Personalised Medicine in Multiple Sclerosis
University of Milano-Bicocca, Milan, Italy
Agostini S1, Guerini FR1, Mancuso R1, Zanzottera M1, Hernis A1, Liuzzo G1, Rovaris M2, Clerici M1,3
1Laboratory of Molecular Medicine and Biotechnologies, Don Carlo Gnocchi Foundation – ONLUS IRCCS, Milan, Italy; 2Multiple Sclerosis Center, Don Carlo Gnocchi Foundation – ONLUS IRCCS, Milan, Italy; 3Department of Physiopathology and Transplantation, University of Milan, Milan, Italy
Multiple Sclerosis (MS) is a chronic inflammatory disease of the central nervous system. The exact etiopathology of MS is still unclear, although both genetic and environmental factors has been suggested to influence disease susceptibility. Epstein Barr Virus (EBV) has long been suspected to be one of the environmental risk factor for MS and, on the other hand, HLA alleles are among the most important genetic risk factor associated to MS. HLA class I genes present antigens to T lymphocytes and initiate immune responses against bacteria and viruses. The aim of the present study is to evaluate if host HLA may have a role in EBV infection and in the development of MS. 51 MS patients and 47 healthy controls (HC) were enrolled in the study. All subjects were genotyped for HLA alleles and characterized for EBV and cytomegalovirus (CMV) infection (seroprevalence and DNA viral load). EBV seroprevalence was analyzed using an EBNA-1 and VCA antibody (Ab) ELISA test, whereas CMV seroprevalence using CMV IgG ELISA test. EBV and CMV viral loads were analyzed by qPCR. Genetic analyses were performed by SSP-PCR. All the enrolled individuals were EBV seropositive, whereas the 67% of MS and the 77% of HC were CMV seropositive. No differences were observed between the two groups regarding the EBV or CMV Ab levels. EBV viral load was more frequently detectable in MS (52.9%) than in HC (34%)(p=0.07), whereas the CMV viral load was not detectable in blood in all the enrolled subject but in one HC. Higher EBV viral loads were detected in HLA-B*07+ MS patients (p=0.02;OR: +2.4), whereas HLA-A*02+ MS patients were characterized by the lowest loads (p=0.04;OR: -2.04). HLA-A*02–B*07+ MS patients stood out as they had has the highest observed EBV viral loads (p=0.05 vs. all other HLAs). No differences were observed in EBNA-1, VCA and CMV Ab titers in relationship with HLA distribution. All together, these data confirm the involvement of EBV and of HLA class I alleles in MS development and suggest a possible interaction between the expression of given HLA molecules and EBV infection in the development and progression of the disease.
Cross C1, Cooke D1, Kidd T1, Embrey N2, Sterr A1, Brown D1, Carey N1
1University of Surrey, Guildford, UK, 2Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust
In order for people with MS to effectively self-manage their condition they access to timely information, advice and support. However, evidence suggests that there is a lack of available technology to promote self-management in people with MS across the disease trajectory, especially those with more severe symptoms. The aim of this study is to develop content for a remote delivery self-management program based on the information requirements and needs specified by people with secondary progressive MS and key stakeholders. Data from focus groups (n=4-6) comprising people with SPMS, carers of people with MS) and expert stakeholders (e.g. nurses, doctors, allied health professionals, managers, support workers) will be analysed to explore views and opinions regarding the use and acceptability of a remote delivery self-management program for people with SPMS. A volunteer sample using MS support groups and professional contacts established during our previous study. Qualitative data will be analysed using thematic analysis Results will be discussed at a dissemination workshop with key stakeholders (e.g. nurses, doctors, allied health professionals, managers, support workers, services users and carers) who will be invited to review findings, inform content of the a remote delivery self-management program for people with secondary progressive multiple sclerosis and create a platform for future grant application. Data collection is underway and the study will be completed by end of July 2017.
Cogo MG1, Patassini M 2 , Suzani M3, Morzenti S4, Cammaroto V.5, Cereda D1, Grimoldi M1, Balducci C1, Cutellè C1, Fusco ML1, Frigo M1
1Department of Neurology, San Gerardo Hospital and University of Milano-Bicocca, Monza, Italy, 2Department of Neuroradiology, San Gerardo Hospital and University of Milano-Bicocca, Monza, Italy, 3Department of Ophthalmology , San Gerardo Hospital and University of Milano-Bicocca, Monza, Italy, 4Department of Health Physics , San Gerardo Hospital and University of Milano-Bicocca, Monza, Italy, 5Department of Neuroscience and Biomedical Technology , San Gerardo Hospital and University of Milano-Bicocca, Monza, Italy
Multiple sclerosis (MS) is an inflammatory demyelinating and neurodegenerative disease of the central nervous system. Recently axonal loss has arised as the predominant cause of ongoing disability in MS. Even in the early stages of the disease, Magnetic Resonance Imaging (MRI) may show neurodegeneration by the examination of total brain volume (TBV), white matter volume (WMV) and gray matter volume (GMV). Optical Coeherence Tomography (OCT) is currently being investigated as a useful tool in identifying early neurodegeneration in MS. OCT can quantify neuroaxonal loss in the retina of MS patients both with and without history of Optic Neuritis (ON) and retinal axonal loss shows correlation with disease progression and disability. Several studies reported Ganglionar Cell Layer (GCL) and macular and peripapillary Retinal Nuclear Fiber Layer (mRNFL, pRNFL) as the best predictors of axonal damage in MS. We included 18 consecutive MS patients, with a definite and recent diagnosis of disease based on the McDonald criteria, and 17 healthy controls without history of neurological or ophthalmic illness. All patients were studied with 3D MRI at baseline and after 12 months: TBV, WMV,GMV and regional atrophy parameters were evaluated. Patients also underwent an extensive battery of neuropsychological tests and OCT study. MS patients group shows a volumetric reduction in the corresponding area of left insular cortex and left frontal inferior cortex compared to controls. Preliminary results show a significant reduction(p < 0.005) of p-RNFL thickness in MS patients and a correlation with specific brain areas, notably in the frontal and prefrontal lobes. Further correlation analysis with the performance in neuropsychological tests and OCT parameters are still ongoing.
Pinardi S1, Di Coste F2, La Pietra G3 .
1,3Educational Factory srl, Milan, Italy; 2Associazione Italiana Health Coaching, Rome, Italy
The personal sensors are now commonly found in smartphones, bracelet, smart watches, and other similar market-devices. These electronic artefacts can profitably be used to detect and classify human movements in everyday life, especially in patient with chronic disease like Multiple Sclerosis’, Parkinson’s, Alzheimer’s. The practical benefits are evident: wearable instruments can follow the patient everywhere, they are non intrusive and respect intimacy. This enables a new approach to telemedicine and medicine 4.0: continuous monitoring of the patients activities during daily life using off-the-shelf tools can be exploited to evaluate biomechanical capabilities, human behavior, and even cognitive abilities. On the other hand, these methodologies rise important questions: are the relative results reliable enough to ensure a correct medical diagnosis and to support the therapy, and under which conditions and why?
A newly proposed approach, the FfxIVFf transform for sensor analysis, a supervised machine-learning method developed by one of the authors, has made it possible to achieve high precision on inertial and environmental sensors in real-time analysis (Pinardi S, Bisiani R, 2010). Thanks to this method it is also possible to reduce the number of worn body sensors without losing overall accuracy even on low cost sensors (98.4%, p < 0.01, to be submitted).
On this evidence we implement a new model of healthcare that is based on patient involvement, where assistance is brought from the clinic to the home with invariance in the quality of patient services, giving social, psychological and economic benefits.
Intelligent analysis give flexibility to the approach and objectivity to data and can reduce socio-assistive costs. The continuous monitoring allows to identify epiphenomena that may not be noticed in a normal medical scrutiny. Cluster analysis on these data allows the patient to be profiled on objective aspects and to tune medical and pharmacological therapies to measurable evidences and individual responses.
Vanna R1, Abols A4, Sguassero A1, Morasso C1, Alvaro Artiga Folch5, Ambra Hernis2, Rafael Ramirez Jimenez4, Roberta Mancuso2, Simone Agostini2, Silvia Picciolini1, Alice Gualerzi1, Marzia Bedoni1, Jesus M. de la Fuente5, Furio Gramatica1, Aija Line4 and Marco Rovaris3
1 Laboratory of Nanomedicine and Clinical Biophotonics (LABION); 2 Laboratory of Molecular Medicine and Biotechnologies; 3 Multiple Sclerosis Unit; IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy; 4 Latvian Biomedical Research and Study Centre, Riga, Latvia; 5 Instituto de Ciencia de Materiales de Aragon, CSIC/University of Zaragoza, Spain
Clinical evaluation and magnetic resonance imaging (MRI) are still the only currently available approaches for multiple sclerosis (MS) staging and monitoring. Even if few MS biomarkers have been proposed (i.e. IgG oligoclonal bands, axonal damaging markers and noncoding RNAs) none of them have been clinically implemented . MicroRNAs (miRNAs) are very promising diagnostic, subtyping and prognostic biomarkers but the major limits for their use are the lack of standardized assays and the lack of validation studies in very large cohorts. In particular, the simultaneous screening and accurate quantification of several miRNAs in large cohorts is still a technological challenge even for the most used current methods (RT-PCR, microarray, sequencing) .
Here we report the proof-of-concept of a new approach for the PCR-free simultaneous detection of a theoretically unlimited number of miRNAs using a single nano-structured assay reagent. In details, Surface Plasmon Resonance imaging (SPRi) (able to recognize multiple DNA:RNA hybridizations in label-free) has been enhanced in order to detect miRNA which cannot be normally seen at low concentration by SPRi. For this purpose, ad-hoc produced gold nanoparticles have been optimized and functionalized with an antibody able to recognize DNA:RNA hybrids without sequence-specificity. As result, the injection of this nano-structured reagent, after the injection of miRNAs onto a SPRi-array, has permitted the simultaneous detection of miRNAs in the femtomolar range.
In parallel, contextually to the “NanoPlasmiRNA” ERA-NET project, in order to define the miRNAs to be detected on a single SPRi-array chip, next-generation sequencing (Ion-torrent) of small RNA plasma of around 10 MS patients and 10 sex and age (+/-1) matched healthy volunteers is ongoing and preliminary results will be reported.
 Teunissen, Charlotte E., et al. Nature Reviews Neurology 11.10 (2015): 585-596.
 R.M. Graybill and R.C. Bailey, Anal. Chem., 88, 431–450 (2013).
Varoli E3, Romero L J1,2, Pisoni A1,2, Mattavelli G1,2, Rosanova M4,5, Bolognini N1,2, Vallar G1,2.
1Department of Psychology, University of Milano-Bicocca, Milan, Italy; 2NeuroMi – Milan Center of Neuroscience, Milan, Italy; 3Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; 4Department of Biomedical and Clinical Sciences “L.Sacco”, University of Milano, Milan, Italy; 5Fondazione Europea di Ricerca Biomedica FERB Onlus, Milan, Italy
Despite transcranial direct current stimulation (tDCS) is increasingly used in experimental and clinical settings, its precise mechanisms of action remain largely unknown. At a neuronal level, tDCS modulates the cortical excitability by shifting the resting membrane potential in a polarity-dependent way: anodal stimulation increases the spontaneous firing rate in the stimulated region, while cathodal decreases it. So far, the neurophysiological underpinnings of the immediate and delayed effects of tDCS are still unclear, as well as, it is not fully understood how the stimulation of a given cerebral region may affect the activity of anatomically connected regions. In a previous study it has been investigated the tDCS anodal’s role in the cortical excitability, by a combination of Transcranial Magnetic Stimulation (TMS) and Electroencephalography (EEG). Results showed a diffuse rise of cortical excitability in a bilateral fronto-parietal networks. In the present study, we used the same technique and methodological setting in order to explore local and global cortical excitability modulation during and after cathodal tDCS. Single pulse TMS was delivered over the left posterior parietal cortex (PPC), before, during, and after 10 minutes of tDCS over the right PPC, while EEG was recorded from 60 channels. For each session, indexes of global and local cerebral excitability were obtained, computed as global and local mean field power (Global Mean Field Power, GMFP and Local Mean Field Power, LMFP) on mean TMS-evoked potentials (TEPs) for four temporal windows: 0-50, 50-100, 100-150 and 150-200 milliseconds. The global index was computed on all 60 channels. The local indexes were computed in four clusters of electrodes: left and right, in frontal and parietal regions. The preliminary results on nine subjects show no differences in both sessions during and after cathodal tDCS compared to pre-stimulation session. These preliminary results suggest the existence of a difference effect due to anodal and cathodal tDCS stimulation, also in other areas, different from the motor cortex.
Pietroboni AM1, Caprioli M1, Scarioni M1, Fenoglio C1, Spanò B2, Arighi A1, Cioffi SM1, Oldoni E1, De Riz MA1, Basilico P1, Calvi A1, Fumagalli GG1, Triulzi F1, Bozzali M2, Galimberti D1, Scarpini E1
1University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy, 2IRCCS Santa Lucia Foundation, Rome, Italy
Background: Neurodegeneration plays a major role in determining disability in multiple sclerosis (MS) patients. Hence, there is increasing need to identify reliable biomarkers, which could serve as prognostic measure of disease progression.
Objectives: To assess whether cerebrospinal fluid (CSF) tau and β-amyloid (Aβ) levels were altered in newly diagnosed MS patients and correlated with disability. Moreover, we investigated whether these CSF biomarkers associate with macroscopic brain tissue damage measures’.
Methods: CSF Aβ and tau levels were determined by enzyme-linked immunosorbent assay in CSF samples from 70 newly diagnosed MS patients, followed-up clinically for 3-5 years by recording their Expanded Disability Status Scale score at 6 months intervals, and 45 controls. All patients underwent Magnetic Resonance Imaging at baseline and at the end of follow-up to quantify their lesion load (LL).
Results: CSF Aβ levels were significantly reduced in patients compared to controls (p<0.001). Lower CSF Aβ levels at baseline were a disability predictor at 3 year follow-up (p=0.009). CSF tau levels correlated with T2- and T1-LL (p<0.001).
Conclusions: CSF Aβ reduction is a promising biomarker of neurodegeneration and may predict patients’ clinical outcome. Therefore, CSF Aβ should be considered as a potential biomarker of prognostic value.
Barbone G1, Ceresa C2,3, Monfrini M2,3, Eckermann M1, Chiorazzi A2,3, Canta A2,3, Bossi M2,3, Mittone A4, Bravin A4, Cavaletti G2,3, Coan P4,5.
1Department of Physics, Ludwig Maximilians University, MunichGermany; 2School of Surgery and Medicine, University of Milano-Bicocca, Monza, Italy; 3Milan Center for Neuroscience, Milano, Italy; 4ID17, European Synchrotron Radiation Facility, Grenoble, France; 5 Dept. Clinical Radiology and Dept. Physics, Ludwig Maximilians University, Munich.
The study of spinal cord micro-vasculature plays a key role in the comprehension of vascular and neurodegenerative disorders and in the patient evaluation during treatment. However, its visualization is still limited by conventional imaging modalities. Currently available neuroimaging techniques used to investigate vascular and neurodegenerative disorders cannot provide full-organ volumetric visualizations of Central Nervous System (CNS) blood vessels at micrometric-resolution. Furthermore, existing methods are often based on sample-invasive imaging protocols involving dissections, labeling or contrast-agent injection. The aim of this study is to visualize the complex vasculature network of the spinal in an animal model. For this purpose, a staining- and dissection-free imaging technique, the so-called X-ray phase contrast micro-tomography (μPCI-CT), was applied. Rat lumbar spinal cord samples from healthy rats were imaged using a 3 μm spatial resolution μPCI-CT setup at the Biomedical Beamline ID17 of the European Synchrotron (ESRF). We used 40 keV monochromatic coherent X-rays, a PCO camera, and a variable sample-to-detector distance. Moreover, we tested different spinal cord tissue fixation protocols (based on paraformaldehyde, glutaraldehyde or osmium staining) and their influence on vessel contrast in μPCI-CT images. Using this technique, we were able to visualize both superficial and deep vessels without the use of any contrast-agent. Moreover, we observed the best μPCI-CT vascular contrast after spinal cord fixation with a paraformaldehyde 4%, glutaraldehyde 2% solution. Full-organ spinal cord anatomical morphology was also detected. This study shows that μPCI-CT provides a non-invasive, volumetric and histology-like analysis of micro-vascular networks within full-organ rat spinal cords and that this experimental imaging approach, readily available at synchrotron facilities, but also implementable in laboratory setups, could impact neurology studies on vessel-driven neurodegeneration, when precise blood-vessel morphological characterization is warranted.
Giatti S1, Rigolio R2, Diviccaro S1, Pesaresi M1, Spezzano R1, Caruso D1, Cavaletti G2 and Melcangi RC1 1Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy; 2Department Surgery and Translational Medicine, Università degli Studi Milano-Bicocca, Monza, Italy
Neuroactive steroids are cholesterol derived molecules able to affect nervous system (NS). They can be produced by de novo synthesis in NS, or metabolized after uptake from circulation, in which are present parental compounds originating in steroidogenic glands. Neuroactive steroids exert important functions in NS, regulating memory and learning processes, neuroinflammation, myelin production, oligodendrocytes proliferation and maturation. Moreover, they exert important protective effects in neurodegenerative diseases and after injury. Interestingly, clinical and pre-clinical studies also suggest a role in multiple sclerosis (MS). For instance, sex difference in incidence have been reported. Moreover, pathological progression is modulated by steroid level fluctuations and disease progression alters neuroactive steroid levels. Then, as reported by us and other groups in clinical and experimental studies, neuroactive steroid administration resulted in improved clinical course and disease outcome. Overall, these data indicate that it is important to characterize how MS impacts the synthesis and mechanisms of action of these molecules and whether these changes could be different depending on the sex. To this aim, we studied male and female EAE rats, presenting a relapsing-remitting course, similar to the most common human form. Analysis were performed at peak of disability, that occurred at 14 day-post induction (dpi) and during the chronic phase of the disease, at 40-45 dpi. To study neuroactive steroid metabolism and mechanism of action, we evaluated the expression of different enzymes and proteins involved in neurosteroidogenesis, and the levels of neuroactive steroid receptors. The results we obtained indicate that the parameters evaluated are impaired in male and female EAE animals, and these alterations are dependent on disease course. Our data represent important insights to better understand MS progression and to possibly propose therapeutic strategies based on neuroactive steroids.
Rigolio R1, Parlanti P2,3 Cavaletti G1, Gemmi M3, Cappello V3
1 Dipartimento di Medicina e Chirurgia, Experimental Neurology Unit, NEUROMI, Università degli Studi di Milano-Bicocca, Monza, Italy; 2 NEST, Scuola Normale Superiore,Pisa, Italy;
3 Center for Nanotechnology Innovation @NEST, Istituto Italiano di Tecnologia, Italy
Multiple Sclerosis (MS) is a chronic neuroinflammatory disease affecting the Central Nervous System (CNS) and it is clinically characterized by demyelinating processes disseminated in time and space along the CNS resulting from the activation of parenchyma infiltrating immune cells at least in the early disease phase.
Experimental Autoimmune Encephalomyelitis is the main MS animal model and a useful tool to dissect immunological and pathological processes. In EAE the analysis on the CNS infiltrating leukocytes has been mainly performed on spinal cord. While studies on the type of infiltrating cells are available, information about a comprehensive leukocyte localization is missing as well as few data are available on the relationship of the infiltrating leukocytes with the other cellular component of the CNS.
Therefore, our final goal is to localize and deeply characterize the infiltrating leukocytes in a wide spinal cord volume highlighting their relationship with the other CNS elements.
These purposes will be reached through a correlative approach using X-ray tomography (micro-CT) and TEM analysis after tuning an adequate preparative protocol.
Our results demonstrated that the chemical protocols have to be finely tuned to achieve both contrast for micro-CT, and preserved ultrastructure for the TEM characterization on the same sample. Moreover modifying the embedding procedure strictly depends upon the size and the morphological characteristics of the sample.
This correlative approach has been validated on TWI mice (experimental model of Krabbe disease) sciatic nerves showing it is possible to identify a single infiltrating cell within the tissue in the 3D rendering of micro-CT and to follow it during the sectioning process and further characterization it with TEM.
Scuteri A1, Donzelli E1, Rigolio R1, Ballarini E1, Monfrini M1, Chiorazzi A1, Meregalli C1, Cavaletti G1
School of Medicine and Surgery, University of Milan-Bicocca, Monza (MB), Italy
Multiple Sclerosis (MS) is a chronic disease of the Central Nervous System characterized by the presence of self-antibodies which progressively damage axonal myelin sheath, thus causing axonal transmission impairment and the development of neurological symptoms. Current therapy for MS is based on immunosuppressant agents, but recently Mesenchymal Stem Cells (MSCs) have been proposed as therapeutic treatment for MS, demonstrating a positive effect when administered before disease onset, mainly due to their immunomodulatory properties. Here, we investigate the therapeutic potential of MSC administration after disease onset into an animal model of MS, represented by Dark Agouti rats affected by chronic Relapsing-Remitting Experimental Autoimmune Encephalomyelitis (EAE). MSC were intravenously injected in EAE rats after disease onset. Clinical score was assessed daily, and after 45 days rats were sacrificed and histological analysis of spinal cords performed to evaluate the demyelinating lesions. After the first peak of disease, no further relapses were observed in EAE rats treated with MSCs, differently from what observed in EAE group. Histological analysis demonstrated the presence of demyelinated plaques in spinal cords of EAE rats. On the contrary the therapeutic schedule with MSCs significantly reduces the number and the extension of demyelinated areas in the spinal cords, confirming clinical score evaluations. These results demonstrated that MSCs ameliorate the clinical course of EAE and hamper the disease relapsing by reducing the areas of demyelinated lesions. Granted by MIUR – FIRB Futuro in Ricerca 2008 Prot. N° RBFR08VSVI_001.
Personalized photo-thermally active gold nanoparticle surfaces. Novel opportunities for “smart” patches
Borzenkov M, Chirico G, Collini M.
Nanomedicine Center, University of Milano-Bicocca Milan, Italy
Multiple sclerosis is a life-long condition that needs personalized continuative treatments. Transdermal patches are widely used with this purpose. We are studying a new class of patches with enhanced efficiency for a delivery on demand of compounds. Nowadays inkjet-printing has met important challenges to pattern a broad range of functional materials with promising biomedical application. This approach can be also applied in the fabrication of smart patches with on-demand drug release properties, possibly triggered remotely by irradiation with near infrared radiation. As a proof-of-concept of this concept stable inks containing PEGylated gold nanostars (GNS) were prepared and inkjet printed on a biocompatible latex coated flexible paper substrate. A significant photothermal effect (DT @20 oC) of the printed patterns was observed under Near Infrared (NIR) excitation of the Localized Surface Plasmon Resonance (LSPR) of the GNS with low laser intensity (I @ 0.2 W/cm2). We found that, beside the direct impact of the radiation intensity, the printing parameters (drop density and number of layers) also affect the photo-thermal efficiency. In addition, model compound, the Bodipy-thiol dye, was bound to the gold surface and its photo-thermally induced release from the patterns was demonstrated as additional effect. Future research will be focused on the improvement of drugs loading and their active release from patterned gold surfaces by external application of NIR radiation aimed at the development of wearable “smart” patches with well tuned local drug release profiles.
Theory of mind in high-functioning patients with relapsing-remitting multiple sclerosis
Cammaroto V1,2, Fusco ML2, Cogo MG2, Traficante D1,2, Frigo M2, and Isella V1
1Neuropsychology Section and 2Neuroimmunology Center, Department of Neurology, S. Gerardo Hospital, Monza, University of Milano Bicocca, Italy
Social cognition is a complex of cognitive abilities including so called theory of mind (ToM), necessary to interpret interpersonal relationships and act flexibly in the social environment. ToM refers to the ability to attribute mental states to self and others and deals with both cognitive (i.e. thoughts, intentions, beliefs) and affective (i.e., emotions, feelings) components of social life. ToM impairment and its neuropsychological correlates in relapsing-remitting multiple sclerosis (RRMS) is still controversial, especially in patients with minimal disability and short disease duration. The aim of this study was to assess social cognition, and in particular ToM, in adults with very mild RRMS. We analyzed performance on the Faux Pas test and on a social cognition battery including ‘Emotions attribution’, ‘ToM’ and ‘Social situations’ tests in 42 RRMS patients and 30 matched healthy controls, and correlated experimental tasks with executive functions, mood and clinical features of MS (disease duration and disability level). Results showed that patients and controls did not differ significantly in the Faux Pas, ToM and Social Situation tests, while the RRMS group encountered more difficulties than controls in correctly recognizing negative emotions (sadness and anger). At correlation analysis only the Faux Pas scores showed some significant association, and only with executive measures (p <.01). Our findings suggest that the correct attribution of negative emotions may be affected even in the early stages of RRMS. The impact of executive dysfunction does not appear relevant for affective ToM, but will need to be investigated further.
Barriers and facilitators in care coordination for people with multiple sclerosis: a systematic review
Carey N1, Westwood S2, Cooke D1, Peacock M1, Cross C1, Embrey N3, Mold F1
1University of Surrey, Guildford, UK; 2Keele University, Stafford, UK; 3Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, UK
Multiple sclerosis is a highly complex and unpredictable condition that necessitates highly coordinated care and frequently requires support from a range of healthcare professionals. The aim of the review was to identify barriers and facilitators in coordination of care for people with MS and priority areas for improvement. Comprehensive searches were conducted across health and social care electronic databases (including Medline, CINAHL, PsychINFO, Cochrane, EMBSE and the British Library) using index/ MeSH (Medical Subject Heading) and keyword terms (1st January 2010 to 31st October 2015). Hand searches were performed using relevant journals and citations from papers. Searches yielded 601 articles, 61 were appraised using the Mixed Methods Appraisal Tool, and 31 selected for inclusion and subject to a narrative synthesis Enduring problems, specifically inflexible systems in care delivery and support, a lack of holistic care, in particular psychological elements, and shortcomings in the timely provision of individually tailored information were identified as key barriers to care coordination. Enduring problems in care coordination have resulted in an inflexible system unable to meet variable and fluctuating needs of people with multiple sclerosis. We recommend a more holistic approach. Information provision could be improved by increased use of technology and introduction of a new multiple sclerosis support worker role, making services more personalised, accessible and cost effective. Given the complexity and disease burden of multiple sclerosis to patients and families this has important implications that need to be considered by those responsible for commissioning services in the United Kingdom and other countries.
A systematic review of the effectiveness of self-management interventions in people with multiple sclerosis at improving depression, anxiety and quality of life
Kidd T1, Carey, N1, Mold F1, Westwood S2, Miklaucich M1, Konstantara E1, Sterr A1, Cooke, D1
1University of Surrey, Guildford, UK; 2Keele University, Stafford, UK
Self-management interventions have become increasingly popular in the management of long term health conditions; however, little is known about their impact on psychological well-being in people with MS. It is well established that many people with MS have impaired health-related quality of life (HRQOL), and higher rates of depression and anxiety than the general population. A structured literature search was conducted using multiple electronic databases including Medline and Embase for the years 2000 to 2016. The review identified 10 RCT trials that fulfilled selection criteria and had acceptable methodological quality. Self-management interventions improved HRQOL in 6 out of 7 studies, with some evidence of improvement in depression and anxiety. Evaluation of the data was impeded by a number of methodological issues including lack of detail regarding the content and delivery of the intervention and the exclusion of participants representing the disease spectrum. Recommendations are made for developing services and improving quality of the research conducted in this area.
Benign multiple sclerosis: assessment of main prognostic factors and long-term disability acknowledgments
Cereda D1, Balducci C1, Cogo MG 1, Cutellè C1, Frigo M1, Grimoldi M1, Trotta G1, Fusco ML1
1 Milan Center for Neuroscience, University of Milano-Bicocca, Department of Neurology, S. Gerardo Hospital, Monza, Italy
The existence of a benign variant of Multiple Sclerosis (MS) remains a controversial topic. There is no unique definition of benign MS in the literature; usually, it refers to patients with preserved motor functions, assessed through the Expanded Disability Status Scale (EDSS), mainly influenced by deambulatory capacity. Although lacking uniformity in the definition, it is possible to speak of benign MS in the presence of an EDSS ≤ 3 to 10 years after the onset, which corresponds to a moderate disability in a functional system or to a mild disability in three or four functional systems. Some recent studies have shown that a better definition of benign MS may be EDSS ≤ 2 to 10 years after the onset, as these patients exhibit a variable probability of between 68% and 93% to remain stable over the following 20 years. At present there is no immunological or genetic marker capable of predicting a benign disease course; so, the diagnosis of benign MS remains retrospective. However, it would be crucial to be able to early identify the likelihood of accumulation of individual patient disability in order to implement an individualized therapeutic strategy. The aim of this research project is to identify the main clinical, radiological or laboratory prognostic factors that predict a benign disease course. For this purpose we evaluated 114 patients with MS, regardless of the degree of disability, followed at the Neuroimmunology Clinic of the Neurological Clinic of San Gerardo Hospital in Monza. They had a history of illness of at least 10 years. In addition, in patients with a longer duration of illness, EDSS score was evaluated to effectively define Benign Multiple Sclerosis. The present study has shown that no clinical, radiological, laboratory or demographic characteristics of the disease appear to be associated with a benign course of MS; on the other hand, this study has confirmed that the most commonly used definition in the literature, ie EDSS score ≤ 3 after at least 10 years of illness, is unable to effectively classify patients with benign course and probably overestimating the actual frequency of the benign variant.
Early diagnosis of pml: results from the Italian cohort
De Rossi N1, Scarpazza C1, Prosperini L2, Cosottini M3, Capra R1, Gerevini S4 on behalf of the Italian PML group.
1 Multiple Sclerosis Centre, Spedali Civili di Brescia, Montichiari, Brescia, Italy; 2 Department of Neurology and Psychiatry, Sapienza University, Rome, Italy; 3 Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Pisa, Italy; 4 Department of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
Background: Progressive Multifocal Leukoencephalopathy (PML) is an uncommon side effect emerging in natalizumab (NTZ) treated patient. Despite previous studies suggest that an early diagnosis leads to better prognosis, PML is frequently diagnosed in its advanced stages. Goals: To investigate if the PML early diagnosis is feasible and to determine whether the frequency of magnetic resonance images (MRI) impact on the early PML identification. Methods: Clinical and MRI data at PML diagnosis of 49 PML patients were retrospectively collected. The MRI prior to the diagnostic one (i.e. pre-diagnostic) was also collected. MRIs were analyzed for PML lesions by two experts, the PML lesions at diagnosis and pre-diagnosis were manually delineated and their volume was automatically calculated. An index was created to estimate the monthly increment of lesions during the diagnostic delay. Finally, lesions volume at their first appearance was compared between patients who performed MRI infrequently (every 12 or 6 months) vs frequently (every 3 or 4 months). Results: Pre-diagnostic MRI (performed about 5 months prior to the diagnostic MRI) was available for 28 patients (57.14%). In 20 pre-diagnostic MRIs out of 28 (71.42%) the PML lesion was already noticeable, but was not detected. The lesions volume was 1.94 cm3 (mean) at pre-diagnosis and 17.6 cm3 (mean) at diagnosis. The lesion volume change (diagnosis/pre-diagnosis, mean 13.91) correlates with the diagnostic delay (in months) (r=0.44, p=0.04). Each month of diagnostic delay, the lesion triplicate its volume (lesion change months of diagnostic delay: 13.91/5=2.75). Prior to PML onset, 26% of patients underwent routinely MRI every 12 months; 36% every 6 months; 22% every 4 months and 16% every 3 months. 7 patients (14.2%) were asymptomatic at PML onset: they performed a MRI scan every 3 (n=3) or 4 months (n=4). The frequency of MRI significantly affected the lesion volume at their first appearance (t=4.55, p=0.033), being the lesions smaller in patients who underwent MRI scan more frequently. Conclusions: Early diagnosis of PML is feasible since in the 71.4% of patients PML lesion was detectable 5 months prior to PML diagnosis. Frequent monitoring using MRI is helpful for the early detection of PML lesions.
Disclosures: Dr. Scarpazza has nothing to disclose. Dr. De Rossi received speaker honoraria from Biogen and Teva and travel grants from Biogen, Teva and Merk Serono. Dr. Prosperini received consulting fees from Biogen and Novartis; speaker honoraria from Biogen, Genzyme, Novartis and Teva; travel grants from Biogen, Genzyme, Novartis and Teva; research grants from the Italian MS Society (Associazione Italiana Sclerosi Multipla) and Genzyme. Dr. Cosottini received speaker honoraria from Biogen. Dr. Capra received consulting fees from Novartis, Biogen-Idec and lecture fees and/or travel grants from Novartis, Biogen-Idec, Genzyme and Sanofi-Aventis. Dr. Gerevini received speaker honoraria from Biogen-Idec. Acknowledgements: We would like to acknowledge all the members of the Italian PML Cohort Consortium, who shared the patient’s data. In alphabetic order: Marta Altieri; Maria Pia Amato; Fabio Bandini; Valeria Barcella; Antonio Bertolotto; Vincenzo Bresciamorra; Guido Cavaletti; Marco Capobianco; Paola Cavalla; Marinella Clerico; Cinzia Cordioli; Mirco Cosottini; Giangaetano D’Aleo; Giovanna De Luca; Milena de Riz; Luciano Deotto; Luca Durelli; Mario Falcini; Ernesta Ferrari; Claudio Ferrante; Maria Letizia Fusco; Simonetta Gerevini; Angelo Ghezzi; Luigi Grimaldi; Mario Guidotti; Alessandra Lugaresi; Lucia Moiola; Paola Naldi; Patrizia Perrone; Matteo Pizzorno; Carlo Pozzilli; Monica Rezzonico; Marco Rovaris; Giuseppe Salemi; Marco Salvetti; Giuseppe Santuccio; Elio Scarpini; Claudio Solaro; Giulietta Tabiadon; Carla Tortorella; Maria Trojano.
Role of comorbidity in multiple sclerosis: prevalence in a single center
Frigeni B, Barcella V, La Gioia S , Gardinetti M, Conti MZ , Vedovello M, Zanchi C, Rottoli MR
Centro Sclerosi Multipla, USS Neuroimmunologia, ASST Papa Giovanni XXII Bergamo, Italy
OBJECTIVES: Comorbidity is an area of increasing interest in multiple sclerosis (MS): 40-65% of MS patients have at least one other disease. Several reviews showed that comorbidities have been associated to diagnostic delay, increased hospitalization and mortality. Moreover the presence of comorbidities should be considered during the choice of disease-modifying drugs (DMDs) and may affect the MS therapy adherence and response. Our aims were to characterize the comorbidities of the MS center of Bergamo.
MATERIALS AND METHODS: We retrospectively evaluated the clinical history of 601 consecutive patients afferent to our MS center in 2016. We reported all comorbidities which could be relevant to health care utilization and could influence treatment choices in MS patients.
RESULTS: Overall we evaluated the data of 487 patients with relapsing remitting MS, 103 patient with secondary progressive MS and 11 patients with primary progressive MS. 67% of our cohort were females and 33% were males. Mean age was 43.9 years old (SD 11.7). Median EDSS was 2.0 (range 1.0-9.0). 42.2% of patients had at least one comorbidity (28.2% only one comorbities, 14.0% two or more comorbidities). Overall, at least one comorbidity was already present at diagnosis in 8.8% of our sample; 33.4% of subjects developed at least one comorbidity during MS disease course. 9.8% of our patients were affected by hypertension, 5.8 % by dyslipidemia, 2.3% by diabetes, 2.8% by cardiac diseases, 4.7% by malignant tumors (21.4% breast cancer, 25.0% genito-urinary tumors, 7.1% gastrointestinal tumors, 3.6% lung cancer, 32.1% skin cancers, 10.8% other tumors), 20% by psychiatric disorders ( 86.6 % anxiety-depressive disorder, 13.4% psychosis or bipolar disorder) and 9.7% by autoimmune diseases (64,7% autoimmune thyroiditis, 9.8% psoriasis, 7,8% celiac disease, 17,7% other mixed autoimmune diseases). Diabetes and autoimmune disorders were equally detected before and after MS diagnosis, while the remaining comorbidities onset was more frequent during MS disease course.
DISCUSSION AND CONCLUSIONS: We reviewed the prevalence of comorbidities in a single MS center. The high prevalence of comorbidities in our cohort underlines the complexity of MS patients, which is not confined to MS direct complications. A high rate of subjects developed comorbidities after diagnosis. An adequate identification and a prompt management of comorbidities during MS disease course is essential and might be the key to ameliorate the health care utilization, prevent serious adverse events during MS treatment and obtain better clinical outcomes.
Diagnostic pitfalls in rare neurological diseases: the TTR FAP (transthyretin familial amyloid polyneuropathy) case
Dipartimento Neuroscienze Cliniche – Malattie Neurologiche Rare dell’Adulto – Fondazione UIRCCS, Istituto Neurologico “C.Besta”, Milan, Italy
Transthyretin familial amyloid polyneuropathy (TTR-FAP) is a devastating neuropathy with multisystem involvement, which leads to death in 10 years on average. It is transmitted as an autosomal dominant trait with a high penetrance.
Originally reported in Portugal,1 TTR-FAP is distributed worldwide with a strong clustering of the most common Val30Met variant in Portugal, Sweden, and Japan and notable phenotypic differences. In Portugal, where the disease prevalence rate is estimated at 1 in 1,000, the mean age at onset is 33 years and a positive familial history is found in 85% of the patients.2 In northern Sweden, the second focus of Val30Met families, the inaugural neurologic manifestations occur later, at age 56, on average.3 In Japan, the third focus of the disease, Val30Met families with early-onset neuropathy were initially identified in two limited areas (Arao district and Ogawa village).4 In contrast, the presence of a late-onset type of FAP-TTR Val30Met was reported in a wide distribution throughout Japan.5 In France a large population of Portuguese families coexists with families of French descent. In families of French descent, TTR variants are heterogeneous with the Val30Met in 40% of them. The mean age at onset is 58, and a family history is missing in many.6,8 In The Italian population, 72 % of the TTR FAP patients are non-Val30Met mutations, of which Phe64Leu and Glu89Gln are the most common, reflecting the high genetic heterogeneity of ATTR. Of note, patients with Glu89Gln mutation had earlier onset of the disease and more prominent heart involvement, while patients with Phe64Leu mutation showed more aggressive neuropathy.7
The most common neuropathic misdiagnosis for sporadic TTR-FAP is chronic inflammatory demyelinating polyneuropathy (CIDP). There have been also cases where TTR-related amyloidosis was initially misdiagnosed as amyloid light-chain (AL) amyloidosis .
TTR-FAP is unlikely to be mistaken for other forms of hereditary amyloid neuropathy caused by mutation of the apolipoprotein A-I, gelsolin, or β2-microglobulin genes. However, although very rare and less rapidly progressive, hereditary neuropathy due to truncation mutations of the prion protein can closely mimic TTR-FAP and should be considered in the differential diagnosis.8
1. Andrade C. A peculiar form of peripheral neuropathy: familial atypical generalized amyloidosis with special involvement of the peripheral nerves. Brain 1952;75:408–427.2 Sousa A, Coelho T,
2. Barros J, Sequeiros J. Genetic epidemiology of familial amyloidotic polyneuropathy (FAP)-Type I in Povoa do Varzim and Vila do Conde (north of Portugal). Am J Med Genet (Neuropsych Genet) 1995;60:512–521.
3. Holmgren G, Costa PMP, Andersson C, et al. Geographical distribution of TTR met 30 carriers in northern Sweden: discrepancy between carrier frequency and prevalence rate. J Med Genet 1994;31:351–354.
4. Araki S, Mawatari S, Ohta M, Nakajima A, Kuroiwa Y. Polyneuritic amyloidosis in a Japanese family. Arch Neurol 1968;18:593–602.
5. Misu K, Hattori N, Nagamatsu M, et al. Late-onset familial amyloid polyneuropathy type I (transthyretin Met30-associated familial amyloid polyneuropathy) unrelated to endemic focus in Japan. Clinicopathological and genetic features. Brain 1999;122:1951–1962.
6. Plante-Bordeneuve V, Carayol J, Ferreira A, et al. Genetic study of transthyretin amyloid neuropathies: carrier risks among French and Portuguese families. J Med Genet 2003;40:120.
7. Cortese A, Vita G, Luigetti M et al Monitoring effectiveness and safety of Tafamidis in transthyretin amyloidosis in Italy: a longitudinal multicenter study in a non-endemic area. J Neurol. 2016 May;263(5):916-924
8. Isabel Conceição, Alejandra González-Duarte,Laura Obici Red-flag” symptom clusters in transthyretin familial amyloid polyneuropathy JPNS Volume 21, Issue 1 March 2016 Pages 5–9
Isolation and characterization of neutrophils from multiple sclerosis patients
Rigolio R1,2,3, Fusco ML4, Malacrida A1,2,3, Cogo M4, Avezza F1,2, Foti M1, Cavaletti G1,2,3,4
1Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy, 2Experimental Neurology Unit, Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Monza, Italy; 3NEUROMI, Università degli Studi di Milano-Bicocca, Monza, Italy; 4Neuroimmunology Clinic, S. Gerardo Hospital, Monza, Italy
Multiple Sclerosis (MS) is an inflammatory demyelinating disease affecting the Central Nervous System (CNS) mainly involving adaptive immunity while little attention has been generally paid to the innate immunity. Nevertheless the contribution of neutrophils, monocytes and other innate immune cells have been recently highlighted in disease onset and development in humans and MS animal models.
For a long time polymorphonuclear Neutrophils have only been considered the first defence line towards pathogens and danger signals. For sustaining this role, Neutrophils show a “prone-to be activated” behaviour which make them a challenging cell population to be isolated and managed.
Nevertheless, in the last few years increasing knowledge in their biology and cell-cell communication mechanisms made their reputation gradually evolving. In fact, they have been demonstrated to be not so short-term lifetime cells and to be able to shape the adaptive immune response contributing to demyelinating processes.
Neutrophils have been tentatively studied in MS patients showing increased life span together with morphological changes in the activation state. Moreover, they have been suggested to be relevant in MS animal model.
miRNA are small non coding RNA sequence relevant in innate immune development and response which can be altered along with disease course. Although tentative miRNA signature has been described in MS patient body fluid and T-cells, no data are actually available for the circulating innate immune cells.
The final aim of our work is to define the Neutrophils epigenetic signature in MS patients to dissect their role and contribution in the disease.
In order to run accurate epigenetic analysis, we tuned isolation procedure to obtain pure and no-activated Neutrophils form the blood stream. After miRNA extraction and enrichment, we evaluated the differential expression of several miRNA in MS patients and age-matched healthy control isolated Neutrophils The preliminary results are presented.
Supported by Cariplo Foundation “Ricerca scientifica in ambito biomedico. 2013”, grant n° 2013-0941.
Modulation of glutamate transport in platelets from multiple sclerosis patients
Zoia CP1, Frigo M2, Bazzini C1, Andreoni S1, Fusco ML2, Gironi M3, Ferrarese C1, 2 and Cavaletti GA.1, 2
University of Milano-Bicocca, School of Medicine, Milan Center for Neuroscience; 2Dept. of Neurology, San Gerardo Hospital; 3CAM, Polidiagnostic Center; Monza, Italy
CNS-chronic-inflammation involvement and neurodegenerative processes seem to play an important role in the pathogenesis of multiple sclerosis (MS). This is a CNS disorder associated with demyelination and neurodegeneration, which cause temporary or permanent neurological symptoms. Mitochondrial homeostasis alterations lead to excitotoxins formation and redox disturbances that produce excitotoxicity, playing an important role in disease progression, and axonal and neuronal damage.
Excitotoxic-neuronal-damage driven by glutamate uptake impairment is widely documented in MS neurodegeneration. Excessive neuronal stimulation, due to deficient removal of glutamate and\or excessive release by activated Tcell and microglia, may trigger an enzymatic cascade leading to cell death. For MS, however, is still not cleared-up whether this imbalance relies to a glutamate overproduction or its reduced clearance. Furthermore, activated Tcells and microglia may release glutamate. In CSF from patients with active disease, and in patient serum, glutamate high levels were observed.
Our group previously reported an impairment of platelet glutamate transporters (EAAT) in neurodegenerative diseases, mirroring that was observed in central nervous system.
We observed a statistic significant glu-uptake decrease, in platelets from secondary progressive and relapsing-remitting MS compared to healthy controls (HC) and benign patients, and a reduction in primary progressive patients.
Moreover, unaffected EAAT activity in benign MS might suggest a different involvement of glu excitotoxicity for the different MS subtypes,
Since uptake values was significantly decreased in all MS group compared to HC, but EAAT affinity was unaffected between patients and HC, we suggest that the uptake impairment is not due to a reduced glu EAAT affinity but it may be due to a reduced EAAT activity.
Although the origin of the alterations is still unknown, a structural damage and/or interference with other environmental molecules (i.e.:TNF-alpha, IL6,…) and energy impairment could be contributing factors. A reduced protein synthesis is a slightly probable cause in relapsing-remitting patients, since MS is an “acute” and phasic disorder, while in progressive patients this is possible, allowing a differentiation of the disease types.