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Bainbridge J, Barnhart R, Fuller R, Hellerslia VT, Kidd J, Merrill S, Volger E, Montgomery JH. The Role of Clinical Pharmacists in Patient-Centric Comprehensive Multiple Sclerosis Care. Int J MS Care 2024; 26:1-7. [PMID: 38213670 PMCID: PMC10779712 DOI: 10.7224/1537-2073.2022-051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND Individuals with multiple sclerosis (MS) may experience a variety of visible and invisible symptoms and, as they age, comorbidities related and unrelated to their MS. This can result in a complex medication regimen that includes disease-modifying therapies, symptom management drugs, and prescriptions for other comorbid disorders. METHODS We reviewed the existing literature to discover how to optimally integrate neurology clinical pharmacists into the MS care team and how clinical pharmacists can directly support both providers and patients through their expertise in pharmacology and medication management. RESULTS With approaches founded on a shared decision-making process alongside neurology providers, patients, and care partners, clinical pharmacists can help meet the complex challenges of MS care in a variety of ways. Especially within MS clinics, they are well positioned to enhance current neurology practices given their extensive training in comprehensive medication management and their ability to identify nuances in medication management to promote pharmacovigilance and patient-centered care. CONCLUSIONS Neurology clinical pharmacists bring multifaceted medication management and patient counseling and education skills to the MS care team and can support the shared decision-making process by serving as an accessible resource for patients and clinicians. By building trusted partnerships between neurology providers and clinical pharmacists, MS care teams can achieve effective and efficient patient care. Future research should compare clinical and patient-reported outcomes between patients receiving standard care and those receiving multidisciplinary, pharmacist-integrated care.
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Affiliation(s)
- Jacquelyn Bainbridge
- From the Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA (JB)
| | - Rebecca Barnhart
- University of Colorado Health, Ambulatory Care Pharmacy Services, Aurora, CO, USA (RB)
| | - Ryan Fuller
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA (RF)
| | - Van T. Hellerslia
- Temple University School of Pharmacy; Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA (VTH)
| | - Julie Kidd
- Roanoke Area MS Center, Salem, VA, USA (JK)
| | - Steven Merrill
- UCSF MS & Neuroinflammation Center, UCSF Medical Center, San Francisco, CA, USA (SM)
| | - Emily Volger
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA (EV)
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Hecker M, Frahm N, Zettl UK. Update and Application of a Deep Learning Model for the Prediction of Interactions between Drugs Used by Patients with Multiple Sclerosis. Pharmaceutics 2023; 16:3. [PMID: 38276481 PMCID: PMC10819178 DOI: 10.3390/pharmaceutics16010003] [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: 09/25/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 01/27/2024] Open
Abstract
Patients with multiple sclerosis (MS) often take multiple drugs at the same time to modify the course of disease, alleviate neurological symptoms and manage co-existing conditions. A major consequence for a patient taking different medications is a higher risk of treatment failure and side effects. This is because a drug may alter the pharmacokinetic and/or pharmacodynamic properties of another drug, which is referred to as drug-drug interaction (DDI). We aimed to predict interactions of drugs that are used by patients with MS based on a deep neural network (DNN) using structural information as input. We further aimed to identify potential drug-food interactions (DFIs), which can affect drug efficacy and patient safety as well. We used DeepDDI, a multi-label classification model of specific DDI types, to predict changes in pharmacological effects and/or the risk of adverse drug events when two or more drugs are taken together. The original model with ~34 million trainable parameters was updated using >1 million DDIs recorded in the DrugBank database. Structure data of food components were obtained from the FooDB database. The medication plans of patients with MS (n = 627) were then searched for pairwise interactions between drug and food compounds. The updated DeepDDI model achieved accuracies of 92.2% and 92.1% on the validation and testing sets, respectively. The patients with MS used 312 different small molecule drugs as prescription or over-the-counter medications. In the medication plans, we identified 3748 DDIs in DrugBank and 13,365 DDIs using DeepDDI. At least one DDI was found for most patients (n = 509 or 81.2% based on the DNN model). The predictions revealed that many patients would be at increased risk of bleeding and bradycardic complications due to a potential DDI if they were to start a disease-modifying therapy with cladribine (n = 242 or 38.6%) and fingolimod (n = 279 or 44.5%), respectively. We also obtained numerous potential interactions for Bruton's tyrosine kinase inhibitors that are in clinical development for MS, such as evobrutinib (n = 434 DDIs). Food sources most often related to DFIs were corn (n = 5456 DFIs) and cow's milk (n = 4243 DFIs). We demonstrate that deep learning techniques can exploit chemical structure similarity to accurately predict DDIs and DFIs in patients with MS. Our study specifies drug pairs that potentially interact, suggests mechanisms causing adverse drug effects, informs about whether interacting drugs can be replaced with alternative drugs to avoid critical DDIs and provides dietary recommendations for MS patients who are taking certain drugs.
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Affiliation(s)
- Michael Hecker
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147 Rostock, Germany; (N.F.); (U.K.Z.)
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Chapman WD, Herink MC, Cameron MH, Bourdette D. Polypharmacy in Multiple Sclerosis: Prevalence, Risks, and Mitigation Strategies. Curr Neurol Neurosci Rep 2023; 23:521-529. [PMID: 37523105 DOI: 10.1007/s11910-023-01289-9] [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] [Accepted: 07/18/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW Polypharmacy, the use of ≥ 5 medications, is common in people with multiple sclerosis and is associated with negative outcomes. The use of multiple medications is common for symptom management in people with multiple sclerosis, but risks drug-drug interactions and additive side effects. Multiple sclerosis providers should therefore focus on the appropriateness and risks versus benefits of pharmacotherapy in each patient. This review describes the prevalence and risks associated with polypharmacy in people with multiple sclerosis and offers strategies to identify and mitigate inappropriate polypharmacy. RECENT FINDINGS Research in people with multiple sclerosis has identified risk factors and negative outcomes associated with polypharmacy. Medication class-specific investigations highlight their contribution to potentially inappropriate polypharmacy in people with multiple sclerosis. People with multiple sclerosis are at risk for inappropriate polypharmacy. Multiple sclerosis providers should review medications and consider their appropriateness and potential for deprescribing within the context of each patient.
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Affiliation(s)
- W Daniel Chapman
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA.
| | - Megan C Herink
- College of Pharmacy, Oregon Health & Science University/Oregon State University, Portland, OR, USA
| | - Michelle H Cameron
- Department of Neurology, Oregon Health & Science University and VA Portland Health Care System, Portland, OR, USA
| | - Dennis Bourdette
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
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Baldt J, Frahm N, Hecker M, Streckenbach B, Langhorst SE, Mashhadiakbar P, Burian K, Meißner J, Heidler F, Richter J, Zettl UK. Depression and Anxiety in Association with Polypharmacy in Patients with Multiple Sclerosis. J Clin Med 2023; 12:5379. [PMID: 37629420 PMCID: PMC10456074 DOI: 10.3390/jcm12165379] [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: 06/21/2023] [Revised: 08/04/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Polypharmacy (intake of ≥5 drugs) is an important issue for patients with chronic diseases such as multiple sclerosis (MS). We aimed to assess the prevalence of polypharmacy with regard to the severity of anxiety/depression and to comorbidities. Therefore, 374 MS patients from two German neurological sites were examined for drug burden, comorbidities, disability level and psychopathological measures capturing depression and anxiety using the Hospital Anxiety and Depression Scale (HADS-A and HADS-D). We found that patients with a higher HADS-D score take more medication (r = 0.217, p < 0.001). Furthermore, patients with higher depression severity were more likely to show polypharmacy (p < 0.001). These differences were not significant for anxiety. (p = 0.413). Regarding the frequency of ≥1 comorbidities, there were no significant differences between patients with different HADS-A (p = 0.375) or HADS-D (p = 0.860) severity levels, whereas the concrete number of comorbidities showed a significant positive linear correlation with HADS-A (r = 0.10, p = 0.045) and HADS-D scores (r = 0.19, p < 0.001). In conclusion, symptoms of depression pose a relevant issue for MS patients and are correlated with polypharmacy and comorbidities. Anxiety is not correlated with polypharmacy but with the frequency of several comorbidity groups in MS patients.
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Affiliation(s)
- Julia Baldt
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, 18147 Rostock, Germany; (N.F.); (M.H.); (B.S.); (S.E.L.); (P.M.); (K.B.); (J.M.); (U.K.Z.)
- Ecumenic Hainich Hospital GmbH, 99974 Mühlhausen, Germany; (F.H.); (J.R.)
| | - Niklas Frahm
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, 18147 Rostock, Germany; (N.F.); (M.H.); (B.S.); (S.E.L.); (P.M.); (K.B.); (J.M.); (U.K.Z.)
| | - Michael Hecker
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, 18147 Rostock, Germany; (N.F.); (M.H.); (B.S.); (S.E.L.); (P.M.); (K.B.); (J.M.); (U.K.Z.)
| | - Barbara Streckenbach
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, 18147 Rostock, Germany; (N.F.); (M.H.); (B.S.); (S.E.L.); (P.M.); (K.B.); (J.M.); (U.K.Z.)
- Ecumenic Hainich Hospital GmbH, 99974 Mühlhausen, Germany; (F.H.); (J.R.)
| | - Silvan Elias Langhorst
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, 18147 Rostock, Germany; (N.F.); (M.H.); (B.S.); (S.E.L.); (P.M.); (K.B.); (J.M.); (U.K.Z.)
| | - Pegah Mashhadiakbar
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, 18147 Rostock, Germany; (N.F.); (M.H.); (B.S.); (S.E.L.); (P.M.); (K.B.); (J.M.); (U.K.Z.)
| | - Katja Burian
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, 18147 Rostock, Germany; (N.F.); (M.H.); (B.S.); (S.E.L.); (P.M.); (K.B.); (J.M.); (U.K.Z.)
- Ecumenic Hainich Hospital GmbH, 99974 Mühlhausen, Germany; (F.H.); (J.R.)
| | - Janina Meißner
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, 18147 Rostock, Germany; (N.F.); (M.H.); (B.S.); (S.E.L.); (P.M.); (K.B.); (J.M.); (U.K.Z.)
- Ecumenic Hainich Hospital GmbH, 99974 Mühlhausen, Germany; (F.H.); (J.R.)
| | - Felicita Heidler
- Ecumenic Hainich Hospital GmbH, 99974 Mühlhausen, Germany; (F.H.); (J.R.)
| | - Jörg Richter
- Ecumenic Hainich Hospital GmbH, 99974 Mühlhausen, Germany; (F.H.); (J.R.)
- Faculty of Health Sciences, University of Hull, Hull HU6 7RX, UK
- The Palatine Centre, Durham Law School, Durham University, Durham DH1 3LE, UK
| | - Uwe Klaus Zettl
- Section of Neuroimmunology, Department of Neurology, Rostock University Medical Centre, 18147 Rostock, Germany; (N.F.); (M.H.); (B.S.); (S.E.L.); (P.M.); (K.B.); (J.M.); (U.K.Z.)
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Tangsuwanaruk T, Wittayachamnankul B. Factors associated with a basic common drug-drug interaction knowledge among emergency department medical personnel. BMC Pharmacol Toxicol 2022; 23:84. [PMID: 36316720 PMCID: PMC9620625 DOI: 10.1186/s40360-022-00623-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Drug-drug interactions (DDIs) are common but less concerning in clinical practice of time-sensitive situations. We aimed to identify factors associated with a basic common DDI knowledge among an emergency physician (EP), an emergency medicine resident (EMR), and an emergency care nurse (ECN). Methods This was a prospective cross-sectional study. EP, EMR, and ECN did the examination (multiple-choice questions, 40 points) about common DDI. Prespecified factors associated with examination scores were profession, longer emergency medicine experience, pharmacological training, last advanced cardiovascular life support (ACLS) training, DDI checker book, and application user experience. The outcome was an examination score to evaluate the ability of DDI knowledge. Univariable and multivariable means regressions were used. Results A total of 244 participants were enrolled. Factors associated with high examination score were EP (unadjusted mean difference 3.3 points, 95% confidence interval [CI] 2.1 to 4.5, p < 0.001), EMR (2.1, 95% CI 0.7 to 3.5, p 0.005) compared to ECN. Last ACLS training within 2 years (3.7, 95% CI 0.7 to 6.6, p 0.015), 2–4 years (3.4, 95% CI 0.4 to 6.5, p 0.027), and ≥4 years (4.4, 95% CI 1.2 to 7.6, p 0.007) were higher score than no ACLS training. Moreover, the DDI checker application experience user (1.7, 95% CI 0.6 to 2.8, p 0.003) also had a high score compared to the non-experienced user. After adjustment for all factors, EP (adjusted mean difference 3.3 points, 95% CI 1.8 to 4.7, p < 0.001), EMR (2.5, 95% CI 0.6 to 4.3, p 0.010) were higher scores compared to ECN. Meanwhile, the last ACLS training ≥4 years (3.3, 95% CI 0.1 to 6.6, p 0.042) was a higher score than no ACLS training. Conclusion EP, EMR, and the last ACLS training ≥4 years were associated with higher DDI knowledge than ECN and no ACLS training, respectively. Supplementary Information The online version contains supplementary material available at 10.1186/s40360-022-00623-0.
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Affiliation(s)
- Theerapon Tangsuwanaruk
- grid.7132.70000 0000 9039 7662Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, 110 Inthawaroros Road, Sribhumi, Amphoe Muang Chiang Mai, Chiang Mai, 50200 Thailand
| | - Borwon Wittayachamnankul
- grid.7132.70000 0000 9039 7662Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, 110 Inthawaroros Road, Sribhumi, Amphoe Muang Chiang Mai, Chiang Mai, 50200 Thailand
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Hecker M, Frahm N, Bachmann P, Debus JL, Haker MC, Mashhadiakbar P, Langhorst SE, Baldt J, Streckenbach B, Heidler F, Zettl UK. Screening for severe drug-drug interactions in patients with multiple sclerosis: A comparison of three drug interaction databases. Front Pharmacol 2022; 13:946351. [PMID: 36034780 PMCID: PMC9416235 DOI: 10.3389/fphar.2022.946351] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Patients with multiple sclerosis (MS) often undergo complex treatment regimens, resulting in an increased risk of polypharmacy and potential drug-drug interactions (pDDIs). Drug interaction databases are useful for identifying pDDIs to support safer medication use. Objective: To compare three different screening tools regarding the detection and classification of pDDIs in a cohort of MS patients. Furthermore, we aimed at ascertaining sociodemographic and clinical factors that are associated with the occurrence of severe pDDIs. Methods: The databases Stockley's, Drugs.com and MediQ were used to identify pDDIs by screening the medication schedules of 627 patients. We determined the overlap of the identified pDDIs and the level of agreement in pDDI severity ratings between the three databases. Logistic regression analyses were conducted to determine patient risk factors of having a severe pDDI. Results: The most different pDDIs were identified using MediQ (n = 1,161), followed by Drugs.com (n = 923) and Stockley's (n = 706). The proportion of pDDIs classified as severe was much higher for Stockley's (37.4%) than for Drugs.com (14.4%) and MediQ (0.9%). Overall, 1,684 different pDDIs were identified by at least one database, of which 318 pDDIs (18.9%) were detected with all three databases. Only 55 pDDIs (3.3%) have been reported with the same severity level across all databases. A total of 336 pDDIs were classified as severe (271 pDDIs by one database, 59 by two databases and 6 by three databases). Stockley's and Drugs.com revealed 47 and 23 severe pDDIs, respectively, that were not included in the other databases. At least one severe pDDI was found for 35.2% of the patients. The most common severe pDDI was the combination of acetylsalicylic acid with enoxaparin, and citalopram was the drug most frequently involved in different severe pDDIs. The strongest predictors of having a severe pDDI were a greater number of drugs taken, an older age, living alone, a higher number of comorbidities and a lower educational level. Conclusions: The information on pDDIs are heterogeneous between the databases examined. More than one resource should be used in clinical practice to evaluate pDDIs. Regular medication reviews and exchange of information between treating physicians can help avoid severe pDDIs.
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Affiliation(s)
- Michael Hecker
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Niklas Frahm
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Paula Bachmann
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Jane Louisa Debus
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Marie-Celine Haker
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Pegah Mashhadiakbar
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Silvan Elias Langhorst
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Julia Baldt
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany.,Ecumenic Hainich Hospital gGmbH, Mühlhausen, Germany
| | - Barbara Streckenbach
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany.,Ecumenic Hainich Hospital gGmbH, Mühlhausen, Germany
| | | | - Uwe Klaus Zettl
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Rostock, Germany
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Debus JL, Bachmann P, Frahm N, Mashhadiakbar P, Langhorst SE, Streckenbach B, Baldt J, Heidler F, Hecker M, Zettl UK. Associated factors of potential drug-drug interactions and drug-food interactions in patients with multiple sclerosis. Ther Adv Chronic Dis 2022; 13:20406223221108391. [PMID: 35959503 PMCID: PMC9358348 DOI: 10.1177/20406223221108391] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/01/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Multiple sclerosis (MS) is the most common immune-mediated demyelinating
disease in younger adults. Patients with MS (PwMS) are vulnerable to the
presence of potential drug–drug interactions (pDDIs) and potential drug–food
interactions (pDFIs) as they take numerous medications to treat MS,
associated symptoms and comorbidities. Knowledge about pDDIs and pDFIs can
increase treatment success and reduce side effects. Objective: We aimed at determining the frequency and severity of pDDIs and pDFIs in
PwMS, with regard to polypharmacy. Methods: In the cross-sectional study, we analysed pDDIs and pDFIs of 627 PwMS aged
⩾18 years. Data collection was performed through patient record reviews,
clinical examinations and structured patient interviews. pDDIs and pDFIs
were identified using two DDI databases: Drugs.com Interactions Checker and
Stockley’s Interactions Checker. Results: We identified 2587 pDDIs (counted with repetitions). Of 627 PwMS, 408 (65.1%)
had ⩾ 1 pDDI. Polypharmacy (concomitant use of ⩾ 5 drugs) was found for 334
patients (53.3%). Patients with polypharmacy (Pw/P) were found to have a
15-fold higher likelihood of having ⩾ 1 severe pDDI compared with patients
without polypharmacy (Pw/oP) (OR: 14.920, p < 0.001).
The most frequently recorded severe pDDI was between citalopram and
fingolimod. Regarding pDFIs, ibuprofen and alcohol was the most frequent
severe pDFI. Conclusion: Pw/P were particularly at risk of severe pDDIs. Age and educational level
were found to be factors associated with the occurrence of pDDIs,
independent of the number of medications taken. Screening for pDDIs/pDFIs
should be routinely done by the clinical physician to increase drug safety
and reduce side effects.
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Affiliation(s)
- Jane Louisa Debus
- Neuroimmunology Section, Department of Neurology, Rostock University Medical Centre, Gehlsheimer Str. 20, 18147 Rostock, Germany
| | - Paula Bachmann
- Neuroimmunology Section, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Niklas Frahm
- Neuroimmunology Section, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Pegah Mashhadiakbar
- Neuroimmunology Section, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Silvan Elias Langhorst
- Neuroimmunology Section, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Barbara Streckenbach
- Neuroimmunology Section, Department of Neurology, Rostock University Medical Centre, Rostock, Germany; Department for Neurology, Ecumenic Hainich Hospital gGmbH, Mühlhausen, Germany
| | - Julia Baldt
- Neuroimmunology Section, Department of Neurology, Rostock University Medical Centre, Rostock, Germany; Department for Neurology, Ecumenic Hainich Hospital gGmbH, Mühlhausen, Germany
| | - Felicita Heidler
- Department for Neurology, Ecumenic Hainich Hospital gGmbH, Mühlhausen, Germany
| | - Michael Hecker
- Neuroimmunology Section, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
| | - Uwe Klaus Zettl
- Neuroimmunology Section, Department of Neurology, Rostock University Medical Centre, Rostock, Germany
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