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Portaccio E, Annovazzi P, Ghezzi A, Zaffaroni M, Moiola L, Martinelli V, Lanzillo R, Brescia Morra V, Rinaldi F, Gallo P, Tortorella C, Paolicelli D, Pozzilli C, De Giglio L, Cavalla P, Cocco E, Marrosu MG, Patti F, Solaro C, Bellantonio P, Uccelli A, Laroni A, Pastò L, Giannini M, Trojano M, Comi G, Amato MP. Pregnancy decision-making in women with multiple sclerosis treated with natalizumab: I: Fetal risks. Neurology 2018; 90:e823-e831. [PMID: 29438046 DOI: 10.1212/wnl.0000000000005067] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/16/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess fetal risk after pregnancy exposure to natalizumab in women with multiple sclerosis (MS), with a specific focus on spontaneous abortion (SA) and congenital anomalies (CA). METHODS Data of all pregnancies occurring between 2009 and 2015 in patients with MS treated with natalizumab and referring to 19 participating sites were collected and compared with those of pregnancies in untreated patients and patients treated with injectable immunomodulatory agents. Rates of SA and CA were also compared with those reported in the Italian population. Multivariable logistic and linear regression models were performed. RESULTS A total of 92 pregnancies were tracked in 83 women. In the multivariable analysis, natalizumab exposure was associated with SA (odds ratio [OR] 3.9, 95% confidence interval [CI] 1.9-8.5, p < 0.001). However, the rate of SA (17.4%) was within the estimates for the general population, as well as the rate of major CA (3.7%). Moreover, exposure to natalizumab and interferon-β (IFN-β) was associated with lower length and weight of the babies (p < 0.001). CONCLUSION Our results showed that natalizumab exposure to up 12 weeks of gestation is associated with an increased risk of SA, although within the limits expected in the general population, whereas the risk of CA needs further investigation. Taking into account the high risk of disease reactivation after natalizumab suspension, pregnancy could be planned continuing natalizumab while strictly monitoring conception. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that in women with MS, natalizumab exposure increases the risk of spontaneous abortion as compared to IFN-β-exposed or untreated patients (OR 3.9, 95% CI 1.9-8.5).
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Affiliation(s)
- Emilio Portaccio
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy.
| | - Pietro Annovazzi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Angelo Ghezzi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Mauro Zaffaroni
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Lucia Moiola
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Vittorio Martinelli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Roberta Lanzillo
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Vincenzo Brescia Morra
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Francesca Rinaldi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Paolo Gallo
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Carla Tortorella
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Damiano Paolicelli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Carlo Pozzilli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Laura De Giglio
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Paola Cavalla
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Eleonora Cocco
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Maria Giovanna Marrosu
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Francesco Patti
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Claudio Solaro
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Paolo Bellantonio
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Antonio Uccelli
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Alice Laroni
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Luisa Pastò
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Marta Giannini
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Maria Trojano
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Giancarlo Comi
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
| | - Maria Pia Amato
- From IRCCS Don Gnocchi Foundation (E.P.), Florence; Multiple Sclerosis Study Center (P.A., A.G., M.Z.), ASST Valle Olona, Gallarate Hospital (VA); Scientific Institute University Vita-Salute San Raffaele (L.M., V.M., G.C.), Milan; Department of Neurosciences, Reproductive and Odontostomatological Sciences (R.L., V.B.M.), Federico II University of Naples; Department of Neurosciences (F.R., P.G.), Multiple Sclerosis Centre-Veneto Region (CeSMuV), University Hospital of Padova; Department of Neurology (C.T., D.P., M.T.), University of Bari; Department of Neurology and Psychiatry (C.P., L.D.G.), "La Sapienza" University, Rome; Department of Neurology (P.C.), University of Torino; Department of Medical Sciences and Public Health (E.C., M.G.M.), University of Cagliari; Department of Neurology (F.P.), University of Catania; Department of Neurology (C.S.), ASL3 Genovese; Multiple Sclerosis Center (P.B.), IRCCS Neuromed, Pozzilli; Department of Neurology (A.U., A.L.), University of Genova; and Department of NEUROFARBA (L.P., M.G., M.P.A.), University of Florence, Italy
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