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Hillert J, Bove R, Haddad LB, Hellwig K, Houtchens M, Magyari M, Merki-Feld GS, Montgomery S, Nappi RE, Stenager E, Thompson H, Tulek Z, Verdun Di Cantogno E, Simoni M. Expert opinion on the use of contraception in people with multiple sclerosis. Mult Scler 2024:13524585241228103. [PMID: 38456514 DOI: 10.1177/13524585241228103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Current guidance on the selection of appropriate contraception for people with multiple sclerosis (PwMS) is lacking. OBJECTIVE To address this gap, an expert-led consensus program developed recommendations to support clinicians in discussing family planning and contraception with women and men with multiple sclerosis (MS). METHODS A multidisciplinary steering committee (SC) of 13 international clinical experts led the program, supported by an extended faculty of 32 experts representing 18 countries. A modified Delphi methodology was used for decision-making and consensus-building. The SC drafted 15 clinical questions focused on patient-centered care, selection of contraception, and timing of stopping/starting contraception and disease-modifying therapies (DMTs). Statements addressing each question were drafted based on evaluation of published evidence and the experts' clinical experience. Consensus was reached if ⩾75% of respondents agreed (scoring 7-9 on a 9-point scale) with each recommendation. RESULTS Consensus was reached on 24 of 25 proposed recommendations, including how and when to discuss contraception, types and safety of contraceptives, and how to evaluate the most appropriate contraceptive options for specific patient groups, including those with significant disability or being treated with DMTs. CONCLUSION These expert recommendations provide the first practical, relevant, and comprehensive guidance for clinicians on the selection of contraception in PwMS.
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Affiliation(s)
- Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Riley Bove
- UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Lisa B Haddad
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Kerstin Hellwig
- Katholisches Klinikum Bochum GmbH, Nordrhein-Westfalen, Bochum, Germany
| | - Maria Houtchens
- Brigham and Women's Hospital, Boston, MA, USA/ Harvard Medical School, Boston, MA, USA
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, University Hospital Boston, MA, USA/ Rigshospitalet, Copenhagen, Denmark
| | - Gabriele S Merki-Feld
- Clinic of Reproductive Endocrinology, University Hospital Zürich, Zürich, Switzerland
| | - Scott Montgomery
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
- Research Center of Reproductive Medicine, IRCCS San Matteo Foundation, Pavia, Italy
| | - Egon Stenager
- Department of Regional Research, University of Southern Denmark, Odense, Denmark
- MS-Clinic of Southern Jutland (Aabenraa, Esbjerg, Kolding), Sønderborg, Denmark
| | - Heidi Thompson
- Southern Health & Social Care Trust, Portadown, Northern Ireland
| | - Zeliha Tulek
- Istanbul University-Cerrahpasa, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Manuela Simoni
- Unit of Endocrinology, Department of Medical Specialties, University Hospital and Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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Meca-Lallana JE, Martínez Yélamos S, Eichau S, Llaneza MÁ, Martín Martínez J, Peña Martínez J, Meca Lallana V, Alonso Torres AM, Moral Torres E, Río J, Calles C, Ares Luque A, Ramió-Torrentà L, Marzo Sola ME, Prieto JM, Martínez Ginés ML, Arroyo R, Otano Martínez MÁ, Brieva Ruiz L, Gómez Gutiérrez M, Rodríguez-Antigüedad Zarranz A, Sánchez-Seco VG, Costa-Frossard L, Hernández Pérez MÁ, Landete Pascual L, González Platas M, Oreja-Guevara C. Consensus statement of the Spanish Society of Neurology on the treatment of multiple sclerosis and holistic patient management in 2023. Neurologia 2024; 39:196-208. [PMID: 38237804 DOI: 10.1016/j.nrleng.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/14/2023] [Indexed: 01/25/2024] Open
Abstract
The last consensus statement of the Spanish Society of Neurology's Demyelinating Diseases Study Group on the treatment of multiple sclerosis (MS) was issued in 2016. Although many of the positions taken remain valid, there have been significant changes in the management and treatment of MS, both due to the approval of new drugs with different action mechanisms and due to the evolution of previously fixed concepts. This has enabled new approaches to specific situations such as pregnancy and vaccination, and the inclusion of new variables in clinical decision-making, such as the early use of high-efficacy disease-modifying therapies (DMT), consideration of the patient's perspective, and the use of such novel technologies as remote monitoring. In the light of these changes, this updated consensus statement, developed according to the Delphi method, seeks to reflect the new paradigm in the management of patients with MS, based on the available scientific evidence and the clinical expertise of the participants. The most significant recommendations are that immunomodulatory DMT be started in patients with radiologically isolated syndrome with persistent radiological activity, that patient perspectives be considered, and that the term "lines of therapy" no longer be used in the classification of DMTs (> 90% consensus). Following diagnosis of MS, the first DMT should be selected according to the presence/absence of factors of poor prognosis (whether epidemiological, clinical, radiological, or biomarkers) for the occurrence of new relapses or progression of disability; high-efficacy DMTs may be considered from disease onset.
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Affiliation(s)
- J E Meca-Lallana
- Unidad de Neuroinmunología Clínica y CSUR Esclerosis Múltiple, Servicio de Neurología, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca)/Cátedra de Neuroinmunología Clínica y Esclerosis Múltiple, Universidad Católica San Antonio (UCAM), Murcia, Spain.
| | - S Martínez Yélamos
- Unidad de Esclerosis Múltiple «EMxarxa», Servicio de Neurología. H.U. de Bellvitge, IDIBELL, Departament de Ciències Clíniques, Universitat de Barcelona, Barcelona, Spain
| | - S Eichau
- Servicio de Neurología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - M Á Llaneza
- Servicio de Neurología, Complejo Hospitalario Universitario de Ferrol, Ferrol, Spain
| | - J Martín Martínez
- Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - V Meca Lallana
- Servicio de Neurología, Hospital Universitario La Princesa, Madrid, Spain
| | - A M Alonso Torres
- Unidad de Esclerosis Múltiple, Servicio de Neurología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - E Moral Torres
- Servicio de Neurología, Complejo Hospitalario y Universitario Moisès Broggi, Barcelona, Spain
| | - J Río
- Servicio de Neurología, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - C Calles
- Servicio de Neurología, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - A Ares Luque
- Servicio de Neurología, Complejo Asistencial Universitario de León, León, Spain
| | - L Ramió-Torrentà
- Unitat de Neuroimmunologia i Esclerosi Múltiple Territorial de Girona (UNIEMTG), Hospital Universitari Dr. Josep Trueta y Hospital Santa Caterina. Grupo Neurodegeneració i Neuroinflamació, IDIBGI. Departamento de Ciencias Médicas, Universidad de Girona, Girona, Spain
| | - M E Marzo Sola
- Servicio de Neurología, Hospital San Pedro, Logroño, Spain
| | - J M Prieto
- Servicio de Neurología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - M L Martínez Ginés
- Servicio de Neurología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - R Arroyo
- Servicio de Neurología, Hospital Universitario Quirón Salud Madrid, Madrid, Spain
| | - M Á Otano Martínez
- Servicio de Neurología, Hospital Universitario de Navarra, Navarra, Spain
| | - L Brieva Ruiz
- Hospital Universitari Arnau de Vilanova, Universitat de Lleida, Lleida, Spain
| | - M Gómez Gutiérrez
- Servicio de Neurología, Hospital San Pedro de Alcántara, Cáceres, Spain
| | | | - V G Sánchez-Seco
- Servicio de Neurología, Hospital Universitario de Toledo, Toledo, Spain
| | - L Costa-Frossard
- CSUR de Esclerosis Múltiple, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Á Hernández Pérez
- Unidad de Esclerosis Múltiple, Servicio de Neurología, Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - L Landete Pascual
- Servicio de Neurología, Hospital Universitario Dr. Peset, Valencia, Spain
| | - M González Platas
- Servicio de Neurología, Hospital Universitario de Canarias, La Laguna, Spain
| | - C Oreja-Guevara
- Departamento de Neurología, Hospital Clínico San Carlos, IdISSC, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain
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3
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Wang Y, Wang J, Feng J. Multiple sclerosis and pregnancy: Pathogenesis, influencing factors, and treatment options. Autoimmun Rev 2023; 22:103449. [PMID: 37741528 DOI: 10.1016/j.autrev.2023.103449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 09/18/2023] [Indexed: 09/25/2023]
Abstract
Multiple sclerosis (MS) is an autoimmune-mediated degenerative disease of the central nervous system, characterized by inflammatory demyelination. It is primarily found in women of childbearing age, making pregnancy a significant concern for both patients with MS and clinicians. To assist these patients in achieving their desire for pregnancy, reducing MS relapses during all stages of pregnancy, preventing the progression of MS, mitigating the impact of MS treatment on the course and outcome of pregnancy, and a thorough understanding of the relationship between pregnancy and MS, as well as specific management and the application of relevant medications for MS patients at each stage of pregnancy, are essential. This article provides an update on pregnancy-related issues in women with MS, including the general recommendations for management at each stage of pregnancy.
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Affiliation(s)
- Yinxiang Wang
- Department of Neurology, Shengjing Hospital of China Medical University, 36 Sanhao St., Shenyang 110004, China
| | - Jue Wang
- Department of Neurology, Shengjing Hospital of China Medical University, 36 Sanhao St., Shenyang 110004, China
| | - Juan Feng
- Department of Neurology, Shengjing Hospital of China Medical University, 36 Sanhao St., Shenyang 110004, China.
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4
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Albahrani FA, Al Amer FA, AlSahaf FA, Alhamoud AA, Alshamrani F. The Effect of Multiple Sclerosis on Family Planning Among Saudi Families. Cureus 2023; 15:e49353. [PMID: 38024016 PMCID: PMC10670974 DOI: 10.7759/cureus.49353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2023] [Indexed: 12/01/2023] Open
Abstract
Background Multiple sclerosis (MS) is one of the most common neurological disorders in the world, and it is the leading cause of non-traumatic disability among young adults. While genetic susceptibility plays a role in MS development, the condition is not directly hereditary. Nevertheless, MS tends to aggregate within families, with first-degree relatives of affected individuals facing a higher risk than the general population. Additionally, family planning knowledge is insufficient among MS patients. Hence, this study aimed to assess the influence of MS disease on family planning and define the factors influencing decision-making regarding family planning in multiple sclerosis patients in the Eastern province of Saudi Arabia. Methodology A prospective study was conducted in Eastern Province, Saudi Arabia, during the period of 2022-2023 through directly interviewing the patients using a pre-validated questionnaire. This study would improve counseling and future care plans regarding family planning during patients' visits. Results A total of 57 women with MS were enrolled in this study; 35 (61.4%) patients got pregnant after the onset of the disease, and 46 (97.9%) had healthy children. A total of 23 (40.4%) were previously aborted due to the disease. Only five (8.8%) diseased women experienced relapses of the disease during previous pregnancies. A total of 14 (24.6%) women reported that generally their condition improved during pregnancy and childbirth, and 12 (21.1%) had no change, while four (7%) reported that their condition generally deteriorated. Also, 15 (26.3%) had no change in their condition during the first three months after birth, while four (7%) experienced deteriorated condition. Exactly 71.2% reported that the disease mostly affected their planning for pregnancy, which was of greater extent among 24.6% and partial among 14%. Conclusion Multiple sclerosis affects women's decisions regarding family planning. The most reported causes among affected women included anxiety about weakness and lack of strength during childbirth, concern about possible side effects from MS drugs on the fetus (congenital malformations), worry about not being able to take care of a child due to illness and the severe impact of the disease on their health.
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Affiliation(s)
| | | | | | | | - Foziah Alshamrani
- Neurology, King Fahad University Hospital, Al Khobar, SAU
- Neurology, Imam Abdulrahman Bin Faisal University, Al Khobar, SAU
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5
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Carbone L, Landi D, Di Girolamo R, Anserini P, Centonze D, Marfia GA, Alviggi C. Optimizing the "Time to pregnancy" in women with multiple sclerosis: the OPTIMUS Delphi survey. Front Neurol 2023; 14:1255496. [PMID: 37869135 PMCID: PMC10588727 DOI: 10.3389/fneur.2023.1255496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 08/22/2023] [Indexed: 10/24/2023] Open
Abstract
Background The debate on how to manage women affected by multiple sclerosis (MS) during reproductive age is still open, as is the issue of fertility in such patients. Main issue regard the identification of the optimal window for pregnancy and how to deal with medical therapy before and during conception. The aim of this Delphi consensus was to collect the opinions of a multidisciplinary group, involving reproductive medicine specialists and neurologists with experience in the management of multiple sclerosis women with reproductive desire. Methods Four experts plus scientific coordinators developed a questionnaire distributed online to 10 neurologists and later discussed the responses and amended a list of statements. The statements were then distributed via an online survey to 23 neurologists (comprising the first 10), who voted on their level of agreement/disagreement with each statement. Consensus was achieved if agreement or disagreement with a statement exceeded 66%. Results Twenty-one statements reached consensus after two rounds of voting, leading to the following main recommendations: (1) Fertility evaluation should be suggested to wMS, in case of the need to shorten time to pregnancy and before treatment switch in women on DMTs contraindicated in pregnancy, particularly in case of highly active disease and age > 35 years. (2) ART should not be discouraged in wMS, but the use of DMTs until pregnancy confirmation should be suggested; ART may be considered in order to reduce time to pregnancy in MS women with a reduced ovarian reserve and/or age > 35 years, but in case of an expected poor ART prognosis and the need for more than one ART cycle, a switch to a high-efficacy DMD before ART should be offered. (3) Oocyte cryopreservation may be considered in women with reduced ovarian reserve, with unpredictable time to complete diagnostic workup and achieve disease control; a risk/cost-benefit analysis must be performed in women >35 years, considering the diminished ovarian reserve. Conclusion This consensus will help MS neurologists to support family planning in wMS, respecting MS therapeutic needs while also taking into account the safety and impact of advancing age on fertility.
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Affiliation(s)
- Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, University Hospital of Rome Tor Vergata, Rome, Italy
| | - Raffaella Di Girolamo
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Paola Anserini
- UOS Physiopathology of Human Reproduction, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Diego Centonze
- Department of Systems Medicine, Laboratory of Synaptic Immunopathology, “Tor Vergata” University, Rome, Italy
- Unit of Neurology, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | | | - Carlo Alviggi
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
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6
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Moccia M, Affinito G, Fumo MG, Giordana R, Di Gennaro M, Mercogliano M, Carotenuto A, Petracca M, Lanzillo R, Triassi M, Brescia Morra V, Palladino R. Fertility, pregnancy and childbirth in women with multiple sclerosis: a population-based study from 2018 to 2020. J Neurol Neurosurg Psychiatry 2023; 94:689-697. [PMID: 37068930 DOI: 10.1136/jnnp-2022-330883] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/28/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND We aim to evaluate whether fertility, pregnancy, delivery and breastfeeding have been actually improving in women with multiple sclerosis (MS), compared with general population, and in relation to treatment features. METHODS We included 2018-2020 population-level healthcare data on women with MS living in the Campania region (Italy). Fertility, pregnancy and delivery outcomes were obtained from Certificate of Delivery Assistance; breastfeeding was collected up to 6 months after delivery by trained personnel. RESULTS Out of 2748 women with MS in childbearing age, 151 women delivered 156 babies. Fertility rate was 0.58 live births per woman with MS, compared with 1.29 in Campania region and 1.25 in Italy. Disease-modifying treatment (DMT) continuation during pregnancy was associated with lower birth weight (coeff -107.09; 95% CI -207.91 to -6.26; p=0.03). Exposure to DMTs with unknown/negative effects on pregnancy was associated with birth defects (OR 8.88; 95% CI 1.35 to 58.41; p=0.02). Birth defects occurred in pregnancies exposed to dimethyl fumarate (2/21 exposed pregnancies), fingolimod (1/11 exposed pregnancies) and natalizumab (2/30 exposed pregnancies). After delivery, 18.8% of women with MS were escalated of DMT efficacy, while 50.7% started on same/similar-efficacy DMTs, and 30.5% did not receive DMT. The probability of breastfeeding was higher in women who were treated with breastfeeding-safe DMTs (OR 5.57; 95% CI 1.09 to 28.55; p=0.03). CONCLUSIONS Fertility rate in women with MS remains below the general population. Family planning and subsequent DMT decisions should aim to achieve successful pregnancy, delivery and breastfeeding outcomes, while controlling disease activity.
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Affiliation(s)
- Marcello Moccia
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Napoli, Italy
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
| | - Giuseppina Affinito
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | | | - Roberta Giordana
- Campania Region Healthcare System Commissioner Office, Naples, Italy
| | - Massimo Di Gennaro
- Innovation and Data Analytics, Regional Healthcare Society (So.Re.Sa), Naples, Italy
| | | | - Antonio Carotenuto
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Maria Petracca
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
- Department of Human Neurosciences, Sapienza University, Rome, Italy
| | - Roberta Lanzillo
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Maria Triassi
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Raffaele Palladino
- Department of Public Health, University of Naples Federico II, Naples, Italy
- Department of Primary Care and Public Health, Imperial College, London, UK
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7
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Fragkoudi A, Rumbold AR, Grzeskowiak LE. Family planning and multiple sclerosis: A qualitative study of patient experiences to understand information needs and promote informed decision-making. PATIENT EDUCATION AND COUNSELING 2023; 110:107673. [PMID: 36812770 DOI: 10.1016/j.pec.2023.107673] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/17/2023] [Accepted: 02/11/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Ambiguity exists about the impact of multiple sclerosis (MS) on fertility and pregnancy. We explored female and male patients' experiences with MS regarding family planning to understand information needs and opportunities to improve informed decision-making. METHODS Semi-structured interviews were conducted with Australian female (n = 19) and male (n = 3) patients of reproductive age diagnosed with MS. Transcripts were analysed thematically, adopting a phenomenological approach. RESULTS Four main themes emerged: 'reproductive planning', revealing inconsistent experiences about pregnancy intention discussions with health care professionals (HCPs), and involvement in decisions about MS management and pregnancy; 'reproductive concerns', about the impact of the disease and its management; 'information awareness and accessibility', with participants generally reporting they had limited access to desired information and received conflicting information about family planning; and 'trust and emotional support', with continuity of care and engagement with peer-support groups about family planning needs valued. CONCLUSION Patients with MS want consistent engagement with HCPs regarding discussion of pregnancy intent and desire improvements in quality and accessibility of available resources and support services to address reproductive concerns. PRACTICE IMPLICATIONS Family planning conversations should be a part of routine care planning for MS patients and contemporary resources are required to support these discussions.
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Affiliation(s)
- Anna Fragkoudi
- Adelaide Medical School, University of Adelaide, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia.
| | - Alice R Rumbold
- Adelaide Medical School, University of Adelaide, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Luke E Grzeskowiak
- Adelaide Medical School, University of Adelaide, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia; College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Iyer P, Wiles K, Ismail A, Nanda S, Murray K, Hughes S, Ford HL, Pearson OR, White S, Bonham N, Hoyle N, Witts J, Middleton R, Brex PA, Rog D, Dobson R. Developing evidence-based guidelines for the safety of symptomatic drugs in multiple sclerosis during pregnancy and breastfeeding: A systematic review and Delphi consensus. Mult Scler 2023; 29:395-406. [PMID: 36740816 DOI: 10.1177/13524585221148094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is frequently diagnosed in people of reproductive age, many of whom will become pregnant following diagnosis. Although many women report an improvement in symptoms and relapses during pregnancy, symptoms such as fatigue and spasticity are commonly reported and can worsen. Prescribing medications during pregnancy and breastfeeding presents unique challenges and guidance on the use of symptomatic therapies is limited. OBJECTIVES This paper aims to provide a consensus on the current evidence base to facilitate informed decision-making and optimise pre-conception counselling. METHODS A list of most commonly prescribed medications for symptom management in MS was created using pregnancy and MS-related READ codes in the Welsh GP Dataset, followed by a review by MS neurologists. RESULTS A final list of 24 medications was generated for review. Searches were performed on each medication, and evidence graded using standardised criteria. Evidence-based recommendations were developed and distributed to experts in the field and revised according to feedback using modified Delphi criteria. CONCLUSIONS Our guidelines provide evidence-based recommendations on the safety of symptomatic therapies during pregnancy and breastfeeding for general practitioners and specialist teams working with people with MS who are hoping to embark on pregnancy or are currently pregnant. Individual risk-benefit ratios should be considered during pre-conception counselling to optimise symptom burden and minimise harm to both parent and child.
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Affiliation(s)
- Priyanka Iyer
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University of London (QMUL), London, UK
| | - Kate Wiles
- Department of Women's Health, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Azza Ismail
- Department of Neurology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Institute for Translational Neuroscience (SITraN), Sheffield, UK
| | - Surabhi Nanda
- Evelina Women's and Children's Team, King's College London, London, UK
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK / Department of Neurology, Forth Valley Royal Hospital, Larbert, UK
| | - Stella Hughes
- Department of Neurology, Belfast Health and Social Care Trust, Belfast, UK
| | - Helen L Ford
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK / School of Medicine, University of Leeds, Leeds, UK
| | - Owen R Pearson
- Department of Neurology, Morriston Hospital, Swansea, UK
| | - Sarah White
- Department of Neurology, St. George's Hospital NHS Foundation Trust, London, UK
| | - Nicola Bonham
- Department of Neurology, Forth Valley Royal Hospital, Larbert, UK
| | - Natasha Hoyle
- Department of Neurology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Institute for Translational Neuroscience (SITraN), Sheffield, UK
| | - James Witts
- UK MS Register, Swansea University, Swansea, UK
| | | | - Peter A Brex
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
| | - David Rog
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University of London (QMUL), London, UK / Department of Neurology, The Royal London Hospital, Barts Health NHS Trust, London, UK
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9
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Andersen ML, Jølving LR, Stenager E, Knudsen T, Nørgård BM. Maternal Multiple Sclerosis and Health Outcomes Among the Children: A Systematic Review. Clin Epidemiol 2023; 15:375-389. [PMID: 36969978 PMCID: PMC10035355 DOI: 10.2147/clep.s392273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/20/2023] [Indexed: 03/20/2023] Open
Abstract
Objective To summarize the available literature and provide an overview of in utero exposure to maternal multiple sclerosis (MS) and the influence on offspring health outcomes. Methods We conducted a systematic review by searching Embase, Medline and PubMed.gov databases, and we used covidence.org to conduct a thorough sorting of the articles into three groups; 1) women with MS and the influence on birth outcomes; 2) women with MS treated with disease-modifying therapy (DMT) during pregnancy and the influence on birth outcomes; and 3) women with MS and the influence on long-term health outcomes in the children. Results In total, 22 cohort studies were identified. Ten studies reported on MS without DMT and compared with a control group without MS, and nine studies on women with MS and DMT prior to or during pregnancy met the criteria. We found only four studies reporting on long-term child health outcomes. One study had results belonging to more than one group. Conclusion The studies pointed towards an increased risk of preterm birth and small for gestational age among women with MS. In terms of women with MS treated with DMT prior to or during pregnancy, no clear conclusions could be reached. The few studies on long-term child outcomes all had different outcomes within the areas of neurodevelopment and psychiatric impairment. In this systematic review, we have highlighted the research gaps on the impact of maternal MS on offspring health.
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Affiliation(s)
- Mette Louise Andersen
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Gynecology and Obstetrics, University Hospital of Southern Jutland, Esbjerg, Denmark
- Correspondence: Mette Louise Andersen, Center for Clinical Epidemiology, Odense University Hospital, Kloevervaenget 30, Entrance 216, Odense, DK- 5000, Denmark, Email
| | - Line Riis Jølving
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Egon Stenager
- Department of Regional Research, University of Southern Denmark, Odense, Denmark
- Multiple Sclerosis Clinic Hospital of Southern Jutland, Aabenraa, University of Southern Denmark, Odense, Denmark
| | - Torben Knudsen
- Department of Regional Research, University of Southern Denmark, Odense, Denmark
- Department of Gastroenterology, University Hospital of Southern Jutland, Esbjerg, Denmark
| | - Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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10
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Oreja-Guevara C, Rabanal A, Rodríguez CH, Benito YA, Bilbao MM, Gónzalez-Suarez I, Gómez-Palomares JL. Assisted Reproductive Techniques in Multiple Sclerosis: Recommendations from an Expert Panel. Neurol Ther 2023; 12:427-439. [PMID: 36746871 PMCID: PMC10043068 DOI: 10.1007/s40120-023-00439-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Multiple sclerosis (MS) is mainly diagnosed in women of reproductive age. However, there is a paucity of guidelines jointly prepared by neurologists and gynaecologists on managing women with MS and the desire for motherhood. Therefore, in this review we propose recommendations for such cases, with an particular focus on those requiring assisted reproductive techniques (ART). METHODS A group of seven MS experts (4 neurologists and 3 gynaecologists) came together for three discussion sessions to achieve consensus. RESULTS The recommendations reported here focus on the importance of early preconception counselling, the management of disease-modifying therapies before and during ART procedures, important considerations for women with MS regarding ART (intrauterine insemination, in vitro fertilisation and oocyte cryopreservation) and the paramount relevance of multidisciplinary units to manage these patients. CONCLUSIONS Early preconception consultations are essential to individualising pregnancy management in women with MS, and an early, well-planned, spontaneous pregnancy should be the aim whenever possible. The management of women with MS and the desire for motherhood by multidisciplinary units is warranted to ensure appropriate guidance through the entire pregnancy.
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Affiliation(s)
- Celia Oreja-Guevara
- Department of Neurology, Health Research Institute of the Hospital Clínico San Carlos (IdISSC), Hospital Clinico San Carlos, Madrid, Spain. .,Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Madrid, Spain.
| | - Aintzane Rabanal
- Human Reproduction Unit, Obstetrics and Gynaecology Department, Biocruces Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain
| | | | - Yolanda Aladro Benito
- Department of Neurology, Research Institute, Hospital Universitario de Getafe, Madrid, Spain
| | - Mar Mendibe Bilbao
- Neuroscience Department, Biocruces Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain
| | | | - José Luis Gómez-Palomares
- Wilson Fertiliy-Balearic Center for In Vitro Fertilization CEFIVBA-Wilson Fertility, Mallorca, Spain
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11
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Vukusic S, Carra-Dalliere C, Ciron J, Maillart E, Michel L, Leray E, Guennoc AM, Bourre B, Laplaud D, Androdias G, Bensa C, Bigaut K, Biotti D, Branger P, Casez O, Cohen M, Daval E, Deschamps R, Donze C, Dubessy AL, Dulau C, Durand-Dubief F, Guillaume M, Hebant B, Kremer L, Kwiatkowski A, Lannoy J, Maarouf A, Manchon E, Mathey G, Moisset X, Montcuquet A, Pique J, Roux T, Marignier R, Lebrun-Frenay C. Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society. Mult Scler 2023; 29:11-36. [PMID: 36317497 DOI: 10.1177/13524585221129472] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS). BACKGROUND MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues. METHODS The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence. RESULTS A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments. CONCLUSION The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.
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Affiliation(s)
- Sandra Vukusic
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Observatoire Français de la Sclérose en Plaques, Centre de Recherche en Neurosciences de Lyon, Bron, France/Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France/Eugène Devic EDMUS Foundation against Multiple Sclerosis, State-approved Foundation, Bron, France
| | | | - Jonathan Ciron
- Centre Ressources et Compétences sclérose en plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Elisabeth Maillart
- Neurology Department, Pitié-Salpêtrière Hospital, CRC-SEP, Paris, France
| | - Laure Michel
- Neurology Department, CIC_P1414 INSERM, Rennes University Hospital, Rennes, France
| | - Emmanuelle Leray
- EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS (Recherche sur les Services et Management en Santé) - U 1309, Université de Rennes, Rennes, France
| | | | | | - David Laplaud
- Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes Université and INSERM, Nantes, France/CIC INSERM 1413, CRC-SEP Pays de la Loire, CHU Nantes, Nantes, France
| | - Géraldine Androdias
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/Clinique de la Sauvegarde, Ramsay Santé, Lyon, France
| | - Caroline Bensa
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Kevin Bigaut
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Damien Biotti
- Centre Ressources et Compétences sclérose en plaques (CRC-SEP) et Service de Neurologie B4, Hôpital Pierre-Paul Riquet, CHU Toulouse Purpan, Toulouse, France INSERM UMR1291 - CNRS UMR5051, Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse 3, Toulouse, France
| | - Pierre Branger
- Service de Neurologie, CHU de Caen Normandie, Caen, France
| | - Olivier Casez
- Pathologies Inflammatoires du Système Nerveux, Neurologie, CHU Grenoble Alpes, Grenoble, France/Translational Research in Autoimmunity and Inflammation Group (T-RAIG), TIMC-IMAG, Université de Grenoble Alpes, Grenoble, France
| | - Mikael Cohen
- CRCSEP Côte d'Azur, CHU de Nice Pasteur 2, Nice, France/Université Nice Côte d'Azur UR2CA-URRIS, Nice, France
| | - Elodie Daval
- Service de Neurologie, CHU de Besançon, Besançon, France
| | - Romain Deschamps
- CRC-SEP, Neurology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Cécile Donze
- Hôpital saint Philibert, Groupement des Hôpitaux de l'Institut Catholique de Lille, Faculté de médecine et de maïeutique de Lille, Lomme, France
| | - Anne-Laure Dubessy
- Department of Neurology, Saint-Antoine Hospital, APHP-6, Paris, France/Sorbonne University, Paris, France
| | - Cécile Dulau
- CRC-SEP, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - Françoise Durand-Dubief
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
| | | | | | - Laurent Kremer
- CRC-SEP, Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Arnaud Kwiatkowski
- Department of Neurology, Lille Catholic Hospitals, Lille Catholic University, Lille, France
| | - Julien Lannoy
- Service de Neurologie, Centre Hospitalier de Lens, Lens, France
| | - Adil Maarouf
- CRMBM, UMR 7339, CNRS, Aix-Marseille Université, Marseille, France/APHM Hôpital de la Timone, Marseille, France
| | - Eric Manchon
- Department of Neurology, Gonesse Hospital, Gonesse, France
| | - Guillaume Mathey
- Service de neurologie, Centre Hospitalier Régional Universitaire de Nancy - Hôpital Central, Nancy, France
| | - Xavier Moisset
- Neuro-Dol, Inserm, Université Clermont Auvergne, Clermont-Ferrand, France/Department of neurology et CRC-SEP, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Julie Pique
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Centre de Recherche en Neurosciences de Lyon, Bron, France/Université Claude Bernard Lyon 1, Lyon, France
| | - Thomas Roux
- Neurology Department, Pitié-Salpêtrière Hospital, CRC-SEP, Paris, France
| | - Romain Marignier
- Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Service de Neurologie, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France/INSERM 1028 et CNRS UMR 5292, Centre de Recherche en Neurosciences de Lyon, Lyon, France/Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Christine Lebrun-Frenay
- Service de Neurologie, CHU de Besançon, Besançon, France/Université Nice Côte d'Azur UR2CA-URRIS, Nice, France
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Acosta-Martínez M, Chandran L, Cohen S, Biegon A. Design, Implementation, and Evaluation of an Intensive Course on Issues in Women's Health and Gender-Based Medicine. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2023; 10:23821205231203783. [PMID: 37744420 PMCID: PMC10517607 DOI: 10.1177/23821205231203783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 06/08/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVES Sex and gender have profound effects on disease prevalence, presentation, and outcome, but these issues are not covered in depth in standard medical school curricula. To improve understanding of women's health, an intensive 1-month class was offered to fourth-year medical students. METHODS The class combined background lectures on the biological and social determinants of women's health with presentations on specific medical conditions by practicing clinicians and students. Students' anonymous responses to end-of-class evaluation used by Stony Brook University School of Medicine as well as pre- and post-class answers to the question "why are women twice as likely to go to the doctor" were analyzed using quantitative, descriptive, and qualitative approaches. RESULTS The class was given between 2017 and 2022 to a total of 154 students. Course evaluations were submitted by 133 students. Over 80% of responders ranked the class as good or excellent and many expressed surprise about how much sex and gender influence health. Furthermore, before taking the class responders favored gender stereotypes (82%) and OB/GYN visits (56%) as the main reasons why women utilize healthcare more often than men, whereas only 31% of post-class answers included these factors (p < .0001), which were replaced by others including misdiagnosis, high rate of adverse effects of medications, implicit bias, and longevity. CONCLUSION A dedicated class given to students at the end of their undergraduate medical training increased awareness and knowledge of the effects of sex and gender on women's health.
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Affiliation(s)
- Maricedes Acosta-Martínez
- Department of Physiology & Biophysics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Latha Chandran
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
- Current address: Department of Medical Education, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Siobhan Cohen
- Department of Radiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Anat Biegon
- Department of Radiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
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Lowe P, Rowlands S. Long-acting reversible contraception: Targeting those judged to be unfit for parenthood in the United States and the United Kingdom. Glob Public Health 2022; 17:3773-3784. [PMID: 35239450 DOI: 10.1080/17441692.2022.2048408] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There is a long history of regarding marginalised groups as unfit to parent and of eugenic policies targeting those with 'undesirable' bodily conditions or behaviours. This is part of a broader pattern of stratified reproduction - structural conditions that enable or discourage certain groups from reproducing - that often brings about and exacerbates injustices. This paper critically assesses the US and UK social and medical literature on applying pressure to marginalised groups, or those who have behaved 'irresponsibly', to use long-acting reversible contraception (LARC). Targeting young people for LARC fails to recognise that social inequality is the context for teenage pregnancy, not the result of it. Provider pressure on women of colour to use LARC is linked to institutional racism, whilst policy for those with physical and intellectual disabilities is shaped by disability discrimination. Other groups to be targeted include so-called 'welfare mothers', substance users, those who have had children put into care and offenders. Particularly controversial are cases in which LARC has been ordered by courts. LARC policy incorporating these kind of discriminatory practices needs to stop; future policy should focus on person-centred care that bolsters reproductive justice.
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Affiliation(s)
- Pam Lowe
- Department of Sociology and Policy, Aston University, Birmingham, UK
| | - Sam Rowlands
- Department of Medical Science & Public Health, Bournemouth University, Bournemouth, UK
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14
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Meca-Lallana V, García Domínguez JM, López Ruiz R, Martín-Martínez J, Arés Luque A, Hernández Pérez MA, Prieto González JM, Landete Pascual L, Sastre-Garriga J. Expert-Agreed Practical Recommendations on the Use of Cladribine. Neurol Ther 2022; 11:1475-1488. [PMID: 36068429 PMCID: PMC9447968 DOI: 10.1007/s40120-022-00394-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/03/2022] [Indexed: 12/13/2022] Open
Abstract
Cladribine is a disease-modifying selective immune reconstitution oral therapy for adult patients with highly active relapsing multiple sclerosis (RMS). It was approved in the USA in 2019 and in Europe in 2017, thus there are still gaps in existing guidelines for using cladribine tablets in clinical practice. Nine experts with extensive experience in managing patients with multiple sclerosis in Spain identified some of the unanswered questions related to the real-life use of cladribine tablets. They reviewed the available clinical trial data and real-world evidence, including their own experiences of using cladribine, over the course of three virtual meetings held between November 2020 and January 2021. This article gathers their practical recommendations to aid treatment decision-making and optimise the use of cladribine tablets in patients with RMS. The consensus recommendations cover the following areas: candidate patient profiles, switching strategies (to and from cladribine), managing response to cladribine and safety considerations.
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Affiliation(s)
- Virginia Meca-Lallana
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitario "La Princesa", Madrid, Spain.
| | | | - Rocío López Ruiz
- Multiple Sclerosis Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | | | - Adrián Arés Luque
- Neurology Department, Complejo Asistencial Universitario de León, León, Spain
| | | | | | | | - Jaume Sastre-Garriga
- Neurology Department, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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15
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Marfia GA, Centonze D, Salvetti M, Ferraro E, Panetta V, Gasperini C, Mirabella M, Conte A. Bridging Therapies With Injectable Immunomodulatory Drugs in the Management of Multiple Sclerosis: A Delphi Survey of an Italian Expert Panel of Neurologists. Front Neurol 2022; 13:898741. [PMID: 35911920 PMCID: PMC9337240 DOI: 10.3389/fneur.2022.898741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/20/2022] [Indexed: 11/26/2022] Open
Abstract
Background In multiple sclerosis (MS), bridging therapies are usually administered when switching from one therapy to another. Such treatments generally consist of injectable immunomodulatory drugs (interferon or glatiramer acetate), whose efficacy, safety, and tolerability data are consolidated for use even in fragile patients. We performed a nationwide survey to gather expert opinions regarding the most appropriate use of bridging therapies in MS. Methods An independent steering committee of Italian neurologists with expertise in MS treatment identified critical issues in the use of bridging therapies and formulated a questionnaire. This questionnaire was used to conduct a Delphi web survey, involving a panel of Italian neurologists with experience in MS treatment. Their anonymous opinions were collected in three sequential rounds. Consensus was defined as an interquartile range (IQR) ≤2. Results Responses were obtained from 38 experts (100%) in all three rounds. Injectable immunomodulatory drugs were considered first-line therapy in patients with mild-to-moderate disease activity and in women planning to become pregnant. In addition, the experts were confident about prescribing these drugs in patients at risk of cancer recurrence, while the panel agreed to discontinue any treatments in patients with uncontrolled cardiovascular or metabolic disorders. Moreover, bridging therapy with injectable immunomodulatory drugs was considered appropriate in order to protect the patient from disease reactivation when a prolonged washout was needed and also while waiting for the completion of the immunization schedule. Conclusion The results of this nationwide survey confirm that, among Italian neurologists, there was wide agreement on the use of bridging therapies with injectable immunomodulatory drugs in several conditions in order to minimize the risk of disease reactivation when a prolonged washout was required or when the immunization schedule still needed to be completed in patients planning to become pregnant and in patients at risk of cancer recurrence.
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Affiliation(s)
- Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Diego Centonze
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
- Unit of Neurology, IRCCS Neuromed, Pozzilli, Italy
| | - Marco Salvetti
- Unit of Neurology, IRCCS Neuromed, Pozzilli, Italy
- Department of Neuroscience, Mental Health, and Sensory Organs, Sapienza University of Rome, Rome, Italy
| | - Elisabetta Ferraro
- ASL Rome1 P.O. San Filippo Neri U.O.C Neurologia -Centro Sclerosi Multipla, Rome, Italy
| | - Valentina Panetta
- L'AltraStatistica srl – Consultancy & Training, Biostatistics Office, Rome, Italy
| | - Claudio Gasperini
- Department of Neuroscience, S. Camillo Forlanini Hospital, Rome, Italy
| | - Massimiliano Mirabella
- Multiple Sclerosis Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Department of Neurosciences, Centro di Ricerca Sclerosi Multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy
- *Correspondence: Massimiliano Mirabella ; orcid.org/0000-0002-7783-114X
| | - Antonella Conte
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed, Pozzilli, Italy
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Houtchens M, Mahlanza T, Ciplea AI, Manieri MC, Ramia NF, Zhao Y, England S, Avila R, Altincatal A, Vignos M, Hellwig K. Peginterferon beta-1a concentrations in breast milk of lactating multiple sclerosis patients. Mult Scler Relat Disord 2022; 60:103700. [DOI: 10.1016/j.msard.2022.103700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/08/2022] [Accepted: 02/19/2022] [Indexed: 10/19/2022]
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Villaverde-González R. Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy. Degener Neurol Neuromuscul Dis 2022; 12:1-21. [PMID: 35023987 PMCID: PMC8743861 DOI: 10.2147/dnnd.s203406] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.
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Guarnaccia JB, Cabot A, Garten LL, Napoli S, Hasbani MJ. Teriflunomide levels in women whose male sexual partner is on teriflunomide for relapsing multiple sclerosis. Mult Scler Relat Disord 2022; 57:103347. [PMID: 35158456 DOI: 10.1016/j.msard.2021.103347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/05/2021] [Accepted: 10/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND For small molecules such as teriflunomide, used to treat relapsing multiple sclerosis (MS), that are potentially embryotoxic, there is a theoretical risk of transmission of the medication from males on the drug to female sexual partners. However, that risk has been undefined up to now. METHODS Teriflunomide concentrations were assayed concomitantly in ten sexually active couples, not using barrier methods of contraception, in whom the male partner with MS was on treatment with teriflunomide 14 mg daily for at least two months. These results were compared by male and female age, teriflunomide concentrations and reported average number of incidences of sexual intercourse per month. The threshold level of detection of teriflunomide was 0.020 µg/ml in females. RESULTS The average age of the cohort was 46.70 for males and 47.10 for females. Four of ten females had detectible teriflunomide concentrations (mean 0.046 µg/ml (range 0.22-0.077, standard deviation 0.025). Male age and both female teriflunomide positive threshold and female teriflunomide concentration were inversely correlated (r = 0.67, R2=0.45, p = 0.034) for the former and (r = 0.62, R2=0.39, p = 0.05, ns) for the latter. No significant correlations were observed for female age, male teriflunomide concentrations, or reported mean monthly episodes of sexual intercourse. CONCLUSION This limited study suggests that the small risk that low levels of teriflunomide can be transmitted from male to female partners via sexual intercourse is related to male age. This supports the recommendations found in the United States Product Insert (USPI) stating that men taking teriflunomide who do not wish to father a child, and their female partners, should use reliable contraception. Men wishing to father a child should discontinue use of teriflunomide and undergo an accelerated elimination procedure to reduce the plasma concentrations of the medication to less than 0.02 mg/L (0.02 µg/ml1.
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Affiliation(s)
| | - Ann Cabot
- MS Specialty Care Program, Concord Hospital, NH, United States
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19
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Saposnik G, Andhavarapu S, Fernández Ó, Kim HJ, Wiendl H, Foss M, Zuo F, Havrdová EK, Celius EG, Caceres F, Magyari M, Bermel R, Costa A, Terzaghi M, Kalincik T, Popescu V, Amato MP, Montalban X, Oh J. Effect of desire for pregnancy on decisions to escalate treatment in multiple sclerosis care: Differences between MS specialists and non-MS specialists. Mult Scler Relat Disord 2022; 57:103389. [PMID: 35158479 DOI: 10.1016/j.msard.2021.103389] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/24/2021] [Accepted: 11/07/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Therapeutic inertia (TI) is a worldwide phenomenon that affects 60 to 90% of neurologists and up to 25% of daily treatment decisions during management of multiple sclerosis (MS) patients. A large volume of MS patients are women of childbearing age, and desire for pregnancy is a complex variable often affecting MS care. The objective of this study was to determine the effect of desire for pregnancy on decisions to escalate treatment during management of MS patients. METHODS 300 neurologists with expertise in MS from 20 countries were invited to participate in the study. Participants were presented with 12 pairs of simulated MS patient profiles reflective of case scenarios encountered in clinical practice. Participants were asked to select the ideal candidate for treatment escalation from modest to higher-efficacy therapies. Disaggregated discrete choice experiments were used to estimate the weight of factors and attributes affecting physicians' decisions when considering treatment selection. An excel calculator that provides estimates as the percentage of participants that would escalate treatment for a simulated case-scenario was constructed. RESULTS 229 (76.3%) completed the study. The mean age (SD) of study participants was 44 (±10) years. The mean (SD) number of MS patients seen per month by each neurologist was 18 (±16). Non-MS specialists were significantly less likely to escalate treatment than MS specialists across mild, moderate, and severe patient cases. These differences were accentuated when case scenarios introduced a desire for pregnancy. The findings were consistent when MRI-lesions, severity of symptoms, and number of relapses were included. CONCLUSIONS Desire for pregnancy differentially influences decisions to escalate treatment, suggesting knowledge-to-action gaps between MS and non-MS specialists. Our findings indicate the need for educational strategies to overcome these gaps and improve clinical outcomes for MS patients who desire pregnancy.
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Affiliation(s)
- Gustavo Saposnik
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Canada; Zurich Center for Neuroeconomics (ZNE), Department of Economics, University of Zurich, Switzerland; Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada.
| | - Sanketh Andhavarapu
- Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Óscar Fernández
- Department of Pharmacology, Faculty of Medicine, University of Malaga, Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, Spain
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea (the Republic of)
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Germany
| | - Mona Foss
- Bootstrap Analytics, Calgary, Canada
| | - Fei Zuo
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
| | - Eva Kubala Havrdová
- Department of Neurology and Center for Clinical Neuroscience, First Medical Faculty, Charles University in Prague, Prague, Czech Republic
| | - Elisabeth Gulowsen Celius
- Department of Neurology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Fernando Caceres
- Institute of Restorative Neurosciences (INERE), Buenos Aires, Argentina
| | - Melinda Magyari
- Danish Multiple Sclerosis Center, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Robert Bermel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, United States
| | - Andreia Costa
- Neurology Department, Centro Hospitalar Universitário São João, Faculty of Medicine University of Porto, Portugal
| | - Maria Terzaghi
- Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
| | - Tomas Kalincik
- MS Centre, Royal Melbourne Hospital, Melborne, Australia; CORe, Department of Medicine, University of Melbourne, SA
| | - Veronica Popescu
- University MS Centre, Noorderhart Hospital, Pelt, Belgium; Hasselt University, Hasselt, Belgium
| | - Maria Pia Amato
- Department NEUROFARBA, University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Xavier Montalban
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Canada; Department of Neurology. Cemcat. Hospital Vall d´Hebron. Universitat Autonoma de Barcelona. Spain
| | - Jiwon Oh
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
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20
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Coyle PK. What Can We Learn from Sex Differences in MS? J Pers Med 2021; 11:1006. [PMID: 34683148 PMCID: PMC8537319 DOI: 10.3390/jpm11101006] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/26/2021] [Indexed: 01/05/2023] Open
Abstract
Multiple sclerosis (MS) is the major acquired central nervous system disease of young adults. It is a female predominant disease. Multiple aspects of MS are influenced by sex-based differences. This has become an important area of research and study. It teaches us how the impact of sex on a disease can lead to new insights, guidelines, management, and treatments.
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Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University, Stony Brook, NY 11794, USA
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21
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Alonso R, Patrucco L, Silva B, Quarracino C, Eizaguirre MB, Vrech C, López P, Carnero Contentti E, Deri N, Carrá A, Chercorff A, Tkachuk V, Balbuena ME, Pettinicchi JP, Tavolini D, Barboza A, Rojas JI, Cristiano E, Lázaro L, Garcea O, Fernández Liguori N. Family planning in Argentinian women with multiple sclerosis: An important yet seldom approached issue. Mult Scler J Exp Transl Clin 2021; 7:20552173211025312. [PMID: 34211724 PMCID: PMC8216353 DOI: 10.1177/20552173211025312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/26/2021] [Indexed: 12/02/2022] Open
Abstract
Background The purpose of this study was to assess family planning (FP) among women with multiple sclerosis (WwMS). Methods We invited 604 WwMS to answer a survey focused on FP: a) Temporal relationship between pregnancy and the diagnosis of multiple sclerosis; b) History of FP; c) Childbearing desire; d) Information on family planning. Comparisons between pregnancy and not pregnancy after MS, as well as, planned and unplanned pregnancy were analyzed. Multivariate and univariate analyses were used to assess the impact of independent variables and FP Result 428 (71.7%) WwMS completed the survey. A 19.1% got pregnant after MS diagnosis and we evaluated FP in the last pregnancy, 56.1% patients had a planned pregnancy. Professional addressing FP (OR = 0.27, 95%-CI 0.08-0.92, p = 0.03) and non-injection drug treatment before pregnancy (OR = 2.88, 95%-CI 1.01-8.21, p = 0.047) were independent predictors of unplanned pregnancy in our multivariate model. Among WwMS ≤ 40 years, 48.7% had future childbearing desire. Young age (p < 0.001), PDDS <3 (p = 0.018), disease duration <5 years (p = 0.02), not childbearing before MS diagnosis (p < 0.001) and neurologist addressing family planning (p = 0.01) were significantly associated with childbearing desire. Conclusions This research highlights that pregnancy remains an important concern among WwMS.
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Affiliation(s)
- Ricardo Alonso
- Servicio de Neurología, Sanatorio Güemes, Buenos Aires, Argentina
| | - Liliana Patrucco
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Berenice Silva
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Facultad de Medicina - UBA, Buenos Aires, Argentina
| | - Cecilia Quarracino
- Servicio de Neurología. Instituto Alfredo Lanari, Hospital Universitario, Buenos Aires, Argentina
| | - María Barbara Eizaguirre
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Facultad de Medicina - UBA, Buenos Aires, Argentina
| | - Carlos Vrech
- Departamento de Enfermedades desmielinizantes, Sanatorio Allende, Córdoba, Argentina
| | - Pablo López
- Neuroimmunology Unit, Department of Neuroscience, Hospital Alemán, Buenos Aires, Argentina
| | | | - Norma Deri
- Centro de Investigaciones Diabaid, Buenos Aires, Argentina
| | - Adriana Carrá
- Sección de Enfermedades Desmielinizantes, Hospital Británico, Buenos Aires, Argentina
| | - Aníbal Chercorff
- Sección de Enfermedades Desmielinizantes, Hospital Británico, Buenos Aires, Argentina
| | - Verónica Tkachuk
- Sección de Esclerosis Múltiple y Enfermedades Desmielinizantes, Servicio de Neurología, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - María Eugenia Balbuena
- Sección de Esclerosis Múltiple y Enfermedades Desmielinizantes, Servicio de Neurología, Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Juan Pablo Pettinicchi
- Neuroimmunology Unit, Department of Neuroscience, Hospital Alemán, Buenos Aires, Argentina
| | | | | | - Juan I Rojas
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Edgardo Cristiano
- Centro de Esclerosis Múltiple de Buenos Aires, Buenos Aires, Argentina
| | - Luciana Lázaro
- Servicio de Neurología, Sanatorio Güemes, Buenos Aires, Argentina
| | - Orlando Garcea
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Facultad de Medicina - UBA, Buenos Aires, Argentina
| | - Nora Fernández Liguori
- Servicio de Neurología, Sanatorio Güemes, Buenos Aires, Argentina.,Servicio de Neurología. Hospital Enrique Tornú, Buenos Aires, Argentina
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22
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Bonavita S, Lavorgna L, Worton H, Russell S, Jack D. Family Planning Decision Making in People With Multiple Sclerosis. Front Neurol 2021; 12:620772. [PMID: 33995240 PMCID: PMC8113643 DOI: 10.3389/fneur.2021.620772] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/06/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: The majority of people diagnosed with MS are of childbearing or child fathering age, therefore family planning is an important issue for both women and men with MS. Fertility and the course of pregnancy are not affected by MS; however, people with MS (pwMS) may have concerns that there will be a greater risk of complications to the mother and/or adverse pregnancy outcomes either due to the disease or to ongoing medication. This survey aimed to understand family planning decision making in pwMS and related unmet educational needs. Methods: A total of 332 pwMS across the USA, UK, France, Germany, Italy, and Spain were recruited from a specialist patient panel agency to participate in a smartphone-enabled standing panel. The 80-question survey focussed on decision making and information sources for pwMS regarding family planning, as well as behavior during and after pregnancy. Male patients with MS did not respond to specific questions on pregnancy. Survey results were directly compared with the 2016 US and 2010 UN census data. Results: pwMS were more likely to have no children than the general population, particularly in the subgroup of patients aged 36–45 years. A total of 56% of pwMS reported that the disease affected, with different degrees of impact, their family planning decision making. Of these, 21% significantly changed their plans for timing of pregnancy and the number of children, and 14% decided against having children. Participants indicated that healthcare professionals were the primary source of information on family planning (81% of responses). The timing of planned pregnancy was not considered when selecting treatment by 78% of participants. Conclusion: MS was found to significantly impact family planning decision making, with pwMS significantly less likely to have children in comparison with the general population.
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Affiliation(s)
- Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy.,Neurological Institute for Diagnosis and Care "Hermitage Capodimonte," Naples, Italy
| | - Luigi Lavorgna
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | | | - Susan Russell
- EMD Serono Research & Development Institute, Inc., Billerica, MA, United States.,Merck KGaA, Darmstadt, Germany
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23
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Vermersch P, Oh J, Cascione M, Oreja-Guevara C, Gobbi C, Travis LH, Myhr KM, Coyle PK. Teriflunomide vs injectable disease modifying therapies for relapsing forms of MS. Mult Scler Relat Disord 2020; 43:102158. [DOI: 10.1016/j.msard.2020.102158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/24/2020] [Accepted: 04/26/2020] [Indexed: 02/08/2023]
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24
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Andersen JB, Magyari M. Pharmacotherapeutic considerations in women with multiple sclerosis. Expert Opin Pharmacother 2020; 21:1591-1602. [PMID: 32521172 DOI: 10.1080/14656566.2020.1774554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Multiple sclerosis (MS) is a chronically progressive disease of the central nervous system. The relapsing form of the disease predominantly affects women with onset between the ages 20 to 40 years. Therefore, timing, choice, and treatment options should take pregnancy planning into consideration to accommodate both the needs and safety of the mother and health of the fetus. AREAS COVERED In this review, the authors discuss and summarize the recent evidence of different pharmacotherapeutic possibilities in the treatment of women with MS. EXPERT OPINION There is evidence that disease modifying therapy reduces the risk of relapses and diminishes disability progression in people with relapsing MS. The disease is often diagnosed in the childbearing years, and thus pregnancy planning can possibly be a part of the pharmacotherapeutic considerations. The management of women planning pregnancy requires a balancing of risks. The clinician must consider the risks related to treatment discontinuation versus the risk of exposing the developing fetus to drugs that are potential fetotoxic. Randomized controlled trials of medication safety - if used during pregnancy, are prohibited for ethical reasons; hence, the evidence is continuously gathered from observational data, post-authorization studies and pregnancy registries.
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Affiliation(s)
- Johanna B Andersen
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark
| | - Melinda Magyari
- Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark.,Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital , Copenhagen, Denmark
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25
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Liguori NF, Alonso R, Pinheiro AA, Balbuena ME, Barboza A, Bestoso S, Burgos M, Cáceres F, Carnero Contentti E, Carrá A, Cristiano E, Curbelo MC, Deri N, Fiol M, Gaitán MI, Garcea O, Halfon M, Hryb J, Jacobo M, José G, Knorre E, López P, Luetic G, Mainella C, Martínez A, Miguez J, Nofal P, Pagani Cassará F, Marcilla MP, Piedrabuena R, Pita C, Quarracino C, Rojas JI, Silva B, Sinay V, Steinberg J, Tarulla A, Tavolini D, Tkachuk V, Tizio S, Villa A, Vrech C, Ysrraelit C, Patrucco L. Consensus recommendations for family planning and pregnancy in multiple sclerosis in argentina. Mult Scler Relat Disord 2020; 43:102147. [PMID: 32442883 DOI: 10.1016/j.msard.2020.102147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/30/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) is the most common chronic immune-mediated neurological disorder in young adults, more frequently found in women than in men. Therefore, pregnancy-related issues have become an object of concern for MS professionals and patients. The aim of this work was to review the existing data to develop the first Argentine consensus for family planning and pregnancy in MS patients. METHODS A panel of expert neurologists from Argentina engaged in the diagnosis and care of MS patients met both virtually and in person during 2019 to carry out a consensus recommendation for family planning and pregnancy in MS. To achieve consensus, the procedure of the "formal consensus-RAND/UCLA method" was used. RESULTS Recommendations were established based on published evidence and expert opinion focusing on pre-pregnancy counseling, pregnancy, and postpartum issues. CONCLUSION The recommendations of these consensus guidelines are intended to optimize the management and treatment of MS patients during their reproductive age in Argentina.
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Affiliation(s)
- Nora Fernández Liguori
- Hospital Universitario Sanatorio Güemes, Buenos Aires, Argentina; Sección Neurología, Hospital Enrique Tornú, Buenos Aires, Argentina.
| | - Ricardo Alonso
- Hospital Universitario Sanatorio Güemes, Buenos Aires, Argentina; Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | | | - María E Balbuena
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología, Hospital de Clínicas José de San Martín, Argentina
| | | | | | | | | | | | - Adriana Carrá
- Fundación Favaloro/INECO, Buenos Aires, Argentina; MS Section Hospital Británico, Buenos Aires, Argentina
| | | | | | - Norma Deri
- Centro de Investigaciones Diabaid, Argentina; Hospital Fernández de Buenos Aires, Argentina
| | - Marcela Fiol
- Department of Neurology, Institute for Neurological Research Dr Raul Carrea, FLENI, Argentina
| | - María I Gaitán
- Department of Neurology, Institute for Neurological Research Dr Raul Carrea, FLENI, Argentina
| | - Orlando Garcea
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | | | - Javier Hryb
- Servicio de Neurología, Hospital Carlos G. Durand, CABA
| | - Miguel Jacobo
- RIAPEM (Red Integral Asistencial al Paciente con EM), Santiago del Estero, Argentina
| | - Gustavo José
- Servicio de Neurología, Hospital Ángel Padilla, Tucumán, Argentina
| | - Eduardo Knorre
- Servicio de Neurología, Hospital Teodoro Álvarez, Buenos Aires, Argentina
| | - Pablo López
- Department of Neuroscience - Neuroimmunology Unit, Hospital Alemán, Buenos Aires, Argentina
| | | | | | | | | | - Pedro Nofal
- Hospital de Clínicas Ntra. Sra. del Carmen, San Miguel de Tucumán, Argentina
| | | | | | | | - Cecilia Pita
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | - Cecilia Quarracino
- Departamento de neurología, Instituto de Investigaciones Médicas Alfredo Lanari
| | - Juan I Rojas
- Centro de Esclerosis Múltiple de Buenos Aires, Argentina
| | - Berenice Silva
- Centro Universitario de Esclerosis Múltiple, Hospital Dr. J. M. Ramos Mejía, Buenos Aires, Argentina
| | | | | | - Adriana Tarulla
- Hospital de Agudos Parmenio Piñero, Municipalidad de Ciudad de Buenos Aires, MCBA, Argentina
| | - Darío Tavolini
- INECO Neurociencias Oroño. Fundación INECO Rosario, Argentina
| | - Verónica Tkachuk
- Sección de Neuroinmunología y Enfermedades Desmielinizantes, Servicio de Neurología, Hospital de Clínicas José de San Martín, Argentina
| | - Santiago Tizio
- Departamento de Neurología, Hospital Italiano y Español de La Plata, Argentina
| | - Andrés Villa
- Sección Neuroinmunología, Hospital Ramos Mejía, Buenos Aires, Argentina
| | - Carlos Vrech
- Departamento de Enfermedades desmielinizantes, Sanatorio Allende Córdoba, Argentina
| | - Célica Ysrraelit
- Department of Neurology, Institute for Neurological Research Dr Raul Carrea, FLENI, Argentina
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26
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Lopez-Leon S, Geissbühler Y, Sabidó M, Turkson M, Wahlich C, Morris JK. A systematic review and meta-analyses of pregnancy and fetal outcomes in women with multiple sclerosis: a contribution from the IMI2 ConcePTION project. J Neurol 2020; 267:2721-2731. [PMID: 32444984 PMCID: PMC7419441 DOI: 10.1007/s00415-020-09913-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/05/2023]
Abstract
Neurologists managing women with Multiple Sclerosis (MS) need information about the safety of disease modifying drugs (DMDs) during pregnancy. However, this knowledge is limited. The present study aims to summarize previous studies by performing a systematic review and meta-analyses. The terms "multiple sclerosis" combined with DMDs of interest and a broad profile for pregnancy terms were used to search Embase and Medline databases to identify relevant studies published from January 2000 to July 2019.1260 studies were identified and ten studies met our inclusion criteria. Pooled risk ratios (RR) of pregnancy and birth outcomes in pregnancies exposed to DMDs compared to those not exposed were calculated using a random effects model. For spontaneous abortion RR = 1.14, 95% CI 0.99-1.32, for preterm births RR = 0.93, 95% CI 0.72-1.21 and for major congenital malformations RR = 0.86, 95% CI 0.47-1.56. The most common major congenital malformations reported in MS patients exposed to MS drugs were atrial septal defect (ASD) (N = 4), polydactyly (N = 4) and club foot (N = 3), which are among the most prevalent birth defects observed in the general population. In conclusion, interferons, glatiramer acetate or natalizumab, do not appear to increase the risk for spontaneous abortions, pre-term birth or major congenital malformations. There were very few patients included that were exposed to fingolimod, azathioprine and rituximab; therefore, these results cannot be generalized across drugs. Future studies including internal comparators are needed to enable treating physicians and their patients to decide on the best treatment options.
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Affiliation(s)
- Sandra Lopez-Leon
- Novartis Pharmaceuticals Corporation, One Health Plaza, Building 339-1131, East Hanover, NJ, 07936-1080, USA.
| | | | | | | | - Charlotte Wahlich
- Population Health Research Institute, St George's, University of London, London, UK
| | - Joan K Morris
- Population Health Research Institute, St George's, University of London, London, UK.
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Vorobeychik G, Black D, Cooper P, Cox A. Multiple sclerosis and related challenges to young women's health: Canadian expert review. Neurodegener Dis Manag 2020; 10:1-13. [PMID: 32372725 DOI: 10.2217/nmt-2020-0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Multiple sclerosis (MS) is among the most common chronic neurological diseases, with a highly variable degree of disability during its long-term course. The majority of patients develop significant permanent disability later in life. MS is often diagnosed in women of childbearing age, with a 3:1 ratio of young women to young men with MS. Comorbidities such as depression, anxiety, migraines and reproductive, urological and bowel issues are common and negatively impact patients' quality of life. The objective of this supplement is to review the most common comorbidities occurring in young women with MS, and to propose a multidisciplinary, holistic approach to management.
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Affiliation(s)
- Galina Vorobeychik
- Department of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9.,Fraser Health Multiple Sclerosis Clinic, Burnaby Hospital, Burnaby, BC V5G 2X6
| | - Denise Black
- Seine River Medical Centre, Winnipeg, MB R2N 0A5
| | - Paul Cooper
- Department of Clinical Neurological Sciences, Western University, London, ON N6A 3K7.,Schulich School of Medicine & Dentistry, London, ON N6A 5C1
| | - Ashley Cox
- Department of Urology, Dalhousie University, Halifax, NS B3H 1Y6
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28
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Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations. Can J Neurol Sci 2020; 47:437-455. [DOI: 10.1017/cjn.2020.66] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract:The Canadian Multiple Sclerosis Working Group has updated its treatment optimization recommendations (TORs) on the optimal use of disease-modifying therapies for patients with all forms of multiple sclerosis (MS). Recommendations provide guidance on initiating effective treatment early in the course of disease, monitoring response to therapy, and modifying or switching therapies to optimize disease control. The current TORs also address the treatment of pediatric MS, progressive MS and the identification and treatment of aggressive forms of the disease. Newer therapies offer improved efficacy, but also have potential safety concerns that must be adequately balanced, notably when treatment sequencing is considered. There are added discussions regarding the management of pregnancy, the future potential of biomarkers and consideration as to when it may be prudent to stop therapy. These TORs are meant to be used and interpreted by all neurologists with a special interest in the management of MS.
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29
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Oreja-Guevara C. Family planning is the second most relevant factor for treatment decisions after disease activity - No. Mult Scler 2020; 26:642-643. [PMID: 32081082 DOI: 10.1177/1352458520902343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain/Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid (UCM), IdISSC, Madrid, Spain
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30
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Varytė G, Zakarevičienė J, Ramašauskaitė D, Laužikienė D, Arlauskienė A. Pregnancy and Multiple Sclerosis: An Update on the Disease Modifying Treatment Strategy and a Review of Pregnancy's Impact on Disease Activity. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E49. [PMID: 31973138 PMCID: PMC7074401 DOI: 10.3390/medicina56020049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 12/17/2019] [Accepted: 01/16/2020] [Indexed: 01/28/2023]
Abstract
Pregnancy rates are rapidly increasing among women of reproductive age diagnosed with multiple sclerosis (MS). Through pre-conception, pregnancy and post-partum periods, there is a need for disease control management, to decrease chances of MS relapses while avoiding potential risks to the mother and the fetus. However, pregnancy is not always compatible with the available highly effective MS treatments. This narrative review provides the aspects of pregnancy's outcomes and the impact on disease activity, choices of anesthesia and the management of relapses during the pregnancy and breastfeeding period. Available disease modifying treatment is discussed in the article with new data supporting the strategy of continuing natalizumab after conception, as it is related to a decreased risk of MS relapses during the pregnancy and postpartum period.
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Affiliation(s)
- Guoda Varytė
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
| | - Jolita Zakarevičienė
- Clinic of Obstetrics and Gynaecology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (J.Z.); (D.R.); (D.L.); (A.A.)
| | - Diana Ramašauskaitė
- Clinic of Obstetrics and Gynaecology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (J.Z.); (D.R.); (D.L.); (A.A.)
| | - Dalia Laužikienė
- Clinic of Obstetrics and Gynaecology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (J.Z.); (D.R.); (D.L.); (A.A.)
| | - Audronė Arlauskienė
- Clinic of Obstetrics and Gynaecology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (J.Z.); (D.R.); (D.L.); (A.A.)
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Brussé IA, Kluivers ACM, Zambrano MD, Shetler K, Miller EC. Neuro-obstetrics: A multidisciplinary approach to care of women with neurologic disease. HANDBOOK OF CLINICAL NEUROLOGY 2020; 171:143-160. [PMID: 32736747 DOI: 10.1016/b978-0-444-64239-4.00007-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The term "neuro-obstetrics" refers to a multidisciplinary approach to the care of pregnant women with neurologic comorbidities, both preconceptionally and throughout pregnancy. General preconception care should be offered to all women, including women with neurologic disease. Women with neurologic comorbidities should also be offered specialist preconception care by an obstetrician who consults with a neurologist, anesthesiologist, and if indicated clinical geneticist and/or other specialists. In women with neurologic comorbidities, neurologic sequelae may influence the course of the pregnancy and delivery. Also, pregnancy may influence the severity of the neurologic condition, depending on the type of disease. Physiologic adaptations during pregnancy and altered pharmacokinetics may cause altered blood serum levels of drugs, leading to decreased or increased drug effects. When administering drugs to a woman who wishes to conceive, it is important to consider possible teratogenic effects and possible secretion in breast milk. Tailoring medication regimens should be considered, preferably preconceptionally. In this chapter, we review general principles of neuro-obstetric care, as well as some specific considerations for neurologists, obstetricians, and anesthesiologists caring for pregnant women with common neurologic conditions.
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Affiliation(s)
- Ingrid A Brussé
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Anna C M Kluivers
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maria D Zambrano
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Kara Shetler
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States
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