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Melo EMVD, Rodrigues BCA, Cabral FT, Villarim LAMT, Mendes MF. Patient-centered pregnancy planning in multiple sclerosis: evidence for a new era. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-11. [PMID: 39357853 DOI: 10.1055/s-0044-1791202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
A few decades ago, women diagnosed with multiple sclerosis were discouraged from becoming pregnant. However, with new knowledge about the disease and treatments, this recommendation has changed, and it is pregnancy after the diagnosis of the disease is no longer contraindicated, with family planning being essential in this process. This review aims to provide a comprehensive overview of the family planning process for people with multiple sclerosis.
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Affiliation(s)
| | | | - Felipe Teijeiro Cabral
- Santa Casa de São Paulo, Faculdade de Ciências Médicas, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Maria Fernanda Mendes
- Santa Casa de São Paulo, Faculdade de Ciências Médicas, Departamento de Neurologia, São Paulo SP, Brazil
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2
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Shephard A, Kolaczkowski L, Barker N, Nahal D, Oreja-Guevara C, Reyes S, Gray H, Salloukh H, Giovannoni G. Making Information About Cladribine Tablets Accessible to People with Multiple Sclerosis: A Patient-Survey-Led Narrative Review for Healthcare Professionals. Neurol Ther 2024; 13:1015-1038. [PMID: 38760637 PMCID: PMC11263527 DOI: 10.1007/s40120-024-00608-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/18/2024] [Indexed: 05/19/2024] Open
Abstract
Cladribine tablets have been granted marketing authorization in Europe and approved by the Food and Drug Administration (FDA) in the USA to treat relapsing forms of multiple sclerosis (MS). However, people with MS (PwMS) may be more familiar, and therefore more confident, with treatments requiring long-term and frequent dosing. Differences in such treatment strategies can lead to questions relating to how short-course non-continuous treatments, such as cladribine tablets, can work and how well they are tolerated. In response to this, we aimed to create an evidence-based report on patient-focused aspects of treatment with cladribine. To inform development, MS experts, including healthcare professionals (HCPs) and PwMS, proposed topics that PwMS and their families and caregivers would most like to discuss with HCPs during consultations to help them better understand cladribine treatment. The statements regarding each topic were then ranked by PwMS and used to inform the topics covered in this report. We explain here the use of cladribine tablets, which includes explanations of how cladribine tablets work, how to take cladribine tablets, and considerations required prior to and while taking cladribine tablets. We also describe how cladribine tablets affect relapse rate and quality of life and detail side effects, when they are likely to happen, and for how long. We also discuss how cladribine tablets affect family planning, fertility, and the use of vaccines. Alongside each section is a brief, plain language description of what is covered and an accompanying visual to aid conversations between HCPs and PwMS. Improved understanding by PwMS of treatments, such as cladribine, can empower them to play a bigger role in shared decision-making regarding their treatment. Additionally, the open dialogue we aim to promote with this type of report could lead to treatment choices being better tailored for individuals with chronic diseases on the basis of personal experiences, preferences, and circumstances.
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Affiliation(s)
- Ardra Shephard
- Patient Author: MS blogger and podcaster [trippingonair.com], patient speaker and advocate, creator, based in Toronto, ON, Canada
| | - Laura Kolaczkowski
- Patient Author: MS blogger [MultipleSclerosis.net], lead patient representative [iConquerMS], patient expert, speaker and advocate, based in Beavercreek, OH, USA
| | - Noreen Barker
- The National Hospital for Neurology and Neurosurgery, London, UK
| | - Donna Nahal
- Patient Author: MS patient advocate and speaker, based in Birmingham, UK
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Saúl Reyes
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Fundación Santa Fe de Bogotá, Bogotá, Colombia
- School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Helen Gray
- Merck Healthcare KGaA, Darmstadt, Germany
| | | | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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Signoriello E, Foschi M, Lanzillo R, Frau J, Cocco E, Borriello G, Ianniello A, Trotta M, Landi D, Maniscalco GT, Ruscica F, Toscano S, Patti F, Zanghì A, D'Amico E, Fantozzi R, Centonze D, Lus G, Bonavita S. Pregnancy effect on disease activity in women with multiple sclerosis treated with cladribine. J Neurol 2024; 271:4039-4045. [PMID: 38568225 PMCID: PMC11233318 DOI: 10.1007/s00415-024-12291-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION Cladribine is an oral immune reconstitution therapy for relapsing multiple sclerosis (RMS). Hormonal and immune changes are responsible for the decline of disease activity in the third trimester of pregnancy and disease reactivation in the early post-partum period.We investigate the impact of pregnancy on disease activity in women with MS who conceived after cladribine treatment. METHODS We recruited women of childbearing age with relapsing-remitting MS (RRMS) who became pregnant or not after being treated with cladribine. For both groups, demographic, clinical and radiological data were collected 1 year before and after treatment during a mean follow-up of 3.53 years. We compared disease activity over time between groups using variance analysis for repeated measures. RESULTS 48 childbearing women were included. 25 women had a pregnancy after a mean of 1.75 years from the first treatment cycle. Women with or without pregnancy did not differ in demographics or pre-cladribine disease activity. No significant differences in disease activity or EDSS worsening were found between women with or without pregnancy. DISCUSSION Our findings suggest that pregnancy does not appear to influence disease activity and disability in women previously treated with cladribine; further studies with larger numbers and longer follow-up are needed to confirm this finding.
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Affiliation(s)
- E Signoriello
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - M Foschi
- Department of Neuroscience, MS Center-Neurology Unit, S. Maria Delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - R Lanzillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - J Frau
- Multiple Sclerosis Center, Department of Medical Sciences and Public Health University of Cagliari, Binaghi Hospital Cagliari/Italy, Cagliari, Italy
| | - E Cocco
- Multiple Sclerosis Center, Department of Medical Sciences and Public Health University of Cagliari, Binaghi Hospital Cagliari/Italy, Cagliari, Italy
| | - G Borriello
- San Pietro Fatebenefratelli-Hospital-MS Center Rome, Rome, Italy
| | - A Ianniello
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - M Trotta
- Unit of Neurology A.O. Annunziata, Cosenza, Italy
| | - D Landi
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Tor VergataUniveristy Hospital, Rome, Italy
| | - G T Maniscalco
- Neurological Clinic and Multiple Sclerosis Center, A Cardarelli Hospital, Naples, Italy
| | - F Ruscica
- U.O.C. Neurologia E Centro SMFondazione Istituto G. Giglio, Cefalù, PA, Italy
| | - S Toscano
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - F Patti
- Department "GF Ingrassia", Section of Neurosciences, University of Catania, Catania, Italy
| | - A Zanghì
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - E D'Amico
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - R Fantozzi
- Unit of Neurology, IRCCS Neuromed, Pozzilli, IS, Italy
| | - D Centonze
- Unit of Neurology, IRCCS Neuromed, Pozzilli, IS, Italy
| | - G Lus
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - S Bonavita
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy.
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Witt L, Thiel S, Hellwig K. [Pregnancy and breastfeeding in women with multiple sclerosis]. DER NERVENARZT 2024; 95:329-334. [PMID: 38393359 DOI: 10.1007/s00115-024-01621-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/25/2024]
Abstract
The diagnosis of multiple sclerosis (MS) in women of reproductive age is associated with many uncertainties regarding childbearing and lactation. Pregnancies of MS patients are not usually considered high-risk pregnancies per se. The likelihood of pregnancy complications or adverse pregnancy outcomes is not increased by the disease; however, a careful planning of pregnancy is important in order to choose the treatment option with the greatest benefit for the mother and the least possible risk for the baby. For highly active courses of the disease, anti-CD20 antibodies, cladribine, or continued administration of natalizumab show the best data. Patients with MS can be supported in their desire to breastfeed. If women have had a very active disease course, it is recommended that treatment should be started as soon as possible postpartum. Interferon-beta preparations, glatiramer acetate and ofatumumab are also approved for use during breastfeeding but off-label breastfeeding is also possible with other monoclonal antibodies.
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Affiliation(s)
- Laura Witt
- Neurologische Klinik St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland
| | - Sandra Thiel
- Neurologische Klinik St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland
| | - Kerstin Hellwig
- Neurologische Klinik St. Josef Hospital, Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland.
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Bove R, Sutton P, Nicholas J. Women's Health and Pregnancy in Multiple Sclerosis. Neurol Clin 2024; 42:275-293. [PMID: 37980119 DOI: 10.1016/j.ncl.2023.07.004] [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: 11/20/2023]
Abstract
Multiple sclerosis has a 3:1 female-to-male predominance and commonly presents in young adult women. The hormonal changes in women throughout their lifetime do affect the underlying pathology of multiple sclerosis, and the needs of women therefore change with age. Although multiple sclerosis does not adversely affect fertility or pregnancy, there are many factors to consider when caring for women throughout family planning, pregnancy, and the postpartum period. The care of these women and complex decisions regarding disease-modifying therapy use in family planning should be individualized and comprehensive.
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Affiliation(s)
- Riley Bove
- UCSF Weill Institute for Neurosciences, 1651 Fourth Street, San Francisco, CA 94158, USA
| | - Paige Sutton
- OhioHealth Multiple Sclerosis Center, 3535 Olentangy River Road, Columbus, OH 43214, USA.
| | - Jacqueline Nicholas
- OhioHealth Multiple Sclerosis Center, 3535 Olentangy River Road, Columbus, OH 43214, USA
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Zakroyshchikova IV, Simaniv TO, Zemlyanaya DO, Timofeeva AA, Zakharova MN. [The effect of pregnancy on multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:43-49. [PMID: 39175239 DOI: 10.17116/jnevro202412407243] [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: 08/24/2024]
Abstract
Planning for pregnancy and possibility of disease modifying treatment (DMTs) is an important question in female patients of reproductive age who suffer from multiple sclerosis (MS). The frequency of refusals to plan pregnancy is 14%. This is due to numerous concerns about the course of pregnancy, its outcomes, as well as the possible effect of DMTs on the fetus and the probability of disease transmission to a child. The article discusses immunological reactions taking place in MS patients during pregnancy, which are protective in its nature. Data for all groups of DMTs regarding pregnancy planning, possible risks of their impact on fertility and teratogenicity is presented.
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Affiliation(s)
| | - T O Simaniv
- Research Center of Neurology, Moscow, Russia
| | - D O Zemlyanaya
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Timofeeva
- Pirogov Russian National Research Medical University, Moscow, Russia
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Khan E, Kagzi Y, Elkhooly M, Surpur S, Wen S, Sharma K, Sriwastava S. Disease modifying therapy and pregnancy outcomes in multiple sclerosis: A systematic review and meta-analysis. J Neuroimmunol 2023; 383:578178. [PMID: 37672841 DOI: 10.1016/j.jneuroim.2023.578178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVES To report pregnancy outcomes among multiple sclerosis (MS) patients treated with disease-modifying therapies (DMTs). METHODS We performed a retrospective chart review of articles published from June 1996 to May 2023. Additional information was acquired from the drug registries of individual pharmaceutical companies. A comparison was also made with pregnancy data of the general population using the World Health Organization database. Summary analysis was achieved using R statistical software (v3.6), and the overall prevalence of outcomes was estimated using a random effects model. RESULTS A meta-analysis of 44 studies was conducted. Dimethyl fumarate had the highest prevalence of premature births at 0.6667% (SD:0.5236-0.7845). The highest rates of stillbirths and infant deaths (perinatal and neonatal) were observed with interferons at 0.004% (SD:0.001-0.010) and 0.009% (SD:0.005-0.0015), respectively. Cladribine had the majority of ectopic pregnancies (0.0234%, SD:0.0041-1217), while natalizumab had the highest prevalence of spontaneous abortions (0.1177%, SD:0.0931-0.1477) and live birth defects (0.0755%, SD:0.0643-0.0943).None of the outcomes were significantly different from those of the general population (p > 0.05), except ectopic pregnancy and spontaneous abortion (p < 0.001), where the odds were 0.665 (0.061-0.886) and 0.537(0.003-0.786), respectively. The pooled prevalence of MS relapses was 221% for a single episode (SD:0.001-0.714), 0.075% for more than one episode (SD:0.006-0.167), and 0.141% for at least one episode requiring steroids (SD:0.073-0.206) none of these reached clinical significance. CONCLUSION Existing research suggests that DMT use in MS patients during pregnancy is generally considered safe. This study supports their utilization on a case-by-case basis. However, further primary research on this topic with clinical trials is warranted.
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Affiliation(s)
- Erum Khan
- Department of Neurology, University of Alabama at Birmingham, AL,USA
| | - Yusuf Kagzi
- Mahatma Gandhi Memorial Medical College, Indore, India
| | - Mahmoud Elkhooly
- Department of Neurology, Wayne State University, Detroit, MI, USA; Department of Neurology, Southern Illinois University, Springfield, IL, USA; Department of Neuropsychiatry, Minia University, Egypt
| | | | - Sijin Wen
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Kanika Sharma
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA.
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Clavelou P, Castelnovo G, Pourcher V, De Sèze J, Vermersch P, Ben-Amor AF, Savarin C, Defer G. Expert Narrative Review of the Safety of Cladribine Tablets for the Management of Relapsing Multiple Sclerosis. Neurol Ther 2023; 12:1457-1476. [PMID: 37382841 PMCID: PMC10444734 DOI: 10.1007/s40120-023-00496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/11/2023] [Indexed: 06/30/2023] Open
Abstract
Cladribine tablets (CladT) is a highly active oral disease-modifying therapy (DMT) for the management of relapsing multiple sclerosis (RMS). CladT acts as an immune reconstitution therapy, in that two short courses of treatment 1 year apart have been shown to suppress disease activity for a prolonged period in most patients, without need for continued DMT. Each course of CladT induces a profound reduction in B lymphocytes that recovers over months, and serious lymphopenia (Grade 3-4) is uncommon. Smaller reductions in levels of T lymphocytes occur slightly later: on average, these remain within the normal range and repopulate progressively. A larger effect occurs on CD8 vs. CD4 cells. Reactivation of latent or opportunistic infections (e.g. varicella zoster, tuberculosis) is mostly associated with very low lymphocyte counts (< 200/mm3). Screening and managing pre-existing infections, vaccinating non-exposed patients and delaying the 2nd year of treatment with CladT to allow lymphocytes to recover to > 800/mm3 (if necessary) are important for avoiding infections and higher-grade lymphopenia. There was no demonstrable or apparent effect of CladT on the efficacy of vaccinations, including against Covid-19. Adverse events consistent with drug-induced liver injury (DILI) represent a rare but potentially serious complication of CladT therapy in spontaneous adverse event reporting; patients should be screened for liver dysfunction before starting treatment. Ongoing hepatic monitoring is not required, but CladT must be withdrawn if signs and symptoms of DILI develop. There was a numerical imbalance for malignancies when comparing cladribine to placebo in the clinical programme, particularly in short-term data, but recent evidence shows that the risk of malignancy with CladT is similar to the background rate in the general population and to that with other DMTs. Overall, CladT is well tolerated with a favorable safety profile appropriate for the management of RMS.
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Affiliation(s)
- Pierre Clavelou
- Department of Neurology, Clermont-Ferrand University Hospital, 58 Rue Montalembert, 63003, Clermont-Ferrand Cedex 1, France.
| | - Giovanni Castelnovo
- Department of Neurology, Nîmes University Hospital, Hopital Caremeau, Nîmes, France
| | - Valérie Pourcher
- Department of Infectious and Tropical Diseases, Pitié-Salpêtrière Hospital, APHP, Sorbonne Université, INSERM 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique Paris, Paris, France
| | - Jerome De Sèze
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Ali-Frederic Ben-Amor
- Global Medical Affairs Neurology and Immunology, Ares Trading SA (An affiliate of Merck KGaA, Darmstadt, Germany), Eysins, Switzerland
| | - Carine Savarin
- Neurology Department, Medical Affairs (An affiliate of Merck KGaA, Darmstadt, Germany), Merck Santé, Lyon, France
| | - Gilles Defer
- Department of Neurology, Caen University Hospital, Caen, France
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Collorone S, Kodali S, Toosy AT. The protective role of breastfeeding in multiple sclerosis: Latest evidence and practical considerations. Front Neurol 2023; 13:1090133. [PMID: 36761920 PMCID: PMC9902945 DOI: 10.3389/fneur.2022.1090133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/23/2022] [Indexed: 01/25/2023] Open
Abstract
The immunoprotective role of pregnancy in multiple sclerosis (MS) has been known for decades. Conversely, there has been rich debate on the topic of breastfeeding and disease activity in MS. In clinical practice, women are often offered to restart their disease-modifying drug (DMD) soon after delivery to maintain their relapse risk protection. Limited available information about peri-partum DMD safety can discourage women to choose breastfeeding, despite the World Health Organization's recommendation to breastfeed children for the first 6 months of life exclusively. New evidence is emerging about the protective role of exclusive breastfeeding on relapse rate. Research studies shed light on the hormonal and immunological mechanisms driving the risk of relapses during pregnancy and postpartum. Finally, case reports, real-world data, and clinical trials are increasing our knowledge of the safety of DMDs for the fetus and infant. While some DMDs must be avoided, others may be considered in highly active pregnant or lactating women with MS. This mini-review conveys recent evidence regarding the protective role of exclusive breastfeeding in MS and offers clinicians practical considerations for a patient-tailored approach.
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Affiliation(s)
- Sara Collorone
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Srikirti Kodali
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Ahmed T Toosy
- NMR Research Unit, Department of Neuroinflammation, Queen Square MS Centre, Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
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