n=11 age-matched controls. CISSMS patients generated a significantly greater proportion of unwanted prosaccades towards targets for both the AS (p=.007) and MG paradigms (p=.028), and a significantly greater proportion of unwanted anticipatory saccades for endogenously cued saccades (p=.009). This indicates that CISSMS patients have difficulty inhibiting a prepotent response, whether exogenously or endogenously generated, reflecting reduced integrity of connections within and between (pre)frontal regions and sub cortical areas. Voxelwise regression analysis identified regions of significant covariance between AS, Endogenous and MG errors and fractional anisotropy and mean diffusivity using a non-parametric permutation sampling method (Randomise, FSL, FMRIB). Preliminary findings show reduced integrity of WM tracts in/across regions associated with eye movement generation which correlate with error rate on the eye movement tasks. This demonstrates the sensitivity of eye movement paradigms in identifying sub-clinical deficit in CISSMS with the potential to assess disease activity early on in the disease process in MS, informing both diagnosis and timing of pharmacological interventions.

Meaghan Clough - has nothing to disclose.

Joanne Fielding - Has been granted funds by Bayer Australia/New Zealand, for use in the completion of this study.

Amanda Ng - has nothing to disclose.

Professor Gary Egan - has nothing to disclose.

Associate Professor Owen White - Has been granted funds by Bayer Australia/New Zealand, for use in the completion of this study.

Does OCT predict conversion to MS? A longitudinal study

C. Oreja-Guevara, S. Noval, A. Royo, B. Chamorro, J. Moreno, J. Alvarez-Linera

University Hospital San Carlos (Madrid, ES); University Hospital La Paz (Madrid, ES); Ruber International Hospital (Madrid, ES)

Background: Optical coherence tomography (OCT) is a simple high resolution noninvasive technique to quantify the thickness of retinal nerve fiber layer (RNFL) and an indirect measurement of axonal damage in multiple sclerosis (MS). Measurement obtained with OCT may represent a surrogate biomarker for multiple sclerosis.

Objectives: To determine whether RNFL thickness predicts conversion to clinically definite multiple sclerosis (CDMS) in patients with clinically isolated syndromes (CIS) over the subsequent three years.

Methods: Patients with CIS underwent a complete neurological examination. High field brain MRI, cervical MRI and lumbal puncture were performed within two months of the first attack and after three years. They also underwent an ophthalmological evaluation including visual acuity and optical coherence tomography (OCT, Stratus) within the first week after diagnosis and after three years. The sensitivity and specificity of OCT to predict conversion to CDMS were analyzed.

Results: Twenty-three patients with CIS with a mean EDSS of 1.72 were recruited, including 7 patients with optic neuritis (ON),6 with spinal cord syndrome, 5 with brainstem symptoms and 5 with sensory and other syndromes and followed during three years. Oligoclonal IgG bands were present in 57% of patients. Eight patients did not have demyelinating lesions on baseline cranial MRI. Seven patients fulfilled at least three out of four Barkhof criteria in MRI. 54,2 % of all patients showed the presence of at least one quadrant of an optic nerve with a decreased RNFL thickness.

The presence of at least one quadrant of an optic nerve with a RNFL thickness at a P<5% cut-off value had a sensitivity of 69% and a specificity of 60% for predicting conversion to CDMS in a period of three years. Specificity increased to 90% if the cut-off value is set at P<1% but sensitivity decreased to 46%.

Conclusion:RNFL thickness reduction has a high specificity but less sensitivity for early prediction of conversion to multiple sclerosis. Axonal damage in very early stages of disease may be useful for predicting conversion in multiple sclerosis and useful a surrogate biomarker.

Susana Nova, Arancha Royo, Beatriz Chamorro, Julian Moreno and Juan Alvarez-Linera have nothing to disclose.

Celia Oreja-Guevara has received honoraria as consultant on scientific advisory boards by Bayer Schering, Merck, Serono, Biogen, Teva, and Novartis, and has participated in clinical trials and other research projects supported by Biogen Idec, GSK, Teva, and Novartis.

Does inclusion of visual contrast acuity testing increase the informative value of the Multiple Sclerosis Functional Composite (MSFC)?

A.U. Brandt, J. Schinzel, K. Stoesslein, F. Paul, J. Dörr

Charité - Universitätsmedizin Berlin (Berlin, DE)

Background: Since its introduction in the late 1990s the Multiple Sclerosis Functional Composite (MSFC) has been established as major secondary outcome parameter in clinical trials on MS. While covering the important clinical dimensions of arm, leg and cognitive function one major shortcoming of the MSFC is that it completely disregards vision as another dimension frequently impaired in MS patients. Currently, considerations exist to complement the original three-dimensional MSFC with a fourth visual component.

Objectives: To evaluate whether the implementation of visual contrast acuity testing increases the ability of the MSFC to predict quality of life (QoL) in MS patients.

Methods: For this cross-sectional analysis, we used the baseline data set of a prospective observational trial on 100 patients with definite MS or clinically isolated syndrome (CIS). MSFC was performed by a trained person according to standardized procedures. For evaluation of visual contrast sensitivity, Sloan low-contrast letter charts were used at 2.5% and 1.25%. Short form (SF)-36 was used for measuring QoL, obtaining a physical and mental health score. Spearman Rank correlations between MSFC components, visual contrast sensitivity and QoL were assessed.

Results: MSFC, contrast sensitivity and QoL data were available from 100 patients with MS or CIS (28 male/72 female, age 41±11 years, EDSS median 2.0). QoL, as assessed by the SF-36 physical health score, was predominantly predicted by ambulation and to a lesser degree by upper extremity function. The correlation between contrast sensitivity and QoL was weak. None of the MSFC components, as well as contrast sensitivity correlated with the SF-36 mental health score. Consequently, creating a four-dimensional MSFC that included contrast sensitivity did not result in a better correlation with QoL.

Conclusion: In this cross-sectional setting physical health QoL was mainly determined by ambulation whereas the impact of visual contrast sensitivity was surprisingly negligible. Interestingly, the MSFC cognition component was not correlated with either the physical or the mental health QoL score. These data need to be confirmed in a longitudinal setting. One and two-year data from the same cohort will be available by 2013.

AUB is cofounder and director of gfnmediber who was not involved in this study. AUB received travel grants from Biogen Idec, Bayer and Novartis, research grants from Novartis and speaker honoraria from Heidelberg Engineering.

JS and KS have nothing to disclose.

FP has received research grants, travel grants and speaker honoraria from Bayer, Merck Serono, Teva-Sanofi, Aventis and Novartis.

JD received travel and research grants from Novartis.

This study was funded in part by a grant from Novartis.

Construct validity of a novel tool to measure balance ability in MS patients

C. Soaz, P. Stellmann, M. Jlussi, C. Heesen, A. Neuhaus, M. Daumer

SLCMSR (Munich, DE); UKE Hamburg Eppendorf- INIMS (Hamburg, DE); RehaCentrum Hamburg Bad Bramstedt (Hamburg, DE)

Background: Standard methods to assess balance in MS patients include the Romberg and Tandem Balance Test. These tests have essentially a binary outcome and it is impossible to quantify differences between those who pass the test. Expensive alternatives to quantify postural control ability require force plates or 3D tracking in a gait laboratory. We have used actibelt technology, a 3D accelerometer in a belt buckle (512 MB, 100Hz), validated in a cohort of patients with osteoporosis (1903 tests, 173 patients), to objectively quantify the balance ability of MS patients. Here we were interested in the feasibility and in the construct validity of the test by checking if the numerical values correlate with test difficulty.

Methods: Multiple Sclerosis patients (17 female, age: 49.4 ± 9.4 yrs and 11 males, age: 48.7 ± 7.5 yrs, EDSS 4-6.5) were seen at the Hamburg-Eppendorf University Clinic. The following 4 tests were performed with actibelt: Romberg Eyes Open/Closed (R1, R2), Tandem Romberg Eyes Open/Closed (R3, R4). All data were pre-processed and balance parameters were extracted. For the balance test the key outcome is the area covered by the acceleration vector moving in the horizontal plane during the test. A large area means poor balance. This area is measured in “balance units” [1BU=0.96 m²/s⁴] based on the eigenvalues of the best matching ellipse that covers 95% of the “acceleration stabilogram” points.

Results: The recordings were transferred to the analysis center. Baseline data from 17 patients, 68 tests in total, could be analysed semi-automatically, data from 1 patient was missing, data from 10 patients need additional inspection by an expert reader. The mean area of the stabilogramm for the test T1-T4 at the baseline visits was (mean [sd] in BU): R1: 0.31 [0.3], R2: 1.12 [2.1], R3: 3.16 [4.0], R4: 5.28 [5.9]. Rank correlation across all tests ρ=0.5, p<0.0001.

Conclusion: Balance tests using mobile accelerometry in MS patients are feasible and provide plausible quantitative results. The area of the acceleration stabilogram is increasing with the level of test difficulty. The considerable variability may easily be reduced by repeating the more difficult tests and selection. Modern developments using android smart phones and data communication by bluetooth can provide instant feedback and may facilitate the use as a standard clinical assessment tool - if a cost-effective added value can be seen.

C. Soaz, P. Stellmann, M. Jlussi, C. Heesen and A. Neuhaus have nothing to disclose.

Dr. M. Daumer Scientific Director of the Sylvia Lawry Centre for Multiple Sclerosis Research e.V. and Managing Director of Trium Analysis Online GmbH, serves on the Editorial Board of /MedNous/ and holds Patent 102007 044 705.3-35, German patent and trade mark office 307 19 449.3/09. The Sylvia Lawry Centre received funding for travel from ECTRIMS, served on the advisory board for EPOSA study and as consultant for Biopartners; and received research grants from the following governmental entities: BMBF, FKZ 01Gl0920 (2009-2012);BMBF, FKZ 01Gl0904 (2009-2012); EU FP7, FP7-223865 (2008-2012); EU FP7, 215820-2 (2008-2012); Hertie Foundation Grant No: 101107011; Porticus Foundation Grant No 900.50578.

Assessment of relapse activity in the CombiRx randomised clinical trial

F. Lublin, S. Cofield, T. Gustafson, R. Conwit, J. Wolinsky, G. Cutter for the The CombiRx Investigators

Background: Annualized relapse rate (ARR) reduction is the most common outcome of therapeutic trials in relapsing MS (RRMS). While the definitions used in most studies are similar, they may differ in important ways that confound understanding of comparative efficacy. CombiRx was a 3-year, multicenter, double-blind, randomized clinical trial comparing the combination of IFN and GA to either agent alone in subjects with RRMS. We previously reported that at 3 years, the combination was not superior to the better of the two single agents (GA). Both the combination and GA reduced the risk of relapse compared to IFN.

Objectives: Relapse definitions in CombiRx were carefully documented, defined by pre-determined criteria and analyzed per protocol by treatment arm and sensitivity analyses to determine relative behavior. Relapse types included: protocol defined, non-protocol defined and suspect exacerbations (PDE, NPDE, SE) analyzed as PDE, PDE+NPDE (PNPE), PDE+NPDE+SE (ALL) for 1, 2, and 3 yrs of follow up time.

Design/Methods: 1008 participants were randomized and followed until the last participant completed 3 yrs. PDE required: new/worsening symptoms ≥ 24hours, no fever, change in EDSS/FS, examined ≤ 7 days; NPDE: same as PDE but examined > 7 days; SE: no change in EDSS/FS. ARR, Cox proportional hazards (CPH) and Poisson (PS), age adjusted regression were used to assess relapse types by treatment.

Results: With the increase in follow up time, ARR estimates decrease from years 1 to 3; new confirmed exacerbations decreased in year 2 and 3, but the relapse rates in years 2 and 3 were similar. Both CPH and PS show GA superior to IFN, but IFN+GA not superior to GA for the three relapse definitions for 3 years; with pattern of differences similar for years 1 and 2.

Conclusions: Analysis of relapse rates over the three years of the study show similar trends in efficacy, with all definitions, from years one through three. The combination of IFN + GA was not superior to GA alone, but both the combination and GA had lower relapse rates than IFN. It is not always clear from published study results which relapse definition was used and how stringently it was applied. We show that the strict adherence to pre-planned relapse definitions can have a profound effect on the estimation of ARR, while different types of modeling did not change the conclusions. This has important implications for clinical trial design and powering and for developing comparative efficacy strategies.

Dr. Lublin received compensation from the following commercial entities: for consulting: Bayer HealthCare Pharmaceuticals; Biogen Idec, EMD Serono, Novartis, Pfizer, Teva Neuroscience, Genmab, Medicinova, Actelion, Allozyne, Sanofi, Acorda, Questcor, Avanir, Roche, Celgene, Abbott, MorphoSys, Johnson & Johnson; Revalesio, Coronado Bioscience, Genzyme, MedImmune; compensation from Elsevier for serving as Co-Chief Editor of Multiple Sclerosis and Related Diseases.

Dr. Cofield received personal compensation from GlaxoSmithKline, TEVA Pharmaceuticals, Orthotech Biotech, the Department of Defense and the American Academy for Orthopedic Surgery for consulting services, research funds and/or DSMB service.

Dr. Cutter received compensation for participating in Data and Safety Monitoring Committees: Sanofi-Aventis, Cleveland Clinic, Daichi-Sankyo, Glaxo Smith Klein Pharmaceuticals, Genmab Biopharmaceuticals, Eli Lilly, Medivation, Modigenetech, Ono Pharmaceuticals, Teva, NHLBI, NINDS, NMSS and Consulting services: Abbott, Bayer, Novartis, Consortium of MS Centers (grant), Genzyme, Klein-Buendel Incorporated, Nuron Biotech, Biogen, Somnus Pharmaceuticals and Teva; Dr. Cutter is president of Pythagoras, Inc.; Dr. Cutter reports received CMSC task orders which involve research from various Pharma organizations.

Dr. Wolinsky received compensation from the following commercial entities: Astellas, consultant services, Bayer HealthCare, member/consultant Bayer Multiple Sclerosis Council, Celgene, consultant services, Eli Lilly, member Data Safety Monitoring Board, Hoffman LaRoche, member Steering Committee, Novartis Pharmaceuticals Corp., member Steering Committee and consultant, sanofi aventis, member Steering Committee, Teva Neuroscience, consultant, Teva Pharmaceuticals, member Scientific Advisory Board, member Data Safety Monitoring Board, consultant; royalties received for out licensed monoclonal antibodies through the UTHSCH to Millipore (Chemicon International) Corporation since 1993; contractual support from sanofi-aventis.

Dr. Conwit & Ms. Gustafson report no conflicts.

The CombiRx Investigators have varied relationships.

Deciphering distance-induced deceleration of gait and ataxia in people with multiple sclerosis

R. Phan-Ba, S. Pierard, G. Moonen, M. Vandroogenbroeck, S. Belachew

University and CHU of Liège (Liège, BE); University of Liège (Liège, BE); MYelin Disorders ResEArch teaM (MYDREAM) (Liège, BE)

Background and goals: We previously described distance-induced deceleration of walking speed (WS) in people with multiple sclerosis (pMS) as a manifestation of motor fatigue. Using range laser scanners (RLS), we recently designed a system capable to capture feet paths and measure multiple gait attributes in various walk tests, allowing the distinction between healthy volunteers (HV) and pMS with mild or moderate disability. The goal of this study was to decipher mechanisms underlying WS deceleration of pMS during a long distance walking test.

Methods: The internal validation of the RLS system has been described elsewhere (see: http://www.ulg.ac.be/telecom/research/vgaims). Sixteen pMS and 28 HV were enrolled in this study, approved by the ethics committee of the CHU of Liège. Subjects were asked to perform the Timed 500-Meter Test (T500M) by walking as fast as possible 25 laps on a 20-meter long 8-shape trajectory. Twenty-six gait attributes classified in 2 categories were computed: (i) Efficiency of gait attributes (EA), including mean WS, mean/maximum left/right foot WS, and (ii) Quality of gait attributes (QA), including mean/maximum of the deviation from target line, mean lateral inter-foot distance, total/left/right foot gait cycle and double/single limb support times. EA and QA were then compared between the first and last 100m of the T500M by paired t-tests and their intergroup absolute differences were compared by unpaired t-tests.

Results: Between the first and last 100m of the T500M, gait deceleration was observed in each group, resulting in a highly significant decrease of all EA measures. In pMS and HV, a significant increase of the total gait cycle time was observed. Interestingly, a significant increase of double limb support time was observed in pMS with moderate to severe disability, but not in HV or pMS with mild disability. A major increase of the mean lateral inter-foot distance was seen in pMS with mild or moderate disability, but not in HV. Finally, distance-induced alteration of total gait cycle time, double limb support time and mean lateral inter-foot distance was significantly more pronounced in pMS than in HV.

Conclusions: This study provides further insights into mechanisms underlying distance-induced deceleration of walk in HV versus pMS. We provide evidence that beyond motor fatigue and in contrast to HV, pMS experience an increase of gait ataxia over a 500-meter distance of locomotor effort even at mild level of disability.

Remy Phan-Ba, Sebastien Pierard, Gustave Moonen and Marc Vandroogenbroeck have nothing to disclose.

Shibeshih Belachew serves on scientific advisory boards for Bayer Schering Pharma, Biogen Idec, Genzyme- Sanofi Aventis, Novartis Pharma and Merck-Serono; has received fundings for travel and speaker honoraria from Bayer Schering Pharma, Biogen Idec, Genzyme-Sanofi Aventis, Novartis Pharma, TEVA and Merck-Serono; and has received research and/or educational grant supports from Biogen Idec, Merck- Serono, Sanofi-Aventis, TEVA, and Novartis Pharma.

Plasma vitamin B12, uric acid levels and lipids profiles in multiple sclerosis patients

A. Celebi, O. Tehneldere, E. Gursoy, M. Kolukisa, G. Babacan-Yildiz, A. Kocer

Bezmialem Vakif University (Istanbul, TR); Kahta State Hospital (Adiyaman, TR)

Objectives: To assess Uric Acid (UA), vitamin B12, Lipid Profile variables (serum cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), very low density lipoprotein, triglycerides) in multiple sclerosis (MS) patients.

Background: Vitamin B12, in addition to its known role as a co-factor in myelin formation, has important immunomodulatory and neurotrophic effects. UA is a potent endogenous antioxidant and scavenger of peroxynitrite, which is hypothesized to be involved in the pathogenesis of MS. Dyslipidemia can potentiate inflammatory processes at the vascular endothelium.

Methods: The study population consisted of 131 clinically defined consecutive MS patients according to McDonald criteria. Control group consisted 118 volunteers without any specific disease or complaint whose age and gender were in accordance with the patients’. Patients with systemic diseases, pregnancy, MS patients with EDSS score higher than 6, MS patients who have experienced attacks in the last three months and subjects who have used ASA, thiazide group diuretic, steroids, antiepileptic, antilipidemic medications, and vitamins-B were excluded.

Results: Control group’s uric acid levels were significantly higher than MS group’s uric acid levels (p<0.001). Control group’s vitamin B12 levels were significantly higher than MS group’s vitamin B12 levels (p<0.001). MS group’s cholesterol levels were significantly higher than control group’s cholesterol levels (p<0.001).

Conclusions: Our study indicates low levels of UA and B12 in MS patients. These results are in accordance with other several studies. Cholesterol levels were found to be high in the MS group. Further studies are needed to clarify these issues.

The authors have nothing to disclose.

The effect of standardised EDSS re-training on the performance of EDSS raters

M. D’Souza, O. Yaldizli, E. Lucassen, E. Kornyeyeva, L. Kappos

University Hospital of Basel (Basel, CH); Novartis Pharmaceuticals Corporation (East Hanover, US)

Background: The Expanded Disability Status Scale (EDSS) is the most frequently used scale for rating impairment and disability in MS. Neurostatus is a standardized documentation, teaching and certification tool for physicians involved in the assessment of EDSS and Functional System (FS) scores in MS clinical studies that provides standardized definitions of gradings based on a standardized neurological examination.

Objectives: To test whether a standardized EDSS refresher training session can improve the consistency of EDSS and FS ratings.

Methods: 73 physicians from Europe, Northamerica (USA, Canada) and Australia involved in the assessment of the EDSS in a controlled trial participated in one of eight standardized EDSS refresher training sessions in February and March 2012. Before and after each training session participants completed a questionnaire to assess consistency of FS and EDSS ratings with the Neurostatus definitions. Forms A and B of the questionnaire were randomly assigned to participants for pre – and post training tests.

Results: Participants had an average of 6.6 years (y) of experience with MS patients (range 0-30y) and performed an average of 23 EDSS assessments per month (range 0-160). 50/73 (68.5%) showed an improvement in their test performance after the training, while 11/73 raters (15.1%) showed no improvement and 12/73 (16.4%) performed worse after the training. Pre-test average performance was 6.33 (SD 1.74) points, which increased to 7.77 (SD 1.74) after the training, mean improvement was 1.44 (SD 1.8995% CI: 1-1.88, p<0.001). We found a trend (r=-0.214, p=0.073) implying more improvement after training for raters with less years of experience.

Conclusion: Even a single repeat standardized EDSS training session results in higher assesment consistency and may help to reduce inter- and intra-rater variability and noise in FS and EDSS assessments in clinical trials.

Study supported by NovartisPharma AG, Basel.

M.D’Souza received travel support from Bayer AG Switzerland and research grants from Novartis Switzerland and the Swiss Multiple Sclerosis Society.

O.Yaldizli received speaking fees from Teva that were exclusively used for funding of research by the Department of Neurology at the University Hospital Basel and he received a grant from Bayer Schering which was used to finance an educational course for neurologists-in training at the University Hospital Basel.

E.Lucassen has nothing to disclose.

E.Kornyeyeva is employed full-time by Novartis.

L.Kappos: has received institutional research support from Acorda, Actelion, Advancell, Allozyne, Barofold, Bayer, Bayhill, Biogen Idec, BioMarin, Boehringer Ingelheim, CSL Behring, Eli Lilly, Geneuro, Genmab, GlaxoSmithKline, Glenmark, Merck Serono, MediciNova, Novartis, Sanofi -Aventis, Santhera, Shire, Roche, Teva, UCB, Wyeth, Swiss MS Society, Swiss National Research Foundation, European Union, Gianni Rubatto Foundation, the Novartis and Roche Research Foundations.

Knowledge, attitude assessment of Iranian patients with MS receiving interferon-β

R. Abolfazli, A. Elyasi, M. Javadi, K. Gholami, H. Torkamandi

Tehran University of Medical Science (Tehran, IR)

Background: There are few studies on patient knowledge in multiple sclerosis (MS), and only three published questionnaires. The purpose of this study was to describe MS patients’ understanding of their treatments. Consequently, guidance for developing educational programs for MS patients.

Method: A total of 425 randomly selected MS patients participated in this survey (response rate 85%). The knowledge levels of correct using IFN β and their attitude towards some aspects of medical care were measured using self-reported questionnaires consisted of 25 items with validity of multidisciplinary panel and pre-testing on 20 patients. The data were analyzed using descriptive statistical methods.

Results: Acceptably, knowledge and attitude internal consistency ( cronbach’s α=0.73,0.71) and content validity were established. Iranian MS patients’ knowledge of treatment with IFN β was very low, however their attitudes was at a very high level. Female patients, self-injection ability, The higher educational level, normal functional status, longitudinal delay from the start of diagnostic workup to definite diagnosis, and being younger were related to higher level of knowledge. Attitude was associated with functional status, family history of disease and the summary of knowledge variable (positive association).

Conclusion: Low levels of patients’ knowledge disclose their needs for developing educational interventions, with considering key role of some other important factors on patients’ attitude.

The authors have nothing to disclose.

Symptoms and quality of life of adults with multiple sclerosis by employment status

K. Johnson, D. Amtmann, A. Verrall, V. Weir, R. Salem

University of Washington (Seattle, US)

Background: Patients with multiple sclerosis (MS) face high unemployment rates as symptoms pose a significant barrier to finding and maintaining employment. Secondary symptoms have not been extensively studied in relation to employment partly because of lack of common metrics across measures. The PROMIS initiative uses modern psychometric methods to develop instruments using the same metric and providing US population norms. The objective of the current study was to construct profiles of secondary symptoms and cognitive function in patients with MS compared to US population norms by employment status.

Methods: PROMIS symptom measures including fatigue, pain, physical and social function, depression, anxiety, and sleep disturbance and Neuro-QoL measures of executive functioning and general cognitive concerns were completed via telephone by 414 community-dwelling adults with MS as part of a needs assessment survey. Employment status, work preference, and demographics were also collected. T-scores were compared to US population norms (mean of 50 and SD of 10) by employment status group (employed >20 hours/week, employed <20 hours/week, unemployed and satisfied and unemployed but prefer to work).

Results: Most respondents were unemployed (70%) and only 14% were actively seeking work. Of the unemployed, 62% preferred to be working, but most (79%) were unable to work due to symptom burden. The employed group had significantly worse fatigue, pain interference, executive function and general cognitive concern scores in contrast to US population norms, (p<0.001). The unemployed and prefer to work group reported worse functioning than population norms on all measures, (p<0.001) and had greater symptom burden than the employed group on all measures but sleep disturbance, (p<0.001).

Conclusions: Employed patients with MS report fewer secondary conditions than unemployed. However, this group is still burdened with pain, fatigue and cognitive issues and should be counseled on how to use compensatory strategies to preserve employment. Unemployed patients with MS who prefer to be working report the highest symptom burden. This group is generally younger than those who are satisfied with their unemployment and may feel that they should be working, but are unable to do so because of MS symptoms. Those who are unemployed but would prefer to work may benefit from interdisciplinary, in-depth consultation on symptom management, compensatory strategies, and employment options.

The authors have nothing to disclose.

Multiple Sclerosis Severity Scale: cognition and employment correlates

M. Gudesblatt, M. Zarif, O. Gorbatsevych, B. Bumstead, M. Buhse, L. Fafard, I. Topalli, G. Doniger

South Shore Neurologic Associates (Patchogue, US); School of Nursing State University at Stony Brook (Stony Brook, US); Biogen Idec (Cambridge, US); NeuroTrax Corporation (Bellaire, US)

Background: Cognitive impairment is common in patients with Multiple Sclerosis. The routine neurological examination and the EDSS are largely insensitive to cognitive function. Cognitive impairment in MS can impact disability and employment independently of EDSS. The Multiple Sclerosis Severity Scale (MSSS) has been devised to compare disease progression using single assessment data. The MSSS is also insensitive to cognitive function. Objective measures are needed in multiple domains to assess the impact of MS on cognition.

Objective: To identify the presence, prevalence and types of cognitive impairments and employment as related to MSSS, as well as the relationship between employment and MSSS.

Methods: Retrospective review of an MS cohort database evaluated by age, gender, Disease Duration, EDSS, Employment status (self-reported) and by means of a standardized validated MindStreams Battery.

Results: 837 MS patients, 628 (75%) female, age (range 19.6- 78.2 years, mean 47.7 yrs) were analyzed. …..for each cognitive domains measured (executive function, attention, information processing, memory, motor skills, verbal function, visual spatial processing) and a global cognitive score MS patients with >1 standard deviation (SD) below average for age, have a higher MSSS compared to those who do not (p<0.001). Increasing number of total cognitive domain scores >1SD below average from: 0 to ≥3 domains correlates with increasing MSSS ((0 domains: mean MSSS=3.09; 1 domain=3.65; 2 domains=4.09; ≥3 domains=5.07; p<0.001; Cohen’s d effect sizes: 0 vs. 1: d=0.22; 0 vs. 2: d=0.38; 0 vs. ≥3: d=0.74).). Unemployed individuals had higher MSSS scores (p<0.001; d=0.65).

Conclusion: Cognitive impairment in MS as measured by scores >1SD below average as well as an accumulating burden of disease reflected by an increasing number of cognitive domains with scores >1SD track with MSSS. MSSS is also related to employment status. Computerized cognitive evaluation provides information not obtained from EDSS, disease duration or MSSS alone.

A. Mark Gudesblatt, MD - no disclosures.

B. Myassar Zarif, MD - no disclosures.

C. Oleksandr Borbatsevych, BA - no disclosures.

D. Barbara Bumstead, ANP - no disclosures.

E. Marijean Buhse, ANP, PhD - no disclosures.

F. Lori Fafard, RN - no disclosures.

G. Ilir Topalli, PhD - no disclosures.

I. Glen Doniger, PhD - Employee of NeuroTrax Corp.

Clinical audit: establishing reasons and patterns of non-elective admissions of patients with multiple sclerosis in a UK centre

S. Binks, W. Rashid

Brighton and Sussex Medical School (Brighton, UK); Brighton and Sussex University Hospitals NHS Trust (Brighton, UK)

Background: UK rates of non-elective admissions for long-term neurological disorders, including multiple sclerosis (MS), have risen in excess of those for other conditions and are currently increasing at 6% annually. Although national hospital episode statistics cite emergency admission rates of 12.5% in MS, considerable geographical variation was detected in a pooled UK analysis for MS, Parkinson’s Disease and Motor Neurone Disease ranging from <30% to >70%. This audit sought to benchmark the rate of emergency admissions and understand causative factors, in order to plan strategies to reduce costs and distress to patients of unplanned hospital stays.

Patients and methods: Brighton and Sussex University Hospitals NHS Trust is a large teaching centre in South East England. Central information compiled a spreadsheet of cases admitted to the trust with a discharge date between 1 April 2009 and 31 March 2012 and a primary diagnosis of MS (G35X). Elective admissions in 2011-12 were excluded due to a rise in daycases after institution of natalizumab therapy in this centre. After removal of duplicate entries, 83 non-elective and 84 elective cases were available for audit.

Results: Comparison of elective and non-elective cases in 2009-10 and 2010-11 showed an emergency MS admission rate of 42%, but this represented 57% of their total cost. Mean age of emergency cases from 2009-12 was 47 and there were more female (70%) than male cases (30%). Eleven women and five men had more than one non-elective admission, such that 24% of non-elective admissions were of repeat or frequent attenders. Non-elective MS admissions peaked in April-July (39 admissions, 47%) and October (9 admissions, 11%). A previous pilot analysis of the 28 emergency admissions in 2010-11 had identified main presentations of relapse or disease worsening, and a leading trigger of urinary tract infections among patients with progressive MS. Additional data to be presented will explore reasons for admission in this larger cohort.

Conclusions: Emergency admissions for MS carry a disproportionate financial impact to healthcare budgets. Their rate may be influenced by seasonal factors with increased admissions in spring and summer months. Nearly a quarter of emergency admissions are of repeat attenders, and initiatives to reduce non-elective admissions could focus on this group. Multiple admissions were also more common among female patients which may be relevant to devising appropriate interventions.

The authors have nothing to disclose.

Assessing prognostic factors of severe relapse requiring hospitalisation and/or IV methylprednisolone in RRMS treated with placebo or laquinimod: pooled analysis from the ALLEGRO and BRAVO trials

C.A. Carroll, P. Lindgren, A. Lang on behalf of the Allegro & BRAVO Study Group

Background: Historically, clinical trials assessing the efficacy of alternative agents to treat relapsing-remitting multiple sclerosis (RRMS) patients, have focused on annualized relapse rates, changes in MRI results, brain volume loss and/or disease progression. Prior studies, however, did not report prognostic factors of rates of hospitalization and/or IV Methylprednisolone required for the treatment of severe relapse.

Methods: Using intent-to-treat and completer data sets pooled from the ALLERGO and BRAVO trials, severe relapse was defined as a confirmed relapse requiring either (1) hospitalization or (2) IV Methylprednisolone use without hospitalization. Prognostic markers of severe relapse defined by either of the two above criteria were assessed using logistic, Poisson and Cox Proportional Hazards models with a-priori level of significance of 0.05.

Results: Prognostic factors linked with reduced rates of hospitalization to treat severe relapse included (1) the use of Laquinimod (p = 0.004) and (2) lower age at baseline (p = 0.003). High baseline EDSS (p = 0.000) and male gender (0.001) were associated with greater need for hospitalization for severe relapse while disease duration yielded no predictive value (p = 0.308). Prognostic factors linked with reduced rates of IV Methylprednisolone mirrored the findings observed with hospitalization rates with reductions in severe relapse associated with use of Laquinimod and lower baseline age. High baseline EDSS was also associated with greater risk of IV Methylprednisolone use.

Conclusions: Treatment of RRMS patients with Laquinimod reduces the patient’s risk of relapse-induced hospitalization and IV Methylprednisolone use.

The ALLEGRO and BRAVO study were funded by Teva Pharmaceuticals.

Dr. Carroll is an employee of Teva Pharmaceutical.

Dr. Lindgren and Ms Lang are paid research consultants for the study.

Economic costs, utility and social participation of patients with multiple sclerosis treated by natalizumab

A. Kwiatkowski, M. Puyfaucon, J. Pelzer, JP. Marissal, B. Dervaux, P. Vermersch, P. Hautecoeur

Lille Catholic University (Lille, FR); University Lille Nord de France (Lille, FR)

Background: Economic costs related to treatment of multiple sclerosis (MS) must be justified by the improvement of health status, quality of life (QOL) and social participation of patients and caregivers.

Objectives: First, this pilot study evaluates feasibility and acceptability of a medico-economic survey in an individual interview. Then we assess economic costs (direct and indirect costs), the impact on QOL (utility) and social participation in MS patients receiving natalizumab.

Methods: By individual interviews of 40 consecutive patients treated by natalizumab in one centre, we reported clinical and medical data including the Expanded Disability Status Scale score (EDSS). We measured resource consumption, productivity loss, QOL (utility) with a French validated value set of EQ-5D, social participation with the Impact on Participation and Autonomy questionnaire (IPA). We performed descriptive and correlation analyses.

Results: 39 patients (median age: 43 [23-72] years, mean disease duration: 11.8 years [2-40]) accepted to complete the questionnaire. Mean annual global cost per patient was 58710 ± 19867 Euros. Resource consumption accounted for 55% of global cost, non-medical direct costs for 18% (including informal care by caregivers for 8%) and productivity loss for 26%. Mean EQ-5D value were 0.52 ± 0.27. EDSS score correlated with global cost (p=0.02, r=0.27), non-medical direct cost (p<0.01, r=0.47), utility values (p=0.01, r=-0.5) and social participation (p<0.01, r=-0.47). Social participation and utility values were also correlated (p<0.01, r=-0.47). Productivity losses were not correlated to health status (EDSS).

Discussion/Conclusion: Our descriptive study from a small but homogeneous MS patients sample provides consistent results with older French data collected by postal questionnaires with lower response rates. Our overall costs of MS seem increased over those of earlier studies. But this effect can be mainly explicated by treatment of every patient with natalizumab. Productivity losses could be limited by the medication. Prospective studies with similar method could be useful to better understand the links between medico-economic data, QOL and social participation.

The authors declare that there are no conflicts of interest.

Difficulties felt in the work in persons with multiple sclerosis

J.C. Ongagna, J. Pinelli, C. Zaenker, J. De Sèze

Alsacep Pasteur Hospital (Colmar, FR)

Background: The physical and psychological stressors of MS seriously disrupt personal and social functioning for the MS patients. Due to the young age of MS patient the impact on working abilities is particularly high on this chronic desease.

The purpose of this work was to described the problems that MS patients met within the framework of their work in order to propose possible solutions.

Methods: Two hundred and seven working patients ages between 20 and 60 years were questioned about employment problems. The following were taken onto account : demographic, medical and professional data. This questionnaire was administered during neurologist or rehabilition outpatient clinics.

Results: Our results shows that physical fatigue (74%) and mental fatigue (40%) were the primary symptomatic factor causing difficulties in work. 15 % of the patients suffered from the misunderstanding of colleagues and 14 % of employers. More than half of the patients would like to benefit from a professional help very early during the first years following MS diagnosis.

Conclusion: This study shows that among the usual for workin maintain the physical and mental fatigue take an important part. Having supportive employer and colleagues possibilities was also identified as one of the key factors enabling people with MS to remain in or return to work. To improve the preservation in the employment, it is advisable to favor the premature, multidisciplinary coverage in network to optimize the already available tools or propose original issues.

The authors have nothing to disclose.

CHI3L1 expression in chronic active multiple sclerosis lesions

C. Costa, E. Cantó, A.C. Wing, L. Agulló, X. Montalban, M. Comabella

Vall Hebron University Hospital (Barcelona, ES)

Background: Chitinase 3-like 1 (CHI3L1) is a member of the human chitinase family of proteins. It is a normal component of human serum and is produced by different cell types, including macrophages, neutrophils, chondrocytes, synovial cells, osteoblasts, vascular smooth muscle cells, and astrocytes. Although the physiological and biological roles of chitinases remain unclear, elevated levels have been related to arthritis, asthma, neuromyelitis optica, multiple sclerosis (MS) and other inflammatory diseases.

Increased levels of CHI3L1 have been found in cerebrospinal fluid (CSF) samples of patients with relapsing-remitting and secondary progressive MS compared with patients with non-inflammatory neurological conditions. In a study published by our group it has been shown that in patients with clinically isolated syndromes (CIS), CHI3L1 CSF levels are higher in patients who convert to clinically definite MS compared to those who remain as CIS. Despite these observations, little is known about the role of CHI3L1 in the pathogenesis of MS and its expression in MS lesions. Objective: To characterize CHI3L1 expression in MS chronic active lesions. Methods: Brain samples of chronic active lesions embedded in paraffin from 15 MS patients and 2 controls, provided by The UK Multiple Sclerosis Tissue Bank, were stained with haematoxylin-eosin and Kluver-Barrera. MS lesions were classified as chronic active with high inflammatory activity (5 lesions) and with low inflammatory activity (10 lesions). Double immunohistochemistries for GFAP, CD68, CD3 and CHI3L1 were performed.

Results: Double immunohistochemical stainings showed that MS lesions with high inflammatory activity had higher CHI3L1 expression and it was located in the cytoplasm of macrophages/microglia (CD68+ cells) and reactive astrocytes (GFAP+ cells). In MS lesions with low inflammatory activity CHI3L1 expression was overall lower and restricted to the cytoplasm of few macrophages/microglia. Endothelial cells had low CHI3L1 expression in all lesions and no staining was observed in T lymphocytes (CD3+ cells). Control samples did not show immunostaining for CD68, CD3 and CHI3L1, and only discrete staining for GFAP was observed in the perivascular endfeet of astrocytes.

Conclusion: In MS chronic active lesions, the distribution and expression level of CHI3L1 change according to the inflammatory activity.

The authors have nothing to disclose.

Is there a functional role for KCNMA1 in multiple sclerosis?

A. Vanheel, B. Brône, R. Daniels, P. Stinissen, J.P. Noben, N. Hellings

Hasselt University (Diepenbeek, BE)

A more detailed insight into disease mechanisms of multiple sclerosis (MS) is crucial for the development of new and more effective therapies. MS is a chronic inflammatory autoimmune disease of the central nervous system. The aim of this study is to identify novel disease associated proteins that are functionally involved in the MS brain pathology. In a previous proteomics study, brainstem proteins were obtained from Lewis rats with MBP induced acute experimental autoimmune encephalomyelitis (EAE), a well characterized disease model of MS. Samples were collected at different time points: just before onset of symptoms, at the top of the disease and following recovery. To analyze changes in the brainstem proteome during the disease course, a quantitative proteomics study was performed using two-dimensional difference in-gel electrophoresis (2D-DIGE) followed by mass spectrometry. We identified 75 proteins with a significant abundance difference between the different disease stages. Regulated proteins were mapped to existing biological networks by Ingenuity Pathway Analysis (IPA). Post-synaptic density protein 95 (DLG4), a key player in neuronal signalling and calcium-activated potassium channel α 1 (KCNMA1), involved in neurotransmitter release, are 2 putative regulators connecting 64% of the proteins identified. The involvement of KCNMA1 in macrophage functionality was studied in vitro by using a specific functional blocker for KCNMA1, paxillin. We show that blocking of KCNMA1 altered myelin phagocytosis and proinflammatory cytokine release, disease mechanisms which are highly involved in EAE and MS pathology. We are currently investigating possible influences of this blocker on functionality of other disease relevant cells and processes using in vitro and in vivo models. This study will elucidate to what extent modulation via this ion channel affects disease processes in the context of EAE/MS.

The authors have nothing to disclose.

Oxidative stress is associated with disability in relapsing-remitting multiple sclerosis patients

S.R. Oliveira, A.P. Kallaur, A.N.C. Simão, D.R. Kaimen-Maciel, J. Lopes, C. Panis, W.L.C.J. Pereira, R.M. de Andrade, E.M.V. Reiche

State University of Londrina (Londrina, BR)

Increased levels of oxidative stress markers and/or decreased levels of antioxidant molecules are described in patients with multiple sclerosis (MS) and this imbalance has been implicated in demyelination and axonal damage. Accumulating data indicate that oxidative stress plays a major role in the pathogenesis of MS. The aim of this study was to evaluate oxidative stress in relapsing-remitting multiple sclerosis (RRMS) patients and to verify its correlation with disability assessed by the Expanded Disability Status Scale (EDSS). This study included 91 RRMS during clinical remission (65 females and 26 males) and all RRMS were using interferon β 1a or 1b. They were clinically evaluated to disability using EDSS and separated into two groups according to EDSS cutoff value of 3.5 and patients with EDSS ≤ 3.5 were considered with low disability. The EDSS scores ranged from 0.0 to 6.5 (median 3.0), 71 (78.0%) of MS patients had EDSS ≤ 3.5 (low disability) and 20 (22.0%) had EDSS >3.5 (high disability). The control group had 196 healthy individuals (151 females and 45 males) controlled by age, gender, ethnicity, smoking, and body mass index. The oxidative stress was evaluated in plasma by tert-butyl hydroperoxide-initiated chemiluminescence (CL-LOOH), carbonyl protein, metabolites of nitric oxide (NOx), sulfhydryl groups of protein, uric acid and total radical-trapping antioxidant parameter (TRAP). MS patients had higher plasma levels of lipid hydroperoxide (p<0.0001), carbonyl protein (p=0.0081), and lower plasma levels of NOx (p<0.0001), TRAP (p=0.0088), sulfhydryl groups (p=0.0003) than controls. Uric acid levels did not differ among the individuals (p=0.110). Patients with an EDSS > 3.5 showed higher CL-LOOH than control subjects (p=0.0093).In addition, a positive correlation was observed between CL-LOOH and EDSS (r=0.3244, p=0.0026) and carbonyl protein and EDSS (r=0.3012, p=0.0041). The multivariate analysis also demonstrated that the CL-LOOH marker was associated with the EDSS of the RRMS patients (r=0.0461, p=0.0001). These results underscore that oxidative stress may have an important role in the physiopathology of the MS progression, even in patients with clinical remission and further studies are needed to evaluate the effects of antioxidant therapies associated with conventional treatments in MS patients.

All the authors have nothing to disclose.

This study was supported by grants obtained from the Institutional Program for Scientific Initiation Scholarship (PIBIC) of the National Council for Scientific and Technological Development (CNPq); State University of Londrina (PROPPG); and Bayer HealthCare. We thank the State University of Londrina, the University Hospital of State University of Londrina, and HUTEC for their technical and administrative support.

Fractalkine its receptor (CX3CR1) expression in the spinal cord associated with MS-induced neuropathic pain

M.P. Namaka, W. Zhu, C.M.R. Acosta, B. MacNeil, E.E. Frost

University of Manitoba (Winnipeg, CA)

Introduction: Neuropathic pain (NPP) is reportedly the 2nd worst symptom of MS. Fractalkine and its receptor (CX3CR1) are involved in the pathogenesis of NPP. Induction of NPP results in increased fractalkine expression in sensory neurons of dorsal root ganglia (DRG), and increased CX3CR1 in spinal cord microglia. Further, fractalkine is increased in serum of MS patients. We hypothesized that fractalkine and CX3CR1 expression are increased in correlation with the onset of NPP in an experimental autoimmune encephalomyelitis (EAE) model of MS.

Methods: We used the Lewis rat, myelin basic protein (MBP) EAE model to correlate changes in fractalkine and CX3CR1 expression with neurological disability (ND) and the onset of behavioural changes associated with NPP (assessed by thermal withdrawal latency). Rats were assigned to active control (AC: Freund’s adjuvant, M. tuberculosis and pertussis toxin) and active EAE (EAE: as AC + MBP) groups. Gene expression was assessed by qRT-PCR (shown as mRNA ratio to GAPDH). Protein expression was assessed by ELISA (shown as ng/10µg total protein) and immunohistochemistry (IHC). Statistics were ANOVA followed by Tukey’s posthoc test *=p<0.05, **=p<0.01, ***=p<0.005).

Results: Peak ND occurs 12 days post disease induction, 4 days after onset. Withdrawal latencies were significantly increased 1 day post disease onset* indicating onset of NPP.

EAE rats show a significant increase in fractalkine mRNA expression vs AC (0.13 ± 0.02 vs 0.04 ± 0.01***), and protein expression vs AC (53.5 ± 8.9 vs 44.4 ± 13.6*) in lumbar DRG. EAE animals show a significant increase in CX3CR1 mRNA expression (0.03 ± 0.00 vs 0.02 ± 0.00*) and protein vs AC (3.10 ± 0.54 vs 2.24 ± 0.24**) in lumbar DRG. EAE animals show a significant increase of fractalkine mRNA (0.21 ± 0.02 vs 0.11 ± 0.01**) and protein vs AC (93.6 ± 29.6 vs 40.1 ± 6.1***) in spinal cord. Levels of CX3CR1 mRNA (0.06 ± 0.08 vs 0.04 ± 0.01**) and protein are significantly increased vs AC (3.56 ± 1.29 vs 2.20 ± 0.54***) in spinal cord. All increases correlated with ND and NPP.

IHC analysis showed neurons and astrocytes expressed fractalkine, and neurons and microglia expressed CX3CR1 in spinal cord of EAE animals.

Conclusions: Fractalkine and CX3CR1 gene and protein levels are significantly increased in DRG and spinal cord correlating with peak ND and sensory changes. Fractalkine is expressed by neurons and astrocytes in spinal cord. CX3CR1 is expressed by neurons and microglia in spinal cord.

The authors have nothing to disclose.

Funding provided by investigator initiated research grants from Manitoba Medical Sciences Foundation, University of Manitoba Research Grants Program, Pfizer Canada, Pfizer UK Global, Purdue Pharma.

Co-localisation of grey matter volume reduction and grey matter lesions in multiple sclerosis

S.H.P. van de Pavert, N. Muhlert, V. Sethi, C.A. Wheeler-Kingshott, A.J. Thompson, J.J.G. Geurts, T.A. Yousry, D.H. Miller, D.T. Chard, O. Ciccarelli

UCL Institute of Neurology (London, UK); VU University Medical Center (Amsterdam, NL)

Background and Aim: The involvement and clinical relevance of grey matter (GM) pathology in MS is increasingly recognised. Recent development of double inversion recovery (DIR) magnetic resonance imaging sequences improves detection of GM lesions in vivo. We aimed to determine whether GM lesions co-localize with regional GM volume loss in vivo.

Methods: Sixty MS patients (30 relapsing-remitting, 15 primary progressive, and 15 secondary progressive) and 30 healthy controls underwent T1-weighted (1mm³) and DIR (1x1x3mm) scans on a Philips Achieva 3T system. Three raters marked GM lesions on DIR scans independently and a consensus was reached on all lesions.

A custom DARTEL template was generated from participants’ T1 scans using SPM8 to account for ventricular widening in MS. Each participant’s T1 scan was registered to this template and then to MNI152 space using a nonlinear and an affine transformation, respectively. These transformation parameters were applied to binary DIR lesion masks, which had been affine registered onto the individual T1 scan. The resulting DIR lesion maps were then smoothed with an 8mm kernel. Voxel based morphometry (VBM) and lesion probability mapping (LPM) were carried out in SPM8 to assess differences in GM volume (p<.05 FWE corrected) and probability of each voxel being lesional between patients and controls. To co-localise GM volume changes and lesion probability, VBM was performed by masking regions that showed GM lesions in patients (p<.05 (uncorrected)).

Results: Reduced GM volume in patients was observed bilaterally in the thalamus, caudate, and putamen. In patients, cortical GM lesions were seen throughout the brain with the highest probability in the pre- and post-central gyri, cerebellum, and in the temporal lobes. Co-localisation of GM volume reductions and higher lesion probability was observed in the right insula and putamen, right pre- and post-central gyri, and left cerebellum.

Conclusions: When using a patient-specific brain template and SPM8, spatial overlapping of reduced GM volume and GM lesions in MS patients was seen in a minority of regions, compared to regions with GM lesions only. Despite the limited sensitivity of the techniques used, these data suggest that there may be additional mechanisms for GM atrophy than due to GM lesions visualised on DIR. Further work can assess regional changes in atrophy and lesion location over time, and their relationship with cognitive and physical impairment.

The NMR Research Unit is supported by the MS Society of Great Britain and Northern Ireland and the Department of Health UCL/UCLH Biomedical Research Centre. The MS Society of Great Britain and Northern Ireland has provided financial support for staff and research costs. (Grant number 917-09).

Van de Pavert SHP receives research support from Stichting MS Research and Prinses Beatrix Fonds.

Muhlert N has nothing to disclose.

Sethi V receives research support from Biogen Idec and Novartis.

Wheeler-Kingshott CA is on the advisory board for BG12 (Biogen) and receives grants (PI and co-applicant) from ISRT, EPSRC, Wings of Life, MS Society, Biogen Idec and Novartis.

Thompson AJ has received honoraria for consultancy from Eisai Ltd, BTG International, Novartis; honoraria and support for travel from lecturing from Serono Symposia International Foundation and Novartis. Support for travel for consultancy from MSIF; honorarium from Sage for editorship of Multiple Sclerosis Journal.

Geurts JJG has nothing to disclose.

Yousry TA serves as Editor for European Radiology Journal and has received honoraria (Board Membership) from UCB, Bristol-Myers Squibb, Biogen Idec, and grants (PI or Co-PI Coordinator) from NIHR CBRC, MRC, MS Society, PSP, Stroke, BHF, Wellcome Trust, GSK, Biogen Idec, Novartis;

Miller DH has received honoraria from Biogen Idec, Novartis, GlaxoSmithKline, and Bayer Schering, and research grant support for doing MRI analysis in multiple sclerosis trials sponsored by GlaxoSmithKline, Biogen Idec, and Novartis.

Chard DT receives research support from the Multiple Sclerosis Society of Great Britain and Northern Ireland and holds stock in GlaxoSmithKline.

Ciccarelli O receives research grant support from the Multiple Sclerosis Society of Great Britain and Northern Ireland, the Department of Health Comprehensive Biomedical Centre, the International Spinal Cord Research Trust (ISRT) and the Engineering and Physical Sciences Research Council (EPSRC); she has received honoraria from Bayer Schering and GE.

Grey matter microstructural and volumetric short-term changes in early relapsing and progressive MS

B. Bodini, M. Battaglini, M.L. Stromillo, A. Eshaghi, C. Gasperini, C. Pozzilli, A.J. Thompson, N. De Stefano, O. Ciccarelli

UCL Institute of Neurology (London, UK); University of Siena (Siena, IT); Tehran University of Medical Sciences (Tehran, IR); University “La Sapienza” (Rome, IT)

Introduction: Grey matter (GM) damage and atrophy are observed early in the course of MS. However, changes in regional GM damage and atrophy over time are unknown. The aim of this study was to map the microstructural and volumetric changes of the cortical GM in patients with early relapsing-remitting (RR) and early primary-progressive (PP) MS when compared to healthy controls, and to investigate their evolution in patients over one year.

Methods: Thirty-two patients with RRMS and 33 with PPMS within 5 years from onset, underwent conventional and magnetisation transfer (MT) imaging at baseline and after one year in Siena and London, respectively. Two age- and gender-matched groups of controls were studied at baseline in both centres. Two study-specific GM templates were created. For each subject, the GM-MT ratio (GM-MTR) map and the GM probability T1-w map (GM-T1w) were non-linearly registered to the corresponding template and smoothed. Differences in MTR intensity and GM volume between patients and HC were assessed at voxelwise level using an unpaired t-test (p<0.05). Each pair (baseline-12 months) of GM-MTR maps and GM-T1w images were non-linearly registered to the standard space template, subtracted and smoothed. Changes in MTR intensity and GM volume in patients over the follow-up were assessed at voxelwise level using a paired t-test (p<0.05).

Results: At baseline, early RRMS patients showed a significant reduction in both MTR and volume in the pre- and post-central cortex, cingulate gyrus (CG), precuneus (PC), and superior and inferior temporal gyri, when compared with HC; the regions showing reduced GM-MTR were more extensive than those showing GM atrophy. During follow-up, early RRMS patients showed further atrophy development in the PC, CG and pre-central gyrus. At baseline, early PPMS patients showed a significant reduction in MTR and volume in pre- and post-central gyrus and in the PC when compared with HC; the areas of reduced GM-MTR were larger than those showing GM atrophy. During follow-up, early PPMS patients showed further atrophy development in the pre- and post-central gyrus, and the PC.

Conclusions: Our novel approach demonstrated the occurrence of microstructural and atrophic GM changes in key areas involved in motor and cognitive functions in early RRMS and early PPMS patients. The areas showing reduced MTR and volume at baseline continued to develop significant atrophy over the following year.

B.Bodini, M.Battaglini, M.L.Stromillo, C.Gasperini, C.Pozzilli do not have disclosures to declare.

N. De Stefano has received honoraria from Schering, Biogen-Dompè, Teva and Merck-Serono for consulting services, speaking and travel support. He serves on advisory boards for Merck Serono. He has received research grant support from the Italian MS Society.

Alan J Thompson has received honoraria for consultancy from Eisai Ltd, BTG International, Novartis; honoraria and support for travel for lecturing from Serono Symposia International Foundation and Novartis. Support for travel for consultancy from MSIF; honorarium from Sage for editorship of Multiple Sclerosis Journal.

Olga Ciccarelli receives research grant support from the Multiple Sclerosis Society of Great Britain and Northern Ireland, the Department of Health Comprehensive Biomedical Centre, the International Spinal Cord Research Trust (ISRT) and the Engineering and Physical Sciences Research Council (EPSRC); she has received honoraria from Bayer Schering and GE.

Morphology of cortical grey matter lesions – a possible diagnostic role?

V. Sethi, T. Yousry, N. Muhlert, M. Ron, X. Golay, C. Wheeler-Kingshott, D. Miller, D. Chard

UCL Institute of Neurology (London, UK)

Background: In multiple sclerosis (MS) cortical grey matter (CGM) lesions, that include both intracortical (IC) and leucocortical (LC) lesions, have been classified histopathologically based on their location in the cortex and juxtacortical white matter. Using imaging with double inversion recovery (DIR) scans, CGM lesions are classified according to their morphological appearance as being oval, wedge, and worm-shaped (curvilinear). Phase Sensitive Inversion recovery (PSIR) enables higher resolution scanning, in clinically acceptable scan times, allowing for a qualitative and quantitative improvement in CGM lesion detection.

Aim: To assess the frequency of different lesion shapes in patients with MS, using DIR and PSIR, and compare this with healthy controls (HC).

Methods: 60 MS patients (30 relapsing remitting (RR), 15 primary (PP), 15 secondary progressive (SP)) and 30 HC underwent MRI scanning on a Philips 3T Achieva system. DIR (1x1x3mm,4 minutes) and PSIR scans (0.5x0.5x2mm, 11 minutes) were acquired, along with T2-weighted and fluid attenuated inversion recovery sequences. Lesions marked on DIR and PSIR scans independently and were classified as oval, wedge or curvilinear shaped. Criteria for identifying lesions were established under expert guidance (TY). The number of patients and HC with ≥1 lesion of each shape (IC/LC) was determined.

Results: Curvilinear lesions were seen in 85% and 37% of all MS patients using PSIR and DIR respectively. Wedge shaped lesions were seen in 33% and 55% and oval shaped lesions were seen in 78% and 87% respectively. In HC, no curvilinear lesion was detected using either scan and a wedge shaped lesion was seen in one control (DIR), oval lesions were seen in 20% (PSIR) and 17% (DIR); of these 1 lesion was IC (PSIR) and all others were LC. In MS clinical subgroups, the frequency on PSIR of curvilinear lesion in RR, SP and PPMS was 97%, 80% and 67% respectively; of oval lesions: 73%, 87%, 80% and wedge shaped lesions: 27%, 47%, 33%.

Conclusions: The morphology of lesions is more clearly visible on PSIR than DIR scans. Using the higher resolution PSIR scan, curvilinear shaped lesions were the commonest in all patients but were not seen in any of the HC, suggesting that these lesions may be characteristic for MS; curvilinear lesions are more common in the relapse onset (RR and SP) group, while oval and wedge shaped lesions are more common in progressive disease.

The NMR Research Unit is supported by the MS Society of Great Britain and Northern Ireland and the UCL UCLH Comprehensive Biomedical Research Centre. The MS Society of Great Britain and Northern Ireland has provided financial support for staff and research costs for this project. ( Grant number 917-09).

Sethi V receives research support from Biogen Idec and Novartis.

Yousry TA serves as Editor for European Radiology Journal and has received honoraria (Board Membership) from UCB, Bristol-Myers Squibb, Biogen Idec, and grants (PI or Co-PI Coordinator) from NIHR CBRC, MRC, MS Society, PSP, Stroke, BHF, Wellcome Trust, GSK, Biogen Idec, Novartis.

Muhlert N reports no disclosures.

Ron M reports no disclosures.

Golay X has acted as a consultant for Philips Healthcare regarding the implementation of our ASL sequence in their product.

Wheeler-Kingshott CA is on the advisory board for BG12 (Biogen) and receives grants (PI and co-applicant) from ISRT, EPSRC, Wings of Life, MS Society, Biogen Idec and Novartis.

Miller DH DHM has received honoraria from Biogen Idec, Novartis, GlaxoSmithKline, and Bayer Schering, and research grant support for doing MRI analysis in multiple sclerosis trials sponsored by GlaxoSmithKline, Biogen Idec, and Novartis.

Chard DT receives research support from the Multiple Sclerosis Society of Great Britain and Northern Ireland and holds stock in GlaxoSmithKline.

Grey matter changes in Relapsing-Remitting Multiple Sclerosis: a meta-analysis of voxel-based morphometry studies

J.A. Lansley, M. Grau, J. Radua, D. Mataix-Cols, J. Sastre-Garriga

Norfolk and Norwich University Hospital (Norwich, UK); King’s College (London, UK); FIDMAG, CIBERSAM, Sant Boi de Llobregat (Barcelona, ES); Hospital Vall d’Hebron (Barcelona, ES)

Introduction: Extensive grey matter (GM) demyelination described in MS seems to occur largely independent of white matter (WM) lesions. Cortical lesions are underestimated by standard histopathological techniques and MRI which may contribute to the clinico-radiological paradox in MS. Voxel-based morphometry (VBM) studies have shown GM atrophy in various MS subtypes but there has been no meta-analysis to date. The aims of this study were to establish the replicable GM changes in MS and whether these are associated with the Expanded Disability Status Scale (EDSS).

Method: Database searches were performed using keywords “Multiple Sclerosis” plus “morphometry”, “voxel-based” or “voxelwise”. Manual searches were also conducted. Case-control VBM studies with sample size greater than ten were included.

Meta-analytical differences in global and regional GM volumes were calculated using Signed Differential Mapping (SDM) software (sdmproject.com). GM SDM maps were created for each dataset using cluster co-ordinates. SDM maps were synthesised into a meta-analytic map by assigning voxel values weighted by study and cluster characteristics. Null distributions of meta-analytic values then tested which voxels reported GM differences more than expected by chance. Analyses of robustness were then performed.

Results: The search yielded 17 studies. Ten of 11 Relapsing-Remitting MS (RRMS) studies were available for analysis (401 patients, 241 controls).

Global differences: MS Patients (137) had significantly smaller global GM volume compared with controls (89), 7.49% reduction, p=0.003.

Regional differences: Six clusters were identified involving bilateral basal ganglia (right thalamic pulvinar peak = 2416 voxels); left pre/post-central gyri (776 voxels); left frontal gyri (353 voxels); right pre-central/middle frontal gyrus (86 voxels); left cingulate/medial frontal gyrus (55 voxels) and right inferior parietal lobule (14 voxels).

Reliability analysis: Jack-knife analyses showed the three largest clusters were highly replicable being preserved in all 12 study combinations.

EDSS meta-regression: EDSS score was negatively associated with GM volumes in the left pre/post-central gyri (166 voxels).

Discussion: SDM meta-analysis of VBM studies in RRMS demonstrates highly replicable findings of GM atrophy. Meta-regression analyses reveal a negative association between left pre/post-central gyrus volume and EDSS score. This association may reflect a bias towards locomotor disability inherent in the EDSS.

The authors have nothing to disclose.

Is the development of T2 hypointensity a global process?

R. Kane, V. Ikonomidou, J. Ohayon, F. Cantor, S. Stern, A. Gallo, S. Pellegrini, M. Ehrmantraut, F. Bagnato

University of Maryland (Washington DC, US); George Mason University (Fairfax, US); National Institutes of Health (Washington DC, US); Georgia State University (Atlanta, US)

Introduction: Neuroimaging studies are often faced with the so-called “curse of dimensionality” i.e., the combination of a large number of imaging-derived features with a small number of subjects.

Dimensionality reduction techniques, such as principal component analysis (PCA) are used to identify similarly-behaving brain networks. We used PCA to explore the possible presence of a network-type, rather than individual-structure, evolution of T2 hypointensities in deep gray matter (dGM) in patients with multiple sclerosis (MS); we further used correlations with cognitive testing results to validate the relevance of our observations.

Methods: Twenty-one MS patients and 21 healthy volunteers (HVs) underwent a 3.0T magnetic resonance imaging (MRI) and cognitive testing (MACFIMS battery). Masks of the caudate, putamen, pallidum, thalamus and the ventricles were created and normalized-to-the-ventricle intensity values of the dGM measured on T2-weighted images. PCA was used to analyze and reduce the dimensionality of the resulting dataset, which subsequently was compared to the cognitive testing results using Spearman correlation analysis.

Results: 82% of the variation in the T2 hypointensity data was described by the first principal component. Its form showed a simultaneous reduction, by different degrees, in T2 intensity in all structures studied. The projection of the whole dataset on the first principal component revealed significant differences between patients and HVs (p = 0.04). Patient projection values on the first principal component were significantly associated with scores from the Delis Kaplan Sorting Test (DKS; R=-0.6259, p=0.0024; R=-0.5912, p=0.0048) tests. Thalamus MTR showed a correlation trend with the first principal component projections. The second principal component accounted for 10% of the variability and pointed to simultaneous development of hypointensity in the caudate and the putamen.

Discussion: PCA results in complex composite scores that may be difficult to interpret. In this case however, the form of the first principal component suggests that, to a large degree, the development of T2 hypointensity in dGM proceeds simultaneously, albeit at different rates, in all structures studied, possibly regulated by a global disease process. Correlation with cognitive test results affirms the physiological relevance of a common progression amongst dGM structures.

The authors have nothing to disclose.

Thalamic lesion analysis on 7-Tesla MRI as a surrogate for cortical demyelination

D. Harrison, J. Oh, M. Seigo, J. Aquino, C. Jones, P. van Zijl, D. Reich, P. Calabresi

Johns Hopkins School of Medicine (Baltimore, US); Kennedy Krieger Institute (Baltimore, US); National Institutes of Health (Baltimore, US)

Introduction: Pathology in both the cortex and deep grey matter (GM) contribute to disability in multiple sclerosis (MS). While visualization of lesions within cortical GM has received much recent attention, studies of the thalamus in MS have been more focused on global markers of pathology; lesion analysis is not well described. However, demyelinating lesions in the thalamus are described pathologically, and these lesions have strong correlations with demyelination in the cortex. In this study, we have used the increased resolution of high field MRI to visualize small lesions within the thalamus and relate this to clinical information and cortical pathology.

Methods: 7-Tesla MRI scans were obtained on 33 participants with MS and 10 healthy volunteers. High resolution magnetization prepared rapid acquisition gradient echo (MPRAGE, 0.5mm isotropic) and magnetization prepared fluid attenuated inversion recovery (MPFLAIR, 1.0mm isotropic) were analyzed for the presence of lesions in the thalamus. Lesions were identified as hyperintense on MPFLAIR and hypointense on MPRAGE. Lesion burden was analyzed in relation to demographic data, clinical disability measures, and lesion analysis results from cortical GM (in a subgroup of 10 MS cases that also underwent manual identification of cortical GM lesions).

Results: The mean age of participants with MS was 43.4 (SD 9.8) years and was 36.7 (SD 8.8) for healthy volunteers. Twenty-seven MS participants were classified as relapsing, while 3 each were secondary (SPMS) and primary progressive. Thalamic lesions were detected in 11 MS subjects, and 1 lesion was found in 1 healthy control. Mean thalamic lesion count was 1.1 (range 0 - 9) in MS, and mean lesion volume was 45.8 µL (range 0 - 812.6). Mean thalamic lesion count and volume was greatest in those with SPMS (mean: 4 lesions, 164.6 µL). EDSS score correlated significantly with thalamic lesion count (Spearman ρ: 0.37, p = 0.04) and volume (ρ: 0.38, p = 0.03). In a regression model adjusted for age, the number of thalamic lesions significantly predicted the number of cortical GM lesions (p = 0.004, R2 = 0.85).

Conclusions: High field MRI allows identification of thalamic lesions in MS, which are significantly associated with disability, secondary progression, and cortical GM lesions. Thus, thalamic lesion analysis may provide a more focused and rapid method for analysis of the impact of demyelination in GM, as opposed to labor-intensive cortical lesion analysis.

Funding Source: This study was supported by grants from Bayer Schering Pharma and NIH Supplemental Grant 5P41 RR15241-09S1.

Dr. Harrison has received research support from Bayer Schering Pharma and consultation fees from MedImmune.

Dr. Oh has received an educational grant from TEVA Neurosciences.

Drs. van Zijl and Jones receive research support from Philips Medical Systems.

Dr. Calabresi has received research funding from Biogen Idec, TEVA, Merck, Serono, Vertex, Genentech, and Bayer.

Ms. Seigo and Aquino and Dr. Reich have nothing to disclose.

The relative contribution of cortical versus white matter lesions to cognitive dysfunction in MS: evidence from an MRI study with double inversion recovery imaging

A. Papadopoulou, N. Müller-Lenke, Y. Nägelin, G. Kalt, K. Bendfeldt, P. Kuster, A. Gass, T. Sprenger, E.-W. Radue, L. Kappos, I.K. Penner

University Hospital Basel (Basel, CH); Medical Image Analysis Center (Basel, CH); University Hospital Mannheim (Mannheim, DE); University of Basel (Basel, CH)

Background: Cortical lesion (CL) load is thought to be a better predictor for cognitive impairment than white matter (WM) lesion load in relapsing-remitting multiple sclerosis (RRMS).

Objectives: To investigate the relative contribution of CLs to cognitive performance in a cohort of patients with MS and clinically isolated syndrome (CIS). Moreover, to test potential correlations of CL burden with fatigue and depression.

Methods: Ninety-one MS and CIS patients were included (71.4% with RRMS and CIS and 28.6% with progressive MS). Lesions were scored and segmented on 3D Double Inversion Recovery sequences (1.5x1.3x1.3mm). Seven lesion subtypes were defined, according to the lesion location (cortical, juxtacortical, WM, thalamic, basal ganglia, hippocampal and infratentorial lesions). Normalized neocortical gray matter (GM) volume was also assessed using statistical parametric mapping (SPM). Eighty-five patients underwent neuropsychological testing. The cognitive test battery included the Paced Auditory Serial Addition Test 3s (PASAT-3), the Symbol Digit Modalities Test (SDMT) and tests of verbal immediate- and delayed recall memory, verbal fluency and cognitive interference. For the assessment of fatigue and depression we used the Fatigue Scale for Motor and Cognitive functions (FSMC) and the Center for Epidemiologic Studies Depression Scale (CES-D).

Results: A total of 1040 CLs were scored (mean CL/patient 11.43±19.52). CL volume correlated modestly with disease duration (r=0.245, p=0.019) and by trend with the Expanded Disability Status Scale (EDSS) (r=0.206, p=0.051), but not with age, sex or disease course. CL volume did not corelate with fatigue or depression, but there was a significant correlation with most neuropsychological test results: PASAT (r=-0.275, p=0.009), SDMT (r=-0.377, p<0.001), verbal immediate (r=-0.293, p=0.005) and delayed recall (r=-0.331, p=0.002), verbal fluency (r=-0.379, p<0.001) and speed of naming (r=0.409, p≤0.001). The multivariate regression analysis with other lesion subtypes, GM volume, age and disease duration as covariates did not reveal CL load as a significant predictor for any neuropsychological outcome measure. On the contrary, WM lesion volume contributed to the performance in SDMT and interference testing, while thalamic lesion volume contributed to SDMT, motor fatigue and depression.

Conclusion: The burden of CLs may be less important than white matter- or thalamic lesions for the development of cognitive dysfunction in MS.

Athina Papadopoulou, Yvonne Naegelin, Gaby Kalt, Kerstin Bendfeldt and Pascal Kuster have nothing to disclose.

Nicole Müller-Lenke hasreceived honoraria from Biogen Idec for consulting services.

Achim Gass has received honoraria for lecturing, travel expenses for attending meetings, and financial support for research from Bayer Schering, Biogen Idec, Merck Serono, Novartis and TEVA Neurosciences.

Till Sprenger served on advisory boards for Mitsubishi Pharma, Eli Lilly, Biogen and Allergan. He received travel support from Pfizer, Bayer Schering, Eli Lilly and Allergan.

Ernst Wilhelm Radue has received research support (mainly for MS projects) and lecture fees from: Actelion, Basilea, Bayer Schering, Biogen Idec, Merck- Serono, Novartis and others. Lecture fees have have been exclusively used for research funding at the Medical Image Analysis Center (former MS MRI Evaluation Center), University Hospital Basel.

Ludwig Kappos has received institutional research support from Acorda, Actelion, Advancell, Allozyne, Barofold, Bayer, Bayhill, Biogen Idec, BioMarin, Boehringer Ingelheim, CSL Behring, Eli Lilly, Geneuro, Genmab, GlaxoSmithKline, Glenmark, Merck Serono, MediciNova, Novartis, Sanofi -Aventis, Santhera, Shire, Roche, Teva, UCB, Wyeth, Swiss MS Society, Swiss National Research Foundation, European Union, Gianni Rubatto Foundation, the Novartis and Roche Research Foundations.

Iris-Katharina Penner has received research grants from Bayer AG Switzerland and the Swiss Multiple Sclerosis Society; has received honoraria forserving as speaker at scientific meetings, consultant, and as member of scientific advisory boards for Actelion, Bayer Pharma AG, Biogen Idec, Merck Serono, Roche, and Teva Aventis.

Cortical pathology in Caucasian multiplex MS families of the Veneto region, Italy

M. Calabrese, V. Bernardi, E. Cocco, D. Seppi, V. Poretto, A. Favaretto, S. Alessio, S. Miante, F. Rinaldi, P. Perini, P. Gallo

The Multiple Sclerosis Center of Veneto Region (Padua, IT); University of Cagliari (Cagliari, IT)

Background: Grey matter lesions and atrophy, two relevant aspects of multiple sclerosis (MS) pathology, have profound physical and cognitive implications. Their pathogenesis, however, has not been definitely clarified yet. The comparison between the familial and the sporadic cases of MS might help to clarify the role played by genetic and environmental factors in determining grey matter damage in this disease.

Methods: Sixty-eight multiplex MS families (154 patients, 94 females and 60 males) were included in this cross-sectional study. All families were Caucasian. Their clinical and grey matter magnetic resonance parameters (grey matter lesions and regional cortical atrophy) were compared with those of 50 age- and gender-matched healthy controls and 75 sporadic MS cases matched for age, gender, disease duration, EDSS and white matter T2 lesion load.

Results: The entire familial MS group showed a significant global cortical thinning (2.27±0.11, range 1.78-2.54 mm; p=0.008) and higher grey matter lesion number (8.5±2.3 range 0-25; p<0.001) and volume (1.1±0.8, range 0-2.6; p<0.001) compared to the sporadic MS cohort (global cortical thinning = 2.38±0.11, range 1.80-2.87 mm; grey matter lesion number = 6.3±3.0, range 0-21 and volume = 0.7±0.6,range 0-1.8 cm3). The severity of grey matter damage was highly concordant across families. Indeed all the members of 49/68 (72.0%) families had a severe focal or diffuse grey matter damage (i.e., > 1 standard deviation above the mean of the sporadic MS population). All the members of 13/68 (19.1%) families showed a mild/absent focal and diffuse cortical pathology, while the affected members of the remaining 6 (8.8%) families were not concordant with regard to GM damage.

Discussion: Our findings are interesting since they suggest that familial-shared factors could play a role in determining the degree of cortical pathology in MS. This hypothesis is supported by the high concordance in the severity of cortical pathology observed among the affected members of the same family, and by the heterogeneity of the cortical involvement across different families. Although obtained in a small number of families, our data suggest further investigations on the possible familial factors that may favour/minimize grey matter damage in MS.

Massimiliano Calabrese received honoraria for speaking from Sanofi Aventis, Merck-Serono, Biogen Idec and funds for travel from Sanofi Aventis, Merck-Serono.

Francesca Rinaldi has received speaker honoraria from Biogen Idec, and funding for travel from Biogen Idec, Merck Serono, Sanofi-Aventis, and Bayer Schering Pharma.

Paola Perini received honoraria for speaking from Biogen Idec and funds for travel from Merck-Serono.

Paolo Gallo serves on the Scientific Advisory Boards for Biogen Idec, Merck-Serono, Bayer- Shering, Genzyme, Sanofi-Aventis, and Novartis Farma; has received honoraria for speaking and funds for travel from Biogen-Idec Italy, Merck-Serono, Bayer-Shering, Genzyme, Sanofi-Aventis, and Novartis Farma; and has received research support from Biogen Idec-Italy, Merck-Serono, Bayer-Shering, Sanofi-Aventis, Novartis Farma, Italian Ministry of Public Health, 2009-2010 – Prog. 3: “Biomarkers and Diagnosis” ISS.17, the University of Padova, Interarea Pr. CPDA 099394, 2009-2010.

The other authors have nothing to disclose.

Deficits in memory and spatial cognition correlate with regional hippocampal atrophy in multiple sclerosis

M.A. Rocca, G. Longoni, E. Pagani, G. Riccitelli, B. Colombo, M. Rodegher, G. Comi, M. Filippi

Vita-Salute San Raffaele University (Milan, IT)

Objective: The hippocampus has a critical role in episodic memory and visuospatial abilities, which are frequently affected in multiple sclerosis (MS). Aim of our study is to assess the patterns of whole and regional hippocampal atrophy in a large group of MS patients, and their correlations with neuropsychological impairment.

Methods: From 103 MS patients and 28 sex- and age-matched healthy controls (HC), brain dual-echo and 3D T1-weighted images were acquired using a 3.0 Tesla scanner. All subjects underwent neuropsychological evaluation, including word-list (WL), short-story (SS), delayed recall of Rey-Osterrieth Complex Figure (ROCF-recall) and ROCF-copy. The hippocampi were manually segmented and their volumes derived. From contours, radial atrophy was calculated for assessment of regional atrophy distribution. Correlations between regional hippocampal atrophy and clinical, neuropsychological and T2 lesion metrics were assessed.

Results: Right and left hippocampal volumes differed significantly between MS patients and HC (p<0.001 for the right and p=0.002 for the left hippocampus). In MS patients, radial atrophy was detected in the lateral portion of the body and tail (CA1 subfield) and the subiculum, bilaterally. The ventral surface of the subiculum was also affected. Significant correlations (p<0.01) were found between performance at: 1) WL vs. tail (CA1 subfield) of the left hippocampus atrophy; 2) ROCF-recall vs. tail (CA1 subfield) of the right hippocampus atrophy; and 3) ROCF-copy vs. body of the left hippocampus atrophy. Regional hippocampal atrophy correlated with brain T2 lesion volumes, while no correlation was found with clinical disability.

Conclusion: Hippocampal subregions have a different vulnerability to MS-related damage, with a relative sparing of the head. The assessment of hippocampal atrophy at a regional level may contribute explaining deficits in specific cognitive functions, including memory and spatial cognition.

M.A. Rocca serves as consultant to Bayer Schering Pharma; received speakers’ bureaus for Biogen-Dompé, and receives research support from Italian Ministry of Health.

G. Longoni, E. Pagani, G. Riccitelli, B. Colombo, and M. Rodegher report no disclosures.

G. Comi serves on speakers’ bureaus for Teva Pharmaceutical Industries Ltd., Sanofi-Aventis, Merck Serono, Bayer Schering Pharma, Boehringer Ingelheim Italia, and Novartis; and has received speaker honoraria from Sanofi-Aventis, Merck Serono SA, Serono Symposia International Foundation, Bayer Schering Pharma, Novartis, Biogen-Dompè, and Merz Pharmaceuticals GmbH.

M. Filippi serves on scientific advisory boards for Teva Pharmaceutical Industries Ltd. and Genmab A/S; has received funding for consultancies, speaking and travels from Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, and Teva Pharmaceutical Industries Ltd.; receives research support from Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, Teva Pharmaceutical Industries Ltd., and Fondazione Italiana Sclerosi Multipla. He is Editor-in-Chief of the Journal of Neurology and serves on editorial boards of the American Journal of Neuroradiology, BMC Musculoskeletal Disorders, Clinical Neurology and Neurosurgery, Erciyes Medical Journal, Journal of Alzheimer’s Disease, Journal of Neuroimaging, Journal of Neurovirology, Lancet Neurology, Magnetic Resonance Imaging, Multiple Sclerosis, and Neurological Sciences.

Imaging cortical lesions in multiple sclerosis brains – a combined post-mortem 7 Tesla MRI and histopathological study

S. Hametner, B. Yao, P. van Gelderen, H. Merkle, H. Lassmann, F.K. Cantor, C. Chen, J. Duyn, F. Bagnato

Medical University of Vienna (Vienna, AT); National Institutes of Health (Bethesda, US)

Objective: To: (1) visualize neocortical lesions (NLs) in brains of patients with multiple sclerosis (MS) using multi echo gradient echo (ME-GRE) T2*-weighted images at 7.0 Tesla, (2) assess the sensitivity of ME-GRE in depicting NLs compared to myelin and iron staining, and (3) quantify the iron content in NLs compared to normal-appearing grey matter (NAGM).

Methods: Samples from two MS patients were imaged post mortem using a whole body 7T MRI scanner equipped with a 24-channel receive-only array. A 3D multi-GRE 200 micron isotropic sequence was obtained and quantitative R2* and phase maps were reconstructed. Immunohistochemical staining for myelin and 3,3’-diaminobenzidine-tetrahydrochloride enhanced Turnbull blue staining for nonheme iron were performed on 3- to 5-µm thick paraffin sections. Amounts of nonheme iron in NLs versus adjacent NAGM were estimated by digital optical densitometry on all available 40 tissue blocks. For a subset of 16 tissue blocks, NLs were identified by MRI and PLP/iron staining side-by-side.

Results: Excellent MRI contrast and resolution permitted visualizing different layers within cortex. A total of 66 NLs were identified. Of these 66 NLs, 31 (47%) NLs were identified by MRI prospectively and 43 (65%), retrospectively. Compared to PLP staining, MRI had prospective sensitivity of 48% and a retrospective sensitivity of 66%. For 20 subpial NLs extending over relatively large surfaces of the cortex by immunohistochemical staining, we observed MRI maps successfully identifying only a very small portion. Digital optical densitometry revealed significantly reduced iron in cortical lesions compared to NAGM (p<0.001 for the data of the two brains pooled together).

Interpretation: Increasing the MRI field strength is an important facilitator for the identification of NLs. High-resolution post mortem imaging using R2* and magnitude maps permits disclosing focal NLs.

Despite the additive R2* contrast effects of iron loss to myelin loss in NLs, disclosing extensive subpial demyelination still remains challenging.

The authors have nothing to disclose.

The regional cortical atrophy is correlated with T1 lesion load in early stages of relapsing-remitting multiple sclerosis

C.M. Rimkus, T.F. Junqueira, D. Callegaro, M.C.G. Otaduy, C.C. Leite

Faculdade de Medicina da Universidade de São Paulo (São Paulo, BR)

Introduction: Recent findings show that neocortical atrophy is present from initial stages of relapsing-remitting multiple sclerosis (RRMS). But it stills not clear the pathological mechanisms associated. The aim of this study is to analyze the prevalence of cortical atrophy in early stages of RRMS and correlate them to T1 lesion load.

Method: Brain exams of 30 RRMS patients (21 females; mean age 30.5 ±8.6; mean EDSS 0.92 ±0.9; mean disease duration 2.38 years ±2.04) 30 healthy controls (HC) (23 females; mean age 32.4 years ±7.4) were acquired in a 3.0T scanner (Intera Achieva, PHILIPS Healthcare, Best, The Netherlands). Imaging protocol included a 3D T1-weighted sequence (Time of echo (TE)/ time of repetition (TR): 2.7/6.2ms; time of inversion (TI): 700ms; matrix: 240x240; voxel size: 1x1x1mm).

Images were post-processed using FreeSurfer software v 5.1.0 (http://surfer.nmr.mgh.harvard.edu), which performs automated cortical and subcortical segmentations, obtaining cortical thickness and T1 lesion loads. The images were registered in a common space and group analyses were performed with the QDEC tool of FreeSurfer, which is based in general linear modelling (GLM) statistical analysis. We performed intergroup differences analysis and the correlation with T1 lesion loads. After Monte-Carlo Null-Z simulation, the clusters with –log(10)p< 1.3 were considered significant (corresponding to a p< 0.05).

Results: There were find two clusters in the right hemisphere with significant decreased cortical thickness in RRMS patients, one of them localized in the intersection between temporal and parietal lobes (banks of the superior temporal sulci, posterior portion of the medial temporal gyri and the inferior parietal sulci) and the other comprehending the pars orbitalis and the anterior half of the insula. In the left hemisphere we found one cluster centred in the superior temporal gyri.

The mean T1 lesion load was 3.76cm3 ±2.3. There were find several clusters of correlation between cortical thickness and T1 lesion loads in both hemispheres, with superimposed areas with the significantly atrophied cortex in the left temporal lobe and in the transition between right temporal and parietal lobes.

Discussion: Cortical atrophy is present from the initial stages of RRMS inferring incipient tissue degeneration. The correlation with T1 lesions shows that these changes can be partially correlated with Wallerian degeneration secondary to axon transection.

Carolina M Rimkus, Thiago F Junqueira, Dagoberto Callegaro and Maria CG Otaduy have nothing to disclose.

Claudia C Leite received a grant from Guerbet in 2011.

Phenotyping multiple sclerosis; clinical relevance of combining MRI features of inflammation and degeneration

E.M.M. Strijbis, J.J.G. Geurts, Y. Naegelin, L. Kappos, E.W. Radue, F. Barkhof, B.M.J. Uitdehaag, C.H. Polman

VU University Medical Center (Amsterdam, NL); University Hospital Basel (Basel, CH)

Introduction: The clinical severity of MS is heterogeneous and is currently difficult to predict. To better understand what drives this heterogeneity, identification of MRI-phenotypes that combine the key pathological features of MS (inflammation and degeneration) could be a useful method for patient stratification. Using multiple cohorts of patients with different disease durations, this study looked at whether stratification into such phenotypes is clinically informative.

Methods: 429 patients were stratified into phenotype-groups based on accepted MRI-measures of inflammation (T2-lesion load (T2LL; “I”)) and degeneration (normalized gray matter volume (NGMV;“D”). 4 groups were created using a median split of log-transformed T2LL data and NGMV data: 1) low-I/low-D, 2) high-I/low-D, 3) low-I/high-D, 4) high-I/high-D. All analyses were performed in the total cohort (N=429) as well as subcohorts of patients with an ultrashort (<5 yrs, N=94), short (<10 yrs, N=210) and long disease duration (≥ 10 yrs, N=219). Subsequently, associations between the 4 groups and clinical measures (Expanded Disability Status Scale (EDSS) scores, 9-Hole Peg Test (9-HPT) and Timed Walk Test (TWT)) were analysed in each cohort separately using a linear regression with correction for disease duration and gender.

Results: In the total cohort, group 4 performed significantly worse compared to group 1 on the EDSS score (4 vs 2.5; p<10^-5), 9-HPT (31.6 vs 18.9 sec; p<10^-5), the 25F-TWT (18.6 vs 7.0 sec; p<0.001). Similar effects were observed for group 3 vs 1 and group 4 vs 2. While in the long cohort group 4 performed only significantly worse on the 9-HPT compared to group 1, in the ultrashort and short cohorts group 4 performed significantly worse on all clinical measures compared to groups 1 and 2.

Discussion: Patient stratification based on MRI features creates clinically informative phenotype-groups. Patients with higher inflammation and degeneration perform significantly worse on clinical measures of disability, even after very short disease duration. Interestingly, patients stratified into a profile with higher degeneration perform clinically worse than those with low degeneration and the same extent of inflammation. Stratification into a predominantly inflammatory, degenerative or combined disease profiles might ultimately serve as a basis for the identification of neurobiological markers that drive the heterogeneous expression of MS.

The authors have nothing to disclose.

Characterization of the expression of semaphorin 3A and 7A and their receptors in experimental autoimmune encephalomyelitis

A. Gutiérrez, H. Eixarch, C. Costa, M. Castillo, X. Montalban, C. Espejo

Vall Hebron University Hospital (Barcelona, ES)

Background & aim: Semaphorins, described as axon guidance cues in the developing central nervous system (CNS), are also expressed in adult tissues. Semaphorin (sema)3A and 7A are immune semaphorins, having a dual function in the immune system and in the CNS. We aimed to characterize the expression pattern of sema3A and 7A as well as their receptors in the different phases of experimental autoimmune encephalomyelitis (EAE), in both the immune system and the CNS.

Methods: For EAE induction, female 8 week-old C57BL/6 mice were immunized with MOG35-55 peptide. Non-immunized mice (basal condition), and immunized mice at the induction, inflammatory, and chronic phases of the disease (5 mice per group) were sacrificed, and then the CNS and spleen were removed. In the CNS, the expression of sema3A and its receptors plexin-A1 (PLXN-A1) and neuropilin-1 (Np-1), and sema7A and its receptors α1- and β1-integrin was assessed by immunohistochemistry. In the immune system, the expression of sema7A, Np-1, and β1-integrin was assessed by flow cytometry in different cell subpopulations (CD4 and CD8 T-cells, myeloid cells, dendritic cells [DC], and B1 and B2-cells). PLXN-A1 was detected by western blot.

Results: In the CNS at baseline, both semaphorins and their receptors were found in different cell populations including neurons, glial cells, and endothelial cells. Besides, in the CNS of EAE mice Sema3A and its receptors were also expressed in infiltrated inflammatory cells present in the white matter and in glial cells (resembling astrocytes and microglia) related to the inflammatory process. Sema7A and β1-integrin were detected in glial cells (resembling astrocytes) but in a few inflammatory cells, while α1-Integrin was only observed in cells of the inflammatory infiltrate. In the immune system, the expression of sema7A was increased at the inflammatory phase of the disease in CD4 and CD8 T-cells, and at the induction phase in myeloid cells and DC. Its receptor β1-integrin was highly increased in the induction phase in DC. In B-cells the increase of sema7A was sustained along EAE progression. Conversely the level of expression of sema3A receptors Np-1 and PLXN-A1 were drastically decreased upon EAE induction.

Conclusions: Our results show that sema3A and sema7A change their expression pattern in both immune and CNS cells along EAE progression, suggesting a possible role of both semaphorins in the pathogenesis of EAE.

This project is supported by Fondo de Investigación Sanitaria (FIS) (PS09/01180), Instituto de Salud Carlos III, Ministry of Economy and Competitivity, Spain.

Magnetic resonance imaging characterisation of the therapeutic effect of glatiramer acetate in different models of experimental autoimmune encephalomyelitis

R. Aharoni, E. Sason, T. Katzir, M. Sela, Y. Asssaf, R. Arnon

The Weizmann Institute of Science (Rehovot, IL); Bioimage (Ramat Gan, IL); Tel Aviv Universitiy (Tel Aviv, IL)

The respective roles of inflammatory and neurodegenerative processes in multiple sclerosis (MS) and its experimental autoimmune encephalomyelitis (EAE) models are controversial. The immunomodulator glatiramer acetate (GA, Copaxoneâ) alleviates MS/EAE pathological inflammation and induces neuroprotective repair processes within the CNS. Magnetic resonance imaging (MRI) is an essential noninvasive tool for in vivo diagnosis and evaluation of MS therapies. In the present study we analyzed the different pathological manifestations in chronic versus relapsing-remitting EAE and the in situ therapeutic effect of GA using advanced MRI parameters. Mice inflicted with either the chronic EAE model induced by MOG 35-55 or the relapsing-remitting model induced by PLP 139-151 peptide, were treated with GA (7 daily injections) starting immediately after disease induction (prevention) or after clinical symptoms development (suppression). Brain MRI measurements were performed at several time points along disease progression. MRI protocols included quantitative T2, magnetization transfer ratio (MTR) and diffusion tensor imaging (DTI), analyzed both by whole brain histograms and by voxel based analysis. Brains of EAE mice of both models revealed increased T2-values with associated enlargement of ventricle size indicating substantial CNS inflammation. Ventricle swelling was characteristic to the PLP-induced model in which 5-fold elevation of ventricle size was detected. Decreased MTR values and increased apparent diffusion coefficient (ADC) were observed mainly in MOG-induced EAE mice, indicative of macromolecular loss and structural CNS damage involvement in the chronic disease. GA applied by both prevention and suppression regimens affected all the MRI pathological manifestations, resulting in significant reduction of T2 values and ventricle volume, elevated MTR and decreased ADC, in comparison to sham-treated mice. Furthermore, following GA treatment, histogram peaks of all MRI parameters were statistically not different from naïve controls. These results indicate that inflammatory manifestations are involved in both EAE models, whereas macromolecular loss and structural CNS damage are more prominent in chronic EAE. The improvement of the MRI parameters: T2-relaxation, ventricle swelling, MTR and ADC, on the level of the whole brain as well as in specific brain regions, supports the in situ anti-inflammatory and structural repair consequences of GA treatment.

Rina aharoni recived reserch grant from Teva.

Efrat Sason has nothing to disclose.

Tamar Katzir has nothing to disclose.

Michael Sela recived reserch grant from Teva.

Yaniv Assaf has nothing to disclose.

Ruth Arnon reserch grant from Teva.

The envelope of human endogenous retrovirus mediates neuro-inflammation in mice

H-L. Reynaud-Dougier, C. Lomparski, C.L. Villiers, E. Jouvin-Marche, H. Perron, P.N. Marche

U823 INSERM-UJF (Grenoble, FR); GeNeuro Innovation (Lyon, FR)

Several viruses are known to interact with the host defences either to escape from the immune responses or to gain advantage of inflammatory mediators to survive. Human endogenous retroviruses (HERV) are integrated and are estimated represent up to 8% of the human genome. Among HERV, an exogenous virus (MSRV) was initially isolated from brain of multiple sclerosis (MS) patients. Its envelope protein (ENV), or its soluble extracellular subunit (ENV-SU), promotes inflammation by the expansion of T lymphocytes and the activation of monocytes and dendritic cells (DC) through CD14 and TLR4 pathway. To study in vivo effects, mice were treated for experimental allergic encephalopathy (EAE) induction, a mouse model for MS, by myelin peptide immunization either with complete Freund’s adjuvant or ENV-SU. Clinical scores showed EAE symptoms in both groups of mice but no symptom in control mice (neither adjuvant nor ENV). Anti-ENV-SU antibodies blocked EAE symptoms only in ENV-SU treated mice. Splenocytes from either ENV-SU or adjuvant treated mice, recalled with the myelin antigen, led to IFN-γ production, suggesting T lymphocyte reactivity towards the myelin antigen. To characterize the mode of action of ENV in mice, DC were cultured from C57BL/6 bone marrow and incubated with ENV-SU. DC secreted IL-6 and IL-12p70. Flow cytometry analysis for CMH-II, CD11c, B7.1 and B7.2 expressions demonstrated that DC were activated and underwent differentiation. DC derived from TLR4, CD14 or MyD88 deficient mice did not respond to ENV-SU stimulation, arguing that, as found in humans, TLR4 pathway is involved in DC responses in mice. In conclusion, by promoting inflammatory response through CD14/TLR4 pathway, the envelope of MSRV contributes to EAE in mice. These data further support that virus of the HERV family may be one of the key actors of MS etiology and of neuro-inflammatory disorders in humans.

Part of the work was supported by “Fondation ARSEP” and “AFM”.

Development of a high-content screening assay to identify and evaluate remyelination therapeutics for multiple sclerosis

B. Bai, R. Avila, S. Medicetty, B. Trapp

Renovo Neural Inc (Cleveland, US)

Background: Multiple sclerosis (MS) is the most common inflammatory demyelinating disease of the central nervous system (CNS). Current MS therapies are anti-inflammatory or immunomodulatory in nature, but these therapies are partially preventive (delay the disease progression) ant not restorative. Replacement of oligodendrocytes and the subsequent remyelination of demyelinated axons have the potential to reduce axonal loss and reverse neurological decline. One approach to increasing remyelination is through therapeutic stimulation of endogenous oligodendrocyte progenitor cell (OPC) differentiation. Despite repeated screening efforts, few small molecule leads have been shown to directly stimulate oligodendrocyte differentiation and remyelination in animal models.

Objective: Develop a primary cell-based, robust high-content screening system to identify and evaluate small molecules and biologics that promote differentiation of OPCs.

Methods: OPCs were generated from transgenic mice expressing PLP:EGFP, where enhanced green fluorescent protein (EGFP) is driven by proteolipid protein (PLP) promoter. Embryonic (E14.5) mouse brains were used to generate a relatively homogeneous (>90% pure) population of OPCs. Following a 4-day incubation period, the cells were fixed, imaged and evaluated by Cellomics Arrayscan system. Differentiation of OPCs into oligodendrocytes was evaluated by quantifying EGFP cells. The differentiated cells were immunostained with O4 or Myelin Basic Protein (MBP) to confirm the oligodendrocyte phenotype. Thyroid Hormone (T3) was used to generate dose-response curves EC50 (half maximal effective concentration).

Results: Studies using CNTF (ciliary neurotrophic factor) and T3 showed that the screening system consistently achieved a positive Z’ score, indicating good sensitivity and robustness. In addition, immunostaining for oligodendrocyte-specific markers demonstrated that most if not all the EGFP cells expressed O4 and/or MBP, confirming cell-type specificity of the in vitro differentiation system. Lastly, multiple runs of dose-response curve of T3 showed that EC50 obtained were all within a half-log range, further validating the reproducibility of the assay.

Conclusion: The high-content screening system using OPCs expressing PLP:EGFP provides a quick, reliable and reproducible assay for identification and evaluation of new therapeutics for MS and other demyelinating diseases.

Brian Bai, Robin Avila and Satish Medicetty are full time employees of Renovo Neural, Inc. Bruce Trapp is the founder and consulting Chief Scientific Officer of Renovo Neural, Inc. Renovo Neural provides contract research services using the cell-based screening assay described above.

Supported By: A grant from Ohio Third Frontier and Renovo Neural, Inc.

BIIB033 Anti-LINGO-1 antibody reduces optic nerve axonal degeneration in MOG- EAE rodent models

D. Cadavid, H. Butzkueven, Y. Liu, S. Mi

Biogen Idec (Cambridge, US); Royal Melbourne Hospital and University of Melbourne (Melbourne, AU); Capital Medical University (Beijing, CN)

Background: LINGO-1 is an inhibitor of oligodendrocyte differentiation, myelination and axon regeneration in the central nervous system. Inhibition of LINGO-1 with the monoclonal antibody BIIB033, an investigational treatment for multiple sclerosis (MS), promotes axonal integrity/remyelination in myelin oligodendrocyte glycoprotein-induced experimental autoimmune encephalomyelitis (MOG-EAE). Acute optic neuritis (AON) is a frequent early manifestation of MS but the efficacy of BIIB033 for treatment of AON is unknown.

Objective: To study the efficacy of BIIB033 in rodent models of AON.

Methods: Two separate studies were performed in rodent MOG-EAE models. In the first study, MOG-EAE was induced in C57BL/6 mice (2 cohorts, n=7 each, BIIB033 or placebo). BIIB033 or negative control antibody (cAb) was administered by intraperitoneal (IP) injection on days 6, 9, 12 and 15 after EAE induction. Assessments included clinical severity (EAE score and survival), diffusion magnetic resonance imaging (MRI) and histology. In the second study, MOG-EAE was induced in Brown Norway rats. After EAE onset, rats were treated for 3 days with either methylprednisone (MP; dose/duration mimicking treatment of AON in the clinic) or vehicle (Veh). Beginning on Day 2 of MP treatment, the animals were given 3 once-weekly IP doses of either BIIB033 or cAb. Axonal pathology was assessed 1 week after the final BIIB033 dose using anti-β III-tubulin immunohistochemistry on the optic nerves.

Results: In mice, severity of EAE was reduced with BIIB033 treatment relative to cAb. In MRI analyses, the apparent diffusion coefficient parallel to the long axis of the optic nerve (longitudinal diffusivity) was higher with BIIB033 than cAb (means, 1400 mm²/s versus 1183 mm²/s, respectively; P<0.01; mean for healthy control nerves 1570 mm²/s). Axonal atrophy in optic nerves was reduced by 13% with BIIB033 relative to cAb (P=0.07). In rats with EAE treated with Veh + cAb, there was marked axonal loss in optic nerves, whereas axonal numbers were slightly higher in rats treated with MP + cAb. In contrast, axonal density was increased about 5-fold in rats treated with Veh + BIIB033 (P<0.01) and about 8-fold in rats treated with MP + BIIB033 (P<0.001).

Conclusions: LINGO-1 inhibition with BIIB033 reduced optic nerve axonal pathology in MOG-EAE rodent models. These data provide further support for BIIB033 as potential therapy for MS and supports the use of AON to assess efficacy of BIIB033 in the clinic.

This study was funded by Biogen Idec. Editorial support was provided by Ed Parr, PhD, CMPP of UBC Scientific Solutions and funded by Biogen Idec.

D. Cadavid is a full-time employee of Biogen Idec and owns stocks/options in Biogen Idec.

H. Butzkueven performed the study under a Sponsored Research Agreement with Biogen Idec.

Y. Liu has nothing to disclose.

S. Mi is a full-time employee of Biogen Idec and owns stocks/options in Biogen Idec.

Intranasal HHV-6A infection accelerates EAE in the common marmoset

E. Leibovitch, P. Maggi, S. Cummings Macri, G. Brunetto, K. Motanic, J. Wohler, S. Westmoreland, A. Silva, D. Reich, S. Jacobson

National Institutes of Health (NIH) (Bethesda, US); New England Primate Research Center (Southborough, US)

Introduction: The ubiquitous human herpesvirus HHV6A is associated with several neurologic diseases including multiple sclerosis (MS).The biology of HHV6A infection is largely unknown, though it is considered neurotropic.We investigated HHV6A infection in common marmosets (C.jacchus), which unlike rodents express the receptor for viral entry.Experimental autoimmune encephalomyelitis (EAE) is an inflammatory demyelinating disease of the CNS induced by immunization with CNS tissue.Marmoset EAE recapitulates specific aspects of MS pathology and enables tracking of lesion development by MRI.As viruses may act as triggers in MS, we asked if marmosets previously inoculated with HHV6A exhibit an altered EAE disease course compared to previously naïve marmosets.

Methods: We inoculated four marmosets with HHV6A intranasally, in light of our recent work demonstrating the olfactory pathway as a route of HHV6 entry.Subsequently, two of these marmosets were immunized with human white matter homogenate (WMH) in CFA to induce EAE (WMH+virus) along with two previously naïve control marmosets (WMH alone).Disease was monitored clinically, immunologically and by MRI through to humane endpoints.

Results: WMH+virus marmosets exhibited clinical symptoms earlier than WMH alone marmosets.WMH+virus marmosets also exhibited more severe disease by MRI, with increased white matter lesion load and leukocortical lesions in the brain.Seropositivity for an immunogenic myelin protein, MOG, often correlates with overt clinical EAE.We detected increased levels of serum anti-MOG IgG in WMH+virus marmosets compared to WMH alone marmosets.Following HHV6A intranasal infection, virus-specific antibodies were not detected but upon EAE induction, virus-specific IgM was detected in one WMH+virus marmoset.Ongoing studies may elucidate the mechanism(s) of accelerated disease including immunohistochemical analyses of CNS tissues, detection of viral DNA from CNS tissues and flow cytometry-based analyses of cellular responses to HHV6 and MOG.

Conclusions: We observed accelerated clinical EAE disease in marmosets previously inoculated with HHV6A compared to previously naïve marmosets.These preliminary observations support a role for viruses in exacerbating CNS immunopathology.Viruses may act as triggers in autoimmune conditions such as MS through molecular mimicry, bystander activation or unknown mechanisms that compromise or activate the blood brain barrier.This animal model may further our understanding of the longstanding association between viruses and MS.

The authors have nothing to disclose.

Ameliorating effects of anti a v integrin mAb on Theiler’s Murine encephalomyelitis virus-induced demyelinating disease

H. Tomiki, T. Kaneyama, S. Tsugane, I. Nakashima, M. Ichikawa, H. Yagita, B.S. Kim, C.S. Koh

Shinhsu University School of Health Sciences (Matsumoto, JP); Juntendo University School of Medicine (Tokyo, JP); Northwestern University School of Medicine (Chicago, US)

Integrins are transmembrane receptors that bind extracellular matrix proteins or other adhesion receptors on neighboring cells. It is reported that α v integrin is increased on the CD4+ T cells and microvessels in patients with multiple sclerosis (MS) and is involved in differential regulation of Th17 cell and CD4+ T cell cytokine production during experimental autoimmune encephalomyelitis (EAE). In this study, we examined the regulatory and adherent role of α v integrin in the development of Theiler’s murine encephalomyelitis virus (TMEV) -induced demyelinating disease (TMEV-IDD), an infectious animal model of MS.

Administration of anti-α v integrin monoclonal antibody (mAb) during the effector phase significantly suppressed the disease development of TMEV-IDD both clinically and histologically. Furthermore the number of infiltrating mononuclear inflammatory cells in the central nervous system (CNS) was decreased in mice treated with anti-α v integrin mAb at the effector phase. Flow cytometric analysis of cytokine staining revealed that absolute cell numbers of IFN-γ-producing CD4+ and CD8+ T cells were significantly decreased, and TNF-α-producing CD4+ T cells were increased in the CNS of mice treated with anti-α v integrin mAb in effector phase compared to control mice treated with nonspecific IgG.

On the other hand, utilizing a neutralizing antibody, we demonstrate that α v integrin up-regulates TMEV-specific ex vivo production of TNF-α and IL-10 from CD4+ T cells and TNF-α from CD8+ T cells from the CNS of TMEV infected mice sacrificed at the 36 days post infection.

Taken together, these data suggest that anti-α v integrin mAb may ameliorate TMEV-IDD by blocking adhesion rather than inhibiting differential regulation and that antibodies to α v integrin could be used as a novel therapeutic treatment of MS.

The authors have nothing to disclose.

Pharmacological characterisation of HCA3551: a novel, orally active a4 integrin antagonist with a long duration of action

S. Kageyama, A. Andou, H. Ito, Y. Shima, K. Sagi, T. Yamada, T. Okuzumi, M. Tokumasu, T. Koyama, Y. Okamatsu, T. Miyazawa, K. Fujita, H. Kihara, M. Shoji

Ajinomoto Pharmaceuticals Co., Ltd. (Tokyo, JP)

Background & Aim: Α4 integrin blockade with monoclonal antibody has successfully demonstrated the clinical benefit for patients with multiple sclerosis (MS). However, the orally effective α4-integrin therapy may be more attractive. HCA3551 is a newly synthesized, orally active small molecule α4 integrin antagonist. The aim of this study was to characterize the pharmacological properties of HCA3551 and to investigate the efficacy in a rat model of experimental autoimmune encephalomyelitis (EAE).

Methods: Integrin-inhibitory activities were investigated by cell-binding assay. Integrin-expressing cells were pretreated with HCA3551 and added to microplates which were coated with cell adhesion molecules (CAM), in the absence or presence of 50% human serum. Since the increase in peripheral lymphocyte count was considered as a pharmacodynamic biomarker of α4 integrin antagonist, a serial blood sampling for lymphocyte counts as well as measurement of drug concentrations in plasma was performed after a single oral administration of HCA3551 to Wistar rats or beagle dogs. EAE was induced in Lewis rats by the subcutaneous injection of incomplete Freund’s adjuvant containing Mycobacterium and myelin basic protein peptide 68-82. HCA3551 (3, 10 or 30 mg/kg) or vehicle was orally administered twice daily, prophylactically. Clinical disease score was daily recorded.

Results: HCA3551 inhibited the binding of α4β1 integrin to VCAM-1, but not αLβ2 integrin to ICAM-1. The IC50 values were 8.2 and >5,000 nM, respectively. In addition, the inhibitory activity of HCA3551 was not reduced by adding 50% human serum at all (IC50; 11 nM), although that of firategrast was drastically reduced. The increase in peripheral lymphocyte count was observed after an oral administration of HCA3551 in rats and dogs. Especially in dogs, the 24-hour durable effect was observed at 3 mg/kg. The increase in peripheral lymphocyte count was well associated with the maintenance of drug concentration of IC50 value (in the presence of serum) or above. Finally, a prophylactic oral administration with HCA3551 significantly decreased the increase in clinical disease score at 3 mg/kg b.i.d. or above in a rat model of EAE.

Conclusion: These results suggest that HCA3551 was an orally active, selective α4 integrin antagonist with a long duration of action and effective in rat EAE. HCA3551 might be the potentially once-daily oral drug for the treatment of MS.

The authors have nothing to disclose.

Astrocytes are essential for activation of microglia to clear myelin debris in cuprizone induced demyelination

T Skripuletz, D. Hackstette, K. Bauer, V. Gudi, R. Pul, E. Voss, M. Kipp, W. Baumgärtner, M. Stangel

Hannover Medical School (Hannover, DE); RWTH Aachen University (Aachen, DE); University of Veterinary Medicine Hannover (Hannover, DE)

Background: Astrocytes are supposed to play an important role in regulating demyelination in multiple sclerosis (MS). But it remains unclear how astrocytes exert effects on demyelination and both beneficial as well as detrimental effects on demyelination are being discussed. Thus, we have performed loss of function studies based on astrocyte depletion and using the cuprizone model of toxic induced demyelination.

Objectives: We analyzed the effects of astrocyte ablation in GFAP-TK transgenic mice during cuprizone induced demyelination.

Methods: To induce demyelination 8-week old GFAP-TK and wildtype C57BL/6 male mice were fed with 0.2% cuprizone for up to 5 weeks. To selectively ablate reactive astrocytes, GFAP-TK transgenic mice of line 7.1 were used, in which thymidine kinase (TK) from the herpes simplex virus (HSV) is targeted to astrocytes using the mouse glial fibrillary acid protein (GFAP) promoter. To induce astrocyte loss transgenis mice were treated with ganciclovir by daily intraperitoneal injections (25 mg/kg). Animals were sacrificed at weeks 3, 4, and 5 to analyze the effects of astrocyte loss on demyelination. Immunohistochemistry was performed for myelin (PLP), astrocytes (GFAP, vimentin), microglia (RCA-1, Mac-3), and oligodendrocytes (NogoA, APC).

Results: Ablation of astrocytes in transgenic mice was associated with delayed demyelination. Mature oligodendrocytes were not protected and ultrastructual investigations showed that the structure of myelin was mainly destroyed. These changes were associated with a decrease of microglia activation showing that astrocyte loss prevented from clearing the myelin debris via influencing the recruitment of microglia to damaged lesions. Further analyses showed that the chemokine CXCL10 may be involved in migration and activation of microglia to demyelinating lesions since in the brain tissue of astrocyte ablated animals the mRNA expression of CXCL10 was reduced and further analyses revealed that CXCL10 was expressed by reactive astrocytes.

Conclusions: Our findings show that astrocytes are required for clearing of myelin debris in the CNS through recruitment of phagocyting cells such as microglia to the lesion.

Martin Stangel received grants/honoraria from Bayer, Biogen Idec, Merck, Novartis, Sanofi Aventis, and Teva.

Thomas Skripuletz received grants/honoraria from Bayer, Merck, Novartis.

Elke Voß received grants/honoraria from Novartis.

All other authors declare that they have no competing interests concerning this abstract.

Laquinimod enhances the frequency of regulatory T-cells in peripheral lymphoid organs after EAE induction

F. Lühder, D. Lodygin, T. Borchert, S. Michanski, A. Flügel

Institute for Multiple Sclerosis Research (Göttingen, DE)

Laquinimiod is a new orally active immunomodulatory drug for which two large phase-III clinical trials of relapsing remitting (RR) MS patients have recently been completed. It could be shown that laquinimod significantly reduced relapse rate, disability progression and brain atrophy in RRMS patients at a dosage of 0.6 mg/day and was generally well tolerated. In EAE models it was shown that laquinimod potentially acts at different levels resulting in a reduction of Th1/Th17 cytokine production and proliferation of autoantigen-specific T cells. In this study, we investigated the influence of laquinimod on antigen-specific regulatory T cells.

Transgenic MOG-specific T cells were transferred into C57Bl/6 mice in which two days later EAE was induced by active immunization. This allows the direct analysis of autoantigen-specific T cells in different locations and at various time points. The animals were treated with laquinimod by oral gavage and analyzed by intracellular staining for FoxP3 using FACS analysis. Additionally, an adoptive transfer (AT) model of EAE in the Lewis rat was used where antigen-specific T cells were retrovirally labeled with fluorescence marker proteins.

Laquinimod is effective in this EAE mouse model in a preventive (starting the treatment at the time of immunization for 14 days) and therapeutic setting. A detailed analysis of regulatory T cells by FACS revealed that laquinimod significantly increased the percentage of CD4+CD25+FoxP3+ T cells in peripheral lymphoid organs such as spleen and draining and non-draining lymph nodes. In the next step, the frequency of autoantigen-specific regulatory T cells will be analyzed at different times in different organs.

Laquinimod was also able to ameliorate clinical symptoms in the AT-EAE model of the Lewis rat when given in a preventive setting and reduced the number of infiltrating autoantigen-specific effector T cells into the CNS. T cell activation in the CNS was not influenced by laquinimod. The analysis of the frequency of regulatory T cells in this model in different peripheral lymphoid organs and the CNS as well as the direct influence of T cell migration into the CNS by laquinimod are currently under investigation.

Laquinimod influences the frequency of regulatory T cells during the priming phase of autoantigen-specific T cells in peripheral lymphoid organs which can be one of its potential mechanisms of reduction of the autoimmune response and consequent autoimmune demyelination.

F. Lühder received a research grant from TEVA.

D. Lodygin has notheing to disclose.

T. Borchert has notheing to disclose.

S. Michanski has notheing to disclose.

A. Flügel received a research grant from TEVA.

Dual roles of adenosine 2a receptor in experimental autoimmune encephalomyelitis

J. Ingwersen, B. Wingerath, K. Lepka, M. Hofrichter, J. Graf, F. Schröter, S. Burghoff, H.-P. Hartung, J. Schrader, T. Prozorovski, O. Aktas

Heinrich-Heine-University (Düsseldorf, DE)

Adenosine is a local signaling molecule that plays a role in sensing tissue damage. In the peripheral immune system an anti-inflammatory effect of adenosine is well documented and one of the four receptors for adenosine, the adenosine 2a receptor (A2aR), is primarily responsible for this protective effect. Adenosine tissue levels also rise upon autoimmune CNS damage. However, it is not clear to date whether adenosine confers tissue protection or exacerbates damage and which adenosine receptors are responsible for these effects.

Here, we investigated the roles of A2aR in the experimental autoimmune encephalomyelitis (EAE) model of multiple sclerosis. We first showed that A2aR is upregulated in mouse EAE spinal cord tissue. In line with the notion of an anti-inflammatory role of A2aR, mice with an A2aR deficiency (A2aR-/-) develop exacerbated disease scores in the early phase of disease with higher numbers of microglia/macrophage and T cell infiltration, as compared to wildtype littermates. Furthermore, we found increased frequencies of interferon (IFN)-γ, interleukin (IL)-17 and granulocyte macrophage colony-stimulating factor (GM-CSF)-producing T helper cells ex vivo. However, this effect on disease course was transient, as EAE ameliorated in A2aR-/- mice and no difference in disease scores between A2aR-/- and wildtype littermates could be detected in late EAE phases.

We therefore hypothesized that A2aR signaling could confer both protective and detrimental effects. To test this, we treated wildtype mice with the A2aR-specific agonist CGS21680 only in early EAE or only after disease onset. As expected, early (preventive) CGS treatment led to a strong suppression of disease and a reduction of antigen-specific ex vivo proliferation, implying a role of T cells in this effect. Late (therapeutic) CGS treatment, however, led to an opposite effect: CGS-treatment exacerbated EAE progression and resulted in more severe tissue destruction. Histological examination revealed enhanced activation of microglia/macrophage cells upon treatment. Furthermore, in a model of in vivo microglial activation by systemic LPS injection, CGS application led to stronger microglial activation and an upregulation of proinflammatory IL-1β.

Taken together, we confirm and expand recent data on the complex roles of A2aR in CNS inflammation. Our data show a differential contribution of T cells and microglia/macrophages to A2aR-mediated processes during tissue damage and inflammation in autoimmune neuroinflammation.

J. Ingwersen, B. Wingerath, K. Lepka, M. Hofrichter, J. Graf, F. Schröter, S. Burghoff and T. Prozorovski have nothing to disclose.

H.-P. Hartung, J. Schrader and O. Akt have nothing to dislose in relation to this work.

Siponimod (BAF312) (and/or its metabolites) penetrates into the CNS and distributes to white matter areas

V. Aslanis, T. Faller, E. Van de Kerkhof, A. Schubart, E. Wallström, A. Beyerbach

Novartis Institutes of BioMedical Research (Basel, CH)

Background: Siponimod (BAF312) is a selective sphingosine-1-phosphate receptor 1 and 5 (S1P1/S1P5) modulator. Siponimod efficacy in reducing MRI lesions has been demonstrated in a recent phase 2 study in relapsing remitting multiple sclerosis (RR-MS). In addition to retaining lymphocytes in the peripheral lymphoid organs mediated via S1P1 internalisation, which is currently considered as the major mechanism responsible for clinical and MRI outcomes, there is increasing evidence that S1P signalling may also enhance remyelination and reduce neuronal loss within the CNS.

Objectives: The aim of the study was to investigate the distribution of Siponimod-related compounds in the body and particularly to the CNS in rats using 14C-radiolabelled compound in order to determine if CNS exposure could lead to possible CNS specific effects.

Methods: Male Wistar rats were dosed orally with [14C]BAF312 and quantitative whole-body autoradioluminography (QWBAL) was performed at different time points after cessation of treatment.

Results: Siponimod (BAF312) (and/or its metabolites) penetrates into the CNS and distributes to white matter areas with a slight delay after appearance in the blood and at peak exposure (4-8 hours post administration) reaches higher concentrations in CNS than in blood. Due to a slower elimination in the CNS in contrast to blood, in particular in white matter areas (cerebellar white matter and spinal cord white matter), CNS-blood concentration ratios increase further over later time points, although the absolute levels decline. For all CNS substructures, the CNS-blood exposure ratio was at least 2. In addition to the CNS, the exposure to Siponimod and/or its metabolites was in most tissues greater than in blood.

Conclusions: This study demonstrates that Siponimod (BAF312)(and/or its metabolites) reaches distinct exposure in the CNS. This may allow direct effects on CNS cells such as increased remyelination, which was demonstrated in different in vitro systems, as well as effects on astrocytes and neurons. Further studies will address if Siponimod CNS distribution translates into beneficial effects in different in vivo animal models.

This study was funded by Novartis Pharma AG, Basel.

All authors are employees of Novartis Pharma AG.

Systemic treatment with hepatocyte growth factor suppresses the development of experimental autoimmune encephalomyelitis and induces the differentiation of regulatory dendritic cells

M. Benkhoucha, N. Molnarfi, M.-L. Santiago-Raber, G. Schneiter, P.H. Lalive

Geneva University Hospital (Geneva, CH); Geneva Faculty of Medicine (Geneva, CH)

Objective: To study the regulatory effects of hepatocyte growth factor (HGF) treatment in experimental autoimmune encephalomyelitis (EAE).

Background: HGF is a multifunctional cytokine that suppresses inflammation in a variety of organ systems and disease models. In EAE, a common model of Multiple Sclerosis (MS), we have recently demonstrated that overexpression of neuronal HGF attenuated disease progression via at least anti-inflammatory signals (Benkhoucha M. et al., PNAS, 2010). As studies further identified HGF as a novel neurotrophic and neuroregenerative factor (Lalive P. et al., Eur J Immunol., 2005; Bai L. et al., Nat Neurosci. 2012), the mechanisms through which HGF exerts its beneficial effects in EAE remains only partially elucidated. We addressed here the effects of systemic administration of HGF on peripheral immune responses and EAE progression.

Design/Methods: EAE was induced by myelin oligodendrocyte glycoprotein (MOG) peptide 35-55. Gelatin microspheres incorporating HGF (50 ug) and HGF-free, empty gelatin microspheres were intravenously injected into mice before disease induction. Clinical assessment of EAE was performed daily. CNS inflammation and demyelination was quantitatively evaluated in the spinal cords of mice from both experimental groups at peak disease. The consequence of HGF treatment on the frequency of activated T cell within a peripheral lymphoid organ (spleen) of MOG-immunized mice was evaluated by flow cytometry.

Results: HGF by prevention treatment significantly reduced clinical manifestations, perivascular cell infiltration and myelin damages in the spinal cord of EAE-induced mice. In the periphery, HGF-treated mice had reduced frequency of encephalitogenic T helper (Th)1 and Th17 CD4+ T-cells but increased fraction of regulatory CD4+Foxp3+ T cells. Dendritic cells (DCs) from HGF-treated mice produced low levels of pro-inflammatory cytokines IL-12 but higher levels of the immunossupressive IL-10 and program death ligand (PD-L)1 molecules. Complementary in vitro studies demonstrated that HGF-treated DCs suppressed autoreactive Th1 and Th17 cells and promoted IL-10-producing regulatory T cells.

Conclusion/Relevance: These results suggest that HGF exerts a peripheral anti-inflammatory effect, leading to reduced CNS injury. By coupling neuroprotective, neurorepair and immunosuppressive properties, HGF occurs to be a promising candidate for the treatment of inflammatory demyelinating neurodegenerative diseases such as MS.

This study was supported by the Swiss National Foundation (#310030_132705 to PHL) and the Swiss Multiple Sclerosis Society (to P.H.L. and N.M.). N.M. is a recipient of an ECTRIMS fellowship exchange programme.

M.B., N.M., M.-L.S.R., G.S., and P.H.L. have nothing to disclose.

BNN27, a neuroprotective neurosteroid derivative, induces IL-10-producing regulatory T-cells and treats established experimental autoimmune encephalomyelitis

M. Aggelakopoulou, E. Kourepini, I. Lazarides, D.C.M. Simoes, N. Paschalidis, D. Kalavrizioti, I. Pediaditakis, A. Mouzaki, I. Charalampopoulos, A. Gravanis, V. Panoutsakopoulou

Biomedical Research Foundation Academy of Athens (Athens, GR); University of Crete Medical School (Heraklion, GR); University of Patras Medical School (Patras, GR); Foundation of Research Technology-Hellas (IESL-FORTH) (Heraklion, GR)

Multiple sclerosis (MS) has been widely studied using the mouse model experimental autoimmune encephalomyelitis (EAE). In EAE, disease develops when CNS is infiltrated by autoreactive Th1 and Th17 lymphocytes causing demyelination. Both Th1 and Th17 cells have been demonstrated in brain lesions of MS patients. Suppressive regulatory T and B cells and certain antigen-presenting cells are very important in limiting autoreactive Th1 and Th17 responses. It is of high importance to develop therapies for MS that cause induction of functional regulatory cells concomitant with suppression of pathogenic T cell responses. In parallel, it would be highly beneficial if these treatments could also rescue neurons from inflammation-induced apoptosis. Here, we demonstrate that the synthetic dehydroepiandrosterone-derivative BNN27, which is not metabolized to estrogens or androgens and has strong neuroprotective properties, dramatically suppressed established acute and relapsing-remitting EAE. Disease suppression was characterized by significantly decreased Th1 and mainly Th17 pathogenic effector responses, concomitant with a significant expansion of IL-10-producing CD4+ T regulatory cell subsets. BNN27 treatment down-regulated CCR6 expression on remaining Th17 cells, and rendered CD4+ T cells suppressive in vitro and, upon adoptive transfer, in vivo. These effects were mainly dependent on IL-10 production by CD4+ T cells, and the efficacy of BNN27 was blunted in IL-10 knock-out mice. Also, BNN27 almost completely reversed gliosis and neuronal damage in the spinal cord of EAE mice. Part of the immunomodulatory and neuroprotective effects of BNN27 were mediated by NGF receptors. Importantly, BNN27 suppressed human Th17 cell differentiation and pathogenic responses from MS patients ex vivo. Our findings suggest that BNN27 represents a non-toxic lead molecule to develop new CNS bioavailable therapeutic agents for MS.

Funded by the European Research Council and Bionature Ltd.

Funded by the European Research Council and Bionature Ltd.

No conflict of interest.

Preferential decrease in Th1 and Th17 cells within the CNS of EAE mice in response to oral laquinimod

S. Begum-Haque, M. Christy, K. Telesford, Y. Wang, A. Haque, L.H. Kasper

The Geisel School of Medicine (Lebanon, US)

Background: Recent evidence suggests that IL-17-producing CD4+ T cells (Th17 cells) are critical to the development of autoimmune disease, in particular EAE and with increasing likelihood, MS. Laquinimod has recently demonstrated a favorable effect in Phase III studies in those with relapsing MS. Although the mechanism for disease reduction is not yet clarified recent studies (Wegner, 2010) in EAE mice have demonstrated a global anti-cytokine effect with reduced Th1 and Th17 secretion in the periphery of laquinimod treated mice.

Objective: We investigated both the anti-inflammatory as well as the neurotrophic effect of laquinimod within the CNS of EAE treated mice.

Design and Methods: Tissue samples from spleens and brains were examined for expression of Th1/IL-17 cytokines, chemokines and transcription factors for Th1 and Th2 cytokines and compared with untreated diseased mice. A repertoire of cytokines (IL-4, IL-6, IL-10, IL-12, IL-17, IFNg, and BDNF) were assayed from EAE treated mice at day 3 post induction (100 ug/mouse) and starting at day 3 than weekly (days 10, 17 and 24) (300 ug/mouse) by RT-PCR. We compared the effect of this therapy on the immune cytokine response in the periphery (spleen) compared to within the CNS.

Results/Conclusions: We observed a modest but global reduction in both Th1/Th17 and Th2 cytokines in the spleen consistent with previous reports (Wegner, 2010). Of particular novelty, was a profound reduction of both Th1 and Th17 cytokines within the CNS compared to the peripheral splenocyte response. Further, there was a reduction in both MIPα and MIPβ chemokines within the CNS of EAE mice treated with laquinimod suggesting a tissue specific intrinsic effect of this therapy. Of particular note, IL-12 levels in spleen did not appear to be affected by treatment with laquinimod. Confirmation of an anti-inflammatory effect of drug within the CNS was the decreased expression of STAT4 (associated with Th1 polarization) and a marked increase in the expression of smad3 consistent with a rise in the production of TGFβ, a critical T-reg polarizing cytokine. Moreover, there was a substantial increase in BDNF expression within the CNS of laquinimod treated EAE mice that may further reflect immune regulatory activity within the CNS. These findings support a potentially important effect of laquinimod in CNS tissue specific reduction of inflammation as measure by reduced Th1 and Th17.

S.B-H. received research funding for this study from Teva Pharmaceuticals, Petah Tiqva, Israel. L.H.K. has received honoraria from Teva Neuroscience, EMD Serono, Bayer Pharmaceuticals, Genzyme, Novartis, Genentech, and Ono Pharmaceuticals. MC, KT,YW have nothing to disclose.

The regulatory function of B-cells in protection against EAE by a human commensal bacteria polysaccharide

Y. Wang, K. Telesford, S. Begum-Haque, J. Ochoa-Repáraz, D.L. Kasper, L.H. Kasper

Dartmouth College (Lebanon, US); Harvard Medical School (Boston, US)

Intestinal commensal microbiota have the potential to modulate immune system against CNS demyelination and inflammation. Polysaccharide A (PSA), a zwitterionic capsular polysaccharide derived from the intestinal commensal Bacteroides fragilis and TLR2 agonist, is shown to protect mice against experimental autoimmune encephalomyelitis (EAE) via oral administration route. Foxp3+/IL-10 secreting Treg cells sensitized by gut associated CD103+ dendritic cells in PSA treated mice mediate this protection. In this study, we investigate the regulatory function of B cells in PSA mediated protection against EAE.

CD19+ B cells isolated from PSA or PBS orally administrated B6 donor mice were adoptively transferred to EAE-induced B6 recipient mice. TLR2± CD19+ B cells were cultured in vitro with PSA and supernatant IL-10 was measured by ELISA. IL-10-Thy1.1 (10BiT) reporter mice were induced with EAE and treated per os with either PSA or PBS as control. Cervical, mesenteric LNs and peyer’s patches were collected. Total CD19+ B cells were analyzed for either phenotype or IL-10 expression. To determine the in vivo role of B cell specific TLR signaling in PSA protection, CD19cre x Myd88flox and WT B6 mice were treated with PSA in active EAE and clinic curves were monitored.

We show that CD19+ B cells from PSA sensitized donors demonstrated an enhanced dose-dependent therapeutic effect against EAE when compared to normal age matched control mice. In vitro, PSA could stimulate CD19+ B cells production of IL-10 via TLR2 signaling. In vivo at early EAE development stage, PSA shifts the CD19+ B cell composition to CD5+ B1-a phenotype, which is associated with increased IL-10 expression. Within the CNS, enhanced expression of homing CD29+ B cells was observed in association with an elevated IL-10+CD5+ frequency. B cell conditional Myd88 KO abrogates PSA protection of EAE in vivo.

These findings suggest that in addition to its reported effect on gut derived CD103+ dendritic cells, PSA can modulate CNS immune homeostasis via B cells in control of EAE. Initial findings indicate that PSA can increase the IL-10 producing B1-a subset. PSA enriches IL-10+ regulatory B cell type within brain homing niche, consistent with anti-inflammatory effect observed with PSA treatment. TLR2 signaling both in vivo and in vitro is essential for the establishment of this anti-inflammatory effect by PSA. More specifically, B cell sensing of PSA by TLRs is critical to PSA protection of EAE.

This work was supported by Supported by Teva Neuroscience and NIAID-AI061938, and CA1027A1/3-National MS Society.

DMF treatment prevents cellular infiltration and reduces the frequency of IFN[c]-positive CD4-T-lymphocytes in EAE spinal cords

P. Bista, A. Thomas, K. Fu, W. Zeng, M.N. Shackett, D. Huss, Y. Luo, E. Drummond, A. Tsolias, S. Ryan, R.H. Scannevin, B. Wipke, M. Lukashev

Biogen Idec Inc (Weston, US)

Background: BG-12 (dimethyl fumarate, DMF) is an oral agent in development for the treatment of relapsing multiple sclerosis. Previous studies have shown both neuroprotective and anti-inflammatory activities of DMF in preclinical models, including experimental autoimmune encephalomyelitis (EAE). However, DMF-induced changes in specific cellular subsets in EAE have not been fully investigated.

Objective: To characterize DMF-induced changes in lymphocyte and monocyte subsets in EAE.

Methods: C57BL/6 mice were immunized with myelin oligodendrocyte glycoprotein (MOG) peptide fragment (35-55) in complete Freund’s adjuvant, followed by treatment with pertussis toxin to initiate EAE. Mice were dosed once per day with vehicle or DMF (either 50 or 100 mg/kg) via oral gavage for 20 days. Blood, spinal cords, spleens, and inguinal lymph nodes were harvested to study treatment-related changes in different cell populations. Additionally, cells were re-stimulated in-vitro with MOG(35-55) peptide to study changes in T-cell polarization. All phenotyping was performed using fluorescent antibodies to cell-surface and intracellular targets, and analyzed by flow cytometry.

Results: DMF treatment reduced the frequency of CD45+ cells infiltrating the spinal cords of EAE mice. The frequencies of CD45+ cells in the blood, spleens and inguinal lymph nodes remained unaffected. CD4+ T cells, CD8+ T cells and CD11b+ monocytes were decreased in the spinal cord infiltrates, while there were no treatment-related changes in CD19+ B cells or DX5+ natural killer cells. DMF treatment selectively reduced the frequency of spinal cord infiltrating interferon-γ-positive CD4 T-cells as measured by in-vitro re-stimulation with MOG(35-55) peptide.

Conclusion: These data confirm and expand upon earlier studies demonstrating that DMF can inhibit neuroinflammation in EAE. DMF treatment reduced the frequencies of CD4+ and CD8+ T cells and CD11b+ macrophages infiltrating the spinal cord but not those of CD19+ B cells or DX5+ NK cells. The frequencies of these populations in the blood, spleen, and inguinal lymph nodes were not affected by DMF. These findings suggest that inhibition of neuroinflammation by DMF may be due to specific suppression of certain T cell and myeloid subsets rather than general immunosuppression.

All authors are full-time employees of Biogen Idec, Inc.

Supported By: Biogen Idec Inc.

Multiple sclerosis risk genotypes correlate with elevated cerebrospinal fluid levels of the suggestive prognostic marker CXCL13

M. Lindén, M. Khademi, I. Lima Bomfim, F. Piehl, M. Jagodic, I. Kockum, T. Olsson

Karolinska Institutet (Stockholm, SE)

The mechanisms of MS pathogenesis are still largely unknown and the heterogeneity of disease manifestations make prognosis prediction and choice of appropriate treatment protocols challenging. Recently, increased CSF levels of the B cell chemokine CXCL13 has been proposed as a possible marker for conversion of clinically isolated syndrome (CIS) to relapsing-remitting MS (RRMS) and for a more severe disease course. The objective of this study was to investigate whether there are genetic susceptibility variants in MS that correlate with levels of CXCL13 in CSF of MS patients.

We genotyped HLA-DRB1, HLA-A and a panel of single nucleotide polymorphisms (SNPs) associated with susceptibility to MS and correlated the genotypes to levels of CXCL13 measured with ELISA in CSF of in total 635 patients with MS, CIS, other neurological diseases (OND) or OND with an inflammatory component (iOND). The Wald test was performed in order to assess correlation of the quantitative trait CXCL13 with the markers, and the student’s t-test was used to test the mean CXCL13 levels between different genotypes at one locus. Benjamini-Hochberg (BH) corrections were used to adjust for multiple testing. Gene expression was measured by quantitative real-time PCR.

Increased protein levels of CXCL13 in CSF of MS and CIS patients correlated significantly with the presence of the HLA-DRB1*15 variant (p<0.002) and homozygous carriage of the MS risk alleles of rs2760524 (RGS1),(p<0.004), rs4728142, rs3807306 (IRF5), (p<0.005 and p<0.02, respectively), and rs9321619 (OLIG3/TNFAIP3), (p<0.01). The correlations were significant when OND patients were included in the analysis, but not when iOND patients were added. Correlations in the OND group alone were not significant.There are no reports of direct regulation of CXCL13 by any of the genes in closest proximity to these susceptibility loci. Attempting to find possible indirect regulatory links between the correlated genotypes and CXCL13, we measured mRNA expression of IL6, TNF and IFN-g in CSF cells from 390 patients and in peripheral blood mononuclear cells (PBMCs) from 369 patients included in this study. No significant difference in gene expression between the different genotype groups was found and IL6, TNF or IFN-g expression did not correlate with levels of CXCL13 protein.In conclusion, our findings point towards a genetic predisposition for increased CXCL13 levels, which in turn is correlated with severity of the disease course of MS.

Ms. Lindén, Dr. Khademi, Dr. Lima Bomfim, Dr. Jagodic and Dr. Kockum have nothing to disclose.

Prof. Piehl has received unrestricted support for MS research from Biogen Idec.

Prof. Olsson has received unrestricted support for MS research from Biogen Idec., Bayer-Schering Pharma, Sanofiaventis, TEVA, Novartis and Merck Serono. The same companies have given lecture fees and/or compensations for consultancy.

Natalizumab treatment impacts on deregulated expression profile of miRNAs in CD4+ T-cells of patients with relapsing-remitting MS

M. Meira, C. Sievers, F. Hoffmann, J. Kuhle, L. Kappos, R.L.P. Lindberg

University Hospital Basel (Basel, CH)

Background: MicroRNAs (miRNAs) are small endogenous single-stranded non-coding ribonucleic acids that play essential roles in the regulation of gene expression at the post-transcriptional level for a broad range of biological processes. Deregulated miRNA expression has been associated with a wide variety of human diseases including cancer and autoimmune diseases. Of interest, recent studies have shown deregulated miRNA expression profiles in lymphocyte subpopulations of MS patients.

Objectives: To investigate the expression profile of miRNAs in CD4+ T cells from untreated (N=12) and Natalizumab treated relapsing-remitting (RR) MS patients (N=19), and evaluate subsequent effects on the expression of potential target genes.

Methods: Peripheral blood mononuclear cells (PBMCs) were isolated using a Ficoll gradient. The CD4+ T-cell subpopulation was separated from PBMCs with MACS technology. Total (including micro-) RNA was isolated and expression analysis of miRNAs and potential target genes was performed using RT-PCR based assays.

Results: Our previous low-density array and RT-PCR analyses revealed deregulated expression of 10 miRNAs in CD4+ T cells from RRMS patients (N=23) compared to healthy volunteers (HV) (N=18) (Lindberg et al., 2010). Upregulation of 4 of these miRNAs, namely miR-1, miR-17, miR-126 and miR-376a, was significantly reversed in Natalizumab treated patients. However, expression of miR-1, miR-17 and miR-126 was upregulated in Natalizumab treated patients during relapse. Two additional miRNAs, miR-106b and miR-548c were significantly upregulated in Natalizumab treated compared to untreated patients. Furthermore, down-regulation of miR-17 expression in Natalizumab treated patients correlated with up-regulation of target genes such as PTEN, an inhibitor of PI3K, E2F1, a transcription factor that is involved in cell cycle control, and p21, a potent cyclin-dependent kinase inhibitor.

Conclusion: The altered miRNA expression upon Natalizumab treatment and during relapse supports a role for miRNAs in the immunopathogenesis of MS. The unique effect of Natalizumab on specific miRNA expressions and subsequent differential expression of potentially related target genes involved in proliferation and control of the cell cycle adds to our understanding of the mode of action of Natalizumab.

RLP Lindberg has received research support from Swiss MS Society, Swiss National Science Foundation, European FP6 and IMI JU programs, Roche Postdoc Fellowship Program (RPF-program), unrestricted research grants from Novartis and Biogen.

M. Meira is supported by SNSF and C. Sievers is supported by Roche RPF-Program.

F. Hoffmann has nothing to disclose.

J. Kuhle got research support from Novartis, Roche Ltd, Protagen AG.

L. Kappos has participated in the last 24 months as principal investigator, member or chair of planning and steering committees or advisory boards in corporate-sponsored clinical trials in multiple sclerosis and other neurological diseases. The sponsoring pharmaceutical companies for these trials include Abbott, Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CSL Behring, Elan, Genmab, GeNeuro SA, Genmark, GlaxoSmithKline, Lilly, Merck Serono, Novartis, Novonordisk, Peptimmune, sanofiaventis, Santhera, Roche, Teva, UCB and Wyeth. He has also lectured at medical conferences or in public on various aspects of the diagnosis and management of multiple sclerosis. In many cases these talks have been sponsored by non-restricted educational grants to his institution from one or another of the above listed companies. Honoraria and other payments for all these activities have been exclusively used for funding of research of his department. Research and the clinical operations (nursing and patient care services) of the MS Center in Basel have been supported by non-restricted grants from one or more of these companies.

Gene variants in interferon regulatory factor 5 regulate the endogenous type 1 interferon-response in multiple sclerosis

H.B. Søndergaard, A.B. Oturai, P. Soelberg Sørensen, F. Sellebjerg

University Hospital Rigshospitalet (Copenhagen, DK)

Introduction: A proportion of multiple sclerosis (MS) patients have a higher endogenous type 1 interferon (IFN) activity, resulting in higher expression levels of IFN-induced genes such as MX1 and a lower T-cell response. The transcription factor Interferon Regulatory Factor (IRF) 5 is critical for the induction of type I IFNs. We hypothesised that three IRF5 single nucleotide polymorphisms (SNPs) could possibly be involved in the regulation of the endogenous type I IFN response in untreated MS patients.

Methods: Genotyping of the rs20046403 (T/G), rs3807306 (T/G) and rs4728142 (A/G) IRF5 SNPs was performed by TaqMan allelic discrimination (Applied Biosystems) on DNA from 39 untreated RRMS patients in clinical remission. The same individuals had 21 IFN response genes and other immunologically relevant targets amplified by real-time qPCR analysis on total RNA from whole blood. A Kruskal-Wallis test was used for comparison of the genotypes versus gene expression indexes. A gene expression microarray (HG Focus, Affymetrix) analysis was performed on total RNA from PBMCs from 36 of the patients. The microarray results were compared with gene expression data from patients treated with IFN-β.

Results: We found that expression of MX1 mRNA differed significantly in patients carrying the different IRF5 alleles in rs2004640, rs3807306 and rs4728142 in untreated MS (p<0.0001, p=0.003 and p=0.002, respectively). The rs2004640 (TT), rs3807306 (TT) and rs4728142 (AA) genotypes are in strong linkage disequilibrium. When we compared the rs2004640-rs3807306-rs4728142 TTA-haplotype (n=10) with the GGG-haplotype (n=10), a higher induction of MX1 (p=0.001) was found in MS patients with the TTA-haplotype. We went on to study microarray data of the most induced genes in MS patients with the TTA-haplotype, compared with the GGG-haplotype, and compared these with a list of expressed genes after IFN-β treatment, and found a highly significant overlap between induced genes in patients with the TTA-haplotype and IFN-β induced genes (Chi-square 112, p<0.0000001).

Conclusion: We show that SNPs in the IRF5 gene are associated with the expression of MX1 and an increased type I IFN gene expression signature in untreated MS patients. This may have relevance for the pathogenesis of MS. The genetic regulation of the type I IFN gene expression signature should also be taken into account in studies where the induction of type I IFN-induced genes is used as a biomarker for IFN-β therapy.

Helle Bach Søndergaard has nothing to disclose.

Annette Bang Oturai has served on scientific advisory boards for Novartis, has received speaker honoraria from Biogen Idec, Merck Serono, and Novartis; and has received research support from the Danish Multiple Sclerosis Society, the Warwara Larsen Foundation and the Johnsen Foundation.

Per Soelberg Sorensen has served on scientific advisory boards Biogen Idec, Merck Serono, Novartis, Genmab, TEVA, Elan, GSK, has been on steering committees or independent data monitoring boards in clinical trials sponsored by Merck Serono, Genmab, TEVA, GSK, Bayer Schering, and he has received funding of travel for these activities; has served as Editor-in-Chief of the European Journal of Neurology, and is currently editorial board member for Multiple Sclerosis Journal, European Journal of Neurology, Therapeutic Advances in Neurological Disorders and; has received speaker honoraria from Biogen Idec, Merck Serono, TEVA, Bayer Schering, Sanofi-aventis, and Novartis. His department has received research support from Biogen Idec, Bayer Schering, Merck Serono, TEVA, Baxter, Sanofi-Aventis, BioMS, Novartis, Bayer, RoFAR, Roche, Genzyme, from the Danish Multiple Sclerosis Society, the Danish Medical Research Council, and the European Union Sixth Framework Programme: Life sciences, Genomics and Biotechnology for health.

Finn Sellebjerg has served on scientific advisory boards for Biogen Idec, Merck Serono, Novartis, Sanofi-Aventis and TEVA and as consultant for Biogen Idec and Novo Nordisk; has received support for congress participation from Biogen Idec and Sanofi Aventis; has received speaker honoraria from Biogen Idec, Merck Serono, Bayer Schering, Schering-Plough, Sanofi-aventis and Novartis; and has received research support from Biogen Idec, Bayer Schering, Merck Serono, Sanofi-Aventis and Novartis.

Conventional and non-conventional MRI characteristics of familial and sporadic multiple sclerosis patients

A. Tipirneni, B. Weinstock-Guttman, M. Ramanathan, N. Abdelrahman, S. Hussein, J. Hagemeier, J. Durfee, B. Teter, D. Hojnacki, M. Dwyer, F. Munschauer, R. Zivadinov

Buffalo Neuroimaging Analysis Center (Buffalo, US); Jacobs Neruological Institute (Buffalo, US); University at Buffalo (Buffalo, US)

Background: Although studies have hypothesized that familial and sporadic multiple sclerosis (MS) might be different forms of the disease, the findings from these studies were not able to detect differences in clinical characteristics. The available studies were limited by their small sample size and to date there have been no large-cohort studies investigating specific differences in conventional or non-conventional MRI characteristics of familial and sporadic MS patients.

Objectives: To investigate the MRI characteristics in a large cohort of MS patients with and without a family history of MS.

Methods: 758 consecutive MS patients (mean age 46.2 ± 10.1 years, disease duration: 13.6 ± 9.2 years and EDSS: 3.4 ± 2.1), of which 477 had relapsing-remitting, 222 secondary-progressive, 30 primary-progressive disease course and 29 were clinically isolated syndrome, were enrolled in this prospective study. 196 patients (25.9%) had a positive family history of MS (82 had first-degree affected relative, 35 second-degree and 79 had third-degree). Patients were assessed using conventional and non-conventional MRI metrics, including measurements of lesions, brain atrophy, magnetization transfer ratio (MTR) and diffusion-weighted imaging.

Results: The familial MS group had greater T1 lesion volume (LV) (p=0.008) and T2-LV (p=0.026), lower normalized whole brain (WB) volume (p=0.048), and lower MTR of T1-LV (p=0.012) than the sporadic MS group. There was a significant difference between the first-, second- and third-degree affected relative subgroups in normalized white matter (WM) volume (p=0.036), and in MTR of normal appearing (NA) WM (p=0.005), NA brain tissue (p=0.007), WB (p=0.008), NA gray matter (p=0.043) and T2-LV (p=0.046). No clinical differences between familial vs. sporadic, or by a degree of affected relative subgroups, were found.

Conclusions: Familial MS is associated with more severe tissue destruction, as measured by lesion volume and its MTR characteristics, and more advanced global brain atrophy. A better understanding of the genetic and/or epigenetic influences causing these differences can advance the understanding and management of MS.

Jesper Hagemeier, Nadair Abdelrahman, Sara Hussein, Anita Tipirneni, Jacueline Durfee, Barbara Teter, Michael G. Dwyer have nothing to disclose.

Frederick Munschauer is an employee of Biogen Idec but during the writing of this paper he was employed at Jacobs Neurological Institute.

David Hojnacki has received speaker honoraria and consultant fees from Biogen Idec, Teva Pharmaceutical Industries Ltd., EMD Serono, Pfizer Inc, and Novartis.

Bianca Weinstock-Guttman received personal compensation for consulting, speaking and serving on a scientific advisory board for Biogen& Idec, Teva Neuroscience and EMD Serono. Dr. Weinstock-Guttman also received financial support for research activities from NMSS, NIH, ITN, Teva Neuroscience, Biogen Idec, EMD Serono, and Aspreva.

Murali Ramanathan served as an editor for the American Association of Pharmaceutical Scientists Journal, receives royalties for publishing The Pharmacy Calculations Workbook [Pinnacle, Summit and Zenith, 2008], and received research support from EMD Serono, Novartis, Pfizer, the National Multiple Sclerosis Society, and the National Science Foundation.

Robert Zivadinov received personal compensation from Teva Neuroscience, Biogen Idec, EMD Serono and Questcor Pharmaceuticals for speaking and consultant fees. Dr. Zivadinov received financial support for research activities from Biogen Idec, Teva Neuroscience, Genzyme, Bracco, Questcor Pharmaceuticals and EMD Serono.

Study of the TNFRSF1A polymorphisms rs4149584 and rs1800693 in patients with multiple sclerosis

M. Comabella, A.B. Caminero, S. Malhotra, L. Agulló, F. Reverter, K. Vandenbroeck, O. Fernández, F. Matesanz, G. Izquierdo, A. López-Larios, E. Urcelay, A. Sánchez, A. Rodríguez-Antigüedad, S. Otero, M. Tintoré, X. Montalban

Vall Hebron University Hospital (Barcelona, ES); Universitat de Barcelona (Barcelona, ES); Universidad del País Vasco (Leioa, ES); Hospital Regional Universitario Carlos Haya (Málaga, ES); Instituto de Parasitología y Biomedicina López Neyra (Granada, ES); Hospital Virgen Macarena (Sevilla, ES); Hospital Clínico San Carlos (Madrid, ES); Vall Hebron Research Institute (Barcelona, ES); Hospital de Basurto (Bilbao, ES)

Background: The TNF receptor superfamily member 1A (TNFRSF1A) gene codes for TNF-R1, a main TNF receptors mediating its inflammatory actions. Two polymorphisms of this are associated with increased risk for MS: the high-frequency polymorphism rs1800693, located within the sixth intron of TNFRSF1A, and the low-frequency nonsynonymous coding polymorphism rs4149584, resulting in an arginine-to-glutamine substitution at amino acid position 92 (R92Q). The R92Q mutation is also associated with the TNF receptor-associated periodic syndrome (TRAPS).

Objective: To investigate SNPs rs4149584, rs1800693 as MS genetic modifiers, and evaluate their potential functional implications in the disease.

Methods: The study included 2032 MS patients genotyped for the TNFRSF1A SNPs rs4149584 and rs1800693. The effect of genotypes on age at disease onset and MS Severity Score (MSSS) was analyzed by three factor ANOVA (incl. cohort, clinical form and genotype) on each variable. In a subgroup of patients stratified as to risk genotypes for rs4149584 and rs1800693, the soluble form of TNF-R1 (sTNF-R1) was determined in serum samples by ELISA, and the cell surface expression of TNF-R1 investigated in CD4+ and CD8+ T cells by flow cytometry. To analyze the effect of the R92Q mutation on receptor structure and interaction with TNF, models of native and mutated extracellular segments of the receptor with and without ligand were constructed and submitted to molecular dynamics.

Results: SNP rs4149584 (CT and TT carriers) was significantly associated with lower age at disease onset (p=0.04). No significant associations were observed between SNPs rs4149584 and rs1800693 and MSSS. Serum levels of sTNF-R1 were significantly higher in CT heterozygotes for rs4149584 compared with CC homozygotes (p=0.003). No differences in sTNF-R1 serum levels were observed between rs1800693 genotypes. Surface expression of the TNF-R1 was similarly distributed among patients with different genotypes for both SNPs. Studies on molecular dynamics revealed differences in the interaction between TNF and the two receptors, native and mutated, suggesting a more favourable coupling of TNFR1-R92Q with ligand: higher number of hydrogen bonds, stronger energy of interaction, and lower distance between receptor and TNF.

Conclusions: These findings suggest a role of the low-frequency polymorphism rs4149584 as genetic modifier in MS. The mutated receptor R92Q is associated with increased shedding of the TNF-R1 and stronger interaction with its ligand, TNF

The authors have nothing to disclose.

A weighted genetic risk score to predict neutralising antibodies to interferon-β in multiple sclerosis patients

B. Hemmer, W. Igl, D. Buck, M. Mühlau, S. Schwenke, B. Müller-Myhsok, R. Sandbrink, C. Pohl

Technische Universität München (Munich, DE); stats-con.com (Berlin, DE); Bayer Schering Pharma AG (Berlin, DE); Max-Planck-Institut für Psychiatarie (Munich, DE)

Interferon-β (IFN-β) is a baseline therapy approved for treatment of clinically isolated syndrome, relapsing-remitting and secondary-progressive multiple sclerosis. One of the possible reasons for treatment failure is the development of neutralizing antibodies (NAbs) to IFN-β. Recent studies have suggested that genetic factors might influence the development of NAbs. Our study aimed to validate previous genetic studies on NAbs and to establish a genetic risk score in a well-controlled phase III trial setting.

Patients treated with IFN-β-1b from the BENEFIT(R) and BEYOND(R) phase III trials were tested at baseline and 6, 12, 18 and 24 months after initiation of therapy for the development of NAbs to IFN-β by the myxovirus protein A induction assay. 940 patients were genotyped (Affymetrix human genome-wide array 6.0) and 667 patients were high resolution HLA-class II typed. A weighted genetic risk score (wGRS) was calculated based on the allele dosages of HLA alleles (HLA-DRB1*1601, 0401, 0408, 0301, 0404, 1104) and SNPs (rs9272105, rs4961252), which were shown to be associated with the development of NAbs to IFN-β in previous studies. Association of NAbs positivity (>20 TRU and > 400 TRU) with the wGRS was performed based on logistic models with different sets of covariates.

When analysing single genetic markers, association was confirmed for the HLA allele *0401 and the SNP rs9272105 (G) on development of Nabs in 349 of the 940 patients. High NAb titres were found to be associated with the HLA allele *0408, the SNP rs9272105 (G) and the SNP rs4961252 (A). The GRS score was significantly associated with NAb (>20TRU) and NAb (>400TRU) positivity after correction for population stratification and correlatedness of patients. The GRS had a stronger predictive value for the NAb+>400 TRU endpoint (odds ratio = 1.62, p = 0.00029) than for the NAb+>20 TRU endpoint (odds ratio = 1.34, p=0.0016) reflecting the fact that some risk alleles/SNPs were associated with NAb titres, but not with NAb occurrence (HLA-DRB1*0408, and SNP rs4961252).

Our genetic risk score, which involves mainly alleles and SNPs in the HLA class II region, is associated with the development of NABs in patients treated with IFN-β-1b. Our study confirms previous findings from cross-sectional patient series and the important role of the HLA class II locus for the development of NAbs to IFN-β. Genetic factors differentially impact on development of NAbs and on the strength of the immune response.

This work was supported by a grant from the German Ministry for Education and Research (BMBF, “German Competence Network Multiple Sclerosis” (KKNMS), Control-MS, 01GI0917) and Bayer Schering Pharma AG.

Axonal and oligodendrocyte-localised antibody deposits in MS lesions

M.C. Sadaba, M.M. Esiri, J. Tzartos, C. Paino, M. Garcia-Villanueva, J.C. Alvarez-Cermeno, L.M. Villar

Universidad San Pablo CEU (Madrid, ES); Oxford Unjversity (Oxford, UK); Hospital Ramon y Cajal (Madrid, ES)

Background: Recent findings support the important role of antibodies in multiple sclerosis (MS) physiopathology. Thus, more than 95% show local IgG synthesis, and about 40% show intrathecal IgM secretion, which associates with a poor disease outcome.

Methodology: We investigated the presence of IgM and IgG in 71 formalin-fixed, paraffin embedded tissue blocks from 14 MSpatients, two stroke cases, two herpes encephalitis and four patients with no neurological diseases.

Results: IgG and IgM were absent in controls. Conversely, we found IgM in about 50% and IgG in 75% of MS patients. The presence of IgM and IgG antibodies was independent of disease duration, clinical disease type or lesion stage. IgM and IgG were present in acute, chronic active and chronic inactive lesions. Both IgM and IgG were detected on axons and oligodendrocytes in demyelinated areaa, and, in some cases, on oligodendrocytes in NAWM. IgG and IgM colocalized with complement C3b and antibody-antigen immunocomplexes were detected in foamy macrophages in active lesion areas. These findings were absent from cases of non-neurological disease and cases with non-MS CNS inflammatory disease.

Conclusions: These observations provide further evidence on the role of antibodies, complement and macrophages in plaque development, and strongly suggest they can induce axonal injury, an important cause of disability in MS. They may provide novel therapeutic strategies to limit tissue degeneration in the disease.

The authors have nothing to disclose.

CD5-positive B cell subsets in secondary-progressive multiple sclerosis

M. Niino, T. Fukazawa, N. Minami, I. Amino, J. Tashiro, N. Fujiki, S. Doi, S. Kikuchi

Hokkaido Medical Center (Sapporo, JP); Sapporo Neurology Clinic (Sapporo, JP)

Background: Evidence of the role of humoral immunity in the pathogenesis of multiple sclerosis (MS) is increasing. In particular, it is important to consider which B cell subpopulations play critical roles in MS. Recent studies have discussed the roles of CD5-positive B cells in autoimmune diseases.

Objectives: The objective of the present study was to determine whether CD5-positive B cell populations are associated with secondary-progressive multiple sclerosis (SPMS). Furthermore, we explored which CD5-positive B cell subsets are associated with SPMS and whether disease severity and prognosis are also associated with these B cell populations.

Methods: A total of 26 patients with SPMS, of whom 11 were treated with IFN-β (IFN-SPMS) and 15 were untreated (non-IFN-SPMS), and 19 healthy control (HC) subjects were included in the study. Expression of CD11a, CD23, CD25, CD38, CD49d, CD80, CD86, CD138, CCR5, and CXCR5 on CD5-positive B cells in blood samples was examined by flow cytometry. Disease severity was evaluated using the Expanded Disability Status Scale score (EDSS), and prognosis was evaluated using the Multiple Sclerosis Severity Score (MSSS).

Results: The percentage of CD5-positive B cells in the non-IFN-SPMS group was significantly lower than in the HC group (p<0.05). Within the subsets of CD5-positive B cells, mean fluorescence intensity values of CD11a in the non-IFN-SPMS group were significantly decreased compared with the HC subjects (p<0.05). SPMS patients both with and without IFN-treatment showed lower CCR5 positivity on CD5-positive B cells than healthy controls (p<0.001 for non-IFN-SPMS and p<0.01 for IFN-SPMS). CD138 positivity on CD5-positive B cells in the non-IFN-SPMS group was significantly lower than in the HC group (p<0.01). The positivity of CD25 in CD5-positive B cells was significantly decreased in SPMS patients, regardless of IFN-β treatment, compared with healthy controls (p<0.001 for non-IFN-SPMS and p<0.01 for IFN-SPMS). Neither the EDSS score nor the MSSS showed an association with positivity of CD5 on B cells.

Conclusions/Relevance: Previous studies reported that CD5-, CD25-, and CD138-positive B cells produce higher IL-10 than other B cell subsets. Our results suggest that decreased CD5-positive B cells and CD5-positive B cell subsets might be associated with the pathogenesis of SPMS through decreased production of the downregulatory cytokine IL-10 by B cells.

The authors have no relevant potential conflicts of interest to declare. This work was supported in part by a Health and Labor Sciences Research Grant on Intractable Diseases (Neuroimmunological Diseases) from the Ministry of Health, Labor and Welfare of Japan.

Inflammatory response of endothelial cells to an endogenous retrovirus associated to MS is mediated by TLR4

D. Barbe, G. Raguenez, H. Perron, P.N. Marche, A. Duperray

U823 INSERM-UJF (Grenoble, FR); GeNeuro Innovation (Lyon, FR)

The MSRV (Multiple Sclerosis Associated Retro Virus) belongs to human endogenous retrovirus HERV-W family. An envelope protein originating from the MSRV was found in most patients with multiple sclerosis (MS). This protein (Env-ms) has pro-inflammatory properties on several immune cells and could therefore play a role in the MS pathogenesis by promoting the leukocyte diapedesis observed in the central nervous system of patients. Our study aims to analyze the effects of Env-ms on the blood-brain barrier (BBB) at a molecular and functional level.

For this purpose, we assessed the effects of the recombinant Env-ms protein on several immune parameters using an in vitro model of the brain endothelium (HCMEC/D3 cell line). After overnight treatment with Env-ms, the pro-inflammatory cytokine production was measured with ELISA assays and the expression of ICAM-1, a major mediator of leukocyte adhesion to endothelial cells was measured by flow cytometry.

We demonstrate that the recombinant Env-ms stimulates HCMEC/D3 by 1) the production of the pro-inflammatory cytokines IL-6 and IL-8 in a dose dependent manner, 2) the overexpression of ICAM-1 in a dose dependent manner and 3) the adhesion of activated monocytes to the monolayer of endothelial cells.

We also show that Env-ms-induced pro-inflammatory effects are specific of the recombinant protein since they can be inhibited using monoclonal antibodies raised against the envelope. In addition we performed polymyxin B inhibition assays revealing that these effects are not due to a contamination with endotoxins.

Moreover, by assessing the effects of Env-ms on primary endothelial cells HUVECs, we demonstrate that the envelope strongly stimulates the production of IL-8 but has weaker effects regarding the overexpression of ICAM-1 and the production of IL-6.

Finally, we show that Env-ms acts via the TLR4 (Toll Like Receptor), a pattern recognition receptor expressed by endothelial cells, by using a silencing approach with siRNAs which knock down TLR4 thus abolishing pro-inflammatory responses to Env-ms.

Previous work has established that Env-ms stimulates monocytes and dendritic cells through TLR4. Our present data reinforce the hypothesis that MSRV could be involved in the pathogenesis of inflammatory diseases, such as MS, by initiating or maintaining inflammatory conditions through TLR4 stimulation then leading to auto-immune disorder.

This work was in part supported by “Fondation ARSEP and “AFM”.

Effector CD8+ T-cells recognise cognate and cross-reactive peptides presented in non-inflamed CNS tissue

E. Zindler, N. Boldakowa, J. Herz, F. Zipp, V. Siffrin

University Medical Center (Mainz, DE); Max Delbrück Center for Molecular Medicine (Berlin, DE); University Clinic (Essen, DE)

Objective: In general, specific interactions of CD8+ T cells with target cells require MHC class I expression, which can be induced in neurons by danger signals. Even under healthy conditions low-level, non-detectable MHC I expression and loading of endogenous or supposedly also exogenous peptides may lead to activation of CD8+ T cells. We investigated here if CD8+ T cells may interact with neurons in the non-inflamed CNS in the absence of MHC I induction and inflammatory cytokines.

Methods: We used the T cell-acute hippocampal brain slice co-culture model to monitor interactions of the immune and the neuronal cells with two-photon laser scanning microscopy. We transferred in vitro activated Ovalbumin (Ova) transgenic OT1 CD8+ T cells or OT2 CD4+ T cells onto acute organotypic hippocampal slices and perfused the co-culture with Ovalbumin peptide or myelin-oligodendrocyte-glycoprotein (MOG) peptide. For in vivo studies, we transferred OT1 CD8+ T cells in C57/Bl6 mice and induced active experimental autoimmune encephalomyelitis (EAE) by immunization with MOG33-55 after a reconstitution period of 4 weeks.

Results and conclusion: After treatment of T cell-brain slice co-culture with OT1-OVA, a strong decrease in instantaneous velocity of the OT1 CD8+ T cells was detectable. Furthermore, we detected cross-reactivity of the OVA-transgenic CD8+ T cells with a myelin antigen, as treatment with MOG33-55 led to reduced activation motility in the CD8+ T cells. After transfer of in vitro activated OT1 CD8+ T cells in C57Bl/6 mice followed by active immunization with MOG, OT1 CD8+ T cells were detectable in the CNS. In conclusion, our findings indicate that cytotoxic CD8+ T cells are able to recognize antigen within the CNS even under non-inflamed conditions. Furthermore, we detected cross-reactivity of OT1 CD8+ T cells with myelin protein, emphasizing a highly degenerate T cell receptor of CD8+ T cells.

Eva Zindler, Nadia Boldakowa, Josephine Herz and Volker Siffrin have nothing to disclose.

Frauke Zipp received research grants from Teva, Novartis, Merck Serono, and Bayer as well as consultation funds from Johnson & Johnson, Novartis, Ono and Octapharma.

Regulatory T-cells unequally inhibit Ca2+ signalling in conventional T-cells: nonsuppressors determine the treg defect in multiple sclerosis

A. Schwarz, J. Haas, M. Schumacher, D. Pfaff, K. Schumacher, S. Jarius, B. Wildemann

University Hospital Heidelberg (Heidelberg, DE)

Objective: CD4+CD25+FOXP3+ regulatory T cells (Treg) are essential to prevent overshooting and self-destructive immune responses by conventional CD4+ T cells (Tcon). Functional impairment of Treg is a common feature in human autoimmunity, also in multiple sclerosis (MS). Both the mode of action and mechanisms underlying the functional defect of Treg are poorly understood. As sustained elevation of intracellular Ca2+ is indispensable for Tcon activation, we hypothesized that interference with Ca2+ signaling in Tcon represents an essential feature of Treg function. Accordingly, MS-related Treg dysfunction would be characterized by reduced interference with Tcon Ca2+ signaling.

Methods: Peripheral blood specimens from 13 patients with relapsing remitting MS and 19 age-matched controls were analyzed. We used an in-house live-cell imaging protocol to determine the impact of Treg on T-cell receptor-triggered Ca2+ signaling in Tcon at the single-cell level.

Results: We observed that cell contact to Treg rapidly reduced Ca2+ signaling and nuclear translocation of Ca2±driven transcription factor NFAT in Tcon. Notably, the number of Tcon that were suppressed by adjacent Treg was significantly diminished in MS patients. This coincided with distinctive abnormalities in patient-derived Treg, namely, a downscaled Ca2+ signature in preactivated cells, elevated frequencies of constituents failing to inhibit calcium influx in Tcon, and decreased quantities of naïve subtypes.

Conclusion: We conclude that downregulation of Ca2+ signals is a primary mechanism of Treg-mediated Tcon suppression and an increase in nonsuppressing Treg contributes to the Treg defect in MS.

The authors have nothing to disclose.

Funding sources had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the abstract for publication.

Non-classical and intermediate monocytes in relapsing-remitting multiple sclerosis

S.D. Schröder, D.H. Lee, S. Pfeifenbring, C. Stadelmann, R.A. Linker, A. Waschbisch

University Hospital of Erlangen (Erlangen, DE); University of Göttingen (Göttingen, DE)

Monocytes represent a heterogeneous population of primary immune effector cells. Besides classical monocytes that comprise ~90% of circulating monocytes, a population of so-called non-classical/intermediate monocytes, characterized by the expression of the FC γ receptor III CD16, has been identified. Monocytes seem to play an important role in the autoimmune pathogenesis of multiple sclerosis (MS), however, little is known on non-classical monocyte populations and how they contribute to the pathogenesis of the disease. Therefore, we analyzed the frequency and phenotype of monocyte subpopulations and addressed a potential dysfunction of non-classical monocytes in MS.

The frequency of circulating CD14+CD16- classical, CD14++CD16+ intermediate and CD14+CD16++ non-classical monocytes was assessed by flow cytometry in treatment-naïve relapsing-remitting MS patients (n=20) as well as controls (n=42). In addition, monocyte immune phenotyping was performed on cerebrospinal fluid (CSF) and paired blood samples derived from patients with MS (n=10) or non-inflammatory neurological diseases (n=25). Potential differences in monocyte functions were addressed in bead based phagocytosis, production of reactive-oxygen-species (ROS) and CFSE proliferation assays.

Compared to healthy controls, untreated MS patients had lower percentages of circulating CD14++CD16+ intermediate (4.3 ±- 0,85 % vs. 2,2 ± 0,35%) and CD14+CD16++ non-classical monocytes (6,5 ±0,67% vs. 3,3 ±0,48) within the monocyte pool. In contrast to the low frequency of CD16+ monocytes within the periphery, approximately 50% of CD14+ cells within the CSF displayed a CD16+ phenotype. CD16 positive cells were also found in demyelinating MS lesions. Interestingly, RRMS patients had significantly lower levels of CD16+ CSF monocytes compared to patients with non-inflammatory neurological diseases. Functional assays revealed strong differences between classical and CD16+ monocytes concerning phagocytosis and basal ROS production. In contrast to their CD16- counterparts, CD16+ monocytes proved to be highly potent antigen-presenters that evoked strong responses to MBP in T cell proliferation assays.

In conclusion, our data demonstrate an aberrant composition of the peripheral blood and CSF monocyte pool in treatment-naïve MS patients. This may be of biological significance for immune responses to auto-antigens in the periphery and even more important, the immune surveillance of the central nervous system.

This project was funded by the Else-Kröner-Fresenius-Stiftung.

SDS has nothing to disclose.

DHL has received funding for travel and speaker honoraria from Bayer Schering Pharma, Biogen Idec/Elan Corporation, Merck Serono, Novartis, Sanofi-Aventis, and Teva Pharmaceuticals as well as research support from Biogen Idec, Merck Serono, Novartis, and Teva Pharmaceuticals.

SP has nothing to disclose.

CS has nothing to disclose.

RL has received funding for travel and speaker honoraria from Bayer Schering Pharma, Biogen Idec/Elan Corporation, Merck Serono, Novartis, Sanofi-Aventis, and Teva Pharmaceuticals as well as research support from Biogen Idec, Merck Serono, Novartis, and Teva Pharmaceuticals.

AW has received funding for travel or speaker honoraria from Bayer Schering Pharma, Biogen Idec/Elan Corporation, Novartis, Sanofi-aventis/Teva Pharmaceutical Industries Ltd., and Merck Serono.as well as research support from Biogen Idec and Merck Serono.

Peripheral blood depletion-kinetics after S1P-receptor blockade allow better understanding of lymph node access-hierarchy and homing-frequency of human T-cells in MS

M. Mehling, V. Brinkmann, A.-V. Burgener, P. Gubser, L. Kappos, C. Hess

University Hospital Basel (Basel, CH); Novartis AG (Basel, CH)

Background: Naïve and central memory (CM) T cells re-circulate through lymph nodes (LN), whereas T cells with an effector memory (EM) phenotype preferentially screen peripheral tissues. Little is known about the hierarchy of LN-access and homing-frequencies of LN-homing CD4+ and CD8+ naïve and central memory [CM] T cells. Within the LN, T cell migration is directed to cortical sinuses where sphingosine 1-phosphate (S1P) is secreted by the sinus-lining endothelium to support firm attachment of cells and direct egress into the efferent lymph and peripheral blood circulation. Fingolimod blocks T cell egress from LN through functional S1P-receptor antagonism.

Objective: To study (i) depletion-kinetics of T cell naive, CM and EM upon de novo exposure of study subjects to fingolimod and (ii) to evaluate the migration characteristics of T cell subsets towards given chemokines to derive information regarding recirculation-frequencies of LN-homing T cells.

Methods: Ex vivo assessment of the impact of de novo fingolimod-exposure on the number of circulating CD4+ and CD8+ T cell subsets in patients with multiple sclerosis (MS) during a six hours observation period (hourly measurements) by flow cytometry. In vitro characterization of the migration of CD4+ and CD8+ T cells (bulk, naïve, CM and EM T cells) in gradients of chemokines known to mediate homing to LN (CXCL12, CCL19 and CCL21) and towards S1P by the use of a transwell system.

Results: Depletion of naïve CD4+ and CD8+ T cells was observed already after 2 and 3 hours, of CM CD4+ and CD8+ T cells 5 and >6 hours after the first dose of fingolimod, respectively. These depletion-kinetics imply respective LN-homing frequencies of 2.4/d and 1.9/d for naïve CD4+ vs. CD8+ T cells, 0.9/d and <0.9/d for CM CD4+ vs. CD8+ T cells. In vitro, naïve CD4+ and CD8+ T cells more efficiently responded to the LN-homing chemokines CXCL12 and CCL19/20 than their CM counterparts. Contrasting to this, S1P-mediated migration was not different across these T cell subsets.

Conclusion: Together these data indicate that naïve T cells home 2-3 times as often to LN as CM T cells and CD4+ T cells more frequently than CD8+ T cells. This indirectly observed subset-specific homing is compatible with CXCL12, CCL19/20-directed LN-entrance. These differential homing hierarchies reflect an unexplored level at which access of T cells to antigen is regulated and link a quantitative measure to the basic concept of immune surveillance.

This work was supported by a grant from Novartis AG, Basel, Switzerland and by the Swiss Multiple Sclerosis Society.

C.H. and P.G. are supported by grants from the Swiss National Science Foundation (31003A_135677/1 and PB323630-128881). V. Brinkmann is an employees of Novartis AG Basel, Switzerland. L. Kappos has participated in the last 24 months as principal investigator, member or chair of planning and steering committees or advisory boards in corporate-sponsored clinical trials in multiple sclerosis and other neurological diseases. The sponsoring pharmaceutical companies for these trials include Abbott, Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CSL Behring, Elan, Genmab, GeNeuro SA, Genmark, GlaxoSmithKline, Lilly, Merck Serono, Novartis, Novonordisk, Peptimmune, sanofi- aventis, Santhera, Roche, Teva, UCB and Wyeth. L. Kappos has also lectured at medical conferences or in public on various aspects of the diagnosis and management of multiple sclerosis. In many cases these talks have been sponsored by non-restricted educational grants to the Neurology Department of the University Hospital Basel from one or another of the above listed companies. Honoraria and other payments for all these activities have been exclusively used for funding of research of the Neurology Department of the University Hospital Basel. M. Mehlingh and A.-V. Burgener have nothing to disclose.

Peripheral B-lymphocyte subpopulations in relapsing remitting MS - who plays what?

C. Sievers, M. Meira, J. Kuhle, T. Derfuss, P. Fontoura, L. Kappos, R.L.P. Lindberg

Clinical Neuroimmunology (Basel, CH)

Background: B-lymphocytes play an essential role in the pathogenesis of MS. Although the peripheral distribution of B-cell subtypes has already been described, knowledge of possible functional changes is limited.

Objectives: Phenotypic analysis of peripheral B-cell subpopulations from untreated and treated relapsing remitting (RR)MS patients and healthy volunteers (HV).

Methods: B-cell subtypes (naive, memory, plasma cells, plasma blasts, pre- and pro- B-cells) from 17 untreated, 16 natalizumab treated RRMS patients and 8 HVs were analyzed in terms of α-4 integrin (CD49d), HLA-DR and CD86 expression by using flowcytometry.

Results: We found cell type specific changes of HLA-DR, CD86 and CD49d expression in untreated RRMS compared with HVs, although the distribution of B cell subtypes was similar in both groups. HLA-DR expression was unchanged in naïve B-cells, but decreased in memory B-cells and plasma blasts in MS. Interestingly treatment with natalizumab restored the expression of HLA-DR to HV levels. Furthermore, CD49d expression was significantly lower in memory B-cells from untreated RRMS patients compared with HVs, whereas the expression in naïve B-cells and plasma cells was unchanged. Natalizumab further decreased the expression of CD49d in naïve B-cells, while all other subtypes were unaffected.

Discussion and conclusion: Our findings of a lower expression of HLA-DR and CD86 on memory B-cells and plasma blasts from untreated RRMS patients might indicate a diminished antigen presenting capacity of these cells compared with HVs. Both cell types are described as a major source of antibody (Ab) secreting cells in the CNS in MS. A potential association with an altered production of antibodies needs to be further investigated. Furthermore, the expression of CD49d was significantly reduced in these cells in untreated RRMS compared with HVs. However, treatment with natalizumab had no further effects on CD49d expression in memory B-cells or plasma blasts. Our results suggest an early peripheral initiation of Ab secreting B-cells in RRMS. This provides new insights into the function of B-cell subtypes in the immuno pathogenesis of MS.

RLP Lindberg has received research support from Swiss MS Society, Swiss National Science Foundation, European FP6 and IMI JU programs, Roche Postdoc Fellowship Program (RPF-program), unrestricted research grants from Novartis and Biogen.

C. Sievers is supported by RPF program.

M. Meira is supported by SNSF foundation.

J. Kuhle got research support from Novartis, Roche Ltd, Protagen AG.

T. Derfuss served on advisory boards for Novartis, Merck-Serono, Bayer Schering, Biogen Idec, and TEVA. He received travel support from Biogen Idec, Bayer Schering, and Merck Serono. He received research and/or unrestricted grants from Novartis, Biogen Idec, Merck Serono, the German Research Foundation, the Swiss MS Society, and the European Union.

P. Fontura has received funding and travel support in the past from Schering-AG, Biogen Idec, Sanofi-Aventis and Merck-Serono, and is currently an employee of F. Hoffmann-La Roche.

L. Kappos has participated in the last 24 months as principal investigator, member or chair of planning and steering committees or advisory boards in corporate-sponsored clinical trials in multiple sclerosis and other neurological diseases. The sponsoring pharmaceutical companies for these trials include Abbott, Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CSL Behring, Elan, Genmab, GeNeuro SA, Genmark, GlaxoSmithKline, Lilly, Merck Serono, Novartis, Novonordisk, Peptimmune, sanofiaventis, Santhera, Roche, Teva, UCB and Wyeth. He has also lectured at medical conferences or in public on various aspects of the diagnosis and management of multiple sclerosis. In many cases these talks have been sponsored by non-restricted educational grants to his institution from one or another of the above listed companies. Honoraria and other payments for all these activities have been exclusively used for funding of research of his department. Research and the clinical operations (nursing and patient care services) of the MS Center in Basel have been supported by non-restricted grants from one or more of these companies.

Comparison of skin cell immunity in patients receiving treatment with fingolimod and healthy individuals

S.M. Newman, P. Hays, N. Harrington, S. Chin, G. Lee, J. Kelemen, T.M. Harding

The Comprehensive MS Care Center at Island Neurological Associates, P.C. (New York, US); Therapath (New York, US)

Background: Fingolimod (FTY720) is an immunomodulator treatment that has been shown to be a highly effective treatment in relapsing-remitting multiple sclerosis (RRMS). Fingolimod is a sphingosine-1-phosphate receptor 1 antagonist and therefore inhibits sphingosine-1-phosphate-dependent lymphocyte egress from secondary lymphoid tissues, resulting in significant lymphopenia in peripheral blood. Much concern has been expressed regarding decreased immune surveillance and the possibility of an increased incidence of serious infection. Thus far, no increased rate of infection has been reported with fingolimod therapy. To date, no data exists on the effect of fingolimod in skin cell immunity in patients with RRMS.

Methods: Data was reviewed from skin biopsy results from 2 fingolimod treated patients with approximately 13 months of fingolimod exposure and 2 aged matched non-MS patients. Specifically enumeration of CD3, CD4, CD8 positive T cells and CD68 positive macrophage lineage cells, as well as CD4/CD8 ratios and detailed absolute cell counts were evaluated in both immune antigen challenged thigh and control calf specimens.

Results: We have demonstrated in this small population, a similarity in immune composition between fingolimod treated patients and healthy aged-matched non-MS patients. The absolute number of CD3, CD4,CD8 and CD68 cells were not significantly different in calf biopsy samples or in thigh samples where a delayed-type hypersensitivity response was demonstrated. The distribution of immune cells was found to be similar in luminal, perivascular, interstitial, and epidermal areas of both innoculated and non-innoculated sites.

Conclusion: Our findings suggest fingolimod treated patients have a similar immune composition of CD3, CD4, CD8, CD68 skin cells similar to the normal population as well as the ability to mobilize cells to an immune challenge area. It appears fingolimod treatment does not have a profound impact on skin cell immunity as compared to healthy patients. Additionally, a large clinical study would appear to be warranted to evaluate these findings further.

The authors have nothing to disclose.

Laquinimod’s effects on innate immunity directs adaptive T-cell modulation

U. Schulze-Topphoff, M. Varrin-Doyer, A. Shetty, P.A. Nelson, S.S. Zamvil

University of California, San Francisco (San Francisco, US)

Background and Goals: Laquinimod is a novel oral agent with immunomodulatory properties for the treatment of relapsing-remitting (RR) multiple sclerosis (MS) and other autoimmune diseases. In two-phase three clinical trials Laquinimod has shown to be efficacious in reducing disease activity and disease progression. In this study, we investigated laquinimod’s mechanism of action for immune modulation.

Methods and Results: In vivo laquinimod treatment by daily oral gavage prevented chronic EAE in C57Bl/6 (H-2^b) and in DBA/1 (H-2^q) mice, respectively immunized with MOG35-55 and recombinant MOG1-125. Ex vivo FACS analyses revealed that the beneficial effects of laquinimod is associated with reduced CNS infiltration and decreased Th1/Th17 responses. Rather than a direct influence on T cells, we observed that Laquinimod exerts its effect by modulating myeloid APC function. In addition to an induction of type II myeloid cells, we observed a profound reduction of a specific DC population (CD11c+CD4+) in spleen and lymph node of mice treated with laquinimod. CD11c+CD4+ cells are potent immunogenic DCs that participate in the generation of BCL-6 expressing T follicular helper cells (TFH). In vivo laquinimod treatment was associated with decrease frequencies of TFH as compared to vehicle treated controls. TFH are highly activated T helper cells that are needed to regulate antigen-specific B cell immunity and antibody class switch. To further investigate laquinimod’s effect on B cell function, laquinimod was administered in a model of spontaneous “opticospinal” EAE with ectopic lymphoid structures in the CNS, which was obtained by crossing MOG T cell receptor transgenic mice (2D2) with MOG-specific B cell receptor knock-in (Th) mice.

Conclusions: Laquinimod prevents chronic EAE by its direct function on innate immune cells. Laquinimod also affects frequency of an immunogenic DC population, which may affect TFH cells and B cell immunity.

Support for this work was provided to S.S.Z. by the National Institute of Health (NIH) (RO1 AI073737 and RO1 NS063008), the NMSS (RG 4124), Teva Pharmaceuticals, Inc. and the Maisin Foundation.

Follicular T-helper cell activation in progressive multiple sclerosis

J. Romme Christensen, L. Börnsen, R. Ratzer, F. Piehl, M. Khademi, T. Olsson, P. Soelberg Sorensen, F. Sellebjerg

Danish Multiple Sclerosis Center (Copenhagen, DK); Karolinska University Hospital (Stockholm, SE)

Background: Recent pathology studies of multiple sclerosis (MS) indicate a fundamental role of central nervous system (CNS) inflammation in progressive MS. However, it is still debated to what extent systemic inflammation influences CNS inflammation in progressive MS. Based on pathology findings Th17 and follicular T-helper (TFH) cells and activated B-cells are likely to be involved in CNS inflammation.

Aim: To characterise the systemic immune activation in progressive forms of MS and relate the findings to disease progression and markers of CNS inflammation.

Materials and methods: For flow cytometry and gene expression studies on blood and cerebrospinal fluid (CSF) cells we recruited untreated relapsing-remitting (RRMS), secondary progressive (SPMS) and primary progressive MS (PPMS) patients, non-inflammatory neurological controls (NINDs), and healthy controls (HCs). Flow cytometry analysis involved a broad range of T-cell, B-cell, monocyte and dendritic cell phenotypes and statistical analysis was corrected for multiple comparisons by the false discovery rate method. Gene expression analysis was done on isolated peripheral blood mononuclear cells (PBMCs) subsets and CSF cells with corresponding PBMCs.

Results: Flow cytometry studies revealed increased frequency of Th17 interleukin (IL)23-receptor+CD4+T-cells in SPMS and PPMS patients compared to HCs. ICOS+TFH-cells were increased in RRMS and SPMS patients compared to HCs and in SPMS patients ICOS+TFH-cell frequency correlated with disease progression. Th1-like TFH-cells were decreased in RRMS, SPMS and PPMS patients; PPMS patients had an increased frequency of Th17-like TFH-cells compared to HCs. Main findings in B-cells, monocytes and dendritic cells were increased frequencies of plasmablasts and DC-SIGN+ and CD83+B-cells in SPMS patients as compared to HCs, and DC-SIGN+B-cells frequency correlated with disease progression in SPMS. Gene expression analysis of CD4+T-cells showed increased expression of the TFH-cell transcripts IL21 in SPMS patients and IL21-receptor and ICOS in SPMS and PPMS patients compared to HCs. Markers of TFH-cells and plasmablasts had increased expression in CSF-cells from both RRMS and progressive MS patients compared to NINDs.

Conclusion: Our findings emphasise a role of the systemic immune compartment in progressive MS and indicate a central role of activated TFH- and B-cells. The observation may have therapeutic implications for the treatment of progressive forms of MS.

Jeppe Romme Christensen received honoraria for lecturing from Biogen Idec. Lars Börnsen, Rikke Ratzer and Mohsen Khademi report no conflict of interest. Fredrik Piehl has a research grant pending from Biogen Idec; has received payment for development of educational presentations from Biogen Idec, Novartis, and Merck Serono and has had travel expenses reimbursed by Sanofi Aventis, Biogen Idec and Novartis. Tomas Olsson has received honoraria for lectures, participation in advisory boards and unrestricted MS research grants from Biogen Idec, Novartis, Merck, Sanofi Aventis and Bayer. Per Soelberg Sorensen has served on scientific advisory boards Biogen Idec, Merck Serono, Novartis, Genmab, TEVA, Elan, GSK, has been on steering committees or independent data monitoring boards in clinical trials sponsored by Merck Serono, Genmab, TEVA, GSK, Bayer Schering, and he has received funding of travel for these activities; has served as Editor-in-Chief of the European Journal of Neurology, and is currently editorial board member for Multiple Sclerosis Journal, European Journal of Neurology, Therapeutic Advances in Neurological Disorders and; has received speaker honoraria from Biogen Idec, Merck Serono, TEVA, Bayer Schering, Sanofi Aventis, and Novartis. His department has received research support from Biogen Idec, Bayer Schering, Merck Serono, TEVA, Baxter, Sanofi-Aventis, BioMS, Novartis, Bayer, RoFAR, Roche, Genzyme, from the Danish Multiple Sclerosis Society, the Danish Medical Research Council, and the European Union Sixth Framework Programme: Life sciences, Genomics and Biotechnology for health. Finn Sellebjerg has served on scientific advisory boards for Biogen Idec, Merck Serono, Novartis, Sanofi-Aventis and TEVA and as consultant for Biogen Idec and Novo Nordisk; has received support for congress participation from Biogen Idec and Sanofi Aventis; has received speaker honoraria from Biogen Idec, Merck Serono, Bayer Schering, Schering-Plough, Sanofi-Aventis and Novartis; and has received research support from Biogen Idec, Bayer Schering, Merck Serono, Sanofi-Aventis and Novartis.

Impaired suppressor function of CD56bright NK cells in early multiple sclerosis

A. Laroni, E. Armentani, I. Gandoglia, F. Ivaldi, A. Uccelli

University of Genoa (Genoa, IT)

Background: Multiple Sclerosis (MS) pathogenesis might be linked to impaired function of regulatory subsets of immune cells. In vitro, activation of NK cells with IL-27 or IL-2 or treatment with the anti-CD25 monoclonal antibody can induce suppressor function of CD56bright NK cells, with mechanisms which are not fully explained but might involve lytic enzymes such as perforin and granzyme K, while the CD56dim NK cell subpopulation is believed to maintain prominent cytotoxic feature.

Objective: To assess the suppressor function of CD56bright and CD56dim NK cells isolated from subjects with early MS and healthy controls (HC) following activation with IL-12 and IL-15.

Methods: NK cells were negatively isolated from buffy coats of five healthy donors or peripheral blood of five subjects with early MS. NK cells were sorted based on the lack of expression of CD3 and expression of CD56 into CD56bright and CD56dim populations. Isolated cell populations from HC and MS subjects were cultured without activation or under activation with IL-12 and IL-15. Gene expression and cytokine production were assessed at various time-points. Viable cells were then re-sorted and co-cultured with autologous CD3+ T cells to assess suppressor function of NK cells.

Results: No differences in CD56bright/CD56dim proportion were observed between MS subjects and HC. Culture with IL-12 plus IL-15 induced proliferation of CD56bright and CD56dim NK cells from MS subjects and HC. CD56bright NK cells from HC, but not MS patients, were able to suppress autologous T cell proliferation. Interestingly, also CD56dim NK cells displayed some suppressor function in HC. The expression of granzyme K or other cytotoxic enzymes was not impaired in NK cells from HC nor in NK cells from MS subjects.

Conclusions: Our data provide evidence that the suppressor function of CD56bright NK cells is impaired in early MS under multiple activation conditions. Functional studies are required to dissect the mechanism of such suppressor function in HC and the altered response observed in MS. Interestingly, also CD56dim NK cells could be able to suppress autologous T cell proliferation under selected stimuli in HC.

A. Laroni received honoraria for speaking by Biogen-Dompè, received funding for travel fom Bayer-Schering, Biogen-Dompé, Merck Serono, and Sanofi Aventis.

E. Armentani, I. Gandoglia and F. Ivaldi have nothing to disclose.

A. Uccelli received financial support honoraria for consultation, speaking or both at meeting for BiogenIdec, Biogen-Dompè, Genetech, Roche, Allergan, Merck-Serono, Bayer-Schering, Novartis and Sanofi-Aventis. He also received financial support for research form Fondazione Italiana Sclerosi Multipla, Fondazione CARIGE, Fondazione CARIPLO, the Italian Ministry of Health (Ricerca Finalizzata), the Italian Ministry of the University and Scientific Research (MIUR), the “Regione Liguria” (Limonte Project) and Merck-Serono.

Alemtuzumab treatment in MS: how do the Treg cell function and suppressor cytokine mRNA (IL-10, TGF-β, IL-27) levels change? 24-month immunological report during 323 and 324 genzyme trials

S. De Mercanti, S. Rolla, A. Cucci, E. Viglietta, A. Giai Via, D. Taverna, V. Bardina, F. Novelli, F. Piazza, J. Vargas, M. Gibbin, A. Vladic, I. Adamec, V. Brinar, M. Habek, E. Cocco, P. Annovazzi, D. Horàkovà, I. Kovàrovà, M. Clerico, L. Durelli

Universitary Neurological Division (Orbassano, IT); University of Turin (Turin, IT); Zagreb University Hospital Center (Zagreb, HR); Università di Cagliari (Cagliari, IT); Ospedale di Gallarate (Gallarate, IT); General Hospital (Prague, CZ)

Background: Alemtuzumab is associated with a long-standing reduction of T CD4+ subset.

Objective: T cell phenotypic and functional analysis;cytokine, chemokine, and chemokine receptor mRNA level after alemtuzumab in RRMS: A 2-year follow-up.

Methods: Multicenter follow-up of alemtuzumab-treated relapsing-remitting multiple sclerosis(RRMS)patients in CAMMS323 or 324 trials. FACS analysis of Treg, Th1 and Th17 cells. Immunological molecule mRNA levels (chemokines:CCL-11,CXCL-10; chemokine receptors:CCR-4,CCR-6; cytokines:IFNγ,TGFβ,TNFα,IL-1β,IL-2,IL-6,IL-10,IL-12p35,IL-17A,IL-17F,IL22,IL-23,IL-26,IL-27; and T-bet,RORγt,Foxp3) quantified by TaqMan® low density array (TLDA) real-time polymerase chain reaction in whole blood. Treg suppressor activity assessed at M12 and M24 by ELISPOT on PBMC depleted of CD25highT cells and activated with myelin basic protein (MBP) or anti-CD3-CD28. Definitions: Baseline: before first alemtuzumab course; Month (M) 6,M12,M18,M24: 6,12,18 or 24 months after first alemtuzumab course. M12 was before second alemtuzumab course. The relative mean difference between baseline and subsequent timepoints estimated through the formula: (Timepoint-Baseline)/Baseline, and significance of the differences tested.

Results: Twenty-nine patients from 6 European sites. After alemtuzumab, CD4+ lymphocytes decreased from 45 to 14%. Within this population, Th17 increased at M18 while no significant variation were observed in Th1 cells. T-bet and IL-23 decreased, while Foxp3, TGFβ IL-10 and IL-27 increased from M6 to M24. Treg cell specific suppressive function on MBP auto-reactive Th1 and Th17 cell increased only at M24, whereas the number of Treg cells and their overall suppressor function did not significantly change during the follow-up. Four Relapses were observed in 3 patients. Severe autoimmune disease occurred in no patient; slight changes of thyroid function in 3.

Conclusions: The overall alemtuzumab-induced CD4+ lymphocyte depletion might relate to the reduction of MS disease activity. The increase of suppressor cytokines IL-27, IL-10, TGFβ and of MBP-specific Treg suppressor function could have resulted in the decrease of T-bet, modulating the anti-CNS pathogenicity of Th1 and Th17 cells. The lack of an increase of the overall Treg suppressor function might allow the development in some patient of non MBP-specific autoimmunity. Immunological data will be correlated with relapse or thyroid function abnormality occurrence in individual patients.

Study supported by: Genzyme Corporation.

Interferon-b therapy differently modulates Toll-like receptor 7 and 9- induced differentiation of B lymphocytes in multiple sclerosis patients

M. Severa, E. Giacomini, F. Rizzo, V. Annibali, M.E. Remoli, S. Romano, A. Fornasiero, V. Riccieri, M. Salvetti, E.M. Coccia

Istituto Superiore di Sanità (Rome, IT); S. Andrea Hospital (Rome, IT); La Sapienza University (Rome, IT)

The implication of B lymphocytes in MS immunopathology is increasingly recognized. Hence, several clinical studies have demonstrated the effectiveness of B cell depletion in the treatment of MS and, as a consequence, studying B cell responses may have very important therapeutic implications for this disease.

Interferon-b (IFN-b) is considered one of the main therapy for patients with relapsing-remitting MS for its effectiveness in reducing relapse frequency and progression towards disability. Effects likely mediated by the immunomodulatory activity that this cytokine exerts on different cell types, even if the molecular basis of the therapeutic response to IFN-b is still not well understood.

In an attempt to evaluate whether B cell responses would be dysregulated in MS patients and whether IFN-b therapy would modulate them, proliferation and differentiation of this cell type was investigated upon stimulation with TLR7 and 9, two pattern recognition receptors selectively expressed by B lymphocytes.

Interestingly, the frequency of TLR7-induced Immunoglobulin (Ig) M and IgG-secreting cells was significantly lower in MS patients than healthy donors (HD), showing a specific defect in TLR7 responses, while no differences were observed upon TLR9 ligation. Surprisingly, IFN-b therapy replenished this deficiency and selectively induced the production of Abs and the maturation of these cells only upon TLR7 triggering.

Accordingly, the release of IL10 and IL6, two cytokines involved in B cell maturation and differentiation, was significantly lower in TLR7-treated PBMC from therapy-free MS patients than that from HD. This defecting cytokine production was restored following IFN-b administration.

Thus, to characterize the mechanisms underlying the differential responsiveness to TLR triggering in MS patients, we measured by real time RT-PCR the expression of TLR7 and TLR9 genes in PBMC from HD and MS individuals. It was of great interest to find that MS PBMC display a clear defect in TLR7 expression, which was re-established by IFN-b therapy, in spite of a comparable TLR9 transcription.

In conclusion, these results suggest that IFN-b treatment can exert its therapeutic effects also by acting on the differentiation and/or activation status of B lymphocytes and in particular by modulating the responsiveness to TLR7 and, in turn, B cells functions.

This work was supported by FISM grant (#2009/R/7 to EMC).

The authors have nothing to disclose.

Epstein-Barr virus seroprevalence in multiple sclerosis patients: a systematic review and meta-analysis

J. Pakpoor, G. Disanto, U.C Meier, G. Giovannoni, S.V Ramagopalan

University of Oxford (Oxford, UK); Barts and The London School of Medicine and Dentistry (London, UK)

Background: Epstein-Barr virus (EBV) infection is widely considered to be a risk factor for multiple sclerosis (MS). A previous meta-analysis estimated an odds ratio (OR) for MS in individuals seronegative for EBV of 0.06. Given the potential importance of this finding, we aimed to establish a more precise OR for adult and paediatric onset MS in EBV seronegative individuals. Further, we investigated whether EBV seropositivity increases with distance from the equator in light of the well known association between MS prevalence and latitude.

Methods: PubMed and EMBASE searches were undertaken and 22 adult and 3 paediatric studies were selected for inclusion. ORs were calculated using a fixed effects model. Sub-group analysis based on method of EBV detection was performed. Nineteen studies were used for analysis to investigate the relationship between latitude and EBV seroprevalence using logistic regression.

Results: The OR for developing adult MS in EBV seronegatives was 0.18 (95% CI 0.13-0.26) and for paediatric MS was 0.18 (95% CI 0.11-0.30). We did not identify significant study heterogeneity for the adult analysis, p= 0.47, but heterogeneity was significant for paediatric analysis, p= 0.03. Sub-group analysis of EBV detection method showed that studies which used immunofluoresence generated an OR= 0.07 (95% CI 0.03- 0.16); those that used enzyme-linked immunosorbent assay (ELISA) OR= 0.33 (95% CI 0.22-0.50) and studies which used ELISA and immunofluoresence OR= 0.00 (95% CI 0-0.43).

We also found that the proportion of EBV positive individuals is positively associated with latitude independently of MS status (OR=1.06, 95%CI=1.02-1.09, p=0.002). The effect of latitude remained upon inclusion of mean age and sex ratio, and by performing a subgroup analysis of studies using ELISA.

Conclusions: Sensitivity and specificity of the assay used to measure EBV antibody titres has an influence on the association between MS and EBV. Looking at all studies where two independent methods are used and therefore likely to be the most robust, EBV appears to be present in 100% of MS patients. This has implications for future studies of EBV in MS. We also show that EBV seroprevalence in both MS patients and controls is positively associated with latitude. Thus, latitude related factors may be implicated in the immune response to/ability to detect EBV. MS patients without EBV infection, if they truly exist, should be studied in more detail.

This work was funded by the Medical Research Council [GRANT NUMBER G0801976]. No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The authors have nothing to disclose.

Mycobacterium avium subsp. Paratuberculosis and multiple sclerosis in Sardinian patients

E. Cocco, J. Frau, D. Cossu, G. Coghe, L. Lorefice, G. Fenu, M. Melis, M.R. Murru, C. Sardu, L. Sechi, M.G. Marrosu

Centro Sclerosi Multipla (Cagliari, IT); University of Sassari (Sassari, IT); University of Cagliari (Cagliari, IT)

Background: The etiology of MS remains unknown, although it is commonly believed that genetic susceptibility combined with exposure to environmental factors are required for its development. MS triggering factors, on a permissive genetic background, may be infectious antigens; among various candidates Mycobacterium avium subspecies paratuberculosis (MAP) has been recently found in association with MS in Sardinia (Cossu D, et al 2011).

Aims of the study were to look for a confirmation regarding the association between MAP and MS in Sardinia and evaluate its role in MS clinical and therapeutic features.

Methods: We included in the study 351 MS patients and 264 demographically and ethnically healthy controls (HC). The presence of MAP was analyzed in blood obtained by each individual, searching MAP DNA by IS900 specific PCR and Abs against MAP2694 protein by ELISA.

Differences in MAP presence between MS patients and HC were evaluated. MS patients were categorized on the basis of positivity of MAP DNA, MAP2694 Abs, positivity for both or negativity. Differences between groups were calculated regarding the following variables: gender, age at onset, actual age, duration of disease, course, EDSS score, previous or actual immune-modulant/immunosuppressive therapy, presence of relapse or steroids therapy at time of sample, presence of oligoclonal bands in the CSF.

Results: The MAP DNA and MAP2694 Abs were detected respectively in 51 (14.5%) and 97 (27.6%) MS, in 6 (2.6%) and 10 (3.8%) HC. Considered together 131 (37.3%) MS and 16 (6%) HC were positive for at least one MAP parameter (p= 0.0000001). Patients positive and negative for MAP did not differ regarding age, age at onset, gender, disability, previous or actual immunomodulant or immunosuppressive therapies. A trend toward a higher number of patients with MAP positivity was present in patients with oligoclonal bands (p=0.07). The relapsing course showed a trend of higher presence of MAP respect progressive one (p=0.07).

Discussion: The association of MAP and MS in Sardinia has been confirmed in our study; in fact MAP was detected in 37.3% vs 3.8% of HC. Patients with relapsing course and oligoclonal bands in CSF seem to be more frequently positive to MAP suggesting a possible role of the infective agent in inflammatory process. In conclusion MAP is a good candidate in MS pathogenesis at least in Sardinia and further studies in other populations are needed to confirm its role in MS.

The authors have nothing to disclose regarding this work. The research has been fund by Sardinian Region Legge 7 project.

Cocco E, Marrosu MG, Lorefice L, Fenu G, Frau J and Coghe G, Melis M, have received travel grants from Merck Serono, Sanofi Aventis, Biogen Idec, Novartis, Teva, Bayer.

Sechi L, Cossu D and Valera P have nothing to disclose.

Cocco E and Marrosu M have received consultancy fees, speaker fees or honoraria from Merck Serono, Sanofi Aventis, Biogen Idec, Novartis, Teva, Bayer.

The risk of developing MS following vacination for hepatitis B, Human papilloma virus and influenza including H1N1

A. Holstebroe, J.L. Frederiksen

Glostrup Hospital (Glostrup, DK)

Introduction: Multiple Sclerosis (MS) is serious autoimmune neurological disease. One leading theory of its initiation is the process of viral mimicry by foreign antigens. The immunological actions of infections and vaccine are quite similar. Thus, it is compelling to study if there are any serious adverse effects when given vaccines. Do vaccines induce MS or its borderline diseases, or do they higher the risk of relapse among already known MS-patients?

Materials and methods: This systematic literature review based on relevant Mesh Words in PubMed examined the adverse effects of the four most common vaccines given to adults, namely against the common flu, HPV, HBV and H1N1.

Results: The available studies were examined and analysed, and there was found to be no significant association between the vaccine against HPV, common flu and H1N1 when considering it’s effects as initiator of MS nor its effect on relapse.

Most studies concerning the HBV-vaccine concluded that the vaccine was safe, but because of one particular well founded study (Hernan et al.) that found a significantly increased association between the HBV-vaccine and MS initiation, the case is not completely closed.

Discussion: Because of some of the vaccines being very new, more studies on a bigger scale have to be conducted, though this is expensive considering examining relatively rare autoimmune events as MS.

Conclusion: There is still much more to gain from a cost/benefit perspective, when administering these four vaccines to patients being at risk for MS or having MS. In general there is still much to improve when considering scientific practice when handling autoimmune adverse effects, such as standardized protocols and better association considerations. We propose to establish a huge international database registering prospectively patients having one of these vaccinations to establish evidende if these patients have a higher risk of developing MS than the generlat population and if these vaccinations increase the risk of relapses in patients with MS.

The authors have nothing to disclose.

Progressive multifocal leukoencephalopathy in natalizumab-treated multiple sclerosis patients in Spain: more than expected?

T. Castillo-Trivino, R. Arroyo, C. De Andres, R. Fernandez-Bolaños, A. Garcia-Merino, L. Landete, M. Menendez, P. Oliva, A. Oterino, M.D. Paramo, A. Saiz, J. Olascoaga

Hospital Universitario Donostia (San Sebastian, ES); Hospital Clinico San Carlos (Madrid, ES); Hospital General Universitario Gregorio Marañon (Madrid, ES); Hospital de Valme (Sevilla, ES); Hospital Puerta de Hierro (Madrid, ES); Hospital Dr. Pesset (Valencia, ES); Hospital Alvarez-Buylla (Mieres, ES); Hospital Central de Asturias (Oviedo, ES); Hospital Universitario Marques de Valdecilla (Santander, ES); Hospital Universitario Virgen Macarena (Sevilla, ES); Hospital Clinico (Barcelona, ES)

Background: Progressive multifocal leukoencephalopathy (PML) is a recognized complication of natalizumab treatment in multiple sclerosis (MS) patients. The incidence of this complication might be higher than what initially reported with an estimate risk of 2.4/1000. More than two years of treatment, positivity for JC virus antibodies in blood and previous immunosuppression are the main risk factors and allow clinicians to stratify the individual risk.

Objective: To quantify the natalizumab-associated PML incidence in MS patients in Spain and to analyze clinical and demographic characteristics of these patients.

Methods: All MS patients diagnosed with natalizumab-associated PML from June 2007 (treatment availability) to February 2012 were identified and clinical and demographic characteristics such as gender, age at PML onset, number of natalizumab infusions, disease duration, previous received treatments and final expanded disability status scale (EDSS) were collected. In all cases determination of JC virus (JCV) antibodies seropositivity was evaluated.

Results: In this period of time twelve cases (58.3% females) of natalizumab-associated PML occurred in Spain out of a total of 3,050 treated patients (3.93/1000, 95% CI [2.03, 6.86]), all of them positive for JCV antibodies. Mean age (±SD) and disease duration at PML onset were 44.6 years (±5.0) and 15.3 years (±8.2), respectively. Four patients received previous immunosuppression and one received bone marrow transplantation. Median (range) number of natalizumab infusions and viral DNA copies in CSF were 27 (13-49) and 462 (0-650000) respectively. Two patients required brain biopsy for diagnosis. Three patients (25%) had gadolinium-enhancing lesions in brain MRI scans at diagnosis. Except for one, all patients were treated with PLEX (3-8 sessions), some received mefloquine and mirtazapine. Cidofovir was used in three patients. Nine patients (75%) developed immune reconstitution inflammatory syndrome (IRIS), seven of them (77.8%) associating gadolinium-enhancing lesions on brain MRI scans. Mean (±SD) time to IRIS and median (range) EDSS in the last visit were 1.9 months (±1.2) and 6.5 (4-10), respectively. Three patients died (25%).

Conclusions: In Spain the incidence of natalizumab-associated PML is higher than expected. The main risk factor is the positivity for JCV antibodies in blood while previous immunosuppression might play a minor role.

The authors have nothing to disclose.

Study of the JC virus presence in multiple sclerosis patients treated with natalizumab

M.I. Dominguez-Mozo, M. García-Montojo, V. De las Heras, M.A. García-Martínez, A. Arias-Leal, I. Casanova, R. Álvarez-Lafuente, R. Arroyo

Hospital Clínico San Carlos (Madrid, ES)

Background: Around two hundred of cases of progressive multifocal leukoencephalopathy (PML) have been reported in the last years among the multiple sclerosis (MS) patients treated with natalizumab. Thus, the international scientific community should determine the best way to detect the virus in order to study the evident increased viral reactivation throughout the treatment in every patient, which causes an increase of the PML risk with longer treatment duration.

Objective: To analyze the effect of natalizumab treatment over the active replication of JCV in MS patients.

Methods: Peripheral blood mononuclear cells (PBMCs), serum and urine samples obtained from 88 MS natalizumab treated-patients from 9 to 36 months were tested for JC virus at different points: basal visit without treatment (BV), visit at the third month of treatment (V3) and every three months thereafter. DNA was analyzed by real-time PCR (qPCR) with one set of primers and probe amplifying agnoprotein-VP1 region.

Results: We observed a significant increase of viral prevalence in urine between the basal visit and the other ones starting V9: e.g., the prevalence at BV was 54.5% vs. 77.3% at V9 (p=0.0002). In the group of patients with positive and negative urine samples throughout the treatment (68%) a significant difference was observed between the viral load at the diverse points of treatment (p=0.000002), but not in patients with permanent presence of DNA of JC virus in urine. Only one patient was always negative during the twelve months of treatment. Finally, we also detected the virus in PBMCs and in serum samples in 13.6% and 21.6% of patients respectively, all of them positives in urine at those points of treatment.

Among these patients were two cases of PML at month 22 and 47 with natalizumab. The first one had been treated previously with immunosuppressive therapy but not the second one. The JC virus was detected in urine by qPCR intermittently throughout the treatment and in PBMCs, serum, urine and cephaloraquid liquid at the time of PML diagnosis.

Conclusions: There seems to be an increase of JC virus prevalence in urine of MS natalizumab treated patients, and a viral reactivation in serum and PBMCs. Therefore, this qPCR could be an useful tool for detecting the virus along the treatment, and to identify those MS patients with a higher PML risk when we reach a better understanding of the JC virus behaviour.

MI Dominguez-Mozo, M García-Montojo, MA García-Martínez, A Arias-Leal and R Álvarez-Lafuente have nothing to disclose.

I Casanova receives honoraria for speaking and participating as investigator in clinical trails for Biogen, Novartis, Bayer-Schering.

R Arroyo receives honoraria for speaking and participating as investigator in clinical trails for Biogen, Novartis, Bayer-Schering.

V de las Heras receives honoraria for speaking and participating as investigator in clinical trails for Biogen, Novartis, Bayer-Schering.

An alternative assay to assess the anti-JC virus status in MS patients

C. Warnke, M. Pawlita, T. Dehmel, H.-P. Hartung, H. Wiendl, BC Kieseier, O. Adams

Uniklinikum Düsseldorf (Düsseldorf, DE); German Cancer Research Center (Heidelberg, DE); University of Münster (Münster, DE)

Background: Progressive multifocal leukoencephalopathy (PML), caused by an infection with the JC virus (JCV), is a side effect seen in patients with multiple sclerosis (MS) treated with natalizumab. For PML risk stratification a test to determine the anti-JCV antibody status (Stratify JCV®) has been introduced recently. However, this test has not yet been validated against alternative assays; as such its validity remains speculative.

Objective: To determine anti-JCV and anti-BK virus (BKV) antibody status and antibody levels in a German cohort of patients with and without MS applying an alternative assay, and to compare the results with those from Stratify JCV®.

Methods: Patients with MS and known anti-JCV antibody status from the Stratify JCV® protocol (n=175), and matched non-MS-controls (n=165) were included. Sera were tested in a two-step capture ELISA, using JCV- or BKV-VP1 fused to glutathione S-transferase (GST) as antigen, and BKV-VP1 or JCV-VP1 fused to maltose binding protein as blocker for the detection of anti-JCV or anti-BKV antibodies, respectively.

Results: The alternative assay exhibited a trend to a lower positivity for anti-JCV antibodies compared with the Stratify JCV® protocol (53% vs. 62%; p=0.104). While the seropositivity for anti-JCV antibodies increased with age, the antibody levels were unchanged across the age groups. In contrast, for anti-BKV antibodies, a decrease both in seropositivity and antibody levels with age was noted. Interestingly, in line with this observation a strong negative correlation between the seropositivity for JCV and BKV was found.

Conclusions: Our alternative two-step GST capture-ELISA confirms previous reports on the prevalence of anti-JCV antibodies in MS patients; our assay may actually be more virus-type specific, with similar sensitivity. This is of importance, as we noted a strong negative correlation between the seropositivity for JCV and BKV. Clearly, further studies are warranted to evaluate the potential of this method in predicting the risk of polyomavirus-associated complications in patients treated with immunosuppressive drugs.

C.W. is funded by an ECTRIMS fellowship stipend. M.P. has received travel expenses for attending meetings from Johnson and Johnson. T.D. has received travel expenses for attending meetings from Novartis Pharma GmbH and Bayer HealthCare AG. H-P.H, B.C.K and H.W have received honoraria for lecturing, travel expenses for attending meetings and financial support for research from Bayer Health Care, Biogen Idec, Merck Serono, Novartis, Sanofi Aventis, and TEVA. O.A. has nothing to disclose.

Anti-JC virus antibody prevalence in the JCV Epidemiology in MS trial

C. Bozic, M. Subramanyam, D. Paes, S. Richman, T. Plavina, A. Zhang, B. Ticho

Biogen Idec Inc. (Weston, US)

Background: Progressive multifocal leucoencephalopathy (PML) is caused by JC virus (JCV). Using STRATIFY JCV (2 step anti-JCV assay), anti-JCV seroprevalence in multiple sclerosis (MS) patients is approximately 50%-60%. Reported seroprevalence varies, depending upon assay, sample size, patient ages, and country, and requires confirmation in a multinational MS population.

Objectives: To describe the prevalence of anti-JCV antibodies in geographically diverse cohorts of MS patients.

Methods: JCV Epidemiology in MS (JEMS) is a cross-sectional, multicentre, multinational, epidemiological study designed to enrol ≥2000 MS patients in Europe, Canada, and Australia. Patients with a diagnosis of MS (any type or treatment) are eligible to participate. Anti-JCV antibody testing is performed centrally using STRATIFY JCV. Anti-JCV antibody prevalence is estimated as the percentage of patients with detectable anti-JCV antibodies, and prevalence by geographic area, demographics, disease characteristics, and treatment history are also evaluated. Descriptive statistics and chi-square test are used.

Results: In an interim analysis, 6367 patients had available results. The average age was 43 years, median MS disease duration was 10 years, 71% were women, 95% were white, and 79% had a relapsing form of MS. The overall prevalence for anti-JCV antibodies was 57.8% (95% confidence interval: 56.5%-59.0%). Prevalence ranged from approximately 50% to 60%; Australia had the lowest (49%) and Portugal had the highest (69%) seropositivity. Anti-JCV antibody prevalence increased significantly by age, from 48% in 15- to 29-year-old patients to 65% in ≥50-year-old patients (P<0.0001). Females had a significantly lower anti-JCV antibody prevalence than males (56% vs 62%; P<0.0001 [age adjusted]). No significant associations were observed between anti-JCV antibody status and race, MS disease duration, MS type, MS therapy use, or MS treatment duration.

Conclusions: The overall anti-JCV antibody seroprevalence of 57.8% is consistent with seroprevalences of 50%-60% from prior reports using this assay. Anti-JCV antibody prevalence differed significantly by age and gender. While geographic differences were observed, seroprevalence was generally consistent with the 50%-60% range observed in previous studies. No significant associations were observed between anti-JCV antibody status and MS disease duration, MS type, MS therapy use, or MS treatment duration. Final results will be presented.

Supported by Biogen Idec Inc. and Elan Pharmaceuticals, Inc.

All authors are Biogen Idec employees.

Ex vivo and in vitro expression of the neuroinflammatory endogenous protein MSRV-Env (Envelope protein of Multiple Sclerosis Associated Retrovirus) from human endogenous type W elements and interaction with Epstein-Barr virus in multiple sclerosis

N. Morel, R. Germi, O. Casez, O. Epaulard, L. Grossi, L. Morand, M. Zaccaria, H. Perron, P. Morand

University Hospital (Grenoble, FR); UMI3265 UJF-EMBL-CNRS (Grenoble, FR); GeNeuro (Geneva, CH)

Background: Multiple Sclerosis (MS) is a multifactorial disease, involving environnemental factors probably interfering with elements of genetic susceptibility. Among environmental factors, the Epstein-Barr Virus (EBV) may be involved through the transactivation of the Multiple Sclerosis Associated Retrovirus (MSRV) which belong to the Human Endogenous type W elements (HERV-W). As a consequence, the neuroinflammatory envelope protein MSRV-Env, with superantigen and Toll-Like Receptor 4 agonist properties, is expressed in permissive cells. Since detected ex vivo in MS patients and post mortem in MS lesions (Multiple Sclerosis Journal, 2012), such a transactivation of this endogenous retroviral protein could fuel the neuroinflammation.

Methodology: MSRV-Env expression was analysed ex vivo by specific PCR and RT-PCR, in peripheral blood mononuclear cells (PBMC) of relapsing-remitting MS patients (in acute relapse before intravenous corticosteroids treatment), and compared with healthy controls. Interaction with EBV was studied in vitro on MS B-lymphocytes cultures, immortalized by the EBV B95-8 strain, and through quantification of HERV-W/MSRV-env cellular RNA, protein expression and eventual release of extracellular MSRV virions.

Principal findings: HERV-W sequences of MSRV-env type were detected in PBMC of all healthy controls and MS patients. Interestingly, the number of MSRV-env DNA copies in PBMC was significantly higher in MS patients than in healthy controls. Similar results were obtained at the RNA level, despite a smaller number of currently tested samples (in progress).

Furthermore, intracellular HERV-W RNA of MSRV-env type was transcribed at high levels in all B-cell lines, either obtained from MS patients and immortalized by the EBV B95-8 strain or spontaneously obtained from infectious mononucleosis patients.

Conclusion: Our results suggest a potential role of MSRV and EBV in multiple sclerosis, possibly through an activation of MSRV-Env expression by the Epstein-Barr virus. Research work is continuing to evaluate expression of MSRV-Env at the protein level by Fluorescence Activated Cell Sorter and to elucidate precise mechanisms involved in potential MSRV and EBV interaction.

The authors have nothing to disclose.

Vitamin A not associated with exacerbations in multiple sclerosis

T.F. Runia, W.C.J. Hop, Y.B. De Rijke, D. Buljevac, R.Q. Hintzen

Erasmus MC (Rotterdam, NL)

Background: Th17 cells are a subset of CD4+ T cells that produce IL-17. They are effector cells implicated in many autoimmune disorders including multiple sclerosis (MS). Although the exact role for Th17 cells in the pathogenesis of MS remains to be fully elucidated, they are probably involved in the development of relapses in MS.

Vitamin A is a multifunctional vitamin, that has been shown to inhibit Th17 formation in vitro, synergistic with 1,25-diOH-vitamin D. By inhibiting Th17 formation, vitamin A can be hypothesized to be 1) lower in patients than in healthy controls, and 2) associated with relapse risk in patients. We therefore performed two studies: a case-control study of vitamin A levels, and a longitudinal study of vitamin A levels in relapsing-remitting MS (RRMS) patients to investigate the association between vitamin A and relapse risk. We also investigated the association between vitamin A and D.

Methods: All-trans retinol levels were measured in 31 RRMS patients and 29 age and sex matched controls. T test was used to compare serum all-trans retinol concentrations of patients and controls.

Furthermore, a prospective longitudinal study in 73 RR MS patients was performed, in which blood samples for vitamin A measurements were taken every eight weeks. Associations between all-trans retinol concentrations and relapse rates were calculated using Poisson regression with the individual serum levels as time-dependent variable. Associations between vitamin A and vitamin D were calculated using linear regression.

Results: Mean vitamin A levels were a little lower in patients (2.16 µmol/l) than in controls (2.44µmol/l), but this difference was only borderline significant (p=0.05).

In the longitudinal study, during follow-up (mean 1.7 years), 58 patients experienced a total of 139 relapses. Monthly moving averages of all-trans retinol levels were categorized into tertiles: a low (<2.9 µmol/l), medium (2.9-3.7 µ;mol/l) and high level (>3.7 µmol/l). Relapse rates were not associated with serum all-trans retinol levels (p>0.2), in univariate nor in multivariate analysis.

Serum concentrations of all-trans retinol and 25-OH-vitamin D were correlated in a linear manner (R=0.23, p<0.001).

Conclusion: Vitamin A is slightly lower in patients than in controls but is not associated with relapse risk in RRMS patients. We found an association between vitamin A and D levels in the RRMS patients, probably explained by dietary products that contain both fat-soluble vitamins.

The authors have nothing to disclose.

High dietary salt aggravates autoimmune neuroinflammation via induction of Th17 cells

A. Manzel, M. Kleinewietfeld, J. Titze, D. Hafler, D. Müller, R. Linker

University Erlangen-Nuremberg (Erlangen, DE); Yale School of Medicine (New Haven, US); Vanderbilt University (Nashville, US)

Over the past half century there has been a marked increase in the incidence of multiple sclerosis (MS), a neuroinflammatory disease that may partly be driven by the novel Th17 subset of helper T cells. This rapid epidemiological development must be related to changes in the environment. Excess salt (sodium chloride, NaCl) uptake increased along with consumption of “western diet” and processed foods predominantly in developed countries, where MS incidence is high.

To explore if salt-load may influence autoimmune neuroinflammation, we investigated effects of a high salt diet (HSD) in murine myelin oligodendrocyte glycoprotein (MOG) induced experimental autoimmune encephalomyelitis (EAE) which mimics aspects of human MS.

Salt-load led to a significant exacerbation of MOG-EAE. While mice on a HSD (4%NaCl) suffered from moderate paraparesis mice on a normal diet (0.4% NaCl) only developed gait ataxia (n = 12 p.g., p < 0.05). This finding was corroborated by histological analyses. Spinal cord lesions from mice in the HSD group showed greater infiltration of Mac3+ macrophages/microglia (n = 5 p.g. p < 0.05) and CD3+ T cells (n = 6-7 p.g., p < 0.05). Analysis of gene expression under HSD revealed a shift towards Th17 driven autoimmunity. Expression of IL-17A, the prototypic Th17 effector cytokine, but not interferon-γ was elevated in the spleen (n = 5-6 p.g. p < 0.05) and spinal cord (n = 5-6 p.g. p < 0.05) of mice on a HSD. In vitro restimulation of MOG primed splenocytes in medium with a surplus of 40 mM NaCl increased IL-17A but not interferon-γ secretion into the culture supernatant. Flow cytometric analysis of the same MOG restimulated splenocytes showed increased frequencies of CD4+IL17A+ cells (n = 4-5 p < 0.01). To dissect the NaCl effect on a cellular level, we performed in vitro T cell polarization assays. Increasing medium NaCl concentration by 40 mM boosts Th17 cell polarization of naïve T cells either stimulated by CD3 antibody or antigen presenting cells up to 5-fold (n = 3 p.g. p < 0.001). These findings were confirmed in human T cell culture where the increased induction of Th17 cells under high salt conditions is specifically regulated on the molecular level.

Our findings demonstrate that a high salt diet exacerbates MOG-EAE by boosting Th17 cells and suggest that excess sodium uptake may be considered as a new dietary factor possibly influencing complex autoimmune diseases such as MS.

A.M., M.K., J.T., D.M. and D.H. have nothing to disclose.

R.L. has received funding for travel and speaker honoraria from Bayer Schering Pharma, Biogen Idec/Elan Corporation, Merck Serono, Novartis, Sanofi-Aventis, and Teva Pharmaceuticals as well as research support from Biogen Idec, Merck Serono, Novartis, and Teva Pharmaceuticals.

Smoking as a risk factor for multiple sclerosis

J. Salzer, M. Nyström, G. Hallmans, H. Stenlund, G. Wadell, P. Sundström

Umeå University (Umeå, SE)

Objective: The aim of this study was to investigate the effects of laboratory defined tobacco use on the risk for multiple sclerosis (MS) using prospectively collected biobank blood samples.

Methods: This nested case-control study was performed in northern Sweden, and used two population-based biobank cohorts to identify blood samples collected before MS onset (n=192, controls matched 2:1). Levels of cotinine, a recognized biochemical marker for tobacco use, were measured using an immunoassay. Self-reported questionnaire data on tobacco use was collected retrospectively. The risk for MS was estimated using matched logistic regression.

Results: Elevated cotinine levels (≥10 ng/ml) was associated with a significantly increased risk for MS, (OR 1.5, 95% CI 1.0-2.1). This association was most pronounced in young individuals (below median age at blood sampling, <26.4 years), (OR 2.2, 95% CI 1.3-3.8). No dose-response effect was evident. The findings were replicated by retrospective smoking questionnaire data.

Conclusions: This study confirms that smoking is associated with an increased risk for MS. It has the advantage of using analyses of cotinine levels in samples collected several years before disease onset, thus excluding any risk for recall bias and minimizing the risk for reversed causation. A more pronounced effect in young subjects may indicate that smoking related immunological events contributing to the development of MS may occur early in life.

Dr. Salzer received financial support for this study from Biogen Idec, Merck Serono and The Swedish Association of Neurologically Disabled, received honoraria from Merck Serono for a lecture, and received support to travel to scientific meetings from Biogen Idec and Merck Serono.

Biomed. Sci. Nyström received support to travel to a scientific meeting from Novartis.

Ph.D. Stenlund, Dr. Hallmans and Dr. Wadell report no disclosures.

Dr. Sundström served on the scientific advisory board for Novartis, and received support to travel to scientific meetings from Biogen Idec and Novartis.

Epstein-Barr virus and vitamin D as risk factors for multiple sclerosis

J. Salzer, M. Nyström, G. Hallmans, H. Stenlund, G. Wadell, P. Sundström

Umeå University (Umeå, SE)

Objective: To examine the association between the antibody reactivity towards Epstein-Barr Nuclear Antigen-1 (EBNA-1) as well as five different EBNA-1 domains and the risk for multiple sclerosis (MS), and to examine whether 25-Hydroxyvitamin D (25[OH]D) status interact with, or confound these associations in prospectively collected blood samples.

Methods: In this nested case-control study two population-based biobanks with 291,500 samples from 164,000 persons collected since 1975 in the northern half of Sweden were used to identify prospectively collected blood samples from MS cases (n=192, controls matched 2:1). Antibody reactivity towards EBNA-1 and specific EBNA-1 domains and 25(OH)D levels were measured using ELISAs, and the risk for MS was analyzed using matched logistic regression.

Results: A higher risk for MS was observed across antibody reactivity tertiles to EBNA-1 and the EBNA-1(402–502) and (385–420) fragments (p trend < 0.001). In young individuals (below median age at sampling, <26.4 years) the association between antibody reactivity tertiles towards EBNA-1 and the EBNA-1 fragments and MS risk was more pronounced. No signs of confounding or interaction were found, although a negative correlation in young individuals between 25(OH)D and antibodies to EBNA-1, as well as to the two fragments showing the strongest association to MS risk, was observed.

Interpretation: We confirm that antibodies towards EBNA-1, and specifically the EBNA-1(385–420) fragment constitute robust risk markers for MS. The finding of a negative correlation between 25(OH)D and antibody reactivity to EBNA-1 in young suggest that 25(OH)D status might influence the immune response towards EBV, and thereby modulate MS risk.

Dr. Salzer received financial support for this study from Biogen Idec, Merck Serono and The Swedish Association of Neurologically Disabled, received honoraria from Merck Serono for a lecture, and received support to travel to scientific meetings from Biogen Idec and Merck Serono.

Biomed. Sci. Nyström received support to travel to a scientific meeting from Novartis.

Ph.D. Stenlund, Dr. Hallmans and Dr. Wadell report no disclosures.

Dr. Sundström served on the scientific advisory board for Novartis, and received support to travel to scientific meetings from Biogen Idec and Novartis.

Smoking and alcohol are related to multiple sclerosis severity, a case-control study

A. Lucenti, A. Ivashynka, O. Raymkulova, M. Leone, P. Naldi

Multiple Sclerosis Center, AOU Maggiore della Carità (Novara, IT); Univercity Piemnonte Orientale (Novara, IT)

Objectives: The influence of smoking on the clinical course of multiple sclerosis (MS) is controversial. We aimed to evaluate the relationship of smoking and alcohol use with the severity of the disease.

Methods: We included 259 consecutive MS patients with disease duration >1 year and an age range of 20-69 years. Smoking and alcohol history were evaluated with the European Prospective Investigation into Cancer and Nutrition project (EPIC) questionnaire, after informed consent. Severity of MS was estimated through the Multiple Sclerosis Severity Score (MSSS). Patients were examined at outpatient’s department during the follow-up visits.

Results: Patients were 168 women and 91 men. Clinical forms were 188 relapsing-remitting (RR), 47 secondary progressive (SP), and 24 primary progressive (PP). 145 patients had ever smoked (86 women, 59 men), whereas 114 never smoked (82 women, 32 men). 185 were current drinkers (111 women, 74 men), 51 non-drinkers (43 women, 8 men), and 23 ex-drinkers (14 women, 9 men). Mean age and mean disease duration were not different between smokers and non-smokers (p=0.07; 0.64), drinkers and non-drinkers (p=0.65; 0.06). The median and interquartile range of MSSS in smokers was 3.17 (1.69-6.0), not significantly different than in non-smokers (2.33; 1.26-5.24). The median and interquartile range of MSSS in current drinkers (2.82; 1.28-5.15) was not significantly different than in non-drinkers (3.17; 1.77-6.66). In another statistical approach, we compared the extreme quartiles of the MSSS score distribution in our patients (score <2 vs. ≥6). Smokers were 40 in the lower and 37 in the higher quartile, non-smokers were 48 and 26; the odds ratio (OR) of being in the worst MSSS quartile was 1.7 (0.9-3.3). After correction for alcohol use, the Mantel-Haenszel OR for smokers was 2.0 (1.0-4.0). Drinkers were 69 in the lower and 39 in the higher quartile, non-drinkers were 14 and 17; the OR of being in the worst MSSS quartile was 0.5 (0.2-1.1). After correction for smoking, the OR was 0.4 (0.2-1.0). After stratification (reference category = non-smokers/non-drinkers), the OR was highest in smokers/non-drinkers (8.8; 1.7-45.8), followed by smokers/drinkers (1.4;0.6-3.1) and non-smokers/drinkers (1.0; 0.4-4.0).

Discussion: This study shows that smoking is a risk factor for severity, whereas alcohol use may be a protective factor.

The authors have nothing to disclose.

Serum 25-hydroxyvitamin D concentrations among patients in BENEFIT predicts conversion to multiple sclerosis, MRI lesions, and brain volume loss

A. Ascherio, K. Munger, C. Simon, L. Kappos, C.H. Polman, M.S. Freedman, H.-P. Hartung, D.H. Miller, X. Montalbán, G. Edan, F. Barkhof, R. White, R. Sandbrink, C. Pohl

Harvard University (Cambridge, US); University Hospital Basel (Basel, CH); VU Medical Center (Amsterdam, NL); Ottawa Hospital Research Institute (Ottawa, CA); Heinrich-Heine University (Düsseldorf, DE); UCL Institute of Neurology (London, UK); Hospital Universitari Vall d’Hebron (Barcelona, ES); CHU-Hopital Pontchaillou (Rennes, FR); The University of British Columbia (Vancouver, CA); Bayer HealthCare (Berlin, DE)

Preliminary evidence suggests that vitamin D insufficiency in clinically isolated syndromes (CIS) is a risk factor for conversion to multiple sclerosis (MS) and may adversely affect MS progression. We examined these hypotheses in BENEFIT, a trial of interferon β-1b (IFNB-1b) in patients with CIS. The study comprised a placebo-controlled phase of up to 2 years or earlier diagnosis of MS and a follow-up study of up to 5 years where all patients were offered IFNB-1b.

A total of 333 patients with 25-hydroxyvitamin D (25[OH]D) measurements at 6 and 12 months after randomization were analyzed. Multivariate regression models were used to estimate the relation between 25(OH)D levels and 1) time to conversion to clinically definite MS (CDMS) or McDonald MS (MDMS); 2) sustained increase in disability (EDSS); and 3) MRI outcomes (cumulative number of active lesions [CNAL] and rates of percent change in T2 lesion volume [VCT2] and brain volume [PCBV]. Deseasonalized 25(OH)D level was treated as a time-dependent variable, using the average of 6- and 12-month levels for clinical and MRI outcomes after 12 months. Results are adjusted for initial treatment (IFNB-1b or placebo), age, gender, number of T2 lesions at baseline, and monofocal vs multifocal onset.

CIS patients with higher 25(OH)D levels were less likely to convert to MS (hazard ratio [HR] corresponding to a 50 nmol/L increase in 25(OH)D 0.40 [95% confidence interval (CI), 0.20-0.77; p=.005] for CDMS and 0.30 [CI, 0.16-0.56; p≤001] for MDMS). In analyses by quintiles, HR in the highest quintile (average 25(OH)D > 58 nmol/L) was 42% lower than in the lowest quintile (average 25(OH)D < 33 nmol/L) for conversion to CDMS, and 60% lower for conversion to MDMS. These associations were similar across treatment arms, suggesting an additive effect of 25(OH)D and IFNB-1b (HR for conversion to MDMS for IFNB-1b and a 50 nmol/L increase in 25(OH)D was 0.2). 25(OH)D levels were also associated with lower CNAL (HR 0.46; CI, 0.28-0.76), and slower increase in VCT2 (p=.007) and PCBV (p=.03), but not with sustained changes in EDSS. Similar associations for all end points were observed in men and women.

These results provide evidence that low serum 25(OH)D levels are an important risk factor for conversion from CIS to MS and for long-term progression. They suggest that vitamin D supplementation in combination with IFNB-1b may improve outcomes in CIS, which needs to be prospectively tested in controlled studies.

Dr. Alberto Ascherio, Kassandra Munger and Claire Simon have no conflicts of interest to disclose.

The University Hospital Basel has received research support for activities of Ludwig Kappos with Actelion, Bayer HealthCare Pharmaceuticals, Bayer Schering-Pharma, Biogen-Idec, BioMarin, CLC Behring, Elan, Genmab, Genmark, GENeuro SA, GlaxoSmithKline, Lilly, Merck Serono, Novartis, Novonordisk, Peptimmune, Sanofi-Aventis, Santhera, Roche, Teva, UCB, and Wyeth. Dr. Kappos has received research support from the Swiss MS Society, the Swiss National Research Foundation, the European Union, the Gianni Rubatto, Novartis, and Roche Research Foundations.

Chris H. Polman has received compensation for activities with Biogen Idec, Schering AG, Teva Neuroscience, EMD Serono, Novartis, GlaxoSmithKline, Inc., UCB Pharma, AstraZeneca Pharmaceuticals, Roche Diagnostics, Actelion and Antisense Therapeutics as a consultant or speaker. Dr. Polman has received research support from Biogen Idec, Schering AG, GlaxoSmithKline, Inc., Novartis, EMD Serono, and Teva Neuroscience.

Mark S. Freedman has received compensation for activities with Bayer Healthcare, Genzyme Corporation, EMD Canada, Novartis, Sanofi-Aventis Pharmaceuticals, Inc., Celgene, Glycominds, and Teva Canada Innovation.

Hans-Peter Hartung has received compensation from Biogen-Idec, TEVA, Sanofi-Aventis, Novartis Pharma, Merck Serono, and Bayer Schering Pharma for consulting services.

David H. Miller has received compensation for activities with Biogen Idec, GlaxoSmithKline, Novartis and Bayer Schering Pharma as a consultant and member of the advisory board. Dr Miller has research support from GlaxoSmithKline, Biogen Idec, and Novartis.

Xavier Montalbán has received compensation for activities with Bayer Schering Pharma, Biogen Idec, EMD Serono, Genentech, Inc., Genzyme, Novartis, Sanofi Aventis, Teva Neuroscience, and Almirall.

Gilles Edan has received compensation for activities with Biogen-Idec and Teva as a consultant. Dr Edan has received compensation for serving on the advisory board for BENEFIT and LFB. Dr Edan has received research support from Serono.

Frederik Barkhof has received compensation for activities with Novartis, Biogen Idec, Sanofi-Aventis, Roche, Merck-Serono, and Bayer-Schering as a consultant.

Rick White has served as a consultant for and received financial compensation from Bayer Schering Pharma.

Rupert Sandbrink and Christoph Pohl are salaried employees of Bayer Healthcare Pharmaceuticals. Rupert Sandbrink holds stocks and stock options for Bayer AG.

Supported by: Bayer HealthCare Pharmaceuticals, Inc.

The association between sunlight hours and month of birth in multiple sclerosis patients across UK regions

L.A.E. Matthews, M. Oppenheimer, A. Cavey, N. Evangelou, C. Constantinescu, N. Robertson, J. Zajicek, R. Nicholas, M. Boggild, G. Giovannoni, O. Gray, S. Hawkins, P. Rothwell, J. Palace

University of Oxford (Oxford, UK)

Introduction: A spring peak and autumn nadir in the births of people who develop MS has previously been reported with a postulated link to maternal vitamin D levels. Our objective was to investigate the date of birth associations in a large UK-wide MS cohort with regional and annual sunlight data.

Methods: The dataset comprised the dates of birth of 18176 people with MS, from regionally defined cohorts scattered across the UK; Cardiff, Nottingham, London (Imperial College and Barts and The London hospitals), Liverpool, Belfast and Plymouth, as well as the national Risk Sharing Scheme cohort covering 72 UK centres including Scotland. UK Office of National Statistics data was used to adjust for the expected birth rate of the general population.

Historical climate data from the UK Met Office documenting the average sunlight hours per region of the country was used to divide the UK into two areas: one of relatively high annual sunlight exposure (>1400 hours) and one of relatively low (≤1400 hours).

Years with high and low variability in sunlight exposure were also indentified using a ratio of summer: winter sunlight hours.

Results: For the whole cohort there was a spring peak and autumn nadir in the number of MS births when compared with the general population, with an observed/ expected ratio of 1.12 in April and 0.85 in November, corrected p<0.01 (Chi-square).There was greater variability in the frequency of MS births in the South and East (SE) region of the UK (with higher sunlight exposure; n=10433) with a coefficient of variation (CoV) of 9.5% compared with the region of low annual sunlight in the North and West (n=6433) with CoV of 6.1%. There were 6.2% more MS births in May in the SE and 15.7% less in November, p<0.05.

Within this SE region the years in the upper quartile of summer: winter sunlight hours (n=1133) had a trend towards a higher variability in the month of MS birth with a CoV of 15.2%, compared with the lower quartile (n=1677) that had a CoV of 10.1%, p=0.12.

Conclusion: The spring peak and autumn nadir in the frequency of MS births is confirmed in a large UK cohort. This pattern is greater in the SE of the UK that receives higher summer sunlight, and in years with a higher summer/ winter sunlight variability that equated to years with good summers.

These results support previous suggestions that greater maternal sunlight exposure may be a protective factor against the risk of developing MS.

LM is funded by the Medical Research Council, UK. MO, AC, NE, CC, NR, JZ, RN, MB, GG, SH and PR have no conflicts of interest to declare in relation to this abstract.

OG has received unrestricted educational grants from Biogen Idec and Merck Serono.

JP has received support for scientific meetings and scientific advisory honorariums from Merk Serono, TEVA, Biogen, Bayer Schering and Novartis, and unrestricted grants. JP has held MS society grants and is a clinical lead for the UK DOH RSS.

Immune system modulation by UV radiation in multiple sclerosis: effects of urocanic acid

J. Correale, M. Farez

FLENI (Buenos Aires, AR)

Background and goals: One of the most striking features of multiple sclerosis (MS) epidemiology has been its striking geographic prevalence distribution. Ultraviolet (UV) radiation, which correlates closely with latitude, has been the most favored explanation for this phenomenon. Urocanic acid (UCA) absorbs UV radiation in the skin. A trans-isomer formed from histidine in the upper epidermis, it is converted to a systemically-distributed cis-isomer on exposure to sunlight, conferring immunosuppression. The goal of this study was to study the role of cis-UCA in MS pathogenesis.

Methods: Ninety-two patients with relapsing remitting MS were examined, 58 patients in remission and 32 during exacerbations. Forty age and gender-matched healthy subjects served as controls. Trans and cis-UCA plasma levels were measured by HPLC. MBP- and MOG- peptide-specific T cell lines were stimulated with cognate Ags in presence and in the absence of cis-UCA, after which IL-4, IL-10, IL-6, IL-8, IL-17, TGF-b, TNF-a, IFN-g, ERK 1/2, and JNK1/2 were measured using ELISA. CD4+CD25+FoxP3+ regulatory T cells were assessed by flow cytometry.

Results: Plasma levels of cis-UCA were lower in MS patients compared to controls (p= 0.0001). No differences in plasma trans-UCA levels were found, nor was there any association between disease activity and cis-UCA plasma levels.Stimulation of MBP- and MOG-specific T cells with specific Ags in the presence of cis-UCA, significantly increased IL-10, and inhibited IFN-g production. No effect was observed on secretion of other cytokines investigated. PBMCs cultured in the presence of cis-UCA increased CD4+CD25+FoxP3+ regulatory T cell percentages. Finally, dendritic cells (DCs) cultured in the presence of cis-UCA reduced Ags presentation capacity.

Tests using serotonin receptor agonists and antagonists with specificity for various 5HT receptor subtypes revealed cis-UCA activated the 5-HT2a receptor to suppress autoimmune responses. Finally, increase in phosphorylated forms of ERK 1/2 and JNK2 was observed in response to cis-UCA treatment in T cells, an effect abrogated by specific inhibitors such as SP6000125, and PD98059, suggesting strong activation of these pathways.

Conclusions: In addition to Vitamin D, cis-UCA is another UV-mediated immunomodulator binding to the 5HT2a receptor. Immunosuppressive effects are mediated, by ERK1/2 and JNK2. Cis-UCA effects may help explain increased prevalence of MS observed at higher latitudes.

JC is a board member of Merck-Serono Argentina, Novartis Argentina, Biogen-Idec LATAm, and Merck Serono LATAM.

Dr Correale has received reimbursement for developing educational presentations for Merck-Serono Argentina y LATAM.

Biogen –Idec Argentina, and TEVA-Tuteur Argentina as well as professional travel accommodations stipends.

MF has nothing to disclose.

The effects of reactive oxygen species on axonal transport: implications for multiple sclerosis

C. Fang, G. Banker, D. Bourdette

Oregon Health & Science University (Portland, US)

Reactive oxygen species (ROS) released by microglia and other inflammatory cells may cause axonal degeneration in multiple sclerosis (MS) and other neurologic diseases. Despite this, there is a paucity of experimental data concerning the effects of ROS on axonal transport. We used live cell imaging to examine the effects of hydrogen peroxide on the axonal transport of mitochondria and Golgi-derived vesicles in cultured rat hippocampal neurons.

Hydrogen peroxide rapidly inhibited axonal transport, hours before any detectable changes in mitochondrial morphology or other signs of axonal degeneration. Mitochondrial transport was affected earlier and was more severely inhibited than the transport of Golgi-derived vesicles. Anterograde vesicle transport was more susceptible to hydrogen peroxide inhibition than retrograde transport. Following removal of hydrogen peroxide, vesicle transport completely recovered in both directions while mitochondrial transport was only partially recovered. By using Xona chamber, we locally applied hydrogen peroxide to axonal region without affecting somato-dendritic area. Interestingly, axonal application of hydrogen peroxide inhibited transport, suggesting that the effects were not simply a result of nerve cell death. These results indicate that inhibition of axonal transport is an early consequence of exposure to ROS and may contribute to subsequent axonal degeneration.

We used this cell culture model to identify pathways that may protect the transport system against ROS damage. We focused our initial work on nicotinamide mononucleotide adenylyltransferase (NmNAT), the NAD+ synthesizing enzyme that appears to be responsible for protecting axons against Wallerian degeneration in Wlds mutant mice. We demonstrated that over-expressing NmNAT1 protects axons of hippocampal neurons against hydrogen peroxide-induced degeneration, as previously described by others (Press and Milbrant 2008). However, in neurons over-expressing NmNAT1, hydrogen peroxide caused a profound, irreversible inhibition of mitochondrial transport. Thus our data suggest that NmNAT protects axons against the later, downstream effects of hydrogen peroxide, perhaps by altering mitochondrial calcium dynamics, but does not protect against damage to the axonal transport machinery.

ROS can selectively alter axonal transport and this may contribute to progressive axonal degeneration in MS.

Cheng Fang, Dennis Bourdette and Gary Banker have nothing to disclose.

Microglia responses during early pathological changes in the cuprizone animal model for multiple sclerosis

S. Diederichs, T. Clarner, J. Goldberg, T. Reiss, K. Berger, M. Viktor, C. Beyer, M. Kipp

Institute of Neuroanatomy (Aachen, DE)

Background: Small clusters of stressed oligodendrocytes (ODC) and activated microglia can frequently be found in the normal appearing white matter (NAWM) of multiple sclerosis (MS) patients. These early lesions develop without the involvement of invading T cells. Why some of these early lesions resolve, whereas others develop into full blown active destructive lesions is not known but microglia cells are thought to actively modulate lesion progression. The toxic murine demyelination model “cuprizone” (cu) offers a unique tool to investigate the underlying mechanisms of lesion progression in the presence of an intact blood brain barrier (BBB).

Objective: To study the relevance of microglia in MS lesion development.

Methods: Mice were fed 0.2% cu for up to 5wks and cellular stress responses, microglia morphology and myelin status in different white matter tracts were analyzed by means of immunohistochemistry (IHC). Additionally, we performed a detailed region specific gene expression study focusing on microglia-related genes in the white matter tracts corpus callosum (CC) and the hippocampal fimbria (HF).

Results: Cu treatment induced ODC apoptosis and microglia activation in both regions included in the current study to a similar extent, but just the CC progressed to an acutely demyelinated white matter lesion. In contrast, the HF appeared normal in routine myelin stains. The morphological appearance of microglia cells did not reveal overt differences in both regions. However, parallel gene expression studies disclosed significant differences in the expression levels of microglia markers known to be involved in the modulation of innate immune responses. Interestingly, higher expression levels of M2-related microglia transcripts were found in those regions which are resistant to the cu challenge.

Conclusion: Our studies clearly show that cu induces global ODC stress and microglia activation but this ODC stress progresses in a highly region specific manner to an actively demyelinated white matter lesion. Our gene expression studies suggest that regional differences in microglia activity modulate lesion development. Although further electrophysiological studies have to reveal whether the myelin in cuprizone resistant brain areas is functional intact, the therapeutic manipulation of microglia cells is a promising strategy in the future.

The authors have nothing to disclose.

Functional genomic analysis of cuprizone-induced demyelination reveals the importance of oligodendrocytes for MS lesion formation

K. Berger, B. Krauspe, W. Baumgartner, M. Rickert, T. Clarner, J.-P. Buschmann, C. Beutner, B. Linnartz, H. Neumann, L. Valliéres, C. Beyer, M. Kipp

Institute of Neuroanatomy (Aachen, DE); RWTH (Aachen, DE); University Bonn (Bonn, DE); Laval University Hospital Research Center (Quebec, CA)

Background and goals: There is a growing body of evidence that focal microglia activation within the so called “normal appearing white matter” of MS patients precedes inflammatory demyelinating events. Our understanding which factors contribute to microglia cell activation is scant at best, but recent reports suggest that oligodendrocytes might be involved in focal microglia cell activation. The aim of this study was to analyze the contribution of oligodendrocyte stress for microglia activation/attraction.

Methods: We used the toxic demyelination model cuprizone to study a possible association between oligodendrocyte stress and microglia cell activation, both histopathological hallmarks in the early phase of this model. Animals were fed cuprizone for up to one week and the expression of various chemokines in the isolated corpus callosum was analyzed by gene array studies and rt-PCR. The chemokine transcription pattern was compared to oligodendrocyte stress and microglia activation on the histological and ultrastructural level. The cellular source of chemokines was addressed by in situ hybridization and subsequent immunohistochemical studies. CCL2, CCL3 and CXCL10-deficient animals were included, to study the relevance of these chemokines for early microglia activation. Various in vitro experiments (ELISA, migration assays, phenotyping and phagocytosis assays) were performed to study the direct relevance of oligodendrocyte stress for microglia activation and attraction.

Results: We were able to show that short-term cuprizone feeding leads to heavy oligodendrocyte stress and apoptosis followed by microglia accumulation. Gene expression studies revealed that the expression of a distinct number of chemokines is induced after cuprizone treatment; predominantly Cxcl10. Loss-of-function studies showed that CXCL10 plays a role in microglia attraction evident after cuprizone feeding. By means of in situ hybridization we could show that stressed oligodendrocytes express Cxcl10 mRNA after cuprizone treatment and in vitro experiments clearly showed that oligodendrocyte-derived CXCL10 attracts microglia cells. Furthermore oligodendrocyte-derived CXCL10 induces a proinflammatory phenotype (M1) in cultured microglia cells, but do not influence phagocytosis activity.

Conclusion: Our results suggest that oligodendrocytes actively participate in the initiation of neuroinflammatory processes and thus might be important players in the regulation of MS lesion development.

This study was supported by a START grant (TC) of the Faculty of Medicine (RWTH Aachen University; Germany).

Disclosure: All authors state no conflict of interest.

Olfactory bulb volume and neuropsychological performance, fatigue severity and depression in multiple sclerosis patients

T. Yonekawa, I.K. Penner, Y. Naegelin, J. Kuhle, C. Stippich, E.-W. Radue, L. Kappos, T. Sprenger, O. Yaldizli

Kyushu University (Fukuoka, JP); University of Basel (Basel, CH)

Objective: To correlate the olfactory bulb (OB) volume with neuropsychological performance, depression and fatigue severity in multiple sclerosis (MS) patients.

Methods: The data presented are part of an ongoing prospective study on the pheno-genotype characterisation of MS patients including 169 subjects who are undergoing neuropsychological testing and MRI assessment. Data of 21 patients had to be excluded due to insufficient image quality for the delineation of the OB. Thus, this analysis includes the data of 148 patients (64.9% women; mean age 47.9±10.9 years; 75% relapsing-remitting MS; 18.9% secondary-progressiv (SP) MS; 5.4% primary-progressive (PP) MS; mean disease duration 16.7±9.3 years; mean Expanded Disability Status Scale (EDSS) Score 3.3±1.8; 38.5% with an optic neuritis in past medical history; 34.5% high school degree or university graduates). All patients were investigated with regard to cognition, fatigue severity and depression. The test battery included the Paced Auditory Serial Addition Test 3s, Symbol Digit Modalities Test, Verbal Fluency Test, Interference Test and Delayed Recall Test. Cognitive fatigue was assessed by using the Fatigue Scale for Motor and Cognitive Functions. Depressive symptoms were assessed by using the German version of the Center for Epidemiologic Studies Depression Scale. Brain MRI was obtained on a 1.5T MRI system (Siemens). OB volume was calculated based on the standardized segmentation of the OB between the crista galli and the rostral level of corpus callosum on T1 weighted MPRage images.

Results: Mean total OB volume was 184.1±39.9 mcl. Normalised OB volume did not correlate with age, neuropsychological performance, fatigue severity, depression, EDSS or conventional imaging markers of the disease burden such as T1 black hole or T2 lesion volume. Moreover, normalised OB volume was not associated with gender, school education, use of disease modifying drugs, optic neuritis in the past medical history or the disease course. Only in the subgroup of patients with progressive MS (SPMS+PPMS) normalised OB volume was correlated with the depression score (Bonferroni-corrected p-value=0.03; ρ=-0.51).

Conclusions: The OB volume seems not to be related to cognitive dysfunction, fatigue severity or depression in a non-selected MS population. Significance of the correlation between OB volume and depressive symptoms in patients with progressive forms of disease needs further confirmation.

TY has nothing to disclose. IKP has received research grants from Bayer AG Switzerland and the Swiss Multiple Sclerosis Society; has received honoraria forserving as speaker at scientific meetings, consultant, and as member of scientific advisory boards for Actelion, Bayer Pharma AG, Biogen Idec, Merck Serono, Roche, and Teva Aventis. YN has nothing to disclose. JK has nothing to disclose. CS has nothing to disclose. EWR has nothing to disclose. LK has participated in the last 24 months as principal investigator, member or chair of planning and steering committees or advisory boards in corporate-sponsored clinical trials in multiple sclerosis and other neurological diseases. The sponsoring pharmaceutical companies for these trials include Abbott, Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CSL Behring, Elan, Genmab, GeNeuro SA, Genmark, GlaxoSmithKline, Lilly, Merck Serono, Novartis, Novonordisk, Peptimmune, sanofi- aventis, Santhera, Roche, Teva, UCB and Wyeth. LK has also lectured at medical conferences or in public on various aspects of the diagnosis and management of multiple sclerosis. In many cases these talks have been sponsored by non-restricted educational grants to my institution from one or another of the above listed companies.

Honoraria and other payments for all these activities have been exclusively used for funding of research of my department. Research and the clinical operations (nursing and patient care services) of the MS Center in Basel have been supported by non-restricted grants from one or more of these companies. TS has consulted for Eli Lilly, Biogen, Mitsubishi Pharma.

Europe and Allergan. Travel support: Pfizer, Bayer Schering, Eli Lilly, Allergan.

OY has received lecture fee from Teva and Bayer Schering which was exclusively used for funding of research and continuous education in the Department of Neurology at the University Hospital Basel.

Reproducibility of surface-based laminar measures of T2* relaxation decay in the cortex at 7 Tesla MRI

S.T. Govindarajan, M.P. Sormani, J. Cohen-Adad, C. Mainero

Athinoula A. Martinos Center for Biomedical Imaging (Charlestown, US); University of Genoa (Genoa, IT)

Background: We recently demonstrated the ability of a surface-based technique to study the spatial distribution of cortical demyelination in MS using quantitative measures of T2* relaxation decay from multi-echo 7 Tesla (T) data. Surface-based methods allow T2* to be sampled as a function of cortical depth to provide a laminar analysis of cortical MS pathology.

Objective: We report the scan-rescan variability of surface-based laminar analysis of T2* at various depths from the pial surface in healthy individuals. In addition to comparing changes in the whole cortex, we focused reproducibility measures on individual cortical regions as defined by Freesurfer.

Methods: We scanned 8 subjects (mean±SD age = 38.5±8.7 years) twice, a week apart, on a 7 T Siemens system to acquire multi-echo T2*-weighted Fast Low Angle Shot (FLASH) spoiled gradient-echo images (resolution = 0.33 × 0.33 × 1 mm³), and once on a 3 T MR system to acquire T1-weighted data for cortical surface models reconstruction using FreeSurfer. T2* maps were calculated voxelwise using Levenberg–Marquardt non-linear regression, and registered to the cortical surfaces. T2* was then sampled along the cortex at 25%, 50%, and 75% depth from the pial surface. Scan-rescan reproducibility was assessed using coefficients of variations (COV), SD/mean of each couple (scan-rescan) of measurements, at each cortical depth. Heterogeneity of T2* at each cortical depth across the cortex was assessed using Kruskal-Wallis test.

Results: T2* is significantly heterogeneous across regions (p<0.001). Across the entire cortex (whole cortex mean± SD T2* = 30.27±1.53ms, 32.16±1.42ms and 33.69±1.46ms at 25%, 50% and 75% depths respectively), and in most individual cortical regions T2* is higher at 75% and 50% than at 25% depth, reflecting the greater degree of myelination in deeper cortical layers. On average T2* is 1.6ms greater at 50% relative to 25% depth and 2.9ms greater at 75% relative to 25% depth (p<0.001), and there is no difference between hemispheres (p=0.27). Scan-rescan COVs across cortical regions range from 0.5% to 6.15% (average COV across regions, across depths = 1.64%). COVs between sessions for whole cortex T2* at 25%, 50% and 75% depths were 0.86%, 1.79% and 0.83%.

Conclusion: Surface-based laminar T2* measures are a reproducible tool that can prove useful to study in vivo the distribution of cortical lesions and the presence of a gradient in MS cortical pathology, as suggested by post-mortem studies.

Ms Govindarajan and Dr Cohen-Adad have nothing to disclose.

Dr Sormani served as a consultant for Biogen Idec, Merck Serono, Synthon, Actelion, and received payment for lectures from Teva, Merck Serono, Biogen Idec.

Dr Mainero served as a consultant for Biogen Idec.

Brain distribution of BZM055, an analog of fingolimod (FTY720), in human

G. Tamagnan, A. Tavares, O. Barret, D. Alagille, J. Seibyl, K. Marek, P.R Maguire, E. Briard, R. Schmouder, R. Behrje, D. Jennings

Molecular NeuroImaging (New Haven, US); Institute for Neurodegenerative Disorders (New Haven, US); Novartis (Basel, CH)

FTY720 fingolimod has recently been approved as the first oral treatment for relapsing MS and shown to reduce rate of clinical relapses (or to reduce disease activity) and brain atrophy (Kappos, et al., 2010). In order to understand how CNS penetration influences the efficacy of the compound, we need to study the distribution in-vivo in man. A radio-iodine labeled analogue, [123I]BZM055 (radioactive half life 13.2 hr), has been developed to enable clinical imaging of the in-vivo distribution. We report here on the dynamic brain uptake and washout of [123I]BZM055.

Methods: Four healthy male volunteers aged 32 ± 8 were enrolled in the study. Subjects were studied up to 3.5 hr post-injection on day 1 (2 sessions of 3 x 30min with 30min rest) and again on day 2 between 22 and 26 hr post-injection (3 sessions of 1 x 60min with 30min rest). A [123I]BZM055 dose of 4.3 ± 0.2 mCi was administered intravenously as a slow bolus. All imaging was performed on a Prism 3000XP SPECT scanner. Venous plasma samples were obtained throughout the study and HPLC separation determined the parent and [123I]BZM055-P content. Images of the brain were reconstructed using iterative algorithms, motion corrected, decay corrected and attenuation corrected and subsequently aligned onto the subject MRI.

Results: [123I]BZM055 was safe and well tolerated in all subjects. Radiolabelling with Iodine-123 resulted in high specific activity and allowed a microdosing injected mass < 1 microgram.

Images showed an initial grey matter activity concentration between 0.82 and 1.12 kBq/mL, which increased to 1.30 - 1.75 kBq/mL on day 2. Parent [123I]BZM055 represents approximately 70-80% of the total activity concentration in plasma at 15 min post-injection. By 2 hr post-injection, the ratio of metabolite and parent was stable (20-30% of parent) over the duration of the study (up to 26 hr).

Conclusions: [123I]BZM055 is a suitable SPECT imaging agent and can be used to demonstrate brain penetration of FTY720 in man. Plasma metabolite data suggest that [123I]BZM055 is metabolized to BZM055-P in man.

The authors have nothing to disclose.

Improved longitudinal gray matter atrophy assessment via a combination of SIENA and a 4-dimensional hidden Markov random field model

M.G. Dwyer, N.P. Bergsland, R. Zivadinov

Buffalo Neuroimaging Analysis Center (Buffalo, US)

Background: SIENA and similar techniques have demonstrated the utility of performing direct measurements as opposed to post-hoc comparison of cross-sectional data for the measurement of whole brain (WB) atrophy over time. However, gray matter specific (GM) atrophy is now widely recognized as an important component of MS disease progression, and is being actively evaluated in clinical trials. Unfortunately, fundamentally cross-sectional approaches like SIENAX are still widely used to measure GM changes, leading to potentially less accurate results and more analysis failures. Direct measures of GM change with advantages similar to SIENA have been lacking.

Objective: To create and validate a robust and easily-implemented method for more direct longitudinal analysis of GM atrophy.

Methods: We built on the basic halfway-registration and scaling factor estimation components of SIENA, combining them with the raw output of FMRIB’s FAST tissue segmentation tool to correct for brain extraction and positioning errors. In addition, we modified FAST itself to incorporate a 4th dimension in its hidden Markov random field model, in order to directly represent time and correct for joint misclassification errors. Like SIENAX, the output provides individual GM volumes, but with significantly reduced error between timepoints. To evaluate our method, we compared it to a conventional SIENAX-based approach on a dataset of 206 CIS patients with baseline and 1 year followup scans. Both approaches received identical input images and were subjected to the same QC procedures. We also compared each of the two approaches to independent output from SIENA and FIRST.

Results: Both approaches yielded similar mean GM changes: -0.93% for our approach and -0.91% for SIENAX. Using our proposed approach to measure WB atrophy, correlation with SIENA was r=0.61, compared to r=0.45 for standard SIENAX (p=0.02 comparing r-values). GM-specific atrophy measured with our method also significantly correlated with changes in FIRST-derived deep GM volumes, whereas traditional SIENAX measures did not. Additionally, the std. deviation for GM measurements with our approach was 1.92, compared to 2.94 for SIENAX. Finally, 12 cases failed QC checks for SIENAX, whereas only 4 failed with the proposed approach.

Conclusion: The proposed measurement approach improves on the standard SIENAX technique, and may provide more precise data and additional statistical power for studies evaluating GM atrophy.

Michael Dwyer and Niels Bergsland have nothing to disclose.

Robert Zivadinov received personal compensation from Teva Neuroscience, Biogen Idec, EMD Serono and Questcor Pharmaceuticals for speaking and consultant fees. He received financial support for research activities from Biogen Idec, Teva Neuroscience, Genzyme, Bracco, Questcor Pharmaceuticals and EMD Serono.

Longitudinal changes of cerebral glutathione levels in patients with secondary progressive multiple sclerosis may reflect the clinical course of disease progression

I.-Y. Choi, P. Lee, D. Denney, S. Lynch

University of Kansas Medical Center (Kansas City, US); University of Kansas (Lawrence, US)

Glutathione (GSH) is critical in cerebral antioxidant defense, with increased oxidative stress leading to decreases in brain GSH levels. We have reported lower levels of GSH in the brains of multiple sclerosis (MS) patients, indicating the presence of oxidative damage and associated cell death in secondary progressive MS (SPMS). Thus, GSH may serve as a potential in vivo biomarker of the underlying pathophysiology of SPMS, one involving oxidative stress-induced neurodegeneration. The focus of the present study was on the association between GSH and disease progression.

In this longitudinal study, we followed up 13 SPMS patients and 12 age- and sex-matched normal controls between the ages of 28 and 65 with EDSS ranging from 4.0-8.5, who participated in our initial study of GSH conducted over 3 years ago (3.7 ± 0.3 years, mean ± SD). The neuroimaging protocol was identical to our initial study and employed a specially designed MR chemical shift imaging of GSH. Levels were measured in three brain regions: mainly frontal; mainly parietal; and fronto-parietal regions. Comparison between SPMS patients and controls showed a reduction of GSH at Time 2 in both frontal and fronto-parietal regions, but not the parietal region, which is consistent with our initial findings. The MS group also showed a greater reduction in GSH levels from Time 1 to Time 2, compared to controls. Changes in GSH levels were not significantly correlated with EDSS measures, but were associated with a blinded clinical appraisal of each patient regarding the stability or worsening of each patient’s condition. While patients with stable clinical conditions (n=6) showed no change in GSH, patients whose condition was judged to be worsening (n=6) had a significant reduction in GSH levels except in the parietal region.

Further reduction in GSH levels in these patients over 3 years indicates the presence of ongoing oxidative stress in SPMS, which could explain the ongoing clinical decline in patients with SPMS.

The authors have nothing to disclose.

Diffusion tensor imaging of cervical spinal cord tracts is specific to clinical function in demyelinating disease

R.T. Naismith, J. Xu, E.C. Klawiter, N.T. Tutlam, S. Lancia, K. Trinkaus, S.K. Song, A.H. Cross

Washington University (Saint Louis, US)

Objective: Determine how clinical disability relates to corticospinal tract (CST) and posterior column (PC) tissue integrity as measured by diffusion tensor imaging.

Background: Spinal cord injury is common in multiple sclerosis (MS) and neuromyelitis optica (NMO), but imaging methods to evaluate axon and myelin injury are limited. Diffusion tensor imaging has potential to quantify tissue integrity with tract-specific resolution and correspond to clinical function.

Methods: 37 participants with either MS or NMO, who had past evidence of cervical cord involvement by clinical symptoms and MRI, were imaged at least 12 months from their last relapse. Clinical testing included the Expanded Disability Status Score (EDSS), the 25-Foot Timed Walk (25FTW), the 9-Hole Peg Test (9HPT), and upper extremity vibratory threshold by the automated Computer Aided Sensory Evaluator (CASE IV). Four averages of diffusion-weighted images were collected in 25 directions at 3 Tesla by a reduced field-of-view single-shot spin-echo echo-planar imaging sequence and b values 400-800 s/mm². Eighteen slices with 0.9x0.9x5mm resolution spanned C1-C6. The cord was segmented to include left and right PCs, the lateral CSTs, in addition to the entire slice. Generalized estimating equations evaluated the relationship of DTI within tracts to clinical parameters, while accounting for multiple measures per subject.

Results: Vibratory thresholds were strongly associated with radial diffusivity (RD) in the PCs (p=0.007), but not in CSTs(p=0.29) or whole slices (p=0.15). RD in combined PCs and CSTs differentiated healthy controls 0.334 mm2/ms [95% CI: 0.324, 0.344] from MS 0.373 [0.364, 0.383] and NMO 0.394 [0.381, 0.407]. Combined CSTs and PCs differentiated EDSS 0-3.0 (0.326 [0.320, 0.332]) from EDSS 3.5-5.5 (0.362 [0.350, 0.374]) from EDSS 6.0+ (0.416 [0.393, 0.439]). RD in combined PCs and CSTs differentiated 25FTW at 2-4 standard deviations (SD) of normal (0.337 [0.328, 0.346]) from 4+ SD of normal (0.370 [0.361, 0.380]). RD in combined PCs and CSTs differentiated 9HPT at 2-4 SD of normal (0.331 [0.323, 0.339]) from 4+ SD of normal (0.377 [0.367, 0.387]).

Conclusions: DTI of individual spinal cord tracts quantifies tissue injury that is specific to the clinical function of that tract. DTI can be used throughout the central nervous system as a clinically-relevant measure of tissue integrity.

Funding: NIH (K23NS052430-01A1 to RTN, K24 RR017100 and P01 NS059560-01 to AHC, R01 NS047592 to SKS); National MS Society (FG1782A1 to J.X., CA1012 to A.H.C. and S.K.S., RG 3670 to S.K.S.); American Academy of Neurology Clinical Research Fellowship to E.C.K.

This publication was made possible by Grant Number UL1 RR024992 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research. This research was also supported in part by NIH grants CO6 RR020092 and RR024992 (Washington University Institute of Clinical and Translational Sciences - Brain, Behavioral and Performance Unit). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.

RTN: Acorda Therapeutics, Bayer Healthcare, Biogen Idec, EMD Serono, Genzyme, Teva Neurosciences.

ECK: Bayer Healthcare, Teva Neurosciences.

AHC: Pfizer, Hoffman-La Roche, Sanofi-Aventis, Genzyme, Novartis, Bayer Healthcare, Biogen Idec, Teva Neurosciences.

JX, NTT, SL, KT, SKK have nothing to disclose.

Diffusional kurtosis imaging in relapsing-remitting MS: towards a more specific characterisation of white matter damage

M. Inglese, J. Jensen, E. Fieremans

Mount Sinai School of Medicine (New York, US); Medical University of South Carolina (Charleston, US); New York University (New York, US)

Background: Diffusion weighted MRI (DWI) is sensitive to the diffuse microscopic injury in normal appearing white matter (NAWM). Diffusional kurtosis imaging (DKI) is a clinically feasible DWI method to probe non-Gaussian diffusion properties. A diffusion model of white matter (WM) suitable for DKI analysis has been introduced, which allows for quantifying the intra- and extra-axonal diffusivities, the axonal water fraction (AWF) and the tortuosity of the extra-axonal space. These WM-parameters may be more specific to demyelination and neurodegeneration.

Goals: To investigate the changes in these WM-parameters in patients with relapse-remitting MS (RR-MS) and healthy controls (NC).

Methods: Thirty two patients with RR-MS and 19 matched NC underwent MRI on a 3 Tesla scanner. The MRI protocol included an axial T2 TSE and a TRSE sequence for DKI. DKI parametric maps were calculated, and then used to derive WM parametric maps of the intra-axonal diffusivity Daxon, extra-axonal axial and radial diffusivity, De parallel and De radial, tortuosity, and AWF. The fractional anisotropy (FA) maps were non-linearly registered to the MNI FA template and all parametric maps were transformed to a standard space according to this registration using FSL. Lesion masks were drawn on T2-weighted images and transformed into standard space to yield a mean lesion mask across subjects. Using tract-based spatial statistics (TBSS) skeletonized voxel-wise analysis was performed of the DKI and WM metrics using FSL’s “randomize”. In addition, regions of interest (ROI) were drawn of the genu and splenium of the corpus callosum to determine between group differences for each parameter.

Results: TBSS showed a widespread pattern of significant changes in all DKI parameters of RR-MS patients compared to NC. Of the WM parameters, significant changes were observed in De radial, the tortuosity, and the AWF, whereas Daxon and De parallel did not significantly differ between groups. The ROI-based analysis showed similar results in both the genu and splenium of the corpus callosum.

Conclusions: Our study shows that DKI measures are sensitive to ‘occult’ brain tissue damage in NAWM. These changes in the WM-parameters may provide more insight in the specific underlying disease processes occurring in the NAWM: The decrease in the AWF, tortuosity and the increase in De radial can be explained by demyelination, while the lack of change in Daxon suggests an absence of intra-axonal injury in the NAWM.

This study was supported in part by R01 NS051623-05 to M Inglese.

Association between Cognitive Reserve and White Matter Integrity in Multiple Sclerosis

J. Stojanovic-Radic, A. Das, P. Girgis, H. Genova, N. Chiaravalloti, J. DeLuca, J. Sumowski, G. Wylie

Kessler Foundation Research Center (West Orange, US)

Objective: To evaluate the relationship between the white matter (WM) integrity and cognitive reserve (CR) in individuals with multiple sclerosis (MS).

Background: MS is an autoimmune disease primarily affecting the WM, thereby causing cognitive deficits. Fractional anisotropy (FA), derived from Diffusion Tensor Imaging (DTI), is one method of investigating WM integrity. Previous studies have shown that CR is protective against cognitive decline in MS. In the present study, we investigated the relationship between the CR and FA in individuals with MS. We hypothesized that there would be a positive correlation between the CR and the integrity of WM projections to the brain areas involved in learning and memory.

Methods: DTI was obtained in 21 MS subjects (19 female), in a 3T Allegra Siemens scanner. DTI data were pre-processed with FSL Software using tract-based spatial statistics (TBSS) to obtain the FA values. A CR composite score, resulting from principal components analysis of years of education and scores on Wechsler Test of Adult Reading, was entered into the analysis as a regressor to identify the WM tracts in which CR correlated with FA.

Results: A positive correlation between FA and CR was found in the WM tracts within the middle temporal regions. More specifically, higher FA was associated with higher CR scores in the WM tracts projecting from the parahippocampi, bilaterally (p = 0.005).

Conclusions: The present study showed a positive relationship between the WM integrity and CR in individuals with MS in the temporal lobe regions associated with learning and memory. This finding may explain how higher intellectual enrichment, through better WM integrity in brain regions essential for learning and memory in MS, attenuates cognitive decline in MS patients with high CR.

The study has been supported by National Institutes of Health, Grant # R01 HD045798s and National Multiple Sclerosis Society, Grant # RG 4232A1.

Dr. Jelena Stojanovic-Radic, Dr. Abhijit, Mr. Peter Girgis and Dr. Helen Genova have nothing to disclose.

Dr. Chiaravalloti has had MS funding from NIH, NMSS, and Memen Pharmaceuticals for MS-cognition work, not directly related to this presentation.

Dr. John DeLuca is a consultant for Biogen Idec. and Memen Pharmaceuticals, and he is grant funded by that National Multiple Sclerosis Society, NIDRR, Biogen Idec., and Memen Pharmaceuticals.

Dr. James Sumowski has nothing to disclose.

Dr. Glenn Wylie has nothing to disclose.

Longitudinal prediction of cognition in multiple sclerosis

M.M. Schoonheim, V. Popescu, H. Vrenken, C.H. Polman, J.J.G. Geurts, F. Barkhof

VU University Medical Center (Amsterdam, NL)

Introduction: Cognitive dysfunction is frequent in multiple sclerosis (MS). Although previous cross-sectional studies have shown lesion load and atrophy to be important determinants of cognitive performance, longitudinal studies are needed. In this study, we attempted to predict cognitive function using longitudinal as well as cross-sectional data in a homogeneous early inception cohort, six years after diagnosis.

Methods: Structural MRI scans were performed in 110 MS patients (38 men) at baseline (very near diagnosis), two years later and six years later. T1-hypointense and T2-lesion volumes were calculated at each visit. Longitudinal whole-brain and central atrophy rates were calculated between baseline and year two, as well as changes in EDSS scores of one point or more. Thalamic volume and the amount of voxels displaying strong abnormalities (Z<-3.1) on fractional anisotropy (FA) images at year six were calculated, as both are known to be important for cognition in this cohort.

Cognition was assessed in eight domains to derive a composite Z-score, after comparing scores to 50 healthy age-matched controls (20 men). Stepwise linear regression was used to determine which variables explain global cognition in patients using abovementioned variables, as well as age, gender, disease duration and disease phenotype. A second similar regression analysis was performed for the variable most important for cognition.

Results: The cohort displayed mild disability levels (median EDSS 2, range 0-8) and cognitive dysfunction was less severe in women: mean Z=-0.4 (range -2.2-1.0); men: mean Z=-1.0 (range -4.6-0.5). Cognition could best be explained (adjusted R2=0.37) by cross-sectional measures: thalamic volume, gender and EDSS scores at year six. Thalamic volume was best explained (adjusted R2=0.51) by the extent of damage on FA, early whole-brain atrophy rate and T2-lesion volume increases, and EDSS scores at baseline and at year six.

Conclusion: Cognitive performance, six years after diagnosis, is best explained by cross-sectional parameters like thalamic volume. Thalamic volume itself is best predicted by longitudinal measures, such as early changes in whole-brain and lesion volumes, as well as cross-sectional data like DTI parameters that describe whole-brain damage beyond focal lesions.

These results underline the importance of the thalamus for cognition, indicating that future longitudinal studies should perhaps investigate changes over time in this structure more closely.

Mr. Schoonheim receives research support from the Dutch MS Research Foundation, grant number 08-650.

Ms. Popescu receives research support from the Dutch MS Research Foundation, grant number 10-718.

Dr. Vrenken receives research support from the Dutch MS Research Foundation, grant numbers 05-358c, 09-358d and 10-718.

Dr. Polman has nothing to disclose with regard to this study.

Dr. Geurts has nothing to disclose with regard to this study.

Dr. Barkhof has nothing to disclose with regard to this study.

Ganglion cells loss in non-optic neuritis eyes of MS patients

P. Sriram, N. Saakova, C. Wang, H. Arvind, S. Graham, C. Yiannikus, R. Garrick, A. Klistorner

Macquarie University (Sydney, AU); University of Sydney (Sydney, AU); Concord Hospital (Sydney, AU); St Vincent Hospital (Sydney, AU)

Objective: Loss of retinal ganglion cells (RGCs) in non-optic neuritis (non-ON) eyes of MS patients has recently been reported. Several factors such as anterograde degeneration initiated by abnormalities in the outer retinal layer (ORL) or inner nuclear layer (INL), or primary degeneration of RGCs themselves may contribute to this process. Alternatively, RGC loss can result from retrograde degeneration caused by sub-clinical inflammation proximal to the RGC body. In the case of optic radiation lesions such neurodegeneration would require trans-synaptic transmission. Therefore, the purpose of the current study was to look for evidence of sub-clinical inflammation along the visual pathway and/or structural and functional changes in outer retina to investigate their role in RGC loss in NON-ON eyes of MS patients.

Methods: Forty NON-ON eyes of 40 RRMS patients and thirty controls were included. The thickness of the retinal layers was measured by OCT (Spectralis, Heidelberg) and analysed using custom design segmentation software. RGCs were assessed using thickness of the Ganglion Cell Complex (GCC). Structural and functional integrity of outer retina was analysed using thickness of INL and ORL and full-field electroretinogram (ERG), while multifocal visual evoked potentials (mfVEP) were performed to assess evidence of sub-clinical inflammation along the visual pathway.

Results: The thickness of GCC was significantly reduced in non-ON eyes (80.4±7.9µ vs 87.0±5.5µ, p=0.0003). No significant change in INL or ORL was detected (p=0.2 and 0.06). There was also no significant change in any of the ERG parameters. The latency of mfVEP, however, was significantly delayed (p=0.00001). GCC thickness correlated significantly with latency delay of the mfVEP (r2 =0.34, p<0.001), but not with thickness of outer retina layers or any ERG parameters. There was no significant thinning of GCC (84.0±3.6µ, p=0.08) in patients with normal (<99th percentile) mfVEP latency (17 patients). However in patients with a delayed latency (>99th percentile, 23 patients) GCC reduction become even more apparent (78.0±8.9µ, p=0.00005).

Conclusions: Our results demonstrate a significant association of RGC loss with mfVEP latency delay, indicating that sub-clinical inflammation along the visual pathway contributes significantly to neuronal damage. No evidence of primary retinal degeneration was found.

The authors have nothing to disclose.

Resting-state functional magnetic resonance imaging in the assessment of patients with neuromyelitis optica

F. Rueda-Lopes, F. Miraldi, F. Malfetano, I. Meira, S. Alves-leon, R. Domingues, E. Gasparetto

UFRJ (Rio de Janeiro, BR)

Objective: Neuromyelitis optica (NMO) spectrum is an auto-imune demyelinating disease usually related to optical neuritis and extensive myelitis. Diffuse white matter damage has been shown, but the cortex was poorly studied in such disease. Our objective was to investigate NMO patients using the resting-state functional magnetic resonance imaging (RS fMRI) compared to the controls, regarding the default-mode network and the visual network, in order to evaluate the cortical adaptations in NMO.

Methods: We studied 28 NMO spectrum patients (including myelitis, neuritis optica and/or both) [mean age 38 years (SD ± 3,2, 18 female), and also 19 sex and age matched controls. All participants signed informed consent. MRI was performed in a 1.5 Tesla scanner, including 3D T1 weighted-images and RS fMRI was performed during rest. fMRI data was post-processed using MELODIC, part of FMRIB’s Software Library. The fMRI data set was decomposed using independent component analysis (ICA) to identify large-scale patterns of functional connectivity. After that, a ‘dual-regression’ approach was carried out allowing voxel-wise comparisons of resting functional connectivity between both groups. Threshold-Free Cluster Enhancement (tfce) and p-corrected maps of comparison between both groups were analysed. A p-value of 0.05 was considered statistically significant.

Results: Fourteen components were computed in the entire subject group by ICA. Default-mode (DMN) and visual networks were clearly detected among the subjects and were compared between both groups. In the DMN, the evaluation of tfce maps showed areas of significantly higher synchronization in NMO patients compared to healthy controls in the parietal lobes, precuneus region and also in the right hippocampus (p<0.01), which remained after p-correction. Also for DMN, controls had areas of higher synchronization in the frontal areas compared to patients in the tfce maps, which were markedly reduced but still detected after p-correction. In the visual network, there were increased synchronization values in the whole occipital cortex in NMO patients compared to controls (p<0.01) in both maps.

Conclusions: NMO patients have an increased synchronization during rest in the parietal and precuneus areas of DMN as a form of compensation for the decreased synchronization in the frontal area. Also, the higher synchronization values found in the occipital cortex in patients may be a form of compensation for the optical neuritis.

The authors have nothing to disclose.

SWI phase values of the whole grey and white matter in patients with multiple sclerosis and neuromyelitis optica: a comparative study with controls

V. Itagiba, E. Gasparetto, F. Lopes-Rueda, T. Doring, P. Bahia, R. Domingues

Federal university of Rio de Janeiro (Rio de Janeiro, BR); CDPI- Clinica de Diagnóstico por Imagem (Rio de Janeiro, BR)

Purpose: To analyze the phase change on susceptibility-weighted imaging (SWI)-filtered phase images in the whole gray and white matter (WM) of multiple sclerosis (MS) and neuromyelitis optica (NMO) patients compared to healthy controls (HC). First, we sought to create a reliable, reproducible and highly-automated framework for structure-specific analysis of SWI-filtered phase images. Second we aim to apply this technique to groups of MS and NMO patients and HC in order to analyze the phase change in the whole gray matter (GM) and WM, of these groups.

Material and Methods: 16 relapsing-remitting multiple sclerosis (RRMS) patients, 9 NMO patients and 24 HC were imaged on a 1.5T scanner. A post processing method was used to create single automated generated masks for the whole GM and WM. Radian values (RV) were determined for the whole GM and WM of MS and NMO patients and HC.

Results: A trend for differentiation (p= 0.0556) was detected between RV of the GM of MS patients and HC. No significant difference was detected when comparing the RV of the WM of MS patients and HC (p=0.7907). There was also no significant difference of the RV of the GM (p=0.0923) and WM (p=0.8212) when comparing NMO patients and HC, neither when comparing NMO and MS patients GM (p=0.4527) and WM (p= 0.4668).

Conclusions: We were able to assess the whole GM and WM of MS and NMO patients and we found a trend for differentiation between the RV of the GM in MS patients compared to HC. The possibility of having a single mask including the whole GM and WM would improve the iron overload detection. Future studies should focus on testing this method with a larger cohort, in order to improve the technique and to demonstrate its utility.

Clinical Relevance statement: This post processing method is fast, easy to execute and provides a wider range of information of the whole brain’s phase changes what would improve the iron overload detection.

The authors have nothing to disclose.

MTR analysis of inner and outer cortical bands in multiple sclerosis

R.S. Samson, M.J. Cardoso, N. Muhlert, V. Sethi, C.A.M. Wheeler-Kingshott, S. Ourselin, T. Yousry, M. Ron, D.H. Miller, D.T. Chard

UCL Institute of Neurology (London, UK); UCL Department of Computer Sciences (London, UK)

Background: Histopathology of the cortex has found subpial lesions in secondary progressive (SP) multiple sclerosis (MS), but there is less information on cortical lesion distribution in primary progressive (PP) and relapsing remitting (RR) MS, and magnetic resonance imaging (MRI) is poor at identifying subpial lesions in life. An alternative technique to infer demyelination is to quantify the magnetisation transfer ratio (MTR).

Objective: To determine whether cortical MTR (cMTR) abnormalities in the inner (abutting the white matter) and outer (subpial) cortex differ in healthy controls (HC), and RR, PP and SPMS patients.

Methods: Thirty two HC (mean age 37.0 years (SD 11.3)), 16 PP (53.6 (9.3) years, median EDSS 6.0), 14 SP (51.3 (8.6) years, EDSS 6.5) and 30 RR (44.3 (9.9) years, EDSS 2.5) MS patients were scanned using a 3T Philips system. 3D 1x1x1mm3 T1-weighted images and 1x1x1mm3 MTR data were acquired. Subject-specific T1 volumes were segmented using NiftySeg, and the cortex subdivided into inner and outer bands by calculating the mid-harmonic location using the Laplace equation-based cortical thickness framework. Mean MTR values were calculated for each band following co-registration to the MTR maps using NiftyReg. Within-subject differences between inner and outer cMTR were assessed using paired t-tests. Between-group differences were examined using one-way ANOVA tests, with adjustments for age and cortical region volume.

Results: Inner cMTR (mean (SD)) was 34.7 (0.7)pu in HC, 34.1 (0.8)pu in PP, 33.4 (1.0)pu in SP and 34.3 (0.7)pu in RR MS patients. Outer cMTR was 32.3 (0.7) pu in HC, 31.5 (1.1) pu in PP, 29.6 (1.4)pu in SP and 31.6 (1.0) pu in RR MS patients. Outer cMTR was lower than inner cMTR in all groups (p<0.001). Inner cMTR was reduced compared to HC in PP (p<0.05) and SP (p<0.001) but not RRMS. Inner cMTR was lower in SP than RR (p<0.01), but not PPMS. Outer cMTR was decreased compared to HC in SP (p<0.001) and RR (p<0.05), but not PPMS. No differences between PP and RRMS patients were seen, but SPMS patients had lower outer cMTR than both PP (p<0.001) and RRMS (p<0.001).

Conclusions: An MTR gradient is seen in the cortex in patients and controls. This gradient was greater in SPMS than PP and RRMS. The largest cMTR abnormalities were seen in SPMS, especially in the outer cortex, concordant with extensive subpial demyelination in SPMS. The potential for outer cMTR to detect subpial pathology in MS warrants further investigation.

Rebecca Samson, Manuel Cardoso and Nils Muhlert have nothing to declare.

Varun Sethi is funded by grants from Biogen and Novartis.

Claudia Wheeler-Kingshott is on the advisory board for BG12 (Biogen) and receives grants (PI and co-applicant) from ISRT, EPSRC, Wings of Life, MS Society, Biogen Idec and Novartis.

Sebastian Ourselin, Tarek Yousry, Maria Ron and David Miller have nothing to declare.

Declan Chard receives research support from the Multiple Sclerosis Society of Great Britain and Northern Ireland, and holds stock in GlaxoSmithKline.

Regional changes in tissue sodium concentration in relapsing-remitting and secondary progressive MS

D. Paling, B. Solanky, F. Riemer, C. Wheeler-Kingshott, X. Golay, R. Kapoor, D. Miller

University College London (London, UK)

Introduction: Sodium is at lower concentration within cells (12mM) compared to extracellular fluid (140mM). In multiple sclerosis (MS) tissue sodium concentration may be greater due to intraneuronal increase, or due to neuroaxonal loss causing an increase in proportion of higher sodium concentration extracellular fluid within the voxel. Our aim was to investigate regional tissue sodium concentrations in patients with relapsing remitting and secondary progressive MS, and assess association with disability.

Methods: 17 patients with relapsing remitting MS (median EDSS 3.5), 11 patients with secondary progressive MS (median EDSS 6.5) and 15 controls were scanned using a 3 Tesla scanner and 23Na head coil. 1H T1 and T2 weighted spin echo scans were also obtained using a 32 channel coil. Lesions and normal appearing white matter (NAWM) regions of interest were outlined on the 1H scans, and used to calculate mean sodium concentrations from co-registered sodium maps. Disability was assessed using the 9 hole peg test, timed 25ft walk and PASAT B 3s test from which the MS Functional Composite (MSFC) was calculated.

Results: Sodium concentration in NAWM was significantly higher in patients with MS as compared to controls (35.9 ± 2.7 vs. 32.9 ± 2.8, p=0.001) and was significantly higher in patients with secondary progressive as compared to relapsing remitting MS (38.2 ±4.74 vs, 35.3 ±2.9, p=0.038). Increase in NAWM sodium predicted worse z score in the PASAT B test, (B=-0.393, p=0.039). There were no differences in lesions sodium content between SPMS and RRMS patients.

Sodium was significantly increased in T1 hypointense lesions, (50.8 ± 6.1 vs. 35.9 ± 2.7, p<0.001) and T1 isointense lesions (46.2 ± 5.4 vs. 35.9 ± 2.7, p<0.001) as compared to NAWM. Increase in sodium concentration within lesions predicted a worse score on the MSFC score, with the strongest association seen between mean sodium concentration in T1 isointense lesions and MSFC (B=0.528, p=0.012).

Conclusions: Increase in sodium within lesions and within NAWM in patients with MS would be suggestive of neuroaxonal loss or metabolic disturbance. Increase in NAWM sodium in patients with secondary progressive MS suggests that this could be a marker of progression. The association between T1 isointense lesion sodium concentration and MSFC, and NAWM sodium with PASAT B score suggests potential of regional sodium concentrations to be used as markers of clinically relevant pathophysiology.

David Paling has nothing to disclose.

Dr Bhavana Solanky receives grants from Philips Healthcare for development of MRI techniques.

Frank Riemer has nothing to declare.

Dr C Wheeler-Kingshott is on the advisory board for BG12 (Biogen) and receives grants (PI and co-applicant) from ISRT, EPSRC, Wings of Life, MS Society, Biogen Idec and Novartis.

Professor Xavier Golay receives funding from the commercial company Philips for advisory work, holds two patents for arterial spin labelling imaging and serves on the journal editorial boards of MAGMA and NMR in biomedicine.

Dr Raju Kapoor receives funding for serving on the advisory boards for the commercial companies Biogen Iden, Novartis and Genetech.

Professor David Miller has received research grants (held by University College London) from Biogen Idec Inc, GlaxoSmithKline, Schering AG, and Novartis to perform MRI analysis in multiple sclerosis trials.

Registration of serial brain MRI scans from multiple sclerosis patients. Analysis of 3D intensity-based methods

Y. Díez, X. Lladó, A. Oliver, R. Martí, E. Roura, M. Cabezas, O. Ganiler, J. Freixenet, J.C. Vilanova, L. Valls, L. Ramió-Torrentà, D. Pareto, A. Rovira

University of Girona (Girona, ES); Girona Magnetic Resonance Center (Girona, ES); Dr. Josep Trueta University Hospital (Girona, ES); Vall d’Hebron University Hospital (Barcelona, ES)

Background: Registration is a crucial task in serial MRI. Although many methods exist, the most simple ones (Rigid and Affine) are commonly used. This happens mainly because the automatic evaluation of registration results is still an unsolved problem. As a result, the strengths and weaknesses of each particular method for a given application are not widely known.

Aim: To study the performance of intensity-based registration methods for temporal registration of MRI images from multiple sclerosis (MS) patients.

Materials and methods: 30 MS patients from two different hospitals with two temporal MRI studies (baseline and twelve months) were used to evaluate the registration methods. Manual lesion annotations done by expert radiologists were available for all patients. Regarding the methods, a total of 10 state-of-the-art intensity-based registration techniques were evaluated: Rigid, Affine, Bsplines, Demons (Diffeomorphic and classic), SPM8 (DARTEL and HDW), IRTK, ART and SyN. To assess the performance and quality of registration we used different evaluation measures: 1) Distance Values: Mutual Information (MI) and Sum of Squared Distances; 2) Difference Image Regularity measures: Mean, Standard Deviation, Entropy; 3) Measures on distance between lesions: Area Overlap (AO), Dice coefficient. The first two criteria groups are multi-purpose and image-based. The third is included to provide insight in the suitability of registration methods for serial analysis of MS lesions. All criteria were studied using descriptive statistics and hypothesis tests.

Results: Experiments show how, for all criteria, not only the initial values could be improved, but also those of commonly used methods (Affine, Rigid and Bsplines). For example, for MI metric, the average improved from an initial 0.58 to 1.12 for Rigid, 1.18 for Bsplines and a best value of 1.43 for Diffeomorphic Demons. We also saw how registering images helped bringing MS lesions closer. Specifically, the area overlap between MS lesions was improved on average from an initial 0.10 for Rigid to a best value of 0.41 by SyN.

Conclusion: We have provided insight in different aspects on the quality of the registration methods studied and the improvements brought by non-rigid methods. More important, we have also seen how registration helps bringing MS lesions closer. This shows the potential for state-of-the-art registration methods to help improve semi-automatic and automatic monitoring of MS lesion evolution.

The authors have nothing to disclose.

Detecting evolving white matter MS lesions in serial brain MRI studies: analysis of a subtraction approach

O. Ganiler, X. Lladó, A. Oliver, Y. Díez, J. Freixenet, J.C. Vilanova, A. Quiles, G. Laguillo, L. Ramió-Torrentà, D. Pareto, A. Rovira

University of Girona (Girona, ES); Girona Magnetic Resonance Center (Girona, ES); Dr. Josep Trueta University Hospital (Girona, ES); Vall d’Hebron University Hospital (Barcelona, ES)

Background: One of the common strategies for detecting evolving MS lesions in serial brain MRI is the point-to-point subtraction between two successive scans. However, the methods based on this strategy suffer from repositioning errors due to patient movement, image artifacts, and partial volume effects. Thus, they are challenging methods which require robust steps for providing useful and reliable subtracted images.

Aim: To analyze and evaluate a subtraction approach used for detecting evolving white matter MS lesions in serial brain MRI scans.

Methods: We analyzed in detail all the steps required for a subtraction pipeline: skull stripping, bias field correction, histogram matching, rigid body registration, point-to-point subtraction, white matter masking, intensity thresholding and removal of small spots. The intracranial cavity (ICC) is identified for each time point using the BET extraction tool, while the soft tissues of the MRI scans are also automatically obtained. In the second step, bias field correction is applied to the ICC masked MR images at all time points. Afterwards, the gray scale values between two-time points are normalized by using a histogram matching technique. Thereafter, the outcome normalized MR images are aligned by a rigid half-way registration which reduces the errors due to interpolation. Finally, the images are subtracted and then thresholded with respect to the intensity values on the union of white matter masks.

Results: The experiments were performed using real data sets (PD-w and T2-w FLAIR images) on 1.5T, and the corresponding ground truth annotations provided by expert radiologists (full lesion annotation on the baseline and new appearing lesions in the 12-month control). In total, 42 new WM lesions were correctly identified by our pipeline among 67 lesions detected by experts (63% of success). The results of the subtraction approach as well as the impact of the pipeline steps were quantitatively evaluated using several voxel-based and region-based measures, providing insight in different aspects of the detection of evolving MS lesions.

Conclusion: We have obtained promising MS lesion change detection results, analyzing also the importance of each of the proposed pipeline steps. We have seen how the necessity of fixing an intensity threshold is still an open issue while the false-positive and false-negative voxel detections have to be improved in order to have a fully automatic approach ready for the clinical practice.

The authors have nothing to disclose.

Cortical-juxtacortical lesions in clinically isolated syndromes: distribution and diagnostic value

D. Pareto, C. Auger, A. Pla, R. Mitjana, M. Tintoré, J.F. Corral, X. Montalban, A. Rovira

Hospital Vall d’Hebron (Barcelona, ES)

Purpose: To evaluate the presence and spatial distribution of cortical-juxtacortical lesion and the contribution of such lesions to dissemination in space fulfilment in patients with a clinical isolated syndrome (CIS).

Methods: 71 CIS patients (mean age 34 years) underwent brain and spinal cord 3T MRI within the first five months after symptoms onset. The following sequences were obtained: 1) PD and T2-weighted; 2) T2-fast FLAIR; 3) Un-enhanced and contrast-enhanced T1-weigthed; and 4) 3D double inversion-recovery. Cortical-juxtacortical lesions were identified, manually outlined and segmented into a binarized mask. A cortical-juxtacortical MRI-based lesion probability map was obtained.

Results: Cortical-juxtacortical lesions were identified in 31 (44%) patients. Incidence of cortico-subcortical lesions was 48% in the frontal lobe, 20% in the temporal lobe and 29% in the parietal lobe p values. According to the MS 2010 McDonald diagnostic criteria, identification of cortico-juxtacortical lesion contributed to demonstrate lesions disseminated in space (DIS) in 27% of cases.

Conclusions: Cortical-juxtacortical lesions are a common MRI finding in patients with a CIS, predominantly involving the frontal, parietal and temporal lobes. Its demonstration has a high relevance for demonstrating dissemination in space according to the MS 2010 McDonald diagnostic criteria.

The authors have nothing to disclose.

Perfusion and permeability MR imaging in differentiating tumefactive demyelinating lesions from high-grade gliomas

A. Rovira, S. Cavalletto, P. Alcaide, C. Auger, J. Sastre-Garriga, E. Huerga, X. Montalban

Hospital Vall d’Hebron (Barcelona, ES)

Purpose: Acute tumefactive demyelinating lesions (TDLs) may present as single or multiple lesions that may mimic high grade gliomas (HGG) Although the presence of some imaging findings may suggest, with a high degree of certainty, the diagnosis of TDLs, not infrequently a definitive diagnosis requires a biopsy despite clinical suspicion of demyelination. However, even the biopsy specimen may resemble a brain tumor because of the hypercellular nature of the lesions, which are often associated with large protoplasmatic glial cells with fragmented chromatin and abnormal mitosis (Creutzfeldt cells). Although multiple functional imaging methods may provide useful information for the characterization of brain mass lesions, none of them has been validated for routine clinical use. The purpose of this study is to compare differences in perfusion and vascular permeability MR imaging between TDLs and HGG.

Patients and methods: We retrospectively reviewed 4 patients with acute TDLs and 5 patients with biopsy proven HGG (gliobastoma) in whom perfusion studies with arterial spin labelling (ASL), dynamic contrast-enhanced T2*-weighted MR Imaging (DSC-MRI) and dynamic contrast enhanced T1 MR imaging (DCE-MRI) sequences were obtained on a 3 T magnet. From these sequences the relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV) and contrast wash-in slope were calculated from the contrast-enhancing areas of lesions, using the contralateral normal appearing white matter as a reference.

Results: A non-parametric test (Mann-Whitney) showed significant differences in all three measures between the two groups, being the mean rCBF, rCBV and wash-in lower in TDLs compared to HGG (rCBF 0.02; rCBV 0.72; wash-in 1.01 in TDLs vs. rCBF 8.74; rCBV 6.25; wash-in 5.57 in HGG) (p<0.001).

Conclusion: Perfusion and permeability MR imaging can be used to discriminate between active TDLs from HGG based on the important biological dissimilarities between these two types of lesions, with HGG characterized by presence of neoangiogenesis and vascular endothelial proliferation and TDLs characterized by intrinsically normal or inflamed vessels with mild inflammatory angiogenesis.

The authors have nothing to disclose.

Increased functional connectivity of multiple resting state networks after motor training in multiple sclerosis

N. Petsas, V. Tomassini, E. Sbardella, F. Tona, C. Pozzilli, RG. Wise, P. Pantano

Sapienza University of Rome (Rome, IT); Cardiff University (Cardiff, UK)

Background: Resting-state networks’ (RSN) activity is a marker of co-activation between anatomically separated brain regions, reflecting functional connectivity (rs-FC). RSN activity is modulated by motor tasks to adapt to function. In Multiple Sclerosis (MS) patients, altered rs-FC has been reported and associated with altered function and disability, but few is known about how it is modulated by a motor training.

Aim: To assess changes in rs-FC in patients with relapsing-remitting (RR-MS) disease, associated with dominant hand motor training.

Methods: Twenty right-handed patients with RR-MS underwent MRI scanning with two Blood Oxygen Level-dependent (BOLD) resting fMRI acquisitions before and after a 25 minute training of right thumb movements. We performed interregional correlation analysis using a seed region at the level of the right hand cortical representation and extracted the corresponding time courses. Maps of the regression coefficients with these time courses were entered into a paired two-sample analysis.

Results: Increased functional connectivity with the right hand region after motor training was demonstrated within several areas belonging to the resting motor network. Also, areas involved in other RSNs showed increased connectivity with this motor seed region, such as cuneous, precuneous, anterior and posterior cingulate and several frontal, temporal and parietal areas. We did not observe significant decreases in functional connectivity.

Conclusion: Training induces an increase in functional connectivity at rest in MS patients. This suggests that a multi-modal adaptation involving areas outside the motor network may contribute to functional motor reorganization and recovery in MS.

The authors have nothing to disclose.

Alterated resting state fMRI connectivity in thalamic networks correlates with cognitive impairment in multiple sclerosis

F. Tona, N. Petsas, E. Sbardella, L. Prosperini, M. Carmellini, C. Pozzilli, P. Pantano

Sapienza University of Rome (Rome, IT)

Background: Several histopathological and Magnetic Resonance Imaging (MRI) studies have demostrated the pathological involvement of both cortical and subcortical grey matter regions in Multiple Sclerosis (MS) patients; in particular, the thalamic damage may play an important role in patient disability and cognitive dysfunction.

Objective: To investigate, using resting-state functional MRI (rs fMRI), the correlations between thalamo-cortical connectivity and clinical scores assessing cognitive impairment in MS patients.

Methods: Forty-eight patients with relapsing-emitting MS (mean age: 34.8; median EDSS score: 2.5) were scanned using a 3T magnet to obtain a gradient-echo echo-planar imaging sequence. The rs fMRI data were analyzed by using a seed-based whole-brain correlation method to identify both left and right thalamic resting-state networks (RSNs). The Paced Auditory Serial Addition Test (PASAT) with increasing difficulty level (at 3 and 2 seconds, respectively) was performed to evaluate attention, executive functioning and working memory, as aspects of cognitive impairment. Data were analyzed by using tools from FMRIB Software Library (FSL).

Results: Our analysis showed that the PASAT score at 3 seconds was significantly inversely related to the strength of thalamic RSNs including the contralateral thalamus, cerebellum and temporo-occipital cortices bilaterally (P < 0.05, cluster level corrected); the PASAT score at 2 seconds was significantly inversely related to an increased synchronization within the thalamic RSNs, which additionally involved the anterior cingulate gyrus, frontal and parietal cortices (P < 0.05, cluster level corrected).

Conclusion: These findings show that decreased cognitive abilities in MS patients are associated with increased functional thalamo-cortical connectivity, thus confirming the crucial role the thalamus plays in attention, executive functioning and working memory abilities in MS patients.

The authors have nothing to disclose.

Load-dependent dysfunction of the putamen during attentional processing in patients with clinically isolated syndrome suggestive of multiple sclerosis

C. Tortorella, R. Romano, V. Direnzo, L. Fazio, P. Taurisano, S. Zoccolella, P. Iaffaldano, R.G. Viterbo, T. Popolizio, G. Blasi, A. Bertolino, M. Trojano

University of Bari (Bari, IT)

Background: Load-related abnormalities of brain activity during performance of attention and working memory tasks measured with fMRI have been described in clinically definite multiple sclerosis (MS) since the earliest stages of disease. Thus far, no data are available in clinically isolated syndrome (CIS) suggestive of MS. Aims. To evaluate the load-related fMRI pattern of brain activity associated with attention in CIS patients.

Methods: Twenty-seven untreated CIS patients and 32 age and sex matched healthy controls (HC) underwent Blood Oxygen Level Dependent (BOLD)-fMRI while performing the Variable Attentional Control (VAC) task, a cognitive paradigm which requires increasing levels of attentional control processing. VAC task was presented with an event-related design. SPM5 random-effects models were used for statistical analyses of fMRI data (p<.05, corrected).

Results: CIS patients had altered behavioral performance at the VAC task showing lower accuracy and higher reaction time in comparison to HC (p=0.007). fMRI analyses demonstrated a main effect of diagnosis on BOLD response in right parietal cortex (p=0.04) with greater activity in CIS patients in comparison to HC (F(1,55)=14.02, p=0.0004). Furthermore, there was an interaction between diagnosis and attentional load demand in left putamen (p=0.01). The physiological increase in response observed in left putamen in HC was not present in CIS patients, who had greater (p=0.05) activity at the lower load and reduced (p=0.04) activity at the higher load.

Conclusions: Our study demonstrates that abnormal variable attentional control processing in patients with CIS is associated with load-independent abnormalities of the inferior parietal lobule and load-dependent dysfunction of the putamen. These results suggest regional specificity and load sensitivity for the involvement of brain activity during abnormal attentional processing in patients at the very early stage of demyelinating disorders.

Prof Trojano and Dr Tortorella have received personal compensation for activities by Biogen Dompè, Bayer Shering and Sanofi Aventis Pharmaceuticals as consultant and speaker. Dr R. Romano has nothing to disclose, Dr V. Direnzo has nothing to disclose,Dr L. Fazio has nothing to disclose, Dr P. Taurisano has nothing to disclose, Dr S. Zoccolella has nothing to disclose, Dr P. Iaffaldano has nothing to disclose,Dr R. Viterbo has nothing to disclose, Dr T. Popolizio has nothing to disclose,Dr G. Blasi has nothing to disclose and Prof A. Bertolino has nothing to disclose.

A Voxel-based assessment of cervical cord damage in MS patients

M.A. Rocca, P. Valsasina, D. Damjanovic, S. Mesaros, M.A. Horsfield, T. Stosic-Opincal, J. Drulovic, G. Comi, M. Filippi

Vita-Salute San Raffaele University (Milan, IT); University of Belgrade (Belgrade, RS); University of Leicester (Leicester, UK)

Objective: Aim of this study was to apply a voxel-based method to map the regional distribution of atrophy in the cervical cord of multiple sclerosis (MS) patients with different clinical phenotypes.

Methods: T2- and 3-D T1-weighted cervical cord scans, and dual-echo brain scans were acquired from 31 healthy controls (HC), 15 clinically isolated syndrome (CIS), 15 relapsing-remitting (RR), 19 benign (BMS), 15 primary-progressive (PP) and 13 secondary-progressive (SP) MS patients. Cervical cord images were analyzed using an active surface method, which segmented the cord outline from C1 to C7 and created output images reformatted in planes perpendicularly to the estimated cord centre line. Unfolded cervical cord images were co-registered into a common standard space, and smoothed cord binary masks were used as input images for spatial statistics. Between-group comparisons of regional cervical cord atrophy as well as and correlations with clinical and structural MRI variables were assessed (SPM8).

Results: Compared to HC, CIS patients showed no cord atrophy, while PPMS had significant cord atrophy. Several clusters of cord atrophy were found in BMS vs. RRMS, and in SPMS vs. RRMS, BMS and PPMS patients. Atrophy mainly involved the posterior and lateral cord segments at different levels. In PPMS, regional cord atrophy was correlated (p<0.001) with disability (r values ranging from -0.76 to -0.86) and brain lesion volume (r values ranging from -0.78 to -0.90), while in the remaining MS phenotypes, taken separately, no correlations were found between regional cord atrophy and clinical and conventional MRI measures of cord and brain damage.

Conclusions: Voxel-based assessment of cervical cord atrophy allows a precise localization of regional cord tissue loss and may contribute to a better characterization of the clinical heterogeneity of MS patients.

M.A. Rocca serves as consultant to Bayer Schering Pharma; and received speakers’ bureaus for Biogen-Dompé and receives research support from Italian Ministry of Health.

P. Valsasina, D. Damjanovic, and T. Stosic-Opincal have nothing to disclose.

S. Mesaros received speaker grants form Merck-Serono S.A. and travel grants from Bayer Schering Pharma.

J. Drulovic has received research grant support from Bayer Schering Pharma and has received speaker honoraria from Merck Serono S.A. and Bayer Schering Pharma.

M.A. Horsfield has acted as a consultant to Biogen Idec and to GE Healthcare, and is a stock holder of Xinapse Systems.

G. Comi has received personal compensation for activities with Teva Neuroscience, Merck Serono, Bayer-Schering, Novartis, Sanofi-Aventis Pharmaceuticals, and Biogen-Dompè as a consultant, speaker, or scientific advisory board member.

M. Filippi serves on scientific advisory boards for Teva Pharmaceutical Industries Ltd. and Genmab A/S; has received funding for travel from Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, and Teva Pharmaceutical Industries Ltd.; serves as a consultant to Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, and Teva Pharmaceutical Industries Ltd.; serves on speakers’ bureaus for Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, and Teva Pharmaceutical Industries Ltd.; and receives research support from Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, Teva Pharmaceutical Industries Ltd. and Fondazione Italiana Sclerosi Multipla.

Regional hippocampal involvement differs across multiple sclerosis clinical phenotypes: evidences from a radial mapping MR-based study

M. Filippi, M.A. Rocca, G. Longoni, E. Pagani, B. Colombo, M. Rodegher, G. Comi

Vita-Salute San Raffaele University (Milan, IT)

Objective: Emerging data support the evidence of hippocampal demyelination and neurodegeneration early and throughout the course of MS. Aim of the present work is to localize and compare the patterns of regional hippocampal atrophy associated to the main MS clinical phenotypes.

Methods: Brain dual-echo and 3D T1-weighted scans were acquired from 115 MS patients (28 relapsing remitting [RR], 34 secondary progressive [SP], 27 primary progressive [PP], and 26 benign [B] MS) and 28 healthy controls (HC). Hippocampal segmentation was performed manually according to a standardized procedure, and global volumes derived. From contours, radial atrophy distribution was assessed using three-dimensional parametric surface mesh models.

Results: Right and left hippocampal volumes differed significantly between groups (p<0.001 and p=0.001 respectively. Significant differences were found, for the right and left hippocampus respectively, in: RRMS vs. HC (p=0.002, p=0.01) and SPMS vs. PPMS (p=0.031, n.s.) (GLM, age adjusted). When compared to HC, RRMS patients showed significant radial atrophy (p<0.001) involving the medial and lateral aspects of CA1 subfield and subiculum of the left hippocampal body and tail. The right hippocampus showed also additional involvement of the head. Compared to HC, PPMS patients demonstrated significant volume loss affecting lateral CA1 subfield, bilaterally, and right tail subicular region, with mild involvement of right hippocampal head. Compared to RRMS and PPMS, SPMS patients showed atrophy of the left hippocampal head. Compared to RRMS, BMS patients had focal decrease of radial distance in left hippocampal body. Interestingly, an abnormal enlargement of CA2-CA3 regions of left hippocampal body was found in RRMS and SPMS patients, which survived in most group comparisons. Significant correlation (p<0.001) was found between T2 and T1 lesion load and atrophy of subicular and CA1 subregions of hippocampal body and CA1 subfield of hippocampal head. Regional hippocampal atrophy correlated with global brain and gray matter atrophy, while no correlation was found with EDSS score.

Conclusions: Regional hippocampal atrophy differs among the major MS disease clinical phenotypes, possibly reflecting differential susceptibility to inflammatory insults and neurodegenerative processes of the hippocampal subfields. These results support the feasibility of MR-based radial mapping methods for the development of reliable markers of disease progression in MS.

M. Filippi serves on scientific advisory boards for Teva Pharmaceutical Industries Ltd. and Genmab A/S; has received funding for consultancies, speaking and travels from Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, and Teva Pharmaceutical Industries Ltd.; receives research support from Bayer Schering Pharma, Biogen-Dompè, Genmab A/S, Merck Serono, Teva Pharmaceutical Industries Ltd., and Fondazione Italiana Sclerosi Multipla. He is Editor-in-Chief of the Journal of Neurology and serves on editorial boards of the American Journal of Neuroradiology, BMC Musculoskeletal Disorders, Clinical Neurology and Neurosurgery, Erciyes Medical Journal, Journal of Alzheimer’s Disease, Journal of Neuroimaging, Journal of Neurovirology, Lancet Neurology, Magnetic Resonance Imaging, Multiple Sclerosis, and Neurological Sciences.

G. Longoni, E. Pagani, B. Colombo, and M. Rodegher report no disclosures.

M.A. Rocca serves as consultant to Bayer Schering Pharma; received speakers’ bureaus for Biogen-Dompé, and receives research support from Italian Ministry of Health.

G. Comi serves on speakers’ bureaus for Teva Pharmaceutical Industries Ltd., Sanofi-Aventis, Merck Serono, Bayer Schering Pharma, Boehringer Ingelheim Italia, and Novartis; and has received speaker honoraria from Sanofi-Aventis, Merck Serono SA, Serono Symposia International Foundation, Bayer Schering Pharma, Novartis, Biogen-Dompè, and Merz Pharmaceuticals GmbH.

Evidence for a neuroprotective effect of oral laquinimod in relapsing-remitting multiple sclerosis

M. Filippi, M.A. Rocca, N. De Stefano, D. Jeffery, L. Kappos, X. Montalban, A.N. Boyko, G. Comi on behalf of the ALLEGRO Study Group

Background: The ALLEGRO trial, a phase III study of oral laquinimod in multiple sclerosis (MS) showed that laquinimod slowed disability and brain atrophy progression, suggesting the drug may have neuroprotective properties in addition to anti-inflammatory effects. Potential neuroprotective effects of laquinimod in ALLEGRO were further investigated using magnetic resonance imaging (MRI) techniques sensitive to irreversible tissue damage.

Methods: Patients with relapsing-remitting MS (RRMS) were randomized 1:1 to receive once-daily oral laquinimod (0.6 mg) or placebo for 24 months. Gray matter (GM), white matter (WM), and thalamic volumes were derived from 3D T1-weighted images at months 0, 12 and 24. Additional MRI sub-studies assessed the evolution of gadolinium-enhancing (GdE) and new T2 lesions into permanent black holes [PBH]); magnetization transfer ratio (MTR) of WM, GM, normal appearing brain tissue (NABT), and T2 lesions; and WM N-acetyl asparate to Creatine (NAA/Cr) levels using proton magnetic resonance spectroscopy (1H-MRS).

Findings: Compared with placebo, patients treated with laquinimod showed lower percentages of WM and GM volume loss at month 12 (p < 0.01) and a trend at month 24 (both p = 0.07). Laquinimod also slowed thalamic volume loss and reduced the number of PBH at 12 and 24 months (all p < 0.01). At 24 months, WM NAA/Cr ratio tended to increase with laquinimod and decrease with placebo (p = 0.17). MTR decreased significantly in WM (p = 0.04) and NABT (p = 0.05) for those treated with placebo but not for those treated with laquinimod.

Conclusions: These results from a variety of MRI measures suggest a neuroprotective effect of oral laquinimod in patients with RRMS and are consistent with benefits of the drug on disability progression.

M.F. serves on scientific advisory boards for Teva, Pepgen, and Genmab A/S; travel expenses from Bayer Schering Pharma,Biogen-Dompe, Genmab A/S, Merck Serono, and Teva; serves as a consultant to Bayer Schering Pharma, Biogen-Dompe, Genmab A/S, Merck Serono, and Teva; serves on speakers; bureaus for Bayer Schering Pharma, Biogen-Dompe, Genmab A/S, Merck Serono, and Teva.

M.R. received honoraria and travel expenses from Teva Pharmaceutical Industries, Sanofi Aventis, and Biogen-Dompe.

N.D.S. has received honoraria from Schering, Biogen Idec, Teva, and Merck Serono for consulting services, speaking and travel support; advisory boards for Merck Serono research grant support from the Italian MS Society.

D.J. has received honoria and consulting fees from Berlex, Serono, Teva, Glaxo and Pfizer and has received financial support for research from Bayer, Serono, Teva, and Pfizer.

L.K. has received personal compensation from Actelion, Advancell, Allozyne, BaroFold, Bayer Health.

Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CLC Behring, Elan, Genmab, Genmark, GeNeuro SA GlaxoSmithKline, Lilly and has received personal compensation from Bayer HealthCare Pharmaceuticals for being on the Editorial board for the International MS Journal.

X.M. has received honoraria for speaking and travel expenses to scientific meetings; steering member or participated in advisory boards in corporate-sponsored clinical trials or has had consulting agreements with Bayer Schering Pharma, Biogen Idec, EMD Merck Serono, Genentech, Genzyme, Novartis, Sanofi-Aventis, and Teva.

A.B. is a member of advisory boards, speaker and participant of clinical trials from Novartis, Merck Serono, Teva, Genzyme, Biogen Idec, and Nicomed.

G.C. has received consulting fees for advisory boards, consultancy, and speaker activities from Novartis, Teva, Sanofi-Aventis, Merck Serono, and Bayer Schering; and lecture fees from Novartis, Teva, Sanofi-Aventis, Merck Serono, Biogen Dompe; and Bayer Schering.

Specific in vivo imaging of inflammation, de-and remyelination using fluorescence molecular tomography

S. Albrecht, M. Eisenblätter, L. Wachsmuth, T. Vogl, C. Faber, T. Kuhlmann

University Hospital Münster (Münster, DE)

The histopathological characteristics of Multiple sclerosis as well as different demyelinating animal models are inflammation, demyelination, gliosis and relative axonal loss. So far, no imaging techniques exist that allows the specific detection of these different pathologies. Therefore, our aim was to establish imaging techniques to follow specifically inflammation as well as de- and remyelination in vivo. On the basis of the cuprizone mouse model we are able to follow these processes using Fluorescence Molecular Tomography (FMT). Cuprizone induced inflammation and the reduction as well as progression of myelin after cuprizone withdrawal can be imaged using a fluorescent conjugated antibody against the proinflammatory macrophage marker myeloid-related protein 14 (MRP-14) and the fluorescent myelin binding compound 3,3ß-diethylthiatricarbocyanine iodide (DBT). Due to different fluorescence characteristics of the antibody and the myelin binding compound, we are able to longitudinally and simultaneously image the degree of inflammation and de- and remyelination. The FMT studies were collaborated by Diffusion Tensor Imaging (DTI) studies that visualise the changed radial diffusivity of the corpus callosum in Cuprizone-fed mice during de- and remyelination. To verify the imaging results we additionally applied extensive histological and electronmicroscopical analyses.

With these combinatorial techniques we have a toolkit in hand to specifically study inflammation as well as de-and remyelination in vivo.

The authors have nothing to disclose.

Brain sodium accumulation and spreading correlate with disability in multiple sclerosis

W. Zaaraoui, B. Audoin, S. Konstandin, A.M. Nagel, E. Soulier, I. Malikova, A. Rico, F. Reuter, P. Viout, S. Confort-Gouny, P.J. Cozzone, J. Pelletier, L.R. Schad, J.-P. Ranjeva

Aix-Marseille University (Marseille, FR); Heidelberg University (Mannheim, DE); German Cancer Research Center (DKFZ) (Heidelberg, DE)

Purpose: Recent histopathological studies have highlighted the potential key role of sodium accumulation that leads to neuronal injury in multiple sclerosis (MS). We aimed to quantify brain sodium accumulation and characterize for the first time the spatial location of sodium abnormalities at different stages of relapsing remitting multiple sclerosis (RRMS) using sodium MRI.

Materials and methods: MR explorations were performed at 3T (Verio, Siemens) in two groups of RRMS patients, 14 early RRMS (disease duration<5years) and 12 advanced RRMS (>5years) and 15 controls. Sodium 23Na MRI was acquired using a double-tuned 23Na-1H volume head coil (RapidBiomed) and a density-adapted 3D radial projection reconstruction pulse sequence (Nagel et al 2009) (TE=200µs, TR=120ms, 17000 projections, resolution 3.6x3.6x3.6 mm³) with two external references. Proton MRI 3D-MPRAGE (resolution 1x1x1mm³) and T2-weighted were also obtained. The post-processing included reconstruction of the quantitative 3D radial sodium images (q23Na-MRI); coregistration of the q23Na-MRI with 1H-3D-MPRAGE; normalization and segmentation of the 1H-3D-MPRAGE (VBM8); application of the resulting grey matter (GM), white matter (WM) and T2-lesions masks to the normalized q23Na-MRI; smoothing of the resulting q23Na-MRI maps and statistical mapping analysis (SPM8) to locate total sodium concentration (TSC) abnormalities.

Results: For the two groups of MS patients, TSC was increased inside demyelinating lesions while increased TSC was observed in normal appearing WM and GM only in advanced RRMS. In patients, increased TSC inside GM was correlated to disability (EDSS) (p=0.046) and T2 lesion load (p=0.003) but not to disease duration (p=0.089). Statistical mapping analysis (SPM8, Anova, p<0.001) showed that abnormal TSC are already present at the early stage of RRMS in limited regions (brainstem, cerebellum and temporal poles) and are widespread, affecting the whole brain parenchyma, at the advanced stage of RRMS. EDSS was correlated to TSC increases inside a coherent motor network including bilateral cerebellum, primary motor area and bilateral prefrontal cortices (SPM8, simple regression, p<0.001).

Conclusions: Total sodium accumulation dramatically increases in advanced stage of RRMS especially in the normal appearing brain tissues concomitantly to disability. Further brain sodium MRI longitudinal studies with more patients are required to help monitoring the occurrence of tissue injury and disability.

The authors have nothing to disclose.

High-field phase contrast imaging in multiple sclerosis

V. Ovtcharov, M. Matzke, E. Stadler, K. Zhong, O. Speck, M. Sailer

Otto-von-Guericke University (Magdeburg, DE)

Phase contrast imaging (PC) at 7 Tesla as an alternative imaging contrast method for brain investigations has become increasingly popular in the last few years. This method promises additional information on the underlying pathology and is expected to be valuable for defining distinct pathological processes in the brain of patients with multiple sclerosis (MS) that may contribute to a better prognostication of lesion evolution and therefore prognosis of the disease. The aim of this study is to differentiate the T2-w MS lesions according to the information gained by PC method.

We recruited 30 patients with definite MS with mean age of 40 years, mean disease duration of 9 years and median score of 4, measured with Expanded Disability Status Scale (EDSS).

The patients were classified into three severity groups according their EDSS: (mild: 1-3; n=10/ moderate: 3.5-5.5; n=11 / severe: 6+; n=9). Fifteen patients received a follow-up scan within a median time of 9 months.

Scanning procedures included a 3D gradient echo sequence for phase image acquisition, a hyper turbo spin echo (TSE) 2D sequence and a high resolution 3D magnetization prepared rapid acquisition gradient echo (MPRAGE) for T1-W images. Lesions were identified on the T2-w scans and were compared to T1-w and phase contrast. Segmentation of all lesions and calculation of lesion volume was performed semi-automatically.

Since phase is expressing local field shift it reveals on a PC sequence a heterogeneous contrast although the same lesion has a homogeneous appearance on the corresponding T2-w scan. As described previously we subdivided the lesions according to their pattern detected on the PC scans into different sub-groups (heterogeneous, surrounded by rim, dark centre, dark).

A total number of 2600 sharp and demarcated lesions were counted (T2- 1040 / T1- 874 / PC- 686). Compared with T2-w contrast we only could identify 66% of the lesions on the PC, whereas 84% of the lesions detected on T2-w scans were confirmed on T1-w images. In the fifteen follow-up scans we did not observe a shift of the predominant pattern.

Patients with a predominant dark pattern were characterized by a higher median EDSS (6.5) when compared to the other groups (p= 0.001). This suggests that the phenomenology of the lesion in PC is stable at least over a median observation time of 9 months and a negative phase shift may characterise a lesion that is responsible for a more profound brain tissue damage leading to disability.

The authors have nothing to disclose.

Assessment of myelin content by positron emission tomography with [methyl-¹¹C]-2-(4’-methylaminophenyl)- 6-hydroxybenzothiazole in relapsing-remitting MS

B. Bodini, L. Bottin, L. Freeman, A. Chardain, M. Battaglini, O. Ciccarelli, C. Papeix, D. Galanaud, B. Zalc, D. García-Lorenzo, S. Lehéricy, C. Lubetzki, M. Bottlaender, B. Stankoff

Hôpital de la Salpêtrière (Paris, FR); APHP, Hôpital Tenon (Paris, FR); University of Siena (Siena, IT); UCL Institute of Neurology (London, UK); Service Hospitalier Frédéric Joliot (Orsay, FR)

Introduction: It has been shown that thioflavine derivative 2-(4’-methylaminophenyl)- 6-hydroxybenzothiazole (PIB) selectively binds to myelin in animals and post mortem human brain sections and that the level of PIB fixation parallels the amount of myelin contained in the white matter (WM). In this study, we used PET imaging with 11C-PIB to quantify in vivo the myelin content of the white matter of patients with multiple sclerosis (MS). We hypothesize that 11C-PIB uptake could successfully differentiate MS lesions, dirty white matter (DWM) and normal appearing white matter (NAWM).

Methods: Twelve patients with active relapsing-remitting MS underwent PET examination with 11C-PIB on a High Resolution Research Tomograph (HRRT, spatial resolution: 2.5mm) as well as conventional MRI at 3.0T. PIB-PET images were corrected by injected dose and body weight and expressed as standardized uptake values (SUV). SUV maps were then coregistered onto the corresponding 3D-T1 scans using a rigid transformation. White matter lesions (WML) were contoured semi-automatically on the T2 weighted scans, and registered to the 3D T1-weighted images with a rigid transformation. NAWM, DWM (defined as perilesional WM) and WML masks were generated on the T1w images, registered to the PIB-PET images, and corrected for partial volume effects. We then quantified the 11C-PIB uptake in the different WM regions of interest during the latest frames (30 to 70 minutes). Wilcoxon signed rank test for paired data was employed to test for difference in PIB uptake between NAWM and WML, between NAWM and DWM, and between DWM and WML.

Results: PIB uptake was found to be significantly lower in WML compared with NAWM (mean reduction in PIB SUV= -15%, range -28% to -4%, p=0.002), in the DWM compared to the NAWM (mean reduction in PIB SUV= -6%, range -17% to 0%, p=0.01), and in the WML compared to the DWM (mean PIB-SUV reduction -9%, range -2% to -13%, p=0.002).

Conclusion: Our preliminary results suggest that PET with 11C-PIB allows successful discrimination in the myelin content of MS lesions, DWM, and NAWM in vivo, reflecting the histo-pathological gradient in myelin concentration from lesional to normal appearing tissue. These results support the potential role of PIB as an imaging marker able to quantify and monitor demyelination and myelin repair in MS.

B.Bodini is supported by the grant INFLASEP ANR-08-MNP-016.

L.Bottin, L.Freeman, A.Chardain, M.Battaglini, D.Galanaud, B.Zalc, S.Lehéricy and Michel Bottlaender have nothing to disclose.

O.Ciccarelli receives research grant support from the Multiple Sclerosis Society of Great Britain and Northern Ireland, the Department of Health Comprehensive Biomedical Centre, the International Spinal Cord Research Trust (ISRT) and the Engineering and Physical Sciences Research Council (EPSRC); she has received honoraria from Bayer Schering and GE.

Caroline Papeix reports receiving consulting fees from Biogen Idec, Novartis, Bayer- schering, Sanofi Aventis and Teva Pharma, Roche ; lecture fees from Bayer-Schering, Biogen Idec, Sanofi Aventis and Teva ; and participating in clinical trials for Biogen Idec, Novartis, Merck Serono, Bayer- schering, Sanofi Aventis and Teva Pharma, Genzyme and Roche.

Bruno Stankoff reports receiving consulting fees from Biogen Idec, Novartis, Sanofi Aventis, Bayer-Schering and Teva Pharma; lecture fees from Bayer-Schering, Biogen Idec, Merck Serono, Sanofi Aventis and Teva Pharma; and research support from, Biogen Idec, Sanofi Aventis.

Catherine Lubetzki reports consulting fees from Roche, Novartis, Sanofi Aventis and Teva Pharma, lecture fees from Merck-Serono, Biogen-Idec, Sanofi Aventis and Teva, participating in clinical trials for Biogen Idec, Novartis, Merck Serono, Bayer- schering, Sanofi Aventis and Teva Pharma, Genzyme and Roche.

Short-term evolution of spinal cord damage in multiple sclerosis: a diffusion tensor MRI study

M. Théaudin, G. Saliou, B. Ducot, C. Denier, K. Deiva, D. Adams, D. Ducreux

CHU Bicêtre (Kremlin-Bicêtre, FR); INSERM 788 (Kremlin-Bicêtre, FR)

Purpose: The potential of DTI to detect spinal cord abnormalities in patients with multiple sclerosis has already been demonstrated. The objective of this study was to apply DTI techniques to Multiple Sclerosis patients with a recently diagnosed spinal cord lesion, in order to demonstrate a correlation between variations of DTI parameters and clinical outcome, and to try to identify DTI parameters predictive of outcome.

Methods: a prospective single-centre study of patients with spinal cord relapse treated by intravenous steroid therapy. Patients were assessed clinically and by conventional MRI with DTI sequences at baseline and at 3 months.

Results: Sixteen patients were recruited. At 3 months, 12 patients were clinically improved. All but one patient had lower FA and ADC values than normal subjects in either inflammatory lesions or Normal-Appearing Spinal Cord. Patients who improved at 3 months presented a significant reduction in the Radial Diffusivity (p=0.05) in lesions during the follow-up period. They also had a significant reduction in the mean ADC (p=0.002), Axial Diffusivity (p=0.02), Radial Diffusivity (p=0.02) and a significant increase in FA values (p=0.02) in Normal-Appearing Spinal Cord. Patients in whom the American Spinal Injury Association sensory score improved at 3 months showed a significantly higher FA (p=0.009) and lower Radial Diffusivity (p=0.04) in inflammatory lesion at baseline compared to patients with no improvement.

Conclusion: DTI MRI detects more extensive abnormalities than conventional T2 MRI. A less marked decrease in FA value and more marked decrease in Radial Diffusivity inside the inflammatory lesion were associated with better outcome.

The authors have nothing to disclose.

Assessing brain connectivity at rest is clinically relevant in early multiple sclerosis

A. Faivre, A. Rico, W. Zaaraoui, L. Crespy, F. Reuter, D. Wybrecht, E. Soulier, I. Malikova, S. Confort-Gouny, P.J. Cozzone, J. Pelletier, J.-P. Ranjeva, B. Audoin

Aix-Marseille Univ-CRMBM-UMR 6612 (Marseille, FR)

Objective: The present study aims to determine the clinical counterpart of brain resting-state networks reorganization recently evidenced in early multiple sclerosis.

Methods: Thirteen patients with early relapsing–remitting multiple sclerosis and 14 matched healthy controls were included in a resting state functional MRI study performed at 3 T. Data were analyzed using group spatial Independent Component Analysis using concatenation approach (FSL 4.1.3) and double regression analyses (SPM5) to extract local and global levels of connectivity inside various resting state networks (RSNs). Differences in global levels of connectivity of each network between patients and controls were assessed using Mann–Whitney U-test. In patients, relationship between clinical data (Expanded Disability Status Scale and Multiple Sclerosis Functional Composite Score – MSFC) and global RSN connectivity were assessed using Spearman rank correlation.

Results: Independent component analysis provided eight consistent neuronal networks involved in motor, sensory and cognitive processes. For seven RSNs, the global level of connectivity was significantly increased in patients compared with controls. No significant decrease in RSN connectivity was found in early multiple sclerosis patients. MSFC values were negatively correlated with increased RSN connectivity within the dorsal frontoparietal network (r=-0.811, p=0.001), the right ventral frontoparietal network (r=-0.587, p=0.045) and the prefronto-insular network (r=-0.615, p=0.033).

Conclusions: This study demonstrates that resting state networks reorganization is strongly associated with disability in early multiple sclerosis.These findings suggest that resting state functional MRI may represent a promising surrogate marker of disease burden.

The authors have nothing to disclose.

Cortical reorganisation and white matter tracts structural features matching in relapse-remitting multiple sclerosis during the relapse with motor disorders

S. Kulikova, V. Bryukhov, A. Peresedova, O. Trifonova, M. Krotenkova, I. Zavalishin

Research Center of Neurology RAMS (Moscow, RU)

Purpose: To investigate functional and structural features of motor disorders in patients with relapse-remitting multiple sclerosis(RRMS) during relapse.

Materials and methods: 16 patients with RRMS(4 men), all right handed,aged 19-50, underwent MRI (Avanto 1,5T,Siemens) during relapse characterized by light hand palsy. Scanning protocol included functional MRI(fMRI) and DTI sequences. FMRI was performed using a simple movement paradigm for both hands. DTI data were assessed in regions of interest (pons, internal capsules(IC), corpus callosum(CC) and medial lemniscuses(ML)). 10 healthy subjects aged 23-31 were included as control group.

Results:FMRI data analysis showed differently directed changes of functional activity of primary sensorimotor cortex(SMC) in contralateral hemisphere in contrast with ipsilateral one:11 patients were characterized by a decrease of its functional activity and 5 ones by an increase. These 2 groups differed significantly by fractional anisotropy(FA) (mean 0,597 and 0,501 respectively) and radial diffusivity(RD) (mean 478x10^-5 and 548x10^-5 mm²/s respectively) values in contralateral corticospinal tract(CST) (pons level), the larger group didn’t differ from the control one (mean 0,597 and 0,599 for FA;478x10^-5 and 454x10^-5 mm²/s for RD respectively),but the smaller one did (Mann-Whitney U test,p<0,05). Thus we could speculate that more severe CST damage can cause an increase of SMC activation as a type of reorganization pattern. The whole sample DTI data analysis showed increase of mean diffusivity(MD) and RD in the corresponding CST in comparison with the other one (IC level):mean 772x10^-5 and 749x10^-5 mm²/s for MD, 423x10^-5 and 392x10^-5 mm²/s for RD respectively;and in the motor area of CC in comparison with control group:mean 837 x10^-5 and 711 x10^-5 mm²/s for MD, 373 x10^-5 and 211 x10^-5 mm²/s for RD respectively (Mann-Whitney U test,p<0,05). Changes of diffusion indexes were not observed in ipsilateral CST and both ML in comparison with control group,thus being a sign of tract-specific damage.

Conclusion: Heterogeneity of SMC activation pattern depending on the structural state of CST was shown in RRMS patients with similar hand palsy during the relapse. Tract-specific structural changes were found in the contralateral CST and in the CC motor area. Longitudinal studies are warranted to specify structural and functional changes,which accompany temporal evolution of motor symptoms in RRMS patients.

S. Kulikova has nothing to disclose.

Quantification of independent cervical spinal cord atrophy measures correlate to motor and sensory deficits in MS

E. Garde, H. Lundell, A.-M. Dogonowski, S. Gude, H. Schmidt, P. Soelberg Sorensen, M. Blinkenberg, H.R. Siebner

Copenhagen University Hospital Hvidovre (Hvidovre, DK); Copenhagen University Rigshospitalet (Copenhagen, DK)

Objective: To assess whether measures of spinal cord width in the antero-posterior and left-right direction can provide clinically useful information about the atrophy of specific spinal pathways in individuals with Multiple sclerosis (MS).

Background: In MS tissue damage delays and disrupts neuronal signal transmission along essential spinal tracts. Recently we reported new magnetic resonance imaging (MRI) morphological measures of the cervical spinal cord extracted from conventional structural images of the brain which correlate specifically with sensory (antero-posterior width (APW)) and motor (left-right width (LRW)) deficits in patients with spinal cord injury.

Material and method: Analysis was based on 3D T1-weighted scans from 39 MS patients presenting with a wide range in clinical disability (26 relapsing-remitting (RR), 13 with secondary progressive (SP) MS. After correction for gradient nonlinearities a transversal spinal cord mask was created with the spinal process of C2 as caudal landmark. Spinal cord area (SCA), LRW, and APW were extracted from the mask and used for the statistical analysis. Quantification of lesion volume was obtained from T2-weighted and FLAIR images. Clinical disability was assessed using the Expanded Disability Status Scale (EDSS) and sensory and motor function using Multiple Sclerosis Impairment Scale (MSIS) creating sub-scores for sensation of touch and motor weakness. Statistical analysis was performed using Spearman correlations.

Results: APW correlated with total MSIS (p=0.0007/r=-0.52), MSIS sensation of touch (p=0.003/r=-0.46), MSIS motor weakness (p=0.005/r=-0.45), and EDSS (p=0.01/r=-0.39). Similar patterns were found for RR and SP. SCA correlated with total MSIS (p=0.001/r=-0.51), MSIS sensation of touch (p=0.01/r=-0.40), MSIS motor weakness (p=0.005/r=-0.44), and EDSS (p=0.009/r=-0.41). LRW was not significantly correlated to any of these functional parameters. Lesion load was not correlated to SCA, APW or LRW.

Conclusion: In patients with MS both sensory and motor deficits are reflected in spinal cord atrophy. Our results show that the anterior-posterior width but not left-to-right width of the cervical spinal cord correlates with clinical symptoms and disability and therefore, should primarily be used as neuroimaging marker in clinical trials.

Ellen Garde received honoraria for lecturing and travel expenses for attending meetings from Biogen Idec.

Henrik Lundell has no conflicts of interest.

Anne-Marie Dogonowski received honoraria for lecturing from Biogen Idec and travel expenses for attending ECTRIMS 2010 were covered by Merck Serono.

Sascha Gude has no conflict of interest.

Hanne Schmidt has no conflict of interest.

Per Soelberg Sorensen has received honoraria for lecturing and advisory councils, trial steering committees or travel expenses for attending meetings from Biogen Idec, Bayer Schering, Merck Serono, TEVA, Sanofi-aventis, Novartis, and Genmab.

Morten B Blinkenberg has nothing to declare.

Hartwig Siebner received honoraria for lecturing from Biogen Idec.

Quantitative susceptibility mapping in multiple sclerosis

C. Langkammer, T. Liu, M. Khalil, C. Enzinger, M. Jehna, S. Fuchs, F. Fazekas, Y. Wang, S. Ropele

Medical University of Graz (Graz, AT); Cornell Medical College (New York City, US)

Introduction: Iron levels have been shown significantly increased in the basal ganglia (BG) of multiple sclerosis (MS) patients when compared to healthy controls (HC) [1-2]. Additionally, iron accumulation has been linked to disease duration and loss of cortical brain volume [2]. In contrast, there was no evidence for abnormal high iron levels in the BG in patients with clinically isolated syndrome (CIS) suggestive of MS. Quantitative susceptibility mapping (QSM) is a novel MRI technique that can directly assess iron related susceptibility changes [3]. Thus, this explorative study aimed at assessing changes of the magnetic susceptibility in the BG of MS and CIS patients and relating these findings to clinical status, lesion load, and brain tissue loss. Additionally, the sensitivity of QSM and conventional R2*-based iron mapping for assessing disease related tissue changes was compared.

Materials: 68 patients (26 CIS, 42 relapsing-remitting MS) and 23 age-matched HC underwent quantitative MRI at 3T. Magnetic susceptibility and R2* maps were reconstructed from the same 3D multi-echo spoiled gradient echo sequence. The Morphology Enabled Dipole Inversion (MEDI) method was used for the QSM reconstruction, allowing the determination of magnetic susceptibility from a single oriented clinical MRI scan [4]. Susceptibility and R2* were measured in the BG and then were related to phenotype, clinical parameters and regional brain volumes.

Results: MS and CIS patients had increased (more paramagnetic) magnetic susceptibilities in the BG when compared to HC. R2* mapping proved less sensitive than QSM regarding group differences. The strongest predictor of magnetic susceptibility was age. BG susceptibility was higher with increasing EDSS (r=0.3, p<0.01), and lower with normalized volumes of gray matter (r=-0.4, p<0.001) and cortex (r=-0.4, p<0.001).

Conclusion: Disease related tissue changes were already observed in CIS patients suggesting that QSM can serve as a sensitive marker for pathophysiological aspects already from the earliest stages of the disease. Additionally, QSM provides superior sensitivity over R2* mapping in the detection of disease related tissue changes in the BG in MS. We interpret this increased susceptibility as a consequence of higher iron content, but demyelination might play an additive role [5].

References

1. Brass, 2006, Top MRI.

2. Khalil, 2011, Neurology.

3. de Rochefort, 2008, MRM.

4. Liu T, 2011, MRM.

5. Langkammer, 2012, NeuroImage.

The authors have nothing to disclose.

Relation of baseline cortical blood flow and whole-brain volume reduction over five years

M. Amann, K. Weier, Y. Naegelin, J. G. Hirsch, J. Reinhardt, J. Gregori, M. Günther, E.W. Radue, L. Kappos, A. Gass, C. Stippich, T. Sprenger

University Hospital Basel (Basel, CH); University of Bremen (Bremen, DE); Fraunhofer MEVIS (Bremen, DE); Medical Image Analysis Center (Basel, CH)

Introduction: Progressive brain atrophy has been used as a marker of irreversible tissue damage in MS patients. It is known to be associated with hypo-perfusion and decreased metabolic activity [1]. Therefore, blood flow changes may precede brain atrophy. We investigated whether cortical perfusion at baseline measured by arterial spin labelling (ASL) may predict whole brain atrophy at follow-up five years later.

Methods: 136 clinically stable MS patients (97 women, mean age 45.7y (19y-67y), mean disease duration 14.3y (1-38y)) with different disease courses (103 RRMS, 28 SPMS, 5 PPMS) were analysed.

At baseline, patients underwent a comprehensive MRI protocol on a 1.5T MR system (Avanto, Siemens) including a double-echo PD/T2-weighted sequence and a 3D T1-weighted scan (1x1x1mm³). Cortical blood flow (CBF), was assessed with a pulsed ASL sequence (FAIR preparation combined with 3D-GRASE readout [2]; 2.3x2.3x4mm³). From the ASL time series (TI=300ms up to 3000ms in steps of 300ms), CBF was calculated by using a cortex mask. Patients received a follow up 3D T1-weighted scan at the same scanner with identical parameters after 5 years (±6 months). Annual Percentage Brain Volume Change (aPBVC) was calculated from the 3D data sets at both time points using SIENA. To investigate the relationship of different clinical and MRI parameters with aPBVC, stepwise Multiple Linear Regression (MLR) models were calculated and controlled for multicollinearity.

Results: The mean aPBVC of the entire cohort was -0.43% (SD: 0.42%, range -1.9%, +0.5%). Subgroup analysis showed a significantly lower mean aPBVC in women compared to men (w: -0.37%; m: -0.56%, p=0.02) and a higher aPBVC in PPMS patients compared to patients with other disease courses (PPMS: -0.92%; RRMS: -0.40%; SPMS: -0.41%). Mean CBF was 46.2ml/100g/min (29.5-64.2ml/100g/min); mean T2 lesion load was 6.2ml (0ml-29.8ml). The model with the highest R² predicting aPBVC included CBF (p=0.05), gender (p=0.02) and disease duration (p=0.05) as significant factors.

Discussion: Our results are in line with previous data regarding the correlation of brain atrophy and disease duration resp. gender. Furthermore, we found a significant correlation between the cortical blood flow at baseline and annual PBVC after five years. We therefore conclude that low cortical blood flow at baseline could serve as a predictive marker for neurodegeneration in MS patients.

References

1. Pozzilli C et al, JNNP 1991.

2. Günther M et al, MRM 2005.

M. Amann, K. Weier, Y. Naegelin, J.G. Hirsch, J. Reinhardt, E.W. Radue, and C. Stippich have nothing to disclose.

M. Günther participated in the development of the Siemens product version of the described ASL sequence and has financial arrangements with Siemens, Erlangen.

L. Kappos has received institutional research support from Acorda, Actelion, Advancell, Allozyne, Barofold, Bayer, Bayhill, Biogen Idec, BioMarin, Boehringer Ingelheim, CSL Behring, Eli Lilly, Geneuro, Genmab, GlaxoSmithKline, Glenmark, Merck Serono, MediciNova, Novartis, Sanofi -Aventis, Santhera, Shire, Roche, Teva, UCB, Wyeth, Swiss MS Society, Swiss National Research Foundation, European Union, Gianni Rubatto Foundation, the Novartis and Roche Research Foundations.

Dr. Gass has received honoraria for lecturing, travel expenses for attending meetings, and financial support for research from Bayer Schering, Biogen Idec, Merck Serono, Novartis and TEVA Neurosciences.

T. Sprenger served on advisory boards for Mitsubishi Pharma, Eli Lilly, Biogen and Allergan. He received travel supportfrom Pfizer, Bayer Schering, Eli Lilly and Allergan.

Deformation based MRI analysis of deep grey matter structures in MS

S. Magon, M. Chakravarty, M. Amann, K. Weier, Y. Naegelin, M. Andelova, E.-W. Radue, C. Stippich, J. Lerch, L. Kappos, T. Sprenger

University Hospital Basel (Basel, CH); University of Toronto (Toronto, CA); Medical Image Analysis Center (Basel, CH)

Background: Brain atrophy is a well-known feature of multiple sclerosis. Most recent studies have focused on global or cortical brain atrophy. Few studies investigated the volume and shape of deep gray matter (DGM) areas such as the striatum, globus pallidus and thalamus.

Aim: To investigate the relationship of disease duration (DD), white matter lesion load (WMLL) and the morphology of DGM in relapsing remitting multiple sclerosis (RRMS) patients using a novel deformation-based approach taking into account volume and shape of DGM.

Methods: T1 MPRAGE MRI data were acquired at 1.5T in 115 patients with RRMS (80 woman; age 44.9±10.4 y; DD 15.3±8.6 y; EDSS 2.7±1.4). The DGM were segmented using a multi-atlas technique that relies on the generation of an automatically generated template library (Chakravarty et al., in press). To localize morphological changes, shape analysis was performed by estimating the vertex-wise displacement each subject must undergo to deform to a template. Multiple regression analysis was used to study the relation between DGM volume and WMLL as well as DD. We also identified the best EDSS predictor among the DGM areas using stepwise regression.

Results: WMLL and DD were good predictors of DGM atrophy in the regression analysis. WMLL correlated with the volume of globus pallidus (left, β (b)=0.331, p<0.001; right, b=-0.340, P<0.001), thalamus (left, b=-0.556, p<0.001; right, b=-0.497, P<0.001) and striatum (left, b=-0.309 p< 0.001; right, b=-0.280, P<0.01). The DD correlated with left globus pallidus (b=-0.241 p<0.01) and bilateral thalamic volume (left, b=-0.197 p<0.013; right b=-0.241 p<0.01). Left thalamic volume was the most important predictor of EDSS (b=-447, p<0.001). Shape analysis showed that WMLL mainly affects the anterior-ventral thalamus (left, F=1.6, FDR (False Discovery Rate)=0.05; right, F=4.02, FDR=0.05), the internal segment of the globus pallidus (left, F=0.015, FDR=0.01; right, F=4.09, FDR=0.01) and the ventral portion of the striatum (left, F=2.4, FDR=0.01, right, F=5.28, FDR=0.01). Changes in shape of the superior portion of the left thalamus correlated with DD (F=2.55, FDR=0.05).

Conclusion: Our results suggest that this novel shape analysis methodology may allow to depict specific roles of DGM structures in the manifestation of neurological deficits. Both EDSS and DD are related to alterations in the thalamus. WMLL relates to a more generalized involvement of DGM.

S. Magon, M. Chakravarty, M. Amann, K. Weier, Y. Naegelin, M. Andelova, E.-W. Radue, Ch. Stippich and J. Lerch have nothing to disclose.

L. Kappos has participated in the last 24 months as principal investigator, member or chair of planning and steering committees or advisory boards in corporate-sponsored clinical trials in multiple sclerosis and other neurological diseases. The sponsoring pharmaceutical companies for these trials include Abbott, Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CSL Behring, Elan, Genmab, GeNeuro SA, Genmark, GlaxoSmithKline, Lilly, Merck Serono, Novartis, Novonordisk, Peptimmune, Sanofiaventis, Santhera, Roche, Teva, UCB and Wyeth. He has also lectured at medical conferences or in public on various aspects of the diagnosis and management of multiple sclerosis. In many cases these talks have been sponsored by non-restricted educational grants to my institution from one or another of the above listed companies. Honoraria and other payments for all these activities have been exclusively used for funding of research of my department. Research and the clinical operations (nursing and patient care services) of the MS Center in Basel have been supported by non-restricted grants from one or more of these companies.

T. Sprenger served on advisory boards for Mitsubishi Pharma, Eli Lilly, Biogen and Allergan. He received travel supportfrom Pfizer, Bayer Schering, Eli Lilly and Allergan.

All Gd lesions are not the same: impact of protocol sensitivity on lesion detection assessed using quantitative dynamic contrast-enhanced MRI

I.R. Leppert, S. Narayanan, D. Araújo, R. Arnaoutelis, I.O. Jelescu, D.L. Arnold, G.B. Pike

Montreal Neurological Institute (Montreal, CA)

Introduction: Dynamic-contrast-enhanced (DCE) MRI provides a quantitative tool for assessing the integrity of the blood-brain-barrier (BBB). We used DCE MRI to compare the impact of using “standard” and “optimized” protocols for gadolinium (Gd) enhanced scanning on the permeability threshold for enhancing lesion detection and the apparent time course of enhancement.

Methods: 10 RRMS patients were scanned with standard and optimized protocols at baseline and 1-month, yielding 4 scans per patient. The standard protocol used a single-dose of Gd-BT-DO3A on a 1.5T scanner, while the optimized protocol was acquired at 3T with DCE-MRI obtained during and after a single-dose injection of contrast. A second injection at double-dose was administered 20 min after the first, with a final post-contrast image acquired 15min later[1]. BBB permeability values were estimated using the Extended-Tofts-Kermode model[2]. Barely detectable voxels, defined as having an intensity increase of 20-30% on the post-Gd relative to the pre-Gd images, were used to determine the detection threshold for each protocol and estimate the time course and phase of lesion enhancement.

Results: 35 lesions enhanced with the standard and 86 with the optimized protocol, demonstrating a significant increase in detectability with the optimized protocol. In addition, 38% of scan pairs showed lesion activity on the 3T but not the 1.5T. The detection threshold of the optimized protocol was significantly lower than that of the standard protocol (2.1E-3min-1 vs. 4.1E-3min-1, p<.01). Most lesions (86%) were in the recovery phase over the 1-month time interval studied; none were captured in the acute onset phase and 14% of lesions were at the peak of enhancement. Combining our results with literature values[3], the estimated duration of detectability with the optimized protocol ranges from 12-18 weeks, at least 3 times that estimated for the standard protocol.

Conclusion: The thresholds for detection of Gd-enhancing lesions and the apparent duration of enhancement differ when using a standard 1.5T and an optimized 3T triple-dose, delayed protocol. Our observations have important implications for understanding the effects of anti-inflammatory therapies on Gd lesions and the interpretation of Gd suppression, or lack thereof. A probable enhancement time course is presented, suggesting that lesions have a rapid onset and a much slower recovery phase.

1. Jelescu IO et al, JMRI 33, 2011

2. Tofts PS et al, MRM 17, 1991

3. Cotton F et al, Neurol 60, 2003

IR Leppert, Dr. D Araújo, R Arnaoutelis and IO Jelescu have nothing to disclose.

Dr. S Narayanan has received personal compensation from NeuroRx Research, Teva Neurosciences Canada and Biogen Idec Canada for consulting services.

Dr. Arnold has served on advisory boards, received speaker honoraria, served as a consultant or received research support from Bayer, Biogen Idec, Coronado Biosciences, Consortium of Multiple Sclerosis Centers, Eli Lilly, EMD Serono, Genentech, Genzyme, GlaxoSmithKline, MS Forum, NeuroRx Research, Novartis, Opexa Therapeutics, Roche, Merck Serono, S.A.,Serono Symposia International Foundation, Teva, the Canadian Institutes of Health Research, and the Multiple Sclerosis Society of Canada; and holds stock in NeuroRx Research.

Dr. GB Pike has nothing to disclose.

The study was supported by a grant from the Multiple Sclerosis Society of Canada.

Inter-rater variability of new T2 determination in the clinic has implications for MS diagnosis and monitoring

C. Elliott, J. Maranzano, D. Cadavid, N. Richert, P. Duda, E. Fisher, S. Narayanan, D.L. Collins, T. Arbel, D.L. Arnold

McGill University (Montreal, CA); NeuroRx Research (Montreal, CA); Biogen Idec (Cambridge, US); Cleveland Clinic (Cleveland, US)

Purpose: Diagnosis and monitoring of treatment in treated MS is increasingly relying on the assessment of new lesion formation on MRI. The objective of this study was to determine the inter-rater variability and accuracy of expert readers (5 neurologists and 4 neuroradiologists) for detection of new T2-lesion counts identified using only FLAIR MRI of brain (which is commonly done) and to determine the effect of co-registration of sequential MRIs on the accuracy of manual identification of new lesions.

Methods: New T2-lesions were manually identified independently by 9 readers in 60 follow-up scans of RRMS patients, taken on average 12.4 weeks after a reference scan. Manual identification was performed using axial FLAIR sequences only and was first performed using unregistered images, and then at a later date (minimum 2 week interval), using co-registered images. Subjects were considered active if at least 1 new T2 lesion was detected. Ground truth for new T2-lesions was generated in the same cohort using an optimized, computer-assisted method that considered T1-weighted, T2-weighted, PD-weighted, FLAIR and contrast enhanced T1-weighted images at reference and follow-up scans, as well as prior, intervening and subsequent scans of the same subject. New lesion counts were compared for unregistered and registered images. Counts of 4 or more new lesions were considered equivalent.

Results: As per ground truth, 29 of 60 subjects were inactive (had no new lesions between reference and follow-up scans), 3 had 1 new lesion, 6 had 2 new lesions, 9 had 3 new lesions, and 13 had 4 or more new lesions. Mean inter-rater agreement on subject activity among the readers was 71.4% using unregistered images and 75.4% using registered images. Mean inter-rater agreement on lesion counts among readers was 45.7% using unregistered images and 54.4% using registered images. Mean agreement of readers with the ground truth on subject activity was 73.9% using unregistered images and 80.7% using registered images. Mean agreement with the ground truth on lesion counts was 48.3% using unregistered images and 55.6% using registered images.

Conclusions: Manual identification of lesion activity using only FLAIR sequences leads to relatively low inter-rater reliability and accuracy, whether or not the images are co-registered prior to assessment. These results imply, that in a clinical setting, approximately one-quarter of patients may be misclassified in terms of new lesion activity.

This study was funded by Biogen Idec.

CE is funded by NSERC grant CRDPJ 411455-10 and has received personal compensation from NeuroRx Research.

JE is an employee of NeuroRx Research.

DC is an employee of Biogen Idec.

NR is an employee of Biogen Idec.

PD is an employee of Biogen Idec.

EF has received personal compensation in the form of consulting fees and/or speaking honoraria from Biogen Idec, Genzyme, Teva, and Wyeth/Pfizer and research support paid to the Cleveland Clinic from Biogen Idec and Genzyme.

SN has received personal compensation from NeuroRx Research, Teva Neurosciences Canada and Biogen Idec Canada for consulting services.

DLC has received personal compensation from NeuroRx Research and Teva Neurosciences Canada.

TA has nothing to disclose.

DLA has served on advisory boards, received speaker honoraria, served as a consultant or received research support from Bayer, Biogen Idec, Coronado Biosciences, Consortium of Multiple Sclerosis Centers, Eli Lilly, EMD Serono, Genentech, Genzyme, GlaxoSmithKline, MS Forum, NeuroRx Research, Novartis, Opexa Therapeutics, Roche, Merck Serono, S.A.,Serono Symposia International Foundation, Teva, the Canadian Institutes of Health Research, and the Multiple Sclerosis Society of Canada; and holds stock in NeuroRx Research.

Natural history of MRI lesion accrual in children with MS: a national prospective cohort study of children with acute CNS demyelination

L.H. Verhey, D.L. Arnold, H.M. Branson, M.M. Shroff, S. Narayanan, J.G. Sled, A. Bar-Or, A.D. Sadovnick, R.A. Marrie, B. Banwell on behalf of the Canadian Paediatric Demyelinating Disease Network

Background: Understanding the natural history of new lesion accrual over time in children with MS is essential for planning therapeutic studies utilizing MRI measures of lesion accrual as primary or secondary study outcomes. We evaluated the rate of new T2 and contrast-enhancing lesions over time in children with MS who have been followed using a prospective standard serial MRI protocol from the time of first attack.

Methods: T1-weighted pre- and post-contrast, PD-/T2-weighted and FLAIR images were acquired on 1.5 Tesla scanners at 23 Canadian paediatric healthcare centers using a standardized protocol for children with acute demyelinating syndromes (ADS) at baseline, 3 months, 6 months and 1 year (and annually thereafter at the lead site). MS diagnosis was based on the occurrence of a second demyelinating episode or dissemination in time according to the 2005 McDonald criteria. None of the MS patients were treated with immunomodulatory therapies prior to second attack. For children with MS, two experts counted the number of new T2 and contrast-enhancing lesions on each serial scan. The rate of new lesion accrual is based on the number of person-years at risk. Annualized rates of new lesion accrual are summarized using mean (SD).

Results: Of the 284 children with ADS who have been followed for a mean of 3.9 (1.7) years, 57 (20%) have been diagnosed with MS to date. All 57 children had a baseline scan for analysis, and a total of 210 serial scans were evaluated (155 during year 1; 55 during years 2-5). Using a total of 106.8 person years, the rate of new T2 lesions was 8.1 per individual per year. During the first year of observation, 52 (91%) children had ≥ 1 new T2 lesion; 23/30 (77%) children with serial imaging during years 2-5 had ≥ 1 new T2 lesion. The number of new contrast-enhancing lesions per scan during the first year of observation was 1.2 (2.0). At 3-month follow-up, the number of new contrast-enhancing lesions per child was 1.3 (2.1). In the first year of observation, 31/55 (56%) children had ≥ 1 new contrast-enhancing lesion; 9/25 (36%) children who had serial contrast-enhanced imaging during years 2-5 had ≥ 1 new contrast-enhancing lesion.

Conclusions: New lesion accrual occurs in the first year following initial attack in nearly all paediatric MS patients, indicating that MRI evidence of active disease is a reasonable metric to evaluate therapeutic agents that have inflammatory disease-suppressive capacity.

This study was funded by the Canadian Multiple Sclerosis Scientific Research Foundation. ADS, AB-O, DLA, RAM, and BB serve as lead investigators and funds from the study grant have supported work done at their institutions. None of the investigators receive personal salary support from the study sponsor. Funds from the study grant have supported travel for presentation at national and international meetings. LHV receives studentship support from the Canadian Institutes of Health Research (CIHR) Frederick Banting and Charles Best Master’s and Doctoral Canada Graduate Scholarships: 201010GSD-249751-175560 and 200802CGM-186751-175560, Multiple Sclerosis Society of Canada (MSSC) Master’s Award, and The Hospital for Sick Children Foundation Research Training Award. HMB, MMS, and JGS report no disclosures. DLA has served as a speaker at meetings or as a consultant for Bayer, Biogen, Elan, GlaxoSmithKline, Roche, and Teva Neuroscience. DLA receives financial remuneration and stock options from NeuroRx Research. SN has received consultancy fees or speaker’s honoraria from Teva Neuroscience and NeuroRx Research. AB-O has received consultancy fees from Bayhill Therapeutics, Berlex, Biogen-IDEC, BioMS, Diogenix, Eli-Lilly, Genentech, GlaxoSmithKline, Guthy-Jackson/GGF, Merck-Serono, Novartis, Roche, Teva Neuroscience, and Wyeth. AB-O has funding from the US National Institutes of Health, the CIHR, MSSC, Biogen-IDEC, and Teva Neuroscience for research unrelated to the present study. ADS has received speaker’s honoraria from Biogen, Merck-Serono, Teva Neuroscience, and Bayer and has grant support from CIHR, the MSSC and the Canadian Multiple Sclerosis Scientific Research Foundation for research unrelated to the present study. RAM has funding from the CIHR, MSSC, Manitoba Health Research Council, HSC Foundation, Public Health Agency of Canada, Rx&D Health Research Foundation, Consortium of MS Centers, and sanofi-aventis for research unrelated to the present study. BB has received speaker’s honoraria from Merck-Serono, Biogen-IDEC, Bayer Healthcare, and Teva Neuroscience. BB serves as an advisor on pediatric therapies for Biogen-IDEC, Merk-Serono, and Genzyme. BB is supported by the MSSC, the Canadian Multiple Sclerosis Scientific Research Foundation, and by a New Emerging Team Grant in Autoimmunity supported by the CIHR and MSSC.

Myelin water imaging changes in primary progressive multiple sclerosis brain

S. Kolind, A. Seddigh, N. Sibtain, S. Deoni, G.J. Barker, A. Traboulsee, S.C.R. Williams, P.A. Brex

University of British Columbia (Vancouver, CA); King’s College Hospital (London, UK); Brown University (Providence, US); King’s College (London, UK)

Background: Multi-component relaxation imaging is an advanced MRI technique that can be used to assess the myelin water fraction (MWF), a measure related to myelin content. mcDESPOT permits high-resolution whole-brain multi-component relaxation imaging in under 12 minutes. In a previous study, we demonstrated correlations (R=-0.58) between MWF decreases and the Expanded Disability Status Scale (EDSS) in primary progressive MS (PPMS) throughout white matter. Two of the functional system scores that make up the EDSS showed more regionally focused correlations with MWF decreases: the mental score was correlated in anterior regions while the sensory score was correlated in posterior regions near the sensory cortex, suggesting that MWF reflects changes in focal pathology that are relevant to disease expression.

The goal of this study was to assess the correlation between MWF and the Multiple Sclerosis Functional Composite (MSFC) score and its components, which consist of measures of motor function including upper limb (nine-hole peg test, 9HPT), lower limb (timed walk) and cognitive function (paced auditory serial addition test, PASAT).

Methods: 15 PPMS patients underwent whole-brain mcDESPOT imaging and MSFC assessment on the same day. Voxelwise MWF maps were derived, and a white matter tract skeleton was created from the MWF maps using tract-based spatial statistics. Voxelwise non-parametric testing was performed on the skeletonised MWF data across the brain to assess correlations with the mean time (across both hands) for the 9HPT and the timed walk, the PASAT score, and the MSFC.

Results: Significant correlations between longer 9HPT times and lower MWF values were found in the genu and body of the corpus callosum and minor forceps (R = 0.67, p=0.008 in significant regions). No significant correlations were found between MWF and the timed walk or the PASAT score. Significant correlations (R = 0.55, p=0.03) between the MSFC score and MWF were observed in very similar regions to the 9HPT, implying that these correlations were driven by the correlation with the 9HPT times.

Conclusions: Modest correlations were found between MWF and the MSFC score, and in this small PPMS cohort they appear to have been accounted for by the results of the 9HPT. Future work will involve serial studies and include spinal cord imaging; changes in these scores over time may correlate more strongly with MWF, and motor-related scores may correlate more strongly with spinal cord MWF.

S. Kolind is funded by a fellowship from the Michael Smith Foundation for Health Research.

A. Seddigh, N. Sibtain and S. Deoni have nothing to disclose.

G.J. Barker received honoraria for teaching from General Electric during the course of this study, and is a consultant for IXICO.

A. Traboulsee is supported by the MS Society of Canada, the Canadian Institute for Health Research and Bayer Pharmaceutical, has received honoraria for membership on clinical trial steering committee for Roche and data safety monitoring board for Merck Serono, as well as for presentations received from EMD Serono, Biogen, Bayer and Sanofi Genzyme Committee Board.

S.C.R. Williams has nothing to disclose.

P.A. Brex has received support for scientific meetings and honorariums for advisory boards and lectures from Merck Serono, TEVA, Biogen Idec, Bayer and Novartis.

Effect of alemtuzumab vs. Rebif® on brain MRI measurements

D.L. Arnold, J. Cohen, A.J. Coles, C. Confavreux, E. Fisher, E.J. Fox, H.-P. Hartung, E. Havrdova, K. Selmaj, H. Weiner, T. Miller, C.L. Twyman, S.L. Lake, D.H. Margolin, M. Panzara, M. Rizzo, D.A.S. Compston for the CARE-MS II investigators

Objective: Compare effects of alemtuzumab and interferon β-1a (SC IFNB-1a) on MRI outcomes in a phase 3 trial in relapsing-remitting multiple sclerosis (RRMS).

Background: In a 2-year, phase 3 trial comparing alemtuzumab and SC IFNB-1a in RRMS (CARE-MS II), alemtuzumab reduced relapse rate by 49% (p<0.0001) and sustained accumulation of disability measured by EDSS by 42% (p=0.0084). In prior trials comparing alemtuzumab and SC IFNB-1a (CAMMS223, CARE-MS I), alemtuzumab was superior on several MRI outcomes.

Methods: CARE-MS II was a 2-year, randomized, rater-blinded, global trial comparing efficacy and safety of alemtuzumab (12mg/day intravenously on 5 days at entry and 3 days one year later) and SC IFNB-1a (44mcg subcutaneously 3 times weekly) in RRMS patients who relapsed on prior therapy; patients in a third, exploratory arm received 24mg/day alemtuzumab. MRI scans acquired at baseline, 12, and 24 months were analyzed to measure lesions and brain atrophy. Lesion measurements included counts of new or enlarging T2 hyperintense lesions, gadolinium (Gd)-enhancing lesions, and new T1 hypointense lesions as well as total volumes of T2 and T1 lesions. Treatment effects were compared for changes in T2 and T1 lesion volumes and change in brain parenchymal fraction (BPF) using a ranked ANCOVA model, and for the percentage of patients with active lesions using logistic regression.

Results: Alemtuzumab 12 mg/day was significantly more effective than SC IFNB-1a on many measures of disease activity and overall burden of disease. Compared with SC IFNB-1a, alemtuzumab significantly reduced the risk of developing Gd-enhancing lesions by 69% at 24 months, and reduced cumulative risk of developing new or enlarging T2 hyperintense lesions by 62% and new T1 hypointense lesions by 63% (all p<0.0001). Small reductions from baseline to Year 2 in T2 hyperintense lesion volume occurred with no significant difference overall between groups, but T2 lesion volume change from Year 1 to Year 2 was significantly better with alemtuzumab (p=0.0261). BPF decrease (whole brain atrophy) over 2 years was lower in the alemtuzumab group compared with the SC IFNB-1a group (median percent change -0.62 vs. -0.81, p=0.0121).

Conslusions: Alemtuzumab was superior to SC IFNB-1a on numerous MRI outcome measures, despite well-established, substantial effects of SC IFNB-1a on MRI outcomes. These findings support the clinical evidence of alemtuzumab’s superior efficacy over SC INFB-1a in RRMS patients with active disease who relapsed on prior therapy.

Dr Douglas L. Arnold reports receiving personal compensation or research support from Bayer Healthcare, Biogen Idec, Genentech, Genzyme, Roche, and Teva Pharmaceuticals.

Dr Jeffrey Cohen reports receiving personal compensation as a consultant or speaker from Biogen Idec, Eli Lilly, Novartis, Teva Pharmaceuticals, Receptos, and Vaccinex.

Dr Alasdair J. Coles reports receiving consulting fees, lecture fees, and institutional grant support from Genzyme, Merck-Serono, and UCB-Celltech.

Dr Christian Confavreux reports receiving consulting fees from Biogen Idec, Gemacbio, Genzyme, Novartis, Sanofi-Aventis, Teva Pharmaceuticals, and UCB; lecture fees from Bayer-Schering, Biogen Idec, Genzyme, Merck-Serono, Novartis, Octapharma, Sanofi-Aventis, and Teva Pharmaceuticals; and research support from Bayer-Schering, Biogen Idec, Merck-Serono, Novartis, Sanofi-Aventis, and Teva Pharmaceuticals.

Dr. Fisher has received personal compensation in the form of consulting fees from Biogen Idec and financial support for research activities from Biogen Idec and Genzyme.

Dr Edward Fox reports receiving consultancy fees, honoraria, travel, and research support from Bayer Healthcare, Novartis, Ono, Sanofi-Aventis, Biogen Idec, EMD Serono, Genzyme, Opexa Therapeutics, Pfizer, Teva Pharmaceuticals, and Eli Lilly.

Dr Hans-Peter Hartung reports receiving the approval of the Rector of HHU fees for consulting, lectures, and activities in Steering Committees of the following companies: Bayer Schering, Biogen Idec, BioMS, Genzyme, Merck-Serono, Novartis, Teva Pharmaceuticals, and Sanofi-Aventis.

Prof Eva Havrdova reports receiving honoraria and grant support from Bayer-Schering, Biogen Idec, Genentech, Genzyme, GlaxoSmithKline, Merck-Serono, Octapharma, Pfizer, Roche, Sanofi-Aventis, and Teva Pharmaceuticals.

Dr Krzysztof Selmaj reports receiving consulting fees from Genzyme, Novartis, Biogen, and Roche; lecture fees from Novartis, Merck-Serono, Biogen, and Bayer Healthcare; and financial compensation, including travel, from Genzyme for scientific presentations.

Dr Howard Weiner reports receiving consulting/honoraria from Biogen Idec, EMD Serono, Genzyme, Teva Pharmaceuticals, Novartis, Nasvax, and GlaxoSmithKline and research support from EMD Serono and GlaxoSmithKline.

Dr Tamara Miller reports receiving compensation for speaker activities from Accorda, Allergan, Biogen Idec, Eli Lilly, Forest, Questcor, and Teva Pharmaceuticals; until clinical trial closure, Dr Miller was an independent contractor for Allergan, Biogen Idec, Genzyme, Elan, Teva Pharmaceuticals, Ono, Sanofi-Aventis, EMD Serono, and Roche/Genentech.

Dr Cary L. Twyman reports receiving compensation for clinical trials from Genzyme, Sanofi-Aventis, Eli Lilly, Opexa Therapeutics, Biogen Idec, Teva Pharmaceuticals, Roche, Novartis, Xenoport, Accorda, and Pfizer Inc and compensation for speaker activities and consultation activities from Accorda, Biogen Idec, Novartis, Forrest, and Teva Pharmaceuticals.

Drs David H. Margolin, Stephen L. Lake, Marco Rizzo and Michael Panzara report receiving personal compensation as employees of Genzyme, a Sanofi company.

Prof Alastair Compston reports receiving consulting fees, lecture fees, and grant support from Genzyme and lecture fees from Bayer Schering Pharma on behalf of the University of Cambridge.

Funding provided by Genzyme, a Sanofi company, and Bayer Healthcare Pharmaceuticals.

Assessment of disease activity in multiple sclerosis phenotypes using a combined gadolinium and iron oxide nanoparticles MR contrast

S. Roggerone, T. Tourdias, B. Brochet, S. Molinier, J. Bocquet, S. Vukusic, F. Durand-dubief, C. Confavreux, D. Miller, J.-P. Pruvo, M. Dufour, M. Rovaris, M. Filippi, V. Dousset

Hôpital Neurologique Pierre Wertheimer (Bron, FR); CHU Pellegrin (Bordeaux, FR); Institute of Neurology (London, UK); CHU Lille (Lille, FR); Neuroimaging Research Unit (Milan, IT); Neuroimaging Research Unit (Milan, IT)

Purpose: (1) To compare the sensitivity of ultrasmall superparamagnetic iron oxide (USPIO) and gadolinium (Gd) for the detection of active lesions in MS including comparison of MR phenotype according to the clinical phenotype and (2) to investigate the predictive value of each post-contrast MR feature (Gd-only, USPIO-only, USPIO+Gd).

Materials and methods: Local Ethical Committees approval and written informed consent were obtained from all patients prior to study initiation. Twenty four MS patients (14 relapsing and 10 progressive forms) were prospectively included in a longitudinal, multicenter, phase IIb study. Clinical evaluation and Gd and USPIO (Ferumoxtran-10) MRI were performed at baseline (M0) and at 6 months (M6).

Results: At M0, 56 lesions presented contrast enhancement. Gd classified 37 lesions in 10 patients as active while USPIO detected 19 additional enhanced lesions and identified 2 additional patients as active. Enhancement was more frequent in relapsing than in progressive forms with both contrast (p<0.0001) but faint USPIO enhancement could also be observed on T1-weighted images in progressive forms detecting 56% additional lesions in this phenotype. Among the 3 post-contrast MR features seen at M0, the USPIO+Gd pattern was found in larger lesions (p=0.05) that were more prone to keep enhancing at M6 (p<0.0001). This double enhancement at M0 was more frequently observed in patients exhibiting radiological and clinical progression at M6.

Conclusion: Combining Gd and USPIO in MS patients provides additional information even for progressive MS and the presence of combined USPIO+Gd enhancement may identify more aggressive lesions.

S. Roggerone and T. Tourdias have nothing to disclose.

B. Brochet has received personal compensation for activities with Bayer HealthCare, Novartis, Merck Serono, and Biogen Idec. Dr. Brochet has received personal compensation in an editorial capacity for LEN. Dr. Brochet has received research support from Merck Serono, Biogen Idec, and Bayer HealthCare.

V. Dousset has nothing to disclose.

Early pseudoatrophy on natalizumab is due to white matter volume changes

À. Vidal-Jordana, J. Sastre-Garriga, C. Tur, F. Pérez-Miralles, A. Horga, M. Tintoré, C. Auger, J. Río, C. Nos, E. Huerga, J. Castilló, A. Rovira, X. Montalban

Vall Hebron University Hospital (Barcelona, ES); Vall Hebron University Hospital-IDI (Barcelona, ES)

Background: In previous studies, we demonstrated that brain volume loss occurred at an accelerated rate during the first year of natalizumab therapy for those patients with gadolinium (Gd)-enhancing lesions at baseline, which was most probably due to a pseudoatrophy effect. It is not known whether pseudoatrophy is a global phenomenon or whether mostly affects grey or white matter or both.

Aim: To assess grey and white matter volume changes and its relation to global brain volume changes and baseline inflammation during the first year of natalizumab therapy in relapsing-remitting MS patients. Methods: From a consecutive cohort of patients who started natalizumab treatment at our center, patients who were on therapy for at least 12 months and who had MRI studies amenable for volumetric analysis were selected for the study (n=39). Patients underwent T1 pre- and post-gadolinium administration MRI scans at baseline and after one year of treatment. The percentage brain volume change (PBVC) was calculated with the SIENA software. Brain parenchymal fraction (BPF) and grey and white matter fractions (GMF and WMF) were calculated with SPM5 using lesion masks. Linear regression analyses were performed to predict PBVC, WMF and GMF evolution using the following independent variables: age, disease duration, presence of Gd-enhancing lesions at baseline MRI, corticosteroid treatment one month prior to baseline MRI and corticosteroid treatment between baseline and one-year MRI.

Results: Mean age at natalizumab initiation was 34.9 years (SD 8.7); 28 patients (71.8%) were female and 22 patients (56.4%) had Gd-enhancing lesions at baseline MRI. Mean percentage brain volume changes during the first year of treatment were: PBVC -1.10% (p<0.001), BPF -0.04% (n.s.), GMF +1.15% (n.s.) and WMF -1.72% (p=0.017). A linear regression analysis showed that: (a) PBVC was independently predicted by the presence of Gd-enhancing lesions at baseline (p=0.014); (b) WMF volume change was independently predicted by the presence of Gd-enhancing lesions at baseline (PCC=-0.41; p=0.012) and corticosteroid treatment between baseline and 12 months MRI (PCC=-0.43; p=0.008); and (c) no predictors were found for GMF volume changes.

Conclusion: Early brain volume loss during natalizumab therapy is mostly due to WMF volume loss and it is related to inflammatory activity at therapy instauration and steroid treatment. Pseudoatrophy effects are mostly due to white matter volume changes.

The authors have nothing to disclose.

Simultaneous rTMS and piano playing improve hand dexterity and induce changes in cortical excitability in a professional pianist affected by multiple sclerosis: a case report

A. Nuara, L. Straffi, F. Spagnolo, P. Rossi, G. Comi, M. Comola, L. Leocani

Ospedale San Raffaele (Milan, IT)

Introduction: Motor learning is a fundamental process of neurorehabilitation. One of its neurophysiological substrates -modulation cortex excitability- provides the rationale for non invasive brain stimulation techniques, such as repetitive transcranial stimulation (rTMS). Therefore, association of neuromotor rehabilitation and rTMS may be more effective than their use alone. The objective of this study was to assess the effectiveness of simultaneous rTMS and piano playing in improving hand dexterity and inducing changes in cortical excitability in a professional pianist affected by multiple sclerosis undergoing a 3-week period intensive neurorehabilitation.

Methods: A 39 y.o. pianist affected by multiple sclerosis with a bimanual (L>R) sensory-motor impairment due to 3 cervical relapses in the previous 3-12 months underwent 3-weeks neurorehabilitation sessions (twice a day, 5 days a week) together with treatment sessions of H-coil rTMS (10 Hz, bilateral fronto-parietal cortex) simultaneously to piano exercises performed during waiting times. Before (T0) and at the end (T1) of the study, functional (Nine-Hole-Peg-Test, Pinch, Jamar, MIDI sequencing) and neurophysiological tests (focal cortical mapping at 115% MT) were performed. Nine hole peg test and MIDI sequencing were also collected before and after each rTMS-piano session.

Results: At T1, the patient improved at NHPT in both hands (Right: 27.1’’ vs 15.45’’ ; Left 49.5’’ vs 36.4’’) and in piano performance. We found a decrease of cortical map motor area in both hemispheres (R>L). Improvement of these parameters occurring within single sessions was more evident in the first week of treatment.

Discussion and conclusion: Improvement of hand dexterity and changes in cortical excitability can be explained through several mechanisms: rTMS applied simultaneously to a motor exercise may interact with the networks related to motor learning processes recruited by the ongoing task. Neurophysiologic data (reduction of right cortical map of APB), functional test and piano performance parameters indicated a process of inter-hemispheric motor re-balance, possibly owing to a gain in cortical efficiency. Our single case-study confirms that neurorehabilitation, followed by combined, simultaneous association of hand motor training and rTMS, could improve hand motor performance and modulate cortical excitability. Placebo-controlled studies are needed to quantify the hypothetical synergic effect of rTMS and motor training

Arturo Nuara, Laura Straffi, Francesca Spagnolo, Mauro Comola, Paolo Rossi have nothing to disclose.

Giancarlo Comi has disclosed the following financial relationships: Served as an advisor or consultant for: Bayer HealthCare Pharmaceuticals; Merck Serono; Novartis Pharmaceuticals Corporation; sanofi-aventis; Schering-Plough Corporation; and Teva Pharmaceutical Industries Ltd. Other: Bayer HealthCare Pharmaceuticals (participated in speaking activities); Biogen-Dompé AG (participated in speaking activities); Merck Serono (participated in speaking activities); Novartis Pharmaceuticals Corporation (participated in speaking activities); sanofi-aventis (participated in speaking activities); Schering-Plough Corporation (participated in speaking activities); and Teva Pharmaceutical Industries Ltd (participated in speaking activities).

Evoked potentials may predict response to immunomodulating treatment in multiple sclerosis

L. Leocani, M. Bianco, G. Di Maggio, A. Nuara, S. Medaglini, J. Gonzalez Rosa, R. Chieffo, U. Del Carro, V. Martinelli, L. Moiola, G. Comi

Ospedale San Raffaele (Milan, IT)

Introduction: Early diagnosis and treatment of multiple sclerosis (MS) is now granted after the advent of magnetic resonance imaging (MRI), raising the need of biomarkers for monitoring and predicting treatment response and disability. Evoked potentials (EPs) are good candidate since they explore functional involvement of eloquent pathways.

Methods: Disability (EDSS) and multimodal EPs were assessed in patients with RRMS (96) before immunomodulating treatment and after 2.5 ± 0.8 years follow-up (75), when patients were classified as non-responders (<50% relapse rate reduction, or > 2MRI enhancing lesions, or >4 new lesions), full responders (no MRI/clinical activity), or partial responders. The severity of all EPs abnormalities was scored using a 0-3 conventional scale from normal to absent and summed to obtain a global EPs score.

Results: EPs score and EDSS at baseline was significantly correlated with EDSS at baseline (r=0.511, p<0.001) and even more at follow-up (r=0,686 p<0.001), and was significantly higher in non responders subgroup vs the other subgroups. At follow-up, the EPs score significantly increased in the whole group, more significantly in the non-responders vs other subgroups, while EDSS significantly increased in non-responders. Moreover, 34% of full responders had a global EPs score increase >2. Patients with baseline global EPs score >6 had increased risk (OR=5.82) of worsened follow-up EDSS (positive predictive value 78%, negative predictive value 67,5%, chi square p=0.001).

Conclusions: If performed early, EPs may help predicting and monitoring treatment response better than clinical or MRI assessment alone, suggesting their validation as surrogate biomarker in MS.

L. Leocani, M.Bianco, G. Di Maggio, A. Nuara, S. Medaglini, J. Gonzalez-Rosa, R. Chieffo, U. Del Carro, V. Martinelli, L. Moiola have nothing to disclose.

G. Comi declared receipt of honoraria or consulting fees from Serono Symposia International Foundation, Bayer Schering, Merck Serono International, Sanofi-Aventis, Biogen Dompè, Novartis, Teva Pharmaceutical Ind. Ltd.

Clinical disability in MS correlates with resting-state oscillatory brain activity: an MEG source-space study

M.L. vd Meer, P. Tewarie, M.M. Schoonheim, L. Douw, F. Barkhof, C.H. Polman, C.J. Stam, A. Hillebrand

VU University Medical Center (Amsterdam, NL)

Objective: Clinicocognitive decline in multiple sclerosis (MS) is insufficiently explained by structural damage as identified by structural magnetic resonance imaging (MRI) of the brain. Structural damage may lead to altered brain function to circumvent functional loss, indicating the need for reliable functional measures in MS. We investigated changes in brain function using resting-state magnetoencephalography (MEG) in MS patients. A recently developed atlas-based MEG beamforming approach was used to provide a detailed anatomical mapping of oscillatory power differences between patients and controls.

Methods: MEG recordings were acquired using a 151-channel whole-head MEG system from 21 relapsing remitting MS patients and 17 healthy age-, gender, and education-matched controls, using an eyes-closed no-task condition. Spectral power was estimated for 78 atlas-based regions of interest for the δ, θ, α1, α2, β and γ frequency bands. These cortical power estimates were compared between groups by means of permutation analysis and correlated with clinical disability (Expanded Disability Status Scale: EDSS), cognitive performance and MRI measures of atrophy and lesion load.

Results: Patients showed more power in the α1 band and less power in the α2 band, compared to controls, mainly in occipital areas. The average cortical β power correlated positively with clinical disability, whereas other correlations between power, EDSS, cognition and MRI measurements were not significant.

Conclusion: Our quantitative relative power analysis of MEG recordings showed abnormalities in oscillatory brain dynamics in MS patients in the α band. By applying source space analysis, this study provides a detailed topographical view of abnormal brain activity in MS patients, especially localized in occipital areas. Interestingly, more severe clinical disability was related to increased resting-state β power, indicating that MEG changes might be of value as an objective measure of disease burden in MS patients.

The authors have nothing to disclose.

The response of the blink reflex test in a group of Brazilian patients with multiple sclerosis

J.B.B. Brooks, Y.D. Fragoso, C.L.S. Oliveira, M.R. Kai, C.A.C. Silva

Universidade Metropolitana de Santos (Santos, BR); Insituto de Assistência à Saúde do Servidor Público de São Paulo (São Paulo, BR)

Although neurological anamnesis and examination are cornerstones of multiple sclerosis (MS) diagnoses, judicious use of paraclinical information enables clinical precision. Among electrophysiological tests, BlinkReflex (BR) provides structural-functional brainstem assessments and may assist in clinically diagnosing MS.BR is simple to perform, inexpensive and noninvasive, but not routinely used in diagnosing or following up MS patients.

The aim here was to show the role of BR in investigating structural-functional brainstem pathways.

Methods: A prospective case-control study was conducted on 41 patients with MS and clinically isolated syndrome (CIS) and 200 healthy volunteers. Patients’ BR values were correlated with magnetic resonance imaging (MRI),Expanded Disability Status Scale (EDSS), time since clinical diagnosis and time since last relapse.

Patients and controls who did not sign the test agreement statement, and previously diagnosed peripheral neuropathy cases, were excluded.BR was assessed using Nicolet Viking Quest electromyography equipment. Patients and controls were assessed while lying down comfortably, face up,with their eyes open.Recordings from the orbicularis eye muscles were made bilaterally and simultaneously. Ten stimulations were recorded on each side of the face. Statistical analyses on the variables included risk ratio, odds ratio, Pearson correlation and Student t-test.

Results:The control group (1M:2F;mean age 35 years) showed BR within international reference values. In the MS group, with equivalent gender ratio and mean age,32 patients (79%) had relapsing-remitting MS (RRMS), 4 had secondary progressiveMS (SPMS) and 5 had CIS. The mean disease duration was 7 years.The last relapse was typically over a year earlier. Abnormal BR values, i.e. more than 3 standard deviations higher, were observed in older patients with higher EDSS and longer disease duration,patients with SPMS and those with histories and/or images of systematic brainstem demyelination. Abnormal values were also correlated with brain atrophy, black holes and acute (Gd+) lesions on MRI.

Conclusion: BR may be an important tool indiagnosing temporal and/or spatial dissemination of brain lesions, and as a significant marker of disease progression or acute attack. This low-cost, easy-to-perform and noninvasive test should be kept in mind for diagnosis and follow-up purposes. Its use may be particularly interesting in countries with lower economic resources.

The authors have nothing to disclose.

EEG index related to altered orienting network in multiple sclerosis patients

A. Galvao-Carmona, A.R. Hidalgo-Muñoz, M. Borges, M. García-Valdecasas, J.M. García-Moreno, D. Páramo, J.L. Ruíz-Peña, G. Izquierdo, M. Vázquez-Marrufo

University of Seville (Seville, ES); Virgen Macarena University Hospital (Seville, ES)

Background: Cognitive Evoked Potentials is a sensitive technique for assessing cognitive impairment in Multiple Sclerosis. Between 40 and 60% of patients with multiple sclerosis (MS) experience some form of cognitive impairment. In this work, we studied the electrophysiological correlates of the expectation failures in multiple sclerosis patients (MS).

Material and methods: Twenty patients and twenty healthy controls were recorded in 64 channels when Attention Network Test paradigm was displayed. Reaction times (RT), Accuracy and the amplitude values of the Contingent Negative Variation (CNV) were analyzed in Spatial Cue (SC) and Center Cue conditions (CC) of the paradigm. The CNV analyses were done in the interval between the cue and the imperative stimulus.

Results: Both groups showed classical results of RT that is observed in ANT (F(2,76)=242,810 p<0.001). However, the MS patients showed a general slowing for the RT (F (1,38)=20,305; p<0.001). In the MS group, the CNV amplitude showed an increment for the spatial cue 300 ms before the imperative stimulus (F (1,19)=17,218; p<0.01). In the control group these differences were only 100 ms before the imperative stimulus (F (1,19)=7,5581; p=0.01).

Conclusions: The results indicate an increase in amplitude in the late phases of CNV component what corresponds with the activity of the orienting network engaged in the spatial cue condition. However, this effect is much earlier in time for the patients, suggesting changes in the process of expectation in MS patients that may explain the higher RT found in this group. The behavioural slowdown in MS patients may be caused by failure prediction of the precise space-time onset of the imperative stimulus.

The authors have nothing to disclose.

Brain atrophy correlates with cognitive impairment and event-related potentials P300 in multiple sclerosis

N. Tevzadze, M. Janelidze

S.Khechinashvili University Clinic (Tbilisi, GE)

Background/Aims: It is known that varieties of cognitive deficits occur in approximately 50% of MS population. Cognitive event related potentials were found in majority of MS patients, correlating with number and size of white matter lesions. The aim of this study is to examine the P300 wave and cognitive impairment in MS patients .

Materials/Methods: We examined auditory-cognitive P300 potentials in 30 patients with MS, in comparison with disease severity based on MRI findings, Kurtzke Expanded Disability Status Scale (EDSS) and cognitive dysfunction tested by Short Test of Mental Status (STMS).

Results: P2N2P3 latencies were significantly longer and the N2P2 amplitude were significantly lower in patients manifesting subcortical demyelinative brain lesions than in patients free of brain atrophy. P300 prolonged latency was associated with EDSS and STMS being milder in relapsing-remitting and secondary progressive variants compared with a primary-progressive course and the scores of all neuropsychological tests were significantly lower in patients with subcortical brain atrophy.

Conclusion: P300 long latency event-related auditory evoked potentials suggests to be a sensitive marker of the brain atrophy and cognitive impairment in MS patiens.

The authors have nothing to disclose.

Longitudinal change in PASAT performance following immunoablative therapy and haematopoietic stem cell transplant in MS

L.A.S. Walker, J. Berard, M. Bowman, H.L. Atkins, H. Lee, M.S. Freedman

The Ottawa Hospital - General Campus (Ottawa, CA); University of Ottawa (Ottawa, CA); McGill University (Montreal, CA)

Background and Goals: Immediately following hematopoietic stem cell transplantation (HSCT) for refractory MS a median decrease in total brain volume of 3.2% over 2.4 months has been observed. However, beyond 2 years following HSCT, the rate of brain volume loss is similar in magnitude to that reported for normal volunteers. The potential impact of this decrease in brain volume on cognition (i.e. information processing speed [IPS] and working memory [WM]) was evaluated by examining performance on the Paced Auditory Serial Addition Test (PASAT) pre- and post-HSCT.

Methods: Twenty-three individuals with rapidly progressing MS and poor prognosis underwent high dose immunoablation and subsequent HSCT. Subjects completed the 3” PASAT at baseline and 6/12/18/24/30/36 months post-HSCT.

Results: A mean decline in performance was noted between baseline and 6-months post- HSCT. However, the change was not to a statistically significant degree as assessed by reliable change analyses. Minor declines initially noted were offset by an overall trend for improvement over time. The largest cognitive gains took place between months 30 and 36, but again not to a statistically significant degree. Level of impairment at baseline did not influence the likelihood of improvement over time. No differences in demographic variables were noted between those who improved and those who did not.

Conclusions: While an initial decline in IPS/WM was noted 6 months post-HSCT, there were no lasting negative effects of treatment given the overall trend for improvement over time. The initial cognitive decline and marked volume loss are likely secondary to acute toxic effects of the chemotherapy. While gains in cognition were made over time, their clinical significance remains unclear; however, results at 36 months suggest that long-term follow-up is essential.

This research was funded by the Multiple Sclerosis Society of Canada.

The authors have nothing to disclose.

Function is in the eye of self-efficacy

L. Strober, J. DeLuca, N. Chiaravalloti

Kessler Foundation Research Center (West Orange, US)

Introduction: Self-efficacy is defined as a person’s belief in his or her ability to succeed in a particular situation. Bandura further described these beliefs as determinants of how an individual will think, behave, and feel. Thus, one’s perceived self-efficacy could certainly influence how an individual with multiple sclerosis (MS) will cope and manage their illness. The present investigation sought to examine the role of self-efficacy on individuals’ health status, perception of symptoms, cognitive complaints, and everyday function (e.g., employment).

Methods: Eighty individuals with MS completed a comprehensive neuropsychological test battery as part of a larger clinical trial. Participants also completed questionnaires pertaining to their overall health status (SF-36), MS symptoms, cognitive complaints, psychological functioning, and factors related to their ability to work (Work Assessment Scale for Persons with MS). Individuals were subsequently categorized as being either high or low on self-efficacy (SE) as measured by the MS Self-Efficacy Scale.

Results: There were no significant differences with regard to disease duration, MS course, gender, cognitive functioning, or employment status between the two groups. However, individuals with high SE reported less anxiety (p <.001), depression (p <.05), fatigue (p <.001), bowel/bladder complaints (p <.05), pain (p<.001), and cognitive difficulties (p<.001). They also reported having an overall greater health status (p<.05). With regard to employment, individuals with high SE reported that their personal attitude and engagement in positive health behaviors helped them maintain their work status more than individuals with low SE (p<.05) while individuals low on SE perceived their MS symptoms (p<.001) and physical limitations (p<.05) as barriers in the work environment more than individuals with high SE.

Conclusions: Results suggest that self-efficacy plays a significant role in how individuals with MS perceive and manage their illness and the role that has on their overall quality of life and functioning. Proper attention should be given to this important psychological construct in clinical care and could better inform interventions aimed at improving the lives of individuals with MS and management of the illness.

Dr. Strober has no disclosures.

Dr. DeLuca has been funded by the NMSS, NIDRR, Biogen Idec, and Memen Pharmaceuticals. He has also served as a consultant to Biogen Idec and Memen.

Dr. Chiaravalloti has been funded by the NIH, NMSS and Memen Pharmaceuticals for her MS and cognition work. This study was funded by the NIH.

‘’Benign’’ multiple sclerosis: long disease duration and low EDSS is not cognitively benign

M. Gudesblatt, M. Zarif, B. Bumstead, M. Buhse, L. Fafard, J. Cruz, O. Gorbatsevych, G. Thippeswamy, L. Strober, J. DeLuca, G. Doniger

South Shore Neurologic Associates (Patchogue, US); State University at Stony Brook (Stony Brook, US); Kessler Foundation Research Center (West Orange, US); NeuroTrax Corporation (Bellaire, US)

Background: “Benign MS” is typically “defined” as: both a disease duration >10years and an EDSS<3. Identifying a population of patients with MS as “benign” suggests these patients have no significant disability. Since the EDSS is largely insensitive to cognition, patients with cognitive impairment cannot be defined as having “benign disease” by such a cognition insensitive definition. Published cohorts evaluating “benign MS” typically have limited population size.

Objective: To identify the presence, prevalence, and types of cognitive impairment in a large “benign MS” cohort (simultaneously EDSS<3 and disease duration >10years, “late benign MS”), compare/contrast with cognition, fatigue, depression, quality of life, and employment in “early benign MS” (defined as simultaneously <5years disease duration and EDSS<3).

Methods: Retrospective review of an MS cohort database evaluated by Fatigue severity (Modified Fatigue Impact Scale, Fatigue Severity Scale), Beck depression scale, a validated standardized MindStreams Battery, and employment status.

Results: Patients with MS disease duration >10 years (N=299), 130(44%) with EDSS<3 (“late benign MS”); disease duration <5years (N=232), 204(88%) with EDSS<3 (early benign MS). The late benign is older (59.84±8.57 vs 41.83±10.34); has worse EDSS (1.78±0.60 vs 1.46±0.55 p<0.001, d=0.55); higher fatigue: MFIS(45.73±18.9 vs 38.48±α20.49, p=0.003) and FSS(45.30±14.34 vs 38.27±15.00, p<0.001). These groups do not differ on the Beck scale, but both report mild depression (14.54±11.31, vs. 13.44±9.96). A greater proportion of late benign scored: >1 standard deviation (SD) below average on executive function index (26% vs. 19%, p<0.05); and a larger proportion have: one (68% vs. 60%, p=0.04), two (52% vs. 36%, p<0.001), or three (40% vs. 24%, p<0.001) MindStreams index cognitive domain scores >1SD below average for a cognitively healthy group of similar age and education; and lower employment (45% vs. 72%, p<0.001).

Conclusions: Those MS patients with both EDSS<3 and Disease Duration >10 report: mild depression, higher likelihood of: fatigue, >1 standard deviation impairment in 1, 2, and 3 cognitive domains and unemployment. These long duration low EDSS so called “benign” MS patients should not be considered to have benign disease. Computerized cognitive testing provides valuable clinical information not obtained from EDSS alone.

A. Mark Gudesblatt, MD - no disclosures.

B. Myassar Zarif, MD - no disclosures.

C. Barbara Bumstead, ANP - no disclosures.

D. Marijean Buhse, ANP, PhD - no disclosures.

E. Lori Fafard, RN - no disclosures.

F. John Cruz - no disclosures.

G. Oleksandr Borbatsevych, BA - no disclosures.

H. Ganesh Thippeswamy, BA - no disclosures.

I. Lauren Strober, PhD - no disclosures.

J. John DeLuca, PhD - no disclosures.

K. Glen Doniger, PhD - Employee of NeuroTrax Corp.

Difficulties in planning among MS patients: a relative consequence of deficits in information processing speed

E. Owens, D. Denney, S. Lynch

University of Kansas (Lawrence, US); University of Kansas Medical Center (Kansas City, US)

Background: Previous studies of planning ability in patients with multiple sclerosis (MS) using the Tower of London (TOL) task have yielded mixed findings. While MS patients consistently take longer time than healthy controls to plan their solutions to TOL problems (i.e., planning time), there are conflicting results regarding the quality of their solutions (i.e., planning ability) relative to that of healthy controls. Careful consideration of the literature suggests that differences in planning ability might only occur when some limitation is imposed on the amount of time patients are allowed to solve the problems.

Objective: The present study was designed to evaluate TOL performance of MS patients and healthy controls under untimed and time-restricted conditions.

Method: Relapsing-remitting and secondary-progressive MS patients (n=39) and healthy controls (n=43) completed a 16-problem, computerized version of the TOL under either an untimed or a time-restricted condition. In the former, participants were given as much time as needed to solve each problem; in the latter, a time limit was imposed and a countdown of the time remaining was displayed with each problem. Planning ability was measured as the number of problems solved.

Results: Participants solved significantly fewer problems under the timed-restricted condition. However, a significant interaction between Group and Condition was found: when untimed, patients and controls achieved the same total point score, but when time-restricted, patients solved significantly fewer problems than controls. Results for planning time were consistent with previous untimed studies: patients exhibited longer planning times overall and their planning times increased with greater problem difficulty to a greater extent than for controls.

Conclusion: Planning ability is considered an index of executive functioning. MS patients’ planning ability is intact when they are allowed sufficient time to evolve the required plan. Deficiencies in planning only appear when time is restricted, and as such, may be more accurately considered a relative consequence of disease-related problems in the speed of information processing.

Emily M. Owens has nothing to disclose. Douglas R. Denney is a research and statistical consultant for Teva Pharmaceuticals and a co-investigator on grants funded by the National Multiple Sclerosis Society and the Dairy Research Institute. Sharon G. Lynch is a principal investigator or co-investigator on grants funded by the National Multiple Sclerosis Society, and Kansas City Area Life Sciences Institute, and she participates in clinical trials sponsored from entities such as NIH, Norvatis, Biogen IDEC, Teva Pharmaceuticals, Genentech,Genzyme, Pfizer, UCB Pharma SA, Artielle Therapeutics, and Protein Design Labs. The present study was an unfunded project.

A process approach to letter fluency performance in multiple sclerosis - evidence for derailed temporal gradients

A. Tart-Zelvin, J. Eppig, C. Nieves, D. Libon, J. DeLuca, M. Williams

Drexel University College of Medicine (Philadelphia, US); Kessler Foundation (West Orange, US)

Previous research (Eppig et al, 2012; Lamar et al, 2002) has identified impaired temporal gradients during mental search tasks among individuals with dementia and patients statistically determined to have dysexecutive mild cognitive impairment. The current study used a similar process analysis of behavior to examine derailed temporal gradients (i.e., a precipitous decline in output over time) on letter fluency tests (‘FAS’) in patients with Multiple Sclerosis (MS). Letter fluency was administered to 71 MS patients and 34 age and education matched NC participants. Output per epoch, percent output per epoch, and slope over all epochs were calculated. MS patients exhibited a significantly steeper decline in slope than NC, t(103) = 3.881; p < .001. A two-way repeated-measures ANOVA revealed a significant group x epoch interaction (Greenhouse-Geiser, p < 001). Post-hoc analyses reveal that NC output decline only from epoch 1 to 2. MS patients produced a similar profile; however, there was continued decline in output from epochs 2 to 3 (p < .001) with a borderline drop from epochs 3 to 4 (p < .068). These data provide evidence to suggest that impaired temporal gradients may underlie reduced letter fluency/ mental search performance in MS.

Dr. Tabby: TEVA: Research grant, Advisory board; Biogen: Research grant, Advisory board; Avanir: Research grant; Sanofi: Research grant; Novartis: Advisory board; Bayer: Advisory board.

Dr. Libon: Bayer:Research grant; Avanir:Research grant.

Dr. DeLuca: MS Sociey:Research grant.

Mr.Eppig: nothing to disclose.

Ms. Nieves: nothing to disclose.

Ms. Tart-Zelvin: nothing to disclose.

Longitudinal assessment of attention and cognitive functions related to fronto-temporal circuits in relapsing-remitting multiple sclerosis 6-year follow-up

A. Fuchs, S. Schlegel, M. Lang, M. Freidel, W. Hofmann, W. Elias, G. Reifschneider, S. Ries, B. Bühler, A. Bergmann, I. Uttner, C. Ring, I. Penner, H. Schreiber on behalf of the NTD Study Group on Multiple Sclerosis

Objective: To study long-term evolution of attention and fronto-temporal cognitive functions over a period of 6 years in treated and untreated relapsing-remitting multiple sclerosis (RRMS) patients compared to healthy controls.

Methods: Multicenter trial at MS outpatient centers, longitudinal analyses 1, 2 and 6 years (M12, M24, M72) after baseline (BL). Inclusion criteria: 18-55 yr, RRMS/Mc Donald, EDSS 0-3.0. Among 106 RRMS patients (38 Avonex, 40 Copaxone, 18 untreated) and 30 matched controls at BL, a total of 100/29 (M12), 87/28 (M24) and 50/16 (M72) patients and controls were available for follow-up. Assessments: clinical and behavioral parameters (neurostatus, EDSS, clinical global impression/CGI, ambulation index, functional status, Fatigue Severity Scale, depression/BDI, quality of life/EQ5d; neuropsychology (verbal and non-verbal fluency, interference processing, working memory, learning and memory, attention (TAP vigilance, flexibility, divided attention). As a compound measure of cognitive deficit, a global Cognitive Impairment-Index (CIIglobal) was calculated across 54 cognitive variables (in reference to Amato), and a specific CIIdom in relation to cognitive domains.

Results: The CIIglobal was highest in untreated patients (RRMS-U) and therapy switchers at all time points. Across time, it increased in RRMS-U and switchers, while it remained relatively stable in Avonex and Copaxone treated patients (RRMA-A, RRMS-C), and even decreased in controls due to test repetition effects. There was a significantly negative influence of time on the CIIglobal in the total RRMS group (BL/M12 p<0.01, BL/M24 p<0.05, BL/M72 p<0.05). The CIIglobal showed increased cognitive deficit in RRMS patients compared to controls (p<0.04) and, comparing RRMS subgroups, in untreated vs treated patients (0.1). Within the CIIdom, there was a significantly different impairment of single domains (p<0.0001). Particular vulnerability was attributed to “learning and memory” and “executive functions”, however, without specific link to a RRMS subgroup.

Conclusion: (1) Cognitive and attention deficits start in early MS and evolve over time. In contrast, healthy controls improve and benefit from test repetition effects (2) General cognitive deficit (CIIglobal) is more expressed in untreated and switch patients tending to increase in the former compared to those adherent to long-term treatment (3) Selection/drop-out bias and test repetition effects seem to mask more expressed effects (4) Cognitive vulnerability is domain-related.

A. Fuchs, S Schlegel, C Ring, I Uttner: have nothing to disclose.

M. Lang, M. Freidel, W Hofmann, W. Elias, G. Reifschneider, S. Ries, B. Bühler, A. Bermann: received speakers’ fees, research grants, travel support and honoraria for being members of advisory boards from Almirall, Bayer, Biogen, Merck, Novartis, TevaAventis, Sanofi.

I. Penner: received research grants from Bayer AG Switzerland and the Swiss Multiple Sclerosis Society; has received honoraria for serving as speaker at scientific meetings, consultant, and as a member of scientific advisory boards for Actelion, Bayer, Biogen, MerckSerono, Roche and TevaAventis.

H. Schreiber: received speaker’s fees, research grants, travel support and honoraria for serving as a member of scientific advisory boards from Almirall, Bayer, Biogen, MerckSerono, Novartis, TevaAventis.

Personality and capacity for coping with stress in patients with MS

A. Ožura, S. Šega, A. Horvat Ledinek, U. Rot, A. Noc

University Medical Centre Ljubljana (Ljubljana, SI)

Background: Most of research on personality changes in multiple sclerosis (MS) up to date was based on the Big Five model of personality and assessed with self-report questionnaires. Self report measures are limited due to the lack of insight described in MS patients. The main aim of our research was an indebt analysis of personality characteristics with an emphasis on stress related variables in MS patients using the Rorschach Inkblot Method.

Participants and methods: 95 patients with MS and 44 healthy controls were included into the study. The Rorschach Inkblot Method scored according to the Exner Comprehensive system was performed on all the participants. Differences between groups were assessed using nonparametric tests. Furthermore we calculated linear regression to assess the possible connection between EDSS score and the Rorschach variables. We also performed logistic regression to assess the connections between variables in a multivariate model.

Results: Healthy controls gave more answers (R) and had higher organizational activity (Zf). In the field of coping with stress we found that patients had lower capacity for coping with stress (EA) and a higher index of coping deficit (CDI). At the same time their level of internal conflict was lowered (es). Furthermore we found that patients more often perceived their body as dysfunctional (MOR%), were less receptive to emotional input (Afr) and had lowered interpersonal interest (Human Cont). The assessed Rorschach variables were not significantly associated with EDSS score in the regression model. However a logistic regression model correctly classified 85% of participants into the group of patients vs. controls.

Conclusions: Psychological characteristics measured with the Rorschach Inkblot Method are one of the important areas where patients differ from the healthy controls. Patients show lower mental flexibility and originality. At the same time patients are relatively free from internal conflict and unworried, which is surprising considering their health state and uncertain prognosis. These findings are consistent with the data about a lack of insight and descriptions of euphoric characteristics in MS. Bearing in mind the low capacity for coping with stress we propose that behavioral interventions should focus on techniques for improving stress management, behavioral activation and improvement of interpersonal contact.

The authors have nothing to disclose.

Neuroanatomical substrates of mentalisation: a multimodal MRI study in multiple sclerosis

A. Mike, E. Strammer, M. Aradi, G. Orsi, G. Perlaki, R. Herold, A. Hajnal, M. Banati, E. Illes, C. Guttmann, Z. Illes

University of Pecs (Pecs, HU); Harvard Medical School (Boston, US)

Background: Successful integration into the society requires the understanding of mental states of other people. Mentalization (Theory of Mind) is a human ability, which enables us to make inferences about thoughts, intentions, desires, and beliefs of other people. Mentalization ability may be deficient in multiple sclerosis (MS), and may contribute to every day life difficulties encountered by these patients.

Objective: Our goal was to explore the impact of structural pathology in MS on mentalization performance; and to map neuroanatomical substrates which, if damaged impair mentalization.

Methods: Mentalization performance of 49 MS patients was compared to 24 age- and gender matched healthy controls. Mentalization ability was assessed with tests evaluating emotion recognition from faces (Faces test), mental state decoding from eye gazes (Eyes test), and perspective taking and reasoning about mental and emotional states of others (Faux pas test). Depression was measured with Beck Depression Inventory, and anxiety was evaluated with Spielberger Trait Anxiety Inventory. Severity of physical disability of MS patients was assessed with Expanded Disability Status Scale (EDSS). T1 and T2-weighted three-dimensional brain MRI images were acquired at 3 Tesla from MS patients and 18 gender- and age matched healthy controls. We assessed overall brain cortical thickness in MS and scanned healthy control group. We measured total and regional T1 and T2 white matter lesion volumes in MS group. Regional white matter lesion load was assessed within each major fiber bundle by the use of a white matter atlas.

Results: Mentalization performance of MS group was significantly poorer in tests investigating decoding from facial expressions. Decoding from eye gazes were independently predicted by T1 lesion load within the splenium of corpus callosum mediating inter-hemispheric visual integration, cortical atrophy the in left fusiform gyrus contributing to visual processing of facial emotions, and left anterior inferior temporal gyrus involved in high-level integrative functions. Focal cortical thinning in the right premotor frontal eye field correlated with the performance in the test of mental state decoding from eye gazes, suggesting a simulation mechanism related to mirror neurons.

Discussion and conclusion: Mentalization performance may be independently compromised by disconnection mechanism related to white matter lesions and focal cortical atrophy.

Dr. Mike was a recipient of the 2008 McDonald Fellowship from the Multiple Sclerosis International Federation. The study was supported by the Hungarian National Research Fund (OTKA K77892), the Hungarian Neuroimaging Foundation (both to Dr. Illes), EEA/Norwegian Financial Mechanism HU 0114 – “Save what can be saved” – applied neurological research using high-field magnetic resonance imaging (to the Diagnostic Center of Pecs, Hungary), and the National Multiple Sclerosis Society (Grant RG3574A1) (to Dr. Guttmann).

Developing paperless, portable cognitive applications for smartphones

D. Langdon, J. Hujol, N. Chiaravalloti, M.C. Botfield, R.K. Ramachandran, G. Giovannoni, P.L. De Jager on behalf of the MSCODES3 Consortium

Background: Assessing cognition in Multiple Sclerosis (MS) remains an expensive and lengthy process, requiring specialist expertise and equipment and is not routinely available outside of specialist centres. Smartphone apps plausibly offer a convenient and cost effective means of assessing cognition in MS.

Goal: Develop the first generation smartphones apps for assessing cognition in MS that mimic existing clinical measures and patient-oriented surveys.

Methods: Smartphones with powerful computer processing, internet access, accelerometers, gyroscopes, light sensors, high-definition cameras, high-resolution display screens, and an intuitive graphical interface offer the potential for rich, real-time data acquisition that may fundamentally shift the paradigm for diagnosis and monitoring of disease. An open source consortium of academic institutions, patient-advocacy organizations and pharmaceutical companies was created, the MSCODES3 (Multiple Sclerosis Consortium for the Development of Smartphone Support Systems) to develop this idea further. Three natural history studies are planned to develop and assess smartphone applications in MS by the MSCODES3 consortium. The development of four cognitive apps: n-back, trail making, verbal fluency and a continuous performance task for selective and sustained attention will be presented. These focus on the cognitive skills most likely to be affected by MS, information processing speed and working memory. Regular practice may improve performance on these tests, but significant decline in performance, or even reduced learning, may represent a meaningful clinical change.

The four cognitive apps developed for the smartphone draw on previous desktop evaluation scales with good psychometric pedigrees.

The first of three studies will test the feasibility of longitudinal data collection, data upload and security and subject compliance among other observations. Data from the results from each test completed and the underlying metadata e.g., device and subject identification, time/date stamp for start and completion of each test, local ambient weather information will also be collected. Data will be presented.

Conclusions: The MSCODES3 consortium has successfully designed the components of an application suite as a preliminary to testing the potential for smartphones to improve diagnosis and detection of disease progression in MS. Data from this study will be used to further refine and improve the apps for future studies.

DL has received funding for travel to scientific meetings from Bayer Healthcare, Vertex; her institution has received honoraria, consultancy fees, research contracts and sponsorship from Bayer Healthcare, Serono Symposia, Merck-Serono.

JH is a full time employee of Vertex.

NC has had MS funding from NIH, NMSS, and Memen Pharmaceuticals for other MS-cognition work.

MC is a full time employee of Vertex.

RR is a full time employee of Vertex.

GG reports having received consulting fees from Bayer-Schering Healthcare, Biogen-Idec, Elan, FivePrime, Genzyme, GlaxoSmithKline, GW Pharma, Ironwood, Merck-Serono, Novartis, Protein Discovery Laboratories, Teva, Sanofi-Aventis, Vertex Pharmaceuticals and UCB Pharma; lecture fees from Bayer-Schering Healthcare, Biogen-Idec, Genzyme, Pfizer, Teva-Aventis, Vertex Pharmaceuticals; and grant support from Bayer-Schering Healthcare, Biogen-Idec, GW Pharma, Merck-Serono, Merz, Novartis, Teva-Aventis and UCB Pharma.

PDJ has received consultancy fees from TEVA neuroscience, research grant and lecture honorarium from Biogen IDEC, research grant from Merck Serono and is lead investigator at a Vertex trial site.

Pattern of cognitive impairment and related factors in clinically isolated syndrome

S. Özakbas, B. Piri Cinar, A. Gürkan, O. Öztürk, E. Idiman

Dokuz Eylul University (Izmir, TR)

Cognitive impairment in patients with multiple sclerosis (MS) is a common occurrence and is generally fairly circumscribed. The presence of cognitive dysfunction in a sizeable proportion of patients with clinically isolated syndrome (CIS) has been reported. The prevalence of the cognitive deficits usually encountered could vary with the clinical course of the disease. The aim of the present study was to investigate the prevalence and pattern of cognitive impairment in CIS patients. 25 patients with CIS (mean age 36.3) included in the study. Age and sex matched 22 healthy control subject (mean age 36.0) were also included. Cognitive performance was assessed by using a battery of tests consisting of Paced Auditory Serial Addition Test (PASAT), Stroop, Controlled Oral Word Association (COWAT), Rey Auditory Verbal Learning (RAVLT), Benton’s Judgment of Line Orientation (BJLO), Trial making test (TMT), and digit span test (DST) to measure attention and concentration, verbal memory, verbal fluency and visual-spatial memory. Beck depression scale, Fatigue impact scale (FIS), and Multiple Sclerosis International Quality of Life (MUSIQoL) were also administered. Globally, 21% of patients were found to be cognitively impaired at least two tests. When compared healthy controls, 44% of patients failed in Stroop test. Impairment in COVAT was 56%. Impairment in RAVLT, BJLO, TMT and DST were relatively rare (10%, 9%, 5% and 12%, respectively. Impairment in PASAT was 12%. CIS patients were found more depressed (p=0.045), more fatigued both socially (p=0.30) and cognitively (p=0.011). Their QoL score was extremely depressed (p=0.002) compared with healthy subjects. MUSIQoL scores were significantly correlated with Stroop test, PASAT, COVAT and RAVLT). Cognitive fatigue was correlated with Stroop, PASAT and COVAT. Our results supported the early onset cognitive impairment in demyelinating diseases. The most prominent impairment was found to be in verbal fluency (COVAT), attention and executive functions (Stroop). Fatigue (especially cognitive sub-group) found to be related with cognitive impairment in CIS.

The authors have nothing to disclose.

Cognitive impairment in relapsing-remitting multiple sclerosis patients

A. Altinkaya, E. Ozcan, D. Yandim-Kuscu, E. Kurt, A. Bingol, D. Kirbas, B. Topcular

Istanbul Bilim University (Istanbul, TR); Bakirkoy Prof. Dr. Mazhar Osman Teaching and Research Hospital for Mental Health and Neurological Disorders (Istanbul, TR); Mayis Psychology Center (Istanbul, TR)

Aim: Quality of life in MS patients is associated with cognitive disorder as well as physical disability and psychiatric symptoms. For this purpose, we aimed to assess the prevalence of cognitive impairment in Relapsing Remitting Multiple Sclerosis(RRMS) patients.

Materials and Methods: All patients had Beck Depression Inventory(BDI), Functional Assessment of Multiple Sclerisis(FAMS) quality of life instrument, Multiple Sclerosis Neuropsychological Questionnairree(MSNQ) and Rao’s Brief Repeatable Battery(BRB). Fifthyone consecutive RRMS patients were included in the study.

Results: The mean age of the study group is 37.87 ± 9.79 years. 78.4% of patient (n = 40) are female and 21.6% of patient (n = 11) are male. Education levels of the patients are primary school or lower n=36(70.6%), high school n=10(19.6%), university or higher n=5(9.8%). Patients performing below 50th percentile in at least two tests in BRB were considered as cognitively impaired. Twentyfive patients(49%) were cognitively impaired. Cognitively impaired patients were significantly older (p<0,01). There were no significant differences between male and female patients (p>0,05). There was a significant correlation between education level and cognitive status(P <0.05). There was no significant relation between cognitive status and disease duration (p>0,05). Cognitively impaired patients had significantly higher EDSS scores(p<0,01). Cognitively impaired patients had higher BDI scores (p=0,003) whereas cognitively preserved patients had significant higher quality of life scores in FAMS (p=0,001).

Conclusions: Our findings show that cognitive impairment is frequent in RRMS patients and it has a significant effect on quality of life. Low education level seems to be a major risk factor RRMS related cognitive impairment.

The authors have nothing to disclose.

Is information processing speed or verbal fluency the primary deficit in multiple sclerosis?

H. Brissart, E. Morele, C. Baumann, M. LePerf, M. Leininger, L. Taillemite, M. Pagura, C. Dillier, S. Pittion, E. Spitz, M. Debouverie

Central Hospital (Nancy, FR); LORSEP (Vandoeuvre les Nancy, FR); CIC-EC (Vandoeuvre les Nancy, FR); CHU Nancy (Nancy, FR); University of Psychology (Metz, FR)

Background: As of yet, no consensus has been reached regarding cognitive impairment profiles in multiple sclerosis (MS) patients based on the MS type and disease duration.

The purpose of this study was twofold: to compare cognitive impairment in patients with relapsing remitting Multiple Sclerosis (RR), Secondary Progressive MS (SP) and Primary Progressive MS (PP) as well as the possible impact of disease duration on relapsing remitting forms.

Methods: 128 MS patients and 63 healthy controls (HC) were included. Five groups were constituted: Early RR (< 3 years: ERR); Late RR (> 10 years: LRR), Secondary Progressive (SP), Primary Progressive (PP) and Healthy Controls (HC). A neuropsychological assessment was performed including information processing speed (IPS), working memory, verbal episodic memory and executive functions (self generation, inhibition and flexibility).

Results: Compared to HC, only impairment in phonemic fluency was observed in ERR. Slowing IPS, impairment in working memory and in phonemic fluency were shown in LRR. In progressive forms, cognitive impairment was observed in verbal episodic memory, in working memory, in flexibility, in semantic and phonemic fluencies, with a slowing IPS.

Conclusions: Results of this study suggest that at early stage phonemic fluency was impaired and then, when disease duration increases, impairment is observed in other cognitive functions. Also, these results suggest that impairment increases with MS duration, and that there are distinct cognitive profiles between remittent and progressive MS forms. An assessment of these cognitive profiles is needed in order to develop specific cognitive rehabilitation programs.

MD has done consulting research and/or workshops for Biogen-Idec, Bayer-Schering, Merck-Serono, Novartis, Sanofi-Aventis and Teva Pharma. The organizations mentioned in this statement did not participate in any aspects of the design, execution, analysis, or write-up of this study.

HYPNOSEP : Brief Hypnotherapy Treating Chronic Fatigue for Multiple Sclerosis Patients

R. Devy, P. Cormier, O. Anne, I. Devy-Gourdon, G. Chedeau, G. Edan

Association DNS (Saumur, FR); Association Neurologues Centre Loire (Laval, FR); CH (La Rochelle, FR); Institut Milton Erickson (Geneva, CH); CHU (Rennes, FR)

Introduction: Chronic fatigue syndrome (CFS)severely affects Multiple Sclerosis (MS) patients’ quality of life (QoL). It is the most common debilitating symptom in their daily lives.

Clinicians have been using existing specific scales: Fatigue Severity Scale (FSS) Modified Fatigue Impact (MFIS) to detect CFS however the only two evaluated molecules (Amadantine, Modafinil) have low efficacy.

Objective: Our objective is to assess efficacy of brief hypnotherapy treating CFS in MS context.

Materials and Methods: We conducted a multicenter French interventional study of 40 MS patients, 3 centers, 3 neurologists and 3 hypnotherapists using the Erikson’s approach.

Out of 40 preselected patients, 20 underwent brief therapy while 20 twins had a standard follow-up.

There were two assessments, one prior to therapy and one at the end of the programme.

The main objective was evaluated by Fatigue Severity Scale(FSS) and the secondary criteria used the following scales: Two-Lives Scale-Quality of Life (TLS-QoL10) for QoL, Two-Lives Scale Coping (TLS-coping10) and Ways of Coping Checklist (WCC) for coping, Visual Analog Scale (VAS) and DN4 for pain, Hospital Anxiety and Depression Scale (HAD) for anxiety and depression, Profile of Mood States Scale (POMS) for emotions, Epworth Sleepiness Scale (ESS) for sleepiness.

In order to measure the impact of brief therapy on CFS,we compared scores obtained for each patient before and after therapy. Then, we compared average scores of the brief hypnotherapy and standard follow-up MS patient samples.

Results: Most of the 20 patients undergoing brief hypnotherapy obtained a lower CFS score. The lower CFS score generates higher quality of life and coping scores. Therefore, anxiety,depression, negative emotions and sleepiness are receding.

When comparing both patient samples, FSS scores are lower on average in the brief hypnotherapy group compared to the standard follow-up MS patients.

Conclusion: This study has enabled us to assess the impact of brief hypnotherapy on CFS for MS patients.

Most patients have a lower level of fatigue which leads us to conclude that this kind of therapy can be used daily by clinicians in their therapy range.

The authors have nothing to disclose.

Prediction of vocational status 10 years after the MS diagnosis by early information processing speed assessment

A. Ruet, M. Deloire, J.C. Ouallet, B. Brochet

INSERM U1049 (Bordeaux, FR)

Background: Cognitive impairment is frequent at early stages of MS and could limit working and social activities.

Objectives: To determine the predictive value of neuropsychological scores assessed at the time of diagnosis for vocational status 10 years later in RRMS patients.

Methods: Thirty seven patients were enrolled at the time of their diagnosis and followed over 10 years. Patients were tested for clinical and cognitive scores at baseline and at ten years. At baseline, MS patients were classified as patients cognitively impaired (PCI) if they performed less than 1.5 standard deviations below scores of a sample of individually matched controls on at least two tests out of 7 of the battery. Vocational status was established at baseline and at ten years. The employed group consisted of patients who were paid workers, working full-time or with a reduction in their duties, and students. The unemployed group consisted of housewives, volunteers, recipients of disability benefits, persons on prolonged medical leave and retired workers. Logistic regression analyses were used to assess the baseline neuropsychological scores that predict vocational status 10 years later. The independent variables were baseline neuropsychological scores, MADRS and fatigue scores. Baseline EDSS was forced as a covariate.

Results: At baseline, patients presented significantly deficits for verbal and visual memory, information processing speed and executive function. At baseline, 54 % of MS patients were PCI and 83.8 % MS patients worked. After 10 years 62.2 % of MS patients worked. The final multivariate logistic model retained only baseline symbol-digit-modalities test (SDMT) score [odds ratio =4.28, 95% % confidence interval=1.3-14.1; p =0.017] as independent predictors of vocational status 10 years later (R2=0.30). The SDMT score in unemployed group (33.6 ± 11.2) was significantly lower than in the employed group (45.8 ± 10.7) (p= 0.002). ROC curves will be presented.

Conclusion: The SDMT score measured in newly diagnosed RRMS patients is predictive of vocational limitation in the following 10 years.

This work has been supported in parts by grants of ARSEP and Schering France SA.

Dr A.Ruet received honorarias for speaking at scientific meetings for Teva. AR received research grant from Fondation pour la Recherche Médicale (FRM).

Pr B.Brochet or his institution has received honorarias for speaking at scientific meetings and serving as member of scientific advisory boards for Bayer Pharma, Biogen Idec, Merck Serono, Genzyme, Novartis and Teva and BB’s instistution received research grants from Bayer Pharma, Teva, Merck Serono, Novartis, Biogen-Idec, Sanofi-Aventis and ARSEP and Roche.

Dr JC.Ouallet has received consultancy fees, speaker fees, research grants (non-personal), and honoraria from Novartis, Biogen-Idec, Merck-Serono, and Sanofi-Aventis.

M. Deloire : No disclosure

Working memory training in patients treated with INFB-1b – Effects on cognitive performance, functional MRI and resting state networks

M. Hubacher, K. Weier, K. Opwis, M. Stoecklin, L. Kappos, T. Sprenger, I.K. Penner

University of Basel (Basel, CH); University Hospital (Basel, CH)

Background: Deficits of processing speed, working memory and cognitive flexibility are frequently observed in patients with Multiple Sclerosis (MS) even at the earliest stages of the disease and have a high impact on daily live. Cognitive deficits are related to increased activity in cognitive circuits as measured by functional magnetic resonance imaging (fMRI), which is thought to indicate spontaneous functional reorganisation.

Objectives: To evaluate the effects of a computerized working memory training (BrainStim) on cognitive performance and brain function.

Methods: Patients with clinically isolated syndrome (CIS) or early relapsing remitting MS (RRMS) under treatment with INFB-1b are randomly assigned to either the treatment group (TG), receiving training with BrainStim, or the control group (CG) without additional cognitive intervention. A neuropsychological test battery and self-reported outcomes for depression, fatigue and quality of life are applied at baseline (double measurement of cognitive performance, T1), immediately after the training (T2), after 3 months (T3) and after 6 months (T4). In addition, treatment effects on cerebral function are assessed at T1, T2 and T4. The training between T1 and T2 consists of three different modules, which are applied for 15 minutes each in a 45 minutes session. The whole training consists of 16 sessions in four weeks.

Results: We present preliminary data of the first 6 patients in the TG. All patients improved their performance in the training during the four-week period. After the training, patients improved in tonic and phasic alertness, visual working memory, verbal working memory, processing speed, and executive functioning. Additionally, a shift from parietal activation during T1 to frontal activation during T2 was observed in fMRI when patients were solving a working memory task with increasing task complexity. Resting state networks (related to working memory and default-mode) identified by an independent component analysis (ICA) were stable over time in this small group of patients.

Conclusion: Our experience with the training so far indicates a high acceptance by the participating patients. Preliminary data analysis shows a training effect on neuropsychological and fMRI outcomes indicating normalisation of brain function. However, findings have to be confirmed when data collection is completed.

MH, KW, KO and MS have nothing to disclose.

LK has participated in the last 24 months as principal investigator, member or chair of planning and steering committees or advisory boards in corporate-sponsored clinical trials in multiple sclerosis and other neurological diseases. The sponsoring pharmaceutical companies for these trials include Abbott, Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CSL Behring, Elan, Genmab, GeNeuro SA, Genmark, GlaxoSmithKline, Lilly, Merck Serono, Novartis, Novonordisk, Peptimmune, Sanofiaventis, Santhera, Roche, Teva, UCB and Wyeth. He has also lectured at medical conferences or in public on various aspects of the diagnosis and management of multiple sclerosis. In many cases these talks have been sponsored by non-restricted educational grants to my institution from one or another of the above listed companies. Honoraria and other payments for all these activities have been exclusively used for funding of research of his department. Research and the clinical operations (nursing and patient care services) of the MS Center in Basel have been supported by non-restricted grants from one or more of these companies.

TS served on advisory boards for Mitsubishi Pharma, Eli Lilly, Biogen and Allergan. He received travel support from Pfizer, Bayer Schering, Eli Lilly and Allergan.

IKP has received research grants from Bayer AG Switzerland and the Swiss Multiple Sclerosis Society; has received honoraria forserving as speaker at scientific meetings, consultant, and as member of scientific advisory boards for Actelion, Bayer Pharma AG, Biogen Idec, Merck Serono, Roche, and Teva Aventis.

Emotional and neutral verbal memory impairment in multiple sclerosis

P. Iaffaldano, R.G. Viterbo, B. Goretti, E. Portaccio, M.P. Amato, M. Trojano

University of Bari (Bari, IT); University of Florence (Florence, IT)

Background: Emotionally salient information is more likely to be recalled than neutral information. To date emotional memory has not been investigated in Multiple Sclerosis (MS) patients.

Objectives: To assess verbal memory performances during learning of emotionally significant words in patients with Clinically Isolated Syndrome suggestive of MS (CIS) and Relapsing (RR) MS in comparison to Healthy Controls (HC).

Methods: Seventy-one patients (N=22 CIS [16 F; mean Age 32.1; mean disease duration 1.19] N=49 RRMS [34 F; mean Age 38.1; mean disease duration 13.44]) and 21 age- and sex-matched HC were evaluated. The Brief Repeatable Battery (BRB) was used to detect cognitive impairment (CI). CI was defined as failure in at least 3 tests of the BRB. Immediate (Long Term Storage [LTS] and Consistent Long-Term Retrieval [CLTR]) and delayed recall (Delayed[D]) were evaluated by the Selective Reminding Test (SRT). A list of 12 emotionally significant words was used to assess the Emotional (E) variants of the SRT. Patients with a Beck Depression Inventory (BDI) score > 9 were classified as depressed.

Results: The prevalence of CI and of depression did not differ between RRMS (27.3%; 32.6%) and CIS (26.5%; 27.3%). Retrieval of neutral and emotional stimuli was found to be impaired in RRMS and CIS patients in comparison to HC in all the 3 SRT tasks (ANOVA: p<.05), but no difference was found between RRMS and CIS. Cognitively preserved patients performed significantly better than patients with CI in all the SRT tasks (p<.0001). No differences in the performances in both memory tests were found between depressed and non-depressed patients (p=ns). Emotionally salient words were more recalled than neutral words by HC and CIS patients while performing the immediate recall tasks (E-LTS vs LTS: 52.48 vs 45.29 in HC; 42.82 vs 34.86 in CIS [p=.001]; E-CLTR vs CLTR: 44.14 vs 38.48 in HC; 29.86 vs 25.59 in CIS [p<.05]); delayed recall was not affected by emotional stimuli in both groups. In RRMS patients no differences (p=ns) were found between emotional and neutral stimuli in both the immediate and in the delayed recall tests.

Conclusions: Our results confirm the presence of a global CI along with emotional memory dysfunctions since the first MS clinical attack. An enhanced verbal memory retention based on emotionally significant stimuli is still evident in CIS patients, but the emotion processing impairment seems to further worsen during the RR phase.

Pietro Iaffaldano has nothing to disclose; Rosa Gemma Viterbo serves on scientific advisory boards for Biogen-Idec and received honoraria for speaking from Novartis and Biogen; Benedetta Goretti serves on scientific advisory boards for Biogen Idec and honoraria from Merck Serono, Biogen Idec and Novartis; Emilio Portaccio serves on a scientific advisory board for Biogen Idec and receives research support and honoraria from Merck Serono, Biogen Idec, Bayer Schering, Sanofi Aventis and Novartis; Maria Pia Amato serves on scientific advisory boards for Biogen-Idec, Merck Serono, Bayer Schering and Sanofi Aventis and receives research support and honoraria for speaking from Biogen-Idec, Merck Serono, Bayer Schering and Sanofi Aventis; Maria Trojano received honoraria for consultancy or speaking from Biogen, Sanofi-Aventis, Merck Serono and Bayer-Schering and research grants from Merck Serono, Biogen and Novartis.

Symptom overlap in anxiety and multiple sclerosis: on the need for caution

S. Ó Donnchadha, T. Burke, J. Bramham, M.C. O’Brien, R. Whelan, R. Reilly, H. Kiiski, R. Lonergan, K. Kinsella, S.B. Kelly, C. McGuigan, M. Hutchinson, N. Tubridy

University College Dublin (Dublin, IE); University of Vermont (Burlington, US); Trinity College Dublin (Dublin, IE); St. Vincent’s University Hospital (Dublin, IE)

Background: The validity of self-rated anxiety inventories for multiple sclerosis (MS) samples is unclear. The appropriateness of self-reported depression scales has been widely examined, however. Given somatic symptom overlap between depression and MS, research emphasises caution when using such scales.

Objective: This study evaluates symptom overlap between anxiety and MS in a group of 33 individuals with MS, using the Beck Anxiety Inventory (BAI: Beck, Epstein, Brown & Steer, 1988).

Methods: Participants underwent a neurological examination and completed the BAI (a 21-item self-report screening tool that measures anxiety from a multidimensional perspective).

Results: A novel procedure using hierarchical cluster analysis revealed three distinct symptom clusters. Cluster one (‘wobbliness in legs’ and ‘unsteady’) grouped separately from all other BAI items. These symptoms are well recognised MS-related symptoms and we question whether their endorsement in MS can be considered to reflect anxiety. Cluster two relates to temperature regulation and subjective complaints, whereas cluster three is associated with neurophysiological and evaluative symptoms of anxiety. Due to the overlap between cluster one and MS symptomatology, a modified 19-item BAI (mBAI) was created which excludes these items. This removal reduced the number of MS participants considered ‘anxious’ by 21%, reduced the severity of anxiety in 37.5% of cases initially classified as anxious, and overall, altered the level of anxiety severity for 27% of the total sample.

Conclusion: Based on these data, it is suggested that, as with depression measures, researchers and clinicians should exercise caution when using brief screening tools for anxiety in MS.

S. Ó Donnchadha: Has received PhD funding from the Irish Research Council for Science Engineering and Technology (IRCSET).

T. Burke: Has nothing to disclose.

J. Bramham:Has nothing to disclose.

M.C. O’Brien: Received funding from the Health Service Executive as part of her doctoral training in clinical psychology in University College Dublin.

R. Whelan: Has nothing to disclose.

R. Reilly: Has nothing to disclose.

H. Kiiski: Has received PhD funding from the Irish Research Council for Science Engineering and Technology (IRCSET).

R. Lonergan: Has nothing to disclose.

K. Kinsella: Has received compensation for travel expenses from Sanofi-Aventis & Biogen Idec.

S.B. Kelly: Has received financial compensation for travel and presentations given on behalf of Biogen Idec & Novartis.

C. McGuigan: Has received honoraria and grant support from Biogen Idec, Teva, Novartis, Merck Serono & Bayer Schering.

M. Hutchinson: Serves on a medical advisory board [BG00012] for Biogen-Idec; serves on the editorial boards of the Multiple Sclerosis journal and the International MS journal and receives research support from Dystonia Ireland and the Health Research Board of Ireland.

N. Tubridy: Has received advisory board honoraria from Novartis.

Self-reported behavioural changes and executive function impairment

M. López-Góngora, A. Martínez-Domeño, A. Escartín

Hospital de la Santa Creu i Sant Pau (Barcelona, ES)

Background and Objective: Behavioural changes occur frequently in patients with multiple sclerosis. The most common symptoms are depression, emotional lability, irritability, apathy and aggression. These variations may be assessed by means of the Frontal Systems Behaviour Scale (FrSBe) which evaluates changes over time in apathy, disinhibition and executive dysfunction. This scale has shown being a sensitive measurement in multiple sclerosis patients.

The aim of the present study is to determine if there is any correlation between self-reported variations in actions or attitudes and cognitive tests of executive functions.

Method: A total of 153 patients (98 females, 55 males) with a mean age of 39.9 years (SD = 11 years) and 9.3 years (SD = 7.3 years) of disease evolution, underwent a comprehensive neuropsychological assessment. This assessment included measures of executive functions such as mental flexibility, attention, inhibition, abstract reasoning and verbal fluency. Patients were asked to answer the Frontal Systems Behaviour Scale.

People with psychiatric history were not included in the study.

Results: All of the executive function variables were correlated with the three frontal systems behavioural symptoms scores and with the total outcome of the scale. The total scores of the Symbol Digit Modalities Test (SDMT), semantic verbal fluency, the word-colour stroop test task, as well as the perseverative responses and the number of completed categories of the Wisconsin Card Sorting Test (WCST), showed a significant correlation with all the FrSBe scores.

The Paced Auditory Serial Addition Test (PASAT) in the 3 and 2 seconds versions did not show any correlation with the different subscales of the FrSBe or with the total scale score.

Other executive functions variables, correlated with some of the frontal systems behaviour scale scores, mostly with the executive dysfunction subscale.

Conclusions: Results of the present study show that self reported behavioural changes may indicate executive functions impairment. In centres where neuropsychological assessment is not done routinely, a self administered test that can be answered by the patient alone and in a short period of time as the FrSBe, may be useful in deciding which patients should be assessed by the neuropsychologist.

The authors have nothing to disclose.

Survival analysis of the BRB-N supports SDMT as a sentinel test for cognitive deterioration in MS

J. Van Schependom, M.B. D’hooghe, A. Symons, K. Cleynhens, M. D’hooghe, S. Neirinckx, M.C. Haelewyck, G. Nagels

UMons (Mons, BE); National MS Center Melsbroek (Melsbroek, BE)

Introduction: One might expect that cognitive deterioration in MS, much like physical deterioration, does not follow a fixed pattern because it is caused by pseudo-random distribution of lesions in the CNS. However, information processing speed is often decreased, and might be a primum movens for cognitive deterioration in MS. In that case we would expect a recurring pattern, rather than a pseudorandom failure in cognitive function in MS, and in that case, it might also be possible to select one test as a sentinel test. We therefore examined possible patterns in cognitive failure in a cross-sectional dataset obtained in the National MS Center Melsbroek, Belgium.

Methods: We retrospectively analyzed neuropsychological tests that were administered to 315 patients with MS. Out of 315 included patients, 199 were female, 259 had relapsing onset, and 56 progressive onset MS. Mean age was 48.5 ± 11.7 yr.

A survival analysis was performed for the SDMT, PASAT-2, COWAT, CLTR and SRT. A score below the fifth percentile of a normal population was considered a failure. Rao score was defined as the number of tests from the set (PASAT-2, SRT, COWAT and CLTR), on which the subject did not fail.

We performed a ROC analysis to evaluate the predictive value of failing the SDMT on failure on the Rao score, defined as a Rao score below 2. This allowed us to assess the value of the SDMT at the individual level.

Results: SDMT (using a 5th percentile cutoff) showed a significantly faster attrition in the survival analysis In comparison to PASAT-2 (log rank test, p<0.05), SRT(p<0.001), COWAT (p<0.005) and CLTR (p<0.001). PASAT-2 also showed a significantly worse attrition compared to CLTR (p<0.05).

ROC analysis showed an AUC of 85.4%. The sensitivity of finding cognitive impairment on the Rao score, using the SDMT as predictor, was 90 % with an SDMT cut-off of 39. At this point the specificity was 65 %, positive predictive value 54 % and negative predictive value 94 %. For a cutoff of 34, which corresponds to the 5th percentile, sensitivity was 76 %, specificity 80%, positive predictive value 63 % and negative predictive value 88 %.

Conclusion: The attrition of cognitive functions in MS may follow a recurrent pattern. The SDMT performs well, both on a group and individual level, as a sentinel test for cognition in MS.

The authors have nothing to disclose.

The research was funded by the university of Mons (UMons).

Decisions under ambiguity and decisions under risk in multiple sclerosis

M.F. Farez, L. Crivelli, R. Leiguarda, J. Correale

FLENI (Buenos Aires, AR)

Background: Decision-making (DM) is the ability to choose among different options. Decisions are usually made under two conditions: conditions of ambiguity in which the options are implicitly related to the outcome and no information about it is available to the decision maker; and conditions under risk, in which probabilities and rewards are explicit to the subject. The present study evaluates DM under both conditions and its relationship to other cognitive functions typically affected in MS.

Methods: Twenty-seven patients with RRMS and 27 matched controls underwent neuropsychological evaluation and DM assessment using two tests: Iowa Gambling Task (IGT), which evaluates DM under conditions of ambiguity –mainly in its initial part- and the Game of Dice Task (GDT), in which subjects face explicit probabilities and outcomes.

The IGT consists of 4 decks of cards, in the long term A and B are disadvantageous whereas C and D are advantageous. Participants are unaware of gain and loss bias at the beginning of the task. Over the course of 100 card selections (divided in 5 blocks of 20 cards), subjects are expected to develop the strategy of choosing from the advantageous decks. In the GDT, participants have to guess during 18 throws of a single dice, which number will appear before selecting a single number or a combination of two, three or four numbers. Safe options are three or four number combinations, whereas a single number or two number combinations are defined as risky.

Results: MS patients had significantly lower scores in the overall IGT score (P=0.007). Block analysis showed that MS patients and controls were comparable in the scores of blocks 1 and 2 (P=0.15 and P=0.24, respectively), which are those that most likely assess DM under ambiguity. Conversely, MS patients performed worse in blocks 4 (P=0.003) and 5 (P=0.02), corresponding most likely to DM under conditions of risk. Significant differences were also found in the GDT, with MS patients choosing the unfavorable dices more often (P=0.02). A significant correlation between performance in the GDT and the last three blocks of the IGT (P=0.02) was observed, but not with the first two blocks (P=0.40). Finally, performance in the last 3 blocks of the IGT and in the GDT was correlated with visuo-spatial learning, processing speed and working memory.

Conclusions: MS patients showed deficits in DM under risk conditions, which may be related to decreased visuo-spatial learning, processing speed and working memory.

Mauricio F. Farez MD MPH, Lucía Crivelli BsC and Ramón Leiguarda MD have nothing to disclose.

Jorge Correale MD is a board member of Merck-Serono Argentina, Biogen-Idec LATAM, and Merck-Serono LATAM. Dr. Correale has received reimbursement for developing educational presentations for Merck-Serono Argentina, Merck-Serono LATAM, Biogen-Idec Argentina, and TEVA-Tuteur Argentina as well as professional travel/accommodations stipends.

Memory and attention disorders in a large sample of out-patients with multiple sclerosis

G. Adler, Y. Lembach, M. Feger, M. Bektas, N. Baumgart, Y. Ko-Inoshishi

ISPG (Mannheim, DE)

Many patients with multiple sclerosis (MS) suffer from cognitive impairments, which may have an impact on their functional level and quality of life. Little is known about the severity and frequency of these impairments in large unselected out-patient groups. Applying conventional methods of neuropsychological assessment, such studies would be extremely laborious and expensive. However, the computer-based Memory and Attention Test (MAT) allows a valid and reliable assessment of cognitive performance, which can be easily performed with little personnel expenses and little strain for the patients.

In a cross-sectional study at practice-based neurologists and specialized multiple sclerosis out-patient clinics, cognitive performance was evaluated in a large non-selected out-patient sample of not-acutely-ill multiple sclerosis patients by means of the MAT. Additionally, we assessed disease history, severity of neurological symptoms (by means of the EDSS), the medication and whether depression or fatigue was present. The MAT findings of the MS patients were compared to those in an age-, education- and sex-matched control group.

The study was conducted in 502 patients (67% women, 33% men) at ages between 17 and 60 years (mean/SD: 39.6/10.1 years). The course of the disease was relapsing-remitting in the majority of patients (78%). The EDSS score was between 0 and 7.5 (mean/SD: 2.8/1.7). We found significant impairments of the episodic and the verbal short-term memory as well as of the episodic working memory in the MS patients. In 19.9% of the patients, the score in the episodic short-term memory was two or more SD below the mean score of the reference group. Performance in the other memory domains and in the selective attention task was not found significantly impaired. There were significant correlations of the episodic short-term memory impairment with the EDSS score as well as with the duration of disease (after elimination of partial correlations only with the EDSS score).

About 20% of not-acutely-ill MS out-patients suffer from substantial memory impairments, particularly of the episodic short-term memory. These impairments are of such a strong degree that they should have a material impact on functional level and quality of life.

The study was sponsored by an unrestricted research grant of Novartis GmbH, Nürnberg.

The authors have nothing else to disclose.

Relationship between self-efficacy and cognitive performance in clinically isolated syndrome and early relapsing-remitting multiple sclerosis

P. Jongen, K. Wesnes, B. Van Geel, P. Pop, E. Sanders, H. Schrijver, L. Visser, J. Gilhuis, O. Sinnige, A. Brands

MS4 Research Institute (Nijmegen, NL); Bracket (Goring, UK); Medisch Centrum Alkmaar (Alkmaar, NL); Viecuri Medisch Centrum (Venray, NL); Amphia Ziekenhuis (Breda, NL); Westfries Gasthuis (Hoorn, NL); St. Elisabeth Ziekenhuis (Tilburg, NL); Reinier de Graaf Gasthuis (Delft, NL); Medisch Centrum Leeuwarden (Leeuwarden, NL); Utrecht University (Utrecht, NL)

Introduction: In people with (Pw) multiple sclerosis (MS) self-efficacy correlates with lev¬els of physical activity, psychological well-being and health-related quality of life. It is not known whether self-efficacy affects cognitive performance in PwMS. The Cognition and Socio-Economics (COGNISEC) study is assessing relations between cognition and socio-economics in Pw Clinically Isolated Syndrome (CIS) and early relapsing remitting MS (eRRMS) in the Netherlands. The study includes a sub-study on the relation between self-efficacy and cognitive performance.

Methods: Inclusion criteria. CIS or eRRMS, <2 years since diagnosis, no relapse, no or <6 months disease modifying treatment, clinically stable for 30 days. Self-efficacy assessment: 9-item MS Self-Efficacy Function (MSSE-F) scale and 9-item MSSE Control (MSSE-C) scale, both ranging from 0 to 100. Cognitive assessment: CDR System automated cognitive testing; calculation of composite scores for Focused Attention (FA), Sustained Attention (SA), Working Memory (WM), Long-Term Memory (LTM) and Speed of Memory (SM) (Edgar et al. 2011). Other assessments: Disability (Expanded Disability Status Scale [EDSS]), depression (Beck Depression Inventory-13 [BDI-13]) and fatigue (Modified Fatigue Impact Scale-5 [MFIS-5]). Statistics: Associations between MSSE scores and CDR composite, EDSS, BDI-13 and MFIS-5 scores were evaluated using Pearson coefficients.

Results: 27 patients were studied (female:male, 2.2:1). Mean (standard deviation [SD]) values: Age 39.5 (7.6) years; EDSS 1.21 (1.17); CDR composite scores: FA 1227 (173.7), SA 92.1 (3.4), WM 1.89 (0.11), LTM 1.48 (0.28) and SM 4002 (880.3). MSSE-F score correlated positively with FA (0.47; p = 0.014), SA (0.54; p = 0.005), LTM (0.47; p = 0.017) and SM (0.54; p = 0.004). MSSE-C score correlated positively with FA (0.53; p= 0.005) and SM (0.039; p = 0.048). MSSE-F score correlated negatively with EDSS (-0.68; p= 0.007) and MFIS-5 (-0.54; p = 0.004) values and MSSE-C score correlated negatively with MFIS-5 (-0.76; p < 0.0001) and BDI-13 (-0.67; p = 0.0001) scores.

Conclusion: The positive correlations between self-efficacy and cognitive test results suggest a direct relationship between self-efficacy and major domains of cognitive function in Pw CIS and eRRMS.

Reference

Edgar et al. BMC Neurology 2011; 11: 68-79.

Peter Jongen has received honoraria from sanofi aventis, Teva, Merck Serono, Novartis, Bayer, Biogen Idec and Allergan for activities as speaker, advice or research support.

Keith Wesnes is also an employee of Bracket, and has acted as a consultant to Astellas, Roche and Bristol Myers Squibb.

Björn van Geel, Paul Pop, Evert Sanders, Hans Schrijver, Leo Visser and Jacobus Gilhuis have nothing to disclose.

Okke Sinnige received honoraria for advisory activities and travel grants from Biogen Idec, Novartis, Merck Serono and Bayer.

Augustina Brands has nothing to disclose.

Therapeutic treatment with an anti-mouse CD52 antibody reverses disease symptoms in a murine EAE model of multiple sclerosis

M. Turner, N. Chretien, E. Havari, M. LaMorte, B. Roberts, J. Kaplan, W. Siders

Genzyme, a Sanofi company (Framingham, US)

Objective: The goal of these studies was to characterize the effects of anti-mouse CD52 treatment in an experimental autoimmune encephalomyelitis (EAE) mouse model of multiple sclerosis.

Background: Alemtuzumab is an anti- human CD52 humanized monoclonal antibody that alters the circulating lymphocyte pool. Alemtuzumab has demonstrated superior clinical efficacy compared to interferon-β in relapsing-remitting multiple sclerosis patients. A depleting antibody against murine CD52 (muCD52) was generated for exploratory studies in an EAE model to expand our understanding of anti-CD52 therapy.

Methods: C57BL/6 mice were immunized with MOG35-55 peptide to induce EAE and treated therapeutically with anti-muCD52 antibody. Cohorts were evaluated for the development and severity of disease symptoms and polychromatic flow cytometric analysis was used to determine the impact of anti-muCD52 therapy on various lymphocyte populations in both the spleen and central nervous system (CNS). Histological readouts were used to evaluate the level of cellular infiltrate and myelination within the CNS.

Results: Administration of the anti-muCD52 antibody to C57BL/6 mice resulted in lymphocyte depletion and subsequent repopulation with blood counts returning to baseline approximately 40 days post dosing. Therapeutic administration in an EAE model reversed existing paralytic symptoms and inhibited disease progression. Longitudinal flow cytometric evaluation showed a decrease in both the total number of circulating CD4 T cells as well as MOG35-55 specific CD4 T cells as measured by intracellular cytokine staining for IFN-γ and IL-17. Histological evaluation showed a reduction in the level of lymphocytic infiltrate in the CNS of anti-muCD52 treated animals compared to control animals treated with vehicle.

Conclusions: Treatment with a depleting anti-muCD52 antibody in the MOG induced EAE model was effective in reversing paralytic disease. The effect was associated with a reduction in autoreactive MOG-specific T cells and diminished lymphocyte infiltration into the CNS.

All authors are current employees of Genzyme, a Sanofi company.

Effect of switching from intramuscular interferon b-1a to fingolimod on time to relapse in patients with relapsing-remitting multiple sclerosis enrolled in a 1-year extension of TRANSFORMS

G. Cutter, X. Meng, P. Chin, R. Hashmonay, M.Z. Islam

University of Alabama at Birmingham (Birmingham, US); Novartis Pharmaceuticals Corporation (East Hanover, US)

Background: In TRANSFORMS, a phase 3 randomised, double-blind trial, oral fingolimod 0.5 or 1.25 mg once daily significantly reduced the annualised relapse rate (ARR) over 12 months compared with intramuscular (IM) interferon (IFN) β-1a 30 µg once weekly in relapsing-remitting multiple sclerosis (RRMS) patients (ARR: fingolimod 0.5 mg, 0.16; fingolimod 1.25 mg, 0.20; IFN β-1a IM, 0.33). In a 1-year extension study, IFN β-1a IM patients were randomly reassigned to fingolimod 0.5 or 1.25 mg, resulting in relative reductions in ARR of 29% and 38%, respectively, compared with the previous 12 months.

Objective: To compare A/B where (A) is the observed time to first confirmed relapse after switching from IFN β-1a IM to fingolimod and (B) is the estimated time if patients had remained on IFN β-1a IM.

Methods: The analysis included patients in the intent-to-treat population who switched from IFN β-1a IM to fingolimod during the extension phase. The Branson and Whitehead switch model with iterative parameter estimation (Branson M and Whitehead J. Stats Med. 2002;21:2449-2463) was used to estimate the ratio of A to B. Ratios >1 (greater time to relapse) show a benefit of switching to fingolimod.

Results: Of 431 patients who received IFN β-1a IM in the original trial, 341 entered the extension phase, with 167 switching to fingolimod 0.5 mg and 174 switching to fingolimod 1.25 mg. Overall, 31 of these patients had a relapse after switching (IFN β-1a IM to fingolimod 0.5 mg, n=16; IFN β-1a IM to fingolimod 1.25 mg, n=15). The estimated ratio of A to B was 2.09 (95% CI, 1.45–3.04) for IFN β-1a IM to fingolimod 0.5 mg switch group and 1.84 (95% CI, 1.30–2.65) for IFN β-1a IM to fingolimod 1.25 mg switch group.

Conclusions: This analysis demonstrated an advantage of switching to fingolimod over remaining on IFN β-1a IM with regard to time to relapse in RRMS. This modeling approach could be useful in providing an estimate of the treatment benefit in trials that include a rescue for the placebo arm.

Supported by Novartis Pharmaceuticals Corporation.

G. Cutter is on the following Data and Safety Monitoring Committees: Apotek, Biogen, Cleveland Clinic, Eli Lilly, Glaxo Smith Klein, Medivation, Merck, Modigenetech (Prolor), National Institute of Nuerological Disorders and Stroke, National MS Society, National Institute of Child Health and Human Development, National Heart Lung and Blood Institute (Protocol Review Committee), Ono Pharmaceuticals, Sanofi-Aventis, Teva; he is also on the following Consulting & Advisory Boards: Alexion, Abbott, Allozyne, Bayer, Celgene, Consortium of MS Centers (grant), Coronado Biosciences, Diogenix, Medimmune, Klein-Buendel Incorporated, Novartis, Nuron Biotech, Receptos, Somnus, Spinifex Pharmaceuticals, Teva; he is employed by the University of Alabama at Birmingham and President of Pythagoras, Inc. a private consulting company located in Birmingham AL.

X. Meng, P.S. Chin, R. Hashmonay and M.Z. Islam are employees of Novartis Pharmaceuticals Corporation. X. Meng is also a stockholder of Novartis Pharmaceuticals Corporation.

MEDI-551, a novel antibody that depletes CD19+ B-cells: rationale for clinical development In multiple sclerosis

L. Carter, V. Knappertz, Y. Wang, C. Groves, E. Ward, S. Gallagher, I. Yusuf, J. Karnell, B. Rajan, R. Ettinger, R. Herbst

MedImmune (Gaithersburg, US)

In MS patients, B cell depletion with anti-CD20 antibodies (Abs) decreases gadolinium enhanced lesions and annualized relapse rates. MedImmune is developing MEDI-551 an antibody-dependent cellular cytotoxicity (ADCC)-enhanced, humanized anti-CD19 Ab for B cell depletion therapy in hematologic malignancies and autoimmune diseases including MS. In contrast to CD20, CD19 is more broadly expressed during B cell development and differentiation. For example, CD19 expression is maintained on plasmablasts and early plasma cells (PCs), cells which have been suggested to contribute to MS pathogenesis. Using flow cytometry and a panel of Abs including CD19 and CD20, B cell subsets were delineated in blood, spleen, tonsil and bone marrow from normal human subjects. PCs in these compartments were predominantly CD19+ CD20-. The expression of CD19, but not CD20, on PCs raises the possibility of greater impact on auto-Ab production with CD19-mediated depletion. In further experiments, in vitro ADCC and antibody-dependent cellular phagocytosis (ADCP) assays were performed. The EC50 of MEDI-551 was ~10-15X lower than that of rituximab in human ADCC and murine ADCP assays. ADCC and ADCP were unaffected by inclusion of IFNb, glatiramer acetate or steroid in the assays. MS patients and control subjects had comparable NK:B cell ratios in peripheral blood suggesting that ADCC mechanism will be active in MS patients. Similar to in vitro results, in vivo the ability of MEDI-551 to deplete B cells compared favorably to rituximab treatment at low doses of antibody in hCD19 x hCD20 double transgenic mice. Additionally, in an autoimmune model, MEDI-551 depletion resulted in decreased autoAb titers. These rodent results are consistent with observations in autoimmune patients in a Phase 1 clinical trial where MEDI-551 showed efficient depletion of B cells in peripheral blood. Based on the pre-clinical data and initial clinical trial results, MEDI-551 is currently being tested in RRMS patients (NCT01585766).

Employees of MedImmune, LLC.

Development of anti-CXCL13 monoclonal antibody for the treatment of multiple sclerosis

E. Klimatcheva, T. Pandina, C. Reilly, J. Decker, A. Jonason, M. Scrivens, H. Huang, C. Cornelius, M. Doherty, J. Veeraraghavan, R. Kirk, J. Caplan, A. Howell, P. Kenney, G. Seigel, S. Torno, T. Richards, T. Fisher, E. Evans, M. Paris, J. Leonard, R. Watkins, P. Foster, W. Bowers, M. Zauderer, E. Smith

Vaccinex, Inc (Rochester, US)

The chemokine CXCL13 is expressed in secondary lymphoid organs by follicular dendritic cells, macrophages and TH17 cells. It is the only known ligand for the CXCR5 receptor which is expressed on mature B cells, follicular helper T cells, TH17 cells and Treg cells.

Aberrant expression of CXCL13 within ectopic germinal centers has been linked to the development of autoimmune disorders (e.g. Multiple Sclerosis (MS)). In patients with secondary progressive MS, CXCL13-producing cells have been shown to accumulate in cerebral meninges, and elevated levels of CXCL13 have been found in serum and the cerebrospinal fluid of patients with Relapsing Remitting, Primary Progressive, and Secondary Progressive MS.

We hypothesize that antibody-mediated blockade of CXCL13 interaction with its receptor would interfere with formation of ectopic lymphoid follicles in the CNS and inhibit MS progression.

We developed a human IgG1 monoclonal antibody that specifically binds to human, rodent and primate CXCL13 with an affinity of approximately 5 nM. It is capable of neutralizing CXCL13 function from these various species in several in vitro functional assays. For in vivo studies we have engineered a chimeric antibody to contain the same human heavy and light chain variable genes along with mouse constant regions. This anti-CXCL13 antibody has demonstrated efficacy in both active immunization and Th17-mediated adoptive transfer Experimental Autoimmune Encephalomyelitis (EAE). In addition, treatment with this antibody reduced the number of ectopic follicles in several different autoimmune disease models, and, in adoptive transfer studies, interfered with the trafficking of B cells to the B cell areas of spleen and lymph nodes.

The human antibody is currently undergoing pre-clinical development in preparation for filing an FDA Investigational New Drug application for potential therapy of inflammatory disease.

The authors are employees of Vaccinex, Inc.

A multinational, multicentre, randomised, parallel-group study to assess efficacy, safety, and tolerability of glatiramer acetate 40 mg injection three times a week in subjects with RRMS: baseline patient characteristics of the GALA study

O. Khan, P. Rieckmann, A. Boyko, K. Selmaj, R. Zivadinov

Wayne-State University School of Medicine (Detroit, US); University of Erlangen (Bamberg, DE); Russian National Medical Research University (Moscow, RU); Medical University of Lodz (Lodz, PL); State University of New York (Buffalo, US)

Background: The currently approved regimen for glatiramer acetate (GA) for the treatment of relapsing-remitting multiple sclerosis (RRMS) is 20 mg/day. In order to reduce the number of injections without substantially reducing the total dose, a new three-times weekly (t.i.w.) 40 mg formulation of GA was developed. The GALA study was designed to examine the efficacy and safety of GA 40 mg administered t.i.w. in patients with RRMS. Here, we present the baseline data for patients enrolled in the GALA study.

Methods: This is a Phase 3, multinational, multicenter, parallel-group, double-blind study. Patients included in the study were aged 18–55 years, with a diagnosis of RRMS (Revised McDonald criteria), EDSS score of ≤5.5, and relapse free for at least 30 days. Participants treated previously with GA, those with progressive disease, or those using interferons, natalizumab, cladribine, or immunosuppressive agents for the previous 2 years were not permitted in the study. Participants were randomized 2:1 to receive either GA 40 mg t.i.w. or placebo, respectively. The primary endpoint is the annual relapse rate at Month 12. Secondary and exploratory outcomes include cumulative number of new T2 and gadolinium (Gd)-enhancing lesions and changes in brain volume.

Results: 1404 RRMS patients (954 females, 450 males) were randomized. Of these, 1370 subjects (97.6%) were Caucasian, and 1243 patients (88.5%) were between 29 and 50 years of age. Enrolled patients were from 17 countries and 155 sites. The mean time (SD) from diagnosis to screening was 3.7 (4.9) years, while the mean time from their first symptom of MS to screening was 7.6 (6.6) years. Mean (SD) baseline EDSS score was 2.5 (1.2) and mean (SD) baseline MRI characteristics included Gd-enhancing lesion number of 1.6 (1.4) [volume 0.2 (0.7) mL], T2 lesion number of 37.5 (26.5) [volume 19.0 (19.7) mL], and T1 hypointense lesion number of 22.6 (20.7) [volume 5.1 (7.3) mL]. The mean total brain volume (SD) at baseline was 1535 (111) mL, with a grey matter volume of 802.5 (68.5) mL and a white matter volume of 732.1 (64.4) mL.

Conclusions: The baseline demographic and MS disease characteristics in this study represent a large multinational RRMS patient cohort. The results of this study will determine whether GA 40 mg t.i.w. is an effective and safe therapy for patients with RRMS.

P. Rieckmann received speaker’s honoraria from Bayer, biogenidec, Boehringer Ingelheim, Novartis, Merck-Serono, TEVA and genzyme. He serves on steering committee for clinical trials from Novartis, Merck-Serono and TEVA.

Krzysztof Selmaj received honoraria for advisory board membership, consulting and speaking from Biogen Idec, Genzyme, ONO Pharma, Novartis, Bayer, Hoffmann La-Roche, Merck Serono and Synthon.

Robert Zivadinov received personal compensation from Teva Neuroscience, Biogen Idec, EMD Serono, Questcor Pharmaceuticals and Novartis for speaking and consultant fees. Dr. Zivadinov received financial support for research activities from Biogen Idec, Teva Neuroscience, Novartis, Genzyme, Bracco, Questcor Pharmaceuticals and EMD Serono.

Omar Khan conducted reserach for: NIH, NINDS, NMSS, TEVA, BIOGEN IDEC, GENZYME, ROCHE, NOVARTIS.

Consulting: BIOGEN IDEC, GENZYME, NOVARTIS SPEAKERS BUREAU: TEVA, NOVARTIS, BIOGEN IDEC.

Bioequivalence of BG-12 administered as a single 240 mg capsule and two 120 mg capsules: findings from a randomised, two-period crossover study

K.T. Dawson, I. Nestorov, R. Manchanda, D. Goldman, J. O’Gorman, H. Russell, M.A. Matson, M. Tighe, S.I. Sheikh

Biogen Idec (Weston, US); PROMETRIKA, LLC (Cambridge, US); Prism Research (St Paul, US)

Background: BG-12 is an oral agent, formulated as enteric-coated microtablets containing dimethyl fumarate (DMF) in a gelatin capsule, in development for treatment of relapsing multiple sclerosis (MS). Phase 3 studies demonstrated clinical and neuroradiological efficacy of BG-12 240 mg (dosed as two 120 mg capsules) given two or three times daily. In this study, we evaluated the bioequivalence of BG-12 administered as two 120 mg capsules and as a single, same-size, 240 mg capsule in healthy volunteers.

Methods: In this randomized, open-label, two-period crossover study, healthy volunteers received two 120 mg capsules or a single 240 mg capsule of BG-12 after an overnight fast. Blood samples were drawn 15 minutes pre-dose and serially at twelve time points 30 minutes to 12 hours post-dose to determine the pharmacokinetics of monomethyl fumarate (MMF; the primary metabolite of DMF), calculated by noncompartmental analysis.

Results: Eighty-one subjects were enrolled in the study; 77 completed both treatment periods. Concentration–time profiles were very similar after dosing regimens (one 240 mg capsule or two 120 mg capsules): mean maximum plasma concentrations (Cmax) of 2.42 and 2.34 mg/L, respectively, were reached at a mean of approximately 2.5 hours post-dose; mean values for area under the curve (AUC), extrapolated to infinity, were 3.98 and 3.87 h.mg/L, respectively. Bioequivalence between formulations was established per standard regulatory criteria, with ratios of geometric means of 1.06 (90% confidence interval [CI] 0.96–1.16) for Cmax and 1.03 (90% CI 0.99–1.07) for AUC in patients who completed both treatment periods. Adverse events (AEs) were predominantly mild in severity. The most common AE was flushing, consistent with previous studies of BG-12. There were no serious or severe AEs.

Conclusion: Single-capsule administration of BG-12 240 mg demonstrated bioequivalence with the same dosage administered as two capsules. Administering the 240 mg dose in a single capsule would halve the number of capsules required per dose, which could further promote treatment adherence.

Dr. Dawson, Dr. Nestorov, Dr. Manchanda, Dr. Goldman, Dr. O’Gorman, Dr. Tighe and Dr. Sheikh are all employees of Biogen Idec Inc.

Dr. Russell and Dr. Matson have nothing to declare.

Supported by: Biogen Idec Inc.

Laquinimod regulates inflammatory gene induction in a human model of reactive astrogliosis

T. Pham, J. Zhang, J. Seto, B. Hartmann, L. Hayardeny, G. John

Mount Sinai School of Medicine (New York, US); Teva Pharmaceuticals (Netanya, IL)

Laquinimod is an orally-delivered agent currently in phase III clinical trials for relapsing-remitting multiple sclerosis. Laquinimod crosses the blood-brain barrier and enters the CNS, thus in addition to peripheral effects it may act directly on CNS-resident lineages including oligodendrocytes, microglia and astrocytes. Increasing evidence implicates reactive astrocytes as central regulators of CNS inflammation and repair in MS, and here we report that laquinimod profoundly impacts proinflammatory gene expression in an in vitro model of reactive astrogliosis. Interleukin-1β (IL-1β) is implicated in lesion pathogenesis in RRMS, and in primary human astrocyte cultures it strongly induced inflammatory cytokines, chemokines, adhesion molecules, matrix metalloproteinases, extracellular matrix and MHC molecules, as shown by microarray analysis, QPCR and multiplex ELISA. Importantly, at therapeutic concentrations, laquinimod abrogated IL-1 β -induced induction of cytokines including TNF α, IL-6, IL-12 and IL-23, inducible nitric oxide synthase, and type I MHC molecules. Laquinimod also differentially regulated IL-1 β -induced expression of CXC and CC chemokines, suggesting that it acts as an immunomodulator rather than an immunosuppressant in astrocyte cultures. IL-1β exerts its effects via the transcription factor NF- β B, and suggesting mechanism, IL-1 β -induced I κ B α degradation and NF-κ B p65 nuclear translocation were both delayed in laquinimod-treated human astrocyte cultures. Collectively, these data reveal laquinimod as a regulator of the proinflammatory phenotype in a human model of reactive astrogliosis, and suggest that it may act on resident cells to restrict lesion pathogenesis in MS.

Trinh Pham, Jingya Zhang, Jeremy Seto and Boris Hartmann has nothing to disclose.

Liat Hayardeny is an employee of Teva Pharmaceuticals.

The laboratory of Gareth John is the recipient of a research grant from Teva Pharmaceuticals, which funded this work.

RPC1063, a potent, selective S1P1 receptor modulator, is active in a therapeutic EAE model and exhibits favourable PK/PD properties in healthy volunteers

J. Brooks, R. Peach, F. Scott, G. Timony, J. Hartung, M. Boehm, H. Rosen, S. Gujrathi

Receptos, Inc. (San Diego, US); Scripps Research Institute (San Diego, US)

Background: RPC1063 is a potent, selective sphingosine 1-phosphate 1receptor (S1P1R) modulator in clinical development as an oral monotherapy for the treatment of multiple sclerosis.

Objective: Characterize the preclinical specificity, potency and efficacy, and clinical pharmacokinetics (PK) and pharmacodynamics (PD) of RPC1063.

Methods: Potency was determined by measuring pharmacologic activity in S1P1-5R expressing cell lines. Experimental autoimmune encephalomyelitis (EAE) was induced in mice via immunization with myelin oligodendrocyte glycoprotein peptide. Healthy volunteers received RPC1063 as single oral doses (0.3, 1, 2 or 3 mg) or multiple oral doses (0.3, 1, or 1.5 mg) for 7 and 28 days; PK and PD (total lymphocytes and lymphocyte subsets) were assessed.

Results: RPC1063 is a potent (EC50 0.156 nM) and highly selective agonist of S1P1R. RPC1063 is 353 to 20,000-fold selective towards S1P1R over S1P2R, S1P3R, S1P4R and S1P5R. Therapeutic treatment with RPC1063 in mice showing clinical signs of EAE reversed established disease progression in a dose dependent manner. Absorption was slow in healthy human volunteers with a median time to maximum plasma RPC1063 concentration (Cmax) of 8 hrs. The steady state Cmax at doses producing maximal lymphopenia response was low (~ 1nM). After single and multiple dose administration for up to 28 days, average RPC1063 Cmax and AUC values increased approximately in proportion to the administered dose, and with low inter-subject variability. After 28 days of dosing, the median decreases in lymphocyte count at trough were -34%, -65% and -68% at RPC1063 dose levels of 0.3, 1 and 1.5 mg. Consistent with the median RPC1063 half life of 17.1 hrs, recovery of lymphocyte count to the normal range following 28 days of dosing occurred within 48 hours at the 0.3 and 1 mg doses. RPC1063 caused marked decreases in circulating B cells and in T lymphocyte subsets expressing CCR7 (naïve and central memory T cells) and had varying effects on lymphocyte subsets lacking CCR7 expression.

Conclusion: RPC1063 potently and selectively activates S1P1R, and shows efficacy in EAE. The clinical PK of RPC1063 was dose-linear with low variability, and characterized by a half life supporting once daily oral dosing and facilitating rapid lymphocyte recovery. RPC1063 absorption was slow and the steady state Cmax was low. RPC1063 differentially reduces peripheral lymphocyte subsets, potentially providing maintenance of protective immunity.

All work was supported by Receptos, Inc. With the exception of H. Rosen, all authors are employees of Receptos, Inc. H. Rosen is an employee of the Scripps Research Institute and is a scientific founder of Receptos, Inc.

Intravenous administration of human MultiStem® cells provides functional benefit through immunomodulation in rodent models of multiple sclerosis

J. Hamilton, R. Cutrone, J. Hecker, C. Wylie, J. Krasno, K. Wyatt, S. Busch, L. Bai, R. Deans, R. Miller, R. Mays

Athersys Inc. (Cleveland, US); Case Western Reserve University (Cleveland, US)

Stem cell therapies are currently being investigated as potential therapeutic treatments for autoimmune disorders such as multiple sclerosis (MS). However, the mechanistic interaction between the diseased tissue environment and transplanted cells is poorly understood. In the present study, we demonstrate sustained functional benefit in mice with experimental allergic encephalomyelitis (EAE) after intravenous (IV) administration of MultiStem®, an adherent human adult stem cell product. EAE was induced via myelin oligodendrocyte glycoprotein (MOG) peptide and subsequent pertussis toxin injections. MultiStem administration was tested using three different doses of stem cells (1, 3 or 9 million cells), as well as three different times of administration. Behavioral assessment was performed daily for 28 days after cell administration. Each cell dose level resulted in statistically significant improvement compared to vehicle treatment; however, no functional benefit was observed when the cells were administered pre-symptomatically whereas cell administration early or late after symptom onset was efficacious. Luxol fast blue (LFB) staining demonstrated decreased lesion burden within the spinal cord and a shift from complete to partial lesions in MultiStem-treated animals compared to controls. Toluidine blue staining, and electron microscopic analysis, provided evidence of reduced myelin debris and improved remyelination, respectively. To look for specific effects of MultiStem upon remyelination, we tested administration in lysophosphatidylcholine (LPC)-lesioned rats. Two days after induction of demyelination, MultiStem was administered either intravenously or directly into the LPC lesion. Ten days after cell administration, animals were sacrificed for analysis of lesion status. Increased LFB staining of myelin within the lesions of MultiStem-treated animals was observed, and was confirmed using myelin basic protein (MBP) immunohistochemistry. Immunohistochemical examination of macrophage/microglia status demonstrated significant changes in immune cell infiltration of the lesions, as well as a shift in activation status (from M1 to M2) of infiltrating macrophages/microglia in MultiStem-treated animals. The results of these studies suggest that treatment of MS patients with MultiStem may provide clinical benefit through modulation of immune status and promotion of remyelination.

J. Hamilton is an employee of Athersys Inc. R. Cutrone is an employee of Athersys Inc. J. Hecker has nothing to disclose. C. Wylie is an employee of Athersys Inc. J. Krasno has nothing to disclose. K. Wyatt has nothing to disclose. S. Busch is an employee of Athersys Inc. L. Bai has nothing to disclose. R. Deans is an employee of Athersys Inc. R. Miller has nothing to disclose. R. Mays is an employee of Athersys Inc. This study was partially funded by Fast Forward / National MS Society.

Correlation between EDSS and MSFC in the FREEDOMS study

R.A. Rudick, R. Hashmonay, X. Meng, P. Chin, G. Cutter

Mellen Center for MS Treatment and Research, Cleveland Clinic (Cleveland, US); Novartis Pharmaceuticals Corporation (East Hanover, US); University of Alabama at Birmingham (Birmingham, US)

Background: In FREEDOMS, once-daily oral fingolimod 0.5 mg was significantly superior to placebo as measured by either the Expanded Disability Status Scale (EDSS) or the Multiple Sclerosis Functional Composite (MSFC). The EDSS is a well-accepted disability scale for MS trials, but has relatively poor psychometric properties. The MSFC is a reliable, sensitive, functional disability measure comprising a timed 25-foot walk (T25-FW), 9-hole peg test (9-HPT), and paced auditory serial addition test (PASAT). Previous studies in relapsing MS indicated moderate correlations between EDSS and MSFC. The strength of the correlation was driven primarily by the T25-FW component.

Objective: To investigate the correlation between EDSS and MSFC scores over 4 years in the FREEDOMS study and its extension phase.

Methods: FREEDOMS was a phase 3 study in which 1272 relapsing-remitting MS patients aged 18-55 years with an EDSS score of 0-5.5 were randomised to fingolimod 0.5 mg, fingolimod 1.25 mg, or placebo once-daily by mouth for 24 months. Patients who completed the 24-month double-blind phase were eligible to enter the long-term extension; placebo-treated patients switched to fingolimod 0.5 mg or 1.25 mg during this phase. Pearson correlation coefficients between EDSS and MSFC were calculated at baseline, month 24, and month 48.

Results: Data are for the overall study population. Mean (SD) EDSS score at baseline was 2.40 (1.3), n=1272; at month 24, 2.39 (1.5), n=1044; and at month 48, 2.42 (1.5), n=408. Mean (SD) MSFC z-score at baseline was 0.002 (0.71), n=1259; at month 24, 0.049 (0.80), n=1015; and at month 48, 0.032 (0.90), n=398. Correlation coefficients for EDSS vs MSFC at baseline, month 24, and month 48 were -0.47, -0.57, and -0.64, respectively (all P<0.0001); for EDSS vs T25-FW they were 0.31, 0.51, and 0.57 (all P<0.0001); for EDSS vs 9-HPT they were 0.35, 0.39, and 0.55 (all P<0.0001); and for EDSS vs PASAT they were -0.26, -0.32, and -0.44 (all P<0.0001). There were no notable differences in correlation across treatment groups.

Conclusions: A detailed and comprehensive analysis—including additional endpoints—will be presented to further explore the relationship between EDSS and MSFC. Moderate correlation between EDSS and MSFC was observed in the FREEDOMS study population, with an apparent strengthening trend over time. EDSS correlations with the T25-FW and 9-HPT were generally similar and stronger than the correlation with the PASAT.

Supported by Novartis Pharmaceuticals Corporation.

R. Rudick has accepted fees in the past 3 years for consulting or speaking from Biogen Idec, Genzyme, Novartis, and Pfizer, and has received grant funding from Biogen Idec, National Institutes of Health, and National MS Society.

R. Hashmonay, X. Meng, and P.S. Chin are employees of Novartis Pharmaceuticals Corporation. X. Meng is also a stockholder of Novartis Pharmaceuticals Corporation.

G. Cutter is on the following Data and Safety Monitoring Committees: Apotek, Biogen, Cleveland Clinic, Eli Lilly, Glaxo Smith Klein, Medivation, Merck, Modigenetech (Prolor), National Institute of Nuerological Disorders and Stroke, National MS Society, National Institute of Child Health and Human Development, National Heart Lung and Blood Institute (Protocol Review Committee), Ono Pharmaceuticals, Sanofi-Aventis, Teva; he is also on the following Consulting & Advisory Boards: Alexion, Abbott, Allozyne, Bayer, Celgene, Consortium of MS Centers (grant), Coronado Biosciences, Diogenix, Medimmune, Klein-Buendel Incorporated, Novartis, Nuron Biotech, Receptos, Somnus, Spinifex Pharmaceuticals, Teva; he is employed by the University of Alabama at Birmingham and President of Pythagoras, Inc. a private consulting company located in Birmingham AL.

Clinical efficacy of anti-IL-6 receptor monoclonal antibody tocilizumab in three patients with neuromyelitis optica

M. Araki, T. Aranami, T. Matsuoka, M. Nakamura, T. Okamoto, M. Murata, S. Miyake, T. Yamamura

National Center of Neurology and Psychiatry (Kodaira, Tokyo, JP)

Neuromyelitis optica (NMO) is an intractable autoimmune disease associated with anti-aquaporin 4 (AQP4) autoantibodies. We have recently described that plasmablasts (PB), a subpopulation of B cells, is a main producer of anti-AQP4 antibody and increased in number in the peripheral blood of patients with NMO. We also found that exogenous IL-6 promotes production of anti-AQP4 antibody from PB in vitro, and serum IL-6 level is elevated in active NMO in vivo, suggesting that IL-6 receptor (IL-6R) signaling pathways are involved in the pathogenesis of NMO. Hence, we set up a clinical study to explore an efficacy of Tocilizumab (TCZ), humanized anti-IL6R monoclonal antibody, in vivo in the treatment of NMO [The safety and efficacy of tocilizumab in patients with neuromyelitis optica (SET-NMO); UMIN000005889].

Three female patients were enrolled in the SET-NMO study after informed consent was obtained. They had one relapse for six months before the study. EDSS was 3.5, 6.5, and 3.5 respectively. Numeric Rating Scale (NRS) was 4, 4, and 2. TCZ was monthly given for six months. As clinical outcome measures, we evaluated the number of relapses and changes of EDSS and Numeric Rating Scale (NRS). Serum levels of anti-AQP4 antibody and IL-6, and PB (CD19+CD27^highCD38^highCD180- cells) numbers in peripheral blood were also examined.

First patient experienced no severe relapses for six months course, while remaining two patients so far had no relapses until third administration. The sensory disturbances and pain on the extremities and trunk gradually improved. The score of NRS and EDSS lowered within several administrations. While serum level of IL-6 was increased after the initiation of TCZ treatment, PB frequency and serum titers of anti-AQP4 antibody was decreased. Adverse events following TCZ were a slight decline of systolic blood pressure, a lymphocytopenia, viral enteritis, and upper respiratory infection.

In conclusion, significant effects of TCZ were observed in clinical as well as immunological parameters. Overall, TCZ therapy was thought to be safe and satisfactory, as the stable remission was maintained during the 6-month period of SET-NMO study. Moreover, neuropathic pain and paresthesia remarkably improved. We assume that the clinical improvement results from the anti-inflammatory effect of TCZ on the inflammatory responses of central nervous system.

Manabu Araki has nothing to disclose.

Pharmacodynamic effect, safety and tolerability of ponesimod, a selective sphingosine 1-phosphate receptor-1 modulator, in patients with relapsing-remitting multiple sclerosis

O. Fernandez, C. Pozzilli, M.S. Freedman, T. Olsson, M. Melanson, D. Bach, O. Berkani, M. Mueller, T. Sidorenko, A. Boster

University Regional Hospital Carlos Haya (Malaga, ES); Sapienza University (Rome, IT); The Ottawa Hospital - General Campus (Ottawa, CA); Karolinska Institutet (Stockholm, SE); University of Cincinnati (Cincinnati, US); Actelion Pharmaceuticals Ltd (Allschwil, CH); Ohio State University (Columbus, US)

Background: Ponesimod is an oral, selective and reversible sphingosine 1-phosphate receptor-1 modulator under investigation for the treatment of multiple sclerosis.

Objectives: To evaluate the pharmacodynamic (PD) effect, safety and tolerability of ponesimod in patients with relapsing-remitting multiple sclerosis.

Methods: In a multicentre, double-blind, dose-ranging phase IIb study, 464 patients were randomised in a 1:1:1:1 ratio to once-daily treatment with placebo or ponesimod 10, 20 or 40 mg (using up-titration on Days 8 and 15 for the higher doses) for 24 weeks. The primary endpoint was the mean cumulative number of new T1-weighted gadolinium-enhancing (T1 Gd+) lesions detected on monthly MRI scans from Week 12 to 24. The main PD endpoint was the peripheral blood lymphocyte count at each visit.

Results: Compared to placebo, the primary endpoint was reduced by 43% (p<0.05), 83% (p<0.0001) and 77% (p<0.0001) with ponesimod 10, 20 and 40 mg, respectively. Lymphocyte count was rapidly reduced by Day 8 and remained stable throughout treatment; mean reductions from baseline to end of treatment were 51%, 65% and 69% in the 10, 20 and 40 mg dose groups, respectively. Lymphocyte count returned to normal ranges within 7 days after end of treatment in a subgroup of patients not entering the extension study. Treatment-emergent adverse events (AEs), reported with higher incidence in the 40 mg group, included dyspnoea, cough, peripheral oedema and dizziness. One case of macular oedema, confirmed with optical coherence tomography, was reported with ponesimod 20 mg, which resolved on discontinuation. Cardiac AEs associated with initiation of ponesimod included atrioventricular block 1st (1.2%) and 2nd degree (0.9%, no cases of Mobitz type II) and bradycardia (2%). All AEs related to heart rate and rhythm effects occurred on Day 1. Seven patients discontinued ponesimod due to dyspnoea, 6 from the 40 mg group. ALT or AST increase ≥3 x ULN occurred in 2.8-4.5% patients on ponesimod, none on placebo; there were no cases of total bilirubin elevation ≥2 x ULN. There was no difference between groups in the incidence of infection-related AEs, and no deaths.

Conclusion: Ponesimod at doses of 10 and 20 mg was generally well tolerated; 40 mg showed signs of reduced tolerability with no additional benefit with respect to PD or MRI outcomes. Lymphocyte count reduction was rapidly reversible following end of treatment. First-dose cardiac effects were minimised by dose titration.

Oscar Fernandez has received honoraria as a consultant in advisory boards, and as chairman or lecturer in meetings, from Biogen Idec, Bayer-Schering, Merck Serono, Teva, Novartis, Almirall, Genzyme and Actelion Pharmaceuticals, and has also participated in clinical trials and other research projects conducted by the same companies. Carlo Pozzilli has received honoraria for consultancy or speaking engagements from Bayer, Merck Serono, Novartis, Teva, Sanofi Aventis and Biogen, and has received research grants from Biogen, Merck Serono, Bayer and Sanofi Aventis. Mark S. Freedman receives research or educational grants from BayerHealthcare and Genzyme; he receives honoraria or consultation fees from Actelion, BayerHealthcare, Biogen Idec, Celgene, EMD Canada, Glycominds, Novartis, Sanofi Aventis and Teva Canada Innovation; he is a member of a company advisory board, board of directors or other similar group for BayerHealthcare, Biogen Idec, Merck Serono, Novartis, Sanofi Aventis and Celgene. Tomas Olsson has received lecture fees or advisory board honoraria from Biogen Idec, Sanofi Aventis, Novartis and Merck; the same companies have provided unrestricted MS research grants. Maria Melanson is on the Multiple Sclerosis Advisory Council; she carries out speaking engagements and consultancy work for Biogen Idec; she carries out speaking engagements for Teva, Pfizer, QuestCor, Novartis, and Accordia; the source of funding for all of these activities is the individual companies. Doris Bach is an employee and stockholder of Actelion Pharmaceuticals Ltd. Ouali Berkani is an employee and stockholder of Actelion Pharmaceuticals Ltd. Markus Mueller is an employee and stockholder of Actelion Pharmaceuticals Ltd. Tatiana Sidorenko is an employee and stockholder of Actelion Pharmaceuticals Ltd; prior to current employment she received research grants, travel support or personal compensation from affiliates of Lundbeck, Merck Serono, Novartis, Johnson&Johnson, Sanofi Aventis, Teva and the Russian Neurological Society. Aaron Boster has received research funding from Novartis, Biogen Idec, Teva Neuroscience, Accorda, Actelion, Merck Serono and Roche; he has received compensation for consulting with Novartis, Biogen Idec, Teva Neuroscience, Merck Serono and Medtronic.

Effects of BG-12 on magnetic resonance imaging outcomes in relapsing–remitting multiple sclerosis: an integrated analysis of the phase 3 DEFINE and CONFIRM studies

D. H. Miller, R. Gold, R. J. Fox, D. MacManus, T. Yousry, A. Bar-Or, R. Zhang, V. Viglietta, M. Stephan, K. T. Dawson, D. L. Arnold

University College London’s Institute of Neurology (London, UK); St Josef Hospital, Ruhr University (Bochum, DE); Mellen Center for Multiple Sclerosis Treatment and Research (Cleveland, US); McGill University (Montreal, CA); Biogen Idec Inc (Weston, US)

Background: In the Phase 3 DEFINE and CONFIRM studies, BG-12 (dimethyl fumarate) demonstrated significant efficacy in patients with relapsing–remitting multiple sclerosis (RRMS) over 2 years based on clinical and magnetic resonance imaging (MRI) measures. Here we describe the efficacy of BG-12 on MRI endpoints from a pre-specified integrated analysis of DEFINE and CONFIRM.

Methods: Eligible patients were aged 18–55 years with RRMS (per McDonald criteria) and an Expanded Disability Status Scale (EDSS) score of 0–5.0. In DEFINE, patients were randomized 1:1:1 to oral BG-12 240 mg twice (BID) or three times daily (TID) or placebo. In CONFIRM, patients were randomized 1:1:1:1 to oral BG-12 240 mg BID or TID, placebo, or subcutaneous glatiramer acetate 20 mg/day (reference comparator). In each study, MRI was performed in a subset of patients at sites with MRI capability. MRI endpoints included numbers of new or newly enlarging T2 hyperintense, new T1 hypointense, and gadolinium-enhancing (Gd+) lesions at 2 years. The integrated analysis plan was finalized prior to unblinding of CONFIRM and was to be conducted only if baseline characteristics and treatment effects were homogeneous across the studies.

Results: The MRI cohort for the integrated analysis comprised 347, 345, and 354 patients who received placebo, BG-12 BID, and BG-12 TID, respectively. Baseline characteristics were similar between MRI and non-MRI cohorts as well as between studies and across treatment groups; treatment effects were similar in each study. BG-12 BID and TID significantly reduced lesion numbers at 2 years, vs placebo, with relative adjusted mean reductions of 78% (lesion mean ratio 0.22 [95% confidence interval 0.17–0.28]) and 73% (0.27 [0.21–0.34]) for new/newly enlarging T2 hyperintense (both p<0.0001) and 65% (0.35 [0.27–0.45]) and 64% (0.36 [0.29–0.46]) for new non-enhancing T1 hypointense lesions (both p<0.0001). Reductions in the odds of having a greater number of Gd+ lesions vs placebo were 83% (odds ratio 0.17 [95% confidence interval 0.11–0.27]) and 70% (0.30 [0.21–0.45]) with BG-12 BID and TID, respectively (both p<0.0001).

Conclusion: The results from the integrated analysis demonstrate consistent benefits of both BG-12 dosing regimens on MRI activity. Alongside significant clinical efficacy and an acceptable safety profile, these results suggest that BG-12 has the potential to become a valuable oral option for patients with relapsing MS.

Prof. Miller has received honoraria through payments to his employer, UCL Institute of Neurology, for Advisory Committee and/or Consultancy advice in multiple sclerosis studies from Biogen Idec, GlaxoSmithKline and Bayer Schering Pharma. Prof. Miller also received honoraria through payments to his employer, UCL Institute of Neurology, for serving as the editor of Journal of Neurology. Prof. Miller received research support through payments to his employer, UCL Institute of Neurology, for performing central MRI analysis of multiple sclerosis trials from GlaxoSmithKline, Biogen Idec, and Novartis.

Dr. Gold has received honoraria from Bayer HealthCare, Biogen Idec, Merck Serono, and Teva. He is Editor-in-Chief of Therapeutic Advances in Neurological Disorders and has received a license fee from Biogen Idec (no future rights).

Dr. Fox has received consultant fees from Avanir, Biogen Idec, EMD Serono, Novartis, Questcor and research support from Biogen Idec. He has also received research support from Biogen Idec and Genentech.

Dr. MacManus has received research grants (held by University College London) from Biogen Idec, GlaxoSmithKline, Schering AG, Apitope, Richmond Pharma, and Novartis for analysis of MRI data in MS trials.

Dr. Yousry has received research grants (held by University College London) from Biogen Idec, GlaxoSmithKline, Schering AG, and Novartis for analysis of data from MS trials and has received honoraria and travel expenses for advisory committee work from Biogen Idec, Bayer Schering, Novartis.

Dr. Bar-Or reports having received honoraria and/or research support from Aventis, Biogen Idec, Bayhill Therapeutics, Berlex, Diogenix, Eli-Lilly, GlaxoSmithKline, Merck Serono, Novartis, Ono Pharma, Receptos, Roche/Genentech, and Teva Neuroscience.

Dr. Zhang, Dr. Viglietta, Dr. Stephan and Dr. Dawson are all employees of Biogen Idec Inc.

Dr. Arnold has received personal compensation or research support from Bayer Healthcare, Biogen Idec, Genetech, NeuroRx Research, Roche, Schering, Serono, and Teva.

Supported by: Biogen Idec Inc.

Increase in proportion of patients free from disease activity following 1 year of treatment with daclizumab high-yield process in relapsing-remitting multiple sclerosis: results from the SELECT study

G. Giovannoni, D. Stefoski, K. Umans, S. Greenberg, S. Glyman, J. Elkins

Queen Mary University of London, Barts and The London School of Medicine and Dentistry (London, UK); Rush University Medical Center (Chicago, US); Biogen Idec (Cambridge, US); Abbott Biotherapeutics (Redwood City, US)

Objective: Daclizumab (DAC) is a humanized monoclonal antibody specific for CD25, the α subunit of the high-affinity IL-2 receptor. The objective of this analysis was to evaluate the proportion of patients treated with monthly, subcutaneous (SC) DAC high yield process (HYP) who were disease-activity free following 1 year of treatment in the SELECT trial, as compared with placebo.

Methods: SELECT was a randomized, double-blind, placebo-controlled 1-year study of DAC HYP 150mg and 300mg or placebo SC every 4 weeks in patients with RRMS. Since the efficacy outcomes were similar between doses in the trial, the DAC HYP 150mg and DAC HYP 300mg dose groups were pooled for the analyses. Disease-activity free was defined as completion of the study through Week 52 without relapses or disability progression, with no new or newly enlarging T2 hyperintense lesions or no new Gd±enhancing lesions at Week 52. P-values were based on a logistic regression model adjusted for baseline disease status and age. Specifically, covariates in the model included age (≤35 vs >35 years), baseline Expanded Disability Status Score (≤2.5 vs >2.5), baseline Gd+ lesions, number of relapses in 1 year prior to study entry, and baseline T2 lesions.

Results: A significantly greater proportion of patients treated with DAC HYP were disease-activity free compared with placebo (39% vs. 11%, respectively; odds ratio [95% confidence interval], 6.18 [3.71-10.32]; P<0.0001). Furthermore, a greater proportion of DAC HYP-treated patients were free of each component of disease activity compared with placebo. 81% (n=326) of DAC HYP-treated patients were relapse free compared with 65% (n=127) of patients in the placebo group (P<0.0001). 94% (n=378) of DAC HYP-treated patients did not have progression of disability compared with 87% (n=171) of patients in the placebo group (P=0.013). There were no new or newly-enlarging T2-hyperintense lesions in 48% (n=195) of DAC HYP-treated patients compared with 19% (n=38) of patients in the placebo group (P<0.0001). There were no new Gd+ lesions in 73% (n=296) of DAC HYP-treated patients compared with 50% (n=98) of patients in the placebo group (P<0.0001).

Conclusions: DAC HYP treatment resulted in a meaningful increase in the proportion of patients who were disease-activity free following 1 year of treatment.

Gavin Giovannoni has received consulting fees for participating on advisory boards in relation to clinical trial design, trial steering committees and data and safety monitoring committees from Bayer-Schering Healthcare, Biogen Idec, Five Prime, Genzyme, Ironwood, Merck-Serono, Novartis, Teva, Sanofi Aventis and Vertex Pharmaceuticals; lecture fees from Bayer Schering Healthcare, Merck Serono and Vertex Pharmaceuticals; compensation from Elsevier for his role as co-chief editor on the journal “MS and Related Disorders”; and received research grant support from Biogen Idec, Ironwood, Merck Serono, Merz, and Novartis.

Dusan Stefoski has received honoraria from Biogen Idec, Acorda, Serono, and Teva for consulting services and has received research support from Biogen Idec, Novartis, Serono, and Pfizer.

Kimberly Umans, Steve Glyman and Jacob Elkins are full-time employees of Biogen Idec.

Steven Greenberg is a full-time employee of Abbott Biotherapeutics, a subsidiary of Abbott Labs.

This study was funded by Biogen Idec and Abbott Biotherapeutics. Ed Parr of UBC Scientific Solutions provided medical writing and editorial support to the authors in the development of this abstract, which was funded by Biogen Idec and Abbott. Biogen Idec and Abbott had the opportunity to review and comment on the abstract content; however, the authors had full editorial control of the abstract and provided their final approval of all content.

Disability improvement with alemtuzumab vs. interferon-β-1a in relapsing-remitting multiple sclerosis patients who relapsed on prior therapy (CARE-MS II)

G. Giovannoni, D.L. Arnold, J. Cohen, A.J. Coles, C. Confavreux, E. Fox, H.-P. Hartung, E. Havrdova, K. Selmaj, H. Weiner, C.L. Twyman, T. Miller, S.L. Lake, D.H. Margolin, M. Panzara, D.A.S. Compston for the CARE-MS II investigators

Objective: Compare the efficacy of alemtuzumab vs. subcutaneous interferon β-1a (SC IFNB-1a) in MS-related disability outcomes.

Background: In the Phase 3 study CARE-MS II, alemtuzumab reduced the relapse rate over 2 years compared with SC IFNB-1a by 49% (0.26 vs. 0.52; p<0.0001) and reduced the risk for 6-month sustained accumulation of disability by 42% (p=0.0084), meeting both co-primary endpoints.

Methods: RRMS patients who had relapsed on prior therapy were randomized to receive alemtuzumab 12mg/day intravenously on 5 days at study start and 3 days one year later or SC IFNB-1a 44mcg 3-times weekly. Expanded Disability Status Scale (EDSS) was assessed by blinded raters at baseline and every 3 months. Worsening and improvement were defined as ≥0.5 point increase and decrease, respectively, from the baseline EDSS score (secondary endpoint). Sustained Reduction in Disability (SRD) was defined as a ≥1 point decrease in EDSS score sustained for 6 months among patients with baseline EDSS ≥2. SRD is a measure that provides insight into the proportion of patients who experienced clinically significant EDSS improvement after the initiation of treatment; 321 alemtuzumab patients (75.4%) and 153 SC IFNB-1a patients (75.7%) had baseline EDSS scores ≥2.

Results: Alemtuzumab patients improved from baseline in mean EDSS score by -0.24 point (p=0.0064) compared to worsening by SC IFNB-1a patients by +0.17 point (p=0.0044), a net difference between treatment groups of 0.41 (p<0.0001). Alemtuzumab patients were more likely to improve from baseline (45.6%) rather than worsen or remain stable compared to SC IFNB-1a patients (29.4%) (odds ratio=2.10, p<0.0001). The estimated proportion of alemtuzumab patients attaining a 3-month improvement by Month 24 was 34.7% and 19.4% for SC IFNB-1a patients (hazard ratio [HR]: 2.15, p=0.0003). The estimated proportion of alemtuzumab patients attaining 6-month SRD by Month 24 was 28.8% compared to 12.9% for SC IFNB-1a patients (HR: 2.57, p=0.0002).

Conclusions: More alemtuzumab patients experienced improvement in disability than SC IFNB-1a patients, who were more likely to worsen over 2 years of treatment. Alemtuzumab patients were more than twice as likely to experience 3-month and 6-month SRD as SC IFNB-1a patients. Neurological recovery with reversal of pre-existing impairments, and not just stability, may be a goal for MS disease-modifying therapies. These data highlight alemtuzumab’s potential to reach this goal.

Dr. Gavin Giovannoni reports receiving personal compensation for participating on advisory boards in relation to clinical trial design, trial steering committees and data and safety monitoring committees from: Bayer-Schering Healthcare, Biogen-Idec, Canbex, Eisai, Elan, Fiveprime, Genzyme, Genentech, GSK, Ironwood, Merck-Serono, Novartis, Pfizer, Roche, Sanofi-Aventis, Synthon BV, Teva, UCB Pharma, and Vertex Pharmaceuticals.

Dr. Doug L. Arnold reports receiving personal compensation or research support form Bayer Healthcare, Biogen Idec, Genentech, Genzyme, Roche and Teva.

Dr. Jeffrey Cohen reports receiving compensation for serving as a consultant or speaker from Biogen Idec and Novartis. He also received research support paid to his institution from Biogen Idec, BioMS, Department of Defense, Genzyme, Immune Tolerance Network, National MS Society, Novartis and Teva.

Dr. Alasdair J. Coles reports receiving consulting fees, lecture fees and institutional grant support from Genzyme, Merck Serono and UCB-Celltech.

Dr. Christian Confavreaux reports receiving compensation acting as an external expert and for giving lectures at the request of Biogen-Idec, Sanofi-Aventis, Schering, Serono, and Teva laboratories.

Dr. Edward Fox reports receiving consultancy fees, honoraria, travel and research support from Bayer, Novartic, Ono, and Sanofi, Biogen Idec, EMD Serono, Genzyme, Opexa Therapeutics, Pfizer, Teva Neuroscience and Eli Lilly.

Dr. Hans-Peter Hartung reports receiving the approval of the Rector of HHU fees for consulting, lectures and activities in Steering Committees of the following companies: Bayer Schering, BiogenIdec, BioMS, Genzyme, MerckSerono, Novartis, Teva, SanofiAventis.

Prof. Eva Havrdova reports receiving honoraria and grant support from Bayer-Schering, Biogen Idec, Genentech, Genzyme, GlaxoSmithKline, Merck-Serono, Octapharma, Pfizer, Roche, Sanofi-Aventis, and Teva.

Dr. Krzysztof Selmaj reports receiving consulting fees from Genzyme, Novartis, Biogen, and Roche; he has received lecture fees from Novartis, Merck-Serono, Biogen, and Bayer; and received financial compensation including travel from Genzyme for scientific presentations.

Dr. Howard Weiner reports receiving consulting/honoraria from: Biogen Idec, EMD Serono, Genzyme, Teva, Novartis, Nasvax, GSK. Research support from EMD Serono and GSK.

Dr. Cary L. Twyman reports receiving financial compensation from Genzyme for making scientific presentations and funding support to conduct research studies.

Dr. Tamara Miller reports receiving compensation for speaker activities for Acorda, Allergan, Biogen Idec, Eli Lilly, Forest, Questcor, and TEVA; until clinical trial closure, Dr Miller was an independent contractor for Allergan, Biogen Idec, Genzyme, Elan, TEVA, ONO, Sanofi-Aventis, EMD Serono and Roche/Genetech.

Drs. David H. Margolin, Stephen L. Lake, and Michael Panzara report receiving personal compensation as employees of Genzyme, a Sanofi company.

Prof. Alastair Compston reports receiving consulting fees, lecture fees and grant support from Genzyme and lecture fees from Bayer Schering Pharma on behalf of himself and the University of Cambridge.

Dose-dependent effect of ponesimod, an oral, selective sphingosine 1-phosphate receptor-1 modulator, on magnetic resonance imaging outcomes in patients with relapsing-remitting multiple sclerosis

M.S. Freedman, T. Olsson, M. Melanson, O. Fernandez, A. Boster, D. Bach, O. Berkani, M. Mueller, T. Sidorenko, C. Pozzilli

The Ottawa Hospital - General Campus (Ottawa, CA); Karolinska Institutet (Stockholm, SE); University of Cincinnati (Cincinnati, US); University Regional Hospital Carlos Haya (Malaga, ES); Ohio State University (Columbus, US); Actelion Pharmaceuticals Ltd (Allschwil, CH); Sapienza University (Rome, IT)

Background: Ponesimod is an oral, selective and reversible sphingosine 1-phosphate receptor-1 (S1P1) modulator under investigation for the treatment of multiple sclerosis.

Objectives: To evaluate the effect of ponesimod on measures of brain inflammatory activity in patients with relapsing-remitting multiple sclerosis.

Methods: In a multicentre, double-blind, dose-ranging phase IIb study, 464 patients were randomised in a 1:1:1:1 ratio to once-daily treatment with placebo or ponesimod 10, 20 or 40 mg (using up-titration on Days 8 and 15 for the higher doses) for 24 weeks. The primary endpoint was the mean cumulative number of new T1-weighted gadolinium-enhancing (T1 Gd+) lesions detected on monthly magnetic resonance imaging (MRI) scans (blinded, central reading) from Week 12 to 24. Exploratory efficacy endpoints included the following MRI-related variables: mean cumulative number of new or enlarging non-enhancing T2 lesions from Week 12 to 24; mean cumulative number of combined unique active lesions (CUAL) from Week 12 to 24; percent change from baseline in brain volume. Count data endpoints were analysed using negative binomial regression; dose-response was investigated using multiple comparison procedures and modelling techniques.

Results: Baseline characteristics were well balanced across groups. As compared to placebo, the primary endpoint was reduced by 43% (p<0.05), 83% (p<0.0001) and 77% (p<0.0001) with ponesimod 10, 20 and 40 mg, respectively. A significant dose-response relationship (p<0.0001) was observed. The mean cumulative number of new or enlarging non-enhancing T2 lesions from Week 12 to 24 was reduced by 31%, 56% and 34% with ponesimod 10, 20 and 40 mg, respectively. The mean cumulative number of CUAL from Week 12 to 24 was reduced by 42%, 80% and 73% with ponesimod 10, 20 and 40 mg, respectively. At Week 24, a small mean increase in brain volume was observed with ponesimod (0.02%, 0.05% and 0.23% in 10, 20 and 40 mg groups, respectively) compared with a small mean decrease (-0.26%) with placebo. Treatment-emergent adverse events, reported with higher incidence in the ponesimod 40 mg group, included dyspnoea, cough, peripheral oedema and dizziness.

Conclusion: Ponesimod treatment was associated with a statistically significant dose-dependent decrease in the number of new T1 Gd+ lesions from Week 12 to 24. This finding was corroborated by reductions in inflammatory activity and brain atrophy as assessed by exploratory MRI endpoints.

Mark S. Freedman receives research or educational grants from BayerHealthcare and Genzyme; he receives honoraria or consultation fees from Actelion, BayerHealthcare, Biogen Idec, Celgene, EMD Canada, Glycominds, Novartis, Sanofi Aventis and Teva Canada Innovation; he is a member of a company advisory board, board of directors or other similar group for BayerHealthcare, Biogen Idec, Merck Serono, Novartis, Sanofi Aventis and Celgene. Tomas Olsson has received lecture fees or advisory board honoraria from Biogen Idec, Sanofi Aventis, Novartis and Merck; the same companies have provided unrestricted MS research grants. Maria Melanson is on the Multiple Sclerosis Advisory Council; she carries out speaking engagements and consultancy work for Biogen Idec; she carries out speaking engagements for Teva, Pfizer, QuestCor, Novartis and Accordia; the source of funding for all of these activities is the individual companies. Oscar Fernandez has received honoraria as a consultant in advisory boards, and as chairman or lecturer in meetings, from Biogen Idec, Bayer-Schering, Merck Serono, Teva, Novartis, Almirall, Genzyme and Actelion Pharmaceuticals, and has also participated in clinical trials and other research projects conducted by the same companies. Aaron Boster has received research funding from Novartis, Biogen Idec, Teva Neuroscience, Accorda, Actelion, Merck Serono and Roche; he has received compensation for consulting with Novartis, Biogen Idec, Teva Neuroscience, Merck Serono and Medtronic. Doris Bach is an employee and stockholder of Actelion Pharmaceuticals Ltd. Ouali Berkani is an employee and stockholder of Actelion Pharmaceuticals Ltd. Markus Mueller is an employee and stockholder of Actelion Pharmaceuticals Ltd. Tatiana Sidorenko is an employee and stockholder of Actelion Pharmaceuticals Ltd; prior to current employment she received research grants, travel support or personal compensation from affiliates of Lundbeck, Merck Serono, Novartis, Johnson&Johnson, Sanofi Aventis, Teva and the Russian Neurological Society. Carlo Pozzilli has received honoraria for consultancy or speaking engagements from Bayer, Merck Serono, Novartis, Teva, Sanofi Aventis, and Biogen, and has received research grants from Biogen, Merck Serono, Bayer, and Sanofi Aventis.

Biological basis of fluctuations in total peripheral lymphocyte counts in patients receiving FTY720 therapy

L. Galleguillos, D. Henault, L.R. Feldman, T.A. Johnson, A. Bar-Or, J.P. Antel

Montreal Neurological Institute (Montreal, CA)

Background: FTY720 therapy results in lymph-node retention of lymphocytes lacking surface sphingosine-1-phosphate (S1P) receptors. CCR7+ cell subsets are attracted to lymph nodes and hence selectively depleted from the circulation. Lymphocytes activated within the lymph nodes to become effector cells (CCR7-CD62L) may be less dependent on S1P to escape from the lymph nodes.

Objective: to document the extent of fluctuations in total peripheral blood lymphocyte counts in MS patients receiving FTY720 therapy and to determine whether such fluctuations are associated with changes in specific lymphocyte subsets.

Methods: Serial counts of total peripheral blood lymphocytes were performed every 3 months over 5-8 years in MS patients (n= 23) receiving 0.5mg daily of FTY720 as part of the extension-phase clinical trials. Multi-parameter flow cytometry to assess lymphocyte subsets was performed on whole blood from a subgroup of these patients as well as on patients treated with FTY720 as part of clinical practice. Lymphocyte markers evaluated were CD4, CD8, and CCR7.

Results: In 15 of 23 (65%) of the patients in the extension phase studies, total lymphocyte counts remained within a range of 0.2-0.6 x 10⁹cells/L. In the remaining 8 patients, values >0.6 x 10⁹cells/L were recorded on more than one occasion, although none had sustained levels >0.6 x 10⁹cells/L. In a cross-sectional analysis of 31 patients with lymphocyte counts within the 0.2-0.6 x 10⁹cells/L range, the mean % of CCR7+ cells within the CD4 (6.2% +4.7) and CD8 (1.7% +1) lymphocyte populations were significantly reduced compared to non-treated individuals (57.6% ±13.3 and 33.1% +14.7, respectively). There was no significant correlation between the total lymphocyte counts and % CCR7+ cells. Serial analysis of a patient who transiently discontinued therapy indicated that the % CD4+CCR7+ cells (33%) remained below mean control values at 7 days, a time when total peripheral lymphocyte count had increased from 0.4 to 0.9 x 10⁹cells/L.

Conclusion: Cells other than the CCR7+ T cell sub-population sequestered in the lymph nodes contribute both to the fluctuations in lymphocyte values observed in some patients receiving the currently approved dosage of FTY720 therapy and to the rapid reconstitution that follows drug cessation. The source of such CCR7- cells would seem to be regional lymph nodes where, when generated, these cells may be less dependent on S1P gradients to exit.

LG, DH, LRF and TAJ have nothing to disclose.

ABO has participated as a speaker at meetings sponsored by, received consulting fees and/or received grant support from: Amplimmune, Bayhill Therapeutics, Berlex/Bayer, Biogen Idec, BioMS, Diogenix, Eli-Lilly, Genentech, Genzyme, GSK, Guthy-Jackson/GGF, EMD Serono, Medimmune, Mitsubishi Pharma, Novartis, Ono Pharma, Receptos, Roche, Sanofi Aventis, Teva Neuroscience, Wyeth.

JPA has received research support from Novartis and from CIHR (Industry partnership program) related to FTY720. He has served as a consultant and/or on safety monitoring boards for Novartis, Biogen IDEC, Sanofi-Aventis, TEVA, EMD Serono, Genzyme, and Cleveland Clinic Foundation. He serves as co-editor of the Multiple Sclerosis Journal.

Effect of teriflunomide on immune responses to seasonal influenza vaccination in patients with relapsing multiple sclerosis: results from the TERIVA study

A. Bar-Or, M. S. Freedman, M. Kremenchutzky, F. Menguy-Vacheron, D. Bauer, S. Jodl, P. Truffinet, M. Benamor, P. O’Connor

Montreal Neurological Institute (Montreal, CA); University of Ottawa (Ottawa, CA); University of Western Ontario (London, CA); sanofi (Chilly Mazarin, FR); sanofi (Bridgewater, US); sanofi (Berlin, DE); University of Toronto (Toronto, CA)

Introduction: Teriflunomide is a novel, once-daily oral disease-modifying therapy being investigated for treatment of relapsing forms of multiple sclerosis (RMS). Teriflunomide inhibits the mitochondrial enzyme dihydro-orotate dehydrogenase (DHODH), required for de novo pyrimidine synthesis, thereby reducing the number of stimulated T and B cells. Cells such as resting memory T cells, which largely rely on existing pyrimidine pools, are not significantly affected by teriflunomide. The ability of patients to respond to influenza vaccine was investigated to determine whether recall antigen responses were preserved under teriflunomide treatment.

Methods: This multicentre, multinational, parallel-group study assessed antibody responses to the 2011/12 seasonal influenza vaccine, which included strains H1N1, H3N2 and B, in RMS patients treated with teriflunomide 7 mg (n=41) or 14 mg (n=41) (median duration 6 years), and a reference population of RMS patients treated with interferon β (median duration 6.4 years) (IFN B-1; n=46). Primary endpoint was the proportion of patients with adequate vaccine response (influenza antibody titres ≥40, 28 days post-vaccination) for each vaccine strain.

Results: The proportion of patients achieving an antibody titre of ≥40 following vaccination was at least 77% for all influenza strains and treatment groups (>90% for H1N1 and B in all treatment groups; >90% for H3N2 in the teriflunomide 7 mg and IFN B-1 groups; 77% for H3N2 in the teriflunomide 14 mg group). While the proportion of patients with such titres pre-vaccination was relatively high (due to previous vaccination), geometric mean titre (GMT) ratios post-/pre-vaccination were >2.5 for all treatment groups and vaccine strains, confirming vaccine efficacy as per European guidelines, except in the teriflunomide 14 mg group for H1N1 (GMT ratio: 2.3). The proportion of patients with a pre-vaccination titre <40 who achieved seroprotection (i.e. Day 28 titre ≥40) was similar in all groups for H1N1 and B strains (>80%), and slightly lower (<80%) for H3N2 in the teriflunomide 14 mg (61.1%) and 7 mg (77.8%) groups than the IFN B-1 (81.8%) group but these difference are not significantly different. Influenza vaccination was well tolerated in all groups.

Conclusions: RMS patients treated with teriflunomide mount appropriate immune responses to seasonal influenza vaccination, suggesting that the memory response to influenza vaccine is not significantly affected by teriflunomide.

Study supported by sanofi. ABO: Dr Bar-Or has participated as a speaker at meetings sponsored by, received consulting fees and/or received grant support from: Amplimmune, Aventis, Bayhill Therapeutics, Berlex/Bayer, Biogen Idec, BioMS, Diogenix, Eli-Lilly, Genentech, Genzyme, GSK, Guthy-Jackson/GGF, EMD Serono, Medimmune, Mitsubishi Pharma, Novartis, Ono Pharma, Receptos, Roche, Sanofi Aventis, Teva Neuroscience, Wyeth.

MF: Grant support (Genzyme), advisor/consultant/steering committee member or speaker (Actelion, Bayer, Biogen Idec, Celgene, Genzyme, Glycominds, Teva, Merck Serono, Novartis, sanofi-aventis).

MK: Consulting fees and/or research support (Bayer, Biogen Idec, EMD Serono, Genzyme, Novartis, sanofi-aventis, Teva).

FMV: Employee of sanofi.

DB: Employee of sanofi.

SJ: Employee of sanofi.

PT: Employee of sanofi.

MB: Employee of sanofi.

POC: Consulting fees and/or research support (Actelion, Bayer, Biogen Idec, BioMS, Cognosci, Daiichi Sankyo, EMD Serono, Genentech, Genmab, Novartis, Roche, sanofi-aventis, Teva, Warburg Pincus).

Ponesimod is a potent S1P1 receptor modulator causing efficient receptor internalisation, degradation and functional antagonism

J. Gatfield, L. Monnier, O. Nayler

Actelion Pharmaceuticals Ltd (Allschwil, CH)

Introduction: Sphingosine-1-phosphate (S1P) receptor modulators are a promising new class of compounds for the treatment of autoimmune disorders, including multiple sclerosis. S1P receptor modulators block egress of normal and autoreactive T cells from secondary lymphoid organs into the circulation. This trapping of lymphocytes is considered to be due to compound-induced desensitization of the S1P1 receptor, which is used by lymphocytes to move along a chemotactic S1P gradient into the blood compartment. Ponesimod, a novel S1P1 receptor modulator with an increased selectivity for the S1P1 receptor subtype, is currently under clinical investigation for the treatment of multiple sclerosis and psoriasis. Here, we describe activation, desensitization and intracellular trafficking of human S1P1 receptors in response to ponesimod and the natural ligand S1P.

Methods and Results: In recombinant S1P1 expressing cells, ponesimod activated G-α-i and b-arrestin pathways (EC50_cAMP=0.32 nM, n=5; EC50_b-arr=9.5 nM, n=3) as potently and efficaciously as the natural ligand S1P (EC50_cAMP=0.52 nM, n=5; EC50_b-arr=7.9 nM, n=3). However, only ponesimod, but not S1P, caused efficient S1P1 receptor internalization (EC50_int~3nM) and degradation (EC50_degrad~3nM) as determined by flow cytometry, immunofluorescence microscopy and immunoblotting. Native S1P1 receptor signaling, desensitization and trafficking was assessed in human umbilical vein endothelial cells (HUVEC). Ponesimod, as well as S1P, potently stimulated the native S1P1 receptor as determined by label-free impedance measurements (ponesimod:EC50_imp=4.8 nM, n=10; S1P: EC50_imp=0.41 nM, n=10). However, while S1P induced long-lasting receptor responses over >8 hours without signs of desensitization, ponesimod gave rise to a short-lived receptor signal (30 min), followed by insensitivity to re-stimulation, demonstrating that ponesimod behaved as functional antagonist. Consistent with these different desensitization profiles, ponesimod, but not S1P, induced receptor internalization (EC50_int=103 nM, n=6) and degradation as determined by automated microscopy and immunoblotting.

Conclusion: The S1P1 receptor modulator ponesimod transiently stimulates S1P1 receptors followed by rapid, potent and efficient receptor internalization, degradation and functional antagonism.

John Gatfield, Lucile Monnier and Oliver Nayler are employed by Actelion Pharmaceuticals Ltd.

A randomised, double-blind, ascending multiple-dose study with ponesimod, a selective S1P1 receptor modulator: safety, pharmacokinetics, pharmacodynamics

P. Brossard, H. Maatouk, A. Halabi, M. Cavallaro, J. Dingemanse

Actelion Pharmaceuticals Ltd (Allschwil, CH); CRS-Kiel (Kiel, DE)

Background/goal: The objectives of this study were to investigate tolerability, safety, pharmacokinetics (PK), and pharmacodynamics (PD) of ponesimod, an orally active, selective sphingosine 1-phosphate 1 receptor (S1P1) modulator reducing circulating lymphocytes.

Methods: This study included 47 healthy male and female subjects. In Part A of the study, ponesimod (5, 10, or 20 mg) was administered once daily for 7 days, each to a new group of 10 subjects (4:1 active:placebo ratio; 1:1 sex ratio). In Part B, ponesimod was administered once daily within an up-titration dosing scheme: 4 days at 10 mg, 4 days at 20 mg, and finally 7 days at 40 mg to 17 subjects (8 males and 9 females; 13 active, 4 placebo).

Results: Ponesimod was well tolerated. No severe or serious adverse events (AE) were reported. Two subjects were discontinued in Part B due to AEs. Bradycardia and atrioventricular (AV)-block 1st degree, as recorded by 12-lead ECG, were most frequent and pronounced on the first day of dosing with ponesimod in Part A. All AV-blocks were transient and required no treatment. Heart rate (HR) reductions were transient, dose-dependent, and observed mainly after the first dose in Part A. This indicated the development of tolerance to ponesimod-induced HR reduction and AV-blocks. This observation was used in designing the up-titration schedule in Part B. The up-titration regimen implemented successfully reduced the expected effects on HR of the 20- and 40-mg doses of ponesimod.

Reductions in pulmonary function tests (PFT) and dyspnoea were reported only following repeated administration of 40 mg, with a maximal mean decrease from baseline in forced expiratory volume in 1 second of 0.8 L. PFT changes and symptoms were mild and resolved spontaneously and rapidly after the end of treatment.

Steady-state conditions for both PK and PD (lymphocyte counts) were reached after ~3 days (Part A). Half-life was approximately 32 h and Cmax was reached 2.5-4 h after dosing.

Dose-dependent lymphocyte reductions were observed with a mean reduction from baseline at trough of 59% on Day 7 for the 20 mg group in Part A and of 70% on Day 15 for the 40 mg group in Part B. On average, lymphocytes returned within normal range 6 days after the end of treatment.

Conclusion: Ponesimod was well tolerated. It induced transient and dose-dependent first-dose effects on HR and rhythm. PFT changes were observed only after administration of doses of 40 mg. Up-titration was successful in reducing HR effects.

PB is full-time employee of Actelion Pharmaceuticals Ltd and owns options/shares of the company.

HA and AH disclosed that no potential competing interests or conflict of interest exist.

MC is an employee of Actelion Pharmaceuticals Ltd.

JD is full-time employee of Actelion Pharmaceuticals Ltd and owns options/shares of the company.

ONO-4641, a potent and selective sphingosine 1-phosphate receptor-1 and -5 agonist, ameliorates relapses in a preclinical model of multiple sclerosis

F. Bernard, A. Soares, A. Spill, A. Attinger, V. Eligert, S. Laustela, T. Seabrook, A. Nichols, F. Beltram, T. Martin, H. Kurata, H. Habashita, S. Nakade, P. Smith, U. Boschert

Merck Serono S.A. (Geneva, CH); ONO Pharmaceutical Co. Ltd (Osaka, JP)

Background: Sphingosine 1-phosphate receptor-1 (S1P1) is a clinically validated target for the treatment of relapsing–remitting multiple sclerosis (RRMS). Its primary mode of action is lymphocyte sequestration within lymph nodes. In addition, brain penetrant S1P1, 5 receptor agonists may have direct repair effects on the central nervous system (CNS) via targeting of the S1P5 receptor, as shown in preclinical models. ONO-4641 is an investigational drug for RRMS, with high selectivity for S1P1 and S1P5 receptors.

Aim: To show in vitro selectivity of ONO-4641 for S1P receptors, and to investigate the effects on blood lymphocyte numbers and efficacy in a preclinical model of MS.

Methods and Results: The affinity of ONO-4641 was measured by competitive ligand binding assay on membranes prepared from CHO-S1P1, 2, 3, 4, 5-overexpressing cells, and efficacy was measured by an impedance measurement after agonist stimulation of intact CHO-S1P1, 2, 3, 4, 5 cells using the label-free CellKey technology. The affinity of ONO-4641 was 0.4 nM for the S1P1 receptor and 0.2 nM for S1P5, resulting in selectivity factors of S1P1 versus S1P3 and S1P1 versus S1P4 of 70,000-fold and 690-fold, respectively. ONO-4641 was not active on the S1P2 receptor. In mice, a single oral treatment of ONO-4641 (0.01, 0.1, 1 and 2 mg/kg) dose dependently reduced the number of circulating lymphocytes over a 72-h time course. Maximum lymphopenia levels were observed at 8 hours for 0.01 mg/kg (–38%) and at 24 hours for 0.1, 1 and 2 mg/kg (−63%, −80% and −80%) versus control animals. Based on these data, we tested ONO-4641 in spinal cord homogenate-induced experimental autoimmune encephalomyelitis in DA rats at 3 doses (0.01, 0.1 and 1 mg/kg, per os, daily treatment). All doses of ONO-4641 significantly prevented the occurrence of locomotor deficits as shown by reduction in clinical scores versus vehicle-treated control animals. Relapse rate was 20% at 0.01 mg/kg (p<0.05) and 0% at 0.1 and 1 mg/kg (p<0.01). Furthermore, histology showed significant reduction in both T-cell and macrophage CNS infiltrates at 0.1 and 1 mg/kg (p<0.05).

Conclusion: Taken together, our data show that therapeutic treatment with ONO-4641 is highly efficacious in a preclinical model of RRMS.

This study was supported by Merck Serono S.A. – Geneva, Switzerland (a branch of Merck Serono SA, Coinsins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany).

F Bernard, A Soares, A Spill, A Attinger, V Eligert, S Laustela, T Seabrook, A Nichols, F Beltram, T Martin, P Smith, and U Boschert are employees of Merck Serono S.A. – Geneva, Switzerland.

H Kurata, H Habashita, and S Nakade are employees of ONO Pharmaceutical Co. Ltd, Osaka, Japan.

Risk of infections and malignancies after treatment with anti-CD20 monoclonal antibodies: ocrelizumab and rituximab in rheumatoid arthritis and multiple sclerosis

L. Kappos, D. Leppert, J. Tinbergen, M. Gerber, S.L. Hauser

University Hospital (Basel, CH); F. Hoffmann – La Roche Ltd (Basel, CH); University of California San Francisco (San Francisco, US)

Background: Ocrelizumab (OCR) and rituximab (RTX) are CD20 targeting B cell depleting monoclonal antibodies. Safety data from their use in MS and rheumatoid arthritis (RA) may inform about expected risks in MS studies.

Methods: Data from all available OCR (RA n=2820; MS n=220), RTX studies (RA n=3914; MS n=569) and post-approval data (RTX RA only; exposure n>188 000) were reviewed for rates of infection and serious infection (SI), including progressive multifocal leucoencephalopathy (PML) and incidence of malignancies.

Results: RTX RA: In the long-term safety extension of the Phase 3 studies (n=3194; ≤9.5y follow-up), AE and SAE rates for RTX were comparable vs pooled placebo (PBO) arms from those double-blind Phase 3 studies. SI event (SIE) rates for RTX were comparable vs PBO (all-exposure RTX: 3.94/100 patient-treated years (PTY) [95% CI 3.60–4.31] vs 3.79/100 PTY [2.80–5.13]), and stable over time and multiple treatment courses up to 9.5y. Serious opportunistic infections (OIs) were rare (all-exposure RTX 0.06 events/100 PTY; PBO 0.09 events/100 PTY). There was no increased risk of malignancy with RTX (all-exposure RTX 0.99/100 PTY [95% CI 0.79–1.23] vs 1.05/100 PTY [1.01–1.09] for adult RA patients). Risk of PML with RTX was rare with 6 confirmed cases in >188 000 RA pts. OCR RA: In a pooled safety analysis of the double-blind PBO-controlled phases of all pivotal Phase 3 OCR studies, SIE rates were comparable between low-dose (200mg x2 or 400mg x1) OCR and PBO. High-dose OCR (500mg x2) was associated with higher SIE rates vs PBO, mainly due to Asia/Pacific data where both dose groups had increased SIE rates. OIs were more frequent with OCR vs PBO irrespective of dose (9 vs 1 event). SIE and OI resolved with appropriate therapy. No PML was reported. RTX RRMS: SIE rates were similar for RTX (2.9%) and PBO (5.7%) in the phase 2 HERMES study; no PML was reported. OCR RRMS: Incidence of infections (serious and non-serious) was similar for both doses of OCR vs PBO (SIEs 0% vs 1.9% during week 0–24, respectively) and did not increase over time with continued OCR; no PML or other OIs were reported.

Conclusions: Incidence of SIEs and OIs with RTX and OCR treatment were generally low. No PML has been reported with OCR. These data inform the anticipated safety of OCR in ongoing phase 3 MS trials where a lower risk of SIEs and/or OIs may be expected owing to disease- (pathophysiology, co-medication, age) and trial design-inherent (dose, region) factors.

Prof. Kappos discloses that the University Hospital Basel has received research support from Biogen Idec, GlaxoSmithKline, Novartis Pharmaceuticals, Sanofi-Aventis, Bayer Schering, Merck Serono, Teva Pharmaceuticals, Wyeth Pharmaceuticals and others.

Dr Leppert, Dr Gerber and Dr Tinbergen are employees of F. Hoffmann – La Roche Ltd a member of the Roche Group.

Dr Hauser has the following conflicts of interest: Pfizer, Wyeth, Roche, Receptos, BioMarin.

Studying the SAfety, tolerability and efficacy of Boswellic Acids in multiple sclerosis (SABA Trial)

K.H. Stürner, P. Stellmann, F. Paul, M. Sospedra, R. Martin, C. Heesen

Institute for Neuroimmunology and Clinical Multiple Sclerosis Research, Center for Molecular Neurobiology (Hamburg, DE); NeuroCure Clinical Research Center (NCRC), Charité (Berlin, DE); University Hospital (Zurich, CH)

Aim: Orally available drugs with a favourable side effect profile for the treatment of Multiple Sclerosis (MS) are of high interest for patients and treaters and are already beginning to change our therapy management in MS.

Boswellic acids (BAs) are the main biologically active compounds of frankincense extracts. BAs are orally available and known to exhibit anti-inflammatory activities by inhibiting key enzymes of the arachidonic acid pathway, e.g. 5-Lipoxygenase, that has been identified as an important component of brain lesions in MS patients. Clinical trials with frankincense extracts in rheumatoid arthritis showed very good tolerability and good efficacy in restraining inflammation, while the effect of BAs on peripheral blood mononuclear cells (PBMCs) is unknown so far. We have been studying the effects BAs in vitro and are currently investigating BAs in an investigator-initiiated clinical phase IIa trial in MS patients.

Methods: We analyzed the effect of the frankincense extract and the most important bioactive BA Acetyl-11-keto-boswellic acid (AKBA) on anti-CD3 stimulated PBMCs in regard to proliferation measured by thymidine incorporation, cytokine production measured by ELISA and surface markers measured by flow cytometry.

We have further started a MRI based clinical trial to test the safety, tolerability, efficacy and mechanism of action of BAs in a Phase IIa bicentric baseline-to-treatment study in relapsing-remitting MS patients (n=30) with a standardized orally available frankincense extract in October 2011.

Results: In-vitro treatment of PBMCs from healthy volunteers with the extract showed antiproliferative properties of BAs on T and B cells without affecting cell viability. Furthermore AKBA reduced IFN-γ production in PBMCs in a dose-dependent manner up to 65% and enhanced the expression of CTLA-4, an immunoregulatory T cell surface marker. Up to now 37 patients have been screened and 9 patients have started treatment in this trial. So far boswellic acids are very well tolerated even at the highest dose of 4800mg/d.

Conclusion: Considering our in vitro data BAs exhibit antiproliferative and immunoregulatory properties that are favourable in the context of MS. BAs are very well tolerated in our Phase IIa trial. As BAs are orally available and have been successfully tested in clinical trials of several other autoimmune diseases showing good tolerability and safety we consider it an interesting novel treatment opportunity for MS.

This study has been supported by the Federal Ministry of Education and Research (Biopharma Neu2 grant Förderkennzeichen 0315610–0315620).

Klarissa Hanja Stürner has nothing to disclose.

Influence of different natalizumab treatment intervals and treatment holiday on CNS/peripheral immunstatus and free and cell bound natalizumab

U. Hainke, T. Sehr, M. Marggraf, K. Thomas, T. Ziemssen

Technical University of Dresden (Dresden, DE)

Objective: Natalizumab(NAT), a humanized recombinant monoclonal antibody, acts by blocking very late antigen-4(VLA-4) integrins on the surface of leukocytes.As decreased CNS immune surveillance by NAT can cause progressive multifocal leukoencephalopathy(PML) during NAT treatment, treatment concepts of treatment holidays and different treatment intervals beyond 4 weeks have been proposed. Up to now, there are no data available about free and cell bound NAT and immune cell frequencies.

Methods: Patients were analyzed at different infusion intervals of 4, 5 and 8 weeks and after cessation of NAT therapy. PBMC were isolated from blood samples and stained together with CSF cells with fluorescence labelled antibodies. Additionally, cell bound and free NAT in blood and CSF as well as frequencies of immune cells were determined using FACS analysis.

Results: We could demonstrate different pre and post infusion plasma concentrations of NAT for treatment intervals of 4 (pre 23,12 1,7 µg/ml, post 93,09±4,16µg/ml), 5 (pre15,84 1,78 µg/ml, post 82,36±3,47µg/ml) and 8 weeks (pre 2,49 1,1µ g/ml, post 63,95±3,72µg/ml).

In parallel we measured higher free CSF NAT concentrations in 4 weeks compared to 5 weeks treated patients. Regarding pre-infusion cell-bound NAT, we could describe MFI of 3701±253 for 4, 1580±108 for 5 and 1379±166 for 8 weeks treatment interval.Ratio of CD4+/CD8+ cells showed no significant difference between treatment groups.Patients treated every 8 weeks demonstrated a different frequency of lymphocyte subpopulations.

After cessation of NAT, plasma concentrations decreased by 54%, 90 % and 99,7 % in month 1, 2 and ¾ respectively.We could observe cell-bound NAT in blood until 2-4 months after last infusion.VLA-4 expressions demonstrated a gradual increase.During treatment holiday, 4 of 5 patients developed quite severe relapses at 3-5 months after last infusion. At relapse, only very low amounts of free NAT could be demonstrated in serum or CSF. We determined a decrease of cell bound NAT on blood CD3+ T-cells to 41,25% and on CSF CD3+ T-cells to 15% when relapse occurred. Increase in CSF cell count at relapse during treatment holiday mainly consisted of CD3 T- cells.

Conclusions: Different treatment intervals had significant effects on lymphocyte subpopulations in blood, CSF and on cell bound and free NAT concentrations.As there is much variability of cell bound and free NAT concentration from patient to patient individual dosing of NAT would be recommended using NAT measurements and immunological analysis.

Undine Hainke, Tony Sehr, Michaela Marggraf and Katja Thomas have nothing to disclose.

Dr. Ziemssen received financial support for research activities from Bayer, Biogen Idec, Novartis, Teva and Sanofi Aventis.

Preventive laquinimod treatment shifts pro-inflammatory to regulatory T-cells and reduces myeloid dendritic cells in experimental autoimmune encephalomyelitis

M. Ott, C. Wegner, S. Nessler, W. Brück

University Medical Center (Göttingen, DE)

Background: Laquinimod (LAQ) is a new orally active, well tolerated drug which significantly reduces the annualized relapse rate, brain volume loss and disability progression in multiple sclerosis (MS). In animals LAQ inhibits acute experimental autoimmune encephalomyelitis (EAE) and suppresses relapses in chronic EAE. Central inflammation is reduced and the cytokine balance is shifted in favor of Th2/Th3 cytokines.

Objective: This study examined the effects of LAQ on antigen presenting cells and T subpopulations during the priming phase of EAE.

Methods: C57BL/6 mice with MOG35-55-induced EAE were treated daily with 0 or 25 mg/kg LAQ. To investigate effects on the priming phase, LAQ was administered from the day of immunisation until day eleven. Single cell suspensions from lymph nodes and spleen were obtained and analysed by flow cytometry and ELISA.

Results: Preventive treatment with LAQ significantly reduced the percentage of Th17 (p=0.0022) and Th1 T cells (p=0.026) among the CD4 T cell population. The absolute number of CD4 T cells producing IL-17 or IFN-γ in response to PMA/Ionomycin was also reduced after therapy. Spleen and lymph node cells of treated animals produced less of these cytokines in a recall assay with MOG35-55 compared to controls. Furthermore, the percentage of FoxP3 regulatory T cells increased with LAQ treatment in the spleen (p=0.0022).

Antigen presenting cells were also affected by LAQ treatment. FACS data revealed a significant decrease of CD11chigh dendritic cells (DC) (p=0.0013) in the spleen of LAQ treated animals. Within the DC population CD11b myeloid DC were significantly reduced (p=0.0001). In contrast, the frequency of CD8 α DEC205 DC, previously described as regulatory subtype, remained unaltered.

Conclusions: In conclusion, preventive treatment with LAQ suppresses the pro-inflammatory autoimmune T cell response after immunisation with MOG35-55. These findings indicate that LAQ interferes with the priming and activation of immune cells and may therefore play a role in future treatment of MS.

Prof. Brück, Dr. Wegner, and Ms Ott received research funding from Teva Pharmaceutical Industries Ltd.

Dr. Nessler has nothing to disclose.

Modulation of dendritic cell chemokine secretion and migration by laquinimod

F. Luessi, S. Kraus, V. Jolivel, M. Hubo, V. Siffrin, H. Jonuleit, A. Waisman, F. Zipp

University Medical Center (Mainz, DE)

Laquinimod is a novel orally administered drug suggested to be safe, well-tolerated and efficacious in multiple sclerosis. Based on our previous findings on the involvement of dendritic cells (DC) in the mechanism of action, we investigated the effect of laquinimod on DC chemokine secretion and migration.

Immature and mature human monocyte-derived DC were cultured in the presence of therapeutic concentrations of laquinimod. We found that laquinimod significantly decreases macrophage inflammatory protein (MIP)-1α, MIP-1β and monokine induced by interferon-γ (MIG) production of human mature DC – similar to results in the mouse model. These chemokines are known to be involved in the induction of leukocyte recruitment to inflammatory tissue sites. We demonstrated functional relevance of reduced chemokine content of human mature DC by significantly decreased monocyte attraction, which has been reported to be essential for the pathogenesis of experimental autoimmune encephalomyelitis (EAE). The analysis of spontaneous DC migration in a 3-dimensional collagen matrix demonstrated a reduced migratory capacity of laquinimod-treated immature monocyte-derived DC compared to untreated DC. It has been demonstrated that during EAE immature DC migrate into the CNS, where they may be essential for perpetuation of the CNS-targeted autoimmune response.

Considering these findings, reduced secretion of chemokines by laquinimod-treated DC may contribute to the impaired recruitment of immune cells into the CNS upon treatment with laquinimod. Moreover, chemokines assessed here may have an auto-regulatory function, as it has been shown that they are capable of triggering and down-regulating their cognate receptors.

This study has been funded by Teva Pharmaceutical Industries, Nettanya, Israel.

The selective sphingosine 1-phosphate receptor modulator siponimod (BAF312): magnetic resonance imaging lesion and lymphocyte relationship in a phase 2 study in relapsing-remitting multiple sclerosis

H.-P. Hartung, E. Pigeolet, D. Li, B. Hemmer, L. Kappos, M.S. Freedman, O. Stüve, P. Rieckmann, X. Montalban, T. Ziemssen, L. Zhang-Auberson, E. Wallström, K. Selmaj

Heinrich Heine University (Düsseldorf, DE); Novartis Pharma AG (Basel, CH); University of British Columbia (Vancouver, CA); Technical University of Munich (Munich, DE); University Hospital Basel (Basel, CH); The Ottawa Hospital-General Campus (Ottawa, CA); University of Texas Southwestern Medical Center (Dallas, US); Sozialstiftung Bamberg Hospital (Bamberg, DE); Vall d’Hebron University Hospital (Barcelona, ES); Technical University of Dresden (Dresden, DE); Medical University of Lodz (Lodz, PL)

Background: Siponimod (BAF312), a next-generation, selective sphingosine 1-phosphate receptor (S1P1/5) modulator, dose-dependently retains lymphocytes in peripheral lymph nodes. The efficacy of BAF312 on magnetic resonance imaging (MRI) parameters observed in the phase 2 study in multiple sclerosis (MS) may therefore correlate with peripheral lymphocyte counts.

Objectives: To characterize the relationship between peripheral lymphocyte counts and gadolinium-enhanced (Gd+) T1 lesion counts in a phase 2 study evaluating BAF312 treatment in relapsing–remitting MS (RRMS).

Methods: Patients were randomized to treatments within two sequential cohorts: cohort 1 (n=188) received once-daily BAF312 10mg, 2mg, 0.5mg or placebo for 6 months; cohort 2 (n=109) received BAF312 1.25mg, 0.25mg or placebo for 3 months; lymphocyte counts were measured at day 7 and months 1, 3 and 6. MRI was performed monthly. The relationship between lymphocyte and Gd+ lesion counts was assessed with a negative binomial model in patients stratified by baseline Gd+ status (0 or ≥1 lesions).

Results: Lymphocyte counts were reduced from baseline with all BAF312 doses at day 7 (0.25mg, 20%; 0.5mg, 45%; 1.25mg, 59%; 2mg, 71%; 10mg, 74%) and remained stable thereafter. Baseline Gd+ lesion status was: 0 lesions, n=124 (47%); ≥1 lesion, n=138 (53%). At month 3, Gd+ lesion counts were reduced vs placebo with all BAF312 doses (0.25mg, 52%; 0.5mg, 50%; 1.25mg, 63%; 2mg, 69%; 10mg, 86%). The negative binomial model predicted the mean Gd+ lesion count for patients with no baseline lesions compared with patients with lesions: for patients without baseline Gd+ lesions, the model predictor was described by a linear function (slope of relationship, 0.56; standard error, 0.20; p=0.005); for patients with baseline Gd+ lesions, the predictor was described by a sigmoidal Emax function (slope of relationship, 2.98; standard error, 0.65; p<0.001). The model showed a correlation between mean lymphocyte count and monthly Gd+ lesions at steady-state, with lower lymphocyte counts associated with lower lesion counts. A more pronounced relationship in patients with baseline Gd+ lesions, vs those without baseline lesions, was observed.

Conclusions: BAF312 treatment reduced mean Gd+ lesion and lymphocyte counts, and the strength of this correlation was dependent on baseline Gd+ lesion count.

This study was funded by Novartis Pharma AG, Basel, Switzerland.

Hans-Peter Hartung, MD, received honoraria with approval by the Rector of Heinrich-Heine-University from Bayer Healthcare GmbH, Biogen Idec GmbH, Novartis Pharma GmbH, Teva Sanofi Aventis, Hoffman-La Roche, Merck Serono GmbH and Genzyme Corporation for consulting and speaking at scientific symposia.

David Li has received research funding from the Canadian Institute of Health Research and Multiple Sclerosis Society of Canada. He is the Director of the UBC MS/MRI Research Group which has been contracted to perform central analysis of MRI scans for therapeutic trials with Angiotech, Bayer, Berlex-Schering, Bio-MS, Boehringer-Ingelheim, Centocor, Daiichi Sankyo, Genentech, Hoffmann-LaRoche, Merck-Serono, Perceptives, Schering-Plough, Teva Neurosciences, Sanofi-Aventis, Transition Therapeutics. He has also acted as a consultant to Genzyme, Novartis and Nuron.

Bernhard Hemmer has received invitational financial support for research activities from Bayer Health Care Pharmaceuticals, Biogen Idec, Merck Serono, Novartis, Metanomics, Protagen, and Roche and fees and honoraria for consulting from Bayer Healthcare, Biogen Idec, Genzyme, Merck Serono, Novartis, Teva Pharmaceuticals and Sanofi-Aventis.

Mark Freedman has received personal compensation for activities with Bayer Healthcare, Genzyme Corporation, EMD Canada, Novartis, Sanofi-Aventis Pharmaceuticals, Inc., and Teva Canada Innovation.

Xavier Montalban has received speaking honoraria and travel expenses for speaking and scientific meetings, has been a steering committee member of clinical trials or participated in advisory boards of clinical trials in the past years with Bayer Schering Pharma, Biogen Idec, EMD Merck Serono, Genentech, Genzyme, Novartis, Sanofi-Aventis, Teva Pharmaceuticals, Almirall and BTG.

L. Kappos received research support from Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CLC Behring, Elan, Genmab, Genmark, GeNeuro SA, GlaxoSmithKline, Lilly, Merck Sereno, Medicinova, Novartis, Novo Nordisk, Peptimmune, Sanofi-Aventis, Santhera, Roche, Teva, UCB and Wyeth.

Olaf Stüve Consultant: Teva Neuroscience, Biogen Idec, Roche, Genzyme, Novartis, Sanofi Aventis.

Speaker: Teva Neuroscience: Editorial Board: Archives of Neurology, Therapeutic Advances in Neurological Disorders.

Peter Rieckmann has received honoraria for lectures from Bayer Healthcare, Biogen idec, Boehringer-Ingelheim, Novartis, Merck-Serono, TEVA, and Sanofi-Aventis.

T Ziemssen has received speaker honoraria from Biogen Idec, GalxoSmithKline, Genzyme, Sanofi-Aventis, Merck Serono, Novartis, Teva, MSD and Bayer Healthcare. He serves as a consultant and steering board member for Biogen Idec, Teva, Novartis, and Bayer HealthCare.

K. Selmaj received honoraria for consultation or invited talks from Novartis, Roche, Biogen Idec, Merck Serono, ONO Pharmaceuticals, Genzyme.

E Pigeolet, L Zhang-Auberson and E Wallström are employees of Novartis Pharma AG.

Lymphocyte subset dynamics following alemtuzumab treatment in the CARE-MS I study

H.-P. Hartung, D.L. Arnold, J. Cohen, C. Confavreux, E.J. Fox, E. Havrdova, K. Selmaj, H. Weiner, V. Brinar, G. Giovannoni, M. Stojanovic, S.L. Lake, D.H. Margolin, M. Panzara, D.A.S. Compston for the CARE-MS I investigators

Objective: To investigate the effect of alemtuzumab on lymphocyte subsets in treatment-naïve patients with relapsing-remitting multiple sclerosis (RRMS).

Background: Alemtuzumab is a humanized monoclonal antibody that alters the circulating lymphocyte pool. In CARE-MS I, alemtuzumab reduced relapse rate by 55% compared to SC IFNB-1a (p<0.0001).

Methods: CARE-MS I was a 2-year, randomized, rater-blinded trial comparing alemtuzumab to SC IFNB-1a in treatment-naïve, RRMS patients (n=563). Alemtuzumab was administered 12mg/day IV as 2 annual courses (on 5 days at study start and on 3 days 12 months later). Blood counts were tested monthly. Circulating lymphocytes were phenotyped by flow cytometry quarterly and at Months 1 and 13.

Results: Alemtuzumab selectively depleted circulating B and T lymphocytes with minimal or transient effects on other leucocytes. Lymphocyte counts were lowest at the earliest post-treatment timepoint (1 month); B-cell recovery was usually complete within 6 months of treatment while T-cells repopulated more gradually. Depletion and recovery were similar after a second treatment course. Lymphocyte subsets were not all equally affected; differential depletion and repopulation led to shifts over time in their relative proportions. Although both memory and naïve CD4+ T cells were depleted at Month 1, the percentage of CD4+ cells with naïve phenotype decreased from baseline to Month 1 (36.2% to 4.9%), while the percentage of memory cells increased (62.8% to 93.9%). The percentages of both cell types returned to baseline by Month 12. The proportion of CD4+ T cells with a regulatory (Treg) phenotype was increased several-fold from baseline to Month 1 (3.4% to 13.7%), and remained above baseline at Month 12. For naïve, memory and Treg cells, a similar pattern was observed after the second treatment course, and also with CD8+ cells.

Conclusion: Alemtuzumab-induced lymphocyte depletion was selective (non-lymphocytes were largely unaffected), and immediately followed by lymphocyte repopulation which occurred with a distinctive pattern. There was no cumulative reduction in lymphocyte repopulation capacity with a second course of alemtuzumab. As previously shown, alterations in the number and relative proportions of lymphocyte subsets suggest a rebalancing of the immune system that could help explain the efficacy and safety profile of alemtuzumab.

Dr Hans-Peter Hartung reports receiving the approval of the Rector of HHU fees for consulting, lectures, and activities in Steering Committees of the following companies: Bayer Schering, Biogen Idec, BioMS, Genzyme, Merck-Serono, Novartis, Teva Pharmaceuticals, and Sanofi-Aventis.

Dr Douglas L. Arnold reports receiving personal compensation or research support from Bayer Healthcare, Biogen Idec, Genentech, Genzyme, Roche, and Teva Pharmaceuticals.

Dr Jeffrey Cohen reports receiving personal compensation as a consultant or speaker from Biogen Idec, Eli Lilly, Novartis, Teva Pharmaceuticals, Receptos, and Vaccinex.

Dr Alasdair J. Coles reports receiving consulting fees, lecture fees, and institutional grant support from Genzyme, Merck-Serono, and UCB-Celltech.

Dr Christian Confavreux reports receiving consulting fees from Biogen Idec, Gemacbio, Genzyme, Novartis, Sanofi-Aventis, Teva Pharmaceuticals, and UCB; lecture fees from Bayer-Schering, Biogen Idec, Genzyme, Merck-Serono, Novartis, Octapharma, Sanofi-Aventis, and Teva Pharmaceuticals; and research support from Bayer-Schering, Biogen Idec, Merck-Serono, Novartis, Sanofi-Aventis, and Teva Pharmaceuticals.

Dr Edward Fox reports receiving consultancy fees, honoraria, travel, and research support from Bayer Healthcare, Novartis, Ono, Sanofi-Aventis, Biogen Idec, EMD Serono, Genzyme, Opexa Therapeutics, Pfizer, Teva Pharmaceuticals, and Eli Lilly.

Prof Eva Havrdova reports receiving honoraria and grant support from Bayer-Schering, Biogen Idec, Genentech, Genzyme, GlaxoSmithKline, Merck-Serono, Octapharma, Pfizer, Roche, Sanofi-Aventis, and Teva Pharmaceuticals.

Dr Krzysztof Selmaj reports receiving consulting fees from Genzyme, Novartis, Biogen, and Roche; lecture fees from Novartis, Merck-Serono, Biogen, and Bayer Healthcare; and financial compensation, including travel, from Genzyme for scientific presentations.

Dr Howard Weiner reports receiving consulting/honoraria from Biogen Idec, EMD Serono, Genzyme, Teva Pharmaceuticals, Novartis, Nasvax, and GlaxoSmithKline and research support from EMD Serono and GlaxoSmithKline.

Dr. Gavin Giovannoni reports receiving personal compensation for participating on advisory boards in relation to clinical trial design, trial steering committees and data and safety monitoring committees from: Bayer-Schering Healthcare, Biogen-Idec, Canbex, Eisai, Elan, Fiveprime, Genzyme, Genentech, GSK, Ironwood, Merck-Serono, Novartis, Pfizer, Roche, Sanofi-Aventis, Synthon BV, Teva, UCB Pharma, and Vertex Pharmaceuticals.

Dr Tamara Miller reports receiving compensation for speaker activities from Accorda, Allergan, Biogen Idec, Eli Lilly, Forest, Questcor, and Teva Pharmaceuticals; until clinical trial closure, Dr Miller was an independent contractor for Allergan, Biogen Idec, Genzyme, Elan, Teva Pharmaceuticals, Ono, Sanofi-Aventis, EMD Serono, and Roche/Genentech.

Dr Cary L. Twyman reports receiving compensation for clinical trials from Genzyme, Sanofi-Aventis, Eli Lilly, Opexa Therapeutics, Biogen Idec, Teva Pharmaceuticals, Roche, Novartis, Xenoport, Accorda, and Pfizer Inc and compensation for speaker activities and consultation activities from Accorda, Biogen Idec, Novartis, Forrest, and Teva Pharmaceuticals.

Drs David H. Margolin, Stephen L. Lake, and Michael Panzara report receiving personal compensation as employees of Genzyme, a Sanofi company.

Prof Alastair Compston reports receiving consulting fees, lecture fees, and grant support from Genzyme and lecture fees from Bayer Schering Pharma on behalf of the University of Cambridge.

Profs. Vesna Brinar and Miroslav Stojanovic have nothing to report.

Funding provided by Genzyme, a Sanofi company, and Bayer Healthcare Pharmaceuticals.

Laquinimod and the human innate immune system

T. Sehr, K. Thomas, M. Marggraf, L. Hayardeny, T. Ziemssen

Medical University Dresden (Dresden, DE); Teva-Pharmaceutical Industries Ltd (Netanya, IL)

Background: Laquinimod (LAQ) is an innovative oral drug under development for the treatment of relapsing remitting multiple sclerosis (MS). The mechanism of action is still under investigation. Whereas on the T cell level, a cytokine shift towards T-helper-2 (Th2) cells was observed, LAQ demonstrated significant effects on the innate immune system as well. Recently antigen presenting cells (APC) populations were reported to be altered in function and frequency by LAQ therapy in experimental autoimmune encephalomyelitis (EAE) model. There could be demonstrated a direct modulatory effect on inhibition of Th1 and TH17 function.

Methods: Patients treated with different doses of LAQ (0.6 mg to 2.7 mg) as part of the MTD trial were analysed before and after 4 weeks on daily LAQ treatment. Frequencies and activation markers of monocytes (MO) and different dendritic cell (DC) populations were analysed. Additionally cytokine release and apoptotic signal of MO and DC were analyzed after immunomagnetic isolation (MACS) and activation by TLR-4 or TLR-7/8 ligands in the presence and absence of LAQ in-vitro.

Results: We could demonstrate a highly significant decrease of slanDC after 4 weeks of LAQ treatment while MO were unaffected. The DC1/DC2 ratio show a trend of decrease (0.65 to 0.45). In-vitro experiments demonstrated increase apoptosis siginals in slan-DCs incubated with LAQ in comparison to untreated slanDC. Ex-vivo analysis revealed a significant effect of LAQ on activation markers (CD83, CD150, TNF) of slan-DC and in smaller amount of MO, while first experiments did not show an in-vitro effect of LAQ coincubation on cytokine markers of sorted slan-DC nor MO.

Conclusions: We could demonstrate a significant effect of LAQ on a new proinflammatory dendritic cell population which is specifically decreased by LAQ in comparison to MO which are not affected. Cell frequency and activation of these cells were decreased. The mechanism and functional impact of this effect need further investigations.

Study supported by: TEVA

Tony Sehr, Katja Thomas and Michaela Marggraf have nothing to disclose.

Liat Hayardeny is the Global Scientific Director GIP of Teva Pharmaceuticals Industries Ltd.

Tjalf Ziemssen received financial support for research activities from Bayer, Biogen Idec, Novartis, Teva, Sanofi Aventis.

Efficacy and safety of glatiramer acetate in multiple sclerosis patients with allergic respiratory diseases

G. Mallucci, L. La Mantia, P.A. Confalonieri, S. Galgani, S. Haggiag, A. Lugaresi, G. De Luca, C. Solaro, E. Trabucco, G. Meola, M. Robotti, G. Cavaletti, B. Frigeni, R. Clerici, L. Chiveri, G. Bono, P. Banfi, E. Ambrosoni, L. Mancardi, F. Della Cava, R. Balgera, R. Bergamaschi

Fondazione “Istituto Neurologico Nazionale C. Mondino”- I.R.C.C.S. (Pavia, IT); Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta (Milan, IT); Azienda Ospedaliera San Camillo Forlanini (Rome, IT); Policlinico SS. Annunziata (Chieti, IT); ASL3 Genovese (Genoa, IT); I.R.C.C.S. Policlinico San Donato (Milan, IT); Azienda Ospedaliera San Gerardo (Monza, IT); Ospedale Valduce (Como, IT); Ospedale di Circolo e Fondazione Macchi (Varese, IT); I.R.C.C.S. Azienda Ospedaliera Universitaria “San Martino” (Genoa, IT); I.R.C.C.S. Azienda Ospedaliera Universitaria “San Martino” (Genoa, IT); Azienda Ospedaliera della Provincia di Lecco (Lecco, IT)

Background: The influence of T-helper1(Th1)/T-helper2(Th2) balance on immune regulation in multiple sclerosis (MS) is still debated. One of the possible mechanisms of efficacy of glatiramer acetate (GA) is promoting the Th1 to Th2 shift. MS patients with allergies, thus more prone to Th2, activations could show a better response to GA treatment through a stronger Th1-Th2 shift. However, the presence of atopy could favor allergic reactions in course of GA therapy, reducing the compliance to treatment.

Objective: To evaluate the efficacy, safety, and tolerability of GA on MS patients with allergic respiratory diseases (ARDs+), compared to MS patients without allergic respiratory diseases (ARDs-).

Materials-Methods: All patients had a diagnosis of relapsing-remitting MS (RRMS) in accordance with the 2005 McDonald criteria, and satisfied the Italian Pharmaceutical Agency indication for GA treatment. We included 80RRMS patients candidates to treatment with GA, followed in a 24-month, prospective, observational, multicenter study. At baseline all patients were tested with the European Community Respiratory Health Survey II questionnaire (ECRHSII) that investigated asthma-like symptoms, asthma, nasal allergies, and correlated factors such as smoking habits, occupational exposure, environmental household exposure and use of asthma therapy. On ECRHSII questionnaire, the 80RRMS patients were divided into ARDs+, 43%, and ARDs-, 67%. Patients were evaluated at baseline and every 3 months. The primary outcome measure was the relapse rate observed during the 24-month study. The secondary outcome measures were systemic/local adverse effects possibly related to GA treatment and Expanded Disability Status Scale (EDSS).

Results: The two groups (ARDs+vs.ARDs-) were comparable for baseline demographic characteristics. At baseline ARDs+ patients had a lower EDSS (p=0.04) and a lower pre-treatment annual relapse rate (p=0.04), compared to ARDs-. Both groups showed a reduction of relapse rate after 24-month GA treatment (difference in relapse rate: ARDs+ -1.41, p=0.01; ARDs- -1.19, p=0.02).After 24-months GA treatment, an increased EDSS had been reported both in ARDs-(+1, p=0.03) and in ARDs+(+0.4,n.s.). The worsening of EDSS was significantly higher in ARDs-vs.ARDs+(p=0.04). We found no significant difference in systemic/local adverse reactions between the two groups.

Conclusions: MS patients with ARDs comorbidity seems to have a less severe form of MS.GA treatment is relatively more effective in MS ARDs+ patients. Side effects and tolerability overlap in MS ARDs+patients and MS ARDs-patients.

Dr. Mallucci received congress and travel expense compensations from Novartis and Sanofi-Aventis.

Dr. La Mantia has nothing to disclose.

Dr. Confalonieri has received support for conference travel from Sanofi-Aventis, Biogen-Dompé AG and Merk Serono.

Dr. Galgani received congress and travel expense compensations from Merck-Serono, Aventis, Biogen, Novartis.

Dr. Haggiag has nothing to disclose.

Dr. Lugaresi is a Biogen Dompé, Merck Serono and Bayer Schering Advisory Board Member. She received travel grants and honoraria from Bayer Schering, Biogen Dompé, Merck Serono, Novartis, Sanofi Aventis and Teva and research grants from Bayer Schering, Biogen Dompé, Merck Serono, Novartis and Sanofi Aventis. Prof Lugaresi has also received travel and research grants from the Associazione Italiana Sclerosi Multipla and is a Consultant of “Fondazione Cesare Serono”.

Dr. De Luca has nothing to disclose.

Dr. Solaro received crongress and travel expense compensations from Merck-Serono, Biogen, Novartis.

Dr. Trabucco has nothing to disclose.

Dr. Meola has nothing to disclose.

Dr Robotti received research grants from Biogen; congress and travel expense compensations from Teva, Novartis, Biogen.

Dr. Cavaletti received research grants from Bayer Schering and Biogen; congress and travel expense compensations from Bayer Schering, Biogen, Novartis, Sanofi-Aventis.

Dr. Frigeni has nothing to disclose.

Dr. Clerici received research grants from Biogen and Merck Serono.

Dr. Chiveri received research grants from Biogen and Merck Serono.

Dr. Bono has nothing to disclose.

Dr. Banfi has nothing to disclose.

Dr. Ambrosoni has nothing to disclose.

Dr. Mancardi G.L. received financial support for research, honoraria for consultation, speaking or both at meeting for Bayer-Schering, Biogen-Idec, Sanofi-Aventis and Merck Serono, the Fondazione Italiana SclerosiMultipla (FISM), the Italian Ministry of Health (Ricerca Finalizzata),the Italian Ministry of the University and Scientific Research (MIUR) and the Fondazione CARIGE.

Dr. Della Cava has nothing to disclose.

Dr. Balgera has nothing to disclose.

Dr. Bergamaschi received: honoraria for speaking from Bayer Schering, Biogen, Novartis, Sanofi-Aventis, Teva; research grants from Bayer Schering, Biogen, Novartis, Sanofi-Aventis, Teva; congress and travel expense compensations from Bayer Schering, Biogen, Novartis, Sanofi-Aventis, Teva.

From natalizumab to fingolimod: an observational study of 32 patients

A. Ghezzi, D. Baroncini, P.O. Annovazzi, A. Bianchi, G. Minonzio, G. Comi

Centro Studi Sclerosi Multipla (Gallarate, IT)

Background: Natalizumab (NA) is approved in Europe as second-line treatment for RR-multiple sclerosis (MS) with high disease activity. The presence of neutralizing autoantibodies (NABs) against the drug or the increasing risk PML are relevant causes of drug withdrawal. A rebound effect has been observed after NA withdrawal (1), not confirmed by other studies (2). It is not well defined what is the best subsequent therapeutical approach. Fingolimod (FTY), a new oral drug recently approved for MS treatment, is an attractive option for patients who have discontinued NA.

Objective: To assess the clinical outcome in patients shifted from NA to FTY.

Materials and Methods: Thirty-two RR MS patients (21 females), mean age of MS onset=27,7±9,4 years previously treated with NA were shifted to FTY after a mean interval of 9.1±6,5 months.

Before NA treatment, 31/32 patients received IFNB or GA, ten of them also immunosuppressants. NA was discontinued after a mean of 21±11 infusions because of: detection of anti-JCV antibodies (23), presence of NABs (7),inefficacy and liver toxicity in one. During NA treatment 6/32 subjects (3 of them NAB+) presented disease activity.

Results: The large majority of patients (23) presented clinical (21) or MRI (2) reactivation over a mean period of 11,1±6,7 months after NA withdrawal. MS reactivation occurred in 7/23 patients after 0-3 months, in 11/22 after 3-6 months and in 13/15 after 6 months. The whole series was shifted to FTY after a mean interval of 9.1±6,5 months (range 3-24 months); the interval to shift was 3,9±1,3 months in the nine relapse free patients. Two subjects discontinued FTY within 2 weeks because of the occurrence of adverse events (bradycardia and allergic dermatitis). Among the patients who continued FTY treatment, 10/30 (33,3%) presented clinical (9) or MRI (1) reactivation:;3 of them discontinued the treatment after 4, 6 and 11 months. Another patient suspended FTY because of oral aftosis, fatigue and weight loss. Up to now, 22 patients have a follow up of 6 months or more: 8 patients (36,4%) reactivated after 0-3 months and 5 (22,7%) after 3-6 months.

Conclusion: The large majority of patients relapsed after NA withdrawal and 1/3 continued to be active despite FTY initiation, particularly during the first trimester. More complete data will be available at the time of presentation.

References

1. Baumgartner A. et al. Int. J. Neurosci. 2012, 122: 35.

2. O’Connor P.W. et al. Neurology 2011, 76: 1858.

A. Ghezzi has served on scientific advisory boards for Merck Serono, Biogen Idec Teva Pharmaceutical Industries Ltd.; has received speaker honoraria from Merck Serono, Biogen Idec, Bayer Schering Pharma, and Novartis, Serono Symposia International; served as a consultant for Novartis; and receives research support from Sanofi-Aventis, Biogen Idec, and Merck Serono.

D. Baroncini, P.O. Annovazzi, A. Bianchi, G. Minonzio and M. Zaffaroni have nothing to disclose.

G. Comi has served on scientific advisory boards for Bayer Schering Pharma, Merck Serono, Teva Pharmaceutical Industries Ltd., sanofi-aventis, Novartis, and Biogen Idec; has received speaker honoraria from Teva Pharmaceutical Industries Ltd., Sanofi-Aventis, Serono Symposia International, Foundation, Biogen Idec, Merck Serono, Novartis, and Bayer Schering Pharma.

Interferon-b therapy targets memory B cells of multiple sclerosis patients: investigation of the mechanisms

F. Rizzo, E. Giacomini, M. Severa, V. Annibali, R. Mechelli, G. Ristori, M. Salvetti, E.M. Coccia

Istituto Superiore di Sanità (Rome, IT); S. Andrea Hospital (La Sapienza University) (Rome, IT)

MS is commonly considered a T cell-driven disorder. However, many evidences have recently suggested how B lymphocytes are central players in the development and pathogenesis of this disease.

Although the precise mechanisms through which Interferon (IFN)-b exerts its therapeutic effects remain uncertain, this compound is one of the most used first-line disease-modifying drugs indicated for the treatment of MS patients. Initially identified for its antiviral properties, IFN-b is also a cytokine with a strong immunoregulatory activity promoting survival, activation and proliferation of different immune cell types, including B cells.

In this study the response of B cells to IFN-b therapy was investigated by quantifying by real time RT-PCR the expression of MxA (Myxovirus protein A) and OAS2 (2’-5’ oligoadenylate synthetase), two genes classically used as biomarkers of type I IFN responses. Then, we observed by cytofluorimetric analysis that IFN-b specifically reduces the frequency of total B lymphocytes, in particular the compartment of memory B cells, whereas it does not influence the percentage of CD3+ T cells and CD14+ monocytes.

All these findings led us to better investigate the mechanisms underling this phenomenon. Firstly, we hypothesized that the reduction in percentage of memory B cells could be due either to the shedding of CD27 from B cell membranes, generating the soluble form of this receptor, or to the migration of memory B cells from peripheral blood to the site of inflammation by the induction of the two chemokine receptors CXCR4 and CXCR5 after therapy. None of these two hypotheses was verified.

Interestingly, we found that the surface expression of CD95 (FAS Receptor) was markedly induced on memory B cells upon IFN-b therapy, suggesting a specific induction of apoptosis in this population. Indeed, an in vitro treatment with an anti-FAS monoclonal antibody of PBMC from IFN-b-treated MS patients strongly reduced the percentage of memory but not that of naïve B cells.

All together, these results indicate that IFN-b treatment exerts part of its therapeutic effects by targeting B cell compartment, as Rituximab, and depleting specifically B cell memory subset in MS patients. A deeper knowledge of the mechanisms underlying these events could allow the definition of novel potential biomarkers with predictive value for beneficial/poor clinical response to therapy and treatment risks.

This work was supported by FISM grant (#2009/R/7 to EMC).

The authors have nothing to disclose.

Effect of two dosing frequencies of subcutaneous interferon-β-1a on conversion to MS and MRI measures of disease in patients with a first clinical demyelinating event: 3-year results of phase III, double-blind, multicentre trials (REFLEX/REFLEXION)

G. Comi, M.S. Freedman, N. De Stefano, F. Barkhof, C.H. Polman, B.M.J. Uitdehaag, L. Lehr, D. Issard, S. Haller, B. Hennessy, L. Kappos

Ospedale San Raffaele (Milan, IT); University of Ottawa (Ottawa, CA); University of Siena (Siena, IT); VU University Medical Center (Amsterdam, NL); Merck Serono S.A. (Geneva, CH); University Hospital Basel (Basel, CH)

Background: In the 24-month REFLEX study, interferon (IFN) β-1a, 44 mcg subcutaneously (sc) three times weekly (tiw) or once weekly (qw), initiated after the first clinical demyelinating event (early treatment), significantly delayed diagnosis of McDonald multiple sclerosis (MS) (2005 criteria) and clinically definite MS (CDMS). The treatment effect on McDonald MS was significantly greater with tiw than qw dosing.

Aim: To determine the benefits of early versus delayed treatment (DT) 36 months after randomization.

Methods: In REFLEX, patients were randomized to IFN β-1a (serum-free formulation), 44 mcg sc tiw or qw, or placebo, for 24 months or until CDMS diagnosis; all patients switched to open-label IFN β-1a, 44 mcg sc tiw, at CDMS. All patients who completed REFLEX were eligible for the extension study REFLEXION. Among patients who had not converted to CDMS at 24 months, those originally randomized to placebo were switched to double-blind tiw (DT), while qw and tiw patients continued their initial regimen and switched to open-label tiw at CDMS conversion. All patients remained blinded to the initial randomization.

Results: 402/517 (77.8%) REFLEX patients entered REFLEXION (DT n=133; qw n=142; tiw n=127). Integrated data from both studies (DT n=171; qw n=175; tiw n=171) were analysed by original treatment group. At Month 36, the cumulative probability of CDMS was: DT 41.3%, qw 27.6% (p=0.006 vs DT), tiw 27.1% (p=0.002 vs DT; p=0.941 vs qw); and of McDonald MS: DT 86.5%, qw 79.1% (p=0.009 vs DT), tiw 66.8% (p<0.001 vs DT; p=0.024 vs qw). Mean (standard deviation; SD) number of new T2 lesions per patient per scan (baseline–Month 36) was: DT 1.14 (0.13), qw 0.61 (0.07; p<0.001 vs DT), tiw 0.47 (0.06; p<0.001 vs DT; p=0.099 vs qw). Mean (SD) change in T2 lesion volume (mm³) per patient, baseline to last observed value (LOV), was: DT −116 (2419), qw −169 (2663; p=0.465 vs DT), tiw −552 (2106; p<0.001 vs DT; p=0.009 vs qw). Mean (SD) change in T1 hypointense lesion volume (mm³) per patient, baseline to LOV, was: DT 265 (969), qw 216 (867; p=0.137 vs DT), 83 (675; p=0.007 vs DT; p=0.217 vs qw). There were no unexpected adverse drug reactions.

Conclusions: Over 36 months, early treatment with IFN β-1a, 44 mcg sc tiw or qw equally delayed CDMS compared with DT, with significantly more pronounced benefits of tiw over qw dosing for the more MRI-dependent outcome of McDonald MS. Significant benefits of early over DT were also seen for MRI outcomes.

Study supported by Merck Serono S.A. – Geneva, Switzerland (a branch of Merck Serono SA, Coinsins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany).

G. Comi has received honoraria and consultation fees from Bayer Schering, Biogen Dompè, Merck Serono, Novartis, Sanofi-Aventis, Serono Symposia International Foundation and Teva Pharmaceutical Industries.

M.S. Freedman has received personal compensation from Bayer HealthCare, Biogen Idec, EMD Serono (Canada), Novartis, Sanofi-Aventis and Teva Canada Innovation.

N. De Stefano has received honoraria from Biogen Idec, Merck Serono, Schering and Teva for consulting services, speaking and travel support; and has served on advisory boards for Merck Serono.

F. Barkhof has received honoraria/consultation fees from Merck Serono, UCB, Novartis, Roche and Serono Symposia International Foundation.

C.H. Polman has received honoraria/consultation fees/research support from Biogen Idec, Bayer Schering, Merck Serono, Novartis, UCB and Roche.

B.M.J. Uitdehaag has received consultation fees from Biogen Idec, Novartis, Merck Serono, Synthon and Danone Research.

L. Lehr, D. Issard, S. Haller and B. Hennessy are employees of Merck Serono S.A. – Geneva, Switzerland.

L. Kappos has received institutional research support from Acorda, Actelion, Advancell, Allozyne, Barofold, Bayer, Bayhill, Biogen Idec, BioMarin, Boehringer Ingelheim, CSL Behring, Eli Lilly, Geneuro, Genmab, GlaxoSmithKline, Glenmark, Merck Serono, MediciNova, Novartis, Sanofi-Aventis, Santhera, Shire, Roche, Teva, UCB and Wyeth.

No beneficial effect of minocycline as add-on therapy to interferon-β-1a for the treatment of relapsing-remitting multiple sclerosis: results of a large double-blind, randomised, placebo-controlled trial

P.S. Sorensen, F. Sellebjerg, J. Lycke, M. Färkkila, A. Creange, C. Lund, M. Schluep, J. L. Frederiksen, E. Stenager, C. Pfleger, E. Garde, K. Marhardt on behalf of the RECYCLINE Study Investigators

Objective: To evaluate the efficacy and safety of minocycline as add-on to subcutaneous (sc) interferon (IFN)-β-1a s.c. in a large phase II-III trial in patients with relapsing-remitting multiple sclerosis (RRMS).

Background: In experimental studies minocycline exhibited immunomodulatory and neuroprotective properties including inhibitory activity on matrix metalloproteinases and decrease in T-cell-mediated activation of microglia.

Methods: We enrolled treatment naïve RRMS patients in a multi-national, double-blind, randomised trial with a parallel group design. After 3 months of sc IFN-β-1a 44 µg three times weekly, patients were randomised to oral minocycline 200 mg per day or placebo for two years. Clinical follow-up took place every 3 months and brain MRI was performed in a subgroup of patients (n=50) at baseline and two years later. The primary outcome was the time to first documented relapse. Secondary outcomes were: annual rate of documented relapses, number of new or enlarging lesions on T2 weighted MRI, and changes in brain parenchymal fraction (BPF).

Results: We randomised 304 patients to minocycline (n=149) or placebo (n=155) as add-on to IFN-β-1a. Baseline characteristics were (minocycline/placebo): age (36/38 years), MS duration (10.5/11.2 months), mean EDSS (2.0/2.0). The time to first documented relapse did not differ between the two groups (p=0.48), hazard ratio for experiencing a relapse (minocycline vs. placebo) was 0.845 (95% CI: 0.53- 1.3). Secondary endpoints (minocycline/placebo): Annual rate of documented relapses: 0.18/0.28 (p=0.37); mean number of new and/or enlarging T2 lesions on MRI: 3.0/3.0 (p=0.92); change in BPF: -0.1%/0.5% (p=0.39). Explorative endpoints (minocycline/placebo): annual rate of reported relapses: 0.27/0.40 (p=0.08); 6 months sustained 1 point increase in EDSS: 6/3 patients (p=0.33); difference in T2 lesion load (p=0.45); difference in T1 lesion load (p=0.41); disease activity free patients: 47.8 %/29.6 % (p=0.22). No unexpected adverse events were seen, but more patients in the minocycline group discontinued because of adverse events.

Conclusion/Relevance: Minocycline did not show any beneficial effect as add-on therapy to sc IFN-1a; however, it is a question whether the study was well powered for the primary endpoint. A trend towards a beneficial effect of add-on of minocycline was observed in some primary and secondary endpoints, none of which were close to statistical significance.

This study was sponsored by Merck AB, Frösundaviks Allé 1, SE-169 70, Solna, Sweden.

Per Soelberg Sorensen has served on scientific advisory boards Biogen Idec, Merck Serono, Novartis, Genmab, TEVA, Elan, GSK, has been on steering committees or independent data monitoring boards in clinical trials sponsored by Merck Serono, Genmab, TEVA, GSK, Bayer Schering, and he has received funding of travel for these activities; has served as Editor-in-Chief of the European Journal of Neurology, and is currently editorial board member for Multiple Sclerosis Journal, European Journal of Neurology, Therapeutic Advances in Neurological Disorders and; has received speaker honoraria from Biogen Idec, Merck Serono, TEVA, Bayer Schering, Sanofi-aventis, and Novartis. His department has received research support from Biogen Idec, Bayer Schering, Merck Serono, TEVA, Baxter, Sanofi-Aventis, BioMS, Novartis, Bayer, RoFAR, Roche, Genzyme, from the Danish Multiple Sclerosis Society, the Danish Medical Research Council, and the European Union Sixth Framework Programme: Life sciences, Genomics and Biotechnology for health.

Finn Sellebjerg has served on scientific advisory boards for Biogen Idec, Merck Serono, Novartis, Sanofi-Aventis and TEVA and as consultant for Novo Nordisk; has received support for congress participation from Biogen Idec and Sanofi Aventis; has received speaker honoraria from Biogen Idec, Merck Serono, Bayer Schering, Schering-Plough, Sanofi-aventis and Novartis; and has received research support from Biogen Idec, Bayer Schering, Merck Serono, Sanofi-Aventis, Novartis the Danish Multiple Sclerosis Society, the Danish Medical Research Council and Council for Strategic Research.

Jan Lycke has received honoraria for lecturing and advisory councils, trial steering committees or travel expenses for attending meetings from Biogen Idec, Bayer Schering, Merck Serono, and Sanofi-aventis.

Markus Färkkila has received honoraria for lecturing and advisory boards, or costs for attending meetings from Biogen Idec, Bayer Schering, Merck Serono, and Sanofi-aventis.

Alain Creange has received expert testimonies, grants, and lecturefees from Bayer-Schering Pharma, Biogen Idec, CSL Behring, LFB, Merck-Serono, Novartis, Sanofi-Aventis, and Teva.

Christian Lund has received funding of travel and or honoraria from Biogen Idec, Merck Serono, Teva and Novartis.

Myriam Schluep has served as a consultant for Merck-Serono, has received honoraria, payment for development of educational presentations and travel support from Merck-Serono, Biogen Dompé, Novartis, Sanofi-Aventis and Bayer Schering.

Jette Lautrup Frederiksen has served on scientific advisory boards for and received funding of travel for these activities and honoraria from Biogen Idec, Merck Serono, Sanofi-Aventis, Teva and Novartis and has received speaker honoraria from Biogen Idec and Merck Serono.

Egon Stenager has received support for research and congress participation from Biogen Idec, Merck Serono, Bayer Schering and Sanofi Aventis.

Claudia Pfleger has received honoraria for advisory council meetings from Novartis and travel expenses for attending meetings from Novartis, Biogen Idec, and Merck Serono. The Department of Neurology, Aalborg Hospital has received compensation for participation in industry sponsored clinical trials from Merck serono and Biogen Idec.

Ellen Garde has received honoraria for lecturing and travel expenses for attending meetings from Biogen Idec.

Kurt Marhardt is an employee of Merck Serono S.A. Geneva, Switzerland.

Effects of inhibitors of the renin-angiotensin-system on clinical and MRI outcomes in patients with multiple sclerosis receiving interferon-β-1b or glatiramer acetate. A post-hoc-analysis of the BEYOND study

M. Doerner, K. Beckmann, V. Knappertz, V. Limmroth and the BEYOND Steering Committee

Background: In experimental autoimmune encephalomyelitis (EAE) inhibition of the renin angiotensin system (RAS) with ACE-inhibitors or angiotensin receptor blockers (ARBs) resulted in a significantly ameliorated disease course.

Methods: We conducted an exploratory post hoc analysis of data up to two years from the BEYOND study (Βferon Efficacy Yielding Outcomes of a New Dose) to determine the effect of concomitant use of ACE-inhibitors or ARBs on clinical and MRI outcomes in patients with relapsing-remitting multiple sclerosis (RRMS). Clinical and MRI endpoints in patients treated with interferon β-1b or glatiramer acetate and concomitant ACE-inhibitors or ARBs (RAS-inhibitor group) were compared with those treated with interferon β-1b or glatiramer acetate only (reference group). For adequate comparability patients were matched for baseline characteristics considering gender, presence of gadolinium enhancing (Gd+) lesions, age, number of Gd+ lesions, T2-lesion volume and baseline EDSS within treatment groups.

Findings: Patients in the RAS-inhibitor group (n=88) had a significantly higher relapse rate than the reference group (0.35 vs. 0.21, p=0.014). More patients in the RAS-inhibitor group experienced a confirmed EDSS progression but the difference was not significant (22% vs. 14%, p=0.235). No significant differences were observed for MRI outcomes.

Interpretation: In the BEYOND study cohort, therapy with ARBs or ACE-inhibitors did not have a beneficial effect in patients with RRMS treated with interferon β-1b or glatiramer acetate. As we showed a higher relapse rate in patients with concomitant ACE-inhibitors or ARBs our results warrant further investigation in future studies. Potential explanations for the higher relapse rate include cardiovascular comorbidity, effects of concomitant RAS-inhibitors or other yet unexplored characteristics or interactions.

Funding: Bayer Healthcare.

Disclosure: M. Doerner is a full-time employee of Bayer HealthCare, K. Beckmann is a full-time employee of Bayer HealthCare, V. Knappertz was a full-time employee of Bayer HealthCare at the time of this study and is currently an employee of MedImmune, V. Limmroth has received research support or speaker honoraria from Bayer, Biogen Idec, Glaxo-SmithKline, Merck-Serono, sanofi-aventis, and Teva Neuroscience.

Integrin expression patterns on naive and memory CD4+ and CD8+ T-cells before and during natalizumab therapy

A. Harrer, K. Oppermann, G. Pilz, B. Holl, P. Wipfler, S. Afazel, E. Haschke-Becher, E. Trinka, J. Kraus

Paracelsus Medical University (Salzburg, AT)

Introduction: The primary effector mechanism of natalizumab (NZB) is blocking immune cell migration into the central nervous system (CNS) by blocking the α-4 subunit of very late activation antigen-4 (VLA-4; α-4/β-1; CD49dCD29). In addition to this blocking function, both VLA-4 subunits and the α-L (CD11a) subunit of leukocyte function antigen-1 (LFA-1) have been shown to partly disappear from the surface of immune cells. Still, some patients suffer relapses. We analyzed VLA-4 and LFA-1 surface levels on naive and memory T cell subpopulations prior to and during NZB therapy to identify immune cell subsets possibly involved in treatment-resistant relapse activity.

Methods: Phenotyping of naive (CD45RA+) and memory (CD45R0+) CD4+ (CD4RA+/CD4R0+) and CD8+ (CD8RA+/CD8R0+) T cells and analysis of CD49d (clone HP2/1), CD29 (clone 4B4), and CD11a (clone 25.3) surface levels on lymphocytes from 7 NZB-treated MS patients were performed by 5-color flow cytometry (Beckman Coulter, Vienna). Results were expressed as percentages or median fluorescence intensities (MFI). Samples were collected prior to infusions at baseline (T0) and after 12 weeks (T2) of therapy.

Results: Baseline data showed significant higher integrin expression on memory than on naive T cells (CD49d p<0.01, CD29 p<0.001, CD11a p<0.01) and revealed disparities of CD49d and CD29 on CD4R0+ (MFI CD29>MFI CD49d; p<0.05) and CD8RA+ T cells (MFI CD49d > MFI CD29; p<0.01). CD29-high subsets were observed in 12.3% (SD 5.7) CD4RA+ and 23.9 (SD 12.6) CD8RA+ T cells. CD11a-high subsets were observed in 15.6% (SD 11.6) CD8RA+ T cells. CD49d surface levels were below cut-off in 25.8% (SD 11.8) of CD4R0+ T cells. NZB therapy resulted in significantly decreased MFIs of CD49d (p<0.001), CD29 (p<0.05), and CD11a (p<0.05) on all subpopulations and subsets. Frequencies of high expressing subsets remained largely unchanged.

Discussion: We were able to discriminate naive CD4+ and CD8+ T cell subsets featuring high levels of CD29 and CD11a similar to those of memory cells. These subsets possibly represent cells in a certain activation state and have not been described so far. NZB treatment only had minor effects on the expression level and no effects on the population size. We conclude that these cells deserve further attention concerning a potential involvement in ongoing disease activity under natalizumab therapy.

This study was supported by Biogen Idec, Austria.

ET received compensation from UCB Pharma (consulting, speaking,research support, clinical trials), Eisai (consulting, speaking, clinical trials), Seppracor (consulting, speaking), Medtronics (Consulting), Pfizer (Speaking) and has received Research Grants from UCB Pharma.

JK received financial support for research activities from Biogen Idec, Bayer, Genzyme, Sanofi-Aventis, Merck Serono, and Novartis. J. Kraus received personal compensation from Biogen Idec, Bayer, Sanofi-Aventis, Merck Serono, and Novartis for lectures, advisory board participations, and consultations.

AH,KO,GP,BH, WP, AS, EHB have nothing to disclose.

Analysis of lymph node dendritic cells induced in multiple sclerosis patients after transdermal immunisation with myelin peptides

M. Jurynczyk, A. Jurewicz, A. Walczak, K. Wodz, K. Selmaj

Medical University of Lodz (Lodz, PL)

Background: In a 12-month randomized placebo-controlled clinical study we have shown that transdermal immunization (TDI) with a mixture of myelin basic protein 85-99, proteolipid protein 139-151 and myelin oligodendrocyte protein 35-55 activates Langerhans cells in the skin, induces a unique population of dendritic cells in local lymph nodes, generates IL-10-dependent regulatory responses and attenuates reactivity against myelin peptides.

Objective: We attempted to characterize a unique population of dendritic cells induced in local lymph nodes of MS patients after treatment with a mixture of myelin peptides applied to the skin.

Methods: Ultrasound-guided biopsies of axillary lymph nodes were performed in MS patients treated with TDI. After immediate processing of lymph node specimen, cells were stained with fluorescence-labeled antibodies and assessed by flow cytometry. Antibodies against CD11b, CD11c, CD1a, CD40, CD45RA, CD123, CD163, BDCA-1, BDCA-2, CD3, MHC-II, CD206 and CD207 were used. Dendritic cells were isolated using the BD FACSAria cell sorter and expression of multiple genes critical for dendritic cell function was assessed using real-time PCR-based microfluidic array.

Results: Flow cytometry analysis revealed that high proportion of TDI-induced dendritic cells were CD11c+MHC-class-II+CD207+ Langerhans cells (46.5). Other dendritic cell populations were also identified, including plasmacytoid cells (28.9%) and dermal dendritic cells (8.2). Real-time PCR-based microarray analysis showed that TDI-induced lymph node Langerhans cells strongly upregulated mRNA for the chemokine receptor CCR7 and the transcritpion factor FOXO3.

Conclusions: Unique population of dendritic cells induced in lymph nodes by transdermally delivered myelin peptides contained skin-derived populations, such as Langerhans cells and dermal dendritic cells. High frequency of plasmacytoid cells was also present. TDI-induced lymph node Langerhans cells strongly upregulated CCR7, a marker for migration and regulatory functions, and Foxo3, a transcription factor involved in induction of immune tolerance. Characterisation of TDI-induced lymph node dendritic cells reveals the presence of cells with typical skin-derived dendritic cell phenotype with potential migratory and regulatory properties.

The authors have nothing to disclose.

The “Immunomodulation and Multiple Sclerosis Epidemiology” (IMSE) study; A Swedish nationwide pharmaco-epidemiological and genetic study focused on long-term safety and efficacy of natalizumab (Tysabri)

C. Holmén, F. Piehl, J. Hillert, P. Nilsson, C. Dahle, N. Feltelius, A. Svenningsson, J. Lycke, J. Fagius, F. Wallentin, C. Martin, T. Olsson

Karolinska Institute (Stockholm, SE); Lunds Universitetssjukhus (Lund, SE); Linköpings Universitetssjukhus (Linköping, SE); Läkemedelsverket (Uppsala, SE); Norrlands Universitetssjukhus (Umeå, SE); Sahlgrenska Univ sjukhuset (Gothenburg, SE); Akademiska sjukhuset (Uppsala, SE); Universitetssjukhuset (Örebro, SE); Danderyds Sjukhus (Stockholm, SE)

Natalizumab is an effective treatment improving quality of life in people with MS. However, the safety and efficacy in a real-world usage setting is important to monitor. In August 2006 a post-marketing surveillance study was initiated to monitor long-term effectiveness, adverse events (AEs) and identification of genes/biomarkers involved in the development of severe MS.

Patients were registered in a web-based quality registry “Swedish Multiple Sclerosis registry” from 46 centers and evaluated every 6 months.

AEs, extended disability status scale (EDSS), multiple sclerosis severity scale (MSSS), symbol digit modalities test (SDMT), multiple sclerosis impact scale (MSIS-29) and relapses were recorded.

Patient blood samples were taken at baseline, 6, 12, 24 months after treatment, and stored for future analyses.

Until 30th of April 2012; 1794 patients had been included and 81.4% were diagnosed with RRMS. 485 patients stopped the treatment, most often due to pregnancy/planned pregnancy and 122 patients later restarted treatment.

Serious AEs were rare (2.6%, 47 events), but included 6 non-fatal cases of progressive multifocal leukoencephalopathy (PML, 0.3%) and 9 deaths (0.5%).

In patients treated with natalizumab for ≥ 5 years (n=100), long lasting improvements over baseline were shown; MSSS (- 21.9%), MSIS-29 physical/psychic scores(-3.6% and -12.9%, respectively) and SDMT score (+16.8%). EDSS score improved slightly with 1.4%.

The Swedish web-based MS quality registry proves to function well as a post-marketing drug surveillance platform, providing long-term data regarding drug effects and AEs.

Natalizumab is generally well tolerated with sustained efficacy, though the risk of PML is an important concern.

J.H, T.O and F.P have received unrestricted research grants and/or honoratia for lectures or advisory boards from BiogenIdec, Novartis, MerckSerono and Sanofi Aventis.

C. H. Does not report any conflicts of interest.

Effect of natalizumab on circulating CD4+ T-cells in multiple sclerosis

L. Börnsen, J. Romme Christensen, R. Ratzer, A. Bang Oturai, P. Soelberg Sørensen, H. Bach Søndergaard, F. Sellebjerg

University Hospital Copenhagen Rigshospitalet (Copenhagen, DK)

Background: Disease activity in relapsing remitting multiple sclerosis (RRMS) is induced by systemically activated myelin reactive T-helper (Th) cells which enter the central nervous system (CNS) and mediate the formation of an acute lesion. Lesion formation is reduced by treatment with natalizumab, which binds to the integrin very late antigen (VLA)-4 on immune cells. Previous studies suggested that the blood compartment in natalizumab-treated MS may be selectively enriched in activated T-cells. Proposed causes are sequestration of activated T-cells or induction of VLA-4-mediated co-stimulatory signals by natalizumab.

Aim: To examine the effects of natalizumab treatment on the distribution of effector and memory T-cell subsets in the blood compartment and whether T-cells in general or myelin-reactive T-cells in particular show signs of increased immune activation.

Methods: We obtained blood samples from 21 untreated and 25 natalizumab-treated MS patients. By RT-PCR we examined the mRNA expression of a panel of 15 T-cell effector cytokines or transcription factors in CD4+ and CD8+ T-cells. VLA-4 expression and frequencies of CD4+ and CD8+ T-cell subsets was determined by flow-cytometry: a) naïve and memory effector T-cell subsets were discriminated staining for CCR7, CD45RA and CD27; b) IL-23 receptor and IL12 receptor expression was determined on CD161-defined subsets; c) CD134 and CD154 expression was determined on CD26-defined subsets. Myelin basic protein (MBP) specific T-cell responses were examined in a CFSE assay.

Results: Natalizumab-treated MS patients had increased numbers of effector-memory T-cells in the blood. In T-cells from natalizumab-treated MS patients, the expression of TNF-α mRNA was increased and the expression of IL-10 mRNA was decreased. The expression of the other effector cytokines or transcription factors was not significantly different. Natalizumab-treated MS patients had significantly decreased expression of the co-stimulatory molecule CD134 on CD4+CD26HIGH T-cells in blood. CD4+ T-cells from untreated and natalizumab-treated MS-patients showed similar responses to MBP.

Conclusion: The effector memory T-cell pool was selectively increased in the blood compartment of natalizumab-treated MS patients. The T-cell pool in the blood compartment of natalizumab-treated MS patients showed no consistent signs of an increased activation state, and was not selectively enriched in myelin-reactive T-cells.

Lars Börnsen reports no disclosures.

Jeppe Romme Christensen has received honoraria for lecturing from Biogen-Idec.

Rikke Ratzer reports no disclosures.

Helle B. Søndergaard reports no disclosures.

Annette Bang Oturai has served on scientific advisory boards for Novartis, has received speaker honoraria from Biogen Idec, Merck Serono, and Novartis; and has received research support from the Danish Multiple Sclerosis Society, theWarwara Larsen Foundation and the Johnsen Foundation.

Per Soelberg Sorensen has served on scientific advisory boards for and received funding of travel for these activities from Biogen Idec, Merck Serono, Novartis, Genmab, TEVA, Elan; has served as Editor-in-Chief of the European Journal of Neurology, and as an editorial board member for Therapeutic Advances in Neurological Disorders and Multiple Sclerosis; receives speaker honoraria from Biogen Idec, Merck Serono, TEVA, Bayer Schering, Sanofi-aventis, and Novartis; and has received research support from Biogen Idec, Bayer Schering, Merck Serono, TEVA, Baxter, Sanofi-Aventis, BioMS, Novartis, Bayer, RoFAR, Roche, Genzyme, and from the Danish Multiple Sclerosis Society, the Danish Medical Research Council, and the European Union Sixth Framework Programme: Life sciences, Genomics and Biotechnology for health.

Finn Sellebjerg has served on scientific advisory boards for Biogen Idec, Merck Serono, Novartis, Sanofi-Aventis and Teva; has received funding for travel from Sanofi-Aventis and Teva; has served as a consultant for Novo Nordisk; has received speaker honoraria from Bayer-Schering, Biogen Idec, Merck-Serono, Sanofi-Aventis, Schering-Ploug; and has received research support from Biogen Idec and Sanofi-Aventis, from the Danish Medical Research Council [#271-06-0246], the Danish Strategic Research Council [#2142-08-0039]; the Lounkær Foundation, the Danish MS Society, the Johnsen Foundation, and the Warwara Larsen Foundation.

Effect of two dosing frequencies of subcutaneous interferon-β-1a on brain volume changes in patients with a first clinical demyelinating event: 36-month results of a phase III, double-blind, multicentre trial (REFLEX) and its extension (REFLEXION)

F. Barkhof, M.S. Freedman, G. Comi, L. Kappos, C.H. Polman, B.M.J. Uitdehaag, L. Lehr, D. Issard, S. Haller, B. Hennessy, N. De Stefano

VU University Medical Center (Amsterdam, NL); University of Ottawa (Ottawa, CA); Ospedale San Raffaele (Milan, IT); University Hospital Basel (Basel, CH); Merck Serono S.A. (Geneva, CH); University of Siena (Siena, IT)

Background: Interferon (IFN) β-1a, 44 mcg subcutaneously (sc) three times weekly (tiw) or once weekly (qw), significantly delayed the diagnosis of McDonald multiple sclerosis (MS) (2005 criteria) and clinically definite MS (CDMS) over 24 months, when initiated after the first clinical demyelinating event (FCDE) in the REFLEX study.

Aim: To study the effects of early versus delayed treatment (DT) with sc IFN β-1a on changes in brain volume (BV) up to 36 months in patients initially presenting with a FCDE.

Methods: In REFLEX, patients were randomized to IFN β-1a, 44 mcg sc tiw or qw, or placebo, for 24 months or until conversion to CDMS (double-blind [DB] period); all patients switched to open-label (OL) IFN β-1a, 44 mcg sc tiw, at CDMS diagnosis. All patients who completed REFLEX were eligible for the extension study REFLEXION; patients randomized to placebo who had not converted to CDMS by Month 24 switched to 44 mcg tiw (DT); other patients continued their original treatment, switching to OL 44 mcg tiw at CDMS. Original blinding was maintained. Magnetic resonance imaging was performed 3-monthly from baseline to Month 24 or until CDMS, and annually after Month 24. Brain volume was assessed annually.

Results: 402/517 (77.8%) REFLEX patients entered REFLEXION (DT n=133; qw n=142; tiw n=127). Integrated data from both trials (DT n=171; qw n=175; tiw n=171) were analysed by original treatment. Mean (standard deviation) baseline BV (cm³) was: DT 1543.6 (65.64); qw 1537.3 (66.47); tiw 1536.2 (73.69). The median decrease in BV (DB period) from baseline to Month 36 was: DT 0.80%, qw 0.70%, tiw 0.90%. Median decreases by year (post hoc analysis) were: 0–12 months, DT 0.30%; qw 0.40%; tiw 0.60%; 12–24 months, DT 0.40%; qw 0.30%; tiw 0.30%; 24–36 months, DT 0.30%; qw 0.30%; tiw 0.20%.

Conclusions: Overall, the percentage change in BV from baseline to Month 36 was greater in the tiw group than either the qw or DT group; however, this difference was driven mostly by a decrease in BV in the first 12 months, suggesting pseudoatrophy, which is commonly associated with IFN β treatment initiation, rather than loss of brain tissue.

Study supported by Merck Serono S.A. – Geneva, Switzerland (a branch of Merck Serono S.A., Coinsins, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany).

F. Barkhof has received honoraria/consultation fees from Merck Serono, UCB, Novartis, Roche and Serono Symposia International Foundation.

M.S. Freedman has received personal compensation from Bayer HealthCare, Biogen Idec, EMD Serono (Canada), Novartis, Sanofi-Aventis and Teva Canada Innovation.

G. Comi has received honoraria and consultation fees from Bayer Schering, Biogen Dompè, Merck Serono, Novartis, Sanofi-Aventis, Serono Symposia International Foundation and Teva Pharmaceutical Industries.

L. Kappos has received institutional research support from Acorda, Actelion, Advancell, Allozyne, Barofold, Bayer, Bayhill, Biogen Idec, BioMarin, Boehringer Ingelheim, CSL Behring, Eli Lilly, Geneuro, Genmab, GlaxoSmithKline, Glenmark, Merck Serono, MediciNova, Novartis, Sanofi-Aventis, Santhera, Shire, Roche, Teva, UCB and Wyeth.

C.H. Polman has received honoraria/consultation fees/research support from Biogen Idec, Bayer Schering, Merck Serono, Novartis, UCB and Roche.

B.M.J. Uitdehaag has received consultation fees from Biogen Idec, Novartis, Merck Serono, Synthon and Danone Research.

L. Lehr, D. Issard, S. Haller and B. Hennessy are employees of Merck Serono S.A. – Geneva, Switzerland.

N. De Stefano has received honoraria from Biogen Idec, Merck Serono, Schering and Teva for consulting services, speaking and travel support; and has served on advisory boards for Merck Serono.

Bradycardia induced by intravenous methylprednisolone treatment in relapsing-remitting multiple sclerosis patients during acute relapse

M. Dolev, D. Elian, D. Magalashvili, H. Raz, A. Achiron

Sheba Medical Center (Rama-Gan, IL)

Background: High-dose intravenous methylprednisolone (IVMP) is the treatment of choice in patients with relapsing-remitting multiple sclerosis (RRMS) during acute relapse administered to reduce the on-going inflammatory process. IVMP was reported to induce bradycardia in RRMS patients, however the incidence and mechanisms underlying the development of bradycardia in association with IVMP are unknown.

Objective: To evaluate the incidence of bradycardia during IVMP therapy in a large cohort of RRMS patients without a preceding cardiac disease.

Methods: Computerized search of the Sheba MS Center database was performed for the period from 01/01/07 to 31/12/11 to identify patients according to the following inclusion criteria: (1) RRMS (2) acute relapse (3) IVMP administered for 5 consecutive days at a dose of 1 g/day (4) No previous known heart disease. Further analysis was performed for patients that developed bradycardia under IVMP treatment. Bradycardia was defined as heart rate less than 50; severe bradycardia was defined as heart rate less than 40.

Results: Within the 5 year-period between 2007 to 2011, a total of 6225 IVMP daily infusions were administered to 1245 RRMS patients during an acute MS relapse. We identified 309 (4.9%) events of bradycardia that occurred in 51 (16.5%) males and 258 (83.5%) females with disease duration of 8.7±0.38 years and neurological disability by the EDSS=3.1±0.12. There were 23 (0.36%) events of severe bradycardia that occurred in 5 (21.7.5%) males and 18 (78.3%) females with disease duration of 7.5±1.3 years and neurological disability by the EDSS=2.4±0.5.

The incidence of bradycardia occurred in the first (23.6%), second (4.8%), third (16.8%), fourth (28.7%) and fifth (26.1%) days of IVMP treatment. All events spontaneously resolved after cessation of treatment.

Conclusions: IVMP induced bradycardia in 4.9% of RRMS patients mainly during onset and at days 4 and 5 of IVMP treatment. Further studies to evaluate the associated mechanism are warranted.

The authors have nothing to disclose.

The effect of daclizumab HYP on sustained disability progression in the SELECT trial

E. Havrdova, R. Gold, G. Giovannoni, K. Umans, S. Glyman, J. Elkins

Charles University in Prague (Prague, CZ); St. Josef-Hospital/Ruhr-University (Bochum, DE); Queen Mary University of London, Barts and The London School of Medicine and Dentistry (London, UK); Biogen Idec (Cambridge, US)

Objective: To determine whether the effect of daclizumab high-yield process (DAC HYP) on disability progression in the SELECT trial was mediated by a reduction in disabling relapses, disability progression independent of relapse, or both.

Methods: SELECT (n=621) was a randomized, double-blind, placebo-controlled study of DAC HYP 150mg or 300mg or placebo administered subcutaneously every 4 weeks for 52 weeks. Patient data for the DAC HYP 150mg (n=201) and DAC HYP 300mg (n=203) groups were pooled and compared with placebo (n=196). Study visits were scheduled every 4 weeks during the double-blind treatment period. Three-month confirmed disability progression was defined as a 1.0-point or more increase in Expanded Disability Status Scale (EDSS) score for patients with a baseline EDSS ≥ 1.0 or a 1.5-point or more increase for those with baseline EDSS = 0 between baseline and Week 52. Sustained disability progression could begin at any visit. Confirmation of the progression had to occur at least 12 weeks later at a visit when a relapse was not occurring. Disabling relapses were defined as a relapse that occurred within 30 days prior to the onset of disability progression.

Results: Disability progression occurred in 13% (n=25) of patients treated with placebo and in 6% (n=26) of patients treated with DAC HYP (Risk reduction = 50% [95% confidence interval: 15%-70%]; P=0.009). The median EDSS score of patients who progressed was 2.5 in both placebo- and DAC HYP-treated groups at baseline and 4.0 in both groups at the time that disability progression was confirmed. The effect of DAC HYP on disability progression was mediated similarly by a reduction in the proportion of patients with disabling relapses in the placebo-treated (6% [n=11]) versus DAC HYP-treated (2% [n=10]) groups and by a reduction in disability progression that was independent of relapse (7% [n=14] of placebo-treated patients vs. 4% [n=16] of DAC HYP-treated patients.

Conclusions: The prevention of disability progression attributable to DAC HYP in the SELECT trial appeared mediated by a similar reduction in both disabling relapses, as well as relapse-independent progression. The robustness of the effect of DAC HYP on disability progression at one year warrants confirmation in larger trials.

Eva Havrdova has received personal compensation for consulting services and clinical trials from Biogen Idec, Novartis, GSK, Bayer, Teva, Merck, and Sanofi.

Ralf Gold has received personal compensation for consulting, speaker and advisory board activities and from SAGE for serving as a journal editor and has received research support from TEVA, Biogen, Merck Serono, Novartis, and Bayer.

Gavin Giovannoni has received consulting fees for participating on advisory boards in relation to clinical trial design, trial steering committees and data and safety monitoring committees from Bayer Schering Healthcare, Biogen Idec, Five Prime, Genzyme, Ironwood, Merck Serono, Novartis, Teva, Sanofi Aventis and Vertex Pharmaceuticals; lecture fees from Bayer Schering Healthcare, Merck Serono and Vertex Pharmaceuticals; compensation from Elsevier for his role as co-chief editor on the journal “MS and Related Disorders”; and received research grant support from Biogen Idec, Ironwood, Merck Serono, Merz, and Novartis.

Kimberly Umans is a full-time employee of Biogen Idec.

Steve Glyman is a full-time employee of Biogen Idec.

Jacob Elkins is a full-time employee of Biogen Idec.

This study was funded by Biogen Idec and Abbott Biotherapeutics. Alison Gagnon of UBC Scientific Solutions provided medical writing and editorial support to the authors in the development of this abstract, which was funded by Biogen Idec and Abbott. Biogen Idec and Abbott had the opportunity to review and comment on the abstract content; however, the authors had full editorial control of the abstract and provided their final approval of all content.

Teriflunomide treatment of human monocyte-derived dendritic cells in vitro does not impair their maturation or ability to induce allogeneic T -cell responses

L. Li, J. Liu, D. Zhang, C. Jones

sanofi R&D (Bridgewater, US)

Introduction:Teriflunomide is known to attenuate the proliferation of stimulated lymphocytes via inhibition of dihydro-orotate dehydrogenase (DHODH)activity, required for de novo pyrimidine synthesis. The studies described were conducted to determine whether teriflunomide impacts the ability of human monocyte-derived dendritic cells (mono-DC) to mature, secrete cytokines and activate allogeneic T cells in vitro.

Methods: Mono-DC were generated by culture of peripheral blood monocytes, from healthy human donors, in medium containing interleukin (IL)-4 and GM-CSF for 6 days. In DC stimulated with lipopolysaccharide (LPS), in either the presence or absence of teriflunomide at 25 µM, 50 µM or 100 µM, and the presence or absence of 50 µM exogenous uridine, function was assessed by flow cytometric evaluation of cell surface marker expression at 24 h and 48 h, and by Luminex analysis of cytokines present in cell culture supernatants at 24 h. The ability of DC to activate allogeneic T cells (mixed lymphocyte reaction) was assessed by cytokine measurement at 72 h and T cell proliferation at 96 h.

Results: Teriflunomide treatment of human mono-DC did not prevent LPS-induced maturation of the DC. No significant differences were observed between teriflunomide-treated and untreated DC in terms of LPS-induced upregulation of CD40, CD54, CD80, CD86 or HLA-DR expression. A decrease (<30%) in the level of CD83 expression was observed in the teriflunomide-treated DC when compared with untreated DC. Analysis of supernatants taken from teriflunomide treated, LPS-stimulated, DC revealed a dose-dependent decrease in secretion of MCP-1 and IL-10 when compared with non-treated DC, which could not be reversed with exogenous uridine. In mixed lymphocyte reactions, teriflunomide treatment of the DC had no significant effects on allogeneic T cell responses as assessed by either proliferative capacity or cytokine-secretion profile.

Conclusions: Teriflunomide did not impair LPS-induced maturation of mono-DC and had no impact on the ability of LPS-matured DC to induce allogeneic T cell responses. In addition, these findings suggest that decreases in cytokine production from DC following teriflunomide treatment may be mediated via a DHODH-independent pathway, the clinical significance of which is unclear. Importantly, these data suggest that teriflunomide does not broadly impair the capacity of DC to regulate adaptive immunity.

Study supported by sanofi. All authors are affiliated with sanofi US.

Trial design and baseline data of the INFORMS (fingolimod in patients with primary progressive multiple sclerosis) study

C.H. Polman, B. Cree, M.S. Freedman, H.-P. Hartung, F. Holdbrook, L. Kappos, E. Kornyeyeva, C. Lubetzki, F.D. Lublin, D.H. Miller, X. Montalban, C. Pirozzi, H.L. Weiner, J.S. Wolinsky

VU Medical Centre (Amsterdam, NL); University of California (San Francisco, US); The Ottawa Hospital (Ottawa, CA); Heinrich-Heine University (Düsseldorf, DE); Novartis Pharmaceuticals Corporation (East Hanover, US); University Hospital (Basel, CH); Hospital de la Salpêtriére (Paris, FR); Mount Sinai Medical Centre (New York, US); UCL Institute of Neurology (London, UK); Hospital Universitari Vall d’Hebron (Barcelona, ES); Harvard Medical School (Bosten, US); University of Texas Health Science Centre (Houston, US)

Background: Fingolimod 0.5 mg, a first-in-class sphingosine 1-phosphate receptor modulator and first approved oral therapy for relapsing multiple sclerosis, is currently being evaluated for primary progressive MS (PPMS) in the INFORMS study.

Objective: To present the trial design and baseline data for the INFORMS study.

Design/Methods: INFORMS is a double-blind, randomised, multicentre, placebo-controlled, parallel group study; enrolment commenced in 2008 and completed in 2011. Patients with PPMS (2005 McDonald criteria) (N=285) were randomised (1:1) to fingolimod 1.25 mg once-daily or placebo. In 2010, 1.25 mg patients were switched to 0.5 mg in a blinded manner and later another 654 patients were randomised to either 0.5 mg or placebo. Maximum duration of the study will not exceed 5 years (yrs) or until the last patient randomised completes 3 yrs on treatment. Eligibility criteria included: age 25-65 yrs, Expanded Disability Status Scale (EDSS) of 3.5-6.0 at screening; pyramidal functional score (FS) ≥ 2.0; increase in the EDSS (at least 0.5) during the 2 yrs prior to screening; duration of disease 2-10 yrs prior to entering the study; any two of the following: positive brain or spinal cord MRI, or positive CSF. The primary endpoint is the effect of 0.5 mg fingolimod relative to placebo on delaying sustained disability progression, defined by 3 month sustained increase (≥20%) from baseline in 25 foot timed walk test, or 9-hole peg test, or sustained increase in EDSS (0.5 or 1).

Results: Baseline data for 961/970 (99%) randomised patients are reported (48.3% women; mean age: 49 yrs and 51.7% men; 47.9 yrs). Median baseline EDSS was 4.5 (range: 1.5-6.0). EDSS distribution among patients: 4.0 in 21.4%, 5.0 in 7.5%, and 6.0 in 24%. Mean baseline FS: visual, 0.7; brainstem, 0.8; pyramidal, 2.9; sensory, 1.7; cerebellar, 2.0; bowel and bladder, 1.2; cerebral, 0.5. At baseline 78.3% of patients had pyramidal FS≥3.0, 36.2% patients were able to walk ≥500m and 19% used unilateral assistance for ambulation. Mean timed 25-foot walk test at baseline was 8.96 seconds (min 5.50; max 9.55).

Conclusions: INFORMS study patients represent an older cohort with advanced stage of disability compared to relapsing-remitting MS population. The inclusion criteria allowed selection of a patient cohort with substantial baseline disability that may experience disability progression during the course of the study.

This study is supported by Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.

CH Polman: has received compensation/honoraria/consultation fees/research support from Actelion, Bayer Schering, Biogen Idec, GlaxoSmithKline, Merck Serono, Novartis, Roche, Teva, and UCB.

B Cree: has received compensation/honoraria/consultation fees/research support from Biogen Idec, EMD Serono, Genzyme, Novartis, Sanofi-Aventis, and Teva.

MS Freedman: has received compensation/honoraria/consultation fees/research support from Bayer, Biogen Idec, Celgene, Genzyme, Lansdowne DIME, Medscape, Merck Serono, Novartis, Sanofi Aventis, and Teva.

HP Hartung: has received compensation/honoraria/consultation fees/research support from Bayer Healthcare, Biogen Idec, EMD Serono, Genzyme, Merck Serono, Novartis, Sanofi-Aventis, and Teva Pharmaceuticals.

L Kappos: has received institutional research support from Acorda, Actelion, Advancell, Allozyne, Barofold, Bayer, Bayhill, Biogen Idec, BioMarin, Boehringer Ingelheim, CSL Behring, Eli Lilly, Geneuro, Genmab, GlaxoSmithKline, Glenmark, Merck Serono, MediciNova, Novartis, Sanofi -Aventis, Santhera, Shire, Roche, Teva, UCB, Wyeth, Swiss MS Society, Swiss National Research Foundation, European Union, Gianni Rubatto Foundation, the Novartis and Roche Research Foundations.

C Lubetzki: has received compensation/honoraria/consultation fees/research support from Biogen-Idec, Merck-Serono, Novartis Roche; Sanofi-Aventis, and Teva.

FD Lublin: has received compensation/honoraria/consultation fees/research support from Abbott, Acorda, Actelion, Allozyne, Avanir, Bayer HealthCare Biogen Idec, Celgene, EMD Serono, Genmab, Genzyme, Johnson & Johnson, MediciNova, MorphoSys, NIH, National MS Society, Novartis, Pfizer, Questcor, Sanofi-aventis, Teva, and owns stock in Cognition Pharmaceuticals.

DH Miller: has received compensation/honoraria/consultation fees/research support from Bayer Schering Pharma, Biogen Idec, GlaxoSmithKline, and Novartis.

X Montalban: has received honoraria/consultation fees/research support from Bayer Schering Pharma, Biogen Idec, EMD Serono, Genentech, Inc., Genzyme, Novartis, Sanofi Aventis, Teva Neuroscience, and Almirall.

HL Weiner: has received compensation/honoraria/consultation fees/research support from Biogen Idec, EMD Serono, Genzyme, Teva, Novartis, Nasvax, and GSK.

JS Wolinsky: has received honoraria/consultation fees/research support from Actelion, Astellas, Bayer Schering Pharma, Biogen Idec, Celgene, Eli Lilly, Genentech Inc, Genzyme, NIH, Novartis, Sanofi-Aventis, Serono Symposia International Foundation, Roche, Teva, The Clayton Foundation, The Consortium of Multiple Sclerosis Centers Inc., The National Multiple Sclerosis Society, The Texas Neurological Society, UCB, USF Health Professionals Conferencing Corp., and receives royalties for monoclonal antibodies out licensed through the University of Texas Health Science Center at Houston to Millipore (Chemicon International) Corporation.

F Holdbrook, E Kornyeyeva and C Pirozzi are the employees of Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.

Effect of fingolimod on severe relapses, healthcare utilisation and relapse recovery in patients with relapsing–remitting multiple sclerosis: results from the phase 3 FREEDOMS II study

T. Vollmer, D. Goodin, D. Jeffery, L. Kappos, E.-W. Radue, K. Rammohan, A.T. Reder, M.A. Agius, L. Cappiello, T. Stites, B.B. Li, M. Malhotra, P. von Rosenstiel, P.A. Calabresi

University of Colorado Denver (Aurora, US); University of California (San Francisco, US); Cornerstone Health Care (North Carolina, US); University Hospital Basel (Basel, CH); University of Miami (Miami, US); University of Chicago Medical Center (Chicago, US); University of Colorado Denver (Davis, US); Novartis Pharmaceuticals Corporation (East Hanover, US); Novartis Pharma AG (Basel, CH); Johns Hopkins Hospital (Baltimore, US)

Background: Multiple sclerosis (MS) relapses vary in severity and may require steroid intervention/hospitalization. Fingolimod significantly reduced the frequency of relapses rated as severe or requiring healthcare utilization in the phase 3 FREEDOMS and TRANSFORMS studies.

Objectives: To report the effects of fingolimod on severe MS relapses, healthcare utilization and relapse recovery in FREEDOMS II – a 2-year, phase 3, placebo (PBO)-controlled study of fingolimod in relapsing–remitting MS.

Methods: Patients were treated with fingolimod 0.5mg (n=358), 1.25mg (n=370), or received PBO (n=355) for 24 months. Primary endpoint was annualized relapse rate (ARR) for fingolimod 0.5mg over 24 months. In a pre-planned analysis, ARR was calculated for confirmed relapses that were severe (Expanded Disability Status Scale [EDSS] score increase >1 point or >2-point change in 1 or 2 (or >1-point change in >4) functional systems) or required steroid treatment. Relapse recovery was assessed based on EDSS scores.

Results: ARR was reduced by fingolimod 0.5mg by 48% and by fingolimod 1.25mg by 50% vs PBO over 24 months (ARR: 0.5mg, 0.21; 1.25mg, 0.20; PBO, 0.40; both p<0.001). A total of 131 (0.5mg) and 130 (1.25mg) patients treated with fingolimod had confirmed relapses compared with 246 patients receiving PBO. ARR was lower with fingolimod 0.5mg (0.05, p=0.012) and 1.25mg (0.06, p=0.031) than with PBO (0.09) for confirmed severe relapses and for confirmed relapses that required steroid treatment (0.5mg, 0.12; 1.25mg, 0.14; PBO, 0.30; both p<0.001). Numerically fewer confirmed relapses in the fingolimod groups vs PBO (non-significant) were severe (0.5mg, n=37; 1.25mg, n=34; PBO, n=60) or required steroid therapy (0.5mg, n=80; 1.25mg, n=97; PBO, n=190) or hospitalization (0.5mg, n=7; 1.25mg, n=11; PBO, n=14). For the majority of confirmed relapses in all treatment groups, complete recovery was reported (0.5mg, 66.4%; 1.25mg, 67.7%; PBO, 71.5%). ARRs for confirmed relapses with no or partial recovery were similar across all treatment groups (0.5mg, 0.18 [p=0.321]; 1.25mg, 0.18 [p=0.424]; PBO, 0.20); however, numerically fewer confirmed relapses with incomplete recovery occurred with fingolimod than with PBO (0.5mg, n=41; 1.25mg, n=36; PBO, n=60; non-significant).

Conclusions: Fingolimod significantly reduced the frequency of severe relapses and those requiring steroid treatment, and was associated with numerically fewer relapses with no or partial recovery compared with PBO.

This study was funded by Novartis Pharma AG, Basel, Switzerland.

Dr. Timothy Vollmer has received compensation as a consultant or for service on advisory boards and/or steering committees from Teva Neuroscience; Biogen Idec; Elan Pharmaceuticals; Hoffman-LaRoche, Accelerated Cure Project; Genzyme; Bristol-Myers Squbb; Novartis Pharmaceuticals; Acorda Pharmaceuticals and the Consortium of MS Centers, and has received research funding from Teva Neuroscience; Biogen Idec; Genzyme, Ono Pharmaceuticals, Lilly Research Laboratories, Novartis Pharmaceuticals, BioMS Technology Corp; Orasi, Sanofi Aventis, EMD Serono and the NIH.

E W Radue has received research support (mainly for MS projects) and lecture fees from: Actelion, Basilea, Bayer Schering, Biogen Idec, Merck Serono, Novartis and others. Lecture fees have have been mainly used for research funding at the Medical Image Analysis Center (former MS MRI Evaluation Center), University Hospital Basel.

Douglas S Goodin has received research support and/or speaker fees from Ares-Serono, Merck-Serono, Novartis, Berlex Laboratories, Bayer Schering HealthCare, Biogen-Idec, Schering AG and Teva Neuroscience.

Dr. Calabresi has received personal compensation for consulting and serving on scientific advisory boards or research funding from Biogen Idec, Teva, EMD Serono, Novonordisk, Novartis; Vertex, Genentech, Abbott, and Bayer.

L. Kappos received research support from Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CLC Behring, Elan, Genmab, Genmark, GeNeuro SA, GlaxoSmithKline, Lilly, Merck Sereno, Medicinova, Novartis, Novo Nordisk, Peptimmune, Sanofi-Aventis, Santhera, Roche, Teva, UCB and Wyeth.

Douglas Jeffery has received honoraria for speaking and consulting from Bayer, Biogen, Teva, Novartis, Acorda, and Genzyme. He has received research support from Bayer, Biogen, Teva, Serono, Pfizer, Novartis, Genzyme, Roche, and Acorda.

Anthony T Reder has received compensation from many of the sources below and is on the advisory board/consultant for: Abbott Laboratories, American Medical Association, Astra Merck, Athena Neurosciences, Aventis Pharma, Bayer HealthCare Pharmaceuticals, Berlex Laboratories, BioMS Medical Corp, Biogen and Biogen/Idec, Blue Cross, Blue Shield, Boehringer Ingelheim Pharmaceuticals Inc, Caremark Rx, Centocor, Inc, Cephalon, Inc, Connectics/Connective Therapeutics, CroMedica Global Inc, Elan Pharmaceuticals, Inc, Eli Lilly and Company, Genentech, Genzyme Corporation, GlaxoSmithKline, Hoechst Marion Roussel Canada Research, Inc, Hoffman-LaRoche, Idec, Immunex, Institute for Health Care Quality, Johnson & Johnson, Pharmaceutical Research & Development, Medlink/Neurobase electronic journal – editor and author, NARCOMS, National MS Society, NMSS & Paralyzed Veterans of America Neurocrine Biosciences, Novartis Corporation, Parke-Davis, Pfizer Inc, NY, Pharmacia & Upjohn, Protein Design Labs, Inc, Quantum Biotechnologies, Inc., Quintiles, Inc, RENEW study (post-marketing study of Novantrone in MS); Serono, Sandoz (now Novartis) and Novartis, Sention, Inc, Schering, Serono, Smith Kline-Beecham, Specialized Therapeutics, a division of Berlipharm, Inc, Takeda Pharmaceuticals and Teva-Marion, and has also received research support from Bayer, Serono, Teva, and the US National MS Society.

K Rammohan: Consultant and advisory Board member for Acorda, Teva, Biogen, Genzyme, EMD Serono, Novartis, and Roche / Genentech. Grant support from Acorda, Biogen, Teva, Roche / Genentech and EMD Serono.

M Agius has received consultant or speaker fees or research support from Novartis, Teva, Biogen Idec, Genzyme, Roche, Actelion and Accorda.

M Malhotra was an employee of Novartis Pharmaceuticals Corporation at the time of the study and is now an employee of Takeda Pharmaceuticals.

P von Rosenstiel is an employee of Novartis Pharma AG.

L Cappiello, T Stites and B Li are employees of Novartis Pharmaceuticals Corporation.

EARLIMS study methodology: open-label, non-randomised trial to assess the efficacy of fingolimod in treatment-naïve patients with RRMS versus fingolimod in patients previously treated with interferons or glatiramer acetate, based on the presence of relapses

X. Montalbán, O. Fernández, H. Butzkueven, M.H. Barnett, A. Gobartt, D. Silva on behalf of the EARLIMS Study Investigators

Background: Fingolimod is the first U.S. Food and Drug Administration and European Medicines Agency-approved oral medication for relapsing-remitting multiple sclerosis (RRMS).

Objectives: The primary objective is to assess whether 0.5 mg dose of fingolimod administered in treatment-naïve patients with short duration RRMS (less than five years) is superior in reducing the annualized relapse rate (ARR), compared with the same 0.5 mg dose administered in patients with the same disease duration who have previously received first-line disease-modifying therapies (DMTs).

Methods: A 13-month (1 month for screening and 12 months of treatment), multi-centre, open-label, non-randomised, parallel group clinical trial. Two groups of patients with short duration RRMS will be included (18-50 years of age; RRMS diagnosis according to the 2010 revision to the McDonald criteria, with 9 or more T2 lesions suggestive of multiple sclerosis; 1-5 years of evolution; 2 or more relapses in the past 2 years; Expanded Disability Status Scale -EDSS- score 0-3.5): treatment-naïve patients (patients who have never received a first-line DMT before) or previously treated patients (patients who have been treated with interferon β-1a, interferon β-1b or glatiramer acetate at least during 1 year). All patients included in the study will be treated with 0.5 mg oral fingolimod once a day for 12 months. The primary efficacy endpoint will be the ARR (number of confirmed relapses over a one-year period). Relapse is defined as a new neurological symptom or the worsening of an existing one that occurs at least 30 days after the start of a previous relapse. A relapse must last at least 24 hours and the patient must not have a fever or infection. To confirm a relapse, symptoms must be accompanied by an increase of 0.5 or more points on the EDSS or an increase of 1 point in two functional systems or an increase of 2 points in one functional system, excluding sphincter and cognitive processes.

Results: The study will be conducted in 29 Spanish and 17 Australian centres. A total of 432 patients are expected to be included. The trial began in Q4 2011. At present there are 17 sites recruiting patients with 21 patients included: 6 treatment-naïve, 12 previously treated and 3 screening failures.

Conclusions: We expect to confirm our hypothesis, by showing superiority of the same 0.5 mg dose of fingolimod in reducing the ARR when used in treatment-naïve patients.

Xavier Montalbán, Oscar Fernández, Helmut Butzkueven and Michael H. Barnett have nothing to disclose.

Ana Gobartt and Diego Silva are employees of Novartis Farmacéutica, S.A.

Reduced dosage treatment for the multiple sclerosis patients developing lymphopenia or neutropenia during the treatment with fingolimod

M. Tanaka, K. Park, R. Motoyama, K. Tanaka

Utano National Hospital (Kyoto, JP); Kanazawa Medical University (Uchinada, JP)

Background: Fingolimod has been approved as the first oral treatment for relapsing-remitting multiple sclerosis (RRMS). However, some patients need to quit this treatment due to adverse effects. Japanese clinical trial reported 8.9% of patients treated with 0.5mg showing less than 200 x 106/L of lymphocytes and mean absolute neutrophil counts reduced by 14%. Dose dependent increase of maximum blood concentration and decrement of lymphocyte count were shown with a single dose of fingolimod.

Objective: To prevent lymphopenia or neutropenia during treatment with fingolimod.

Methods: Plasma maximum drug concentrations (Cmax) after steady state was calculated by Cmax and elimination half-life of a single dose of fingolimod. Cmax after reaching steady state were correlated with total doses during contiguous 6 days (daily to every three days). We treated three patients to prevent lymphopenia or neutropenia at varying intervals.

Results: We experienced two patients with lymphopenia less than 250 x 106/L and one patient with reduction of neutrophil counts by 38% after fingolimod treatment (0.5 mg/day). We tried to decrease total dose per week of fingolimod by prolongation of treatment interval from daily to every other day or every 3 days to avoid lymphopenia or neutropenia.

Patient 1: 71-year-old woman with 12 years’ disease duration. Her lymphocyte counts decreased from 800 to 176 x 106/L within two weeks after daily treatment with fingolimod (3.0 mg per 6 days). Lymphocytes increased to 300 x 106/L with changing its administration from daily (administration dose: 3.0 mg per 6 days) to every other day (1.5 mg; 3 weeks after a start of fingolimod).

Patient 2: 28-year-old woman with a year and 7 months’ duration. Lymphocyte count decreased from 1292 to 244 x 106/L at 5 weeks after treatment, and gradually increased to 474 x 106/L after daily to 5 times in 6 days (2.5 mg) at 15 weeks of treatment.

Patient 3: 35-year-old woman with 14 years’ disease duration. Neutrophil count decreased from 2457 to 1336 x 106/L that was 38% reduction 7 weeks after fingolimod therapy. Neutrophil increased to 1985 x 106/L after a change of administration from 5 times to 4 times in 6 days. Lymphocyte count also increased from 296 to 389 x 106/L at 12 weeks.

Conclusions: This study suggested that we could prevent lymphocyte count reduction even after steady state of drug concentration by reducing the dose with prolonged interval of each administration using only one kind of tablet.

The authors have nothing to disclose.

Mycophenolate mofetil – an underestimated MS rescue treatment?

I. Marques, S. Batista, J. Sargento-Freitas, C. Macário, F. Matias, L. Sousa

Coimbra University Hospital (Coimbra, PT)

Background: Mycophenolate Mofetil (MMF) is a potent immunosuppressant, increasingly being used off-label in many immune-mediated disorders with favorable results. MMF inhibits T and B lymphocytes proliferation, cells believed to be important players in MS pathophysiology.

Objectives: Report our Neurology Department clinical experience with MMF use in MS patients.

Methods: Retrospective review of clinical charts of MS patients regularly followed at our department who were treated with MMF. Demographic, clinical and treatment data were collected and analyzed. Clinical response was assessed based on clinical data and classified as improvement, stabilization or worsening. MMF tolerability and safety were also assessed. Statistical analysis was performed using SPSS software, version 17.0. Independent sample t test and Pearson’s chi-squared test were used for group comparisons. Statistical significance was set at p<0.05.

Results: 31 MS patients were treated with MMF after failure of approved therapies or in forms of disease without approved treatments. 51.6% of patients were female, 51.6% of patients had relapsing-remitting MS, 32.3% secondary progressive MS and 16.1% primary progressive MS. Mean age at MS beginning was 34.2±12.6 years and mean disease duration was 8.9±6.8 years. 71% of patients were previously treated with immunomodulators and 80% with other immunosuppressants. 93.5% of patients were treated with MMF monotherapy and 6.5% with MMF in combination with interferon β. Mean MMF treatment duration was 3.8±2.8 years. Clinical improvement was observed in 29% of patients, stabilization in 38.7% and worsening in 25.8%. Adverse events occurred in 19.4%, in most cases benign infections (12.9%). Treatment was suspended in 32.3% because of inefficacy (19.4%) or adverse events (12.9%). Patients with favorable response to MMF were more likely to be younger at MS beginning (p=0.027) and to have relapsing-remitting MS (p=0.022).

Conclusions: Our study supports that MMF is potentially efficacious in MS patients, as improvement or stabilization was observed in a significant proportion of our patients. It is a well tolerated, safe and relatively low-cost drug that must be considered as an alternative in patients intolerant or refractory to MS approved treatments and in patients with MS forms without approved treatments. Larger, prospective, randomized, placebo-controlled studies are necessary to assess the real efficacy of MMF in MS.

The authors have nothing to disclose.

Daclizumab-induced side effects in multiple organ systems in multiple sclerosis

J. Oh, S. Saidha, P. Calabresi, S. Newsome

Johns Hopkins University (Baltimore, US)

Background: Daclizumab (DAC) is a humanized monoclonal antibody targeted against CD25 on T-cells that is emerging as a useful therapeutic agent in multiple sclerosis (MS). DAC leads to profound expansion of regulatory CD56-bright natural killer (NK) cells, with strong correlations demonstrated between CD56-bright NK cell expansion and clinical and radiographic responses in MS patients, suggesting that this is an important mechanism by which DAC acts in MS. Overall, DAC is a well-tolerated agent, with a spectrum of mild to moderate adverse effects reported. To date, there have been no clinical reports of adverse effects related to DAC-induced NK cell infiltration.

Goal: To report a series of MS patients treated with DAC who presented with adverse effects suggestive of NK cell infiltration.

Methods: A retrospective chart review was performed to identify MS patients treated with DAC with clinical findings suggestive of NK cell infiltration in various organ systems between 2004-2010 at the Johns Hopkins MS Clinic.

Results: 3 MS patients treated with DAC (Zenapax, 1mg/kg monthly intravenous infusions) who manifested with adverse effects suggestive of NK cell infiltration were identified. 2 patients were treated with DAC monotherapy, while 1 patient received DAC as add-on therapy to interferon-β-1a. Adverse effects developed after a mean treatment duration of 23 months (standard deviation=17). Individual clinical manifestations consisted of: diffuse rash and alopecia totalis, diffuse lymphadenopathy, and breast lesions. Tissue immunohistochemistry was positive for CD56-expressing cells in all 3 patients (hair follicle, lymph node, breast lesion), which was suggestive of the presence of NK cells. On discontinuation of daclizumab, the observed clinical manifestations resolved in the 2 patients who presented with rash/alopecia and diffuse lymphadenopathy, and stabilized in the patient with breast lesions.

Conclusions: DAC is generally a well-tolerated agent in MS. We report a case series of MS patients with cytopathological evidence suggestive of the presence of NK cells in 3 disparate organ systems after a relatively long duration of treatment with DAC. Although these observed effects were not progressive after medication discontinuation, and did not result in any serious adverse outcomes, they are nonetheless important potential adverse effects of DAC of which clinicians should be aware. Future studies are needed to better understand the relationship between CD56-expressing cells and DAC-related side effects.

Dr. Jiwon Oh has received educational grant support from Teva Neurosciences.

Dr. Shiv Saidha has received consulting fees from MedicalLogix for the development of continuing medical education programs in neurology and educational grant support from Teva Neurosciences.

Dr. Peter A. Calabresi has provided consultation services to Novartis, EMD-Serono, Teva, Biogen-IDEC, Vertex, Vaccinex, Genzyme, Genentech; and has received grant support from EMD-Serono, Teva, Biogen-IDEC, Genentech, Bayer, Abbott, and Vertex.

Dr. Scott Newsome has received speaker honoraria and/or consulting fees from Biogen Idec, Novartis, and Teva Neurosciences.

Prolonged remission with cyclophosphamide in a patient with CLIPPERS complicating MS

M.R. Ortega, S. Delgado, J. Maldonado, L. Tornes, W. Sheremata, K.W. Rammohan

University of Miami (Miami, US)

Introduction: The first case of CLIPPERS (Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids) in an MS patient has been reported and is in press (Reference Neurology).

Aims: To describe the follow-up clinical course and therapeutic regimen of a patient with MS that developed CLIPPERS that has now been followed for 19 months.

Methods: Case report.

Results: A 61-year-old woman with a 13-year history of multiple sclerosis (MS) treated with natalizumab was diagnosed with CLIPPERS after an extensive evaluation. She developed vertigo, nausea, and severe ataxia in October 2010 that led to her becoming wheelchair-dependent with an EDSS of 7.0. Magnetic resonance imaging (MRI) of the brain in December 2010 showed gadolinium enhancement consistent with CLIPPERS. She underwent extensive serological, cerebrospinal fluid (CSF), and radiological testing and a cerebellar brain biopsy to exclude other possible etiologies. All tests including CSF JC virus PCR were unremarkable.

She was initially treated with dexamethasone 4 mg PO QID for 1 week and then prednisone 40 mg PO every other day. A follow up MRI, 4 weeks later, showed complete resolution of the enhancement. The prednisone was tapered over a period of 8 months. Monthly cyclophosphamide infusions of 1 gm/m2 were started 3 months before steroids were discontinued. A methylprednisolone bolus of 1 gm was administered before the cyclophosphamide. Cyclophosphamide dosing was decreased to every other month after 4 months and to every 3 months after 6 months along with a decrease in the methylprednisolone bolus dose to 500 mg. Brain MRI in February 2012 was stable. In May 2012, 19 months after the onset of her symptoms, she felt well without vertigo. She had gained weight and her EDSS was stable at 6.5.

Conclusions: This patient with MS and CLIPPERS has done well on cyclophosphamide, 9 months off maintenance dose steroids. Many reported cases of CLIPPERS have required maintenance steroids to avoid relapses. It is quite possible that CLIPPERS is a heterogeneous entity comprised of multiple etiologies which may explain why some patients may be steroid dependent. We emphasize that patients with CLIPEPRS need to be followed carefully and treatment with steroids and/or immunosuppression needs to be individualized; however, it is possible that some patients will indeed stabilize and remain relapse free off maintenance steroids.

Melissa R. Ortega, Silvia Delgado, Janice Maldonado, Leticia Tornes, William Sheremata and Kottil W. Rammohan have not received any financial support for the work presented here.

Selective oestrogen receptor b agonist as a possible neuroprotective intervention of multiple sclerosis

M.K. Österlund, P. Fagergren, A. Ökvist, M. Sjöberg

Karo Bio AB (Huddinge, SE)

Current therapies for MS are primarily targeting the immune system exerting antiinflammatory actions, they are effective in the relapse remitting phase when the degree of inflammation is high but has limited effects in the progressive phase when the degree of neurodegeneration is high. There is a big unmet medical need for neuron sparing therapies with other modes of action than attenuating the inflammation. Recently published studies have revealed positive effects of estrogen in experimental autoimmune encephalomyelitis (EAE) that are mediated by both estrogen receptor (ER) subtypes, α and β. However the mechanisms of action are not identical for the two ER subtypes, both subtypes mediates symptomatic relief and neuroprotection but only ERα show significant antiinflammatory actions. By using an ERβ agonist for neuroprotective treatment in MS, the ERα-mediated side effects, such as increased cancer risks and thrombosis, would be avoided.

The present study was conducted to evaluate the effect of a Karo Bio proprietary ERβ agonist (KB-C) on the neurological disease symptoms observed in the model of relapsing-remitting EAE (RR-EAE) in Dark-Agouti rats. RR-EAE was induced in female rats by subcutaneous injection of emulsion consisting of homologous spinal cord homogenate. KB-C was tested at 0.41 and 2.0mg/kg s.c. twice daily from D14 (onset of remission from the first attack) to D25 post-immunization. KB-C significantly reduced the disease symptom over the total treatment period by about 28% after 2 mg/kg treatment but no effect was observed at 0.4mg/kg. Immunohistochemical analyses showed reduced spinal axonal degeneration in KB-C treated animals.

Moreover, we confirm ERβ-induced neuroprotection after in vitro glutamate excitotoxicity. Rat fetal cortical neurons were cultured for two weeks. The cultures were incubated with KB-C 24h prior to a 20 min glutamate exposure (40 µM), followed by further KB-C incubation for 48h. Microtubuli-associated-protein-2 and neurofilament were immunostained for neuron and neurite evaluation respectively. KB-C both increased the number of neurons and the amount of neurite network surviving the glutamate insult already at low nM concentrations.

Taken together, the selective ERβ agonist reduce neurological scorings in a relapsing–remitting EAE rat model and show neuroprotective effects after glutamate excitotoxicity in vitro, suggesting ERβ agonists as a possible novel neuroprotective therapy of MS.

The authors are employees at Karo Bio AB.

Mesenchymal stem cells exert their therapeutic effect by inducing microglia to acquire a neuroprotective phenotype

A. Uccelli, B. Parodi, C. Usai, L. Vergani, S. Bruzzone, G. Mancardi, D. Giunti

University of Genoa (Genoa, IT); Institute of Biophysics - National Research Council (Genoa, IT)

Mesenchymal stem cells (MSC) display a remarkable ability to modulate the immune response and protect the central nervous system (CNS) mainly through the release of soluble factors in a paracrine fashion, affecting the functional behavior of cells in the tissues. Here we investigated the effect of the interaction between MSC and microglia in vitro and we dissected the molecular and cellular mechanisms of this cross talk. We demonstrated that MSC impair microglia activation by inhibiting the expression and release of inflammatory molecules and stress associated proteins. We showed that MSC significantly increase microglial expression and release of molecules associated with a neuroprotective phenotype such as CX3CR1, NURR1, CD200R and IGF1. Interestingly MSC can enhance functional changes on microglia as depicted by the increase of intracellular calcium concentration and phagocytic activity. This last event is associated with an increased expression of TREM2, an innate immune receptor involved in phagocytosis in the absence of inflammation. The observed effects on CX3CR1-expressing microglia are due to the release of CX3CL1 by MSC, driven by inflammatory cues, as demonstrated by the reversal of the observed results when CX3CL1 expression was silenced in MSC or its release was blocked. Last, we showed that exogenous CX3CL1 induce phenotypical and functional changes of microglia similar to those induced by MSC. These findings demonstrate that MSC instruct, through the release of CX3CL1, microglia responsiveness to pro-inflammatory signals by modulating constitutive “calming” receptors, typically expressed by “steady-state microglia” thus switching microglia from a detrimental phenotype to a neuroprotective one.

Antonio Uccelli has received payment for lectures including service on speakers bureaus from Genetech, Merck-Serono, Sanofi Aventis, BiogenIdec, Novartis, Teva, research grants from Merck Serono, Bayer Schering and BiogenIdec and Board membership from Allergan, Merck Serono and Roche.

Benedetta Parodi, Cesare Usai, Laura Vergani and Santina Bruzzone have nothing to disclose.

Gianluigi Mancardi has received payment for lectures from Merck-Serono, Sanofi Aventis, BiogenIdec, Novartis, Teva and research grants from BiogenIdec and Novartis.

Debora Giunti has nothing to disclose.

KATP channel opener NT-KO-003 mediates neuroprotection by a novel mechanism of action and induces beneficial effects in a murine model of multiple sclerosis

N. Virgili, P. Mancera, A. Pastén-Zamorano, B. Wappenhans, G. Sorrosal, M. De Frias, C. Campàs, J. Bustos, M. Pugliese, J.F. Espinosa-Parrilla

Neurotec-Pharma S.L (Barcelona, ES); Advancell S.A. (Barcelona, ES)

Background and objectives: Multiple Sclerosis (MS) is a multiphasic autoimmune and neurodegenerative disease of the Central Nervous System (CNS) in which CD4+ Th1 cells are thought to orchestrate the effectors processes resulting in destruction of myelin sheath. Our previous studies demonstrate that oral administration of ATP-sensitive potassium (KATP) channel opener NT-KO-003 ameliorates disease progression of experimental autoimmune encephalomyelitis (EAE) in mice, accompanied by a decrease in glial activation and neuronal damage. The aim of the current study was to explore which mechanisms are implicated in NT-KO-003 mediated neuroprotection and whether NT-KO-003 could have a direct effect on peripheral immune system.

Methods: Proliferative capacity of stimulated splenocytes and CD4+Tcells was determined by the quantification of bromodeoxyuridine incorporation. To study the neuroprotective effects of NT-KO-003, EAE was induced by immunization with myelin oligodendrocyte glycoprotein peptide. Mice were orally treated with NT-KO-003 from EAE symptom onset. Antioxidative capacity of NT-KO-003 was studied by measuring nitrotyrosine production and expression of the Nuclear Factor Erythroid 2-related factor 2 (Nrf2). In addition, neuroprotective effects of NT-KO-003 were studied in a spinal motorneuron cell line after induction of oxidative damage with hydrogen peroxide.

Results: In the present study we demonstrated for the first time that KATP channel subunits are expressed in infiltrated EAE spinal cord lymphocytes, suggesting a possible peripheral target of NT-KO-003. When proliferative capacity after lymphocytic stimulation of splenocytes and CD4+Tcells was studied, a significant reduction in proliferation rate was observed in cells treated with NT-KO-003. Antioxidative parameters analyzed showed an increased expression of Nrf2 and a reduction of nitrotyrosine immunoreactivity in spinal cord from EAE treated mice. In addition, NT-KO-003 was able to protect spinal cord motorneurons against oxidative damage. Thus, NT-KO-003 constitutes a promising therapeutic approach for the treatment of inflammatory neurodegenerative diseases such as MS by combining anti-inflammatory activity and direct neuroprotective capacities. In this way, Neurotec Pharma, S. L. together with Advancell, S. A. are performing a Clinical trial Phase IIa with NT-KO-003 in 105 patients with RR-MS in 16 hospitals in Spain and Germany, and outcome results are expected by 2Q 2013.

NV,PM,AP,MP and JFEP have applied for a PCT application NT-KO-003 for use in the treatment or prevention of Central Nervous System (CNS) autoimmune demyelinating disease, property of Neurotec-Pharma S.L.

BW,GS,MF,CC,JB have nothing to disclose.

A phase II double-blind, randomised, placebo-controlled trial of neuroprotection with phenytoin in acute optic neuritis

R.E. Raftopoulos, S. Hickman, A. Toosy, C.A. Wheeler-Kingshott, D. Altmann, K. Schmierer, B. Sharrack, R. Sheridan, G. Giovannoni, D.H. Miller, R. Kapoor

Institute of Neurology, UCL (London, UK); Sheffield Teaching Hospitals NHS Foundation Trust (Sheffield, UK); Queen Square MS centre (London, UK); London School of Hygeine and Tropical Medicine (London, UK); Barts and the London School of Medicine (London, UK); School of Life and Medical Sciences (London, UK)

Optic neuritis(ON) is the most common cause of acute visual loss in young adults of Northern European origin. There is a strong association with multiple sclerosis (MS). Approximately 75% of patients with acute ON go on to develop MS during long term follow up.Equally,70% of people with MS have clinical evidence of optic nerve involvement during the course of their illness. The pathology of the lesions in acute ON is comparable to lesions found elsewhere in the central nervous system (CNS) in MS.

Evidence suggests that neuroaxonal degeneration is the pathological correlate of irreversible disability in MS. Pathological studies have shown that axonal loss is present even in the early stages of the disease and that acute axonal damage correlates with the magnitude of inflammation. Experimental evidence suggests that partial blockade of sodium channels during the period when inflammation is active within a plaque may prevent axonal loss and thus delay the accumulation of clinical disability.

The retinal nerve fibre layer (RNFL) is unique in the CNS in that axons are unmyelinated making it a promising biomarker for the processes of neurodegeneration and neuroprotection. Optical coherence tomography (OCT) measured RNFL thickness correlates with clinical, structural and electrophysiological outcomes after acute ON.

We have initiated a phase II randomized double-blind, placebo-controlled trial to assess whether sodium channel blockade with phenytoin has a neuroprotective effect on axons after acute ON. The primary outcome is defined as the mean RNFL thickness after six months adjusted for the corresponding baseline measurement in the unaffected eye. The study is powered to show a 50% reduction in RNFL loss. Secondary aims are to assess whether phenytoin improves visual outcome and remyelination(using visual evoked potentials and optic nerve magnetic resonance imaging including magnetisation transfer ratio) and to assess treatment safety.

Ninety patients with ON will be randomly allocated to receive either phenytoin or placebo for three months. Outcomes will be measured at entry and at six months. To enable successful recruitment a country-wide network of patient identification centres has been set up covering a population of several million people and the trial has been widely publicised to collaborating physicians. They trial is currently recruiting patients.

This investigation is supported by grants from the The MS Society of Great Britain and Northern Ireland, The National Multiple Sclerosis Society and Novartis.

The trial is also supported by the Comprehensive Biomedical Reseach Centre.

The authors would also like to acknowledge Promise 2010.

K.Schmierer is a PI on trials sponsored by Novartis and Roche.He has received speaking honoraria from, and served on advisory boards for, Novartis and Merck-Serono.He is in receipt of a Higher Education Funding Council for England (HEFCE) Clinical Senior Lectureship, and grant support from Barts and The London Charity and from Novartis.

DRA is partially funded by the Multiple Sclerosis Society of Great Britain and Northern Ireland, and, unconnected to this work, has received an honorarium from Merck.

CA Wheeler-Kingshott is on the advisory board for BG12 (Biogen) and receives grants (PI and co-applicant) from ISRT, EPSRC, Wings of Life, MS Society, Biogen Idec and Novartis.

The neuroprotective effects of BG-12 on malonate-induced striatal lesion volume are dependent upon Nrf2

H.M. Arnold, C. Huang, R. Huang, T.M. Engber, M. Yamamoto, K.J. Rhodes, R.H. Scannevin

Biogen Idec Inc (Weston, US); Tohoku University Graduate School of Medicine (Sendai, JP)

Background: BG-12 (dimethyl fumarate, DMF) is an oral agent in development for the treatment of relapsing multiple sclerosis. Previous preclinical and clinical studies have demonstrated that activation of the nuclear factor (erythroid-derived 2)-like 2 (Nrf2) pathway constitutes the major pharmacodynamic response to BG-12 treatment. The Nrf2 pathway is an intrinsic cellular defense system that protects against various forms of oxidative, inflammatory and xenobiotic stress, and has been shown to be important in mediating the neuroprotective effects of BG-12 in preclinical models of oxidative stress and neuroinflammation.

Objective: To determine if the previously demonstrated efficacy of DMF in reducing histological and functional deficits resulting from a neurotoxic malonate injury were consistent or abrogated in Nrf2 knockout mice.

Methods: Twenty-four hours before stereotaxic injection of 2 µmol of malonate in the left striatum (under isoflurane anesthesia), wild-type and Nrf2 knockout mice were treated with 100 mg/kg DMF or vehicle. Mice were dosed with DMF daily thereafter until the conclusion of the study. Animals were sacrificed 30 min after the final administration of DMF, four days following the malonate injection. Malonate-induced lesion volume was quantified using cytochrome oxidase histochemistry and stereology. Monomethyl fumarate (MMF) exposures were measured in plasma and the cerebellum.

Results: Wild-type mice treated with DMF exhibited a significant reduction (71%, n=15, p<0.01) in malonate-induced lesion volume relative to wild-type vehicle control animals (n=13). In Nrf2 knockout animals, DMF treatment resulted in a trend towards reduced lesion volume (34%, n=14) as compared to vehicle controls (n=14), but this change was not statistically significant. Brain and plasma exposures of MMF were generally comparable between groups receiving DMF, but were slightly elevated in the Nrf2 knockout group.

Conclusion: The data in wild-type animals were consistent with previous rat studies demonstrating that DMF reduced neuropathology after a toxic malonate injection into the striatum. While there was a trend towards reduced lesion volume in DMF-treated Nrf2 knockout animals, this effect was not significant and clearly reduced in magnitude relative to the response in wild-type animals. Taken together, these data indicate that Nrf2 has an important role in mediating neuroprotection by DMF in this animal model of neurodegenerative disease.

All authors are full-time employees of Biogen Idec, Inc., with the exception of Dr. Yamamoto. Dr. Yamamoto supplied research reagents necessary for the conduct of these studies under a collaborative agreement with Biogen Idec. Dr. Yamamoto was not monetarily compensated for the collaboration or as a participant of this study, and has no additional conflicts of interest.

Supported by: Biogen Idec Inc.

Development of anti-SEMA4D monoclonal antibody for the treatment of multiple sclerosis

T. Fisher, C. Reilly, L. Winter, J. Veeraraghavan, A. Jonason, J. Seils, H. Huang, H. Bussler, E. Klimatcheva, J. Decker, S. Torno, R. Kirk, C. Cornelius, T. Richards, J Caplan, A. Howell, P. Kenney, M. Scrivens, L. Croy, T. Pandina, M. Doherty, G. Seigel, W. Wang, E. Evans, W. Bowers, M. Paris, J. Leonard, R. Watkins, P. Foster, M. Zauderer, E. Smith

Vaccinex, Inc. (Rochester, US)

Semaphorin 4D (SEMA4D/CD100) is expressed on most immune cells, and its high affinity receptor, Plexin B1 (PLXNB1), is expressed on dendritic, endothelial, and neuronal cells. SEMA4D signaling through PLXNB1 induces growth cone collapse of neurons, inhibits differentiation of oligodendrocyte precursor cells (OPCs), induces oligodendrocyte (OD) process collapse and apoptosis, and disrupts endothelial tight junctions. SEMA4D also plays an important role in the induction of B and T cell responses and glial cell activation. Antibody neutralization of SEMA4D could therefore reduce the severity of multiple sclerosis through several means. First, blocking SEMA4D could reduce the rate of disease relapse by reducing inflammation and secondary immune responses to CNS antigens. Second, to the extent that SEMA4D mediates apoptosis and inhibits maturation of OPCs, blocking SEMA4D could reduce the loss of ODs and promote remyelination. Third, SEMA4D may play a role in breakdown of the blood brain barrier (BBB), and blocking SEMA4D may reduce immune cell infiltration into the CNS.

We have demonstrated in several preclinical models the effects of SEMA4D in the central nervous system. Inhibitory effects on OD differentiation and myelination have been shown using recombinant SEMA4D, and anti-SEMA4D antibody has been shown to protect the integrity of the BBB both in vitro and in vivo, and to promote neural regeneration. Treatment with anti-SEMA4D MAbs attenuates the severity of EAE in several rodent EAE models.

Antibody neutralization of SEMA4D represents a new therapeutic strategy for multiple sclerosis. We selected a humanized IgG4 antibody that recognizes mouse, rat, monkey and human SEMA4D with high affinity. We utilized several in vitro functional assays to demonstrate that this antibody blocks SEMA4D – PLXNB1 interactions. This antibody was characterized in single dose, one month, as well as six month non-clinical IND-enabling toxicology studies. SEMA4D signaling through PLXNB1 has also been implicated in tumor growth and angiogenesis. Using various tumor models we demonstrated that anti-SEMA4D antibody inhibits these processes. A Phase I clinical trial in patients with advanced solid tumors is ongoing; no dose limiting toxicities have been observed following weekly infusions at dose levels up to 9 mg/kg. A randomized, placebo-controlled, single ascending dose Phase 1 study in MS patients is planned for late 2012.

All authors are employees of Vaccinex, Inc.

The effects of glatiramer acetate on the retinal nerve fibre layer in patients with a first episode of acute optic neuritis

M. Kupersmith, R. Sergott, D. Hurtukova, P. Calabresi, G. Cutter, M. Kupersmith

INN @ Roosevelt Hospital (New York, US); Thomas Jefferson University Hospital (Philadelphia, US); Teva Pharmaceuticals Industries Ltd (Kansas City, US); The Johns Hopkins Multiple Sclerosis Center (Baltimore, US); University of Alabama-Birmingham (Birmingham, US)

Background: Retinal nerve fiber layer (RNFL) thinning, reflecting axonal thinning due to optic neuritis can be quantified using optical coherence tomography (OCT). Drugs with potential neuroprotective effects can be tested in patients using RNFL measurement as the primary assessment for efficacy of these drugs.

Objective: To evaluate the potential neuroprotective activity of glatiramer acetate (GA) following acute optic neuritis (AON) demonstrated by reduction of RNFL loss.

Methods: Patients diagnosed with single eye first event of AON were randomized to receive either GA 20 mg SC daily or an identical placebo in a ratio of 1:1 for a period of 6 months. Patients were evaluated using time-domain OCT to measure RNFL thickness and complete eye examination in study centers within 0-9 days of vision loss. Descriptive statistics, change measures and longitudinal generalized linear models were employed to estimate differences between the GA and placebo arms.

Results: Enrollment did not meet expectations. Forty patients, 28 females and 12 males with an average age of 33, were randomized (20 per group), but 2 in each arm dropped at randomization. Five additional patients in each group were lost by 6 months. The mean RNFL thickness at baseline in affected eye was 139 µm, indicative of expected RNFL swelling, compared with 105 µm, in unaffected eyes and was similar between treatment arms. The rate of RNFL thinning over time was less for GA treated affected eyes (p<0.001), while unaffected eyes remained unchanged. The mean difference for eyes evaluated at 6 months was -11.6 microns less loss in the GA group (95% CI : -22.4, 45.6). The estimated difference, when taking into account dropouts using the longitudinal models, is reduced to 0.2 µm suggesting patients who dropout had less RNFL loss.

Conclusion: This study of an injectible established therapy with potential neuroprotective properties in naïve AON patients was difficult to conduct due to the perception of having a benign disease process. Dropouts dramatically impacted the outcomes; nonetheless, there did appear to be some neuroprotective effect of GA, although a larger sample size would be required to be certain.

Mark J. Kupersmith: I have not taken any industry support for more than a year. Any industry studies go through NORDIC, which I Chair. No speaker fees or honorarium from industry.

Robert C. Sergott: Paid consultant and member of speakers’ bureau for Teva, Biogen-Idec, MerckSerono, Novartis. Paid consultant for Thrombogenics, Merck and Company, Basilea, United States Department of Defense, Heidelberg Engineering.

Denisa Hurtukova: Employee of Teva Pharmaceuticals Industries Ltd, Kansas City.

Peter A. Calabresi: Has received personal compensation for consulting and serving on scientific advisory boards from; Biogen-IDEC, Teva, Abbott, Vaccinex, Genzyme, and Novartis; and has received research funding from companies Biogen-IDEC, Teva, EMD-Serono, Abbott, Vertex, Genentech, and Bayer.

Gary R. Cutter: Participation of Data and Safety Monitoring Committees: Apotek,Biogen, Cleveland Clinic, EliLilly, Glaxo Smith Klein, Medivation, Merck, Modigenetech (Prolor), NINDS, NMSS, NICHD, NHLBI (Protocol Review Committee), Ono Pharmaceuticals, Sanofi-Aventis, Teva Consulting & Adviosry Boards: Alexion, Abbott, Allozyne, Bayer, Celgene, Consortium of MS Centers (grant), Coronado Biosciences, Diogenix, Medimmune,Klein-Buendel Incorporated, Novartis, Nuron Biotech, Receptos, Somnus, Spinifex Pharmaceuticals, Teva.Dr. Cutter is employed by the University of Alabama at Birmingham and President of Pythagoras, Inc. a private consulting company located in Birmingham AL.

Oligodendrocyte precursor cell resistance to excitotoxic death through inhibition of a prostaglandin E2 receptor

N. Carlson, J. Redd, S. Bellamkonda, B. Wood, T. Maruyama, J. Rose

VA SLC HCS (Salt Lake City, US); Ono Pharmaceutical Co. (Osaka, JP)

Background: We recently reported that COX-2 expression in mouse oligodendrocyte precursor cells (OPCs) renders these cells more vulnerable to excitotoxicity in vitro. Furthermore, COX-2 inhibitors diminished excitotoxic death of OPCs in vitro. However, the mechanism(s) contributing to excitotoxic death of OPCs through COX-2 is not known. COX-2 is responsible for the rate limiting step in the synthesis of a class of bioactive lipids termed prostanoids, which could be responsible for contributing to OPC cell death. In this study we examined the role of the prostanoid, prostaglandin E2 (PGE2) in OPC excitotoxic death.

Objective: We examined the hypothesis that OPC excitotoxic death is mediated by COX-2 generated PGE2 acting on specific prostanoid receptors which could contribute to demyelination and limit remyelination.

Methods: Dispersed OPC cultures were prepared from mice. Viability of OPCs was assessed in each culture preparation 24 hours after treatment with varying concentrations of the glutamate receptor agonist kainic acid (KA). Amounts of PGE2 were assessed in OPC cultures with and without KA stimulation. Oligodendrocyte expression of PGE receptors was assessed by immunofluorescence confocal microscopy.

Results: In order to assess whether prostanoids could contribute to OPC excitotoxic death, we examined whether PGE2 is made following glutamate receptor activation. We also examined whether PGE receptors are present on OPCs and whether activation or inhibitions of specific EP receptors can modulate viability of OPCs following excitotoxic challenge. Four lines of evidence implicate the EP3 as a contributor to excitotoxic OPC death: 1) stimulation OPC cultures with KA resulted in nearly a two-fold increase in PGE2, 2) OPCs express all four PGE receptors (EP1-EP4) as indicated by immunofluorescence analyses, 3) treatment of OPCs with an EP1/EP3 agonist reversed protection from a COX-2 inhibitor and 4) inhibition of EP3 receptor protects OPCs from excitotoxicity.

Conclusions: Inhibitors of the EP3 receptor on OPCs appear to enhance survival of OPCs following excitotoxic challenge and may help facilitate remyelination.

Takayuki Maruyama is employed by Ono Pharmaceutical Co which produced the EP3 antagonist used in this study.

All other authors have nothing to disclose.

Therapeutic laquinimod treatment restores axon myelination and callosal conduction in a chronic mouse model of multiple sclerosis

S. Moore, G. Hannsun, M. Sasidhar, J. Yoon, T. Yoo, S. Tiwari-Woodruff

David Geffen School of Medicine at UCLA (Los Angeles, US)

Objective: Therapeutic strategies that induce effective neuroprotection and enhance the intrinsic repair mechanism are central goals for future therapy of MS, as well as of other CNS diseases. The aim of this study was to assess the therapeutic effects of laquinimod on axon myelination and callosal axon conduction in the chronic experimental autoimmune encephalomyelitis (EAE) mouse model of multiple sclerosis (MS).

Background: Laquinimod is an orally administered CNS-active immunomodulator. Phase III data in RRMS patients indicate clear effects of laquinimod 0.6mg on clinical disease activity as evidenced by reducing relapse rates, reducing the rate of MRI-measured brain volume loss and, slowing the progression of disability all coupled with a favorable safety and tolerability profile. Laquinimod treatment has shown a significant beneficial effect in rodents with EAE.

Design/Methods: 8-week-old PLP_EGFP C57BL/6 mice were treated with 25 mg/kg/day of laquinimod. Treatment groups received daily oral gavages of laquinimod dissolved in water starting on day 15 or day 21 after first MOG immunization. EAE clinical scores and rotorod was performed throughout the disease course. Immune analysis of splenocytes, electrophysiology conduction of corpus callosum axons, and immunohistochemistry of brain and spinal cord was performed 36 days post-disease induction.

Results: Mean clinical disease scores and rotorod motor performance of EAE mice with therapeutic Laquinimod treatment compared to vehicle-treated mice, were significantly improved throughout disease. Laquinimod treatment significantly reduced Th1 cytokines: IFN-γ, TNF-α, and IL-17; decreased Th2 cytokine IL-5; and significantly reduced MMP9. This was supported by a significant decrease in reactive astrocytes, activated microglia and T cells in the brain. An increase in numbers of myelinated axons and mature oligodendrocytes was observed in the spinal cord and brain of Laquinimod-treated groups. Laquinimod treatment significantly improved callosal conduction and restored axon refractoriness closer to normal levels in contrast to vehicle-treated EAE mice.

Conclusions: Our results show that therapeutic laquinimod treatment has significant beneficial effects in the EAE model, where it improves rotorod motor performance, axon conduction due to its positive effects on oligodendrocyte numbers and myelin density. These results further support laquinimod potential role in the treatment of MS.

Dr. Tiwari-Woodruff has received funding from Teva Pharmaceutical Ind., Israel.

Laquinimod decreases the activation of microglia: potential for neuroprotection?

M. Mishra, C. Silva, J. Wang, V.W. Yong

Hotchkiss Brain Institute (Calgary, CA)

Objective: To characterize the impact of laquinimod on the activity of human microglia.

Background: Persistent activation of microglia is observed in MS lesions and may contribute to pathology including neuronal and axonal degeneration. Laquinimod has demonstrated efficacy in two Phase III clinical trials in reducing the extent of brain volume loss in patients with MS. We investigated the effects of laquinimod on the activity of microglia and evaluated whether laquinimod-treated microglia were less able to kill neurons.

Methods: Microglia were cultured from the brains of human fetal samples or from adult human surgical brain resections to treat drug-intractable epilepsy. Cells were activated with toll-like receptor (TLR) ligands and specific indices of microglia activation, including levels of inflammatory cytokines and matrix metalloproteinase-9 (MMP-9), were measured. Neurons were cultured from human fetal brain samples and toxicity was determined by counting the number of MAP-2 positive cells that survive the exposure to activated microglia.

Results: TLR-2 and -4 activation of fetal or adult human microglia resulted in the significant production of several pro-inflammatory cytokines, chemokines and MMP-9. Elevation of cytokines and MMP-9, but not a majority of chemokines or growth factors, was prevented in activated microglia by laquinimod. The increase in cell size of microglia caused by TLR-4 activation was blocked by laquinimod in a concentration-dependent manner. In co-culture of activated microglia with neurons, the integrity of neurons was compromised. Ongoing experiments seek to establish whether laquinimod protects neurons from the effects of activated microglia.

Conclusions/Relevance: Inhibition of the activity of microglia, including its neurotoxic potential, may reduce injury to neurons. If so, this may help account for the observation that laquinimod reduces brain volume loss in two Phase III trials in MS.

This study was supported by a research operating grant from Teva Pharmaceuticals, Israel.

VW Yong has received honoraria from Teva Neuroscience for speaking engagements.

M Mishra, C Silva and J Wang have nothing to disclose.

Ocrelizumab in relapsing-remitting multiple sclerosis: brain volume results of a phase II randomised placebo-controlled multicentre trial

Y. Zhao, D.K.B. Li, A. Riddehough, A. Traboulsee, D. Masterman, F. Gilberg, L. Kappos, D. Leppert

University of British Columbia (Vancouver, CA); F. Hoffmann-La Roche (Basel, CH); University Hospital (Basel, CH)

Background: Ocrelizumab (OCR), a humanised anti-CD20 monoclonal antibody, reduced gadolinium-enhancing MRI lesions (primary endpoint) by > 89% and annualised relapse rate by > 73% compared with placebo in a 24-week phase II trial in relapsing remitting multiple sclerosis patients. We now report the effect on brain volume.

Methods: Patients were randomised (1:1:1:1) at baseline (BL) to receive placebo (PBO), intravenous OCR (days 1, 15) 600mg or 2000mg, or weekly intramuscular 30ug interferon β-1a (IFN). At week 24, all patients switched to receive open-label OCR: PBO, IFN and OCR 600mg patients received 600mg per 24-week cycle while OCR 2000mg patients received 1000mg at weeks 24 and 48 and 600mg at week 72. Brain volume, determined by the brain fractional ratio (BFR), was measured on MRI scans at weeks 0, 12 and 24 in all patients. MRI follow-up and BFR determination at week 96 occurred only with the initial OCR 600mg and 2000 mg groups. Percentage changes of BFR from BL to week 24 for the four groups were compared using an F-test. An exploratory analysis compared annualised BFR change rates in OCR patients from BL to week 24 versus weeks 24 to 96 using two-sided paired t-tests.

Results: We studied 47 OCR 600mg, 44 OCR 2000mg, 52 PBO and 48 IFN initially randomised patients who had MRI scans and BFR measurements at BL and week 24. Mean decreases in BFR from BL were 0.75% (95% CI: 0.37%, 1.12%) and 0.44% (0.06%, 0.83%) for the OCR 600mg and 2000mg groups, respectively, 0.46% (0.11%, 0.82%) for the PBO group and 0.42% (0.05%, 0.79%) for the IFN group; there were no significant differences between the groups (p = 0.59). For the 39 OCR 600mg patients with follow-up to week 96, the annualised BFR decrease from BL to week 24 was 1.69% (0.79%, 2.60%) per year, compared with 0.56% (0.29%, 0.84%) per year from week 24 to 96, (p = 0.03). Corresponding annualised BFR rates for the 36 OCR 2000mg patients were 1.28% (0.25%, 2.30%) and 0.55% (0.11%, 1.00%), respectively (p = 0.27).

Conclusions: At week 24, brain volume decreases in the OCR patients were not significantly different from those of the placebo or IFN patients, despite the significant therapeutic benefit on inflammatory MRI and relapse outcomes. The current assessment of brain volume loss beyond week 24 is exploratory in nature and limited by the lack of an ongoing concurrent comparison group; effects of OCR on brain volume change will be further examined in the ongoing phase III trials.

Y. Zhao receives research funding from the National Multiple Sclerosis Society, the Canadian Institutes of Health Research and the Multiple Sclerosis Society of Canada.

D. Li, A. Traboulsee and A. Riddehough are the Director, Associate Director and Director of Operations of the UBC MS/MRI Research Group which has been contracted to perform central analysis of MRI scans for therapeutic trials with Angiotech, Bayer, Berlex-Schering, Bio-MS, Boehringer-Ingelheim, Centocor, Daiichi Sankyo, Genentech, F. Hoffmann-La Roche, Merck-Serono, Perceptives, Schering-Plough, Teva Neurosciences, Sanofi-Aventis, Transition Therapeutics.

D. Li acted as a consultant to Genzyme and Novartis and receives research funding from the Canadian Institute of Health Research and Multiple Sclerosis Society of Canada.

A. Traboulsee received honoraria for data safety monitoring committee participation from Merck Serono and Daiichi, honoraria for lectures from Bayer, Merck Serono, Teva Neurosciences and receives research support from the Canadian Institutes of Health Research and the Multiple Sclerosis Society of Canada.

D. Masterman is an employee of F. Hoffmann-La Roche Ltd and receives salary and stock options.

F. Gilberg is an employee of F. Hoffmann-La Roche Ltd.

L kappos discloses that the University Hospital Basel has received research support from Biogen Idec, GlaxoSmithKline, Novartis Pharmaceuticals, Sanofi-Aventis, Bayer Schering, Merck Serono, Teva Pharmaceuticals, Wyeth Pharmaceuticals and others.

D Leppert is an employee and shareholder of F. Hoffmann-La Roche Ltd.

Neuroprotective role of fumarate therapy in chronic EAE

S. Demir, S. Heckers, R. Scannevin, A. Chan, R. Gold

Ruhr University Bochum (Bochum, DE); BiogenIdec (Cambridge, US)

The mechanism of action of fumaric acid esters (FAE) is not fully understood, but there is some evidence that FAE operate through immunomodulatory mechanisms and also mediate neuroprotective effects. Clinical studies, where patients with relapsing-remitting multiple sclerosis (MS) were treated with dimethylfumarate (DMF), showed reduction in relapse rates and gadolinium (Gd) enhancing lesions, indicating a protective effect of this molecule in MS. Further studies in an animal model of MS, the experimental autoimmune encephalomyelitis (EAE) in the C57BL/6 mouse, displayed a significant amelioration of the disease course and a reduction of macrophage/microglia infiltration after DMF treatment. The CNS-protective effect of DMF is proposed to be due to the activation of the transcription factor Nrf2, which mediates oxidative stress response mechanisms.

An appropriate chronic model of EAE is the opticospinal EAE (OSE) double-transgenic mouse model in which both T and B cell receptors recognize the same autoantigen MOG. These animals spontaneously develop a neurological condition that resembles the Devic disease. At an age of 5 weeks, when most of the animals display the first clinical symptoms a treatment with different concentrations of DMF (15 mg/kg BW and 45 mg/kg BW) or sham feeding was performed.

Double transgenic OSE mice showed a significantly (p< 0,0001) ameliorated clinical course in the acute and chronic phase after the treatment with 15 mg/kg BW DMF in comparison to the control group. The higher dosage of 45 mg/kg BW DMF showed no therapeutic effect on the clinical course and was similar to the control group. Treatment with 15 mg/kg BW leads to a diminished macrophage infiltration (255 ± 102 cells/mm2) and less demyelination (8.9 ± 1.8 % of white matter) in the spinal cord as compared to the 45 mg/kg BW DMF (macrophage infiltration: 561 ± 20 cells/mm2, demyelination: 14.1 ± 1.7 % of white matter) and the control group (macrophage infiltration: 338 ± 94 cells/mm2, demyelination: 14.8 ± 5.1 % of white matter). The proposed mode of action via oxidative stress response mechanisms was also confirmed in the 15 mg/kg BW DMF group as the expression of the transcription factor Nrf2 was increased in the lesions of the spinal cord by about 43 % after treatment.

Taken together the treatment with DMF is effective in the therapy of the spontaneous opticospinal EAE model and mediates neuroprotective effects via the oxidative stress response pathway.

S. Demir received research support from BiogenIdec.

S. Heckers has nothing to disclose.

R. Scannevin is an employee of BiogenIdec.

A. Chan received personal compensation as a speaker or consultant for Bayer Schering, Biogen Idec, Merck Serono, Sanofi-Aventis and Teva Neuroscience. A. Chan received research support from the German Ministry for Education and Research (BMBF, “German Competence Network Multiple Sclerosis” (KKNMS), CONTROL MS, 01GI0914), Bayer Schering, Biogen Idec, Merck Serono and Novartis.

R. Gold received research support and personal compensation as a speaker or consultant from TEVA, BiogenIdec, MerckSerono, Bayer, and Novartis.

This work was supported by an unrestricted research grant from BiogenIdec.

Targeting tPA/NMDA interactions with an active immunisation: Proof of concept of a novel strategy for MS treatment

R. Macrez, A. Montagne, M. Gauberti, D. Vivien, G. Defer, F. Docagne

Inserm U919 (Caen, FR)

Background: Multiple sclerosis (MS) is an inflammatory and degenerative disease of the CNS. Results from animal models suggest that excitotoxic processes are involved in MS. For example, blockers of NMDA receptors have been shown to attenuate white matter damage. In addition, the involvement of serine proteases (such as tissue plasminogen activator, tPA) has been suggested in MS. Actually, tPA may promote demyelination because plasmin can directly degrade MBP. Interestingly, tPA was also reported to promote excitotoxic neuronal cell death and to contribute to glutamate-induced oligodendrocyte injury. Recent results indicate that tPA thanks to its interaction with NMDAr facilitates monocyte induced BBB opening and subsequent monocyte traversal across the rat and human BBB in vitro.

Goal: Here we propose an original strategy of active immunisation designed to prevent the interaction between tPA and NDMAr in order to decrease neuroinflammation and improve the therapy of MS in a model of Experimental Autoimmun Encephalomyelitis (EAE) in mice.

Methods: Mice were immunised by intraperitoneal injection of CFA alone (control) or containing the rATD-GluN1. 15 Days after the active immunisation targeting tPA/ NMDAr, EAE was induced with MOG35–55 peptide in CFA containing M. tuberculosis. Animals received pertussis toxin intravenously by injection in the tail at the time of immunization and 48 hours later. Clinical symptoms were daily scored. A molecular imaging sequence was developed to assess brain, cerebellum and spinal cord inflammation: 3D T2*-weighted gradient echo imaging with flow compensation to visualize MPIOs carrying antibodies raised against VCAM-1. This MI was performed at 15D, 21D and 28D after EAE induction (n=5 mice/ group/ time). The global time course of the pathology was followed by measurement of the clinical score and MR imaging as above.

Results: First we showed that MPIOs-αVCAM-1 allow inflammation monitoring in EAE. Then we demonstrated that active immunization to block tPA/NMADr interaction decreases inflammation in brain, cerebellum and spinal cord and improves the neurological score by inhibiting the progression of EAE compared to control mice.

Conlusion: Our data show benefit of a strategy of active vaccination to prevent tPA/NMDAr interaction in an EAE model, reducing both neurological deficits and inflammatory processes. So we report a proof of concept showing that the interaction tPA/NMDAr is a potential target for the development of a new therapeutic modality MS.

RM, AM, MG, DV and FD have no disclosure.

Dr Defer received personal compensation for scientific advisory board from BiogenIdec, Novartis and Teva pharmaceutical Industries Ltd and has received funding for travel and/or speaker honoraria from Merck Serono, BiogenIdec, Guerbet, Novartis and Teva pharmaceutical Industries Ltd.

A two-year, observational study of patients with relapsing-remitting multiple sclerosis to assess the outcome of switching between disease-modifying therapy class in routine UK clinical practice

D. Rog, J. O’Riordan, J.P. Mottershead, D. Croft

Salford Royal NHS Foundation Trust (Salford, UK); Teva Pharmaceuticals Ltd (Aylesbury, UK)

Introduction: Little is known about outcomes in patients who switch from one class of disease modifying treatment (DMT) to another in relapsing-remitting MS (RRMS).

Methods: This was a prospective, longitudinal study conducted in 12 UK MS centres, in patients with RRMS, who were suboptimally managed on their current DMT therapy and who switched to another DMT class (from glatiramer acetate to interferon-B (IFN-B), or from IFN B to glatiramer acetate (GA)). Eligible patients had their RRMS history reviewed for the 2 years preceding switch of DMT, to provide comparative data. Following switch of DMT, patients were followed prospectively for 2 years. Patient data were collected at 6-monthly intervals to reflect routine clinical practice.

Results: Seventy-four patients switched from IFN-B to GA (“GA group”) and 22 patients switched from GA to IFN B (“IFN-B group”). Switching DMT led to a reduction in the annualised relapse rate (ARR) from 0.81 to 0.40 relapses/patient/year (51%) and disabling relapses 0.50 to 0.29 (42%) in the GA group and from 0.98 to 0.61 (38% reduction in ARR) and 0.48 to 0.30 (38% reduction) in the IFN-B group, respectively. Corticosteroids use reduced in both groups (by 40% in GA and by 35% in IFN-B). During the 2 year follow-up after the DMT switch, 23% of the GA group and 64% in the IFN B group discontinued their new DMT therapy. Adverse events (AEs) were most common reasons for DMT discontinuation in both groups. Other reasons included an increase in relapse rate, loss of efficacy, lack of tolerance and pregnancy. Overall AEs were 74% in the GA group and 73% in the IFN-B group. Five patients experienced Serious Adverse Events (SAEs); 1 IFN-B patient experienced a DMT related SAE of urticaria and one patient experienced DMT related SAEs of chest pains and nausea while receiving GA; in both cases, the SAEs led to withdrawal of the DMT treatment and the patients subsequently recovered. The other 3 patients had SAEs which were unrelated to DMT.

Conclusion: This study demonstrates that switching DMT from IFN-B to GA or vice versa can be beneficial in terms of reducing the number of relapses and the need for corticosteroid treatment, and that switching from IFN B to GA led to higher rates of treatment adherence over 2 years.

Dr Rog has served on advisory boards for Teva Pharmaceuticals, Biogen Idec, Genzyme (a Sanofi company and Merck-Serono and is a Principal Investigator on clinical trials for all of these companies. Dr Mottershead has no conflicts of interest. D Croft is an employee of Teva Pharmaceuticals Ltd. The study was sponsored by Teva Pharmaceuticals Ltd.

J. O’Riordan: Consultant in Medical advisory board (Novartis). Principal Investigator in clinical trials for Novartis, Sanofi Aventis, BayerScherin, Biogen Idec, MercSerono, BayerSchering, Teva.

Clinical and MRI aspects of immune reconstitution after natalizumab interruption

A. Guéguen, C. Bensa, R. Deschamps, R. Depaz, M. Obadia, A. Moulignier, O. Gout

Fondation Ophtalmologique A. de Rothschild (Paris, FR)

To better characterize the inflammatory activity observed after the end of Natalizumab (NTZ) treatment we performed a monocentric cohort study.

Among 119 patients treated with NTZ, 36 patients who have stopped NTZ were included. The data related to MS history, disease activity and treatment were prospectively recorded in the database of our center.

The first relapse occurrence was assessed by means of an univariable survival analysis (Kaplan Meier, Weibull plot). The frequency of relapse was calculated by range of two months during the year following the interruption of NTZ. A paired t-test was used to compare the annual rate of relapse, the number of lesions enhanced by gadolinium (Gd+) and the EDSS score.

At 1 year, the cumulative probability of relapse was 46 percent with a hazard ratio (HR) at 0,39 (95% CI: 0,24-0,57). The risk of relapse was not modified by alternative therapy introduced after NTZ (treated, 47 %; HR: 0,35 (0,12-0,68) vs untreated, 43%; HR: 0,41(0,10-0,62)). The first relapse occurred between the 2nd and 7th months. The relapse rate was higher during this period and decreased after the 8th month. The annual rate of relapse between the year preceding NTZ therapy and the year following NTZ interruption was similar (2,33 vs 1,83). Conversely within the same comparison period the number of Gd+ lesions was higher after NTZ (2,2 ± 3,84 vs 9,5 ± 8,26 ; p = 0,04). A progression of disability was observed when comparing EDSS score at the end of NTZ and 1 year later (4,29 ± 1,82 vs 5,37 ± 1,82 ; p = 0,03 ). TheEDSS’s impairment was > - 1 point in four patients who presented an IRIS.

Despite the relative small size of our study and the various alternative therapies proposed the association of methylprednisolone with immunomodulator did not avoid the recurrence of the MS inflammatory activity, as attested by MRI Gd+ lesions and the occurrence of IRIS, responsible for EDSS increase. Moreover, it is worth noting that more than half of the patients were free from relapse during the fist year post NTZ.

The authors have nothing to disclose.

Long-term efficacy and safety of repeated treatment with rituximab in neuromyelitis optica spectrum disorder: a 4-year follow-up study

S.-H. Kim, W. Kim, S.-Y. Huh, S.J. Lee, A.-R. Joung, G.J. Wolbink, D. van der Kleij, P.P. Tak, H.J. Kim

Research Institute and Hospital of National Cancer Center (Goyangsi, KR); Sanquin Research (Amsterdam, NL); Academic Medical Centre (AMC)/ University of Amsterdam (Amsterdam, NL)

Background: In a previous 2-year analysis of repeated rituximab treatment in patients with neuromyelitis optica spectrum disorder (NMOSD), a significant benefit in the relapse rate as well as disability was observed. Here, we report the 4-year analysis of this cohort.

Methods: Of 30 patients in the original study cohort, 28 patients enrolled in the extended study; one patient switched to another treatment 9 months after starting rituximab and another was lost to follow-up 2 years after treatment. After completion of initial 2-year study, patients received single infusion of rituximab at a dose of 375 mg/m2 as a maintenance therapy, whenever the frequency of reemerging CD27+ memory B cells in peripheral blood mononuclear cells (PBMC) exceeded 0.1% by flow cytometry. The outcome measures included the annualized relapse rate (ARR), disability (Expanded Disability Status Scale score), change in anti-aquaporin-4 (AQP4) antibody, and safety of rituximab treatment. The serum level of rituximab and anti-rituximab antibody (ARA) were also determined.

Results: Of the 28 patients, 26 maintained a marked reduction in the ARR over 4 years (mean ARR: pre-treatment 2.4 ± 1.4 vs. post- treatment 0.1 ± 0.3). The disability either improved or stabilized in 96% of the patients. With the increase in the cutoff value of CD27+ memory B cells from 0.05% to 0.1% 2 years after treatment, the median interval to retreatment increased from 22.0 weeks during the initial 2 years to 33.3 weeks afterward. Nevertheless, the ARR in the subsequent 2 years did not differ from that in the initial 2 years. During treatment, 70% of the patients were relapse-free during the initial 2 years, and 86% during the subsequent 2 years. The anti-AQP4 antibody levels declined or remained low following rituximab treatment in the initial 2 years, whereas 18% of the patients had increased anti-AQP4-Ab levels after 3 years, as the interval to retreatment was extended. ARA was found in one patient (3.6%), in which was associated with significantly low serum level of rituximab. The ARA-seropositive patient needed more frequent retreatment, but a clinically significant reduction in the ARR was observed. No serious adverse events leading to discontinuation were observed during follow-up.

Conclusion: These findings indicate that repeated rituximab treatment over 4 years in patients with NMOSD leads to a sustained clinical response with no new adverse events.

The authors have nothing to disclose.

TYSEDMUS: observational prospective follow-up study of patients with MS and treated with natalizumab in France using the French EDMUS (European Database for Multiple Sclerosis) network – Five-year results

S. Vukusic, N. Passante, M. Dufour, F. Rocher, E. Van Ganse, M. Clanet, E. Falip, C. Confavreux on behalf of the TYSEDMUS group

Background: In November 2007, a national institution-driven Risk Management Programme (RMP) has been set up in France by the French Medicines Agency (ANSM), to minimize the risks and monitor the safety and efficacy of Natalizumab (NZ) in daily practice. It is focused on TYSEDMUS, a pharmaco-epidemiological study based on the French network of neurologists using EDMUS.

Objectives: The main objective is to establish the safety profile of NZ in real life settings. Secondary objectives are to describe the efficacy in terms of relapses and disability and the patterns of use.

Methods: TYSEDMUS is a multicentre observational cohort study including all patients exposed at least once to NZ. Patients’ characteristics (including pre-treatment data and clinical evolution), utilisation patterns and occurrence of adverse events are described. All the data are centralised in the OFSEP Coordinating Center in Lyon. The study duration is planned to be at least 5 years.

Preliminary results: In May 2012, circa 5000 MS patients were treated with NZ in France, with 3918 referred to the OFSEP Coordinating Centre and 3730 files fully computerised. Our patients were more severe than in NZ pivotal study. The median follow-up was 23.6 months, with, respectively, 73% and 49% followed at least 1 and 2 years. Ten percent had never received any other treatment. Five percent experienced a serious adverse event: 21 Progressive Multifocal Leukoencephalopathy (10 reported in TYSEDMUS), 1 fatal acute leucoencephalopathy due to Mycoplasma pneumonia, 1 VZV retinitis, 1 Herpetic encephalitis and 18 severe allergic reactions. The immediate infusion-related tolerance was good. 18% of the patients definitively discontinued treatment (data presented in another abstract). The annualised relapse rate decrease by 83% after 1 year and 85% after 2 years. The mean EDSS score decreased from 3.7 ± 1.8 to 3.3 ± 1.9 between inclusion and 1 year and from 3.7 ± 1.8 to 3.4 ± 1.9 between inclusion and 2 years (p<0.0001, paired t-test). The percentage of patients showing active scans decrease by 90% after 1 and 2 years. The French neurologists usually followed the RMP recommendations.

Conclusion: The number of registered files is increasing continuously, reaching nearly 80% of the target population of NZ treated patients in France. Results are confirmative regarding safety data, but also efficacy and good practice of use of NZ by French neurologists. Updated results will be presented at the meeting.

S. Vukusic reports receiving consulting fees from Biogen Idec, Novartis, Merck Serono, Sanofi Aventis and Teva Pharma ; lecture fees from Bayer-Schering, Biogen Idec, Merck Serono, Sanofi Aventis and Teva ; and research support from Bayer-Schering, Biogen Idec, Merck Serono, Sanofi Aventis and Teva.

N. Passante, M. Dufour, E. Van Ganse and F. Rocher have nothing to disclose.

M. Clanet reports reports consulting fees from Genzyme, Biogen Idec, Bayer Schering and research grants from Bayer Schering, Biogen Idec, Merck Serono, Novartis, Sanofi Aventis and Teva Pharma.

E. Falip has nothing to disclose.

C. Confavreux reports receiving consulting fees from Biogen Idec, Genzyme Corporation, Novartis, Merck Serono, Sanofi Aventis, Teva Pharma and UCB Pharma ; lecture fees from Bayer-Schering, Biogen Idec, Genzyme, LFB, Merck Serono, Sanofi Aventis and Teva Pharma ; and research support from Bayer-Schering, Biogen Idec, Genzyme, Merck Serono, Novartis, Sanofi Aventis and Teva Pharma.

Second-line use of Fingolimod in RRMS is as effective as natalizumab

S. Braune on behalf of the NTD Study Group

Clinical studies of efficacy of Fingolimod (F) investigated F as first line medication in RRMS in comparison to placebo or other first line drugs, but F was registered in Europe by the European Medicines Agency (EMEA) only as second line therapy (SLT) in RRMS. This is the first study to analyze efficacy of F as a second line drug in RRMS in comparison to Natalizumab (N).

Design and Population: This is a prospective open health service study of the NeuroTransData (NTD) study group operating a real-time data base documenting clinical data of their outpatient MS patients prospectively. All patients with failing first line treatment and subsequent treatment with either F or N were included if the observation period documented was minimum 6 months before and after begin of SLT. 142 patients were identified receiving F (age 40.11a +9.5, MS duration 11.5a +7.6), 77 patients received N (age 39.6a +8.9, MS duration 11.5 +7.6). The influence of F and N on EDSS and relapse rates (RRs) were analyzed.

Results: Within 6 months prior to initiation of SLT there was a deterioration of mean EDSS in F (-6m 2.28 +1.44, -3m 2.41 +1.40, T0 2,62 +1.35) and N (-6m: EDSS 2.58 +1.99, -3m: 2.64 +1.55, T0: 3.19 +1.60) and an increase in RRs in F (-6m: 0.18 +0.38, -3m: 0.27 +0.54, T0: 0.41 +0.73) and N (-6m: 0.42 +0.7, -3m: 0.73 +0.82, T0: 1.01 +1.03). Within 6 months after initiation of SLT mean values showed a statistically significant decrease of RRs in F (T0: 0.41 +0.73, +3m: 0.32 +0.51, n.s., +6m: 0.18 +0.46, p<0.02) and N (T0: 1.01 +1.03, +3m: 0,25 +0,54, p<0.000, +6m: 0,19 +0,49, p<0.000) and no further deterioration of EDSS with F (T0: 2,62 +1.35, +3m: 2,62 +1.46, +6m: 2.61 +1.58) and N (T0: 3.19 +1.60 +3m. 3.07 +1.69, +6m: 2.99 +1.81).

Discussion: F and N statistically significant decreased RRs within 3 months and even more after 6 months after initiation of therapy, returning RRs to rates before failure of first line therapy. Both drugs stopped further deterioration of EDSS within 3 months of initiation. F and N were equally effective in influencing the course of MS as second line therapy.

S.Braune, M.Lang, A.Bergmann received fees for lectures and advisory boards organized by Biogen Idec, Novartis, Merck, Serono, Teva, Bayer Health Care and others.

Looking for the best therapeutical strategy after the 24th natalizumab administration. The TY-STOP study

M. Clerico, S. De Mercanti, F. Piazza, D. Gned, V. Brescia Morra, R. Lanzillo, L. Amato, M. Quarantelli, A. Ghezzi, A. Bianchi, D. Baroncini, M. Gibbin, J. Vargas, G. Salemi, S. Realmuto, M.T. Ferrò, F. Vitetta, L. Mascolo, D. Paolicelli, M. Trojano, L. Durelli

Neurology Clinic (Orbassano (Turin), IT); Radiology Division (Orbassano (Turin), IT); University Federico II (Naples, IT); Ospedale di Gallarate (Gallarate, IT); Università degli Studi di Palermo (Palermo, IT); Ospedale Maggiore di Crema (Crema, IT); Università di Reggio Emilia (Modena, IT); Policlinico di Bari - Neurologia Universitaria (Bari, IT)

Background: Natalizumab may cause Progressive Multifocal Leucoencephalopathy (PML). According to risk stratification after the 24th course, patients can decide whether to continue therapy with Natalizumab.

Objective: Comparison of disease activity (percentage of patients with relapses and/or magnetic resonance imaging (MRI) activity, defined as the evidence of a new T2 lesion or a new Gadolinium enhancing lesion in the MRI at the different timepoints) between the year before and after Natalizumab discontinuation.

Methods: Multicenter prospective observational study, involving 7 centers, 86 patients enrolled (56 female; average age 40) with relapsing-remitting multiple sclerosis (RRMS) with clinical and radiological stability, treated with 24 Natalizumab administrations. The study provides 6 visits at month (M) 0, 1, 3, 6, 9, 12 and 3 brain MRI at M0, M6, M12. The enrolled patients reached the following timepoints: 73 patients M3, 61 patients M6, 39 patients M9 patients and 27 patients M12. We calculated the percentage of relapses and disease activity on MRI stratified by therapy.

Results: During the year before Natalizumab discontinuation the percentage of patients with relapses was about 15.2 %; the percentage of patients with relapses during the year after Natalizumab discontinuation was 35.6%; the percentage of patients who experienced relapses was 3.7% among patients continuing Natalizumab, 17.8% among those who started other immunomodulatory or immunosuppressive therapy and 16.7% among patients without therapy. During the year before Natalizumab therapy discontinuation the percentage of patients with MRI activity was 5.3 %; the percentage of patients with MRI activity during the year after Natalizumab discontinuation was 34.8%; the percentage of patients who experienced relapses was 3.7% among patients continuing Natalizumab, 20.5% among those who started other immunomodulatory or immunosuppressive therapy and 21.4% among patients without therapy.

Conclusion: The discontinuation of Natalizumab therapy leads to an increased relapse rate and disease activity in either group of patients starting another drug immunomodulatory or immunosuppressant and in patients who do not continue any other therapy. Natalizumab should be continued over the 24 administrations according to the evaluation of patient risk to develop PML. Our data show that the percentage of relapses and disease activity on MRI is similar among patients starting other immunosuppressive or immunomodulatory therapy and among those who quit therapy.

The Authors have nothing to disclose.

Long-term observation on management of natalizumab discontinuation

F. Sangalli, L. Moiola, L. Ferrè, M. Radaelli, V. Barcella, V. Martinelli, G. Comi

Ospedale San Raffaele (Milan, IT)

Background: By now it is recognized that considering natalizumab discontinuation requires a careful stratification of risk of progressive multifocal leukoencephalopathy weighted with the risk of disease reactivation. However long-term management of patients after natalizumab discontinuation is still uncertain, specially regarding risk factors for reactivation and effect of preventive therapy.

Objective: To monitor disease activity after natalizumab discontinuation and to identify both risk and protective factors for reactivation. METODHS: We followed 84 patients who stopped natalizumab after at least 12 cycles and started a first-line treatment. They underwent periodic clinical evaluations and brain MRI scan around 3th, 6th and 12th month after interruption.

Results: We followed patients for a mean time of 18 months. Considering MRI and clinical activity combined or alone, we determined a proportion of “disease free patients” of 75%, 44% and 24% at months 4, 7 and 12, respectively. The annualized relapse rate (ARR) in the first year after natalizumab interruption was 0.8 and time to relapse was 6.5 ± 2.2 months. In most cases, patients presented a return to their pre-natalizumab disease activity, whereas the so-called rebound activity were observed in 6 patients. Due to disease reactivation, 48% of patients shifted from immunomodulants to second-line therapies; interestingly, half of them returned to natalizumab. We found a statistically significant correlation between higher ARR and mean enhancing lesions in the year before natalizumab and an elevated probability of reactivation after discontinuation.

Conclusion: Our data suggest that disease stability, reached on natalizumab therapy, doesn’t maintain after its discontinuation. Critical analysis of these data could identify parameters related to the risk of disease reactivation, thus helping the evaluation of risk/benefit ratio of stopping natalizumab. Moreover patients should be closely monitored to early detect signs of disease activity in order to readily change preventive therapy if needed, either going back to natalizumab, despite PML risk, or trying new treatments.

Dr. F. Sangalli, Dr. L. Moiola, Dr. L. Ferrè, Dr. M.Radaelli and Dr. V. Barcella have nothing to disclose.

Dr. V. Martinelli received honoraria for speaking, consultancy or support for participation to National and International Congresses from Bayer-Schering, Biogen-Dompè, Merck-Serono, Novartis, Sanofi-Aventis and TEVA Pharmaceutical.

Prof. G. Comi has received in the past year consulting fees for participating on advisory boards from Novartis, Teva Pharmaceutical Ind. Ltd, Sanofi-Aventis, Merck Serono, Bayer Schering and Actelion and lecture fees from Novartis, Teva Pharmaceutical Ind. Ltd, Sanofi-Aventis, Merck Serono, Bayer Schering, Biogen Dompè, Serono Symposia International Foundation.

Efficacy of DMD in reducing the accumulation of cortical damage. A 4-year longitudinal study

M. Calabrese, F. Rinaldi, V. Poretto, S. Alessio, S. Miante, A. Favaretto, M. Puthenparampil, L. Federle, P. Perini, P. Gallo

The Multiple Sclerosis Center of Veneto Region (Padua, IT)

Background: Several studies have suggested a relevant role for grey matter pathology in determining physical and cognitive disability in Multiple Sclerosis (MS). However, only a few studies addressing the influence of first-line disease modifying drugs (DMD) on grey matter damage are available. We carry out a four-year extension of a previous two-year longitudinal study on the effects of DMD on the accumulation of cortical lesions (CL) and the progression of cortical atrophy in patients with relapsing–remitting MS (RRMS).

Methods: 141 RRMS patients were randomized to receive subcutaneous (s.c.) interferon (IFN) β-1a, 44 mcg three times weekly, intramuscular (i.m.) IFNβ-1a, 30 mcg weekly, or glatiramer acetate, 20 mg daily. Fifty untreated patients constituted the reference population. Each patient underwent clinical (EDSS) and MRI evaluation at study entry and every year for at least four years. White matter and grey matter lesions (including contrast-enhancing lesions) and grey matter atrophy were evaluated at each time point.

Results: All patients completed the 4-year follow-up. After the first 2 years of the study, 25 treated patients, equally distributed among the three arms of treatment, shifted from a DMD to another, and 43 previously untreated patients initiated a DMD therapy. Patients that continued the original therapy displayed lower accumulation of new CL compared to untreated patients (p<0.001). Patients treated with s.c. IFNβ 1a accumulated less cortical lesions (mean 1.5±1.0, range 0-5) compared to i.m IFNβ 1a (2.3+±1.3, range 0-6, p=0.02) and glatiramer acetate (2.2±1.5, range 0-7, p=0.03). The 43 patients that started DMD during the study showed a reduced CL accumulation in the period following therapy initiation (untreated period: mean = 3.0± 2.0, range 0-8; treatment period: mean 1.2±0.8, range 0-3; p<0.001).

Conclusions: This 4-year longitudinal extension further confirms and reinforces the observation of previous 2-year study on the efficacy of the DMD in reducing the accumulation of CL in RRMS. Significant advantage of the high frequency/high dose IFNβ therapy, already observed after two years of therapy, was further confirmed after four years. The efficacy of immunomodulatory therapies in preventing CL accumulation is in line with recent neuropathological observation indicating the inflammatory origin of CL, and further suggests the opportunity of an early immunomodulatory treatment in RRMS.

Massimiliano Calabrese received honoraria for speaking from Sanofi Aventis, Merck-Serono, Biogen Idec and funds for travel from Sanofi Aventis, Merck-Serono.

Francesca Rinaldi has received speaker honoraria from Biogen Idec, and funding for travel from Biogen Idec, Merck Serono, Sanofi-Aventis, and Bayer Schering Pharma.

Paola Perini received honoraria for speaking from Biogen Idec and funds for travel from Merck-Serono.

Paolo Gallo serves on the Scientific Advisory Boards for Biogen Idec, Merck-Serono, Bayer- Shering, Genzyme, Sanofi-Aventis, and Novartis Farma; has received honoraria for speaking and funds for travel from Biogen-Idec Italy, Merck-Serono, Bayer-Shering, Genzyme, Sanofi-Aventis, and Novartis Farma; and has received research support from Biogen Idec-Italy, Merck-Serono, Bayer-Shering, Sanofi-Aventis, Novartis Farma, Italian Ministry of Public Health, 2009-2010 – Prog. 3: “Biomarkers and Diagnosis” ISS.17, the University of Padova, Interarea Pr. CPDA 099394, 2009-2010.

The other authors have nothing to disclose.

Phase III FREEDOMS study extension: fingolimod (FTY720) efficacy in patients with relapsing–remitting multiple sclerosis receiving continuous or placebo-fingolimod switched therapy for up to 4 years

L. Kappos, E.W. Radue, P. O’Connor, C.H. Polman, R. Hohlfeld, K. Selmaj, C. Agoropoulou, F. Holdbrook, P. von Rosenstiel, L. Zhang-Auberson

University Hospital Basel (Basel, CH); St. Michael’s Hospital (Toronto, CA); VU University Medical Center (Amsterdam, NL); Ludwig-Maximilians University (Munich, DE); Medical University of Lodz (Lodz, PL); Novartis Pharma AG (Basel, CH)

Background: In the 2-year FREEDOMS study, once-daily fingolimod (0.5mg or 1.25mg) showed significant improvements in clinical and magnetic resonance imaging (MRI) endpoints vs placebo (PBO) in patients with relapsing–remitting multiple sclerosis.

Objectives: We report FREEDOMS extension study efficacy outcomes in patients receiving continuous fingolimod or PBO–fingolimod switched therapy for up to 4 years.

Methods: In the extension, patients continued on the fingolimod dose assigned in the core phase (continuous fingolimod) or were re-randomized 1:1 from placebo to fingolimod (0.5mg or 1.25mg).

Results: 1033/1272 patients completed the core study; 920 (72%) entered the extension phase, of which 773/920 (84%) completed. Annualized relapse rates decreased in the PBO–fingolimod groups during the extension vs core phase and remained low in the extension in both continuous-fingolimod groups. Mean percentage brain volume change (PBVC) over months 0–end of study was lower for continuous-fingolimod (1.25mg, −1.64; 0.5mg, −1.67) than PBO–fingolimod (−2.24; p<0.001 for both); similar results were found over months 0–36 and 0–48. The effect of fingolimod on PBVC was also assessed within the extension and core phases: in switch groups, mean PBVC was reduced during months 24–48 (PBO-1.25mg, −1.1; PBO-0.5mg, −0.9) vs months 0–24 (PBO-1.25mg, −1.5, p=0.062; PBO-0.5mg, −1.4, p=0.008). This effect also occurred within the first year of switch (months 24–36: PBO-0.5mg, −0.49; PBO-1.25mg, −0.39) vs first year of PBO (months 0–12: PBO-0.5mg, −0.62, p=0.2; PBO-1.25mg, −0.63, p=0.023); for continuous fingolimod groups, there were no PBVC differences between extension and core, indicating that treatment effects on brain volume loss persist. In the PBO-1.25mg and 0.5mg groups, mean number of new/newly enlarging T2 lesions decreased from 8.1 and 12.8 in months 0–24, respectively, to 2.3 and 1.4 in months 24–48 (p<0.001, both); for continuous fingolimod groups, they remained low (1.25mg, 2.1 vs 1.7; 0.5mg, 2.7 vs 2.6) over the same periods.

Conclusions: PBO–fingolimod patients showed improvements in clinical and MRI outcomes after switching to fingolimod; patients receiving continuous fingolimod for up to 4 years had better overall outcomes than switch patients. In switch patients, brain volume loss reductions with fingolimod were found as early as the first year of treatment. In continuously-treated patients, brain volume loss reductions with fingolimod persisted for up to 4 years.

This study was funded by Novartis Pharma AG.

L. Kappos received research support from Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CLC Behring, Elan, Genmab, Genmark, GeNeuro SA, GlaxoSmithKline, Lilly, Merck Sereno, Medicinova, Novartis, Novo Nordisk, Peptimmune, Sanofi-Aventis, Santhera, Roche, Teva, UCB and Wyeth.

E W Radue has received research support (mainly for MS projects) and lecture fees from: Actelion, Basilea, Bayer Schering, Biogen Idec, Merck Serono, Novartis and others. Lecture fees have have been mainly used for research funding at the Medical Image Analysis Center (former MS MRI Evaluation Center), University Hospital Basel.

Paul O’Connor has received Consulting fees and/or research support (Actelion, Bayer, Biogen Idec, BioMS, Cognosci, Daiichi Sankyo, EMD Serono, Genentech, Genmab, Novartis, Roche, sanofi-aventis, Teva, Warburg Pincus).

C H Polman has received compensation for activities with from Actelion, Biogen Idec, Bayer Schering, Glaxo Smith Kline, Merck Serono, MorphoSys AG, Novartis, TEVA, UCB, and Roche as a consultant/ speaker. Dr Polman has received research support from Biogen Idec, Bayer Schering, Glaxo Smith Kline, Merck Serono, Novartis, TEVA, UCB and Roche.

Reinhard Hohlfeld received grant suppport and consultancy fees from Bayer, Novartis, Teva, Sanofi Aventis, Biogen Idec, Teva, and Merck Serono.

K. Selmaj received honoraria for consultation or invited talks from Novartis, Roche, Biogen Idec, Merck Serono, ONO Pharmaceuticals, Genzyme.

C Agoropoulou, F Holdbrook, L Zhang-Auberson and P von Rosenstiel are employees of Novartis Pharma AG.

Observational program Tysabri 24 plus: evaluating efficacy and safety of natalizumab therapy beyond two years

M. Mäurer, H. Wiendl, C. Heesen, A. Gass, C. Wernsdörfer, V. Zingler, B.C. Kieseier

Caritas Hospital (Bad Mergentheim, DE); University Hospital Münster (Münster, DE); University Hospital Hamburg (Hamburg, DE); University Hospital Mannheim (Mannheim, DE); Biogen Idec (Ismaning, DE); University Hospital Düsseldorf (Düsseldorf, DE)

Background: In the phase III trial AFFIRM and post-marketing observational studies, natalizumab (NAT) revealed high efficacy on clinical and MRI measures with good overall tolerability in patients (pts) with relapsing-remitting MS. Pts receiving NAT may develop progressive multifocal leukoencephalopathy (PML) if previously exposed to JC virus. Additional PML risk factors include pretreatment with immunosuppressants (IS) and NAT therapy >2 years (yrs). Thus, the risk/benefit profile particularly beyond 2 years needs to be better understood.

Methods:This observational multicenter study performed in the clinical setting in Germany prospectively documents clinical status including cognitive functions (Demtect score), MRI findings and pt management in five 3-monthly visits during 1 yr of follow up in MS pts previously treated with NAT for ≥2 yrs. The study started in July 2010 and reached the recruitment goal (1000 pts) in October 2011.

Results: In the present interim analysis (Feb 20, 2012) 948/1014 pts had complete baseline (BL) documentations. Characteristics at BL [mean±SD]: 66.8% female; age 40.4 yrs ± 9.5; MS duration 10.6 yrs ± 5.8; number of NAT infusions before BL 35.7 ± 10.5; annualized relapse rate in the yr before NAT 2.2 ± 1.5, and 0.4 ± 0.7 on NAT in the 24 months (mos) before BL; EDSS before start of NAT 3.5 ± 1.6 and 3.4 ± 1.8 at BL; Demtect score at BL 14.9 ± 3.5; previous therapy with ≥ 1 immunomodulator 92.4%, with ≥ 1 IS 18.9%. The current mean follow up duration is 9.0 mos ± 3.2. MRI was performed in 25% of pts on average in each of the 3-month visit intervals. 393 pts were documented in the last follow-up visit at 12 mos after BL. Their mean annualized relapse rate since BL was 0.14, mean EDSS 3.5 ± 1.7 and mean Demtect score 16.0 ± 2.6. 8.0% of pts discontinued NAT therapy, while 3.4% interrupted it (most common reasons: patient preference, positive JCV serostatus). Serious adverse events were documented in 11 pts. One confirmed PML and 1 suspected PML were reported.

Conclusions: The pts recruited in Tysabri 24 plus had longer mean MS duration and higher mean EDSS than the AFFIRM pts. This interim analysis revealed sustained effective reduction of MS activity by long-term NAT therapy, with a generally consistent known safety profile. A detailed interim analysis after 2 yrs of study (Aug. 2012) will contribute additional long-term data for the optimization of pt selection, monitoring and NAT risk stratification.

Mäurer M: The study Tysabri 24 plus was funded by Biogen Idec.

Wiendl H: The study Tysabri 24 plus was funded by Biogen Idec.

Heesen C: The study Tysabri 24 plus was funded by Biogen Idec.

Gass A: The study Tysabri 24 plus was funded by Biogen Idec.

Wernsdörfer C: employee of Biogen Idec.

Zingler V: employee of Biogen Idec.

Kieseier BC: The study Tysabri 24 plus was funded by Biogen Idec.

A comparison of extreme profiles of disability change in b-interferon treated multiple sclerosis patients: findings from British Columbia, Canada

A. Shirani, Y. Zhao, J. Oger, BC MS Clinic Neurologists, H. Tremlett

University of British Columbia (Vancouver, CA)

Background: Patients with relapsing-onset multiple sclerosis (MS) can vary considerably in terms of changes in disability status over time. Comparing the characteristics of treated patients with extreme profiles of disability change might provide insights into MS as well as tailoring therapeutic interventions.

Objectives: We aimed to characterize and compare the profiles of β-interferon (β -IFN) treated relapsing-onset MS patients at the extremes - from rapid progression to actual improvement in disability.

Methods: In this retrospective cohort study, the British Columbia MS Database was queried for patients with definite relapsing-onset MS who had been exposed to a β -IFN for at least six consecutive months (based on linked data from the British Columbia Ministry of Health’s comprehensive prescription database, PharmaNet) with an Expanded Disability Status Scale (EDSS) between 1.0 and 5.0 at β -IFN initiation (baseline) and with at least three years of active follow-up time from baseline. The approximate lower and upper 10% extremes of the cohort defined by changes in EDSS over three years were compared in terms of sex, baseline age, disease duration, EDSS, and annualized relapse rate (ARR) in the two years prior to baseline.

Results: The approximate 10% lower and upper extremes of the cohort comprised patients with ≥1 point decrease in EDSS (n=64) and ≥3 points increase in EDSS (n=53) over three years, respectively. These lower and upper extreme groups differed little in terms of sex (female: 69% vs. 72%, p=0.73, chi-square test), disease duration at baseline (7.1±6.6 vs. 9.1±7.2 years, p=0.12, t-test), or ARR (1.1±0.9 vs. 0.8±1.1, p=0.07, t-test), respectively. Patients in the lower compared to the upper extreme were slightly younger at baseline (37.6±9.1 vs. 42.7±8.0 years, p=0.002, t-test). Median EDSS at baseline was 3 (range: 1-5) and 2.5 (range: 1-4) in the lower vs. upper extreme, respectively (p=0.052, Mann-Whitney test).

Conclusions: We did not find substantial differences in terms of the baseline characteristics between two groups of β-IFN treated relapsing-onset MS patients with extreme profiles of disability change (over three years). While further research is needed to verify our findings in a larger cohort of treated patients with longer follow-up time, our findings encourage pharmacogenomic and biomarkers research to investigate predictors of the profile of disability change in β-IFN treated MS patients.

A.S. is funded through a Postdoctoral Fellowship from the Multiple Sclerosis Society of Canada, and grants from the Canadian Institutes of Health Research (MOP-93646; PI=H.T.) and the National Multiple Sclerosis Society (RG 4202-A-2; PI=H.T.). She has received travel grants to present at and attend conferences from the endMS Research and Training Network (2010, 2011), ECTRIMS (2010, 2011), and the Consortium of MS Centres (2012). Y.Z. receives research funding from the Canadian Institutes of Health Research, the Multiple Sclerosis Society of Canada and the National Multiple Sclerosis Society. J.O. receives support from the Christopher Foundation and the University of British Columbia. He receives fees for service from the Medical Services Commission of British Columbia. Over the past five years, J.O. has received speaker honoraria, consulting fees, travel grants and/or research grants and/or educational grants from Bayer, Biogen-Idec, Genentech, Novartis, Serono, Shering, Talecris and Teva-neurosciences. He also receives fees for services from Bayer, from Novartis and from Biogen Idec to serve on advisory committees. H.T. is funded by the Multiple Sclerosis Society of Canada (Don Paty Career Development Award), Michael Smith Foundation for Health Research and is the Canada Research Chair for Neuroepidemiology and Multiple Sclerosis. She has received: research support from the US National Multiple Sclerosis Society, Canadian Institutes of Health Research, and UK MS Trust; speaker honoraria and/or travel expenses to attend conferences from the Consortium of MS Centres, US National MS Society, the University of British Columbia Multiple Sclerosis Research Program, Bayer Pharmaceutical (speaker, 2010, honoraria declined), Teva Pharmaceuticals (speaker 2011), ECTRIMS (2011), UK MS Trust (2011) and the Chesapeake Health Education Program, US Veterans Affairs (2012, honorarium declined). Unless otherwise stated, all speaker honoraria are either donated to an MS charity or to an unrestricted grant for use by her research group.

Multiple sclerosis and natalizumab: “between the dose symptoms”

M. Gudesblatt, M. Zarif, B. Bumstead, S. Thotam, L. Fafard, G. Thippeswamy, J. Cruz, L. Cruz, S. Fahie, J. Bohuslaw, M. Buhse

South Shore Neurologic Associates (Patchogue, US); School of Nursing State University at Stony Brook (Stony Brook, US)

Background: Natalizumab is an effective treatment for Multiple Sclerosis. Some MS patients treated with Natalizumab report a transient increase in symptoms such as fatigue, loss of concentration, weakness, and confusion that appear to occur between infusions, approximately 1 week prior to their next infusion, and resolve shortly after their next infusion. The nature and incidence of the “between dose symptoms” have not been described.

Goals: To describe patient characteristics and types of symptoms related to the “between dose symptoms” associated with Natalizumab therapy.

Methods: A retrospective chart review was done on Natalizumab treated patients at a single MS Care Center. Patients who reported “between dose symptoms” were seen and the symptoms were reviewed and noted. At each subsequent Natalizumab infusion, patients were asked whether these symptoms were persistent. Data was retrospectively reviewed of all patients treated one month with Natalizumab and the presence and absence of symptoms were noted. The symptoms were reviewed and categorized into 4 core symptoms: increased fatigue, loss of concentration, weakness, and confusion. Demographic information including gender, body surface area (BSA), body mass index (BMI), and age were collected.

Results: Data were collected on 197 patients, 140 females (71%). 62% reported symptoms, 38% reported no symptoms, while 42% of males and 73% females complained of at least 1 symptom. Women report significantly more fatigue (p=.01) and loss of concentration (p=.05) than men. There was no difference in prevalence of symptoms by age, BMI, BSA, or duration of Natalizumab treatment. There was no difference in the number of symptoms for 6-12 months intervals of duration of Natalizumab treatment.

Conclusions: Numerous patients experience “between dose” symptoms that characteristically affect them the 3rd week after their previous infusion and resolve after their next infusion. These symptoms appear and persist ongoing for the duration of treatment with Natalizumab. Women experience more fatigue and loss of concentration than men. Health care providers should be aware of these symptoms and monitor patients and treat as necessary. Further research is needed to determine the factors that contribute to the “between dose symptoms” and the significance of these reported symptoms.

A. Mark Gudesblatt, MD - Consulting fees Biogen Idec.

B. Myassar Zarif, MD - Consulting fees Biogen Idec.

C. Barbara Bumstead, ANP - Consulting fees Biogen Idec.

D. Smitha Thotam, ANP - no disclosures.

E. Lori Fafard, RN - no disclosures.

F. Ganesh Thippeswamy, BA - no disclosures.

G. John Cruz - no disclosures.

H. Lourdes Cruz, RN - no disclosures.

I. Serina Fahie, RN - no disclosures.

J. Joan Bohuslaw, RN - no disclosures.

K. Marijean Buhse, ANP, PhD - Consulting fee Biogen Idec.

Long-term safety of fingolimod in relapsing multiple sclerosis: update to integrated analyses of phase 2 and 3 studies and extension phases

J.A. Cohen, P. O’Connor, T. Caliolio, P. von Rosenstiel, L. Zhang-Auberson, A. Keil, W. Collins, N. Sfikas, L. Kappos

Cleveland Clinic Foundation (Cleveland, US); St. Michael’s Hospital (Toronto, CA); Novartis Pharmaceuticals Corporation (East Hanover, US); Novartis Pharma AG (Basel, CH); University Hospital Basel (Basel, CH)

Background: Previous clinical trial data show that fingolimod 0.5mg once-daily, approved for relapsing–remitting multiple sclerosis with high disease activity in the EU, has a manageable safety profile; label requirements for treatment initiation monitoring were recently updated.

Objectives: To report updated integrated long-term safety results from fingolimod phase 2 and 3 studies and extensions.

Methods: Safety data for fingolimod 0.5mg and 1.25mg from phase 3 studies (FREEDOMS and FREEDOMS II, both 24 months vs placebo [PBO], and TRANSFORMS, 12 months vs interferon β [IFNb]-1a) and extensions, and from the phase 2, 6-month study and extension, were combined into 2 datasets: population 1 (core study data: fingolimod 0.5mg, n=1212; fingolimod 1.25mg, n=1313; PBO, n=866; IFNb-1a, n=431) and population 2 (core and extension data: fingolimod 0.5mg, n=1640; fingolimod 1.25–0.5mg, n=1776; fingolimod 5.0–1.25–0.5mg, n=137).

Results: In population 1, study drug discontinuation was similar between PBO (28.3%) and fingolimod 1.25mg (26.1%) and lower with 0.5mg (19.8%); discontinuations were more often related to adverse events (AEs) in fingolimod groups (5.4–8.3%) and unsatisfactory therapeutic effect with PBO (8.0%). In population 2, total fingolimod exposure for all patients (n=3553) was 9070 patient-years, with 1510 patients treated for ≥3 years. In population 1, reported AEs were similar across groups (0.5mg, 92.6%; 1.25mg, 93.1%; PBO, 93.2%; IFNb-1a, 91.9%) and serious AEs (up to 31 October 2011) were similar among fingolimod (0.5mg, 10.5%; 1.25mg, 11.6%) and PBO (12.2%); rates of infection AEs (51.0–67.9%) and infection serious AEs (1.4–2.0%) were also similar across groups. In population 1, AEs of interest reported more with fingolimod included: hypertension (0.5mg, 10.6%; 1.25mg, 12.6%; PBO, 4.6%; IFNb-1a, 5.2%), 3-fold liver transaminase elevations (0.5mg, 8.3%; 1.25mg, 9.0%; PBO, 2.8%; IFNb-1a, 1.9%), bradycardia (0.5mg, 1.0%; 1.25mg, 2.3%; PBO, 0.6%; IFNb-1a, 0.5%), macular oedema (0.5mg, 0.5%; 1.25mg, 1.1%; PBO, 0.3%; IFNb-1a, 0.2%) and 2nd-degree atrioventricular block (0.5mg, 0.1%; 1.25mg, 0.5%; PBO, 0.2%; IFNb-1a, 0%); few patients across treatment groups had malignant neoplasms.

Conclusions: Safety data from >3500 patients are consistent with the established profile of fingolimod, with no evidence in this combined clinical trial population of increased risk of infections, malignancies or serious cardiovascular events with fingolimod vs PBO or IFNb-1a.

This study was funded by Novartis Pharma AG, Basel, Switzerland.

Dr. Cohen reports receiving personal compensation for serving as a consultant or speaker from Teva and Vaccinex, and research support paid to his institution from Biogen Idec, Department of Defense, Genzyme, National Institutes of Health, National MS Society, Novartis, Synthon, and Teva.

L. Kappos received research support from Actelion, Advancell, Allozyne, BaroFold, Bayer Health Care Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CLC Behring, Elan, Genmab, Genmark, GeNeuro SA, GlaxoSmithKline, Lilly, Merck Sereno, Medicinova, Novartis, Novo Nordisk, Peptimmune, Sanofi-Aventis, Santhera, Roche, Teva, UCB and Wyeth.

Paul O’Connor has received Consulting fees and/or research support (Actelion, Bayer, Biogen Idec, BioMS, Cognosci, Daiichi Sankyo, EMD Serono, Genentech, Genmab, Novartis, Roche, sanofi-aventis, Teva, Warburg Pincus).

P von Rosenstiel, L Zhang-Auberson, A Keil, W Collins and N Sfikas are employees of Novartis Pharma AG.

T Caliolio is an employee of Novartis Pharmaceutical Corporation.

Five years impact of subcutaneous interferon-β-1a on cognitive impairment in mildly disabled patients with relapsing-remitting multiple sclerosis: the COGIMUS study group

F. Patti, V. Brescia Morra, M. Amato, S. Bastianello, M. Tola, S. Cottone, R. Lanzillo, M. Trojano, D. Centonze, L.M.E. Grimaldi, C. Gasperini on behalf of the Cogimus study Group

Background: The COGIMUS study was designed to evaluate the progression of cognitive decline in patients with early RRMS receiving treatment with scIFNb-1a, either 22 or 44 mcg tiw. 3 years data reported that scIFNb-1a may have dose-dependent cognitive benefits, and may support early initiation of high-dose scIFNb-1a.

Objectives: We report clinical and cognitive findings from the 5-year extension of the original study.

Methods: Patients aged 18-50 years with RRMS(EDSS score ≤4.0) were assigned to scIFN β-1a therapy at the physician’s discretion and underwent neurological examination, NPS testing, MRI at the baseline and regular intervals for up to five years. Results: Out of 265 eligible patients, data from 201 patients (Rebif 44 tiw n= 108; Rebif 22 tiw n= 93) were available for the 5 years follow-up (75.6%). Mean follow-up period was 5.6 years (4.5-6.1). Mean age and disease duration were 39 (±8,2), and 8 (±4,4) years respectively. No differences in terms of clinical-demographic, NPS scores as well as 22/44 ratio were found between patients who did or did not participate to 5 year follow-up, except for EDSS which was greater in patients who had 5 year follow-up (1.63 vs.1.29). The male/female ratio was 0.6. At year 5, the proportion of patients who were cognitively impaired (i.e at least 3 cognitive tests) slightly increased in both treatment group (20.5 at baseline to 21.7% in the scINFß-1a 22 mcg group and 15.6 to 16.7 in the scINFß-1a 44 one). The overall proportion of cognitively impaired patients remained stable between 3 and 5 year follow-up in the scINFß-1a 22 mcg group (21.8% vs 21.8%), while decreased in the sc INFß-1a 44 mcg treatment group (18.1% vs 16.0%). The Hazard Ratio for cognitive impairment over 5 years (44 mcg versus 22 mcg) was 0.68 (95% CI: 0.480-0.972, p = 0.023). We also found a significant higher percentage of men with cognitive impairment (26.5% versus 14.4%, p=0.045). The overall proportion of patient’s progression free at year 3 was 84% while at year 5 71%. The most common adverse events (Aes) reported over the 5-year follow up were consistent with known safety profile of IFN β 1a.

Conclusion: This study showed that early treatment with scINFß-1a is able in a dose dependent manner to stabilize/delay period both cognitive impairment and disease progression in most (3/4) of mildly disabled RRMS enrolled into the study over a 5 year period. Female gender seems to be more protected from developing cognitive impairment.

FP: F Patti has received honoraria for consultancy or speaking from Biogen, sanofi-aventis, Merck Serono, Bayer Schering and Novartis.

VB: Vincenzo Brescia Mora: has received honoraria for consultancy or speaking from Biogen, sanofi-aventis, Merck Serono, Bayer Schering and Novartis.

MPA: MP Amato has received honoraria for consultancy or speaking from Biogen, sanofi-aventis, Merck Serono, Bayer Schering and Novartis.

MT: M Trojano received honoraria for consultancy or speaking from Biogen, sanofi-aventis, Merck Serono, Bayer Schering and Novartis, and research grants from Merck Serono and Biogen.

SC:S Cottone has received personal compensation from CIC International for serving as a member of an editorial advisory board; and financial support for research activities from Biogen-Dompè.

DC: D Centonze has declared having served on scientific advisory boards for Teva Pharmaceutical Industries and Novartis; having received speaker honoraria and funding for travel from sanofi-aventis, Merck Serono, Serono Symposia International Foundation, Bayer Schering, and Biogen-Dompè; and having received research support from sanofi-aventis, Bayer Schering, Merck Serono, Novartis, and Teva Pharmaceutical Industries;

CG: C Gasperini has served as a consultant for Merck Serono and Biogen Idec; and has received speaker honoraria from Teva Pharmaceutical Industries, Merck Serono, Bayer Schering and Biogen Idec.

RL: R Lanzillo has received honoraria for consultancy or speaking from Biogen, sanofi-aventis, Merck Serono, Bayer Schering and Novartis;

LG: L Grimaldi has received honoraria for consultancy or speaking from Biogen, sanofi-aventis, Merck Serono, Bayer Schering and Novartis;

SB: S Bastianello have no conflicts of interest to declare

MRT: MR Tola have no conflicts of interest to declare.

Long-term glatiramer acetate therapy in every-day practice: comparison of MS course in continued 10 years therapy and in cases with treatment stop

A. Boyko on behalf of neurologists at the Moscow MS Center

Background: Β-interferons (BI) and Glatiramer acetate (GA) are used as the first line therapy for relapsing remitting MS (RRMS). We present results of 10-year open-label non-randomised observational study of GA therapy in RRMS patients of Moscow MS Center.

Methods: 205 active RRMS patients started GA therapy (20 mg/day SC) in 2000. All were observed at 3 month intervals and/or in cases of relapses with detailed clinical examination (relapses, EDSS, adverse events, etc.). At baseline they had active RRMS with 2 or more relapses in previous 2 years and EDSS score between 1.5 and 5.0. A total of 82 patients (40%) received GA monotherapy over 10 years at the time of the final analysis in 2011. 8 of 82 had to interrupt GA therapy due to pregnancy and other reasons and were excluded from the final analysis. Therefore, final cohort of ongoing Group A comprised of 74 patients (74.3% female). 123 patients stopped GA therapy, 13 for which the data were incomplete, so final cohort of Group B included 110 “withdrawn” patients (68.2% female).

Results: At baseline, there were no significant differences between Groups A & B. In ongoing GA therapy Group A, mean annualised relapse rate (ARR) had declined from 2.15 (0,06) at baseline to 0.14 (0.02) per year over the 10-year period and remained stable throughout follow-up. The lowest rate was 0.07 (0.11) in first 3 years. 64.8% of patients had less or equal to one relapse over these 10 years. The EDSS score was stable and significant progression of disability was demonstrated only at the 10th year of the observation, 2.5 (0.2). A total of 35 (47.3%) patients from Group A were disease progression-free. In contrast, the EDSS score in GA-withdrawn patients from Group B at 10 years was twice as high at 5.2 (0.4), and no patient was free of EDSS progression. The main reasons for therapy stop in Group B were: 1) high frequency of relapses in 16 patients (8.7% of whole group), 2) EDSS progression with following change of MS course to SPMS, 3) adverse events of GA, and 4) patient decision in 16 cases (8.7%). 78 of these patients (42.4% of the total) were switched to BI, 11 patients to mitoxantrone (5.4%) and 21 remained free of DMT (10.3%).

Conclusion: There is a clear subgroup of RRMS patients who demonstrated GA’s long-term benefits in terms of clinical efficacy (low ARR and stable EDSS) and tolerability. In contrast, at the 10-year long term follow-up time point, withdrawn patients had greater disability and relapse rate.

Prof Alexey Boyko is a member of advisory boards, speaker and participant of clinical trials from Novartis, Merck Serono, Teva, Genzyme, Biogen Idec and Nicomed.

How does risk tolerance to MS therapies change with time: survey results from the NARCOMS registry

R. Fox, J. Alster, N. Dawson, M. Kattan, D. Miller, S. Ramesh, A. Salter, T. Tyry, B. Wells, G. Cutter

Cleveland Clinic (Cleveland, US); Metro Health Systems (Cleveland, US); University of Alabama at Birmingham (Birmingham, US); Barrows Neurological Institute (Phoenix, US)

Background: Newer Multiple Sclerosis (MS) therapies are associated with risks and patients’ acceptance of such risks is variable. Little is known about risk tolerance (RT) changes over time.

Objectives: To determine how MS patients’ tolerance to risky therapies changes with time.

Methods: All MS patients in the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry’s online cohort were invited to complete two annual [years (Y) 1 and 2] questionnaires on risk tolerance to newer therapies and decision-making. Two standard gamble paradigms were used to evaluate RT: 1) curing MS [CureMS], with permanent reversal of all MS symptoms but a risk of immediate painless death; and 2) natalizumab [NAT], with benefits defined from Phase III trial results but a risk of progressive multifocal leukoencephalopathy. Participant demographics, disease and behavior characteristics were also collected. For our analysis we have designated respondents with ≤1:1000 RT values as being intolerant and >1:1000 as tolerant.

Results: 3825 invitees completed both surveys with a mean age (SD) of 53.3 (9.6) years, disease duration 14.3 (8.5) years, 73.8% on MS therapy, and 77% female. Median RT decreased from 1:10,000 for both scenarios at Y1 to 1:1,000,000 for CureMS and 1:100,000 for NAT at Y2. About 21% of respondents reported changes in their RT for both scenarios. 303 (8.3%) respondents for CureMS and 319 (8.8%) for NAT shifted RT to become tolerant to treatment by Y2. These respondents also reported a greater increase in their disability in Y2. A total of 403 (10.5%) respondents reported taking natalizumab in either Y1 or Y2: 251 (62.3%) took natalizumab in both years, 70 (17.4%) stopped natalizumab by Y1 and 82 (20.3%) started natalizumab in Y2. Of the 251 respondents taking natalizumab, 208 (82.9%) were NAT tolerant in both years and 6 (2.4%) were NAT intolerant in both years. Despite their intolerance for NAT in Y1, 13/251 (5.2%) respondents were taking natalizumab in Y1, and became tolerant by Y2. Conversely, 15/251 (6.0%) natalizumab taking respondents were NAT tolerant in Y1, but reported intolerance in Y2.

Conclusions: Over one-fifth of respondents reported RT changes with time. Our results indicate that patient acceptance of risky therapies is dynamic and healthcare providers need to regularly discuss use of newer therapies with their patients.

Dr. Fox received personal compensation for consulting and/or speaking from Avanir, Biogen Idec, Novartis and Questcor; and research support from Novartis. Ms. Alster has nothing to disclose. Dr. Dawson has nothing to disclose. Dr. Kattan has nothing to disclose. Dr. Miller has nothing to disclose. Dr. Ramesh has nothing to disclose. Ms. Salter has nothing to disclose. Dr. Tyry has nothing to disclose. Dr. Wells has nothing to disclose. Dr. Cutter received consulting and speaking fees from Alexion, Abbott, Allozyne, Bayer, Coronado Biosciences, Novartis, Consortium of MS Centers (grant), Genzyme, Klein-Buendel Incorporated, Nuron Biotech, Diogenix, Celgene, Receptos.

Somnus Pharmaceuticals, Teva pharmaceuticals and St. Louis University; and participates on the Data and Safety Monitoring Committees for Apotek, Sanofi-Aventis, Biogen, Cleveland Clinic, Daichi-Sankyo, Glaxo Smith Klein Pharmaceuticals, Genmab Biopharmaceuticals, EliLilly, Medivation, Modigenetech, Ono Pharmaceuticals, Prolor, Teva, NHLBI, NINDS, NMSS. Drs. Dawson, kattan, Miller, Ramesh, Tyry, Wells and

Body mass and natalizumab concentration as potential risk stratification markers for drug-related PML

J. Foley, A. Christensen, T. Hoyt

Rocky Mountain Multiple Sclerosis Clinic (Salt Lake City, US)

Background: Progressive multifocal leukoencephalopathy (PML) remains a significant concern in natalizumab therapy. A relationship between body mass and natalizumab concentration appears to be present with ≤70kg patients manifesting a concentration up to five times greater than the heaviest patients. Some data suggests natalizumab concentration drives pharmacodynamic markers for endothelial adhesion reduction and possibly reduced cell trafficking. No currently published data exists regarding body mass stratification in a natalizumab infusing population.

Methods: A non-trial based cohort of 268 patients was evaluated at a single collection point to define pharmacokinetic and pharmacodynamic characteristics. 226 patients from the first cohort were enrolled in a second evaluation following a mean interval of 14 months. Patients were analyzed for natalizumab concentration and lymphocyte VLA-4 receptor saturation (second trial only). Soluble vascular adhesion molecule (sVCAM) a surrogate marker for VLA-4 mediated cell adhesion and perhaps cell trafficking was assessed. Weights (body mass) were aggregated for all patients receiving natalizumab at a single site (n=307). A normalized “potency” index was derived by dividing natalizumab concentration (ug/ml) by total body mass (kg).

Results: The highest 20% of the potency index population was assessed for body mass and 46/51 (90%) had a body mass of ≤70 kg. 35% (106/307) of an aggregated natalizumab infusing population have a body mass ≤70 kg. The highest 20% of lymphocyte VLA-4 saturations were assessed for body mass (kg), 15/24 (63%) had a body mass ≤70 kg, yielding a relative risk ratio of 1.8 (63%/35%) when compared to the overall infusing population. Additional data regarding the relationship of natalizumab concentration and pharmacodynamic markers will be discussed.

Conclusions: The highest ratios seen using the natalizumab potency index occur almost exclusively in patients with a body mass ≤ 70 kg. Low body mass greatly increases the probability of an elevated serum concentration and natalizumab potency. Most patients with the highest VLA-4 saturations had an elevated natalizumab potency index suggesting that high natalizumab serum concentrations may directly impact pharmacodynamic markers. Further data regarding the effect on sVCAM will be presented as well. Preliminary data assessment for disproportionate relative risk of PML in the patient group with a body mass of ≤ 70 kg using a surrogate single clinic denominator is ongoing.

Received financial support for research from Biogen Idec., Elan Pharmaceuticals.

John Foley receives honoraria from Biogen Idec., Elan Pharmaceutical and Teva.

Tamara Hoyt and Angelene Christensen have nothing to disclose.

Monitoring of expression of two CD49d epitopes as biomarker during natalizumab therapy

R. Johanson, T. Leist

Thomas Jefferson University (Philadelphia, US)

Background: Natalizumab is a non-cytolytic, humanized monoclonal IgG-4 antibody directed against α 4-integrin of VLA-4 (CD49d). The catabolism of natalizumab is variable and it can engage in Fab arm exchange with human IgG-4 possibly increasing the overall level of CD49d binding activity. Among other considerations this as well as the fact that the 3 mg/kg dose was effective in the phase II trial of natalizumab has raised sue whether alternate dosing intervals could provide sufficient CD49d occupancy to maintain clinical efficacy while potentially increasing safety.

Methods: In this crossover study CD49d binding was assessed before retreatment in a cohort of clinically stable individuals with MS who had been treated with monthly infusions of 300 mg of natalizumab for longer than 17 months. Patients were switched to infusions every 6 or 7 weeks and CD49d binding prior to reinfusion was reassessed 3 and 4 infusion cycles after change of the treatment interval. Ex vivo peripheral blood samples drawn into EDTA tubes immediately prior infusion were stained for FACS analysis with fluorescent-labeled natalizumab, clone 9F10, a monoclonal antibody directed against an epitope on CD49d separate from that recognized by natalizumab, and leukocyte subset markers.

Results: Occupancy of the epitope bound by natalizumab measured on CD4+ and CD8+ T cells did not change significantly after extension of the infusion interval. Expression of the epitope recognized by clone 9F10 remained stable. No increase in relapse frequency was observed during follow-up while patients remained on infusion every 6 or 7 weeks.

Conclusion: Continued therapy with natalizumab my provided CD49D blockade sufficient for clinical effect beyond one month. Extension of the dosing interval may represent an alternative to dose reduction may represent an alternate approach to potentially mitigate risks associated with long term use of natalizumab.

The authors have nothing to disclose.

Dynamics of the peripheral blood CD4 cell counts of JCV Ab positive patients at the different phases of natalizumab treatment

R. Berkovich, D. Togasaki, D. Subhani, L. Steinman

USC Keck School of Medicine (Los Angeles, US); Stanford University (Stanford, US)

Natalizumab is an effective treatment of relapsing multiple sclerosis (MS). However, natalizumab-associated progressive multifocal leukoencephalopathy (PML) is a concern, especially in the population positive for JC virus antibodies, who have received more than two years of uninterrupted monthly natalizumab therapy. Interruption of treatment for 24 weeks was studied, and showed return of MS activity to pre-natalizumab levels after around week 16 of natalizumab cessation (Cree B, at al, 2012). Less prolonged dose extension strategies have been used empirically to attempt to reduce PML risk. Pharmacokinetic and immunologic parameters tend to return to pre-natalizumab therapy values at sixty to ninety days after the last natalizumab dose (John Foley, 2012). Incorporation of interval dose extension may help to mitigate natalizumab-induced PML risk, while obviating the return of MS activity.

In our observational study 10 patients with relapsing MS and positive JCV Ab status who elected natalizumab treatment were followed. Natalizumab was administered every 4 weeks for the initial 48 weeks, after which a 12 week-long extended dosing interval was implemented, followed by re-initiation of natalizumab dosing every 4 weeks. The CD4 cells counts were assessed at baseline prior to natalizumab treatment, at weeks 24 and 48 while on regular dosing, at week 60 (end of the extended dosing interval) and at week 72 (after re-initiation of natalizumab dosing). MS relapses and disability changes were assessed throughout the study period.

Results: The 12 week extension dosing interval was well tolerated; no MS relapses or worsening of disability were observed. After natalizumab was started, the CD4 mean counts increased from 1072.8 (baseline) to 1545.6 (week 24) and then to 1560.4 (week 48). The CD4 counts decreased to 1042.5 by the end of the dose extension interval (week 60); after natalizumab re-initiation, the CD4 numbers increased again to 1645.4 (week 72), p=0.004. One patient experienced hypersensitivity reaction with positive natalizumab neutralizing antibodies after natalizumab re-initiation.

Conclusion: A 12 week dosing extension interval may be well tolerated unlike more prolonged dosing extensions. A 12 week extension may be sufficient to promote changes in CD4 counts with return of cell trafficking and redistribution. The possible protective value of this approach in mitigating the risk of PML, deserves further investigation.

Dr. Berkovich served as a consultant for Acorda, Avanir, Bayer, Biogen Idec, Questcor and Teva Pharmaceutical.

Dr. Togasaki, Dr. Subhani and Dr. Steinman have nothing to disclose.

Evaluating results of blood serum anti-JCV antibodies of natalizumab treated multiple sclerosis patients

T. Kalamatas, N. Protopapas, A. Lafionati, A. Nella, A. Graigos, K. Karageorgiou

G.Gennimatas Athens General Hospital (Athens, GR)

Background: Progressive Multifocal Leucoengephalopathy (PML)is associated with natalizumab (Nat) treatment. It is well established that the etiologic agent for PML is the infection with JC Virus.

Objective: The main goal of our study is to evaluate the results of anti-JCV antibodies testing in blood samples of Nat treated MS patients of our day clinic.

Design/Methods: Out of 457 MS patients treated in our day clinic 323 patients were tested with the Stratify(TM) two step ELISA assay for serum anti-JCV antibodies. Blood samples were drawn previous to Nat Infusions and were sent to Unilabs. We analysed demographics data (age, sex, years of Nat treatment, history of immunosuppression treatment) and results of the anti-Jcv test.

Results: 202 patients were female and 121 patients were male and their ages varied from 15 to 72 years (mean 45.8,SD:11.30 years). The duration of Nat treatment varied from 0,5 to 7 years (mean 3,17,SD:1,08). 267 patients were never treated with immunosuppressants. 56 of the above patients were treated with immunosuppressants (mitoxandrone, mycophenolate, azathioprine). 192 patients were found positive for serum anti-JCV antibodies and 131 were found negative (57.7% positive, 42.3% negative). We found that with aging the prevalence of positive serum anti-JCV increases (p<0.005). No other statistical significant relations could be found.

Discussion: Although no significant relations were found we suggest that testing for Anti-JCV as a basic biomarker should always be performed before initiation of treatment with Nat. We also suggest for negative JCV patients to be tested annualy during Nat treatment.

Themistoklis Kalamatas, Nikolaos Protopapas, Klimentini Karageorgiou, Anastasios Graigos, Aimilia Lafioniati and Athina Nella have nothing to disclose.

Stratify (TM) JCV test kits were provided by Genesis Pharma who also financed the courier service to Unilabs.

Suppression of humoral responses after influenza vaccination in patients with neuromyelitis optica spectrum disorder treated with rituximab

W. Kim, S.H. Kim, S.Y. Huh, J.Y. Cho, S.Y. Kong, Y.J. Choi, W.J. Kim, H.J. Kim

The Catholic University of Korea (Seoul, KR); National Cancer Center (Goyang, KR); Inje University Ilsan Paik Hospital (Goyang, KR); Korea University College of Medicine (Seoul, KR)

The vaccination becomes important in patients with NMO spectrum disorder (NMOSD), as they are at increased risk of infection because of the long-term immunosuppression therapy. However, it is not sure if their formation of antibodies (Abs) after vaccination is appropriate. Especially for the patients treated with rituximab, it is a question of concern, as their cellular immune responses must be under suppressed state. We examined the formation of Abs after influenza A (H1N1) vaccination in NMOSD patients receiving rituximab, and compared the results to those of the healthy controls and the patients receiving other therapies. The study enrolled 28 patients with NMOSD, 9 with MS, and 8 controls aged 18-65 years. The patients had been treated more than 2 months with consistent drugs: rituximab (18 patients), mycophenolate (MMF; 5 patients), azathioprine (AZT; 6 patients), and interferon (IFN)-β (8 patients). Patients and controls received 1 dose of a monovalent adjuvanted influenza A (H1N1) virus vaccine, and blood samples were drawn just before (T0) and 3 months after (T1) the vaccination. No serious adverse effects occurred after vaccination in all patients and controls. The geometric mean titers (GMTs) of the Abs against H1N1 influenza at T0 did not differ between the groups, however, at T1, the GMT of rituximab group was lower than AZT group, IFN-β group, and controls (p<0.05). The MMF group also showed lower GMT than IFN-β group and controls (p<0.05). At T1, 3 patients in the rituximab group showed seropositivity, and the seroprotection rate of rituximab group (16.7%) became lower than those of AZT group (83.3%), IFN-β group (87.5%), and controls (100%) (p<0.05). The MMF group also showed lower seroprotection rate (20.0%) than IFN-β group and controls at T1 (p<0.05). The seroconversion rate of rituximab group (33.3%) was lower than those of IFN-β group (100%) and controls (75%) (p<0.05). The MMF group showed lower seroprotection rate (40.0%) than IFN-β group (100%) (p<0.05). The mean fold increase (MFI) of rituximab group (3.1±4.0) was lower than those of AZT group (31.0±47.9), IFN-β group (34.5±39.1), and controls (14.4±21.0) (p<0.05). The MMF group showed lower MFI (3.2±2.9) than only IFN-β group (p<0.05), although it showed lower tendency than AZT group and controls. This study shows a severely hampered humoral immune response to H1N1 influenza vaccine in NMOSD patients treated with rituximab, although the vaccination itself is safe in those patients.

Dr. Ho Jin Kim has received research grant from the Ministry for Health, Welfare and Family Affairs and honoraria for speaking or consulting from Bayer Schering Pharma, Merck Serono, and Novartis.

The authors have nothing to disclose.

Severe multiple sclerosis relapse under fingolimod therapy

E. Meluzinova, M. Bojar, E. Havrdova, P. Liskova, L. Kappos

Charles University in Prague (Prague, CZ); University Hospital Motol (Prague, CZ); University Hospital Basel (Basel, CH)

Objective: To report on severe MS relapse under fingolimod therapy.

Background: Fingolimod is the first oral immunomodulatory drug which has been approved for MS treatment. It causes a reversible sequestration of T and B cells from blood and spleen into lymph nodes.

Methods: Case report.

Results: A 30-years-old woman developed MS in her 18 years. She was treated with glatirameracetate for four years, then underwent three series of cyclophosphamide with methylprednisolone as an escalation therapy for disease activity followed by interferon β treatment for another three years. The treatment was stopped due to positive neutralizing antibodies and MRI progression. The patient refused natalizumab due to JCV positivity and was treated with IV immunoglobulin for another three years. Then she developed two relapses and MRI showed two enhancing lesions. Assuming lack of treatment efficacy immunoglobulin was stopped, patient was treated with IV steroids and fingolimod was initiated. On tenth day of fingolimod treatment she developed mild left sided hemiparesis, aphasia and bilateral hemianopia. MRI disloced four active lesions. The CSF findings including microbiologic and virologic workup (serology and PCR for JC virus, herpes, borrelias and enteroviruses) were normal. Fingolimod was stopped and the high dose IV steroids were started (6g methylprednisolone in total). The symptoms worsened during treatment and a patient developed cortical blindness and transcortical aphasia. She was immediately treated with plasma exchange (four cycles) and showed remarkable clinical improvement.

Conclusions: A patient with high active MS developed a severe atypical MS relapse during the first 10 days of fingolimod treatment which did not respond to IV steroids but improved after plasma exchange. There are few data on fingolimod activity on regulatory T cells and probably a disease exacerbation may be caused in some high active MS patients. Initiating fingolimod treatment only in the period of disease stability should be considered.

Dr. Meluzinova received speaker honoraria and consultant fees from Biogen Idec, Merck Serono, Novartis, Genzyme and Teva.

Dr. Bojar has nothing to disclose.

Dr. Havrdova received speaker honoraria and consultant fees from Biogen Idec, Merck Serono, Novartis, Genzyme and Teva, as well as support for research activities from Biogen Idec and Merck Serono.

Dr. Liskova has nothing to disclose.

Dr. Kappos recieved consulting or advisory fees from Accorda, Actelion, Allergan, Allozyne, Bayer Schering, Biogen Idec, Biogen-Dompé, Boehringer Ingelheim, Genmab, GlaxoSmithKline, Medicinova, Merck Serono, Novartis, Roche, Sanofi Aventis, Santhera, Teva Pharmaceuticals, UCB Pharma, and Wyeth; lecture fees from Biogen Idec, Helvea, GlaxoSmithKline, Mediservice, and Merck Serono; and grant support from Bayer Schering, Biogen Idec, CSL Behring, the European Community Research Fund, Genmab, Genzyme, GlaxoSmithKline, Medicinova, Merck Serono, Novartis, Novartis Foundation, the Rubato Foundation, Roche, Santhera, Sanofi Aventis, and UCB Pharma.

Lyme neuroborreliosis during natalizumab treatment in multiple sclerosis – a case presentation

K. Thomas, T. Schultheiß, T. Ziemssen

University Hospital Dresden Carl Gustav Carus (Dresden, DE)

In this case we report a successful treated neuroborreliosis case as important differential diagnosis to progressive multifocal leucencephalopathy (PML) in a patient with Multiple Sclerosis (MS) on longterm natalizumab (NA).

The 33-year old man was diagnosed with relapsing-remitting MS (RRMS) in 1999. In 2006 the patient started on NA after highly active RRMS despite previous treatment with different immunomodulatory and immunosuppressive drugs. The patient improved rapidly with marked reduction in relapse rate to a stable disease in clinical symptoms as well as T2-weighted lesions in MRI-scans. After 60th NA infusion, patient complained about progressive neuropathic pain, hyperpathy, generalized myalgia and progressive abducens paresis.

Diagnostic procedures were performed with immunological and microbiological analysis of blood, cerebrospinal fluid (CSF) and brain MRI-scans.

Brain MRI-scans and CSF demonstrated no evidence for a PML. Further investigations of CSF were characterized by elevated leucocyte (189MPt/l) and B-cell count (5.3% of leucocytes), CXCL13-concentration increase (170000pg/mL) and positive Borrelia-antibody index (IgM 5.57 E/mL, IgG 2.87 E/mL) reasoning the diagnosis of neuroborreliosis. Additional serological investigations showed significant antibody-index for IgG and IgM (IgM 35.9 E/mL, IgG 43.9 E/mL) as marker of a recent infection with Borrelia burgdorferi. One year before, sera and CSF demonstrated normal levels of analyzed parameters during routine diagnostic workups. After ceftriaxone infusion for 2 weeks, patient’s neurological symptoms recovered constantly, only MS-associated known medical conditions remained. Control CSF samples demonstrated a gradual decrease of cell count up to 35MPt/l 2 weeks and 18MPt/l 10 weeks after antibiotic treatment. Intrathecal IgG-secretion or activated B-cells were not detectable anymore. CXCL13-concentration in CSF declined down to non-significant levels. During diagnostic and therapeutic process the patient received NA treatment till today. Free and cell-bound concentration of NA in CSF and blood kept stable during whole investigated period.

In this report we present an acute neuroborreliosis of the central nervous system and its effective therapy during NA treatment. This is the first detailed report while longterm NA therapy. Our case assumes raised awareness of neuroborreliosis in NA treated MS patients as differential diagnosis to PML to start early treatment and improve clinical outcome.

K. Thomas and T. Schultheiß have nothing to disclose.

T. Ziemssen received personal compensation from Biogen idec, Bayer, Novartis, Sanofi, Teva, Synthon for consulting services.

TYSTART: monitoring and management of MS patients starting natalizumab treatment in Germany

B. Kallmann, R. Hoffmann, U. Walter, C. Wernsdörfer, V. Zingler, A. Chan

Neurological Center (Bamberg, DE); Neurological Center (Berlin, DE); Neurological Center (Fulda, DE); Biogen Idec (Ismaning, DE); Ruhr University, St. Josef-Hospital (Bochum, DE)

Background:The AFFIRM trial in patients (pts) with relapsing-remitting MS (RRMS), showed that natalizumab (NAT) reduced the relapse rate by 68% and the risk of 6-month sustained disability progression by 54% (highly active MS: 81% and 64%). Post-hoc analyses and post-marketing studies showed improvements of EDSS, fatigue and other parameters. Pts on NAT are at increased risk of progressive multifocal leukoencephalopathy (PML) if previously exposed to JC virus (JCV). Additional risk factors include prior treatment with immunosuppressants (IS) and NAT therapy >2 years (yrs). NAT requires structured patient management from start of therapy.

Methods: TYSTART prospectively documents the disease course and pt monitoring in the clinical routine. From 07/2010 to 10/2011, 258 RRMS pts (≥ 2 NAT infusions received) were included. Visits at baseline (BL) and after 3, 6, 9 and 12 months (mos) document clinical, MRI and laboratory parameters, and since 01/2012 optionally anti-JCV antibody status. We report on an interim analysis (Feb 21, 2012) performed at full recruitment.

Results: Patient BL characteristics [mean (± SD)]: 65.9% female, age 39.6 yrs (± 10.5); MS duration 10.7 yrs (± 8.0); NAT infusions before BL 3.9 (±5.6); EDSS 3.6 (±1.6); fatigue severity score (FSS) 4.2 (±1.7). 235 pts with MRI before BL had 2.9 (±4.1) cerebral and 0.9 (±1.5) spinal contrast-enhancing lesions; 11.6 (±11.3) cerebral and 2.2 (±2.7) spinal T2 lesions. 89.5% of pts previously received ≥1 immunomodulator, 19.0% had ≥ 1 IS. Common laboratory tests before NAT start: liver function tests (LFTs) (69.8%), full blood counts (FBCs) (68.6%) and lymphocyte subpopulations (LCSPs) (41.1%). The mean follow-up duration is 7.3 mos (±3.1). In 55 pts documented at 12 mos, the mean EDSS was stable vs. BL (3.4 (±1.5) vs. 3.6 (±1.4)); the mean FSS declined (3.6 (±1.7) vs. 4.2 (±1.7)). In each 3-mo visit interval, an MRI was performed on average in 19.6% of pts; LFT, FBC and LCSP in 45.6%, 49.2% and 25.3% of pts, respectively. One serious adverse event (MS relapse) was documented. No PML case has occurred. NAT was discontinued in 13 pts (5%).

Conclusions: TYSTART pts had longer mean MS duration and higher mean EDSS than AFFIRM pts. NAT stabilized the mean EDSS with good tolerability. Monitoring frequently involved MRI, FBC and LFT. An interim analysis at 2 yrs of study (Aug. 2012) will further evaluate disease course and monitoring in routine clinical practice.

Kallmann B: The study Tystart was funded by Biogen Idec.

Hoffmann R: The study Tystart was funded by Biogen Idec.

Walter U: The study Tystart was funded by Biogen Idec.

Wernsdörfer C: employee of Biogen Idec.

Zingler V: employee of Biogen Idec.

Chan A: The study Tystart was funded by Biogen Idec.

Effect of teriflunomide on lymphocyte and neutrophil levels in patients with relapsing multiple sclerosis: results from the TEMSO study

G. Comi, H. Benzerdjeb, L. Wang, P. Truffinet, P. O’Connor

University Vita-Salute San Raffaele (Milan, IT); sanofi (Chilly Mazarin, FR); sanofi (Bridgewater, US); University of Toronto (Toronto, CA)

Introduction: Teriflunomide is a novel, once-daily, oral disease-modifying therapy in development for treatment of relapsing multiple sclerosis (RMS). Teriflunomide is known to attenuate the proliferation of stimulated lymphocytes via inhibition of dihydro-orotate dehydrogenase (DHODH) activity, required for de novo pyrimidine synthesis. We assessed lymphocyte and neutrophil counts during and after teriflunomide treatment in the TEMSO study (NCT00134563).

Methods: Eligible patients (18–55 years, diagnosed with RMS [McDonald criteria], Expanded Disability Status Scale score ≤5.5) were randomised (1:1:1) to once-daily placebo, teriflunomide 7 mg or 14 mg for approximately 2 years. Safety outcomes were evaluated in the safety population (placebo=360; 7 mg=368 ; 14 mg=358). Blood samples for safety analyses were collected every 2 weeks for 24 weeks, then every 4 weeks up to week 108. Blood samples were also collected up to 16-weeks of post-treatment follow-up.

Results: At baseline, mean (SD) lymphocyte (placebo, 2.01 [0.57]x10⁹/L; 7 mg, 1.95 [0.54]x10⁹/L; 14 mg, 1.93 [0.57]x10⁹/L) and neutrophil counts (placebo, 4.49 [1.83]x10⁹/L; 7 mg, 4.37 [1.67]x10⁹/L; 14 mg, 4.32 [1.63]x10⁹/L) were similar across groups. Small, clinically insignificant reductions in mean (SD) lymphocyte count (placebo, -0.02 [0.50]x10⁹/L; 7 mg, -0.20 [0.46]x10⁹/L; 14 mg, -0.30 [0.48]x10⁹/L) and mean neutrophil count (placebo, -0.14 [1.69]x10⁹/L; 7 mg, -0.42[1.50]x10⁹/L; 14 mg, -0.59 [1.66]x10⁹/L) were seen from baseline to week 108. These reductions occurred during the first 6 weeks of treatment and were sustained over the duration of teriflunomide treatment. Post-treatment data indicate return to baseline levels within 6 weeks post-treatment. Two patients treated with teriflunomide 14 mg experienced neutropenia or neutrophil count decrease, reported as serious adverse events, at 0.95 x 10⁹/L and 0.90 x 10⁹/L. Both patients recovered while continuing treatment with teriflunomide.

Conclusions: Mean reductions in lymphocyte and neutrophil counts observed in TEMSO were small in magnitude (not exceeding a 15% reduction) and were reversible after treatment discontinuation or on-treatment in some cases. No other clinically significant complications to blood cytopenias were reported.

Study supported by sanofi.

GC: Personal compensation (Bayer Schering, Serono Symposia International Foundation, Merck Serono International, sanofi-aventis, Biogen Dompè, and Teva Pharmaceutical Ind. Ltd), and speaking fees (Novartis, Bayer Schering, Serono Symposia Int. Foundation, Merck Serono International, sanofi-aventis, Biogen Dompè, and Teva Pharmaceutical Ind. Ltd).

HB, LW and PT: Employees of sanofi.

POC: has received consulting fees and/or research support for MS trials from Actelion, Bayer, Biogen Idec, BioMS, Cognosci, Daiichi Sankyo, EMD Serono, Genentech, Genmab, Novartis, Roche, sanofi-aventis, Teva, and Warburg Pincus.

Annual rate of JCV seroconversion in a French Cohort of MS Patients under Natalizumab

A. Etxeberria, O. Outteryck, J.C. Ongagna, H. Zéphir, N. Collongues, A. Lacour, F. Blanc, M. Giroux, M.-C. Fleury, P. Vermersch, J. de Sèze

Université Lille Nord de France (Lille, FR); Hopitaux Universitaires de Strasbourg (Strasbourg, FR)

Objective: To measure the annual rate of JCV seroconversion in a French cohort of MS patients treated with natalizumab since one year.

Background: Progressive multifocal leukoencephalopathy (PML) risk may be stratified by anti-JCV antibody status, duration of natalizumab therapy (≥24 months) and prior exposure to immunosuppressive (IS) drugs. In a previous work, we showed that higher age, being of North African origin and duration of natalizumab exposure were independent risk factors of JCV seropositivity.

Materials and Methods: Sixty six patients under natalizumab have been recruited for this study. All patients were under natalizumab since at least 12 months. JCV serology with the previously validated ELISA test has been performed for all patients in May 2011 and 12 months after. All patients recruited were JCV seronegative in May 2011. We also planned serological analysis of all patients (seronegative but also seropositive) belonging to our previous cohort (n=361).

Results: Among the JCV seronegative patients (n=66) tested until now, we observed a seroconversion in 11 patients (16.66%). Analysis of the entire cohort will be presented.

Conclusion: The rate of seroconversion observed in our cohort is higher than expected and previously reported. This information is understandable if one considers that natalizumab exposure duration is a risk factor of being JCV seropositive.

Dr Etxeberria has nothing to disclose.

Dr Outteryck has received funding for travel from Biogen Idec, Bayer Schering Pharma, Merck Serono, Novartis, Teva Pharmaceutical Industries Ltd, and Sanofi-Aventis and for speaker honoraria from Bayer Schering Pharma, Biogen Idec and Sanofi-Aventis.

Dr Ongagna has nothing to disclose.

Dr Zéphir has received funding for travel from Biogen Idec, Bayer Schering Pharma, Merck Serono, Novartis, Teva Pharmaceutical Industries Ltd, and Sanofi-Aventis and for speaker honoraria from Bayer Schering Pharma, Biogen Idec, Teva Pharmaceutical Industries Ltd, and Sanofi-Aventis.

Dr Collongues has received funding for travel from Novartis and Merck Serono.

Dr Fleury has nothing to disclose.

Dr Lacour has received funding for travel from Teva Pharmaceutical Industries Ltd, Biogen Idec, Genzyme and speaker honoraria from Genzyme and LFB.

Dr Blanc has received funding for travel from Novartis, Biogen Idec, Teva Pharmaceutical Industries Ltd and Merck Serono.

Dr Giroux has received funding for travel from Teva Pharmaceutical Industries Ltd, Biogen Idec and Novartis.

Prof. Vermersch serves on scientific advisory board for Biogen Idec, Bayer Schering Pharma, Merck Serono, Novartis, Teva Pharmaceutical Industries Ltd, and Sanofi-Aventis; has received funding for travel and speaker honoraria from Biogen Idec, Bayer Schering Pharma, Novartis, Teva Pharmaceutical Industries Ltd, Sanofi-Aventis and Merck Serono; and receives research support from Biogen Idec, Merck Serono, Sanofi-Aventis, Teva Pharmaceutical Industries Ltd, and Bayer Schering Pharma.

Prof. de Sèze serves on scientific advisory board for Biogen Idec, Bayer Schering Pharma, Merck Serono, Novartis, Teva Pharmaceutical Industries Ltd, and Sanofi-Aventis; has received funding for travel and speaker honoraria from Biogen Idec, Bayer Schering Pharma, Novartis, Teva Pharmaceutical Industries Ltd, Sanofi-Aventis and Merck Serono; and receives research support from Biogen Idec, Merck Serono, Sanofi-Aventis, Teva Pharmaceutical Industries Ltd, and Bayer Schering Pharma.

Cancer and Disease Modifying Therapy in Multiple Sclerosis: an Audit of the Tayside DMT Register

K. Grieve, B. Waddell, P. Walker, J. O’Riordan

Ninewells Hospital and Medical School (Dundee, UK)

Disease modifying therapies (DMTs) have revolutionised the management of multiple sclerosis (MS). There has been speculation that these therapies may increase the risk of cancer (especially haematological malignancy and breast cancer), but the evidence remains equivocal, and the availability and use of immunomodulatory therapies varies widely internationally. We report on the incidence of cancer in an eastern Scottish population of patients treated with DMTs.

A case note review of all patients in the Tayside and North Fife DMT register was used to establish the incidence of new cancer in (n= 540) MS patients treated with DMTs in NHS Tayside. The type of malignancy, type of therapy, and type and duration of DMT treatment was recorded. DMTs included were glatiramer, interferon β 1a, interferon β 1b, mitoxantrone, and natalizumab.

Of 540 patients (age range 20-75, 400 female), 14 (2.6%) developed cancer (10 female). 4 patients were diagnosed with colorectal cancer (0.7% of total DMT population), 2 with breast cancer (0.5% of females), 2 with prostate cancer (1.4%), 1 ovarian cancer (0.25%), 1 cervical cancer, 1 leukaemia, 1 with malignant thymoma, 1 basal cell carcinoma, and 1 vulval intraepithelial neoplasia grade III. The mean time between starting DMT and cancer diagnosis was 54.9 months (range 1-131), mean age at cancer diagnosis was 54 years (range 38-66). 156 patients had been exposed to more than one DMT. Within the cancer group, 4 patients had been on an interferon β 1b drug, 5 patients had been on interferon β 1a, and 2 patients had been on glatiramer. The three patients who had been on mitoxantrone, had previously been on a βinterferon 1a or 1b preparation.

The rate of cancer diagnosis in our population was lower than that recorded in similar studies, and the reasons for this are unclear. In our population, the most common diagnosis was colorectal cancer (extrapolated rate 700 per 100000 people), but the 2009 statistics for Scotland indicate a crude incidence rate of 2177 cases per 100000. Equally, the rates of other cancers were very low. In particular, previous concerns about haematological malignancy and breast cancer appear not to be relevant in the DMT population. Previous studies have suggested that a diagnosis of MS reduces the risk of developing cancer. Our population have also demonstrated low rates of cancer; sufficiently low to limit comprehensive statistical analysis.

K. Grieve, B. Waddell and P. Walker have nothing to disclose.

J. O’Riordan has received consultancy fees for attendance at advisory boards, lecture fees and has been a Principal Investigator in clinical trials with Novartis, Sanofi Aventis, Bayer Schering, Biogen Idec, Merc Serono and Teva Pharmaceuticals.

Management of natalizumab-related PML: a different approach

C. Cordioli, C. Costanzi, N. De Rossi, S. Rasia, R. Capra

MS Center- Montichiari (Brescia, IT)

Objective: To discuss the managment of natalizumab-related Progressive Multifocal Leukoencephalopathy (PML) and Immuno Reconstitution Inflammatory Syndrome (IRIS).

Background: Occurrence of PML is a major life-threatening complication with limited therapeutic options. IRIS has shown to be more severe in patients with natalizumab-associated PML.

Case 1: A 28-years-old woman with RR-MS since 2007, initially treated with interferon β, shifted to natalizumab due to relapses. Shortly after the 25th infusion, follow-up MRI showed two T2W hyperintense enhancing lesions in the left and right precentral cortical-subcortical gyri, consistent with PML. JCV-PCR on the CSF was negative. Neurological evaluation showed impairment on small movements of the right hand evolved in hand dystonia after 3 months, without new MRI lesions. Monthly therapy with methylprednisolone started. Repeated PCR JCV-RNA was positive(73 copies) and right sensory partial seizures confirmed PML diagnosis with superimposed IRIS. Methylprednisolone pulse-treatment and prednisone continued with slow clinical improvement and stabilization on the MRI within 6 months.

Case 2: A 43-years-old woman with RR-MS since 1985, initially treated with Mitoxantrone shifted to natalizumab due to FEV reduction. After the 31st infusion, a follow-up MRI demonstrated hyperintense T2W lesion in the left temporo-occipital region with enhancement in the cortical gyri consistent with PML. PCR JCV-RNA was positive (24 copies). Neurological examination showed right spatial neglect, agraphia and alexia. Plasmapheresis couldn’t be finalized due to venous trombosys. She started pulse-methylprednisolone and prednisone with clinical and radiological improvement within one year.

Conclusions: In both cases follow-up MRIs for surveillance raised the suspect of PML. Since the clinical courses were mild and subsequent MRI features were suggestive of florid IRIS (linear gadolinium enhancement) rather than PML widening, we decided to treat with pulse-methylprednisolone and oral prednisone. The negativity of the first JCV-PCR analysis in the first case did not contrast with our suspect of PML, given the MRIs and clinical features. The contemporary appearance of focal seizure reinforced our hypothesis of IRIS. Sudden clearance of natalizumab through plasmapheresis could have worsened inflammatory process and cause more clinical impairment, as reported in AIDS patients developing PML-IRIS during HAART. A conservative approach with pulse-steroids has been demonstrated a safe solution.

The authors have nothing to disclose.

Fingolimod following natalizumab in RRMS: clinical and MRI findings

F. Rinaldi, D. Seppi, M. Calabrese, P. Perini, P. Gallo

Multiple Sclerosis Centre (Padua, IT)

Background: Relapsing-Remitting Multiple Sclerosis (RRMS) patients under natalizumab treatment for more than 2 years, and previously exposed to immunosuppressive drugs and having JCV antibodies in their serum (JCV+) are at high risk to develop progressive multifocal leukoencephalopathy. Thus, natalizumab break is strongly suggested in these patients. However, clinical and/or neuroimaging evidence of disease reactivation has been observed after natalizumab interruption.

Objective: To evaluate whether fingolimod might be a possible therapeutic option following natalizumab.

Methods: Twenty-two RRMS patients that shifted from natalizumab to fingolimod after three-month of washout were included in a clinical and magnetic resonance imaging (MRI) follow-up. All the patients were JCV+ and had never been treated with immunosuppressive drugs. In the year before natalizumab initiation, while treated with immunomodulatory drugs (interferon β - IFN β or glatiramer acetate - GA), they had a mean relapse rate of 2.4. The mean number of natalizumab infusions was 33 (range: 24-46). Neurological evaluation (EDSS) was performed monthly. Brain MRI was scheduled one month after therapy initiation and was obtained from 20/22 patients. Seven patients, who complained subjective symptoms but had an unchanged EDSS score, repeated the MRI during the follow-up.

Results: In a mean follow-up period of 7.5 months, clinical relapses were observed in 6 patients (4 within the first month of therapy), while MRI evidence of disease reactivation was observed in further 5 patients not presenting clinical evidence of relapse (3 within the first month of therapy). A clinical and/or MRI picture suggestive of a disease rebound was observed in 3 patients.

Conclusions: Although half of fingolimod-treated patients had evidence of MS reactivation, in the majority of the cases this occurred within the first month of therapy. This finding suggests that a shorter wash-out period between natalizumab and fingolimod has to be considered. In half of the patients, not responsive to IFN β and GA, fingolimod appears a valid therapeutic option in patients previously treated with natalizumab.

F. Rinadi and P.Perini have received funding for travel and speaker honoraria from Merck Serono, Biogen Idec, Sanofi-Aventis, and Bayer Schering Pharma.

D. Seppi has received funding for travel from Merck Serono, Biogen Idec, Sanofi-Aventis, and Bayer Schering Pharma.

M. Calabrese serves as advisory board member of Sanofi Aventis and Merck-Serono, has received funding for travel and speaker honoraria from Merck Serono, Biogen Idec, Sanofi-Aventis, and Bayer Schering Pharma.

P. Gallo serves as advisory board member of Novartis Farma, Biogen-Idec, Bayer-Shering and has received funding for travel and speaker honoraria from Merck-Serono, Biogen Idec, Sanofi-Aventis, Novartis Pharma and Bayer-Schering Pharma.

The authors report no conflicts of interest.

Frequency of John Cunningham virus (JCV) DNA and of antibodies against JCV in patients affected by multiple sclerosis and their relationship with natalizumab therapy

V. Lo Re, F. Cardinale, S. De Grazia, S. Alessi, V. Cusimano, M.A. Mazzola, M. Lo Re, S. Realmuto, P. Ragonese, G. Salemi, P. Conaldi, G. Savettieri

University of Palermo (Palermo, IT)

Background: Natalizumab (NAT) is humanized monoclonal antibody used as second line therapy for relapsing-remitting Multiple Sclerosis (MS). It is at present the more efficacious therapy available to reduce clinical and radiological activity of MS and to slow disease progression. A prolonged use of NAT is limited by the risk of developing Progressive Multifocal Leukoencephalopathy.

Objectives: To compare in 2 groups of MS patients:

1) the frequency of JCV-DNA in urine and plasma,

2) the percentage of appearance of JCV-DNA during a two-years period of treatment,

3) the concordance between JCV-DNA presence in the urine and plasma and antibodies against JCV presence in the plasma of MS patients after at least 2 years of treatment.

Methods: We included MS patients before starting NAT (group A), or before the initiation of other therapies (group B), in the period October 2007 - March 2010. The presence of JCV-DNA in the urine and plasma was checked before starting the appropriate therapy, after the first year of treatment and then, every six months for at least two years. When the Stratify test became available, this was performed in each patient.

Results: We included 33 subjects in the group A (10 men, 23 women) and 32 subjects in the group B (10 men, 22 women; 19 patients in β-interferon, 12 in glatiramer acetate, and 1 in cyclophosphamide). At pre-treatment analyses JCV-DNA was detected in the urine of 7 out of 33 subjects in the group A (21%) and of 11 out of 32 subjects in the group B (34%). No JCV-DNA was detected in plasma samples. During the two years follow-up period, 2 other subjects were positive for the presence of JCV-DNA in the urine in group A (at 12 and 24 months, overall positivity 27%), and two in group B (at 12 and 18 months, overall positivity 41%). JCV-DNA presence was persistent and fluctuated in the following tests. JCV-DNA search continued to be negative during the follow-up in plasma. Stratify test positivity was 58% in group A (19/33), and 50% in group B (16/32). In both groups we found subjects positive to Stratify test and negative to JCV-DNA in the urine (10 in group A, 6 in group B), but we did not observed the opposite.

Conclusion: Presence of JCV-DNA in urine ranges in this group of Sicilian MS patients between 21 and 34% (28% for the whole cohort). NAT therapy did not influence the presence of JCV-DNA in the urine during the follow-up period. Stratify test appeared to be more accurate to detect the carrier status for JCV.

MAM has received travel grants from Bayer Schering, Biogen Dompé, Merck Serono, Novartis, Sanofi-Aventis and Teva; FC has nothing to declare; SDG has nothing to declare; SA has nothing to declare; VC has nothing to declare; MLR has received travel grants from Bayer Schering, Biogen Dompé, Merck Serono, Novartis, Sanofi-Aventis and Teva; VLR has received travel grants from Bayer Schering, Biogen Dompé, Merck Serono, Novartis, Sanofi-Aventis and Teva; SR has received travel grants from Bayer Schering, Biogen Dompé, Merck Serono, Novartis, Sanofi-Aventis and Teva; PR has received travel grants from Bayer Schering, Biogen Dompé, Merck Serono, Novartis, Sanofi-Aventis and Teva; has received research grants from Biogen Dompé; GS has received travel grants from Bayer Schering, Biogen Dompé, Merck Serono, Novartis, Sanofi-Aventis and Teva; has received research grants from Biogen Dompé, Merck Serono, Novartis and Sanofi-Aventis; has received research grants from the Associazione Italiana Sclerosi Multipla; PC has nothing to declare, GS has received travel grants from Bayer Schering, Biogen Dompé, Merck Serono, Novartis, Sanofi-Aventis and Teva; has received research grants from Biogen Dompé, Merck Serono, Novartis and Sanofi-Aventis; has received research grants from the Associazione Italiana Sclerosi Multipla.

Natalizumab de-escalation to interferon-β-1b in multiple sclerosis: a randomised, controlled, pilot trial

C. Zecca, S. Meier, S. Tschuor, N. Nadarajah, F. Cotton, M. Sinzel, D. Leppert, C.R.G. Guttmann, C. Gobbi

Neurocenter of Southern Switzerland, Civic Hospital (Lugano, CH); Brigham & Women’s Hospital (Boston, US); University Lyon (Lyon, FR); mcs medical communication services (Küsnacht, CH); University Hospital Basel (Basel, CH)

Background: Natalizumab (NTZ) discontinuation leads to multiple sclerosis (MS) reactivation.

Objective: to explore the therapeutic option of de-escalating NTZ treated patients to interferon β-1b (IFNB) compared to continued NTZ treatment.

Methods: 1-year randomized, rater-blinded, parallel-group, pilot study. Relapsing remitting (RR) MS patients on NTZ for ≥12 months who had been free of disease activity on this therapy (no relapses and disability progression for ≥6 months, no gadolinium-enhancing lesions in baseline MRI) were randomized to NTZ or IFNB. Primary endpoint was time to first on-study relapse. Additional clinical, MRI and safety parameters were assessed. Analyses are based on intention to treat.

Results: 19 patients (NTZ n=10; IFNB n=9) with similar baseline characteristics were included. Time to first on-study relapse was not significantly different between groups (p=0.125). 78% of IFNB treated patients remained relapse free (NTZ group:100%), and 25% remained free of new T2 lesions (NTZ group: 62.5%). Many secondary clinical and radiological endpoints (number of relapses, proportion of relapse free patients, number of new T2 lesions showed a trend, or were significant (new T2 lesions at month 6) in favoring NTZ.

Conclusions: in our selected group of stable MS patients de-escalation therapy from NTZ to IFNB was associated with non significant clinical activity recurrence. Radiological activity recurrence appeared significant at 6 months.

Chiara Zecca has received personal compensation from Teva, Merck Serono, Biogen Idec, Bayer Schering, Novartis. Dominik Meier has nothing to disclose. Silvia Tschuor has nothing to disclose. Navarajah Nadarajah has nothing to disclose. Francois Cotton has nothing to disclose. Martina Sintzel or her agency has received consulting fees and/or honoraria from Bayer HealthCare Pharmaceuticals, Fresenius Medical Care, UCB, Ospedale regionale di Lugano and ETH Zurich. Charles R.G. Gutmann has received personal compensation from Tibotec/Johnson & Johnson and was the recipient of a research grant from Teva Neuroscience, within the last 3 years. David Leppert is an employee of F. Hoffmann – La Roche Ldt. Claudio Gobbi has received personal compensation from Teva, Merck Serono, Biogen Idec, Bayer Schering, Novartis.

Treatment-associated risk acceptance in natalizumab-treated MS patients

C. Tur, M. Tintoré, À. Vidal-Jordana, D. Bichuetti, P. Nieto, M.J. Arévalo, G. Arrambide, E. Anglada, Í. Galán, J. Castilló, C. Nos, J. Río, I. Martín, M. Comabella, J. Sastre-Garriga, X. Montalban

Vall Hebron University Hospital (Barcelona, ES)

Background & Objective: Natalizumab (NLZ) use has been limited due to the risk of progressive multifocal leukoencephalopathy (PML). Since new MS drugs with different safety profiles are soon to be available, we aimed to investigate patients’ attitudes towards potentially risky therapeutic choices and factors involved in such attitudes.

Methods: From a total of 185 patients who had received at least 1 dose of NLZ, 114 patients on NLZ as of July 2011 carried out a survey containing visual analogic scale (VAS) questions (values range: 0-10) aimed to score their perception of disease severity, in general and in their particular case. The NEO Five-Factor Inventory of personality traits (neuroticism, extroversion, opening, kindness, responsibility) was also administered. Finally, VAS questions assessed hypothetical attitudes towards treatment scenarios with high and very high associated risks. We obtained risk-acceptance scores (RAS) so that higher RAS indicated better acceptance of risk. We recorded JC virus status (JCV+/-), prior immunosuppression, number of NLZ doses, and clinical data. NLZ patients were split into subgroups (A-E), depending on their individual PML risk. Some 22 MS patients on first-line drugs (DMD) acted as controls.

Results: NLZ patients had longer disease duration (p<0.01), and higher EDSS scores (p<0.01) than DMD patients. Particular and general disease perception was similar in NLZ and DMD patients. Personality traits disclosed no differences between both groups. RAS were higher in NLZ than in DMD patients (p<0.01). Longer disease duration (p=0.08) and worse disease perception (p=0.07) tended to predict higher RAS, whereas neither disability scores nor pre-treatment relapse rate predicted RAS in either group. Higher neuroticism scores predicted higher RAS in NLZ group as a whole (p=0.04), and in high PML-risk subgroups (A-B) (p=0.02). In low PML-risk subgroups (C-E), higher RAS were associated with a JCV+ status (p=0.01).

Conclusions: Risk acceptance seems marginally related to disease severity perception and disease duration. As expected, patients already on risky therapies accepted high-risk scenarios better than other patients. In patients who still have a low PML risk, JCV+ status would make them more prone to assuming higher risks in the future, maybe indicating an adaptive psychological process. In patients with a high PML risk, personality traits may be the main factor involved in higher risk acceptance.

The authors have nothing to disclose.

A Swiss best practice experience in three different clinical settings of the 6 hour fingolimod first dose observation procedure

S.P. Ramseier, S. Roth, A. Czaplinski

Cantonal Hospital Aarau (Aarau, CH); Private practice with day clinic in Clinique de Carouge SA (Carouge, CH); Neurocenter Bellevue (Zurich, CH)

Background: Fingolimod is the first oral therapy to be approved by Swissmedic for relapsing-remitting multiple sclerosis (RRMS). In Switzerland, the label mandates 6 hour (h) monitoring of patients (pts) (ECG and vital signs) after the first dose (first dose-observation [FDO]).

Objective: An analysis of onsite experience with the 6 h FDO procedure, in three different clinical settings.

Methods: Pts were monitored in a MS center (site 1, n=58), a neurologist practice that uses a day clinic for FDO (site 2, n=17), and an office based neurology practice (site 3, n=61), between Aug 2011 and May 2012. Monitoring consisted of an ECG taken by a physician at the beginning and end of the 6 h observation, and hourly blood pressure (BP) and heart rate (HR) monitoring by a nurse. In the event of pre-defined cardiovascular (CV) changes, observation could be extended to 24 h.

Results: 136 RRMS pts (33 treatment naïve; 103 with prior treatment e.g. interferon β /glatiramer acetate/natalizumab) underwent FDO monitoring. A maximum of 2 pts were monitored simultaneously with 1 ECG device and 1 nurse/MS nurse. Pts spent the 6 h observation period occupied with activities such as reading, using their personal laptop, lunching together or enquiring/discussing about health related aspects. The MS nurse provided detailed information regarding the treatment dosing, procedure and examinations during this time. No significant changes in BP were reported and no pts required 24 h monitoring.

Four pts (1 each in sites 1 and 2, 2 in site 3) exhibited 1st and 2nd degree atrioventricular (AV) blocks which resolved spontaneously within 12-24 h (monitored either with Holter ECG or on site ECG the following day). Fingolimod was stopped in 1 pt who reported a 2nd degree AV block during FDO (resolved on ECG 90 min post FDO). Asymptomatic bradycardia (HR 40-50 bpm) was observed in 8 pts. Symptomatic events (vertigo-like and perceived tachycardia [HR 74 bpm]) reported by 2 pts, resolved spontaneously. On follow-up, treated pts did not report any significant laboratory abnormalities or an increased infection-rate.

Conclusions: The FDO experience indicated fingolimod was generally well tolerated; all 3 sites capably facilitated the FDO procedure. The majority of pts had no events; however, the occurrence of side effects with possible clinical implications in few pts, emphasizes the importance of monitoring pt status, and ensuring pts are well informed at treatment initiation.

Simon P. Ramseier has participated in advisory boards for Merck Serono (Switzerland), Bayer Schering (Switzerland), Teva Pharma AG (Switzerland), Biogen Idec (Switzerland).

Prof Serge Roth and Adam Czaplinski have nothing to disclose.

Natalizumab discontinuation in clinical practice: a systematic observational study from the national TYSEDMUS cohort of 577 multiple sclerosis patients treated with natalizumab in France

C. Papeix, S. Vukusic, N. Passante, I. Ionescu, B. Frangoulis, B. Stankoff, S. Oporto, S. Mrejen, E. Van ganse, F. Rocher, A. Castot, M. Clanet, C. Lubetzki, C. Confavreux on behalf of the TYSEDMUS Group

Background: Natalizumab (NZ), an anti-integrin monoclonal antibody, has shown efficacy in reducing the relapse rate and delaying disability accumulation in multiple sclerosis (MS) patients. In clinical practice, NZ may be discontinued because of concern about progressive multifocal leucoencephalopathy (PML), adverse events, inefficacy or desire to become pregnant. In phase 2 trials, disease activity after NZ interruption returned to levels similar to those seen prior to treatment. However, recent reports suggested that unusually severe relapses with high number of new T2 and gadolinium-enhancing lesions might occur following NZ interruption.

Objective: To assess disease activity within the 12 months period after NZ discontinuation in the TYSEDMUS study.

Methods: In France, patients exposed at least once to NZ are included in the TYSEDMUS study, an observational and multicentric cohort, part of the French NZ Risk management Programme. We analyzed the relapse rate, relapse severity and confirmed disability (EDSS score) during a one year period (M0-M12) of all patients who stopped NZ and compared them to pre-treatment and on-treatment data. Time to first relapse after NZ withdrawal was calculated using Kaplan-Meier analysis.

Preliminary results: In May 2012, 3730 MS patients treated with NZ were included in the TYSEDMUS study and 2921 files have been fully analyzed so far. Among them, 577 patients (19.75%) discontinued treatment for various reasons. Kaplan Meier analysis showed that 50% of the patients experienced a relapse within one year. Most of these relapses occurred 3 to 5 months after NZ withdrawal. The relapse rate post NZ discontinuation was correlated to the relapse rate during the 12-month period before NZ initiation (OR =1.23) with no rebound effect. The influence of other disease-modifying treatments other than NZ and possibly initiated during this one year survey period is currently evaluated. In addition, data collection is currently completed to assess first relapse severity and recovery. The database will be closed in September 2012 and updated results will be presented at the meeting.

Conclusions: This large and systematic survey of MS patients after NZ withdrawal did not show a rebound effect concerning the relapse rate. relapse severity post-NZ is currently evaluated. This study is the first attempt, to our knowledge, to provide large scale, multicenter, systematic and unbiased data after NZ cessation in real life settings.

Caroline Papeix reports receiving consulting fees from Biogen Idec, Novartis, Bayer- schering, Sanofi Aventis and Teva Pharma, Roche ; lecture fees from Bayer-Schering, Biogen Idec, Sanofi Aventis and Teva ; and participating in clinical trials for Biogen Idec, Novartis, Merck Serono, Bayer- schering, Sanofi Aventis and Teva Pharma, Genzyme and Roche.

Sandra. Vukusic reports receiving consulting fees from Biogen Idec, Novartis, Merck Serono, Sanofi Aventis and Teva Pharma; lecture fees from Bayer-Schering, Biogen Idec, Merck Serono, Sanofi Aventis and Teva ; and research support from Bayer-Schering, Biogen Idec, Merck Serono, Sanofi Aventis and Teva.

Nadine Passante, Iuliana Ionescu and Bernard Frangoulis have nothing to disclose.

Bruno Stankoff reports receiving consulting fees from Biogen Idec, Novartis, Merck Serono, Sanofi Aventis and Teva Pharma Bayer- schering ; lecture fees from Bayer-Schering, Biogen Idec, Merck Serono, Sanofi Aventis and Teva ; and research support from Bayer-Schering, Biogen Idec, Merck Serono, Sanofi Aventis and Teva.

Sabrina Oporto, Serge Mrejen, Eric Van Ganse, Fanny Rocher and Anne Castot have nothing to disclose.

Michel Clanet reports receiving consulting fees or research support from Biogen Idec, Genzyme Corporation, Novartis, Merck Serono, Sanofi Aventis, Teva Pharma, Roche.

Catherine Lubetzki reports consulting fees from Roche, Novartis, Sanofi Aventis and Teva Pharma, lecture fees from Merck-Serono, Biogen-Idec, Sanofi Aventis and Teva, participating in clinical trials for Biogen Idec, Novartis, Merck Serono, Bayer- schering, Sanofi Aventis and Teva Pharma, Genzyme and Roche.

Christian Confavreux reports receiving consulting fees from Biogen Idec, Genzyme Corporation, Novartis, Merck Serono, Sanofi Aventis, Teva Pharma and UCB Pharma ; lecture fees from Bayer-Schering, Biogen Idec, LFB, Merck Serono, Sanofi Aventis and Teva Pharma ; and research support from Bayer-Schering, Biogen Idec, Genzyme, Merck Serono, Novartis, Sanofi Aventis and Teva Pharma.

Autoimmunity in patients treated with alemtuzumab for relapsing-remitting multiple sclerosis

E.J. Fox, D.L. Arnold, J. Cohen, A.J. Coles, C. Confavreux, H.-P. Hartung, E. Havrdova, K. Selmaj, H. Weiner, S.L. Lake, D.H. Margolin, P. Oyuela, M. Panzara, D.A.S. Compston for the CARE-MS investigators

Objective: Describe autoimmunity in studies of alemtuzumab for RRMS

Background: Alemtuzumab showed efficacy superior to SC IFNB-1a in two Phase 3 trials and one Phase 2 trial but demonstrated increased risk of some autoimmune disorders.

Methods: Autoimmune disorders after alemtuzumab were reported in a 3-year Phase 2 trial in treatment-naïve patients (CAMMS223), and two 2-year Phase 3 trials in treatment-naïve patients (CARE-MS I) and patients who relapsed on prior therapy (CARE-MS II). Patients received alemtuzumab 12mg/day or 24mg/day IV on 5 days at entry and 3 days 12 months later. Safety measures included patient and investigator education; quarterly thyroid function monitoring; monthly CBC with platelets and symptom monitoring for immune thrombocytopenia (ITP); and monthly serum creatinine and urinalysis to monitor for anti-glomerular basement membrane (anti-GBM) disease. Patients from all 3 studies were enrolled in an ongoing extension study (CAMMS03409). Results are summarized for all alemtuzumab patients from all studies through most recent follow-up, including previously reported events.

Results: As of December 2011, 4262 patient-years of follow-up are available from 1485 alemtuzumab-treated patients (1216 12mg/day, 269 24mg/day). Thyroid AEs were observed in an estimated 36.4% of pooled alemtuzumab patients through 4 years; few had serious thyroid AEs (n=17, 1.4% 12mg/day, n=6, 2.2% 24mg/day). The most common thyroid-related AEs in alemtuzumab-treated patients were hyperthyroidism (8.0%) and hypothyroidism (7.0%). Thyroid AE incidence peaked during the third year and diminished thereafter. Overall incidence of ITP was 1.5% (22 cases) in alemtuzumab-treated patients (n=13, 1.1% 12mg/day, n=9, 3.3% 24mg/day); 16 were confirmed cases without alternative etiology. With the exception of the fatal index case in the Phase 2 study, all subsequent cases were detected through the monitoring program; most responded to conventional therapies, one eventually had splenectomy. A case of autoimmune pancytopenia during the extension study responded to treatment, but subsequent medication noncompliance led to neutropenic sepsis and a fatal outcome. Two cases of anti-GBM disease and two cases of autoimmune haemolytic anemia were detected early with positive outcomes.

Conclusions: Incidence of autoimmune disorders was increased among alemtuzumab-treated MS patients. The safety monitoring program typically allowed for early detection and management with favorable outcomes.

Dr Edward Fox reports receiving consultancy fees, honoraria, travel, and research support from Bayer Healthcare, Novartis, Ono, Sanofi-Aventis, Biogen Idec, EMD Serono, Genzyme, Opexa Therapeutics, Pfizer, Teva Pharmaceuticals, and Eli Lilly.

Dr Douglas L. Arnold reports receiving personal compensation or research support from Bayer Healthcare, Biogen Idec, Genentech, Genzyme, Roche, and Teva Pharmaceuticals.

Dr Jeffrey Cohen reports receiving personal compensation as a consultant or speaker from Biogen Idec, Eli Lilly, Novartis, Teva Pharmaceuticals, Receptos, and Vaccinex.

Dr Alasdair J. Coles reports receiving consulting fees, lecture fees, and institutional grant support from Genzyme, Merck-Serono, and UCB-Celltech.

Dr Christian Confavreux reports receiving consulting fees from Biogen Idec, Gemacbio, Genzyme, Novartis, Sanofi-Aventis, Teva Pharmaceuticals, and UCB; lecture fees from Bayer-Schering, Biogen Idec, Genzyme, Merck-Serono, Novartis, Octapharma, Sanofi-Aventis, and Teva Pharmaceuticals; and research support from Bayer-Schering, Biogen Idec, Merck-Serono, Novartis, Sanofi-Aventis, and Teva Pharmaceuticals.

Dr Hans-Peter Hartung reports receiving the approval of the Rector of HHU fees for consulting, lectures, and activities in Steering Committees of the following companies: Bayer Schering, Biogen Idec, BioMS, Genzyme, Merck-Serono, Novartis, Teva Pharmaceuticals, and Sanofi-Aventis.

Prof Eva Havrdova reports receiving honoraria and grant support from Bayer-Schering, Biogen Idec, Genentech, Genzyme, GlaxoSmithKline, Merck-Serono, Octapharma, Pfizer, Roche, Sanofi-Aventis, and Teva Pharmaceuticals.

Dr Krzysztof Selmaj reports receiving consulting fees from Genzyme, Novartis, Biogen, and Roche; lecture fees from Novartis, Merck-Serono, Biogen, and Bayer Healthcare; and financial compensation, including travel, from Genzyme for scientific presentations.

Dr Howard Weiner reports receiving consulting/honoraria from Biogen Idec, EMD Serono, Genzyme, Teva Pharmaceuticals, Novartis, Nasvax, and GlaxoSmithKline and research support from EMD Serono and GlaxoSmithKline.

Dr Tamara Miller reports receiving compensation for speaker activities from Accorda, Allergan, Biogen Idec, Eli Lilly, Forest, Questcor, and Teva Pharmaceuticals; until clinical trial closure, Dr Miller was an independent contractor for Allergan, Biogen Idec, Genzyme, Elan, Teva Pharmaceuticals, Ono, Sanofi-Aventis, EMD Serono, and Roche/Genentech.

Dr Cary L. Twyman reports receiving compensation for clinical trials from Genzyme, Sanofi-Aventis, Eli Lilly, Opexa Therapeutics, Biogen Idec, Teva Pharmaceuticals, Roche, Novartis, Xenoport, Accorda, and Pfizer Inc and compensation for speaker activities and consultation activities from Accorda, Biogen Idec, Novartis, Forrest, and Teva Pharmaceuticals.

Drs David H. Margolin, Stephen L. Lake, Pedro Oyuela, and Michael Panzara report receiving personal compensation as employees of Genzyme, a Sanofi company.

Prof Alastair Compston reports receiving consulting fees, lecture fees, and grant support from Genzyme and lecture fees from Bayer Schering Pharma on behalf of the University of Cambridge.

Funding provided by Genzyme, a Sanofi company, and Bayer Healthcare Pharmaceuticals.

Low immunogenicity but reduced bioavailability of an interferon-β-1a biosimilar: results of MATRIX, a cross-sectional, multicentre phase 4 study

C. Cuevas, F. Deisenhammer, X. You, M. Scolnik, R. Buffels, B. Sperling on behalf of the MATRIX study group

Background: The clinical efficacy of interferon (IFN) β-1a can be reduced by neutralizing antibody (NAb) formation. While the intramuscular IFN β-1a formulation Avonex(R) (Biogen Idec, Weston, MA, USA) elicits very low immunogenicity (affecting 2%-5% of patients), the immunogenicity of the biosimilar drug Jumtab(R) (Probiomed, Miguel Hidalgo, Mexico) is unknown. Since NAbs can reduce IFN β-1a activity and efficacy, the immunogenicity of biosimilar drugs must be evaluated.

Objective: Compare NAb frequency in multiple sclerosis (MS) patients treated weekly with either Avonex or Jumtab.

Methods: MATRIX was a cross-sectional, retrospective phase 4 study conducted in Mexico and Colombia to determine NAb frequency, as assessed by luciferase assay, in patients with no prior disease-modifying therapy use who were treated exclusively with either Avonex or Jumtab for 1-3 years prior to enrollment. NAb levels >100 IU were considered positive. Neopterin activation, a pharmacodynamic measure of IFN response, was measured as the change in serum neopterin levels from pre-dose to 48 hours post-dose. A retrospective patient record review evaluated possible relationships between NAb status and drug tolerability/safety.

Results: Pharmacy substitution of medication limited study enrollment to 36 and 29 subjects treated with Avonex and Jumtab, respectively (vs the planned 90 patients per group), for a mean duration (±standard deviation) of 24.5±7.5 and 22.1±8.1 months. Avonex patients were significantly younger than Jumtab patients (37.1 vs 44.6 years; P<0.01); otherwise, there were no other significant baseline differences. No patient developed NAb levels >100 IU. However, neopterin activation was significantly greater with Avonex than with Jumtab (2.4±2.2 ng/ml vs 0.7±1.2 ng/ml; P<0.01), and flu-like symptoms (FLS) were seen in 80.6% of Avonex-treated patients versus 31.0% of Jumtab-treated patients (P<0.01). There were no significant group differences in relapses or unexpected adverse events.

Conclusions: Both Avonex and Jumtab exhibited minimal immunogenicity, but Jumtab was associated with significantly less neopterin activation and a significantly lower FLS frequency, suggesting a lower level of IFN bioactivity than for Avonex. These results, which require confirmation in a larger prospective study evaluating the relative safety and efficacy of Avonex and Jumtab in patients with MS, underline the importance of multimodal assessments of new drugs.

Supported by Biogen Idec Inc.

Dr. Cuevas has nothing to disclose. Dr. Deisenhammer has performed contract research supported by Biogen Idec and Bayer, has received honoraria from Biogen Idec and Bayer, and has received consulting fees from Biogen Idec, Bayer, Novartis, and Genzyme/Sanofi. Drs. You, Scolnik, and Sperling are employees of Biogen Idec. Dr. Buffels is a former employee of Biogen Idec.

Interferon-β-1a (Avonex®) as treatment option for untreated MS patients (AXIOM)

C. Kleinschnitz, G. Niemczyk, K. Rehberg-Weber, C. Wernsdörfer for the AXIOM Study Group

Objectives: Intramuscular (IM) interferon (IFN) β-1a is well established as DMT in patients with RRMS. Further approved DMTs are subcutaneous (SC) IFNb-1a, SC IFNb-1b and glatirameracetate. However, large clinical trials can model only certain aspects of the patients’ everyday life, a limitation owed e.g. to pre-selection, intensive monitoring and standardized evaluation of study participants. In contrast to the situation in clinical trials, switching of DMTs or treatment interruptions are common in daily practice. Little is known of how the use of previous DMT or drug discontinuation affects patients’ satisfaction with current treatment or treatment efficacy. Moreover, the factors that lead to a change in treatment regimens are not well characterized. The aim of the German study was to prospectively assess the efficacy of IM IFNb-1a in a real-world-setting after a treatment free period.

Methods: This is an open label multicenter prospective observational study. DMT treatment was allowed previous to this 3 months period. The disease course within the previous 3 to 12 months, the type of preceding MS treatments as well as treatment characteristics (change or interruption of treatment, treatment efficacy) were assessed retrospectively preceding enrolment. Data were collected prospectively at baseline, 3, 6, 9 and 12 months after inclusion. Primary endpoint was the efficacy of IM IFNb-1a by means of disability progression (EDSS) and relapse activity. Secondary endpoints included efficacy as assessed by the Multiple Sclerosis Functional Composite (MSFC) score and MRI parameters.

Results: 235 MS patients in 105 sites with a treatment-free period of at least 3 months initiated therapy with IM IFNb-1a once weekly. Reasons for discontinuation preceding therapies were injection fatigue independently of DMTs, adverse events, injection reactions and flu like symptoms (FLS). After starting IM IFNb-1a therapy injection fatigue, injection reactions, FLS and Quality of life (QoL) improved compared with preceding therapies. During the observation period EDSS and rate of relapses requiring steroid therapy were stable.

Conclusions: Therapy with IM IFNb-1a after a treatment-free period is effective and can reduce injection fatigues compared with more frequently administered therapies. Low frequency (1x/w) administration of IM IFNb-1a was well tolerated and convenient. The results could be useful in optimising MS treatment in everyday clinical practice.

CK: Honoraria, research support, speaking honoraria and travel expenses for scientific meetings from Biogen Idec GmbH. GN, KRW, CW: Employees of Biogen Idec GmbH. Study, medical writing assistance and editorial support was funded by Biogen Idec GmbH.

Detection of polyomavirus JC DNA and anti-JCV antibody in MS patients under natalizumab therapy

V. Clausi, F. Martelli, A.M. Repice, C. Mechi, E. Magnani, L. Massacesi, A. Azzi, S. Giannecchini

University of Florence (Florence, IT); Careggi University Hospital (Florence, IT)

Natalizumab is a humanized monoclonal antibody (Mab) specific for the α4β1 integrin receptor, used for MS therapy. This treatment improves disease course, but after about two years under therapy an increased frequency of progressive multifocal leukoencephalopathy (PML) associated to Polyomavirus JC (JCV) reactivation, has been observed, a severe adverse event that is raising profound concern about long term use of this treatment. In order to assess the presence of JCV infection in single individuals, anti JCV antibody (Ab) frequency evaluation using a highly specific test (Stratify JCV) has been suggested and an algorithm based on this test has been developed for predicting PML risk (Bloomgren G. et al. 2012).

In this study anti JCV Ab frequency was investigated in a cohort of MS patients undergoing natalizumab treatment, in order to evaluate sensitivity of the anti JCV Ab detection based on the Stratify method, for identifying JCV infection. For this purpose JCV-DNA and anti-JCV antibodies have been analyzed in peripheral mononuclear blood cells (PBMC), plasma and urine samples of 37 relapsing remitting MS patients that received between 0 and 33 infusions of natalizumab. Presence of JCV DNA was investigated using real-time quantitative PCR, whereas anti JCV Abs were identified using the Stratify JCV test (a 2-step virus-like particle-based ELISA assay; Focus Diagnostic, provided by Biogen Idec). JCV antibody positivity was observed in 24/37 (62%) of the sera tested. In the same patients Viral DNA was detected in the 41% of PBMC, 13% of the plasma and 28% of the urine samples. Of note out of the 13 anti JCV Ab negative patients, JCV DNA was detected in 5 (38%) of the PBMC and in 3 (23%) of the urine samples. Persintency of viral DNA detection seemed to be associated with higher natalizumab infusion number. According to these results, in order to rule out JCV infection and better evaluate real PML risk under natalizumab treatment in the patients without anti-JCV Ab, it may be reasonable to periodically test for JCV DNA.

The authors have nothing to disclose.

Safety of fingolimod in patients with relapsing forms of multiple sclerosis: subgroup analyses from the 4-month, open-label, multi-centre FIRST study

R. Gold, G. Comi, T. Ziemssen, J. Haas, A. Sinha, F. Dahlke, P. von Rosenstiel, D. Tomic, L. Kappos

Universitatsklinikum der Ruhr-Universität (Bochum, DE); University of Milan (Milan, IT); Klinikum Carl Gustav Carus (Dresden, DE); Jüdisches Krankenhaus (Berlin, DE); Novartis Healthcare Pvt Ltd (Hyderabad, IN); Novartis Pharma AG (Basel, CH); University Hospital (Basel, CH)

Background: Data from previous clinical trials demonstrate that fingolimod has a manageable safety profile. The FIRST study addressed safety during fingolimod initiation and the first four month of use in a multiple sclerosis (MS) population consistent with every-day clinical practice.

Objectives: To evaluate the overall adverse event profile and safety outcomes of interest, associated with the use of fingolimod, in patient subgroups defined by the following baseline characteristics: gender (male/female), age (≤55/>55), MS treatment (experienced/naive), cardiac risks (yes/no) and concomitant diabetes (yes/no) in the large cohort of 2415 relapsing MS patients with broader clinical profiles than included in the fingolimod development program.

Methods: Safety of fingolimod 0.5 mg/day was evaluated by adverse events (AEs), neurological examination, laboratory tests and ophthalmology assessments.

Results: AEs were recorded in similar percentages across most of the pre-defined subgroups (range 71.4%-75.7%), being slightly higher for patients >55 (80%) and diabetics (80.8%). Serious adverse events (SAEs) were recorded more frequently in the subgroup >55 (7.5% vs. 2.5%-4.6% for other subgroups). There were more discontinuations due to AEs in patients >55 (11.3%) than in other subgroups (3.6%-5.1%). Macular oedema was more frequently reported for the group >55 years (5.2%) than ≤55 years (0.5%). MS relapse occurred in less than 1% of patients in any of the subgroups. Cardiac disorders AEs were recorded for 2.8%-4.2% of patients across the subgroups with slightly higher frequency noted in cardiac risk patients (4.7%). Infection AEs occurred in 25%-42.3% of patients across the subgroups. Elevated hepatic enzyme values were more frequently reported for males (3%) than females (0.7%).

Conclusions: The frequency of overall AEs and SAEs was similar across the pre-defined subgroups. There were more cases of macular oedema among patients older than 55 years of age. Elevations of liver enzymes were more frequent in male patients, similarly to what has been noted in the previous clinical trials with fingolimod. Other AEs of interest showed some variations across the subgroups, which can be largely attributed to the numeric imbalance between the subgroups. These results confirm the overall favourable safety profile of fingolimod as observed in >36,000 treated patients amounting to ~34,000 patient-years of exposure by February 2012.

The study was supported by Novartis Pharma AG, Basel, Switzerland.

R Gold has received personal compensation for activities with Bayer Pharmaceuticals Corporation, Biogen Idec, Merck Serono, Teva Neuroscience, personal compensation in an editorial capacity for Therapeutic Advances in Neurological Disorders, payments (royalty or license fee or contractual rights) from Biogen Idec., research support from Bayer Pharmaceuticals Corporation, Biogen Idec, Merck Serono, Novartis and Teva Neuroscience.

G Comi has received consulting fees for participating on advisory boards from Novartis, Teva Pharmaceutical Ind. Ltd, Sanofi-Aventis, Merck Serono, Bayer Schering, Actelion and Geneuro and lecture fees from Novartis, Teva Pharmaceutical Ind. Ltd, Sanofi-Aventis, Merck Serono, Biogen Dompè, Bayer Schering and Serono Symposia International Foundation.

T. Ziemssen has received speaking and consultation honorarium from Biogen Idec, Bayer Healthcare, Novartis, Merck Serono, Genzyme, sanofi-aventis, Teva, MSD.

J Haas has received personal compensation from Bayer, Novartis, Teva, Merck, Almiral and Allergan.

A Sinha is an employee of Novartis Healthcare Pvt. Ltd., Hyderabad, India.

F Dahlke, P von Rosenstiel and D Tomic are employees of Novartis Pharma AG, Basel, Switzerland.

L Kappos has received institutional research support from Acorda, Actelion, Advancell, Allozyne, Barofold, Bayer, Bayhill, Biogen Idec, BioMarin, Boehringer Ingelheim, CSL Behring, Eli Lilly, Geneuro, Genmab, GlaxoSmithKline, Glenmark, Merck Serono, MediciNova, Novartis, Sanofi -Aventis, Santhera, Shire, Roche, Teva, UCB, Wyeth, Swiss MS Society, Swiss National Research Foundation, European Union, Gianni Rubatto Foundation, the Novartis and Roche Research Foundations.

Single cell Stats activation in immune cells reveals NAb effects in vivo

S. Gavasso, T. Marøy, E. Mosleth, K. Jørgensen, B.-T. Gjertsen, K.-M. Myhr, C. Vedeler

University of Bergen (Bergen, NO); Haukeland University Hospital (Bergen, NO); Nofima (Ås, NO)

Background: IFNb is a major first line therapy in MS, but available preparations are immunogenic and can induce the production of neutralizing antibodies (NAbs) that reduce treatment efficacy. Routine testing for NAbs with in vitro assays is recommended. However, reported NAb titers in sera of patients are not necessarily transferable to clinical outcomes. Therefore, a personalized in vivo assay is needed to evaluate the importance of NAbs in individual patients.

Goal: The hypothesis was to test if phospho-specific flow cytometry (phosphoflow) can measure the activation of the IFNb/Stats signaling pathway in immune cell subtypes after administration of IFNb in vivo and to test if an inappropriate response to IFNb due to NAbs can be detected and quantified in vivo. The suitability of the assay was tested against IFNb inducible gene expression changes, including Mx1.

Method: An 8 parameter phosphoflow single cell assay was developed to identify immune cell subtypes in blood and quantify intracellular phosphorylated (activated) Stats transcription factors before IFNb injection and at several time points thereafter and to assess NAb effects in vivo (t=15min-24h; n=10). In addition, IFNb specific gene expression changes (whole blood mRNA) and IFNb concentrations (sera) were measured. Data was subjected to PCA, PLSR, and Ffmanova.

Results: IFNb preparations were significantly different in their Stats signaling signature in immune cells in vivo and NAbs significantly affected this signature in cell subtypes. Phosphorylation of Stat1 in T cells and Monocytes was predictive of NAb class in vivo. Gene expression patterns were significantly affected by NAbs in vivo, but had lower predictive values than Stats. IFNb concentrations in sera were variable but increased after INFb injection in most patients.

Conclusion: Phosphoflow can quantify the activation of the INFb/Stats pathway in immune cell subtypes and detect NAb effects in vivo. This single cell based assay may be more accurate than gene expression changes in whole blood to predict NAbs effect in vivo. The in vivo results support our previously published ex vivo phosphoflow data that shows any titer of NAbs affects the responsiveness of immune cells in patients.

The authors have nothing to disclose.

Long-standing B cells depletion in MS patients treated with combination of rituximab and mitoxantrone

E. Evdoshenko, S. Lapin, A. Maslyanskiy, L. Zaslavsky, A. Totolian, A. Skoromets

Saint-Petersburg Center of multiple sclerosis (Saint-Petersburg, RU)

Introduction: Mitoxantrone (MTX) and Rituximab (RTX) are successfully used for treatment of multiple sclerosis (MS) and can be combined to increase efficacy of treatment. As an antiproliferative agent MTX can also inflict B-cell population and act synergistically to RTX.

Methods and Materials: 28 patients with MS who relapsed at least once during 6 month before enrollment were treated with RTX and MTX. Treatment group included 16 patients who were resistant to standard MS therapy and 12 therapy naïve patients. At the MRI examination conducted within 3 months before enrollment 89,3% (25/28) of patients had GD enhancing MRI lesions (mean 4,43±2,90).

Therapeutic protocol consisted of two infusions within 14 days. First infusion was 1000 mg methylprednisolone (MP) IV and 1000 mg RTX IV and 20 mg MTX IV. The day before and the day after the infusion 1000 mg MP IV were administered. On day 14 1000 mg MP IV and 1000 mg RTX IV were given. Follow up collection of clinical data and MRI examination were performed at 3 time points: 6 months, 9 months and 12 months. Peripheral blood (PB) was taken at the day of lumbal puncture and expression of CD19+ B-cell and CD27+ memory B-cell were studied in PB and cerebrospinal fluid (CSF) with flow cytometry.

Results: There were no relapses among all 28 patients received combined therapy during 12 months of observation. There was no GD enhancing MRI lesions and new T2 lesions in all 28 patients at all time points (6, 9, 12 mo) of follow up.

We performed serial measurements of CD19+ and CD19+/CD27+ memory B-cell subpopulation in PB and CSF. B-cell depletion in PB and CSF was confirmed in all patients. By 9 month B-cells in PB were statistically lower (p=0.001) than before therapy meanwhile in CSF by 9 month B-cells returned to the level before treatment but lack CD27 expression.

Conclusions: Combined treatment of active MS with RTX and MTX had induced prolonged B cell depletion in PB lasting up to 12 months. In CSF B cell reconstitution was faster than in PB and new B-cells lack CD27 expression.

The authors have nothing to disclose.

Predicting the response status to natalizumab in relapsing-remitting multiple sclerosis

L. Prosperini, C.R. Mancinelli, C. Giannì, V. Barletta, F. Fubelli, G. Borriello, C. Pozzilli

S. Andrea Hospital (Rome, IT)

Background: Although natalizumab is considered a very effective treatment for patients with relapsing-remitting multiple sclerosis (RRMS), about 2/3 of treated patients are not ‘’disease free’’ according to the 2-year data from a post-hoc analysis of the AFFIRM trial.

Purpose: To identify baseline predictors of the response to natalizumab in RRMS patients.

Methods: We prospectively collected clinical and MRI data of RRMS patients treated with natalizumab and followed-up for 24 months. They were categorized according to different outcomes of response to natalizumab: (i) “full” responders, i.e. those having no relapses, no sustained disability worsening on Expanded Diasbility Status Scale (EDSS), and no MRI activity; (ii) ‘’partial’’ responders, i.e. those having MRI activity, but not relapses and/or EDSS worsening; (iii) ‘’poor’’ responder, i.e. those experiencing relapses and/or EDSS worsening. A classification tree-based analysis was performed to search the best patient classification by the response to natalizumab over all potential baseline predictors.

Results: We analysed data of 186 patients (125 F, 61 M) with mean (SD) age of 35.1 (9.1), mean MS duration of 9.8 (6.2) years, and median EDSS score of 3.0 (range 1.5-6.5). At the end of the 24-month period, 115 (61.8%), 29 (15.6%), and 42 (22.6%) patients were defined as full, partial or poor responders, respectively. Interestingly, 28/29 patients classified as partial responders experienced MRI activity at the 6-month scan, without any subsequent relapse or sustained disability worsening. A full response to natalizumab were found more likely in patients with ≤2 relapses in the 12 months prior to treatment start (OR=3.28; p=0.002), and in those with an EDSS score ≤3.0 at baseline (OR=2.05; p=0.027). No potential baseline predictors were found to making out the subgroup of partial responders. These figures were replicated even after excluding 18 patients who developed anti-natalizumab antibodies.

Conclusion: Our results suggest that natalizumab may lead to a complete remission of MS if started in patients with less aggressive disease (i.e. few relapses and mild disability), thus supporting the possible role of natalizumab as first-line therapy, at least in JCV-negative patients. Moreover, the occurrence of MRI activity in the scan performed at month 6 of treatment cannot be considered as an early sign of treatment failure, since the majority of patients are full responder later on.

Conflict of interest: all the authors have nothing to disclose.

Funding source: no financial support was received for this research.

List disclosures: LP received consulting fees from Merck Serono, and lectire fees from Biogen Idec. CP received honoraria for consultancy or speaking from Sanofi-Aventis, Biogen Idec, Bayer Schering,Merck Serono, and Novartis, and received research grants from Sanofi-Aventis, Merck Serono, and Bayer Schering. The other authors have nothing to disclose.

Sample sizes for lesion magnetisation transfer ratio outcome measures in remyelination trials for multiple sclerosis

D.R. Altmann, T. Button, K. Schmierer, K. Hunter, D. Tozer, C. Wheeler-Kingshott, A. Coles, D.H. Miller

University College London (London, UK); University of Cambridge (Cambridge, UK)

Background: Demyelinating white matter lesions are a hallmark of multiple sclerosis (MS). The magnetisation transfer ratio (MTR), a magnetic resonance imaging (MRI) measure sensitive to tissue myelin content, may be a useful outcome measure for trials evaluating agents enhancing remyelination.

Objectives: To calculate sample sizes required to detect remyelination in a parallel group, placebo-controlled trial, using mean lesion MTR.

Methods: Two sets of MTR data were used, (i) ex vivo and (ii) in vivo, acquired with the same acquisition parameters using 2D dual spin echo images: (i) 19 demyelinated and 10 remyelinated lesions were identified by an expert rater using proton density (PD) and T2 weighted images in post mortem brain slices from seven patients who died with progressive MS, with lesion myelin content quantified using light transmittance at subsequent histopathological analysis. (ii) 18 patients with relapsing remitting (RR) MS scanned on two occasions one year apart, with lesions defined using PD and T2-weighted images. Sample sizes were calculated for a baseline adjusted comparison of mean lesion MTR from means and standard deviations estimated from the two datasets, and correlation estimated in (ii).

Results: Calculations suggest that 30% remyelination could be detected with 80-90% power in 38-50 patients per arm using the in vivo data, and 66-88 per arm using the ex vivo data, both calculations assuming the in vivo observed inter-scan Pearson correlation of 0.7.

Conclusion: The sample sizes derived are in a range that makes lesion MTR a feasible outcome measure for proof-of-concept trials of putative remyelinating therapies in MS.

Daniel Altmann is partially funded by the Multiple Sclerosis Society of Great Britain and Northern Ireland, and, unconnected to this work, has received an honorarium from Merck.

Tom Button is funded by a David Walker Fellowship and receives a Sackler Studentship.

Klaus Schmierer is a PI on trials sponsored by Novartis and Roche, has received speaking honoraria from, and served on advisory boards for, Novartis and Merck Serono, and is in receipt of a Higher Education Funding Council for England (HEFCE) Clinical Senior Lectureship, and grant support from Barts and The London Charity and from Novartis.

Kelvin Hunter has nothing to disclose.

Dan Tozer is partially funded by the commercial companies Biogen Idec and Novartis, unconnected to this work.

Claudia Wheeler-Kingshott is on the advisory board for BG12 (Biogen) and receives grants (PI and co-applicant) from ISRT, EPSRC, Wings of Life, MS Society, Biogen Idec and Novartis.

Alasdair Coles is funded in part by the National Institute for Health Research (NIHR) Biomedical Research Centre, Cambridge and has received consulting fees, lecture fees, and grant support from Genzyme.

David Miller has received research grants (held by University College London) from Biogen Idec Inc, GlaxoSmithKline, Schering AG, and Novartis to perform MRI analysis in multiple sclerosis trials; and has received honoraria and travel expenses for advisory committee work or as an invited speaker from Biogen Idec Inc, GlaxoKlineSmith, Bayer Schering, Novartis and the US National Institutes of Health.

Magnetic resonance imaging as a surrogate for clinical endpoints in multiple sclerosis

J.S. Wolinksy, L. Wang, P. Truffinet, P.A. Narayana, F. Nelson, P. O’Connor for the TEriflunomide Multiple Sclerosis Oral (TEMSO) Trial Group

Introduction: Teriflunomide is a novel, oral, once-daily disease-modifying therapy for the treatment of relapsing forms of multiple sclerosis (RMS). In the Phase III TEMSO study (NCT00134563), teriflunomide 7 mg and 14 mg significantly reduced the annualised relapse rate (ARR), with risk of 12-week sustained disability progression reduced with 14 mg. Both doses were superior to placebo on a range of MRI endpoints. Recent studies provide evidence for using MRI lesion activity as a surrogate for relapses and disability progression in MS. We formally tested the validity of MRI as a surrogate for the effect of terifunomide on clinical outcomes using e TEMSO trial data.

Methods: TEMSO included 1088 subjects with RMS randomised to teriflunomide 7 mg or 14 mg, or placebo once-daily for 2 years. MRI was obtained at baseline, 24, 48, 72 and 108 weeks on study. The number of combined unique active (CUA) lesions (Gd+ plus Gd- new and enlarged T2) was used as the MRI outcome. The weighted regression equations computed from previously published meta-analyses were used to estimate the treatment effect on ARR and on disability progression predicted by the observed effect on MRI lesions. The Prentice criteria were applied to evaluate the proportion of treatment effect (PTE) on ARR and disability progression explained by the effect on CUA lesions.

Results: The observed effects of teriflunomide 7 mg and 14 mg on ARR were reductions of 31.2% and 31.5% respectively, compared with placebo. The effects predicted from the observed reductions in CUA lesions were reductions in ARR of 31.6% [95% Prediction interval (PI)= [-17.6%, 45.4%] and 49.6% [95%PI= 36.6%, 60.0%], respectively. The observed effects of teriflunomide 7 mg and 14 mg on disability progression were reductions of 20.5% and 26%, respectively. The effects predicted from the observed reductions in CUA lesions were reductions of 3.3% [95% PI= -40.0%, 33.2%] and 20.3% [95%PI= -15.5%, 44.9%], respectively. When applying the Prentice criteria, the PTE explained by CUA lesions on ARR was about 50% for both doses. Details of individual patient analyses will be presented.

Conclusion: At the trial level, the effects of both doses of teriflunomide on disability progression and of the 7 mg dose for ARR are within the 95% PI of the effect that can be predicted by the observed effect on MRI lesions. The effect on ARR of the 14 mg dose predicted from the high reduction of CUA lesions is greater than the observed effect.

Study supported by sanofi. MPS: Consulting fees (Biogen Idec, Merck Serono, Synthon, Actelion), payment for lectures from Teva, Merck Serono, Biogen Idec.

JSW: Consulting agreements with or served as a speaker (Astellas, Bayer HealthCare, Celgene, Consortium of MS Clinics, Eli Lilly, Genzyme, Medscape CME, Novartis, PRIME, sanofi-aventis, Serono Symposia International Foundation, Teva and Teva Neurosciences, the National MS Society; received royalties from Millipore [Chemicon International] Corporation), research (Clayton Foundation for Research, NIH, and sanofi).

LW: Employee of sanofi.

PT: Employee of sanofi.

PAN: Research or contractual support (NIH, Acorda Therapeutics, Inc., Genzyme, and sanofi).

FN: Consulting agreements or speaker (National MS Society, Bayer HealthCare, Novartis, Sanofi-Aventis, Genzyme,Teva Neuroscience, Biogen Idec, Genentech, Medscape, Projects in Knowledge and the University of Massachusetts Medical School. Research or contractual support (NIH, Novartis and Sanofi-Aventis).

POC: Consulting fees and/or research support (Actelion, Bayer, Biogen Idec, BioMS, Cognosci, Daiichi Sankyo, EMD Serono, Genentech, Genmab, Novartis, Roche, sanofi-aventis, Teva, Warburg Pincus.)

Neutralising antibodies against interferon-β and their correlation with clinical and magnetic resonance imaging activity in Japanese multiple sclerosis patients

D. Sato, I. Nakashima, T. Fukazawa, Y. Shimizu, Y. Tomizawa, K. Yokoyama, T. Misu, Y. Itoyama, M. Aoki, K. Fujihara

Tohoku University Graduate School of Medicine (Sendai, JP); Sapporo Neurology Clinic (Sapporo, JP); Tokyo Women’s Medical University School of Medicine (Tokyo, JP); Juntendo University School of Medicine (Tokyo, JP); National Center of Neurology and Psychiatry (Tokyo, JP)

Background: Routine testing for neutralising antibodies (NAbs) against interferon-β (IFN-b) in multiple sclerosis (MS) patients is becoming more common in clinical practice in Western countries. However, the prevalence of NAbs and their impact on clinical outcomes have not been evaluated in Japanese MS patients.

Objective: To investigate the prevalence of NAbs in Japanese MS patients and assess the relationship between NAb status and disease activity.

Methods: Clinical information and sera were collected from 229 MS patients treated with IFN-b in 4 centres in Japan. Sera were tested for NAbs using a luciferase reporter gene assay.

Results: In total, 5.2% of IFN-b 1a IM- and 30.3% of IFN-b 1b SC-treated patients were positive for NAbs. The frequency of NAbs was highest in patients treated for 13 to 24 months. Clinical relapse and magnetic resonance imaging activity increased with NAb levels in this group.

Conclusions: The prevalence of NAbs in Japanese MS patients was similar to that in Caucasian populations and was associated with an increase in disease activity. As a result, routine NAb testing is recommended to ensure the early identification of patients who would benefit from a change in therapy.

Dr. Fukazawa serves/has served on scientific advisory boards for Bayer Schering Pharma, Biogen Idec, Mitsubishi Tanabe Pharma Corporation and Novartis Pharma K.K.; has received funding for travel and speaker honoraria from Bayer Schering Pharma, Biogen Idec, Mitsubishi Tanabe Pharma Corporation and Novartis Pharma K.K.; receives publishing royalties from 110 Questions & Answers about Diagnosis and therapy of Parkinson’s Disease (Chugaiigakusha, 2009). Dr. Shimizu received honoraria for speaking from Bayer Yakuhin, received royalties from the book Quick Reference Guide for Management, and received personal compensation for consulting services from Biogen Idec Japan, Teijin Pharma and Novartis Pharma. Dr. Misu and Dr Fujihara have received a research grant from Bayer Yakuhin and Biogen Idec Japan, manufacturers of interferon-β. All other authors have declared no conflicts of interest.

Funding: This study was supported by KAKENHI (22229008) of The Ministry of Education, Culture, Sports, Science and Technology (MEXT) of Japan, and by the Health and Labour Sciences Research Grant on Intractable Diseases (Neuroimmunological Diseases) from the Ministry of Health, Labour and Welfare of Japan.

Early development of natalizumab antibodies in MS patients

B. Oliver-Martos, P. Urbaneja, T. Órpez- Zafra, C. Arnaiz, M.-J. Pinto-Medel, C. López- Gómez, J.-A. García-León, M. Suardíaz, C. Bañasco, R. Maldonado-Sánchez, L. Leyva, Ó. Fernández

HRU Carlos Haya (Malaga, ES)

Introduction: Natalizumab (NTZ) is a humanized monoclonal antibody approved by the FDA for the treatment of multiple sclerosis.

In a follow up study, we found that any NTZ antibodies to be generated will always occurs within the first four month, since no antibodies were detected after 4 months of the onset of the therapy in any of the patients (Oliver- Martos, 2011). Due to the repercussion that this result could have in the clinical practice, the objective is to validate it in an independent cohort.

Material and Methods: NTZ antibodies determination was performed each month, until the year of treatment was completed in 134 NTZ treated patients (original cohort: 64 patients; validation cohort: 70 patients). The detection and confirmation of antibodies to NTZ in human serum was made by ELISA developed by Biogen Idec. In this procedure, samples are run in both a screening and a confirmation assay on the same plate.

Results: In the validation cohort, 60(85.7%) patients remained negative during the follow up period while 10(14.3%) had at least one positive determination. 6(8.6%) of positives patients, were transiently positive (one positive result) and 4(5.7%) were permanent positives (two consecutive positives results).

From de joint analysis of the two cohorts, 113(84.3%) patients were negative while 21(15.7%) were positive. Ten patients (7.5%) were transiently positive and became negative in the following determination. They continued the treatment with NTZ, remaining negative throughout the observation period. Eleven patients(8.2%) were persistent positive and they had to stop treatment.

In the validation cohort, most patients were first time positives during the first month. After 4 month any patients develop antibodies as first time.

Conclusion: We have reconfirmed that the appearance of NTZ antibodies occur early after initiation of treatment, since most patients who develop antibodies do it in the first month of treatment. Moreover, none of the patients included in the study developed antibodies for the first time beyond the four months of starting treatment.

The presence of antibodies is associated to a reduction in the benefits of NTZ treatment and to the increasing risk of adverse events. Knowing that its development occurs mainly the first month, it makes sense his early assessment. It would be interesting and necessary to establish a consensus about when these antibodies should be determined in order to minimize risks and optimize patient treatment.

Oscar Fernández (MD, PhD) has received honoraria as consultant in advisory boards, and as chairmen or lecturer in meetings, and has also participated in clinical trials and other research projects promoted by Biogen- Idec, Bayer-Schering; Merck-Serono, Teva and Novartis.

The others authors have nothing to disclose.

Use of emerging logistic and linear IRT methods to place common clinical measures of MS progression on a single scale of global neurological disability

E. Chamot, I. Kister, G.R. Cutter

University of Alabama at Birmingham (Birmingham, US); New York University (New York, US)

Background: MS can cause impairment in virtually every neurologic function, but no existing disability scale is able to capture ‘global level of impairment’ caused by MS. Recent research suggests that neurological disability in MS might be best represented by a bifactor measurement model. In psychiatry bifactor models have been successfully used to decompose the relative contribution of symptoms of mental illness to the measurement of general distress and narrower sub-domains (e.g., anxiety and depression).

Objective: To compare the characteristics of the scores of global disability obtained by fitting bifactor models to nine measures of neurological disability with logistic and linear IRT methods. Logistic IRT methods are theoretically more appropriate for categorical measures and linear IRT methods for continuous measures.

Sample and Methods: The study sample consisted of a subset of the original pooled database assembled by the MS Task Force on Outcome Measures for the development of the Multiple Sclerosis Functional Composite (MSFC). Measures consisted of the components of the MSFC, the Expanded Disability Status Scale (EDSS) and five additional tests of leg, cognitive, and arm performances. Data included 480 assessments on 301 men and women with relapsing-remitting MS. Based on previous exploratory work, we hypothesized that the best fit would be obtained with bifactor models where a large fraction of the variability in scores on the observed measures is explained by an underlying dimension of global neurological dysfunction, and additional variability is explained by specific secondary dimensions of leg and cognitive dysfunction.

Results: EDSS scores ranged from 0 to 8 (94% between 0 and 4). The logistic and linear IRT bifactor models fitted the data equally well. Correlation between the two sets of IRT scores of global dysfunction was very high (r=0.96) compared with correlations between either set of scores and MSFC scores (r=0.54). The largest differences between logistic and linear IRT scores were observed for high disability levels where data were sparse. We developed prototype person-measure maps to visually display the relations among IRT, EDSS, timed walk, nine hole peg, and paced auditory serial addition scores.

Conclusion: As a proof of concept, this study suggests that various IRT methods might be useful to represent neurological disability in MS as a bifactor model of general disability and domain-specific disability.

This project was supported by Award Number HC0127 from the National Multiple Sclerosis Society.

Eric Chamot is a consultant for the MSFC Task Force of the National Multiple Sclerosis Society.

Ilya Kister has nothing to declare.

Gary Cutter - Participation of Data and Safety Monitoring Committees: Apotek, Sanofi-Aventis, Biogen, Cleveland Clinic, Daichi-Sankyo, Glaxo Smith Klein Pharmaceuticals, Genmab Biopharmaceuticals, EliLilly, Medivation, Modigenetech, Ono, harmaceuticals, Teva, NHLBI, NINDS, NMSS.

Consulting, Speaking fees & Adviosry Boards: Alexion, Abbott, Bayer, Coronado Biosciences, Novartis, Consortium of MS Centers (grant), Genzyme Klein-Buendel Incorporated, Nuron Biotech, Peptimmune, Receptos, Somnus Pharmaceuticals, Teva pharmaceuticals, St. Louis University.

Relapsing-remitting multiple sclerosis: serial computerised assessment of cognitive changes with natalizumab therapy

M. Gudesblatt, M. Zarif, B. Bumstead, S. Thotam, M. Buhse, L. Fafard, G. Doniger

South Shore Neurologic Associates (Patchogue, US); School of Nursing State University at Stony Brook (Stony Brook, US); NeuroTrax Corporation (Bellaire, US)

Background: Cognitive Impairment is common in patients with Multiple Sclerosis. MS treatment effectiveness is often solely measured by both reductions in relapse rate and MRI enhancing lesions. EDSS and routine clinical care are not sensitive to quantify cognitive changes. Cognitive impairment can vary even within an EDSS group. EDSS and cognitive impairments impact employment differently. Serial examiner-independent quantification of cognitive function might be useful to evaluate medication efficacy in addition to MRI and EDSS.

Objective: To identify changes in cognitive function independently from EDSS and MRI activity in patients newly treated with Natalizumab in the course of routine clinical care.

Methods: Retrospective chart review of patients with MS who initiated treatment with Natalizumab due to disease activity and or failure of another disease modifying therapy and underwent serial examination and a standardized validated computerized cognitive assessment battery for mild impairment (MindSteams, NeuroTrax Corp.).

Results: 100 patients with MS (age 45.0±9.6 years; 74% female; EDSS 3.6±2.1; disease duration <5 yrs N=18; 5 and £10 yrs N=44; >10 yrs N=38) completed the battery twice (inter-test interval: 16.9±6.1 months). Changes identified included: Attention domain improvement on Stroop non-interference levels: p=0.04, d=0.21; faster response times: p=0.01, d=0.18; information processing domain faster response time for a high cognitive load (p=0.005, d=0.30); greater accuracy in memory domain throughout immediate (p<0.001, d=0.34) and delayed (p=0.001, d=0.32) portions of the Verbal Memory test; improvement in verbal function (rhyming: p=0.002, d=0.32; naming: p=0.02, d=0.23). A borderline improvement in EDSS score was found (p=0.05, d=0.07).

Conclusion: Treatment with Natalizumab is associated with improvement in measures of cognitive improvement not detected by EDSS. Improvements included: attention/response time, as well as processing of verbal material. Cognitive improvement independent of EDSS changes might impact employment. Computerized testing detects treatment effects not evident from EDSS. The obtained response time effects may have gone undetected with traditional paper-based methods but were detected with computerized response time measures. Larger, more controlled studies are required.

A. Mark Gudesblatt, MD - consulting fees Biogen Idec.

B. Myassar Zarif, MD - consulting fees Biogen Idec.

C. Barbara Bumstead, ANP - Consulting fees Biogen Idec.

D. Smitha Thotam, ANP - no disclosures.

J. Marijean Buhse, ANP, PhD - Consulting fees Biogen Idec.

K. Lori Fafard, RN - no disclosures.

J. Glen Doniger, PhD - Employee of NeuroTrax Corp.

A novel oral medical nutrition formula (PLP10) for the treatment of relapsing-remitting multiple sclerosis: a randomised, double-blind, placebo-controlled proof-of-concept clinical trial

M.C. Pantzaris, G.N. Loukaides, E.E. Ntzani, I.S. Patrikios

The Cyprus Institute of Neurology and Genetics (CING) (Nicosia, CY); University of Ioannina School of Medicine (UISM) (Ioannina, GR)

Background: Available multiple sclerosis (MS) treatments are products of reductionism, partially effective with no (re)myelinating/neuroprotective abilities associated with significant side-effects. We aimed to assess whether our novel interventions, formulated based on systems medicine (SM)approach, comprising specific polyunsaturated fatty acids (PUFA) and vitamins reduce disease activity in patients with relapsing remitting (RR) MS who were either treated with disease modifying treatment (DMT) or untreated.

Methods: We contacted a 30-month randomized, double-blind, placebo-controlled, proof-of-concept clinical study at the CING. Of a total of 80 patients, 20 were randomly assigned to receive intervention A (docosahexaenoic acid (DHA)/eicosapentaenoic acid (EPA) (3:1 w/w) omega-3, linoleic acid (LA)/γ(g)-linolenic acid (GLA) (2:1 w/w) omega-6 fatty acids, omega-3/omega-6 (1:1 w/w), other specific PUFA, monounsaturated fatty acids (MUFA), minor quantity of specific saturated fatty acids (SFA), vitamin A and vitamin E), 20 to receive g-tocopherol, intervention C, 20 to receive the combination of A and C, intervention B (PLP10) and 20 to receive placebo, as an oral solution, once daily. The primary end point was the annualized relapse rate (ARR) and the key secondary end point was the time to disability progression. ISRCTN87818535.

Results: PLP10 reduced the ARR by 70% (p=0.003), in relation to the baseline ARR and the placebo increased by 46% (p=0.354). During study, for the primary end point, PLP10 reduced the ARR by 58% (95% confidence interval (CI) 0.10 to 0.79, p=0.016) and for the secondary end point, significantly reduced the risk of sustained progression of disability by 86% over the 2-year period (hazard ratio, 0.11; 95% CI 0.01-0.97, p=0.047) vs. placebo. The cumulative probability of progression on basis of survival analysis was 10% in the PLP10 group, and 70% in the placebo group. Proportionately more patients in the PLP10 group (72%) vs. placebo group (20%) were free from new or enlarging T2-weighted lesions on brain MRI scans over the 2-year study. No adverse events were reported. Interventions A and C showed no significant efficacy.

Conclusions: PLP10 treatment significantly reduced the ARR, and the risk of sustained disability progression without any adverse or significant side effects. This is the first clinical study of SM approach medical nutrient formula that holds strong promise as an effective treatment for RRMS.

M.P. received grand support from the Cyprus Ministry of Commerce, Industry and Tourism.G.L.received grand support from the Cyprus Ministry of Commerce, Industry and Tourism. I.P. received grand support from the Cyprus Ministry of Commerce, Industry and Tourism. E.N. has nothing to disclose.

Consequences of different definitions of confirmed disability progression across randomised trials of MS therapies

N. Bergvall, N. Sfikas, J. Alsop, P. Chin, P. von Rosensteil, L. Kappos

Novartis Pharma AG (Basel, CH); Numerus Ltd (Berkshire, UK); Novartis Pharmaceuticals Corporation (New Jersey, US); University Hospital (Basel, CH)

Background and goals: In a previous indirect comparison of 3-month confirmed disability progression, using data from the FREEDOMS and AFFIRM trials, we have shown how important it is to adjust for differences in patient populations and definition of endpoints across trials. In this study we have assessed the impact of differences in definitions of both 3- and 6-month confirmed disability progression utilized across randomized clinical trials of MS therapies.

Methods: The definition of 3- and 6-month confirmed disability progression used in the AFFIRM trial for patients with a baseline EDSS score of 0 (increase of 1.5 or more from a baseline score of 0 that was sustained for 12 and 24 weeks, respectively) was used to perform post-hoc analyses in the ITT population in the FREEDOMS trial. In the FREEDOMS trial, the corresponding definition was an increase of 1 or more. Cox’s proportional hazards model were used to model time to event adjusted for treatment, country, baseline EDSS and age as defined in the study protocol. Hazard ratios, 95% confidence intervals, and p-values for the Cox proportional hazard model were provided.

Results: Utilizing the original definition of confirmed disease progression in the FREEDOMS trial, indicated a risk reduction in 3-month disability progression over 2 years of 30% (hazard ratio of 0.70) for the FTY720 0.5 mg treatment group relative to the placebo group (p=0.024). Utilizing the AFFIRM definition of confirmed disease progression, the corresponding reduction was 36% (hazard ratio of 0.64). In the analyses of 6-month confirmed disability, the corresponding reductions were 37% (hazard ratio of 0.63) and 43 % (hazard ratio of 0.57) relative to the placebo group, using the FREEDOMS and AFFIRM definitions, respectively. Similar trends in changes of point estimates were observed for both the 3- and 6-month confirmed disability progression in the FREEDOMS II trial.

Conclusions: In addition to the importance of adjusting for differences in patient characteristics in indirect comparisons, the presented results show that differences in definition of confirmed disease progression across trials may have a relevant impact when comparing point estimates of both 3 and 6 month confirmed disease progression across trials.

Analyses were supported by Novartis Pharma AG, Basel, Switzerland.

Bergvall N is a paid employee of Novartis Pharma AG.

Sfikas N is a paid employee of Novartis Pharma AG.

Alsop J was a paid consultant to Novartis Pharma AG

Chin P is as paid employee of Novartis Pharmaceuticals Corporation.

Rosenstiel P is a paid employee of Novartis Pharma AG.

Kappos L has received compensation for serving as consultant or speaker, have received research support, prepared manuscripts, or held board membership with the following companies: Actelion, Advancell, Allozyne, BaroFold, Bayer Healthcare Pharmaceuticals, Bayer Schering Pharma, Bayhill, Biogen Idec, BioMarin, CLC Behring, Elan, Genmab, Genmark Diagnostics, GeNeuro, GlaxoSmithKline, Lilly, MediciNova, Merck Serono, Novartis, Novo Nordisk, Peptimmune, sanofiaventis, Santhera Pharmaceuticals, Roche, Teva, UCB and Wyeth.

Symptomatic steroid induced osteonecrosis of distal femur in multiple sclerosis

S. La Gioia, M. Poloni, M. Rottoli

IRCCS S. Raffaele (Milan, IT); Ospedali Riuniti (Bergamo, IT)

Thirty-five percent of non traumatic cases of osteonecrosis are due to long-term corticosteroid treatment. High dose steroid pulses are a well established treatment for multiple sclerosis (MS) relapses. The incidence of steroid induced osteonecrosis (SIO) in MS is uncertain. Only few case series on symptomatic SIO of femoral head or diaphysis were reported.

Objectives: to report symptomatic steroid induced osteonecrosis of distal femur after low cumulative steroid dosage in relapsing-remitting MS during interferon β treatment.

Methods: case reports.

Results: Case 1: A 23-year-old woman was diagnosed relapsing-remitting MS in June 2007. Over a period of 29 months she received intravenous Methylprednisolone (MPD) 15 g for relapses treatment. One month after her last pulse she began suffering pain in her right knee. X-rays and MRI were normal, pain spontaneously disappeared in a few weeks. One year later she complained again pain in her right knee and MRI detected an extensive infarction of the right distal femoral and proximal tibial epiphysis. She was treated with biphosphonate and cholecalciferol with only partial benefit on pain and articular impairment. She carried on interferon treatment without any further MS relapses.

Case 2: A 20-year-old woman was diagnosed relapsing-remitting MS in June 2007. Over a period of 28 months she received intravenous MPD 10 g for relapses treatment. In a few days after her last pulse she complained mild bilateral pain in her knees, which disappeared with NSAIDs. One year later she began suffering severe pain in her right knee. X-rays were normal, but MRI detected avascular necrosis in her right femoral condyle. She was treated with biphoshonate with benefit. MS treatment was then switched to fingolimod without any further relapses.

Conclusions: To our knowledge there are no previous reports of distal femoral SIO in MS. Neurological pain may induce to underestimate the event of avascular bone necrosis after steroid pulse treatment, even with low cumulative dosages and after a long time interval. An early diagnosis before the joints become compromised is crucial for an adequate management. Identification of high risk patients is also an issue to consider while applying repeated high dose steroids. Furthermore, a critical point appears to be MS relapse management after osteonecrosis diagnosis: how risky is a new steroid treatment? How much a therapeutic shift to a second line agent is justified before new relapses?

The authors have nothing to disclose.

Time trends in baseline characteristics and eligibility criteria in trials in relapsing mutliple sclerosis - a systematic review and meta-analysis

S.M. Steinvorth, R. Nicholas, C. Röver, S. Schneider, S. Straube, T. Friede

University of Göttingen (Göttingen, DE); West London Neurosciences Centre (London, UK)

Background: A downward trend in annualised relapse rates (ARR) over time has been described in the placebo groups of randomised controlled trials (RCTs) in relapsing multiple sclerosis (MS). We examined time trends in participant baseline characteristics and eligibility criteria in MS trials as a possible explanation for this phenomenon.

Methods: We searched PubMed, Web Of Knowledge and The Cochrane Library. For inclusion in our systematic review studies had to be placebo-controlled, double-blind RCTs in relapsing MS and report on-trial ARR or number of relapses, from which ARR was calculated. Using weighted linear regression we analysed time trends in on-trial ARR, baseline characteristics such as age, baseline (pre-study) ARR, the period of time over which baseline ARR was defined, and the number eligibility criteria.

Results: We included 51 studies conducted between 1982 and 2012 with a total of 12,881 patients. In these studies there was a downward trend in on-trial ARR in the placebo groups confirming previous findings. The mean number of eligibility criteria increased significantly over time with roughly twice as many criteria in 2012 compared to 1982 (an increase of 4 criteria per decade, p=0.0012). Mean age also increased significantly over time (approximately two months per year, p=0.002). While trial baseline ARR was with 1.5 relapses per year fairly constant over time, the period of time over which baseline ARR was defined decreased over time (by more than 3 weeks per year on average, p<0.001).

Conclusions: The decrease in on-trial ARR is not explained by changes in baseline ARR. However, more complex eligibility criteria and changes in the period of time considered to define baseline ARR may be of relevance; measuring ARR over shorter periods of time, one year in recent studies, means that now patients with one relapse in the last year, but none in the years before may be eligible for inclusion in RCTs, whereas previously they might not have been. This has implications for indirect comparisons of treatments across trials.

The authors have nothing to disclose.

Patient education programme on diagnosis, prognosis and early therapy for persons with early multiple sclerosis – multicentre, randomised, controlled trial (ISRCTN12440282)

S. Köpke, S. Kern, K. Fischer, J. Kasper, I. Kleiter, M. Berghoff, F. Paul, M. Marziniak, T. Ziemssen, C. Heesen

University of Lübeck (Lübeck, DE); University Hospital Dresden (Dresden, DE); University Medical Center (Hamburg, DE); University Hospital Bochum (Bochum, DE); University Hospital Giessen (Giessen, DE); Charitee Berlin (Berlin, DE); University Hospital Münster (Münster, DE)

Background: Uncertainty remains about long-term efficacy of disease modifying drugs (DMD) in multiple sclerosis (MS) as well as about possible benign disease courses. Therefore, evidence-based patient information has been advocated as prerequisite to allow for informed treatment choices and shared decision making. An evidence-based patient education program was developed for persons with early MS. The study aimed to assess the efficacy of the programme in a 12-month randomised controlled trial.

Methods: The intervention group (IG) received a 4-hour interactive educational programme based on the current evidence about diagnosis, prognosis, and early DMD treatment together with a preparatory 57-page information brochure. The control group (CG) received a 4-hour coping-training. Patients with suspected or definite MS diagnosed within the last 2 years were included. Participants and data assessors were blinded to participants’ group allocation. Primary outcome measure was “informed choice” after 6 months assessed with the “Multi-dimensional Measure of Informed Choice (MMIC)”. Further outcomes comprised decision autonomy, anxiety and depression, and risk knowledge. In addition, the newly developed “planned behaviour in MS (PBMS)”-questionnaire was used to assess elaboration of decision making concerning disease modifying therapy.

Results: A total of 192 patients were included (IG=93, CG=99) in 6 hospital-based centres throughout Germany. Results for the primary endpoint showed a significant difference with 58% of IG participants achieving “informed choice” after 6 months compared to 22% in the CG (OR 0.2, 95% CI 0.1-0.4, p<0.001). Four weeks after the intervention, risk knowledge was significantly better in the intervention group. Also using the PBMS, in the IG opinions of others (“social norm”) were less important and attitude towards DMT was more critical, with no difference after 12 months. Four weeks after the intervention, more IG participants preferred autonomous decisions with again no difference after 12-months. After 12 months, no significant differences were found for anxiety and depression, and for treatment compliance.

Conclusion: The program significantly increased “informed choice” and relevant risk knowledge compared to a MS-specific coping program. Effects on autonomy preference and decision making were only seen in the short term indicating that a single education programme might not be sufficient to promote enduring effects.

SK has nothing to declare.

Lisdexamfetamine dimesylate improves processing speed and memory in cognitively impaired MS patients: a phase II study

S.A. Morrow, A Smerbeck, K. Patrick, D. Cookfair, B. Weinstock-Guttman, R.H.B. Benedict

University of Western Ontario (London, CA); Jacobs neurological Institute (Buffalo, US)

Introduction: Multiple Sclerosis (MS) is known to cause cognitive impairment commonly presenting as slowed processing speed and problems with learning and memory. Stimulants such as amphetamines are attractive candidates for improving mental speed but carry risk for addiction and other adverse behavioral effects. Lisdexamfetamine dimesylate (LDX) is a prodrug currently approved for attention deficit (hyperactivity) disorder (ADHD) with the potential to be better tolerated due to its prolonged clinical effect.

Methods: This phase II placebo-controlled, double-blind study aimed to assess the safety and efficacy of LDX in cognitively impaired MS patients. Subjects were ages 18-56 with clinically definite MS impaired on either of the primary outcomes, the Symbol Digit Modalities Test (SDMT) or Paced Auditory Serial Addition Test (PASAT), measures of processing speed. Sixty-three subjects were randomized to 30mg of LDX or placebo in a 2:1 fashion; the dose was increased as tolerated to 70mg over four weeks and then maintained for another four weeks. Secondary outcomes were the Brief Visuospatial Memory Test Revised (BVMTR), the California Verbal Learning Test (CVLT2) both measures of memory, and the Behavioral Rating Inventory of Executive Function for adults (BRIEF-A), a self-report measure of executive function. Fatigue and depression were also evaluated.

Results: There was significant improvement on the SDMT (+4.8 vs. +1.3) and CVLT2 (+4.7 vs. -0.9) in the LDX group vs. placebo in the 49 completers. There was no change on the BRIEF-A or on self-reported measures of fatigue and depression. A high proportion of both LDX and placebo subjects reported adverse events (73.5 vs. 68.4%). However there were no serious adverse events noted in the study.

Conclusion: LDX shows the potential to be an efficacious treatment for MS patients with cognitive impairment.

Dr. Morrow has participated in speaker’s bureaus and served as a consultant for Bayer, BiogenIdec, EMD Serono, Teva Neurosciences and Novartis. She has also received grant/research support from BiogenIdec and Novartis. No other industry financial relationships exist.

Dr. Smerbeck, Dr. Cookfair and Ms. Patrick have nothing to disclose.

Dr. Weinstock-Guttman has participated in speaker’s bureaus and served as a consultant for BiogenIdec, Teva Neurosciences, EMD Serono, Pfizer, Novartis, Genzyme and Accorda. Excluding Genzyme, she has also received grant/research support from the agencies listed above as well as ITN, Questcor and Shire. No other industry financial relationships exist.

Dr. Ralph Benedict has participated in speaker’s bureaus and served as a consultant for Actelion, BiogenIdec, Bayer and Novartis. He has also received grant/research support from Accorda, BiogenIdec and Shire. He also receives royalties from Psychological Assessment Resources. No other industry financial relationships exist.

This research was sponsored by Shire Development LLC.

Office-based single-bolus intrathecal Baclofen trials in MS patients: a call to action

J. Nicholas, M. Bartoszek, C. O’Connell, B. Morgan-Followell, D. Pitt, A. Boster

The Ohio State University (Columbus, US)

Background: Moderate to severe spasticity in MS patients is grossly undertreated. An estimated 13% of MS patients may be good candidates for intrathecal baclofen (ITB) therapy, and yet only 1% of patients are currently receiving ITB. Surprisingly, only 25% of spastic MS patients report having discussed ITB with their clinician. A large barrier to the ITB use in MS patients may be the clinicians’ lack of familiarity with ITB as an effective option. Neurologists are ideally suited to perform office-based, single-bolus ITB trials, one key component of ITB management. We believe that with increased familiarity more Neurologists would become comfortable adding ITB to their armamentarium of symptomatic MS treatments.

Methods: IRB approved retrospective chart review of 60 ITB patients from 1994-2011. Complete data on 27 ITB trials was available from 2009-2011. Demographic data collected included age, gender, ethnicity, disease type, ambulatory status and expanded disability status scale. Outcomes data was collected on Ashworth, VAS pain, Penn Spasm scores, oral antispasmodic use, and adverse events related to the ITB trial. Student T tests were used to compare data before office-based ITB bolus trial, at best response during ITB bolus trial, and at most recent follow up visit.

Results: No adverse events were reported and all patients were later implanted to receive ITB therapy. Statistically significant improvement in all outcome parameters was found comparing pre-ITB trial to best post-ITB trial response (average 3.8 hours after injection). Pain VAS: Pre 4.3(±2.2), Post 0.4(±0.7),p<0.0001; Penn Spasm: Pre 2.9(±1.1), Post 0.2(±0.6), p<0.0001; Ashworth scale: Pre Hip Adductors 2.5(±1.2), Post 0.9(±1.0), p=0.0001; Knee extensors: Pre 3(±1.2), Post 1.1(±1.3),p<0.0001; Knee flexors: Pre 2.7(±1.2), Post 1(±1.1),p<0.0001. These improvements remained statistically significant at most recent follow up (average 24 months later). Pre-ITB oral baclofen dose was 91.4 mg daily (±35.8) decreased to 0 mg daily in all patients at most recent follow up, p<0.0001.

Conclusion: Single-bolus, office-based ITB trials were safe, well tolerated and predictive of a sustained positive response to future ITB therapy. These trials are faster and less expensive than hospital based ITB trials. Adoption of this outpatient protocol would allow more candidate MS patients access to ITB therapy.

J.N. has received funding through a Sylvia Lawry Physician Fellowship award from the National MS Society. M.P.B. has nothing to disclose. C.O. has nothing to disclose. B.M.F. has received funding from a Clinician Fellowship award from the National MS Society. D.P. has nothing to disclose. A.B. has received consulting fees from Medtronic.

Dalfampridine extended release tablets: safety profile after 2 years of post-marketing experience in the United States

M. Jara, M. Adera, A. Adedeji, H. Henney, E. Carrazana

Acorda Therapeutics, Inc. (Hawthorne, US)

Background: Dalfampridine extended release 10 mg tablets (D-ER; prolonged-, modified, or sustained-release fampridine outside the US) were approved by the FDA in January 2010 to improve walking in patients with multiple sclerosis (MS). D-ER has been commercially available in the US since March 2010. Two years of post-marketing safety data are now available from the exposure of approximately 53,500 patients in the US (35,000 patient-years) from product approval through March 31, 2012.

Methods: A descriptive analysis of all spontaneously reported adverse events (AEs) in the 2-year post-marketing period was performed. Commonly reported AEs were defined as those with a prevalence ≥2.0% of all reported AEs. Analysis was conducted to determine the incidence of reported seizures in the population using D-ER. Seizure is an expected event and cases are submitted to the FDA as 15-day alert reports as part of the Risk Evaluation and Mitigation Strategy commitment.

Results: The most frequently reported post-marketing AEs were dizziness, insomnia, balance disorder, headache, nausea, urinary tract infection, back pain, and asthenia. These were similar to the AEs most frequently reported during clinical development and are all included in the US product labeling. Other common events, as identified in the first year of marketing, were related to lack of efficacy and inappropriate dosing, defined as dosing inconsistent with the label, i.e., one 10 mg tablet taken approximately every 12 hours. During the post-marketing period, among the 53,500 patients who were exposed to D-ER, 160 seizures were reported (4.57/1000 patient-years of use). Beyond the MS-related seizure risk, an additional potential risk factor for seizure (i.e., a previous history of convulsion, renal impairment, incorrect dosing, or use of concurrent medications with a labelled seizure risk, or other medical risk) was identified in 53% of cases. Duration of treatment prior to a seizure event ranged from 1 dose to 2 years, with 20% of the seizures occurring within a week of starting treatment.

Conclusion: Spontaneous safety data reported after 2 years from the US post-marketing experience are consistent with those reported at 1 year and in clinical trials. The seizure incidence was similar to what had previously been reported and what may be expected in an MS population.

Supported by Acorda Therapeutics, Inc.

MJ, MA, HH, and EC are employees and stockholders of Acorda Therapeutics, Inc.

AA is an employee of Acorda Therapeutics, Inc.

Open-label extension patient retention rates with dalfampridine extended-release tablets in multiple sclerosis

R. Schapiro, F. Bethoux, T. Brown, L. Williamson, A. Rabinowicz, L. Marinucci, E. Carrazana

University of Minnesota (Minneapolis, US); Cleveland Clinic Foundation (Cleveland, US); Evergreen Hospital Medical Center (Kirkland, US); Acorda Therapeutics, Inc. (Hawthorne, US)

Background: Dalfampridine extended release tablets (D-ER; prolonged-, modified, or sustained-release fampridine outside the US) are approved in the US for patients with multiple sclerosis (MS). D-ER was shown to be effective in improving walking speed in 2 Phase 3 double-blind (DB) clinical trials (MS-F203/MS-F204). Timed walk response rate to D-ER in the DB trials was 37.6%. Patients randomized to D-ER experienced improvement in the Lower Extremity Manual Muscle Test (LEMMT), Ashworth score for spasticity, 12-item MS Walking Scale (MSWS-12), and Subject Global Impression (SGI). Open-label extension trials (MS-F203EXT/MS-F204EXT) further assessed safety and walking speed on D-ER.

Objective: To determine patient retention in MS-F203EXT and MS-F204EXT and to use data from the DB trials to explore factors that may have contributed to patient retention in the extension trials.

Methods: In the DB trials, patients were randomized to receive either D-ER 10 mg twice daily or placebo. In both extension trials, all patients received D-ER 10 mg twice daily. Timed 25-Foot Walk (T25FW) was the primary efficacy variable in the DB studies and was measured in the extension studies. DB timed-walk responders were defined as patients who consistently walked faster on drug than off drug.

Results: Of the 283 patients who completed MS-F203, 269 entered MS-F203EXT. At the time of study completion (maximum exposure=5 years), 57.2% of patients remained enrolled (n=154). Of the 227 patients who completed MS-F204, 214 entered MS-F204EXT. At the time of study completion (maximum exposure=3.3 years), 68.2% of patients remained enrolled (n=146). Retention rates in DB responders, nonresponders, and placebo patients were 62.0% (n=44), 53.8% (n=70), and 58.8% (n=40) in MS-F203EXT and 73.5% (n=36), 68.3% (n=41), and 65.7% (n=69) in MS-F204EXT, respectively.

Conclusion: Retention rates in the D-ER extension studies were higher than the timed-walk responder rate from the DB trials. Patients who were timed-walk responders in the DB trials showed higher retention in the extension phase than those who were not responders. Improvements in leg strength or spasticity may have contributed to patient retention, as may have patients’ perceptions of improvement; however, these outcomes were not measured in the extension trials. Favorable tolerability of D-ER and additional factors not associated with drug effect may have contributed to retention.

Supported by Acorda Therapeutics, Inc.

RS discloses employment with EMD Serono, Inc. Consultancy for Acorda Therapeutics, Inc. and Pfizer. Board memberships with NMSS; CanDo MS.

FB served as a consultant and/or on speakers bureau for Acorda Therapeutics, Inc., Allergan, Biogen Idec, Medtronic Inc., and Merz. FB received research funding from Acorda Therapeutics, Inc. and Innovative Neurotronics.

TB served as a consultant for Acorda Therapeutics, Inc., Bayer, Biogen, EMD Serono, Otsuka Pharmaceutical and Teva Neuroscience. TB received honoraria from Acorda Therapeutics, Inc., Pfizer, and Teva. TB received research funding from Lilly Inc., Acorda, Biogen, and Teva Neuroscience.

LW, AR, LM, and EC are employees and stockholders of Acorda Therapeutics, Inc.

Dalfampridine effects on visual-evoked potentials

R. Schmeck, M. Korsen, U. Runge, U. Schminke, A. Dressel

University Greifswald (Greifswald, DE)

Background: Dalfampridine (extended-release formulation of 4-aminopyridine) is a potassium channel blocker that is known to improve conduction in denuded axons. Clinically it has been shown to improve walking ability in some but not all Multiple Sclerosis (MS) patients. Accordingly, responders (R) are defined as patients in whom walking speed improved significantly, while patients without such improvement are termed non-responders (NR). Here we investigated whether the effects of Dalfampridine on walking ability would be paralleled by alterations in visual evoked potentials (VEP).

Materials and methods: The study was designed as a prospective, single center, single arm, observational study of two weeks duration for a total of 75 patients. Patients had MS according to McDonald criteria, an EDSS of 4-7, creatinine clearance ≥ 80ml/min and no history of seizures. Patients’ visits were scheduled before treatment initiation and 14 days thereafter. Patients were categorized as R (increase in maximal walking distance of ≥ 20%) and NR. In addition the p100 of VEP and fatigue, quality of life and depression scores were assessed using self rating scales. The predefined primary endpoint was the effect of Dalfampridine on VEP latency.

Results: So far a total number of 31 patients were screened, 26 patients fulfilled the inclusion criteria and were enrolled into the study. 18 patients completed the two weeks treatment course and were available for analysis. 11 of those met the criteria as R. R showed a significant improvement in p100 latency (p =0.0217) while no alteration was seen in the NR (p=0.3186). Similarly R (p=0.0374) but not NR (p=0.3100) improved in the FSS fatigue scale.

Conclusion: Here the effects of Dalfampridine on walking ability, VEP p100 latency and fatigue were studied. The increase in walking ability in the R was paralleled by an improvement in the VEP latency and fatigue score while no beneficial effects were seen in NR.

We conclude that VEP may serve as a surrogate marker to identify patients that will benefit from Dalfampridine treatment. Future studies are required to investigate whether the response patterns to Dalfampridine are related to certain patterns of brain pathology.

The study was funded by intramural research support of the University Medicine Greifswald. MK holds a scholarship from the German National Academic Foundation. AD has received funding for research projects and speakers honoraria from Bayer Schering, Merck Serono, Novartis, Teva and Biogen. RS, UR and US have nothing to disclose.

Drug treatment of spasticity in multiple sclerosis – a cross-sectional survey in Germany

P. Flachenecker, U. Zettl, U. Essner, T. Henze

Neurological Rehabilitation Center Quellenhof (Bad Wildbad, DE); University of Rostock (Rostock, DE); Almirall, Medical Affairs (Reinbek, DE); Rehabilitation Center (Nittenau, DE)

Spasticity is a frequent and difficult to manage symptom of multiple sclerosis (MS) which has a huge impact on quality of life in patients with MS and requires relevant resources from the health care system.

Aim: To assess the usage of pharmacological treatment in MS-associated spasticity in Germany.

Methods: This cross-sectional study in German centres specialised for MS treatment was performed in late 2010 and early 2011. Data from patients with MS spasticity included current MS drug treatment (disease modifying drugs and antispastic medication) and satisfaction with the available antispastic drugs. Extent and intensity of concomitant physiotherapy was also assessed.

Results: 414 patients from 42 centres were recruited (64.3% female, mean age 48.5 years, mean disease duration 13.9 years, 44.7% with relapsing-remitting MS and 44.4% with secondary-progressive MS). Mean duration of spasticity was 8.2 years, and the mean Expanded Disability Status Scale (EDSS) score was 5.25.

68.1% of the patients were on treatment with immunomodulators.The most prescribed immunomodulating agents were β-interferons (31.9%) and natalizumab (19.1%). Antispastic drug treatment was given to 60.9% of the patients (mild spasticity 37.2% of patients, moderate spasticity 61.5%, and severe spasticity 82.4%). Baclofen was the most commonly prescribed drug (55.3%), followed by tolperisone (28.1%) and tizanidine (14.9%). The overall satisfaction with the effectiveness of the therapy was poor: only 23.8% of the physicians and 34.4% of the patients were satisfied or very satisfied with the present spasticity treatment.

Conclusion: The currently available pharmacological treatment options are not sufficient to provide satisfactory control for MS-associated spasticity. Therefore, there is an urgent need for better therapies to relief the burden of spasticity in MS patients.

This study was supported by Almirall Hermal GmbH.

Measurement of daily mobility under fampridine-therapy with Movisens-system in patients with multiple sclerosis

R. Kempcke, T. Schultheiß, S. Sobek, K. Thomas, L. Shammas, S. Hey, T. Zentek, A. Rashid, T. Ziemssen

Multiple Sclerosis Centre (Dresden, DE); KIT, House of Competence – hiper.campus (Karlsruhe, DE); FZI Forschungszentrum Informatik (Karlsruhe, DE)

Introduction: Examinations of mobility in different patient populations usually base on situationally taken parameters. Consequently, many study results mirror the mobility of patients in their natural setting insufficiently. The activity sensor Move II is carried continuously in the everyday setting and thereby reflects the activity of patients in different situations during the whole day. In the present study, the Move II was used for the first time in a pilot project for evaluating how daily activity of MS patients changes under fampridine-therapy.

Methods: 26 patients of the MS Center Dresden were investigated (mean age: 49.6 years, mean EDSS score: 5.6). They carried the activity sensor Move II continuously as mobile measurement instrument for recording their physical activity. The Move II registers the row data of an acceleration-sensor in three axes. Secondary parameters (e.g. number of steps, intensity of activity) can be calculated from these data. Patients were instructed to wear the Move II without medication and when taking fampridine. Classification of patients as “responder” or “non-responder” based on T25FW.

Results: 21 patients were classified as responders (mean age: 48.1 years, mean EDSS score: 5.8), whereas 5 patients were classified as non-responders (mean age: 56 years, mean EDSS score: 4.0). The Move II has been carried for 13.4 hours on average per day (responders: 13.4 hours/day, non-responders: 13.2 hours/day). Before taking fampridine, the Move II has been carried for 8 days on average (responders: 8.6 days, non-responders: 7.4 days). Under fampridine-therapy, patients have been carrying the apparatus for an average of 10.7 days (responders: 12.6 days, non-responders: 8.8 days). Move II-data showed an increase of number of steps per day of 3.35% for responders under fampridine-therapy. In contrast, non-responders showed a decrease of number of daily steps with fampridine of more than 5%.

Conclusion: The Move II allows assessing the mobility of MS-patients beyond the situational context. The daily measured number of steps by the Move II shows an improvement of responders under fampridine, while non-responders worsen. This indicates the ability of the Move II to sensitively reflect different effects of fampridine-therapy. The number of steps, which is registered by the Move II, should be related to step length and other gait parameters in future investigations for ensuring a holistic analysis of mobility changes in consideration of the close conjunction of these parameters.

The authors declare having received no financial grants.

Comparison of different endurance trainings in advanced multiple sclerosis patients: a randomised, controlled pilot study

S. Briken, S. Gold, K. Schulz, D. Harbs, S. Patra, G. Ketels, C. Heesen

University Hospital Eppendorf (Hamburg, DE)

Objective: Exercise studies in MS to date have included patients during the early phase of disease with mild to moderate disability. In this pilot study, we investigated if standardized fitness training is feasible for patients with progressive disease and which training form may be most suitable for this group. In addition, we aimed to explore if exercise can enhance physical fitness, walking ability and cognitive function in this population.

Methods: Three different exercise interventions (arm ergometry, rowing, bicycle ergometry) were compared with a waitlist control group, measuring the effects on fitness, walking ability, quality of life, depression, fatigue and cognitive function. Fourty-seven subjects with advanced SP-MS/PP-MS (EDSS 4-6) were included and randomized using a biased-coin algorithm adjusting for age, gender and EDSS. A standardized training schedule was developed for each subject based on the individual results from a bicycle ergometry performance test. Patients completed a training program with gradually increasing work load in each session. All subjects completed at least 20 training sessions in 8-10 weeks.

Results: All three exercise modalities were feasible in MS patients with advanced disability. The drop-out rate was 15% and did not significantly differ between the exercise and the control group. In comparison with the control group, the interventions led to significant improvements in most of the outcome parameters: Walking ability was significantly increased (six-minute-walking test: p=0.008, timed-tandem-walk: p=0.019, timed-up-and-go test: p=0.038). Improvements were seen in depression (p=0.002), fatigue (p=0.049) and cognitive function (verbal-learning-memorytest, subtest learning: p=0.02, subtest delayed recall: p=0.01). Post hoc analyses revealed strongest improvements in the bicycle and hand ergometry groups for walking ability, depression and fatigue compared to the control group. Intriguingly, all three interventions had an effect on memory and learning.

Conclusion: The different interventions had a significant impact, not only on the physical, but also on the other disability domains. We therefore believe, that well adjusted individual endurance training for multiple sclerosis patients should be more advocated also in advanced stages. Moreover, further larger multicenter studies as well as investigations on the putative neuroregenerative or neuroprotective effects of exercise training in MS are warranted.

The authors have nothing to disclose.

An alternative approach to estimate the health economic value of a non-disease modifying therapy for patients with multiple sclerosis: a Swedish application

R.-L. Leskelä, M. Dahlman, J.A. Gaebler, B. Deniz, S. Sarda, F. Herse

Nordic Healthcare Group (Helsinki, FI); Biogen Idec Inc. (Copenhagen, DK); Biogen Idec Inc. (Weston, US)

Background: Traditional health economic assessments of disease modifying therapies (DMTs) in patients with multiple sclerosis (MS) utilize economic models that are based on differential disease progression rates. These models provide little insight on the health economic value of therapies that are not DMTs, such as symptomatics that do not affect disease progression. There is a need for new approaches to evaluate the potential health economic benefit of non-DMTs.

Methods: Prolonged release (PR)-fampridine (dalfampridine extended release in the US) is a symptomatic therapy to improve walking in patients with MS. The primary outcome of the phase 3 trials was consistent improvement on the walking speed (WS) using the Timed 25-foot Walk. To assess health economic value of this new treatment, an alternative model was developed which assumes that treatment only impacts the walking ability of a patient rather than the course of disease progression. In the model, only patients with Expanded Disability Status Scale (EDSS) scores of 4.0-7.0 are included, per the indicated European label. Each EDSS patient-score is associated with quality of life (QoL) index (i.e., utility score) and healthcare costs, based on the published literature. Functional relations between WS, utility score, and healthcare costs were derived through baseline EDSS scores, as there is no data set linking WS to utility scores or healthcare costs directly. The model then estimates the improvement in utility and costs resulting from improvement in WS for PR-fampridine vs. the standard of care (SOC), as well as the incremental cost-effectiveness ratios (ICER). Base case analyses utilized Sweden-specific healthcare costs and patients’ QoL, reflective of the MS population. ICERs for the Swedish base case were calculated for 1, 4, 7, 10, and 20 years.

Results: Applying our new model to the Swedish setting, compared to SOC, we found a utility gain of 0.080 for PR-fampridine in the 7-year base case analysis and an ICER of 616,389 Swedish Kronor (SEK), which is below the assumed 800,000 SEK threshold for severe chronic diseases.

Conclusion: MS treatments that target disease symptoms instead of disease progression may require an alternative approach for health economic assessment. The modeling methodology described here seeks to address this gap utilizing existing information from clinical trials to innovatively assess the cost-effectiveness of PR-fampridine.

R-L Leskelä and F Herse are employees of Nordic Healthcare Group, which has received research funds from Biogen Idec Inc. B Deniz, M Dahlman, and SP Sarda are employees of Biogen Idec Inc. Julia A. Gaebler is a full-time employee of Biogen Idec.

Clinical efficacy of fampridin and the influence of physiotherapy in outpatient MS patients in Germany

S. Braune, A. Kornhuber, M. Lang, A. Bergmann on behalf of the NTD Study Group

Goals: Fampridine in a sustained-release formulation is approved for therapy in MS-patients with Expanded Disability Status Scale (EDSS) > 4 and < 7 according to the German label. The ability to improve walking speed and lower extremity muscle strength has been established in phase II/III trials. Data from the MS registry of the NTD Study Group were analysed with respect to clinical efficacy, quality of life and interaction with physiotherapy under outpatient conditions in Germany.

Method: 370 patients with EDSS > 4 and < 7.5 had received fampridine for a minimum of 3 months (F+). This group was analyzed within group, and was compared with an EDSS matched group of 739 patients without fampridine (F-) over a period of 3 months. Parameters to evaluate clinical efficacy were the total score of the EDSS and its subscore for walking ability (EDSSW), quality of life as assessed by patient (LQA) and treating neurologist (LQN) on a visual analogue scale. The potential influence of accompanying physiotherapy was quantified. Statistical analysis was done with IBM SPSS 20.

Results: Mean EDSS was significantly higher (5.2) in F+ than in F- (2.6). 76% of F+ patients showed a positive response (improvement of LQA or LQN) to fampridine (R+). Total EDSS score, EDSSW, LQA, LQN improved significantly within R+ (p=0.001, p=0.008, p=0.002, p=0.027 resp.), and in comparison with F- over a period of 3 months. R+ had physiotherapy in 70.5%, R- in 75%, (OR 0.79 (n.s.)). These effects of fampridine were independent of additional physiotherapy.

Discussion: Fampridine treatment achieved a statistically significant and clinically meaningful improvement of clinical disability and quality of life in MS patients within 3 months in 76 % of MS patients treated. This underlines the unique therapeutic opportunity of fampridine independent of disease modifying drugs in MS.

Merz, Allergan, MerckSerono, Schering, Novartis, Teva, Bayer Vital, Lundbeck, Sanofi-Aventis, UCB, Biogen, Allmiral, GSK, Talecris, Apothekerkammer, Universität Rostock.

Extensive semi-automated gait analysis by Zebris FDM during treatment of multiple Sclerosis associated gait disturbancies with fampridine-SR

G. Wewerka, B. Holl, H. Bartsch, M. Malisa, C. Illhardt, G. Wewerka, G. Pilz, P. Wipfler, E. Trinka, B. Iglseder, J. Kraus

Paracelsus Medizin. Privatuniversität (Salzburg, AT)

Introduction: In 2011 the „sustained release“ (SR)-formulation of fampridine has been approved by the European Medicines Agency (EMA) for the treatment of multiple sclerosis (MS)-associated gait disorders. The pivotal trials showed a significant effect of fampridine-SR on the “Timed 25 Foot Walking Test”. However, the relevance of this primary outcome measure on daily life has extensively been discussed.

The aim of this study was to investigate the effect of fampridine-SR treatment on parameters obtained by an extensive semi-automated gait analysis.

Methods: Zebris FDM is a gait analysis system which uses a 300 x 60 cm mat containing of more than 22500 pressure sensors. This analysis system is has been evaluated broadly and is therefore commonly applied by physiotherapists in rehabilitation centres. We included 20 patients with MS-associated gait disturbances (EDSS 4,0 to 7,0) and performed a semi-automated gait analysis by the aid of Zebris FDM to determine gait velocity and variability of gait velocity before and during fampridine-SR treatment.

Results: Treatment with fampridine-SR led to a significant and for at least 6 months sustained improvement of gait velocity and variability of gait velocity in 10 out of 20 patients. 1 patient had to discontinue treatment due to side effects (nausea, headaches) despite of improvement. 7 patients showed no improvement after onset of fampridine-SR. 2 patients had to stop treatment due to vertigo. Both parameters obtained by semi-automated gait analysis correlated tightly with the „Timed 25 Foot Walking Test”.

Discussion: Fampridine-SR had a measurable positive effect on MS-associated gait disturbances. In our study we were able to obtain positive effects on parameters measured by semi-automated gait analysis that have been shown to be relevant in daily life in patients with gait disturbances.

This study has been supported by an unrestricted grant from Biogen Idec Austria.

Prof. Trinka received compensation from UCB Pharma (consulting, speaking,research support, clinical trials), Eisai (consulting, speaking, clinical trials), Seppracor (consulting, speaking), Medtronics (Consulting), Pfizer (Speaking) and has received Research Grants from UCB Pharma.

J. Kraus received financial support for research activities from Biogen Idec, Bayer, Genzyme, Sanofi-Aventis, Merck Serono, and Novartis. J. Kraus received personal compensation from Biogen Idec, Bayer, Sanofi-Aventis, Merck Serono, and Novartis for lectures, advisory board participations, and consultations.

Gerti Wewerka, Barbara Holl, Heinrich Bartsch, Michael Malisa, Claudia Illhardt, Gerald Wewerka, Georg Pilz, Peter Wipfler, Eugen Trinka, Bernhard Iglseder have nothing to disclose.

Predictors of changes in work productivity and activity impairment scores

M. Tullman, T. Leist, H. Zwibel, B. Cohen, P.K. Coyle, M. Lage on behalf of the TOP MS Study Steering Committee

Background: Progression of symptoms in multiple sclerosis (MS) has the potential to significantly impact employment and usual daily activities. Other factors such as demographic characteristics, duration of disease, and drug therapy may also play a role.

Objectives: To assess predictors of change in Work and Productivity Activity Impairment: General Health (WPAI:GH) scores in the first year of the Therapy Optimization in MS (TOP MS) Study. Scores associated with health include: percent work time missed, percent impairment while working, percent overall work impairment, and percent activity impairment.

Methods: Potential participants for TOP MS, a prospective, observational study, had a diagnosis of MS and were treated with disease-modifying therapy (DMT) dispensed at specialty pharmacies. Signed informed consent forms were returned to the pharmacies; study enrollment produced log-on instructions for the study website where responses were entered beginning at baseline and at regular intervals. Inclusion criteria for these analyses were one-year study participation and completion of the WPAI, Fatigue Severity Scale (FSS), Perceived Deficits Questionnaire (PDQ), and self-reported EDSS at baseline and month 12. Regression analysis examined the association between one-year change in WPAI scores and patient age, sex, race, family history of MS, duration of MS, DMT, duration of DMT, and one-year change scores for FSS, PDQ, and EDSS.

Results: Of 2131 participants meeting the inclusion criteria, 1097 were employed and answered missed work time questions. Change in FSS scores over the 12 months was a significant predictor of percent work time missed (p <0.01). For impairment while working and overall work impairment due to health, one-year change scores for FSS (p <0.0001), PDQ (p <0.0001) and EDSS (p <0.01) were significant predictors. All participants responded to activity impairment and significant predictors included change scores for FSS (p <0.0001), PDQ (p <0.0001) and EDSS (p <0.0001) as well as the use of interferon (IFN) β-1b (p <0.04) compared to glatiramer acetate (GA). No differences were noted between GA and IFN-1a products. None of the other variables were significantly associated with changes in the WPAI scores.

Conclusion: Change in FSS was a consistent predictor of each WPAI score including missed work time. Change in PDQ and EDSS were added predictors for impairment while working, overall work impairment and activity impairment. Higher EDSS may explain more impaired activity with IFN β-1a.

M. Tullman received consulting/lecture fees from Allergan, Acorda Therapeutics, Biogen Idec, EMD Serono, Novartis, Pfizer, Questcor, Teva Neuroscience, and Sanofi-Aventis.

T. Leist received personal compensation for consulting from Bayer, Biogen IDEC, EMD Serono, Sanofi Aventis, and Teva Neuroscience. Dr. Leist also received financial support for research activities from Bayer, EMD Serono and Teva Neuroscience.

H. Zwibel is or has been a consultant to Acorda Therapeutics, Bayer, Biogen, EMD Serono, Genentech, and Teva Neuroscience, a member of the speakers bureau for Acorda Therapeutics, Biogen, EMD Serono and Teva Neuroscience, and is a member of the advisory board for WebMD, LLC (Medscape).

B. Cohen received consulting compensation from Astelles, Biogen-Idec, EMD Serono, Genzyme, Sanofi-Aventis, and Teva Neuroscience. Dr. Cohen also received research support through Northwestern University from NIH, Biogen-Idec, EMD Serono, Novartis, and Roche and funding support through Northwestern University for a CME course from Teva Neuroscience.

M. Lage received personal compensation for statistical consulting from Teva Neuroscience in her role as a principal member of HealthMetrics Outcomes Research.

P. K. Coyle received personal compensation for consulting and development of educational material from Acorda, Bayer, Biogen, Genentech, Novartis, Pfizer, Questcor, Roche, Sanofi Aventis, and Teva. Dr. Coyle was also compensated for serving on the editorial board for NEURA and received research support from clinical trials sponsored by Actelion, EMD Serono, and Novartis.

Variation of muscle power after twelve weeks of resistance training in multiple sclerosis patients

C. Medina-Pérez, F. de Souza-Teixeira, R. Fernandez-Gonzalo, J.A. de Paz-Fernández

University of Leon (Leon, ES); Federal University of Pelotas (Pelotas, BR); Karolinska Institutet (Stockholm, SE)

Objective: This study was designed to evaluate the variation in leg muscle power after resistance training program of 12-wk and a detraining period of the same duration in multiple sclerosis (MS) patients.

Methods: Forty-two relapsing-remitting MS patients (23 women and 19 men; age range 32-70 yr) volunteered to participate in this study. A neurological evaluation assessing the Expanded Disability Status Scale (EDSS; from 0, normal neurological exam, to 10, death caused by MS) ranged the patients between 1 and 6 (mean ± SD: 4.3 ± 1.3). They followed a resistance training program (2 sessions/week; incremental loads: 35-70% of maximal isometric strength); and a control group (n = 12), who continued their habitual activities. Muscle power was evaluated before and after the 12-wk training program and after 12 weeks of detraining. Participants were evaluated during a single set of coupled CON/ECC repetitions in seated knee extension machine to volitional exhaustion with a load corresponding to the 40% of pre-training maximal isometric voluntary contraction. A linear encoder (Globus Real Power®, Italy; sample rate 300 Hz) adapted to the machine was used to record the displacement of the load-plates across the knee’s range of movement (90° to 180°), and associated software (Globus Real Power® v3.11, Italy) was used to calculate average power for every repetition. Average power from the first five repetitions was considered for further data analysis.

Results: Exercise group increased muscle power after the training period (Baseline: 173.3±72.0 W; Week-12: 200.2±80.5 W). However, muscle power was not affected by the detraining period (Week-24: 193.3±78.3 W). Control group did not present important changes in muscle power during the intervention (Baseline: 149.5±34.1 W; Week-12: 148.1±29.4 W; Week-24: 154.7±43.0 W).

Conclusion: A 12-wk resistance training program improved muscle power in MS patients and muscle power training adaptations were maintained after detraining period.

J.P.F and F.S.T. designed the research; J.P.F and F.S.T. conducted the research; C.M.P and R.G.R. carried out the experiments;,C.M.P and R.G.R analyzed the data; C.M.P and R.G.R. wrote the paper. J.P.F. had primary responsibility for final content.

Also, there is no conflict of interest between the authors of the publication.

WalkAide® FES device improves gait function and quality of life for people with Multiple Sclerosis on Ampyra

L. Mayer, T. Warring, S. Agrella, E.J. Fox

Central Texas Neurology Consultants (Austin, US); MS Clinic of Central Texas (Austin, US)

Background: Foot drop is prevalent in people with Multiple Sclerosis (MS). Foot drop, an inability to dorsiflex during swing, leads to abnormal gait, decreased speed, endurance and balance. Current accepted standards of care are pharmacologic, dalfampridine (Ampyra), or Orthotic, Ankle Foot Orthosis (AFO). Peroneal Nerve Functional Electrical Stimulation (FES), an alternative treatment, electrically stimulates the dorsiflexors resulting in active toe clearance and more natural gait. The purpose of this study was to determine the effect of the WalkAide® FES device (WA) on gait speed, endurance, gait quality, impact of MS on walking ability and Quality of Life (QOL) for people with MS on a stable dosage of Ampyra.

Methods: 20 subjects were recruited from a client list of people with MS and foot drop on a stable dose of Ampyra. Subjects completed the Timed 25 Foot Walk (T25FW), the 6 Minute Walk (6MWT), the Multiple Sclerosis Walking Scale 12 (MSWS 12) and the SF-36 at a screening visit without the WA. All measures were repeated with the WA at baseline, 1 and 3 month follow up visits. A Functional Ambulation Profile (FAP) was calculated at each visit using GaitRite system data.

Results: 16 subjects completed the study (7 male, 9 female). Mean age, duration of MS and time on Ampyra were 53.6, 16.5 and 2.0 years respectively. T25FW times decreased significantly between screening and 3 months (p=.028). 6MWT distances increased significantly between screening and 3 months (p=.019) and baseline and 1 month (p=.018). MSWS 12 scores decreased significantly between screening and baseline (p=.012), 1 (p=.002), and 3 months (p=.006) and between baseline and 1 month (p=.017). Improvements on the SF-36 subscales were significant between screening and baseline (p=.023), 1 (p=.002) and 3 months (p=.012) for Physical Function; screening and 3 months (p=.022) for Role Limitation Physical Health; screening and 1 month (p=.028) for Social Function; and screening and 1 month (p=.014) and baseline and 1 month (p=.008) for Vitality. FAP significantly improved between baseline and 1 month (p=.029).

Conclusions: Use of the WalkAide® significantly improves gait speed, endurance, QOL and gait quality and decreases the impact of MS on walking ability. Improvements, above and beyond benefits derived from an Ampyra regimen, suggest that the WalkAide® can augment pharmacological intervention and facilitate significant additional improvement in gait, function and QOL for people with MS.

Lori Mayer has received an honorarium from the Acorda Therapeutics Speaker’s Bureau.

Stephanie Agrella has received an honorarium from the Acorda Therapeutics Speaker’s Bureau.

Tina Warring has nothing to disclose.

Edward J. Fox has received an honorarium from the Acorda Therapeutics Speaker’s Bureau.

The International Organization of MS Nurses (IOMSN) provided funding for the IRB application, Round Rock Orthopedics provided the study devices (WalkAide) and Innovative Neurotronics provided funding for the processing of the GaitRite data and statistical analysis.

Multiple sclerosis: cognitive reserve and disease impact

M. Gudesblatt, M. Pardini, M. Zarif, B. Bumstead, S. Thotam, M. Buhse, L. Fafard, G. Thippeswamy, L. Strober, J. DeLuca, G. Doniger, I. Topalli, M.P. Sormani

South Shore Neurologic Associates (Patchogue, US); University of Genoa (Genoa, IT); State University at Stony Brook (Stony Brook, US); Kessler Foundation Research Center (West Orange, US); NeuroTrax Corporation (Bellaire, US); Biogen Idec (Cambridge, US)

Background: Cognitive impairment is a significant disability in Multiple Sclerosis (MS) patients. Development of cognitive deficits may be related to an interplay between extent of brain damage and an individuals “cognitive reserve”. Cognitive reserve is characterized as: capacity to maintain normal cognitive functions despite brain pathology present. Formal education is thought to be a proxy measure for a significant part of cognitive reserve capacities. The relationship between cognitive reserve and global cognitive function in MS needs further analysis.

Objective: Evaluate the impact of cognitive reserve on declining neuropsychological function as disability increases independently from other prognostic variables.

Methods: Retrospective cross-sectional analysis: (789) MS patients evaluated by standardized validated computerized cognitive battery. Cognitive performance was correlated with: EDSS, disease duration, age, gender, computer use, ethnicity, marital status, employment, fatigue (MFIS), depression (Beck). Multivariate analysis including an interaction term (years of education X EDSS) to assess the relationship between cognitive performance and years of education changes with increasing levels of disability was run.

Results: The relationship between the global cognitive score and years of education is different in different EDSS subgroups: correlation detectable in patients EDSS<2 (r=0.25, p<0.001) declines in patients EDSS 2-6 (r=0.11, p=0.035) and disappears in patients EDSS >6.5. (r=-0.04, p=0.65). Global cognitive score is significantly associated with all examined factors. The interaction term (years of education X EDSS) indicating decline in the association between the cognitive score with years of education (as a proxy for functional reserve) according to higher EDSS levels is statistically significant (p=0.04).

Conclusion: The moderating effect of cognitive reserve on neuropsychological deficits is significant only in early MS stages. This data confirms the “cognitive reserve” hypothesis in MS and its relationship with the degree of disease progression. These findings are of interest from a therapeutic perspective. Our data suggest that interventions aimed at increasing an individual’s cognitive reserve with therapeutics need be performed in the earliest phases of the disease to impact cognitive reserve.

A. Mark Gudesblatt, MD - no disclosures.

B. Matteo Pardini, MD - no disclosures.

C. Myassar Zarif, MD - no disclosures.

D. Barbara Bumstead, ANP - no disclosures.

E. Smitha Thotam, ANP - no disclosures.

F. Marijean Buhse, ANP, PhD - no disclosures.

G. Lori Fafard, RN - no disclosures.

H. Ganesh Thippeswamy, BA - no disclosures.

I. Lauren Strober, PhD - no disclosures.

J. John DeLuca, PhD - no disclosures.

K. Glen Doniger, PhD - employee of NeuroTrax Corp.

L. Ilir Topalli, PhD - no disclosures.

M. Maria Pia Sormani, PhD - no disclosures.

Effects of different physical activities on the walking capacity for people with MS

C. Jolk, R. Alcantara, L. Bernhardt, P. Platen, M. Marziniak, K. Weßling

University of Münster (Münster, DE)

Introduction: Multiple sclerosis (MS) is a chronic inflammatory disease which may result in motor weakness, spasticity, poor balance that may lead to severe progressive limitations of functioning in daily life. Positive effects of physical activities exist, but little is known about the effects on the walking capacity. Resistance training is a method to strengthen individually muscle groups but little is known about the influence on walking abilities. Exercises in group settings are not well examined with patients in MS.

Objective: To study the effects of physical intervention on the maximum walking capacity on a tread mill for patients with MS.

Methods: A randomized controlled three-armed multi-center trial with a 6 months study period was performed. SUBJECTS: 70 patients with MS and an EDSS from 1-6 were randomly allocated to one of the three groups.

Intervention: Group 1 received a progressive resistance training (PoRT) using weight machines. Group 2 performed a core and stability training (CoaST) in group settings. All Participants followed a detailed exercise protocol within 6 months with one training session over 60 minutes per week.

Group 3 main outcome parameters: The measurements were a maximum walking distance on a tread mill. Patients were assessed at baseline and 12 and 24 weeks post treatment with a standardized examination.

Results: Both intervention groups could improve their maximum walking distance on a tread mill. The mean effect after the resistance training (34.7%, p=0.002) is comparable to the results after the group intervention (32.2%, p=0.001) on the treadmill. Both groups show a linear progression within 3 and 6 months. Highest individual improvements were 243 % compared to baseline. The mean of the PoRT-group improved the walking distance from 1366 to 1806 meters within 6 months the CoaST group improved for 378 meters up to 1468 meters. The control group showed no differences after 12 weeks of waiting.

Conclusion: Resistance training and group intervention could improve the maximum walking distance for people in MS on a tread mill. Both physical interventions indicate an improvement to save independence regarding the importance of walking in daily life.

The study was sponsored by an unrestricted grant of Novartis, Germany. C. Jolk received travel grants from Novartis Pharma GmbH.

L. Bernhardt received fees and travel grants from the following companies: Bayer Health Care Ag, Biogen Idec, Merck Serono, Novartis Pharma GmbH, Sanofi-Aventis, Teva.

M. Marziniak received lecture fees and travel grants from the following companies: Bayer Health Care AG, Beiersdorf AG, Biogen Idec GmbH, Merck KGaAO, Novartis Pharma GmbH, Pfizer Pharma GmbH, Sanofi-Aventis, Teva.

Is virtual reality a useful tool in multiple sclerosis neurorehabilitation? A pilot study

A. Tacchino, M.A. Battaglia, G. Brichetto

Italian Multiple Sclerosis Foundation (Genoa, IT)

In the last years many findings showed that motor and cognitive rehabilitative treatments could take advantages by the use of new tools, such as Virtual Reality (VR), resulting in improved motor and cognitive performances. In fact, although VR is successfully used for different neurological disease, few findings have been performed on VR use for patients with Multiple Sclerosis (PwMS) and, in particular, on their daily living activities such as those treated by occupational therapy (OT). Here we developed and tested a new motor rehabilitation tool based on VR to assess its effectiveness in PwMS and its possible use in clinical neurorehabilitation. Therefore, to define a useful and effective protocol, we evaluated both the ability of PwMS to familiarize with VR and the potential improvements in PwMS rehabilitation when associated with a standard OT treatment. We created 5 virtual environments reproducing 5 typical daily living gesture (positioning a book upon a shelf, bringing a glass to mouth, putting a toothbrush in a toothbrush holder, placing an egg into a pot, pushing a button). We recruited 8 PwMS (age: 39.4 ± 1.5 years; EDSS ≤6) that performed 3 consecutive session (1h/sess.) in 3 different days. Each session consisted in 30min of traditional treatment and 30min of VR. During VR PwMS had to well follow the ideal trajectory of the gestures showed in the 5 virtual environments. At the end of each session PwMS were tested with the same above gestures but with the ideal trajectories hidden. Thus, we verified if PwMS could become familiar with VR improving their motor and cognitive performance or, vice versa, if difficulties in its use could produce disruption in rehabilitative quality of a traditional treatment.

PwMS showed an improvement in temporal and spatial accuracy along the three test-sessions. In particular results showed a statistically significant decrease in duration (from 8.5 sec to 7.0 sec) and spatial error (from 24.5mm² to 20.5mm²) with a p < 0.05 and a statistical significant increase in peak velocity (from 280mm/sec to 340mm/sec) with a p < 0.05 to perform the proposed gestures. Therefore, results confirm the VR effectiveness also for PwMS when they are subjected to a OT treatment involving upper limb motor function. However we suggest that a future study could be designed with protocols with a control group and a major number of subjects.

The authors have nothing to disclose.

Blind randomised controlled study of the efficacy of attentional cognitive rehabilitation in multiple sclerosis as measured by fMRI

G. Mangone, A. Cerasa, P. Valentino, M.C. Gioia, C. Chiriaco, D. Pirritano, R. Nisticò, M. Trotta, F. Rocca, P. Perrotta, A. Augimeri, T. Talarico, G. Bilotti, A. Quattrone

National Research Council-Neuroimaging Research Unit (Catanzaro, IT); “Magna Graecia” University (Catanzaro, IT)

Objectives: In the last years, several studies demonstrated the effectiveness of cognitive rehabilitation (CR) techniques in restoring brain functions of patients with multiple sclerosis (MS). In particular, treatments of attentional abilities and executive functions have been demonstrated to show the most promising results. However, whether this phenomenon is coupled by concomitant neurofunctional changes has not been demonstrated in MS patients. Thus, the present project was aimed at investigating the impact of CR on brain plasticity in MS patients. Functional neuroimaging data (fMRI) have been collected at baseline and after CR.

Materials and methods: Using a blind randomized controlled study, we enrolled 12 MS patients who underwent CR program (Experimental group) and 11 age-gender matched MS patients who underwent placebo intervention (Control group). Experimental group received 6 weeks of 2 weekly 1-hour sessions using computer-aided rehabilitation software (RehaCom). The Control group underwent a similar exposure to computerized tests (finger tapping task).The study treatment consisted of three attentional programs called: “Selective Attention”, “Vigilance” and “Divided Attention”. At the baseline and after rehabilitative program, MS patients received detailed cognitive assessment and fMRI exams (while performing PVSAT). Neuropsychological performances have been assessed by measuring several cognitive domains with particular focus on attentional deficits. fMRI study was performed by using a 3-T Unit (MR-750 General Electrics).

Results: At a phenotypic level, evaluating cognitive performance before and after CR treatment (2-way ANOVA), we detected a significant group x time interaction effect for the Stroop task (p-level < 0.03), where experimental group showed significant improved performance with respect to control group after rehabilitation program.

At an intermediate phenotypic level, after CR experimental group demonstrated a specific increased activity of the right posterior cerebellar lobule (Crus I) and the left superior parietal lobule with respect to control group during the execution of the fMRI cognitive task.

Discussion: Our data confirm the beneficial effect of CR, demonstrating that intensive CR produces adaptive neural plasticity of brain networks underlying attentional processes and executive functions in MS patients.

Conclusion: This study sheds new light on neuronal mechanisms underlying the effect of CR on MS patients.

The authors have nothing to disclose.

Rehabilitation induces brain structural plasticity in multiple sclerosis

E. Robinet, W. Zaaraoui, A. Rico, J. Raillard, S. Tisserand, A. Faivre, F. Reuter, I. Malikova, E. Soulier, S. Confort-Gouny, P. Cozzone, P. Asquinazi, P. Bardot, J. Pelletier, J.P. Ranjeva, B. Audoin

Aix-Marseille University (Marseille, FR); Clinique St Martin (Marseille, FR); Institut Pomponiana (Hyères, FR)

Objective: To test the hypothesis that physical rehabilitation induces efficient brain structural plasticity in disabled patients suffering from multiple sclerosis (MS).

Methods: Fourteen MS patients with a lower limb motor deficit, no progression of the EDSS and no relapse during the preceding 6 months were included in the study. All patients underwent a one-month indoor standardized physical rehabilitation protocol. Clinical examination and structural MRI were performed before rehabilitation, immediately after rehabilitation and three months later. Images processing was performed using the Voxel Based Morphometry method.

Results: Rehabilitation was associated with functional improvement demonstrated by a significant increase of the Multiple Sclerosis Functional Composite score immediately after rehabilitation (p=0.001; Wilcoxon). Afterwards, functional capacities decreased reaching the baseline level within three months after the end of rehabilitation. MRI evidenced an increase of GM density in the left ventrolateral prefrontal cortex immediately after rehabilitation (p<0.05, family-wise error corrected) and secondly a decrease during the 3-month period following the end of rehabilitation. Changes in GM density in the left ventrolateral prefrontal cortex during the entire study period were positively correlated with the changes of the functional score (ρ=0.70, p=0.01; Spearman). Changes in GM density during rehabilitation were positively correlated with changes of the timed 8 meters foot walk (ρ=-0.66, p=0.002; Spearman rank test).

Conclusions: In disabled MS patients, the beneficial effect of rehabilitation is associated with an increase of GM density in a region particularly involved in action selection. This study argues for the existence of efficient brain structural plasticity mechanisms in adults suffering from multiple sclerosis.

Dr Robinet, Dr Zaaraoui, Dr Rico, Miss Raillard, Mr Tisserand, Dr Faivre, Dr Reuter, Dr Malikova, Mrs Soulier, Dr Confort-Gouny, Pr Cozzone, Dr Asquinazi, Dr Bardot, Pr Ranjeva, Dr Audoin have nothing to disclose.

Pr Pelletier serves on the advisory board of Novartis, Bayer Schering, Merck Serono, Sanofi Aventis, TEVA, Biogen Idec.

Evaluating the effects of functional electrical stimulation on ambulation in individuals with secondary progressive multiple sclerosis

S. Newsome, K. Zackowski, P. Calabresi, D. Becker

Johns Hopkins School of Medicine (Baltimore, US)

Background: Individuals with secondary progressive multiple sclerosis (SPMS) experience significant impairments in ambulation which is largely due to a failure of existing therapies altering the disease course. Functional electrical stimulation (FES) cycle ergometry is an intervention that may help improve gait function in MS. In a recent pilot study in progressive MS, FES ergometry treatment demonstrated improvements on a broad array of functional measures and suggested a modulatory effect on CNS inflammation.

Goal: To present preliminary data leading to the rationale and trial design comparing active and passive FES cycle ergometry in SPMS.

Methods: Clinical data (Expanded Disability Status Scale[EDSS];American Spinal Injury Association[ASIA] scores) from 14 SPMS patients who participated in FES rehabilitative therapy in our center were reviewed. Twenty SPMS patients will be randomized to receive 1 hour of either active or passive FES cycling (RT-300 ergometer) 3 times a week for 3 months. Main inclusion criteria:age 18-65;EDSS 5.0-7.0. Main exclusion criteria:contraindication to FES;relapse within thirty days of screening visit. The primary outcome will be timed 25-Foot Walk. Main secondary outcomes include EDSS, MS Functional Composite, Symbol Digit Modalities Test, Two minute walk test, and quantitative sensorimotor testing. Exploratory analysis evaluating changes in serum and CSF cytokines/growth factors, and their relationship to functional improvement will be done.

Results: In a retrospective study we reviewed 14 SPMS patients (age 58.5±9.5 yrs[mean±SD];69% female;disease duration 22.2±9.3 yrs;EDSS 6.2±1.1) who were followed for 22.2±13 months during which time 86% of them received 78±50 hours of FES cycle ergometry. EDSS scores remained stable. Motor and sensory function was further assessed with ASIA scores; upper extremity motor scores did not change or improved in 81%, lower extremity motor scores in 71%, light touch scores in 58%, and pinprick scores in 83%. These changes were dependent on whether or not the patients received FES (p=0.014). Recruitment is underway for the prospective study.

Conclusions: We are proposing a novel, and easy to implement intervention strategy of FES cycling to help improve gait function in individuals with SPMS. A successful outcome on a larger SPMS population would have significant impact towards changing MS clinical care. In addition, we will gain a better understanding of the mechanisms underlying these changes that could be used to design new therapeutic strategies.

Dr. Newsome is a consultant for Biogen-Idec & Novartis & received speakers honoraria from Biogen-Idec and Teva Neuroscience.

Dr. Zackowski has nothing to disclose.

Dr. Calabresi has provided consultation services to Novartis, Teva, Biogen Idec, Vertex, Vaccinex, Genentech; and has received grant support from EMD-Serono, Teva, Biogen Idec, Genentech, Bayer, Abbott, and Vertex.

Dr. Becker has nothing to disclose.

Is the impact of relapsing-remitting multiple sclerosis on carers different between early and older stages of the disease? - REPIT survey in France

P. Clavelou, A. Creange, M. Debouverie, C. Donze, P. Hautecoeur, C. Mekies, M. Montreuil, T. Moreau, S. Pittion-Vouyovitch, A.L. Ramelli, M.S. Behier, I. Bourdeix, G. Thual, K. Rerat on behalf of the REPIT STUDY GROUP

Introduction: The impact of multiple sclerosis (MS) on the relatives, social and professional environment of patients is less known in the early stage of the disease. In France usually, carers described, in chronic diseases, are women and at least 50 years old. Thus, there are few studies about the impact of diseases on men as carers generally and especially during early stages of MS.

Objectives: To compare the impact of MS on the carers’ daily life between two groups with different delay since diagnosis: 1-[6 months-2 years] and 2-[2 years-5 years], and to collect their needs and expectations.

Methods: Treated or untreated relapsing-remitting MS patients, at least 18 year-old, with an EDSS ≤ 4, diagnosed 6 months to 5 years previously, and their principal carers, completed questionnaires on different aspects: socio-demographic data, level of care provided by the carer (Caregiving Tasks in MS Scale, CTiMSS - primary endpoint), psychological, social and emotional effects (French EPSA-SEP scale), impact on mood (HADs) and activities of daily living or on the family, and socio-professional lives of both carer and patient.

Results: The 341 carer-patient pairs analysed were enrolled in France by 75 neurologists from January 20th, 2010 to June 20th, 2011. The diagnosis was done on average 2.7 years [± 1.4) earlier: 1.2 years [group 1; n=126] or 3.6 years [group 2; n=215]. Patients (76% women; 38 year-old on average) had a median EDSS score of 2 [0-4]. 62% of the carers were men (43 year-old on average), usually the patient’s partner, and workers (83 %). The CTiMSS score differed significantly between the two groups of carers with respect to Activities of Daily Living items. Worry and fatigue dominated the EPSA scale. Mood (HADs score) was also affected (fear, worry) and a higher score about sensations of panic is noticed for the group 2. Carers expect more information about disease (more than patients’ wishes).

Conclusion: The carer’s profile was similar to that described in other studies in MS, but the previously less highlighted men’ psychological repercussions are obvious in this study. Activities of daily living, intimacy and professional life were impacted.

This first French study on the effects of MS on carers highlights its marked impact on their daily life as from onset of the disease.

This study has been funded by Novartis Pharma.

The authors have nothing to disclose.

Correlation between quality of life and spasticity in Spanish patients with multiple sclerosis using two different spasticity scales: The CANDLE Study

R. Arroyo, D. González-Segura, M. Viladrich on behalf of the CANDLE Study Collaborative Group

Background: Spasticity is a common symptom in multiple sclerosis (MS) with a great impact on patient’s quality of life. The aim of this study was to determine the relationship between quality of life and degree of spasticity in patients with MS.

Methods: Epidemiological, multicenter and cross-sectional study in patients with spasticity due to MS. SF-12 questionnaire was used for assessing quality of life. Modified Ashworth scale and a 0-10 Numeric Rating Scale (NRS) were used for assessing spasticity severity.

Results: 409 patients from 53 specialized neurology clinics were analyzed. Mean age was 46.4 years (± 11.0), 62.4% women. Most patients had relapsing-remitting MS (42.1%) or secondary progressive MS (43.9%). Mean time since diagnosis of MS was 12.5 years (± 7.4) and mean time since first symptoms of spasticity was 6.1 years (± 4.8). 71.3% of patients were being treated for spasticity, with a mean time under treatment of 4.3 years (± 4.0). 58.1% of patients reported spasms due to spasticity, being painful for 64.2% of them. Moderate to severe spasticity was shown in 59.2% of patients according to modified Ashworth scale and in 83.4% of patients according to NRS (3-6 or > 6 scores). Mean scores on the two 0-100 subscales of the SF-12 of quality of life questionnaire were 31.0 (± 9.3) in the Physical Component Summary (PCS) and 45.4 (± 12.0) in Mental Component Summary (MCS). Scores of all domains of the SF-12 questionnaire showed statistically significant correlations with both scales of spasticity (p ≤ 0.002), bringing higher correlations with the NRS: correlation with PCS was -0.48 for NRS and -0.46 for modified Ashworth scale; and correlation with MCS was -0.27 for NRS and -0.17 for modified Ashworth scale.

Conclusions: These results confirm the association between quality of life and severity of spasticity in patients with MS. The 0-10 Numeric Rating Scale appears to be a more valid tool to reflect the impact of spasticity on quality of life than the modified Ashworth scale.

Dr. Arroyo has been consultant for Almirall. Ms Viladrich is an employee of Adknoma Health Research, a CRO contracted by Almirall to cover logistics and statistical analysis of the study. Dr. González-Segura is a full employee of Almirall.

Dynamics of happiness and personal growth in multiple sclerosis patients treated with interferon-β-1a compared with healthy subjects

D. Mazeh, Y. Barak, A. Achiron

Sheba Medical Center (Tel Hashomer, IL)

Objectives: To re-evaluate happiness and personal growth in patients treated with interferon-β-1a as compared with patient that stopped treatment and with healthy subjects.

Methods: The Oxford Happiness Inventory (OHI), the Satisfaction with Life Scale (SLS) and the Personal Growth Initiative Scale (PGIS) were endorsed by 58 patients (40 females, mean age 48.9±12.9 years, EDSS 4.3±2.3), 32 patients are treated with interferon-β-1a patients (22 females, mean age 46.9±12.7 years, EDSS 3.5±2.3, duration of treatment 7±3.31 years) and 44 healthy subjects (24 females, mean age 42.1±13.5 years). Correlation analysis was performed between scores, disease and treatment related variables.

Results: Mean happiness scores in MS patients for the OHI (93.3+21.8), the SLS (21.6+6.9) and the PGIS (36.3+11.3) were not statistically different from those of healthy subjects. More MS patients were in the “dissatisfied” subgroup (SLS score<20) as compared to healthy subjects (36.2 % vs., 20.5%, p=0.019).On the other hand more patients were in the extremely satisfied subgroup (SLS>30) (15.5% vs., 4.5%).

32 (55.17 %) of the patients were still treated with interferon-β-1a. In comparison to patients that stopped treatment they had higher rates on the OHI (95.3+20.8), the SLS (22.4+6.7) and the PGIS (38.4+8.9), although the difference did not reach statistical significance. Still those rates are minimally lower from those found in the previous study.

Categorical analysis of the SLS demonstrated a different distribution wherein fewer patients with interferon-β-1a compared to patients who stopped it were in the “dissatisfied” subgroup (SLS score<20) (31.3% vs., 38.4%). In the “extremely satisfied” subgroup the rates were similar (SLS>30).

Conclusion: Happiness was scored similarly in RR-MS patients and healthy subjects despite a greater percentage of patients reporting being dissatisfied with their lives. Patients treated with interferon-β-1a demonstrated better scores than patients that stopped treatment. These findings suggest that continuity of treatment contribute to the well being and adaptation and may reflect positive treatment effect.

This study was supported by a grant from Merck-Serono.

Doron Mazeh has nothing to disclose.

Yoram Barak has recieved research grants and honorarium from Merck-Serono.

Anat Achiron has nothing to disclose.

Interim analysis of AMETYST: a phase 4 observational study of the impact of intramuscular interferon b-1a on quality of life, disability, and cognition in patients with clinically isolated syndrome/clinically definite multiple sclerosis

P. Stourac, D. Horakova, M. Tyblova, E. Klimova, J. Szilasiova, I. Fenclova, A. Svorenova, X. You, P. Turcani

Masaryk University and Faculty Hospital (Brno, CZ); Charles University and General University (Prague, CZ); Presov University (Presov, SK); Safaric University (Kosice, SK); Biogen Idec s.r.o. (Prague, CZ); Biogen Idec s.r.o. (Bratislava, SK); Biogen Idec Inc. (Weston, US); Comenius University and University Hospital (Bratislava, SK)

Background: Intramuscular (IM) interferon (IFN) β-1a for multiple sclerosis (MS) shows long-term efficacy in reducing relapse frequency, improving magnetic resonance imaging (MRI) endpoints, and attenuating disability progression. The impact of IM IFN β-1a on quality of life (QoL) is less well established.

Objective: Determine the impact of IM IFN β-1a on patient- and physician-reported QoL for patients with clinically isolated syndrome (CIS) or clinically definite MS (CDMS) every 6 months (patient-reported QoL) and once yearly (physician-reported QoL) for up to 3 years.

Methods: This prospective, observational, multicentre study enrolled patients at least 18 years old with CIS or CDMS who had been on IM IFN β-1a therapy for no more than 3 months and had recently relapsed, though not within 1 month of enrollment. Patient self-evaluations included QoL with respect to the burdens of disease and self-administration (with higher scores indicating poorer QoL), Short Form 36 (SF-36) and employment questionnaires, and the Expanded Disability Status Scale (EDSS). Physician evaluations included QoL (burden of disease), EDSS, and the Paced Auditory Serial Addition Test (PASAT). Continuous variables are summarized with descriptive statistics; discrete variables are presented as frequency distributions.

Results: Data were from 134 patients at baseline and 121 patients (90%) who completed 1 year on study. Patients were 66% female, with a mean (SD) age of 31.8 (8.2) years and a mean duration of IM IFN β-1a treatment of 0.9 months; 57% had CDMS, and 68% had reported a relapse in the previous 6 months. On study, 11% of patients relapsed within 6 months and 14% within 1 year. Mean (SD) QoL burden of disease score decreased from baseline to 1 year by different amounts as assessed by patients (29.3 [26.7] vs 27.7 [24.7], P=0.9275) and physicians (30.8 [23.5] vs 23.2 [21.1], P=0.0001]). Patient- and physician-assessed EDSS scores were moderately correlated at baseline, 6 months, and 1 year (P≤0.0002). Mean PASAT change from baseline to 1 year showed significant improvement (81.9 [18.3] vs 86.7 [14.5], P=0.0001); SF-36 mental and physical components did not change significantly over this span.

Conclusion: Interim analysis results suggested a decrease in patient burden of disease and improved cognition; no assessments indicated patient deterioration. These findings confirm the established benefits of IM IFN β-1a therapy for MS.

Supported by Biogen Idec Inc.

Drs. Stourac, Tyblova, Klimova, Szilasiova, and Turcani have received financial support for research activities from Biogen Idec. Dr. Horakova has received speaker honoraria and consultant fees from Biogen Idec, Merck Serono, Teva, and Novartis, as well as support for research activities from Biogen Idec. Iva Fenclova, Alena Svorenova, and Xiaojun You are employees of Biogen Idec Inc.

Impact on health-related quality of life by cutaneous adverse events associated with long-term disease-modifying therapy in multiple sclerosis: the derMiS study

D.M.W. Balak, G.J.D. Hengstman, E. Hajdarbegovic, R.J.P. van den Brule, R.M.M. Hupperts, H.B. Thio

Erasmus Medical Center (Rotterdam, NL); Catharina Ziekenhuis (Eindhoven, NL); Biogen Idec International B.V. (Badhoevedorp, NL); Academic MS Centre Limburg (Sittard-Geleen, NL)

Introduction: Glatiramer acetate (GA) and interferon-β (IFN-b) are disease-modifying therapies (DMTs) for multiple sclerosis (MS) that are administrated via subcutaneous (SC) or intramuscular (IM) injections. Cutaneous adverse events associated with DMTs are common and may influence patient’s quality of life. We aimed to determine the prevalence of cutaneous adverse events associated with long-term DMT use and to assess the impact on quality of life.

Methods: The derMiS study was a cross-sectional study conducted in 15 Dutch clinics. Eligible for inclusion were MS patients who had been treated with their first DMT for at least 2 years. Cutaneous events were assessed from digital photographs of injection-sites by dermatologists blinded to DMT. Generic and dermatology-specific health-related quality of life (QoL) were measured with the patient-reported questionnaires European Quality of Life Questionnaire 5 Dimensions (EQ-5D) and the Skindex-17, respectively.

Results: A total of 229 patients were enrolled, of whom 44 (19%) were treated with SC GA, 60 (26%) with SC IFN-b-1b, 66 (29%) with SC IFN-b-1a, and 59 (26%) with IM IFN-b-1a. Mean duration of DMT-treatment was 6 years (range 2-18 years). Overall, 156 (68%) had at least one cutaneous adverse event. The prevalence of cutaneous adverse events was higher for the SC DMTs (75 to 82%) compared to IM DMT (41%) (P < 0.001). Local injection-site reactions (erythema and ecchymosis) and lipoatrophy were the most common skin reactions, occurring in 156 (68%) and 45 (20%) patients, respectively. Less frequently occurring reactions were post-inflammatory hyperpigmentation (7%), eczema (6%), healed ulcers (3%), urticaria (2%), and skin necrosis (0.4%). The EQ-5D scores did not differ substantially between patients with and without skin reactions. Patients with cutaneous adverse events had significantly higher Skindex-17 psychological and symptoms scores than did patients without cutaneous adverse events. However, the proportion of patients with a severe impairment of QoL was relatively small for both the psychosocial (5%) and the symptom (8%) Skindex-subscale.

Conclusions: The prevalence of cutaneous adverse events was high in MS patients with long-term treatment with DMTs and the most common cutaneous events were local injection-site reactions and lipoatrophy. Patients with cutaneous adverse events had a somewhat lower perceived dermatology-specific but not generic health-related quality of life.

D.M.W. Balak has nothing to disclose. G.J.D. Hengstman has received consulting fees and lecture fees from Biogen Idec, Merck-Serono, Novartis and Sanofi-Aventis. E. Hajdarbegovic has nothing to disclose. R.J.P. van den Brule is employed as Medical Science Liaison at Biogen Idec. R.M.M. Hupperts received honoraria for lectures, advisory boards, expert meetings and unrestricted grants from Biogen-Idec, Merck-Serono, Teva, Novartis and Bayer. H.B. Thio received research, speaking and consulting support from Biogen Idec.

Support for this study was provided by Biogen Idec.

Impact of yoga on the quality of life of patients with multiple sclerosis

I. Truschel, J.C. Ongagna, M.-R. Metzger, C. Zaenker, J. De Seze

Alsacep Pasteur Hospital (Colmar, FR)

Background: The quality of life of people affected by multiple sclerosis (MS) is reduced in comparison with that of the general population. For these patients, physical exercise is considered beneficial on many levels.

The purpose of this study was to measure the impact of the practice of yoga, as a physical exercise, on the quality of life in MS patients.

Methods: Twenty-nine MS patients (20 women and 9 men) aged 18 to 55 years, with an Expended Disability Status Scale (EDSS) score less than 6, participated in a yoga program supervised by a nurse specialized in a yoga teaching. Fifteen yoga sessions were conducted by all patients at the rate of one session per week. Quality of life was measured using the SEP-59 questionnaire which was completed by patients without any assistance from the nurse in charge of the course. The results before and after the end of the program were compared by a chi² test.

Results: All MS patients completed the program. The SEP-59 found an overall well-being significantly better after the program compared to before. Vitality, social functioning and emotional limitation scores were higher after the yoga program. The mental and physical health were better perceived by patients after the program (mental score: pre = 53.5±6.9, post = 58.2±6.8) (p = 0,02). Furthermore, physical function and physical pain scores were much higher before yoga practice and decreased after the program.

Conclusion: The practice of yoga seems to improve quality of life of MS patients. It was observed that quite often, patients stop practicing any kind of physical activity for fear of aggravating their health condition. This activity may be proposed also in patient with a ligh disability level may help patient to progressively re-introduce physical activity.

The authors have nothing to disclose.

Depression and physical activity among adults with multiple sclerosis, muscular dystrophy, spinal cord injury, and post-polio syndrome

A.M. Verrall, H. Bombardier, R. Rosenberg, B. Artherholt, W. Motl, M. Jensen

University of Washington (Seattle, US); University of Illinois (Urbana, US)

Background and goals: Physical inactivity is thought to be a modifiable risk factor for depression in non-disabled individuals. However, the relationship between inactivity and depression is less certain among adults with multiple sclerosis (MS) and other disability groups including spinal cord injury (SCI), muscular dystrophy (MD), and post-polio syndrome (PPS). People with MS and SCI are characterized by higher rates of inactivity and depression, suggesting a potential relationship. People with MD and PPS are also relatively inactive, yet the prevalence of depression in these two groups remains unclear. This study was designed to examine physical activity and depression as well as the relationship between these two conditions across disability groups. Our goal was to identify overarching predictors of depression and to determine whether physical activity represents a modifiable risk factor for depression that is universal to these groups.

Methods: We conducted a cross-sectional survey of 1,676 community-residing participants (MD=321, PPS=338, MS=556, SCI=411) from throughout the United States. We used the Patient Health Questionnaire (PHQ-9) to assess depression and the International Physical Activity Questionnaire (IPAQ) and Godin Leisure Time Exercise Questionnaire (GLTEQ) to assess physical activity. We performed two multiple linear regression analyses to predict depression scores while adjusting for potential confounders.

Results: The average age was 55.9, 64.4% were female, 91.9% were white, 55.4% had a college degree or higher, and 55.7% walked with an assistive device or had limited self-mobility. Higher PHQ-9 scores were associated with a higher body mass index, female sex, lower education, age (depression was higher in middle age compared to younger and older groups), having MS, and greater mobility disability. The IPAQ and GLTEQ explained a small but significant amount of the variance in PHQ-9 scores with no differences in the relationship by diagnosis, age, or mobility status.

Conclusions: Having MS was associated with higher depression scores compared to other diagnostic groups. Both physical activity measures were significantly related to depression across all diagnostic groups, but only explained a small amount of the variance. The influence of obesity and mobility disability on depression merits further study. Longitudinal research is needed as well as studies of whether physical activity interventions can improve depression among adults with MS and other physical disabilities.

This study was supported by a grant from the National Institute on Disability and Rehabilitation Research.

Drs. Verrall, Bombardier, Rosenberg, Artherholt and Jensen have nothing to disclose.

The utility of the Functional Index for Living with multiple sclerosis in clinical practice: preliminary results

J. Cooper, A. Courtney, E. Fox, L. Jehle, M. Kirk-Junior, V. Nolan, J. Wesson

Research & Education Inst. (Berkeley, US); UT Southwestern Medical Center at Dallas (Texas, US); Central Texas Neurology Consultants (Round Rock, US); Alta Bates Summit Medical Center (Berkeley, US)

Background: Consideration of patient reported outcomes is increasingly important. Currently available Quality of Life (QOL) measures for Multiple Sclerosis (MS) are rarely used in clinical settings. The Functional Index for Living with MS (FILMS) was developed and validated to be a simple to administer, easy to interpret scale for QOL assessment of patients with MS. The availability of such scale could enhance the quality of care that people with MS receive by facilitating clinicians’ ability to assess domains of patients’ experience with greater ease and effectiveness. FILMS is a 125-point, 25-item, easily self-administered scale designed to be comprehensive and rapidly interpreted by clinicians. It consists of questions to evaluate 6 domains (pain, cognition, emotional functioning, fatigue, physical functioning and general QOL). Higher scores correlate with better QOL.

Objectives: To evaluate clinicians’ and patients’ perceptions of effectiveness of FILMS by measuring their satisfaction with a clinic visit where FILMS is used compared to a standard of care encounter. In addition, to measure ease of administration during clinic visits.

Methods: This prospective, IRB approved study of 150-subjects took place in 3 MS centers. Stable patients with clinically definitive MS and their clinicians completed exit questionnaires after each of 2 routine visits several months apart. The questionnaires seek data on the ability of the clinician to elicit information pertinent to the QOL domains as well as the ease of completing and of interpreting the data. The first was a standard of care visit. Prior to the second encounter patients completed the FILMS for clinician review.

Results: To date, 146 patients completed Visit 1; 72 subjects completed Visit 2. The subject mean age is 46 and was 90% female. Preliminary data review of 72 subjects who completed both visits shows time for subject to complete the questionnaire averaged 5.9 min.; Providers spent an average of 2.75 min. to review the instrument; On a scale of 1-not satisfied to 5-highly satisfied, mean score of patient satisfaction was 4.8; mean score for clinician satisfaction is 4.3.

Preliminary Conclusion: FILMS may be an effective tool to aid in the clinical management of MS. References: Wesson JM et al. The Functional Index for Living with MS. Mult Scler 2009; 15(10); 1239. Solari A. Role of Health-Related QOL Measures in Routine Care of People with MS. Health Qual Life Outcomes. 2005; 3:16.

This study was supported by a generous grant from Novartis Pharmaceuticals, Inc.

Summary scores for patient-reported outcome measures in multiple sclerosis. Baseline data from the trial to Evaluate Patient OutComes, safety and tolerability of fingolimod (EPOC)

M. Cascione, D. Wynn, N. Agashivala, K. McCague, L. Pestreich, L. Schofield, E. Kim, L. Barbato

Tampa Neurology Associates, South Tampa Multiple Sclerosis Center (Tampa, US); Consultants in Neurology, Ltd. (Northbrook, US); Novartis Pharmaceuticals Corporation (East Hanover, US)

Background: The EPOC trial is a 6-month, randomised, active comparator, open-label, multicentre study to Evaluate Patient OutComes, safety and tolerability of fingolimod 0.5 mg/day in patients with relapsing forms of multiple sclerosis (MS) who are candidates for MS therapy change from previous disease-modifying therapy (DMT).

Objective: To evaluate the baseline summary scores for patient-reported outcomes in the EPOC trial.

Methods: This 6-month phase 4 trial enrolled patients who were candidates for therapy change and randomised them to either fingolimod or standard-of-care DMT. The patient-reported primary study endpoint, global satisfaction subscale of Treatment Satisfaction Questionnaire for Medication (TSQM v1.4), and secondary endpoints, other subscales of TSQM (effectiveness, side effects and convenience), Activities of Daily Living (ADL) measured by PRIMUS-activities, fatigue measured by Fatigue Severity Scale (FSS), depression measured by the Beck Depression Inventory (BDI-II) and health-related quality of life measured using Short-Form Health Survey v2 standard (SF-36 v2) were collected at baseline, prior to randomisation. Baseline summary scores for the patient-reported scales are reported.

Results: 1053 patients were randomised in the United States and Canada; 966 patients were included in this interim analysis. Mean (SD) age for the cohort was 45.7 (9.9) years and 76.9% were female. Patients were being treated with glatiramer acetate (33.9%), subcutaneous interferon β-1a (25.3%), intramuscular interferon β-1a (24.7%) and interferon β-1b (16.0%) at the time of enrollment. At baseline, the mean (SD) score for global satisfaction subscale of TSQM was 59.4 (22.8) and the effectiveness, side effects and convenience subscale scores were 61.9 (21.4), 68.8 (27.8) and 55.1 (21.2), respectively. Mean (SD) scores for PRIMUS-activities, FSS and BDI-II were 5.2 (5.7), 4.6 (1.6) and 11.5 (9.0), respectively. The physical and mental component mean (SD) scores for SF-36 were 41.8 (10.8) and 46.4 (12.0), respectively.

Conclusion: Satisfaction with prior treatment ranged around 55–69 for the EPOC patients, with lower scores for convenience. Baseline PRIMUS-activities score was low, reflecting mild impairment in the ability to perform daily activities. EPOC patients were not depressed. Fatigue scores were higher compared with normal healthy adults. Health-related quality of life as measured by SF-36 was also lower compared with the general US population.

Supported by Novartis Pharmaceuticals Corporation.

D. Wynn has received research support from Abbott Laboratories, Acorda Therapeutics, Avanir Pharmaceuticals, Biogen Idec, Elan, Eli Lilly, EMD Serono, Facet Biotech, Genentech, Genzyme, GlaxoSmithKline, Hoffman LaRoche, National Institutes of Health, National MS Society, Novartis, Ono Pharmaceuticals, Opexa Therapeutics, Pfizer, sanofi-aventis, Teva, UCB, and XenoPort; and has served as a consultant for Acorda Therapeutics, Allergan, Avanir Pharmaceuticals, Cephalon, EMD Serono, Genzyme, GlaxoSmithKline, Novartis, Pfizer, Questcor, Teva, and XenoPort.

M. Cascione has received research support from Acorda Therapeutics, Bayer HealthCare Pharmaceuticals, Biogen Idec, EMD Serono, Genzyme, Novartis, and sanofi-aventis; has been a speaker for Acorda Therapeutics, Bayer HealthCare Pharmaceuticals, Biogen Idec, EMD Serono, Novartis, Pfizer, and Teva; and has served as a consultant for Acorda Therapeutics, Bayer HealthCare Pharmaceuticals, Biogen Idec, EMD Serono, Genzyme, Novartis, and sanofi-aventis.

N. Agashivala, K. McCague, L. Pestreich, L. Schofield, L. Barbato, and E. Kim are employees of Novartis Pharmaceuticals Corporation.