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Uher T, Adzima A, Srpova B, Noskova L, Maréchal B, Maceski AM, Krasensky J, Stastna D, Andelova M, Novotna K, Vodehnalova K, Motyl J, Friedova L, Lindner J, Ravano V, Burgetova A, Dusek P, Fialova L, Havrdova EK, Horakova D, Kober T, Kuhle J, Vaneckova M. Diagnostic delay of multiple sclerosis: prevalence, determinants and consequences. Mult Scler 2023; 29:1437-1451. [PMID: 37840276 PMCID: PMC10580682 DOI: 10.1177/13524585231197076] [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: 05/22/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Early diagnosis and treatment of patients with multiple sclerosis (MS) are associated with better outcomes; however, diagnostic delays remain a major problem. OBJECTIVE Describe the prevalence, determinants and consequences of delayed diagnoses. METHODS This single-centre ambispective study analysed 146 adult relapsing-remitting MS patients (2016-2021) for frequency and determinants of diagnostic delays and their associations with clinical, cognitive, imaging and biochemical measures. RESULTS Diagnostic delays were identified in 77 patients (52.7%), including 42 (28.7%) physician-dependent cases and 35 (24.0%) patient-dependent cases. Diagnosis was delayed in 22 (15.1%) patients because of misdiagnosis by a neurologist. A longer diagnostic delay was associated with trends towards greater Expanded Disability Status Scale (EDSS) scores (B = 0.03; p = 0.034) and greater z-score of the blood neurofilament light chain (B = 0.35; p = 0.031) at the time of diagnosis. Compared with patients diagnosed at their first clinical relapse, patients with a history of >1 relapse at diagnosis (n = 63; 43.2%) had a trend towards greater EDSS scores (B = 0.06; p = 0.006) and number of total (B = 0.13; p = 0.040) and periventricular (B = 0.06; p = 0.039) brain lesions. CONCLUSION Diagnostic delays in MS are common, often determined by early misdiagnosis and associated with greater disease burden.
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Affiliation(s)
- Tomas Uher
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Adrian Adzima
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Barbora Srpova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Libuse Noskova
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Bénédicte Maréchal
- Advanced Clinical Imaging Technology, Siemens Healthineers International AG, Lausanne, Switzerland/Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland/Signal Processing Laboratory (LTS5), École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Aleksandra Maleska Maceski
- Departments of Medicine, Biomedicine and Clinical Research, Neurologic Clinic and Policlinic, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jan Krasensky
- Department of Radiology, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Dominika Stastna
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Michaela Andelova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Klara Novotna
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Karolina Vodehnalova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Jiri Motyl
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Lucie Friedova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Jiri Lindner
- Department of Radiology, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Veronica Ravano
- Advanced Clinical Imaging Technology, Siemens Healthineers International AG, Lausanne, Switzerland/Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland/Signal Processing Laboratory (LTS5), École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Andrea Burgetova
- Department of Radiology, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Petr Dusek
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic/Department of Radiology, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Lenka Fialova
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Eva Kubala Havrdova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Tobias Kober
- Advanced Clinical Imaging Technology, Siemens Healthineers International AG, Lausanne, Switzerland/Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland/Signal Processing Laboratory (LTS5), École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Jens Kuhle
- Multiple Sclerosis Centre and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital and University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital and University of Basel, Basel, Switzerland
| | - Manuela Vaneckova
- Department of Radiology, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
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Solomon AJ, Marrie RA, Viswanathan S, Correale J, Magyari M, Robertson NP, Saylor DR, Kaye W, Rechtman L, Bae E, Shinohara R, King R, Laurson-Doube J, Helme A. Global Barriers to the Diagnosis of Multiple Sclerosis: Data From the Multiple Sclerosis International Federation Atlas of MS, Third Edition. Neurology 2023; 101:e624-e635. [PMID: 37321866 PMCID: PMC10424832 DOI: 10.1212/wnl.0000000000207481] [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: 09/22/2022] [Accepted: 04/18/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Recent data suggest increasing global prevalence of multiple sclerosis (MS). Early diagnosis of MS reduces the burden of disability-adjusted life years and associated health care costs. Yet diagnostic delays persist in MS care and even within national health care systems with robust resources, comprehensive registries, and MS subspecialist referral networks. The global prevalence and characteristics of barriers to expedited MS diagnosis, particularly in resource-restricted regions, have not been extensively studied. Recent revisions to MS diagnostic criteria demonstrate potential to facilitate earlier diagnosis, but global implementation remains largely unknown. METHODS The Multiple Sclerosis International Federation third edition of the Atlas of MS was a survey that assessed the current global state of diagnosis including adoption of MS diagnostic criteria; barriers to diagnosis with respect to the patient, health care provider, and health system; and existence of national guidelines or national standards for speed of MS diagnosis. RESULTS Coordinators from 107 countries (representing approximately 82% of the world population), participated. Eighty-three percent reported at least 1 "major barrier" to early MS diagnosis. The most frequently reported barriers included the following: "lack of awareness of MS symptoms among general public" (68%), "lack of awareness of MS symptoms among health care professionals" (59%), and "lack of availability of health care professionals with knowledge to diagnose MS" (44%). One-third reported lack of "specialist medical equipment or diagnostic tests." Thirty-four percent reported the use of only 2017 McDonald criteria (McD-C) for diagnosis, and 79% reported 2017 McD-C as the "most commonly used criteria." Sixty-six percent reported at least 1 barrier to the adoption of 2017 McD-C, including "neurologists lack awareness or training" by 45%. There was no significant association between national guidelines pertaining to MS diagnosis or practice standards addressing the speed of diagnosis and presence of barriers to early MS diagnosis and implementation of 2017 McD-C. DISCUSSION This study finds pervasive consistent global barriers to early diagnosis of MS. While these barriers reflected a lack of resources in many countries, data also suggest that interventions designed to develop and implement accessible education and training can provide cost-effective opportunities to improve access to early MS diagnosis.
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Affiliation(s)
- Andrew J Solomon
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom.
| | - Ruth Ann Marrie
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Shanthi Viswanathan
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Jorge Correale
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Melinda Magyari
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Neil P Robertson
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Deanna R Saylor
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Wendy Kaye
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Lindsay Rechtman
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Eunchan Bae
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Russell Shinohara
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Rachel King
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Joanna Laurson-Doube
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
| | - Anne Helme
- From the Department of Neurological Sciences (A.J.S.), Larner College of Medicine at the University of Vermont, Burlington; Departments of Internal Medicine and Community Health Science (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; Department of Neurology (S.V.), Kuala Lumpur Hospital, Malaysia; Departamento de Neurologia (J.C.), Fleni, Buenos Aires; Institute of Biological Chemistry and Physical Chemistry (IQUIFIB) (J.C.), National Council for Scientific and Technical Research/University of Buenos Aires, Argentina; Department of Neurology (M.M.), Rigshospitalet, Copenhagen University Hospital, Denmark; Division of Psychological Medicine and Clinical Neuroscience (N.P.R.), Department of Neurology, Cardiff University, University Hospital of Wales, United Kingdom; Department of Neurology (D.R.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Internal Medicine (D.R.S.), University Teaching Hospital, Lusaka, Zambia; McKing Consulting Corporation (W.K., L.R.), Atlanta, GA; Department of Biostatistics, Epidemiology, and Informatics (E.B., R.S.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Multiple Sclerosis International Federation (R.K., J.L.-D., A.H.), London, United Kingdom
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