Friday, 31 March 2017

Defective T cell control of EBV in MS

Pender MP, Csurhes PA, Burrows JM, Burrows SR. Defective T-cell control of Epstein-Barr virus infection in multiple sclerosis.
Clin Transl Immunology. 2017;6(1):e126.

Mounting evidence indicates that infection with Epstein-Barr virus (EBV) has a major role in the pathogenesis of multiple sclerosis (MS). Defective elimination of EBV-infected B cells by CD8+ T cells might cause MS by allowing EBV-infected autoreactive B cells to accumulate in the brain. Here we undertake a comprehensive analysis of the T-cell response to EBV in MS, using flow cytometry and intracellular IFN-γ staining to measure T-cell responses to EBV-infected autologous lymphoblastoid cell lines and pools of human leukocyte antigen (HLA)-class-I-restricted peptides from EBV lytic or latent proteins and cytomegalovirus (CMV), in 95 patients and 56 EBV-seropositive healthy subjects. In 20 HLA-A2+ healthy subjects and 20 HLA-A2+ patients we also analysed CD8+ T cells specific for individual peptides, measured by binding to HLA-peptide complexes and production of IFN-γ, TNF-α and IL-2. We found a decreased CD8+ T-cell response to EBV lytic, but not CMV lytic, antigens at the onset of MS and at all subsequent disease stages. CD8+ T cells directed against EBV latent antigens were increased but had reduced cytokine polyfunctionality indicating T-cell exhaustion. During attacks the EBV-specific CD4+ and CD8+ T-cell populations expanded, with increased functionality of latent-specific CD8+ T cells. With increasing disease duration, EBV-specific CD4+ and CD8+ T cells progressively declined, consistent with T-cell exhaustion. The anti-EBNA1 IgG titre correlated inversely with the EBV-specific CD8+ T-cell frequency. We postulate that defective CD8+ T-cell control of EBV reactivation leads to an expanded population of latently infected cells, including autoreactive B cells.

Mounting evidence indicates that infection with the Epstein–Barr virus (EBV) is a prerequisite for the development of multiple sclerosis (MS)

EBV, a ubiquitous double-stranded DNA γ-herpesvirus, is unique among human viruses in having the capability of infecting, activating, clonally expanding and persisting latently in B lymphocytes for the lifetime of the infected person. 

To accomplish this, EBV utilizes the normal pathways of B-cell differentiation. 

During primary infection EBV is transmitted through saliva to the tonsil where it infects naive  (mature) B cells and drives them out of the resting state into activated B blasts, which then progress through a germinal centre reaction to become circulating latently infected memory B cells. 

When latently infected memory B cells returning to the tonsil differentiate into plasma cells, the infection is reactivated by initiation of the lytic phase culminating in the generation of virions, which infect tonsil epithelial cells where the virus reproduces at a high rate and is released into saliva continuously for transmission to new hosts.

Newly formed virus also infects additional naive B cells in the same host, thereby completing the cycle necessary for its persistence as a lifelong infection.

To pass through the various stages of its life cycle, EBV makes use of a series of differing transcription programmes. 

After entering mature B cells, it first employs the latency III or ‘growth' programme expressing all viral latent proteins, namely the Epstein–Barr nuclear antigens (EBNA) 1, 2, 3A, 3B, 3C and LP, and the latent membrane proteins (LMP) 1, 2A and 2B, to activate the blast phase. 

After entering a germinal centre, the infected blast switches off expression of the EBNA proteins 2, 3A, 3B, 3C and LP and continues to express EBNA1, LMP1 and LMP2 (latency II or ‘default' programme) while it progresses through the germinal centre phase to differentiate into a memory B cell. 

Because latently infected memory B cells express no viral proteins they are unable to be detected by EBV-specific immune responses, except during cell division, when they express only EBNA1 (latency I), which is needed for duplication of the EBV genome and transmission to daughter cells. When latently infected memory B cells differentiate into plasma cells the virus is reactivated through the lytic transcription programme to generate infectious virions.

In healthy individuals, EBV infection is kept under rigorous control by EBV-specific immune responses, especially by cytotoxic CD8+ T cells, which kill proliferating and lytically infected B cells by targeting the various EBV-encoded latent and lytic proteins respectively.

It is suggested that defective elimination of EBV-infected B cells by cytotoxic CD8+ T cells might predispose to the development of MS by enabling the accumulation of EBV-infected autoreactive B cells in the central nervous system (CNS).

So what did this study find

  • The T-cell response to EBV-infected B cells is reduced at all stages of MS except during clinical attacks
  • The T-cell response to EBV-infected B cells progressively decreases with increasing duration of MS.

These results are consistent with progressive T-cell exhaustion of EBV-specific CD4+ T cells and CD8+ T cells during the course of MS although they could also be due to other factors, for example an age-related decline in the tendency of EBV to reactivate.

T cell exhaustion is a state of T cell dysfunction that arises during many chronic infections and cancer. It is defined by poor effector function, sustained expression of inhibitory receptors and a transcriptional state distinct from that of functional effector or memory T cells.

The CD8+ T-cell response to EBV lytic phase antigens is reduced at the onset of MS and throughout its course

CD8+ T cells recognizing EBV latent phase antigens in MS show T-cell exhaustion##

Proposed model of defective CD8+ T-cell control of EBV infection in MS. In healthy EBV carriers, (a) there is a dynamic equilibrium between the EBV-infected cell populations and the T-cell response. EBV-specific CD8+ T cells (T cell) exert a key role in controlling EBV infection by killing infected cells in the B blast, germinal centre (GC) B cell, plasma cell and tonsil epithelial cell, but not memory B cell, populations. The large arrows indicate the cycle of EBV infection: virion→B blast→GC B cell→memory B cell→plasma cell→virion→epithelial cell→virion→B blast. Smaller arrows indicate stimulation of T cells by EBV antigens from the infected populations. The relative sizes of the different EBV-infected cell populations are indicated by the circle sizes, based on the study by Hawkins et al.6 The relative sizes of the EBV-specific CD8+ T-cell populations are also indicated by the circle sizes; however, it is important to note that the EBV-specific CD8+ T-cell population is several orders of magnitude larger than the EBV-infected cell population, a distinction not depicted here. For simplicity, the EBV-specific CD4+ T-cell population and anti-EBV antibody response are not shown. At all stages of MS (b–d) the EBV-lytic-specific CD8+ T-cell population is decreased, allowing increased production of virions which infect naive B cells driving them into the blast phase. The resultant expansion of the infected blast population stimulates EBV-latent-specific CD8+ T cells which proliferate and restrict this expansion, but not without increased flow out of infected blast cells into a consequently enlarged EBV-infected GC cell population, which in turn is partially controlled by the augmented EBV-latent-specific CD8+ T-cell population. In the same way the EBV-infected memory B cell pool also grows, as does the population of plasma cells reactivating EBV infection. During clinical attacks of MS (c) there is increased differentiation of EBV-infected memory B cells into lytically infected plasma cells as a result of the various microbial infections that trigger attacks of MS. This EBV reactivation is inadequately regulated by the already deficient EBV-lytic-specific CD8+ T-cell response, resulting in increased virion production and increased infection of the blast pool, this in turn stimulating proliferation of the EBV-latent-specific CD8+ T-cell population which restricts further growth of the infected blast population. In progressive MS (d) the EBV-latent-specific CD8+ T-cell response becomes exhausted (indicated by fading), resulting in unchecked expansion of the infected GC population and the development of EBV-infected lymphoid tissue in the CNS.

we have shown that patients with MS have defective T-cell control of EBV infection which might underlie the accumulation of EBV-infected B cells in the CNS and subsequent development of the disease. We have proposed a model where decreased CD8+ T-cell control of EBV reactivation permits increased production of virus and consequent expansion of the latently infected B-cell population. 

To test this model they suggest that further studies are necessary to determine: 
(i) the cause of CD8+ EM/EMRA T-cell deficiency in MS, whether it genetically determined, and related to decreased type I IFN production; 
(ii) whether CD8+ T-cell deficiency precedes the onset of MS and is present in healthy first-degree relatives of people with MS,
(iii) whether sunlight deprivation and vitamin D deficiency aggravate the CD8+ T-cell deficiency
(iv) how and why the EBV-specific CD4+ T-cell response declines during the course of MS; 
(v) whether oral shedding of EBV is increased during clinical attacks; 
(vi) whether the frequency of EBV-infected memory B cells in the blood is increased in MS, as in rheumatoid arthritis and systemic lupus erythematosus;
(vii) whether EBV-infected B cells and plasma cells in the CNS in MS are autoreactive, and (viii) finally and most importantly, whether therapies aimed at controlling EBV infection, such as EBV-specific T-cell therapy,prevent and cure MS.

#NeuroSpeak & #ClinicSpeak: stability of the anti-JC virus antibody index

Interpreting the anti-JCV antibody index is more complicated than you think. #NeuroSpeak #ClinicSpeak

PML seems to raise its ugly head whenever a new MS therapy emerges. A large number of us have gotten used to using JCV serostatus as risk mitigation tool. We use positvie or negative JCV serostatus to assess whether or not our patients are infected with the virus. If they are JCV seropositive we assume they are still infected with the virus, however, this may not be correct. Some people who are JCV seropositive may not be infected with the virus, i.e. their immune systems have cleared the JC virus, and therefore may not be at risk of developing PML in the future. I suspect a proportion of people who have a low and a stable anti-JCV antibody index fall into this category. On the other hand in people with a high index, or an increasing index, or in those who become seropositive with a high index, the virus must be stimulating their immune systems to produce antibody. These are the people who are at highest risk of developing PML. There is a caveat. If you go onto treatments that interfere with the immune system, particularly immunosuppressive drugs, then the immune response to the JC virus cannot be used to assess risk. This is why we need to be very careful about extrapolating the knowledge we have acquired concerning anti-JCV index and PML risk from natalizumab-treated patients to other DMTs. Natalizumab, to the best of my knowledge, does not affect the humoral or antibody responses to viruses. All that we can do is rely on the baseline anti-JCV serostatus for the other immunosuppressive drugs and not the index. 

The study below on the stability of the anti-JCV antibody index is helpful. I am surprised by the high number of annual seroconverters (~3%) this has not been my personal experience. I think it is also important to differentiate low-index from high-index seroconverters; the low-index ones are likely to be false-positives based on the sensitivity of the assay. In comparison, the high-index seroconverters are likely to be true convertes and have unfortunately been infected with the virus. 

You may be intrerested in one of our older posts on the topic of derisking natalizumab in relation to PML. The issues discussed then are as relevant today. 

Hegen et al. Stability and predictive value of anti-JCV antibody index in multiple sclerosis: A 6-year longitudinal study. PLoS One. 2017 Mar 20;12(3):e0174005. doi: 10.1371/journal.pone.0174005.

BACKGROUND: Risk of natalizumab-related progressive multifocal leukoencephalopathy is associated with the presence of anti-JC-virus (JCV) antibodies.

OBJECTIVE: To investigate the longitudinal evolution of anti-JCV antibody index and to determine the predictive value of baseline anti-JCV antibody index for long-term stability of anti-JCV antibody status.

METHODS: MS patients from the MS centre of Medical University of Innsbruck, who had serum sampling for a time period of 4-6 years at intervals of 6±3 months, were included in this retrospective, longitudinal study. Anti-JCV antibody serological status and index were determined by 2-step second-generation anti-JCV antibody assay.

RESULTS: 154 patients were included in this study. Median follow-up time was 63.7 months, with median 11 samples available per patient. At baseline, 111 (72.1%) patients were anti-JCV antibody positive. Baseline anti-JCV antibody index significantly correlated with age (R = 0.22, p = 0.005); there was no difference with respect to sex, disease duration or previously used disease-modifying treatment. During follow-up anti-JCV antibody status changed from negative to positive or vice versa in 17% of patients. In seronegative patients at baseline, baseline anti-JCV antibody index was significantly lower in those remaining seronegative at follow-up compared to those converting to seropositivity (median 0.16 vs. 0.24, p = 0.002). In seropositive patients at baseline, index was higher in those remaining seropositive compared to those reverting to seronegativity (2.6 vs. 0.45, p<10-7). Baseline anti-JCV antibody index >0.90 predicted stable positive serostatus (sensitivity 88.7%, specificity 96.5%) and <0.20 stable negative serostatus (sensitivity 61.3%, specificity 97.6%).

CONCLUSIONS: Anti-JCV antibody index remained relatively stable over 6-year follow-up with annual serostatus change of ~3%. Baseline anti-JCV antibody index predicted stable negative and stable positive JCV serostatus.

CoI: multiple

Thursday, 30 March 2017

#NeuroSpeak: MS MasterClass for learning about managing MS

There are still a few places left on our next MS MasterClass #MSBlog #NeuroSpeak

I chair the Multiple Sclerosis Academy with the specific aim of training neurology specialist registrars and non-specialist neurologists to manage MS. If you are interested in joining the Academy and attending the MasterClass please register your interest via this LINK. The feedback from our first MasterClass was excellent and comes highly recommended by the first group of delegates. Please note this course is also open for non-UK clinicians. 

CoI: multiple and the Neurology Academy is supported by an unrestricted grant from Biogen

Wednesday, 29 March 2017

#NewsSpeak: an eagle called ocrelizumab has landed

FDA licenses ocrelizumab for both relapsing and primary progressive forms of MS. #MSBlog #NewsSpeak #Ocrelizumab

Yesterday was a pretty momentous day for people with MS (pwMS). The FDA licensed ocrelizumab for people with PPMS. The killjoys amongst you will say 'What? The efficacy of ocrelizumab is so small in PPMS that it won't make a difference'. My response to them would be 'Bullshit!' If you have PPMS you would no doubt be celebrating. When innovation happens it is often small and in incremental steps. The ocrelizumab in PPMS trial shows that we can modify the more advanced stages of MS. What you have to realise that the small differences over 2-3 years would become much larger over 5-10, and possibly 20, years. In addition, ocrelizumab was almost twice as effective in preserving arm and hand function (9HPT) when compared to lower limb function (EDSS and T25FW) in the PPMS trial. The latter is explained by our length-dependent axonopathy, therapeutic lag and asynchronous progressive MS hypotheses

This should be a time for quite reflection, deep thought and then asking the question where next? I think most of us at Barts-MS would say we should be taking ocrelizumab into more advanced MS, including wheelchair users (#ThinkHand), and as a combination therapy with add-on neuroprotectants and drugs to target the intrathecal plasma cell. 

CoI: multiple, I am a member of the phase 3 ocrelizumab steering committee

A BAT associated with MS suceptibility

Our number one viewed post is how cats are associated with MS susceptibility, this new study links a BAT to MS susceptibility

Galarza-Muñoz G, Briggs FB, Evsyukova I, Schott-Lerner G, Kennedy EM, Nyanhete T, Wang L, Bergamaschi L, Widen SG, Tomaras GD, Ko DC, Bradrick SS, Barcellos LF, Gregory SG, Garcia-Blanco MA. Human Epistatic Interaction Controls IL7R Splicing and Increases Multiple Sclerosis Risk. Cell. 2017 Mar 23;169(1):72-84.e13.

Multiple sclerosis (MS) is an autoimmune disorder where T cells attack neurons in the central nervous system (CNS) leading to demyelination and neurological deficits. A driver of increased MS risk is the soluble form of the interleukin-7 receptor alpha chain gene (sIL7R) produced by alternative splicing of IL7R exon 6. Here, we identified the RNA helicase DDX39B as a potent activator of this exon and consequently a repressor of sIL7R, and we found strong genetic association of DDX39B with MS risk. I
ndeed, we showed that a genetic variant in the 5' UTR of DDX39B reduces translation of DDX39B mRNAs and increases MS risk. Importantly, this DDX39B variant showed strong genetic and functional epistasis with allelic variants in IL7R exon 6. This study establishes the occurrence of biological epistasis in humans and provides mechanistic insight into the regulation of IL7R exon 6 splicing and its impact on MS risk.

There are about 150 known genes associated with susceptibility to MS. The major locus is the major histocompatilibility complex which is the one that gives you a DNA fingerprint but controls how your immune response recognises infections. The next set of discoveries found the interleukin 7 receptor.

IL-7 is a haematopoietic growth factor secreted by stromal cells in the bone marrow (Place where T and B cells are formed) and thymus (placed where T cells are educated). IL-7 stimulates the differentiation of multipotent (pluripotent) hematopoietic stem cells into lymphoid progenitor cells (as opposed to myeloid (macrophages) progenitor cells where differentiation is stimulated by IL-3). It is important for proliferation during certain stages of B-cell maturation, T and NK cell survival, development and homeostasis 

The interleukin 7 protein acts because it binds to the interleukin-7 receptor. It is made up of two different smaller protein chains - i.e. it is a heterodimer, and consists of two subunits, interleukin-7 receptor-α (CD127) and common-γ chain receptor (CD132).The common-γ chain receptors is shared with various cytokines, including interleukin-2, -4, -9, and -15.Interleukin-7 receptor is expressed on various cell types, including naive and memory T cells and many others. Interleukin-7 receptor has been shown to play a critical role in the development of immune cells called lymphocytes - specifically in a process known as V(D)J recombination (important in antigen recognition) blocking apoptosis (cell death by cell suicide) is an essential function of this protein during differentiation and activation of T lymphocytes.

What about B cells? 

IL-7R (CD127) is down regulated as B cells mature but it can be involved in immunoglobulin (antibody) VDJ re-arrangement and can promote B cell survival and proliferation.

It has been shown that Interleukin-7 (IL-7) promotes the maintenance and activation of peripheral T cells, whereas it does not act directly on mature B cells due to the lack of IL-7Rα expression on these. However, despite the insensitivity of B cells to IL-7, high concentration of IL-7 can lead to increased B cell survival and antibody production in the presence of T cells, without the use of any further B cell stimulatory signal. IL-7 promoted B cell activation through inducing CD70 expression on resting T cells, particularly on CD4+ memory cells. The interaction of CD70 molecules with the B cell costimulatory receptor CD27 led to B cell proliferation, the accumulation of CD38 + CD20- plasmablasts and antibody production. In addition, IL-7 treatment induced BAFF secretion from resting peripheral T cells thereby promoting B cell survival. IL-7 levels can increase in lymphopenic conditions, in autoimmune diseases or in patients receiving T cell regenerative IL-7 therapy. Based on our findings high IL-7 levels can lead to increased B cell activation by inducing the B cell regulatory proteins CD70 and BAFF in resting T cells. Such activity might be beneficial in short term immune-stimulatory IL-7 therapies; permanently increased IL-7 levels, on the other hand, can contribute to impaired B cell tolerance.

The IL-7R gene has 8 exons (coding bits of DNA), 

Alternative splicing generates a soluble isoform lacking exon 6 and introducing a premature stop codon.

In this study they find that DDX39B also known as BAT-1,
RNA-dependent ATPases that mediate ATP hydrolysis during pre-mRNA splicing. The encoded protein is an essential splicing factor required for association of U2 small nuclear ribonucleoprotein with pre-mRNA, and also plays an important role in mRNA export from the nucleus to the cytoplasm. These genes are all within the human major histocompatibility complex class III region.
which favours the production of the splice variant with the exon 6 so favouring lack of soluble (sIL-7R) which is released from the cell into the solution (blood, fluid between cells=interstitial fluid) .

In this study they found that BAT-1 variants are also risk factors for MS and a vriant that has a different untranslated (DNA part of a gene not made into the protien) region (UTR) associated with risk

The 5′ untranslated region (5′ UTR) (also known as a Leader Sequence or Leader RNA) is the region of an mRNA that is directly upstream from the initiation codon. This region is important for the regulation of translation of a transcript. This region can regulate the translation of the main coding sequence of the mRNA.  The 5′ UTR has been found to interact with proteins relating to metabolism; and proteins translate sequences within the 5′ UTR. 

So the BAT-1 variant associated with MS risk makes less DDX39B meaning that more of the soluble IL7R is made and this is associated with MS risk.

BAT-1 variants show epistasis (The effect of one gene is dependent on the presence of one or more modifier gene) with the variants creating the alternatively spliced variant.

It has to be said although this study exposes how one MS susceptibility gene is acting, MS is polygenic and there are lots of genes and gene combinations leading to MS susceptibility. Each one confers only a minor risk and you can get MS without having the gene(s) and likewise you can have the genes and not get MS.

Tuesday, 28 March 2017

#ClinicSpeak & #ResearchSpeak: community integration

How integrated are you in your community? How has MS affected you socially? #ClinicSpeak #MSBlog #MSResearch

I know I am stuck record, but part of the reason why this blog exists is to tell it how it is. We all know MS is a disabling disease and is associated with loss of quality of life. Social isolation is massive problem in MS; it gets worse with increasing disability and is associated with reduced quality of life. 

The following study shows that the majority of pwMS had 'participation restriction', which not surprisingly increased with higher EDSS scores from 40% (EDSS<4) to 82% (EDSS>5.5). Social participation was more restricted than home integration; for example, fewer than 20% of pwMS were able to shop for groceries alone. Cognitive problems were more closely linked with participation restrictions than motor problems or physical disabilities; i.e. balance, gait and hand dexterity limitations.

The results of this study confirm how disabling MS is socially and supports our campaign to rebrand MS a preventable dementia. Please note an impact on social functioning is one of the core diagnostic features of a dementia. 

Knowing this who wouldn't want their disease treated early and effectively to prevent the downstream social consequences of MS? 

I have uploaded the Community Integration Questionnaire that was used in this study. If you are interested you can complete it yourself. Please note this comes with a warning as it may inform you about the impact MS has had on your social life. 

Cattaneo et al. Participation restriction in people with multiple sclerosis: prevalence and correlations with cognitive, walking, balance and upper limb impairments. Archives of Physical Medicine and Rehabilitation Available

Objective: To calculate percentage of participation restrictions according to disability level in Multiple Sclerosis (MS) and to assess relationship between participation restriction, and cognitive, gait, balance and upper limb deficits.

Design: Cross sectional study

Setting: Rehabilitation unit

Participants: 105 people with MS and 20 healthy subjects (HS) were screened in Belgium and Italy.

Interventions: Not applicable

Main outcome measures: The Community integration questionnaire was used to assess participation in Home, Social and Productive Activities. Percentages of people with MS scores lower than the 10th percentile of those of HS were calculated for each sub scale to categorize the persons with participation restrictions. Cognitive deficits (Symbol Digit Modalities Test), walking disability (25-foot walking test / EDSS), balance disorders (Bohannon Standing Balance Test) and manual dexterity (Nine Hole Peg Test), were recorded.

Results: 77% of participants showed participation restrictions, which increased with higher EDSS scores from 40% (EDSS<4) to 82% (EDSS>5.5). Social participation was more restricted than home integration with less than 20% of participants doing shopping for groceries alone. Cognitive deficits were more highly associated (r=0.60) with participation restrictions than balance (r=0.47), gait (r=-0.45) and hand dexterity (r=0.45) limitations.

Conclusions: Participation restrictions are present in MS and increase with disability level. However, the results also show that multiple sclerosis does not restrict participation in all domains. Participation restriction at home is less restricted compared to social participation. Cognitive disorders are more associated to participation restrictions than physical limitations

End of year round-up may end on a good note for Biogen

Eur J Neurol. 2017 Mar 22. doi: 10.1111/ene.13272. [Epub ahead of print]

Effect of delayed-release dimethyl fumarate on no evidence of disease activity in relapsing-remitting multiple sclerosis: integrated analysis of the phase III DEFINE and CONFIRM studies.

Havrdova E, Giovannoni G, Gold R, Fox RJ, Kappos L, Phillips JT, Okwuokenye M7, Marantz JL.


Significant effects on clinical/neuroradiological disease activity have been reported in patients with relapsing-remitting multiple sclerosis treated with delayed-release dimethyl fumarate (DMF) in phase III DEFINE/CONFIRM trials. We conducted a post hoc analysis of integrated data from DEFINE/CONFIRM to evaluate the effect of DMF on achieving no evidence of disease activity (NEDA) in patients with relapsing-remitting multiple sclerosis.


The analysis included patients randomized to DMF 240 mg twice daily, placebo or glatiramer acetate (CONFIRM only) for ≤2 years. A time-to-event method was used to estimate the percentage of patients achieving NEDA. Clinical NEDA (no relapses/no 12-week confirmed disability progression) was analysed in the intention-to-treat (ITT) population. Neuroradiological (no new/newly enlarging T2 hyperintense lesions/no gadolinium-enhancing lesions) and overall NEDA (clinical and neuroradiological NEDA) were analysed in the magnetic resonance imaging (MRI) cohort.


The ITT and MRI populations comprised 1540 and 692 patients, respectively. The percentage of patients with clinical NEDA (ITT population) and neuroradiological NEDA (MRI cohort) was higher with DMF versus placebo over 2 years [clinical NEDA: 38.9% relative reduction; hazard ratio (HR), 0.61; 95% confidence interval (CI), 0.52-0.72; P < 0.0001; neuroradiological NEDA: 40.0% relative reduction; HR, 0.60; 95% CI, 0.49-0.73; P < 0.0001]. The percentage of patients achieving overall NEDA (MRI cohort) was also higher with DMF (26%) versus placebo (12%) over 2 years, with a relative risk reduction of 42.7% (HR, 0.57; 95% CI, 0.48-0.69; P < 0.0001).


A significantly higher percentage of patients treated with DMF achieved NEDA status over 2 years compared with placebo.

The year 2016 was a colossal mistake for most and ditto for many of our large biotechs. Firstly, the increasing momentum on biosimilars in the US, closely followed by the twitterings of Donald Trump on soaring drug prices, which certainly did not do any favors for consumer confidence. So if you were pharma, how would you set about re-couping some modicum of composure that you did not have the day before?...Why, remind everyone of your infallibility, that is!!!

As far as treatment success is concerned in MS therapeutics, it's all about NEDA, or No Evidence of Disease Activity (a composite readout based on clinical and MRI measures of disease activity). Biogen, with natalizumab (in their posthoc analysis of the AFFIRM study) were the first to report on such back in 2009; registering under 40% absence of disease activity with natalizumab vs. under 10% in the placebo/no treatment arm over 2 years. Here, again Havrdova et al. evaluate the achievement of NEDA, but this time with the first line oral drug dimethyl fumerate (DMF or tecfidera) using combined analysis from the DEFINE and CONFIRM studies. The bottom line is that percentage of overall NEDA was 26% in the DMF vs 12% in the placebo arm over 2 years (see figure below).

Figure: Effect of delayed‐release DMF (blue) on NEDA in relapsing–remitting multiple sclerosis vs placebo (red): integrated analysis of the phase III DEFINE and CONFIRM studies

So what does this data add to what we already know about DMF? It tells us that DMF is not only effective at single end-points, such as relapse rate reduction and MRI activity, but can achieve a certain degree of overall NEDA as well. NEDA individuals of course have a better prognosis for the future than those who don't achieve NEDA, and that is the key here. Therefore, even on first-line therapy it is possible to achieve this. Of course, the caveat to this is that the success rate of achieving NEDA is even greater with the most highly-active treatments, such as natalizumab and alemtuzumab, but the trade-off is the risk-benefit profile with the latter.

The key, therefore, it would seem in the current climate of MS therapeutics is to be able to cater for all comers. Have the option of the highly-active treatment, but at the same time offer a less effective one with a better risk profile; and there within comes the power to swap strategies to one's complete inner satisfaction.

Monday, 27 March 2017

#ResearchSpeak: fools rush in where angels fear to tread

AHSCT for children with MS; do the benefits justify the risks? #MSBlog #ResearchSpeak 

Some critics would state that resorting to HSCT to control MS in children is foolish. However, life sometimes rewards the brave. The paper below describes the use of autologous hematopoietic stem cell transplantation (aHSCT) in children with MS. They describe 21 children with MS from across Europe who underwent aHSCT. Please not all these children had very active and aggressive MS. It is quite remarkable that 100% had progression free survival. Is this too good to be true? I note that 2 of the children had relapses so not all children were NEDA. The question is what do you do post aHSCT to suppress disease activity? Could similar results have been achieved with natalizumab, or alemtuzumab, or rituximab/ocrelizumab with fewer side effects and lower risks? This is the real question that needs to be answered. I still think we need a randomised controlled trial to assess the risk:benefit of aHSCT compared to standard of care before we support the widespread use of aHSCT in pwMS, including children. That is why I am supportive of UK trial of AHSCT vs. Alemtuzumab. Do you agree? 

Autologous hematopoietic stem cell transplantation (aHSCT) is a promising therapy for multiple sclerosis (MS), which has mainly been used in adults. The purpose of this study was to investigate efficacy and adverse events of aHSCT in the treatment of children with MS using data from the European Society for Blood and Marrow Transplantation registry. Twenty-one patients with a median follow-up time of 2.8 years could be identified. PFS at 3 years was 100%, 16 patients improved in expanded disability status scale score and only 2 patients experienced a clinical relapse. The procedure was generally well tolerated and only two instances of severe transplant-related toxicity were recorded. There was no treatment-related mortality, although one patient needed intensive care. aHSCT may be a therapeutic option for children with disease that does not respond to standard care.

Sunday, 26 March 2017

#ClinicSpeak & NeuroSpeak: MS drugs and your mouth

How common are oral side effect in pwMS on medication? #ClinicSpeak #NeuroSpeak #MSBlog

Most pwMS are on poly-pharmacy (multiple prescribed medications) both DMTs and symptomatic treatments. The review article below highlights the problem. It identified 18 oral side effects with dryness of the mouth (xerostomia) being the most common, followed by abnormal taste (dysgeusia), difficulty swallowing (dysphagia), mouth ulceration and sinusitis. The anti-cholinergic drugs were the commonest cause of dry mouth, whilst immunosuppressants resulted in more infection related side-effects.

How common is the problem? In my experience, apart from dry mouth, this is not a major problem. As I don't routinely ask about mouth problems I maybe missing this issue. I you are a medication and have a side effect involving the mouth can you please let us know and we can then set-up a survey to see how common it is? Thank you. 

Cockburn et al. Managing the oral side effects of medications used to treat multiple sclerosis. Aust Dent J. 2017 Mar 9. doi: 10.1111/adj.12510.

BACKGROUND: Many medications used to manage multiple sclerosis (MS) affect oral health. This review aimed to identify the oral side effects of the current drugs recommended in Australia to treat MS and make dental practitioners aware of the range of symptoms.

METHODS: The Australian Therapeutic Guidelines and the Australian Medicines Handbook were searched for medications used to treat MS. For each medication, the generic name, class, route of administration, dosage and drug company reported side-effects were extracted from the online Monthly Index of Medical Specialties (MIMs) database. Meyler's Side Effect of Drugs Encyclopaedia was used to identify any additional oral adverse reactions to medications used to treat MS.

RESULTS: Fourteen drugs were identified for the treatment of MS progression and 13 drugs for the treatment of MS symptoms. For these medications, 18 oral side effects were documented: xerostomia was the most common, followed by dysgeusia, dysphagia, mouth ulceration and sinusitis. Anticholinergic drugs caused xerostomia while immunosuppressants resulted in more infection related side-effects.

CONCLUSIONS: Dental practitioners should be aware of the range of symptoms likely to be reported by this population. Clinicians are encouraged to continue providing dental care for their patients who develop MS and refer complex cases to specialists.

The New Publication Paradigm..Money down the toilet

Historically we would publish our papers in scientific journals. We would donate our work for free and sometimes even pay a page charge to do this.

We would assign copyright to the publishers. They may give you 50-100 reprints for free to give away.

Librabries would take a subscription to the journals and academics could get access to the journals via their library.

The Internet occurred and people have instant access and they don't go to libraries anymore.

However, the People who have the ears of Government and the Research Councils said that work paid for by the Public should be accessible to the Public so they generated the concept of "open access" 

The journals laughed not only could they get you to pay publication fees, get libraries to pay for subscriptions but now they could also charge and open access fee. This can be $1,500-$5,000 per article to get this "Gold open access" so they become accessible right away.

This cost is often only a fraction of the actual cost to do the work

The research councils (NIH equivalent) would pay the open access fee, but now the research councils give a set amount to the universities to pay for this. They give less than the actual cost, so universities loose money or they stop funding this and make you do "Green Open access" where the article is embargoed for some time before a copy of the accepted paper (not the published type set version) is available.

Charities said yes do this but won't pay the fees.

Journals had another laugh, because what they did was set up new open access journals. 

They are common in cases of high impact journals where people send their best work to. The top journal turns the paper down but says that you can submit to their open access journal  for quick reviewing and then pay the open access fee "ker ching".

Importantly it allowed for a load of chancers to set up loads of rubbish open-access journals. You submit a paper to them and then pay for the pleasure of publishing. Ten papers could be $20,000 and all you have to do is house the pdf document on a server as there is no printed version and the work can be typeset in the middle or far East using computer software to increase your profit margin. 
Ker-ching, Ker-ching. They don't even pay to put the work on "Pubmed" so no one is aware of paper. 

They invite you submit (we get loads of these each day) and them charge you. Like mugs some people do this. They are desperate to fill their pages and publish any old c**p. 

They also think of loads of titles to make new journal sound like existing good ones so the "Journal of Immunology" could become a new Immunology Journal or International Journal of Immunology.

Today, I got a request to submit to the "Annals of multiple sclerosis and related disorder". 

Wonder what the editors of "Anals of Neurology" and "Multiple Sclerosis and related Disorders think about i?

What next "Multiple Sclerosis and related Disorders journal"

Is this a waste of money?

Saturday, 25 March 2017

#CarerSpeak & #ClinicSpeak: child carers

Austerity Britain and the army of child carers. What should we do? #ClinicSpeak #MSBlog #CarerSpeak

#CarerSpeak is the new label or #tag for posts of direct relevance to MS carers

"Dear Professor Giovannoni, Can you help? I am 14 and I care for my Mum. Her multiple sclerosis is getting worse and I now have to spend most of my time looking after her. I have to prepare her tablets for her each day and remind her to take them. I have started to send her text reminders from school otherwise she forgets to take her lunchtime tablets. When I get home from school I often have to clean-up the mess she has made. My father left us when I was 9 and my aunts and uncles live near Liverpool. My mother does not want help and wants us to cope. Mum is unable to walk down the stairs and has taken to hopping down the stairs on her bum. The other day she slipped and slid down the stairs on her back. She got a carpet burn and now has a row of sores over her spine. I worry about leaving her at home when I go to school."

The scenario above is just one of many I have encountered over the years as a MS expert. There is literally an army of child carers out there looking after disabled parents with chronic diseases. As austerity bites, and social care budgets get squeezed, the number of children in this position will increase. The study below highlights the issue; compared with children of ‘healthy’ parents, children of a parent with MS report all of the issues raised in the case above; they have lower life satisfaction and are less likely to be happy (positive affect). As predicted, better adjustment in children of a parent with MS was related to higher levels of social support, lower stress, greater reliance on approach coping strategies (problem solving, seeking support and acceptance) and less reliance on avoidant coping (wishful thinking and denial). 

JLS met up with young carers who look after relatives suffering from multiple sclerosis.

We realise there is a massive unmet need out there to help adolescents of pwMS and are in the discussion phase of designing a course specifically targeting teenagers of pwMS. If you have been engaged with a course like this before we would be interested to hear from you; what was good and bad? Any suggestions are welcome. If you have MS and teenage children would you enrol them on a course to learn more about MS and more importantly would they attend? 

Pakenham & Bursnall. Relations between social support, appraisal and coping and both positive and negative outcomes for children of a parent with multiple sclerosis and comparisons with children of healthy parents. Clinical Rehabilitation  2006 Vol 20, Issue 8, pp. 709 - 723.

Objective: To examine adjustment in children of a parent with multiple sclerosis within a stress and coping framework and compare them with those who have ‘healthy’ parents.

Subjects: A total of 193 participants between 10 and 25 years completed questionnaires; 48 youngsters who had a parent with multiple sclerosis and 145 youngsters who reported that they did not have a parent with an illness or disability.

Method: A questionnaire survey methodology was used. Variable sets included caregiving context (e.g. additional parental illness, family responsibilities, parental functional impairment, choice in helping), social support (network size, satisfaction), stress appraisal, coping (problem solving, seeking support, acceptance, wishful thinking, denial), and positive (life satisfaction, positive affect, benefits) and negative (distress, health) adjustment outcomes.

Results: Caregiving context variables significantly correlated with poorer adjustment in children of a parent with multiple sclerosis included additional parental illness, higher family responsibilities, parental functional impairment and unpredictability of the parent's multiple sclerosis, and less choice in helping. As predicted, better adjustment in children of a parent with multiple sclerosis was related to higher levels of social support, lower stress appraisals, greater reliance on approach coping strategies (problem solving, seeking support and acceptance) and less reliance on avoidant coping (wishful thinking and denial). Compared with children of ‘healthy’ parents, children of a parent with multiple sclerosis reported greater family responsibilities, less reliance on problem solving and seeking social support coping, higher somatization and lower life satisfaction and positive affect.

Conclusions: Findings delineate the key impacts of young caregiving and support a stress and coping model of adjustment in children of a parent with multiple sclerosis.

MS lymphocytes making new myelin

El Behi M, Sanson C, Bachelin C, Guillot-Noël L, Fransson J, Stankoff B, Maillart E, Sarrazin N, Guillemot V, Abdi H, Cournu-Rebeix I, Fontaine B, Zujovic V.
Brain. 2017. doi: 10.1093/brain/awx008. [Epub ahead of print]

One major challenge in multiple sclerosis is to understand the cellular and molecular mechanisms leading to disease severity progression. The recently demonstrated correlation between disease severity and remyelination emphasizes the importance of identifying factors leading to a favourable outcome. Why remyelination fails or succeeds in multiple sclerosis patients remains largely unknown, mainly because remyelination has never been studied within a humanized pathological context that would recapitulate major events in plaque formation such as infiltration of inflammatory cells. 

Therefore, we developed a new paradigm by grafting healthy donor or multiple sclerosis patient lymphocytes in the demyelinated lesion of nude mice spinal cord. We show that lymphocytes play a major role in remyelination whose efficacy is significantly decreased in mice grafted with multiple sclerosis lymphocytes compared to those grafted with healthy donors lymphocytes. 

Mechanistically, we demonstrated in vitro that lymphocyte-derived mediators influenced differentiation of oligodendrocyte precursor cells through a crosstalk with microglial cells. Among mice grafted with lymphocytes from different patients, we observed diverse remyelination patterns reproducing for the first time the heterogeneity observed in multiple sclerosis patients. 

Comparing lymphocyte secretory profile from patients exhibiting high and low remyelination ability, we identified novel molecules involved in oligodendrocyte precursor cell differentiation and validated CCL19 as a target to improve remyelination. 

Specifically, exogenous CCL19 abolished oligodendrocyte precursor cell differentiation observed in patients with high remyelination pattern. Multiple sclerosis lymphocytes exhibit intrinsic capacities to coordinate myelin repair and further investigation on patients with high remyelination capacities will provide new pro-regenerative strategies.

Last week we had the story that Treg cells produced a molecule that promoted remyelination and this week we have something similar but they take human cells and inject them into a nude mouse.

A nude mouse is a mutant mouse that does not make hair, but they also do not make T cells and so they can't reject human cells that are transplanted into the mouse. They injected a toxin to make demyelinated lesion as the toxin kills oligodendrocytes.

They then inject human cells, which they have activated,into the mice and find that they promote repair. As the mice were not genetically engineered e.g. to be MHC compatible, the T cells would not be able to talk to the lymphocytes. They go a test bleed from the eye by putting a needle into the retro-orbital sinus, which was banned (as their are alternatives) in the UK about 25 years ago, to check the cells are still present. They find there is variability in the repair potential, They found that MS blood cells demonstrate that multiple sclerosis lymphocytes did not interfere with OPC recruitment, but impeded OPC differentiation. This had an effect of via microglial cells and when they looked at 72 secreted molecule they found differences in three IL-7 and IL-20 which are immune growth factors and CCL-19 which is a protein that attracts cells called a chemokine. The latter was lower from people with MS. 
Taking advantage of our innovative in vivo model to study the role of human lymphocytes in remyelination, we demonstrated a strong implication of adaptive immune cells in this repair process. In particular, multiple sclerosis patient lymphocytes induce detrimental environment for the repair process notably by directing MIGs toward a pro-inflammatory M1 phenotype. Strikingly, the molecular cues needed for a successful remyelination were different when considering multiple sclerosis patient and healthy donor lymphocytes

Friday, 24 March 2017

#PoliticalSpeak: impact or lack of impact

Why has academia become so bureaucratic? #PoliticalSpeak #MSBlog

Life as an academic is becoming increasingly complicated and frustrating; I spend an extraordinary amount of time doing administration. We have been asked to start preparing for the next REF, which is likely to be in 2020, and need your help. 

In the UK academic institutions are assessed every 6-7 years as part of the Research Excellence Framework exercise or REF. As part of this assessment we have to provide 'impact case studies' demonstrating the impact of our research on wider society. Impact is defined as ‘an effect on, change or benefit to the economy, society, culture, public policy or services, health, the environment or quality of life, beyond academia’.

We had an informal discussion yesterday about what academic activities we are engaged in have impact and how can we show impact. If we have to submit an impact statement next REF we will need to be able to demonstrate how we are having impact with the relevant metrics, etc. As you are quite close to our activities you could help us prioritise our efforts so that we can focus on the academic activities that are most likely to succeed. This exercise will also help focus our minds as a group. Thank you. 

CoI: multiple

More on B cells.We don't all have the same ideas. Who is right?

We don't normally report on reviews. But we have a couple of recent ones

Nguyen AL, Gresle M, Marshall T, Butzkueven H, Field J. "Monoclonal antibodies in the treatment of MS: emergence of B-cell targeted therapies". Br J Pharmacol. 2017 Mar 20. doi: 10.1111/bph.13780. [Epub ahead of print]

Multiple sclerosis (MS) is a chronic inflammatory disease of the CNS, and one of the most common causes of disability in young adults. Over the last decade, new disease modifying therapies have rapidly emerged, including monoclonal antibodies (mAbs) that have provided highly targeted therapies with superior efficacy compared to platform therapies. In particular, monoclonal antibodies directed against CD20-positive B cells have shown remarkable results in recent clinical trials, and renewed interest in the mechanism of B-cell depleting therapies to ameliorate relapse activity and progression in MS. In this manuscript, we will review the mechanisms of action and clinical evidence of approved and emerging mAbs, with a focus on B-cell targeted therapies

We did the same but came to very different conclusion.
Here it is all to do with B cell regulatory function rather 
than B memory function.

If you work in percentages if one goes down (Memory B cell subsets) the others (Regulatory B cells) must go up.

However in some cases because we have tried to work with absolute numbers we know that B memory cells go down

We have recently published 
our first part of the original series of papers written 
just before Christmas.
The last part of the originally submitted studies 
actually surfaced first

Baker D, Marta M, Pryce G, Giovannoni G, Schmierer K.
EBioMedicine. 2017 Feb;16:41-50. doi: 10.1016/j.ebiom.2017.01.042

This has gained some Interest on the Blog as it becomes evident that this subset of Bcells is infected by Epstein Barr Virus.

Maybe there are alternative explanations to the view that B cells help T cells do it all.

Following dogma can lead us down a garden path, as we will see as the next part of the equation eventually surfaces.

However, this thought does not even occur on some people's radar
So here is a standard view

Ocrelizumab in multiple sclerosis: markers and mechanisms.
Hohlfeld R, Meinl E. Lancet Neurol. 2017;16(4):259-261.

They say

"Anti-CD20 therapy acutely depletes CD20+ cells in the periphery, but only causes a delayed and modest decline of circulating antibodies.CSF studies with rituximab revealed decreased T-cell and B-cell counts, whereas intrathecal IgG production was relatively spared. For these reasons, depletion of pathogenic antibodies might not be the dominant mechanism of action of ocrelizumab in multiple sclerosis, although this cannot be totally excluded". 

"Overall, it seems plausible that anti-CD20 therapy partly acts by eliminating the potent antigen-presenting function of B cells, a view supported by animal experiments. Furthermore, B cells produce many pro-inflammatory and anti-inflammatory cytokines. Profound B-cell depletion might therefore lead to changes in the cytokine network, dampening pathogenic T-cell responses and thereby contributing to the beneficial effect of anti-CD20 therapy in multiple sclerosis".

"Lastly, it should be noted that anti-CD20 therapy is not entirely specific for B cells, as it also depletes CD20+ T cells, which are about 5% of blood T cells".

Whilst our review accommodates all these views, it gives an opinion and then it puts the focus in a very different direction. As memory B cells are not really mentioned. However, again we see that animal studies again tell us how MS drugs work. 

Although I am aware that the animal studies support such a mechanism, I personally think the data from treatment of animals with anti-CD20 is weak. 

Should we do a critique of the animal data? 

If the animal data is on shaky ground, where does it leave the hypothesis?