Podcasts about episode seventy

We brave the conditions and each other's potential germs heading back to The Trap in Episode SEVENTY! While you are busy washing your hands, we go into week 2 of the MLS season with the Home Team collecting win #2 of the season and a WILD 3-3 match held super late with LAFC and Philly and if they should be holding prime time West Coast games earlier in the evening for a maximum audiences. After the break, we touch impact of the Coronavirus pandemic on the European game as well as the incoming impact to American sports and how the leagues will adjust their schedules to deal with the potential of playing with no fans available to come, the victory of Man United in the 182nd Manchester Derby and MORE in 2UP/2Down Go to ftcutd.myshopify.com and get your namesets ordered for your new 2020 jersey!! Listen, subscribe, and SHARE with your homies and baes on your favorite podcast apps! Don't forget to submit feedback on your apps- we see it and we appreciate it! Send in your shoutouts to us for a chance to be featured on an episode. https://anchor.fm/ftcutdshow/message Follow us on Social Media! Twitter - @FTCUTD Instagram - @FTCUTD Like us on Facebook - FTC #ForTheCulture #cultureoverclub --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/ftcutdshow/message Support this podcast: https://anchor.fm/ftcutdshow/support

Episode SEVENTY of High Top Flip Flops is now live! We had to celebrate this milestone by doing a cross-over episode Lateefa and Hadi, the co-creators/co-hosts of a great new podcast titled 'Two Peas in a Pod'! We had the chance to speak with the two of them about their upbringings - which involved moving around a fair bit and creating communities for themselves in the process. The two of them have known each other for as long as they can remember and have remained friends throughout, leading them to start a podcast to share their lived experiences, and host dialogue on issues that young folks face regularly. Hear us talk about code-switching, Nivake's distaste for dancehall, and where Hadi got his ridiculous instagram handle from (@pakibydaycaribbeanbynight). Make sure to check out Two Peas in a Pod (available EVERYWHERE) and ALSO tune in to Lateefa's bi -weekly radio show hosted on @isoradio. Episode available for listening on itunes podcast app, google play, and soundcloud (video coming soon!) Thanks for listening!

Episode Seventy-nine - Sometimes absolutely everything goes wrong... and that can lead to very real disaster or very absurd situations. Featuring "Waterspout" by Shanna Shotwell and "Weary, Stale, Flat and Unprofitable" by Jason R. Wallace. --Please leave us a rating on iTunes!-- Website: pendantaudio.com Twitter: @pendantweb Facebook: facebook.com/pendantaudio Tumblr: pendantaudio.tumblr.com YouTube: youtube.com/pendantproductions

Episode Seventy-eight - The holidays affect us all in different ways, from the homeless to right jolly old elves! Featuring "The Last Temptation of Hal" by Dave Morgan and "The Reykjavik Accords" by Morgan Z. Sowell. --Please leave us a rating on iTunes!-- Website: pendantaudio.com Twitter: @pendantweb Facebook: facebook.com/pendantaudio Tumblr: pendantaudio.tumblr.com YouTube: youtube.com/pendantproductions

Episode Seventy-seven - Conflict is at the core of the human condition, whether it comes from words and trolls, or from within. Featuring "Word Wars" by Landon Beall and "Smores" by Anna Rodriguez. --Please leave us a rating on iTunes!-- Website: pendantaudio.com Twitter: @pendantweb Facebook: facebook.com/pendantaudio Tumblr: pendantaudio.tumblr.com YouTube: youtube.com/pendantproductions

Episode Seventy-six - Life is never short on surprises, be they gas leaks or your life suddenly becoming an advertisement. Featuring "It's Only Logical" by Barry M. Putt, Jr. and "Commercials" by V. C. Morrison. --Please leave us a rating on iTunes!-- Website: pendantaudio.com Twitter: @pendantweb Facebook: facebook.com/pendantaudio Tumblr: pendantaudio.tumblr.com YouTube: youtube.com/pendantproductions

Episode Seventy-five - Sometimes in life (and death)... it's the little things that make the difference. Featuring "Johnson and Johnson" by Dave Morgan and "Ridiculously Tall Freak of Nature" by Joshua Bridges. --Please leave us a rating on iTunes!-- Website: pendantaudio.com Twitter: @pendantweb Facebook: facebook.com/pendantaudio Tumblr: pendantaudio.tumblr.com YouTube: youtube.com/pendantproductions

Episode Seventy-four - Often we can get too wrapped up in our own heads, and the ramifications can be... deadly. Featuring "O! My Hands!" by Pete Lutz and "Talk to Me" by Gabrielle Phelan. --Please leave us a rating on iTunes!-- Website: pendantaudio.com Twitter: @pendantweb Facebook: facebook.com/pendantaudio Tumblr: pendantaudio.tumblr.com YouTube: youtube.com/pendantproductions

Episode Seventy-three - Communication is the root of human interaction, but you can never be sure quite which way a conversation will go. Featuring "Tollbooth Talk" by Barry M. Putt, Jr. and "The Forum" by Evelyn Hill. --Please leave us a rating on iTunes!-- Website: pendantaudio.com Twitter: @pendantweb Facebook: facebook.com/pendantaudio Tumblr: pendantaudio.tumblr.com YouTube: youtube.com/pendantproductions

Episode Seventy-two - Corrupt promoters and know-nothing bosses have one thing in common... they can't see their own failures coming. Featuring "The Last Stand of the Battler" by Morgan Z. Sowell and "The OS Diaries" by Landon Beall. --Please leave us a rating on iTunes!-- Website: pendantaudio.com Twitter: @pendantweb Facebook: facebook.com/pendantaudio Tumblr: pendantaudio.tumblr.com YouTube: youtube.com/pendantproductions

Inch Chua is back in the studio this week to hang out with the Good Hang Guys for Episode Seventy-three! Check this shit out: — Speechless — Hedonistica.com — Tickled

Episode Seventy-one is all about you, Good Hang Gang! Jon & Nathan read your reviews, comments, emails, tweets, Instagram messages, smoke signals, telepathic thoughts, and careless whispers. Support Good Hang on Patreon

Episode Seventy-one - Be careful when you think you know someone... betrayal might be lurking around every corner. Featuring "Terminal Legacy" by Landon Beall and "True Horror" by Jeffrey Bridges. --Please leave us a rating on iTunes!-- Website: pendantaudio.com Twitter: @pendantweb Facebook: facebook.com/pendantaudio Tumblr: pendantaudio.tumblr.com YouTube: youtube.com/pendantproductions

[intro music] Host – Dan Keller Hello, and welcome to Episode Seventy-nine of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller. Wouldn't it be great to be able to predict who will develop MS? Then those people could be followed prospectively, possibly medication could eventually avert the disease, and at least some medical planning could be done early. Immunologist Dr. Nancy Monson, an associate professor in the department of neurology and neurotherapeutics at the University of Texas Southwestern Medical Center in Dallas, has developed a promising diagnostic test for relapsing-remitting MS that looks at unique antibody gene mutation signatures in B cells in cerebrospinal fluid. Interviewee – Nancy Monson We can identify with 86-92% accuracy patients who either have MS or will develop MS in the future. Interviewer – Dan Keller How long is the future? Dr. Monson So the longest patient we've tracked so far is 17 months out. MSDF And how quickly might this turn into MS? Dr. Monson As soon as immediate. It kind of depends on, you know, what the patient's history has been really in that respect. MSDF This is tested so far on a pretty small cohort, is that right? Dr. Monson No, we tested it on three different smaller cohorts here at UT Southwestern. And then when DioGenix licensed the IP on MS PreCISe, they actually took it to clinical trials, and we're writing that workup now. And that was 300 patients in that trial. MSDF It looks like there's very good sensitivity, but what's the specificity in terms of other kinds of neurological diseases, inflammatory diseases, anything else? Dr. Monson Right. So we're just starting to figure that out. So the accuracy is based on comparing true patients who convert or evolve to MS versus patients who do not. That's where the accuracy mathematics comes from. But in that respect, the control patients that we've looked at so far, the majority of them have very low scores to no score detectable at all in those patients. But some of them do have higher scores. And we don't understand that yet, because we don't really understand any CNS disease for that matter and how the immune system is operating in there. But we're working on trying to expand the control cohorts that we can really kind of nail down, you know, which ones they'll be different from and which ones they won't be different from. MSDF Is it worth doing healthy controls also? Dr. Monson Not really. Healthy controls are always really low, and so I don't think that's a very fair comparer because it's just not very stringent, right? It's not very hard to be able to figure out who are the healthy donors with MS PreCISe. But when you start looking at people that mimic MS, like people with sarcoidosis and people with neuromyelitis optica, you know, then, you start to really have a rigorous ability to test MS PreCISe. And it's quite possible, when we start expanding those kind of control cohorts, the mimics of MS, that the MS PreCISe scoring mechanism will have to be adjusted to kind of push those different control groups away from the MS group and distinguish the two better. MSDF When we talk about these gene mutation signatures, what are you really looking at? Or for? Dr. Monson So if you think about B cells in the blood, they produce antibodies, which are designed to survey the entire body for infection. Okay? So the way that they do that is to have a really great ability to bind to infectious agents or foreign agents in your body. So the mechanism that a B cell uses to do that is called somatic hypermutation or affinity maturation. And what that means is just fancy immunology speak for saying that they incorporate mutations into their antibody genes in order to bind to their targets better, okay? So it makes them more effective in being able to find them and to stick to them. So we've done an initial look at the different antibody genes that were being used by MS patients versus our control cohorts, and didn't really see that the genes themselves were that different that they were using. So then we thought, well, maybe it's the somatic hypermutations that they're putting into those genes that are really different from what we see in the controls, and that's what turned out to be true. So it turns out that there is a family of antibody genes that incorporate these somatic hypermutations allowing them to bind to their target better that we don't see in healthy people or people with other neurological diseases. In fact, in some cases some of these codons will accumulate mutations up to seven times more than what we see in control cohorts. And that's what MS PreCISe is based on, is the accumulation of those mutations into those six codons. So the more mutations there are in those six codons, the higher the MS PreCISe score you get, and the more likely it is that you actually have MS. MSDF Are you essentially losing tolerance here, because of the hypermutation there's more chance that you're going to start to recognize self-antigens? Dr. Monson So we have actually taken the antibodies that have these somatic hypermutations in those six codons and looked to see if they bind to human brain tissue. And it turns out that they absolutely do, hands down. We've tested 38 of those so far, and 90% of them bind to neurons in the brain. So we know they bind to self-antigens, right? But that doesn't necessarily mean that they've lost tolerance or that they're proinflammatory, for example. It's possible that the B cells that are making these antibodies are actually somehow able to quiet the immune system. We don't know yet because we haven't been able to do those experiments to see. But obviously, when you see a lot of B cells that are reactive to the brain, right, that they're antibodies are reacted to the brain, that is an alarm to us that they have probably overstepped their boundaries, have not gone to school correctly and done what they're supposed to do. But we still have some experiments to do to make sure that that's what's going on with it. MSDF I suppose that leads to a question of, are they pathogenic in themselves? Or are they bystanders or regulatory somehow else? Dr. Monson Right. That's a really good question, and we don't know the answer to that. There're some experiments we can do to start testing that, but it's very tricky to do those experiments, particularly in the mouse models we have right now. We're not going to give these antibodies to people and see if they get MS, right? So you have to do all that testing in animals or in vitro. And because no one prior to this time has ever actually been able to demonstrate that antibodies from B cells of any type in MS patients actually bind to brain tissue, I mean, this is completely undiscovered country. We're kind of out there on our own trying to figure out how to best ask those questions, and it's a little bit tricky. But I'm fortunate to have a lot of really brilliant people that work with me, and so we'll work on trying to figure out how we can test that in the best way. MSDF It seems that people have been looking for years for the antigen or antigens that are being reacted against in MS. Can you isolate anything and try to stimulate these B cells to nail down what the antigen might be? Or because they're so hypermutable, they might react to anything and then expand on their own anyway? Dr. Monson Well, we know that they don't recognize all targets, right? So we just published a paper in November of this past year, actually it was October when it came out online. But what that shows is that these MS PreCISe-based antibodies bind to neurons and astrocytes in the gray matter of the human brain. And they don't bind to other tissues. They don't bind to other cell type. They are really fairly specific to neurons and glia in the brain. So we know that part of it already. But the question is, you know, what are they doing there? And is it just an epiphenomenon (is what they call it, right)? Is it just a bystander effect that we're even able to find them? So we just don't know the answers to those questions yet. But all those are good possibilities. MSDF Does this depend on the natural propensity of the immune system to create a lot of diversity, generate diversity, because it seems like what you're talking about are all replacement or substitution mutations within these codon hot spots? If you had a deletion or frame shift or something else, you wouldn't see it, because they're not even functional, I assume? Dr. Monson Right. That's exactly right. You got that right. MSDF Is there any value in combining MRI with the antibody gene signatures for a higher predictive power? Dr. Monson So let me be very clear. This test is not meant to replace MRI. MRI is a gold standard in the field. It is essential for physicians to be able to understand the disease and to come up with a plan for how to treat those patients. This is just meant to be a very powerful, supportive, preclinical diagnostic tool to help them base their decisions appropriately. So that's what we're mostly excited about. So, yeah, absolutely. Combined with MRI, I think it'll do an even better job. We actually in the clinical trial we just finished, it's not published yet, what we showed was that when you combine MS PreCISe with oligoclonal banding, the OCB test, that actually you can boost the accuracy of MS PreCISe up to 96% when you combine it with OCB. So that tells us, also, at a scientific level that not only are the genetics of the antibodies important to drive disease, but also that the antibodies probably plays a role in their conversion to MS as well. MSDF Based on the efficacy of rituximab that's been shown, and what you've been finding, is there any thought to doing something more permanent, like using CAR T cells to eliminate B cells almost permanently? Dr. Monson So as a B cell biologist, it's really somewhat offensive to think that we are going to get rid of B cells in all these people, and they're going to be able to be okay with that. We rely a lot on B cells differentiating into plasma cells and living in the bone marrow and making antibodies against things that we see all the time. But when we start depleting B cells from people long-term, it's possible that their humoral immunity, which is composed partly of the B cells and their antibody products, will not be able to fight newer infections because, you know, there's no new B cells to learn about those new infections. So no, I don't think it's a wise decision that we continue to use rituximab and ocrelizumab. I think that they are the next step. They're a transitional stage that we need before we can get to the true gold standard, which would be a way to deplete just the B cells that are involved in pathogenesis of the disease. My stump on that would be that we should be making B cell depleting antibodies that only recognize those B cells that carry the MS PreCISe antibodies, and those are the B cells we should be getting rid of. But we have a lot of work to do to be able to show that they really are the ones that drive evolution to MS. MSDF What is MS PreCISe? Is this a commercial test now? Dr. Monson So MS PreCISe is its commercial name, but it has not been rolled out yet. It's just beginning into a CLIA lab right now. So hopefully within the next year, it will be an orderable test. MSDF One thing I noticed in one of your papers was you said it wasn't feasible at the time the paper was written to be doing this en masse because it was a very tedious procedure. So does this test essentially make it more feasible? Dr. Monson Yeah. The way we discovered MS PreCISe was actually looking at the antibody genetics of single B cells, which we sequenced using Sanger sequencing. Sanger sequencing is a very elegant immunogenetics-type method. So we spent about a year and a half re-tooling that technology to use next-generation sequencing. So now all we need to do is get a spinal fluid from a patient, and then we extract the DNA directly from that, and we sequence from the entire pool instead. And actually, what's nice about it is we also get a much deeper database from each single patient because we see all of the DNA from that sample now instead of just the few B cells we were able to sort before. It's really nice in that respect because we get a much broader idea of the repertoire. So that is what MS PreCISe is based on is being able to use next-generation sequencing now to really pull those antibody genetics out of individual patients. MSDF What are the unanswered questions at this point? Dr. Monson Well, there are a lot. But I think the one that strikes me the most is whether or not we can pull the antibody gene signature out of the blood. If we can do that, it would get rid of all these spinal fluid taps that our patients have to undergo right now. And so we're working really hard to see if we can find a way to pull them out of the blood so we don't have to do these spinal fluid samplings any more. That's probably our biggest one. The other thing that we're really interested in, once we can find the signature in the blood, it shouldn't be too hard for us, then, to start asking questions about whether or not family members have a higher risk of getting MS. Which is probably one of the primary questions I get from patients all the time: Can you test my daughter? You know, I'm worried about her maybe getting MS someday. And so that motivates us to think, yeah, we got to get this test ready in the blood so we can start asking those kind of questions. I also think MS PreCISe will be a good monitoring tool. I mean, maybe we do keep treating patients with rituximab, but we don't re-treat them unless they're MS PreCISe score starts to creep back up again. So we're hoping that it's a way to also monitor efficacy of different drugs for that matter. So those are the things we're really working on pretty hard right now. MSDF Great. I appreciate it. Thanks. Dr. Monson Sure. Thank you. [transition music] MSDF Thank you for listening to Episode Seventy-nine of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. MSDF’s executive editor is Carol Cruzan Morton. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations. Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances. [outro music] We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org. For Multiple Sclerosis Discovery, I'm Dan Keller.

Full Transcript: [intro music] Host – Dan Keller Hello, and welcome to Episode Seventy-eight of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller. A lot can be learned about pregnancy and MS by tracking pregnant women and their offspring over time. Dr. Dessa Sadovnick, a professor of medical genetics and neurology at the University of British Columbia in Canada, has started such a registry with international colleagues. I spoke with her at the World Congress of Neurology in Santiago, Chile, in November, where she described these efforts and what a very focused registry can tell us. Interviewee – Dessa Sadovnick I'm not talking about a general registry. What I'm talking about is a pregnancy and outcome registry. So this is not just taking people who have MS and trying to keep track of them. This is looking at actual pregnancy outcomes and what happens to the children after. So it's a very specific type of registry. Interviewer – Dan Keller It seems like there's a multitude of variables you can look at. What sorts of things are you going to be tracking if you get this going? Dr. Sadovnick Well, I think the important factor is that just because you have a disease such as multiple sclerosis doesn't mean you're immune from other factors that can affect pregnancy outcome and child development. So in addition to knowing about drug therapies, disease course, other exposures related to your MS, it's also important to know about your previous pregnancy history, your family history, your basic demographics, including your ethnic background, comorbid diseases which you may also have with the MS. All these factors can affect pregnancy outcome and child health. MSDF Will you be looking at the mother's longitudinally? Or only the children? Dr. Sadovnick Ideally, we'd like to be able to look at the mothers up to a year post-partum, and then follow the children longitudinally. Because there are situations where children do not have a certain disease that the mother may have, but over time, they might be found to have some late onset problems, for example, related to learning disabilities or something like that. MSDF Can you separate those out by biological cause or environmental cause? They're in a household with people who have a disease and have to deal with it. Dr. Sadovnick Well, we know for a fact in terms of MS that there is certainly no transmissibility within a household. We have done a lot of work over the years that show very clearly that the excess of MS you find within biological relatives of people who have MS is very clearly due to genetic sharing, not shared family environment. So from that point of view of the child inheriting MS, we're not looking at the family environment. Obviously, there're many psychological issues and many socioeconomic issues related to having a parent who has a chronic disabling disorder. And the impact this could have on child development must, of course, be taken into consideration. But what I'm trying to look at here is more the general factors in terms of, if the mother is exposed to a disease-modifying therapy at the time of conception or in early gestation, and if there is an adverse outcome in the pregnancy, is that necessarily correlated? Or could that have happened for many other reasons? Similarly, if the child develops problems down the road, could that be related, maybe, to the uterine environment because the mother has an autoimmune disease? Which does not mean the child gets an autoimmune disease, but maybe, in some way, it impacts the autoimmunity long-term? MSDF How long would you have to track children? And how many would you have to track to get meaningful numbers? Dr. Sadovnick Well, this is obviously always a concern, and you would have to track a sizable number. But when you consider how many people there are with MS in North America, and if you could do a centralized registry, I think it's realistic that you follow them at least for a few years after delivering. Once they start reaching their developmental milestones, you can get some ideas. But I think the main factor is that we're always saying, therapy is not indicated if you're contemplating a pregnancy. And this causes many issues for many people. But the evidence for this is so scarce. And my big concern is that, are we really being overly cautious? And we won't know this if every adverse outcome is automatically trying to be related to exposures either at conception or in the early parts of gestation. MSDF Pregnancy itself is immunosuppressive, but it seems women have a rebound after delivery. So what goes on with treatment during pregnancy? Is it okay to stop treatment if they're naturally going to be somewhat immunosuppressed? Dr. Sadovnick This is one of the big areas that we really don't have information, and we need good information. Obviously, if you look at a series of women, what seems to happen is especially in the third trimester, they seem to do better. And then, of course, once you deliver and their hormonal changes take place, there's an increase of relapses after delivery within the first three months. That's not to say women can't have relapses while they're pregnant. That is not to say that women are going to have relapses necessarily after delivery. But if you look at large numbers, this is the pattern. The question then comes up, if you have a relapse while you're pregnant, how severe is the relapse? And how should it be treated? There're no set guidelines. The same way as after delivery, a big factor is whether the mother's breastfeeding or not breastfeeding. In today's society, you're really encouraged to breastfeed, but that could have impacts on how you treat a relapse. The other big issue in terms of pregnancy-related relapses is something that we also experience when we look at people who have MS and they're going into menopause. And that is, are the symptoms really an MS relapse? Or could they be pregnancy-related? If you have a symptom, say you have urinary problems, say you have balance problems, say you have fatigue, how do you measure if this is specifically an MS relapse versus just part of either the later stages of pregnancy, the early stages of pregnancy, or living with a newborn child? There is really nothing concrete on how to measure what's a true relapse, what's a pseudo-relapse. And there are no really specific guidelines on how to treat these symptoms during gestation and immediately after delivery. This is an area that we really need to develop. One of the things that we have been able to do is a lot of people are interested in this topic, but it's never been looked at in a formalized manner using experts from many different areas. So about a year and a half ago, I put together a meeting of a group of people who are interested in reproduction and child health. And we received some funding to have a two-day meeting from the Canadian Institute of Health Research, as well as some money from Teva Neurosciences and Biogen Idec. And what we did is we had a two-day workshop basically saying, is there a need to learn more about this area? And if there is, how can all these specialists work together to try to develop knowledge-based information? So we gave our little virtual network, which has no ongoing funding; it's basically people just working voluntarily. We've given it the name of MS CERCH, which is Center of Excellence for Reproduction and Child Health. And we've put together a voluntary working group. And where we're at right now is we've actually just had a paper published in Obstetrics and Gynecology, the American main journal. They also call it a Green Journal, but it's not neurology. Just talking about limitations, guidelines, what we know and what we don't know about reproduction and child health. So this was published the end of 2014. We're currently working with the American College of Obstetrics and Gynecology to try to have our paper turned into some guidelines for people with multiple sclerosis. We've also just recently as a group published a paper talking about why there is a need for a disease-specific registry rather than a treatment-specific registry. We are also just submitted a manuscript looking at all the issues dealing with males with MS in terms of reproduction and child health, because the focus, of course, is on females. But there're still a lot of males out there, and they face many issues that have not been addressed. And we're in the process of trying to get some funding for the first-ever grant to look prospectively at the occurrence of peripartum depression in both mothers and fathers who have multiple sclerosis, a topic that's never been looked at before. So from our two-day meeting, which was quite casual and informal, we have been able to move forward, and as a group, had some concrete outcomes. And we're hoping that we're be able to move forward with this group, hopefully obtain appropriate funding, and we're be able to, maybe, really come up with some knowledge-based information for people with MS who are contemplating reproduction. Another major area of concern is we're more frequently now identifying the pediatric population with multiple sclerosis. The focus on this population has largely been the recognition that MS does occur in the pediatric population. But what's happening is as years are progressing, this pediatric population is evolving into a population who are capable of reproduction. How diagnosis of pediatric MS can impact not only reproductive ideas, but also just behavior in teenagers, and how all this is interrelated is not known as well. So it's a whole other area that we really need to understand. MSDF Are you looking for buy in from clinicians in all of North America? Or restricted to Canada? Or worldwide? Dr. Sadovnick Ideally, we'd like worldwide. Realistically, right now in our group, we're basically clinicians who are in Canada and the US. We have some buy in from some clinicians in Europe, and it's the obvious problem when you don't have resources, the buy in has to be voluntary. So we do have strong connections between Canada and the US, and we're working forward to try to make this a topic that is more at the forefront. MSDF You have a pretty good system of linked databases in Canada. Can that help you with this? I mean, you know diagnoses and pharmacy and death records and hospital visits and everything else. Dr. Sadovnick Linked databases are a very important resource, but they are exactly what they are: linked databases. You're not dealing with the actual people. You're dealing with how the information has been recorded. So while for some purposes linked databases are extremely important, and there's been a lot of work published out of Canada, including with our group in British Columbia using the BC record linkages. They are informative. But it's not the same as actually dealing with the actual people, because record linkage cannot tell you everything you need to know about the person. Just to use an example in terms of pregnancy outcome. You can identify a woman who has MS. You can look at when she had prescriptions filled for her disease-modifying therapy, for example. You can look at if any birth defects were registered for the child. But what you don't know is, did this mother have previous pregnancy losses? Registries only have live births. Does the mother have a family history of some relative with a certain disease? Could the mother have comorbid diseases that for some reason are not linked into her medical history? Maybe she's moved from another country. Maybe she doesn't have the health coverage. So there's a lot of issues with record linkage. And I think it's very important to know that it has strengths and limitations. But it's not the actual end of everything. The other issue with record linkage is it's someone's interpretation. For example, if it's recorded through record linkage that you have a given disease, it's assumed that all the appropriate diagnostic tests have been done. But is that necessarily the case? Could the person who's actually doing the coding reading from the records make that assumption? So you have to be careful. Years ago when I started in clinical genetics, we had a BC health surveillance registry. And the idea was to basically identify any children who had been within the hospital system in the first seven years of their life. And it was a provincial recording system. But the truth of the matter was is when we went back, and I spent a lot of time working with colleagues going back and reviewing the actual forms from which the data was collected, and the amount of errors you would find. Even in something as simple as MS, looking at cause of death. If you look at record linkage, sometimes it doesn't always note the cause of death the person had MS. Sometimes if there's asphyxia, the question is, was it just asphyxia? Is it related to the MS? Is it from something else? Another issue is very often people who have a specific disease like multiple sclerosis and they die, the real cause of death is ignored. Very often we know that cancer, for example, is underdiagnosed in a person with a specific disease like MS. Just because you're having bladder problems, it's often attributed to MS, where in fact, you could actually have bladder cancer, as an example, or bowel cancer. So if you look at all these data, I think it's important to realize that record linkage is a very useful tool, but it is not the only tool that should be used. MSDF Finally, where does this all stand? You mentioned that you have people doing it on a voluntary basis. Do you foresee something more formal? Dr. Sadovnick We're trying to get something more formal in North America. Obviously, funding is the issue. And right now we're trying to get the drug companies to realize that, if they would work together to have a proper pregnancy registry, it might be in everybody's interest, rather than just assuming that the drugs are not advised during pregnancy or when trying to conceive. The problem with all these registries is that where does the money come from? In Canada, we have a very interesting scenario right now where they're trying to put together a registry of people who have multiple sclerosis in Canada. This has nothing to do with pregnancy. This is just, who has multiple sclerosis in Canada? A registry with minimal data sets. And this started with the Canadian Institute of Health Informatics. This has been going on for quite a few years, and I'm on both the technical and the medical advisory committee for this. But the problem is, who's going to fund it? The concept was to enlist the ministries of health to get involved and fund it, but each ministry of health has its own issues in each province, and their interests are different. So even though the concept there was to try to get a cross-Canada registry for people who have MS, funding after many years of trying is still a major obstacle. It's a big issue, but this is why I'm hoping at least if we can focus on the idea of pregnancy, maybe through some research funding or company funding, we'll be able to at least get a pilot started that will start to answer some of these questions. A lot of money is being spent by each drug company looking at their treatment-specific pregnancy registries. And if we could get them to realize that if they all work together, we might get somewhere. It would be nice. [transition music] MSDF Thank you for listening to Episode Seventy-eight of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. MSDF’s executive editor is Carol Cruzan Morton. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations. Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances. [outro music] We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org. For Multiple Sclerosis Discovery, I'm Dan Keller.

Full transcript: [intro music] Host — Dan Keller Hello, and welcome to Episode Seventy-seven of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller. Pregnancy and the postpartum period present special concerns to women with MS. Dr. Annette Langer-Gould, a neurologist and epidemiologist at Kaiser Permanente in Los Angeles, investigates ways to lessen the risk of relapses in these women. We discussed the effects of breastfeeding, among other topics, when we met at the ECTRIMS meeting last fall in Barcelona. Interviewer – Dan Keller In terms of pregnancy and breastfeeding in MS, what are you looking at? Interviewee – Annette Langer-Gould We're studying modifiable risk factors for postpartum relapses in women with multiple sclerosis. And specifically, we are looking at starting therapy shortly after delivery, whether that can reduce the risk of postpartum relapses, whether breastfeeding, particularly breastfeeding exclusively, could reduce the risk of postpartum relapses, and whether vitamin D levels play any role in increasing or decreasing the risk of postpartum relapses. MSDF And are these women who are on disease-modifying therapy throughout pregnancy or not? Dr. Langer-Gould No. In our population, a little over 60% were treated prior to pregnancy. But we do have a decent number of women who had decided to never go on disease-modifying therapies before, and almost all of them stopped disease-modifying therapies either shortly before or when they find out that they're pregnant. MSDF In terms of each of those outcomes, what are you finding? Dr. Langer-Gould We haven't analyzed the data for the vitamin D yet, but in the German pregnancy registry, we just published the data in exclusive breastfeeding, and once again showed that exclusive breastfeeding does protect against postpartum relapses. In that population, actually 96% of the women had been on some sort of DMT prior to pregnancy, and none of them were treated throughout pregnancy. We also found that resuming DMTs does not seem to have a big effect on reducing the risk of relapses, particularly in the first six months postpartum. MSDF Is that in women who are exclusively breastfeeding or not? Dr. Langer-Gould Ah, so that's a good question. So there is no good safety data on taking the medications during breastfeeding. And therefore, many clinicians and most patients are concerned about potential theoretical risks. So behaviors are actually mutually exclusive. Women typically will either breastfeed or resume medications early in the postpartum course. The other thing we find in the Kaiser population is that there are still a fair number of women who neither breastfeed exclusively or resume their medications, which presents sort of an interesting opportunity. If we could show that one or the other behaviors is protective, perhaps we could encourage either exclusive breastfeeding or resuming DMT. MSDF If women are not breastfeeding, do you have an idea of the time course of resumption of risk for relapse? Dr. Langer-Gould Yes, so the concern about postpartum relapses really is about having a relapse in the first three to four months postpartum. If we look over at the whole pregnancy year, and that's about 30% to 40% of women. So this is actually still the best defined risk period for having a relapse and actually the only clear trigger—with perhaps the exception of upper respiratory tract infections—of relapses. So we know that having just had a baby or having an upper respiratory tract infection is a pretty strong predictor of having a relapse. So it presents sort of a unique opportunity to also look at other biological factors, like vitamin D, which is why we're interested in it, to see if any of these things have a strong role in relapses as well. MSDF If women are breastfeeding postpartum, what is the hormonal profile like? Is this almost like an extension of pregnancy? Dr. Langer-Gould For women who breastfeed exclusively, meaning that they breastfeed to the point of suppressing their ovaries and not resuming menstruation—so that essentially there's no regular meal that's being replaced by formula or by table food in the baby—they have very high prolactin levels. So it's actually a little bit different than being postmenopausal, in the sense that they have very high prolactin levels. And they have incredibly low nonpulsatile FSH and LH levels. In the postmenopausal period, there occurs a very high FSH and LH levels. The similarity, though, is that they both have bottomed-out estradiol and progesterone levels, in both women who are breastfeeding to the point of suppressing menses and also postmenopausal women. And of course the other similarity is that there's no ovulation occurring, either during pregnancy, during exclusive breastfeeding, or after menopause. MSDF So it sounds like breastfeeding is really a hypothalamic pituitary suppressant as opposed to in menopause, where you still have those cranking away, but just no response from the ovaries. Dr. Langer-Gould Correct. MSDF Can this be used in any clinical sense? Do you see an application? Dr. Langer-Gould The most obvious direct way to translate these findings is that that, if you have a woman with MS in front of you and she is pregnant and she tells you she'd like to breastfeed, we certainly have no good reason to discourage her. And that if anything, I would suggest that the data we've already published would point to the fact that we may want to encourage exclusive breastfeeding, provide them with lactation counseling, and also sort out exactly what the optimal duration of exclusive breastfeeding may be for these women. Is it really only eight weeks, which we had defined arbitrarily? Or does longer duration of exclusive breastfeeding have additional suppressive properties? And that would, of course, have implications in the United States for things like maternity leave and work accommodations to allow that to continue, if it has a strong therapeutic effect for the mother. MSDF What's the relapse rate among postmenopausal women compared to postpartum women? Dr. Langer-Gould So relapse rate declines with age. And so it typically in postmenopausal women, although there's not great data, we would expect them to have relapse rates of less than 0.3 per year, Annualized relapse rates of less than 0.3 per year. And in postpartum women, that first three to four months, the annualized relapse rate exceeds one. MSDF But men also have a decline in relapse rate as they age, too. So you can't attribute it to lower estradiol. Dr. Langer-Gould Exactly. Yeah, I think it's far more complicated than just a simple sex hormone effect. You know, that was sort of our first instinct from pregnancy or the reason pregnancy must be protective. It has to have something to do with estradiol or the very high progesterone levels. And that's what prompted the postpartum study and also the estradiol randomized control trial. And both of those, of course, disappointingly have been negative. In isolation, the sex hormones associated with the protective effect of pregnancy don't really have a protective effect on inflammation. It's probably more of a combination of factors that play into modulating the immune response. MSDF Where do you go from here? Dr. Langer-Gould I think that if we are able to reproduce the findings, looking at this population-based source, that early resumption of DMTs is not particularly helpful, but perhaps it may be later in the postpartum year, and that exclusive breastfeeding is, again, protective, then I think the next step really is to establish the safety of some of these medications during lactation. For several of them, there's really no biologically plausible reason to think that they would have an effect on the baby, as they're not likely to be absorbed through the gut or enter into the baby's bloodstream. Examples of that would be the large molecules like Copaxone, the interferons, and also the infusion medications, Tysabri (natalizumab), and rituximab as well. Although you may be able to detect them in breast milk, they are such large molecules that they would not diffuse across the baby's stomach and into the bloodstream. Think about it. If the mom has to take it as a pill, it is very likely to be transmitted to the baby. If the mom has to take it as an infusion or injection, very unlikely that oral route through the baby would have any effect. MSDF How sensitive is this effect to, as you said, exclusive breastfeeding? Can you start introducing formula, or it's all or none? Dr. Langer-Gould That's a really good question. So we did look at that also in the German pregnancy registry. So first of all, women tend to have very defined behavior. They tend to decide to supplemental feed with formula very, very early, before they've even established their full milk supply. So to back up even further, a healthy woman gives birth to her child. Usually menstruation will resume two months after delivery, not one month. So it does take the HPA gonadal axis a little chance to recover from those high-circulating hormones of pregnancy. And in women who introduce supplemental feedings, particularly early, we also see the very same thing; that they will resume their period at two months postpartum. Actually, most of the work done in this field has been done by nutritionists who are in developing countries who are interested in knowing what you should do if you see a starving mother and a starving baby. Who should you feed? It turns out that if you feed the baby, the mother's ovarian function will resume. So any regular supplemental feedings and very quickly their prolactin levels will drop. The pulsatility of the FSH and LH secretion will return. Ovulation returns, and so does menses. It's essentially sending the mother's body a signal that the baby no longer needs nutrition from the mom to survive, so she's ready to have another child. So the right thing to do in that situation would be feed the mom, and let her nurse the child. Biologically, it's very interesting. Even though some breastfeeding is better than none for the baby, in terms of the effect on the mother's HP [hypothalamic-pituitary] ovarian axis, some supplemental feeding is just like all supplemental feeding. MSDF Have we missed anything or anything interesting to add? Dr. Langer-Gould So I guess I would say just in general, women's, and now even men's, desire to have naturally-born children has taken on a new significance with a lot of the small molecule agents, because we need to consider family planning and discuss it much earlier, as small molecules are likely to have an effect even if they get pregnant accidentally on the developing fetus. This is a challenge we haven't had before, because large molecules won't cross the placenta in the first trimester. And the first trimester is the critical period for organ development. So it's sort of new era for MS neurologists, where we really, really have to think carefully about which medication we put them on if they're planning on having children soon. So I’d strongly encourage that you have that conversation very early and have it with every followup visit. I typically will ask them, are you planning on having children within the next two years? And if they say, no, I ask what kind of birth control they're on, or in some cases they're in same-sex couples. That's obviously an exception. And if they are not on a reliable form of birth control, I think you need to think twice about giving the small-molecule agents—so the pills, basically. MSDF Should MS neurologists work with high-risk OB/GYNs? Dr. Langer-Gould I think for the most part it's not necessary, because women with MS, they don't have abnormal complications at pregnancy. I think there are certainly situations that we're running into now. If they get pregnant accidentally on fingolimod, teriflunomide, or Tysabri, we do need to work with them, mostly for the baby. So you may want to do more intense early screening if the mother is culturally open to the idea of having an abortion. You may want to do more fetal ultrasounds, perhaps even a fetal MRI, if there's suspicion of major malformations early on in pregnancy. And also for the Tysabri, really, it's not so much about organogenesis, but if they've had later exposure to Tysabri during pregnancy, which unfortunately on occasion has been necessary to control rebound disease activity during pregnancy, that, you know, we have seen hematological abnormalities in some of these children, so far none with clinical complications. Only one child had a subclinical intraventricular hemorrhage that resolved. It's still concerning. Our experience is very small, and we would certainly highly recommend that those women give birth in a hospital that has a neonatal intensive care unit available and a pediatrician on call to examine the child and also make sure that the child doesn't have a severe thrombocytopenia or anemia at birth. MSDF Do the different drugs have different risks for fetal malformations or other dysfunctions? Dr. Langer-Gould Yes. So teriflunomide, or Aubagio, is the most concerning medication because if a woman gets pregnant on that accidentally, it is, you know, a category X drug because it can interfere with neural tube development. And although you can chelate to get the medication out very quickly, the safety data from other indications, you know, the rheumatoid arthritis and lupus literature, is not particularly reassuring in terms of fetal outcomes. So I think that's sort of the number one to stay away from if a woman is planning on getting pregnant. And it's also one where, you know, there is some concern, although not strong evidence, that it may also affect the offspring of men with MS who are on the medication. In terms of the other ones, of course, again, small molecules in fingolimod has about a 15% to 16% major fetal malformation risk with early pregnancy exposure. It has a very long half-life. So even if they stop the medicine the minute they find out they're pregnant, it takes over two months for it to be cleared, which means that the baby has seen it now through the entire first trimester. That can have significant effects, both on cardiac and brain development. And then with dimethyl fumarate, we haven't seen—now of course, this is a very new drug, so we don't have nearly as much experience—we have not seen any major malformations, but there was concern in the animal models that it could interfere with cognitive development. In particular, the rats had maze-finding difficulty. MSDF Is alemtuzumab indicated at all? It seems to have a long tail. Dr. Langer-Gould I'm not sure what the half-life of alemtuzumab, but it's probably similar to other monoclonal antibodies, which is usually around 15 to 20 days. So monoclonal antibodies don't cross the placenta in the first trimester, because it's a very large molecule. So large molecules only get across if there's an active transport system. For antibodies, there is an active transport system, because it's very important that the child be born with a high dose of antibodies received from the mother to help protect them during the early part of their infancy while their own immune system is still developing. So we see maternal antibodies being transported, and of course, monoclonal antibody medications would be dragged along with that during second trimester. And it goes up in elliptical fashion, with very, very high amounts being pumped across the placenta in third trimester. And they also, of course, have a very delayed clearance mechanism, both the fetus really has no clearance mechanism, and then even the neonate has a very slow clearance mechanism. So in TNF alpha studies, if the drug is given during third trimester, it's typically not cleared until about six to nine months postpartum. So you also have to be concerned that a baby exposed would have some of that medication hanging around during the early neonatal period and give some thought to whether or not their immunization scheme would need to be adjusted, as the cautionary tale there would be TNF alpha exposure during pregnancy. There was a case reported of a woman who had very severe rheumatological disease, had discussed with her rheumatologist the potential risks and benefits of taking it throughout pregnancy, opted to take it throughout pregnancy. And then living in an endemic area for tuberculosis, the baby got the BCG vaccine and got disseminated mycobacterium and died. And that, you know, was probably directly related to impaired immunity from the TNF alpha antagonist. And sure enough, the baby was born with fairly high cord levels and also had very high levels still remaining in the blood in the neonatal period. So it's not just once the baby's born, it's like the drug is out. So drugs like alemtuzumab and rituximab, the way in which they work, even though the drug could be long gone, but the effect of the medication works very long time. So those are actually good choices for women with highly active disease who are planning on getting pregnant. And you have concerns about rebound. I mean, we typically use rituximab because it's obviously much safer than alemtuzumab and seems to do a fairly good job. But you know, these aren't medications we should be giving while they're pregnant, but probably not a big effect in crossing the placenta and on the baby if they're used prior to pregnancy. MSDF If they can plan that well and get a pulse of that early, and then get pregnant a few months later. Dr. Langer-Gould Yes. Yeah, that's always the trick, right? And they do get pregnant accidentally on just about everything we put them on. So the infrequent infusion medications is the easiest because you can ask about last menstrual period. And you can ask about birth control use, and you can do a pregnancy test the day of, a quick urine dipstick and find out so that you don't accidentally infuse a pregnant woman. Of course with Tysabri, when you're giving them an infusion every month, it gets a little tricky. Usually people just kind of get tired of it. The nurses forget. The doctor forgets to order it, although it's not necessarily bad practice if you know you have a patient who is not on a reliable form of birth control. MSDF Very good. I appreciate it. Thank you. Dr. Langer-Gould You're welcome. [transition music] MSDF Thank you for listening to Episode Seventy-seven of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. MSDF’s executive editor is Carol Cruzan Morton. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations. Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances. [outro music] We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org. For Multiple Sclerosis Discovery, I'm Dan Keller.  

FULL TRANSCRIPT:[intro music]Host — Dan KellerHello, and welcome to Episode Seventy-six of MultipleSclerosisDiscovery, the podcast of the MS Discovery Forum. I’mDanKeller.Pregnancy presents special considerations for women withMS.Beyond the medical and pharmacological issues, there aresocial,socioeconomic, and parenting concerns. Dr. Dessa Sadovnick,aprofessor of medical genetics and neurology at the UniversityofBritish Columbia in Canada, spoke on issues ranging frompregnancyplanning through the postpartum period at the WorldCongress ofNeurology in Santiago, Chile, in November, where we metup.Interviewer – Dan KellerLet's talk about gender and hormonal issues in pregnancy.Whatare some of the things you're looking at now?Interviewee – Dessa SadovnickWell, in terms of gender, it's really been interesting thefactthat initially it was actually thought that men may have MSmoreoften than females. And now, of course, it's very wellestablished,as with many other autoimmune diseases, that femalesare affectedmuch more than males. The question is why? And there'sa lot ofresearch being done into hormones, especially theestrogens, theestradiols, to try to see how that relates to diseaseonset,clinical course, etc. But again, there's no reallyfirmanswers.We do know that the hormonal changes during pregnancy do seemtoreduce the number of relapses during gestation, and as soon asyoudeliver, the relapse rate goes up very high. So this is one areaofbig interest. There's been some recent work published onmenopause,and it does not seem that women who have MS havemenopause earlierthan other women or later than other women. Theredoesn'tnecessarily seem to be a direct effect between clinicalcourse andmenopause, other than to say that a lot of the symptomsdo overlap.So you have to be very careful, as a clinician, todecide whetheryou're talking about MS-related symptoms or symptomsthat might beamenable to treatment just for regular menopause.Puberty is a very key period in MS. We know that you can getMSprior to puberty, but it is recognized now in thepediatricpopulation that the group who have it prior to puberty dohave amore similar female to male ratio. It's only once pubertyhits thatyou have the excess in the females.MSDFDoes pregnancy permanently change physiology compared tothepre-pregnant state, or do people go back to their baselinerelapserisk after some point?Dr. SadovnickThere is no evidence to say that having a pregnancy willchangeyour long-term course or your outcome after a given period oftime.It seems like people on the whole, and everything is always onthewhole because there's always the exception, but in general,youtend to go back to what you were like before, taking intoaccountthat, after pregnancy, you'll have had a longer diseaseduration.Just an example, if it takes you a year to becomepregnant, thennine months pregnancy, three months postpartum, thenext time youlook at it you're two years since before you tried toget pregnant;so you're two years more into the disease. But there'sno evidencethat pregnancy harms the long-term outcome of MS, andthere's noevidence that not getting pregnant is beneficial forwomeneither.MSDFIs there a physiologic explanation for the higher relapserateafter pregnancy? Is it easily identified, or is itprettyhypothetical?Dr. SadovnickWell, it's thought to be related to the changes in hormonesassoon as a woman delivers. But there's nothing that can mark ittosay this woman's going to get it, this woman's not going tohaveit. You know, there's no marker that's going to say who's goingtohave a relapse after delivery, who isn't.MSDFEven though there's not much data right now about many ofthedrugs used in MS and pregnancy, women are advised oftentimes nottobe on the drugs, but they also don't immediately get pregnant.Sodo they have a long period potentially of risk of relapse, anddoesthat affect the long-term course eventually?Dr. SadovnickWell, there's been controversy in the literature aboutwhetherthe number of relapses a woman has while shehasrelapsing-remitting MS affects her emergence intosecondaryprogressive MS. So there's been controversy at thefindings aboutwhether the number of relapses predicts how soonyou're going to gointo a progressive phase or not. As far as I'maware, the mostrecent information suggests that they might be twoindependentfactors. So, it's a hard question to answer.Obviously, the drugs don't cure MS. So it's not that you'regoingto prevent MS by taking the drugs or stop MS dead in itscourse bytaking the drugs. You're taking a risk. [With] anyrelapse, youdon't know whether there's going to be a completerecovery or apartial recovery. The more relapses you have, theharder everythingis in day-to-day life and coping and recovery,and getting pregnantis not something that happens instantaneously.So it's a bigdecision that women do have to make. And there's noreal easy answerfor saying who will do well being off themedication for awhile, whowon't do well being off for awhile.It's an informed decision that people have to make. And wesayit's very important that if you're planning a pregnancy, toreallylook at all the information that's relevant to yourparticularsituation and make an informed decision about yoursituation.There's no general answer for everybody. And we've comeup withsome reproductive counseling models that deal with the wholeareaof reproduction and reproductive planning.Now, one thing that I find that people often don't tend tothinkabout is that they think of getting pregnant in termsofconceiving, having a pregnancy, delivering, and the threemonthspostpartum. But they forget the fact that once you do have achild,there's a lot of commitment you have for a long timemovingforward. It's not just your three-month postpartum relapseratethat you're concerned about. And people have to be verycognizantthat if they do have a chronic disorder, that this willhave someimpact on their socioeconomic status, on their ability toparent,on relationships; all this has to be taken into account. Andtwo ofthe things that we often say to people who are planning apregnancyis: One, remember that it's a long-term commitment; andtwo, as aparent, instead of focusing so much on what youcan't dobecause you're a parent who has MS, maybe youshould focus more onwhat you can do. And I think that's avery good attitudeto have.I remember many years ago we had a woman who was just soupset,because in the city she lived in there was a big annualfestivalfair every year. And she'd take her children there, and bythe endof the day she was hot, she was tired, she'd have a relapse,she'dbe in bed, but she felt it was her duty, as a parent, to takethechildren to this festival. So we just talked about it fromapractical point of view, nothing specifically medical oranythinglike that. And said, well, what would happen if you wentwith yourkids with someone else; you stayed in a nice shady place,you had,you know, something cold to drink. Your kids went off anddid allthe running around, and then they'd come back and report toyouwhat they're doing. And, you know, try a day like that insteadofyou're being the one to kill yourself running around with themtoall the activities. And she came back to the clinic a coupleofyears later, and she says, you know, it was such a difference.Thekids had a good time, and instead of my being in bed for thenexttwo weeks, we went out for dinner after, and lifecontinued.So I think that that's so important when you're talkingaboutplanning pregnancies is you have to think forward. You knowthatfor anybody having a baby in the newborn period, it's tiring,it'sstressful, not only for just the mother, but also for thefatherwhether he has MS or not. So if you know this is going tohappen,before you get to the point where you're in such a stateofexhaustion and relapses start happening, maybe plan ahead.Noteverybody can afford nannies or housekeepers or things likethat;that's a fact of life. But there's nothing to say you can'ttalk tofriends and work out a system where you get a bit of extrahelp inadvance, not just wait till you hit the crisis mode.MSDFAnd I suppose in the early postpartum period you could beverysleep-deprived.Dr. SadovnickYou can be very sleep-deprived, and then you have tostartthinking. If you're a father whose wife has just had a baby,maybeyou should try to sleep in a different room, not worryaboutgetting up when the baby gets up during the night. If you'reamother who has MS, maybe you want to reconsiderbreastfeeding.Maybe you want to consider expressing, so that you'renot upconstantly with the baby. You have to be practical. And Ithinkthat that is the big factor is: in theory there's so manythingsyou're supposed to do, but you actually have to be practical.Thefatigue component with a newborn is not going to go awayregardlessof if you have MS or not. So if you know in advance youhave MS,and it's going to be more of an issue, why not try to makesomepractical plans?MSDFYou had mentioned the changing sex ratio mainly becausemorewomen are being diagnosed with MS. Is it that there is more MSorbetter diagnosis or some other reason for this increase inthegender ratio with women predominating?Dr. SadovnickLooking at it in terms of a gender ratio, you're basicallytakingout factors, such as improved diagnostic techniques. So whatwe'restarting to think is that females react differently toenvironmentaltriggers than do males, and this could be a reasonfor the increasein females. Women are living a very different lifetoday than theydid even 30 years ago in terms of occupation, beingout of thehouse, exposures. Women react differently to vitamin D.Women havedifferent smoking habits in reacting. So we're thinkingthat what'shappening is that the female is actually responding toenvironmentalfactors in a different way now or being exposed morethan she wasmaybe a few decades ago.MSDFDo women live proportionately longer with MS? Could they justbegetting older, and the men aren't getting as old, and thatchangesthe ratio at that end of the spectrum?Dr. SadovnickLife expectancy does not really seem to be dramaticallyalteredin multiple sclerosis for males or for females. We've donestudieswith actuarians from life insurance companies looking atthis, andMS really doesn't kill you. So I don't think lifeexpectancy is afactor.MSDFAnything interesting or important to add?Dr. SadovnickWell, I think that a big difference is that there used to bealong lag time from the onset of the MS symptoms until youwerediagnosed. So a lot of life decisions, whether it wasdating,partnering, reproduction, or in that period when you reallydidn'tknow that you had a diagnosis, so in many ways ignorance wasbliss.You didn't really have to make decisions.Now, of course, with the new techniques, people aregettingdiagnosed so much earlier in the disease. And they're beingtoldthat you have MS, you'll do fine, you know, there are therapiesyoucan try. You're still a person who has a life to lead. You'renotan MS patient for your whole life. So but every decision theymakethey have to go out and decide disclosure and how to deal withthefact that they now have a diagnosis. It's not this periodofignorance is bliss. So let's just take, again, going back tothepediatric example: you're a teenage, you're in university,you'reon the dating scene. When do you tell someone you have MS, doyoutell them? Do you not tell them? You're someone who's in their20s:you have a diagnosis of MS, you're dating, you talk abouthaving apermanent relationship and going on to have childrentogether. Whendo you drop the bomb that you have MS? When do youtell it toemployers? When do you tell it to in-laws? You know, whendo yousay this? That period of being ignorant is really gone now.And so,how you react, how society reacts, is something that wereally haveto look at now. When do you disclose? When don't youdisclose? It'sa very big issue.MSDFVery good. Thank you.[transition music]MSDFThank you for listening to Episode Seventy-six ofMultipleSclerosis Discovery. This podcast was produced by the MSDiscoveryForum, MSDF, the premier source of independent news andinformationon MS research. MSDF’s executive editor is Carol CruzanMorton.Msdiscovery.org is part of the nonprofit Accelerated CureProjectfor Multiple Sclerosis. Robert McBurney is our President andCEO,and Hollie Schmidt is Vice President of ScientificOperations.Msdiscovery.org aims to focus attention on what is known andnotyet known about the causes of MS and related conditions,theirpathological mechanisms, and potential ways to intervene.Bycommunicating this information in a way that builds bridgesamongdifferent disciplines, we hope to open new routestowardsignificant clinical advances.[outro music]We’re interested in your opinions. Please join the discussiononone of our online forums or send comments, criticisms,andsuggestions to editor@msdiscovery.org.For Multiple Sclerosis Discovery, I'm Dan Keller. 

[intro music] Host – Dan Keller Hello, and welcome to Episode Seventy-five of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller. Today's interview features Elaine Kingwell, a research associate at the University of British Columbia in Canada. She and her colleagues have gathered and recently published incidence and prevalence figures for people with MS in the province. I spoke with Dr. Kingwell at the ECTRIMS meeting in Barcelona in October to find out the reason for the study and to explore the changing trends she found and their significance. Interviewer – Dan Keller What prompted you to do this study? Interviewee – Elaine Kingwell In British Columbia, we know that Canada has got a high incidence and prevalence rate of MS, but we don't actually have the numbers, so we've been doing a lot of research on MS in British Columbia for many, many years. But we don't have the incidence numbers for BC, and also the prevalence is out of date – the estimates that we have – so it really was time to get an idea on how many people we have in BC. And also, we wanted to look at change over time, and we have access to some amazing administrative databases in BC and also had some algorithms that we could use that have been validated, so that we could identify people with MS in the databases. MSDF Why are these numbers important? Dr. Kingwell It's important for lots of different reasons. For instance, it's important to monitor trends over time. We're able to do that in BC, because we have data going back several years. And so, it's important to see if populations are changing, so that we can get some clues about whether environmental factors might be changing. And also, for the prevalence estimates, it's important to know how many people have MS in the province, so that healthcare planning can be done wisely and resources. MSDF How do you go about looking at this? Dr. Kingwell So as I mentioned, we did use the health administrative databases in BC, which are big databases that collect data on the whole population. A number of different databases were combined, including hospital admissions and physician visits. It's all claims data, so that when someone goes to see their physician, a billing claim gets put in with their diagnosis. So we use these codes to identify people with MS. And we basically estimated the number of people with MS [over] several years – one year at a time – so that we could look at change over time for prevalence. And we also estimated the incidence, the number of new cases each year, starting in '96 right up until 2008. MSDF What did you find in terms of incidence and prevalence? Dr. Kingwell Well we found the incidence and prevalence are both high. The incidence was around 7.8 per 100,000 per year, and the prevalence was around 180 to 200 per 100,000 in 2008. So they were both high, what is relatively high compared to other places in the world and similar to rates that have been found in Europe, in Northern Europe, and other parts of Canada, as well. MSDF And the prevalence is increasing over time? Dr. Kingwell Yeah, we found that it increased quite significantly by about 4.7% per year, so a big increase. It also shifted in the predominant age of people, so that the peak prevalence age was around in the mid-40s in the 1990s, and it's now shifted up into the mid-50s. So the population of people with MS is getting older in BC. We also saw with incidence … quite differently, the incidence was not changing over time, so it stayed relatively stable; it did fluctuate as incidence always does. But over time, on average, it stayed the same. MSDF Are those two pieces combined—increasing prevalence and older age—good news? Dr. Kingwell I don't know if any of it's good news. It means that we have an older population that are probably requiring more care, as they get older, for the MS, as well as, of course, comorbidities they may have. So, it's certainly something that healthcare planners need to be aware of. And we have an aging population, in general, in Canada, as we do in other parts of the world, but we have a lot more people with MS at an older age. MSDF But doesn't that mean they're surviving longer? Dr. Kingwell That's the good news part, yeah. And it does mean that, because we're not seeing a change in incidence, the most likely explanation is that the survival is better. People are surviving longer with MS. We're seeing an increase in survival for the whole population, but we're also seeing an increase in survival for people with MS. MSDF What about the gender ratio in terms of prevalence but also in terms of survival? Dr. Kingwell We're seeing a gradual increase in the number of women relative to men in prevalence. That's most likely due to the fact that women do survive longer than men, on average, of course that's highly variable. But on average, they survive longer than men. And so, if you've got an aging population and three-quarters of the people with MS are women, then you're going to find the number of women are increasing. MSDF How did the socioeconomic status affect the findings? Dr. Kingwell Yeah, so we did actually look at socioeconomic status. It was measured at the neighborhood level, so not the individual level. It's linked into the databases by postal code. We did find that there were more people with MS in the higher levels of socioeconomic status, but the absolute differences were not that great. And, when we looked at this, it was not linked or adjusted for other factors. So there's so many things that can be attached to socioeconomic status and, of course, age is one of them, and your age is greatly related to whether you have MS or not. And so, there are other possible explanations, so we don't put a lot of emphasis on that. When we look at socioeconomic status, we really think that you need to design a study specifically to look at that. MSDF Could you look at the use of disease-modifying drugs according to socioeconomic status? Dr. Kingwell We could, and we have actually looked at that in other studies. Again, as a kind of an adjustment factor or something to bear in mind when we're looking at lots of variables at once, we find there's the same kind of trend that people in the higher levels tend to be on drug more often. But again, the absolute numbers are very small, and it could totally be related to age or other factors that are not adjusted in. MSDF Were the data there to be able to look at early initiation of disease-modifying drugs and any effects it may have had? Dr. Kingwell Well for this particular study – in the incidence and prevalence study – we looked at just whether people had ever had drug. We looked at the incident population to see if they'd had it in the last three years or so—that's the three years from their first claim, which is close to when they're first diagnosed or recognized as having MS. And for the prevalent population, we looked at whether they'd ever had MS. So we were able to tell that about a third of the cases had had a disease-modifying drug. And this study did start way back in the early 90s and then mid-90s for the incidence cases. So, you would expect it to be a lower rate because the drugs were just starting to become available in the mid-90s. So we didn't look at the actual start date of the drug for this particular study; we certainly are able to look at that because we have access to the databases to look at those kinds of questions, and we are looking at those kinds of questions in other studies. MSDF Can you put your findings in context to other studies at other latitudes, locals, healthcare systems? Dr. Kingwell Yeah, that's a complicated question. Certainly as studies are similar to the findings from some other studies. In particular, in Canada, there's been some very similar studies done in Manitoba and Nova Scotia where we've used exactly the same algorithm that was validated in those provinces led by Dr. Ruth Ann Marrie from the University of Manitoba. So, we found that prevalence and incidence estimates are very similar, and the findings and the change over time are also very comparable. When we look at some of the other countries, there are some similar findings in other places, but they vary a lot. When it comes to latitude, of course, we didn't have a big latitude gradient in our study; we were just looking in BC, and most of the people in BC live in one area around they're concentrated in the south of the province. But certainly there's a lot of variation in findings. But in order to get a look at the change over time, you really need to look within the same population on more than one occasion rather than comparing between populations over time. It's really difficult to make that comparison. MSDF Do you have a particularly good situation in BC in that you can link databases of diagnostic codes, physician visits, hospitalizations, pharmacy benefits, things like that that may not exist in other places with a less coordinated system? Dr. Kingwell Yeah, definitely. We are in a situation where we have access to some amazing databases. Many of the provinces in Canada have the same or similar databases, so it is like that. We also have the great situation that we have a clinical database in BC too where we've been collecting data on MS patients over a very long period of time. And we can link that data into the administrative databases, so we have the depth of the clinical data that we can link in the breadth of the administrative data, which has really put us in a very strong position to look at these long-term followup studies. MSDF Is it pretty smooth to be able to delve into these databases, or do you have any regulatory barriers like, in the US, we have all these HIPAA things. Do you have a problem with de-identifying or anything like that? Dr. Kingwell It's certainly not smooth. It can actually take us several years to access this data. It's a long process. It's a lot of paperwork for all of the reasons that…or some of the reasons you just mentioned. The data is actually all handled through…when we're at UBC, it's handled through Population Data BC, which is kind of the center between the Ministry of Health and the databases. And they strip all the identifiers off, so that by the time we receive any data … we, of course, have to go through a lot of privacy concerns and justification before we get any data sets. All the names and the numbers are removed, so that we don't know who anybody is in our database. Even when we're linking our clinical data, of course, everything is completely anonymized by the time we work on anything like that. MSDF What kind of conclusions can you draw from what you've found so far? Dr. Kingwell One of the main conclusions, I think, is that the incident population has leveled off, apparently, in BC. We started measuring incidence in 1996, and it's possible there were changes in incidence before that, but we can say that in the last 13 years – up to 2008 – that the number of cases has leveled off, which is good news it's not increasing. We also can say that the number of prevalent cases, on the other hand, is increasing a lot, so that the services need to be aware of that that there's going to be a demand on the healthcare system, there already is. And also that our results are very similar to as seen in other parts of Canada and comparable. The other main conclusion I would draw is that this study really shows how you can utilize these types of databases and reliable algorithms and ways of identifying people with MS in order to monitor the number of people and also changes over time. And also can give us some information about the people with MS and what kinds of drugs they're taking because we're linked into the PharmaNet databases, and we can do that too. So there's lots of questions we can answer about the population in British Columbia. [transition music] MSDF Thank you for listening to Episode Seventy-five of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. MSDF’s executive editor is Carol Cruzan Morton. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations. Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances. [outro music] We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org. For Multiple Sclerosis Discovery, I'm Dan Keller.  

[intro music] Host – Dan Keller Hello, and welcome to Episode Seventy-four of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller. Today's interview features Dr. Markus Reindl, an Associate Professor of Neuroscience at Innsbruck Medical University in Innsbruck, Austria. We discuss autoantibodies to myelin oligodendrocyte glycoprotein, or MOG, a protein component of myelin. These anti-MOG antibodies are particularly important in pediatric demyelinating diseases. Interviewer – Dan Keller First of all, why don't you define MOG for our audience. Interviewee – Markus Reindl MOG is myelin oligodendrocyte glycoprotein, and it's a myelin protein which was discovered about 30 years ago. It is of enormous interest to people working in neuroimmunology, because it's one of the main autoantigens used in experimental models for multiple sclerosis. And about 20 to 30 years ago, a lot of people started to work on autoantibodies against MOG in the field of MS because it was suspected to be a key autoantigen. And at that time, there were a lot of papers published with somewhat contradictory results. About five years, six years ago, the interest of MOG was rediscovered again when people developed more specific assays to detect these antibodies. And surprisingly, it was found that they're not present in classical multiple sclerosis but rather in pediatric demyelinating diseases, such as acute disseminated encephalomyelitis, ADEM, or neuromyelitis spectrum disorders. MSDF And what does finding anti-MOG antibodies tell you? Dr. Reindl At the moment, it just tells you that if you have these antibodies the risk that you develop MS is minor. So it points to the direction of a different demyelinating disease, which is in most cases monophasic with a good outcome. Or if it's recurrent, it's often recurrent optic neuritis on multiphasic ADEM. Altogether, all this with a good recovery from relapse. Severe disease causes are rare. MSDF So in the early stages of MS – something like clinically isolated syndrome – does MOG tell you which direction to go in if you find it? Dr. Reindl Usually if you have a clinically isolated syndrome that fulfills the current criteria for multiple sclerosis, looking at the MRI or at the cerebrospinal fluid, it will typically be negative for MOG and autoantibodies, so it's just an exclusion criteria. If you look at the CIS [clinically isolated syndrome], whether it could go to the direction of multiple sclerosis or not, if MOG antibodies are present, the answer would be rather not. MSDF Does it fit into neuromyelitis optica, especially seronegative, where there's no anti-aquaporin-4 antibodies? Dr. Reindl Yes, it can also be observed in cases with neuromyelitis optica that are aquaporin-4 antibodies negative, particularly in pediatric cases, and often in cases that present with simultaneous optic neuritis and transverse myelitis at onset. So the classical description of neuromyelitis optica by Devic back in the 19th century would rather have been a MOG antibody positive case than an aquaporin-4 antibody positive case. And the pathology of both diseases is entirely different. So in aquaporin-4 mediated neuromyelitis optica, you have an astrocytopathy under high risk of future relapses and disease deterioration. Whereas in the case of MOG antibodies, it's often monophasic, and the recovery is much better. MSDF So it sounds like anti-MOG antibodies are not just a marker, but they're actually pathognomonic or pathogenic of the disease. Dr. Reindl This is currently under investigation. So what we know from neuropathology there are currently five cases – if I'm correct, or as far as I know – that have been analyzed for neuropathology. These were in most biopsies/autopsies where MOG antibodies were present. And their pathology was in multiple sclerosis type II pathology, which points to the direction of antibody-mediated pathology. So from a neuropathological point of view, looks like MS. If you look at the clinical criteria that are currently valid for multiple sclerosis, it's clearly not MS. If you look at the pathogenesis, this is currently under investigation. From the in vitro studies, we know that these antibodies can, of course, activate compliment. They also have an affect on oligodendrocyte cell function. In vivo models are currently ongoing, and I expect there to be more results by next year on this. MSDF What is the clinical utility at this point? Is it ready for clinical use, or what more needs to be done? Dr. Reindl I think particular people working in the pediatric field are using it more and more. Because if you look, for an example, at ADEM, earlier this year we published a study that children with ADEM that are positive for MOG antibodies they have certain features in neuroradiology but also in their clinical presentation and their clinical recovery, which could aid the clinician. In particular, in the European countries, many laboratories are now setting up assays for MOG antibodies and using it in clinical routine. What has to be done now is better development of the assay, a comparison of the assays like it has been done for aquaporin-4 antibodies, like international validation experiments. We're currently setting up such an experiment for next year, together with the people in Oxford and other centers. But, my expectation would be that this antibody would have a similar use like aquaporin-4 antibody has. Also, aquaporin-4 antibodies are more specific for a specific type of disease. MSDF You've discussed anti-MOG antibodies in terms of diagnosis. You mentioned prognosis, better course. Can they be useful for following therapy? Do the antibodies actually disappear with immunosuppression, or are they always present? Dr. Reindl The point is in the monophasic cases the antibodies disappear anyway. So, I guess in 70% to 80% of all patients – particular the pediatric patients – they have these antibodies at disease onset at high titers, and with time they disappear. They only are persistent if there is a bad recovery or if there's a recurrent disease cause, like recurrent optic neuritis would be an excellent example for this. If you look at therapies, of course, therapies like plasma exchange or corticosteroid used at high doses will lead to a disappearance or a drop of antibody titers. I think we have no really long-term experience, at the moment, because these antibodies were just discovered a few years ago, until long-term studies are ongoing. MSDF Is there any work on what triggers these antibodies; whether there's exposure of antigens, what agents may be involved—environmental, genetic, viral? Dr. Reindl This is the $100 million question. Of course, we would be happy to know it. It's the similar situation like with aquaporin-4 antibodies. Also there we still don't know it. What is particular interesting is that this is most frequently observed in children at the age under 10 years. These are children that are frequently exposed to infections – the respiratory infections and other infection – therefore it's highly likely that the underlying cause is infectious. But at the moment, as far as I know, there were a couple of studies, at least, but no real systematic study using a lot of patients and with a good epidemiological setup. MSDF If there's an infectious agent, is it that it is causing damage to myelin, which is exposing antigens, or there's some crossreactivity with the infecting agent itself? Dr. Reindl Both things I think could be possible. The animal models tell us a lot of this. This is work published by Hartmut Wekerle’s group three years ago where they discovered that in transgenic animals – animals that are transgenic for MOG T cells – gut bacteria activate these T cells that go into the brain, and then MOG is released, transported out by dendritic cells to the cervical lymph nodes. And at this stage, the antibodies are induced and built. So it's a rather secondary phenomenon, which is caused by T-cell damage and T-cell destruction. I could imagine that a similar phenomenon could also help in the human situation, particularly if you consider ADEM, which has large lesions, a lot of inflammation going on there. I think it's highly likely that antigen is released, and MOG is one of the most antigenic components of the central nervous system. MSDF So what are the big lines of research right now – two or three of them – or the big questions that people are approaching? Dr. Reindl At the moment, of course, a better developmental definition of the assay—I guess this is one of the most important—is we're working together – a lot of laboratories, a couple of groups – to improve our assays to come to a common standard and to develop an assay which could be used by different laboratories in the world. The second is, of course, to better define the clinical and neuropathological diagnosis of the patients presenting with these antibodies. Because at the moment, it's rather diffuse. You have children with ADEM, you have children with optic neuritis, children with myelitis. You have adults with NMO-like symptoms. And to put this together in a better way is, of course, highly challenging, and this is work ongoing at the moment. I think we will have more results of this by the next year. And of course, the third thing is just to look better at the long-term prognosis of these patients. How these antibodies fits in their long-term prognosis, if they are rather beneficial or not. And this is also work that only can be clarified using larger cohorts of patients and international studies. MSDF So is it fairly rare to find anti-MOG antibodies? Dr. Reindl In adults, yes. In children, no. So if you look at children presenting with demyelinating syndromes, from our own ongoing study cohort in Germany and Austria—we know it's about a third of all children presenting with demyelinating syndromes—more than a third have these antibodies. If you look at adults, it's much more rare. I guess it's about 5% or less. MSDF Well, thank you very much. Dr. Reindl You're most welcome. [transition music] MSDF Thank you for listening to Episode Seventy-four of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. MSDF’s executive editor is Carol Cruzan Morton. Msdiscovery.org is part of the non-profit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is vice president of scientific operations. Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances. We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org. For Multiple Sclerosis Discovery, I'm Dan Keller. [outro music]

Full Transcript: [intro music] Host – Dan Keller Hello, and welcome to Episode Seventy-three of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller. Today's interview features Donna Osterhout, a cell biologist at Upstate Medical University in Syracuse, New York, USA. Dr. Osterhout talks about a new way of looking at myelin-making cells, which move and change shape in dramatic ways. Current MS drugs take aim at preventing new immune damage. In the future, researchers hope to figure out how to repair myelin and restore function. But first, let’s look at new content on MS Discovery Forum. Spring brings rain, flowers, and a bouquet of scientific meetings related to multiple sclerosis. See the list at msdiscovery.org under the tab “professional resources.” MSDF sent the only journalist to cover the recent meeting of the American Society of Neurochemistry in Denver, but you can count on a blitz of news from the media pack at the next meeting on the calendar – the American Academy of Neurology in April, happening this year in Vancouver, BC, Canada. The number of research papers about multiple sclerosis has doubled in the last 10 years, and many findings are first reported at meetings before publication. Moving on, let’s sample a few of the new papers we found in our weekly PubMed search of the world’s largest medical library, the National Library of Medicine. You can link to each week’s list of curated papers at msdiscovery.org. Related to this week’s podcast, a new paper reviews the latest research about the molecular cues that allow precursor cells to mature and go through the stages of making myelin. These cues come from axons and from other surrounding tissue. Clinical drug development efforts focus on overcoming inhibitory cues, such as with the experimental agent anti-LINGO-1, now completing phase 2 clinical trials for MS and acute optic neuritis by Biogen. The review authors suggest future drugs to repair myelin could boost permissive and promotional cues, which may go wrong in disease. The paper is published by researchers at the Virginia Commonwealth School of Medicine in the journal Experimental Neurology. Another report updates the Cochrane systematic review on teriflunomide, a daily oral medication for relapsing remitting MS marketed under the brand name Aubagio by Sanofi Genzyme. Cochrane’s systematic reviews are ranked among the highest level of medical evidence, because of the rigorous independent analysis of multiple studies, including randomized controlled trials. The authors write that, as a single drug, the high dose of teriflunomide was as effective as interferon beta 1-a, while the low dose was less effective. They recommended longer follow-up analyses and noted that the available evidence was low-quality, as well as subject to bias, in part because all studies were sponsored by pharmaceutical companies. In general, side effects were mild to moderate and do not usually lead to treatment being stopped, but the higher dose is more prone to cause these side effects. The study is available in the Cochrane Library. The final editor’s pick this week takes a fresh look at how medical images transform a patient’s view of her own body. The paper describes an artistic collaboration between Devan Stahl, a bioethicist at Michigan State University with multiple sclerosis, and her sister Darian Goldin Stahl, a printmaker. The resulting art – some of it life sized – superimposes Devan’s narrative and MRI images with body photos. Devan wrote in the paper that the art collaboration has made it easier to talk about her MS. The paper is published in the journal Medical Humanities. If you're in town for the big Neurology meeting, you can catch Darian’s artist talk on April 17 at 2 pm at Malaspina Printmakers in Vancouver, Canada. [transition music] And now to our interview. We caught up with Donna Osterhout in Denver, Colorado at the March meeting of the American Society for Neurochemistry. She organized a symposium that told a new story about myelin-making cells. In different labs, researchers started looking for clues in the radical shape changes that occur in the cells in their normal process of making myelin. These oligodendrocyte precursor cells sprout “arms” to reach out and touch neighboring axons. Then they push out slabs of fatty membrane and wrap them around and anchor them to the axons. In multiple sclerosis and other demyelinating diseases, the immune system attacks this myelin wrap, and the cells cannot keep up with repair. The unprotected axons may be damaged or destroyed, causing the worsening disability of MS. Learning how the cells make myelin may pave the way toward new therapeutic agents to repair demyelinated axons and restore function. Dr. Osterhout spoke with our executive editor, Carol Cruzan Morton. Interviewer – Carol Cruzan Morton So we are here, in Denver, at the annual meeting of the American Society for Neurochemistry, and you've put together a very interesting panel on a new way of looking at myelin. So can you sort of set the scene for us when you're talking about the myelin research that you're working on? Interviewee – Donna Osterhout Well, myelin is a specialized membrane that is wrapped around axons; it occurs in the last step of development. And oligodendrocyte progenitor cells are the cells that form myelin. They are going to migrate out through the developing brain and they're going to extend processes that come in contact with axons that need to be myelinated. And when they get the appropriate signals, they are going to start a process by which they synthesize and extend a large membrane, which wraps around this axon many times and compacts and forms myelin. The way that this happens has been a mystery thus far, but recent research suggests that there has to be a lot of rearrangements of the internal cytoskeleton for this to happen. And so the symposium was organized to talk about how the cytoskeleton might be changing to allow for this membrane wrapping and myelin formation. MSDF Can you tell me more about the cytoskeleton? Dr. Osterhout The cytoskeleton is comprised of specialized proteins within cells, and every cell has a cytoskeleton; it gives it shape, but it also allows it to migrate, differentiate, and extend processes, so cells wouldn't be able to do much without a cytoskeleton. And in the case of oligodendrocytes, there are a lot of cytoskeletal rearrangements that occur to allow for myelination. MSDF Can you tell me more about the emerging view about how myelination may be working based on this new way of looking at it? Dr. Osterhout Initially, we know that there are early signals that trigger extensive process outgrowth from these cells. Once the axon sends a signal to the oligodendrocyte progenitor cell, they start to put out many, many processes, synthesize myelin proteins, and make this big membrane that will wrap around the axon. What winds up happening is that in the past everybody thinks that we've needed a driving force so that something pushes this forward, and it had been thought that perhaps the actin cytoskeleton was the driving force behind this. The newer research indicates that initially you have to have signals that trigger the process outgrowth, but this is followed by an actual disassembly of the actin cytoskeleton. So it's somewhat opposite of what we had thought previously. MSDF Can you tell me more about the steps that are involved in the process of myelinating that you and your colleagues have been discovering? Dr. Osterhout Well, the initial step is the activation of a cellular kinase called Fyn tyrosine kinase; this is the earliest step in the differentiation of these progenitor cells. Fyn will be activated by any number of signals from the axon including, for example, glutamate that's released. And once Fyn is active, it initiates a rearrangement of cytoskeletal proteins called microtubules in order to facilitate process outgrowth so we can extend processes to form this membrane. In later stages, then we have Fyn helping to trigger the synthesis of myelin proteins, and then you start to get other proteins active that will disassemble the actin cytoskeleton. There is even some evidence that perhaps myelin basic protein can do this. So Fyn signaling will turn on early and promote the synthesis of myelin basic protein, and then myelin basic protein will proceed down these processes and help to disassemble the actin cytoskeleton so the membrane can wrap around the axon. MSDF Can you describe what the cells look like when they're going through this process? Dr. Osterhout Well, this is really interesting to study, especially in vitro. You can set up myelinating cultures of oligodendrocyte progenitor cells. They're very simple cells, they're like bipolar, two to three processes, and that's the earliest progenitor that we might look at. But once you trigger differentiation, they start to put out processes in a somewhat predictable manner. They will first extend five processes, and then these five processes start branching And they produce these intricate branches. At some point these mature cells will actually look like a lace doily; they are spectacular with the cell body in the center and all these highly branched processes surrounding it. And then you see a transformation of these processes into this huge membrane sheet, and in the absence of an axon it's just going to cover the tissue culture dish; it's amazing how large this can get. But if you had an axon in the culture, this membrane sheet would just form myelin. They would form a myelin segment wrapping around the axon. MSDF That’s so interesting. And then can you say, adding to that picture, the steps that are happening in those process that you and your colleagues have been discovering? Dr. Osterhout So when you have the initial process outgrowth, you have Fyn tyrosine kinase active, and that facilitates the initiation and that extensive process outgrowth. But the transition between the process outgrowth and the formation of membrane sheets is going to be the disassembly of the actin cytoskeleton. MSDF And that's the big news is that the actin cytoskeleton is breaking down instead of pushing the myelin forward as it's making its multiple wraps around? Dr. Osterhout Yes, this seems to be the way that this is happening mechanistically. The formation of that myelin membrane requires the actin disassembly, and two of the speakers that we had in our symposium gave evidence to this, using several different experimental systems. And then ultimately when you're going to anchor this myelin sheath, and you can get some specializations in the axonal membrane, and this is what one of the speakers talked about, anchoring the perinodal loops, kind of the ends of the myelin segment. And so we have a process by which we have extensive process outgrowth triggered by Fyn. Then once you get the process outgrowth, you have actin disassembly and you form these membrane sheets, and then they would wrap around the axon, forming myelin, and then you would stabilize it with special proteins in the axon that stabilize the ends at the perinodal loops. MSDF So what does this have to do with diseases like multiple sclerosis? Dr. Osterhout That's a very good question. If we understand what goes on in development, then we might be able to predict how we could facilitate this process in a demyelinating disease like multiple sclerosis. We do have oligodendrocyte progenitor cells in our brain and spinal cord. They persist as a population throughout adulthood. And any time you have a lesion or a trauma to the brain, and especially if you get demyelination, then you'll have these cells migrate to the area of demyelination. And if we can encourage them to remyelinate, they would undergo the same steps. We have shown evidence that the inflammation and other conditions in a demyelinating disease upregulates chondroitin sulfate proteoglycans, and these can actually inhibit the process outgrowth and remyelination by oligodendrocytes, because they ultimately inhibit the activation of Fyn kinase. So if you're considering a disease process, you want to stimulate these steps. And you want to look for agents that might trigger and make sure that these steps proceed, or neutralize things that would be present in the lesion that would inhibit this. MSDF One interesting aspect of your work, and perhaps of science more generally, is that some of these discoveries with relevance to multiple sclerosis come from your work on spinal cord injury. Can you talk about how that works in science? Dr. Osterhout Well, spinal cord injury is another type of lesion, it's a specialized lesion; you have damage to axons as well as demyelination due to trauma. But in diseases in general in the brain and the spinal cord, whenever you have an injury process or inflammation or some kind of destruction of tissue, you get an inflammation and immune influx, and you will get a process called reactive gliosis. And this is common to many diseases that you see in the brain. For example, you can see it easily in spinal cord injury, it's been well documented. You can see these proteoglycans' reactive gliosis in multiple sclerosis, you can see it in Alzheimer's disease, Parkinson's disease, and other conditions, because they all have a common element that you've got some kind of inflammation occurring and tissue destruction occurring at a specific place. MSDF Getting back to multiple sclerosis and the work on how cells myelinate axons, what are the next big questions that you and your colleagues are asking? Dr. Osterhout Well, there still are a lot of questions about exactly how this myelination process is accomplished even during development; we don't fully understand all of the triggers that would activate this process. And, likewise, we don't always understand things that might inhibit this process. So we need to more fully characterize what's going on in development so that we can take a look at it in the remyelinating situations, either in spinal cord injury, or multiple sclerosis, or any other demyelinating condition. MSDF Well, that's really interesting. Well, thank you for taking the time to explain the research. Dr. Osterhout And thank you for your interest; it's been my pleasure. [transition music] MSDF Thank you for listening to Episode Seventy-three of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. MSDF’s executive editor is Carol Cruzan Morton. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations. Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances. [outro music]  

Transcript: [intro music] Host — Dan Keller Hello, and welcome to Episode Seventy-two of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller. Today's interview features Nathaniel Lizak, a young Australian investigator from the University of Melbourne who gave the first talk at the recent meeting in New Orleans of the Americas Committee for Treatment and Research in Multiple Sclerosis, or ACTRIMS. Mr. Lizak discusses new findings showing that moderately advanced and advanced multiple sclerosis are more unpredictable than anyone knew, but worsening disability may be slowed by highly effective therapies. But first, let’s look at new content on Msdiscovery.org. Our latest data visualization shows statistical snapshots of MS worldwide. Survey data from the MS International Federation show that, as of 2013, the estimated number of people in the world with MS increased to 2.3 million, or about 33 people with MS for every 100,000 people. But MS rates and access to care vary widely from country to country, as you can see from the data visualization. In a new job posting, the Stanford-affiliated Santa Clara Valley Medical Center Department of Neurology seeks a general neurologist. Subspecialty training in MS, movement disorders, or vascular neurology is preferred. You can post your job at MSDF at no charge to reach researchers and clinicians specializing in MS and related demyelinating disorders. [transition music] And now to our interview. Australian medical student, Nathaniel Lizak, and his academic mentors took a second look at how disease progresses in people with moderate and advanced MS and what can be done about it. Researchers are looking for better measures of disability, but the most common one is the Expanded Disability Status Scale or EDSS for short. Lizak and colleagues looked at worsening disease from several starting points, using an international registry known as MSBase that tracks medical record data on nearly 38,000 people with MS. They divided people in three epochs ranging from EDSS 3.0 (where people are moderately disabled but are fully ambulatory) to EDSS 6.0 and higher (where people need assistance to walk short distances). An older study suggested a steady worsening of disease after EDSS 3.0, which Lizak and co-workers questioned. Executive editor, Carol Cruzan Morton, spoke with him about their findings. Interviewer – Carol Cruzan Morton We are here at the ACTRIMS meeting in New Orleans, and you opened the conference with a really interesting paper. I wanted you to explain a little bit about what you were asking and why. What area of MS, what questions you are addressing? Interviewee – Nathaniel Lizak So we did this work under the MSBase group, which is an MS-based cohorts; it is an international really large study that has data from over 30,000 patients worldwide. We have access to all of their data, and we really thank our contributors throughout the world who have provided this. We decided – because we have so much power with so many numbers and so much data from patients – to look at the latest stages of multiple sclerosis which, so far, haven't really been that well explored. There have been three studies in the past which looked at disability and how it progresses in what they have called the moderately advanced stage of multiple sclerosis. So yeah, we looked at disability accumulation in the later stage of multiple sclerosis moderately advanced, which is defined before as between the EDSS steps of 3.0 or 4.0 and 6.0, and we wanted to look at what predicts how the disability accumulates, because a lot of the previous studies didn't really suggest anything really changes disability. There is this notion amongst doctors that once it hits these thresholds the trajectory is set, and there is nothing you can do to help patients. We didn't believe that. We were hoping there was something you can still do for patients, even once they have already accumulated substantial amounts of disability. We set this up to look at just how much variability there is in these later stages of disease and what we can do to take it from going really fast to going really slow, to preventing patients from getting even worse. We used our cohorts, ran lots of statistics, and we found some very interesting results. The first is that this late stage of disease is quite independent from what happens before. How many relapses people have early in the disease, how fast they got to the early disability landmarks, how fast they accumulated disability, if they were on therapy in the past—all of those things don't really seem to impact what happens later on in the disease. That is what we call the amnesic disease phenomenon. That is something that has already been explored in the past. We kind of confirmed that and saw that, that happens at lots of stages in multiple sclerosis. What is more interesting, though, is that we still found that patients have a lot of variability in what happens to them, even after they have accumulated substantial disability. So in technical terms, after EDSS 3.0, 4.0, and 6.0, there is still a lot of variability in what happens to patients after they have reached these steps, after they have already obtained disability. That suggestion that after the threshold the disease is set doesn't seem to be at all the case. That is all we observed in our patients. We had over 3,400 patients— we had 3,415 patients exactly. So it is quite I think, generalizable, our results. There is a lot of variation in what will happen at these later stages of disease. MSDF You can't predict what happens next. And it is different. Mr. Lizak It is different for everyone. It is independent of what happened before, and almost nothing predicts what is going to happen next. The only things that we found which did predict such as how does disability progress in these later stages, the first one was how many relapses they are having now. Not before, not early in the disease, but how many relapses are they now having per year at these later stages? We found that more relapses later in the disease still contribute to disability. That wasn't something that the other studies had actually shown, and I think that is to do with their methodology more than anything else. I think we are confirming that relapses are still important, inflammation is still important, we still need to treat it, no matter how far along the disability line the patients are. The relapse is still a problem. A more exciting thing that we found was that the immunomodulatory medications that the disease modifying therapies, the higher efficacies ones, the new medications, the longer patients are on those in the later stages of disease—so again, after those landmarks, after EDSS 3.0, 4.0, and 6.0—he longer patients are on those after they have gone into that disability the lower their likelihood of progressing even further to EDSS 6.0 and 6.5, which is mobility issues needing unilateral assistance or a walking stick, EDSS 6.0 or bilateral walking assistance EDSS 6.5. So those are pretty, obviously, important to patients in being able to move around without needing any aid. We found that we can prevent patients from getting to these later disability stages with longer time on disease therapies later on in the disease. So the conclusion we got from this is patients should continue being treated later in multiple sclerosis. Of course, it's always a risk/benefit calculation. You always need to take the side effects into consideration and look at the patient that you are seeing. It is not a blanket rule, but there are countries in the world where it's by policy you can't give therapies later on in disease after EDSS 4.0. New Zealand is one example. In other places in the world, it is just practice to stop giving treatments later in multiple sclerosis, and we are suggesting no there still is a benefit and you should be weighing that up when considering whether or not to continue patients on therapy, whether to start them on stronger therapies. There is evidence that we can still slow down how the disability will accumulate. That was our main message. We were a bit surprised to find out it was not what we were expecting, but we are very happy that we found such results. MSDF In your study, what drugs were categories as the high efficacy? Mr. Lizak I don't remember exactly every single drug, but we just put into two groups. The low efficacy being primarily the initial very first-line drugs, so interferon, glatiramer acetate, and teriflunomide; everything else categorizes as high-efficacy therapy, so natalizumab, fingolimod, alemtuzumab, dimethyl fumarate, cladribine, mitoxantrone, I might be missing a few. By no means are we saying that one therapy is better than another. We're just looking at the class effect of the really strong medications. We don't yet have the power to say this is the best medication after EDSS 6.0, this is the best medication after EDSS 4.0, or don't go on that one. We're just trying to say that the stronger perhaps second-line therapies often used second-line do have a better effect in this later period of disease, and doctors should be considering that when deciding what treatments their patients should go on, and patients should obviously be made aware of that as well. MSDF The idea that things that happen before don't affect the later stages seems on the surface to be at odds with the idea that progressive disease starts early, like treat early. Mr. Lizak …to try to treat disease as early as possible. I don't think it is at odds. There's been a lot of work, so far, to say that the earlier you treat your patients the better. We agree with all of that. We are not saying treating later is any better. Probably believe that treating earlier is better, but what we are saying is: a) continue treating, and don't stop treating. I completely agree that all of the patients that we found that after EDSS 3.0, 4.0, and 6.0 improved with more therapy after those landmarks, still probably did better earlier on in their phase of disease with therapy then. But I guess what we saw is the therapy they had earlier in disease won't make an impact now. You need to continue treating these patients for them to have an improvement. We still absolutely encourage the earlier treatment, the better. That evidence is beyond doubt in multiple sclerosis. We are definitely not challenging that. We completely agree with that. Our evidence just goes and takes it one step further of, the earlier the better, but it is not too late. MSDF Now you are doing this study in the context of a clinical practice. How has that changed – or has it changed – how people with MS are treated in the decision making? Mr. Lizak The thing is, first of all, I am a medical student, so I don't make any of the decisions. Secondly, where we are based in Melbourne, Australia, there is already a tendency to treat patients later on in disease. Obviously we haven't published the results yet, so we haven't seen how much of an affect it will have worldwide. Perhaps now we will begin to start changing things. But in Australia where nothing was studied, no one was surprised to find that this was the case. All the doctors there already treat their patients later on in the disease. So it just confirmed that what they are doing is correct. No one has yet drastically changed how they are treating patients. We hope though that, say countries like New Zealand whereby policy after a certain EDSS score, after EDSS 4.0, after moderate disability has been accumulated, you can't put patients on disease-modifying therapy anymore—we hope that is where we will have the biggest impact. MDSF When you gave your talk, you talked about the earlier study. There wasn’t an appreciation for the variability. How did you come to ask that question in the first place? Mr. Lizak I have to give credit to my supervisor, as well as the whole MS based team that was behind this study, and obviously they conceptualized it a lot more than I: Dr. Thomas Kalincik and Helmut Butzkueven, in particular. But a lot of doctors, particularly our team, are not happy with that graph. Which it looks like everyone after EDSS 3.0 has the same trajectory. We looked at this, and we thought we wanted to do a study to prove this wrong. We didn't know exactly what we were going to find. We actually proved that what they first suggested of disease being independent to be quite correct. But they just missed the variance in the second half. It is independent, but it is still really variable. We looked at the graphs carefully, and we looked at the study carefully, and we made the note of they only have a mean value on that top half, they don't show how much variability there may or may not be in disease. We got confused. We said it is unlikely that patients have no variability at all after EDSS 3.0, and we decided not only are we going to look at what predicts the later disease, but we need to know just how variable is this disease this late, and we found that it is extremely variable. After EDSS 6.0, patients might go straight through to worse disability, and many will improve, and many will stay stable for many years. We were just unhappy with the message that the graph gave. Then we tried to scrutinize exactly where can we change this message, where can we improve this. MDSF That’s great. What questions are your colleagues asking you here about the study? Mr. Lizak I have had a lot of questions about this study, some more helpful than others. A lot of people have asked how will this change management? And I think we have just spoken a little bit about that. I am asked, as well, how do you tell patients that we can no longer predict their disease? We used to think that we could and now we just outright can't predict their disease and that is something that is going to be difficult to tell the patients. I think you need to frame it differently. It is not we can't predict how your disease is going to go, it is, we have hope for making it better. You might have been doing not so well up until now, but we still have hope to continue fighting. We haven't given up yet. And I think that is what we need to be framing it as. That is one of the questions I have gotten the most. A lot of people have asked about why we chose certain therapies, and there is very little evidence about which therapy is high and which therapy is low. We just used the available studies as well as the clinical experience and just compared how much they reduced relapse rates and so on. It was partly based on intuition and observation. It could be the case that some therapies should have been classified differently to what we did, but it is very hard to tell at this stage. Even then, even looking at the list, you should be mindful that a therapy that we classified as high efficacy might have actually been bringing that group down. And maybe should have been a low efficacy therapy, and maybe a low efficacy therapy was the only one working in that group, and it should have been in the high efficacy group. So obviously, be very careful when you look at that. At that strata, it is not meant to be telling anyone I should be on that drug or I shouldn't be on that drug. It is just meant to be saying that strong medications are better in this stage, but the decision of the medication should be a decision made entirely by the patient and their doctor, and it should only be used to influence and it shouldn't be taken any more than that. MDSF Is rituximab in your …. I was going to say before a B cell therapy. Mr. Lizak I don't think we have many patients on rituximab, but we would have had quite a few. Yes, because it was used quite extensively. MDSF Thanks. Is there anything else that I haven't asked or that you wanted to add? Mr. Lizak Rituximab wasn't the high efficacy group. I should mention that. Yes. Thank you for the fantastic opportunity to showcase the work we have been doing. I obviously have to give credit to everyone at MSBase who conceptualized and gave patients the study. We couldn't have done it without the help of our collaborators worldwide. [transition music] MSDF Thank you for listening to Episode Seventy-two of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. MSDF’s executive editor is Carol Cruzan Morton. The data visualization was developed by Jean Mercier of Khawai Data Visualization at Khawai.com. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations. Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances. [outro music]   We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org. For Multiple Sclerosis Discovery, I'm Dan Keller.      

[intro music] Host – Dan Keller Hello, and welcome to Episode Seventy of Multiple Sclerosis Discovery, the podcast of the MS Discovery Forum. I’m Dan Keller. In today's interview, we'll talk with Dr. Brian Weinshenker of the Mayo Clinic about new diagnostic criteria for neuromyelitis optica spectrum disorder and how it differs from MS. The new criteria build upon and broaden the definition of NMO that was based, in part, on the presence of antibodies to aquaporin-4. But to begin, let’s sample a few of the new studies we found in our weekly PubMed search of the world’s largest medical library, the National Library of Medicine. You can link to each week’s list of curated papers at msdiscovery.org. On topic with our interview, an international team led by researchers in Tianjin, China, found a unique group of people with neuromyelitis optica spectrum disorder, or NMOSD, who carried autoantibodies to both aquaporin-4 and myelin oligodendrocyte glycoprotein or MOG, a minor component of myelin. Among the 125 patients, 10 were double positive for both sets of antibodies, and 14 were positive only for MOG. The double-positive patients had a worse disease course, most having MS-like brain lesions and more disability. Those with only MOG antibodies had a milder disease and less disability. If verified in other studies, the findings may help predict the clinical course of NMOSD or even define a new phenotype somewhere between the two very different diseases of NMOSD and MS. The authors say their paper also raises a new challenge of how to diagnose and treat such patients. Three double-negative patients did not respond to rituximab, a highly effective anti-B cell therapy used off label for MS and NMO. The study is published in the journal Science China Life Sciences. For people with MS and other demyelinating conditions, bladder issues can play an oversized role in the quality of life. A pair of review articles addresses the “neurogenic bladder.” One from Duke University researchers in North Carolina, USA, recommend an evaluation known as urodynamics, calling it the gold standard in helping to break down the complex problem into basic and treatable factors. In the other paper, researchers from Western University in Ontario, Canada, review the 16 different ways to measure patient reported outcomes for neurogenic bladder, and how to choose the best one to track patients’ quality of life. Both reviews are published in the journal Translational Andrology and Urology. In the news section, MS Discovery Forum correspondent Stephani Sutherland wrote about the recent negative results of fingolimod in a large Phase 3 clinical trial of people with primary progressive MS. Even in failure, studies can be informative and can help researchers design better investigations to test potential therapeutics for progressive disease. Now, let’s move on to our drug development database. The drugs with important additions and changes are daclizumab, fingolimod, and ocrelizumab. One update reflects findings presented at last month’s ECTRIMS conference in New Orleans suggesting that in primary progressive MS, the experimental drug ocrelizumab reduces disease activity in subgroups of individuals with and without gadolinium-enhancing images at baseline. [transition music] And now to our interview. It’s been 11 years since neuromyelitis optica, or NMO, was redefined as a separate disease from MS. Thanks to the discovery of the first biomarker for NMO, an antibody against aquaporin-4, diagnostic criteria for neuromyelitis optica, or NMO, were revised. In today's discussion, Dr. Brian Weinshenker of the Mayo Clinic in Rochester, Minnesota, USA, lays out further revisions to the criteria and the reasons for them. He uses a couple of terms that may warrant definition. One is IgG, which is immunoglobulin G, a particular class of antibody. Other terms are seropositive, meaning, in this case, the presence of antibodies to aquaporin-4, and conversely, seronegative, the absence of such antibodies. Finally, ADEM, A-D-E-M, is acute disseminated encephalomyelitis, a sudden, widespread attack of inflammation in the brain and spinal cord, usually seen in children. I spoke with Dr. Weinshenker at the ECTRIMS meeting last fall in Barcelona about the new consensus diagnostic criteria for NMO. Interviewer – Dan Keller Is there something that was lacking before? Interviewee – Brian Weinshenker Well, the first diagnostic criteria for neuromyelitis optica were proposed by our group at Mayo Clinic in 1999. And in 2006, with the advent of the first diagnostic biomarker for neuromyelitis optica, an antibody which we now know is directed against aquaporin-4 – I’ll call it aquaporin-4 IgG – the criteria were revised. But there was a need to revise them. We became increasingly confident in this diagnostic biomarker, and it was possible to make an earlier diagnosis, often after the very first symptom. So that was one key driving factor. And furthermore, with the advent of this biomarker, we’ve appreciated that the spectrum of this disease is far broader than we had previously recognized. And there are a number of clinical syndromes that were previously not recognized as being part of the neuromyelitis optica spectrum that we now know are, and those needed to be integrated. Another key factor was the fact that a number patients that we recognize have this same condition now did not meet the old criteria. For example, you had to have both optic neuritis and myelitis to make this diagnosis, and we recognize some patients with this condition have just recurrent myelitis or just recurrent optic neuritis; they wouldn’t have satisfied the criteria. So those were the key reasons that drove developing new criteria. MSDF What are some of the new criteria? Dr. Weinshenker The first important point is that we’ve eliminated distinction between neuromyelitis optica – that is, having optic neuritis and myelitis – and having some of these more limited forms or unusual forms of the disease with brain lesions. And we’ve used the term neuromyelitis optica spectrum disorder to refer to all of them. Second aspect of the diagnostic criteria is that we’ve stratified them based on whether or not you have this biomarker, the aquaporin-4 IgG. And we’ve separately defined patients with that biomarker and those without, the largest group being those with the biomarker. So in the patients with this biomarker, we really require only one clinical syndrome. The clinical criteria are very, very liberal, and we don’t even require, say, for myelitis, as we had before, we used to require having a long spinal cord lesion. We now recognize that about 10 to 20% of patients do not have those kind of long spinal cord lesions when they have a myelitis, so we no longer require it if you have that biomarker. But we’ve left open a category that we call seronegative neuromyelitis optica spectrum disorder, because some patients who meet all of the various clinical criteria’s, even the strictest clinical criteria, seem to be seronegative for this biomarker. We recognize that’s a heterogeneous group of patients; some of them ultimately will become seropositive. In some of those patients, we’re recognizing other antibodies that seem to be associated with a similar clinical syndrome, so I think, ultimately, we may create new silos based on those biomarkers, but when these criteria were developed, it was felt to be premature to include other antibodies as diagnostic biomarkers. So we’ve grouped them into this group of seronegative NMO spectrum disorder. But we’re much more strict in that category. We do require two clinical syndromes – two different clinical syndromes – and in some situations we do require additional MRI criteria in order to meet those criteria. MSDF Okay, because it was sounding like you were being so liberal about it people could lack this symptom and that symptom and antibody, but, in this case, if they’re lacking antibody, they need other criteria to qualify. Dr. Weinshenker That’s correct; both clinical and radiologic criteria. And we also have exclusionary – well, I shouldn’t say exclusionary. There are no exclusionary criteria. We refer to them as red flags. If you have certain characteristics that would make it more likely that you have MS, which is the major competing diagnosis, or if you have certain comorbidities like, say, cancer or sarcoidosis – we know sarcoidosis can sometimes mimic neuromyelitis optica – we add that as a note of caution, but strictly, no criteria is considered exclusionary for a diagnosis of neuromyelitis optica spectrum disorder. MSDF Would other systemic autoimmune states also fall into the category of red flags: we’re going to have to decide whether it really is NMO or not? Dr. Weinshenker Actually, that used to be excluded by some people that if patients had systemic lupus or Sjögren's disease they were excluded, but we recognize that patients with neuromyelitis optica spectrum disorder have an excess of those other autoimmune diseases. We very frequently detect comorbid disease, so we actually say that, say, a diagnosis of lupus or Sjögren's actually increases the chances that his patient has neuromyelitis optica spectrum disorder if they present, say, with optic neuritis or myelitis. The old literature was replete with patients who were described as having lupus myelitis. Actually the majority of those patients actually have comorbid neuromyelitis optica spectrum disorder. So it’s no longer an exclusionary criterion. MSDF There used to be a requirement for bilateral optic nerve involvement? Is that right? Has that gone by the wayside? Dr. Weinshenker Yes, this is before there were actually formal criteria, but yes, that was considered to be, say, a red flag that you might be dealing with neuromyelitis optica compared to standard MS. We recognize that that applies to a relatively small percentage of patients, so it doesn’t really appear in these current diagnostic criteria, but certainly it would not exclude it. And I would say that it does add to the suspicion that someone has neuromyelitis optica spectrum disorder compared to MS. MSDF What about pediatric neuromyelitis optica spectrum disorder? Dr. Weinshenker We did have several people, who were pediatrics experts, on our international panel and, in general, it was felt that the same criteria that we’ve applied to adults can be applied to children. We do recognize that certain brain syndromes are relatively more common in children, and there is one caveat, that is, in pediatric multiple sclerosis, sometimes patients will have long spinal cord lesions, and that’s one of the criteria that adds to the suspicion that somebody has NMO spectrum disorder as to MS. It may be somewhat less reliable in children. MSDF Is there any confounding or concern about ADEM in children? Dr. Weinshenker Well, neuromyelitis optica spectrum disorder can be associated with brain lesions that can be interpreted as ADEM. They can be large, tumefactive, extensive. Brain biopsy, which is not part of the criteria that we use for neuromyelitis optica spectrum disorder, can sometimes differentiate ADEM – standard ADEM – from the ADEM-like lesions that occur in neuromyelitis optica spectrum disorder, so yes, it can be a diagnostic problem. But generally speaking, if one relies on the other criteria – the presence of optic neuritis and myelitis, which can occur in both ADEM and neuromyelitis optica spectrum disorder – usually one can come to a clinical diagnosis. But there are some situations that can be confusing and occasionally additional tools, even brain biopsy, can be necessary to make a definitive diagnosis. MSDF If serologic testing is not available, do you still require the two other criteria to make the diagnosis? Dr. Weinshenker We propose that, for now, if serologic testing is not available – and there aren’t many places in the world where it’s strictly unavailable; it is offered worldwide – that you rely on the criteria for the seronegative and satisfy those criteria of seronegative NMO spectrum disorder. MSDF Are the criteria fairly straightforward that any neurologist up-to-speed can interpret them and use them clinically? Dr. Weinshenker Yes. We have designed these so that they can be used by neurologists in standard practice. Obviously, they don’t cover every single possibility, and there are complex patients where consultation will be necessary, but these are designed to be as good any diagnostic criteria can be. I think one has to realize that diagnostic criteria are for typical patients with conditions, and there are rare situations in difficult-to-interpret situations where one does need this kind of consultation. MSDF What about other historical terminology, and what kind of recommendations have you made vis-à-vis that? Dr. Weinshenker This has been a confusing element of the literature. For example, one term used in Asia, where it was recognized that you can have a relapsing condition that primarily targets the optic nerves and spinal cord was often referred to as Asian or Japanese opticospinal MS. And historically, this has been a very important contribution. I think our colleagues in Asia were the first to recognize that this relapsing condition was distinct from MS and may be something different, but the terminology was confusing. It was called opticospinal MS. Was this MS or something distinct from MS? And was it the same as neuromyelitis optica? And the panel felt that this term is no longer useful in clinical practice, and it doesn’t distinguish from multiple sclerosis. So it was felt all of those patients could be probably put into either the NMO spectrum disorder category or multiple sclerosis category, proposed that, for clinical practice, that terminology be eliminated. MSDF This is a good way to make the diagnoses, but it leads into the question of then what do you do? And next week’s podcast will focus on new clinical approaches to looking at NMO. [transition music] Thank you for listening to Episode Seventy of Multiple Sclerosis Discovery. This podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. MSDF’s executive editor is Carol Cruzan Morton. Heather McDonald curated the MSDF drug database updates. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations. Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances. We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org. For Multiple Sclerosis Discovery, I’m Dan Keller. [outro music]

Welcome to EPISODE SEVENTY of Succotash, the Comedy Podcast Podcast. 70!!! Seems like only yesterday I was asking myself "How do I get my voice to come out of that sound thingee?" I estimate that, in these first 70 episodes, that we have played over 630 podcast clips. Listenership continues to grow. And we have consistently been showing up on iTunes' "What's Hot" section as well as being recently featured on Stitcher.

Hello:Episode SeventyWe're joined this week by the erudite and engaging Professor Richard Wiseman; psychologist, magician and author of The Luck Factor, Quirkology and 59 Seconds.