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Stampas A, Patel A, Luthra K, Dicks M, Korupolu R, Neshatian L, Triadafilopoulos G. How Can We Treat If We Do Not Measure: A Systematic Review of Neurogenic Bowel Objective Measures. Top Spinal Cord Inj Rehabil 2024; 30:10-40. [PMID: 39139772 PMCID: PMC11317643 DOI: 10.46292/sci23-00065] [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] [Indexed: 08/15/2024]
Abstract
Background Guidelines fail to recommend objective measures to assist with treatment of neurogenic bowel dysfunction (NBD) in spinal cord injury (SCI). Objectives The main objective was to review the literature to identify the objective measures used in all NBD populations and to present their results and any correlations performed to validated subjective measures. Methods A systematic review of the literature was performed in accordance with PRISMA (2020) guidelines, including all records from January 2012 to May 2023 with MeSH terms like "neurogenic bowel" indexed in the following databases: PubMed, EMBASE, CINAHL, Cochrane Central Trials Register, and ClinicalTrials.gov. Abstracts were excluded if they did not include objective measures or if they only mentioned the esophagus, stomach, and/or small bowel. Records were screened independently by at least two collaborators, and differences were resolved by unanimous agreement. Results There were 1290 records identified pertaining to NBD. After duplicates were removed, the remaining records were screened for a total of 49 records. Forty-one records (82%) included subjective measures. Two-thirds of the articles involved the population with SCI/disease (n = 552) and one-third were non-SCI NBD (n = 476). Objective measures were categorized as (1) transit time, (2) anorectal physiology testing, and (3) miscellaneous. Of the 38 articles presenting results, only 16 (42%) performed correlations of objective measures to subjective measures. Conclusion There is an abundance of literature supporting the use of objective outcome measures for NBD in SCI. Strong correlations of subjective measures to objective outcome measures were generally lacking, supporting the need to use both measures to help with NBD management.
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Affiliation(s)
- Argy Stampas
- Department of PM&R, UTHealth McGovern Medical School, Houston, Texas
- TIRR Memorial Hermann, Houston, Texas
| | - Amisha Patel
- Texas A&M University School of Medicine, College Station, Texas
| | - Komal Luthra
- Department of PM&R, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Radha Korupolu
- Department of PM&R, UTHealth McGovern Medical School, Houston, Texas
- TIRR Memorial Hermann, Houston, Texas
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California
| | - George Triadafilopoulos
- Department of Gastroenterology and Hepatology, University of Texas, MD Anderson Cancer Center, Houston, Texas
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Yusuf FLA, Zhu F, Evans C, Fisk JD, Zhao Y, Marrie RA, Tremlett H. Gastrointestinal conditions in the multiple sclerosis prodrome. Ann Clin Transl Neurol 2024; 11:185-193. [PMID: 38115680 PMCID: PMC10791028 DOI: 10.1002/acn3.51945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/26/2023] [Accepted: 10/28/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE To investigate gastrointestinal (GI)-related physician visits and drug dispensations in the 5 years preceding a first recorded demyelinating event or multiple sclerosis (MS) onset. METHODS Using linked administrative and clinical data from British Columbia (1996-2013), Canada, we identified an administrative cohort via a validated algorithm (n = 6863), a clinical cohort diagnosed at a MS clinic (n = 966), and matched controls (administrative cohort: n = 31,865; clinical cohort: n = 4534). In each cohort, the 5 years before a first demyelinating event or MS symptom onset (i.e., index date) were examined. We compared rates of GI-related physician visits and risk of ≥1 GI-related dispensation between MS cases and controls using negative binomial and robust Poisson models. Sex differences were tested using interaction terms. RESULTS The administrative cohort MS cases had higher rates of physician visits related to gastritis and duodenitis (adjusted rate/risk ratio (aRR):1.42, 95% CI: 1.10-1.83) and diseases of the esophagus (aRR: 1.46, 95% CI: 1.06-2.02) prior to the index date. MS cases also had greater risk of at least one dispensation for several drug classes, including constipation-related (aRR: 1.82, 95% CI: 1.50-2.22), antiemetics/antinauseants (aRR: 1.64, 95% CI: 1.43-1.89), and propulsives (promotility drugs; aRR: 1.62, 95% CI: 1.47-1.79). Men had a disproportionally higher relative risk for propulsives than women (aRR: men = 2.32, 95% CI: 1.79-3.00; women = 1.54, 95% CI: 1.36-1.72). Several findings were similar in the smaller clinical cohort though none reached statistical significance. INTERPRETATION GI-related physician visits and drug dispensations were more common in the 5 years before the first demyelinating event versus matched controls. GI symptoms are a measurable feature of the prodromal or early phase of MS, with a sex difference evident.
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Affiliation(s)
- Fardowsa L. A. Yusuf
- Medicine (Neurology), the Djavad Mowafaghian Centre for Brain HealthUniversity of British Columbia2211 Wesbrook MallVancouverBritish ColumbiaV6T 2B5Canada
- School of Population and Public Health, University of British Columbia2206 East MallVancouverBritish ColumbiaV6T 1Z3Canada
| | - Feng Zhu
- Medicine (Neurology), the Djavad Mowafaghian Centre for Brain HealthUniversity of British Columbia2211 Wesbrook MallVancouverBritish ColumbiaV6T 2B5Canada
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan2A20.4 Health Sciences Bldg, 107 Wiggins AveSaskatoonSaskatchewanS7N 5E5Canada
| | - John D. Fisk
- Nova Scotia Health and the Departments of Psychiatry, Psychology & Neuroscience, and MedicineDalhousie University4066 A.J. Lane Memorial Building, 5909 Veterans' Memorial LaneHalifaxNova ScotiaB3H 2E2Canada
| | - Yinshan Zhao
- Medicine (Neurology), the Djavad Mowafaghian Centre for Brain HealthUniversity of British Columbia2211 Wesbrook MallVancouverBritish ColumbiaV6T 2B5Canada
| | - Ruth A. Marrie
- Departments of Internal Medicine and Community Health Sciences, Rady Faculty of Health Sciences, Health Sciences CentreMax Rady College of Medicine, University of ManitobaGF543, 820 Sherbrook StreetWinnipegManitobaR3A 1R9Canada
| | - Helen Tremlett
- Medicine (Neurology), the Djavad Mowafaghian Centre for Brain HealthUniversity of British Columbia2211 Wesbrook MallVancouverBritish ColumbiaV6T 2B5Canada
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Foshati S, Poursadeghfard M, Heidari Z, Amani R. The effects of ginger supplementation on common gastrointestinal symptoms in patients with relapsing-remitting multiple sclerosis: a double-blind randomized placebo-controlled trial. BMC Complement Med Ther 2023; 23:383. [PMID: 37891539 PMCID: PMC10605938 DOI: 10.1186/s12906-023-04227-x] [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: 06/27/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Gastrointestinal (GI) symptoms affect more than 80% of individuals with relapsing-remitting multiple sclerosis (RRMS). Ginger is widely known for its GI relieving properties. Therefore, we investigated the effect of ginger supplementation on common GI symptoms in RRMS patients. METHODS This study was a 12-week double-blind parallel randomized controlled trial with a 3-week run-in period. The intervention (n = 26) and control (n = 26) groups received 500 mg ginger and placebo (as corn) supplements 3 times a day along with main meals, respectively. At the beginning and end of the trial, the frequency and severity of constipation, dysphagia, abdominal pain, diarrhea, bloating, belching, flatulence, heartburn, anorexia, and nausea were assessed using the visual analogue scale ranging from 0 to 100 mm. Totally, 49 participants completed the study. However, data analysis was performed on all 52 participants based on the intention-to-treat principle. RESULTS In comparison with placebo, ginger supplementation resulted in significant or near-significant reductions in the frequency (-23.63 ± 5.36 vs. 14.81 ± 2.78, P < 0.001) and severity (-24.15 ± 5.10 vs. 11.39 ± 3.23, P < 0.001) of constipation, the frequency (-12.41 ± 3.75 vs. 3.75 ± 1.82, P < 0.001) and severity (-13.43 ± 4.91 vs. 6.88 ± 2.69, P = 0.001) of nausea, the frequency (-9.31 ± 4.44 vs. 1.56 ± 4.05, P = 0.098) and severity (-11.57 ± 5.09 vs. 3.97 ± 3.99, P = 0.047) of bloating, and the severity of abdominal pain (-5.69 ± 3.66 vs. 3.43 ± 3.26, P = 0.069). CONCLUSION Ginger consumption can improve constipation, nausea, bloating, and abdominal pain in patients with RRMS. TRIAL REGISTRATION This trial was prospectively registered at the Iranian Registry of Clinical Trials ( www.irct.ir ) under the registration number IRCT20180818040827N3 on 06/10/2021.
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Affiliation(s)
- Sahar Foshati
- Nutrition Research Center, Department of Clinical Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Poursadeghfard
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Heidari
- Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Amani
- Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
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Sakakibara R. Gastrointestinal Dysfunction in Multiple Sclerosis and Related Conditions. Semin Neurol 2023; 43:598-608. [PMID: 37703888 DOI: 10.1055/s-0043-1771462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Nervous system disorders may be accompanied by gastrointestinal (GI) dysfunction. Brain lesions may be responsible for GI problems such as decreased peristalsis (e.g., lesions in the basal ganglia, pontine defecation center/Barrington's nucleus), decreased abdominal strain (e.g., lesions in the parabrachial nucleus), hiccupping and vomiting (e.g., lesions in the area postrema), and appetite loss (e.g., lesions in the hypothalamus). Decreased peristalsis also may be caused by lesions of the spinal long tracts or the intermediolateral nucleus projecting to the myenteric plexus. This review addresses GI dysfunction caused by multiple sclerosis, neuromyelitis optica spectrum disorder, and myelin oligodendrocyte glycoprotein-associated disorder. Neuro-associated GI dysfunction may develop concurrently with brain or spinal cord dysfunction or may predate it. Collaboration between gastroenterologists and neurologists is highly desirable when caring for patients with GI dysfunction related to nervous system disorders, particularly since patients with these symptoms may visit a gastroenterologist prior to the establishment of a neurological diagnosis.
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Affiliation(s)
- Ryuji Sakakibara
- Neurology Clinic Tsudanuma & Dowakai Chiba Hospital Funabashi, Japan
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Naing LY, Mathur P, Chhabra G, Stocker A, Abell TL. Gastroparesis and Gastroparesis Syndromes as Neuromuscular Disorders. Semin Neurol 2023; 43:540-552. [PMID: 37562455 DOI: 10.1055/s-0043-1771469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Gastroparesis syndromes (GpS) are a spectrum of disorders presenting with characteristic symptoms increasingly recognized as being gastrointestinal (GI) neuromuscular disorders (NMDs). This review focuses on GpS as a manifestation of neurologic disorders of GI NMD. GpS can be associated with systemic abnormalities, including inflammatory, metabolic, and serologic disorders, as well as autoimmune antibodies via nerve and muscle targets in the GI tract, which can be treated with immunotherapy, such as intravenous immunoglobulin. GpS are associated with autonomic (ANS) and enteric (ENS) dysfunction. Disorders of ANS may interact with the ENS and are the subject of continued investigation. ENS disorders have been recognized for a century but have only recently begun to be fully quantified. Anatomic structural changes in the GI tract are increasingly recognized in GpS. Detailed descriptions of anatomic changes in GpS, and their correlation with physiologic findings, have opened a new era of investigation. The management of GpS, when viewed as GI NMD, has shifted the paradigms of both diagnosis and treatment. This article concludes with current approaches to GpS directed at underlying neuromuscular pathology.
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Affiliation(s)
- Le Yu Naing
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Prateek Mathur
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Garvit Chhabra
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Abigail Stocker
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Thomas L Abell
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky
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Bicknell B, Liebert A, Borody T, Herkes G, McLachlan C, Kiat H. Neurodegenerative and Neurodevelopmental Diseases and the Gut-Brain Axis: The Potential of Therapeutic Targeting of the Microbiome. Int J Mol Sci 2023; 24:9577. [PMID: 37298527 PMCID: PMC10253993 DOI: 10.3390/ijms24119577] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 04/28/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
The human gut microbiome contains the largest number of bacteria in the body and has the potential to greatly influence metabolism, not only locally but also systemically. There is an established link between a healthy, balanced, and diverse microbiome and overall health. When the gut microbiome becomes unbalanced (dysbiosis) through dietary changes, medication use, lifestyle choices, environmental factors, and ageing, this has a profound effect on our health and is linked to many diseases, including lifestyle diseases, metabolic diseases, inflammatory diseases, and neurological diseases. While this link in humans is largely an association of dysbiosis with disease, in animal models, a causative link can be demonstrated. The link between the gut and the brain is particularly important in maintaining brain health, with a strong association between dysbiosis in the gut and neurodegenerative and neurodevelopmental diseases. This link suggests not only that the gut microbiota composition can be used to make an early diagnosis of neurodegenerative and neurodevelopmental diseases but also that modifying the gut microbiome to influence the microbiome-gut-brain axis might present a therapeutic target for diseases that have proved intractable, with the aim of altering the trajectory of neurodegenerative and neurodevelopmental diseases such as Alzheimer's disease, Parkinson's disease, multiple sclerosis, autism spectrum disorder, and attention-deficit hyperactivity disorder, among others. There is also a microbiome-gut-brain link to other potentially reversible neurological diseases, such as migraine, post-operative cognitive dysfunction, and long COVID, which might be considered models of therapy for neurodegenerative disease. The role of traditional methods in altering the microbiome, as well as newer, more novel treatments such as faecal microbiome transplants and photobiomodulation, are discussed.
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Affiliation(s)
- Brian Bicknell
- NICM Health Research Institute, University of Western Sydney, Westmead, NSW 2145, Australia; (A.L.); (H.K.)
| | - Ann Liebert
- NICM Health Research Institute, University of Western Sydney, Westmead, NSW 2145, Australia; (A.L.); (H.K.)
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2006, Australia
- Department of Governance and Research, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia;
| | - Thomas Borody
- Centre for Digestive Diseases, Five Dock, NSW 2046, Australia;
| | - Geoffrey Herkes
- Department of Governance and Research, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia;
| | - Craig McLachlan
- Centre for Healthy Futures, Torrens University Australia, Ultimo, NSW 2007, Australia;
| | - Hosen Kiat
- NICM Health Research Institute, University of Western Sydney, Westmead, NSW 2145, Australia; (A.L.); (H.K.)
- Centre for Healthy Futures, Torrens University Australia, Ultimo, NSW 2007, Australia;
- Macquarie Medical School, Macquarie University, Macquarie Park, NSW 2109, Australia
- ANU College of Health and Medicine, Australian National University, Canberra, ACT 2601, Australia
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7
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Crnošija L, Adamec I, Krbot Skorić M, Habek M. How to explore and explain autonomic changes in multiple sclerosis. Neurophysiol Clin 2023; 53:102854. [PMID: 36966707 DOI: 10.1016/j.neucli.2023.102854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/29/2023] Open
Abstract
Autonomic dysfunction (AD) in people with MS (pwMS) is a frequent finding. This narrative review will present an overview of central neural mechanisms involved in the control of cardiovascular and thermoregulatory systems, and methods of autonomic nervous system testing will be discussed thereafter. Since the need for standardization of autonomic nervous system (ANS) testing, we will focus on the standard battery of tests (blood pressure and heart rate response to Valsalva maneuver and head-up tilt, and heart rate response to deep breathing test plus one of the tests for sudomotor function), which can detect ANS pathology in the majority of pwMS. The review will briefly discuss the other types of AD in pwMS and the use of appropriate tests. While performing ANS testing in pwMS one has to consider the multiple sclerosis phenotypes, disease duration, and its activity, the degree of clinical disability of patients included in the study, and the disease-modifying therapies taken, as these factors may have a great influence on the results of ANS testing. In other words, detailed patient characteristics presentation and patient stratification are beneficial when reporting results of ANS testing in pwMS.
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Thirion F, Sellebjerg F, Fan Y, Lyu L, Hansen TH, Pons N, Levenez F, Quinquis B, Stankevic E, Søndergaard HB, Dantoft TM, Poulsen CS, Forslund SK, Vestergaard H, Hansen T, Brix S, Oturai A, Sørensen PS, Ehrlich SD, Pedersen O. The gut microbiota in multiple sclerosis varies with disease activity. Genome Med 2023; 15:1. [PMID: 36604748 PMCID: PMC9814178 DOI: 10.1186/s13073-022-01148-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 12/07/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Multiple sclerosis is a chronic immune-mediated disease of the brain and spinal cord resulting in physical and cognitive impairment in young adults. It is hypothesized that a disrupted bacterial and viral gut microbiota is a part of the pathogenesis mediating disease impact through an altered gut microbiota-brain axis. The aim of this study is to explore the characteristics of gut microbiota in multiple sclerosis and to associate it with disease variables, as the etiology of the disease remains only partially known. METHODS Here, in a case-control setting involving 148 Danish cases with multiple sclerosis and 148 matched healthy control subjects, we performed shotgun sequencing of fecal microbial DNA and associated bacterial and viral microbiota findings with plasma cytokines, blood cell gene expression profiles, and disease activity. RESULTS We found 61 bacterial species that were differentially abundant when comparing all multiple sclerosis cases with healthy controls, among which 31 species were enriched in cases. A cluster of inflammation markers composed of blood leukocytes, CRP, and blood cell gene expression of IL17A and IL6 was positively associated with a cluster of multiple sclerosis-related species. Bacterial species that were more abundant in cases with disease-active treatment-naïve multiple sclerosis were positively linked to a group of plasma cytokines including IL-22, IL-17A, IFN-β, IL-33, and TNF-α. The bacterial species richness of treatment-naïve multiple sclerosis cases was associated with number of relapses over a follow-up period of 2 years. However, in non-disease-active cases, we identified two bacterial species, Faecalibacterium prausnitzii and Gordonibacter urolithinfaciens, whose absolute abundance was enriched. These bacteria are known to produce anti-inflammatory metabolites including butyrate and urolithin. In addition, cases with multiple sclerosis had a higher viral species diversity and a higher abundance of Caudovirales bacteriophages. CONCLUSIONS Considerable aberrations are present in the gut microbiota of patients with multiple sclerosis that are directly associated with blood biomarkers of inflammation, and in treatment-naïve cases bacterial richness is positively associated with disease activity. Yet, the finding of two symbiotic bacterial species in non-disease-active cases that produce favorable immune-modulating compounds provides a rationale for testing these bacteria as adjunct therapeutics in future clinical trials.
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Affiliation(s)
- Florence Thirion
- Université Paris-Saclay, INRAE, MGP, 78350, Jouy-en-Josas, France
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, 2600, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Yong Fan
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Liwei Lyu
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Tue H Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Nicolas Pons
- Université Paris-Saclay, INRAE, MGP, 78350, Jouy-en-Josas, France
| | - Florence Levenez
- Université Paris-Saclay, INRAE, MGP, 78350, Jouy-en-Josas, France
| | - Benoit Quinquis
- Université Paris-Saclay, INRAE, MGP, 78350, Jouy-en-Josas, France
| | - Evelina Stankevic
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Helle B Søndergaard
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, 2600, Glostrup, Denmark
| | - Thomas M Dantoft
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg University Hospital, 2400, Frederiksberg, Denmark
| | - Casper S Poulsen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Sofia K Forslund
- Experimental and Clinical Research Center, A Cooperation of Charité-Universitätsmedizin and the Max-Delbrück Center, 10117, Berlin, Germany
- Max Delbrück Center for Molecular Medicine (MDC), 13125, Berlin, Germany
- Charité-Universitätsmedizin Berlin, 10117, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785, Berlin, Germany
- Structural and Computational Biology Unit, European Molecular Biology Laboratory, 69117, Heidelberg, Germany
| | - Henrik Vestergaard
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, 2200, Copenhagen, Denmark
- Department of Medicine, Rønne Hospital, 3700, Bornholm, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Susanne Brix
- Department of Biotechnology and Biomedicine, Technical University of Denmark, 2800, Kongens Lyngby, Denmark
| | - Annette Oturai
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, 2600, Glostrup, Denmark
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, 2600, Glostrup, Denmark
| | - Stanislav D Ehrlich
- Université Paris-Saclay, INRAE, MGP, 78350, Jouy-en-Josas, France
- Department of Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3RX, UK
| | - Oluf Pedersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, 2200, Copenhagen, Denmark.
- Center for Clinical Metabolic Research, Herlev-Gentofte University Hospital, Hellerup, 2900, Copenhagen, Denmark.
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