Complement Profiles in Patients with Amyotrophic Lateral Sclerosis: A Prospective Observational Cohort Study

Background

The complement system has been suggested to be involved in the pathophysiology of amyotrophic lateral sclerosis (ALS), a progressive motor neuron disease. In the present study, we compared levels of selected complement markers to clinical outcome in ALS patients.

Methods

This observational, explorative cohort study included 92 ALS patients, 61 neurological controls (NCs) admitted for suspected aneurysmal subarachnoid haemorrhage, and 96 neurologically healthy controls (NHCs). Peripheral blood and cerebrospinal fluid (CSF) were obtained for the measurement of ficolin-1, −2, and −3; collectin-11, MBL, MASP-3, MAP-1, C4, C3, PTX-3, and complement activation products C4c, C3bc, and sC5b-9. We recorded clinical outcomes of ALS patients for 24 to 48 months after inclusion in order to analyse the effects of the complement markers on survival time.

Results

Compared with both control groups, ALS patients exhibited increased collectin-11, C4 and sC5b-9 in plasma, as well as increased ficolin-3 in CSF. Ficolin-2 was significantly decreased in plasma of the ALS patients compared with NHCs, but not with NCs. The concentration of collectin-11, C3 and C3bc correlated negatively with the revised ALS functional rating scale (ALSFRS-R). No association was found between levels of complement markers and survival as estimated by hazard ratios.

Conclusion

ALS patients exhibit aberrant expression of selected mediators of the lectin complement pathway as well as increased activation of the terminal complement pathway, corroborating the notion that the complement system might be involved in the pathophysiology of ALS.

Amyotrophic lateral sclerosis and the innate immune system: protocol for establishing a biobank and statistical analysis plan

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is a devastating, progressive disease that causes degeneration of the motor neurons leading to paresis of the bulbar and the skeletal musculature. The pathogenesis of ALS remains unknown. We will test the hypothesis that the complement system is involved in the pathophysiology of ALS. This protocol article describes our efforts to establish a national Danish ALS biobank. The primary aim is to obtain biological material from patients with ALS for the current study as well as for future studies.

METHODS AND ANALYSIS

We intend to establish an observational ALS biobank; some of the material from this biobank will be used for a prospective, observational case-control study. The participants are patients with ALS, neurologically healthy controls and non-ALS neurological controls. Each participant consents to be interviewed and to donate blood and cerebrospinal fluid to the biobank. Analysis of the complement system will be carried out on the three groups of patients and compared.

ETHICS AND DISSEMINATION

The project has been approved by the Committees on Health Research Ethics in the Capital Region of Denmark (Approval number H-16017145) and the Danish Data Protection Agency (file number 2012-58-0004). All results will be published in peer-reviewed, medical journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT02869048.

Amyotrophic lateral sclerosis: The complement and inflammatory hypothesis

Amyotrophic lateral sclerosis (ALS) is a devastating, neurodegenerative motor neuron disease. The aetiology of ALS remains an enigma which hinders the design of an effective treatment to prevent, postpone, or reverse the pathophysiological changes occurring during the aggressive progression of this disease. During the last decade, basic research within the innate immune system, and in particular the complement system, has revealed new, important roles of the innate immune system during development, homeostasis, and ageing within as well as outside the central nervous system. Several lines of evidence indicate that aberrant activation of the complement system locally in the central nervous system as well as systemically may be involved in the pathophysiology of ALS. This exciting new knowledge could point towards the innate immune system as a potential target of medical intervention in ALS. Recently, the historic perception of ALS as a central neurodegenerative disease has been challenged due to the significant amount of evidence of a dying-back mechanism causing the selective destruction of the motor neurons, indicating that disease onset occurs outside the borders of the blood-brain-barrier. This review addresses the function of the innate immune system during ALS. We emphasize the role of the complement system and specifically suggest the involvement of ficolin-3 from the lectin pathway in the pathophysiology of ALS.

[Osteoporosis often occurs in Parkinson's disease patients]

The risk of developing osteoporosis, as well as Parkinson's disease (PD) is increased with increasing age, resulting in increased risk of fracture, particularly hip fractures. Each one of these two conditions can be debilitating and affect the individual patient's quality of life negatively. PD patients have higher risk of developing osteoporosis and hip fracture compared to those without PD because of lower bone mineral density (BMD) and lack of vitamin D. Prevention of fracture in PD patients should include fall-risk screening, BMD measurements by DXA scan and screening for risk factors for osteoporosis.

Practical Guidance on How to Handle Levodopa/Carbidopa Intestinal Gel Therapy of Advanced PD in a Movement Disorder Clinic

Continuous dopaminergic delivery is recognized for the capacity to ameliorate symptoms in Parkinson's disease (PD). In advanced PD the short comings of orally administered Levodopa/Carbidopa include fluctuations resulting in unstable effect and dyskinesia. Levodopa/Carbidopa intestinal gel, LCIG, (Duodopa®, Abbott Laboratories) is delivered continuously through a percutaneous endoscopic gastrostomy with the inner tube placed in the duodenum by means of a device (CADD legacy Duodopa pump (CE 0473)). The therapy implies continuous dopaminergic delivery directly to the duodenum and is therefore unaffected by gastric emptying and represents a major adjuvant in the treatment of advanced PD with significant improvement in motor and non-motor symptoms. The aim of this paper is to suggest the prerequisites for a LCIG clinic and propose a feasible set-up and lean organization of a movement disorder clinic. Secondly, the paper proposes practical handling of patients in LCIG treatment for advanced PD based on experience and initiation of LCIG treatment and follow-up in forty patients.

[Pulmonary Legionella infection with CNS manifestations]

A 39 year-old woman with Legionella pneumonia and severe neurological signs is presented. The patient displayed severe gait disturbance, ataxia and anartria. No substantial remission in symptoms was found at a six month follow up. The case and the relevant literature are reviewed.

Stretch-shortening contraction in Parkinson patients: evidence of normal muscle contraction execution with low efficiency

The aim of this study was to compare different muscle contraction types in Parkinson patients and controls. Ten patients with mild to moderate Parkinsonism (7 men, 3 women, mean age 62.3) and 11 controls (7 men, 4 women, mean age 66.0) were investigated. Measurements in eccentric, concentric contraction and stretch-shortening contraction were made using modified Cybex 11 equipment. The torque areas in ankle dorsiflexors at 30 degrees/second, 120 degrees/second and 180 degrees/second were measured. The power (Nm/second) was calculated in a defined range of motion. The power at different angular velocities and contraction types was significantly lower in the patient group than in the control group. In both groups the power in eccentric and stretch-shortening contraction was significantly larger than in concentric contraction. The relative improvement in power in stretch-shortening contraction in patients was equal to the improvement made by the controls. Patients generated significantly more EMG than controls in concentric and eccentric contractions. The EMG in the stretch-shortening cycle was the same in both groups at higher velocities. The patients performed voluntary isolated muscle contraction in the same way as controls, but with a lower efficiency in contraction. The eccentric torque and the supplement of torque generated from the combined eccentric and concentric (stretch-shortening) contraction might be important for achievement of adequate dynamic movements in patients with Parkinson's disease.

Gait analysis, isokinetic muscle strength measurement in patients with Parkinson's disease

The aim of this study was to describe motor performance in Parkinson patients in relation to controls. Gait, concentric isometric and eccentric strength in the ankle dorsiflexors were investigated in 25 patients with Parkinson's disease and in 37 control subjects of the same age. In patients concentric torque was significantly lowered but, eccentric torque was significantly lowered in male patients only. Among controls a significant difference in strength was found between sexes. This was not found in the patient group. No correlation between strength tests and clinical ratings was found in the patient group. Patients walked with significantly lower maximum and ordinary velocity, compared with controls. At constant velocity, stride length was shorter, single support had a shorter duration. The duration for heel on to ball on in males was shorter, reflecting the flat foot strike of Parkinson patients. Single support and the duration of heel on to ball on correlated significantly to the clinical ratings in male but not in female patients. In the male group of patients there was a relation between concentric strength on the one hand and gait velocity, stride length and stride frequency on the other. Female patients generally had fewer symptoms and less deviation from their respective controls in the measurements. The comparatively simple neurophysiological tests presented here may be suitable for evaluation of patients with Parkinson's disease.

Dynamic strength in Parkinson's disease. Quantitative measurements following withdrawal of medication

This study examined the influence of pharmacological treatment on muscle strength in Parkinson's disease (PD). Twelve patients, 7 men and 5 women, were tested with modified Cybex II equipment. Peak torques in isometric, concentric and eccentric contraction at 30, 120 and 180 degrees/s in ankle dorsiflexors were recorded before and after the withdrawal of medication. EMG were recorded during contraction. Clinical assessment was done according to Webster's and Hoehn and Yahr's rating scales. Clinical scores were significantly increased (p < 0.05). Peak torques in isometric, concentric and eccentric contraction (p < 0.05) decreased at almost all velocities after withdrawal of medication. Correlations were found between changes in clinical score and strength. Strength production in PD was influenced by medication, and the results correlated with changes in clinical ratings. Strength measurement may be used in the evaluation of pharmacological therapy.

Characteristics of tetanic muscle contraction in Parkinson patients

The aim of this study was to examine contraction characteristics in striated muscles from Parkinson patients and to measure any changes in characteristics based on changes in medication. Fifteen patients, 9 men and 6 women, mean age 61.6 (range 43-70) with mild to moderate parkinsonism, (Hoehn and Yahr I-III) were investigated, and the results were compared with a group of 8 normal controls (mean age 59.6, range 50-70). Twelve of the patients (7 men and 5 women) were also tested after a 24-h period without medication. Using supramaximal electrical stimulation of the ulnary nerve at the wrist contraction, characteristics in the m. adductor pollicis muscle can be recorded. Stimulation results were printed on a fast paper writer. The following characteristics were recorded: 1) electromechanical delay of contraction EMDc; 2) contraction time to half tetanus CTT1/2; 3) electromechanical delay of relaxation EMDr; 4) relaxation rate RR for 10 ms RR-10; 5) the force produced in the tetanic contraction at stimulus frequencies 5, 10, 20, 50 Hz. The results showed that the in initiation of contraction (EMDc) was normal compared with controls. CTT1/2 was shorter (p less than 0.001) in the group of Parkinson patients compared with normals. EMDr was not changed when compared with normals, but RR-10 was increased, p less than 0.05. Force levels at the different stimulation rates were not significantly changed. After withdrawal of medication all parameters were unchanged. Muscle contraction characteristics in tetanic contraction were found to be abnormal indicating either a possible preactivation in the muscle contraction or a secondary change in the muscles of patients with Parkinson's disease.

Effects of withdrawal of antiparkinson medication on gait and clinical score in the Parkinson patient

Objective testing of medication is needed in Parkinson's disease. Gait analysis and clinical evaluation were done before and after a 24-h withdrawal of Parkinson medication. Twelve patients with stable, mild to moderate idiopathic parkinsonism (Hoehn and Yahr 1-3; seven men and five women mean age 59.9 years, mean duration of disease 6 years) were tested with gait analysis walking in five different paces. Velocity of gait, stride length and stride frequency, as well as stride length at constant velocity were calculated. Regression coefficients for the relation between stride length and stride frequency were also calculated. Clinical scoring according to the Webster rating scale and Hoehn and Yahr were performed for each test. Clinical functional assessment with a specially designed rise and gait test, an arm cycle test and the wooden rods test were done. Evaluated clinical score increased significantly (p less than 0.05) using both clinical tests. Maximum gait velocity (p less than 0.01), stride length at max. velocity (p less than 0.01), and stride length at constant velocity (p less than 0.03) were significantly decreased without medication. Stride frequency did not change. In the functional assessment tests only performance on the arm cycle test (p less than 0.03) was less well performed without medication. There was correlation between clinical score, gait and clinical functional assessment. The methods used detected significant changes in variables of gait as well as clinical scoring and some of the clinical functional assessments when medication was withdrawn for a 24-h period. The methods were useful in evaluation of pharmacological treatment.