Stanley Hawkins

Pharmacogenomics of responsiveness to interferon IFN‐β treatment in multiple sclerosis: A genetic screen of 100 type I interferon‐inducible genes

Interferon IFN‐β is indicated for the treatment of multiple sclerosis. A significant proportion of patients show a poor clinical response to therapy. Type I interferon exerts its effect at least partially through interaction of specific transcription factors with interferon‐stimulated response elements (ISREs), mostly located in promoter regions of its target genes. We hypothesized that polymorphisms may occur within or close to ISRE elements, altering type I interferon inducibility and ultimately leading to a modified clinical response in carriers.

Abdominal massage for the alleviation of constipation symptoms in people with multiple sclerosis: a randomized controlled feasibility study

Background: Constipation affects many people with multiple sclerosis (MS), negatively impacting on their quality of life. The use of abdominal massage has been reported in several populations and has been shown to increase the frequency of defaecation. Objective: The objective of this study was to determine the feasibility of undertaking abdominal massage in people with MS. Methods: Following ethical approval, 30 patients with MS and constipation were recruited. After providing informed written consent and completion of baseline outcome measures, participants were randomly allocated to a massage group or a control group. The massage group participants were provided with advice on bowel management, and they or their carers were taught how to deliver abdominal massage and were recommended to perform it daily during the 4-week intervention period. The control group received bowel management advice only. Outcomes were measured pre (Week 0) and post treatment (Week 4), and at Week 8 and included: the Constipation Scoring System (CSS) (primary outcome), the Neurogenic Bowel Dysfunction Score, and a bowel diary. Results: Both groups demonstrated a decrease in CSS score from Week 0 to Week 4, indicating an improvement in constipation symptoms; however, the massage group improved significantly more than the control groups (mean difference between groups in score change −5.0 (SD 1.5), 95% CI −8.1, −1.8; tu2009=u2009−3.28, dfu2009=u200928, pu2009=u20090.003). Conclusion: The results of this small study suggest a positive effect of the intervention on the symptoms of constipation, and support the feasibility of a substantive trial of abdominal massage for the alleviation of the symptoms of constipation in people with MS.

IFNG polymorphisms are associated with gender differences in susceptibility to multiple sclerosis

Interferon-gamma (IFNγ) treatment is deleterious in multiple sclerosis (MS). MS occurs twice as frequently in women as in men. IFNγ expression varies by gender. We studied a population-based sample of US MS patients and ethnicity-matched controls and independent Northern Irish and Belgian hospital-based patients and controls for association with MS, stratified by gender, of an intron 1 microsatellite [I1(761)*CAn], a single nucleotide polymorphism 3′ of IFNG [3′(325)*G → A] and three flanking microsatellite markers spanning a 118 kb region around IFNG. Men carriers of the 3′(325)*A allele have increased susceptibility to MS compared to noncarriers in the USA (P=0.044; OR: 2.58, 95% CI: 0.97–8.08) and Northern Ireland (P=0.019; OR: 2.37, 95% CI: 1.10–5.13). There is a nonsignificant trend in the same direction in Belgian men (P=0.299; OR: 1.50, 95% CI: 0.71–3.26). Men carriers of I1(761)*CA13, which is in strong linkage disequilibrium with the 3′(325)*A, have increased susceptibility (P=0.050; OR: 2.22, 95% CI: 0.98–5.40), while men carriers of I1(761)*CA12 have decreased susceptibility (P=0.022; OR: 0.46, 95% CI: 0.23–0.90) to MS in the USA. Similar associations were reported in Sardinia between the I1(761)*CA12 allele and reduced risk of MS in men. Flanking markers were not associated with MS susceptibility. Polymorphisms of IFNG may contribute to differences in susceptibility to MS between men and women.

The PROMiSe trial: baseline data review and progress report

The PRO MiSe trial is a multinational, multicentre, double-blind, placebo -controlled trial evaluating the effects of glatiramer acetate treatment over 3 years in patients with primary progressive multiple sclerosis (PPMS). A total of 943 patients were enrolled, and all those remaining on-study had completed at least 24 months as of O ctober 2002. Baseline clinical and MRI character istics and select correlations are reported here. A total of 3.9% of patients exhibited confirmed relapse over 1904 patient-years of exposure, indicating success of efforts to exclude relapsing MS types. O f the 26.3% of patients who have prematurely withdrawn from the study, only 36% discontinued after meeting the study primary endpoint of disease progression. The progression rate in patients in the low Expanded Disability Status Scale (EDSS) stratum (3.0-5.0) observed thus far is markedly lower than the 50% annual progression rate estimate used for determining size and statistical power of the trial; progression was observed in 16.1% of patients with 12 months of study exposure. These early findings raise some concern about the ability of the trial to demonstrate a significant treatment effect, and suggest that the short-term natural history of PPMS may not be as aggressive as previously assumed.

Genetic polymorphisms, their allele combinations and IFN-β treatment response in Irish multiple sclerosis patients

INTRODUCTIONnIFN-beta is widely used as first-line immunomodulatory treatment for multiple sclerosis. Response to treatment is variable (30-50% of patients are nonresponders) and requires a long treatment duration for accurate assessment to be possible. Information about genetic variations that predict responsiveness would allow appropriate treatment selection early after diagnosis, improve patient care, with time saving consequences and more efficient use of resources.nnnMATERIALS & METHODSnWe analyzed 61 SNPs in 34 candidate genes as possible determinants of IFN-beta response in Irish multiple sclerosis patients. Particular emphasis was placed on the exploration of combinations of allelic variants associated with response to therapy by means of a Markov chain Monte Carlo-based approach (APSampler).nnnRESULTSnThe most significant allelic combinations, which differed in frequency between responders and nonresponders, included JAK2-IL10RB-GBP1-PIAS1 (permutation p-value was p(perm) = 0.0008), followed by JAK2-IL10-CASP3 (p(perm) = 0.001).nnnDISCUSSIONnThe genetic mechanism of response to IFN-beta is complex and as yet poorly understood. Data mining algorithms may help in uncovering hidden allele combinations involved in drug response versus nonresponse.

Mapping candidate non-MHC susceptibility regions to multiple sclerosis

Understanding the genetic basis of multiple sclerosis (MS) remains a major challenge, despite decades of intensive research. In order to identify candidate non-MHC susceptibility regions to MS, the results of whole genome screens for linkage or association and follow-up studies in 18 different populations were superimposed together in a combined genomic map. Analysis of this map led to the prediction of at least 38 potential susceptibility regions, each showing linkage and/or association in several populations. Among these, 17 regions were the most reproducibly reported in these studies, thus representing top predicted candidates for MS. This non-formal approach to meta-analysis demonstrated the ability to verify results and retrieve lost information in an association study. Assessment of the map in a Northern Irish refined screen (n=415 cases, n=490 controls) revealed association in 15 regions (P<0.05), including 10 promising candidates on chromosomes 1p13, 2p13, 2q14, 3p23, 7q21, 13q14, 15q13, 17p13, 18q21 and 20p12 (P<0.0025). Seven of these regions were previously overlooked in the Northern Irish whole genome association study. Collating results from numerous studies, this draft map represents a tool that should facilitate the analysis of the genetic backgrounds of MS in many populations.

Haplotype analysis of the preprotachykinin-1 (TAC1) gene in multiple sclerosis.

The potential relevance of chromosome 7q21–22 in susceptibility to multiple sclerosis (MS) has been highlighted in genome-wide linkage screens as well as in association studies of 7q-specific polymorphic microsatellites. Especially, recent, independently performed studies have provided evidence for significant association of the markers D7S554 and D7S3126 with MS in Sardinian, Northern Irish and Spanish–American cohorts. The gene most closely located to these markers is the neuropeptide preprotachykinin-1 (TAC1) gene. Both its position and the array of biological functions exerted by its expression products make it a logical primary choice for further scrutiny as the putative chromosome 7q21–22 MS susceptibility gene. We report identification of eight polymorphisms in this gene by means of a sequencing approach. A Northern Irish case–control was typed for six of these polymorphisms. One of these, an intron 1 single-nucleotide polymorphism (SNP), showed significant association with MS (P=0.009). Two-marker haplotypes composed of allelic combinations of TAC1 promoter–intron 1 SNPs were highly significantly associated with MS and more so with the relapsing-remitting form of this disease. While independent reproduction of these data in other data sets is indicated, our work is suggestive for a role of the TAC1 gene in MS.

Truly benign multiple sclerosis is rare: let’s stop fooling ourselves – No

Over the last 60 years the natural history of multiple sclerosis (MS) has received considerable attention. Mild MS is very common early in the course of the disease. Charcot and those who first described MS encountered cases with low levels of disability after a course of many years. Cases of MS with good levels of function occur frequently in many recent series, but there is no universally agreed definition of benign MS. As with the first two versions, the third iteration of the McDonald criteria ‘Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria’, by Polman and colleagues,1 does not address the topic of benign MS. The novel term ‘truly benign MS’ has no status whatsoever. The clinical presentation of MS is very variable at the time of first diagnosis, and in an individual case the course is unpredictable. MS has a very wide spectrum. At one extreme, cases of demyelinating disease can progress rapidly to death, as in Marburg’s disease. At the other extreme is so-called subclinical MS when, unexpectedly at autopsy, brains have been found to have pathological findings of MS but no symptoms or signs of MS were reported during life. Other examples of extremely mild, asymptomatic MS have been identified in clinically unaffected co-twins subjected to magnetic resonance imaging (MRI) scans. Thorpe et al.2 found scans that met the Fazekas criteria in 13% of monozygotic and 9% of dizygotic asymptomatic co-twins. Also, asymptomatic individuals have been found to have typical MRI scans for MS where there were family members with typical MS. An MRI diagnosis without symptoms or signs does not constitute what has been thought of as benign MS. No systematic follow-up has been performed in the cases of subclinical MS identified by MRI that have been described to date. It could be that the cases reported in the literature have gone on to develop typical forms of MS. Cases of clinically isolated symptoms (CIS) have been subjected to long-term sequential MRI examination. As in the highly informative series of publications on CIS from Queen Square, none of these MRI studies is population based. Estimates of the frequency of benign MS vary from 6–60%.3 Most studies are clinic based, the definitions vary considerably in stringency, and the length of the studies is not uniform. Most studies have published the results of serial cross-sectional follow-up. Few are truly prospective. Few are population based. The definitions of ‘benign MS’ quoted in the literature vary considerably. Before the days of the Kurtzke Disability Status Scale (DSS), it was recognized that some cases of MS presented with typical mild or indeed severe relapses. The relapses recovered and the patients remained with minimal disability, not progressing even over several decades. After the introduction of the Kurtzke DSS and later the Expanded Disability Status Scale (EDSS), more precise definitions of benign MS were formulated. In 1996 Lublin and Reingold4 suggested a consensus definition of benign MS as being ‘fully functional in all neurological systems 15 years after disease onset’. Despite that, the most common definition was EDSS 3.0 or less, 10 or more years after the first symptoms of MS.5 Patients who reach EDSS 3.0 are more likely to progress that those who remain at EDSS 2.0. Pittock et al.6 from the Mayo Clinic, and Sayao and colleagues7 using the University of British Columbia database, have proposed this. The lower the EDSS and the longer the duration of the qualifying period for EDSS, the less likely patients were to progress. Recently, EDSS of 2.0 or less at 15 years has been suggested as being the appropriate criteria for benign MS. Even these mild cases, if followed-up for long periods of time, can convert to secondary progressive MS. Within the last 10 years reports of long-term follow-up of clinic-based cohorts have been published from Dublin,8 Cardiff,9 and the University of British Columbia.7 These have been cross-sectional studies with follow-up at 20 years. All these studies have found that after long periods of mild disability, patients can enter the secondary progressive phase. Patients who have progressive disease from the onset – primary progressive and progressive relapsing MS – are unlikely ever to meet any criteria for benign MS. Of relevance to the present debate is the observation that if Truly benign multiple sclerosis is rare: let’s stop fooling ourselves – No

The neuropeptide genes TAC1, TAC3, TAC4, VIP and PACAP(ADCYAP1), and susceptibility to multiple sclerosis

The related immunomodulatory neuropeptides vasoactive intestinal peptide (VIP) and pituitary adenylyl cyclase activating peptide (PACAP; gene symbol ADCYAP1) have recently been proposed as novel therapeutics for the treatment of multiple sclerosis (MS). These neuropeptides, as well as those belonging to the tachykinin family exert pleiotropic effects, many of which are of relevance to central nervous system inflammation. In the present study, we have analysed 14 single nucleotide polymorphisms (SNPs) and 4 microsatellite markers in the VIP, ADCYAP1, TAC3 and TAC4 genes for susceptibility to MS in a case-control collection from Northern Ireland. Following correction for multiple comparisons, we did not find any significant associations between single polymorphic markers or multiple-marker haplotypes and susceptibility to MS. Furthermore, we analysed 2 SNPs in the TAC1 gene in a set of Sardinian trio MS families, based on our previous observation of association of these SNPs with MS in the Northern Irish (Genes Immun. 2005, 6, 265-270). Analysis of these SNPs in the Sardinians was not significant though a similar trend to that originally observed in the Northern Irish was present. Meta-analysis of the Sardinian and Northern Irish TAC1 SNP genotype data revealed a Mantel-Haenszel Common OR Estimate for the TAC1 intron 1 SNP rs2072100 of 0.76 (95% CI 0.63-0.92; P=0.005; A allele) and for the TAC1 promoter SNP rs7793277 of 0.76 (95% CI 0.615-0.95; P=0.014; C allele). Our data advocate a need for further exploration of the TAC1 gene region in MS.

Chromosome 19 locus apolipoprotein C-II association with multiple sclerosis.

Sir We read with interest the paper of Zouali et al, who in a study of 74 multiple sclerosis (MS) patients and 102 normal controls, identi®ed a microsatellite marker in intron 1 of apoc-2 as being associated with MS. We do however have some concerns regarding the results and methodology of their paper. Firstly, the number of patients and controls is relatively small for a study of this nature. Secondly, in their Materials and methods section, Zouali et al claim to have used the primers described by Fornage et al and print these primer sequences in full. Unfortunately, using these primer sequences one would expect the product sizes to be in the range of 78 ± 114 base pairs (bp) approximately (GDB allele set 61455). Howeer, the product sizes quoted in their results section in Table 1 range from 129 ± 163 bp, compatible with those primers published by Weber et al (GDB allele set 55519). Thirdly, the method of allele grouping employed in the statistical analysis is somewhat unusual, with alleles being analysed together in groups of three. Also, the method of correction for multiple testing is unclear. For example, allele 1 which shows the greatest difference when analysed alone would no longer be statistically signi®cant if a correction for multiple alleles was applied using the Bonferroni method. Their overall results are also in contrast to our own experience. In a previous case-control gene association study, we have examined the (TG)n(AG)m microsatellite marker in the ®rst intron of apoc-2 described by Weber et al, in MS patients (n=176) and normal controls (n=207) from Northern Ireland. MS patients had clinically de®nite and laboratory supported probable MS (according to the Poser criteria). All patients were classi®ed as having relapsing-remitting or secondary progressive MS, were Caucasian and of Northern Irish origin. The control group was made up of 207 healthy normal controls, 106 blood donors collected from the general public in Belfast and 101 normal spouses of individuals with single gene disorders all coded anonymously. Northern Ireland has a homogenous and stable Caucasian population with little immigration. The controls thus mirror closely the racial background of the patients. In the PCR (polymerase chain reaction), the reverse primer was ̄uorescently labelled with 6-fam-amidite (blue). The PCR reaction (10 ml) was constituted as follows: 1 ml DNA (*50 Zg), 1 ml manufacturers PCR buffer (10X), 1 ml dNTPs (2 mM), 0.3 ml MgCl2 (50 mM), 0.4 ml forward and reverse primers (3.9 mM), 0.06 ml Taq pol (5 U/ml, Gibco BRL) and 5.9 ml sterile water. The PCR products were run on a 6% denaturing polyacrylamide gel (National Diagnostics) and visualised on an ABI373A DNA sequencer. Genescan 672 software is used for allele sizing based on internal lane