New rare genetic variants in multiple sclerosis

In recent years, our understanding of genetic factors associated with multiple sclerosis (MS) has considerably increased as a result of new analytical approaches to genome-wide association studies, together with the large numbers of samples available through international collaborations. It is now clear that MS risk is multigenic, and that common variants (now numbering more than 150) contribute only a relatively small proportion to the overall heritability of MS. As a result, attention has once again turned to the possibility of identifying rare variants through a number of novel as well as more traditional methodologies. However, detecting effects of rare variants once again poses challenges of statistical power, and several different approaches can be applied to manage this issue, some of which are illustrated below. In this month’s Journal Club we review five recent publications that have employed large international cohorts, multiplex families, or candidate gene approaches to investigate rare genetic variants and their association with MS risk

Assessing mild cognitive impairment using object-location memory in immersive virtual environments

Pathological changes in the medial temporal lobe (MTL) are found in the early stages of Alzheimer's disease (AD) and aging. The earliest pathological accumulation of tau colocalizes with the areas of the MTL involved in object processing as part of a wider anterolateral network. Here, we sought to assess the diagnostic potential of memory for object locations in iVR environments in individuals at high risk of AD dementia (amnestic mild cognitive impairment [aMCI] n = 23) as compared to age-related cognitive decline. Consistent with our primary hypothesis that early AD would be associated with impaired object location, aMCI patients exhibited impaired spatial feature binding. Compared to both older (n = 24) and younger (n = 53) controls, aMCI patients, recalled object locations with significantly less accuracy (p < .001), with a trend toward an impaired identification of the object's correct context (p = .05). Importantly, these findings were not explained by deficits in object recognition (p = .6). These deficits differentiated aMCI from controls with greater accuracy (AUC = 0.89) than the standard neuropsychological tests. Within the aMCI group, 16 had CSF biomarkers indicative of their likely AD status (MCI+ n = 9 vs. MCI- n = 7). MCI+ showed lower accuracy in the object-context association than MCI- (p = .03) suggesting a selective deficit in object-context binding postulated to be associated with anterior-temporal areas. MRI volumetric analysis across healthy older participants and aMCI revealed that test performance positively correlates with lateral entorhinal cortex volumes (p < .05) and hippocampus volumes (p < .01), consistent with their hypothesized role in binding contextual and spatial information with object identity. Our results indicate that tests relying on the anterolateral object processing stream, and in particular requiring successful binding of an object with spatial information, may aid detection of pre-dementia AD due to the underlying early spread of tau pathology

Alemtuzumab for multiple sclerosis: Long term follow-up in a multi-centre cohort

Background: Alemtuzumab has recently been approved for treatment of relapsing MS, but concerns remain about its use since long-term studies of adverse events remain limited. Furthermore, a clear understanding of its application and durability of effect in clinical practice has yet to evolve. Objectives: To investigate long-term efficacy and safety outcomes in a multicentre cohort of patients treated with alemtuzumab. Methods: Patients treated from 2000 and followed-up at three regional centres were identified. Baseline and prospective data were obtained and validated by clinical record review. Results: One hundred patients were identified with a mean follow-up of 6.1 years (range 1–13). Forty patients were retreated with at least one further treatment cycle. Annualized relapse rates fell from 2.1 to 0.2 (p<0.0001) post-treatment and were sustained for up to eight years of follow-up. Mean change in EDSS score was +0.14. Forty-seven patients developed secondary autoimmunity. Conclusion: Observed reduction in relapse rates reflected those reported in clinical trials, but we were unable to corroborate previous observations of disability reversal. 40% of patients required additional treatment cycles. Autoimmune adverse events were common, occurring at a higher rate than previously reported, but were largely predictable, and could be managed effectively within a rigorous monitoring regime

Plasma complement biomarkers distinguish multiple sclerosis and neuromyelitis optica spectrum disorder

Background: Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) are autoimmune demyelinating diseases distinguished clinically by selective involvement in NMOSD of optic nerves and spinal cord. Early clinical manifestations are similar, complicating clinical management. Aquaporin-4 autoantibody measurement aids diagnosis of NMOSD but is frequently negative, creating unmet need for alternative biomarkers. Objective: We investigated whether plasma complement proteins are altered in MS and NMOSD and whether these provide biomarkers that reliably distinguish the diseases. Methods: Plasma from 53 NMOSD, 49 MS and 69 control donors was tested in multiplex assays measuring complement activation products and proteins. Logistic regression was used to test whether combinations of complement analyte measurements distinguish NMOSD from controls and MS. Results: All activation products were significantly elevated in NMOSD compared to either control or MS. Four complement proteins (C1inh, C1s, C5, FH) were significantly higher in NMOSD compared to MS or controls. A model comprising C1 inhibitor and TCC distinguished NMOSD from MS (area under curve (AUC) 0.98), while C1 inhibitor and C5 distinguished NMOSD from controls (AUC 0.94). Conclusions: NMOSD is distinguished from MS by plasma complement activation

Constraining the High-Energy Emission from Gamma-Ray Bursts with Fermi

We examine 288 GRBs detected by the Fermi Gamma-ray Space Telescope's Gamma-ray Burst Monitor (GBM) that fell within the field-of-view of Fermi's Large Area Telescope (LAT) during the first 2.5 years of observations, which showed no evidence for emission above 100 MeV. We report the photon flux upper limits in the 0.1-10 GeV range during the prompt emission phase as well as for fixed 30 s and 100 s integrations starting from the trigger time for each burst. We compare these limits with the fluxes that would be expected from extrapolations of spectral fits presented in the first GBM spectral catalog and infer that roughly half of the GBM-detected bursts either require spectral breaks between the GBM and LAT energy bands or have intrinsically steeper spectra above the peak of the nuF(sub v) spectra (E(sub pk)). In order to distinguish between these two scenarios, we perform joint GBM and LAT spectral fits to the 30 brightest GBM-detected bursts and find that a majority of these bursts are indeed softer above E(sub pk) than would be inferred from fitting the GBM data alone. Approximately 20% of this spectroscopic subsample show statistically significant evidence for a cut-off in their high-energy spectra, which if assumed to be due to gamma gamma attenuation, places limits on the maximum Lorentz factor associated with the relativistic outflow producing this emission. All of these latter bursts have maximum Lorentz factor estimates that are well below the minimum Lorentz factors calculated for LAT-detected GRBs, revealing a wide distribution in the bulk Lorentz factor of GRB outflows and indicating that LAT-detected bursts may represent the high end of this distribution

Classical sickle beta-globin haplotypes exhibit a high degree of long-range haplotype similarity in African and Afro-Caribbean populations

Background: The sickle (βs) mutation in the beta-globin gene (HBB) occurs on five "classical" βs haplotype backgrounds in ethnic groups of African ancestry. Strong selection in favour of the βs allele - a consequence of protection from severe malarial infection afforded by heterozygotes - has been associated with a high degree of extended haplotype similarity. The relationship between classical βs haplotypes and long-range haplotype similarity may have both anthropological and clinical implications, but to date has not been explored. Here we evaluate the haplotype similarity of classical βs haplotypes over 400 kb in population samples from Jamaica, The Gambia, and among the Yoruba of Nigeria (Hapmap YRI). Results: The most common βs sub-haplotype among Jamaicans and the Yoruba was the Benin haplotype, while in The Gambia the Senegal haplotype was observed most commonly. Both subtypes exhibited a high degree of long-range haplotype similarity extending across approximately 400 kb in all three populations. This long-range similarity was significantly greater than that seen for other haplotypes sampled in these populations (P &lt; 0.001), and was independent of marker choice and marker density. Among the Yoruba, Benin haplotypes were highly conserved, with very strong linkage disequilibrium (LD) extending a megabase across the βs mutation. Conclusion: Two different classical βs haplotypes, sampled from different populations, exhibit comparable and extensive long-range haplotype similarity and strong LD. This LD extends across the adjacent recombination hotspot, and is discernable at distances in excess if 400 kb. Although the multicentric geographic distribution of βs haplotypes indicates strong subdivision among early Holocene sub-Saharan populations, we find no evidence that selective pressures imposed by falciparum malaria varied in intensity or timing between these subpopulations. Our observations also suggest that cis-acting loci, which may influence outcomes in sickle cell disease, could lie considerable distances away from β-globin

A longitudinal model for disease progression was developed and applied to multiple sclerosis

OBJECTIVES: To develop a model of disease progression using multiple sclerosis (MS) as an exemplar. STUDY DESIGN AND SETTINGS: Two observational cohorts, the University of Wales MS (UoWMS), UK (1976), and British Columbia MS (BCMS) database, Canada (1980), with longitudinal disability data [the Expanded Disability Status Scale (EDSS)] were used; individuals potentially eligible for MS disease-modifying drugs treatments, but who were unexposed, were selected. Multilevel modeling was used to estimate the EDSS trajectory over time in one data set and validated in the other; challenges addressed included the choice and function of time axis, complex observation-level variation, adjustments for MS relapses, and autocorrelation. RESULTS: The best-fitting model for the UoWMS cohort (404 individuals, and 2,290 EDSS observations) included a nonlinear function of time since onset. Measurement error decreased over time and ad hoc methods reduced autocorrelation and the effect of relapse. Replication within the BCMS cohort (978 individuals and 7,335 EDSS observations) led to a model with similar time (years) coefficients, time [0.22 (95% confidence interval {CI}: 0.19, 0.26), 0.16 (95% CI: 0.10, 0.22)] and log time [-0.13 (95% CI: -0.39, 0.14), -0.15 (95% CI: -0.70, 0.40)] for BCMS and UoWMS, respectively. CONCLUSION: It is possible to develop robust models of disability progression for chronic disease. However, explicit validation is important given the complex methodological challenges face