gustavo miguel da rocha rodrigues · ocb with ms. while epstein barr virus (ebv) and anti-myelin...
TRANSCRIPT
Gustavo Miguel da Rocha Rodrigues
The role of biomarkers in the diagnosis of Multiple sclerosis
2011/2012
março, 2012
Gustavo Miguel da Rocha Rodrigues
The role of biomarkers in the diagnosis of Multiple Sclerosis
Mestrado Integrado em Medicina
Área: Neurologia
Trabalho efetuado sob a Orientação de:
Dra. Joana da Cruz Guimarães Ferreira de Almeida
Trabalho organizado de acordo com as normas da revista:
Multiple Sclerosis and related Disorders
março, 2012
IIIPORTO Projeto de Opção do 6° ano - DECLARAÇÃO DE INTEGRIDADE
!FMUP! FACULDADE DE MEDICINAUNIVERSIDADE DO PORTO
UNIDADE CURRICUlARPROJETO DE o e c z oDISSERTAÇÃO f MONOGRAFIA
Eu, Gustavo Miguel da Rocha Rodrigues, abaixo assinado, nO mecanográfico 060801225, estudante do
60 ano do Mestrado Integrado em Medicina, na Faculdade de Medicina da Universidade do Porto,
declaro ter atuado com absoluta integridade na elaboração deste projeto de opção.
Neste sentido, confirmo que NÃO incorri em plágio (ato pelo qual um indivíduo, mesmo por omissão,
assume a autoria de um determinado trabalho intelectual, ou partes dele). Mais declaro que todas as
frases que retirei de trabalhos anteriores pertencentes a outros autores, foram referenciadas, ou
redigidas com novas palavras, tendo colocado, neste caso, a citação da fonte bibliográfica.
Faculdade de Medicina da Universidade do Porto, 1b /ó'? / ~o1),
Assinatura:
DlpORTOFMUP FACULDADE DE MEDICINA
UNIVERSIDADE DO PORTO
Projecto de Opção do 6° ano - DECLARAÇÃODEREPRODUÇÃO
Nome: Gustavo Miguel da Rocha Rodrigues
Endereço electrónico: gustavo [email protected] Telefone ou Telemóvel: 912248477
Número do Bilhete de Identidade: 13213739
Título da Monografia:
The role of biomarkers in the diagnosis of Multiple Sclerosis
Orientador:
Dra. Joana da Cruz Guimarães Ferreira de Almeida
Ano de conclusão: 2012
Designação da área do projecto:
Neurologia
É autorizada a reprodução integral desta Monografia para efeitos de investigação e de divulgação
pedagógica, em programas e projectos coordenados pela FMUP.
Faculdade de Medicina da Universidade do Porto, t0~ lo 11
Assinatura: L~josJ{)
Dedicatória
Dedico este trabalho á minha família pela disponibilidade e apoio incondicional
ao longo de todo o meu percurso académico.
MESTRADO INTEGRADO EM MEDICINA
Ano letivo: 2011/2012
Nome do(a) Estudante: Gustavo Miguel da Rocha Rodrigues
Orientador(a): Dra. Joana da Cruz Guimarães Ferreira de Almeida
Área do Projeto: Neurologia
Título do Projeto: The role of biomarkers in the diagnosis of Multiple Sclerosis.
Resumo: Esclerose Múltipla (EM) é uma doença neurológica inflamatória desmielinizante
importante devido à sua incidência, cronicidade e maior prevalência em adultos jovens. No
estudo inicial de uma doença desmielinizante do Sistema Nervoso Central existe a necessidade
de encontrar biomarcadores que possam melhor discriminar a EM de outras patologias.
Atualmente, apenas as bandas oligoclonais (BOC) são utilizadas. Esta revisão pretende, através
de uma pesquisa na base de dados PubMed, examinar a literatura publicada nos últimos 5
anos, sobre o papel dos biomarcadores no diagnóstico da esclerose múltipla. O uso de
marcadores no líquido encéfalo-raquidiano, aumenta a especificidade e valor preditivo
negativo, diminuindo os possíveis falsos positivos da, muito sensível, ressonância magnética.
As BOC confirmaram o seu valor, apoiando o diagnóstico quando presentes e sugerindo a
revisão do mesmo quando ausentes, mostrando contudo algumas limitações: variabilidade
interpopulacional, laboratorial e metodológica, controvérsia sobre o uso do índice IgG, a
interpretação de uma única BOC e a relação das BOC com a EM. Enquanto o vírus Epstein-Barr
e os anticorpos antimielina falharam quando testados, as cadeias leves livres K demonstraram
resultados promissores, especialmente, como todos os biomarcadores, quando combinadas
com ressonância magnética. Na previsão de conversão do síndrome clínico isolado para EM, as
BOC confirmaram o seu papel, enquanto CXC quimiocina motif 13 e a reação MRZ mostraram
bons valores preditivos, e os marcadores de lesão axonal e anticorpos contra a mielina
falharam. Além da deteção de anticorpos aquaporina-4 e a reação MRZ no líquido
céfaloraquidiano a deteção de N-acetil aspartato no sangue mostraram bons resultados a
distinguir EM de neuromielite ótica. Há uma procura para desenvolver métodos automatizados
para estudar biomarcadores, e o desenvolvimento de técnicas proteómicas é promissor para a
identificação de novos alvos moleculares para ensaios de diagnóstico e terapêutica.
Concluindo, o principal contributo dos biomarcadores no diagóstico de EM, consiste no
aumento de especificidade e valor preditivo. É necessário corrigir qualquer possível erro
metodológico, tentando estandardizar ao máximo de modo a obter resultados mais
consistentes. Apesar dos esforços na pesquisa de novos biomarcadores é necessário
compreender melhor a EM de modo a encontrar um teste simplificado.
Palavras-chave: Esclerose Múltipla, Síndrome clínico isolado, bandas oligoclonais, líquido encéfalo-
raquidiano, biomarcadores, diagnóstico.
The role of biomarkers in the diagnosis of Multiple Sclerosis
Rodrigues, Gustavo Faculty of Medicine of Porto University (FMUP)*
Neurology Department, Faculty of Medicine, University of Porto, Hospital de São João,
Alameda Professor Hernâni Monteiro, 4200, Porto, Portugal Faculty of Medicine of Porto University
Telephone and Fax: + 00351 225511200
*Corresponding author, Praça, 135 Vila Nova, 4465-767 Praia da Vitória, Açores - Portugal
E-mail: [email protected]; Telephone: +00351 912248477
Abstract
Multiple Sclerosis (MS) is an important inflammatory demyelinative neurologic
disease, due to its, incidence, chronicity and higher prevalence among young adults. In
the initial approach to a demyelinative disease of the Central Nervous System there is a
urge for biomarkers to best discriminate MS from other diseases. Despite the broad
range of biomarker studies, only oligoclonal bands (OCB) are used by routine in
differential diagnosis. This review aims to access the published literature in the last 5
years (trough a search in PubMed database), regarding the role of biomarkers in the
diagnosis of MS. Regarding MS differential diagnosis, the use of cerebrospinal fluid
markers (CSF) increases specificity and negative predictive, diminishing the possible
false positives from the high sensible magnetic resonance imaging (MRI). OCB
confirmed they value, supporting the MS diagnosis when present and suggesting
revision of this, but some limitations appeared regarding inter-population, inter-
laboratories and inter-methods detection variability and there’s controversy concerning
the current use of IgGindex, interpretation of a single weak OCB and the relation of
OCB with MS. While Epstein Barr Virus (EBV) and anti-myelin antibodies failed when
tested, Kappa free light chains (KFLC) performed in a promising way, specially, as all
biomarkers, when combined with MRI.
In this review, OCB confirmed they importance while C-X-C motif chemokine
13 (CXCL13) and MRZ reaction showed good predictive values results while axonal
damage markers and antibodies against myelin didn’t perform well, predicting clinically
isolated syndrome (CIS) conversion to MS. Besides aquaporin-4 antibody detection and
MRZ reaction in CSF, N-acetyl aspartate detection in serum showed good results
distinguishing MS from neuromyelitis optica (NMO). There has been a struggle to
develop standard easy automated methods to biomarker studying and the development
of more sensitive proteomic techniques is very promising for the identification of new
molecular targets for diagnostic assays and therapies preventing axonal damage.
Concluding, biomarkers major contribute is in terms of Specificity and
predictive value. Methodological standardization, correcting any possible error, is vital
for a more consistent research. Despite the efforts in this field, an accurate simple test is
only possible when the pathophysiology of MS is better understood.
Keywords: Multiple Sclerosis, Clinically isolated syndrome, oligoclonal bands,
cerebrospinal fluid, biomarker, diagnosis.
1. Introducion
1.1 Historic note and state of art
Multiple Sclerosis (MS) is an important inflammatory demyelinative neurologic
disease, due to its incidence, chronicity and tendency to affect young adults.(1) MS
features a broad heterogeneity of clinical, histopathological and immunological
phenotypes, which urges a more accurate defining of patients by biological markers that
reflect the underlying disease process and allow the prediction of disease course and
treatment response.(2, 3) Thus, serious efforts are made in the field of biomarkers to
improve the diagnostic discrimination, to determine prognostic factors, and to identify
markers to monitor the clinical course and response to disease-modifying therapies.(3)
Starting with Charcot (1868) and his triad (nystagmus, intention tremor and
scanning speech), the diagnostic criteria for MS have evolved to reflect the
breakthroughs in our understanding of the disease and the development of new
diagnostic techniques, changing from purely clinical criteria to increasing dependency
upon imaging of the central nervous system (CNS). Only in 1954 the first true
diagnostic scheme appeared, published by Allison and Millar describing three
categories: early, probable and possible disseminated sclerosis.(1)
There was a need for reliable and reproducible diagnostic criteria in order to
provide accurate epidemiological studies and therapeutic trials. A major step in that
direction occurred in 1965, when Broman et al. outlined the principles that were the
basis for following schemes.(4) They consisted of age of onset, the empiric significance
of symptoms for an MS diagnosis, the multiplicity of lesions, the number of bouts, and
the familial “recurrence” of MS. The results of the newly described electrophoretic
examination of cerebrospinal fluid (CSF) protein, the precursor of oligoclonal bands
(OCB), were also introduced. Additionally, all other possible diagnoses were to be
considered and, if possible, excluded. For the first time was stated the twin principles of
dissemination in time and in space, that to this day remain the fundamental criteria for
the diagnosis of MS.(4) The further need for accurate diagnosis criteria, lead to the
formation of an expert panel and elaboration of the Schumacher et al. criteria, used
worldwide.(5)
A adaptation of the Schumacher criteria emerged from a worldwide
investigation by Bauer that was the first to include CSF OCB.(1)
One problem with the diverse published diagnostic classifications is their
different terminology and the subjective judgment required. This problem cannot be
completely overcome but can be diminished in the absence of a totally specific
laboratory test for MS by adding to the clinical evaluation, the results of laboratory,
neuroimaging, and neurophysiological procedures.(1)
New criteria (Poser et al. criteria) were published in 1983 and consisted of two
main groups, definite and probable, each with two subgroups, clinical and laboratory
supported.(6) Furthermore, for the first time definitions of the terms used were agreed.
An attack/exacerbation could consist of symptoms alone lasting at least 24 h. The term
“paraclinical” evidence was introduced to comprise the results of evoked response
studies and neuroimaging. One problem of this scheme was the failure to incorporate
consideration of primary progressive MS (PPMS). These criteria promptly replaced
previous ones for epidemiological studies and selection of patients for therapeutic drug
trials as well in clinical practice.(6) The 2001 McDonald et al. diagnostic criteria
resulted in two major changes: MRI criteria were incorporated into the scheme, and
long-needed guidelines for the diagnosis of primary progressive MS were defined.(7)
OCBs, best detected by isoelectric focusing followed by immunoblotting, is the
only biomarker present on the latest 2005 Revisions to the Mcdonald Criteria for MS.
According to these criteria, “elevated immunoglobulin G (IgG) index or ≥2 OCB in
CSF can be important to support the inflammatory demyelinating nature of the
underlying condition, to evaluate differential diagnosis and to predict clinically
definitive MS”.(8)
1.2 Biomarkers
Biomarkers are measurable indicators of a physiologic or pathologic process or
the effects of a therapeutic intervention. An ideal biomarker would thus be binary,
missing in a healthy individual, only present in the disease state and increasing with the
severity of the latter.(9) Characteristics that define biomarkers are usually limited to
detection of specific proteins in body fluids that become altered as a consequence of a
biologic or pathologic process.(2, 9, 10)
Since MS lesions are rarely biopsied, CSF analysis remains an important and
practical tool to understand the underlying immunopathogenesis in patients presenting
with a first demyelinating event or with early MS. It is possible to detect and measure a
various number of particles by several techniques.(3, 11) Differential therapeutic
approaches requires the development of biological markers that objectively: 1)reflect
the targeted immunopathological process, 2)select patients in which the pathogenic
process predominates, 3)show responses to treatment, 4)provide a simple and economic
monitoring tool in clinical trials and routine patient management.(2) In a complex
disease like MS with different pathogenetic mechanisms, a single biomarker is likely to
reflect only one of many ongoing pathogenic processes. Thus, the stratification of
patients might only be possible by using a defined set of biomarkers. Each biomarker
will have to be validated across diverse patient cohorts in prospective, multicentre
studies for the following goals:
1) clinical relevance: the biomarker has the capability to reflect the change of a
pathologic process and/or therapeutic intervention in a relatively short period;
2) sensitivity: the ability to be measured with adequate precision and sufficient
magnitude of change to reflect a meaningful change in important clinical endpoints;
3) specificity: the power to identify patients by the occurrence of pathologic
processes or the response to an intervention in terms of changes in a clinical endpoint;
4) probability of false positive or false negatives: defined by the situations in
which an estimated change of the biomarker is not reflected by the respective change in
clinical endpoint;
5) accuracy, precision, reproducibility and variability of the laboratory assay or
test measurement of the biomarker.(2, 9)
Some challenges to biomarker discovery and validation are: highly variable
clinical course, heterogeneous mechanisms of disease, nonspecificity of disease
markers, intra- and inter-individual variability in markers, variable responses to
treatment, diagnosis of exclusion without “gold standard”, frequent subclinical disease
activity, heterogeneous treatments with diverse mechanism of action.(12)
The latest promise in biomarker discovery is the proteomic studies, which
revealed a broad range of new possible biomarkers for MS. The discovery of new
biomarkers would be crucial for accurate and earlier diagnosis.(3)
1.3 Objective
The aim of this review is to assess the literature published in the last 5 years
concerning the role of biomarkers in the diagnosis of MS and conversion of CIS to MS.
The biomarkers concerning the MS evolution were excluded.
2. Material and Methods
The bibliography used for this article was obtained on 15/11/2011 by a double
research in the pubmed database. The first was made with the following query:
(("cerebrospinal fluid" [Subheading]) AND ( "Multiple Sclerosis/cerebrospinal
fluid"[Mesh] OR "Multiple Sclerosis/diagnosis"[Mesh] )) AND ( "Biological
Markers/analysis"[Mesh] OR "Biological Markers/cerebrospinal fluid"[Mesh] OR
"Biological Markers/diagnostic use"[Mesh] ), and the limits used were language
(Portuguese, Spanish and English) and publication date (<5 years). After reading the
abstract and/or full article, 68 articles were selected from the 158 that resulted from the
search. A second query (“multiple sclerosis AND diagnosis AND biomarkers”) without
Mesh terms was used, with the same limits for language and with publication data
limited to 6 months. 13 were selected from the 62 obtained and most of them were
included in the previous research. From all the articles, only 4 of them couldn’t be
acquired.
The bibliography of the studies above and additional literature considered
relevant, was included in this review. Microsoft word from Microsoft office 2007,
EndNote X5 and My NCBI were the tools used.
3. Results and discussion
3.1 MS diagnosis
3.1.1 Role of OCB in MS diagnosis
While MRI is now very sensitive, specificity is a problem. The MRI lesions are
compatible with many pathophysiological mechanisms and thus different diseases,
creating “false positives”.(13) MRI criteria for MS show limitations in equivocal MS
cases. Therefore, it is imperative that other investigative procedures, such as CSF
examinations, are established for MS diagnosis.(14)
The major diagnostic contribution of OCB was in terms of Specificity and
negative predictive value. Improved specificity is vital in differential diagnosis to rule
out non-MS cases. Moreover the combination of MRI and CSF analysis proved to be
more accurate than MRI alone.(15) The only marker used in the diagnostic procedure of
MS is the qualitative and quantitative assessment of immunoglobulin G in CSF.(2, 12,
16) Using optimized, standardized methodology, preferentially protein separation by
isoelectric focusing (IEF) followed by immunoblotting, more than 95% of patients with
MS have CSF OCB not detectable in serum, thereby providing powerful evidence for
the diagnosis of MS. Because of the high sensitivity of CSF OB in MS as well as its
high specificity in the appropriate clinical setting, examination of CSF for OB of IgG
class can be strongly recommended to obtain support for the diagnosis of MS.(17)
The IgG index equal to CSF/serum IgG:CSF/serum albumin is elevated in about
70% of MS patients, but infrequently in CSF OB-negative MS. Because of lower
diagnostic sensitivity, IgG index cannot be recommended as surrogate of CSF OB in the
diagnosis of MS but, when elevated, as additional evidence for an augmented B-cell
response within the CNS compatible with MS.(17, 18)
A drawback with determination of the IgG index is that it may become falsely
elevated in patients with moderate severe blood–CSF barrier damage. Detection of a
moderately–strongly elevated CSF/serum albumin ratio should lead to reevaluation of
an MS diagnosis. Still, the IgG index is more or less obtained for free in the context of
practically every routine CSF examination.(17)
Although the clinical picture as well as findings from magnetic resonance
imaging of the brain and spinal cord is essential for an MS diagnosis, this should be
reevaluated in CSF OB-negative patients, remembering the possible diseases imitating
MS. Conversely, OCB are not specific and are found less frequently in other conditions
that can clinically mimic MS, though usually OCB are only transient in these
conditions, whereas they are present continuously in MS patients, regardless of disease
activity or therapy, indicating a stable humoral immune response in CNS of MS
patients.(2, 17, 19) Consequently, a positive laboratory test for OCBs has a high
negative predictive value and a low positive predictive value, making it a sensitive
screening tool but not a diagnostic one.(16)
The significance of IgG migrating as one sharp (rare finding), monoclonal band
in CSF while not detectable in corresponding serum is debated. If the IgG index is
simultaneously elevated, then there is evidence for a local B-cell response, and this
should be reported. Usually, however, the IgG index is normal. The monoclonal CSF
IgG band may reflect a technical problem, and the examination for CSF OCB should be
repeatedly performed on the same CSF and serum specimens. The significance of a
single band in CSF remains unclear.(14, 17, 20)
There are trans-ethnic and/or trans-population differences in OCB sensitivity in
MS. Lower frequencies of CSF OCB have been reported from Asian and Southern
countries: China (63.3%), Italy (73.2%), Turkey (85.7%) and Brazil (54.4%).(17, 21-
25) Different methods adopted for CSF OB detection, various disease sub-types, diverse
genetic background, methodology or patient selection issues, can play a role in this
differences.(17, 21, 22) Due to these differences, OCB are of less diagnostic value for
MS in these areas (there was no significant difference between MS and other
inflammatory neurological diseases in a Chinese study).(21)
Different methods adopted for CSF detection can play a significant role in this
matter. Despite the awareness of the advantages inherent to IEF + immunoblotting,
several laboratories do not this method.(26, 27) It was argued that OCB detection
usefulness is limited by high inter-laboratory variability.(13) A Spanish study
demonstrated a high inter-laboratory reproducibility in high sensitivity techniques like
IEF, while an Italian group identified an unacceptable large inter-laboratory variation
not only in OCB numbering, but also in qualitative reporting of the OCB pattern and in
differentiating OCB+ from OCB-.(23, 28) Nevertheless, results of CSF OCB testing
should be considered in the context of the method used.(17, 28, 29) Recently OCB have
been detected in the tears of patients with CIS with 100% specificity.(30)
External quality control schemes are fundamental steps in standardization
processes, particularly in the field of IEF, the recommended technique for OCB
detection, because many IEF steps may be difficult to standardize and new centers lack
specialized sections for CSF analysis. Misinterpretation of art factual bands, insufficient
IEF skills or poor blotting and staining skills contribute to the inter-laboratory
variability. Educational support and external quality control schemes, scientific
associations involved in CSF analysis play essential roles in promoting quality.(29)
A various number of studies comparing OCB positive MS patients with OCB
negative, sometimes with contradictories results, regarding the OCB pattern, the
fulfillment of MRI criteria, location of the lesions, disease course, CSF pattern
demonstrated once more the heterogeneity of MS.(10, 31-33) Even the correlation
between both parameters of intra-thecal synthesis is not yet clear.(34)
In a patient where CSF OCB are expected but not detectable, the pair of
CSF+serum might be re-examined, but this only very rarely leads to a different result. It
is recommended that a complete routine CSF examination including test for IgG OCB
with appropriate methodology is done before a MS patient is included in clinical trials
with e.g. disease modulating drugs. The intent was that the Criteria could “be used by
the practicing neurologist to better and more reliably diagnose MS, balancing earlier
diagnosis with the need to avoid false-positive diagnosis”.(17)
The diagnosis of PPMS is particularly difficult. The single large study referred
to in the 2005 Revisions consists of 943 patients with a diagnosis of PPMS based on
clinical, MRI and evoked potential data. “Supportive CSF findings” were obtained in
about 80% of the patients, while the remaining 20% were ineligible because they did
not fulfill the supportive CSF findings.(35) These consisted of CSF OCB, elevated IgG
index or elevated IgG synthesis rate. The sensitivity of these variables differs
significantly in the context of a diagnosis of MS (95%, 70%, and 70%, respectively if
optimal tests are performed). Unfortunately, the three variables are equalized in the
study.(35) This is not noticed in the 2005 Revisions. Further, the study gives no
information regarding the procedures used for protein separation. A well-performed
study published in 2004, showed that 58 of 60 patients with PPMS (97%) have IgG OB
in CSF when examined by IEF+immunoblotting.(36) By adopting the 2005 Revisions,
there could be a risk that patients not suffering from MS might be included, thereby
jeopardizing the outcome of the trial.(17)
Other OCB isotypes, like IgA and IgM appear to be of limited additional value
in the diagnosis of MS.(16) IgA presence in MS is uncommon, suggesting other
diagnosis.(37, 38) IgM OCB are identified up to 60% of MS patients (especially in
childhood MS) and are more common in early phases of MS, being useful to select
patients to receive early treatment, because may influence disease prognosis.(16, 39)
Fifty years after their discovery, the OCB therefore continue to puzzle neuro-
immunologists.(19) It is highly recommended that the diagnostic MS criteria are further
revised to incorporate the minimum of CSF tests recommended for use in order to
support a diagnosis of MS and reduce the likelihood of another disease that mimics MS.
Many questions regarding CSF OCB remain to be solved. Some of them are minor like
the significance of a monoclonal band in CSF, the optimal way to proceed with CSF
examinations in a patient who according to clinical and MRI criteria has MS but has no
CSF OCB, the diagnostic role of detection of other Immunoglobulins or free light
chains migrating as OCB in CSF, improved and simplified methods for detection etc.
Some remaining questions are major like elucidating the role of CSF OCB in the
pathogenesis of MS.(2, 17)
3.1.2 Additional markers.
Despite the numerous studies, there has been no definite association of OCB
with a specific antigen in patients with MS and it is clear that the intra-thecal antibody
synthesis is directed against diverse antigens. An association of these antibodies with
the cause of MS is still missing.(2) Epstein-Bar virus (EBV) infection has been
suspected as an initial trigger of autoimmunity in MS and, thus, evidence of EBV
infection could have relevance for MS diagnosis.(10)
A number of studies have shown that almost 100% of MS patients have evidence
of prior EBV infection, whereas approximately 90% of healthy adults also have
evidence of EBV infection.(40) Therefore, the presence of EBV antibodies is not
considered to be diagnostic relevant. Furthermore, CSF reactivity to EBV antigens in
MS compared with healthy controls has not yielded any specific associations.(41)
Current investigations are focused on determining whether MS patients have
antibodies to unique determinants of EBV, or if viral-clearance responses to EBV
infection in MS patients are abnormal.(42) If these investigations are fruitful, they could
have application as diagnostic markers.(10)
Additionally, Bartos et al. (2007) reported no difference in antibodies against
light neurofilaments in all sub-types of MS and other diseases.(43)
Nogo-A, an inhibitor of axonal regeneration, is a perfect example of the
inconsistent and contradictory data gathered in this review. Jurewicz et al. (2007)
reported that CSF Nogo-A may be specific (100%) for MS and its presence may predict
failure of axonal regeneration within the CNS. Nogo-A was found in CSF of 96% of
MS patients and wasn’t present in meningo-encephalomyelitis, control subjects wither
neurologic, and autoimmune diseases.(44) These findings lacked confirmation by
William et al. (2008) with the same methodology.(45) Correspondence between authors,
showed high discordance in this subject.
Numerous studies have demonstrated elevated kappa free light chains (KFCLs)
in CSF of MS patients. However, so far only small cohorts have been examined, and
generally only through qualitative KFLCs analysis. Determining a single quantitative
diagnostic FLC parameter (KFLC index) by nephelometry (highly automated) and IEF,
Presslauer et al. (2008) showed higher sensitivity (96% vs 91%) but lower specificity
(86% vs 92%) compared with OCB, but was far more accurate than IgG index.
Additionally, there was no correlation between MS type, EDSS score, disease duration,
or number/localization of MRI lesions and the value of KFLC or KFLC index.(14)
The combined use of three FLC indices accounting for monomeric FLC –k level
and k/λ ratio values in the CSF and serum was found to be of promising diagnostic
importance for differentiation of MS from other non-MS neurological diseases
(specificity 93%, sensitivity 100% vs OCB 76% and 87% in the same cohort).(46) In
contrast to the OCB test, where the result is interpreted as “positive”, “negative” or
“trace”, this method provides quantitative evaluation of relative amounts of FLCs, as a
measure of the severity of intrathecal immunoglobulin synthesis. This procedure for
FLC analysis can serve as a basis of a new diagnostic test for MS. The described
method is inexpensive, it requires no special requirement, and may be applied in clinical
laboratories.(46) This procedure also allows preparation of samples in a dry state, that is
helpful for prolonged storage and transportation of CSF and serum samples prior to
their analysis.(46)
As it is measured by automated, routinely available laboratory methods, KFLC
quantification can provide a rapid and reproducible indication of intrathecal
immunological processes supporting current MS diagnostic criteria.(14) These results
strongly suggest that the KFLC index should be part of the routine MS diagnostic
algorithm.(14, 46) Additional LFLC index determination can support the exclusion of
alternative diagnoses. Alternative diagnoses should be considered if these are associated
with concurrent significant elevation of LFLC levels.(14)
Elevated CSF anti-MBP antibodies correlate well with acute myelin damage in
the CNS, but are not specific to MS. Reproducible quantification of MBP has been
difficult since immunoassays are not standardized and not commercially available.(3)
CSF MBP has lacked specificity in most studies. The test was recently re-
evaluated by Tian et al. (2009) who reported a diagnostic sensitivity of 83.7% and
specificity of 78.3%. These results need to be confirmed in further studies.(16, 47)
Preliminary studies, approaching Gelsolin, leukemia inhibitory factor and 7-
ketocholesterol, showed good result, needing further evaluation.(48-50)
In table 1, are displayed other biomarkers revised in this search.
3.1.3 Conversion of Clinically Isolated Syndrome to Clinically Definitive Multiple
Sclerosis
In a significant percentage of patients who later develop MS, the disease initially
presents with an acute or sub-acute episode of neurological symptoms due to a single
demyelinating lesion, known as clinically isolated syndrome (CIS). Predict the risk of
future events, confirming the MS diagnosis is crucial to begin an important early
treatment. In the last few years, the main focus has been on diagnostic sensitivity in
order to early detect the patients in need for early therapeutics, resulting therefore in
possible over diagnoses.(51) In this context, the most relevant statistical parameters to
predict conversion from CIS to MS are positive predictive value (PPV) and negative
predictive value (NPV).(51) MRI is the main exam used to this prediction but there is
an ongoing search for accurate biomarkers for this conversion.(52, 53)
Tintoré et al. (2008) showed that detection of OCB in CSF approximately
doubles the risk of having a second attack, autonomously of MRI, but does not seem to
influence the development of disability.(54) This higher risk is more significant when
MRI is normal or when there is not MRI criteria for dissemination in space (DIS) (4%
of patients with normal MRI and negative OCB converted and 23% of those with
normal MRI and positive OCB converted).(54)
The association of OCB to MRI maximizes the risk; therefore they can be used
together to better predict conversion to CDMS. OCB associated with number of
Barkhof criteria and number of lesions but the absence of OCB should suggest
extending the diagnosis workup.(15, 17)
Similar results were found by other displayed on table 2.(15, 55-58)
Additionally, two of these studies suggested that patients with OCB converts faster to
CDMS (55, 57), especially when IgM is associated.(55)
Brettsschneider et al. (2010) in a prospective pilot study with 91 patients and 2
years of follow-up, showed that the presence of C-X-C motif chemokine 13 (CXCL13)
in CSF has a better PPV (70%, augmented to 80% with Barkhof criteria) than OCB,
Measles, Rubella and Varicella zoster reaction (MRZR, intra-thecal synthesis of specific
antiviral IgG antibodies that supports the diagnosis) or Barkhof criteria.(59)
A large clinical case-control cohort, including the whole spectrum of MS forms,
as well as large numbers of inflammatory and non-inflammatory subjects with other
neurologic diseases confirmed the potential role of CXCL13 as a MS disease activity
marker. CXCL13 correlated with relapse rate, Expanded Disability Status Scale
(EDSS), number of lesion on MRI and response to treatment.(60) However, this
biomarker is not a disease-specific biomarker, but showed a close relationship with
OCB and CSF cell counts.(59-61)
Regarding antibodies against myelin, myelin oligodendrocyte glycoprotein
(MOG), and myelin basic protein (MBP), discordant unexplained results have
appeared.(62) Correlation ranged from highly significant (63), significant (64, 65), to
not significant at all (62, 66). It is important to note that these controversial results were
obtained with the same type of analysis of antimyelin antibodies, immunoblotting.
Thus, these different results may primarily reflect differences in study cohorts rather
than methodological problems.(2) Currently there is no proven value in the diagnostic
and prognostic utility of CSF anti-myelin antibodies in patients with CIS.(16)
CSF of patients with MS is characterized by a polyspecific, intrathecal B-cell
response with a prominent antibody production against neurotropic viruses like measles,
rubella and varicella zoster.(51) A prospective study with 89 CIS patients comparing
MRZR with OCB and MRI lesion load showed that MRZR was significantly more
frequent in CIS that developed MS during follow-up. Their data showed MRZR to have
a high PPV. MRZ score, produced according to the different prognostic relevance of
the three antibody included in MRZR, had the best single PPV (79%), augmented when
added to MRI (≥2 lesions, 91%).(51)
An important drawback of MRZR is that there’s no workable combined assay to
determine these antibodies. Therefore, another study from the same authors, following
121 individuals for 2 years values more CXCL13 determination (PPV of 70%).(59)
Axonal damage markers (tau and NfHSMI35) were measured by Brettschneider
et al. (2006) in order to access their power to predict conversion from CIS to MS. CSF
tau and NfHSMI35 were significantly elevated in CIS compared to controls, and
correlated with disease activity.(67) The sensitivity predicting the conversion from CIS
to MS was higher for the combination of CSF markers (either tau or NfHSMI35
elevated) than for MRI (40 versus 34%), but could be further increased to 60% if CSF
and MRI criteria were combined. Similarly, the combination of tau and NfHSMI35
showed higher specificity (94%) than MRI (82%). Tau and NfHSMI35, according to
this study, are valuable biomarkers for axonal damage in the CIS patients.(67)
Other molecules showed results that need further evaluation: increased CSF
cystatin C (in contrast with former studies), dissociation 14-3-3/tau protein in CSF,
blood and CSF white blood cell count and neurofilament light.(68-71)
In other hand, IgM and human leukocyte antigen G failed to be relevant in the
evaluation of CIS.(72, 73)
3.1.4 Multiple Sclerosis vs Neuromyelitis optica (NMO)
An example of success in researching biomarkers for differential diagnosis of
MS is the aquaporin-4 antibody. Recently, highly specific serum IgG antibodies were
detected by immunofluorescence staining of mouse brain tissue in a majority (73%) of
patients with definite NMO and in 46% of patients at high risk for NMO.(74) NMO-IgG
had 91% specificity for NMO and were suggested to be a useful diagnostic biomarker in
patients with their first episode of myelitis.(75, 76) Most recently a number of
confirmatory studies from different laboratories using diverse assays and different
cohorts of patients were published.(77-80)
A positive MRZR, defined by a combination of at least two antibody indices
was found in 37/42 MS patients, while only in 1/20 NMO patients by Jarius et al.
(2008) allowing the differentiation between MS and NMO.(81)
Tortorella et al. (2011) demonstrated that MS patients show higher serum and
CSF N-acetyl aspartate (NAA) levels than NMO patients, and higher serum NAA levels
than healthy controls. High serum NAA values, exceeding the 95th
percentile of serum
NAA value in healthy controls, were found in all MS patients and in none with NMO.
No differences in serum NAA levels were found between NMO and healthy
controls.(82) Therefore, serum and CSF NAA may be valuable in the diagnostic workup
to differentiate MS from NMO.(82)
3.1.5 Proteomics
Multiple proteomic preliminary studies carried out in the past few years have
revealed potential biomarkers candidates that may not otherwise have been discovered
through function-based approaches.(10, 53, 83-88) For most of these candidate proteins,
the pathophysiological relevance in MS remains to be clarified. Generally the disease
specificity of these proteins is rather low, possibly due to common pathological
mechanisms underlying different diseases.(53, 89)
A problem of CSF proteome analysis is that high-abundance proteins, such as
albumin and immunoglobulin, may overlay brain-specific low-abundance CSF proteins
in the electrophoresis. Therefore, CSF has to be pre-processed to extract those extra-
proteins, possibly resulting in wasting proteins that are bounded do albumin.(53, 85)
The advantages of mass spectrometry-based protein quantification are precision,
sensitivity, throughput and convenience.(83) An important aspect in future CSF
proteome studies is the standardization of sampling protocols, experimental design and
data analysis, in order to reach consensus.(53)
Further studies are needed to better characterize the correlation of these new
candidate markers with MS.(88-90)
4. Conclusion
Diagnosis of MS is currently based on clinical presentation, MRI findings, and
CSF examination (OCB and IgG index) and requires the exclusion of alternative
diagnosis.(45) CSF is especially important in not making a diagnosis of MS; that is, in
excluding other conditions that mimic MS and as a predictor of conversion to CDMS.
As long as we do not know what causes MS we will not have a simple diagnostic test
.(91) To understand the relation of marker concentrations in body fluids and
neuropathological processes, the underlying process need further investigation.(92)
With increasing sensitivity and resolution of analytical methods, the demands of
rigorous control of sample handling and storage also increase.(93) Often, early studies
show great potential, but subsequent reports on the same marker yield inconsistent or
even contradictory results. The reasons for this are mainly methodological although the
heterogeneity and the lack of solid knowledge about MS also contribute.(10, 12, 65, 72,
94, 95)
The use of OCB has some limitations and in result of MS heterogeneity, one
marker possibly isn’t enough. In this respect, development of novel laboratory
techniques and search for new reliable MS-specific markers remains of considerable
diagnostic importance for MS.(46, 96)
Other than OCB, MRZR and CXCL13 appeared like valuable markers for
conversion of CIS to MS, and anti-myelin antibodies the opposite. Predicting
conversion from CIS to MS can be improved combining MRI with CSF markers, but
MRI remains as the major prognostic factor.(16, 54, 59, 67)
CSF OCB utility was demonstrated in diagnosing and predicting MS, with the
awareness of the frequency variability in the different communities. When present, is a
strong support for MS but the diagnosis should be reviewed in it absence.(21, 33) The
equivalent use of IgG index comparing with OCB is inadequate according with some
authors.(17)
Quantitative KFCL’s presented as a helpful marker for MS diagnosis, and
should be further investigated.(46)
Besides aquaporin-4 antibody, the presence of NAA in the serum can be
important to distinguish MS from neuromyelitis.(82)
Even though OCB provide important information regarding MS diagnosis, there
are currently no CSF biomarkers that can reliably and definitively diagnose MS at the
time of initial symptoms.(10) The development of more sensitive proteomic techniques
is very promising for the identification of new molecular targets for diagnostic assays
and therapies preventing axonal damage.(92)
5. Acknowledgements
The help and availability of Dr Joana Guimarães were extremely helpful and
welcome during this paper elaboration, reason why I am sincerely grateful.
6. Conflicts of interest
There are no potential conflicts of interest from each author that relate to the
research covered in the article submitted. The authors have no financial disclosures or
nothing to disclose.
References
1. Poser CM, Brinar VV. Diagnostic criteria for multiple sclerosis: an historical review. Clinical neurology and neurosurgery. 2004;106(3):147-58. Epub 2004/06/05. 2. Lutterotti A, Berger T, Reindl M. Biological markers for multiple sclerosis. Current medicinal chemistry. 2007;14(18):1956-65. Epub 2007/08/21. 3. Tumani H, Hartung HP, Hemmer B, Teunissen C, Deisenhammer F, Giovannoni G, et al. Cerebrospinal fluid biomarkers in multiple sclerosis. Neurobiology of disease. 2009;35(2):117-27. Epub 2009/05/12. 4. Broman T, Bergmann L, Fog T, Gilland O, Hyllested K, Lindberg-Broman AM, et al. Aspects on classification methods in multiple sclerosis. Acta neurologica Scandinavica Supplementum. 1965;13 Pt 2:543-8. Epub 1965/01/01. 5. Schumacker GA, Beebe G, Kibler RF, Kurland LT, Kurtzke JF, McDowell F, et al. PROBLEMS OF EXPERIMENTAL TRIALS OF THERAPY IN MULTIPLE SCLEROSIS: REPORT BY THE PANEL ON THE EVALUATION OF EXPERIMENTAL TRIALS OF THERAPY IN MULTIPLE SCLEROSIS. Annals of the New York Academy of Sciences. 1965;122:552-68. Epub 1965/03/31. 6. Poser CM, Paty DW, Scheinberg L, McDonald WI, Davis FA, Ebers GC, et al. New diagnostic criteria for multiple sclerosis: guidelines for research protocols. Annals of neurology. 1983;13(3):227-31. Epub 1983/03/01. 7. McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis. Annals of neurology. 2001;50(1):121-7. Epub 2001/07/18. 8. Polman CH, Reingold SC, Edan G, Filippi M, Hartung HP, Kappos L, et al. Diagnostic criteria for multiple sclerosis: 2005 revisions to the "McDonald Criteria". Annals of neurology. 2005;58(6):840-6. Epub 2005/11/12. 9. Flood DG, Marek GJ, Williams M. Developing predictive CSF biomarkers-a challenge critical to success in Alzheimer's disease and neuropsychiatric translational medicine. Biochemical pharmacology. 2011;81(12):1422-34. Epub 2011/02/08. 10. Harris VK, Sadiq SA. Disease biomarkers in multiple sclerosis: potential for use in therapeutic decision making. Molecular diagnosis & therapy. 2009;13(4):225-44. Epub 2009/08/29.
11. Polman CH, Reingold SC, Banwell B, Clanet M, Cohen JA, Filippi M, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Annals of neurology. 2011;69(2):292-302. Epub 2011/03/10. 12. Graber JJ, Dhib-Jalbut S. Biomarkers of disease activity in multiple sclerosis. Journal of the neurological sciences. 2011;305(1-2):1-10. Epub 2011/04/06. 13. Luque FA, Jaffe SL. Cerebrospinal fluid analysis in multiple sclerosis. International review of neurobiology. 2007;79:341-56. Epub 2007/05/29. 14. Presslauer S, Milosavljevic D, Brucke T, Bayer P, Hubl W. Elevated levels of kappa free light chains in CSF support the diagnosis of multiple sclerosis. Journal of neurology. 2008;255(10):1508-14. Epub 2008/08/08. 15. Zipoli V, Hakiki B, Portaccio E, Lolli F, Siracusa G, Giannini M, et al. The contribution of cerebrospinal fluid oligoclonal bands to the early diagnosis of multiple sclerosis. Multiple sclerosis (Houndmills, Basingstoke, England). 2009;15(4):472-8. Epub 2009/01/21. 16. Awad A, Hemmer B, Hartung HP, Kieseier B, Bennett JL, Stuve O. Analyses of cerebrospinal fluid in the diagnosis and monitoring of multiple sclerosis. Journal of neuroimmunology. 2010;219(1-2):1-7. Epub 2009/09/29. 17. Link H, Huang YM. Oligoclonal bands in multiple sclerosis cerebrospinal fluid: an update on methodology and clinical usefulness. Journal of neuroimmunology. 2006;180(1-2):17-28. Epub 2006/09/02. 18. Galea I, Freedman MS, Thompson EJ. Cerebrospinal fluid analysis in the 2010 revised McDonald's multiple sclerosis diagnostic criteria. Annals of neurology. 2011;70(1):183; author reply -4. Epub 2011/07/26. 19. Holmoy T. The discovery of oligoclonal bands: a 50-year anniversary. European neurology. 2009;62(5):311-5. Epub 2009/09/05. 20. Davies G, Keir G, Thompson EJ, Giovannoni G. The clinical significance of an intrathecal monoclonal immunoglobulin band: a follow-up study. Neurology. 2003;60(7):1163-6. Epub 2003/04/12. 21. Li B, Dong H, Zhang J, Song X, Guo L. Cerebrospinal fluid IgG profiles and oligoclonal bands in Chinese patients with multiple sclerosis. Acta neurologica Scandinavica. 2007;115(5):319-24. Epub 2007/05/11. 22. Gama PD, Machado Ldos R, Livramento JA, Gomes HR, Adoni T, Lino AM, et al. Study of oligoclonal bands restricted to the cerebrospinal fluid in multiple sclerosis patients in the city of Sao Paulo. Arquivos de neuro-psiquiatria. 2009;67(4):1017-22. Epub 2010/01/14. 23. Pichiecchio A, Tavazzi E, Maccabelli G, Ponzio M, Romani A, Schiappacassa R, et al. MR peri-CSF lesions and CSF oligoclonal bands in Italian multiple sclerosis patients. Acta neurologica Scandinavica. 2009;120(4):242-5. Epub 2009/01/22. 24. Idiman E, Ozakbas S, Dogan Y, Kosehasanogullari G. The significance of oligoclonal bands in multiple sclerosis: relevance of demographic and clinical features, and immunogenetic backgrounds. Journal of neuroimmunology. 2009;212(1-2):121-4. Epub 2009/05/22. 25. Rinker JR, 2nd, Trinkaus K, Naismith RT, Cross AH. Higher IgG index found in African Americans versus Caucasians with multiple sclerosis. Neurology. 2007;69(1):68-72. Epub 2007/07/04. 26. Keren DF. Optimizing detection of oligoclonal bands in cerebrospinal fluid by use of isoelectric focusing with IgG immunoblotting. American journal of clinical pathology. 2003;120(5):649-51. Epub 2003/11/12. 27. Verbeek MM, de Reus HP, Weykamp CW. Comparison of methods for the detection of oligoclonal IgG bands in cerebrospinal fluid and serum: results of the Dutch Quality Control survey. Clinical chemistry. 2002;48(9):1578-80. Epub 2002/08/27. 28. Abraira V, Alvarez-Cermeno JC, Arroyo R, Camara C, Casanova B, Cubillo S, et al. Utility of oligoclonal IgG band detection for MS diagnosis in daily clinical practice. Journal of immunological methods. 2011;371(1-2):170-3. Epub 2011/06/28.
29. Franciotta D, Lolli F. Interlaboratory reproducibility of isoelectric focusing in oligoclonal band detection. Clinical chemistry. 2007;53(8):1557-8. Epub 2007/07/24. 30. Calais G, Forzy G, Crinquette C, Mackowiak A, de Seze J, Blanc F, et al. Tear analysis in clinically isolated syndrome as new multiple sclerosis criterion. Multiple sclerosis (Houndmills, Basingstoke, England). 2010;16(1):87-92. Epub 2009/12/24. 31. Huttner HB, Schellinger PD, Struffert T, Richter G, Engelhorn T, Bassemir T, et al. MRI criteria in MS patients with negative and positive oligoclonal bands: equal fulfillment of Barkhof's criteria but different lesion patterns. Journal of neurology. 2009;256(7):1121-5. Epub 2009/03/03. 32. Villar LM, Masterman T, Casanova B, Gomez-Rial J, Espino M, Sadaba MC, et al. CSF oligoclonal band patterns reveal disease heterogeneity in multiple sclerosis. Journal of neuroimmunology. 2009;211(1-2):101-4. Epub 2009/05/16. 33. Siritho S, Freedman MS. The prognostic significance of cerebrospinal fluid in multiple sclerosis. Journal of the neurological sciences. 2009;279(1-2):21-5. Epub 2009/02/03. 34. Mares J, Herzig R, Urbanek K, Sladkova V, Sklenarova J, Bekarek V, et al. Correlation of the IgG index and oligoclonal bands in the cerebrospinal fluid of patients with multiple sclerosis. Biomedical papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia. 2008;152(2):247-9. Epub 2009/02/17. 35. Wolinsky JS. The diagnosis of primary progressive multiple sclerosis. Journal of the neurological sciences. 2003;206(2):145-52. Epub 2003/02/01. 36. Dujmovic I, Mesaros S, Pekmezovic T, Levic Z, Drulovic J. Primary progressive multiple sclerosis: clinical and paraclinical characteristics with application of the new diagnostic criteria. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2004;11(7):439-44. Epub 2004/07/20. 37. Martino G, Servalli C, Filippi M, Buscemi M, Martinelli V, Furlan R, et al. Absence of oligoclonally restricted immunoglobulins in tears from multiple sclerosis patients. Journal of neuroimmunology. 1993;44(2):149-55. Epub 1993/05/01. 38. Mehta PD, Patrick BA, Miller JA. Absence of oligoclonal IgA in CSF and serum of multiple sclerosis patients. Journal of neuroimmunology. 1984;6(1):67-9. Epub 1984/02/01. 39. Pohl D, Rostasy K, Reiber H, Hanefeld F. CSF characteristics in early-onset multiple sclerosis. Neurology. 2004;63(10):1966-7. Epub 2004/11/24. 40. Ascherio A, Munger KL. Environmental risk factors for multiple sclerosis. Part I: the role of infection. Annals of neurology. 2007;61(4):288-99. Epub 2007/04/21. 41. Torkildsen O, Stansberg C, Angelskar SM, Kooi EJ, Geurts JJ, van der Valk P, et al. Upregulation of immunoglobulin-related genes in cortical sections from multiple sclerosis patients. Brain pathology (Zurich, Switzerland). 2010;20(4):720-9. Epub 2009/11/19. 42. Jilek S, Schluep M, Meylan P, Vingerhoets F, Guignard L, Monney A, et al. Strong EBV-specific CD8+ T-cell response in patients with early multiple sclerosis. Brain : a journal of neurology. 2008;131(Pt 7):1712-21. Epub 2008/06/14. 43. Bartos A, Fialova L, Soukupova J, Kukal J, Malbohan I, Pitha J. Antibodies against light neurofilaments in multiple sclerosis patients. Acta neurologica Scandinavica. 2007;116(2):100-7. Epub 2007/07/31. 44. Jurewicz A, Matysiak M, Raine CS, Selmaj K. Soluble Nogo-A, an inhibitor of axonal regeneration, as a biomarker for multiple sclerosis. Neurology. 2007;68(4):283-7. Epub 2007/01/24. 45. Lindsey JW, Crawford MP, Hatfield LM. Soluble Nogo-A in CSF is not a useful biomarker for multiple sclerosis. Neurology. 2008;71(1):35-7. Epub 2008/05/23. 46. Kaplan B, Aizenbud BM, Golderman S, Yaskariev R, Sela BA. Free light chain monomers in the diagnosis of multiple sclerosis. Journal of neuroimmunology. 2010;229(1-2):263-71. Epub 2010/09/28. 47. Tian ZJ, Zhao XX, Li ZH, Zhang F, Cao FT, Li SM, et al. [Evaluation of myelin basic protein levels with receiver operating characteristic curves for diagnosis of multiple sclerosis]. Nan
fang yi ke da xue xue bao = Journal of Southern Medical University. 2009;29(2):250-2. Epub 2009/02/28. 48. Kulakowska A, Drozdowski W, Sadzynski A, Bucki R, Janmey PA. Gelsolin concentration in cerebrospinal fluid from patients with multiple sclerosis and other neurological disorders. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2008;15(6):584-8. Epub 2008/05/14. 49. Mashayekhi F, Salehi Z. Expression of leukemia inhibitory factor in the cerebrospinal fluid of patients with multiple sclerosis. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2011;18(7):951-4. Epub 2011/05/17. 50. Diestel A, Aktas O, Hackel D, Hake I, Meier S, Raine CS, et al. Activation of microglial poly(ADP-ribose)-polymerase-1 by cholesterol breakdown products during neuroinflammation: a link between demyelination and neuronal damage. The Journal of experimental medicine. 2003;198(11):1729-40. Epub 2003/12/06. 51. Brettschneider J, Tumani H, Kiechle U, Muche R, Richards G, Lehmensiek V, et al. IgG antibodies against measles, rubella, and varicella zoster virus predict conversion to multiple sclerosis in clinically isolated syndrome. PloS one. 2009;4(11):e7638. Epub 2009/11/06. 52. Miller D, Barkhof F, Montalban X, Thompson A, Filippi M. Clinically isolated syndromes suggestive of multiple sclerosis, part I: natural history, pathogenesis, diagnosis, and prognosis. Lancet neurology. 2005;4(5):281-8. Epub 2005/04/26. 53. Tumani H, Lehmensiek V, Rau D, Guttmann I, Tauscher G, Mogel H, et al. CSF proteome analysis in clinically isolated syndrome (CIS): candidate markers for conversion to definite multiple sclerosis. Neuroscience letters. 2009;452(2):214-7. Epub 2009/04/23. 54. Tintore M, Rovira A, Rio J, Tur C, Pelayo R, Nos C, et al. Do oligoclonal bands add information to MRI in first attacks of multiple sclerosis? Neurology. 2008;70(13 Pt 2):1079-83. Epub 2007/09/21. 55. Villar LM, Garcia-Barragan N, Sadaba MC, Espino M, Gomez-Rial J, Martinez-San Millan J, et al. Accuracy of CSF and MRI criteria for dissemination in space in the diagnosis of multiple sclerosis. Journal of the neurological sciences. 2008;266(1-2):34-7. Epub 2007/09/22. 56. Perumal J, Zabad R, Caon C, MacKenzie M, Tselis A, Bao F, et al. Acute transverse myelitis with normal brain MRI : long-term risk of MS. Journal of neurology. 2008;255(1):89-93. Epub 2007/12/18. 57. Oligoclonal bands and MRI in clinically isolated syndromes: predicting conversion time to multiple sclerosis. Journal of neurology. 2010;257(7):1188-91. Epub 2010/02/17. 58. Bosca I, Magraner MJ, Coret F, Alvarez-Cermeno JC, Simo-Castello M, Villar LM, et al. The risk of relapse after a clinically isolated syndrome is related to the pattern of oligoclonal bands. Journal of neuroimmunology. 2010;226(1-2):143-6. Epub 2010/06/12. 59. Brettschneider J, Czerwoniak A, Senel M, Fang L, Kassubek J, Pinkhardt E, et al. The chemokine CXCL13 is a prognostic marker in clinically isolated syndrome (CIS). PloS one. 2010;5(8):e11986. Epub 2010/08/12. 60. Khademi M, Kockum I, Andersson ML, Iacobaeus E, Brundin L, Sellebjerg F, et al. Cerebrospinal fluid CXCL13 in multiple sclerosis: a suggestive prognostic marker for the disease course. Multiple sclerosis (Houndmills, Basingstoke, England). 2011;17(3):335-43. Epub 2010/12/08. 61. Ragheb S, Li Y, Simon K, VanHaerents S, Galimberti D, De Riz M, et al. Multiple sclerosis: BAFF and CXCL13 in cerebrospinal fluid. Multiple sclerosis (Houndmills, Basingstoke, England). 2011;17(7):819-29. Epub 2011/03/05. 62. Pelayo R, Tintore M, Montalban X, Rovira A, Espejo C, Reindl M, et al. Antimyelin antibodies with no progression to multiple sclerosis. The New England journal of medicine. 2007;356(4):426-8. Epub 2007/01/26. 63. Tomassini V, De Giglio L, Reindl M, Russo P, Pestalozza I, Pantano P, et al. Anti-myelin antibodies predict the clinical outcome after a first episode suggestive of MS. Multiple sclerosis (Houndmills, Basingstoke, England). 2007;13(9):1086-94. Epub 2007/05/01.
64. Kuhle J, Lindberg RL, Regeniter A, Mehling M, Hoffmann F, Reindl M, et al. Antimyelin antibodies in clinically isolated syndromes correlate with inflammation in MRI and CSF. Journal of neurology. 2007;254(2):160-8. Epub 2007/03/06. 65. Rauer S, Euler B, Reindl M, Berger T. Antimyelin antibodies and the risk of relapse in patients with a primary demyelinating event. Journal of neurology, neurosurgery, and psychiatry. 2006;77(6):739-42. Epub 2006/05/18. 66. Kuhle J, Pohl C, Mehling M, Edan G, Freedman MS, Hartung HP, et al. Lack of association between antimyelin antibodies and progression to multiple sclerosis. The New England journal of medicine. 2007;356(4):371-8. Epub 2007/01/26. 67. Brettschneider J, Petzold A, Junker A, Tumani H. Axonal damage markers in the cerebrospinal fluid of patients with clinically isolated syndrome improve predicting conversion to definite multiple sclerosis. Multiple sclerosis (Houndmills, Basingstoke, England). 2006;12(2):143-8. Epub 2006/04/25. 68. Teunissen CE, Iacobaeus E, Khademi M, Brundin L, Norgren N, Koel-Simmelink MJ, et al. Combination of CSF N-acetylaspartate and neurofilaments in multiple sclerosis. Neurology. 2009;72(15):1322-9. Epub 2009/04/15. 69. Gajofatto A, Monaco S, Fiorini M, Zanusso G, Vedovello M, Rossi F, et al. Assessment of outcome predictors in first-episode acute myelitis: a retrospective study of 53 cases. Archives of neurology. 2010;67(6):724-30. Epub 2010/06/19. 70. Gout O, Bouchareine A, Moulignier A, Deschamps R, Papeix C, Gorochov G, et al. Prognostic value of cerebrospinal fluid analysis at the time of a first demyelinating event. Multiple sclerosis (Houndmills, Basingstoke, England). 2011;17(2):164-72. Epub 2010/10/23. 71. Villar LM, Espino M, Roldan E, Marin N, Costa-Frossard L, Muriel A, et al. Increased peripheral blood CD5+ B cells predict earlier conversion to MS in high-risk clinically isolated syndromes. Multiple sclerosis (Houndmills, Basingstoke, England). 2011;17(6):690-4. Epub 2011/03/26. 72. Schneider R, Euler B, Rauer S. Intrathecal IgM-synthesis does not correlate with the risk of relapse in patients with a primary demyelinating event. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2007;14(8):907-11. Epub 2007/07/31. 73. Waschbisch A, Sandbrink R, Hartung HP, Kappos L, Schwab S, Pohl C, et al. Evaluation of soluble HLA-G as a biomarker for multiple sclerosis. Neurology. 2011;77(6):596-8. Epub 2011/07/29. 74. Lennon VA, Wingerchuk DM, Kryzer TJ, Pittock SJ, Lucchinetti CF, Fujihara K, et al. A serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis. Lancet. 2004;364(9451):2106-12. Epub 2004/12/14. 75. Weinshenker BG, Wingerchuk DM, Vukusic S, Linbo L, Pittock SJ, Lucchinetti CF, et al. Neuromyelitis optica IgG predicts relapse after longitudinally extensive transverse myelitis. Annals of neurology. 2006;59(3):566-9. Epub 2006/02/03. 76. Wingerchuk DM, Lennon VA, Pittock SJ, Lucchinetti CF, Weinshenker BG. Revised diagnostic criteria for neuromyelitis optica. Neurology. 2006;66(10):1485-9. Epub 2006/05/24. 77. Jarius S, Franciotta D, Bergamaschi R, Wright H, Littleton E, Palace J, et al. NMO-IgG in the diagnosis of neuromyelitis optica. Neurology. 2007;68(13):1076-7. Epub 2007/02/09. 78. Matsuoka T, Matsushita T, Kawano Y, Osoegawa M, Ochi H, Ishizu T, et al. Heterogeneity of aquaporin-4 autoimmunity and spinal cord lesions in multiple sclerosis in Japanese. Brain : a journal of neurology. 2007;130(Pt 5):1206-23. Epub 2007/04/19. 79. Paul F, Jarius S, Aktas O, Bluthner M, Bauer O, Appelhans H, et al. Antibody to aquaporin 4 in the diagnosis of neuromyelitis optica. PLoS medicine. 2007;4(4):e133. Epub 2007/04/19. 80. Takahashi T, Fujihara K, Nakashima I, Misu T, Miyazawa I, Nakamura M, et al. Anti-aquaporin-4 antibody is involved in the pathogenesis of NMO: a study on antibody titre. Brain : a journal of neurology. 2007;130(Pt 5):1235-43. Epub 2007/04/24.
81. Jarius S, Franciotta D, Bergamaschi R, Rauer S, Wandinger KP, Petereit HF, et al. Polyspecific, antiviral immune response distinguishes multiple sclerosis and neuromyelitis optica. Journal of neurology, neurosurgery, and psychiatry. 2008;79(10):1134-6. Epub 2008/02/14. 82. Tortorella C, Ruggieri M, Di Monte E, Ceci E, Iaffaldano P, Direnzo V, et al. Serum and CSF N-acetyl aspartate levels differ in multiple sclerosis and neuromyelitis optica. Journal of neurology, neurosurgery, and psychiatry. 2011;82(12):1355-9. Epub 2011/05/31. 83. Comabella M, Fernandez M, Martin R, Rivera-Vallve S, Borras E, Chiva C, et al. Cerebrospinal fluid chitinase 3-like 1 levels are associated with conversion to multiple sclerosis. Brain : a journal of neurology. 2010;133(Pt 4):1082-93. Epub 2010/03/20. 84. Harris VK, Diamanduros A, Good P, Zakin E, Chalivendra V, Sadiq SA. Bri2-23 is a potential cerebrospinal fluid biomarker in multiple sclerosis. Neurobiology of disease. 2010;40(1):331-9. Epub 2010/07/06. 85. Li Y, Qin Z, Yang M, Qin Y, Lin C, Liu S. Differential expression of complement proteins in cerebrospinal fluid from active multiple sclerosis patients. Journal of cellular biochemistry. 2011;112(7):1930-7. Epub 2011/03/30. 86. Teunissen CE, Koel-Simmelink MJ, Pham TV, Knol JC, Khalil M, Trentini A, et al. Identification of biomarkers for diagnosis and progression of MS by MALDI-TOF mass spectrometry. Multiple sclerosis (Houndmills, Basingstoke, England). 2011;17(7):838-50. Epub 2011/04/21. 87. Rajalahti T, Kroksveen AC, Arneberg R, Berven FS, Vedeler CA, Myhr KM, et al. A multivariate approach to reveal biomarker signatures for disease classification: application to mass spectral profiles of cerebrospinal fluid from patients with multiple sclerosis. Journal of proteome research. 2010;9(7):3608-20. Epub 2010/05/27. 88. Chiasserini D, Di Filippo M, Candeliere A, Susta F, Orvietani PL, Calabresi P, et al. CSF proteome analysis in multiple sclerosis patients by two-dimensional electrophoresis. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2008;15(9):998-1001. Epub 2008/07/22. 89. Lehmensiek V, Sussmuth SD, Tauscher G, Brettschneider J, Felk S, Gillardon F, et al. Cerebrospinal fluid proteome profile in multiple sclerosis. Multiple sclerosis (Houndmills, Basingstoke, England). 2007;13(7):840-9. Epub 2007/09/21. 90. Qin Z, Qin Y, Liu S. Alteration of DBP levels in CSF of patients with MS by proteomics analysis. Cellular and molecular neurobiology. 2009;29(2):203-10. Epub 2008/09/23. 91. Hintzen RQ, Giovannoni G. CSF analysis in suspected MS: do bands aid? Neurology. 2008;70(13 Pt 2):1059-60. Epub 2008/03/26. 92. Teunissen CE, Dijkstra C, Polman C. Biological markers in CSF and blood for axonal degeneration in multiple sclerosis. Lancet neurology. 2005;4(1):32-41. Epub 2004/12/29. 93. Hansson SF, Simonsen AH, Zetterberg H, Andersen O, Haghighi S, Fagerberg I, et al. Cystatin C in cerebrospinal fluid and multiple sclerosis. Annals of neurology. 2007;62(2):193-6; discussion 205. Epub 2006/08/11. 94. Lim ET, Berger T, Reindl M, Dalton CM, Fernando K, Keir G, et al. Anti-myelin antibodies do not allow earlier diagnosis of multiple sclerosis. Multiple sclerosis (Houndmills, Basingstoke, England). 2005;11(4):492-4. Epub 2005/07/27. 95. Voumvourakis KI, Kitsos DK, Tsiodras S, Petrikkos G, Stamboulis E. Human herpesvirus 6 infection as a trigger of multiple sclerosis. Mayo Clinic proceedings Mayo Clinic. 2010;85(11):1023-30. Epub 2010/10/12. 96. Somers V, Govarts C, Somers K, Hupperts R, Medaer R, Stinissen P. Autoantibody profiling in multiple sclerosis reveals novel antigenic candidates. Journal of immunology (Baltimore, Md : 1950). 2008;180(6):3957-63. Epub 2008/03/07. 97. Franciotta D, Di Stefano AL, Jarius S, Zardini E, Tavazzi E, Ballerini C, et al. Cerebrospinal BAFF and Epstein-Barr virus-specific oligoclonal bands in multiple sclerosis and other
inflammatory demyelinating neurological diseases. Journal of neuroimmunology. 2011;230(1-2):160-3. Epub 2010/11/27. 98. Probst-Cousin S, Heuss D, Bergmann M. Annexin-1 is no useful surrogate marker of multiple sclerosis - an immunocytochemical study of the cerebrospinal fluid. Clinical neuropathology. 2011;30(1):18-24. Epub 2010/12/24. 99. Svarcova J, Fialova L, Bartos A, Steinbachova M, Malbohan I. Cerebrospinal fluid antibodies to tubulin are elevated in the patients with multiple sclerosis. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2008;15(11):1173-9. Epub 2008/11/01. 100. Lazzarino G, Amorini AM, Eikelenboom MJ, Killestein J, Belli A, Di Pietro V, et al. Cerebrospinal fluid ATP metabolites in multiple sclerosis. Multiple sclerosis (Houndmills, Basingstoke, England). 2010;16(5):549-54. Epub 2010/03/03.
Appendices
Table 2. Association between OCB and/or imaging and conversion from CIS to
CDMS
N
Follow-
up
(years)
Sensibility Specificity PPV NPV RR1 RR2
Tintoré et al.
(2008) 415 4.2 83 48 50 84 1.7 8.9
Jai Perumal
et al.(2007) 58 5.2 100 61 53.1 100 53 -
Isabel Boscá
et al.(2010) 192 6.2 95 60 78 88 9.4
39.2
#
Juan Rojas
et al.(2010) 40 5 87 60 56 88 5 9
Valentina
Zipoli et
al.(2009)
90 3.8 76 37 60 56 1.4 -
Luisa Villar
et al.(2011)
*
58 6 94 96 97 91 - -
Table2. OCB: oligoclonal bands; CIS: Clinically isolated syndrome; CDMS: Clinically definitive
Multiple Sclerosis; *:All values concern OCB+2 MRI lesions. #:This value concerns the
combination of OCB and IgM. N: number of subjects in study; PPV: positive predictive value;
NPV: negative predictive value; RR1: OCB relative risk; RR2: OCB combined with imaging
relative risk.
Table 1. CSF biomarkers valuable or not for the diagnosis of MS
Not Valuable Valuable
12,5 kDa Cystatin C (93) Gelsolin (48)
BAAF (97) Leukemia inhibitory factor (49)
Annexin-1 (98) 7- ketocholesterol(50)
Anti-tubulin (99)
ATP metabolites (100)
Neurospecific enolase (92)
Anexos
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 1
MULTIPLE SCLEROSIS AND RELATEDDISORDERS
AUTHOR INFORMATION PACK
TABLE OF CONTENTS.
XXX.
• Description• Audience• Abstracting and Indexing• Editorial Board• Guide for Authors
p.1p.1p.1p.2p.4
ISSN: 2211-0348
DESCRIPTION.
Multiple Sclerosis is an area of ever expanding research and escalating publications. Multiple Sclerosisand Related Disorders is a wide ranging international journal supported by key researchers from allneuroscience domains that focus on MS and associated disease of the central nervous system. Theprimary aim of this new journal is the rapid publication of high quality original research in the field.Important secondary aims will be timely updates and editorials on important scientific and clinicalcare advances, controversies in the field, and invited opinion articles from current thought leaders ontopical issues. One section of the journal will focus on teaching, written to enhance the practice ofcommunity and academic neurologists involved in the care of MS patients. Summaries of key articleswritten for a lay audience will be provided as an on-line resource.
A team of four chief editors is supported by leading section editors who will commissionand appraise original and review articles concerning: clinical neurology, neuroimaging,neuropathology, neuroepidemiology, therapeutics, genetics / transcriptomics, experimental models,neuroimmunology, biomarkers, neuropsychology, neurorehabilitation, measurement scales, teaching,neuroethics and lay communication.
The journal will publish the following types of articles: Reviews; Original Research Articles; Editorials;Comment; Clinical Trial papers; Letter to the Editors; ; Case Reports; Book reviews; News. Thesubmission of an on-line summary of selected papers of relevance for lay audience, Teaching Lessonsand supporting images and datasets is also encouraged.
AUDIENCE.
All branches of neuroscience: clinical neurologists, neurophysiologists, geneticists, psychologist,molecular biologists, MRI and allied imaging specialists, immunologists, major pharmaceuticalcompanies, ethical and legal specialists, MS specialist nurses, drug trial nurses.
ABSTRACTING AND INDEXING.
EMBASEGoogle Scholar®Scopus
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 2
EDITORIAL BOARD.
Chief Editors:
B. Banwell, Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, CanadaM5G 1X8G. Giovannoni, Neuroimmunology Unit, Neuroscience Centre; Institute of Cell and Molecular Science, Barts andThe London School of Medicine and Dentistry; 4 Newark Street; London E1 2AT, United KingdomC. H. Hawkes, Neuroimmunology Unit, Neuroscience Centre; Institute of Cell and Molecular Science Barts andThe London School of Medicine and Dentistry, 4 Newark Street, London E1 2AT, United KingdomF. D. Lublin, The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, 5East 98th Street, New York, NY 10029-6574, USA
Section Editors:
Experimental Models
S. Amor, Amsterdam, The Netherlands
Epidemiology
A. Ascherio, Boston, MA, USA
Neuro-opthalmology
L. Balcer, Philadelphia, PA, USA
Infection
J. Berger, Lexington, KY, USA
Neuroethics
J. Bernat, Lebanon, NH, USA
Pediatric MS
R. Dale, Sydney, Australia
Biomarkers
F. Deisenhammer, Innsbruck, Austria
Genetics / transcriptomics
R. Hintzen, Rotterdam, The Netherlands
Measurement / quality of life
J. Hobart, Plymouth, United Kingdom
Teaching
M. Keegan, Rochester, MN, USA
Rehabilitation
J. Kesselring, Valens, Switzerland
Clinical Neurology
J.I. Kira, Fukuaka, Japan
Psychology and Fatigue
D. Langdon, Egham Surrey, United Kingdom
Stem Cell Research
G. Martino, Milan, Italy
Therapy
A. Miller, New York, NY, USA
Immunology
F. Sellebjerg, Copenhagen, Denmark
Imaging
J. Wolinsky, Houston, TX, USA
Editorial Board:
H. Butzkueven, Melbourne, AustraliaV. Brinar, Zagreb, Croatia
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 3
J. Correale, Buenos Aires, ArgentinaO. Fernandez, Malaga, SpainE. Havrdova, Prague, Czech RepublicH.P. Hartung, Dusseldorf, GermanyL. Kappos, Basel, SwitzerlandN. Koch-Henriksen, Aarhus, DenmarkP. Li, Hong Kong, ChinaJ. Losy, Poznan, PolandC. Lubetzki, Paris, FranceA.H. Maghzi, Isfahan, IranA. Miller, Haifa, IsraelN. Prayoonwiwat, Bangkok, ThailandT. Saida, Kyoto, JapanB. Singhal, Mumbai, IndiaS. Sveinbjornsdottir, Reykjavik, IcelandJ. Torro, Bogota, ColumbiaC.P. Tsai, Taipei, TaiwanL. Vécsei, Szeged, HungaryE. Willoughby, Auckland, New ZealandB. Yamout, Beirout, Lebanon
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 4
GUIDE FOR AUTHORS.
INTRODUCTIONTypes of articleOriginal Research ArticlesFull length research papers will not normally be more than 3500 words in length from the Inotrductionthrough the Discussion section and will preferably be shorter. Submission of a paper to MultipleSclerosis and Related Disorders will be held to imply that it represents original research not previouslypublished (except in the form of an abstract or preliminary report), that it is not being considered forpublication elsewhere, and that if accepted by Multiple Sclerosis and Related Disorders it will not bepublished elsewhere in the same form in any language without the consent of the Publisher. Majorpapers of topical content will be given priority in publication.
Book ReviewsThese are normally submitted by the Book Review Editors, but they welcome suggestions of booksfor review.
Case ReportsCase reports should detail the clinical, laboratory and neuroimaging features of informative patients.Informative patients should provide insights that inform on genetic contributions to disease, rareclinical manifestations, novel laboratory or imaging features, or highlight important concepts in thedifferential of MS and related disorders. Case reports should be approximately 1200 words, and shouldhave no more than five key references
CommentComments should focus on specific issues relevant to MS and related disorders, or should discussrecent publications. Comments should be less than 800 words and should reference the article(s)upon which the commentary is based.
Clinical Trial papersManuscripts detailing the results of clinical trials in MS and related disorders are encourage. The trialmethodology should account for all screened participants, and analyses should observe an intention-to -treat model where appropriate. All sources of funding for the study must be disclosed, and theinvolvement of the study sponsor must be detailed. Clinical trial manuscripts should be a maximumof 3500 words.
EditorialsThe Editors welcome suggestions for editorials which give personal and topical views on subjectswithin the Journal's area of interest. They should not normally exceed 1500 words in total, includingreferences.
Letters to the EditorsThese normally refer to articles previously published in the Journal. The Editors are also willing toconsider letters on subjects of direct relevance to the Journal's interest. Letters should not exceed1000 words in total and, where appropriate, must begin with the reference to the published articleabout which the author is commenting. Research letters should be submitted as 'letter to the Editors'
Review ArticlesReview papers are normally 4000-5000 words in total. Authors are advised to consult one of theEditors with an outline before submitting a review.
Contact details for submissionAuthors may send queries concerning the submission process, manuscript status, or journalprocedures to the Editorial Office at:MSARD, Editorial Office, ELSEVIER.E-mail: [email protected]
BEFORE YOU BEGINEthics in publishingFor information on Ethics in publishing and Ethical guidelines for journal publication seehttp://www.elsevier.com/publishingethics and http://www.elsevier.com/ethicalguidelines.
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 5
Policy and ethicsThe work described in your article must have been carried out in accordance with The Codeof Ethics of the World Medical Association (Declaration of Helsinki) for experiments involvinghumans http://www.wma.net/en/30publications/10policies/b3/index.html; EU Directive 2010/63/EUfor animal experiments http://ec.europa.eu/environment/chemicals/lab_animals/legislation_en.htm;Uniform Requirements for manuscripts submitted to Biomedical journals http://www.icmje.org. Thismust be stated at an appropriate point in the article.
Conflict of interestAll authors are requested to disclose any actual or potential conflict of interest including any financial,personal or other relationships with other people or organizations within three years of beginning thesubmitted work that could inappropriately influence, or be perceived to influence, their work. Seealso http://www.elsevier.com/conflictsofinterest.
Submission declarationSubmission of an article implies that the work described has not been published previously (exceptin the form of an abstract or as part of a published lecture or academic thesis), that it is not underconsideration for publication elsewhere, that its publication is approved by all authors and tacitly orexplicitly by the responsible authorities where the work was carried out, and that, if accepted, itwill not be published elsewhere including electronically in the same form, in English or in any otherlanguage, without the written consent of the copyright-holder.
Changes to authorshipThis policy concerns the addition, deletion, or rearrangement of author names in the authorship ofaccepted manuscripts:Before the accepted manuscript is published in an online issue: Requests to add or remove an author,or to rearrange the author names, must be sent to the Journal Manager from the corresponding authorof the accepted manuscript and must include: (a) the reason the name should be added or removed,or the author names rearranged and (b) written confirmation (e-mail, fax, letter) from all authors thatthey agree with the addition, removal or rearrangement. In the case of addition or removal of authors,this includes confirmation from the author being added or removed. Requests that are not sent bythe corresponding author will be forwarded by the Journal Manager to the corresponding author, whomust follow the procedure as described above. Note that: (1) Journal Managers will inform the JournalEditors of any such requests and (2) publication of the accepted manuscript in an online issue issuspended until authorship has been agreed.After the accepted manuscript is published in an online issue: Any requests to add, delete, or rearrangeauthor names in an article published in an online issue will follow the same policies as noted aboveand result in a corrigendum.
Clinical trial resultsIn line with the position of the International Committee of Medical Journal Editors, the journal will notconsider results posted in the same clinical trials registry in which primary registration resides to beprior publication if the results posted are presented in the form of a brief structured (less than 500words) abstract or table. However, divulging results in other circumstances (e.g., investors' meetings)is discouraged and may jeopardise consideration of the manuscript. Authors should fully disclose allposting in registries of results of the same or closely related work.
Reporting clinical trialsAll randomised controlled trials submitted for publication should include a completed ConsolidatedStandards of Reporting Trials (CONSORT) flow chart. Please refer to the CONSORT statement websiteat http://www.consort-statement.org for more information. This journal has adopted the proposalfrom the International Committee of Medical Journal Editors (ICMJE) which require, as a conditionof consideration for publication of clinical trials, registration in a public trials registry. Trials mustregister at or before the onset of patient enrolment. The clinical trial registration number should beincluded at the end of the abstract of the article. For this purpose, a clinical trial is defined as anyresearch study that prospectively assigns human participants or groups of humans to one or morehealth-related interventions to evaluate the effects of health outcomes. Health-related interventionsinclude any intervention used to modify a biomedical or health-related outcome (for example drugs,surgical procedures, devices, behavioural treatments, dietary interventions, and process-of-carechanges). Health outcomes include any biomedical or health-related measures obtained in patients or
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 6
participants, including pharmacokinetic measures and adverse events. Purely observational studies(those in which the assignment of the medical intervention is not at the discretion of the investigator)will not require registration. Further information can be found at http://www.icmje.org.
CopyrightUpon acceptance of an article, authors will be asked to complete a 'Journal Publishing Agreement' (formore information on this and copyright see http://www.elsevier.com/copyright). Acceptance of theagreement will ensure the widest possible dissemination of information. An e-mail will be sent tothe corresponding author confirming receipt of the manuscript together with a 'Journal PublishingAgreement' form or a link to the online version of this agreement.Subscribers may reproduce tables of contents or prepare lists of articles including abstracts for internalcirculation within their institutions. Permission of the Publisher is required for resale or distributionoutside the institution and for all other derivative works, including compilations and translations(please consult http://www.elsevier.com/permissions). If excerpts from other copyrighted works areincluded, the author(s) must obtain written permission from the copyright owners and credit thesource(s) in the article. Elsevier has preprinted forms for use by authors in these cases: please consulthttp://www.elsevier.com/permissions.
Retained author rightsAs an author you (or your employer or institution) retain certain rights; for details you are referredto: http://www.elsevier.com/authorsrights.
Role of the funding sourceYou are requested to identify who provided financial support for the conduct of the research and/orpreparation of the article and to briefly describe the role of the sponsor(s), if any, in study design; inthe collection, analysis and interpretation of data; in the writing of the report; and in the decision tosubmit the article for publication. If the funding source(s) had no such involvement then this shouldbe stated. Please see http://www.elsevier.com/funding.
Funding body agreements and policiesElsevier has established agreements and developed policies to allow authors whose articles appear injournals published by Elsevier, to comply with potential manuscript archiving requirements as specifiedas conditions of their grant awards. To learn more about existing agreements and policies please visithttp://www.elsevier.com/fundingbodies.
Language and language servicesPlease write your text in good English (American or British usage is accepted, but not a mixture ofthese). Authors who require information about language editing and copyediting services pre- andpost-submission please visit http://webshop.elsevier.com/languageservices or our customer supportsite at http://support.elsevier.com for more information.
SubmissionSubmission to this journal proceeds totally online and you will be guided stepwise through the creationand uploading of your files. The system automatically converts source files to a single PDF file of thearticle, which is used in the peer-review process. Please note that even though manuscript sourcefiles are converted to PDF files at submission for the review process, these source files are needed forfurther processing after acceptance. All correspondence, including notification of the Editor's decisionand requests for revision, takes place by e-mail removing the need for a paper trail.
Submit your articlePlease submit your article via http://ees.elsevier.com/msard/
RefereesPlease submit, with the manuscript, the names, addresses and e-mail addresses of three potentialreferees. Note that the editor retains the sole right to decide whether or not the suggested reviewersare used.
PREPARATIONUse of wordprocessing softwareIt is important that the file be saved in the native format of the wordprocessor used. The text shouldbe in single-column format. Keep the layout of the text as simple as possible. Most formatting codeswill be removed and replaced on processing the article. In particular, do not use the wordprocessor'soptions to justify text or to hyphenate words. However, do use bold face, italics, subscripts,superscripts etc. When preparing tables, if you are using a table grid, use only one grid for each
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 7
individual table and not a grid for each row. If no grid is used, use tabs, not spaces, to align columns.The electronic text should be prepared in a way very similar to that of conventional manuscripts(see also the Guide to Publishing with Elsevier: http://www.elsevier.com/guidepublication). Note thatsource files of figures, tables and text graphics will be required whether or not you embed your figuresin the text. See also the section on Electronic artwork.To avoid unnecessary errors you are strongly advised to use the 'spell-check' and 'grammar-check'functions of your wordprocessor.
Article structureSubdivision - numbered sectionsDivide your article into clearly defined and numbered sections. Subsections should be numbered1.1 (then 1.1.1, 1.1.2, ...), 1.2, etc. (the abstract is not included in section numbering). Use thisnumbering also for internal cross-referencing: do not just refer to 'the text'. Any subsection may begiven a brief heading. Each heading should appear on its own separate line.
IntroductionState the objectives of the work and provide an adequate background, avoiding a detailed literaturesurvey or a summary of the results.
Material and methodsProvide sufficient detail to allow the work to be reproduced. Methods already published should beindicated by a reference: only relevant modifications should be described.
ResultsResults should be clear and concise.
DiscussionThis should explore the significance of the results of the work, not repeat them. A combined Resultsand Discussion section is often appropriate. Avoid extensive citations and discussion of publishedliterature.
ConclusionsThe main conclusions of the study may be presented in a short Conclusions section, which may standalone or form a subsection of a Discussion or Results and Discussion section.
AppendicesIf there is more than one appendix, they should be identified as A, B, etc. Formulae and equations inappendices should be given separate numbering: Eq. (A.1), Eq. (A.2), etc.; in a subsequent appendix,Eq. (B.1) and so on. Similarly for tables and figures: Table A.1; Fig. A.1, etc.
Essential title page information• Title. Concise and informative. Titles are often used in information-retrieval systems. Avoidabbreviations and formulae where possible.• Author names and affiliations. Where the family name may be ambiguous (e.g., a doublename), please indicate this clearly. Present the authors' affiliation addresses (where the actual workwas done) below the names. Indicate all affiliations with a lower-case superscript letter immediatelyafter the author's name and in front of the appropriate address. Provide the full postal address ofeach affiliation, including the country name and, if available, the e-mail address of each author.• Corresponding author. Clearly indicate who will handle correspondence at all stages of refereeingand publication, also post-publication. Ensure that telephone and fax numbers (with countryand area code) are provided in addition to the e-mail address and the complete postaladdress. Contact details must be kept up to date by the corresponding author.• Present/permanent address. If an author has moved since the work described in the articlewas done, or was visiting at the time, a 'Present address' (or 'Permanent address') may be indicatedas a footnote to that author's name. The address at which the author actually did the work must beretained as the main, affiliation address. Superscript Arabic numerals are used for such footnotes.
AbstractA concise and factual abstract is required. The abstract should state briefly the purpose of theresearch, the principal results and major conclusions. An abstract is often presented separately fromthe article, so it must be able to stand alone. For this reason, References should be avoided, but ifessential, then cite the author(s) and year(s). Also, non-standard or uncommon abbreviations shouldbe avoided, but if essential they must be defined at their first mention in the abstract itself.
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 8
Graphical abstractA Graphical abstract is optional and should summarize the contents of the article in a concise, pictorialform designed to capture the attention of a wide readership online. Authors must provide imagesthat clearly represent the work described in the article. Graphical abstracts should be submitted as aseparate file in the online submission system. Image size: Please provide an image with a minimumof 531 × 1328 pixels (h × w) or proportionally more. The image should be readable at a size of 5 ×13 cm using a regular screen resolution of 96 dpi. Preferred file types: TIFF, EPS, PDF or MS Officefiles. See http://www.elsevier.com/graphicalabstracts for examples.Authors can make use of Elsevier's Illustration and Enhancement service to ensure the bestpresentation of their images also in accordance with all technical requirements: Illustration Service.
HighlightsHighlights are a short collection of bullet points that convey the core findings of the article. Highlightsare optional and should be submitted in a separate file in the online submission system. Please use'Highlights' in the file name and include 3 to 5 bullet points (maximum 85 characters, including spaces,per bullet point). See http://www.elsevier.com/highlights for examples.
KeywordsImmediately after the abstract, provide a maximum of 6 keywords, using American spelling andavoiding general and plural terms and multiple concepts (avoid, for example, 'and', 'of'). Be sparingwith abbreviations: only abbreviations firmly established in the field may be eligible. These keywordswill be used for indexing purposes.
AbbreviationsDefine abbreviations that are not standard in this field in a footnote to be placed on the first pageof the article. Such abbreviations that are unavoidable in the abstract must be defined at their firstmention there, as well as in the footnote. Ensure consistency of abbreviations throughout the article.
AcknowledgementsCollate acknowledgements in a separate section at the end of the article before the references and donot, therefore, include them on the title page, as a footnote to the title or otherwise. List here thoseindividuals who provided help during the research (e.g., providing language help, writing assistanceor proof reading the article, etc.).
Math formulaePresent simple formulae in the line of normal text where possible and use the solidus (/) instead ofa horizontal line for small fractional terms, e.g., X/Y. In principle, variables are to be presented initalics. Powers of e are often more conveniently denoted by exp. Number consecutively any equationsthat have to be displayed separately from the text (if referred to explicitly in the text).
FootnotesFootnotes should be used sparingly. Number them consecutively throughout the article, usingsuperscript Arabic numbers. Many wordprocessors build footnotes into the text, and this feature maybe used. Should this not be the case, indicate the position of footnotes in the text and present thefootnotes themselves separately at the end of the article. Do not include footnotes in the Referencelist.Table footnotesIndicate each footnote in a table with a superscript lowercase letter.
ArtworkElectronic artworkGeneral points• Make sure you use uniform lettering and sizing of your original artwork.• Save text in illustrations as 'graphics' or enclose the font.• Only use the following fonts in your illustrations: Arial, Courier, Times, Symbol.• Number the illustrations according to their sequence in the text.• Use a logical naming convention for your artwork files.• Provide captions to illustrations separately.• Produce images near to the desired size of the printed version.• Submit each figure as a separate file.
A detailed guide on electronic artwork is available on our website:http://www.elsevier.com/artworkinstructions
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 9
You are urged to visit this site; some excerpts from the detailed information are given here.FormatsRegardless of the application used, when your electronic artwork is finalised, please 'save as' orconvert the images to one of the following formats (note the resolution requirements for line drawings,halftones, and line/halftone combinations given below):EPS: Vector drawings. Embed the font or save the text as 'graphics'.TIFF: Color or grayscale photographs (halftones): always use a minimum of 300 dpi.TIFF: Bitmapped line drawings: use a minimum of 1000 dpi.TIFF: Combinations bitmapped line/half-tone (color or grayscale): a minimum of 500 dpi is required.If your electronic artwork is created in a Microsoft Office application (Word, PowerPoint, Excel) thenplease supply 'as is'.Please do not:• Supply files that are optimised for screen use (e.g., GIF, BMP, PICT, WPG); the resolution is too low;• Supply files that are too low in resolution;• Submit graphics that are disproportionately large for the content.
Color artworkPlease make sure that artwork files are in an acceptable format (TIFF, EPS or MS Office files) and withthe correct resolution. If, together with your accepted article, you submit usable color figures thenElsevier will ensure, at no additional charge, that these figures will appear in color on the Web (e.g.,ScienceDirect and other sites) regardless of whether or not these illustrations are reproduced in colorin the printed version. For color reproduction in print, you will receive information regardingthe costs from Elsevier after receipt of your accepted article. Please indicate your preferencefor color: in print or on the Web only. For further information on the preparation of electronic artwork,please see http://www.elsevier.com/artworkinstructions.Please note: Because of technical complications which can arise by converting color figures to 'grayscale' (for the printed version should you not opt for color in print) please submit in addition usableblack and white versions of all the color illustrations.
Figure captionsEnsure that each illustration has a caption. Supply captions separately, not attached to the figure. Acaption should comprise a brief title (not on the figure itself) and a description of the illustration. Keeptext in the illustrations themselves to a minimum but explain all symbols and abbreviations used.
TablesNumber tables consecutively in accordance with their appearance in the text. Place footnotes to tablesbelow the table body and indicate them with superscript lowercase letters. Avoid vertical rules. Besparing in the use of tables and ensure that the data presented in tables do not duplicate resultsdescribed elsewhere in the article.
ReferencesCitation in textPlease ensure that every reference cited in the text is also present in the reference list (and viceversa). Any references cited in the abstract must be given in full. Unpublished results and personalcommunications are not recommended in the reference list, but may be mentioned in the text. If thesereferences are included in the reference list they should follow the standard reference style of thejournal and should include a substitution of the publication date with either 'Unpublished results' or'Personal communication'. Citation of a reference as 'in press' implies that the item has been acceptedfor publication.
Reference management softwareThis journal has standard templates available in key reference managementpackages EndNote http://www.endnote.com/support/enstyles.asp and Reference Managerhttp://refman.com/support/rmstyles.asp. Using plug-ins to wordprocessing packages, authors onlyneed to select the appropriate journal template when preparing their article and the list of referencesand citations to these will be formatted according to the journal style which is described below.
Web referencesAs a minimum, the full URL should be given and the date when the reference was last accessed. Anyfurther information, if known (DOI, author names, dates, reference to a source publication, etc.),should also be given. Web references can be listed separately (e.g., after the reference list) under adifferent heading if desired, or can be included in the reference list.
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 10
References in a special issuePlease ensure that the words 'this issue' are added to any references in the list (and any citations inthe text) to other articles in the same Special Issue.
Reference styleText: All citations in the text should refer to:1. Single author: the author's name (without initials, unless there is ambiguity) and the year ofpublication;2. Two authors: both authors' names and the year of publication;3. Three or more authors: first author's name followed by 'et al.' and the year of publication.Citations may be made directly (or parenthetically). Groups of references should be listed firstalphabetically, then chronologically.Examples: 'as demonstrated in wheat (Allan, 2000a, 2000b, 1999; Allan and Jones, 1999). Krameret al. (2010) have recently shown ....'List: References should be arranged first alphabetically and then further sorted chronologically ifnecessary. More than one reference from the same author(s) in the same year must be identified bythe letters 'a', 'b', 'c', etc., placed after the year of publication.Examples:Reference to a journal publication:Van der Geer J, Hanraads JAJ, Lupton RA. The art of writing a scientific article. J Sci Commun2010;163:51–9.Reference to a book:Strunk Jr W, White EB. The elements of style. 4th ed. New York: Longman; 1979.Reference to a chapter in an edited book:Mettam GR, Adams LB. How to prepare an electronic version of your article. In: Jones BS, Smith RZ,editors. Introduction to the electronic age. New York: E-Publishing Inc; 2009. p. 281–304.Note shortened form for last page number. e.g., 51–9, and that for more than 6 authors the first 6should be listed followed by "et al." For further details you are referred to "Uniform Requirementsfor Manuscripts submitted to Biomedical Journals" (J Am Med Assoc 1997;277:927–34) (see alsohttp://www.nlm.nih.gov/bsd/uniform_requirements.html).
Journal abbreviations sourceJournal names should be abbreviated according toIndex Medicus journal abbreviations: http://www.nlm.nih.gov/tsd/serials/lji.html;List of title word abbreviations: http://www.issn.org/2-22661-LTWA-online.php;CAS (Chemical Abstracts Service): http://www.cas.org/sent.html.
Video dataElsevier accepts video material and animation sequences to support and enhance your scientificresearch. Authors who have video or animation files that they wish to submit with their article arestrongly encouraged to include these within the body of the article. This can be done in the same wayas a figure or table by referring to the video or animation content and noting in the body text where itshould be placed. All submitted files should be properly labeled so that they directly relate to the videofile's content. In order to ensure that your video or animation material is directly usable, please providethe files in one of our recommended file formats with a preferred maximum size of 50 MB. Video andanimation files supplied will be published online in the electronic version of your article in ElsevierWeb products, including ScienceDirect: http://www.sciencedirect.com. Please supply 'stills' with yourfiles: you can choose any frame from the video or animation or make a separate image. These willbe used instead of standard icons and will personalize the link to your video data. For more detailedinstructions please visit our video instruction pages at http://www.elsevier.com/artworkinstructions.Note: since video and animation cannot be embedded in the print version of the journal, pleaseprovide text for both the electronic and the print version for the portions of the article that refer tothis content.
Supplementary dataElsevier accepts electronic supplementary material to support and enhance your scientific research.Supplementary files offer the author additional possibilities to publish supporting applications, high-resolution images, background datasets, sound clips and more. Supplementary files supplied will bepublished online alongside the electronic version of your article in Elsevier Web products, includingScienceDirect: http://www.sciencedirect.com. In order to ensure that your submitted material isdirectly usable, please provide the data in one of our recommended file formats. Authors should
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 11
submit the material in electronic format together with the article and supply a concise and descriptivecaption for each file. For more detailed instructions please visit our artwork instruction pages athttp://www.elsevier.com/artworkinstructions.
Submission checklistThe following list will be useful during the final checking of an article prior to sending it to the journalfor review. Please consult this Guide for Authors for further details of any item.Ensure that the following items are present:One author has been designated as the corresponding author with contact details:• E-mail address• Full postal address• Telephone and fax numbersAll necessary files have been uploaded, and contain:• Keywords• All figure captions• All tables (including title, description, footnotes)Further considerations• Manuscript has been 'spell-checked' and 'grammar-checked'• References are in the correct format for this journal• All references mentioned in the Reference list are cited in the text, and vice versa• Permission has been obtained for use of copyrighted material from other sources (including the Web)• Color figures are clearly marked as being intended for color reproduction on the Web (free of charge)and in print, or to be reproduced in color on the Web (free of charge) and in black-and-white in print• If only color on the Web is required, black-and-white versions of the figures are also supplied forprinting purposesFor any further information please visit our customer support site at http://support.elsevier.com.
AFTER ACCEPTANCEUse of the Digital Object IdentifierThe Digital Object Identifier (DOI) may be used to cite and link to electronic documents. The DOIconsists of a unique alpha-numeric character string which is assigned to a document by the publisherupon the initial electronic publication. The assigned DOI never changes. Therefore, it is an idealmedium for citing a document, particularly 'Articles in press' because they have not yet received theirfull bibliographic information. The correct format for citing a DOI is shown as follows (example takenfrom a document in the journal Physics Letters B):doi:10.1016/j.physletb.2010.09.059When you use the DOI to create URL hyperlinks to documents on the web, the DOIs are guaranteednever to change.
ProofsOne set of page proofs (as PDF files) will be sent by e-mail to the corresponding author (if we donot have an e-mail address then paper proofs will be sent by post) or, a link will be provided inthe e-mail so that authors can download the files themselves. Elsevier now provides authors withPDF proofs which can be annotated; for this you will need to download Adobe Reader version 7 (orhigher) available free from http://get.adobe.com/reader. Instructions on how to annotate PDF fileswill accompany the proofs (also given online). The exact system requirements are given at the Adobesite: http://www.adobe.com/products/reader/tech-specs.html.If you do not wish to use the PDF annotations function, you may list the corrections (includingreplies to the Query Form) and return them to Elsevier in an e-mail. Please list your correctionsquoting line number. If, for any reason, this is not possible, then mark the corrections and any othercomments (including replies to the Query Form) on a printout of your proof and return by fax, or scanthe pages and e-mail, or by post. Please use this proof only for checking the typesetting, editing,completeness and correctness of the text, tables and figures. Significant changes to the article asaccepted for publication will only be considered at this stage with permission from the Editor. We willdo everything possible to get your article published quickly and accurately – please let us have all yourcorrections within 48 hours. It is important to ensure that all corrections are sent back to us in onecommunication: please check carefully before replying, as inclusion of any subsequent correctionscannot be guaranteed. Proofreading is solely your responsibility. Note that Elsevier may proceed withthe publication of your article if no response is received.
AUTHOR INFORMATION PACK 8 Mar 2012 www.elsevier.com/locate/msard 12
OffprintsThe corresponding author, at no cost, will be provided with a PDF file of the article via e-mail. For anextra charge, paper offprints can be ordered via the offprint order form which is sent once the articleis accepted for publication. The PDF file is a watermarked version of the published article and includesa cover sheet with the journal cover image and a disclaimer outlining the terms and conditions of use.
AUTHOR INQUIRIESFor inquiries relating to the submission of articles (including electronic submission) pleasevisit this journal's homepage. Contact details for questions arising after acceptance ofan article, especially those relating to proofs, will be provided by the publisher. Youcan track accepted articles at http://www.elsevier.com/trackarticle. You can also checkour Author FAQs (http://www.elsevier.com/authorFAQ) and/or contact Customer Support viahttp://support.elsevier.com.
© Copyright 2012 Elsevier | http://www.elsevier.com