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Graves J, Grandhe S, Weinfurtner K, Krupp L, Belman A, Chitnis T, Ness J, Weinstock-Guttman B, Gorman M, Patterson M, Rodriguez M, Lotze T, Aaen G, Mowry EM, Rose JW, Simmons T, Casper TC, James J, Waubant E. Protective environmental factors for neuromyelitis optica. Neurology 2014; 83:1923-9. [PMID: 25339213 DOI: 10.1212/wnl.0000000000001001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether early environmental factors, such as cesarean delivery, breastfeeding, and exposure to smoking or herpes viruses, are associated with neuromyelitis optica (NMO) risk in children. METHODS This is a case-control study of pediatric NMO, multiple sclerosis (MS), and healthy subjects. Early-life exposures were obtained by standardized questionnaire. Epstein-Barr virus, cytomegalovirus, and herpes simplex virus 1 antibody responses were determined by ELISA. Multivariate logistic regression models were used to adjust for age at sampling, sex, race, and ethnicity. RESULTS Early-life exposures were obtained from 36 pediatric subjects with NMO, 491 with MS, and 224 healthy controls. Daycare (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.14, 0.78; p < 0.01) and breastfeeding (OR 0.42, 95% CI 0.18, 0.99; p = 0.05) were associated with lower odds of having NMO compared with healthy subjects. Cesarean delivery tended to be associated with 2-fold-higher odds of NMO compared with having MS/clinically isolated syndrome (OR 1.98, 95% CI 0.88, 4.59; p = 0.12) or with being healthy (OR 1.95, 95% CI 0.81, 4.71; p = 0.14). Sera and DNA were available for 31 subjects with NMO, 189 with MS, and 94 healthy controls. Epstein-Barr virus, herpes simplex virus 1, cytomegalovirus exposure, and being HLA-DRB1*15 positive were not associated with odds of having NMO compared with healthy subjects. CONCLUSIONS Exposure to other young children may be an early protective factor against the development of NMO, as previously reported for MS, consistent with the hypothesis that infections contribute to disease risk modification. Unlike MS, pediatric NMO does not appear to be associated with exposures to common herpes viruses.
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Affiliation(s)
- Jennifer Graves
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital.
| | - Siri Grandhe
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Kelley Weinfurtner
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Lauren Krupp
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Anita Belman
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Tanuja Chitnis
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Jayne Ness
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Bianca Weinstock-Guttman
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Mark Gorman
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Marc Patterson
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Moses Rodriguez
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Tim Lotze
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Gregory Aaen
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Ellen M Mowry
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - John W Rose
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Timothy Simmons
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - T Charles Casper
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Judith James
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
| | - Emmanuelle Waubant
- From the Department of Neurology (J.G., K.W., E.W.), University of California, San Francisco; Virginia Commonwealth Medical School (S.G.); Lourie Center for Pediatric MS (L.K., A.B.), Stony Brook Children's Hospital, NY; Partners MS Center (T.C.), Massachusetts General Hospital for Children, Harvard Medical School; UAB Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric Multiple Sclerosis and Related Diseases Program (M.G.), Boston Children's Hospital, MA; Mayo Clinic's Pediatric MS Center (M.P., M.R.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Texas Children's Hospital, Houston; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Multiple Sclerosis Center (E.M.M.), Johns Hopkins University, Baltimore, MD; Department of Pediatrics (J.W.R., T.S., T.C.C.), University of Utah, Salt Lake City; Oklahoma Medical Research Foundation (J.J.), Oklahoma City; and Department of Pediatrics (E.W.), UCSF Benioff Children's Hospital
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