Bimonthly assessment of magnetization transfer magnetic resonance imaging parameters in multiple sclerosis: a 14-month, multicentre, follow-up study.

This study was performed to assess the temporal evolution of damage within lesions and the normal-appearing white matter, measured using frequent magnetization transfer (MT) MRI, in relapsing-remitting multiple sclerosis (RRMS). The relationship of MT ratio (MTR) changes with measures of lesion burden, and the sample sizes needed to demonstrate a treatment effect on MTR metrics in placebo-controlled MS trials were also investigated. Bimonthly brain conventional and MT MRI scans were acquired from 42 patients with RRMS enrolled in the placebo arm of a 14-month, double-blind trial. Longitudinal MRI changes were evaluated using a random effect linear model accounting for repeated measures, and adjusted for centre effects. The Expanded Disability Status Scale (EDSS) score remained stable over the study period. A weak, but not statistically significant, decrease over time was detected for normal-appearing brain tissue (NABT) average MTR (-0.02% per visit; p = 0.14), and MTR peak height (-0.15 per visit; p = 0.17), while average lesion MTR showed a significant decrease over the study period (-0.07% per visit; p = 0.03). At each visit, all MTR variables were significantly correlated with T2 lesion volume (LV) (average coefficients of correlation ranging from -0.54 to -0.28, and p-values from <0.001 to 0.02). At each visit, NABT average MTR was also significantly correlated with T1-hypointense LV (average coefficient of correlation = -0.57, p < 0.001). The estimation of the sample sizes required to demonstrate a reduction of average lesion MTR (the only parameter with a significant decrease over the follow-up) ranged from 101 to 154 patients to detect a treatment effect of 50% in a 1-year trial with a power of 90%. The steady correlation observed between conventional and MT MRI measures over time supports the hypothesis of axonal degeneration of fibres passing through focal lesions as one of the factors contributing to the overall MS burden.

Modulation of serum uric acid levels by inosine in patients with multiple sclerosis does not affect blood pressure.

The role of uric acid (UA) in human physiology is subject to controversy. Either it is an important radical scavenger, a mostly neutral, waste metabolic product that may cause gout and kidney stones if elevated, or it is involved in the causation of hypertension, vascular and renal diseases. Recently we conducted a clinical trial to determine whether raising the serum UA levels through the oral administration of inosine is well tolerated and may benefit patients with multiple sclerosis. An important aspect of the safety profile is whether raising the serum UA levels elevates blood pressure. During the 1-year trial, blood pressure and serum UA levels were monitored in 16 patients. Both parameters were recorded throughout the trial that included 69 visits by patients at baseline and during the placebo phase as well as 138 visits while receiving inosine treatment. We have observed that although the serum UA levels increased significantly during the inosine treatment phase of the trial, from 4.2+/-0.8 to 7.1+/-1.7 mg per 100 ml, blood pressure remained unchanged, averaging 123+/-15/78+/-9. Our findings indicate that raising the serum UA levels to upper normal physiological levels for a period of up to 1-year does not influence blood pressure significantly.

Vision related quality of life in multiple sclerosis: correlation with new measures of low and high contrast letter acuity.

OBJECTIVE: To examine the relation between low contrast letter acuity, a new visual function test for multiple sclerosis (MS) trials, and vision targeted health related quality of life (HRQOL). METHODS: Patients in this cross sectional study were part of an ongoing investigation of visual function in MS. Patients were tested binocularly using low contrast letter acuity and Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity (VA) charts. The 25 Item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25), 10 Item Neuro-Ophthalmic Supplement to the NEI-VFQ-25, Impact of Visual Impairment Scale and Short Form 36 Health Survey (SF-36) were administered. RESULTS: Among 167 patients, mean age was 48 (10) years, with median Expanded Disability Status Scale (EDSS) 2.0 (range 1.0-7.5), and median binocular Snellen acuity equivalent (ETDRS charts) 20/16 (range 20/12.5 to 20/100). Reductions in vision specific HRQOL were associated with lower (worse) scores for low contrast letter acuity and VA (p<0.001, linear regression, accounting for age). Two line differences in visual function were associated, on average, with >4 point (6.7-10.9 point) worsening in the NEI-VFQ-25 composite score, reductions that are considered clinically meaningful. Scores for the 10 Item Neuro-Ophthalmic Supplement to the NEI-VFQ-25 also correlated well with visual function. Associations between reduced low contrast acuity and worse vision targeted HRQOL remained significant in models accounting for high contrast VA, EDSS and history of acute optic neuritis. CONCLUSIONS: Low contrast letter acuity scores correlate well with HRQOL in MS. Two line differences in scores for low contrast acuity and VA reflect clinically meaningful differences in vision targeted HRQOL. Low contrast acuity testing provides information on patient reported aspects of vision, supporting use of these measures in MS clinical trials.

Relation of vision to global and regional brain MRI in multiple sclerosis.

OBJECTIVE: To examine the relation between low-contrast letter acuity, an emerging visual outcome for multiple sclerosis (MS) clinical trials, and brain MRI abnormalities in an MS cohort. METHODS: T2 lesion volume and brain parenchymal fraction were determined for whole brain and within visual pathway regions of interest. Magnetization transfer ratio histograms were examined. Vision testing was performed binocularly using low-contrast letter acuity (2.5%, 1.25% contrast) and high-contrast visual acuity (VA). Linear regression, accounting for age and disease duration, was used to assess the relation between vision and MRI measures. RESULTS: Patients (n = 45) were aged 44 +/- 11 years, with disease duration of 5 years (range <1 to 21), Expanded Disability Status Scale score of 2.0 (0 to 6.0), and binocular Snellen acuity of 20/16 (20/12.5 to 20/25). The average T2 lesion volume was 18.5 mm(3). Patients with lower (worse) low-contrast letter acuity and high-contrast VA scores had greater T2 lesion volumes in whole brain (2.5% contrast: p = 0.004; 1.25%: p = 0.002; VA: p = 0.04), Area 17 white matter (2.5%: p < 0.001; 1.25%: p = 0.02; VA: p = 0.01), and optic radiations (2.5%: p = 0.001; 1.25%: p = 0.02; VA: p = 0.007). Within whole brain, a 3-mm(3) increase in lesion volume corresponded, on average, to a 1-line worsening of low-contrast acuity, whereas 1-line worsening of high-contrast acuity corresponded to a 5.5-mm(3) increase. CONCLUSIONS: Low-contrast letter acuity scores correlate well with brain MRI lesion burden in multiple sclerosis (MS), supporting validity for this vision test as a candidate for clinical trials. Disease in the postgeniculate white matter is a likely contributor to visual dysfunction in MS that may be independent of acute optic neuritis history.

Neuronal cell injury precedes brain atrophy in multiple sclerosis.

Global brain atrophy estimated using MRI and whole brain N-acetylaspartate (WBNAA) concentration measured with proton MR spectroscopy were obtained in 42 patients with relapsing-remitting multiple sclerosis and 41 matched control subjects. Patients exhibited cross-sectional atrophy (0.5%; p = 0.033) and WBNAA decline (1.8%/y; p = 0.005) vs disease duration. The 3.6-fold rate disparity between the two processes suggests that neuronal/axonal dysfunction (N-acetylaspartate decline) precedes parenchyma loss, not its consequence (i.e., is an earlier, more sensitive specific metric of the ongoing disease activity).

Contrast letter acuity as a visual component for the Multiple Sclerosis Functional Composite.

BACKGROUND: Visual dysfunction is one of the most common causes of disability in multiple sclerosis (MS). The Multiple Sclerosis Functional Composite (MSFC), a new clinical trial outcome measure, does not currently include a test of visual function. OBJECTIVE: To examine contrast letter acuity as a candidate visual function test for the MSFC. METHODS: Binocular contrast letter acuity testing (Sloan charts) was performed in a subgroup of participants from the International Multiple Sclerosis Secondary Progressive Avonex Controlled Trial (IMPACT Substudy) and in MS patients and disease-free control subjects from a cross-sectional study of visual outcome measures (Multiple Sclerosis Vision Prospective cohort [MVP cohort]). High-contrast visual acuity was measured in both studies; MVP cohort participants underwent additional binocular testing for contrast sensitivity (Pelli-Robson chart), color vision (D-15 desaturated test), and visual field (Esterman test, Humphrey Field Analyzer II). RESULTS: Contrast letter acuity (Sloan charts, p < 0.0001, receiver operating characteristic curve analysis) and contrast sensitivity (Pelli-Robson chart, p = 0.003) best distinguished MS patients from disease-free control subjects in the MVP cohort. Correlations of Sloan chart scores with MSFC and Expanded Disability Statue Scale (EDSS) scores in both studies were significant and moderate in magnitude, demonstrating that Sloan chart scores reflect visual and neurologic dysfunction not entirely captured by the EDSS or MSFC. CONCLUSIONS: Among clinical measures, contrast letter acuity (Sloan charts) and contrast sensitivity (Pelli-Robson chart) demonstrate the greatest capacity to identify binocular visual dysfunction in MS. Sloan chart testing also captures unique aspects of neurologic dysfunction not captured by current EDSS or MSFC components, making it a strong candidate visual function test for the MSFC.

Evaluating the impact of facilitated communication on the communicative competence of fourteen students with autism.

The purpose of this study was to evaluate facilitated communication (FC) as an augmentative or alternative communication system for 14 students attending the Eden Institute in Princeton, NJ. All participants had an independent diagnosis of autism and standardized testing revealed significant deficits in adaptive behavior across all developmental domains. A pretest-posttest design was utilized to (a) determine if any of the participants were immediately capable of communicating through FC (b) if necessary, instruct the participants in the use FC, and (c) determine if this instruction had any impact on their ability to use FC. At the end of 10 weeks of instruction, no participants were able to produce functional, typed communication. Findings are consistent with other quantitative studies that find no support for the cause-effect relationship proposed by FC proponents.

Effect of opioid receptor antagonism on proopiomelanocortin peptide levels and gene expression in the hypothalamus.

In order to determine how brain beta-endorphin (beta-EP) and its precursor proopiomelanocortin (POMC) adapt to chronic opioid blockade we have examined the effects of treatment with the opioid receptor antagonist naltrexone (NTX) on POMC gene expression and peptide levels in the hypothalamus. Male rats were treated with NTX by daily injection or constant minipump infusion. RNA was isolated from the medial basal hypothalamus (MBH) after an aliquot was removed for peptide RIA and the amount of POMC mRNA was measured by solution hybridization SI nuclease protection assay. beta-EP and several other POMC-derived peptides including alpha-melanocyte-stimulating hormone (alpha-MSH) and corticotropin-like intermediate lobe peptide (CLIP) or gamma(3)-MSH were measured in the MBH and anterior hypothalamus (AH) by RIA. In an initial experiment POMC peptide levels were measured after 7 days of NTX (4.8 mg/day) infusion. There was a marked fall in the concentrations of beta-EP, alpha-MSH, and CLIP; levels in the MBH declined by more than 60% (P < 0.001). In the next experiment NTX (1 mg) was injected daily and POMC peptides and mRNA were measured after 2 and 5 days of treatment. (beta-EP) and alpha-MSH levels fell progressively in the MBH and AH and were significantly less than those of the controls by 5 days of treatment (P < 0.02). POMC mRNA levels, however, did not change after 2 or 5 days. When NTX was infused for 3 weeks there was a decrease in the concentrations of beta-EP, alpha-MSH, and gamma(3)-MSH in the MBH (P < 0.001). The concentration of POMC mRNA in the MBH, however, was significantly higher in the NTX-treated animals, 0.99 +/- 0.06 pg/mug RNA vs 0.81 +/- 0.05 pg/mug RNA (P < 0.05). Since NTX can affect LH and testosterone release, the study was repeated in castrated rats. POMC peptide levels again fell after 3 weeks of NTX. POMC mRNA levels were higher in the castrated rats than in the intact rats, 1.14 +/- 0.06 pg/mug RNA vs 0.85 +/- 0.09 pg/mug RNA (P < 0.05), consistent with our previous findings in longterm castrated rats. However POMC mRNA increased further to 1.40 +/- 0.09 pg/mug RNA in the castrated animals treated with NTX (P < 0.05). We conclude that opioid receptor blockade has significant effects on POMC peptide levels and gene expression in the MBH. The increase in POMC gene expression associated with a fall in peptide levels is consistent with a compensatory increase in brain beta-EP synthesis and release in the setting of chronic opioid receptor blockade.

Antagonism of beta-endorphin-induced prolactin release by alpha-melanocyte-stimulating hormone and corticotropin-like intermediate lobe peptide.

The ability of two proopiomelanocortin-derived peptides, alpha MSH and corticotropin-like intermediate lobe peptide (CLIP) [ACTH (18-39)] to antagonize the stimulation of PRL secretion by beta-endorphin (beta EP) was studied in the rat. When 50 ng beta EP were injected into the lateral cerebral ventricle, plasma PRL rose from a mean baseline of 1.87 +/- 0.43 ng/ml (+/- SEM) to a peak of 23.0 +/- 3.67 ng/ml 10 min after the injection. When the same animals received 500 ng alpha MSH together with 50 ng beta EP, the peak concentration of PRL was reduced by 74% to 6.05 +/- 1.43 ng/ml (P less than 0.005). After the injection of 500 ng CLIP together with 500 ng beta EP, the peak concentration of PRL was reduced by 47% to 12.8 +/- 3.09 ng/ml (P less than 0.01). Total PRL release, determined by calculating the areas under the plasma PRL concentration curves, was also significantly reduced by the injection of alpha MSH or CLIP. A dose of 100 ng alpha-MSH or CLIP also antagonized the stimulation of PRL secretion by 50 ng beta EP. PRL release was reduced by 62% after administration of 100 ng alpha MSH (P less than 0.001) and by 43% after 100 ng CLIP (P less than 0.05). When 100 ng alpha MSH and 100 ng CLIP were injected together, there was an additive effect in blocking the stimulation of PRL release by beta EP, and the peak plasma PRL concentration was reduced by 81%. Des-acetyl alpha MSH, the predominant form of alpha MSH in the hypothalamus, was also very effective in antagonizing beta EP-induced PRL release. The peak PRL concentration was reduced by 52% after administration of 100 ng des-acetyl alpha MSH plus 50 ng beta EP compared with that after beta EP alone (P less than 0.005). We conclude that relatively low doses of both alpha MSH and CLIP can effectively antagonize the actions of beta EP on pituitary PRL release. These findings suggest the possibility that differential posttranslational processing of proopiomelanocortin may serve as a regulator of anterior pituitary function.