Nanotechnology for Detection of Multiple Sclerosis Compared to Autoimmune and Neurological Diseases by Exhaled Samples
Condition: Multiple Sclerosis
MeSH terms: Multiple Sclerosis; Nervous System Diseases; Sclerosis
Study type: Interventional

Summary: 
      Multiple Sclerosis (MS) is a complex multi-factorial disease, with underlying both genetic
      and environmental factors. Different populations have different susceptibility to MS. The
      disease is characterized by 2 main phenotypes: relapsing-remitting or progressive course.
      Clinical disability is due to distraction of the central nervous system (CNS) myelin.

      Repair processes are mainly noted after the acute relapse - and recovery of function can be
      spontaneous. However, in severe relapses sometimes there is need for STEROID TREATMENT.

      For the long term prophylaxis - following the increased understanding of the disease, in the
      last 10-15 years, there are new immunotherapies available (COPAXON / TEVA; Interferon -beta).
      However these can attenuate the disease (reduce the number of relapses per year) but cannot
      cure it. Also, they are beneficial in only ~40 % of the Relapsing -Remitting patients.

      Currently there are no biomarkers available for MS (other than oligoclonal Immunoglobulin G
      (IgG) in the cervical spine fluid (CSF) - which helps confirm diagnosis but require an
      invasive procedure and are not correlated with disease activity nor response to therapy) and
      monitoring of MS and its treatment is by magnetic resonance Imaging (MRI) - which is an
      expensive procedure.

      Dr Hossam Haick from the Technion developed an electronic nose based on nanomaterials for
      diagnosis of diseases (e.g., cancer, kidney failure, etc.) via breath samples.The research
      hypothesis is that Biomarkers of CNS inflammation and/or neurodegeneration and/or CNS repair
      in persons with MS can be detected by the "electronic nose".
    

Detailed description: 
      MS is the most common chronic neurological disease affecting young adults, with onset usually
      at the age 20-40 years. Women are affected 3-4 times more than men. It is a complex
      multi-factorial disease, with underlying both genetic and environmental factors. Different
      populations have different susceptibility (Compston and Coles 2008).

      The disease is characterized by 2 main phenotypes: relapsing-remitting or progressive course.
      Clinical disability is due to destruction of the CNS myelin (mainly oligodendrocytes) due to
      3 processes (Franklin 2002; Franklin and Ffrench-Constant 2008; Frischer, Bramow et al.
      2009):

        1. Inflammation- immune cells with aberrant activity invade the brain and spinal cord and
           cause destruction of CNS myelin (a process called demyelination and secondary
           neurodegeneration - axonal and neuronal loss)

        2. Primary neurodegeneration (axonal and neuronal loss) - without prominent inflammation

        3. Repair - the inflammatory and neurodegenerative processes are followed by an attempt of
           the CNS to repair - however, this partial and incomplete repair is often the basis of
           residual deficits and disability (Chandran, Hunt et al. 2008) .

             -  The acute MS relapse (presented as paralysis, visual loss, etc.) - is considered to
                be due to an aberrant acute immune activation and inflammatory process in the CNS.

             -  The chronic accumulating disability - is considered to be due to the
                Neuro-degenerative process.

      Repair processes are mainly noted after the acute relapse - and recovery of function can be
      spontaneous. However, in severe relapses sometimes there is need for STEROID TREATMENT
      (Tischner and Reichardt 2007).

      Following the increased understanding of the disease, new immunotherapies were developed
      (COPAXON /; Interferon -beta )in the last 10-15 years for long term treatment. However these
      can attenuate the disease (reduce the number of relapses per year) but do not cure it. In
      addition, they are beneficial in only ~40 % of the Relapsing -Remitting patients. Currently
      there are no treatments for patients with the Progressive Disease - who have gradual
      increased disability (Murray 2006).

      Presently there are no biomarkers available for diagnosis and routine follow-up of MS.
      Oligoclonal IgG in the CSF - which help confirm the diagnosis, require an invasive procedure
      and are not correlated with disease activity nor response to therapy; and MRI, which allows
      monitoring of MS activity and response to treatment is too expensive to routine use (Link and
      Huang 2006; Murray 2006).

      Dr Hossam Haick from the Technion, developed an electronic nose for diagnosis of diseases via
      breath samples. Dr Haick's previous studies have shown that an electronic nose based on gold
      nanoparticles could form the basis of an inexpensive and non- invasive diagnostic tool for
      lung cancer (Peng, Tisch et al. 2009) and kidney diseases (Haick, Hakim et al. 2009).

      Research hypothesis Biomarkers of CNS inflammation and/or neurodegeneration and/or CNS repair
      can be detected by the "electronic nose" in breath samples of persons with MS.

      Aim(s)

      Identification of biomarkers of:

        1. CNS inflammation and CNS-autoimmunity

        2. Neurodegeneration

        3. CNS repair

             -  that may serve as markers for: disease (vs controls), disease activity (predicting
                aggressive disease course, predicting Relapse; predicting Malignant vs Benign MS);
                response to therapy (Steroid , immunotherapies or neuroprotective agents).

      Work plan outline:

      Evaluate few groups clinically:

        -  MS patients at acute relapse pre - vs- after 7 ,30 and 90 days of steroids treatment -
           to assess indicators of the acute inflammatory process and of the effects of Steroid
           treatment.

        -  Relapsing MS patients vs Progressive MS patients vs controls which include healthy
           individuals as well as patients suffering from neurological and autoimmune diseases
           other than MS - to assess inflammatory vs neurodegenerative indicators.

        -  MS patients who are Good- vs Poor- Responders to immunotherapy or Steroids.

      BREATH COLLECTION:

      Alveolar breath of the volunteers is collected using an "offline" method that effectively
      separates the endogenous from the exogenous breath volatile biomarkers and excludes the nasal
      entrainment. Two bags of 750 ml of breath samples per volunteer are collected in inert Mylar
      bags (Eco Medics, Duerten, Switzerland). Vapor sampling was performed by extended breath
      sampling into the collection apparatus for 15-20 minutes, with several stops during this
      process. The first three minutes of breath sampling are discarded due to the possible
      contamination of the upper respiratory air. The subsequent deep air is retained for testing
      purposes. The samples are collected with a tube that was introduced in the volunteer's mouth
      and connected to the collection bag. All participants provide a signed informed consent to
      this study, which is performed following the approval and according to the guidelines of the
      Helsinki Committee of Carmel Medical Center and Technion's committee for supervision of
      experiments in humans.

      CHEMICAL ANALYSIS OF THE BREATH SAMPLES:

      Gas-Chromatography/Mass-Spectrometry (GCMS-QP2010; Shimadzu Corporation, Japan), combined
      with a thermal desorption system (TD20; Shimadzu Corporation, Japan), is used for the
      chemical analysis of the breath samples. A Tenax® TA adsorbent tube (Sigma Aldrich Ltd.) is
      employed for pre-concentrating the VOCs in the breath samples. Using a custom-made pump
      system, the breath samples from the Mylar bags are sucked up through the TA tube at 100
      ml/min flow rate, being then transferred to a thermal desorption (TD) tube (Sigma Aldrich
      Ltd.) before being analyzed by GC-MS. The following oven temperature profile was set: (a) 10
      min at 35°C; (b) 4°C/min ramp until 150°C; (c) 10°C/min ramp until 300°C; and (d) 15 min at
      300°C. An SLB-5ms capillary column (Sigma Aldrich Ltd.) with 5% phenyl methyl siloxane (30 m
      length, 0.25 mm internal diameter and 0.5 μm thicknesses) is employed. The splitless
      injection mode is used for 2 min, at 30 cm/sec constant linear speed and 0.70 ml/min column
      flow. The molecular structures of the VOCs are determined via the standard modular set, using
      10 ppm isobutylene (Calgaz, Cambridge, Maryland, USA) as standard calibration gas during each
      run. GC-MS chromatogram analysis is realized using the GCMS solutions version 2.53SU1
      post-run analysis program (Shimadzu Corporation), employing the National Institute of
      Standards and Technology (NIST) compounds library (Gaithersburg, MD 20899-1070, USA).

      SENSING MEASUREMENTS:

      Upon interaction between the breath samples and the detector, the volatile organic compounds
      adsorb into the organic part of the sensing material The result of this adsorption is
      translated to an electrical signal (resistance) that is transmitted to the macro-world (e.g.,
      the screen of the device) through the (semi-)conductive material found in the same film. The
      results are then presented on the computers screen.

      An automated system controlled by a custom LabView (National Instruments) program is used to
      perform the sensing measurements. The sensors are tested simultaneously, in the same exposure
      chamber, using an Agilent 34980A multifunction switch. A Stanford Research System SR830 DSP
      lock-in amplifier controlled by an IEEE 488 bus is used to supply the AC voltage signal (0.2
      V at 1 kHz) and to measure the corresponding current (<10μA in the studied devices). This
      setup allows for measuring normalized changes in conductance as small as 0.01%. Sensor
      resistance was continuously acquired during the experiments. Sensing experiments were
      continuously performed using subsequent exposure cycles (see SOI, section 2).

      DATA ANALYSIS:

      Features extraction. For VOC analysis, three parameters are extracted from each sensor
      response: (i) the normalized change of sensor resistance at the middle of the exposure (S1);
      (ii) the normalized change of sensor resistance at the end of the exposure (S2); and (iii)
      the area under the response curve (S3). S1 and S2 are calculated with regard to the value of
      sensor resistance prior to the exposure. For breath analysis, two parameters are extracted
      from each sensor response (either to the control VOC or to each release of breath sample):
      (i) the normalized change of sensors resistance soon after the exposure (S4); and (ii) the
      normalized change of sensors resistance at the middle of the exposure (S5). S4 and S5 are
      calculated with regard to the value of sensor resistance prior to the exposure. A
      compensation and calibration process is posteriorly applied to these parameters to retain
      from sensor responses only that information related to their response to the VOCs from the
      breath samples. The mean values of the parameters obtained over the two successive exposures
      to the same sample are then calculated.
    

Intervention name(s): NA-NOSE artificial olfactory system
Intervention type(s): Other
Intervention description(s): NA-NOSE is an artificial olfactory system that is based on nanomaterials and connected with machine learning. NA-NOSE can diagnosis diseases or disorders based on volatile biomarkers that are emitted from exhaled breath, blood, or from clinical tissue.
Other intervention name(s): Electronic Nose
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Diagnostic
Keywords: Multiple Sclerosis; Breath; Diagnosis; Discrimination MS/healthy subj. via exhaled breath samples; Discrimination MS/other neurological and autoimmune diseases