Alessia Di Sapio

Learning from nature: pregnancy changes the expression of inflammation-related genes in patients with multiple sclerosis.

Background Pregnancy is associated with reduced activity of multiple sclerosis (MS). However, the biological mechanisms underlying this pregnancy-related decrease in disease activity are poorly understood. Methodology We conducted a genome-wide transcription analysis in peripheral blood mononuclear cells (PBMCs) from 12 women (7 MS patients and 5 healthy controls) followed during their pregnancy. Samples were obtained before, during (i.e. at the third, sixth, and ninth month of gestation) and after pregnancy. A validation of the expression profiles has been conducted by using the same samples and an independent group of 25 MS patients and 11 healthy controls. Finally, considering the total group of 32 MS patients, we compared expression profiles of patients relapsing during pregnancy (n = 6) with those of relapse-free patients (n = 26). Principal Findings Results showed an altered expression of 347 transcripts in non-pregnant MS patients with respect to non-pregnant healthy controls. Complementary changes in expression, occurring during pregnancy, reverted the previous imbalance particularly for seven inflammation-related transcripts, i.e. SOCS2, TNFAIP3, NR4A2, CXCR4, POLR2J, FAM49B, and STAG3L1. Longitudinal analysis showed that the overall deregulation of gene expression reverted to “normal” already within the third month of gestation, while in the post-partum gene expressions rebounded to pre-pregnancy levels. Six (18.7%) of the 32 MS patients had a relapse during pregnancy, mostly in the first trimester. The latter showed delayed expression profiles when compared to relapse-free patients: in these patients expression imbalance was reverted later in the pregnancy, i.e. at sixth month. Conclusions Specific changes in expression during pregnancy were associated with a decrease in disease activity assessed by occurrence of relapses during pregnancy. Findings might help in understanding the pathogenesis of MS and may provide basis for the development of novel therapeutic strategies.

Anti-interferon-β neutralising activity is not entirely mediated by antibodies

Abstract Many multiple sclerosis (MS) patients treated with interferon-β (IFNβ) develop anti-IFNβ antibodies (BAbs), which can interfere with both in vitro and in vivo bioactivity of the injected cytokine. Objective of this study was to correlate these measures. Among the 256 enrolled patients, 11 (4.3%) showed a significant inhibition of the IFNβ activity in vitro , but no measurable BAbs. As a whole, in vivo bioactivity was inhibited in 9/11 (82%) of these patients. A minority of IFNβ treated patients have a non-antibody mediated neutralising activity, which competitively inhibits the bioactivity both in vitro and in vivo .

A methodological reappraisal of non invasive high voltage electrical stimulation of lumbosacral nerve roots.

OBJECTIVE To describe a neurophysiological method to locate the optimal stimulation site (OSS) over the vertebral column, customized to the individual subject, to achieve maximal activation of lumbosacral roots by means of non-invasive high voltage electrical stimulation (HVES). METHODS OSS was located in 30 volunteers by testing different stimulation points of a surface multi-electrode array placed over the dorso-lumbar junction of the vertebral column. The dorso-ventral stimulating montage was used (Troni et al., 1996). Motor responses to root stimulation (rCMAPs) were bilaterally recorded from Vastus Medialis (VM), Tibialis Anterior (TA), Soleus (SL) and Flexor Hallucis Brevis (FHB) muscles. The direct nature of rCMAPs was tested by delivering two maximal stimuli 50 ms apart. RESULTS Except for a few subjects with large girth, maximal rCMAPs could be obtained from all muscles with a stimulating current intensity up to 550 V (1050 mA). Maximal double HVES excluded any reflex component in the recorded rCMAPs. The procedure was well tolerated and no side effects were observed. CONCLUSIONS A single maximal electric shock delivered at the proper vertebral level by means of the dorso-ventral montage is able to safely achieve synchronous, bilateral maximal activation of several roots, from L3 to S1. SIGNIFICANCE Maximal activation of lumbosacral roots at their origin, unattainable with magnetic stimulation, is the essential requirement for direct detection of proximal nerve conduction slowing and block in lower limbs.

Glatiramer acetate is a treatment option in neutralising antibodies to interferon-beta-positive patients

Neutralising antibodies develop in 15% of interferon-beta (IFNβ)-treated patients, causing the reduction of the clinical effects of the treatment. This is the first study that shows that switching patients from IFNβ to glatiramer acetate (GA) in case of neutralising antibodies (NAb) positivity is effective in reducing relapse rate and in delaying the time to first relapse. In conclusion, our data suggest the use of GA in NAb-positive patients.

Assessing association of comorbidities with treatment choice and persistence in MS: A real-life multicenter study

Objective: To assess whether the presence of concomitant diseases at multiple sclerosis (MS) diagnosis is associated with the choice and the treatment persistence in an Italian MS cohort. Methods: We included newly diagnosed patients (2010–2016) followed in 20 MS centers and collected demographic and clinical data. We evaluated baseline factors related to the presence of comorbidities and the association between comorbidities and the clinical course of MS and the time to the first treatment switch. Results: The study cohort included 2,076 patients. Data on comorbidities were available for 1,877/2,076 patients (90.4%). A total of 449/1,877 (23.9%) patients had at least 1 comorbidity at MS diagnosis. Age at diagnosis (odds ratio 1.05, 95% confidence interval [CI] 1.04–1.06; p < 0.001) was the only baseline factor independently related to the presence of comorbidities. Comorbidities were not significantly associated with the choice of the first disease-modifying treatment, but were significantly associated with higher risk to switch from the first treatment due to intolerance (hazard ratio 1.42, CI 1.07–1.87; p = 0.014). Association of comorbidities with risk of switching for intolerance was significantly heterogeneous among treatments (interferon β, glatiramer acetate, natalizumab, or fingolimod; interaction test, p = 0.04). Conclusions: Comorbidities at diagnosis should be taken into account at the first treatment choice because they are associated with lower persistence on treatment.

The use of the 25 Sprotte needle markedly reduces post-dural puncture headache in routine neurological practice

Objectives The objectives of this article are to test the feasibility of lumbar puncture (LP) using 25-gauge (G) needles in daily neurological practice and to compare the risk of post-dural puncture headache (PDPH) with four types of needles. Methods In a prospective rater-blind study, pros and cons of four different LP needles, the 20G Quincke (20Q), 22G Sprotte (22S), 25G Whitacre (25W) and 25G Sprotte (25S), were evaluated in 394 LPs performed by seven neurologists. The neurologist performing the LP recorded the type and size of needle, intensity of pain, safety, time of the procedure and failure or success. Between five and 15 days later another neurologist, blind to the type of needle used, completed an ad-hoc questionnaire for PDPH. Results PDPH developed in 35.9% patients when using a 20Q needle, and in 12.9%, 6.8% and 1.6%, respectively, when using a 22S, 25W or 25S needle. The difference in incidence of PDPH following LP performed with the 20Q needle and the 25S or 22S was statistically significant (p < 0.001 and p = 0.008, respectively) and it approached significance when comparing the 25S and 25W (p = 0.06). As 25W and 25S needles need CSF aspiration, LP requires more time and skill. Pain caused by LP was similar with the four needles. Conclusion The use of the 25S needle in diagnostic LP reduces the frequency and severity of PDPH.

Normative Values for Intertrial Variability of Motor Responses to Nerve Root and Transcranial Stimulation: A Condition for Follow-Up Studies in Individual Subjects

Objective Intertrial variability (ITV) of motor responses to peripheral (CMAP) and transcranial (MEP) stimulation prevents their use in follow-up studies. Our purpose was to develop strategies to reduce and measure CMAP and MEP ITV to guide long-term monitoring of conduction slowing and conduction failure of peripheral and central motor pathway in the individual patient. Methods Maximal compound muscle action potentials to High Voltage Electrical Stimulation (HVES) of lumbo-sacral nerve roots (r-CMAP) and activated, averaged motor evoked potentials (MEPs) to Transcranial Magnetic Stimulation (TMS) using double cone coil were recorded from 10 proximal and distal muscle districts of lower limbs. The procedure was repeated twice, 1–2 days apart, in 30 subjects, including healthy volunteers and clinically stable multiple sclerosis patients, using constant stimulating and recording sites and adopting a standardized procedure of voluntary activation. ITV for latency and area indexes and for the ratio between MEP and r-CMAP areas (a-Ratio) was expressed as Relative Intertrial Variation (RIV, 5th-95th percentile). As an inverse correlation between the size of area and ITV was found, raw ITV values were normalized as a function of area to make them comparable with one another. Results All RIV values for latencies were significantly below the optimum threshold of ± 10%, with the exception of r-CMAP latencies recorded from Vastus Lateralis muscle. RIVs for a-Ratio, the most important index of central conduction failure, ranged from a maximum of -25.3% to +32.2% (Vastus Medialis) to a minimum of -15.0% to + 17.4% (Flexor Hallucis Brevis). Conclusions The described procedure represents an effort to lower as much as possible variability of motor responses in serial recording; the reported ITV normative values are the necessary premise to detect significant changes of motor conduction slowing and failure in the individual patient in follow-up studies.

Acute confusional state in HaNDL syndrome (transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis)

Dear Editor, We describe the case of a woman with acute onset of confusion and restlessness and lymphocytic pleocytosis in the cerebrospinal fluid (CSF). In the previous days she had several episodes of headache and transient focal neurological deficits. The syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL) is a benign, self-limited condition characterized by episodes of severe headache, transient neurological deficit and lymphocytic pleocytosis in the CSF [1, 2]. Confusional state is a very rare clinical manifestation of the syndrome [3]. We report the case of a 40-year-old woman, with a history of left renal colic in 2013 and dysplasia of the cervix (CIN3) treated with loop electrosurgical excision in 2012. She had no previous history of migraine. In May 2014, she began to complain of lateral homonymous right hemianopia, intense frontal throbbing headache associated with nausea and vomiting, phonophobia and photophobia. The headache did not increase with exertion. The visual deficit completely receded in 1 h but the headache persisted. After few hours, she developed transient focal neurological deficit, characterized by paresthesias of the right upper limb and right perioral region. The headache lasted until the next day. She did not have febrile illness or infection before the onset of the disorder. During the following days she experienced again intense throbbing headache unresponsive to common analgesics associated with vomit, phonophobia and photophobia. She also developed confusion and restlessness. Therefore, she went to the ER. At admission she showed marked restlessness and aggressiveness, which improved after sedation in few hours. Neurological examination showed neither focal neurologic signs nor meningeal irritation. The patient had memories of the episodes of neurological impairment but she had no memory of her confusional state. Brain CT was normal. Brain Magnetic Resonance Imaging (MRI) did not reveal any abnormal findings on T1-weighted or T2-weighted images, gadolinium enhancement, diffusion-weighted images, fluid-attenuated inversion recovery (FLAIR) images. Electroencephalography did not reveal any abnormal findings including epileptic abnormal waves. Specific tests excluded intoxications (alcohol serum, dibucaine and cannabinoids serum and urine) or infections. CSF examination showed lymphocytic pleocytosis M. Lo Re (&) Department of Experimental Medicine and Clinical Neuroscience, University of Palermo, Palermo, Italy e-mail: marianna.lore@gmail.com

A new neurophysiological approach to assess central motor conduction damage to proximal and distal muscles of lower limbs

OBJECTIVE To develop a neurophysiological method to explore central motor pathways to proximal and distal muscles of lower limbs. METHODS MEPs to transcranial magnetic stimulation using the double cone coil were bilaterally and simultaneously recorded from vastus medialis, tibialis anterior and flexor hallucis brevis. Voluntary facilitation was controlled using a predefined sequence of movements of constant amplitude. Compound motor action potentials elicited by maximal high voltage electrical stimulation of lumbosacral roots (root-CMAPs) were recorded from the same muscles to obtain the corresponding peripheral conduction times. We studied 28 healthy subjects and 28 multiple sclerosis (MS) patients with no or mild motor impairment. RESULTS The described facilitation procedure and the averaging of 5 MEPs reduced area variability to about 10%. In MS patients conduction slowing and/or MEP area reduction in at least one muscle was found in 91.7% of cases, with significant correlation with individual motor impairment. CONCLUSIONS Combined use of stable MEPs and maximal root-CMAPs was able to detect both conduction slowing and conduction failure in central motor pathways to proximal and distal districts of lower limbs in MS patients. SIGNIFICANCE The proposed method provides an extensive electrophysiological mapping of central motor impairment of lower limbs in clinical application.

Computerized posturography is more sensitive than clinical Romberg Test in detecting postural control impairment in minimally impaired Multiple Sclerosis patients

Balance impairment, frequent in Multiple Sclerosis patients (MS), is difficult to detect promptly with routine clinical examination. Computerized platforms can measure subtle deficit but, given the complexity of postural system, multiple tests should be adopted. To evaluate whether platform was more sensitive than Romberg Test (RT) in detecting balance abnormalities, we 1) chose a battery of posturographic tests, 2) collected normative data from 58 healthy subjects 3) applied the tests to Clinically Isolated Syndrome (n=42) and minimally impaired MS (n=76). Subjects underwent 3 trials of quiet standing with eyes open and closed (modified Clinical Test of Sensory Interaction on Balance, mCTSIB) and 4 trials of voluntary anterior and lateral maximal leaning on right and left sides (Limits of Stability, LOS), giving 10 postural indexes. For every subject, the best trials were selected for subsequent analysis. Normative values were established in a range from 1st to 99th percentile, defining balance impairment by the presence of at least 2 indexes out of range. Even adopting the above mentioned strict definition of balance impairment, the forceplate resulted more sensitive than RT, detecting abnormalities in 25% of patients, while RT was abnormal in 7% only. In RT-negative patients with 1-year follow-up (n =67) the detection of a single abnormal index was able to predict a subsequent onset of symptomatic balance impairment. The proposed procedure is quick, easy to perform and can improve the assessment of the clinical course of MS, from a pre-clinical stage up to medium degree of disability.