A phase I/II dose-escalation trial of vitamin D3 and calcium in multiple sclerosis.

OBJECTIVE: Low vitamin D status has been associated with multiple sclerosis (MS) prevalence and risk, but the therapeutic potential of vitamin D in established MS has not been explored. Our aim was to assess the tolerability of high-dose oral vitamin D and its impact on biochemical, immunologic, and clinical outcomes in patients with MS prospectively. METHODS: An open-label randomized prospective controlled 52-week trial matched patients with MS for demographic and disease characteristics, with randomization to treatment or control groups. Treatment patients received escalating vitamin D doses up to 40,000 IU/day over 28 weeks to raise serum 25-hydroxyvitamin D [25(OH)D] rapidly and assess tolerability, followed by 10,000 IU/day (12 weeks), and further downtitrated to 0 IU/day. Calcium (1,200 mg/day) was given throughout the trial. Primary endpoints were mean change in serum calcium at each vitamin D dose and a comparison of serum calcium between groups. Secondary endpoints included 25(OH)D and other biochemical measures, immunologic biomarkers, relapse events, and Expanded Disability Status Scale (EDSS) score. RESULTS: Forty-nine patients (25 treatment, 24 control) were enrolled [mean age 40.5 years, EDSS 1.34, and 25(OH)D 78 nmol/L]. All calcium-related measures within and between groups were normal. Despite a mean peak 25(OH)D of 413 nmol/L, no significant adverse events occurred. Although there may have been confounding variables in clinical outcomes, treatment group patients appeared to have fewer relapse events and a persistent reduction in T-cell proliferation compared to controls. CONCLUSIONS: High-dose vitamin D (approximately 10,000 IU/day) in multiple sclerosis is safe, with evidence of immunomodulatory effects. CLASSIFICATION OF EVIDENCE: This trial provides Class II evidence that high-dose vitamin D use for 52 weeks in patients with multiple sclerosis does not significantly increase serum calcium levels when compared to patients not on high-dose supplementation. The trial, however, lacked statistical precision and the design requirements to adequately assess changes in clinical disease measures (relapses and Expanded Disability Status Scale scores), providing only Class level IV evidence for these outcomes.

A rapid ELISA-based serum assay for myelin basic protein in multiple sclerosis.

We have developed a sensitive, ELISA-based assay to detect autoantibodies to myelin basic protein (MBP) in human serum. Autoantibody levels were measured in 98 normal healthy adults (age range 20-66) and 94 clinically definite multiple sclerosis (MS) cases (age range 18-63). Of the MS patients, 77% had elevated levels of MBP autoantibodies (IgG) whereas only five normal individuals had antibody levels increased over normal. From the receiver-operator curve (ROC), the mean+/-2SD as clinical decision limit offers high sensitivity (77%) and specificity (95%). No change in assay performance was observed when hemoglobin, triglycerides or bilirubin were added to serum samples. The success of the assay is dependent on the use of heparin, an anionic molecule, which neutralizes the positive charge on the highly cationic MBP.

Recurrent intracranial hemorrhage due to postpartum cerebral angiopathy: implications for management.

BACKGROUND: Postpartum cerebral angiopathy as a cause of hemorrhagic stroke in young women is not well recognized. It is unknown whether this disorder represents a true inflammatory vasculitis or transient vasoconstriction related to the hormonal events of pregnancy and the postpartum period. CASE DESCRIPTION: A 39-year-old woman presented with postpartum intracranial hemorrhage and, 32 months later, with subarachnoid hemorrhage, following normal pregnancies. Cerebral angiography obtained after each stroke demonstrated diffuse irregularity of branches of the middle cerebral arteries consistent with a diffuse vasospastic process or classic vasculitis. Neurological deficits resolved and results of a transcranial Doppler study normalized after a short course of high-dose corticosteroids following the second stroke. CONCLUSIONS: Postpartum cerebral angiopathy should be considered in the differential diagnosis of recurrent intracranial hemorrhagic stroke in young women. Recognition of this condition may preclude treatment with potentially toxic therapies for vasculitis and will have important implications for counseling women on subsequent pregnancies.

Localization and partial characterization of a 60 kDa citrulline-containing transport form of myelin basic protein from MO3-13 cells and human white matter.

The localization of myelin basic proteins (MBPs) in an immortalized human-human hybrid cell line (MO3-13) formed by fusion of rhabdomyosarcoma TE671-TG6 with primary human oligodendrocytes, cultured from surgical specimens, demonstrated an intracellular localization in vesicles and vacuoles with an intricate internal membranous network and to the external surface of the cell by immunogold electron microscopy. The availability of antibodies to one of the components of MBP, i.e., the citrulline containing component ("C-8"), permitted us to localize this component of MBP to intracellular vacuoles and also on the external surface of the MO3-13 cells. Since the apposition of the external surfaces of the oligodendrocyte is responsible for the intraperiod line of the myelin sheath, localization of C-8 to the external surface of non-permeabilized cells by immunogold scanning electron microscopy is consistent with our observations that C-8 is localized to the intraperiod line of myelin (McLaurin et al.: J Neurosci Res 35:618-628, 1993). Western blots of isolated MBP from MO3-13 cells, probed with an antibody reactive with residues 130-137 of MBP, recognized a protein in the 60 kDa range. No immunoreactivity was found in the 18.5 kDa range. This 60 kDa protein also reacted with a monoclonal antibody raised with residues 70-84 of MBP, 2 different polyclonals raised with whole bovine MBP, an antibody to human MBP raised in monkeys, and the anti-citrulline antibody. These data strongly suggested that the 60 kDa protein contained MBP sequences within its primary structure. A similar protein has been isolated from human myelin-containing fractions but not from compact myelin demonstrating that the 60 kDa protein from MO3-13 cells was not an artefact related to fusion. Sequence determination of peptides obtained from enzymic and chemical cleavages revealed that the 60 kDa protein contained MBP sequences and peptides with 55-60% homology with dynamin, a protein involved in intracellular transport. These data suggest that the externalization of MBP in this cell involves transport by fusion of MBP with another protein. By sequestering MBP in a larger protein, the possibility of inducing autoimmune disease by MBP released, due to cell death, is minimized.

Relationships between alveolar bone levels measured at surgery, estimated by transgingival probing and clinical attachment level measurements.

Alveolar bone level measurements obtained by transgingival probing were compared with alveolar bone levels measured during surgery at 178 sites in 9 patients. Probing depth measurements using constant loads of 30 g and 60 g were also compared with bone levels measured at surgery at the above sites. The effects of inflammation, location of the site on the tooth surface and tooth type were also investigated. Transgingival probing was unaffected by these factors and proved to be an accurate method of measuring alveolar bone levels (r = 0.975). Probing depth measurements were affected by the presence of inflammation, assessed by the bleeding response to probing, and variation in probing load. The effect of inflammation was to reduce the mean distance between the probe tip and the alveolar bone from 2.4 mm to 1.9 mm. None of the relationships between the measurements were significantly affected by the location of the site on the tooth surface, or by tooth type.