Purpose: Measurements of non-displaceable binding (V ND ) of positron emission tomography (PET) ligands are not often made in vivo in humans because they require ligands to displace binding to target receptors and there are few readily available, safe ones to use. A technique to measure V ND for ligands for the 18-kDa translocator protein (TSPO) has recently been developed which compares the total volume of distribution (V T ) before and after administration of the TSPO ligand XBD173. Here, we used XBD173 with an occupancy plot to quantify V ND for two TSPO radiotracers, [ 18 F]GE-180 and [ 11 C]PBR28, in cohorts of people with multiple sclerosis (MS). Additionally, we compared plots of subjects carrying high (HAB) or mixed binding (MAB) affinity polymorphisms of TSPO to estimate V ND without receptor blockade. Procedures: Twelve people with MS underwent baseline MRI and 90-min dynamic [ 18 F]GE-180 PET or [ 11 C]PBR28 PET (n = 6; three HAB, three MAB each). Arterial blood sampling was used to generate plasma input functions for the two-tissue compartment model. V ND was calculated using two independent methods: the occupancy plot (by modelling the differences in signal post XBD173) and the polymorphism plot (by modelling the differences in signal across presence and absence of rs6971 genotypes). Results: Whole brain V T (mean ± standard deviation) was 0.29 ± 0.17 ml/cm 3 for [ 18 F]GE-180 and 5.01 ± 1.88 ml/cm 3 for [ 11 C]PBR28. Using the occupancy and polymorphism plots respectively, V ND for [ 18 F]GE-180 was 0.11 ml/cm 3 (95 % CI = 0.02, 0.16) and 0.20 ml/cm 3 (0.16, 0.34), accounting for, on average, 55 % of V T in the whole brain. For [ 11 C]PBR28, these values were 3.81 ml/cm 3 (3.02, 4.21) and 3.49 ml/cm 3 (1.38, 4.27), accounting for 67 % of average whole brain V T .Sujata Sridharan and Joel Raffel are joint first authors. Conclusions:Although V T for [ 18 F]GE-180 is low, indicating low brain penetration, half the signal shown by MS subjects reflected specific TSPO binding. V T for [ 11 C]PBR28 was higher and two thirds of the binding was non-specific. No brain ROIs were devoid of specific signal, further confirming that true reference tissue approaches are potentially problematic for estimating TSPO levels.

Schizophrenia does not affect treatment delivery or outcomes in women with breast cancer. The presence of schizophrenia should not be a limiting factor for entry into clinical trials. Breast cancer patients with this illness should be offered standard treatment without discrimination, including entry into clinical trials.

It is well recognised that the majority of the impact of multiple sclerosis (MS), both personal and societal, arises in the progressive phase where disability accumulates inexorably. As such, progressive MS (PMS) has been the target of pharmacological therapies for many years. However, there are no current licensed treatments for PMS. This stands in marked contrast to relapsing remitting MS (RRMS) where trials have resulted in numerous licensed therapies. PMS has proven to be a more difficult challenge compared to RRMS and this review focuses on secondary progressive MS (SPMS), where relapses occur before the onset of gradual, irreversible disability, and not primary progressive MS where disability accumulation occurs without prior relapses. Although there are similarities between the two forms, in both cases pinpointing when PMS starts is difficult in a condition in which disability can vary from day to day. There is also an overlap between the pathology of relapsing and progressive MS and this has contributed to the lack of well-defined outcomes, both surrogates and clinically relevant outcomes in PMS. In this review, we used the search term 'randomised controlled clinical drug trials in secondary progressive MS' in publications since 1988 together with recently completed trials where results were available. We found 34 trials involving 21 different molecules, of which 38% were successful in reaching their primary outcome. In general, the trials were well designed (e.g. double blind) with sample sizes ranging from 35 to 1949 subjects. The majority were parallel group, but there were also multi-arm and multidose trials as well as the more recent use of adaptive designs. The disability outcome most commonly used was the Expanded Disability Status Scale (EDSS) in all phases, but also magnetic resonance imaging (MRI)-measured brain atrophy has been utilised as a surrogate endpoint in phase II studies. The majority of the treatments tested in SPMS over the years were initially successful in RRMS. This has a number of implications in terms of targeting SPMS, but principally implies that the optimal strategy to target SPMS is to utilise the prodrome of relapses to initiate a therapy that will aim to both prevent progression and slow its accumulation. This approach is in agreement with the early targeting of MS but requires treatments that are both effective and safe if it is to be used before disability is a major problem. Recent successes will hopefully result in the first licensed therapy for PMS and enable us to test this approach.

Context Alemtuzumab is an anti-CD52 monoclonal antibody used in the treatment of relapsing-remitting multiple sclerosis (MS). Between 20-40% of alemtuzumab-treated MS patients develop autoimmune thyroid disease (AITD) as a side effect. Objective To determine whether MS disease progression following alemtuzumab treatment differs in patients that develop AITD compared to those who do not. Design, setting and patients A retrospective analysis of 126 patients with relapsing-remitting MS receiving alemtuzumab from 2012 to 2017 at a tertiary referral centre. Main outcome measures Thyroid status, new relapses, Expanded Disability Status Score (EDSS) change and disability progression following alemtuzumab were evaluated. Results Twenty-six percent (33 out of 126, 25 female, 8 male) of alemtuzumab-treated patients developed AITD, 55% of which was Graves’ disease. EDSS score following alemtuzumab was reduced in patients who developed AITD compared to those who did not (median [IQR]; AITD: -0.25 [-1 - 0.5] vs non-AITD: 0 [1 - 0]. P=0.007]. Multivariate regression analysis confirmed that the development of AITD was independently associated with EDSS score improvement (p=0.011). Moreover, AITD patients had higher relapse-free survival following alemtuzumab (p=0.023). There was no difference in the number of new focal T2-lesions and contrast-enhancing MRI lesions developed following alemtuzumab between the two groups. Conclusion Graves’ disease was the most common form of AITD developed by MS patients following alemtuzumab. This study suggests that MS patients who develop AITD may have an improved response to alemtuzumab, as measured by reduced disability and lower relapse rate.

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PurposeThe aim of the study was to analyse the referrals for patients presenting with neurological emergency to the district hospital, as this aspect of the neurologist’s workload is often under-recognised, in comparison to attention dedicated to out-patient clinics.MethodsWe retrospectively reviewed acute medicine and ward referrals to Neurology service at the Hillingdon Hospital (July 2019-June 2020).ResultsTotal 1480 referrals were identified, with 50% of them from the Acute Medicine, 42% from the General Medicine, 8% from the other units. A 73.2% of referrals constitute delirium, falls, and other multi- factorial syndromes, presented as ill-defined and clinically challenging cases, 14.5% - acute headaches and neuroinflammatory disorders, 12.3% seizures/fits/syncopes. Regarding ward referrals, there was an average 5.4 days’ time lag between time of admission and neurological input, at the average 11.8 days of hospitalization. An early neurological consultation was likely to lead to more tailored diagnostic workup, improving outcome for the patient.ConclusionThe amount of referrals reaffirms the importance of the neurologist’s role in the Emergency Care and the unmet need for acute neurology service, which is likely to increase with pressure on the district general hospitals to manage complex neurological cases locally given that the pandemic affects the safe transfer of patients to tertiary neurosciences centre for onward management.ehmelikyan@yandex.ru47

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