Emerging Cerebrospinal Fluid Biomarkers of Disease Activity and Progression in Multiple Sclerosis.

Importance: Biomarkers distinguishing nonrelapsing progressive disease biology from relapsing biology in multiple sclerosis (MS) are lacking. Cerebrospinal fluid (CSF) is an accessible fluid that most closely reflects central nervous system biology. Objective: To identify CSF biological measures associated with progressive MS pathobiology. Design, Setting, and Participants: This cohort study assessed data from 2 prospective MS cohorts: a test cohort provided serial CSF, clinical, and imaging assessments in a multicenter study of patients with relapsing MS (RMS) or primary progressive MS (PPMS) who were initiating anti-CD20 treatment (recruitment: 2016-2018; analysis: 2020-2023). A single-site confirmation cohort was used to assess CSF at baseline and long-term (>10 year) clinical follow-up (analysis: 2022-2023). Exposures: Test-cohort participants initiated standard-of-care ocrelizumab treatment. Confirmation-cohort participants were untreated or received standard-of-care disease-modifying MS therapies. Main Outcomes and Measures: Twenty-five CSF markers, including neurofilament light chain, neurofilament heavy chain, and glial fibrillary acid protein (GFAP); 24-week confirmed disability progression (CDP24); and brain magnetic resonance imaging measures reflecting focal injury, tissue loss, and progressive biology (slowly expanding lesions [SELs]). Results: The test cohort (n = 131) included 100 patients with RMS (mean [SD] age, 36.6 [10.4] years; 68 [68%] female and 32 [32%] male; Expanded Disability Status Scale [EDSS] score, 0-5.5), and 31 patients with PPMS (mean [SD] age, 44.9 [7.4] years; 15 [48%] female and 16 [52%] male; EDSS score, 3.0-6.5). The confirmation cohort (n = 68) included 41 patients with RMS and 27 with PPMS enrolled at diagnosis (age, 40 years [range, 20-61 years]; 47 [69%] female and 21 [31%] male). In the test cohort, GFAP was correlated with SEL count (r = 0.33), greater proportion of T2 lesion volume from SELs (r = 0.24), and lower T1-weighted intensity within SELs (r = -0.33) but not with acute inflammatory measures. Neurofilament heavy chain was correlated with SEL count (r = 0.25) and lower T1-weighted intensity within SELs (r = -0.28). Immune markers correlated with measures of acute inflammation and, unlike GFAP, were impacted by anti-CD20. In the confirmation cohort, higher baseline CSF GFAP levels were associated with long-term CDP24 (hazard ratio, 2.1; 95% CI, 1.3-3.4; P = .002). Conclusions and Relevance: In this study, activated glial markers (in particular GFAP) and neurofilament heavy chain were associated specifically with nonrelapsing progressive disease outcomes (independent of acute inflammatory activity). Elevated CSF GFAP was associated with long-term MS disease progression.

Differential effects of anti-CD20 therapy on CD4 and CD8 T cells and implication of CD20-expressing CD8 T cells in MS disease activity.

A small proportion of multiple sclerosis (MS) patients develop new disease activity soon after starting anti-CD20 therapy. This activity does not recur with further dosing, possibly reflecting deeper depletion of CD20-expressing cells with repeat infusions. We assessed cellular immune profiles and their association with transient disease activity following anti-CD20 initiation as a window into relapsing disease biology. Peripheral blood mononuclear cells from independent discovery and validation cohorts of MS patients initiating ocrelizumab were assessed for phenotypic and functional profiles using multiparametric flow cytometry. Pretreatment CD20-expressing T cells, especially CD20dimCD8+ T cells with a highly inflammatory and central nervous system (CNS)-homing phenotype, were significantly inversely correlated with pretreatment MRI gadolinium-lesion counts, and also predictive of early disease activity observed after anti-CD20 initiation. Direct removal of pretreatment proinflammatory CD20dimCD8+ T cells had a greater contribution to treatment-associated changes in the CD8+ T cell pool than was the case for CD4+ T cells. Early disease activity following anti-CD20 initiation was not associated with reconstituting CD20dimCD8+ T cells, which were less proinflammatory compared with pretreatment. Similarly, this disease activity did not correlate with early reconstituting B cells, which were predominantly transitional CD19+CD24highCD38high with a more anti-inflammatory profile. We provide insights into the mode-of-action of anti-CD20 and highlight a potential role for CD20dimCD8+ T cells in MS relapse biology; their strong inverse correlation with both pretreatment and early posttreatment disease activity suggests that CD20-expressing CD8+ T cells leaving the circulation (possibly to the CNS) play a particularly early role in the immune cascades involved in relapse development.

Prevalence and Progression of Macular Atrophy in Eyes with Neovascular Age-Related Macular Degeneration in the Phase 2 Ladder Trial of the Port Delivery System with Ranibizumab.

PURPOSE: To determine whether the rates of macular atrophy (MA) differ between eyes with neovascular age-related macular degeneration (nAMD) treated continuously with the Port Delivery System with ranibizumab (PDS) and those treated with ranibizumab given as a bolus intravitreal injection. DESIGN: A preplanned exploratory analysis of a phase 2, multicenter, randomized, active treatment-controlled, dose-ranging study. PARTICIPANTS: Patients diagnosed with nAMD within 9 months of screening who had received at least 2 previous intravitreal anti-vascular endothelial growth factor injections of any agent and were responsive to the treatment. METHODS: Eyes were randomized (3:3:3:2) to treatment with either the PDS (filled with a customized formulation of ranibizumab at 10, 40, or 100 mg/ml and refilled pro re nata) or monthly intravitreal ranibizumab 0.5-mg injections. MAIN OUTCOME MEASURES: The prevalence, incidence, and progression of MA. RESULTS: The analysis population consisted of 220 eyes (58, 62, 59, and 41 eyes in the PDS 10-mg/ml, 40-mg/ml, 100-mg/ml, and monthly intravitreal ranibizumab 0.5-mg injection arms, respectively). At study baseline, MA was observed in 14.5% (PDS 10-mg/ml), 11.5% (PDS 40-mg/ml), 13.6% (PDS 100-mg/ml), and 7.6% (monthly ranibizumab) of eyes. At the last assessment (mean, 22.1 months), the prevalence of MA had increased to 38.6% (PDS 10-mg/ml), 40.0% (PDS 40-mg/ml), 40.4% (PDS 100-mg/ml), and 45.7% (monthly ranibizumab). In patients without MA at baseline, a higher proportion of eyes in the monthly ranibizumab arm (40.6%) developed MA than in those in the PDS arms (28.6%, 32.1%, and 30.6% of eyes in the PDS 10-, 40-, and 100-mg/ml arms, respectively). The mean change in the area of MA from baseline to the last assessment for the PDS 10-mg/ml, 40-mg/ml, 100-mg/ml, and monthly ranibizumab arms was +2.46, +1.61, +1.09, and +1.15 mm2, respectively. At 9 months, for patients without MA at baseline, the difference in the incidence of MA between the PDS 100-mg/ml and monthly ranibizumab groups was -12% (95% confidence interval, -31% to 7%). CONCLUSIONS: In the phase 2 Ladder trial, there was no evidence of worse MA with the PDS compared with that with monthly intravitreal ranibizumab 0.5-mg injections. Larger trials focusing on MA are needed to confirm this finding.

Demographic, spatial and temporal dietary intake patterns among 526 774 23andMe research participants.

OBJECTIVE: To characterise dietary habits, their temporal and spatial patterns and associations with BMI in the 23andMe study population. DESIGN: We present a large-scale cross-sectional analysis of self-reported dietary intake data derived from the web-based National Health and Nutrition Examination Survey 2009-2010 dietary screener. Survey-weighted estimates for each food item were characterised by age, sex, race/ethnicity, education and BMI. Temporal patterns were plotted over a 2-year time period, and average consumption for select food items was mapped by state. Finally, dietary intake variables were tested for association with BMI. SETTING: US-based adults 20-85 years of age participating in the 23andMe research programme. PARTICIPANTS: Participants were 23andMe customers who consented to participate in research (n 526 774) and completed web-based surveys on demographic and dietary habits. RESULTS: Survey-weighted estimates show very few participants met federal recommendations for fruit: 2·6 %, vegetables: 5·9 % and dairy intake: 2·8 %. Between 2017 and 2019, fruit, vegetables and milk intake frequency declined, while total dairy remained stable and added sugars increased. Seasonal patterns in reporting were most pronounced for ice cream, chocolate, fruits and vegetables. Dietary habits varied across the USA, with higher intake of sugar and energy dense foods characterising areas with higher average BMI. In multivariate-adjusted models, BMI was directly associated with the intake of processed meat, red meat, dairy and inversely associated with consumption of fruit, vegetables and whole grains. CONCLUSIONS: 23andMe research participants have created an opportunity for rapid, large-scale, real-time nutritional data collection, informing demographic, seasonal and spatial patterns with broad geographical coverage across the USA.

Two-stage randomized trial design for testing treatment, preference, and self-selection effects for count outcomes.

While the traditional clinical trial design lays emphasis on testing the treatment effect between randomly assigned groups, it ignores the role of patient preference for a particular treatment in the trial. Yet, for healthcare providers who seek to optimize the patient-centered treatment strategy, the evaluation of a patient's psychology toward each treatment could be a key consideration. The two-stage randomized trial design allows researchers to test patient's preference and selection effects, in addition to the treatment effect. The current methodology for the two-stage design is limited to continuous and binary outcomes; this article extends the model to include count outcomes. The test statistics for preference, selection, and treatment effects are derived. Closed-form sample size formulae are presented for each effect. Simulations are presented to demonstrate the properties of the unstratified and stratified designs. Finally, we apply methods to the use of antimicrobials at the end of life to demonstrate the applicability of the methods.

On weighted composite scores for early Alzheimer's trials.

Recent research on finding appropriate composite endpoints for preclinical Alzheimer's disease has focused considerable effort on finding "optimized" weights in the construction of a weighted composite score. In this paper, several proposed methods are reviewed. Our results indicate no evidence that these methods will increase the power of the test statistics, and some of these weights will introduce biases to the study. Our recommendation is to focus on identifying more sensitive items from clinical practice and appropriate statistical analyses of a large Alzheimer's data set. Once a set of items has been selected, there is no evidence that adding weights will generate more sensitive composite endpoints.

Extensions to the two-stage randomized trial design for testing treatment, self-selection, and treatment preference effects to binary outcomes.

While traditional clinical trials seek to determine treatment efficacy within a specified population, they often ignore the role of a patient's treatment preference on his or her treatment response. The two-stage (doubly) randomized preference trial design provides one approach for researchers seeking to disentangle preference effects from treatment effects. Currently, this two-stage design is limited to the design and analysis of continuous outcome variables; in this presentation, we extend this current design to include binary variables. We present test statistics for testing preference, selection, and treatment effects in a two-stage randomized design with a binary outcome measure, with and without stratification. We also derive closed-form sample size formulas to indicate the number of patients needed to detect each effect. A series of simulation studies explore the properties and efficiency of both the unstratified and stratified two-stage randomized trial designs. Finally, we demonstrate the applicability of these methods using an example of a trial of Hepatitis C treatment.

Sample size and power for a stratified doubly randomized preference design.

The two-stage (or doubly) randomized preference trial design is an important tool for researchers seeking to disentangle the role of patient treatment preference on treatment response through estimation of selection and preference effects. Up until now, these designs have been limited by their assumption of equal preference rates and effect sizes across the entire study population. We propose a stratified two-stage randomized trial design that addresses this limitation. We begin by deriving stratified test statistics for the treatment, preference, and selection effects. Next, we develop a sample size formula for the number of patients required to detect each effect. The properties of the model and the efficiency of the design are established using a series of simulation studies. We demonstrate the applicability of the design using a study of Hepatitis C treatment modality, specialty clinic versus mobile medical clinic. In this example, a stratified preference design (stratified by alcohol/drug use) may more closely capture the true distribution of patient preferences and allow for a more efficient design than a design which ignores these differences (unstratified version).