The Impact of Relapses on Pain and Quality of Life in Patients with Multiple Sclerosis Treated with Corticosteroids

Background: We assessed the prevalence and risks associated with pain during and after a multiple sclerosis (MS) relapse, and the impact of pain on quality of life (QoL), in MS patients. // Methods: 117 patients suffering an acute MS relapse were evaluated with clinician- and patient-reported outcomes, including the expanded disability status scale (EDSS), Multiple Sclerosis Impact Scale (MSIS-29), and MS Walking scale-12 (MSWS-12). Relapse-related pain was assessed via the short-form 36 (SF-36) questionnaire upon first visit (relapse onset) and at 6 weeks after treatment with intravenous methylprednisolone (follow-up visit). // Results: Pain was present in 80% of patients at relapse onset. Patients with pain were more impaired physically (higher mean scores on MSIS-29phys and MSWS-12 and lower mean scores on SF-36 role physical, physical, and vitality scales) at relapse and six weeks after. In total, 74% of patients with MS relapse reported a poorer QoL due to pain. A lower psychological well-being was correlated with greater pain (MSIS29psy score). An increased number of prior relapses was a predictor of more pain at relapse onset. // Conclusions: Pain was common at the time of MS relapse and improved, but was still significant, six weeks after treatment with corticosteroids. Further studies are required to better understand relapse-related pain

Reduced Expression of IFIH1 Is Protective for Type 1 Diabetes

IFIH1 (interferon induced with helicase C domain 1), also known as MDA5 (melanoma differentiation-associated protein 5), is one of a family of intracellular proteins known to recognise viral RNA and mediate the innate immune response. IFIH1 is causal in type 1 diabetes based on the protective associations of four rare variants, where the derived alleles are predicted to reduce gene expression or function. Originally, however, T1D protection was mapped to the common IFIH1 nsSNP, rs1990760 or Thr946Ala. This common amino acid substitution does not cause a loss of function and evidence suggests the protective allele, Ala946, may mark a haplotype with reduced expression of IFIH1 in line with the protection conferred by the four rare loss of function alleles. We have performed allele specific expression analysis that supports this hypothesis: the T1D protective haplotype correlates with reduced IFIH1 transcription in interferon-β stimulated peripheral blood mononuclear cells (overall p = 0.012). In addition, we have used multiflow cytometry analysis and quantitative PCR assays to prove reduced expression of IFIH1 in individuals heterozygous for three of the T1D-associated rare alleles: a premature stop codon, rs35744605 (Glu627X) and predicted splice variants, rs35337543 (IVS8+1) and rs35732034 (IVS14+1). We also show that the nsSNP, Ile923V, does not alter pre-mRNA levels of IFIH1. These results confirm and extend the new autoimmune disease pathway of reduced IFIH1 expression and protein function protecting from T1D

Four cornerstones of lymphoedema care

Lymphoedema is a progressive, debilitating condition caused by reduced or damaged lymphatic function. The condition can have a profound effect on individuals’ quality of life and wellbeing. Lymphoedema’s complex, enduring nature necessitates prevention wherever possible, early detection, self-management and integrated interventions based on the four cornerstones of care. Lymphoedema prevalence is increasing, particularly amongst older people. As the population of nursing and care home residents is ageing, lymphoedema prevention and management should be a serious concern for those working in nursing and residential care

Rapid tests and urine sampling techniques for the diagnosis of urinary tract infection (UTI) in children under five years: a systematic review

Background: Urinary tract infection (UTI) is one of the most common sources of infection in children under five. Prompt diagnosis and treatment is important to reduce the risk of renal scarring. Rapid, cost-effective, methods of UTI diagnosis are required as an alternative to culture. Methods: We conducted a systematic review to determine the diagnostic accuracy of rapid tests for detecting UTI in children under five years of age. Results: The evidence supports the use of dipstick positive for both leukocyte esterase and nitrite (pooled LR+ = 28.2, 95% CI: 17.3, 46.0) or microscopy positive for both pyuria and bacteriuria (pooled LR+ = 37.0, 95% CI: 11.0, 125.9) to rule in UTI. Similarly dipstick negative for both LE and nitrite (Pooled LR- = 0.20, 95% CI: 0.16, 0.26) or microscopy negative for both pyuria and bacteriuria (Pooled LR- = 0.11, 95% CI: 0.05, 0.23) can be used to rule out UTI. A test for glucose showed promise in potty-trained children. However, all studies were over 30 years old. Further evaluation of this test may be useful. Conclusion: Dipstick negative for both LE and nitrite or microscopic analysis negative for both pyuria and bacteriuria of a clean voided urine, bag, or nappy/pad specimen may reasonably be used to rule out UTI. These patients can then reasonably be excluded from further investigation, without the need for confirmatory culture. Similarly, combinations of positive tests could be used to rule in UTI, and trigger further investigation

Vitamin D did not reduce multiple sclerosis disease activity after a clinically isolated syndrome

Low serum levels of 25-hydroxyvitamin D (25(OH)D), and low sunlight exposure, are known risk factors for the development of multiple sclerosis. Add-on vitamin D supplementation trials in established multiple sclerosis have been inconclusive. The effects of vitamin D supplementation to prevent multiple sclerosis is unknown. We aimed to test the hypothesis that oral vitamin D3 supplementation in high-risk clinically isolated syndrome (abnormal MRI, at least three T2 brain and/or spinal cord lesions), delays time to conversion to definite multiple sclerosis, that the therapeutic effect is dose-dependent, and that all doses are safe and well tolerated. We conducted a double-blind trial in Australia and New Zealand. Eligible participants were randomised 1:1:1:1 to placebo, 1000, 5000, or 10 000 IU of oral vitamin D3 daily within each study centre (n=23) and followed for up to 48 weeks. Between 2013 and 2021, we enrolled 204 participants. Brain MRI scans were performed at baseline, 24 and 48 weeks. The main study outcome was conversion to clinically definite multiple sclerosis based on the 2010 McDonald criteria defined as either a clinical relapse or new brain MRI T2 lesion development. We included 199 cases in the intention-to-treat analysis based on assigned dose. Of these, 116 converted to multiple sclerosis by 48 weeks (58%). Compared to placebo, the HRs (95%CI) for conversion were 1000 IU 0.87 (0.50, 1.50); 5000 IU 1.37 (0.82, 2.29); and 10 000 IU 1.28 (0.76, 2.14). In an adjusted model including age, sex, latitude, study centre, and baseline symptom number, clinically isolated syndrome onset site, presence of infratentorial lesions, and use of steroids, the HRs (versus placebo) were 1000 IU 0.80 (0.45, 1.44); 5000 IU 1.36 (0.78, 2.38); 10 000 IU 1.07 (0.62, 1.85). Vitamin D3 supplementation was safe and well tolerated. We did not demonstrate reduction in multiple sclerosis disease activity by vitamin D3 supplementation after a high-risk clinically isolated syndrome. Trial registration Australian Clinical Trials Registration Number ACTRN12612001160820

How does study quality affect the results of a diagnostic meta-analysis?

Background: The use of systematic literature review to inform evidence based practice in diagnostics is rapidly expanding. Although the primary diagnostic literature is extensive, studies are often of low methodological quality or poorly reported. There has been no rigorously evaluated, evidence based tool to assess the methodological quality of diagnostic studies. The primary objective of this study was to determine the extent to which variations in the quality of primary studies impact the results of a diagnostic meta-analysis and whether this differs with diagnostic test type. A secondary objective was to contribute to the evaluation of QUADAS, an evidence-based tool for the assessment of quality in diagnostic accuracy studies. Methods: This study was conducted as part of large systematic review of tests used in the diagnosis and further investigation of urinary tract infection (UTI) in children. All studies included in this review were assessed using QUADAS, an evidence-based tool for the assessment of quality in systematic reviews of diagnostic accuracy studies. The impact of individual components of QUADAS on a summary measure of diagnostic accuracy was investigated using regression analysis. The review divided the diagnosis and further investigation of UTI into the following three clinical stages: diagnosis of UTI, localisation of infection, and further investigation of the UTI. Each stage used different types of diagnostic test, which were considered to involve different quality concerns. Results: Many of the studies included in our review were poorly reported. The proportion of QUADAS items fulfilled was similar for studies in different sections of the review. However, as might be expected, the individual items fulfilled differed between the three clinical stages. Regression analysis found that different items showed a strong association with test performance for the different tests evaluated. These differences were observed both within and between the three clinical stages assessed by the review. The results of regression analyses were also affected by whether or not a weighting (by sample size) was applied. Our analysis was severely limited by the completeness of reporting and the differences between the index tests evaluated and the reference standards used to confirm diagnoses in the primary studies. Few tests were evaluated by sufficient studies to allow meaningful use of meta-analytic pooling and investigation of heterogeneity. This meant that further analysis to investigate heterogeneity could only be undertaken using a subset of studies, and that the findings are open to various interpretations. Conclusion: Further work is needed to investigate the influence of methodological quality on the results of diagnostic meta-analyses. Large data sets of well-reported primary studies are needed to address this question. Without significant improvements in the completeness of reporting of primary studies, progress in this area will be limited

A Predictive Model for Corticosteroid Response in Individual Patients with MS Relapses

<div><p>Objectives</p><p>To derive a simple predictive model to guide the use of corticosteroids in patients with relapsing remitting MS suffering an acute relapse.</p><p>Materials and Methods</p><p>We analysed individual patient randomised controlled trial data (n=98) using a binary logistic regression model based on age, gender, baseline disability scores [physician-observed: expanded disability status scale (EDSS) and patient reported: multiple sclerosis impact scale 29 (MSIS-29)], and the time intervals between symptom onset or referral and treatment.</p><p>Results</p><p>Based on two a priori selected cut-off points (improvement in EDSS ≥ 0.5 and ≥ 1.0), we found that variables which predicted better response to corticosteroids after 6 weeks were younger age and lower MSIS-29 physical score at the time of relapse (model fit 71.2% - 73.1%).</p><p>Conclusions</p><p>This pilot study suggests two clinical variables which may predict the majority of the response to corticosteroid treatment in patients undergoing an MS relapse. The study is limited in being able to clearly distinguish factors associated with treatment response or spontaneous recovery and needs to be replicated in a larger prospective study.</p></div

Integration of GWAS SNPs and tissue specific expression profiling reveal discrete eQTLs for human traits in blood and brain

Our knowledge of the transcriptome has become much more complex since the days of the central dogma of molecular biology. We now know that splicing takes place to create potentially thousands of isoforms from a single gene, and we know that RNA does not always faithfully recapitulate DNA if RNA editing occurs. Collectively, these observations show that the transcriptome is amazingly rich with intricate regulatory mechanisms for overall gene expression, splicing, and RNA editing. Genetic variability can play a role in controlling gene expression, which can be identified by examining expression quantitative trait loci (eQTLs). eQTLs are genomic regions where genetic variants, including single nucleotide polymorphisms (SNPs) show a statistical association with expression of mRNA transcripts. In humans, many SNPs are also associated with disease, and have been identified using genome wide association studies (GWAS) but the biological effects of those SNPs are usually not known. If SNPs found in GWAS are also found in eQTLs, then one could hypothesize that expression levels may contribute to disease risk. Performing eQTL analysis with GWAS SNPs in both blood and brain, specifically the frontal cortex and the cerebellum, we found both shared and tissue unique eQTLS. The identification of tissue-unique eQTLs supports the argument that choice of tissue type is important in eQTL studies (Paper I). Aging is a complex process with the mechanisms underlying aging still being poorly defined. There is evidence that the transcriptome changes with age, and hence we used the brain dataset from our first paper as a discovery set, with an additional replication dataset, to investigate any aging-gene expression associations. We found evidence that many genes were associated with aging. We further found that there were more statically significant expression changes in the frontal cortex versus the cerebellum, indicating that brain regions may age at different rates. As the brain is a heterogeneous tissue including both neurons and non-neuronal cells, we used LCM to capture Purkinje cells as a representative neuronal type and repeated the age analysis. Looking at the discovery, replication and Purkinje cell datasets we found five genes with strong, replicated evidence of age-expression associations (Paper II). Being able to capture and quantify the depth of the transcriptome has been a lengthy process starting with methods that could only measure a single gene to genome-wide techniques such as microarray. A recently developed technology, RNA-Seq, shows promise in its ability to capture expression, splicing, and editing and with its broad dynamic range quantification is accurate and reliable. RNA-Seq is, however, data intensive and a great deal of computational expertise is required to fully utilize the strengths of this method. We aimed to create a small, well-controlled, experiment in order to test the performance of this relatively new technology in the brain. We chose embryonic versus adult cerebral cortex, as mice are genetically homogenous and there are many known differences in gene expression related to brain development that we could use as benchmarks for analysis testing. We found a large number of differences in total gene expression between embryonic and adult brain. Rigorous technical and biological validation illustrated the accuracy and dynamic range of RNA-Seq. We were also able to interrogate differences in exon usage in the same dataset. Finally we were able to identify and quantify both well-known and novel A-to-I edit sites. Overall this project helped us develop the tools needed to build usable pipelines for RNA-Seq data processing (Paper III). Our studies in the developing brain (Paper III) illustrated that RNA-Seq was a useful unbiased method for investigating RNA editing. To extend this further, we utilized a genetically modified mouse model to study the transcriptomic role of the RNA editing enzyme ADAR2. We found that ADAR2 was important for editing of the coding region of mRNA as a large proportion of RNA editing sites in coding regions had a statistically significant decrease in editing percentages in Adar2 -/-Gria2 R/R mice versus controls. However, despite indications in the literature that ADAR2 may also be involved in splicing and expression regulatory machinery we found no changes in gene expression or exon utilization in Adar2 -/-Gria2 R/R mice as compared to their littermate controls (Paper IV). In our final study, based on the methods developed in Papers III and IV, we revisited the idea of age related gene expression associations from Paper II. We used a subset of human frontal cortices for RNA sequencing. Interestingly we found more gene expression changes with aging compared to the previous data using microarrays in Paper II. When the significant gene lists were analysed for gene ontology enrichment, we found that there was a large number of downregulated genes involved in synaptic function while those that were upregulated had enrichment in immune function. This dataset illustrates that the aging brain may be predisposed to the processes found in neurodegenerative diseases (Paper V)