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Singer BA, Feng J, Chiong-Rivero H. Early use of high-efficacy therapies in multiple sclerosis in the United States: benefits, barriers, and strategies for encouraging adoption. J Neurol 2024; 271:3116-3130. [PMID: 38615277 PMCID: PMC11136864 DOI: 10.1007/s00415-024-12305-4] [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: 12/19/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Multiple sclerosis (MS) is characterized by progressive neuroinflammation and neurodegeneration from disease onset that, if left untreated, can result in the accumulation of irreversible neurological disability. Early intervention with high-efficacy therapies (HETs) is increasingly recognized as the best strategy to delay or mitigate disease progression from the earliest stages of the disease and to prevent long-term neurodegeneration. Although there is growing clinical and real-world evidence supporting early HET intervention, foregoing this strategy in favor of a traditional escalation approach prioritizing lower-efficacy disease-modifying therapies remains a common approach in clinical practice. This review explores potential health care professional- and patient-related barriers to the early use of HETs in patients with MS in the United States. Barriers can include regulatory and reimbursement restrictions; knowledge gaps and long-term safety concerns among health care professionals; and various individual, cultural, and societal factors affecting patients. Potential strategies for overcoming these barriers and encouraging early HET use are proposed.
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Affiliation(s)
- Barry A Singer
- The MS Center for Innovations in Care, Missouri Baptist Medical Center, St Louis, MO, USA.
| | - Jenny Feng
- Ochsner Medical Center, New Orleans, LA, USA
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Stoll S, Costello K, Newsome SD, Schmidt H, Sullivan AB, Hendin B. Insights for Healthcare Providers on Shared Decision-Making in Multiple Sclerosis: A Narrative Review. Neurol Ther 2024; 13:21-37. [PMID: 38180727 PMCID: PMC10787702 DOI: 10.1007/s40120-023-00573-7] [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: 09/06/2023] [Accepted: 12/07/2023] [Indexed: 01/06/2024] Open
Abstract
Shared decision-making (SDM) between the patient and their healthcare provider (HCP) in developing treatment plans is increasingly recognized as central to improving treatment adherence and, ultimately, patient outcomes. In multiple sclerosis (MS), SDM is particularly crucial for optimizing treatment in a landscape that has grown more complex with the availability of newer, high-efficacy MS therapies. However, little direct evidence on the effectiveness of SDM is available to guide practice. Multiple factors, including patient age, ethnic background, perceptions, invisible MS symptoms, and psychological comorbidities can influence a patient's willingness and ability to participate in SDM. HCPs need to appreciate these factors and ask the right questions to break down obstacles to SDM. The HCP has a responsibility to help patients feel adequately informed and comfortable in having an active role in their care. This review identifies potential barriers to SDM and provides a strategy for HCPs to overcome these obstacles through patient (and caregiver) discussions to ensure optimal patient satisfaction with treatment and thus the best possible outcomes for their patients.
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Affiliation(s)
| | | | - Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hollie Schmidt
- Accelerated Cure Project for Multiple Sclerosis, Waltham, MA, USA
| | - Amy B Sullivan
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Barry Hendin
- Integrated Multiple Sclerosis Center, Phoenix, AZ, USA
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3
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Amezcua L, Robers MV, Soneji D, Manouvakhova O, Martinez A, Islam T. Inclusion of optic neuritis in dissemination in space improves the performance of McDonald 2017 criteria in Hispanic people with suspected multiple sclerosis. Mult Scler 2023; 29:1748-1754. [PMID: 37942880 PMCID: PMC10841903 DOI: 10.1177/13524585231209016] [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] [Indexed: 11/10/2023]
Abstract
BACKGROUND Hispanic people compared to White people with multiple sclerosis (MS) are two times more likely to present with optic neuritis (ON). ON in dissemination in space (DIS) after a single attack is not part of the current McDonald 2017 criteria. OBJECTIVE To evaluate if adding ON in DIS (ON-modified criteria) improves the performance of the McDonald 2017 criteria in the diagnosis of MS after a single attack of ON. METHODS Retrospective study of 102 patients of Hispanic background. Cases were reviewed between 2017 and 2021. Clinical ON was reported for 35 cases. ON in DIS was verified for 28 patients via MRI, optical coherence tomography, and/or visual evoked potential. We investigated the performance of the McDonald 2017 criteria and ON-modified criteria and calculated sensitivity, specificity, positive and negative predictive values, and accuracy. RESULTS The ON-modified criteria significantly improved the performance of the McDonald 2017 criteria (p = 0.003) and identified an additional nine patients. Both sensitivity and accuracy increased from 64% to 74% and 62% to 71%, respectively, while specificity remained unchanged (40% (95% confidence interval (CI): 0.10, 0.70)). CONCLUSION This study provides evidence that the inclusion of ON in DIS improved the overall performance of the McDonald 2017 criteria among Hispanic people.
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Affiliation(s)
- Lilyana Amezcua
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Deepak Soneji
- Neurology and Neuroophthalmology, Sutter East Bay Medical Group, Lafayette, CA, USA
| | - Olga Manouvakhova
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andrea Martinez
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Talat Islam
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Hersh CM, Morrow SA, Williams MJ, Amezcua L, Halper J, Wandersee K. Diversity, Equity, and Inclusion in the Multiple Sclerosis Community: A Call to Action. Int J MS Care 2023; 25:199-205. [PMID: 37720263 PMCID: PMC10503818 DOI: 10.7224/1537-2073.2023-039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Many medical organizations have begun to confront the longstanding problem of inequalities in health care delivery and the undeniable effect of disparities on health outcomes. The Consortium of Multiple Sclerosis Centers (CMSC) recognizes that disparities affect the lives of many people with multiple sclerosis (MS) and acknowledges the need to address this as an organization. The CMSC recently (1) appointed a task force, (2) conducted a survey of its membership, (3) commissioned this review article and call to action, and (4) formulated a mission statement on diversity, equity, and inclusion (DEI), which was adopted by the CMSC's Board of Governors in March 2023. This paper summarizes recent literature on health care disparities in MS, particularly those relating to race/ethnicity, sexual orientation, and gender identity. It presents findings from CMSC's survey of members' awareness of DEI issues, the need for education and resources for MS care providers, and existing institutional policies on DEI in the members' practice settings. It also presents the task force's recommendations for next steps, which includes the goal of greater diversity in the MS workforce of the future. The CMSC will continue to revisit DEI policies and practices over time with the goal of motivating greater awareness, momentum, and positive changes within the MS community.
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Affiliation(s)
- Carrie M. Hersh
- From the Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas, NV (CMH)
| | - Sarah A. Morrow
- London Multiple Sclerosis Clinic, University of Western Ontario, London, ON (SAM)
| | | | - Lilyana Amezcua
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA (LA)
| | - June Halper
- Consortium of Multiple Sclerosis Centers, Hackensack, NJ (JH, KW)
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Chase Huizar C, Raphael I, Forsthuber TG. Genomic, proteomic, and systems biology approaches in biomarker discovery for multiple sclerosis. Cell Immunol 2020; 358:104219. [PMID: 33039896 PMCID: PMC7927152 DOI: 10.1016/j.cellimm.2020.104219] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 12/12/2022]
Abstract
Multiple sclerosis (MS) is a neuroinflammatory disorder characterized by autoimmune-mediated inflammatory lesions in CNS leading to myelin damage and axonal loss. MS is a heterogenous disease with variable and unpredictable disease course. Due to its complex nature, MS is difficult to diagnose and responses to specific treatments may vary between individuals. Therefore, there is an indisputable need for biomarkers for early diagnosis, prediction of disease exacerbations, monitoring the progression of disease, and for measuring responses to therapy. Genomic and proteomic studies have sought to understand the molecular basis of MS and find biomarker candidates. Advances in next-generation sequencing and mass-spectrometry techniques have yielded an unprecedented amount of genomic and proteomic data; yet, translation of the results into the clinic has been underwhelming. This has prompted the development of novel data science techniques for exploring these large datasets to identify biologically relevant relationships and ultimately point towards useful biomarkers. Herein we discuss optimization of omics study designs, advances in the generation of omics data, and systems biology approaches aimed at improving biomarker discovery and translation to the clinic for MS.
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Affiliation(s)
- Carol Chase Huizar
- Department of Biology, University of Texas at San Antonio, San Antonio, TX, USA
| | - Itay Raphael
- Department of Neurological Surgery, University of Pittsburgh, UPMC Children's Hospital, Pittsburgh, PA, USA.
| | - Thomas G Forsthuber
- Department of Biology, University of Texas at San Antonio, San Antonio, TX, USA.
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Beecham AH, Amezcua L, Chinea A, Manrique CP, Rubi C, Isobe N, Lund BT, Santaniello A, Beecham GW, Burchard EG, Comabella M, Patsopoulos N, Fitzgerald K, Calabresi PA, De Jager P, Conti DV, Delgado SR, Oksenberg JR, McCauley JL. The genetic diversity of multiple sclerosis risk among Hispanic and African American populations living in the United States. Mult Scler 2020; 26:1329-1339. [PMID: 31368393 PMCID: PMC6994382 DOI: 10.1177/1352458519863764] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Substantial progress has been made toward unraveling the genetic architecture of multiple sclerosis (MS) within populations of European ancestry, but few genetic studies have focused on Hispanic and African American populations within the United States. OBJECTIVE We sought to test the relevance of common European MS risk variants outside of the major histocompatibility complex (n = 200) within these populations. METHODS Genotype data were available on 2652 Hispanics (1298 with MS, 1354 controls) and 2435 African Americans (1298 with MS, 1137 controls). We conducted single variant, pathway, and cumulative genetic risk score analyses. RESULTS We found less replication than statistical power suggested, particularly among African Americans. This could be due to limited correlation between the tested and causal variants within the sample or alternatively could indicate allelic and locus heterogeneity. Differences were observed between pathways enriched among the replicating versus all 200 variants. Although these differences should be examined in larger samples, a potential role exists for gene-environment or gene-gene interactions which alter phenotype differentially across racial and ethnic groups. Cumulative genetic risk scores were associated with MS within each study sample but showed limited diagnostic capability. CONCLUSION These findings provide a framework for fine-mapping efforts in multi-ethnic populations of MS.
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Affiliation(s)
- A H Beecham
- John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, Miami, FL, USA/The Dr. John T. Macdonald Foundation Department of Human Genetics, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - L Amezcua
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A Chinea
- San Juan MS Center, Guaynabo, Puerto Rico, USA; Universidad Central del Caribe, Bayamon, Puerto Rico, USA
| | - C P Manrique
- John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - C Rubi
- San Juan MS Center, Guaynabo, Puerto Rico, USA; Universidad Central del Caribe, Bayamon, Puerto Rico, USA
| | - N Isobe
- Department of Neurological Therapeutics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - B T Lund
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A Santaniello
- Department of Neurology, University of California at San Francisco, San Francisco, CA, USA
| | - G W Beecham
- John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, Miami, FL, USA/The Dr. John T. Macdonald Foundation Department of Human Genetics, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - E G Burchard
- Departments of Medicine and Bioengineering and Therapeutic Sciences, University of California at San Francisco, San Francisco, CA, USA
| | - M Comabella
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - N Patsopoulos
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - K Fitzgerald
- Department of Neurology and The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P A Calabresi
- Department of Neurology and The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P De Jager
- Center for Translational and Computational Neuroimmunology, Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - D V Conti
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - S R Delgado
- Multiple Sclerosis Division, Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - J R Oksenberg
- Department of Neurology, University of California at San Francisco, San Francisco, CA, USA
| | - J L McCauley
- John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, Miami, FL, USA/The Dr. John T. Macdonald Foundation Department of Human Genetics, Miller School of Medicine, University of Miami, Miami, FL, USA
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Pérez CA, Salehbeiki A, Zhu L, Wolinsky JS, Lincoln JA. Assessment of Racial/Ethnic Disparities in Volumetric MRI Correlates of Clinical Disability in Multiple Sclerosis: A Preliminary Study. J Neuroimaging 2020; 31:115-123. [PMID: 32949483 DOI: 10.1111/jon.12788] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 08/31/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Although global and regional brain volume has been established as a relevant measure to define and predict multiple sclerosis (MS) severity, characterization of specific trends by race/ethnicity is currently lacking. We aim to (1) characterize racial disparities in disability-specific patterns of brain MRI volumetric measures between Hispanic and Caucasian individuals with MS and (2) explore the relevance of these measures as predictors of clinical disability progression. METHODS Brain MRI scans from 94 Hispanic and 94 age- and gender-matched Caucasian MS patients were analyzed using automatic and manual segmentation techniques. Select global and regional volume measures were correlated to Expanded Disability Status Scale (EDSS) scores at baseline and subsequent follow-up visits. RESULTS Hispanic patients had a higher baseline median EDSS score (interquartile range [IQR], 2.0; [1.0-3.5]) compared to Caucasians (median [IQR], 1.0 [.0-2.0]) and an increased risk of requiring ambulatory assistance (hazard ratio [HR], 9.7; 95% confidence interval [CI], 2.8-32.5). Normalized thalamic volume was moderately associated with EDSS scores (rs = -.42, P < .001 in Hispanics; rs = -.32, P = .002 in Caucasians) and was the best predictor of sustained disability worsening in both racial groups in a time-to-event analysis. CONCLUSIONS The confounding impact of race on quantitative brain volume measures may affect the interpretation of outcome measures in MS clinical trials.
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Affiliation(s)
- Carlos A Pérez
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX
| | - Alireza Salehbeiki
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX
| | - Liang Zhu
- Biostatistics & Epidemiology Research Design Core Center for Clinical and Translational Sciences, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX
| | - Jerry S Wolinsky
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX
| | - John A Lincoln
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX
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McComb M, Ramanathan M. Generalized Pharmacometric Modeling, a Novel Paradigm for Integrating Machine Learning Algorithms: A Case Study of Metabolomic Biomarkers. Clin Pharmacol Ther 2020; 107:1343-1351. [PMID: 31863460 DOI: 10.1002/cpt.1746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/03/2019] [Indexed: 12/27/2022]
Abstract
There is an unmet need for identifying innovative machine learning (ML) strategies to improve drug treatment regimens and therapeutic outcomes. We investigate Generalized Pharmacometric Modeling (GPM), a novel paradigm that integrates ML algorithms with pharmacokinetic and pharmacodynamic structural models, population covariate modeling, and "big data," and enables identification of patient-specific factors contributing to drug disposition. We hypothesize that GPM will enhance forecasting of drug outcomes in diverse populations. We assessed random forest regression in conjunction with Bayesian networks as the ML methods within GPM and used the National Health and Nutrition Examination Survey population-based study database. GPM was utilized to identify subject-specific factors associated with cholesterol dynamics. Our results demonstrate the utility of GPM to enhance pharmacometrics modeling and its potential for modeling drug outcomes in diverse populations.
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Affiliation(s)
- Mason McComb
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Murali Ramanathan
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA.,Department of Neurology, University at Buffalo, The State University of New York, Buffalo, New York, USA
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Abstract
Multiple sclerosis (MS) has a strong racial and ethnic component and disproportionately affects whites of European background. Recent incidence reports suggest an increasing rate of MS among African Americans compared with whites. Despite this recent increase in MS in African Americans, Hispanics and Asians are significantly less likely to develop MS than whites of European ancestry. MS-specific mortality trends demonstrate distinctive disparities by race/ethnicity and age, suggesting that there is an unequal burden of disease. Inequalities in health along with differences in clinical characteristics that may be genetic, environmental, and social in origin may be contributing to disease variability and be suggestive of endophenotypes. The overarching goal of this review was to summarize the current understanding on the variability of disease that we observe in selected racial and ethnic populations: Hispanics and African Americans. Future challenges will be to unravel the genetic, environmental, and social determinants of the observed racial/ethnic disparities.
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Affiliation(s)
- Lilyana Amezcua
- Multiple Sclerosis Comprehensive Care Center, University of Southern California, Los Angeles, CA, USA/Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jacob L McCauley
- John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, Miami, FL, USA
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Krch D, Lequerica A, Aguayo Arelis A, Rábago Barajas BV, Arango-Lasprilla JC, Chiaravalloti ND. Efficacy of the Spanish modified Story Memory Technique in Mexicans with multiple sclerosis: A pilot randomized controlled trial. NeuroRehabilitation 2019; 45:349-358. [DOI: 10.3233/nre-192808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Denise Krch
- Center for Traumatic Brain Injury Research, Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Anthony Lequerica
- Center for Traumatic Brain Injury Research, Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Adriana Aguayo Arelis
- Departamento de Investigación, Psicología, Universidad Enrique Díaz de León, Guadalajara, Mexico
- Department of Neuropsychology, Mexican Foundation for Multiple Sclerosis, Mexico
| | - Brenda Viridiana Rábago Barajas
- Departamento de Investigación, Psicología, Universidad Enrique Díaz de León, Guadalajara, Mexico
- Department of Neuropsychology, Mexican Foundation for Multiple Sclerosis, Mexico
| | - Juan Carlos Arango-Lasprilla
- BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Bizkaia, Spain
- IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
- Department of Cell Biology, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Nancy D. Chiaravalloti
- Center for Traumatic Brain Injury Research, Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
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