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Benallegue N, Rollot F, Wiertlewski S, Casey R, Debouverie M, Kerbrat A, De Seze J, Ciron J, Ruet A, Labauge P, Maillart E, Zephir H, Papeix C, Defer G, Lebrun-Frenay C, Moreau T, Berger E, Stankoff B, Clavelou P, Heinzlef O, Pelletier J, Thouvenot E, Al Khedr A, Bourre B, Casez O, Cabre P, Wahab A, Magy L, Vukusic S, Laplaud DA. Highly Effective Therapies as First-Line Treatment for Pediatric-Onset Multiple Sclerosis. JAMA Neurol 2024; 81:273-282. [PMID: 38345791 PMCID: PMC10862269 DOI: 10.1001/jamaneurol.2023.5566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/07/2023] [Indexed: 02/15/2024]
Abstract
Importance Moderately effective therapies (METs) have been the main treatment in pediatric-onset multiple sclerosis (POMS) for years. Despite the expanding use of highly effective therapies (HETs), treatment strategies for POMS still lack consensus. Objective To assess the real-world association of HET as an index treatment compared with MET with disease activity. Design, Setting, and Participants This was a retrospective cohort study conducted from January 1, 2010, to December 8, 2022, until the last recorded visit. The median follow-up was 5.8 years. A total of 36 French MS centers participated in the Observatoire Français de la Sclérose en Plaques (OFSEP) cohort. Of the total participants in OFSEP, only treatment-naive children with relapsing-remitting POMS who received a first HET or MET before adulthood and at least 1 follow-up clinical visit were included in the study. All eligible participants were included in the study, and none declined to participate. Exposure HET or MET at treatment initiation. Main Outcomes and Measures The primary outcome was the time to first relapse after treatment. Secondary outcomes were annualized relapse rate (ARR), magnetic resonance imaging (MRI) activity, time to Expanded Disability Status Scale (EDSS) progression, tertiary education attainment, and treatment safety/tolerability. An adapted statistical method was used to model the logarithm of event rate by penalized splines of time, allowing adjustment for effects of covariates that is sensitive to nonlinearity and interactions. Results Of the 3841 children (5.2% of 74 367 total participants in OFSEP), 530 patients (mean [SD] age, 16.0 [1.8] years; 364 female [68.7%]) were included in the study. In study patients, both treatment strategies were associated with a reduced risk of first relapse within the first 2 years. HET dampened disease activity with a 54% reduction in first relapse risk (adjusted hazard ratio [HR], 0.46; 95% CI, 0.31-0.67; P < .001) sustained over 5 years, confirmed on MRI activity (adjusted odds ratio [OR], 0.34; 95% CI, 0.18-0.66; P = .001), and with a better tolerability pattern than MET. The risk of discontinuation at 2 years was 6 times higher with MET (HR, 5.97; 95% CI, 2.92-12.20). The primary reasons for treatment discontinuation were lack of efficacy and intolerance. Index treatment was not associated with EDSS progression or tertiary education attainment (adjusted OR, 0.51; 95% CI, 0.24-1.10; P = .09). Conclusions and Relevance Results of this cohort study suggest that compared with MET, initial HET in POMS was associated with a reduction in the risk of first relapse with an optimal outcome within the first 2 years and was associated with a lower rate of treatment switching and a better midterm tolerance in children. These findings suggest prioritizing initial HET in POMS, although long-term safety studies are needed.
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Affiliation(s)
- Nail Benallegue
- Department of Paediatric Neurology, Universitaire Angers, CHU Angers, Angers, France
- Nantes Université, CHU Nantes, Inserm, CIC 14131413, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
| | - Fabien Rollot
- Université de Lyon, Université Claude Bernard, Lyon 1, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Infammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, Inserm 1028 et CNRS UMR 5292, Lyon, France
- EUGENE DEVIC EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Sandrine Wiertlewski
- Nantes Université, CHU Nantes, Inserm, CIC 14131413, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- Department of Neurology, CHU Nantes, Nantes, France
| | - Romain Casey
- Université de Lyon, Université Claude Bernard, Lyon 1, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Infammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, Inserm 1028 et CNRS UMR 5292, Lyon, France
- EUGENE DEVIC EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - Marc Debouverie
- Department of Neurology, Centre Hospitalier Régional Et Universitaire de Nancy, Université de Lorraine, 4360 APEMAC Vandoeuvre-Lès-Nancy, EA, France
| | - Anne Kerbrat
- Rennes University, CHU Rennes, CRC-SEP Neurology Department, and EMPENN U 1228, Inserm, INRIA, CNRS, Rennes, France
| | - Jérôme De Seze
- Department of Neurology Et Centre d’Investigation Clinique, CHU de Strasbourg, INSERM 1434, Strasbourg, France
| | - Jonathan Ciron
- Department of Neurology, CRC-SEP, CHU de Toulouse, Hôpital Pierre-Paul Riquet, Toulouse, France
- Institut Toulousain Des Maladies Infectieuses Et Inflammatoires (Infinity), Inserm UMR 1291, CNRS UMR 5051, Université Toulouse III, Toulouse, France
| | - Aurelie Ruet
- Department of Neurology, CHU de Bordeaux, Bordeaux, France
- Université de Bordeaux, Inserm, Neurocentre Magendie, U1215 Bordeaux, France
| | - Pierre Labauge
- CRC SEP, Department of Neurology, Montpellier Universitary Hospital, Montpellier, France
| | | | - Helene Zephir
- Pôle Des Neurosciences Et de L’appareil Locomoteur, CRC-SEP, Hôpital Roger Salengro, Université de Lille, Inserm U1172, Lille, France
| | - Caroline Papeix
- Département of Neurology, Hôpital Fondation A.de Rothschild, Paris, France
| | - Gilles Defer
- Department of Neurology, Centre Expert SEP, CHU de Caen, Université Normandie, Caen, France
| | - Christine Lebrun-Frenay
- CRC-SEP Neurologie Pasteur 2, CHU de Nice, Université Cote d’Azur, UMR2CA (URRIS), Nice, France
| | | | - Eric Berger
- Department of Neurology, CHU de Besançon, Besançon, France
| | - Bruno Stankoff
- Department of Neurology, CHU Saint-Antoine, Paris, France
| | - Pierre Clavelou
- Department of Neurology, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Olivier Heinzlef
- Département de Neurologie, Centre Hospitalier de Poissy, St Germain, France
| | - Jean Pelletier
- Aix Marseille Univ, APHM, Hôpital de la Timone, Pôle de Neurosciences Cliniques, Service de Neurologie – MICeME, CRMBM CEMEREM UMR7339, Marseille, France
| | - Eric Thouvenot
- Department of Neurology, CHU de Nîmes, Nîmes, France
- IGF, University Montpellier, CNRS, Inserm, Montpellier, France
| | | | | | - Olivier Casez
- Department of Neurology, CHU de Grenoble, Grenoble, France
| | - Philippe Cabre
- Department of Neurology, CHU de Fort de France, Fort de France, France
| | - Abir Wahab
- Department of Neurology, Assistance Publique des Hôpitaux de Paris, Hôpital Henri Mondor, Université Paris Est, Créteil, France
| | - Laurent Magy
- Department of Neurology, CHU de Limoges, Limoges, France
| | - Sandra Vukusic
- Université de Lyon, Université Claude Bernard, Lyon 1, Lyon, France
- Department of Neurology, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Sclérose en Plaques, Pathologies de la Myéline et Neuro-Infammation, Bron, France
- Centre de Recherche en Neurosciences de Lyon, Observatoire Français de La Sclérose en Plaques, Inserm 1028 et CNRS UMR 5292, Lyon, France
- EUGENE DEVIC EDMUS Foundation Against Multiple Sclerosis, State-Approved Foundation, Bron, France
| | - David-Axel Laplaud
- Nantes Université, CHU Nantes, Inserm, CIC 14131413, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- Department of Neurology, CHU Nantes, Nantes, France
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Abdel-Mannan OA, Manchoon C, Rossor T, Southin JC, Tur C, Brownlee W, Byrne S, Chitre M, Coles A, Forsyth R, Kneen R, Mankad K, Ram D, West S, Wright S, Wassmer E, Lim M, Ciccarelli O, Hemingway C, Hacohen Y. Use of Disease-Modifying Therapies in Pediatric Relapsing-Remitting Multiple Sclerosis in the United Kingdom. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/4/e1008. [PMID: 34021056 PMCID: PMC8143699 DOI: 10.1212/nxi.0000000000001008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/18/2021] [Indexed: 11/18/2022]
Abstract
Objectives To compare the real-world effectiveness of newer disease-modifying therapies (DMTs) vs injectables in children with relapsing-remitting multiple sclerosis (RRMS). Methods In this retrospective, multicenter study, from the UK Childhood Inflammatory Demyelination Network, we identified children with RRMS receiving DMTs from January 2012 to December 2018. Clinical and paraclinical data were retrieved from the medical records. Annualized relapse rates (ARRs) before and on treatment, time to relapse, time to new MRI lesions, and change in Expanded Disability Status Scale (EDSS) score were calculated. Results Of 103 children treated with DMTs, followed up for 3.8 years, relapses on treatment were recorded in 53/89 (59.5%) on injectables vs 8/54 (15%) on newer DMTs. The ARR was reduced from 1.9 to 1.1 on injectables (p < 0.001) vs 1.6 to 0.3 on newer DMTs (p = 0.002). New MRI lesions occurred in 77/89 (86.5%) of patients on injectables vs 26/54 (47%) on newer DMTs (p = 0.0001). Children on newer DMTs showed longer time to relapse, time to switch treatment, and time to new radiologic activity than patients on injectables (log-rank p < 0.01). After adjustment for potential confounders, multivariable analysis showed that injectables were associated with 12-fold increased risk of clinical relapse (adjusted hazard ratio [HR] = 12.12, 95% CI = 1.64–89.87, p = 0.015) and a 2-fold increased risk of new radiologic activity (adjusted HR = 2.78, 95% CI = 1.08–7.13, p = 0.034) compared with newer DMTs. At 2 years from treatment initiation, 38/103 (37%) patients had MRI activity in the absence of clinical relapses. The EDSS score did not change during the follow-up, and only 2 patients had cognitive impairment. Conclusion Newer DMTs were associated with a lower risk of clinical and radiologic relapses in patients compared with injectables. Our study adds weight to the argument for an imminent shift in practice toward the use of newer, more efficacious DMTs in the first instance. Classification of Evidence This study provides Class IV evidence that newer DMTs (oral or infusions) are superior to injectables (interferon beta/glatiramer acetate) in reducing both clinical relapses and radiologic activity in children with RRMS.
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Affiliation(s)
- Omar A Abdel-Mannan
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Celeste Manchoon
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Thomas Rossor
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Justine-Clair Southin
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Carmen Tur
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Wallace Brownlee
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Susan Byrne
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Manali Chitre
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Alasdair Coles
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Rob Forsyth
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Rachel Kneen
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Kshitij Mankad
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Dipak Ram
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Siobhan West
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Sukhvir Wright
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Evangeline Wassmer
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Ming Lim
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Olga Ciccarelli
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Cheryl Hemingway
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.)
| | - Yael Hacohen
- From the Queen Square MS Centre (O.A.A., W.B., O.C., C.H., Y.H.), UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London; Department of Neurology (O.A.A., O.C., C.H., Y.H.), Great Ormond Street Hospital for Children, London; Children's Neurosciences (C.M.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation; Department of Paediatric Neurology (T.R., M.C.), Addenbrooke's Hospital, Cambridge; Department of Neurology (J.-C.S., R.K.), Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Queen Square Institute of Neurology (C.T.), Faculty of Brain Sciences, University College London; Multiple Sclerosis Centre of Catalonia (Cemcat) (C.T.), Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Spain; Children's Neurosciences (S.B.), Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London; Department of Clinical Neurosciences (A.C.), Addenbrooke's Hospital, Cambridge; Translational and Clinical Research Institute (R.F.), Newcastle University; Department of Neuroradiology (K.M.), Great Ormond Street Hospital for Children, London; Department of Neurology (D.R., S. West), Royal Manchester Children's Hospital, Manchester; Department of Neurology (S. Wright, E.W.), Birmingham Children's Hospital, Birmingham; Aston Neuroscience Institute (S. Wright, E.W.), College of Health and Life Sciences, Aston University, Birmingham, United Kingdom; Evelina London Children's Hospital (M.L.), Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, United Kingdom; and NIHR University College London Hospitals Biomedical Research Centre (O.C.).
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