Multiple Sclerosis Panel Discussion

Multiple Sclerosis Panel Discussion


– Good morning, everyone,
almost afternoon. My name is Rob Pace. It’s a pleasure to be here, and it’s a pleasure to see so many people, some of whom I’ve seen in clinic and many of whom I hope
I get the chance to meet at some point in the future. We got a lot of great questions that we’ve just been sifting through. We apologize if there are any questions that we’re not able to get to. Many of the questions
were asked several times, and we wanna start with some of those. I think it’s only
appropriate that we start the first question off with the one that was asked the most, and– – I’m sorry to interrupt you, Dr. Pace, but I was instructed to
make one quick announcement before we actually
launched into questions, if you could bear with me? Is that okay? – Dr. Irani’s gonna make
a quick announcement. (audience laughs) – So, a number of people
wrote on their cards about questions related
to the presentations that were given this morning, asking about whether the material that was presented would
be available in the future, and the answer is yes. And so Carol Gregory has instructed me to tell everyone that the
material will be posted on the neurology website,
is that right, Carol? And also on YouTube, is that right? So, I believe we’re being videotaped, and there may be a YouTube
presentation available. So you’ll be able to get
access to the information you heard about if you
have other questions or things you wanted to
follow up on in that regard. – We’re gonna be famous. – Yeah, right. The other thing I was
asked to remind people of is in your packet, we’ve provided you with an evaluation form for
the morning’s presentation, and we would greatly value your feedback on the presentations and the
formats that we’ve selected. We wanna hear from you about
what you thought worked well. We also wanna hear from you about things that we can improve on, so
please take a few minutes to fill out your evaluation form. I think Carol and Joanne have a box up at the registration desk where
we’ll be collecting them. That information will be collated, and we’re gonna use it to try to improve our presentation for next year. So that’s another feedback
that we’d like to get from you. So take a few minutes for that. Now, we’re gonna, oh,
and then, that’s right. The last, the last reminder, Carol’s flagging me from the back, is please turn in your
name tag when you’re done. We’d like to recycle those, and so she’s gonna have
a basket or something where we’re gonna be collecting
name tags on the way out. So, thank you. Sorry, Dr. Pace. – No problem at all. First question is the most
frequently asked question, and it appropriately is going
to to go our fearless leader. I’ve been waiting for several months to be able to put my boss on the spot. I’ll pay for this later. Dr. Segal, can you tell
us a little bit more about the effects of a gluten-free diet or avoiding other allergens
and its role in MS? – So, the relationship between allergies and multiple sclerosis
is not very well defined by clinical studies. As many of you know, people
could be gluten intolerant. If you are gluten intolerant, you’re said to have celiac disease, and there’s a blood
test that could be done in order to confirm that diagnosis. If you do have celiac disease, some patients suffer from imbalance. It’s believed to be due
to the allergic response affecting part of the brain
called the cerebellum. That is somewhat controversial, but many people do describe imbalance as an aspect of celiac disease. Some people also think you
can get some nerve damage in the extremities from it, but that is not very well confirmed. I don’t know of any good
evidence that there’s a clear relationship
between celiac disease and multiple sclerosis,
but if you do believe you have a gluten intolerance, and I should’ve mentioned that gluten is a component of wheat, you
could talk to your doctor about getting that test done. And there’s nothing wrong
with trying a gluten-free diet if you think it would help
you, a wheat-free diet. – So just to introduce myself. I’m Jessica Stulc, the other fellow, and Rob and I are gonna
kinda alternate questions. One of the second most commonly
answered, asked question was about stem cell therapy, and a lot of people indicated
they weren’t here last year and would like Dr. Irani
to address his thoughts on stem cell therapy in the treatment for multiple sclerosis. – So, I think it’s safe
to say that there’s a lot of excitement about the
possibility of using cells that are recovered from
another source and maybe grown in a Petri dish and
reinfused into an animal or a patient to try to promote repair. We heard from Kevin about
the fact that there’s a lot of exciting research at
the level of animals, and much progress has been made. The obstacles going from
animal studies to human studies are great, and progress is
slowly being made in that regard. So there are a few clinical trials starting using stem cells
in patients with MS. The one that I’m most
familiar with uses stem cells that are derived from the bone marrow, so hematopoietic stem cells,
and there’s been some interest in using these cells
reinfused into patients to try to promote regeneration. It’s in the very, very earliest
stages of investigation. We do not, here at the
University of Michigan, have a stem cell protocol
or a stem cell trial active, but other centers in the
United States are doing that. So there’s, we’re just at
the very beginning now, and one of the obstacles that we face is we’re trying to promote regeneration and repair over a wide area. You saw in the MRI scans
the lesions that appear can be in both the brain
and the spinal cord. It’s not like there’s damage
in one particular part, so the cells have to
get to many locations. We’re talking about
billions of connections that have to reform or myelin sheaths that have to be repaired. So the obstacles are huge. The short answer is, it’s very
much at the beginning here. There’s a lot of optimism, but it’s probably something that’s still, I don’t know what my colleagues would say, but my conservative estimate is, we’re still five or 10 years away from really being able to
use stem cells effectively in the clinic in patients. Is that something you’d agree with? – Yes, I would say at
least five, 10 years. And there is some potential dangers with stem cell therapy that
also have to be worked out. There’s a proclivity of stem cells to form into tumor cells or cancers. That has to be something
that’s dealt with, and as Dr. Irani mentioned, getting the stem cells
to the right location is another big hurdle,
particularly in multiple sclerosis, where you can’t just inject stem cells into one particular region, because there are multiple plaques scattered throughout the
brain and spinal cord. So there are a lot of issues, but we’re very supportive of
investigations in stem cells, and are hopeful it will evolve
into a treatment one day. But I agree, it’s in its infancy. – We have a couple of questions that we’ll direct at Dr. Chadd that involve rehab modalities. One, is there a benefit
to electrical stimulation to improve muscle in mobility? And two, do you know of
benefit, and can you talk about the benefit, of acupuncture therapy? – I’ll address the second one first, because it’s a much shorter answer. I can’t point to any clinical
trials with acupuncture that have shown proven benefit. But at the same time, a lot
of people report improvement in a variety of subjective symptoms or objective symptoms,
whether it’s spasticity, or in particular, pain, with acupuncture. So with MS, there can be a
couple different types of pain that we commonly deal with. One is neuropathic pain that’s generated in the damaged areas
of the nervous system. That has been studied and some good response with acupuncture. And then also, more musculoskeletal pain, pain that results from
the physical impairments in the muscles, joints, pathologies that can result with MS. But for the first question,
the electrical stimulation, yes, that can be quite effective for a couple of different
uses, again, primarily, for muscle strengthening,
the electrical stimulation can be most effective
as a adjunctive modality to build strength in a muscle. So in a muscle that has
voluntary firing, or contraction, but weak muscle contraction,
the electrical stimulation can help augment that voluntary
strength and improve it. In a muscle that has
no voluntary strength, or more completely paralyzed muscle, the electrical stimulation
wouldn’t necessarily improve someone’s voluntary strength,
but there is still some work out there that has shown
benefits, long-term benefits, to having a muscle contraction
just from the e-stim, whether or not it translates
into a functional use of the muscle with voluntary strength. So getting that muscle fiber to undergo its physiologic contractile
actions can have benefits for metabolic health,
cholesterol, diabetes, so some uses in that
realm with the e-stim. But we do see it being very effective to help with strengthening. A common use might be
your ankle dorsiflexion, a foot drop, e-stim’s used a lot there to help build strength
in the muscles involved and can be quite effective. And I’ll just mention additionally, besides using the e-stim
in therapy as a tool to build strength, there
are some products out there to wear an e-stim unit on a daily basis to provide that function. And some people can have
good results with that. For other people, it
might not be as effective, but it’s an option that’s out there. – So I’ll address the next
question to Dr. Braley, and it’s could you
explain some of the effect that MS has on mental
capacity and cognitive skills? – So, the effects of MS on mental capacity and cognitive skills, that’s actually quite
a complicated question. We do know that many
MS patients will report at least some from of
cognitive dysfunction, whether it be something that’s
subtle that only they notice, or something that’s more apparent, in which family members or
even employers can notice this. And it doesn’t always seem to correlate with the physical symptoms
of multiple sclerosis. We do think that this
is related to the damage that’s caused by MS, not
only in the white matter of the brain, but also a part of the brain called the cerebral cortex. But it is highly variable, and even though we’re getting better at
using different tests and tools to evaluate
cognition, it’s still something that’s a work in progress, and we actually are using
cognitive measures now as an outcome measure in clinical trials, because we are interested, not only in the physical
disability with multiple sclerosis, but also the cognitive effects,
which has been something that’s been largely overlooked
for the last several years. I should mention that
there are other things that can contribute to
cognitive dysfunction, as well, and even though we’re starting
to design better medications to help the MS related cognition problems, it’s also important to talk to your doctor about other factors that
can influence cognition. It’s not always just the MS itself. Mood disorders, depression,
and sleep disorder, especially sleep deprivation,
other sleep disorders, can also add to the cognitive dysfunction, and actually, that’s something that we’re interested
in studying right now. We have a new study
enrolling now for cognition and sleep disturbances in
mutliple sclerosis patients. Does anybody else wanna add anything? – Yeah, I’d just make one
additional comment to that in saying that we heard about
these various clinical trials that are being done to test therapies in patients with MS, so
there are examples where, in past clinical trials,
where patients underwent cognitive tests, tests of
memory and thinking speed, whether they were on a new treatment or on placebo group, and when
that was followed over time, it became clear that treating the MS with a disease-modifying therapy was actually able to
slow down the progression of cognitive change over time compared to patients who
weren’t on an active treatment. So I often get asked in the clinic, well, what can I do to
treat my forgetfulness on a day to day basis? And the answer right now really is let’s try to treat your MS itself as aggressively as possible, because unfortunately, we don’t yet have specific treatments or interventions that target the memory problem itself. As many people know, there are other neurological diseases that
cause memory impairment. Alzheimer’s disease is one of them, and even though there are
approved medications right now to treat Alzheimer’s
disease that have been shown to slow the progression, regrettably, they’re not that potent, and there’s very limited evidence that Alzheimer’s medications,
like Aricept and the like, have a beneficial effect
in other diseases like MS. – For Dr. Mao-Draayer,
over the past few years, there’ve been several oral pills that have become available
for multiple sclerosis. Could you compare and contrast these and give a sense of what goes into your decision process
about prescribing one? – Great question. Did you ask that question? David, you have a question. Maybe we could… (man in audience speaks off mic) So to answer the question, we
have three oral therapy now. The first drug, Fingolimod,
was approved three years ago. It’s based on three large pivotal trials, as I mentioned before. One is comparing to active, not placebos, Avonex treated arm. It showed great benefit in
terms of reducing relapse rate, MRI lesion load, and the brain atrophy. I would say based on the relapse rate, it seems to reduce by 55%. It’s pretty robust in
terms of relapse rate, reduction in brain atrophy. But it does come with a
cumbersome monitoring. There’s a potential side
effects of macular edema because of receptors also
located in your retina, as well as bradycardia. So we have to observe
patient in our clinic for the first six hours. So later drugs, such as
BG-12, that was just approved in March this year, have
become easier to use, even though it’s twice a day dosing. But we don’t have head to head
comparison of the three drug, Aubagio, Fingolimod, and the BG-12. So even though when the
pivotal trial was done, they all based on two
to three large clinical randomized, double-blind
placebo-controlled phase three studies,
they were all approved based on placebo-controlled study, as well as the active comparable, like Dr. Braler mentioned,
BG-12 was done by comparing to placebo, as well as
comparing to Copaxone. At least it is not worse than Copaxone. So based on the reduction of relapse rate, they are very similar. In a way, I would say, if you have relapse and remitting disease, it’s really based on each individual. You may have response better
to one or the other drug. For the reasons yet we don’t know, like Dr. Segaal mentioned,
biomarker studies, we’re trying to predict
which patient may respond to which category’s drug better or more. So the short answer is, as long as you start disease
modifying treatment early, they seem to have great benefits, all early at the diagnosis,
so in terms of long-term, they prevent progression. But bottom line, we don’t
know which oral drugs would help for progressive patients, so that’s in the stage of being tested. So we are moving on to clinical trial with the Sphingosine-1,
phosphate receptor modulator, like agent first, because
it was the first approved in relapsing/remitting MS. So it’s understandable, this trial is more maturely operating,
but I anticipate other drug may be also test in progressive patient. So stay tuned, and there’s
other more drugs coming out, such as CAMPATH and Eculizumab,
like Dr. Braler mentioned, Eculizumab is already being tested in progressive MS patient. So there’s a lot of hope
for many, many MS patients. So sorry about talking too– – So just to elaborate
a little more on that. I mean, the decision, when
I’m one on one with a patient in the clinic about which medication to start is a complicated one. With more choices, there are
more variables to think about. My personal approach is
that I like to involve the patient in the
decision-making process. I mean, after all, it is his or her body that we’re trying to manipulate here, and they, I think, have
a say in the matter. So you know, on one hand,
the oral medications, as you’ve heard about,
there’s three of them, have a great advantage of convenience, of easy dosing for patients. There really are a lot of people where self-injection is a major obstacle. The main disadvantage of the
oral medications right now is that they’re all brand new. I mean, we don’t have a long
track record using them. The injectable medicines,
on the other hand, are less convenient. They’re a hassle sometimes. But at the same time, they’ve been around since the early to mid 1990s,
and we really have 25 years of experience now using them. So it’s complicated. There isn’t a single algorithm
that I use in the clinic to decide what therapy
is best for a patient. Sometimes there’s situations
like, for example, I have a patient that has
both MS and psoriasis, so you heard earlier that BG-12
or Tecfidera has been used in Europe in a slightly different version to treat psoriasis, so we
thought maybe we would try that therapy, hoping to hit both diseases with one treatment. Gilenya has this issue related
to slowing of the heart rate, and sometimes I choose to
maybe steer a patient away from that treatment if they
have a known cardiac condition. So you have to weigh in lots of variables. It’s not something that’s really amenable to a flow chart or an
algorithm, and it’s complicated. They’re individualized decisions. – I would also add that the
safety profiles are important, and it always has to be considered in the context of your
other medical problems. So like Dr. Irani said,
somebody with cardiac problems may not be the best candidate for Gilenya. A woman of childbearing age
that wants to plan a family might want to stay away from Aubagio. Someone with a lot of stomach trouble, BG-12 may not be the best choice for them. Of course, then we can also
discuss this in more detail, but these are things
that should be running through your mind when
you’re choosing a therapy, and something that you should be discussing with your doctor. – So I got a couple questions that I think are best targeted for our
nurse practitioner Carol, and a couple of those questions are do you know of good home care resources, and do you know of good
resources for respite care? – Okay, the best way to find out good care for respite care and good for home care is to find other people that have used this. A good clearinghouse or
place to go to start getting this information is the Michigan
Multiple Sclerosis Society. They can help some. There is also a group
called Area Agency on Aging, and they are done per county. The Area Agency on Aging
is federally funded, so they have resources available to help get home placement for you. For respite care, there is
limited numbers around the state that would provide respite
care for either the MS patient, or if the MS patient is the caregiver for another person, for that patient. You can go to, there’s
an organization called Citizens for Better Care. And Citizens for Better Care is a group that goes in and looks at all of the long-term care facilities and can give you a rating for it. So those would be some of
the ones to start with. And then, equally, if you
are in support groups, and you’re talking to
them in support groups, ask everybody, do your consumer question, and ask, did you, have you used this? Did you like this service? – I guess one follow-up
comment I would make is is that we’re really excited to have Carol as part of our clinical team now, and she’s a very organized person, so if you’re in clinic,
if you’ve found a facility or a resource that’s worked well for you or your family with
regards to respite care or something like that, tell Carol. She’ll keep a list, and then we can pass that information on to other
patients and family members. So we need your help to
bring your experiences to spread to other patients. – I’d also like to add,
if you are a veteran, we have an MS specialty
clinic at the VA hospital, and there are special benefits, particularly if you are deemed to have MS that’s service-connected. That means you had your first symptoms while on active duty or within
seven years of discharge from the armed services. And there are some wonderful benefits, including respite,
including physical therapy, and even remodeling homes
for handicapped issues, that are at your disposal. So if you are a veteran,
you should contact, and you’re in the area,
well, throughout the state, we have patients who
even come from Indiana, Ohio, et cetera, to our VA clinic. – Question for Dr. Braley. Should patients be
supplementing extra vitamin D? Should their family members,
particularly their children, even in their young children, also be supplementing vitamin D? And are there other
supplements that should either be considered or avoided in patients with multiple sclerosis? – So I’ll start with the
vitamin D question first. So, many of you may know that there are some recent epidemiological
studies that have shown that patients who have
low vitamin D levels are more likely to develop
multiple sclerosis, and we think that this might be related to the geographical location of patients, the further we are from the equator, the less sunlight exposure we get, and we need the sunlight in
order to convert vitamin D. And our skin does that, actually. And so there’s definitely a link between low vitamin D
status and the development of multiple sclerosis, but we know that it’s more complicated than
that, that most likely MS is a combination of both genetic
and environmental factors, and perhaps the low vitamin
D levels might provide some evidence of the
environmental trigger. That said, children of patients with mult, I’ll start with the kids question first. Kids of parents who have MS, or kids with a first-degree relative with multiple sclerosis,
are thought to be somewhat more genetically
susceptible, so in that case, it may be worth talking
to the child’s or the, I’m not saying it has
to be a little child, but the offspring’s physician
to see if vitamin D is safe in terms of their other
health problems, and if so, supplementing it might be a good idea. In terms of the patient,
in terms of the patients who have MS, we usually do recommend supplementing vitamin D. Although most of the studies,
with the really strong data we have so far, suggests the low vitamin D may predispose patients to MS, we do have some early
clinical trial data coming in suggesting that taking
vitamin D, if you have MS, may improve the course to some extent. I think there’s a lot
of work that still needs to be done in this area. What we don’t know yet is
what level to shoot for, so we get patients on supplements, and then we’re not quite
sure if their blood levels have to be within a certain range, but because vitamin D
is good for your bones, and many patients with
MS, especially the ones who are immobile, have
issues with bone health, we do recommend supplementing it. Now in terms of the question about other vitamin supplements,
I’m not aware of any other specific vitamin
supplements that have been shown, at least in rigorous clinical trials, to influence the course
of multiple sclerosis. – Yeah, I’ll just jump in
here for a second as well. So, if you’re deficient in vitamin B12, you can get neurological symptoms that sometime look like MS, so I’ll check B12 levels in patients as I’m trying to evaluate whether they do or don’t have MS, and if they have a low B12 level, that might be something to supplement. But I agree with Dr. Braley
that there really aren’t other great studies that
clarify for providers whether other vitamin
supplements are indicated. The other difficult
issue that she touched on is how much vitamin D should you take. For those of you who do take vitamin D, you’ll know that the
bottle comes with pills that are in units, not milligrams, so a usual adult dose of vitamin D is one to three thousand
international units a day. It is actually possible to
take too much vitamin D. It requires ingesting a lot of it, but vitamin D is very closely
related to calcium metabolism, and if you take too much vitamin D, you can predispose yourself to changes in blood calcium concentrations
that can cause problems. So it’s not a matter that
more is automatically better. So I typically advise my patients, I don’t know what my colleagues would say, that somewhere on the order of two or three thousand
international units a day is a pretty standard adult dose. – Yeah, but there are ongoing studies trying to determine the proper dose and to really document its exact effect, but I’ve seen studies where
10,000 international units were given, or even higher, 12,000, and it appears to be safe. I mean, you have to take a
huge amount of vitamin D, but I think Dr Irani’s
remarks need to be heard, because you could
definitely overdose on it. But within the one
thousand to five thousand international units range is usually where I recommend people start. – [Man Walking By] Sorry. – No problem. – [Rob] Thanks for coming. – To kind of piggyback on that question, we received a couple questions
about Dr. Wahls’ diet, or quote, unquote, the mitochondrial diet. And Dr. Seagal, do you wanna address that, or if there’s somebody else on the panel who’s familiar with that? – So, Dr. Wahls’ diet actually, I think, capitalizes on things that have been known about MS diet for a while, that vitamin rich diet is important, the vitamins that you can get
from a healthy balanced diet. It also involves eating a lot of fish because of the omega-3 and
omega-8 fatty acids in fish, which for a long time
people have hoped might ameliorate multiple sclerosis. There is, what Dr. Stulc was referring to, mitochondria are little organelles, or little structures in cells
that help provide energy, and there’s some evidence that
there’s insufficient energy being produced in the
cells that make myelin, and that could contribute to MS. So there are substances which help these energy generators work better. One called co-enzyme Q, and so
the Wahl diet also recommends increasing your intake of co-enzyme Q through eating organ meats, you know, like liver and et cetera. I think that the diet is
a very reasonable diet. I advocate a well-balanced diet. The Wahl diet advocates leafy vegetables, fruits, fish, organ meats,
et cetera, and so forth. I think it’s a sensible approach. The whole question about
omega-3 and omega-8 fatty acids, which are in fish like
salmon, sardines, et cetera, has been bandied around
a long time in MS clinics and in MS research. There was a Dr. Swank many years ago who felt that diets high in
fish decreased your risk of MS based on some studies he did in Sweden. And he actually outlined
a very rigorous diet high in fish and low in unsaturated fats, and he claimed that his
patients did better. That was never subjected
to rigorous trials. There was a recent study of
omega-3 and eight fatty acid supplements that was done,
I believe, in Finland, and it didn’t show much of
an effect on relapse rate or MRI lesions, but a lot of
these dietary recommendations make sense for your general health, and I think it is possible
that omega-3 and eight are beneficial, but that
trial wasn’t sensitive enough to detect it. So once again, I just
advocate a well-balanced diet, lots of fruits and vegetables, fish, omega-3 and omega-8 fatty acid
supplements are important. And I think co-enzyme Q, there’s not a lot of rigorous evidence that it’s helpful, but there are supplements you could take, and it is rich in organ
meats, as I mentioned. – The only other comment
I would make about that is what my colleagues have already said is, a lot of these dietary
adjustments are also good for your general health, so for example, there’s a very large
study recently published in the prestigious New
England Journal of Medicine about the Mediterranean
diet, which is very high in things like olive oils, which
shows a significant benefit in favor of the diet from
cardiovascular standpoint. So a lot of these things
are good for you in general, and I touched briefly on the salt issue, so whether or not
they’re good for your MS, we may not know, but they may
be good for you in general, so it’s reasonable to watch what you eat. – We’ve got about four
or five minutes left. There was a couple of
questions about the effects of pregnancy and pregnancy
hormones on multiple sclerosis. Dr. Irani, are you able
to comment on that? – Sure, so we’ve known for many years that women who become pregnant who have a pre-existing diagnosis of MS, that the relapses and symptoms of MS tend to go into a
relative state of dormancy during pregnancy, and it’s likely a result of hormonal changes that come about as a
result of the pregnancy. So investigators in the
MS field have capitalized on that observation, and
there actually are studies now making hormonal manipulations
in patients to try to, in a sense, recapitulate
the state of pregnancy as a way to suppress disease. So there’s a lot of
exciting work in this area. I don’t think we yet know
exactly how to do that, but I think there are
things to be learned, and it’s an important observation. – If I could just add to that, there is a clinical
trial going on right now of an estrogen compound called estriol. Estriol has been used
in Europe for many years as an oral contraceptive. It has less side effects than conventional estrogen compounds used
for oral contraception in this country, and in a phase two study, it looked to be possibly
beneficial in decreasing new lesion formation
in multiple sclerosis. So right now, there is a
phase three study going on. It’s being conducted by Rhonda Voskuhl, who’s the head of the MS Center at UCLA and a good friend of ours. It’s the addition of estriol to Copaxone in women with multiple sclerosis. So we don’t know the
results of that study yet, but it’s something that
we’re following closely. You know, sometimes, I
have patients who are on oral contraception
anyway, or plan to go on an estrogen compound, and I
will raise the possibility of considering estriol, in consultation with their gynecologist. The dose is a bit higher than what’s used in oral contraception in the trials; it’s eight milligrams a day. I think that’s the most relevant
clinical trial right now regarding hormones developed in pregnancy as a therapeutic in multiple sclerosis. – I guess they do, we
wanna do one last question, or do we kinda wanna have the panel kind of give their final comments? Thoughts, feelings. (audience laughs) – [Dr. Segal] We could
have one more question. We usually don’t do final comments. – Okay, no final comments. All right, I’ll do one last question. We had a question about
the development of MS, and if having Epstein-barr
diagnosis as a child increases your risk of developing MS, and I’ll direct that to Dr. Mao-Draayer. – Well, actually, Dr. Irani,
probably, is a virologist, but you can grab from what I know. As I talked about, there
is a nature versus nature as a trigger of MS that
is not yet identified, and genetic susceptible individuals may be exposed early
on, in certain fashion. EB viral infection is so common, and actually 90% of population
carry the antibodies, so it doesn’t necessarily triggers MS unless you’re genetically susceptible. So there is a huge study done
by George Ebers school at UK, and has a demonstrated link
of EBV and vitamin D receptor. There’s, the story is still developing. Again, pointed out,
there’s so much unknowns, but we know there is
an epitope presented on antigen-presenting cells
that look like myelin, and EBV may be one of them. And there’s other
infectious early childhood, exposure to other infectious agents, may be also play a role. So it’s not the only triggers. – So if I could just add to that. I think the most compelling
epidemiological evidence suggests that exposure
to Epstein-barr virus, which causes infections mononucleosis, as an adult is a risk factor for MS. Epstein-barr virus exposure as a child, there is not good evidence that
it increases the risk of MS. It’s if you haven’t had
infectious mononucleosis as an adolescent or earlier, if you are exposed to it later in life, then it may be a risk factor. So that concludes our conference. I see a raised hand in the back. – Maybe we could be
available after we break up if you have a question,
we could take it on individually with you. (woman in audience speaking off mic) – Okay. (woman in audience speaking off mic) – So we both have comments here. So I know Noel Rose well,
having trained at Johns Hopkins. He’s an outstanding
expert in autoimmunity, and he’s exactly right,
there are definitely things that people studying MS can teach people who study diabetes or
autoimmune thyroid disease. So we can learn from each other. And so developing networks like this are critically important in understanding these diseases, not to
mention issues like you raised about raising awareness and raising funds to support research and the like, all of which is important. Having said that, not
all autoimmune diseases are created equally, and we’ve learned, unfortunately the hard way, that treatment of one autoimmune disease might make another autoimmune
disease appear or get worse. So, we work very closely
with our colleagues in other departments to
study these situations. So for example, here at
the University of Michigan, we have close collaborations
with colleagues in the rheumatology clinics
who take care of patients that have lupus, and rheumatoid arthritis, and also, with colleagues
in the GI clinic, for patients that have
Crohn’s disease and the like. So many of our patients have more than one autoimmune disease, and it
really requires extreme care that your treatment for one disease isn’t gonna make the other disease worse. So I agree with you that we’d
like to speak with one voice, and that’s an important
goal for the future, but it’s a very, very
complicated situation, so I don’t know, Ben, do
you have comments on… – I agree with everything you said. We do have close interactions
with our colleagues who study other autoimmune diseases. In fact, we recently
put together a proposal to establish an autoimmunity
center of excellence. I was involved in one of those at the institution I was before. That probably is not gonna go
through for technical reasons, but we do have strong collaborations, we have joint lecture series sometimes, and we sit on each other’s
students committees. So there is a lot that we can learn from other autoimmune diseases
about MS and vice versa, and we wanna take full advantage of that. – Okay, thank you very much.
(audience applauds) – So I’d like to thank all the speakers and panelists once again, Carol Gregory, and Joanne Naprokowski,
but most of all, you, for helping us in our vision and support. – [Jessica] And then just a reminder to turn in your evaluations. There’s a box up front, and then they’ll also help
with collecting the name tags.

Leave a Reply

Your email address will not be published. Required fields are marked *