The utility of computerized neuropsychological assessment of cognitive dysfunction in patients with relapsing-remitting multiple sclerosis

Traditional paper-and-pencil neuropsychological batteries used to document cognitive deficits in multiple sclerosis (MS) patients lack timing precision. This makes it difficult to accurately measure psychomotor slowing, a central cognitive symptom of MS. Additionally, traditional batteries lack multiple alternate forms necessary to control for practice effects when assessing cognition over time. Finally such batteries are lengthy and expensive. Computerized neuropsychological batteries address many of these shortcomings. They measure response time more precisely, require less administration time, include alternate forms, and are ideal for rapid screening/triage. Although there are normative data on the reliability and validity of computerized measures, there have been no controlled validation studies with MS patients. The current study was designed to validate a computerized neuropsychological battery (ANAM) for use with relapsing-remitting (RR) MS patients. Prior to initiation of interferon-beta-1a (Avonex) treatment, subjects participated in a neuropsychological evaluation consisting of traditional and computerized measures. Moderate-to-high correlations were found between computerized and traditional measures. Computerized tests accurately predicted performance on key traditional tests. The battery was also concordant with traditional measures in identifying RR MS patients with and without neurocognitive impairment. Findings are discussed with respect to increased accuracy and accessibility of neuropsychological evaluations for MS patients.

Phase III randomized trial of gabapentin in patients with amyotrophic lateral sclerosis

BACKGROUND

Preclinical and clinical studies of gabapentin in patients with ALS led the authors to undertake a phase III randomized clinical trial.

METHODS

Patients were randomly assigned, in a double-blinded fashion, to receive oral gabapentin 3,600 mg or placebo daily for 9 months. The primary outcome measure was the average rate of decline in isometric arm muscle strength for those with two or more evaluations.

RESULTS

Two hundred four patients enrolled, 196 had two or more evaluations, and 128 patients completed the study. The mean rate of decline of the arm muscle strength was not significantly different between the groups. Moreover, there was no beneficial effect upon the rate of decline of other secondary measures (vital capacity, survival, ALS functional rating scale, timed walking) nor was there any symptomatic benefit. In fact, analysis of the combined data from the phase II and III trials revealed a significantly more rapid decline of forced vital capacity in patients treated with gabapentin.

CONCLUSION

These data provide no evidence of a beneficial effect of gabapentin on disease progression or symptoms in patients with ALS.

Immunoconjugates of geldanamycin and anti-HER2 monoclonal antibodies: antiproliferative activity on human breast carcinoma cell lines

BACKGROUND

HER2 is a membrane receptor whose overexpression is strongly associated with poor prognosis in breast carcinomas. Inhibition of HER2 activity can reduce tumor growth, which led to the development of Herceptin, an anti-HER2 monoclonal antibody (MAb) that is already in clinical use. However, the objective response rate to Herceptin monotherapy is quite low. HER2 activity can also be inhibited by the highly cytotoxic antibiotic geldanamycin (GA). However, GA is not used clinically because of its adverse toxicity. Our purpose was to enhance the inhibitory activity of anti-HER2 MAb by coupling it to GA.

METHODS

We synthesized 17-(3-aminopropylamino)GA (17-APA-GA) and conjugated it to the anti-HER2 MAb e21, to form e21 : GA. The noninternalizing anti-HER2 MAb AE1 was used as a control. Internalization assays and western blot analyses were used to determine whether the anti-HER2 MAbs and their immunoconjugates were internalized into HER2-expressing cells and reduced HER2 levels. All statistical tests were two-sided.

RESULTS

The immunoconjugate e21 : GA inhibited the proliferation of HER2-overexpressing cell lines better than unconjugated e21 (concentration required for 50% inhibition = 40 versus 1650 microg/mL, respectively). At 15 microg/mL, e21 : GA reduced HER2 levels by 86% within 16 hours, whereas unconjugated e21, 17-APA-GA, or AE1 : GA reduced HER2 levels by only 20%. These effects were not caused by release of 17-APA-GA from the immunoconjugate because immunoconjugates containing [(3)H]GA were stable in serum at 37 degrees C. Furthermore, e21 : GA did not significantly inhibit proliferation of the adult T-cell leukemia cell line HuT102, which is HER2 negative yet highly sensitive to GA.

CONCLUSIONS

Our findings suggest that conjugating GA to internalizing MAbs enhances the inhibitory effect of the MAbs. This approach might also be applied in cellular targeting via growth factors and may be of clinical interest.

Synthesis and evaluation of antiproliferative activity of a geldanamycin-Herceptin immunoconjugate

Geldanamycin was modified with 1,4-diaminobutane to introduce a primary amine that was subsequently employed to provide a maleimide for protein linkage. Monoclonal antibody Herceptin was then derivatized to generate thiol groups that reacted with the maleimide derivative to produce the immunoconjugate. The product showed antiproliferative activity greater than native Herceptin.

Growth hormone-dependent tyrosine phosphorylation of a GH receptor-associated high molecular WEIGHT protein immunologically related to JAK2

A critical step in growth hormone (GH) signalling is the GH-induced activation of the GH receptor (GHR)-associated tyrosine kinase, JAK2. JAK2 is a 120 kD member of the Janus family of tyrosine kinases, whose other mammalian members include JAK1, JAK3, and TYK2. Using 3T3-F442A murine preadipocytes, we now report detection of a Mr approximately 170 kD protein, referred to as HMW ("high molecular weight") JAK2, that is specifically reactive in immunoprecipitation and immunoblotting experiments with three independently-derived anti-JAK2 antibodies--two directed at carboxyl-terminal regions of the molecule and one directed at the amino-terminus. Like JAK2, HMW JAK2 is tyrosine phosphorylated in response to GH treatment of cells and is coimmunoprecipitated with anti-GHR serum. Thus, HMW JAK2 is a protein not heretofore described that is immunologically related to JAK2 and is physically and functionally associated with the GHR.

Neuromyelitis optica (Devic's syndrome): no association with the primary mitochondrial DNA mutations found in Leber hereditary optic neuropathy

Devic's neuromyelitis optica is a rare syndrome characterised by the combination of acute or subacute optic neuritis and transverse myelitis, in some cases considered to be a variant of multiple sclerosis. Mutations of mitochondrial DNA (mtDNA) associated with Leber hereditary optic neuropathy (LHON) have been identified in some patients with multiple sclerosis in whom optic neuritis is a prominent early feature. Using restriction enzyme digestion of mtDNA products amplified by the polymerase chain reaction, the primary LHON mtDNA mutations at positions 3460 bp, 11,778 bp, and 14,484 bp have been excluded in four women with Devic's neuromyelitis optica. A mutation at 4160 bp associated in some LHON families with more widespread neurological disease was also not detected. It is concluded that the primary mtDNA mutations currently associated with LHON are not responsible for the prominence of optic nerve disease in Devic's neuromyelitis optica.

Interleukin 5 induces S mu-S gamma 1 DNA rearrangement in B cells activated with dextran-anti-IgD antibodies and interleukin 4: a three component model for Ig class switching

The cellular signals required for induction of immunoglobulin (Ig) class switching are only partially understood. Two processes that are considered to be necessary for such induction are DNA synthesis and germline constant heavy (CH) gene transcription. We now show that an additional signal, as mediated by interleukin 5 (IL-5), is also required. To induce proliferation of resting B cells, but not Ig secretion, we utilized anti-IgD antibodies conjugated to dextran (alpha delta-dex). The addition of IL-4, a well-established switch factor for the IgG1 subclass, to alpha delta-dex-activated cell cultures failed to induce IgG1 secretion or mIgG1+ cells unless IL-5 was also present. While IL-4 stimulated an increase in germline gamma 1 RNA in alpha delta-dex-activated cells, this effect could neither be induced nor enhanced by IL-5. By contrast, IL-5 strongly enhanced steady-state levels of productive gamma 1 RNA induced by alpha delta-dex and IL-4, suggesting that IL-5 stimulated IgG1 switch rearrangement. To test this possibility we measured switch (S) mu-S gamma 1 DNA recombination events using a newly developed assay, digestion circularization polymerase chain reaction (DC-PCR). We demonstrated that IL-5 was necessary for induction of S mu-S gamma 1 DNA rearrangement in alpha delta-dex plus IL-4-activated cells but that it had little effect on rearrangement in the absence of IL-4. Our data strongly suggest, therefore, a three-component model for induction of Ig class switching. This model includes germline CH gene transcription, DNA synthesis, and a third component that is necessary for recombination.

IL-4 induction of IgE class switching by lipopolysaccharide-activated murine B cells occurs predominantly through sequential switching

Resting murine B cells activated with bacterial LPS co-express membrane (m)IgG1 and mIgE upon stimulation with IL-4. In this report, we combine both cellular and molecular approaches to elucidate the mechanism underlying this co-expression. We demonstrate that an anti-IgG1 antibody specifically and selectively inhibits IgE secretion (approximately 70%) by LPS + IL-4-stimulated B cells, which provides functional evidence for mIgG1 expression by precursors of IgE-secreting cells. The IgG1 and IgE secretory responses are separated temporally by approximately 16 h, with IgE production developing later than IgG1. A similar delay is observed in the appearance of mIgE+ cells suggesting that class switching to IgG1 precedes that to IgE. In the sort-purified, mIgG1+mIgE+ B cell population approximately 25% of cells expressed cytoplasmic (c) (secretory) IgG1 and approximately 15% expressed cIgE at the time of their isolation. However, only a small percent of the mIgG1+mIgE+ cells co-expressed cIgG1 and cIgE, further suggesting a temporal separation in IgG1 and IgE secretion within individual cells, but indicating that single cells can co-secrete these two Ig isotypes. Furthermore, the absolute level and rate of increase of IgG1 secretion by mIgG1+mIgE+ cells, upon their isolation and reculture, is lower than that for mIgG1+mIgE- cells suggesting a loss of CH gamma 1 expression in the former population. Analysis of total, unselected circular DNA excision products in LPS + IL-4-activated B cells demonstrates that most, if not all, of the DNA encoding the IgG1 constant heavy gene (CH gamma 1) (i.e., products of a class switch to IgE) have been rearranged. Collectively this data provides strong evidence at both the cellular and molecular level that the predominant mode of switching to IgE in response to in vitro stimulation by LPS + IL-4 is from IgM to IgG1 to IgE.

IL-4 induction of IgE class switching by lipopolysaccharide-activated murine B cells occurs predominantly through sequential switching

Resting murine B cells activated with bacterial LPS co-express membrane (m)IgG1 and mIgE upon stimulation with IL-4. In this report, we combine both cellular and molecular approaches to elucidate the mechanism underlying this co-expression. We demonstrate that an anti-IgG1 antibody specifically and selectively inhibits IgE secretion (approximately 70%) by LPS + IL-4-stimulated B cells, which provides functional evidence for mIgG1 expression by precursors of IgE-secreting cells. The IgG1 and IgE secretory responses are separated temporally by approximately 16 h, with IgE production developing later than IgG1. A similar delay is observed in the appearance of mIgE+ cells suggesting that class switching to IgG1 precedes that to IgE. In the sort-purified, mIgG1+mIgE+ B cell population approximately 25% of cells expressed cytoplasmic (c) (secretory) IgG1 and approximately 15% expressed cIgE at the time of their isolation. However, only a small percent of the mIgG1+mIgE+ cells co-expressed cIgG1 and cIgE, further suggesting a temporal separation in IgG1 and IgE secretion within individual cells, but indicating that single cells can co-secrete these two Ig isotypes. Furthermore, the absolute level and rate of increase of IgG1 secretion by mIgG1+mIgE+ cells, upon their isolation and reculture, is lower than that for mIgG1+mIgE- cells suggesting a loss of CH gamma 1 expression in the former population. Analysis of total, unselected circular DNA excision products in LPS + IL-4-activated B cells demonstrates that most, if not all, of the DNA encoding the IgG1 constant heavy gene (CH gamma 1) (i.e., products of a class switch to IgE) have been rearranged. Collectively this data provides strong evidence at both the cellular and molecular level that the predominant mode of switching to IgE in response to in vitro stimulation by LPS + IL-4 is from IgM to IgG1 to IgE.

Induction of IgG3 secretion by interferon gamma: a model for T cell-independent class switching in response to T cell-independent type 2 antigens

T cell-independent type 2 (TI-2), in contrast to T-dependent, antigens stimulate the production of murine IgG3. To investigate a possible role for cytokines in mediating the induction of this IgG subclass, we established an in vitro polyclonal model system for studying TI-2 antigen-mediated B cell activation by using dextran-conjugated anti-IgD antibody (alpha delta-dex). We demonstrate that interferon gamma (IFN-gamma) stimulates, and interleukin 4 inhibits, the expression of IgG3 by alpha delta-dexactivated cells. The production of IFN-gamma by non-T cells in response to bacterial products, possibly capsular polysaccharides, may provide an explanation underlying the ability of TI antigens, which are unable to directly stimulate T cell-derived cytokines to induce Ig isotype switching.

Tumor cell autocrine motility factor

A cell motility-stimulating factor has been isolated, purified, and partially characterized from the serum-free conditioned medium of human A2058 melanoma cells. We term this activity "autocrine motility factor" (AMF). AMF has the properties of a protein with an estimated size of 55 kDa. At concentrations of 10 nM or less, AMF stimulated the random or directed motility of the producer cells. However, AMF is not an attractant for neutrophils. Amino acid analysis of the purified AMF protein revealed a high content of serine, glycine, glutamic acid, and aspartic acid residues. The activity of AMF was not replaced or blocked by known growth factors such as epidermal growth factor or type beta transforming growth factor. Mechanistic studies showed that AMF stimulated the incorporation of [3H]methyl into cell membrane phospholipids after incubation with [methyl-3H]methionine with a sustained increase in the methylation of phosphatidyldimethylethanolamine to phosphatidylcholine. In contrast, AMF did not affect the incorporation of [1,2-14C]choline into phosphatidylcholine. AMF was produced in large amounts by three different clones of ras oncogene-transfected metastatic NIH 3T3 cells but not by the nontransformed parental cells. AMF may play a major role in the local invasive behavior of tumor cells and may also facilitate the concerted invasion by groups of tumor cells.

beta-Endorphin augments the cytolytic activity and interferon production of natural killer cells

We have investigated the in vitro effects of the neurohormone beta-endorphin (b-end) on natural killer (NK) activity and interferon (IFN) production mediated by large granular lymphocytes (LGL). LGL-enriched fractions from peripheral blood mononuclear cells (PBMC) from normal human volunteers were obtained by fractionation over discontinuous Percoll gradients. LGL were preincubated with or without various concentrations of b-end or the closely related peptides alpha-endorphin (a-end), gamma-endorphin (g-end), or D-ALA2-beta-endorphin (D-ALA2-b-end), a synthetic b-end analogue. NK activity was assayed on 51Cr-labeled K562 target cells. Preincubation of LGL effectors (but not K562 targets) for 2 to 18 hr with concentrations of b-end between 10(-7) M and 10(-10) M produced significant augmentation of NK cytolytic activity (mean percentage increase: 63%). The classic opiate antagonist naloxone blocked the enhancing effect when used at a 100-fold molar excess relative to b-end. Neither a-end nor g-end could augment NK activity, whereas D-ALA2-b-end produced an enhancement comparable with that produced by b-end. In addition, incubation of LGL with b-end in the presence of phytohemagglutinin or poly I:C significantly augmented IFN production. These findings demonstrate that b-end enhances NK activity and IFN production of purified LGL, and suggests that b-end might bind to an opioid receptor on LGL that can be blocked by naloxone. These results lend support to the concepts of regulation of the immune response by neurohormones and the functional relationship between the nervous and immune systems.

beta-Endorphin augments the cytolytic activity and interferon production of natural killer cells

We have investigated the in vitro effects of the neurohormone beta-endorphin (b-end) on natural killer (NK) activity and interferon (IFN) production mediated by large granular lymphocytes (LGL). LGL-enriched fractions from peripheral blood mononuclear cells (PBMC) from normal human volunteers were obtained by fractionation over discontinuous Percoll gradients. LGL were preincubated with or without various concentrations of b-end or the closely related peptides alpha-endorphin (a-end), gamma-endorphin (g-end), or D-ALA2-beta-endorphin (D-ALA2-b-end), a synthetic b-end analogue. NK activity was assayed on 51Cr-labeled K562 target cells. Preincubation of LGL effectors (but not K562 targets) for 2 to 18 hr with concentrations of b-end between 10(-7) M and 10(-10) M produced significant augmentation of NK cytolytic activity (mean percentage increase: 63%). The classic opiate antagonist naloxone blocked the enhancing effect when used at a 100-fold molar excess relative to b-end. Neither a-end nor g-end could augment NK activity, whereas D-ALA2-b-end produced an enhancement comparable with that produced by b-end. In addition, incubation of LGL with b-end in the presence of phytohemagglutinin or poly I:C significantly augmented IFN production. These findings demonstrate that b-end enhances NK activity and IFN production of purified LGL, and suggests that b-end might bind to an opioid receptor on LGL that can be blocked by naloxone. These results lend support to the concepts of regulation of the immune response by neurohormones and the functional relationship between the nervous and immune systems.

Abnormal adenosine-induced immunosuppression and cAMP metabolism in T lymphocytes of patients with systemic lupus erythematosus

Normal human T lymphocytes incubated with adenosine (10 muM) for 30 min at 37 degrees C show an increase in the percentage of cells expressing receptors for the Fc portion of IgG (RFc(gamma)) and the OKT8 antigen, while the proportion of OKT4(+) cells decreases. These effects occur exclusively in a subset of T cells with theophylline-resistant sheep erythrocyte receptors (T(R) cells) that is enriched for OKT4(+) cells. Untreated normal T(R) cells express helper/inducer cell activity for T-cell-dependent B-cell differentiation, while adenosine-treated T(R) cells suppress B-cell differentiation. In contrast, in T(R) cells isolated from patients with systemic lupus erythematosus (SLE), adenosine fails to induce immunosuppressor activity or to increase the percentage of OKT8(+) and RFc(gamma) (+) cells. In addition, although incubation of normal T(R) cells with adenosine causes a transient increase in cAMP levels (up to 160% of control within 5 min), in SLE T(R) cells, cAMP levels fall by 50% within 10 min. The photoaffinity label 8-azidoadenosine cyclic [(32)P]monophosphate has been used to show that human T lymphocytes have a single cAMP receptor site that appears to be the regulatory subunit of type I protein kinase. In normal T(R) cells, this receptor becomes occupied in response to adenosine. In contrast, in SLE T(R) cells, no change in cAMP receptor occupancy is detected. Although adenosine has a differential effect on normal and SLE T(R) cells, cAMP derivatives that can traverse the cell membrane (8-bromo- and 8-azidoadenosine cyclic monophosphates) induce an increase in the RFc(gamma) (+) cell subset in both normal and SLE T(R) cells. These results suggest that cAMP mediates the effects of adenosine on cell surface markers of T lymphocytes. The lack of an adenosine receptor-coupled adenylate cyclase activity in SLE T(R) cells may account, in part, for their lack of immunosuppressive activity.

Immunonephelometric quantitation of central nervous system IgG daily synthesis in multiple sclerosis. Clinical evaluation using predictive value theory

With a laser nephelometric immunoassay and an empirical formula for the quantitation of central nervous system (CNS) daily IgG synthesis, we studied prospectively a population of 101 individuals divided into four groups: 31 normals, 25 patients with definite multiple sclerosis (DMS), 18 patients with probable or possible multiple sclerosis (PMS), and 27 patients with neurologic disease other than multiple sclerosis (NMS). By the Kruskal-Wallis, test the results of the DMS and PMS patients were significantly different from the normals and NMS patients (P less than 0.0003). Considering normals, DMS, and NMS patients only, the sensitivity of the test was 96%, the specificity was 98%, the positive predictive value was 96%, the negative predictive value was 98%, and the efficiency was 98%. Based on our study data, we applied the predictive value theory to different hypothetical populations (our Neurology Ward, Northeastern U. S., and patients with optic neuritis and chronic progressive myelopathy). In all these situations, the test gave a diagnostic efficiency for multiple sclerosis greater than 95%.

Value of central nervous system IgG daily synthesis determination in the diagnosis of multiple sclerosis

Using laser beam immunonephelometry, we confirmed the value of Tourtellotte's formula in the diagnosis of MS. Moreover, since immunonephelometry presents several advantages, including simplicity, rapidity, and precision, it is a promising technique for the diagnosis of MS. Complicated measurements are not necessary. Determinations take only minutes. The results are reproducible. Mathematics manipulations are simple with readily available computers.