Improving longitudinal spinal cord atrophy measurements for clinical trials in multiple sclerosis by using the generalised boundary shift integral (GBSI)

Spinal cord atrophy is a common and clinically relevant feature of multiple sclerosis (MS), and can be used to monitor disease progression and as an outcome measure in clinical trials. Spinal cord atrophy is conventionally estimated with segmentation-based methods (e.g., cross-sectional spinal cord area (CSA)), where spinal cord change is calculated indirectly by numerical difference between timepoints. In this thesis, I validated the generalised boundary shift integral (GBSI), as the first registration-based method for longitudinal spinal cord atrophy measurement. The GBSI registers the baseline and follow-up spinal cord scans in a common half-way space, to directly determine atrophy on the cord edges. First, on a test dataset (9 MS patients and 9 controls), I have found that GBSI presented with lower random measurement error, than CSA, reflected by lower standard deviation, coefficient of variation and median absolute deviation. Then, on multi-centre, multi-manufacturer, and multi–field‐strength scans (282 MS patients and 82 controls), I confirmed that GBSI provided lower measurement variability in all MS subtypes and controls, than CSA, resulting into better separation between MS patients and controls, improved statistical power, and reduced sample size estimates. Finally, on a phase 2 clinical trial (220 primary-progressive MS patients), I demonstrated that spinal cord atrophy measurements on GBSI could be obtained from brain scans, considering their quality and association with corresponding spinal cord MRI-derived measurements. Not least, 1-year spinal cord atrophy measurements on GBSI, but not CSA, were associated with upper and lower limb motor function. In conclusion, spinal cord atrophy on the GBSI had higher measurement precision and stronger clinical correlates, than the segmentation method, and could be derived from high-quality brain acquisitions. Longitudinal spinal cord atrophy on GBSI could become a gold standard for clinical trials including spinal cord atrophy as an outcome measure, but should remain a secondary outcome measure, until further advancements increase the ease of acquisition and processing

Post mortem and in vivo study of multiple sclerosis pathogenesis

Multiple Sclerosis (MS) is a chronic inflammatory disease of the central nervous system. A number of pathological mechanisms could be responsible for acute demyelination and chronic tissue remodelling in MS, including inflammation, oxidative stress, microglia activation, and astrocyte infiltrates. In the present work, we aim to further explore the heterogeneity of MS pathogenesis on post mortem brains, and to evaluate the possibility to study MS pathogenesis by using magnetic resonance imaging (MRI) and peripheral blood biomarkers. In the first part of the study, we applied a data driven approach to classify MS patients in relation to the variety of pathological changes occurring in lesional and normal-appearing (NA) white matter (WM) and grey matter (GM), with subsequent clinical correlates. Tissue blocks from 16 MS brains were immunostained and quantified for neuro-axonal structures (NF200), myelin (SMI94), macrophages (CD68), B-lymphocytes (CD20), T-lymphocytes (CD3), cytotoxic T-lymphocytes (CD8), microglia (IBA1), astrocytes (GFAP), and mitochondrial damage. After semi-automatic registration of digitized histologic sections, regions-of-interest (ROIs) were manually defined in lesion and NA WM and GM. A latent class analysis was employed to characterize pathology subtypes in MS; different goodness of fit parameters (AIC, BIC, and G2 statistics) were used to identify the number of classes that better characterize the MS sub-populations. Profile 1 (active remodelling) was characterized by normal-appearing neuro-axonal structures and intact energetic metabolism, with high levels of macrophages/microglia and astrocytes. Profile 2 (mitochondrial dysfunction) was characterized by severely impaired mitochondrial function, along with demyelination and neuroaxonal loss, and ongoing inflammatory changes, mainly driven by cytotoxic T-cells (CD8+); patients in profile 2 presented with more severe symptoms at onset and faster disability accrual, when compared with other profiles. Profile 3 (inactive) was characterized by severe demyelination and axonal loss, with similarly reduced mitochondrial function, without any concomitant pathological process contributing to further tissue remodelling and/or damage. The possibility to classify each patient depending on his/her prevalent pathology profile support the concept of MS immunopathological homogeneity within the same patient and heterogeneity between different patients, and could be used to better profile MS patients and individualize their treatment. In the second part of the study, we explored post mortem pathology-MRI correlates and specifically focused on an advanced MRI technique (magnetization transfer ratio -MTR-), ideally detecting myelin content. MTR is widely used in MS observational studies and clinical trials, but its pathological correlates remain unclear. MTR maps were acquired at 3 Tesla from sixteen fixed MS brains and four healthy controls. 101 tissue blocks were immunostained and quantified, as previously described. After semi-automatic registration of digitized histologic sections and MTR maps, ROIs were manually defined. Associations between MTR and each stain were explored using linear mixed regression models (with cassettes nested within patients); differences in the associations between ROIs were explored using interaction terms. Lower MTR was associated with lower levels of NF200, SMI94, CD68, IBA1 and GFAP, with higher levels of CD8 and greater mitochondrial damage; MTR was more strongly associated with SMI94 in GM than WM. In a multivariate linear mixed regression model including all ROIs and brains, SMI94 was the best correlate of MTR. Myelin immunostain intensity is the strongest correlate of MTR, especially when measured in the GM. However, the additional histological correlates of MTR have to be kept in mind when interpreting the results of MTR clinical studies and designing experimental trials in MS. Finally, we evaluated the possibility to study (and to modify) MS pathology in vivo, by using biomarkers in the peripheral blood. Considering that oxidative stress is a driver of MS pathology, we evaluated the effect of coenzyme Q10 (CoQ10) on laboratory markers of oxidative stress and inflammation, and on MS clinical severity, and, then, calculated the sample size needed to detect significant variations to define most promising biomarkers. We included 60 relapsing-remitting MS patients treated with Interferon-Beta1a-44μg with CoQ10 for 3 months, and with Interferon-Beta1a-44μg alone for 3 more months (open-label cross-over design). At baseline, 3- and 6-month visits, we measured markers of scavenging activity, oxidative damage and inflammation in the peripheral blood, and collected data on disease severity. After 3 months, CoQ10 supplementation was associated with improved scavenging activity (as mediated by uric acid), reduced intracellular reactive oxygen species production, reduced oxidative DNA damage, and shift towards a more anti-inflammatory milieu in the peripheral blood (with higher IL-4 and IL-13, and lower Eotaxin, GM-CSF, HGF, IFN-γ, IL-1α, IL-2R, IL-9, IL-17F, MIP-1α, RANTES, TNF-α and VEGF). Also, CoQ10 supplementation was associated with lower expanded disability status scale, fatigue severity scale, Beck's depression inventory, and visual analogic scale for pain. For sample size estimates, we used adjusted-beta-coefficients of observed 3-month variation for each laboratory measure (and respective standard deviation); we assumed that the observed variation was the highest achievable treatment effect (100%), and we estimated sample size for conservative treatment effects (e.g., 70%), smaller than what observed. Setting 5% alpha-error and 80% power, low sample size requirements to detect 70% observed variation from a baseline pre-treatment timepoint to a 3-month follow-up were found for IL-3 (n=1), IL-5 (n=1), IL-7 (n=4), IL-2R (n=4), IL-13 (n=6), IL-6 (n=14), IL-8 (n=22), IL-4 (n=23), RANTES (n=25), TNF-α (n=26), IL-1β (n=27), and uric acid (n=29). CoQ10 supplementation improved scavenging activity, reduced oxidative damage, and induced a shift towards a more anti-inflammatory milieu, in the peripheral blood of relapsing-remitting MS patients treated with Interferon-Beta1a 44μg, along with clinical improvements. Peripheral biomarkers of oxidative stress and inflammation could be used in small proof-of-concept studies to quickly screen the mechanisms of action of new or already-existing medications for MS

Dorsal Prefrontal Cortex Impairment in Methoxetamine-Induced Psychosis: an 18F-FDG PET/CT Case Study

Submitted15 June 2018. Accepted 13 December 2018. Epub ahead of print 13 February 2019Novel psychoactive substances (NPSs) have currently become a major public health concern because of relatively easy accessibility to these compounds and difficulty in identifying them with routine laboratory techniques. Here, we report the 18 F-fluorodeoxyglucose positron emission tomography/computerized tomography ( 18 F-FDG PET/CT) case study of a 23-year-old man who developed a substance-induced psychotic disorder after having intravenously injected himself with an unspecified amount of methoxetamine (MXE), a ketamine derivative hallucinogen. From a clinical perspective, a blunted affective responsiveness with diminished social drive and sense of purpose, along with a profound detachment from the environment, was observed. Psychometric and neuropsychological assessments highlighted severe dissociative symptoms and lack of motivation, along with a mild impairment of verbal fluency, working memory, and attention. Patient’s 18 F-FDG PET/CT scans displayed a significant bilateral deficit of tracer uptake within the dorsolateral prefrontal cortex (DLPFC). DLPFC activity is critical to goal-oriented cognitive functions, including working memory and sustained attention. DLPFC is also involved in both the temporal integration across multiple sensory modes and in the volitional control of actions, leading to the possibility to construct logically coherent temporal configurations of thought, speech, and behavior. This report highlights that a single acute MXE intoxication may produce severe brain impairment.Peer reviewedFinal Accepted Versio

Biomarkers of Parkinson's disease: recent insights, current challenges, and future prospects

Marina Picillo,1 Marcello Moccia,2 Emanuele Spina,2 Paolo Barone,1 Maria Teresa Pellecchia1 1Department of Medicine and Surgery, Center for Neurodegenerative Diseases (CEMAND), Neuroscience Section, University of Salerno, Salerno, Italy; 2Department of Neuroscience, Reproductive and Odontostomatologic Sciences, Federico II University, Naples, Italy Abstract: A biomarker represents a tool possibly helping physicians in predicting onset, diagnosis, and progression of a disease as well as evaluating the response to disease-modifying treatments. Currently, there is no biomarker fulfilling all such ideal criteria for Parkinson's disease (PD). In this article, we have critically reviewed the literature searching for the most reliable and reproducible clinical, biochemical, and imaging biomarkers for prodromal phase, diagnosis, and progression of PD. Different comprehensive batteries of biomarkers have been proposed as a sensitive approach to predict the onset of PD during the prodromal phase. There is a discussion about the redefinition of the clinical diagnosis of PD, including clinical biomarkers as non-motor symptoms; however, on the other hand, we have also observed that imaging biomarkers support the differential diagnosis from other causes of parkinsonism. Various clinical (eg, freezing of gait or cognitive impairment), biochemical (eg, epidermal growth factor, insulin-like growth factor 1, uric acid, etc), and imaging (eg, functional magnetic resonance imaging, voxel-based morphometry, etc) biomarkers may help envisaging disease progression of PD. To conclude, given the lack of a single biomarker that could track the entire course of the disease, our challenge is to find the best combinations of biomarkers for the different stages of the disease. Keywords: biomarkers, Parkinson's disease, progression, motor, imaging , staging, non moto

Telemedicine in Parkinson's Disease: How to Ensure Patient Needs and Continuity of Care at the Time of COVID-19 Pandemic

Introduction: With the spread of the SARS-CoV2 pandemic, telemedicine has become the safest way to guarantee care continuity, especially for chronic disabling diseases requiring frequent medical consultations and therapeutic adjustments, such as Parkinson's disease (PD). The age-related prevalence of PD, combined with increased vulnerability due to age-related comorbidities, makes PD patients protection a priority. Methodology: We reviewed potentials and limitations of teleneurology in PD and suggested a specific battery of tests, including patient-reported outcomes, smartphone applications, and neurological examination through telemedicine. Conclusions: These tools can provide full neurological consultations, with the engagement of both patients and caregivers, and can support clinicians in defining whether patients need to access diagnostic and therapeutic procedures. Telemedicine will also carry a value in the future, within conventional health care, to support clinicians in decision making, enabling more efficacious follow-up, reducing burden for caregivers, and delivering neurological expertise to local realities. These advantages are very important when there is physical distance between patients and neurologists, and when patients are not recommended to attend in-person consultations

Do the current MS clinical course descriptors need to change and if so how? A survey of the MS community

Multiple sclerosis; Clinical course; ProgressionEsclerosis múltiple; Curso clínico; ProgresiónEsclerosi múltiple; Curs clínic; ProgressióBackground and Objectives: The current clinical course descriptors of multiple sclerosis (MS) include a combination of clinical and magnetic resonance imaging (MRI) features. Recently there has been a growing call to base these descriptors more firmly on biological mechanisms. We investigated the implications of proposing a new mechanism-driven framework for describing MS. Methods: In a web-based survey, multiple stakeholders rated the need to change current MS clinical course descriptors, the definitions of disease course and their value in clinical practice and related topics. Results: We received 502 responses across 49 countries. In all, 77% of the survey respondents supported changing the current MS clinical course descriptors. They preferred a framework that informs treatment decisions, aids the design and conduct of clinical trials, allows patients to understand their disease, and links disease mechanisms and clinical expression of disease. Clinical validation before dissemination and ease of communication to patients were rated as the most important aspects to consider when developing any new framework for describing MS. Conclusion: A majority of MS stakeholders agreed that the current MS clinical course descriptors need to change. Any change process will need to engage a wide range of affected stakeholders and be guided by foundational principles.This work and the International Advisory Committee on Clinical Trials in MS are funded by the European Committee for Treatment and Research in Multiple Sclerosis and the National Multiple Sclerosis Society

Google Maps Timeline: An open-access digital tool to monitor walking abilities in people with multiple sclerosis

Introduction: Gait impairment is common in multiple sclerosis (MS), but difficult to evaluate in clinical practice. In this proof-of-concept observational study, we compared walking ability recorded by Google Maps Timeline to conventional clinical measures in people with MS. Methods: We used open-access Google Maps Timeline to record the total number of days with walking activity, walking distance, walking time, and walking speed. Each Google Maps Timeline variable was included in a different stepwise linear regression model including all conventional clinical variables. Results: We included nine people with MS (age 43.1 ± 6.6 years; females 55.6%; disease duration 12.7 ± 3.1 years; median Expanded Disability Status Scale 3.0 (range 1.0-5.5)). Higher percentage of days with recorded walking was associated with lower Fatigue Severity Scale (p = 0.01), and higher MS Walking Scale (p = 0.04). Longer average daily walking distance was associated with shorter Timed-25 Foot Walking Test (p = 0.02), lower Expanded Disability Status Scale (p = 0.01), and higher Euro-Quality of Life (p = 0.04). Longer average daily walking time was associated with shorter Timed-25 Foot Walking Test (p = 0.03). Higher walking speed was associated with lower Fatigue Severity Scale (p = 0.04). Conclusion: Google Maps Timeline parameters provide actual estimates of daily walking activities in MS

Determinants of early working impairments in multiple sclerosis

IntroductionUnemployment can directly affect social status and identity. Assessing and adjusting determinants of early working impairments in a chronic disease can thus reduce its long-term burden. Hereby, we aim to evaluate differences in occupational history and early working impairments between people with multiple sclerosis (MS) and healthy workers.MethodsThis is a cross-sectional study comparing 71 workers with MS [age 41.7 ± 9.4 years; females 59.1%; EDSS 2.0 (1.0–6.0)] and 71 controls (age 42.6 ± 11.9 years; females 33.8%). All participants filled in Work Ability Index (WAI), Work Productivity and Activity Impairment (WPAI), European Questionnaire for Quality of Life (EuroQoL), Beck Depression Inventory II (BDI-II), and Pittsburgh Sleep Quality Index (PSQI). In MS, we further collected expanded disability status scale (EDSS), MS Questionnaire for Job difficulties (MSQ-Job), Fatigue severity scale (FSS), and the Brief International Cognitive Assessment for MS (BICAMS).ResultsWorkers with MS were more working disabled (p < 0.01), less exposed to workplace risks (p < 0.01), and more limited in fitness to work (p = 0.01), compared with controls. On linear regression models adjusted by age, sex, education, and type of contract, people with MS had worse WAI (Coeff=−5.47; 95% CI = −7.41, −3.53; p < 0.01), EuroQoL (Coeff = −4.24; 95% CI = −17.85, −6.50; p < 0.01), BDI-II (Coeff = 3.99; 95% CI = 2.37, 7.01; p < 0.01), and PSQI (Coeff = 4.74; 95% CI = 3.13, 7.61; p < 0.01), compared with controls, but no differences in WPAI (p = 0.60). EuroQoL, BDI-II, and PSQI were equally associated with both WAI and WPAI in MS and controls (all p< 0.01). In MS, worse MSQJob was associated with higher EDSS (Coeff = 5.22; 95% CI = 2.24, 7.95; p < 0.01), progressive disease (Coeff = 14.62; 95% CI = 5.56, 23.69; p < 0.01), EuroQoL (Coeff = 4.63; 95% CI = 2.92, 6.35; p < 0.01), FSS (Coeff = 0.55; 95% CI = 0.38, 0.72; p < 0.01), and cognitive impairment (Coeff = 4.42; 95% CI = 0.67, 8.22; p = 0.02).DiscussionEarly factors associated with working difficulties in MS include disability, fatigue, depression, and cognitive dysfunction. Early identification of clinical features potentially causing working difficulties should be considered to enhance job retention, along with targeted prevention and protection measures

Low serum 25‐hydroxy-vitamin D levels are associated with cognitive impairment in multiple sclerosis

Background: Cognitive impairment frequently affects people with multiple sclerosis (MS). Low vitamin D has been associated with cognitive dysfunction in different neurodegenerative diseases, and, in MS, with motor disability and disease activity. We aim to investigate associations between vitamin D and cognitive status in MS. Methods: In this cross-sectional study, we included 181 MS patients, recruited consecutively at the MS Unit of the Policlinico Federico II University Hospital of Naples, Italy, between January and April 2022, with serum 25‐hydroxy (25-OH) vitamin D measurements using Chemiluminescence-ImmunoAssay, and cognitive assessment using the Brief International Cognitive Assessment for MS (BICAMS), which includes Symbol Digit Modalities Test (SDMT), California Verbal Learning Test-II (CVLT-II) and Brief Visuospatial Memory Test-Revised (BVMT-R). We collected demographics (age, sex, education), and clinical variables (disease duration, disease subtype, expanded disability status scale (EDSS), disease modifying treatment, relapses in previous 12 months, vitamin D supplementation, comorbidities). For a subset of patients (n = 41, 23.2% of the total sample), we collected Beck Depression Inventory-II, Beck Anxiety Inventory, and Modified Fatigue Impact Scale. Results: At univariable linear regression models, serum 25-OH-vitamin D levels were 0.9 ng/mL higher for each unit increase of SDMT adjusted scores (Coeff=0.93; 95%CI=0.81, 1.04; p<0.01), 0.7 ng/mL higher for each unit increase of CVLT-II adjusted scores (Coeff=0.68; 95%CI=0.53, 0.83; p<0. 01), 0.6 ng/mL higher for each unit increase of BVMT-R adjusted scores (Coeff=0.58; 95%CI=0.43, 0.73; p<0.01), -9.63 ng/mL lower for each impaired BICAMS test (Coeff=-9.63; 95%CI=-11.48, -7.79; p<0.01), and -2.2 ng/mL lower for each unit increase of EDSS (Coeff=-2.16; 95%CI=-3.57, -0.75; p<0.01). At multivariable linear regression models, we confirmed associations between 25-OH-vitamin D and EDSS (Coeff=-2.09; 95%CI=-4.45, -0.43; p<0.01), SDMT (Coeff=0.75; 95%CI=0.60, 0.90; p<0.01), and CVLT-II (Coeff=0.14; 95%CI=0.01, 0.28; p = 0. 04). Results remained unchanged when including depression, anxiety and fatigue scores. Conclusions: Lower serum 25-OH-vitamin D was associated with worse cognitive function in MS. Future studies should consider longitudinal variations in cognitive function in relation to vitamin D supplementation