Autologous haematopoietic stem cell transplantation with an intermediate intensity conditioning regimen in multiple sclerosis: the Italian multi-centre experience.

BACKGROUND: Over recent years numerous patients with severe forms of multiple sclerosis (MS) refractory to conventional therapies have been treated with intense immunosuppression followed by autologous haematopoietic stem cell transplantation (AHSCT). The clinical outcome and the toxicity of AHSCT can be diverse, depending on the various types of conditioning protocols and on the disease phase. OBJECTIVES: To report the Italian experience on all the consecutive patients with MS treated with AHSCT with an intermediate intensity conditioning regimen, named BEAM/ATG, in the period from 1996 to 2008. METHODS: Clinical and magnetic resonance imaging outcomes of 74 patients were collected after a median follow-up period of 48.3 (range = 0.8-126) months. RESULTS: Two patients (2.7%) died from transplant-related causes. After 5 years, 66% of patients remained stable or improved. Among patients with a follow-up longer than 1 year, eight out of 25 subjects with a relapsing-remitting course (31%) had a 6-12 months confirmed Expanded Disability Status Scale improvement > 1 point after AHSCT as compared with one out of 36 (3%) patients with a secondary progressive disease course (p = 0.009). Among the 18 cases with a follow-up longer than 7 years, eight (44%) remained stable or had a sustained improvement while 10 (56%), after an initial period of stabilization or improvement with median duration of 3.5 years, showed a slow disability progression. CONCLUSIONS: This study shows that AHSCT with a BEAM/ATG conditioning regimen has a sustained effect in suppressing disease progression in aggressive MS cases unresponsive to conventional therapies. It can also cause a sustained clinical improvement, especially if treated subjects are still in the relapsing-remitting phase of the disease.

Modeling the cell cycle: from deterministic models to hybrid systems.

The cell cycle is a complex biological system frequently investigated from a mathematical perspective. In fact, over the past years a huge number of deterministic mathematical models describing the dynamics and the regulation of this process have been proposed. A crucial point concerning the cell cycle modeling is the combination of continuous and discrete dynamics in order to obtain results which are coherent with the biological context. To face with this problem we propose a novel approach to the mathematical modeling of biological processes based on the use of hybrid systems. This new methodology essentially consists in a model reduction (using the modified Prony's method) which allows to define the crucial features of the dynamical system. The final aim is to implement a corresponding hybrid system which preserves the properties of the starting deterministic model. Thus, we implemented a methodology which allows to describe the cellular system by combining continuous behavior with discrete events by using the hybrid automata technology. In this way we try to overcome some drawbacks of the deterministic approach, especially regarding the possibility to introduce new variables during simulation and the associated variation of parameters in a more efficient way than the continuous method can do. We applied this innovative methodology to the reconstruction of a simplified hybrid model concerning one of the crucial mammalian cell cycle control point. In particular, we investigated the role of the transcription factors E2F in the R-point transition. The resulting hybrid model preserve the properties of the deterministic one and it allows the identification of the parameter which controls the transition from the inactive (quiescent) to the active state (R-point transition) after the mitogenic stimulation. At the best of our knowledge no hybrid model for the R-point transition are available in literature.

Autologous stem cell transplantation for progressive multiple sclerosis: update of the European Group for Blood and Marrow Transplantation autoimmune diseases working party database.

Over the last decade, hematopoietic stem cells transplantation (HSCT) has been increasingly used in the treatment of severe progressive autoimmune diseases. We report a retrospective survey of 183 multiple sclerosis (MS) patients, recorded in the database of the European Blood and Marrow Transplantation Group (EBMT). Transplant data were available from 178 patients who received an autologous graft. Overall, transplant related mortality (TRM) was 5.3% and was restricted to the period 1995-2000, with no further TRM reported since then. Busulphan-based regimens were significantly associated with TRM. Clinical status at the time of transplant and transplant techniques showed some correlations with toxicity. No toxic deaths were reported among the 53 patients treated with the BEAM (carmustine, etoposide, cytosine-arabinoside, melphalan)/antithymocyte globulin (ATG) regimen without graft manipulation, irrespective of their clinical condition at the time of the transplant. Improvement or stabilization of neurological conditions occurred in 63% of patients at a median follow-up of 41.7 months, and was not associated with the intensity of the conditioning regimen. In this large series, HSCT was shown as a promising procedure to slow down progression in a subset of patients affected by severe, progressive MS; the safety and feasibility of the procedure can be significantly improved by appropriate patient selection and choice of transplant regimen.

[Psychological issues related to multiple sclerosis]. / Aspetti psicologici dello sclerosi multipla.

This study sought to investigate some psychological issues related to multiple sclerosis (MS), in particular, the relations existing between illness representations, personality factors and coping strategies and, consequently, the specific coping strategies employed in adjusting emotionally to MS. Sixty-nine MS patients attending the University Polyclinic of Modena were administered the following battery: a questionnaire regarding demographic and illness features, the Illness Perception Questionnaire-Revised (IPQ-R), the Coping Orientations to Problems Experienced Questionnaire (COPE) and Cognitive Behavioural Assessment Hospital Form (CBA-H). Patients' physical disability level was also evaluated using the Expanded Disability Status Scale (EDSS). Results suggest that personality factors and patients' perception of their illness play an important role in activating one or other type of coping strategy. Regarding problem-focused coping strategies, the most significant predictors that emerged from stepwise linear multiple regression analysis were perception of the disease as cyclical (timeline cyclical dimension) and a low score in neuroticism, indicating good emotional stability of the subject. For emotion-centered coping strategies, the regression model identified as best predictors: the belief that chance or bad luck are the most important causes of the illness, perception of the disease as cyclical, extroversion and a cooperative mode of interacting with others, and the presence of interpersonal difficulties. Finally, with regard to disadaptive coping strategies, the best predictors resulting from the analysis were, once again, perception of the disease as cyclical, and interpersonal difficulties.

Psychiatric disorders and depression in multiple sclerosis outpatients: impact of disability and interferon beta therapy.

Associations between psychopathology and gender, duration of MS, disability and therapy with beta-interferons were studied in multiple sclerosis (MS) outpatients. A controlled descriptive epidemiological study was carried out in two Italian outpatient MS centres on 50 outpatients with clinically definite relapsing-remitting MS presenting for regular follow-up and 50 healthy controls matched for sex, age and educational level. Subjects were assessed with the Structured Clinical Interview for DSM-IV (SCID I), the Beck Depression Inventory (BDI) and the State Trait Anxiety Inventory (STAI). MS patients reported a higher prevalence of psychiatric disorders (odds ratio 3.17), with 46% (n=23) suffering from major depressive disorder. The risk of suffering from any non-mood psychiatric disorder was also higher in MS patients than in controls (odds ratio 2.67). Risk factors for depression were female sex and severity of disability, but not therapy with interferon beta or longer duration of illness. Disability level, but not therapy with beta-interferons, is a risk factor for depression in MS outpatients. Regular screening for depression in this population is appropriate.

Intense immunosuppression followed by autologous stem cell transplantation in severe multiple sclerosis.

Aggressive forms of multiple sclerosis (MS) represent a limited group of demyelinating diseases that rapidly progress to severe disability. Currently available therapies are poorly effective against these clinical entities. Recently, it has been demonstrated that intense immunosuppression followed by autologous haematopoietic stem cell transplantation (AHSCT) can affect the clinical course of individuals with severe MS and completely abrogate the inflammatory activity detected by MRI. We report the result of the Italian phase 2 GITMO study, a multicentre study in which 21 MS patients, who were rapidly deteriorating and not responding to the usual therapeutic strategies, were treated with this procedure. The clinical effect of the treatment is long lasting, with a striking abrogation of inflammation detected by MRI findings. These results support a role for intense immunosuppression followed by ASCT as treatment in rapidly evolving MS cases unresponsive to conventional therapies.

Is serum neopterin level a marker of responsiveness to interferon beta-1a therapy in multiple sclerosis?

BACKGROUND: Interferon beta (INFbeta) may induce the expression of several proteins, including neopterin, considered a biological marker of INFbeta activity. OBJECTIVES: The aim of this study was to determine the serum neopterin concentration at the beginning of, and during, IFNbeta-1a therapy in relapsing-remitting multiple sclerosis (r-r MS) patients, and to look for a possible correlation between protein synthesis and the clinical course of the disease. METHODS: Thirteen r-r MS patients were treated with INFbeta-1a (i.m. 6 MIU/week) for 2 years. Blood samples for neopterin determinations were taken daily over a period of 1 week at the end of each 6 months of therapy, and tested for neutralizing antibodies (NABs). RESULTS: Neopterin levels peaked 24-48 h post-injection and returned to baseline after 120 h. After 1 year of therapy, four patients dropped out of the study because of progression of the disease: in these subjects a significant decrement of neopterin was observed. CONCLUSION: Neopterin baseline values were not found to decrease over the 2 years of therapy, and neopterin may be considered to be a useful marker of responsiveness to IFNbeta.

Monofocal acute large demyelinating lesion mimicking brain glioma.

We report the case of a 34-year-old woman with clinical, neuroradiological and intraoperative histological findings, suggesting a low-grade astrocytic tumour. The demyelinating nature of the lesion was established through biopsy only after neurosurgery. The lesion size, in fact, greatly exceeded that of the perivenous demyelination seen in typical multiple sclerosis (MS) and tended to present as a space-occupying mass. This case underlines the importance of considering demyelinating isolated lesions in the differential diagnosis of a brain mass. Since misdiagnosis can result in unwarranted and aggressive therapy, it is critical for the neurologist to be aware of this serious diagnostic pitfall.

Acute disseminated encephalomyelitis associated with hepatitis C virus infection.

BACKGROUND: Acute disseminated encephalomyelitis (ADEM) is an autoimmune demyelinating disease of the central nervous system that is frequently preceded by an acute viral infection. This is the first reported case of ADEM associated with hepatitis C virus (HCV) infection. CASE DESCRIPTION: A 46-year-old woman underwent a surgical procedure and received multiple blood transfusions, at which time serologic testing for HCV was negative. Fifty days later, she suddenly developed seizures, alteration of consciousness, right hemiparesis, hemianopsia, and urinary retention. Magnetic resonance imaging revealed symmetric multifocal changes on T2-weighted images in the cerebral gray and white matter and in the cerebellar white matter with some lesion enhancement after gadolinium administration. Blood testing showed a recent HCV infection with high titer of IgM early antigens and a strongly positive reaction for HCV RNA. All other microbiological and virological test results were negative both in serum and in cerebrospinal fluid. Treatment with high-dose dexamethasone was followed by a dramatic improvement of the clinical and magnetic resonance picture. Within a few months the patient recovered completely and there were no relapses during 2 years of follow-up. CONCLUSIONS: Infection with HCV is associated with several autoimmune neurological manifestations. It is recommended the patients with ADEM be screened for HCV.

Verbal learning strategies in patients with multiple sclerosis.

Word list learning was studied in patients with a definite diagnosis of Multiple Sclerosis and in Normal Control subjects by means of the selective reminding procedure of Buschke and Fuld in two learning conditions: (1) using unrelated items and (2) paired-associate items. The Multiple Sclerosis patients displayed poor learning in both conditions. To identify the functional locus of their deficit, stochastic Markov chain analyses were performed, which allowed individual measurements of encoding, automatic and intentional retrieval abilities. On both tasks, encoding on the first trial and automatic retrieval on the subsequent trials were impaired in Multiple Sclerosis patients, whereas intentional retrieval, both with and without reminding by the examiner, appeared to be preserved. As all of the impaired abilities require a normal speed of information processing, the salient learning deficit of the Multiple Sclerosis patients could be tentatively traced back to the slowing down of their mental activity.

Prognostic factors in multiple sclerosis: role of intercurrent infections and vaccinations against influenza and hepatitis B.

Since the first historical description of multiple sclerosis (MS) it has been known that febrile illnesses frequently trigger relapses of the disease. In spite of this knowledge, vaccination against influenza has been hampered for a long period by neurologists on the basis of anecdotal cases of post-vaccination encephalomyelitis. Randomized, double-blind, placebo-controlled studies during the past decade have shown that influenza vaccination of MS patients neither increases the relapse rate nor worsens the course of the disease. In contrast, the reduction of viral infection episodes leads to a lower number of exacerbations of MS. Influenza vaccination is safe and should be recommended to MS patients in order to avoid attacks of the disease. After publication of case reports of hepatitis B (HB) vaccination followed by onset of MS, a media-driven scare campaign mainly in France was conducted. The French health authorities decided to suspend routine vaccination of adolescents in schools, invoking the "principle of precaution". This fact has caused widespread confusion and concern about the HB vaccination. Epidemiological studies in large populations have recently been performed to investigate a possible link between HB vaccination and MS: all results argue against a causal relation between HB vaccine and MS or other demyelinating diseases. Since the vaccination provides complete protection against hepatitis B and its severe long-term complications, the World Health Organization recommends continuing the implementation of the HB vaccination programs.

A successive overrelaxation backpropagation algorithm for neural-network training.

A variation of the classical backpropagation algorithm for neural network training is proposed and convergence is established using the perturbation results of Mangasarian and Solodov. The algorithm is similar to the successive overrelaxation (SOR) algorithm for systems of linear equations and linear complementary problems in using the most recently computed values of the weights to update the values on the remaining arcs.

Human herpes virus 6 and human herpes virus 8 DNA sequences in brains of multiple sclerosis patients, normal adults and children.

In order to determine whether the newly discovered human herpesviruses (HHVs) are involved in multiple sclerosis (MS), we investigated by polymerase chain reaction the presence of specific deoxyribonucleic acid (DNA) sequences belonging to human herpesvirus 6 (HHV-6) and to human herpesvirus 8 (HHV-8), in the peripheral blood mononuclear cells (PBMCs), and in the brain and spinal cord plaques from MS patients. Normal adult and stillborn children's brains were investigated as controls. PBMCs from 56 MS patients contained HHV-6 DNA in only 3 cases and in none were there HHV-8 sequences. The cerebral DNA from 5 MS patients was positive for HHV-8 and not for HHV-6 sequences, while the nervous tissue of one patient who died with neuromyelitis optica was positive for HHV-6 and negative for HHV-8. The brains of 4/8 adult controls were positive for HHV-6, as were 3/8 for HHV-8; none of the 7 stillborn children's cerebral tissue contained HHV-6 sequences, while 2 contained HHV-8 DNA. Although these data do not support a hypothesis that there is a role for these two HHVs in the pathogenesis of MS, nevertheless it may be suggested that (1) the two viruses possess strong neurotropism and the central nervous system seems to be a reservoir for them (2) HHV-6 infection is probably not transmitted maternally, but is acquired later in infancy.

Lesion load quantification in serial MR of early relapsing multiple sclerosis patients in azathioprine treatment. A retrospective study.

Azathioprine (AZA) has a slight but consistent effect on clinical outcome in multiple sclerosis (MS), but very few data are available on magnetic resonance imaging (MRI) changes. We performed a retrospective study aimed to quantify changes of lesion load in two serial proton density weighted MRI sequences (TR 2500, TE 30, 1.5 T) at a mean interval of 2.5 years in 36 relapsing-remitting (RR) MS patients: 19 had been treated with AZA, beside steroids after relapses (AZA group), and 17 had been treated with steroids only (control group). All but 3 patients were in the early phase of the disease. Total lesion area (TLA) was measured by manual outlining method and the arbitrary score proposed by Ormerod (total score) was also calculated from the number and diameter of lesions. Lesion load was the same at baseline, but median percentage difference of TLA between first and second scan was + 15.6% in control, -43.7% in the AZA group (p < 0.05, Mann-Whitney test). The distribution of patients according to TLA change, assuming that an increase or decrease was significant if larger than 50%, was found to be significantly different in favor of AZA-treated patients (chi(2) = 35.92, p < 0.001). These results suggest an effect of AZA treatment on MRI lesion load in early RR MS: a larger prospective study is worthwhile.

Encephalomyeloradiculopathy associated with Epstein-Barr virus: primary infection or reactivation?

INTRODUCTION: Encephalomyeloradiculopathy (EMR) is a new syndrome, characterized by extensive involvement of the nervous system at different levels, including brain, medulla and spinal roots. We describe a patient presenting with prodromal febrile illness, followed by a wide infection of the nervous system with transverse myelitis and less severe meningitis, encephalitis and polyradiculopathy. The patient was treated with high-dose corticosteroids, antibiotics and acyclovir; in spite of therapy his condition improved very slowly, with severe neurological sequelae. MATERIAL AND METHODS: Antiviral antibodies were searched for in serum and cerebrospinal fluid (CSF) by commercially available ELISA kits. Viral investigations were performed by cell culture isolation and search for viral antigens, and genomic nucleic acids were investigated by polymerase chain reaction (PCR). RESULTS: Virological and serological studies evidenced a primary infection by cytomegalovirus (CMV), possibly responsible for the prodromal illness, persisting in the course of the disease. PCR performed in the peripheral blood mononuclear cells (PBMCs), DNA collected early and in the CSF drawn 30 days after the onset of the disease showed Epstein-Barr virus (EBV) DNA. The serum panel of EBV antibodies was typical of an intercurrent virus reactivation, more than of a primary infection. CONCLUSION: EBV is known to be highly infectious for the nervous system, in this case of EMR the presence of DNA sequences in the PBMCs and CSF suggests that EBV plays a role in the development of this newly described syndrome.

An encephalitic episode in a multiple sclerosis patient with human herpesvirus 6 latent infection.

All the human herpesviruses may cause central nervous system (CNS) diseases, including benign aseptic meningitis or fatal encephalitis. It has recently been stated that human herpesvirus 6 (HHV-6) may also be neuropathogenic in children after primary infection, while in the adult, cases of fatal encephalitis have been reported only in immune-compromised hosts such as AIDS patients, and in one case of an immunosuppressed bone marrow transplant patient. We describe a multiple sclerosis (MS) patient, carrier of HHV-6 latent infection, who experienced an acute inflammation of the CNS diagnosed as encephalitis. HHV-6 specific genomic sequences have been detected by PCR in the patient's PBMCs DNA collected before and during the encephalitis. The PCR performed in the CSF in course of the acute episode was positive, while the CSF collected before the encephalitis was negative. This finding is consistent with an acute encephalopathy caused by the reactivation of a HHV-6 latent infection within the CNS, in a patient with altered immune response due to MS.

Targeted integration of human herpesvirus 6 in the p arm of chromosome 17 of human peripheral blood mononuclear cells in vivo.

Out of 64 cases of non-Hodgkin's lymphomas (NHL), 55 cases of Hodgkin's disease (HD) and 31 cases of multiple sclerosis (MS), 2 NHL, 7 HD and 1 MS cases were found positive by polymerase chain reaction (PCR) for the presence of HHV-6 sequences in pathologic lymph nodes of the lymphomas and in peripheral blood mononuclear cells (PBMCs) of MS. A further analysis of the PBMCs of the PCR positive cases by standard Southern blot technique revealed only 2 NHL, 3 HD and 1 MS cases as positive, indicating that these six patients have an unusually high viral copy number in the PBMCs. Restriction analysis, carried out using probes representative of different regions of the virus, showed that three cases retain only a deleted portion of the viral genome. In the remaining three cases a complete viral genome was present, containing the right end sequences in which the rep-like gene, possibly crucial to the viral and cellular life cycle, is located. The analysis by pulsed field gel electrophoresis (PFGE) of the total DNA of the PBMCs obtained directly, without culture from PBMCs of these last three cases (1 NHL, 1 HD, and 1 MS), using the same probes, showed the absence of free viral molecules and the association of viral sequences with high molecular weight DNA. These results are consistent with in vivo integration of the entire virus in the cellular genome. A further study of the same patients with chromosome fluorescence in situ hybridization (FISH) showed in all the three cases the presence of a specific hybridization site, located at the telomeric extremity of the short arm of chromosome 17 (17p13), suggesting that this location is at least a preferred site of an infrequent, but possibly biologically important, integration phenomenon.