Monday, 25 July 2016

Th17 important in MS

Bühler U, Fleischer V, Luessi F, Rezk A, Belikan P, Graetz C, Gollan R, Wolf C, Lutz J, Bar-Or A, Siffrin V, Zipp F. Role of IL-17-producing lymphocytes in severity of multiple sclerosis upon natalizumab treatment. Mult Scler. 2016 . pii: 1352458516658559. [Epub ahead of print]

OBJECTIVE: Natalizumab is known to prevent T-helper cells entering the central nervous system (CNS). We hypothesize that more pathogenic T-helper cells are present outside the CNS and a possible relationship to disease severity.
METHODS:Characterization and enrichment of human CD4+IL-17+ cells were performed ex vivo using peripheral blood mononuclear cells from natalizumab-treated relapsing-remitting multiple sclerosis (RRMS) patients (n = 33), untreated RRMS patients (n = 13), and healthy controls (n = 33). Magnetic resonance imaging (MRI) scans were performed routinely for patients.
RESULTS: Lymphocytes were elevated in peripheral blood of natalizumab-treated patients compared to untreated patients and healthy controls. Whereas group comparison for CD4+IL-17+ numbers also differed, CD4+IFN-γ+ and CD4+IL-22+ counts were not increased. CD4+IL-17+ cells not only expressed but also secreted IL-17. In natalizumab-treated patients, IL-17+ cell frequency was found to correlate with T1-hypointense lesions, but was not an indicator for rebound activity after treatment discontinuation, except in one patient who experienced a fulminant rebound, and interestingly, in whom the highest IL-17+ cell levels were observed.
CONCLUSION: Increased lymphocytes and CD4+IL-17+ cells in the blood of RRMS patients receiving natalizumab corroborate the drug's mechanism of action, that is, blocking transmigration to CNS. Correlation between IL-17-expressing lymphocytes and T1-hypointense lesions underlines the important role of these cells in the disease pathology

MS is caused by Th17 cells becuase this now dogma. So when we give natalizumab there are more CD4, IL-17 cells in the blood and the numbers correlate with T1-hypointense lesion.Therefore this validates the value of Th17 in disease pathogenesis. 

However, proof is really getting rid of CD4+, IL-17+ T cells and it having an impact on MS.

However, so far depletion of CD4 T cells did not have a marked impact on MS lesions (although depletion levels were correlated relapse) and interleukin 17 neutralising antibodies reduced gadolinium lesions by about 50%. This gets the Th17ers mouths watering but remember beta interferon is much more effective than that and so many things do much better.

We need to be cautious until this action is shown

Sunday, 24 July 2016

ThinkHand: how important is your arm and hand function to you?

Did you know that hand functions involving power and precision probably evolved separately? #ThinkHand #MSBlog #MSResearch

"If you a veteran visitor to this blog you will be aware that as an extension of our length-dependent axonopathy (LENDAXON) and therapeutic lag hypotheses we are proposing that progressive trials in people already using a walking stick (EDSS = 6.0 and 6.5) or wheelchair (EDSS>=7.0) should focus on upper limb (arm and hand) function as the primary outcome. This proposal is supported by many data sets and is strongly supported by the recent results of the ASCEND trial (natalizumab in SPMS). Although this trial was negative overall it showed that natalizumab was effective in maintaining upper limb function compared to placebo in pwSPMS. Despite presenting and writing about the LENDAXON and therapeutic lag hypotheses, lobbying pharma and discussing things face-to-face with colleagues there seems to be some resistance to adopting our ideas and trial proposal. We are hoping to change things at ECTRIMS; we have had one of our Blog Surveys on the importance of arm and hand function to pwMS accepted as a poster and there will be a debate on this exact issue as well. Dr K or Dr Schmierer will be making the case for trials in more advanced MS using upper limb function as the primary outcome."

"We also planning to launch an initiative around ECTRIMS to allow pwMS to perform their own 9-hole peg test (9-HPT), i.e. a self- or home-administered 9-HPT, so that you can start monitoring your own arm and hand function. If we don't get people to ThinkHand then the chances of getting effective treatments for people with more advanced MS will remain slim. One of the problems we face is that both the 9-HPT and the ABILHAND (a patient-related outcome measure or PROM) to assess arm and hand function are designed and weighted towards assessing precision, rather than power, tasks. It is clear from the evolution of the hand (see abstract below) that we need both precision and power. As MS impacts on both of these functions we may need newer and better outcome measures that are more sensitive to change to measure these functions in more detail. We also believe that the current upper-limb outcome measures are not that meaningful to pwMS; Alison Thomson in our group is hoping to change that as well. She is currently ruminating on how to develop and improve on the current PROMS; she is passionate about making a PROM that reflects the impact MS is having on your life."

"To help expand the data set for our ECTRIMS poster; I would appreciate it if you could help by completing another, more detailed survey on arm and hand function. Thank you."

Richard W Young. Evolution of the human hand: the role of throwing and clubbing. J Anat. 2003 Jan; 202(1): 165–174.

It has been proposed that the hominid lineage began when a group of chimpanzee-like apes began to throw rocks and swing clubs at adversaries, and that this behaviour yielded reproductive advantages for millions of years, driving natural selection for improved throwing and clubbing prowess. This assertion leads to the prediction that the human hand should be adapted for throwing and clubbing, a topic that is explored in the following report. It is shown that the two fundamental human handgrips, first identified by J. R. Napier, and named by him the ‘precision grip’ and ‘power grip’, represent a throwing grip and a clubbing grip, thereby providing an evolutionary explanation for the two unique grips, and the extensive anatomical remodelling of the hand that made them possible. These results are supported by palaeoanthropological evidence.

Cancer Risk with Mitoxantrone

Buttmann M, Seuffert L, Mäder U, Toyka KV. Malignancies after mitoxantrone for multiple sclerosis: A retrospective cohort study. Neurology. 2016 Jun 7;86(23):2203-7.

OBJECTIVE:To assess the therapy-related risk of malignancies in mitoxantrone-treated patients with multiple sclerosis.
METHODS:This retrospective observational cohort study included all mitoxantrone-treated patients with multiple sclerosis seen at our department between 1994 and 2007. We collected follow-up information on medically confirmed malignancies, life status, and cause of death, as of 2010. Malignancy rates were compared to the German national cancer registry matched for sex, age, and year of occurrence.
RESULTS: Follow-up was completed in 676 of 677 identified patients. Median follow-up time was 8.7 years (interquartile range 6.8-11.2), corresponding to 6,220 person-years. Median cumulative mitoxantrone dose was 79.0 mg/m(2) (interquartile range 50.8-102.4). Thirty-seven patients (5.5%) were diagnosed with a malignancy after mitoxantrone initiation, revealing a standardized incidence ratio of 1.50 (95% confidence interval [CI] 1.05-2.08). Entities included breast cancer (n = 9), colorectal cancer (n = 7), acute myeloid leukemia (n = 4, 0.6%), and others (each entity n = 1 or 2). The standardized incidence ratio of colorectal cancer was 2.98 (95% CI 1.20-6.14) and of acute myeloid leukemia 10.44 (95% CI 3.39-24.36). It was not increased for other entities including breast cancer. Multivariate Cox regression identified higher age at treatment initiation but neither cumulative mitoxantrone dose (>75 vs ≤75 mg/m(2)) nor treatment with other immunosuppressive drugs or sex as a risk factor. Fifty-five patients had died, among them 12 of a malignancy and 43 reportedly of other causes.
CONCLUSIONS: While the overall incidence of malignancies was only mildly increased, the risk of leukemia and colorectal cancer was heightened. If confirmed, posttherapy colonoscopy could become advisable.

Mitoxantrone is an anti-cancer drug that is not licenced in the UK ut is sometimes used to treat MS. Its use is limited because it can cause damage to the heart muscles meaning that you can only take a limited number of doses. It is already known that there is a increased risk of cancer. In this German cohort followed for up to a number of years, they report that 5% of people got cancer so that is 1 in 20 people. Whilst life is assocaited with a cancer risk, this appears high and is one of the reasons that our use of ths agent has dwindled. It is strange that there is a resistance against cladribine and I wonder if such people will supply mitoxantrone when the risk of cancer is probably higher.

Saturday, 23 July 2016

SurveySpeak: is wound healing a problem on DMTs?

I am sick and tired of my current DMT; it seems to be affecting wound healing. What about you? #SurveySpeak #MSBlog 

"Prof B (aka the MouseDoctor) was speaking to a person with MS who mentioned to him that since starting drug X they had noticed that minor cuts and abrasions were taking much longer to heal. The process of wound healing is complex and uses many of the same biological processes that the immune system uses to function. Therefore it is quite possible that some DMTs that are used in MS may impact on wound healing. To assess whether or not this is an anecdote, or a real phenomenon, ProfB has asked me to do a quick poll. We would therefore appreciate it if you could complete the following survey. Thank you."

Eming et al. Wound repair and regeneration: mechanisms, signaling, and translation. Sci Transl Med. 2014 Dec 3;6(265):265sr6.

The cellular and molecular mechanisms underpinning tissue repair and its failure to heal are still poorly understood, and current therapies are limited. Poor wound healing after trauma, surgery, acute illness, or chronic disease conditions affects millions of people worldwide each year and is the consequence of poorly regulated elements of the healthy tissue repair response, including inflammation, angiogenesis, matrix deposition, and cell recruitment. Failure of one or several of these cellular processes is generally linked to an underlying clinical condition, such as vascular disease, diabetes, or aging, which are all frequently associated with healing pathologies. The search for clinical strategies that might improve the body's natural repair mechanisms will need to be based on a thorough understanding of the basic biology of repair and regeneration. In this review, we highlight emerging concepts in tissue regeneration and repair, and provide some perspectives on how to translate current knowledge into viable clinical approaches for treating patients with wound-healing pathologies.

Assessing Animal Data is it Pants or Not?

EAE #MSresearch #MSBlog
This week ProfB presented to a group of students on EAE and left his slides on the blog. The students also had a session on experimental design. Central to this is how to analyse data. Someone commented on this.

I must admit we are all pretty bad a statistics, but it seems that some EAEologists are worse than others

Someone I know had a grant sent back because the referees were saying that they had to analyse their EAE data in a certain way, that was........statistically wrong.

It is amazing how many people do their EAE analysis in the wrong way. 

They often use a test called a Student's t test to measure the severity of a neurological score. 

Here signs are given a arbitaory score say 0-5 see in the example below. This test assumes a few things such that the measurement item is continuous (such as height where you could be 1m tall or 2m tall but also everything in between as an example of parametric data), but a few other things too. If those assumuptions are not evident you need to use non-parametric analysis such as the Wilcoxon/Mann Whitney U tests.

It is amazing that 65% of the EAE paper published in Nature/Science/Cell journals assume neurological scores are parametric and of those a whopping 67% of studies use a t test to analyse their data. This is in my humble opinion not correct.

In the picture you can see the crux of the problem. In EAE you get T cells infiltrating the spinal cord and in the picture above the cells are red. In the picture above look at the extra amount of red between 0 = normal and 1 = limp tail. Now look at the difference between 3 = paresis= partial paralysis and 4 = hindlimb paralysis. So the amount of red detween 0 and 1 and 3 and 4 is not the same  yet they get an arbitary score of diffeence of 1. But you can see there is more red in 3 than 1 and more red in 4 than 3. So the neurological score is non-linear and non-parametric meaning that non-parametric statistics should be used. This is based on ranking from the smallest to the largest. Does this mak a difference?

It can do. This is an real example that we use to teach, It was a nature paper and the animal experiment was the culmination of the work. In the study they used a t test and showed the drug gave a signficant inhibition (p=0.029)...Yipppie they said. But if only the referees had asked them to do it properly.  Look at the graph and the drug drops the neurological score by about a half

Or does it?
They seem to show the actual scores of individual animals and yes if you do a t test it is P=0.029. But looking at the data 5 animals have no disease but the drug does essentialy nothing in the six animals that got disease. 

However if you do non-parametric statistics the result is P=0.082 and so the drug does nothing and the value of the Nature paper is flushed down the loo. 

So the paper may not get a mention because of the idea but as a teching example of data analysis

Was it a fluke where it just happened that 5 animals failed to get disease. We never know because the work was not repeated. So looks like there is no quality control which is a problem with some EAE studies.

So when you read EAE papers look out for the way the data is analysed. Does it pass the "snack you in the eye test" or are the results pants?

Pharma is having to deposit trial data  with the regulators so that it can be re-analysed by others requesting the info. It is a probably only a matter of time before they make people deposit raw data when they publish (people are asking about this), so the data can be re-analysed. This will be fun and games. How many other studies will fail?

Should we not do these posts and pretend it is all great?
It clearly isn't