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It is well known that B lymphocytes differentiate into plasma cells that produce antibodies. B cells also perform a number of less well-known roles including antigen presentation, regulation of T cells and innate immune cells, cytokine production, and maintenance of subcapsular sinus macrophages. Given that there is clear evidence of inflammation in Parkinson’s disease (PD) both in the central nervous system and in the periphery, it is almost certain that B lymphocytes are involved. This involvement is likely to be complicated given the variety of roles B cells play via a number of distinct subsets. They have received less attention to date than their counterparts, T cells, and monocytes. B lymphocytes are decreased in PD overall with some limited evidence that this may be driven by a decrease in regulatory subsets. There is also evidence that regulatory B cells are protective in PD. There is evidence for a role played by antibodies to alpha-synuclein in PD with a possible increase in early disease. There are many exciting potential future avenues for further exploration of the role of B lymphocytes including improving our understanding of the role of meningeal and calvarial (skull bone marrow) based B cells in health and disease, the use of larger, well phenotyped clinical cohorts to understand changes in peripheral and cerebrospinal fluid B cells over time and the potential application of B cell targeted therapies in PD.

The innate immune system is implicated in Parkinson’s disease (PD), but peripheral in-vivo clinical evidence of the components and driving mechanisms involved and their relationship with clinical heterogeneity and progression to dementia remain poorly explored. We examined changes in peripheral innate immune-related markers in PD cases (n = 41) stratified according to risk of developing early dementia. ‘Higher Risk’(HR) (n = 23) and ‘Lower Risk’ (LR) (n = 18) groups were defined according to neuropsychological predictors and MAPT H1/H2 genotype, and compared to age, gender and genotype-matched controls. Monocyte subsets and expression of key surface markers were measured using flow cytometry. Serum markers including alpha-synuclein, inflammasome-related caspase-1 and bacterial translocation-related endotoxin were measured using quantitative immuno-based assays. Specific markers were further investigated using monocyte assays and validated in plasma samples from a larger incident PD cohort (n = 95). We found that classical monocyte frequency was elevated in PD cases compared to controls, driven predominantly by the HR group, in whom Toll-Like Receptor (TLR)4+ monocytes and monocyte Triggering Receptor Expressed on Myeloid cells-2 (TREM2) expression were also increased. Monocyte Human Leukocyte Antigen (HLA)-DR expression correlated with clinical variables, with lower levels associated with worse cognitive/motor performance. Notably, monocyte changes were accompanied by elevated serum bacterial endotoxin, again predominantly in the HR group. Serum alpha-synuclein and inflammasome-related caspase-1 were decreased in PD cases compared to controls regardless of group, with decreased monocyte alpha-synuclein secretion in HR cases. Further, alpha-synuclein and caspase-1 correlated positively in serum and monocyte lysates, and in plasma from the larger cohort, though no associations were seen with baseline or 36-month longitudinal clinical data. Principal Components Analysis of all monocyte and significant serum markers indicated 3 major components. Component 1 (alpha-synuclein, caspase-1, TLR2+ monocytes) differentiated PD cases and controls in both groups, while Component 2 (endotoxin, monocyte TREM2, alpha-synuclein) did so predominantly in the HR group. Component 3 (classical monocytes, alpha-synuclein) also differentiated cases and controls overall in both groups. These findings demonstrate that systemic innate immune changes are present in PD and are greatest in those at higher risk of rapid progression to dementia. Markers associated with PD per-se (alpha-synuclein, caspase-1), differ from those related to cognitive progression and clinical heterogeneity (endotoxin, TREM2, TLR4, classical monocytes, HLA-DR), with mechanistic and therapeutic implications. Alpha-synuclein and caspase-1 are associated, suggesting inflammasome involvement common to all PD, while bacterial translocation associated changes may contribute towards progression to Parkinson’s dementia. Additionally, HLA-DR-associated variations in antigen presentation/clearance may modulate existing clinical disease.

Background Immune involvement is well-described in Parkinson’s disease (PD), including an adaptive T lymphocyte response. Given the increasing prevalence of Parkinson’s disease in older age, age-related dysregulation of T lymphocytes may be relevant in this disorder, and we have previously observed changes in age-associated CD8+ T cell subsets in mid-stage PD. This study aimed to further characterise T cell immunosenescence in newly diagnosed PD patients, including shifts in CD4+ and CD8+ subpopulations, and changes in markers of cellular ageing in CD8+ T lymphocytes. Methods Peripheral blood mononuclear cells were extracted from the blood of 61 newly diagnosed PD patients and 63 age- and sex-matched controls. Flow cytometric analysis was used for immunophenotyping of CD8+ and CD4+ lymphocyte subsets, and analysis of recent thymic emigrant cells. Telomere length within CD8+ T lymphocytes was assessed, as well as the expression of the telomerase reverse transcriptase enzyme (hTERT), and the cell-ageing markers p16INK4a and p21CIP1/Waf1. Results The number of CD8+ TEMRA T cells was found to be significantly reduced in PD patients compared to controls. The expression of p16INK4a in CD8+ lymphocytes was also lower in patients versus controls. Chronic latent CMV infection was associated with increased senescent CD8+ lymphocytes in healthy controls, but this shift was less apparent in PD patients. Conclusions Taken together, our data demonstrate a reduction in CD8+ T cell replicative senescence which is present at the earliest stages of Parkinson’s disease.

Amyotrophic lateral sclerosis (ALS, motor neuron disease) is a neurodegenerative disorder of motor neurons leading to paralysis and eventual death by respiratory failure. Median survival is 2-3 years. Susceptibility genes, environmental triggers and disease related prognostic factors have been established, but environmental effects on survival are yet to be investigated. We analysed survival in the South-East England ALS register (SEALS register). Kaplan-Meier and Cox regression analyses were used to investigate survival in London, coastal and rural areas according to postcode at diagnosis. Results showed that there were 933 cases of ALS identified in the catchment area during the study period (1994-January 2012). Cox regression demonstrated a highly significant model for survival with significant protective variables: coastal residency, riluzole use and younger age at onset. Significantly worse survival was associated with London residency, older age as well as definite and probable El Escorial classifications. In conclusion, these findings suggest the possibility of an environmental effect on survival in ALS.

Item does not contain fulltext BACKGROUND: Several reports have identified different patterns of Parkinson's disease progression in individuals carrying missense variants in GBA or LRRK2 genes. The overall contribution of genetic factors to the severity and progression of Parkinson's disease, however, has not been well studied. OBJECTIVES: To test the association between genetic variants and the clinical features of Parkinson's disease on a genomewide scale. METHODS: We accumulated individual data from 12 longitudinal cohorts in a total of 4093 patients with 22,307 observations for a median of 3.81 years. Genomewide associations were evaluated for 25 cross-sectional and longitudinal phenotypes. Specific variants of interest, including 90 recently identified disease-risk variants, were also investigated post hoc for candidate associations with these phenotypes. RESULTS: Two variants were genomewide significant. Rs382940(T>A), within the intron of SLC44A1, was associated with reaching Hoehn and Yahr stage 3 or higher faster (hazard ratio 2.04 [1.58-2.62]; P value = 3.46E-8). Rs61863020(G>A), an intergenic variant and expression quantitative trait loci for alpha-2A adrenergic receptor, was associated with a lower prevalence of insomnia at baseline (odds ratio 0.63 [0.52-0.75]; P value = 4.74E-8). In the targeted analysis, we found 9 associations between known Parkinson's risk variants and more severe motor/cognitive symptoms. Also, we replicated previous reports of GBA coding variants (rs2230288: p.E365K; rs75548401: p.T408M) being associated with greater motor and cognitive decline over time, and an APOE E4 tagging variant (rs429358) being associated with greater cognitive deficits in patients. CONCLUSIONS: We identified novel genetic factors associated with heterogeneity of Parkinson's disease. The results can be used for validation or hypothesis tests regarding Parkinson's disease. (c) 2019 International Parkinson and Movement Disorder Society.

Objective: To model the effects of demographic change under various scenarios of possible future treatment developments in ALS. Methods: Patients diagnosed with ALS at the King’s College Hospital Motor Nerve Clinic between 2004 and 2017, and living within the London boroughs of Lambeth, Southwark, and Lewisham (LSL), were included as incident cases. We also ascertained incident cases from the Canterbury region over the same period. Future incidence of ALS was estimated by applying the calculated age- and sex-specific incidence rates to the UK population projections from 2020 to 2116. The number of prevalent cases for each future year was estimated based on an established method. Assuming constant incidence, we modelled four possible future prevalence scenarios by altering the median disease duration for varying subsets of the population, to represent the impact of new treatments. Results: The total number of people newly diagnosed with ALS per year in the UK is projected to rise from a baseline of 1415 UK cases in 2010 to 1701 in 2020 and 2635 in 2116. Overall prevalence of ALS was predicted to increase from 8.58 per 100,000 persons in 2020 to 9.67 per 100,000 persons in 2116. Halting disease progression in patients with C9orf72 mutations would yield the greatest impact of the modelled treatment scenarios, increasing prevalence in the year 2066 from a baseline of 9.50 per 100,000 persons to 15.68 per 100,000 persons. Conclusions: Future developments in treatment would combine with the effects of demographic change to result in more people living longer with ALS.

BackgroundSeveral reports have identified different patterns of Parkinson’s disease progression in individuals carrying missense variants in theGBAorLRRK2genes. The overall contribution of genetic factors to the severity and progression of Parkinson’s disease, however, has not been well studied.ObjectivesTo test the association between genetic variants and the clinical features and progression of Parkinson’s disease on a genome-wide scale.MethodsWe accumulated individual data from 12 longitudinal cohorts in a total of 4,093 patients with 25,254 observations over a median of 3.81 years. Genome-wide associations were evaluated for 25 cross-sectional and longitudinal phenotypes. Specific variants of interest, including 90 recently-identified disease risk variants, were also investigated for the associations with these phenotypes.ResultsTwo variants were genome-wide significant. Rs382940(T>A), within the intron ofSLC44A1, was associated with reaching Hoehn and Yahr stage 3 or higher faster (HR 2.04 [1.58, 2.62], P-value = 3.46E-8). Rs61863020(G>A), an intergenic variant and eQTL forADRA2A, was associated with a lower prevalence of insomnia at baseline (OR 0.63 [0,52, 0.75], P-value = 4.74E-8). In the targeted analysis, we found nine associations between known Parkinson’s risk variants and more severe motor/cognitive symptoms. Also, we replicated previous reports ofGBAcoding variants (rs2230288: p.E365K, rs75548401: p.T408M) being associated with greater motor and cognitive decline over time, andAPOEE4 tagging variant (rs429358) being associated with greater cognitive deficits in patients.ConclusionsWe identified novel genetic factors associated with heterogeneity of progression in Parkinson’s disease. The results provide new insights into the pathogenesis of Parkinson’s disease as well as patient stratification for clinical trials.

ObjectiveTo determine if any association between previously identified alleles that confer risk for Parkinson disease and variables measuring disease progression.MethodsWe evaluated the association between 31 risk variants and variables measuring disease progression. A total of 23,423 visits by 4,307 patients of European ancestry from 13 longitudinal cohorts in Europe, North America, and Australia were analyzed.ResultsWe confirmed the importance ofGBAon phenotypes.GBAvariants were associated with the development of daytime sleepiness (p.N370S: hazard ratio [HR] 3.28 [1.69–6.34]) and possible REM sleep behavior (p.T408M: odds ratio 6.48 [2.04–20.60]). We also replicated previously reported associations ofGBAvariants with motor/cognitive declines. The other genotype-phenotype associations include an intergenic variant nearLRRK2and the faster development of motor symptom (Hoehn and Yahr scale 3.0 HR 1.33 [1.16–1.52] for the C allele of rs76904798) and an intronic variant inPMVKand the development of wearing-off effects (HR 1.66 [1.19–2.31] for the C allele of rs114138760). Age at onset was associated withTMEM175variant p.M393T (−0.72 [−1.21 to −0.23] in years), the C allele of rs199347 (intronic region ofGPNMB, 0.70 [0.27–1.14]), and G allele of rs1106180 (intronic region ofCCDC62, 0.62 [0.21–1.03]).ConclusionsThis study provides evidence that alleles associated with Parkinson disease risk, in particularGBAvariants, also contribute to the heterogeneity of multiple motor and nonmotor aspects. Accounting for genetic variability will be a useful factor in understanding disease course and in minimizing heterogeneity in clinical trials.

SUMMARY Exposure to the herbicide paraquat (PQ) is associated with an increased risk of idiopathic Parkinson’s disease (PD). Therapies based on PQ’s presumed mechanisms of action have not, however, yielded effective disease therapies. Cellular senescence is an anticancer mechanism that arrests proliferation of replication-competent cells and results in a pro-inflammatory senescence-associated secretory phenotype (SASP) capable of damaging neighboring tissues. Here, we demonstrate that senescent cell markers are preferentially present within astrocytes in PD brain tissues. Additionally, PQ was found to induce astrocytic senescence and an SASP in vitro and in vivo, and senescent cell depletion in the latter protects against PQ-induced neuropathology. Our data suggest that exposure to certain environmental toxins promotes accumulation of senescent cells in the aging brain, which can contribute to dopaminergic neurodegeneration. Therapies that target senescent cells may constitute a strategy for treatment of sporadic PD, for which environmental exposure is a major risk factor., In Brief Chinta et al. argue that eliminating senescent cells could hold therapeutic promise for halting progression of sporadic PD, where environmental exposure is a major risk factor. They find that senescence cell depletion abrogates development of neurodegenerative phenotypes associated with systemic PQ exposure, indicating that senescent cells can contribute to neurodegeneration.

The immune system is activated in Parkinson's Disease (PD), as evidenced by neuroinflammatory changes within the brain as well as elevated immune markers in peripheral blood. Furthermore, inflammatory cytokine levels in the blood are associated with disease severity and rate of progression. However, the factors driving this immune response in PD are not well established. We investigated cell-extrinsic factors in systemic immune activation by using α-synuclein monomers and fibrils, as well as bacterial toxins, to stimulate peripheral blood mononuclear cells (PBMCs) derived from 31 patients and age/gender-matched controls. α-synuclein monomers or fibrils resulted in a robust cytokine response (as measured by supernatant cytokine concentrations and mRNA expression in cultured cells) in both PD and control PBMCs, similar to that induced by bacterial LPS. We found no PD vs. control differences in cytokine production, nor in mRNA expression. Levels of endotoxin within the recombinant α-synuclein used in these experiments were very low (0.2-1.3EU/mL), but nonetheless we found that comparable levels were sufficient to potentially confound our cytokine concentration measurements for a number of cytokines. However, α-synuclein monomers increased production of IL-1β and IL-18 to levels significantly in excess of those induced by low-level endotoxin. In conclusion, this study: (i) highlights the importance of accounting for low-level endotoxin in antigen-PBMC stimulation experiments; (ii) indicates that cell-extrinsic factors may be a major contributor to immune activation in PD; and (iii) suggests that α-synuclein may play a role in inflammasome-related cytokine production in the periphery.

IntroductionEvidence suggests the immune system contributes to Parkinson’s disease (PD) aetiopathogenesis and this represents a tractable target for disease-modifying therapy. As ageing is a risk factor for PD, it is relevant to investigate age-related immune changes (immunosenescence) in PD.MethodsBlood samples were collected from 20 early PD patients and 20 controls. T- and B-cell senescence subsets were identified using flow cytometric immunophenotyping. CMV/EBV serostatus was ascertained given its well-documented effect on immunosenescence.ResultsCD4+ TEMRA cells, T-cell senescence markers, were reduced in PD cases versus controls (p=0.046). This was not driven by differences in age or CMV/EBV serostatus across groups. CMV positivity was associated with increased CD4+ TEMRA cells as expected in controls, but not in PD cases. Switched memory B-cells were lower in patients versus controls (p=0.040). No changes were observed in the CD8+ T-cell pool.ConclusionsThese findings suggest that the senescent ‘shift’ induced by viral infection and ageing is atypical in PD. Reductions in senescent lymphocytes may favour the passage of activated lymphocytes across the blood brain barrier, promoting central inflammation and neurodegeneration. Pragmatically, this study shows that immune abnormalities occur in early-stage disease, adding urgency to the search for immune-modulating therapies in PD.

A massive hexanucleotide repeat expansion mutation (HREM) in C9ORF72 has recently been linked to amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Here we describe the frequency, origin and stability of this mutation in ALS+/-FTD from five European cohorts (total n=1347). Single-nucleotide polymorphisms defining the risk haplotype in linked kindreds were genotyped in cases (n=434) and controls (n=856). Haplotypes were analysed using PLINK and aged using DMLE+. In a London clinic cohort, the HREM was the most common mutation in familial ALS+/-FTD: C9ORF72 29/112 (26%), SOD1 27/112 (24%), TARDBP 1/112 (1%) and FUS 4/112 (4%) and detected in 13/216 (6%) of unselected sporadic ALS cases but was rare in controls (3/856, 0.3%). HREM prevalence was high for familial ALS+/-FTD throughout Europe: Belgium 19/22 (86%), Sweden 30/41 (73%), the Netherlands 10/27 (37%) and Italy 4/20 (20%). The HREM did not affect the age at onset or survival of ALS patients. Haplotype analysis identified a common founder in all 137 HREM carriers that arose around 6300 years ago. The haplotype from which the HREM arose is intrinsically unstable with an increased number of repeats (average 8, compared with 2 for controls, P

We aimed to assess whether rural residence is associated with amyotrophic lateral sclerosis in the south-east of England using a population based register. Previous studies in different populations have produced contradictory findings. Residence defined by London borough or non-metropolitan district at time of diagnosis was recorded for each incident case in the South-East England ALS Register between 1995 and 2005. Each of the 26 boroughs or districts of the catchment area of the register was classified according to population density. Age- and sex-adjusted incidence of ALS was calculated for each region and the relationship with population density tested by linear regression, thereby controlling for the underlying population structure. We found that population density in region of residence at diagnosis explained 25% of the variance in ALS rates (r = 0.5, p < 0.01). Thus, in this cohort in the south-east of England, people with ALS were more likely to be resident in areas of high population density at diagnosis.

Our objective was to generate a prognostic classification method for amyotrophic lateral sclerosis (ALS) from a prognostic model built using clinical variables from a population register. We carried out a retrospective multivariate analysis of 713 patients with ALS over a 20-year period from the South-East England Amyotrophic Lateral Sclerosis (SEALS) population register. Patients were randomly allocated to 'discovery' or 'test' cohorts. A prognostic score was calculated using the discovery cohort and then used to predict survival in the test cohort. The score was used as a predictor variable to split the test cohort in four prognostic categories (good, moderate, average, poor). The accuracy of the score in predicting survival was tested by checking whether the predicted survival fell within the actual survival tertile which that patient was in. A prognostic score generated from one cohort of patients predicted survival for a second cohort of patients (r(2) = 0.72). Six variables were included in the survival model: age at onset, diagnostic delay, El Escorial category, use of riluzole, gender and site of onset. Cox regression demonstrated a strong relationship between these variables and survival (χ(2) 80.8, df 1, p

Amyotrophic lateral sclerosis is a neurodegenerative disorder characterized by progressive loss of upper and lower motor neurons, with a median survival of 2–3 years. Although various phenotypic and research diagnostic classification systems exist and several prognostic models have been generated, there is no staging system. Staging criteria for amyotrophic lateral sclerosis would help to provide a universal and objective measure of disease progression with benefits for patient care, resource allocation, research classifications and clinical trial design. We therefore sought to define easily identified clinical milestones that could be shown to occur at specific points in the disease course, reflect disease progression and impact prognosis and treatment. A tertiary referral centre clinical database was analysed, consisting of 1471 patients with amyotrophic lateral sclerosis seen between 1993 and 2007. Milestones were defined as symptom onset (functional involvement by weakness, wasting, spasticity, dysarthria or dysphagia of one central nervous system region defined as bulbar, upper limb, lower limb or diaphragmatic), diagnosis, functional involvement of a second region, functional involvement of a third region, needing gastrostomy and non-invasive ventilation. Milestone timings were standardized as proportions of time elapsed through the disease course using information from patients who had died by dividing time to a milestone by disease duration. Milestones occurred at predictable proportions of the disease course. Diagnosis occurred at 35% through the disease course, involvement of a second region at 38%, a third region at 61%, need for gastrostomy at 77% and need for non-invasive ventilation at 80%. We therefore propose a simple staging system for amyotrophic lateral sclerosis. Stage 1: symptom onset (involvement of first region); Stage 2A: diagnosis; Stage 2B: involvement of second region; Stage 3: involvement of third region; Stage 4A: need for gastrostomy; and Stage 4B: need for non-invasive ventilation. Validation of this staging system will require further studies in other populations, in population registers and in other clinic databases. The standardized times to milestones may well vary between different studies and populations, although the stages themselves and their meanings are likely to remain unchanged.

PURPOSE The eye, like other organs, is affected by the hypobaric hypoxia of high altitude. Corneal swelling is known to occur under hypoxic conditions at sea level, for instance when wearing contact lenses. The aim of this study was to measure central corneal thickness (CCT) in lowlanders ascending to altitude. METHODS The Apex 2 medical research expedition provided the opportunity to measure CCT in 63 healthy lowlanders. The subjects arrived in La Paz, Bolivia (3700 m), where they spent 4 days acclimatizing before being driven over 2 hours to the Cosmic Physics Laboratory at Chacaltaya (5200 m), where they stayed for 7 days. CCT was measured in the early afternoon by using ultrasound pachymetry on the first, third, and seventh day at 5200 m and before and after the expedition at sea level. RESULTS Mean CCT increased significantly from 543 microm at sea level to 561 microm on the first day at 5200 m (P < 0.001). This continued to increase to 563 microm on the third day and 571 microm on the seventh day but returned to 541 microm after descent to sea level. CONCLUSIONS This study showed that altitude caused a significant increase in CCT in a large group of healthy lowlanders with normal corneas. This finding confirms the results of previous studies and is likely to be caused by endothelial dysfunction causing stromal swelling. This could potentially cause visual problems for high-altitude mountaineers among whom refractive surgery is popular.

We aimed to design alternative estimates of pre-morbid/prior intelligence to the National Adult Reading Test (NART) and the Spot-the-Word (STW) in order to tap non-vocabulary based knowledge stores. The rationale for the development of the new tests was that more cognitively able individuals acquire and retain more ‘singular facts’ from their environment. Such facts appear to include knowing how to pronounce irregular words and knowing whether a letter string is a word. We examine if they also include whether a word string is a book title or whether a line drawing is the outline of a country. In the new Spot-the-Book test, subjects were required to identify the real book from a real book-fake book pair of titles. The Spot-the-Country test involved identifying which of two named countries is shown in a line-drawn outline of its borders. There were 126 participants (75 women and 51 men) with mean age 42.2 years (SD = 16.5) and from a wide range of social and occupational backgrounds. Participants undertook a battery of tests including the NART and STW, two tests of more fluid-type ability (Digit Symbol and Matrix Reasoning from the WAIS-III UK ), and the two new tests: Spot-the-Book and Spot-the-Country. These new tests had high internal consistencies and were highly correlated with the established measures, suggesting that they have concurrent validity. Spot-the-Book test correlated highly with the NART ( r = .75, p r = .72, p r = .53, p r = .41, p

Previous studies have suggested a lower incidence of ALS in people of African origin. We used a population based register in an urban setting from inner city London postcodes where there is a large population of people of African ancestry to compare the frequency of ALS in people of European and African origin. Population statistics stratified by age, gender and ethnicity were obtained from the 2001 census. Incidence and prevalence were calculated in each ethnic group. Results showed that in a population of 683,194, of which 22% were of African ancestry, 88 individuals with ALS were identified over a seven-year period, including 14 people with African ancestry. The adjusted incidence in people of African ancestry was 1.35 per 100,000 person-years (95% CI 0.72-2.3) and in those of European ancestry 1.97 per 100,000 person-years (95% CI 1.55-2.48). In conclusion, in this small population based study we could not detect a difference in rates of ALS between people of African ancestry and those of European ancestry.

Summary Background Amyotrophic lateral sclerosis shares characteristics with some cancers, such as onset being more common in later life, progression usually being rapid, the disease affecting a particular cell type, and showing complex inheritance. We used a model originally applied to cancer epidemiology to investigate the hypothesis that amyotrophic lateral sclerosis is a multistep process. Methods We generated incidence data by age and sex from amyotrophic lateral sclerosis population registers in Ireland (registration dates 1995–2012), the Netherlands (2006–12), Italy (1995–2004), Scotland (1989–98), and England (2002–09), and calculated age and sex-adjusted incidences for each register. We regressed the log of age-specific incidence against the log of age with least squares regression. We did the analyses within each register, and also did a combined analysis, adjusting for register. Findings We identified 6274 cases of amyotrophic lateral sclerosis from a catchment population of about 34 million people. We noted a linear relationship between log incidence and log age in all five registers: England r 2 =0·95, Ireland r 2 =0·99, Italy r 2 =0·95, the Netherlands r 2 =0·99, and Scotland r 2 =0·97; overall r 2 =0·99. All five registers gave similar estimates of the linear slope ranging from 4·5 to 5·1, with overlapping confidence intervals. The combination of all five registers gave an overall slope of 4·8 (95% CI 4·5–5·0), with similar estimates for men (4·6, 4·3–4·9) and women (5·0, 4·5–5·5). Interpretation A linear relationship between the log incidence and log age of onset of amyotrophic lateral sclerosis is consistent with a multistage model of disease. The slope estimate suggests that amyotrophic lateral sclerosis is a six-step process. Identification of these steps could lead to preventive and therapeutic avenues. Funding UK Medical Research Council; UK Economic and Social Research Council; Ireland Health Research Board; The Netherlands Organisation for Health Research and Development (ZonMw); the Ministry of Health and Ministry of Education, University, and Research in Italy; the Motor Neurone Disease Association of England, Wales, and Northern Ireland; and the European Commission (Seventh Framework Programme).

Amyotrophic lateral sclerosis is a neurodegenerative disease of motor neurons with a median survival of 2 years. Most patients have no family history of amyotrophic lateral sclerosis, but current understanding of such diseases suggests there should be an increased risk to relatives. Furthermore, it is a common question to be asked by patients and relatives in clinic. We therefore set out to determine the risk of amyotrophic lateral sclerosis to first degree relatives of patients with sporadic amyotrophic lateral sclerosis attending a specialist clinic. Case records of patients with sporadic amyotrophic lateral sclerosis seen at a tertiary referral centre over a 16-year period were reviewed, and pedigree structures extracted. All individuals who had originally presented with sporadic amyotrophic lateral sclerosis, but who subsequently had an affected first degree relative, were identified. Calculations were age-adjusted using clinic population demographics. Probands (n = 1502), full siblings (n = 1622) and full offspring (n = 1545) were identified. Eight of the siblings and 18 offspring had developed amyotrophic lateral sclerosis. The unadjusted risk of amyotrophic lateral sclerosis over the observation period was 0.5% for siblings and 1.0% for offspring. Age information was available for 476 siblings and 824 offspring. For this subset, the crude incidence of amyotrophic lateral sclerosis was 0.11% per year (0.05-0.21%) in siblings and 0.11% per year (0.06-0.19%) in offspring, and the clinic age-adjusted incidence rate was 0.12% per year (0.04-0.21%) in siblings. By age 85, siblings were found to have an 8-fold increased risk of amyotrophic lateral sclerosis, in comparison to the background population. In practice, this means the risk of remaining unaffected by age 85 dropped from 99.7% to 97.6%. Relatives of people with sporadic amyotrophic lateral sclerosis have a small but definite increased risk of being affected.

Replicable risk factors for ALS include increasing age, family history and being male. The male: female ratio has been reported as being between 1 and 3. We tested the hypothesis that the sex ratio changes with age in a population register covering the south-east of England. The sex ratio before and after the age of 51 years was compared using a Z-test for proportions. Kendall’s tau was used to assess the relationship between age group and sex ratio using incidence and prevalence data. Publicly available data from Italian and Irish population registers were compared with results. There was a significant difference in the proportion of females with ALS between those in the younger group (30.11%) and those in the older group (43.66%) (p = 0.013). The adjusted male: female ratio dropped from 2.5 in the younger group to 1.4 in the older group using prevalence data (Kendall’s tau = –0.73, p = 0.039). Similar ratios were found in the Italian but not the Irish registry. We concluded that sex ratios in ALS may change with age. Over-representation of younger patients in clinic registers may explain the variation in sex ratios between studies. Menopause may also play a role.

Opsoclonus-myoclonus syndrome (OMS) typically presents with chaotic eye movements and myoclonus with some patients exhibiting ataxia and behavioural disturbance. The pathogenesis may be inflammatory with an infectious or paraneoplastic trigger. In this report, we describe four HIV-infected cases with OMS presenting to a tertiary referral centre in Cape Town, South Africa, over a 10-year period. OMS was the initial neurological presentation of HIV-infection in three subjects of whom two had preserved CD4+ cell counts. Immunosuppressive therapy, mainly prednisone, led to a dramatic improvement of symptoms in all cases suggesting an inflammatory aetiology, consistent with the observation that HIV-infection can be associated with both inflammatory and autoimmune conditions. Three previous reports of OMS associated with HIV-infection have been documented including a sero-conversion syndrome and as part of an immune reconstitution syndrome. We suggest that in HIV-associated OMS the pathophysiology may be the consequence of a dysregulated immune system in which a reduced CD4/CD8 ratio, in addition to a critical level of functional CD4+ cells for efficient CD8+ cytotoxicity, results in dysfunction of the brainstem-cerebellar circuitry in susceptible individuals.

Background: Amyotrophic lateral sclerosis (ALS) is a degenerative disease of motor neurons that causes progressive paralysis and eventually results in death from respiratory failure. Environmental factors that trigger ALS might result in a pattern of geographical clustering of cases. We tested this hypothesis using the South-East England ALS population register, which covers south-east London, Kent and parts of neighbouring counties. Methods: The register’s catchment area was divided into postcode districts and sectors. The expected rates of ALS (adjusted for age and sex) were compared with the observed rates using a standardised residuals method and the SaTScan programme. Results: There were 406 cases of ALS identified in the catchment area during the study period. Four of the 126 postcode districts, all in Greater London, had residuals >2.5 SDs from the mean. Similarly, there were 15 postcode sectors (out of 420) that had residuals >1.96 SDs from the mean. Nine of these were in Greater London. SaTScan identified an area that had a 5.61-km radius in which the relative risk of ALS was 1.70 (p = 0.012). This area overlapped with the postcode districts and some of the sectors identified using the residuals method. Conclusions: These findings suggest an excess of ALS cases in some postcode districts in south-east England.

A growing scientific consensus states that the global climate is changing and that human activity is responsible for these changes. It folLows that each of us has a responsibility to look at how our own lives impact on the environment. This study aimed to investigate water use during surgical scrubbing. Two water delivery systems were assessed to see whether technological innovation can promote more 'environmentally friendly' scrubbing behaviour. At least 10 different individuals, comprising surgeons, assistants and scrub nurses, were observed at two sites. Twenty-five separate surgical scrubs were observed in each location and the length of time for which the tap was on recorded. The tap was on during surgical scrubbing for a mean of 2 min 23 s at Gartnavel General Hospital (maximum: 4 min 37 s; minimum: 49 s; SD: 55 s) and for a mean of 1 min 7 s at Stobhill Hospital (maximum: 2 min 25 s; minimum: 19 s; SD: 33 s). The mean 'tap on' time (in seconds) at Gartnavel was significantly greater than that at Stobhill [t(39.5)=P0.001]. A different tap design resulted in a net saving of 5.7 L of hot water, approximately 600 kJ of energy and 80 g of carbon dioxide emitted per surgical scrub. Surgical scrubbing is a ubiquitous procedure performed daily in healthcare settings. A simple technological solution can reduce water and energy use by modifying hand-washing behaviour and thereby reduce the carbon footprint of surgical scrubbing.

Purpose To investigate changes of intraocular pressure on ascent to high altitude. Methods The Apex 2 medical research expedition provided the opportunity to measure intraocular pressure (IOP) and central corneal thickness (CCT) in 76 healthy lowlanders. They all arrived in La Paz, Bolivia (altitude, 3700 m), where they spent 4 days before being driven more than 2 hours to the Cosmic Physics Laboratory at Chacaltaya (5200 m) where they stayed for 7 days. IOP and CCT were measured with a hand-held tonometer and ultrasound pachymetry on the first, third, and seventh days at 5200 m. Pre- and postexpedition CCT and postexpedition IOP readings at sea-level were also measured. Results IOP increased significantly from baseline after acute exposure to altitude before returning to baseline with time. IOP at baseline, change in IOP from baseline, and IOP at altitude did not predict symptoms of acute mountain sickness (AMS) or development of high-altitude retinopathy (HAR). Conclusions Acute exposure to altitude caused a statistically significant but clinically insignificant increase in IOP. This finding may be partially explained by the change in CCT. IOP returned to baseline levels and possibly lower with prolonged exposure to altitude. Changes in IOP at altitude are not predictive of symptoms of acute mountain sickness (AMS) or development of high-altitude retinopathy (HAR).

Sensory and cognitive mechanisms allow stimuli to be perceived with properties relating to sight, sound, touch, etc, and ensure, for example, that visual properties are perceived as visual experiences, rather than sounds, tastes, smells, etc. Theories of normal development can be informed by cases where this modularity breaks down, in a condition known as synaesthesia. Conventional wisdom has held that this occurs extremely rarely (0.05% of births) and affects women more than men. Here we present the first test of synaesthesia prevalence with sampling that does not rely on self-referral, and which uses objective tests to establish genuineness. We show that (a) the prevalence of synaesthesia is 88 times higher than previously assumed, (b) the most common variant is coloured days, (c) the most studied variant (grapheme - colour synaesthesia)—previously believed most common—is prevalent at 1%, and (d) there is no strong asymmetry in the distribution of synaesthesia across the sexes. Hence, we suggest that female biases reported earlier likely arose from (or were exaggerated by) sex differences in self-disclosure.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease of motor neurons. Single-nucleotide polymorphism rs3849942 is associated with ALS, tagging a hexanucleotide repeat mutation in the C9orf72 gene. It is possible that there is more than 1 disease-causing genetic variation at this locus, in which case association might remain after removal of cases carrying the mutation. DNA from patients with ALS was therefore tested for the mutation. Genome-wide association testing was performed first using all samples, and then restricting the analysis to samples not carrying the mutation. rs3849942 and rs903603 were strongly associated with ALS when all samples were included (rs3849942, p = [3 × 2] × 10−6, rank 7/442,057; rs903603, p = [7 × 6] × 10−8, rank 2/442,057). Removal of the mutation-carrying cases resulted in loss of association for rs3849942 (p = [2 × 6] × 10−3, rank 1225/442,068), but had little effect on rs903603 (p = [1 × 9] × 10−5, rank 8/442,068). Those with a risk allele of rs903603 had an excess of apparent homozygosity for wild type repeat alleles, consistent with polymerase chain reaction failure of 1 allele because of massive repeat expansion. These results indicate residual association at the C9orf72 locus suggesting a second disease-causing repeat mutation.

Objectives To generate a prognostic classification method for Amyotrophic Lateral Sclerosis (ALS) from a prognostic model built using clinical variables from a population register. Materials and Methods We carried out a retrospective multivariate analysis of 713 patients with ALS over a 20 year period from the South-East England Amyotrophic Lateral Sclerosis (SEALS) population register. Patients were randomly allocated to ‘discovery’ or ‘test’ cohorts. A prognostic score was calculated using the discovery cohort and then used to predict survival in the test cohort. This score was used as a predictor variable in subsequent survival analyses, either as a raw value for a Cox regression or split into four prognostic categories (good, moderate, average, poor). Results A prognostic score generated from one cohort of patients predicted survival for a second cohort of patients (r2=0.72). Six variables were included in the survival model: age at onset, diagnostic delay, El Escorial category, use of riluzole, gender and site of onset. Cox regression demonstrated a strong relationship between these variables and survival (χ2 80.8, df 1, p Conclusion It is possible to correctly classify patients into prognostic categories using clinical data easily available at time of diagnosis.