Progressive multiple sclerosis is characterized by gradual neurological decline, often occurring independently of relapses or MRI activity-a phenomenon known as progression independent of relapse and MRI activity (PIRMA). Despite the effectiveness of disease-modifying therapies in controlling inflammatory activity, identifying individuals at risk of PIRMA remains an unmet clinical need. The objective of this exploratory study was to identify biomarkers and underlying molecular pathways associated with multiple sclerosis progression and especially PIRMA. Using the NUcleic acid Linked Immuno-Sandwich Assay (NULISA) inflammatory panel, we quantified 250 immune-related proteins in CSF and plasma from 49 controls, 49 patients with early active relapsing-remitting multiple sclerosis (RRMS) and 33 patients with inactive progressive multiple sclerosis (iPMS). Longitudinal clinical data were used to define PIRMA and conversion to secondary progressive multiple sclerosis (SPMS). We identified distinct proteomic signatures in CSF of both RRMS and iPMS patients compared with controls, with no significant differences in plasma. Both were associated with elevated markers of adaptive immunity, while iPMS showed a shift towards innate immune markers. Among RRMS patients, low baseline CSF concentrations of KIT ligand (KITLG) predicted both conversion to SPMS and future PIRMA events. Receiver operating characteristic analysis demonstrated KITLG's potential as a prognostic biomarker. Additionally, plasma concentrations of interleukin 1 beta and 36 gamma were elevated in RRMS patients who later developed SPMS. A model selection analysis identified a two-protein logistic regression model including interleukin 1 beta and interleukin 36 gamma as the best-performing combination (area under the curve = 0.990). Our findings reveal distinct immunological profiles across multiple sclerosis subtypes and identify KITLG as a promising biomarker for predicting disease progression and PIRMA. These results highlight potential targets for therapeutic intervention and demonstrate the utility of NULISA in uncovering novel molecular signatures in multiple sclerosis.

Importance:Capturing individual multiple sclerosis (MS) progression is difficult; few studies have evaluated glial fibrillary acidic protein (GFAP) in large longitudinal cohorts with independent validation. Objective:To investigate whether serum GFAP levels and treatment-related changes are associated with future progression independent of relapse activity (PIRA). Design, Setting, and Participants:This was a prospective observational study using 2 large MS cohorts: the Swiss MS Cohort (SMSC; initiated in June 2012; data extraction September 22, 2025) and the Expression, Proteomics, Imaging, Clinical study (EPIC; initiated in July 2004; data extraction February 21, 2024). The study took place at tertiary MS centers (8 for SMSC and 1 for EPIC). A total of 2329 persons with MS from both cohorts with at least 1 available time point with neurofilament light chain (NfL) and GFAP measurements were included (overall 18 629 measurements). Exposures:Clinical data and NfL and GFAP z scores, collected and calculated every 6 or 12 months. Main Outcomes and Measures:Risk of future PIRA, defined as Expanded Disability Status Scale score worsening confirmed after 6 or more months without relapses (in SMSC), or a composite additionally including greater than 20% worsening in the 9-hole peg test or timed 25-ft walk test (in EPIC). Results:The SMSC and EPIC cohorts consisted of 1709 (13 375 samples; median [IQR] follow-up, 6.9 [2.5-10.7] years and age, 40.6 [32.1-50.1] years; 1128 [66.0%] female) and 620 (5254 samples; median [IQR] follow-up, 13.1 [9.4-14.0] years and age, 42.0 [35.0-50.0] years; 432 [69.7%] female) persons with MS, respectively. Consistent with prior work, high NfL was associated with relapse risk within the next year, whereas high GFAP was associated with long-term PIRA risk. In addition, elevated GFAP (z score >1.0 [84th percentile]) was associated with an average 40% higher hazard of short-term PIRA in the subsequent visit interval (SMSC: median [IQR] 346 [190-375] days; hazard ratio [HR], 1.45, 95% CI, 1.21-1.75; P < .001; EPIC: 385 [355-518] days; HR, 1.36; 95% CI, 1.07-1.71; P = .01). GFAP-based cohort enrichment in clinical trials targeting PIRA as an end point could reduce sample size by approximately 20%. Further, in SMSC, every yearly GFAP z score unit reduction during the first 2 years receiving fingolimod or B-cell-depleting therapy was associated with a lower risk of subsequent PIRA (54% risk reduction; HR, 0.46; 95% CI, 0.26-0.84; P = .01 and 67% risk reduction; HR, 0.33; 95% CI, 0.18-0.61; P < .001), respectively. Conclusions and Relevance:In this cohort study, elevated GFAP was associated with a higher risk of PIRA, while treatment-associated reductions were associated with a lower PIRA risk. Together, these results suggest that serum GFAP may serve as a biomarker for personalized risk stratification and treatment monitoring and as a screening tool to reduce cohort size in clinical trials targeting MS progression.

OBJECTIVES:Compare Elecsys (Roche) and Simoa (Quanterix) immunoassays for serum glial fibrillary acidic protein (GFAP) using our reference database and Z scores, and evaluate their prognostic value for progression independent of relapse activity (PIRA) in multiple sclerosis (MS). METHODS:Platform correlation was assessed in 612 samples from healthy controls (n=188; median [interquartile range, IQR] age 45.1 [36.4-61.7] years) and people with MS (n=424; 45.3 [35.2-53.9] years). Elecsys values were converted to Z scores via Passing-Bablok-derived regression and validated in fingolimod (n=414), and B-cell depleting therapy (BCDT; n=353) cohorts. Z scores and hazard ratios (HRs) for time-to-PIRA were compared using Cox regression. RESULTS:GFAPSimoa and GFAPElecsys measurements were correlated (r=0.94), with Elecsys values ∼54 % lower (GFAPElecsys, ng/L=2.847 [95 % confidence interval, CI: 1.335 - 4.98] + 0.457 [0.434 - 0.478] * GFAPSimoa, ng/L). In univariable Cox models, GFAPSimoa and GFAPElecsys Z scores were associated with time-to-PIRA in both validation cohorts. In multivariable Cox models, higher GFAPSimoa Z scores were associated with shorter time-to-PIRA in fingolimod cohort (HR: 1.27 [95 % CI 1.08 - 1.50], p=0.0031) and trended toward significance in BCDT (1.18 [0.99 - 1.41, p=0.0693). In contrast, GFAPElecsys Z scores were associated with time-to-PIRA in both cohorts (fingolimod: 1.27 [1.09 - 1.48], p=0.0023; BCDT: (1.19 [1.00 - 1.40], p=0.0487). CONCLUSIONS:Serum GFAP measured by Elecsys shows a comparable association with time-to-PIRA as Simoa, and GFAPSimoa Z scores can be successfully bridged to GFAPElecsys Z scores, supporting Elecsys`s potential for clinical implementation.

BACKGROUND AND OBJECTIVES:Understanding the immunologic changes induced by immune reconstitution therapies (IRTs) is key to optimizing multiple sclerosis (MS) treatment. We evaluate lymphocyte dynamics and their association with secondary autoimmune disease (SAD) and its recurrence after treatment with alemtuzumab (ALZ), autologous hematopoietic stem cell transplantation (AHSCT), and cladribine tablets (CladT). METHODS:People with MS (pwMS) initiating treatment with ALZ, AHSCT, and CladT were included in this cohort study. Blood samples were collected at baseline (BL) and at months (M) 6, 12, and 24 for flow cytometry analysis of lymphocyte subpopulation. RESULTS:A total of 130 pwMS (ALZ: n = 51; AHSCT: n = 20; CladT: n = 59) were included, with a mean (SD) age of 35.5 (±8.2) years. The median (IQR) Expanded Disability Status Scale (EDSS) score was 1.5 (1.0-2.5) at BL. The median follow-up duration was 4.7 (ALZ: 5.0; AHSCT: 4.2; CladT: 3.7) years. During follow-up, 29.2% (38/130; ALZ n = 29; AHSCT n = 3; CladT n = 6) received a SAD diagnosis and 43.1% (56/130; ALZ n = 15; AHSCT n = 13; CladT n = 28) showed no disease activity. The SAD cohort (n = 38) showed lower median BL ratios of CD4+ T-cell recent thymic emigrant (Trte):CD4 (0.26 [0.12-0.34], p = 0.04) and CD4+ Trte:CD8+ terminally differentiated effector memory (Temra) (1.73 [0.76-4.39], p = 0.02) compared with the non-SAD cohort (CD4+ Trte:CD4 = 0.31 [0.23-0.42]; CD4+ Trte:CD8+ Temra = 3.61 [1.47-7.24]). During follow-up, the SAD cohort exhibited a greater relative increase in CD4+ Trte:CD4, CD4+ Trte:CD8+ Temra, and CD4+ T regulatory cell (Treg):CD8+ Temra ratios at M12 and M24, compared with BL, relative to the non-SAD group. The difference at M24 was most pronounced for the CD4+ Trte:CD8+ Temra ratio (SAD: +100% vs non-SAD: -23%, p < 0.001), with this difference being confirmed in the ALZ cohort (SAD: +123% vs non-SAD: -21%, p = 0.03), but not in the CladT cohort (SAD: -62% vs non-SAD: -38%, p = 0.39). In a multivariable Cox analysis, BL CD8+ T-cell count (aHR 0.34, 95% CI 0.15-0.80, p = 0.01) was associated with a reduced hazard of evidence of disease activity. DISCUSSION:A low BL CD4+ Trte:CD8+ Temra ratio, accompanied by a sharp relative increase during follow-up, was associated with SAD development. While no definitive associations were found between BL lymphocyte subpopulations and disease activity, a lower CD8+ T-cell count may suggest an increased risk.

BACKGROUND/OBJECTIVES:This cohort study aimed to identify blood-based biomarkers associated with progression independent of relapse activity (PIRA) in persons with multiple sclerosis (pwMS) using the multiplex NUcleic Acid-Linked Immuno-Sandwich Assay (NULISA). METHODS:NULISA 'CNS Disease Panel' and 'Inflammation Panel' were applied on plasma samples from pwMS following B cell-depleting therapy (BCDT; n = 185) or fingolimod (n = 200), median follow-up 4.0 (BCDT) and 9.1 (fingolimod) years. Plasma NULISA results (322 unique proteins; 0.9 and 1 year after treatment start, respectively) were investigated for their potential to prognosticate PIRA. RESULTS:'CNS Disease Panel' derived glial fibrillary acidic protein (GFAP) and neurofilament light chain (NfL) were identified as predictive of PIRA by multivariable Cox regression models (GFAP: BCDT: hazard ratio (HR) = 1.79, 95% confidence interval (CI) = 1.26-2.55, p = 0.0011; fingolimod: HR = 1.73, 95% CI = 1.14-2.64, p = 0.0104; NfL: BCDT: HR = 1.99, 95% CI = 1.31-3.02, p = 0.0013). GFAP derived from the 'Inflammation Panel' exhibited patterns like those observed with 'CNS Disease Panel' derived GFAP. Beyond GFAP and NfL, 12 biomarker candidates predictive of PIRA were identified. No target passed multiple test corrections, but GFAP consistently showed the highest hazard. CONCLUSION:Among over 300 proteins investigated by NULISA, GFAP was the main biomarker significantly associated with future PIRA risk in our cohort.

ABSTRACT Objective Prognostication of disease course and prediction of treatment response in multiple sclerosis is an unmet need. We compared the performance of serum neurofilament light chain Z scores (age‐ and BMI‐adjusted) with absolute concentrations for the prediction of response to disease‐modifying therapy. Methods Observational cohort study including the first serum sample of participants after the start of fingolimod therapy. We estimated hazard ratios for future relapses comparing participants with high (upper quartile) versus lower neurofilament light chain levels, based on either absolute concentration or Z score cutoffs. We compared the prognostic/predictive performance of these two measures for the occurrence of new/enlarging T2w lesions in longitudinal MRI. Results We included 447 participants (median [IQR] age, 41.3 [32.1–49.2] years; 65.1% female); median follow‐up 8.3 years [6.0–10.3]. Participants with a high neurofilament light chain Z score ( Z ≥ 1.2/88.5 percentile) were more likely to experience future relapses (HR: 1.80, 95% CI 1.27–2.54, p < 0.001) compared to those below this threshold while this dichotomy could not be demonstrated with absolute concentration cutoffs (≥ vs. < 10.8 pg/mL; HR: 0.94, 95% CI 0.64–1.38, p = 0.75). Furthermore, patients with upper quartile Z scores were associated with a higher incidence of new/enlarging T2w lesions compared with those below this threshold (OR: 1.88, 95% CI 1.31–2.70, p < 0.001); again, absolute concentration cutoffs failed to identify this risk (OR: 1.20, 95% CI 0.82–1.77, p = 0.34). These findings were confirmed when patients having started alternative oral treatments were also included ( n = 713). Interpretation Serum neurofilament light chain Z scores consistently outperformed absolute concentration cutoffs for prognostication of clinical/radiological disease activity and may facilitate individual prediction of treatment response.

Introduction: Reduced quality of life (QoL) is an early feature of multiple sclerosis (MS). The effect of progression independent of relapse activity (PIRA) on QoL is poorly investigated. Objective: To assess the impact of PIRA on QoL using patient-reported outcome measures (PROMs). Methods: In a prospective observational study, 125 newly diagnosed persons with relapsing-remitting MS (PwRRMS) were assessed over 5 years with: EuroQoL-5-Dimension-3-level (EQ-5D-3L), EQ-visual-analogous-scale (EQ-VAS) and 29-item-MS-Impact-Scale (MSIS-29). PwRRMS were dichotomized: PIRA (worsening of expanded disability status scale (EDSS), timed-25-foot-walk or 9-hole-peg-test, independent of relapses) versus non-PIRA. PwRRMS were compared at baseline, year 5 (y5) and delta values (baseline scores subtracted from y5 scores) and annually using linear-mixed-effects-models. Results: At y5, 19.2% had PIRA. PIRA versus non-PIRA PwRRMS were older ( p < 0.001). At y5 PIRA PwRRMS had lower EQ-5D-3L ( p = 0.001), higher MSIS-29-PHYS ( p < 0.001), delta values showed lower EQ-5D-3L ( p < 0.001) and EQ-VAS ( p = 0.010), higher MSIS-29-PHYS ( p = 0.004) and MSIS-29-PSYCH ( p = 0.036). Linear-mixed-effects-models showed that, compared to PIRA, non-PIRA PwRRMS had an improvement in QoL: EQ-5D-3L: β = 0.039, p < 0.001; EQ-VAS: β = 2.401, p < 0.001; MSIS-29-PHYS: β = −0.107, p < 0.001; MSIS-29-PSYCH, β = −0.115, p < 0.001, during the 5-year study period. Conclusion: Deteriorating QoL in the early course of relapsing-remitting multiple sclerosis (RRMS) is strongly associated with PIRA. Our results suggest that QoL PROMs should be monitored and recognized as an important aspect of progression.

Abstract Background The Gas6/TAM (Tyro3, Axl, and Mer) receptor system has been implicated in demyelination and delayed remyelination in experimental animal models, but data in humans are scarce. We aimed to investigate the role of Gas6/TAM in neurodegenerative processes in multiple sclerosis (MS). Methods From a prospective 5-year follow-up study, soluble Gas6/TAM biomarkers were analyzed in cerebrospinal fluid (CSF) by enzyme-linked immunosorbent assay (ELISA) at baseline in patients with relapsing–remitting MS (RRMS) (n = 40), progressive MS (PMS) (n = 20), and healthy controls (HC) (n = 25). Brain volumes, including myelin content (MyC) and white matter (WM) were measured by synthetic magnetic resonance imaging at baseline, 12 months, and 60-month follow-up. Associations with brain volume changes were investigated in multivariable linear regression models. Gas6/TAM concentrations were also determined at 12 months follow-up in RRMS to assess treatment response. Results Baseline concentrations of Tyro3, Axl, and Gas6 were significantly higher in PMS vs. RRMS and HC. Mer was higher in PMS vs. HC. Tyro3 and Gas6 were associated with reduced WM (β = 25.5, 95% confidence interval [CI] [6.11–44.96, p = 0.012; β = 11.4, 95% CI [0.42–22.4], p = 0.042, respectively) and MyC (β = 7.95, 95%CI [1.84–14.07], p = 0.012; β = 4.4, 95%CI [1.04–7.75], p = 0.012 respectively) at 60 months. Patients with evidence of remyelination at last follow-up had lower baseline soluble Tyro3 (p = 0.033) and Gas6 (p = 0.014). Except Mer, Gas6/TAM concentrations did not change with treatment in RRMS. Discussion Our data indicate a potential role for the Gas6/TAM receptor system in neurodegenerative processes influencing demyelination and ineffective remyelination.

BACKGROUND:Relapsing-remitting multiple sclerosis (RRMS) is an inflammatory and neurodegenerative disease. After two or more short courses of alemtuzumab (ALZ), an immune reconstitution is achieved, which long-term results in reduced disease activity. We aimed to investigate the effect of ALZ on measures of neurodegeneration (i.e., brain atrophy, and retinal layer thinning). METHODS:We designed an observational prospective mono-center study in RRMS patients initiating ALZ treatment. Patients were assessed at baseline (month 0) and thereafter annually for five years with clinical measures, synthetic magnetic resonance imaging (SyMRI) and optical coherence tomography (OCT), with a re-baseline SyMRI scan and an OCT exam 24 months after initiating ALZ. Persons with neurological symptoms but without evidence of neurological disease served as symptomatic controls (SCs, n = 27). RESULTS:Forty-nine RRMS patients were included. Baseline median expanded disability status scale [2.0 (IQR 1.5)] was unchanged during follow-up, 71 % were progression-free, 33 % achieved no evidence of disease activity-3 (NEDA-3). Between baseline and month 60, SyMRI showed a reduction of brain parenchymal fraction (BPF) and grey matter (GM) volume in patients. The BPF reduction was greater in RRMS patients than in SCs (p < 0.05), and more pronounced in patients with high pre-baseline disease activity than in those without (p < 0.01). OCT showed significant thinning of macular ganglion cell and inner plexiform layers (mGCIPL) and in peripapillary retinal nerve fiber layer (pRNFL) in patients. In contrast, absolute values of white matter (WM) volume and myelin content (MyC) quantified by SyMRI, were stable or increased after re-baseline (month 24) and up to month 60, and this increase appeared limited to patients without high pre-baseline disease activity and to patients with NEDA-3 or disability worsening during follow-up. A strong positive correlation between WM volume and GM volume at baseline was lost after ALZ intervention for their delta values, i.e., change from re-baseline (month 24) to month 60. While the positive baseline correlation between WM volume and MyC increased for their delta values, the positive baseline correlation between GM volume and MyC changed to negative for their delta values. CONCLUSION:We showed that neurodegeneration continued in RRMS patients under ALZ treatment, but it appeared to be limited to BPF and GM, and more pronounced in patients with disease activity. Our data suggest that patients who respond to ALZ treatment show signs of remyelination. OCT and SyMRI have potential to quantify measures of neurodegeneration that is affected by treatment intervention in RRMS.

BackgroundAlemtuzumab (ALZ) is a pulsed immune reconstitution therapy for multiple sclerosis (MS).ObjectiveTo assess basic characteristics, therapeutic effects, and prognostic biomarkers on clinical and imaging parameters of disease activity for relapsing–remitting MS (RRMS) patients selected for ALZ, in a real-world long-term setting.MethodsFifty-one RRMS patients [female = 31; mean age 36 (standard deviation 7.1) years; median expanded disability status scale (EDSS) 2 (interquartile range (IQR) 1.5)] initiating ALZ treatment, were consecutively included. Patients were assessed at baseline and thereafter annually for 5 years with clinical measures, symbol digit modality test (SDMT), and magnetic resonance imaging (MRI). Concentrations of glial fibrillary acidic protein (GFAP), reflecting astrogliosis, and neurofilament light (NfL), reflecting axonal damage, were measured in cerebrospinal fluid (CSF) and serum samples collected at baseline and after 2 years in CSF, and annually in serum. Control subjects were symptomatic controls (SCs, n = 27), who were examined at baseline and after 5 years without evidence of neurological disease.ResultsWhile the mean annualized relapse rate was significantly reduced from baseline at each year of follow-up, disability was essentially maintained at a median EDSS of 1.5 and IQR between 1.13 and 2.25. New MRI activity was recorded in 26 patients (53%) over 5 years. The proportion of patients who achieved no evidence of disease activity (NEDA-3), 6-months confirmed disability worsening (CDW), and 6-months confirmed disability improvement (CDI) at 5 years were 33, 31, and 31%, respectively. The SDMT score was reduced for patients (p < 0.001), but unchanged for SCs. ALZ treatment did not change GFAP levels, whereas there was a significant decrease for RRMS patients in median CSF and serum NfL levels at follow-up [CSF month 24: 456 pg./mL (IQR 285.4) (p = 0.05); serum month 24: 6.7 pg/mL (IQR 4.7) (p < 0.01); serum month 60: 7.2 pg/mL (IQR 4.7) (p < 0.01)], compared to baseline [CSF: 1014 pg/mL (IQR 2832.5); serum 8.6 pg/mL (IQR 17.4)].ConclusionIn this real-world mono-center population, we observed a progression-free survival of 69%, cumulative NEDA-3 of 33%, and reduced NfL levels, over a five-year follow-up. This confirms ALZ as an effective pulsed immune reconstitution therapy that significantly reduces neuro axonal loss, and therefore has the potential to reduce long-term neurological disability. ALZ did not appear to affect astrogliosis.

BackgroundAlemtuzumab (ALZ) is an immune reconstitution therapy for treating relapsing-remitting multiple sclerosis (RRMS). However, ALZ increases the risk of secondary autoimmune diseases (SADs). ObjectiveWe explored whether the detection of autoimmune antibodies (auto-Abs) could predict the development of SADs. MethodsWe included all patients with RRMS in Sweden who initiated ALZ treatment (n = 124, 74 female subjects) from 2009 to 2019. The presence of auto-Abs was determined in plasma samples obtained at the baseline and at 6, 12, and 24 months of follow-up, as well as in a subgroup of patients (n = 51), it was determined in plasma samples obtained at the remaining 3-month intervals up to 24 months. Monthly blood tests, urine tests, and the assessment of clinical symptoms were performed for monitoring safety including that of SADs. ResultsAutoimmune thyroid disease (AITD) developed in 40% of patients, within a median follow-up of 4.5 years. Thyroid auto-Abs were detected in 62% of patients with AITD. The presence of thyrotropin receptor antibodies (TRAbs) at the baseline increased the risk of AITD by 50%. At 24 months, thyroid auto-Abs were detected in 27 patients, and 93% (25/27) developed AITD. Among patients without thyroid auto-Abs, only 30% (15/51) developed AITD (p < 0.0001). In the subgroup of patients (n = 51) with more frequent sampling for auto-Abs, 27 patients developed ALZ-induced AITD, and 19 of them had detectable thyroid auto-Abs prior to the AITD onset, with a median interval of 216 days. Eight patients (6.5%) developed non-thyroid SAD, and none had detectable non-thyroid auto-Abs. ConclusionWe conclude that monitoring thyroid auto-Abs, essentially TRAbs, may improve the surveillance of AITD associated with ALZ treatment. The risk for non-thyroid SADs was low, and monitoring non-thyroid auto-Abs did not seem to provide any additional information for predicting non-thyroid SADs.

ObjectiveTo compare outcomes after treatment with autologous haematopoietic stem cell transplantation (AHSCT) and alemtuzumab (ALZ) in patients with relapsing–remitting multiple sclerosis.MethodsPatients treated with AHSCT (n=69) received a conditioning regimen of cyclophosphamide (200 mg/kg) and rabbit anti-thymocyte globulinerG (6.0 mg/kg). Patients treated with ALZ (n=75) received a dose of 60 mg over 5 days, a repeated dose of 36 mg over 3 days after 1 year and then as needed. Follow-up visits with assessment of the expanded disability status scale score, adverse events and MR investigations were made at least yearly.ResultsThe Kaplan-Meier estimates of the primary outcome measure ‘no evidence of disease activity’ was 88% for AHSCT and 37% for ALZ at 3 years, p<0.0001. The secondary endpoint of annualised relapse rate was 0.04 for AHSCT and 0.1 for ALZ, p=0.03. At last follow-up, the proportions of patients who improved, were stable or worsened were 57%/41%/1% (AHSCT) and 45%/43%/12% (ALZ), p=0.06 Adverse events grade three or higher were present in 48/69 patients treated with AHSCT and 0/75 treated with ALZ in the first 100 days after treatment initiation. The most common long-term adverse event was thyroid disease with Kaplan-Meier estimates at 3 years of 21% for AHSCT and 46% for ALZ, p=0.005.ConclusionsIn this observational cohort study, treatment with AHSCT was associated with a higher likelihood of maintaining ‘no evidence of disease activity’. Adverse events were more frequent with AHSCT in the first 100 days, but thereafter more common in patients treated with ALZ.

Neurodegeneration in multiple sclerosis (MS) correlates with disease progression and reparative processes may be triggered. Growth-associated protein 43 (GAP-43) exhibits induced expression during axonal growth and reduced expression during MS progression. We aimed to evaluate if GAP-43 can serve as a biomarker of regeneration in relapsing-remitting MS (RRMS) and whether disease-modifying therapies (DMTs) influence GAP-43 concentration in cerebrospinal fluid (CSF). GAP-43 was measured using an enzyme-linked immunosorbent assay in 105 MS patients (73 RRMS, 12 primary progressive MS, 20 secondary progressive MS) and 23 healthy controls (HCs). In 35 of the patients, lumbar puncture, clinical assessment, and magnetic resonance imaging was performed before initiation of therapeutic intervention, and at follow-up. CSF GAP-43 concentration was significantly lower in progressive MS compared with HCs (p = 0.004) and RRMS (p = < 0.001) and correlated negatively with disability (p = 0.026). However, DMTs did not alter CSF GAP-43. Interestingly, in RRMS CSF GAP-43 levels were higher in patients with signs of active inflammatory disease than in patients in remission (p = 0.042). According to CSF GAP-43 concentrations, regeneration seems reduced in progressive MS, increased during disease activity in RRMS but is unaffected by treatment of highly active DMTs.

Purpose This paper seeks to shed light on the challenges and opportunities demographic transitions bring about to the banking sector. Increasing life expectancy, coupled with an increasing old age dependency ratio has implications for the demand for financial services. This opens a window of opportunity for the banking sector to adjust its services so as to meet these changes and reap the benefit of demographic changes. Design/methodology/approach The paper uses demographic forecasts made by the United Nations Population Division, to which are applied established economic models on life cycle behaviour. Based on the findings, light is shed on potential scenarios that banks may encounter. Findings The life cycle models predict a higher overall asset accumulation level and a higher savings level, at least initially, in an ageing population. Other life cycle behaviour models point out that individuals' risk aversion increases with age, while evidence shows that population ageing exposes individuals to greater risks. This increases the need for households to appropriately diversify and manage the risks they face, and encourages the development of products that are better tailored to these growing needs. Originality/value The paper proposes that banks can contribute to creating financial stability. Banks can participate in financial education and consequently increase households' motivation to save more and in better ways. Consumer demand encountered by banks is shifting from credit products to savings products. The investment packages currently offered by banks need to adapt to changing needs: combined annuity and life insurance packages are one option.