Jessica Frau

Background: Long‐term disease control after the standard two‐year cladribine course in multiple sclerosis (MS) remains insufficiently characterized in real‐world settings. We evaluated disease control, treatment re‐initiation, and safety during extended follow‐up of the multicenter CladStop cohort after treatment completion. Methods: We included 204 patients with relapsing MS who completed the approved two‐year cladribine regimen and had ≥ 6 months of follow‐up after treatment completion. Time zero (“CladStop”) was defined as 24 months after first cladribine dosing. Co‐primary endpoints were time to loss of no evidence of disease activity (NEDA‐3) and annualized relapse rate (ARR) after CladStop. Kaplan–Meier analyses, multivariable Cox models, and mixed‐effects Poisson regression were applied. Results: Mean follow‐up after CladStop was 44.2 ± 8.6 months. Overall, 81/204 patients (39.7%) lost NEDA‐3. NEDA‐3 survival was 82.8% (95% CI 77.8–88.2) at 12 months, 69.6% (95% CI 63.6–76.2) at 24 months, and 56.4% (95% CI 49.2–64.8) at 48 months. Forty‐two patients (20.6%) relapsed, with an overall ARR of 0.06 (95% CI 0.04–0.08). Relapse rates decreased over time (rate ratio/year 0.74, 95% CI 0.55–0.999; p = 0.044). MRI activity occurred in 29.9% of patients and 6‐month confirmed disability progression in 7.4%. A new DMT was initiated in 40.7% of patients. Relapses during treatment predicted earlier DMT initiation. Conclusions: Disease control remained durable in many patients after completion of cladribine treatment. However, over 40% initiated subsequent DMT during follow‐up, indicating that prolonged treatment‐free remission is not universal. Disease reactivation was driven mainly by inflammatory activity rather than disability worsening.

Multiple sclerosis (MS) is a chronic immune-mediated disease for which non-invasive biomarkers, able to detect disease- and treatment-associated molecular changes, are needed. We characterized the whole-saliva proteome of patients with relapsing-remitting (RR) MS at baseline before treatment initiation (MS-T0; n = 66) and after six months of disease-modifying therapy (MS-T1; n = 40), in comparison with healthy controls (HC; n = 31). Nano-liquid chromatography-high-resolution tandem mass spectrometry identified 1305 proteins, of which 209 differed among the main comparisons. Pairwise and paired analyses distinguished persistent RRMS-associated alterations, baseline-attenuation patterns with changes shifting towards HC levels, treatment-associated differences emerging at MS-T1, and longitudinal-only alterations. The identified patterns are descriptive and cannot be interpreted as evidence of pharmacological treatment effects or clinical response. The existence of specific RRMS alterations was supported by exploratory Random Forest, which classified HC, MS-T0 and MS-T1 samples using a panel of 50 proteins, most of which (96%) also showed significant changes in univariate tests. Reactome enrichment evidenced that proteins pertaining to the identified patterns are mainly involved in innate immunity, neutrophil degranulation, cell-death pathways, cytokine signalling, and protein folding. These findings indicate that six months of therapy was associated with substantial salivary proteome changes and support saliva as a candidate biofluid for longitudinal molecular monitoring and non-invasive detection of treatment-associated salivary proteome variations in RRMS.

Background: Charcot–Marie–Tooth (CMT) is a group of inherited diseases impairing the peripheral nervous system. CMT originates from genetic variants that affect proteins fundamental for the myelination of peripheral nerves and survival. Moreover, environmental and humoral factors can impact disease development and evolution. Currently, no therapy is available. Metabolomics is an emerging field of biomedical research that enables the development of novel biomarkers for neurodegenerative diseases by targeting metabolic pathways or metabolites. This study aimed to evaluate the metabolomics profile of CMT disease by comparing patients with healthy individuals. Methods: A total of 22 CMT patients (CMT) were included in this study and were demographically matched with 26 healthy individuals (C). Serum samples were analyzed through Nuclear Magnetic Resonance spectroscopy, and multivariate and univariate statistical analyses were subsequently applied. Results: A supervised model showed a clear separation (R²X = 0.3; R²Y = 0.7; Q² = 0.4; p-value = 0.0004) between the two classes of subjects, and nine metabolites were found to be significantly different (2-hydroxybutyrate, 3-hydroxybutyrate, 3-methyl-2-oxovalerate, choline, citrate, glutamate, isoleucine, lysine, and methyl succinate). The combined ROC curve showed an AUC of 0.94 (CI: 0.9–1). Additional altered metabolic pathways were also identified within the disease context. Conclusion: This study represents a promising starting point, demonstrating the efficacy of metabolomics in evaluating CMT patients and identifying novel potential disease biomarkers.

Background and purpose: Cladribine tablets, a purine analogue antimetabolite, offer a unique treatment regimen, involving short courses at the start of the first and second year, with no further treatment needed in years 3 and 4. However, comprehensive evidence regarding patient outcomes beyond the initial 24 months of cladribine treatment is limited.Methods: This retrospective, multicenter study enrolled 204 patients with multiple sclerosis who had completed the 2‐year course of cladribine treatment. The primary outcomes were therapeutic choices and clinical disease activity assessed by annualized relapse rate after the 2‐year treatment course.Results: A total of 204 patients were enrolled; most patients (75.4%) did not initiate new treatments in the 12 months postcladribine. The study found a significant reduction in annualized relapse rate at the 12‐month follow‐up after cladribine completion compared to the year prior to starting therapy (0.07 ± 0.25 vs. 0.82 ± 0.80, p < 0.001). Furthermore, patients with relapses during cladribine treatment were more likely to start new therapies, whereas older patients were less likely. The safety profile of cladribine was favorable, with lymphopenia being the primary registered adverse event.Conclusions: This study provides insights into therapeutic choices and disease activity following cladribine treatment. It highlights cladribine's effectiveness in reducing relapse rates and disability progression, reaffirming its favorable safety profile. Real‐world data, aligned with previous reports, draw attention to ocrelizumab and natalizumab as common choices after cladribine. However, larger, prospective studies for validation and a more comprehensive understanding of cladribine's long‐term impact are necessary.

Together with the wide range of possible benefits for the rehabilitation/training of people with multiple sclerosis (pwMS) and other neurologic conditions, exposure to immersive virtual reality (VR) has often been associated with unpleasant symptoms, such as transient dizziness, headache, nausea, disorientation and impaired postural control (i.e., cybersickness). Since these symptoms can significantly impact the safety and tolerability of the treatment, it appears important to correctly estimate their presence and magnitude. Given the existing data scarcity, this study aims to assess the existence and severity of possible adverse effects associated with exposure to immersive VR in a cohort of pwMS using both objective measurements of postural control effectiveness and subjective evaluations of perceived symptoms. To this aim, postural sway under upright quiet posture (in the presence and absence of visual input) of 56 pwMS with an Expanded Disability Status Scale score (EDSS) in the range of 0–6.5 (mean EDSS 2.3) and 33 unaffected individuals was measured before and after a 10-min immersive VR session and at 10 min follow-up on the basis of center of pressure (COP) trajectories. The severity of cybersickness symptoms associated with VR exposure was also self-rated by the participants using the Italian version of the Simulator Sickness Questionnaire (SSQ). Temporary impairments of postural control in terms of significantly increased sway area were observed after the VR session only in pwMS with mild–moderate disability (i.e., EDSS in the range of 2.5–6.5) in the presence of visual input. No changes were observed in pwMS with low disability (EDSS 0–2) and unaffected individuals. In contrast, when the visual input was removed, there was a decrease in sway area (pwMS with mild–moderate disability) and COP path length relating to the use of VR (pwMS with mild–moderate disability and unaffected individuals), thus suggesting a sort of “balance training effect”. Even in this case, the baseline values were restored at follow-up. All participants, regardless of their status, experienced significant post-VR side effects, especially in terms of blurred vision and nausea. Taken together, the findings of the present study suggest that a short immersive VR session negatively (eyes open) and positively (eyes closed) impacts the postural control of pwMS and causes significant disorientation. However, such effects are of limited duration. While it is reasonable to state that immersive VR is sufficiently safe and tolerable to not be contraindicated in the rehabilitation/training of pwMS, in order to reduce possible negative effects and maximize the efficacy, safety and comfort of the treatment, it appears necessary to develop specific guidelines that consider important factors like individual susceptibility, maximum exposure time according to the specific features of the simulation, posture to adopt and protocols to assess objective and perceived effects on participants.